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Is this OK? What next?
Sep 18, 2005

Dr Benjamin, I was infected in 82, status and meds began in 95. T-cell range from 70-160. History:AZT/3TC/Norvier (VL upto 50,000), next: Zerit/Videx/Viracept (constant diarrhea), next: Videx/Viramune/Zerit (wasting/extream fatiuge), next: Videx/Sustiva/viread (extream dizziness), Current: Videx 250mg/Viread/Reyatiz/Norvier-booster. Videx was reduced from 500mg due to viread/videx interaction lowering tcell count. These two also have a higher viral failure rate. Would viral failure make Reyataz ineffective with other choices? Should I switch now? Wasting is still an issue, have had Bio Alcamid treatments in Canada. What is left in the way of treatment combinations with this history?

Response from Dr. Young

Thank you for your post.

The key issue in deciding what your optimal regimen is at this point is to know what pattern of drug resistance mutations (or phenotype) you had at the time of the AZT/3TC/ritonavir failure. Because it appears that you had problems primarily with the side effects of the other regimens, it's generally unlikely that you had developed drug resistance, though that possibility remains.

Ritonavir-boosted atazanavir (Reyataz) has been shown to be effective in persons with relatively limited protease resistance (as might be your case), though I'd somewhat concerned about the chance that tenofovir + ddI might not be optimal (given the data that suggests both excess toxicity and treatment failure among first-line regimens).

As whether to switch now, I'd like to know more about your viral load response to the treatment- if you've had a good initial response (95% drop in ~4 weeks), I'd be satisfied. Nevertheless, careful monitoring of viral load changes is essential, especially following the start of second- or subsequent rounds of treatment.

Lastly, predicting what's left again depends on the pattern of resistance, not the number of drugs that have been used in the past. We do have a number of potent agents that can be used, even in persons with quite advanced drug resistance, including enfuvirtide (Fuzeon) and the recently approved protease inhibitor, tipranavir (Aptivus).

Good luck, feel free to write back with additional details. BY



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