Conflicting Advice - Resistance Tests
Apr 13, 2008
The patient is heavily pretreated first resistance test ran while pt was off medications indicate resistance to most of the nukes except epivir and ftc no resistance to pis and others. Prior pi therapy generated an unacceptable level of gastric distress and prior psychological problems rule out sustiva. Pt began using epivir, viramume and viread and the reaction was positive but after two years cd4 is dropping under 200, vl is not rising but stays in a tight range slightly above undetectable no disease progression depending on your definition.
Second resistance test was run while pt was on these three drugs all of the nuke resistance has disappeared and resistance now only shows for epivir, ftc and viramune. Pt has a strong medical science education and had a discussion with the manufacturer of the second resistance test and was told information that contradicts what pts hiv specialist has told pt. Discussions with pt is a challenge pts knowledge of hiv therapy is superior to many specialists (this is New York City) and pt can easily put the average medical specialist in a position of saying I dont know not sure need to think about this that some use when faced with an unanswerable question.
Pt reviewed the new drugs and feels that dropping viread and adding isentress is the best solution. HIV specialist thinks this is monothreapy since the second resistance test now shows resistance to epivir and viramume. Pt got a second opinion and received more conflicting advice and decided to drop viread and add isentress. Pt is not problematic from a clinical perspective does what pt is directed, no adherence issues in good health. Advising pt is nearly impossible given the conflicting information that pt has received and science background.
In your opinion, with the three drugs (epivir, viramune and isentress) and given the results of the first and second resistance test is pt on monotherapy?
Response from Dr. Young
Thanks for your post.
If a patient has a prior history of drug resistance to a HIV drug, that resistance is likely to persist, even if undetected while on different treatments.
Hence, based on what you've described, this patient has the aggregate sum of resistance to all nukes and nevirapine. Resistance to nevirapine often results in resistance to efavirenz and etravirine too.
So, for this patient, I'd be very, very concerned that he or she is on effective monotherapy with raltegravir (Isentress). This is unfortunate, since raltegravir is a well tolerated and key component to any regimen for drug resistance; further worsened in my view, because there are sufficient treatment options (including well tolerated PIs, maraviroc) that should allow the construction of a well tolerated regimen with at least 2, if not 3 fully active drugs.
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