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ART choice in cirrhosis

  • 1.  ART choice in cirrhosis

    Posted 12-11-2020 10:30
    Edited by Elliot Goodenough 12-11-2020 11:10
    It seems like many ARVs haven't been well studied in cirrhotic patients. But I'm often using them anyway in compensated cirrhosis, despite warnings. I've seen a few studies mildly reassuring about certain meds, e.g. RAL, but mixed reviews even about TDF/TAF. So, other than ABC, what ARVs are to be avoided in cirrhosis?

    Here's my current case:
    HIV+ man in his late 60s with complex medical hx - incl HF with pulmonary hypertension (on sildenafil), severe emphysema, and stable cirrhosis with encephalopathy, esophageal varices (on PPI), icterus, and thrombocytopenia (now s/p HCV tx and sober). HIV well controlled on Intelence/Isentress/Prezista/norvir x 10+ years and interested in simplifying. Past genotype includes 184V, 67N, 70R, 219Q and 84V, 90M.

    I don't see a perfect option. He's been on DRV and several meds w RTV/CYP3 interactions (sildenafil, inhaled corticosteroid, tamsulosin) x years, so maybe I could keep DRV and switch booster to cobi? But probably better to stop the PI+booster given these interactions...?

    Maybe DOR instead of ETR? Keep RAL (or could I switch to a once a day INSTI)? And add TAF/FTC (TAF likely to have some activity)?

    Hm... Thanks for any wisdom. I'm still learning.

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    Elliot Goodenough
    Philadelphia PA
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  • 2.  RE: ART choice in cirrhosis

    Posted 12-11-2020 15:36

    Elliot,

     

    I don't know if your patient has HCV but perhaps this lesson, Treatment of HCV in Persons with HIV Coinfection, in our 100% CDC-funded Hepatitis C Online curriculum might prove helpful for you.  Our 100% HRSA-funded National HIV Curriculum lesson, Hepatitis C Coinfection, also discusses treatment options and ART interactions.  Both sites offer free CME, CNE, and CE contact hours. 

     

    Julia






  • 3.  RE: ART choice in cirrhosis

    Posted 12-11-2020 17:32
    Hi Elliot,

    I'm in Infectious Diseases in Philadelphia. I believe we were classmates at Jefferson too. Based on the information you provided, I believe the best single-tablet regimen for your patient to be BIC/TAF/FTC. You'd definitely want to use the M184V to your advantage by using Tenofovir. The INSTI is preferred over the PI since you also have an 84V mutation. There are several studies showing the use of TAF in patients with Hep B and cirrhosis is safe. Since we do not have sufficient data of BIC use in patients with Child-Pugh class C, you would probably want to monitor the LFTs more closely. Hope that helps.

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    Regards,
    Qi Quan Leong
    Philadelphia, PA
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  • 4.  RE: ART choice in cirrhosis

    Posted 12-11-2020 19:12
    Yes, thanks! I've used Biktarvy in pts with less severe cirrhosis and was considering it for this pt. I expected to need another med (e.g. DOR) because of those TAMS, but is that not necessary? I did see a recent study* that was encouraging on that point...

    So, my general impression has been that we're ok trying most STRs in cirrhosis (while monitoring symptoms and LFTs)...

    Thanks again!
    elliot

    *Margot et al. Antimicrob Agents Chemother. 2020 Mar 24;64(4):e02557-19.

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    Elliot Goodenough
    Philadelphia PA
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  • 5.  RE: ART choice in cirrhosis

    Posted 12-12-2020 16:29
    I have had a couple of patients with liver disease in which I have used Odefsey. There are no use limitations for Child Pugh class A,B,or C however, I do not believe it was studied in Child Pugh Class C and neither of my patients had decompensated Cirrhosis. One of these patients could not tolerate Biktarvy at all, that's when the trouble started. Anyway, it's something to keep in your back pocket.

    Amber.

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    Amber Siegel MSN APRN AGNP-C
    Orlando, Florida
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