HIV Meds and Making the Best Choice for My Kidneys (Editor's Pick)

Question

Dear Dr. Young,

First of all, thank you for the excellent advice you provide, it is deeply appreciated by so many of us.

My question(s): I have been on a successful Kaletra/Truvada regimen for nearly 7 years. My VL is consistently 0, and my T-cells have improved, even over the past year, to now regularly over 600. I have minimal side effects that do not interfere with a full life. In my past three blood tests, however, I have had very slightly elevated kidney levels, not dangerous, but above normal. As a result, my (very trusted) doctor recommended that I switch to Triumeq, to get off Truvada. Almost everything I have read about Triumeq sounds very promising, and I would be willing to switch immediately except for one misgiving: the reports about abacavir possibly being associated with cardiological events. I have a concern about family history with heart problems: my father's father died of a heart attack at age 68, and my father had a heart attack at 62 (but after bypass surgery lived to the age of 86, with high quality of life). Also, I am a light smoker (average about 7 cigarettes a day).

My question is: given my family history, is there any need to be concerned about starting a regime that includes abacavir? Or are there already enough cardio-related concerns with Kaletra - which I have tolerated very well so far - that would mean switching to Triumeq would likely be no more dangerous than the drugs I am already taking?

Your advice would be greatly appreciated.

Answer

Hello and thanks for posting.

Sorry for the late response.

Kidney function monitoring is important for people living with HIV and is part of recommendations for routine care. Serum creatinine and urinalysis are the typical tests used for this purpose. Rising creatinine levels can indicate a decline in kidney function (usually as estimated glomerular filtration rate or eGRF). There are multiple causes of loss of kidney function, including aging, high blood pressure, diabetes, non-steroidal anti-inflammatory drugs (NSAIDs), and other medications.

The combination of ritonavir (Norvir, part of Kaletra) and tenofovir (part of Truvada) can be particularly troubling to kidneys, especially for those people who have other kidney risk factors. For this reason, it's understandable why your doctor is recommending a switch to an alternative regimen.

A switch to Triumeq is reasonable as long as your genetic tests (called HLA B5701, a determinate of risk of abacavir allergy) is negative and your virus is not resistant to any of the medications in Triumeq (abacavir, lamivudine and dolutegravir). While there is some disagreement about the risk of abacavir and heart disease, I'm in the camp that does not find this association compelling- or compelling enough to avoid the drug in most people. Our own CDC/HOPS analysis and similar analyses from the FDA have not found an association between heart disease and abacavir, so if there are risks, they are either low, or found only in selected populations of people. In patients without active heart disease (not just a family history), and if abacavir is an otherwise appropriate drug, I have no reservations. Remember that suppressing HIV alone has significant cardiac risk reduction.

You're also correct that the Kaletra that you take has also been associated with increased cardiovascular risk- in part due to the elevations in cholesterol and triglycerides that typically come with the medication.

All the while, it's perfectly reasonable to try to reduce your cardiovascular disease risks- this includes reducing (if not quitting) tobacco, having better exercise and dietary habits, perhaps (and ask your doctor if it's appropriate) taking low-dose aspirin (81 mg) as has been recommended for positives who are either over 40- or 50-years of age.

Hope that's helpful, BY