Thank you to Scott Goldberg for presenting his first case in morning report today! We are super grateful for the strong intern attendance at ZSFG report =)
Choosing a regimen
- goal is three active drugs from two different classes
Where should I go to get up to date info on recommended regimens? Two awesome resources
- HHS guidelines: The US Department of health and human services regularly publishes guidelines about many aspects of HIV care. You can find their recommend regimens here: https://aidsinfo.nih.gov/contentfiles/lvguidelines/aa_recommendations.pdf
- UCSF HIV Insite: guidelines, educational articles, and policy pieces on everything from how to tell a patient they have HIV to rare manifestations of CMV. Developed by ZSFG’s HIV experts and available to the public http://hivinsite.ucsf.edu
Here are HHS recommendations for first-line ART
- Many HIV docs are pumped about dolutegravir-based regimens due to their high tolerability, high barrier to resistance, and impressive ability to suppress the virus.
What the heck is tenofovir alafenamide?!
- Old fashioned tenofovir is tenofovir diisoproxyl fumarate.
- Tenofovir is a sternralong-time mainstay of ART and PREP regimens with some serious downsides with long term use
- renal impairment, specifically a fanconi’s syndrome
- TAF is a new (very expensive, conveniently timed for when tenfovir became generic) medication that, based on it’s pharmacokinetics, should be less nephrotoxic.
- The TAF-involved regimen above is highlighted because it’s new, not because it’s preferred
- TAF cannot be used for PReP because it is unclear whether it is present in adequate level in the anal mucosa.
Bonus pearl – LGV proctitis
- lymphogranuloma venerum is caused by the L1, L2, and L3 serovars of chlamydia
- It used to be rare outside the US but there have been outbreaks of LGV ano-rectal syndrome among MSM.
- LGV ano-rectal syndrome
- primary LGV infection is an ulcer at the site of infection with inflammation ~ 1 week after infection
- ano-rectal syndrome presents 2-6 weeks after primary infection with a rectal mass, fevers, tenesmus, constipation, fevers, or bloody diarrhea. It can be mistaken for inflammatory bowel disease.
Blank S, Schillinger JA, Harbatkin D Lymphogranuloma venereum in the industrialised world.Lancet. 2005;365(9471):1607.