Exam 5 - HIV/AIDS Flashcards
General Rule of treatment:
need at least __#__ active agents from at least __#___ classes
3 active agents;
from 2 classes
HIV expresses receptor proteins _____ which preferentially binds to ______ receptors T cells, macrophages, dendritic cells
gp120;
CD4 receptors
T or F: HIV is spread through breastmilk
true
hepatitis B NOT spread via breastmilk though
3 stages of HIV infection?
- Acute retroviral syndrome
- Chronic HIV infection (asymptomatic)
- AIDS (acquired immunodeficiency syndrome) symptomatic
3 main routes of transmission for HIV/AIDs
- Exposure of mucous membrane/damaged tissue to infected body fluids
- Blood stream exposure to infected body fluids
- Mother to child
When CD4 cells are infected with HIV/AIDs the cell is not able to do ______ production or secrete _______
antibody;
secrete cytokines
At CD4 counts below ________ is kinda start of opportunistic infections
500 cells/mm3
Sequence of appearance of laboratory markers for HIV infection:
1st seen:
2nd seen:
3rd seen:
1st seen: HIV RNA
2nd seen: HIV p24 antigen
3rd seen: HIV antibody
HIV RNA is first lab marker detectable — approx how long after infection?
10 days
A diagnosis of HIV an be made from either of the following:
-Positive result from __________
Positive ______ test (ex: _________)
- multitest algorithm (initial and supplemental tests MUST be differnet)
- virologic (ex: viral load or qualitative HIV NAT)
OraQuick Test:
Used to detect ________
uses ________ to test
detect HIV
use ORAL FLUID (not saliva tho)
OraQuick Test:
results seen how?
like pregnancy test
2 lines = positive
what is a seroconversion window?
a time THAT VARIES BETWEEN DIAGNOSTIC TESTS;
at end of window it will show a positive test/when antibodies will be seen…
OraQuick Test:
how long is the seroconversion for this test?
3 months
two main surrogate markers for HIV?
CD4 T lymphocyte cell count HIV RNA (viral load)
CD4 count or HIV RNA?
which one is used to assess a patients overall immunocopetence
CD4 T lymphocyte cell count
CD4 count or HIV RNA?
used to assess the effectiveness of therapy
HIV RNA (Viral load)
CD4 count or HIV RNA?
more useful BEFORE initiation of therapy
CD4
CD4 count or HIV RNA?
more useful AFTER initiation of therapy
Viral RNA
CD4 count is a calculated value based on __________ and can fluctuate depending on _________
based on total WBC count
may fluctuate with bone marrow suppressing medication/acute infections
Staging of HIV infection is split into __#___ of classifications and is based primarily on _______
into 4 classifications
based on CD4 count
two ways you can be in stage 3/AIDS?
CD4 count < 200
OR
any AIDS defining opportunistic infection
what drugs are the backbone of initial antiretroviral therapy in treatment naive patients?
NRTIs “nukes”
what NRTIs are adenosine analogues
Tenofovir
Didanosine
what NRTIs are cytidine analogues
lamivudine and emtricitabine
what NRTIs are thymidine analogues
stavudine and zidovudine
what NRTIs are guanosine analogue
abacavir
Prior to initiation of _______ pts must undergo screening for HLA-B5701 genotype
Abacavir
Class effects/ADEs of NRTIs?
mitochondrial toxicity lactic acidosis (w/ or w/out hepatomegaly and hepatic steatosis)
what are examples of mitochondrial toxicity
anemia granulocytopenia myopathy peripheral neuropathy pancreatitis
Some agents have low affinity for mitochondrial DNA polymerase gamma —- these agents are (1st or last line) and are what specific agents
they are 1st line! if low affinity for mitochondrial = better ADE profile
Specific agents are TEAL!!!
Tenofovir, Emtricitabine, Abacavir, Lamivudine
TDF (tenofovir disoproxil fumarate) has been assoc. with new onset/worsening _________ and decreases in ________
renal impairment
decrease in BMD (bone mineral density)
most NRTIs are eliminated via ________
renal excretion
the only NRTIs that are hepatic glucuronidated are _________ and __________\
zidovudine
abacavir
All NRTIs (except _______) need dose adjusted in renal insufficiency
abacavir
NRTIs:
few or lots of drug interactions?
few
Due to inhibition of intracellular phosphorylation and minimal additive antiviral activity _______ and _______ should not be used as NRTI backbone therapy
emtricitabine
+
lamivudine
class effect ADE with NNRTIs
rash (usually happens within the first 4 weeks of therapy)
SJS is a potential issue
NNRTIs:
few or a lot of drug interactions?
lots of drug interactions
NNRTIs:
eliminated renally or hepatically?
hepatically
use in caution with hepatic impairment
Class effects/ADEs of Protease Inhibitors:
GI intolerance-N/V/D
Insulin resistance
lipodystrophy
PIs:
few or a lot of drug interactions?
SO MANY — because they get metabolized by CYP3A4
what drug class can have “boosting”
protease inhibitors (bc of CYP3A4 metabolism)
also elvitegravir in INSTIs
INSTIs is what drug class?
integrase strand transfer inhibitors
class effect/ADE for INSTIs
weight gain
INSTIs are mainly eliminated via __________
and also subject to _______
UGT1A1 glucuronidation;
cationic chelation
which INSTI needs boosting to be allowed to dose once a day
elvitegravir
what does bPI stand for
boosted PI
what drug is a chemokine coreceptor antagonist
maraviroc
what drug is a fusion inhibitor
enfuviritide
HIV Goals of Therapy:
Suppress plasma HIV RNA to below detecable levels (aka < _______)
20 copies/mL
Persistent viremia results in immune activation/inflammation:
will cause what issues?
CV and thromboembolic events
cancer
neurocognitive dysfunction and frailty
do ART therapy for how long?
indefinitely (lifelong)
you can or not eradicate HIV infections with current treatments
can not (duh we have not cured AIDS)
ART is recommended for who?
ALL PTS!! regardless of CD4 count
what trial showed that it is best to start ART ASAP rather than wait for CD4 count to get below a certain #
START trial…
_____________ and ___________ are NOT recommended for 1st line therapy since they have not demonstrated potent/sustained antiviral activity
monotherapy and dual therapy ART
triple drug regimen is best
in general antiretroviral regimens for a treatment naive pt consist of what drugs?
TWO NRTIs in combo with a 3rd active antitetroviral agent from one of the following 3 drug classes:
INSTI, NNRTI, or PI boosted
______ is the “backbone” of therapy
2 NRTIs
what are the two common drug combos for NRTI backbone in ARV(antiretroviral) therapy
abacavir(ABC) + lamivudine (3TC)
or
TDF/TAF + emtricitabine (FTC)
4 main recommended initial regimens for people with HIV?
- ABC + 3TC + DTG
- DTG + TDF/FTC OR TAF/FTC
- BIC + TAF + FTC
- RAL + TDF/FTC OR TAF/FTC
what is abacavir’s abbreviation
ABC
what is lamivudine’s abbreviation
3TC
what is emtricitabine’s abbreviation
FTC
what is dolutegravir’s abbreviation
DTG
what is bictegravir’s abbreviation
BIC
what is Raltegravir’s abbreviation
RAL
Clinical Scenarios + Considerations:
if HLA-B5701 is + or unknown
AVOID ABC regimens!
Clinical Scenarios + Considerations:
if we must start antiretroviral therapy before we have the drug resistance results available – what drugs should we DEFINITELY AVOID
ABC regimens
and NNRTI based regimens
Clinical Scenarios + Considerations:
if we must start antiretroviral therapy before we have the drug resistance results available – what drug regimens should we do and why??
Tenofovir/FTC +
DRV/r or DRV/c or DTG
DRV and DTG have slow resistance to develop— so safe bet about low resistance!!
Clinical Scenarios + Considerations:
what regimen should be taken on an empty stomach?
Efavirenz based regimens
what is ritonavir’s abbreviation?
RTV
Clinical Scenarios + Considerations:
what regimens SHOULD be taken with food
ATV based
DRV based
EVG based
RPV based
Clinical Scenarios + Considerations:
what drug should be avoided in CKD
and
which one should be considered as avoided
avoid TDF
consider avoiding atazanivir
what is atazanavir’s abbreviation
ATV
Clinical Scenarios + Considerations:
which drug should be avoided in osteoporosis?
and what 2 specific ones can be used
AVOID TDF!!
TAF and ABC are ok
Clinical Scenarios + Considerations:
avoid what drug based regimens if psychiatric illnesses are present
EFV and RPV based
what is ritonavir’s abbreviation
RTV
avoid what antivirals if high cardiac risk
abacavir or lopinavir regimens
which antiviral may cause opioid withdrawal if initiated in patients who are on a stable dose of methadone
EFV
______ and ______ are not recommended with any rifamycin containing regimen
TAF and BIC
Antiviral Drug Interactions:
Boosted-PIs are CYP3A4 ______
inhibitors
Antiviral Drug Interactions:
NNRTIs are CYP3A4 ______
inducers
Antiviral Drug Interactions:
_______ are UGT1A1 substrates
INSTIs
Antiviral Drug Interactions:
Statins and __________ interact (will need to decrease dose)
Statins also interact with _______ (will need to increase dose maybe)
Protease inhibitors/cobicstat
NNRTIs
(CYP interactions)
Antiviral Drug Interactions:
_________ will increase metformin
dolutegravir
Antiviral Drug Interactions:
PDE5 inhibitors and ______ interact
protease inhibitors/cobcistat
Antiviral Drug Interactions:
Corticosteroids and _________ interact
protease inhibitors/cobcistat
Antiviral Drug Interactions:
BZDs and ________ interact
protease inhibitors/cobcistat
Antiviral Drug Interactions:
________ is contraindicated with PPIs
Rilpivirine
Antiviral Drug Interactions:
antacids should be separated from _______ by 6 hrs because of chelation
INSTIs
Antiviral Drug Interactions:
Never give _______ with Al or Mg
Raltegravir
what does RAM stand for
resistance associated mutation
to do resistance testing:
need a viral load of at least _______ copies/mL
1000
clinical scenarios where resistance testing is warranted?
at entry to care
and
if virologic failure
if a pregnant woman with HIV is near delivery:
if viral load is > 1000 copies/mL or unknown — do what?
schedule caesarian section at 38 weeks!!
and give IV zidovudine to mother during labor
when can pregnant lady do vaginal birth?
when viral load is less than 50 copies/mL
Postpartum considerations with HIV:
all newborns should get ARVs within ______ of life
6 - 12 hours of life
ARV prophylaxis for newborns born to HIV + moms?
4 weeks of PO zidovudine
PrEP vs PEP?
pre-expsoure phophylaxis
or
post exposure prophylaxis
what is currently only approved PrEP regimen
TDF/emtricitabine
who gets PrEP?
HIV NEGATIVE pts at high risk for HIV acquisition aka
- men who sex with men in not in monogamous with neg. partner
- heterosexual men or women in not in monogamous with neg. partner
- infrequent condom user w/ 1 or more high risk partner
- any bacterial STI in past 6 mos
- or if known HIV + partner
- ppl who inject drugs (sharing within past 6 mos)
Testing needed PRIOR to PrEP initiation
- documented negative HIV antibody or antigen test within 7 days
- any Sxs of acute HIV retroviral syndrome
- Hep B or Hep C serology
- CrCl gotta be above 60 mL/min
- pregnancy test
monitoring for PrEP?
do not have the prescription exceed _______ in length
90 days
If pt is on PrEP and at a return visit becomes HIV infected: do what?
stop PrEP therapy because only 2 drugs – need to bump up to 3 drug therapy options!
who is PEP recommended for
pts that have had an accidental exposure to HIV
healthcare needlesticks, sexual assualt victims, or accidental condom break
for PEP therapy:
how long to do it?
x 28 days;
OR
if source patient is found to be NEGATIVE – can just stop PEP therapy
for PEP therapy:
Should start ASAP and needs to be started within _______ or little benefit will be obtained
within 72 hours
PEP therapy option?
Emtrictabine/TDF +
(RAL or DTG) x 28 days
for PEP therapy: if pt is women of childbearing potential/are pregnant — avoid what drug in the PEP therapy?
avoid DTG!
Monitoring with PEP:
Rapid testing at baseline — if positive do not do PEP;
Repeat testing at ______ and ______
4 - 6 weeks;
and 3 months
PEP Counseling:
Patient should use precaution to prevent __________
secondary transmission (esp first 6 - 12 weeks) (use barrier to contraception/avoid blood/tissue donation, avoid pregnancy or breastfeeding)
