Case Discussions Complications of HIV Professor Alan Winston St. - PowerPoint PPT Presentation

Case Discussions Complications of HIV Professor Alan Winston St. Mary’s Hospital London October 2016

Alan Winston Disclosure Alan Winston has received honoraria or research grants from or been a consultant or investigator in clinical trials Life long AR sponsored by Abbott, Boehringer Ingelheim, Bristol‐ Myers Squibb, Gilead Sciences, GlaxoSmithKline, Janssen‐Cilag, Roche, Pfizer and ViiV Healthcare.

Case Study (2006) Life long AR

Case Study (2006) 55‐year‐old Black African gentleman 2006 (10 years ago) Presented with CAP Nadir CD4+ count 80 cells/uL Life long AR Commenced on an efavirenz containing regimen Suppressed virologically

Case Study (2008) 55‐year‐old Black African gentleman 2006 (10 years ago) Presented with CAP Nadir CD4+ count 80 cells/uL Life long AR Commenced on an efavirenz containing regimen Suppressed virologically 2008 Doing well on cART Fall with # wrist

Case Study (2008) – medical workup Cardiovascular risk factors Controlled hypertension (on amlodipine) Mild hyperlipidaemia DXA scan Life long AR Life long AR Lumbar spine: Z‐score: ‐3.2 T‐score: ‐3.3

Question 1 Low bone mineral density in HIV‐disease is predominantly related to: 1 Traditional risk factors 2 HIV‐disease itself 3 Antiretroviral therapy 4 Combinations of the above

Considerations J Infect Dis. 2015 Feb 15;211(4):539‐48

Considerations J Infect Dis. 2015 Feb 15;211(4):539‐48

Management considerations Prevention and drug therapy  Assess risk  General  reduce risk of falls  exercise (weight‐bearing, muscle strength, balance training)  vitamin D replacement  calcium supplementation  Bisphosphonate therapy  Switch ART

Management considerations Güerri‐Fernandez et al. J Bone Miner Res 2013

Case Study (2016) 10 years later Patient on Atripla™ (TDF, FTC, efavirenz) Bone DXA follow up scanning some improvement (had bisphosphonates and on vitamin D replacement) Life long AR Hypertension remains controlled Lipids now very high (tried a statin and didn’t like it) 10 year Q‐risk is over 20% Non smoker Medication history ART Amlodipine Bone management therapy

Question 2 What would you do? 1 Dietary and lifestyle advice 2 Try a different statin 3 Change antiretroviral therapy 4 Combinations of the above

Management considerations – switching ART EFV/FTC/TDF to RPV/FTC/TDF switch study Mills AM et al. HIV Clinical Trials 2013;14(5):216–223

EACS guidelines

EACS guidelines Thank you