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Can 1 or 2 PI's be enough?
Aug 14, 2006

Dear Dr. I have been on meds since 1986. I have taken azt, ddc, ddi, d4t,3tc, viramune, abacavir (although for a very short time) and sustiva. The first several mostly as single agents and some in combos. I took forotvase and norvir and developed severe diabetes so switched to my current combo of several years Viracept, viread and Fortovase which is now failing. CD4 of 576 and vl of 35k. My Dr has done the genotype but the results aren't back yet. My choices are limited with regards to picking drugs from different classes. The only PI's I have taken are viracept, Fortovase and norvir. The norvir and Fortovase did work wonders but nearly killed me with a blood sugar of over 600 and 30lb weight loss. What do you think should be my next move and still leave further treatment options open? I am really hesitant to start the Fuzeon at this time. Any guidance would be much appreciated. Many Thanks

Response from Dr. Young

Thanks for your post.

You're definitely a survivor, with all of your treatment combinations.

The best way to choose a new drug regimen isn't only on the basis of your previous regimens, but on what the results of your resistance test show. Because of this, I'm reluctant to make a definite recommendation.

For patients like you, with such an extensive prior treatment and resistance history, I strongly recommend getting both a genotypic and phenotypic resistance test (if at all possible) to guide the next decisions.

It's quite likely that you have resistance to all non-nukes and a complex and difficult to predict remaining susceptibility pattern to the nukes and protease inhibitors. That said, its likely that you may have susceptibility to the new high affinity protease inhibitors, tipranavir (Aptivus) or darunavir (Prezista). Additionally, since you've not been exposed to enfuvirtide (T20, Fuzeon) or experimental drug classes, such as the CCR5 inhibitors or integrase inhibitors, I'd think that it's very possible to construct a regimen that can fully suppress your virus. T20 can be a deterent because of the injections, but I'll say that it's better tolerated and easier adminstrated that most people think-- as such, I'd hate to jeopardize the long-term durability of other drugs on the basis of this inconvenience alone.

The newest data on the Merck integrase inhibitor (INI) that was presented this week in Toronto continues to shine a bright light on this apparently well tolerated new drug class; it may very well be that a future INI could pave the way to a T20-free regimen for you down the road.

I hope you find this helpful. BY



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