CASE 1 54 yo man HIV positive 8 yrs ago Tenofovir/FTC/RTV/Atazanavir x 4 yrs Previously documented NNRTI resistance with Y181C, G190A,and mixed m184v/wt.

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Presentation transcript:

CASE 1 54 yo man HIV positive 8 yrs ago Tenofovir/FTC/RTV/Atazanavir x 4 yrs Previously documented NNRTI resistance with Y181C, G190A,and mixed m184v/wt CD4 320 HIV Viral Load<40

CASE 1 Genotype 1a Hepatitis C biopsy proven cirrhosis Compensated and clinically stable Previous therapy in 2009 with Peg INF/1200mg RBV daily resulted in a null response by history from the patient

CASE 1 Patient is interested in a retrial of therapy for Hepatitis C with the new direct acting antiviral agents Would you offer treatment? Chance of cure? Which 3 rd agent would you choose and why? Does patient’s antiretroviral history play a role in 3 rd agent choice? Is there a role for a 4 week lead in here regardless of agent chosen and if so…why?

CASE 1 It was decided to move forwards with Peg INF/ 1200mg RBV/Telaprevir Is it necessary to change current ARVs? Would it be necessary to change ARVs if Boceprevir was chosen?...to what?

CASE 1 Peg INF/1200mg RBV/Telaprevir…no lead in performed Week 0 HCVRNA 3.7 x 10e7 Week 4 HCVRNA detectable but<12 Would you continue? Are you concerned about the result? When would you do the next HCVRNA?

CASE 1 It was decided to continue with Peg INF/1200mg RBV/Telaprevir and HCVRNA rechecked Week 0 HCVRNA 3.7 x 10e7 Week 4 HCVRNA detectable but<12 Week 6 HCVRNA <12 Would you continue?

CASE 1 Peg INF/1200mg RBV/Telaprevir Week 0 HB 140 Week 2 HB 125 Week 4 HB 109 Week 6 HB 99…symptomatic How would you manage anemia?

CASE 1 Peg INF/600mg RBV/Telaprevir Week 0 HCVRNA 3.7 x 10e7 Week 4 HCVRNA detectable but<12 Week 6 HCVRNA <12 HB 99 (symptoms) Week 8 HCVRNA <12 HB 98 (less sympt.) What would you do? How would you further manage anemia

CASE 1 Peg INF/600mg RBV/Telaprevir Week 0 HCVRNA 3.7 x 10e7 Week 4 HCVRNA detectable but<12 Week 6 HCVRNA <12 Week 8 HCVRNA <12 Week 12 HCVRNA detectable but <12 HB 103 What would you do? When would you do your next HCVRNA?

CASE 1 Peg INF/RBV re-increased to 1200mg Week 0 HCVRNA 3.7 x 10e7 Week 4 HCVRNA detectable but<12 Week 8 HCVRNA <12 Week 12 HCVRNA detectable but <12 Week 14 HCVRNA <12 HB 101 What would you do?

CASE 1 Peg INF/1200mg RBV Week 0 HCVRNA 3.7 x 10e7 Week 4 HCVRNA detectable but<12 Week 12 HCVRNA detectable but <12 Week 14 HCVRNA <12 HB 101 Week 24 HCVRNA <12 HB 105 How much longer would you treat? When would you do your next HCVRNA?

CASE 1 Peg INF/1200mg RBV Week 0 HCVRNA 3.7 x 10e7 Week 4 HCVRNA detectable but<12 Week 12 HCVRNA detectable but <12 Week 24 HCVRNA <12 Week 36 HCVRNA <12 Week 48 HCVRNA <12 Are we finished therapy?

CASE 1 An additional 24 weeks of PEG INF/RBV (for a total of 72 weeks of therapy) was offered to the patient given the existence of cirrhosis and ?slow HCVRNA clearance as evidenced by a detectable HCVRNA at week 4 and 12 Week 12 and 24 HCVRNA post 72 weeks of therapy were undetectable!