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VIRTUAL MEDZONE

VIRTUAL MEDZONE. Your Resource for HIV Related Innovative Medical Communication. HIV CASE PRESENTATIONS. Roger Leblanc MD FRCPC Joss DeWet MBChB CCFP David Fletcher MD FRCPC. CASE 1 . 31 yo man HIV+ mid 2008 Clade B CD4 1130/38%, VL 100,000-200,000 Genotype clear. CASE 1.

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VIRTUAL MEDZONE

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  1. VIRTUAL MEDZONE Your Resource for HIV Related Innovative Medical Communication

  2. HIV CASE PRESENTATIONS Roger Leblanc MD FRCPC Joss DeWetMBChB CCFP David Fletcher MD FRCPC

  3. CASE 1 • 31 yo man • HIV+ mid 2008 • Clade B • CD4 1130/38%, • VL 100,000-200,000 • Genotype clear

  4. CASE 1 BASELINE GENOTYPE JUL/08

  5. CASE 1 Late 2009…1 year later • VL >500,000 • CD4 down to 440/22% • Feeling weak/tired

  6. CASE 1 Late 2009 • Initiated TDF/FTC/EFV/RTV/LPV as induction therapy given high viral load and precipitous decline in CD4 from over 1100 1 year previously

  7. CASE 1 Late 2009 • Diarrhea/vomiting/abdominal pain and anorexia • Unable to tolerate therapy • RTV/LPV discontinued from regime within first week • continued TDF/FTC/EFV

  8. CASE 1 Late 2009 • Began to feel much improved from a GI standpoint so RTV/Darunavir added to TDF/FTC/ EFV • Nausea/vomiting restarted so RTV/DRV discontinued within 1 wk

  9. CASE 1 1 MONTH into therapy…TDF/FTC/EFV • CD4 440/22% → 840/31% • VL >500,000 → 1659 c/ml

  10. CASE 1 2 Months into therapy…TDF/FTC/EFV • CD4 730/28% • VL 1659 → 2085 WHAT WOULD YOU DO?

  11. CASE 1 • Persisted with TDF/FTC/EFV and was adherent by history

  12. CASE 1 GENOTYPE JAN/10

  13. CASE 1 GENOTYPE JAN/10

  14. CASE 1 TROPISM JAN/10

  15. CASE 1 MAY 2010 • Raltegravir added to TDF/FTC/EFV • Tolerated well/no problems

  16. CASE 1 JUNE 2010 • TDF/FTC/EFV/RGV • CD4 1010/36% • VL 918 WHAT WOULD YOU DO?

  17. CASE 1 GENOTYPE JUN/10

  18. CASE 1 GENOTYPE JUN/10

  19. CASE 1 GENOTYPE JUN/10

  20. CASE 1 JUNE 2010 • TDF/FTC/EFV/RGV… tolerating well • TDM…adequate levels of medication WHAT WOULD YOU DO?

  21. CASE 1 AUGUST 2010 • Regimen switched to TDF/FTC/RGV/RTV/fAPV/MVC

  22. CASE 1 OCTOBER 2010 • Regimen switched to TDF/FTC/RGV/ETR/RTV/DRV

  23. CASE 1 NOVEMBER 2010 • Tolerating TDF/FTC/RGV/ETR/RTV/DRV • Maraviroc added WHAT WOULD YOU DO?

  24. CASE 1 FEBRUARY 2011 • 3 months of TDF/RGV/ETR/RTV/DRV/ MVC • TDM of RGV + DRV shows no RGV level and low DRV levels • Readjusted DRV dose and of course reinforced adherence

  25. CASE 1 GENOTYPE JAN/11

  26. CASE 1 MARCH 2011 • Checked pharmacy log → all pills picked up at appropriate times • Repeat TDM → therapeutic levels of all medications

  27. CASE 1 MAY 2011 • TDF/FTC/RGV/ETR/RTV/DRV/MVC WHAT WOULD YOU DO?

  28. CASE 1 MAY 2011 • Regimen simplified to TDF/FTC//RTV/DRV Is this an issue related to patient, virus, or Inadequate immune control?

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