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Tenofovir as first drug?
Jul 24, 2002

Hi doctor.

Thank you for your help. I read so much on the body about tenofovir from this recent conference. I am talking to my doctor about starting my first drugs.

It sounds like tenofovir is a good option, but is this still very new and should I wait to see if more reports support the information?

Would you use tenofovir to start? What other drugs would you suggest?

Mike

Response from Dr. Wohl

The choice of what to start, as you can see by reading through some of the questions and responses on this site, is dictated by such factors as viral load, CD4 cell count, requirements for convenience, tolerance for particular side effects, coexisting illnesses, as well as a patient's own perceptions about the regimen. If you are fearful or uncomfortable about your therapy the risk of experiencing a side effect that causes you to stop that treatment is increased.

Tenofovir has been getting a lot of press because it has emerged as the 'little antiretroviral that could'. The company that makes this drug has been very clever in designing clinical trials that are rigorous and showcase the abilities of this agent. The data look good. In the most recently reported study, tenofovir was compared with d4T (Zerit) in patients who had never been treated with HIV therapy and who also received 3TC+efavirenz. In both the tenofovir+3TC+efavirenz assigned group and the d4T+3TC+efavirenz group over 80% had less than 50 copies of virus per milliliter of blood (=undetectable) after a year of treatment. These are extremely good results and they indicate that the regimens were at least equivalent in their potency. Side effects were not much different between the study arms either. One major thing that was different was that there was an increase in triglycerides in the subjects getting d4T. It is important to note that other work has demonstrated that when most anything is combined with 3TC+efavirenz people do very well in getting their viral loads down.

Certainly, this is only one, albeit large (600 patients), study and if you are a person who wears both a belt and suspenders you may want to see another study, maybe even a study not sponsored by the manufacturer, Gilead. However, if you are the kind of person who was the first on your block to get a palm pilot, you recognize that in this field things move quickly and you may be more open to start on tenofovir without need for more info. I feel tenofovir is a potent drug that given its once daily dosing and tolerability will be used more and more first line. I have already started prescribing it as part of initial therapy.

Are there other options? Certainly. And, the difficulties associated with these other drugs are well known. Accumulating data on the combination of AZT+3TC+efavirenz first line also make this an attractive first choice. The fixed dose combination of AZT+3TC+abacavir (Trizivir) has also been studied and offers low pill burden and good success rates among patients with viral loads that are less than 100,000 or so. When the viral load is high (several hundred thousand or more) and the CD4 cell count is low a protease inhibitor combination may be warranted. I like Kaletra (lopinavir+ritonavir) but others use different ritonavir boosted protease inhibitors with good result.

There are many ways to start therapy. I have only mentioned some of the combinations I have used. There are others that I look to when some of the above mentioned agents are not appropriate. In every case the regimen must be tailored to the needs of the patient, otherwise, you risk a bad fit. Good luck. -DW



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