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Medicine Chest: Combination Dosing Adjustments

By Glen Pietrandoni, R.Ph.

January/February 2003

The International AIDS Society-USA and the U.S. Department of Health and Human Services are continuously updating guidelines to help physicians and patients choose the best ways to use drugs in combinations for treating HIV/AIDS. You have probably seen the "one from column A and two from column B" charts that have been around for years. These tables have been a wonderful tool to determine treatment options for those newly diagnosed and treatment naive. This is the basis of most treatment decisions for a patient's first few drug regimens. How do physicians use the list of drugs to choose a drug regimen for patients with limited drug options? Sometimes drugs can be arranged together in ways to get more potent regimens, to cut down on pill count, or simply because there are no other choices at the time.

In the United States, it is the standard of care today to use phenotype and genotype testing to see which drugs are effective in halting viral replication in a particular patient. After a few drugs or drug classes are eliminated due to resistance (drug doesn't work any longer), it may be more difficult to find a drug regimen that fits neatly on the DHHS guideline chart. Because HIV medicine is as much an "art" as it is a science, your provider may need to combine drugs together that normally would not be used in the same cocktail. When certain drugs are combined, adverse reactions can occur, but drug interactions are not always bad things. Again, sometimes agents can be combined to our benefit. The best example of this is when Norvir (ritonavir) is combined with other protease inhibitors. The drug level of these protease inhibitors are higher and last longer when taken with Norvir than using the drug without Norvir. The benefits often include better viral control and lower pill burden. The downside of throwing all these drugs together can mean an increase in side effects if the blood levels go too high. Always communicate with your health care team to let them know what's going on. Remember, while most side effects can be managed and are temporary, more serious complications may require a change in therapy. There still needs to be that target of 95% adherence to achieve maximal viral suppression and get those T-cells up!

The combination drug chart shows some optional ways to combine drugs with each other. Some combinations have more data to support their use, while other combinations are only now being studied for the first time. Some of these regimens are not yet FDA approved, but many physicians treating HIV/AIDS have experience in using regimens "off label" with some success. As always, learn about your treatment options and discuss the benefits and disadvantages of a new regimen before you start taking the medication.

Glen Pietrandoni is director of Clinical Pharmacy Services for the Walgreens Specialty Pharmacy, focusing on HIV, located in the Howard Brown Health Center of Chicago. Contact: Glen.Pietrandoni@walgreens.com.

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Key

RTV =

Norvir (ritonavir)

DLV =Rescriptor (delavirdine)

LPVr =

Kaletra (lopinavir/ritonavir)

DDI =Videx (didanosine, ddI)

NFV =

Viracept (nelfinavir)

EFV =Sustiva (efavirenz)

IDV =

Crixivan (indinavir)

QD =once daily

SQV =

Fortovase, Invirase (saquinavir)

BID =twice daily

APV =

Agenerase (amprenavir)

TID =three times daily

NVP =

Viramune (nevirapine)

Q8H =every 8 hours


Combination Drug Chart

Compiled by Glen Pietrandoni, R.Ph.

Norvir (ritonavir) RTV with:Tips:

Agenerase (amprenavir)

600 mg APV BID + 100 mg RTV BID
1,200 mg APV QD + 200 mg RTV QD

 
Crixivan (indinavir)

400 mg IDV BID + 400 mg RTV BID
800 mg IDV BID + 100 mg RTV BID
800 mg IDV BID + 200 mg RTV BID

Take with food
Take with food
Take with food
Fortovase (saquinavir sgc)
400 mg SQV BID + 400 mg RTV BID
800 mg SQV BID + 200 mg RTV BID
 
1,000 mg SQV BID + 100 mg RTV BID
1,600 mg SQV QD+ 100 mg RTV QD
Can use Invirase
Can use Invirase
800 mg SQV BID + 100 mg RTV BID + 600 mg EFV QD 
Viracept (nelfinavir)
750 mg NFV BID + 400 mg RTV BID 
Sustiva (efavirenz)
600 mg EFV QD + 500 mg RTV BID
600 mg EFV QD + 800 mg SQV BID + 100 mg RTV BID
600 mg EFV QD + 1,200 mg APV BID + 200 mg RTV BID
 
Viramune (nevirapine)
200 mg NVP BID + 600 mg RTV BID 
Rescriptor (delavirdine)
600 mg DLV BID + 600 mg RTV BIDMay reduce RTV to 400 mg or 500 mg BID if side effects
Kaletra (lopinavir, ritonavir) LPVr with:Tips:
Agenerase (amprenavir)
750 mg APV BID + 533 mg/133 mg LPVr BIDNew data suggests using this combination with caution because of decreased lopinavir levels
Crixivan (indinavir)
600 mg IDV BID + 400 mg/100 mg LPVr BIDTake with food
Fortovase (saquinavir sgc)
800 mg SQV BID + 400 mg/100mg LPVr BID 
Viracept (nelfinavir)
750 mg NFV BID + 400 mg/100 mg LPVr BID 
Sustiva (efavirenz)
600 mg EFV QD + 533 mg/133 mg LPVr BID 
Viramune (nevirapine)

200 mg NVP BID + 533 mg/133 mg LPVr BID

 
Viracept (nelfinavir) NFV with:
Agenerase (amprenavir)
1,200 mg APV BID + 1250 mg NFV BID 
Crixivan (indinavir)
1,200 mg IDV BID + 1250 mg NFV BID 
Fortovase (saquinavir sgc)
1,200 mg SQV BID + 1250 mg NFV BID
800 mg SQV TID + 750 mg NFV TID
 
Sustiva (efavirenz)
600 mg EFV QD + 1250 mg NFV BID 
Viramune (nevirapine) 
200 mg NVP BID + 1250 mg NFV BID 
Crixivan (indinavir) IDV with:Tips:
Agenerase (amprenavir)
750 mg APV TID + 800 mg IDV TID 
Kaletra (lopinavir/ritonavir)
400 mg/100 mg LPVr BID + 600 mg IDV BIDTake with food
Norvir (ritonavir)
400 mg RTV BID + 400 mg IDV BID
100 mg RTV BID + 800 mg IDV BID
200 mg RTV BID + 800 mg IDV BID
Take with food
Take with food
Take with food
Sustiva (efavirenz)
600 mg EFV QD + 1,000 mg IDV Q8HEmpty stomach
Viramune (nevirapine)
200 mg NVP BID + 1,000 mg IDV Q8HEmpty stomach
Rescriptor (delavirdine)
400 mg DLV TID + 600 mg IDV Q8HEmpty stomach
Fortovase (saquinavir soft gel capsule) SQV with:
Agenerase (amprenavir)
750 mg APV TID + 800 mg SQV TID 
Rescriptor (delavirdine)
600 mg DLV BID + 1,600 mg SQV BID
400 mg DLV TID + 1,200 mg SQV TID
 
Agenerase (amprenavir) APV with:
Sustiva (efavirenz)
600 mg EFV QD + 1,200 mg APV TID
600 mg EFV QD + 1,200 mg APV BID + 200 mg RTV BID
 
Norvir (ritonavir)
600 mg APV BID + 100 mg RTV BID
1,200 mg APV QD + 200 mg RTV QD
 
Viread (tenofovir) with:
Videx-EC (didanosine, ddI)
300 mg Viread QD + 250 mg ddI QD 


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This article was provided by Positively Aware. It is a part of the publication Positively Aware. Visit Positively Aware's website to find out more about the publication.
 

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