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First Line Atazanavir
Sep 30, 2004

I am probably quite close to starting antiretroviral treatment due to a declining CD4 %. My Doc is suggesting a regimen including Atazanavir as he feels that this is a particularly well tolerated medication. Sounds great to me. My concern is whether or not there is sufficiant data to support use of Atazanavir first line in a treatment naive patient. Does this make sense or would you still recommend a "more tried and true" regimen with Kaletra or Sustiva first line.

Response from Dr. Young

Thanks for your post.

You have raised one of the central issues with the selection of initial HIV treatments-- namely, how much clinical data does one need before feeling comfortable in adopting new medications.

Clearly, as you point out, both efavirenz (Sustiva) and lopinavir/ritonavir (Kaletra) have an outstanding amount of clinical trials data and clinical experience in a wide varietyh of patients-- these points provide the support for multiple guideline agencies in their recommendations to use either of the two medications.

By nature, thers is less clinical trials data with newer medications, such as atazanavir, though the available data is suggestive of the drug's use when indicated. The ability to construct a once-daily PI-based regimen is indeed, attractive. Be clear though, that while listed as an alternative PI for first treatment in US guidelines; the drug is not approved for first-line use in Europe; additionally while most US doctors use atazanavir with ritonavir boosting, this approach is yet to be studied in patients receiving their first treatment. Unboosted atazanavir has been studied in treatment naive persons in the BMS-034 study-- this study showed similarity between atazanavir and efavirenz-- a remarkable result, though many have methodological questions that remain unanswered. I also think that it's fair to say that most US doctors are using only boosted PIs as their first option, so the relevance of the 034 study to this situation is extrapolatory.

Personally, I think that time has come for HIV patients and doctors alike to look at clinical studies very carefully; we have well studied treatment regimens with studies that have met the test of scientific and peer reviewed publications. Since the stakes are so high in selection of the correct medications, I tend to stick to tried and true (or at least tested and presented) regimens.

I hope this helps. BY



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