Learning objective 5. Given a prescription for antiretroviral agents, provide patient counseling for adverse effects and proper administration.
We looked at the mechanism of action of antiretroviral agents and what dhhs skyland recommends for treatments of hiv patients we ensured adherence to a rt is optimized and designed an individualized monitoring plan now given a prescription for antiretroviral agents provide patient counseling for adverse effects so you can see that these are the drugs that are most
Commonly used this is not a you know complete list but these are the most commonly used so you should definitely know all of these so it’s important to know which one needs to be so if it says no for food that means it you can take it with or without food but in a particular ly tech revere needs to be taken with food so is roper varying so anything that has real
Papering and juliaca was also recently fda approved note that jokah is a little different and it’s not in the guideline yet so you know you should the only thing you need to know about it is that it doesn’t have a backbone so this is an exception to the rule that you need tuned to nooks plus a third agent so they eliminated the nooks as the backbone and you said
They’re using two highly potent drugs together but this is so it’s not in the guidelines yet and per fda approved package insert you can only start it in someone who’s already been treated for hiv and the viral load is suppressed for at least six months and then you can so if the backbone is causing problems so most specifically you know if someone isn’t enough
Over here and they have nephrotoxicity and bone toxicity then you can actually switch those patients to dilute anger of years or papering because it doesn’t have the backbone so you want to have some of that toxicity so we’ll see how the guidelines will actually recommend these once the new one comes but regardless because there’s a real paper in here you have to
Take it with food than with the computer and odf see there’s real power in so you need to take it with food because ralph every needs an acidic environment to be absorb so you know eating with food helps release the acid so he helps with absorption now with a fabrice it’s the other way around you actually want empty stomach because of severe adverse effects of a
Fabrice we actually do not want it to be absorbed as much so what they said is you know with a trip la take it on empty it has to be on empty stomach because if they eat food you know you’re gonna get too much toxicity in fact this was so important that they actually came up with a new formulation called simple low so the low means the if a burns actually a lower
Dose and they still want you to take it on an empty stomach okay so because of those adverse effects so simple low is actually pretty new was fda approved last week and then so for the rest of them when he says no it doesn’t matter you can take it with or without food and with protease inhibitors in general you need to take it with food so but there’s the runa
Beer or it ate as a nevere you need to take you with food now let’s take a look at some of our nukes or nrt is so nrt is our nucleotide reverse transcriptase inhibitors so nukes soul mm adenine abacavir so generally speaking as an entire class of nukes because their nucleotide analogs you know what they can actually cause mitochondrial toxicity and the reason is
Inside the mitochondrial in the host cell there are dna polymerase dna polymerases in the mitochondrial that actually uses nucleotides to to replicate mitochondrial dna and because these are analogs of nucleotides that dna polymers can actually be inhibited by these nucleotide analogs so especially older nokes cause severe mitochondrial toxicity leading to lactic
Acidosis so you will see lactic acidosis as a black box warning for pretty much all of the nukes but note that these are primarily from the old nukes that we don’t really use anymore so the current and you know for newer nukes that we actually use they have less in him less affinity for dna polymerase so you don’t see those side effects as much but still important
To be aware of a just-in-case because not all patients are equal so occasionally you will see a patient that is most likely to have these adverse effects and of course with a buck every year you have to check for hla-b 5701 allele polymorphism and if the patient is positive you should not start it because they will be at and you know there will be at least a 50%
Chance of having a severe and possibly fatal hypersensitivity reaction another problem that was with abacavir you know around a decade ago was that there was talks about increased risk of myocardial infraction with abacavir and this all was mostly from observational studies and the problem with observational studies is that they are at high risk for bias so that’s
Why you will see a lot of the drugs actually using the backbone of emtricitabine and tenofovir here and that was because a lot of people were reluctant to use a behavior because of the increased risk of mi so the fda actually reviewed 26 randomized clinical trials and they did the meta-analysis and they actually said that no abacavir does not increase mi so this
Is so if a patient hears about the risk of mi you should let them know that fda has done a meta-analysis and they have not found an increased risk for mi so it’s safe to use turn off over here as i mentioned you know so nephrotoxicity and osteo toxicity are the two top adverse effects of tanf aveer which is higher with this infraction fumarate because of the higher
Dose and it’s less likely to happen with one calf as i do voiding is one of those older nukes that can actually cause mitochondrial toxicity the reason we still have the adobe dean on the market and we use it because it actually available as iv and because it’s pretty old we’ve had this since the 1980s there’s a good data in pregnancy and during delivery so this is
One of the iv infusions that we actually do when someone is giving birth to a baby who has hiv so that for that reason as i don’t we didn’t still on the market and we still use it so with my tegra of year which needs to be boosted with the pharmacokinetic booster could be cysts that and of course this uses the backbone of tanaka veer so on top oh so tanaka viera
Cousins nephrotoxicity but one thing in particular that kobe sees that does it can actually cause a small increase of serum creatinine and this is although it increases the number it you know kobe sis that does not cause nephrotoxicity it actually blocks one of the channels in the kidney that that actually normally secretes serum creatinine so he actually blocks the
Secretion of serum creatinine in the kidney and because of that the number artificially goes up but it really does kobe sister alone does not cause nephrotoxicity and of course big tegra of year which was approved last week is second-generation integrase inhibitor one thing that’s great about the second-generation integrity inhibitors that they’re well tolerated
They have a high barrier to resistance and they don’t need the pharmacokinetic booster try bank which is the only combination regimen that actually uses abacavir and llama llama budin as a backbone is also second-generation integrase inhibitor it also comes alone if if somebody you know is so if someone had hla-b 5701 positive you cannot use trimack so it comes
As tbk alone so that you can use a backbone off turn off over here and em try side have been like truvada for example you would have to give them two pills i’ll take over here is a first generation integrity inhibitor so if you use the 400 milligram it has to be those twice a day if you do the two of hundred milligram then you can do the once a day dosing now the
Two protease inhibitors that we use are the rune of year and a dozen of year so the rune of year should be taken with food and it also needs to be boosted in fact most pretty much all of the protease inhibitors need to be boosted and here’s a nun nuke so nn rti or non-nucleoside reverse transcriptase inhibitors rope heparin as i mentioned earlier you should only
Use this if the patient’s cd4 count is greater than 200 and the viral load is less than a hundred thousand don’t worry about these groups one good thing about the non noakes is that they do not inhibit the mitochondrial polymerase so you should not have those mitochondrial related toxicities and then the other non nuke that we use is a favorites one thing about
The favorites is that there’s it’s actually increases the risk of depression suicidality and that’s actually the primary reason that this is an alternative because of the risk of suicide the other thing is that it can actually because it primarily causes cns toxicity so whether it’s depression or suicide you know it’s cns toxicity but another thing that they can
Actually do it can cause vivid nightmares so vivid dreams so for that reason it’s recommended to take it at night because by the time it’s actually absorbed and you know the side effects kick in you know the patient wakes up in the morning so the vivid dreams which becomes you know a real problem it will be one way of dealing with it and of course you know a lot
Of these cns effects will resolve after – two to four weeks so if it’s you know within two weeks and someone’s complaining you know you may continue for four weeks but if there’s a complaining beyond four weeks then you may want to change to switch to something else
Transcribed from video
HIV in Adults LO 5 By Alireza FakhriRavari PharmD BCPS BCIDP AAHIVP