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Starting off with Kaletra good?
Mar 16, 2002

Hello Doctor,

I am a 20yo male who has been HIV+ for almost two years now. I started meds a year ago through a study. My Viral Load was over 50,000 and my T-cells were around 600. I enrolled in a study and got put on a combo of Ritonavir, Stavudine, & Coviracil. They seem to be working okay with my VL down to <28 and my T-cells up to 718. My question is, should I be worried that they started me off with an aggressive therapy right away, especially when there is speculation that Ritonavir (Kaletra) is best used as a pill for people whose meds have failed them? I am worried about becoming resistant to Kaletra now and being left with already having used my best option... Thanks

Response from Dr. Young

Thanks for your question.

This is an excellent question that has no clear cut answer, just opinions. It is very clear the Kaletra-based therapy is very potent and very durable (see results of the Abbott 863 clinical trial); more durable than nelfinavir in this clinical trial.

There are always pros and cons to any treatment; with Kaletra potency is a strong card--you've raised the issue which has nagged the uptake of first-line Kaletra, that is, resistance. The available data from the Kaletra studies (as well as limited data from other boosted PI studies (like the Merck 094-DIRECT study) show that patients who experienc failure of these regimens don't seem to have resistance mutations (and loss of susceptibility) to protease; but have mutations in the reverse transcriptase. This has been argued by some that you don't need to concern yourself with protease resistance while taking Kaletra--especially since the regimen is so durable.

I find this story less than convincing, since, while the long-term data shows that only a handful of patients have treatment failure, failures do happen. Will there be persons who take first line Kaletra who have protease resistance? Perhaps. What will the resistance pattern be at time of treatment failure and what treatment options will be preserved? We just don't know.

Other negative issues (sure to make me unpopular) are concerns about the consequences of long-term administration of ritonavir, elevations of cholesterol and triglycerides and risk of insulin resistance. Not that these issues are unique to Kaletra, but something that we have to concern ourselves with, using any boosted protease regimen.

With that said, I do suscribe to the school of thought to use the most potent regimen possible, one that is well tolerated, has long-term safety and durability. Kaletra-based therapy definately falls into this category. Are other regimens better? We just don't know. In the end, I like to have a package where we have all of this, and as you point out, a plan if and when treatments fail.

Hope that you find this helpful, BY



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