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Drug Resistance
Feb 19, 2005

Drug Resistance: Posted: Feb 4, 2005

Okayy i have been HIV+ for about 16 years and have for the past 3 years fallen to resistance to ALL the meds out there , i have been told even though one may be totally resistant to meds its better to be on something than nothing so its been almost 2 years on Fuzeon and its keeping the VL under a 1/2 Million and a CD4 of 3 and no real OI"S a little anemia and ITP is a sensable approach and should i not fix what is not totally broken or take a break from the meds entirely i have tried that under supervision but my CD4 was higher at that point not like now at 3 ,the Doctor does not understand me at all he just says to keep doing what i am doing which is fine but very frustrating any ideas would be greatly appreciated imensely thank you as a RN i can understand what you might have to say appreciate your time and opinion take care be well

Dr. Bob's response:

Hi,

Drug resistance is one of the biggest problems we face today, particularly in those of us who have been positive for many years and extensively treated with a variety of drugs in the past. So, aside form continuing to push pharmaceutical companies and the FDA to develop and approve new medications, what do we do? Here are a few ideas to consider:

1. Make sure you are working with an HIV specialist who is competent, compassionate and experienced in managing these types of complex medical problems. A second opinion never hurts if you feel your doctor "does not understand me at all and just says to keep doing what I am doing."

2. Are you really "totally resistant to all meds?" Resistance testing is a complex science. Resistance is also not an "all or nothing" phenomena. It may be that your virus still has some sensitivity to certain drugs in certain combinations, despite being "resistant" on the lab report. You should have both genotype and phenotype tests done to help put together your best option for a salvage regimen.

3. It is true that even if you are "resistant to everything," being on something is better than being on nothing. There appears to be a beneficial and protective effect, possibly because viral fitness may be compromised as viral resistance develops. If you stop all the drugs, your virus may become more "fit" or aggressive.

4. STIs (strategic treatment interruptions) were all the rage a few years ago then again so were "Hootie and the Blowfish". However, we now know they are a bad idea, particularly in folks with advanced disease and low CD4 counts (that's referring to STI's, not Hootie). Yes, there are reasons to stop meds cumulative drug toxicity, for example but in cases like yours, I would certainly advise against a drug holiday at this time.

5. Regarding your current meds, I would hope you are on something other than Fuzeon as a solo agent. I would also hope you are on prophylaxis to protect against various opportunistic illnesses PCP, MAC, etc.

6. Regarding your anemia, has a specific cause been identified yet? If not, you should talk to your HIV specialist and determine the potential causes of your anemia anemia of chronic disease (HIV related), medication side effects, blood loss, unrecognized opportunistic process, etc. and treat the specific cause or causes.

OK RN, that should give you something to work on for now! Write back if you need additional advice. And don't forget to consider getting a second opinion. It's true you're not broke yet, but you are creaking at the seams a bit.

Good luck!

Dr Bob , thank you for your insight on my question i am on Viread and 3tc and Videx which are the only 3 that i have sensitivity to and Fuezon but Resistant across the board to all the PI's i feel like you at this point a second opinion is indicated , because im not sick at this point with OI's i dont want to get any either , and when i ask to do a Geno-Pheno I get its not needed its like he has "given up " because of the complex issues associated with me and meds, i did seek a second opinion at one point to another ID specialist and she had nothing positive to say either looked at the Geno-Pheno tests and other labs and said there was nothing that she could do that he was doing and this was at a Major University here In Ohio (OSU) so i know of a few in the field that really take this to heart and not burned out because that is what i am seeing in my Doctor and will seek another opinion i think its that time im on the sulfa and fungal meds and Zithro. but i appreciate your taking the time i have looked at the Resistance testing and i have a great deal of markers on the drugs so i have been told its the Wild Type virus? any thoughts about that would be greatly appreciated be well and thank you Eriq

Response from Dr. Frascino

Hi Eriq,

It's difficult for me to give specific information about your resistance profile without actually seeing the resistance test results. So I'll just make a few general comments/suggestions:

1. If you have resistance to all the currently available PIs, then you do not have "wild type" virus.

2. If your CD4 count is 3, I agree you should be on broad-spectrum opportunistic infection prophylaxis.

3. You can search for a certified HIV specialist in your area by checking the American Academy of HIV Medicine's Web Site at www.aahivm.org. They have certified specialists listed by location.

4. Regarding your PI-resistance problem, there was one piece of encouraging news from November's AIDS conference (ICAAC: Interscience Conference on Antimicrobial Agents and Chemotherapy) that reported that HIVers with heavy resistance to PIs did better if their combos included the soon-to-be-released PI tipranavir than any other PI. Those who paired tipranavir with Fuzeon did best: nearly half got their viral loads below 400. Tipranavir is now available in expanded access programs. Your HIV specialist will let you know if you qualify. (I think you should.) The moral of the story here is that if you've been around the protease inhibitor block a few too many times, save Fuzeon until you can snag some tipranavir to double-barrel it with!

Good luck, Eriq!

Dr. Bob


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