November, 2010

Thanks to everyone who was able to make it to the conference this month.  Next month's case conference is on Wed, December 15th from 1-2pm in the CHCC basement conference room.  Please send me any cases you would like to discuss.  You are also welcome to call, email or page me with questions or suggestions at any time.

This month we discussed three challenging cases including:

Case 1:
A woman doing very poorly (CD4 count <5, VL >100,000) for several months despite being prescribed ARVs.   She came in stating that she lost her ARVs and needed an override to get an early refill and also needed more narcotic pain medication. The patient resides at the Brook where they have a voluntary medication supervision program. The program allows patients to have their medications stored and doses monitored by staff at the Brook.  She refused to join the supervision program and insists that she wants her ARVs and pain medications as she has always been getting them.

Discussion:
For patients in these types of situations (advanced AIDS failing treatment) it is appropriate to begin talking about end of life issues including designating a health care proxy and discussing what they would want done if and when they become seriously ill.  Sometimes this type of discussion can be a wake-up call for people to recognize that what they have been doing so far is not working and that a drastic change needs to take place in their approach to treatment.  Because based on the available evidence (no resistance mutations on a genotype taken while she was on therapy) it seems highly likely that the patient has not been taking her ARV medications one could consider explaining to her that you will no longer continue to prescribe ARV therapy unless she is willing to participate in medication supervision.

Case 2:
A patient currently receiving ARV therapy through the ARGUS DOT program who has also been doing poorly with a high VL and low CD4.  She receives several days worth of methadone at a time because she has a waiver stating that she can't travel to the clinic daily to get her doses due to her medical condition.  The staff at ARGUS are concerned because she seems to have significant cognitive deficits (dementia) and forgets whether or not she took her methadone and then frequently takes too much methadone making her even more confused and lethargic.  In addition she is frequently not at home making it difficult for DOT to administer her medications. 

We discussed that for this patient we need to arrange a meeting with the methadone clinic, CHCC physician and the ARGUS case management staff to address these issues and to try and arrange a safer way for her to get her methadone.  One possibility is for her to go back to getting daily pick-up of her methadone with DOT of her ARVs at the methadone clinic.

Case 3:
A patient who has had an elevated VL for many months recently noted to have resistance on a prior genotype to his current ARV therapy.  The patient had suppressed his VL on this regimen in the past, but now has persistent viremia. 

We discussed how to approach the loss of viral suppression and when patients need to change to a new ARV regimen.  The bottom line is that if your patient has persistent viremia on therapy you need to discuss the patient with an HIV provider and we can help you make use of the many resources available to investigate and help solve the problem.  See below for a more detailed discussion on how to do this.

FINDING OUT WHY THE VL IS ELEVATED:
Any time a patient has an elevated VL after they have suppressed to <50 there is need for concern and more investigation needs to be done.  Possibilities include: poor adherence to their medications (due to a variety of reasons including side effects, pill burden, substance use, depression, forgetfulness, etc.), drug interactions (for example taking a PPI or other acid-reducing medications while on reyataz leading to poor absorption of the reyataz), the development of resistance to their ARVs, or a "blip" (a SINGLE episode of elevation in VL (51-1,000) that could be due to lab variation).

To assess the cause of the elevated VL you need to bring the patient back to clinic (ideally within 2-4 weeks) repeat the VL and discuss adherence, side effects, review possible drug interactions and consider obtaining a genotype and reviewing ALL previous genotype results.

GETTING PRIOR GENOTYPE RESULTS:
Prior genotype results can be obtained by calling Biosciences Monogram at 1-800-777-0177 and asking them to fax them to you.

ORDERING A GENOTPYE:
The most frequent cause of a rise in VL after initial suppression is lack of adherence and lack of adherence leads to the development of resistance mutations so resistance needs to be excluded (get a genotype on therapy) if a patient has repeated elevated VL measurements (>=2 elevated VLs in a row).  The VL needs to be >500 in order to obtain a genotype and this is something you should probably discuss with an HIV provider when you are considering ordering it, to make sure you order the correct test based on the medications the patient is taking and their particular situation.

Genotype results typically take just over a week to come back and you can call 1-800-777-0177 to get them faxed to you.

WHAT TO DO WHEN THE GENOTYPE SHOWS RESISTANCE:
If there is evidence of resistance to the patient's current regimen you need to change therapy.  Patients should NOT continue taking a regimen that they have known resistance to as this can result in the development of additional resistance mutations (to additional drugs) further limiting their future treatment options.  The only time we do continue patients on a failing regimen is when there are NO other options, and this is rarely the case.

The next step is to start the patient on a new regimen with at least 2 and ideally 3 active drugs based on ALL prior genotype results.  When starting a new regimen it is important to make sure the patient will be able to adhere to their therapy (see next section).  You should always consult an HIV provider when changing a patient to a new ARV regimen.

IMPROVING ADHERENCE:
If adherence is an issue.  We have several options available to help patients adhere to their medications including DOT, pillboxing (at CHCC with Norma Cordero and Angela (917-568-7676) or through MOMS pharmacy), MOMS packs (meds dispensed in daily dose packets that are easy to carry to work etc. More info at http://www.momspharmacy.com/HealthcareProfessionals.html   MOMS pharmacy is an HIV specialty pharmacy and they can be reached at 1-800-218-5604 phone or fax 1-800-218-4924)

MENTAL HEALTH RESOURCES:
For patients struggling with depression and/or other mental illnesses you can refer them to Dr. Veronika Voyages (CICERO psychologist) and Dr. Karin Glover (CICERO psychiatrist) for psychiatric care and counseling.  Please remember to always send Dr. Voyages and Dr. Glover an email explaining why you are making the referral and make sure to book any new patients in NEW patient appointment slots.


Please let me know if you have any other resources or suggestions to share.  Hope to see you at our next conference, Wed Dec 15th.

Laura

646-267-4307 cell, 917-949-8771 pager, laguderi@montefiore.org

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