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Kaletra in naive patients
Apr 3, 2002

When do you recommend starting HIV naivepatients on Kaletra instead of other PI? Is the issue of potential emergence of cross-resistance to other IPs relevant in your consideration?

Response from Dr. Boyle

While I commonly start therapy with a non-nucleoside reverse transcriptase inhibitor-based HAART regimen, if I am going to use a PI, I routinely use Kaletra as first line in patients who are naive to protease inhibitors (PIs). It has a relatively low pill burden, is generally well tolerated and has very impressive and forgiving pharmacokinetics. The same, of course, can not be said about the other non-ritonavir boosted PIs, especially Viracept (nelfinavir). Almost all of my patients started on Kaletra are less than 50 copies/mL, which decreases my concern about PI cross-resistance, and studies show that unlike Viracept the first drug to fail in a Kaletra-based HAART regimen is usually not the Kaletra but one of the nucleoside analogues (NAs). Regarding Kaletra resistance, high-grade resistance and cross-resistance are not going to develop suddenly, so patients should be watched carefully and consideration should be given to changing or adjusting the regimen as soon as virologic failure occurs (unless it can be documented to be one of the NAs and then a change of those might be in order instead). In a more general vein, my view of the main goal of antiretroviral therapy is for patients to get to undetectable and stay there. If patients do that, HIV can't progress, immunologic recovery occurs, and it is very difficult for resistance to develop. In my experience Kaletra is one of the best agents for this job. Of course, some patients aren't appropriate for Kaletra or don't tolerate it and then use of another ritonavir-boosted PI, if possible, is appropriate. To be honest, I rarely use Viracept anymore.

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