Atripla 5 days a week

[tommy246]

i read something i think sometime ago that some people are taking atripla 5 days on and 2 days off and doing well i cant remember if it was a trial or a member on here, can anyone throw any light on this subject.

[hope_for_a_cure]

I was told that I should NEVER miss a dose.  I have not heard of skipping two days each week on purpose. 

[peteb]

I was also told not to miss a dose never less two days

[phildinftlaudy]

i read something i think sometime ago that some people are taking atripla 5 days on and 2 days off and doing well i cant remember if it was a trial or a member on here, can anyone throw any light on this subject.

There was a small study done: The FOTOSTUDY - here is the link to what I found on it:
http://www.natap.org/2009/IAS/IAS_63.htm

Personally, it seems like the only real benefit would be a cost savings (taking less meds over a one month period, etc.) --- I guess I am of the belief in many ways that if "it ain't broke, don't try to fix it" (at least in this instance I feel that way)... and as pointed out, it was a small study.

[Boze]

There was a small study done: The FOTOSTUDY - here is the link to what I found on it:
http://www.natap.org/2009/IAS/IAS_63.htm

Personally, it seems like the only real benefit would be a cost savings (taking less meds over a one month period, etc.)

Well, if you assume that

a) taking HAART is somewhat damaging to your body
b) the dosage of Atripla taken every day exceeds the amount required by your body to keep HIV in check

then it would make sense to follow a regimen where you take it for a number of days followed by a 1 or 2 day break.

In other words - think of HAART as this potion that kills HIV but also does some damage to the body. Assume that each pill lasts for 30 hours (that is actually based on an individual - maybe genetic testing will be able to figure out the time) . Taking it every 24 hours leaves you with an excess of 6 hours - that builds up over a week.

This is only the theory behind this study - i don't think it proved anything.

[tommy246]

Sounds good to me having read that article anybody on here tried this or takes even 1 day off a week

[hotpuppy]

In other words - think of HAART as this potion that kills HIV but also does some damage to the body. Assume that each pill lasts for 30 hours (that is actually based on an individual - maybe genetic testing will be able to figure out the time) . Taking it every 24 hours leaves you with an excess of 6 hours - that builds up over a week.

This is only the theory behind this study - i don't think it proved anything.

I think this is false logic.  The body eventually establishes an equilibrium at which chemicals are eliminated from the body.  Urea (the chief component of Urine) is a toxin... that's why it's eliminated.  From the moment you ingest something the body begins to eliminate it.  Drugs (medicines) work most effectively provided that the level in your blood remains above a therapeutic threshhold.

Moving back to FOTO.  BAD BAD Idea for ATRIPLA.  HIV easily evades ATRIPLA when you start skipping doses.  It becomes resistant and then the components are off your list of functional meds.

I can't think of a good reason to mess with dosage recommendations.  The cost savings (8 pills/mo) is unlikely to offset the resistance testing ($$$) or the parmacokinetic (PK) testing needed.  PK testing is how drug companies figure out how much dosage is in your body.  When I was in a drug study they would check drug levels after fasting over night, have me take the med, and then check them again in an hour.  They check by taking blood btw, and PK testing is a routine part of the clinical trials process.  It's part of how they confirm the needed dosage for an average person.

[Hellraiser]

Moving back to FOTO.  BAD BAD Idea for ATRIPLA.  HIV easily evades ATRIPLA when you start skipping doses.  It becomes resistant and then the components are off your list of functional meds.

You do realize there was a 48 week study in which all participates were on a 5on/2off dosing regimen and they all exited the study still undetectable (granted with blips in between) and no resistances, right?

[Boze]

I think this is false logic.  The body eventually establishes an equilibrium at which chemicals are eliminated from the body.  Urea (the chief component of Urine) is a toxin... that's why it's eliminated.  From the moment you ingest something the body begins to eliminate it.  Drugs (medicines) work most effectively provided that the level in your blood remains above a therapeutic threshhold.

I specifically read that the amount of each drug in Atripla was roughly estimated to work for **everybody**. Meanwhile the therapeutic threshold that you refer to is very individual - and may be much less than the actual dosage. That's the theoretic idea behind foto - that if a person only needs 60% of each dose, they are being over-medicated.
Moving to the other point you made - I don't think the body can get ride of any toxic compound. Urea is produced by the body - so we know what to do with it. But Atripla - I don't think so. So whatever damage it's doing to the body, if the damage can be reduced I think it's a good thing.

[Hellraiser]

Moving to the other point you made - I don't think the body can get ride of any toxic compound. Urea is produced by the body - so we know what to do with it. But Atripla - I don't think so. So whatever damage it's doing to the body, if the damage can be reduced I think it's a good thing.

Wait, what?  No.  Any drug put into your body begins to be removed as soon as it's ingested.  He's right about that.

[Boze]

Wait, what?  No.  Any drug put into your body begins to be removed as soon as it's ingested.  He's right about that.

Yes, of course. But the removal process happens over time. Say you start with 300mg of Sustiva when you take it. Then it goes out of your body at a certain rate - being fully gone in 3 days (assume uniform rate of decline). So after day 1 you still have 200mg left.
Now - how much Sustiva you actually **need** is very individual. Some people may require 300mg for it to do its job, some 100mg. Maybe the average is 200 - but the pharma company put 300mg just to be very safe.

[newt]

Yes, of course. But the removal process happens over time. Say you start with 300mg of Sustiva when you take it. Then it goes out of your body at a certain rate - being fully gone in 3 days (assume uniform rate of decline). So after day 1 you still have 200mg left.
Now - how much Sustiva you actually **need** is very individual. Some people may require 300mg for it to do its job, some 100mg. Maybe the average is 200 - but the pharma company put 300mg just to be very safe.

Erm, just saw this and really need to comment:

After 5 days, efavirenz (Sustiva), the key drug in Atripla, reaches a steady state concentration in the body. If you stop taking it the time to no drug being present is 2-3 weeks, sometimes more. The time to a noneffective level of the drug is is 5-7 days. This is why 5 days on/2 days off is a possibly workable approach.

The crab in the net is the tenofovir (Viread), which falls to sub-therapeutic levels in 24-36 hours. The presence of the other two drugs in Atripla may be sufficient to cover this.

Article (technical):

Drug levels can persist for more than two weeks after stopping efavirenz
http://i-base.info/htb/3261

Edited to add link from NATAP:

Risks and Benefits of 5 Days On/2 Days Off in the FOTO Study
http://www.natap.org/2008/InterHIV/InterHIV_23.htm

- matt

[bufguy]

I talked to my doctor about this and he said two things. 1. The study was very small and therfore not totally conclusive. 2. He felt from his experience that Atripla does maintain a concentration in the body longer than 24 hours. Thatis to your advantage if you miss a dose, basically a safety margin. By taking one or two days off atripla you will have eliminated that safety margin and left no room for error. Also NRRTi's have a very low barrier to resistance.
Consider  Atripla to be tolerant to missing a dose once in a while a blessing, not an opportunity to skip doses.

[phildinftlaudy]

I talked to my doctor about this and he said two things. 1. The study was very small and therfore not totally conclusive. 2. He felt from his experience that Atripla does maintain a concentration in the body longer than 24 hours. Thatis to your advantage if you miss a dose, basically a safety margin. By taking one or two days off atripla you will have eliminated that safety margin and left no room for error. Also NRRTi's have a very low barrier to resistance.
Consider  Atripla to be tolerant to missing a dose once in a while a blessing, not an opportunity to skip doses.

Buf, Right on point - Thanks for posting this follow up.

[YaKaMein]

Despite the good discussion here, we're still left to only ONE study to support variations in Atripla dosage. There is anecdotal reporting among patients of 5on/2off adherence or even longer and remaining undetectable and non-resistant to components of Atripla.

But, one does this at her/his own risk!! Individually, we can decide to vary our adherence without evidence to support it wisely. I hope that researchers will [if not already] begin investigations on various safe and effective dosing of Atripla, which does have rather long half-lives for its components.

Maybe the 2 days off don't have to be consecutive?? ... but the risk of forgetting or a tendency to push it to 3-4 days may be too risky and lead to treatment failure. We don't have any information at this time.

It would be irresponsible for physicians to recommend any variations without further controlled studies. Yet, patients have the right to experiment [and we do] against informed advice.

[tommy246]

i agree its not proven yet but was wondering do you personally know many people out there who miss a dose intentionally maybe on a saturday for example . although i limit my drinking now to 2 or 3 small beers or wine glasses a day i usually have a few extra on a saturday and take my pill when i get in 4 or 5 in the morning as against my normal time of 11-12 pm. my doc said this was ok by the way.