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Adding Viread to a working regimen
Mar 27, 2004

Hi,

I have been positive for over 12 years, and started my first antiretroviral regimen 13 months ago. I am currently on Videx EC, Sustiva, Epivir (150mg 2 times a day). Essentially, I take my Videx EC and 150mg Epivir in the a.m on an empty stomach and take the Sustiva and 150mg of Epivir (2nd daily dose) in the p.m. My most recent labs are as follows: Viral load undetectable. CD4 402, (17) (My viral load became undetectable approx. 7 mos. after starting therapy) My Dr., a well-known HIV specialist, is recommending to add Viread to my current regimen, and also to switch out the Epivir for Emtriva, which he says has a longer half-life. I expressed my concern about adding a 4th drug. (Viread). I have not read anything recommending 4 drugs for someone on their 1st regimen, and that since the current regimen seems to be working why add another potentially toxic drug?. I also asked about what would happen if this new regimen fails, he said then I would be put on 2 protease inhibitors and also T-20. I have heard that T-20 is very expensive and hard to tolerate due to mulitple daily injections. He said that adding the Viread and switching to Emtriva would increase my chances of better immune reconstitution, etc. (I have always been asymptomatic and am tolerating the current regimen without any side effects) Does this make sense to change drugs when the current ones seem to be working? I have been with this Dr. for 10 years and respect his expertise, but would like a second opinion.

Thank You.

Response from Dr. Cohen

Well - like yourself - I am a bit puzzled by the push from 3 meds to four. Given that your three seem to be working just fine. I can better understand the issues of changing which three you are on - there is some validity for example in noting that emtriva has a longer half life than epivir - and theoretically this might mean a better long term outcome - though that has not yet been shown in the initial head-to-head studies. And sometime later in 2004 or 2005 - we do expect a combo tablet containing viread plus emtriva - which would allow simpler dosing - from your current combo down to just two pills per day (without the videx - with it there'd be three pills per day). For some - the lower pill burden is enough of a reason. For others it is a minor difference. But it is something that some might value. Emtriva certainly seems as safe as epivir - so little reason not to consider the change. The longer half-life of emtriva would allow confidence in going to all once daily dosing versus the twice a day combo you are now on - and that too is a plus for some. However -epivir certainly seems decent when given once a day - so that could be done now as well based on studies presented so far - taking just all once daily videx, epivir and sustiva. In fact we're doing a study of this combination - and so far it has been highly successful.

But like yourself - I am not familiar with the info suggesting that 4 potent meds is more successful at immune reconstitution versus three. This has been studied for a few years - and as far as I know - we continue to search for proof that four is more successful than three in any tests we do of the immune system. There may be some info I don't know about -- there are many involved in research who have results that I'm not aware of - so I'd certainly be interested in understanding what info there is that four are better than three.

If I'm on target however - and three vs four meds is still up to debate - then "which three" is the ongoing question. As you have noted - your three can work well. Whether there is any reason to change to a different triple given these excellent results is certainly a reasonable question - though the predicted long-term differences between these combinations would likely be small - since triples based on combinations of videx plus epivir have done well for years, as have combos of viread/emtriva. As has been seen with videx/emtriva, or viread/epivir - lots of ways to put these together. Seems to me that you'd be choosing between several attractive approaches.

But like you - I'd want a "second opinion" - at least more about the first opinion - on the push in four meds versus three. Maybe the idea was to add viread/emtriva to the videx/sustiva - and then stop the Videx?

Let us know what you find out - perhaps you can share with us something new...



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