Antivirals HSV, VZV, CMV, HIV, Rabies Flashcards
Treatment for HSV and VZV
Generic and brand name
MOA
This antiviral can also treat what?
In terms of prevention in i.c patients, it works for HSV, VZV and what other virus?
ADR? 2 ⚠️
Acyclovir (Zovirax)
MOA: chain termination of DNA
—Bell palsy
—HSV meningitis, encephalitis & mucocutaneous infections
—Herpes & varicella zoster (shingles and chickenpox)
—prevention against CMV as well as HSV and VZV in i.c patients
ADR:
—interstitial nephritis if given IV
—neurotoxicity 😵💫🧠
give slowly and hydrate well
—Which is a prodrug to acyclovir?
—How is it activated? What are its characteristics
—What is a prodrug to penciclovir
—How is it activated?
—What is the MOA for penciclovir?
—What is the indication for valacyclovir and famciclovir?
—What is the indication for penciclovir?
—What are the toxicities for acyclovir and valacyclovir?
—Acyclovir regimen?
What is the MOA of valacyclovir ?
Indications
Dose regimen
Toxicities
Clinical pearls
!! Interstitial nephritis especially when given IV !! — so make sure you monitor SCr
!! Neurotoxicities: tremors, hallucination, delirium etc, esp. in the elderly or renal dysfunction !!
Famciclovir MOA
Key toxicities (same as all cyclovirs)
Clinical pearls
!! Interstitial nephritis especially when given IV !!
!! Neurotoxicities: tremors, hallucination, delirium etc, esp. in the elderly or renal dysfunction !!
Herpes Zoster
What is the directed therapy? When do you administer?
Which medication? Two options. Give the route
How long is the treatment?
What else do you prescribe?
Supportive therapy
What do you treat, with what?
What do you watch out for?
— <72hrs from onset
— PO valacyclovir and famciclovir x7d (zos-vala-fam)
— + corticosteroid taper 2-3w
supportive
know aluminium acetate (Burrow’s solution) or calamine lotion
Watch out for secondary bacterial infection
Who should be given the varicella zoster vaccine (Shingrix) ?
What is the dose?
What is the schedule?
What about chickenpox?
What is the dose
What is the schedule?
Shingrex:
—2 doses
—0 and 2-6mo
— >50y/o even if already had shingles!
Varicella vaccines
—2 doses
—1 month apart
—can be given anytime after Shingrex
What is this?
Which virus
What would you treat it with
Herpes labialis
HSV1
Treat your Pie hole with PPPenciclovir
What is this?
Herpes labialis
What are the topical agents for herpes simplex labialis? Give the drug & brand name
How do they work?
When do you apply it? How many times per day?
What do you treat CMV with?
Ganciclovir (IV)
ValGANciclovir (PO)
Ganciclovir & valganciclovir
MOA
Indications — 3 variations from the same virus…
Toxicities four of them
Clinical pearls
- CMV retinitis
- CMV prophylaxis
- CMV off-label as treatment
BBWs
—hematologic 🩸
—infertility 🤰
—Fetal 👶
—carcinogenic 🚬
What are the 2nd line for HSV and CMV infections?
(Don’t need to know, just be familiar)
What are some antiviral treatment considerations
Conservative/moderate ➡️ topical/oral/supportive
—healthy, no comorbidities
—good compliance/follow up
—limited lesions
—late presentation (>72hr)
Aggressive ➡️ oral/IV or admit
—i.c patients
—poor compliance
—incapable of PO
—extensive lesions/vulnerable locations
—CNS/organ involvement
What are the key principles for highly active antiretroviral therapy ? (HAART)
—combination
—first chance/best chance
—complexity
—resistance
—motivation/compliance
—monitoring
—goals of Tx
Familiarise
Focus on NRTIs and integrase inhibitors
Integrase inhibitors
—prevent integration of viral DNA into the nucleus
NRTIs
—prevent reverse transcription (the conversion of a single-stranded RNA (ssRNA) copy of the genome into a double-stranded DNA (dsDNA))
What are HIV patients on? Generally speaking
All on NRTI backbone and then most on INSTI (younger/newer meds are INSTI)
—NRTI backbone
—INSTI
—NNRTI
—entry inhibitors
—protease inhibitors
What is the backbone of HIV therapy?
What was the OG med?
What are the four common meds in this category?
NRTIs
OG: zidofudine
Tenofovir (think 10)
Abacavir (think abracadabra)
Emtricitabine (EMily blunt)
Lamivudine (Lamborghini)
NRTIs
What are they?
What is the MOA?
What are the common agents (1 OG, 4 common and one of which has two names)
What do you need to screen for?
How many NRTIs do you need to prescribe?
What are the key toxicity common to all?
Abacavir
Em & Lam?
Ten?
Zido? 3
Have to have two of these agents plus a third from somewhere else
Screen for Hep B because Em, Lami and teno are active against HBV infection
!! Have to check renal function on tenofovir !!
“It mimics the building blocks of DNA, buy they’re broken so they disrupt the DNA making process
—peripheral neuropathy common to all
—RASH in abacavir
—mild rash in Em and Lam
—nephrotoxicity in Ten (teno-nephro)
—lactic acidosis, hepatitis and anemia in Zido
NNRTIs
Non-nucleoside Reverse Transcriptase Inhibitors
What is the common med? Name
Main toxicity 1
3 adverse manifestations
Common in the first month?
Efavirenz ⬅️ one to know
—all the others end in -ine : (nevirapine, delatvirdine, etravirine, rilivirine)
—rash in first month
1. neuro disturbances 🧠 in efavirenz (like the other meds)
2. dyslipidemia (sunken in face under cheekbones)
3. lipodystrophy (fat deposit back of neck)
—nevirapine : fatal hepatitis
INSTIs
Integrate Strand Transfer Inhibitor
Which agents? (4)
Key toxicities
Pearls
Which are once a day doses?
part of first line treatment regimen
—well-tolerated
—nausea🤢 headaches 🤕 insomnia 🥱
—chelation (binding) w/ GI tract electrolytes
~tegravir (to remember this, think INSTIgram/INSTIgravir)
and if you surfed instagram all day, you would get nausea🤢 headaches 🤕 insomnia 🥱
once a day formulations becoming widely used
Bic — once a day
Dolu — once a day
Ral
Cabo
Protease Inhibitors (PIs)
Which agents (-suffix)
Pearls
Key toxicities / side effects, one you need to know
~NAVIRs (PIs, private investigator, have to NAVIgate around town to get evidence)
—rarely used anymore — many drug-drug interactions
—lipodystrophy like NNRTIs
—GI upset, diarrhea
Note the initial combination regimens for HIV patients
Note: tenofovir is always prescribed!
Except with ”abracadabra, you have a Lamborghini! (Abacavir and lamivudine = Triumeq)
What is the name of the only 2 drug HIV regimen? Only approved in 2020!
What are the caveats? 2
DOVATO
DOlutegravir + lamivudine
demo lovato probably drives a lambourghini
DO not prescribe if HIV RNA >500,000
OR coinfected with HBV
What is PrEP?
What are the drugs/regimens? Brand names (3)
What test do you have to take before hand?
1. Truvada has been the main stay for years
Don’t assume the patient has HIV. It’s for PrEP
2. Descovy
3. Apretude — cabotegravir — mono therapy, injection q2mo after 2 initiation vaccines one month apart
What are post-exposure prophylaxis options for HIV:
Which meds?
How long?
2NRTIs + INSTI
embtricitabine/tenofovir + raltegravir or dolutegravir
x28 DAYS
What is the rabies vaccine series?
Pre-exposure?
People at high risk who are getting regular vaccines
Vaccine name?
3-injection series
Imovax or RabAvert
Vets, animal handlers, peace corps, travelers
What are the considerations for the post-exposure prophylaxis for rabies ?
—type of attack
—which animal
—timing
—extent of wound
—hx of vaccination
—epidemiological studies basically showing that dog bites in the US are rarely the cause of rabies. Usually bat bites. Very rare generally.
Rabies: post exposure without prior vaccination — how do you treat? What is the timeline
What else might you treat/prescribe?
—4-injection series (5 if i.c pt)
— + HRIG (human rabies immune Glo in)
—0,3,7,14 (+/-28)
+/- tetanus & abx
Learning objectives
Takeaways
