Managing HIV/AIDS Therapy in Special Populations What are the treatment considerations for pregnant women?
	Enlarged Version of Graphics Below	Dr. Bellos (OC): I think the regimen considerations are expanding as time goes on. I think clearly, we now know that we cannot use efavirenz in that particular patient population, because of neural tube defects that have been discovered. (I think obviously-not "obviously"-but) the regimen that has been used most frequently has been one consisting of AZT/3TC and nelfinavir. That has been the most common regimen used in pregnant patients. I think our goal in pregnant patients is to have Mom undetectable at the time of delivery, and I think the thing that's important for clinicians to remember if they are going to care for HIV-impacted patients that are pregnant is that you really do need pediatric support to be sure that the child is taken care of at the time of delivery, and that Mom maintains her follow-up during delivery. Announcer (VO): When selecting antiretroviral therapy for pregnant women, several considerations must be kept in mind. Pregnancy can cause PK changes, requiring different dosing. There is also the potential for adverse effects in these women. The regimen's effect on perinatal transmission must also be considered. Finally, the potential short- and long-term effects on the fetus and newborn must be examined.   See Slide Dr. Bellos (OC): Most of the patients that I have had have traditionally been, in all honesty, relatively well-controlled during the early part of their pregnancy, and their viral loads have been less than 1,000, or right around 1,000, and we probably treat two to three pregnant patients a year, which may not seem like a lot, but that's actually a fair number, of two to three pregnant patients a year, and we actually have patients in our practice who have come knowing that they are HIV-positive, and my goal with those patients has been to maintain their viral load as low as possible, for as long as possible. And ultimately, if I can maintain their viral loads at less than 1,000, or if that's where their natural setpoint is, then, I will hold off therapy until right before delivery, to make them undetectable. Dr. Bellos (VO): As an anecdote, I have one patient I have treated for many, many years, and her viral load was always around 400 to 500. She would see her obstetrician on a monthly basis, and I would constantly receive a call after the visit about, "When are you going to start her on therapy? When are you going to start her on therapy?" when her viral load was running between 300 and 500, so I would have to reassure him, and ultimately state that, you know, "We will start her on therapy as close to delivery as we can," and that's what we ended up doing. We ended up beginning AZT/3TC and nelfinavir. She was undetectable within two weeks. She delivered, and the baby is fine.   See Slide Announcer (VO): AZT and 3TC are the two nucleosides recommended by the DHHS Guidelines for use in pregnant women. The two should be used as the nucleoside backbone of the regimen.   See Slide Dr. Kwakwa (OC): The antiretroviral agents, partly because of the rapid approval process, have always elicited concerns about use in pregnancy, and the one drug that has done this perhaps the most has been efavirenz. Dr. Kwakwa (VO): Previously a Category C, within the past year, it has been recategorized to "D" because of some reports of damage to the central nervous system of fetuses and newborns, so efavirenz is absolutely contraindicated in pregnant women, and in some women of childbearing age, it should be used, if at all, with extreme caution.   See Slide Dr. Kwakwa (VO): The issue of nevirapine, though-although it is a Category B drug in pregnancy, the CD4 limits on it used sometimes really make it difficult to use in pregnancy, because it really has to be used in women with CD4 counts of less than 250. There aren't many women with those CD4 counts choosing to get pregnant. Because of that, its use has been limited. Dr. Kwakwa (VO): There are also concerns about the use of tenofovir in pregnancy. It is a category B drug in pregnancy, but because of the potential complications of osteoporosis and osteopenia, there have been concerns about its effects on the developing fetus.   See Slide Dr. Kwakwa (OC): Of course, d4T/ddI in combination should not be used in pregnancy, ever. Dr. Kwakwa (VO): Some of the protease inhibitors have shown fairly good data over years about their use in pregnant women. Examples include nelfinavir, lopinavir, ritonavir, Kaletra; Lexiva also is a Category B drug. Now, there have been some concerns about Agenerase, which is the drug of which Lexiva or fosamprenavir is the pro-drug. However, the concern about Agenerase in pregnancy is really limited to the oral solution, and does not translate to Lexiva, as far as we know.   See Slide
Program Menu		Next