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Adherence Issues
Mar 16, 2004

I started taking meds 110 days ago. I am on viramune, viread, epivir twice a day. I have missed 4 evening doses and 2 morning doses in the past 100 days. Sometimes I take my morning dose a few hours late but never outside of the 3 hour window i've been told about. If I really clamp down now should I be OK or should I throw in the towell and switch to a once a day treatment. I would like to try to find some new ways to remind myself to take my meds before I change. On the other hand I'm wondering if its worth the risk. How long does it take to build resistance? At what point, if I still haven't manage to achieve the 95 mark, should I ask to be changed to a once a day which I assume would be a change from viramune to Sustiva. I wanted to avoid Sustiva because of the cns side effects but I take my chances with nightmares if it means not building resistance.

Response from Dr. Sherer

Only you can answer whether once daily will improve your adherence. You have done very well, actually above 95% with your adherence so far, i.e. 6 misses out of 200 doses. You didn't mention what you CD4 cells and viral load are, so I can't judge whether there is evidence that this regimen is not working. I would suggest that you stay with this regimen unless you have solid evidence that the regimen is failing.

There is no clear evidence that once daily is better or easier or more effective than twice daily to date. Some patients do find that it fits their lifestyle, but that is not true for other patients.

You are right to be concerned about resistance occuring rapidly with this regimen, however. With viramune and sustiva (nevirapine and efavirenz), resistance can happen very quickly. I might be more concerned if I knew you had missed two doses in a row, or 2 of 3 doses in a row, becuase lower levels of drug in the blood may lead to resistance.

The other class of drugs - the protease inhibitors - are characterized by a higher genetic barrier, i.e. it is more difficult to become resistant to them, particuarly with the good adherence you have shown. With the boosted PIs, such as lopinavir/r (Kaletra), resistance has not been seen in patients who take it as their first PI.

VL rising, CD4 steady, worried
Resistance of outlier strains

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