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kaletra switch --can I go back?
Dec 15, 2003

Dr. Boyle:

I was diagnosed March 03--last neg test March 02. After 6 monhs of testing, my vl remained high (200K) and tcells went to 250. So I began therapy in Sept 03. My doctor has prescribed Kaletra, Viread and Emtriva. He never explained lipo possiblitities or I would have objected. I had not had a resistance test at that point, but the later test showed I am sensistive to all major meds. (I have an ok mutation to PIs). I am currently expecting results on labs from 2 months on treartment. After I was on Kaletra, et al. I raised the fat issue--my dr then told me that he had planned all alomg on switching me off kaltera once I went undectable. (I am upset about dr's failure to fully inform me, but that is another issue. Funny ting is, when I went to him, I expliscit said I wanted to be involved in decionmaking as my prior dr, his former partner, also left me aout and had an authoritation approach, e.g., just handed me a list of meds and said here is what you should take). I want to swtich to viramune or sustiva. My question is--if I swich off kaletra, can I go back to it later or will I most likely be resistant? I hear it is a great med if others fail. I will be very upset if I have now lost that option. If I can switch off, is here a way to do it that preserves kaletra?

Is there a of my odds of being resistant later (probably no such number yet, right?) Another question--one dr I spoke to (I am dr shopping naturally) said he would recommend keeping me on a PI--but the new one that does not seem to have lipo assoc. with it (begins with "a" and I would take it with ritnovir). He said now that I am on a PI, I should stay on it. Can you advise me. I feel lost. Thanks so much. Fellow JD but no MD, Kevin

Response from Dr. Boyle

The causes of lipodystrophy remain largely unknown and poorly understood, and although there is some evidence that PIs may be associated with it (for example, in one study rates lipodystrophy were higher in the nelfinavir than in the efavirenz arm), that is not settled. So, while you may decide to switch off Kaletra to decrease your risk, that strategy has not been definitively established as a method for doing that. Also, there is no evidence yet that the risk of lipodystrophy is different from one PI to another, although there is evidence that the "a" PI to which you refer (atazanavir) may have better lipid profiles and insulin resistance profiles than some of the other PIs. So, to actually answer your primary question about how to avoid resistance if you decide to switch off Kaletra, I would advise you to stay on Kaletra until your viral load is <50, which should just take 3-6 months at the most, and then you should be able to do a one-for-one switch for Kaletra without much risk. In the meantime, to minimize your risk of resistance and to maximize your chance of virologic success, you should remain religiously adherent to the Kaletra.



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