The Hospitalized HIV+ Patient

Similar documents
Medication Errors Focus on the HIV-Infected Patient

THE HIV LIFE CYCLE. Understanding How Antiretroviral Medications Work

HIV basics. Katya Calvo Medical Director of Antimicrobial Stewardship

TORONTO GENERAL HOSPITAL HIV AMBULATORY CARE ROTATION

WOMENS INTERAGENCY HIV STUDY ANTIRETROVIRAL DOSAGE FORM SECTION A. GENERAL INFORMATION

Comprehensive Guideline Summary

HIV MEDICATIONS AT A GLANCE. Atripla 600/200/300 mg tablet tablet daily. Complera 200/25/300 mg tablet tablet daily

Sasisopin Kiertiburanakul, MD, MHS

Industry Data Request

Continuing Education for Pharmacy Technicians

Central Nervous System Penetration of ARVs: Does it Matter?

PHARMACOKINETICS OF ANTIRETROVIRAL AND ANTI-HCV AGENTS

Antiretroviral Dosing in Renal Impairment

Simplifying HIV Treatment Now and in the Future

The ART of Antiretroviral Therapy in Critically-ill Patients with HIV

HIV/AIDS Update 2007

TB Intensive Tyler, Texas December 2-4, Tuberculosis and HIV Co-Infection. Lisa Y. Armitige, MD, PhD. December 4, 2008.

TB/HIV Co-Infection. Tuberculosis and HIV

HIV associated CNS disease in the era of HAART

Distribution and Effectiveness of Antiretrovirals in the Central Nervous System

Second-Line Therapy NORTHWEST AIDS EDUCATION AND TRAINING CENTER

Principles of Antiretroviral Therapy

HIV medications HIV medication and schedule plan

Approach to Co-infection with TB and HIV: 2011 Henry Fraimow, MD

NON-OCCUPATIONAL POST EXPOSURE PROPHYLAXIS IN HIV PREVENTION. Jason E. Vercher, PA-C, AAHIVM

This graph displays the natural history of the HIV disease. During acute infection there is high levels of HIV RNA in plasma, and CD4 s counts

HIV in the Brain MANAGING COMORBIDITIES IN PATIENTS WITH HIV

The use of antiretroviral agents during pregnancy in Canada and compliance with North-American guidelines

Industry Request Integrase Inhibitors

Susan L. Koletar, MD

HIV Drugs and the HIV Lifecycle

Fluconazole dimenhydrinate, diphenhydramine. Raltegravir or dolutegravir with antacids

Pharmacological considerations on the use of ARVs in pregnancy

ADAP Monitoring Provider Prescribing Patterns. Amanda Bowes, NASTAD Christine Rivera and Dr. Charles Gonzalez, NYS AIDS Institute

Drug Treatment Program Update

HIV Update Objectives. Epidemiology. Epidemiology, Transmission and Natural History. Transmission Risk by Exposure. Transmission 9/29/2014

British HIV Association Guidelines for the Management of Hepatitis Viruses in Adults Infected with HIV 2013 Appendix 2

When to Start ART. Reduction in HIV transmission. ? Reduction in HIV-associated inflammation and associated complications» i.e. CV disease, neuro, etc

20 Years of Tears and Triumphs

Dr Alan Winston. Imperial College Healthcare NHS Trust London. 7-8 October 2010, Queen Elizabeth II Conference Centre, London.

0.14 ( 0.053%) UNAIDS 10% (94) ( ) (73-94/6 ) 8,920

HIV for the Non-ID Pharmacist

Nothing to disclose.

1/18/2011. Handling TB and HIV. Fargo, North Dakota September 15-16, Treatment of TB in the HIV Co-Infected Patient

Susan L. Koletar, MD

REIMBURSEMENT STATUS OF HIV MEDICATIONS IN ONTARIO

The ART of Managing Drug-Drug Interactions in Patients with HIV

HIV in in Women Women

ART and Prevention: What do we know?

Antiretroviral Therapy During Pregnancy and Delivery: 2015 Update

PHCP 403 by L. K. Sarki

The Global HIV Epidemic. Jerome Larkin, MD

Clinical Vignette: Patient 1. Approach to Co-infection with TB. TB and HIV Co-infection: Some Resources. Objectives.

POST-EXPOSURE PROPHYLAXIS, PRE-EXPOSURE PROPHYLAXIS, & TREATMENT OF HIV

2 nd Line Treatment and Resistance. Dr Rohit Talwani & Dr Dave Riedel 12 th June 2012

HIV and AIDS. Shan Nanji

Too small, too soon: antiretroviral prophylaxis and treatment in preterm and low birth weight infants

Overview of HIV. LTC Paige Waterman

Northwest AIDS Education and Training Center Educating health care professionals to provide quality HIV care

Overview of HIV WRAIR- GEIS 'Operational Clinical Infectious Disease' Course

WESTERN CAPE ART GUIDELINES PRESENTATION 2013

Didactic Series. HIV Drug-Drug Interactions: OTC and non-prescription medications. Kirsten B. Balano, PharmD UCSF School of Pharmacy February 26, 2015

HIV Update. Divya Ahuja, MD Associate Professor of Medicine University of South Carolina School of Medicine

Pediatric Antiretroviral Resistance Challenges

CLINICAL VIGNETTE: Patient 1. Approach to Co-infection with TB and HIV: TB and HIV Co-infection: Some Resources. Goals and Objectives

HIV DISEASE! Neurobehavioral! Neuromedical. Igor Grant, MD, FRCP(C) Director HIV Neurobehavioral Research Program University of California, San Diego

Selecting an Initial Antiretroviral Therapy (ART) Regimen

WOMEN'S INTERAGENCY HIV STUDY METABOLIC STUDY: MS01 SPECIMEN COLLECTION FORM

Terapia antirretroviral inicial y de rescate: Utilidad actual y futura de nuevos medicamentos

PAEDIATRIC HIV INFECTION. Dr Ashendri Pillay Paediatric Infectious Diseases Specialist

The Annotated Bibliography of the UCSF HIV Solid Organ Transplantation Project. ARV Dosing in End Stage Renal Disease

Nurse Case Management Phoenix, Arizona February 20-22, 2008

HIV Pharmacology 101ish - 202ish: New HIV Clinicians Workshop

ANTIRETROVIRAL TREATMENTS (Part 1of

Didactic Series. Update: 2012 HIV Treatment Guidelines. Daniel Lee, MD August 30, 2012

104 MMWR December 17, 2004

/AIDS HIV/ HIV Overview. Nelson L. Michael, MD, PhD Division of Retrovirology Walter Reed Army Institute of Research US Military HIV Research Program

HIV THERAPY STRATEGIES FOR THIRD LINE. issues to consider when faced with few drug options

Risk of HIV-1 low level viremia to treatment. Germany. Nadine Lübke Düsseldorf


ART rapid scale up: the implications for patient care and retention. Dr Francesca Conradie Southern African HIV Clinicians Society

Case # 1. Case #1 (cont d)

MEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 03/07/18 SECTION: DRUGS LAST REVIEW DATE: 02/19/19 LAST CRITERIA REVISION DATE: ARCHIVE DATE:

ANTIRETROVIRAL THERAPY

Monographs on ARV and hepatitis medicines in The International Pharmacopoeia

STATEMENT OF DISCLOSURE

ALABAMA S ADAP FORMULARY OFFERS 117 MEDICATIONS

COMPREHENSIVE ANTIRETROVIRAL TABLE: ADULT DOSING, DOSAGE FORM MODIFICATIONS, ADVERSE REACTIONS and INTERACTION POTENTIAL

Actualización y Futuro en VIH

Update on Antiretroviral Treatment for HIV Infection 2008

HIV and the Central Nervous System Impact of Drug Distribution Scott L. Letendre, MD. Professor of Medicine University of California, San Diego

Criteria for Oral PrEP

Approach to a Patient Newly Diagnosed with HIV, Including ART Basics Rajesh T. Gandhi, M.D.

Pediatric HIV Infection and the Medical Management of Pregnant Women infected with HIV. Ernesto Parra, M.D., M.P.H.

HIV Management Update 2015

ARVs on an Empty Stomach: Food Interaction Studies in a resource Limited Setting

Cost impact of an HIV MDT for managing anti-retroviral switch

Epidemiology Testing Clinical Features Management

Second and third line paediatric ART strategies

Transcription:

The Hospitalized HIV+ Patient Danny Toub MD dannyt@srheathcenters.org October 8, 2012 Santa Rosa Family Medicine Residency List 3 ways of risk-stratifying known or suspected HIV+ inpatients Perform differential diagnosis and workup of suspected Opportunistic Infections List 3 common reasons for ART medication errors in hospitalized HIV+ patients Stable HIV Continue ART (formulary) Adherence Drug Interactions Renal Insufficiency NPO IRIS (recently stable) Known or Suspected HIV+ Inpatient Assess Risk End organ damage to Immune System? Clinical exam: Thrush, LAD, Wasting Absolute Lymphocyte Count <1000? CD4: <200, <14% HIV Viral Load: Detectable? HIV Urgency/Emergency: Pregnant? Needlestick? Pulm Sx Bacterial pneumonia PCP TB Histo GI Sx MAC/TB Cryptosporidia CMV Unstable HIV (new diagnosis or out of care) Neuro Sx Baseline labs Toxoplasma Cryptococcus CNS Lymphoma CMV Fever PCP TB Lymphoma Other Lymphoma cancer Assess for end-organ damage to Immune System Absolute Lymphocyte Count: <1000? Nadir or current CD4: <200? <14% www.nccc.ucsf.edu/ about_nccc/pepline/ 1

The Stable HIV Inpatient Continue ART (formulary) Adherence Drug Interactions Renal Insufficiency NPO IRIS (recently stable) www.nccc.ucsf.edu/about_nccc/perinatal_hotline/ Formulary/Adherence 2

Contraindications with common ICU medications All NRTIs (except Abacavir) need renal dosing Contraindicated with NNRTIs Contraindicated with PIs Midazolam/Triazolam (both with Efavirenz) Midazolam/Triazolam Proton-Pump Inhibitors (Atazanavir) H2-blockers (If bid with Atazanavir) Amiodarone(Indinavir, Ritonavir or Tipranavir) Propafenone (Lopinavir/Ritonavir, Ritonavir, Tipranavir) Quinidine(Ritonavir or Tipranavir) Liquid Formulation -Practical/Palatable -OK for NG/feeding tubes -Impractical or powder OK to open capsules or crush/dissolve tablets (immediately) Not OK to crush/dissolve tablets Injectable formulations available ART Zidovudine, Lamivudine, Abacavir, Nevirapine, Emtricitabine, Fosamprenavir Ritonavir, Lopinavir/Ritonavir Nelfinavir(very impractical), Stavudine, (moderately impractical), Didanosine (somewhat cumbersome), Delavirdine (100mg), Etravirine, Nelfinavir Atazanavir, Delavirdine(200mg), Darunavir, Efavirenz,Emtricitabine, Nelfinavir, Tenofovir ALL COFORMULATIONS Darunavir,Indinavir, Maraviroc, Raltegravir, Rilpivirine, Tipranavir, Saquinavir, Enfuvirtide(SQ), Zidovudine(IV) 3

Improved survival in ICU for HIV patients Chest. 2009 January; 135(1): 11 17. doi: 10.1378/chest.08-0980 Common ART medication errors Error class Rxas ordered Specific error Day 1 Errors (N=145) Incomplete regimen Incorrect dosage Darunavir600bid/ Ritonavir100bid Darunavir600bid/ Ritonavir100bid/ Abacavir 600qd/ Lamivudine 50 qd Missing additional Tenofovir/FTC Lamivudine dosage 150mg qd based on CrCl=40 64 (58%) 42 (38%) Day 2 Errors (N=22) 0 (0%) 11 (50%) Incorrect schedule Nonrecommended drug-drug combinations Lopinavir 200mg/Ritonavir 50mg two tabs qd and TDF/FTC qd Atazanavir 300mg/Ritonavir 100mg and TDF/FTC qdwith Inhaled Fluticasone daily Kaletra tablets are dosed bid Fluticasoneand Ritonavircan cause Cushing s 25 (23%) 14 (13%) 11 (50%) 0 (0%) Antiretroviral medication errors remain high but are quickly corrected among hospitalized HIV-infected adults. Yehia BR, Mehta JM, Ciuffetelli D, et al. ClinInfect Dis2012;55:593-9. Antiretroviral medication errors remain high but are quickly corrected among hospitalized HIVinfected adults. YehiaBR, Mehta JM, Ciuffetelli D, et al. ClinInfect Dis2012;55:593-9. Conclusion: ART medication errors are typically corrected within 48 hours (if you have two ID specialist PharmD s reviewing all medication orders for: ART medication errors and ART drug interaction errors) Immune Reconsitution Inflammation Syndrome (IRIS) Unmasking IRIS Clinical presentation of preexisting, subclinical OI after HAART initiation Viable pathogens Usually 3 months of HAART Example: Non-tuberculous mycobacteria (MAC), TB Paradoxical IRIS Exacerbation and/or return of sxs of currently or recently treated OI Non-viable antigens of pathogens Usually 3 months of HAART Months to years for immune recovery (CMV) uveitis Examples: TB, Cryptococcal disease, Kaposi s sarcoma (KS) 8:30AM-5:30PM: 707-583-8819 (SRCHC x425) HIV Nurse Case Manager 24/7 HIV Specialist on-call: 707-583-8823 to reach cell phone of an HIV Specialist MD Newly diagnosed HIV+ pts: clients call 707-583-8816 for the HIV Outreach Worker. HIV Case Manager will assess hospitalized clients within 48 hours: Newly diagnosed: in hospital within 48 hrs after notification of admission All HIV+ patients: Telephone or in office within 48 hrs after hospital discharge 4

www.faetc.org/pdf/pocket_guides/opportunistic_infections_drug_card.pdf 5

6

Questions? 7

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback