If it is necessary to individually select the dose, it is recommended to use separate preparations of lamivudine and zidovudine. Doctors should be guided by information on the use of these drugs.
Patients should be warned about the possible consequences associated with the joint use of other drugs without prescribing a doctor.
Patients should be informed that treatment with antiretroviral drugs, such as medication Zidovudine + Lamivudine, does not prevent the risk of HIV transmission to other people during sexual intercourse or blood contamination, so patients should take appropriate precautions.
Opportunistic infections
Despite taking the drug Zidovudine + Lamivudine or any other antiretroviral drug, patients may develop opportunistic infections and other complications of HIV infection. Therefore, patients should be under constant supervision of physicians with experience in treating patients with HIV-associated diseases.
Undesirable reactions from the hematopoiesis system
Possible development of anemia, neutropenia and leukopenia (the latter is usually secondary to neutropenia) in patients receiving zidovudine. These phenomena are more often observed when zidovudine is administered in high doses (1200-1500 mg / day) in patients with advanced stages of HIV infection with a reduced bone marrow reserve before the start of treatment. Therefore, in patients receiving the drug Zidovudine + Lamivudine, it is necessary to carefully monitor hematological parameters. These hematologic changes usually appear no earlier than 4-6 weeks after the start of therapy. In patients with developed clinical it is recommended to monitor blood levels at least once every 2 weeks during the first 3 months of therapy, and then at least once a month. In patients with early stage of HIV infection, unwanted reactions from the blood system are rare. In this situation, a general blood test can be done less often, focusing on the general condition of patients, for example, 1 time in 1-3 months. A special dose of zidovudine may be required if severe anemia or myelosuppression develops during treatment with the drug, as well as in patients with previous bone marrow suppression, for example, hemoglobin concentration less than 9 g / dL (5.59 mmol / L) or neutrophil count less than 1.0x 10 / l. Because the individual dose of the drug Zidovudine + Lamivudine It is impossible, it is recommended to use separate preparations of zidovudine and lamivudine.
Pancreatitis
In patients who took zidovudine and lamivudine, rare cases of development of pancreatitis are described. However, it is not established whether this complication is caused by medications or the underlying disease - HIV infection. If a patient experiences abdominal pain, nausea, vomiting, or an increase in biochemical markers, the possibility of developing pancreatitis should be considered. You should stop taking the drug Zidovudine + Lamivudine until the diagnosis of pancreatitis.
Lactic acidosis / severe hepatomegaly with steatosis
There are reports of the development of lactic acidosis, severe hepatomegaly with steatosis, including fatal Apt analogues of nucleosides in the form of individual preparations, including lamivudine or a combination thereof. Similar phenomena were observed, mainly, in women. Clinical signs of developing lactic acidosis are general weakness, anorexia, rapid unexplained weight loss, symptoms of gastrointestinal tract damage (nausea, vomiting, abdominal pain) and respiratory system (rapid and / or deep breathing), neurological symptoms (including motor weakness).
Treatment with analogues of nucleosides should be discontinued in case of development of symptomatic hyperlactatemia and metabolic acidosis / lactic acidosis, progressive hepatomegaly, or a rapid increase in aminotransferase levels.
Caution should be exercised when using nucleoside analogues to treat any patient (especially obese women) with hepatomegaly, hepatitis, or other known risk factors for liver damage and liver steatosis (including the use of certain drugs and alcohol use).
Patients with co-infection with hepatitis C and patients who receive treatment with alpha interferon and ribavirin may constitute a special risk group.
Lipodystrophy
In some patients receiving combined Apt, redistribution and / or accumulation of subcutaneous fat can be observed, including obesity in the central type, dorsocervical fat deposition ("buffalo buffalo"), a reduction in the subcutaneous fat layer on the face and extremities, enlargement of the mammary glands, increased serum lipid concentrations and concentration glucose in the blood, either individually or together.
Although all drugs from HIV and NRTI classes can cause one or more of the above unwanted reactions associated with a common syndrome, often called lipodystrophy, the accumulated data suggest that there are differences between individual representatives of these classes of drugs in the ability to induce these undesirable reactions.
It should also be noted that lipodystrophy syndrome has a multifactorial etiology; for example, the stage of HIV infection, the elderly age and the duration of antiretroviral therapy play an important, possibly synergistic role in the development of this complication.
The long-term consequences of these undesirable reactions are currently unknown. During the clinical examination of patients, attention should be paid to the signs of redistribution of subcutaneous fat. It is necessary to closely monitor the serum lipids concentration and blood glucose concentration. If the lipid metabolism is disturbed, an appropriate treatment is prescribed.
Immunodeficiency Syndrome
In the presence of HIV-infected patients with severe immunodeficiency asymptomatic opportunistic infections or their residual effects at the time of onset Apt, such therapy may lead to an increase in the symptoms of opportunistic infections or other severe consequences. Usually, these reactions occur within the first weeks or months after the onset Apt. Typical examples are cytomegalovirus retinitis, generalized or focal mycobacterial infection and pneumonia caused by Pneumocystis jiroveci (R. carinii). The appearance of any symptoms of inflammation requires immediate examination and, if necessary, treatment.
Autoimmune diseases (such as Graves' disease, polymyositis and Guillain-Barre syndrome) were observed against the background of restoration of immunity, but the time of primary manifestations varied, and the disease could occur many months after the initiation of therapy and have an atypical course.
Co-infection of HIV and viral hepatitis B
Clinical studies and post-registration data on the use of lamivudine suggest that in some patients with concomitant viral hepatitis B (HBV), clinical or laboratory signs of hepatitis recurrence may appear after stopping lamivudine, which may have more severe consequences in patients with decompensated liver damage.As a consequence, in patients with concomitant viral hepatitis B when the drug is withdrawn Zidovudine + Lamivudine should monitor the performance of functional hepatic samples and regularly determine the level of replication of viral hepatitis B for 4 months.
In patients with initially existing impairments of liver function, including an active form of chronic hepatitis, there is an increase in the incidence of liver function abnormalities in combination antiretroviral therapy. Such patients need to be monitored in accordance with standard clinical practice. It is necessary to consider the possibility of suspending or stopping treatment in the event of a worsening of liver disease in such patients.
Co-infection of HIV and viral hepatitis C
The aggravation of anemia was observed with the combined administration of ribavirin and zidovudine, although the mechanism of development of this phenomenon remains unclear. Thus, simultaneous use of ribavirin and zidovudine is not recommended, especially in patients with a history of zidovudine-induced anemia. In these cases, it is recommended to consider the possibility of regime change Apt with the goal of reversing zidovudine.
Diseases of the liver
The safety and effectiveness of zidovudine have not been established in patients with severe concomitant liver disease. Patients with chronic hepatitis B or C receiving combination antiretroviral therapy are at increased risk of developing serious and potentially leading to the death of unwanted reactions from the liver. In case of concomitant antiviral therapy for the treatment of hepatitis B or C, also refer to the relevant instructions for use for the medications used.
Mitochondrial dysfunction
Research in vitro and in vivo showed that the analogues of nucleosides and nucleotides can cause a different degree of damage to the mitochondria. Mitochondrial dysfunction was observed in HIV-negative children who received intrauterine and / or post-nucleoside analogues. The main undesirable reactions were hematologic disorders (anemia, neutropenia), metabolic disorders (hyperlactatemia, hyperlipazemia). These undesirable reactions are often transient. Some neurological disorders with late onset have been reported (hypertension, seizures,impaired behavior). Whether neurological disorders are transient or persistent is currently unknown. Any child, even HIV-negative, who has undergone intrauterine exposure to nucleoside and nucleotide analogues, must undergo a clinical and laboratory examination in order to exclude mitochondrial dysfunction in case of revealing the relevant signs or symptoms. The data described do not affect the current national Apt in pregnant women, for the prevention of vertical transmission of HIV infection.
Osteonecrosis
Although the etiology of this disease is multifactorial (including corticosteroids, alcohol consumption, severe immunosuppression, high body mass index), cases of osteonecrosis were most often seen in patients at a late stage of HIV infection and / or long-term combined Apt. Patients should consult a doctor if they experience pain and joint stiffness or difficulty in moving.