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Introduction
  • Drugs
    • HIV anti-viral medications or highly active antiretroviral therapy (HAART)
      • nucleoside analog reverse transcriptase inhibitors (NRTI)
      • non-nucleoside reverse transcriptase inhibitors (NNRTI)
      • fusion inhibitors
      • integrase inhibitors
      • protease inhibitors
    • HCV anti-viral medications
    • other anti-viral medications
  • Clinical use
    • viral infections 
      • for HIV infections, regimen often consists of 3 drugs to prevent resistance: 2 NRTIs and an integrase inhibitor or protease inhibitor
        • increasingly, regimens are tailored to viral genomics and resistance patterns
      • for HCV infections, regimen also consists of multiple drugs to prevent resistance
 
HIV Highly Active Antiretroviral Therapy (HAART)
Drugs Mechanism of Action
High Yield Adverse Effects

Abacavir (ABC)
Didanosine (DDL)
Emtricitabine
Lamivudine
Stavudine
Zidovudine (ZDV)
Tenofovir (a nucleotide rather than nucleoside)

  • NRTI
  • Bone marrow suppression
  • Peripheral neuropathy
  • Lactic acidosis
  • Anemia (ZDV)
  • Pancreatitis (DDL)
  • Drug hypersensitivity (ABC) (HLA-B*5701 positive patients)
  • ZDV can be used during pregnancy
Delavirdine
Efavirenz
Nevirapine
  • NNRTI
  • Drug rash
  • Liver toxicity
  • Vivid dreams (efavirenz)
  • Neurologic symptoms (efavirenz)
  • Contraindicated in pregnancy (efavirenz and delavirdine)
Atazanavir
Darunavir
Fosamprenavir
Indinavir
Lopinavir
Ritonavir
Saquinavir
  • Protease inhibitors, preventing maturation of new viruses
  • Hyperglycemia
  • Gastrointestinal upset
  • Cushing-like syndrome
  • Renal toxicity (indinavir)
  • Thrombocytopenia (indinavir)
  • Inhibits cytochrome P450 (ritonavir)

Dolutegravir
Elvitegravir
Raltegravir

  • Integrase inhibitors, inhibiting integration of viral genome into host cell chromosome
  • Increased serum creatine kinase
Enfuvirtide
Maraviroc
  • Fusion inhibitors
  • Enfuvirtide: inhibits viral entry by binding to viral gp41
  • Maraviroc: inhibits viral entry by binding CCR-5 on host T-cells, inhibiting its interaction with viral gp120
  • Injection site reactions (enfuvirtide)
  • Peripheral neuropathy (enfuvirtide)
  • Hepatotoxicity (maraviroc)
Griseofulvin
  • Disrupts mitosis via microtubule dysfunction
  • Especially targets keratin-containing tissues such as nails
  • Fungistatic
  • Teratogenic
  • Disulfiram-like reaction
  • Neurologic symptoms
    • confusion
    • headaches
  • Induces cytochrome P450
 
HCV Anti-Viral Medications
Drug Mechanism of Action
High Yield Adverse Effects
Indications
Ribavirin
  • Guanine nucleotide synthesis inhibition
  • Hemolytic anemia
  • Teratogenic
  • RSV
  • HCV
Interferons
  • Glycoprotein analogs (normally synthesized by infected cells, as well as tumor cells)
  • Flu-like symptoms
  • Neutropenia
  • Myopathy
  • Depression
  • HBV
  • HCV
  • Kaposi sarcoma
  • Condyloma acuminatum
Ledipasvir
  • Viral phosphoprotein (NS5A) inhibitor, which disrupts viral replication
  • Fatigue
  • Headache
  • HCV
Simeprevir
  • HCV protease (NS3/4A) inhibitor, disrupting replication
  • Photosensitivity
  • Pruritus
  • Fatigue
  • Headache
  • HCV
Sofosbuvir
  • HCV RNA-dependent RNA polymerase (NS5B) inhibitor
  • Fatigue
  • Headache
  • Nausea
  • HCV
Other Anti-Viral Medications

Oseltamivir
Zanamivir

  • Inhibits neuraminidase, which results in decrease of progeny virus release
  • Gastrointestinal upset
  • Influenza A and B

Acyclovir
Famciclovir
Valacyclovir

  • Guanosine analogs and inhibits viral DNA polymerase
  • Specifically processed by HSV/VZV enzymes
  • Obstructive crystalline nephropathy which can lead to acute renal failure
    • hydration can prevent this
  • HSV
  • VZV

Ganciclovir
Valganciclovir

  • Guanosine analogs and inhibits viral DNA polymerase
  • Specifically processed by CMV viral enzymes
  • Bone marrow suppression
  • Renal toxicity
  • CMV
Foscarnet
  • Viral DNA and RNA polymerase inhibitor
  • HIV reverse transcriptase inhibitor
  • Renal toxicity
  • Seizures secondary to electrolyte abnormalities
  • Acyclovir-resistant HSV
  • Ganciclovir-resistant CMV
Cidofovir
  • Viral DNA polymerase inhibitor
  • Renal toxicity
    • coadminister with probenecid and hydration
  • CMV retinitis
  • Acyclovir-resistant HSV
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.MC.75) A thymidine kinase-deficient varicella-zoster virus strain has been isolated at a retirement home. Many of the elderly had been infected with this strain and are experiencing shingles. Which of the following would be the best antiviral agent to treat this population? Review Topic

QID: 106859
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Acyclovir

23%

(5/22)

2

Famciclovir

41%

(9/22)

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Ganciclovir

18%

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Cidofovir

18%

(4/22)

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Amantadine

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