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Multi Symptom Regimen
May 22, 2005

Grettings;

I an HIV+ with End-Stage Renal Failure along with Hepatitis B.

I need to start a regimen with all these other ailments to consider. What do you suggest.

thank you...

Response from Dr. Young

Thanks for your post.

Your case illustrates why it's never as easy as reading the guidelines in choosing HIV medications. Each person has their own set of needs and medical specifics.

In the case of renal failure, many of the nucleosides (or nucleotide) will need to have their doses adjusted. Fixed dose combination pills, like Combivir, Epzicom, Trizivir and Truvada cannot be used, since (by definition), their doses cannot be adjusted. Other medication classes (NNRTIs and protease inhibitors) generally have fewer issues with kidney failure and can be used (with caution).

You've mentioned hepatitis B-- assuming that you have HBV viremia (detectable virus in the blood, not just positive antibodies); several of the nukes have HBV cross-activity and would be preferred, all other things equal. These meds include tenofovir, 3TC and FTC. All of these can have their doses adjusted for renal failure. Patients with active hepatitis appear to be at somewhat greater risk of liver toxicity from some medications and this will need to be monitored closely.

So, what would this boil down to? I'd be looking at a combination of tenofovir and 3TC (3TC has considerably greater experience in treating HBV than FTC). The Truvada combination cannot be used, since the doses need to be changed. What third drug? Either a NNRTI such as efavirenz (Sustiva-- but there's some renal metabolism of this drug) or a protease inhibitor (preferably boosted with ritonavir, but this needs to be monitored closely for toxicity). I'd consider the use of Kaletra or fosamprenavir (Lexiva). Fosamprenavir has been recently shown not to cause measureable increased toxicity among persons with HBV and might get the nod. Parenthetically, I'd tend not to use atazanavir here(though some would), since tenofovir lowers atazanavir drug levels, and since I'd preferentially want to use tenofovir to treat HBV.

These are just one doctor's suggestions from a very limited description of your case. I'd make sure to review all you options with the healthcare provider that knows you personally.

Good luck, let us know what you decide. BY



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