ID - Fungal, Viral, and Opportunistic Infections Flashcards

Question

List the preferred and alternative regimens: Aspergillus, invasive

Answer 1

-Preferred: Voriconazole -Alternative: AmpB, Isavuconazonium

Answer 2

-Preferred: AmpB + flucytosine -Alternative: high-dose fluconazole + flucytosine

Answer 3

-Prefered: terbinafine or itraconazole (confirm infection first) -Alternative: fluconazole

Answer 4

1. They depend on host cell metabolic processes for survival 2. Many virsuses have NO treatment -Can treat: influenza, COVID-19, cold sores, varicella zoster virus, cytomegalvorius 3. Directly inhibiting viruses (antiviral agents) or augmeting/modifying host defenses to viral infections (immunomodulating agents)

Answer 5

1. A and B 2. Pregnant pts, immunocompromised, childen <5 yo, adults >/= 65 yo, comorbid conditions (ex. CVD, DM, asthma) 3. Diagnostic tests: molecular assays, antigen detection tests -Rapid influenza diagnostic test often done as a nasopharyngeal swab 4. 6 months and older 5. Adamantanes (amantadine, rimantadine)

Answer 6

Brand: Relenza Diskhaler MOA: neuraminidase inhibitor - inhibits enzyme that enables relase of new viral particles from infected cells in influenza ROA: DPI inhaler Administration Considerations: -Active against influenza A and B, reducing duration of symptoms by about one day and reducing complications -Should be STARTED WITHIN 48 hours of illness onset or exposure (if hospitalized, can start >48 hrs) AVEs: HA, throat pain, cough Warnings: neuropsychiatric events, BRONCHOSPASM (do NOT use in asthma/COPD or any breathing issues) -Powder in drug is specifically more irritating -Stop drug if wheezing or breathing problems develop

Answer 7

Brand: Tamiflu MOA: neuraminidase inhibitor - inhibits enzyme that enables relase of new viral particles from infected cells in influenza ROA: PO AVEs: HEADACHE, NAUSEA/VOMITING, diarrhea, abdominal pain Warnings: NEUROPSYCHIATRIC EVENTS (confusion, delirum, hallucinations, unusual behavior or self-injury) especially in young pts, serious skin rxns, anaphylaxis -Discovered during swine flu when antivirals used on massive levels, and pts reported weird behaviors in their children

Answer 8

Administration Considerations: -Active against influenza A and B, reducing duration of symptoms by about one day and reducing complications -Should be STARTED WITHIN 48 hours of illness onset or exposure (if hospitalized, can start >48 hrs) -Preferred in pregnancy over other neuramindase inhibitors -Store reconstitution suspension at room temp x10D or in fridge x17D Treatment dosing, age >12 yo: 75mg BID x5D Prophylaxis dosing, age >12 yo: 75mg QD x10D

Answer 9

Brand: Rapivab MOA: neuaminidase inhibitor (same considerations as oseltamivir) ROA: injection

Answer 10

Brand: Xofluza MOA: endonculease inhibitor, halting influenza replication TX: treatment and post-exposure prophylaxis of influenza ROA: PO as a single dose-regimen Administration considerations: -Start within 48 hours of symptom onset or exposure -Store in original blister packaging -Suspension: once reconstituted, administer wtihin 10 days storing at room temp; dose may require more than one bottle AVEs: diarrhea Warnings: hypersensitivity (including skin rxns: erythema multiforme, uticaria), monitor for secondary bacterial infections DDIs: diary products, antacids, or toher supplkements containing polyvalent cations --> avoid

Answer 11

Diagnosis: polymerase chain reaction (PCR) using a nasopharyngeal swab specimen and/or rapid antigen test Testing positive: -Isolate for at least 5 days after and continue to wear mask for 11 days -Consult the CDC, NIH, and IDSA for most current recommendations -Symptomatic care: hydration, analgesics/antipyretics, antitussives -Prefered outpatient TX: nirmatrelvir/ritonavir (Paxlovid) --> BBW for DDIs from ritonavir (alternative: IV remdesivir, PO molnpiravir) -Hospital TX: can include systemic steroids, antivirals (particularly remdesivir), and/or immunomodulator TX (baricitinib, tocilizumab)

Answer 12

1. HSV1; HSV2 2. Highly contagious - avoid kissing and sharing drinks when lesions ar oozing 3. Stress/fatigue, stress to skin (acid peels, sun exposure), dental work 4. Cold sore eruption is preceded by peridrome (symptoms that occur before lesions appear) of tingling, itching, or soreness which is the optimal time to use medication Topical TX: -Docosanol (Abreva): OTC --> apply 5x daily at first sign of outbreak, continue until healed -Acyclovir (Zovirax): Rx --> apply 5x daily x4D (can also be used on genital sores) -Others: acyclovir buccal tablet, penciclovir cream Systemic TX: acyclovir, valacyclovir, famciclovir

Answer 13

1. HSV2 2. Chronic life-long condition that may start as asymptomatic or with flu-like symptoms before development of pustular or ulcerative leasions on genitalia ---> lesions usually begin as papules or vesicles that spread rapidly associated w/ itching, dysuria, and vaginal/urethral discharge 3. Must initiate during prodrome period or within one day of lesion onset 4. -Acyclovir: inexpensive, but dosed up to TID -Valacyclovir: prodrug of acyclovir that reaches higher concentrations and less frequent dosing -If R to acyclovir, will be R to valacylovir, likely R to famciclovir ---> treat w/ foscarnet 5. Pts w/ frequent recurrences (>6/year)

Answer 14

Viral encephalitis: IV acyclovir 10mg/kg/dose Q8H x14-21D Esophagitis, pneumonitis: IV acyclovir 5mg/kg/dose Q8H **Calculate dose by IBW

Answer 15

Drugs: acyclovir (Zovirax), valacyclovir (Valtrex), famciclovir ROA: PO, topical (acyclovir), IV (acyclovir) Administration considrations: -Acyclovir dosing based on IBW including IN OBESE PTS -Dose decrease or extended interval in renal impairment -Valacylovir is prodrug of acyclovir (acyclovir NOT as absorbed as well PO) -Famciclovir is prodrug of penciclovir -NOT an actual TX of herpes infections (cold sores, chickenpox, shingles, or genital herpes) --> practice safe sex -Start TX within 24 hours of onset of symptoms

Answer 16

AVEs; malaise, HA, N/V/D, rash, pruriuts, increased LFTs, neutropenia, transient burning/stinging w/ topical formulations, anaphylaxis (famciclovir), increased BUN/SCr w/ crystal neuropathy (IV acyclovir) Warnings: -Caution in RENAL IMPAIRMENT, elderly, or those receive nephrotoxic drugs (infuse acyaclovir over at least one hour and maintain hydration to reduce renal tubular damage -Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (TTP/HUS) has been reported in immuncompromised pts Resistance: -If R to acyclovir, R to valacyclovir or vice versa -If R to acyclovir or valacyclovir, likely R to famciclovir

Answer 17

1. Chickenpox; Herpes Zoster (shingles) 2. Prevention: shingles vaccine for Herpes Zoster in adults 50 yo or older and adults 19 yo or older who are immunosuppressed -Pts previously vaccinated w/ Zostavasx should be re-vaccinated w/ Shingrix -Pts w/ previous episode of shingles should be vaccined to decrease likelihood of recurrence/severity -Helps to prevent POSTHERPETIC NEURAGLIA (PNA) TX: initate at earliest sign of shingles (antiviral therapy most effective within 72 hours of rash development - the sooner, the better) -Pain: topical medications such as Lidoderm patch/gel, neuropathic pain medication (gabapentin, pregabalin, duloxetine, TCAs), NSAIDs, or opioids -Antiviral therapy: acyclovir x7D, valacylovir x7D, or famciclovir x7D

Answer 18

1. HHV-5 2. Immunocompromised pts at most risk with most common complications of retinitis, colitis, or esophagitis 3. -DOC: ganciclovir or valgnaciclovir -Refractory: foscarnet, cidofovir -Post-transplant CMV disease refractory to all other TX: maribavir 4. "Maintenance Therapy" -CMV prophylaxis in kidney transplant if donor is CMV-(+) and recepient is (-): letermovir -Solid organ trasplant at high risk (donor positive, recipient negative): ganciclovir, valganciclovir

Answer 19

Drugs: ganciclovir (Zirgan = opthalamic gel), valganciclovir (Valcyte) ROA: -Ganciclovir: injection, opthalamic gel -Valganciclovir: PO Adminisration considerations: -Valganciclovir is prodrug of ganciclovir w/ better F -Ganciclovir injection: reconstitute w/ sterile water NOT bacteriostatic water -Valganciclovir solution: refrigerate when reconstituted, discard after 49 days -Hazardous agent: special handling required -Females should use contraception during TX and for 30D after (males: 90D after) AVEs: fever, N/V/D, anorexia, increased SCr, seizures (rare), retinal detachment (in CMV retinitis) BBW: MYLEOSUPPRESSION, carcinogenic, fetal toxicity, impaired fertility Monitoring: CBC w/ differential, SCr, retinal exam

Answer 20

ROA: injection Administration considerations: -Pt should receive hydration before each dose and probenaecid before andf ater each dose to decrease nephrotoxicity -Hazardous agent: special handling required TX: CMV retinitis in HIV pts only AVEs: myleosupression (less than ganciclovir), metabolic acidosis CI: -SCr > 1.5mg/dL, CrCl /=100 mg/dL (>/=2+ proteinuria) -Sulfa allergy -Use w/ or within &D of other nephrotoxic drugs -Direct intraocular injection BBW: nephrotoxicity, neutropenia, carcinogenic, teratogenic

Answer 21

Brand: Foscavir ROA: injection Administration considerations: do NOT exceed max infusion rate (increases toxicity) AVEs: electrolyte abnormalities (low: K, Ca, Mg, Phos), increased BUN/SCr, Qt prolongation BBW: RENAL IMPAIRMENT (prehydration recommended); seizures due to electrolylte imbalances (has led to status epilepticus or death)

Answer 22

Brand: Prevymis ROA: injection, PO Administration considerations: IV vehicle (hydroxypropyl betadex) can accumuate if CrCl <50mL/min AVEs: atrial fibrilaltion, tachycardia, peripheral edema, thromboyctopenia, N/V/D, fatigue, HA, cough CI: concomitant use w/ pimozide, ergot alkaloids OR pitavastain and simvastatin if taking cyclosporine

Answer 23

1. Mononucleosis --> "Mono" 2. Bodily fluids, primarily saliva (kissing, sharing food/drinks/objects in contact w/ mouth) 3. fatigue, fever, sore throat, swollen lymph nodes that usually resolve within 2-4 weeks 4. NO TX exists -Amoxicilin or ampicillin TX in child w/ EBV can cause non-pruritic rash that appears similar to allergic rxn (should NOT be included as an allergy)

Answer 24

1. Disease that destroy components of immune response, primarily HIV with CD4 T lymphocyte count <200 cells/mm3 (definining criteria for AIDs) 2. Use of systemic steroids for 14 days or longer at a prednisone equivalent of >/= 20mg/day or >/=2mg/kg/day 3. Asplenia (lack of functioning spleen) due to sickle cell disease or splenectomy 4. Use of immunosuppressants for autoimmune conditions or post-transplant 5. Use of cancer chemotherapy that destroy WBCs, particularly if severe neutropenia (ANC <500 cells/mm3)

Answer 25

Criteria to start: CD4 count <200 cells/mm3 or AIDS-defining illness or oropharyngeal candidiasis Preferred regimen: Bactrim DS QD (or SS) Alternatives: -Bactrim DS 3x weekly -Sulfa allergy: dapsone OR atovaquone -Dapsolone alone OR with pyrimethamine + leucovorin (rescue therapy for pyrimethamine-induced myleosuppression) -Atovoquone alone OR with pyrimethamine + leucovorin -G6PD deficiency: inhaled pentamidine Criteria to D/C: CD4 count >200 for >3 months and remains on anti-retroviral therapy (ART)

Answer 26

Criteria to start prophylaxis: toxoplasma IgG (+) AND CD4 count <100 cells/mm3 Primary regimen: Bactrim DS QD Alternatives: -Bactrim 3x weekly or SS QD -Sulfa allergy: atovaquone OR atovaquone + pyrimethamine + leucovorin OR daspone + pyrimethamine + leucovorin Criteria to D/C: CD4 count >200 cells/mm3 for >3 months and remains on anti-retroviral thearpy (ART)

Answer 27

Criteria to start prophylaxis: if NOT taking ART, CD4 count <50 cells/mm3, and NO active MAC infection -NOT recommneded if ART started immediately -RULE OUT dissemintated MAC disease: needs several drugs for TX Primary regimen: azithromycin 1200mg weekly or 600mg twice weekly Alternatives: clarithromycin 500mg BID Criteria to D/C: taking fully suppressive ART

Answer 28

Prefered regimen: fluconazole -In HIV: prefered to have systemic disease even in mild Alternative regimen: -Oropharyngeal: itraconazole, posaconazole, topicals (clotrimazole troche, nystatin) -Esophageal: voriconazole, isavuconazonium, echinocandin Secondary prophylaxis: NOT usually recommended

Answer 29

Preferred regimen: amphotericin B (liposomal preferred) + flucytosine Alternative: -High dose fluconazole + flucytosine -High dose fluconazole + amphotericin B Secondary prophylaxis: low dose fluconazole

Answer 30

Preferred regimen: valganciclovir PO or ganciclovir IV Alternative regimen: if toxicities to ganciclovir or resistant strains, foscarnet or cidofovir Secondary prophylaxis: none -For HIV: continue ART and maintain CD4 count >100 cells/mm3

Answer 31

Preferred regimen: clarithyomycin or azithromycin AND ethambutol Alternative regimen: add 3rd or 4th agent (rifabutin, amikacin, streptomycin, moxifloxacin, or levofloxacin) Secondary prophylaxis: same as primary prophylaxis

Answer 32

Preferred regimen: Bactrim (high dose - see ID) +/- prednisone OR methylprednisolone for 21 days Alternative regimen: pentamidine IV OR clindamycin + primaquine Secondary prophylaxis: same as primary prophylaxis

Answer 33

Preferred regimen: pyrimethamine + leucovorin + sulfadiazine -Leucovorin helping prevent myleosuppression with pyrimethamine Alternative regimen: -Bactrim -Clindamycin + pyrimethamine + leucovorin Secondary prophylaxis: same as TX, but reduced doses

Answer 34

1. CD4 T-helper cells 2. Increase 3. CD4 <200 cells/mm3 4. Bodily fluids (blood, semen, vaginal/rectal secretions, or breast milk), mucus membranes, or open wounds -Most commonly from unprotected vaginal or rectal sex or sharing injection drug equipment 5. When a mother passes HIV to her child

Answer 35

1. Binding and attachment: HIV attaches to CD4 cell and a co-receptor (CCR5 and/or CXCR4) -CCR5 antagonist: maraviroc -Attachment inhibitor: fostemasvir -Post-attachment inhibitor: ibalizumab-uiky 2. Fusion: HIV viral envelop fuses w/ cell membrane and can enter cell to release inner capsid containing HIV RNA and viral enzymes -Fusion inhibitor: enfuviritide 3. Reverse Transcription: HIV RNA converted to DNA -NRTIs and NNRTIs 4. Nuclear Import: HIV capsid transported into cell nucleus -Capsid inhibitor: lenacapavir 5. Integration: Integrase inserts HIV DNA into host DNA -INSTIs 6. Transcription and Translation: host cell machinery used to transcribe and translate HIV DNA into RNA nad proteins -NO drug targets 7. Assembly: new HIV RNA, proteins, and enzymes (including protease) assesmble at cell surface -Capsid inhibitor: lenacapavir 8. Budding and Maturation: immature virus pinches off cell and protease breaks up the long viral protein chains to infect other cells -PIs, capsid inhibitor: lenacapavir

Answer 36

Initial Screen: HIV-1 and HIV-2 antibodies and p24 antigens -p24 antigen: structural protein that makes up most of the viral capsid If intial screen positive: confirm with second HIV-1 and HIV-2 antibody differentiation immunoassay (can determine if its HIV-1 or HIV-2) -If nonreactive or indeterminate: HIV-1 nucleic acid test (quantifies viral load) -If reactive: HIV positive OTC: OraQuick (swab from upper and lower gums) ---> if positive, confirm w/ laboratory test -Testing sooner than 3 months after exposure can lead to false negative from antibody development lag

Answer 37

Everyone: once per lifetime in those 13-64 yo unless at high risk Annual Screening: 1. Hx of STIs, hepatitis, or TB 2. Sexual hx: partner w/ HIV, multiple partners, partner w/ unknown sexual hx, men who have sex with men especially between 13-24 yo 3. Sharing drug injection equipment Highest risk of transmission: anal transmision > needle sharing > vaginal transmission

Answer 38

S/Sx: non-specific flu-like symptomas (ex. fever, myalgia, swollen lymph nodes, rash) which last a few days to weeks Progression to AIDs: -CD4 Count <200 cells/mm3 -AIDS-defining condition (OIs, malignancy - Kaposi's sarcoma, and HIV wasting syndrome) HIV wasting syndrome: unwanted weight loss of more than 10% of person's body weight -TX to stimulate appetite: dronabinol (Marinol, Syndros), megestrol (progestin)

Answer 39

Initial evaluation: -CD4 count: major indicator of immune function and determines if pts need OI prophylaxis -HIV viral load: indicator of response to ART (antiretroviral therapy) -Resistance testing to ART -Others: CMP, CBC, urinalysis, HepB/C, pregnancy test, HLA-B*5701 (if abacavir added), tropism assay (if maraviroc added) Goals: -U=U (Undetectable = Untransmittable): <200 copies/mL of HIV --> 100% untransmittable for sexual transmission -Infection prevention: raise CD4 count, vaccines, prophylaxis for opportunistic infections (OIs) if needed Considerations when starting: immune reconstitution inflammatory syndrome typically when medications are started and higher risk in low CD4 counts <100 -Body's immune system begins to recover, but inflammation ramps up -Continue TX with supportive care

Answer 40

Preferred regimen of 2 NRTIs + 1 INSTI (Dovato is exception); most have an INSTI with high barrier to resistance; fixed dosing (avoid in CrCl <30mL/min) -One pill, QD regimens: Biktarvy (bictegravir / emtricitabine / TAF), Triumeq (dolutegravir / abacavir / lamivudine), and Dovato (dolutegravir / lamivudine) -Two pills, QD regimens: Tivicay (dolutegravir) + Truvada (emtricitabine / TDF) OR Tivicay + Descovy (emtricitabine / TAF)

Answer 41

2 NRTIs + 1 "base" (PI, NNRTI, or INSTI) -NRTI backbone: TDF or TAF or abacavir + emtricitabine or lamvudine* -PI based: darunavir or atazanavir boosted w/ cobicistat or ritonavir -NNRTI based: efavirenz, rilpivirine, doravirine -INSTI based: elvitegravir (only in combos), raltegravir *Emtricitabine and lamivudine should NOT ber used together since both are cytosine analogs that will have no additional benefit (potentially antagonistic effects since similar structure and would complete with each other) *Alternative regimens: more DDIs/AVEs, lower resistance barrier (except PIs), less virologic efficacy

Answer 42

May continue regimen in most cases -New starts: 3 components (dolutegravir or booster darunavir + dual NRTI backbone) -Perinatal transmission prophylaxis: maternal administration of IV zidovudine prior to delivery or neonatal administration of ART

Answer 43

1. Engaged in high-risk activities (multiple sexual partners, men who have sex with men, IV drug use) 2. Prior to therapy: -Confirm HIV-negative since regimen is NOT appropriate for TX and resistance can develop -Ask about recent symptoms: helps consider lag time in detectable antibody -Screen for: hepatitis B and STIs 3. Options: -PO options: Truvada (if CrCl 60mL/min or greater) or Descovy (if CrCL 30mL/min or greater) -IM: cabotegravir: administered by healthcare provider for 2 doses then Q2 months 4. Follow Ups: -Truvada, Descovy: Q3 months -Cabotegravir: 1 month after 1st injection then Q2 months -Continue to test for HIV and confirm (-) result

Answer 44

1. Indicated when: -Emergency exposure from bodily fluids w/ known or suspected HIV -Able to start treatment within 72 hours of exposure 2. Types: -Nonoccupational (nPEP): for use after sex w/o condom, injection drug use, etc. -Occupational (oPEP): healthcare personel exposure typically from needlesticks 3. Options: take within 72 hours and for 28 days -Truvada: if CrCl 60mL/min or greater PLUS -Dolutegravir or raltegravir 4. Follow up: should receive baseline HIV antibody test then follow up at 4-6 weeks, 3 months, and 6 months post exposure

Answer 45

Drugs: abacavir (Ziagen), emtricitabine (Emtriva), lamivudine (Epivir), zidovudine (Retrovir), tenofovir disoproxil fumarate (TDF: Viread), tenofovovir alafenamide (TAF - only in combo products) MOA: inhibits conversion of HIV RNA to HIV DNA Administration Considerations: -Vemlidy (TAF): single entity product for HepB, ONLY in combo w/ HIV -Renal dose adjustements except in abacavir -CrCl <50mL/min: do NOT start TDF -CrCl <30mL/min: do NOT start TAF -Zidovudine: administered IV during labor and delivery to prevent perinatal HIV transmission -Lamivudine: has two different strengths, make sure to use higher strength in HIV Resistance Considerations: LOW barrier to resistance

Answer 46

AVEs: most common are diarrhea and nausea Warnings: lactic acidosis, hepatomegaly with steatosis BBW -Severe HepB exacerbation if D/C of emtricitabine, lamivudine, or tenofovir-containing products -Epivir-HBV: low dose of lamivudine that needed for TX of HIV -Lamivudine: fatty liver Unique Considerations: -Abacavir: risk of hypersensitivity risk ESPECIALLY if HLA-B*5701 (REQUIRED to test prior) --> never rechallenge -Emtricitabine: hyperpigmentation of palms of hands or soles of feet -Zidovudine: hepatomegaly w/ steatosis; hematologic toxicity (anemia, neutropenia) --> will occur that high MCV is an indication of adherence -TDF renal impairment and Fanconi syndrome (renal tubular injery, electrolyte abnormalities, and decreased BMD > TAF -TAF: lipid abnormalities

Answer 47

Drugs: contain "vir" -- efavirenz, rilpivirine (Edurant), doravirine (Pifeltro), etravirine (Intelence), nevirapine MOA: prevents conversion of HIV RNA to HIV DNA Administration Considerations: -Rilpivirine PO: take with meals and water, do NOT initiate if viral load >100,000 copies/mL and.or CD4 count <200 cells/mm3 (higher failure rate) -Efavirenz: food increases F and risk for CNS effects --> take OES to avoid and QHS to sleep through side effects Resistance Consideration: lower barrier to resistance than INSTIs or PIs

Answer 48

AVEs: hepatotoxicity, rash including severe reactions DDIs: -ALL: major CYP3A4 substrates -Rilpivirine, doravirine: do NOT use w/ strong CYP3A4 inducers (treatment failure) -Efavirenz, etravirine: moderate inducers of CYP3A4 -Rilpivirine: avoid PPIs, take H2RAs at least 12 hours before or 4 hours after, take antacids at least 2 hours before or 4 hours after Unique Considerations: -Efavirenz: increased cholestrol/TG, psychiatric sympoms (depression/SI), CNS effects (impaired concentration, abnormal dreams, confusion), that usually lasts generally resolves in 2-4 weeks -Rilpivirine: depression, increased SCr (no effect on eGFR) -Nevirapine: highest risk of severe rash

Answer 49

Drugs: -"gravir"; bictegravir, elvitegravir, cabotegravir (Vocabria, Apretude), dolutegravir (Tivicay), raltegravir (Isentress, Isentress HD) MOA: prevents HIV DNA from inserting into host cell DNA Administration considerations: -Once daily: Biktarvy, Stribild, Genvoya, Tivicay, Triumeq, Dovato, Isentress -BID: Isentress -Apretude (cabotegravir XR IM injection): only for PrEP -Vocabria (cabotegravir PO): indicated for optional lead-in TX to assess tolerability of Cabenuva injection (cabotegravir/rilpivirine) or bridge therapy in pts that have missed >7D -CrCl <70mL/min: do NOT start Stribild -CrCl <50mL/min: D/C Stribild -CrCl <30mL/min: do NOT start Biktarvy or Genvoya Resistance Considerations: bictegravir and dolutegravir have higher barrier to resistance than NRTIs, NNRTIs, and other INSTIs

Answer 50

AVEs: weight gain, insomnia Warnings: rare risk of depresion/SI in pre-existing psychiatric conditions DDIs: PO agents - always need to seperate from polyvalent cations --> look at package insert to determine exact timing (2 hours before or 6 hours after) Unique considerations: -Bictegravir, dolutegravir: increased SCr via inhibitor of tubular section (no imapact on eGFR) -Raltegravir, dolutegravir: increased CPK, myopathy, rhabdomyloysis, hypersensivity rxn -Dolutegravir: hepatotoxicity especially in coinfection of HCV/HBV -Cabotgravir: injection site rxns -Elvitegravir: coformulated w/ cobicistat (strong CYP3A4 inhibitor)

Answer 51

Drugs: -"navir"; atazanavir (Reyataz), darunavir (Prezista), fosamprenavir, tipranavir (Aptivus), lopinavir/ritonavir (Keletra) MOA: prevents long viral protein chains from being broken down into smaller chains for budding and maturation Administration Considerations: -Recommended w/ booster (ritonavir or cobicostat) --> ritonavir is a PI, but only used at low doses for PK boosting -No renal dose adjustments -Darunavir, atazanavir: CF to minimize GI AVEs -Atazanavir: needs acidic gut for absorption Resistance Considerations: HIGH barrier to resistance

Answer 52

AVEs: D/N common -Metabolic abnormalities: increased BP, LDL, TG, body fat, lipodystrophy -Hepatic dysfunction: increased LFTs, hepatitis, and/or exacerbation of hepatic disease -Hypersensitivity rxns: rash, angioedema, bronchospasm, anaphylaxis Warnings: sulfa allergy (caution in darunavir, fosamprenavir, tipranavir) DDIs: -ALL: major CYP3A4 substrates and most strong CYP inhibitors -Atazanavir: avoid PPis w/ unboosted; take boosted atazanavir at least 12 hours after PPI (do NOT exceed omeprazole 20mg or equivalent) Unique Considerations: -Lopinavir/ritonavir (Kaletra): PO solution contains 42% alcohol and can cause disulfiram rxns if taken w/ metronidazole -Atazanavir: hyperbilirubinemia, but does NOT require D/C and reversible (doesn't actually indicate liver harm)

Answer 53

1. Biktarvy = bictegravir / emtricitabine / TAF 2. Delstrigo = doravirine / lamivudine / TDF 3. Symtuza = darunavir / cobicistat / emtricitabine / TAF 4. Epzicom = abacavir / lamivudine -Criteria: test for HLA-B*5701

Answer 54

1. Cimduo = lamivudine / TDF 2. Symfi = efavirenz / lamivudine / TDF 3. Dovato = dolutegravir / lamivudine 4. Triumeq = dolutegrabvir / abacavir / lamivudine -Criteria: test for HLA-B*5701

Answer 55

1. Cabenuva = cabotegravir / rilpivirine -Criteria: meant to replace regimen w/ undetected viral load 2. Complera = rilpivirine / emtricitaibine / TDF 3. Odefsey = rilpivirine / emtricitabine / TAF 4. Combivir = lamivudine / zidovudine

Answer 56

1. Truvada = emtricitabine / TDF 2. Juluca = dolutegravir / rilpivirine -Criteria: meant to replace regimen w/ undetected viral load 3. Stribild = elvitegravir / cobicistat / emtricitabine / TDF 4. Genvoya = elvitegravir / cobicistat / emtricitabine / TAF 5. Descovy = emtricitabine / TAF

Answer 57

Brand: Selzentry MOA: blocks HIV from binding and subsquently entering the CD4 cell in virus strains that use the CCR5 co-receptor ROA: PO Safety Concerns: -BBW: Hepatotoxicity -Hypersenstivity rxn (including SJS/TEN) -Orthostatic hypotension int pts w/ renal impairment -do NOT use in severe impairemnt <30mL/min and taking potent CYP3A4 inhibitors/inducers When to use: MUST have toposim assay done before; CANNOT use in strains with CXCR4 or mixed co-receptors

Answer 58

Brand: Rukobia MOA: converted to tamsavir (active form) that binds to gp120 subunit of HIV envelop proteins, inhibiting interaction between virus and CD4 host cell ROA: PO Safety Issues: -do NOT use w/ strong CYP3A4 inducers -Must maintain effective HBV TX in pts coinfected with HBV -Can increase SCr (higher risk if underlying renal disease) When to use: in combo with other ART in heavily-TX experience pts failing current therapy

Answer 59

Brand: Trogarzo MOA: MAB that binds to a select domain of CD4 cell receptors, blocking entry of virus into cell ROA: IV administered by healthcare professional Safety Concerns: -Infusion-related rxns: observe for 1 hour after first infusion -Diarrhea, nausea, dizziness, rash When to Use: in combo w/ other ART in heavily-TX experienced pts who are failing current therapy

Answer 60

Brand: Fuzeon MOA: prevents HIV from fusing to CD4 cell membrane, preventing virus entry into cell ROA: SQ Safety concerns: -Risk of bacterial pneumonitis, hypersensitivity rxns -Local injection site rxns (occurs in nearly ALL pts): pain, erythema, nodules, cysts, ecchymosis, N/D, fatigue When to use: reserved as salvage therapy with extensive HIV resistance

Answer 61

Brand: Sunlenca MOA: inhibits multiple stages of HIV including capsid transport into nucleus, virus assembly, and capsid formation resulting in malformed capsid ROA: PO, SQ Safety concerns: -CI with strong CYP3A4 inducers -Local injection site rxns: erythema, induration, nodule, pain, swelling When to use: in combo with other ARTs in heavily TX-expierneced pts who are failing current therapy

Answer 62

1. Viral load <500,000 copies/mL 2. NO HBV coinfection 3. NO resistance to either component

Answer 63

Drugs: cobicistat (Tybost), ritonavir (Norvir) Administration: -Administer at same time as requiring boosting -NOT interchangeable, do NOT use together -Ritonavir: 100-200mg PO QD or BID CF -Cobicistat: 150mg PO QD CF

Answer 64

-Alpha-1a blockers (ex. alfuzosin, silodosin, tamsulosin) -Amiodarone, dronedarone -Anticoagulants/antiplatelets -Azole antifungals -PIs for hepatitis C (ex. grazoprevir, glecaprevir) -Lovastatin and simvastatin -PDE5is for pulmonary HTN (ex. sildenafil, tadalafil) -Strong CYP3A4 inducers -Systemic, inhaled, and intranasal steroids (except beclomethasone)

Answer 65

1. CF - due to cobicistat 2. CF - due to cobicistat 3. OES - due to efavirenz (reduce CNS AVEs)

Answer 66

ALL: CF due to cobicistat

ID - Fungal, Viral, and Opportunistic Infections Flashcards

(90 cards)