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KALETRA versus "boosted" REYATAZ: Decision Needed ASAP
Apr 26, 2004

Thanks in advance for your help.

I'm 39, male, positive 5 years, never on meds. I've been monitoring my labs all this time and, with my doctor, recently decided to begin meds. Although my CD4s are still over 400, my VL has jumped to almost 200,000 from the 20,000 level where it has been for a number of years.

In addition to my doctor's opinion (an HIV specialist), I have recently sought a second opinion on an initial treatment regimen from another specialist. Interesting (and fortunately for me), the doctors have recommended similar treatments. Because of my high VL, both have recommended a PI-based regimen. One doctor recommended KALETRA + VIREAD + EMTRIVA and the other recommended REYATAZ ("boosted" with ritonovir) + VIREAD + EMTRIVA.

I know KALETRA has a longer "track record", but I believe that the "boosted REYATAZ" regimen would allow for once daily dosing. I've also heard that boosted REYATAZ may offer better sequencing opportunities and less cross-resistance to other PIs and that its side effects may be lower than KALETRA (less issues with cholesterol and lipidystrophy).

Can you please comment on the pros/cons of these 2 regimens and specifically on the KALETRA versus "boosted" REYATAZ? Thanks again.

Response from Dr. Wohl

This is an excellent question that many of us have been asking ourselves. As you point out both Kaletra and ritonavir boosted atazanavir are attractive options for initial therapy.

In Kaletra's corner are the data that have been accumulated about this drug in different combinations and even as a once a day therapy. We know a lot about interactions with other agents, resistance issues and side effects. It is clearly one of the most potent HIV drugs around. All this has led the U.S. Public Health Service to list this agent as a component of initial therapy (efavirenz is the other agent that shares this distinction).

Atanzanavir, however, may soon enter the same league as an initial heavy hitter. There are less data regarding this drug relative to Kaletra or most any other protease inhibitor but what does exist has been fairly impressive. In a study in which people failing therapy switched to either Kaletra or boosted atavanavir (plus tenofovir and another nucleoside) the two agents had similar virologic effects (a trend favored Kaletra). But, lipid-wise, atazanavir was better. This can be a big factor if you have pre-existing lipid problems, diabetes or other risk factors for cardiovascular disease. One thing to be aware of is that there is a drug interaction between tenofovir and atazanavir wherein atazanavir levels are reduced by 25% and the tenofovir is raised by 25%. Ritonavir boosting may compensate for this but there is not a whole heck of a lot of data on this just yet, even though many of us are using this combo.

So, in the absence of a head to head trial of these agents in treatment naive patients, you must balance the above and determine which features of each are more attractive to you and suits your medical history, lifestyle and personality. Probably, either way, you will not go wrong. DW

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