Infectious Disease Flashcards
Key Counseling points: Azole antifungals
can cause liver damage, QT prolongation (except cresemba), many drug interactions
Key Counseling points: Ketoconazole
hepatotoxicity has led to liver damage and/or death, possible drug interactions due to high gastric pH (need acidic environment)
Key Counseling points: Itraconazole
tablets and capsules must be taken with food, solution must be taken on an empty stomach, can cause heart failure, possible drug interactions due to high gastric pH (need acidic environment)
Key Counseling points: Posaconazole (Noxafil)
tablets - take with food
suspension - take with full meal or oral liquid nutritional supplement
Key counseling points: Voriconazole (Vfend)
take on an empty stomach - at least one hour before or one hour after meals, can cause photosensitivity and vision changes, store reconstituted oral suspension at room temperature
Key counseling points: nystatin
oral suspension - shake well before using
Key counseling points: terbinafine
oral - can cause liver damage, can take several months after finishing treatment to see the full benefit of this drug - takes time for new healthy nails to grow and replace the infected ones
Key counseling points: oseltamivir
treatment should begin within 2 days of onset of influenza symptoms, can cause delirium
Key counseling points: acyclovir and valacyclovir
does not cure herpes infections - use safe practices to lower transmission risk, start treatment within 24 hours of the onset of symptoms
Key counseling points: acyclovir
drink plenty of fluids, topical cream can cause temporary burning and stinging
ZDS <3 LATTE (NRTIs)
Zidovudine
Didanosine (NLR)
Stavudine (NLR)
Lamivudine
Abacavir
TDF
TAF
Emtricitabine
NRTIs
competitively inhibit the reverse transcriptase enzyme - preventing the conversion of HIV RNA to HIV DNA in Stage 3 of the HIV Life cycle
[low barrier to resistance]
All NRTIs
lactic acidosis and hepatomegaly with steatosis (fatty liver); boxed warning for didanosine, stavudine, and zidivudine
-common side effects: nausea, diarrhea, headache, increased LFTs
NRTIs: HBV and HIV Confection boxed warnings
severe acute HBV exacerbation can occur if emtricitabine, lamuvidine, or tenofovir-containing products are discontinued (some NRTIs treat HBV). DO NOT USE Epivir-HBV for the treatment of HIV (contains lower dose of lamivudine)
Abacavir (Ziagen)
-boxed warning for HSR
-must be screened for HLA-B*5071 allele before starting
-must carry a card indicating HSR is an emergency
-never re-challenge patients with a history of HSR
-Consider avoid with CVD due to a potential increase risk of MI
Emtricitabine (Entrivia)
hyperpigmentation of the palms of the hands or soles of the feet
Tenofovir Formulations (Higher risk with TDF)
-renal impairment (acute renal failure and Fanconi syndrome)
-decrease dose with renal impairment and avoid other nephrotoxic drugs
-decrease bone mineral density: consider calcium/vitamin D supplementation and DEXA scan
-monitor lipids if switching from TDF to TAF for an improved side effect profile
Zidovudine
-hematologic toxicity: neutropenia and anemia (increased MCV is a sign of adherence)
-myopathy
Didanosine and stavudine
pancreatitis, peripheral neuropathy (can be irreversible)
BRED
Bictegravir
Raltegravir
Elvitegravir
Dolutegravir
BRED Side Effects and Warnings
-Bictagravir and dolutegravir; increase SCr with no effect on GFR
-Raltegravir; increase CPK, myopathy, and rhabdo
-Elvitegravir; proteinuria
-Dolutegravir; HSR, neural tube defects in fetus, increased CPK/myalgia
-All: HA, insomnia, D, weight gain, rare risk of depression and suicidal ideation in patients with pre-existing psychiatric conditions (except bictegravir)
Preferred regimen for HIV
2 NRTI and 1 INSTI
INSTIs drug interaction with polyvalent cations
Take INSTIs 2 hours before or 6 hours after; aluminum, calcium, magnesium and iron-containing products - except for dolutegravir, bictegravir, and raltegravir
Polyvalent cations and dolutegravir and bictegravir
can be taken with oral calcium or iron if also taken with food
Polyvalent cations and raltegravir
dose separations with raltegravir may not be effective; avoid polyvalent cations if possible
INSTIs
block the integrase enzyme, preventing HIV DNA from inserting into the host cell DNA in stage 4 (integration) of the HIV life cycle
-higher barrier to resistance than NRTIs and NNRTIs
NRTIs
non-competitively inhibit the reverse transcriptase enzyme, preventing the conversion of HIV RNA to HIV DNA in stage 3 (reverse transcription) of the HIV life cycles
-lower barrier to resistance than INSTIs or PIs
REDDEN
Rilpivirine, Efavirenz, Doravirine, Delavirdine (NLR), Etravirine, Nevirapine
All NNRTIs
hepatotoxicity and rash/severe rash, including SJS/TEN
Efavirenz
psychiatric symptoms (depression, suicidal thoughts), CNS effects (impaired concentration, abnormal dreams, confusion), generally resolve in 2-4 weeks, increase total cholesterol and TG
Rilpivirine
depression, increased SCr with no effect on GFR, do not use if viral load > 100,000 copies/mL and/or CD4 count < 200 cells/mm3 (higher failure rate), take with a meal and water (DO NOT substitute with a protein drink)
NNRTI drug interactions
all are major CYP3A4 substrates. Rilpivirine and doravirine - do not use with strong CYP3A4 inducers (carbamazepine, oxacarbazepine, phenobarbital, phenytoin, rifampin, rifapentine, St. Johns Wort)
-efavirenz and etravirine are moderate CYP3A4 inducers
-rilpivirine and acid suppressants
Rilpivirine and PPIs
DO NOT USE
Rilpivirine and H2RAs
take at least 12 hours before or 4 hours after rilpivirine
Rilpivirine and antacids
take antacids at least 2 hours before or 4 hours after rilpivirine
-navir
protease inhibitor
PI key features and safety
-metabolic abnormalities (increased LDL/TG & blood glucose, insulin resistance, increased risk of CVD (lowest risk with atazanavir and darunavir & highest with LPV/r)
-hepatic dysfunction (increased LFTs, hepatitis, and/or exacerbation of preexisting hepatic disease)
-HSR
-D/N
Atazanavir (Reyataz)
-hyperbilinrubinemia (reversible does not require discontinuation)
-requires acidic gut for absorption
Atazanavir and antacids
take atazanavir 2 hours before or 1 hour after
Atazanavir and H2RAs
avoid or take atazanavir 2 hours before or 10 hours after
Atazanavir and PPIs
-avoid with unboosted atazanavir
-boosted atazanavir: take boosted at least 12 hours after the PPI (dose should not exceed omeprazole 20 mg or equivalent)
Darunavir, fosamprenavir, tipranavir
caution with sulfa allergy
LPV/r (Kaletra)
oral solution contains 42% alcohol can cause a disulfram reaction if taken with metronidazole
Tipranavir
intracranial hemorrhage
PIs and CYP3A drug interactions
alfuzosin, colchicine, dronedarone, lovastatin and simvastatin, CYP3A4 inducers, anticoagulants/antiplatelets (apixaban, rivaroxaban, edoxaban, ticagrelor), direct acting-antivirals for hepatitis C, some hormonal contraceptives, steroids
PIs and warfarin
not contraindicated but should monitor INR frequently
Which HMG-CoA can be used with PIs
rosuvastatin and atorvastatin are preferred
Pharmacokinetic boosters
ritonavir (Norvir) and cobicistat (Tybost)
which pharmacokinetic booster can be co-formulated
cobicistat
Booster drug interactions
Alfuzosin, tamsulosin
Colchicine (with hepatic or renal impairment),
Lovastatin and simvastatin,
Azole antifungals (especially isavuconazonium, itraconazole, or voriconazole),
Cardiovascular drugs: amiodarone (ritonavir only), dronedarone, eplerenone, ivabradine, ranolazine,
PDE-5 inhibitors used for pulmonary hypertension (tadalafil, sildenafil) (dose reductions required if taking it for erectile dysfunction or BPH),
Many tyrosine kinase inhibitors (nibs),
CYP3A4 inducers
Any NTI drug that is highly dependent on CYP3A4 for clearance
CCR5 Antagonist
Blocks HIV from binding (and subsequently entering) the CD4 cell in virus strains that use CCR5 co-receptor in stage 1 of the HIV life cycle
Attachment Inhibitor
Converted to temsavir (active form) which binds to the gp120 subunit of HIV envelope proteins, inhibiting the interaction between the virus and CD4 host cell in stage 1 of the cell cycle
Post-attachment Inhibitor
Binds to a select domain of CD4 cell receptors in stage 1 (binding/attachment) of the HIV life cycles, blocking entry of the virus into the cell
Fusion Inhibitor
Prevents HIV from fusing to the CD4 cell membrane in stage 2 (fusion) of the HIV life cycle, which prevents virus entry into the cell
TDF
CrCl < 50 mL/min: do not start - TDF or TDF containing products (< 70 mL/min for Stribild)
TAF
CrCl < 30 mL/min: do not start TAF containing products
Stribild
Eltivegravir/ cobicistat/ emtricitabine/ TDF
-take with food
Atripla
Efavirenz / emtricitabine/ TDF
-take on an empty stomach
Complera
Rilpivirine/ emtricitabine/ TDF
-take with food
Genvoya
Elvitegravir/ cobicistat/ emtricitabine/ TAF
-take with food
Biktarvy
bictegrvair/ emtricitabine/ TAF
Triumeq
Dolutegravir/ abacavir/ lamivudine
Dovato
dolutegravir/ lamivudine
Odefsey
Rilpivirine/ emtricitabine/ TAF
-take with food
Descovy
Emtricitabine/ TAF
-do not use if CrCl < 30 mL/min