May 15, 2001
Hello! I have been on medications since 1999, July - Invirase 600 mg tree times daily and Combivir 1 tablet twice daily. My viral load is still below 50 copies, my CD4 cells above 500. My doctor suggests to add Norvir to my current combination in the so-called "baby-doses" 100 mg twice daily. But the clinical data is limited how exactly to take Invirase in this new combination - how much in milligrams and how many times a day. I know that Invirase should not be taken alone without Norvir. I am ready to add Norvir but just want it to be in the most appropriate way.
Hope my question is clear. Thank you in advance, Valeria
Response from Dr. Pavia
Your doctor is right on both counts. Adding Norvir can give better saquinavir levels and easier dosing, AND we don't know the best dosing regimens. I am surprised you are on invirase alone. Invirase, the hard gel formulation of saquinavir has been replaced by Fortavase, the soft gel, because the blood levels of saquinavir are dangerously low with invirase. It is likely that the combivir is doing most of the work.
I would wonder about the reasons that that combination was chosen - are the drugs limited where you are?, where there reasons not to try other drugs? Is your doctor not keeping up with HIV medication changes amidst all the other areas s/he has to keep up on? I wonder how high your viral load was to start.
The best studied combination regimen is Norvir 400 mg with Fortavase 400 mg (or invirase 400 mg) both twice a day. This is an extremely effective regimen, but the higher dose of norvir may cause problems for some people with nausea, fatigue, diarrhea or increase cholesterol or triglycerides. Studies are currently looking at Norvir 100mg with Fortavase 1600 mg once a day, but the efficacy results will not be out for a few months. I am not aware of studies that clearly identify the best dose of Fortavase to use twice a day with norvir at 100 mg twice a day, although 800 to 1200 mg of Fortavase seem appropriate.
Another possibility is to change to a regimen that is all twice a day. Possibilities to consider might be combivir with Viracept (another protease inhibitor), Sustiva or Viramune (non nucleoside reverse transcriptase inhibitors) or combivir with Ziagen, which actually can be given as one pill twice a day marketed as Trizivir, which contains all three drugs.
Talk this over with your doctor or get an in person second opinion from an HIV expert in your community. Good luck
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