Cases AMC HIV/HCV Conference 2015

Transcription

1 Cases AMC HIV/HCV Conference 2015 CYNTHIA MILLER, MD SHELLEY GILROY, MD DIVISION OF H IV MEDICI N E A LBANY MEDICAL COLLEG E JUNE 3, 2015 Pre-Exposure Prophylaxis A 32 y.o. male comes to your office for HIV testing. On review, you learn that he is sexually active with several men, usually without condoms. At completion of the appointment, you: A. Refer him for STD testing B. Refer him for STD testing and recommend he consider PrEP C. Test him for HIV with no further discussion D. Tell him what he s doing is immoral 91% 3% 6% 0% Refer him for STD testing Refer him for STD testing... Test him for HIV with no... Tell him what he s doing i... 1

2 You refer him for STD testing (or do it yourself if that is an option) and recommend consideration of PrEP. PrEP has been found to be: 88% A. 25% effective at HIV prevention when the patient takes all doses of medication B. 46% effective C. 71% effective D. 92% effective 0% 0% 12% 25% effective at HIV prev... 46% effective 71% effective 92% effective What is the recommended medication for PrEP? A. Tenofovir alone B. Tenofovir and emtricitabine C. Lamivudine and abacavir D. Both B and C 53% 23% 23% 0% Tenofovir alone Tenofovir and emtricitabine Lamivudine and abacavir Both B and C 2

3 What laboratories should be monitored regularly? A. Serum Cr B. RPR C. Urine, throat, and rectal chlamydia and gonorrhea D. All of the above 36% 51% 7% 7% Serum Cr RPR Urine, throat, and rectal... All of the above Success or Failure? A 54 y.o. male is new to your office. He is known to be HCV positive and has failed therapy in the past with pegylated interferon (PEG) and ribavirin (RBV). Further details are not known and are unavailable. Additional past medical history includes coronary artery disease, s/p CABG, and moderate but stable renal failure. He is HIV negative. 3

4 Baseline laboratories include normal CBC and chemistries as follows: Na- 139 K- 4.2 Cl- 115 Bicarb- 25 BUN- 10 Cr- 1.9 Glucose- 102 AST- 30 (12-30) ALT- 45 (15-60) Evaluation of the liver should include: A. Liver biopsy, the gold standard 91% B. HCV genotype; no further evaluation needed if he has genotype 4 because disease will not advance C. No evaluation is necessary because his transaminases are normal D. FibroSURE or FibroSPECT, HCV genotype 5% 3% 0% Liver biopsy, the gold st... HCV genotype; no furthe... No evaluation is necessa.. FibroSURE or FibroSPECT... 4

5 Do you need a viral load in order to decide whether to treat? A. Yes B. No 77% 23% Yes No The patient s results return with Fibrosis level 3, Activity level (inflammation) 1. This patient should A. Be treated, as he has significant disease B. Not be treated, as he does not have significant disease C. He cannot be treated due to his renal disease 96% 2% 2% Be treated, as he has sign... Not be treated, as he do.. He cannot be treated du... 5

6 The patient has genotype 1a virus. What is the best choice for treatment among those listed? A. Sofosbuvir/ledipasvir for 12 weeks B. Sofosbuvir/simeprevir for 24 weeks C. Sofosbuvir/ribavirin for 24 weeks 62% 29% 9% Sofosbuvir/ledipasvir for... Sofosbuvir/simeprevir fo... Sofosbuvir/ribavirin for... At 12 weeks, this pt s HCV viral load is detectable but <12. Has this patient failed therapy? A. Yes B. No 65% 35% Yes No 6

7 Drug-Drug Interactions A 36 y.o. male with a history of IV drug use has both HIV and HCV infections. He is not co-infected with HBV. He is known to have compensated cirrhosis with a history of small nonbleeding varices. He has a history of a psychotic break while taking PEG/ RBV. After treatment with respiradone, he was shepherded carefully through re-treatment with triple therapy including PEG, RBV, and telaprevir, but failed at 24 weeks, after initial success. You would like to try again to treat. He is genotype 1a. Medications: Tenofovir-emtricitabine, nelfinavir, and risperadone You can go ahead with treatment: 50% 50% A. True B. False 7

8 Change nelfinavir to: A. Darunavir/ritonavir B. Raltegravir C. Rilpivirine D. Elvitegravir/cobicistat 30% 48% 15% 7% Darunavir/ritonavir Raltegravir Rilpivirine Elvitegravir/cobicistat The patient is now on Tenofovir-emtricitabine and raltegravir. Now you can treat? A. True B. False 84% 16% True False 8

9 Change tenofovir to: A. Abacavir, after checking HLA B5701 B. Lamivudine C. Maraviroc 67% 17% 17% Abacavir, after checking... Lamivudine Maraviroc Now you can treat: A. True B. False 0% 0% True False 9

10 Our patient is more than halfway through his 24 week therapy, currently with viral load undetectable. Acute Hepatitis A 54 y.o. male relocated to Albany was seen in the office to resume medication. He had previously been on a darunavir/ritonavir combination but had not tolerated it well. He is HIV positive, CDC class C3, with recent diarrhea due to giardiasis, now resolving after treatment. He is sexually active with his long- term partner, without consistent use of condoms. He has no known HIV resistance mutations. His baseline CD4 cell count is

11 He is begun on tenofovir-emtricitabine and raltegravir in the summer of When seen 1, 3, and 6 months later, He is tolerating this regimen well. Diarrhea has resolved. He is asymptomatic. Past labs include HCV Ab negative and HBV sab positive. 3 months ago transaminases were normal. Routine labs return with CD4 cell count 67, HIV VL<40, AST 271 and ALT 340. What has happened? A. Acute Hepatitis due to antiretrovirals B. Acute hepatitis due to hepatitis B C. Acute hepatitis due to hepatitis C D. Acute hepatitis due to hepatitis D 33% 15% 52% 0% Acute Hepatitis due to an... Acute hepatitis due to h... Acute hepatitis due to h... Acute hepatitis due to h... 11

12 On questioning he admits unsafe sex outside his partnership. What tests should you order now? A. Hepatitis C Ab 54% B. Hepatitis C viral load C. Both A and B D. Hepatitis C genotype E. And don t forget to test for other STDs! 10% 10% 5% 22% Hepatitis C Ab Hepatitis C viral load Both A and B Hepatitis C genotype And don t forget to test... Hepatitis C Ab is negative and viral load is positive at IU/ml, consistent with acute hepatitis C. What should you do next? A. Treat for hepatitis C B. Hold treatment for hepatitis C 55% 45% Treat for hepatitis C Hold treatment for hepati... 12

13 Transaminases As time passes it becomes clear that he has developed chronic hepatitis C. His transaminases have returned to normal but HCV viral load remains positive. The CD4 cell count is 106. What should you do now? A. Treat for hepatitis C B. Hold treatment for hepatitis C 67% 33% Treat for hepatitis C Hold treatment for hepati... 13

14 Six months later his CD4 cell count is over 200 and you decide to treat HCV. He is genotype 3. What is the recommended therapy? 49% A. Sofosbuvir/ledisasvir B. Sofosbuvir /declatasvir C. Ombitasvir/paritaprevir/ritonavir and dasabuvir D. Sofosbuvir and RBV 10% 15% 26% Sofosbuvir/ledisasvir Sofosbuvir /declatasvir Ombitasvir/paritaprevir/... Sofosbuvir and RBV Does he have significant drug-drug interactions? He is now on tenofovir- emtricitabine-elvitegravir-cobicistat, having changed due to wishing to be on a simpler regimen: A. Yes B. No 54% 46% Yes No 14

15 The patient begins therapy with sofosbuvir/ribavirin for 24 weeks. He is currently undetectable at 12 weeks. HIV remains in control. HIV Treatment Failure A 54 y.o. male with HIV CDC class C3 returns to Albany after 10 years in another community. In the past he had been treated with serial mono- and duotherapy: AZT (zidovudine) alone, ddi (didanosine) alone, AZT plus 3TC (lamivudine), indinavir plus AZT and 3TC, nelfinavir plus AZT and 3TC. He cannot recall everything he took while he was away. For a while, he took a drug holiday (off therapy for 2 years). At present he is on tipranavir, ritonavir, tenofovir, and raltegravir. 15

16 He is HCV negative. He is HBV negative, vaccinated but with no response. He is 100% adherent to medication and has not been sexually active in many years. His only symptom is chronic diarrhea, for many years, both on and off medication. Workup for GI pathology including colonoscopy is negative. He uses imodium regularly. Current CD4 cell count is over 500. On routine follow up in late 2014 (1.5 years later), HIV viral load is 123. What should you do now? A. Repeat VL in one month. He may have had a blip. B. Repeat VL at the next office visit 80% 20% Repeat VL in one month... Repeat VL at the next offi.. 16

17 Repeat VL done now is 320. What should you do now? A. Obtain a genotype B. Obtain a phenotype C. Review old genos/phenos 31% 22% 47% Obtain a genotype Obtain a phenotype Review old genos/phenos Review of old genos/phenos reveals: 67N, 70R, 184V, 211K, 98G, 1791, 198A and multiple PI mutations. (9) He has never had resistance testing for integrase inhibitors. However, his most recent genotype, done at his previous doctor s, is pansensitive. What should you do now? 17

18 March 2, 2006 July 13,

19 January 15, 2015 A genotype Archive is obtained. At present the patient remains stable with an excellent CD4 cell count and low but positive VL. 19

20 February 2,