The 3rd International Workshop on Salvage Therapy for HIV Infection was held in Chicago in April. It's when you hit that third group of drugs that you're considered to be on "salvage" therapy. (The second combination of meds is being called the "second-line regimen.") Following are highlights from the conference.
Let's start with side effects -- the reason many regimens fail in the first place. A tiny study of four people taking 1,500 mg twice a day of L-acetyl carnitine (or LAC, not to be confused with regular carnitine supplements) found it improved their peripheral neuropathy. Patients reported relief in symptoms of numbness, tingling and pain in the hands and feet caused by this common HIV condition. (The symptoms don't sound like much, but neuropathy tends to be extremely painful and permanently disabling.) The self-reported improvements were confirmed by laboratory testing. One person was even able to stop taking narcotic painkillers after several months on LAC (the average time it took for people to see improvements). The only side effect noted was mild diarrhea. Dr. Michael Youle and colleagues from the Royal Free Center for HIV Medicine in London conducted this trial to follow up on another small study finding neuropathy improvement with LAC. There are now about 60 people in the clinic taking the drug.
Two reports confirmed earlier findings that the more HIV patients doctors have, the more experience those doctors have, and the better their patients do. HIV is a complicated disease that's best not left to amateurs.
The odious little drug (okay, lots of people take it without trouble, but it's infamous for nausea, diarrhea and regurgitation) looks pretty good in small amounts for boosting the levels of other protease inhibitors. The conference organizing panel ended up deciding they want to see more data before determining Norvir's usefulness for this job. Naturally, since doctors like to be careful. Because low-dose Norvir is getting so popular, even observational databases would be helpful, they said.
What they saw here was that 800 mg of Crixivan boosted by 200 mg of Norvir -- both given twice a day -- resulted in half the people on this salvage regimen measuring undetectable (using 400 copies viral load) at 12 weeks. The 41 men had previously taken an average of three protease inhibitors and on average had gone through six regimens. Their median starting baseline viral load was 30,015 and median T-cells was 258. The results are from a retrospective chart review and not as scientifically strong as would be found in a controlled clinical trial. Also, the number of participants is small and the results short-term (48 weeks is ideal). There were two drop-outs, one due to hair loss (Crixivan, undoubtedly) and one to nausea/vomiting (Mr. Odious, himself, undoubtedly). Good news is there are no food restrictions as there generally are with Crixivan alone, but you still need to drink lots and lots of water to avoid painful kidney stones.
Norvir also helps people manage to take Agenerase protease inhibitor with Sustiva, a non-nuke. Otherwise, the two drugs shouldn't be taken together because Agenerase levels are greatly lowered. Jean-Louis Vilde and colleagues, from Paris, prescribed Agenerase at 450 mg and Norvir at 100 mg, both twice daily, with Sustiva at its standard dose of 600 mg once a day (three capsules). The standard dosing of Agenerase horse pills (they may be soft-gelatin capsules, but that doesn't help much) is 1,200 mg twice daily. Viral load results were good in the seven people taking the five-drug regimen (including two nucleoside analogs, such as AZT).
Therapeutic drug monitoring (TDM) is expected to become the next big test for HIV. It measures your blood levels of different drugs. However, there are lots of complications that need to be figured out. It is also still experimental for HIV (but used in other diseases).
According to HIVandHepatitis.com, Dr. Richard Hoetelmans from Slotervaart Hospital in Amsterdam made the following points during an oral presentation on TDM: there is good predictability between protease inhibitor blood levels and undetectable viral load for salvage patients, but not for people taking meds for the first time (however, he expects that to change so that you can predict success in this latter group, as well); it's the opposite for the non-nukes -- you can predict success for the so-called "treatment naive" group (the first-timers), but not for the non-nuke experienced; and there is no association at all for the nukes (the AZT class of drugs).