HIV Flashcards
HIV pts susceptible to opportunistic infections (OIs) when CD4 counts are below < ______
200
HIV infections mainly attack _______ cells
CD4+ helper T cells
HIV can be transmitted via
blood, semen, and vaginal secretions (unprotected sex and needle sharing)
or pregnancy, breastfeeding, or birth
The anti-HIV antibodies take about _____ to become positive and ______ to be detected/aka to get diagnosed
positive: 4 - 8 weeks after
3 - 6 months to be detected
what are the OTC HIV tests available?
counseling point for patients ?
blood test — sends envelope to get results
oral swab test (takes 20-40 mins)
have to wait 3 months after exposure for it to even show up also need another confirmatory lab test for diagnosis
_______ is an indicator of immune function
and
_____ is an indicator of response to ART (antiretroviral therapy)
CD4+ count
HIV Viral load
Treatment goals:
CD4+ count want value ____
HIV Viral load want value ______
CD4: normal ~ 800 - 1200
HIV viral: undetectable
HIV patients need an adherence rate of ____ or higher to be effective long term
95%
____ based regimens with a _______ backbone are recommended as initial therapy for most patients
INSTI; NRTI backbone
________ requires testing for HLA-B 5701 allele
abacavir
do NOT use this drug if positive for the allele! it is contraindicated
which HIV drug should be used with caution if renal insufficiency?
tenofovir disoproxil fumarate
Key Features of NRTIs:
All NRTIs have a boxed warning for ___________ and severe _____________
- lactic acidosis
- severe hepatomegaly with steatosis
Key Features of NRTIs:
T or F: need renal dose adjustment?
true – all need it except abacavir
Key Features of NRTIs:
T or F: No CYP450 drug intreactions
true
Key Features of NRTIs:
_______ has the hypersensitivity reactions (test for HLA-B 5701)
abacavir
Key Features of NRTIs:
Tenofovir toxicities include what 3 things?
– which tenofovir is thought to have less toxicities: disoproxil fumarate or alafenamide
nephrotoxicity
osteoporosis
fanconi syndrome
alafenamide is “safer”
The following drugs are what class of HIV drugs? abacavir tenofovir emtricitabine lamivudine zidovudine didanosine
NRTIs
Brand/Generic:
Lamivudine
Epivir
Boxed warning for Epivir/lamivudine:
Do not use the ______ formulation for HIV
Epivir-HB (aka the hepatitis B formulation…)
Boxed warning for Epivir/lamivudine:
severe/acute exacerbations of _______ can occur
hep B
also with emtricitabine, and tenofovir derivatives
these two NRTIs,Lamivudine and Emtricitabine, should not be used together why?
they are BOTH cytosine analogs…..
Key Features of NRTIs:
T or F: take without regard to meals
true
Truvada for PrEP (pre exposure prophylaxis):
patients must be confirmed as HIV negative prior to use and every ______ during use
every 3 months
which NRTI is used as IV option when HIV + mothers are in labor
zidovudine
Stavudine and Didanosine come in oral solutions — stability notes about them?
stable in fridge for 30 days
Key features of NNRTIs:
T or F: needs renal adjustment
false (they do not but majority NRTIs do)
Key features of NNRTIs:
T or F: no CYP 450 interactions
false (majority are cyp450 substrates and some are inducers)
Key features of NNRTIs:
Most common ADEs include: _______ and ______
hepatotoxicity and rash (SJS/TEN)
Key features of NNRTIs:
Because of rash issues: monitor fro what?
erythema, facial edema, skin necrosis, blisters, and tongue swelling
Key features of NNRTIs:
which two are required to be taken with food
etravirine, rilpivirine
Key features of NNRTIs:
which one is required to NOT be taken with food
efavirenz
Efavirenz warnings and how to decrease incidence?
CNS effects (impaired concentrations, abnormal dreams, confusion, dizziness — resolve in 2 - 4 weeks) — TAKE AT BEDTIME
another warning: serious psychiatric symptoms
Which antiviral drug class are the following drugs from? Efavirenz Rilpivirine Nevirapine Etravirine
NNRTIs
Rilpivirine requires _______ environment for absorption
acidic (THUS TAKE WITH FOOD and avoid concurrent use of PPIs and separate from H2RAs and antacids)
which NNRTI needs a 14 day lead in period to prevent the SJS/TEN/rash and hepatoxicity ADEs?
nevirapine
Boxed warnings of nevirapine
hepatoxicity
SJS/TEN
Do not initiate nevirapine if ____ counts above 250 (female) or above 400 (men) because of hepatoxicity risk
CD4 counts
For rilpivirine: higher rates of failure if viral load > _________
100,000 copies/mL
_______ levels can be decreased by efavirenz and nevirapine — monitor for withdrawl symptoms
also _____ levels can be decreased
methadone;
hormonal contrapceptive counsel for alt or or additional methods
what antiviral drugs are “boosting agents”
ritonavir
cobicistat
Key Features of Protease inhibitors:
all generic names end in -____
-navir
Key Features of Protease inhibitors:
T or F: There are CYP interactions
true- they are CYP INHIBITORS
Key Features of Protease inhibitors:
T or F: they need renal adjustment
false — they do not
Key Features of Protease inhibitors:
Some common side effects include?
- hepatoxicity
- metabolic abnormalities (hyperlipidemia, lipohypertrophy, hyperglycemia, insulin resistance)
- increased CVD risk
- GI upset (N/V/D)
- bleeding events (mainly hemophilia patients)
- ECG changes
- Rash
Which antiviral drug class do the following drugs belong to? atazanavir darunavir lopinavir nelfinavir saquinavir
PIs (protease inhibitors)
Darunavir warnings:
drug induced _____
serious _______
caution for patients with _____ allergy
hepatitis;
serious skin reactions;
sulfa allergy
T or F: Darunavir MUST be given with ritonavir or cobicistat
true
Contaminant RitonavirL
which of the following MUST have it and which one is it not recommended to be used with?
Nelfinavir, Saquinavir, Tipranavir
Nelfin: NOT recommended
Saquin and Tipra MUST be given with it
Drug Interactions for PIs:
Avoid with CYP3A4 inducers (ex:_____ or ______)
rifampin or st johns wort
Drug Interactions for PIs:
what are some drug classes should be AVOIDED with PIs?
- antiarrhythmics
- anticoagulants/antiplatelets
- direct acting antivirals
what is the effect of PIs and hormonal contraceptives?
ritonavir may decrease levels – use back up or alternative
what is the effect of PIs and methadone?
ritonavir will decrease levels – monitor for methadone withdrawl
what is the effect of PIs and PDE-5 inhibitors?
can increase PDE-5 levels – increase toxicity
what is the effect of PIs and statins?
which two are completely contraindicated
increase statin levels:
lovastatin and simvastatin are CONTRAINDICATED
(atorvastatin and rosuvastatin are preferred)
Which PI has to have caution with acid suppressing agents?
atazanavir
out of the two pk boosters (ritonavir or cobicistat) for PIs which one has antiviral properties
ritonavir
out of the two pk boosters (ritonavir or cobicistat) for PIs: take with food?
both
which of the preferred initial regimens contain cobicistat (aka watch out for drug interactions)
Genvoya and Stirbild
A ritonavir solution as a high content of what?
alcohol (43%)
For both of the two pk boosters (ritonavir or cobicistat) what drugs are contraindicated
alfuzosin(an alpha blocker) amiodarone/dronedarone carbamazepine lovastatin/simvastatin rifampin St. Johns wort Phenytoin/phenobarbital
out of the two pk boosters (ritonavir or cobicistat) for PIs:
which one can be coformulated with other antivirals?
cobicistat can be
ritonavir is difficult to coformulate with
Key features of INSTIs
generic names end with “ ______”
-tegravir
Key features of INSTIs:
Any major CYP450 interactions?
no
Key features of INSTIs:
most common side effects?
increased CPK
headache/insomnia
Key features of INSTIs:
No renal adjustment needed…but for the drug ______ do not start if CrCl < 70 mL/min
and
Do not start ______ or ______ if CrCl < 30 mL/min
Stirbild
Genvoya/Biktarvy
Key features of INSTIs:
Drug interaction with _______ - must separate
polyvalent cations
INSTIs should be taken how in relation to cation containing products?
2 hours prior or 6 hours after
INSTIs:
T or F: they need to be avoided with H2RAs and PPIs
False!! only the polyvalent items affect the absorption
which drug is a CCR5 antagonist and what does this MOA mean?
maraviroc;
there is a CCR5 receptor on some CD4+ cells – that receptor normally allows/helps HIV get into cells —
blocking CCR5 when present in patients helps prevent HIV from entering cells
what kind of test must be done before starting maraviroc?
a tropism test (to see if CCR5 receptor is present)
Enfuviritide works via a MOA of _______ and is given by what route?
fusion inhibitor;
given SQ — 98% of people have local site inj reactions
what is IRIS
IRIS = immune reconstruction inflammatory syndrome
paradoxical worsening of a PREEXISTING opportunistic infection or malignancy (bc immune system is being stimulated) after ART is started;
-can happen 1 -3 months after starting
-worse when pt has low CD4+ and high viral load
if a patient has an Opportunistic infection – do you stop or continue ART?
continue it (should be started within at least 2 weeks of OI treatment)
difference between lipodystrophy, lipoatrophy, lipohypertrophy
dys: changes in fat distribution
atro: loss of SQ fat
hyper: fat accumulation in neck/back = buffalo hump
what drug class causes lipoatrophy the most
NRTIs (esp stavudine)
All ARTs tend to cause ______ but protease inhibitors are typically worse
diarrhea
what drug is used for PrEP (pre exporsure prophylaxis)
Truvada 1 tablet daily
what drug options are there for non ocupational post exposure prophylaxis (nPEP)
Truvada 1 tablet daily PLUS raltegravir or dolutegravir
aka a 3 drug regimen total – for 4 weeks
to get non ocupational post exposure prophylaxis (nPEP) you have to get it ASAP (but at least within ______)
72 hours
what drugs make up Atripla?
NNRTI based efavirenz entricitabine tenofovir disoproxil fumurate (aka a complete regimen because it has 3 drug combo)
what drugs make up Genvoya?
INSTI based
elvitegravir + cobicistat + emtricitabine + tenofovir ALAFENAMIDE
(aka a complete regimen because it has 3 drug combo)
what drugs make up Truvada
NRTI combo products
Emtricitabine + tenofovir disoproxil fumurate
(aka will need another tablet to be a full regimen)
what drugs make up Complera?
NNRTI based
Rilpivirine + emtricitabine + tenofovir disoproxil fumurate
(aka a complete regimen because it has 3 drug combo)
what drugs make up Stribild?
NSTI based
elvitegravir + cobicistat + emtricitabine + tenofovir disoproxil fumurate
(aka a complete regimen because it has 3 drug combo)
what drugs make up Triumeq?
dolutegravir + abacavir + lamivudine
aka a complete regimen because it has 3 drug combo
what drugs make up Epzicom?
Abacavir + lamivudine
aka will need another tablet to be a full regimen
class effect ADE of NRTIs
lactic acidosis
class effect ADE of NNRTIs
rash
class effect ADE of PI’s
metabolic abnormalities (hyperlipidemia/ hyperglycemia/ lipohypertrophy)
