Academy Exchange

Good afternoon! 

We have a complicated situation on our hands. We have a patient who has been out of care ~15 months. He was getting HD TIW and transitioned to daily PD at home the last time we saw him in clinic. His regimen at the time was changed to DTG 50mg daily, ABC 600mg daily, and 3TC 25mg daily (on BIC/FTC/TAF until he transitioned to PD). He was recently admitted for osteomyelitis and ESRD (since out of care, he was transitioned back to HD TIW but is not getting as scheduled). He now has cirrhosis and is requiring paracentesis at least weekly. He reports no missed doses due to being in and out of the hospital over the last 15 months and has been getting scripts written at discharge. Last viral load obtained by hospitalist was 120 copies/mL in September - no viral load drawn since 8/2023 other than this. Drew while in clinic yesterday but still pending.

We have plenty of options for ESRD but his ESLD really complicates the picture. From what I can gather with DHHS guidelines, the best options given the hepatic complications include FTC, TDF, FTV, and T-20. All the NNRTIs and INSTIs are either not studied in hepatic failure or recommend against use. Ritonavir boosting is not recommended in patients with hepatic impairment and cobicistat has not been studied either.

We have one genotype from when he entered care - only mutation relevant would be K101E resulting in moderate resistance to NVP and RPV. 

Most viable regimen I can come up with is FTV 600mg BID, FTC 200mg q96h (looks like we can do 200mg daily and just monitor side effects more frequently?), and TDF 300mg weekly.

Can we even get FTV considering lack of drug resistance and that he is not failing his current regimen? Are we stuck trying to use Fuzeon? This patient has medicaid which may complicate things as well. 

Does anybody have experience with this situation? Any insight would be much appreciated.

Happy thanksgiving… great case… what I would do is DTG and DOR full strength of each. I love this combination and think that if you were to monitor them closer this would be the best option with least interactions.  I think fuzeon has been discontinued… and honestly the regimen you came up with is likely appropriate but is very complicated and improper dosing will lead to resistance… two pills once a day is much easier! Good luck!

Good afternoon! 

We have a complicated situation on our hands. We have a patient who has been out of care ~15 months. He was getting HD TIW and transitioned to daily PD at home the last time we saw him in clinic. His regimen at the time was changed to DTG 50mg daily, ABC 600mg daily, and 3TC 25mg daily (on BIC/FTC/TAF until he transitioned to PD). He was recently admitted for osteomyelitis and ESRD (since out of care, he was transitioned back to HD TIW but is not getting as scheduled). He now has cirrhosis and is requiring paracentesis at least weekly. He reports no missed doses due to being in and out of the hospital over the last 15 months and has been getting scripts written at discharge. Last viral load obtained by hospitalist was 120 copies/mL in September - no viral load drawn since 8/2023 other than this. Drew while in clinic yesterday but still pending.

We have plenty of options for ESRD but his ESLD really complicates the picture. From what I can gather with DHHS guidelines, the best options given the hepatic complications include FTC, TDF, FTV, and T-20. All the NNRTIs and INSTIs are either not studied in hepatic failure or recommend against use. Ritonavir boosting is not recommended in patients with hepatic impairment and cobicistat has not been studied either.

We have one genotype from when he entered care - only mutation relevant would be K101E resulting in moderate resistance to NVP and RPV. 

Most viable regimen I can come up with is FTV 600mg BID, FTC 200mg q96h (looks like we can do 200mg daily and just monitor side effects more frequently?), and TDF 300mg weekly.

Can we even get FTV considering lack of drug resistance and that he is not failing his current regimen? Are we stuck trying to use Fuzeon? This patient has medicaid which may complicate things as well. 

Does anybody have experience with this situation? Any insight would be much appreciated.

Happy thanksgiving… great case… what I would do is DTG and DOR full strength of each. I love this combination and think that if you were to monitor them closer this would be the best option with least interactions.  I think fuzeon has been discontinued… and honestly the regimen you came up with is likely appropriate but is very complicated and improper dosing will lead to resistance… two pills once a day is much easier! Good luck!

Good afternoon! 

We have a complicated situation on our hands. We have a patient who has been out of care ~15 months. He was getting HD TIW and transitioned to daily PD at home the last time we saw him in clinic. His regimen at the time was changed to DTG 50mg daily, ABC 600mg daily, and 3TC 25mg daily (on BIC/FTC/TAF until he transitioned to PD). He was recently admitted for osteomyelitis and ESRD (since out of care, he was transitioned back to HD TIW but is not getting as scheduled). He now has cirrhosis and is requiring paracentesis at least weekly. He reports no missed doses due to being in and out of the hospital over the last 15 months and has been getting scripts written at discharge. Last viral load obtained by hospitalist was 120 copies/mL in September - no viral load drawn since 8/2023 other than this. Drew while in clinic yesterday but still pending.

We have plenty of options for ESRD but his ESLD really complicates the picture. From what I can gather with DHHS guidelines, the best options given the hepatic complications include FTC, TDF, FTV, and T-20. All the NNRTIs and INSTIs are either not studied in hepatic failure or recommend against use. Ritonavir boosting is not recommended in patients with hepatic impairment and cobicistat has not been studied either.

We have one genotype from when he entered care - only mutation relevant would be K101E resulting in moderate resistance to NVP and RPV. 

Most viable regimen I can come up with is FTV 600mg BID, FTC 200mg q96h (looks like we can do 200mg daily and just monitor side effects more frequently?), and TDF 300mg weekly.

Can we even get FTV considering lack of drug resistance and that he is not failing his current regimen? Are we stuck trying to use Fuzeon? This patient has medicaid which may complicate things as well. 

Does anybody have experience with this situation? Any insight would be much appreciated.

Happy thanksgiving… great case… what I would do is DTG and DOR full strength of each. I love this combination and think that if you were to monitor them closer this would be the best option with least interactions.  I think fuzeon has been discontinued… and honestly the regimen you came up with is likely appropriate but is very complicated and improper dosing will lead to resistance… two pills once a day is much easier! Good luck!

Good afternoon! 

We have a complicated situation on our hands. We have a patient who has been out of care ~15 months. He was getting HD TIW and transitioned to daily PD at home the last time we saw him in clinic. His regimen at the time was changed to DTG 50mg daily, ABC 600mg daily, and 3TC 25mg daily (on BIC/FTC/TAF until he transitioned to PD). He was recently admitted for osteomyelitis and ESRD (since out of care, he was transitioned back to HD TIW but is not getting as scheduled). He now has cirrhosis and is requiring paracentesis at least weekly. He reports no missed doses due to being in and out of the hospital over the last 15 months and has been getting scripts written at discharge. Last viral load obtained by hospitalist was 120 copies/mL in September - no viral load drawn since 8/2023 other than this. Drew while in clinic yesterday but still pending.

We have plenty of options for ESRD but his ESLD really complicates the picture. From what I can gather with DHHS guidelines, the best options given the hepatic complications include FTC, TDF, FTV, and T-20. All the NNRTIs and INSTIs are either not studied in hepatic failure or recommend against use. Ritonavir boosting is not recommended in patients with hepatic impairment and cobicistat has not been studied either.

We have one genotype from when he entered care - only mutation relevant would be K101E resulting in moderate resistance to NVP and RPV. 

Most viable regimen I can come up with is FTV 600mg BID, FTC 200mg q96h (looks like we can do 200mg daily and just monitor side effects more frequently?), and TDF 300mg weekly.

Can we even get FTV considering lack of drug resistance and that he is not failing his current regimen? Are we stuck trying to use Fuzeon? This patient has medicaid which may complicate things as well. 

Does anybody have experience with this situation? Any insight would be much appreciated.

I like DTG + DOR as well. Some possible resistance to the DOR with the K101E (score of 10 via Stanford) but a much simpler regimen option. Thank you!

Happy thanksgiving… great case… what I would do is DTG and DOR full strength of each. I love this combination and think that if you were to monitor them closer this would be the best option with least interactions.  I think fuzeon has been discontinued… and honestly the regimen you came up with is likely appropriate but is very complicated and improper dosing will lead to resistance… two pills once a day is much easier! Good luck!

Good afternoon! 

We have a complicated situation on our hands. We have a patient who has been out of care ~15 months. He was getting HD TIW and transitioned to daily PD at home the last time we saw him in clinic. His regimen at the time was changed to DTG 50mg daily, ABC 600mg daily, and 3TC 25mg daily (on BIC/FTC/TAF until he transitioned to PD). He was recently admitted for osteomyelitis and ESRD (since out of care, he was transitioned back to HD TIW but is not getting as scheduled). He now has cirrhosis and is requiring paracentesis at least weekly. He reports no missed doses due to being in and out of the hospital over the last 15 months and has been getting scripts written at discharge. Last viral load obtained by hospitalist was 120 copies/mL in September - no viral load drawn since 8/2023 other than this. Drew while in clinic yesterday but still pending.

We have plenty of options for ESRD but his ESLD really complicates the picture. From what I can gather with DHHS guidelines, the best options given the hepatic complications include FTC, TDF, FTV, and T-20. All the NNRTIs and INSTIs are either not studied in hepatic failure or recommend against use. Ritonavir boosting is not recommended in patients with hepatic impairment and cobicistat has not been studied either.

We have one genotype from when he entered care - only mutation relevant would be K101E resulting in moderate resistance to NVP and RPV. 

Most viable regimen I can come up with is FTV 600mg BID, FTC 200mg q96h (looks like we can do 200mg daily and just monitor side effects more frequently?), and TDF 300mg weekly.

Can we even get FTV considering lack of drug resistance and that he is not failing his current regimen? Are we stuck trying to use Fuzeon? This patient has medicaid which may complicate things as well. 

Does anybody have experience with this situation? Any insight would be much appreciated.

Hi Jacob,

Be careful with DTG.  I imagine your patient has advanced liver disease if he requires regular paracentesis.   Per the guidelines below, DTG is "not recommended" in those with Child-Pugh class C.   I am not sure why.  There may just not be enough data in this patient population.   Raltegravir has a "no recommendation" rating.

Appendix B: Antiretroviral Dosing in Adults with Renal or Hepatic Insufficiency | NIH

I like DTG + DOR as well. Some possible resistance to the DOR with the K101E (score of 10 via Stanford) but a much simpler regimen option. Thank you!

Happy thanksgiving… great case… what I would do is DTG and DOR full strength of each. I love this combination and think that if you were to monitor them closer this would be the best option with least interactions.  I think fuzeon has been discontinued… and honestly the regimen you came up with is likely appropriate but is very complicated and improper dosing will lead to resistance… two pills once a day is much easier! Good luck!

Good afternoon! 

We have a complicated situation on our hands. We have a patient who has been out of care ~15 months. He was getting HD TIW and transitioned to daily PD at home the last time we saw him in clinic. His regimen at the time was changed to DTG 50mg daily, ABC 600mg daily, and 3TC 25mg daily (on BIC/FTC/TAF until he transitioned to PD). He was recently admitted for osteomyelitis and ESRD (since out of care, he was transitioned back to HD TIW but is not getting as scheduled). He now has cirrhosis and is requiring paracentesis at least weekly. He reports no missed doses due to being in and out of the hospital over the last 15 months and has been getting scripts written at discharge. Last viral load obtained by hospitalist was 120 copies/mL in September - no viral load drawn since 8/2023 other than this. Drew while in clinic yesterday but still pending.

We have plenty of options for ESRD but his ESLD really complicates the picture. From what I can gather with DHHS guidelines, the best options given the hepatic complications include FTC, TDF, FTV, and T-20. All the NNRTIs and INSTIs are either not studied in hepatic failure or recommend against use. Ritonavir boosting is not recommended in patients with hepatic impairment and cobicistat has not been studied either.

We have one genotype from when he entered care - only mutation relevant would be K101E resulting in moderate resistance to NVP and RPV. 

Most viable regimen I can come up with is FTV 600mg BID, FTC 200mg q96h (looks like we can do 200mg daily and just monitor side effects more frequently?), and TDF 300mg weekly.

Can we even get FTV considering lack of drug resistance and that he is not failing his current regimen? Are we stuck trying to use Fuzeon? This patient has medicaid which may complicate things as well. 

Does anybody have experience with this situation? Any insight would be much appreciated.