Post on 28-Jan-2020
Case discussion: How do drugs/patients impact need and
type of monitoring – CASE 2
Marta BoffitoHead of Clinical Trials, St. Stephen’s Centre (SSAT)
Consultant Physician, Chelsea and Westminster Foundation TrustReader, Imperial College London
Mr DB
• 54 years old MSM• HIV dx in 2004• cART (TDF/FTC + NVP) since 2006
• Acute hep C treatment with Harvoniapproximately 6 months ago (8 weeks)– HCV PCR negative
Mr DBWell•
Co• -medicationsSildenafil 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?
Increasingage,
ageingprocess1
Lifestyle(drugs,
alcohol)1
Drug toxicity(e.g. TDF andNephrotoxicit
y1)
Persistentimmune
dysfunctioninflammatio
n1PREMATURE
AGEING
Polypharmacy
Cancer1,3
Bonedisease1,5
Kidneydisease1,7
Neurological Impairments1,2
CVD1,4
Liverdisease1,6
1. Deeks SG et al. BMJ 2009;338:a31722. McArthur JC et al. Ann Neurol 2010;67:699–714
3. Nguyen ML et al. 18th IAC. Vienna, Austria 2010. Abstract WEAB01054. Freiberg MS et al. JAMA Intern Med 2013;173:614–22
5. Brown TT et al. AIDS 2006;20:2165–746. Towner WJ et al. JAIDS 2012;60:321–77. Lucas GM et al. Clin Infect Dis 2014;59
Do patients with HIV age prematurely?
HIV=human immunodeficiency virus; TDM=therapeutic drug monitoring; CACS=coronary artery calcium scores; BMD=bone mineral densityWaters L, et al. Int J STD AIDS 2012;23:546‒52
…full medication and drug interactions review, neurocognitive assessment, adherence self-
assessment and investigations, including TDM, CACS and BMD.
…osteoporosis……prostate cancer…
The clinic has improved general practitioner (GP) liaison…
A dedicated clinic for the over 50’s at C&W
Older patients (> 50)
BHIVA monitoring Guidelines, www.BHIVA.org
• N of drugs• Type of drugs
– Prescribed– OTC– Herbals– Recreational– Alcohol
• Drug interactions
Drug history
Drug interaction resources HIV
MenCheck for hypogonadism• low libido• depression• osteoporosis
TestosteroneTotal and FREE
Endocrine systemWomen
Menopausal clinic• depression• osteoporosis• ….
Transexual• symptomatology• drug interactions
Full hormonalprofile, if needed
Full hormonalprofile with
appropriate referral
Cancer screening
MEN• PSA• 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
5866 65 67 69
6171
5242 41
51 5245
53
0
20
40
60
80
Mea
n ag
e of
ca
ncer
dia
gnos
is
SCC, squamous cell carcinoma, SEER, Surveillance, Epidemiology and End Results
Average age at cancer diagnosis for 516 HIV-positive individuals and uninfected individuals (SEER database), by cancer type, 2000–20072
Uninfected(SEER database)
HIV-positiveindividuals
Anal/rectalSCC
Non-Hodgkinlymphoma Liver Head
and neck Lung Breast Prostate
p=0.0001 for all comparisons
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
CVD risk assessment (Framingham score)Should be performed in all men > 40 years and women > 50 years without CVD
https://www.qrisk.org/2017/
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).
Coronary artery calcification scoreCACS
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)
Depression
Anxiety
Cognitive assessment: PHQ9 and GAD7
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 > 75th centile?)