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Missed 5 Doses and Terrified!
Jun 12, 2006

Through a bizarre screwup, I missed 5 doses of my Truvada, part of a regimen that includes Reyataz and Norvir. This, my first regimen, started 5/13 with CD4 - 186, VL - 52,000. I am absolutely terrified that I will now develop resistance, and I am already resistant to all non-nukes (despite the fact that I've never been on meds before.) What are the chances that I've screwed this up and am in big trouble? Thanks so much.

Response from Dr. Sherer

Missed doses are always undesirable - so this big lesson here is to ensure that you prevent this particular screwup from happening again, if thats at all possible.

There is always to be a possible price for missed doses, in that they open a small window for the virus to get a competitive advantage over your regimen.

You missed two of the three active drugs for 5 days, if I understand the problem correctly. You did not say exactly when this happended, but if you just started on 5/13, and you posed the question 3 weeks later on June 8th, it is not likely that you were fully suppressed when it happened. Because there is evidence that viremia requires several days to recur once full suppression has been achieved, there may be a lesser risk of missed doses once that has been achieved, compared to missed doses during the initial treatment phase.

There is strong evidence that boosted PIs are themselves less prone to resistance, even in the presence of viremia, and that they reduce the risk of resistance with other members of the regimen as well. Hence if you were taking your Reyataz and Norvir faithfully during these five days, that's good news.

I can't give you a number for the chances of resistance - it is real, but small. Your initial viral load was somewhat low - we expect to see a one log reduction after 4 weeks, so you may have achieved a viral load below 10,000 when this happened.

Ultimately, you and your physician will answer this question with your next viral load and CD4 cell count values. He or she could also request a genotype test looking for common early mutations, i.e. the M184V, if you have not already developed that mutation. I urge you to take your questions and fears to him or her, as well as these answers.

virual load & cell count

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