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Human Immunodeficiency Virus > HIV > Flashcards

HIV Flashcards

1
Q

When is Acquired Immunodeficiency Syndrome (AIDS) diagnosed?

A

When CD4 count falls below 200 cells/mm3 or the patient develops an AIDS-defining condition.

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2
Q

How is AIDS infection spread? (hint: 5 ways)

A

1) blood
2) semen
3) vaginal secretions
4) rectal secretions
5) breast milk

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3
Q

When does the CDC recommend routine HIV screening? Who are considered High Risk?

A

At leasts once for all patients who are 13-64 years old. If a patient is high risk for infection, testing should be done at least annually.

High risk for infection are:
1) sharing drug-injection equipment (needles, syringes)
2) High-risk sexual behaviors: men who have sex with men, multiple sexual partners, sex with a person known to be infected or a history of sexually transmitted infections (syphilis, chlamydia, gonorrhea)
3) Hx of hepatitis or tuberculosis (TB) infection

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4
Q

How does Acute HIV infection present?

A

With non-specific flu-like symptoms that can last a few days to several weeks, including fear, myalgias, headache, lymphadenopathy (swollen lymph glands), pharyngitis and rash. Pts can become symptomatic after this initial phase but the virus is still replicating and capable of being transmitted.

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5
Q

When is the viral load high enough for HIV RNA and HIV p24 antigens to be detected with an initial HIV-1/HIV-2 antigen/antibody screening test?

A

Approximately 2 weeks post-infection the viral load is high enough.

Positive results should be confirmed with an antibody differentiation immunoassay with differentiates HIV-1 (most common subtype in the US) with HIV 2 antibodies. (can be detected in most people about 4 to 12 weeks after contracting disease but can take up to 6 months for some).

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6
Q

What is the In-Home HIV Test that is available OTC called?

A

OraQuick - provides immediate results (other OTC test kits require that a sample be sent to a lab). The upper and lower gums are swabbed with a test stick, put into a test tube containing liquid. After 20 minutes, test stick can be read.

Negative of OraQuick: tests should be used at least 3 months from exposure due to the lag in antibody production. testing sooner can cause a false negative result.

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7
Q

What is the major indicator of immune function and used to determine the need for OI prophylaxis?

A

CD4 count

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8
Q

What is the most important indicator of response to ART?

A

HIV viral load (how much HIV RNA is in the blood). High viral load can be due to medication non-adherence or drug resistance. The treatment goal is an undetectable HIV viral load.

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9
Q

What needs to be monitored or tested for when considering use of abacavir (Ziagen)?

A

HLA-B*5701 allele

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10
Q

What needs to be monitored or done if considering using maraviroc (Selzentry)?

A

tropism assay

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11
Q

What are the one-pill, once daily (single tablet regimens) recommended for patients who are treatment-naive adults? (3 options)

A
  1. Biktarvy (Bictegravir/emtricitabine/tenofovir alafenamide)
  2. Triumeq (Dolutegravir/abacavir/lamivudine)
  3. Dovato (dolutegravir/lamivudine)
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12
Q

What are the Two-pills (once daily for most) options for treatment-naive adults? (4 options)

A
  1. Tivicay + truvada
    (dolutegravir + emtricitabine/tenofovir disoproxil fumarate)
  2. Tivicay + Descovy
    (dolutegravir + emtricitabine/tenofovir alafenamide)
  3. Isentress + Truvada
    (raltegravir + emtricitabine/tenofovir disoproxil fumarate)
  4. Isentress + Descovy
    (raltegravir + emtricitabine/tenofovir alafenamide)

(Isentress if twice daily; Isentress HD is 2 pills once daily)

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13
Q

What do most preferred regimens for treatment-naive adults contain?

A

Most preferred regimens contain 2 NRTIs and 1 INSTI (“teg”)

-Truvada (emtricitabine/tenofovir disoproxil fumarate) OR Descovy (emtricitabine/tenofovir alafenamide) make up the NRTI backbone in most regimens.

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14
Q

Which NRTIs should not be used together since they are both cytosine analogs and are therefore antagonistic)?

A

Lamivudine and emtricitabine

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15
Q

When should one not use Dovato (1 NRTI and 1 INSTIs) in treatment naive patients? (clue: 3 reasons)

A
  1. When HIV RNA > 500,000 copies/mL
  2. Known hepatitis B virus (HBV) confection (or HBV status unknown)
    OR
  3. HIV genotypic testing not yet available
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16
Q

What should one do prior to starting Triumeq?

A

Test for the HLA-B*5701 allele before using. A positive result indicates a higher risk for a severe hypersensitivity reaction (HSR) and any abacavir-containing product is contraindicated.

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17
Q

When should Biktarvy, Triumeq, Dovato, Truvada, and Descovy not be used?

A

do not use if CrCl <30 mL/min

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18
Q

What is the alternative ART regimen that is PI-based (protease inhibitors, “navir’s”) (boosted with cobicistat or ritonavir)? (in addition to 2 NRTIs to serve as the “backbone”)

A

Darunavir (Prezista) or atazanavir (Reyataz)

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19
Q

What is the alternative ART regimen that is NNRTI based? (in addition to 2 NRTIs to serve as the “backbone”)

A

Efavirenz (Sustiva) or rilpivirine (Edurant)

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20
Q

What is the alternative ART regimen that is INSTI-based? (co-formulated in one pill)

A

Elvitegravir/cobicistat/TDF or TAF
I.e. Genvoya (elvitegravir/Cobicistat/TAF)
i.e. Stribild (elvitegravir/cobicistat/TDF/emtricitabine)

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21
Q

For the NRTI backbone for ALTERNATIVE ART regimens, what are the NRTI backbone options?

A

NRTI backbone (2 drugs, 1 from each row)
- TDF or TAF or abacavir PLUS
- emtricitabine or lamivudine

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22
Q

What is the brand name for abacavir and what class is it in?

A

Ziagen (NRTI)

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23
Q

What is the brand name for emtricitabine and what class is it in?

A

Emtriva (NRTI)

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24
Q

What is the brand name for lamivudine and what class is it in?

A

Epivir (NRTI)

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25
Q

What is the brand name for tenofovir disoproxil fumarate and what class is it in?

A

Viread (NRTI)

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26
Q

What is the brand name for tenofovir alafenamide, TAF?

A

Vemlidy (but that is a single agent only used for HBV); TAF is in combination products for HIV

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27
Q

What is the brand name for zidovudine and what class is it in?

A

Retrovir (NRTI)

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28
Q

True or False: NRTIs have a low barrier to resistance (i.e. resistance develops easily)

A

True

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29
Q

How can we remember the names of the NRTIs?

A

ZDS “loves” LATTE
zidovudine
didanosine
stavudine
lamivudine
abacavir
tenofovir disoproxil fumarate
tenofovir alafenamide
emtricitabine

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30
Q

What is the frequency of dosing for zidovudine (Retrovir)?

A

twice daily

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31
Q

What is the frequency of dosing for tenofovir (both formulations)?

A

once daily

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32
Q

What is the frequency of dosing for abacavir and lamivudine?

A

once daily and twice daily regimens

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33
Q

Which NRTIs should be dose decreased due to renal impairment?

A

All NRTIs, except abacavir (Ziagen)

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34
Q

How would you counsel TDF (tenofovir disoproxil fumarate) oral powder?

A
  1. Mix with 2 to 4 ounces of soft food (applesauce, yogurt) to avoid bitter taste
  2. Do not use liquid
  3. Contains lactose
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35
Q

What NRTI is administered during labor and delivery in some with HIV RNA >1,000 copies/mL to protect the baby? What is the route of administration?

A

Zidovudine (Retrovir); administered IV

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36
Q

What is the warning for all NRTIs?

A

1) lactic acidosis
2) hepatomegaly with steatosis (fat build up in the liver)
3) boxed warnings for “ZDS” zidovudine, didanosine, stavudine

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37
Q

What are the common side effects with NRTIs?

A
  1. Nausea
  2. Diarrhea
  3. Headache
  4. Increased LFTs
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38
Q

What is the HBV and HIV Confection Boxed Warnings?

A

Severe acute HBV exacerbation can occur if (LTE) lamivudine, tenofovir-containing products, and emtricitabine are discontinued (some NRTIs treat HBV)

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39
Q

When a patient is on abacavir (Ziagen) what should they always carry?

A

Patient must carry a medication card indicating that HSR (hypersensitivity reaction) is an emergency

(signs and symptoms: fever, rash, N/V/D, abdominal pain, fatigue, dyspnea, cough)

Never rechallenge if history of HSR

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40
Q

Other than the hypersensitivity reaction (HSR) concern with abacavir what is something else to be careful with?

A

Consider avoiding abacavir with cardiovascular disease due to a potential increase risk for MI.

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41
Q

What is a key feature or safety issue with emtricitabine? Counseling point.

A

Hyperpigmentation of the palms of the hands or soles of the feet.

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42
Q

What is the key feature and safety issue with tenofovir formulations (higher risk with TDF)? What would you counsel patients on?

A
  1. Renal impairment, including acute renal failure and Fanconi syndrome (renal tubular injury with hyperphosphatemia).
  2. Decrease dose with renal impairment and avoid other nephrotoxic drugs (i.e. NSAIDs)
  3. Decrease bone mineral density; consider calcium/vitamin D supplementation and DEXA scan if at risk
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43
Q

What is difference between TDF and TAF?

A
  1. Renal impairment (higher risk with TDF)
  2. TAF associated with higher risk of lipid abnormalities (monitor lipids if switching from TDF to TAF)
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44
Q

What is the concern with zidovudine?

A
  1. Hematologic toxicity (neutropenia and anemia ) increased MCV (mean corpuscular volume; measures the size of RBCs) is a sign of adherence
  2. Myopathy
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45
Q

What is the concern with didanosine and stavudine?

A

pancreatitis, peripheral neuropathy (can be irreversible)

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46
Q

What is the brand name that contains Bictegravir? What is the drug class of bictegravir?

A
  1. Biktarvy
  2. Integrase Strand Transfer Inhibitors
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47
Q

What is the brand name of cabotegravir?

A
  1. Vocabria (oral lead)
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48
Q

What is the brand name of dolutegravir?

A

Tivicay

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49
Q

What is the brand name that contains elvitegravir?

A

Elvitegravir only in combination drugs
1. Genvoya
2. Stribild

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50
Q

What is the brand name of raltegravir?

A

Isentress or Isentress HD

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51
Q

What is the MOA for Integrase Strand Transfer inhibitors (ISTIs)?

A

Block the INTEGRASE enzyme, preventing HIV DNA from INSERTING into the host cell DNA in STAGE 4 (integration) of the HIV life cycle

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52
Q

What is the perk of using a INSTI (integrate strand transfer inhibitors)?

A

INSTis have a higher barrier to resistance than NRTIs and NNRTIs

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53
Q

How can you remember which ones are the INSTIs?

A

The generic names end in “-tegravir”

Remember the common INSTIs with BRED

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54
Q

What is the frequency of use for 1. Biktarvy, 2. Stribild, 3. Genvoya, 4. Isentress HD, and 5. Tivicay?

A

Once daily

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55
Q

What is the frequency of use for Isentress and Tivicay if used on pts who are 1. treatment-experienced patients, 2. those with INSTI resistance or 3. the taking UGT1a1 or CYP3A4 inducers?

A

Twice daily

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56
Q

If a patient’s CrCl is <70 mL/min, what do we need to know in regards to INSTI (Integrase Strand Transfer Inhibitors) treatment?

A

do not start Stribild (elvitegravir combo)…may not be for the elvitegravir part since Genvoya is fine

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57
Q

If a patient’s CrCl is <50 mL/min, what do we need to know in regards to INSTI (Integrase Strand Transfer Inhibitor) treatment?

A

discontinue Stribild (elvitegravir combo).. may not be for the elvitegravir part since Genvoya is fine

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58
Q

If a patient’s CrCl is <30 mL/min what do we need to know in regards to INSTI (integrate strand transfer inhibitor) treatment?

A

do not start Biktarvy or Genvoya

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59
Q

When is cabotegravir PO (Vocabria) indicated?

A

indicated only for
1. lead-in treatment to assess tolerability prior to initiation of cabotegravir/rilpivirine (Cabenuva) injection OR
2. as a bridge therapy in patients who will miss a scheduled cabotegravir/rilpivirine injection for > 7 days

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60
Q

What are the side effects and warnings associated with bicetegravir (Biktarvy) and dolutegravir (Tivicay)?

A

increase SCr* (by inhibiting tubular secretions) with no effect on GFR

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61
Q

What are the side effects and warnings associated with raltegravir (Isentress, Isentress HD)?

A

increased CPK, myopathy, rhabdomyolysis

Creatine phosphokinase (CPK): is an enzyme (a protein that helps to elicit chemical changes in your body) found in your heart, brain, and skeletal muscles. When muscle tissue is damaged, CPK leaks into your blood. Therefore, high levels of CPK usually indicate some sort of stress or injury to your heart or other muscles

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62
Q

What is the main side effect or warning with elvitegravir?

A

(Genvoya and Stribild) Proteinuria

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63
Q

What are the main side effects and warnings associated with dolutegravir (Tivicay)?

A
  1. Hypersensitivity reaction (HSR) with severe rash and organ dysfunction
  2. Small risk of neural tube defects in women (though still a preferred drug for treatment of HIV during pregnancy)
  3. increased CPK (creatine phosphokinase), myalgia
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64
Q

What are the side effects that you counsel on for patients starting INSTIs (integrate strand transfer inhibitors)?

A
  1. headache
  2. insomnia
  3. diarrhea
  4. weight gain
  5. rare risk of depression and suicidal ideation in patients with pre-existing psychiatric conditions (except bictegravir)
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65
Q

In regards to DDIs how would you counsel someone who is on (BD) bictegravir (Biktarvy) or dolutegravir (Tivicay)?

A

dolutegravir (Tivicay) and bictegravir (Biktarvy) can be taken with oral calcium or iron IF ALSO TAKEN WITH FOOD

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66
Q

In regards to DDIs how would you counsel someone who is on raltegravir (Isentress)?

A

Dose separations with raltegravir may not be effective; AVOID POLYVALENT CATIONS IF POSSIBLE.

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67
Q

Counseling Cations and INSTIs

A

Take INSTIs 2 hours before or 6 hours after: aluminum, calcium, magnesium, and iron-containing products

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68
Q

What is the brand name and class of efavirenz?

A

Sustiva - non-nucleoside reverse transcriptase inhibitors (NNRTIs)

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69
Q

What is the brand name for rilpivirine and class?

A

Edurant - non-nucleoside reverse transcriptase inhibitors (NNRTIs)

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70
Q

What is the brand name for doravirine and class?

A

Pifeltro - non-nucleoside reverse transcriptase inhibitors (NNRTIs)

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71
Q

What is the brand name for etravirine and class?

A

Intelence - non-nucleoside reverse transcriptase inhibitors (NNRTIs)

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72
Q

What is the brand name for nevirapine and the class?

A

Viramune and Viramune XR - non-nucleoside reverse transcriptase inhibitors (NNRTIs)

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73
Q

What is the MOA for non-nucleoside reverse transcriptase inhibitors (NNRTIs)?

A

Non-competitively INHIBIT the REVERSE TRANSCRIPTASE enzyme, preventing the conversion of HIV RNA to HIV DNA in STAGE 3 (reverse transcription) of the HIV life cycle

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74
Q

What is a con to using NNRTIs?

A

NNRTIs have a lower barrier to resistance than INSTIs or PIs

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75
Q

How can we remember which ones are NNRTIs?

A
  1. Generic names contain “-vir-“
  2. REDDEN
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76
Q

How would you counsel someone on how to take rilpivirine (Edurant)?

A
  1. Take with water
  2. and a Meal (do not substitute with protein drink)
  3. Requires acidic environment for absorption; do not use with PPIs and separate from H2RAs and antacids
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77
Q

How would you take efavirenz (Sustiva) or how would you counsel someone on Sustiva?

A
  1. Food increases bioavailability and risk for CNS effects
  2. Take ON AN EMPTY STOMACH QHS to decrease (and sleep through) CNS effects
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78
Q

What is a key feature to remember with NNRTI?

A

Use in ALTERNATIVE ART regimens (not first line in most patients) 1 NNRTI plus 2 NRTIs

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79
Q

What is the safety issue with NNRTIs?

A
  1. Hepatotoxicity
  2. Rash/severe rash, including SJS/TEN
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80
Q

What NNRTI has the highest risk of SJS/TEN?

A

Nevirapine (Viramune)

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81
Q

How would you counsel someone taking efavirenz (Sustiva)?

A
  1. Psychiatric symptoms (depression, suicidal thoughts)
  2. CNS effects (impaired concentration, abnormal dreams, confusion) generally resolve in 2 to 4 weeks
  3. increase total cholesterol and triglycerides
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82
Q

What is important to note with NNRTIs and DDIs?

A

NNRTIs are major CYP3A4 substrates (and some are substrates of other CYP enzymes)

83
Q

Which NNRTIs should we not use with strong CYP3A4 inducers (carbamazepine, oxcarbazepine, phenobarbital, phenytoin, rifampin, rifapentine, St. John’s wort)?

A
  1. Rilpivirine (Edurant*)
  2. doravirine (Pifeltro)
84
Q

Which NNRTIs are considerate moderate 3A4 inducers?

A
  1. efavirenz (Sustiva)
  2. etravirine (Intelence)

many drug interactions

85
Q

What is important to note about rilpivirine in regards to side effects and when not to use it?

A

Rilpivirine (Edurant*)

  1. depression
  2. increase SCr* with no effect on GFR
  3. Do not use if viral load >100,000 copies/mL and/or CD4 count < 200 cells/mm3 (higher failure rate)
86
Q

How would you counsel a patient with rilpivirine (Edurant) in regards to DDIs? Be specific with the OTCs.

A

Rilpivirine (Edurant) needs an acidic gut for absorption

  1. Do not use with PPIs
  2. Take H2RAs at least 12 hours before or 4 hours after rilpivirine
  3. Take antacids at least 2 hours before or 4 hours after rilpivirine (separation times vary with antacid brands)
87
Q

What is the brand name for atazanavir and what is the drug class?

A

Reyataz; protease inhibitors (PIs)

88
Q

What is the brand name for darunavir and the drug class?

A

Prezista; protease inhibitors (PIs)

89
Q

What is the brand name of fosamprenavir and the drug class?

A

Lexiva; protease inhibitors (PIs)

90
Q

What is the brand name for lopinavir/ritonavir (LPV/r)? drug class?

A

Kaletra; protease inhibitor

91
Q

What is the MOA for protease inhibitors?

A

inhibit the HIV PROTEASE ENZYME, preventing long viral protein chains from being broken down into the smaller chains needed to produce mature (infectious) virus in STAGE 7 (budding and maturation) of the HIV life cycle; HIV continues to replicate, but produces immature visions that are not infectious

92
Q

Do PIs have a low or high barrier to resistance?

A

Have a high barrier to resistance (especially darunavir, Prezista)

93
Q

How can we remember Protease Inhibitors?

A

They end in “-navir”

94
Q

What are all PIs (protease inhibitors) recommended to take with?

A

Take WITH A BOOSTER (ritonavir or cobicistat)

95
Q

Do protease inhibitors need to be renal dose adjusted?

A

No renal dose adjustments

96
Q

How would you counsel someone who is starting protease inhibitors?

A

Take WITH FOOD to decrease GI upset except:
1. fosamprenavir oral solution (in adults) is without food
2. lopinavir/ritonavir (Kaletra) tablets are with or without food

97
Q

What is something to remember when counseling a patient on atazanavir (Reyataz)?

A

Needs an ACIDIC gut for ABSORPTION

98
Q

When are protease inhibitors (PIs) used?

A

They are used in alternative ART regimens (not first line in most patients): 1 PI (boosted with ritonavir or cobicistat) plus 2 NRTIs

99
Q

What are the side effects associated with all PIs?

A
  1. Metabolic abnormalities: hyperglycemia/insulin resistance, dyslipidemia (with inc LDL and inc TGs), inc body fat and lipodystrophy
  2. PIs increase CVD risk (lower risk with atazanavir, Reyataz and darunavir, Prezista, higher risk with lopinavir/ritonavir, Kaletra)
  3. hepatic dysfunction: inc LFTs, hepatitis (highest risk with tipranavir, Aptivus)
  4. hypersensitivity reactions: rash (including SJS/TEN), bronchospasm, angioedema, anaphylaxis
  5. Common side effects: diarrhea, nausea
100
Q

How would you counsel someone taking atazanavir? Side effects? Food or no food?

A
  1. Hyperbilirubinemia (jaundice or scleral icterus): reversible, does not require discontinuation (remember with “bananavir”)
  2. Requires acidic gut for absorption:
    Antacids: take atazanavir 2 hours before or 1 hour after
    H2RAs: avoid or take atazanavir 2 hours before or 10 hours after
    PPIs: avoid with unboosted atazanavir; take boosted atazanavir at least 12 hours after the PPI (dose should not exceed omeprazole 20mg or equivalent)
101
Q

What HIV medications should be used in caution with someone has a sulfa allergy?

A

Some PIs:
1. Darunavir (Prezista)
2. Fosamprenavir (Lexiva)
3. Tipranavir (Aptivus)

102
Q

What HIV medication has alcohol in it and what should one watch out for?

A

Lopinavir/Ritonavir (Kaletra) the oral solution contains 42% alcohol: can cause a disulfiram reaction if taken with metronidazole

103
Q

What is the safety issue with tipranavir (Aptivus)?

A

Can cause intracranial hemorrhage

104
Q

What is the concern with DDIs and protease inhibitors (PIs)? What are some medication that should not be used with PIs?

A
  1. All PIs are major CYP3A4 substrates and most are strong CYP3A4 inhibitors
  2. Do not use the following drugs with PIs:
    a. alfuzosin
    b. colchicine
    c. dronedarone
    d. lovastatin and simvastatin (rosuvastatin or atorvastatin are preferred with PIs)
    c. CYP3A4 inducers (i.e. carbamazepine, phenytoin, phenobarbital, rifampin, St. John’s wort)
    d. anticoagulants/antiplatelets: apixaban, edoxaban, rivaroxaban, ticagrelor <Brilinta> (warfarin is not CI but INR should be monitored closely)
    e. direct acting antivirals (DAAs) for Hep C
    f. some hormonal contraceptives (counsel on additional use of contraceptive methods)
    g. steroids (systemic, intranasal and inhaled, with the exception of beclomethasone; increased risk of Cushing's syndrome)</Brilinta>
105
Q

What is the brand name of ritonavir?

A

Norvir (pharmacokinetic boosters/enhancers)

106
Q

What is the brand name for cobicistat?

A

Tybost (pharmacokinetic boosters/enhancers) (can be co-formulated - found in many combination products)

107
Q

What is the dose of ritonavir (Norvir)?

A

100 to 400 mg PO daily (in 1 to 2 divided doses) WITH FOOD

108
Q

What is something to counsel in regards to the oral solution of ritonavir (Norvir)?

A

Oral solution contains 43% ALCOHOL; can cause a DISULFIRAM REACTION if taken with METRONIDAZOLE

109
Q

How would you counsel someone on ritonavir (Norvir) powder?

A

Mix with soft food or liquid and take within 2 hours

110
Q

What is the dose for cobicistat (Tybost)?

A

150 mg PO daily WITH THE BOOSTED DRUG (i.e. darunavir, atazanavir) AND WITH FOOD

111
Q

What is MOA of ritonavir and cobicistat?

A

They are inhibitors of CYP3A4. They inhibit ART metabolism, which INCREASES (BOOSTS) the ART level and therapeutic effect.

112
Q

Can ritonavir and cobicstat be use interchangeably?

A

No, they are not interchangeable. Do not use both together.

113
Q

What type of DDIs are ritonavir and cobicistat involved in?

A

They are strong CYP3A4 inhibitors and CYP2D6, P-gp transporters and some of the OAT family of transporters.

114
Q

Which pharmacokinetic booster/enhancer should not be used with amiodarone?

A

Ritonavir

115
Q

What is the name (brand and generic) of the CCR5 antagonist?

A

Maraviroc (Selzentry)

116
Q

What formulations are available for maraviroc (Selzentry)?

A

Tablets, solutions

117
Q

What is the MOA for maraviroc (Selzentry)?

A

BLOCKS HIV from BINDING (and subsequently entering) the CD4 cell in virus strains that use the CCR5 CO-RECEPTOR in STAGE 1 of the HIV life cycle (binding/attachment)

118
Q

What are the safety issues with maraviroc (Selzentry)?

A
  1. hepatotoxicity (boxed warning)
  2. hypersensitivity reactions (including SJS/TEN)
  3. CV events (including MI)
  4. orthostatic hypotension in patients with renal impairment
    **Do not use if severe renal impairment CrCl <30 mL/min and taking potent CYP3A4 inhibitors/inducers
119
Q

What is required before starting maraviroc (Selzentry)?

A

MUST have TROPISM assay results before starting (test that ermines if the HIV strain infecting the patient can ONLY BIND to the CCR5 CO-RECEPTOR.

If the HIV strain can bind to CXCR4 or MIXED (CXCR4/CCR5) co-receptors, maraviroc WILL NOT WORK and HIV will still be able to enter the CD4 cell.

120
Q

What is the brand name for fostemsavir and what is the MOA?

A
  1. Rukobia
  2. Attachment Inhibitor
  3. Converted to temsavir (active form), which binds to the gp120 subunit of HIV envelope proteins, inhibiting the interaction between the virus and the CD4 host cell in STAGE 1 of the HIV life cycle (binding/attachment)
121
Q

What are the safety issues associated with fostemsavir (Rukobia)?

A
  1. Do not use with strong CYP3A4 inducers.
  2. Must maintain effective HBV treatment in patients connected with HBV.
  3. Can increase SCr (higher risk if underlying renal disease)
122
Q

When is fostemsaviar (Rukobia) indicated?

A

Indicated in combination with other ARTs in heavily treatment-experienced patients who are failing current therapy.

123
Q

What is the brand name for ibalizumab-uiyk and what is the MOA?

A
  1. Trogarzo
  2. post-attachment inhibitor: Monoclonal antibody that binds to a select domain of CD4 cell receptors in STAGE 1 (binding/attachment) of the HIV life cycle, blocking entry of the gvirust into the cell
123
Q

What is the brand name for ibalizumab-uiyk and what is the MOA?

A
  1. Trogarzo
  2. post-attachment inhibitor: Monoclonal antibody that binds to a select domain of CD4 cell receptors in STAGE 1 (binding/attachment) of the HIV life cycle, blocking entry of the virus into the cell
124
Q

What is the route of administration for ibalizumab-uiyk (Trogarzo)?

A

Injection (administered IV)

125
Q

What are the safety issues associated with ibalizumab-uiyk (Trogarzo)?

A
  1. infusion-related reactions (observe for 1 hour after first infusion)
  2. diarrhea
  3. dizziness
  4. nausea
  5. rash
126
Q

Where should ibalizumab-uiyk (Trogarzo) be stored and how should it be handled?

A

Refrigerate unused vials and administer immediately after dilution

127
Q

When is ibalizumab-uiyk (Trogarzo) indicated?

A

Indicated in combination with other ARTs in heavily treatment-experienced patients who are failing current therapy

128
Q

What is the brand name of enfuvirtide and what is the MOA?

A
  1. Fuzeon
  2. fusion inhibitor - prevents HIV from fusing to the CD4 cell membrane in STAGE 2 (fusion) of the HIV life cycle, which prevents virus entry into the cell
129
Q

How is enfuvirtide (Fuzeon) supplied and given?

A

Powder for injection (administered by SC self-injection into the abdomen, front thigh, or back of arm)

130
Q

What are the safety issues and side effects associated with enfuvirtide (Fuzeon)?

A
  1. Risk of bacterial pneumonia
  2. hypersensitivity reactions
  3. local INJECTION SITE REACTIONS (nearly all patients)
  4. pain, erythema, nodules and cysts, ecchymosis (bruising), nausea, diarrhea and fatigue
131
Q

How is enfuvirtide (Fuzeon) stored?

A

Store unused drug/supplies at room temperature; once RECONSTITUTED, refrigerate and use within 24 hours

132
Q

What is Biktarvy composed of?

A

BETa
Bictegravir/emtricitabine/tenofovir alafenamide

133
Q

What is Cabenuva composed of?

A

CR
Cabotegravir/rilpivirine

134
Q

What is Triumeq composed of?

A

DAL
Dolutegravir/abacavir/lamivudine

135
Q

What is Dovato composed of?

A

DL
Dolutegravir/lamivudine

136
Q

What is Juluca composed of?

A

DR
Dolutegravir/rilpivirine

137
Q

What is Stribild composed of?

A

ECET
elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate

138
Q

What is Genvoya composed of?

A

ECETa (aka genvoyA)
elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide

139
Q

What INSTI-based single tablet regimen can be used as first line?

A

BDT
Biktarvy, Dovato, Triumeq

140
Q

What is the route of administration for Cabenuva, frequency, and how is it administered?

A

Cabenuva: administered IM once monthly BY A HEALTHCARE PROFESSIONAL (must be preceded by one month of lead-in treatment with oral cabotegravir to assess tolerability)

141
Q

When can Cabenuva, Dovato, or Juluca be used?

A

Can be used
1. to REPLACE A CURRENT STABLE ART REGIMEN in patients
2. with VIROLOGIC SUPPRESSION and
3. no hx of treatment failure or known resistance

142
Q

When should one not start tenofovir disoproxil fumarate products?

A

When CrCl < 50 mL/min (except for Stribild at CrCl < 70 mL/min)

143
Q

When should one no start tenofovir alafenamide products?

A

When CrCl < 30 mL/min

144
Q

Which INSTI-based 1 tablet regimens should be taken with food?

A
  1. Stribild
  2. Genvoya

(The elvitegravir combos)

145
Q

What is in Delstrigo? What is the backbone for this combo single pill drug?

A

DLT
doravirine / lamivudine / tenofovir disoproxil fumarate

NNRTi-based

146
Q

What is in Atripla? What is the backbone for this combo single pill drug?

A

EET
efavirenz /emtricitabine /tenofovir disoproxil fumarate

NNRTI-based

147
Q

What is in Symfi/Symfi Lo? What is the backbone for this combo single drug?

A

ELT

efavirenz / lamivudine /tenofovir disoproxil fumarate

NNRTI-baed

148
Q

What is in Complera? What is the backbone for this combo single drug?

A

RET

rilpivirine /emtricitabine /tenofovir disoproxil fumarate

(Odefsey is the same but with tenofovir alafenamide)

NNRTI-based

149
Q

What is in Odefsey? What is the backbone for this combo drug?

A

RETa

rilpivirine /emtricitabine /tenofovir alafenamide

(Complera is the same but with tenofovir disoproxil fumarate)

150
Q

How would you counsel someone taking Atripla, Symfi, or Symfi Lo? Should it be taken with or without food?

A

Take on EMPTY STOMACH (contains efavirenz)

151
Q

How would you counsel someone who is starting Complera or Odefsey? Should it be taken with food or no food?

A

Take with food (contains rilpivirine).

152
Q

What does Symtuza contain?

A

D C E Ta

Darunavir / cobicistat / emtricitabine /tenofovir alafenamide

153
Q

How would you counsel someone who is taking Symtuza?

A

Take with food.

Do not start if CrCl < 30 mL/min (contains tenofovir alafenamide)

154
Q

What is in Epzicom?

A

Abacavir / lamivudine

Must be used with additional ARTs to make complete regimen

NRTI Combo Product

155
Q

What is in Trizivir?

A

ALZ
Abacavir / lamivudine /zidovudine

Must be used with additional ARTs to make complete regimen

NRTI Combo Product

156
Q

What is in Descovy?

A

Emtricitabine / tenofovir alafenamide

Must be used with additional ARTs to make a complete regimen

NRTI Combo Product

157
Q

What is in Truvada?

A

Emtricitabine / tenofovir disoproxil fumarate

Must be used with additional ARTs to make a complete regimen

NRTI Combo Product

158
Q

What is in Combivir?

A

Lamivudine / zidovudine

Must be used with additional ARTs to make complete regimen

NRTI Combo Product

159
Q

What is in Cimduo?

A

lamivudine /tenofovir disoproxil fumarate

160
Q

What is needed before initiating Epzicom and Trizivir?

A

Requires baseline testing for HLA-B*5701 (contains abacavir)

161
Q

T/F Are Descovy and Truvada part of FIRST-LINE regimens?

A

True; yes

162
Q

When should one not use Descovy/Truvada?

A

Do not use if CrCl < 30 mL/min

[< 60 mL/min for Truvada if using for PrEP]

163
Q

What is the frequency of use for Trizivir and Combivir?

A

Twice daily

164
Q

When should Cimduo not be used?

A

Do not use if CrCl is <50 mL/min

165
Q

What is in Evotaz?

A

atazanavir / cobicistat
AC

PI combo product

166
Q

What is in Prezcobix?

A

darunavir / cobicistat

PI combo product

167
Q

How would you counsel someone taking Evotaz and Prezcobix?

A

Take with food (take cobicistat-containing products with food)

168
Q

When is AIDS diagnosed?

A

When the
1. CD4 count is < 200 cells/mm3 OR BY
2. presence of an AIDS-defining condition

169
Q

What is an AIDS defining condition?

A
  1. Opportunistic infections (OIs) [e.g. mycobacterium avid complex (MAC), pneumocystis jirovecii pneumonia (PJP or PCP), cryptococcal neoformans, histoplasmosis, severe Candida albicans infections, including esophageal and bronchial thrush, tuberculosis]
  2. Several cancers, including Kapok’s sarcoma.
  3. HIV WASTING SYNDROME, a debilitating condition with loss of fat tissue (lipoatrophy), muscle mass and appetite (anorexia), and diarrhea
170
Q

What are options to increase appetite in HIV patients with HIV wasting syndrome?

A
  1. Dronabinol (Syndros)
  2. Nabilone
  3. Megestrol, a progestin that stimulates appetite
171
Q

What is immune reconstitution inflammatory syndrome (IRIS)?

A

A paradoxical (unexpected) WORSENING of a known UNDERLYING CONDITION, or a previously unidentified condition, after ART is STARTED or treatment is changed to amore effective regimen.

As the immune system begins to recover, it becomes capable of mounting an inflammatory response, and symptoms of the underlying condition can become UNMASKED.

172
Q

What are some key points about IRIS (immune reconstitution inflammatory syndrome)?

A
  1. It is more likely to occur as the viral load decreases and the CD4 count recovers.
    2.Underlying conditions that can appear or worsen include common OIs, AUTOIMMUNE CONDITIONS and SOME CANCERS (I.E. KAPOSI’S SARCOMA), hep B and C, herpes simplex virus (HSV), varicella zoster virus (VZV, shingles).

In some cases, a known underlying condition will be treated for a short time prior to starting ART to help prevent IRIS.

173
Q

What happens if IRIS (immune reconstitution inflammatory syndrome) occurs?

A
  1. ART should be continued
  2. UNMASKED condition should be treated
174
Q

T/F Most HIV medications are considered safe to use during pregnancy without an increased risk of birth defects.

A

True

In most cases, women who are ALREADY ON AN EFFECTIVE ART REGIMEN should CONTINUE using the same regimen throughout their pregnancy.

175
Q

Which HIV medication can cause a very small risk of neural tube defects but the benefits outweigh the risks making it a preferred drug?

A

Dolutegravir (Tivicay)

176
Q

Can one breastfeed while on HIV medication?

A

No, breastfeeding should be avoided.

177
Q

What is the backbone that is recommended for TREATMENT-NAIVE pregnant women?

A

Treatment should include 2 NRTIs plus either an INSTI or a boosted PI

178
Q

What are the NRTI combinations that are recommended in treatment-naive pregnant women?

A
  1. abacavir / lamivudine (Epzicom)
  2. tenofovir disoproxil fumarate / emtricitabine (Truvada)
  3. tenofovir disoproxil fumarate / lamivudine (Cimduo)
179
Q

What are the INSTI (integrase strand transfer inhibitor) that are recommended in treatment-naive pregnant women?

A
  1. Raltegravir (Isentress, Isentress HD)
  2. Dolutegravir (Tivicay)
180
Q

What are the boosted PIs that are recommended in treatment-naive pregnant women?

A
  1. Atazanavir + ritonavir (Reyataz + Norvir)
  2. Darunavir + ritonavir (Prezista + Norvir)
181
Q

Which meds are used for pre-exposure prophylaxis (PrEP)?

A

Either
1. Truvada
or
2. Descovy

182
Q

What should be done before starting PrEP?

A
  1. CONFIRM that the person is HIV-NEGATIVE with an HIV AB test (use of a 2-drug regimen in an HIV-positive person would cause resistance to commonly used treatments) this step is different from PEP where you shouldn’t wait for Ab results
  2. Ask about recent symptoms that could indicate HIV infection, due to the lag time for detectable antibody
  3. Confirm CrCl is at least 60 mL/min (if using Truvada) or at least 30 mL/min (if using Descovy) [Note: the CrCl cutoff for Truvada is higher for PrEP than when used for HIV treatment.]
  4. Screen for Hep B and STIs
183
Q

When someone is on PrEP when should they followed-up on? Why?

A

Follow up at least every 3 months (do not provide more than 3 months supply). At each visit: test for HIV and document negative result (do not refill drug without confirming HIV-negative status)

184
Q

When on PrEP, what should be checked every 6 months?

A

Check SCr (to calculate CrCl) and test for STIs

185
Q

What are the two types of PEP?

A
  1. nonoccupational (nPEP)
    and
  2. occupational (oPEP)
186
Q

When should PEP be started?

A
  1. Treatment should be STARTED as soon as possible WITHIN 72 HOURS (3 days) of the exposure
  2. and continued for 28 days
  3. the exposed individual should receive a baseline HIV Ab test (do not wait for results before starting PEP)
  4. and a follow-up test at 4 to 6 weeks, 3 months, and 6 months after the exposure
187
Q

When can PrEP be started?

A

When a negative HIV Test is attained

188
Q

Can Descovy be used for PrEP in patients who are assigned female at birth?

A

No: Descovy is not approved for PrEP in patients assigned female at birth (i.e. at risk of getting HIV from vaginal sex), and don’t approved for PEP

189
Q

What is the treatment for PEP?

A
  1. Truvada (if CrCl is at least 60 mL/min)
    +
  2. Dolutegravir (Tivicay) OR raltegravir (Isentress)**

**Isentress may be preferred in woman of child bearing age due to small risk of neural tube defects with dolutegravir

190
Q

How would you counsel someone who is starting ART in regards to IRIS (immune reconstitution inflammatory syndrome?

A
  1. do not stop taking ART
  2. notify healthcare provider of a new or worsening condition
191
Q

What would you counsel on if a patient is to start an NRTI?

A
  1. If you have hepatitis B, do not stop taking this medication without discussing with your healthcare provider as severe worsening of the hepatitis can occur.
  2. Can cause lactic acidosis. (abdominal or stomach discomfort, decreased appetite, diarrhea, fast, shallow breathing, a general feeling of discomfort, muscle pain or cramping, and unusual sleepiness, tiredness, or weakness)
192
Q

What are key counseling points for someone starting abacavir (Ziagen)?

A
  1. do not stop taking medication if have hepatitis
  2. s/sxm of lactic acidosis
  3. your blood should be tested to see if you are at higher risk for a severe reaction before using this med
193
Q

What are key counseling points for someone starting emtricitabine (Emtriva)?

A
  1. do not stop taking medication if have hepatitis
  2. s/sxm of lactic acidosis
  3. this medication can cause darkened spots on the palms of hands and on the soles of feet
194
Q

What are key counseling points for someone starting tenofovir disoproxil fumarate (Viread) and tenofovir alafenamide?

A
  1. do not stop taking medication if have hepatitis
  2. s/sxm of lactic acidosis
  3. Can cause (less with alafenamide)
    kidney impairment, low bone density/fracture risk
195
Q

What is a key counseling point for someone starting INSTIs?

A

can interact with antacids. Take 2 hours before or 6 hours after INSTI.

196
Q

What is a key counseling point for someone starting NNRTIs?

A

Can cause
1. rash/severe rash
2. hepatotoxicity

197
Q

What are key counseling points for someone starting efavirenz (Sustiva)?

A
  1. rash/severe rash
  2. hepatotoxicity
  3. Take on empty stomach at bedtime to reduce side effects
  4. can cause depression/psychosis, confusion and abnormal dreams (at start, gets better in 2 to 4 weeks)
198
Q

What are key counseling points for someone starting rilpivirine (Durant)

A
  1. rash/severe rash
  2. hepatotoxicity
  3. take with a full meal and water, not a protein drink
  4. do not use PPI; take H2RAs 12 hours before or 4 hours after, and antacids 2 hours before or 4 hours after rilpivirine
  5. can cause depression
199
Q

What are key counseling points when someone is starting a PI?

A
  1. take with food (except fosamprenavir oral solution in adults)
  2. can cause high blood glucose, high triglycerides or body fat redistribution
200
Q

What are key counseling points when someone is starting atazanavir (Reyataz) or Darunavir (Prezista)?

A
  1. take with food (except fosamprenavir oral solution in adults)
  2. can cause high blood glucose, high triglycerides or body fat redistribution
  3. If taking ritonavir, make sure to take both at the SAME TIME.
201
Q

What are key counseling points when someone is starting atazanavir (Reyataz)

A
  1. take with food (except fosamprenavir oral solution in adults)
  2. can cause high blood glucose, high triglycerides or body fat redistribution
  3. If taking ritonavir, make sure to take both at the SAME TIME.
  4. do not take acid-suppressing medications with atazanavir
  5. can cause hyperbilirubinemia
202
Q

What are key counseling points when someone is starting darunavir (Prezista) fosamprenavir (Lexiva), and tipranavir (Aptivus)?

A

Caution with sulfa allergy

Human Immunodeficiency Virus (1 decks)

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