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change of treatment . only nucleoside analogues?
Sep 1, 2000

Dear doctors: I've been just changed (after 4 months without medication)to videx/epivir/ziagen, due to high lactic acidosis and resistances results on my last resistance test. I have 280.000 copies viral load and 250 cd4. According to my doctors, this is the only combination due to resistances and my previous historial. I thought it was necessary to include always protease inhibitors to get results. Do you think it is a good cocktail? Thanks a lot for your attention.

Response from Dr. Pavia

I am a bit concerned about the story here. It is always hard to give you a fair answer without knowing the past history in detail and seeing your resistance tests, and even if I had that info, the purpose of the site is to give you information for you to use, not to treat you!!!

But here goes. The three nuke combo of azt, 3TC (epivir) and ziagen has shown very good results in treatment naive patients. In several studies, it seems comparable to protease based regimens over the short term in patients with viral loads under 100,000. But you don't fit this profile. Your viral load is very high and you say you have been through other drugs. Lactic acidosis has been reported with all of the nucleoside analogues, and while it may be that d4T and AZT are slightly riskier, I don't know of any data that says epivir and videx will be safe if you really have significant lactic acidosis.

Resistance interpretation is part art and part science, especially for the PI's. Some of the newer "enhanced" PI regimens can show good activity even when there significant PI resistance mutations or a resistant phenotype. Thus, the reports that come back from the lab are not perfect for predicting response. The most promising results are for ritonavir/amprenavir and for ABT-378/ritonavir. A clinical trial with T-20 might be another option. I would certainly be considering one of those combinations as a possible part of a regimen for you.

Having said all of this, I think you need to talk this over with your doctors, and, if they have limited experience with treatment of people with highly resistant virus, they may want to run your case by other "experts" Just exactly what makes one an expert in an area where we don't have many of the answers continues to escape me...

Good luck

ATP

Andrew T. Pavia



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