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ID Therapeutics > HIV > Flashcards

HIV Flashcards

1
Q

Primary goals of ART

A
  • Maximal and durable viral suppression
  • Restoration and preservation of immune function (CD4 count)
  • Improved quality of life
  • Reduced HIV-related opportunistic infections
  • Reduced morbidity and mortality
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2
Q

First-line ART (recommended for most people)

A

INSTI + 2 NRTIs
or
INSTI + 1 NRTI

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3
Q

Single tablet regimens available for initial ART

A
  • INSTI
    • BIC/FTC,TAF(weight gain)
    • DTG/3TC (do not use is viral load is >500,000, with HBV coinfection, or w/o resistance testing results
    • DTG/3TC/ABC (only use if HLA-B*5701 negative)
  • NNRTI
    • RPV/FTC/(TAF or TDF) (only is HIV-1 RNA < 100,000 and CD4+ cell count >200
  • Boosted PI
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4
Q

INSTI

A
  • BIC/FTC/TAF
  • DTG/3TC
  • DTG/3TC/ABC
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5
Q

DTG/3TC (INSTI + 1 NRTI) caveat

A

Do not use if HIV-1 RNA > 500,000 c/mL, HBV coinfection, or without resistance testing results

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6
Q

DTG/3TC/ABC (INSTI + 2 NRTI) caveat

A

Only use if HLA-B*5701 negative

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7
Q

Bictegravir (INSTI) advantages

A
  • Single tablet regimen daily with FTC/TAF
  • Few drug/food interactions
  • High barrier to resistance
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8
Q

Bictegravir (INSTI) disadvantages

A
  • Least amount of data (new drug)
  • Only available as single tablet regimen
  • Limited safety data in pregnancy
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9
Q

Dolutegravir (INSTI) advantages

A
  • Single tablet regimen once daily with 3TC or 3TC/ABC
  • Available as single agent
  • Few drug/food interactions
  • Higher barrier to resistance
  • A preferred agent for pregnant women in every trimester
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10
Q

Dolutegravir (INSTI) disadvantages

A
  • ABC coformulation requires HLA-B*5701 testing
  • Increases metformin levels
  • Limited data at conception
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11
Q

Raltegravir (INSTI) advantages

A
  • Longest experience
  • Few drug or food interactions
  • A preferred option for pregnant women
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12
Q

Raltegravir (INSTI) disadvantages

A
  • Multiple pills (no STR)
  • Lower barrier to resistance than BIC or DTG
  • Limited safety data at conception
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13
Q

INSTI AE

A
  • GI distress
  • CNS disturbances (Most with Dolutegravir)
  • Rash (less with Bictegravir)
  • False elevation in creatinine
  • Weight gain
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14
Q

INSTI DDI

A

-Cations (acid reducers), Metformin

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15
Q

Interaction of INSTI with acid reducers

A

Decreases absorption, so wait at least 2 hours before taking antacids or take INSTI 6 hours or more after supplement.

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16
Q

Rilpivirine (NNRTI) Contraindication

A

Acid reducers

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17
Q

DTG + 3TC

A

cost effective compared to 3 drug regimen

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18
Q

DTG + 3TC

A

Rates of genital HIV-1 RNA shedding decreases with treatment

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19
Q

Preferred ART in pregnant women or women trying to conceive

A

Dual NRTI backbone plus INSTI or boosted PI
ex:
-3TC/ABC + DTG or ATV/RTV

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20
Q

Alternative ART in pregnant women or women trying to conceive

A

Dual NRTI backbone plus NNRTI
ex:
FTC/TAF + EFV

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21
Q

Raltegravir (RAL) pregnancy outcomes

A

No Neural tube defects after RAL exposure at conception/during 1st trimester

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22
Q

Rapid ART initiation

A

Improves clinical outcomes. Same day ART increased patient retention and viral suppression at 12 months.

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23
Q

NNRTI AE (except doravarine)

A
  • liver toxicity
  • rash usually six weeks
  • hyperglycemia
  • hyperlipidemia
  • Efavirenz (dose QHS) and Rilpivirine cause neuropsychiatric effects
24
Q

NNRTI DDI (except doravarine)

A
  • Efavirenz, Nevirapine, and Etravirine are CYP3A4 inhibitors
  • Rilpivirine is a substrate of CYP3A4
25
Q

Supporting TDF

A
  • Longer experience with greater number of patients with TDF VS TAF
  • Coformulations with many regimens
  • Lipid decreases of uncertain clinical significance seen with use of TDF
  • Weight gain signal with TAF
  • Preferred NRTI in pregnancy
  • Available with generic NRTI combinations with 3TC and FTC
26
Q

Supporting TAF

A
  • Has less impact on bone mineral density

- Less impact on markers of renal tubular dysfunction

27
Q

BIC

A

Bictegravir

28
Q

FTC

A

Emtricitabine

29
Q

TAF

A

Tenofovir Alafenamide

30
Q

DTG

A

Dolutegravir

31
Q

ABC

A

Abacavir

32
Q

3TC

A

Lamivudine

33
Q

TDF

A

Tenofovir Disoproxil Fumarate

34
Q

Supporting ABC

A
  • coformulated with DTG in first line regimen
  • long history of use
  • not renally cleared
35
Q

Opposing ABC

A
  • HLA-B*5701 test required before use - grade 1 to 5 threatening reaction
  • Continuing evidence of association of ABC with increased risk of MI
36
Q

Entry/fusion inhibitors

A
  • Enfuvirtide
  • Maraviroc
  • Ibalizumab
  • well tolerated, manly used for heavily treatment experienced patients
37
Q

Supporting Boosted PI

A
  • Starting ART before availability of resistance data
  • If high risk for poor adherence
  • Highest known genetic barrier to resistance
38
Q

Opposing Boosted PI

A
  • DDI
  • GI intolerance
  • Hyperlipidemia
  • CV risk with some PIs
  • Metabolic syndromes
  • Multiple daily dosing for some
39
Q

Stribild/Genvoya (Elvitegravir/cobicistat/emtricitabine/tenofovir)

A
  • STR
  • Meal restrictions (must take with food, high fat meal is good for absorption)
  • Renal dysfunction (CrCl must be > 70 ml/min at baseline and not fall below 50 ml/min)
  • Expect SrCr elevations during therapy
  • Reasonable option for pregnancy
40
Q

Cobicistat

A
  • inhibits CYP enzymes 3A, 2D6, p-gp
  • induces 2C9
  • drug interactions are overwhelming
  • Contraindicated with corticosteroids
41
Q

Emtricitabine/Tenofovir

A

Black box warnings:

  • lactic acidosis/severe hepatomegaly
  • Hepatitis B coinfection (severe exacerbations of Hep B)
42
Q

FTC/TAF

A

Has improved safety and tolerability over FTC/TDF and ABC/3TC, but appears to be associated with greater weight gain

43
Q

Potential drawbacks with INSTIs

A

Weight gain, CNS AEs, drug interactions with antacids

44
Q

MSM risk factors for HIV

A
  • HIV + sex partner
  • Recent bacterial STI
  • High number of sex partners
  • History of inconsistent/no condom use
  • commercial sex work
45
Q

Heterosexual women/men risk factors for HIV

A
  • HIV + sex partner
  • Recent bacterial STI
  • High number of sex partners
  • History of inconsistent/no condom use
  • commercial sex work
  • in high HIV prevalence are/network
46
Q

PWID risk factors for HIV

A
  • HIV + injecting partner

- sharing injection equipment

47
Q

PrEP eligibility criteria

A
  • Documented negative HIV test result
  • No signs/symptoms of acute HIV
  • normal renal function
  • no contraindicated comedications
  • documented HBV infection/vaccination status
48
Q

PrEP prescription

A

Daily, continued, oral FTC/TDF, = 90 day supply

49
Q

Other services for PrEP

A

Follow-up visits at least every 3 months for: HIV test, medication adherence counseling, behavioral risk reduction support, adverse event assessment, STI symptom assessment

50
Q

Recommended indications for PrEP use by MSM

A

Have to meet all criteria:

  • adult male or adolescent weighing >35 kg
  • no acute or established HIV infection
  • any male sex partner in previous 6 months
  • Not in monogamous relationship w/ recently tested, HIV negative man

and 1 or more of these criteria:

  • any anal sex w/o a condom in previous 6 months
  • bacterial STI in previous 6 months
51
Q

Recommended indications for PrEP use by heterosexuals

A

Have to meet all criteria:

  • adult male or adolescent weighing >35 kg
  • no acute or established HIV infection
  • any male sex partner in previous 6 months
  • Not in monogamous relationship w/ recently tested, HIV negative man

and 1 or more of these criteria:

  • is a male who is bisexual
  • infrequent condom use with 1 or more partners with unknown HIV status at substantial risk of HIV infection (PWID or bisexual male)
  • is in ongoing relationship with HIV + partner
  • bacterial STI in previous 6 months
52
Q

Recommended indications for PrEP use by people who inject drugs

A

Have to meet all criteria:

  • adult male or adolescent weighing >35 kg
  • no acute or established HIV infection
  • any injection of drugs not prescribed by a clinician in the previous 6 months

and 1 or more of these criteria:
-any sharing of injection or drug prescription equipment in the past 6 months

53
Q

NRTI

A

FTC, 3TC, AZT/ZDV, TDF, ABC

54
Q

NNRTI

A

RPV, ETV, EFV, NVP

55
Q

PI

A

LPV, FPV, DRV, ATV, NFV

56
Q

INSTI

A

RAL, DTG

ID Therapeutics (11 decks)

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