ardis ann moe, m.d. ucla care clinic/nevhc hiv clinic van nuys. 29 august 2014 amoe@mednet.ucla.edu

Ardis Ann Moe, M.D.UCLA CARE Clinic/NEVHC HIV Clinic Van Nuys.

29 August 2014amoe@mednet.ucla.edu

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

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

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

Most common nucleotide backbone of most HIV cocktails (part of truvada)

Causes kidney damage Causes bone thinning Occasional GI upset

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

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 a class, they all cause rash and liver inflammation

Sustiva (part of Atripla) Causes depression, suicidality, panic

attacks, insomnia (interferes with REM sleep), vivid dreams, elevated cholesterol and triglycerides.

Controversy on whether it causes birth defects

Sold on streets as alternative to LSD

Viramune Most likely to cause severe rash (Stevens

Johnson syndrome). Proper dosing when starting medication can make rash less likely

Intelence Vivid dreams, gritty taste

Edurant Some depression, some vivid dreams.

As a class they all cause diarrhea and occasional vivid dreams.

Rarely they cause depression

Isentress; most likely to cause diarrhea

Elvitegravir; as part of Stribild, has drug interactions and risk of kidney and bone damage. Also causes diarrhea

Tivicay; drug interactions, diarrhea

As a class they all cause diabetes and insulin resistance.

They all cause diarrhea and GI upset

The older drugs also raise cholesterol, triglycerides significantly (Crixivan, Invirase, Viracept, Kaletra) and can cause fat accumulation (lipodystrophy)

For older drugs, risk of lipodystrophy 75% after 2 years of use. Approx 5% for newer PI’s

Reyataz: 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

Abacavir: HLA B5701 genetic marker of allergic reaction

Kidney function tests: creatinine and urinalysis, especially for patients on truvada or Viread 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)

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

Hemoglobin A1c, glucose Especially for patients on PI’s

Cholesterol, triglycerides◦ Especially for patients on atripla and PI’s

Plan A: “A pill A day for type A personalities” Atripla, Complera, Stribild, Triumeq◦ Low barrier to resistance◦ NOT for patients who are unreliable about

medications or appointments

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

◦ Reyataz/norvir/truvada◦ Prezista/norvir/truvada

High barriers to resistance. May aggravate diabetes Can substitute epzicom for truvada if there is kidney

damage

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

Isentress +truvada Has fewest drug interactions Preferred drugs for needlestick injuries

Diabetic:

Triumeq (dolutegravir/lamivudine/abacavir)

Stribild Atripla Complera Isentress/truvada

◦ Recall that the above 4 cocktails all contain tenofovir, which can damage kidneys

Kaletra/Combivir Prezista/Norvir/Epzicom Isentress/Epzicom

32 yo homeless man, HIV+ new diagnosis. Alcoholic, depressed, Cr 2.3 (normal 1.2).

Hepatitis C. What drugs would you try to AVOID. What initial labs do you need to make a

drug choice decision?

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?

31 yo pregnant woman with HIV and hepatitis C.

What are her best choices of HIV meds?

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?

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 other tests do you need to perform in order to change meds?

What other questions do you need to ask before changing meds?

What would be his choices for HIV meds?

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

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?

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 drug cocktails can still be used?

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.

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”.

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!