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Missed Morning Dose of Kaletra & Invirase
May 26, 2007

Hello, I apologize upfront for any duplications if this question has been asked before -?? In any case, in 1995, at age 36, I was diagnosed with HIV. My physician initially started me on AZT. Later, he changed to Viracept, Epivir and Zerit. I was naive back then and knew nothing about developing resistance. And, because of the gastronomical side-effects, I began skipping morning dosing due to the difficulties presented at work. Subsequently, I became resistant to this regimen. My physician changed me to Sustiva and Truvada (I think this is correct-?) Anyway, my numbers were not improving, but becoming worse. He felt the Sustiva was failing. By this time, my CD4 was 172 and my viral load was 800,000. I became gravely ill with CMV colitis (as well as other complications); I lost 35% of my body weight, was bed-ridden for months and almost died - things were very bleak. Thanks to an army of doctors and a long list of various meds, things started to turn around. My doctor had changed my regimen to Kaletra, Invirase and Truvada. Last report, my viral load was 78 and CD4 of 428 and I feel miraculously great ! I have been very adherent to my regimen, never wanting to go "back there" again. Even when traveling, etc., I have been mindful of adherence to my drug regimen. The other day, things started off hectic and busy. When it came time for my evening dose, I saw where I had completely missed my morning dose of Kaletra and Invirase. (I didn't miss my Truvada as I take that in the evening.) It had been 26 hours since I took the last dose of Kaletra and Invirase. It is my understanding that Kaletra is one the most "forgiving," however given my history, I am extremely concerned about possible resistance. Could you please comment on the chances that potential resistance could develop? Not trying to "borrow trouble," but in case resistance develops, are there other medications/regimens currently available that will work - after exhausting these regimens (based on my previously-mentioned drug history) ? I can't seem to stop worrying about this and wanted to ask your esteemed panel their opinion. Thanks very much for your time and the opportunity to ask these questions. -CP

Response from Dr. Wohl

Don't worry. Your single mishap is highly unlikely to have led to any change in resistance of the virus. If you continue to be as diligent as you have been about taking your meds, I suspect you will continue to do well.

Further good news is that there are medications out or soon to be that will work against your virus. The integrase inhibitors should have full activity and raltegravir, the first drug of this class, is likely to be approved in the US this year. In addition, there is a possibility maraviroc, a CCR5 antagonist, will work and that is expected to be approved very shortly.

There remain even other options including Fuzeon and TMC-125, a drug that can work like Sustiva but against virus that is resistant to Sustiva.

So, keep taking your meds as you are. Do not fret about your one time episode of forgetting your dose and be aware that when the time comes there is a critical mass of new meds that will help to extend your success for a long time to come.

DW



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