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Author Topic: GERRY AND MATT I NEED YOU!!!!  (Read 8417 times)

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Offline Jena

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  • To God Be The Glory!
GERRY AND MATT I NEED YOU!!!!
« on: August 12, 2006, 04:41:22 PM »
I got the  genotype report.  It shows I am resistant to all the NNRTI, NRTI, except  Viread and thats resistant possible. I'm sensitive to all PI's.  This isn't good is it? >:(

Offline RapidRod

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #1 on: August 12, 2006, 04:45:17 PM »
Jena, you hang in there girl. They'll find something for you.

Offline blondbeauty

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #2 on: August 12, 2006, 04:51:37 PM »
And what did your Dr say? Did she give you any alternative combination of meds or just sent you home with the news?
The only member in these forums approved by WINBA: World International Nail and Beauty Association.
Epstein Barr +; CMV +; Toxoplasmosis +; HIV-1 +.
Counts when starting treatment:
V.L.:80.200 copies. CD4: 25%=503
Started Sustiva-Truvada 14/August/2006
Last V.L.count (Oct 2013): Undetectable
Last CD4 count (OCT 2013): 52%= 933

Offline Eldon

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #3 on: August 12, 2006, 05:01:43 PM »
Hello Jena, it is Eldon. I know what stress you are going through right now. Hang in there , stay on top of the Doctor and they will find something for you I am sure. We are behind you 100% with the support you need right now.

Offline newt

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #4 on: August 12, 2006, 05:17:26 PM »
Jena

1. Sit down

2. Post the info from the genotype here, or PM me for an email address and scan it and send it me or an IM address so we can talk through it.

3. Nuke resistance can sometimes be useful. Since PIs still work the NNRTI resistance is not that important.

4. If you have some Viread workability and the M184V mutation the you can just use Viread+FTC or 3TC and two PIs plus a booster. This is perfectly okay. Depending on the exact picture adding AZT may also be useful.

5. Since you have no PI resistance you have tons of options here.  Very good.

Even without seeing the genotype I think it highly probable that a combo like Kaletra + Reyataz + Truvada (or perhaps Viread + Ziagen), with or without AZT, will bring your viral load to undetectable. But let's see the info off the genotype sheet, it will be a series of numbers categorised by PI mutations and then NNRTI + NRTI mutations.

Plus there should be a list of drugs with cut-off (effectiveness) numbers eg Viread 3.3, Kaletra 1.1 in the phenotype part etc. These are also useful.  And the name of the test maker.

Best wishes and a big hug.

- matt

Now playing: BBC Radio 4
"The object is to be a well patient, not a good patient"

Offline Jena

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #5 on: August 12, 2006, 05:50:46 PM »
Matt
 I lost all the information you just told me when we talked! Please tell me again the drugs you said I need.
You are my guardian angel honey!  Thank you from the bottom of my heart and I'm on the way to the  store for the ingredients for my "Jena"  :D

Offline newt

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #6 on: August 12, 2006, 06:00:21 PM »
Okay Jena, here we go.

Gerry (others), your view if you would like, the mutation info, from a LabCorp geno test...

PIs - 63P
NNRTIs - 103N
NRTI - 67N, 70R, 118I, 184V, 215F, 219E, 219Q

Okay. Newt sez...

NNRTIs - these are out (Sustiva, Viramune etc)

Nukes - mutations are extensive,  M184V is helpful because this type of virus is extra sensitive to Viread - Viread+3TC or FTC (eg Truvada) are probably viable under the circumstances if combined with some...

PIs - 63P may contribute to resistance but not on it's own - a double PI plus Norvir booster is in order, I suggest: Kaletra+Reyataz (perhaps 400mg rather than 300mg under the circumstances) or Prezista + Reyataz + 200mg/day Norvir booster or as an outside 3rd option Invirase + Reyataz + 200mg Norvir booster.

Also, consider T-20.

A further resistance test, one with genotype and phenotype info is a good idea 2 weeks to 3 months after starting a new combo if your viral load is over 500.  However, I fully expect it to be under this value if you start taking now:

Truvada PLUS Reyataz PLUS EITHER Kaletra OR Prezista + Norvir OR Invirase + Norvir.  T-20 may be added if necessary.

- matt

Now drinking: a Jena, 1 part gin, 5 parts white guava juice, big twist of lime over ice
« Last Edit: August 12, 2006, 06:04:10 PM by newt »
"The object is to be a well patient, not a good patient"

Offline newt

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #7 on: August 12, 2006, 06:11:51 PM »
If your doc says this is too much or not in line with guidelines (1) roll up the genotype report and shove it up her arse (2) get a new doctor.  ;)

- matt

Now playing: BBC Radio 4
« Last Edit: August 12, 2006, 09:00:07 PM by newt »
"The object is to be a well patient, not a good patient"

Offline gerry

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #8 on: August 12, 2006, 07:02:46 PM »
Hi Jena:

First off, it was wrong for your doc to suggest that you take Reyataz/Norvir/Viread with a resistance pattern such as yours.  So you really need to get a hold of a more knowledgeable doc.  Letting you continue to take the Viramune/Combivir for as long as you have with your viral load stuck in the 40K range was also not the right thing to do.  The genotype test should have been done a lot sooner on that combo.

You also mentioned that your CD4 is in the 200s so that means you need to start taking PCP prophylaxis.  It also means you'd not be a good candidate for a treatment break.

As for what meds to use next, I agree with Matt that the NNRTIs are out, and the NRTIs are fairly unreliable at this time because you have already developed 5 TAMS.  These are the mutations that accumulate in step-wise fashion when one is on AZT or d4T and remains unsuppressed.  The bad effect is it causes cross-resistance to other NRTIs the more TAMS one accumulates.  As Matt already mentioned, inducing the M184V mutation by adding Epivir or Emtriva may make the virus more susceptible to Viread.  Thus, there is some utility to adding Truvada (Viread/Emtriva) to your combo.

You would need a double-boosted PI as Matt has already mentioned.  I tend to lean toward Kaletra/Invirase since there is more experience out there with this unconventional combo and there are no interactions to think about.  Plus, the Kaletra already has the Norvir in it as the booster so there tends to be less pills to take.  The dose would be Kaletra (200 mg lopinavir, 50 mg ritonavir) 2 tablets twice a day and Invirase (500 mg) 2 tablets twice a day.

I also agree with considering T-20 (Fuzeon) at this point.

You may want to post your question at the Hopkins Website with Dr. Gallant and he could make further recommendations.  He would need your treatment history, counts, and genotype test results.  Here's the link.

Please do this expeditiously.  What you don't want to happen is to be on a regimen that your doc has put you on which is not potent enough to suppress the virus and end up with more resistance to the new drugs that were introduced (Reyataz and Viread).

Gerry

P.S. To summarize, your current circumstances would require using active, potent drugs to try to get you to undetectable.  One combo would be T-20, Kaletra, Invirase, Truvada.  Good luck and keep us posted.
« Last Edit: August 12, 2006, 07:16:59 PM by gerry »

Offline Jena

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #9 on: August 12, 2006, 07:22:05 PM »
Thanks Gerry!
 Would you feel comfortable posting on the Hopkins website for me? I'm not sure what I need to be asking or what I need to tell him. I am going to call the new HIV clinic that I have an appointmrnt with, but not till November to see if they will let me come sooner. I dont have any confidence in my current doctor anymore at all and I dont think I can wait till November to see the new doctor. I have made  copies of the information you and Matt have given me and will take it with me, if I cant get into the new doc's  then I will make another appointment with my current doctor and show her the information. Shes not  very patient friendly and  doesnt like to be challenged but thats too bad isn't it?
 Like I  told Matt, you  are my guardian angels and I thank God for  you! 

In Great Appreciaion
Jena

Offline gerry

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #10 on: August 12, 2006, 08:25:38 PM »
Jena:

This is the question I submitted:

Title: NNRTI and multiple NRTI resistance

Dear Dr. Gallant,

I am asking this question in behalf of a friend for a second opinion.  In September 2005, she was started on Combivir/Viramune with a viral load of over 1 million and CD4 count of 90.  CD4 and VL subsequently were 306 and 55K in April 2006.  No resistance test done and she was continued on same combo.  In July 2006, CD4 and VL were 206 and 69K.  Finally, a genotype test was done.

PIs - 63P
NNRTIs - 103N
NRTI - 67N, 70R, 118I, 184V, 215F, 219E, 219Q

The doc is now prescribing her Reyataz/Norvir/Viread.  We had advised her to seek a second opinion but it might take a while to do that.  In the mean time, we are all concerned that the doc has not and continues not to treat her adequately.

Questions:
1. With this resistance profile, shouldn't she be on a double-boosted PI such as Kaletra/Invirase?
2. Should she be on T-20 as well?
3. Would Truvada be useful to induce the 184V and squeeze some susceptibility out of the Viread?
4. Do you have other suggestions for the next combo?
5. What should she do if she could not get her doc to listen at this point?  Isn't she inviting more resistance and further endangering future treatment options by remaining on just the Reyataz/Norvir/viread?

Thank you for your time and expertise as always.

Gerry


Look for the response in this link and click on "Recent Questions;" look for the specific title.  Maybe if you print Dr. G's response, your doc would be more inclined to listen. Good luck.

Offline Jena

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #11 on: August 12, 2006, 08:34:19 PM »
Thank You Gerry

Offline gerry

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #12 on: August 12, 2006, 09:01:38 PM »
I guess Dr. G is working overtime.  You can print it out of their webpage as well: LINK

Dr. Gallant's response:

The decision to use Combivir/Viramune is not one I would have made. Not that it's a bad regimen, but in someone with a viral load of over 1,000,000, I would have used something with more data behind it. She now has resistance to NNRTIs and also shows evidence of significant NRTI resistance.

The combination of Reyataz/Norvir/Viread is at best a 2-drug regimen, and that's being optimistic. Her virus should be fully susceptible to the Reyataz, but the Norvir is being used only to boost the Reyataz, and the Viread, while probably having some activity, may not be fully active because of all the NRTI mutations. I would agree that a more aggressive regimen in justified. The choices would include either a boosted PI plus T-20 or a double-boosted PI. I also agree that Truvada would be better than Viread, for the reasons you mention in question 3. If her doc insists on treating her with a 1-1/2 to 2-drug regimen, she should consider getting another opinion.

Offline newt

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #13 on: August 12, 2006, 09:19:36 PM »
Good on yer Gerry

(are we all smart here or wot?)

- matt
"The object is to be a well patient, not a good patient"

Offline zephyr

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    • Zephyr L.T.N.P. Foundation, Inc.
Re: GERRY AND MATT I NEED YOU!!!!
« Reply #14 on: August 13, 2006, 12:37:03 AM »
Matt, Gerry, dears,

DAMN, you guys are GOOD.

Jena, darlin'....who needs Allstate when you've got our guys???

Amazing thread.

Thinking about you, girlfriend, good luck!

Love,

Zeph

"It is character that communicates most eloquently."

Offline Robert

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #15 on: August 13, 2006, 12:56:07 AM »
   
YOU GUYS JUST MAKE ME SOOOOO HAPPY!!!

WOW........  ABSOLUTELY INCWEDABLE

robert

(who come next friday is going to raise his glass of champagne in your honor!)
..........

Offline J.R.E.

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  • Joined Dec-2003 Living positive, since 1985.
Re: GERRY AND MATT I NEED YOU!!!!
« Reply #16 on: August 13, 2006, 02:01:43 AM »

This has been a real learning experience. Gerry, Matt, you guys are something else.

 Jena, I wish you the best, and will be thinking of you. Let us know how you make out.


  ((((HUGS))) Ray
Current Meds ; Viramune, Epzicom, 40mg of simvastatin, 12.5mg of Hydrochlorothiazide.
Metoprolol tartrate 25mg



http://forums.poz.com/index.php?topic=40802.0

http://forums.poz.com/index.php?topic=45159.0

http://forums.poz.com/index.php?topic=39722.msg495621;topicseen#msg495621

http://forums.poz.com/index.php?topic=46806.0

http://forums.poz.com/index.php?topic=39414.msg491701#msg491701


 In October of 2003, My t-cell count was 16, Viral load was over 500,000, Percentage at that time was 5%. I started my first  HAART regimen  on October 24th,03.

 As of 6/4/14,  t-cells are at 423, Viral load <40

 Current % is at 13% 

  
 62 years young.

Offline Miss Philicia

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #17 on: August 13, 2006, 02:13:38 AM »
I can't believe they didn't give her a resistance test in the first place.
"Iíve slept with enough men to know that Iím not gay"

Offline blondbeauty

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #18 on: August 13, 2006, 05:20:05 AM »
You are both very good! I am happy we can have your help in these forums.
Jena I hope you find a really good Dr. very soon.
Hugs and Kisses!
The only member in these forums approved by WINBA: World International Nail and Beauty Association.
Epstein Barr +; CMV +; Toxoplasmosis +; HIV-1 +.
Counts when starting treatment:
V.L.:80.200 copies. CD4: 25%=503
Started Sustiva-Truvada 14/August/2006
Last V.L.count (Oct 2013): Undetectable
Last CD4 count (OCT 2013): 52%= 933

Offline newt

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #19 on: August 13, 2006, 05:44:50 AM »
Gerry I take your point on Kaletra/Invirase and there being more evidence on it's use in the clinic. There are no drug level interactions between the drugs in the four (between us) suggested boosted double PI combos except Reyataz/Invirase, where the level of Invirase is raised a bit, but not usually enough for a dose adjustment. Invirase reduces the level of Prezista by about 25%. Reyataz may have advantages over Invirase side-effects wise.  It is also a little stronger/more durable.

To summarise, 4 possible double PI options:

Kaletra (includes Norvir booster) + Invirase
Kaletra  (includes Norvir booster) + Reyataz
Prezista + Reyataz (+ Norvir booster)
Invirase + Reyataz (+ Norvir booster - probably)

Alternative to consider:

T-20 + a boosted PI

Nukes that may usefully be included in the new combo:

Truvada (Viread+FTC in one tablet)

- matt
« Last Edit: August 14, 2006, 06:50:12 PM by newt »
"The object is to be a well patient, not a good patient"

Offline Christine

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #20 on: August 13, 2006, 10:26:07 AM »
Smart?? I think you guys are brilliant!! Simply brilliant!!

Hang in there Jena. Be strong and be aggressive in getting the best treatment for yourself. Good thoughts and prayers going out to you!

Christine
Poz since '93. Currently on Procrit, Azithromax, Pentamidine, Valcyte, Levothyroxine, Zoloft, Epzicom, Prezista, Viread, Norvir, and GS-9137 study drug. As needed: Trazodone, Atavan, Diflucan, Zofran, Hydrocodone, Octreotide

5/30/07 t-cells 9; vl 275,000

Offline Life

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #21 on: August 13, 2006, 10:31:07 AM »
Gerry, Matt - I sent your Post to Dr. Young as well...
« Last Edit: August 13, 2006, 10:56:35 AM by Eric »

Offline gerry

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #22 on: August 13, 2006, 10:55:00 AM »
Hi Matt, Jena and others,

For double-boosted PI, I think it would be a toss-up between Kaletra/Invirase and Kaletra/Reyataz. 

Kaletra/Invirase has both pharmacokinetic and clinical response data available.  The dose is Kaletra (200 mg lopinavir/50 mg ritonavir) 2 tablets twice a day + Invirase (500 mg) 2 tablets twice a day

Saquinavir drug exposure is not impaired by the boosted double protease inhibitor combination of lopinavir/ritonavir.

Virologic and immunologic response to a boosted double-protease inhibitor-based therapy in highly pretreated HIV-1-infected patients.

Kaletra/Reyataz is still relatively new being used in combination but the pharmacokinetic data seems promising (in fact, drug levels of lopinavir achieved were even higher).  The dose is Kaletra (200 mg lopinavir/50 mg ritonavir) 2 tablets twice a day + Reyataz (150 mg) 2 capsules once a day.

Atazanavir and lopinavir/ritonavir: pharmacokinetics, safety and efficacy of a promising double-boosted protease inhibitor regimen.

As for Reyataz/Invirase, I don't think Norvir is needed for this combo because they both boost each other.  The dose is Reyataz (200 mg) 2 capsules once a day and Invirase (200 mg) 6 capsules once a day.  Those who achieved viral loads < 400 were only 41% though.

Therapy with atazanavir plus saquinavir in patients failing highly active antiretroviral therapy: a randomized comparative pilot trial.

Prezista is even newer.  I would probably save that for combining with T-20 later as another option should the double-boosted PI not work out for some reason.

Jena, please have your doc review Dr. Gallant's response.

At the very least, your combo should be:

Kaletra/Invirase/Truvada

or

Kaletra/Reyataz/Truvada

If you prefer to use the T-20 now, you could combine it with Kaletra/Truvada or Reyataz/Norvir/Truvada or Lexiva/Norvir/Truvada or Invirase/Norvir/Truvada.

Good luck.
Gerry
« Last Edit: August 13, 2006, 10:59:47 AM by gerry »

Offline gerry

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #23 on: August 13, 2006, 11:15:17 AM »
P.S. to Jena,

If you want to continue taking some of the meds you already have, it would be easy to do as well.

You are already on Reyataz/Norvir/Viread.

You can have your doc prescribe the Kaletra and you drop the Norvir once you start the Kaletra (since Kaletra already has Norvir) and continue with the same dose of Reyataz.  You can also have her prescribe Epivir or Emtriva to add to the Viread (which will be equivalent to the Truvada).  You can then switch to Truvada later when you are close to running out of the Viread.

Gerry

Offline HIVworker

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #24 on: August 13, 2006, 12:44:36 PM »
There is no doubt that Gerry and Matt make this forum one of the premier resources for HIV on the web. Much saluting to both of you for your excellent work!

R
NB. Any advice about HIV is given in addition to your own medical advice and not intended to replace it. You should never make clinical decisions based on what anyone says on the internet but rather check with your ID doctor first. Discussions from the internet are just that - Discussions. They may give you food for thought, but they should not direct you to do anything but fuel discussion.

Offline JohnOso

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #25 on: August 13, 2006, 01:43:50 PM »
Excellent, excellent work guys!   Thanks for taking care of Jena (and countless others).

And Jena....hang in there girl.  We're with you.

Love,
john
(who knows KY gals are TOUGH!)

Offline Miss Philicia

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #26 on: August 13, 2006, 02:17:25 PM »
As far as what Gerry is saying I was on exactly similar combos in the past 2 years:

Kaletra/Invirase/Truvada (there was a 4th something I'm blanking on at the moment)
this maintained and even increased my CD4's from around 500 to 700, though my viral load always remained around 30-40,000 but was always stable.  I had resistance to all PI's and have had so since at least '02 that I can recall.

I've now been on Prevista, Fuzeon, Norvir and Truvada for 3 months and my CD4's have gone up over 1,000 and my VL is undectable (for the first time in my life).
"Iíve slept with enough men to know that Iím not gay"

Offline gerry

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #27 on: August 13, 2006, 03:00:10 PM »
Philly:

Thanks for sharing your experience.  That's one piece that's very important in this forum as well.

So since Jena should still be responsive to all PIs, perhaps a good strategy would be to use Kaletra + Reyataz or Invirase + Truvada (or Viread/Epivir), and save the T-20 + Prezista/Norvir (+ Truvada) for later just in case it's necessary to switch again.  It's always good to have a back-up plan.

Jena, hope you're doing okay.  Don't be overwhelmed by all these.  Just think about moving forward.  Hope you also get the tummy ache problem taken care of.  Feel free to ask questions.

Gerry

Offline newt

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #28 on: August 13, 2006, 04:53:50 PM »
Eric kindly PM'd me Dr Young's response to the question he posted on (identical to Gerry's) on The Body's Ask The Expert forum, which differs only on the question of double boosted PIs.  He favours a single, strong boosted PI:

"Given the potential for the relative lack of nuke potency, I'd look for the most potent boosted PI combination. Some would argue that atazanavir (Reyataz), boosted or otherwise, but particularly in combination with TDF [Viread] wouldn't meet that criteria , since TDF lowers atazanavir levels.

Seems to me that lopinavir/ritonavir (Kaletra) or fosamprenavir (Lexiva, Telzir)/ritonavir (Norvir) would be possibilities; the former actually increases TDF levels by about 30%, something that actually might be a good thing in this situation. I'm not a big fan of double boosted PIs at this time (or for your friend's situation), given the paucity of data that shows increased benefit and the availability of very potent PIs now."

Full answer on The Body Ask The Experts forum

I can see his point. For me it does not fulfil the tried and tested rule of thumb of at least 3 active drugs from at least 2 classes (the nukes being marginally potent here and 3TC/FTC included for a special reason, so in my view downgraded to one drug in the count). But, I believe Dr Young's position represents another valid option to explore.

- matt
"The object is to be a well patient, not a good patient"

Offline gerry

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #29 on: August 13, 2006, 07:37:13 PM »
Thanks, Eric, for sending the PM.  The more expert advise we can get, the more comfortable we'd be with the recommendations.  I would agree that if a single boosted PI would be chosen in Jena's case, Kaletra (combined with Truvada) would probably be the option with good data behind it.  I would still be nervous about a single boosted PI since we don't know how sensitive the virus is to Viread.  A phenotype resistance test would probably help in this regard.  He did bring up a good point about Viread/Reyataz interaction.  I think I will ask Dr. G a follow-up question about this should Jena opt for Kaletra/Reyataz/Truvada.  Will keep you posted.

Offline Life

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #30 on: August 13, 2006, 07:47:08 PM »
Jena, your in good hands with these two!

Offline Jena

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #31 on: August 13, 2006, 08:17:43 PM »
Hello Everyone!
 Eric thank you so much for taking the time to get a fourth opinion for me, I appreciate it more than you know. You're right, I feel  safer in my two guardian angels hands here than I  ever did  with this goofy woman I've been trusting my life with.
 To everyone else who have taken the time to post your  thoughts and  ideas and prayers, all I can say is, as always, this forum absolutely blows me away!!!
 NOW, Matt and Eric, you guys have given me so many suggestions I am throughly confused ( which doesnt take much! )  Please, would the two of you put your heads together and tell me EXACTLY which drugs I should demand  her to  give me. Pretend like  you are the doctors and you are ready to write th RX's, tell me what, how much and how often please, that way if I go in with it all spelled out for the dumb cow prehaps she  can get it right this time.  :D

I love you guys and to say thank you to the  both of you just isn't adequate. In all reality you have probably saved my life. I know some people dont believe in this, but I absolutely, believe that God  sent  the two of you to my rescue. Thank  you Matt, Thank you Gerry and Thank You My God!
 I hope that someday, somewhere we will meet and I will be able to thank you both properly. Until that day please  know how much you are thought of for taking the time to  help a stranger you dont even know all that well.  Peace and  Love to you both...

Jena

Offline gerry

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #32 on: August 13, 2006, 09:05:36 PM »
Hi Jena,

I would love to put my head together with Mattís but he's too far away!  Anyway, hereís the gist of what you should ask for.  Matt, please feel free to express your thoughts.

1. Have her give you a prescription for Epivir.  The dose is 300 mg, one tablet once a day.  You will add this to the Viread which you will continue to take at 300 mg, one tablet once a day.  You were already taking the Epivir in the Combivir but you donít need the AZT in the Combivir anymore because it would not work.  You just need the Epivir to make the Viread work better.  If thereís any delay, you could probably take the Combivir (same dose as usual) while youíre waiting for the Epivir.

2. Have her write you a prescription for the Kaletra.  The dose is 2 tablets (200 mg lopinavir + 50 mg Norvir in each tablet) twice a day.  When you do get the Keletra, you need to make a decision.

a. You could just take the Kaletra with Viread and Epivir and stop the Reyataz/Norvir (Dr. Youngís suggestion).

b. You could combine the Kaletra/Viread/Epivir with Reyataz.  The Reyataz dose is still the same 150 mg capsule, 2 capsules once a day.  If you do this combo, you do not have to take the extra Norvir since the Kaletra already has Norvir (one of Dr. Gallant's implied recommendation but I'm still waiting for a response to a follow-up question for specifics)

I think this is the simplest strategy but you would have to decide between option 2a and option 2b.  I tend to lean toward Dr. G's more aggressive stance (2b).

Gerry
« Last Edit: August 13, 2006, 10:27:22 PM by gerry »

Offline newt

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #33 on: August 14, 2006, 02:40:31 AM »
I agree with Gerry 100%, not much to add, except if your doc is stubborn this is good too:

c. Kaletra/Viread/Epivir with Invirase.  The Invirase dose is two 500mg capsules 2 x day.

All these combos (a, b and c) need to be taken with food.

- matt
"The object is to be a well patient, not a good patient"

Offline newt

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #34 on: August 14, 2006, 02:58:32 AM »
To tell your doc...

"Dear doctor

Because of my resistance I need to be on these two nukes:

Viread + Epivir.

I also need to be on some protease inhibitors:

1. Kaletra OR 2. Kaletra + Reyataz OR 3. Kaletra + Invirase

I need to be on a strong protease inhibitor to get my viral load right down and prevent even more resistance.  Boosted Reyataz won't be strong enough on its own. I need to be on Kaletra at least. I would like to be on Kaletra  + another PI. I believe using two active protease inhibitors will be better for me right now because the nukes aren't working very well. 

I believe a phenotype resistance test is a good idea to find out how well the nukes are working.

I need to change my combination now, not in November.

Yours ever"

- matt

"The object is to be a well patient, not a good patient"

Offline Cliff

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #35 on: August 14, 2006, 04:32:11 AM »
Are there studies available that shows the results/impacts of combining Reyataz with Kaletra, particularly on drug levels?

Is Epivir similar to Emtriva, albeit slightly less potent?  Can Jena substitute Emtriva, (well Truvada actually), as opposed to using Epivir and Viread separately, (you guys mentioned Truvada earlier, but the recommendation changed slightly to Epivir/Viread)?  I don't know if Jena is paying drug co pays, but if she is, that could be a way to lower her quarterly/monthly drug bill (and pill count).
« Last Edit: August 14, 2006, 04:51:44 AM by Cliff »

Offline gerry

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #36 on: August 14, 2006, 09:22:44 AM »
Cliff:

Read posts 22 and 23 which have the answers to your questions.

Gerry

P.S. All you need the Epivir to do is to keep the virus mutating into the 184V (one of Jena's already established mutations) so Viread could work better.  This means that Epivir by itself would not count as an active drug; therefore the potency issue between Epivir and Emtriva is quite moot.  Certainly, Jena can switch to Truvada later once she is almost out of the Viread that she already has on hand (but was not given the prescription for either Epivir or Emtriva to add to it).
« Last Edit: August 14, 2006, 09:32:53 AM by gerry »

Offline Cliff

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #37 on: August 14, 2006, 09:41:52 AM »
Ah, got it.  Is it typical for patients to obtain a test of drug levels (TDM?) in this (and other) circumstances?  Or is it an unnecessary expense considering the studies available for review?

Offline ACinKC

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #38 on: August 14, 2006, 11:31:51 AM »
What an amazing thread!  Family at it's best.  Knowledge is power people!
LIFE is not a race to the grave with the intention of arriving safely
in a pretty and well-preserved body, but, rather to skid in broadside,
thoroughly used up, totally worn out, and loudly proclaiming--WOW! WHAT A
RIDE!!!

Offline newt

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #39 on: August 14, 2006, 12:21:00 PM »
Cliff, in the UK it would be routine for people on double PI combos to get their drug levels measured. It would be free to the patient (paid for by the pharma co's or NHS). - matt
"The object is to be a well patient, not a good patient"

Offline Jena

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #40 on: August 14, 2006, 03:29:18 PM »
OK!!!
 I spoke to my case manager this morning. He called the new  doctor's nurse and they moved my appointment up from November to next Monday morning!!!  I have all the information from this weekend.

MATT AND GERRY YOU GUYS ROCK!!!!  THANK YOU!!!!

Offline Life

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #41 on: August 14, 2006, 03:54:25 PM »
You GO Girl! ;D

Offline Eldon

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #42 on: August 14, 2006, 05:11:37 PM »
Hello Jena, they gave you an earlier appointment, this is good news!

Offline blondbeauty

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #43 on: August 14, 2006, 06:26:20 PM »
You did very well, Jena. You couldnīt wait till November.
Good luck in your next appointment.
 ;)
The only member in these forums approved by WINBA: World International Nail and Beauty Association.
Epstein Barr +; CMV +; Toxoplasmosis +; HIV-1 +.
Counts when starting treatment:
V.L.:80.200 copies. CD4: 25%=503
Started Sustiva-Truvada 14/August/2006
Last V.L.count (Oct 2013): Undetectable
Last CD4 count (OCT 2013): 52%= 933

Offline anniebc

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #44 on: August 14, 2006, 07:27:55 PM »
Hi jena

Your gaurdian angels are certainly looking  after you...thinking of you, please keep us posted.

You guys are amazing....hugs to you all


Hugs Jena

Jan :-*
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Offline jack

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #45 on: August 14, 2006, 07:47:12 PM »
I am in a similar situation. My Dr. has a lot people in our situation on Kaletra, just Kaletra. He has had pretty good results. He has many patients out of options. Of course it only worked a couple of  months for me.
I an now on tmc 114 which has just been approved and is called something else which I cant remember at this moment. I take it with a small dose of norvir and one truvada today. Who knows, I was resistant at one time to norvir and also to emtriva and viread which are in the truvada. My vl is back down to undetectable for the second time ever(its only been a couple months) and my ts are stable at 230. I was very sick the first couple of weeks,and I am sure it was the truvada cause emtriva and viread made me sick, but has subsided and I only feel crummy two or three days a week.

Offline Nadine

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #46 on: August 14, 2006, 07:48:02 PM »
Hey Jena,
I'm so happy to hear that you can go see the doc next Monday.
You guys are amazing....hugs to you all
I second that! You guys did a wonderful job getting information to Jena. 

Hang in there honey! You are in my thoughts and prayers.


Offline jack

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #47 on: August 14, 2006, 07:53:05 PM »
this was the study I was in. I guess I was the one loser who failed.
http://www.thebody.com/confs/icaac2003/pierone2.html

Offline gerry

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #48 on: August 14, 2006, 11:01:00 PM »
Jena:

One final note about the follow-up question I submitted to Dr. Gallant (here's the link)



Q: Thank you for your response, Dr. Gallant. As a follow-up question, about double-boosted PI, would Kaletra/Reyataz/Truvada be a reasonable option or would you be concerned about the atazanavir/tenofovir interaction? Or would you recommend Kaletra/Invirase/Truvada instead since there would be no interaction to be concerned about? Thanks again for your time and expertise.

Dr. G: Based on her resistance profile, either choice should be fine. We have a little more data on Kaletra/Invirase than on Kaletra/Reyataz, though it's worth noting that we don't have a lot of data on ANY double-boosted PI regimen. I wouldn't worry about the tenofovir interaction, because it's compensated for when you boost atazanavir with ritonavir (in this case, using the ritonavir that's contained in Kaletra).




This has not really changed any of the recommendations above, just reinforces that if you go the Kaletra/Reyataz/Viread/Epivir (or Truvada to replace the Viread/Epivir) route, you have one expert backing you up.  Good to hear about the appointment.  Now you can move forward more confidently.

Gerry

Offline Jena

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Re: GERRY AND MATT I NEED YOU!!!!
« Reply #49 on: August 15, 2006, 06:15:53 AM »
Thanks Gerry

 


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