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The Perfect First Combination?
Apr 14, 2005

Dr Pierone, I am most likely going to have to start drug therapy soon and was wondering if you could give me your clinical opinion on which combination would increase my compliance, decrease VL, increase my CD4 and less side effects...the perfect combination! ;)

My doc suggested Truvada/Sustiva or Truvada with PI (I think he suggested amprenavir or Reyataz?)...what about Epzicom?

And what's the advantage or disadvantage long term and short term of using NNRTI compared to using PI in terms of efficacy, resistance profile and side effects.

Thanks you so much

Response from Dr. Pierone

Ah yes, the perfect combination for treating HIV infection. We certainly are getting closer, but are not there yet. The traditional approach for treating HIV infection is a nucleoside pair along with either an NNRTI or protease inhibitor.

What is the best nucleoside backbone? We don't know for sure, but there are 3 main contenders - Combivir (AZT and 3TC), Epzicom (abacavir and 3TC), and Truvada (tenofovir and FTC). Combivir is a twice daily agent instead of once daily so it has a strike against it from the get-go. However, it has been shown to be roughly equivalent to Epzicom in a large clinical trial (both groups received Sustiva). Combivir has also been matched against Truvada and came up short. We don't have studies that directly compare Epzicom to Truvada, but one is underway. Based on the available data, most doctors are choosing Truvada over the other 2 agents for patients who are initiating therapy.

What about NNRTI versus PI? The advantages of using NNRTI based therapy include fewer pills, better effectiveness data when patients miss doses, less risk of metabolic toxicity, and cost. Disadvantages include CNS side effects (Sustiva) that are often temporary, birth defects (Sustiva), liver toxicity (Viramune), and greater risk of rapid resistance in the face of non-adherence. Based on the available data, most doctors are choosing NNRTIs over PIs for patients who are initiating therapy.

Hope this helps and thanks for posting.



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