First time therapy : Truvada, Isentress & Intelence ... Normal combination ??

[nomatterhow]

Hi, I am a 30 yo gay male from Paris and was diagnosed with HIV just 4 weeks ago , my CD4 rate is very low ( between 150 and 210 ) and my doctor wants me immediately yo start a therapy ... I am resistant to many many medications, so this is the combination he came up with : truvada, Isentress and Intelence ... It's like 7 pills per day, while truvada and Isentress according to this site and DHHS are highly recommended for first time therapy, Intelence according to the same sources is not... This has made me really worried over the last few days , I am spending my timer online googling and wonder whom I should trust ... My doctor is a good one I am sure but I am just worried , what you guys know/experience about this combination ? You find it normal for a starter ? Thanks a lot !!!!

Ps : I see that Intelence is not recommended for people allergic to lactose but my doc didn't even ask if I am allergic to that ... Is it a bad sign ?? Apparently my situation is kinda urgent so she wants me to get a normal CD4 again but at any price ??

[Assurbanipal]

Its somewhat unusual for people to be diagnosed with multidrug resistance -- a big majority of newly diagnosed people don't have that issue.

So if you compare yourself to most newly diagnosed people, they will have the full range of drugs to choose from and won't be starting with the drugs you are on.

But that doesn't mean you should panic -- there's lots of good drugs out there for most all newly diagnosed people these days -- its just that you won't necessarily be on a typical starter combination.

There are some highly knowledgeable people about resistance on here (I'm not one of them).  Perhaps if you post the details of your resistance test they can chime in.

[Miss Philicia]

Basically you're being given a first line HAART regimen (Isentress + Truvada, technically three drugs in two pills) plus one extra anti-viral (Intelence) the extra one being to safeguard your resistance profile. Similarly, I have resistance issues and am on a similar regimen except instead of Intelence I have Prezista (aka Darunavir).

Your doctor seems on top of things. Perhaps at some point down the road he'll take out the extra Intelence and just have you on the other stuff, but even that's iffy so don't count on it. You're just going to have to suck up the larger than usual amount of pills for now. Down the road there are more regimens coming out that combine 3 drugs in one pill so it's not set in stone that you will always have to take 7 pills/day. There are always advances in treatment if you think in terms of blocks of about 5 years.

[nomatterhow]

Hey thanks! I just joined this forum 15 mins ago  how can I find those resistance expert people here My doc told me in the last 10 years she has seen 2 people with my resistance which is evidence I got it from someone who has not been respecting his adherence


My resistance : I am resistant or possibly resistant  to ALL PI's

Among NNRTI I am not resistant only to Intelence

[Miss Philicia]

which is evidence I got it from someone who has not been respecting his adherence

No necessarily. I didn't get resistance issues from bad adherence. Many HIV patients that were on meds before around 1996 developed resistance issues because before that year only a few drugs were available and not from multiple classes as is found in today's standard drug regiemens.

So you could have been infected by someone like that, or from someone with adherence issues. Or also from someone else that got it as described above but has not yet even been diagnosed.

My resistance : I am resistant or possibly resistant  to ALL PI's

Most patients that show resistance to the entire PI class of meds can take Prezista -- it was formulated just for that purpose even though it's still a PI. You might want to ask your doctor about this possibility.

[newt]

If resistance test indicate, this is a fine combo

- matt

[nomatterhow]

On this link from this very site it's indicated Intelence should not be prescribed for first time therapy beginners !!!


http://www.aidsmeds.com/archive/intelence_1618.shtml

[Ann]

Hi nomatterhow, welcome to the forums.

Newt is one of our most well-versed when it comes to workable combos. He's in the UK and is most likely sleeping by now - but I'll shoot him a PM for you to draw his attention to your thread. He usually does see these types of threads in this subforum, but I'll give him a nudge all the same.

From what I know of salvage therapy, the combo is a good one for your needs. However, if you have any labwork to hand that lists the exact mutations you have or that spells out your resistance profile, post it here and that will give newt more information so he can in turn give you a more informed response.

It does sound as though you're in good hands, so hang in there. Things do get better in time.

Ann

You posted this while I was typing... (and so did newt, but he does not have your resistance details. If you gave him more to go on, he could give you a more comprehensive answer)

On this link from this very site it's indicated Intelence should not be prescribed for first time therapy beginners !!!


http://www.aidsmeds.com/archive/intelence_1618.shtml

When a person is diagnosed with resistance issues from point of diagnosis, it's a little different. While you yourself are treatment naive, the strain of the virus is treatment experienced - otherwise, it would not have resistance issues. Therefore, you will not be treated as treatment naive when they are figuring out your first combo. Hope that makes sense.

[nomatterhow]

Thank Ann, thanks newt!!

Here my resistance

PI'S :  Atazanavir (ATV).                                  Resistant
          ATV/r **.                                              Resistant
          Darunavir+Ritonavir  ( DRV/r).               Possibly Resistant
          Fosamprenavir (FPV).                            Resistant
          FPV/r **                                               Resistant
          Indinavir (IDV)                                      Resistant
          IDV/r **.                                              Resistant
          Lopinavir + Ritonavir (LPV/r).                 Possibly Resistant
          Nelfinavir(NFV).                                     Resistant
          Sequinavir + Ritonavir.                          Resistant
          Tipranavir + Ritonavir.                           NO evidence of resistance


NNRTI's :

          Efavirenz                                               Reisitant
          Nevirapin                                               Resistant
          Etravirin.                                               NO evidence of resistance

NRTI's.  :

          Abacavir (ABC).                                     NO evidence of resistance
          Didanosin ( ddi).                                    NO evidence of resistance
          Lamivudin (3TC)/Emtricitabin (FTC).        NO evidence of resistance
          Stavudin (d4T).                                      NO evidence of resistance
          Tenofovir (TDF).                                     NO evidence of resistance
           Zidovudin (AZT).                                   NO evidence of resistance




 Voila !! * ouch my fingers!!! ;-) *

[newt]

Hello again

There are no interactions between raltegravir (Isentress) and etravirine (Intelence) so these drugs may be used together.

You have extensive resistance to "standard" 1st line PIs (atazanavir, darunavir et al) and NNRTIs (efavirenz, nevirapine) which leaves from the guidelines menu Isentress + 2 nukes ie Truvada (tenofovir + emtricitabine in one pill).

I am sure your doc is adding the Intelence to be safe. Perhaps in due course you can drop this, cos Isentress + Truvada is a guideline compliant 3 drugs from 2 or more drug classes 1st line combo and these alone may well keep your viral load "undetectable", which is the goal of therapy. Think about dropping the Intelence in 6 months to 1 year if you like (in discussion with your doc, obviously).

Guideline recommendations do not apply to people with pre-existing resistance, the choice of meds need to be determined by a resistance test (as your doc seems to be doing).

All the drugs in your combo are modern and effective, whatever guidelines say about preferred/alternative etc (indeed, alternative in guidelines doesn't mean it don't work, rather means it does work but is best reserved for special situations eg yours).

Hope this helps

- matt

edited for spelling

[nomatterhow]

Thanks newt! This has been very helpful ...  Just a few questions before I start them in few days , I have to confess I am going paranoid.

Well my question is why Intelence ? Why can't I just be on truvada and Isentress which seems like a good combo ?? 

Do you have an idea of side effects of these 3 taken altogether?

Do you think my doctor should have asked me if I was allergic to lactose before prescribing me the Intelence ? I am not but I find it strange that she has not this med is not for lactose allergic people according to this very site

Thanks again !!

[newt]

The amount of lactose in Intelence is unlikely to be sufficient to cause an allergic reaction. If it does, well, you will have to try it to find out.

Why the extra drug? Prob for this reason: Isentress has a low barrier to resistance, and, even if you are 100% compliant with meds, if this combo goes wrong you have few options. Therefore an extra drug to start is a safety measure.

I do agree Isentress + Truvada might (perhaps should) be enough. Trouble is, doing this and it going wrong will leave you with lots of Norvir in your combo and also a combo that might not quite work, and there's no going back.

So, on starting, safety or less drugs? Up to you (soz, not a nice choice to make).

- matt

[eric48]

It's like 7 pills per day...

welcome to this forum

The number of pills sounds impressive but in fact once you have them in your hands, you swallow your dose and that is it...

I did not check your drugs in details but I guess it is 2 x per day.

Get yourself organized... Once packed in a pill box the number of pills is not an issue.

My combo is 3 pills (but luckily, once a day), and when you include a bit of supplements or vitamin you easily get to that 7 number...

I have tried various types of pill boxes (they hardly cost more than $5) so you can buy several and see the one that fit your needs best.

the one I like best is from here:
http://www.muji.com/storelocator/

http://www.muji.eu/pages/online.asp?V=1&Sec=18&Sub=74&PID=4958

each case can be separated from the 1 week line and they look less 'pharmaceutical' than others.

Once you this regimen is stabilized, you may want to manage to get some stock ahead.

Get as many pill boxes as you thing reasonable, transfer your many pills into these fashionable container and you will not feel like a walking pharmacy.

While every drug may come with some (rare) side effects the drugs in your combo seems to be among the easiest ones to initiate treatment with...

Hope this helps

Eric

[eric48]

On this link from this very site it's indicated Intelence should not be prescribed for first time therapy beginners !!!

Intelence, like any new drug (more expensive, less clinical data, etc...), is first tested on people that need it most (resistance issues), then as experience builds up they may move up to first line

Intellence is a very modern alternative to EFV or NVP and newer drugs in the same class are in the pipe.
Sometime down the road, you may be one a once a day regimen.

The resistance test can not detect sub populations that are below 10-20%. Since your initial test show a fairly good amount of resistances, it can not be ruled out that there are some underlying, archived resistance that may show up once you initiate treatment. Using the brute force of quadritherapy, as your doctor suggests, may be the safest way to go

Some doctors will do a second resistance test, shortly after the treatment initiated, when VL is still high enough to perform a resistance test (VL must be above 500 to perform a resistance test) and not yet low enough to be under the radar. You may want to discuss this as this would be an interesting set of data to have at hand in case you have second thoughts about quadritherapy and would like to simplify to tritherapy.

My doc conce commented that he merely made a proposal and I could have opted out.

The ultimate choice remains in the patient's hands.

As Matt said, this is your call.

Given the petty complicated initial resistance profile, I would go for the safest and disregard this number of pills issue

Hope this helps

Eric 

[james3000]

I have been on this Combo for 6 months 3tc, isentress ,intelence ,norvir, Prezista.

Have to take twice a day but just open mouth and swallow with breakfast and dinner.

Working well so far.

[wolfter]

I am on the Truvada, Isentress and Intelence combo.  My lay understanding is that with my extreme resistance issues, I need components of each of the drugs.  I've been on pretty much every combo since the AZT days.  From taking a hand full of pills every 4 hours, requiring setting an alarm for the middle of the night, to taking pills that required they be chilled.  Nothing like going out and having to take a cooler along.  Took combos that I debated with myself if the side affects were worth living for.

Now, 20+ years later, this combo finally affords me a productive life.  It's 7 pills a day, 4 in the morning and 3 at night.  You will receive varying opinions when to take the Truvada and if they should be taken with food...etc....   Experiment a little and see which method works best for you.  I take the Truvada in the morning along with the other 2 without food....just coffee.  Now that I'm undetectable, I'll skip my evening dose all together if I want to have an evening out without the possibility of experiencing side effects.  My doctor is ok with doing this occassionally as long as I never go over the 24 hour rule without taking them.

Hope this eases your mind a little
Wolfie