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Co-Infection with active TB

  • 1.  Co-Infection with active TB

    Posted 05-06-2020 17:24
    ​Good afternoon all.

    I have a new to me HIV patient who is co-infected with TB. sputums are now negative. Diagnosed in 2013, but never started medications. I did rapid start with Biktarvy, but when the Rifampen and Isoniazid were started his liver enzymes skyrocket. I held Rifampen and Isoniazid for 2 weeks per ID recommendation, liver enzymes normalized.

    My question or I am looking for recommendations for treatment options. Patient has been compliant with medications and is almost undetectable at this time.

    Thank you for the guidance and recommendations.

    Shannon Stewart, ARNP, AAHIV
    Siouxland Community Health Center
    Sioux City, Iowa

  • 2.  RE: Co-Infection with active TB

    Posted 05-07-2020 09:43
    Hi Shannon - there is a major drug drug interaction between Biktarvy (CONTRAINDICATED with bictegravir and aovid use with TAF). I actually dont think that is the reason the LFTs bumped as INH and RIF together can cause that which is why they should be monitored closely and close attention to dosing is important, however I would look for an alternative to the antiretroviral. What we have done in our office is done BID Tivicay with either Truvada or Epzicom (so we have done Triumeq QD and Tivicay 12 hr after triumeq) and use Rifabutin and NOT rifampin. I would suggest getting an AAHIVP PharmD involved in this case to mitigate any DDI issues.

    Angela Kapalko
    Physician Assistant Chairperson for AAHIVM
    Philadelphia FIGHT CommunityHealth Centers
    Philadelphia PA

  • 3.  RE: Co-Infection with active TB

    Posted 05-07-2020 20:38
    Hi Shannon,

    We typically use DTG dosed twice daily plus FTC/TDF for our HIV/TB co-infected patients. You could also swap PZA for Moxi which is a less offensive to the liver but I definitely suggest consulting with a PharmD who is experienced in managing TB/HIV. How many days of full RIPE did he get in before the liver enzymes went up? Just curious, when you said sputums are now negative do you mean actual AFB cultures or the smears? 

    Thank you for sharing the case and for the learning opportunity.

    Gina Tomkus
    San Diego CA

  • 4.  RE: Co-Infection with active TB

    Posted 05-15-2020 20:32
    The federally-funded National HIV Curriculum's Latent Tuberculosis Infection has extensive treatment options for you to consider.  

    BTW, If you register on the site, you can also earn free CNE and we also offer a lot of free pharmacology CE for advanced practice nurses.

    Julia Freimund
    National HIV Curriculum, University of Washington Infectious Diseases Education and Assessment (IDEA) Program

  • 5.  RE: Co-Infection with active TB

    Posted 05-16-2020 14:43
    Great. Thank you for the information!

    Sent from my Verizon, Samsung Galaxy smartphone

  • 6.  RE: Co-Infection with active TB

    Posted 05-18-2020 11:10
    I think the sudden elevation of liver enzymes is due to IRIS(Immune reconstitution and  inflammatory syndrome)

    Pa Bojang