Ardis Ann Moe, M.D. UCLA CARE Clinic/NEVHC HIV Clinic Van Nuys. 28 August 2015 [email protected].
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Transcript of Ardis Ann Moe, M.D. UCLA CARE Clinic/NEVHC HIV Clinic Van Nuys. 28 August 2015 [email protected].
HIV medications: Side Effects and Choices of
TreatmentArdis Ann Moe, M.D.
UCLA CARE Clinic/NEVHC HIV Clinic Van Nuys.28 August 2015
To describe the major side effects of HIV treatment
To know useful lab tests for HIV side effect monitoring
To review case studies of how to choose initial HIV regimen, and what regimen to switch to in the event of side effects
Benefits of treatment
Objectives
Fuzeon causes painful lumps on the skin that persist for weeks
Shots need to be done twice daily
Selzentry rarely causes rash; can cause orthostatic hypotension, nausea, dizziness. Cannot be used in kidney failure
Entry inhibitors
As a class, they are associated with liver problems: lactic acidosis, fatty liver disease
Pancreatitis—rare in most of the nucs, common in Videx and Zerit
Liver problems fairly rare now with non-DDI, non-AZT nucs
Most common nucleotide backbone of most HIV cocktails (part of truvada)
Causes kidney damage Causes bone thinning Occasional GI upset Likely to be replaced with tenofovir
alafenamide (TAF)—TAF MUCH less toxic to kidneys and bone—likely out fall 2015.
Viread/tenofovir disoproxil (TDF)
Emtriva (part of truvada) Essentially as safe as Epivir, but more rash
Epivir likely the safest of all the nucs
Abacavir: as noted, an allergic reaction for persons with genetic trait: HLAB5701
Can cause headaches, nausea
Combination drug Epzicom can cause more nausea than either drug alone
AZT; Zidovudine: Anemia, low white cells, fatigue, headache, nausea. Muscle wasting: “AZT butt”
Facial wasting, fat loss on legs and arms
Stavudine (Zerit) Neuropathy, facial wasting, fat loss in legs
and arms. Side effects start after 5 months or more of
use—can be used as a “bridge” drug, as in cases of needlestick injuries
Sustiva (part of Atripla) Causes depression, suicidality, panic
attacks, insomnia (interferes with REM sleep), vivid dreams, elevated cholesterol and triglycerides.
Not recommended for women in 1st trimester, or who are likely to become pregnant (US)
Sold on streets as alternative to LSD
Viramune/Neviripine Most likely to cause severe rash (Stevens
Johnson syndrome). Proper dosing when starting medication can make rash less likely
Isentress; most likely to cause diarrhea Low barrier to resistance; twice daily drug
increases risk of missing doses
Elvitegravir: gas, diarrhea. Has to be given with cobisistat so there will
be drug interactionslow barrier to resistance
The older drugs also raise cholesterol, triglycerides significantly (Crixivan, Invirase, Viracept, Kaletra) and can cause fat accumulation (lipodystrophy)
PI’s
Reyataz/atazanavir: can also cause yellow eyes (jaundice)
May cause confusion about liver function when patients have chronic hepatitis B or hepatitis C
Lexiva, Prezista have significant risk of skin rash
Prezista has the worse GI side effects of all the newer PI’s
Kidney function tests: creatinine and urinalysis, especially for patients on truvada or Viread/TDF containing regimens
Liver function tests: Bilirubin (jaundice test) usually around 2-3
in persons on reyataz. If >3.5 then alternatives to reyataz should be used
ALT, AST especially for patients on non- nucleosides
Note that hepatitis B usually gets better on certain HIV medications (Viread, truvada, Epivir, Emtriva)
Hepatitis C can get better on any effective HIV cocktail. (note jaundice risk with reyataz) BUT only certain HIV cocktails are compatible with hep C treatments
CBC with platelets and differential◦ Low platelets (bleeding risk) can improve within a
few days of starting an effective HIV drug regimen◦ AZT can initially worsen, and then improve
anemia◦ AZT can cause low white cells especially in patient
with advanced AIDS
Plan A: “A pill A day for type A personalities” Atripla, Complera, Stribild, Triumeq◦ Low barrier to resistance (usually)◦ NOT for patients who are unreliable about
medications or appointments
Quick-and-dirty: Plans A,B,C and D
Plan B: “Boosted protease inhibitor for batty buddies on the brink”◦ Most useful when you have patients with OI or AIDS
cancers OR mentally ill patients OR patients with other adherence risks OR <200 CD4 cells at baseline
◦ Reyataz/norvir/truvada◦ Evotaz◦ Prezista/norvir/truvada◦ Prezcobix
High barriers to resistance. May aggravate diabetes Can substitute epzicom for truvada if there is kidney
damage(HLA B5701 neg only)
Plan C: “Curses, I forgot the Contraception” Kaletra and Combivir (AZT/epivir) First choice for pregnant women with HIV
Plan D: for Drug-drug interactions OR DARN I stuck myself/DARN I had sex
Isentress +truvada Has fewest drug interactions Preferred drugs for needlestick injuries or
PEP
Alternative cocktail for pregnant women with HIV
Diabetic:
Avoid PI’s if possible Avoid TDF if possible, given risk of kidney
damage with diabetes
Special cases
Avoid TDF
Check HLA B5701; if negative, then can use abacavir (part of Epzicom)
If HLA B5701 +, may need to use unusual cocktail to attend HIV control
Kidney disease
Best cocktails with hep C meds: isentress + truvada or epzicom, or tivcay + truvada or epzicom
Non nuc’s and boosted PI’s limit hep C treatment options (ok with declatisivir and sofosbuvir, however)
Hepatitis C
32 yo homeless man, HIV+ new diagnosis. Alcoholic, depressed, Cr 2.3 (normal 1.2).
Hepatitis C. CD4 count 130. HIV viral load 300,000.
What drugs would you try to AVOID?
#1
65 yo male new dx of HIV infection. Hx of cardiac disease. On amiroidarone and
warfarin (coumadin).normal kidney function Takes medications regularly What HIV medications do you need to
AVOID? What drug cocktails can be used in him?
#2
31 yo woman with HIV and hepatitis B. She wants to get pregnant.
What drug should she avoid?What are good choices for her?
#3
45 yo male, new dx of HIV. Bad heartburn, has to take twice daily
protonix. Reliable on taking meds Diabetic, on insulin What HIV meds should he AVOID? What cocktails can he use?
#4
23 yo male with HIV, on atripla for 2 years. Has creatinine increased from 1.2 to 1.5 in the past 6 months. Chronic depression, insomnia.
What would be his choices for HIV meds?
#5
34 yo homeless man, new diagnosis of AIDS, severely anemic, +HLA B5701, Cr 2.3 (kidney damage), and severe MAC infection with CD4 count <10 and HIV RNA PCR >100,000 on admission
#6
55 yo female with AIDS and CMV retinitis, going blind with syphilis. Homeless, cocaine addict. Normal Cr. Resistant to truvada and reyataz and norvir. CD4 count <50, HIV viral load >100,000
How would you decide what, and when to change HIV meds?
#7
31 yo male, dx AIDS and MAC 6 months ago. Has tried multiple HIV meds.CD4 count <10, HIV RNA PCR >100,000
Allergic to efavirenz, neviripine, intelence, abacavir, truvada, norvir, prezista, kaletra, lexiva, reyataz.
What drugs can still be used?
#8
24 yo MSM male, pre-med student, discovers he is HIV+
2 hours of counseling to prevent suicide in clinic
Later becomes a HIV testing counselor, a medical student, and then a successful physician.
Married, and now has adopted four children.
#9
AIDS patient in his 50’s, doing well, discovers that he is the only adult child willing to care for his demented evangelical homophobic minister father.
Dad moves into the apartment, overlooking the Gay Pride route in West Hollywood.
Dad looks out the window: “I think I hate those people but I forgot why”.
#10
Decide first if a patient is Plan A, B, C or D. Evaluate renal function, diabetes issues,
hepatitis, allergies, severity of HIV disease, mental illness.
Consider resistance issues and evaluate patient for ability to take medications.
Tailor HIV medications to patient’s profile Getting older also means getting revenge!