HIV Update Disclosures

Transcription

1 HIV Update 2017 Lori A. Gordon, PharmD, BCPS AQ ID, AAHIVP Clinical Assistant Professor Xavier University of Louisiana College of Pharmacy LPA Disclosures Lori A. Gordon, PharmD, reports the following disclosures: ViiV Healthcare (Regional Medical Advisory Board Expert) 2 1

2 Pharmacists Learning Objectives Following this presentation, the viewer should be able to: Relate the steps of the HIV life cycle to targets of antiretroviral therapeutic classes Recommend appropriate complete regimens for treatment naïve HIV patients Identify common and unique adverse drug reactions within antiretroviral therapeutic classes Recognize potential mechanisms of drug drug interactions between antiretroviral agents and other concomitant medications 3 Technicians Learning Objectives Following this presentation, the viewer should be able to: Identify antiretroviral therapeutic classes required for complete regimens in treatment naïve HIV patients Identify common adverse reactions within antiretroviral therapeutic classes Identify common drug drug interactions between antiretroviral agents and other concomitant medications 4 2

3 Natural Course of HIV Infection 5 Rates of Diagnoses of HIV Infection among Adults and Adolescents, 2014 United States and 6 Dependent Areas N = 44,609 Total Rate = 16.6 Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. 3

4 Louisiana Statistics (2014) Persons living with HIV: 20,627 52% with AIDS 2 nd highest state in nation for new HIV diagnoses Baton Rouge ranked highest and New Orleans ranked 2 nd highest among large metropolitan areas in nation for new HIV diagnoses Major risk factors Men who have sex with men (MSM): 70% African American: 71% Youth/young adult: 31% (25 34yo); 27% (13 24yo); 2 nd highest state in nation for new AIDS diagnoses Baton Rouge ranked 1 st ; New Orleans ranked 4 th LA OPH SHP 2015, On average, I provide care to HIV+ patients on a weekly basis

5 Hands up! The HIV Hijack Targets for Antiretroviral Therapy Life Cycle of HIV: Pharmacological Targets Binding 5

6 Life Cycle of HIV: Pharmacological Targets Binding Fusion/Penetration Life Cycle of HIV: Pharmacological Targets Binding Fusion/Penetration Transcription 6

7 Life Cycle of HIV: Pharmacological Targets Binding Fusion/Penetration Transcription Integration Life Cycle of HIV: Pharmacological Targets Binding Fusion/Penetration Transcription Integration Translation Assembly/Budding/Maturation 7

8 Life Cycle of HIV: Pharmacological Targets Binding CCR5 antagonists Fusion/Penetration Fusion inhibitors Transcription Nucleoside/Non nucleoside reverse transcriptase inhibitors (NRTI/nNRTI) Integration Integrase strand transfer inhibitors (InSTIs) Translation Assembly/Budding/Maturation Protease inhibitors (PI) Putting the cart before the horse Recommended Antiretroviral Regimens 8

9 Ms. Jones Ms. Jones is a 26yo female who is newly diagnosed HIV+ patient. She is treatment naïve, with a baseline viral load of 893,000 copies/ml and CD4 count of 351 cells/mm 3 What would you select as an appropriate initial regimen for her? 17 Combination AntiRetroviral Therapy (cart) 18 Courtesy of AS Fauci 9

10 Stage 3 (AIDS) Classifications and Deaths of Persons with HIV Infection Ever Classified as Stage 3 (AIDS), among Adults and Adolescents, United States and 6 Dependent Areas Note. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. Deaths of persons with HIV infection, stage 3 (AIDS) may be due to any cause. HIV Treatment Regimens Anchor Drug NRTI Backbone (2 NRTIs) InSTI PI InSTI = integrase strand transfer inhibitor nnrti = non nucleoside reverse transcriptase inhibitor NRTI = nucleoside reverse transcriptase inhibitor PI = protease inhibitor nnrti Department of Health & Human Services

11 Recommended Initial Regimens Emtricitabine/ Tenofovir (FTC/TDF or FTC/TAF) Darunavir/ ritonavir (DRV/rtv) Dolutegravir (DTG) Elvitegravir/ cobicistat (EVG/cobi) Raltegravir (RAL) Abacavir/ Lamivduine (ABC/3TC) DTG TAF = tenofovir alafenamide TDF = tenofovir disoproxil fumarate Department of Health & Human Services 2016 A Superior Anchor Drug: The SINGLE Trial 22 Walmsley SL, et al. N Engl J Med

12 A Superior Anchor Drug: The SINGLE Trial 23 Walmsley SL, et al. N Engl J Med 2013 Alternative Initial Regimens Emtricitabine/ Tenofovir (FTC/TDF or FTC/TAF) Efavirenz (EFV) Atazanavir/ ritonavir (ATV/rtv) Rilpivirine^ (RPV) Atazanavir/ cobicistat (ATV/cobi) Darunavir/ cobicistat (DRV/cobi) Abacavir/ Lamivduine (ABC/3TC) DRV/rtv DRV/cobi ^ Pre treatment viral load < 100,000 copies/ml & CD4 count > 200 cells/mm 3 TAF = tenofovir alafenamide TDF = tenofovir disoproxil fumarate Department of Health & Human Services

13 ECHO & THRIVE: RPV vs. EFV N = 1368 (ITT population) 84% (RPV) vs. 82% (EFV) [95 CI 2.0% to 6.0%] at 48 weeks 25 Cohen CJ, et al. J Acquir Immune Defic Syndr 2012 Rilpivirine Virologic Outcomes According to Baseline Viral Load & CD4 26 Complera prescribing information

14 Other Regimens: When an NRTI Backbone Cannot Be Used Raltegravir (RAL)^ Lamivduine (3TC) Darunavir/ritonavir (DRV/rtv)^ Lopinavir/ritonavir (LPV/rtv) ^ Pre treatment viral load < 100,000 copies/ml & CD4 count > 200 cells/mm 3 NRTI = nucleotide reverse transcriptase inhibitor Department of Health & Human Services 2016 Dual Therapy in Healthy Patients: The NEAT Study 28 Raffi F, et.al. Lancet

15 Single Tablet Regimens Reduce Pill Burden Genvoya (EVG/cobi/FTC/TAF) Stribild (EVG/cobi/FTC/TDF) Triumeq (DTG/3TC/ABC) NRTIs INSTIs Atripla (EFV/FTC/TDF) Complera (RPV/FTC/TDF) Odefsey (RPV/FTC/TAF) NRTIs NNRTIs 3TC = lamivudine; ABC = abacavir; cobi = cobicistat; DTG = dolutegravir; EFV = efavirenz; EVG = elvitegravir; FTC = emtricitabine; RPV = rilpivirine; TAF = tenofovir alafenamide; TDF = tenofovir disoproxil fumarate 29 Fixed Dose Combination Tablets Reduce Pill Burden NRTIs Epzicom (ABC/3TC) Descovy (FTC/TAF) Truvada (FTC/TDF) Combivir (3TC/AZT) PIs Evotaz (ATV/cobi) Prezcobix (DRV/cobi) Kaletra (LPV/rtv) 3TC = lamivudine; ABC = abacavir; ATV = atazanavir; AZT = zidovudine; cobi = cobicistat; DRV = darunavir; 30 FTC = emtricitabine; LPV = lopinavir; rtv = ritonavir; TAF = tenofovir alafenamide; TDF = tenofovir disoproxil fumarate 15

16 The Risk of Non Adherence Genotype Phenotype 31 Ms. Jones Ms. Jones is a 26yo female who is newly diagnosed HIV+ patient. She is treatment naïve, with a baseline viral load of 893,000 copies/ml and CD4 count of 351 cells/mm 3 What would you select as an appropriate initial regimen for her? 32 16

17 A. Dolutegravir + abacavir + lamivudine A. Darunavir + cobicistat + emtricitabine + tenofovir A. Efavirenz + emtricitabine + tenofovir A. Elvitegravir + cobicistat + abacavir + lamivudine A. Rilpivirine + emtricitabine + tenofovir 33 A. Dolutegravir + abacavir + lamivudine A. Darunavir + cobicistat + emtricitabine + tenofovir A. Efavirenz + emtricitabine + tenofovir A. Elvitegravir + cobicistat + abacavir + lamivudine A. Rilpivirine + emtricitabine + tenofovir 34 17

18 First, do no harm Potential Adverse Drug Reactions NRTIs Nucleoside Reverse Transcriptase Inhibitors: The d Drugs & Mitochondrial Toxicity Inhibition of mitochondrial DNA polymerase (pol γ) Decreased mitochondrial DNA copy number, diminished ATP pools ddc ddi d4t > AZT TDF 3TC = FTC ABC Clinical Manifestations Boxed warning: Lactic acidosis and severe hepatomegaly with hepatic steatosis Pancreatitis Peripheral neuropathy Lipodystrophy Clinical relevance? Predominantly with d drugs ±AZT Stavudine, d4t (Zerit ) Didanosine, ddi (Videx ) Zalcitabine, ddc (Hivid ) 36 Koczor CA, et.al Expert Opin Drug Metab Toxicol

19 NRTIs Nucleoside Reverse Transcriptase Inhibitors Drug Adverse Drug Reactions 3TC^/FTC # Skin hyperpigmentation Hepatitis B related hepatic flare ABC AZT* TAF*/TDF^ Hypersensitivity reaction (fever, rash, malaise, GI/respiratory symptoms) Increased risk of MI? Bone marrow suppression (macrocytic anemia, neutropenia) GI intolerance Nail hyperpigmentation Nephrotoxicity Renal proximal tubulopathy (hypophoshatemia, glucosuria [with normoglycemia], hypouricemia proteinuria, scr elevation) Decreased bone mineral density Hepatitis B related hepatic flare ^ Requires dose adjustment if CrCl < 50 ml/min # Requires dose adjustment if CrCl < 30 ml/min * Requires dose adjustment if CrCl < 15 ml/min Department of Health & Human Services 2016 Genvoya prescribing information Vemlidy prescribing information 2017 Abacavir Hypersensitivity: The PREDICT 1 Study Comparison of HLA B*57:01 screening vs. abacavir skin patch test Positive predictive value: 58% If you are HLA B*57:01(+) it is possible to develop hypersensitivity reaction (HSR) Likely additional genes involved in the development of HSR Negative predictive value: 100% If you are HLA B*57:01( ) it is unlikely to develop HSR 38 Mallal S, et.al. N Engl J Med

20 Abacavir & Myocardial Infarction The D:A:D Collaboration International, prospective, observational cohort 33,308 patients 178,835 person years (PYs) Evaluated incident cases of MI Recent exposure to ABC associated with increased risk of MI (RR 1.70) Cumulative exposure to ABC associated with increased risk of MI (RR 1.07) Higher burden if pre existing cardiac risk factors Remains controversial Studies with similar vs. weak/no association ABC = abacavir; MI = myocardial infarction; RR = relative risk Sabin CA, et.al. Lancet Worm SW, et.al. J Infect Dis 2010 A Tale of Two Prodrugs: TDF vs TAF TAF = tenofovir alafenamide 40 TDF = tenofovir disoproxil fumarate Callebaut C, et.al. Antimicrob Agents Chemother

21 Choose TAF over TDF: Renal Markers 41 Wohl D, et.al. J Acquir Immune Defic Syndr 2016 Choose TAF over TDF: Bone Mineral Density 42 Wohl D, et.al. J Acquir Immune Defic Syndr

22 INSTIs Integrase Strand Transfer Inhibitors Drug ADRs DTG Non progressive scr elevation (via OCT2 inhibition) Neuropsychiatric symptoms (insomnia, depression) Hypersensitivity reaction EVG/cobi Nausea Diarrhea Neuropsychiatric symptoms (depression) RAL Rash (including Stevens Johnson syndrome) CPK elevation/muscle weakness Neuropsychiatric symptoms (depression) 43 Department of Health & Human Services 2016 Integrase Strand Transfer Inhibitors & Neuropsychiatric Events: The OPERA data DRV = darunavir; DTG = dolutegravir EFV = efavirenz; RAL = raltegravir 44 Fettiplace A, et.al. J Acquir Immune Defic Syndr

23 PIs Protease Inhibitors: Out with the Old Drug Drug ADRs ADRs Skin hyperpigmentation Rash (sulfonamide moiety) 3TC/FTC Fosamprenavir (FPV) Hepatitis B related Nephrolithiasis hepatic flare Hypersensitivity reaction ABC Indinavir (IDV) Nephrolithiasis Increased risk of MI? GI intolerance Lopinavir/ritonavir Bone(LPV/r) marrow suppression Hyperlipidemia (macrocytic (hypertg) anemia, neutropenia) AZT GI intolerance PR/QT prolongation Nail hyperpigmentation Diarrhea Nelfinavir Renal (NFV) proximal tubulopathy LFTs elevation (hypophoshatemia, glucosuria (with normoglycemia, hypouricemia proteinuria, scr elevation) TDF Decreased bone mineral PR/QT density prolongation Saquinavir (SQV) Hepatitis B related LFTs hepatic elevation flare Hepatotoxicity Tipranavir (TPV) Rash (sulfonamide moiety) Intracranial hemorrhage 45 Department of Health & Human Services 2016 PIs Protease Inhibitors: In With the New Drug ADRs Atazanavir (ATV) Darunavir (DRV) rtv GI intolerance Hyperlipidemia Hyperglycemia Indirect hyperbilirubinemia Nephrolithiasis Cholethiaisis Rash (sulfate moiety) PR prolongation/1 AV block Hepatotoxicity/LFTs elevation Rash (sulfonamide moiety) 46 Department of Health & Human Services

24 NNRTIs Non Nucleoside Reverse Transcriptase Inhibitors Drug ADRs EFV Neuropsychiatric symptoms (vivid dreams/nightmares, dizziness, suicidal ideation/attempt/completion) Rash Teratogenicity (D/C/C) False positive tests (cannabinoid, benzodiazepine) RPV Rash Neuropsychiatric symptoms (depression, insomnia, headache) Etravirine (ETR) Rash Hypersensitivity reaction 47 Department of Health & Human Services 2016 DDI not ddi Drug Drug Interactions 24

25 Mr. Smith Mr. Smith is a 54yo patient who has been living with HIV for the past 10 years. He is currently virologically suppressed on DRV/cobi + FTC/TAF with a high CD4 count. His past medical history includes: GERD Hyperlipidemia (ASCVD 10 yr risk = 13.5%) HCV Seasonal allergies How would you appropriately manage his other chronic co morbidities? ASCVD = atherosclerotic cardiovascular disease; cobi = cobicistat; DRV = darunavir; FTC = emtricitabine; GERD = gastroesophageal reflux disease; HCV = hepatitis C; TAF = tenofovir alafenamide 49 The Pharmacokinetics of An Oral Dose of Medication 50 Courtesy of SR Penzak 25

26 The Pharmacokinetics of Therapy: Concentration vs Time Curve CMAX OVERALL DRUG EXPOSURE TROUGH 51 Courtesy of A Pau Food & Antiretroviral Interactions DRUG LEVELS Take with food elvitegravir etravirine rilpivirine Take on an empty stomach efavirenz SIDE EFFECTS SIDE EFFECTS atazanavir darunavir lopinavir/rito navir 52 Department of Health & Human Services

27 Acid Reducing Agents & Antiretrovirals Antacids H2RAs PPIs Antacids H2RAs ATV Directions Treatment Naïve Treatment Experienced Give ATV 2h before/1h after Give ATV simultaneously or 2h before/10h after Give ATV 12 after Give RPV 4h before/2h after Give RPV 4h before/12h after ATV 400mg ATV 300mg + RTV 100mg ATV 400mg Not to exceed famotidine 20mg PO bid ATV 300mg + RTV 100mg Not to exceed famotidine 40mg PO bid ATV 300mg + RTV 100mg No to exceed omeprazole 20mg PO daily RPV ATV 400mg ATV 300mg + RTV 100mg ATV 300mg + RTV 100mg * ATV 400mg + RTV 100mg Not to exceed famotidine 20mg PO bid Do not co administer RPV 25mg RPV 25mg PPIs Do not co administer * without concomitant TDF 53 Department of Health & Human Services 2015 Integrase Strand Transfer Inhibitors & Polyvalent Cations Al 3+, Ca 2+, Fe 2+/3+, Mg 2+, Zn 2+ Give INSTI 2h before (4 6 hours after) polyvalent cations*^& Potential sources: Antacids Laxatives Multivitamins/supplements ^ no need to separate DTG from Ca 2+ or Fe 2+/3+ if given with food * no need to separate administration of RAL and Ca & do not co administer RAL and Al 3+ Department of Health & Human Services

28 Types of Metabolism Phase I/Oxidation Increases water solubility Mediated by Cytochrome P450 (CYP450) enzyme family CYP3A4 responsible for 82% of CYP mediated drug elimination Phase II/Conjugation Renders pharmacologically inactive Attach additional chemical group to drug Mediated by uridine diphosphate glucuronosyltransferase (UGT) 55 Galetin et.al. Exp Opin Drug Metab Toxicol 2008 CYP Inhibition 56 Courtesy of SR Penzak 28

29 CYP Induction 57 Courtesy of SR Penzak Exploiting CYP3A Inhibition 58 van Heeswijk RPG, et.al. AIDS

30 Pharmacokinetic Boosting Agents: Ritonavir & Cobicistat GS 9350 = cobicistat; RTV = ritonavir 59 Mathias A, et.al. IWCPHT 2010 COBI Considerations: ATV/c & DRV/c 60 Gallant JE et.al. J Infect Dis

31 ARV CYP Mechanism of Interactions 3A4 ATV cobi* DRV rtv 2C9/2C19 EFV, ETR 2D6 COBI* 3A4 ATV cobi* DRV EFV ETR EVG RPV rtv 2B6 2D6 2C9/2C19 EFV rtv ETR 3A4 EFV ETR 1A2 RTV 2B6 EFV, rtv 2C9/2C19 rtv Inhibitors Substrates Inducers 61 * COBI is not an antiretroviral Department of Health & Human Services 2016 asda Anti infectives: Rifamycins ARV Rifampin Rifabutin Dosing Recommendations Protease Inhibitors PI C min : >75% Rif AUC: > 100% EFV EFV AUC: 26% Rif AUC: 38% ETR ETR possible Rif AUC: 17% ETR AUC: 37% RPV RPV AUC: 80% RPV AUC: 46% RAL RAL AUC: 40% RAL AUC: 19% EVG/c EVG possible EVG C min : 67% Rif AUC: > 600% DTG DTG AUC: 54% DTG C min : 30% Rifampin: Do not co administer Rifabutin: 150mg/day or 300mg 3x/week Rifampin: 600mg/day; EFV 600mg/day Rifabutin: mg/day; EFV 600mg/day Rifampin: Do not co administer Rifabutin: 300 mg/day*; ETR 200mg BID Rifampin: Do not co administer Rifabutin: 300mg/day; RPV 50mg/day Rifampin: 600mg/day; RAL 800mg BID Rifabutin: 300mg/day; RAL 400mg BID Rifampin: Do not co administer Rifabutin: Do not co administer Rifampin: 600mg/day; DTG 50mg BID^ Rifabutin: 300mg/day; DTG 50mg/day^ Rifampin: Use only if necessary; MVC 600mg MVC MVC AUC: 64% MVC possible BID (MVC 300mg BID # ) Rifabutin: 300mg once daily (MVC 150mg BID # ) * without concomitant PI Department of Health & Human Services # with concomitant PI ^ unless certain INSTI RAMs 25 O desacetyl rifabutin (metabolite) Complera prescribing information

32 Anti infectives: Azoles and CYP 3A4 Modulators CYP3A4 Metabolism Substrate Recommendation Inhibitor Recommendation Minor Moderate Major Voriconazole Itraconazole Isavuconazonium Voriconazole 400mg BID + EFV 300mg/day Monitor itraconazole levels^ (especially if >200mg/day) Caution in coadministration (consider alternative?) Weak Moderate Strong Fluconazole No adjustment necessary Isavuconazonium (see recommendation above) Posaconazole Voriconazole Monitor for ARV related toxicities; co administer if benefit outweighs risk^ 63 ^ Do not co administer with EFV Department of Health & Human Services 2016 Anti infectives: Hepatitis C Antiretrovirals Daclatasvir Elbasvir/ Grazoprevir Direct Acting Antivirals Ledipasvir/ Sofosbuvir Ombitasvir/ Paritaprevir/rtv + Dasabuvir Simeprevir Velpatasvir/ Sofosbuvir ATV decrease DCV dose use ATV 300mg (no additional booster) DRV DTG increase EFV DCV dose increase ETR DCV dose decrease EVG/cobi DCV dose LPV/rtv RAL RPV TAF TDF caution caution ATV = atazanavir; cobi = cobicistat; DCV = daclatasvir; DRV = darunavir; DTG = dolutegravir; EFV = efavirenz; ETR = etravirine; EVG = elvitegravir; LPV = lopinavir; RAL = raltegravir; RPV = rilpivirine; TAF = tenofovir alafenamide; TDF = tenofovir disoproxil fumarate; rtv = ritonavir Department of Health & Human Services Harvoni prescribing information

33 HMG CoA Reductase Inhibitors ( statins ) and CYP 3A4 Inhibitors CYP Metabolism 3A4 (3A4) Mixed Non CYP (UGT) Lovastatin Simvastatin Pravastatin Atorvastatin (3A4, UGT) Fluvastatin (3A4, 2C9, 2D6) Rosuvastatin (3A4, 2C9) Pitavastatin Do not coadminister No adjustment necessary Titrate carefully and use lowest necessary dose No adjustment necessary 65 Department of Health & Human Services 2016 Phosphodiesterase 5 (PDE 5) Inhibitors and CYP 3A4 Inhibitors PDE 5 Inhibitor Recommendation Avanafil Do not co administer Sildenafil 25mg q48h (erectile dysfunction) Do not co administer (for PAH) Tadalafil 5 10mg q72h (erectile dysfunction) 20 40mg once daily (PAH) 2.5mg once daily (BPH) Vardenafil 2.5mg q72h (erectile dysfunction) Benign prostatic hyperplasia (BPH); 66 Pulmonary arterial hypertension (PAH) Department of Health & Human Services

34 Substrate Recommendation Induction Neuropsychiatric Medications & and CYP 3A4 Modulators CYP Metabolism Only non 3A4 3A4 (minor) 3A4 (major) Lamotrigine Phenobarbital Valproic acid Oxazepam Paroxetine Lorazepam No adjustment necessary Valproic acid Amitriptyline Phenytoin* Bupropion Sertaline Temazepam Titrate dose of substrate based on clinical response Alprazolam Diazepam Carbamazepine Clonazepam Ethosuximide Quetiapine # Consider alternative or monitor levels/effectiveness of substrate Carbamazepine Phenobarbital Phenytoin Oxcarbazepine No adjustment Consider alternative or Recommendation necessary monitor levels of ARV^ DRUG CLASS: Anti depressant; Anti epileptic; Anti psychotic; Benzodiazepine ^ Do not co administer with PI without RTV, ETR, or RPV * Consider alternative/levels (narrow therapeutic index) 67 # Reduce quetiapine dose by 1/6 if starting PI Department of Health & Human Services 2016 Hormonal Contraceptives ARV Contraceptive Dosing Recommendations Estrogen ATV/r & DRV/r Ethinyl estradiol AUC: 19 44%^ EFV Ethinyl estradiol AUC: no change EVG/c/FTC/TDF Ethinyl estradiol AUC: 25% ETR Ethinyl estradiol AUC: 22% RPV Ethinyl estradiol AUC: 14% Progesterone ATV/r & DRV/r Norethindrone AUC: 14 34%^ EFV Levonorgestrel AUC: 58 83%* EFV Etonogestrel AUC: 63% EVG/c/FTC/TDF Norgestimate AUC: > 200% ^ Without RTV boosting, AUC increase * Case reports of contraceptive failure with implants Recommend alternative/additional contraception No adjustment necessary Recommend alternative/additional contraception Department of Health & Human Services 2016 Scarsi KK, et.al. CROI Perry SH, et.al. AIDS

35 Local Corticosteroids and CYP 3A4 Inhibitors 69 Ramanathan R, et.al. Clin Infect Dis 2008 Local Corticosteroids and CYP 3A4 Inhibitors 70 Boyd SD et.al. J Acquir Immune Defic Syndr

36 Types of Transport Breast cancer resistance protein (BCRP); Multi drug resistance associated protein (MRP); Organic anion transporting polypeptide (OATP); Organic anion transport (OAT); Organic cation transport (OCT); P glycoprotein (P gp, also ABC) Ayrton A, et.al. Xenobiotica 2001 Limit Metformin Dose with Dolutegravir 72 Song IH, et.al. J Acquir Immune Defic Syndr

37 Mr. Smith Mr. Smith is a 54yo patient who has been living with HIV for the past 10 years. He is currently virologically suppressed on DRV/r + FTC/TDF with a high CD4 count. His past medical history includes: GERD Hyperlipidemia (ASCVD 10 yr risk = 13.5%) HCV Seasonal allergies How would you appropriately manage his other chronic co morbidities? 73 Can Mr. Smith receive a PPI with his cart? Yes Which HMG CoA reductase inhibitor would be best for Mr. Smith? Atorvastatin Rosuvastatin Which HCV medications should Mr. Smith avoid? Ledipasvir Paritepravir (+ Ombitasvir + Dasabuvir) Simeprevir Which corticosteroid intranasal spray would you recommend for Mr. Smith? Beclomethasone 74 37

38 Conclusions Combination antiretroviral therapy results in HIV virologic suppression, leading to increased longevity and quality of life Recommended and alternative antiretroviral regimens are generally well tolerated Patients should be educated regarding hallmark adverse drug reactions that may commonly or rarely occur As patients age with HIV, it is important to conduct a comprehensive medication review to reconcile potential drug drug interactions. 75 Questions? Lori A. Gordon, PharmD, BCPS, AAHIVP Xavier University of Louisiana College of Pharmacy lgordon4@xula.edu 38