HIV Flashcards
Which cell type does HIV cause death of
T-Cells
How does HIV replicate
CD4+ T-helper cells
ART
antiretroviral therapy (HIV treatment)
As HIV replicates _____ increases while ____ decreases
viral load increases
CD4+ count decreases
CD4+ count that causes AIDS diagnosis
CD4+ count <200 cells/mm3
Treatment goal
normal CD4+ count (800-1200)
undectable HIV viral load
HIV viral load indicates _____
response to ART
High viral load can indicate 2 things
- medication nonadherence
2. drug resistance
Lab tests for HIV
CD4+ count, HIV viral load, drug resistance genotyping, CMP, CBC with differential, lipid panel, urinary analysis, Hep B+C, pregnancy test, drug-specific allele screening
What drug do you screen for HLA-B*5701 allele?
abacavir
what drug do you get a tropism assay for?
maraviroc
What must a patient be willing to commit to in order to prevent resistance?
ADHERENCE
what must the adherence rate be to prevent resistance?
> /=95% (no more than one dose/month for once daily dosing)
One pill, once daily initial ART options in treament-naive adults
Biktarvy, Triumeq, Dovato
Biktarvy
2 NRTIs: Tenofovir alafenamide, emtricitabine
1 INSTI: Bictegravir
Triumeq
2 NRTIs: Abacavir, lamivudine
1 INSTI: Dolutegravir
Dovato
1 NRTI: Lamivudine
1 INSTI: Dolutegravir
2 pill initial ART in treatment naive adults
Tivicay + Truvada
Tivicay + Descovy
Isentress + Truvada
Isentress + Descovy
TDF vs TAF
TDF has more renal and bone issues, use TAF if renal impairment or high fracture risk
Supplementation while using TDF
calcium and vit D.
HLA-B*5701 present
high risk of hypersentivity reaction to ABACAVIR - CONTRAINDICATED
Do not use Dovato when…
HIV RNA is >500,000 copies/mL or hep B co-infection present (only has two drugs/not as strong)
NRTIs MoA
competitively block reverse transcriptase preventing viral RNA from being converted into DNA
List of NRTIs
TDF- Viread TAF - combos and Vemlidy (Hep B) Lamivudine - Epivir Emtricitabine - Emtriva Abacavir - Ziagen Zidovudine - Retrovir Stavudine + didanosine (old, many AEs)
What NRTI is given during labor to protect baby if mother’s IV load is >1000
zidovudine
when do we give zidovudine during labor?
if mother’s viral load is >1000
_____ impairment indicates decrease NRTI dosing (except abacavir)
renal!
Tenofovir combo place in therapy
ART regmines usually compose of tenofovir and emtricitabine
also used in PrEP & PEP (Truvada and Descovy)
Why are 2 NRTIs a backbone of treatment-naive therapy?
good tolerability
few interactions
lack of resistance in ART naive patients
Caution in older NRTIs (didanosine, zidovudine, + stavudine)
HIGHER risk of lactic acidosis and hepatomegaly with steatosis and pancreatitis
Caution: abacavir
hypersensitivity risk - allele testing required prior to use
CI if history of reaction - NEVER rechallenge
Do not use ______ if treating HIV and HBV
abacavir
What drug class should a patient avoid if taking TDF (tenofovir disoproxil fumarate)
NSAIDs
Side effects of NRTIs
N/D, increase LFTs, headache
Abacavir: rash, increase risk of MI
emtricitabine: hyperpigmentation of palms of hands and soles of feet
______ and _______ can be replaced by each other in treatment regimens, but don’t use together because they are antagonistic
emtricitabine and lamivudine
INSTIs MOA
block integrase enzyme preventing viral DNA from integrating into host cell DNA
list of INSTIs
"-tegravir" Bictegravir Elvitegravir Doletegravir Raltegravir
Caution with INSTIs:
Don’t mix with cations (Al,Mg)
Which INSTI needs to be used with caution with UGT1A1s?
Raltegravir
Which drug should be avoided when using INSTIs
Rifampin
Which INSTIs can exacerbate HBV if discontinued? (two)
bictegravir, elvitegravir
Side effects of INSTIs
headache, insomnia, diarrhea, weight gain, rhabdomyolysis, proteinuria
____ can be increased by bictegravir and dolutegravir but _____ is not effected
SCr can be increased, GFR not effected
NNRTIs MoA
inhibit reverse transcriptase by non-competitively binding unlike NRTIs (competetitive)
list of NNRTIs
efavirenz (Sustiva)
rilpivirine (Edurant)
NNRTIs place in therapy
not-first line
used with 2 NRTIs
Rilpivirine administration
take with a real meal (not protein drink)
requires acidic gut for absorption, do not use with PPIs and separate from H2RAs and Antacids
which drug class can not be used with rilpivirine
PPIs
Which NNRTI should be taken on an empty stomach at bedtime
Efavirenz
Atripla
efavirenz/emtricitabine/tenofovir
not first-line anymore due to CNS/psych effects
NNRTI boxed warnings:
hepatotoxicity: do not start in women with a CD4+ count >250 or men >400
rash (SJS)
psych effects
Do not use Rilpivirine if_____ (counts)
viral load > 100,000 and/or CD4+ counts <200
PI (protease inhibitors) MOA
inhibits protease enzyme to prevent protein strands from being cut into small pieces needed for assembly of new virions. Replication still occurs but virions produced are immature and non-infectious
list of PIs
"-navir" atazanavir - Reyataz darunavir - Prezista fosamprenavir - lexiva indinavir - Crixivan lopinavir + ritonavir Kaletra (rit is booster)
Why are PIs not first line?
metabolic porblemcs
lipodystrophy
CVD risk
Interactiosn with CYP3A4
What do PIs require that is unique to this class
Boosters!
_____ and _____ require one of the two boosters ____ or ____
atazanavir and darunavir
boosters: ritonavir or cobicistat
Which PIs don’t require to be taken with food
fosamprenavir solution - don’t take with food
Kaletra (lopi/rito) - with or without
Kaletra and Ritonavir have high ______ content
ALCOHOL
do NOT take with metronidazole or disulfiram
Boxed warning for Tinpranavir
hepatitis
intracranial hemorrhage
Side Effects with PIs
diarrhea, nausea, metalic taste
Atazanaivr specific side effects
hyperbilirubinemia (“bananavir”)
PR interval prolongation
skin reactions
Darunavir, fosamprenavir, tipranavir: caution with ____ allergy
sulfa!
SJS
PIs are strong ______
CYP3A4 inhibitors
Drugs that should NOT be used with PIs (could make ART resistant)
- alfuzosin, colchicine
- dronedarone, amoidarone
- apixaban, edoxaban, rivaroxaban
- hormonal contraception
- lovastatin and simvastatin
which statins SHOULD be used with PIs
rosuvastatin and atorvastatin
Booster MOA
CYP3A4 inhibitors preventing the metabolism of ART increasing/enhancing the effect.
Why is Ritonavir used as a booster?
It has too many metabolic issues when used at its full PI dose
What are restrictions with ritonavir and cobicistat?
NOT interchangeable
do NOT use together
Interactions and boosters:
COMMON! can boost other drugs
Any combo with a booster will have many interactions
Cobicistat side effects:
nausea, diarrhea, headache, ^SCr, hyperbilirubinemia
Ritonavir side effects:
circumoral paresthesia (tingling, burning around mouth), bitter taste/change in taste
Cobicistat Combo Drugs
- Stribild (not for CrCl <50) elvitegrar/cobi/emtricitabine/TDF
- Genoya (not for CrCl<30) elvitegravir/cobi/emtricitabine/ TAF
-Symtuza: darunavir, cobi, emtricitabine, TAF
-Evotaz: atazanavir/cobi
=Prezcobix: darunavir/cobi
Maraviroc is useful if the ___ is present not if it and ____ are present
CCR5 receptor is the only one present but not useful if the CXCR4 is also present
AIDS defining conditions
CD4+ count <200
Opportunistic infections
Cancer types - Kaposi’s sarcoma
HIV Wasting syndrome
what is IRIS
Immune reconstitution inflammatory syndrome - paradoxical worsening of new or known condition that has been suppressed but becomes unmasked after ART is started or changed to a more effective regimen.
It occurs because the immune system is recovering and could become capable of mounting a response
What to do if IRIS occurs
Continue ART and treat unmasked condition
HIV and pregnancy
continue treatment if effective even if dolutegravir is being used.
If not on ART, start either w NRTIs + Boosted PI or INSTI
Do not breastfeed as it can pass HIV to the baby
What is PrEP?
pre-exposure prophylaxis to prevent infection
Requirements before starting PrEP
- confirm HIV-negative with antibody testing
- CrCl >/= 60
- Screening for hep B and STIs
After starting PrEP (Truvada or Descovy) what needs to be done every 3 months?
- HIV test and document negative result
- 90 Day supply only
- document pregnancy status
- counsel on adherence and safe sex/behaviors
- Crcl and STI testing q 6 months
PrEP options
Must have negative HIV test
Truvada
Descovy: not for vaginal-receptive PrEP but less risk of BMD and renal tox
PEP options
within 72 hours of exposure - taken for 28 days
More drugs needed due to actual possible exposure:
Truvada + Trivicay or Isentress
PEP must be started within _____ hours of exposure
72! Emergency situtation!
Abacavir
must be HLA-B*5701 negative
Triumeq
abacavir/lamivudine/dolutegrative
HLA-B*5701 negative
didanosine, stavudine
pancreatitis, hepatomegaly w/ steatosis (no alcohol)
Emtricitabine
hyperpigmentation
Don’t use with lamivudine
headaches
Truvada
emtricitabine/TDF
PrEP, PEP, and two pill regimens
Descovy
emtricitabine/TAF
PrEP
Lamivudine
HBV indication, don’t stop suddenly
headache
TDF
do not take with didanosine
kidney and fracture issues
supplement with vitamin D and calcium
avoid NSAIDs
Retrovir
zidovudine myopathy neutropenia anemia food required
Biktarvy
bictegravir/emcitritabine/TAF
separate Al and Mg due to bictegravir
Stribid
elvitegravir/cobicistat/emcitritabine/TDF
take with food
avoid NSAIDS
CrCl should be >/= 50
Gentoya
elvitegravir/cobicistat/emcitritabine/TAF
take with food
CrCL>30
Tivicay
dolutegravir
caution if pregnant (neural tube defects)
preferred with descovy or truvada
Isentress
Raltegravir
Descovy or Truvada
Efavirenz
CNS effects (dreams, confusion) goes away in 2-3 weeks empty stomach
Symfi
efavirenz/lamivudine/TDF
empty stomach
bedtime
Atripla
efavirenz/TDF/emtricitabine
empty stomach
bedtime
calcium + vit D for bone problems (TDF)
nevirapine
high risk for liver damage and rash
etravirine
after meaal
rilpivirine
with water and meal (not protein drink)
Prezista
darunavir
food
booster
caution with sulfa allergies
Reyataz
atazanavir
take with food
booster
fosamprenavir
empty stomach
sulfa allergies
indinavir
kindey stones
bad metabolic issues
Lopinavir/ritonavir
empty stomach
solution has high alcohol level
Norvir
ritonavir
booster in low dose
take with food
Saquinavir
qt prolongation
tipranavir
sulfa allergy
liver damage
intracranial hemorrahge
recommended treatement for naive patients 1 ____ and 2___- or 1 of each with ____-
1 INSTI
2 NRTIs
or one each with Dovato
Caution with sulfa allergy
tipranavir, fosamprenavir, tipranavir
What labs do are PIs known to raise
HDL, TGs, BG
which drug raises bilirubin and also known as “bananavir”
atazanavir
If oraquick comes back positive, what is the confirmation test needed?
Antibody differentiation assay
