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Regimen Change
Sep 1, 2003

I had a viral rebound (VL 1750) in January after being undectable for a year. I was on a Videx EC/Viread and Epivir regimen. My doctor and I decided to stop meds and do resistance testing as it wasn't done when I started treatment. I had a severe case of food poisoing and a bad flu over the holidays and wasn't sure if I was developing resistance or just had a VL rebound due to other illness. I had been 100 compliant in taking my meds.

I had a PHENOTYPE done and it showed sensitivity to all classes of drugs and to all drugs. My doctor felt very confident about the wide range of regimens available to me and was very upbeat about a "near normal life expectancy."

I travel with my job and need to be alert at all hours so I couldn't fit Sustiva side effects into my life right now but I wanted a more potent regimen than what I had been taking. My doctor and I chose the combination of Viramune/Viread/Epivir and after 4 weeks back on the combo my VL went from 32,000 to 450.

I had a VL test done last week at week # 9 and haven't gotten the results yet. How long should I wait for my VL to go below 50 before considering another switch. I have read that switching to Sustiva early on in Viramune failure might save the resistance from developing to Sustiva. I am also confused about how often I should have liver functions tested. Some websites say monthly, others every 90 days?

I could feel the virus building in my body when I was off meds for 4 months and feel fantastic on this combo. I have no side effects. For those people who are looking for good quality of life regimens, this one seems to work very well for me. Also, is there any reason to swap the Epivir for Emtriva? If I have not developed resistance to Epivir, is Emtriva a more potent drug?

Thanks for all the great answers and support you give to the HIV community.

Response from Dr. Boyle

You have a lot of questions, don't you? Make sure you discuss all of these with your doctor. The internet is not a substitute for good communications with your primary care provider! The phenotype may be correct or it may have missed resistance that you have devleoped. In this case, the most likely "missed" mutation would be 184V which is associated with Epivir resistance. Therefore, while it is likely that the phenotype is correct, especially if your viral breakthrough was due to an interecurrent infection, I probably would not have used that drug in your new regimen, especially since you are using an NNRTI (Viramune) which has a very low genetic barrier. Regardless, it appears that you have had a pretty good response to the therapy chosen and I would expect that you would be <50 no later than 6 months into therapy (although with some high viral load patients this may take longer). Liver enzymes should be checked frequently during the first few months of Viramune (at baseline, prior to dose escalation, and roughly monthly thereafter) and you should keep an eye out for symptoms suggestive of liver disease including nausea, vomiting, diarrhea, abdominal pain, jaundice, malaise/fatigue. The main benefit of Emtriva over Epivir is a longer half-life (roughly 40 vs. 16 hours) and in some patients this improved "forgiveness" may prove beneficial. Other than that, there are no clinically signifcant differences between the two drugs.



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