Dr Katharine Cartwright
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1 Fifth Annual BHIVA Conference for the Management of HIV/Hepatitis Co-Infection in collaboration with BASL and BVHG Dr Katharine Cartwright Leicester Royal Infirmary Wednesday 3 October 2012, One Great George Street Conference Centre, London
2 A case of complications for BHIVA co-infection meeting 3rd October 2012 Dr Katharine Cartwright StR Infection
3 60 yr old male Media worker MSM Moderate alcohol & recreational drug use Unprotected sex various partners Tattoos HIV-1 Ab pos 1999 HBcAb pos HBsAg neg HBV DNA neg HCV Ab pos 2004
4 HIV positive 1999; nadir CD4 120 Dates HAART Reason for switch EFV, 3TC, AZT Jan 2004 NVP, 3TC, AZT Neuropsychiatric intolerance EFV Fibrosing cholestatic hepatitis (FCH) due to acute HCV Nov 2004 May 2005 NVP, 3TC, AZT Acute hepatitis May 2005 Oct 2011 ATV/RTV, FTC, TDF Renal toxicity secondary to TDF Oct 2011 present ATV/RTV, Raltegravir
5 HCV genotype 1a: 2004 Date HCV RNA ALT Comments 2000 Negative 30 HCV Ab negative 2004 Detected < Acute HCV Fibrosing cholestatic hepatitis on biopsy ,000, Acute hepatitis : NVP? , PegIFN & Ribavirin failed with thrombocytopaenia, neutropaenia ,000, Cryoglobulinaemia ,090, Biopsy: I7 + F ,200, Deferring retreatment until after retirement ,140, Awaiting data from protease inhibitor trials
6 Would you now Continue current treatment (HAART) 2. Retreat with 48 weeks Peg IFN & Ribavirin 3. Retreat with 72 weeks Peg IFN & Ribavirin 4. Retreat with Telaprevir/Peg IFN/Ribavirin?
7 Treatment May 2012 Telaprevir 750mg tds (12 weeks) Peg IFN 100mcg weekly (48 weeks) Ribavirin 1000mg daily (48 weeks) No lead in To stop if response <1 log at week 4
8 Wk 2: Develops rash elbows, knees, bottom (10%) Would you Stop Telaprevir/Peg IFN/Riba 2. Stop Telaprevir only 3. Commence Dovobet cream 4. Commence oral prednisolone?
9 Wk 8: Hb has fallen steadily g/dl. Despite reducing Ribavirin from 1000mg to 600mg a week ago he has become dizzy, tired and SOB with Hb Platelets have fallen to 80. Would you Stop Ribavirin 2. Stop Telaprevir 3. Start Eprex 4. Watch & wait?
10 Wk 10: Creatinine rises to 160 (baseline μmol/l) You request an urgent renal USS and Watch & wait 2. Reduce Ribavirin from 600 to 400mg daily 3. Stop Ribavirin 4. Switch Atazanavir/r to Maraviroc (after urgent CCR5/CXCR4 tropism testing)
11 Wk 14: CD4 cell count drops: 440 (28%) to 190 (27%) Would you Reduce dose of Interferon 2. Commence G-CSF injections 3. Commence prophylactic Co-trimoxazole 4. Switch Atazanavir/r to Maraviroc?
12 Success? Week HCV RNA ALT Hb Creat 0 4,666, < ? 48?
13 LEARNING POINTS
14 Side effects of HCV triple therapy may be exacerbated in HIV co-infection Rash: Manage Telaprevir rash according to product guidance Anaemia due to triple therapy for HCV may be worse in HIV co-infection? worse than with dual therapy reducing Ribavirin after viral response is probably safe Monitor CD4 count Renal impairment can be multifactorial in complex patients Drug-drug interactions: Atazanavir levels
15 The good news Triple therapy with PI is more effective than dual therapy Side effects can often be managed with pre-treatment counselling to maintain motivation close supervision by a specialist nurse and medics Complex HIV co-infected patients may have a good outcome
16 Thank you for listening!
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