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Kaletra + Sustiva??
Nov 30, 2005

My doctor changed my regimen to sustiva and kaletra, because the nuke I was yaking were not giving complete suppression. What is your opinion of this two drug regimen?

Response from Dr. Young

Thank you for your post.

In patients without drug resistance, the combination of efavirenz (Sustiva, Stocrin) with lopinavir/ritonavir (Kaletra) has been shown in preliminary studies to be very potent and effective.

Here's from a 2005 Journal of AIDS publication:

Efficacy and tolerability of a nucleoside reverse transcriptase inhibitor-sparing combination of lopinavir/ritonavir and efavirenz in HIV-1-infected patients.

Allavena C, Ferre V, Brunet-Francois C, Delfraissy JF, Lafeuillade A, Valantin MA, Bentata M, Michelet C, Poizot-Martin I, Dailly E, Launay O, Raffi F; the Bitherapy Kaletra-Sustiva Study Group.

Service des Maladies Infectieuses et Tropicales/IFR26, Hotel-Dieu, Nantes, France.

BACKGROUND: Recommended antiretroviral regimens include a nucleoside reverse transcriptase inhibitor (NRTI) component. Class cross-resistance and mitochondrial toxicity are recognized as problems with this class of antiretrovirals. METHODS: In a pilot open-label study, 65 antiretroviral-naive and 21 experienced but nonnucleoside reverse transcriptase inhibitor-naive HIV-1-infected adults were given a combination of lopinavir/ritonavir (533.3/133.3 mg twice daily) and efavirenz (600 mg once daily) for 48 weeks. RESULTS: At baseline, the mean viral load was 4.84 log10 copies/mL and the mean CD4 count was 311 cells/mm. At week 24, the proportions of patients with a viral load <400 copies/mL were 78% and 93% using an intent-to-treat and on-treatment analysis, respectively. At week 48, proportions were 73% and 97%, respectively. Treatment discontinuation occurred in 21 patients during the 48-week period, with 33% of those attributable to drug-related adverse effects. A viral load >400 copies/mL at week 24 or 48 was associated with nonadherence in 3 patients and virologic failure in 1 patient. After an increase during the first 8 weeks, fasting lipid levels remained stable up to 48 weeks. CONCLUSION: The lopinavir/ritonavir-efavirenz combination is associated with a high rate of virologic response and should be compared with more classic NRTI-containing regimens in randomized and controlled clinical trials.

Understanding the basis of your lack of response of the nuke-based regimen is important- which nukes were used? Was there a problem with adherence to any part of the regimen (or dietary restrictions)? I think that the key issue relates to the pattern of drug resistance (if any) that you were experiencing prior to the treatment switch; any time that I switch a patient's regimen, I'll want to keep a very close eye on adherence, side effect issues and of course, viral load changes.

Good luck, I hope this helps. BY



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