How should a 28-year-old female be managed after ingesting five antiretroviral tablets in an overdose?

Management of Antiretroviral Overdose in a 28-Year-Old Female

This patient should receive supportive care with monitoring and does not require gastrointestinal decontamination or specific antidotes, as antiretroviral overdoses are generally well-tolerated with minimal serious toxicity.

Immediate Management

Initial Assessment and Monitoring

The patient should be evaluated for:

• Vital signs: Blood pressure, heart rate, temperature, respiratory rate
• Mental status: Level of consciousness, neurological symptoms (dizziness, drowsiness, confusion)
• Gastrointestinal symptoms: Nausea, vomiting, abdominal pain
• Cardiovascular status: Cardiac rhythm monitoring if available

Most antiretroviral overdoses are not serious 1. In a large case series of 632 antiretroviral exposures, 88.7% were classified as not serious, with the majority managed outside healthcare facilities 1.

Laboratory Evaluation

Obtain baseline laboratory tests:

• Complete blood count (CBC)
• Renal function: Serum creatinine, blood urea nitrogen
• Hepatic function: AST, ALT, bilirubin
• Electrolytes: Particularly potassium and bicarbonate
• Pregnancy test (given patient is a 28-year-old female of childbearing age)

Specific Considerations by Drug Class

Common Clinical Presentations

The most frequently reported adverse effects from antiretroviral overdoses include 1:

• Vomiting (5.7%)
• Nausea (4.8%)
• Dizziness/vertigo (3.2%)
• Drowsiness/lethargy (3.2%)

Drug-Specific Toxicities to Monitor

If the specific antiretroviral is known:

• NNRTIs (e.g., Efavirenz): Monitor for neuropsychiatric symptoms including visual disturbances, tremors, motor deficits, and severe psychiatric symptoms 2. One case reported burning throat sensation, visual impairment within one hour, and motor deficits lasting 5 days 2.

• NRTIs containing Tenofovir: Watch for delayed renal toxicity. In one documented case, serum creatinine increased to high-normal values (1.2 mg/dl) 5 days post-ingestion but normalized by 8-12 weeks 3.

• Integrase Inhibitors (e.g., Dolutegravir): Generally well-tolerated even in overdose. One case of massive overdose showed no clinical signs of intoxication on admission with only mild transient renal effects 3.

• Protease Inhibitors: Monitor for gastrointestinal symptoms, hyperbilirubinemia (especially with Indinavir), and hyperglycemia 4.

Treatment Protocol

Supportive Care (Primary Management)

1. No gastrointestinal decontamination needed: Activated charcoal is not routinely indicated unless presentation is within 1 hour of massive ingestion and patient is alert with intact airway

2. Intravenous hydration: Administer crystalloid fluids for dehydration or hypotension

3. Symptomatic treatment:

   • Antiemetics for nausea/vomiting
   • Analgesics for headache or abdominal pain
   • Benzodiazepines for severe agitation or psychiatric symptoms

4. Monitoring duration:

   • Minimum 6 hours of observation for asymptomatic patients 3
   • 24 hours for symptomatic patients
   • Extended monitoring if neurological symptoms develop

Follow-Up Laboratory Monitoring

Renal function monitoring is critical 3:

• Repeat creatinine at 5-7 days post-ingestion
• If elevated, recheck at 8 and 12 weeks
• Monitor for crystalluria if protease inhibitors involved

Hepatic function:

• Repeat liver enzymes at 2 weeks if initially abnormal
• Monitor for delayed hepatotoxicity, particularly with NRTIs 4

Psychiatric Evaluation

Mandatory psychiatric assessment is required given the intentional nature of overdose 5:

• Evaluate suicide risk before discharge
• Arrange psychiatric follow-up
• Consider inpatient psychiatric admission if high risk

This is particularly important as studies show increasing numbers of HIV-positive individuals attempting suicide with antiretroviral medications 5.

Common Pitfalls to Avoid

1. Do not assume immediate toxicity: Many patients present asymptomatically and develop symptoms hours to days later 3, 6

2. Do not discharge without renal function follow-up: Delayed nephrotoxicity can occur 5-7 days post-ingestion 3

3. Do not overlook pregnancy status: Several antiretrovirals have teratogenic concerns, particularly efavirenz 4. If pregnant, obstetric consultation is warranted.

4. Do not miss co-ingestions: Verify whether other medications or substances were taken concurrently

5. Do not forget HIV status assessment: If the patient is not known to be HIV-positive, determine why they had access to antiretrovirals

Disposition

• Discharge criteria: Asymptomatic after 6-24 hours observation with normal vital signs, normal or stable laboratory values, and cleared psychiatric evaluation
• Admission criteria: Persistent symptoms, abnormal vital signs, significant laboratory abnormalities, or high suicide risk
• Outpatient follow-up: Renal and hepatic function testing at 5-7 days, psychiatric follow-up within 1 week

The prognosis is generally excellent with supportive care 3, 1. Most patients recover without permanent impairment when managed appropriately.