HIV Management Update 2015 Larry Pineda, PharmD, PhC, BCPS - - PDF document

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HIV Management Update 2015 Larry Pineda, PharmD, PhC, BCPS - - PDF document

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9/30/15 HIV Management Update 2015 Larry Pineda, PharmD, PhC, BCPS Visiting Assistant Professor Pharmacy Practice and Administrative Science ljpineda@salud.unm.edu Pharmacist Learning Objectives Describe the HIV life cycle and

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HIV Management Update 2015

Larry Pineda, PharmD, PhC, BCPS Visiting Assistant Professor Pharmacy Practice and Administrative Science ljpineda@salud.unm.edu

Pharmacist Learning Objectives

  • Describe the HIV life cycle and recognize

antiretroviral drug targets

  • Classify an antiretroviral agent by its mechanism of

action

  • Summarize pertinent changes to the 2015 DHHS

HIV guidelines

  • List the antiretroviral agents which are

recommended for the treatment of HIV+ patients

  • List the antiretroviral agents which are

recommended for post exposure prophylaxis (PEP)

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Technician Learning Objectives

  • Define HAART
  • Identify the minimum number of antiretroviral

drugs in an appropriate HAART regimen

  • Understand the importance of HAART

adherence

  • List the antiretroviral agents which are

recommended for post exposure prophylaxis (PEP)

Human Immunodeficiency Virus (HIV)

  • Retrovirus (RNA)
  • Two distinct groups: HIV-1, HIV-2
  • Acquired Immune Deficiency Syndrome (AIDS)
  • Transmission
  • Sex
  • Injection drug use
  • Perinatal
  • Breast milk
  • HIV/AIDS among leading causes of morbidity/

mortality in U.S.

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Mature HIV Virion Natural Progression of HIV

http://tuningpp.com/hiv-to-aids-progression/

Stage ¡1 ¡ Stage ¡3 ¡ Stage ¡2 ¡

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Epidemiology

  • 1.2 million persons 13 years and older living

with HIV in U.S.1

  • 168,300 (14%) are unaware of their infection1
  • Undiagnosed responsible for over half of new HIV

cases2

  • Only ~50% of U.S. adults ever tested3
  • CDC expanded screening 2006
  • Annual incidence approximately 50,000 cases1

1. http://www.cdc.gov/hiv/library/reports/surveillance/index.html 2. Marks G et al. AIDS. 2006;20:1447-50 3. Kaiser Family Foundation, 2011 Survey of Americans on HIV/AIDS

“Late Testers” in New Mexico

  • Diagnosed in stage 3
  • 43.2% diagnosed with HIV received concurrent

AIDS diagnosis

  • Relatively higher than U.S. average 38%

New Mexico DOH Summer Quarterly Report: July 2010

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Living With HIV

Campsmith M et al. JAMA 2008;300(5):520-29

Early Initiation of Therapy

  • Improves outcomes1
  • Prevents progression to AIDS
  • Reduce hospitalizations
  • Decrease risk of opportunistic infections
  • Long healthy life
  • Reduces chance of transmitting to others2
  • Undetectable viral load <4% risk
  • Condom use + undetectable viral load <1% risk

1. Kitahata MM et al. N Engl J Med.2009;360(18):1815-26 2. Das M et al. PLoS One. 2010;5(6):e11068

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Question

What is the minimum number of antiretroviral drugs that should be included in an ideal HIV treatment regimen?

  • A. One
  • B. Two
  • C. Three
  • D. Four
  • E. Five

HAART

  • Highly Active Anti-Retroviral Therapy
  • 3 active antiretroviral drugs
  • 2 nucleoside reverse transcriptase inhibitors
  • Plus 3rd active agent:
  • Integrase strand transfer inhibitor
  • Non-nucleoside reverse transcriptase inhibitor
  • Protease inhibitor with pharmacokinetic enhancer

(cobicistat, ritonavir)

  • Adherence critical for success
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Question

What is the percentage of adherence to HAART needed for optimal virologic supression?

  • A. < 70%
  • B. 70 – 79.9%
  • C. 80 – 89.9%
  • D. 90 – 94.9%
  • E. > 95%

Adherence Goal > 95%

Patterson DL et al. Ann Intern Med. 2000;133:21-30

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The Drugs Antiretroviral Drug Classes

  • Entry inhibitor
  • Fusion inhibitor
  • Reverse transcriptase (RT) inhibitors
  • Nucleoside RT inhibitors (NRTI)
  • Non-nucleoside RT inhibitors (NNRTI)
  • Integrase strand transfer inhibitors (INSTI)
  • Protease inhibitors (PI)
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HIV Life Cycle

www.aidsinfonet.org

Entry/Fusion Inhibitors

  • Selzentry (maraviroc)
  • CCR5-inhibitor
  • Requires tropism assay
  • Twice a day
  • Fuzeon (enfuvirtide)
  • Subcutaneous injection
  • Twice a day
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NRTIs

  • Truvada (tenofovir/emtricitabine)
  • Viread (tenofovir)
  • Emtriva (emtricitabine)
  • Once a day
  • Epzicom (abacavir/lamivudine)
  • Ziagen (abacavir)
  • Epivir (lamivudine)
  • Once a day
  • Combivir (zidovudine/lamivudine)
  • Retrovir (zidovudine)
  • Twice a day

NNRTIs

  • Sustiva (efavirenz)
  • Atripla (efavirenz/tenofovir/emtricitabine)
  • Edurant (rilpivirine)
  • Complera (rilpivirine/tenofovir/emtricitabine)
  • Viramune (nevirapine)
  • Intelence (etravirine)
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PIs

  • Prezista (darunavir)
  • Reyataz (atazanavir)
  • Norvir (ritonavir)
  • Prezcobix (darunavir/cobicistat)
  • Evotaz (atazanavir/cobicistat)

INSTIs

  • Isentress (raltegravir)
  • Twice a day
  • Vitekta (elvitegravir)
  • Needs to be boosted
  • Tivicay (dolutegravir)
  • Stribild (elvitegravir/cobicistat/tenofovir/

emtricitabine)

  • Triumeq (dolutegravir/abacavir/lamivudine)

Stribild ¡ Triumeq ¡ Tivicay ¡

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DHHS HIV Guidelines 2015

  • Updated April 2015
  • 5 recommended HAART regimens:
  • 4 integrase strand transfer inhibitor (INSTI)-based

regimens

  • 1 ritonavir-boosted protease inhibitor (PI/r)-based

regimen

  • 2 regimens previously categorized as

recommended moved to alternative

INSTI-Based Regimens

  • Dolutegravir/abacavir/lamivudine (AI)
  • Only if HLA-B*5701 negative
  • Dolutegravir plus tenofovir/emtricitabine (AI)
  • Elvitegravir/cobicistat/tenofovir/emtricitabine

(AI)

  • Raltegravir plus tenofovir/emtricitabine (AI)
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PI-Based Regimen

  • Darunavir/ritonavir + tenofovir/emtricitabine (AI)
  • Atazanavir/ritonavir has been moved to

alternative list

Alternative List

  • Limitations for use in certain patient populations
  • May be the preferred regimen for some patients
  • NNRTI-based regimens
  • Efavirenz/tenofovir/emtricitabine (BI)
  • Rilpivirine/tenofovir/emtricitabine (BI)
  • PI-based regimens
  • Atazanavir/ritonavir + tenofovir/emtricitabine (BI)
  • Atazanavir/cobicistat* + tenofovir/emtricitabine (BI)
  • Darunavir/ritonavir + abacavir/lamivudine (BII)

* Creatinine clearance 70 ml/min

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Triumeq

  • Dolutegravir/abacavir/lamivudine
  • One pill once a day, with/without food
  • Adverse effects
  • Headache
  • Insomnia
  • Rash, hypersensitivity reaction
  • HLA-B*5701 negative only
  • Drug interactions
  • Polyvalent cations, separate

Prezcobix

  • Darunavir/cobicistat
  • One pill once a day, with food
  • Adverse effects
  • Diarrhea, nausea, vomiting
  • Rash
  • Increased serum creatinine
  • Treatment-naïve only
  • Drug interactions
  • CYP-3A4 substrates
  • http://www.hiv-druginteractions.org/
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Evotaz

  • Atazanavir/cobicistat
  • One pill once a day, with food
  • Adverse effects
  • Elevated bilirubin levels, jaundice, scleral icterus
  • Diarrhea, nausea, vomiting
  • Increased serum creatinine
  • Drug interactions
  • CYP-3A4 substrates
  • http://www.hiv-druginteractions.org/

Tenofovir Alafenamide (TAF)

  • In phase III trials
  • Prodrug of the nucleotide analog tenofovir
  • Conversion occurs intracellulary
  • Lower plasma exposure than tenofovir disoproxil

fumarate (TDF)

  • Higher active [drug] in mononuclear cells
  • Benefits over TDF:
  • Less toxicities (nephrotoxicity, BMD/fractures)
  • Smaller dose required (pill size)
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Question

(True/False) All 3 INSTIs are listed as recommended agents in the 2015 DHHS HIV treatment guidelines.

  • A. True
  • B. False

Post Exposure Prophylaxis (PEP)

  • Last updated 2013
  • Elimination of risk stratification for exposure

incidents

  • 3-drug PEP regimen for all
  • Expanded list of ARVs for PEP
  • Emphasis on tolerability and convenience of

PEP regimen

  • New recommendations for follow-up HIV testing

www.aidsetc.org

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Occupational Risk Exposures

  • Percutaneous injury or contact of mucous

membrane or non-intact skin

  • Blood
  • Tissue
  • Body fluids that are potentially infectious
  • CSF, synovial, pleural, pericardial, peritoneal, amniotic, semen,

vaginal secretions

  • Not considered infectious:*
  • Feces, nasal secretions, saliva, sputum, sweat, tears, urine,

vomitus

* Unless visibly bloody

Toxicity of PEP Regimens

  • Previous PEP boosted PI-based regimens
  • GI side effects common
  • Major reason for not completing PEP
  • Ritonavir has many drug interactions
  • Tolerability major emphasis for recommended

PEP

  • Potential side effects should be discussed
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HIV PEP Recommendations

  • Newer agents better tolerated and have better

toxicity profiles than previous agents

  • 3 or more tolerable agents now recommended for all
  • ccupational exposures to HIV
  • 2 NRTIs (backbone)
  • 1 INSTI, ritonavir-boosted PI or NNRTI
  • Other classes may be indicated (resistant virus)
  • To facilitate completion of PEP
  • Optimize side effect and toxicity profiles
  • Optimize dosing convenience

Preferred PEP Regimen

Raltegravir 400 mg BID + Truvada 1 tab QD

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Alternative PEP Regimens

  • Raltegravir
  • Darunavir + ritonavir
  • Etravirine
  • Rilpivirine
  • Atazanavir + ritonavir
  • Lopinavir/ritonavir
  • Stribild*
  • Tivicay#
  • Tenofovir +

emtricitabine

  • Tenofovir +

lamivudine

  • Zidovudine +

lamivudine

  • Zidovudine +

emtricitabine 1 from each column

* Single tablet daily # Approved 2013 for treatment of HIV

Timing and Duration of PEP

  • Most effective when begun soon after the

exposure in animal studies

  • Start as soon as possible after the exposure,

preferably within hours (72 hours)

  • Point at which no benefit gained not defined
  • Duration of PEP is full 4 weeks (28 days)
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Question

Which of the following statements is TRUE regarding occupational exposure HIV PEP?

  • A. The recommended duration of PEP is 2 weeks
  • B. A positive HIV test is required before initiation of

PEP

  • C. An ideal PEP regimen includes abacavir +

lamivudine backbone

  • D. PEP should be started as soon as possible after

exposure

  • E. Dolutegravir is included as part of the preferred

PEP regimen

Questions