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HIV and Antiretrovirals Flashcards

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1
Q

Goals of HIV Tx

A
  • Maximally and durably suppress Plasma HIV RNA, - Restore and Preserve immunologic function
  • Reduce HIV associated morbidity and prolong the duration and quality of survival
  • Prevent transmission
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2
Q

When to initiate treatment

A

ART is recommended for ALL individuals w/ HIV regardless of CD4-Tlymphocyte count

  • ASAP if HIV(+)

And transmission Prevention

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3
Q

When to initiate tx (Like now)

A 
Prego
AIDS
Acute opportunistic infection
Low CD4 count
HIV-AN
Acute/Early HIV infection
Hep B or C coinfect
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4
Q

What baseline lab data to have

A 
HIV viral load
HIV genotype
CD4 count
CBC w. Diff
CMP
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5
Q

Generic Formula for antiretroviral treatment

A

3 active antiretrovirals

from at least 2 different antiretroviral classes

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6
Q

Nucleotide Reverse Transcriptase Inhibitors (NRTI)

  • MOA
  • Class ADR
A

Cause premature DNA chain termination during reverse transcription

  • Renal Dosing (excp Abacavir)
  • Lactic Acidosis
  • Hepatic Steatosis
  • Peripheral Neuropahy
  • Lipoatrophy
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7
Q

Pregnancy preferred NRTIs

A 
Lamivudine
Emtricitabine
Tenofovir (TDF)
Abacavir
Zidovudine ~ ?
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8
Q

Hep B preferred NRTIs

A

Lamivudine
Emtricitabine
Tenofovir (TFD & TAF)

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9
Q

Lamivudine

  • Class
  • Dosing
  • Bonuses
A

NRTI
150mg BID or 300 QD
Reduced replication capacity benefit of m184V mutation
(active against Hep B; preferred in pregnancy)

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10
Q

Emtricitabine

  • Class
  • Dosing
  • Bonuses
A

NRTI
200mg QD
May cause skin darkening

Reduced replication capacity benefit of m184V mutation
(active against Hep B; preferred in pregnancy)

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11
Q

Tenofovir (TDF) ADRs

A 
Nephrotoxic (avoid in renal insufficiency)
GI effects (gas/nausea)
Dec. Bone mineral density (avoid in osteoporosis)
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12
Q

Tenofovir (TAF) ADRs

A 
Nausea
Diarrhea
HA
(DO not use for PREP)
Strong inducer in rifamycins
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13
Q

Abacavir ADRs

A 
Hypersensitivity Rxn (test for HLA-B*5701 allele) - Never rechallenge
Potential Cardiotoxicity
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14
Q

Zidovudine ADRs

A

Neutropenia
Anemia
GI upset (Take w/ food)

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15
Q

NRTI preferred for M184V mutation

A

Tenofovir (TDF & TAF)

Zidovudine if M184V AND k65r mutations

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16
Q

NRTI w/ Best CNS penetration

A

Abacavir

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17
Q

Epzicom

  • Combo
  • Dosing
A

Lamivudine + Abacavir combo

1 tablet Daily

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18
Q

Truvada

  • Combo
  • Dosing
A

Emtricitabine + Tenofovir (TDF) combo

1 tablet daily

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19
Q

Descovy

  • Combo
  • Dosing
A

Emtricitabine + Tenofovir (TAF) combo

1 tablet daily

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20
Q

Combivir (generic now available)

  • Combo
  • Dosing
A

Lamivudine + Zidovudine

1 tablet BID

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21
Q

ARV-ARV interaction w/ Atazanavir and Tenofovir

A

Must be “boosted” with Ritonavir or Cobicistat (PK boosters)

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22
Q

ARV-ARV interaction w/ Didanosine + Tenofovir

A

Must dose adjust didanosine

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23
Q

ARV-ARV interaction w/ Stavudine + Zidovudine

A

Antagonistic effect; do not use

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24
Q

Tenofovir Intrxn w/ Ledipasvir

A

Do not do

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25
Zidovdine intxn w/ Ribavirin
May decrase efficacy of zidovudine | Anemia
26
Didanosine intxn w/ Ribavirin
Increases didanosine toxicity
27
Zidovidine Intxn w/ Methadone
May increase zidovudine levels (monitor toxicity)
28
Didanosine intxn w/ Allopurinol
Contraindicated | increases didanosine levels and toxicity
29
Integrase Inhibitors - MOA - Class ADR
Inhibits the "strand transfer" phase of HIV DNA integration into the host DNA. HA, Insomnia, CPK elevation, Nausea, Hyperglycemia?, and Intxns w/ divalent/polyvalent cations
30
Raltegravir - Class - ADR
Integrase Inhibitor HA (resolves after 2-4wks) Insomnia, CPK elevation, Hyperglycemia
31
Raltegravir (bonuses) | - Dosing
Lowest risk for infection must increase dose w/ rifampin or other UGT inducers Preferred Integrase Inhibitor in pregos 400mg BID 1200mg QD
32
Dolutegravir - Class - ADR
Integrase Inhibitor Nausesa/bloating, fecal urgency, HA, Insomnia, all generally resolve, mood side effects, hyperglycemia, and increased SCr
33
Dolutegravir (bonuses) | - Dosing
Low/moderate risk for interactions High barrier to resistance and active against some resistant virus - 50mg QD 50mg BID (if suspected integrase inhibitor resistance or with concomitant metabolic inducer)
34
Elvitegravir - Class - ADR
Integrase Inhibitor | GI upset, Insomnia, HA, Increased SCr (generally not if decreased GFR)
35
Elvitegravir (bonuses) | - Dosing
Do not use if CrCl <70 mL/min HIGH-risk for intxns do NOT use in pregnancy - 150mg QD w/ food
36
Protease Inhibitors - MOA - Class ADRs
Inhibits protease cleaving of gag and gag-pol viral proteins GI side effects, Hyperlipidemia, Hypertriglyceridemia, Insulin Resistance, 3A4 inxns (inhibition mostly), and Lipodystrophy
37
Ritonavir - Class - ADR
Protease Inhibitor GI side effects; Hyperlipidemia, Hyper TG, glucose intolerance
38
Ritonavir Bonuses | - Dosing
Avoid humidity > 2wks, solution tastes awful - 100-200mg qd or bid
39
Darunavir - Class - ADR
Protease Inhibitor GI side effects, LFT elevations, more lipid sparing
40
Darunavir bonuses | - dosing
Newest Take w/ food No if SULFA allergy Preferred in Pregos ``` 800mg qd w/ booster OR 150mg QD OR 600mg BID w/ RTV ```
41
Atazanavir - Class - ADR
Protease Inhibitor Hyperbilirubinemia (jaundice), LFT elevations, Considered "Lipid sparing"
42
Atazanavir bonuses | - Dosing
Take w/ Food, ACID suppressant interactions (no PPI or H2RA) Consider dose inc w/ Ritonavir
43
Lopinavir/Ritonavir - CLass - ADR
Protease Inhibitors GI side effects, Hyperlipidemia, Hyper TG, Elevated blood glucose
44
Nelfinavir - Class - ADR - bonus/dose
Protease Inhibitor (alternative tx) Diarrhea, Hyperlipid/TGemia, LFT and Glucose elevations Take w/ snack or meal Only proteasome inhibitor never boosted with RTV
45
Tipranavir - Class - ADR - Bonus/Dose
Protease Inhibitor Hepatotoxicity, GI side effects, Reports of Intracranial hemorrhage Take w/ food, Caution in Sulfa Allergies, keep refrigerated
46
Protease Inhibitor general Drug-Drug interactions
CYP 3a4 high risk interaction (inducers) - No use of Simva or Lovastatin - Careful w/ corticosteroids - Careful w/ Hep C meds ``` Antipyschs (quetiapine) Antifungals (vori) Anti-mycobacterium Benzos Cardiac Glycosides ```
47
Which Protease Inhibitors are CYP 3A4 INDUCERS
Tipranavir + Ritonavir
48
Non-Nucleoside Reverse Transcriptase Inhibitors (Non Nucs) - MOA - Class ADRs
Bind Reverse transciptase at an allosteric site to inhibir enzymatic activity Cross Resistance, Low barrier to resistance Rash, 3A4 induction (except delavirdine)
49
Efavirenz - class - ADR - Bonuses/dose
non-Nuc Rash, CNS effects, Insomnia Avoid high fat content (snack), false pos w/ CBD assays 600mg QD
50
Rilpivirine - Class - ADR - Bonuses/dose
Non-Nuc Less incidence of Rash and CNS effects, may inc SCr, no effect on GFR Avoid if HIV VL >100,000 or CD4 count <200, Avoid if ACID suppressants, Take w. Food
51
Nevirapine - Class - ADR - Bonuses/dose
Non-Nuc Rash (SJS) and Hepatotoxicity Metabolic autoinducer, and Hepatotoxicity risk (if CD4 > 250 in women; >500 in men)
52
Maraviroc - Class/Moa - Requirements - ADR
CCR5 antagonist - Inhibits Chemotaxis Requires Tropism Assay Rash, GI upset, HA, caution in pts w/ history of orthostatic HTN
53
Cobicistat - Class/MOA - ADR - Bonuses
Pk Booster inhibits 3A4 and 2D6 metabolism to allow greater pharmacologic effects from other antiretrovirals Increases SCr
54
Opportunistic Infections - Bacterial - Viral - Fungal - Protozoal - Malignancy
``` Bacterial - MAC Viral - CMV Fungal - PCP Proto - Toxoplasmosis Gondii Malig - NH Lymph, Burkitts Lymph ```
55
When to start primary prophylaxis for PCP/PJP When to stop? When Secondary?
Start: CD4 <200 Stop: CD4 >200 x 3mo 2nd : PJP occurred start at >200
56
When to start primary prophylaxis for Toxo Gondii When to stop? When Secondary?
Start: CD4 <100 Stop: CD4 >200 x 3mo 2nd: CD4 <200
57
When to start primary prophylaxis for MAC When to stop? When Secondary?
Start: CD4 <50 Stop: CD4 >100 2nd: CD4 <100
58
When to start primary prophylaxis for CMV When to stop? When Secondary?
Start: None Stop: N/A 2nd: CD4 < 100
59
Tx for PCP PPx
Bactim/Septra
60
Tx for Toxo Gondii PPx
Bactrim/Septra
61
Tx for MAC PPx
Azithromycin 1200mg q wk Clarithromycin 500mg bid Azithromycin 600mg biw
62
Single tablet complete therapy combos
Elvitagrevir + Emtricitabine + Tenofovir (AF) + Cobicistat Elvitagrevir + Emtricitabine + Tenofovir (DF) + Cobicistat Dolutegravir + Abacavir + Lamuvidine all once daily dosing

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