HIV: Boards Flashcards
(30 cards)
PIs effect on other drugs (1)
Voriconazole: reduces
Fanconi’s syndrome: E, C, T
E: TDF
C: weakness, type II RTA, hypophosphatemia, glucosuria, hypokalemia, non-anion gap metabolic acidosis (may not have all present)
T: stop TDF
HIV-AN: E, C, D, T
E: more in blacks, moreif CD4<200
C: high-grade proteinuria, normal or large kidneys, no edema, rapid progression
D: biopsy, r/o other causes
T: ARVs
Vaccines (11)
- -Influenza: inactivated vaccine annually
- -Td/Tdap: every 10 years and once in adulthood with Tdap
- -Varicella: if CD4 >200 (otherwise contraindicated); give 2 doses
- -Zoster: maybe give if CD4 >200 (otherwise contraindicated) and age > 60
- -HPV: up until age 26; give 3 doses
- -MMR: if CD4 >200; give 1-2 doses
- -PPSV-23: one dose and one booster at 5yrs (if <65)
- -PCV-13: one dose
- -Meningococcal: if risk factors; 1 or more doses
- -Hepatitis A: if risk factors; 2 doses
- -Hepatitis B: 3 doses
Causes of polyneuropathy (5)
- -HIV-associated: subacute or chronic presentation
- -Guillain-Barré syndrome: develops over 1-2wks
- -ARVs: ddI, d4T, ddc
- -Abx: dapsone, ethionamide, INH, metronidazole, linezolid
- -Others: phenytoin, thalidomide
Primary OI PPx: Start, Stop, Use
PCP
- -start: CD4 <250 AND new positive IgG or IgM (screen yearly)
- -stop: ???
- -use: fluconazole 400mg daily
PCP: D, T
D: B-D-glucan sensitive (92%) but not specific (65%); induced sputum uncertain if sensitive (55-95%) but specific (99%)
T: 1) TMP-SMX, 2) clindamycin + primaquine, 3) dapsone + trimethoprim, 4) atovaquone, 5) parenteral pentamidine
Toxo: T
1) sulfadiazine + pyrimethamine + leucovorin
2) clindamycin + pyrimethamine + leucovorin (need PCP ppx)
3) TMP-SMX
4) atovaquone +/- (pyrimethamine + leucovorin)
Cryptococcus: T (2)
Meningitis: ampho B + flucytosine x2wks (consider LP then and consider extending if cx positive) → fluconazole 400mg x8wks → fluconazole 200mg x >52wks; also daily LP if CSF OP >20-25 (goal is 50% reduction or bring to 100 x3mo and VL undetectable
CMV: D, T
D: CMV PCR in blood and BAL has poor positive and negative predictive value (but pretty reliable with CSF and vitreous fluid); inclusion bodies on organ bx also non-specific
T: valganciclovir +/- intravitreal ganciclovir
HIV and diarrhea: D, T
D: modified acid fast stain (Cryptosporidum, Isospora, Cyclospora); trichrome or Giemsa or PAS (Microsporidia), Giardia stool antigen, C. diff toxin PCR, O&P (Entamoeba, Cyclospora, Cryptosporidium, Giardia), c-scope (CMV, MAC), Rotavirus ELISA, stool cx, AFB (MAC)
T: Salmonella → if recurs suppress for 6mo; Isospora → TMP-SMX, ciprofloxacin, or pyrimethamine; Cyclospora → TMP-SMX, ciprofloxacin; Cryptosporidium → ART (maybe paromomycin or nitazoxanide but not good data); Microsporidium → ART, albendazole
HIV and encephalopathies: C
–HIV encephalopathy: CD4 <50; acute; no sensory deficit; symmetrical; imaging → periventricular enhancement and micronodularity characteristic
Secondary OI PPx: Use, Stop
PCP --use: TMP-SMX daily --stop: CD4 >200 x3mo Toxo --use: usual treatment regimen at lower dose --stop: CD4 >200 x6mo MAC --use: treatment regimen --stop: CD4 >100 x6mo CMV --use: valganciclovir --stop: CD4 >100 x3-6mo Crypto --use: fluconazole (then itra) --stop: CD4 >100 AND HIV VL undetectable for > 3mo AND minimum of 12mo therapy Histo --use: itraconazole 200mg daily --stop: Negative blood cx AND serum Ag = 150 AND ART x > 6mo Cocci --use: fluconazole 400mg daily --stop: indefinitely if disease was severe
Side effects: dapsone, pentamidine, primaquine, pyrimethamine, sulfadiazine, TMP-SMX
- -dapsone: hemolytic anemia from G6PD deficiency (screen high risk – African and Mediterranean descent), methemoglobinemia, hepatitis, rash; 50% with TMP-SMX rash are cross reactive to dapsone
- -pentamidine: ARF, hypotension, electrolyte abnormalities, pancreatitis, prolonged QTc
- -primaquine: methemoglobinemia
- -pyrimethamine: similar to TMP-SMX
- -sulfadiazine: GI upset, rash, bone marrow suppression, renal stones, hepatitis
- -TMP-SMX: leukopenia, thrombocytopenia, rash, fever, increased Cr, K, amylase, LFTs
When to start ARVs in HIV+ patient with TB
CD4 < 50: within 2wks
CD4 > 50 and severe clinical disease (weight loss, low Karnofsky score, low BMI, etc): 2-4wks
CD4>50 and no severe clinical disease: 8-12wks
ARV considerations with rifampin and rifabutin
Rifampin: no PIs, increase EFV to 800mg if >60kg, dose RTG at 800mg q12
Rifabutin: decrease rifabutin with ATV, NFV, increase wtih EFV (no change NVP, ETV, RTG)
HIV Dx algorithm with 4th generation ELISA
–Ag+/Ab-: likely acute infection, check HIV VL
–Ag+/Ab+: likely acute infection, check HIV VL
–Ag-/Ab+: likely chronic infection, check Western blot (see below)
–Ag-/Ab-: negative
If checking Western Blot…
–Positive: HIV
–Indeterminate: do HIV VL; if positive HIV, if negative check HIV-2 Western blot
–Negative: check HIV-2 Western blot
ARVs and PPIs
Can’t take PPIs and ATV/r or RPV
Can take H2 blocker with the above meds but must be at leats 12hrs before or 4hrs after dose of ARV
When to avoid starting NVP
In men if CD4 >400
In women if CD4 >250
Reommended ARVs for pregnancy
Most experience with AZT, 3TC, NVP, LPV/r
TAMs
TAM1: M41L, L201W, T215Y, all NRTIs (especially if all three present)
TAM2: D67N, K70R, K219Q/E, all NRTIs
K65R
TDF, ABC (increased AZT susceptibility)
T69ins
all NRTIs
L74V
ABC (increased AZT susceptibility)
