Feb 4, 2014
Hi Dr. Young. Thanks for taking the time to read this and hopefully respond. I am recently positive. Cd4 is 750 and vl is in the neighborhood of 4000. I really haven't had any real symptoms other than random aches, headaches and the occasional 3:00 bathroom trip (which wasn't normal). I am looking at choosing medications. I have no resistance to anything, kidneys and liver are fine and so the sky is the limit. If you had to recommend any particular regimen, which would it be? I don't care whether it's a once a day regimen as I don't think adherence will be a problem. Instead I am looking for most effective with lowest toxicity. I look forward to hearing from you.
Response from Dr. Young
Hello and thanks for posting.
I believe that the treatment paradigm is shifting away from our old standards- regimens that contain a NNRTI or boosted PI. Today,as we expect people living with HIV who access care and treatment to live longer, we're growing more aware of the concerns of long term treatment, particularly in an aging population. As such, the concerns about kidney, liver and bone health as well as concerns about drug-drug interactions is increasing.
IMHO, the best first line regimens today now involve using an integrase inhibitor with 2 NRTIs. Until recently, this was almost entirely done with the twice-daily Isentress, but now we've got two once-daily options with elvitegravir (part of the single tablet regimen Stribild) and the recently FDA and European agency approved dolutegravir (Tivicay).
Given that Tivicay was found to be statistically superior in first line treatment to our industry workhorse meds Atripla and boosted Prezista (with 2NRTIs), it's hard to say that this isn't a candidate for initiation of treatment today. If you'r genetically screened negative for the HLA B5701 marker, this means that Tivicay + Epzicom is a good option for you. Epzicom has lower risk of kidney and bone toxicity and the combination will likely be available as a single pill by summer of 2014. If your genetic screening is positive (meaning that you are likely allergic to one of the medications in Epzicom), then Tivicay+ Truvada would be a very suitable option. Both combinations are endorsed by the US government panel as "preferred" first-line treatments.
If one pill a day is required, then Stribild is currently the only one pill integrase regimen. This is also very well tolerated, but comes with (probably) higher risk of GI side effects and requires pharmacologic boosting (and inherent drug interaction risk) that the other integrase meds don't have.
Hope that's helpful, let us know what you decide. BY
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