Academy Exchange

Greetings, esteemed colleagues,

I would like to seek your valuable insights regarding a case involving non-occupational post-exposure prophylaxis (nPEP) for a patient who recently sought medical assistance at my clinic. The individual in question is a sexually active man who engaged in sexual activity with a partner of unknown HIV status, posing a potential risk. The encounter took place within the past 72 hours, and the patient is seeking immediate nPEP treatment.

Presently, the patient is receiving phenytoin for epilepsy management, with his most recent epileptic episode occurring seven months ago. However, referring him back to his previous neurologist for a medication change would likely result in a delay that exceeds the appropriate time frame for initiating nPEP. Given this situation, I am seeking your expert opinions on the most suitable nPEP regimen for this patient.

Initially, I considered initiating a combination of Tenofovir Disoproxil Fumarate (TDF), Emtricitabine (FTC), and Dolutegravir (DTG) for his nPEP treatment. However, I am aware that coadministration of DTG, a UGT1A1 inducer, and phenytoin, a UGT1A1 substrate, may necessitate dosage adjustments or alternative options. Therefore, I kindly request any suggestions or comments you may have to navigate this particular situation.

As a temporary solution, I have already prescribed TDF/FTC/DTG to the patient while strongly urging him to promptly visit his neurologist to explore the possibility of transitioning to levetiracetam, which does not exhibit known interactions with DTG or other antiretroviral medications. I have emphasized the importance of this medication change and the urgency of the situation.

I humbly request your valuable expertise and insights to ensure optimal management of this patient, effectively addressing his HIV risk while considering his epilepsy treatment requirements.

Thank you sincerely for your attention and support.

Best regards,
Nuntana Chumpa, MD 
Bangkok, Thailand

Hi Dr. Chumpa,

I would consider Dolutegravir twice a day with the TDF/FTC, to play it conservatively. Just not sure whether this is only available in coformulation in your country or if you can get dolutegravir as a single agent (and either dose with TDF/FTC/DTG at different time in day).

Greetings, esteemed colleagues,

I would like to seek your valuable insights regarding a case involving non-occupational post-exposure prophylaxis (nPEP) for a patient who recently sought medical assistance at my clinic. The individual in question is a sexually active man who engaged in sexual activity with a partner of unknown HIV status, posing a potential risk. The encounter took place within the past 72 hours, and the patient is seeking immediate nPEP treatment.

Presently, the patient is receiving phenytoin for epilepsy management, with his most recent epileptic episode occurring seven months ago. However, referring him back to his previous neurologist for a medication change would likely result in a delay that exceeds the appropriate time frame for initiating nPEP. Given this situation, I am seeking your expert opinions on the most suitable nPEP regimen for this patient.

Initially, I considered initiating a combination of Tenofovir Disoproxil Fumarate (TDF), Emtricitabine (FTC), and Dolutegravir (DTG) for his nPEP treatment. However, I am aware that coadministration of DTG, a UGT1A1 inducer, and phenytoin, a UGT1A1 substrate, may necessitate dosage adjustments or alternative options. Therefore, I kindly request any suggestions or comments you may have to navigate this particular situation.

As a temporary solution, I have already prescribed TDF/FTC/DTG to the patient while strongly urging him to promptly visit his neurologist to explore the possibility of transitioning to levetiracetam, which does not exhibit known interactions with DTG or other antiretroviral medications. I have emphasized the importance of this medication change and the urgency of the situation.

I humbly request your valuable expertise and insights to ensure optimal management of this patient, effectively addressing his HIV risk while considering his epilepsy treatment requirements.

Thank you sincerely for your attention and support.

Best regards,
Nuntana Chumpa, MD 
Bangkok, Thailand

Greetings, esteemed colleagues,

I would like to seek your valuable insights regarding a case involving non-occupational post-exposure prophylaxis (nPEP) for a patient who recently sought medical assistance at my clinic. The individual in question is a sexually active man who engaged in sexual activity with a partner of unknown HIV status, posing a potential risk. The encounter took place within the past 72 hours, and the patient is seeking immediate nPEP treatment.

Presently, the patient is receiving phenytoin for epilepsy management, with his most recent epileptic episode occurring seven months ago. However, referring him back to his previous neurologist for a medication change would likely result in a delay that exceeds the appropriate time frame for initiating nPEP. Given this situation, I am seeking your expert opinions on the most suitable nPEP regimen for this patient.

Initially, I considered initiating a combination of Tenofovir Disoproxil Fumarate (TDF), Emtricitabine (FTC), and Dolutegravir (DTG) for his nPEP treatment. However, I am aware that coadministration of DTG, a UGT1A1 inducer, and phenytoin, a UGT1A1 substrate, may necessitate dosage adjustments or alternative options. Therefore, I kindly request any suggestions or comments you may have to navigate this particular situation.

As a temporary solution, I have already prescribed TDF/FTC/DTG to the patient while strongly urging him to promptly visit his neurologist to explore the possibility of transitioning to levetiracetam, which does not exhibit known interactions with DTG or other antiretroviral medications. I have emphasized the importance of this medication change and the urgency of the situation.

I humbly request your valuable expertise and insights to ensure optimal management of this patient, effectively addressing his HIV risk while considering his epilepsy treatment requirements.

Thank you sincerely for your attention and support.

Best regards,
Nuntana Chumpa, MD 
Bangkok, Thailand

Hi Dr. Chumpa:

A couple of questions I have re: your case.  What was the sexual activity in question?  Was it receptive anal intercourse or insertive, or oral sex?  So I think DTG is fine, but I would dose it BID with Phenytoin for nPEP for the month.  See Liverpool interaction comment: "Coadministration has not been studied but is expected to decrease dolutegravir exposure due to induction of UGT1A1 and CYP3A by phenytoin. Interaction studies with dolutegravir and rifampicin (a strong inducer) showed that the effect of induction on dolutegravir concentrations can be overcome by administering an additional 50 mg dose of dolutegravir. The US Prescribing Information for dolutegravir advises to avoid coadministration with phenytoin due to insufficient data to make dosing recommendations. However, the European SPC recommends that dolutegravir be dosed at 50 mg twice daily, but that alternative combinations should be used where possible in INSTI-resistant patients. This dose adjustment should be maintained for approximately 2 weeks after stopping phenytoin as the inducing effect may persist after discontinuation of a strong inducer." This is from Liverpool HIV Interactions (hiv-druginteractions.org)

Thanks!

James Adams, MD

Greetings, esteemed colleagues,

I would like to seek your valuable insights regarding a case involving non-occupational post-exposure prophylaxis (nPEP) for a patient who recently sought medical assistance at my clinic. The individual in question is a sexually active man who engaged in sexual activity with a partner of unknown HIV status, posing a potential risk. The encounter took place within the past 72 hours, and the patient is seeking immediate nPEP treatment.

Presently, the patient is receiving phenytoin for epilepsy management, with his most recent epileptic episode occurring seven months ago. However, referring him back to his previous neurologist for a medication change would likely result in a delay that exceeds the appropriate time frame for initiating nPEP. Given this situation, I am seeking your expert opinions on the most suitable nPEP regimen for this patient.

Initially, I considered initiating a combination of Tenofovir Disoproxil Fumarate (TDF), Emtricitabine (FTC), and Dolutegravir (DTG) for his nPEP treatment. However, I am aware that coadministration of DTG, a UGT1A1 inducer, and phenytoin, a UGT1A1 substrate, may necessitate dosage adjustments or alternative options. Therefore, I kindly request any suggestions or comments you may have to navigate this particular situation.

As a temporary solution, I have already prescribed TDF/FTC/DTG to the patient while strongly urging him to promptly visit his neurologist to explore the possibility of transitioning to levetiracetam, which does not exhibit known interactions with DTG or other antiretroviral medications. I have emphasized the importance of this medication change and the urgency of the situation.

I humbly request your valuable expertise and insights to ensure optimal management of this patient, effectively addressing his HIV risk while considering his epilepsy treatment requirements.

Thank you sincerely for your attention and support.

Best regards,
Nuntana Chumpa, MD 
Bangkok, Thailand

Greetings, esteemed colleagues,

I would like to seek your valuable insights regarding a case involving non-occupational post-exposure prophylaxis (nPEP) for a patient who recently sought medical assistance at my clinic. The individual in question is a sexually active man who engaged in sexual activity with a partner of unknown HIV status, posing a potential risk. The encounter took place within the past 72 hours, and the patient is seeking immediate nPEP treatment.

Presently, the patient is receiving phenytoin for epilepsy management, with his most recent epileptic episode occurring seven months ago. However, referring him back to his previous neurologist for a medication change would likely result in a delay that exceeds the appropriate time frame for initiating nPEP. Given this situation, I am seeking your expert opinions on the most suitable nPEP regimen for this patient.

Initially, I considered initiating a combination of Tenofovir Disoproxil Fumarate (TDF), Emtricitabine (FTC), and Dolutegravir (DTG) for his nPEP treatment. However, I am aware that coadministration of DTG, a UGT1A1 inducer, and phenytoin, a UGT1A1 substrate, may necessitate dosage adjustments or alternative options. Therefore, I kindly request any suggestions or comments you may have to navigate this particular situation.

As a temporary solution, I have already prescribed TDF/FTC/DTG to the patient while strongly urging him to promptly visit his neurologist to explore the possibility of transitioning to levetiracetam, which does not exhibit known interactions with DTG or other antiretroviral medications. I have emphasized the importance of this medication change and the urgency of the situation.

I humbly request your valuable expertise and insights to ensure optimal management of this patient, effectively addressing his HIV risk while considering his epilepsy treatment requirements.

Thank you sincerely for your attention and support.

Best regards,
Nuntana Chumpa, MD 
Bangkok, Thailand

Greetings, esteemed colleagues,

I would like to seek your valuable insights regarding a case involving non-occupational post-exposure prophylaxis (nPEP) for a patient who recently sought medical assistance at my clinic. The individual in question is a sexually active man who engaged in sexual activity with a partner of unknown HIV status, posing a potential risk. The encounter took place within the past 72 hours, and the patient is seeking immediate nPEP treatment.

Presently, the patient is receiving phenytoin for epilepsy management, with his most recent epileptic episode occurring seven months ago. However, referring him back to his previous neurologist for a medication change would likely result in a delay that exceeds the appropriate time frame for initiating nPEP. Given this situation, I am seeking your expert opinions on the most suitable nPEP regimen for this patient.

Initially, I considered initiating a combination of Tenofovir Disoproxil Fumarate (TDF), Emtricitabine (FTC), and Dolutegravir (DTG) for his nPEP treatment. However, I am aware that coadministration of DTG, a UGT1A1 inducer, and phenytoin, a UGT1A1 substrate, may necessitate dosage adjustments or alternative options. Therefore, I kindly request any suggestions or comments you may have to navigate this particular situation.

As a temporary solution, I have already prescribed TDF/FTC/DTG to the patient while strongly urging him to promptly visit his neurologist to explore the possibility of transitioning to levetiracetam, which does not exhibit known interactions with DTG or other antiretroviral medications. I have emphasized the importance of this medication change and the urgency of the situation.

I humbly request your valuable expertise and insights to ensure optimal management of this patient, effectively addressing his HIV risk while considering his epilepsy treatment requirements.

Thank you sincerely for your attention and support.

Best regards,
Nuntana Chumpa, MD 
Bangkok, Thailand

Greetings, esteemed colleagues,

I would like to seek your valuable insights regarding a case involving non-occupational post-exposure prophylaxis (nPEP) for a patient who recently sought medical assistance at my clinic. The individual in question is a sexually active man who engaged in sexual activity with a partner of unknown HIV status, posing a potential risk. The encounter took place within the past 72 hours, and the patient is seeking immediate nPEP treatment.

Presently, the patient is receiving phenytoin for epilepsy management, with his most recent epileptic episode occurring seven months ago. However, referring him back to his previous neurologist for a medication change would likely result in a delay that exceeds the appropriate time frame for initiating nPEP. Given this situation, I am seeking your expert opinions on the most suitable nPEP regimen for this patient.

Initially, I considered initiating a combination of Tenofovir Disoproxil Fumarate (TDF), Emtricitabine (FTC), and Dolutegravir (DTG) for his nPEP treatment. However, I am aware that coadministration of DTG, a UGT1A1 inducer, and phenytoin, a UGT1A1 substrate, may necessitate dosage adjustments or alternative options. Therefore, I kindly request any suggestions or comments you may have to navigate this particular situation.

As a temporary solution, I have already prescribed TDF/FTC/DTG to the patient while strongly urging him to promptly visit his neurologist to explore the possibility of transitioning to levetiracetam, which does not exhibit known interactions with DTG or other antiretroviral medications. I have emphasized the importance of this medication change and the urgency of the situation.

I humbly request your valuable expertise and insights to ensure optimal management of this patient, effectively addressing his HIV risk while considering his epilepsy treatment requirements.

Thank you sincerely for your attention and support.

Best regards,
Nuntana Chumpa, MD 
Bangkok, Thailand