Aug 11, 2004
I've got some resistance and need to pick a new regimen. RT: 67N 70R 184V 219Q 333E 103N 106I PI: 10I 30N 36I 71T 88D Drug history: AZT, d4T, AZT/3TC; at this point I added IDV, which reduced my VL from 300K to <400 over about a year; swapped NFV for IDV due to kidney stones and within a year VL was up to 30K; tried ddI/d4T/HU for a while, VL stayed under 10K; switched to EFV/ABC/adevofir/3TC/HU and was <40 within 4 months; almost immediately became detectable, but never more than a few hundred copies; went back to the ddI/d4T/HU to avoid accumulating resistance; quit that in 2002 due to incipient neuropathy. So... I think that since the IDV suppressed my virus, with little or no help from the AZT/3TC, with which I had prior experience, I probably don't have much PI resistance other than the 30N mutation that shows up on my tests. This would account for the NFV failure. In a similar way, the fact that I was suppressed or had low viral loads on EFV/ABC/adefovir/3TC/HU even though I have 103N indicates that I probably don't have much nuke resistance other than the 67N/70R/219Q TAM pattern. Otherwise, what's suppressing the virus if the EFV is knocked out by the 103N? This leads me to a combination that includes a PI, obviously, and maybe TDF. I'm thinking either LPV/r/TDF/AZT/3TC/T20 or LPV/r/SQV/T20. The AZT/3TC in the first possible regimen is there because my doctor believes it will prevent K65R and keep the TDF active. Any thoughts or suggestions you have would be greatly appreciated
Response from Dr. Conway
You have an interesting pattern of resistance. The NNRTIs are not likely to be of much help to you, with the 103 & 106 mutations. With respect to the PIs, I think the choice of Kaletra is excellent and this should work well. It is unclear to me whether a double PI here would be of any advantage.
With respect to the nucleoside analogues, I would think that a combination of zidovudine and tenofovir could work, but I would want to see a phenotypic resistance test to see that the zidovudine is still active. If not, I might consider didanosine instead of the zidovudine. The combination of didanosine and tenofovir allows you to reduce the dose of didanosine and give it with or without food. If you add Kaletra to this, you could have a total regimen of 8 pills once a day.
I would not see the need for T20 right now, unless virologic suppression is not achieved in the first 2 months or so of therapy.
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