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DipHIV > Interactions/Pregnancy/Neonatal > Flashcards

Interactions/Pregnancy/Neonatal Flashcards

1
Q

Breastfeeding advice

A
  • Only if 36 week VL<50, on ART>10 weeks and at least 2 undetectable VL at least 4 weeks apart
  • for 6 month only
  • Not with mixed feeding, definitely no solids, if have to use small amount of formula occasionally, new BHIVA statement says this is ok (when establishing BF, when switching off BF, gastro in either and mastitis)
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2
Q

Risk of HIV transmission with breastfeeding in setting of well controlled HIV

A
  • Breastfeeding to 6 months: 3/1000 risk
  • Breastfeeding to 12 months: 6/1000 risk
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3
Q

TAF with PI dose adjustment

A

PIs and cob inhibit P-gp transporter that usually pumps TAF back into gut lumen, thus TAF levels will be higher
So reduced TAF dose to 10mg with PI/cobi

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4
Q

Statins

A
  • Simvastatin/lovastatin contraindicated with PIs
  • Caution with atorvastatin, start low, don’t exceed 20mg, fluvastatin might be better.
  • Generally all statins are fine with INSTIs/NRTIs
  • NNRTI (EFV/NVP) may interact so either dose monitoring or choose rosuvastatin
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5
Q

Assessment of post natal mental health and sexual health screening in pregnancy

A

Assess maternal mental health at 4-6 weeks and 3-4 months post partum.
Sexual health screening is recommended if newly diagnosed with HIV in pregnancy, otherwise it is suggested

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6
Q

When should you wait for resistance testing when initiating ART in pregnancy?

A

Before 28 weeks, after 28 weeks start anyway
(if pt stops ART post delivery, get another one to try and capture mutations)

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7
Q

When to check CD4 in pregnancy?

A
  • If conceiving on ART, one at baseline and one at delivery
  • If start ART in pregnancy, as per usual guidelines plus another at delivery (even if starting one was >350)
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8
Q

When to check VL in pregnancy?

A
  • If starting ART in pregnancy then 2-4 weeks after starting, at least every trimester, at 36 weeks and at delivery (and do LFTs each time)
  • If already on ART??
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9
Q

A pregnant woman has not suppressed viral load, what to do?

A
  • Asses adherence
  • Resistance test
  • Review other meds
  • Consider TDM
  • Optimise regimen
  • Consider intesnsification
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10
Q

What ART in pregnancy should be switched?

A
  • PI monotherapy
  • Darunavir/cobi, Elvitegravir/cobi
  • Raltegravir 1200mg OD should be switched to 400mg BD
  • Women on dolutegravir TTC or in first trimester should be advised to take folic acid 5mg (rest can take usually 400mcg)
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11
Q

All pregnancy women, including elite controllers should start ART in pregnancy, when should they start?

A
  • If viral load <30,000 as soon as able to do so in the 2nd trimester
  • VL 30,000-100,000 then at start of 2nd trimester
  • VL>100,000 or CD4<200 then in first trimester
  • All should have started by 24 weeks
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12
Q

What ART to start in pregnancy?

A
  • Backbone: any combination of TDF, abacavir, emtricitabine, lamivudine. TAF only if after 1st trimester
  • 3rd agent: best evidence for EFV or atazanavir, alternatively rilpivirine 25mg OD, raltegravir 400mg BD, darunavir/rit 600/100mg (could give BD), or dolutegravir if after 6 weeks gestation
  • Consider an INSTI if baseline VL>100,000 or where ART failing to suppress
  • (Zidovudine mono therapy only if women declining ART, VL<10,000 and willing to have C-section)
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13
Q

What ART to start in late presenting woman (ie. over 28 weeks)?

A
  • If viral load unknown or >100,000 start a 3 or 4 drug regimen that includes raltegravir 400mg BD or dolutegravir 50mg OD
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14
Q

Management of untreated woman in labour?
(if no documented HIV test, INSTI should be done and actions started without waiting for confirmation)

A
  • Stat oral NVP 200mg (crosses placenta in 2 hours and maintains effective concentrations in neonate for up to 10 days)
  • Commence ART with oral zidovudine 300mg, lamivudine 150mg BD and raltegravir 400mg BD (also crosses placenta rapidly)
  • IV ziduvudine for duration of labour, loading with 2mg/kg for first hour, the maintenance at 1mg/kg/hr until cord clamped
  • In pre-term labour consider addition of double dose TDF to further load infant (poor oral absorption anticipated)
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15
Q

When might you considered TDM in pregnancy?

A
  • Dosing off licence or particularly if combining TDF and atazanavir/r
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16
Q

HIV-2 in pregnancy

A
  • Case discussion with experts
  • Boosted PI based regimen such as darunavir/r is recommended
  • General recommendations in HIV2 are for 2NRTI (ideally TDF/FTC) with second gen iNSTI (BD DTG) or DAR/r (BD)
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17
Q

What tests to do on diagnosis of new Hep B infection in pregnancy?

A
  • HBV, ‘e’ antigen status, Hep D, HCV, HAV (?need immunising) and tests to assess liver inflammation and fibrosis (Fibroscan and biopsy relatively contraindicated)- AST, ALT, alb, INR
  • Fib 4 index, or AST to platelet ratio (APRI), and ultrasound liver/spleen if advanced disease suspected
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18
Q

ART in Hep B in pregnancy

A
  • Should include TDF (or TAF if after 1st trimester)
  • FTC/3TC can be omitted and TDF/TAF as sole anti-HIV treatment if known FTC/3TC resistance
  • Cannot give 3TC/FTC as sole anti-HBV agent
  • FTC better than 3TC
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19
Q

Hep A vaccination in pregnancy with HBV diagnosis

A
  • After first trimester at 0 and 6 months
  • If CD4<100 additional dose (0, 1 and 6 months) recommended
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20
Q

Preventing vertical transmission HBV

A
  • NVD can be recommended regardless of HBV viral load
  • Neonatal immunisation +/- HBIG within 24 hours delivery
  • BF does not seem to increase transmission although possibly with cracked nipples etc.
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21
Q

Which babies should get HBIG?

A
  • Maternal HBV DNA >E6
  • HBeAg pos
  • anti-HBe negative/unknown
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22
Q

Management of HCV detected in pregnancy

A
  • Confirm HCV RNA, HBV, HAV, LFTs, ALT/AST, Alb/plt/INR, consider non-invasive scoring for fibrosis (Fib4 or APRI), ultrasound liver.spleen
  • Repeat LFT 2 and 4 weeks after starting ART as well as all other routine bloods
  • Monitor HCV VL although treatment is not recommended in pregnancy
  • Ensuring HIV VL suppressed will help reduce HCV VT
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23
Q

Antenatal management (invasive testing and ECV)

A
  • Invasive pre-natal testing should not be done until HIV status is known and ideally deferred until VL<50
  • If not on ART and cannot delay, start ART including raltegravir 400mg and give stat NVP 2-4 hours before procedure
  • ECV if VL<50
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24
Q

Mode of delivery depending on 36 week VL

A
  • <50, planned NVD
  • 50-399, PLCS should be considered
  • > 400 PLCS recommended
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25
Q

Timing of PLCS to prevent VT

A

Between 38 and 39 weeks

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26
Q

Management of SROM depending on HIV VL

A
  • <50: induction of labour aiming for birth <24 hours
  • 50-399: CS advised
  • > 400 CS recommended
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27
Q

Very low risk, low risk and high risk neonatal PEP regimens

A

START WITHIN 4. HOURS
Very low risk (mother on ART>10 weeks, 2 HIV VL<50 at least 4 weeks apart and 36 week VL <50): 2 weeks zidovudine monotherapy
Low risk: (not all of above but 36 weeks VL<50): zidovudine 4 weeks
High risk (36 VL >50 or not known): 2 weeks NVP, 4 weeks lamivudine + zidovudine
(generally give zidovudine when VL<50 even if known maternal resistance, if VL>50 seek. expert advice)

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28
Q

Neonatal PEP in HIV2

A
  • Same as HIV1 of low and very low risk
  • NVP won’t work if high risk so zidovudine, lamivudine, raltegravir
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29
Q

Neonatal HIV testing in non breast fed baby

A
  • During first 48 hours life
  • (If high risk at 2 weeks)
  • At 6 weeks (or at least 2 weeks after stopping PEP)
  • At 12 weeks (or at least 8 weeks after stopping PEP)
  • HIV antibody test 22-24 months
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30
Q

Neonatal HIV testing in breastfed infant

A
  • During 48 hours prior to discharge
  • At 2 weeks
  • Monthly whilst BF
  • 4 and 8 weeks after stopping BF
  • HIV antibody testing at 22-24 months or minimum 8 weeks after stopping BF if this is later
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31
Q

Tmax, Cmax, Cmin, AUC, definitions

A
  • Tmax: Time to reach maximum concentration
  • Cmax: actual concentration
  • Cmin: minimum concerntraion
  • AUC: area under the curve is total exposure to drug in the systemic circulation
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32
Q

Which ART can prolong QT?

A
  • Atazanavir
  • Lopinavir
  • Ritonavir
  • Rilpiverine (supra therapeutic doses)
  • Cabotegravir/rilprivirine
  • Efavirenz
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33
Q

Explain P-gp transporter and TAF dose

A
  • P-gp transporter in intestinal lumen pumps TAF into the lumen thus reducing absorption
  • PIs inhibit it allowing more TAF absorption, thus if giving TAF with PI reduce dose from 25mg to 10mg
34
Q

St John Wort mechanism and which ART allowed

A
  • Potent inducer of CYP3A4 and probably P-gp, may inhibit others
  • Essentially contraindicated with most ART (except NRTI although also CI with TAF)
  • On the whole will reduce levels of ART substantially
  • Inhibiting effect lasting up to 2 weeks
35
Q

Statins and anti-retrovirals

A
  • If using a PI, then prescribe atorvastatin or rosuvastatin starting at lowest possible dose and titrating up if necessary e.g. 10mg atorvastatin
  • PIs + elvitegravir contraindicated with simvastatin/lovastatin (lipophilic statins, CYP3A4 substrates)
  • Caution with EFV/NVP, or pick rosuvastatin
  • No issues with any statins and INSTIs/NRTIs (except elvitegravir)
  • NB fenofibrate fine with all
36
Q

Calcium channel blocker interactions (e.g. amlodipine, verapamil, diltiazem)

A
  • CCBs are substrates of CYP3A4 which protease inhibitors inhibit, therefore levels may be increased, may need to monitor BP/ECG or start half dose, or avoid
  • amlodipine levels increased by PIs, risk of QT prolongation, same with citalopram
  • Lercandipine very increased by PI therefore contraindicated
  • NNRTI may decrease CCB, advised to monitor effect and increase dose if needed
37
Q

Beta-blockers and ART

A
  • Caution as levels could be increased by PIs
38
Q

Diuretics/ACEi/ARBs generally ok with all ART, except:

A
  • Caution with eplerenone and indapamide and PIs/elvitegravir
39
Q

PPIs and ART

A
  • Atazanavir and rilpivirine essentially contraindicated
  • Fine with PIs and INSTIs
40
Q

H2 blockers e.g. ranitidine and ART

A
  • If with rilpivirine give H2 blocker 12 hours before or 4 hours after rilpivirine
  • Dose/timing adjustments can be required with atazanavir
  • Rest of PIs and INSTIs are fine
41
Q

Oral supplements/Fe/MVT

A
  • Take together with INSTI with food or take ART at least 2 hours before or 6 hours after the supplement
  • Raltegravir OD not recommended with any (BD separate from supplement by 4 Horus)
  • Elvitegravir separate from supplement by 4 hours
42
Q

Antacids (cations) and ART

A

Raltegravir:
- Do not give Al or Mg antacids at all
- Calcium antacids ok with BD RAL, cannot have with OD RAL

Dolutegravir:
- Al/Mg/Ca antacids all ok but must be taken at least 6 hours before DTG or 2 hours after

Rilpivirine:
- Antacids at least 2 hours before or 4 hours after rilpivirine

43
Q

Steroids and protease inhibitors

A
  • Fluticasone, budesonide and memetasone inhaled all interact ++ so avoid
  • Inhaled beclametasone is ok (clenil modulate or fostair which is beclametasome with formoterol)
  • intra-articular triamcinolone not ok
  • Pred/dex etc. likely to be increased but can be given, topical hydrocortisone no interactions
44
Q

Which steroid inhalers allowed and not allowed with PIs?

A
  • Clenil modulate (beclomethasone) and Fostair (Beclomethasone and formoterol) both good
  • Seretide (fluticasone and salmeterol), pulmacort (budesonide), symbicort (budesonide and formoterol) not allowed
45
Q

LMWH and ART
Warfarin and ART

A

All are fine as is heparin
Warfarin not recommended with PI/NNRTI (would require careful INR monitoring), aim to get onto INSTI

46
Q

Anti-platelets and ART:

A
  • Apirin and prasugrel are fine with all
  • Clopidogrel should not be used with PIs/EVGc/EFV/NVP (will decrease clopidogrel response)
  • Ticagrelor will be increase by PIs/EVG so contraindicated
  • Dipyrimadole can be used with caution
47
Q

Protease inhibitors and DOACs

A
  • Apixaban and rivaroxaban are contraindicated
  • Dabigatran and edoxaban can be used but might start lower dose
  • (INSTI no issues, caution with EFV/NVP and apix/rivarox, ok with dabigatran and edoxaban)
48
Q

Who should be started on same day ART?

A
  • Those with primary HIV
  • Those who wish to and are ready to and have no clinical contraindications
  • Can counsel that evidence showing benefit to same day is not from high income settings so may not be relevant ‘lack of proven benefit or harm”
49
Q

When to start if presenting with AIDS defining, serious bacterial infection or CD4<200? What evidence?

A
  • Generally advisable within 2 weeks.
  • Largely from ACTG 5164: fewer AIDS progressions/deaths when ART started within 14 days than if started after acute infection treated (most had PCP, Tb were excluded, ITU unwell were excluded as had to be able to give consent and take PO meds) -> no increase in IRIS seen
  • Most still in favour of delayed (at least we weeks) with crypto
50
Q

PHI definition

A

HIV infection within a maximum of 6 months from estimated time of transmission

51
Q

Criteria associated with PHI indicating urgent ART

A
  • neurological involvement
  • CD4<350
  • AIDS defining illness
  • less than 12 weeks since last negative result
52
Q

In those choosing not to start ART:

A
  • Ensure fully counselled
  • Assess capacity
  • Offer PrEP to partners
  • Offer 3 monthly appointments
  • START study showed that in those with CD4>500 significant increase in relative risk if don’t start ART, absolute risk still quite low (4.1% risk disease progression Vs 1.5% in immediate treatment arm)
53
Q

Management of elite controllers

A
  • strong recommendation to start ART if any evidence disease progression
  • possible to monitor if the following excluded: Hep B and C, HTLV, pregnancy/planned pregnancy, current or previous cancer/autoimmune disease/CVD, planned immunosuppressive of chemotherapy
  • if not starting, monitor for the above plus VL and CD4, CD4:CD8 every 6 months
54
Q

Dolutegravir/lamivudine can be started first line except for the following caveats:

A
  • Hep B pos
  • Pregnant
  • Baseline VL > 500,000
  • CD4<200
  • M148V documented/suspected
  • In context of transmitted drug resistance
  • HIV cognitive impairment
  • Caution in those with PHI, OI or renal disease
55
Q

Tablets it’s ok to crush:

A

Truvada (in 100ml water/juice)
Tenofovir
Dolutegravir
Triumeq
Darunavir
Abacavir
Lamivudine
Nevirapine but BD

56
Q

Tablets you must take whole:

A

Biktarvy
Atripla
Odefsy
Stribild
Genyoya
Cobi
Ritonavir
Atazanavir
Raltegravir
Rilpivirine
Kivexa
Eviplera
Descovy
Symtuza (symtuza can be split in 2)

57
Q

Oral solution or granules available for these ART:

A

TDF (granules/powder), abacavir, darunavir, ritonavir, FTC, 3TC NVP

58
Q

Anti-epileptics and ART:

A
  • Levetiracetem not metabolised by any p450 system and is often drug of choice
  • Sodium valproate and gabapentin also good
  • Carbamazapine/phenytoin/phenobarbitol,
    —> levels likely to be increased by PIs so do not give
    –> do not give with rilpivirine/doravirine (RPV will be decreased), can give with EFV/NVP but with caution and do drug levels
    –> Don’t give with biktarvy or raltegravir
    –>DTG if double dose
  • Lamotrigine, potential interaction with ritonavir, ok with cobi, potential with NNRTI, fine with INSTI
59
Q

Antipsychotics and ART:

A
  • Many are metabolised by CYP3A4 thus levels can rise with PIs
  • Start quetiapine at lowest possible dose if already on PI, if starting whilst on PI already, start at 1/6th normal dose (or some would say it’s contraindicated with PI)
  • Olanzipine on the other hand is metabolised by CYP14A and glucuronidation with ritonavir induces thus levels will decrease with PIs and NNRTI, so if stopping a PI monitor for side effects from olanzipine (but it’s not contraindicated)
60
Q

Benzodiazepines and ART:

A
  • Lorazepam/tempazepam/oxazepam no interactions
  • Diazepam/alprazolam/chlordiazepoxide/clonazepam may all be increased by PIs and may be reduced by NNRTI
  • Midazolam contraindicated with PIs and NNRTI, both likely to increase levels (potentially could give a one off dose for anaesthesia in monitored environement)
61
Q

SSRIs and SNRIs and ART:

A
  • Citalopram/escitalopram: levels may be increased by PIs, decreased by NNRTI, can prolong QT so especially if giving with QT prolonging drug should do ECG (ATV/LPV/RPV/CAB)
  • Paroxetine interacts with PIs
  • Sertraline fewer but variable interactions
  • SNRIs: duloxetine ok, venlafaxine caution with QT
62
Q

Contraceptives that are fine with all ART:

A
  • IUD, IUS and depot
  • (CD4<200 IUD is UKMEC 3 due to higher risk infection)
63
Q

Hormonal contraception (other that depot/IUS) and ART:

A
  • No issues with INSTIs (except EVG/c), rilpivirine/doravirine
  • Atazanavir/r and EVG/c: for the COC can use when dose of EE=30ng or more with norgestimate (not advised with other hormones)
  • Remainder of PIs and NNRTI are NOT recommended with all hormonal contraception (except depot and IUS)
64
Q

Which Tb treatments are fine with ALL ART:

A
  • Ethambutol, isoniazid, pyrazinamide
65
Q

Rifamycins and ART:

A
  • Rifamycins are potent CYPP450 inducers so will reduce ART levels
  • TDF/FTC + EFV is first line with rifampicin
  • RAL or DTG but at double dose (Raltegravir 800mg BD, DTG 50mg BD and for 2/52 after rifampicin stopped)
  • Rilpivirine should not be given with rifampicin or Rifabutin
  • PIs/c/r and doravirine should not be given with rifampicin
  • Rifabutin instead of rifampicin where ART requires ritonavir boosted PI, don’t give with cobi boosting as not studies
  • Do not used FDC with TAF/BIC or dual therapy or injectables as don’t have the data
  • Descovy not recommended although likely to be ok
66
Q

PDE5 inhibitors e.g. sildenafil, tadafanil

A
  • Metabolised by CYP3A4
  • PIs inhibit this so levels of sildafenil will increase
  • Start low and titrate up e.g. 25mg Sildenafil 48 hours apart
67
Q

Which ART inhibit tubular secretion of creatinine?

A
  • Biktegravir, dolutegravir, rilpivirine, doravirine, cobi
68
Q

ART food requirements?

A
  • EFV ideally on empty stomach, higher risk of side effects with fatty meal as will absorb more quickly
  • Rilpivirine with a normal caloric meal e.g. 500 calories
69
Q

What are the mitochondrial toxicities seen with older NRTI?

A

Lactic acidosis, hepatitis steatosis, myopathy, cardiomyopathy, peripheral neuropathy, pancreatitis, lipoatrophy

70
Q

Atazanavir side effects

A
  • Unconjugated hyperbilirubinaemia
  • Renal stones, gallstones
  • Long term increased CKD risk
71
Q

Most common darunavir side effects

A
  • GI (diarrhoea, abdo pain, vomiting)
  • Rash (usually self resolves, requires discontinuation in less than 1%)
  • Insomnia
  • Headache
  • Hypertrigs, hyperlipidaemia, raised ALT
72
Q

ART and lipids:

A
  • PIs generally have adverse effects on lipids
  • INSTIs generally lipid neutral except EVG/c which adverse
  • NRTIs: most are lipid neutral and TDF may have lipid lowering effects
  • EFV usually raises lipids and newer such as RPV/DOR are lipid neutral
73
Q

Methadone and ART

A
  • Methadone metabolised primarily by CYP3A4
  • CYP3A4 induced by NNRTI, therefore methadone levels will be reduced, beware of withdrawal when starting ART or overdose when stopping
  • Ritonavir also seems to reduce methadone levels, need to monitor for withdrawal if starting, close monitoring with cobi too
  • Methadone and INSTI no issue
74
Q

Maraviroc tropism

A
  • Maraviroc binds to CCR5 co-receptor, blocking CCR5 tropic virus from entering the cell
  • It is only effective against CCR5 tropic virus
  • CCR5 tropic (R5 tropic) virus predominates in early infection in treatment naive, but in later infection in treatment naive CXCR4 (X4 tropic) virus emerges in 20% and in treatment experienced up to 50% may have CXCR4 tropic virus
  • Maraviroc will not work against X4 tropic or dual tropic virus
75
Q

Other common drugs that prolong QT

A
  • ART: atazanavir, lopinavir, rilpivirine, RPV/CAB, ritonavir, EFV
  • Chlorpromazine/ venlafaxine, citalopram/ escitalopram/haloperidol/risperidone
  • Fluconazole/voriconazole
  • Clarithromycin/erythromycin/ moxifloxacin
  • Methadone
  • Quinine
  • Ondansetron
  • Sildafenil
76
Q

Raltegravir most common side effects and to be aware of:

A
  • Most frequent side effects: headache, nausea, abdominal pain
  • Aslo common decreased appetite, insomnia, abnormal dreams, depression (uncommon suicidal), vertigo, rash , fatigue, AST/ALT rise
  • Myopathy/rhabdo, rare but severe
  • Skin reactions including SJS/TEN
  • Contains lactose
  • Rash
  • Osteonecrosis
  • Depression
  • If giving with strong inducers e.g. rifampicin, double dose and BD, so 800mg BD
  • Don’t give raltegravir with aluminium or magnesium antacids
  • No dose adjustment is required for calcium carbonate antacid and BD RAL, but don’t give with OD RAL
77
Q

Dolutegravir interactions and main side effects

A
  • Magnesium/aluminium/calcium/ iron/MVT should be well separated from DTG, so take the supplement minimum of 6 hours before DTG or 2 hours after
  • DTG increases metformin levels (OCT2 inhibition), consider max metformin dose of 1000mg/day when starting/stopping either and monitoring glucose and renal function
  • Rifampicin double dose 50mg BD, no change needed with rifabutin
  • Inhibits renal creatinine secretion, no change in GFR
  • No dose adjustments of oral contraceptives
  • No dose adjustments of methadone
  • Very common side effects nausea, diarrhoea and headache
  • Common were insomnia, abnormal dreams, depression/anxiety (suicidal ideation rare), vomiting, flatulence, abdominal pain, ASLT/AST raise, rash, itch, fatigue, CK elevation
  • Uncommon hepatitis, myalgia, suicidal ideation
  • Very rare acute hepatic flare
78
Q

Common side effects of biktarvy

A
  • Headache, diarrhoea, nausea most common
  • Also common depression, abnormal dreams, dizziness, fatigue
  • Uncommon suicidal ideation, rash, arthralgia
79
Q

Common side effects of biktarvy

A
  • Headache, diarrhoea, nausea most common
  • Also common depression, abnormal dreams, dizziness, fatigue
  • Uncommon suicidal ideation, rash, arthralgia
80
Q

Rilpivirine common side effects and interactions

A
  • Do not give with carbamazepine, phenobarbital, phenytoin as low levels or rilpivirine are expected
  • Don’t give with rifampicin, could double RPV dose for use with rifabutin, and continue for after 2 weeks post stopping rifabutin
  • Do not use with PPI
  • H2 antagonists (famotidine/ranitidine): at least 12 hours before or 4 hours after RPV
  • Antacids at least 2 hours before or 4 hours after RPV
  • Common side effects depression (not suicidal), headache, insomnia, rash, abdominal pain
  • Also common abnormal dreams, increased AST/ALT, rash, fatigue
81
Q

Doravirine common side effects and interactions

A
  • No dose changes needed with antacids, PPIs, H2
  • Don’t give with carbamazepine, phenytoin, phenobarbital
  • Don’t give with rifampicin, can give double dose with rifabutin
  • Most frequent side effects were headache and nausea
  • Also common abnormal dreams/insomnia, headache, dizziness, nausea, diarrhoea, abdominal pain, rash, fatigue, ALT/AST increased

DipHIV (8 decks)

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