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IRIS Risk Factors in People with Advanced HIV - Clinical Research Update 9.15.2020

  • 1.  IRIS Risk Factors in People with Advanced HIV - Clinical Research Update 9.15.2020

    Posted 09-15-2020 11:10
    A study about the risk factors for Immune Reconstitution Inflammatory Syndrome in people with advanced HIV disease is the subject of this week's Clinical Research Update.  While we are seeing fewer patients with advanced AIDS, this study suggests some strategies for identifying risk for IRIS for those that do present to our clinics.

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    Jeffrey Kirchner
    Lancaster General Health Physicians (LGHP) - Comprehensive Care
    Lancaster PA
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  • 2.  RE: IRIS Risk Factors in People with Advanced HIV - Clinical Research Update 9.15.2020

    Posted 08-10-2021 10:01
    Hello, 
    I wonder if you might be able to comment about one of my challenging patients:
    JL is an AA M in his early 50's, Dx'd with HIV in or before 2012 (as far as current records are available). nonadherence to HIV meds. 
    CD4s most recently 75, but have ranged from 166 (in 2019) to 4 (in 2017);  HIV Viral Loads most recently 329,000, and ranging from ~100-300k, with a nadir of 120 in 2019, and Not Detectable in 2017. VL bounce back up due to his non-adherence to meds. Most recent HBG 10.9. C-RP pending.

    Besides OI suppressive therapy (azithro for MAC, bactrim for PCP/PJ, fluconazole for crypto, and valacyclovir for HSV/VZ.  ARTs over the last 10 years have included: Norvir, Reyataz, Truvada, Stribild, Prezista, Isentress, and most recently, Prezcobix & Tivicay.  He also takes amlodipine and atorvastatin for HTN and DLD, respectively, and misses doses as well (with less severe consequences!). 

    Just completed his HAV/HBV and pneumo 23 vax series, but has not yet had COVID vax, but uncertain of it's effectiveness due to his immune status. Nonetheless, will try to schedule him for injection. 

    We are concerned about potential risk for IRIS, if we can actually get him to remain on meds (such as Biktarvy) consistently.  He has "no time" for hospitalization for induction of therapy, but since IRIS can occur anytime up to 6 months following reinstitution of ART, am not sure whether that represent a significant concern.  

    Any suggestions for an effective approach? Should we subject him to therapy given his risk for IRIS?  He is also resistant to behavioral therapy.  

    Best wishes, 
    --Mark P Behar, PA-C

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    Mark Behar
    Milwaukee Health Services
    Milwaukee WI
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  • 3.  RE: IRIS Risk Factors in People with Advanced HIV - Clinical Research Update 9.15.2020

    Posted 08-10-2021 15:46
    I've never heard of anyone being hospitalized just in case they get IRIS, and I doubt you could get coverage for that hospitalization. This man's greatest risk is not IRIS, but death from AIDS if he remains untreated. You can always deal with IRIS if it happens.

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    Joel Gallant, MD, MPH
    Santa Fe, NM
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  • 4.  RE: IRIS Risk Factors in People with Advanced HIV - Clinical Research Update 9.15.2020

    Posted 08-12-2021 11:50
    I dont have a recommendation re: iris prevention other than you need to be a look out for it - but question:  did the pt have crypto to start with?  I personally have never put someone on crypto prophylaxis if they did not have crypo and prophylaxis for HSV?  What was your rationale here with this prophylaxis?

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    Sara Back
    North Central Bronx Hospital
    New York NY
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  • 5.  RE: IRIS Risk Factors in People with Advanced HIV - Clinical Research Update 9.15.2020

    Posted 08-12-2021 15:56

    I wouldn't worry about IRIS. While you are right to think about the possibility, it is not common, and should not be an impediment to treat the HIV. I would not prophylax against CMV as you are doing. That practice recommendation changed a few years ago no longer advising it. And glad you are providing Covid vaccine. A third shot of mRNA vaccine will likely be recommended when CDC updates their guidance. 

    Gary



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    Gary F. Spinner PA,MPH,AAHIVS
    Medical Director
    Ryan White HIV/AIDS Program
    Southwest Community Health Center
    Bridgeport, CT
    gspinner@swchc.org
    Gary.spinner@aya.yale.edu
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  • 6.  RE: IRIS Risk Factors in People with Advanced HIV - Clinical Research Update 9.15.2020

    Posted 08-17-2021 23:22
    To add to other comments- unsure of the need for all that prophylaxis unless pt actually has the disease. Bactrim - sure for PCP. Azithro - sure for MAC (that guideline also changed once the pt is successfully stays on ARVs). As Joel said, his biggest risk is death from AIDS and IRIS can be dealt with. I would follow this pt very closely, monitor kidney function on Bactrim etc. and keep them engaged - that's the most important agenda.

    Also to be honest, I would have waited to vaccinate him for HAV/HBV till cd4 builds up more so he can actually mount immunity. Since you already did I would check immunity in few months. If not immune, I would wait to vaccinate till his counts increase and have an immune system. Other vaccines like PCV13, PPSv23 (which you did) and Menactra are important ones to give now. 

    Amit

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    Amit Dhir, CRNP, MSN, MBA, AAHIVS
    Staff Nurse Practitioner
    O: 410-837-2050 x 1161 I C: 860-965-4458 I F: 443-573-5022 I E: adhir@chasebrexton.org
    Pronouns: He/him/his
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  • 7.  RE: IRIS Risk Factors in People with Advanced HIV - Clinical Research Update 9.15.2020

    Posted 09-25-2021 12:06
    He is on a lot of preventative medications. I am assuming he has cryptococcus via a positive crypto latex antigen and you are consistently monitoring his titers? Biktarvy and Bactrim DS should suffice unless he has very symptomatic Herpes 1,2; or Herpes 5(CMV) with symptomatic response such as photo sensitivity headaches lymphadenopathy a very low EIPS score of 4 or below (malaise) etc. ARV consistently reduces the risk of developing these opportunistic infections. Bactrim DS would be the most appropriate prophylaxis only, if the patient doesn't have other markers such as crypto or CMV. Applying all of these medications can increase the risk of pill exhaustion just coming out of the gate. That and other risks associated with adverse effects of which medication they perceive to be causing problems.

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    Amber Siegel DNP AAHIVS
    Crew Healthcare
    Orlando, Florida
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  • 8.  RE: IRIS Risk Factors in People with Advanced HIV - Clinical Research Update 9.15.2020

    Posted 09-26-2021 16:16
    Hi 
    IRIS definition itself requires CD4 cells to increase and decrease in Viral load >1log10 copies/ml  including the parodoxical worsening of a pre-existing infection or
    presentation ( called unmasking) of previously undiagnosed condition in HIV soon after the commencement of ART ,mostly within weeks or months
    In this case  the viral load has increased and CD4 has consistently decreased , so we are not dealing with  an IRIS .
    What we need to do to improve his adherence and do a  Resistance test (Here Genotype Resistance test ) as the patient is highly ART Experienced   and then accordingly pick ARVs  .
    Given his CD4 being 75, he must be persuaded to take Covid Vaccine .
    Hope it helps 
    Dr Matin Ahmad Khan
    MBBS,MPH ,MMSc (HIV Med) PhD (HIV Med) 
    Fellowship in HIV Med, AAHIVS ( USA )

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    Matin Ahmad Khan
    MGM Medical College, Jamshedpur
    Jamshedpur
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  • 9.  RE: IRIS Risk Factors in People with Advanced HIV - Clinical Research Update 9.15.2020

    Posted 09-26-2021 02:06
    Edited by Ahmad Akbar Sapie 09-26-2021 02:07
    I would recommend prophylaxis based on CD4 counts (cell/mm3):
    1.  < 200 for PCP = Bactrim or alternatively Dapsone (check G6PD deficiency)
    2. <100 for toxoplasmosis = Bactrim
    3. < 50 for Mycabacterium = azithromycin

    Is prednisone proved efficacy as IRIS-prophylaxis?

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    Akbar Jaya
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  • 10.  RE: IRIS Risk Factors in People with Advanced HIV - Clinical Research Update 9.15.2020

    Posted 09-26-2021 20:09
    Primary MAC prophylaxis is not recommended anymore in the OI guidelines because people at risk for MAC will be started immediately on ART, resulting in a rapid rise in CD4 count and a sharp reduction in risk. Starting a macrolide in addition to ART could lead to side effects that might be falsely attributed to the ART, which could adversely affect adherence.  In a case like this, it's far more important that the patient take ART than MAC prophylaxis.  Getting him to take any meds at all is obviously a challenge, so you'd want to focus on what's most important.

    As for specific Toxoplasmosis prophylaxis, it's indicated only for those with CD4 <100 and a positive anti-Toxoplasma IgG.  However, someone on double-strength TMP/SMX once a day for PCP prophylaxis is already covered, so the recommendation is relevant mainly for someone on a lower dose for PCP prevention.

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    Joel Gallant, MD, MPH
    Santa Fe, NM
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  • 11.  RE: IRIS Risk Factors in People with Advanced HIV - Clinical Research Update 9.15.2020

    Posted 09-29-2021 21:27

    For patients with IRIS, NSAIDs should suffice, but if after 4-6 weeks of increased symptomatic IRIS one could prescribe corticosteroids.  I was under the impression that were no longer supporting MAC prophylaxis. Symptomatic MAC Avium treated with Zithromax or Clarithromycin would be a different story. 

    Amber 



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    Amber Siegel DNP AAHIVS
    Crew Healthcare
    Orlando, Florida
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