The mind of a pharmacy student (recent notes in preparation of NAPLEX board exam)

HAART for HIV

Guideline for ART Initiation

Preferred therapy should include the following → 2 NRTIs + one more of the following:
- Protease inhibitor

- Non-nucleotide Reverse Transcriptase Inhibitor (NNRTI)

- Integrase Strand Transfer Inhibitor

1. Nucleotide Reverse Transcriptase Inhibitor (NRTI)s
   1. Preferred: Tenofovir + Emtricitabine (Truvada)
      
   2. Alternative:
      1. Abacavir + Lamivudine (w/negative HLA-B*5701 test)
         
      2. Zidovudine + Lamivudine (DOC pregnancy)
         
      3. Didanosine + Lamivudine
         
2. Protease inhibitors
   1. Preferred:
      1. Atazanavir + Ritonavir
         
      2. Darunavir + Ritonavir
         
   2. Alternative:
      1. Lopinavir + Ritonavir (DOC pregnancy)
         
      2. Fosamprinivir + Ritonavir
         
      3. Saquinavir + Ritonavir
         
3. Non-nucleotide Reverse Transcriptase Inhibitors (NNRTIs)
   1. Preferred: Efavirenz (Sustiva)
      
   2. Alternative: Nevirapine (DOC pregnancy)
      
4. Integrase Strand Transfer Inhibitor: Raltegravir
   

ART Drug Specifics

1. NRTIs: terminate reverse transcription of viral DNA
   1. ADEs: Lactic acidosis, hepatic stenosis, pancreatitis, lipoatrophy, lipodystrophy, peripheral neuropathy, N/D, flatulence
      
   2. Do not give stavudine + zidovudine (antagonistic)
      
   3. Stavudine → hyperlipidemia
      
   4. ABC → HLA-B*5701 testing
      
   5. Emtricitabine → hyperpigmentation
      
   6. Zidovudine → bone marrow suppression
      
2. NNRTIs: inhibit reverse transcriptase
   1. ADEs: rash (SJS, TENs, etc. ~14 days), ↑LFTs, hepatitis
      
   2. Induce CYP3A4 (except delavirdine)
      
   3. EFV → QHS, empty stomach, false positive cannabinoid test, vertigo, vivid dreams, anxiety, euphoria
      
   4. Etravirine → active in K103N mutation, take with food (↑ bioavailability)
      
3. PIs: inhibit protease cleaving gag and gag-pol proteins
   1. ADEs: hyperlipidemia, ↑blood glucose, ↑LFTs, fat maldistribution, bad GIT (take with food)
      
   2. Inhibitor/substrate CYP3A4
      1. except boosted tipranavir
         
      2. Don't use Atorvastatin, Simvastatin or Lovastatin (3A4)
         
   3. Atazanavir → hyperbilirubinemia, 'lipid sparing', always boost w/ritonavir
      
   4. Indinavir → nephrolithiasis (1.5L H₂O/day), blurred vision, metallic taste
      
   5. Caution in sulfa allergy: F DAT
      1. Fosamprenavir
         
      2. Darunavir
         
      3. Amprenavir
         
      4. Tipranavir
         

Other Importances

1. Renal Dosing: ST ZELD
   1. Stavudine
      
   2. Tenofovir
      
   3. Zidovudine
      
   4. Emtricitabine
      
   5. Lamivudine
      
   6. Didanosine
      
2. Hepatic Dosing: FIAA
   1. Fosamprenavir
      
   2. Indinavir
      
   3. Abacavir
      
   4. Atazanavir
      
3. Preferred in Pregnancy: AZT + 3TC + (NVP or LPV/r)
   1. Zidovudine
      
   2. Lamivudine
      
   3. Nevirapine
      
   4. Lopinavir/Ritonavir
      
4. Avoid in Pregnancy: TED → 2 forms birth control
   1. Tenofovir: changes bone growth
      
   2. Efavirenz: teratogenic
      
   3. Didanosine: birth defects