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kaletra or kivex
Oct 15, 2005

Dear dr. Young

I am a 45 yo man in the Netherlands and positive since 3 years and with a high VL (280.000) and t-cells dropped to 250 my doctor adviced me to start treatment. There are 2 possibilities: Stocrin with Kaletra (2 times a day) or Stocrin with Kivexa(abacavir and lamivudine) wich is a once a day combination. Ofcourse a once a day treatment is more attractive but is this also the best choice with this high viral load? Is a combination without a pi just as good as one without a pi? Hope to hear from you. John

Response from Dr. Young

John in Netherlands, thanks for your post.

I'd agree with your doctor that it's time to start medications for HIV.

Of your two proposed regimens, efavirenz (Stocrin, Sustiva) with Kivexa (abacavir/3TC) is the more conventional and in keeping with most international treatment guidelines that suggest the use of 2 nukes with a non-nuke (efavirenz). This regimen is typically very well tolerated and has very good demonstrated potency in patients with high viral loads.

The second of your regimens-- efavirenz with lopinavir/ritonavir (Kaletra) is an unconventional combination of a non-nuke with a boosted protease inhibitor (PI). Given the relative lack of extensive clinical trials data and guideline recommendations, I'd reserve this combination for patients, who for one reason or another, don't tolerate one of the more conventional regimens (2 nukes with either a non-nuke or PI). In keeping with this, using Kivexa with Kaletra would make more sense to me. To your point, Kaletra has been recently approved in the US to be dosed once-daily, eliminating this potential variable. Dosed once-daily (for treatment naive patients), the potency is similar though the gastrointestinal side effects are somewhat increased.

Other PI options than can be dosed once-daily are used with considerable frequency here in the States-- including ritonavir-boosted, or unboosted atazanavir (Reyataz) or ritonavir-boosted fosamprenavir (Telzir, Lexiva). Neither has made the British Treatment guidelines as such, but are viewed as alternates on the US guidelines. We've used both in a number of patients with excellent tolerability.

Among my patients with high viral loads, I tend to prescribe a boosted PI over non-nukes (though the data asserting superiority is lacking), because of the potential to minimize the risk of having multi-drug resistance at treatment failure.

I hope that you find this helpful, BY



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