Issentress v atripla

[tommy246]

Most people on here recently on meds seem to be on atripla and it seems to be doing a good job .Are there many out there on issentress and in your opinion is it better.

[Inchlingblue]

Isentress (raltegravir) is one drug, an integrase inhibitor. Atripla is three drugs in one pill: Sustiva plus two other drugs which are also sold separately as Truvada.

The direct comparison to make is:

Isentress + Truvada   v. Atripla (Sustiva + Truvada)

In studies up to 96 weeks, Isentress/Truvada compared very favorably against Atripla. There are pros and cons to both. Right now Isentress must be taken twice a day (in future it might be available as once daily). Some  people prefer Atripla b/c it is once a day. The Sustiva in Atripla has been known to cause vivid dreams  in some people and other CNS (central nervous system) side effects, Isentress does not seem to cause any of this.

I just started Isentress/Truvada on July 18th and I find it to be very easy as far as side effects, I am not experiencing any so far.

Here are links to studies comparing Isentress/Truvada to Atripla:

http://www.aidsmap.com/en/news/82A67A30-B689-46D7-9BAB-2DE43B46AA8C.asp

http://www.hivandhepatitis.com/2009icr/ias/docs/072109_c.html

[GNYC09]

What are some of the cons of taking Isentress (raltegravir) vs. Atripla?  Maybe the fact it needs to be taken twice a day (vs once for Atripla) and it doesn't have a long history of usage?  I'm not very familiar with Isentress and, based on the Aidsmap article, I see a number of pluses including: dizziness 8.8% Insentress vs 28.9% Atripla and nightmares 0% Insentress vs 10.5% Atripla.

[Miss Philicia]

People have been on Isentress for 3 years (if you include phase 3 trials) -- how much longer do you want?  I think it's a no brainer that the side effects potential versus Atripla are rather apparent.

[Inchlingblue]

What are some of the cons of taking Isentress (raltegravir) vs. Atripla?  Maybe the fact it needs to be taken twice a day (vs once for Atripla) and it doesn't have a long history of usage?  

Exactly, lol. Those are the two cons to Isentress that I know of.  Also, I have read that there are a number of people on Isentress that experience elevated CPK levels. Overall it seems to be a great drug, hope it stays that way!

Miss P: yeah, I guess 3 years is enough but maybe not? I mean, who knows? How long did it take before people realized the body changes and other bad things were occurring on some of the earlier drugs such as zerit, crixivan, ddI, etc? I'm not saying this will happen with Isentress, believe me I would not be on it if I did, but curious about how long it took with these other drugs for people to realize their toxicity.

 

[AboutToStart]

3rd advantage: Atripla has better brain penetration than Isentress. Does it make it a better med??

Isentress has just now been approved for first time paitients in USA and pending in Europe... "Approved" doesn't mean Recommended though. The lack of sufficient data (as per the head of my medical institution) didn't change overnight just coz it got approved. Looks appealing and effective as the atripla, but for the longer run - it's up to you if you like to gamble or play safe... Just a thought..

[Inchlingblue]

3rd advantage: Atripla has better brain penetration than Isentress. Does it make it a better med??

What do you mean by "3rd advantage"? What are the other two? The arguments made above were that they each have their pros and cons. The only real advantage of Sustiva as far as I'm concerned, and I have done alot of research on the subject, is the once a day dosing.

Isentress has a low barrier to resistance which is not good but it is very potent so as long as a person is adherent and is taking the right combo in terms of their resistance profile, that should not be a problem.

As far as brain penetration there have been several studies, including one recently that have shown no link between brain penetration of HIV meds and neurocognitive impairment.

Unexpected Finding: Penetration of ARVs Into Nervous System Doesn’t Protect the Brain

LINK:

http://www.poz.com/articles/hiv_brain_cns_761_16868.shtml

[tommy246]

What does elevated cpk levels mean ? .My specialist told me (over 20 years experience ) meds are becoming less toxic and constantly improving especially on the lipo fat side effects. This issentress truvada med sounds better to me if given the choice i would go for that one.

[Miss Philicia]

Miss P: yeah, I guess 3 years is enough but maybe not? I mean, who knows? How long did it take before people realized the body changes and other bad things were occurring on some of the earlier drugs such as zerit, crixivan, ddI, etc? I'm not saying the this will happen with Isentress, believe me I would not be on it if I did, but curious about how long it took with these other drugs for people to realize their toxicity.

 

With the advantage of hindsight and current knowledge of what lipoatrophy is (which obviously we didn't have at the time) I can now see that Zerit's side effects, which was FDA approved mid-1994 began showing up in my body roughly within 2 years and perhaps less.  It began on the bottom of my feet, and then very gradually over several years became apparent elsewhere.

We should keep in mind that new drugs like Isentress are evaluated during clinical trials for things like lipid and carbohydrate metabolism and mitochondrial function which is why they're fairly confident that it has a low propensity to cause lipodystrophy.

[David_CA]

One benefit to Atripla is financial.  Combo meds just cost less.  This may not be important to an individual depending on the source of funding one uses for meds.  I know that, with my insurance, I eliminate a copay or two by using a combo drug.  If I took Truvada and Reyataz/Norvir, I'd have spend $105 per month in copays; with Atripla, I spend $35.  I'm curious as to the 'real' cost of these new meds.  If a combo drug will work with minimal side effects, wouldn't it be better for ADAP / other assistance to push for a combo as first-line treatment?  Less money spent for any one person's drugs means more assistance to go around.  (I'm not suggesting that treatment should be governed by finance, but isn't everything else in ones life - food, housing, vehicles, etc?)

[Inchlingblue]

What does elevated cpk levels mean ? .My specialist told me (over 20 years experience ) meds are becoming less toxic and constantly improving especially on the lipo fat side effects. This issentress truvada med sounds better to me if given the choice i would go for that one.

Overall, I agree with your doctor's assessment. CPK enzymes are released when there is muscle damage; sometimes just working out can increase CPK levels. The 96-week study comparing Isentress with Sustiva (both with Truvada) found that 10 out of 160 people on the Isentress arm experienced elevated CPK. Most, or all of the other markers were better with Isentress than with Sustiva.

There were ten reports of grade four elevations in creatine phosphokinase (CPK) in patients on raltegravir. Otherwise, serious laboratory abnormalities remained infrequent in both arms. Raltegravir had significantly less effect on total cholesterol (TC), LDL cholesterol (LDL-C), and triglycerides. In raltegravir and efavirenz respectively, the mean change in TC levels were +1.1 vs +24.0 mg/dl (p=.002), in LDL-C levels -5.8 vs +4.4 mg/dl (p=.045), and in triglycerides -10.8 vs +13.4 mg/dl (p=0.145). Raltegravir also resulted in smaller increases in the beneficial HDL cholesterol (+7.4 vs +13.0 mg/dl, p=.017). . . Raltegravir was generally well tolerated; drug related AEs appeared less frequent in patients treated with raltegravir compared to efavirenz."

LINK:

http://www.aidsmap.com/en/news/82A67A30-B689-46D7-9BAB-2DE43B46AA8C.asp

Miss P: Thanks for sharing your experience, it's good to know.

[mjmel]

What are some of the cons of taking Isentress (raltegravir) vs. Atripla?  Maybe the fact it needs to be taken twice a day (vs once for Atripla) and it doesn't have a long history of usage?  I'm not very familiar with Isentress and, based on the Aidsmap article, I see a number of pluses including: dizziness 8.8% Insentress vs 28.9% Atripla and nightmares 0% Insentress vs 10.5% Atripla.

Consider, some people have little to no side effects from Atripla dosing. I've been taking Atripla for a week now and nothing noticeable yet. No dizziness. No intense dreaming. No grogginess upon awakening from a nights sleep. I just love the ease of swallowing one pill each night compared to previous dosing of 4 twice daily.

Mike

[David_CA]

Consider, some people have little to no side effects from Atripla dosing. I've been taking Atripla for a week now and nothing noticeable yet. No dizziness. No intense dreaming. No grogginess upon awakening from a nights sleep. I just love the ease of swallowing one pill each night compared to previous dosing of 4 twice daily.

Mike

Same here regarding effects from Atripla, though I did have a few funky dreams initially.  I take mine in the morning and go about my business as I always have. 

[Inchlingblue]

July 21, 2009

Isentress Going Strong After Three Years in Treatment Starters

by Tim Horn

Long-term data from a Phase II clinical trial show that Merck’s integrase inhibitor Isentress (raltegravir) works just as well as mainstay therapy efavirenz (found in Sustiva and Atripla) in HIV-positive individuals starting treatment for the first time. These encouraging results were reported Monday, July 20, by Eduardo Gotuzzo, MD, of the Hospital Nacional Cayetano Heredia in Lima, Peru, and his colleagues at the Fifth International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention in Cape Town.


Continued...

LINK:

http://www.poz.com/articles/hiv_isentress_raltegravir_761_16948.shtml

[AboutToStart]

Consider, some people have little to no side effects from Atripla dosing. I've been taking Atripla for a week now and nothing noticeable yet. No dizziness. No intense dreaming. No grogginess upon awakening from a nights sleep. I just love the ease of swallowing one pill each night compared to previous dosing of 4 twice daily.

After completing a third week on atripla I think it's safe to say I'm "out of the woods" as far as side effects.. The only "con" I can think about taking that one-a-day pill is the need to take it on empty stomach. That takes daily planning on my meals' schedule so that I can have that 3-hour window of no food b4 popping that pinkish pill.. a bit of a husstle sometimes..  

[Jeff64]

Most people on here recently on meds seem to be on atripla and it seems to be doing a good job .Are there many out there on issentress and in your opinion is it better.

The dreams on atripla are awesome...better than any movie.

[positivmat]

For me I liked the concept that atripla broke the brain barrier. But lately I am wondering if that is a benefit if the nervous system is already protected from HIV. However, I take some comfort in hoping that the atripla will protect from cognitive disorders later. But not really sure if it is doing that.

I love the once a day and the lower copay. I don't think people get "nightmares" rather they get really vivid dreams.

My side effects were really strong dizziness, then a high feeling which lasted for a few weeks, insomnia for the first 8 weeks. And I really believe that it exacerbated my feelings of depression from my diagnosis. I say this because when the insomnia went away so did my (severe) depression. (I still had some bad days fom time to time.

I think if I had thought that the benefit of atripla breaking the brain barrier was minimal then I might have been more apt to go with isentress.

Btw, eating right before taking the atripla is a non-issue as are all the other side effects since the ninth week.

Matt

[Miss Philicia]

Consider, some people have little to no side effects from Atripla dosing. I've been taking Atripla for a week now and nothing noticeable yet. No dizziness. No intense dreaming. No grogginess upon awakening from a nights sleep. I just love the ease of swallowing one pill each night compared to previous dosing of 4 twice daily.

Don't count your chickens too soon -- the severe depression can often set in 6 months down the road.  But you're right, the majority are fine with it.

[Ann]

I don't think people get "nightmares" rather they get really vivid dreams.

Some people get nightmares alright. My bf used to wake the whole house with his screaming. Another friend of mine regularly has dreams of being chased by a man with a knife or of her family dying in gruesome ways.

I'm glad to hear you're doing well with it though. Count your blessings.

Ann

[positivmat]

I hope that they are new to atripla. If not, then I think it is time to switch meds if they can. my sense of what atripla did to me was that it took a few slight tendencies and amplified them to an unbearable level for my side effect period. During the first 8 weeks, my depression was not my normal self deprecating humorous light shameful tendency but an unrelenting loudspeaker in my head that constantly said "I was bad for being a sex addict who fucked up my life with HIV Yadda yadda yadda....". When I started being able to sleep through the night, I realized that those thoughts didn't survive long any more. I then decided that it was chemical.


If your friends still have the nightmares and refuse to switch meds, you might suggest they try to "direct" their dreams.  Before going to sleep, by telling themselves to either wake up or change the nightmare, they can practice "lucid" dreaming and gain some degree of control over their dreams. I have had success with that kind of lucid dreaming before atripla. Since taking atripla, I have used it for my regular dreaming. I have heard many say that the atripla dreams are very susceptible to that type of control. Which might be one for atripla vs isentress if you want that.

All this is to say that atripla is a very powerful drug for the brain. People with any depression, drinking, substance abuse or dream issues should consider alternative meds very carefully I think.

However, I am happy that it keeps me alive and healthy.

Matt

[Miss Philicia]

I fail to understand why it's not mandatory that everyone going on Atripla be screened for depression by a professional.  I find this incredibly short-sighted and border negligent.

[Ann]

Matt,

My bf underwent therapeutic drug monitoring (TDM) a few years ago and it was discovered that he had far too much Sustiva in his system. They first dropped his dose to 400mgs (standard is 600mgs) but the levels were still too high. They then dropped him to 200mgs and that's where he's remained, and has also remained undetectable. He's also on Truvada, started out with Combivir. He still has some problems with sleep, although not as bad, and he also has problems with mood-swings, which are likely to be a result of the Sustiva.

I've talked to him until I'm blue in the face about switching, but he says, "if it ain't broke, don't fix it. I'm undetectable." I can't get him to see that if he's still having problems, it IS broke. I've sung the praises of Isentress to him, and the twice daily dosing wouldn't make any difference as he takes his Truvada in the AM and the Sustiva in the PM. He can't take the Sustiva in the AM because he still, after eight years on it, feels woozy after he takes it and he's afraid to drive (and driving is part of his job) on it. I've given up talking to him about it to be honest. He has to live in his skin, not me. ~sigh~

My other friend has repeatedly complained to her doc about Sustiva, but he comes out with pretty much the same line as my bf. She doesn't have this problem as much as she used to, it mainly happens when she's stressed out about something. She's tried the directional dreaming thing, but when she's stressed, she finds it difficult to accomplish. She's been stressed a lot lately and is planning on bringing this subject up again at her next appointment, and being more forceful about it. Wish her luck for me, I hate seeing her go through this.

I fail to understand why it's not mandatory that everyone going on Atripla be screened for depression by a professional.  I find this incredibly short-sighted and border negligent.

I couldn't agree more - and I also think it's borderline negligence, and very nearly criminally so. I know I will absolutely point-blank refuse to take Sustiva, because of my history of having psych side-effects with other drugs. There's no way in hell I'd chance that happening again if I can help it.

Ann

[positivmat]

Ann, I will send out good energy to your bf and your gf. And to you Ann. I know how frustrating it is to watch someone struggle with chemical imbalance no matter what it is from. I think part of the imbalance itself makes one more determined to "tough" out the bad times. I know that I got my back up about being on atripla. No one was going to take me off of it, no matter what it did to me. I was already in a place of fear and I was holding on to meds as the thing that was going to make everything alright.

I have seen my mom go through the same thing over a 20 year mission to get her clinical depression in a balanced state. She would only agree to change meds from a "balanced" state (which was usually in a psych ward).  These are extreme examples but it is definitely worthy of taking pause if you have any issues regarding chemical imbalance. You should take note and steer toward a more forgiving side effect profile like isentress. It is important that you do this because doctors might not think that you will be in the low % of patients who are effected. My dr knew of my family history of imbalance and still recommended atripla while we discussed it. He also said that my early reactions of depression were a normal reaction to my then recent diagnosis. In short, we are all resposible for ourselves and must know ourselves when we research our own treatment. Once you are on a medication anxiety about getting better can make you stay when you should switch.

Miss P. I agree there needs to be a "standard" to review the right fit for patients. When I came down off the side effects, I told my dr that I had been dangerously close to some really irrational thinking early on in the atripla meds. He seemed to take note after the fact.

Matt

[Moffie65]

I have been on Issentris since I had drug failure two years ago.  The first day of approval for this medication with the VA system was the day my Dr. put me on it.  My virus has very acute resistance to most of the drugs, and some of them in the Atripla combination.  The introduction of Issentris, and Presista, was a life saver for me and my very experienced virus, simply because the combination of these two drugs has saved the lives of many of us who are long term survivors with heavy resistence issues.

As far as side effects; it is vitally important for those of you who are new to this disease to remember that side effects can come on well after the initial start of any of these medications.  I have had some side effects from the two new drugs mentioned above, and some of the sides came on a full six months after first starting.  Some, started soon after, and then tapered off at the six month mark.  This brings me to one small fact that few doctors acknowledge, and that is, we all need to try to tolerate these meds as long as is feasible, simply because if you stick with it, many times the body adjusts and we end up being able to tolerate drugs that were giving us a fit of sides when started.  This has proven true with me, except for zerit and some of the earlier drugs, like crixivan.

Remember, if you have problems with triple and double combos, it is important to find out which of the two or three is causing your discomfort.  In the future, when you have more experience with the medications and the virus; it is really important to have a history of your resistances.

[mjmel]

Don't count your chickens too soon -- the severe depression can often set in 6 months down the road.  But you're right, the majority are fine with it.

thanks for the heads-up. will periodically check mental state in the next few months. i have fought (and won) depressive bouts before so i know what to look for.

Mike
delicate flower

[Inchlingblue]

My bf underwent therapeutic drug monitoring (TDM) a few years ago and it was discovered that he had far too much Sustiva in his system. They first dropped his dose to 400mgs (standard is 600mgs) but the levels were still too high. They then dropped him to 200mgs and that's where he's remained, and has also remained undetectable. He's also on Truvada, started out with Combivir.

I'm convinced, based on some research I've done, that many people on HIV meds must have higher levels of the drugs in their system than is necessary. What's frustrating is that it's dangerous to play around with dosage so it's  not like any of us can do anything about it.

I guess this TDM thing is an option?

Additionally, a recent study determined that even the standard approved levels are too high: "Lower levels of drug exposure are required to prevent viral rebound because the overall viral burden declines over time."

I hope that more studies are done that look at this issue, since it could mean much less toxicity, not to mention costs.

LINK:

Duration of Viral Suppression Strongly Modifies the Adherence-Viral Rebound Relationship

http://www.natap.org/

[Ann]

I guess this TDM thing is an option?

I'm not sure how wide-spread its use is. The doc who did this for him is an hiv pharmacologist (who only does clinical one day a week and also happens to be my doc - "The Wizard of Poz"). He's mainly involved in research (and you'll find his name on quite a few studies - Saye Khoo). He's also one of the authors of the University of Liverpool's drug interactions website. You can see his photo under: about us > meet the team. He's a cutie! hehehe, I think so anyway. He's got a lovely smile, nice bedside manner and loves to laugh.

I would imagine in the States TDM might be a difficult thing to access, unless you're in a study, perhaps, because I can't see it as being something the insurance companies would pay for/approve, or ADAP or Ryan White for that matter. From what I understand, it's expensive.

You know, I have to wonder sometimes if his taking only 200mgs of Sustiva might make him more prone to becoming resistant to it (and therefore the whole class) but so far, so good, aside from the continuing side-effects, that is.

Ann
 

edited to fix broken link

[Inchlingblue]

You can see his photo under: about us > meet the team. He's a cutie! hehehe, I think so anyway. He's got a lovely smile, nice bedside manner and loves to laugh.
 
You know, I have to wonder sometimes if his taking only 200mgs of Sustiva might make him more prone to becoming resistant to it (and therefore the whole class) but so far, so good, aside from the continuing side-effects, that is.
 

I saw his pic, he is kinda cute

Thanks for the info.  It seems like in your bf's case, the 200 mg is enough, so that's great. As that recent study published in NATAP that I cited states, lower levels of drugs are required to prevent viral rebound once you're undetectable (which when you think about it makes perfect logical sense).

You're lucky to be in the UK, Ann, and get the level of treatment you guys get without having to worry you'll lose it all of a sudden (the way many people in the US do). And I guess we here in the US are luckier than others elsewhere, it's all relative. Still, I do hope we can get our health care act together.

[David_CA]

I'm convinced, based on some research I've done, that many people on HIV meds must have higher levels of the drugs in their system than is necessary. What's frustrating is that it's dangerous to play around with dosage so it's  not like any of us can do anything about it.

I guess this TDM thing is an option?

Additionally, a recent study determined that even the standard approved levels are too high: "Lower levels of drug exposure are required to prevent viral rebound because the overall viral burden declines over time."

I hope that more studies are done that look at this issue, since it could mean much less toxicity, not to mention costs.

LINK:

Duration of Viral Suppression Strongly Modifies the Adherence-Viral Rebound Relationship

http://www.natap.org/

It was an option for me, though I never had it done.  I took about 18 months to reach undetectable but showed no resistance to the three drugs in Atripla.  We never scheduled the TDM since I finally became undetectable!

[Inchlingblue]

More on Isentress:

HIV integrase inhibitor effective when beginning treatment

August 3, 2009

A member of a new class of antiretroviral drugs is safe and effective for patients beginning treatment against HIV, according to researchers who have completed a two-year multisite phase III clinical trial comparing it with standard antiretroviral drugs.

The results are online and scheduled for publication in an upcoming issue of the Lancet.

Lead author of the Lancet article is Jeffrey Lennox, MD, professor of medicine (infectious diseases) at Emory University School of Medicine. Lennox is chief of Emory's HIV/AIDS clinical trials unit and vice-chair of medicine dealing with Grady Memorial Hospital.

"These results provide an additional potent, well tolerated treatment option for newly diagnosed patients with HIV infection," says Lennox.

Raltegravir, a HIV integrase inhibitor, is overall as effective as widely used efavirenz, a reverse transcriptase inhibitor, the researchers found. Raltegravir also had faster onset of action and fewer adverse side effects. In the clinical trial, both were combined with two other standard retroviral drugs, tenofovir and emtricitabine.

The trial included 566 patients from 67 medical centres on five continents. The "primary endpoint" of the trial was pushing viral levels below 50 copies per ml of blood by week 48. Of the raltegravir group, 86 percent reached that goal, compared with 82 percent of the efavirenz group.

Continued....

LINK:

http://www.scientistlive.com/European-Science-News/Pharmacology/HIV_integrase_inhibitor_effective_when_beginning_treatment/23101/