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ID 3 Fuller HIV only

ID 3 Fuller

Define AIDS Infected with virus and have CD4 count < 200 (Normal CD4 count > 700) Have had an opportunistic infection or cancer
Name the gold standard tests for HIV diagnosis Elisa and Western Blot
What do the Elisa and Western Blot test look for and how long does it take to get results? Antigen/antibody the results take 6 weeks
What is the name of the in home test, how long does it take to get results, what does it test for and what body fluid is used? ORA QUICK, 20 minutes, ag/ab and it uses saliva not blood
Define Viral Load Viral Load is the measure of the number of viral copies per ml of blood
What test is used to determine viral load? PCR reaction test, RNA or DNA
how sensitive are the current RNA tests? 20 copies / ML
Is Viral load used to diagnose HIV No! it is used to measure survivability
What are T-helper cells AKA? T4 or CD4
What is the normal function of CD4 cells? A cell involved in protecting against viral, fungal and protozoal infections. These cells normally orchestrate immune responses. “General” of the immune system
Do we use CD4 count to diagnose HIV? NO!
What is Viral load related to? Disease progression, the higher the viral load the faster the disease progresses
What is CD4 count related to? Disease staging, the higher the CD4 count the earlier the stage of disease.
What is the first CD4 count magic number and what occurs when it is reached? CD4 < 200, Aids diagnosis, and PCP prophylaxis
What is the lower CD4 magic number and what can occur when it is reached? CD4< 50 toxoplasmosis and CMV, also must prophylaxis for MAC
Sites for HIV medication therapy? Cell fusion inhibitors, reverse transcriptase inhibitors, protease inhibitors, integrase inhibitors, interleukin and interferon's
types of cell entry inhibitors? Fusion Inhibitors(fuzeon) Binding Site Inhibitors Co-receptor Antagonists
Reverse transcriptase inhibitors? NUKES, Non-NUKES and Tides
What does NUKE stand for? Nucleoside reverse transcriptase inhibitor
What drugs are considered NUKES? zidovudine (Retrovir)(azt) didanosine (Videx)(DDI) stavudine (Zerit) (D4T) lamivudine (Epivir) (3TC) abacavir (Ziagen) emtricitabine (Emtriva) tenofovir (Viread)
What does Non-Nuke stand for? Non nucleoside reverse transcriptase inhibitors
What drugs are considered Non- Nukes? (Sustiva) efavirenz (EFV) (Viramune) nevirapine (NVP) (Rescriptor) delaviridine (DLV) (Edurant) rilpivirine (RPV) 2nd Generation (Intelence) etravirine (ETR)
What makes up Combivir? zidovudine and lamivudine
What makes up Epzicom abacavir and lamivudine
What makes up Truvada? tenofovir and emtricitabine
What makes up Trizivir? abacavir, lamivudine, zidovudine
What makes up Atripla? efavirenz, tenofovir and emtricitabine
What makes up Complera? rilpivirine, tenofovir, emtricitabine
What makes up Stribild? elvitegravir, cobicistat,tenofovir, emtricitabine
Generic name and class for Invirase Protease inhibitor, saquinavir
Generic name and class for Norvir Protease inhibitor, ritonavir
Generic name and class for Crixavan Protease inhibitor, indinavir
Generic name and class for Viracept Protease inhibitor, nelfinavir
Generic name and class for Lexiva Protease inhibitor, fosamprenavir
Generic name and class for Kaletra Protease inhibitor, lopinavir/ritonavir
Generic name and class for Reyataz Protease inhibitor, atazanavir
Generic name and class for Aptivus Protease inhibitor, tipranavir
Generic name and class for Prezista Protease inhibitor, darunavir
Generic name and class for Fuzeon Fusion inhibitor, enfuviritide
Generic name and class for Selzentry co-receptor antagonist, maraviroc
Generic name and class for Isentress Integrase inhibitor, raltegravir
Generic name and class for Stribild Integrase inhibitor, elvitegravir, only available in quad combo pill
Current HIV Medications Nucleoside Reverse Transcriptase Inhibitors: single meds Nukes (NRTI) Zidovudine (AZT) Didanosine (ddI) Stavudine (D4T) Lamivudine (3TC) Abacavir Emtricitabine
Current HIV Medications Nucleoside Reverse Transcriptase Inhibitors: Co-formulated tablets Combivir Zidovudine/Lamivudine Trivizir Zidovudine/Lamivudine/Abacavir Epzicom Abacavir/Lamivudine
Current HIV Medications: Nucleotide Reverse Transcriptase Inhibitors (NtRTI) Tenofovir Combination Truvada Emtricitabine/Tenofovir
Current HIV Medications: Cell Entry Inhibitors Fusion inhibitor: Enfuvirtide Co-receptor Antagonist Maraviroc
Current HIV Medications: Non-nucleoside Reverse Transcriptase Inhibitors Non-Nukes (NNRTI) Delavirdine Nevirapine Efavirenz Rilpivirine Etravirine
Current HIV Medications: Non-nucleoside Reverse Transcriptase Inhibitors Non-Nukes (NNRTI) : Co-Formulated tablets Atripla Efavirenz, tenofovir, emtricitabine Complera Rilpivirine, tenofovir, emtricitabine
Current HIV Medications: Protease inhibitors; Older less potent drugs Saquinavir Ritonavir Indinavir Nelfinavir
Current HIV Medications: Protease inhibitors; Newer more effective and potent drugs Lopinavir/Ritonavir Atazanavir Fosamprenavir Tipranavir Darunavir
Nucleoside Reverse Transcriptase Inhibitors, Names and Adult Dosing: Videx - ddI, didanosine Wt > 60kg 400mg qd Wt < 60kg 250mg qd
Nucleoside Reverse Transcriptase Inhibitors, Names and Adult Dosing: Zerit - D4T, stavudine Wt > 60kg 40mg bid Wt < 60kg 30mg bid
Nucleoside Reverse Transcriptase Inhibitors, Common Adverse Effects: Zidovudine (Retrovir) (AZT or ZVD) Nausea, vomiting, headaches, myalgia, anemia, mitochondrial dysfunction Side effects less when combined with Epivir
Nucleoside Reverse Transcriptase Inhibitors, Common Adverse Effects: Epivir (almost always used med) Pancreatitis, AST/ALT Very Well Tolerated The pancreatitis is often in people with prior issues not alone on its own.
Nucleoside Reverse Transcriptase Inhibitors, Common Adverse Effects: Emtriva Nausea, rash, diarrhea, headache, skin discoloration Very Well Tolerated
Nucleoside Reverse Transcriptase Inhibitors, Common Adverse Effects Zerit and Videx Pancreatitis, peripheral neuropathy, nausea, vomiting, fatigue, myalgia, bone marrow suppression, mitochondrial dysfunction
Nucleoside Reverse Transcriptase Inhibitors, Common Adverse Effects: Ziagen – Abacavir Hypersensitivity rxn Seen 8% Caucasian pop Rash, fever, fatigue, nausea, vomiting, abdominal cramping, respiratory symptoms. Death—hypotension. Less frequent in Afro-Americans HLA B5701 status negative then they can take. Test only once
tenofovir (Viread side effects Minimal, Well tolerated Liver GI Rena
tenofovir (Viread) Renal side effects and who they effect they most. Diabetics/HTN Hispanics and Afro-Americans Worse with other Nephrotoxins Scr < 50ml/min requires dosing changes (increased interval)
Nukes that do not require renal dose adjustment rather hepatic adjustment? Abacavir all other Nukes require renal dose adjustment
Side Effects Nucleoside Reverse Transcriptase Inhibitors as a class Mitochondrial Toxicity Lipoatrophy
MOA of mitochondrial toxicity in D4T, AZT and DDI Inhibition of mitochondrial γ DNA polymerase
Symptoms of mitochondrial toxicity in D4T, AZT and DDI Nausea, abdominal dyscomfort, vague feeling of wrongness
Therapy of Mitochondrial Toxicity STOP offending agent do not re-challenge with another agent from the same group, remove from therapy Supportive therapy Folate Bicarbonate L-carnitine B-vitamins Co-enzyme Q
Non-nucleoside Reverse Transcriptase Inhibitors, Common Side Effects: nevirapine and Delavirdine RASH, itching, Drug interactions and Liver dysfunction
What NNRTI has a BBW for liver toxicity? Nevirapine, Men Do not use CD4 > 400 Women Do not use CD4 > 250
Non-nucleoside Reverse Transcriptase Inhibitors, Common Side Effects Efavirenz Mental status changes, worsens depression/mania, Dreams, hung-over feeling, “Manic” feeling,Drug interactions Pregnancy Category D (especially first trimester,
rilpivirine (Edurant) Side effects counseling points Side effects less than Efavirenz Most common Rash Depression Insomnia Headache
rilpivirine (Edurant): counseling points Take with food Regular meal best Category B pregnancy Drug Interactions Risk for virologic failure when VL>100,000
etravirine is what kind of medication? 2nd Generation NNRTI Approved for treatment experienced patients. Has activity against virus resistant to 1st generation NNRTIs.
etravirine counseling pints and pregnancy info? Must take with food. Food increase medication absorption by 50%. Pregnancy Category B: use in pregnancy only if the benefit justifies the potential risk
Non-nucleoside Reverse Transcriptase Inhibitors: Resistance, Efavirenz, nevirapine, delavirdine Most commonly resistance to one = resistance to all
Non-nucleoside Reverse Transcriptase Inhibitors: Resistance, rilpivirine Can induce resistance to 1st generation NNRTIs and Etravirine
Non-nucleoside Reverse Transcriptase Inhibitors: Resistance,etravirine Can induce resistance to all NNRTIs
Drug class and brand name for saquinavir Protease inhibitor, Invirase
Drug class and brand name for indinavir Protease inhibitor, Crixavan
Drug class and brand name for ritonavir Protease inhibitor, Norvir
Drug class and brand name for nelfinavir Protease inhibitor, Viracept
Drug class and brand name for Lopinavir/Ritonavir Protease inhibitor, Kaletra
Drug class and brand name for atazanavir Protease inhibitor, Reyataz
Drug class and brand name for fosamprenavir Protease inhibitor, Lexiva
Drug class and brand name for tipranavir Protease inhibitor, Aptivus
Drug class and brand name for darunavir Protease inhibitor, Prezista
Protease Inhibitors Side Effects- Family hallmark side effects Nausea, diarrhea, gas, bloating,
Protease Inhibitors Side Effects- Family lipodystrophy increased dorsicervical, neck and abdominal fat pads, in women increase breast fat.
Protease Inhibitors- Side Effects: ritonavir Nausea, vomiting, rash, liver function abnormalities,drug interaction, circumoral paresthesias. Side Effects limit Ritonavir mainly to “boosting” other PIs Boosting applies Ritonavir side effects and drug interactions to cocktail
Protease Inhibitors Side Effects: Atazanavir Does not effect cholesterol and triglycerides to the same degree as other protease inhibitors.Hyperbilirubinemia, Jaundice, Rash (20%), Bloating/gas, Lipodystrophy
Protease Inhibitors Side Effects: Indinavir(Crixivan) older drug not used much anymore Nephrolithiasis Jaundice Skin changes
Protease Inhibitors Side Effects" Fosamprenavir Older drug not used much now, Most commonly RASH
Protease Inhibitors Side Effects: Tipranavir Probably most difficult PI to take overall Amount of ritonavir Liver CNS bleeding (BBW) Rash (3-21%)
PI Side Effects rated by severity for nausea, gas and bloating and diarrhea Kaletra = Aptivus > Invirase > Reyataz = Lexiva > Prezista > Sustiva
Worst PI for side effect of diarrhea? Viracept > Kaletra = Aptivus
name the two boosting HIV medications ritonavir and cobicistat
benefits of ritonavir usage Extended dosing of other PI, and/or fewer pills Protective against PI resistance mutations
Enfuvirtide, Fuzeon (T-20) MOA and administration Fusion Inhibitor: GP41 binding agent Must be reconstituted and injected Time consuming 24 hour stability under refrigeration 90mg bid Subq
Enfuvirtide, Fuzeon (T-20): side effects Injection Site Reactions Injection Fatigue
Where does fuseon work? how is it different than other antiretrovirals It works outside the cell to prevent fusion
Maraviroc Dosing With boosted PI (Strong 3A inhibitors) ritonavir, cobicistat 150mg bid With Tipranavir/NRTI’s/Nevirapine (Neither Strong 3A4 inducers or inhibitors) 300mg bid With Efavirenz (Strong 3A inducers) 600mg bid
Maraviroc Side Effects Hepatotoxicity (Black Box) Allergic Reactions (Systemic) Skin rash Fever, abdominal pain, muscle and joint pain Cough, upper respiratory tract infection Sleep disturbances
Integrase Inhibitors Raltegravir Elvitegravir
Isentress™, raltegravir: side effects well tolerated, Do not use with Rifampin
Stribild™, Elvitegravir The “Quad”, GS-9350 Elvitegravir/cobicistat/tenofovir/emtricitabine
Stribild™, Elvitegravir: side effects Nausea, diarrhea, gas Increased serum creatinine 0.1 – 0.2mg/dL- cobicistat effect 0.4mg/dL or more renal toxicity
Drug Interactions Tenofovir and DDI Tenofovir increases ddI AUC by 66-75%. Dose modify ddI when given with Tenofovir Dose ddI 60kg – 250mg daily <60kg – 200mg daily
Drug Interactions Tenofovir and atazanavir Decreases ATA levels and AUC 25%
Drug Interactions Tenofovir and atazanavir: Solutions Boost Atazanavir (rayavaz) Norvir (ritonavir) 100mg daily Atazanavir 300mg daily
Drug Interactions Nukes:Stavudine and Zidovudine AZT and d4T require the same phosphoralation enzyme. Solution Do not give together.
Drug Interactions Nukes:AZT/ddI/D4t Additive Mito Tox Solution Avoid giving together
Drug Interaction Nukes: Zidovudine and Ganciclovir Interferon Chemotherapy Solution Avoid if possible
Drug Interactions, CYP450 ca4 All PI’s except for Nelfinavir are Substrates
Drug Interactions, CYP450: inducers Nevirapine, Tipranavir
Drug Interactions, CYP450: inhibitors Ritonavir, Delavirdine , Cobicistat
Drug Interactions PIs : contraindications PIs decrease metabolism/increase serum level: Cisapride, pimozide, ergots (cause strokes) Triazolam, midazolam (sleep or sedation) Simvastatin, lovastatin, pitavastatin(rhabdo) Amiodarone, bepridil, flecainide, propafenone, quinidine Salmeterol Ethinyl Estradiol
Drug Interactions PIs CYP Contraindications These medications Incease PI metabolism/decrease serum level: Rifampin, rifabutin St. John’s Wort Garlic pills
Drug Interactions Atazanavir and PPI Absorption of Ata decreased (Severe) Solution Avoid concomitant use
Drug Interactions Atazanavir and H2 Absorption of Ata decreased (Moderate) Solution Separate by 12 hours Boost Atazanavir
Drug Interactions Atazanavir and Antacids Decreased Ata (mild/mod) Solution Antacid 2hrs before or 1 hour after ATA.
Drug Interactions NNRTIs All St. John’s Wort Contraindicated (↓NNRTIs
Drug Interactions NNRTIs: Etravirine Carbamazepine Phenobarbital Phenytoin Contraindicated (↓both)
Drug Interactions NNRTIs: Efavirenz Midazolam, triazolam Contraindicated (↑ level) Methadone Decreased Methadone Level 42 – 52%
Drug Interactions NNRTIs: Rilpivirine Antacids 2 hrs prior 4 hrs after H2 antagonists 12 hrs prior 4 hrs after PPIs contraindicated (↓ RPV)
Drug Interactions NNRTIs: Rilpivirine Carbamazepine Phenobarbital Phenytoin Contraindicated (↓ RPV) Dexemethasone Contraindicated (↓ RPV)
Drug Interactions Stribild™ Contraindications Stribild™- decrease metabolism/increase serum level: Alfuzosin Sildenafil for pulmonary hypertension Cisapride, pimozide, ergots Triazolam, midazolam Simvastatin, lovastatin
Drug Interactions Stribild™ Contraindications These medications Increase Stribild™ metabolism/decrease serum level: Rifampin St. John’s Wort
Rifampin drug interactions with HIV meds PIs destroyed Rilpivirine destroyed Etravirine , elvitegravir decreased Efavirenz concentration decreased 25% Solution Do NOT use with PIs Rilpivirine , etravirine, or elvitegravir Increase efavirenz to 800mg daily
Rifabutin Drug Interactions with PI's Serum concentration of PI decreased Rifabutin half-life increased Solution Use boosted PI Decrease Rifabutin to TIW
Rifabutin Drug Interactions wit Sustiva Decreased rifabutin concentration Solution Increase dose of Rifabutin 450mg- 600mg daily
Rilpivirine and Rifabutin Drug interactions Contraindicated Decreased RPV levels
Stribild and Rifabutin drug interactions Just do not use together
Drug interactions with Sustiva and antifungals Posaconazole Posa decrease 50% Voriconazole Sustiva increased 45% Vori decreased 75% Itraconazole Itraconazole decreased Use different antifungal (will destroy the liver)
What do we have to ask a patient before starting HAART? Are you ready?
Goals of HAART therapy Complete Viral Suppression Minimize Side Effects GI Body Morphing Lipids Minimize Pill Burden Once Daily
starting medications guide At least 3 medications At least 1 PI, NNRTI, Entry Inhibitor or Integrase Inhibitor Avoid combos of Zerit/Videx Zerit/AZT
Starting medication anchor medications Efavirenz Atazanavir/Ritonavir Darunavir/Ritonavir Raltegravir
Starting guideline NUKES Truvada
Treatment Regimens for Antiretroviral Naïve Patients Efavirenz/tenofovir/emtricitabine (Atripla) Atazanavir/ritonavir/tenofovir/emtricitabine Darunavir/ritonavir/tenofovir/emtricitabine Raltegravir/tenofovir/emtricitabine
Treatment Regimens for Antiretroviral Pregnancy Lopinavir/ritonavir/zidovudine/lamivudine (because we have more experience with this combo in pregnant women
Rules for medication intolerance Replace the medication with another in THE SAME FAMILY
Treatment Therapies to Avoid d4T +ZDV Monotherapy* All Nuke Regimens Epivir + Emtriva NNRTI + NNRTI d4T + ddI Ritonavir + Cobicistat
What is Immune Reconstitution Inflammatory Syndrome (IRIS)? Side Effect of Therapy Related to rapid response to HAART tx Rapid decrease in Viral Load Rapid increase in CD4 cell count
How does IRIS typically present? Previously undiagnosed Opportunistic Infection (OI) Inflammatory response to Previous OI
what can we do if IRIS occurs? give steroid, nsaid or stop HAART
What is salvage therapy? Cocktail therapy that is necessary due to viral escape. Can be 1st salvage Can be “Deep Salvage
What are the rules of salvage therapy? Resistance Testing Genotype/Phenotype New “Family” of Drugs New Medications At least 2 with full activity Keep Epivir/Emtriva
How can pharmacists prevent salvage therapy? avoid drug interactions, get the right medication and promote adherance
Why Adherence is important Need 95% or better Resistance!!! Can have class effects Next combo less effective More side effects Viral Progression
HIV Treatment in Pregnancy: On Therapy Prior to Pregnancy Undetectable Viral Load Don’t Mess With Efavirenz Detectable Viral Load Viral Resistance Testing Adherence Get Viral Load Undetectable
HIV Treatment in Pregnancy: Not On Therapy Prior to Pregnancy HIV Viral Resistance Testing Treat Without Regard to CD4 Cell Count Start as Soon as Possible Morning Sickness Medications to Avoid Efavirenz Nevirapine if CD4 >250
Treatment Points for Delivery If Mother’s Viral Load >1000 copies/ml Scheduled C-Section IV Zidovudine 2mg/kg Load, 1mg/kg/hr until Delivery Avoid Breaking Skin of Fetus Oxygen Probes Forceps/Suction
HIV and Pregnancy treatment for fetus Fetus to Receive Zidovudine for 6 Weeks 2mg/kg oral Zidovudine every 6 hours Start 6 to 8 hours after birth
PrEP- Pre-exposure Prophylaxis Used in HIV negative patients Prior to sex Oral medication therapy taken daily
nPEP-Nonoccupational Postexposure Prophylaxis Used in HIV negative patients after risk of exposure, usually sexual
PEP- Occupational Exposure Postexposure Proph Most commonly associated with EMS and health care personnel
PrEP medication Truvada approved for PrEP by FDA 7/2012 Truvada 1 tablet daily Trials supporting PrEP iPrEx- international MSM TDF2- heterosexual men and women Partners PrEP- heterosexual sero-discordant couples Protection related to adherence
nPEP: HIV negative patient potentially exposed to HIV Needs to start within 72 hours of exposure (prefer within 24 hours) Kaletra/Combivir Atripla or Efavirenz/Combivir Treatment for 28 days
PEP Postexposure prophylaxis for healthcare workers Remember test for HIV, HepB and HepC PEP subject should be HIV Treatment within 72 hours of exposure Treatment for 28 days
PEP Treatment Regimens Severity based on Viral load or experience of source Kind of exposure Less severe exposure 2 drug regimen Combivir preferred More severe exposure 3 drug regimen Kaletra/Combivir
What is STI? Strategic Treatment Interruption Interruption of therapy at a scheduled interval Time off of therapy Pill Fatigue Break between regimens
Created by: btrain67



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