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What can be a good "match" with Isentress for a naive patient ??

Mar 31, 2009

Dear Doctor, I'm getting ready to start meds after my cd4 count took a 200 point dive in the past 6 months (from 485 to 285). Though it came back up some (lower 300's) just one month after being treated for an acute infection (Syphilis) I still believe it's time to start meds. The 'common' treatment at my facility is Atripla, however I'm really concerned about the potential side effects of Sustiva. Taking the pill right before bedtime is not a good solution for me since I'm a commercial pilot who often have to fly late into the night, sometimes without much warning. From my online research Isentress came up as a very potent med with low toxicity/ side effects however it is not (yet) approved for first time patients. If I still choose to try it (due to my job), what would be a good combination with it? I read some are taking it with Truvada, some with boosted (or unboosted) Reyataz, and some (like yourself) with Prezista and Intelence. Thank's for any thoughts/ recommendations. PS: I am not resistant to any drug and VL is about 30K.

Response from Dr. Frascino

Hello Fly-Guy,

Commercial pilot, eh? OK, if I answer your questions about antiretrovirals will you get me bumped up to first class or at least an exit-row seat?

Isentress (raltegravir) was approved in 2007 for use in combination with other antiretroviral drugs for treatment-experienced patients with multiple-drug resistance (those who have failed other antiretroviral therapies). Isentress is the first drug approved in a new and novel class of antiretrovirals integrase inhibitors. The HIV integrase enzyme inserts the viral DNA into the host DNA, a critical step in the HIV lifecycle. Obviously a drug that blocks this critical step has great promise and potential. Isentress appears to be delivering on this promise. Because this drug is new we do not know if there will be any long-term toxicities or adverse effects. However, presently it appears to be well tolerated and to have relatively few drug-drug interactions.

Studies in treatment-nave patients are still ongoing. However, Isentress has shown good potency in early (two weeks) results in treatment-nave patients when compared to the current "gold standard" Sustiva (plus an optimized background). Isentress recently received FDA-approved review status for treatment-nave patients. There is a possibility the FDA may approve the drug for initial therapy in treatment-nave patients as early as this summer. Of course some of us haven't waited for this official approval to come through! As far as what to combine Isentress with, the pharmacotherapy studies are still underway. Aptivus/Norvir can decrease the blood concentration of Isentress, but no clinically significant interactions were observed from clinical studies in patients receiving this combination. Dose adjustment is not required. Reyataz and Reyataz/Norvir increase blood levels of Isentress, but no dose adjustment is recommended. The combination of Isentress, Prezista/Norvir and Intelence appears to be doing well in treatment-experienced folks. At this time there are no specific contraindications for HIV drugs to combine with Isentress. Preliminary studies suggested that Isentress may have some effect on blood concentrations of Epivir and Viread, but so far there have not been any recommendations to adjust dosages when using these agents together. Needless to say we are still learning about Isentress's potential and watching for any potential adverse effects and/or drug interactions.

Finally I should mention I'm concerned about your recent bout of syphilis, which apparently knocked your CD4 count for quite a loop! Chances are it also increased your HIV plasma viral load at least transiently as well. What concerns me most is that despite your HIV disease you are continuing to put yourself and consequently others at risk for STDs. What's up with that? Fly-Guy, would you pilot your plane without buckling your seatbelt? Then why are you allowing rides on your pocket rocket without buckling up for safety with latex condoms before takeoff??? Time to wise up Fly-Guy!

Dr. Bob

STD' s and HIV TEST Results
Can I Whooo Haaaa, doc?

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