Primary Care Perspective on HIV Treatment Bloomquist
Upcoming SlideShare
Loading in...5
×
 

Primary Care Perspective on HIV Treatment Bloomquist

on

  • 385 views

 

Statistics

Views

Total Views
385
Views on SlideShare
385
Embed Views
0

Actions

Likes
0
Downloads
3
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • HIV transmission between sero-discordant partners. Dash line is with + partner delaying treatment, solid line is with partner treated early. Clinical events were TB, candidiasis, pneumocysitits. The composite group was #C plus transmission to seronegative partner

Primary Care Perspective on HIV Treatment Bloomquist Primary Care Perspective on HIV Treatment Bloomquist Presentation Transcript

  • HIV treatment is::Primary care with “benefits”
  • the scoop : :• Guidelines Rule• treat anyone who is willing• compliance is KING• beware of the drugs
  • DHHS Guidelines for the Use ofAntiretroviral Agents in HIV-1-Infected Adults and Adolescents www.aidsinfo.nih.gov
  • who to treat : :• CD4 < 200, 350, 500, what next?• treatment is prevention – serodiscordant couples – pregnancy• think of the viral load of the community
  • who to treat::Clinical Category CD4 Count RecommendationAIDS defining illness or Any value TREATsevere symptoms*Pregnancy, HIVAN, Any value TREATtx HBV co-infectionAsymptomatic <350/mm3 TREATAsymptomatic 350-500/mm3 55% strongly 45% moderatelyAsymptomatic >500/mm3 50% favored 50% optional *http://www.aegis.com/topics/definition.html
  • HPTN 052
  • who not to treat::• anyone who is not going to take their medicine AKA: Non-compliance It is really more like Why Not to treat – when you know the details of a situation, the situation is unchanged. when you don’t know the details of a situation, it still is unchanged. Zen proverb
  • how to treat::• is this person sick?• No
  • how to treat::• is this person sick? – CD4 < 200 – CD4 < 50 – Symptoms i.e. opportunistic infection
  • CD4 < 200• At risk for PCP• GI symptoms?• Candidiasis?• Rash?• Needs meds as soon as ready
  • CD4 < 50• This group of patients is TROUBLE• Must look for OI’s, frequently more than 1• IRIS is common• TB is bad in this group, skin test not reliable• 1/3 mortality in first year after diagnosis
  • what to use::
  • therapy naïve regimens::• NNRTI based-regimen – efavirenz/tenofovir/emtricitabine• PI based-regimens – atazanavir/ritonavir/tenofovir/emtricitabine – darunavir/ritonavir/tenofovir/emtricitabine• Integrase Inhibitor based-regimen – raltegravir/tenofovir/emtricitabine• Pregnancy – lopinavir/ritonavir/zidovudine/lamivudine
  • how it works::1. Fusion2. Reverse transcription3. Integration4. Transcription5. Assembly of virus particles6. Budding of virus particles
  • efavirenz• Category D, neural tube defects – Recommend 2 birth control methods, negative HCG prior to initiation• Caution with use in prior psychiatric disease• False + cannabinoid & benzos on screening• AEs: Drowsiness, dizziness, insomnia, abnormal dreaming, agitation• Take at bedtime on an empty stomach to ↓CNS SE • If need to eat, avoid taking with fatty food• Rash is possible, as long as no other symptoms keep taking meds but need medical eval ASAP
  • efavirenz rash
  • efavirenz rash
  • tenofovir/emtricitabine ::• Generally well tolerated: gas, headaches• Fanconi’s syndrome and renal insufficiency • Check urinalysis every 6 months; PO4 suggested• Hyperpigmentation possible• Osteopenia• Active against HBV • Know pt’s status and counsel accordingly• Once daily with or without food• Both agents need renal adjustment when <50ml/min
  • Fanconi’s Syndrome::• The Fanconi syndrome refers to a generalized impairment in proximal tubular function leading to urinary wasting of compounds normally reabsorbed in the proximal tubule. The consequences are hypophosphatemia (which can lead to osteomalacia), renal glucosuria, hypouricemia, aminoaciduria, and proximal renal tubular acidosis due to bicarbonate loss in the urine (Up To Date).
  • Preferred Protease Inhibitors
  • atazanavir/ritonavir• Interacts with PPIs, antacids, & H2A • All available OTC• Increased unconjugated bili • Scleral icterus or jaundice• Take with food• Less impact on lipids• Prolonged PR interval, asymptomatic 1st degree AV block• 3 total: 1 atazanavir, 1 ritonavir, 1 tenofovir/emtricitabine
  • darunavir/ritonavir• CAUTION with sulfa allergy (not contraindicated)• Take with food• Rash 10%• Abdominal pain• Headache• Hepatotoxicity• Diarrhea (usually less than Kaletra)• 4 tablets total: 1 ritonavir, 2 darunavir, 1 tenofovir/emtricitabine
  • preferred integrase inhibitor::
  • raltegravir::• Taken BID• Minimal drug interactions • PPI increases raltegravir• AEs: diarrhea, nausea, headache, and pyrexia• Increased ALT, AST, CPK possible • Myopathy and rhabdomyolysis reported• 3 tablets total: 1 raltegravir BID, 1 tenofovir/emtricitabine
  • compliance ::• The tendency to yield to others especially in a weak or subservient way• The strain of an elastic body expressed as a function of the force applied to it• How many doses have you missed in the last month?• How many have you taken late?
  • compliance ::• How many doses have you missed in the last month?• How many have you taken late?• WHY?• How can we improve this?
  • compliance ::• 95% compliance is MINIMUM required to receive maximal drug benefit• 19/20 days or once per month for a once daily drug• compare self-report to pill counts• works great with diabetes too
  • beware of the drugs::
  • bone disease::• Osteoppenia• Avascular Necrosis• Vitamin D metabolism impacted• Osteoporosis down the road?
  • AVN on the left
  • energy metabolism complications::• Lactic acidosis• Lipoatrophy• Fat redistribution• Hyperlipidemia• Glucose intolerance• Hypertriglyceridemia
  • Lipoatrophy
  • renal complications::• Fanconi’s syndrome• Stone disease
  • Fanconi’s Syndrome::• The Fanconi syndrome refers to a generalized impairment in proximal tubular function leading to urinary wasting of compounds normally reabsorbed in the proximal tubule. The consequences are hypophosphatemia (which can lead to osteomalacia), renal glucosuria, hypouricemia, aminoaciduria, and proximal renal tubular acidosis due to bicarbonate loss in the urine (Up To Date).
  • Fanconi’s labs::• Creat 1.0 ->1.4->1.2• PO4 3.0 ->2.1->2.9• Urine glucose 150-> neg• Urine protein 100 mg/dl-> neg
  • resources::• consult with US – AFCAHN, phone, email• Guidelines• Warmline is AWESOME• Community providers