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Author Topic: 3 option combos  (Read 1800 times)

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Offline Valmont

  • Member
  • Posts: 328
3 option combos
« on: January 24, 2012, 07:37:52 PM »
Well, Im not yet for starting treatment, but it may be soon (my numbers this month:  VL: 95.000 that stays high and CD 4.  714).  Ive never been on meds, and am asymptomatic

I have 3 option, and would like your feedback about benefits and side effects  (I have an idea about what I may use at the beginning...):

Option 1: tenofovir 300 mhg+ emtricitabina 200 mg + efavirenz 600 mg, la dosis es 1 (una) sola tableta en la noche, una hora posterior a la cena y de preferencia al acostarse. 1 pill per day

Option 2: tenofovir 300 mg + emtricitabina 200 mg 1 (una) tableta per day + darunavir 300 mg (prezista) 2 (dos) tabletas  cada 12 horas + ritonavir 100 mg (norvir)  1 (one) pill each 12 hours. Total 7 (siete) pills each day.

Option 3: Tenofovir 300 mg + emtricitabina 200 mg 1 (one) pill per day + raltegravir 400 mg (isentress)  1 (one) pill each 12 hours. Total 3 pills each day

Thanks for reading and for your comments...
Apr 2011: Diagnotized
Jun 2011: CD4: 504  VL: 176.000
Dic 2011: CD4: 714  VL: 95.000
May 2012: CD4: 395 VL: 67.000
Jun 2012: CD4: 367
Agu 2012: Starting Emtricitabine 200 mg / Tenofovir 300 mg and Efavirenz 600 mg (2 pills) different brands or VIRADAY
Sep 2012: VL: 138
Dic 2012: CD4: 708 VL: <34  %CD4: 32%
Jan 2013: CD4: 707 VL: <20
May 2013: CD4: 945 VL: <34 %CD4: 33%
Agu 2013: CD4: 636 VL: <34 %CD4: 50% (is that possible?)

Offline buginme2

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  • Posts: 2,748
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Re: 3 option combos
« Reply #1 on: January 24, 2012, 08:10:10 PM »
They are all first line US recommended treatments so whichever you choose will be fine.

Personally, my first choice would be option 3.

Then option 1

Then

Option 2.


Good luck
"All I need are some tasty waves, a cool buzz, and I'm fine."

http://www.youtube.com/watch?v=6e0gcEC1TWE

Offline Valmont

  • Member
  • Posts: 328
Re: 3 option combos
« Reply #2 on: January 25, 2012, 08:37:39 AM »
Many thanks, bugin...  Can you explain why youd prefer this combo in relation with option 1?

My medic let me choose, but he did not explained me a lot about each of these solutions...

Well, I read the lessons here, and wht people says.  Many are well with option 1 or 3, but 3 has to be taken twice a day...

I realized I can activate french public insurance here in a few months, with a 100% couverture (but expensiiiiiiiiive; well, nothing in comparation with what means a good health...).

In Ecuador, only the first combo is available.

Despite my insurance can cover the cost of other meds, they may be difficult (impossible?) to find here.  Raltegravir is avalable...

Apr 2011: Diagnotized
Jun 2011: CD4: 504  VL: 176.000
Dic 2011: CD4: 714  VL: 95.000
May 2012: CD4: 395 VL: 67.000
Jun 2012: CD4: 367
Agu 2012: Starting Emtricitabine 200 mg / Tenofovir 300 mg and Efavirenz 600 mg (2 pills) different brands or VIRADAY
Sep 2012: VL: 138
Dic 2012: CD4: 708 VL: <34  %CD4: 32%
Jan 2013: CD4: 707 VL: <20
May 2013: CD4: 945 VL: <34 %CD4: 33%
Agu 2013: CD4: 636 VL: <34 %CD4: 50% (is that possible?)

Offline Assurbanipal

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  • Posts: 2,173
  • Taking a forums break, still see PM's
Re: 3 option combos
« Reply #3 on: January 25, 2012, 12:22:02 PM »
Hello Valmont

Just to translate the options so you get a few more responses:

Option 1 = Atripla
Option 2 = Truvada, Prezista, Norvir
Option 3 = Truvada, Isentress

Both Option 2 and Option 3 are twice a day for part of the therapy as listed.

If I were you, I'd start with option 3.

Even though it is twice a day, given what you've said about your schedule and work it may be the most convenient for you because it has relatively rare side effects and there are no food restrictions.  The second dose (and the first too for that matter) is heat stable and can just be put in your pocket to be taken when it is time.  It is really quite easy to manage, especially since it is small enough to swallow without water.

Both Option 1 and Option 3 have food restrictions -- Option 1 needs to be taken several hours after eating and can cause considerable grogginess if you have a tight schedule and need to be awake shortly after taking it.  Option 3 needs to be taken with food (twice a day). 

As far as side effects, Option 1 does have some side effects for many people that sound like fun (wild dreams and erections) but tends to cause depression and anger for a lot of people.  If you are in a bad spot emotionally or have suffered from depression, you might want to avoid it.  There's also some concern if you have a schedule where you might need to be on call, since many people have a period of several hours where they are groggy after taking it (which is why most people take it before bed).

Option 2 and option 3 seem to have less frequent side effects, although option 2 often raises cholesterol. Option 3 side effects seem to be relatively rare, although they can be serious when they happen (I'm one of the unlucky few percent who wasn't able to continue on raltegravir -- even though it was otherwise the most convenient regimen for me)

But they are all good options with some potential risks.  Many people have no problems.

Given what we know about how easy it is to switch from med to med without a problem these days, I'd start with the most convenient and see if it works out well for you.  If there's a problem -- switch.

Best
Assurbanipal

P.S.  the above assumes that you have no drug resistance.  If you haven't done so, make sure you have gotten a resistance test before you choose a regimen.
5/06 VL 1M+, CD4 22, 5% , pneumonia, thrush -- O2 support 2 months, 6/06 +Kaletra/Truvada
9/06 VL 3959 CD4 297 13.5% 12/06 VL <400 CD4 350 15.2% +Pravachol
2007 VL<400, 70, 50 CD4 408-729 16.0% -19.7%
2008 VL UD CD4 468 - 538 16.7% - 24.6% Osteoporosis 11/08 doubled Pravachol, +Calcium/D
02/09 VL 100 CD4 616 23.7% 03/09 VL 130 5/09 VL 100 CD4 540 28.4% +Actonel (osteoporosis) 7/09 VL 130
8/09  new regimen Isentress/Epzicom 9/09 VL UD CD4 621 32.7% 11/09 VL UD CD4 607 26.4% swap Isentress for Prezista/Norvir 12/09 (liver and muscle issues) VL 50
2010 VL UD CD4 573-680 26.1% - 30.9% 12/10 VL 20
2011 VL UD-20 CD4 568-673 24.7%-30.6%
2012 VL UD swap Prezista/Norvir for Reyataz drop statin CD4 768-828 26.7%-30.7%

Offline newt

  • Member
  • Posts: 3,868
  • the one and original newt
Re: 3 option combos
« Reply #4 on: January 25, 2012, 02:29:16 PM »
All 3 work very well

For people who have never done treatment, darunavir is generally prescribed as 800mg darunavir (2 tablets) + 100mg ritonavir (1 tablet) 1 x day. With the tenofovir/emtricitabine tablet this = 4 tablets 1 x a day.

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

Offline eric48

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  • Posts: 1,010
  • @HIVPharmaCure & tinyurl.com/HIVPharmaCure
Re: 3 option combos
« Reply #5 on: January 25, 2012, 04:51:29 PM »
It is always difficult to answer a question like this when you have no experience on either of the meds.
(I chose a fairly 'unusual' combo and pretty happy I did - I would do the same choice now that I learnt more, so...)

A lot of factors enter into that choice : availability, cost, ease of use etc.

One of the points I can tell from a risk management point of view (and not medical) is that:
my combo is initially 2 x /day and after 6 months my doc allowed to take 1 x /day (off label).
Therefore I have experience both.
One should not underestimate the convenience of the once daily. The number of pills is not an issue since you will most likely take some other supplement or vitamin along with it, any way.

I can assure you : once daily is real cool. Some people (including myself) can stand the morning intake (some can't)
The one thing about morning is that once it is done you do not have to worry about it any more, no need to carry pills (unless you have a plan to sleep out, but you can organize yourself more freely)

One person was mentioning that he was embarrassed swallowing in front of friends at diners or at work. He also has to take his meds with food... He drives all the way home just for that! Me, I do not have to worry about it.
Think of food. The easiest one to fix is breakfast (which you usually take at home...)

One of the benefits of option 1 or 2 it that it lets open the other one in case the first fails
Option 3, in case of failure might be more tricky. This WAS explained in the previous version of:

http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf

(I did not really understand the point, but, it was written by experts so I think it is a point worth considering, but, of note, I could not find that comment again in the latest version)

the other question is:

ANY meds has risks (short terms or long terms). Long term is was you would want to avoid most. Short term are easily noticeable and a switch can be done timely, without any harm left behind
(sudden death being one exception...)
on long terms risk, they are now, with current meds, either minimal (as far as we know) or unknown (because the drug is pretty new, for example RAL)
Short term risks are pretty well identified

So the risk management question is:

should one take the very low (short term) risk as a first option or the other way around.
I think it is worth considering taking the one that has the highest incidence of short term reversible SE.
Because, in case you fail on this one (about 20% patients experience failure on their first regimen, at least as per published clinical studies, I suppose it is much less if you can be really adherent)
then your plan B is the one with the higher incidence of short term SE, which is no fun...

it is said that about 20% have to quit option 1 . then , go to option 3: no problem
On the other hand if you virologically fail on option 3, then you have to switch to option 1 . Stress...

Of 2 dishes, which one to take first? the one you prefer or the other

So I think that choosing plan A should take into consideration what plan B is.

Option 1 will sooner have generics, so if, in the course of your life, funding (or getting insurance becomes a problem), then you may be on the safer side.
You will also want to make sure that your insurance will cover option 3 which is, here where I live, significantly more expensive than option 1.

Option 1 is the most popular: most likely not without reasons

At the time I started, Option 3 was NOT covered by my insurance, so for me, was not an option. you will really want to verify that first.
at that time, it was not yet known if option 3 would ever become a Once daily. I was hopefull. It turned out that it must be 2 x/day

Due to my own specifics, I decided to shy away from option 1 and 2 and decided to go for a recommended alternative option (viramune + kivexa)
The initial risks are higher, but, now that I have passed that, I'm fine with it...

While you ALWAYS have the right to ask for a switch, once successfull on one regimen, many docs are reluctant to switch

So this choice of first regimen is at the same time not irreversible, but still important

Good Luck

Eric

PS: at of today, you are not elligible for my combo, as your CD4 count is way higher than the imposed limit of 400 (although, my doc said this limitation will be revisited, he once mentionned that he would be reluctant to offer it to people with CD4s 600 and above)
« Last Edit: January 25, 2012, 05:07:12 PM by eric48 »

Offline Valmont

  • Member
  • Posts: 328
Re: 3 option combos
« Reply #6 on: January 25, 2012, 08:10:02 PM »
Thank you Assurbanipal, Matt and Eric, for your large and interesting point of view, with many details, definitively veru usefull...

Ive check, the insurance can cover Isentress at 100%, but it should not be used as a first option, which may generate some problems...  This seems me the best option because of side effects....

Option 2, may not be a good option for the beginning...

Im lucky, my CD 4 are still high (for how long with my VL?), so I can see with tranquility the best option for me...  On abril, Ill do a Genotip test, which will give me more information  about what to do...  I dont want to wait so much and see my CD 4 going very low...
Apr 2011: Diagnotized
Jun 2011: CD4: 504  VL: 176.000
Dic 2011: CD4: 714  VL: 95.000
May 2012: CD4: 395 VL: 67.000
Jun 2012: CD4: 367
Agu 2012: Starting Emtricitabine 200 mg / Tenofovir 300 mg and Efavirenz 600 mg (2 pills) different brands or VIRADAY
Sep 2012: VL: 138
Dic 2012: CD4: 708 VL: <34  %CD4: 32%
Jan 2013: CD4: 707 VL: <20
May 2013: CD4: 945 VL: <34 %CD4: 33%
Agu 2013: CD4: 636 VL: <34 %CD4: 50% (is that possible?)

Offline eric48

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  • Posts: 1,010
  • @HIVPharmaCure & tinyurl.com/HIVPharmaCure
Re: 3 option combos
« Reply #7 on: January 26, 2012, 06:21:42 AM »
cover Isentress at 100%, but it should not be used as a first option, which may generate some problems... 
Option 2, may not be a good option for the beginning...

Hi,

This is very precisely why I suggested you really check and cross check with this insurance coverage before making any decision.

I do not make comments on meds I do not take. I know that many docs I have met seems relieved when I told them that I have never been using PIs (part of your option 2). Use of PI was a question asked by my neurologist, cardiologist, etc. I think older PI may have had some issues. Newer PIs , though, may be a different story...

I am not implying that PIs are not 'preferable' : they save lives !

The decision (and actually your question about options) should be taken AFTER the resistance test is done anyway

In my case both PI based and PI saving options where available. My doc said that he prefers to offer PIs when the resistance test mandates PIs or is otherwise quite complex. He mentioned it is his preferred option also in case someone has (very) low CD4, since one does not have the luxury of time and failure is not an option.

My personal, naive, newbie, choice for myself was:
option3, 1 then 2. When I learnt that 3 would not be covered for first line, I was really upset!
When my doc offered to me option V&K I was very surprised.

If you start with option 1 and have problems with the CNS effects (incidence about 10%) and they do not resolve, please bear in mind that , then , the option Viramune + Truvada becomes a valid option for you with the benefit of lower incidence of CNS effect with viramune (ca 1%) AND the low cost (and generic availability) AND still once daily. The reason is that, despite option V&T, is NOT an option for treatment naives with CD4 > 400 (males), it is an OK option as second line.
After you have initiated option 1 , you are NOT treatment naive anymore...
If consider that option in case of CNS effect, I would nonetheless recommend that you try to bear with the option 1 , if this is possible, until you are UD. A switch for reasons other than virologic failure, seems easier once the patient is UD

In other words, V&T or V&K can not be part of your plan A, but can be of your plan B...

A few people here have made that switch and are happy with it.

Once again you have time and should not worry about options until you get the genotype results

Even when you get these, you will still have time to revisit your options and decision taking...

Hope this helps
« Last Edit: January 26, 2012, 06:26:14 AM by eric48 »

Offline jason1972

  • Member
  • Posts: 8
Re: 3 option combos
« Reply #8 on: January 26, 2012, 10:52:12 AM »
I am curently taking option #1 but was not my 1st treatment..

The two times meds where a topic alot of things came up.
I have a great ID doc and always explains all my options to me in great detail.
have you ever seen you geno maping it might help make a better choice it did for me..even though my virus could of been crontroled by alot of different combos my geno type showed there was a best option for me..I trust my doc and with his assistance I make the best choice for me..

In the end it is your choice and i could tell you all the good things about what I take but it might not be the best thing for you that is something needs to be disscussed between you and your doc..and part of that is having a good realationship with you ID doc and trusting in what he tells you..

Offline Valmont

  • Member
  • Posts: 328
Re: 3 option combos
« Reply #9 on: January 26, 2012, 01:26:24 PM »
For sure, this is my choice, that is also what my doc says...

Well, here, it is impossible for me to switch of doc, there are so little.  My has the best reputation from the infected people, he is very kind and available, and also always answer to any doubt by mail.  Well, he does not explain a lot about therapeutic option because here, there is not a lot for choosing and people generaly dont ask a lot to the doc...

Im lucky to have the possibility to have a good insurance, that allow me to get other kind of medecine that are not offered in a developping country, by the way, despite my doc knows them, he has not so many experience with them (they only use it in extreme cases, when the other medecines dont work)...  Also, I have to consider to make the deal to buy some drugs directly with pharmaceutic companies, this is the case with Isentress, and because here they are sold cheaper than in developped countries, I noticed that they dont like a lot selling them one client to on client, it means some work for them they dont seem to like doing..........  With Merck, well, they are kind, but it sucks to have to bargaring the prices (it is not because I have an insurance they have to rise it up...)...

Having VIH here is all an adventure, by the way, all this makes me distraction and I dont have time to think of the bad ways relationated with HIV, no time for depression too...

Well, after the genotype test (another adventure because of laws, papers and prblem for selling results by mails...), Ill be completelly ready for the day I will have to start medecine...


I like option 3, but logistic fact and insurance can give me some problems...  It is so difficult to have information from the insurance about it....

Option 1 is a better one in relation with my reality.  I dont like a lot side effects relationated with depression (well, since Ive been diagnosticated, Ive been very very well; but in the past I used to have some low depresive levels). Anyway, I undestand I can change to option 3 in the future...

Genotype test will confirm everything, despite my doc says that there are very very little resistance to meds here in comparation with other countries...
Apr 2011: Diagnotized
Jun 2011: CD4: 504  VL: 176.000
Dic 2011: CD4: 714  VL: 95.000
May 2012: CD4: 395 VL: 67.000
Jun 2012: CD4: 367
Agu 2012: Starting Emtricitabine 200 mg / Tenofovir 300 mg and Efavirenz 600 mg (2 pills) different brands or VIRADAY
Sep 2012: VL: 138
Dic 2012: CD4: 708 VL: <34  %CD4: 32%
Jan 2013: CD4: 707 VL: <20
May 2013: CD4: 945 VL: <34 %CD4: 33%
Agu 2013: CD4: 636 VL: <34 %CD4: 50% (is that possible?)

Offline eric48

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  • Posts: 1,010
  • @HIVPharmaCure & tinyurl.com/HIVPharmaCure
Re: 3 option combos
« Reply #10 on: January 26, 2012, 04:03:23 PM »
Hi,

In socialized health system, it is not uncommon practice that doc or patient may have to request authorisation from the insurrance.

Insurrance have their own doctors and if they think the treatment is costly and that there are cheaper alternatives, it is in the general interest of the insurred general public that they ask to reconsider and or deny that (expensive treatment).

Insurrance are also kind people but not 100% charity.

They have 2 ways of barring you from benefits:

A- with CD4 at 700, they can claim they you are not IN NEED for treatment. that value is usually set at 350.
B- Option 3 cost about 3 times option 1

I had that discussion with my doc. My CD4 where in 450-550. Insurrance COULD have denied coverage. If I was asking for the most expensive treatment, that would definitively give them a point.

He suggested that I take no risk: ask for treatment (eventhough I am not classified as in-need for it), but ask for a reasonnably priced.

Bear in mind that, expecially in socialized health care, insurrance may have their say-so.

It is fear enough. You get the luxury of early treatment for a small insurrance premium.

If you are lucky, you can hope to travel in second class with a third class ticket.
Hoping to travel first class with a third class ticket, may be asking for too much.

Things will go in that order:
get the resistance test results
get your doc recommendation
make sure you have the insurrance thumbs up

And do not be upset if you can not get option 3 at first. Option 1 works fine for a vast majority of people...

What upsets me though, is that as long as I&T was a second line treatment only option, it made sense that the drug manufacturer asks for a higher price.
It is a bit disappointing that they did not lower the price when it became approved to treatment naives (first line). They have significantly increased their market size and not lowered the price by one cent...

Cheers

Eric


Offline Billy B

  • Member
  • Posts: 374
Re: 3 option combos
« Reply #11 on: January 27, 2012, 12:34:05 PM »
Hello Valmont,
I picked #3 and it has been very easy for me. The 2x daily Isentress is no big deal since it can be taken without food.
Peace,
Billy
VL 4420 CD4 340 CD4% 24   3/15/10 Started I&T
VL  UD   CD4 340 CD4% 26.5 05/13/10
VL  UD   CD4 360 CD4% 27.1 08/3/10
VL  UD   CD4 310 CD4% 28.4 11/22/10
VL  UD   CD4 420 CD4% 27.9 02/11/11
VL  UD   CD4 370 CD4% 26.4 06/08/11
VL  UD   CD4 360 CD4% 27.7 09/23/11
VL  UD   CD4 370 CD4% 28.3 01/20/12
VL  UD   CD4 430 CD4% 28.8 05/11/12
VL  UD   CD4 370 CD4% 28.1 09/07/12
VL  UD   CD4 390 CD4% 32.3 03/14/13

Offline Valmont

  • Member
  • Posts: 328
Re: 3 option combos
« Reply #12 on: January 27, 2012, 03:20:23 PM »
Thank you Eric, youre kind, yoularge message is very usefull...

I go to France next month, so Ill be able to ask directly to insurance, I will also do genotype tests there at that moment... 

I dont want to start treatment at CD 4 above 700, by the way I will do at 500.  My VL is high and I think I will see my CD decreasing quickly, that is why I want to be ready (I think Im lucky to be able to plan well the start of a treatment...)

Good data, Billy, thank you...
Apr 2011: Diagnotized
Jun 2011: CD4: 504  VL: 176.000
Dic 2011: CD4: 714  VL: 95.000
May 2012: CD4: 395 VL: 67.000
Jun 2012: CD4: 367
Agu 2012: Starting Emtricitabine 200 mg / Tenofovir 300 mg and Efavirenz 600 mg (2 pills) different brands or VIRADAY
Sep 2012: VL: 138
Dic 2012: CD4: 708 VL: <34  %CD4: 32%
Jan 2013: CD4: 707 VL: <20
May 2013: CD4: 945 VL: <34 %CD4: 33%
Agu 2013: CD4: 636 VL: <34 %CD4: 50% (is that possible?)

 


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