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Unusual Drug Combinations
Dec 14, 2003

I am a 56 yr old GWM with HIV for 20 years. Current CD4=400+/-, VL=5000+/. Highs were CD4=1200/VL=300,000 about 10 yr ago. Traumatic spleenectomy 30+ yr ago skews results. Orig treatment 10 yrs ago = Hydroxy/ddI. Discontinued due to neuropathy & limited effects. Kaletra+viracept tried but too many side effects (heart palps). Have emphysema and Irrit-Bowel-Synd both causing other non-HIV (age) related med probs, esp. weight loss (35#/3 yrs). Current meds=Combivir & Viread. Work well but numbers plateaued. Ziagen tried w/no probs but stopped taking & Dr. concerned about restart. Sustiva recommended but possible phsych. side-effects keep me from trying due to family/home problems (caregiver for HIV partner who has mental health/durg/alcohol probs) and am only breadwinner. Waiting on drug-res test. Would like to add another simple drug, such as viramune or viracept along w/current Viread & combivir. Please discuss ramifications since this is not usual combination.

Response from Dr. Pierone

Although is makes sense to follow standard treatment algorithms for those starting therapy, it is accepted to use unusual combinations of medications when treating drug resistant virus. This is driven by practical issues, use what is available and what should be expected to work for the individual.

In your case, it is difficult to make a complete suggestion without the results of the resistance test. The good news is that you have not been exposed to a NNRTI in the past so this potent class of drugs is available to you. Sustiva is often not a problem even in people with depression, but Viramune appears to be equivalent in potency and should be fine to add when you change. What to combine the Viramune with is the million dollar question. You likely have resistance to Epivir (in Combivir), and may have resistance to AZT (in Combivir) and Viread. The resistance test should answer this question. The history of neuropathy makes Videx and Zerit less attractive choices (although does not completely rule them out). There are some preliminary data combining Viramune (or Sustiva) with Kaletra as a nuke sparing combination. In summary, you have options, but the resistance test can help guide a rational treatment decision. Good luck!



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