Ardis Ann Moe, M.D.
UCLA CARE Clinic/NEVHC HIV Clinic Van Nuys.
28 August 2015
amoe@mednet.ucla.edu
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To describe the major side effects of HIV
treatment
To know useful lab tests for HIV side effect
monitoring
To review case studies of how to choose
initial HIV regimen, and what regimen to
switch to in the event of side effects
Benefits of treatment
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Fuzeon causes painful lumps on the skin that
persist for weeks
Shots need to be done twice daily
Selzentry rarely causes rash; can cause
orthostatic hypotension, nausea, dizziness.
Cannot be used in kidney failure
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As a class, they are associated with liver
problems: lactic acidosis, fatty liver disease
Pancreatitis—rare in most of the nucs,
common in Videx and Zerit
Liver problems fairly rare now with non-DDI,
non-AZT nucs
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Most common nucleotide backbone of most
HIV cocktails (part of truvada)
Causes kidney damage
Causes bone thinning
Occasional GI upset
Likely to be replaced with tenofovir
alafenamide (TAF)—TAF MUCH less toxic to
kidneys and bone—likely out fall 2015.
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Emtriva (part of truvada)
Essentially as safe as Epivir, but more rash
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Epivir likely the safest of all the nucs
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Abacavir: as noted, an allergic reaction for
persons with genetic trait: HLAB5701
Can cause headaches, nausea
Combination drug Epzicom can cause more
nausea than either drug alone
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AZT; Zidovudine: Anemia, low white cells,
fatigue, headache, nausea. Muscle wasting:
“AZT butt”
Facial wasting, fat loss on legs and arms
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Stavudine (Zerit)
Neuropathy, facial wasting, fat loss in legs
and arms.
Side effects start after 5 months or more of
use—can be used as a “bridge” drug, as in
cases of needlestick injuries
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As a class, they all cause rash and liver
inflammation and have multiple drug
interactions
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Sustiva (part of Atripla)
Causes depression, suicidality, panic attacks,
insomnia (interferes with REM sleep), vivid
dreams, elevated cholesterol and
triglycerides.
Not recommended for women in 1st trimester,
or who are likely to become pregnant (US)
Sold on streets as alternative to LSD
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Viramune/Neviripine
Most likely to cause severe rash (Stevens
Johnson syndrome). Proper dosing when
starting medication can make rash less likely
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Intelence
Vivid dreams, gritty taste
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Edurant
Some depression, some vivid dreams.
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As a class they all cause diarrhea,gas, and
occasional vivid dreams.
Rarely they cause depression
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Isentress; most likely to cause diarrhea
Low barrier to resistance; twice daily drug
increases risk of missing doses
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Elvitegravir: gas, diarrhea.
Has to be given with cobisistat so there will
be drug interactions
low barrier to resistance
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Tivicay/dolutegravir; drug interactions,
diarrhea
Somewhat higher barrier to resistance
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As a class they all cause diabetes and insulin
resistance.
They all cause diarrhea and GI upset
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The older drugs also raise cholesterol,
triglycerides significantly (Crixivan, Invirase,
Viracept, Kaletra) and can cause fat
accumulation (lipodystrophy)
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For older drugs, risk of lipodystrophy 75%
after 2 years of use. Approx 5% for newer PI’s
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Reyataz/atazanavir: can also cause yellow
eyes (jaundice)
May cause confusion about liver function
when patients have chronic hepatitis B or
hepatitis C
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Lexiva, Prezista have significant risk of skin
rash
Prezista has the worse GI side effects of all
the newer PI’s
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Abacavir: HLA B5701 genetic marker of
allergic reaction
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Kidney function tests: creatinine and
urinalysis, especially for patients on truvada
or Viread/TDF containing regimens
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Liver function tests:
Bilirubin (jaundice test) usually around 2-3 in
persons on reyataz. If >3.5 then alternatives
to reyataz should be used
ALT, AST especially for patients on nonnucleosides
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Note that hepatitis B usually gets better on
certain HIV medications (Viread, truvada,
Epivir, Emtriva)
Hepatitis C can get better on any effective HIV
cocktail. (note jaundice risk with reyataz) BUT
only certain HIV cocktails are compatible with
hep C treatments
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CBC with platelets and differential
◦ Low platelets (bleeding risk) can improve within a
few days of starting an effective HIV drug regimen
◦ AZT can initially worsen, and then improve anemia
◦ AZT can cause low white cells especially in patient
with advanced AIDS
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Hemoglobin A1c, glucose
Especially for patients on PI’s
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Cholesterol, triglycerides
◦ Especially for patients on atripla and PI’s
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Plan A: “A pill A day for type A personalities”
Atripla, Complera, Stribild, Triumeq
◦ Low barrier to resistance (usually)
◦ NOT for patients who are unreliable about
medications or appointments
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Plan B: “Boosted protease inhibitor for batty
buddies on the brink”
◦ Most useful when you have patients with OI or AIDS
cancers OR mentally ill patients OR patients with other
adherence risks OR <200 CD4 cells at baseline
◦ Reyataz/norvir/truvada
◦ Evotaz
◦ Prezista/norvir/truvada
◦ Prezcobix
 High barriers to resistance.
 May aggravate diabetes
 Can substitute epzicom for truvada if there is kidney
damage(HLA B5701 neg only)
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Plan C: “Curses, I forgot the Contraception”
Kaletra and Combivir (AZT/epivir)
First choice for pregnant women with HIV
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Plan D: for Drug-drug interactions OR DARN I
stuck myself/DARN I had sex
Isentress +truvada
Has fewest drug interactions
Preferred drugs for needlestick injuries or PEP
Alternative cocktail for pregnant women with
HIV
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Diabetic:
Avoid PI’s if possible
Avoid TDF if possible, given risk of kidney
damage with diabetes
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Kaletra/Combivir
Prezista/Norvir/Epzicom
Isentress/Epzicom
Tivicay/Epzicom
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Avoid TDF
Check HLA B5701; if negative, then can use
abacavir (part of Epzicom)
If HLA B5701 +, may need to use unusual
cocktail to attend HIV control
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Best cocktails with hep C meds: isentress +
truvada or epzicom, or tivcay + truvada or
epzicom
Non nuc’s and boosted PI’s limit hep C
treatment options (ok with declatisivir and
sofosbuvir, however)
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32 yo homeless man, HIV+ new diagnosis.
Alcoholic, depressed, Cr 2.3 (normal 1.2).
Hepatitis C. CD4 count 130. HIV viral load
300,000.
What drugs would you try to AVOID?
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65 yo male new dx of HIV infection.
Hx of cardiac disease. On amiroidarone and
warfarin (coumadin).normal kidney function
Takes medications regularly
What HIV medications do you need to AVOID?
What drug cocktails can be used in him?
31 yo woman with HIV and hepatitis B. She
wants to get pregnant.
What drug should she avoid?
What are good choices for her?
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45 yo male, new dx of HIV.
Bad heartburn, has to take twice daily
protonix. Reliable on taking meds
Diabetic, on insulin
What HIV meds should he AVOID?
What cocktails can he use?
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23 yo male with HIV, on atripla for 2 years.
Has creatinine increased from 1.2 to 1.5 in
the past 6 months. Chronic depression,
insomnia.
What would be his choices for HIV meds?
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34 yo homeless man, new diagnosis of AIDS,
severely anemic, +HLA B5701, Cr 2.3 (kidney
damage), and severe MAC infection with CD4
count <10 and HIV RNA PCR >100,000 on
admission
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55 yo female with AIDS and CMV retinitis,
going blind with syphilis. Homeless, cocaine
addict. Normal Cr. Resistant to truvada and
reyataz and norvir. CD4 count <50, HIV viral
load >100,000
How would you decide what, and when to
change HIV meds?
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31 yo male, dx AIDS and MAC 6 months ago.
Has tried multiple HIV meds.CD4 count <10,
HIV RNA PCR >100,000
Allergic to efavirenz, neviripine, intelence,
abacavir, truvada, norvir, prezista, kaletra,
lexiva, reyataz.
What drugs can still be used?
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24 yo MSM male, pre-med student, discovers
he is HIV+
2 hours of counseling to prevent suicide in
clinic
Later becomes a HIV testing counselor, a
medical student, and then a successful
physician.
Married, and now has adopted four children.
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AIDS patient in his 50’s, doing well, discovers
that he is the only adult child willing to care
for his demented evangelical homophobic
minister father.
Dad moves into the apartment, overlooking
the Gay Pride route in West Hollywood.
Dad looks out the window: “I think I hate
those people but I forgot why”.
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Decide first if a patient is Plan A, B, C or D.
Evaluate renal function, diabetes issues,
hepatitis, allergies, severity of HIV disease,
mental illness.
Consider resistance issues and evaluate
patient for ability to take medications.
Tailor HIV medications to patient’s profile
Getting older also means getting revenge!