1. VIRTUAL MEDZONE Your Resource for HIV Related Innovative Medical Communication

2. CASE PRESENTATIONS Mahin Baqi MD FRCPC Ken Logue MD David Fletcher MD FRCPC

3. CASE 1 58 y.o. man HIV + 1989 CD4 200 on diagnosis Previous history of depression and chronic intermittent diarrhea

4. CASE 1 DATEARV REGIMEN 1989AZT 1992AZT/ddI 1994AZT/ddC/3TC 1996D4T/3TC/Saquinavir… viremia 1997D4T/3TC/Indinavir… viremia 1999D4T/ddI/Nevirapine… viremia

5. CASE 1 2001 stopped meds due to neuropathy, ongoing viremia and chronic diarrhea CD4 104 HIV VL 266, 131 c/ml No genotype available

6. CASE 1 Restarted AZT/3TC/Abacavir/Lopinavir/ Amprenavir/Nevirapine TIMECD4HIV VIRAL LOAD 0104266131 6 wks1861408 10 wks230461 18 wks2443257

7. CASE 1 GENOTYPE SEPTEMBER 2001

8. CASE 1 TIMECD4HIV VIRAL LOAD 18 wks2443257 24 wks1954613 32 wks1824917 48 wks2505766 72 wks16011,464 96 wks23015,421

9. CASE 1 AZT/3TC/Abacavir/Lopinavir/Amprenavir /Nevirapine/Fenofibrate/Fish oil/Niacin TESTVALUE TG5 - >40 mmol/l Cholesterol4 – 7 mmol/l HDL0.4 mmol/l LDL? – 1.73 mmol/l

10. CASE 1 AZT/3TC/Abacavir/Lopinavir/Amprenavir/ Nevirapine/Fenofibrate/Fish oil/Niacin 104 wks… CD4 150 VL 14,895 c/ml Went to Kingston, Ontario in 2003 to live with partner

11. CASE 1 Returned to Toronto in 2005 on D4T/Tenofovir/ddI/Fuzeon CD4 100 VL 18,295 c/ml

12. CASE 1 GENOTYPE June 2005

13. CASE 1 Genotype September 2005

14. CASE 1 WHAT WOULD YOU DO?

15. CASE 1 Tropism Testing…R5 2005-2007 3TC/Maraviroc/Lopinavir/Amprenavir /T20 CD4 165-250 VL 4,000-10,000

16. CASE 1 Genotype January 2007

17. CASE 1 2007 anal carcinoma in situ Lipids terrible…Triglycerides >40mmole/l develops pancreatitis, bowel obstruction ARVS discontinued

18. CASE 1 Late 2007 3TC/T20/Ritonavir/Darunavir/Etravirine/ Raltegravir/Maraviroc CD4 30 on initiation

19. CASE 1 TIMECD4HIV VIRAL LOAD 03085,363 6 wks270985 12 wks246<50

20. CASE 1 2008 Develops Diabetes on regimen – Metformin initiated Triglycerides continue out of control despite bezafibrate/fish oil/crestor Angina → Severe CAD → CABG

21. CASE 1 2008 T20 stopped due to injection site reactions and associated fatigue…viral load remains <50 on 3TC/Ritonavir/Darunavir/ Etravirine/ Raltegravir /Maraviroc

22. CASE 1 Lipids remain terrible with TG>40mmole/l Bezafibrate/fish oil/Ezetrol/Crestor/ ASA/Coumadin Recurrent angina – 4/5 bypassed vessel restenosed via angiography WHAT WOULD YOU DO?

23. CASE 1 Late 2008 Ritonavir/Darunavir discontinued Remains on 3TC/Maraviroc/Raltegravir /Etravirine CD4 275 VL <50! TG 34.70 → 3.78 – 6.07

24. CASE 1 2009/10 3TC/Maraviroc/Raltegravir/Etravirine Angina free, mitral regurgitation, Grade 1 LV CD4 250-275 VL <50! TG 8.46-6.07 LDL <0.5 HDL 0.5-0.6

25. CASE 1 2010 Furosemide/Perindopril for mitral regurgitation Some intermittent orthopnea Stable angina New onset prostatism

26. CASE 1 TIMECREATININE 10/09107 01/1080 04/10167 05/10196 What would you do ?

27. CASE 1 No NSAIDS No New Meds/holistics/illicit drugs Not dry on clinical examination Normotensive No CHF clinically No swelling of ankles

28. CASE 1 U/S – no obstruction U/A – normal albumin/creatinine + protein/creatinine ratio Urinalysis normal Urine sodium-100 mmol/l CAUSE? MANAGEMENT?

29. CASE 1 TIMECREATININE 05/10157, 183 06/10140 07/10213 08/10175 09/10153 Perindopril + Furosemide discontinued EGFR 45-50 ml/min

30. CASE 1 Given sudden onset, bland urinalysis and lack of significant proteinuria, likely cause is vascular …awaiting MRI Angiography of kidneys

31. CASE 1 Doses of all medications readjusted for renal dysfunction Not required for 3TC/Maraviroc/Raltegravir/ Etravirine