Id Therapeutics Exam 2 Set 5

Front 1

CD4 count where tuberculosis is most likely to manifest

Back 1

350

Front 2

CD4 count where oral candidaisis is most likely to manifest

Back 2

300-250

Front 3

CD4 count where cryptosporidiosis is most likely to manifest

Back 3

200

Front 4

CD4 count where kaposi's sarcoma is most likely to manifest

Back 4

350-200

Front 5

CD4 count where herpes simplex virus is most likely to manifest

Back 5

150-100

Front 6

CD4 count where PCP is most likely to manifest

Back 6

250-100

Front 7

CD4 count where MAC is most likely to manifest

Back 7

100-50

Front 8

CD4 count where toxoplasmosis is most likely to manifest

Back 8

100

Front 9

CD4 count where cryptococcus is most likely to manifest

Back 9

150-75

Front 10

CD4 count where esophageal candidaisis is most likely to manifest

Back 10

75

Front 11

CD4 count where CMV is most likely to manifest

Back 11

50

Front 12

clinical presentation sx of PCP (3)

Back 12

1. SOB
2. fever
3. nonproductive cough

Front 13

physical findings of PCP (2)

Back 13

1. tachycardia
2. tachypnea

Front 14

Lab findings for PCP (2)

Back 14

1. decreased PaO2 (impaired oxygenation)
2. increased lactic dehydrogenase (LDH--subtypes found in liver, muscle, lungs, and brain)

Front 15

1. first line agent for PCP
2. Inhibits folic acid synthesis.
3. 19% get rash/fever
4. Other ADRs: neutropenia, thrombocytopenia, nausea, vomiting, hyperkalemia, and hepatitis
5. Rash: generally 8th to 12th day of therapy
6. Toxicity is due to sulfonamide component.
7. Mild symptoms may be managed by decreasing the dose or using antihistamines; however, sometimes require discontinuation of the drug.

Back 15

bactrim (TMP-SMX)

Front 16

dose for bactrim (TMP-SMX) in PCP

Back 16

**dose based on TMP component
15-20 mg/kg/day divided into TID or QID

Front 17

PCP

Dapsone is a sulfone and may be used in patients who fail or are intolerant to SMX. What is the dose of TMP and dapsone for PCP?

Back 17

TMP 300 mg TID and dapsone 100 mg QD

Efficacy: > 80%
10% get rash/fever
Other ADRs include methemoglobinemianausea, vomiting, and hemolysis (patients with glucose-6 phosphate dehydrogenase (G6PD) deficiency).

Front 18

Second line regimen for PCP?

Back 18

Second-line regimen
1. Dose: Clindamycin 300 to 450 mg PO QID or 600 mg IV q 8 hrs plus Primaquine 15 mg PO QD.
2. Efficacy: > 80%
3. 21% get rash/fever
4. Fever, neutropenia, and methemoglobinemia occur in ~20% of patients and may necessitate discontinuation.
5. Primaquine may cause hemolysis in patients with G6PD deficiency.

Front 19

trimetrexate used as second-line agent for PCP has what AE associated with it and what should be administered with it to prevent/reduce this event?

Back 19

bone marrow suppression

administer leucovorin 20 mg/m2 PO or IV qid (administer IV if single dose is >25 mg)

**also rash and abnormal LFTs

Front 20

PCP
1. first line agents (1)
2. second line agents (4)

Back 20

1. bactrim 15-20 mg/kg/day (TMP component) given TID-QID

2. second line

clinda 300-450 QID + primaquine 15 mg QD
pentamidine
atovaquone
trimetrexate

Front 21

How long is active therapy continued for in patients with PCP?

Back 21

21 days

Front 22

When administering steroids (prednisone) to patients with PCP within the first 72 hours to reduce inflammatory effects what is the taper dose?

Back 22

40 mg BID on days 1-5
40 mg QD on days 6-10
20 mg QD on days 11-21

Front 23

what is the prophylaxis regimen for PCP?

Back 23

1. consider for patients---primary: CD4 <200; secondary: any patient with previous episode
2. TMP-SMX tx of choice

regimens
1 tab TMP-SMX DS QD (preferred)
1 tab TMP-SMX SS QD (if difficult tolerating DS)
1 tab TMP-SMX DS 3x/week (not as effective)

Front 24

when can prophylaxis for PCP be d/c

Back 24

when CD4 count greater than 200 for 3+ months

Front 25

how would a patient with TE (toxoplasmic encephalitis) present? (2_

Back 25

1. hemiparesis (weakness on one side of body)
2. abnormalities in speech

Front 26

preferred tx for TE?

Back 26

1. sulfadiazine 1-1.5 g QID + pyrimethamine 200 mg x 1 then 75-100 mg QD (preferred)
**administer with leucovorin 10-20 mg QD
**respond in 7-10 days but continued for 3-6 weeks following resolution of sx

other
1. Clindamycin 600 mg QID plus pyrimethamine 200 mg x 1 then 75-100 mg QD
2. Pyrimethamine may also be combined with clarithromycin, azithromycin, atovaquone, or dapsone
3. TMP-SMX
**Relapse ~100% once therapy is stopped

Front 27

when to consider primary prophylaxis for TE

Back 27

when CD4 counts are 100 or less

use bactrim DS 1 QD is preferred

Front 28

when to consider secondary prophylaxis for TE and what to use

Back 28

following treatment of active disease

use pyrimethamine 25-50 mg QD + sulfadiazine 500-1000 mg QID; leucovorin 10-25 mg QD

Front 29

when to stop prophylaxis (primary and secondary) in TE

Back 29

1. Primary prophylaxis may be discontinued once CD4+ >200 cells/mm3 for 3-6 months.

2. Secondary prophylaxis should continue until: patient has completed initial therapy and patient is asymptomatic for toxoplasmosis
3. CD4+ >200 cells/mm3 for > 6 months
4. Secondary prophylaxis should be restarted if the CD4+ cells < 200 cells/mm3

Front 30

tx for cryptococal meningitis

1. preferred (1)

Back 30

1. Amphotericin B (0.7-1 mg/kg/day) + flucytosine (37.5 mg/kg PO QID) is the preferred regimen if severe infection is present.


2. Positive blood cultures
3. CSF antigen > 128:1
4. Positive CSF India ink
5 .Impaired mental status

Front 31

tx for cryptococcal meningitis

1. alternative (1)

Back 31

Fluconazole 400-800 mg IV or PO QD plus flucytosine may be considered if unable to tolerate standard treatment

**continued for 8-10 weeks

Front 32

for cryptococcal meningitis if flucytosine is used serum concentrations must remain below what to minimze hematologic adverse events

Back 32

100 mcg/ml

Front 33

cryptococcal meningitis prophylaxis

1. primary
2. secondary

Back 33

1. Secondary prophylaxis (maintenance therapy) with fluconazole (preferred) 200 mg QD or amphotericin B 0.6-1 mg/kg IV q.w. - t.i.w. recommended until: CD4+ count > 200 cells/mm3 for > 6 months
***Maintenance therapy should be restarted if CD4 decreaese below 200 cells/mm3

2. Primary prophylaxis is not recommended.

Front 34

histoplasmosis primary prevention?

when to consider
what to use

Back 34

Primary prophylaxis not generally used but may be considered if CD4 < 150 (Itraconazole 200 mg daily)

Front 35

clinical presentation of mycobacterium avium complex (10)

Back 35

common
1. Fever
2. night sweats
3. weight loss are common findings.

frequently present
4. Diarrhea
5. malaise
6. anorexia

also detected
7. Hepatomegaly
8. splenomegaly
9. lymphadenopathy

Chest x-ray: Unremarkable
10. Laboratory findings: Non-specific, alkaline phosphatase may be elevated

Front 36

anti-MAC therapy (3 components for induction therapy)

first line agents

Back 36

azithomycin (clarithromycin), ethambutol, rifabutin

1. Azithromycin--Dose: 600 mg PO QD; First-line agent; Toxicity: GI intolerance OR
Clarithromycin--Dose: 500 mg PO BID; First-line agent; Toxicity: GI intolerance; Blood levels may be decreased with concomitant use of rifampin or rifabutin.

2. Ethambutol--Dose: 15-25 mg/kg (2.5 g max) PO QD; First-line agent; Toxicity: Optic neuritis; Second most active agent; Avoid use in young children

3. Rifabutin--Dose: 300 mg PO QD; First-line agent; Toxicities (hypersensitivity, GI intolerance, neutropenia, hepatotoxicity, fluid discoloration)

Front 37

anti-MAC therapy

second- line agents (5)

Back 37

1. amikacin--Dose: 7.5-15 mg/kg/day IM or IV; Toxicities: Ototoxicity, nephrotoxicity
2. ciprofloxacin--Dose: 750 mg PO BID; Toxicities: GI and CNS intolerance; Drug interactions are common; Levofloxacin may be preferred
3. levofloxacin--Dose: 500 mg PO QD; Toxicities: GI and CNS intolerance
4. clofazimine--Dose: 100-200 mg PO QD; Toxicities: Dose-related skin discoloration and GI intolerance; May not be useful for pulmonary MAC
5. rifampin--Dose: 10 mg/kg (600 mg max) PO QD; Toxicities (hepatotoxicity, fluid discoloration, hypersensitivity) ; Drug interactions are common

Front 38

anti-MAC therapy lifelng suppressive therapy is necessary unless: (3)

Back 38

1. asymptomatic for MAC
2. has completed 12 months of MAC therapy
3. CD4 count is greater than 100 for more than 6 months

**restart prophylaxis if CD4 drops below 100

Front 39

secondary prophylaxis for MAC (2)

Back 39

Azithromycin 500 mg po qd plus ethambutol 15 mg/kg po qd

Clarithromycin 500 mg po bid plus ethambutol 15 mg/kg po qd

Front 40

primary prophylaxis for MAC (2)

Back 40

Azithromycin (1,200 mg po weekly) or clarithromycin (500 mg po bid)
Alternative: rifabutin 300 mg po qd

Recommended for patients with CD4+ < 50 cells/mm3
May discontinue if CD4+ > 100 cells/mm3 for 3-6 months

Front 41

how could CMV present? (7)

Back 41

CMV may present as
1. Retinitis is the most common presentation (20-25%).
2. pneumonitis
3. hepatitis
4. GI ulcerations
5. encephalopathy
6. myeloradiculopathy
7. endocrine disorders.

Front 42

Implantable ganciclovir-containing disk delivers_____ of drug over _____

Back 42

1-2 mcg/hr of drug over 6-7 months

Front 43

prophylaxis of CMV

1. primary
2. secondary

Back 43

1. Primary prophylaxis for CMV is not recommended.

2. Intraocular plus oral ganciclovir may also be used as suppressive therapy; Valganciclovir 900 mg po qd may also be used as suppressive therapy.

Front 44

Immunocompromised patients require lifelong suppressive therapy for coccidiomycosis what is the drug used?

Back 44

fluconazole 400 mg QD

Front 45

therapy for coccidiomycosis (3)

Back 45

1. Amphotericin B 0.5-1 mg/kg/day IV for 7 days followed by 0.8 mg/kg IV QOD (preferred).
2. Fluconazole 400-800 mg PO QD.
3. Itraconazole 200 mg PO BID

Front 46

_______as become a preferred agent for treatment of candidiasis in HIV/AIDS patients because of ease of administration and high rates of clinical cure.

Back 46

Fluconazole

May be treated with a variety of topical (e.g., nystatin or clotrimazole), oral (e.g., fluconazole, itraconazole, or ketoconazole), or intravenous (e.g., fluconazole or amphotericin B) therapies

Repeated courses of fluconazole or prophylaxis with fluconazole may select for resistant Candida species.

Front 47

KS: predicts mild course (10)

Back 47

Few lesions (less than 25)
Slow spread
No visceral lesions
No systemic symptoms
No previous OI
CD4+ 400+ cells/mm3
Normal ESR
Undetectable p24
Normal beta-microglobulin
Normal blood counts

Front 48

KS: predicts aggressive course (10)

Back 48

Many lesions
Rapid spread
Intraoral or GI lesions
Systemic symptoms
History of OIs
CD4+ less than 200
ESR greater than 40 mm/hr
Detectable p24 antigen
beta-microglobulin greater than 5
Leukopenia or anemia

Front 49

KS treatment:non-life threatening cases (1)

Back 49

Interferon-alpha-2a (INFalpha-2a)
Dose: 10-36 MU/day IV, IM, or SC followed by 36 MU three times weekly.

Response 35-50%
If pretreatment CD4+ greater than 200 cells/mm3, better response.
toxicities: CNS, GI, rash, bone marrow suppression, and flu-like symptoms
Response can be observed in 6-8 weeks; however, maximal response may take months.

Front 50

KS treatment: life threatening (1 regimen-2 components)

Back 50

chemo with cytotoxic agents and radiation

cytotoxic agents: etoposide, vinblastine, vincristine, bleomycin, liposome-encapsulated doxorubicin, and liposome-encapsulated daunorubicin

Front 51

treatment of mild lesions of HSV in HIV/AIDS (3)

Back 51

1. Acyclovir 400 mg PO three to five times daily.
2. Famciclovir 250 mg PO TID or
3. valacyclovir 1 g PO BID have also been studied.

Treatment should continue until all lesions have completely crusted over.

Front 52

treatment of severe HSV infections (perianal uclers, colitis, esophagitis, and pneumonia) in HIV/AIDS (3)

Back 52

1. Acyclovir 5 mg/kg IV Q8H (increase to 10 mg/kg if CNS involvement)

Acyclovir resistance suspected or persistent infection:
2. Foscarnet 40 mg/kg IV Q8H
3. Ganciclovir 5 mg/kg IV Q12H

Front 53

suppressive therapy for HSV infections in HIV/AIDS (4)

Back 53

Acyclovir 400 mg PO PO BID or 200 mg TID
Foscarnet 40 mg/kg IV QD
Famciclovir 250 mg PO BID
Valacyclovir 500 mg PO QD

Front 54

varicella zoster virus dermotomal infections usually resolve without therapy but if the lesions persist or become troublesome what therapy is used? (3)

Back 54

Acyclovir 800 mg PO five times daily
Famciclovir 500 mg PO TID
Valacyclovir 1 g PO TID may also be used.