Back Back
ART Switch for Comorbidities
ART Switch for Comorbidities in a Middle-Aged Black Woman

Released: May 12, 2017

Expiration: May 11, 2018

Activity Information

Activity

Progress
1
Course Completed
Continue

In this HIV cases series, we highlight common patient case scenarios and the critical decision making that goes into selecting optimal patient management strategies. This case features a middle-aged woman with stable HIV suppression on ART for nearly 10 years who has developed comorbidities that make her current regimen less than optimal. Herein, I discuss key considerations for what may influence a clinician’s choice of a switch regimen for this woman with cardiovascular risk factors and diminished renal function.

Case Details
The patient is a 52-year-old black woman diagnosed with HIV in 2007. She is a patient who I initiated on what was a rather new regimen at the time: coformulated efavirenz (EFV)/emtricitabine (FTC)/tenofovir DF (TDF). She did very well on this regimen; after a few weeks of reporting that she was experiencing “funny dreams,” she adapted to the regimen and her HIV-1 RNA remained undetectable for nearly 10 years. Recently, she was hospitalized and found to have type 2 diabetes and hypertension. During that stay, the doctors in the hospital started her on 2 hypertension medications and insulin. The hospitalists discontinued her ARV medications during that 3-day stay and she returned to the clinic the following week to consider resuming her medications. At her appointment, she requested to restart her EFV/FTC/TDF based on her success with that regimen and the 1-pill, once-daily dosing.

Here is a summary of what I saw: She is a moderately obese woman with elevated blood pressure—142/98 mm Hg, even on 2 blood pressure medications. Her CD4+ cell count is 522 cells/mm³. HIV-1 RNA has remained undetectable. Her serum creatinine has risen to 1.8 mg/dL; it previously was in the normal range. Her CrCl is 52 mL/min; it previously was also normal at > 90 mL/min. We know from her labs early in her treatment that she is HLA-B*5701 negative.

Key Considerations
When I was considering what I should prescribe for ARV medications, I was a bit concerned about restarting EFV/FTC/TDF. In fact, I would be concerned about prescribing any regimen including TDF, given her reduced CrCl.

The other coformulated regimens that do not contain TDF include dolutegravir (DTG)/abacavir (ABC)/lamivudine (3TC), rilpivirine (RPV)/FTC/tenofovir AF (TAF), or elvitegravir (EVG)/cobicistat (COBI)/FTC/TAF. I have a small concern with each of these, but not so great a concern to eliminate them from consideration. Many papers have been published on the potential cardiovascular issues related to ABC. Some of them have found an association between use of ABC and increased risk of myocardial infarction; others have not. Given that this patient has only moderately elevated blood pressure and has not had a recent myocardial infarction, I am less concerned about this, but I certainly would monitor her closely if I chose this regimen. With the EVG/COBI/FTC/TAF coformulated choice, one would have to consider any potential drug–drug interactions between COBI and other medications the patient is receiving. In the absence of potential interactions, this regimen would be appropriate for this patient. RPV/FTC/TAF would also be a reasonable option, but I would likely favor an INSTI-based regimen, given that INSTIs are preferred over NNRTIs in current US initial ART guidelines.

Another option that I would suggest—if the patient were to consent to 2 once-daily pills—is DTG plus FTC/TAF. Use of this regimen obviates the concerns related to the other 2 regimens and TAF is associated with less effect on renal function than TDF. I would show the patient the pills (they are both small) and see if this is an adjustment she could make along with the other new medications in her life. In the end, however, I would let her make the choice among these options.

Multiple comorbidities are things we all deal with among our aging patients. How do you work with your patients to choose the best regimens? I’m interested in your comments below.

Continue

Poll

1.
Which of the following switch regimens would you recommend for a middle-aged black woman receiving suppressive EFV/FTC/TDF who has developed moderate renal impairment and elevated cardiovascular disease risk?
Submit