Case studies: Prescribing ART and Methadone

Objectives
Apply knowledge on prescribing and dosing of ARV to methadone patients using case
studies
Discuss cases with colleagues, trainers and invited guests from the local AIDS
clinic/hospital ward. Use real cases where available.

a. Why do you think the regimen described were chosen

b. Do you think the physician made the correct choice?
c. Do you think that other drug combinations might be better? If so why?
d. Consider the symptoms reported at each follow-up appointment
described. What (if anything) should the doctor do
Case One

Tono is 28 years old and was diagnosed with HIV 2 years ago, and reached stage WHO 3 of
the HIV classification of the stages of the disease a year ago suffering from serious weight
loss and severe bacterial infections. At that time his CD-4 count was 280/mm 3 . Since then he
had sinusitis, repetitive diarrhoea and his CD4 count is now 175/ mm3 .

It was decided that as he had considerable social support (a wife and parents who cared about
him and accompanied him to the clinic for all the preliminary discussions) that he should be
given ARV treatment. Tono has been attending the methadone clinic for nine months and is
taking 100 milligrams of methadone daily. His adherence record (to methadone) has been
exemplary and he has done much to obtain employment and build bridges with his family.
The regimen chosen was AZT (ZDV)-3TC-NVP .

(Discuss:
Why do you think the regimen described were chosen
Do you think the physician made the correct choice?
Do you think that other drug combinations might be better? If so why?
What else would you like to know about Tono to decide about the prescription?)

First follow up interview: (one week after beginning treatment)

Patient reported mild nausea, headache and fatigue. But otherwise no major problems

How do you judge this? What do you do?

Second follow- up interview (One week later)

Patient said that he started feeling bad soon after his last interview with the health care
provider. He said that he was told about potential side effects, but what he felt was truly
alarming! He described stomach ache, felt feverish, and was shaking feeling hot and cold.
Tono said that he hadnt felt like that since the days when he was using heroin in the streets.
He was alarmed and frightened. In addition he noticed that a rash was developing on his torso.

What is your likely diagnosis?

What the differential diagnosis?
What action do you take?
Any (changes in) medication? Should he stop the ARV medication?

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Third follow up interview: Patient presented with persistent gastrointestinal problems and a
mild rash on his body. However no symptoms of opiate withdrawal (as methadone dose had
been adjusted. Patient reported feeling very fearful that he will not be able to tolerate the
medication and attributes his ill health to the ARV.

What do you do?

After these side effects had been dealt with successfully Tono reported no difficulties in
adherence for a number of months and he was feeling better overall. His family was delighted
with his progress and he was able to work regularly.

However at the five month follow up the doctor observed that he was jaundiced and that
Tonoos liver was tender. Apart from that he was doing well on the ARV treatment.

What will you do now?

What is the diagnosis? DD?
What action do you take? Switch or substitute? Discuss!

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ART and Methadone

Case two

Adji is 30 years old and has been attending the clinic for 4 months and was put on ARV
treatment three weeks ago. He is receiving 60 milligrams of methadone daily. In addition Adji
is also being treated for severe diarrhoea. Adji has been suffering from hepatitis C for some
time and there was some clinical evidence of slight liver damage.

ARV treatment, its potential side effects and the importance of adherence were well explained
to this patient.
The clinic doctor decided to put Adji on the d4T- 3TC-NVP regimen.

First follow up visit: (3 weeks later) Patient reported a number of unpleasant symptoms
these included liver tenderness Jaundice, abdominal discomfort, nausea and fatigue. He said
that he did not think that his reaction to methadone has been affected.

How do you judge his history?

What is the likely diagnosis? On what basis? Discuss!
What else would you like to know from him?

Second follow up visit: (one week latert:

Patient said that he felt a lot worse than prior to starting this medication. He wondered if it
could be changed?

So far he has managed to come to the clinic for his methadone and ARV medication every day
but said that on some days he seriously considered not coming, as he felt so ill. On medical
examination patient was found to have a mild rash (which he forgot to report on last time).

Diagnosis? What do you do?

Third follow up interview :

For a while Adji was managing to take his medication as prescribed. Attending all follow up
appointments. However six months after starting ARV treatment he presented with more
serious symptoms. patient reported severe and persistent abdominal pains, fatigue and
shortness of breath.

Diagnosis? Action taken?