Arv dose protocol
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antiretroviral ARV dosing protocol adults
Use of Antiretroviral Agents in Pediatric HIV Infection
Page 458
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ARV dose HIV treatment regimen first line second line
Use of Antiretroviral Agents in Pediatric HIV Infection
Page 434
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Here is a comprehensive overview of ARV (antiretroviral) dosing protocols for HIV treatment:
ARV Dosing Protocol
Overview
ARV regimens are broadly classified into preferred, alternative, and special situation options. Most regimens consist of a backbone (2 NRTIs) + a third agent (INSTI, NNRTI, or PI).
First-Line (ART-Naive) Preferred Regimens
Integrase Strand Transfer Inhibitor (INSTI)-Based (Preferred)
| Regimen | Dose | Notes |
|---|---|---|
| Bictegravir/TAF/FTC (Biktarvy) | 1 tablet once daily | With or without food |
| Dolutegravir + TAF/FTC (DTG + Descovy) | DTG 50 mg once daily + 1 Descovy tablet once daily | With or without food |
| Dolutegravir/Lamivudine (Dovato) | 1 tablet once daily | Not for baseline HIV RNA >500,000 or HBV co-infection |
| Cabotegravir + Rilpivirine (Cabenuva) | Monthly or every 2 months IM injection | For virologically suppressed patients only |
NNRTI-Based Regimens
| Regimen | Dose | Notes |
|---|---|---|
| Doravirine (DOR)/3TC/TDF (Delstrigo) | 1 tablet once daily | ART-naive or virologically suppressed (HIV RNA <50) on stable regimen, no prior treatment failure |
| Rilpivirine/FTC/TDF (Complera) | 1 tablet once daily with ≥500 kcal meal | ART-naive with baseline HIV RNA ≤100,000 copies/mL; or suppressed on 1st/2nd regimen |
| Efavirenz 600 mg/3TC/TDF (Symfi) | 1 tablet once daily | Take on empty stomach |
| Efavirenz 400 mg/3TC/TDF (Symfi Lo) | 1 tablet once daily | Take on empty stomach |
INSTI + NNRTI Single Tablet (INSTI-Based)
| Regimen | Dose | Notes |
|---|---|---|
| Elvitegravir/Cobicistat/FTC/TDF (Stribild) | 1 tablet once daily | Administer with food; for ART-naive or virologically suppressed (HIV RNA <50) with no prior failure |
| Doravirine (DOR) alone | 100 mg once daily | For ART-naive or virologically suppressed, no prior resistance to DOR |
Key Dosing Principles
- Start with preferred INSTI-based regimens — superior efficacy, tolerability, and barrier to resistance
- Assess for resistance before initiating (baseline genotype)
- Check HLA-B*5701 before abacavir use (to prevent hypersensitivity)
- Renal function (eGFR): TDF contraindicated if eGFR <50 mL/min; switch to TAF
- Food requirements:
- Efavirenz-based: empty stomach
- Rilpivirine-based: with ≥500 kcal meal
- Elvitegravir/cobicistat: with food
- Bictegravir, dolutegravir: no food restriction
Pediatric Weight-Based Thresholds
For adolescents, most adult fixed-dose combinations (FDCs) apply at ≥35 kg (some require ≥40 kg for efavirenz 600 mg regimens) per Use of Antiretroviral Agents in Pediatric HIV Infection guidelines (p. 434, 458).
Special Populations
| Situation | Modification |
|---|---|
| Pregnancy | DTG preferred; avoid EFV in 1st trimester |
| TB co-infection | Use EFV 600 mg-based regimen (avoid PIs); rifabutin if PI-based required |
| Renal impairment | TAF preferred over TDF; dose-adjust if needed |
| Hepatic impairment | Avoid PIs with severe hepatic disease |
| HBV co-infection | Include TDF or TAF (dual HBV/HIV active) |
Switching (Virologically Suppressed)
Patients may switch to single-tablet regimens such as Biktarvy, Dovato, or Delstrigo if:
- HIV RNA <50 copies/mL on a stable regimen
- No history of virologic failure
- No known resistance mutations to the new regimen's components
Sources: Use of Antiretroviral Agents in Pediatric HIV Infection (p. 434, 458); DHHS Adult and Adolescent ARV Guidelines.
Note: This is a clinical reference summary. Always consult current DHHS or WHO guidelines and individualize therapy based on patient-specific factors including resistance profile, comorbidities, drug interactions, and adherence considerations.
A 45 year old lady presents with complaint of epigastric pain for 1 day and nausea and vomiting. Vomit after anything she eats or drinks. Vomit is white is color, no foul smelling. Give me diagnosis and treatment
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I have sufficient information. Here is the clinical assessment and management plan:
Clinical Assessment: 45-Year-Old Female with Epigastric Pain, Nausea & Vomiting
Most Likely Diagnoses
Given the presentation — acute epigastric pain (1 day), nausea, vomiting after anything eaten/drunk, white non-foul-smelling vomit — the differential in order of likelihood:
| # | Diagnosis | Key Supporting Features |
|---|---|---|
| 1 | Acute Gastritis | Epigastric pain, nausea/vomiting, white vomit (no bile/blood), common in women |
| 2 | Peptic Ulcer Disease (PUD) | Epigastric pain, postprandial vomiting, 45-year-old age group |
| 3 | Functional Dyspepsia | Epigastric pain, bloating, nausea; diagnosis of exclusion |
| 4 | Acute Pancreatitis | Epigastric pain radiating to back, nausea/vomiting — consider especially if pain is severe |
| 5 | Gastric Outlet Obstruction | Persistent vomiting of undigested food, non-bilious white vomit — a serious complication to rule out |
| 6 | GERD / Gastroparesis | Postprandial symptoms, nausea, white vomit |
White, non-foul-smelling vomit (undigested food/gastric secretions, no bile staining, no feculent odor) is particularly consistent with gastric origin — pointing to gastritis, PUD, or early gastric outlet obstruction.
History to Clarify Diagnosis
- NSAID / aspirin / steroid / alcohol use? (key for gastritis/PUD)
- H. pylori risk factors (prior infection, family history)?
- Relief or worsening with food?
- Any hematemesis, melena, weight loss, or dysphagia? (alarm symptoms)
- LMP / pregnancy status?
- Prior similar episodes?
Investigations
Immediate
- FBC — anemia (suggesting chronic bleeding)
- Serum amylase/lipase — to rule out pancreatitis
- LFTs, RFTs — baseline
- Blood glucose
- Urine pregnancy test — mandatory in 45-year-old woman (perimenopausal)
- Urea & electrolytes — assess dehydration from vomiting
Definitive
- Upper GI endoscopy (OGD) — gold standard; identifies gastritis, ulcer, H. pylori; allows biopsy
- Preferred over barium meal due to diagnostic superiority and ability to biopsy — Textbook of Family Medicine, p. 1125
- H. pylori testing: Urea breath test, stool antigen, or rapid urease test at endoscopy
- Abdominal USS — if gallstones or pancreatitis suspected
Treatment
1. Immediate Supportive Care
- IV fluid resuscitation if dehydrated (vomiting after all intake)
- Antiemetics:
- Metoclopramide 10 mg IV/IM 8-hourly or
- Ondansetron 4–8 mg IV 8-hourly
- NBM or clear fluids initially if vomiting is persistent; reintroduce diet as tolerated
2. Acid Suppression (Mainstay)
- Proton Pump Inhibitor (PPI) — first-line:
- Omeprazole 20–40 mg once daily (oral) or IV if unable to swallow
- Pantoprazole 40 mg once daily
- Esomeprazole 40 mg once daily
- H2 blocker (alternative if PPI unavailable):
- Ranitidine 150 mg BD or Famotidine 20 mg BD
3. H. pylori Eradication (if confirmed)
Triple Therapy — 14 days (standard first-line):
| Drug | Dose |
|---|---|
| PPI (e.g., Omeprazole) | 20 mg BD |
| Amoxicillin | 1 g BD |
| Clarithromycin | 500 mg BD |
If penicillin allergy: replace Amoxicillin with Metronidazole 400–500 mg BD.
Evidence strongly supports that H. pylori eradication virtually eliminates ulcer recurrence — Textbook of Family Medicine, p. 1125
4. Lifestyle & Dietary Advice
- Avoid NSAIDs, aspirin, alcohol, spicy food, caffeine
- Eat small frequent meals
- Avoid lying down immediately after meals
- Smoking cessation
5. If Gastric Outlet Obstruction Suspected
- Keep NBM, NG tube decompression
- Urgent surgical or endoscopic consultation
Alarm Symptoms Requiring Urgent Endoscopy / Referral
- Hematemesis or melena
- Unintentional weight loss
- Dysphagia or odynophagia
- Persistent vomiting
- Anemia
- Abdominal mass
- Age >45–50 with new-onset dyspepsia
- Family history of GI malignancy
Summary
This patient most likely has acute gastritis or peptic ulcer disease. Immediate management includes IV fluids, antiemetics, and PPI therapy. Confirm diagnosis with OGD + H. pylori testing; if positive, complete a 14-day eradication course. Review for alarm features that would necessitate urgent endoscopy or surgical referral.
Sources: Textbook of Family Medicine 9e, p. 1125; Sleisenger and Fordtran's Gastrointestinal and Liver Disease; Tintinalli's Emergency Medicine.
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