suggestions needed - urgent

[iamindie]

i am 57
last Sept i diagnosed HIV+
and i started taking Zidolam (Lamivudine (150mg) + Zidovudine (300mg)) two times a day after meal and Naivex (Dolutegravir 50mg)one time daily at night after meal


my HIV viral load is 70
%CD3+/CD45+      75.3
Absolute CD3+     812
%CD3+/CD4+      34.6
Absolute CD4+     373

But the medicine is affecting my liver
my SGPT is 148.20
ang SGOT is 97.40

Please suggest what should i do

[Expat1]

It is probably the AZT.

Dr could switch it out with Tenofovir.

Dolutegravir can be given as a 2 drug combo with just the lamivudine.

I am not a doctor.  Consult you doctor on those options.

How far above normal are your liver tests. Ok.  About 2.5X and 4.5x.

Not uncommon when starting.  It happened to me when I started ART.  Dr just kept real close tabs on it for a month and it returned to Normal levels.  He also checked for Hep A, B, and C.  Asked about alcohol consumption.l

I really can't drink while on ART. 

[joemutt]

I suggest you talk to a doctor.

[iamindie]

It is probably the AZT.

Dr could switch it out with Tenofovir.

Dolutegravir can be given as a 2 drug combo with just the lamivudine.

I am not a doctor.  Consult you doctor on those options.

How far above normal are your liver tests. Ok.  About 2.5X and 4.5x.

Not uncommon when starting.  It happened to me when I started ART.  Dr just kept real close tabs on it for a month and it returned to Normal levels.  He also checked for Hep A, B, and C.  Asked about alcohol consumption.l

I really can't drink while on ART. 

Hi expat
Thanx for reply
I don't drink
I started ART last September (2019)
And Dr checked my hepatitis A B & C, they are ok
After starting ART from Sept 2019my liver function was ok untill April 2020. Then my sgpt and sgot started increasing. But Dr stick to medicine he is giving. Now my SGPT is about 3.5 times normal and SGOT is about 2.5 times normal
Due to civic I couldn't meet Dr. Next week I will try to consult him.

[Expat1]

My liver also had its 3x normal phase at about 6 months.

Good luck.  Your doctor seems on top of this. 

[iamindie]

i was diagnosed poz last year in sept,2019
and my VL was 2250 and CD4 was 384
Doc advised me to take Dolutegravir 50 mg at night
and lamivudine+zidovudine (150+300) two times a day
in may,2020 this year my VL was 70, CD4 was 373 and cd4/cd8 ratio was 0.90
but i got my ALT(SGPT) and AST(SGOT) raised about 4 times normal values
so Doc switched lamivudine+zidovudine (150+300) to Darunavir+ritonavir(800+100) in August,2020
today my VL is 66, CD4 is 859 and CD4/CD8 ratio is 0.99

I dont understand,
why my VL is still about 70, not less than 20 after taking ART for a year
My CD4/CD8 ratio is less than 1, is it too bad??
Side effects of Darunavir+ritonavir(800+100), is it kidney friendly
is Dolutegravir kidney friendly??

please anyone
thanks in advance

[Jim Allen]

Hiya,

Well the good thing is anything under 200 is considered UD in terms of prevention (transmission). So you can't sexually pass it on. https://forums.poz.com/index.php?topic=71848.0

Treatment wise, generally under 50 copies is fully suppressed/UD. However, there are people who find themselves being in the 50-100 or 100-200 group, there are also some people who experience that it takes longer than a year to get there.

I have included a Q&A with Paul E. Sax, MD on the topic, i find it's good but easy to digest insights on the topic, it might help you. 

What has your own doctor said about the 66 VL?
How are you feeling/doing otherwise?

Best, Jim

https://www.healio.com/news/infectious-disease/20190318/qa-understanding-persistent-lowlevel-viremia-in-people-with-hiv

P.S

Your CD4/CD8 ratio and counts are whatever they are, as far as I know there is nothing you can directly do about them. As such I stopped asking my doctor about these details.

https://i-base.info/qa/5224
https://www.poz.com/basics/hiv-basics/understanding-lab-work-blood-tests

[iamindie]

Thanks Jim

Hiya,

Well the good thing is anything under 200 is considered UD in terms of prevention (transmission). So you can't sexually pass it on. https://forums.poz.com/index.php?topic=71848.0

Treatment wise, generally under 50 copies is fully suppressed/UD. However, there are people who find themselves being in the 50-100 or 100-200 group, there are also some people who experience that it takes longer than a year to get there.

I have included a Q&A with Paul E. Sax, MD on the topic, i find it's good but easy to digest insights on the topic, it might help you. 

What has your own doctor said about the 66 VL?
How are you feeling/doing otherwise?

Best, Jim

https://www.healio.com/news/infectious-disease/20190318/qa-understanding-persistent-lowlevel-viremia-in-people-with-hiv

P.S

Your CD4/CD8 ratio and counts are whatever they are, as far as I know there is nothing you can directly do about them. As such I stopped asking my doctor about these details.

https://i-base.info/qa/5224
https://www.poz.com/basics/hiv-basics/understanding-lab-work-blood-tests

my Doc says my VL @ 66 is ok, good.
i just read all the articles and  Paul E. Sax, MD interview.
got to know about VL
thanks again.

[iamindie]

I was diagnosed poz last year in Sept 2019
My VL was 2250 and CD4 was 384
Doc advised me to take Dolutegravir(DTG) 50 mg at night
and lamivudine(3TC)+zidovudine(AZT) (150+300) two times a day

This year in may,2020after taking medicine for eight months, my VL was 70, CD4 was 373 and cd4/cd8 ratio was 0.90
but I got my ALT(SGPT) and AST(SGOT) raised about 4 times normal values
so Doc switched lamivudine(3TC)+zidovudine(AZT) (150+300) to Darunavir(DRV)+ritonavir(RTV)(800+100) in August,2020

today my VL is 66, CD4 is 859 and CD4/CD8 ratio is 0.99
my ALT(SGPT) and AST(SGOT) values are normal now

But during medication, I started having two symptoms.

In the morning when I wake up my body temp.(in mouth) is 97 F (36.11 Celcius) but when I return from the office it is 99F (37.22C). then again it slowly decreases.

My weight is gone down by 11kg, from 65 kg to 54 kg.

And I started getting edema.

Then I met my Dr again, after a lot of tests he referred me to a nephrologist, as my creatinine level shot up to 1.91. The nephrologist adjusted my hypertension medicine and gave me a diet chart to follow.

I am shocked
Why my creatinine level shot up and I became CKD patient?

My Doc doesn’t understand why my weight went down and I developed CKD. He says all the medicine (Darunavir(DRV)+ritonavir(RTV)(800+100)and Dolutegravir(DTG) 50 mg) I am taking are kidney-friendly.

He also doesn’t understand why my VL is 66, not less than 20. He then again added lamivudine(3TC)150mg twice daily.

Hence, I am taking Dolutegravir(DTG) 50 mg at night, Darunavir(DRV)+ritonavir(RTV)(800+100) in the morning, and lamivudine(3TC)150mg twice daily.

Can anyone suggest, why my VL is still 66, my weight gone down by 11 kg and I developed CKD. And what should I do? I am in India.
 
thanks in advance.

[Jim Allen]

Hiya,

Not sure why you are measuring your body temperature, it will fluctuate hour to hour even and 36-37 +- range you report would be perfectly normal. https://www.webmd.com/first-aid/normal-body-temperature#1

Sorry to hear that you are still stressing about the VL, why did the doc add additional HIV meds? I thought they had said it was fine? VL 66 I would not be changing anything.

my Doc says my VL @ 66 is ok, good.
i just read all the articles and  Paul E. Sax, MD interview.
got to know about VL
thanks again.

he referred me to a nephrologist, as my creatinine level shot up to 1.91. The nephrologist adjusted my hypertension medicine and gave me a diet chart to follow.

Keep us posted on the adjustment of the meds and diet and how things go. When is the next checkup? What's the diet like?

Best, Jim

[iamindie]

Hi Jim
Thanx for yr response
Yes during last check up my doc said my VL 66 is ok
But this time he thought about my loss of weight añd added lamivudine 150 mg twice daily

I went to my nephrologist today
He said your ART medicine has some molecules which is damaging kidney. He told me to discuss about it with my ART Doc. But thus Doc says my ART medicine are kidney safe.
Tell me if u have any idea about the effect of medicines I am taking on kidney.

[Jim Allen]

Hiya,

Dolutegravir can be given as a 2 drug combo with just the lamivudine.

I am not a doctor.  Consult you doctor on those options.

I would agree with the above.
Was there any HIV resistance profile or something?

To be honest as a patient myself I don't understand the dosage or combination of meds that you are taking at the moment.

Plenty of other options like trying 2 NRTIs + DTG would be a possible combo, Example, Dolutegravir + abacavir + lamivudine.  Since you have Dolutegravir & lamivudine already it's just adding abacavir and dropping the rest.

He said your ART medicine has some molecules which is damaging kidney. He told me to discuss about it with my ART Doc. But thus Doc says my ART medicine are kidney safe.

Generally, they are safe. Might have nothing to do with the issues you have.
That said, and not to be mean, some of the concerns are not issues.

Talk to your HIV doctor again, ask him about combinations. Stick to the diet, retest when asked to see what the creatinine level situation is after making the diet changes and changes to the hypertension meds.

Jim.

https://forums.poz.com/index.php?topic=69107.0

[iamindie]

Thanx him
I will soon talk to my Doc
I don't know abacavir us available in India or not

[Matths]

Hello, I’m following your interesting conversation. My question is why your doctor or you even consider adding a 3rd medicine to a dolutegravir + lamivudine combination? Generally, it takes a while for some people to achieve VL < 50 or < 20, which I believe is what we all aim for. There is plenty of evidence that adding a 3rd medicine or more to a treatment combo that already suppressed your VL below 200 will add anything. You allies at the moment are patience, adherence and time. I understand it’s difficult but with dolutegravir +lamivudine you have a treatment combo that was shown to be highly effective (and seems to work for you too) and safe and my suggestion is to give this combo the time necessary to get you fully suppressed as defined by a VL < 50 or < 20 (depending on your lab). Best Matt

[Matths]

To clarify an error in my comment above: there is plenty of evidence that adding a 3rd medicine or more to a combo
Of dolutegravir +lamivudine will NOT add anything. Sorry for the confusion. Best Matt

[Jim Allen]

Thanx him
I will soon talk to my Doc
I don't know abacavir us available in India or not

No problem. DTG+3TC+ABC is just one of many proven combo's. There are plenty of other combos that could work, just have a look at the link I posted earlier.

Depending on what's available to you, they should be able to come up with a proven combo that will work for you. What I don't understand though is your current combination.

- DTG + DRV + 2x RTV daily + 2x 3TC daily.

Prehaps there are things you have not mentioned that factor into the doctor's drug choice like previous resistance noted? Otherwise, it just seems to be a tad excessive to me. Again its something to discuss with your doctor.

[iamindie]

Hi Jim
A small correction regarding my current combo of medicines

"Depending on what's available to you, they should be able to come up with a proven combo that will work for you. What I don't understand though is your current combination.

- DTG + DRV + 2x RTV daily + 2x 3TC daily."

It is DTG+ DRV+RTV+2x 3TC daily
My doc says DRV is always given in combination with RTV

"Prehaps there are things you have not mentioned that factor into the doctor's drug choice like previous resistance noted? Otherwise, it just seems to be a tad excessive to me."

No other factors and I didn't hv any prior resistance to any medicine
I started with DTG + 2x3TC + 2x AZT
After I got liver problems, Doc withdrew 2x3TC + 2x AZT and switched to DRV+ RTV
I mean untill last week I was taking DTG + DRV+ RTV combo. But during this combo I developed kidney problems ( my creatinine level shot up) and my weight wend down by 11 kg.
Doc again added 3TC
So now my combo is DTG+ DRV+RTV+2x 3TC daily

[iamindie]

Thanx Matths for yr reply.and suggestion.

[iamindie]

Afterthought

Jim is abacavir renal safe?

[Jim Allen]

It is DTG+ DRV+RTV+2x 3TC daily
My doc says DRV is always given in combination with RTV

Yeah, that correct, well Darunavir requires a booster like Cobicistat or Ritonavir.
https://www.poz.com/drug/prezista

No other factors and I didn't hv any prior resistance to any medicine

Okay, so then you could even talk to your doctor about just keeping, 50mg Dolutegravir + 300mg lamivudine. So dropping the Darunavir, Ritonavir. Or another combo with just 2 NRTIs + DTG.

Jim

HIV meds: https://forums.poz.com/index.php?topic=69107.0
https://www.poz.com/article/fda-approves-dovato-hiv-switch-option
https://www.poz.com/drug/dovato

[Matths]

An add-on to Jim’s posting on the 2-drug combo of dolutegravir + lamivudine is that it was shown that this combo also works long-term. The 3-year data were released recently and show that this combo is as good as a 3-drug combo, and is safe.

https://www.poz.com/article/dovato-posts-3year-marks-par-tivicay-plus-truvada-hiv-treatment

[iamindie]

Hi Matths n Jim
Today I met my Doc
And discussed about my on going medicine.
He says as my weight went down considerably ( 11 kg ), he is suspicious of my VL. Ideally it sud be less than 20 but it is hovering around 70.
That's why, considering my weight loss, he added lamivudine  in my on going treatment with DTG + DRV+ RTV
He says he will not take the risk if decreasing medicine because he thinks my virus is not suppressed fully( considerable loss of weight).
He suggested me to visit a reputed hospital(3000km away from my present location) and get consultation. After that he will do anything.

[Jim Allen]

It's your choice at the end of the day.

Considering the VL is suppressed I would be reducing the meds if I was you.

Anyhow keep us posted on the diet etc. Hopefully next round of monitor the creatinine will drop off again.

[iamindie]

Considering the VL is suppressed I would be reducing the meds if I was you.

So, what do u say.
I should leave DRV+ RTV and stick to 2-drug combo of dolutegravir + lamivudine regime.

[Jim Allen]

50 mg Dolutegravir + 300mg lamivudine. So dropping the Darunavir, Ritonavir. Or another combo with just 2 NRTIs + DTG.

Jim

HIV meds: https://forums.poz.com/index.php?topic=69107.0

There are plenty of other combos that could work, just have a look at the link I posted earlier.

As mentioned before, if it was me with those results I would be looking at the possibility of 2 NRTIs + DTG. Or considering the DTG+lamivudine.

End of the day it's your health, not mine or your doctors. You need doctors to aid you in making wise decisions but you are the pilot, they are ground control.

Edit that reminded me of the panti bliss video on hiv air.
https://www.facebook.com/GayStarNews/videos/1190317401044575/

[Matths]

Hello again, first and most important, you should work with your doctor since you two build the team in your situation.

What I would do (assuming your VL is 70) and you have to Hep B (or any other Hep), and you have no resistance documented, is to take dolutegravir 50 mg + lamivudine 300 mg daily. Continue monitoring your VL (next check in 1 month, if around the same or less next check in 3 months and if the same VL or less another check in 3 months). Then you will have taken this combo for 6 months which allows a better interpretation of whether this treatment works or not. If you keep changing your medications too often, you will not be able to understand if a treatment works or not. Make sure you take this combo everyday and don’t miss a dose.

Of course, if your VL starts to increase with this combo and continues to increase, you probably need resistance testing which then will inform next steps. There are so many medication combos available these days that one  will work for you too.