HIV Flashcards
All NRTIs
- Warning: lactic acidosis and hepatomegaly with steatosis (fatty liver); boxed warning for zidovudine
HBV and HIV coinfection boxed warnings
- Severe acute HBV exacerbation can occur if emtricitabine, lamivudine or tenofovir-containing products are discontinued (some NRTIs treat HBV)
- Do not use Epivir-HBV for the treatment of HIV (contains a lower dose of lamivudine)
Abacavir
- Screen for HLA-B*5701 allele before starting; abacavir is contraindicated if positive (boxed warnings: risk for hypersensitivity reaction)
- Consider avoiding with CVD due to a potential risk of MI
Emtricitabine
Hyperpigmentation of the palms of the hands or soles of the feet
Tenofovir-containing products
- Nephrotoxicity
- Osteoporosis/osteopenia
- Fanconi syndrome
Fanconi syndrome: renal tubular injury and electrolyte abnormalities
Zidovudine safety issues
- Hematologic toxicity: neutropenia and anemia
- Myopathy
All INSTIs
- Headache
- Insomnia
- Diarrhea
- Weight gain
- Rare risk of depression and suicial ideation in patients with pre-existing psuchiatric conditions
INSTI interactions with polyvalent cations
Separate from INSTIs from polyvalent cations: take INSTIs 2 hours before or 6 hours after aluminum, calcium, magnesium and iron-containing products; exceptions:
* Dolutegravir and bictegravir can be taken with oral calcium or iron if also taken with food
* Dose separations with raltegravir may not be effective; avoid polyvalent cations if possible
ART that ↑ SCr with no effect on GFR
- Bictegravir
- Dolutegravir
- Rilpivirine
ART that cause muscle damage (↑ CPK, myopathy and rhabdomyolysis)
- Raltegravir
- Dolutegravir
Dolutegravir
- A preferred drug for treatment of HIV during pregnancy
- Hepatotoxicity
All NNRTIs
- Hepatotixicity
- Rash/severe rash, including SJS/TEN
NNRTI drug interactions
- All NNRTIs are CYP3A4 substrates
- Efavirenz is a moderate CYP3A4 inducer
- Do not use rilpivirine with PPIs and separate from H2RAs and antacids
Efavirenz (Sustiva) safety issues
- Psychiatric symptoms (depression, suicidal thoughts)
- CNS effects (impaired concentration, abnormal dreams, confusion), generally resolve in 2-4 weeks
- ↑ total cholesterol and triglycerides
Food increases the bioavailability and risk for CNS effects; take on an empty stomach QHS to ↓ (and sleep through) CNS effects
Rilpivirine (Edurant)
- Take with food (with a meal, do not substitute with a protein drink)
- Depression
- Do not use if viral load > 100,000 copies/mL and/or CD4 count < 200 cells/mm3 (higher failure rate)
All PIs
- Metabolic abnormalities: hyperglycemia/insulin resistance, dyslipidemia (↑ LDL, ↑ TGs), ↑ body fat and lipodystrophy
- Hepatic dysfunction: ↑ LFTs
- Hypersensitivity reactions: rash (including SJS/TEN), angioedema, bronchospasm, anaphylaxis
- Common side effects: diarrhea, nausea
- Take with food (except for fosamprenavir oral solution in adults)
Atazanavir (Reyataz)
- Hyperbilirubinemia (jaundice or scleral icterus, remember with “bananavir”): reversible, dose not require discontinuation
- Requires acidic gut for absorption
Darunavir (Prezista)
- Caution with sulfa allergy
PI drug interactions
All PIs are CYP3A4 substrates and most are strong CYP3A4 inhibitors
Ritonavir and cobicistat drug interactions
- Strong CYP3A4 inhibitors
- Also inhibit CYP2D6 and P-gp
Take ritonavir and cobicistat with/without food?
Take with food
Maraviroc
Must have tropism assay results before starting
Tenofovir-containing products CrCl cutoff
- CrCl < 50: do not start TDF-containing products (< 70 for Stribild)
- CrCl < 30: do not start TAF-containing products
PrEP
- BEFORE high-risk activity
- Do not start PrEP without a NEGATIVE HIV test
- Treatment option 1: oral regimen of either Truvada or Descovy, taken daily, with no more than a 90-day supply provided at a time
- Treatment option 2: a long-acting intramuscular injection of cabotegravir (Apretude); administered by a healthcare provider monthly for 2 doses, then every 2 months
PEP
- AFTER HIV-exposure, start within 72-hours and take for 28 days
- Truvada (if CrCl ≥ 60) + Tivicay or Isentress
