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follow up to nPEP
Jul 21, 2007

Dr. Bob,

Thanks for your response to my recent inquiry about the PEP drugs administered in the ER.

I encountered significant resistance at my follow up visit, but working with the health department and our local infectious disease specialist, I was encouraged to continue the drug course.

As you noted, the drugs and doses initially administered were WAY OFF. Whether this will result in a less desirable outcome, we'll never know. I'm now on a kaletra and combivir regimen.

Thanks for your response.

Response from Dr. Frascino

Hi,

Kaletra plus Combivir is a more common nPEP three-drug regimen.

I would suggest you file a complaint with the hospital administration regarding the dosage errors. There really is no excuse for that kind of carelessness. Not only could dosage errors potentially decrease the efficacy of nPEP, but they could also result in significant side effects and toxicity problems. The physician who prescribed the increased dosage and the pharmacist who filled the prescription should both be made aware of their significant error and counseled.

I'm glad you are now under the care of an HIV-experienced physician.

Good luck.

Dr. Bob

PEP Drug Coctail (nPEP) Jul 20, 2007

I'm now 72 hours out from having unprotected oral sex with a partner who I learned is positive. I would be less concerned, however I have two wisdom teeth coming in and my gums have been bleeding regularly.

I was given a two day supply of Retrovir (zidovudine 100mg) twice daily and 3-TC (Lamivuoine 150 x 3) twice daily. This supply is intended to last me long enough to get assistance through the county or state department of health with the remaining 27 days of medication.

I followed up with the positive partner to inquire about his viral load. He says it is currently undetectable.

The guidelines the hospital used to administer the Post Exposure Prophylaxis were last revised in 2006, and the original recommendations were from the CDC many years ago.

I'd like to know if the drug combination is appropriate, or if any other drug should be added to my regimen that may improve my odds. What does the latest research recommend?

Response from Dr. Frascino

Hello,

Your HIV-transmission risk remains extremely low, even with all your incoming "wisdom." The recommendation for PEP in this situation is not a firm one. Most HIV specialists would "offer" PEP, but it would not be "strongly encouraged".

Your starter pack of PEP is a standard two-drug regimen of AZT (Retrovir) + 3TC (lamivudine). However, I'm a bit concerned by the doses you describe. You report Retrovir 100 mg twice daily. The correct dose is 300 mg twice daily. You also report "3TC/lamivudine 150 x 3 twice daily." The correct dose is 150 mg twice daily (or 300 mg once daily).

As for the optimal PEP regimen, we honestly don't know the answer to that question. Some HIV specialists will recommend a three-drug regimen, knowing that maximal suppression of viral replication is best achieved by three-drug HAART regimens and therefore assume this would provide the best chance for preventing HIV infection in a person who has been recently exposed. However, we do not have good clinical studies or solid evidence to indicate that a three-drug HAART regimen is more likely to be effective PEP than a two-drug regimen. Adherence and toxicity issues also come into play when considering two versus three drugs. Recently some HIV specialists have been recommending Atripla (efavirenz, tenofovir and emtricitabine combined into a single tablet) as a "one pill once a day" PEP regimen due to its dosing convenience and potency.

You can download the complete updated CDC guidelines for nPEP (non-occupational post-exposure prophylaxis) at this Web site:

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm

Good luck.

Dr. Bob



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