RESUMO
BACKGROUND: Tenofovir disoproxil is efficacious in the preventing HIV infection as part of a pre-exposure prophylaxis (PrEP) regimen. Although its use has been associated with impaired renal function, instances of Fanconi syndrome are extremely rare. This may change with increased uptake of PrEP. METHODS: A 55-year-old male patient (he/him/his) was commenced on PrEP with a baseline estimated glomerular filtration rate (eGFR) of approximately 60mL/min/1.73m2 . RESULTS: Within 6months, he developed new and worsening proteinuria, glycosuria and aminoaciduria despite no apparent change in eGFR. PrEP was discontinued and his urinary abnormalities rapidly resolved. The patient remains off PrEP. CONCLUSIONS: Fanconi syndrome is a rare, but known complication of tenofovir disoproxil. This is the first report related to PrEP in Australia. While tenofovir associated nephrotoxicity in patients taking PrEP is uncommon, the patient's age and pre-existing renal impairment placed him at substantially higher risk. At-risk patients need more frequent monitoring of their eGFR and proteinuria. Urinary protein to creatinine ratio is the preferred to dipstick testing for proteinuria and the latter does not readily detect the low molecular wight proteinuria characteristic of tenofovir toxicity. Early recognition of these patients is essential, as prompt cessation of PrEP can often reverse renal abnormalities.
Assuntos
Fármacos Anti-HIV , Síndrome de Fanconi , Infecções por HIV , Profilaxia Pré-Exposição , Insuficiência Renal , Fármacos Anti-HIV/efeitos adversos , Emtricitabina/efeitos adversos , Síndrome de Fanconi/induzido quimicamente , Síndrome de Fanconi/tratamento farmacológico , Infecções por HIV/tratamento farmacológico , Infecções por HIV/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Proteinúria/induzido quimicamente , Proteinúria/tratamento farmacológico , Tenofovir/efeitos adversosRESUMO
We report the first case of reactive arthritis associated with lymphogranuloma venereum (LGV) proctitis in Australia. Since 2004, LGV proctitis has emerged as an important infection worldwide in men who have sex with men. While reactive arthritis is usually associated with serovars D to K of Chlamydia trachomatis, association with LGV serovars is historically rare. Screening for chlamydial infection should be considered in this group if they present with an acute arthritis otherwise the condition could go undiagnosed. Asymptomatic infections are being increasingly reported in Europe and prolonged treatment is required to ensure a cure.
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Artrite Reativa/etiologia , Infecções por Chlamydia/complicações , Chlamydia trachomatis/isolamento & purificação , Linfogranuloma Venéreo/complicações , Proctite/complicações , Administração Oral , Antibacterianos/uso terapêutico , Austrália , Infecções por Chlamydia/tratamento farmacológico , Infecções por Chlamydia/microbiologia , Chlamydia trachomatis/efeitos dos fármacos , Chlamydia trachomatis/genética , Doxiciclina/uso terapêutico , Infecções por HIV/virologia , Homossexualidade Masculina , Humanos , Linfogranuloma Venéreo/diagnóstico , Linfogranuloma Venéreo/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Proctite/tratamento farmacológico , Proctite/microbiologia , Comportamento Sexual , Parceiros SexuaisRESUMO
Ritonavir, a protease inhibitor (PI), is a potent inhibitor of cytochrome P450 3A4. This pharmacological effect, even at low doses (=200 mg/d), is used to "boost" levels of other PIs in the treatment of HIV infection and facilitate once or twice daily dosing with reduced pill burden. Six patients with preexisting HIV-lipodystrophy developed symptomatic Cushing's syndrome when treated with inhaled fluticasone at varying doses for asthma while concurrently treated with low-dose ritonavir-boosted PI antiretroviral therapy (ART) regimens for HIV infection. There was evidence of adrenal suppression in all patients on stimulation studies. After the withdrawal of inhaled fluticasone, four patients became symptomatic of hypocortisolism, and three required oral corticosteroid support for several months. Other complications included evidence of osteoporosis (n = 3), crush fractures (n = 1), and exacerbation of preexisting type 2 diabetes mellitus (n = 1). In part, the diagnosis of fluticasone-induced Cushing's syndrome was delayed because all patients had preexisting body composition changes of ART-associated lipodystrophy, masking the Cushing's features. Practitioners should be aware of the impact on the adrenal axis of coadministration of PI-based ART regimens with inhaled corticosteroids and the potential for exacerbating or even inducing other metabolic conditions, such as osteoporosis or diabetes.
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Insuficiência Adrenal/induzido quimicamente , Androstadienos/efeitos adversos , Síndrome de Cushing/induzido quimicamente , Inibidores da Protease de HIV/efeitos adversos , Osteoporose/induzido quimicamente , Ritonavir/efeitos adversos , Administração por Inalação , Adulto , Interações Medicamentosas , Fluticasona , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
INTRODUCTION: The increasing age, higher modifiable and inherent cardiovascular disease (CVD) risk of HIV-infected patients [1] necessitates improved approaches to reducing co-morbidities. We aimed to assess the effectiveness of a team intervention in reducing modifiable CVD risk. MATERIALS AND METHODS: HIV-infected patients ≥50 years attending a large HIV caseload primary-care practice, who were virologically suppressed on antiretroviral therapy (ART), with moderate or severe 10-year CVD Framingham risk (≥10%) were recruited for this prospective case-control study. Intervention participants were provided a team approach to care, which involved treatment by study doctors for lipid, hypertension and ART management, and monthly review by a team of research nurses and dieticians for smoking cessation, exercise and dietary advice over 12 months. Controls were matched on age and smoking status, and were given standard of care (SOC) by non-study doctors. Outcomes included CVD risk factors, body composition and CVD risk assessment, including Framingham 10-yr risk [2] and D:A:D 5-year estimated risk of coronary heart disease (CHD) [3]. Repeated measures analysis of variance was used to examine pre- and post-intervention differences, with p-values used to assess time and main effects of approach to care (Intervention, SOC). RESULTS: A total of 33 patients completed the intervention, with 33 controls (58.0±6.8 and 59.1±6.9 years, respectively). Smoking cessation occurred in 25% cases versus nil controls. There was a significant change in CVD risk between intervention and control groups, in both Framingham scores (time and group×time interaction) and D:A:D scores (group×time interaction only) (Table 1). There was also a significant difference in change in total cholesterol over the study period (time and group×time interaction). Body composition was only measured in intervention patients, with a significant loss in % body fat observed in pre- and post-intervention. CONCLUSIONS: Team intervention was significantly more effective than standard of care in reducing CVD risk in HIV-infected patients on ART. A team approach to care may be an important component of reducing CVD risk in this population.
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OBJECTIVE: To determine the prevalence, characteristics and virological outcomes of triple-class antiretroviral drug failure (TCF) and triple-class virological failure (TCVF) in HIV-infected patients attending an Australian high caseload primary care clinic. METHODS: Cross-sectional observational study using a retrospective review of electronic medical records from 1007 patients with HIV attending Holdsworth House Medical Practice in Darlinghurst, Australia, between 2007 and 2008. TCF was defined as failure (virological, immunological, clinical, intolerance or other) of at least one drug in each of the three major classes of highly active antiretroviral therapy. RESULTS: A total of 51 patients (5.1%) with TCF were identified. Of these patients, 31.4% had experienced virological failure of each of the three main drug classes. Eighty-eight percent of patients with TCF and 75% of patients with TCVF had achieved virological suppression (HIV RNA <400 copies mL(-1)). Total mean (s.d.) duration on antiretroviral therapy (ART) was 12.2 (3.3) years, with patients receiving an average of 18 antiretroviral drugs during this period. Reasons for treatment change included intolerance (88% of patients), virological failure (84%), immunological failure (24%) and poor adherence (20%). CONCLUSIONS: The prevalence of TCF and TCVF in patients with long-term HIV infection and extensive antiretroviral experience is low in primary care sites. Despite experiencing failure to the three main classes of ART, successful virological outcomes are still achievable in the majority of such patients.
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Fármacos Anti-HIV/administração & dosagem , Terapia Antirretroviral de Alta Atividade/métodos , Infecções por HIV/tratamento farmacológico , Inibidores da Transcriptase Reversa/administração & dosagem , Adulto , Fármacos Anti-HIV/farmacologia , Austrália/epidemiologia , Contagem de Linfócito CD4 , Estudos Transversais , Farmacorresistência Viral Múltipla , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/virologia , HIV-1/efeitos dos fármacos , Homossexualidade Masculina/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Atenção Primária à Saúde , Estudos Retrospectivos , Inibidores da Transcriptase Reversa/farmacologia , Resultado do Tratamento , Carga Viral , Adulto JovemRESUMO
Since 2002, biennial production of sexually transmissible infection testing guidelines for men who have sex with men has supported sexually transmitted infection control efforts in inner Sydney, Australia.