doc_clotaire
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A 37-year-old, HIV-positive man comes for evaluation of generalized
weakness, diffuse muscle pain, and frequent headaches that began eight
weeks after the start of new HIV medications. He has never had any
symptoms from his HIV infection, and he has a CD4 of 255/μL and
an HIV RNA viral load of 25,000 (by PCR). He was recently started on
zidovudine, lamivudine, and ritonavir/lopinavir. His past medical
history is significant for hypertension and hypercholesterolemia. His
medications include simvastatin and metoprolol. His physical
examination is significant for diffuse muscle tenderness of the
extremities. The range of motion is decreased because of pain with
movement. His potassium level is 5.4 mEq/L, serum bicarbonate is 16
mEq/L, BUN is 35 mg/dL, creatinine is 1.6 mg/dL, and his viral load is
RNA 40,000. The genotyping test result is pending. What will you do
while waiting for this result?
(A) Switch zidovudine and lamivudine to didanosine and stavudine, and
continue ritonavir
(B) Switch zidovudine, lamivudine, and ritonavir/lopinavir to
didanosine, stavudine, and indinavir, and stop simvastatin
(C) Continue all medications but stop simvastatin
(D) Continue zidovudine and lamivudine, and switch ritonavir/lopinavir
to efavirenz
(E) Switch to didanosine, stavudine, and efavirenz, and stop simvastatin
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| sprint123
Forum Guru
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Posts: 870
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Muscle weakness can be due to both STATINS and ZIDOVUDINE.
So,I think we must switch both and continue qith other new set of drugs till the genotype results come to determine resistanxce.
I am going with E..tRICKY QUESTION
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| cookie909
Forum Newbie
Topics: 0
Posts: 18
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sprint123...the only diff b/w B and E is indinavir and efavirenz respectively...how do u know wch to choose?? 
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| vanshita
Forum Guru
Topics: 31
Posts: 933
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C?
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| sprint123
Forum Guru
Topics: 129
Posts: 870
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Indinavir can cause renal stones----And hence better drug for this patient is efavirenz---That;s what I think..I am not sure what doc_clotaire thinks
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| doc_clotaire
Forum Guru
Topics: 159
Posts: 1,301
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Answer:
(E) Switch to didanosine, stavudine, and efavirenz, and stop simvastatin
Explanation:
This patient presents with a drug interaction between the protease
inhibitors and the HMG-CoA reductase inhibitor. In this case, it is
with ritonavir and simvastatin. This can produce significant toxicity
from the statin. Ritonavir can increase the serum concentration of
simvastatin, causing severe myalgias, rhabdomyolysis, and potential
renal insufficiency. The next necessary step is to stop simvastatin or
change the protease inhibitor to a non-nucleoside
reverse-transcriptase inhibitor, such as efavirenz. However, in this
case, the patient also presents with failure to achieve a reduction in
HIV viral load of 1 log after eight weeks of therapy. In the event of
inadequate treatment of HIV infection, the best choice would be to
start two new nucleoside reverse-transcriptase inhibitors (NRTIs) and
use efavirenz instead of ritonavir, in addition to discontinuing the
simvastatin. It is not enough to change ritonavir to indinavir because
high-level cross-resistance is very likely. Genotyping guides the
therapeutic choice of all treatment failures. The best thing to do
when treatment is insufficient is to use as least two, and preferably
three, new drugs.
___________________
The elevator to succes is broke ,you must take the stairs
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