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Kidney friendly alternative to Atripla without Efavirenz

May 7, 2012

I have mile but worsening protein in my urine for about 5 years. Went ahead and started Atripla anyway. The CNS side effects are too much for me to deal with even months down the road. My question - Can you suggest an alternative to Atripla which is more kidney friendly than the Tenofovir and without Efaverinz ? Thanks so much for all you do. Michael

Response from Dr. Young

Hi Michael and thanks for posting your questions and comments.

You raise several important topics.

First, is the understanding that while the medications in Atripla are widely recommended and are listed as "preferred" in current US treatment guidelines, that for some people a DHHS "alternate" regimen might actually be preferred.

So, in regard to your kidney function, many would probably avoid the use of tenofovir in patients with significant kidney problems. This could be because of low blood flow through the kidney (low glomerular filtration rate, or GFR) or because of significant problems with protein leakage into the urine. Current guidelines suggest the use of abacavir (Ziagen, part of Epzicom/Kivexa) for patients in whom tenofovir might not be appropriate. Genetic screening (HLAB5701 testing) is recommended to ensure low risk of developing abacavir allergic reactions. A substitution from tenofovir to abacavir (or other alternate) might be expected to decrease the risk of ART-induced kidney problems. Abacavir doesn't come in a single tablet regimen as is tenofovir, but could be used as part of a low pill count (2-4 daiily) regimen.

The other issue you raise is that of efavirenz intolerance. While the psychological side effects of efavirenz are usually mild and fade with time, for some patients, the persistence of unwanted side effects is a reason to consider a change. Current treatment options would include the use of a boosted PI (atazanavir or darunavir are "preferred") or integrase inhibitor (twice daily raltegravir). Alternate agents would include other PIs, the NNRTIs nevirapine or rilpivirine or the CCR5 inhibitor, maraviroc. Which one to use is a mater of discussion with your health care provider about their relative merits and limitations, but all would be expected to combine into a very well tolerated (and efavirenz-avoiding) regimen for you.

For more information about these medications, I'd suggest looking at's Resource Center for Starting HIV Treatment.

Be well, BY


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