HIV meds

What are the 3 enzymes needed for the viral replication of HIV?

• Reverse Transcriptase (Step 3)

• Intergrase (Step 5)

• Protease (Step 10)

Abacavir (Ziagen)

(antiviral) (PO Nucleoside Reverse Transcriptase Inhibitor) (NRTI) (Step 3)

MOA: NRTI that inhibit HIV replication by suppressing synthesis of DNA through acting as substrates for reverse transcriptase.

Abacavir (Ziagen) Adverse Effects

• Lactic acidosis and hepatic steatosis (fatty liver) r/t mitochondrial toxicity.

• Possible evidence for increased risk for MI.

• Hypersensitivity

Abacavir (Ziagen) Nursing Considerations

• Genetic testing for HLA-B*5701—to determine whether pt’s are sensitive to the medication.

• Monitor for cardiac and Lactic Acidosis s/s (ABGs)

• Use of safe (sex) practices to prevent transmission

• Other first-line NRTI include lamivudine, tenofovir, and emtricitabine.

Efavirenz (Sustiva)

(antiviral) (PO Non-Nucleoside Reverse Transcriptase Inhibitor) (NNRTI)

MOA: NNRTI that inhibit HIV replication by suppressing synthesis of DNA through binding to active center of reverse transcriptase enzyme. (working outside of the nucleus)

Efavirenz (Sustiva) Adverse Effects

• CNS symptoms are common (dizziness, drowsiness)

• Rash (SJS)

• Teratogenicity

Efavirenz (Sustiva) Nursing Considerations

• Numerous drug interactions, including those for HIV.

• Taking medication at hs (bedtime) on empty stomach can reduce CNS symptoms.

• Educate on CNS symptoms and rash.

• Educate on contraception.

Darunavir (Prestiza)

(antiviral) (PO Protease Inhibitor) (Step 10)

MOA: Dorunavir inhibits protease, an enzyme needed for HIV virion maturation, leaving the virus immature and noninfectious.

Darunavir (Prestiza) Adverse Effects

• Most common is N/D/Headache

• Rash due to sulfa drugs

• Hyperglycemia occurs much less compared to other Protease Inhibitors.

• Lipodystrophy (redistribution of fat) and *hyperlipidemia (statin med, monitoring lipid panel—LDL, HDL, TG)

• Can increase serum levels of other antiretrovirals (abacavir).

• Drug interactions w/ HCV medications and other antidysrhythmic.

Darunavir (Prestiza) Nursing Considerations

• Virus less resistant to drug combination—meaning that less resistant when Prestiza is used in combo w/ other antiretroviral drugs.

• Stable at room temperature for short-term; put in refrigerator for long-term.

• Educate patient on lipid control and a low cholesterol diet.

Raltegravir (Insentress)

(antiviral) (PO Integrase Strand Transfer Inhibitor) (INSTI)

MOA: Inhibits integrase, an enzyme needed for HIV replication, by preventing insertion into host DNA.

Raltegravir (Insentress) Adverse Effects

• Generally, well tolerated.

• Elevated liver enzymes (monitor ALT & AST)

• Skin hypersensitivity reactions rare.

• Viral medication resistance more common.

Raltegravir (Insentress) Nursing Considerations

• Assess for hepatic injury and trend LFT.

• Instruct patient to report skin manifestations and stop med immediately! (Stop the meds if pt. presents w/ a rash!)

• Other first-line INSTI is dolutegravir.

Enfuvirtide (Fuzeon)

(antiviral) (SQ Fusion Inhibitor)

MOA: Blocks HIV entry into CD4 T cells by preventing the fusion of the HIV lipid bilayer w/ the CD4 cell’s lipid bilayer through binding of medication to glycoprotein in HIV envelope.

Indications:

• For infections resistant to other intial treatments.

• Used as a last resort when the patient is resistant to a lot of medications they are taking.

Enfuvirtide (Fuzeon) Adverse Effects

• SQ injection site reactions

• Pneumonia s/s

• Hypersensitivity reactions

Enfuvirtide (Fuzeon) Nursing Considerations

• Medication administration technique.

• Rotate injection sites (SQ).

• Monitor respiratory (due to pneumonia) and integumentary systems (due to hypersensitivity).

Maraviroc (Selzentry)

(antiviral) (PO CCR5 Antagonist)

MOA: CCR5 antagonist that blocks HIV entry into CD4 T cells by binding w/ CCR5, a co-receptor needed for entry.

Indiactions:

• Indicated for infections resistant to other initial treatments.

Maraviroc (Selzentry) Adverse Effects

• Hepatic injury

• Possible increased risk for CV events, including MI.

Maraviroc (Selzentry) Nursing Considerations

• Educate and assess for liver injury

• Assess CV status

• CCR5 tropism assay (a pharmacogenomic genetic test—kind of like abacavir) is performed first to determine if use is appropriate.

Cabotegravir/Rilpilvirine (Cabenuva)

(Integrase Inhibitor)

**If they run a genotype and the patient is resistant to one of the medications in the combination med Cabenuva, then they cannot use the medication.

MOA: Inhibits HIV integrase by binding the integrase active site and block the strand transfer step of retroviral deoxyribonucleic acid (DNA) integration that is essential for the HIV replication cycle.

Indications:

• Indicated as a complete regimen for the treatment of HIV-1 infection in adults and adolescents 12 years of age and older.

Cabotegravir/Rilpilvirine (Cabenuva) Administration Schedule

Single dose gluteal IM injection given once monthly every month or every 2 months.

Cabotegravir/Rilpilvirine (Cabenuva) Adverse Effects

• Hypersensitivity reactions

• Post injection site reactions

• Hepatotoxicity

Cabotegravir/Rilpilvirine (Cabenuva) Nursing Considerations

• Administer each injection at separate gluteal injection sites.

• A complete dose requires 2 injections.

• Allow 15 minutes for the medicine to become room temperature.

• May remain in a syringe for 2 hours.

• Patient education on adverse reactions and s/s.

Emtricitabine and Tenofovir Alafenamide (Descovy)

(PO Combination NRTI and NNRTI) (PrEP—Pre-Exposure Prophylaxis)

MOA: Same as NRTI and NNRTI.

Indications:

• For the prevention and treatment of HIV-1.

Emtricitabine and Tenofovir Alafenamide (Descovy) Adverse Effects

• Nausea

• Diarrhea

Emtricitabine and Tenofovir Alafenamide (Descovy) Nursing Considerations

• Educate patient to report adverse effects to provider.

• Educate patient on adherence (take the medication every day!)

• Cannot use alone for a patient w/ a positive status of HIV. (b/c you need a combination of drugs that attack the virus at different angles and this med alone is NRTI and NNRTI.)

• HIV test every 6 months—if they become positive, they have to be switched to something else.