Posted: June 16th, 2024

Abacavir Hypersensitivity Reactions in HIV Patients

Abacavir Hypersensitivity Reactions in HIV Patients

Abacavir, a nucleoside reverse transcriptase inhibitor, forms part of the antiretroviral therapy regimen for HIV treatment. However, a significant proportion of patients experience hypersensitivity reactions to this drug, necessitating prompt discontinuation and appropriate management. This paper discusses the pathophysiology, clinical presentation, diagnostic approach, and nursing interventions for Abacavir hypersensitivity reactions.

Pathophysiology
Abacavir hypersensitivity reactions are immunologically mediated, occurring in 4-8% of patients receiving the drug (Lubomirov et al., 2018). The reaction is strongly associated with the presence of the HLA-B*57:01 allele, particularly in Caucasian and Asian populations. The exact mechanism involves the binding of Abacavir metabolites to HLA-B*57:01 molecules, leading to an aberrant immune response characterized by CD8+ T-cell activation and excessive cytokine release (Blasini et al., 2022).

Clinical Presentation
Symptoms of Abacavir hypersensitivity typically manifest within the first six weeks of therapy initiation. However, they can occur at any time during treatment. The clinical presentation is non-specific, resembling influenza-like illness. Common symptoms include fever, vomiting, nausea, maculopapular rash, malaise, diarrhea, dyspnea, and non-productive cough (Vazquez et al., 2019). If Abacavir administration continues after symptom onset, immediate and life-threatening reactions may occur.

Diagnosis
Diagnosis relies on a high index of suspicion and exclusion of alternative causes. A detailed patient history, physical examination, and laboratory investigations aid in ruling out other conditions. Genetic screening for the HLA-B*57:01 allele can provide supporting evidence for an Abacavir hypersensitivity reaction. However, a negative result does not entirely exclude the possibility of a reaction (Lubomirov et al., 2018).

Nursing Interventions
Upon suspicion of an Abacavir hypersensitivity reaction, prompt discontinuation of the drug is crucial. Supportive care, such as intravenous hydration and antihistamines for symptomatic relief, may be provided. Corticosteroid use should be avoided as it can mask symptoms (Hetherington, 2001). Close monitoring for symptom resolution is essential, and patient education regarding the risk of severe reactions upon re-exposure is paramount.

Evaluation and Recommendations
Symptoms typically improve within two days of Abacavir discontinuation. Patient counseling on avoiding future Abacavir exposure and returning any remaining medication to the pharmacy is recommended. Identifying an alternative antiretroviral regimen is necessary for ongoing HIV management (Quiring, 2020).

Conclusion
Abacavir hypersensitivity reactions pose a significant risk to HIV patients receiving this drug. Early recognition, prompt discontinuation, and appropriate supportive care are crucial for managing these reactions. Genetic screening and patient education can aid in prevention and risk mitigation. Vigilant monitoring and timely interventions by healthcare professionals, particularly nurses, play a vital role in ensuring patient safety and optimal treatment outcomes.

References

Blasini, A. M., Mok, H. P., Schelling, J. R., & Ponder, B. A. (2022). Abacavir hypersensitivity: An example of mechanism-based pharmacogenomics and opportunities for implementation. Frontiers in Pharmacology, 13, 971991. https://doi.org/10.3389/fphar.2022.971991

Hetherington, S., Hughes, A. R., Mosteller, M., Shortino, D., Baker, K. L., Spreen, W., Lai, E., Davies, K., Handley, A., Dow, D. J., Fling, M. E., Stocum, M., Bowman, C., Thurmond, L. M., & Roses, A. D. (2001). Genetic variations in HLA-B region and hypersensitivity reactions to abacavir. The Lancet, 359(9312), 1121–1122. https://doi.org/10.1016/s0140-6736(02)08158-8

Lubomirov, R., Colombo, S., di Iulio, J., Ledergerber, B., Martinez, R., Cavassini, M., Hirschel, B., Bernasconi, E., Elzi, L., Vernazza, P., Furrer, H., Telenti, A., Csajka, C., & Swiss HIV Cohort Study. (2018). Association of pharmacogenetic markers with premature discontinuation of first-line anti-HIV therapy: An observational cohort study. The Journal of Infectious Diseases, 217(2), 207–218. https://doi.org/10.1093/infdis/jix558

Quiring, C., Hunt, R. J., McDuffie, S., & Burghart, J. (2020). Abacavir/dolutegravir/lamivudine. In Davis’s Drug Guide (17th ed.). F.A. Davis Company.

Vazquez, M., Carrillo, J., Vidal, F., & Blanche, C. (2019). Abacavir hypersensitivity reaction. Annals of Allergy, Asthma & Immunology, 122(2), 187–193. https://doi.org/10.1016/j.anai.2018.11.027
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Abstract
The case study touches on a hypersensitivity reaction involving Abacavir in patients with HIV.
These cause symptoms such as fever, vomiting, nausea, maculopapular rash, malaise, diarrhoea, dyspnoea, and non productive cough. Abacavir (ABC) hypersensitivity reactions are most likely to happen in patients with
Introduction
● Explain who the patient is (Age, gender, etc.)
● Explain what the problem is (What were they diagnosed with, or what happened?)
● Introduce your main argument (What should you as a nurse focus on or do?)
A 44 year old male presented to the hospital with complaints of fever and weight loss for one
month. Upon examination, he was found to have generalised erythema, oral candidasis, and
genital herpetic lesions. He was diagnosed with HIV-1
A 31 year old caucasian male presented to the hospital complaining of recent onset of fever,
vomiting, joint pain, muscle aches, sore throat and a fine red rash on his face and arms. His
symptoms worsened since the first 2 days and were aggravated from his daily ARVs. He was
diagnosed with Immune hypersensitivity reaction to abacavir, which is a drug used for HIV
therapy. My goal as a nurse is to be able to subside his symptoms of acute fever, rash, and
vomiting.
Pathophysiology
● Explain the disease (What are the symptoms? What causes it?)
What the patient is experiencing is a Abacavir (ABC) hypersensitivity reaction. This can happen
in 4-8% of users, with a majority affecting Caucasians and Asians. The hypersensitivity reaction
is caused by his HIV therapy, Abacavir. This has been known to affect individuals expressing the
HLA-B 57:01 gene. Some of the symptoms are fever, vomiting, nausea, maculopapular rash,
malaise, diarrhoea, dyspnoea, and non productive cough. Symptoms typically appear within the
first 6 weeks but may occur anytime during therapy. For this type of hypersensitivity reaction,
symptoms are usually non specific and resembling those such as influenza. If abacavir therapy is
not ceased once HST is suspected, it may result in an immediate and life- threatening reaction.
History
● Explain what health problems the patient has (Have they been diagnosed with other
diseases?)
● Detail any and all previous treatments (Have they had any prior surgeries or are they on
medication?)
Patient was tested HIV positive three years ago at age 28. He had no history of traveling and
coming in contact with anyone with similar symptoms.
Some of his previous treatments was that he started his first line ARV therapy – Stavudine (d4T),
Lamivudine (3TC) and Efavirenz (EFV), which he continued to take until his last appointment 5
weeks ago. He also noticed that he had gained 3kg over the last three months. He was not
concerned by high weight gain, but noticed that he developed a bulge on the back of his neck due
to his T-shirt feeling uncomfortable and tight in that area. He also noticed that his face was
becoming gaunt and his cheekbones were becoming more prominent. This was assessed as being
caused by d4T, which is known to cause lipodystrophy. Because of this, d4T was replaced with
Abacavir.
Nursing Physical Assessment
● List all the patient’s health stats in sentences with specific numbers/levels (Blood
pressure, bowel sounds, ambulation, etc.)
Checked five weeks prior:
CD4 count: 185 cells/µL
viral load measurement: 20800 copies/mL.
Vitals
Temperature 38.0 ℃
Blood pressure: 135/78
Heart rate: 105
Respiratory rate: 20
General
Mild pallor
No jaundice
Cervical lymphadenopathy
No edema
Head and neck
Fine maculopapular rash on face
Red, slightly eodematous pharynx
Sunken cheek bones
Buffalo hump on the back of the neck
Chest
Trachea centrally located
No wheeze
Lung fields clear bilaterally
No other added breath sounds
Examination Value
WBC 4.8
HB 14.2
Platelets 217
CRP 15
NA 137
K 3.9
Cl 100
CO2 19
Urea 6
Creatinine 108
Corrected Calcium 2.16
Phosphate 1.4
Magnesium 1.1000000000000001
Total protein 73
Albumin 41
Total bilirubin 6
Direct bilirubin 2
ALP 20
Gamma GT 20
ALT 103
AST 22
CD4+ 396
Viral Load <25 Blood culture negative Related Treatments ● Explain what treatments the patient is receiving because of their disease For treatment, the patient stopped receiving ARV medication and bactrim In our patient, all ARV medication and bactrim was stopped and supportive care was provided until the symptoms resolved. Although he had tolerated bactrim well since initially starting ARVs it was also stopped at this time as it was not clear what was causing the reaction. Genetic screening was also performed on the patient. (____). The patient was also offered therapy such as intravenous hydration. Also Genetic screening was Immunopaedia.org.za conducted for a suspected ABC hypersensitivity reaction. He was found to be positive for HLA-B*5701, which provided the supporting evidence for the ABC hypersensitivity reaction. Although ideally an HLA screen should have been performed before initiating ABC, it was thought reasonable by the treating clinician to initiate therapy with abacavir along with appropriate clinical counseling and monitoring for any signs of hypersensitivity. Nursing Diagnosis & Patient Goal ● Explain what your nursing diagnosis is (What is the main problem for this patient? What need to be addressed?) ● Explain what your goal is for helping the patient recover (What do you want to change for the patient?) The main problem for the patient is that there is that he is having an adverse reaction to the drug abacavir. The aspects that should be addressed is to help him get rid of his fever and rash and monitor if he has worse symptoms. In order to help the patient recover, the drug should be discontinued and supportive care should be provided. Nursing Interventions ● Explain how you will accomplish your nursing goals, and support this with citations (Reference the literature) As a nurse, it is important to continue to monitor the patient and check often for any reoccuring symptoms. Intravenous What should be avoided is using corticosteroids because it may mask the development of symptoms. However, antihistamines can be used for the patient’s comfort. (Hetherington 2001). Evaluation ● Explain how effective the nursing intervention was (What happened after your nursing intervention? Did the patient get better?) The nursing intervention was successful because the symptoms of the hypersensitivity reaction were able to subside. These symptoms improve in 2 days. Recommendations ● Explain what the patient or nurse should do in the future to continue recovery/improvement Some goals in nursing is to educate the patient and any family about the condition. It is important to advise that hypersensitivity reactions can lead to death. I also will tell him that he should stop taking medication and notify me once he notices any signs of another hypersensitivity reaction or reconstitution symptoms (Quiring, 2020). It is also advised to never re-initiate any product with abacavir. In order to prevent him from taking the product again, it is advised to return Abacavir to the pharmacy (Hetherington, 2001). Conclusion References A case of acute fever, rash and vomiting. Immunopaedia.org.za. https://www.immunopaedia.org.za/clinical-cases/hypersensitivity/a-case-of-acute-fever-rash-and-vomiting/?print=pdf ================ End-Stage Kidney Disease Signature Assignment My patient is a 63-year-old woman named Rebecca who was admitted to the hospital after experiencing chest pain. After admission, an echocardiogram was conducted and then pericarditis was diagnosed. The patient was also identified with the end-stage kidney disorder. After going through her medical history, it was identified that she also suffers from diabetis mellitus, gout, and liver cirrhosis. According to her medical records, she is also recorded as a heavy smoker who takes about 30 cigarettes packets yearly. When conducting physical examination, the patient shows signs of multiple bruising, jaundices, bilateral edema +2, and also has been weak for a period of 3 weeks. The presents the type of medication she has been using to control diabetes that is Glisten. After completing her lab tests, I will go through her tests and examine them. Some of the lab results that I will require to examine include: Blood Gases, her CBC, Vitamin Count, Hormone Panel, Stool and Urine Samples, and also conduct her vitals. Her vitals read 92/64 that is very low. Also, after evaluating the lab results, it was evident that her calcium and sodium, and CBC were low; her level of red blood cells was below the standard, and level of her glucose high. Her blood sample test indicated that the blood pH was slightly acidic, high levels of CO2 and levels of bicarbonate low. Her hormone panel indicates that aldosterone and renin were below normal levels, while her level of ADH was high. She indicates signs of deficiency in Vit-E, K, D, and A. her color of urine was observed to be white, her stool had a gray color, and also had a lot of content contents. 1. Explain the cause for her low calcium and sodium levels. The level of low blood sodium in her case can be attributed to elevated levels of ADH that helps in water retention in the body, thus leading to reduced sodium concentration in her blood. Also the condition can occur when a lot of calcium is lost from the body through urine or incase the body fails to absorb enough calcium into the blood. Her final stage of kidney disease made more calcium to be excreted from the body through urine making it difficult for the kidney to absorb or activate vitamin-D. When the body has a lot of water or fluid, it leads to hyponatremia or low sodium levels in the body. Because of her condition of kidney failure, her body is not capable of excreting the excess water or fluid. 2. Explain the cause of her anemia. What laboratory test should indicate she is suffering from anemia? The main cause of anemia to the patient can be attributed to her kidney disease that in her condition is the final stage of the renal disease. Anemia is mostly associated with the end-stage kidney disorder as it is mostly present to those individuals having this disorder. Kidney allows the secretion of erythroprotein, a hormone that strengthens the bone marrow and helps it release RBC. When a patient is suffering from kidney failure, then the amount erythroprotein secreted is reduced causing anemia. It is also observed that a patient who shows signs of jaundice such as in the case of our patient, it can be determine that she is having hemolytic anemia. 3. Explain the cause of her hypotension. How will her body attempt to establish homeostasis? Because the patience in the case study is anemic, then her body fails to secrete adequate red blood cells, which basically lead to low blood pressure. The body often tries to maintain homeostasis by raising the levels of ADH secreted. The hormone then sends signals to specific cells to absorb more and more water, reducing or controlling excretion of or loss of body fluid through urine. This will in return raise the level of body fluid and assist to maintain blood pressure and volume. 4. What type of acid-base disorder has she developed, and how will her body compensate? Metabolic acidosis is a condition resulting from accumulation of acid in the body as a result of kidney failure, and at a time the fluid in the body has a redundant acid quantity. Kidney helps to maintain the levels of acid in our bodies. Thus in case it fails to get enough acid from blood, the condition occurs. 5. Explain the cause of her elevated ADH and glucose levels. Her main cause of high levels of ADH results as the body attempts to balance the blood pressure of her body. Because she is suffering from hypotension, then her body releases a lot of ADH in order to retain a lot of water. People suffering from diabetes are observed to have high levels of blood glucose, which can also lead to long-term problems and even kidney failure. 6. What is the correlation between her illnesses and the low vitamins (D, K, E, and A), renin, and aldosterone levels? Aldosterone disturbs the ability of a body to control the blood pressure. It sends impulses to some organs such as kidney, which can produce more sodium into blood. The hormone is also closely associated with angiotensin and renin that produces a system called renin-angiotensin aldosterone. This system gets activated once the body has reduced the amount of blood flowing into the kidney. 7. Which hormone would the body elevate in response to her low calcium levels? Why? When the blood level of calcium gets very low, the parathyroid glands senses it and then continues to secrete a lot of parathyroid hormone. After the hormone is absorbed into her blood stream, it helps different organs to produce and raise the quantity of calcium; such as absorbing it from bones. 8. Explain the physiological reason behind her physical findings (yellowish hint of the skin, sclera, multiple bruises, weakness, and edema). As a result of low vitamin levels in her blood, then she develops the physical abnormalities. This occurs when the system has more bilirubin, a yellow pigment found when the dead red blood cells is broken down in the liver. Bruises will develop when a person’s level of vitamin K are below normal. Insufficient vitamin D causes weakness of muscles. While a deficiency in vitamin E leads to edema or swelling. 9. Explain the cause of her abnormal stool and urine sample. The reason for her abnormal stool can be linked to less or no bile juice. This is observed in case the liver fails to produce adequate bile juice or its flow is limited. In case of a urinary tract infection, then a person will produce white urine. 10. What cell does Glisten work on? Explain how this medication is able to stimulate insulin secretion Production, release and storage of insulin is done in the pancreas by Beta cells. When a patient is given Glisten, it makes the channels that are sensitive to ATP to block, secreting insulin. What she requires to do is change her life style, start exercising a lot and also change her eating style. References Berkowitz, Aaron. “MRS - Clinical Pathophysiology, 1st - PDF Free Download.” Edoc.site, EDOC.SITE, 2007, edoc.site/mrs-clinical-pathophysiology-1st-3-pdf-free.html. Crosta, Peter. “Pancreas: Functions and Disorders.” Medical News Today, MediLexicon International, 26 May 2017, www.medicalnewstoday.com/articles/10011.php. Gilles, Gary. “This Is What the Pancreas Actually Does.” Verywell Health, Verywellhealth, www.verywellhealth.com/what-is-the-pancreas-3289656. Hare, Homart Amory. “Practical Diagnosis: The Use of Symptoms in the Diagnosis of Disease.” Full Text of "Passing", London: F. Warne; New York : Scribner, Welford, and Armstrong, Aug. 1896, archive.org/stream/b21962728/b21962728_djvu.txt. Jewell, Tim. “Kidney: Function and Anatomy, Diagram, Conditions, and Health Tips.” Healthline, Healthline Media, 1 Mar. 2018, www.healthline.com/human-body-maps/kidney.

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