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Use of Fuzeon
May 21, 2005

My doc in Toronto is recommending (after a 3 year drug break), that I consider Fuzeon + Tenofovir + Trizivir + Sustiva as the best combo because of my Genotyping evidence of significant Protease Inhibitor resistance -- I'm 10 years positive; initially took AZT & 3TC; did Crixivan & then Nelfinavir; latest levels are TC 270 with 13.9% CD4 count, VL 80,000 Dr. David Bray, Chinese Medicine suggested I speak with you for advice on Fuzeon.

Response from Dr. Young

Thanks for your post.

It's difficult to answer your question precisely, without knowing all of the details of your previous treatments and drug resistance testing data-- these are factors that should go into any decision about treatment, especially when talking about 3rd or later rounds of treatment.

Your CD4 cell count of 270 (14%) indicates that you should consider resumption of treatment, though if you're asymptomatic, there is no need to rush. (This is really a way of saying that this is a good time to fully weigh all of your options, as well as take a glimpse at future treatments in the pipeline.)

Sounds like your naive to non-nukes and have had previous failure of at least two PI regimens (indinavir and nelfinavir). The key data is exactly what type of genotypic resistance was seen at the time of EACH previous treatment failure. One might predict that you have some degree of PI and NRTI resistance, but exactly how much requires the details. Not everyone who's failed your pattern of drugs has high level cross resistance to the entire drug class. Additionally, I find that in such complex cases that the genotypic data is sometimes less compelling than knowing both genotype and phenotype (but that's the subject of a different query).

Assuming that you and your doctor have decided that now is the time to resume treatment, enfuvirtide (ENF, T20, Fuzeon) can be a very important, though somewhat difficult-to-take, component of a new regimen. The drug works best if there are 2 or more drugs that have full activity. In this light, combining ENF with efavirenz (Sustiva) makes sense (assuming my assumption above is correct). I'm not sure, by contrast, that taking four NRTIs (tenofovir + Trizivir) is adding much more to the regimen than well chosen 2- or 3-NRTI components.

The key thing is to not utilize new classes of drugs if one cannot have some sense that the other components of the regimen aren't going to be sufficiently potent; otherwise, you might be in the situation of using a virtual monotherapy regimen and risk early emergence of additional drug resistance.

So, in sum, from this distance, I see no major flaws in the reasoning, though I'd love to see the details of all of the resistance tests to be sure.

I hope that you find this helpful. Write back if you have any follow up questions.

Good luck, good health to you. BY



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