Savvy Psychopharmacology

Treating psychosis in patients with HIV/AIDS

Current Psychiatry. 2018 May;17(5):35-36,41-44,46

References

1. Freudenreich O, Goforth HW, Cozza KL, et al. Psychiatric treatment of persons with HIV/AIDS: An HIV-psychiatry consensus survey of current practices. Psychosomatics. 2010;51(6):480-488.
2. Hill L, Lee KC. Pharmacotherapy considerations in patients with HIV and psychiatric disorders: Focus on antidepressants and antipsychotics. Ann Pharmacother. 2013;47(1):75-89.
3. Watkins CC, Treisman GJ. Neuropsychiatric complications of aging with HIV. J Neurovirol. 2012;18(4):277-290.
4. Prior TI, Baker GB. Interactions between the cytochrome P450 system and the second-generation antipsychotics. J Psychiatry Neurosci. 2003;28(2):99-112.
5. Ponte ML, Keller GA, Di Girolamo G. Mechanisms of drug induced QT interval prolongation. Curr Drug Saf. 2010;5(1):44-53.
6. Reyataz [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2017.
7. Prezista [package insert]. Toronto, ON: Janssen Inc.; 2017.
8. Lexiva [package insert]. Research Triangle Park, NC: Viiv Healthcare; 2017
9. Crixivan [package insert]. Whitehouse Station, NJ; Merck; 2016.
10. Kaletra [package insert]. North Chicago, IL: AbbVie Inc; 2017
11. Viracept [package insert]. Kirkland, QC: Pfizer Canada Inc.; 2016
12. Norvir tablets and oral solution [package insert]. North Chicago, IL: AbbVie Inc; 2017
13. Invirase [package insert]. South San Francisco, CA: Genentech USA, Inc.; 2016.
14. Aptivus [package insert]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals Inc.; 2016.
15. Sustiva [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2017
16. Intelence [package insert]. Titusville, NJ: Tibotec Pharmaceuticals; 2014.
17. Viramune [package insert]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals Inc.; 2017.
18. Rescriptor [package insert]. Laval, QC: ViiV Healthcare ULC; 2013.
19. Ziagen [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2017.
20. Videx EC [package insert]. Princeton, NJ: Bristol-Myers Squibb; 2015.
21. Emtriva [package insert]. Foster City, CA: Gilead Sciences, Inc.; 2017.
22. Epivir [package insert]. Research Triangle Park, NC: ViiV Healthcare; 2017.
23. Zerit [package insert]. Princeton, NJ: Bristol-Myers Squibb; 2017.
24. Viread [package insert]. Foster City, CA: Gilead Sciences, Inc.; 2017.
25. Retrovir [package insert]. Research Triangle Park, NC: ViiV Healthcare; 2015.
26. Fuzeon [package insert]. South San Francisco, CA: Genentech USA, Inc; 2017.
27. Selzentry [package insert]. Research Triangle Park, NC: ViiV Healthcare; 2016.
28. Isentress [package insert]. Whitehouse Station, NJ: Merck Sharp & Dohme Corp.; 2017.
29. American Psychiatry Association. Practice guidelines for treatment of patients with HIV/AIDS. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/hivaids.pdf. Published 2010. Accessed March 1, 2018.
30. Buchanan RW, Kreyenbuhl J, Kelly DL, et al; Schizophrenia Patient Outcomes Research Team (PORT). The 2009 Schizophrenia PORT psychopharmacological treatment recommendations and summary statements. Schizophr Bull. 2010;36(1):71-93.
31. Hughes PJ, Cretton-Scott E, Teague A, et al. Protease inhibitors for patients with HIV-1 infection. P T. 2011;36(6):332-336,341-345.
32. Ortiz R, Dejesus E, Khanlou H, et al. Efficacy and safety of once-daily darunavir/ritonavir versus lopinavir/ritonavir in treatment-naive HIV-1-infected patients at week 48. AIDS. 2008;22(12):1389-1397.
33. Leucht S, Cipriani A, Spineli L, et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet. 2013;382(9896):951-962.
34. Zeier K, Connell R, Resch W, et al. Recommendations for lab monitoring of atypical antipsychotics. Current Psychiatry. 2013;12(9):51-54.
35. Singh D, Goodkin K. Choice of antipsychotic in HIV-infected patients. J Clin Psychiatry. 2007;68(3):479-480.
36. Max B, Sherer R. Management of the adverse effects of antiretroviral therapy and medication adherence. Clin Infect Dis. 2000;30(suppl 2):S96-S116.

Management of metabolic adverse effects involves switching the antiretroviral agent and/or antipsychotic agent to an alternative associated with lower metabolic risk. Antipsychotics with low metabolic risk include aripiprazole, lurasidone, and ziprasidone. Lifestyle modifications are encouraged. Additionally, medication interventions, such as metformin, are also recommended in patients meeting criteria for pre-diabetes or type 2 diabetes mellitus.² Lipid panels and metabolic parameters should be monitored periodically, according to guidelines.^25,34

Bone marrow toxicity and blood dyscrasias. Lastly, consider the risk of bone marrow suppression. Patients receiving clozapine for treatment-resistant schizophrenia should be closely monitored for neutropenia and agranulocytosis. Although zidovudine is rarely used, its use is associated with adverse myelosuppressive effects, and the combination of clozapine and zidovudine could pose danger to the patient.^2,35,36

CASE CONTINUED

Because Mr. S’s diagnosis of HIV puts him at a higher risk of developing EPS, and because he is already experiencing increased wrist rigidity, the treatment team decides to switch his antipsychotic therapy to an agent with a lower risk of EPS. His comorbidities, including type 2 diabetes mellitus, hypertension, and hyperlipidemia, are taken into account, and an SGA with a benign metabolic profile is considered. Aripiprazole and ziprasidone are favorable options. However, because efavirenz, ATZ, and ritonavir may cause QTc prolongation, ziprasidone, the SGA with the highest rate of QTc prolongation, is not the preferred option.

Mr. S’s SGA therapy is switched from risperidone to aripiprazole. Because potential CYP-related interactions between aripiprazole and Mr. S’s current antiretroviral therapy could lead to increased aripiprazole levels. Mr. S is started on a low dose (5 mg/d) with the goal to titrate based on response and tolerability. Increased levels of aripiprazole may increase the risk of akathisia, drowsiness, headaches, and fatigue. Mr. S is monitored closely for improvement of EPS, adverse effects of medication, and metabolic parameters. Furthermore, if the treatment team believes there is a more preferred antipsychotic for the patient that it did not prescribe because of the risk of DDIs, it may be worthwhile to consider discussing the HAART regimen with the patient’s infectious disease treatment team.

Continue to: Acknowledgements

Treating psychosis in patients with HIV/AIDS

References

CASE CONTINUED

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