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Optimising paediatric antiretroviral therapy

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On 25 October, Medical Academic and Activo Health were proud to host a webinar about paediatric ARV protocols, presented by subject expert Dr Leon Levin.

The first question we must answer is ‘Why would you want to optimise ARV treatments?” Dr Levin said. “That’s simple: we get better viral suppression, and the new treatments improve adherence, providing better tolerance, a reduced pill burden, and once-daily dosing.” However, the general attitude among clinicians is that ARV regimens do not have to be changed if the current regimens are working. “Yet we upgrade our phones every two years, not because the old one has stopped working, but because a new one offers improvements,” Dr Levin said. “Unfortunately we don’t take the same approach to ARVs.”

NEW FORMULATIONS

New paediatric formulations, as well as updated guidelines for the management of paediatric HIV, present just such an opportunity to upgrade our approach to ARV therapy. The new formulations include abacavir/lamivudine 120/60 (ABC/3TC) combination therapy. Until recently, this formulation was only available in 600/300 tablets for adults or children who weigh more than 25kg. “This formulation can be swallowed, crushed, chewed or dissolved in water,” Dr Levin said. Another formulation that has been making waves is paediatric dolutegravir, available in 10mg scored dispersible tablet form. This can be given to children who are four weeks and older and weigh at least 3kg. It can be added to water, milk or soft foods, can be swallowed whole but cannot be chewed or crushed.

“Surprisingly, the new formulation is not bioequivalent to the old 50mg tablets,” Dr Levin said. “In fact, 30mg of the new formulation is equal to one of the old 50mg doses.” This implies that the new formulation is more potent by a factor of 1.6, an important point since it means the two formulations are not interchangeable, and if one does switch from one to the other dosages have to be adjusted appropriately.

PRIVATE SECTOR

In the private sector, no new ARV guidelines have been published since 2009. “For this reason, the private sector relies on the National Department of Health’s ARV guidelines, with modifications since there are formulations available in the private sector that the public sector doesn’t have access to. In the private sector, a regimen of azithromycin (AZT), 3TC and nevirapine (NVP) is recommended for the treatment of neonates. After they are four weeks old and at least 3kg, they can be placed on a regimen of ABC/3TC and dolutegravir (DTG). As soon as they weigh more than 25kg, children can be given a combination of tenofovir alafenamide (TFA), emtricitabine (FTC) and DTG, known as TAFED. This combination is currently only available for private patients.

But what’s the treatment protocol like in the public sector? Can paediatric patients on third-line regimens also receive optimised therapy? Have the side effect profiles improved at all? To find out, watch our recording of the webinar here https://vimeo.com/event/3770738 and earn 1 CPD point.

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