HIV Flashcards
Examples of immune-compromised states
- Diseases (e.g. HIV) with CD4 < 200
- Systemic steroids for 14 days + at prednisone equivalent dose of ≥ 20mg/day or 2mg/kg/day
- Asplenia
- Use of immunosuppressants
- Cancer chemotherapy (ANC < 500)
Common OIs requiring PPX
- PCP/PJP
- Toxoplasmosis gondii encephalitis
- Mycobacterium avium complex (MAC)
PCP: criteria for starting + preferred regimen (Prophylaxis)
CDC < 200 or AIDs defining illness
Bactrim SS or DS daily
PCP: Criteria for discontinuing ppx
CD4 count > 200 or > 3 months on ART Same for toxo
ALT agents when sulfa allergy is present for OI
Atovaquone
Dapsone
Pentamidine
ALT in setting of G6PD deficiency in OI
Atovaquone
Pentamidine
Toxoplasmosis: criteria for starting + preferred regimen (ppx)
IgG positive AND CD4 < 100
Bactrim DS daily
When is leucovorin added to OI regimens?
Whenever Pyrimethamine-containing regimens are used to reduce risk of pyrimethamine-induced myelosuppression
MAC: criteria for starting + preferred regimen (ppx)
If NOT taking ART & CD4 < 50
Azithromycin 1,200 mg weekly
MAC: when to d/c ppx
Taking fully suppressive ART
Candidiasis (thrush) preferred, + ALT treatment
Fluconazole
ALT = Itraconazole, Posaconazole
Oropharngeal: Topicals
Esophageal: Voriconazole
Cryptococcal meningitis preferred + ALT treatment
Amp B + Flucytosine
ALT = fluconazole + flucytosine OR Amp B. + fluconazole
Cytomegalovirus preferred + ALT treatment
Valganciclovir or ganciclovir
ALT = Foscarnet or cidofovir
PCP preferred + ALT treatment (active infection)
Bactrim high dose +/- prednisone or methylprednisone
ALT = atovaquone or pentamidine IV
MAC preferred + ALT treatment (active infection)
(Clarithromycin/azithromycin) + ethambutol
ALT = add 3rd or 4th agent using rifabutin, amikacin, or levofloxacin
Toxoplasmosis: risk factors
undercooked/raw meats, raw shellfish or contact with cat feces/litter
Toxoplasmosis preferred + ALT treatment (active infection)
Pyrimethamine + leucovorin + sulfadiazine
ALT = Bactrim
HIV drugs that act on stage 1 (binding/attachment)
CCR5 antagonist: Maraviroc
Attachment inhibitor: Fostemsavir
Post-attachment inhibitor: Ibalizumab-uiyk
HIV drugs that act on stage 2 (fusion)
Fusion inhibitor: Enfuvirtide
HIV drugs that act on stage 3 (Reverse transcription)
NRTIs: emtricitabine, tenofovir
NNRTIs: efavirenz, rilpivirine
HIV drugs that act on stage 4 (Integration)
INSTIs: Bictegravir, Dolutegravir, Raltegravir
HIV drugs that act on stage 7 (Budding & maturation)
Protease inhibitors: Atazanavir, darunavir
Initial evaluation + labs
- CD4 count
- Viral load
- Drug resistance genotyping
- CMP (including LFTs, CBC, lipids, BG, UA)
- Hep B & C screening
- Pregnancy test
- HLA-B*5701 (for abacavir) or tropism assay (for maraviroc)
When NOT to use Dovato?
HIV RNA > 500,000 copies/mL
Known Hep B co-infection or unknown
HIV genotyping unavailable
Zidovudine: use
IV during labor to protect the baby in pts with unknown HIV RNA or HIV RNA lvl > 1,000 copies/mL
All NRTIs: warnings
Lactic acidosis + hepatomegaly
Emtricitabine: warning
Hyperpigmentation of palms of hand or soles of feet
INSTIs: drug interactions
Polyvalent cations, must take 2 hours before or 6 hours after (Al, Ca, Fe, Mg)
Which INSTIs “falsely” raise SCr?
Bictegravir
Dolutegravir
Which INSTIs cause inc in CPK & myopathy?
Raltegravir
Dolutegravir
Which INSTI is preferred in pregnancy?
Dolutegravir
All NNRTIs warnings
Hepatotoxicity
rash (SJS/TEN) –> highest risk with rilpivarine
Rilpivirine (Edurant): administration
Take with meal & water
Requires acidic environment (C/I with PPIs, separate with H2RAs and Tums)
Efavirenz (Sustiva): administration
Empty stomach @ HS to dec. CNS effects
Atazanavir: features
Hyperbilirubinemia
Needs acidic environment
All PIs: warnings
Metabolic abnormalities
Hepatic dysfunction
Hypersensitivity reactions (rash, angioedema, anaphylaxis)
Which PI should you be concerned with regarding sulfa allergy?
Darunavir
Which PI is preferred in pregnancy?
Darunavir
PEP: when to start & end treatment
Start within 72 hours and continue for 28 days
CrCl and PrEP
Must be ≥ 60 mL/min for Truvada or ≥30 mL/min for Descovy
