| |
New HIVMA Guidelines/Comorbidities
|
| |
| |
pdf published today attached
"The previously reported adverse effects that complicated the management of HIV infection, including hyperlipidemia, diabetes, body morphology changes (lipohypertrophy and lipoatrophy), and lactic acidosis, are much less frequent with the use of the newer agents. Concern has heightened about long-term cardiovascular morbidity in patients who experience dyslipidemia and/or glucose intolerance, as well as other common comorbidities associated with age.......Baseline bone densitometry by dual-energy X-ray absorptiometry (DXA) should be performed in all postmenopausal women and men aged ≥50 years.......Patients with vitamin D deficiency and osteopenia by DXA should be treated with vitamin D and calcium..... A follow-up DXA should be repeated 1 year later to monitor the response to therapy......Patients should be reminded of the health benefits of regular exercise in addition to adequate calcium and vitamin D intake."
Primary Care Key to Management of Patients with HIV Infection - Publication in CID, FUll Text Below
press release from HIVMA
11/14/2013
Updated HIVMA Guidelines Indicate Doctors Should Focus on Common Health
Condition
The HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) has updated its HIV care guidelines to reflect the fact that people with HIV are now living normal life spans, and their physicians need to focus on preventive care, including screening for high cholesterol, diabetes and osteoporosis.
"In many HIV practices now, 80 percent of patients with HIV infection have the virus under control and live long, full lives. This means that HIV specialists need to provide the full spectrum of primary care to these patients, and primary care physicians need a better grasp of the impact HIV care has on routine healthcare," said Judith A. Aberg, MD, lead author of the guidelines and director of the Division of Infectious Diseases and Immunology at the New York University School of Medicine. "Doctors need to tell their HIV-infected patients, 'Your HIV disease is controlled and we need to think about the rest of you.' As with primary care in general, it's about prevention."
"Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus," an update on HIVMA's 2009 guidelines, will appear in print in January in Clinical Infectious Diseases. Reflecting changes in the HIV landscape, the guidelines note patients whose HIV is under control should have their blood monitored for levels of the virus every six to 12 months, rather than every three to four months as previously recommended.
People with HIV are at increased risk for common health conditions, such as high cholesterol and triglycerides, due to the infection itself, ART or traditional risk factors such as smoking and eating unhealthy foods, and doctors must be vigilant about monitoring those levels.
The guidelines include new recommendations for screening for diabetes, osteoporosis and colon cancer, and suggest patients with HIV infection should be vaccinated against pneumococcal infection, influenza, varicella and hepatitis A and B. A table outlining interactions between specific antiretrovirals and statins (the medications commonly used for lipid management) is also included. There also is a more robust section on sexually transmitted diseases, including a recommendation for annual screening of trichomoniasis in women and yearly screening for gonorrhea and chlamydia for all who may be at risk.
The guidelines authors note that doctors should consistently discuss and counsel patients on their sexual history (current and past) and any risky behaviors, such as the use of illicit drugs, in a nonjudgmental manner and determine how patients are coping with living with HIV infection and if they have a sufficient support network.
HIV-infected patients typically are seen by an HIV specialist or a primary care physician. HIV specialists need to be familiar with primary care issues, and primary care physicians need to be familiar with HIV care recommendations and these guidelines are designed to bridge both gaps, said Dr. Aberg.
"Patients whose HIV is under control might feel they don't need to see a doctor regularly, but adherence is about more than just taking ART regularly; it's also about receiving regular primary care," she said. "These guidelines are designed to help ensure patients with HIV infection live long and healthy lives."
Nearly 1.2 million Americans are living with HIV and approximately 50,000 people are infected each year, according to the Centers for Disease Control and Prevention.
The six-member HIV guidelines update panel includes specialists in internal medicine, pediatrics and infectious diseases. In addition to Dr. Aberg, the panel includes: Joel E. Gallant, MD, Khalil G. Ghanem, MD, Patricia Emmanuel, MD, Barry S. Zingman, MD, and Michael A. Horberg, MD. As with other IDSA guidelines, the HIV guidelines update will be available in mobile device and pocket-sized quick-reference editions.
---------------------------------
Primary Care Guidelines for the Management of Persons Infected With HIV: 2013 Update by the HIV Medicine Association of the Infectious Diseases Society of America
Abstract
Evidence-based guidelines for the management of persons infected with human immunodeficiency virus (HIV) were prepared by an expert panel of the HIV Medicine Association of the Infectious Diseases Society of America. These updated guidelines replace those published in 2009. The guidelines are intended for use by healthcare providers who care for HIV-infected patients. Since 2009, new antiretroviral drugs and classes have become available, and the prognosis of persons with HIV infection continues to improve. However, with fewer complications and increased survival, HIV-infected persons are increasingly developing common health problems that also affect the general population. Some of these conditions may be related to HIV infection itself or its treatment. HIV-infected persons should be managed and monitored for all relevant age- and sex-specific health problems. New information based on publications from the period 2009-2013 has been incorporated into this document.
Excertped from the full Guidelines
V. What are the metabolic comorbidities associated with HIV and antiretroviral therapy?
The previously reported adverse effects that complicated the management of HIV infection, including hyperlipidemia, diabetes, body morphology changes (lipohypertrophy and lipoatrophy), and lactic acidosis, are much less frequent with the use of the newer agents. Concern has heightened about long-term cardiovascular morbidity in patients who experience dyslipidemia and/or glucose intolerance, as well as other common comorbidities associated with age. In general, it appears that the benefits of ART used in accordance with published guidelines outweigh the risk of cardiovascular disease and other comorbidities associated with long-term exposure [76, 77]. Guidelines and expert recommendations have been developed to assist providers in the identification and management of lipid abnormalities, metabolic complications, and bone disorders [25, 78, 79].
Recommendations
· 67. Fasting blood glucose (FBG) and/or hemoglobin A1c (HbA1c) should be obtained prior to and within 1-3 months after starting ART. Patients with diabetes mellitus should have an HbA1c level monitored every 6 months with a goal of <7%, in accordance with the American Diabetes Association Guidelines (strong recommendation, moderate quality evidence).
· 68. Fasting lipid levels should be obtained prior to and within 1-3 months after starting ART. Patients with abnormal lipid levels should be managed according to the National Cholesterol Education Program Guidelines (strong recommendation, moderate quality evidence).
· 69. Baseline bone densitometry (DXA) screening for osteoporosis in HIV-infected patients should be performed in postmenopausal women and men aged ≥50 years (strong recommendation, moderate quality evidence).
Evidence Summary
The HbA1c is a preferred alternative for diagnosing diabetes, especially given the difficulty of obtaining fasting blood samples. The American Diabetes Association (ADA) established the diagnostic criteria of diabetes mellitus of a fasting plasma glucose level of ≥126 mg/dL (7.0 mmol/L) or a 2-hour plasma glucose level of ≥200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test (OGTT) conducted with a standard loading dose of 75 g, or an HbA1c ≥6.5% [80]; however, using the National Health and Nutrition Examination Survey cutoff of ≥5.8% improves the sensitivity for diagnosis for patients on ARVs [81]. As of 2011, the ADA altered its recommendations to say that in cases of HbA1c and FBG discordance, the abnormal laboratory test should be repeated, and the diagnosis of diabetes should be made only if repeat testing is again above the diagnostic cut-point [78].
In most cases, blood glucose abnormalities can be effectively managed by lifestyle changes that include weight loss, increased exercise, and dietary modification. However, if therapeutic intervention is needed, insulin-sensitizing agents are preferred. Patients should be managed according to the ADA guidelines [78, 82]. There are no data suggesting that switching ARVs is beneficial in patients with impaired glucose tolerance associated with HIV infection itself or traditional risk factors.
Similar to the reports on insulin resistance, dyslipidemia has been associated with traditional risk factors, HIV infection itself, and ARVs. It is recommended that all patients be assessed for coronary heart disease risk, and those with ≥2 risk factors should be further evaluated and managed according to the National Cholesterol Education Program guidelines [25]. As HIV itself may be considered an independent risk factor for heart disease, many experts favor more aggressive management of lipids. Caution should be used when prescribing statins with protease inhibitors (PIs) and nonnucleoside reverse transcriptase inhibitors due to potential serious drug-drug interactions (Table 8). Most PIs inhibit the metabolism of statins, thereby increasing potential for statin toxicity. However, there are exceptions such as pitavastatin and pravastatin, which are metabolized by glucuronidation, thereby having little effects when coadministered with a PI. In addition, atorvastatin and rosuvastatin may be used in patients on a PI but should be initiated at low doses and titrated carefully according to tolerability and effect. Efavirenz induces statin metabolism, resulting in lowering of statin levels. Nevirapine, etravirine, and rilpivirine have not been extensively studied. Cobicistat is expected to have similar interactions as ritonavir with statins; however, these interactions have not been formally studied. There may be other pathways effecting drug metabolism leading to unexpected interactions, and it is advised to refer to the package insert of the ARV before prescribing lipid-lowering agents. All patients should be encouraged to stop smoking regardless of cardiovascular risk, and hypertension and diabetes mellitus should be managed as appropriate.
Baseline bone densitometry by dual-energy X-ray absorptiometry (DXA) should be performed in all postmenopausal women and men aged ≥50 years. If the DXA demonstrates osteopenia or if the patient has a history of fragility or fracture, intervention with vitamin D, calcium, and a bisphosphonate or other medical therapy may be warranted. Bisphosphonates appear to be effective in improving bone density in small studies of HIV-infected patients, but the data are limited [79, 83, 84]. It is important to exclude osteomalacia prior to initiating a bisphosphonate, as this could lead to increased fragility and fracture. Common reasons for osteomalacia in this population are tenofovir-induced renal phosphate wasting and vitamin D deficiency, which has been reported in 40%-80% of HIV-infected persons. The spectrum and severity of metabolic complications associated with vitamin D deficiency in HIV-infected adults remain to be better characterized. Patients with vitamin D deficiency and osteopenia by DXA should be treated with vitamin D and calcium without bisphosphonates until the vitamin D deficiency has resolved. A follow-up DXA should be repeated 1 year later to monitor the response to therapy.
Patients should be reminded of the health benefits of regular exercise in addition to adequate calcium and vitamin D intake. They should also be counseled about the risks of cigarette smoking and excessive alcohol consumption. Secondary causes of decreased bone density, such as hypogonadism, alcoholism, glucocorticoid exposure, and vitamin D deficiency, should be investigated and treated accordingly.
Routine radiographic monitoring for avascular necrosis in asymptomatic persons is not recommended, but for patients presenting with persistent hip pain who have normal standard radiologic studies, magnetic resonance imaging is the preferred method of diagnosis, and both sides should be imaged. Most patients with symptomatic avascular necrosis will ultimately require surgical intervention (eg, hip replacement).
|
|
| |
| |
|
|
|
