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Treatment Naive patient: PI or Integrase Inhibitors
Apr 3, 2015

Dear. Dr. Young, I was just diagnosed in December 2014 with a VL of 1,600,000 copies/ul and a CD4 of 88. After 7 weeks of treatment, my CD4 is 350 (CD4% still low is 12%) and my VL is down to 5,000 copies/ul. I am currently on Truvada/Prezista/Norvir. Given the latest results of the SAILING study and others, and given that my viral resistance tests are negative so far, do you think it would be a good idea to switch to Triumeq or other PI-sparing regimen (given the likelihood of lipodystrophy and metabolic problems associated with PIs)?. Also, do you think it would be better to stay on Tenofovir ( or the new upcoming Tenofovir, for that matter) plus an integrase inhibitor(Dolutegravir) or switch to Abacabir altogether to avoid future renal problems?. Like all of us here, I am trying to reduce the likelihood of long term toxicity without compromising efficacy.

Looking forward to your response. Thank you very much for your help. John

Response from Dr. Young

Hello John and thanks for posting.

First off, it seems like the trajectory of your labs is excellent, and while you've not yet reached an undetectable viral load, your headed that way. There will likely soon be a single pill version of your regimen, if pill number is a negative aspect of your current regimen, using a new formulation of tenofovir (called TAF) which has slightly improved kidney and bone safety characteristics.

You're on a very good regimen, and there's no immediate need to switch. That said, I'm a fan of integrase inhibitor-based treatments- and recent studies with raltegravir (Isentress) and dolutegravir (Tivicay, part of Triumeq) have actually shown superior results overall compared with your Truvada + boosted Prezista regimen.

If you have normal kidney function, there's no rush or need to switch off of tenofovir (part of Truvada); make sure that you have some type of assessment for bone health too. If your genetic screen is negative for the HLA B5701 marker, then abacavir (part of Epzicom and Triumeq) could be an option, and one that carries no significant kidney or bone toxicity (though some people question if there might be increased cardiovascular disease risk- I for one don't find it of great concern).

In the end, it would be good to take a careful inventory of your current health, and health risks, then balance that against the known safety profile of the medications. In general, most of my patients are migrating to integrase-based treatments for their improved tolerability profile.

I hope that helps, and feel free to write back. Be well, BY


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