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HIV/AIDS PATIENT CASE SAMUEL GYAWU-AMOATENG APPE BLOCK 7: HOLYOKE HEALTH CENTER PRECEPTOR: JARED OSTROFF PHARM.D, BCACP Meet PATIENT RW Patient RW is a 57 year old Caucasian male who was scheduled for a hospital discharge follow up after a recent hospital admission for Left sided Cellulitis. He was treated with IV Rocephin (Ceftriaxone, a 3rd generation) and Vancomycin. He was discharged with Cefpodoxime (Vantin, a 3rd gen) 200mg by mouth twice daily for 1 week. Allergies: Cephalexin Monohydrates Clarithromycin Paroxetine : Pt. reports Dizziness Height: 5’11” Weight: 290 pounds, 131.542 kg BP Today: 140/70 BMI: 40.45 kg/m² RW Past Medical History Anemia Unspecified type Chronic Hepatitis C w/o Hepatic coma Essential Hypertension Cirrhosis Hyperlipidemia LDL goal <70 Tinea Cruris HIV/AIDs Opioid dependence Type 2 DM Chronic back pain Diabetic Peripheral Nephropathy Cocaine dependences remission Anxiety Disorder Polysubstance dependence. Depression Vitamin D deficiency Cirrhosis Obesity GERD Chronic Peripheral Venous Insufficiency Medication History Acyclovir 400mg Albuterol Sulfate HFA 90mcg Viread 300mg Bactrim SS 400-80mg QVAR 80mcg Mupirocin 2% Prilosec 20mg Lactulose 10g/15mL Vitamin C500mg Epoetin Alfa 20,000 U Vitamin D2 50,000U Epzicom 600mg-300mg Nystatin 100,000 units Gabapentin 300mg Suboxone 8-2mg film Lisinopril 40mg Ferrous Sulfate 325mg (65) Harvoni 90-400mg Sertraline 50mg Tivicay 50mg Pertinent LABS WBC 7.9 RBC 4.02M/uL HEMOGLOBIN 11.0g/dL HEMATOCRIT 35.5g/dL PLATELET COUNT 93 x 10^3 /mL NA 136 mEq/L K 3.9 mEq/L CL 104 mEq/L BICARB 22 mEq/L BUN 18 mEq/dL ALBUMIN 3.2 g/dL CALCIUM 8.6 mg/dL AST 70 U/L ALT 31 U/L ALKALINE PHOS 96 u/L CREATINE 0.8mg/dL T CELL COUNT Around 90s C-Reactive Protein 4.9 mg/dL Pertinent Medications Bactrim SS 400-80mg Mupirocin 2% Acyclovir 400mg Lactulose 10g/15mL Epoetin Alfa 20,000 U Epzicom 600mg-300mg Harvoni 90-400mg Tivicay 50mg Nystatin 100,000 units Viread 300mg Suboxone 8-2mg film HIV/AIDS HIV:- A retrovirus that uses reverse transcriptase to replicate in the host. Two types HIV-1 and Hiv-2. In the US, CDC estimates that Over 1.2 million persons aged 13 yrs and older are living with HIV infections including 156,300 (12.8%) wo are not even aware that they are infected. Deaths in US: Estimated 13,712 people with AIDs dx died in 2012, and ~ 658,507 people with AIDS diagnosis have died overall. HIV/AIDS Three Phases 1. Acute: 2-3 weeks. Flu-like symptoms. HA, Fever, Fatigues. 2. Chronic: Could take several years. 3. Terminal (AIDS):- This is when CD4 counts are depleted. HIV/AIDS – Transmission/Spread HIV/AIDS STATS in the US HIV/AIDS:- Prevention and Cure HIV is not curable at the moment, but it is controllable and manageable. Protection is key. Avoidance of IV drug usage Avoidance of multiple sexual relations Adhering to SOP’s at work places (clinicians) Clinical Question How to Treat HIV/AIDS in patients with CD4T cell count < 200 HAART Highly Active Anti-Retroviral Therapy ( commonly known as ART Recommended for every HIV patients Commitment is Key ADHERENCE IS VERY CRUCIAL. Therapy includes 2 NRTI (Nucleoside Reverse Transcriptase Inhibitor) plus NNRTI (Non-nucleoside reverse transcriptase) OR Ritonavir Boosted Protease Inhibitors (PI) OR INSTI (Integrase Strand Transfer Inhibitors) CCR5 Antagonist Fusion Inhibitors Indinavir Study A Controlled Trial of two Nucleoside Analogues plus Indinavir in Persons with HIV infections and CD4 Cell counts of 200 per Cubit mL or Less. In this study total of 1156 patients not previously treated with lamivudine or PI’s were stratified according to CD4 counts. They were randomly assigned to receive A. Zidovudine 600mg and lamivudine 300mg OR Treatment A plus indinavir 2400mg. (Stavudine could be sub for zidovudine) Goal of the study was to accessed the efficacy and safety of 3 drug regimen containing indinavir. Indinavir Study Results N Engl J Med 1997; 337: 725–33 Indinavir Study Conclusion. Study showed a clinical superiority of the three-drug regimen containing indinavir (a PI), lamivudine, and zidovudine, over the two-nucleoside combination alone in patient previously on zidovudine (NRTI) plus CD4 of less or equal to 200. Proportion of patient whose HIV disease progressed to AIDs decreased from 1% to 6% Increased in CD4 counts for both persisted above base-line values seen with both arms, but superior response in the indinavir group. 91 AIDs defining events. With 60 on other group and 31 on indinavir group. N Engl J Med 1997; 337: 725–33 Study 2: Early ART Trial Early Antiretroviral Therapy Reduces AIDs Progression/Death in individuals with Acute Opportunistic Infections: A Multicenter Randomized Strategy Trial The primary endpoint of this study was a 3-level,ordered, categorical variable: alive without AIDS progression and with HIV viral load <50 (best outcome) Alive w/o AIDS progression and with detectable HIV viral load >50 copies/mL (intermediate) AIDS progression or death (worst outcome) at any time. Secondary endpoint included clinical outcomes such as Death/AIDS progression independent of virology response, Virologic response independent of clinical endpoint. CD4 courts changes from baseline, safety and tolerability. Hospitalizations. Early ART Trial Results Early ART Trial Conclusion No significant difference in the primary endpoint However there was a significant difference favoring the early treatment group in the secondary outcome of AIDS progression/death. Impact seen in morbidity and mortality events in the first 6 months. Subjects in the early ART group spent less time with CD4 counts <50 or <100 an therefore the less vulnerable to AIDS-related complication. Cautious to generalized study to every country. Guideline: NEW https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/0 Guideline: NEW Common Opportunistic Infections Bacterial Skin Infections Varicella Zoster Kaposi’s Sarcoma Oral Candidiasis Pneumocystis Jiroveci Pneumonia Non-Hodgkin’s Lymphoma Cryptococcal Meningitis Herpes Simplex Virus Infection Cytomegalovirus Infections Mycobacterium Avium Complex Source: Dipiro JT Back to RW RW missed appointment. RW has completed his discharged Antibiotics. RW was using Bactroban as needed for reddish area around groin. RW uses Nystatin cream for rash around groin. RW is a Med box patient RW is very picky in his medications, and therefore treatment options especially antibiotics are very limited. Current HIV/AIDS Therapy Viread 300mg. Take 1 tablet b mouth daily with meals Tivacy 50mg. Take 1 tablet by mouth daily with. Generic: Dolutegravir: Integrase Strand Transfer Inhibitor Epzicom 600mg-3000mg. 1 tablet by mouth daily Generic: Tenofovir : An NRTI Generic: Abacavir and Lamivudine: NRTI Plan:- Continue current therapy. Due to CD4 counts trending <100 PCP https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/0 RW OI Prophylaxis PCP Bactrim SS 400mg-80mg daily for PCP prophylaxis. Plan: Continue Current Treatment. Get Lab works, then decide if other prophylaxis needed. Possible Changes Would have recommended the addition of statins. Discontinue the Doxycycline that was given to patient. Would recommend the Addition of Azithromycin for MAC prophylaxis. Continue Nystatin powder until gone for the groin area rash. PCP Changes. PCP ordered Labs LFT’s CBC’s Glucose Panels Lipid Panels Chem 7 A1c Will initiate Azithromycin 250 for MAC prophylaxis if CD4 count < 100 Continue other therapy. Other Disease States Anemia & Vitamin D Deficiency Current Therapy: Current therapy: Epoetin Alpha 20,000 units/mL Ferrous Sulfate 355mg (65) Last Level: 28.9ng/mL on 11/18/15 Plan: Continue current therapy Plan: Continue Current therapy. Vitamin D2 50,000 Units Q weekly Hepatitis C and Cirrhosis Hepatitis C On Lactulose 10g/15mL. 30mL BID Cirrhosis Not accessed, will defer to specialist. Plan: Continue current therapy Patient to follow up with GI and Specialist for Cirrhosis due to complains black stool. Not accessed Plan: Continue Current therapy Type 2 DM & Diabetic Peripheral Neuropathy Type 2 DM A1c well controlled Plan: Continue lifestyle modifications. Get A1c labs Check kidney functions Peripheral Neuropathy Taking Gabapentin 300mg Currently asymptomatic. Plan: Continue Gabapentin Hypertension & Hyperlipidemia Hypertension Hyperlipidemia On Lisinopril 40mg daily. Not on Any Active treatment Last two BP’s ASCVD risk score: 122/68mmHg on 02/10/2016 140/70mmHg on 03/07/2016 Plan: Continue Lisinopril 40mg N/A due to lack of Lipid panels Plan: Order CBC w/diff, Chem 7, Lipid panels Will be accessed next visit Anxiety and Depression Disorder On Sertraline 50mg Plan: Continue Sertraline 50gm Reassessed disease state again. Cocaine & Polysubstance Abuse Dependency On Suboxone 8-2mg film Enrolled in BH Services program. Plan:- Continue current plan. Discussions What is the major concern for this patient at this moment? Is his ART therapy Ok What changes would be appropriate if any? Credits Hammer SM, Squires K, Hughes MD et al . A controlled trial of two nucleoside analogues plus indinavir in persons with human immunodeficiency virus infection and CD4 cell counts of 200 per cubic millimeter or less. N Engl J Med 1997; 337: 725–33 Zolopa AR, Andersen J, Komarow L, et al. Early Antiretroviral Therapy Reduces AIDS Progression/Death in Individuals with Acute Opportunistic Infections: A Multicenter Randomized Strategy Trial. Carr A, ed. PLoS ONE. 2009;4(5):e5575. doi:10.1371/journal.pone.0005575. https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/0
