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Maraviroc, Isentress & Atripla?
Jun 12, 2008

It is time to change meds. My t-cells are down to 203 (12%) but I have a low, but measurable viral load (500 or so). I have the 69-insertion mutation, so nuks don't work - but I am sensitive to all other classes. I also am CCR5- tropic. I have never taken a PI; or NNRTI. My doctor suggests Maraviroc; Istentress & Atripla. He is adding Atripla to keep a particular mutation he said I have, that is 'good.' I am concerned about taking all the 'new' drugs. Should I be? Do we know enough about Isentress & Maraviroc and their side effects and efficacy? He says it is this combination or a boosted PI w/ Atripla. I have no lipodystrophy and I think this played into his decision. What do you think? Should I go for it?

Response from Dr. DeJesus

Auchhh! Somehow this story is not adding up well. If you have never taken a PI or an NNRTI, I assume that you were treated in the past only with nucleosides! That was not an acceptable treatment. If you developed the insertion 69, I also have to assume that you were treated in the past with one or two nucleosides at a time; so it is time for you to go into a potent regimen. On that part, I agree with your doctor; but I strongly disagree with the regimen offered to you (assuming the information you provided is complete and correct).

I share your concerns of using all these new agents at once, if you have never taken non-nucleosides and PI's. In order to suppress your virus you only need 2, but better 3, fully active drugs. The benefit of continuing other drugs to perpetuate preexisting mutations needs to be balanced by the toxicity of combining those drugs, drugs interactions, cost, complexity of treatment, how likely are you to take all those pills, and what is the real gain to put you on such a complex regimen. If your viral load is that low (<1000 copies), it should be very easy to drive to undetectable by just 2, max 3 active agents. I do not have the full resistant test result, nor your past medication history to make a formal recommendation on what your regimen should be, but perhaps using a PI and an NNRTI, with a consideration of adding a 3rd drug (Isentress or Maraviroc, or even a nucleoside on some circumstances) may be quite enough. Although all those new drugs have been studied individually, they have not been studied well in the setting that you are describing them.

My advice is that you should discuss these issues further with your doctor, and try to get a better understanding of the rationale for those recommendations. If your facts are correct, and you remain with concerns of using all these new drugs at once, be aware that you do not have to, and that there are other options. I would like to get a follow up on your case. Good luck!



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