assesment multiorganocome fattore chiave per prevenire la ... · slide credit: clinicaloptions.com....
TRANSCRIPT
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Assesment multiorgano come
fattore chiave per prevenire la
comorbidità nell’HIV
Gian Carlo Orofino
Malattie Infettive e Tropicali I
ASL Città di Torino
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Rapporti di natura finanziaria nei due
anni precedenti questo evento
• BMS
• MSD
• Viiv Healthcare
• Gilead
• Janssen Cilag
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“Paradosso” attuale
Seguiamo dei pazienti sostanzialmente
“ guariti ”dall’HIV ( alti CD4, viremia HIV soppressa ), che nel tempo accumulano comorbilità
Il follow up della infezione da HIV è il driver principale di attenzione sulle altre patologie
Si configura per l’infettivologo un modello nuovo gestionale di cura, che deve trovare motivazioni, organizzazione e tempi, competenza
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Linee guida italiane 2017
L’inquadramento clinico si attua
attraverso la valutazione del rischio
globale per patologia non infettiva
associata alla infezione da HIV e si
basa su livelli successivi di valutazioni
e azioni che possono richiedere
interventi specialistici
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Linee guida italiane 2017
Percorsi condivisi tra la
medicina di base e la medicina
specialisitica
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Linee guida italiane 2017
La tossicità farmacologica può
aumentare il livello di rischio per danno
d’organo
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ART and Effects on Lipids
TDF ABCTAFRALDTG
ATV/RTV or ATV/COBIDRV/RTV or DRV/COBIEVG/COBI
EFVRPVETV
Slide credit: clinicaloptions.com
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TAF vs TDF in Studies 104/111: BMD Changes by Age in Treatment-Naive Pts
Wk 144 data: persistence of greater spine and hip BMD loss with TDF vs TAF; 6 discontinuations for bone AEs in TDF arm vs 0 in TAF arm[2]
1. Wohl D, et al. EACS 2015. Abstract 1091.2. Arribas JR, et al. CROI 2017. Abstract 453. Slide credit: clinicaloptions.com
DifferenceE/C/F/TAFE/C/F/TDF
Mea
n %
Cha
nge
in B
MD
Fro
m B
asel
ine
Difference in LS
M (%
)
Hip[1]Spine[1]
18-25 Yrs of Age
All Ages All Ages0
-1
-2
-3
-4 0
2
1
3
4
0
-1
-2
-3
-4 0
2
1
3
4
0 24 48 72 96
0
-1
-2
-3
-4 0
2
1
3
4
18-25 Yrs of Age0
-1
-2
-3
-4 0
2
1
3
4
0 24 48 72 96Wk Wk
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Slide credit: clinicaloptions.com
HIV Pts More Likely to Experience Bone Fractures, CVD, Diabetes, Renal Failure
Guaraldi G, et al. Clinicoecon Outcomes Res. 2013;5:481-488.
0
10
20
30
40
60
< 40 41-50 51-60 > 60
Ris
k (%
)
Age (Yrs)
50
Bone Fractures
0
10
20
30
40
60
< 40 41-50 51-60 > 60
Ris
k (%
)
Age (Yrs)
50
Diabetes
0
10
20
30
40
60
< 40 41-50 51-60 > 60
Ris
k (%
)
Age (Yrs)
50
CVD
0
10
20
30
40
60
< 40 41-50 51-60 > 60
Ris
k (%
)
50
Renal Failure
Age (Yrs)
0
10
20
30
40
60
< 40 41-50 51-60 > 60
Ris
k (%
)
Age (Yrs)
50
Hypertension
HIV-
HIV+
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Predicted comorbitities
(A) Predicted burden of NCDs in HIV-infected patients
between 2010 and 2030 as simulated by the model
(B) Distribution of the number of NCDs by age group for
HIV-infected and HIV-uninfected patients in 2030
29%84%
0,3% 28%
Smit M et al., Lancet Infect Dis. 2015; 15: 810–18
The profile of NCD burden is higher than is
expected for the HIV-infected population with
the same age structure and sex ratio
27%19%
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Malattie cardiovascolari, incluse
le iperlipemie
Diabete
Insufficienza renale cronica
Osteoporosi
Tumori non AIDS definenti
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Ageing of the HIV Epidemic:Treatment Targets Beyond Viral Suppression
21Raftopoulos V, et al. EACS 2017. Milan, Italy. PE11/21
Cross-sectional study of 622 Greek HIV+ individuals in routine follow-up in 2015 (male 85%, MSM 72%, median age 42 years, 89% on ART, 80% VL<200 c/mL)
0%
20%
40%
60%
80%
100%
18-30 31-40 41-50 51-60 61-70 70+
Age Groups
HIV-positive individuals have a “heart age” on average 6 years older than HIV-negative, requiring
additional vigilance to care of comorbidities and CV risk factors in routine care
N=84 N=198 N=168 N=104 N=53 N=15
≥1 comorbidityeGFR(<60 mL/min)
High BMI(>25 kg/m2)
SmokingHigh BP(>140/90mmHg)
High LDL(>130 mg/dL)
Greece
Pa
rtic
ipa
nts
(%
)
Age-specific analysis illustrates the significant gap in
achievement of treatment targets that exists and is seen
across all age groups
*‘heart age’: the age of an individual with the same score but ideal risk factor values
6 4 7 812 14
0
20
40
60
80
100
18-30 31-40 41-50 51-60 61-70 70+
Median age difference
Median age
Median heart age
Me
dia
na
ge
(ye
ars
)
Age Groups
Median heart age* 50 years with median age
difference of 6 years
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Panel of International Experts:
State of the Science of Comorbidities
in HIV+ AdultsKey Insights:
• Comorbidities are an increasing burden in the care of virologicallystable HIV+ patients
• There is a critical need for HIV providers to implement lifestyle interventions into their practices (diet, physical activity, smoking cessation)
• The involvement of specialists in multiple disciplines (cardiology, endocrinology, nephrology, pulmonology, oncology, psychology, etc.) is needed to optimise clinical outcomes
• Identifying patients at highest risk of serious non-AIDS events cannot be accurately done with any one biomarker or current clinical risk algorithm; an adaptive Phase 2 design with several biomarkers and rigid criteria may be required to move appropriate surrogate markers into Phase 3 (a “panel of biomarkers” may be the answer)
Currier J, et al. IWCADRHIV 2017; EACS 2017 22
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Linee guida italiane 2017
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Linee guida italiane 2017
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PLoS Med, 2017
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Incoraggiamento per i clinici a dare
priorità su come affrontare i rischi
modificabili per malattia
cardiovascolare e malattia renale
nella popolazione HIV +
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Principi generali, : individuazione dei fattori di rischio
per singola NDC, stratificazione del rischio attraverso
algoritmi di screening, valutazione della fragilità del
singolo paziente
PREVENZIONE : stabilisce valutazioni e tempistica
Per singola NCD : individuazione del paziente a
rischio elevato
Per singola NCD : gestione del paziente a rischio
elevato
Linee guida italiane 2017
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MALATTIA CARDIOVASCOLARE
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STIMA DEL RISCHIO
Scegliere
un
algoritmo
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INDIVIDUAZIONE DEI FATTORI DI RISCHIOBuona anamesi,
comprensiva di eventuale
uso di sostanze, esami di
routine, misurare la
PAO,
Tenere soppressa la
viremia HIV
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VALUTAZIONE INDIVIDUALE DI VULNERABILITA’
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MALATTIA RENALE
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INDIVIDUAZIONE DEI FATTORI DI RISCHIO
Buona anamnesi,
anamnesi farmacologica,
misurare la PAO, esami
di routine
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STIMA DEL RISCHIO - I
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STIMA DEL RISCHIO - II
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VALUTAZIONE INDIVIDUALE
DI VULNERABILITA’
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Abitudini di vita
Il riconoscimento e la correzione degli
stili di vita ( fumo , dieta, attività fisica)
rappresentano gli interventi più efficaci
per la prevenzione e il trattamento delle
comorbosità non infettive
Linee guida italiane 2017
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Per i cambiamenti degli stili di vita lo schema delle
“5 A” del counselling può essere un utilissimo
riferimentoNon è una “materia” da psicologi, qualsiasi operatore sanitario
può facilmente utilizzarlo
CHIEDERE ( ASK )
RACCOMANDARE ( ADVISE )
IDENTIFICARE I MOTIVATI ( ASSESS )
AIUTARE ( ASSIST )
PIANIFICARE IL FOLLOW UP ( ARRANGE )
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TABAGISMO
DISORDINI ALIMENTARI
SEDENTARIETA’
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TABAGISMO
SCORRETTE ABITUDINI ALIMENTARI
SEDENTARIETA’
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IL TABAGISMO è una patologia da dipendenza e
come tale deve essere affrontata
IL GRADO DI DIPENDENZA DA NICOTINA SI
SINTETIZZA NELLA PRIMA DOMANDA DEL TEST DI
FAGERSTOM : QUANTO TEMPO INTERCORRE TRA IL RISVEGLIO E LA ACCENSIONE DELLA PRIMA SIGARETTA ?
Se è meno di 5 minuti, grave dipendenza
Pack/year : n° sigarette/die x anni di fumo
20Costruire dei percorsi facilitati, favorire dei riferimenti
utili
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Smoking Cessation as Part of HIV Care
0,00
0,25
0,50
0,75
1,00
35 40 45 50 55 60 65 70 75 80
Age (years)
Control, non-smoking Control, smoking HIV, non-smoking HIV, smoking
1. Helleberg M, et al. Clinical Infectious Diseases 2013;56:727-734.
2. Veterans Health Administration. HIV Provider Smoking Cessation Handbook. July 2012.
3. Bedimo R, et al. ID Week 2017. San Diego, CA. Oral #2473
Current smoking ratesHIV-infected: 47.4%General: 20.6%
HIV(-) Smoker
HIV(+) smoker
Evaluation of mortality in HIV+ patients and smokers living in Denmark from 1995-2010 (N=13,563)
Survival by Age, Stratified by HIV and Smoking Status1
Smoking is a substantial contributor to mortality.3
Smoking cessation needs to be prioritisedas an intervention for HIV-infected adults.3
Life Expectancy of 35-year-old HIV Patients, Stratified by Smoking Status1
Smoking Status Age (95% CI)
Current 62.6 (60.9-64.9)
Previous 69.1 (67.5-71.2)
Never 78.4 (71.9-84.9)
CI, confidence interval.
Non-smoker
Efficacy of Smoking Cessation Medications2
MedicationAbstinent at 6
months, %
Patch +
Gum/lozenge37
Varenicline 2mg 33
Bupropion +
Lozenge30
Patch + Bupropion 29
Gum 26
47
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Prevalenza overall
di depressione = 39,1 %
(111 studi, 42366 pazienti HIV +)
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DTG vs. EVG
DTG vs. RAL
RAL vs. EVG
1.18
1.07
0.92
Depression and Sleep Disturbance
10,869,01 9,31
0
2
4
6
8
10
12
14
DTG RAL EVG
Inci
de
nce
Ra
te p
er
10
0 P
Y
(95
% C
I)Adjusted Incidence Rate Ratios (95%CI)Incidence Rates
7,145,42 4,96
0
2
4
6
8
10
12
14
DTG RAL EVG
Inci
de
nce
Ra
te p
er
10
0 P
Y (
95
%
CI)
DTG vs. EVG
DTG vs. RAL
RAL vs. EVG1.06
1.21
1.04
Quintiles Database Analysis of INSTI CNS Outcomes
Wohl D, et al. ID Week 2017. San Diego, CA. Oral # 1687
De
pre
ssio
nS
lee
p D
istu
rba
nce
In the largest database analysis to date, with over 54,000 INSTI-treated patients,
Sleep Disturbances and Depression occurred
significantly more with DTG than EVG 49
‡
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TABAGISMO
SCORRETTE ABITUDINI ALIMENTARI
SEDENTARIETA’
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Fondamentale è la collaborazione con un
centro di dietologia / dietistica / nutrizione
clinica
Indagare il consumo di alcolici
Suggerire di limitare l’assunzione di grassi
saturi, colesterolo e carboidrati raffinati
Ridurre l’apporto di grassi a < 30 %
Promuovere il consumo di pesce, pollame (
senza pelle) e carne magra
Limitare / evitare bevande e cibi con zucchero
aggiunto
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TABAGISMO
SCORRETTE ABITUDINI ALIMENTARI
SEDENTARIETA’
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Insegnare ( facendosi aiutare anche dagli infermieri )
ad utilizzare le strategie innovative di rilevamento
della attività motoria ormai molto diffuse sui cellulari
( app)
Incoraggiare attività fisica moderata ( salire le scale,
andare al lavoro a piedi o in bici, girare in bicicletta,
nuotare, fare escursioni, andare 30 minuti a piedi tutti
i giorni, esercizi di stretching e flessioni, etc)
Dare indicazioni su palestre, attività comunali,
riferimenti associativi HIV e non HIV
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Grazie
per
l’atten-
zione