My 1st “skeettorial”! #IDSky
When seeing virally suppressed pts, there's an "inertia" to just refilling the current ART regimen - "if it ain't broke, don't fix it".
While that is true (to an extent,) here's a few situations in ART management that should prompt at least a conversation w/ the pt:
When seeing virally suppressed pts, there's an "inertia" to just refilling the current ART regimen - "if it ain't broke, don't fix it".
While that is true (to an extent,) here's a few situations in ART management that should prompt at least a conversation w/ the pt:
Comments
Pause, review ART history, cumulative genotypes, & think if a simpler regimen is possible/desired by the pt.
Calling Monogram might help recover lost genotypes.
https://HIVassist.com & StanfordDB are great resources!
Well >90% of pts w/ NRTI resistance (184V, K65R, TAMs, etc) can be suppressed w/ "recycled" NRTIs + fully active high-resistance barrier drug (BIC, DTG, or boosted PI)!
If adherent & suppressed, B/F/TAF is fine & VF rare!
Cobicistat/ritonavir may expose patients (esp if older w/ growing list of meds) to dangerous drug interactions by unaware providers - Cushing's from intra-articular steroids, amiodarone intoxication, bleeding w/ DOACs, etc.
Consider if PIs are really necessary!
Great when well indicated, however, besides DDIs, there's cumulative metabolic (& other) risk.
Again, pause, review ART/genotypes, viremias & hx's of VF. Proviral "archived" genotypes can sometimes add a layer of info when unclear indication.
RAL & EVG/c have a lower barrier to resistance, and EVG needs Pk boosting (w/ its downsides). Pts w/ sub-optimal adherence, Pk issues, very high VL/low CD4, etc, can develop major INSTI mutations (eg, Q148H & N155H), w/ cross-resistance to CAB, BIC, & DTG.
INSTIs are amazing, but there's a few DDIs. DTG increases metformin levels. Several anti-epileptics decrease INSTI levels!
The issue of pts on IM CAB (or PO INSTIs) who get phenobarbital for EtOH withdrawal sometimes comes up as well!
(+/- the only person I follow there , with Geno Tai)