Efavirenz (STOCRIN/SUSTIVA) cf Nevirapine (VIRAMUNE)

[Sydney]

Hi everyone.  I'm new to the site. It feels like a big jungle, but I'll have to take the bull by the udders and plunge in!

I'm 63, male, seroconverted in Jan 1986, have remained healthy for 23 years, and have never been on treatment.  However the time has come.  My CD4s have been hovering around and below 250 for a couple of years, and are currently at 10%. Viral load seems to oscillate around the 30,000 mark (13,000 in March; 27,000 in July; the highest ever has been 183,000 at a high-stress time last year).
Psychologically, I'm fairly robust, but inclined toward anxiety-depression. Needless to say, this is escalating dramatically as I approach decision-making about treatment.

My doctor wanted to start me on TRUVADA (FTC & Tenofovir) plus STOCRAN/SUSTIVA (Efavirenz).  For reasons I won't go into, I persuaded him to change the NRTI to KIVEXA (Abacavir & 3TC).  Then consultation time ran out and muttering darkly about the need for sleeping tablets, he wrote scripts for KIVEXA and STOCRIN/SUSTIVA and sleeping tablets.  I left the session feeling very agitated, pressured and unconvinced.

Given my pre-disposition to anxiety and depression, I am very worried about the possible CNS side-effects of Efavirenz.  After reading inputs into this forum, I'm even more worried about the side-effects of Efavirenz and the impact that might have on my quality of life. My strong insinct is to go for VIRAMUNE (Nevirapine) unless there are very good reasons not to.

When I sought a second opinion (from a highly qualified expert), he went with the judgment KIVEXA plus Efavirenz.  When I asked him "why not Nevirpine?"  He made a reference to a "recent" clinical trial suggesting that Nevirapine (combined with the two NRTIs) may not result in complete viral suppression in people who are new to treatment.  I subsequently asked for a reference for that - and was sent the Abstract of a study conducted in 2000  - Bartlett, Demasi et al,  "Meta-Analysis of Efficay of Triple Combination Therapy ....".  There was nothing in the Abstract that touched on the comparison I'm interested in (Efavirenz  versus  Nevirapine)

I have two questions:
1) I'm interested in the experience of people in living with the risks and side-effects of Efavirenz, as compared with the risks and side-effects of Nevirapine - when combined with KIVEXA (Abacavir + 3TC) or perhaps with STOCRIN/SUSTIVA.

2) Does anyone know of research suggesting that Nevirapine combined with an NRTI may not result in complete suppression?  And if so, what's the strength of that evidence?

Many thanks. And down here,  :DSpring is on the way

[Peter Staley]

Sydney -- you have every right to look at other options besides Sustiva, especially with your history of anxiety/depression.

With you VL being so low, Viramune is definitely an option.  If your VL was above 100K, then that would be an adequate excuse to look for stronger options, but your VL is well below that.

You should also discuss Kaletra or Reyataz+Norvir as options (both are strong protease inhibitors).

[Sydney]

Thanks, Peter, for the very helpful reply. I've subsequently learned how to use the "search" to tap into others' experiences with these drugs.

Just in case I've sown seeds of doubt about the efficacy of Nevirapine: I pressed for the research details about "incomplete viral suppression" (as in my posting).  The doctor sent me a copy of a paper: Bartlett, Fath, De Masi (et al.), (2006): An updated systematic overview of triple combination therapy in antiretrovira in naive HIV-infected adults, AIDS 2006, 20:2052-2064.  In an accompanying email he said: "Here's the most updated publication comparing different classes of drugs. Unfortunately there has been only one study comparing Nevirapine against Efavirenz (the 2NN study), which did not detect any significant differences bewteen drugs."  That supports your observation and gives me confidence in going with the KIVEXA + VIRAMUNE option - though I'll cerainly check out your suggestion.

I think I have a lurking preconception that PIs are more likely to cause lipodistrophy/lipoatrophy - any comments about that? (It's not something I know anything about)

Many thanks, and if there are others who can share their experiences, I'd be really grateful.

[Nashvegas]

I would think you might also consider a Viramune and Truvada combo.  It's been working well for me, with absolutely no side effects..

[Sydney]

Hi Nashvegas.  Your suggestion for VIRAMUNE and TRUVADA is the combination that, in the abstract, I'd prefer. And the doctor's original advice for the NRTI was TRUVADA. I argued for a change to KIVEXA because I was matching the drugs' most serious side-effects with my personal risk profile.

I have a low risk profile on cardio-vascular problems - the most serious side effect of Abacavir)).
On the other hand, I am aged 63 and assessed as osteopaenic -  and thinning of bone-mineral density is a possible side effect of the Tenofovir in Truvada.  I figured, therefore, that Abacavir was less risky for me than Tenofovir.   It also seems to me that it's easier to monitor cardio-vascular risk in an ongoing way than to monitor bone-mineral density.

That was my reasoning - however I'm more than happy to get feedback about other considerations I'm not throwing into the balance.

[Peter Staley]

I think I have a lurking preconception that PIs are more likely to cause lipodistrophy/lipoatrophy - any comments about that? (It's not something I know anything about)

We've got a great lesson on lipodystrophy here:
http://www.aidsmeds.com/articles/Lipodystrophy_10726.shtml

It discusses how each class of meds may or may not play a role.

Reyataz is one of the only PIs that doesn't affect lipid levels, and thus far, it doesn't seem to be a culprit in lipodystrophy either (but ALL HIV meds are still suspect when it comes to lipodystrophy until absolutely proven otherwise -- scientists might never figure all this out with certainty).

[Sydney]

Thanks Peter and Nashville - and thanks for the link to the lipo**y article.  Your replies have given me a really good focus and I'm feeling more in control (and marginally less anxious)

The meta-analytic research article that I referred to (Bartlett et al., 2006) backs what you've both said.  The authors conclude that the best starting point is two NRTIs (in my case, either TRUVADA or KIVEXA) combined with either an NNRTI (in my case hopefully Nevirapine) or a ritonavir-boosed PI (your suggestions).  The NRTIs+BPI option has an edge over the other in terms of a) increased CD4 cells, b) less risk of drug resistance, and c) a lower resistance cost in the event of resistance.  Ergo ...

I went back to the notes I took when my choices were being explained to me. The private practice I go to has adopted a policy of keeping the NRTIs+boosted PI as "kept in reserve for fallback". I guess I can see the point of that. Anyway, I'll discuss it with the "second opinion" agency I go to (a public system clinic).

If there are any other considerations I should take into account .... gopher!