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New Dosages for Norvir/Fortovase Effective?
Aug 19, 2001

Hey Doc Cal...

I've really enjoyed your responses on here! Thanks for all your effort... !!

My history:

HIV+ for about 4 years. First counts were CD4=160, VL=35000.

Went on Crixivan, 3tc and AZT. VL dropped to undetectable, but I hated the regiment (I was puking). So then I went to Crixivan/Norvir and 3tc, AZT. Better, because it was twice a day, and I could eat with it, but still not great. So, I then switched to Norvir/Fortovase and Combivir. I did well on this, until the Norvir capsules were discontinued because of something I still don't understand, and the only Norvir option was liquid, which, I hated. So, I became less compliant, and the doc finally switched me to Viracept, Zerit and 3tc. That was good, but I wasn't very compliant because I was in the throws of active drug addiction. All through this treatment, I never got above 260 CD4, I'm guessing because of my drug use. My viral load was undetectable most of the time I was on my meds.

I went to rehab last summer, where they took me off my meds until I could get stable. One year later, I'm clean, and doing well. Interesting to note, 4 months clean, I went in for a numbers check, and my CD4 had risen to 305, while my viral load was 50,000. That was the highest either had been! The next test wasn't as good (my CD4 dropped to 260, and my viral load went up to 55000) so I went back on meds, but I'm wondering about the dosages:

I'm taking 200mg Norvir, 400mg Fortovase, and Trizivir twice a day, with food. I haven't missed a dose yet! But, I saw on many websites that the correct dose is 400mg Norvir with 400 mg Fortovase.

What do you think? Do I have anything to be worried about? Especially considering I may have caused resistances?

thanks, Still Alive in Washington, DC

Response from Dr. Cohen

Hey DC - Glad to hear you made it through the addiction challenge - at least so far.

As for dosing - there are increasing numbers and variation on the dosing theme for protease inhibitors. There are several issues to consider.

First, is that it sounds like you don't have high level resistance to these meds. In other meds, while on meds, your HIV was usually suppressed. That is a key issue - since the doses that work well against the original "wild type" or sensitive strains are lower than what is needed to compensate for resistant strains. Since, almost by definition, a strain that is resistant is simply resistant to suppression by a certain amount of the drug. And at least with the PIs, we can often compensate for some degrees of resistance by "boosting" the blood level upward. And then we try to define a level at which the PI is once again active against this partially resistant strain. And we have been successful for at least some degrees of resistance.

Now, you do mention that while on meds, your viral load was undetectable "most" of the time. So I'll assume that there were some readings that might have even led to resistance to some of the meds you were on - zerit, 3TC, and viracept. We therefore might assume you have resistance to the 3TC, and perhaps to the viracept as well. But if I guess correctly, you may have just early levels of resistance to the viracept. And boosted saquinavir/fortovase can be expected to work well against virus that is just starting to become resistant to viracept/nelfinavir. And various amounts of norvir/ritonavir and saquinavir are used to do this. While you are correct - most of the work was originally done using 400 mg of both twice a day, there are recently more studies using other ratios. Now, I am not familiar with the exact ratio your own clinician is using - 200/400 - but it seems reasonable to use for those with low level resistance in the PI class. Other options that increase the potency of the saquinavir tend to increase the saquinavir up higher - as high as 1000 mg twice a day, and either 100 or 200 mg twice a day of the norvir with it.

Now, the combo you mention is actually four meds since Trizivir is three meds in one tablet. And in your case, two of them - AZT and Abacavir - are likely to be fully potent for you, while the 3TC in there still may have some activity despite resistance that may have happened earlier on. And so this four drug combo should be successful for you.

As you know we don't have to guess - your own viral load should drop to <400 in the first month or two, and either near or below 50 in the first three months or so. Since 50 thousand is actually not all that difficult for a good combo to control.

As for the prior norvir capsule/liquid thing - we hopefully won't see that problem again - but it wasn't anything more than a production glitch that made the older version of the capsules less than fully potent - the new ones seem to have fixed that problem.

Hope that helps.



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