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The medication algorithm
Dec 29, 2013

Hi Dr. Holodniy!

It's the analogy guy once again! Can you believe it's the end of the year already? I can't! Well, anyway, this time around I had some questions regarding initial labs and which meds are subsequently prescribed.

First, how does a physician know which meds to prescribe? Is it based off of the doctor's preference or is it just the same for everyone? Does every doctor do initial genotypic and phenotypic testing to determine what kind of strain the HIV is and whether certain individuals will be resistant to certain types of meds? Given the cost (it makes me wish that my initial 2,000,000 vl was my income for the year!) I imagine that would be difficult for all patients to foot that bill.

Second, and this makes me as overwhelmed as Scottie in Hitchcock's "Vertigo" just thinking about it, are all patients meds regimens customized? If that's the case, isn't that a tremendously difficult and multi-variable algorithm taking into account patients' genetic predispositions need to be taken into account that might put them at a greater risk for developing certain conditions? Or is it ever based off of what a patients initial labs look like?

I've always wanted to ask my doctor what made him decide that Atripla was best for me, but I dreaded hearing "because that's what everyone takes."

In a perfect world the patient would walk in with a name tag that said "Hello, my name is (fill in the blank), I will respond best to treatment X," but I bet that almost never happens.

And again, if these questions are too off topic, no worries!

***if you decide to answer them, I have an end-of-the-year challenge for you; in your response, include: 1.) at least one analogy 2.) at least one instance of the word "fabulous" 3.) a reference to either a Hitchcock or Spielberg movie

And, at the end of the response, answer this quick question (it helps to read it in the Alex Trebek voice):

Which popular 1960's hairdo, in which long hair is piled up to resemble that of this naturally occuring dwelling that pollinating insects inhabit, is often popular to sport during New Years Eve?

Thank you, and have a happy New Year's!

Response from Dr. Holodniy

The US Department of Health and Human Services has a fabulous expert panel in place that weighs all the evidence from published data to come up with guidelines on when to start HIV meds (based on CD4 count and viral load), and what to start based on potency and outcomes from clinical studies. They are not like precogs in Minority Report who can predict the future. The panel interprets what has happened and adjusts the recommendations at least annually. Like some restaurant menus, there are several A-list combinations and several alternative B-list combinations for clinicians and patients to choose from. The decision is based on resistance test results, presence or absence of other medical conditions, particularly if these require ongoing medications that could interact with HIV meds, patient preference, among other reasons.

In Jeopardy parlance, "What is a beehive"?



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