Exam 5 Flashcards
NRTI: Renal
Require dose adjustment besides (Abacavir)
Empiric Therapy for Febrile Neutropenia
Cefepime
Zosyn
Ceftazidime (no gram+)
Imipenem
Meropenem
PIs: MOA
Inhibt the action of viral protease.
-Navir
Antifungal Drugs: Azole Drugs
-azole
Selective for fungal enzymes
Metabolised by P450s
Febrile Neutropenia Pathogen Directed Therapies
MRSA- Vanco
VRE- Dapto or Linezolid
ESBL- Carbapenem
KPC- Meropenem
NDM/IMP/VIM- Cefiderocol
Drugs to avoid in first trimester and CI
Fluconazole, itraconazole,posaconazole and isavuconazole. first
CI: Voriconazole, flucytosine, and griseofulvin
Ibalizumab Dosing Consideration
(Post-Attachment Inhibitor)
IV Loading dose then 2 weeks of IV maintance
Antifungal Drug: Echinocandins SOA
Broad Spectrum: Synergistic with Voriconazole and Amp B
-fungin
Not metabolized by liver CYPs
ANC level for Neutropenia for risk of infeciton
ANC <500 cells
Prefered Pregnancy Regimen
Dolutegravir plus (TDF or TAF) plus (emtricitabine or lamivudine)
or
Dolutegravir/abacavir/lamivudine
Only for HLAB negative and without HEPB
PrEP Injection Regimen
Cabotegravir IM 600 mg
Residual concentration
HIV Diagnosis
Positive virologic tests NAT
Polyvalent cations Drug interactions
IGIs 6 hours apart
AntiFungal Therapy for Febrile Neutropenia/Diagnosis
4-7 days of broad spectrum, Autopsy
Tx: Amp B
Azoles
Echinocandins(fungin)
Continue for 2 weeks in absense of s/sx of IFI
Febrile Neutropenia Prophylaxis
Cipro or Levo
DO NOT reuse for breakthrought infecitons
NNRTI: Renal
no.
only caution in hepatic
Virenz..
TMP/SMX Prophylaxis reduces which 2 infections
PJP and Toxoplasm
Histoplasmosis Treatment
Itraconazole 200 mg PO TID x 3 then 200 mg PO BID for 12months
Severe: Amp B plus itraconazole
NNRTI: Class adverse Effect
Rash
OI- Thrush Treatment
Fluconazole 200mg Loading dose, then 100-200 mg PO once daily for 7 days
Can also use Nystatin and Clotrimazole
Monitor LFTs and QTC
OI- Vulvovaginal Candidiasis TX
Uncomplicated: Fluconazole 150 mg PO
or Topicals
Severe: Fluconazole 100-200 mg PO daily for >7daus or topical azoles for >7 days
Recurrent (acute+long term):
Otesceconazole
or Flucanzole 150 PO q72 hours then ibrexafungerp
Azole- Boric Acid
Cryptococcal men Prophylaxis
Not recommended;
Secondary after completion of therapy
Drug: Flucanzole 200 mg for 12 months
If you are considering pregnancy HIV. what do you need to do.
Max-suppressive ARV regimen
Account for PK changes
If already on pregancay, continue same regimen.
If not- Obtain genotype.
MAC Treatment
Clarithromycin + Ethambutal
Azithromycin + Ethambutol
if Severe: add Rifabutin
If super Severe add: Levo, or moxi, or Amikacin or Streptomycin
PDE5-I drug interactions
With protease inhibitors use low does
Benzodiazepine Drug Interactions
With PIs and Cobicistat, Preferred benzos are lorazepam, oxazepam, and temazepam.
Antifungal Drug that is once-weekly novel. IV
Rezafungin (Echinocandin)
Up-to-date HIV website
Clinicalinfo.hiv.gov for updates
Capsid Inhibitor: MOA
Binds to interface b/w capsid protein p24
Uprake of proviral DNA interferes
For failing ART
Toxoplasma Prophylaxis
IgG 100.
Required : TMP-SMX
Stop if >200
Primary: TMP-SMX
Secondary: Pyrimethamine+ Sulfadiazine + Leucovorin
or TMP BID
Biguanide Drug interactions
Dolutegravir increases metformin, decrease dose
Toxoplasmosis Treatment
Pyrimethamine 200 mg x1 then weight based dosing
<60: Pyrimethamine 50 mg PO + Sulfadiazine + Leucovorin
>60: Pyrimethamine 75 mg+ 1500 Sulfadiazine + 10-15 leucovorin
OR
TMP-SMX
6 weeks
Prefered Benzos with what class/drugs
PIs prefere lorazepam, oxazepam, temazepam.
Antifungal Toxicities
Hepatic- Azole, AmpB, 5-FC, Echino
Renal Toxicity- Amp B
CNS- Voriconazole
Photopsia- Voriconazole
GI- Itraconazole, 5-FC
Cardia- Itra
QTC- Azole
Antifungal Drugs: Polyenes MOA
Amphotericin B
Amphotericin B binds to ergosterol
Creates leakage of intracellular cations and proteins
Elvitegravir Dosing Considerations
(INSTIs)
Take with food
PJP Treatment
TMP-SMX 15-20 mg/kg/day for 21 days
Alts: Primaquine plus clinda
Pentamidine
Add CS for O2 <70 mmJg
HIV Route of Transmission
1) Mucous membrane exposure
2) Blood Stream Exposure
3) Mother-Child
Lab screening prior to PrEP
HIV test within 1 week before prep
HIV RNA
STI testing
Creatinine
HBV
RIsk factors for Invasive fungal
Prolonged neutropenia + Broad spectrum antibiotics/steroids
Nevirapine Dosing Considerations
(NNRTIs)
Titrate dose over 14 days
Antifungal Drugs: Flucytosine AE
Intestinal flora can metabolize to 5-FU- anti-cancer
Monitor levels when combined with amp B
What is a polymorphic mutation
major and minor?
Naturally occurring variants in the absence of therapy
Major- amino acid substitution
Minor- Accessory mutation little effect
Attachment Inhibitor: MOA
Binds gp120 on surfance of HIV, blocking attachement to CD4
-savir
CYP3A4
PrEP Regimens On-Demand
Emtricitabine/TDF- for people who have sex with men
Corticosteroids Drug interactions
With PIs and cobicistat= beclomethasome is preferred.
Antifungal Drugs: Flucytosine MOA converases
Cytosine deaminase, then PRT then Ribonucleotide reductase.
This inhibits thymidylate which stops dUMP to dTMP.
Nearly always with AMP B or Fluconazole. Narrow window.
Cryptococcus candida
HIV Rapid Testing
OraQuick
OTC- + go to medical provider
Negative- counsel on seroconversion window.
retest
Antifungal Drugs: Polyenes PK and AE
Poor GI. IV for systemtic
AE: Infusion related reactions. Renal Damage.
INSTIs: Class Adverse Effect
Weight Gain
Which PI requires a “boosting drug”
Ritonavir and Cobicistat- inhibitors of CYP3A4
Statins drug interacitons.
With PIs and Cobicistat. Must do a low dose of atorvastatin, rosuvastatin, pitavastatin or pravastatin preffered.
with NNRTIs= increase dose
MAC Prophylaxis
Primary: CD4<50 and not recieving ART:
Not recommended ART
Secondary: duration 12 months
Drugs: Azithro 1200 mg PO once weekkly
Alt: Clithr, Azithro
Secondary: Clarithro + Ethambutol + Rifabutin
NNRTI: MOA
Binds to allosteric site of reverse transcriptase
Immune System- B-lymphocyte defect
Reduce ability against EXTRACELLULAR
HIV treatment Recommendations
Two NRTIs in combo with a third active ARV from one of three classes:
INSTI, NNRTI, or PI
Data: Dolutegravir plus lamivudine for initial treatment
Acid Reducers Drug Interactions
Seperate antacids from po INSTIs by 6 hours.
Never give raltegravir with Al or Mg.
OI- Esophageal Candidiasis TX
Fluconazole 200 mg loading dose,follwed by 100-200 mg up to 400 po or IV for 14-21 days
PDE5 Inhibitors drug interactions.
With PIs and Cobicistat, use very low dose
Febrile Neutropenia Oral low risk
Oral FQ + Augmentin
Cipro+Aug
Levo
Cipro+Clinda
What to seperate acid reducers with
Avoid Antacids with INSTIs by 6.
Atazanavir and Rilpivirine reducded by acid reducers. Rilpivirine CI with PPIs
Antifungal Drugs: Azoles MOA
Large 5 membered ring
MOA: Inhibits 14-a-demethylase
Inhibits conversion of lanosterol to ergosterol.
Cabotegravir Dosing Considerations
(INSTIs)
30 day lead in with the oral before IM injection
Intrapartum HIV Considerations
If VL>1000 or unknown = C-section
IV Zidovudine during labor
if <50; no zidovudine
VL 50-1000 can consider IV Zidovudine
Polyvalent cation supplements Drug interactions.
with IgIs splace apart by 6 hours.
Coadmin of Ca/Fe with dolutegraviro or bictegraviir ok with food.
Histoplasma Prophylaxis
150 CD4 maintance for 12 months
drugs: priamary: Itraconazole
Secondary: Itraconazole 200 mg PO daily
Stop if CD4>150
Etravirine Dosing consideration
(NNRTIs)
Take with food
Antiviral Febrile Neutropenia TX
Acyclovir, Valcyclovir for HSV/VZV
CMV: Ganciclovir, valganciclovir
HIV Stages
Acute, Chronic HIV (Asymptomatic), Aquired Immuno (AIDS)
INSTIs: MOA
Inhibits HIB Integrase, preventing the proviral DNA integration
Antifungal Drugs: Flucytosine MOA
Antimetabolite-
Inhibits thymidylate synthase, interfers with protein synthesis.
synergizes with Amp B
Target cells for HIV
gp120 binds to CD4 on T Cells
destroyed by cytolytic effect
Febrile Neutropenia Penicillin allergy Regimen
Ciprto+Aztreonam+Vanco
NRTI MOA:
Synthetic purine and pyrimide analogues which result in termination of elongation of growing proviral DNA chain
Thrush Prophylaxis
Not recommened
Fluconazole 100 or 200 mg PO
post-attachment: MOA
Binds to domain D2 of the Cd4 T-cell co-receptor and interrupts the post-attachment
Lenacapavir Dosing Consideration
(Capsid Inhibitor)
SubQ every 6 months
Antifungal Drugs: Allylamines MOA
Disrupts ergosterol synthesis;
Inhibits squalene epoxidase
Empiric Therapy for Febrile Neutropenia High Risk
Cefepime
Zosyn
Ceftazidime (no gram+)
Imipenem
Meropenem
Add IV Vanco for sepsis, shock, gram + , pneumonia, cellulitis. IV catheter
For Septic Shock gram - or pneumonia: Add AG or Ciproro or Levo
Immune System - T-lymphons defect
Reduce ability of host of defend against INTRACELLULAR
Statin Drug intreactions
PI must do low doses of atorvastatin, rosuvastatin, pitastatin.
With NNRTIs dose may need increased.
CCR5 Antagonist:MOA
Binds to CCR5 on Cd4 blocks gp120 and orevents entry of HIV into host
Consider tropism assay. CYP3A4!!
PrEP Regimens
Oral Daily:
Emtricitabine/TDF- PO daily for all risks
Emtricitabine/TAF- PO daily for men and transgender women
CI for PrEP
HIV Infection
<77 pounds
CrCL<60 - TDF/FTC
CrCL<30 - TAF
Possible HIV exposure within 72 hours
PIs: Class adverse effects
GI Intolerance, Insulin Resistance, lipodystrophy
Resistance- Stahlin
Candida Krusei- Fluconazole; and flucytosine and amp B
Candida glab- Multiazole,echinocandin and MDR
Asper- Amp B
PEP Regimen
Emtricitabine/TDF + (Raltegraviro or Dolutegravir)
Antifungal Drugs: Griseofulvin MOA
Discrupts microtubules- Fungistatic Oral
used dermatophytes
HIV Markers
Cd4 and HIB RNA PCR(viral load)
NRTI: Class Adverse Effect
Mitochondrial toxicity adn lactic acidosis
w/wo hepatomegaly and hepatic steatosis
cavir…
Biguanide Drug Interactions
Dolutegravir increases metformin.
Treatment of choice antifungal prego-
Amp B. and topical
Cryptococcal Meningitis Treatment
Liposomal AmpB + Flucytosine
Consoloation: Fluconazole 800 mh PO 8 weeks
Maintance Fluconazole 200 mg 1 year
rilpivirine Dosing considration
(NNRTIs)
take with low protien meal
PJP Prophylaxis
CD4 100-200
Must be given after completion of therapy
DrugsL Bactrim
Tavaborole MOA
Inhibits leucyl transfer RNA (LeuRS)- Inhibits protein synthesis.
Boron needed
Topical for nail fungus
CSF in Febrile Neutropenia
ANC<500, uncontrolled, IFI, hypotension, sepsis.
Prolonged infections
Antifungal Drugs: Allylamines Drugs
Terbinafine, Naftifine, Butenafine
Tolnafatate
Low vs High Risk Febrile Neutropenia
Low: Neutropenia <7days, Clinically stable, Inpatient or outpatient, IV or oraL
High Risk: ANC <100, Clincally unstable, inpatient, IV therapy
Efavirenz Dosing Consideration
(NNRTIs)
empty stomach at bed time
Antifungal Drugs: Echinocandins MOA
long cyclic hexapeptides with fatty acid side chains.
inhibit 1-3 glucoan well wall component.
