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Viread and Fungal Infections

Aug 17, 2003

Dr. Aberg, Thank you for taking my question. Can you please give me your opinion on Viread? I know it works and is a good treatment. But do foresee resistance in the future? Also, do you think the co-formulation will be a huge introduction, or do you think it will be less exciting than Combivir? Also, what is the standard of care for opportunistic fungal infections? What is the general clinical sentiment on Ambisome? Do you think Anidulafungin will be better? Thanks so much. I look forward to your insight. Sincerely,

Response from Dr. Aberg

Viread (TDF, tenofovir) is a nucleotide that is used in combination with other antiretroviral agents and has proven to be quite efficacious in studies. Like all the medications we have, resistance may develop. The K65R is a mutation that can be selected for during first prescribed therapies when virologic failure has occurred. Also, tenofovir is of limited to no benefit in those individuals who have been heavily pre-treated with nucleosides and have numerous nucleoside analogue mutations.

If a person does not have mutations conferring resistance to TDF, it is a good option. It is well tolerated and is only one pill taken once daily. It does need to be dose adjusted in patients with kidney disease. I am not sure what co-formulation you are talking about but I am assuming you are thinking about FTC and TDF given Gilead markets both. This combination is frequently used in antiretroviral naive patients in combination with a 3rd drug. The problem is that FTC is like 3TC and resistance may easily occur. Another advantage of the FTC/TDF is that they both are active against Hepatitis B (HBV). I frequently prescribe 3TC and TDF as first line therapy to HIV patients co-infected with HBV. I don't like to make predictions about marketing and cannot answer those type of questions.

The standard of care for opportunistic infections is beyond the scope of answering a question. There are several different fungal infections and there may be differences in responsiveness to the various classes of anti-fungals. I suggest you review the fungal chapters available in the HIV Knowledge Base available on-line at the UCSF web site ( Anidulafungin is still investigational. It is similar to caspofungin which is FDA approved for the treatment of refractory aspergillosis. I do believe that the echinocandins will displace some of the use of the lipid formulations of amphotericin B as they are better tolerated and have less toxicity. Having said that, there is limited data on the clinical efficacy of the echinocandins compared with amphotericin on many of the fungal infections. Plus, some of the fungi will not respond to echinocandins due to the composition of the fungus. Also, the mortality rate of systemic infections in immunocompromised patients is very high and the best treatment may wind up being a combination of both amphotericin B and an echinicandin. In fact some centers have reported using combinations of 3 antifungal drugs: azole and amphotericin B and echinocandin. This again is a topic outside the scope of our question/answers. I would suggest you do a literature search on each antifungal agent. I would be happy to answer specific questions if you have them.

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