Antivirals

Question 1

Acyclovir (Zovirax®)(B) (PO, IV, top)

Answer 1

inhibit viral replication, does not cure-only reduces the pain, severity & symptoms of the outbreak, shortens its duration and may prevent the overall number of recurrences.
ADRs - itching, hives, nephrotoxic - elevated BUN & creatinine, N,V,D, headache, paresthesias

Question 2

valacyclovir (Valtrex®)(B) PO

famciclovir (Famvir®)(B) PO

Answer 2

ADRs: less than acyclovir, N,V, headache
 bioavailability – less frequent dosing

ADRs: headache, fatigue, diarrhea
 bioavailability – less frequent dosing

Both of these more effective than acyclovir for shingles

Question 3

Penciclovir (Denavir®)(B) - topical

Docosanol (Abreva®) (B)

Answer 3

Active metabolite of famciclovir
Topical for herpes labialis
Potentially used for Epstein-Barr virus
ADRs – mild erythema, headache

First OTC topical for herpes labialis
Limited info available – may inhibit the fusion of the human host cell with the viral envelope
ADRs – local irritation, headache
NOT a nucleoside analog

Question 4

Varivax – SC – Live vaccine

Answer 4

active immunization for the prevention of varicella in individuals 12 months of age and older
Administration – 0.5ml
Children (12 months to 12 years of age)
If a second dose is administered, there should be a minimum interval of 3 months between doses
Adolescents (≥13 years of age) and Adults
Two doses, to be administered a minimum of 4 weeks apart
CI
Primary or acquired immunodeficiency states, any febrile illness or active infection (including untreated Tuberculosis), pregnancy
ADR
Fever, injection site reactions, varicella like rash

Question 5

Varizig

Answer 5

Postexposure prophylaxis in high risk individuals intended to reduce severity
immunocompromised children and adults
newborns of mothers with varicella shortly before or after delivery
premature infants
infants less than one year of age
adults without evidence of immunity
pregnant women

Question 6

Zostavax SC injection

Answer 6

Indications: Prevention of herpes zoster (shingles) in pts > 50 years old
boost VZV-specific immune response
Live attenuated varicella zoster virus
More potent than chickenpox vaccine
Can reduce shingles cases by 50% and patients who get shingles will get milder cases. Also, in pts who get shingles - 1/3 less likely to develop postherpetic neuralgia.

Question 7

Shingrix

Answer 7

Herpes Zoster

NOT live

ADRs
pain, redness, and swelling
myalgia, fatigue, headache, shivering, fever, and GI symptoms

Question 8

vidarabine (Vira-A®)(C)
(ophth oint) – blocks vision, use HS

trifluridine (Viroptic®)(C)
(ophth sol.)

Answer 8

both used for keratoconjunctivitis and recurrent epithelial keratitis due to HSV I and II.

ADRs: burning, irritation, lacrimation

Question 9

ganciclovir (Cytovene®) (C) (PO, IV, implant)

Answer 9

Used for treatment of CMV retinitis in immunocompromised patients and prevention of CMV diseases in HIV and transplant pts.
PO form has low bioavailability (use for long term suppression of CMV)
ADRs: bone marrow suppression (BMS), H/A, confusion, retinal detachment, liver and renal dysfunction, rash, fever, gi effects
Mutagenic, long term carcinogenic effects

Question 10

valganciclovir (Valcyte®) (C) (PO)

cidofovir (Vistide®)(C) (IV)

Answer 10

For CMV

Same indication as ganciclovir, prodrug – can give less frequently

Same indications as ganciclovir
Reserved use for resistant viruses
Higher incidence of more serious adverse effects (nephrotoxicity, neutropenia, metabolic acidosis)

Question 11

foscarnet (Foscavir®)(C) (IV) (NOT nucleoside)

Answer 11

Inhibits DNA polymerase
Tx of CMV retinitis in immunocompromised pts when ganciclovir alone has failed
Often given in combo with ganciclovir to reduce toxicity
Also used for acyclovir rst HSV infx and shingles

ADRs: fever, H/A, renal impairment, acute renal failure, N,V,D, hematologic deficiencies, seizures, cardiac arrhythmias, heart failure and pancreatitis

Question 12

Letermovir (Prevymis)

Answer 12

prophylaxis of CMV infection and disease in adult CMV-seropositive recipients [R+] of an allogeneic hematopoietic stem cell transplant
CMV DNA terminase complex inhibitor
ADR - nausea, diarrhea, vomiting, peripheral edema, cough, headache, fatigue, and abdominal pain

Question 13

Ganciclovir (Vitrasert) implant – CMV retinitis

Fomiversin (Vitravene) (C) inj – CMV retinitis

Answer 13

ocular antivirals for CMV

Question 14

Flumist®

Answer 14

intranasal influenza vaccine
Live attenuated vaccine (LAIV)
About as effective as IM vaccine
2010 guidelines: can be used in healthy patients aged 2-49 years old.
Not approved in pts > 50 y.o or pts with chronic illness
ADRs: runny nose, nasal congestion, fever, cough, vomiting, sore throat

Question 15

Drugs for Flu A

Answer 15

amantadine (Symmetrel) (C) PO
rimantadine (Flumadine) (C) PO - has lower incidence of ADRs and no dose adjustment in renal dysfunction

MOA: inhibits the replication of the Influenza A virus ONLY by blocking the viral membrane matrix protein (M2)

ADRs: GI effects, CNS side effects:

Question 16

Drugs for Flu A and B

Answer 16

oseltamivir (Tamiflu ®)(PO) (for pts >1 y.o)
zanamivir (Relenza ®)(INH) (for pts> 7 y.o.)
Tablet that must be crushed into a powder
Peramivir (Rapivab) IV
single dose within 2 days of onset of influenza symptoms

MOA: blocks neuraminidase, an enzyme needed for viral release from infected cell.

ADRs -N, V, D, abdominal pain, dizziness, headache

Question 17

ribavirin (Virazole ®) (Inhalational) (X):

Answer 17

Indications: aerosol for severe lower respiratory infections due to Respiratory Syncytial Virus (RSV) in children. It reduces duration of disease, allows children to be removed from ventilator sooner, improves arterial oxygenation

MOA: Prevents mRNA capping and blocks RNA-dependent polymerase

ADRs serious pulmonary and cardiovascular effects – (apnea, pneumothorax, worsening of resp status and cardiac arrest), conjunctivitis, rash.

Question 18

palivizumab (Synagis) (IM) (C)

Answer 18

Recombinant drug – monoclonal antibody

New drug for prevention of serious lower respiratory tract infections caused by RSV in infants and children < 2 y.o.

ADRs – nervousness, fever, fungal dermatitis, eczema, N/V/D, anemia, otitis media, cough, wheezing

Question 19

Interferons

Answer 19

Recombinant DNA technology drug with immunomodulating and antiproliferative effects

Forms – alfa 2a, alfa 2b, pegylated alfa 2a

Can be used in Tx of hepatitis B & C (all forms)

Can also be used in Tx of certain cancers (all forms) and in Tx of anogenital warts (alfa 2a) and

ADRs: hematological toxicity, cardiac arrhythmias, changes in BP, CNS dysfunction, gi distress, chills, fatigue, H/A, myalgia, alopecia

Question 20

Ribaviran (Rebetol ®, Copegus ®)(X) (PO)

Answer 20

Given in combo with interferon alpha 2b for the treatment of chronic hepatitis C in pts with compensated liver disease

ADRs: CNS side effects (dizziness, H/A, fatigue), alopecia, rash, pruritis, gi effects, bone marrow suppression (all observed when given w/ interferon alfa 2b)
may cause birth defects and fetal death

Question 21

Drugs for Hep B

Answer 21

Nucleotides: (some may also be used for HIV infection)
Lamivudine (Epivir)

Adefovir (Hepsera)

Entecavir (Baraclude)

Telbivudine (Tyzeka)

tenofovir alafenamide (Vemlidy)

Question 22

HEPLISAV-B

Answer 22

Hep B vaccine
adults 18 years of age and older
Administer two doses (0.5 mL each) of HEPLISAV-B intramuscularly one month apart

Question 23

Hep C protease inhibitor MOA ADR

Answer 23

MOA - inhibitor of the HCV NS3/4A serine protease, necessary for the proteolytic cleavage of the HCV encoded polyprotein essential for viral replication

Indication - combination with peginterferon alfa and ribavirin (must not be used as monotherapy), chronic hepatitis C in adult patients who are treatment-naïve or who have been previously treated with interferon-based treatment, including prior null responders, partial responders, and relapsers

ADR-rash, pruritus, anemia, nausea, hemorrhoids, diarrhea, anorectal discomfort, dysgeusia, fatigue, vomiting, anemia, neutropenia and anal pruritus

Question 24

Hep C protease inhibitor drugs

Answer 24

Telaprevir (Incivek) PO tab
BBW – serious skin reactions (including SJS), fatal cases have been reported, D/C immediately

Boceprevir (Victrelis) PO cap

Simeprevir (Olysio) PO cap
not recommended in patients with moderate or severe hepatic impairment
serious symptomatic bradycardia when co-administered with sofosbuvir and amiodarone, Photosensitivity

Glecaprevir

Paritaprevir – PO tab
Available in combination with ombitasvir, ritonavir and dasabuvir (Viekira Pak) -May use with ribavirin
Available in combination w/ ombitasvir, paritaprevir and ritonavir (Technivie) – may use with ribavirin
Hepatic Decompensation and Hepatic Failure in Patient with Cirrhosis and ALT Elevations

Grazoprevir (Zepatier -combo w/elbasvir) –PO tab
W/ or w/o ribavirin
CI w/ Patients with moderate or severe hepatic impairment and strong CYP3A inducers, and efavirenz

Question 25

Hep C nucleotide MOA, Indication, ADR

Answer 25

MOA - nucleotide prodrug that undergoes intracellular metabolism to form the pharmacologically active uridine analog

Indication - treatment of chronic hepatitis C virus (HCV) infection as a component of a combination antiviral treatment regimen

ADR-fatigue, headache, insomnia, anemia

Question 26

Hep C nucleotide drugs

Answer 26

Sofosbuvir (Sovaldi) – PO tab
combination with ribavirin or in combination with pegylated interferon and ribavirin
Epclusa – combination with velpatasvir (NS5A inhibitor)
used in combination with ribavirin for decompensated cirrhosis

Ledipasvir – PO tab
Available in combination with sofosbuvir ( Harvoni)
indicated with or without ribavirin

Ombitasvir – PO tab
Hepatic Decompensation and Hepatic Failure in Patient with Cirrhosis and ALT Elevations

Question 27

NS5A inhibitors for Hep C

Answer 27

Daclatasvir (Daklinza) – PO tab
binds to the N-terminus of NS5A and inhibits both viral RNA replication and virion assembly
indicated for use with sofosbuvir, with or without ribavirin
CI w/ Strong inducers of CYP3A, including phenytoin, carbamazepine, rifampin, and St. John’s wort
Bradycardia when coadministered with sofosbuvir and amiodarone
ADRs
headache, anemia, fatigue, and nausea

Elbasvir (Zepatier -combo w/grazoprevir) – PO tab
w/ or w/o ribavirin
CI w/ Patients with moderate or severe hepatic impairment and strong CYP3A inducers, and efavirenz
ADRs
headache, anemia, fatigue, and nausea

Pibrentasvir ( Mavyret combination w/glecaprevir)

Question 28

HPV IM vaccine (Gardasil)

Answer 28

Indicated to prevent diseases caused by HPV virus types 6,11,16 and 18 (cervical cancer & genital warts) in women b/w 9-26 years old.

Given in 3 doses at 0, 2 and 6 months.

ADRs – local reactions, fever

Question 29

Rotavirus vaccine (RotaTeq)

Answer 29

LIVE oral vaccine for rotavirus

Rotavirus most common cause of severe diarrhea and vomiting in young children

Given to infants at age 2, 4 and 6 months

Question 30

Cholera Vaccine, Live, Oral - Vaxchora

Answer 30

active immunization against disease caused by Vibrio cholerae serogroup O1
adults 18 through 64 years of age traveling to cholera-affected areas
Administer a minimum of 10 days before potential exposure to cholera