Lecture 5 - HIV Infection 2 Flashcards
labs prior to starting ART therapy
CD4 count
Viral load, goal = below limit @ 6 months
Genotypic resistance
CBC, BMP, lipid panel at BL & Q3-6months
NRTI class effects
Lactic acidosis and hepatic steatosis
Lipodystrophy
mostly with older drugs
Lamivudine
** NRTI **
300mg QD or 150 BID
Renal adjusted w/ < 50
Dont use w/ Emtracitabine…essentially same drug
Lamivudine
** NRTI **
300mg QD or 150 BID
Renal adjusted w/ < 50
Dont use w/ Emtracitabine…essentially same drug
Emtracacitabine
** NRTI **
200mg QD
Really adjusted w/ <50
Tenofovir disoproxil fumarate = TDF
** NRTI **
300mg
can cause nephrotoxicity
monitor Serum creatinine, Renally adjusted < 50
Can decrease bone mineral density
Less weight gain
Tenofovir alafenamide = TAF
** NRTI **
25mg QD combo w/ FTC
10mg QD if part of boosted single tab regimen
Lower incidence of nephrotoxicity/lower BMD reductions
No renal adjustment
Abacavir
** NRTI **
600mg QD or 300mg BID
** Requires HLA-B*5701 ** cant use if positive
Possible inc risk of MI, avoid if high cardiac risk
Zidovudine
** NRTI **
300mg BID
Take w/ food due to GI
can cause bone marrow suppression
Only NRTI w/ IV formulation
New borns and pregnant ppl main use*
NNRTI class effects
Rash, including Steven-johnson syndrome…less common second gen
DDI
Hepatotoxicity
Efavirenz
** NNRTI **
600QD, 800mg w/ rifampin or 300mq w/ voriconazole
Can cause dyslipidemia
Vivid dreams = inc taken w/ high fat meals
Worsen depression
Multiple CYP interactions
Insert says to not take w/ food due to inc absorption and inc side effects
Rilpivirine
** NNRTI **
Req acidic environment for absorption
25mgQD w/ high calorie meal
Dont start if CD4 <200 or VL > 100,000
Can worsen depression
May cause QTc prolongation
possible to use if resistance
Doravirine
** NNRTI **
100mg QD w/ or w/o food
fever CNS effects than otehrs
Fever DI
No cross-resistance w/ other NNRTIs
possible to use if resistance
INSTI class effects
Weight gain
~ 4kg up to 7kg depending on drugs
worse women than men
Raltegravir
1st INSTI
Dosed BID, inc w/ rifampin
High dose came out but still have to take 2 tablets
Can cause CK elevations and rhambdo
Elvitegravir
** INSTI **
QD
must be taken w/ booster
Taken with food to inc absorption
Causes nausea/diarrhea
INSTI conc can be reduced by co-admin with……
polyvalent cations
Dolutegravir = Tivicay
** INSTI **
QD
BID w/ INSTI mutations, efavirenz or rifampin
Can cause benign inc in serum creatine
May cause headache and/or insomnia
Bictegravir
** INSTI **
50mg QD
only comes as single tab combo with FTC/TAF
Can cause benign inc in serum creatine
May cause headache and/or insomnia
Cabotegravir
** INSTI **
30mg QD for 28 days before IM dosing to get viral suppression
Monthly dosing after viral suppression
Loading dose + Monthly/Q2 months
Cabotegravir counseling points
+/- 7 day window for admin
conc remain measurable for 12 months
Can cause CPK elevations, headache, insomnia, injection site reactions
Protease inhibitor effects
Hyperipidemia
Lipodystrophy = protease paunch or buffalo hump
Hepatotoxicity
GI intolerance
Possibility of inc bleeding risk for hemophiliacs
DD interactions
Darunavir
** Protease inhibitor **
800mg QD, 600 BID w/ certain resistnce
Req boosting
May cause rash or liver toxicity
Atazanavir
** Protease inhibitor**
400mg QD if not boosted
300mg QD if boosted, must be if given with Tenofovir
causes hyperbilirubinemia
Req acidic environment for absorption
Ritonavir
Booster
100mg QD, BID w/ lopinavir or BID darunavir
only used as booster
Cobicistat
150mg QD
No antiretroviral activity
more specific for CYP3A4 than ritonavir
can cause benign inc in SCr
CYP mediated drug interactions w/ ARVs
Inducers = Phenobarbital, phenytoin, smoking, oxcarbazepine, rifomycin, st.john wart
Inhibitors = GPACMAN = Grapefruit, protease inhib, azoles, cimetidine, macrolides, amiodarone, Non-DHP CCB
Non-Cyp mediated drug interactions ARVs
Metoformin w/ Dolutegravir
Antacids ( INSTI 2hr before or 6hr after given)( Separate Atazanavir/Rilpivirine by 2hrs)
H2RAs w/ Atazanavir and Rilpivirine…coadmin or separate by 12hrs
PPI CI in Rilpivirine, avoid Atazanavir ideally or max coadmin 20mg omeprazole equiv
Safe corticosteroid to give with PI?
Beclomethasone
Combo tablets NNRTI Backbones
Truvada = emtric/TDF
Descovy = emtric/TAF
Combiner = Lam/Zido = used in pedis usually
Single tab regimen Combo tabs
Biktarvy = Descovy + Bictegravir
Complera/Odefesy = Rilpivirine/ Truvada or Descovy
Stribild/Genvoya = Elvitegravir/cobicistat/Truvada or Descovy
Symtuza = Darunavir/cobicistat /Descovy
Triumeq = Dolutegravir + Epzicom
Regimen recommended for most people, no CAB exposure
**Biktarvy
**Tivicay + Emtricitabine or Lamivudine + TAF/TDF
Triumeq = require HLA-B testing
Dovato = VL < 100,000, no HBV coinfection, no resistance
Switch therapy
Cabotegravir + rilpivirine (Cabenuva) = just need to be suppressed
Dolutegravir + rilpivirine (Juluca) = 6 months suppression atleast
Predictors of poor adherence
Pill burden
costs
side effects
low lvls of literacy
age-related challenges
Psychosocial issues
active substance abuse
stigma
difficulty taking med
