Antifungals & Antivirals Flashcards
1
Q
What are classified as fungi infections?
A
- yeasts
- mold
- dimorphic species
2
Q
What are common yeasts that cause infections?
A
- Candida albicans
- Candida tropicalis
- Candida parapsilosis
- Candida glabrata
- Candida krusei
- Cryptococcus neoformans
3
Q
What are common molds that cause infections?
A
- Aspergillus species
- Zygomycetes (Mucor and Rhizopus species; mucormycosis)
4
Q
What are common dimorphic fungi that cause infections?
A
- Histoplasma capsulatum
- Blastomyces dermatitidis
- Coccidioides immitis
5
Q
What fungi infections does Amphotericin B treat?
A
- Cryptococcus neoforms and most candida species (yeast)
- Aspergillus and Zygomycetes (molds)
- Histoplasma capsulatum, Blastomyces dermatitidis, and Coccidioides immitis (dimorphic fungi)
6
Q
Which formulation of Amphotericin B (deoxycholate or lipid formulations) is associated with less toxicity?
A
lipid formulations
7
Q
What are boxed warnings with Amphotericin B?
A
- med errors with deoxycholate vs. lipid formulations have resulted in cardiopulmonary arrest and death
- Conventional amphotericin B (deoxycholate) dose should not exceed 1.5 mg/kg/day
8
Q
What are SEs with Amphotericin B?
A
- infusion-related reactions: fever, chills, headache, malaise, rigors, hypo/hypertension, thrombophlebitis, N/V
- hypokalemia
- hypomagnesemia
- nephrotoxicity
- anemia
9
Q
What SEs are specific to AmBisome?
A
severe back/chest pain with the first dose
10
Q
What are the monitoring parameters for Amphotericin B?
A
- renal function
- LFTs
- electrolytes (K and Mg)
- CBC
11
Q
What is the MOA of Amphotericin B?
A
binds to ergosterol, altering membrane permeability and causing cell death
12
Q
What must Amphotericin B be diluted with for injection?
A
D5W
13
Q
What must be done to administer lipid Amphotericin B formulations?
A
Lipid formulations must be filtered during preparation
14
Q
What must be done to administer conventional Amphotericin B deoxycholate injection?
A
requires pre-medication 30-60 minutes prior to infusion to reduce infusion-related reactions
15
Q
What medications are used to prevent infusion-related reactions with Amphotericin B deoxycholate?
A
- Acetaminophen/ NSAIDs
- diphenhydramineand/or hydrocortisone
- NS boluses to decrease the risk of nephrotoxicity
- meperidine to decrease the duration of rigors
16
Q
What dosage forms of Amphotericin B are available?
A
injection; conventional and lipid formulations are yellow-orange in color
17
Q
Amphotericin B Lipid Complex
A
Abeicet
18
Q
Liposomal Amphotericin B
A
AmBisome
19
Q
What drugs interact with Amphotericin B?
A
- additive risk of nephrotoxicity with nephrotoxic agents (aminoglycosides, cisplatin, polymixins, cyclosporine, loop diuretics, NSAIDs, radiocontrast dye, tacrolimus, vancomycin)
- increases the risk of digoxin toxicity due to hypokalemia
- caution with any agent that decreases potassium or magnesium
20
Q
What is the MOA of flucytosine?
A
penetrates fungal cells and is converted to fluorouracil, which competes with uracil and interferes with fungal RNA and protein synthesis
21
Q
Why should flucytosine not be used alone?
A
resistance has developed
22
Q
What is flucytosine used in combination with to treat
invasive cryptococcal and candida infections?
A
Amphotericin B
23
Q
What are boxed warnings with flucytosine?
A
use extreme caution in patients with renal dysfunction; monitor hematologic, renal, and hepatic status
24
Q
What are SEs with flucytosine?
A
- dose-related myelosuppression (anemia, neutropenia, thrombocytopenia)
- increased BUN/SCr
- liver injury
- increased bilirubin
- many CNS effects
- hypoglycemia
- aplastic anemia (bone marrow stops making RBCs)
- hypokalemia
25
When does flucytosine require renal dosage adjustment?
CrCl ≤40
26
What is the normal dosing of flucytosine?
50-150 mg/kg/day PO divided Q6H
27
Flucytosine, 5-FC
Ancoban
28
What is the MOA of -azole antifungals?
decrease ergosterol synthesis and cell membrane formation
29
Which strains of Candida are resistant to fluconazole?
1. C. glabrata
2. C. krusei
30
What are the common uses for itraconazole?
1. dimorphic fungi (Blastomycoses and Histoplasma)
2. nail bed infections (onychomycosis)
31
What is the DOC for Aspergillus?
Voriconazole
32
What are SEs with all azole antifungals?
1. Heaptotoxicity; elevated LFTs
2. QT prolongation
33
Which azole antifungal requires renal dosage adjustment?
fluconazole
34
What are boxed warnings for Itraconazole?
1. Can cause or worsen HF
2. Do Not use to treat onychomycosis in patients with ventricular dysfunction or hx of HF
3. can cause increased concentrations of drugs and can lead to QT prolongation and ventricular arrhythmias, including Torsades de Pointes
35
What are boxed warnings for ketoconazole?
1. Hepatotoxicity; which has lead to liver transplant/ death
2. QT prolongation
3. Only use PO tabs when other antifungal therapy is unavailable or not tolerated and benefits outweigh risks (hepatotoxicity, drug interactions)
36
What are the warnings with fluconazole?
1. exfoliative skin reactions
2. NOT recommended in pregnancy
37
What are SEs with fluconazole, itraconazole, and ketoconazole?
1. elevated LFTs
2. QT prolongation
3. headache
4. N/V
5. abdominal pain
6. rash/pruritus
7. dizziness
38
What are SEs with ketoconazole shampoo?
1. hair loss/growth
2. altered hair texture
39
Why is fluconazole the only azole that needs renal dose adjustment?
all other azoles are cleared hepatically (therefore, LFTs)
40
Which azole antifungals penetrate the CNS to treat fungal meningitis?
1. Fluconazole
2. Voriconazole
41
What is dosing for fluconazole?
50-800mg PO/IV QD
42
What is the dosing and duration of fluconazole for vaginal candidiasis?
150 mg PO x 1
43
What is the dosing of fluconazole for those with impaired renal function?
CrCl≤ 50mL/min: decrease the dose by 50%
44
Fluconazole
Diflucan
45
What dosage forms are available for fluconazole?
1. tablet
2. suspension
3. injection (IV)
46
Itraconazole
Sporanox
Tolsura
47
What is the dosing for itraconazole?
200mg PO QD/BID
48
How is Tolsura dosed?
130mg PO QD/BID
49
What are the counseling points for itraconazole solution?
1. solution should be taken on an empty stomach
2. solution and capsule dosage forms are NOT interchangeable
50
What are the counseling points for itraconazole capsules?
1. take with food
2. not absorbed as well as solution and is not interchangable
51
How is itraconazole dosed for renal impairment?
limited data on use; use caution
52
What dosage forms are ketoconazole available in?
1. tablet
2. cream
3. foam
4. gel
5. shampoo
53
What ketoconazole product is available OTC?
Nizoral A-D shampoo for dandruff
54
What is dosing for PO ketoconazole?
200-400mg PO daily
55
How is ketoconazole dosed for renal imapirment?
No adjustment
56
Voriconazole
Vfend
Vfend IV
57
What are CI to using voriconazole?
co-administration with barbituates (long-acting), carbamazepine, efavirenz (≥400mg/day), ergot alkaloids, pimozide, quinidine, rifabutin, rifampin, ritonavir (≥800mg/day), sirolimus, St. John's wort
58
What are the warnings with Voriconazole?
1. hepatotoxicity
2. phototoxicity
3. visual disturbances (optic neuritis and papilledema)
4. QT prolongation (correct K, Ca, and Mg before initiating)
5. nephrotoxicity
6. avoid in pregnancy
7. infusion-related reactions
8. serious skin reactions (SJS/TENS)
9. skeletal adverse effects (fluorosis, periostitis)
10. pancreatitis
59
What are SEs with voriconazole?
1. visual changes (~20% blurred vision, photophobia, altered color and visual acuity)
2. elevated LFTs
3. elevated SCr
4. CNS toxicity (hallucinations, headache, dizziness)
5. photosensitivity
6. hypo/hyperkalemia
60
What should be monitored while taking voriconazole?
1. LFTs
2. renal function
3. visual function (when used >28 days)
4. trough concentrations (toxicity more likely when trough >5 mcg/mL)
61
What are the dosage forms for voriconazole?
1. tablet
2. suspension
3. injection
62
What are the counseling points for PO voriconazole?
1. take on an empty stomach, at least 1 hour before or after a meal
2. hold tube feed for 1 hour before and 1 hour after doses
3. use caution when driving at night due to vision changes
4. avoid direct sunlight
5. shake suspension for 10 seconds before use; DO NOT refrigerate
63
What are important considerations when dosing voriconazole?
1. reduce maintenance dose by 50% for mild-mod hepatic impairment
2. only use in severe hepatic impairment if benefit >risk
3. PO preferred in renal impairment
64
What are important considerations when dosing IV voriconazole?
1. CrCl <50: SBECD accumulates in renal impairment; PO preferred
2. Monitor SCr when IV vorconazole used and switch to oral when possible
3. therapeutic through =1-5 mcg/mL
65
How is voriconazole dosed IV?
Loading dose: 6mg/kg IV Q12H x 2 doses
Maintenance dose: 4mg/kg IV Q12H
66
How is voriconazole dosed PO?
200mg PO Q12H
67
Posaconazole
Noxafil
68
What are the dosage forms for Posaconazole?
1. DR tablet
2. suspension
3. injection
69
How is posaconazole suspension dosed?
1. 200mg TID or 400 mg BID given with a full meal (during or within 20 minutes following a meal)
2. PPIs and cimetidine decrease abs of sus, D/C to avoid treatment failure
70
How are posaconazole tablets dosed?
300mg PO BID on day 1 then 300mg QD with food (100-400mg/day divided in 1-3 doses)
71
How is posaconazole IV dosed?
300mg BID on day 1 then 300mg QD
72
How is posaconazole IV dosed for renal impairment?
oral treatment is preferred because SBECD can accumulate and worsen renal function
73
What are CIs to using posaconazole?
Co-administration with sirolimus, ergot alkaloids, pimozide, quinidine, atorvastatin, lovastatin, and simvastatin
74
What are the warnings with posaconazole?
1. QT prolongation (correct K, Ca, and Mg prior to initiating treatment)
2. prescribing and dispensing errors; suspension and tablet are NOT interchangeable and dosing regimens differ (tablet better absorbed)
3. neurotoxicity when used wth vincristine due to increased vincristine levels (seizures, SIADH, paralytic ileus)
75
What are SEs with posaconazole?
1. N/V/D
2. fever
3. headache
4. elevated LFTs
5. rash
6. hypokalemia
7. low Mg
8. cough
76
What is monitored on posaconazole?
1. LFTs
2. renal function
3. electrolytes
4. CBC
77
Isavuconazonium sulfate (prodrug of isavuconazole)
Cresemba
78
What are the dosage forms of isavuconazonium sulfate?
1. capsules
2. injection
79
What is the dosing for Isavuconazonium sulfate?
372mg Q8H x 6 doses, then 372mg QD IV/PO
80
What are dosing considerations for renal/hepatic impairment when using Isavuconazonium sulfate?
1. use caution with severe hepatic impairment
2. no adjustment for renal dysfunction
81
What are counseling points for Isavuconazonium sulfate capsules?
swallow whole; do NOT crush or open
82
What are the CIs to using Isavuconazonium sulfate?
1. use with strong CYP3A4 inhibitors/inducers
2. familial short QT syndrome (causes QT shortening)
83
What are the warnings with Isavuconazonium sulfate?
1. hepatotoxicity
2. infusion-related reactions (hypotension, dyspnea, chills, dizziness, tingling and numbness)
3. hypersensitivity reactions (anaphylaxis, SJS/TENS)
4. teratogenic
5. drug interactions
6. particulates (undissolved IV drug)
84
What are SEs with Isavuconazonium sulfate?
1. N/V/D
2. headache
3. injection site reactions
4. peripheral edema
5. low K
6. elevated LFTs
85
What should be monitored with Isavuconazonium sulfate?
1. LFTs
2. electrolytes
86
What are counseling points for Isavuconazonium sulfate administration?
1. IV formulation requires a 0.2-1.2 micron filter during administration
2. capsules must be protected from moisture; original container has desicant
87
What CYP enzyme is affected by azoles causing drug interactions?
azoles are mod-strong CYP3A4 inhibitors
88
Which CYP enzyme does fluconazole and voriconazole inhibit, increasing the effects of warfarin?
CYP2C9; monitor increased INR and s/s of bleeding
89
Which azoles require an acidic gut for absorption?
1. Sporanox brand itraconazole capsules
2. ketoconazole
90
What are counseling points for PO Sporanox brand itraconazole capsules and ketoconazole?
1. separate antacids 2 hours before and after doses
2. avoid PPis and H2RAs
3. if PPI/H2RA must be used while on ketoconazole take with an acidic beverage (non-diet cola) to provide an acidic environment for absorption
91
What drugs do azoles interact with causing safety concerns?
1. can increase concentrations of apixaban and rivaroxaban; monitor s/s of bleeding
2. Other QT prolonging drugs: antiarrhythmic, quinolones, macrolides, antidepressants, antpsychotics, 5HT3 antagonists
92
What are major drug interactions with vorconazole?
1. exhibits 1st order then 0 order (non-linear) kinetics; dangerously increased concentrations when given with CYP2C19, 2C9, or 3A4 inhibitors
2. boxed warning
93
What is the MOA of echinocandins?
inhibits synthesis of beta 1,3-D-glucan an essential component of the fungal cell wall
94
Which fungi do echinocandins cover?
1. most candida, including azole-resistant C.glabrata and C.krusei
2. alternative combination regimen to treat aspergillus
95
What are warnings with echinocandins?
1. anaphylaxis
2. histamine-mediated symptoms (rash, pruritus, facial swelling, flushing, hypotension) have occurred
96
What dosage forms are echinocandins available in?
IV injection only
97
What are SEs with echinocandins?
1. elevated LFTs
2. headache
3. hyper/hypokalemia
4. low Mg
5. fever
6. N/V/D
7. anemia
8. increased SCr
9. rash
98
What SEs are specific to capsofungin?
severe skin reactions, including SJS/TENS
99
What should be monitored when taking echinocandins?
LFTs
100
How often are echinocandins dosed (except rezafungin)?
once daily
101
How are echinocandins dosed for renal impairment?
No adjustment needed
102
Which echinocandin required protection from light during IV administration?
micafungin
103
Caspofungin
Cancidas
104
How is capsofungin dosed?
1. 70mg IV on day 1, then 50mg IV daily
2. moderate hepatic impairment: 70mg IV on day 1, then 35mg IV daily
3. in combination with enzyme inhibitors or rifampin: 70mg IV QD
105
Micafungin
Mycamine
106
How is micafungin dosed?
candidemia: 100mg IV QD
esophageal candidiasis: 150mg IV QD
107
Anidulafungin
Eraxis
108
How is anidulafungin dosed?
candidemia: 200mg IV day, then 100mg IV QD
esophageal candidiasis: 100mg IV day 1, then 50mg IV QD
109
Rezafungin
Rezzayo
110
How is Rezafungin dosed?
candidemia/invasive candidiasis: 400mg IV day 1 then 200mg IV weekly starting on day 8 for up to 4 doses
111
What dosage forms is nystatin available in?
1. suspension
2. tablet
3. cream
4. ointment
5. powder
112
How is nystatin dosed?
1. oral candidiasis: suspension 400,000-600,000 U QID x 7-14 days; swish in the mouth and retain for as long as possible (several minutes) then swallow
2. intestinal infections: oral tablets 500,000-1,000,000 U Q8H
113
What are SEs with nystatin?
1. N/V/D
2. stomach pain (otherwise low systemic risk due to minimal GI abs)
114
What is Griseofulvin used for?
fungal infections of the hair skin and naiils; arrow therapeutic index and less effective than other systemic drugs
115
What are CIs to using Griseofulvin?
1. Pregnancy
2. severe liver disease
3. porphyria (body can't convert porphyrins into heme, a substance that carries oxygen)
116
What are SEs with Griseofulvin?
1. Photosensitivity
2. elevated LFTs
3. HA, rash
4. urtcaria (hives)
5. dizziness
6. leukopenia
7. severe skin reactions
117
What should be monitored if on griseofulvin?
1. LFTs
2. renal function
3. CBC
4. cross-reaction possible with PCN allergy
118
How is griseofulvin dosed tablet/suspension?
Take with a fatty meal to increase absorption and with food/milk to decrease GI upset
tinea corpis (ringworm): 2-4 weeks
tinea pedis (athletes foot): 4-8 weeks
119
What OTC terbinafine is available for athletes foot?
Lamisil AT topical cream
120
How are terbinafine tablets dosed?
250 mg/day 1-2 divided doses without regard to meals
121
What are CIs to using terbinafine?
chronic or active liver disease
122
What are warnings with terbinafine?
1. Hepatotoxicity
2. smell/taste disturbances (including permanent loss)
3. depression
4. neutropenia
5. thrombotic thrombocytopenic purapura (TTP)
6. hemolytic uremic syndrome (UHS)
7. serious skin reactions (SJS/TENS/DRESS/ erythemia multiforme
8. can worsen symptoms of lupus
123
What are SEs with terbinafine?
1. Headache
2. elevated LFTs
3. skin rash
4. abdominal pain
5. pruritis
6. diarrhea
7. dyspnea
124
What should be monitored if taking terbinafine?
1. CBC
2. LFTs
125
What is the dosing of clotrimazole 10mg troche/lozenge?
Oral candidiasis
prophylaxis: 10mg TID
treatment:10mg 5 times daily x7-14 days
Allow troche to dissolve over 15-30 minutes
126
What are SEs with clotrimazole lozenge/troche?
1. elevated LFTs
2. nausea
3. dysgeusia (taste disorder that causes a persistent abnormal taste in the mouth, such as a metallic, salty, rancid, or foul taste)
127
How is miconazole buccal tablet dosed for oropharyngeal candidiasis?
50mg 1 tablet applied to the upper gum region daily for 7-14 days
128
MIconazole buccal tablet
Oravig
129
What are CIs to using miconazole buccal?
hypersensitivity to milk protein concentrate
130
What are SEs with miconazole?
local application site reactions (pain burining, pruritis, edema, toothaches)
131
What is oteseconazole used for?
only indicated for recurrent vulvovaginal candidiasis
132
Otesconazole
Vivjoa
133
How is otesconazole dosed?
PO: 600mg x 1 day then 450mg X 1 on day 2, then starting on day 14
150 mg weekly x 11 weeks
134
What are CIs to using otesconazole?
Pregnancy (or reproductive potential), breastfeeding, moderate-severe liver impairment (child-pugh class B or C) or eGFR<30
135
What are SEs with otesconazole?
1. nausea
2. headache
3. menstrual bleeding
4. vulvovaginal irritation/pain
136
What drugs interact with griseofulvin?
increased metabolism of hormonal contraceptives leading to failure
137
How does terbinafine affect CYP metabolism?
1. strong CYP2D6 inhibitor
2. moderate CYP3A4 inducer
138
What are the preferred regimens for candida ablicans oropharyngeal infection (thrush)?
Mild disease: topical clotrimazole, miconazole
Moderate-severe/HIV: fluconazole
139
What are the alternative regimens for candida ablicans oropharyngeal infection (thrush)?
nystatin
140
What are the preferred regimens for candida ablicans esophageal infection?
fluconazole
141
What are the alternative regimens for candida ablicans esophageal infection?
echinocandin
142
What are the preferred regimens for candida glabrata/krusei/all candidemia?
Echinochandin
143
What are the alternate regimens for candida glabrata/krusei/all candidemia?
1. Amphotericin B
2. high dose fluconazole
144
What are the preferred regimens for invasive aspergillus?
voriconazole
145
What are the alternative regimens for invasive aspergillus?
1. Amphotericin B
2. isavuconazonium
146
What are preferred regimens for cryptococcal neoformans meningitis?
Amphotericin B + Flucytosine (5-FC)
147
What are alternative regimens for cryptococcal neoformans meningitis?
High dose flconazole+ Flucytosine (%-FC)
148
What are the preferred regimens for dermatophytes (nail bed infections)?
terbinafine/itraconazole (confirm fungal infection prior to treatment)
149
What are the alternative regimens for dermatophytes (nail bed infections)?
fluconazole
150
What patients are at increased risk of hospitalization and death from influenza A/B?
1. pregnant
2. immunocompromised
3. children <5
4. ≥ 65
5. comorbid conditions (diabetes, asthma, cardiovascular disease)
151
How are most influenza A/B antigen detection tests delivered?
nasopharyngeal swab
152
What are s/s of the flu?
1. fever
2. chills
3. fatigue
4. myalgia
153
At what age is the influenza vaccine recommended with no CIs?
≥ 6 months
154
What is the MOA of neuraminidase inhibitors (oseltamivir, zanamivir, peramivir)?
Inhibits the neuraminidase enzymes in influenza A/B, which enables the release of new viral particles from infected cells
155
What is the benefit of taking neuraminidase inhibitors for the flu?
1. reduces symptoms by about 1 day
2. reduces complications
156
When should neuraminidase inhibitors be started in order to be most effective?
within 48 hours of symptom onset
157
What is the MOA of baloxavir?
endonuclease inhibitor approved for the treatment of post-exposure prophylaxis of influenza
158
What are advantages of baloxavir for flu treatment?
single-dose regimen
159
What medications should no longer be used to treat the flu due to widespread resistance?
1. amantadine (used for Parkinsons)
2. rimantadine
160
What are the warnings with Oseltamivir?
1. Neuropsychiatric events (sudden confusion, delirium, hallucinations, unusual behavior, and self-injury)
2. serious skin reactions (SJS/TEN)
3. anaphylaxis
161
What are SEs with oseltamivir?
1. headache
2. N/V/D
3. abdominal pain
162
How is oseltamivir dosed for treatment > 12 years old?
75mg BID x 5 days
163
How is oseltamivir dosed for prophylaxis >12 years old?
75mg BID x 10 days
164
How is oseltamivir dosed for pediatric patients <12?
based on body weight
165
What dosage forms are oseltamivir available in?
capsule
suspension
166
What are the counseling points for oseltamivir suspension storage?
Store reconstituted suspension at room temperature for 10 days and in refrigerator for 17 days
167
What medications for influenza are preferred in pregnancy?
oseltamivir
168
When should the oseltamivir dose be adjusted for renal function?
CrCl ≤60
169
Oseltamivir
Tamiflu
170
Zanamivir
Relenza Diskhaler
171
What is the dosing of zanamivir for treatment in patients ≥7 years old?
10mg (two 5mg inhalations) BID x 5 days
172
What is the dosing of zanamivir for prevention in patients ≥5 years old?
10mg (two 5mg inhalations) BID x 10 days (household setting) or 28 days (community outbreak)
173
What are the warnings for zanamivir inhalation?
1. Neuropsychiatric events
2. bronchospasm (do not use in asthma, COPD, breathing problems)
3. stop the drug if wheezing or breathing problems occur
174
Peramivir
Rapivab
175
What is the dosing for peramivir?
600mg IV x 1
CrCl<50: adjust dose
176
What are the warnings with peramivir?
1. Neuropsychiatric events (sudden confusion, delirium, hallucinations, unusual behavior, and self-injury)
2. serious skin reactions (SJS/TEN)
3. anaphylaxis
4. renal impairment
177
What are SEs with peramivir?
1. HTN
2. insomnia
3. hyperglycemia
4. diarrhea
5. constipation
6. neutropenia
7. elevated AST/ALT
178
Baloxacir marboxil
Xofluza
179
How is baloxavir dosed in patients ≥ 5 years for treatment and prophylaxis?
≥80 kg: 80mg PO x 1
20 to <80kg: 40mg PO x 1
<20 kg: 2mg/kg PO x 1 dose
Use cautions with renal/hepatic impairment
180
What are warnings with baloxavir?
hypersensitivity including skin reactions (erythema multiforme, urticaria)
181
What are SEs with baloxavir?
diarrhea
182
What dosage froms do baloxavir come in?
1. capsules (store in original packaging)
2. suspension (administer within 10 hours of reconstitution (store at room temperature) doses may require more than 1 bottle
183
What drugs should be separated when dosing baloxavir?
1. dairy products
2. antacids
3. supplements containing polyvalent cations
184
How are COVID and Influenza spread?
respiratory droplets
185
Paxlovid
nirmatrelvir
186
What are alternative therapies for severe COVID cases?
1. IV remdesivir (Veklury)
2. molnupiravir (Lagevrio)
187
What are the s/s of COVID?
1. fever/chills
2. cough
3. SOB
4. fatigue
5. myalgia
6. loss of taste/smell
188
What antivirals are for HSV and VZV (shingles)?
1. acyclovir
2. valacyclovir
3. famciclovir
189
What are warnings with the cyclovir antivirals?
1. Caution in patients with renal impairment, the elderly and/or those receiving nephrotoxic drug: infuse acyclovir over at least 1 hour and maintain adequate hydration to reduce the risk of renal tubular secretion
2. Thrombotic thrombocytopenic purapura/ hemolytic uremic syndrome (TTP/HUS) and has been reported in immunocompromised patients
190
What are SEs with the acyclovir?
1. mailaise
2. headache
3. N/V/D
4. rash
5. puritis
6. elevate LFTs
7. neutropenia
8. transient burning or stinging with topical formulations (acyclovir)
191
What are SEs with the IV acyclovir?
increased BUN/SCr with crystal nephropathy
192
What are SEs with famciclovir?
anaphylaxis
193
What should be monitored while on cyclovir antivirals?
1. renal function
2. LFTs
3. CBC
194
How is IV acyclovir dosed?
1. based on IBW including obese patients
2. decrease dose or extend interval for renal imapirment
195
What is a general conversion of IV acyclovir to PO valacyclovir?
5mg/kg IV acyclovir = 1g PO valacyclovir
196
When is the best time to start topical or oral medications for HSV-1 labialis (cold sores)?
prior to eruption during the Prodrome (symptoms that occur before the lesion appears) of tingling, itching, or soreness
197
Which cold sore treatment is OTC?
docosanol (Abreva)
198
What is famciclovir the prodrug of?
penciclovir (active drug)
199
Acyclovir
Zovirax (cream)
Sitavig (buccal tablet)
200
Valacyclovir
Valtrex
201
Docosanol
Abreva
202
How is docosanol dosed for HSV-1?
Apply 5x daily at first sign of outbreak until healed
203
How is acyclovir cream (zivorax) dosed for herpes labialis?
apply 5x daily for 4 days (can be used on genital sores)
204
How is penciclovir cream (Denavir) dosed for cold sores?
apply every 2 hours during waking hours for 2 days
205
What is the dosing of PO acyclovir for cold sores?
Treatment 7-10 days: 200mg 5x daily or 400 mg TID
Recurrence: 400mg TID x 5-10 days
Chronic suppression: 400mg BID
206
What is the dosing of PO Valacyclovir for cold sores?
Treatment 7-10 days: 1g BID
Recurrence: 2g BID x 1 day
Chronic suppression: 500mg-1g QD
207
What is the dosing of PO famciclovir for cold sores?
Treatment 7-10 days: 250mg TID or 500mg BID
Recurrence: 1.5g x 1
208
When must treatment be initiated for HSV-2?
during prodrome period or within 1 day of lesion onset
209
What are the benefits of using valacyclovir for HSV-2?
1. reaches higher concentrations
2. less frequent dosing advances adherence
210
When is chronic therapy recommended for HSV-2?
frequent recurrences >6/year
211
How is acyclovir dosed for HSV-2?
Treatment (7-10 days): 400mg TID or 200mg 5x/day
Recurrence: 400mg TID or 800mg BID x 5 days, 800mg TID x 2 days
Chronic suppression: 400mg BID
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How is Valacyclovir dosed for HSV-2?
Treatment (7-10 days): 1g BID
Recurrence: 500mg BID x 3 days, 1g QD x 5 days
Chronic suppression: 500mg /1g QD
213
How is famciclovir dosed for HSV-2?
Treatment (7-10 days): 250mg TID
Recurrence: 125mg BID x 5 days, 500mg x 1 then 250mg BID x 2 days, 1g BID x 1 day
Chronic suppression: 250mg BID
214
What is the treatment for invasive HSV (viral encephalitis)?
IV acyclovir 10mg/kg/dose Q8H x 14-21 days
215
What are s/s of shingles (herpes zoster virus)?
distinctive rash: a cluster of fluid filled blisters often in band; itchy, tingly, painful, unilateral
216
How does someone get shingles (herpes zoster) virus?
varicella zoster virus (chickenpox) can lie dormant for decades in the nerve and cause recurrence of symptoms, usually in adults >60
217
What can be used to treat pain associated with shingles/ postherpetic neuralgia?
1. topical analgesics (Lidoderm patch, lidocaine gel)
2. neuropathic pain medications (pregabalin, gabapentin, duloxetine, TCAs)
3. NSAIDs
4. opioids
218
Who is recommended to get the singles vaccine according to ACIP?
1. adults ≥50
2. adults ≥19 years old who are or will be immunocompromised
219
How is acyclovir dosed to treat herpes zoster shingles?
800mg PO 5x daily for 7 days (or 10 days)
220
How is valacyclovir dosed to treat herpes zoster shingles?
1g PO TID x 7 days
221
How is famciclovir dosed to treat shingles?
500mg PO TID x 7 days
222
What are boxed warnings for (val)ganciclovir?
1. Myelosuppression
2. carcinogenic
3. fetal toxicity
4. impaired fertility
223
What are SEs with (val)ganciclovir?
1. fever
2. N/V/D
3. anorexia
4. increased SCr
5. seizures (rare)
6. retinal detachment (with CMV retinitis)
224
What should be monitored with (val)ganciclovir?
1. CBC with differential
2. SCr
3. retinal exam
225
What are counseling points for minimizing teratogenic potential of (val)ganciclovir
1. females should use contraception during treatment and 30 days after
2. males should use a barrier contraceptive for 90 days after
3. special handling required due to hazard
226
How is ganciclovir dosed?
Treatment: 5mg/kg IV BID x 14-21 days
Maintenance/prophylaxis: 5mg/kg IV QD
CrCl <70: decrease dose and interval
227
What is ganciclovir reconstituted with?
sterile water (NOT bacteriostatic)
228
What dosage forms is valganciclovir avalible in?
1. tablet
2. oral solution (refrigerate after reconstitution and discard after 49 days)
229
How is valganciclovir dosed?
Treatment: 900mg PO BID x 21 days
Maintenance: 900mg PO QD
CrCl< 60 decrease dose and extend interval
230
What are boxed warnings with cidofovor?
1. nephrotoxicity
2. beutropenia
3. carcinogenic
4. teratogenic
231
What are CIs to using cidofovir?
1. SCr >1.5
2. CrCl ≤55
3. urine protein ≥100mg/dL (≥ 2+proteinuria)
4. sulfa allergy
5. use with or within 7 days of other nephrotoxic drugs
6. direct intraocular injection
232
What are SEs with cidofovir?
1. myelosuppression (less than ganciclovir)
2. metabolic acidosis
233
What should be given with cidofovir to reduce nephrotoxicity?
1. hydration before each dose
2. probenecid before and after each dose
234
How is cidofovir dosed?
5mg/kg/week IV x 2 weeks then 5mg/kg once every 2 weeks
renal impairment: decrease dose or D/C based on SCr
235
What should cidofovir use be reserved for?
CMV retinitis in HIV patients only
236
What are uses of foscarnet?
1. CMV retinitis
2. resistent HSV
237
What are boxed warnings for fosacarnet?
1. Renal impairment (pre hydration recommended)
2. seizures due to electrolyte imbalance (low K, Ca, Mg, Phos)
3. elevated SCr/BUN
4. QT prolongation
238
How is foscarnet dosed?
Induction: 90mg/kg IV Q12H or 60mg/kg Q8H x 2-3weeks
Maintenance: 90-120 mg/kg IV QD
Renal impairment: decrease dose and extend interval
239
Foscarnet
Foscavir
240
What is Letermovir used for?
CMV prophylaxis in select kidney (donor CMV + and recipient CMV-) and bone marrow transplant recipients (recipient CMV+)
241
What are CIs to using letermovir?
concomitant administration with pimozide or ergot alkaloids or pitavastatin and simvastatin (is also taking cyclosporine)
242
What are SEs with letermovir?
1. AF
2. tachycardia
3. peripheral edema
4. thrombocytopenia
5. N/V/D
6. fatigue
7. headache
8. cough
243
How is letermovir dosed?
480mg PO/IV QD: continue through day 100 post bone marrow transplant, continue through day 200 post kidney transplant
Not recommended if severe hepatic impairment (Child-Pugh class C)
CrCr< 50: IV vehicle hydroxypropyl betadex can accumulate
244
Letermovir
Prevymis
245
What populations does cytomegalovirus (CMV) usually occur in?
immunocompromised states (AIDS, transplant recipients)
246
What does CMV cause
1. retinitis
2. colitis
3. esophagitis
247
What is preferred treatment for CMV?
(Val) ganciclovir
248
What is an option for post-transplant CMV disease refractory to all other therapies?
maribavir (Livtencity)
249
What agents are used for secondary prophylaxis/ maintenance therapy of CMV in post- solid organ transplant patients?
(val)ganciclovir
250
How is mononucleosis/ Epstein Barr Virus spread?
bodily fluids, usually saliva (kissing, sharing food/drink, child's toy)
251
What is true about treatment with amoxicillin/ampicillin for mono?
can cause a non-pruritic rash that appears similar to an allergic reaction; it is not and should not be included as an allergy
