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McGill
University Health Centre (Montreal Chest Institute)
HIV
AMBULATORY CARE ROTATION
Site:
McGill
University Health Centre
Montreal
Chest Institute
3650
rue St-Urbain
Montreal,
Quebec
H2X
2P4
The
immunodeficiency service of the Montreal Chest Institute
serves approximately 850 HIV - infected patients. It is
amongst one of the largest HIV ambulatory care clinics in
the province
of Quebec. The Montreall Chest Institute is also specialized
in tuberculosis.
The
population treated includes people living
with HIV / AIDS
who have various risk factors: endemic, MSM
(men having sex
with men), IV drug users (coinfected Hep C / HIV), and heterosexual
men and women. Most patients referred to the
pharmacist for pharmaceutical care are refugees
from Africa (Burundi, Congo,
Rwanda, Cameroon, Zimbabwe) and Haiti. Cultural, economic,
psycho-social, emotional, and linguistic barriers are important
issues that play a huge role in the management of these patients.
Many of these patients are also co-infected with tuberculosis.
An
interdisciplinary team approach is provided
to patients. The medical staff includes
infectious disease specialists, immunologists, general practitioners
with an interest for HIV patient care and a
tuberculosis specialist.
The team also includes nurses (outreach nurse for IV drug users,
research nurses and clinical nurses), a dietitian, a social
worker, a psychiatrist and a psychologist. Since August 2002,
a pharmacist offers pharmaceutical care to HIV - infected
patients on a full-time basis.
The
Immunodeficiency Service also conducts a
1-800 hotline for
HIV disease and drug related queries. Physicians,
pharmacists
and nurses from across the province of Québec consult the
Immunodeficiency Service hotline. The clinic`s pharmacist
is responsible for answering most of the drug-related queries
in a timely manner.
The
Immunodeficiency Service is an ambulatory
clinic. However,
twice weekly, HIV medical rounds of hospitalized HIV - infected
patients are conducted. The physician on call, pharmacist
and nurse attend.
The
Quebec division of the Canadian HIV / AIDS Trial Network
is located at the Montréal Chest Institute. Clinical studies
and fundamental research on HIV are ongoing. Specific
research interests include protease inhibitor boosted
regimens, viral
resistance to antiretrovirals in primo-infection and in later
stages of the disease, hepatitis C / HIV co-infected
patients,
cytokines and interleukins, immunopharmacology, and viral
strains from endemic countries. Eventually, research
interests will also focus on therapeutic drug monitoring
of antiretrovirals.
Preceptor:
Nancy
Sheehan, M.Sc.Pharm
HIV
pharmacotherapy specialist
Immunodeficiency
Service
Montreal
Chest Institute
tel:
(514) 934-1934, ext 32546
Fax:
(514) 849-1709
e-mail: nancy.sheehan@muhc.mcgill.ca
Pager:
(514) 406 - 3379
Duration
of rotation: 4 weeks
The
resident must be comfortable speaking French as 70 %
of the clinic patients are French. All interventions with
the team and all written notes, however, can be done
in English.
Goals:
The
resident will be asked to apply the pharmaceutical care model
to HIV ambulatory patient care.
1)
To increase the resident`s knowledge on antiretrovirals and
other medications used for the management of opportunistic
infections and complications related to HIV / AIDS.
2)
To increase the resident`s ability to identify, manage and
monitor drug-related problems seen in HIV - infected patients
and collaborate, when necessary, with other health professionals.
3) To
increase the resident`s awareness of cultural, psycho-social,
economic, emotional, legal and ethical issues which accompany
HIV infection.
Objectives:
By
the end of the rotation, the student will be able to:
-Discuss the current recommendations for the
management of HIV in the adult population.
-Disease
process: transmission risk factors and preventative measures,
natural history of infection, laboratory measures monitored,
clinical presentation, epidemiology
-Pharmacotherapy: when
to start and change therapy, choosing an initial and salvage
antiretroviral regimen, individualizing therapy
-Monitoring:
monitoring of efficacy and adverse drug reactions, goals of
antiretroviral therapy, virologic and immunologic failure
-Discuss
the current recommendations for the management of the most
common opportunistic infections (primary prophylaxis, secondary
prophylaxis and treatment) and complications seen in advanced
AIDS.
-
Pneumocystis carinii pneumonia
-
Toxoplasmosis gondii encephalitis
-
Oral and esophageal candidiasis
-
Herpesvirus infections
-
Mycobacterium avium complex
-
Tuberculosis in the HIV infected population
-
Cryptococcal meningitis
-
AIDS dementia
-
Lymphoma
-
Progressive multifocal leukoencephalopathy (PML)
-
HIV nephropathy
-
Discuss the pharmacologic properties of the antiretrovirals
(nucleoside / nucleotide reverse transcriptase inhibitors,
non-nucleoside reverse transcriptase inhibitors, protease
inhibitors, investigational drugs) and medications used
for
the prophylaxis and treatment of opportunistic infections.
- Mechanism of action, efficacy
-
Indications, contraindications
-
Pharmacokinetics
-
Doses
-
Food and liquid requirements
-
Adverse drug reactions
-
Drug - drug and drug - food interactions
-
Protease inhibitor boosting
-
Therapeutic drug monitoring of antiretrovirals
-
Viral resistance patterns
-
Availability / Reimbursement in the province of Quebec
-
Contrast the advantages and disadvantages of the antiretrovirals
and medications used for the management of opportunistic
infections. For a given patient, justify your choice in
treatment.
-
Discuss the management of common adverse drug reactions induced
by the antiretrovirals.
-
GI upset (nausea, vomiting, diarrhea)
-
Peripheral neuropathy
-
Pancreatitis
-
Myelosuppression (anemia, thrombocytopenia, neutropenia)
-
Hyperlactatemia, lactic acidosis
-
Dyslipidemia
-
Glucose intolerance
-
etc.
-
Counsel patients on new antiretroviral regimens.
-
Counselling will include goals of therapy, medication schedule,
food and liquid requirements, storage recommendations,
possible
adverse drug reactions, risk of interactions, importance
of complete adherence.
-
For a given patient, identify barriers to adherence and
offer
tools to help improve adherence.
-
Identify drug - related problems and develop an individualized
plan to manage these drug - related problems.
-
Collect pertinent disease, drug and patient information
from
the patient`s chart and by interacting with the patient
-
Identify actual and potential drug - related problems
-
Prioritize the drug - related problems
-
For each drug-related problem, provide appropriate recommendations
for the management of the problem and communicate a management
plan to the medical team and to the patient
-
Develop a monitoring plan for the intervention, including
efficacy and toxicity endpoints
-
Follow through with the monitoring plan by meeting with the
patient at the clinic or by doing regular telephone follow-ups
-
Provide appropriate and concise drug information in a timely
manner to patients and health professionals who have queries
on the management of HIV and opportunistic infections.
-
Act as a responsible, mature, professional and motivated member
of the interdisciplinary team.
Other
activities
Other
than direct pharmaceutical care, the resident will be asked
to participate in the following:
HIV medical inpatient rounds (twice a week)
-Interdisciplinary
psycho-social meetings (every Thursday 8h30 - 10h00)
-HIV rounds (once a month)
-Research meetings (once a month)
-HIV team meetings (once a month)
The resident
will also be asked to give one presentation at the HIV rounds
and will be asked to do 1 or 2 short written projects.
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