HIV - Opportunistic Disease Flashcards

Question

Ritonavir (Norvir®, RTV)

Answer 1

The “Booster” Boosting dose: 100 mg with PI with food MANY drug interactions Hepatotoxicity Lipid abnormalities: Elevated triglycerides and LDL Monitor frequently Pre-existing abnormality may not be a reason to avoid

Answer 2

``` Associated with long-term antiretroviral use: Lipid abnormalities Lipodystrophy Hyperglycemia Decreased bone mineral density ```

Answer 3

Ritoravir - Rosuvastatin and Atorvastatin | Simvastatin level increase significantly with PI use

Answer 4

Gradual onset Fever (Temp >38.1°) Tachypnea Chest exam may be normal (50%) if ↓air movement Ronchi Crackles Radiologic manifestations differ from CAP or HAP

Answer 5

Parasite: Toxoplasma gondii Encephalitis/cerebral abscess Headache Fever Mental status changes Pneumonitis Fever Dyspnea Cough Chorioretinitis Eye pain Decreased visual acuity

Answer 6

``` Disseminated Infection Fever Night sweats Abdominal pain Diarrhea Weight loss Elevated alkaline phosphase, LDH ``` Localized infection Lymphadenopathy Fever

Answer 7

Bactrim DS QD or Dapsone 100mg QD | G6PD Deficiency

Answer 8

Bactrim DS QD

Answer 9

Azithromycin 1200mg Qweek

Answer 10

PCP MAC Toxoplasmosis Oral (thrush), oropharyngeal, & vaginal candidiasis Disseminated infection: Cryptococcal meningitis Histoplasmosis Blastomycosis

Answer 11

Increased risk of invasive cervical cancer Screening PAP testing Q 6 months during first year of diagnosis PAP testing yearly if stable PAP testing Q 6 months if CD4 <200

Answer 12

Earlier onset of menopause Osteoporosis increase Heart disease increase Interruption in menstrual cycle Hormone production Oral contraceptives Interaction with ethinyl estradiol; PI may decrease EE Depo-Provera OK

Answer 13

TAF is an oral prodrug of tenofovir TAF converted to TFV, and then to TFV-diphosphate intracellularly TFV: nephrotoxic TDF: readily converts to TFV in plasma after absorption TAF remains stable in plasma resulting in lower plasma and higher intracellular concentrations TAF MOA in ppt

Answer 14

HIV increases HCV replication and progression Hepatotoxicity & antiretrovirals Test for HCV initially and Q year HCV viral load & LFTs to monitor progression in patients that are co-infected

Answer 15

Antacids Give antacid at least 2 hours before or at least 4 hours after RPV H2RAs Give H2RA at least 12 hours before or at least 4 hours after RPV PPIs CONTRAINDICATED: Do no co-administer

Answer 16

Must confirm G6PD Deficiency If G6PD deficient: THEN Atovaquone suspension 1500mg QD If G6DP is not deficient: THEN Dapsone 100mg QD (or 50mg BID)

Answer 17

Dapsone alone does not cover Toxo Dapsone 50mg QD + pyrimethamine 50mg Q week + leucovorin 25mg PO weekly OR Dapsone 200mg + pyrimethamine 75mg + leucovorin 25mg PO Q week OR Atovaquone 1500mg PO QD

Answer 18

Antacids Give ATV at least 2 hours before or 1 hour after antacids H2RAs Do not exceed famotidine 40mg BID in naïve pts Give ATV 300mg + RTV 100mg simultaneously with and/or ≥ 10 hours after H2RA PPIs Do not exceed omeprazole 20mg QD in naïve pts Should be given at least 12 hours before ATV/r

Answer 19

``` Transient hyperbilirubinemia Increase in indirect (unconjugated) bilirubin (avg: 0.3-0.5 mg/dL) Reversible upon discontinuation Inhibition of UDP glucuronyl transferase Liver unable to conjugate Scleral icterus Jaundice Typically resolves within 2 months ``` Nephrolithiasis and cholelithiasis have been reported Consider temporary interruption or discontinuation Hydration Possible PR interval prolongation

Answer 20

``` Has a sulfa moiety Use in caution in patients with a known sulfonamide allergy NOT a contraindication for use Drug-induced hepatitis Monitor LFTs before and during therapy Skin reactions Stevens-Johnson Syndrome Toxic Epidermal Necrolysis Discontinue use if severe reaction develops ```

Answer 21

Cobicistat is a pharmacokinetic booster with NO antiretroviral activity It is a potent CYP3A4 inhibitor Inhibits renal tubular secretion of creatinine SCr will return to baseline after cobicistat discontinuation DO NOT initiate COBI if Est CrCl < 70 mg/dL DISCONTINUE COBI if Est CrCl < 50 mg/dL Separate STRIBILD and antacids by 2 hours (due to elvitegravir)

Answer 22

Tivicay (dolutegravir) may be taken with or without food Tivicay should be taken 2 hours before or 6 hours after taking cation-dontaining antacids or laxatives, sucralfate, oral supplements containing iron or calcium, or buffered medications. ALTERNATIVELY: Tivicay and supplements containing calcium or iron can be taken together with food.

Answer 23

<200 cells/mm^3

Answer 24

<100 cells/mm^3

Answer 25

<50 cells/mm^3

Answer 26

>200 cells/mm^3 for 3 months or longer

Answer 27

>200 cells/mm^3 for 3 months or longer

Answer 28

>100 cells/mm^3 for 3 months or longer

Answer 29

“Break-in” period Almost all medications ``` Concern for dehydration, weight loss Calcium supplements (Tums) ``` Pharmacologic therapies Loperamide (Immodium®) Diphenoxylate/atropine (Lomotil®) ``` Tips for patients Eat foods high in soluble fiber (oatmeal, bananas, bread) Avoid milk products Avoid greasy foods Plenty of fluids ```

Answer 30

Tums (calcium carbonate) regular or extra-strength Take 2 tablets every 6 hours as needed (Skip Step 1 if you are taking Reyataz® (atazanavir) or Viracept® (nelfinavir)) IF THAT DOESN’T WORK add… Fibercon (calcium polycarbophil) Take 1 tablet twice daily IF THAT DOESN’T WORK add… Imodium A-D (loperamide 2mg) Take 2 capsules (4mg) now, then 1 every 4-6 hours as needed (16 mg/day max)

Answer 31

Verapamil, diltiazem PIs increase drug levels, cautious use ->Increased antihypertensive effect Peripherally acting CCBs okay to use Amlodipine

Answer 32

Once daily and Twice daily: If you miss a dose by less than 6/12 hours, take your missed dose right away. Then take your next dose at your regularly scheduled time. If you miss a dose by more than 6/12 hours, wait and then take the next dose at your regularly scheduled time. Do not take two doses at the same time to make up for a missed dose.

Answer 33

NNRTIs & NRTIs: - Efavirenz and several NRTIs have low barrier for resistance - K103N mutation: all it takes to render efavirenz and nevirapine useless - M184V mutation: all it takes to render emtricitabine or lamivudine useless - Cross resistance possible Protease Inhibitors: -Unboosted protease inhibitors have resistance similar to NNRTIs and NRTIs -Boosted protease inhibitors have high degree of forgiveness1 -May take several major mutations to confer resistance -May take combination of major and minor mutations to confer resistance Selective non-adherence to ritonavir is common2

Answer 34

300mg BID or 600mg QD with or without food ``` Hypersensitivity Reaction Fever N/V Malaise Myalgia/arthralgia Rash ``` First 2 months of therapy, gradual worsening of symptoms with each dose -->Do NOT re-challenge, next reaction could be FATAL HLA-B*5701 allele test

Answer 35

A biomedical intervention to prevent HIV infection in HIV-negative people. 1 tablet of Truvada taken every day Truvada approved for PrEP in 2012 PrEP guideline in ppt

Answer 36

Dosing: one tablet by mouth once daily Contraindications: unknown or positive HIV-1 status, monotherapy for HIV-1 infection Precautions: hepatitis B virus co-infection, lactic acidosis, autoimmune disorders, osteomalacia Mechanism of action: blocks virus from establishing infection Inhibition of HIV-1 reverse transcriptase Pregnancy category: B Safe in pregnant patients if benefit outweighs risk Breast Feeding: Infant risk cannot be ruled out Dietary modifications: none, take with or without food Side Effects: upset stomach, headache, vomiting, loss of appetite Initial lab work: HIV test, CMP, Hepatitis B & C serology, STI screening Routine monitoring every 3 months Rapid HIV test (ELISA) Antibodies can take 3 to 6 months to develop Kidney function (BMP) PrEP affordability in ppt