12/13/19 1 Antiretroviral Therapy Initiation: From Guidelines to Practice: ART 101 Medical Management of AIDS & Hepatitis December 12, 2019 Vivek Jain, M.D., M.A.S. Associate Professor of Medicine Division of HIV, Infectious Diseases & Global Medicine San Francisco General Hospital, University of California, San Francisco 1 Disclosures • Research grant support from National Institutes for Health (NIH), Centers for Disease Control (CDC) & President’s Emergency Plan for AIDS Relief (PEPFAR) – – For work ongoing in East Africa related to HIV care models – This disclosure is unrelated to this presentation 2
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Transcript
12/13/19
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Antiretroviral Therapy Initiation:
From Guidelines to Practice: ART 101
Medical Management of AIDS & HepatitisDecember 12, 2019
Vivek Jain, M.D., M.A.S.Associate Professor of Medicine
Division of HIV, Infectious Diseases & Global Medicine
San Francisco General Hospital, University of California, San Francisco
1
Disclosures
• Research grant support from National Institutes for Health (NIH), Centers for Disease Control (CDC) & President’s Emergency Plan for AIDS Relief (PEPFAR) –
– For work ongoing in East Africa related to HIV care models
– This disclosure is unrelated to this presentation
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Goals
• Working proficiency in selecting initial ART regimens
• Review DHHS first line & alternate regimens– Pros and cons, considerations, choices– Many updates from last year (4 new drugs FDA approved in 2018)
• Will not focus on:– HIV drug resistance– ART switching in virally suppressed patients– ART for pediatric or pregnant patients– Drugs still in development (but not yet FDA approved)– There's lots at this conference on all of the above, but we will focus on ART
initiation
• 45 minutes… lots to cover!
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Outline
• Review of Guideline regimens• Nucleotide reverse transcriptase inhibitors (NRTI's):
– tenofovir, TAF, abacavir• Integrase strand transfer inhibitors (INSTI's):
US DHHS Guidelines: 1st Line TherapyMost recent version: July, 2019
Recommended regimens are those with demonstrated durable virologic efficacy, favorable tolerability and toxicity profiles, and ease of use.
These regimens are effective and tolerable, but have some disadvantages when compared with the regimens listed above, or have less supporting data from randomized clinical trials. However, in certain clinical situations, one of these regimens may be preferred.
Adapted Footnotes:a 3TC may be substituted for FTC, or vice versa. ABC/3TC, TDF/3TC, TDF/FTC, TAF/FTC areavailable as tablets, and as part of single tablet regimens. Cost, access, and availability of of STRs can influence choice of 3TC vs FTC.b TAF and TDF are two forms of tenofovir approved by the FDA. TAF has fewer bone and kidneytoxicities than TDF, while TDF is associated with lower lipid levels. Safety, cost, and access are among the factors to consider when choosing between these drugs.c RAL can be given as 400 mg BID or 1200 mg (two 600-mg tablets) once daily.
US DHHS ART Guidelines – October 28, 2018 Update http://aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf
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U.S. DHHS Guideline Update: October, 2018
Initial Regimens Initial Regimens“for Most People” “in Certain ClinicalSituations”
BIC/TAF/FTC EVG/cobi + (TDF/FTC or TAF/FTC)* If reproductive potential, consult guidance * If reproductive potential, consult guidance
DTG/ABC/3TC RAL/ABC/3TCOnly if HLB57-01 negative Only if HLAB57 negative and VL<100,000* If reproductive potential, consult guidance * If reproductive potential, consult guidance
DTG + (TDF/FTC or TAF/FTC) (DRV/RTV or DRV/cobi) + (TDF/FTC or TAF/FTC)* If reproductive potential, consult guidance
RAL + (TDF/FTC or TAF/FTC) (DRV/RTV or DRV/cobi) + ABC/3TC* If reproductive potential, consult guidance Only if HLB57-01 negative
(ATV/RTV or ATV/cobi) + (TDF/FTC orTAF/FTC)
(ATV/RTV or ATV/cobi) + ABC/3TCOnly if HLAB57 negative and VL<100,000
DOR/TDF/FTC or (DOR + TAF/FTC)
EFV + (TDF/FTC or TAF/FTC)
Adapted from: US DHHS ART Guidelines – July, 2019 Update RPV + (TDF/FTC or TAF/FTC)Only if VL<100,000 & CD4+ >200
Issues: controversial topic• observational studies vs. RCTs• other CV risks: accounted for?• risks from other ARVs?• duration of follow-up?• what outcomes assessed?
Guideline Language: “Increase in CV events is associated with ABC use in some, but not all, cohort studies”
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NRTIs for Patients with HBV
• For Hepatitis B positive patients:– TDF/FTC:
• 2 active agents: good choice
– TAF/FTC:• 2 active agents• also FDA approved for HBV+ patients; good choice
– ABC/3TC:• only the 3TC is active• if using ABC, typically combine with entecavir
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Outline
• Review of Guideline regimens• Nucleotide reverse transcriptase inhibitors (NRTI's):
– tenofovir, TAF, abacavir• Integrase strand transfer inhibitors (INSTI's):
•25mg dose as part ofsingle tablet Biktarvy(TAF/FTC/BIC)
• No booster
Trial 1489: Biktarvy vs. Triumeq•92% VS (BIC) vs. 93% (DTG) at Week 48•VS similar in VL<100K, VL 100K-400K and
VL>400K• 88% (BIC) vs. 90% (DTG) at Week 96• 82% (BIC) vs. 84% (DTG) at Week 144
Trial 1490: Biktarvy vs. TAF/FTC + DTG• 89% VS (BIC) vs. 93% (DTG) at Week 48• 84% VS (BIC) vs. 86% (DTG) at Week 96• 82% VS (BIC) vs. 84% (DTG) at Week 144
Integrase Inhibitors: BIC
Biktarvy (BIC 25mg/TAF 10mg/FTC 200mg)
Sax PE et al.,Lancet, 2017 Wohl et al., LancetHIV, 2019 Gallant, J et al.,Lancet, 2017
Stellbrink et al., Lancet HIV,2019
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Integrase Inhibitors: BIC
Cautions:
•Inhibits tubular secretion of creatinine: raises Cr by 0.1mg/dL
• Only for eGFR>30• Not for liver disease Child-Pugh C
•Substrate of CYP3A: so any inducer of CYP3A will decrease BIC levels
• Vice versa for inhibitors of CYP3A•Same for inducer or inhibitor of
UGT1A1
•TAF component is a substrate of P-gp and BCRP… so inducers can reduce TAF, inhibitors can increase TAF…
•Do no co-administer with rifampin (reduces BIC and TAF)
• Boosts metformin levels
•Caution for patients with HBV when discontinuing: risk of HBV flare
•Antacids with Al/Mg/Ca: take BIC 2h before
•Fe/Ca supplements: take with BIC and food
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•Hypersensitivity rare•1/866 patients had rash in EVG studies
•Very well-tolerated, good potency/efficacy• 400mg BID dosing•Can dose at 1200mg QD (noninferior to 400mg BID; 89% vs 88% VS atW48)• No boosting required• Lower genetic barrier to resistance
Isentress HD (RAL 600 x 2 QD)
•Hypersensitivity reaction (rare, mild)• Even rarer: DRESS syndrome
Ripamonti et al. AIDS 2014
ONCEMRK Study: Cahn P et al.Lancet HIV, 2017
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Integrase Inhibitor Drug Interactions
• There are a lot of these… EVG most problematic because of cobi…• DTG, BIC, RAL less problematic…• Key to remember (and look up): antacids, cations (Mg/Al/Ca), metformin,
rifamycins, steroids (dex)
Dolutegravir Bictegravir Raltegravir Elvitegravir
Al/Mg/Ca antacids
2h before or 6h after antacid with cations
2h before antacids with Al/Mg/Ca,
Don’t combine with Al/Mg antacids…For Ca antacids, only use 400 BID RAL dose
Separate from antacids by >2h
H2-receptor blockers
No dose adjustments needed
PPI’s No dose adjustments needed
Must screen your patient for these, and good to document (esp. if on EVG) in your notes for others: ”patient on INSTI: consult pharmacy team before starting antacids, anticoagulants, antiepileptics, antidepressives, metformin, rifamycins, cations, or steroids.”
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Dolutegravir and Pregnancy
• Dolutegravir in preliminary/emerging data has been associated with low rate of neural tube defects
• 2018 Guidelines: “preliminary data suggest that there is an increased risk of neuraltube defects (NTDs) in infants born to people who were receiving DTG at the timeof conception”
– “negative pregnancy test result should be documented prior to initiating DTG in antiretroviral therapy (ART)-naive individuals of childbearing potential
– DTG is not recommended for those who are pregnant and within 12 weeks post-conception– DTG is also not recommended for those of childbearing potential who are planning to
become pregnant or who are sexually active and not using effective contraception– For those who are using effective contraception, use of a DTG-based regimen can be
considered after discussing the risks and benefits of this drug with the patient”
• It is not yet known whether other INSTIs pose a similar risk of NTDs (i.e., a class effect).
• Update from July 2019 IAS & NEJM 8/2019: Zash R et al:– Background rate: 98 NTD s among 119,033 infants analyzed (0.08%)– On DTG: 5 NTDs amoing 1683 infants (0.30%): elevated rate, but less than seen earlier– Botswana: lacks folate fortification. ?Possible DTG antagonism of folate?
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INSTI's and Weight Gain
• There is a talk at 1pm today on this topic: highly recommend
• Weight gain being increasingly recognized with ART initiation with DTG
• Additional possibly synergistic role of TAF• Weight gain seen in multiple registrational drug trials in
US/Europe• Also seen in ADVANCE & NAMSAL trials from Africa• Unclear if a class effect or if certain INSTI's worse than
others• Mechanism/metabolic pathway unclear, but does appear
separate from 'return to health' phenomenon• Thursday lecture devoted to this topic: will be detailed!
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Integrase Inhibitor Overview
Dolutegravir Bictegravir Raltegravir Elvitegravir
QD (ART-naïve or INSTI-naïve) 1200mg QD
FrequencyBID: with CYP3A4 or UGT1A1inducers, or with INSTI
QD or400mg BID
QD
mutations
Genetic barrier to resistance
High High Lower Lower
Single tablet option?
Yes, Triumeq Yes, Biktarvy No Yes, Genvoya orStribild
• Guidelines mention three 2-drug regimens in alternate section (for situations where TAF, TDF, ABC can't be used or are not optimal):– DTG+3TC
– DRV/RTV + RAL BID– DRV/RTV + 3TC
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Certain 2-Drug Regimens
• Dolutegravir + lamivudine (DTG/3TC; Dovato)– GEMINI-1, GEMINI-2 trials: ART-naïve, VL<500K, 48W data led to
FDA approval for ART naïve patients– Week 48: 91% (2 drug) vs. 93% (3 drug), pooled trials analysis– Week 96: 86% (2 drug) vs. 90% (3 drug), pooled– Risks of adherence, sub-20% M184V, the "non-perfect patient"
Cahn, P et al., Lancet, 2018 Cahn P et al., IAS 2019
• DRV/RTV + RAL BID• DRV/RTV + 3TC• Not in guidelines: Dolutegravir + rilpivirine (DTG/RPV; Juluca)
– SWORD-1/SWORD-2 Trials: led to FDA approved for switch of virally suppressed patients, not FDA approved for ART-naïve patients
– Not mentioned in guidelines for ART initiation since not FDA approved for this
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Single Tablet
Regimens
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Single Tablet Co-Formulations
Emtricitabine
Lamivudine
Abacavir
Tenofovir
Efavirenz
Rilpivirine
Ritonavir
Atazanavir
Darunavir
Raltegravir
Elvitegravir
NRTI
NNRTI
Protease
INSTI
Epzicom
Truvada Evotaz
Cobicistat
Prezcobix
TAF
DescovyApril, 2016
2004
2004
January, 2015
January, 2015
Dolutegravir
Bictegravir
Doravirine
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Single Tablet Regimens
Emtricitabine
Lamivudine
Abacavir
Tenofovir
Efavirenz
Rilpivirine
Ritonavir
Atazanavir
Darunavir
Raltegravir
Elvitegravir
NRTI
NNRTI
Protease
INSTI
Atripla
Cobicistat
TAF
2006
Dolutegravir
Bictegravir
Doravirine
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Single Tablet Regimens
Emtricitabine
Lamivudine
Abacavir
Tenofovir
Efavirenz
Rilpivirine
Ritonavir
Atazanavir
Darunavir
Raltegravir
Elvitegravir
NRTI
NNRTI
Protease
INSTI
Complera Cobicistat
TAF
August,2011
Dolutegravir
Bictegravir
Doravirine
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Single Tablet Regimens
Emtricitabine
Lamivudine
Abacavir
Tenofovir
Efavirenz
Rilpivirine
Ritonavir
Atazanavir
Darunavir
Raltegravir
Elvitegravir
NRTI
NNRTI
Protease
INSTI
Odefsey Cobicistat
TAF
March, 2016
Dolutegravir
Bictegravir
Doravirine
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Single Tablet Regimens
Emtricitabine
Lamivudine
Abacavir
Tenofovir
Efavirenz
Rilpivirine
Ritonavir
Atazanavir
Darunavir
Raltegravir
Elvitegravir
NRTI
NNRTI
Protease
INSTI
Cobicistat
Stribild
TAF
August, 2012
Dolutegravir
Bictegravir
Doravirine
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Single Tablet Regimens
Emtricitabine
Lamivudine
Abacavir
Tenofovir
Efavirenz
Rilpivirine
Ritonavir
Atazanavir
Darunavir
Raltegravir
Elvitegravir
NRTI
NNRTI
Protease
INSTI
Cobicistat
Triumeq
TAF
August, 2014
Dolutegravir
Bictegravir
Doravirine
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Single Tablet Regimens
Emtricitabine
Lamivudine
Abacavir
Tenofovir
Efavirenz
Rilpivirine
Ritonavir
Atazanavir
Darunavir
Raltegravir
Elvitegravir
NRTI
NNRTI
Protease
INSTI
Cobicistat
Genvoya
TAF
November, 2015
Dolutegravir
Bictegravir
Doravirine
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Single Tablet Regimens
Emtricitabine
Lamivudine
Abacavir
Tenofovir
Efavirenz
Rilpivirine
Ritonavir
Atazanavir
Darunavir
Raltegravir
Elvitegravir
NRTI
NNRTI
Protease
INSTI
Cobicistat
Biktarvy
TAF
February, 2018
Dolutegravir
Bictegravir
Doravirine
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Single Tablet Regimens
Emtricitabine
Lamivudine
Abacavir
Tenofovir
Efavirenz
Rilpivirine
Ritonavir
Atazanavir
Darunavir
Raltegravir
Elvitegravir
NRTI
NNRTI
Protease
INSTI
Cobicistat
Symtuza
TAF
July, 2018
Dolutegravir
Bictegravir
Doravirine
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Single Tablet Regimens
Emtricitabine
Lamivudine
Abacavir
Tenofovir
Efavirenz
Rilpivirine
Ritonavir
Atazanavir
Darunavir
Raltegravir
Elvitegravir
NRTI
NNRTI
Protease
INSTI
Delstrigo Cobicistat
TAF
August, 2018
Dolutegravir
Bictegravir
Doravirine
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Single Tablet Regimens
Emtricitabine
Lamivudine
Abacavir
Tenofovir
Efavirenz
Rilpivirine
Ritonavir
Atazanavir
Darunavir
Raltegravir
Elvitegravir
NRTI
NNRTI
Protease
INSTI
Dovato Cobicistat
TAF
XXXX
Dolutegravir
Bictegravir
Doravirine
get new pic
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U.S. DHHS Guideline Update: October, 2018
Initial Regimens Initial Regimens“for Most People” “in Certain ClinicalSituations”
BIC/TAF/FTC EVG/cobi + (TDF/FTC or TAF/FTC)* If reproductive potential, consult guidance * If reproductive potential, consult guidance
DTG/ABC/3TC RAL/ABC/3TCOnly if HLB57-01 negative Only if HLAB57 negative and VL<100,000* If reproductive potential, consult guidance * If reproductive potential, consult guidance
DTG + (TDF/FTC or TAF/FTC) (DRV/RTV or DRV/cobi) + (TDF/FTC or TAF/FTC)* If reproductive potential, consult guidance
RAL + (TDF/FTC or TAF/FTC) (DRV/cobi or DRV/RTV) + ABC/3TC* If reproductive potential, consult guidance Only if HLB57-01 negative
(ATV/cobi or ATV/RTV) + (TDF/FTC orTAF/FTC)
(ATV/cobi or ATVRTV) + ABC/3TCOnly if HLAB57 negative and VL<100,000
DOR/TDF/FTC or (DOR + TAF/FTC)
EFV + (TDF/FTC or TAF/FTC)
Adapted from: US DHHS ART Guidelines – July, 2019 Update RPV + (TDF/FTC or TAF/FTC)Only if VL<100,000 & CD4+ >200
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Case 1
• 51 year old man registering for care. VL = 41,000, CD4+ count = 682. Creatinine = 1.4, and eGFR = 55 mL/min. LDL = 68. HLAB57-01 is negative. No other medical problems. Which regimen(s) would you offer?
• A) TAF/FTC/BIC (Biktarvy)• B) TAF/FTC (Descovy) + DTG (Tivicay)• C) ABC/3TC/DTG (Triumeq)• D) TDF/FTC (Truvada) + RTV/DRV• E) EVG/cobi/TAF/FTC (Genvoya)• F) RAL + TAF/FTC (Descovy)
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Case 1
• 51 year old man registering for care. VL = 41,000, CD4+ count = 682. Creatinine clearance = 55 mL/min. LDL = 68. HLAB57-01 is negative. No other medical problems. Which regimen(s) would you offer?
• A) TDF/FTC (Truvada) + DTG (Tivicay) à eGFR is <60: avoidTDF.
• B) TAF/FTC (Descovy) + DTG (Tivicay) à Fine choice.
• C) ABC/3TC/DTG (Triumeq) à Fine choice.
– B57 negative, thus eligible. No major CV concerns. Triumeq for eGFR>50.
• D) TDF/FTC (Truvada) + RTV/DRV à eGFR is <60: would avoid TDF, and especially in combination with RTV/PI, which boosts TDF. Also, second line.
• E) EVG/cobi/TAF/FTC (Genvoya) à eligible since GFR is >30, but favor unboosted INSTI instead of using cobi. Also, second line.
• F) RAL + TAF/FTC (Descovy) à Fine, but prefer potency/genetic barrier of DTG or BIC.
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Case 2
• Same patient as Case 1, but lower eGFR:• 51 year old man registering for care. VL = 41,000, CD4+ count = 682.
Creatinine = 1.6, creatinine clearance = 31 mL/min. LDL = 68. HLAB57-01 is negative. No other medical problems. Which regimen would you offer?
• A) TDF/FTC (Truvada) + DTG• B) TAF/FTC (Descovy) + DTG• C) TAF/FTC/BIC (Biktarvy)• ABC/3TC/DTG (Triumeq)• D) TDF/FTC + RTV/DRV• E) EVG/cobi/TAF/FTC (Genvoya)• F) TAF/FTC (Descovy) + RAL 1200 QD
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Case 2
• 51 year old man registering for care. VL = 41,000, CD4+ count = 682. Creatinine = 1.6, and creatinine clearance = 31 mL/min. LDL = 68. HLAB57-01 is negative. No other medical problems. Which regimen would you offer?
• A) TDF/FTC (Truvada) + DTG à eGFR is <60: avoidTDF
• B) TAF/FTC (Descovy) + DTG à eGFR is >30: fine choice; monitor.
• C) TAF/FTC/BIC (Biktarvy) à eGFR is >30: fine choice; monitor.
• D) ABC/3TC/DTG (Triumeq)– B57 negative: eligible. Some CV concerns with renal disease.– But Triumeq is only for eGFR>50.
• D) TDF/FTC + RTV/DRV à eGFR is <60: avoid TDF, esp. with RTV/PI.
• E) EVG/cobi/TAF/FTC (Genvoya) à Since eGFR<70, favor unboosted INSTI
• F) TAF/FTC (Descovy) + RAL 1200 QD à Fine choice at eGFR>30, but lower barrier to resistance, and 3 pills where single tablet is possible
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Case 3
• 48 y.o. man, newly diagnosed last month, VL 105,000, CD4+count = 487. Has history of hyperlipidemia (LDL = 140, Totalcholesterol = 221), smokes 10 cigarettes/day, and has HBA1c= 7.1%. BUN/creatinine 14/1.2, CrCl=73 mL/min, UA: 1+ protein. Which ART is optimal?
• A) TAF/FTC (Descovy) + DTG
• B) TDF/FTC (Truvada) + DTG• C) TAF/FTC/BIC (Biktarvy)
– eGFR>60 is ok, but with 1+ proteinuria, favor TAF over TDF
• B) TAF/FTC (Descovy) + DTG– OK choice, eGFR>30, but already has proteinuria…
• C) TAF/FTC/BIC (Biktarvy)– OK choice, eGFR>30, but already has proteinuria…
• D) ABC/3TC/DTG (Triumeq)– OK choice, eGFR>50; but with CV risk factors
(lipids/smoking/DM), balance CV risk with ABC vs. using TAF in patient with proteinuria
• E) TAF/FTC + RTV/DRV– With cardiac and renal risk factors, avoid PI if
possible. Second line.
• F) TDF/FTC/DOR (Delstrigo)– With proteinuria, avoid TDF. Second line.
• 48 y.o. man, newly diagnosed, VL 105,000, CD4+ =487. Has hyperlipidemia (LDL= 140, Totalcholesterol = 221),smokes 10 cigarettes/day, HBA1c = 7.1%,BUN/creatinine 14/1.2, CrCl=73mL/min, UA: 1+ protein. Which ART is optimal?
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Case 4
• 34 y.o. woman, VL 23,000, CD4+ 610. Has chronic HBV: HBsAg+ HBsAb+ HBcAb+ HBV DNA = 6M IU/mL. HLAB57-01 negative. CrCl=90 mL/min.Which regimen(s) would you offer?
• A) TAF/FTC (Descovy) + DTG• B) TDF/FTC (Truvada) + DTG
• C) TAF/FTC/BIC (Biktarvy)
• D) ABC/3TC/DTG (Triumeq)
• E) TDF/FTC (Truvada) + RTV/DRV
• F) ABC/3TC (Epzicom) + RAL
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Case 4
• 34 y.o. woman, HIV VL 123,000, CD4+ 610. Has chronic HBV: HBsAg+ HBsAb+ HBcAb+ HBV DNA+. HLAB57-01 negative. CrCl=90.Which regimen(s) would you offer?
à finechoice
à finechoice
à finechoice
• A) TAF/FTC (Descovy) + DTG• B) TDF/FTC (Truvada) + DTG• C) TAF/FTC/BIC (Biktarvy)• D) ABC/3TC/DTG (Triumeq) à 3TC alone: would add entecavir
• E) TDF/FTC (Truvada) + RTV/DRV à OK, but prefer integrase > PI
• F) ABC/3TC (Epzicom) + RAL à Combo is second line, not for HIV VL>100K (always check), would need to add entecavir with 3TC, and would prefer integrase over PI
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Case 5
• 57 y.o. woman, VL=14K, CD4=390. DM2: A1c=8.0%,takes metformin at maximum 875mg TID dose + glipizide 5mg BID, CrCl=90mL/min, UA with no protein. HLAB57 negative. Which ART regimen do you favor?
• A) TAF/FTC (Descovy) + DTG• B) TDF/FTC (Truvada) + DTG• C) TAF/FTC/BIC (Biktarvy)• D) ABC/3TC/DTG (Triumeq)• E) TDF/FTC/cobi/EVG (Stribild)• F) TAF/FTC (Truvada) + RAL
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Case 5
• 57 y.o. woman, VL=14K, CD4=390. DM2: A1c=8.0%, takes metformin at maximum 850mg TID dose + glipizide 5mg BID, CrCl=90, UA with no protein. HLAB57 negative. Which ART regimen do you favor?
A) TDF/FTC (Truvada) + DTG
•Potentially ok; potentially not•DTG boosts metformin à would need close monitoring as already on max dose (but might be ok)•If need to reduce metformin, might have to add 2nd med, or DM2 control may get worse
B) TAF/FTC (Descovy) + DTG • Same as choiceA
C) TAF/FTC/BIC(Biktarvy) • Same as choiceA
E) TDF/FTC/cobi/EVG(Stribild) • eGFR>70, no DDI*à fine choice,• but prefer to avoid cobicistat if RAL possible
F) TAF/FTC (Truvada) + RAL • eGFR>30, no DDI*à fine choice• Balance your view of RAL vs. DTG/BIC against DM control
D) ABC/3TC/DTG (Triumeq) • Same as choice A “DDI” = drug-drug interaction*
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Summary / Principles
• Choosing the NRTI backbone:– Consider TDF vs. TAF
• Assess creatinine clearance, proteinuria, osteoporosis, importance of pill size– Consider ABC vs. TDF/TAF
• Need HLAB57-01 test. Assess question/opinion of cardiac risk issues– Consult with experts when all NRTI’s seem problematic
• Goal is to use INSTI in most patients unless other issues prevail– Consider prior history, drug intolerance, side effect, desire for single-
tablet regimen, drug interactions– Consider DTG, BIC for most patients if possible
• Assess PI and NNRTI possibilities if needed:– Consider dosing (QD vs. BID), desire for single tablet regimen, psychiatric
history, lipid profile, GI issues, renal status, likelihood of strong adherence/genetic barrier
– Assess baseline VL and CD4 count
• Focus on DHHS first-line recommended regimens
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References
• Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV. Department of Health and Human Services. Version: October 17, 2017. Available at: http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed 11/1/17.
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