ASTHMA and HIV :-)

Biktarvy

INSTI-based combo

• Bictegravir/Emtricitabine/TAF

Triumeq

INSTI-based combo

• Dolutegravir/abacavir/lamivudine

Stribild

INSTI-based combo

• Elvitegravir/cobicistat/emtricitabine/TDF

Genvoya

INSTI-based combo

• Elvitegravir/cobicistat/emtricitabine/TAF

Dovato

INSTI-based combo

• Dolutegravir/lamivudine

Cabenuva

INSTI-based combo

• Cabotegravir/rilpivirine

Complera

NNRTI-based combination

• Rilpivirine/emtricitabine/TDF

Odefsey

NNRTI-based combination

• Rlipivirine/emtricitibine/TAF

Symfi + Symfi Lo

NNRTI-based combination

Efavirenz/(emtricitabine or Lamivudine)/TDF

Symtuza

PI-based combo

• Darunavir/Cobicistat/Emtricitabine/TAF

Descovy

Dual NRTI

• Emtricitabine/TAF

Truvada

Dual NRTI

• Emtricitabine/TDF

What are the options for PrEP?

• Truvada daily (CrCl> 60)

• Descovy daily (CrCl >30)

• Apretude monthly x2 doses, then q2month

• Negative HIV test q90d for orals, q2months for Apretude

What are the options for PEP?

• Start within 72 hours, continue x28d

• Complete regimen: 3 agents

  • Truvada (Dual NRTI) + Dolutegravir or raltegravir

• Testing at 4-6weeks, 3 months, and 6 months

What are the preferred initial ARTS?

One INSTI base + Two NRTIs backbone

• Biktarvy (one pill)

• Triumeq (one pill)

• Tivicay + Truvada (2 pills)

  Tivicay + Descovy (2 pills)

• Dovato is exception to this, only two ingredients (one pill)

What are alternative ARTS?

Base options

• INSTI, Boosted PI, NNRTI

Plus two NRTIs

• Abacavir or tenofovir PLUS Emtricitabine or Lamivudine

When to not use Dovato?

• HIV RNA >500,000 copies

• HBV coinfection

• ART needs to be started before HIV genotyping or HBV testing

TDF vs TAF side effects?

TDF = Decreases bone density, increased renal problems, GI Effects

TAF = Greater lipid effects

Considerations for Abacavir?

• Requires HLA-B*5701 test for hypersensitivity risk

• Only NRTI that doesn’t require renal dose adjustment

Consideration for Emtricitabine?

Can cause hyperpigmentation

NRTIS

Z <3 LATTE

• Zidovudine

• Lamivudine

• Abacavir

• TDF/TAF

• Emtricitabine

NNRTIs

REDEN

• Rilpivirine

• Efavirenz

• Doravirine

• Etravirine

• Nevirapine

Protease Inhibitors

The “navirs”

• Ritonavir (PK enhancer)

• Atzanavir

• Darunavir

• Lopinavir

CCR5 Inhibitor

Maraviroc

Attachment inhibitor

Fostemsavir

Post-Attachment Inhibitor

Ibalizumab

Fusion inhibitor

Enfuvirtide

Capsid inhibitor

Lencapavir

Generic for Viread?

TDF

Generic for Vemlidy?

TAF (note this is for HBV only, it’s a low dose)

Generic for Isentress? Isentress HD?

Raltegravir (HD = two pills)

Generic for Apretude?

Cabotegravir

Generic for Tricavay?

Dolutegravir

CrCl Cut offs?

<70 = do not start Stribild

<50 = D/C Stribild if already started

<30 = do not start Biktarvy or Genvoya

Tips with Zidovudine

• NRTI

• Admin during labor + delivery to prevent HIV transmission to newborn

• BBW for hepatomegaly w/ steatosis

• Can cause hematologic toxicities (neutropenia, anemia, macrocytosis)

Side effects of all NRTIs

• Lactic acidosis

• Fatty liver

• Nausea/diarrhea

Considerations for stopping NNRTIS?

• Do not abrupt stop if HBV coinfection, can worsen

Side effects of all NNRTIS

• Hepatotoxicity

• Rash (including SJS/TEN)

Considerations for Efavirens?

• CNS effects

• Increases cholesterol

• Take on empty stomach at bedtime

Considerations for Rilpivirine?

• Depression

• Falsely elevate SCr

• Take WITH food

• Separate from antacids

Side effects of all PIs

• Diarrhea, nausea

• Metabolic effects

• Hepatoxicity (all hepatically cleared)

• Hypersensitivity

• Drug interactions

Considerations for Atazanavir?

• Hyperbilirubinemia

• Requires acidic gut for absorption

• Take with food

Considerations for Darunavir?

• Has sulfa moiety

• Take with food

Considerations for Ritonavir?

• Only used for PK boosting (no antiviral activity)

Side effects of all PIs?

• Weight gain

• CNS effects

• Interactions with multivitamins

Considerations for Bictegravir

• Increased SCr

Considerations for Dolutegravir?

• Muscle toxicity (rhabdo)

• Increased SCr

• Hypersensitivity

• Hepatotoxicity

Considerations for Raltegravir?

• Muscle toxicity (rhabdo)

• Hypersensitivity

• SJS/TEN

Insert that Helpful Picture of the Drugs and their components on the other side here

Recommended initial ARTS image

Alternative ARTS image

When would you do Step 1 therapy for asthma? What is it in terms of rescue + maintenance inhalers?

Step 1 Intermittent. If symptoms are happening less than twice monthly.

• Rescue only (ICS-formoterol or SABA + ICS)

When would you do Step 2 therapy for asthma? What is it in terms of rescue + maintenance inhalers?

Step 2 = Mild. When symptoms are more than twice monthly but less than 4 day days a week.

• ICS-formoterol alone (as rescue)

  OR

• SABA/SABA-ICS + Low dose ICS maintenance

When would you do Step 3 therapy for asthma? What is it in terms of rescue + maintenance inhalers?

Step 3 = Moderate. When symptoms are most days and can be with nighttime awakenings

ICS-formoterol low dose as both PRN and maintenance

OR

SABA/SABA-ICS + Low dose ICS-LABA maintenance

When would you do Step 4 therapy for asthma? What is it in terms of rescue + maintenance inhalers?

Step 4 = Severe. When symptoms are daily + can be with nighttime awakenings

ICS-formoterol low for PRN and medium for maintenance

OR

SABA/SABA-ICS + medium dose ICS-LABA maintenance

When would you do Step 5 therapy for asthma? What is it in terms of rescue + maintenance inhalers?

Same as step 5 but use high dose ICS-formoterol and they need to be referred for assessment

Asthma Algorithm All Laid Out

Which drugs are short acting beta 2 agonists? Special side effects?

Products include

• Albuterol = ProAir, Proventil, Ventolin

• Levalbuterol = R-isomer of albuterol

• Epinephrine (Primitene Mist) = Should not be used since it is non-selective

Can cause nervousness, tremor, tachy, palpitations, hyperglycemia, hypokalemia (remember can be used in hyperkalemia)

Which drugs are long acting beta 2 agonists? Special side effects?

Products include

• Salmeterol (Serevent Diskus)

• Formoterol

Special BBW = INCREASED DEATH WHEN USED AS MONOTHERAPY. So use with ICS plz

Which drugs are inhaled corticosteroids? Special side effects?

Products include

• Beclomethasone (QVAR Redihaler)

• Budesonide (Pulmicort)

• Fluticasone (Flovent, Arnuity)

• Mometasone (Asmanex)

• Circlesonide (Alvesco)

WARNINGS for increased fracture risk, growth retardation, immunosuppression, THRUSH, dysphonia (difficult speaking), increased blood glucose

What kind of asthma is Montelukast approved for?

Exercise induced asthma

What is theophylline used for, what are its side effects and why? therapeutic range? What body weight is used to dose it?

• Blocks phosphodiesterase, causing increase in cAMP and releases epinephrine -> bronchodilation

• Active metabolite is caffeine so has many CV effects. Can cause arrhythmias and seizures

• Therapeutic range = 5-15 mcg/mL

• Dose with IBW (5 mg/kg) or use TBW if < IBW

Aminophylline to Theophylline conversion?

ATM (aminophylline to Theophylline Multiply)

aminophylline dose * 0.8 = theophylline dose

What is the only anticholinergic approved for use in asthma?

Tiotropium (LAMA)

But also note that in Trelegy Ellipta, umeclidinium is an ingredient

What are the asthma shots? Most common one? What are they approved for? How often given? Where are they given?

Monoclonal Antibodies

• These are reserved for either allergic asthma or eosinophilic asthma

• They are given either SC or IV every couple of weeks

• Omalaziumab (XOLAIR) = Blocks IgE binding

BBW FOR ANAPHYLAXIS, every dose given in healthcare setting

What is the order of inhalers to be given? How long must you wait between inhalations?

SABA → LABA/LAMA → ICS

Wait 60 seconds between inhalations

What are the limits for the “zones” from Peak Flow Meters? What dose each zone mean?

• Green zone = 80-100% of personal best. Follow routine maintenance

• Yellow zone = 50-80% of personal best. Indicates caution. Alter action plan

• Red zone = <50% of personal best. Get your ass to hospital

Brand names for Albuterol?

Ventolin, ProAir, Proventil

Ingredients in QVAR Redihaler?

Beclomethasone

Ingredients in Symbicort?

Budesonide + Formoterol

Ingredients in Advair?

Fluticasone + Salmoterol

Ingredients in Breo Ellipta?

Fluticasone + Vilanterol

Ingredients in Asmanex?

Mometasone

Ingredients in Dulera?

Mometasone + Formoterol

Ingredients in Alvesco?

Circlesonide

Brand names for fluticasone?

• Flovent, Arnuity

Ingredients in Trelegy Ellipta?

Fluticasone, umeclidinium, vilanterol

What combination of inhaler is not approved in asthma?

LABA/LAMA

Which inhalers are dry powder inhalers?

• Diskus

• Ellipta

• Pressair

• Handihaler

• Neohaler

• RespiClick

• Flexhaler

Which inhalers are metered dose inhalers?

• Ends in HFA

• Respimat

• Breztri Aerosphere

• Has no suffix, like Alvesco

Which inhalers do you need to prime?

• All MDIs

• Flexhaler (a DPI, its the twisty one)

• Respimat (An MDI, the other twisty one)

Which MDI can you not use with a spacer

QVAR redihaler, Respimat

Which inhalers should you not shake

• Any DPI

• QVAR Redihaler

• Alvesco

• Respimat

Ingredients in Spiriva?

Tiotropium

Ingredients in Asmanex?

Mometasone

Ingredients in Pulmicort?

Budesonide

Ingredients in Serevent?

Salmeterol

There are two triple therapy inhalers (LABA/LAMA/ICS) what are their names

• BrezTRI Aerosphere

• TRElegy Ellipta

  Both kinda have “TRI” in the name! Kinda.

Can you use a spacer with MDIs? DPIs?

• MDI, yes (except QVAR and Respimat devices)

• DPIs, no (they will not stay suspended)

What kind of inhalers are Respimat inhalers?

MDI: They are soft mist inhalers

Which inhaler requires two inhalations to get full dose?

Spiriva Handihaler (tiotropium)

Which inhaler has a control window that turns from red to green when its ready?

Pressair (Aclidinium)

What test is needed to diagnosis COPD that shows irreversible damage?

FEV1/FVC of <=0.7

Category A COPD is defined as….

0-1 moderate exacerbations with no hospitalization, mMRC of 0-1, CAT of <10

Category B COPD is defined as….

0-1 moderate exacerbations with no hospitalization, mMRC >=2, CAT of >=10

Category E COPD is defined as…

>=2 moderate exacerbations or 1 requiring hospitalization

Treatment for Group A COPD? Group B? Group E?

A = A bronchodilator (LABA/LAMA)

B= LABA+ LAMA

E= LABA + LAMA (+ ICS if blood eos >300)

What is the lower cut off blood eosinophils in which ICS cannot be considered at all for COPD?

<100

What are the two adjuncts that can be considered last line for COPD?

• Roflumilast

• Azithromycin

What drugs are short acting muscarinic antagonists for COPD? Which receptor does it act at? Special side effects?

• Ipratropium is the only one

• Works at M3 receptor

• Anti muscarinic can dry out your mouth, cough, bitter taste, can cause upper respiratory tract infections