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Time to switch?
May 19, 2002

hello doc,

I have been poz since 1988 and have been on azt, 3tc, ddi, ddc, d4t, Fortavase and Norvir. I show some resistance to all. (result of single and double therapy from the early days)

Oveer the last 10 years, my t-cells have ranged from 300 - 800 and my viral load has never been detectable, but never been above 15,000 either.

I am currently only on Fortavase/Norvir (Before I give up on these drugs, we wanted to try this simple combo based on some research it might work) My current numbers are t-cells 300, 28 with VL of 9,000.

My doc says it might be getting time to switch me to a whole new regiment. She wants to use five drugs... Sustiva, Abacavir, Tenoofovir and Kaletra.

Obviously this is a very potent combination. My concern is that I am using up all my remaining options in one regiment and that I could save one or two drugs for a future combination.

Questions: Is it best to "go for it", or should I be more conservative and lay out two future combination options using two to three drugs each?

Do I even have to make a switch? Even though I am on a minimal regiment that shows resistance, I have been pretty stable. Can I hold out longer or do my numbers say I should finally make a change? I am so worried about using up all future options.

You guys are an incredible resource. Thanks!!!!

Response from Dr. Aberg

I would really like to see what your genotype looks like. There is a good chance neither abacavir nor tenofovir will work depending on the type and number of nucleoside mutations. Also, your doctor may have gotten a phenotype which could assist with what your options are. Switching you to Sustiva and Kaletra will certainly limit any future options should you develop resistance on this combination. Again without knowing what your genotype shows, it is a little more difficult for me to say what the best options are.

I certainly do not like having you just on SQV/RTV (Fortovase/Norvir) because staying on this combination will lead to further protease mutations. Your CD4 count is on the low side for stopping meds completely and watching. You could try that for a short period and see if your CD4 counts hangs around 300 with the low viral load. I think that is a little risky in your case but certainly you could immediately start a combination as soon as your CD4 count dropped or viral load increased.

If you do have 2 nucleoside options, I would give the 2 nucleosides with Kaletra or Sustiva but not both. If you really have significant nucleoside resistance, then a combination of Sustiva and Kaletra as dual therapy is a potent regimen and should work. You will need complete adherence because if you develop a NNRTI mutation, we currently do not have any FDA-approved options left.



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