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Trizivir or Viracept/Combivir
Apr 6, 2001

My T cell count is 132 and viral load 250000 I have never been on any hiv meds. I have met with 2 doctors. One is suggesting viracept/combivir and the other trizivir. Any help or insight you could give would be appreciated.....these are hard decisions. I want to do the best, aggressive treatment I can.

Response from Dr. Young

Thank you for your question. You've raised the difficult, but very important question about which regimen to start with.

With the understanding that you have moderately advanced AIDS and a relatively high baseline viral load; most opinion leaders would use triple nucleosides with some caution; this is because recently presented clinical trials (published last month in JAMA) suggested that in patients with high viral loads (in this case, >100,000 copies) were less likely to acheive viral loads less than 50 copies after one year of treatment with combivir/abacavir (essentially Trizivir) than those who took combivir/indinavir. Important to note that this study was a placebo controlled trial, meaning that all patients took 16 pills a day, three times a day with meal restrictions.

In a more "real-world" exmaination of the same question, an international study (headed by Dr. Pedro Cahn in Argentina) found that in an open label comparison of Combivir/abacavir vs Combivir/indinavir- there was no difference between the two treatment arms, independent of starting viral loads. The patients that received combivir/abacavir took 2 pills twice a day, while the combivir/indinavir patients took 8 pills three times a day.

What accounts for the difference? Likely, the lower number of pills taken by the second study patients contributed to greater adherence, and hence offset any possible differnce in intrinsic virological effect.

Nevertheless, for now, given the option between the two regimens that you have listed, I'd favor the Combivir/Nelfinavir regimen. It is worth mentioning that other alternatives exist, and for many patients may be more suitable; Combivir/efavirenz is one such combination that we have used with success (with excellent clinical trials data too). The choice of initial nucleosides is open for discussion too, and we have used both AZT/3TC and d4T/3TC with success. The recent Department of Health and Human Services Guidelines give a detailed outline of first-line options. Some investigators have suggested a role for quadruple initial therapy with Trizivir with either a protease inhibitor or non-nucleoside. It is also important to never underestimate the importance of not missing doses of medications; and the generic recommendation of one drug regimen over another does not take the place of one-on-one counseling.

good luck, BY



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