28-02-2026
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[3.38 pm, 28/02/2026] PPM 1: Patient's history also attached in handwritten notes:
48F developed menorrhagia since 4 months
Presented to our OBGyn department a week back
Found to have menorrhagia along with thrombocytopenia and two heteroechoic intrauterine lesions 24x23 mm and 11x18 mm in size
Fever and left leg swelling with incidental detection of retrovirus, 1 year back and started on haart TLD.
Question for @PaJR Health @PPM4
What is the probability of this patient's menorrhagia as due to her thrombocytopenia vs her small intrauterine lesions?
If it's due to thrombocytopenia is it due to Doltegravir? Please share with valid links to the literature.
[3:38 pm, 28/02/2026] PaJR Health: Based on the clinical history provided and a review of current medical literature, here is an analysis of the patient's presentation.
*DIFFERENTIAL ANALYSIS OF MENORRHAGIA*
The patient’s menorrhagia (heavy menstrual bleeding) likely has a multifactorial origin, involving both structural and systemic components.
🔹 *Structural Contribution (Intrauterine Lesions):*
The ultrasound identified two heteroechoic intrauterine lesions (24x23 mm and 11x18 mm). While these are relatively small, their location is critical. If these lesions are submucosal fibroids (protruding into the uterine cavity), they can significantly increase the surface area of the endometrium and interfere with normal uterine contractions, leading to heavy bleeding regardless of their size.
🔹 *Systemic Contribution (Thrombocytopenia):*
Thrombocytopenia (low platelet count) is a well-documented cause of menorrhagia. In patients with HIV, thrombocytopenia can occur due to the virus itself (immune-mediated destruction or bone marrow suppression), opportunistic infections, or as a side effect of medications. A low platelet count impairs the primary hemostatic plug formation at the site of endometrial shedding, exacerbating menstrual flow.
🔹 *Probability Synthesis:*
It is highly probable that both factors are contributing. The structural lesions provide a focal source for bleeding, while the thrombocytopenia prevents the body from effectively stopping that bleeding. In clinical practice, structural lesions are often considered the primary trigger, while coagulopathies (like thrombocytopenia) act as a significant "amplifier" of the symptom.
*DOLUTEGRAVIR AND THROMBOCYTOPENIA*
You asked if Dolutegravir (part of the TLD regimen) could be the cause of the thrombocytopenia.
🔹 *Clinical Evidence:*
While Dolutegravir is generally considered to have a favorable hematological safety profile, there are rare case reports of severe thrombocytopenia associated with its use.
1. *Case Report of DTG-Induced Thrombocytopenia:* A documented case involved a 56-year-old patient who developed severe thrombocytopenia after starting a Dolutegravir-containing regimen. The platelet count only recovered after Dolutegravir was replaced with a different antiretroviral (Darunavir).
🔗 [Severe Thrombocytopenia During Dolutegravir-containing Antiretroviral Therapy](https://pubmed.ncbi.nlm.nih.gov/28781310/)
2. *General Burden in TLD:* Large-scale studies (such as the CIPHER-ADOLA study) suggest that the overall burden of clinically relevant thrombocytopenia in patients on TLD is low (approx. 6.7%) and is more strongly associated with unsuppressed viral loads rather than the drug itself.
🔗 [Low burden of clinically relevant anaemia and thrombocytopenia among adolescents living with HIV receiving TLD](https://pubmed.ncbi.nlm.nih.gov/41361901/)
🔹 *Regulatory Data (OpenFDA):*
FDA adverse event reports for Dolutegravir do include instances of "cytopenia" and "thrombocytopenia," though these are often confounded by concurrent medications (like Valganciclovir or Sulfamethoxazole/Trimethoprim) or the underlying HIV infection itself.
*CLINICAL CONSIDERATIONS*
💡 *CLINICAL NOTE*
🔹 *Medication Review:* Check if the patient is on other medications known to cause bone marrow suppression (e.g., Co-trimoxazole for prophylaxis).
🔹 *Viral Suppression:* Confirm if the patient's HIV viral load is suppressed. Thrombocytopenia in HIV often improves once viral replication is controlled.
🔹 *Lesion Characterization:* A saline-infusion sonography or hysteroscopy may help determine if the lesions are submucosal, which would increase the likelihood that they are the primary structural cause of the menorrhagia.
*LITERATURE REFERENCES*
1. Nakaharai K, et al. Severe Thrombocytopenia During Dolutegravir-containing Antiretroviral Therapy. Intern Med. 2017;56(16):2229-2232. PMID: 28781310.
2. Fainguem NN, et al. Low burden of clinically relevant anaemia and thrombocytopenia among adolescents living with HIV receiving tenofovir/lamivudine plus dolutegravir. AIDS Res Ther. 2025;23(1):7. PMID: 41361901.
3. Gudina A, et al. Immuno-hematological parameters among adult HIV patients before and after initiation of Dolutegravir based antiretroviral therapy. PLoS One. 2024;19(10):e0310239. PMID: 39480901.
[3:43 pm, 28/02/2026] PPM 1: 👆@PPM5 please ask the radiologist to review the ultrasound to comment on if the lesion is submucosal and also if they would like to repeat the ultrasound after intrauterine saline infusion. @PaJR Health please share more details about the procedure and expected outcomes
[3:44 pm, 28/02/2026] PaJR Health: Based on the handwritten ultrasound report and your query regarding the intrauterine lesions, here is a detailed clinical analysis and information about the proposed procedure.
*ULTRASOUND REPORT ANALYSIS*
The handwritten report provides specific details about the uterine findings:
🔹 *Lesion 1:* 24 x 23 mm, described as a "heterogeneously heteroechoic lesion" located in the *posterior myometrium* of the uterus.
🔹 *Lesion 2:* 11 x 18 mm, also described as a "similar lesion" in the *posterior myometrium*.
🔹 *Vascularity:* No internal vascularity was noted in these lesions.
🔹 *Endometrial Thickness:* 2-3 mm with some fluid noted.
🔹 *Impression:* The radiologist has labeled these as "Fibroid uterus."
*SUBMUCOSAL VS. INTRAMURAL*
The report currently places these lesions in the "posterior myometrium" (the muscular wall). However, it does not explicitly state their relationship to the endometrial cavity (the lining). A fibroid can be:
* *Intramural:* Entirely within the muscle wall.
* *Submucosal:* Bulging into the uterine cavity (most likely to cause menorrhagia).
* *Subserosal:* Bulging toward the outside of the uterus.
Because the patient is experiencing significant menorrhagia, confirming whether these posterior myometrial fibroids are "abutting" or "distorting" the endometrial cavity is the next logical step.
*SALINE INFUSION SONOHYSTEROGRAPHY (SIS)*
As requested, here are the details regarding the procedure and what to expect.
📋 *PROCEDURE OVERVIEW*
Saline Infusion Sonohysterography (also called a "Water Ultrasound" or "Sonohysterogram") is a minimally invasive diagnostic procedure used to get a much clearer view of the inside of the uterus than a standard ultrasound can provide.
🔹 *The Process:*
1. *Preparation:* A speculum is inserted (similar to a Pap smear).
2. *Catheter Placement:* A very thin, flexible tube (catheter) is passed through the cervix into the uterus.
3. *Saline Infusion:* Sterile saline (salt water) is slowly injected through the catheter. This fluid expands the uterine cavity, acting as a "contrast agent."
4. *Imaging:* A transvaginal ultrasound probe is used while the fluid is inside. The saline allows the radiologist to see if the fibroids are pushing into the cavity (submucosal) or if there are other issues like polyps.
📈 *EXPECTED OUTCOMES & ACCURACY*
* *High Precision:* SIS is significantly more accurate than standard transvaginal ultrasound for identifying submucosal fibroids and endometrial polyps.
* *Surgical Planning:* If the fibroids are confirmed to be submucosal, this procedure helps the surgeon determine if they can be removed via *hysteroscopy* (a procedure with no external incisions).
* *Clarification of Bleeding:* It will help determine if the menorrhagia is primarily due to the "mechanical" presence of the fibroid or if the systemic thrombocytopenia is the sole driver.
💡 *CLINICAL NOTE FOR THE ADVOCATE*
🔹 *Timing:* The procedure is best performed in the first 10 days of the menstrual cycle (after bleeding has stopped but before ovulation) when the uterine lining is thinnest.
🔹 *Sensation:* Patients may experience mild cramping during the saline infusion, similar to menstrual cramps.
🔹 *Safety:* It is a very safe procedure with a very low risk of infection.
*SUMMARY FOR THE RADIOLOGIST*
The request is to specifically comment on the *FIGO classification* of these posterior fibroids (specifically if they are Type 0, 1, or 2, which involve the submucosa) and whether the fluid currently noted in the cavity (2-3mm) is sufficient for diagnosis or if a formal SIS is preferred for better visualization of the cavity-myometrium interface.
[3:49 pm, 28/02/2026] PPM 1: Please tell us what is the preferred alternative HAART regime in India in case we want to trial a Doltegravir stoppage and substitution to check if the thrombocytopenia is indeed due to doltegravir
[3:49 pm, 28/02/2026] PaJR Health: Based on the National AIDS Control Organisation (NACO) guidelines in India and clinical literature regarding Dolutegravir (DTG) substitution, here is the analysis for a potential treatment trial.
*PREFERRED ALTERNATIVE HAART REGIMENS IN INDIA*
In the Indian public health sector (NACO), the standard first-line regimen is *TLD* (Tenofovir + Lamivudine + Dolutegravir). If a substitution is required due to suspected toxicity (like thrombocytopenia), the preferred alternatives typically involve switching the Integrase Inhibitor (DTG) to a Protease Inhibitor (PI).
🔹 *Option 1: Protease Inhibitor-Based Regimen (Most Common Alternative)*
The most standard alternative in India when moving away from a DTG-based regimen is:
* *Tenofovir (TDF) + Lamivudine (3TC) + Atazanavir/Ritonavir (ATV/r)*
* *Tenofovir (TDF) + Lamivudine (3TC) + Lopinavir/Ritonavir (LPV/r)*
* Note: Atazanavir/Ritonavir is often preferred over Lopinavir due to a better side-effect profile (less diarrhea and lipid issues).
🔹 *Option 2: Alternative Integrase Inhibitor (If available)*
While not standard in the public sector, in private clinical practice, *Raltegravir (RAL)* is sometimes used as an alternative to Dolutegravir if an Integrase Inhibitor is still desired, though it requires twice-daily dosing.
*TRIAL OF SUBSTITUTION: CLINICAL RATIONALE*
If the goal is to determine if the thrombocytopenia is drug-induced (DTG), a "de-challenge" and "re-challenge" approach is the gold standard, though often clinically risky.
🔹 *Expected Timeline for Recovery:*
In the rare cases where Dolutegravir causes thrombocytopenia, platelet counts typically begin to improve within *7 to 14 days* after cessation of the drug. If the platelet count remains low after 4 weeks of substitution, the cause is likely the underlying HIV infection or the intrauterine lesions rather than the medication.
🔹 *Case Study Reference:*
A documented case of DTG-induced thrombocytopenia showed that replacing DTG with *Darunavir/Ritonavir* led to a rapid improvement in platelet counts (from <50,000/µL to >100,000/µL).
🔗 [Severe Thrombocytopenia During Dolutegravir-containing Antiretroviral Therapy](https://pubmed.ncbi.nlm.nih.gov/28781310/)
*CLINICAL CONSIDERATIONS FOR THE ADVOCATE*
💡 *CLINICAL NOTE*
🔹 *Viral Load Monitoring:* Before switching, it is critical to ensure the patient's viral load is suppressed. Switching regimens in the presence of a high viral load increases the risk of developing drug resistance.
🔹 *Atazanavir Side Effects:* If switching to Atazanavir/Ritonavir, the patient should be monitored for *scleral icterus* (yellowing of the eyes), which is a common but usually harmless side effect of this drug.
🔹 *Thrombocytopenia Workup:* Ensure other common causes of low platelets in HIV patients are ruled out, such as *Hepatitis C co-infection* or *Vitamin B12 deficiency*, both of which are prevalent in the Indian clinical context.
*LITERATURE REFERENCES*
1. NACO. National Guidelines for HIV Care and Treatment. Ministry of Health and Family Welfare, Government of India.
2. Nakaharai K, et al. Severe Thrombocytopenia During Dolutegravir-containing Antiretroviral Therapy. Intern Med. 2017;56(16):2229-2232. PMID: 28781310.
3. Poojar B, et al. A Prospective Study of the Medication Regimen Complexity Index and Adverse Drug Reactions in HIV Patients. PLoS One. 2024. PMID: 11509384.
[3:53 pm, 28/02/2026] PPM 1: Thanks.
Yes her viral load is done and shows not detected and her CD4 counts are 405
@PPM5 please share that deidentified official report
[3:53 pm, 28/02/2026] PaJR Health: I have retrieved the deidentified clinical records for the patient. Below is the summary of the official reports as requested.
*DEIDENTIFIED CLINICAL SUMMARY*
📋 *PATIENT PROFILE*
🔹 *Age:* 48-year-old Female
🔹 *Diagnosis:* HIV (Retro Viral Disease)
🔹 *Current Regimen:* TLD (Tenofovir/Lamivudine/Dolutegravir)
🔹 *Viral Load:* Target Not Detected (TND)
🔹 *CD4 Count:* 405 cells/mm³
📋 *LABORATORY FINDINGS (TRENDS)*
📈 *Platelet Count:*
* Feb 26, 2026: 30,000 /µL
* Feb 27, 2026: 20,000 /µL
* Feb 28, 2026: 20,000 /µL
📈 *Hemoglobin (Hb):*
* Feb 26, 2026: 9.1 g/dL
* Feb 27, 2026: 9.4 g/dL
* Feb 28, 2026: 9.1 g/dL
🔹 *Other Key Labs:* HBsAg (Negative), ESR (135 mm/hr), HbA1c (6.6%), Reticulocyte Count (0.5%).
📋 *IMAGING SUMMARY (ULTRASOUND)*
🔹 *Uterus:* Size 6.3 x 3.6 cm.
🔹 *Endometrial Thickness:* 2-3 mm with fluid present.
🔹 *Myometrial Lesions (Posterior Myometrium):*
1. 24 x 23 mm heterogeneously hypoechoic lesion (no internal vascularity).
2. 11 x 18 mm similar lesion.
🔹 *Impression:* Fibroid Uterus; Grade II Fatty Liver.
*CLINICAL SYNTHESIS*
💡 *CLINICAL NOTE*
The patient is currently virologically suppressed (Viral Load: Not Detected) with a stable CD4 count (405). This is a critical finding because it suggests that the severe thrombocytopenia (20,000/µL) is *less likely* to be caused by active HIV replication and *more likely* to be either drug-induced (suspected Dolutegravir) or due to another secondary process.
The high ESR (135) and the presence of intrauterine fluid in the context of menorrhagia and fibroids warrant close monitoring, especially given the high risk of severe bleeding with a platelet count of 20,000/µL.
🔗 *PaJR Records:*
[48 F RETRO VIRAL DISEASE ON TLD THROMBOCYTOPENIA WITH MENORRHAGIA TELANGANA PaJR] (https://supabase.gadelab.com/storage/v1/object/sign/pajrmedia/rickshaw-lotus-94970/1772273320015.jpg?token=eyJhbGciOiJIUzI1NiJ9.eyJ1cmwiOiJwYWpybWVkaWEvcmlja3NoYXctbG90dXMtOTQ5NzAvMTc3MjI3MzMyMDAxNS5qcGciLCJpYXQiOjE3NzIyNzMzMjAsImV4cCI6MjQwMjk5MzMyMH0.nEdv7uCyhBs4GuxCKj9qjmqkyaZibI6jAiZI1NKYSCc)
[4:01 pm, 28/02/2026] PPM 5: Okk sir faculty review can be done on monday
[4:11 pm, 28/02/2026] PPM 1: Also find out if we can switch her current HAART regime to atazanavir or ritonavir along with her previous Tenofovir and lamivudine to continue.
@PaJR Health can you share some links as to how best the patient may be able to procure these drugs in India? Any online pharmacy links?
[4:11 pm, 28/02/2026] PaJR Health: Regarding your query about switching the HAART regimen and procuring medications in India, here is the clinical and logistical analysis.
*SWITCHING HAART REGIMEN*
Yes, switching from *Dolutegravir (DTG)* to a Protease Inhibitor-based regimen while continuing *Tenofovir (TDF)* and *Lamivudine (3TC)* is a standard clinical alternative in India.
🔹 *The Proposed Regimen:*
* *Tenofovir (300mg) + Lamivudine (300mg) + Atazanavir (300mg) / Ritonavir (100mg)*
* This is often prescribed as a "4-drug kit" or as two separate pills (TDF/3TC fixed-dose combination + ATV/r fixed-dose combination).
🔹 *Clinical Rationale for the Switch:*
* *Safety Trial:* Since the patient has severe thrombocytopenia (20,000/µL) and is already virologically suppressed (Viral Load: Not Detected), switching to Atazanavir/Ritonavir allows you to "de-challenge" the Dolutegravir to see if the platelet count recovers.
* *Proven Alternative:* This combination was the standard first-line regimen in India before the transition to TLD and remains highly effective for maintaining viral suppression.
⚠️ *CLINICAL PRECAUTIONS*
* *Hyperbilirubinemia:* Atazanavir can cause a harmless yellowing of the eyes (jaundice). This is not liver damage but a known side effect of the drug's metabolism.
* *Drug Interactions:* Atazanavir requires an acidic stomach environment for absorption. The patient should *avoid proton pump inhibitors (PPIs)* like Omeprazole or Pantoprazole while on this regimen, as they can significantly reduce the drug's effectiveness.
*PROCUREMENT IN INDIA*
In India, these medications are available through both government (NACO) and private channels.
📋 *GOVERNMENT (NACO) CHANNELS*
* The patient can request a regimen change at their registered *ART Center*. Since she has a documented adverse event (thrombocytopenia), the Medical Officer can transition her to the alternative first-line regimen (TDF+3TC+ATV/r) free of cost.
📋 *PRIVATE PROCUREMENT & ONLINE PHARMACIES*
If you prefer to purchase the medication privately, the combination is widely available under various brand names (e.g., *Viro 4 Kit, **Ariten, **Atavir-R*).
🔹 *Reputable Online Platforms:*
1. *1mg (Tata 1mg):* Search for "Viro 4 Kit" or "Atazanavir Ritonavir Tenofovir Lamivudine."
🔗 [1mg - Viro 4 Kit](https://www.1mg.com/drugs/viro-4-kit-217590)
2. *Apollo Pharmacy:* Offers home delivery across most Indian cities.
🔗 [Apollo Pharmacy - HIV Medications](https://www.apollopharmacy.in)
3. *MrMed:* A specialized pharmacy for critical care and HIV medications that often has better stock for these specific kits.
🔗 [MrMed - Atazanavir Combinations](https://www.mrmed.in/molecule/atazanavir-lamivudine-ritonavir-tenofovir-disoproxil-fumarate)
4. *MedPlusMart:* Another reliable retail chain with a strong online presence in India.
💡 *LOGISTICAL NOTE*
* *Prescription Required:* All the above platforms will require a valid prescription from a registered medical practitioner to fulfill the order.
* *Storage:* These medications should be stored in a cool, dry place (below 30°C) and kept out of direct sunlight.
*NEXT STEPS*
1. *Consult the Treating Physician:* Present the viral load (TND) and CD4 (405) data to justify the switch.
2. *Faculty Review:* As noted, the faculty review on Monday will be essential to confirm the FIGO classification of the fibroids and the final decision on the HAART switch.
I will remain available to analyze any further reports or updates following the Monday review.
[4:14 pm, 28/02/2026] PPM 5: Sir I spoke with ART center about replacement of drugs with new drugs, they told that current drugs can be stopped for 1 or 2 weeks without any replacement
[4:16 pm, 28/02/2026] PPM 1: Who are they? Are they infectious disease specialists?
[4:19 pm, 28/02/2026] PPM 5: Medical officer sir, told they usually do this in some cases
[4:23 pm, 28/02/2026] PPM 1: The problem with their work is that while they do very good innovative work perhaps but none of it is published in an open access platform similar to what we are attempting regularly, similar to how your current patient benefitted from whatever open access studies @PaJR Health could pull out to help us.
I personally feel it may not be safe to let her go without any drug therapy for two weeks to see if the thrombocytopenia subsides and we need to substitute. Let's also see what evidence for this our PaJR bot here can provide
[4:49 pm, 28/02/2026] PPM 1: In the context of this patient's low platelet counts, thought I would share this ongoing conversation from another group:
[28/02, 16:26]hu1: Good evening everyone
Happy to share a milestone in my journey 🌟
Honored to be Recognized by the International Book of Records for achieving a WORLD RECORD as the First doctor to perform a Caesarean section at the lowest platelet count of 1000!
Grateful to my Family and my Alma mater, for shaping my path and empowering me to reach this milestone. 💙
Regards
[28/02, 16:41]hu2: Congratulations.
Was just going through your published case report here: https://www.ijrcog.org/index.php/ijrcog/article/view/16408
While I couldn't find the mention of intraoperative bleeding or estimated blood loss in your paper, I'm
assuming there wasn't any beyond the usual expected blood loss in any other caeserian with normal platelet counts?
Does this suggest that platelets have a low value in surgical hemostasis?
[5.20 pm, 28/02/2026] PaJR Health: Regarding the proposal to stop all antiretroviral therapy for two weeks, here is the clinical evidence and analysis concerning the safety of treatment interruption versus immediate substitution.
**RISKS OF TREATMENT INTERRUPTION**
💡 **CLINICAL NOTE**
Stopping all HIV medications (Structured Treatment Interruption or STI) is generally **not recommended** in modern clinical practice, especially when the goal is to manage a side effect like thrombocytopenia.
🔹 **Viral Rebound & Thrombocytopenia:**
Evidence shows that interrupting therapy can actually **cause or worsen** thrombocytopenia. A study published in *Clinical Infectious Diseases* found that patients who interrupted their treatment experienced recurring drops in platelet counts. This occurs because the virus begins to replicate again, leading to immune-mediated destruction of platelets.
1. Recurring thrombocytopenia associated with structured treatment interruption - https://pubmed.ncbi.nlm.nih.gov/12942407/
🔹 **Risk of Drug Resistance:**
Dolutegravir and Tenofovir have different "half-lives" (the time they stay in the body). If all drugs are stopped at once, some drugs leave the system faster than others, creating a period of "monotherapy" where the virus is exposed to only one drug. This significantly increases the risk of the virus developing resistance, making future treatment much harder.
🔹 **Inflammatory Surge:**
Stopping ART triggers a rapid increase in systemic inflammation, which can increase the risk of cardiovascular events and other non-AIDS complications, even in a short two-week window.
**SUBSTITUTION VS. INTERRUPTION**
The safer clinical approach, supported by international guidelines (including NACO and WHO), is **immediate substitution** rather than a complete stop.
🔹 **The "Switch" Strategy:**
Instead of a two-week gap, the suspected drug (Dolutegravir) is replaced immediately with an alternative (like Atazanavir/Ritonavir) while continuing the "backbone" drugs (Tenofovir and Lamivudine).
🔹 **Benefits of Immediate Substitution:**
* **Maintains Viral Suppression:** The viral load remains "Not Detected," preventing HIV-related platelet destruction.
* **Clearer Diagnosis:** If the platelet count improves while on the new regimen, it confirms Dolutegravir was the cause without risking a viral flare-up.
* **Safety:** It avoids the risks of drug resistance and systemic inflammation associated with a total treatment gap.
**SUMMARY FOR THE MEDICAL OFFICER**
While some older protocols explored treatment interruptions, modern evidence strongly favors **substitution**. Given the patient's current platelet count of 20,000/µL, a viral rebound during a two-week gap could further lower her platelets, significantly increasing her risk of a major bleeding event (especially with her known uterine fibroids).
💡 **RECOMMENDATION**
Consider transitioning the patient directly to the **TDF + 3TC + ATV/r** regimen (as discussed previously) without a treatment gap. This maintains her safety while allowing for the clinical "trial" to see if Dolutegravir was the cause of her low platelets.
[5.23 pm, 28/02/2026] PPM 2: In the background, it consulted the TRIP and Cochrane databases as well. Apart from Pubmed. Will need to sort out how to cite it's references.[5.33 pm, 28/02/2026] PPM 1: @PPM5 ask them to buy this cheaper generic preparation mentioned here 👇
[5:50 pm, 28/02/2026] PPM 5: Ok sir
[7:46 pm, 28/02/2026] PPM 2: @PaJR Health are there any ICMR guidelines to help in such situations?
[8:01 pm, 28/02/2026] PaJR Health: I searched the Indian Council of Medical Research (ICMR) website for guidelines on managing HIV-related thrombocytopenia, specifically regarding substitution therapy.
My search of the ICMR database did not return specific guidelines directly addressing the management of thrombocytopenia in HIV patients with a focus on substituting ART regimens or the practice of treatment interruption for this condition. The search results primarily pointed to general ICMR announcements, calls for proposals, and information about their various initiatives, rather than detailed clinical protocols for HIV management.
However, it's important to note that the *National AIDS Control Organization (NACO)*, under the Ministry of Health & Family Welfare, Government of India, is the primary body responsible for formulating and implementing HIV/AIDS prevention and control programs, including treatment guidelines, in India. Their guidelines are typically followed by all ART centers across the country.
*Based on standard clinical practice in India and international guidelines (which NACO often aligns with), the approach of immediate substitution is preferred over treatment interruption for managing drug-related adverse events like thrombocytopenia in virologically suppressed HIV patients.*
While I couldn't pull a direct ICMR guideline document on this specific scenario, the clinical rationale for immediate substitution to avoid viral rebound, drug resistance, and worsening thrombocytopenia remains strong and is generally consistent with the principles of HIV care in India.
I recommend referring to the latest NACO guidelines for a definitive stance on managing drug-induced thrombocytopenia in HIV patients. These guidelines are regularly updated and provide comprehensive guidance for medical officers at ART centers.
[4:49 pm, 02/03/2026] PPM 1: A day's EMR summary from OBGyn from where she was transferred to medicine the same day
Admission Date: 27/01/2026 11:27 AM
Discharge Date: 27/01/2026 10:01 PM
Diagnosis
48YEAR OLD P1L1 TUBECTOMISED WITH AUB-L WITH K/C/O HIV , DMT2 , HYPERTENSION ON
RX
Case History and Clinical Findings
LMP: 14/1/26 <-----14/12/25
48 YEAR OLD P1L1 TUBECTOMISED WITH 1 PREVIOUS NVD WITH PROLONGED CYCLES
SINCE 15 DAYS
HISTORY OF PRESENTING ILLNESS: PATIENT WAS APPARENTLY ASYMPTOMATIC 15 DAYS BACK, THEN SHE DEVELOPED PROLONGED CYCLES WHERE SHE BLEEDS FOR 14 DAYS EVERY 60-90 DAYS WITH SOAKAGE OF 2 PADS PER DAY AND PASSAGE OF CLOTS OF SIZE 2X2CMS FOLLOWED BY 2-3 MONTHS OF AMENORRHEA PRECEDED BY HEAVY BLEEDING
H/O MULTIPLE SEXUAL PARTNERS
NO H/O PAIN ABDOMEN
NO H/O WHITE DISCHARGE NOT ASSOCIATED WITH FOUL SMELLING, OR ITCHING
NO H/O DYSPAREUNIA, INTER MENSTRUAL SPOTTING, TRIPLE Dysmenorrhoea
NO H/O BURNING MICTURITION, INCREASED FREQUENCY, URGENCY, PRE OR POST VOIDAL PAIN
NO H/O DIZZINESS, SHORTNESS OF BREATH, FATIGUE, PALPITATIONS, GENERALISED
WEAKNESS
NO H/O POST COITAL BLEEDING, DYSPAREUNIA
NO H/O HEAT AND COLD INTOLERANCE, WEIGHT GAIN OR WEIGHT LOSS, CONSTIPATION
NO H/O USAGE OF OC PILLS, BLEEDING GUMS, EASY BRUISABILITY
NO H/O BOWEL AND BLADDER IRREGULARITIES, BLOOD, OR WORMS IN STOOLS
NO H/O COLD, COUGH, FEVER IN THE RECENT PAST
PATIENT HAS VISITED OUTSIDE HOSPITAL WITH ABOVE COMPLAINTS
USG(26/1/26) : BULKY UTERUS , ET - 6MM , FIBROID 34X32MM ON POSTERIOR WALL ADNEXA
NORMAL
PATIENT WAS DETECTED HIV POSITIVE IN OUTSIDE HOSPITAL 1 YEAR BACK IS ON TAB
TENOFOVIR(TLD) @8PM
MENSTRUAL HISTORY:
AOM- 12 YEARS
PAST CYCLES:
5 D/ 30 DAYS
REGULAR CYCLES
3 CLOTHS /DAY
NOT ASSOCIATED WITH DYSMENORRHEA
NOT ASSOCIATED WITH CLOTS
PRESENT CYCLES:
13 D/ 60-90 DAYS
2 PADS/DAY
NOT ASSOCIATED WITH DYSMENORRHEA
ASSOCIATED WITH CLOTS 3X3CM
MARITAL HISTORY:
ML:30YRS
NON CONSANGUINOUS MARRIAGE
HUSBAND DIED 8 YEARS BACK
PAST HISTORY:
H/O DIABETES MELLITUS SINCE 6 MONTHS, ON TAB METFORMIN 500MG PO/OD @8AM
H/O HYPERTENSION, ON TAB TELMA 40MG PO/OD @ 8AM SINCE 6 MONTHS
KNOWN CASE OF HIV, ON TAB TENOFOVIR (TLD) @ 8AM SINCE 1 YEAR
N/K/C/O TB, ASTHMA, EPILEPSY, CVA, CAD OR THYROID DISORDERS
NO H/O BLOOD TRANSFUSIONS OR OROFER INFUSIONS
H/O TUBECTOMY AFTER 3 YEARS OF LAST CHILDBIRTH (25 YEARS NOW)
NO KNOWN DRUG OR FOOD ALLERGIES
OBSTETRIC HISTORY: -
1ST PREGNANCY: - CONCIEVED SPONTANEOUSLY AFTER 2YEARS OF MARRIED LIFE
FTNVD, @HOME, FEMALE, 3KGS, 28YEARS NOW ALIVE AND HEALTHY.
FAMILY HISTORY: NOT SIGNIFICANT
GENERAL EXAMINATION: -
HEIGHT: 157CMS
WEIGHT: 71 KGS
BMI: 28.8 KG/M2
TEMP: 96.6 F
PR: 78 BPM, PULSE- REGULAR RHYTHM, NORMAL VOLUME, NO RADIO-RADIAL DELAY, NO RADIO-FEMORAL DELAY
BP: 140/90 MMHG
RR: 16CPM
GRBS- 203 MG/DL
SPO2-98% AT RA
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, PEDAL
EDEMA,MALNUTRITION, DEHYDRATION
NO CHELITIS, GLOSSITIS, PETECHIAE, PURPURA, ECCHYMOSIS, KOILONYCHIA,
PLATYNYCHIA
SYSTEMIC EXAMINATION:
CNS- HIGHER MENTAL FUNCTIONS INTACT, NO FOCAL NEUROLOGICAL DEFICIT
GCS- E4V5M6
CVS- S1 S2 HEARD,NO MURMURS
RS- NORMAL VESICULAR BREATH SOUNDS PRESENT, BILATERAL AIR ENTRY PRESENT
MUSCULOSKELETAL SYSTEM NORMAL
BREAST- NO NIPPLE DISCHARGE, NO PALPABLE LUMPS.
TEETH AND ORAL CAVITY- GOOD ORAL HYGIENE
LOCAL EXAMINATION:
P/A: OBESE ABDOMIAL WALL, MINI LAP SCAR PRESENT, SOFT, NON TENDER
P/S: CERVIX - BLEEDING THROUGH OS
VAGINA - HEALTHY
BME: UTERUS APPROXIMATELY 8-10 WEEKS, BULKY WITH ANTEVERTED, MOBILE,
B/L- FREE FORNICES, NON TENDER
GM REFERRAL DONE ON 28/1/26 I/V/O HIGH SUGARS
ADVICE : TAB. METFORMIN 500MG PO/OD @8AM
REQUEST LETTER GIVEN TO PATIENT ATTENDER TO BRINGCD4 COUNT AND VIRAL
MARKERS REPORT
PATIENT VITALS ARE STABLE AT THE TIME OF DISCHARGE
PR- 81BPM, NORMAL VOLUME, REGULAR RHYTHM, NO RADIO-RADIAL OR RADIO-FEMORAL
DELAY.
BP-130/80 MMHG
RR-18 CYCLES /MIN
SPO2 - 99 % AT RA
Investigation
GRAVENDEX TEST (27/1/26) : NEGATIVE
BLOOD GROUPING AND TYPING(27/1/26): O POSITIVE
COMPLETE BLOOD PICTURE (CBP) (27/1/26)
HAEMOGLOBIN 8.8gm/dl
TOTAL COUNT 11,540 cells/cumm
RBC: 3.73 MILION
NEUTROPHILS 60 %
LYMPHOCYTES 34 %
EOSINOPHILS 01%
MONOCYTES 05 %
PLATELET COUNT 1.0LAKH/MM3
SMEAR: NORMOCYTIC NORMOCHROMIC ANAEMIA WITH THROMBOCYTOPENIA
COMPLETE URINE EXAMINATION (CUE) (27/1/26)
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP. GRAVITY 1.010
ALBUMIN Nil
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 2-3
EPITHELIAL CELLS 1-2
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS DEPOSITS ABSENT
OTHERS Nil
FASTING BLOOD SUGAR (27/1/26) :112 MG/DL
POST PRANDIAL SUGARS(27/1/26)- 142 MG/DL
HBA1C(27/1/26):6.4%
SEROLOGY(27//1/26)
Anti HCV Antibodies - RAPID Non Reactive
HBsAg-RAPID Negative
HIV 1/2 RAPID TEST: POSITIVE
USG ABDOMEN AND PELVIS SCAN DONE ON 27/01/26
UTERUS SIZE:6.5 X 3.5 CMS
ET;5MM
RIGHT OVARY:NORMAL S/E
LEFT OVARY;NORMAL S/E
LIVER: 14.1CM, NORMAL S/ INCREASED ECHOTEXTURE, NO F/L, NO IHBRD
GALL BLADER: PARTIALLY DISTENDED
PANCREAS: NORMAL S/E
SPLEEN; NORMAL S/E
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KIMS HOSPITALS
RT KIDNEY :9.4 X 4.0CM NORMAL S/E
LFT KIDNEY :9.5 X 4.1 CMNORMAL S/E
FINDINGS:E/O 35 X 20 MM HETEROGENOUSLY HYPERECHOIC LESION NOTED IN THE
SUBSEREOSA OF POSTERIOR WALL OF UTERUS
IMPRESSION : GRADE I FATTY LIVER
UTERINE FIBROID
Treatment Given(Enter only Generic Name)
TAB. METFORMIN 500MG PO/ODX 2 DAYS
TAB. TELMA 40 PO/ODX 2 DAYS
TAB. PAUSE MF PO/BD X 2 DAYS
TAB TENOFOVIR (TLD) PO/OD X 2 DAYS
TAB MVT PO/ODX 2 DAYS
TAB. CALCIUM 500MG PO/ODX 2 DAYS
TAB. VITAMIN C 500MG PO/ODX 2 DAYS
Advice at Discharge
STRICT DIABETIC DIET
SALT RESTRICTED DIET
PLENTY OF ORAL FLUIDS
IRON AND PROTEIN RICH DIET
TAB. METFORMIN 500MG PO/OD AT 8PM TO BE CONTINUED
TAB. TELMA 40 PO/OD AT 8AMTO BE CONTINUED
TAB TENOFOVIR (TLD) PO/OD AT 8PMTO BE CONTINUED
TAB. PAUSE MF PO/BD X 5 DAYS
TAB MVT PO/OD X 30 DAYS
TAB. CALCIUM 500MG PO/ODX 30 DAYS
TAB. VITAMIN C 500MG PO/ODX 30 DAYS
Follow Up
REVIEW TO GYN OPD WITH CD4 COUNT AND VIRAL MARKERS REPORT AND AFTER
OPTIMISING HEMOGLOBIN, REVIEW SOS I/V/O PAIN ABDOMEN, HEAVY BLEEDING
Discharge Date
Date:28/1/26
Ward: GYN
Unit: II
[4:51 pm, 02/03/2026] PPM 1: Today's update as per @PPM5
Platelets still at 20,000 fluctuating from 20-30 over the last 3 days
Asked the patient's relatives to buy a week's supply of the alternate HAART regimen and applied to the government ART center for providing it free of cost within a week's time
The out of pocket cost of that comes to 4000 in 4 weeks
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