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Pharmacology > HIV, TB, Immunizations > Flashcards

HIV, TB, Immunizations Flashcards

1
Q

HIV transmission

A

sexual contact
bloodborne contact
perinatal transmission
breastmilk

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2
Q

HIV Diagnosing

A

> 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

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3
Q

HIV things to consider

A

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

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4
Q

HIV lifecycle

A
  1. Enters host cell via receptors (CCR5 or CxCR4)
  2. reverse transcriptase forms single strand DNA from virus RNA
  3. Single strand DNA duplicated into double stranded DNA
  4. Using integrase, double stranded DNA enters nucleus
  5. 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

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5
Q

HIV treatment CHALLENGES

A

complex regimen, large pill burden
AEs
Nonadherence = tx failure and possible resistance
drug resistance testing (preinitiation of meds)

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6
Q

HIV treatment WHEN TO START w/o AIDS conditions

A

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

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7
Q

HIV treatment

A

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

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8
Q

HIV Goals of treatment

A
  1. suppress viral replication to undetectable levels
  2. restoration and preservation of immune system function
  3. enhance quality of life
  4. reduce morbidity and mortality
  5. prevent transmission
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9
Q

HIV treatment Drug Resistance Assays

A

2 types

  1. genotypic testing: patterns of genetic mutations in virus
  2. phenotypic testing: drug susceptibility
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10
Q

HIV ART (Antiretroviral treatment)

A

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

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11
Q

HIV ART Side Effects

A

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)

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12
Q

HIV ART Treatment of SE

A

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!

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13
Q

HIV ART Drug interactions

A

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

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14
Q

HIV Reverse Transcriptase Inhibitors (NRTI and NNRTI)
(-ine)

NRTI: Abacavir, Emtricitabine, Lamivudine, Zidovudine

NNRTI: Doravirine, Efavirenz, Etravirine, Nevirapine

A

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

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15
Q

HIV Protease Inhibitors
(-navir)

A

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

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16
Q

HIV Fusion Inhibitors

Enfuvirtide (Fuzeon)

A

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)

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17
Q

HIV Integrase Inhibitors
(-gravir)

A

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

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18
Q

HIV CCR5 Antagonists

Maraviroc (Selzentry)

A

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

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19
Q

HIV Primary care guidelines

A

> 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

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20
Q

HIV Opportunistic Infections

A

infections that occur d/t weakened or depleted immune system

meds are used to:
>prevent initial occurrence
>treat
>prevent secondary recurrence

21
Q

HIV Management: OI Primary Prophylaxis

A

prevent infections from occurring

time-limited, usually started before ART

  1. If CD4 <200, begin PCP prophy: TMP-SMX
  2. If CD4 <100, begin toxoplasmosis prophy: also TMP-SMX
  3. If CD4 <50, begin MAC prophy: Azithromycin
22
Q

HIV Management: OI Secondary Prophylaxis

A

prevent recurrence of infection

usually some or all of the same drugs used to tx infection

may be d/c after sustained immune recovery

23
Q

Latent TB

A
  1. Inactive, contained tubercle bacilli in the body
  2. TST or blood tests POSITIVE
  3. Sputum smears/cultures NEGATIVE
  4. NO symptoms
  5. NOT infectious
  6. NOT a dx of active TB
24
Q

Active TB

A
  1. Active, multiplying tubercle bacilli in the body
  2. TST or blood tests POSITIVE
  3. Sputum smear/culture POSITIVE
  4. HAS symptoms
  5. INFECTIOUS before tx
  6. ACTIVE TB
25
Q

Latent TB DRUGS

A
  1. Isoniazid (INH)
  2. Rifapentine (RPT)
26
Q

TX Latent TB: Isoniazid (INH)

A

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

27
Q

TX Latent TB: Rifamycins

A

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

28
Q

Active TB DRUGS: First Line

A
  1. Isoniazid (INH)
  2. Rifampin (RIF)
  3. Pyrazinamide (PZA)
  4. Ethambutol (EMB)
29
Q

Active TB DRUGS: Second line

A

If patient unable to tolerate 1st line or resistant

  1. cycloserine
    2.ethionamide
    3.streptomycin
    4.amikacin/kanamycin
    5.capreomycin
    6.para-amino salicylic acid
    7.levofloxacin
    8.moxifloxacin
30
Q

Direct Observational Therapy (DOT)

A
  1. a healthcare worker watches the patient swallow every dose of drug therapy
  2. required therapy
  3. verified medication taken and can check for AEs
  4. provides documentation of therapy
31
Q

Isoniazid (INH) AEs

A

MONITOR:
LFTs
peripheral neuropathy

VIT B recommended to help prevent

32
Q

Ethambutol (EMB) AEs

A

Baseline eye exam, monitor visual acuity, CBC

MONITOR CNS effects

33
Q

Pyrazinamide (PZA) AEs

A

MONITOR: GI effects, arthralgia, myalgias

34
Q

Rifampin (RIF) AEs

A

MONITOR: liver function, change in body fluids, CBC, CNS effects

Turns body fluids ORANGE

35
Q

Adherence to TB meds

A

Availability
Accessibility
Tolerance
Understanding (disease and communicability)

36
Q

Resistant TB

A
  1. drug resistant TB = resistant to at least ONE first line drug (INH or RIF)
  2. Multi-drug resistant TB = resistant to MORE than one anti-TB drug & at least INH and RIF
  3. 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)
37
Q

TB lab monitoring

A

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

38
Q

TB Clinical Monitoring

A
  1. for resolution
  2. sputum cultures weekly x3 wks after initiation of treatment, then monthly
  3. 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)

39
Q

HIV and TB

A
  1. HIV patients are HIGH risk
  2. Screened yearly
  3. IRIS: get immune system working again in a HIV+ patient and LATENT TB can suddenly look like active
  4. multiple drug interactions possible
40
Q

Vaccine type: Attenuated (modified-live)

A
  1. influenza live, attenuated vaccine (LAIV), inhaled flu vaccine
  2. MMR
  3. MMRV
  4. oral polio (OPV)
  5. rotavirus
  6. varicella virus (varivax)
  7. zoster vaccine (zostavax)
  8. bacillus Calmette-Geruin (BCG)
41
Q

Vaccine type: Inactivated (killed)

A
  1. DTap
  2. HIB
  3. inactivate polio virus (IPV)
  4. Hep A & B
  5. HPV
  6. Influenza vaccine
  7. Pneumococcal vaccine
  8. meningococcal vaccine
  9. rabies
42
Q

Attenuated vaccines

A
  1. contains live virus that is weakened
  2. live virus stimulates immune system to create antibodies which provide immunity
  3. CONTRA in pregnancy, those w/ weakened immune systems (chemo, transplant, HIV, immunosuppressive therapy)
43
Q

Influenza vaccine

A

2 types: live attenuated influenza vaccine (LAIV) and influenza vaccine

  1. live attenuated is a MIST = into nose
  2. LAIV survives in cooler environment of the nose and is killed by warmer temps in other parts of the resp system
  3. influenza vaccine is injectable; may be used in PREGNANCY and IMMUNOCOMPROMISED
  4. CONTRA w/ egg sensitivity or HX of Guillain-Barre
44
Q

Zoster Vaccine

A

2 types of zoster vaccine:
1.TWO doses of RZV at age >50 (recombinant zoster vaccine)

  1. ONE dose of ZVL at age >60 (zoster live-attenuated vaccine)
  2. get vaccinated even if you’ve had zoster
  3. REDUCE risk of post-herpetic neuralgia
  4. immunocompromised: recommend LOW-dose immunosuppressive therapy (<20mg prednisone) CONTRA in mod-HIGH dose immunosuppressive
45
Q

Bacillus Calmette-Guerin (BCG) Vaccine

A
  1. Lowers risk of serious complications of primary TB in children
  2. used in TB endemic countries
  3. CONTRA in HIV patients or immunocompromised
  4. Sensitivity may last up to 10 years
46
Q

Diphtheria, Tetanus, Pertussis Vaccine

A
  1. whole-cell pertussis no longer available in US
  2. replaced w/ acellular pertussis
  3. immune response may be less in immunocompromised patients
  4. Tdap is booster. administered every 10 years. Booster every 5 yrs w/ any injury that breaks the skin
  5. pregnant women and pregnant adolescents receive between 27-36 wks
47
Q

Human Papilloma Virus (HPV) Vaccine

A

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

48
Q

Pneumococcal vaccine (2 types)

A

> 65 yrs w/ NO vaccine before= PCV13, PPSV23 given 1 yr later

Need only 2 vaccines during lifetime

49
Q

Rabies Vaccine

A

CONTRA: prev sensitivity to any components, esp neomycin

Moderate to severe illness, w/ or w/o fever: defer vaccine

Post-exposure prophylaxis: (2 shots)

  1. administer both passive antibody and vaccine
  2. 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

Pharmacology (12 decks)

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