Download pharmacokinetics

PHARMACOKINETICS:
HIV DRUGS
ALLIE PUNKE ([email protected])
RENAL FUNCTION
• Patients with HIV are at an increased risk of having
nephropathy that can lead to ESRD
• DJ is a Caucasian female who was just diagnosed
with HIV. When/should you recommend for her to
be screened for renal function?
• What are you specifically screening for when
performing renal function tests?
RENAL FUNCTION
• CG is a HIV+ (diagnosed about a year ago) African
American male. At your appointment with him
today, he tells you he sometimes forgets to take his
medications for HIV. The CD4 and HIV RNA count
today is 150 and 900, respectively. His renal function
was stable when he was diagnosed with HIV.
Should we check his renal function today?
RENAL FUNCTION
• When to screen patients for renal function:
• Screen ALL patients when they are diagnosed with HIV
• Yearly screening if patients are at high risk
•
•
•
•
African American
CD4<200
HIV RNA>400
Family history of renal problems
HEPATIC FUNCTION
• What makes HIV + patients at increased risk for liver
function abnormalities?
HEPATIC FUNCTION
• GP is a 28 YO AA male who was just diagnosed with
HIV. How often should we monitor his hepatic
function?
DOSE ADJUSTMENTS
• Patients with renal or hepatic issues will most likely:
• Not be able to take medications that are _________.
• Will often require _________ doses
• Will be advised to take medications _________ HD session.
• Will or will not require trough concentrations.
DOSE ADJUSTMENTS
• 1. INST:
• General dose adjustments:
• Renal
• Hepatic
• Dolutegravir (DTG) Trivicay:
• Elvitegravir (EVG) Vitekta:
• Genvoya (Elvitegravir/cobicistat/emtricitabine/tenofovir
alafenamide):
• Stribild (Elvitegravir/cobicistat/ emtricitabine/tenofovir
disoproxil fumarate)
DOSE ADJUSTMENTS
• 2. NNRTI:
• General dose adjustments:
• Renal
• Hepatic
• Efavirenz (EFV) Sustiva
DOSE ADJUSTMENTS
• 3. PI
• General dose adjustments:
• Renal
• Hepatic
• Darunavir + cobicistat
• 4. NRTI
• General dose adjustments:
• Renal
• Hepatic
•
•
•
•
•
Abacavir
Emtricitabine
Lamivudine
Tenofovir disoproxil fumarate
Truvada (tenofovir disoproxil fumarate/emtricitabine)
DOSE ADJUSTMENTS
• In general, patients with renal/hepatic issues should
avoid co-formulated products; however, name two
combination products that have lower renal cut-off
that may allow patients to continue until renal
dysfunction becomes worse:
DOSE ADJUSTMENTS
• T/F: Emtricitabine is a member of the NNRTI class,
which generally does not require renal dose
adjustment.
• T/F: Atripla does not require dose adjustment for
patients with decreased renal function.
• T/F: Stribild can be recommended without testing
renal function when initiating, but yearly renal
function screening is recommended.
DRUG MONITORING
• T/F: Most patients with HIV receiving antiretroviral
medication should have their medications
monitored through the use of drug concentrations
• T/F: Patients who do have their HIV medications
monitored experience quicker time to
undetectable RNA load and less side effects
• T/F: Monitoring HIV medications is recommended in
HIV guidelines due to clinical trials showing that
monitoring improves clinical outcomes
PATIENT CASE
• A patient who was recently diagnosed with HIV has
been on anti-retroviral therapy for the past 3
months. She reports being extremely adherent (the
pill counts also show she has been adherent).
However, her CD4 count is still very low and her RNA
is quite high. What can we consider doing?
PRE/POST EXPOSURE PROPHYLAXIS
• PEP:
• Start when:
• Stop when:
• Drug:
• nPEP:
• Substantial vs negligible risk:
• Drug:
• PrEP:
• Drug:
PRE-EXPOSURE PROPHYLAXIS
• If you start a patient on Truvada, when would you
want to schedule a follow up visit?
• What are some things to monitor for a patient
receiving pre-exposure prophylaxis?
• If a patient becomes HIV + while on prophylaxis
(and the diagnosis is confirmed and CD4 count is
ordered), what could you consider doing?
PRE-EXPOSURE PROPHYLAXIS
• For all groups (MSM, heterosexuals, IVDU)…what
must we make sure they do NOT have before
initiating HIV pre-exposure prophylaxis?
PRE-EXPOSURE PROPHYLAXIS
SUMMARY
• Recognize the need to monitor for renal and
hepatic function in HIV + patients
• Recognize the classes of medications as well as the
combination products that generally need to be
adjusted for renal or hepatic function
• Know the drug used for pre and pre-exposure
prophylaxis
QUESTIONS?