VIRTUAL MEDZONE Your Resource for HIV Related Innovative Medical Communication.

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Presentation transcript:

VIRTUAL MEDZONE Your Resource for HIV Related Innovative Medical Communication

HIV CASE PRESENTATIONS Roger Leblanc MD FRCPC Joss DeWet MBChB CCFP David Fletcher MD FRCPC

CASE 1 31 yo man HIV+ mid 2008 Clade B CD4 1130/38%, VL 100, ,000 Genotype clear

CASE 1 BASELINE GENOTYPE JUL/08

CASE 1 Late 2009…1 year later VL >500,000 CD4 down to 440/22% Feeling weak/tired

CASE 1 Late 2009 Initiated TDF/FTC/EFV/RTV/LPV as induction therapy given high viral load and precipitous decline in CD4 from over year previously

CASE 1 Late 2009 Diarrhea/vomiting/abdominal pain and anorexia Unable to tolerate therapy RTV/LPV discontinued from regime within first week continued TDF/FTC/EFV

CASE 1 Late 2009 Began to feel much improved from a GI standpoint so RTV/Darunavir added to TDF/FTC/ EFV Nausea/vomiting restarted so RTV/DRV discontinued within 1 wk

CASE 1 1 MONTH into therapy…TDF/FTC/EFV CD4 440/22% → 840/31% VL >500,000 → 1659 c/ml

CASE 1 2 Months into therapy…TDF/FTC/EFV CD4 730/28 % VL 1659 → 2085 WHAT WOULD YOU DO?

CASE 1 Persisted with TDF/FTC/EFV and was adherent by history DATEVIRAL LOADCD4 01/ /28% 02/ /33% 03/ /32% 04/ /40%

CASE 1 GENOTYPE JAN/10

CASE 1 GENOTYPE JAN/10

CASE 1 TROPISM JAN/10

CASE 1 MAY 2010 Raltegravir added to TDF/FTC/EFV Tolerated well/no problems

CASE 1 JUNE 2010 TDF/FTC/EFV/RGV CD4 1010/36% VL 918 WHAT WOULD YOU DO?

CASE 1 GENOTYPE JUN/10

CASE 1 GENOTYPE JUN/10

CASE 1 GENOTYPE JUN/10

CASE 1 JUNE 2010 TDF/FTC/EFV/RGV… tolerating well TDM…adequate levels of medication DATEVIRAL LOADCD4 06/ /36% 08/ /39% WHAT WOULD YOU DO?

CASE 1 AUGUST 2010 Regimen switched to TDF/FTC/RGV/RTV/fAPV/MVC DATEVIRAL LOADCD4 08/ /39% 09/ /42% 10/ /37%

CASE 1 OCTOBER 2010 Regimen switched to TDF/FTC/RGV/ETR/RTV/DRV DATEVIRAL LOADCD4 10/ /37% 11/ /38%

CASE 1 NOVEMBER 2010 Tolerating TDF/FTC/RGV/ETR/RTV/DRV Maraviroc added DATEVIRAL LOADCD4 11/ /38% 12/ /38% 01/ /40% 02/ /40% WHAT WOULD YOU DO?

CASE 1 FEBRUARY months of TDF/RGV/ETR/RTV/DRV/ MVC TDM of RGV + DRV shows no RGV level and low DRV levels Readjusted DRV dose and of course reinforced adherence

CASE 1 GENOTYPE JAN/11

CASE 1 MARCH 2011 Checked pharmacy log → all pills picked up at appropriate times Repeat TDM → therapeutic levels of all medications

CASE 1 MAY 2011 TDF/FTC/RGV/ETR/RTV/DRV/MVC DATEVIRAL LOADCD4 03/11129− 04/ /31% 05/11193− WHAT WOULD YOU DO?

CASE 1 MAY 2011 Regimen simplified to TDF/FTC//RTV/DRV DATEVIRAL LOADCD4 05/11193− 06/ /43% 07/ /44% Is this an issue related to patient, virus, or Inadequate immune control?