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Can be an option?

Feb 9, 2013

Hello Benjamin,

I have been on Truvada + Sustiva, then Atripla, since 2004. My last DEXA scan to measure bone density showed osteoporosis. In the last year I also developed a kind of toxicity to Truvada, in fact when I take it, really painful blotches appear on my armhole and on my belly, systematically. They are not like normal blotches, they are just inflammations without pus and purulence, but they are painful.

Because of osteoporosis and those blotches, I had to stop taking Truvada. So, I switched from Atripla to Kivexa + Viramune. Both, Viramune and Kivexa are causing me GERD, but in particular Kivexa. Kivexa is giving me cough and sometimes, because the cough, vomit. I'm taking pantoprazole also, but Kivexa is causing me too much reflux acid, no way out.

I have over 700 CD4 and negative viral load and I haven't drugs' resistances. I don't drink, I don't smoke, I don't take drugs and I'm straight (but who cares?). It's really important for me, avoid lipoatrophy, that's because I must exclude a regimen based on Combivir or any other med that can cause lipoatrophy.

Can Emtriva + Viramune + Isentress be a good option? As you know, emtricitabine is also part of Truvada, so I'm a bit worried that Emtriva can cause those blotches I was talking previously. Do you think it's a tenofovir side effect or can be emtricitabine related? Can you suggest any other good alternative without collateral effects, especial lipoatrophy?

Thank you for your time!

A goodbye from Italy

Response from Dr. Young

Buon giorno and thanks for posting from one of my favorite places!

As a bone health researcher, I'm heartened to hear that your care providers are paying attention to your bones' health. On the other hand, I'm not happy to hear that you have osteoporosis.

It would make sense that your doctors would switch you off of Truvada with this finding-as tenofovir is associated with increased risk of low bone mineral density. What's not so clear is what caused you to have the painful blotches- this is a rather unusual complication, and I can't really tell you which of your medications was responsible. Did the lesions resolve after you switched treatment? Assuming this is the case, we can at least say that one of the three medications was the cause.

It's unusual that the Kivexa (we call it Epzicom here in the US), is causing the reflux and cough.

To your questions; I'd think that the regimen of Emtriva (FTC)+Viramune (nevirapine) and Isentress (raltegravir), while unusual would be a very well tolerated and potent regimen. Having said that it might be relevant to know that FTC is associated with hyperpigmentation of the skin (though usually mild and painless)- so if an alternative is desired for FTC, you could readily substitute 3TC (Epivir). None of these are particularly associated with fat changes.

I hope that helps. Please feel free to write back anytime. BY

Best cocktail?
Choice of meds

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