An ongoing dialogue on HIV/AIDS, infectious diseases,
November 28th, 2012
A Complicated Curbside Consult I Won’t be Doing — But One Day Might Have To
From a local primary care provider comes this email:
Any chance you can look at my notes and scanned outside records from 6/22/2010 till today (including Nov 6 notation that details extensive past evaluation, including two previous ID consults) and labs? Briefly: 72 yr old woman with 6 episodes over the last 4 years of prolonged fever, malaise, normochromocytic, normochromic anemia, very high sed rate, negative cultures and scans. She has an upcoming rheum appt; I’m going to set up heme appt for consideration of bone marrow biopsy. Am I missing something?
Thanks in advance.
Nelson
(For the record, one stylistic part of this email to highlight — “Thanks in advance”. For some reason, I find “Thanks in advance” nettlesome, while a simple “Thanks” or “Thank you” or even “Tx” all strike me as polite — and I like it. Why? What’s wrong with me? My wife thinks I’m way too sensitive, and should get a life.)
Ok, we’ve all been there. You get a curbside that is staggeringly complex, with a truckload of data already accumulated, and you, the ID doctor, are asked to review the chart and render an opinion without seeing the patient.
It’s obviously not that this is a stupid question — on the contrary, it’s completely understandable and quite appropriate that this PCP is asking for help on this challenging case.
It’s just that there are multiple reasons why this patient should actually be seen, interviewed, examined — you know, a “formal” consultation.
Why? Let me count the ways:
- History. If there’s one thing ID doctors pride ourselves on, it’s getting the history right. For more on this, read here. If you don’t want to click the link, it’s a lengthy but I hope entertaining brag about how ID doctors take the best histories. Look, we have to boast about something.
Other specialist appointments. The patient has appointments set up with a rheumatologist and hematologist. What, are the ID doctors chopped liver? Given the duration and waxing/waning nature of the symptoms, the negative cultures, and the negative scans, the PCP is correct that a non-infectious diagnosis is more likely than an infection — but then why not schedule the ID appointment to take place after these two other brilliant specialists weigh in? (This is what I recommended, by the way.)- Medicolegal risk. Chart reviews of patients you have never seen or will never see are frowned upon by malpractice lawyers, who view this as establishing a doctor-patient relationship, increasing medicolegal risk. For more on this dicey subject, read here. Hey, I don’t make the rules.
- Time and dollars. All that chart review takes time. And time is money, especially in our current payment structure. ID doctor’s RVUs per visit may pale in comparison to replacing someone’s knee or removing a mole or screening for colon cancer with a long scope with a light on its end, but what else can we do?
And it’s this last financial issue that could, and probably will, end up changing how ID (and other) doctors balance formal and curbside consultations.
Under Accountable Care Organizations (ACOs), groups of clinicians receive a lump sum to work together to provide the best care for their patients — and with the greatest efficiency. (Read: “Lowest cost.”) No more payment by RVU, and medical utilization is discouraged. My gut feeling is that I’d still want to see this patient, but perhaps instead I’d be encouraged to be part of a practice group panel to review all the outside records before she gets her specialty appointments.
So if ACOs don’t end up increasing the volume and complexity of curbside consults, I’d be shocked. Capitation in the 1990s, which had a similar (but not identical) structure to ACOs, triggered an increase in curbside consults, for obvious reasons.
The plus side of ACOs could be greater efficiency and more collaborative care. Let’s just hope that with greater demand for this sort of clinical work — informal, curbside consultation — there’s greater recognition of its value, both for patients and providers.
November 22nd, 2012
The U.S. Preventive Services Task Force Recommends HIV Screening — And Why is This News?
A flurry of coverage recently appeared about the U.S. Preventive Services Task Force’s recommendation for one-time HIV screening for all Americans, ages 15-64.
Some might wonder why this is news — um, hasn’t this been recommended now for years? — and I think I’ve figured it out.
Let me start by relaying that every ID/HIV specialists can tell some version of the following sad story, which is still repeated on a regular basis (including just the other day, in our very own hospital):
- Person sees several clinicians over months-years for various medical issues (some combination of fatigue, swollen glands, anemia, thrombocytopenia, skin rashes — especially zoster).
- Many tests (blood tests, X-rays, sometimes even biopsies) are done, but because the person is not identified as being “at risk”, no HIV test is sent; or, ironically, he/she is “known” to be HIV negative based on a test done several years ago.
- Person eventually shows up in the hospital with some serious complication that all but screams “AIDS” — PCP, toxoplasmosis, cryptococcal meningitis, or even worse, PML or lymphoma — and the HIV test is finally done, of course returning positive.
Because the above sequence of events is all but 100% preventable with early identification of HIV — and because people who are unaware they are infected continue to spread the virus — in 2006 (yes, it was that long ago) the CDC made a big splash by recommending one-time HIV screening for adolescent and adult patients in all health care settings.
(They also said that high risk patients should be screened annually — unfortunately this is all too rarely done, but that’s an issue for a different day.)
To say that the ID/HIV provider community (docs, nurses, PAs, social workers) supported the CDC recommendations is like saying dermatologists support wearing sunscreen and a hat in the tropical sun.
“Support” just isn’t strong enough — we were strongly, unanimously, and vociferously behind them, so much so that virtually every lecture on HIV for the next several years mentioned the guidelines. To us, this was a total no-brainer — how could anyone oppose screening?
Indeed, the American College of Physicians, the American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics all came out with guidelines that said pretty much the same thing.
But not everyone did agree — namely, on the books already were guidelines from the U.S. Preventive Services Task Force, who had come out with their recommendation in 2005 for risk-based testing only.
For the unaware, the USPSTF is “an independent group of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, or preventive medications.”
I picture these USPSTF folks with hats, T-shirts, and coffee mugs emblazoned with “Evidenced-Based Only, Please.” Nothing speaks more clearly about their mission than these slide presentations entitled “Too Much Prevention” and “What Not to Do in Primary Care“. In plain English, the presenters make the excellent case that many well-intentioned screening strategies don’t help patients — and actually hurt them by uncovering clinically silent conditions that lead inexorably to procedures and medical treatments that are harmful and expensive.
Most cancer screening (infamously PSA) falls into this category. Cardiac CT. EKGs. Regular physical exams. Spirometry as a screen for COPD. Routine urinalysis. RPR. Hepatitis C testing (ahem).
And I generally agree with them. But HIV testing? That cheap, accurate test that identifies a clinically silent, eventually deadly infection that is both treatable and can be spread to others? Don’t they realize that the “risk based” testing they favored has been a failure?
Well now they do. In the plain language so characteristic of this committee, they write:
Previous studies have shown that HIV screening is accurate, targeted screening misses a substantial proportion of cases, and treatments are effective in patients with advanced immunodeficiency. New [well, “new” since 2005!] evidence indicates that ART reduces risk for AIDS-defining events and death in persons with less advanced immunodeficiency and reduces sexual transmission of HIV.
The bottom line is if this group recommends screening, it must be the right thing to do. Because these guys are tough.
Welcome to the club, USPSTF.
November 18th, 2012
The 800-mg Darunavir Tablet Arrives, and Scoring the Top Protease Inhibitors
The FDA has approved an 800-mg tablet of darunavir for treatment naive patients. This single tablet will obviously replace the two darunavir 400-mg tablets in first-line therapy. (Yes, my math is that good.) Darunavir will still require 100-mg ritonavir boosting plus two NRTIs to make a complete regimen.
Once upon a time I might have thought this was no big deal, but patients love taking fewer pills, even if it’s only reduced by one.
More importantly, it brings the darunavir-based regimen pill burden into parity with boosted atazanavir, with both now at three — PI (one), ritonavir (two), and TDF/FTC or ABC/3TC (three). What was once a win for atazanavir — fewer pills — is now a wash.
(I should mention here parenthetically that some day this could all be one pill made up of darunavir, cobicistat, FTC, and the recently named “TAF” — a.k.a., tenofovir alafenamide, GS-7340.)
So let’s assume you’re starting with a boosted-PI based regimen; which of these two “preferred” PIs should you choose, atazanavir or darunavir? Pending the results of ACTG A5257 — which is a fully-powered three-way comparison of atazanavir vs. darunavir vs. raltegravir — we have to make some inferences from existing data:
- Efficacy — Atazanavir was not demonstrably different from efavirenz in A5202, and that’s saying something (efavirenz generally beats PIs); plus, it recently all but tied TDF/FTC/EVG/c (“Quad”). Fewer studies have looked at darunavir in naives — there’s really only this one vs. LPV/r — but there’s abundant evidence darunavir works well in treatment-experienced patients, who are arguably harder to treat. ASSESSMENT: EVEN.
- Safety and tolerability — Atazanavir can (rarely) cause jaundice, and kidney stones, and even gallstones. Darunavir seems to have a higher rate of rash, though this isn’t completely clear from clinical studies (but anecdotally it is). Darunavir also has a special warning about liver toxicity in the package insert, but LFT abnormalities are not significantly different from comparators in clinical trials. ASSESSMENT: DARUNAVIR WINS.
- Metabolics — Among the PIs, atazanavir has consistently had the most favorable metabolic profile, and in A5202, lipids were actually better than efavirenz. Moreover, it’s been given the A-OK on cardiovascular risk from the D:A:D folks — not enough data yet for darunavir. And while this small study suggests no major differences between atazanavir and darunavir in lipid effects, if you squint at the data, they sort of favor atazanavir. Finally, did you know that raising bilirubin might actually have some favorable cardiovascular attributes? ASSESSMENT: ATAZANAVIR WINS.
- Resistance — These are both boosted PIs, which means they are unfathomably and inexplicably and consistently great at preventing resistance. Patients can start and stop and start and stop and start and stop these regimens, and they will still work once people commit to treatment. Who can explain this mysterious property? Not me. ASSESSMENT: EVEN.
- Drug-drug interactions — Atazanavir requires stomach acidity for optimal absorption, which means that PPIs are generally to be avoided. Yes, the package insert has some advice about taking acid-reducing therapy and atazanavir, but why risk it? Darunavir has something funny going on with pravastatin, but there are plenty of other (better) statin options anyway. Similarly, even though only atazanavir among the PIs can be given with telaprevir, who will be using that drug in 12-24 months? ASSESSMENT: DARUNAVIR WINS.
- Pharmacokinetics: Let’s imagine that your patient is a ritonophobe, and periodically (or regularly) takes everything in the regimen but ritonavir. (Not that anyone would ever do that. Sarcasm.) Unboosted atazanavir is almost a legitimate first-line option, whereas darunavir without ritonavir isn’t even close. ASSESSMENT: ATAZANAVIR WINS.
- Pill burden — weren’t you listening? Both are now the same. ASSESSMENT: EVEN.
Note I didn’t include the “sequencing” argument — you know, that darunavir is our most important PI in patients with extensive PI resistance, so we should save it for that setting, using atazanavir as the initial PI. First, very few patients get high-level PI resistance cases these days, and second, all the prior sequencing arguments (e.g., nelfinavir before lopinavir, d4T before AZT, nevirapine before efavirenz) have been more about marketing than science. And some were just wrong.
Cost is another factor I didn’t include, since the prices of these drugs are pretty close, vary by payor, and also differ based on region. Given how similar they are clinically, it seems to me that if one were significantly cheaper that would make a big difference.
In sum, as you can see from my list above, I have atazanavir vs. darunavir as a draw.
What do you think?
November 8th, 2012
Steroids for Bell’s Palsy and the ID Doctor
OK, let’s imagine you’ve just gotten a call/email/text from one of your colleagues about Bell’s palsy; he/she is a busy PCP who periodically asks you very reasonable ID questions.
I suspect it went something like this:
COLLEAGUE: Hi Friendly ID Doctor, quick question — I have a patient with Bell’s palsy — wondering whether to give him steroids.
FRIENDLY ID DOCTOR: Steroids? Absolutely not! Don’t you know that a host of infectious diseases cause Bell’s palsy, including Lyme, HSV, VZV, HIV, syphilis [and other obscure diagnoses I’m too tired or too forgetful to list]. Have you excluded these?
COLLEAGUE: Well, I just read that the neurologists are recommending steroids …
FRIENDLY ID DOCTOR: I’d get Lyme titers, and start the patient on doxycycline and high-dose valacyclovir. In addition, [insert boilerplate language about the limitations of curbside ID consults here].
COLLEAGUE: But the neurologists say antiviral therapy doesn’t really work. And doxycycline? Why?
LESS-FRIENDLY ID DOCTOR: Never mind — how about you call a neurologist and ask what to do?
Every so often, something comes along that shows that you are absolutely and completely and totally biased in your approach to a problem by your perspective. Whoppingly biased, if that’s a word. I confess that Bell’s palsy is one of those things.
(I didn’t even know that the preferred term is now “Bell palsy”, without the possessive. Sounds weird. I’m sticking with “Bell’s”.)
To me — and probably to most Infectious Diseases specialists — a patient with Bell’s is an ID problem worth solving.
But to the vast majority of the rest of the world, including these new guidelines and the great swath of primary care providers and neurologists, it’s “an acute, peripheral facial paresis of unknown cause.”
Emphasis mine.
And after reading this evidence–based review, I confess that the data supporting the use of steroids for Bell’s palsy are far stronger than those for antiviral agents or, with my New England bias, doxycycline, which was not even mentioned in the guidelines. Oh well.
Nonetheless, for providers who see a new case, especially in the warm months, please humor me — send a Lyme titer. And at least think about those other ID diagnoses that cause Bell’s.
I mean Bell.
November 7th, 2012
Vitamins and the Department of Bad Timing
Now that the election is over, we can get back to something that really matters — namely vitamins, and specifically whether they really help people.
Last month there was a large, well-done study from Tanzania showing that mega-doses of vitamins not only didn’t help those HIV starting ART, but they actually were harmful — LFTs went up, and there was a non-significant trend towards more deaths among the sickest patients who got the vitamins.
Granted, I’ve never been a fan of high-dose supplements, but given these results, and the fact that they cost a boatload of money, I came out pretty strongly against them. Spend the money on real food — you know, the stuff we evolved as a species to eat — not the shiny capsules from GNC that come in plastic bottles with pseudoscientific labels.
Then, that same day I had fun blasting mega-vitamins, this study came out showing that a single multivitamin daily reduces the risk of cancer in men.
And the papers are in the same journal. Jeeze.
First, in my defense, it’s high doses of vitamin that I really object to — the list of studies showing that mega-supplements do no good (and may do harm) is not short. Second, while this particular multivitamin study (part of the giant Physicians’ Health Study II) showed a cancer prevention benefit, even the authors acknowledge that the effect size was small, and that cancer-related and overall mortality were similar. Third, this separate analysis of that same study showed no benefit in prevention of cardiovascular disease.
So for our patients wedded to taking something, let’s leave it as “take a daily multivitamin — if you must.”
And by the way, Mitt, those Lyme Disease flyers in Virginia didn’t do the trick.
November 2nd, 2012
Antiretroviral Rounds: Resistance on Two Fronts
Got this challenging curbside consult from a colleague, and it has a interesting wrinkle:
I have a longstanding patient with HIV who had many failed regimens in the 1990’s with resultant following mutations on a genotype done in 2003:
NRTI (M184V, Q151M mutations); PI (A71, I54V, K20M, L10I, L90M, V82A mutations); no NNRTI resistance.
She has been undetectable since then on TDF/FTC/EFV; CD4 of >700 and never a low nadir.
Now, however, her insurance is making her pay tremendous copays of ~2K/month and she can’t afford it. She makes just enough that she doesn’t qualify for any drug assistance programs — she’s been to every advocacy group in the area, and is told no assistance is available.
Somehow, Complera is a tier 3 (favorable), while Atripla and many of the other drugs she is not resistant to is a tier 5.
Should I switch to Complera? Any other ideas? Other less expensive meds are abacavir/3TC, Kaletra, plus a bunch of others we never use anymore.
Two thoughts on this case, one medical, one much less so.
First, the medical part — my gut feeling here is that she’d probably be fine on TDF/FTC/RPV, given the duration of virologic suppression. These patients with long-term undetectable HIV RNA can generally make lots of changes to their regimens (within reason), and they maintain control of the virus. And the TDF and RPV both would be active.
But with broad NRTI resistance, I confess I’m kind of worried about changing to a drug (RPV) that is arguably less potent than what she’s on (EFV).
So I’m undecided.
Now the non-medical part — isn’t it ridiculous that someone whose treatment has been working well for nearly a decade must now consider switching based on 1) a higher “tier” of costs passed along by the mega-million dollar insurance company, who probably earn that much profit in a nanosecond, and 2) her not meeting criteria for patient assistance?
Answer: Yes.
October 28th, 2012
Dolutegravir and the 88% Rule
In the latest treatment-naive trials of elvitegravir and dolutegravir, there’s a striking consistency in the results of the “test” regimen. Here are the studies, with the percentage of responders by treatment arm:
- Study 102: TDF/FTC/EFV (84%) vs. TDF/FTC/EVG/c (88%) — non-inferior
- Study 103: TDF/FTC + ATV/r (87%) vs. TDF/FTC/EVG/c (90%) — non-inferior
- SPRING-2: TDF/FTC or ABC/3TC + RAL (85%) vs. DTG (88%) — non-inferior
- SINGLE: TDF/FTC/EFV (81%) vs. ABC/3TC + DTG (88%) — ABC/3TC + DTG — superior
The last of these, the SINGLE study, is the only one where there’s superiority in the primary outcome for the experimental arm, here ABC/3TC + dolutegravir. As the lead investigator Sharon Walmsley note, this favorable result was largely due to a significantly higher proportion of subjects in the TDF/FTC/EFV group discontinuing therapy for adverse events (10% vs 2%), as rates of virologic failure were similar between arms. ABC/3TC + dolutegravir also was better than TDF/FTC/EFV from both the immunologic and resistance perspective.
And though cross study comparisons are frowned upon by purists, we can’t resist. Just a quick glance at all four of the EVG and DTG arms, and you can easily see that an 88% response rate is the new price of admission for any treatment-naive regimen.
Anything shy of the high 80s, and there has to be something else very special about the treatment — for example, better tolerability, much lower cost, better long-term safety, it helps you become a virtuoso violinist — to make it compete with options for therapy we already have, or will have soon.
October 17th, 2012
It’s Time to Tell Our Patients to Stop Their Vitamin Supplements
Over in JAMA, there’s a large study out today that (yet again) failed to demonstrate a benefit of vitamins.
Over 3000 patients with HIV in Tanzania were randomized to receive either high-dose or standard-dose multivitamin supplementation, in addition to “HAART” (ugh). Though the study was planned for 24 months, it was stopped early by the Data Safety and Monitoring Board due to a higher rate of LFT abnormalities in the high-dose vitamin group. Not only that, the sickest patients — those with BMI < 16 — seemed to do even worse on the mega-dose, with a higher risk of death that almost reached statistical significance (relative risk 1.36; 95% CI, 0.93-1.98; p=.11).
One could quibble with the generalizability of the results to current standard of care in well-resourced areas — for example, the most common regimen was d4T, 3TC, and nevirapine, used in nearly 60% — but it’s hard to imagine how this makes the results less convincing. After all, one would expect that vitamin supplementation would be more important in settings where malnutrition and advanced HIV disease are highly prevalent.
So what should we do?
I’ve been keeping quiet with my patients who insist on taking handfuls of vitamins, despite their having access to real food and nothing at all to suggest dietary insufficiency. With this study, however, I will strongly encourage them to save their money — the only people benefiting from their daily intake are those in the $27-billion dollar/year vitamin industry.
October 16th, 2012
Some Liver Meeting “Wow!” Studies Start to Emerge
The Liver Meeting, the annual meeting of the American Association for the Study of Liver Disease, does not take place until November 9-13, in Boston.
But if you want a preview, a couple of notable studies have already been “announced” in the press.
Specifically, there’s
Abbott today announced initial results from “Aviator,” a phase 2b study of its interferon-free, investigational regimen for the treatment of hepatitis C (HCV). Initial results show sustained virological response at 12 weeks post treatment (SVR12) in 99 percent of treatment-naïve (n=77) and 93 percent of null responders (n=41) for genotype 1 (GT1) HCV patients taking a combination of ABT-450/r, ABT-267, ABT-333 and ribavirin for 12 weeks, based on an observed data analysis.
That regimen contains 5 drugs — HIV/ID docs will recognize the “/r” as familiar short hand for ritonavir boosting — but it’s hard to beat those response numbers. Note especially the 93% cure rate in interferon null responders — amazing.
If 5 drugs seems like too many, there’s also this:
[Bristol-Myers Squibb] said 94 percent of patients who took a combination of three experimental drugs, daclatasvir, asunaprevir, and BMS-791325, were cured in a 12-week study. Those patients did not take interferon or ribavirin.
Looks like it’s going to be an interesting meeting. That sentence may be the understatement of the year.
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
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