VIRTUAL MEDZONEYour Resource for HIV Related Innovative Medical Communication

CASE PRESENTATIONSMahin Baqi MD FRCPCKen Logue MDDavid Fletcher MD FRCPC

CASE 1

• 58 y.o. man• HIV + 1989

• CD4 200 on diagnosis

• Previous history of depression and chronic intermittent diarrhea

CASE 1DATE ARV REGIMEN1989 AZT1992 AZT/ddI1994 AZT/ddC/3TC1996 D4T/3TC/Saquinavir… viremia1997 D4T/3TC/Indinavir… viremia1999 D4T/ddI/Nevirapine… viremia

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• 2001 stopped meds due to neuropathy, ongoing viremia and chronic diarrhea

• CD4 104 HIV VL 266, 131 c/ml

• No genotype available

CASE 1• Restarted AZT/3TC/Abacavir/Lopinavir/

Amprenavir/Nevirapine

TIME CD4 HIV VIRAL LOAD0 104 2661316 wks 186 140810 wks 230 46118 wks 244 3257

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GENOTYPE SEPTEMBER2001

CASE 1TIME CD4 HIV VIRAL LOAD18 wks 244 325724 wks 195 461332 wks 182 491748 wks 250 576672 wks 160 11,46496 wks 230 15,421

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• AZT/3TC/Abacavir/Lopinavir/Amprenavir/Nevirapine/Fenofibrate/Fish oil/NiacinTEST VALUETG 5 - >40 mmol/lCholesterol 4 – 7 mmol/lHDL 0.4 mmol/lLDL ? – 1.73 mmol/l

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AZT/3TC/Abacavir/Lopinavir/Amprenavir/Nevirapine/Fenofibrate/Fish oil/Niacin

• 104 wks… CD4 150 VL 14,895 c/ml

• Went to Kingston, Ontario in 2003 to live with partner

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• Returned to Toronto in 2005 on D4T/Tenofovir/ddI/Fuzeon

• CD4 100 VL 18,295 c/ml

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GENOTYPE June 2005

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Genotype September 2005

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WHAT WOULD YOU DO?

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• Tropism Testing…R5

2005-2007

3TC/Maraviroc/Lopinavir/Amprenavir

/T20• CD4 165-250 VL 4,000-10,000

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Genotype January 2007

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2007

• anal carcinoma in situ

• Lipids terrible…Triglycerides

>40mmole/l develops pancreatitis,

bowel obstruction

• ARVS discontinued

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Late 2007

3TC/T20/Ritonavir/Darunavir/Etravirine/

Raltegravir/Maraviroc

• CD4 30 on initiation

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TIME CD4 HIV VIRAL LOAD0 30 85,3636 wks 270 98512 wks 246 <50

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2008• Develops Diabetes on regimen –

Metformin initiated

• Triglycerides continue out of control despite bezafibrate/fish oil/crestor

• Angina → Severe CAD → CABG

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2008

• T20 stopped due to injection site reactions and associated fatigue…viral load remains <50 on 3TC/Ritonavir/Darunavir/ Etravirine/ Raltegravir /Maraviroc

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• Lipids remain terrible with TG>40mmole/l

• Bezafibrate/fish oil/Ezetrol/Crestor/ ASA/Coumadin

• Recurrent angina – 4/5 bypassed vessel restenosed via angiography

WHAT WOULD YOU DO?

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Late 2008

• Ritonavir/Darunavir discontinued

• Remains on 3TC/Maraviroc/Raltegravir /Etravirine

• CD4 275 VL <50!

• TG 34.70→ 3.78 – 6.07

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2009/10 3TC/Maraviroc/Raltegravir/Etravirine

• Angina free, mitral regurgitation, Grade 1 LV

• CD4 250-275 VL <50!

• TG 8.46-6.07• LDL <0.5 • HDL 0.5-0.6

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2010

• Furosemide/Perindopril for mitral regurgitation

• Some intermittent orthopnea

• Stable angina

• New onset prostatism

CASE 1TIME CREATININE10/09 10701/10 8004/10 16705/10 196

What would you do ?

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• No NSAIDS

• No New Meds/holistics/illicit drugs

• Not dry on clinical examination

• Normotensive

• No CHF clinically

• No swelling of ankles

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• U/S – no obstruction

• U/A – normal albumin/creatinine + protein/creatinine ratio

• Urinalysis normal

• Urine sodium-100 mmol/l

CAUSE? MANAGEMENT?

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TIME CREATININE05/10 157, 18306/10 14007/10 21308/10 17509/10 153

Perindopril + Furosemide discontinued

EGFR 45-50 ml/min

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• Given sudden onset, bland urinalysis

and lack of significant proteinuria,

likely cause is vascular …awaiting MRI

Angiography of kidneys

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• Doses of all medications readjusted for

renal dysfunction

• Not required for

3TC/Maraviroc/Raltegravir/ Etravirine