Lam Cumulative (HIV)

What class is the preferred backbone for an antiretroviral therapy (ART)?

NRTIs (nucleoside reverse transcriptase inhibitors) ⇒ 1 or 2

What class is the preferred anchoring for an antiretroviral therapy (ART)?

INSTIs (integrase strand transfer inhibitors) ⇒ 1 or 0

Which antiretrovirals (ARVs) inhibit the HIV integrase enzyme?

(-gravirs)

• Dolutegravir (Tivicay)

• Elvitegravir (In FDC)

• Raltegravir (Isentress)

• Bictegravir (in FDC)

• Cabotegravir (Vocabria)

Which antiretrovirals (ARVs) inhibit the HIV protease enzyme?

(-navirs)

• Atazanavir (Reyataz)

• Darunavir (Prezista)

• Fosamprenavir (Lexiva)

• Lopinavir/ritonavir (Kaletra)

• Ritonavir (Norvir)

Which antiretrovirals (ARVs) or NNRTIs (non-nucleotside reverse transcriptase inhibitors)?

• Efavirenz (Efavirenz/Susteva)

• Nevirapine (Viramune)

• Rilpivirine (Edurant)

• Doravirine (Pifeltro)

Which antiretrovirals (ARVs) or NNRTIs (nucleotside reverse transcriptase inhibitors)?

• Abacavir (Ziagen)

• Emtricitabine (emtriva)

• Lamivudine (Epivir)

• Tenofovir alafenamide (Vemlidy)

• Tenofovir disoproxil dumarate (Viread)

• Zidovudine (Retrovir)

What is the preferred regimen for initial ARV treatment?

1 INSTI + 2 NRTS or 1 NRTI

What are the class specific ADEs of NRTIs?

Lactic acidosis 🍼🐮🥛

Hepatic Steatosis

Myopathy

Lipodystrophy → tummy big and nerd neck

What are the class specific ADEs of NNRTIs?

Rash/SJS → (NVP > EFP > RPV = ETR) → (nevirapine > efavirenz > rilpivirine = etravirine)

Hepatotoxicity

What are the class specific ADEs of PIs?

Insulin resistance → hyperglycemia → T2DM

Hyperlipidemia → except ATV + DRV

Lipodystrophy

Before initiating an HIV+ patient on maraviroc (Selzentry®), what test needs to be performed for this patient

Tropism Assay

Before initiating an HIV+ patient on an abacavir-based regimen, what genetic test needs to be performed? What does it mean if the test result is positive?

HLA-B*5701 → patient is at a higher risk of developing a hypersensitivity (RASH)

• do not rechallenge patient if developed a hypersensitivity reaction

List the laboratory monitoring parameters associated with TAF and TDF.

TAF ⇒ lipid panel → lipodystrophy

TDF

• eGFR (BUN + SCr) ⇒ nephrotoxicity

• BMD, Dexascan ⇒ osteopenia/osteoporosis

What are the ADEs of tenofovir alafenamide?

Faconi syndrome

Nephrotoxicity ⇒ monitor eGFR

Ostopenia/Osteoporosis ⇒ monitor BMD

What are the ADEs of tenofovir disoproxil fumerate?

• same TDF but less

• weight gain

• Bad lipid profile

Which NRTI does not need RNA dose adjustment?

Abacavir (Ziagen)

Which 2 NNRTI agents could cause CNS side effects?

• Efavirenz (vivid dreams)

• Rilpivirine (worsen depression and drowsiness)

Which ART medications do you need to take with food?

• Rilpivirine

• Elvitegravir

• TDF

• TAF

• ALL PIs

  • Atazanavir (Reyataz)

  • Darunavir (Prezista)

  • Fosamprenavir (Lexiva)

  • Lopinavir/ritonavir (Kaletra)

  • Ritonavir (Norvir)

Which ART medications do you need to take on an empty stomach?

• Efavirenz —> @ bedtime to reduce CNS side effects

What is the main difference between Stribild® and Genvoya®?

Genovoya (EVG/COBI/TAF/FTC)

Stribilid (EVG/COBI/TAD/FTC)

What is the main difference between Complera® and Odefsey®?

Odefsey (RPV/TAF/FTC)

Complera (RPV/TAD/FTC)

What to ART medications are used as boosters?

• Cobicistat

• Ritonavir

What enzyme does cobicistant and ritonavir inhibit?

CYP3A4

When would you use rilpivirine?

use when HIV < 100,000 copies/mL + CD4 > 200

When would you use dolutegravir?

not use if HIV VL > 500,000 copies/mL

(True/False): Maraviroc is effective in HIV-positive patients with CCR5 tropic virus only.

True

A patient with HIV-1 infection presents to the clinic for a follow-up visit. The medical resident is reviewing the patient’s medications and labs. She comes to you and reports that patient’s total bilirubin (T. bili) is 3.0 mg/dL! The patient’s LFTs are WNL. You suspect the elevated T. bili is drug-induced. Which ARV could elevate the T. bili?

Atazanavir → jaundice, kidney stones, (prolong PR interval)

Which antiretroviral agent contains a sulfonamide moiety and should be used with caution in patients with serious sulfa or sulfonamide allergies (e.g., SJS or anaphylaxis)?

Darunavir

What is the MOA of ibalizumab (Trogarzo)?

humanized monoclonal antibody that targets CD4 receptor + glycoprotein 120 envelope → cause steric hindrance → prevents viral entry

What is enfuvirtide (Fuzeon)’s MOA?

binds to gp41 → prevents fusion of virus to host CD4+ cell surface coreceptors

What is the MOA of fostemsavir (Rukobia)?

binds to gp120 → prevents the virus from attaching to host CD4+ cell surface glycoprotein

What is the MOA of maraviroc (Selezentry)?

binds to the CCR5 coreceptor → causing a conformational change in the coreceptor that prevents HIV gp120 from binding to the CCR5 coreceptor

What is the MOA of lenacapavir (Sunleca)

inhibits HIV-1 capside function that binds to p24 subunit → inhibits replication by interfering with capsid-mediated nuclear uptake of HIV proviral DNA, virus assembly and release, and capsid core formation

What is one common adverse effect caused by INSTIs and TAF?

Weight gain (BIC, DTG)

Fostemsavir, ibalizumab, maraviroc, and lenacapavir could be considered for which type of HIV+ patients?

Salvage therapy

Treatment-experienced pts w/ resistant HIV + failing current ARV treatments

Identify the antiretroviral agents that are available in parenteral formulation (Hint: there are 4 agents).

Ibalizumab (Trogarzo) → IV

Cabotegravir + Rilpivirine (Cabenuva) → IM (in the butt)

Enfuvirtide (Fuzeon) → SQ

Lenacapavir (Sunleca) → SQ

Which NNRTI agent should be taken on an empty stomach and preferably at bedtime?

Efavirenz (Sustiva®)

Which ARV agents are associated with CNS and neuropsychiatric adverse effects?

Efavirenz (Sustiva®) → CNS (vivid dreams, mood changes)

Dolutegravir (Tivicay®) → insomnia + HA + diarrhea

Rilpivirine (Edurant®)→ less than EFV

Which ARTs cause weight gain?

• Bictegravir

• Dolutegravir

• Tenofovir alafenamide

Based on the final data analysis of the Tsepamo study from Botswana, which ARV agent could be used in women of childbearing age and pregnant women as part of the preferred ART regimen?

Triumeq (abacavir, dolutegravir, and lamivudine)

(True/False): A pregnant woman with HIV infection can deliver an HIV-negative baby as long as her HIV is controlled (undetectable VL) on an ART regimen.

True

What is the ARV medication given to a low-risk newborn baby from an HIV+ mother to prevent HIV acquisition? What is the duration of prophylaxis?

Zidovudine (AZT/ZDV) PO for two weeks

• High risk ⇒ PO 2 drug 2-6 weeks

What was the original concern with Triumeq from the interim data analysis of the study?

Neural Tubes Defects —> Folic acid

When can raltegravir be used for HIV?

HIV < 100,000 copies/mL

You are working with BP, a 45-year-old woman with HIV infection. Her HIV is controlled on Biktarvy®, and she requests a long-acting injectable (LAI) ART regimen so to avoid taking a daily pill. Which LAI ART regimen would you recommend for BP?

Cabenuva®

What are the laboratory biomarkers that should be monitored in a neonate on zidovudine prophylaxis?

CBC w/ differential

H/H

MCV

(True/False): In the US, it is strongly recommended for an HIV+ mother to breastfeed her baby.

False

Which ARVs are FDA-approved for pre-exposure prophylaxis (PrEP)?

Descovy® (FTC/TAF)

Cabotegravir® (CAB)

Truvada® (FTC/TDF)

Apretude® (CAB)

Based on the DISCOVER trial, Descovy® is only approved as PrEP for which patient populations?

Men who have sex with men

Transgender women

What baseline tests need to be obtained from an individual before initiating PrEP? When should labs be followed up after the individual starts PrEP?

HIV antigen antiviral test

HIV RNA

BUN/SCr

LFTs

HEP B/C

STI

Pregnancy Test

What are the preferred ARV classes and agents for post-exposure prophylaxis (PEP)?

INSTI (Dolutegravir)

NRTIS (Truvada)

What is the duration of PEP?

28 days/4 weeks

A lab technician accidentally cuts his finger with a broken glass tube containing some blood. Upon further investigation, his lab manager found out that the blood belongs to an HIV-positive patient. When should PEP be initiated for the technician after his recent possible exposure to HIV?

PEP should be started within 72 hours after recent possible exposure to HIV.

A medical resident has been working long shifts in the past week and accidentally exposed herself to blood of an HIV-positive patient. Based on the current HHS guidelines, which treatment and duration would be MOST preferred for PEP?

Dolutegravir + Truvada for 28 days (both QD)

Ritovnavir (BID)

An HIV-negative woman (pronouns: she, her, hers) is in a monogamous relationship with her boyfriend who is HIV-positive. His HIV is virally suppressed on ART (VL <20 copies/mL). She asks you if she should be on PrEP. They occasionally use condoms during sex. Select the MOST appropriate answer.

She does not need PrEP because her boyfriend’s HIV VL is undetectable on ART

Which PrEP medication is safe and preferred in pregnant women?

Truvada

Which PrEP medication could be used as 2-1-1 or “on demand” PrEP?

Truvada

• 2 tablets day of sex and 1 tablet 24 hrs and 1 tablets 48 hrs

Which PrEP medications could be used in adolescents ≥35 kg and adults?

Truvada & Descovy & Cabenuva

How often should patients on PrEP receive laboratory monitoring after their initial (baseline) assessment?

After 3 months (Q3M) → for STI

What is the main difference between SB 159 vs. SB 339 in terms of amount of PrEP that a CA pharmacist can furnish?

PrEP furnishing

• SB 159: 30-60 every 2 year

• SB 339⬆90 days every 2 days

(True/False): A patient on Symtuza® (DRV/c/TAF/FTC) can take low dose atorvastatin .

cobicistat: (NMT than 20 mg daily)

Explain the significant drug-drug interaction between rifampin and protease inhibitors. What is the alternative anti-mycobacterial agent that can be used instead of rifampin?

Rifampin → CYP3A4 inducer

Rifabutin (less potent)

An HIV-positive woman is currently taking Genvoya® (EVG/c/FTC/TAF). She is recently diagnosed with mixed hyperlipidemia. Which HMG-CoA reductase inhibitors should NOT be considered for her? (Select all that apply)

Atorvastatin

Lovastatin

Rosuvastatin

Simvastatin

Lovastatin & Simvastatin

Which HMG-CoA reductase inhibitors are NOT contraindicated with ritonavir and cobicistat-based regimens?

Pravastatin

Rosuvastatin

Pitavastatin

A patient comes to your pharmacy to pick up a prescription of temazepam 10 mg PO QHS PRN. Upon review of her medication history, you noticed she is currently on Symtuza® (darunavir/cobi/TAF/emtricitabine). What do you do?

Fill the prescription as there are no significant drug-drug interactions between temazepam and patient’s ART regimen.

A person with HIV (PWH) is planning to take St. John’s wort to manage her depression. Her current ART regimen includes Odefsey® (rilpivirine/emtricitabine/TAF). Do you agree or disagree with her decision? Please explain.

Disagree → Risk of viral breakthrough due to interaction of medication with St John’s wart

What OTCs should consider separating from integrase strand inhibitors?

polyvalent cations (MVI, antacids, etc)

• 2 hrs before or 6 hrs after or take with with food

A 60-year-old PWH has been stable on warfarin for his atrial fibrillation (INR goal 2-3) for many years now. He is treatment-experienced and recently switched from Biktarvy® to Symtuza® for better control of his HIV. Are there any concerns with the patient’s warfarin and the new ART regimen?

Cobicistat in Symtuza can affect warfarin metabolism, potentially altering INR.

Action: Intensify INR monitoring and adjust warfarin dose as needed.

A 47-year-old transgender male (pronouns: he, him, his) is newly diagnosed with HIV-1 infection. He has essential hypertension and hyperlipidemia. He is taking chlorthalidone and lovastatin. His physician plans to start him on Genvoya®. Which is true regarding a potential drug-drug interaction between Genvoya® and his current medications?

Cobicistat will significantly increase the plasma levels of lovastatin.

Which medications can potentially interact with the INSTI class and affect its AUC if given concomitantly in a fasting condition?

Milk of magnesium

Calcium carbonate

What ARV is contraindicated with PI co-administration?

Rilpivirine (RPV)

A 28-year-old female presents to the emergency department with wheezing and exacerbation of her asthma. She is HIV+ and currently takes Genvoya® (elvitegravir/cobicistat/emtricitabine/TAF). Which steroid could she take to manage her symptoms without any significant drug-drug interaction?

beclomethasone

Which medication will interact with Triumeq® (dolutegravir/abacavir/lamivudine) and its maximum daily dose needs to be lowered?

metformin (max DD: 1000 mg)

Which INSTI agent could be coadministered with anticonvulsants, but its dose needs to be increased due to its decreased AUC from their inductive effects?

Dolutegravir

Raltegravir

Which INSTIs have a C/I with anticonvulsants?

Bictegravir

Cabotegravir

Which antiplatelet medication could be administered to a patient taking Symtuza® (DRV/c/FTC/TAF)?

Apixaban

Clopidogrel

Prasugrel

Rivaroxaban

Prasugrel

Name the 3 benzodiazepines that would NOT interact with protease inhibitors and cobicistat-based regimens.

Lorazepam

Oxazepam

Temazepam

Name the 3 antiepileptics that should NOT be administered with protease inhibitors and cobicistat-based regimens.

Carbamazepine

Phenytoin

Phenobarbitol

Which ARV is a substrate of the CYP3A4 enzyme and should be monitored when given with potent CYP3A4 inducers/inhibitors? (Select all that apply)

Fostemsavir

Ibalizumab

Maraviroc

Rilpivirine

Fostemsavir

Maraviroc

Rilpivirine

(True/False): Rifampin is contraindicated with all protease inhibitors, TAF- and cobicistat-based regimens.

True

Name the INSTI that is mainly metabolized by CYP3A4 enzyme and requires boosting.

Elvitegravir