Improving the Management of HIV Diseases Interactive Session

第 22 回日本学会教育セッション　ｴｲｽﾞ2008.11.27

Improving the Management of HIV Improving the Management of HIV DiseasesDiseases

Interactive SessionInteractive Session

Nov. 27, 2008The 22nd Annual Meeting of the JSAREvening Seminer 3

Plannning ： HIV Care Management Initiative-JapanCo-hosting ： The 22nd Annual Meeting of the JSAR/GSK

Cases studies

Professor David A Cooper

NCHECR

November 2008

Case 1- IF

47 year old Caucasian man

diagnosed with HIV 1986

nadir CD4+ cell count: 252/µL

pre treatment VL: 376,100 c/mL

alcohol and recreational drug use including speed

hep B sAg negative, cAb positive

hepatitis C negative

previous regimens:

d4T + 3TC

ABC + IDV/r Nov 2000- May 2001

ABC + LPV/r May 2001- Sep 2004

ABC + fAPV/r Aug 2005- Jan 2007

AZT + 3TC + ATV/r Jan 2007-

HIV had been suppressed all the time.

Case 1- IF

October 2007: fatigue and right upper quadrant pain

Case 1 - IF

What is the cause of his hepatitis?

1) reactivation of hepatitis B

2) acute hepatitis C

3) alcoholic hepatitis

4) pancreatitis

5) lactic acidosis

Case 1- IF

What is the cause of his hepatitis?

1) reactivation of hepatitis B

2) acute hepatitis C

3) alcoholic hepatitis

4) pancreatitis

5) lactic acidosis

Case 1- IF

hepatitis B DNA: negative

hepatitis C viral load: 700,000 c/mL

lactate: 1.6 mmol/L

glucose: 4.2 mmol/L

cholesterol: 1.5 mmol/L

HDL-chol: 0.7 mmol/L

LDL-chol: 0.2 mmol/L

triglycerides: 2.1 mmol/L

Case 1- IF

How would you treat his acute HCV?

1) wait and see

2) PEG-IFN

3) PEG-IFN + RBV

4) intensify ART

5) something else

Case 1- IF

How would you treat his acute HCV?

1) wait and see

2) PEG-IFN

3) PEG-IFN + RBV

4) intensify ART

5) something else

Case 1- IF

HCV spontaneously cleared September 2008

What percentage of HIV-infected persons

with acute HCV spontaneously clear?

1) 1-2%

2) 10-20%

3) 50-60%

4) 90-100%

Case 1- IF

What percentage of HIV-infected persons

with acute HCV spontaneously clear?

1) 1-2%

2) 10-20%

3) 50-60%

4) 90-100%

Case 1- IF

AIDS CDC C3

PJP 1994 treated with pentamidine and corticosteroids

CMV retinitis 1997 treated with GCV and cidofovir

NHL 2002 treated with CHOP and high dose methotrexate

Case 2- MB

pre ART: CD4+ cells: 60/µL

viral load: 310,900 c/mL

previous regimens

AZT+ddC Jan 1995- Oct 1995

AZT+3TC+loviride Oct 1995- Mar 1996

ddI+d4T+3TC+loviride Mar 1996- Sep 1996

d4T+DLV+SQV Jan 1998- May 2002

d4T+ABC+3TC+DLV+SQV May 2002- Jul

Case 2- MB

August 2003

urea 4.9 mmol/L

creatinine 90 µmol/L

He has developed severe lipodystrophy.

What regimen would you choose?

1) AZT+3TC+EFV

2) TDF+3TC+EFV

3) TDF+3TC+LPV/r

4) ABC+3TC+EFV

5) ABC+3TC+LPV/r

Case 2- MB

He has developed severe lipodystrophy.

What regimen would you choose?

1) AZT+3TC+EFV

2) TDF+3TC+EFV

3) TDF+3TC+LPV/r

4) ABC+3TC+EFV

5) ABC+3TC+LPV/r

Case 2- MB

changed to TDF+ABC+3TC+DLV+SQV

develops severe narcotic dependent pain in wrists and knees

Case 2- MB

August 2005

urea 10.1 mmol/L

region date measured

BMD (g/cm2)

change vs baseline (%)

young-adult age-matched

% T-score

% Z-score

right femur May 2002 0.979

August 2005

0.778 -20.5 71 -2.4 76 -1.9

spine: L2-L4

May 2002 1.153

August 2005

1.128 -2.2 91 -0.9 96 -0.4

Case 2- MB

Bone densitometry August 2005

Case 2- MB

Bone densitometry August 2005

right femur left femur

What is the cause of the renal failure and bone pain?

1) TDF

2) HIV nephropathy

3) TDF and previous pentamidine

4) previous cidofovir and corticosteroids

5) TDF and previous cidofovir

Case 2- MB

What is the cause of the renal failure and bone pain?

1) TDF

2) HIV nephropathy

3) TDF and previous pentamidine

4) previous cidofovir and corticosteroids

5) TDF and previous cidofovir

Case 2- MB

ceased TDF August 2005

new regimen: ABC+3TC+DLV+SQVceased tenofovir

October 2008

urea 10 mmol/L

Renal biopsy was performed December 2005.

What changes would you expect to see in the

renal biopsy?

1) tubular toxicity

2) interstitial nephritis

3) collapsing glomerulopathy

4) glomerulosclerosis

5) glomerular and tubular disease

Case 2- MB

Renal biopsy was performed December 2005.

What changes would you expect to see in the

renal biopsy?

1) tubular toxicity

2) interstitial nephritis

3) collapsing glomerulopathy

4) glomerulosclerosis

5) glomerular and tubular disease

Case 2- MB

renal biopsy showed

severe interstitial fibrosis

globally sclerosed glomeruli

tubular degeneration

BK polyoma viral inclusions

Case 2- MB

52 year old Asian man

AIDS CDC B1

mild type 2 diabetes 1998

works as a chef

Case 3- EN

pretreatment CD4+ cells: 207/µL

viral load: 40,000 c/mL

previous regimens

d4T+3TC+SQV Feb 1997- Sep 1997

d4T+3TC+NVP Sep 1997- Nov 1997

d4T+ddI+NVP Nov 1997- Jan 1998

d4T+ddI Jan 1998- Apr 1998

Jul 1998- Nov

Feb 1999- Oct 1999

EFV+IDV/r Oct 1999- Mar 2002

EFV+ATV/r Mar 2002-

HIV had been suppressed with EFV

Case 3- EN

metabolic profile February 2002- August 2003

August 2003

triglycerides

7.4 mmol/L

cholesterol

5.6 mmol/L

HDL-chol

1.17 mmol/L

glucose

11.5 mmol/L

How would you treat the dyslipidemia?

1) diet

2) fibrate

3) statin

4) fibrate and statin

5) metformin and statin

Case 3- EN

How would you treat the dyslipidemia?

1) diet

2) fibrate

3) statin

4) fibrate and statin

5) metformin and statin

Case 3- EN

ceased gemfibrozil due to myopathy February 2005

Case 3- EN

started gemfibrozil

commenced fibrate October 2003

February 2005

triglycerides

2.1 mmol/L

cholesterol

5.9 mmol/L

HDL-chol

1.7 mmol/L

glucose

8.1 mmol/L

How would you treat dyslipidaemia now?

1) diet

2) metformin

3) statin

4) statin and ezetimibe

5) switch regimen

Case 3- EN

How would you treat dyslipidaemia now?

1) diet

2) metformin

3) statin

4) statin and ezetimibe

5) switch regimen

Case 3- EN

started pravastatin

commenced pravastatin February 2005

October 2006

triglycerides

14 mmol/L

cholesterol

8 mmol/L

HDL-chol

0.8 mmol/L

glucose

9.3 mmol/L

What would you do now?

1) change to more potent statin

2) add insulin to pravastatin

3) add metformin to pravastatin

4) add ezetimibe to pravastatin

5) switch ART regimen to lipid neutral

Case 3- EN

What would you do now?

1) change to more potent statin

2) add insulin to pravastatin

3) add metformin to pravastatin

4) add ezetimibe to pravastatin

5) switch ART regimen to lipid neutral

Case 3- EN

started rosuvastatin

commenced rosuvastatin February 2007

November 2007

triglycerides

10.8 mmol/L

cholesterol

6.1 mmol/L

HDL-chol

0.9 mmol/L

glucose

6.1 mmol/L

Decided to change regimen.

What would you recommend?

1) TDF+FTC+EFV

2) TDF+FTC+ATV

3) ABC+3TC+ATV

4) TDF+FTC+ATV/r

5) ATV + raltegravir

Case 3- EN

Decided to change regimen.

What would you recommend?

1) TDF+FTC+EFV

2) TDF+FTC+ATV

3) ABC+3TC+ATV

4) TDF+FTC+ATV/r

5) ATV + raltegravir

Case 3- EN

started ATV + raltegravir

commenced ATV + raltegravir November 2007

August 2008

triglycerides

0.9 mmol/L

cholesterol

3.4 mmol/L

HDL-chol

1.1 mmol/L

glucose

3.4 mmol/L

Case 4- RVB

nadir CD4+ cell count: 96/µL

Case 4- RVB

previous regimens:

AZT monotherapy: Aug 1988- Nov 1994

Jan 1995- Aug 1995

AZT+ delavirdine: Nov 1994- Jan 1995

d4T monotherapy: Aug 1995- Aug 1996

d4T+3TC+IDV: Aug 1996- Nov 1996

August 1996 PJP diagnosis

treated with

pentamidine

November 1996 muscle wasting

weight loss

glucose: 26 mmol/L

HbA1C: 10.9%

Case 4- RVB

What is the most likely cause of his diabetes

mellitus?

1) protease inhibitor therapy

2) mitochondrial toxicity from TANRTIs

3) pentamidine therapy

4) pancreatitis from hypertriglyceridemia

5) hepatitis C

Case 4- RVB

What is the most likely cause of his diabetes

mellitus?

1) protease inhibitor therapy

2) mitochondrial toxicity from TANRTIs

3) pentamidine therapy

4) pancreatitis from hypertriglyceridemia

5) hepatitis C

Case 4- RVB

He was treated with insulin which was

stopped in 1999

HCV was positive in 1998

After stopping his fasting chemistry is

glucose: 8.8 mmol/L

HbA1C: 8%

HDL-chol: 0.6 mmol/L

Case 4- RVB

How would you treat his diabetes?

1) diet

2) insulin

3) oral hypoglycaemics

4) treat hepatitis C

Case 4- RVB

How would you treat his diabetes?

1) diet

2) insulin

4) treat hepatitis C

Case 4- RVB

He is now stable on ABC + 3TC + NVP

No diabetes therapy

Hepatitis C treated with PEG-IFN + RBV in April 2001 with SVR

Case 4- RVB

Aug 2006

triglycerides

29 mmol/L

cholesterol

11 mmol/L

HDL-chol

2 mmol/L

glucose

8 mmol/L

stopped Pravastatindue to severe headache

What changes would you make to his

management now?

1) no change

3) oral hypoglycaemics + fibrate

4) fibrate

5) fibrate + statin

Case 4- RVB

What changes would you make to his

management now?

1) no change

3) oral hypoglycaemics + fibrate

4) fibrate

5) fibrate + statin

Case 4- RVB

started fenofibrate October 2006

started metformin and rosiglitazone July 2007

Case 4- RVB

rosiglitazone + metformin

fenofibrate

June 2008

triglycerides

34.8 mmol/L

cholesterol

12.3 mmol/L

HDL-chol

3.6 mmol/L

glucose

11.9 mmol/L

stopped Pravastatindue to severe headache

How would you manage his dyslipidaemia now?

1) stop oral hypoglycaemics and continue

fibrate only

2) stop oral hypoglycaemics and add potent

statin to fibrate

3) keep oral hypoglycaemics and fibrate and

add potent statin

4) change to insulin and continue fibrate

5) give metformin and rosuvastatin

Case 4- RVB

How would you manage his dyslipidaemia now?

1) stop oral hypoglycaemics and continue

fibrate only

2) stop oral hypoglycaemics and add potent

statin to fibrate

3) keep oral hypoglycaemics and fibrate and

add potent statin

4) change to insulin and continue fibrate

5) give metformin and rosuvastatin

Case 4- RVB

insulin restarted in June 2008

ACE inhibitor and aspirin added

Case 4- RVB

insulin October 2008

triglycerides

4.7 mmol/L

cholesterol

5.7 mmol/L

HDL-chol

0.9 mmol/L

glucose

5.1 mmol/L

6.3 mmol/L

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