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 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 infection 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 (usually secondary due to neutropenia) in patients receiving zidovudine. These phenomena are more often observed with the appointment of high doses of zidovudine (1200-1500 mg / day) in patients in the late 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 a developed clinical picture of HIV infection, blood tests should be monitored at least once every 2 weeks during the first three months of therapy, and then at least once a month.
In patients at an 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 the patient, for example, once every 1-3 months. A special dose of zidovudine may be required if severe anemia or myelosuppression develops during treatment with the drug Zidovudine + Lamivudine, as well as in patients with previous bone marrow suppression, for example, with a hemoglobin level of less than 9 g / dL (5.59 mmol / L) or neutrophil counts of less than 1.0 x 109/ l. Because the individual dose of the drug Zidovudine + Lamivudine It is impossible, it is recommended to use separate preparations of lamivudine and zidovudine.
Pancreatitis
In patients who took lamivudine and zidovudine, 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 the patient has abdominal pain, nausea, vomiting, or increased biochemical markers, the possibility of developing pancreatitis should be considered.Immediately stop taking the drug Zidovudine + Lamivudine until the diagnosis of pancreatitis.
Lactic acidosis and severe hepatomegaly with steatosis
There are reports of the development of lactic acidosis, severe hepatomegaly with steatosis, including fatal outcome due to the use of Apt analogues of nucleosides in the form of separate preparations, including lamivudine or a combination thereof. Similar phenomena were mainly observed in women.
The clinical signs of developing lactic acidosis are general weakness, anorexia, rapid unexplained weight loss, symptoms of gastrointestinal tract damage (nausea, vomiting and abdominal pain) and respiratory system (rapid and / or deep breathing), neurological symptoms (including motor weakness) .
Treatment with nucleoside analogues should be discontinued if symptomatic hyperlactatemia and metabolic acidosis / lactic acidosis develop, 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 steatosis of the liver (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 glucose concentration in the blood, both individually and together.
Although all drugs from HIV classes and NRTIs can cause one or more of the above unwanted reactions associated with a common syndrome, often called lipodystrophy, the accumulated data suggest that there is a difference 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 effects of these side effects are currently unknown. During the clinical examination, attention should be paid to the signs of redistribution of subcutaneous fat. Serum lipids and glucose concentration in the blood should be closely monitored. In violation of lipid metabolism is prescribed appropriate treatment.
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, the conduct of 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 infection caused by mycobacteria, and pneumonia caused by Pneumocystis jiroveci (P.carinii).The appearance of any symptoms of inflammation requires immediate examination and, if necessary, appropriate treatment.
Autoimmune diseases (such as Graves' disease, polymyositis, 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 B recurrence may appear after stopping lamivudine, which may have more severe consequences in patients with uncompensated 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 liver samples and regularly determine the markers of hepatitis B virus replication within 4 months.
In patients with an initially present impaired hepatic function, including an active form of chronic hepatitis, there is an increase in the incidence of liver dysfunction in combination Apt. 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 manifestations of worsening liver disease in such patients.
Co-infection of HIV and viral hepatitis C
The aggravation of anemia was observed with the combined use 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 patients with zidovudine-induced anemia in the anamnesis. In these cases, it is recommended to consider the possibility of regime change Apt with the goal of reversing zidovudine.
Liver diseases:
The efficacy and safety of zidovudine have not been established in patients with severe concomitant liver disease.
In patients with chronic hepatitis B or C, using a combination Apt. the risk of serious and potentially leading to death, unwanted reactions from the liver increases.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, behavioral disorders). Whether these neurological disorders are transient or persistent is currently unknown. Any child, even HIV-negative, exposed to prenatal exposure to nucleoside and nucleotide analogues, must undergo a clinical and laboratory examination in order to exclude mitochondrial dysfunction in case of revealing the corresponding signs or symptoms.These data do not affect the current national recommendations for use 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.