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BCPS study guide

HIV

QuestionAnswer
PrEP therapy Truvada (emtricitabine/tenofovir) 300mg/200mg QD
what drug should be included in perinatal therapy for HIV prevention zidovudine
normal CD4 count 500-1300
what percent change in CD4 count is considered clinically relevant 30%
percent change in CD4 counts to be expected in pts getting potent ART therapy increase 50-100/mm^3 annually
CD4 count diagnostic of AIDS (stage 3 HIV) <200/uL or <14%
other than CD4 count, what defines AIDS documentation of an AIDS defining condition along with laboratory confirmation of HIV
symptoms of acute/primary HIV infection lethargy, sweats, arthralgias, myalgias,fevers, headache, photophobia, sore throat, lymphadenopathy, diarrhea
when are live vaccines contraindicated in pts with HIV if CD4 count <200
vaccines recommended in pts with HIV flu, pneumococcal (once), Hep B (in all susceptible) and Hep A (if at high risk)
how long and with what should the baby be treated with post natally if mom has HIV 6 weeks with zidovudine 4 mg/kg/dose Q12H. if mom didn't take ART during preggers add nevirapine at birth and repeat at 48 hours then 96 hours after the second dose, repeat.
what HIV drug should be avoided in women of childbearing age to avoid first trimester exposure efavirenz
how long should post exposure prophylaxis continue and how soon after exposure should it start continue therapy for 4 weeks. if non-occupational exposure start within 72 hours. if occupational try to start within hours and start treatment while status is evaluated
preferred post exposure prophylaxis raltegravir PLUS Truvada (emtricitabine/tenofovir) [occupational]. no preference for ART if non-occupational other than that it be potent combination ART.
in a low risk HIV positive pt, when should ART be initiated when CD4 counts drop below 350 FOR SURE. 350-500 and over 500 can consider. if pt likely to transmit HIV to sexual partners start as well. if pt preggers or AIDs defining condition or Hep B coinfection as well.
what are the principles of HIV opportunistic infections severe and typically not curable, suppressive therapy is used; not contagious to others typically as usually reactivation of previous exposure; depends on local bugs; more B cell associated infections such as pneumococcal becoming more common
preferred treatment for PCP bactrim x 21 days. if Aa gradient of 35 or more or Po2<70 indicating severe dz then do adjuvant corticosteroids
calculate Aa gradient 150-PCO2-PO2
alternatives to Bactrim for PCP clinda + primaquine; pentamidine; trimethoprim + dapsone; atovaquone
preferred follow up treatment for cryptococcus meningitis fluconazole 200 mg QD
diagnostic tests for cryptococcus meningitis positive CSF cultures, CSF india ink, CSF cryptococcal antigen titer, elevated opening pressure >20, serum cryptococcal antigen more than 1:8
preferred treatment for cryptococcus meningitis amphotericin B and flucytosine for at least 2 weeks followed by fluconazole for at least 8 weeks. can also do amp B monotherapy or just fluconazole and flucytosine or amp B and fluconazole but this is the preferred treatment
treatment for CMV infections same for all. valgancyclovir or gancyclovir [both interact with zidovudine, gancyclovir can do lower doses but not recommended]; foscarnet - no notable DDIs and has anti-HIV activity and decreased mortality,; cidofovir - can cause renal impairment.
what prophylaxis is recommended in CMV. primary or secondary or both. secondary is required fo rall. can d/c when CD4 ct is >100 for 3-6 months or longer with ART. primary ppx not recommended but if cd4 ct is <50 recommend funduscopic exam regularly
standard therapy for toxoplasmosis pyrimethamine and sulfasalazine and leucovorin to prevent bone marrow effects of pyrimethamine. if sulfa allergy can use clindamycin.
prophylaxis for toxoplasmosis seropositive pts should get primary ppx if cd4 is less than 100. use bactrim. for secondary until cd4 greater than 200 for 6 months due to ART. use pyrimethamine and leucovorin or clinda or atovaquone
treatment for latent TB in pts NOT coinfected with HIV isoniazid 300 mg daily or 900 mg twice weekly for 6-9 months. may also use rifampin 600 mg daily for 4 months. other options require DOT or are not CDC recommended regimens
treatment for latent TB in pts coinfected with HIV isoniazid 300 mg daily for 9 months. may also do 900 mg twice weekly for 9 months but requires DOT
treatment for active TB infection in pts WITHOUT HIV coinfection isoniazid, rifampin, pyrazinamide and ethambutol for 2 months followed by isoniazid and rifampin for 4 more months
treatment for active TB in pt coinfected with HIV isoniazid, rifampin, pyrazinamide and ethambutol for 2 months followed by isoniazidand rifampin for 4 months (same as for non-HIV) may need to change to rifabutin due to DDI with PI and NNRTIs. decrease rifabutin dose with PIs. need HIV RNA conc. checked
prevention of renal toxicity with amphotericin B 1 L NS for 24 hrs or 500 ml before and after dose. avoid diuretics and liberalize salt intake
prevention of thrombophlebitis with amphotericin B dilute to 0.1 mg/ml and infuse over at least 4 hours. use a central site and may add heparin
treatment of fever/chills with amphotericin B and MOA amp B induces PGE synthesis. hydrocortisone or ibuprofen may help. ASA/APAP/benadryl have not been shown to help but were also not specifically studied
treatment of rigors for amp B meperidine 50 mg. can be used prophylactically if needed for recurrent reactions
why is there no renal adjustment dose for voriconazole? crcl <50 should not get vori due to vehicle sulfobutyl ether-B-cyclodextrin
drugs contraindicated with voriconazole rifampin, rifabutin, carbamazepine, barbituates, sirolimus
dose adjustments for voriconazole with tacrolimus and cyclosporine tac decrease dose by 2/3. cyclosporine decrease dose by 1/2
Created by: mjuhlin