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DHHS on viramune
Sep 21, 2003

Dr. Pierone,

In a recent answer you linked to the recent DHHS guidelines. I read through them with particular interest in the viramune vs. sustiva section.

My doctor started me on viramune late last year and I've done quite well on it. I've been reading about the 2NN study this year and have been encouraged. Now, I see that the DHHS guidelines recommend Sustiva first-line.

Can you explain the reasoning here? Do you agree?

Thank you, Robert M.

Response from Dr. Pierone

The DHHS guidelines did make Sustiva a preferred agent for first line treatment and I am speculating that they did so based on the higher rate of liver toxicity that was seen with Viramune. The higher rate of medication discontinuation for adverse effects in the Viramune group is what led to the slight differences in clinical response at 48 weeks. This study showed that Viramune is as potent as Sustiva, but has a higher rate of liver toxicity.

From other studies we know that the liver toxicity from Viramune tends to occur within the first 6 to 8 weeks. So close monitoring during treatment initiation is important, but once people get the first 2 months it is usually smooth sailing with this medication. The lipid benefits, lower rates of neurological side effects, safety in pregnancy, and lower cost are the counter arguments for its use over Sustiva. Persons on treatment with Viramune should not look at these guidelines and interpret this to mean that they are on a less desirable regimen.

A lot of work went into the DHHS guidelines and they should be part of the core reading for all HIV providers. However, these guidelines are not intended to supercede the judgment of experienced HIV providers and cannot take the place of individualized treatment considerations.

Both medications have been extemely useful and essential components of the advances in HIV treatment over the last 5 years.



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