Alexandra Bieniek

AP is a 67-year-old woman with a history of depression, gout, and hypercholesterolemia. Her primary care provider issued a prescription for doxycycline for the treatment of cellulitis. AP is concerned about stomach problems, as most oral medications cause her to experience bloating and diarrhea. She remembers that the pharmacist recently told her she can take 1 of her medications with food or milk to help minimize stomach issues. AP wants to know if she can take her new prescription for doxycycline with milk. 

Counsel AP to take her doxycycline on an empty stomach 1 hour before or 2 hours after meals. The calcium in dairy products, such as milk, can interfere with the absorption of doxycycline. Calcium ions can bind to doxycycline and form a chelate, thus reducing its absorption. This may also reduce the effectiveness of AP's cellulitis treatment.

 To be safe, she will need to change how she takes her medications for the duration of her doxycycline therapy.

Meyer FP, Specht H, Quednow B, Walther H. Influence of milk on the bioavailability of doxycyclie—new aspects. 

. 1989;17(4):245-246. doi:10.1007/BF01639529

JC is a 21-year-old woman who calls the pharmacy in a panic. She reports having unprotected sex with a new partner about 12 weeks ago and is concerned about possible HIV infection. JC called her primary care provider's (PCP) office to schedule an appointment for HIV testing but learned that her PCP is on vacation this week. JC is very anxious about this situation and has been having trouble sleeping. She wants to know if there is a reliable screening test she can take or if she needs to wait until her PCP returns from vacation. 

What advice should the pharmacist give JC?

Because it has been 3 months since JC had unprotected sex, she can purchase an at-home HIV testing kit, such as OraQuick. The FDA-approved saliva-based test is designed to detect antibodies to the HIV virus. Results are reported in 20 to 40 minutes, which should give JC the answers she needs without waiting for her PCP to return from vacation. If the test is positive, a health care provider should confirm the result. If the test is negative, it is likely that JC does not have HIV, assuming she followed the directions carefully. 

 are PharmD candidates at the University of Connecticut School of Pharmacy in Storrs.

is an associate clinical professor at the University of Connecticut School of Pharmacy in Storrs.

Articles

How would you respond to these patients' questions?

July 2021 Interactives: Case Studies

Everyone has neutralizing antibodies (NAbs).

NAbs defend our cells against pathogens by diminishing their infectivity. While binding antibodies attach to a pathogen and activate immune cells to destroy it, NAbs simply inhibit the pathogen’s biological effect.

Scientists use NAbs in both active and passive immunization. Vaccines are the most common active immunization example. Serum therapy is a passive immunization treatment that involves administering a recovered patient’s blood serum to an infected patient. Recently, investigators have been studying NAb-based therapies to treat and prevent COVID-19.

Most NAbs are very specific for one pathogen. Consequently, pathogens that frequently mutate, like HIV, pose a challenge. However, broadly neutralizing antibodies (bNAbs) are a potential solution that can inactive multiple strains of a virus. Currently, investigators have found bNAbs for HIV, hepatitis C, and influenza, among others.

 investigated if a bNAb (VRC01) can prevent HIV-1 infection. One trial enrolled 2699 at-risk cisgender men and transgender individuals in the Americas and Europe, and a second trial enrolled at-risk women in sub-Saharan Africa. Investigators randomized patients to receive either:

The investigators looked at 2 things: acquisition and prophylaxis of infection. Participants received 10 infusions in total and underwent HIV-1 testing every 4 weeks. The results concluded that VRC01 did not prevent HIV-1 acquisition. However, VRC01-sensitive HIV-1 isolate analyses suggest bnAb prophylaxis can be effective. The investigators assert that virus strain’s susceptibility to VRC01 was an important factor in antiviral activity. VRC01 only effectively inhibited 30% of the virus strains in the trial regions but provided 75% protection in participants with VRC01-sensitive strains.

While VRC01 did not prevent HIV-1 acquisition, the study demonstrated that preventing HIV infection with bNAbs is feasible. Researchers are currently conducting early phase clinical trials on various bnAbs, including combination products. If these new bnAbs are effective, they can be used to prevent HIV infections and save countless of lives.

 is a 2022 PharmD candidate at the University of Connecticut in Storrs.

Corey L, Gilbert PB, Juraska M, et al. Two Randomized Trials of Neutralizing Antibodies to Prevent HIV-1 Acquisition. 

. 2021;384(11):1003-1014. doi:10.1056/NEJMoa2031738

Investigators have found bNAbs for HIV, hepatitis C, and influenza, among others. 

Neutralizing Antibodies May Provide a New Approach to Longstanding Infections

HIV is an infectious virus frequently transmitted through blood and it has spread during the opioid crisis. Since many patients with opioid use disorder are also people who inject drugs (PWID), increased HIV diagnoses is a consequence.

 published an analysis that explored HIV spread during the opioid crisis. The analysis examined the deadly synergy’s history, treatment barriers, and evidence-based interventions. While several effective interventions exist to combat HIV spread and opioid use disorder, patients face many barriers in accessing these resources. Syringe services programs (SSPs, or needle exchange programs), medications for opioid use disorder (MOUD), and psychosocial treatment are not universally available in the United States.

Scott County, Indiana, illustrates the many challenges that PWID face. In Scott County, SSPs were illegal and only 1 clinician with minimal experience in treating addiction and HIV served the entire county. As a result, the community faced a large HIV and hepatitis C outbreak, which researchers attribute to inadequate treatment and prevention resources. The Scott County case demonstrates how vulnerable rural communities are to the opioid and HIV epidemics.

As the best proven intervention for opioid use disorder, MOUD like methadone, buprenorphine, and naltrexone are extremely effective for HIV prevention. However, only 11% of patients receive MOUD. Patient barriers include stigma, no health insurance, and MOUD misinformation, among others. Furthermore, inadequate reimbursement and low prescription rates can prevent providers from treating opioid use disorder.

Despite progress in treating and preventing HIV in patients with opioid use disorder, these interventions cannot be successful unless health care professionals and policy makers eliminate the barriers. Researchers emphasized these key recommendations as follows:

Ensure universal health care for all PWID

Expand primary care clinics to provide medical care and support for PWID

Furthermore, pharmacists can implement several recommendations into their practice, regardless of the setting. Many PWID face overwhelming stigma that may discourage them from pursuing treatment. Additionally, they may believe misinformation spread about treatment like MOUD. Pharmacists can be an empathetic resource for these patients, providing guidance without stigma. With this knowledge, pharmacists can help combat HIV spread in patients with opioid use disorder.

Hodder SL, Feinberg J, Strathdee SA, et al. The opioid crisis and HIV in the USA: deadly synergies. 

. 2021;397(10279):1139-1150. doi:10.1016/S0140-6736(21)00391-3

Pharmacists can implement several recommendations into their practice, regardless of the setting.

Medications for Opioid Use Disorder and HIV Prevention Go Hand in Hand

Solve this riddle: I am a fraction of a whole, rarely the same, a long time I remain. What am I?

If your answer is intravenous immunoglobulin (IVIG), you are correct.

IVIG is a cornerstone in autoimmune disease treatment, among other conditions such as idiopathic thrombocytopenia purpura, allogenic bone transplant, and off-label use in multiple sclerosis.

The treatment is vastly different from other intravenous medications. Each preparation contains blood donor plasma from between 3000 and 10,000 different individuals. Consequently, IVIG can have unique effects on a patient’s serology tests.

A case study published in the March 2021 

 recounts an incident in which a patient presenting with thrombocytopenia received IVIG. Prior to treatment, the patient’s viral serology tests were negative for any bloodborne disease.

However, post-treatment, the blood sample contained CMV and hepatitis A antibodies. Even after retesting both blood samples, the results remained unchanged.

The patient case was not unique, with numerous studies previously reporting immune status changes following IVIG administration. Researchers even reported viewing anti-troponemal antibody and anti-toxoplasma gondii antibodies in patients after IVIG treatment. A large donor pool and different manufacturing methods may cause IVIG product variability and subsequent serological changes.

As medication experts, pharmacists can educate both patients and providers about the effect of IVIG therapy on laboratory tests. For example, pharmacists can help investigate abnormal serological results and correlate them to previous IVIG treatment. False positives may occur for several days or even weeks, depending on factors pertaining the patient, donors, and manufacturers. The authors recommend:

Obtaining patient histories of IVIG exposure.

Refraining from immediate serological testing following treatment.

Not identifying prior IVIG exposure before serological testing may cause harm. False positive results may create unnecessary treatments, costs, and adverse effects for patients. Therefore, health care professionals should be aware that IVIG can affect patients’ viral serology and educate patients to disclose IVIG history to all future providers.

Ms. Bieniek is a 2022 PharmD Candidate at the University of Connecticut.

Suresh J, Kyle BD. Clinical false positives resulting from recent intravenous immunoglobulin therapy: case report. 

. 2021;21(1):288. Published 2021 Mar 21. doi:10.1186/s12879-021-05986-z.

Intravenous immunoglobulin is a cornerstone in autoimmune disease treatment.