Ask the Experts: Practice Issues Related to the Management of Patients with HIV in the Inpatient and Ambulatory Care Setting

Transcription

1 Ask the Experts: Practice Issues Related to the Management of Patients with HIV in the Inpatient and Ambulatory Care Setting Presented as a Live Webinar Thursday, March 5, :00 p.m. 4:00 p.m. ET Planned by ASHP Advantage and supported by an educational grant from Merck.

2 Ask the Experts: Practice Issues Related to the Management of Patients with HIV in the Inpatient and Ambulatory Care Setting Activity Overview This activity will provide pharmacists guidance on managing the unique medication needs of patients with HIV on antiretroviral therapy in the inpatient and ambulatory care setting. The content of this activity is based on questions raised by participants in a recent educational symposium on this topic as well as clinical aspects of treating patients with HIV that faculty want to discuss further. Learning Objectives At the conclusion of this knowledge-based educational activity, participants should be able to Describe medication therapy management and disease state issues in HIV patients on antiretroviral therapy in the inpatient setting. Describe medication therapy management and disease state issues in HIV patients on antiretroviral therapy in the ambulatory care setting. Continuing Education Accreditation The American Society of Health-System Pharmacists is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This activity provides 1.0 hour (0.1 CEU no partial credit) of continuing pharmacy education credit (ACPE activity # L02-P for the live activity). Participants will process CPE credit online at with the option of printing a CE certificate. CPE credit will be reported directly to CPE Monitor. Per ACPE, CPE credit must be claimed no later than 60 days from the date of the live activity or completion of a home study activity. Webinar Information Visit to find: Webinar registration link Group viewing information and technical requirements CPE webinar processing instructions 2

3 Ask the Experts: Practice Issues Related to the Management of Patients with HIV in the Inpatient and Ambulatory Care Setting Activity Faculty Douglas Slain, Pharm.D., BCPS, FCCP, FASHP, Activity Chair Associate Professor Infectious Diseases Clinical Specialist West Virginia University Morgantown, West Virginia Douglas Slain, Pharm.D., BCPS, FCCP, FASHP, is currently Associate Professor and Infectious Diseases Specialist at West Virginia University (WVU) in Morgantown, West Virginia. He received his Bachelor of Pharmacy degree and Doctor of Pharmacy degree from Duquesne University in Pittsburgh, Pennsylvania. He completed a residency and fellowship in infectious diseases pharmacotherapy at the Medical College of Virginia in Richmond and is a board certified pharmacotherapy specialist with added qualifications in infectious diseases. Dr. Slain is an anti-infective clinical specialist on the WVU infectious diseases consult service and in the outpatient infectious diseases clinic. In addition, he teaches in the schools of Pharmacy, Medicine, and Graduate Nursing and is the program director and principal mentor for the infectious diseases pharmacotherapy specialty residency at WVU. He serves as an international consultant to schools of pharmacy and hospitals in other countries and has helped programs in their development of clinical pharmacy education, pharmacy residency training, and antibiotic stewardship. Dr. Slain was a 2013 recipient of a Fulbright Scholars grant, which funded a project in Chennai, India and he serves as the School of Pharmacy s Global Affairs Liaison. He was selected as Clinician of the Year by The Society of Infectious Diseases Pharmacists (SIDP) and has received multiple teaching awards in the School of Pharmacy. Dr. Slain s research has been published extensively and he speaks frequently at regional, national, and international meetings and conferences. 3

4 Ask the Experts: Practice Issues Related to the Management of Patients with HIV in the Inpatient and Ambulatory Care Setting E. Kelly Hester, Pharm.D., BCPS, AAHIVP Associate Clinical Professor Department of Pharmacy Practice Auburn University Harrison School of Pharmacy Auburn, Alabama E. Kelly Hester, Pharm.D., BCPS, AAHIVP, is Associate Clinical Professor in the Department of Pharmacy Practice at Auburn University Harrison School of Pharmacy in Auburn, Alabama. She received her Bachelor of Science and Doctor of Pharmacy from Auburn University. She completed a residency in pharmacy practice at Wake Forest University Baptist Medical Center in Winston-Salem, North Carolina. Dr. Hester currently has practice affiliations with two adult HIV clinics in Alabama and provides collaborative medication therapy management pharmaceutical care services for the HIV and primary care needs of her patients. Prior to her current position, she worked for three years at the University of Alabama-Birmingham AIDS outpatient/research clinic serving as a clinical and investigational drug pharmacist. 4

5 Ask the Experts: Practice Issues Related to the Management of Patients with HIV in the Inpatient and Ambulatory Care Setting Disclosure Statement In accordance with the Accreditation Council for Continuing Medical Education s Standards for Commercial Support and the Accreditation Council for Pharmacy Education s Guidelines for Standards for Commercial Support, ASHP Advantage requires that all individuals involved in the development of activity content disclose their relevant financial relationships. A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. A person has a relevant financial relationship if the individual or his or her spouse/partner has a financial relationship (e.g., employee, consultant, research grant recipient, speakers bureau, or stockholder) in any amount occurring in the last 12 months with a commercial interest whose products or services may be discussed in the educational activity content over which the individual has control. The existence of these relationships is provided for the information of participants and should not be assumed to have an adverse impact on presentations. All faculty and planners for ASHP Advantage education activities are qualified and selected by ASHP Advantage and required to disclose any relevant financial relationships with commercial interests. ASHP Advantage identifies and resolves conflicts of interest prior to an individual s participation in development of content for an educational activity. E. Kelly Hester, Pharm.D., BCPS, AAHIVP, is on the ViiV speakers Bureau. All other faculty and planners report no financial relationships relevant to this activity. 5

6 CE IN THE MIDDAY Ask the Experts: Practice Issues Related to the Management of Patients with HIV in the Inpatient and Ambulatory Care Setting Douglas Slain, Pharm.D., BCPS, FASHP, Activity Chair Associate Professor Infectious Diseases Clinical Specialist West Virginia University Morgantown, West Virginia Disclosures E. Kelly Hester, Pharm.D., BCPS, AAHIVP, is on the ViiV Speakers Bureau. All other faculty and planners report no financial relationships relevant to this activity E. Kelly Hester, Pharm.D., BCPS, AAHIVP Associate Clinical Professor Auburn University Harrison School of Pharmacy Auburn, Alabama Planned by ASHP Advantage and supported by an educational grant from Merck Learning Objectives CE IN THE MIDDAY Describe medication therapy management and disease state issues in HIV patients on antiretroviral therapy in the inpatient setting. Describe medication therapy management and disease state issues in HIV patients on antiretroviral therapy in the ambulatory care setting. Antiretroviral Therapy Update: Issues at Hospital Admission Douglas Slain, Pharm.D., BCPS, FCCP, FASHP Activity Chair Associate Professor Infectious Diseases Clinical Specialist West Virginia University Morgantown, West Virginia Formulary Decisions How do you select antiretrovirals for the hospital formulary? National guidelines New initiations Continuations Usage trends Expert consultation Post exposure prophylaxis Perinatal prophylaxis 6

7 One Pill Once a Day Efavirenz/emtricitabine/tenofovir disoproxil fumarate (Atripla ) Emtricitabine/rilpivirine/tenofovir disoproxil fumarate (Complera ) Elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate (Stribild ) Abacavir/dolutegravir/lamivudine (Triumeq ) All commercially available combination antiretroviral agents were added to the hospital formulary, because we found that combining single agent formulary antiretroviral medications to imitate nonformulary combination products was associated with a higher rate of errors. Daniels LM et al. Am J Health Syst Pharm. 2012; 69: Maybe Do you allow the use of patient s own supply of antiretrovirals during hospitalization? Could be an old prescription Partial prescription Dose may not be appropriate (renal/hepatic) Have they been stored properly How long would it take to get from wholesaler or other pharmacy? Are there policies on this? Joint Commission View on Home Medication Use in Hospitals Standard MM states: The hospital safely controls medications brought into the hospital by patients, their families, or licensed independent practitioners. This standard includes the following elements of performance: The hospital defines when medications brought into the hospital by patients, their families, or licensed independent practitioners can be administered. Before use or administration of a medication brought into the hospital by a patient, his or her family, or a licensed independent practitioner, the hospital identifies the medication and visually evaluates the medication s integrity. The hospital informs the prescriber and patient if the medication brought into the hospital by patients, their families, or licensed independent practitioners is not permitted. Accessed February 23, ASHP Policy on Use of Home Medications During Hospital Admission The use of a patient s own or home medications should be avoided to the fullest extent possible. Use of such medications should be allowed only if there is a need for the patient to receive the therapy, the drug product is not obtainable by the pharmacy, and no alternative therapy can be prescribed. If such medications are used, the prescribing physician must write an appropriate order in the patient s medical record. Before use, a pharmacist should inspect and identify the medication. If there are any unresolved questions with respect to product identity or integrity, the medication must not be used. Accessed February 23,

8 Question 1 What medication issues are most problematic when patients with HIV are admitted to the hospital? JB is a 42 year old male with HIV infection who is admitted to the ICU for presumptive respiratory tract infection. He may have a bacterial or Pneumocystis jirovecii pneumonia. He admits to not taking his ART (antiretroviral therapy) for the past two months. What should be done with JB s ART at this point? A. Restart his same ART regimen. B. Hold ART until his respiratory issue is resolved. C. Order a resistance test and start an ART regimen that is deemed susceptible. D. Start him on an ART regimen composed of new classes of drugs. Question 2 JB s home regimen was atazanavir+ ritonovir + tenofovir/emtricitabine. The hospital carries these medications on formulary. He also has a sulfa drug allergy. According to available research, what factor is most associated with medication related errors upon admission? A. Pneumonia admission. B. Protease inhibitor therapy. C. Sulfa drug allergy. D. Non adherence. Transitions of Care: Room for Improvement Over 70% of hospitalized HIV infected patients may experience an antiretroviral error Majority of patients are admitted by services without Infectious Diseases expert input Kelly LS et al. Am J Health Syst Pharm. 2013; 70: Mok S et al. Am J Health Syst Pharm. 2008; 65:55 9. Hospital Physician Survey on Antiretrovirals Correct Responses (%) Frequency of Drug Related Problems in Hospitalized HIV Infected Patients % Residents Non ID Attendings ID Physicians Problem % Patients Incomplete ART regimen 43 Inappropriate ART regimen 4 No opportunistic infection (OI) prophylaxis 11 OI prophylaxis not needed 10 Inappropriate ART regimen Overdosage 15 Inappropriate ART regimen Underdosage 8 Drug interaction (Between ART medications) 10 Drug interaction (Between ART and other medications) 46 Adverse drug reactions 21 Arshad S et al. J Int AIDS Soc. 2009; 12:1 10. Mok S et al. Am J Health Syst Pharm. 2008; 65:

9 Risk Factors for ART Errors on Hospital Admission Non Formulary Medications Protease Inhibitor Regimens Weekend Admission Antiretroviral Drug Interactions Cytochrome (CYP) P 450 Isoenzymes Primarily CYP3A4 P Glycoprotein ph alteration Kelly LS et al. Am J Health Syst Pharm. 2013; 70: P 450 CYP3A4 Drug Interactions Substrates Inhibitors Inducers PIs Azole antifungals Rifampin Statins Macrolides Rifabutin Macrolides NNRTIs NNRTIs Some NNRTIs Grapefruit juice Phenobarbital Maraviroc PIs Carbamazepine Benzodiazepines Sertraline Phenytoin Azoles antifungals Fluoxetine Methadone Cobicistat Elvitegravir Other P 450 isoenzymes may be involved in interactions Special Issues Renal dosing Liver failure or toxicity Food effects PPI use Starting a patient back on ART who is not a good historian NPO or cannot swallow PI=protease inhibitors NNRTI=non nucleoside reverse transcriptase inhibitor Developed from: Michalets EL. Pharmacotherapy. 1998; 18: Antiretroviral Options for Patients Who Cannot Swallow Oral Tablets or Capsules Liquid Manufacturer s product Compound product NG tube administration Do not crush list Prohaska ES et al. Am J Health Syst Pharm. 2012; 69: druginteractions.org/data/extraprintablecharts/extraprintablechartid10.pdf. Accessed 2015 Feb 25. Pharmacist led Inpatient Services Identify as high risk patients Make hospital pocket or web reference for ART Bring to attention of ID pharmacy specialist Decision support software (e.g., TheraDoc, Sentri 7, etc.) Mandatory drug interaction screening Antiretroviral support service South Carolina College of Pharmacy (Columbia) Daniels LM et al. Am J Health Syst Pharm. 2012; 69: Kelly LS et al. Am J Health Syst Pharm. 2013; 70: th ASHP Midyear Clinical Meeting Abstract

10 Discontinuation of Antiretrovirals During Hospitalization If they are really sick with an opportunistic infection, then the ART must not be working Myth or fact? Continuing ART medication may reduce overall mortality Even if viral strain has resistance ART adverse reactions need to be considered in regimen continuation Meybeck A et al. AIDS Res Ther. 2012; 9:27. Immune Reconstitution Inflammatory Syndrome (IRIS) Inflammatory syndrome triggered by supercharged immune system after HAART initiation Usually occurs during an acute or subacute infection or disease. MAC Tuberculosis CMV Cryptococcal Meningitis PCP Paradoxical worsening of their underlying opportunistic infection. Role of corticosteroids or delay of HAART initiation? HAART Highly active antiretroviral therapy MAC Mycobacterium avium complex Dhasmana DJ et al. Drugs. 2008; 68: Discharge Planning: A Role for Pharmacists Discharge counseling Contact the patient s pharmacy Contact the patient s HIV clinic Help the patient identify resources Ryan White Clinics Conclusion Errors with medications in HIV infected patients are fairly common. Meticulous evaluation of medications during transitions of care is essential to avoiding medication errors. Outline Practice Issues Related to the Management of Patients with HIV in the Ambulatory Care Setting E. Kelly Hester, Pharm.D., BCPS, AAHIVP Associate Clinical Professor Auburn University Harrison School of Pharmacy Auburn, Alabama Discuss special considerations in treating concomitant disease states in patients with HIV infection Review strategies for managing concomitant disease states Highlight important drug drug interactions with antiretroviral therapy Provide recommendations for resource references 10

11 HIV in 2015 In the US, >50% of the HIV infected population will be over the age of 50 Increased number of comorbid conditions Shah et al: 89% 1 comorbidity 2.4 conditions per person (mean) Greater potential for drug drug interactions with polypharmacy Effros RB et al. Clin Infect Dis. 2008; 47(4) Shah SS et al. Clin Infect Dis. 2002; 35: Krentz HB et al. HIV Med. 2015; 16: Tseng A et al. Ann Pharmacother. 2013; 47: Increased CV Risk Inflammation ARV Tx HIV viral load CD4 count Endothelial Anemia dysfunction CV RISK Hepatitis C Impaired arterial elasticity Dyslipidemia Accelerated Renal disease Insulin resistance Aging Freiberg MS et al. JAMA Intern Med. 2013; 173; Triant VA et al. J Acquir Immune Defic Syndr. 2009; 51: Lichtenstein KA et al. Clin Infect Dis. 2010; 51: Kuller LH et al. PLoS Med. 2008; 5:e203. Riddler SA et al. JAMA. 2003; 289: Baker JV et al. J Acquir Defic Syndr. 2009; 52: Torriani FJ et al. J Am Coll Cardiol. 2008; 52: Deeks SG. Top HIV Med. 2009; 17: Law MG et al. HIV Med. 2006; 7: Zanni MV et al. AIDS. 2014; 28: Diabetes and HIV Rates of new onset diabetes in HIV patients receiving ART are 4 fold higher than in uninfected patients. Reducing CVD Risk Insulin resistance with protease inhibitor based ART is estimated >60%. HIV Disease Antiretroviral Therapy Inflammation Viral load Endocrine alterations Hepatitis C coinfection Increases insulin resistance Reduces insulin secretion Increases proinflammatory markers (CRP, IL-6, TNFα) Lipodystrophy (fat redistribution) Tsiodras S et al. Arch Intern Med. 2000; 160: Brown TT et al. Arch Intern Med. 2005; 165: Kalra S et al. Curr Diab Rep. 2013; 13: Diabetes Management Strategies Management individualized and according to diabetes guidelines for HIV-uninfected patients Treatment Comments Metformin First line therapy unless contraindicated Lactic acidosis with cart is rare and no restrictions with concomitant use of NRTIs Monitor renal function closely with concomitant tenofovir Cobicistat and dolutegravir inhibit creatinine clearance but do not reduce GFR Monitor tolerability with dolutegravir and consider dose reductions Incretin Therapy GLP 1agonists No interactions Dose reduce saxagliptin with strong 3A4 inhibitors (ex: DPP IV inhibitors ritonavir, atazanavir, darunavir) HIV Therapy May switch lopinavir/ritonavir to another ART therapy Diabetes Screening and Monitoring Screening Hemoglobin A1c may underestimate glycemia in HIV infected patients Fasting plasma glucose is recommended Monitoring Therapy A more stringent HbA1c goal may be appropriate cart combination antiretroviral therapy Monroe AK, et al. Clin Infect Dis. 2015; 60: Dolutegravir [package insert]. Research Triangle Park, NC: ViiV Healthcare. December Accessed February Monroe, AK et al. Clin Infect Dis. 2015; 60:

12 Dyslipidemia and HIV Cardiovascular Disease HIV infected patients more likely have low total cholesterol, HDL, LDL and elevated triglycerides (TG) than uninfected patients ART can potentially increase LDL, HDL and worsen TG Dyslipidemic effects vary between antiretroviral drug classes Estimated annual risk of AMI 1.26 (95% CI ) with cumulative cart exposure. Grunfeld C et al. J Clin Endocrinol Metab. 1992; 74: Periard D et al. Circulation. 1999; 100: Haubrich RH et al. AIDS. 2009; 23: Frijs Moller N et al. AIDS. 2003; 17: Case A 48 year old male presents to the clinic following hospitalization for stent placement. His medication list includes the following: Elvitegravir/cobicistat/ emtricitabine/ tenofovir disoproxil fumarate (Stribild ) one tablet once daily Lisinopril 20 mg once daily Amlodipine 5 mg once daily Prasugrel 10 mg once daily Aspirin 81 mg once daily Simvastatin 20 mg once daily Which of the following statements is correct regarding concomitant therapy with Stribild (elvitegravir/cobicistat/emtricitabine/ tenofovir disoproxil fumarate)? a. Prasugrel concentrations may be increased. b. Prasugrel concentrations may be decreased. c. Simvastatin concentrations may be decreased. d. Amlodipine is contraindicated. ARV Class Protease inhibitors and Cobicistat Antiplatelet Therapies and Antiretrovirals Antiplatelet Therapy Clopidogrel Prasugrel Ticagrelor Comments Clopidogrel is suggested for use with concomitant PIs or cobicistat; No clinically significant effect expected. Ritonavir and cobicistat (strong CYP3A4 inhibitors) expected to reduce clinical effect (decreased bioactivation) of prasugrel. Potential for increased bleeding risk with inhibition of CYP3A4 metabolism of ticagrelor and P gp efflux inhibition. Ritonavir and cobicistat pharmacokinetic booster with ARV therapy Egan G et al. Ann Pharmacother. 2014; 48: Antiplatelet Therapies and Antiretrovirals ARV Class Integrase Inhibitors Raltegravir Elvitegravir Dolutegravir NNRTIS Efavirenz Rilpivirine Etravirine Nevirapine * Contraindicated Antiplatelet Therapy Clopidogrel Prasugrel Ticagrelor Clopidogrel Prasugrel Ticagrelor Comments No expected drug interactions except when elvitegravir is co formulated with cobicistat. Prasugrel or ticagrelor is recommended. Clopidogrel bioactivation may be reduced by efavirenz and etravirine * through inhibition of CYP2C19/2C9. Rilpivirine interactions not expected to be clinically relevant. Prasugrel metabolite and ticagrelor AUCs and plasma concentrations may be reduced by CYP3A4 induction by efavirenz, nevirapine and etravirine, but not expected to be clinically relevant. No interactions expected with rilpivirine. Egan G et al. Ann Pharmacother. 2014; 48:

13 Statin Therapy and Antiretrovirals ARV Class Protease Inhibitors and Cobicistat NNRTIs Efavirenz Rilpivirine Etravirine Nevirapine Comments Simvastatin and lovastatin contraindicated: Significant increases in concentrations and risk of rhabdomyolysis and myopathy. Atorvastatin levels increased with CYP3A4 inhibition: Use lowest dose possible (do not exceed 20mg) and titrate slowly Rosuvastatin levels may be increased with cobicistat and boosted PIs: Use lowest dose possible (do not exceed 10mg with boosted atazanavir and lopinavir); titrate slowly. Atorvastatin: levels decreased by efavirenz and etravirine up to 43%. Simvastatin: levels may be decreased by efavirenz, etravirine and nevirapine. Rosuvastatin: no data Pravastatin levels decreased 44% by efavirenz Doses should be adjusted according to lipid responses. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV 1 infected adults and adolescents. Department of Health and Human Services. Available at May 1, p. L13 14, L 23. Accessed February, Case ASSESSMENT: CYP3A4 inhibition by cobicistat PLAN: 1. Change prasugrel to clopidogrel for optimal efficacy. 2. Change simvastatin to atorvastatin 10 mg daily for safety. May titrate to 20 mg daily. 3. Monitor for hypotensive side effects with amlodipine. Case Pulmonary Disease A 52 year old female presents to the clinic for routine HIV medical follow up. Her medication list includes the following: Emtricitabine/tenofovir disoproxil fumarate 1 tablet once daily Atazanavir 300 mg once daily Ritonavir 100 mg once daily Hydrochlorothiazide 25mg once daily Fluticasone 220 mcg, 1 puff BID Albuterol 2 puffs Q 4 6 hours PRN ARV Class Protease inhibitors Corticosteroid Therapy and Antiretrovirals and Cobicistat Inhaled* Therapy Fluticasone Budesonide Beclomethasone Triamcinolone Flunisolide Comments Fluticasone and budesonide concentrations increased significantly resulting in adrenal insufficiency and Cushing s syndrome. Should not be used concomitantly. Beclomethasone most studied with antiretroviral therapy. These alternatives have shorter GC receptor binding half lives and less lipophilic. ARV Class Protease inhibitors Corticosteroid Therapy and Antiretrovirals and Cobicistat CS Therapy ORAL: Dexamethasone Prednisone INJECTABLE: Methylprednisolone Prednisolone Triamcinolone Comments Concerns with potential adrenal insufficiency and Cushing s syndrome Monitor closely with short term use. Use alternative HIV therapy without CYP for anticipated long term/recurrent use. DEX may decrease cobicistat concentrations. Do not co administer Use alternative HIV therapy without CYP interactions. *Inhaled or intranasal Ritonavir and cobicistat pharmacokinetic booster with ARV therapy Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at May 1, p. L11-12, L-30. Accessed February, Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at May 1, p. L11-12, L-30. Accessed February,

14 Case ASSESSMENT: Risk for adrenal insufficiency with fluticasone and ritonavir PLAN: Change fluticasone to beclomethasone Role of the Pharmacist CV Risk Reduction Services ART adherence Smoking cessation, dyslipidemia, HTN, and diabetes management Address ASCVD risk and underutilization of statin therapy Chronic co morbid conditions Monitor and address significant drug drug interactions Guidelines Helpful Resources Accessed February Treatment Guidelines Drug Interaction Databases Web and smart phone apps IDSA Guidelines available at 14

15 Ask the Experts: Practice Issues Related to the Management of Patients with HIV in the Inpatient and Ambulatory Care Setting Self-assessment Questions The presentation self-assessment questions are listed here for your convenience. Note the correct answers for future reference. 1. JB is a 42 year old male with HIV infection who is admitted to the ICU for presumptive respiratory tract infection. He may have a bacterial or Pneumocystis jirovecii pneumonia. He admits to not taking his ART (antiretroviral therapy) for the past two months. What should be done with JB s ART at this point? a. Restart his same ART regimen. b. Hold ART until his respiratory issue is resolved. c. Order a resistance test and start an ART regimen that is deemed susceptible. d. Start him on an ART regimen composed of new classes of drugs. 2. JB s home regimen was atazanavir+ ritonovir + tenofovir/emtricitabine. The hospital carries these medications on formulary. He also has a sulfa drug allergy. According to available research, what factor is most associated with medication-related errors upon admission? a. Pneumonia admission. b. Protease inhibitor therapy. c. Sulfa drug allergy. d. Non-adherence. 3. Which of the following statements is correct regarding concomitant therapy with Stribild (elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate)? a. Prasugrel concentrations may be increased. b. Prasugrel concentrations may be decreased. c. Simvastatin concentrations may be decreased. d. Amlodipine is contraindicated. 15