Case discussion: How do drugs/patients impact need and type of monitoring CASE 2 Marta Boffito Head of Clinical Trials, St. Stephen s Centre (SSAT) Consultant Physician, Chelsea and Westminster Foundation Trust Reader, Imperial College London
Mr DB 54 years old MSM HIV dx in 2004 cart (TDF/FTC + NVP) since 2006 Acute hep C treatment with Harvoni approximately 6 months ago (8 weeks) HCV PCR negative
Mr DB Well Co-medications Sildenafil purchased on line Recreational drugs Poppers Alcohol intake Limited (a couple of glasses of wine/week, socially) BP 170/98, GP wrote to you to ask whether he can start amlodipine 10 mg OD
Mr DB U&E within normal range LFTs within normal range FBC within normal range Lipids TC 6 mmol/l (231.7 mg/dl) TG 1.39 mmol/l (53.7 mg/dl) HDL 1.25 mmol/l (48.3 mg/dl) LDL 4.11 mmmol/l (158.7mg/dL) HDL:chol ratio 4.76 NON HDL chol 4.7 mmol/l (NV <2.5) 181.5 mg/dl HIV VL < 20 copies/ml CD4 584 cells/mm3 Hep A IgG + anti-hbsag > 1000 Sexual health screen: RPR negative, syphilis IgG/IgM positive, GC negative, CT negative
What other aspect of Mr DB health require monitoring?
Do patients with HIV age prematurely? Lifestyle (drugs, alcohol) 1 Increasing age, ageing process 1 Persistent immune dysfunction inflammatio n 1 Drug toxicity (e.g. TDF and Nephrotoxicit y 1 ) PREMATURE AGEING Neurological Impairments 1,2 CVD 1,4 Liver disease 1,6 Cancer 1,3 Kidney disease 1,7 Bone disease 1,5 Polypharmacy 1. Deeks SG et al. BMJ 2009;338:a3172 2. McArthur JC et al. Ann Neurol 2010;67:699 714 3. Nguyen ML et al. 18th IAC. Vienna, Austria 2010. Abstract WEAB0105 4. Freiberg MS et al. JAMA Intern Med 2013;173:614 22 5. Brown TT et al. AIDS 2006;20:2165 74 6. Towner WJ et al. JAIDS 2012;60:321 7 7. Lucas GM et al. Clin Infect Dis 2014;59
A dedicated clinic for the over 50 s at C&W full medication and drug interactions review, neurocognitive assessment, adherence selfassessment and investigations, including TDM, CACS and BMD. osteoporosis prostate cancer The clinic has improved general practitioner (GP) liaison HIV=human immunodeficiency virus; TDM=therapeutic drug monitoring; CACS=coronary artery calcium scores; BMD=bone mineral density Waters L, et al. IntJ STD AIDS 2012;23:546 52
Older patients (> 50) BHIVA monitoring Guidelines, www.bhiva.org
Drug history N of drugs Type of drugs Prescribed OTC Herbals Recreational Alcohol Drug interactions
Drug interaction resources HIV
Endocrine system Men Check for hypogonadism low libido depression osteoporosis Women Menopausal clinic depression osteoporosis. Transexual symptomatology drug interactions Testosterone Total and FREE Full hormonal profile, if needed Full hormonal profile with appropriate referral
Cancer screening PSA MEN Anal cytology Referral to anoscopy clinic if cytology is abnormal WOMEN Cervical smear* Ensure mammography is done or planned *cervical smear test is recommended every year regardless of patient s age
PLWHIV are diagnosed with cancer at an earlier age than uninfected adults Average age at cancer diagnosis for 516 HIV-positive individuals and uninfected individuals (SEER database), by cancer type, 2000 2007 2 Mean age of cancer diagnosis 80 60 40 20 58 52 66 65 67 69 42 41 51 52 61 45 71 53 0 Anal/rectal SCC Non-Hodgkin lymphoma Liver Head and neck Lung Breast Prostate Uninfected (SEER database) HIV-positive individuals p=0.0001 for all comparisons SCC, squamous cell carcinoma, SEER, Surveillance, Epidemiology and End Results 1. National Cancer Institute Fact Sheet. HIV Infection and Cancer Risk. National Institutes of Health. 2013, 2. Nguyen ML et al. 18th IAC, 2010. Vienna, Austria. Abstract WEAB0105
Monitoring of CVD We recommend baseline assessment of CVR on HIV-positive patients who are aged > 40 years and/or have significant CVD risk factors using QRISK2, taking into account that it will underestimate risk (1B). https://www.qrisk.org/2017/ CVD risk assessment (Framingham score) Should be performed in all men > 40 years and women > 50 years without CVD
Coronary artery calcification score CACS
Bone mineral density FRAX score DEXA scan Vitamin D
Cognitive assessment Are you concerned about your memory/concentration/cognition? Has anybody around you expressed concern about your memory/concentration/cognition? SOCIAL SITUATION: combination of all social factors that come into play at any one time (e.g. isolation, alcohol use, anxiety regarding future)
Cognitive assessment: PHQ9 and GAD7 Depression Anxiety
Cognitive assessment: EMQ
Algorithm for Diagnosis and Management of HIV-Associated Neurocognitive Impairment (NCI) in Persons without Obvious Confounding Conditions 1. Exclude depression 2. If NP examination is abnormal, consider neurology referral/brain MRI 3. Importance of cart 4. Need for LP to evaluate active CNS HIV NP = neuropsychological
Mr DB Needs treatment for hypertesion, potential DDI between NVP and amlodipine, review cart unboosted InSTI? Had osteoporosis review cart should he change from TDF to TAF or ABC (CVR?) CVR 12% Does he need a statin? CACS zero (what about if > 75 th centile?)