HIV Drug Adverse Reactions / Interactions

List the NRTIs

Abacavir
Emtricitabine
Lamivudine
Tenofovir disproxil (TDF)
Tenofovir alafenamide (TAF)

What are the NRTI class adverse effects?

Lactic acidosis and hepatic steatosis (BBW; but tech no clinical incidence)
Lipodystrophy (mat maldistribution, irreversible)

What are the NRTI drug specific adverse effects?

Didansoine: GI intolerance, pancreatitis, peripheral neuropathy, hepatotoxicity
Stavudine: Peripheral neuropathy, pancreatitis
Zidovudine: IV form, pref for HIV peds, headache, GI intolerance, bone marrow suppresion, leuopkenia

Why avoid stavudine + didanosine in preg women

increased risk for lactic acidosis and liver damage

What is unique about abacavir? How should you screen patients?

Recommended HLA-B*5701 Testing prior to reduce risk of hypersensitvity

Possible increased risk of CV disease

What is the difference between tenofovir DF and AF formulation?

DF	AF
Renal dosing CrCl <50 ml/min	Renal dosing CrCl <30ml/min
Active metabolite	Prodrug
	Improvement in kidney function and bone mineral density
NO interaction with rifamycins	Interaction with rifamycins makes TAF ineffective

List the NNRTIs

Doravirine
Efavirenz
Etravirine
Rilpivirine
Nevirapine

What NNRTI requires 500 calories with each dose?

Rilpivirine

Which NNRTIs cause rash

Riplivirine, Efavirenz, Etravirine, Nevirapine

Which NNRTI has the ADR of neuropsychiatric symptoms including nightmares and vivid dreams?

Efavirenz!

Riplivirine Counseling Pearls

500 cal with each dose daily
Only use if HIV Viral load is <100,000 copies
PPI contraindacated

Doravirine Counseling Pearls

No food requirements
Once daily
Minimal ADRS
Metabolized by 3A4

Efavirenz Counseling Pearls

Preg class D (risk-benefit)
ADRs: Neuropsych sx, hyperlipidemia
Aderence is SUPER important! only 1 mutation to develop resistance
Take on empty stomach at bedtime due to sedation
CYP inducer

Etravirine Counseling Pearls

BID
Used in multidrug resistant virus
CYP inducer

Nevirapine Counseling Pearls

ADRS: hepatotocity
No food requirements
Contraindicated in liver failure

What are the protease inhibitors

Common: Atazanavir, Datunavir
Less common: Fosamprenavir, Indinavir, Lopinavir/ritonavir

Should protease inhibitors be taken with or without food?

With food

Why is ritonavir or cobicistat used with select protease inhibitors? For which commonly

used PIs?

to boost efficacy

Atazanavir- with or without boost is OK

Darunavir- must boost!!

What are the general ADRs of protease inhibitors?

GI intolerance
Hyperlipidemia
Insulin resistance and diabetes
Lipodystrophy
Elevated liver function tests
Possible increased bleeding risk in hemophiliacs

What are the general drug interaction pathways for PIs?

Entry Inhibitors

Enfuvirtide - multi drug resistant HIV
Maraviroc
Fostemsavir - multi drug resistant HIV

List the integrase inhibitors

Bictegravir
Dolutegravir
Cabotegravir
Raltegravir
Elvitegravir
Lebecapavir

What is the most used integrase inhibitor?

Bictegravir

Which integrase inhibitor has a clinical interaction with metformin?

Bictegravir increases metformin by 38%

When should you start statin therapy in patients with ARV induced hyperlipidemia?

ALL patients >40 with ASCVD risk >5% should be on statin therapy
Cosider ARV swtich if on a PI or lipid lowering agents

Which statins don’t interact with ARVs? How do you use statins that do interact

Avoid simvastatin and Lovastatin

Use: Prava, Rosuva, and Atorva (low dose)

What ARVs interact with different gastrointestinal agents (H2s,PPIs, antacids)? How do you manage it?

Rilpivirine, Atazanavir- Avoid PPIs. May use HR2A is separated by >12 hours

Avoid cimetidine due to 3A4 inhibition- use ranitidine or famotidine

Antacids- separate from atazanavir and tipranavir by 1-2 hours
Separate from integrase inhibtors by >4 horus

What ARV class interacts with erectile dysfunction medications? How do you manage it?

What drugs should you avoid with ARVs?

No rifampin or rifapentine or eryhthromycin