What recommendations should be made re: EtOH consumption and what are the Mx options?
- No more than 2 standard drinks daily
- No more than 4 standard drinks on any one occasion
Mx
- Disulfiram (raises acetaldehyde levels)
- Acamprosate (reduces withdrawal symptoms)
- Naltrexone
What conditions are associated with functional hyposplenism?
- EtOH liver disease
- Cirrhosis
- Coeliac disease
- Lymphoma
- Autoimmune disease
- IBD
- Whipple’s disease
- Chronic GVHD (eg HSCT)
- HIV
- Sickle cell disease
How is suspected functional hyposplenism investigated?
- Howell-Jolly bodies
- Pitted erythrocytes > 4% of at least 2000 RBC in total
- Spleen scintigraphy with T99msulfur colloid => reduced uptake
When should vaccination first doses be given pre- elective splenectomy or post- emergency splenectomy?
7-14 days pre-elective
>7 days post emergency
What is the vaccination schedule for asplenia/hyposplenism?
Pneumococcus
- Conjugate => 5wks => Polysaccharide => 5yrs => Polysaccharide
Meningococcus
- Conjugate ACWY and recombinant B+ => 8 wks => repeat
- 5yrly Conjugate ACWY
Hib
- Conjugate Hib => no boosters required
What are the live vaccines contraindicated in immunosuppressed individuals?
MMR VZV Oral polio Yellow fever Live typhoid BCG
What is involved in the management of HIV?
- CD4 count and viral load q3-6months (viral load should be undetectable after 3 months)
Meds
- Drug interactions
- Adherence to ART
- ART side effects
Infection prophylaxis
- If CD4 count of < 200 cells/μL or < 14% of lymphocyte count => Bactrim
- If CD4 < 50 cells/μL => azithromycin 1.2g PO weekly for MAC prophylaxis
- Influenza and pneumococcal vaccinations
- MMR and VZV vaccinations safe. Other live vaccines C/I.
Infection screening
- STI screens annually in MSM: chlamydia, gonorrhoea, syphilis
- Hep A and B vaccination. Aim HBsAb > 10
- Hep C screening annually if high risk
CVS
- Smoking cessation
- Weight loss: BMI, waist <94cm males, <80cm females
- Diet
- Exercise ~150min weekly
- EtOH max 2 drinks daily
- BP <140/90, or <130/80 if DM, albuminuria
- Lipids
Metabolic
- BSL
- eGFR and U/A q3-6m while on ART
- LFT q3-6m while on ART
- Osteoporosis risk Ax
Malignancy screening
- FOBT q2y from 50-75
- Mammo q2y
- PAP smear q1y
- Regular skin checks
- Consider PSA/DRE from age 50
Psychosocial
- Depression
- Drug use
- Housing, financial, social support
- Sexual and reproductive function
What investigations are relevant in cognitive impairment?
TSH - hypothyroidism B12 - deficiency HIV Syphilis MRI brain - frontotemporal vs Alzheimer's
Which patients should not be commenced on efavirenz for HIV?
Those with neuropsychiatric issues
Which patients should not have abacavir?
HLA-B57*01 => hypersensitivity reaction
AMI
Which HIV treatments may cause a rise in Cr?
- Cobicistat, Dolutegravir => reduce Cr excretion but do not affect renal function
- Tenofovir disoproxyl fumarate (TDF). TAF is better.
