Have finally decided to start HART after nearly 1l years of infection. T-cells hovering at 190 and viral load at 30 thousand or less. The two suggestions given to me by two doctors are Ziagen/3TC/AZT or Ziagen/3TC/Viramune.

I am concerned about the complaints of AZT toxicity, bone marrow depletion, headaches, and nausea. The problems with viramune, besides the possibility of rash, are wear on the liver. I have been told that this problem is preventable with diet and other liver enhancing supplements. Given my low VL the possiblity of mutation appears relatively insignificant.

What do you suggest?

Thanks,

SJ

Well, one of the things about the list of side effects is that they represent a list of things that ever happened to those who took these meds on studies before you. However, to make use of it, there are a few issues to consider - how common was this side effect, how troubling was it, and did it go away over time. For example, there are several side effects like rash that come, and usually go as you continue on the meds. This is true for Viramune for example. So what about the meds you've mentioned and the side effects you list?

AZT certainly is associated with risk of nausea and headache - although it is commonly observed these seem less common when AZT is taken as part of Combivir than when it was just AZT, for reasons that are unclear. Some have a mild degree of nausea that passes quickly or is preventable by taking this medication with a meal - something that should be possible given that the combos you mention are just twice a day. So if you took them at breakfast and dinner, this side effect would be minimized. And it seems that even for those who initially had nausea, it can fade in time. Unfortunately, some did have nausea despite taking it with food - and for some it was troubling enough to lead them to try some other antiviral. The frustating thing is that there is still no way to know if you will be one of those who can't tolerate AZT no way no how no matter what, or one who takes it just fine no nausea at all don't even need food what was all the fuss about. One day we might be able to predict - but not yet. A similar story is true for headaches. As for bone marrow - if you are OK to begin with - then this is a rare event, and one that can be monitored, and reversed when the meds are stopped.

So - are you willing to give it a try? Willing to see which group you are in? While nausea/headache are certainly unpleasant, they do pass and you can switch if it is a problem for you. If you are not willing - you can try alternatives - some of our options have much less nausea/headache/bone marrow suppression - common alternatives include the new formulation of ddI/Videx, zerit/d4T, or ziagen/abacavir. As with all things, each of these has a pro and a con - no perfect choices... if there were, this would have been a much shorter answer.

Viramune does have the risk of rash - although this often fades as you continue with it and is then gone forever. One way to decrease this side effect may be to take it with an antihistamine - recent studies suggest that the risk goes from about 16% to 8% rash when adding an antihistamine. As for liver toxicity - again perhaps 15% have this problem and you must have blood work done in the first few weeks on this medication to check for this - you should not wait for symptoms before having blood work done. Thankfully, liver toxicity almost always reverses when this medication is promptly stopped - but there are cases where it did progress, although these are very very rare. It also seems that any liver toxicity happens in the first few months - if it does not happen initially, it appears that this issue has not been a problem in those who stay on this medication over time. As for the ability of supplements to prevent this - we have stories about this, but there is unfortunately no good evidence yet that any supplement prevents these side effects that we see on nevirapine. The only predictor of who might get liver toxicity is gender - women seem to have this problem more often than men, although men can have this as well. There are other meds that have a lower risk of liver toxicity so that is one option to consider if the risk of liver toxicity is enough to get you to switch to another option. For example, ziagen has a lower risk of liver toxicity. So does Sustiva.

So what to do? Well, you describe two common options - in fact, I was just at a meeting with nearly 100 physicians in Australia and it seems that AZT, 3TC, and Viramune is their most common initial regimen. And there are others also commonly chosen to begin with - the recent US guidelines are posted on the Web and list the other common options. Since I don't know you, nor why you chose these over other options, it is impossible for me to say which I would suggest. What I can say is that both of these are commonly successful, and with good monitoring, very reasonable opening moves that may last for as long as you need them to.

Good luck. CC