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Truvada or Kivexa
May 31, 2009

Hello I started treatment 3 years ago and during that time went from a Sustiva/Truvada regime to Sustiva/Kivexa due to suspected kidney problems. We have now established Truvada had nothing to do with this and am able to switch back. My question is should I? Sustiva/Truvada is often refered too as the gold standard treatment, so it would seem common sense to switch back. However I did great on both regimes. And have read reports of bone problems with Truvada and heart risk with Kivexa. So which do u think is the lesser of the two evils. My own consultant is dimissive of the heart risk studies as he believes it is not proven or related to patients being switched from an older regime to Kivexa and Kivexa being blamed for a problem that was already there. I just wondered what your view was. Over the 3 year period my CD4 continued to rise on both regimes from 126 to 495 at present - which is after all the most important thing. Thanks

Response from Dr. McGowan

Thanks for your question which hits at an issue that is very controversial at this time.

You have to weigh the risks and benefits of each medication:

For truvada: if your kidney function is back to normal then it is true that the risk to switch back may be minimal. However, if you still have some underlying kidney dysfunction then truvada (specifically tenofovir) may "piggy-back" on top of that problem and make it worse. Even though the tenofovir may not be the cause of the problem, it is known that kidney problems from tenofovir will be more likely in people with pre-existing kidney disease.

For Kivexa (or Epzicom in the US): A number os studies have found that people taking kivexa had a higher rate of heart attacks than people who had never taken it. The risk appeared highest within the first 6 months of treatment (although one large study has shown a persistant and slightly increasing risk with longer exposure). Other studies have not confirmed this. Your doctor points out that these associations between taking a medicine and having an adverse outcome can be confusing if the medication was chosen specifically for a person at risk for a medical problem because the doctor thought it would be a safer drug than an alternative. It is like the study that found that more obese people can be seen drinking diet soda than thin people...was it the cause of obesity or associated with it after the fact? In the studies that found a higher risk for heart attacks it seemed to be highest in people who had other risk factors for a heart attack (smokers, diabetics, men, those with high cholesterol, older age, strong family history of heart attacks at a young age in close relatives, etc). If you have these risk factors for a heart attack then the potential for problems with kivexa may be more important.

Best, Joe



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