Case Presentation AIDS Resource Center of Wisconsin (ARCW)

Transcription

1 Case Presentation AIDS Resource Center of Wisconsin (ARCW) Kia Saeian, MD, MSc Epi Associate Professor John Fangman, MD Associate Professor Medical College of Wisconsin

2 Case History 34-year-old man with HIV-hepatitis C co-infection presents for possible therapy for his hepatitis C. Asymptomatic from liver standpoint. Genotype 3E and is quite eager to undergo treatment. He has had no decompensation and he has not had a previous liver biopsy. Normal Hgb, platelets and albumin 4.3 HIV: Dx d in 2005 after developing oral thrush. Nadir CD On Atripla with a CD4 count of 772 on 04/01/2011 and undetectable HIV viral load since 9/09 Most recent ALT 84, AST 118, alkaline phosphatase of 175, total bilirubin 0.8 and INR 1.1.

3 No known drug allergies. MEDICATIONS: Atripla one daily, folic acid, hydrochlorothiazide, ibuprofen, Imodium as needed, lisinopril daily and multivitamin. PAST MEDICAL HISTORY: AIDS, abnormal anal Pap smear, prior alcohol abuse, oral Candidiasis, depression, giardiasis, hepatitis C, herpes zoster, insomnia, back pain, hypertension and tobacco dependence. Developed 2 palatal lesions after starting ART which were biopsied Kaposi s sarcoma. Metastatic w/u negative and he was treated supportively with resolution of palatal lesions PSYCHOSOCIAL: He is not currently sexually active. HABITS: He continues to smoke tobacco and rarely uses alcohol. He denies any illicit drugs. FAMILY HISTORY: Negative for significant liver disease.

4 PHYSICAL EXAMINATION VITAL SIGNS: Temperature Heart rate 98. Respiratory rate 14. Blood pressure 147/91. Weight 156 pounds. Anicteric with no stigmata of chronic liver disease. Oropharynx is remarkable for small KS lesions on the palate. RESPIRATORY: Lungs are clear. GI: Abdomen is soft and nontender. No hepatosplenomegaly. EXTREMITIES: No edema.

5 Objectives Discuss special considerations for HIV-HCV coinfected patients with genotype 3 infection Length of therapy Ribavirin dosing Impact of protease inhibitors Develop familiarity with interferon-based therapy for HCV in the setting of Kaposi s sarcoma

6 Response Rates for GT 2-3 HIV-HCV Co-infected PEG+Riba Author (1 st ) Year Published SVR GT 2-3 SVR GT 1 Torriani (Apricot) % 29% Carrat % (GT 5 included) Chung % (11/15) 17% 14% (7/51) Laguno % 38% (GT 1 or 4) Nunez (Prescoe) % 35% Torriani et al. NEJM 2004;351: Carrat et al. JAMA 2004;292: Chung et al. NEJM 2004;351: Laguno AIDS 2004;18: Nunez et al. AIDS Res. Hum. Retro 2007;23:

7 Extrapolation of Monoinfected Trials Length of Therapy & Dosing of Ribavirin 12 or 16 weeks vs. 24 weeks Baseline low HCV viral load, low BMI and possibly early fibrosis who exhibit RVR (negative after 4 weeks of therapy) may be candidates If considering shorter course, avoid routine 800 mg daily ribavirin due to high relapse rate (relapse rate of>25% if use of the 12 week course only) but rather use weight-based dosing of ribavirin ( mg) (relapse rate of less than 12%). Mangia et al. Hepatology 2009;49: Yu et al. Hepatology 2008;47: Lagging et al. Hepatology2008;47: you will will

8 Graziadei IW. Vogel W. Hepatology. 49(2):345-7, 2009 Feb.

9 Should you add a protease inhibitor (PI)? Initial data suggested PI s not useful in non-1 genotypes Study by Foster et al on telaprevir raised questions (abstract) Abstract form only Phase 2a study with only 49 total naïve monoinfected patients Ribavirin dose 800 mg daily when used GR Foster, et al. EASL Vienna, Austria. April 14-18, 2010.

10 SVR Rates-Foster Study Genotype 2 Genotype 3 Telaprevir Monotherapy Telaprevir +Pegasys+Ribavirin 56% 50% 100% 67% Pegasys+Ribavirin 89% 44% GR Foster, et al. EASL Vienna, Austria. April 14-18, 2010.

11 Kaposi s Sarcoma and Interferon Sparse recent data on the use of interferon for KS in the combination antiretroviral era No data with pegylated interferon Reports of interferon alpha-2b in doses of 1 million to 10 million IU daily If late stages HIV (CD4 <100) Little benefit Deleterious If early, particularly with CD4 > 200 Positive response reported with rates of approximately 40% Increasing response rates with increasing CD4 counts No flares of KS reported Lane, H C. Semin Oncol. 18(5 Suppl 7):46-52, 1991 Oct

12 Case Patient elected to proceed with treatment with Pegylated interferon alpha-2a and ribavirin (800 mg daily) Six weeks in to therapy Mild initial flu symptoms No evidence of KS flare ALT/AST remain elevated HCV viral load