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First Therapy recomendation and low platelets
Nov 12, 2002

Dear Dr. Thank you for the service you provide to the community, the world wide community i must say, is very nice from you to heal the hearts of so many people. There should be many more Dr. Bobs around. Well the question is wich treatment should you recomend to start with, the doctors sugest many types, but they dont seem very sure. It seems they dont want to start with new drugs in order to leave them for later option, and the patient in this case, is a very good friend of mine and gets more lost with so many options. Her status is as follows, havent taken any meds, infection suspect 7 years ago, cd4 340, vl 14,000. Aparently no resistance is present, cbc almost normal except for mild leukopenia and low plateles at 120,000. What would you suggest to start with, and for how long do you think the treatment could be effective, before needing to change to another option?. Please tell us what drugs would you recommend. By the way, for making international donations to your foundation post the phone number of your foundation to ask for the bank numbers for wire transfers. Thank you in advance Sincerly A worried friend in Buenos Aires.

Response from Dr. Frascino

Hello Worried Friend in Buenos Aires,

Thank you for your very kind comments. I wish there was a simple answer to your question; unfortunately, there is not. The selection of a specific initial regimen is difficult, because there are many potential drug combinations that could be used effectively. A simplified way of considering the initial treatment options is to think of 3 basic approaches:

1. 2 nucleoside reverse transcriptase inhibitors (NRTI) plus a non-nucleoside reverse transcriptase inhibitor (NNRTI) 2. 2 NRTI's plus a protease inhibitor (PI) 3. Triple NRTI's

There are advantages and disadvantages to each of these basic approaches. For instance, "triple NRTI's" (Trizivir) has the advantage of being easy to use and avoids the adverse effects of protease inhibitors. However, the long-term efficacy of this regimen may be less than optimal, especially in people who have a very high baseline viral load. If you chose 2 NRTI's plus a NNRTI, the advantages would include avoiding the adverse effects of PI's and fewer drug-drug interactions. However, resistance and cross-resistance can occur quite easily with NNRTI's if adherence isn't optimal. Protease Inhibitor-based regimens have documented clinical and immunological efficacy as an advantage; however, disadvantages include a variety of long-term adverse effects.

Ultimately, the best way to choose a regimen is to discuss all the available options with an AIDS specialist. Clinical judgment, resistance tests, frequency of dosing, number and size of pills, food restrictions, and drug interactions, must all be taken into account.

Assuming your friend does not have resistance, I'd consider a regimen of Combivir (AZT and 3TC combination pill) plus Sustiva (a once-a-day non-nucleoside reverse transcriptase inhibitor). This is assuming adherence would be good and that he/she was able to tolerate these medications. Trizivir (triple nucleoside) could be considered as the most convenient option, but this regimen is most likely less potent than the other two options. Ultimately, whatever is chosen hopefully will bring your friend's viral load to the undetectable level quickly and boost the CD4 count.

How long will the regimen work? Again, this is difficult to predict and depends on many factors, including the strain of virus your friend has acquired, how effectively his/her immune system is functioning, and how adherent they are with their medication. My initial HAART regimen lasted over 6 years.

I know this is all very confusing and the complex information can be overwhelming. Your friend is in no immediate danger. He or she can take their time, exploring and learning about the various options before committing to a specific regimen. The old adage of "One size fits all" does not apply here. Rather, each regimen must be tailored to each person's unique set of circumstances. That's where your HIV specialist can really be helpful. Your friend can also get a second opinion, if they are confused about their options.

I spent a wonderful week in your beautiful city last summer. I have vivid memories of the Tango dancers in La Boca. And just as it "takes 2 to Tango," it takes both the patient's particular situation and the HIV specialist's knowledge working together to come up with an optimal initial regimen. If, for instance, the patient is set on the simplest regimen with the fewest number of pills and the physician is set on a potent PI-based regimen requiring many pills, well the two are not compatible. That would be like one person dancing a Samba and the other, a Tango. Both can be great dances individually, but you can't dance them together at the same time.

I hope that helps clarify things at least a bit for you and your friend.

The best way to make a direct wire transfer to our foundation is to follow these wiring instructions (for international transfers like yours, be sure to include the Swift number):

Mellon Bank Pittsburgh, P.A. ABA # 043000261 Credit ML Account Number 101-1730 Further Credit to: Robert James Frascino AIDS Foundation Account # 830-04C48 For international transfers add: Swift number MELN US 3P

Best of luck to you and your friend.

Dr. Bob


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