NAPLEX® Review Question of the Week: Before we get stARTed...
A 41-year-old man with newly diagnosed HIV is being evaluated for initiation of antiretroviral therapy (ART). Genotypic resistance testing is negative. His CD4 count is 340 cells/mm3 and his RNA viral load is 110,000 copies/mL. The provider is considering initiating Triumeq due to the patient’s desire to only take one pill one time daily.
Which of the following is absolutely required before initiating Triumeq specifically?
A. HLA-B*5701 testing
B. Test for G6PD deficiency
C. Baseline EKG
D. Screen for depression
E. No additional testing is required
Answer with rationale: In patients newly diagnosed with HIV, baseline evaluations before starting antiretroviral therapy are essential to ensure safe and effective treatment. Standard assessments include CD4 count, viral load, resistance testing, and screening for co-infections like hepatitis B and tuberculosis. The goal is to start ART promptly, safely, and on a regimen that the patient can appropriately adhere to long term.
Triumeq is a single-pill, once daily combination of dolutegravir, abacavir, and lamivudine, making it a convenient and effective option for many people with HIV. It is no longer a first line therapy due to a requirement for HLA-B*5701 testing before initiation because abacavir can cause a serious hypersensitivity reaction in patients who carry the HLA-B*5701 allele. Let's go through each option and discuss.
Answer A is correct: The HLA genes in the body help regulate the immune system and allow the body to recognize self and non-self cell presentations. HLA-B*5701 can sometimes make abacavir look like a non-self entity, leading to a hypersensitivity reaction to try to get rid of the perceived threat. A number of drugs are associated with severe, life-threatening hypersensitivity reactions due to various alleles such as allopurinol (HLA-B*5801) and carbamazepine (HLA-B*1502 or HLA-A*3101)
Answer B is incorrect: G6PD (glucose-6-phosphate-dehydrogenase) is important in preventing hemolytic anemia by protecting red blood cells from increased oxidative stress. While it may become important to know a patient’s G6PD status when prescribing known oxidative drugs like dapsone or primaquine for opportunistic infections, it is not a requirement before starting Triumeq.
Answer C is incorrect: EKG testing is not required before initiating Triumeq as none of the components should cause EKG changes. Some HIV medications, such as rilpirivirine, efavirenz, darunavir, or atazanavir may cause EKG changes.
Answer D is incorrect: Depression screening is not required before initiation any of the components of Triumeq, but is often recommended before initiating efavirenz, as it is associated with significant potential CNS side effects including depression, anxiety, psychosis, and suicidal ideation.
Answer E is incorrect: While initiating ART in a timely manner is important for treating and suppressing HIV, confirming the HLA-B*5701 allele is negative is a required step before initiating an abacavir-containing regimen to reduce the risk of a potentially life threatening hypersensitivity reaction.
Brand/generics Covered:
Dolutegravir/Lamivudine (Dovato), Efavirenz/Lamivudine/Tenofovir DF (Atripla), Bictegravir/Emtricitibine/Tenofovir AF (Biktarvy), Dolutegravir (Tivicay), Emtricitabine/Tenofovir DF (Truvada), Darunavir/Cobicistat (Prezcobix), Emtricitabine/Tenofovir AF (Descovy)
Naplex Content Domains Covered
3.B: Person-centered health histories and screenings
3.C.2,3: Appropriateness of therapy (contraindications and drug-laboratory interactions)
Dr. Christopher M. Bland is the Albert W. Jowdy Professor in Pharmacy Care at the University of Georgia College of Pharmacy at the Southeast GA campus in Savannah, GA. Dr. Bland has nearly 25 years of academic and clinical experience both in the inpatient and community patient care settings. He is a Fellow of both the Infectious Diseases Society of America as well as the American College of Clinical Pharmacy and has been named Teacher of the Year at the University of Georgia College of Pharmacy. He is co-author of the book "InteGREAT: A Guidebook for Creating Great Healthcare Teams."
He is co-founder of the Southeastern Research Group Endeavor, SERGE-45, with nearly 100 practitioners across 14 states involved. Dr. Bland serves as Associate Editor for the NAPLEX Review Guide 4th edition as well as upcoming 5th edition, as well as the Editor-In-Chief for the Question of the Week. He has provided hundreds of hours in live, interactive NAPLEX reviews for more than 10 Colleges/Schools of Pharmacy over the course of his career.
Create a Free MyAccess Profile
AccessMedicine Network is the place to keep up on new releases for the Access products, get short form didactic content, read up on practice impacting highlights, and watch video featuring authors of your favorite books in medicine. Create a MyAccess profile and follow our contributors to stay informed via email updates.