Lecture 5 - HIV Infection 2

Question 1

labs prior to starting ART therapy

Answer 1

CD4 count
Viral load, goal = below limit @ 6 months
Genotypic resistance
CBC, BMP, lipid panel at BL & Q3-6months

Question 2

NRTI class effects

Answer 2

Lactic acidosis and hepatic steatosis
Lipodystrophy

mostly with older drugs

Question 3

Lamivudine

Answer 3

** NRTI **
300mg QD or 150 BID
Renal adjusted w/ < 50

Dont use w/ Emtracitabine…essentially same drug

Question 4

Lamivudine

Answer 4

** NRTI **
300mg QD or 150 BID
Renal adjusted w/ < 50

Dont use w/ Emtracitabine…essentially same drug

Question 5

Emtracacitabine

Answer 5

** NRTI **
200mg QD
Really adjusted w/ <50

Question 6

Tenofovir disoproxil fumarate = TDF

Answer 6

** NRTI **
300mg
can cause nephrotoxicity
monitor Serum creatinine, Renally adjusted < 50

Can decrease bone mineral density
Less weight gain

Question 7

Tenofovir alafenamide = TAF

Answer 7

** 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

Question 8

Abacavir

Answer 8

** NRTI **
600mg QD or 300mg BID
** Requires HLA-B*5701 ** cant use if positive

Possible inc risk of MI, avoid if high cardiac risk

Question 9

Zidovudine

Answer 9

** 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*

Question 10

NNRTI class effects

Answer 10

Rash, including Steven-johnson syndrome…less common second gen
DDI
Hepatotoxicity

Question 11

Efavirenz

Answer 11

** 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

Question 12

Rilpivirine

Answer 12

** 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

Question 13

Doravirine

Answer 13

** 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

Question 14

INSTI class effects

Answer 14

Weight gain
~ 4kg up to 7kg depending on drugs
worse women than men

Question 15

Raltegravir

Answer 15

1st INSTI

Dosed BID, inc w/ rifampin
High dose came out but still have to take 2 tablets

Can cause CK elevations and rhambdo

Question 16

Elvitegravir

Answer 16

** INSTI **
QD
must be taken w/ booster
Taken with food to inc absorption
Causes nausea/diarrhea

Question 17

INSTI conc can be reduced by co-admin with……

Answer 17

polyvalent cations

Question 18

Dolutegravir = Tivicay

Answer 18

** INSTI **
QD
BID w/ INSTI mutations, efavirenz or rifampin

Can cause benign inc in serum creatine
May cause headache and/or insomnia

Question 19

Bictegravir

Answer 19

** 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

Question 20

Cabotegravir

Answer 20

** INSTI **
30mg QD for 28 days before IM dosing to get viral suppression

Monthly dosing after viral suppression
Loading dose + Monthly/Q2 months

Question 21

Cabotegravir counseling points

Answer 21

+/- 7 day window for admin
conc remain measurable for 12 months

Can cause CPK elevations, headache, insomnia, injection site reactions

Question 22

Protease inhibitor effects

Answer 22

Hyperipidemia
Lipodystrophy = protease paunch or buffalo hump
Hepatotoxicity
GI intolerance
Possibility of inc bleeding risk for hemophiliacs
DD interactions

Question 23

Darunavir

Answer 23

** Protease inhibitor **
800mg QD, 600 BID w/ certain resistnce

Req boosting

May cause rash or liver toxicity

Question 24

Atazanavir

Answer 24

** Protease inhibitor**
400mg QD if not boosted
300mg QD if boosted, must be if given with Tenofovir

causes hyperbilirubinemia

Req acidic environment for absorption

Question 25

Ritonavir

Answer 25

Booster

100mg QD, BID w/ lopinavir or BID darunavir

only used as booster

Question 26

Cobicistat

Answer 26

150mg QD
No antiretroviral activity
more specific for CYP3A4 than ritonavir
can cause benign inc in SCr

Question 27

CYP mediated drug interactions w/ ARVs

Answer 27

Inducers = Phenobarbital, phenytoin, smoking, oxcarbazepine, rifomycin, st.john wart

Inhibitors = GPACMAN = Grapefruit, protease inhib, azoles, cimetidine, macrolides, amiodarone, Non-DHP CCB

Question 28

Non-Cyp mediated drug interactions ARVs

Answer 28

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

Question 29

Safe corticosteroid to give with PI?

Answer 29

Beclomethasone

Question 30

Combo tablets NNRTI Backbones

Answer 30

Truvada = emtric/TDF
Descovy = emtric/TAF
Combiner = Lam/Zido = used in pedis usually

Question 31

Single tab regimen Combo tabs

Answer 31

Biktarvy = Descovy + Bictegravir
Complera/Odefesy = Rilpivirine/ Truvada or Descovy
Stribild/Genvoya = Elvitegravir/cobicistat/Truvada or Descovy
Symtuza = Darunavir/cobicistat /Descovy
Triumeq = Dolutegravir + Epzicom

Question 32

Regimen recommended for most people, no CAB exposure

Answer 32

**Biktarvy
**Tivicay + Emtricitabine or Lamivudine + TAF/TDF
Triumeq = require HLA-B testing
Dovato = VL < 100,000, no HBV coinfection, no resistance

Question 33

Switch therapy

Answer 33

Cabotegravir + rilpivirine (Cabenuva) = just need to be suppressed
Dolutegravir + rilpivirine (Juluca) = 6 months suppression atleast

Question 34

Predictors of poor adherence

Answer 34

Pill burden
costs
side effects
low lvls of literacy
age-related challenges
Psychosocial issues
active substance abuse
stigma
difficulty taking med