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Author Topic: New combinations: What do you think?  (Read 2834 times)

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Offline buffaloboy

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New combinations: What do you think?
« on: December 31, 2009, 08:45:10 AM »
I started on HAART back in September with Atripla. Like many people the central nervous system side effects of the Sustiva in the Atripla were just too much for me and I had to stop.

I saw my doctor again in the middle of December and he talked about other combinations to try:

1) Nevirapine and Kivexa

2) Lamivudine and Truvada

So, are these combinations you'd be happy to switch to?  Has anyone been on them themselves and were they OK? What should I consider in deciding which of the two combinations to opt for? Or should I press the doctor to come up with something else?

If helps with your responses, I've had resistance tests done and I'm able to take drugs in all the classes at this point. My last viral load was 2,400 and CD4 count of 84.

I'm a bit confused about 'where next?' as far as medication is concerned, so any advice or guidance would be greatly appreciated.

Offline stephenhoward

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Re: New combinations: What do you think?
« Reply #1 on: December 31, 2009, 10:25:34 AM »
I'm on Truvada and Kaletra.  (2 kaletra at breakfast and 2 at dinner, 1 truvada 1 hour after lunch).  Load undetectable, CD count around 900 and percent around 40%.  Very pleased with that regimen.  Also got off Sustiva.

Hope this helps

Offline Trout

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Re: New combinations: What do you think?
« Reply #2 on: December 31, 2009, 11:01:56 AM »

I saw my doctor again in the middle of December and he talked about other combinations to try:

1) Nevirapine and Kivexa
2) Lamivudine and Truvada


Hi Buffaloboy,

1. Nevirapine (Viramune) + Kivexa.
You'll need to pass a HLAB5701 test (allergy) in order to use Kivexa.
A more common combination would be: Truvada + Viramune.

2. Lamivudine (Epivir) + Truvada
A regimen based on NRTI's only is a bit odd
Maybe you could combine the Truvada with a boosted PI (Prezista, Reyataz)
or with an integrase inhibitor (Isentress).





Offline buffaloboy

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Re: New combinations: What do you think?
« Reply #3 on: December 31, 2009, 02:12:00 PM »
Hi Buffaloboy,

1. Nevirapine (Viramune) + Kivexa.
You'll need to pass a HLAB5701 test (allergy) in order to use Kivexa.
A more common combination would be: Truvada + Viramune.

2. Lamivudine (Epivir) + Truvada
A regimen based on NRTI's only is a bit odd
Maybe you could combine the Truvada with a boosted PI (Prezista, Reyataz)
or with an integrase inhibitor (Isentress).


Oh, perhaps I got the second one wrong then. The doctor was scrawling things on a small Post-it as he was talking to me and then at the end of the conversation handed me the bit of paper and told me to go off and do my homework. But looking at it now, I can't really make any sense of it all as there's double ended arrows all over the place and doodles and then different drug names written amidst  all of that.

I wish there was a straightforward chart that showed all the different drug combinations so you at least had a clear sense of which drugs go together.
« Last Edit: December 31, 2009, 02:13:50 PM by buffaloboy »

Offline newt

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Re: New combinations: What do you think?
« Reply #4 on: January 02, 2010, 12:34:01 PM »
Ahem, lamivudine and Truvada, your doc suggested this!?!?!

No is the answer. This is so wrong.

The other suggestion, well why not keep Truvada, which is 2/3rds of Atripla and replace the efavirenz, the other 1/3rd, with sommat else? It is the efavirenz which is causing the dreams etc.

Nevirapine should be a straightforward swap, and, resistance permitting, any boosted PI or the integrase inhibitor raltegravir (Isentress) are options (ie what Trout said).

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

Offline Miss Philicia

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Re: New combinations: What do you think?
« Reply #5 on: January 02, 2010, 12:40:29 PM »
If you want something easy, I'd totally just go with Isentress + Truvada, in line with what matt/newt just stated in his last paragraph.
"Iíve slept with enough men to know that Iím not gay"

Offline Inchlingblue

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Re: New combinations: What do you think?
« Reply #6 on: January 02, 2010, 10:27:17 PM »
Lamivudine/Truvada is an all-NRTI combo which has been shown not to work very well (link below).

If that is one of the choices he suggested I would have serious questions about his competency.

LINK TO EUROPEAN TREATMENT GUIDELINES:

http://www.europeanaidsclinicalsociety.org/guidelinespdf/1_Treatment_of_HIV_Infected_Adults.pdf

   
A Quad NRTI Regimen Fails to Perform


LINK:

http://www.aidsmeds.com/articles/hiv_quad_nuke_2351_16979.shtml


I agree with what Newt and Miss P have recommended although as far as Isentress, it's an "Alternative" under European Guidelines (in the US it's one of the "Preferred" options) so he might give you a hard time but it's a great combo with Truvada, despite the twice a day dosing.
 
« Last Edit: January 02, 2010, 10:35:11 PM by Inchlingblue »

Offline buffaloboy

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Re: New combinations: What do you think?
« Reply #7 on: January 03, 2010, 04:01:46 PM »
Well,  like I say, the bit of paper the doctor handed me was very confusing, so it could easily be that I've got that second combination wrong.

To be honest, I feel quite weary of the whole thing as I'm not entirely sure how I'm supposed to reach any decision when the information presented isn't clear at all.

I'm not sure about Isentress in the UK - he definitely didn't mention that drug during the consultation, so I'm not sure how easy it will be to get him to prescribe it.

Offline Inchlingblue

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Re: New combinations: What do you think?
« Reply #8 on: January 03, 2010, 06:24:02 PM »
To be honest, I feel quite weary of the whole thing as I'm not entirely sure how I'm supposed to reach any decision when the information presented isn't clear at all.
 

Don't get too overwhelmed, choosing an initial combo for someone who does not have resistance issues is actually very clear and straightforward (as opposed to choosing a combo for someone who is heavily treatment-experienced and has resistances). Since you are in the UK, they follow European Guidelines so that's where you will get the information you need. The link above has the recommendations for starting on pages 14-15.

Basically there are "preferred" and "alternative" choices. Doctors and patients usually start with the  various "preferred" choices and see if there is a good fit looking at things such as pill burden and side effect profile, etc.  If there is nothing in the "preferred" that looks good, then take a look at the "alternative" choices.

The thing about Isentress is that in the US it's considered "preferred" and in the UK it's "alternative."  

As Miss P said, and I very much agree, if you want to simplify things just go for Isentress and Truvada. I started this combo in July 2009 and feel great, I'm not experiencing any side effects and went undetectable in less than 2 weeks. If you do a search on here you can find lots of info and read about the experience others have had with this combo.

As far as getting him to prescribe it, I find that the main concern that doctors have with Isentress is that it's twice a day dosing so they want to make sure that the patients who they prescribe it to will be adherent. My doctor initially had reservations for that reason (I think he has had experiences where some of his patients were less than adherent in taking their meds). I had to assure him that I take these things very seriously and am not likely to be missing any doses. Anyway, it's likely to be approved for once-daily use in the near future.

  


« Last Edit: January 05, 2010, 01:18:57 AM by Inchlingblue »

Offline buffaloboy

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Re: New combinations: What do you think?
« Reply #9 on: January 05, 2010, 12:39:44 AM »
''The thing about Isentress is that in the US it's considered "preferred" and in the UK it's "alternative." ''

Accordin to Wikipedia:

''Raltegravir is approved only for use in individuals whose infection has proven resistant to other HAART drugs''.

So does this mean that it's not actually that widely prescribed in the States at present?

Offline Inchlingblue

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Re: New combinations: What do you think?
« Reply #10 on: January 05, 2010, 01:17:23 AM »
''The thing about Isentress is that in the US it's considered "preferred" and in the UK it's "alternative." ''

Accordin to Wikipedia:

''Raltegravir is approved only for use in individuals whose infection has proven resistant to other HAART drugs''.

So does this mean that it's not actually that widely prescribed in the States at present?

If that's what Wikipedia says it's in need of an update.

In July 2009 it was approved for use by those starting meds for the first time and a few weeks ago when the US Guidelines were updated it was added as one of the "Preferred" first-line options.

LINKS:

http://www.hivandhepatitis.com/recent/2009/120409_a.html

http://www.aidsmeds.com/archive/Isentress_1639.shtml

Offline buffaloboy

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Re: New combinations: What do you think?
« Reply #11 on: January 05, 2010, 07:36:16 PM »
Which other drugs can Isentress be combined with, apart from Truvada?

Offline newt

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Re: New combinations: What do you think?
« Reply #12 on: January 05, 2010, 07:43:31 PM »
Based on existing research, tipranavir (a rarely used protease inhibitor) is probably the only drug to avoid - matt
"The object is to be a well patient, not a good patient"

Offline Miss Philicia

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Re: New combinations: What do you think?
« Reply #13 on: January 05, 2010, 08:57:12 PM »
Which other drugs can Isentress be combined with, apart from Truvada?

Most HAART regimens combine one class (in this case integrase inhibitor) with two meds from the NRTI class.  The reason you see it (and most other combos) using Truvada is that it's 1) two NRTI meds in one pill form, and 2) has the lowest incidence of lipo/body shape change issues
"Iíve slept with enough men to know that Iím not gay"

Offline Inchlingblue

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Re: New combinations: What do you think?
« Reply #14 on: January 05, 2010, 09:24:42 PM »
Which other drugs can Isentress be combined with, apart from Truvada?

For now, Truvada is the the drug that has been most studied in combination with Isentress so there's lots of data on it.

I'm on that combo, as I've mentioned before, and doing great but honestly, I'm not thrilled with Truvada since I have concerns about long-term kidney issues that it can possibly cause.

There have been small non-randomized studies that have looked at Isentress and Reyataz (unboosted) which looked very promising. There are more studies underway that will look at this combo more in-depth. It seems that Reyataz boosts the levels of Isentress (or is it vice versa?) so it looks like they work well together. If it's found to work I think it would be great since it would only be a two-drug combo hence fewer toxicities and cheaper to boot but it's not yet ready for prime time so it's best to be on the safe side and wait until the official results are in.

Somebody recently asked on thebody.com if Isentress/Epzicom (Kivexa) would work and the doctor basically said, yes.

LINKS:

http://clinicaltrials.gov/ct2/results?term=isentress+reyataz

http://www.thebody.com/Forums/AIDS/Meds/Archive/Thoughts/Q203136.html

PS: I just got my latest results today and CD4s are 686 with undetectable viral load. I started meds in July 2009 with about 9k viral load and about 330 (or so) CD4s. Liver and Kidney panels look good too.
« Last Edit: January 05, 2010, 09:42:29 PM by Inchlingblue »

Offline Okealyshire

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Re: New combinations: What do you think?
« Reply #15 on: January 09, 2010, 01:55:54 AM »
There have been small non-randomized studies that have looked at Isentress and Reyataz (unboosted) which looked very promising. There are more studies underway that will look at this combo more in-depth. It seems that Reyataz boosts the levels of Isentress (or is it vice versa?) so it looks like they work well together. If it's found to work I think it would be great since it would only be a two-drug combo hence fewer toxicities and cheaper to boot but it's not yet ready for prime time so it's best to be on the safe side and wait until the official results are in.

Sounds kind of interesting, but it's got me wondering. NRTIs and NNRTIs block HIV replication at an earlier step than integrase inhibitors like Isentress. For people who haven't acquired resistance to all available RTIs, wouldn't it make more sense to keep a couple of these in one's regimen? I'm trying to apply my computer security background here, where catching an intruder early is always better.

 


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