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ID 3 Fuller HIV only
ID 3 Fuller
| Question | Answer |
|---|---|
| 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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