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Salvage Therapy Please Help
Apr 13, 2005

What salvage treatments can be started for a patient with Cryptococcal meningitis, CD4s of 8, a Viral Load over 100,000, off therapy for six months because of wasting that may have been caused by meds?

weight returned from about 129lbs. to 160lb after stopping Crixivan, Kaletra, Combivir, Viread.

Resistance to all usual antivirals, Protease Inhibitors and Fuzeon.

Diflucan is no longer effective. Vfend (Voriconazole), also not effective.

Taking Valcyte(for CMV), Bactrim and Acyclovir. Also taking injections of Neupogen, anddaily infusions of Ampho B. Kidney labs bad.

Response from Dr. Pierone

There are two inter-related aspects to consider in your situation. The first is management of refractory cryptococcal meningitis and the second is management of drug-resistant HIV. When the HIV infection is brought under control this usually leads to CD4 count recovery and this makes the cryptococcal infection easier to clear up.

There are very promising results being reported with the use of Tipranavir, TMC-114, and maraviroc (Pfizer CCR-5 inhibitor) for patients with virus resistant to multiple drugs. Tipranavir is available on expanded access and should be released soon. The other two experimental agents are more difficult to get (but not impossible) while on active treatment for an opportunistic infection. Another factor is the decline in kidney function this can limit access to experimental agents.

With regard to cryptococcal infection there are some other options depending on the specifics of your case. Sometimes itraconazole (Sporanox) will work in refractory infection. Increasing the dose of Diflucan sometimes works and adding flucytosine as dual therapy (to either agent) can also be effective. Additionally, liposomal amphotericin B (Abelcet, Ambisome) is often useful as a substitute for regular amphotericin B when kidney function declines.

If you can provide more details I might have some more information. Hope this information helps and I wish you the best.



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