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Author Topic: Can I stop after just one dose? (Combivir + Nirvirapine)  (Read 1116 times)

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Offline open_end

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Can I stop after just one dose? (Combivir + Nirvirapine)
« on: November 13, 2013, 12:54:17 AM »
Hello all,

This is my first post and I am very glad to be here. Never knew there was such a place until i tested positive but the support I have seen shown to others and the amount of knowledge shared is inspiring.

Now to the subject of my post.

I'm not sure my doctor know what he is doing unfortunately my suspicion is coming after taking one dose of the regimen he prescribed.

My CD4 count taken on Oct 11 was 589 yet he placed me on combivir and nirvirapine. My reason for wanting to stop is because I don't think I have the right support system yet and might be doing more harm to myself than good by following this doctor blindly.

He didn't inform me of the lead in period for the viramune based drug and when i told him he just said "yea do that". he did not give me a follow up date to test the effects on my liver etc. I have asked for a print out of my lab results and he keeps shrugging it off like it is no big deal. I informed him of the concerns regarding CD4 > 400 and the use of the drug and he shrugged it off too but from further reading i think its a big deal.

My question is what are the implications of stopping HART treatment after just one dose? Will I become resistant to this class of drugs as a result?

My next dose should be taken in 2 hours. I am really considering not taking it. I plan to go to the hospital and discuss with another doctor before stopping  but i am worried there is no HIV specialist there and I don't have immediate access to other hospitals.

For a bit of context, I am in Nigeria but I have access to a fairly good hospital by Nigerian standards on account of my job. 
« Last Edit: November 13, 2013, 01:02:06 AM by open_end »

Offline newt

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Re: Can I stop after just one dose? (Combivir + Nirvirapine)
« Reply #1 on: November 13, 2013, 04:33:38 AM »
Hello

There is a small chance after one dose of viramine of a temporary resistance to viramine and some similar drugs. If it happens, this seems to fade after about 12 months.

Your CD4 count is within normal range, and there is no advantage in terms of risk of illness or death in taking antiretrovirals now. So you have time to think and put in place support systems.

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

Offline open_end

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Re: Can I stop after just one dose? (Combivir + Nirvirapine)
« Reply #2 on: November 13, 2013, 05:43:46 AM »
thanks newt. can you share some more details on this temporary resistance? thanks.

i took the pill this morning because i wasn't sure what to do. the doctor i saw this morning was even more clueless but he insisted i continue the therapy until the first doctor weighs in. i will try to see that one this afternoon.

anyone with more info on developing resistance after short exposure please weigh in. i read that when given as a single shot to pregnant women some developed resistance i don't know how applicable that is to my case though.

my plan is that if i don't get more comfortable after the meeting with the doctor this afternoon, i will stop the treatment until i have more competent advise.
« Last Edit: November 13, 2013, 05:46:00 AM by open_end »

Offline leatherman

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Re: Can I stop after just one dose? (Combivir + Nirvirapine)
« Reply #3 on: November 13, 2013, 10:19:27 AM »
thanks newt. can you share some more details on this temporary resistance?
resistance is a mutation of the HIV that allows it to be unaffected by a specific medication. However, not all mutations are good - meaning not all mutations allow the virus to be "stronger".  Several types of resistance/mutation actually make HIV a non-viable organism and unable to replicate properly.

temporary resistance then is when HIV develops a specific type of mutation. Because the HIV is too damaged to reproduce properly "eventually" (an undetermined time period), all of these mutated HIV will die off leaving only healthy unmutated HIV - which would once again be susceptible to the medication.

my HIV developed resistance to epivir; however 5 years later a test revealed that epivir would once again be effective against my HIV.
leatherman (aka mIkIE)


chart from 1992-2013; updated 2/09/13  Reyataz/Norvir/Truvada

Offline eric48

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Re: Can I stop after just one dose? (Combivir + Nirvirapine)
« Reply #4 on: November 13, 2013, 06:04:04 PM »
Hi, (and welcome to the forums)

I started V at CD4 500 and it scared the shit out of me.

I had very proper follow up by my veteran doctor (he likes V...)

I have questionned him and he said that in his entire career he knows of only 3 cases of people dying before the <400 and < 100.000 rule came into force.

In his mind, this screening is too conservative.

He mentioned recent work done in order to see if the < 400 could be lifted and sounds like it could.

He said he would be confident to start as high (but not exceeding) 600 (for males)

One problem is the boot up dosage which is 200 mg /day for about 15 days, then 2 x 200 mg / day in twice daily if doctor allows (no major problem reported, I suppose) for 6 months, then you can go 2 x 200 mg / day once daily.

This is the 'standard' dosing pattern (more or less) for IMMEDIATE release Nevirapine (Viramune). On Extended release (400 mg/pill once daily), one should still follow the 2 weeks bootup. Problem: nowhere we can find the 'old' immediate release, which you need. I 'll see him soon and will ask

While your doc seems to take things lightly, mine did it by the book. He runs the clinic and does not want trouble: Yet, he told me that, with (his) proper follow up at initiating and swift action ready in case of rash or liver pb , etc, NVP has never been a problem for him.

he said that he is more favorable to NVP than most doctors because he is doing a lot of consulting jogs for training docs in Africa and he think that NVP is underrated and does a better job than younger docs get to learn in the books.

I have leaved 6 months in anxiety
(see www.tinyurl.com/HIVPharmaCure for the entire story)

Sound like management in some countries is more based on docs experience than on lab results ... They kind of work on a trial and error basis, kind of. Did you have a resistance test done?

Anyway, I can sympathize with the anxiety, yet, based on what my doctor told me about initiating at > 400, I think you should put it to rest.

If NVP+Combivir was offered to me at CD4 like yours, I'd rather wait, not so much because of the NVP, but, because better options than Combivir might become available in your country one day or another

You may want to have another doctor involved, like a GP, in order to get your liver checked. In some countries you may get the extra lab test done for a fee, if you want the follow up done by the book. You go to a lab, without presciption and cash, that's it. then go to a GP in case the markers skyrocket. The markers to look for are ALT and AST. When the liver has a bad reaction, the makers raise up to several times the upper range value. The Lab biologist should be able to explain you if you are OK or if doctor visit is needed

Mine didn't move at all

I would hate to be treated with the kind of arrogance your doc seems to have, but, doc is one thing, meds another.

Meds are designed and tested and approved to help you even if the doc is a F**g B**d. Meds are at your bedside, doc is not.

Your doc may think he is underpaid and his time too worthy for paying attention to your concerns. Or, this is his way to make people more confident in their meds.
Dr Google, on the other hand is very good at generating anxiety

If someone would come to me and ask me what I think about initiating NVP at CD4 > 400, I'd rather say, don't do it, just because of the extra anxiety load
If  someone would come to me and ask me what I think about my starting NVP at CD4 > 400, I'd say that it went OK with me, and that I did it because I was really trusting my doc.

Sadly enough, though, my meds are at my bedside, while my doc is not ;-)


Hope this helps

Eric

     
« Last Edit: November 13, 2013, 06:14:36 PM by eric48 »
NVP/ABC/3TC/... UD; CD4 > 1000; CD4/CD8 ~ 2.0   safety stock : 2 months

Offline newt

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Re: Can I stop after just one dose? (Combivir + Nirvirapine)
« Reply #5 on: November 13, 2013, 08:41:59 PM »
Eric, whatever your doc says, it is an opinion, the data on nevirapine (viramune) rash/liver problems and starting this drug at high CD4 counts is extensive.

The reason the CD4 count warning is there for men with CD4 counts over 400 prescribed nevirapine is because an avoidable number of liver complications happen. This is data from many studies. This is what has been seen in many countries who have had to use nevirapine as first line therapy.

Granted, it is worse in women and less pronounced in men, and not a massive amount of people overall (maybe just under 1 in 20 to a little over 1 in 6) who get life-threatening effects from nevirapine at high or low CD4 counts, but would you risk a slightly higher than 1 x risk to maybe even 10 x risk of serious side effects when an alternative drug or a wait would avoid this risk?

I believe nevirapine is under-rated, it's side effect profile is all things considered good, it is a cheap, effective switch drug, but the cautions on starting at high CD4 counts are there for a reason (risk of serious liver problem and death).

- matt
« Last Edit: November 13, 2013, 08:52:32 PM by newt »
"The object is to be a well patient, not a good patient"

Offline open_end

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Re: Can I stop after just one dose? (Combivir + Nirvirapine)
« Reply #6 on: November 14, 2013, 06:42:34 AM »
thanks guys for the info. From all this discussion I think i rushed into starting the drug and I am very convinced I don't want to take the chance with the NVP and as Eric pointed out even combivir is not best.

so do i stop for now? my doctor thinks i should continue but it is my call.

Offline eric48

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Re: Can I stop after just one dose? (Combivir + Nirvirapine)
« Reply #7 on: November 16, 2013, 06:21:14 PM »
Hi,

sounds like your doctor is not explaining things properly.

Here is a patient's forum, you will find it helpful for many 'tweaks' and support. Yet, there are no doctors here, and these kind of meds can be tricky.

In a situation like this, you would usually get a : 'Talk to your doctor' answer

One other thing you may want to realize is that many patients, here, have access to a large panel of combos, at a zero or marginal cost to them.

So, in general, the issue with resistance is underestimated, because, I, or many posters, here, have (free or almost free) access to a plan B, even a plan C.

Decision making in some countries can be tricky. Some have a very limited selection of meds to offer, some have a growing selection (but not the entire range), etc.

Having seconds thoughts after starting meds is easier when you have a plan B or C at hand. People on this forum may not be fully aware of the drug selection available in Nigeria

On top of this, you may not have the luxury of some lab test that can guide your choices such as VL or resistance test (today or in the future)

Moreover, not all meds are equal when it comes to treatment interruption.

Combivir is not in use anymore where I live, so I have no clue.

NVP is still quite popular. Yet among all the many older and newer drugs that we have here at out disposal, I would rather think that NVP is the trickiest when you want to evaluate your risk of developing resistance.

Stopping meds (for the sake of convinience, or money saving,etc.) is not recommended. Yet some people do it, or , like myself, consider that this could be an option in the future and I expect more people will be tempted to do it, if they have a plan B.

If you would like to stop meds, then one question is the timing and procedure

And for this, you would really want to ask an expert opinion;

You may want to post your question on thebody.com

their forum is not at all like this one, friendly and supportive, but, answers are posted by MDs

And the answers there are usually: keep with your treatment and trust your Doc

you also have to know that there is still a good number of patients on Combivir and who do have the opportunity to switch out; They don't because Combivir was OK with them.

You may want to split your question in 2:
- Do I want to stop ?
and if yes
- Do I stop now ?

Stopping now or in 6 months (or 12)(when the Viral Load will most likely be down very much) , which one is more favorable ?

Stopping when VL is confirmed to be UD (or most likely to be so, in case VL measurement not available), that is, say in 6 to 12 months seems (to me, not an expert, and not giving an 'advise') more favorable than stopping now

I know this is not going to help much, but, I hope this one non-expert opinion may help you

Eric 
NVP/ABC/3TC/... UD; CD4 > 1000; CD4/CD8 ~ 2.0   safety stock : 2 months

Offline open_end

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Re: Can I stop after just one dose? (Combivir + Nirvirapine)
« Reply #8 on: December 02, 2013, 11:39:48 AM »
Hi guys,

Thanks for all the comments. After several discussions with my doctor, I decided not to stop the treatment. I had liver and kidney function tests done 2 weeks into the the drug and they were all normal. I will go for a follow up in another month or so.

Funny enough I have had no side effects so far. I know it is early yet but my doctor says that's a good thing. I'm trusting them while also being very vigilant.

I'm not super excited about the drugs available here and I plan to discuss this at higher levels. I guess I'll post updates here from time to time.

oh and i did get my lab results
CD4 - 586
VL - 35,567 copies/ltr.

 


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