-HIV-1: subtype most commonly found in ________

-AIDS:  CD4 count less than ____cell/mm3  OR
History of an opportunistic infection:
i.e., unexplained fever for greater than __ weeks, thrush, pneumocystis carinii pneumonia, toxoplasmosis, cryptococcal meningitis, histoplasmosis, mycobacterium avium, others

-US

-200

-2

-What does teh Western blot look for? 

-When does seroconversion usually occur?

-A minimally significant change in viral load is considered to be a ____-fold increase or decrease

-Lower limits of detection include ____ copies /mL

-anti-HIV Abs..(gold standard..99% spec/sens)

-3 weeks PI (range 2wks-6mo)

-3-fold

-400 copies/mL (ultrasensitive gets down to 20-50 copies/mL)

-Those on antivirals should have viral titer loads lower than ___ copies/mL by 6 mo.

-when are they monitored?

-Normal CD4+ cell counts are ____-____ cell/mm3
-CD4+ cell counts should be measured every __-__ months in patients on or off antiretroviral therapy

-Fewer than 50

-every 3-4 months

- 800-1,200

-3-6 months

-The most common HIV symptom is what?

-2nd most?

-To achieve therapeutic goals what must the compliance rate of HIV pts be to their meds?

-Fever

-Muscle/joint aches

-95%

What HIV stage is this: HIV DNA enters the host cell’s nucleus, where an HIV enzyme integrase “hides” the HIV DNA within the host cell’s own DNA.

-Now teh HIV DNA is called a _______.

-Integration

-provirus

-What do NUCs (NRTI's) do?

-What are the class toxicities?

-What are S/S for lactic acidosis?

-PREVENTS VIRAL RNA FROM BECOMING DNA; Inhibits viral replication.

-Lactic Acidosis; severe Hepatomegaly with steatosis (fatty stools)

-N/V, Abd pain, Wt loss, Malaise

-Which Entry/Fusion Inhibitor is this?:

Fusion Inhibitor
MOA : Binds to gp41 on HIV surface inhibiting HIV binding to CD4 cell

-What is the other Entry/Fusion Inhibitor?

-Enfuvirtide (T20…chemical name) - Fuzeon®

- Maraviroc (MCV) - Selzentry®

Which Nuc am I:

- Dose: every 12 hours
o    Only therapy available in IV form
o    Adverse Effect: Macrocytic Anemia (so we can use this to monitor drug adherence)
o    Do not use with Zerit (Stavudine-d4T) due to antagonism (they work in the same area)

-AZT or Zidovudine-Retrovir

Which Nuc am I? 

Dose: every 12 or 24 hours, depending on mg.
o    No dose adjustment needed in renal impairment.
o    M184V resistance issue, but it could be used as an advantage
o    Also can be used for hepatitis B treatment

-Lamivudine-Epivir (3TC)

Which Nuc am I:

Dose: every 24 hours with or without food
o    Well tolerated, SKIN DISCOLORATION no significant drug interactions
o    M184V resistance issue, but it could be used as an advantage

-    Emtricitabine-Emtriva-FTC

Which Nuc am I?

Dose: every 12 or 24 hours, depending on mg.
o    EtOH increases levels up to 41%
o    Adverse effects: HYPERSENSITIVITY
•    PRESCREEN: We see a greater hypersensitivity rxn if pt tests positive for HLA- B* 5701
•    Rash and Fever most common;    Severity increases with each dose
•    NEVER rechallenge pts
•    Counsel all pts ab warning S/S: BIG FAT HAIRY DEAL!!!! Have them contact prescriber IMMEDIATELY.

•    Abacavir-Ziagen-ABC   

What are these teh risk factors for?

Female gender
Obesity
Prolonged use of NRTI’s
Controlled virus…a weird SE since this is the goal

 Lactic Acidosis by using NRTI's (Nucs)

T/F...All NRTI's are prodrugs?

-What is the good drug resistance strain that can develop in response to certain Nucs?

-True

-Strain M184V

NucleoTIDE reverse transcriptase inhibitor

Dose:  300mg po every 24 hours
Adjust dose in renal impairment
Adverse effects:
Asthenia, D/N/V, headache, flatulence, renal insufficency

Viread (tenofovir) or TDF

Which Nuc am I?:

   Dose: every 12 hours
o    Dose reduction in renal impairment
o    Avoid use w/Retrovir (AZT) due to antagonism
o    Use w/caution w/Videx (ddI) due to increased risk of L. acidosis, peripheral neuropathy, and pancreatitis
o    AE:  lipdystrophy, dose related peripheral neuropathy, hyperlipidemia

  Stavudine-Zerit-d4T

NNRTI's (non-nucleside reverse transcriptase inhibitors)

Which NNTRI am I?:

-Dose:  600mg po every 24 hours (HS)
Contraindication:
Pregnancy, 1st trimester
May cause false positive cannabinoid test

Adverse effects: CNS side effects are unique to EFV (~50%)(ABNORMAL DREAMS)

Sustiva® (efavirenz or EFV)

T/F...if one NNRTI develops a resistence...try another?

-T/F...you can use a Nuc and NNRTI together?

-False...resistent to one=resistence to all.

-True...they work in different places.

NNRTI:

Dose: every 12 hours; take WITH food!
o    AE: rash, nausea
o    Has a different resistance pathway

   Etravirine-Intelence-ETV

NNRTI:

 Dose: every 24 hours x 14 days; then increase to every 12 hours
o    Dose differences due to AUTOINDUCTION—affects itself by increased metabolism
o    AE: rash, hepatotoxicity
o    TONS of drug rxns

    Nevirapine-Viramune-NVP

NNRTI:

  Dose: every 8 hours → prob won’t see this med due to compliance
o    AE: rash, increased LFTs
o    May inhibit its own metabolism
o    Separate 2 hours from antacids b/c it needs acidic environment to be absorbed.

⇒    Delavirdine-Rescriptor-DLV

INTEGRASE INHIBITOR:

   Dose: every 12 hours
o    Inhibits the catalytic activity of HIV-1 integrase, an HIV-1 encoded enzyme that is required for viral replication.
o    No food restrictions
o    AE: mild

- Raltegravir-Isentress-RAL (inhibits formation of Provirus)

-What is the class SE/toxicities of Protease Inhibitors?

-What is teh MOA of Protease Inhibitors?

-Whole Class: Must be dose adjusted for liver impairment; lots of drug interactions; lots of toxicities (Hypergly, hyperlipid, inc Tris, Increased bleeding in hemophiliacs, Lipodystropy, OSTEONECROSIS)

-Prevent cleavage of HIV, resulting in immature noninfectious viral particles.

Which PI am I?

    Dose: every 12 hours
o    NOT USED BY ITSELF; USED TO BOOST OTHER PROTEASE INHIBITORS!!!
o    AE: Taste perversion

Ritonavir-Norvir-RTV   

Which PI am I?

Dose: every 8 hours (TID) → won’t see it much
o    Take w/low fat meal or on empty stomach
o    Drink >48 oz water daily
•    Causes kidney stones
•    Increased incidence with boosted regimens

   Indinavir-Crixivan-IDV

Which PI am I:?

Dose: every 12 hours WITH food
o    Oral solution contains 42% alcohol

Lopinavir/ritonavir-Kaletra-LPV/r

Which PI am I?

Dose: every 24 hours
o    TDF  decreases it's levels...so increase dosage if taken with TDF

-Interactions with H2 blockers, PPI's, and CCB's

-Decreased hyperlipidemia (use in CAD pts)

  Atazanavir-Reyataz-ATV

Which PI am I:

Doses: depends on naïve or experienced pt.
o    Caution w/sulfa allergy

-Naive pt will get higher doses initially (1400mg po BID) vs. Experienced (700 mb po BID with RTV 100 mcg po bid)

  Fosamprenavir-Lexiva-f-APV

Which PI am I?

Dose: BID w/RTV BID
o    Caution w/sulfa allergy

Take with food

  Darunavir-Prezista-DRV

Which PI am I?:

Dose: BID w/RTV BID
o    Capsules contain EtOH-be careful!
o    Caution w/sulfa allergy
o    Decreased Abavavir-Ziagen-ABC &     Zidovudine-Retrovir-AZT Levels
o    Separate from Didanosine-ddl by at least 2 hours

  Tipranavir-Aptivus-TPV

-Preferred Initial Regiments for new HIV pt: PICK ONE OF THESE

•    _______ + Ritonavir - QD
•    ________ + Ritonavir - QD
•    _______ + Ritonavir – QD or BID
•    ________ + Ritonavir - BID
•    _______ – QD

-Atazanavir (ATV)

-Darunavir (DRV)

-Lopinavir (LPV)

-Fosamprenavir (f-APV)

-Efavirenz

Preferred Initial Regiments: ADD ONE OF THESE

•    Tenofovir + ________
•    Tenofovir + _______
•    _______ + Lamivudine  → In pregnant women only

-Emtricitabine(FTC NRTI)

-Lamivudine (3TC NRTI)

-Zidovudine (AZT NRTI)

HIV regiments to avoid:

•    ______therapy
•    ___-drug combinations
•    ____ drug combinations all from same class
•    _____ NRTI regimens:  ABC/AZT/3TC/TDF
•    _______ in first trimester

-monotherapy

-Two

-Three

-Quadruple

-Efavirenze

HIV REGIMENS TO AVOID

•    Generally not recommended: ___/AZT/3TC
•    Cannot be recommended: ____/AZT/3TC

-_____urea

• Stavudine + ________ - antagonism

•    Stavudine + ________ - toxicities

•    Lamivudine + ______ – similar products

-ABC

-TDF

hydroxyurea

-Zidovudine

-Didanoside

-Emtricitabine

PI's

Which PI am I?:

Drug interactions:

H2 blockers
PPI’s
Calcium channel blockers

-Reyataz (Atazanavir or ATV)

-Who has a higher risk for abacavir hypersensitivity reaction (ABC HSR)...whites or blacks?

-THose who usually have a ABC HSR are also positive for what allele?

-Whites

-HLA-B*5701

T/F Nevirapine is a NNRTI that is okay to use on those who have severe hepatic impairment?

-Recommended guidelines for naive retroviral pts: 

__-NNRTI + __NRTI

or

__PI (boosted with __) + __NRTI

-False....DO NOT

-

1-NNRTI + 2-NRTI

or

1 PI (boosted with Ritonavir) + 2 NRTI

Who can't have Lopinavir/ritonavir BID?

-Atazanavir + Indinavir are not recommended together b/c they cause?

-Saquinavir / Darunavir / Tipranavir are all only virologic when used with?

-Pregnant women.

-Jaundince and Hyperbillirubinemia

-Ritonavir (booster PI)

What happens when we combine the NRTI's Didanosine (ddl)and Stavudine (d4T)?

-NRTI's:  Why shouldn't Lamivudine (3TC) + Emtricitabine (FTC) be used together?

-High risk of toxicities (esp peripheral neuropathy)

-They have similiar resistence profiles and therefore have little additive benefit when used together.

What Opportunistic HIV infection am I:?

Fever
Exertional dyspnea
Dry cough
O2 saturation
LDH> 500 mg/dL
X-ray showing symmetrical infiltrates
CD4 count <200 mm3

Treatment for PCP?

-Adjunct if PO2 levels are below 70mmHg?

-Can Clindamycin also be used as alternative?

-If Atovaquone is used as alternative...how often is it dosed?

-TMP 15mg/kg/day +SMZ 75mg/kg/day po or IV 3-4 divided doses

-Prednisone

-Yes if used with primaquin...Clindamycin 600 mg IV q8h or 300-450mg po q6h + primaquine 30 mg base po qd
- 750mg PO with meal bid

When do you prophylact for PCP?

-What should you use?

-When do you stop?

-When CD4 is less than 200

-Bactrim DS...DAILY (3x weekly show to be ineffective)

-When CD4 back over 200 for THREE MONTHS

Mycobacterium avium complex (MAC)

Tx for MAC?

-Stop Tx when?

Clarithromycin 500 mg po bid + ethambutol 15 mg/kg/d po ± rifabutin 300 mg po qd

-Stop when CD4 count >100/mm3 for 6 months and received 12 months of treatment and asymptomatic

Primary Prophylaxis for MAC is what?

-Stop when?

-Azithromycin 1,200 mg po once per week

-Can stop when CD4 cells are greater than 100/mm3 for 3 months

-Toxoplasma gondii encephalitis

-6 weeks

-Pyrimethamine, leucovorin, sulfadiazine

Which HIV Opp Inf am I:?

Symptoms and Diagnosis
Fever
Headache
+ cryptococcal antigen in CSF +/- blood
CSF usually shows ↑ protein and mononuclear pleocytosis
Can have cryptococcal infections at other sites (skin, lung)
CD4 cell count less than 100/mm3

Cryptococcal meningitis

Tx for Crypto meng?

-Prophylactic Tx for Crypto meng is?

-Stop when?

-Ampho B 0.7-1.0 mg/kg/d IV ± flucytosine 100 mg/kg/d po 14 days then fluconazole 200 mg po bid x 8 weeks

-Fluconazole 200 mg daily

-Discontinue secondary prophylaxis when CD4 cells are greater than 100-200/mm3 for 6 months, initial therapy is completed, and
patient is asymptomatic

WHich HIV Opp Inf am I?:

Fever
Weight loss
Fatigue
Often with lung, marrow, GI tract, +/-CNS involvement
H. capsulatum can be detected in urine, blood, respiratory tract secretions, marrow, CSF or focal lesions
CD4 cell count <100/mm3

Histoplasmosis (Histo)

Histo Tx?

-Prophylaxis?

-Stop when?

-Preferred regimens:
Ampho B 0.7-1.0 mg/kg/d IV 3-14 days THEN
Itraconazole 200 mg po bid x 12 weeks

– itraconazole 200 mg po daily

-Discontinue after
12 months if CD4 >150 mm/3,
on ART for greater than 6 months and
urine and serum antigen is less than 4.1 units.

-Histo: What is a key consideration when deciding whether or not to prophylax for someone with a CD4 count below 100

-Where are CMV infections CD4 counts usually below?

-Are you in an Endemic area (Southeast/Miss River basin)

-50

CMV

-What is main thing to consider when treating CMV?

-Which group gets what?

-Vision-threatening or not.

-Vision threating lesion:
Intraocular ganciclovir implant every 6-8 months + valganciclovir 900 mg bid x 14-21 days, then 900 mg daily
Peripheral lesions:
Valganciclovir 900 mg bid x 14-21 days, then 900 mg daily

T/F...Live-Attenuated Vaccines are usually effective with one dose

-T/F...Inactivated vacciens cause fewer site reactions and require only 1 dose?

-True *except those administered orally (to name some live attenuateds...Yellow Fever, Nasal Flu mist, Zoster, and MMR)

-False, generally 3-5 doses are required

-Vaccine Adjuvants (Hib, HPV, PCV7, DTap, and DT all use them)

-How long should a SubQ needle be?

-Where should an IM injection be given on an infant?

-IM needle lengths depend on?

-5/8 of an inch (inj at 45 degree angle)

-Thigh Muscle (Quad area)...Adults get Deltoid of course

-Age group (Newborn:5/8 inch
Infant: 1 inch
Older Children: 5/8* to 1¼inch
Adolescent/adult: 1 to 1½ inch

When are DTaP boosters to be given?

-What does DTaP vaccine cover?

-Which is adult strength 'D' or 'd'

-every 10 years

- Diptheria toxin generally given in combination with tetanus toxoid AND acellular pertussis vaccine [DTaP]

-'d'

For those with recent traumatic wounds how do we help them with passive immuninity to Tetanus?

-For which age group is the HIb Vaccine reccommended?

-What type of vaccine is it and what is the most common adverse rxn?

-T Ig or Tetanus Immunoglobulin

-Those under 5 yo (natural immunity develops from thence on)

- IM conjugate vaccine... Erythema (25%),

Which Flu virus (A or B) is more prone to mutation?

-Optimal time for Flu vaccine is?

-What age group can have Live Attenuated Flu vaccine?

-A

-October – mid November

-5-49 (those 5-8 need split doses)

What does this group of pts represent:

Patients >50
Nursing home residents
Adults/children with CV or pulmonary dz
Adults/children with chronic dz/immunsupp
Children/teens receiving aspirin therapy
Pregnant women

Pneumonococcal Conjugated Polysaccharide Vaccine

-Which Pneumonococcal vaccine covers 23 serotypes of S. pneumo and is recommended for those over 2yo.

-Where should Rabies Ig be administered post exposure?

-What allergy might Rabies vaccine trigger?

-Unconjugated Pneumonococcal Polysacc Vaccine.

-Around potential infiltrated wound (DONE IM...never IV)

-Thimerosal

-Which rotavirus vaccine provides teh most protection (against the most Rota strains)

-What allergy shouldn't be given Rubella vaccine

-Rotateq® (live, oral, pentavalent vaccine)...

-Neomycin allergic people

WHo better seroconverts to Varicella vaccine (adults or children)?

-How must this vaccine be stored?

-Post-exposure prophylaxis indicated?

-What allergy is contraindicated?

-Single dose results in 94% seroconversion in children, but only 80% in adults

-Frozen

-Yes 3-5 days Post-Exp

-Neomycin

When must Varicella Ig be administered Post-Exp?

-HPV vaccine: ACIP recommends routine vaccination of females __-__ years of age with __ doses of quadrivalent HPV vaccine

-Cancerous strains?

-within 48 hours (may only attenuate infection)

-11-12 yo with 3 doses (Vaccination is recommended for females 13-26 years of age who have not been previously vaccinated)

-16 and 18

What preservative is possibly linked to Autism and contains 50% mercury?

-What is the reporting site should a pt of yours experience a new adverse event due to vaccination?

-What is imp to document in these events?

-Thimersol (DD, TT, Td, and Influ all can have this)

-VAERS – Vaccine Adverse Event Reporting System

-Lot number of the injection