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Nov 13, 2007

Is there any data available on the penetration of Isentress into the CNS and the reproductive tracks? I have a patient with a POSSIBLE mild neurocognitive impairment, but its hard to tell. He and his wife are also trying to get pregnant. He has a great deal of resistance to all of the brain penetrating ARVs.

Response from Dr. Young

Thanks for your post.

I suppose that my first questions about your patient would be to understand the basis of the neurocognitive symptoms and the extent of drug resistance to existing agents.

You comment on the presence of drug resistance; does this mean that the patient is currently not suppress on treatment? If so, my very first steps would be to find the most effective regimen to suppress circulating virus, irrespective of the CNS (central nervous system) drug penetration.

In select cases, one could consider obtaining CSF viral load testing to determine if there is truly a disconnect between plasma and CSF viral suppression. In the unusual cases of discordance, it makes intuitive sense that in patients with known (insomuch as this is ever certain) HIV encephalopathy in the face of suppression of circulating plasma virus, that one would select medications that enter this anatomic site.

Unfortunately, there is insufficient data at this time about the degree of CNS penetration by raltegravir, though I have heard that at first glance, this is not one of the antiretroviral medications that reach the CNS with high levels.

Hope this helps. Good luck, BY

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