May 31, 2013
My doctor has recently switched me from Truvada to Epzicom, due to the renal inefficiency I was experiencing. I have been on Epzicom for 12 weeks now, and my recent labs show a slow but gradual improvement in kidney function. I tested negative for the hypersensitivity allergy to abacavir, yet I appear to be having a minor rash/itching breakout on my trunk the last 2 weeks. My doctor still believes it's due to the Epzicom.
Here is my question..actually 2.
I am also taking Isentress...and would like to continue doing so. If we switch out the Epzicom, what options remain since I cannot do tenofovir?? Also, my doctor wants me to consider taking a treatment holiday due to this reaction. I believe this is a bad - and unnecessary suggestion but I would like your confirmation on that!
Response from Dr. Young
Hello and thanks for posting.
Healthy aging with HIV requires thoughtful monitoring of HIV medications as well as prevention HIV-related comorbid illnesses. Among these kidney disease and renal impairment are well recognized. A switch from Truvada to Epzicom certainly is reasonable if you had tenofovir-related kidney injury, or if as a function of other factors, decline in estimated kidney function.
If you tested negative for HLA B5701 genetic markers, then the risk of abacavir hypyersensitivity reaction (HSR) is virtually zero, but it's conceivable that you could still develop a mild allergy. Sometimes this allergy is very mild and improves without additional intervention, and in other circumstances can require treatment switch. We have successfully treated people through mild allergic reaction (without HSR) in the past.
If its decided that you can't take either tenofovir or abacavir, you'd begin to fall outside of the range of the usual first-line treatment (hence part of my desire to see if you really need to discontinue abacavir). Three active medications would be preferred, unless one was a boosted protease inhibitor. Options could include other NRTIs (such as AZT- but potentially side effect prone), a NNRTI, PI or CCR5 inhibitor- maraviroc. There's no clear winner in this set, but since you're already taking the twice-daily raltegravir (Isentress), I'd be intrigued by the possibility of using the also twice-daily maraviroc- it's very well tolerated, and if anything should be used in earlier rounds of treatment.
As for the treatment discontinuation; if the rash is not severe, it's not absolutely indicated and generally it's better from an immunological perspective not to stop treatment. Having said that, a short-term stop to allow side effects to resolve rarely causes significant problems and should allow your current symptoms to abate.
I hope that's helpful. Stay in touch and let us know how things resolve. BY
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