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Improving the Management of HIV Diseases Interactive Session

Improving the Management of HIV Diseases Interactive Session. Nov. 27, 2008 The 22 nd Annual Meeting of the JSAR Evening Seminer 3. Plannning ： HIV Care Management Initiative-Japan Co-hosting ： The 22 nd Annual Meeting of the JSAR/GSK. Cases studies. Professor David A Cooper NCHECR

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Improving the Management of HIV Diseases Interactive Session

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  1. Improving the Management of HIV DiseasesInteractive Session Nov. 27, 2008 The 22nd Annual Meeting of the JSAR EveningSeminer 3 Plannning：HIV Care Management Initiative-Japan Co-hosting：The 22nd Annual Meeting of the JSAR/GSK

  2. Cases studies Professor David A Cooper NCHECR November 2008

  3. Case 1- IF • 47 year old Caucasian man • diagnosed with HIV 1986 • CDC B • nadir CD4+ cell count: 252/µL • pre treatment VL: 376,100 c/mL • alcohol and recreational drug use including speed • hep B sAg negative, cAb positive • hepatitis C negative

  4. Case 1- IF • previous regimens: • d4T + 3TC • ABC + IDV/r Nov 2000- May 2001 • ABC + LPV/r May 2001- Sep 2004 • ABC + fAPV/r Aug 2005- Jan 2007 • AZT + 3TC + ATV/r Jan 2007- HIV had been suppressed all the time.

  5. Case 1 - IF • October 2007: fatigue and right upper quadrant pain

  6. Case 1- IF • What is the cause of his hepatitis? 1) reactivation of hepatitis B 2) acute hepatitis C 3) alcoholic hepatitis 4) pancreatitis 5) lactic acidosis

  7. Case 1- IF • What is the cause of his hepatitis? 1) reactivation of hepatitis B 2) acute hepatitis C 3) alcoholic hepatitis 4) pancreatitis 5) lactic acidosis

  8. Case 1- IF • hepatitis B DNA: negative • hepatitis C viral load: 700,000 c/mL • lactate: 1.6 mmol/L • glucose: 4.2 mmol/L • cholesterol: 1.5 mmol/L • HDL-chol: 0.7 mmol/L • LDL-chol: 0.2 mmol/L • triglycerides: 2.1 mmol/L

  9. Case 1- IF • How would you treat his acute HCV? 1) wait and see 2) PEG-IFN 3) PEG-IFN + RBV 4) intensify ART 5) something else

  10. Case 1- IF • How would you treat his acute HCV? 1) wait and see 2) PEG-IFN 3) PEG-IFN + RBV 4) intensify ART 5) something else

  11. Case 1- IF • HCV spontaneously cleared September 2008

  12. Case 1- IF • What percentage of HIV-infected persons with acute HCV spontaneously clear? 1) 1-2% 2) 10-20% 3) 50-60% 4) 90-100%

  13. Case 1- IF • What percentage of HIV-infected persons with acute HCV spontaneously clear? 1) 1-2% 2) 10-20% 3) 50-60% 4) 90-100%

  14. Case 2- MB • 41 year old Caucasian man • diagnosed with HIV 1985 • AIDS CDC C3 • PJP 1994 treated with pentamidine and corticosteroids • CMV retinitis 1997 treated with GCV and cidofovir • NHL 2002 treated with CHOP and high dose methotrexate

  15. Case 2- MB • pre ART: CD4+ cells: 60/µL viral load: 310,900 c/mL • previous regimens • AZT+ddC Jan 1995- Oct 1995 • AZT+3TC+loviride Oct 1995- Mar 1996 • ddI+d4T+3TC+loviride Mar 1996- Sep 1996 • d4T+DLV+SQV Jan 1998- May 2002 • d4T+ABC+3TC+DLV+SQV May 2002- Jul 2004

  16. Case 2- MB • August 2003 • urea 4.9 mmol/L • creatinine 90 µmol/L

  17. Case 2- MB • He has developed severe lipodystrophy. What regimen would you choose? 1) AZT+3TC+EFV 2) TDF+3TC+EFV 3) TDF+3TC+LPV/r 4) ABC+3TC+EFV 5) ABC+3TC+LPV/r

  18. Case 2- MB • He has developed severe lipodystrophy. What regimen would you choose? 1) AZT+3TC+EFV 2) TDF+3TC+EFV 3) TDF+3TC+LPV/r 4) ABC+3TC+EFV 5) ABC+3TC+LPV/r

  19. Case 2- MB • changed to TDF+ABC+3TC+DLV+SQV • develops severe narcotic dependent pain in wrists and knees • August 2005 • urea 10.1 mmol/L • creatinine 246 µmol/L

  20. Case 2- MB • Bone densitometry August 2005

  21. Case 2- MB • Bone densitometry August 2005 left femur spine right femur

  22. Case 2- MB • What is the cause of the renal failure and bone pain? 1) TDF 2) HIV nephropathy 3) TDF and previous pentamidine 4) previous cidofovir and corticosteroids 5) TDF and previous cidofovir

  23. Case 2- MB • What is the cause of the renal failure and bone pain? 1) TDF 2) HIV nephropathy 3) TDF and previous pentamidine 4) previous cidofovir and corticosteroids 5) TDF and previous cidofovir

  24. Case 2- MB • ceased TDF August 2005 • new regimen: ABC+3TC+DLV+SQV ceased tenofovir • October 2008 • urea 10 mmol/L • creatinine 161 µmol/L

  25. Case 2- MB • Renal biopsy was performed December 2005. What changes would you expect to see in the renal biopsy? 1) tubular toxicity 2) interstitial nephritis 3) collapsing glomerulopathy 4) glomerulosclerosis 5) glomerular and tubular disease

  26. Case 2- MB • Renal biopsy was performed December 2005. What changes would you expect to see in the renal biopsy? 1) tubular toxicity 2) interstitial nephritis 3) collapsing glomerulopathy 4) glomerulosclerosis 5) glomerular and tubular disease

  27. Case 2- MB • renal biopsy showed • severe interstitial fibrosis • globally sclerosed glomeruli • tubular degeneration • BK polyoma viral inclusions

  28. Case 3- EN • 52 year old Asian man • diagnosed with HIV 1991 • AIDS CDC B1 • mild type 2 diabetes 1998 • works as a chef

  29. Case 3- EN • pretreatment CD4+ cells: 207/µL viral load: 40,000 c/mL • previous regimens • d4T+3TC+SQV Feb 1997- Sep 1997 • d4T+3TC+NVP Sep 1997- Nov 1997 • d4T+ddI+NVP Nov 1997- Jan 1998 • d4T+ddI Jan 1998- Apr 1998 Jul 1998- Nov 1998 Feb 1999- Oct 1999 • EFV+IDV/r Oct 1999- Mar 2002 • EFV+ATV/r Mar 2002- HIV had been suppressed with EFV

  30. Case 3- EN • metabolic profile February 2002- August 2003 • August 2003 • triglycerides • 7.4 mmol/L • cholesterol • 5.6 mmol/L • HDL-chol • 1.17 mmol/L • glucose • 11.5 mmol/L • HbA1c • 8.6%

  31. Case 3- EN • How would you treat the dyslipidemia? 1) diet 2) fibrate 3) statin 4) fibrate and statin 5) metformin and statin

  32. Case 3- EN • How would you treat the dyslipidemia? 1) diet 2) fibrate 3) statin 4) fibrate and statin 5) metformin and statin

  33. Case 3- EN • commenced fibrate October 2003 started gemfibrozil • ceased gemfibrozil due to myopathy February 2005 • February 2005 • triglycerides • 2.1 mmol/L • cholesterol • 5.9 mmol/L • HDL-chol • 1.7 mmol/L • glucose • 8.1 mmol/L • HbA1c • 8.1%

  34. Case 3- EN • How would you treat dyslipidaemia now? 1) diet 2) metformin 3) statin 4) statin and ezetimibe 5) switch regimen

  35. Case 3- EN • How would you treat dyslipidaemia now? 1) diet 2) metformin 3) statin 4) statin and ezetimibe 5) switch regimen

  36. Case 3- EN • commenced pravastatin February 2005 • October 2006 • triglycerides • 14 mmol/L • cholesterol • 8 mmol/L • HDL-chol • 0.8 mmol/L • glucose • 9.3 mmol/L • HbA1c • 6.9% started pravastatin

  37. Case 3- EN • What would you do now? 1) change to more potent statin 2) add insulin to pravastatin 3) add metformin to pravastatin 4) add ezetimibe to pravastatin 5) switch ART regimen to lipid neutral drugs

  38. Case 3- EN • What would you do now? 1) change to more potent statin 2) add insulin to pravastatin 3) add metformin to pravastatin 4) add ezetimibe to pravastatin 5) switch ART regimen to lipid neutral drugs

  39. Case 3- EN • commenced rosuvastatin February 2007 • November 2007 • triglycerides • 10.8 mmol/L • cholesterol • 6.1 mmol/L • HDL-chol • 0.9 mmol/L • glucose • 6.1 mmol/L • HbA1c • 5.9% started rosuvastatin

  40. Case 3- EN • Decided to change regimen. What would you recommend? 1) TDF+FTC+EFV 2) TDF+FTC+ATV 3) ABC+3TC+ATV 4) TDF+FTC+ATV/r 5) ATV + raltegravir

  41. Case 3- EN • Decided to change regimen. What would you recommend? 1) TDF+FTC+EFV 2) TDF+FTC+ATV 3) ABC+3TC+ATV 4) TDF+FTC+ATV/r 5) ATV + raltegravir

  42. Case 3- EN • commenced ATV + raltegravir November 2007 • August 2008 • triglycerides • 0.9 mmol/L • cholesterol • 3.4 mmol/L • HDL-chol • 1.1 mmol/L • glucose • 3.4 mmol/L • HbA1c • 5.1% started ATV + raltegravir

  43. Case 4- RVB 60 year old Caucasian man diagnosed with HIV 1982 nadir CD4+ cell count: 96/µL

  44. Case 4- RVB • previous regimens: • AZT monotherapy: Aug 1988- Nov 1994 Jan 1995- Aug 1995 • AZT+ delavirdine: Nov 1994- Jan 1995 • d4T monotherapy: Aug 1995- Aug 1996 • d4T+3TC+IDV: Aug 1996- Nov 1996

  45. Case 4- RVB • August 1996 PJP diagnosis treated with pentamidine • November 1996 muscle wasting weight loss glucose: 26 mmol/L triglycerides: 7.3 mmol/L cholesterol: 3.6 mmol/L HbA1C: 10.9%

  46. Case 4- RVB • What is the most likely cause of his diabetes mellitus? 1) protease inhibitor therapy 2) mitochondrial toxicity from TANRTIs 3) pentamidine therapy 4) pancreatitis from hypertriglyceridemia 5) hepatitis C

  47. Case 4- RVB • What is the most likely cause of his diabetes mellitus? 1) protease inhibitor therapy 2) mitochondrial toxicity from TANRTIs 3) pentamidine therapy 4) pancreatitis from hypertriglyceridemia 5) hepatitis C

  48. Case 4- RVB • He was treated with insulin which was stopped in 1999 • HCV was positive in 1998 • After stopping his fasting chemistry is • glucose: 8.8 mmol/L • HbA1C: 8% • cholesterol: 6.2 mmol/L • HDL-chol: 0.6 mmol/L • triglycerides: 18.3 mmol/L

  49. Case 4- RVB • How would you treat his diabetes? 1) diet 2) insulin 3) oral hypoglycaemics 4) treat hepatitis C

  50. Case 4- RVB • How would you treat his diabetes? 1) diet 2) insulin 3) oral hypoglycaemics 4) treat hepatitis C

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