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Please help - changing from Combivir/Norvir
Feb 22, 2004

Hello, I live in Eastern Europe and my government just ceased importing Norvir, and Combivir is in deficit supply. I have been told by my doctor that we have to change the regimen and I worry about the impact of this decision.

About me: CD4 count increased from 204 in first measurement (at diagnosis) to 600 early January, viral load is 960K at first measurement.

Medications that appear to be in better supply here are: - Epivir - Ziagen - Sustiva - Crixivan - Viracept - Fortovase

Please help... I have just another four-five days of the Norvir/Combivir supply... and I cannot even pay for extras.

Thank you so much! Not sure what I would have done without you!!

Response from Dr. Cohen

There are a few combinations that you can make from those meds you list. And perhaps there are other meds available you don't list - such as AZT? Or Videx / ddI? If so you'd have more choices than what I'll describe.

As a side note - it is of some concern that you're writing in here to get this recommendation - since at least from your note - it sounds like you are making the decision without much assistance from an HIV trained clinician? I can hope that you can have access to someone who knows these options well.

Especially since we don't know your history in any detail... so we'll make some assumptions and general statements. If the first combination was Combivir/Norvir - and you've done well with viral suppression to "undetectable" levels since starting - we would have several choices. For example - several studies have been done showing that Sustiva (or Stocrin as it is usually called in Europe) can be just as successful as Norvir - as likely as any protease inhibitor - in maintaining control of HIV. In fact - as it is just one (or up to 3 capsules depending on what dosage capsules you have) capsule a day, studies have shown improved long term success after switching from some protease inhibitors like Norvir.

As for the rest of the regimen, Combivir is just epivir plus retrovir (or AZT). And studies have shown that ziagen is just as successful - and perhaps even more potent - that AZT. The issue for that drug is that perhaps 7% of people in studies have had allergic reactions to this drug. And so the combination of Sustiva, epivir, and ziagen is the most obvious selection given the assumptions I started with.

But if you do have the allergic reaction and cannot use that as your "third" drug here - you'd need to be a bit more creative in creating a new combination.

Studies done in the past did show a few two-drug combinations can do OK in establishing control - as good as some of the 3-drug combinations that have been used. For example, Sustiva plus either Viracept or Indinavir have done OK to maintain HIV suppression. The latter combination based on indinavir would likely be more difficult to fit into your days as you'd need to take indinavir three times a day on an empty stomach - and while some have done this successfully, it is certainly not easy to do. Sustiva plus Viracept is easier - just twice a day dosing - but there was only one study done a few years ago - and there are at least theoretical concerns about the potency of this combination given the lack of adequate studies. Given this concern - one could add the epivir to the Sustiva and Viracept for a reasonable if innovative combination. Fortovase cannot be used with Sustiva unless you have Norvir available.

You don't mention having Kaletra available - that would provide a more provide potent choice here if you did have it...

So - there are choices. But not many. And I'll hope that with the input of someone knowledgeable - you can find something that works for you.

Good luck.



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