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Editor's Note: Winners and Losers

By Jeff Berry

January/February 2005

Editor's Note: Winners and Losers
A little over a month ago, I phoned my doctor's office to schedule an appointment to have my labs done. I've been on a combination of Sustiva plus Kaletra for three years, and have remained undetectable with a T-cell count in the near-normal range, and a high CD4 percentage. I'm way beyond "third-line" therapy, this is probably easily "sixth" or "seventh" line for me, but who's counting?

Crixivan was my first protease inhibitor, and almost immediately I went to undetectable, and my T-cells turned around and started to increase gradually after having steadily declined for years. Suddenly, I thought, "Maybe I'm going to beat this thing". The food restrictions on un-boosted Crixivan were nearly impossible, and yet I figured out how to adjust my lifestyle to take it three times a day on an empty stomach, eight hours apart, and drink copious amounts of water. I learned to live with it.

And then all it took was one street fair, throw in a little too much sun, a couple of beers and not enough water, and voila: "Crix" stones, which were so painful that I ended up being hospitalized. I was crushed when my doctor told me I had to stop the drug. But pain is a great motivator, and so I agreed to switch to the next best thing at the time, Viracept.

Thus I traded one side effect for another, this time enduring frequent and excessive diarrhea for several years, and, not surprisingly, after a while my viral load broke through, and slowly began to rise. But then it stabilized around 1,000, and my immune system remained intact. So we watched, and we waited, because at the time there weren't a whole lot of other options. And remember the first formulation? Five chalky pills that got stuck in your throat every time you tried to swallow them, twice a day? Yuck! But, again, I learned to live with it.

Fast-forward several years later: My viral load started climbing, and my T-cells had begun their gradual decline once again, like troops of soldiers valiantly marching to certain death. A resistance test confirmed our worst fears: the dreaded D30N mutation, which is associated with Viracept resistance. And I began to see the effects of lipodystrophy. Was it brought on by the years on AZT, then Zerit, was it the mitochondrial toxicity, or the protease inhibitors, or all of the above? Maybe it was the virus itself that caused my face to begin caving in. Or was it because I am an HIV-positive white man over 40? Who could say for sure?

After careful thought and consideration, my doctor and I decided to pull out the big guns: Kaletra plus Sustiva. The plan was, let's get back to undetectable, restore my immune system, and knock the crap out of this virus. I had been on Viramune for about a month several years earlier, but I didn't respond to it well, so I switched off right away. While a resistance test now didn't present with the typical non-nuke mutations, it probably wouldn't have anyway, since I hadn't been on the drug for quite a while. So it was a gamble to go with another non-nuke, which I could be resistant to, but one I was willing to take.

So back to the future, here I am, I have 905 T-cells, my CD4 percentage is 30%, and my virus is undetectable. Kaletra and Sustiva had lived up to their promise, even exceeding my wildest expectations. I had a new lease on life. Aside from that first couple of days on Sustiva, when I felt like I was on a mix of qualuudes and downers, and other than a few really bad nightmares now and then, I actually started to enjoy the "vivid" dreams, and Immodium is my new best friend. I'd learned to live with it once again.

I quit smoking over seven months ago, I've been taking better care of myself, watching my diet, and back at the gym 3-4 days a week, back up to my ideal weight, and feel and look better than I have in a long time. So what's wrong with this picture?

Well, my labs from the doctor raised a few flags. My cholesterol, while not ideal, was "okay" at 213 (normal is under 200). It was my triglycerides that had gone through the roof, at 965. We always knew that this was a distinct possibility, if not highly probable, with my current combination. But it had been three years without a hitch, so I thought I was home-free.

Life with HIV is like being part of a professional sports team. You're the owner. Your doctor is your coach. The meds are your players. At the end of the season, you make high profile deals and trades. Sometimes you take a gamble on a new player, sometimes you stick with the tried and true, even when they're not performing at their best. Some coaches focus more on offense, others on defense. And sometimes you have to break up a winning team.

My players have decided they want to renegotiate their contract. If we want to see them back next year, we're going to have to pay.

So we brought in a mediator. Enter Lipitor. He doesn't have the stature and the star-power of Kaletra or Sustiva, in fact, he's just a little guy. He's not even in the same league. But guess what? It's working: my total cholesterol is down to 160, triglycerides are at 475, and liver functions are normal. I can't wait to see what next season brings.

I'd like to thank the players for this season's winning team in helping with the Drug Guide: Enid Vázquez, without whom this year's Drug Guide would have been nearly impossible; Russell McGonagle for making the magazine come to life on the page; Ross Slotten, M.D., for everything you do -- thanks, doc; Tony Hosey, Pharm.D. at StatScript for the skinny on the drugs; Heidi M. Nass for your insightful look at the flip side; Keith Green for putting together the index; Matt Sharp; Patrick G. Clay, Pharm.D.; Andrew Halbur, R.Ph., at Walgreens; and last but not least, Dr. Dan Berger for your invaluable contributions over the years.

Jeff Berry
Interim Editor

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