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An Update

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jkinatl2:
Well as I see it, there are a ton of other medication options available to the person. Is there a reason he can't just switch to a new combo?

I have loads of friends who are long term survivors, and many of them stay on antiquated combinations until things get dicey - from lipo to crazy lipid levels and other stuff. I don't know where you are, but is there a reason why a new combination can't be tried?

Sorry, I am not Newt, but I have been on a bunch of drugs for HIV and though my current combo is doing great things for my viral load, it's not nearly as nice for my lipids and blood pressure as I would prefer. At the end of the year, some new drugs will be out and perhaps available through Medicare, and I find myself in the position to be researching new combos to deal with these issues.

Clara zetkin:
Thank you for your reply Jkinatl2! Really appreciated.
 
I know there are other medications out there and to tell you the truth I am not sure why the doc did not change his combination on the last visit...Maybe she did not want to make a new change to his regime too quickly also because of the things he is dealing at the moment - (loss of his mother and other losses in the family...). But if his viral load continues to raise, I think there is no really other options. And maybe it's just worth changing even if it remains the same...! I tend to think that this will be the right thing to do. I am just unsure about cross-resistance and what his options are. I suppose we have to trust the doctor on this one.

It's (always) good to know new drugs are coming out and hope that once this happens you find a combo that works for you and that does not cause you too many side effects.

Thank you again and take care.

newt:
Hello

I am unclear in my mind why exactly your doc changed the combination in the first place. A viral load of around 400 followed by 70 is not a rising viral load.

Up to 50% of blips are down to lab errors. Find out if there are new machines at the lab, or new people doing the tests. Ask the doc if many others have had a similar experience.

Daranuvir and Indinivar is not a useful combination. Indinavir is an old drug no lon ger used, really. Darunavir is given with a small dose of Norvir as a booster, which makes the darunavir last in the body a long time. I am hoping you really meant Norvir not Indinavir...

How the gut absorbs drugs can affect drug levels, so any GI problems need sorting.

The doc can measure drug levels with a test call TDM (therapeutic drug monitoring) and if necessary up the dose of the darunavir (or change meds if none at all is measured, occasionally people's bodies just won't accept a particular drug).

Food is important with darunavir too, you mus take the meds with some.

Using darunavir 600mg 2 x day rather than 800 mg 1 x day dose is probably a good idea.

Swapping the Kivexa for Truvada might help. It would be common to consider making this swap.

Adding Isentress (raltegravir) might help too (will help rather than might, I would bet).

I am inclined to believe the resistance test results. A viral load around 500 is enough virus for an informative test.

Since resistance emerges slowly on darunavir you have time to check this out. Many months.

There is a phenomenon where people with suppressed virus get a series of blips and then everything settles down. Something of a mystery. It doesn't seem to affect long-term outcomes or generate resistance.

Hope this helps

- matt

Clara zetkin:
Matt, this is very helpful! I cannot thank you enough.

About the change, I think the doctor was concerned about Viramune as she mentioned that resistance to it can develop quickly and she said “considering that he stayed quite a long time on that regime"...I think she thought this was a prudent strategy.

Anyway, I’ll certainly ask her to do a TDM test if the viral load is still detectable at the next visit, as well as mentioning the possibility of using Daranuvir 2 x day and of swapping Kivexa for Truvada!

I also ask about the possibility of adding Isentress.

(He does take Daranuvir with food but perhaps not as strictly as he should (sometimes after half an hour)...GI problems, yes...but not that much. However, I suppose we are all different and the problems he is having might be enough for him...the TDM test should tell us that).

The doc mentioned that she was seeing an increase in blips lately and that the people at the lab test wanted to count viral load under 20 (where undetectable = <20) but they refused. But she did not say anything about new machines or people. I’ll ask this too.

We’ll let you (all) know how things progress.
Thanks all and take care,

Clara

P.S. yes Norvir not Indinavir (not sure where I got that from... ???).

newt:

--- Quote ---to count viral load under 20
--- End quote ---

hmmmm....

Strictly speaking 20 or under is undetectable.

UK uses under 50. There is good reason, since there is evidence that under 50 on viral load indicates the virus is fully supressed and doing nothing. So, in which case, what is the point of counting lower?

One of the tests that measures down to 20 is flaky and when it was used in the UK docs were counting 200 or less as undetectable, and seeing lots of blips in the low hundreds...

The manufacturers have corrected the error, but there's nowt to say labs didn't buy/aren't still using an older version.

If the doc is seeing lots of blips in patients with a long record of being stable with suppressed virus, I, personally, would suspect the lab, especially if adherence has been, as you indicate, nigh on perfect.

- matt

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