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Isentress and Resistance
Jun 30, 2009

I have been on Norvir, Reyetaz, and Truvada for over 15 months now and am still not undetectable but not resistant to anything. Since starting I've also how lots of low abdominable pain but CT scan is clean. I worry about Norvir and Reyetaz both for potential CVD issues with a family history. I wanted to change to Isentress and Truvada but my doctor says they are seeing large cases of Isentress resistance specifically with Truvada. Is this true? Now he's going to switch me to Intelence with Truvada. I'm trying for the safest, most potent, heart friendly regimen WITHOUT the need for food and enormous other drug interactions. I started at VL 179K and CD4 of 14. After 4 months VL was less than 1000 and CD4 was 70. 8 months later I've leveled off at 350VL 120CD4. Any suggestions or thoughts that may help me feel better would be appreciated.

Response from Dr. McGowan

Thanks for the question.

This is a challenging problem that is still controversial: What to do with an incomplete response. You have had a great initial drop in viral load and a good CD4 increase, but the VL is stalled at a low level, too low to reliably get a resistance test. Some would just sit tight and measure the viral loads frequently, others would change or "intensify" treatment (by adding one or more active drugs to the mix). There have been studies (most notably ACTG 5142) that have shown that NNRTI regimens may be better at getting the viral load to undetectable than Protease inhibitor regimens. So, if there was no underlying resistance to medications (that is no resistance test showing drug resistance prior to starting therapy and no previous treatment that failed to suppress the virus) than a NNRTI treatment (like Intelence) might make sense. I tend to be more in the camp that intensifies treatment by adding another active drug rather than switching off. Your slow response is likely a product of the high viral load pre-treatment.

The cases of Isentress resistance after switching from a protease inhibitor (SWITCHMRK study) were in patients with long treatment histories many of whom had been on multiple regimens before switching off the PI. If there is any chance that your virus may harbor drug resistance it might not be a good switch.

Of course all is based on the assumption that you are not missing any doses or taking anything (like antacids, especially proton pump inhibitors) that could effect the Reyataz blood level.

Good luck,

Joe



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