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Viracept/Combivir vs. Trizivir
Apr 21, 2002

I've been knowingly HIV+ since March 1998 (viral load 12,000 and Tcell 320). I was put on Viracept/Combivir and have done well on it, without suffering major side effects. I've only missed my meds 4 times and currently my viral load is undetectable and my tcell is at 672 (ratio 28.4). Apparently my bad chlorestorol is a bit on the high side but so is my good chloresterol. My dr. thinks I might want to consider switching to Trizivir. My questions: is Trizivir less toxic than my current regimen and would it be just as effective?

Response from Dr. Cohen

It can be. And we have many studies to help you decide what to do next.

First - a word about cholesterol and these blood tests. As you point out - it is not so simple - as there are good and bad types of cholesterol. So not all increases in cholesterol are bad for us - sometimes it can be good. But if the total cholesterol is high, and if the "bad" fractions are high as well, this increases the long term risks for heart disease and many other problems over time. Now, there are several other risk factors for heart disease - cholesterol is just one - others include cigarette smoking and a lack of exercise... so if this combo turned out to be the best one for you - there are other ways to minimize the impact of cholesterol elevations.

But it has been noted over the past few years that one of the side effect concerns for at least some of the protease inhibitors is an increase in total cholesterol. For some people, the changes are modest if they happen at all. For others, the changes are dramatic and lead us to want to alter the regimen. And research has been going on for years to see how we can make changes to maintain control of HIV while improving the cholesterol pattern.

There are studies done over the years that clarify what we can do safely to achieve both goals. For those on the first combo - with no history of resistance to these meds - you have the most options open to you. In fact, a recent randomized study was just completed and presented to us by a team of researchers in Spain. They compared the outcome of substituting any of the three most common choices for this issue - either abacavir/ziagen (note that combivir plus abacavir equals Trizivir), or nevirapine/viramune, or efavirenz/sustiva.

First - they noted that each drug was similarly successful at maintaining control of HIV -- which was true only for those who don't have a history of resistance to the nucleoside class. (Those who do have a history of resistance were less successful on the abacavir arm, since it too is a nucleoside and would be less potent as a result.)

In terms of cholesterol - each drug had a beneficial impact - with each having slightly differing profiles. The overall drop in cholesterol was similar with any of the three, while the "bad" cholesterol was slighly lower more on trizivir than with the other meds used. However, viramune notably had the best increase in the "good" or HDL type of cholesterol of the three tested in this study. Also, triglycerides, another blood fat, will also improve on these meds - and is another good reason to consider switching to an alternative -- for this issue, viramune again did the best of the three. Sustiva was in the middle on each of these outcomes between abacavir and viramune. Overall, each med has some reason to consider it as the next option. In addition, it is fair to note that both saquinavir/fortovase and amprenavir/agenerase are two Protease Inhibitors that don't seem to increase blood cholesterol - but these are 8 capsules twice a day and are less commonly used as a result. In the next year we expect to have two new protease inhibitors - one is a reformulated version of amprenavir, and the other is a new PI called atazanavir - which don't increase cholesterol. So we'll have options aplenty. And we haven't even mentioned viread... which also doesn't increase these blood lipids... and just treating the lipids which can help... or even treatment interruptions given your initially low viral load and now higher cd4 counts... much to say and do for this issue...

So, in sum, yes, you could change to Trizivir. It should work well and improve the lipids. If you are in the 5% or so who are allergic to it, you also know there are other options to consider.



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