Case discussion: How do drugs/patients impact need and

type of monitoring – CASE 2

Marta BoffitoHead of Clinical Trials, St. Stephen’s Centre (SSAT)

Consultant Physician, Chelsea and Westminster Foundation TrustReader, Imperial College London

Mr DB

• 54 years old MSM• HIV dx in 2004• cART (TDF/FTC + NVP) since 2006

• Acute hep C treatment with Harvoniapproximately 6 months ago (8 weeks)– HCV PCR negative

Mr DBWell•

Co• -medicationsSildenafil purchased on line–

Recreational drugs•Poppers–

Alcohol intake•Limited (a couple of glasses of wine/week, socially)–

BP • 170/98, GP wrote to you to ask whether he can start amlodipine 10 mg OD

Mr DB

• U&E within normal range• LFTs within normal range• FBC within normal range

• Lipids– TC 6 mmol/L (231.7 mg/dL)– TG 1.39 mmol/L (53.7 mg/dL)– HDL 1.25 mmol/L (48.3 mg/dL)– LDL 4.11 mmmol/L (158.7mg/dL)– HDL:chol ratio 4.76– NON HDL chol 4.7 mmol/L (NV

<2.5) – 181.5 mg/dL

• HIV VL < 20 copies/mL• CD4 584 cells/mm3

• Hep A IgG +• anti-HBsAg > 1000

• Sexual health screen: RPR negative, syphilis IgG/IgM positive, GC negative, CT negative

What other aspect of Mr DB health require monitoring?

Increasingage,

ageingprocess1

Lifestyle(drugs,

alcohol)1

Drug toxicity(e.g. TDF andNephrotoxicit

y1)

Persistentimmune

dysfunctioninflammatio

n1PREMATURE

AGEING

Polypharmacy

Cancer1,3

Bonedisease1,5

Kidneydisease1,7

Neurological Impairments1,2

CVD1,4

Liverdisease1,6

1. Deeks SG et al. BMJ 2009;338:a31722. McArthur JC et al. Ann Neurol 2010;67:699–714

3. Nguyen ML et al. 18th IAC. Vienna, Austria 2010. Abstract WEAB01054. Freiberg MS et al. JAMA Intern Med 2013;173:614–22

5. Brown TT et al. AIDS 2006;20:2165–746. Towner WJ et al. JAIDS 2012;60:321–77. Lucas GM et al. Clin Infect Dis 2014;59

Do patients with HIV age prematurely?

HIV=human immunodeficiency virus; TDM=therapeutic drug monitoring; CACS=coronary artery calcium scores; BMD=bone mineral densityWaters L, et al. Int J STD AIDS 2012;23:546‒52

…full medication and drug interactions review, neurocognitive assessment, adherence self-

assessment and investigations, including TDM, CACS and BMD.

…osteoporosis……prostate cancer…

The clinic has improved general practitioner (GP) liaison…

A dedicated clinic for the over 50’s at C&W

Older patients (> 50)

BHIVA monitoring Guidelines, www.BHIVA.org

• N of drugs• Type of drugs

– Prescribed– OTC– Herbals– Recreational– Alcohol

• Drug interactions

Drug history

Drug interaction resources HIV

MenCheck for hypogonadism• low libido• depression• osteoporosis

TestosteroneTotal and FREE

Endocrine systemWomen

Menopausal clinic• depression• osteoporosis• ….

Transexual• symptomatology• drug interactions

Full hormonalprofile, if needed

Full hormonalprofile with

appropriate referral

Cancer screening

MEN• PSA• Anal cytology • Referral to anoscopy

clinic if cytology is abnormal

WOMEN• Cervical smear*• Ensure mammography

is done or planned

*cervical smear test is recommended every year regardless of patient’s age

PLWHIV are diagnosed with cancer at an earlier age than uninfected adults

5866 65 67 69

6171

5242 41

51 5245

53

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20

40

60

80

Mea

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SCC, squamous cell carcinoma, SEER, Surveillance, Epidemiology and End Results

Average age at cancer diagnosis for 516 HIV-positive individuals and uninfected individuals (SEER database), by cancer type, 2000–20072

Uninfected(SEER database)

HIV-positiveindividuals

Anal/rectalSCC

Non-Hodgkinlymphoma Liver Head

and neck Lung Breast Prostate

p=0.0001 for all comparisons

1. National Cancer Institute Fact Sheet. HIV Infection and Cancer Risk. National Institutes of Health. 2013,

2. Nguyen ML et al. 18th IAC, 2010. Vienna, Austria. Abstract WEAB0105

Monitoring of CVD

CVD risk assessment (Framingham score)Should be performed in all men > 40 years and women > 50 years without CVD

https://www.qrisk.org/2017/

We recommend baseline assessment of CVR on HIV-positive patients who are aged > 40 years and/or have significant CVD risk factors using QRISK2, taking into account that it will underestimate risk (1B).

Coronary artery calcification scoreCACS

Bone mineral density

• FRAX score

• DEXA scan• Vitamin D

Cognitive assessment

• Are you concerned about your memory/concentration/cognition?

• Has anybody around you expressed concern about your memory/concentration/cognition?

• SOCIAL SITUATION: combination of all social factors that come into play at any one time (e.g. isolation, alcohol use, anxiety regarding future)

Depression

Anxiety

Cognitive assessment: PHQ9 and GAD7

Cognitive assessment: EMQ

Algorithm for Diagnosis and Management of HIV-Associated Neurocognitive Impairment (NCI) in Persons without Obvious

Confounding Conditions

1. Exclude depression

2. If NP examination is abnormal,consider neurology referral/brain MRI

3. Importance of cART

4. Need for LP to evaluate active CNS HIV

NP = neuropsychological

Mr DB

• Needs treatment for hypertesion, potential DDI between NVP and amlodipine, review cART – unboosted InSTI?

• Had osteoporosis – review cART – should he change from TDF to TAF or ABC (CVR?)

• CVR 12%• Does he need a statin?• CACS zero (what about if > 75th centile?)