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HIV Treatment Flashcards

1
Q

Treatment is indicated for ____, to reduce/prevent…

A

All individuals diagnosed with HIV - to reduce morbidity and mortality, and to prevent transmission to sexual partners and infants

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2
Q

HIV treatment should be initiated…

A

As soon as possible

Especially important for those who have AIDS-defining conditions, acute/recent infection, and pregnancy

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3
Q

Benefits of ARV’s (Antiretroviral) therapy include…

A

Restoration and preservation of immunologic function
Reduces HIV-related morbidity + mortality
Increases duration and quality of life
Prevents transmission

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4
Q

When assessing a patient’s readiness to start ARV’s, we should evaluate…

A

Ability to take medications consistently
Mentally ready to start medication
Does patient require any supports

Is patient well-educated on HIV + treatment, importance of adherence, and AE’s

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5
Q

ARV’s block viral replication within the CD4 cell, which…

A

Prevents destruction of CD4 cells and allows restoration of immune function

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6
Q

Proper HIV treatment requires…

Drug regimen issue; common DTP

A

More than 1 active ARV to achieve and maintain suppression

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7
Q

Nucleoside reverse transcriptase inhibitors (NRTI’s) work by…

A

Acting as host nucleotide decoys, and causing termination of the elongating HIV DNA chain

HIV reverse transcription process produces linear, double-strand HIV DNA from single strand HIV RNA. HIV reverse transcriptase incorporates host nucleotides forming strand opposite to HIV template strand

HIV is prevented from entering CD4 cell nucleus and combining with cell’s genetic material

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8
Q

Non-nucleoside reverse transcriptase inhibitors (NNRTI’s) work by…

A

Binding directly to HIV reverse transcriptase enzyme and inhibiting the function of the enzyme

Similar to NRTI, just a different mechanism

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9
Q

Integrase strand transfer inhibitors (INSTI’s) work by…

A

Utilizing multiple mechanisms to block integrase transfer step (which is the process of linear, double-stranded HIV DNA integrating into host DNA)

Blockage of HIV integration process causes HIV DNA to become substrate for host repair enzymes converting HIV DNA into byproduct 2-long terminal repeat circles

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10
Q

Protease inhibitors (PI’s) work by…

A

Disrupting normal polyprotein processing, stopping normal maturation process preventing infection of new cells

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11
Q

The 4 classes of ARV’s commonly used to make up a regimen include…

A

NRTI’s
NNRTI’s
INSTI’s
PI’s

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12
Q

A typical triple ARV regimen includes…

A

3 active agents from 2 different classes

Dual therapy regimens are used now

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13
Q

Monotherapy with ARV’s…

A

Is never used due to development of resistance

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14
Q

Tenofovir disoproxil fumurate (TDF) is a ____ that is dosed ____

A

NRTI - once daily

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15
Q

TDF is often paired with ____ or ____ to form the NRTI backbone of a regimen.

A

Emtricitabine
Lamivudine

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16
Q

Notable AE’s with TDF or TAF may include…

A

Decreased BMD
Potential for renal toxicity
H/A, Diarrhea, nausea, exacerbation of hepatitis on discontinuation

Renal toxicity may be more severe especially combined with PK booster

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17
Q

Tenofovir Alafenamide (TAF) is a ____ that is dosed…

A

NRTI - once daily

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18
Q

TAF is often paired with ____ to form NRTI backbone.

A

Emtricitabine

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19
Q

Abacavir is an ____ that is dosed…

A

NRTI - once daily

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20
Q

Abacavir is often paired with ____ to form an NRTI backbone.

A

Lamivudine

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21
Q

Some AE’s that may manfiest with abacavir include…

A

Hypersensitivity reaction
Potential risk of MI + other CV events
Nausea, diarrhea, headache

Hypersensitivity - check HLA-B*5601 prior to initiating)

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22
Q

Emtricitabine is an ____ that is dosed…

A

NRTI - once daily

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23
Q

AE’s with emtricitabine + lamivudine include…

A

MInimal toxicity
Rare - hyperpigmentation with emtricitabine
Exacerbation of hepatitis in those co-infected upon discontinuation

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24
Q

Lamivudine is an ____ that is dosed…

A

NRTI - once daily

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25
Doravirine is a ____ that is dosed...
NNRTI - once daily
26
Some AE's of doravirine include...
Overall well tolerated Nausea, dizziness, abnormal dreams
27
Efavirenz is a ____ that is dosed...
NNRTI - once daily **on an empty stomach at bedtime**
28
Some notable AE's with efavirenz includes...
**Neuropsychiatric symptoms - fatigue, depression, anxiety** LFT elevations Hyperlidemia QT prolongation
29
Nevirapine is a ____ that is dosed...
NNRTI - once daily for 14 days, then twice daily ## Footnote Lead in repeated if d/c more than 7 days. Development of rash = continue lead in until resolved, but do not extend lead in more than 28 days.
30
Some AE's with nevirapine include...
Rash - SJS Symptomatic hepatitis
31
Bictegravir is an ____ that is dosed...
INSTI - once daily
32
AE's of bictegravir include...
Overall well tolerated Diarrhea, headache, nausea, weight gain
33
Dolutegravir is an ____ that is dosed...
INSTI - once daily (BID if resistance present)
34
Some AE's with dolutegravir include...
Well tolerated, but more than bictegravir. Insomnia, headache Anxiety, depression Weight gain Rare - hypersensitivity Neural tube defects
35
Rilpivirine is a ____ that is dosed...
NNRTI - once daily, or part of Cabenuva injectable regimen
36
AE's of rilpivirine may include...
Injection site rxn with Cabenuva Depression, insomnia, headache QT prolongation
37
Cabotegravir is an ____ that is dosed...
INSTI - part of Cabenuva injection regimen
38
Common AE's with cabotegravir include...
Overall well tolerated Headache, nausea Abnormal dreams, anxiety, insomnia, depression
39
Elvitegravir is an ____ that is dosed...
INSTI - once daily ## Footnote Low potency INSTI - not the best if adherence is low since resistance could develop
40
Some AE's with elvitegravir include...
Nausea, diarrhea, headache Sleep disturbance Weight gain, dyslipidemia
41
Raltegravir is an ____ that is dosed...
INSTI - twice daily ## Footnote No single target regimen available - not in formulary
42
AE's with raltegravir include...
Nausea, diarrhea, headache CK elevation Weight gain ## Footnote Rash is rare
43
Darunavir is a ____ that is dosed...
PI - once daily, or twice daily is resistance present
44
Darunavir is unique in that it should always be given with a ____ such as...
PK booster - ritonavir or cobicistat (CYP 3A4 inhibitors)
45
AE's with darunavir include...
Significant GI AE's - diarrhea, nausea Fat maldistribution CVD - hyperlipidemia Skin rash Hepatoxicity
46
Recall that 3 active agents from 2 different ARV classes should be used. However there are some dual regimens, such as...
Dovato (dolutegravir + lamivudine) PO OD Juluca (dolutegravir + rilpivirine) PO OD Cabenuva (cabotegravir + rilpivirine) IM injection Q1-2 months
47
Cabenuva is unique in that it has a very long ____ in that...
PK tail - has implications for resistance if patient discontinues the injection
48
Someone who is suitable for a Cabenuva injection formulation includes...
No resistance No hepatitis/renal dysfunction Not pregnant/planning to be pregnant Virally suppressed before receiving their first injection, ideally for 6+ months Patient able to commit to regular injections No significant drug interactions
49
Recommended initial regimens for people who do not have a history of using cabotegravir injectable as PrEP include...
Biktarvy (Bictegravir/tenofovir AF/emtricitabine) Truvada + Tivicay (Dolutegravir + Tenofovir (TAF or TDF) Lamivudine/Emtricitabine) Dovado (Dolutegravir + emtricitabine) ## Footnote Dovado exceptions - people with high viral load (500 000+), HBV coinfection, or where ARV therapy is started before resistance testing is available
50
If individuals have a history of Cabotegravir long-acting injectable, this should be done ____ before starting ARV. However, if ART is to be started before this, the recommended regimen is...
INSTI genotype resistance testing: Darunavir + cobicostat/ritonavir AND tenofovir (TAF or TDF) + emtricitabine/lamivudine
51
Rapid start refers to...
Starting ARV therapy within days, up to 2 weeks from when the patient is diagnosed
52
Benefits of rapid initiation include...
Earlier linkage to care Higher rates of retention Higher rates of suppression + shortter time to suppression Overall health benefit Reduces onward transmission
53
These are good lab values to obtain before initiating ART
HIV viral load + CD4 for staging For choosing specific ART: Resistance testing Renal + hepatic function Viral hepatitis Pregnancy
54
Patient characteristics that may influence ART selection include...
Comorbidities (CV, renal/liver disease, psychiatric, osteoporosis, opportunistic infections) Other medications Pregnancy, child-bearing age Social factors
55
HIV viral load should be monitored...
4-6 weeks after initiating ARV's or after switching, otherwise every 3-6 months generally
56
CD4 count should be monitored...
Every 3-6 months. If consistent adherence + suppressed, can lengthen to q12 months If CD4 is above 500, CD4 monitoring is option after 2 years with suppressed viral load
57
The most common AE's with most of the new ARV regimens include ____ and some management strategies include...
GI + Psych - usually self-limiting Nausea - gravol/ondansetron Diarrhea - metamucil/immodium Headache - usual pain remedies ## Footnote Care with NSAID + Tenofovir, possible renal toxicity If AE's ongoing or worsen comorbid conditions, refer back to HIV specialist
58
Transmitted resistance refers to...
A person acquiring a strain of HIV that is already resistant to certain ARV drugs
59
Acquired resistance refers to...
When a drug-resistant strain of HIV emerges while a person is taking ARV therapy
60
Acquired resistance can be due to...
Bad adherence DI's that lower levels
61
Drug resistance develops from bad adherence since...
Once the patient stops taking ARV's regularly, the virus multiplies again with the possibility of mutating
62
Generally, the viral load should be lowering ____ per month while on ARV therapy.
1-2 log differences per month. Higher loads will take longer. ## Footnote If there is an INSTI it will be quicker
63
Regarding DI's with ARV's, we should...
Always remember to check - since ARV efficacy is crucial: Enzyme inhibition + inducing interactions, increased gastric pH affecting ARV absorption, cation complex formation with INSTI's ## Footnote Rule of thumb = any regimen with a booster will likely have DI potential

HIV (4 decks)

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