Are My Lipid Levels Worth Switching HIV Meds For? (Editor's Pick)

Question

Dear Dr. Young,

Thank you beforehand for answering all our questions. I have been on Truvada/Prezista/Norvir for 10 months now, after being diagnosed in Dec 2014 with a VL of 1,600,000 and a CD4 of 88. I have been undetectable for 3 months now, and my CD4 has increased to 480 (16%). I have developed moderate increases in my total cholesterol and triglycerides, and I have started to build up some gut I did not have before. I would like to switch to something more lipid-friendly (such as Triumeq) but my HIV doctor, with good judgment, prefers I stay on this regimen until I remain undetectable for another year ( "first well focus on efficacy, and then, we will deal with toxicity"). However, I have read that treatment-naive patients with very high viral loads such as mine do equal well on Triumeq as they do on a PI-based regimen, with fewer side effects. I would truly appreciate your input. Warm regards PS: My initial viral genotype study showed no resistances

Answer

Hello and thanks for posting.

You're discussing two of the five US Department of Health and Human Services Panel recommended first line treatments. Truvada and boosted Prezista is the lone PI-based regimen, and dolutegravir containing treatments like Triumeq are two of four recommended integrase-based regimens. Because of this, I'd first feel that if things are working there's no urgency to change things up, if at all.

Having said that, it's very clear that the world is shifting to integrase-based treatments, indeed, even the very conservative World Health Organization will add dolutegravir to their very short list of recommended first-line regimens later this year.

The results of the
FLAMINGO clinical trial showed that regimens like Triumeq were actually statistically superior to regimens with even the best boosted PI (Prezista) for patients starting treatment. Contrary to the old belief that boosted PIs are better in people with high pretreatment viral loads, Triumeq did numerically better in people with high viral loads, with 82 vs 52% of those with baseline viral loads >100,000 achieving viral suppression. Tolerability favored Triumeq too. Regarding lipids, integrase beat the PI, with a roughly 20 point improvement in total cholesterol, and 30 point difference in triglycerides.

But switching should be done thoughtfully, with knowledge of resistance (not an issue for you), side effects (tend to favor Triumeq), ease of adherence (also in favor) and life style considerations (Triumeq has no food requirement). I'd discuss these issues in an open and evidence-based way.

Hope that helps, and be well, BY