Academy Exchange

Hello and thank you for your help!

I recently spoke to a patient who is new to my clinic, for ongoing mgmt of HIV. She is taking Biktarvy, and reports overall good adherence, good viral control, last CD4 >800. Diagnosed with HIV in 2021, later diagnosed with hyperthyroidism and Graves Disease in 2024 (estimated). Her hyperthyroidism was noted due to enlarged thyroid and later, low TSH and elevated FT4. TSI was also noted to be elevated. She is managed by endocrinology but started, then stopped taking methimazole due to insomnia. 

The question we have is... what would be the best ART option. She has not reported adverse effects with Biktarvy, but has concern about potential impact of these medications on Graves. I am unable to find literature which makes recommendation on which drugs are preferable for ART in this situation. If you have recommendations or links to articles I can review, I would be grateful for your input. Thank you, I still have alot to learn!

Barbara Hart APRN

I'm not aware of any data suggesting that her thyroid disease should affect the choice of regimen. Biktarvy should be fine. Let me know if there's something I'm missing.

Hello and thank you for your help!

I recently spoke to a patient who is new to my clinic, for ongoing mgmt of HIV. She is taking Biktarvy, and reports overall good adherence, good viral control, last CD4 >800. Diagnosed with HIV in 2021, later diagnosed with hyperthyroidism and Graves Disease in 2024 (estimated). Her hyperthyroidism was noted due to enlarged thyroid and later, low TSH and elevated FT4. TSI was also noted to be elevated. She is managed by endocrinology but started, then stopped taking methimazole due to insomnia. 

The question we have is... what would be the best ART option. She has not reported adverse effects with Biktarvy, but has concern about potential impact of these medications on Graves. I am unable to find literature which makes recommendation on which drugs are preferable for ART in this situation. If you have recommendations or links to articles I can review, I would be grateful for your input. Thank you, I still have alot to learn!

Barbara Hart APRN

In my research I can see that you want to avoid drugs that have a higher potential for IRIS reactions.  The INSTI class is very useful with here.  I also see that lamivudine does not have a high potential for IRIS either.  I would look at Dovato as a possible treatment option.  Some of the NRTI and NNRTI's have greater potential for IRIS reactions.  With a good history of undetectable viral load and a good CD4 I would consider Dovato as a very good option for this patient.  Hope this helps.

I'm not aware of any data suggesting that her thyroid disease should affect the choice of regimen. Biktarvy should be fine. Let me know if there's something I'm missing.

Hello and thank you for your help!

I recently spoke to a patient who is new to my clinic, for ongoing mgmt of HIV. She is taking Biktarvy, and reports overall good adherence, good viral control, last CD4 >800. Diagnosed with HIV in 2021, later diagnosed with hyperthyroidism and Graves Disease in 2024 (estimated). Her hyperthyroidism was noted due to enlarged thyroid and later, low TSH and elevated FT4. TSI was also noted to be elevated. She is managed by endocrinology but started, then stopped taking methimazole due to insomnia. 

The question we have is... what would be the best ART option. She has not reported adverse effects with Biktarvy, but has concern about potential impact of these medications on Graves. I am unable to find literature which makes recommendation on which drugs are preferable for ART in this situation. If you have recommendations or links to articles I can review, I would be grateful for your input. Thank you, I still have alot to learn!

Barbara Hart APRN

In my research I can see that you want to avoid drugs that have a higher potential for IRIS reactions.  The INSTI class is very useful with here.  I also see that lamivudine does not have a high potential for IRIS either.  I would look at Dovato as a possible treatment option.  Some of the NRTI and NNRTI's have greater potential for IRIS reactions.  With a good history of undetectable viral load and a good CD4 I would consider Dovato as a very good option for this patient.  Hope this helps.

I'm not aware of any data suggesting that her thyroid disease should affect the choice of regimen. Biktarvy should be fine. Let me know if there's something I'm missing.

Hello and thank you for your help!

I recently spoke to a patient who is new to my clinic, for ongoing mgmt of HIV. She is taking Biktarvy, and reports overall good adherence, good viral control, last CD4 >800. Diagnosed with HIV in 2021, later diagnosed with hyperthyroidism and Graves Disease in 2024 (estimated). Her hyperthyroidism was noted due to enlarged thyroid and later, low TSH and elevated FT4. TSI was also noted to be elevated. She is managed by endocrinology but started, then stopped taking methimazole due to insomnia. 

The question we have is... what would be the best ART option. She has not reported adverse effects with Biktarvy, but has concern about potential impact of these medications on Graves. I am unable to find literature which makes recommendation on which drugs are preferable for ART in this situation. If you have recommendations or links to articles I can review, I would be grateful for your input. Thank you, I still have alot to learn!

Barbara Hart APRN

I may be misunderstanding.  Is the Graves' disease possibly being caused by an IRIS reaction?  I understand they can be linked even a couple years later depending on the starting point of the original CD4 (not reported).  I guess I was trying to recommend a regimen that would avoid that possibility.   If I am wrong, I apologize.  

In my research I can see that you want to avoid drugs that have a higher potential for IRIS reactions.  The INSTI class is very useful with here.  I also see that lamivudine does not have a high potential for IRIS either.  I would look at Dovato as a possible treatment option.  Some of the NRTI and NNRTI's have greater potential for IRIS reactions.  With a good history of undetectable viral load and a good CD4 I would consider Dovato as a very good option for this patient.  Hope this helps.

I'm not aware of any data suggesting that her thyroid disease should affect the choice of regimen. Biktarvy should be fine. Let me know if there's something I'm missing.

Hello and thank you for your help!

I recently spoke to a patient who is new to my clinic, for ongoing mgmt of HIV. She is taking Biktarvy, and reports overall good adherence, good viral control, last CD4 >800. Diagnosed with HIV in 2021, later diagnosed with hyperthyroidism and Graves Disease in 2024 (estimated). Her hyperthyroidism was noted due to enlarged thyroid and later, low TSH and elevated FT4. TSI was also noted to be elevated. She is managed by endocrinology but started, then stopped taking methimazole due to insomnia. 

The question we have is... what would be the best ART option. She has not reported adverse effects with Biktarvy, but has concern about potential impact of these medications on Graves. I am unable to find literature which makes recommendation on which drugs are preferable for ART in this situation. If you have recommendations or links to articles I can review, I would be grateful for your input. Thank you, I still have alot to learn!

Barbara Hart APRN

This patient already has a high CD4 count and an undetectable viral load. Immune reconstitution has already occurred, so IRIS is not an issue, and there are no specific drugs or regimens that are better or worse from that standpoint. While INSTI-based regimens result in more rapid virologic suppression and immune restoration than other classes of regimens, that has not translated into greater risk of IRIS, and no one would recommend avoiding INSTI-based regimens to prevent IRIS. No regimen will "avoid" IRIS. The risk of IRIS has to do with the timing of treatment, the baseline CD4 count, viral load, and the presence of diagnosed or undiagnosed opportunistic infections.

I may be misunderstanding.  Is the Graves' disease possibly being caused by an IRIS reaction?  I understand they can be linked even a couple years later depending on the starting point of the original CD4 (not reported).  I guess I was trying to recommend a regimen that would avoid that possibility.   If I am wrong, I apologize.  

In my research I can see that you want to avoid drugs that have a higher potential for IRIS reactions.  The INSTI class is very useful with here.  I also see that lamivudine does not have a high potential for IRIS either.  I would look at Dovato as a possible treatment option.  Some of the NRTI and NNRTI's have greater potential for IRIS reactions.  With a good history of undetectable viral load and a good CD4 I would consider Dovato as a very good option for this patient.  Hope this helps.

I'm not aware of any data suggesting that her thyroid disease should affect the choice of regimen. Biktarvy should be fine. Let me know if there's something I'm missing.

Hello and thank you for your help!

I recently spoke to a patient who is new to my clinic, for ongoing mgmt of HIV. She is taking Biktarvy, and reports overall good adherence, good viral control, last CD4 >800. Diagnosed with HIV in 2021, later diagnosed with hyperthyroidism and Graves Disease in 2024 (estimated). Her hyperthyroidism was noted due to enlarged thyroid and later, low TSH and elevated FT4. TSI was also noted to be elevated. She is managed by endocrinology but started, then stopped taking methimazole due to insomnia. 

The question we have is... what would be the best ART option. She has not reported adverse effects with Biktarvy, but has concern about potential impact of these medications on Graves. I am unable to find literature which makes recommendation on which drugs are preferable for ART in this situation. If you have recommendations or links to articles I can review, I would be grateful for your input. Thank you, I still have alot to learn!

Barbara Hart APRN