Systemic therapy for malignancy in patients on anti retroviral medications
- Michelle A Rudek, PharmD, PhD
Michelle A Rudek, PharmD, PhD
- Associate Professor of Oncology
- Director of the Analytical Pharmacology Core Lab
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
- Richard F Ambinder, MD, PhD
Richard F Ambinder, MD, PhD
- James B Murphy Professor of Oncology
- Johns Hopkins School of Medicine
- Charles W Flexner, MD
Charles W Flexner, MD
- Professor of Medicine, Pharmacology and Molecular Sciences, and International Health
- Johns Hopkins University School of Medicine and Bloomberg School of Public Health
- John F Deeken, MD
John F Deeken, MD
- Associate Professor
- Virginia Commonwealth University
- Associate Director for Medical Oncology and Clinical Research
- Inova Comprehensive Cancer and Research Institute
The morbidity and mortality associated with human immunodeficiency virus (HIV) has been substantially decreased with the use of potent antiretroviral therapy (ART). For most HIV-infected individuals treated with potent ART, the acquired immunodeficiency syndrome (AIDS) has been transformed into a chronic disease. (See "The impact of antiretroviral therapy on morbidity and mortality of HIV infection in resource-limited settings" and "When to initiate antiretroviral therapy in HIV-infected patients", section on 'Benefits of antiretroviral therapy'.)
With increased longevity, both AIDS-related and non-AIDS-related malignancies have become an important cause of illness among individuals infected with HIV. The specific malignancies associated with an increased incidence in people infected with HIV are reviewed elsewhere. (See "HIV infection and malignancy: Epidemiology and pathogenesis" and "HIV infection and malignancy: Management considerations".)
PRIORITIZATION BETWEEN CANCER AND HIV TREATMENT
Systemic therapy of malignancy in patients infected with HIV presents difficult challenges because of the overlapping toxicities and potential drug-drug interactions between anticancer and antiretroviral agents. Avoiding unexpected toxicity or lack of therapeutic effectiveness requires a close collaboration between the infectious disease expert managing the antiretroviral therapy (ART) for HIV infection and the medical oncologist treating the cancer.
Optimal management of HIV infection generally utilizes continuous treatment with multiple antiretroviral agents to minimize the risk of developing resistant HIV strains, opportunistic infection, and/or death. However, advanced malignancy can pose an immediate threat to health and survival, and this may require that antineoplastic treatment take priority over ART [1,2]. As the agents utilized to treat both cancer and HIV infection evolve, it may be possible to maintain the optimal regimens to maximize treatment benefit for the HIV infection and malignancy.
There are significant risks associated with stopping ART, as was demonstrated when intermittent ART was found to be inferior to constant dosing. Dose modifications or the use of alternative medications for either the ART or the anticancer medications may be required to balance the competing treatment needs. Newer generation antiretroviral drugs (eg, dolutegravir, raltegravir, maraviroc) have a decreased risk of drug-drug interactions with anticancer agents and may be reasonable alternatives. (See 'Management' below.)
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