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doctor changed meds now i have breakthrough
May 25, 2001

43 years old. last possibble exposure to hiv would be 1983. last regimen was norvir, ziagen, and 3tc. nearly 5 years of undetectable viral load. My doctor switched me to trizivir due mainly to concerns about side effects of protease. (Increased lipids, using lipitor and colestid=220). After one month viral load came back 11,000. Now he wants to switch me to sustiva, ddi, and zerit. Geno test shows resistance to AZT, 3TC, & Ziagen. No resistance to protease and "low level" resistance to ddi and zerit. My question is wouldn't I be better off going back onto a protease? Isn't it better to use the therapy we know will probably return to viral load to <50?

Response from Dr. Pavia

If I have the full story, you have never failed a protease inhibitor, never been on a non nuke, but have been on at least AZT, 3TC, and abacavir (ziagen). There is usually more information in the actual genotype than in the interpretation, but I am assuming you have at least 3 to 5 mutations in the "nucleoside analog mutation" or NAM/TAM family in order for them to label it resistant to abacavir.

Both proteases and non nukes are likely to be fully active. Here's the bad news. If you really have extensive AZT/3TC/abacavir mutations, the benefits of d4T (zerit) and videx are likely to be limited, despite what the genotype report says. That means that a protease or a non-nuke will not have as much support as we would usually like.

I would suggest you need at least 2 fully active drugs. You could do this by using both a non nuke (viramune or sustiva) and a protease (probably boosted with ritonavir). I would probably use the zerit and ddi as a backbone. Another option would be to use either the PI or the non nuke with ddI and tenofovir (in expanded access).

A cholesterol of 220 usually does not make me want to change therapy, unless you have a lot of heart risk factors (smoking, overweight, previous heart disease, high blood pressure). I would suggest working on those factors first.

Nevirapine has the least effect on cholesterol of the non nukes. Amprenavir (Agenerase) may have less effect on choldesterol than the other PI's, but since we usually give it as 600mg with 100 mg of norvir, it is a wash.

Hope this helps, although I have not given you "one right answer" since I don't think there is one right answer.

Good luck

ATP



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