1. Therapeutics IV Tutoring Lisa Hayes lhayes3@uthsc.edu March 17, 2016

2. Outline HIV Transplant – Meds – Immunology – Complications Infectious Non-infectious

3. HIV – Things to Know If you have an APhA Manual – use it for practice questions* Know major SE of drugs Know class of drugs Know common regimens and what should be included in regimen Know pregnancy and baby recommendations Did he tell you to learn the three letter abbreviations? :/

4. Based on current recommendations, which of the following patients should be started on HAART? A – 34 year old female with PCP PNA and CD4 count of 138 B – 54 year old male IVDA with CD4 count of 396 positive for Hepatitis C C – 62 year old female nurse with CD4 count of 505 who contracted HIV from needle stick exposure without proper post-exposure prophylaxis D – all of the above

5. BB is starting the following medications for treatment of HIV: --- Efavirenz --- Tenofovir --- Lamivudine --- TMP-SMX What should we counsel BB about regarding efavirenz? A – anemia B- CNS side effects C – neutropenia D – renal toxicity E – kidney stones

6. Which of the classes of drugs has a class warning for hepatomegaly and lactic acidosis? A – NNRTI B – PI C – NRTI D – Integrase Inhibitor E – pharmacoenhancer

7. Which of the following can cause hepatotoxicity and requires monitoring liver enzymes? A – Zidovudine B – Zalcitabine C – Lopinavir-ritonavir D – Fosamprenavir E – Nevirapine

8. Which medication requires HLAB*5701 testing before administration? A – Abacavir B – Ritonavir C – Zidovudine D- Lamivudine E – Efavirenz

9. Which of the following drugs is both adjusted in renal failure and if the patient is less than 60kg? A – Lamivudine B – Stavudine C – Zidovudine D – Efavirenz

10. AA is a patient who presents to your clinic with signs of PNA. It is discovered that she has PCP PNA. Her CD4 count is measured and is 250. She has never been diagnosed with HIV or AIDS before. Provide an appropriate diagnosis. A – AIDS, no HAART B – AIDS, start HAART C – HIV, no HAART D – HIV, start HAART

11. What drug could have been used to prevent AA’s PCP PNA if it had been known she had AIDS? A – Cipro B – SMP-TMX C – Acyclovir D – Doxycycline

12. Which HIV medication is known to cause kidney stones? A – indinavir B – lamivudine C – didanosine D – efavirenz

13. GG is a pregnant woman who arrives to your ER in labor. She has had no prenatal care. A rapid HIV test is preformed and is determined she is positive for HIV. What should be your course of action? A – start HAART B – give zidovudine gtt C – give zidovudine gtt + infant prophylaxis D – nothing

14. EC is a 25 year old female with HIV. She is on HAART containing efavirenz. She is also on Lo-Estrin. What should you counsel her on? A – Efavirenz will increase the efficacy of her Lo-Estrin. B – Lo-Estrin will decrease the efficacy of her Efavirenz. C - Efavirenz can be teratogenic especially in the second trimester. D – Efavirenz will decrease the efficacy of her Lo-Estrin.

15. CG has a CD4 count of 25. Choose the correct group of prophylactic medications given his immunosuppression. (High rates of Histo in his community) A – Clarithromycin 1200mg every week, Septra DS 1 tab daily B - Azithromycin 1200mg/day, Septra DS 1 tab daily, Itraconazole 100mg/day C- Azithromycin 1200mg/week, Septra DS 1 tab/day, Itraconzole 200mg/day D – Septra DS BID, Clarithromycin 500mg/day, Itraconazole 200mg/day

16. Transplant – Things to Know If you have APhA manual – use for practice questions* Know MOA for drugs, what signal they inhibit Know risk factors (low v high) and when to use double, triple, quadruple therapy Know SE of drugs and how to work around these Know how to treat rejection – Different types of rejection (telling them apart)

17. Determine the number of risk factors for the following patient: GG is a 12 year old AA patient receiving a kidney transplant. CIT was 3 hours. Her graft had good function after transplant and her UOP has been good since surgery. This is her first transplant. PRA was 35% and HLA match was poor (2). Her kidney is coming from her father. A – 5 B – 4 C – 3 D- 2

18. Recommend appropriate therapy for GG. A - single therapy B – double therapy C – triple therapy D – quadruple therapy

19. Determine the HLA match. Recipient: A 2, 4 B 5,6 DR 11, 12 Donor: A 2, -- B 5, -- DR 11, ---

20. During which phase is the largest amount of immunosuppressants given? A – induction B – maintenance C – adjustment

21. What signal does Belatacept block? A – Signal 1 B – Signal 2 C – Signal 3

22. Which signal does Basoliximab block? A – Signal 1 B – Signal 2 C – Signal 3

23. Which drug can be used for B-cell rejection but cannot be used for T-cell rejection? A – prednisone B – thymocyte globulin C – Rituximab D - Methylprednisolone

24. What disease is common when a patient is co-infected with Epstein Barr virus? A – Cytomegalovirus B – Hepatitis C – Post Transplant Lymphoproliferative Dx D – skin and lip malignancies

25. YY is profoundly hypertensive 3 months after liver transplant. Immunosuppressive therapy includes Cyclosporine, AZA, Prednisone. What would be the best recommendation? A – Add metoprolol B – Add nifedipine C – lifestyle modifications only D – Add furosemide

26. Which drug is the worst offender for hypertriglyceridemia? A – CSA B – Sirolimus C – Rituximab D – Tacrolimus

27. What is the most common malignancy in transplant patients? A – skin and lip cancer B – leukemia C – bone cancer D – PTLD

28. If a patient with a kidney transplant has high blood glucose on CSA, What would be an appropriate solution? A – start insulin at every meal B – change from CSA to sirolimus C – change from CSA to tacrolimus D – start metformin

29. What drug can be used to treat tremors associated with calcineurin inhibitors? A – furosemide B – nifedipine C – phenytoin D - propranolol

30. A female patient is experiencing severe hair loss on tacrolimus. She comes to you in your community pharmacy. What would you recommend to her MD since she is now refusing to take the medication? A – stop tacrolimus, start sirolimus B – stop tacrolimus, start CSA C – stop tacrolimus, increase prednisone

31. A patient on mycophenolate mofetil BID and tacrolimus QD is experiencing diarrhea that is interfering with his life. At his clinic appointment, he expresses his concern about this and asks you what he could do to help with this severe SE. A – change from BID to QID B – decrease dose of mycophenolate C – change to mycophenolic acid D – change to AZA

32. Which vaccine could you administer to a transplant patient? A – Varicella B – Zoster C - MMR D – Influenza

33. Prophylaxis for Infections Review – Kidney No fungal prophylaxis Need VIRAL + PCP – All other organs Fungal VIRAL PCP

34. Prophylaxis Fungal Prophylaxis Fluconazole 200-400mg PO daily Viral Prophylaxis (1 mo post transplant) – CMV prophylaxis or – Acyclovir 400 PO BID – Valacylovir 500 PO BID PCP – SMX-TMP 400/80mg – 800/160mg PO daily for 6-12 mo SULFA allergy – Dapsone 50-100mg daily

35. HT is a kidney transplant who has presented with a UTI because you did not provide the appropriate prophylaxis. Her UTI appears to be mild and was diagnosed at a routine visit before she began exhibiting symptoms. What drug regimen would you recommend? A – Unasyn x 7 days B – Cipro x 7 days C – Cipro x 14 days D – Zosyn x 14 days

36. A patient is high risk for CMV due to the donor being positive and recipient being negative. What should you recommend? A – Ganciclovir 5mg/kg IV q12 hours B – Ganciclovir 5mg/kg IV daily C – Valganciclovir PO daily based on CRCL D – Acyclovir PO 400 BID

37. There was a question at the end of tutoring about patient:graft ratio and which one was best. I have looked at the graphs. It appears that for overall survival – it looks like patient survival is best for kidney (living donor). Additionally it looks like the best patient:graft survival ratio is also for living donor kidney. You must pay special attention to the AXES on these graphs because they are different for each graph and make the graphs misleading when comparing them side/side.

38. Questions?