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ID 1183 > 27. Human Immunodeficiency Virus (HIV) > Flashcards

27. Human Immunodeficiency Virus (HIV) Flashcards

1
Q

A HIV positive patient comes in complaining of yellowing of the skin, but is otherwise asymptomatic. Upon further review, it was determined that the patient has asymptomatic jaundice. What medication is he likely receiving that is causing this side effect?

A. Reyataz
B. Emtriva
C. Epivir
D. Prezista
E. Fuzeon

A

A. Reyataz is commonly associated with asymptomatic jaundice. The HIV community often refers to the drug as “bananavir” due to it’s association with yellowing the skin (jaundice). The Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents were updated on April 8, 2015. The Recommended regimens for initial treatment have changed. The atazanvir containing PI-based regimen has been reclassified from a Recommended Regimen to an Alternative Regimen.

Reyataz (atazanavir) - “bananavir”

Emtriva (emtricitabine)

Epivir (lamivudine)

Prezista (darunavir)

Fuzeon (enfuvirtide)

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2
Q

A laboratory technician had an accidental needlestick injury from a needle potentially contaminated with HIV. Which drug combination is the preferred regimen for post-exposure prophylaxis therapy?

A. Zidovudine + nevirapine
B. Zidovudine + abacavir
C. Raltegravir + tenofovir + emtricitibine
D. Zidovudine + lamivudine + nevirapine
E. Zidovudine + lamivudine + abacavir

A

C. Per the updated guidelines a three drug regimen including raltegravir + tenofovir + emtricitibine should be utilized.

Raltegravir (Isentress)

Remember: Truvada for pre-exposure prophylaxis

Raltegravir + Truvada for post-exposure prophylaxis

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3
Q

A patient comes to the pharmacy with a new prescription for emtricitabine. Choose the correct drug class for emtricitabine:

A. Nucleoside Reverse Transcriptase Inhibitor
B. Non-Nucleoside Reverse Transcriptase Inhibitor
C. CCR5 Receptor Antagonist
D. Integrase Inhibitor
E. Protease Inhibitor

A

A. Emtricitabine (Emtriva) is a nucleoside reverse transcriptase inhibitor. The Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents were updated on April 8, 2015.

Class side effects: lactic acidosis, hepatomegaly with steatosis

Class overall: renal adjustments required for all except abacavir (Ziagen), no CYP interactions, generally taken without regards to food.

D-Z T S-A-L-E, pronounced “Dozen T Sale”, helps you name all the NRTIs

Didanosine (Videx)

Zidovudine (Retrovir)

Tenofovir (Viread)

Stavudine (Zerit)

Abacavir (Ziagen)

Lamivudine (Epivir)

Emtricitabine (Emtriva)

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4
Q

A patient gave the pharmacist a prescription for Isentress. Which of the following is an appropriate generic substitution forIsentress?

A. Rilpivirine
B. Tenofovir
C. Raltegravir
D. Tipranavir
E. Maraviroc

A

C. The generic name of Isentress is raltegravir.

Rilpivirine (Edurant) - NNRTI - CYP interaction, no renal adjust

Tenofovir (Viread) - NRTI - renal adjust, no CYP interactions

Tipranavir (Aptivus) - PI - with food, lipid problems

Maraviroc (Selzentry) - CCR5 antagonist - tropism testing

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5
Q

A patient gave the pharmacist a prescription for Sustiva 600 mg PO daily. Which of the following is an appropriate generic substitution for Sustiva?

A. Emtricitabine
B. Etravirine
C. Efavirenz
D. Nevirapine
E. Abacavir

A

C. Efavirenz is the generic name for Sustiva.

Emtricitabine (Emtriva)

Etravirine (Intelence)

Nevirapine (Viramune)

Abacavir (Ziagen)

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6
Q

A patient gave the pharmacist a prescription for Viread 300 mg po daily. Which of the following is an appropriate generic substitution for Viread?

A. Tenofovir
B. Atazanavir
C. Emtricitabine
D. Emtricitabine and tenofovir
E. Nevirapine

A

A. The generic name of Viread is tenofovir.
Atazanavir (Reyataz)
Emtricitabine (Emtriva)
Emtricitabine and tenofovir (Truvada)
Nevirapine (Viramune)

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7
Q

A patient has a HIV infection and does not want to start drug therapy. Which of the following laboratory parameters would be expected to change over time as described below?

A. The viral load will decrease and the CD4+ count will increase
B. The viral load will increase and the CD4+ count will decrease
C. The viral load will increase and the CD4+ count will stay the same
D. The viral load with remain the same and the CD4+ count will increase
E. Both the viral load and the CD4+ count will decrease

A

B. If HIV infection is not treated, the disease will continue to progress. HIV disease progression is indicated by a decreasing CD4+ count and an increasing viral load.

CD4 count: tells us the severity of HIV infection, tells how immune suppressed patients are, lower number is bad, higher is good

Viral load: tells us how many virus is floating around in the body. Helps us determine how well the regimen is working, higher number bad, lower number good.

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8
Q

A patient has been taking atazanavir, ritonavir, tenofovir and emtricitabine for the past two years. The patient is highly compliant and doing well on the medications. The patient understands that atazanavir should not be taken with this class of medications:

A. Phosphodiesterase inhibitors
B. Beta blockers
C. Proton pump inhibitors
D. Anticholinergics
E. Tricyclic antidepressants

A

C. In antiretroviral-experienced patients, the concurrent use of atazanavir (Reyataz) and proton pump inhibitors is not recommended. This drug requires a low gastric pH for absorption. The Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents were updated on April 8, 2015.

“Bananavir” - jaundice

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9
Q

A patient gave the pharmacist a prescription for Prezista. Which of the following is an appropriate generic substitution forPrezista?

A. Tipranavir
B. Maraviroc
C. Emtricitabine
D. Darunavir
E. Fosamprenavir

A

D. The generic name of Prezista is darunavir.

Tipranavir (Aptivus)
Maraviroc (Selzentry)
Emtricitabine (Emtriva)
Fosamprenavir (Lexiva)

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10
Q

A patient is prescribed Epzicom one tablet daily. Epzicom contains the following medications:

A. Zidovudine and lamivudine
B. Efavirenz and tenofovir
C. Emtricitabine and tenofovir
D. Lamivudine and abacavir
E. Abacavir and zidovudine

A

D. Epzicom contains lamivudine and abacavir.

lamivudine (Epivir)

abacavir (Ziagen)

Combination Epi-Zi-Com

zidovudine (Retrovir)

emtricitabine (Emtriva)

tenofovir (Viread)

efavirenz (Sustiva)

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11
Q

A patient is prescribed Atripla. Atripla contains the following medications:

A. Tenofovir, emtricitabine, and efavirenz
B. Atazanavir, ritonavir, emtricitabine
C. Tenofovir, etravirine, and rilpivirine
D. Atazanavir, nevirapine, and delavirdine
E. Efavirenz, lopinavir, and ritonavir

A

A. Atripla is a combination product that contains tenofovir, emtricitabine, and efavirenz. This medication is a top seller. The Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents were updated on April 8, 2015. The Recommended Regimens for initial treatment have changed. Atripla has been reclassified from a Recommended regimen to an Alternative regimen.

Tenofovir (Viread)

Emtricitabine (Emtriva)

Efavirenz (Sustiva)

Atazanavir (Reyataz)

Ritonavir (Norvir)

Etravirine (Intelence)

Rilpivirine (Edurant)

Nevirapine (Viramune)

Delavirdine (Rescriptor)

Lopinavir/ritonavir (Kaletra)

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12
Q

A patient is started on antiretroviral therapy for newly diagnosed HIV infection. Which of the following is a recommended regimen for initial HIV treatment according to the 2015 Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents?

A. Dolutegravir + emtricitabine + tenofovir
B. Abacavir + lamivudine + nevirapine
C. Emtricitabine + lamivudine + zidovudine + delavirdine
D. Etravirine + nevirapine + ritonavir + saquinavir
E. None of the above

A

A. The Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents were updated on April 8, 2015. The Recommended regimens for initial treatment have changed. The RxPrep Test Bank questions have been updated to reflect the new guidelines. Please refer to the Errata and Updates document on the RxPrep website for more information.

There are now 5 Recommended regimens for initial treatment of HIV:

4 INSTI-based regimens

dolutegravir + abacavir/lamivudine (Epzicom)

dolutegravir + tenofovir/emtricitabine (Truvada)

elvitegravir/cobicistat/tenofovir/emtricitabine (Stribild)

raltegravir + tenofovir/emtricitabine (Truvada)

1 ritonavir-boosted PI-based regimen

darunavir + ritonavir + tenofovir/emtricitabine (Truvada)

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13
Q

A patient is started on Videx EC 400 mg daily. Which of the following counseling points are appropriate for the pharmacist to review with the patient? (Select ALL that apply.)

A. The generic name for this medication is didanosine.
B. This medication should be taken on an empty stomach.
C. Store the medication in tightly closed bottles at room temperature.
D. Common side effects such as fat redistribution, hyperlipidemia, hyperglycemia and insulin insensitivity.
E. Rarely, this medication can cause severe liver problems and lactic acidosis.

A

A, B, C, E. Didanosine (Videx EC) is a nucleoside reverse transcriptase inhibitor (NRTI) and should be taken on an empty stomach, 1 hour before or 2 hours after meals. Rarely NRTIs are associated with hepatic steatosis and lactic acidosis. The patient should be counseled on signs/symptoms of these side effects.

Class side effects: lactic acidosis, hepatomegaly with steatosis

Class overall: renal adjustments required for all except abacavir (Ziagen), no CYP interactions, generally taken without regards to food.

D-Z T S-A-L-E, pronounced “Dozen T Sale”, helps you name all the NRTIs

Didanosine (Videx)

Zidovudine (Retrovir)

Tenofovir (Viread)

Stavudine (Zerit)

Abacavir (Ziagen)

Lamivudine (Epivir)

Emtricitabine (Emtriva)

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14
Q

A patient is taking indinavir. Which of the following statements regarding indinavir are correct? (Select ALL that apply.)

A. This medication can cause nephrolithiasis. Drink at least 48 ounces of water daily.
B. Capsules are sensitive to moisture; desiccant should remain in the bottle.
C. The brand name is Invirase.
D. This medication should be taken once daily.
E. This medication interacts with many medications. Tell your pharmacist and/or doctor if you start a new medication, including herbal products.

A

A, B, E. Indinavir (Crixivan) can cause nephrolithiasis; therefore, it is recommended to drink at least 48 ounces of water daily. Indinavir should be stored at room temperature and dispensed in the original container and the desiccant should remain in the bottle. The capsules are sensitive to moisture. Indinavir should be taken three times daily (unboosted) or twice daily (boosted). Patients should be counseled about the risk for drug interactions with all protease inhibitors.

Invirase (saquinavir)

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15
Q

A patient with HIV has a CD4+ count of 93 cells/mm3 and is toxoplasma IgG positive. Based on CD4+ count, which of the following opportunistic infections should this patient receive prophylaxis against at this time? (Select ALL that apply.)

A. Pneumocystis pneumonia
B. Toxoplasma gondii
C. Mycobacterium avium
D. Cytomegalovirus
E. Cryptococcus meningitis

A

A, B. Pneumocystis prophylaxis is indicated for a CD4+ count

Pneumocystis pneumonia: CD4 3
Toxoplasma gondii: CD4 3
Mycobacterium avium complex (MAC): CD4 3

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16
Q

A pharmacist receives a prescription for Combivir. What medications are in this product?

A. Emtricitabine + tenofovir
B. Lopinavir + ritonavir
C. Emtricitabine + tenofovir + rilpivirine
D. Zidovudine + lamivudine
E. Zidovudine + abacavir

A

D. Combivir contains zidovudine (Retrovir) + lamivudine (Epivir).

emtricitabine (Emtriva) + tenofovir (Viread) = Truvada

lopinavir + ritonavir (Norvir) = Kaletra

rilpivirine (Edurant) + Truvada = Complera - take with food

zidovudine (Retrovir) + abacavir (Ziagen) + lamivudine (Epivir) = Trizivir

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17
Q

A pharmacist receives a prescription for Stribild. What medications are in this product?

A. Atazanavir + ritonavir + emtricitabine + tenofovir
B. Raltegravir + emtricitibine + tenofovir
C. Dolutegravir + rilpivirine + emtricitibine + tenofovir
D. Elvitegravir + cobicistat + emtricitabine + tenofovir
E. Rilpivirine + emtricitibine + tenofovir

A

D. Stribild contains elvitegravir + cobicistat + emtricitabine + tenofovir.

Elvitegravir (Vitekta)

Cobicistat (Tybost)

Emtricitabine (Emtriva)

Tenofovir (Viread)

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18
Q

A pharmacist receives a prescription for Complera. What medications are in this product?

A. Zidovudine + lamivudine
B. Zidovudine + lamivudine + abacavir
C. Emtricitabine + tenofovir
D. Emtricitabine + tenofovir + efavirenz
E. Emtricitabine + tenofovir + rilpivirine

A

E. Complera contains emtricitabine + tenofovir + rilpivirine. The Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents were updated on April 8, 2015. The Recommended regimens for initial treatment have changed. Complera was previously listed as Recommended regimens for baseline HIV RNA 200 cells/mm3 are now reclassified as an Alternative regimen, with the same caveat about limiting their use in these populations.

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19
Q

A pharmacist receives a prescription for Truvada. What medications are in this product?

A. Emtricitabine + tenofovir + efavirenz
B. Emtricitabine + tenofovir + rilpivirine
C. Zidovudine + lamivudine
D. Zidovudine + lamivudine + abacavir
E. Emtricitabine + tenofovir

A

E. Truvada contains emtricitabine + tenofovir.

emtricitabine (Emtriva) + tenofovir (Viread) = Truvada

Truvada + efavirenz (Sustiva) = Atripla

Truvada + rilpivirine (Edurant) = Complera

zidovudine (Retrovir) + lamivudine (Epivir) = Combivir

Combivir + abacavir (Ziagen) = Trizivir

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20
Q

A physician is considering starting abacavir on a patient diagnosed with HIV. Which of the following statements regarding abacavir is correct? (Select ALL that apply.)

A. This medication can cause a severe hypersensitivity reaction.
B. Patients must be screened for the HLA-B 1502 allele. If positive, the medication should not be given.
C. When combined with lamivudine, the brand name is Truvada.
D. Abacavir is a protease inhibitor.
E. The brand name is Ziagen.

A

A, E. Abacavir (Ziagen) has a boxed warning regarding the risk of serious, and possibly fatal, hypersensitivity reaction. Every patient should be screened for the HLA-B*5701 allele. If the test is positive, the patient should not receive the drug. Abacavir plus lamivudine is Epzicom. Abacavir is a NRTI.

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21
Q

An HIV patient is admitted to the hospital. The pharmacist conducts the admission medication reconciliation and documents the following information in the medical record:
Home medications and dosing:
Tipranavir 500 mg capsule at 10am and 10pm with food
Lamivudine 300 mg tablet at 12pm with lunch
Ritonavir 200 mg capsule at 7am and 7pm with food
Zidovudine 300 mg tablet at 10am and 10pm with food
What is wrong with the information obtained in this medication reconciliation?

A. Tipranavir must be taken without food.
B. This lamivudine dosing regimen is for Epivir HBV and should not be used for HIV patients.
C. When ritonavir is used to boost another PI, they must be administered at the same time.
D. Zidovudine is only available as an IV formulation.
E. Ritonavir must be taken without food.

A

C. Ritonavir is mainly used to “boost” the levels of other PIs. For this reason, it is critical that ritonavir be given at the same time as the other PI. Not administering them together or omitting one of the PIs is a common error during transitions of care that could contribute to resistance.

Tipranavir (Aptivus) - PI

Lamivudine (Epivir) - NRTI

Ritonavir (Norvir) - PI

Zidovudine (Retrovir) - NRTI

Most PIs are taken with food.

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22
Q

Adherence is critical to successful antiretroviral therapy. When counseling a patient on his antiretroviral regimen, which of the following statements regarding adherence would be most accurate?

A. To achieve the best outcome, you must never miss a dose. If you miss a dose, resistance will develop, and we will not be able to treat your HIV.
B. Everyone misses doses occasionally. If you miss a dose or two every couple of days, it is no big deal as long as you double your dose on the days you missed.
C. Everyone misses doses occasionally; however research has shown to achieve the best control of your HIV infection, you should take 95 out of every 100 doses (or more) as prescribed by your doctor.
D. Everyone misses doses occasionally; however research has shown to achieve the best control of your HIV infection, you should take 75% of your prescribed doses.
E. As long as protease inhibitors are boosted with ritonavir and all antiretrovirals are taken with food to facilitate absorption, missing doses becomes irrelevant.

A

C. Patients need to be advised that they need to have an adherence rate of 95% or higher in order for their ART regimen to be effective long-term.

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23
Q

Barbara is at risk of developing Mycobacterium avium complex (MAC). Which of the following agents should be given to prevent this opportunistic infection?

A. Azithromycin 1,200 mg PO daily
B. Trimethoprim-sulfamethoxazole 1 single strength tab daily
C. Azithromycin 1,200 mg PO weekly
D. Clarithromycin 600 mg PO twice weekly
E. Trimethoprim-sulfamethoxazole 1 double strength tab daily

A

C.

Pneumocystis pneumonia: CD4 3
Toxoplasma gondii: CD4 3
Mycobacterium avium complex (MAC): CD4 3

Pneumocystis pneumonia: TMP/SMX 1 DS or SS PO daily
Toxoplasma gondii: TMP/SMX 1 DS PO daily
Mycobacterium avium complex (MAC): azithromycin 1200mg PO weekly (or 600mg PO twice weekly)

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24
Q

Chief Complaint: “I think I have HIV”

History of Present Illness: QL is a 25 y/o white female who presents to the family medicine clinic. She is crying and says she thinks she has HIV. She admits to having unprotected sex “several times”. She just found out that one of the men she had unprotected sex with tested positive for HIV. She took an OTC HIV test several days ago and it was positive. QL is single and lives with her parents who are helping her raise her 3 year-old daughter.

Allergies: Penicillin

Past Medical History: None

Medications: None

Vitals:

Height: 5’8” Weight: 132 pounds

BP: 122/76 mmHg HR: 78 BPM RR: 13 BPM Temp: 98.5°F Pain: 0/10

Labs:

Na (mEq/L) = 136 (135 - 145)

WBC (cells/mm3) = 10.2 (4 - 11 x 10^3)

K (mEq/L) = 3.6 (3.5 - 5)

Hgb (g/dL) = 11.2 (13.5 - 18 male, 12 - 16 female)

Cl (mEq/L) = 99 (95 - 103)

Hct (%) = 33.4 (38 - 50 male, 36 - 46 female)

HCO3 (mEq/L) = 27 (24 - 30)

Plt (cells/mm3) = 160 (150 - 450 x 10^3)

BUN (mg/dL) = 12 (7 - 20)

Albumin (g/dL) = 3.6 (3.5 - 5)

SCr (mg/dL) = 0.8 (0.6 - 1.3)

Glucose (mg/dL) = 102 (100 - 125)

Ca (mg/dL) = 8.8 (8.5 - 10.5)

Mg (mEq/L) = 1.5 (1.3 - 2.1)

PO4 (mg/dL) = 2.5 (2.3 - 4.7)

Tests:

HIV ELISA pending

Question:
Which of the following statements is true regarding over-the counter HIV tests?

A. The OTC tests report the patient’s CD4+ count and viral load if the result is positive.
B. Patients who get a positive result on an OTC test require a confirmatory HIV Ab test at their physician’s office.
C. Patients should take the OTC tests within 48 hours after the risk event for most accurate results.
D. The OraQuick test involves a fingerstick blood sample that is shipped in a pre-paid overnight envelope.
E. The Express HIV-1 Test System involves a urine sample that is shipped in a pre-paid overnight envelope.

A

B. Patients with a positive result on an OTC HIV test must get a confirmatory test in a physician’s office. The OTC tests should be taken at least 3 months after the risk event.

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25
Q

GH comes into the pharmacy with a prescription for Emtriva capsules. What is the correct dose for a patient without renal impairment?

A. 100 mg PO daily
B. 150 mg PO daily
C. 200 mg PO daily
D. 300 mg PO daily
E. 400 mg PO BID

A

C. Emtriva (emtricitabine) capsules are dosed at 200 mg PO daily in normal renal function.

Remember Truvada = 200mg/300mg (emtricitabine/tenofovir) once daily.

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26
Q

Ernesto has been on antiretroviral therapy for three years and has been compliant. His doctor recently noticed some side effects from the medicines he is taking. Ernesto is experiencing dyslipidemia, fat maldistribution and insulin resistance. These side effects most commonly occur with the following class of medications:

A. Nucleoside Reverse Transcriptase Inhibitors
B. Non-Nucleoside Reverse Transcriptase Inhibitors
C. Protease Inhibitors
D. Integrase Inhibitors
E. Entry Inhibitors

A

C. Dyslipidemia, fat maldistribution (peripheral fat loss and central fat accumulation), and insulin resistance commonly occur with protease inhibitor (PI) therapy. Dyslipidemia occurs in up to 70% of patients and fat maldistribution in about 50% of PI-treated patients. Blood glucose and lipids must be monitored and treatment initiated if the parameters are elevated.

Remember PI sounds like “pie”.

NRTI class side effects: lactic acidosis, hepatomegaly with steatosis

Class overall: renal adjustments required for all except abacavir (Ziagen), no CYP interactions, generally taken without regards to food.

NNRTI class side effects: rash, Steven Johnson’s Syndrome (SJS), hepatoxicity

No renal dose adjustment

Watch for CYP interactions

PI class side effects: hyperlipotrophy, fat accumulation, buffalo hump, liver toxicity, metabolic problems such as high sugars or lipids.

No renal adjustments needed

Many CYP interactions – PI = Potent Inhibitor

Most should be taken with food, some exceptions

No renal adjustments usually means there will be CYP interactions for HIV drugs.

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27
Q

HIV is a communicable disease. Transmission can occur by: (Select ALL that apply.)

A. Blood
B. Semen
C. Vaginal fluid
D. Saliva
E. Breast milk

A

A, B, C, E. HIV can be transmitted via blood, semen, vaginal fluid, pre-ejaculate, and breast milk, but NOT saliva or fecal matter (non-bloody).

28
Q

In which of the following scenarios should antiretroviral therapy be initiated regardless of the CD4 count? (Select ALL that apply.)

A. A 21 year old asymptomatic women with confirmed HIV who is eager to start therapy.
B. Presence of an AIDS defining illness (e.g., Kaposi’s sarcoma).
C. A 33 year old male who is co-infected with hepatitis C virus.
D. 24 year old pregnant women with HIV.
E. 49 year old male with HIV-associated nephropathy.

A

A, B, C, D, E. Antiretroviral therapy should be initiated for all of the following scenarios. Recall that co-infection of hepatitis B and C virus are compelling indications to start antiretroviral therapy. Therapy should be offered to all individuals who are willing/eager to start therapy regardless of the CD4 count.

29
Q

JR, who is clinically depressed and self-medicating with St. John’s wort, was recently diagnosed with HIV/AIDS and was started on the following regimen: Prezista 800 mg + 100 mg ritonavir PO daily and Truvada 1 tablet PO daily. He is allergic to sulfa which causes a mild rash. Which of the following counseling points are appropriate regarding Prezista? (Select ALLthat apply.)

A. Discuss with his doctor regarding his St. John’s wort as it may decrease the levels of Prezista.
B. Take on an empty stomach and swallow the tablet whole.
C. Take his Prezista with the ritonavir.
D. Changes in body fat may occur while you are taking this medication.
E. The patient should be instructed to monitor for rash given his sulfa allergy and contact his doctor if occurs.

A

A, C, D, E. Darunavir (Prezista) should always be prescribed/given with ritonavir. It has a sulfa moiety and should be used with caution among patients with a sulfa allergy (not contraindicated) - patients should be instructed to monitor for rash. St Johns Wort, a CYP 3A4 inducer, may reduce the levels of darunavir and should be avoided if possible. All protease inhibitors are associated with fat redistribution and patients should be counseled on this side effect.

Sulfa moiety with darunavir (Prezista), tipranvavir (Aptivus), fosamprenavir (Lexiva)

30
Q

LA is a 31 year old female who recently started antiretroviral therapy. Her medical record shows that 2 months ago she was found to be HIV positive (viral HIV RNA load of 140,000 copies/mL and a CD4+ count of 190 cells/mm3) and started on antiretroviral therapy. She now presents with signs and symptoms of Pneumocystis pneumonia and immune reconstitution syndrome. How would you manage her Pneumocystis infection and immune reconstitution syndrome?

A. Start treatment for Pneumocystis pneumonia and continue her current antiretroviral regimen.
B. Start treatment for Pneumocystis pneumonia and discontinue her current antiretroviral regimen.
C. Start treatment for Pneumocystis pneumonia and change her current antiretroviral regimen since it is not working.
D. Do not treat the Pneumocystis pneumonia and continue her current HIV antiretroviral regimen. The Pneumocystis pneumonia infection will resolve on its own with proper antiretroviral therapy.
E. Stop all medications and treat with corticosteroids only.

A

A. Treatment of immune reconstitution syndrome includes treating the underlying pathogen, continuing antiretroviral therapy and possibly the addition of corticosteroids.

Pneumocystis pneumonia: CD4 3
Toxoplasma gondii: CD4 3
Mycobacterium avium complex (MAC): CD4 3

Pneumocystis pneumonia: TMP/SMX 1 DS or SS PO daily
Toxoplasma gondii: TMP/SMX 1 DS PO daily
Mycobacterium avium complex (MAC): azithromycin 1200mg PO weekly (or 600mg PO twice weekly)

31
Q

Max comes to the emergency department with a severe skin rash and epidermal detachment. He is diagnosed with toxic epidermal necrolysis (TEN). He states he was recently started on some HIV medications. Which of the following medications is most likely the cause of his TEN reaction?

A. Nevirapine
B. Delavirdine
C. Emtricitabine
D. Stavudine
E. Tipranavir

A

A. Nevirapine has a boxed warning regarding the risk of severe, life-threatening skin reactions. Intensive monitoring is required during the first 18 weeks of therapy.

Nevirapine (Viramune) - 14 day lead-in period before increasing dose from 200mg daily to 400mg daily

Delavirdine (Rescriptor)

Emtricitabine (Emtriva)

Stavudine (Zerit)

Tipranavir (Aptivus)

32
Q

Patrick requires prophylaxis for Pneumocystis pneumonia. Which medications could be recommended for prophylaxis ofPneumocystis pneumonia depending on the patients allergies? (Select ALL that apply.)

A. Trimethoprim-Sulfamethoxazole Single Strength 1 tablet PO daily
B. Trimethoprim-Sulfamethoxazole Double Strength 1 tablet PO daily
C. Clarithromycin 500 mg PO BID
D. Moxifloxacin 400 mg PO daily
E. Dapsone 100 mg PO daily

A

A, B, E. Trimethoprim-sulfamethoxazole (either as the single strength or double strength tablet) is most commonly used. Dapsone or atovaquone can be used in the setting of sulfa allergy.

Pneumocystis pneumonia: CD4 3
Toxoplasma gondii: CD4 3
Mycobacterium avium complex (MAC): CD4 3

Pneumocystis pneumonia: TMP/SMX 1 DS or SS PO daily
Toxoplasma gondii: TMP/SMX 1 DS PO daily
Mycobacterium avium complex (MAC): azithromycin 1200mg PO weekly (or 600mg PO twice weekly)

33
Q

JR, a 32 year old HIV positive male, is initiated on antiretroviral therapy. Which of the following protease inhibitor based regimens are considered first line therapy according to the 2015 Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents and is/are dosed once daily? (Select ALL that apply.)

A. Raltegravir + lamivudine + zidovudine
B. Efavirenz + emtricitabine + tenofovir
C. Delavirdine + lamivudine + zidovudine
D. Lopinavir + ritonavir + abacavir + lamivudine
E. Darunavir + ritonavir + emtricitabine + tenofovir

A

E. Darunavir/ritonavir + tenofovir/emtricitabine is considered a preferred combination and is dosed once daily. Other choices are not once daily, are not preferred regimens or are not PI-based. The Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents were updated on April 8, 2015.

There are now 5 Recommended regimens for initial treatment of HIV:

4 INSTI-based regimens

dolutegravir + abacavir/lamivudine (Epzicom)

dolutegravir + tenofovir/emtricitabine (Truvada)

elvitegravir/cobicistat/tenofovir/emtricitabine (Stribild)

raltegravir + tenofovir/emtricitabine (Truvada)

1 ritonavir-boosted PI-based regimen

darunavir + ritonavir + tenofovir/emtricitabine (Truvada)

Remember: Truvada + DRDr (Dolutegravir OR Raltegravir OR Darunavir/ritonavir)

34
Q

Proton pump inhibitors are contraindicated with which of the following medications?

A. Prezista
B. Crixivan
C. Aptivus
D. Edurant
E. Vitekta

A

D. All PPIs are contraindicated with rilpivirine (Edurant), so PPIs are also contraindicated with the combination product containing it. NNRTIs as a class have many drug interactions.

Prezista (darunavir)

Crixivan (indinavir)

Aptivus (tipranavir)

Edurant (rilpivirine)

Vitekta (elvitegravir)

NNRTIs class side effects: rash, Steven Johnson’s Syndrome (SJS), hepatoxicity

No renal dose adjustment

Watch for CYP interactions

35
Q

RP comes into the pharmacy with a prescription for Viread tablets. What is the correct dose for a patient without renal impairment?

A. 100 mg PO daily
B. 150 mg PO daily
C. 200 mg PO daily
D. 300 mg PO daily
E. 400 mg PO BID

A

D. Viread is dosed at 300 mg PO daily in normal renal function.

Viread (tenofovir)

Decrease dose when CrCl

36
Q

Tammi comes into the pharmacy with a prescription for Sustiva. What is the correct dose of this medication?

A. 100 mg PO QHS
B. 200 mg PO QHS
C. 400 mg PO QHS
D. 600 mg PO QHS
E. 1200 mg PO QHS

A

D. Sustiva (efavirenz) is dosed at 600 mg PO QHS.

37
Q

Tanya comes in for a routine clinic appointment today. She has HIV and has been stable on her regimen of darunavir plus ritonavir, tenofovir, and emtricitabine. Which of the following statements regarding ritonavir are correct? (Select ALL that apply.)

A. Ritonavir is used as monotherapy for treating HIV during pregnancy.
B. Ritonavir is a strong inhibitor of 3A4 and 2D6 and has many drug interactions.
C. Ritonavir should be taken on an empty stomach.
D. The brand name is Norvir.
E. Ritonavir can be used to increase the serum drug level of another, concurrently-used protease inhibitor.

A

B, D, E. Ritonavir (Norvir) is a protease inhibitor that is often used to “boost” the level of a concurrent protease inhibitor serum drug concentration (PI-boosted regimen). Ritonavir is a major inhibitor of 3A4 and 2D6 (and 2C8) and has a boxed warning regarding serious, and potentially fatal, drug interactions.

38
Q

Devin was started on antiretroviral therapy and had poor adherence. He was put into counseling and a patient support group. Despite intensive help, he was not able to demonstrate adherence with therapy. Devin has decided that forces other than medicine will decide if he lives or if he dies. Today his CD4+ count is 105 cells/mm3. Choose the correct statements: (Select ALL that apply.)

A. Devin should be restarted on HIV medications right away.
B. It may be best for Devin to defer treatment until he is able to take the medicines as directed.
C. Taking medications intermittently will increase the risk of drug resistance.
D. Devin should receive prophylaxis to prevent Cytomegalovirus infection.
E. Devin should be educated on safe sex practices.

A

B, C, E. Patients initiating ART should be willing and able to commit to lifelong treatment and should understand the benefits and risks of therapy and the importance of adherence. Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy based on clinical and/or psychosocial factors. Primary prophylaxis for Cytomegalovirus (CMV) is not indicated regardless of patients CD4 count. He should be educated on safe sex practices with the goal of reduced risk for transmission of HIV.

39
Q

The primary care doctor of DJ, a 52 year old HIV positive male with a CD4 count of 142 cells/mm3 who has a history of hyperlipidemia treated with simvastatin and poorly controlled schizophrenia treated with ziprasidone, has decided to initiate antiretroviral therapy. Which of the following statements are true regarding initiating antiretroviral therapy and other supportive care in DJ? (Select ALL that apply.)

A. Change his simvastatin to pravastatin.
B. Initiate sulfamethoxazole/trimethoprim for prevention of Pneumocystis.
C. Consider initiation of a darunavir based regimen. It is a recommended regimen and less likely to be associated with hyperlipidemia.
D. Consider initiation of a efavirenz based regimen as it has the least effect on his psychiatric disease.
E. Reinforce the importance of diet and exercise in the setting of hyperlipidemia.

A

A, B, C, E. Darunavir/ritonavir + tenofovir/emtricitabine is a Recommended regimen. Darunavir has less effect on lipids than other PIs. Simvastatin and PIs would have a critical drug interaction and it is recommended to change simvastatin to pravastatin. Efavirenz should be avoided in active psychiatric disease. Reinforcement of diet/exercise should be considered at each visit for patients with active hyperlipidemia. The Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents were updated on April 8, 2015. The Recommended regimens for initial treatment have changed.

40
Q

The primary goals of antiretrovirals are to: (Select ALL that apply.)

A. Restore and preserve the immune function.
B. Suppress HIV viral load.
C. Decrease CD4 lymphocyte count.
D. Decrease incidence of opportunistic infections.
E. Reduce the risk of HIV transmission.

A

A, B, D, E. All of the following are goals of initiation of antiretroviral therapy except decreasing CD4 count (goal is to increase CD4 count).

41
Q

TW comes into the pharmacy with a prescription for Isentress tablets. What is the correct dose for this medication?

A. 100 mg PO daily
B. 150 mg PO daily
C. 200 mg PO daily
D. 300 mg PO daily
E. 400 mg PO BID

A

E. Isentress (raltegravir) is dosed at 400 mg PO BID.

42
Q

Chief Complaint: “I think I have HIV”

History of Present Illness: QL is a 25 y/o white female who presents to the family medicine clinic. She is crying and says she thinks she has HIV. She admits to having unprotected sex “several times”. She just found out that one of the men she had unprotected sex with tested positive for HIV. She took an OTC HIV test several days ago and it was positive. QL is single and lives with her parents who are helping her raise her 3 year-old daughter.

Allergies: Penicillin

Past Medical History: None

Medications: None

Vitals:

Height: 5’8” Weight: 132 pounds

BP: 122/76 mmHg HR: 78 BPM RR: 13 BPM Temp: 98.5°F Pain: 0/10

Labs:

Na (mEq/L) = 136 (135 - 145)

WBC (cells/mm3) = 10.2 (4 - 11 x 10^3)

K (mEq/L) = 3.6 (3.5 - 5)

Hgb (g/dL) = 11.2 (13.5 - 18 male, 12 - 16 female)

Cl (mEq/L) = 99 (95 - 103)

Hct (%) = 33.4 (38 - 50 male, 36 - 46 female)

HCO3 (mEq/L) = 27 (24 - 30)

Plt (cells/mm3) = 160 (150 - 450 x 10^3)

BUN (mg/dL) = 12 (7 - 20)

Albumin (g/dL) = 3.6 (3.5 - 5)

SCr (mg/dL) = 0.8 (0.6 - 1.3)

Glucose (mg/dL) = 102 (100 - 125)

Ca (mg/dL) = 8.8 (8.5 - 10.5)

Mg (mEq/L) = 1.5 (1.3 - 2.1)

PO4 (mg/dL) = 2.5 (2.3 - 4.7)

Tests:

HIV ELISA pending

Question:
QL’s labs confirm a diagnosis of HIV. At diagnosis, her CD4+ count is 156 cells/mm3 and her viral load is 267,540 copies/mL. HIV resistance testing is also performed. The HIV Specialist caring for her starts her on Triumeq. What is the integrase strand transfer inhibitor (INSTI) component of Triumeq?

A. Rilpivirine
B. Abacavir
C. Dolutegravir
D. Elvitegravir
E. Cobicistat

A

C.

Rilpivirine (Edurant) - NNRTI

Abacavir (Ziagen) - NRTI

Dolutegravir (Tivicay) - PI

Elvitegravir (Vitekta) - INSTI

Cobicistat (Tybost) - PI

43
Q

TY is a 62 y/o male patient with multiple medical problems including HIV. He has been on several different ART regimens since his diagnosis 3 years ago, but has never had an opportunistic infection. He is currently taking the following medications: Truvada, Tivicay, and Bactrim DS for HIV/OI prophylaxis and Zestril, Lasix, Coreg, Lantus, and Protonix for his other medical problems. His most recent CD4+ and viral load results are listed:
11/2/14
Viral load: 35,000 copies/mL
CD4+: 450 cells/mm3
9/15/14
Viral load: 42,675 copies/mL
CD4+: 525 cell/mm3
7/14/14
Viral load: 32,999 copies/mL
CD4+: 487 cells/mm3
6/2/14
Viral load: 21,895 copies/mL
CD4+: 250 cells/mm3
What change in TY’s medication regimen should be recommended today?

A. Discontinue Tivicay.
B. Discontinue Bactrim.
C. Discontinue Protonix.
D. Initiate azithromycin.
E. Change Truvada to Triumeq.

A

B. Bactrim for primary prophylaxis of PCP can be discontinued when CD4+ count is > 200 cells/mm3 for > 3 months on ART.

Tivicay (dolutegravir) -

Triumeq (abacavir, dolutegravir, lamivudine)

Integrase Inhibitors (INSTIs)

Class SE; headache, insomnia, myopathy

3 drugs in this class: dolutegravir, elvitegravir, raltegravir

No renal adjustments, except with Stribild (do not start if CrCl

Separate from polyvalent cations (e.g antacids)

With or without food; Stribild with food because Cobicistat is a PI and that’s usually with food

44
Q

Wendy has a new prescription for Kaletra. Which of the following statements regarding Kaletra is correct?

A. Kaletra is a combination product of ritonavir and saquinavir.
B. Kaletra oral solution should be taken with food.
C. Kaletra has little risk of drug interactions.
D. Kaletra tablets should be taken on an empty stomach.
E. Kaletra is a non-nucleoside reverse transcriptase inhibitor.

A

B. Kaletra comes in oral tablets and an oral solution. The solution should be taken with food while the tablets are taken without regard to meals.

Kaletra (lopinavir/ritonavir) - PI - lots of drug interactions

Saquinavir (Invirase) - PI

Ritonavir (Norvir) - PI booster

45
Q

A pharmacist receives a prescription for Trizivir. What medications are in this product?

A. Zidovudine + lamivudine
B. Zidovudine + lamivudine + abacavir
C. Emtricitabine + tenofovir
D. Emtricitabine + tenofovir + efavirenz
E. Emtricitabine + tenofovir + rilpivirine

A

B. Trizivir contains zidovudine + lamivudine + abacavir.

Zidovudine (Retrovir)

Lamivudine (Epivir)

Abacavir (Ziagen)

Emtricitabine (Emtriva)

Tenofovir (Viread)

Efavirenz (Sustiva)

Rilpivirine (Edurant)

46
Q

What is the role of cobicistat in the combination product for HIV?

A. Integrase strand transfer inhibitor
B. Protease inhibitor
C. Protease inhibitor booster
D. CCR5 antagonist
E. Non-nucleoside reverse transcriptase inhibitor

A

C. Cobicistat in a combination product is used as a protease inhibitor booster similar to ritonavir. It is also approved as a single entity, but clinical use of the single drug is yet to be established.

Cobicistat (Tybost) is found in Stribild containing elvitegravir (Vitekta), emtricitabine (Emtriva), tenofovir (Viread)

47
Q

A patient comes in to fill the following prescription: Atripla 1 tablet PO QHS. She also asks for a refill on her Sustiva tablets as she does not want to run out of her medicine. You should tell the patient which of the following?

A. You cannot fill them because there is a drug interaction.
B. Her medications will be ready in a few minutes.
C. You fill them but tell the patient to separate the doses by 6 hours.
D. You cannot fill them because there is duplicate therapy of tenofovir.
E. You cannot fill them because there is duplicate therapy of efavirenz.

A

E. Both Atripla and Sustiva contain efavirenz. The Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents were updated on April 8, 2015. The Recommended regimens for initial treatment have changed. Atripla has been reclassified as an Alternative regimen.

Atripla (efavrienz/tenofovir/emtricitabine)

Sustiva (efavirenz) - NNRTI

48
Q

Which antiretroviral is available in intravenous formulation that is used to prevent perinatal transmission of HIV?

A. Sustiva
B. Selzentry
C. Retrovir
D. Rescriptor
E. Kaletra

A

C. Zidovudine (Retrovir) is available in intravenous formulation and is used to prevent perinatal transmission of HIV during labor.

49
Q

Which antiretroviral is most likely to cause anemia?

A. Lamivudine
B. Flucytosine
C. Abacavir
D. Zidovudine
E. Efavirenz

A

D. Zidovudine (Retrovir) is associated with anemia. Flucytosine can cause bone marrow suppression, but is a antifungal agent.

Myopathy and hematologic toxicity are black boxed warnings.

Lamivudine (Epivir)

Flucytosine (Ancobon)

Abacavir (Ziagen)

Efavirenz (Sustiva)

50
Q

Which medication requires patients to have a screening test performed before starting to determine the tropism of the HIV?

A. Enfuvirtide
B. Cobicistat
C. Elvitegravir
D. Maraviroc
E. Epzicom

A

D. Maraviroc (Selzentry) will only be effective in patients with the CCR5-tropic disease.

Enfuvirtide (Fuzeon)

Cobicistat (Tybost)

Elvitegravir (Vitekta)

Epzicom (lamivudine/abacavir)

51
Q

Which of the following HIV medications should be taken with food? (Select ALL that apply.)

A. Edurant
B. Reyataz
C. Prezista
D. Sustiva
E. Atripla

A

A, B, C.

Edurant (rilpivirine)

Reyataz (atazanavir)

Prezista (darunavir)

Sustiva (efavirenz)

Atripla (Truvada + efavirenz)

52
Q

A healthcare worker has started post-exposure prophylaxis therapy for a needlestick injury. How long should the patient take the recommended therapy?

A. 2 weeks
B. 4 weeks
C. 6 weeks
D. 12 weeks
E. 24 weeks

A

B. Treatment should be started as soon as possible (ideally within 72 hours) and continued for a full 4-week regimen.

53
Q

Which of the following is a recommended ART regimen in a pregnant woman?

A. Elvitegravir + cobicistat + tenofovir + emtricitabine
B. Lopinavir + ritonavir + zidovudine + lamivudine
C. Efavirenz + abacavir + atazanvir + ritonavir
D. Tenofovir + lamivudine + zidovudine + ritonavir
E. None of the above, pregnant women should not be started on ART

A

B.

Preferred regimen in Pregnant HIV women

2 NRTIs backbone

Abacavir/lamivudine (Epzicom)

Tenofovir/emtricitabine (Truvada)

Zidovudine/lamivudine (Combivir) – most clinical data

PI (boosted with ritonavir) + 2 NRTIs

Atazanavir/ritonavir + 2 NRTIs

Lopinavir/ritonavir (Kaletra) + 2 NRTIs – most clinical data

NNRTI + 2 NRTIs

Efavirenz + 2 NRTIs – Efavirenz is category D

54
Q

Which of the following is correct regarding initiation and discontinuation of Stribild in patients with renal impairment?

A. Stribild should not be started in patients with CrCl B. Stribild should not be started in patients with CrCl C. Stribild should not be started in patients with CrCl D. Stribild should not be started in patients with CrCl E. Stribild should not be started in patients with CrCl

A

D. Stribild causes proteinuria and increased SCr.

Taken once daily with food because combination contains elvitegravir (Vitekta), cobicistat (Tybost), emtricitabine (Emtriva), tenofovir (Viread)

55
Q

Which of the following medications are nucleoside/tide reverse transcriptase inhibitors? (Select ALL that apply.)

A. Fuzeon
B. Viread
C. Reyataz
D. Epivir
E. Viramune

A

B, D.

Class side effects: lactic acidosis, hepatomegaly with steatosis

Class overall: renal adjustments required for all except abacavir (Ziagen), no CYP interactions, generally taken without regards to food.

D-Z T S-A-L-E, pronounced “Dozen T Sale”, helps you name all the NRTIs

Didanosine (Videx)

Zidovudine (Retrovir)

Tenofovir (Viread)

Stavudine (Zerit)

Abacavir (Ziagen)

Lamivudine (Epivir)

Emtricitabine (Emtriva)

56
Q

A HIV-positive patient with a history of poor medication adherence has a CD4+ count less than 50 cells/mm3. He develops cytomegalovirus (CMV) retinitis. Which medication should be recommended?

A. Fluconazole
B. Valganciclovir
C. Clarithromycin
D. Nystatin
E. Trimethoprim-Sulfamethoxazole

A

B. Cytomegalovirus (CMV) is a double-stranded DNA virus in the Herpes virus family that can cause disseminated or localized end-organ disease among patients with advanced immunosuppression. Valganciclovir is a first-line treatment option for CMV.

HSV, VZV coverage: acyclovir (Zovirax), valacyclovir (Valtrex), famciclovir (Famvir)

CMV coverage: ganciclovir (Cytovene), valganciclovir (Valcyte), cidofovir (Vistide), foscarnet (Foscavir)

57
Q

Which of the following medications is administered via SC injection?

A. Selzentry
B. Lexiva
C. Aptivus
D. Crixivan
E. Fuzeon

A

E. Enfuvirtide (Fuzeon) is a fusion inhibitor given via SC injection. It has no significant drug interactions, but almost 100% of patients experience injection site reactions.

Selzentry (maraviroc) - need to test tropism before starting for CCR5

Lexiva (fosamprenavir) - sulfa moiety

Aptivus (tipranavir) - sulfa moiety

Crixivan (indinavir) - kidney stones

Prezista (darunavir) - sulfa moiety

58
Q

Which of the following medications should be taken on an empty stomach? (Select ALL that apply.)

A. Atazanavir
B. Efavirenz
C. Darunavir
D. Ritonavir
E. Didanosine

A

B, E. Efavirenz and didanosine should be taken on an empty stomach.

Atazanavir (Reyataz) - PI

Efavirenz (Sustiva) - empty stomach to reduce side effect risk, also taken at bedtime due to CNS SEs - NNRTI

Darunavir (Prezista) - PI

Ritonavir (Norvir) - PI

Didanosine (Videx) - NRTI

59
Q

Which of the following statements are accurate regarding Nucleoside Reverse Transcriptase Inhibitors (NRTIs)? (Select ALLthat apply.)

A. The entire class has a boxed warning for pancreatitis.
B. The entire class has a boxed warning for Stevens-Johnson Syndrome.
C. They interfere with viral replication by binding to the catalytic site of reverse transcriptase.
D. The entire class has a boxed warning for lactic acidosis.
E. They do not undergo hepatic transformation via the CYP 450 pathway.
A

C, D, E.

Class side effects: lactic acidosis, hepatomegaly with steatosis

Class overall: renal adjustments required for all except abacavir (Ziagen), no CYP interactions, generally taken without regards to food.

D-Z T S-A-L-E, pronounced “Dozen T Sale”, helps you name all the NRTIs

Didanosine (Videx)

Zidovudine (Retrovir)

Tenofovir (Viread)

Stavudine (Zerit)

Abacavir (Ziagen)

Lamivudine (Epivir)

Emtricitabine (Emtriva)

60
Q

Which of the following statements are true regarding CD4+ T-cells? (Select ALL that apply.)

A. Once they fall below a certain level, there is an increased risk of opportunistic infections.
B. They are commonly used to assess severity of disease.
C. They serve as the primary marker for determining development of drug resistance.
D. They are the primary target of the immune system by HIV.
E. They are not needed for survival.

A

A, B, D. CD4 is the primary target of the immune system by HIV. They are used to assess the severity of disease and guide the need for primary prophylaxis of certain opportunistic infections, but do not serve as markers of resistance.

CD4 count: tells us the severity of HIV infection, tells how immune suppressed patients are, lower number is bad, higher is good

Viral load: tells us how many virus is floating around in the body. Helps us determine how well the regimen is working (resistance), higher number bad, lower number good.

61
Q

Which of the following statements are valid reasons for changing antiretroviral therapy? (Select ALL that apply.)

A. Drug toxicities
B. Non-adherence to the regimen
C. An undetectable viral load
D. Virologic failure
E. Clinical cure of an opportunistic infection

A

A, B, D. All of the following statements are valid reasons to stop antiretrovirals except an undetectable viral load or resolution of an opportunistic infection. Recall that treatment of HIV is considered a chronic disease that requires lifelong treatment for maximal viral suppression and patient outcomes.

62
Q

Which of the following statements concerning efavirenz are correct? (Select ALL that apply.)

A. A different agent should be chosen in women with high pregnancy potential.
B. A single combination tablet of tenofovir, emtricitabine, and efavirenz provides once daily dosing.
C. This medication should be taken with food.
D. It is important to dispense this medication is the original container and protect from light.
E. CNS side effects usually dissipate after a few weeks in most patients.

A

A, B, E. Efavirenz is Pregnancy Category D and should not be used in women with a high likelihood of becoming pregnant. The combination product contains emtricitabine + efavirenz + tenofovir and is dosed once daily. The most common side effects are CNS side effects which usually improve or resolve within a few weeks. Taking the medicine on an empty stomach at night can help lessen CNS side effects. The Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents were updated on April 8, 2015. The Recommended Regimens for initial treatment have changed. Atripla has been reclassified from a Recommended Regimen to an Alternative Regimen.

Atripla (efavirenz/emtricitabine/tenofovir) - Atripla “Take without A meal”

63
Q

Which of the following statements regarding tenofovir is correct? (Select ALL that apply.)

A. Tenofovir can cause osteomalacia and lactic acidosis
B. Tenofovir is a nucleotide reverse transcriptase inhibitor
C. Tenofovir can be used concurrently with didanosine
D. Tenofovir is not dose adjusted in renal impairment
E. Tenofovir tablets must be taken with meals.

A

A, B. Tenofovir tablets can be taken without regard to meals.

NOF in tenofovir can help you remember – N for nephrotoxicity, O for osteoporosis, F for Fanconi’s

Do not combine with didanosine (Videx)

64
Q

A patient has been on antiretroviral therapy now for eight years. During the last clinic visit, the patient had signs of drug resistance on his laboratory work up. The CD4+ count was 350 cells/mm3. Which of the following medications should this patient be placed on to prevent an opportunistic infection (OI)?

A. Trimethoprim-sulfamethoxazole double strength should be initiated.
B. Azithromycin should be initiated.
C. Valganciclovir should be initiated.
D. This patient should not be started on any prophylactic medications at this time.
E. Trimethoprim-sulfamethoxazole single strength should be initiated.

A

D. Since this patient has a CD4+ count of 350 cells/mm3, prophylaxis of opportunistic infections is not recommended.

Pneumocystis pneumonia: CD4 Toxoplasma gondii: CD4 Mycobacterium avium complex (MAC): CD4

Pneumocystis pneumonia: TMP/SMX 1 DS or SS PO daily
Toxoplasma gondii: TMP/SMX 1 DS PO daily
Mycobacterium avium complex (MAC): azithromycin 1200mg PO weekly (or 600mg PO twice weekly)

65
Q

Chief Complaint: “I think I have HIV”

History of Present Illness: QL is a 25 y/o white female who presents to the family medicine clinic. She is crying and says she thinks she has HIV. She admits to having unprotected sex “several times”. She just found out that one of the men she had unprotected sex with tested positive for HIV. She took an OTC HIV test several days ago and it was positive. QL is single and lives with her parents who are helping her raise her 3 year-old daughter.

Allergies: Penicillin

Past Medical History: None

Medications: None

Vitals:

Height: 5’8” Weight: 132 pounds

BP: 122/76 mmHg HR: 78 BPM RR: 13 BPM Temp: 98.5°F Pain: 0/10

Labs:

Na (mEq/L) = 136 (135 - 145)

WBC (cells/mm3) = 10.2 (4 - 11 x 10^3)

K (mEq/L) = 3.6 (3.5 - 5)

Hgb (g/dL) = 11.2 (13.5 - 18 male, 12 - 16 female)

Cl (mEq/L) = 99 (95 - 103)

Hct (%) = 33.4 (38 - 50 male, 36 - 46 female)

HCO3 (mEq/L) = 27 (24 - 30)

Plt (cells/mm3) = 160 (150 - 450 x 10^3)

BUN (mg/dL) = 12 (7 - 20)

Albumin (g/dL) = 3.6 (3.5 - 5)

SCr (mg/dL) = 0.8 (0.6 - 1.3)

Glucose (mg/dL) = 102 (100 - 125)

Ca (mg/dL) = 8.8 (8.5 - 10.5)

Mg (mEq/L) = 1.5 (1.3 - 2.1)

PO4 (mg/dL) = 2.5 (2.3 - 4.7)

Tests:

HIV ELISA pending

Question:
QL’s labs confirm a diagnosis of HIV. Over the next year, she requires several changes to her ART regimen. On this visit to her PCP, she complains that she is extremely depressed and having trouble sleeping. It is impacting her ability to care for her daughter. She states, “having HIV isn’t worth living”. She is currently taking Complera, Bactrim, and azithromycin. What is the most likely rationale for QL’s complaints?

A. Most patients with HIV experience depression and suicidal ideation.
B. QL is experiencing the effects of a drug interaction between Bactrim and the fosamprenavir component ofComplera.
C. QL is experiencing the effects of a drug interaction between azithromycin and the tenofovir component ofComplera.
D. QL is experiencing a side effect from the rilpivirine component of Complera.
E. QL is experiencing a side effect from the etravirine component of Complera.

A

D. CNS side effects from rilpivirine include depression, mood changes, insomnia, and suicidal ideation.

Complera (rilpivirine, tenofovir, emtricitabine)

Rilpivirine (Edurant)

Tenofovir (Viread)

Emtricitabine (Emtriva)

Tenofovir/emtricitabine (Truvada)

ID 1183 (19 decks)

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