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Hi Doctor! I started with my first meds on janaury this year I am infected Virus resistance to NNRTIS..The lab result at the end of august this year was CD4 572,CD4 % 25 and V.L under 20 copies.Before treatment CD4 280,CD4 % 15 and V.L 142000.MY meds includs Reyataz (150mg*2),Norvir (100mg),Viread ( 245mg)and Epivir (300mg) once daily..Now the problem is that the level of concentration of Reyataz in the blood is very low i.e in janjaury 0.5 and in september less than 0.2 My doctor advised me that I should make drug adjustment because in the long run there may be a risk of drug resistance.What is your opinion and your advice too.
Hope to hear your respons soon,
Dav.
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Response from Dr. Young
Thanks Dav for your post.
The regimen of tenfovir (Viread), 3TC (Viread) and ritonavir (Norvir) boosted atazanavir (Reyataz) is used here in the US quite commonly. I certainly agree that you should be receiving a boosted PI regimen, given that you have acquired NNRTI resistant virus.
Therapeutic drug monitoring, like you've had, isn't done frequently here, but is commonplace in Western Europe-- your levels do suggest to me that your atazanavir levels are suprisingly and perhaps dangerously low.
This could occur for a variety of reasons, first is whether you're taking your medications with food or not- atazanavir is very poorly absorbed on an empty stomach; the use of antacids, like the proton pump inhibitor, omeprazole is similarly associated with very poor absorption of atazanvir. Because of these factors, be sure that you take your medications with food and avoid antacids.
Tenofovir also lowers atazanavir levels (boosted or not) by about 25%, another potential contributing factor.
Lastly, your levels might simply be due to rapid metabolism of the drug.
No matter what, your viral load results are reassuring, but if I were your doctor, I'd be concerned enough to consider a switch. You've already got some significant resistance; I'd really want to avoid placing you at risk for having further resistance.
Most likely a move to either ritonavir-boosted lopinavir (Kaletra) or fosamprenavir (Lexiva, Telzir) would make the most sense. Both have no significant food requirements or interaction with antacids or tenofovir.
I hope this helps, BY
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