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Author Topic: Time to Change Meds?  (Read 2469 times)

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Offline racerxsf

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Time to Change Meds?
« on: November 02, 2007, 02:02:20 AM »
I've been on Kaletra, Truvada and Zerit since May.  I've blown through most nucs and protease inhibitors and I am allergic to Prezista and Sustiva.  >:(  I still have other non-nucs, but I am co-infected with Hep C, so there's the liver toxicity issue.  I went from undetectable in July to a viral load of 243 in October (too low for a resistance test).  Numbers below.  My Dr. wants me to change to Aptivus boosted by Norvir, Isentress and continue on Truvada along with 90 days of induction therapy with Fuzeon. 

WOW I'm a bit overwhelmed. 

Does anyone have any ideas?  Thanks

               CD4       V/L
07/07       343       >75
08/07       223       170
09/07       376       203
10/07       246       243

"We are the hero of our own story."

Offline Matty the Damned

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Re: Time to Change Meds?
« Reply #1 on: November 02, 2007, 02:45:25 AM »
Change.

Dear god in heaven change.

Your current combo is a real bastard in terms of ghastly side effects (as I'm sure you know) especially with Zerit in the mix.

I'd whack out on that new high powered combo if I were you.

Oh, and welcome to the forums. ;)

MtD

Offline racerxsf

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Re: Time to Change Meds?
« Reply #2 on: November 02, 2007, 03:48:07 AM »
Hey -thanks for the input and the welcome.  Yeah, it's about as powerful as it gets. But there's always the fear of the unknown side effects. 
"We are the hero of our own story."

Offline Matty the Damned

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Re: Time to Change Meds?
« Reply #3 on: November 02, 2007, 03:54:16 AM »
Yeah true, but consider the known side effects of a medieval drug like Zerit.

Ick.

MtD

Offline Dragonette

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Re: Time to Change Meds?
« Reply #4 on: November 02, 2007, 04:37:32 AM »
Hi Racer

I have just changed b/c of a detectable VL 3 times in a row which was lower that yours. They sent it for a resistence test, here they can do it if the VL is >200, also in the UK. So that is possible, maybe if you insist they will send to another lab if they can't do it locally? They did with mine and it takes 5-6 weeks. I am not waiting though, I changed already as the longer you wait the more resistences you develop (first it is just to 1 drug in the combo, then 2 then 3)

Even regardless of the frightening sides, this combo is obviously not doing it's job in terms of suppressing VL so you need to change.

Good luck and all the best to you.
"If you keep one foot in yesterday, and one in tomorrow, you piss all over today". Betty Tacy

Offline newt

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Re: Time to Change Meds?
« Reply #5 on: November 02, 2007, 05:27:35 AM »
Hello

Difficult situation...

Perhaps, yes, time to change, with 3 detectable viral loads.

Aptivus, like Prezista, is a sulfa-containing drug, should be used with caution in patients with a known sulfa allergy. Also, Aptivus/Norvir, there are reports of hepatitis and significant liver damage from this drug, caution is recommended for HIV-positive people with chronic hepatitis C, who are at the highest risk of liver-related side effects.

Is Kaletra really wiped? is a good question, and would Reyataz be viable? is another << especially as this uses less Norvir as a booster than other PIs.  A resistance test would be helpful. It may be better to wait until your viral load is high enough to get one.

Fuzeon induction + Isentress is wild west prescribing, bit gung ho. Isentress is prob sufficient.

But, Isentress, the good bit in the suggested prescription is Isentress.

The prescribing info on Isentress says of hepatitis C coinfection that in general the safety profile of Isentress in subjects with hepatitis B and/or hepatitis C virus coinfection was similar to subjects without hepatitis coinfection.  Little higher liver enzyme levels sometimes but not serious.

Interaction wise, not studied with Kaletra, but is with Aptivus and Reyataz. None of important to note.

Isentress interactions chart PDF

It might be worth exploring a boosted PI + Isentress alone (+ perhaps just 3TC). 

If the suspected resistance is nuke related, removing the nukes from the combo removes the evolutionary pressure for these to develop, and may be strong enough to sustain an undetectable viral load (3TC is a bonus because it selects for a particular mutation that leads to a less fit type of virus, therefore, theoretically, useful and deffo won't make the situation worse).

But, this really depends on your PI mutations, how many you got, too many and you are effectively on Isentress monotherapy, not a good idea.

A resistance test, by hook or by crook, seems essential before deciding.

Hope this helps.

- matt


PS - can someone add Isentress to the spell checker?
« Last Edit: November 02, 2007, 05:35:22 AM by newt »
"The object is to be a well patient, not a good patient"

Offline Tim Horn

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Re: Time to Change Meds?
« Reply #6 on: November 02, 2007, 12:28:23 PM »
Adding to Matt's advice (and, racer, I hope you'll ask for clarification if what he has written isn't clear) --

There's a chance that your viral load is high enough -- and has been detectable long enough -- to yield some drug-resistant mutation information, especially if you use a genotypic assay. It looks as if you've been having blood drawn for viral load testing once a month for the past three months. Perhaps next month -- if you decide to wait -- you can have blood drawn for a follow-up viral load and a genotypic test and simply see what the results are. If the lab wasn't able to conduct genotypic testing because your viral load is low, or if the lab doesn't have confidence in the results, they'll let you and your doctor know.

In the absence of trustworthy genotypic results, let's clear up a few things:

1) The Prezista allergy. As Matt points out, it (and Aptivus) contain sulfa, which is a major source of allergic reactions in people with HIV (much more so than in the general population, for reasons that have yet to be determined). But is it, in fact, the sulfa in Prezista you're allergic to? People can have allergic reactions to other "innactive" ingredients in medications. If it is a sulfa allergy, you might want to talk with your doctor about a desensitization protocol. While I'm not aware of this being done for people allergic to the sulfa in Prezista or Aptivus, its highly effective for people allergic to Bactrim (TMP/SMX). A desensitization protocol involves starting with tiny doses of Bactrim and increasing it gradually -- over the course of a day, a few days, or even a few weeks -- to desensitize your immune system to sulfa-based compounds. If it's successful, you should then be able to switch on to either Prezista or Aptivus. Again, such desensitization protocols haven't been done (or studied) to decrease the risk of an allergic reaction to Prezista or Aptivus -- Newt will probably blast me for such a "wild west" idea  ;) -- but, fact of the matter is, Prezista remains one of the best protease inhibitor options for people with HIV resistant to other PIs available... I'd hate to see you write off this option without first exploring ways to overcome whatever allergy it is you have to the drug.

2) The Sustiva allergy. What happened here? Rash? Other allergy-related symptoms? Unfortunately, if you're seriously allergic to Sustiva, chances are you'll also have a hard time tolerating Viramune (nevirapine) -- perhaps even moreso. A number of people who develop a rash while on Sustiva are able to manage it with over-the-counter agents and, very often, the rash goes away with continued use of the drug. Of course, if you're rash was severe -- especially if you had other symptoms -- this simply might not be an option for you. But here too, depending on your experience using Sustiva the first time around and the discussion you have with your doctor, retrying Sustiva might not be totally off the table.

Regardless of whether or not the above issues are moot -- and, again, these suggestions are talking points only for you ponder discussing with your doc -- Isentress really is a dynamite option to consider.

Another option is Selzentry (maraviroc), Pfizer's entry inhibitor. However, to know if this drug will work or not, you'll first need a test -- called a tropism assay -- to see if your virus is CCR5-using, CXCR4-using, or dual/mixed.  Check out "The Trouble With Tropism" to learn a bit more about this. And with a low viral load, the lab conducting this test might have a difficult time concluding whether or not you'll respond well to Selzentry -- here, too, you might need to wait for the viral load to increase a bit before moving forward.

Let us know your thoughts when you have the time,

Tim Horn




Offline Miss Philicia

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Re: Time to Change Meds?
« Reply #7 on: November 02, 2007, 12:44:55 PM »
Isn't TMC-125 (etravirine) in the same class as Sustiva?  Is that a possibility?  I believe it's currently in Phase 3 and for some reason I thought it was to be FDA approved in January, so I guess he could get on an expanded access until then.  Though IIRC you have to have at least 1,000 VL to do that, not sure.
"Iíve slept with enough men to know that Iím not gay"

Offline Tim Horn

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Re: Time to Change Meds?
« Reply #8 on: November 02, 2007, 01:25:03 PM »
Yes, etravirine is an option... didn't mean to leave that off. It's in expanded access now and, on the surface of things racer, you may very well qualify. Here's a link to the full EAP description. Like Sustiva, however, it can cause rash.

Offline Miss Philicia

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Re: Time to Change Meds?
« Reply #9 on: November 02, 2007, 01:38:10 PM »
In terms of the rash issue, I'll just add that I was one of those unfortunate types who had allergic reactions to both Bactrim and Sustiva, but when it came time for me to take Prezista I had absolutely no reaction.  Just thought I'd throw that out for what it's worth, and I'm not sure how common that scenario is but I guess when your options are few anything is worth trying out.

My old reactions to Bactrim and Sustiva were 12 and 7 years ago respectively. 
"Iíve slept with enough men to know that Iím not gay"

Offline racerxsf

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Re: Time to Change Meds?
« Reply #10 on: November 02, 2007, 07:23:31 PM »
Thanks for everyone's responses. I really appreciate it!  I have a lot to talk with my doctor about. 

I'm not allergic to sulfa drugs.  I take bactrim everyday.  So it had to be something else in the Prezista that gave me a terrible rash.  I didn't get a rash from the Sustiva, so perhaps allergic was the wrong terminology.  I was so dizzy I couldn't get out of bed at all.  I couldn't stand up without bouncing off the walls.  I've tried it on three separate occasions and I was bedridden each time.  I couldn't go to work or even make it to the restroom without help. 

Thanks - Brian
"We are the hero of our own story."

Offline Tim Horn

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Re: Time to Change Meds?
« Reply #11 on: November 02, 2007, 08:30:47 PM »
Racer:

That certainly clarifies things a bit.

That dizziness you experienced while on Sustiva is extremely common. In fact, central nervous system effects of Sustiva in general are very common, and include dizziness, muddled thinking, vivid dreams, nightmares, difficulty concentrating... and can be an even bigger problem for people with a history of mental illness. Some people don't experience any of these problems at all (the first time I took it, I woke up feeling as if I'd had too many bourbons the night before, but that was the last of it), whereas others -- yourself, quite possible, really get taken for a ride on the drug. This definitely isn't an allergy, but rather a unique side effect of Sustiva. And this is good to know -- the NNRTI Viramune doesn't cause this problem, nor does Tibotec's experimental etravirine... so these are strong options to consider, provided that your virus didn't develop resistance to Sustiva while you were on it.

Yes, Prezista has been shown to cause rash. While this is often tied to the sulfa in the drug, it sounds as if there may be something else in the drug that your immune system is hypersensitive too. If trying Prezista again isn't an option -- perhaps with the use of a mild antihistamine, and definitely under close supervision from your doc to make sure the rash doesn't become severe (a sign of serious erythema multiforme or Stevens-Johns syndrome) -- the Aptivus might serve you well. But as Matt points out, the relatively high dose of Norvir used to boost Aptivus levels in the bloodstream can be harsh on the liver, especially for folks with hep C coinfection (here too you and your doc can keep a close eye on your liver enzymes to make sure that no additional harm is being done).

The question still remains -- do you want to alter your regimen now or wait to see if your viral load increases a bit to get more-or-less solid answers using drug-resistance testing? Sounds as if you're doc is very "forward thinking," so I imagine you two will have an interesting conversation either way.

Tim Horn 

Offline Peter Staley

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Re: Time to Change Meds?
« Reply #12 on: November 05, 2007, 09:56:49 AM »
PS - can someone add Isentress to the spell checker?

Done.

Peter

 


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