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Sustiva -- Three Single Doses Daily?
Aug 28, 2000

Dear Dr. Cohen:

I have decided to take my Sustiva -- every 8 hours, rather than the nightly mega dose of the 3 pills which I have been doing for a year. The insomnia was difficult and I would be quite tired from the vivid dreams, in the morning. I did try taking my 3 capsules during the day -- but I found that made me sleepy...and a little too high for my liking. Have you had any clinical experience with triple dosing of sustiva, Dr. Cohen? I called Dupont and they had no real studies except for a 12 hour dosing schedule which was favorable.

My VL is 200 and cd4 is 680 with Sustiva, Ziagen and 3TC from just over a year ago...when my baseline

counts were 750K and 274CD4. I am aware of the long half life of sustiva -- which doesn't necessarily mean it is effective...just wondering if every 8 hours will do the same

amount of benefit... (?) Have you ever recommended a patient to take a 4th Sustiva and increase the overall level of sustiva in body?

I am hoping for UD VL, and gradual restoration of my CD4's but wish to balance that with manageable side effects.

Thank you, Dr. Cohen.

Michael

Response from Dr. Cohen

Sure thing Michael. I am hoping it works for you as well.

In theory a dose of one pill every 8 hours, or even just scattered 3 times per day - should work fine. This is a very long acting drug and after you have been on it for a few weeks you have a high blood level of this med. And we think that these meds work best when we sustain a level above a certain amount -- known as a trough concentration -- above which HIV is controlled by the medication. And with Sustiva one pill three times a day is likely to maintain that level as well as three pills once a day. We also think that a "peak" level of drug -- like what you would have just after taking the three Sustivas -- would have some relationship to side effects -- although we don't have much that proves this for this drug. So while there is little info that proves what you are doing is gonna work -- it should.

And the only other comment is that if your VL is 200 -- and not below 200 -- there is some concern that this combo just isn't as strong as it should be to maintain viral suppression for as long as possible. An occasional measurement above 50 copies to 200 seems to be OK -- and it may be that having a viral load of 200 lasts a good while. But in general we'd expect that this combo would last even longer if the viral load were below 50 rather than above it. But based on our principles -- splitting the Sustiva to every 8 hrs probably won't change the degree of viral suppression assuming you've been good about taking it all just once a day.

So would a 4th Sustiva work if three haven't fully suppressed your HIV fully? Well -- we have no info -- and much of what he have suggests that three Sustiva should be enough for almost everyone to have a high enough concentration to work fully. But there may be some whose blood levels may not be above the target range -- whose trough concentrations are lower than average. And if so -- then raising the dose would be reasonable. The problem is that we don't have a reliable way to know what your blood level is nor much info to support that raising your dose, especially at this point, would work. But it is the kind of approach that some centers are studying since the average dose may not be perfect for everyone.

For all we know, Michael, you could be 250 lbs and 6 foot 5, and have one of those livers that just chews these meds right up... or then again, a stocky 5'2" and a fourth pill would do nothing except add side effects... wish we could predict but we can't yet.

Hope you find that balance of effectiveness and lack of side effects.



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