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Resistance - and serious worries about potential new regimen
Mar 27, 2011

Hi Gerald, I hope you can help me with advice in a difficult situation. I was recently told I have resistance towards atazanavir and emtricitabin, and moderate resistance to tenofovir, and that I should quit the combination I've been on for tree years: emtriva, viread, reyataz. I have tolerated this very well, with good healt, no side-effects, good CD4, but the last two years a steady VL of 5000. I am a bit surprised my VL isn't higher with the resistance.. My doctor has suggested Truvada, Isentress, Prezista and Norvir. This sounds a bit heavy for me. I read in a previous advice from you, that Truvada and Isentress together is a good (and sufficient) combination (STARTMRK study). Alternatively, he suggests: Isentress, viread,and Retrovir (azt). I feel more confidence towards american specialists here. Advice will be very much appreciated. I have a very demanding job, and I fear serious side-effects would mean I would have to quit my (dream)job, and I dread the thought of azt or prezista, which I understand from your forum can have tough side-effects. Best regards, -Mike, Sweden

Response from Dr. Pierone

Hello Mike, and thanks for posting.

This question is a bit off topic, but does have some bearing on lipoatrophy issues because drug-resistant virus sometimes leads to the use of more toxic regimens.

The conventional wisdom (and guidelines) suggests that if viral rebound and drug-resistant virus emerges, then antiretroviral therapy should be revamped as soon as possible in order to prevent progressive cross resistance that might limit future treatment options.

However, there are many cases in clinical practice where we see viral rebound and evidence of drug resistance, but immunologic function remains stable, and drug resistance does not appear to progress and lead to more cross-resistance.

In the face of uncertainty, a prudent middle of the road approach seems to be most appropriate to deal with emerging drug resistance and viral rebound. My approach is to revamp treatment when the new treatment choice is likely to be effective and not produce more side effects than the current regimen.

In your situation, a switch from Reyataz to Norvir/Prezista seems reasonable because the boosted protease inhibitor is much more potent and fairly well tolerated. There may actually be no need for the Isentress and Truvada because Norvir/Prezista alone appears to control viral replication for the majority of treated patients. So I agree that the Norvir/Prezista/Isentress/Truvada combination would be a heavy approach for your situation. Choosing Isentress, Viread, and AZT would mean going to an agent (AZT) that is largely obsolete because of side effects. Another important question is whether your genotype or phenotype showed resistance to NNRTIs. If not, the combination of Isentress and Intelence may be a consideration

I hope this information helps and best of luck!



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