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VIRTUAL MEDZONE

VIRTUAL MEDZONE. Your Resource for HIV Related Innovative Medical Communication. HIV CASE PRESENTATIONS. Alice Tseng Pharm.D ., FCSHP, AAHIVP David Fletcher MD FRCPC. CASE 1. 54 yo Caucasian woman, Dx HIV & HCV in 2002 ARV treatment (CD4 280, VL 40,526). CASE 1.

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VIRTUAL MEDZONE

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  1. VIRTUAL MEDZONE Your Resource for HIV Related Innovative Medical Communication

  2. HIV CASE PRESENTATIONS Alice Tseng Pharm.D., FCSHP, AAHIVP David Fletcher MD FRCPC

  3. CASE 1 • 54 yo Caucasian woman, Dx HIV & HCV in 2002 • ARV treatment (CD4 280, VL 40,526)

  4. CASE 1 HCV 1a (gr 3-4 fibrosis, RNA 1.32E+6 IU/mL)

  5. CASE 1 Considerations with HCV protease inhibitors: • Telaprevir: • LPVr: 54%  AUC, 52%  Cmin of TVR • DRVr: 35%  AUC, 32%  Cmin of TVR; also 40%  AUC, 42%  Cmin of darunavir • ATVr: 20%  AUC, 15%  Cmin of TVR; least impact of all current PIs  ongoing evaluation in HIV/HCV • Tenofovir:  AUC (relevance?). Monitor Scr. • Boceprevir: • minimal effects of RTV 100 mg QD and BID on BOC AUC

  6. CASE 1 So how should we manage this patient on TDF /FTC/LPVr?...switch ARVs Telaprevir • RTV/ATZ • EFV • Raltegravir Boceprevir…stay tuned

  7. CASE 2 • 50 yo, Caucasian male, • HIV+ since 1992 • VL suppressed since 1996, CD4 720 • some NRTI mutations, no PI mutations, R5+ • on 3TC, SQV 600/RTV 300 mg BID, RAL BID since 2008

  8. CASE 2 Asthma: prev. on Symbicort (budesonide/formoterol) inhaler • interaction with RTV/SAQ  adrenal suppression/ insufficiency, Cushings Syndrome (2010) • also has osteoporosis, hyperlipidemia, autoimmune retinopathy How do you manage his asthma?

  9. CASE 3 • 62 yo male, HIV+ 1992 • extensive ARV history with AEs & resistance • CAD, CHF, HTN, hyperlipidemia, NIDDM, gout, chronic renal insufficiency

  10. CASE 3 Meds: • ABC, 3TC, LPVr, T20 • TMP/SMX DS, allopurinol, metoprolol, furosemide, Aggrenox (dipyridamole 200 mg/ASA 25 mg), amlodipine, rosuvastatin • Dx pulmonary arterial hypertension (PAH) 2003, respirologist Rx bosentan… How do you manage this patient?

  11. PAH THERAPIES

  12. POTENTIAL INTERACTION BETWEEN BOSENTAN & PIS • Possibility of  bosentan and/or  lopinavir/r concentrations via CYP450 inhibition/induction • Usual bosentan dose: • 62.5 mg BID x 4 weeks, then 125 mg BID

  13. POTENTIAL INTERACTION BETWEEN BOSENTAN & PIS • May 2004: Rx bosentan 62.5 mg BID,  LPV/r to 5 capsules BID • 1 month later developed recurrent anemia requiring transfusions despite iron supplementation & EPO

  14. POTENTIAL INTERACTION BETWEEN BOSENTAN & PIS • anemia associated with bosentan is dose-related • in controlled studies,  Hgb of at least 10 g/L observed in 57% bosentan-tx subjects vs. 29% placebo group

  15. ADMINISTERING BOSENTAN WITH PROTEASE INHIBITORS Management: • if already on stable PI tx: initiate bosentan 62.5 mg q1-2days • if on stable bosentan and require PI: d/c bosentan for >36 h, start PI x 10 days, re-start bosentan at 62.5 mg q1-2days [DHHS Guidelines, Oct 14/11; Tracleer monograph, June 2011; Reyataz monograph, May 2011.]

  16. ADMINISTERING BOSENTAN WITH PROTEASE INHIBITORS Monitoring parameters: • efficacy: improvement in exercise tolerance, NYHA functional status severity and hemodynamic measures via right heart catheterization. Also suggest PI TDM & VL. [DHHS Guidelines, Oct 14/11; Tracleer monograph, June 2011; Reyataz monograph, May 2011.]

  17. ADMINISTERING BOSENTAN WITH PROTEASE INHIBITORS Monitoring parameters: • toxicity: headache, flushing, GI effects, anemia, liver injury, worsening CHF (wt gain, leg edema) and pulmonary edema (SOB, painful/difficult breathing) • Atazanavir: do not use unboostedatazanavir with bosentan (may  ATV) [DHHS Guidelines, Oct 14/11; Tracleer monograph, June 2011; Reyataz monograph, May 2011.]

  18. CASE 4 • 66 yo male, HIV+ 1992 • NIDDM, hyperlipidemia, HTN, renal dysfunction (multifactorial), peripheral neuropathy, depression, BPH, chronic pain

  19. CASE 4 Medications • DRV/r BID, RAL BID, ETV BID • ASA, amlodipine, ramipril, coenzyme Q10, fenofibrate, ezetimibe, atorvastatin, metformin, Prandase (acarbose), Januvia (sitagliptin), Cymbalta (duloxetine), ACV, Detrol (tolterodine), dulcolax, colace, metamucil, Flonase prn, testosterone cream • Urologist wants to add daily tadalafil:Interaction with DRV/r?

  20. IMPACT OF PIS ON PDE5 INHIBITORS

  21. DOSING OF PDE5 INHIBITORS WITH PIS *if on stable tadalafil and starting PI therapy: d/c tadalafil for at least 24 h, start PI, restart tadalafil after 7 days at 20 mg QD with  to 40 mg QD prn

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