VIRTUAL MEDZONEYour Resource for HIV Related Innovative Medical Communication

CASE PRESENTATIONSMahin Baqi MD FRCPCKen Logue MDDavid Fletcher MD FRCPC

CASE 1• 58 y.o. man• HIV + 1989

• CD4 200 on diagnosis

• Previous history of depression and chronic intermittent diarrhea

CASE 1DATE ARV REGIMEN1989 AZT1992 AZT/ddI1994 AZT/ddC/3TC1996 D4T/3TC/Saquinavir… viremia1997 D4T/3TC/Indinavir… viremia1999 D4T/ddI/Nevirapine… viremia

CASE 1• 2001 stopped meds due to

neuropathy, ongoing viremia and chronic diarrhea

• CD4 104 HIV VL 266, 131 c/ml• No genotype available

CASE 1• Restarted AZT/3TC/Abacavir/Lopinavir/

Amprenavir/NevirapineTIME CD4 HIV VIRAL LOAD0 104 2661316 wks 186 140810 wks 230 46118 wks 244 3257

CASE 1

GENOTYPE SEPTEMBER2001

CASE 1TIME CD4 HIV VIRAL LOAD18 wks 244 325724 wks 195 461332 wks 182 491748 wks 250 576672 wks 160 11,46496 wks 230 15,421

CASE 1• AZT/3TC/Abacavir/Lopinavir/

Amprenavir/Nevirapine/Fenofibrate/Fish oil/NiacinTEST VALUETG 5 - >40 mmol/lCholesterol 4 – 7 mmol/lHDL 0.4 mmol/lLDL ? – 1.73 mmol/l

CASE 1AZT/3TC/Abacavir/Lopinavir/

Amprenavir/Nevirapine/Fenofibrate/Fish oil/Niacin

• 104 wks… CD4 150 VL 14,895 c/ml

• Went to Kingston, Ontario in 2003 to live with partner

CASE 1• Returned to Toronto in 2005 on

D4T/Tenofovir/ddI/Fuzeon

• CD4 100 VL 18,295 c/ml

CASE 1

GENOTYPE June 2005

CASE 1

Genotype September 2005

CASE 1

WHAT WOULD YOU DO?

CASE 1• Tropism Testing…R52005-2007

3TC/Maraviroc/Lopinavir/Amprenavir /T20• CD4 165-250 VL 4,000-10,000

CASE 1

Genotype January 2007

CASE 12007• anal carcinoma in situ• Lipids terrible…Triglycerides

>40mmole/l develops pancreatitis, bowel obstruction

• ARVS discontinued

CASE 1Late 20073TC/T20/Ritonavir/Darunavir/Etravirine/ Raltegravir/Maraviroc

• CD4 30 on initiation

CASE 1

TIME CD4 HIV VIRAL LOAD0 30 85,3636 wks 270 98512 wks 246 <50

CASE 12008• Develops Diabetes on regimen –

Metformin initiated• Triglycerides continue out of control

despite bezafibrate/fish oil/crestor• Angina → Severe CAD → CABG

CASE 12008

• T20 stopped due to injection site reactions and associated fatigue…viral load remains <50 on 3TC/Ritonavir/Darunavir/ Etravirine/ Raltegravir /Maraviroc

CASE 1• Lipids remain terrible with

TG>40mmole/l• Bezafibrate/fish oil/Ezetrol/Crestor/

ASA/Coumadin• Recurrent angina – 4/5 bypassed

vessel restenosed via angiography

WHAT WOULD YOU DO?

CASE 1Late 2008 • Ritonavir/Darunavir discontinued• Remains on 3TC/Maraviroc/Raltegravir

/Etravirine• CD4 275 VL <50!• TG 34.70→ 3.78 – 6.07

CASE 12009/10

3TC/Maraviroc/Raltegravir/Etravirine• Angina free, mitral regurgitation,

Grade 1 LV• CD4 250-275 VL <50!• TG 8.46-6.07• LDL <0.5 • HDL 0.5-0.6

CASE 12010• Furosemide/Perindopril for mitral

regurgitation• Some intermittent orthopnea• Stable angina• New onset prostatism

CASE 1TIME CREATININE10/09 10701/10 8004/10 16705/10 196

What would you do ?

CASE 1• No NSAIDS• No New Meds/holistics/illicit drugs• Not dry on clinical examination• Normotensive• No CHF clinically• No swelling of ankles

CASE 1• U/S – no obstruction• U/A – normal albumin/creatinine +

protein/creatinine ratio• Urinalysis normal• Urine sodium-100 mmol/l

CAUSE? MANAGEMENT?

CASE 1

TIME CREATININE05/10 157, 18306/10 14007/10 21308/10 17509/10 153

Perindopril + Furosemide discontinued

EGFR 45-50 ml/min

CASE 1• Given sudden onset, bland urinalysis

and lack of significant proteinuria, likely cause is vascular …awaiting MRI Angiography of kidneys

CASE 1• Doses of all medications readjusted for

renal dysfunction• Not required for

3TC/Maraviroc/Raltegravir/ Etravirine