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Sustiva or Viramune
May 28, 2008

I see you have been on just about every HIV drug company's speaker bureau. As an HIV patient and research chemist, I would like to know what data you can point me to that suggest Sustiva is better than Viramune. I am actively involved in keeping up to date with the current literature. As a research chemist, I could not afford to deal with the side effects of vivid dreams, depression..etc. Could you please point me to statisticaly significant data showing your strong support for sustiva? As a physician, would you take sustiva without taking off a month of work?

Response from Dr. Wohl

I would not say that efavirenz is "better' than nevirapine. Better at what? For some people, one is a better choice than the other. For you, leery of the central nervous system side effects of efavirenz, nevirapine may be a better option - provided your CD4 cell count is not above 400 if you are a man or 250 if you are a women.

As far as potency, the one large head to head trial comparing these drugs, the 2NN Trial (Google it for details), showed a better virologic response with efavirenz (statistically, the results did not allow for these two drugs to be considered equivalent). Lipids favored nevirapine. Liver toxicity was greater with nevirapine - especially when taken once a day. Since that study was performed there have been several large and rigorously conducted trials comparing efavirenz to other drugs including protease inhibitors and in all efavirenz was found to be at least as potent, if not more so, than the comparators (e.g. ACTG Study A5142, Dupont 006, ACTG 5095). There is much less compelling comparative data regarding nevirapine.

I share your concerns regarding the central nervous system side effects of efavirenz. But, we should not exaggerate the severity or frequency of these problems. In clinical studies the vast majority of people tolerate efavirenz just fine. You can try it (before a three day weekend rather than a month off of work) and If you experience problems you can always switch to an alternative (nevirpaine or etravirine).

So, pharma slut that I am, I have to say no one drug is best for all and that each has its own baggage. A look at the robust data on efavirenz makes this a known quantity and many clinicians find that familiarity comforting.

DW



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