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Should I change meds to simplify treatment?
Dec 8, 2013

I was diagnosed in 1994, had little treatment success up until 2000, which is when I started Combivir, Sustiva, Amprenavir, and Norvir. To date, I've been undetectable since starting that regimen. The only changes to the regimen are Amprenavir to Lexiva in '04 and Combivir to Epzicom in '07.

I am now seeing a new MD due to moving out of state. He wants to change my regimen to an Integrase Inhibitor (either Isentress or Tivicay), Selzentry, and possible Edurant. The reasons for the suggested changes are to simplify my regimen, remove the PI since I do have a history of osteonecrosis and had left hip replacement surgery in 2000, and I think to help with cholesterol levels.

My question is whether or not I should change since this regimen has done well for me. I don't have any noticeable adverse affects. But my new doctor suggested that I could notice increased energy if I change, in addition to the other benefits previously mentioned. My previous MD didn't ever mention changing, though his PA thought my regimen was "quirky" and thought Sustiva could be removed. So maybe there are better regimens available for me now. Any insight or advice you can provide is greatly appreciated.

Response from Dr. Young

Hi and thanks for posting.

So if I understand, you have multidrug resistant HIV, but suppressed since 2000; and from the looks of it, have never been on an integrase inhibitor.

The decision to change from an apparently well tolerated, suppressive treatment, should be made very carefully, weight the pros and cons of a switch. If your viral load has been really suppressed on this regimen, including not having periods of persistently low viral loads, then you can assume full sensitivity to NNRTIs and probably (though tests would be ideal) to the CCR5 coreceptor inhibitor maraviroc.

The goal of treatment selection in your case should be to identify three fully active (if possible) and well tolerated regimen. Fewer pills or number of doses would be ideal too. Knowledge of your virus' resistance test results would be helpful- I like using the Stanford HIV database or RDI algorithm to help sort out what medications would be predicted to be active.

So-called salvage regimens are by nature, "quirky", and frequently don't resemble compact three drug, low pill count first-line regimens. Usually a modern boosted protease inhibitor (in my clinic, usually darunavir/Prezista) forms the central core of treatment for treating people with multidrug resistant virus, though it's possible to consider using an integrase inhibitor for this- particularly dolutegravir (Tivicay). Dolutegravir was just shown to be superior to raltegravir (Isentress) in this setting, so I'd favor it's use in your case. It'd be worth knowing if your virus is sensitive to at least one of the meds in Epzicom, to determine if this could be part of your next regimen. With a fully potent Epzicom and darunavir (or dolutegravir), this alone might be sufficient to carry the weight of your treatment.

So, that's not really a direct answer to your question, but a series of questions and options for your and your provider to consider. Check out the resistance algorithms, perhaps there will be some additional instruction there too.

Be well, BY



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