A MANAGEMENT TOOL FOR H V "03%̞"03%ô',2#0!2'-,1 The Canadian HIV/AIDS Pharmacists Network (CHAP) INTRODUCTION CU@MBDRÓHMÓ@MSHQDSQNUHQ@KÓSGDQ@OXÓG@UDÓSTQMDCÓ'(5ÓHMSNÓ@ÓBGQNMHB ÓL@M@FD@AKDÓCHRD@RD Ó/@SHDMSRÓNȓDMÓQDPTHQDÓSQD@SLDMSÓENQÓBN LNQAHCÓBNMCHSHNMRÓ@RÓVDKKÓ@RÓ'(5 Ó@MCÓBNMRDPTDMSKX Ó OG@QL@BNJHMDSHBÓHMSDQ@BSHNMRÓADSVDDMÓ@MSHQDSQNUHQ@KRÓ 15RÓ@MCÓNSGDQÓCQTFÓBK@RRDRÓ@QDÓ@MÓHMBQD@RHMFÓBNMBDQM ÓÓ3GHRÓSNNKÓG@RÓADDMÓBQD@SDCÓ@RÓ@ÓPTHBJÓQDEDQDMBDÓSNÓ@RRHRSÓBKHMHBH@MRÓHMÓSGDÓ BKHMHB@KÓL@M@FDLDMSÓNEÓSGDRDÓHMSDQ@BSHNMRÓ@MCÓHRÓHMSDMCDCÓENQÓTRDÓAXÓ@MCÓVHSGÓDWODQHDMBDCÓOGXRHBH@MR ÓMTQRDRÓ@MCÓOG@QL@BHRSR ÓÓ Disclaimer 3GDÓHMENQL@SHNMÓVHSGHMÓHRÓMNSÓHMSDMCDCÓSNÓQDOK@BDÓRNTMCÓOQNEDRRHNM@KÓITCFLDMSÓHMÓHMCHUHCT@KÓRHST@SHNMR Ó@MCÓRGNTKCÓADÓTRDCÓHMÓBNMITMBSHNMÓVHSGÓNSGDQÓQDKH@AKDÓRNTQBDRÓNEÓHMENQL@SHNM Ó#TDÓSNÓ SGDÓQ@OHCKXÓBG@MFHMFÓM@STQDÓNEÓHMENQL@SHNMÓ@ANTSÓ'(5ÓSQD@SLDMSÓ@MCÓSGDQ@OHDR ÓTRDQRÓ@QDÓ@CUHRDCÓSNÓQDBGDBJÓSGDÓHMENQL@SHNMÓBNMS@HMDCÓGDQDHMÓVHSGÓSGDÓNQHFHM@KÓRNTQBDÓADENQDÓ@OOKXHMFÓHSÓSNÓ O@SHDMSÓB@QD ÓÓ#DBHRHNMRÓ@ANTSÓO@QSHBTK@QÓLDCHB@KÓSQD@SLDMSRÓRGNTKCÓ@KV@XRÓADÓL@CDÓHMÓBNMRTKS@SHNMÓVHSGÓ@ÓPT@KHȏDCÓLDCHB@KÓOQ@BSHSHNMDQÓJMNVKDCFD@AKDÓ@ANTSÓ'(5 QDK@SDCÓHKKMDRRÓ@MCÓSGDÓ SQD@SLDMSRÓHMÓPTDRSHNM ÓÓ -DHSGDQÓ"' / Ó3NQNMSNÓ&DMDQ@KÓ'NROHS@K Ó2S Ó,HBG@DKRÓ'NROHS@K Ó4MHUDQRHSXÓNEÓ3NQNMSN Ó6HMCRNQÓ1DFHNM@KÓ'NROHS@K Ó1DFHM@Ó&DMDQ@KÓ'NROHS@K Ó"DMSQDÓ'NROHS@KHDQÓCDÓK4MHUDQRHS~ÓCDÓ,NMSQ~@KÓ ÓMNQÓ SGDÓ@TSGNQRÓ@QDÓQDRONMRHAKDÓENQÓCDKDSHNMRÓNQÓHM@BBTQ@BHDRÓHMÓHMENQL@SHNMÓNQÓENQÓBK@HLRÓNEÓHMITQXÓQDRTKSHMFÓEQNLÓ@MXÓRTBGÓCDKDSHNMRÓNQÓHM@BBTQ@BHDR ÓÓ,DMSHNMÓNEÓRODBHȏBÓCQTFR ÓCQTFÓCNRDRÓNQÓ CQTFÓBNLAHM@SHNMRÓVHSGHMÓSGHRÓSNNKÓCNDRÓMNSÓBNMRSHSTSDÓDMCNQRDLDMSÓAXÓ"' / ÓSGDÓ@TSGNQRÓNQÓSGDHQÓ@ȑKH@SDCÓHMRSHSTSHNMR Acknowledgements: 3GDÓCDUDKNOLDMSÓSD@LÓNMÓADG@KEÓNEÓSGDÓ"@M@CH@MÓ'(5 (#2Ó/G@QL@BHRSRÓ-DSVNQJÓ"' /ÓHMBKTCDR gÓÓ+HMC@Ó1NAHMRNM Ó!2B /GL Ó '(5$ Ó6HMCRNQÓ1DFHNM@KÓ'NROHS@K gÓÓ,HBG@DKÓ2STADQ Ó!2/ Ó1DFHM@Ó&DMDQ@KÓ'NROHS@K gÓÓ1@BGDKÓ3GDQQHDM Ó! /GL Ó, 2B Ó"DMSQDÓ'NROHS@KHDQÓCDÓK4MHUDQRHS~ÓCDÓ,NMSQ~@KÓÓ"'4, gÓÓ KHBDÓ3RDMF Ó/G@QL # Ó%"2'/ Ó '(5/ Ó3NQNMSNÓ&DMDQ@KÓ'NROHS@KÓ @MCÓ&NQCNMÓ QADRR Ó,# Ó""%/ Ó#DO@QSLDMSÓNEÓ"NLLTMHSXÓÓ%@LHKXÓ,DCHBHMD Ó2S Ó,HBG@DKRÓ'NROHS@K Ó%@BTKSXÓNEÓ,DCHBHMD Ó4MHUDQRHSXÓNEÓ3NQNMSN /QHMSÓOQNCTBSHNMÓNEÓSGHRÓSNNKÓV@RÓL@CDÓONRRHAKDÓSGQNTFGÓ@MÓTMQDRSQHBSDCÓDCTB@SHNM@KÓFQ@MSÓEQNLÓ,DQBJÓ"@M@C@ H V !0"'-41!3*0ô"03%1ô ,2'&7.#02#,1'4#1ô,"ô"'%-6', !*!'3+ô!&,,#*ô ACEI ARBs #2̝ *-!)#01 "'30#2'!1 DIGOXIN *-!)#01ơ̂!! ̜ Acebutolol, $OQNR@QS@M Ó bisoprolol, %TQNRDLHCD Ó !DM@YDOQHK ÓDM@K@OQHK Ó Candesartan, LKNCHOHMD ÓCHKSH@YDL Ó olmesartan, Atenolol, labetalol, GXCQNBGKNQN lisinopril, perindopril, irbesartan, EDKNCHOHMD ÓMHEDCHOHMD Ó Indapamide telmisartan, nadolol metoprolol, SGH@YHCD Ó ramipril, etc. losartan verapamil valsartan pindolol, spironolactone propranolol ',2#%01#ô',&' '2-01 • "-*32#%04'0ô (Tivicay, Triumeq) ȖȖȖȖȖȖȖȖȖ η η η η η Potential /NSDMSH@KÓENQÓ Ó""! ÓÓÓ /NSDMSH@KÓENQÓ • #*4'2#%04'0ô ô!- '!'122ô1RPG@GJB ô%CLTMW? ȖȖ /NSDMSH@KÓENQÓ Ȗ ENQÓ Consider 50% dose Ȗ /NSDMSH@KÓENQÓ ÓÓ Ó 1! ADS@ NQÓRS@QSÓVHSGÓKNVDRSÓ indapamide CHFNWHM blocker dose possible • 0*2#%04'0ô'QCLRPCQQ ȖȖȖȖȖȖȖȖȖ .0-2#1#ô',&' '2-01 0'2-,4'0ô,MPTGPôMPôAM@GAGQR?R @MMQRCBô.'Q ôC E η η η η η • 28,4'0 (Evotaz, Reyataz) Potential Potential ȖȖ /NSDMSH@KÓENQÓ Ȗ ENQÓ /NSDMSH@KÓENQÓ Ó""! ÓÓÓ Ȗ /NSDMSH@KÓENQÓ • "03,4'0ô.PCXAM@GV ô.PCXGQR?ô ÓÓ Ó 1! ENQÓ CHFNWHM ADS@ Consider 50% dose indapamide • *-.',4'0 (Kaletra) blocker !0"'-41!3*0 !*!'3+ô!&,,#*ô ACEI ARBs #2̝ *-!)#01 "'30#2'!1 DIGOXIN *-!)#01ơ̂!! ̜ Acebutolol, $OQNR@QS@M Ó bisoprolol, %TQNRDLHCD Ó !DM@YDOQHK ÓDM@K@OQHK Ó Candesartan, LKNCHOHMD ÓCHKSH@YDL Ó olmesartan, Atenolol, labetalol, 'XCQNBGKNQN lisinopril, perindopril, irbesartan, EDKNCHOHMD ÓMHEDCHOHMD Ó Indapamide telmisartan, nadolol metoprolol, SGH@YHCD Ó ramipril, etc. losartan verapamil valsartan propranolol, spironolactone pindolol ,-,̝,3!*#-1'"#ô0#4#01#ô20,1!0'.21#ô',&' '2-01 • 0'*.'4'0',#ô!MKNJCP? ô#BSP?LR ȖȖȖȖȖȖȖȖȖ • #$4'0#,8ô1SQRGT? ôRPGNJ? η η η /NSDMSH@KÓENQÓ /NSDMSH@KÓENQÓ • #204'0',#ô'LRCJCLAC ȖȖ ȖȖ /NSDMSH@KÓENQÓ Ó""! Ȗ Ȗô ÓÓ Ó 1! • ,#4'0.',#ô(Viramune) indapamide ,-2#1 !0"'-41!3*0 !0"'-41!3*0ô"03%1ô ,2'&7.#02#,1'4#1ô,"ô"'%-6', +CAF?LGQKôMDô"PSEô'LRCP?ARGMLQ ô+?L?ECKCLRô?LBô+MLGRMPGLE !*!'3+ô!&,,#*ô ACEI ARBs #2̝ *-!)#01 *-!)#01ơ̂!! ̜ "'30#2'!1 DIGOXIN Conversion via 2C9 to ,HWDCÓ"8/ÓRTARSQ@SDRÓ active metabolite @BDATSNKNK ÓAHRNOQNKNK Ó (MGHAHSHNMÓNEÓ (MCTBSHNMÓNEÓ ,HWDCÓ"8/ÓRTARSQ@SDRÓ 1DM@KKXÓBKD@QDC KNR@QS@M Ó2TARSQ@SDÓNEÓ (MGHAHSHNMÓNEÓ/ FKXBNOQNSDHM +#!&,'1+ô-$ô',2#0!2'-, labetalol, metoprolol, "8/ "8/ HMC@O@LHCD "ÓB@MCDR@QS@M Ó OHMCNKNK ÓOQNOQ@MNKNK HQADR@QS@M 1HSNM@UHQÓ@MCÓ BNAHBHRS@S 1HSNM@UHQÓ@MCÓBNAHBHRS@S $KUHSDFQ@UHQÓHMCTBSHNM Ó 1HSNM@UHQÓ@MCÓBNAHBHRS@S 1HSNM@UHQÓ@MCÓBNAHBHRS@S -NÓRHFMHȏB@MSÓHMSDQ@BSHNMRÓ boosted boosted protease DE@UHQDY ÓDSQ@UHQHMDÓ boosted protease ,NRSÓ--13(R boosted protease inhibitors +',ô',2#0!2',%ô04s predicted protease inhibitors and elvitegravir HMGHAHSHNM inhibitors and elvitegravir and elvitegravir inhibitors and @MCÓLNRSÓ--13(R elvitegravir CITRSÓB@MCDR@QS@M Ó CITRSÓADS@ AKNBJDQÓCNRDÓ CITRSÓ""!Ó CITRSÓHMC@O@LHCDÓCNRDÓ irbesartan, losartan dose @BBNQCHMFÓSNÓQDRONMRD Consider 50% dose @BBNQCHMFÓSNÓQDRONMRD CITRSÓCHFNWHMÓCNRDÓ @BBNQCHMFÓSNÓQDRONMRD SNWHBHSX ÓÓ.SGDQÓ dose 4RDÓRS@MC@QCÓCQTFÓCNRDR according to SNWHBHSX ÓÓ.SGDQÓCHTQDSHBRÓ @BBNQCHMFÓSNÓQDRONMRD MANAGEMENT SNWHBHSX ÓÓ.SGDQÓ 1!RÓL@XÓ ADS@ AKNBJDQRÓ@SDMNKNK Ó reduction in DȑB@BX L@XÓADÓTRDCÓVHSGNTSÓ SNWHBHSX ADÓTRDCÓVHSGNTSÓCNRDÓ M@CNKNKÓL@XÓADÓTRDCÓ ""! SNWHBHSX CNRDÓ@CITRSLDMS @CITRSLDMS VHSGNTSÓCNRDÓ@CITRSLDMS ""!ÓSNWHBHSXÓ #HFNWHMÓBNMBDMSQ@SHNMR Ó heart rate, !DS@ AKNBJDQÓSNWHBHSXÓÓ (MC@O@LHCDÓSNWHBHSXÓÓ SNWHBHSXÓ@QQGXSGLH@R Ó blood heart rate, blood CHYYHMDRR ÓGD@C@BGD Ó ventricular tachycardia, 1!ÓDȑB@BXÓ@MCÓSNWHBHSX pressure, ""!ÓDȑB@BX +-,'2-0',% OQDRRTQD ÓRGNQSMDRRÓNEÓ hyperglycemia, bradycardia, AV block, RGNQSMDRRÓNEÓ breath. hypokalemia @MNQDWH@ ÓM@TRD@ ÓAKTQQDC breath, XDKKNVÓUHRHNM ÓGD@C@BGD CHYYHMDRR !0"'-41!3*0 !0"'-41!3*0ô"03%1ô ,2'.*2#*#21ô,"ô,2'!-%3*,21 ,2'.*2#*#21 ,2'!-%3*,21 "+./(#.&1$+ /1 24&1$+ 3(" &1$+.1Ó # !(& 31 - 1(5 1.7 ! - /(7 ! - 6 1% 1(- 2 /K@UHW $ȑDMS !QHKHMS@ /Q@C@W@ 7@QDKSN $KHPTHR "NTL@CHM ',2#%01#ô',&' '2-01 • "-*32#%04'0ô (Tivicay, Triumeq) ȖȖȖȖȖȖȖȖ X η X X η /NSDMSH@KÓENQÓ /NSDMSH@KÓENQÓ /NSDMSH@KÓENQÓ /NSDMSH@KÓENQÓ • #*4'2#%04'0ô ô!- '!'122ô1RPG@GJB ô%CLTMW? ȖȖȖ dabigatran and /NSDMSH@KÓENQÓ ticagrelor and QHU@QNW@A@MÓ@MCÓ @OHW@A@MÓ@MCÓ V@QE@QHM SNWHBHSX SNWHBHSX SNWHBHSX SNWHBHSX • 0*2#%04'0ô'QCLRPCQQ ȖȖȖȖȖȖȖȖ .0-2#1#ô',&' '2-01 η 1HSNM@UHQ ANNRSDCÓ/(RÓÓ 0'2-,4'0ô,MPTGPôMPôAM@GAGQR?R @MMQRCBô.'Q ôC E X η X X ONSDMSH@KÓENQÓÓ • 28,4'0 (Evotaz, Reyataz) ȖȖȖ /NSDMSH@KÓENQÓ /NSDMSH@KÓENQÓ /NSDMSH@KÓENQÓ /NSDMSH@KÓENQÓ V@QE@QHM • "03,4'0ô.PCXAM@GV ô.PCXGQR?ô ticagrelor and dabigatran and QHU@QNW@A@MÓ@MCÓ @OHW@A@MÓ@MCÓ "NAHBHRS@S • *-.',4'0 (Kaletra) SNWHBHSX SNWHBHSX SNWHBHSX SNWHBHSX ANNRSDCÓ/(RÓÓ ONSDMSH@KÓENQÓ V@QE@QHMÓ concentrations !0"'-41!3*0 ,2'.*2#*#21 ,2'!-%3*,21 "+./(#.&1$+ /1 24&1$+ 3(" &1$+.1 # !(& 31 - 1(5 1.7 ! - /(7 ! - 6 1% 1(- 2 /K@UHW $ȑDMS !QHKHMS@ /Q@C@W@ 7@QDKSN $KHPTHR "NTL@CHM ,-,̝,3!*#-1'"#ô0#4#01#ô20,1!0'.21#ô',&' '2-01 • 0'*.'4'0',#ô!MKNJCP? ô#BSP?LR ȖȖȖȖȖȖȖȖ Ȗô η $E@UHQDMY Ó $E@UHQDMY Ó nevirapine DSQ@UHQHMDÓÓ • #$4'0#,8ô1SQRGT? ôRPGNJ? ONSDMSH@KÓENQÓ X X X V@QE@QHMÓ • #204'0',#ô'LRCJCLAC Ȗ η Ȗ Ȗ $SQ@UHQHMDÓÓ /NSDMSH@KÓENQÓ /NSDMSH@KÓENQÓ /NSDMSH@KÓENQÓ concentrations • ,#4'0.',#ô(Viramune) /NSDMSH@KÓENQÓ ticagrelor QHU@QNW@A@MÓ @OHW@A@MÓÓ -DUHQ@OHMDÓÓ active ONSDMSH@KÓENQÓ LDS@ANKHSDÓNEÓ V@QE@QHMÓ clopidogrel concentrations ,3!*#-2'"#ô0#4#01#ô20,1!0'.21#ô',&' '2-01 η /NSDMSH@KÓENQÓ • 2#,-$-4'0ô"'1-.0-6'* (Viread, Truvada, QDM@KÓSNWHBHSXÓ ȖȖȖȖȖȖȖ RPGNJ? ô!MKNJCP? ô1RPG@GJB VHSGÓGHFGÓCNRDÓ or prolonged 2 ÓTRD !0"'-41!3*0 !0"'-41!3*0ô"03%1ô ,2'.*2#*#21ô,"ô,2'!-%3*,21 +CAF?LGQKôMDô"PSEô'LRCP?ARGMLQ ô+?L?ECKCLRô?LBô+MLGRMPGLE ,2'.*2#*#21 ,-4#*ô-0*ô,2'!-%3*,21ơ̂,-!1̜ WARFARIN (MGHAHSHNMÓNEÓ (MCTBSHNMÓNEÓ (MGHAHSHNMÓNEÓ (MCTBSHNMÓNEÓ Combining (MGHAHSHNMÓNEÓ"Ó "8/ Ó/ FOÓ "8/ Ó/ FOÓ (MGHAHSHNMÓNEÓ/ FOÓ "8/ Ó/ FOÓ "8/ Ó/ FOÓ MDOGQNSNWHBÓ@FDMSRÓ (MCTBSHNMÓNEÓ"8/" (MGHAHSHNMÓNEÓ"8/" +#!&,'1+ô-$ô',2#0!2'-, BKNOHCNFQDK QHU@QNW@A@M Ó QHU@QNW@A@M Ó C@AHF@SQ@M SHB@FQDKNQ SHB@FQDKNQ 2 @OHW@A@M @OHW@A@M 1HSNM@UHQÓANNRSDCÓ 1HSNM@UHQÓ@MCÓ ,NRSÓ--13(RÓ 1HSNM@UHQÓ@MCÓ ,NRSÓ--13(RÓ 1HSNM@UHQÓ@MCÓ 3DMNENUHQÓCHRNOQNWHKÓ regimens, BNAHBHRS@S ANNRSDCÓ DE@UHQDMY Ó BNAHBHRS@S ANNRSDCÓ DE@UHQDMY Ó BNAHBHRS@S ANNRSDCÓ $SQ@UHQHMD 3#%ÓBNMS@HMHMFÓ nevirapine, $E@UHQDMY ÓDSQ@UHQHMD +',ô',2#0!2',%ô04s protease inhibitors etravirine, protease inhibitors etravirine, protease inhibitors regimens DKUHSDFQ@UHQ and elvitegravir MDUHQ@OHMD and elvitegravir MDUHQ@OHMD and elvitegravir cobicistat #@AHF@SQ@MÓ UNHCÓGHFG CNRDÓNQÓ monograph advises 4RDÓVHSGÓB@TSHNM ÓÓ OQNKNMFDCÓ 2 ÓTRDÓ B@TSHNMÓVHSGÓ/ FOÓ Avoid ,@XÓVHRGÓSNÓ HEÓONRRHAKD ÓÓ inhibitors. (MBQD@RDÓV@QE@QHMÓ #DBQD@RDÓV@QE@QHMÓ Contraindicated. OHW@A@MÓ@MCÓ Avoid use. Consider coadministration. consider Consider alternate Preliminary dose as needed to dose as needed to Prasugrel may be QHU@QNW@A@MÓ@QDÓ alternative such as MANAGEMENT Prasugrel may be alternatives to HIV agent, such as pharmacokinetic maintain maintain used contraindicated V@QE@QHM used clopidogrel, such as abacavir or data suggest that a SGDQ@ODTSHBÓ(-1 SGDQ@ODTSHBÓ(-1 prasugrel. SDMNENUHQÓ BKHMHB@KKXÓRHFMHȏB@MSÓ @K@EDM@LHCDÓ3 % interaction may not occur 3HB@FQDKNQÓSNWHBHSXÓÓ ,NMHSNQÓQDM@KÓ 6@QE@QHMÓSNWHBHSXÓÓ dyspnea, headache, AKDDCHMF ÓCHYYHMDRR Ó ETMBSHNM Anticoagulant Anticoagulant Anticoagulant DOHRS@WHR ÓBGDRSÓ 3HB@FQDKNQÓDȑB@BX Antiplatelet activity headache, +-,'2-0',% SNWHBHSX SNWHBHSX DȑB@BX pain, bleeding RRDRRÓ.3"Ó RGNQSMDRRÓNEÓAQD@SG Ó events -2 (#ÓTRD hypotension !0"'-41!3*0 !0"'-41!3*0ô"03%1ô 122',1 2-04122', 0-134122',ô .'24122',ô .04122', *-4122',ôô 1'+4122',ôô *GNGRMP !PCQRMP *GT?JM .P?T?AFMJ +CT?AMP 8MAMP ',2#%01#ô',&' '2-01 • "-*32#%04'0ô (Tivicay, Triumeq) ȖȖȖȖȖȖ • #*4'2#%04'0ô ô!- '!'122ô1RPG@GJB ô%CLTMW? η ȖȖ η X /NSDMSH@KÓENQÓ statin /NSDMSH@KÓENQÓ statin /NSDMSH@KÓENQÓ ÓRS@SHMÓ@MCÓSNWHBHSX • 0*2#%04'0ô'QCLRPCQQ ȖȖȖȖȖȖ .0-2#1#ô',&' '2-01 η η 0'2-,4'0ô,MPTGPôMPôAM@GAGQR?R @MMQRCBô.'Q ôC E /NSDMSH@KÓENQÓ statin.