Author Topic: Crappy Latest Lab Results (Read 7329 times)

David_CA · « **on:** February 28, 2008, 08:14:32 am »

I got the results from blood drawn last week. It was a surprise, to say the least. My viral load was 600 (vs 140 in November). My CD4's were 648 and 32.4% (vs 570 and 30%). It's strange that my CD4's were that high, as I was at the tail end of a nasty cold / sinus issues. I kind of expected my CD4's to be a bit less due to the cold, but I never expected my viral load to increase. I wasn't concerned as much with reaching undetectable as for the viral load to keep dropping. I didn't show resistance to any meds when tested back in '06 - both genotype and phenotype. I notice that the memo I received with my results stresses compliance... how's 100% for being compliant?

To me, this is a significant increase, but I'm not sure that it really is or in terms of logs (Matt / Newt always knows those things). It's also possible that it was just a blip or improper handling. The two numbers are both from LabCorp but in different locations. I want to be retested again soon instead of waiting three months, but I'm not sure that's really needed (or if it'll be covered by my insurance). Wanting to retest so soon is probably just me not liking the results (denial?). Just when I think I have a grip on this crap...

David

aztecan · « **Reply #1 on:** February 28, 2008, 08:35:40 am »

Hey David,

Well, on the plus side, your CD4s are looking really good, as is the percentage.

As for the increase in viral load, while it looks like a lot, it may well just be a blip or improper handling, as you mentioned, and really is only a few hundred difference.

I don't understand the whole log thing either. Never did. Damn nuisance.

But I understand completely your feelings in the matter. I hate it when these things happen. Remember my blip early in 2007. It wasn't much and it turned out to be a novice phlebotomist.

If memory serves, you are on Atripla, right?

Keep us posted on how things pan out.

HUGS,

Mark

BT65 · « **Reply #2 on:** February 28, 2008, 08:39:32 am »

Ditto what Mark said. It's probably just a blip.

Iggy · « **Reply #3 on:** February 28, 2008, 10:00:17 am »

David,

I understand a disappointment in the VL, but these are far from crappy lab results. Be kind to yourself and your body - it is doing a damn fine job and you'll probably be telling others in a few months to not worry about such fluctuations.

I'm certain your next labs will be moving again in the right direction on the VL.

Mark

newt · « **Reply #4 on:** February 28, 2008, 11:15:52 am »

First on the logs thing, "undetectable" (<50 copies) is 1.7 in a log value. A viral load of 500 is 2.7 logs. You wanna drop another log (so to speak).

This doesn't look like a blip as such. It may be the tail of a long, bumpy trip to <50. Or it may just be Atripla is only good for reducing your viral load to 500 or thereabouts. All the last few results could be the same viral load. Or not...

Either you wait/get a retest or think about a switch to a PI. I note, purely on an anecdotal basis, it took my last partner 11 months to get to <50 on the same combo. So don't give up on the Atripla yet

- matt

John2038 · « **Reply #5 on:** February 28, 2008, 11:42:40 am »

I'd like to understand something:

While not on meds, a VL such as 500 and CD4 of more than 500 are considered as great.
Why is it not the case while on meds ? Just cause switching to another meds will allows to reach undetectable ?

David_NC
Early this month, I was having fever and others symptoms, so I decided to do another lab to get the NADIR.
Surprisingly, as for you, my CD4 have increased (so did the VL as well), and my FBC is the best since my first lab ever.
A mystery, but I good news.

newt · « **Reply #6 on:** February 28, 2008, 11:53:13 am »

The aim of combo is to suppress viral replication. Therefore an "undetectable" viral load = treatment "success". A viral load of 500 copies is enough for low level HIV replication which may lead to resistance which may lead to treatment not working = treatment "failure".

Off treatment a CD4 of 500+ is v good because this is in "normal" range. Likewise when on treatment.

- matt

John2038 · « **Reply #7 on:** February 28, 2008, 11:57:23 am »

Thanks newt.

Is the probability of mutation on meds/not on meds the same for a same VL (assuming the same CD4) ?

E.g. with
On meds VL = 500
Not on meds VL = 500

David_CA · « **Reply #8 on:** February 28, 2008, 12:12:23 pm »

Thanks everybody. Matt, I knew (was hoping) you'd chime in with some info. I've been on Atripla since Dec 01, 2006. I've not been undetectable yet, but have slowly been getting there.... until my most recent test. I tend to look for trends, which for me so far have been reduced viral load and increased T-cells. I guess I'm just concerned that this count of 600 is the start of a trend, but I won't know that until at least another set of labs. My Dr's nurse said he wants to retest in three months (likely due to insurance), so I'll just be waiting until then. I guess we'll do labs as usual then. If the results warrant it, we'll do resistance testing again.

I know that the PI's work well, but the Atripla has been so gentle and easy for me. It doesn't bother me mentally or emotionally. It's also cheap(er) - only one co-pay instead of three. No constant trips to the bathroom, etc. I've heard it said before how frustrating it is to have these problems and appearing to be non-compliant to ones Dr. I mean, the Atripla should be working according to my earlier resistance tests.

Quote from: Iggy on February 28, 2008, 10:00:17 am

David,

I understand a disappointment in the VL, but these are far from crappy lab results. Be kind to yourself and your body - it is doing a damn fine job and you'll probably be telling others in a few months to not worry about such fluctuations.

I'm certain your next labs will be moving again in the right direction on the VL.

Mark

That is so true. You know how it is... easier said than done!

It'll work out; I know that. It's just not what I wanted to find out right before I left the house for work. I remembered I asked the office to fax the results to me yesterday and had forgotten them last night. I'll just wait for the next labs (what else is there?) and keep on doing what I'm doing. Hopefully, like Matt said, "It may be the tail of a long, bumpy trip to <50."

David

aztecan · « **Reply #9 on:** February 28, 2008, 03:00:08 pm »

Hey David,

Since you've never been on a PI, I believe you could start with one without having to boost it. I know Reyataz and Lexiva both are available without the Norvir boost for the treatment naive. I really don't know if that means all treatment or no PIs in the treatment.

Crixivan can also be taken without a boost, but I don't think you want to go there.

I just thought I would throw this out just in case the need arises. I hope this is just a temporary thing and the Atripla keeps on working for you.

HUGS,

Mark

newt · « **Reply #10 on:** February 28, 2008, 03:11:15 pm »

Trouble is 140 on a viral load test could be a bit higher and 600 could be as low as 200 etc so you could still be on a downward trend. There is no way of telling. I know my doc would be discssing, but not quite pressing, a switch.

PIs these days are not so evil as Crixivan, which I wholly agreeshould not be an option. The co-pays is a pain but a really well suppressed viral load may be something worth buying eh?

The problem with Atripla resistance, specifically mutations which affect how the efavirenz component works, is they can hide, and do not appear until the drug creates an evolutionary pressure. The other alternative is that you ain't getting enough of the drugs into your body. There's not much to do about this really, add some more efavirenz?...hmmm. Difficult to disentangle this kind of situation.

A long time to undetectable is not textbook, but is more common than people think in practice, regardless of combo. Took me 8-9 months or so on a PI based combo, so there you go...

I personally would test in a month, and if the overall trend is no longer down, consider a switch, but then my tests and drugs are free...

- matt

Assurbanipal · « **Reply #11 on:** February 28, 2008, 09:53:31 pm »

Quote from: David_NC on February 28, 2008, 12:12:23 pm

. . .. I guess I'm just concerned that this count of 600 is the start of a trend, but I won't know that until at least another set of labs. My Dr's nurse said he wants to retest in three months (likely due to insurance), so I'll just be waiting until then. I guess we'll do labs as usual then. If the results warrant it, we'll do resistance testing again. . . .

Hello David

Just reading your post from a distance, I wonder if you might want to invest some more time (and emotional energy) in seeing if you could actually talk with your Dr about this rather than getting fobbed off with the nurse. One may not want to raise a fuss all the time, but this sounds like you are worrying over it and it might be worth telling the doctor that you are concerned and would REALLY like to retest within the month. Also sounds like there's a pretty sympathetic case to be made that you are trying to be proactive with your health, and your doc should be listening up.

It looks like you are in an employer plan, and for most of those plans, even if an expense is "not covered" you usually get the group discount on services if you have a prescription. This can be a big deal with Labcorp (my latest tests had a retail price of $1300 but the group discounted price the plan paid was only about $300 -- and those tests included all the lipid panels too).

Good luck with this

Assurbanipal

jabez · « **Reply #12 on:** February 28, 2008, 10:17:09 pm »

I agree with Mr. Newt ... I think you should insist on testing again in a month. (Not that I'm expecting trouble, but I believe your peace of mind outweighs your co-pay.) When I started Atripla, my viral load was about 500,000. My next scheduled appointment fell 12 days after starting the regimen. At that appointment, my viral load had dropped from half a million to about 20,000. The doctor took this as very good news, and she suggested we schedule our next appointment for 60 days. My jaw dropped. I mean, sure that was a substantial drop, but it was still nowhere near undetectable, and at 20,000, I was still very worried about mutations and resistance developing. I just said, "No ma'am, I would rather come back in 30 days." She smiled and said, "Good idea. I only suggested 60 days for insurance reasons. I'm glad you decided to come back in thirty instead."

The next appointment showed a drop to a near-undectable range (about 332 copies per milileter). I was satisfied with that, and I went along with the insurance guidelines of waiting 90 days for my next appointment.

At the end of the 90 days, I was undetectable, and the doctor had written "STABILIZED" in my file. She informed me that most of her "asymptomatic, stablized patients" start coming in every FOUR months instead of every 90 days. I just shook my head and said, "No ma'am, I would like two undetectable results before I switch to a quarterly schedule." She smiled and said she completely agreed. So yes, my extra tests have resulted in a couple of extra co-pays, but I haven't had to worry for long periods of time about potential mutations and all of that crap. It's been well worth the few hundred extra dollars.

I think you should go back in 30 days. I bet they'll be glad to test you again. And I hope you get the big UND this time!

Lou-ah-vull · « **Reply #13 on:** February 29, 2008, 01:39:17 am »

David,

I agree with the others. It may be best for your own peace of mind to test in a 30 day window. It is natural for any of us to stress over these numbers if they show the slightest inclination of moving in the wrong direction (never mind that we react the opposite way when they go in the perceived right direction!) Since the purpose of the test is to detect whether or not there may be low level resistance or possible regimen failure (although it does not seem this is the case,) I think the retest is "medically defensible" and thus coverable by your employer-based insurance. Your doctor's office handles the justification for this anyway. I recommend asserting the need for a test in 30 days and then seeing what the trends look like. Of course, everyone here will be happy to "chime in" and support you with advice as well.

Your overall numbers look very good...try not to lose sight of that!

Take care,

Gary

trellium · « **Reply #14 on:** February 29, 2008, 06:09:30 am »

Quote from: newt on February 28, 2008, 03:11:15 pm

.....
The problem with Atripla resistance, specifically mutations which affect how the efavirenz component works, is they can hide, and do not appear until the drug creates an evolutionary pressure. The other alternative is that you ain't getting enough of the drugs into your body. There's not much to do about this really, add some more efavirenz?...hmmm. Difficult to disentangle this kind of situation......

From the Atripla full prescribing info:

ATRIPLA (efavirenz 600 mg/emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg) has not been evaluated in the presence of food. Administration of efavirenz tablets with a high fat meal increased the mean AUC and Cmax of efavirenz by 28% and 79%, respectively, compared to administration in the fasted state. Compared to fasted administration, dosing of tenofovir DF and emtricitabine in combination with either a high fat meal or a light meal increased the mean AUC and Cmax of tenofovir by 35% and 15%, respectively, without affecting emtricitabine exposures

If David isn't affected by the common CNS effects of Sustiva (efavirenz), how about taking Atripla with a high fat or light meal?
I wonder if thats worth a shot by manipulating the AUC and Cmax levels?

bocker3 · « **Reply #15 on:** February 29, 2008, 07:21:53 am »

Hi David,

I'm going to take a slightly different road here..... Look at my signature line and you'll see that I seemed to have a hard time getting to UD -- even after adding a PI to the Atripla. It turns out that most of the "low" VL's may well have been "lab error". Now, anyone who knows me, knows that I am the last one to blame a lab -- I worked in them for many years and they are often the first place folks go to when things don't turn as expected. So, you may ask, how did I get to this conclusion? I followed the advice of Dr. Gallant and had a branched-DNA VL test performed instead of the quantitative RNA test. Guess what -- I got an UD result (it is <75 for bDNA).
My conclusion (not based in fact, because I never did a side by side test) is that something incorrect was happening to my sample from the time the doctor drew it to the time it was tested. The bDNA test is not as prone to falsely elevated resulted due to handling issues. I am now back to having the quant RNA test done because I had to switch labs due to insurance (from LabCorp to Quest) and can no longer be drawn at by my doctor. I am now also UD with the Quant RNA.
So...... Call you doctor and ask him/her to order a branched DNA test before you start adding or changing medicine -- as I believe you've been very happy with the Atripla. Seems to me, that there is no need to wait and that you doctor would be as anxious as you are to see if you are truly already UD.

Let us know!
Mike

riverlassie · « **Reply #16 on:** February 29, 2008, 11:36:27 am »

I've been on meds for just over 15 years , poz for 20. And my numbers were once only in the teens and then as high as the 700's . I've personally have decided that the numbers aren't as relevant as your feel. Numbers can cause un -necessary stress.Now don't get me wrong, I'm not saying they aren't important. But I can only do what I can do for my health. The rest I ultimatly leave in Gods hands. And the meds are for the docs to work out, You got to trust their knowledge . But I've grown very in tune to how my health feels. And I truly believe my attitude has had me un-decectable irregardless of what the numbers say for many many years now. And being on hep tx Im sure they'll drop again but I'm not sweating it or fretting. I truly trust Above.

"Worrying is like a rocking chair, it gives you something to do but doesn't get you anywhere"

David_CA · « **Reply #17 on:** March 03, 2008, 09:24:07 am »

Thanks for all the input and info. I have to go back to my Dr's office later this month for some other things and will bring up retesting again. Having had a few days to think about all this has been good, too. Plus, relaxing at the campground over a weekend always seems to reduce stress!

(edited to add)
In reading about (fatty) meals and Atripla... I wonder if I should switch my dosing to night time instead of morning. I MUCH prefer to have mostly dreamless sleep and a slight buzz in the morning. I don't eat a fatty meal when taking my meds in the morning and don't plan on adding one - I'm having a hard enough time with the post 40 gut as is. I generally do eat at night, so that might be a way to increase the concentration of the drugs. I guess it's another thing to talk over with my Dr.
(end of edit)

As Gary said, my overall numbers are good ('cept for that damned V.L.) including things not directly related to HIV. I feel good, have as much energy as I ever do in the winter, and am in a good state of mind. Of course, if the virus isn't controlled, all that will change! After retesting, I'll see how things look. At that point, I think I'll be in a better position to think about things such as staying on Atripla, changing meds, etc. Even if I have to switch meds, I think it's the fear of the change itself that gets to me. I wasn't all that apprehensive about starting Atripla when I started, as I was sick as hell (PCP) and in the hospital. With 4 liters / min. of O2 to breath, I wasn't too concerned about many things! For those who haven't tried it, oxygen is a great high!

Whatever happens, it's just another 'thing' to which I'll adjust and accept (and probably bitch about a little, too).

David

BreakerOneNine · « **Reply #18 on:** March 03, 2008, 11:29:06 am »

Well...I am right there with you with crappy test results.....I just got my new results...CD4 went from 390 to 140....my viral load did go to undetectable though...I insisted that they bring me in next week for new labs...i am hoping this was a blip and they agree that they think it was, or is it possible for this to happen?...I am a little freaked out right now.

Pippet · « **Reply #19 on:** March 03, 2008, 12:26:23 pm »

I am also feeling your frustration. Almost a year on my latest combo and still not UD.

Thanks for the post, and all the great information.

Best of Luck, Pip

bocker3 · « **Reply #20 on:** March 03, 2008, 06:46:18 pm »

Quote from: David_NC on March 03, 2008, 09:24:07 am

Thanks for all the input and info. I have to go back to my Dr's office later this month for some other things and will bring up retesting again. Having had a few days to think about all this has been good, too. Plus, relaxing at the campground over a weekend always seems to reduce stress!

(edited to add)
In reading about (fatty) meals and Atripla... I wonder if I should switch my dosing to night time instead of morning. I MUCH prefer to have mostly dreamless sleep and a slight buzz in the morning. I don't eat a fatty meal when taking my meds in the morning and don't plan on adding one - I'm having a hard enough time with the post 40 gut as is. I generally do eat at night, so that might be a way to increase the concentration of the drugs. I guess it's another thing to talk over with my Dr.
(end of edit)

As Gary said, my overall numbers are good ('cept for that damned V.L.) including things not directly related to HIV. I feel good, have as much energy as I ever do in the winter, and am in a good state of mind. Of course, if the virus isn't controlled, all that will change! After retesting, I'll see how things look. At that point, I think I'll be in a better position to think about things such as staying on Atripla, changing meds, etc. Even if I have to switch meds, I think it's the fear of the change itself that gets to me. I wasn't all that apprehensive about starting Atripla when I started, as I was sick as hell (PCP) and in the hospital. With 4 liters / min. of O2 to breath, I wasn't too concerned about many things! For those who haven't tried it, oxygen is a great high! Whatever happens, it's just another 'thing' to which I'll adjust and accept (and probably bitch about a little, too).

David

Hi David,

I hear so much of myself, a little over a year ago, in this post. I was playing all the angles -- eat fatty foods, get some therapeutic drug level testing done, etc...... Then I finally listened to Dr. Gallant and asked for that branched-DNA VL test -- WHAM -- all my worries were gone. I just know it's gonna be the same with you.
Keep the faith!

Hugs,
Mike

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