Evaluation of rates of virologic suppression in HIV-positive patients with varying numbers of comorbidities.

PURPOSE: To evaluate the impact of the number of comorbidities on virologic suppression in HIV-positive patients. METHODS: This study included patients 18 years or older who were on antiretroviral therapy (ART) with at least 2 visits to an HIV primary care clinic in the past year. The primary outcome was the percentage of patients with an undetectable viral load (a blood HIV RNA level of <20 copies/mL) among groups of patients with 0, 1 or 2, 3 or 4, and 5 comorbidities, respectively. The secondary outcome was the percentage of patients with undetectable viral loads per each comorbidity, as listed above. The study was reviewed by an institutional review board and approved as exempt from full review. RESULTS: Among the 1,144 patients (median age of 52 years, 43% female, 74% Black) included in the study, 80% had an undetectable viral load, and the mean CD4 count was 638 cells/mm3. The majority of patients (48%) had 1 or 2 comorbidities, with only 2 patients having 5 comorbidities. For patients with 0, 1 or 2, 3 or 4, and 5 comorbidities, the percentages of patients with undetectable HIV viral loads were 76%, 81.7%, 87.9%, and 100%, respectively (P = 0.0009 in χ 2 test for trend). When looking at individual comorbidities, corresponding viral suppression rates were as follows: chronic kidney disease, 88.6%; hypertension, 85.8%; type 2 diabetes, 85.7%; clinical atherosclerotic cardiovascular disease, 83.1%; substance abuse, 76%; and psychiatric disorders, 75.2%. CONCLUSION: Improved viral suppression was seen among HIV-positive patients with an increased number of comorbidities. Patients with psychiatric disorders had the lowest viral suppression rates amongst all of the comorbidity subgroups.

Evaluation of virologic suppression rates during the COVID-19 pandemic with outpatient interdisciplinary HIV care.

Introduction: The Coronavirus Disease 2019 (COVID-19) pandemic has presented social distancing challenges leading healthcare systems to adapt and utilize telemedicine platforms more than ever before. Reducing patient exposure to COVID-19 became a primary concern, especially for populations at an increased risk for severe illness, such as human immunodeficiency virus (HIV) positive patients. Objectives: The primary objective of this study was to measure the impact of pharmacy services including telehealth through the percentage of virologically suppressed patients (HIV ribonucleic acid [RNA] < 200 copies/mL) during the pre-COVID and post-COVID time periods. Secondary objectives included the percentage of patients with undetectable viral loads (HIV RNA < 20 copies/mL), percentage of patients with cluster of differentiation 4 (CD4) cell counts greater than 200 cells/mm3, and changes in CD4 cell counts and percentages pre-COVID and post-COVID. Methods: This was a retrospective chart review at a single center HIV primary care clinic in Brooklyn, NY evaluating electronic medical records (EMRs) of 211 HIV-positive patients. Pre-COVID was defined as 1 year prior to March 13, 2020, and post-COVID was defined as March 13 to July 20, 2020. Results: Viral load suppression rates for pre and post-COVID were 88.6% and 85.3%, respectively (P = .28). Undetectable viral load rates for pre and post-COVID were approximately 81.5% and 74.4% (P = .096). Mean CD4 cell counts and percentages were 617 cells/mm3 and 29% for pre-COVID, and 460 cells/mm3 and 22% for post-COVID. CD4 cell counts greater than 200 cells/mm3 pre-COVID and post-COVID was 92.6% and 78.3%, respectively (P = .001). Conclusion: Utilization of pharmacy services including telehealth, may allow clinical pharmacists to collaboratively provide remote services without jeopardizing patient outcomes. Larger studies are needed to confirm these findings, and display the long-term impact and satisfaction of these services.

The Role of Antisense Therapies Targeting Lipoprotein(a).

ABSTRACT: Atherosclerotic cardiovascular disease (ASCVD) continues to be the leading cause of preventable death in the United States. Elevated low-density lipoprotein cholesterol (LDL-C) is well known to result in cardiovascular disease. Mainstay therapy for reducing LDL-C and ASCVD risk is statin therapy. Despite achieving desired LDL-C levels with lipid-lowering therapy, cardiovascular residual risk often persists. Elevated lipoprotein(a) [Lp(a)] levels have been highlighted as an inherent independent predictor of ASCVD, and decreasing Lp(a) levels may result in a significant reduction in the residual risk in high-risk patients. To date, there are no approved medications to lower Lp(a) levels. Nicotinic acid, proprotein convertase subtilisin/kexin 9 inhibitors, and antisense oligonucleotide have demonstrated modest to potent Lp(a) reduction. Spotlight has been placed on antisense oligonucleotides and their role in Lp(a) lowering. APO(a)LRx is in the frontline for selectively decreasing Lp(a) concentrations and ongoing research may prove that this medication may lower Lp(a)-mediated residual risk, translating into cardiovascular benefit.

Safety and Efficacy of Weight-Loss Pharmacotherapy in Persons Living with HIV: A Review of the Literature and Potential Drug-Drug Interactions with Antiretroviral Therapy.

The prevalence of obesity among persons living with human immunodeficiency virus (HIV) has increased significantly and may be linked to the use of antiretroviral therapy. Although weight-loss medications approved by the U.S. Food and Drug Administration are recommended as an adjunct to diet and exercise to treat obesity in the general population, little is known about the safety and efficacy of these drugs specifically in persons living with HIV. We review the available evidence regarding the effective use of weight-loss pharmacotherapy in persons living with HIV and its potential to interact with antiretroviral therapy. Persons living with HIV are frequently not reported or included in clinical trials for weight-loss medications; however, treatment efficacy is likely similar to the general population. Several important reported or theoretical drug-drug interactions exist between antiobesity pharmacotherapy and antiretroviral therapy. Orlistat is a weight-loss drug available in the United States without a prescription and was linked to HIV viral rebound in several case reports. Clinicians should be aware of the potential for loss of HIV viremia control when certain weight-loss pharmacotherapies are used in combination with antiretrovirals.

New and Emerging Evidence on the Use of Second-Generation Direct Acting Antivirals for the Treatment of Hepatitis C Virus in Renal Impairment.

Due to the intimate relationship between liver and kidney disease in hepatitis C virus (HCV) infection, treatment options for HCV-positive patients at any stage of chronic kidney disease (CKD) are essential. The availability of second-generation, direct-acting antiviral (DAA) combinations has allowed for the advent of interferon-sparing treatment regimens with shorter durations and minimal side effects. While many of the second-generation DAAs are principally metabolized by the hepatic system, dosing in severe renal impairment (creatinine clearance [CrCl] <30 mL/min) or dialysis has remained questionable due to limited experience. New evidence regarding the use of these agents in renal impairment continues to become available, as real-world experience with these treatment regimens is reported. Simeprevir, ledipasvir, paritaprevir, ombitasvir, dasabuvir, and daclatasvir have data to suggest safety in end-stage renal disease. While safety and efficacy with sofosbuvir remains uncertain, data are now available to support utilizing a dose adjustment when glomerular filtration rates are <30 mL/min. Upcoming regimens grazoprevir/elbasvir and daclatasvir/asunaprevir/beclavubir may provide further options for patients with advanced kidney disease, and ongoing studies will continue to provide guidance for this unique patient population. This article will review the currently available literature, including the newest emerging evidence, on the use of second-generation DAAs in CKD stages 3 to 5 and dialysis.

Elevated International Normalized Ratio in a Patient Taking Warfarin and Mauby: A Case Report.

We describe a 70-year-old Haitian man who had been taking warfarin for 5 years for atrial fibrillation and pulmonary hypertension. This patient had his international normalized ratio (INR) checked in the pharmacist-run anticoagulation clinic and was followed monthly. Prior to the interaction, his INR was therapeutic for 5 months while taking warfarin 10.5 mg/d. The patient presented with an INR > 8.0. Patient held 4 days of warfarin and restarted on warfarin 8.5 mg/d. Two weeks later, his INR was 2.5. After continuing dose, patient presented 2 weeks later and INR was 4.8. Upon further questioning, the patient stated he recently began ingesting mauby. Mauby is a bitter dark liquid extracted from the bark of the mauby tree that is commonly used in the Caribbean population as a folk remedy with many health benefits. This case report illustrates that mauby may have a probable drug-herb interaction (Naranjo Algorithm Score of 6) when given with warfarin. There is a lack of published literature and unclear information on the Internet describing the interaction of mauby and warfarin. Health professionals should be cautious regarding interactions between warfarin and mauby until the interaction is fully elucidated.

Real-World Sustained Virologic Response Rates of Sofosbuvir-Containing Regimens in Patients Coinfected With Hepatitis C and HIV.

BACKGROUND: Patients with hepatitis C virus (HCV) with or without human immunodeficiency virus (HIV) achieve high sustained virological response (SVR) rates on sofosbuvir (SOF)-containing regimens in clinical trials. Real world data on patients coinfected with HCV and HIV treated with SOF-based regimens are lacking. METHODS: This observational cohort study included HIV/HCV-coinfected adults with genotype 1 HCV who initiated treatment with a SOF-containing regimen between December 2013 and December 2014 (n = 89) at the Mount Sinai Hospital or the Brooklyn Hospital Center. The primary outcome was SVR at 12 weeks after the end of treatment. The secondary outcomes were risk factors for treatment failure, serious adverse events, and side effects. A post hoc per protocol analysis of SVR was performed on patients who completed treatment and follow-up. RESULTS: In an intention-to-treat analysis, SVR rates were 76% (31/41) for simeprevir (SMV)/SOF, 94% (16/17) for SMV/SOF/ribavirin (RBV), and 52% (16/31) for SOF/RBV. The SVR rates of SMV/SOF/RBV and SMV/SOF did not differ significantly in this small study (P = .15). However the SVR rate of SMV/SOF/RBV was higher than that of SOF/RBV (P < .01). In a per protocol analysis, SMV/SOF/RBV had a higher SVR rate than SOF/RBV: 100% (16/16) vs 57% (16/28) (P < .01). The most commonly reported adverse effects were rash, pruritus, fatigue, and insomnia. One patient who had decompensated cirrhosis prior to treatment initiation died after receiving SMV/SOF. CONCLUSIONS: SMV/SOF ± RBV is an effective option with minimal adverse effects for most HIV-positive patients with genotype 1 HCV. SMV should be used with caution in patients with decompensated cirrhosis.

Ceftolozane/Tazobactam: a new option in the treatment of complicated gram-negative infections.

Ceftolozane/tazobactam: a new option in the treatment of complicated gram-negative infections.