Hi Dr. Cohen,

I have read several references to the peripherial neuropathy that seems to occur from taking zerit. What are the dangers of reducing the daily dosage from 40 MG BID to something less than that to offset the neuropathy side effect that I am currently experiencing ? I am 52 yrs old, have tcells approx 650 and viral load undetectable. Weight is 205 lbs. Had major probs with fatigue from earlier use of azt so switched to zerit ( along with epivir and ziagen ) Good results other than the neuropathy problem. Can I safely decrease to attempt to diminish the pain and inflamed nerves in my legs ? Thanks once again for the wonderful service you guys perform - Bob

Well, big guy, the short answer is maybe.

For this answer, I'll assume your viral load is undetectable at a level of <50 copies. This, if true, gives you the most options. If your viral load is not fully suppressed already, then you need to defer dose reduction and explore even more potent combos. But I'll assume the former.

You mention your weight of 205 lbs. Zerit/stavudine/d4T is one of the meds that has been studied with dosing adjusted by weight. Now, in general it is true that for those who had neuropathy, 30 mg can be similarly successful, and have less neuropathy. However, it is reasonable to be a bit concerned about its success rate for you. But it is an option to try. Factors that may influence whether it is worth the risk include your viral load before you started meds - the higher it was, the more the concern that dose reductions could lead to rebound at least in theory.

Another option is to consider another medication instead of either d4T or AZT that has less of a risk of neuropathy. One option that allows you to stay in this same class of meds is ddI/Videx. It certainly is at least as potent as zerit and it does work well - with less risk of neuropathy. And, ddI just came out this year as a capsule taken on an empty stomach just once a day - so is pretty easy to take. There are some experimental data looking at taking the other two meds in your combo also just once daily - so if that data continues to look successful, this combo could be pretty easy to manage.

Of course, there are options in the other classes of meds you haven't mentioned - but I would assume that part of why you started this regimen was to limit the number of classes of meds. But they are nevertheless options to keep in mind.

Neuropathy is one of the more frustrating issues. While we have meds that can alleviate the discomfort, we don't have anything that clearly reverses the nerve damage - so it is reasonable to consider doing something to prevent any more neuropathy. Since it sounds likely that, if you can find a combo that you tolerate, you can do well for decades to come.

Hope that helps.