Caso Clínico

Tânia R. C. VergaraMestre em infectologia – UFRJDoutora em Medicina – UNIFESPPesquisadora associada do Laboratório de Retrovirologia da UNIFESPPresidente da Sociedade de Infectologia do Estado do Rio de Janeiro- SIERJCoordenadora de Terapia do Comitê de HIV/ aids da SBI

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Declaração sobre Conflito de Interesses

De acordo com a Resolução 1931/2009 do ConselhoFederal de Medicina e com a RDC 96 / 2008 da ANVISA,declaro que:

• Apresentações:como palestrante convidado ou elaboração de material gráfico participo/ei dos eventos de: GSK, Janssen, BMS, Roche, Abbvie.

• Consultoria: GSK, Janssen, Roche.

• Pesquisa Clínica: como médico investigador, participei de estudo patrocinado por: Abbvie.

• Não sou acionista de qualquer uma destas companhias farmacêuticas.

• Meus pré-requisitos para participar destas atividades são a autonomia do pensamento científico, a independência de opiniões e a liberdade de expressão.

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Case report

• 2007– Weight loss, lymph node enlargement in the thorax and addome.

• Heavy smoker. COPD. Moderate alcohol intake. • Anti HIV +; PPD anergic;

• Thorax CT: Calcified micronodules disseminated in both lungs. Small lymph nodes for tracheal.

• TB empirical treatment.

• TARV beginning AZT + 3TC + EFV

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First recommendations – to stop smoking

• Did not quit smoking

• 08/2009 Prostate cancer- hormonal therapy

• In the following years - insulin resistance, liver steatosis, hypertension, hyperuricemia, hypertriglyceridemia.

• ARV switched to AZT + 3TC + ATV / r and then AZT + 3TC + FPV / r because he takes pump inhibitor to treat gastroesophageal reflux.

• In 2010, in addition to the antiretrovirals he was takingfenofibrate, esomeprazole, enalapril, allopurinol, buffered aspirin and bupropion.

• In 10/11 switched for ABC + 3TC + FPV/r

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CARDIOVASCULAR PREVENTION POLICY IN HIV: RECOMMENDATIONS FROM A MODELING STUDY

Tvergara 5Rosan van Zoest. CROI 2017 Abstract 129

• In 03 / 12- cardiac arrhythmia. Precribed by cardiologist -> propafenone, amlodipine, ramipril, venlaflaxine, ciclesonide inhaled, formoterol inhaled , fenofibrate, rosuvastatin.

• He quit smoking for a short time and returned shortly thereafter..

• All vaccinations up to date: hepatitis B, pneumococcal 13 and 23 valent, meningococcal ACYW, hepatitis A, Influenza, DTPa

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DEXA in 05/15 – osteoporosisIt was added risedronate, vitamine D3, Ca dietary intake- 1000 mg/day

Would you make any changes to the TARV?

In September / 2015-> TARV simplification -> DRV/r + RALIt improved the metabolic disturbance and maintained viral suppressionCD4> 1400/mm3.

04/2017 Switch -> DRV/r + DTG as a recommendation of the National HIV/AUDSTreatment Protocol (PCDT)

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D:A:D: Exposição a ARV e risco de doença renal cronica(DRC)

• Analise retrospectiva de pacientes com eGFR > 90/mL/min no baseline (N = 23,560)

• Exposição cumulativa a TDF, ABC, ATV/r, LPV/r, outros e risco de DRC

• 210 pts desenvolveram DRC

• Análise Multivariada: exposição a TDF, ATV/r, e LPV/r significantemente associada com desenvolvimentno de DRC

• Risco ao longo de 5 anos

Risco de DRC por anos de esposição, IRR (95% CI)

Drug 1 Yr 2 Yrs 5 Yrs

TDF 1.12 (1.06-1.18)

1.25 (1.12-1.39)

1.74 (1.33-2.27)

ATV/ r 1.27 (1.18-1.36)

1.61 (1.40-1.84)

3.27(2.32-4.61)

LPV/ r 1.16 (1.10-1.22)

1.35(1.21-1.50)

2.11(1.62-2.75)

Mocroft A, et al. CROI 2015. Abstract 142. Reproduced with permission. Tvergara 8

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Emergence of resistance mutations in full data set(confirmed HIV RNA > 50 c/ mL or any single HIV RNA ≥ 500 c/ml at or after W32)

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A frequência de mutações IN na falha foi significativamente associada à LV basal: 7,1% para uma LV <100 mil cópias / mL, 25,0% para uma LV de ≥100 mil cópias / mL e <500 mil cópias / mL e 53,8% para VL ≥500.000 cópias / ml (PTREND = 0,007). De nota, 4/1

The frequency of IN mutations at failure was significantly associated with baseline VL• 7.1% for a VL of <100 000 copies/mL• 25.0% for a VL of ≥100 000 copies/mL and <500 000 copies/mL • 53.8% for a VL of ≥500 000 copies/mL (PTREND = 0.007).

Of note, 4/15 participants with IN RAM had a VL < 200 copies/mL at time of testing.No assiciation with baseline CD4 count nor HIV RNA do HIV at time of testing p=0.25

• December 2017 - Lung cancer. Metastasis to brain, liver and bone. He began high-dose corticosteroids and radiotherapy to reduce the brain lesions size and begun chemotherapy. VL < 40 cp/ml

• TARV switched to DTG + 3TC -> no interactions with the chemotherapy.• VL checked monthly at the first 3 months.

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Reasons to Consider Regimen Switching in

Virologically Suppressed Pts

DHHS ART Guidelines. May 2018. Adapted Slide credit: clinicaloptions.com

• Simplification

• Avoid toxicity

• Improve tolerability or convenience

• Manage drug–drug or drug–food interactions

• Pregnancy

• Cost

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• April 2018 VL <40 cp / ml• CD4> 1300/mm3 CD4 / CD8 1,2• Jul 2018 VL <40 cp / ml• CD4 1350 /mm3

• Excellent responso to chemotherapy

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Thank you very much for your attention.taniavergara@globo.com