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DDI - should I switch?
Mar 22, 2001

Dear Dr. Little: Thank you for your participation in this useful forum. My situation - I have been on ddI, 3TC and Viracept for about 2.5 years. Before that I was on AZT + 3TC for about one year. When I started the triple combination, my viral load was not super high (30,000) and my t-cells were about 400. My t-cells have been pretty stable around 600 or 700 for the whole time I've been on the combination and until about three months ago, my viral load had been undetectable. (I think for the last year my doctor has been using the really sensitive test). Anyhow, in December, my viral load came back at about 700. It dipped back down again two weeks later, and has been slowly climbing again and as of about four weeks ago it was around 5,000. My t-cells are still fine. My doctor did a resistance test, I think the genotype one, and it seems like I'm resistant to the 3TC and the Nelfinavir. Because I've already done AZT/3TC he is reluctant to try Abacavir, but he thinks I should stay on the ddI and just add a combination of Ritonavir and Crixivan. I'm wondering if we shouldn't just try to start from scratch. My question, I guess, is how conclusive is it the resistance test for ddI? I had read, I think, that it was possible to be resistant or at least fail on ddI, but not have it show up. What do you think?

Response from Dr. Little

You are correct about your concern about interpretation of resistance testing for ddI. Based upon your history, I would assume that you may have some degree of resistance to AZT in addition to ddI, 3TC, and nelfinavir (Viracept) - the latter two confirmed by your resistance test results. I think that the indinavir/ritonavir combination sounds reasonable, but the choice of ddI is possibly problematic (though difficult to predict, simply because resistance testing for this drug does not always identify mutations associated with drug resistance, EVEN in patient who are clinically failing the drug). Having said all this though, the alternatives to ddI are limited as well - including non-nucleosides or ddI plus d4T in addition to the PI combination.


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