Declaração sobre Conflito de Interesses

Transcrição

1 Caso Clínico Tânia R. C. Vergara Mestre em infectologia UFRJ Doutora em Medicina UNIFESP Pesquisadora associada do Laboratório de Retrovirologia da UNIFESP Presidente da Sociedade de Infectologia do Estado do Rio de Janeiro- SIERJ Coordenadora de Terapia do Comitê de HIV/ aids da SBI Tvergara 1

2 Declaração sobre Conflito de Interesses De acordo com a Resolução 1931/2009 do Conselho Federal de Medicina e com a RDC 96 / 2008 da ANVISA, declaro que: Apresentações:como palestrante convidado ou elaboração de material gráfico participo/ei dos eventos de: GSK, Janssen, BMS, Roche, Abbvie. Consultoria: GSK, Janssen, Roche. Pesquisa Clínica: como médico investigador, participei de estudo patrocinado por: Abbvie. Não sou acionista de qualquer uma destas companhias farmacêuticas. Meus pré-requisitos para participar destas atividades são a autonomia do pensamento científico, a independência de opiniões e a liberdade de expressão. Tvergara 2

3 Case report 2007 Weight loss, lymph node enlargement in the thorax and addome. Heavy smoker. COPD. Moderate alcohol intake. Anti HIV +; PPD anergic; Thorax CT: Calcified micronodules disseminated in both lungs. Small lymph nodes for tracheal. TB empirical treatment. TARV beginning AZT + 3TC + EFV First recommendations to stop smoking Tvergara 3

4 Did not quit smoking Continuing 08/2009 Prostate cancer- hormonal therapy In the following years - insulin resistance, liver steatosis, hypertension, hyperuricemia, hypertriglyceridemia. ARV switched to AZT + 3TC + ATV / r and then AZT + 3TC + FPV / r because he takes pump inhibitor to treat gastroesophageal reflux. In 2010, in addition to the antiretrovirals he was taking fenofibrate, esomeprazole, enalapril, allopurinol, buffered aspirin and bupropion. In 10/11 switched for ABC + 3TC + FPV/r Tvergara 4

5 CARDIOVASCULAR PREVENTION POLICY IN HIV: RECOMMENDATIONS FROM A MODELING STUDY Rosan van Zoest. CROI 2017 Abstract 129 Tvergara 5

6 In 03 / 12- cardiac arrhythmia. Precribed by cardiologist -> propafenone, amlodipine, ramipril, venlaflaxine, ciclesonide inhaled, formoterol inhaled, fenofibrate, rosuvastatin. He quit smoking for a short time and returned shortly thereafter.. All vaccinations up to date: hepatitis B, pneumococcal 13 and 23 valent, meningococcal ACYW, hepatitis A, Influenza, DTPa Tvergara 6

7 DEXA in 05/15 osteoporosis It was added risedronate, vitamine D3, Ca dietary intake mg/day Would you make any changes to the TARV? In September / 2015-> TARV simplification -> DRV/r + RAL It improved the metabolic disturbance and maintained viral suppression CD4> 1400/mm 3. 04/2017 Switch -> DRV/r + DTG as a recommendation of the National HIV/AUDS Treatment Protocol (PCDT) Tvergara 7

8 D:A:D: Exposição a ARV e risco de doença renal cronica (DRC) Analise retrospectiva de pacientes com egfr > 90/mL/min no baseline (N = 23,560) Exposição cumulativa a TDF, ABC, ATV/r, LPV/r, outros e risco de DRC 210 pts desenvolveram DRC Análise Multivariada: exposição a TDF, ATV/r, e LPV/r significantemente associada com desenvolvimentno de DRC Risco ao longo de 5 anos Risco de DRC por anos de esposição, IRR (95% CI) Drug 1 Yr 2 Yrs 5 Yrs TDF 1.12 ( ) ATV/ r 1.27 ( ) LPV/ r 1.16 ( ) 1.25 ( ) 1.61 ( ) 1.35 ( ) 1.74 ( ) 3.27 ( ) 2.11 ( ) Mocroft A, et al. CROI Abstract 142. Reproduced with permission. Tvergara 8

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11 Emergence of resistance mutations in full data set (confirmed HIV RNA > 50 c/ ml or any single HIV RNA 500 c/ml at or after W32) 11

12 A frequência de mutações IN na falha foi significativamente associada à LV basal: 7,1% para uma LV <100 mil cópias / ml, 25,0% para uma LV de 100 mil cópias / ml e <500 mil cópias / ml e 53,8% p The frequency of IN mutations at failure was significantly associated with baseline VL 7.1% for a VL of < copies/ml 25.0% for a VL of copies/ml and < copies/ml 53.8% for a VL of copies/ml (P TREND = 0.007). Of note, 4/15 participants with IN RAM had a VL < 200 copies/ml at time of testing. No assiciation with baseline CD4 count nor HIV RNA do HIV at time of testing p=0.25 Tvergara 12

13 December Lung cancer. Metastasis to brain, liver and bone. He began high-dose corticosteroids and radiotherapy to reduce the brain lesions size and begun chemotherapy. VL < 40 cp/ml TARV switched to DTG + 3TC -> no interactions with the chemotherapy. VL checked monthly at the first 3 months. Tvergara 13

14 Reasons to Consider Regimen Switching in Virologically Suppressed Pts Simplification Avoid toxicity Improve tolerability or convenience Manage drug drug or drug food interactions Pregnancy Cost DHHS ART Guidelines. May Adapted Slide credit: clinicaloptions.com

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16 April 2018 VL <40 cp / ml CD4> 1300/mm 3 CD4 / CD8 1,2 Jul 2018 VL <40 cp / ml CD /mm 3 Excellent responso to chemotherapy Thank you very much for your attention. taniavergara@globo.com Tvergara 16