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D&D Infectious Disease FINAL > Therapeutics - HIV part 2 > Flashcards

Therapeutics - HIV part 2 Flashcards

1
Q

name 4 types of entry inhibitors

A

fusion inhibitor
CCR5 antagonist
post attachment inhibitor
attachment inhibitor

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2
Q

name a fusion inhibitor

A

enfuviritide

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3
Q

name a CCR5 antagonist

A

maraviroc

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4
Q

name a post attachment inhibitor

A

ibalizumab

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5
Q

name an attachment inhibitor

A

fostemsavir

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6
Q

in general, what is the role in therapy for entry inhibitors

A

usually reserved for people who are failing the other classes of antiretrovirals, with the exception of maraviroc - may be used besides in failing therapy

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7
Q

***which HIV drug has a need for tropism testing? why? what class is it?

A

MARAVIROC

it’s a CCR5 antagonist - therefore, it will only work on a CCR5 tropic virus and we need to test for this

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8
Q

true or false

ALL of the entry inhibitors can be taken with or without food

A

true

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9
Q

true or false

there is no concern with CYP450 interactions with entry inhibitors

A

FALSE - there is for most of them

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10
Q

fostemsavir + ethinyl estradiol

what class is fostemsavir?

A

attachment inhibitor

levels of ethinyl estradiol will increase

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11
Q

true or false

several entry inhibitors are given by injection

A

true

enfuvirtide, ibalizumab

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12
Q

which entry inhibitor has a BBW of hepatotoxicity

A

maraviroc

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13
Q

name 5 integrase inhibitors

A

raltegravir
bictegravir
elvitegravir
dolutegravir
cabotegravir

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14
Q

true or false

integrase inhibitors are not used often

A

FALSE - they are

not a lot of side effects, they work well, and resistance is pretty rare

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15
Q

only integrase inhibitor that MUST be taken with food
(all others are with or without)

A

elvitegravir

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16
Q

which 2 integrase inhibitors undergo UGTA1A1 glucuronidation

A

cabotegravir and raltegravir

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17
Q

which integrase inhibitor’s use is restricted only to those whose creatinine clearance is over 70mL/min?

A

raltegravir

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18
Q

which 2 integrase inhibitors have CYP450 interaction concern?? which additionally has a binding interaction concern?

A

elvitegravir and dolutegravir

dolutegravir

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19
Q

which integrase inhibitor causes neural tube defects in utero?

A

dolutegravir

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20
Q

what class is considered last line therapy for HIV

A

capsid inhibitors - they’re new and not really used yet at all in practice – only for heavily experienced adults with multi-drug resistance HIV infection

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21
Q

name the only capsid inhibitor

A

lenacapavir

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22
Q

what is lenacapavir contraindicated with?

A

strong CYP3A4 inducers

it is a moderate CYP3A4 inhibitor

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23
Q

true or false

lenacapavir can be taken with or without food

A

true

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24
Q

HAART meaning

A

highly active antiretroviral therapy

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25
Q

true or false

if a patient is antiretroviral naive, they do not have a resistant strain

A

FALSE - they still can - even if they never took any HIV meds

for example, the virus transmitted to you may have been resistant already

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26
Q

name some baseline labs that may be conducted before antiretroviral therapy is started

A

scr/cr cl
hepatic function

for abacavir - HLAB701 test
for miraviroc - tropism test for CCR5

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27
Q

name 4 goals for treating HIV

A

-suppress viral load
-restore immunologic function (increase CD4)
-reduce morbidity/mortality and improve quality of life
-prevent HIV transmission to others

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28
Q

CD4 and viral load test should be conducted at baseline, and how long for routine monitoring?

A

every 3-6 months

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29
Q

true or false

after initiating ART (antiretroviral therapy), CD4 count should be assessed at 2-8 weeks following initiation of therapy

A

FALSE

should asses VIRAL LOAD 2-8 weeks after initiating therapy

we do NOT check the CD4 count this soon. viral load is more indicitive of how the patient is responding to therapy

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30
Q

when is HIV treatment started

A

ASAP and aggressively. there is zero reason to wait

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31
Q

ART is recommended for ALL persons with HIV to reduce morbidity and mortality AND….

A

to prevent transmitting HIV to others

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32
Q

based on the guidelines, name 3 therapies that are considered 1st line for STARTING PATIENTS on HIV medication who do NOT have a history of using long acting cabotegravir as PREP

A

-biktarvy: Bictegravir + TAF + Emtricitabine

-Dolutegavir + TAF or TDF + Emtricitabine or Lamuvidine

-DO NOT USE this regimen if patient’s viral load is greater than 500,000, HBV coinfection, or have been started on therapy before the results of the resistance test:

Dolutegravir + Lamuvidine (dovato)

ALL HAVE AN INTEGRASE INHIBITORS!!!! GUIDELINES RECOMMEND THE USE OF AN INTEGRASE INHIBITOR

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33
Q

patient HAS a history of using long acting cabotegravir as PREP, and therapy is being started BEFORE the results of the INSTI genotype resistance testing

what therapy should they be put on?

A

Darunavir or Darunavir + low dose ritonavir + TAF or TDF + Emtricitabine or Lamuvidine
(pending the results of the genotype test)

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34
Q

physician is concerned about the renal or bone adverse effects associated with TAF/TDF

what therapy is recommended by the guidelines

A

integrase inhibitor + 2 NRTIs

(ie: dolutegravir + abacavir + lamuvidine)

IF HLA-B*5701 IS NEGATIVE (abacavir concern) also avoid in CV disease bc of abacavir

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35
Q

give 2 general regimens that the guidelines recommend to avoid an integrase inhibitor based regimen

A

boosted protease inhibitor + 2 NRTIs

NNRTI + 2 NRTIs

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36
Q

name 5 therapies that are NOT recommended as INITIAL antiretroviral treatments by the guidelines

A

raltegravir-based regimens

elvitegravir/cobicistat-based regimens

booster Atazanavir-based regimens

Efavirenz-based regimens

Rilpivirine + TDF + FTC

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37
Q

2 examples of when we should NOT use rilpivirine as initial therapy

A

CD4 count less than 200, viral load greater than 100,000 copies

because higher rates of failure

38
Q

HLAB5701 allele test is positive OR is unknown

what drug should we NOT use

A

abacavir

39
Q

viral load is higher than 500,000

what 2 therapies should NOT be used

A

rilpivirine + TAF + emtricitabine

dolutegravir + lamuvidine

40
Q

in general, if the patient has chronic kidney disease (CrCl <60mL/min), which drug should definitely be avoided

A

TDF - TAF has better renal and bone properties

41
Q

patient has osteoporosis

which particular drug should be avoided

A

TDF - TAF is better

42
Q

2 drugs that should be avoided if patient has psychiatric illness

A

rilpivirine, efavirenz

43
Q

after the initiation of appropriate antiretroviral therapy, how long should it be until the viral load should become UNDETECTABLE? (<50copies/mL)

How long should it be just to see improvement in the viral load?

A

12-24 weeks – or within 6 MONTHS

should be around 4 weeks to see improvement in the viral load

44
Q

1 of the reasons a patient may fail their initial antiretroviral treatment is if their is an alteration in the drugs’ pharmacokinetics

given an example of this

A

if the patient has bad diarrhea as a side effect of one of the drugs, the drug isn’t being absorbed well and the patient will fail treatment

45
Q

true or false

therapeutic drug monitoring is not done for HIV drugs

A

true

46
Q

define virologic suppression

A

confirmed viral load levels below LLOD (lower limit of detection) should occur within 24 weeks

47
Q

explain what virologic failure is

A

inability to achieve OR MAINTAIN viral load less than 200

sometimes pt is on therapy and doing well, but it goes above 200 again

48
Q

what is a virologic blip

A

after suppression, random test comes back as extremely high, even when the patient has been controlled consistently

when you repeat the test, it comes back less than 200

we dont know why this happens

49
Q

define an incomplete virologic response

A

2 consecutive viral load levels greater than 200 even after 6 months on therapy

50
Q

low-level viremia

A

confirmed detectible viral load less than 200

51
Q

true or false

drug resistance is not considered cumulative

A

FALSE - it is

meaning that prior history is very important – all adds up

52
Q

a patient is on a 3 drug regimen. they develop resistance to 1 or 2 of the drugs

what should be done?

A

throw the entire regimen away and start over

53
Q

PREP vs PEP

A

prep = pre exposure prophylaxis. HIV-negative patient takes combo drug on a daily basis (or cabotegravir XR injectable suspension bimonthly) BEFORE the potential exposure occurs

PEP = post exposure prophylaxis
HIV negative patient takes a full 3-drug HIV regimen for 28 days AFTER the potential exposure occurs

54
Q

how can PEP be dividied

A

occupational and non occupational (ie - sexual, IV drug user)

55
Q

as mentioned, PrEP is when an HIV negative patient takes either combo drug therapy daily, or cabotegravir XR injectable bimonthly BEFORE the potential exposure occurs

name 2 of these possible combination drugs

A

TDF + emtricitabine

TAF + emtricitabine

56
Q

PEP should be started within how long after the exposure?

A

within 72 hours after the exposure

57
Q

give an example of a PEP regimen

how long is it taken?

A

for 28 days and started within 72 hours after exposure

dolutegravir + TDF or emtricitabine

58
Q

according to the CDC, prep is ONLY for……

A

people who are at ongoing, substantial risk of HIV infection

59
Q

according to the CDC, PEP should be offered to who

A

people who present to dr after a single high risk event of potential HIV exposure

60
Q

true or false

PREP protects against HIV as well as other STI’s

A

FALSE

ONLY HIV

61
Q

name the conditions that identify the patient as having a substantial risk of acquiring HIV infection

A

anal or vaginal sex in the past 6 months and ANY of the following:

-HIV positive partner (esp if unknown or undetectable VL)
-bacterial STI in the past 6 months
-history of inconsistent or no condom use

OR

HIV positive injecting partner OR share injecting equipment

62
Q

name 4 conditions in which ALL must be met to be considered CLINICALLY eligible to receive PREP

A

-documented negative HIV test result within 1 week after initially prescribing prep

-no signs or symptoms of acute HIV

-creatinine clearance greater than 30

-no contraindicated meds

63
Q

what are common signs and symptoms of an acute HIV infection

A

flu like symptoms

64
Q

true or false

if a person tests (+) for HIV, they are not a candidate for prep

A

TRUE

want to give full therapy immediately

65
Q

name the med/duration for prep treatment

A

truvada (TDF + Emtricitabine)

less than or equal to a 90 day supply

oral, once daily dosing

OR

for men and trans women at risk for sexual acquisition - daily, continual dosing of descovy (TAF + emtricitabine) up to 90 day supply

NO MORE THAN 3 MONTHS AND NO REFILLS!!!! want to test them and make sure it’s working and they’re not (+)

66
Q

why is descovy (TAF + emtricitabine) not used in heterosexual women, and only used in men and trans women?

A

bc not studied in heterosexual women for prep

truvada is used instead

67
Q

when prep is being administered, what information should be collected every 3, 6, and 12 months?

A

3 months - HIV test, adherence

6 months - assess renal function if over 50 or have low cr cl at start

12 months - assess renal function of ALL patients. chlamydia screening for hetersexual women and men

if on TAF + emtricitabine, assess weight, triglycerides, cholesterol

68
Q

what is the only not oral prep

A

cabotegravir injection

69
Q

only difference between determining if a patient is eligible for prep between truvada/descovy vs cabotegravir

A

all same requirements, except for cabotegravir there is no creatinine clearance cut off

70
Q

dosage cabotegravir for prep

A

600mg IM 3mL single dose

4 weeks later - 2nd dose

every 8 weeks thereafter they get another dose

71
Q

differentiate between primary and secondary prophylaxis for opportunistic infections

A

primary - for patients who have NEVER HAD infection. to prevent the first episode of an opportunistic infection

secondary - prophylaxis for patients who have had previous cases of the opportunistic infection

72
Q

most common opportunistic infection in HIV patients

A

candidiasis fungus

oral or esophageal

73
Q

treatment for oral candidiasis (thrush)

also what is duration

A

7-14 days

most often - fluconazole 100mg PO QD
ALTS are clotrimazole troche 5x a day, nystatin suspension, posaconazole

74
Q

treatment for esophageal candidiasis
also what is duration

A

14-21 days (longer than thrush)

fluconazole 100mg QD or itraconazole solution 200mg QD

alts = viriconazole, isavuconazole, caspfungin

75
Q

true or false

we normally do not give prophylaxis for thrush

A

TRUE

only if they have it an absurd amount of times every year (which is rare)

76
Q

name 4 opportunistic infections in HIV patients

A

candidiasis
PCP (pneumocystis pneumonia)
toxoplasma gondii
MAC (mycobacterium avium complex)

77
Q

when is primary prophlyaxis for PCP indicated

A

HIV + and CD4 count less than 200

78
Q

primary prophylaxis regimen for PCP

when is the therapy discontinued

A

bactrim (DS) QD – can be on for years

alts are tmp/smx SS QD, dapsone, atovaquone, pentamide

discontinued when CD4 is greater than 200 for 3 or more months
(can consider if between 100-200 and VL undetectable for 3-6 months tho)

79
Q

when is secondary prophylaxis indicated for PCP

A

following a PCP episode

treatment is same as primary prophylaxis. also stopped under same conditions

80
Q

when is primary prophylaxis for toxoplasma gondii indicated?
what is the treatment?
when can it be stopped?

A

when CD4 count less than 100 and IgG antibody (+) to toxo

treatment, like PCP, is bactrim DS QD

stopped under same conditions - when CD4 greater than 200 for 3 or more months. (can consider when cd4 100-200 and VL undetectable for 3-6 months)

81
Q

**patient has CD4 count 80
what opportunistic infections are they at risk for

A

PCP
toxoplasma gondii

82
Q

how does a patient with toxoplasma gondii present

A

stiff neck, altered mental status

83
Q

when is secondary prophylaxis for toxoplasma gondii indicated?
what is treatment?
when can it be discontinued?

A

indicated following a toxo episode

treatment is same

can stop when CD4 greater than 200 for 6 or more months and have no signs or symptoms of toxo infection

84
Q

when is primary prophylaxis for MAC (mycobacterium avium complex) indicated?

A

NOT recommended for adults/adolescents who immediately initiate antiretroviral therapy

however, IS indicated if:
-HIV (+)
-not on fully suppressive therapy (this is not recommended therapy by guidelines - so not rly on prophylaxis usually)
-CD4 count less than 50 after ruling out disseminated MAC

85
Q

treatment for primary prophylaxis of mac

A

azithromycin 1200mg q weekly
clarithromycin 500mg BID

86
Q

when is primary prophylaxis for mac discontinued

A

the initiation of effective antiretroviral therapy (according to guidelines)

87
Q

*CD4 of 30
what are they at risk for

they are starting a new HIV regimen today. what prophylactic regimen should they be put on?

A

PCP
toxoplasma
MAC

ONLY BACTRIM

starting guideline therapy - do not need prophylaxis for MAC, if they were NOT starting HIV regimen today, would need clarithromycin or azithromycin

88
Q

HIV patients who have AIDS (CD4 less than 200) should not receive which vaccines

A

live vaccines - whether bacterial or viral

ALL OTHERS can be given

89
Q

true or false

TAF and TDF cannot be given together

A

true

90
Q
A

D&D Infectious Disease FINAL (21 decks)

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