Antiretroviral therapy- Underdosing
Author: Pediatric Oncall
Question.
An 11 years old HIV infected boy on antiretroviral therapy {ART} consisting of Stavudine {d4T} 30 mg, Lamivudine {3TC} 150 mg and Nevirapine {NVP} 200 mg for the past 1 year was referred for further management. He had jaundice 1 year back and herpes zoster 1½ years back and had received antituberculous therapy {ATT} at 5 years of age in view of symptomatic mantoux positive. His CD4 count 1 year ago was 355 cells, cumm and HIV viral load was 248,776 copies, ml. On examination, weight was 28 kg, height was 135 cms. Other systems were normal. In view of improper doses of d4T, 3TC, NVP, the doses were adjusted and he was continued on the same. At age of 14 years, his viral load was undetectable and CD4 was 744 cells, cumm. At end of 15½ years, his viral load was 6192 copies, ml and CD4 was 600 cells, cumm.
Answers of this discussion
Author :- agnes dikec on 17 December 2011.
Answer :- thank you very much for sending this out for rubbing minds. first of all,i think this child was taking the right doses albinitio for his age at 11,provided the meds were given bid.the child was seen to have a high viral load,despite taking art for a year,which qualifies as having failed virologicaly provided the dose of art is correct,with good adherence. however,child was continued on d same regimen,n appeared to do well for some time.in view of the current vl,d child may have failed virologically.immunological failure is known to lag behind vl, n clinical failure behind immunologic failure.i believe,if adherence has been good ,that the child should undergo a virus resistance testing, and probably switch to a second line drug.

Author :- Pediatric Oncall on 19 December 2011.
Answer :- The child is being underdosed. As per his weight and surface area, he should receive 56mg of stavudine, 224 mg of lamivudine and nevirapine of 300mg. Since this child has shown a blip on the viral load, we have asked the patient to repeat the viral load again after 3 months and if it shows a rise, then change in ART will be warranted. Currently we have adjusted his doses as per the adult doses.

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