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Leitliniennachkonsens05:07:08

Leitlinien der Deutschen Gesellschaft für Suchtmedizin
(DGS e.V.), der Deutschen AIDS-Gesellschaft (DAIG) und
der Deutschen Arbeitsgemeinschaft niedergelassener Ärzte
(DAGNÄ):
HIV-Infektion bei intravenös Drogenabhängigen

Konsensustext zur Abstimmung am 5. Juli 2008 auf dem 9. Interdisziplinären Kongress für Suchtmedizin in München Mitglieder der ArbeitsgruppeMarkus BackmundJohannes BognerJürgen RockstrohJörg Gölz Ramona Pauli-Volkert Zu den folgenden Fragen sollte Stellung bezogen werden: 1. Wie hoch sind Prävalenz und Inzidenz der HIV-Infektion unter IVDA? 3. Wann sollen IVDA mit einer HIV-Infektion antiretroviral behandelt werden? 4. Gibt es Besonderheiten bei der Initialtherapie? 5. Wie soll bei psychiatrischer Komorbidität vorgegangen werden? 6. Welche Wechselwirkungen sind zu beachten? 7. Gibt es speziell zu beachtende Nebenwirkungen? Tabelle: Evidenzgrade zur Bewertung von Studien - Empfehlungsklasse A Ia Evidenz aufgrund von Metaanalysen randomisierter, kontrollierter Studien Ib Evidenz aufgrund von mindestens einer randomisierten, kontrollierten Studie IIa Evidenz aufgrund von mindestens einer gut angelegten, kontrollierten Studie IIb Evidenz aufgrund mindestens einer anderen Art von gut angelegter, quasiexperimenteller III Evidenz aufgrund gut angelegter, nichtexperimenteller, deskriptiver Studien wie z. B. Vergleichsstudien, Korrelationsstudien und Fallkontrollstudien IV Evidenz aufgrund von Berichten von Expertenausschüssen oder Expertenmeinungen und/oder klinischen Erfahrungen anerkannter Autoritäten; Fehlen direkt anwendbarer klinischer Studien guter Qualität Der Textentwurf wurde aufgrund der Literaturrecherche, den Vorträgen und Diskussionsbeiträgen des Expertentreffens am 5. April 2008 in Köln von der Arbeitsgruppe und den von den Experten zu verschiedenen Themen publizierten Artikel formuliert.
Vorträge auf der Expertentagung zur Erstellung der Leitlinien für HIV bei Drogenkonsumenten Differentialtherapie bei psychiatrischer Komorbidität Publizierte Artikel der Experten in Suchtmedizin in Forschung und Praxis 2008; 10 (S1): Diagnostik bei HIV-infizierten i.v. Drogenkonsumenten Differentialtherapie bei psychiatrischer Wechselwirkungen zwischen antiretroviraler Therapie (ART) Nebenwirkungen der antiretroviralen Therapie bei Management von opioidabhängigen Patienten Dem Text liegen nachstehende Definitionen und Begriffe zugrunde: „intravenös Drogenabhängige“ (IVDA) meint alle Patienten, die früher intravenös Drogen konsumiert haben oder aktuell konsumieren.
Definition von integriertem Setting: intaktes Netzwerk von psychiatrisch und infektiologisch erfahrenen Suchtmedizinern möglichst an einem Ort.
Hinsichtlich der Diagnostik und Therapie der HIV-Infektion werden die jeweils bestehenden Deutsch-Österreichischen Leitlinien sowie die europäischen Leitlinien der European AIDS Clinical Society zur Behandlung der HIV-Infektion bei Erwachsenen zu Grunde gelegt. Bei Initialtherapie werden derzeit die europäischen Leitlinien herangezogen.
1Wie hoch sind Prävalenz und Inzidenz der HIV-Infektion unter IVDA? Welche Präventionsmassnahmen sind sinnvoll? Empfehlung
Die Aufklärung von IVDA über die Verhinderung von HIV- und Hepatitis B und C-Infektionen muss sowohl „safer use“ als auch „safer sex“ beinhalten Eine niedrigschwellige Verfügbarkeit von sterilen Injektionsutensilien wie z.B. über Nadel- Spritzen-Austauschprogramme reduziert die HIV-Inzidenz unter Drogenabhängigen und sollte flächendeckend und auch in Haftanstalten angeboten werden (A).
Die Substitutionsbehandlung verhindert HIV-Neuinfektionen unter IVDA und soll als Kassenleistung flächendeckend angeboten werden (A). Konsens: 1. Satz 100%, 2. Satz 96,2%, 3. Satz 100% Repräsentative nationale oder regionale Studien zur Prävalenz und Inzidenz von Infektionen mit HIV und Hepatitis B- und C-Viren bei IVDU wurden in Deutschland bislang nicht durchgeführt. Alle Daten zur Prävalenz und Inzidenz beziehen sich daher auf mehr oder weniger stark selektierte Subpopulationen oder es handelt sich um Schätzungen.
Die Angaben zur HIV-Prävalenz unter IVDA sind je nach Untersuchungspopulation und Region sehr unterschiedlich (A). In Deutschland betragen sie zwischen 5% in München und 50% in Das Robert Koch-Institut schätzt die Gesamtzahl der aktuell mit HIV in Deutschland lebenden Personen, die sich im Kontext von intravenösem Drogenkonsum mit HIV infiziert haben, auf derzeit ca. 7.000 Personen. Der Nenner, auf den diese Zahl bezogen werden müsste, ist nicht klar quantifizierbar. Nicht alle Personen, die sich im Kontext von intravenösem Drogenkonsum mit HIV infiziert haben, sind auch aktuell noch aktive Drogenkonsumenten, und zur Gesamtzahl der aktiv intravenös Drogen konsumierenden Personen in Deutschland liegen unterschiedliche Schätzungen vor. Die Zahl der HIV-Neuinfektionen pro Jahr, die auf intravenösen Drogenkonsum zurückzuführen sind, wird auf aktuell knapp über 200 geschätzt. Ein Teil dieser Infektionen könnte allerdings auch durch sexuelle Übertragungen bedingt sein.
In besonders stark betroffenen Regionen osteuropäischer Länder wurden in lokalen Populationen von aktiven Drogenkonsumenten HIV-Prävalenzraten von bis zu über 90% beschrieben (B).
Weltweit betreffen 10% aller HIV-Neuinfektionen IVDU, in Deutschland sind es aktuell ca. 7% (B). In osteuropäischen und asiatischen Ländern wird die HIV-Epidemie wesentlich durch IVDA Weltweit wird die Zahl von IVDA auf 13 Millionen Menschen geschätzt (Aceijas et al. 2004). HIV-Epidemien, die durch IVDA vorangetrieben werden, sind vor allem in Osteuropa, Zentralasien, Südostasien und China zu beobachten (Platt et al. 2006, UNAIDS 2006, Dehne et al. 1999). In Deutschland ist die Gruppe der IVDA seit mehr als 10 Jahren mit 13% die viertgrößte Gruppe hinsichtlich Neuinfektionen (Hamouda et al. 2007). Das gemeinsame Benutzen von Nadeln und Spritzen birgt das größte Risiko einer HIV-Transmission bei IVDA und kann effektiv durch Spritzen und Nadel-Austauschprogramme vermindert werden (Johnson et al. 2002, WHO 2007). Zusätzlich sind IVDU durch sexuelle Übertragung des HI-Virus gefährdet, insbesondere dann, wenn sich die HIV-Infektion in der IVDU-Population etabliert hat und/oder durch erhöhtes Risikoverhalten nach Drogeneinnahme (Backmund et al. 2005, DesJarlais et al. 2005, Bolding et al. 2006, RKI 2006, Neaigus et al. 2007, Marcus 2008). Backmund M, Meyer K, Henkel C, Reimer J, Wächtler M, Schütz CG. Risk factors and predictors of human immunodeficiency virus infection among injection drug users. Eur Addict Res 2005; Bolding G, Hart G, Sherr L et al. Use of crystal methamphetamine among gay men in London. Dehne, K. L., L. Khodakevich, et al. (1999). "The HIV/AIDS epidemic in eastern Europe: recent patterns and trends and their implications for policy-making." AIDS 13(7): 741-9.
Des Jarlais DC, Perlis T, Arasteh K, Torian LV, Hagan H, Beatrice S, Smith L, Wethers J, Milliken J, Mildvan D, Yancovitz S, Friedman SR. Reductions in hepatitis C virus and HIV infections among injecting drug users in New York City, 1990-2001. AIDS 2005 Oct;19 Suppl 3:S20-5 Hamouda O, Marcus U, Voß L, Kollan C. Verlauf der HIV-Epidemie in Deutschland. Bundesgesundheitsbl 2007; 50: 399-411.
Johnson RA, Gerstein DR, Cerbone FG, Brown J. HIV risk behaviors in African-American drug injector networks: implications of injection-partner mixing and partnership characteristics. Marcus U. Epidemiologie bei i.v.-Drogenkonsumenten. Suchtmed 2008; 10 (S1): in Druck.
Neaigus A, Gyarmathy VA, Miller M, Frajzyngier V, Zhao M, Friedman SR, Des Jarlais DC. Injecting and sexual risk correlates of HBV and HCV seroprevalence among new drug injectors. Platt L, Bobraca N, Rhodes T, Uuskula A, Parry JV, Ruutel K, Talu A, Abel K, Rajaleid K, Judd A. High HIV prevalence among injecting drug uses in Estonia: implications for understanding the risk environment. AIDS 2006; 20: 2120-2123.
RKI - Robert Koch Institut. Epidemiologisches Bulletin 2006; 47: 411-426.
UNAIDS (Joint United Nations Programme on HIV/AIDS). 2006 Report on the Global AIDS Epidemic: A UNAIDS 10th anniversary special edition. Geneva, Switzerland: UNAIDS 2006.
WHO. HIV/AIDS Treatment and Care – Clinical protocols for the WHO European Region. Empfehlung
Die Anamnese muss die Einnahme psychotroper Substanzen im Verlauf beinhalten (A).
Die Anamnese muss den aktuellen Konsum psychotroper Substanzen beinhalten (A).
Psychische Beschwerden müssen wegen der hohen Komorbidität psychiatrischer Krankheiten Es muss überprüft werden, ob sich die Patientin/der Patient in einer Substitutionsbehandlung Die Angaben sollten durch ein Drogenscreening im Urin verifiziert werden (A).
Beim Erstkontakt muss der Hepatitis A-, Hepatitis B- und Hepatitis C- Status überprüft werden Patienten mit HIV-Infektion haben gemäß den Empfehlungen der STIKO eine Indikation für die Impfung gegen Hepatitis A und B sowie Pneumokokken, Menigokokken und Influenza (A).
Einmal jährlich muss der Hepatitis C- Status überprüft werden (A). Bei nicht oder nicht ausreichend Geimpften und noch Suszeptiblen muss der Hepatitis A- und B- Status einmal Konsens: 1. – 4. Satz, 7., 8. Satz jeweils 100%, 5., 6.Satz 92% Prinzipiell soll gemäß den bestehenden HIV-Leitlinien diagnostiziert werden, die in der Regel eine umfassende Anamnese und die Erhebung des körperlichen und psychischen Status beinhalten (Deutsch-Österreichische AIDS-Gesellschaft 2008, Panel on Antiretroviral Guidelines for Adults and Adolescents 2008). IVDA leiden sehr häufig zusätzlich an psychiatrischen Erkrankungen (Krausz 2008, Krausz et al. 1998).
Deutsche und Österreichische AIDS-Gesellschaft. Deutsch-Österreichische Leitlinien zur antiretroviralen Therapie der HIV-Infektion (Teilaktualisierung Indikationsstellung, Stand Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Sciences. January 29, 2008; 1-128.
Krausz M, Degkwitz P, Kuhne A, Verthein U. Comorbidity and mental disorders. Addict Behav Krausz M. Differentialtherapie bei IVDA. Suchtmed 2008; 10: in Druck.
Schmutz G. Diagnostik bei HIV-infizierten i.v. Drogenkonsumenten. Suchtmed 2008; 10 (S1): in 3Wann sollen IVDA mit einer HIV-Infektion antiretroviral behandelt werden? Empfehlung
Ehemalige IVDA und IVDA, die sich in einer stabilen Substitutionsbehandlung befinden, sollen nach den gleichen Kriterien und zum gleichen Zeitpunkt wie Nicht-IVDA eine antiretrovirale Bei IVDA, die sich in einer nicht stabilen Substitutionsbehandlung befinden (Termine nicht zuverlässig einhalten können, unregelmäßig kommen) soll vor einer antiretroviralen Therapie u.a. mit Hilfe der psychosozialen Betreuung versucht werden, die Patientin/den Patienten in eine stabile Substitutionsbehandlung zu bringen (A). IVDA, die keine Substitutionsbehandlung erhalten, sollen vor Beginn einer HIV-Therapie in eine stabile Substitutionsbehandlung gebracht werden (A). IVDA, die eine HIV-Therapie wünschen, bei denen die Indikation zu einer solchen besteht und die keine Substitutionsbehandlung wünschen, ist eine HIV-Therapie anzubieten (A).
Alle anerkannten Behandlungsrichtlinien empfehlen für IVDA keinen abweichenden Behandlungszeitpunkt für den Beginn einer antiretroviralen Therapie (ART) (European AIDS Clinical Society 2007, (Deutsch-Österreichische AIDS-Gesellschaft 2008, Panel on Antiretroviral Guidelines for Adults and Adolescents 2008, WHO 2007). Sie weisen darauf hin, dass eine gute Therapieadhärenz angestrebt werden soll (Deutsch-Österreichische AIDS-Gesellschaft 2008, Panel on Antiretroviral Guidelines for Adults and Adolescents 2008, WHO 2007). Das beste Setting für die Behandlung chronischer Erkrankungen bei IVDA stellt die Substitutionsbehandlung dar (Backmund et al. 2001, Backmund et al. 2005, Backmund 2007). Allen HIV-Patienten soll bei entsprechender Indikation eine HIV-Therapie angeboten bzw. ermöglicht werden (WHO 2007, Panel on Antiretroviral Guidelines for Adults and Adolescents In der Fachwelt ist unbestritten, dass ein Immunstatus mit weniger 200 CD4-Zellen/µl eine dringliche Indikation zur antiretroviralen Therapie darstellt (Übersicht bei Hoffmann et al. 2007, Huber 2008, Deutsch-Österreichische AIDS-Gesellschaft 2008). Symptomatische Patientinnen und Patienten und schwangere Patientinnen sollten unabhängig von der CD4-Zellzahl therapiert werden, wobei eine opportunistische Infektion in der Regel vor Beginn der antiretroviralen Therapie behandelt werden muss, um ein Immunrekonstitutions-Syndrom (IRIS) zu verhindern. >55Jahre oder CD4-Abfall >50-100/µl/Jahr CDC A Quelle: European AIDS Clinical Society 2007 Backmund M, Meyer K, von Zielonka M, Eichenlaub D. Treatment of hepatitis C infection in injection drug users. Hepatology 2001a 34: 188-193.
Backmund M, Meyer K, Henkel C, Reimer J, Wächtler M, Schütz CG. Risk factors and predictors of human immunodeficiency virus infection among injection drug users. Eur Addict Res 2005; Backmund M. Ansprechbarkeit von Drogengebrauchern über Infektionsrisiken für HIV und HCV. Opioidabhängigkeit und HIV-Infektion. Bundesgesundheitsbl 2007; 50: 471-475.
Deutsche und Österreichische AIDS-Gesellschaft. Deutsch-Österreichische Leitlinien zur antiretroviralen Therapie der HIV-Infektion (Teilaktualisierung Indikationsstellung, Stand European AIDS Clinical Society (EACS): Guidelines 2007. Guidelines for the Clinical Management and Treatment of HIV Infected Adults in Europe.
Hoffmann C, Rockstroh J, Kamps B. HIV.NET 2007. Steinhäuser Verlag. Wuppertal-Beyenburg Huber M. Strategien zur Ersttherapie. Suchtmed 2008; 10 (1S): in Druck.
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Sciences. January 29, 2008; 1-128.
WHO. HIV/AIDS Treatment and Care – Clinical protocols for the WHO European Region. 4Gibt es Besonderheiten bei der Initialtherapie? Empfehlung
Bei der Auswahl des antiretroviralen Therapieregimes ist die Adhärenz des Patienten/in zu Bei IDVA ohne stabile Substitution soll ein ART-Regime gewählt werden, dass nur einmal täglich Die ART sollte direkt vor dem Substitutionsmittel unter Sicht des Arztes/medizinischen Konsensus: 1., 2. Satz 100%, 3. Satz 88,6% Da während der Substitutionsbehandlung in der Regel die Patientinnen und Patienten täglich vom Arzt oder dem medizinischen Personal gesehen werden, kann eine Koppelung der Einnahme der ART an die Substitutionsmittelvergabe zu einer sehr hohen Adhärenz führen (Backmund et al. 2001, , Conway et al. 2004, Lucas et al. 2004, Altice et al. 2007, Backmund 2008, Medikamente für die HIV-Therapie bei Opioidabhängigen (aus Backmund 2008) 1bei vorbehandelten Patienten; 2 Boostern mit je 100 mg RTV; 3 nur bei CCR5-Tropismus Die europäischen Leitlinien zur antiretroviralen Initialtherapie empfehlen Tenofovir und Emtricitabin oder Abacavir und Lamivudin in Kombination mit Efavirenz oder Nevirapin oder geboostertem Fosamprenavir oder Lopinavir oder Saquinavir (European AIDS Clinical Society 2007). Bei Patienten mit replikativer Hepatitis B sollte Tenofovir/Emtricitabin Bestandteil der Altice FL, Maru DS, Bruce RD, Springer SA, Friedland GH. Superiority of directly administered antiretroviral therapy over selfadministered therapy among HIV-infected drug users: a prospective, randomized, controlled trial. Clin Infect Dis 2007; 45: 770-778.
Backmund M, Meyer K, von Zielonka M, Eichenlaub D. Treatment of hepatitis C infection in injection drug users. Hepatology 2001a 34: 188-193.
Backmund M. Heroinabhängigkeit – Hepatitis C – HIV. Ecomed-verlag 2008, in Druck Conway B, Prasad J, Reynolds R, Farley J, Jones M, Jutha S, Smith N, Mead A, DeVlaming S. Directly observed therapy fort he management of HIV-infected patients in a methadone program. Clin Infect Dis 2004; 38 Suppl5: S402-S408.
European AIDS Clinical Society (EACS): Guidelines 2007. Guidelines for the Clinical Management and Treatment of HIV Infected Adults in Europe.
Lucas GM, Mullen BA, McCaul ME, Weidle PJ, Hader S, Moore RD. Adherence, drug use, and treatment failure in a methadone-clinic-based program of directly admininistered antiretroviral therapy. AIDS Patient Care STDS 2007; 21: 564-574.
Viciana P, Rubio R, Ribera E, Knobel H, Iribarren JA, Arribas JR, Pérez-Molina JA; Investigadores del Estudio CUVA. Enferm Infecc Microbiol Clin 2008; 26: 127-134.
5Wie soll bei psychiatrischer Komorbidität vorgegangen werden? Empfehlung
Der bei der initialen Diagnostik erhobene psychopathologische Befund soll im Verlauf Psychiatrische Erkrankungen wie bipolare Störungen und Erkrankungen aus dem schizophrenen Formenkreis müssen medikamentös und psychotherapeutisch behandelt werden (A).
Antidepressiva der ersten Wahl sind SSRI, insbesondere Citalopram und Escitalopram (C).
Zur Behandlung der Schizophrenie sollten primär atypische Neuroleptika eingesetzt werden (C).
Konsens: 1. Satz 96,2%, 2. Satz 92,3%, 3. Satz 87%, 4. Satz 85,7% IVDA leiden sehr häufig zusätzlich an psychiatrischen Erkrankungen (Krausz 2008, Krausz et al. 1998). Inwieweit Antidepressiva und/oder Neuroleptika bei gleichzeitiger Gabe von Opioiden wirken, ist noch kaum untersucht worden. Die wenigen Studien kommen zu unterschiedlichen Ergebnissen. Citalopram allein oder in Kombination mit Bupropion scheint bei mit Methadon behandelten Patienten hinsichtlich der Therapie der Depression nicht erfolgreich zu sein (Poling et al. 2007). Eine ältere Arbeit zeigte keine Wirkung von Fluoxetin in der Therapie depressiver Patienten während einer Methadonsubstitutionsbehandlung (Petrakis et al. 1998). Eine neuere Arbeit konnte hingegen zeigen, dass eine Reduktion des Benzodiazepinkonsums bei Steigerung der Psychopharmakotherapie zu einer Verminderung der depressiven Symptomatik bei mit Methadon behandelten Patienten führte (Schreiber et al. 2008). Auch für die Behandlung suchtkranker Menschen, die zusätzlich an einer Psychose erkrankt sind, liegen praktisch keine randomisierten Studien vor. Empfohlen wird der Einsatz von atypischen Neuroleptika, z.B. von Clozapin und Quetiapin (Potvin et al. 2006, San et al. 2007, Hanley et Kenna 2008).
Hanley MJ, Kenna GA. Quetiapine: treatment for substance abuse and drug or abuse. Am J Health Syst Pharm 2008; 65: 611-618.
Petrakis I, Carroll KM, Nich C, Gordon L, Kosten T, Rounsaville B. Fluoxetine treatment of depressive disorders in methadone-maintined opioid addicts. Drug Alcohol Depend 1998; 50: Poling J, Przuinsky R, Kosten TR, Gonsai K, Sofuoglu M, Gonzalez G, Oliveto A. Clinical efficacy of citalopram alone or augmented with bupropion in methadone-stabilized patients. Am Potvin S, Stip E, Lipp O, Elie R, Mancini-Marie A, Demers MF, Roy MA, Bouchard RH, Gendron A. Quetiapine in patients with comorbid schizophrenia-spectrum and substance use San L, Arranz B, Martinez-Raga J. Antipsychotic drug treatment of schizophrenic patients with substance abuse disorders. Eur Addict Res 2007; 13: 230-243.
Schreiber S, Peles E, Adelson M. Association between improvement in depression, reduced benzodiazepine (BZD) abuse, and increased psychotropic medication use in methadone maintenance treatment (MMT) patients. Drug Alcohol Depend 2008; 92: 79-85.
6Welche Wechselwirkungen sind zu beachten? Empfehlung
IVDA, die im Rahmen einer Substitutionsbehandlung antiretroviral behandelt werden, müssen engmaschig auf Entzugs- und/oder Intoxikationssymptome beobachtet werden (A). Bei Auftreten von Entzugs- und/oder Intoxikationssymtomen muss die Dosis des Substitutionsmittels angepasst werden (A).
Sowohl Methadon als auch Buprenorphin werden über das Cytochrom P450-System metabolisiert. Bei der HIV-Therapie müssen daher die Interaktionen von Methadon und Buprenorphin beachtet werden. Es kann zu Enzyminduktion und Enzyminhibition kommen. Je nachdem kann dies dazu führen, dass das eine Medikament überdosiert und das andere unterdosiert ist (Übersicht bei Klinker 2008, Tabelle 1 und 2). Vor allem die Wechselwirkungen zwischen Methadon und den beiden Nicht Nukleosidischen Reverse Transkriptase Inhibitoren (NNRTI) Efavirenz und Nevirapin müssen berücksichtigt werden. Pharmakologische und klinische Studien haben gezeigt, dass es zu einer deutlichen Wirkminderung von Methadon kommen kann (Altice et al. 1999, Ottero et al. 1999, Clarke et al. 2001, Marzolini et al. 2000, Clarke et al. 2001). Dadurch können nach wenigen Tagen Entzugssymptome entstehen. Um diese zu verhindern, muss die Methadondosis teilweise um bis zu 50% gesteigert werden (Ottero et al. Tabelle 1:
Metabolismus von Opioid-Agonisten und antiretroviralen Substanzen (Klinker 2008) Nukleosidische Reverse
Transkriptase Inhibitoren
Nicht Nukleosidische Reverse
Transkriptase Inhibitoren
Protease-Inhibitoren
Fusions-Inhibitoren
CCR5-Korezeptor-Inhibitoren
Integrase-Inhibitoren
Opioid-Agonisten
Tabelle 2:
Interaktionen zwischen antiretroviralen Wirksubstanzen und Opioid-Aganisten (Ø = kein Effekt, n. u. = nicht untersucht, Cmax = maximale Konzentration, AUC = Area under Curve = Fläche unter der Konzentrations-Zeit-Kurve, NRTI = Nukleosidischer Reverse Transkriptase Inhibitor, NNRTI = Nicht Nukleosidischer Reverse Transkriptase Inhibitor, PI = Protease-Inhibitor, FI = Fusions- Inhibitor, CCR5-I = CCR5-Korezeptor-Inhibitor, II = Integrase-Inhibitor) (Klinker 2008) ART-Substanz
Effekt auf
Effekt auf BUP Effekt auf ART-
Kommentar
Methadon
Substanz
Altice FL, Friedland GH, Cooney EL. Nevirapine induced opiate withdrawal among injection drug users with HIV infection receiving methadone. AIDS 1999; 13: 957-962 Clarke SM, Mulcahy FM, Tjia J et al. The pharmacokinetics of methadone in HIV-positive patients receiving the non-nucleoside reverse transcriptase inhibitor efavirenz. Br J Clin Khara M, McLean M, Duncan F et al. Methadone dosing strategies in HIV-infected injection drug users enrolled in a directly observed therapy program. J AIDS 2007; 45: 324-327.
Klinker H. Wechselwirkungen zwischen antiretroviraler Therapie (ART) und Substitutionsmedikamenten. Suchtmed 2008; 10 (S1): in Druck.
Marzolini C, Troillet N, Telenti A et al. Efavirenz decreases methadone blood concentrations. Ottero MJ, Fuertes A, Sanchez R et al. Nevirapine-induced withdrawal symptoms in HIV patients on methadone maintenance programme: an alert. AIDS 1999; 13: 1004-1005 7Gibt es speziell zu beachtende Nebenwirkungen? Empfehlung
Die frühen Nebenwirkungen sind bei der Therapie von IVDU ähnlich wie bei anderen Patienten Die Hepatotoxizität verschiedener HIV-Medikamente muss vor allem bei den sehr häufig HCV- koinfizierten IVDU berücksichtigt werden (C).
Konsensus: 1. Satz 95,8%, 2. Satz 100%.
Generell wurde in den letzten Jahren darauf geachtet, die Nebenwirkungen zu therapieren um die Adhärenz zu erhöhen. 90% der HIV-infizierten IVDU sind HCV-koinfiziert. ( ). Ob bestimmte Medikamente wie zum Beispiel Nevirapin oder aber die HIV-Therapie insgesamt die Progression einer Leberfibrose bei HIV/HCV –infizierten Patienten begünstigt, unbeeinflusst lässt oder aber verhindert, wird in der wissenschaftlichen Literatur noch kontrovers diskutiert (Macias et al. 2006, Berenger et al. 2008, Macias et al. 2004, Qurishi et al. 2003). Zu berücksichtigen ist, dass die HCV-bedingte Mortalität bei guter Behandlung der HIV-Infektion bei IVDU in den Aceijas C, Oppenheimer E, Stimson GV, Ashcroft RE, Matic S, Hickman M. Antiretroviral treatment for injecting drug users in developing and transitional countries 1 year before the end of the "Treating 3 million by 2005. Making it happen. The WHO strategy" ("3 by 5"). Addiction al-Haddad MK, Khashaba AS, Baig BZ, Khalfan S. HIV antibodies among intravenous drug users in Bahrain. J Commun Dis 1994; 26(3):127-132.
Alexander CS, Dong W, Schechter MT et al. Prevalence of primary HIV drug resistance among seroconverters during an explosive outbreak of HIV infection among injecting drug users. AIDS Aloisi MS, Serraino D, Girardi E et al. Sexual behaviour of women living with HIV/AIDS naive for antiretroviral therapy: the ICONA-BEHEPI Study. AIDS Care 2000; 12(6):789-795.
Altice FL, Friedland GH, Cooney EL. Nevirapine induced opiate withdrawal among injection drug users with HIV infection receiving methadone. AIDS 1999; 13(8):957-962.
Altice FL, Springer S, Buitrago M, Hunt DP, Friedland GH. Pilot study to enhance HIV care using needle exchange-based health services for out-of-treatment injecting drug users. J Urban Altice FL, Springer S, Buitrago M, Hunt DP, Friedland GH. Pilot study to enhance HIV care using needle exchange-based health services for out-of-treatment injecting drug users. J Urban Altice FL, Springer S, Buitrago M, Hunt DP, Friedland GH. Pilot study to enhance HIV care using needle exchange-based health services for out-of-treatment injecting drug users. J Urban Altice FL, Springer S, Buitrago M, Hunt DP, Friedland GH. Pilot study to enhance HIV care using needle exchange-based health services for out-of-treatment injecting drug users. J Urban Altice FL, Springer S, Buitrago M, Hunt DP, Friedland GH. Pilot study to enhance HIV care using needle exchange-based health services for out-of-treatment injecting drug users. J Urban Altice FL, Springer S, Buitrago M, Hunt DP, Friedland GH. Pilot study to enhance HIV care using needle exchange-based health services for out-of-treatment injecting drug users. J Urban Amin J, Kaye M, Skidmore S, Pillay D, Cooper DA, Dore GJ. HIV and hepatitis C coinfection within the CAESAR study. HIV Med 2004; 5(3):174-179.
Amundsen EJ, Fekjaer H. Progression to AIDS slowed even more after the first two years with highly active antiretroviral therapy. Scand J Public Health 2003; 31(4):312-318.
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