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IDT Study > HIV and Antiretrovirals > Flashcards

HIV and Antiretrovirals Flashcards

1
Q

Goals of HIV Tx

A
  • Maximally and durably suppress Plasma HIV RNA, - Restore and Preserve immunologic function
  • Reduce HIV associated morbidity and prolong the duration and quality of survival
  • Prevent transmission
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2
Q

When to initiate treatment

A

ART is recommended for ALL individuals w/ HIV regardless of CD4-Tlymphocyte count

  • ASAP if HIV(+)

And transmission Prevention

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3
Q

When to initiate tx (Like now)

A 
Prego
AIDS
Acute opportunistic infection
Low CD4 count
HIV-AN
Acute/Early HIV infection
Hep B or C coinfect
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4
Q

What baseline lab data to have

A 
HIV viral load
HIV genotype
CD4 count
CBC w. Diff
CMP
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5
Q

Generic Formula for antiretroviral treatment

A

3 active antiretrovirals

from at least 2 different antiretroviral classes

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6
Q

Nucleotide Reverse Transcriptase Inhibitors (NRTI)

  • MOA
  • Class ADR
A

Cause premature DNA chain termination during reverse transcription

  • Renal Dosing (excp Abacavir)
  • Lactic Acidosis
  • Hepatic Steatosis
  • Peripheral Neuropahy
  • Lipoatrophy
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7
Q

Pregnancy preferred NRTIs

A 
Lamivudine
Emtricitabine
Tenofovir (TDF)
Abacavir
Zidovudine ~ ?
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8
Q

Hep B preferred NRTIs

A

Lamivudine
Emtricitabine
Tenofovir (TFD & TAF)

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9
Q

Lamivudine

  • Class
  • Dosing
  • Bonuses
A

NRTI
150mg BID or 300 QD
Reduced replication capacity benefit of m184V mutation
(active against Hep B; preferred in pregnancy)

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10
Q

Emtricitabine

  • Class
  • Dosing
  • Bonuses
A

NRTI
200mg QD
May cause skin darkening

Reduced replication capacity benefit of m184V mutation
(active against Hep B; preferred in pregnancy)

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11
Q

Tenofovir (TDF) ADRs

A 
Nephrotoxic (avoid in renal insufficiency)
GI effects (gas/nausea)
Dec. Bone mineral density (avoid in osteoporosis)
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12
Q

Tenofovir (TAF) ADRs

A 
Nausea
Diarrhea
HA
(DO not use for PREP)
Strong inducer in rifamycins
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13
Q

Abacavir ADRs

A 
Hypersensitivity Rxn (test for HLA-B*5701 allele) - Never rechallenge
Potential Cardiotoxicity
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14
Q

Zidovudine ADRs

A

Neutropenia
Anemia
GI upset (Take w/ food)

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15
Q

NRTI preferred for M184V mutation

A

Tenofovir (TDF & TAF)

Zidovudine if M184V AND k65r mutations

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16
Q

NRTI w/ Best CNS penetration

A

Abacavir

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17
Q

Epzicom

  • Combo
  • Dosing
A

Lamivudine + Abacavir combo

1 tablet Daily

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18
Q

Truvada

  • Combo
  • Dosing
A

Emtricitabine + Tenofovir (TDF) combo

1 tablet daily

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19
Q

Descovy

  • Combo
  • Dosing
A

Emtricitabine + Tenofovir (TAF) combo

1 tablet daily

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20
Q

Combivir (generic now available)

  • Combo
  • Dosing
A

Lamivudine + Zidovudine

1 tablet BID

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21
Q

ARV-ARV interaction w/ Atazanavir and Tenofovir

A

Must be “boosted” with Ritonavir or Cobicistat (PK boosters)

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22
Q

ARV-ARV interaction w/ Didanosine + Tenofovir

A

Must dose adjust didanosine

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23
Q

ARV-ARV interaction w/ Stavudine + Zidovudine

A

Antagonistic effect; do not use

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24
Q

Tenofovir Intrxn w/ Ledipasvir

A

Do not do

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25
Q

Zidovdine intxn w/ Ribavirin

A

May decrase efficacy of zidovudine

Anemia

26
Q

Didanosine intxn w/ Ribavirin

A

Increases didanosine toxicity

27
Q

Zidovidine Intxn w/ Methadone

A

May increase zidovudine levels (monitor toxicity)

28
Q

Didanosine intxn w/ Allopurinol

A

Contraindicated

increases didanosine levels and toxicity

29
Q

Integrase Inhibitors

  • MOA
  • Class ADR
A

Inhibits the “strand transfer” phase of HIV DNA integration into the host DNA.

HA, Insomnia, CPK elevation, Nausea, Hyperglycemia?, and Intxns w/ divalent/polyvalent cations

30
Q

Raltegravir

  • Class
  • ADR
A

Integrase Inhibitor
HA (resolves after 2-4wks)
Insomnia, CPK elevation,
Hyperglycemia

31
Q

Raltegravir (bonuses)

- Dosing

A

Lowest risk for infection must increase dose w/ rifampin or other UGT inducers
Preferred Integrase Inhibitor in pregos
400mg BID
1200mg QD

32
Q

Dolutegravir

  • Class
  • ADR
A

Integrase Inhibitor
Nausesa/bloating, fecal urgency, HA, Insomnia, all generally resolve, mood side effects, hyperglycemia, and increased SCr

33
Q

Dolutegravir (bonuses)

- Dosing

A

Low/moderate risk for interactions
High barrier to resistance and active against some resistant virus
- 50mg QD
50mg BID (if suspected integrase inhibitor resistance or with concomitant metabolic inducer)

34
Q

Elvitegravir

  • Class
  • ADR
A

Integrase Inhibitor

GI upset, Insomnia, HA, Increased SCr (generally not if decreased GFR)

35
Q

Elvitegravir (bonuses)

- Dosing

A

Do not use if CrCl <70 mL/min
HIGH-risk for intxns
do NOT use in pregnancy
- 150mg QD w/ food

36
Q

Protease Inhibitors

  • MOA
  • Class ADRs
A

Inhibits protease cleaving of gag and gag-pol viral proteins

GI side effects, Hyperlipidemia, Hypertriglyceridemia, Insulin Resistance, 3A4 inxns (inhibition mostly), and Lipodystrophy

37
Q

Ritonavir

  • Class
  • ADR
A

Protease Inhibitor

GI side effects; Hyperlipidemia, Hyper TG, glucose intolerance

38
Q

Ritonavir Bonuses

- Dosing

A

Avoid humidity > 2wks, solution tastes awful

  • 100-200mg qd or bid
39
Q

Darunavir

  • Class
  • ADR
A

Protease Inhibitor

GI side effects, LFT elevations, more lipid sparing

40
Q

Darunavir bonuses

- dosing

A

Newest
Take w/ food
No if SULFA allergy Preferred in Pregos

800mg qd w/ booster
OR
150mg QD
OR
600mg BID w/ RTV
41
Q

Atazanavir

  • Class
  • ADR
A

Protease Inhibitor

Hyperbilirubinemia (jaundice), LFT elevations, Considered “Lipid sparing”

42
Q

Atazanavir bonuses

- Dosing

A

Take w/ Food, ACID suppressant interactions (no PPI or H2RA)
Consider dose inc w/ Ritonavir

43
Q

Lopinavir/Ritonavir

  • CLass
  • ADR
A

Protease Inhibitors

GI side effects, Hyperlipidemia, Hyper TG, Elevated blood glucose

44
Q

Nelfinavir

  • Class
  • ADR
  • bonus/dose
A

Protease Inhibitor (alternative tx)

Diarrhea, Hyperlipid/TGemia, LFT and Glucose elevations

Take w/ snack or meal
Only proteasome inhibitor never boosted with RTV

45
Q

Tipranavir

  • Class
  • ADR
  • Bonus/Dose
A

Protease Inhibitor

Hepatotoxicity, GI side effects, Reports of Intracranial hemorrhage

Take w/ food, Caution in Sulfa Allergies, keep refrigerated

46
Q

Protease Inhibitor general Drug-Drug interactions

A

CYP 3a4 high risk interaction (inducers)

  • No use of Simva or Lovastatin
  • Careful w/ corticosteroids
  • Careful w/ Hep C meds
Antipyschs (quetiapine)
Antifungals (vori)
Anti-mycobacterium 
Benzos
Cardiac Glycosides
47
Q

Which Protease Inhibitors are CYP 3A4 INDUCERS

A

Tipranavir + Ritonavir

48
Q

Non-Nucleoside Reverse Transcriptase Inhibitors (Non Nucs)

  • MOA
  • Class ADRs
A

Bind Reverse transciptase at an allosteric site to inhibir enzymatic activity

Cross Resistance, Low barrier to resistance
Rash, 3A4 induction (except delavirdine)

49
Q

Efavirenz

  • class
  • ADR
  • Bonuses/dose
A

non-Nuc

Rash, CNS effects, Insomnia

Avoid high fat content (snack), false pos w/ CBD assays
600mg QD

50
Q

Rilpivirine

  • Class
  • ADR
  • Bonuses/dose
A

Non-Nuc

Less incidence of Rash and CNS effects, may inc SCr, no effect on GFR

Avoid if HIV VL >100,000 or CD4 count <200, Avoid if ACID suppressants, Take w. Food

51
Q

Nevirapine

  • Class
  • ADR
  • Bonuses/dose
A

Non-Nuc

Rash (SJS) and Hepatotoxicity

Metabolic autoinducer, and Hepatotoxicity risk (if CD4 > 250 in women; >500 in men)

52
Q

Maraviroc

  • Class/Moa
  • Requirements
  • ADR
A

CCR5 antagonist - Inhibits Chemotaxis

Requires Tropism Assay

Rash, GI upset, HA, caution in pts w/ history of orthostatic HTN

53
Q

Cobicistat

  • Class/MOA
  • ADR
  • Bonuses
A

Pk Booster

inhibits 3A4 and 2D6 metabolism to allow greater pharmacologic effects from other antiretrovirals

Increases SCr

54
Q

Opportunistic Infections

  • Bacterial
  • Viral
  • Fungal
  • Protozoal
  • Malignancy
A 
Bacterial - MAC
Viral - CMV
Fungal - PCP
Proto - Toxoplasmosis Gondii
Malig - NH Lymph, Burkitts Lymph
55
Q

When to start primary prophylaxis for PCP/PJP
When to stop?
When Secondary?

A

Start: CD4 <200
Stop: CD4 >200 x 3mo

2nd : PJP occurred start at >200

56
Q

When to start primary prophylaxis for Toxo Gondii
When to stop?
When Secondary?

A

Start: CD4 <100
Stop: CD4 >200 x 3mo

2nd: CD4 <200

57
Q

When to start primary prophylaxis for MAC
When to stop?
When Secondary?

A

Start: CD4 <50
Stop: CD4 >100

2nd: CD4 <100

58
Q

When to start primary prophylaxis for CMV
When to stop?
When Secondary?

A

Start: None
Stop: N/A

2nd: CD4 < 100

59
Q

Tx for PCP PPx

A

Bactim/Septra

60
Q

Tx for Toxo Gondii PPx

A

Bactrim/Septra

61
Q

Tx for MAC PPx

A

Azithromycin 1200mg q wk
Clarithromycin 500mg bid
Azithromycin 600mg biw

62
Q

Single tablet complete therapy combos

A

Elvitagrevir + Emtricitabine + Tenofovir (AF) + Cobicistat
Elvitagrevir + Emtricitabine + Tenofovir (DF) + Cobicistat
Dolutegravir + Abacavir + Lamuvidine

all once daily dosing

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