MEDICATION RELATED ISSUES IN THE HIV PATIENT LEONARD SOWAH, MBChB, MPH, FACP
Overview Evalua;on and ini;al of a HIV pa;ent with respect to medica;ons Triaging of pa;ent to determine ideal follow up plan Iden;fying poten;al drug interac;ons Developing a plan to reduce risk of treatment failure
Ini4al Evalua4on Review sources of past medical care Obtain records whenever possible Talk to previous providers as much as possible Always get a record of medica;ons used currently and prior HIV medica;ons
Ini;al Evalua;on Pa;ent needs a full history and physical exam with a focus on; HIV risk factors and ;me of diagnosis Other medical comorbidi;es (DM, HTN, COPD) Prior ART medica;ons if any and response to therapy Evalua;on of adherence, based on prior medica;on history and pa;ent self efficacy Substance abuse and social support Prior CD4 counts and viral loads History of opportunis;c infec;ons
Health Literacy Assessment Use simple markers to gauge literacy Understanding of CD 4 count & HIV viral load and disease progression Knowledge of transmission risk and protec;on of sexual partners Knowledge of current and ini;al indices CD4 and HIV viral load Knowledge of general lifestyle associated risks such as exercise and diet Insurance and coverage issues J Assoc Nurses AIDS Care. 2016 Jul-Aug; 27(4): 372 375
Integrated health literacy framework SES/Occupa;on and income Psychosocial and Social support Individual xs;cs Age, sex, gender Health Literacy Culture Language and Religion Previous Experience with health system General literacy (Reading and Arithme;c skills)
Medica;on History and Current HMG-CoA reductase inhibitors (sta;ns) Calcium channel blockers An;convulsants Phosphodiesterase Inhibitors Oral Contracep;ves Systemic and Inhaled cor;costeroids Antacids medica;ons Mecormin Benzodiazepines Buprenorphine/Naloxone (Suboxone) Immunosuppressants (e.g., cyclosporine) Rifamycins Azole an;fungals Macrolides Methadone St. John s wort
HIV Viral Replica4on Cycle Nature Medicine 9, 867-873 (2003) c
Current FDA approved ART drugs hgp://www.edurant.com/hcp/key-resources/hiv-pa;ent-resources
Available Treatment Op4ons NRTIs Zidovudine (Retrovir) Didanosine (Videx EC) Stavudine (Zerit) Lamivudine (Epivir) Abacavir (Ziagen) Tenofovir disoproxil fumarate (Viread) (TDF) Emtricitabine (Emtriva) Tenofovir alafenamide*** (TAF) NNRTIs Efavirenz (Sus;va) Nevirapine (Viramune) Delavirdine (Rescriptor) Etravirine (Intelence) Rilpivirine (Edurant) PIs Saquinavir (Invirase) Ritonavir (Norvir) Indinavir (Crixivan) Nelfinavir (Viracept) Fosamprenavir (Lexiva) Lopinavir+ritonavir (Kaletra) Atazanavir (Reyataz) Tipranavir (Ap;vus) Darunavir (Prezista) Fusion inhibitor Enfuvir;de (Fuzeon) CCR5 antagonist Maraviroc (Selzentry) Integrase inhibitor Raltegravir (Isentress) Elvitegravir (Vitekta) Dolutegravir (Tivicay) ***Only available as combo formula;ons Panel on An;retroviral Guidelines for Adults and Adolescents. Guidelines for the use of an;retroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at hgp://www.aidsinfo.nih.gov/contentfiles/adultandadolescentgl.pdf. Accessed September 10, 2016.
Available Treatment Op4ons Combina4on products Combivir Lamivudine + zidovudine Truvada Emtricitabine + tenofovir (TDF) Epzicom Abacavir + lamivudine Trizivir Abacavir + lamivudine + zidovudine Atripla Efavirenz + tenofovir (TDF) + emtricitabine Combina4on products Complera Rilpivirine + tenofovir (TDF) + emtricitabine Stribild Elvitegravir + cobicistat + tenofovir (TDF) + emtricitabine Triumeq Dolutegravir + abacavir + lamivudine Evotaz Atazanavir + cobicistat Prezcobix Darunavir + cobicistat Panel on An;retroviral Guidelines for Adults and Adolescents. Guidelines for the use of an;retroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at hgp://www.aidsinfo.nih.gov/contentfiles/adultandadolescentgl.pdf. Accessed September 10, 2016.
Available Treatment Op4ons Combina4on products Genvoya Elvitegravir + cobicistat + tenofovir (TAF) + emtricitabine Descovy Tenofovir (TAF) + emtricitabine Odefsey Rilpivirne + tenofovir (TAF) + emtricitabine Panel on An;retroviral Guidelines for Adults and Adolescents. Guidelines for the use of an;retroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at hgp://www.aidsinfo.nih.gov/contentfiles/adultandadolescentgl.pdf. Accessed September 10, 2016.
Case 1 A 25-year-old female with a CD4 cell count of 168 cells/mm 3 presents to clinic to 3 months aoer having a new diagnosis of HIV. Three weeks ago she was started on trimethoprimsulfamethoxazole (Bactrim, Septra) and she is tolera;ng this well. She takes norethindrone/ ethinyl estradiol (Ortho Novum 7/7/7 Triphasic) for birth control and admits that her boyfriend is unlikely to consistently use condoms. You are planning to start her on an;retroviral therapy, but are concerned about how the an;retroviral medica;ons may interact with her birth control pills. What HIV treatment regimen would be most appropriate for this pa;ent?
Drug interac4ons in HIV pa4ents Sta4ns (Cholesterol lowering drugs Simvasta;n Lovasta;n With pa;ents on Protease Inhibitors An4convulsants Phenytoin Phenobarb Tegretol Leve4racetam Start at lowest dose in pa;ent on protease inhibitors Pravasta;n Pitavasta;n Atorvasta;n Rosuvasta;n Hormonal Contracep4ves Depo-Provera Hormonal OCP Levonorgestrel (Norplant) inplants
Drug Interac4ons in HIV pa4ents Steroids Oral steroids Prednisone Hydrocor;sone Solumedrol Intranasal and inhaled steroids Flu;casone (Flonase/Flovent) Budesonide (Pulmicort/Symbicort) Momethasone (Nasonex/Asmanez) Beclomethasone (Qvar) Flunisolide (Nasarel/Aerobid) Phosphodiesterace Inhibitor Sildenafil (Viagra) Taladafil (Cialis) Vardenafil ( Levitra) Opioid Replacment Therapy Methadone Buprenorphine
Drug Interac4ons in HIV pa4ents Acid Lowering medica4ons Antacids Proton pump inhibitors H-2 Receptor blockers An4-tuberculous agents Rifampin Rifabu;n Non Pharmalogics/Herbals St John s wort
Case 2 The 64 year old mechanic who would not see an infec;ous disease doctor.
Medica;on Adherence
Why is adherence important?! Because it makes your work easy! 95 % adherence is required for viral suppression! HIV drug resistance develops rapidly in the seung of non-adherence! HAART regimens in the seung of resistance are more complex! Adverse events are more common in pa;ents with mul;-drug resistant virus
Case 3 The 24 year old trans female who wanted a regimen that would have the most minimal impact on her busy lifestyle
Adherence, pa;ent related factors Reasons given for missing medica0on doses Kalichman et al, J Gen Intern Med 1999; 14:267-273
Treatment related Adverse effects Images: www.hiv.va.gov
Immune ac;va;on Inflamma;on Macrophage Recruitment Endothelial Dysfunc;on CARDIOVASCULAR DISEASE IN HIV HIV Viral Replica;on Insulin Resistance & Diabetes Atherosclerosis An;-retroviral Therapy Dyslipidemia Hypertension Smoking Gene;cs Modified from: Currier J.S., Topics in HIV Medicine, 2009, 17(3); 98-103
Tobacco use and substance abuse AIDS. 2015 Jan 2; 29(1): 117 123
Scenario Follow-up and monitoring Viral Load Monitoring CD4 Count Monitoring Comprehensive Metabolic Panel Prior to ART therapy At entry in care At entry in care and if ART deferred 3 6 mths At entry in care and at ART ini;a;on Aoer ini;a;ng ART Every 4 weeks ;ll suppressed 3 mths aoer ini;a;ng ART 2 8 weeks aoer ini;a;on and every 3 6 month thereaoer Aoer switching therapy in a suppressed pa;ent 4 8 weeks aoer change No recommenda;on Post switch for virologic failure Every 4 weeks ;ll suppressed Every 3 6 months Aoer 2 years of ART Every 6 month Every 12 months On ART with detectable viremia (VL > 200 copies) Every 3 months???? Every 3 6 mths
Metabolic issues and lipids HIV/AIDS Research and Pallia;ve Care 2015:7 1 10
Immuniza4on and preven4on Mumps, Measles and Rubella only if CD4 count > 200 Zoster vaccine only if CD4 > 400 cells HPV vaccine as in non HIV Up ;ll age 26 yrs Pneumovax at diagnosis and repeat in 5 years Prevnar 13 once but at least 12 mths aoer Pneumovax 23 dose Advisory Commigee on Immuniza;on Prac;ces (ACIP). MMWR. Morbidity and mortality weekly report, 61(40), 816.
Summary As HIV pa;ents age more and more pa;ents will require mul;ple medica;ons Drug to drug interac;ons are very important in these pa;ents Knowledge of current medica;ons and poten;al interac;ons significant reduces risk of morbidity and improves adherence Choice of medica;ons such as lipid lowering therapy and an;convulsants must be done with care in the HIV pa;ent