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switching treatment, high LDL/cholesterol levels

Mar 28, 2004

Dear Brian,

I have been diagnosted HIV+ since Dec. 2001. My VL has always until now undetectable. My CD4 has remained relatively high (between 1100-1300) and I have no side effects of my current treatment (Sustiva & combivir. Most recent analyis (last 6 months)have shown an increased LDL value of 161 and an increased cholesterol level of 284. All other serological data seem acceptable. My doctor suggested to switch to RAYADAZ or ATAZANAVIR. I have read that this treatment is relatively new (not much experience)and that this treatment has undesirable side effects such as jaundice (increased bilirubin levels. Whould it not be better to stay on the current treatemnt (Sustiva and Combivir) together with a cholesterol reducing medication & diet, or switch to the new proposed RAYADAZ or ATAZANAVIR treatment. Could you please let me know. Thanks in advance!

Response from Dr. Boyle

It's unclear from your question whether the cholesterol/LDL changes are new or old. If new, it is possible that those are not related to the Sustiva since you've been on that for 2 1/2 years, and I might look for another culprit (e.g., another medication, diet change). Since you're tolerating the current regimen well, and have had durable success with it, I would be tempted to give diet, exercise and a lipid-lowering agent a try first, rather than switch you to a new regimen. If you're going to switch, I think that atazanavir is a good choice since its efficacy and safety have been demonstrated in several clinical trials and patients switched to atazanavir from another medication usually experience an improvement in their lipid profile. While bilirubin increases are common with atazanavir, since it inhibits an enzyme inolved in bilirubin metabolism, the incidence of clinical jaundice (even with ritonavir boosting) is low, with just a little over 1 in 20 patients getting it. If it does occur, your doctor can consider atazanavir dose adjustment or discontinuation, and the jaundice quickly resolves once atazanavir is discontinued. Finally, since your current CD4 count is very high, if you started therapy with a high CD4 count, i.e., >200-350, you might also consider taking a drug holiday and watching your CD4 count carefully. You may be able to get a year or more off therapy altogether.

A good combination?
A good combination?

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