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ACTG 5095- Trizivir Time to Jump Ship?

Aug 26, 2003

In your review of the the recent Trizivir study, you warned against using Trizivir without a fourth drug:

"There may remain a small subset of patients for whom these regimens are appropriate, but given the high rates of failure relative to the efavirenz-containing arms of ACTG 5095, clinicians should think long and hard before using Trizivir alone."

When might using Trizivir alone be appropriate? What is this small subset?

I was told by my doctor that these results don't apply to me since my viral load was <50 to begin with (switched from Sustiva/Combivir because of high (800) Triglycerides) Began treatment 6 weeks after WB indeterminate CD4 391 24 vl (blanched) 185 000 in 2001. Currently CD4 800 40 vl<50.

What are you telling patients in a situation like mine? I imagine that no virally-supressed patients were included in this study.

Response from Dr. Boyle

You're right that ACTG 5095 is not directly applicable to your situation, but it still provides some guidance. ACTG 5095 enrolled antiretroviral naive patients who then started on an assigned therapy, so it does not involve patients switching therapy as you did. Still, the results indicate that patients treated with an efavirenz (Sustiva/Stocrin)-based regimen have more effective and durable viral suppression than those treated with a Trizivir, a triple nucleoside analog regimen. This was true in patients with low (<100,000) and high (>100,000) viral loads at baseline. It was also true in patients who achieved a viral load <200 on therapy, and appears likely to be true in patients who achieved a viral load <50 on therapy. So, this study indicates that efavirenz-based therapy is preferrable to Trizivir, because it is more effective. But, it does not mean that Trizivir should never, ever be used alone. First, there are some switch studies which spport the approach taken by your doctor. Second, if you have been consistently <50 on Trizivir, and you remain absolutely adherent, you may do fine. Third, every treatment decision needs to be individualized to meet the needs of each patient. If you were my patient, I would discuss intensification with you (using either atazanavir or efavirenz), but if you did not want to do that I would keep you on the Trizivir with careful monitoring so that when you fail it that is detected quickly and the least resistance possible has developed. Good luck.

Sustiva, Viread, Emtriva as once daily

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