Protease Inhibitors vs Itegrase Inhibitors

[efox020]

Hello,

I'm on my second treatment option Triumeq. I was initially on prescobix/truvada but switched due to that I developed severe tinnitus while on the PI regimen.

My doctor said last time that if my VL doesn't drop faster he would switch me back to a PI regimen.

Are PI's more effective reducing VL? I Don't want to switch and risk another round of unknown side effects again. I Was on the PI regimen for four months and the last two on the triumeq. Current VL 750 cd4 5%.

He left a message today that I'm due for labs. My fear is that if my VL has not dropped enough I would have to change treatments again I dont like this risk unless absolutely necessary.

And what PI would be better? I read that Tivicay has one of the better safety profiles.

I'm confused.

[eric48]

Not all guidelines are the same.

Ours say that the requirement is:
- VL drop of at least 1 log at month 1 (1 log drop means it has been divided by a factor 10)
- VL below 400 at month 3
- VL below 50 at month 6

While I did pass, I noticed that some doctors or guidelines are somewhat more relax with the targets, as long as it keeps going down.

Technically, a VL of 750 at month 6 is defined as virologic failure.
At that level, a resistance test is doable.

Virologic failure does not necessarily mean resistance. Somes times, the situation resolves by itself and/or no resistance is detected.

100% adherence is a must do to achieve treatment target, namely viral suppression (aka UD, i.e. VL <50)

Virologic failure must be handled by expert virologist.

With a CD4 % in the low range, your initial VL was most likely very high. Therefore, targets, as defined like above, may be nuanced accordingly.

You may want to know that it is possible to increase bio-availability of 2 components of Triumeq by taking it with food. (namely Abacavir and Dolutegravir)

In some trials with difficult to treat patients, it has been possible to achieve target by doubling the amount of Dolutegravir, which, in your case would mean adding one Tivicay to Triumeq.

Also make a note that in clinical trials including treatment naive patients (naive to INI...) , resistance to Dolutegravir has never happened, as pointed out by Dr Weinberg, a INI expert.
This is supported by clinical practice

An adjustment of regimen will most likely be discussed with your doctor. This adjustment may only be temporary.

While treatment iniation may be somewhat treaky, please bear in mind that the modern medication allow for the suppression of virus in the very vast majority of patients.

A very very tiny fraction of patients do not achieve VL < 50, but remain with low VL ... Even for those patients, immune system improves and they can stay healthy.

Since I was myself a borderline virologic failure (a situation which resolved nicely with time) I do appreciate that this may put lots of stress on the patient.
Yet, as stated before, we have solutions...

Take care

[bocker3]

Pay no attention to Eric's comments on virologic failure.  He is so wrapped up in his "facts" that he can't actually see the difference between academia and reality.  Not all humans react the same way to meds.  Studies discuss populations, not individuals and doctors treat individuals!!

It took me over a year to get to undetectable - that was achieved in July 2007 for me, and I have been UD ever since.  My last measurable VL was 1,600. 
Trust your doctor, ask questions and try (though I know it's hard) not to worry.

I started on Sustiva and Truvada (now Atripla) in Dec 2005.  We added (not changed) Reyataz in July 2006 -- a year later I was UD.  I'm still taking Atripla and Reyataz today, though I do plan on asking my doc about switching and/or eliminating something.

You may want to try another drug, if your doc recommends it, but sometimes, it just takes longer for someone to achieve an UD VL.

Good luck,
Mike

[efox020]

Thank you both for the answers. My Viral load was initially 80-million so it makes sense to take longer to reach UD although the first month the drop was huge down 20k then 5k, 1500 and now 750.

[efox020]

I went for my labs this morning and see my doctor on Monday to review the results.

I'm scared to death about this it's been six weeks since my last labs.

[bocker3]

I went for my labs this morning and see my doctor on Monday to review the results.

I'm scared to death about this it's been six weeks since my last labs.

I understand the scared feelings, but remember -- the meds ARE WORKING!!  You've had your VL go from tens of millions down to 750 -- that is a fantastic response.  When the fear strikes don't focus on the 750 that remain, focus on the 79.999,250 that have been wiped out!!!

At this point, assuming that you are taking all your meds, as prescribed, there is nothing you can do except wait for your results.  Worry over something you can't control is a waste -- of course, I know that is easier for me to say than for you to do, but try -- just take some deep breathes, and go do something that you enjoy.

Let us know how things turn out -- I'll be rooting for you!!!

Mike

[efox020]

The last time I got my lab's my doctor just said my VL was "lower" and to  re-test in six weeks. I went for labs  again this morning and I'm hoping to be UD this time.

I'm still curious why a protease inhibitors would be more effective than a intergease inhibitor.

[AusShep]

The last time I got my lab's my doctor just said my VL was "lower" and to  re-test in six weeks. I went for labs  again this morning and I'm hoping to be UD this time.

I'm still curious why a protease inhibitors would be more effective than a intergease inhibitor.

I'm not sure that they really are, they were also said to better for CD4 recovery.  PI's are common in salvage routines or with unknown resistance, but most of these profiles have been around for a long time, before there even were II regimens. 

Also your Dr just saying "lower" bugs me a bit.  I'd ask for the number and copies of my lab test results.

[efox020]

That could be the case, I was put on treatment immediately, the same day I saw the HIV specialists so I don't think any resistance testing was done. I was in pretty bad shape at the time.

I read somewhere that an individual with rapid progression to AIDS with a high VL as and low CD4s and no resistances it took over 10 months to become UD. The case sound similar to mine.

I'm gonna find that link.

My doctor sent me a message via the online service. I'll ask next time I should hear back mid next week.

[efox020]

Here's that article.
http://www.ncbi.nlm.nih.gov/pubmed/20835515

[titik]

Yeah, always ask for a copy of your lab results. You can ask the clinic front desk and they should give you a print out at least.

[efox020]

New numbers are in! VL 105 CD4 158 doctor says continue with current medication and re-test in 6 weeks.

I know the numbers are not great but it continues to improve.

[AusShep]

It's still going down.  It may take a few more months, but I'm sure it'll get there eventually.  Is your cd4% improving too?

[efox020]

Yes! It went up from 5% to 8%.

[harleymc]

I like those latest results.
"I know the numbers are not great", what teh heck they are fabulous compared with last time, and the time before that.
You've got more cd4 cells than I do, so I reckon that's pretty fab for someone new to medications.