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Simpler regime? Or stay with what I've got?
Dec 20, 2004

Dear Doctor,

My first antiretroviral cocktail, which I began in June, 1996, was Crixivan, Epivir, and Zerit. Zerit gave me neuropathy, so I went off it in December 1996, and switched to Viramune.

I began my second cocktail of antiretroviral in May of 1997: Fortovase, Viracept, Viramune, Epivir. In 2002 I experienced some lower back pain (which continues, as of 2004, to be a periodic problem), and in May 2002 an x-ray, MRI, and bone density tests revealed marked osteopenia and disk degeneration which was causing nerve compression. In May 2002 I switched to a protease-sparing cocktail (Viread, Ziagen, Viramune, Epivir) to try to put a stop to the bone loss, and began calcium supplements. In April, 2003 I began taking Fosomax. In June 2004, a bone density test showed improvement in mineral density at the lumbar spine, but no change at the left hip. Ive had a couple of painful back episodes in the last year--stress related, or exercise related, I think--but most of the time Ive been fine.

My health is excellent, and I have no side effects except the bone density issue. My liver values and lipids are good. Im not showing signs--in terms of viral breakthroughs--of having developed resistance to any drugs. My viral load has been undetectable for a long time, and CD 4 cells are stable between 350 and 400, and between 35 - 38 %.

Heres the issue: my current doctor would like to change my cocktail so I can take less pills. He has suggested Truvada once a day, and Viramune (once or twice a day).

Here, from my experience and from consultation with my former doctor, are a few reasons not to make this change:

--I dont have trouble taking the amount of pills I do; the impulse for this change came from my current doctor, not in response to my request. Im very disciplined, and dont forget doses often. Also, even if I simplify my antiretroviral regimen, Im going to need to other pills twice a day (Minocycline, calcium, Docusate, numerous vitamins), plus other drugs I take once a day or once a week (Acyclovir, Zyrtec and Fosomax.). So my experience of needing to take a fair amount pills twice a day wont be markedly different just from simplifying the cocktail.

--My current doctor suggests that a reason to take less drugs (by eliminating the Ziagen from my cocktail) would be to protect my liver. Ordinarily I would agree, but my liver values are good, and have been for a long time.

--My older doctor suggests that a good reason to stay on four drugs--and why she kept me on four--is that even though my viral load suppression is still excellent I may have developed a resistance to one of the drugs. I began antiretroviral with a fairly high viral load (380,000) and a CD 4 nadir of 8. She says there is a very good chance Id do well on the simplified regimen, but that if I do develop resistance to the non-nukes on the new regimen, I have no choice but to go back to protease inhibitors, which I quit to protect my bones.

It would be helpful to have your opinion on whether you think the change to a new regimen is advisable or warranted under these circumstances.

Response from Dr. Lee

The only reason you have listed for changing the treatment regimen is because your current doctor wants to simplify your treatment. You have no difficulty with the twice daily regimen and will continue to take other meds twice daily, so I do not see a real advantage for you in changing the treatment. Your current doc sounds well intentioned, but since you don't have a problem to prompt this "fix", perhaps you should decline. Your previous doc does have some sound reasoning, particularly if you hope to stay away from the protease inhibitors as long as possible.

Be well.



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