HIV, TB, Immunizations Flashcards
HIV transmission
sexual contact
bloodborne contact
perinatal transmission
breastmilk
HIV Diagnosing
> ELISA followed by Western blot if +
> CD4 cell count (# of CD4 T lymphocytes) <200 INC risk of AIDS
WANT HIGH
Viral Load (# HIV RNA particles in plasma) <40 copies/mL associated w/ longer duration of suppression
WANT LOW
HIV things to consider
consider common AEs
drug-to-drug interactions
drug adherence
treatment fatigue
opportunistic infections
current treatment guidelines
be aware when patient ill
childbearing years- counseled on family planning
contraception- check for interactions
HIV lifecycle
- Enters host cell via receptors (CCR5 or CxCR4)
- reverse transcriptase forms single strand DNA from virus RNA
- Single strand DNA duplicated into double stranded DNA
- Using integrase, double stranded DNA enters nucleus
- DNA transcribed and long chains of polyproteins formed which are split by protease to form new copies of HIV RNA
half-life of viral particle 6 hours
HIV treatment CHALLENGES
complex regimen, large pill burden
AEs
Nonadherence = tx failure and possible resistance
drug resistance testing (preinitiation of meds)
HIV treatment WHEN TO START w/o AIDS conditions
CD4 count <500 or <350
CD4 count >500:
1. prevent immune system damage, DEC risk of complications, transmission, non-HIV conditions
2. optional b/c not enough data to support benefits and long-term AE risk
HIV treatment
when to tx individualized decision
defer tx if CD4 count >500 if adherence suboptimal or comorbidities prohibit the use of ART
monitor CD4 counts and viral loads
HIV Goals of treatment
- suppress viral replication to undetectable levels
- restoration and preservation of immune system function
- enhance quality of life
- reduce morbidity and mortality
- prevent transmission
HIV treatment Drug Resistance Assays
2 types
- genotypic testing: patterns of genetic mutations in virus
- phenotypic testing: drug susceptibility
HIV ART (Antiretroviral treatment)
6 families of meds
> HIV virus quickly mutates to become resistant
requires STRICT adherence to regimen
daily dosing, some BID
numerous SEs, both short and long term
HIV ART Side Effects
N/V/D
rash
anaphylactic hypersensitivity
HA
fatigue
anemia
vivid dreams/insomnia
possible CNS birth defects
PCP SE concerns:
INC cholesterol/TGs
INC LFTs
insulin resistance/DM
peripheral neuropathy
lipodystrophy and lipoatrophy (changes in body fat distribution)
HIV ART Treatment of SE
meds to treat:
1. DM or poor insulin control
2. HIGH lipid levels
3. neuropathy
4. N/V/D
5. Anemia
Always ask about medications!
HIV ART Drug interactions
TB meds
Statins
ED meds
Antidepressants
birth control
PPIs
St. John’s Wort
some interactions can be managed by adjusting doses of one or more meds
HIV Reverse Transcriptase Inhibitors (NRTI and NNRTI)
(-ine)
NRTI: Abacavir, Emtricitabine, Lamivudine, Zidovudine
NNRTI: Doravirine, Efavirenz, Etravirine, Nevirapine
NRTI: nucleoside
NNRTI: non-nucleoside
Interfere w/ conversion of RNA to DNA
NRTI MOA: interfere w/ transcription of RNA to DNA by halting production of DNA
NNRTI MOA: bind to reverse transcriptase
NRTI AE: lactic acidosis w/ hepatic steatosis (RARE but high death rate) = IMMEDIATE D/C MED
NNRTI: CYP450 drug interactions
HIV Protease Inhibitors
(-navir)
high barrier to resistance
DEC production of HIV RNA by inhibiting cleavage of polyproteins
bioavailability affected by food
AE: N/V/D: loperamide, elevate LFTs, lipodystrophy, HLD (pravastatin OK), hyperglycemia
metabolized by CYP450
HIV Fusion Inhibitors
Enfuvirtide (Fuzeon)
one agent: prevents fusion of HIV virus to cell membrane of the CD4 T cell
useful when other agents resistant
subQ injection BID
AE: injection site reactions
Drug interactions: INC concentration of tipranavir/ritonavir (NNRTI)
HIV Integrase Inhibitors
(-gravir)
one agent
MOA: prevent viral DNA integrations into host cell genome
used in multiple resistance and treatment-naïve patients: use w/ tenofovir and emtricitabine
minimal drug interactions
INC creatine kinase: MONITOR for RHABDO
HIV CCR5 Antagonists
Maraviroc (Selzentry)
one agent
MOA: blocks CCR5 receptor on CD4 T cell preventing entry on HIV virus
BLACK BOX: hepatotoxicity preceded by systemic allergic reaction
many drug interactions
acceptable treatment for naïve patients
HIV Primary care guidelines
> work w/ infectious disease provider
always ask about meds
discuss contraception/family planning
ask about risk factors for AIDS/HIV
always check for AIDS/HIV when patient is high risk, STI, opportunistic infections are present
HIV Opportunistic Infections
infections that occur d/t weakened or depleted immune system
meds are used to:
>prevent initial occurrence
>treat
>prevent secondary recurrence
HIV Management: OI Primary Prophylaxis
prevent infections from occurring
time-limited, usually started before ART
- If CD4 <200, begin PCP prophy: TMP-SMX
- If CD4 <100, begin toxoplasmosis prophy: also TMP-SMX
- If CD4 <50, begin MAC prophy: Azithromycin
HIV Management: OI Secondary Prophylaxis
prevent recurrence of infection
usually some or all of the same drugs used to tx infection
may be d/c after sustained immune recovery
Latent TB
- Inactive, contained tubercle bacilli in the body
- TST or blood tests POSITIVE
- Sputum smears/cultures NEGATIVE
- NO symptoms
- NOT infectious
- NOT a dx of active TB
Active TB
- Active, multiplying tubercle bacilli in the body
- TST or blood tests POSITIVE
- Sputum smear/culture POSITIVE
- HAS symptoms
- INFECTIOUS before tx
- ACTIVE TB
Latent TB DRUGS
- Isoniazid (INH)
- Rifapentine (RPT)
TX Latent TB: Isoniazid (INH)
Adults: 300mg daily or 900mg 2-3x/wk
Children: 10-5mg/kg, usual dose 300mg daily or 900mg 2x/wk
AE: INC LFTs, peripheral neuropathy, CNS effects, lupus like syndrome
Prevent peripheral neuropathy w/ pyridoxine (B6) 10-25mg daily
MONITOR: LFTs before tx, Q12 wks, after tx
TX Latent TB: Rifamycins
Rifampin:
ADULTS: 600mg daily or 2-3x/wk
CHILDREN: 600mg daily or 2x/wk
Rifabutin: ADULTS: 300mg daily or 2-3x/wk
Rifapentine: ADULTS: 600mg weekly
CONTRA: CNS, contraceptives, methadone, warfarin, HIV drugs (PIs/NNRTIs)
AE: discoloration of body fluids (orange), neutropenia, GI, polyarthralgia, hepatotoxicity, rash, dermatitis
Active TB DRUGS: First Line
- Isoniazid (INH)
- Rifampin (RIF)
- Pyrazinamide (PZA)
- Ethambutol (EMB)
Active TB DRUGS: Second line
If patient unable to tolerate 1st line or resistant
- cycloserine
2.ethionamide
3.streptomycin
4.amikacin/kanamycin
5.capreomycin
6.para-amino salicylic acid
7.levofloxacin
8.moxifloxacin
Direct Observational Therapy (DOT)
- a healthcare worker watches the patient swallow every dose of drug therapy
- required therapy
- verified medication taken and can check for AEs
- provides documentation of therapy
Isoniazid (INH) AEs
MONITOR:
LFTs
peripheral neuropathy
VIT B recommended to help prevent
Ethambutol (EMB) AEs
Baseline eye exam, monitor visual acuity, CBC
MONITOR CNS effects
Pyrazinamide (PZA) AEs
MONITOR: GI effects, arthralgia, myalgias
Rifampin (RIF) AEs
MONITOR: liver function, change in body fluids, CBC, CNS effects
Turns body fluids ORANGE
Adherence to TB meds
Availability
Accessibility
Tolerance
Understanding (disease and communicability)
Resistant TB
- drug resistant TB = resistant to at least ONE first line drug (INH or RIF)
- Multi-drug resistant TB = resistant to MORE than one anti-TB drug & at least INH and RIF
- Extensively drug-resistant TB = resistant to INH, RIF, and any FQ and at least ONE of 3 injectable 2nd line drugs (amikacin, kanamycin, or capreomycin)
TB lab monitoring
HEPATOTOXICITY: AST, ALT, bilirubin, alkaline phosphatase
RENAL FUNCTION: serum creatinine
PLATELET DEFICIENCY: platelet count
Monitor for one month of tx and then Q3 months or as needed based on symptoms of AE
TB Clinical Monitoring
- for resolution
- sputum cultures weekly x3 wks after initiation of treatment, then monthly
- isolation of patient can be d/c after 3 negative sputum cultures
MONITOR:
AEs
INH: peripheral neuropathy
EMB: visual disturbances (blurred vision, scotomata, poor color discrimination)
HIV and TB
- HIV patients are HIGH risk
- Screened yearly
- IRIS: get immune system working again in a HIV+ patient and LATENT TB can suddenly look like active
- multiple drug interactions possible
Vaccine type: Attenuated (modified-live)
- influenza live, attenuated vaccine (LAIV), inhaled flu vaccine
- MMR
- MMRV
- oral polio (OPV)
- rotavirus
- varicella virus (varivax)
- zoster vaccine (zostavax)
- bacillus Calmette-Geruin (BCG)
Vaccine type: Inactivated (killed)
- DTap
- HIB
- inactivate polio virus (IPV)
- Hep A & B
- HPV
- Influenza vaccine
- Pneumococcal vaccine
- meningococcal vaccine
- rabies
Attenuated vaccines
- contains live virus that is weakened
- live virus stimulates immune system to create antibodies which provide immunity
- CONTRA in pregnancy, those w/ weakened immune systems (chemo, transplant, HIV, immunosuppressive therapy)
Influenza vaccine
2 types: live attenuated influenza vaccine (LAIV) and influenza vaccine
- live attenuated is a MIST = into nose
- LAIV survives in cooler environment of the nose and is killed by warmer temps in other parts of the resp system
- influenza vaccine is injectable; may be used in PREGNANCY and IMMUNOCOMPROMISED
- CONTRA w/ egg sensitivity or HX of Guillain-Barre
Zoster Vaccine
2 types of zoster vaccine:
1.TWO doses of RZV at age >50 (recombinant zoster vaccine)
- ONE dose of ZVL at age >60 (zoster live-attenuated vaccine)
- get vaccinated even if you’ve had zoster
- REDUCE risk of post-herpetic neuralgia
- immunocompromised: recommend LOW-dose immunosuppressive therapy (<20mg prednisone) CONTRA in mod-HIGH dose immunosuppressive
Bacillus Calmette-Guerin (BCG) Vaccine
- Lowers risk of serious complications of primary TB in children
- used in TB endemic countries
- CONTRA in HIV patients or immunocompromised
- Sensitivity may last up to 10 years
Diphtheria, Tetanus, Pertussis Vaccine
- whole-cell pertussis no longer available in US
- replaced w/ acellular pertussis
- immune response may be less in immunocompromised patients
- Tdap is booster. administered every 10 years. Booster every 5 yrs w/ any injury that breaks the skin
- pregnant women and pregnant adolescents receive between 27-36 wks
Human Papilloma Virus (HPV) Vaccine
protects against HPV, virus that causes genital warts or cervical CA
pregnancy safe, but NOT recommended
ideally given before first sexual contact
Risk for SYNCOPE after vaccination, esp Adult patients
Pneumococcal vaccine (2 types)
> 65 yrs w/ NO vaccine before= PCV13, PPSV23 given 1 yr later
Need only 2 vaccines during lifetime
Rabies Vaccine
CONTRA: prev sensitivity to any components, esp neomycin
Moderate to severe illness, w/ or w/o fever: defer vaccine
Post-exposure prophylaxis: (2 shots)
- administer both passive antibody and vaccine
- FOUR doses given on DAYS 0, 3, 7, and 14 w/ RIG given on day 0
AE: pain, erythema, swelling at site, HA, nausea, abd pain, muscles aches, dizziness
