Ardis Ann Moe, M.D. UCLA CARE Clinic/NEVHC HIV Clinic Van Nuys. 29 August 2014

 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 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 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 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!