Safety switching to Nevirapine with High CD4

[Anqueetas]

Hello, I have been on treatment since April 2012 on Sustiva+Truvada. It been hell for the first 5 months, I almost didn't make it through in class because of Sustiva side effect, its really disrupt my ability to thinks of anything. I was switch to Etravirine for a month and that is a big relieve. I get my life back but it is so expensive (340$/months) so I have doubt that I can afford this long term. I went back to my doc yesterday(16/10/12), I brought up Nevirapine but he hesitate to switch me to it again. Then he prescribe Aluvia(Lopinavir/ritonavir) instead to try it out because it half the price of Etravirine.

My blood work is pretreatment CD4 360 19% VL 69000  currently CD4 530 24% VL UD

My question is
1. Anyone know about safety for switch to Nevirapine with high CD4 count in my case 530 and UD VL. ( I read about the warning of starting treatment for the first time with Nevirapine for people with CD4 about 400 with high risk of liver toxicity)

2. My doctor claim NVP is an inferior drug compare to other like Efavirenz, in term of viral suppression and resistant profile, is this true?

I been reading online and find several study about this all seems to agree that it safe to do so. SO I'm wondering why my doctor is so against this medication. I consult another HIV doctor and he also said the same thing.   

BTW I'm Asian and live in Thailand, it would be a great help if I can switch to NVP for financial reason because NVP is so cheap here, 10 times less than Aluvia.

Thank you for reading.

[newt]

Nevirapine is not inferior to efavirenz. It is equal in terms of its resistance profile.

The CD4 count caution applies to starting treatment, not switching. A switch to nevirapine when your viral load is suppressed is generally safe. The way to do it is to use a half dose for 2 weeks and if your liver is ok at that point, use the full dose from then on.

Hope this helps

 -matt

[eric48]

Hi,
Welcome to this forum.

You are not alone...

Since I started this thread
http://forums.poz.com/index.php?topic=33062.0

I have been in contact with various patients either initiating or switching to NVP (including people from Thailand)

Like you and you doc, I was scared to death.

What your doc says about NVP being slightly inferior to EFV may have some truth in it, but, this is relevant only at initiation. For treatment experienced and UD, there is no reason to think that there is any danger (virologically speaking)

This relative lesser efficiency seems to vanish with time.

Adverse effects such as the Viramune rash is unpredictable so there is no way to say whether you will be doing OK or not. same with livertoxicity.

All those I have been in contact with , who either initiated or switched to NVP have done so with success and have reported (publicly or privately) that they are happy with the switch.

That being said, after doing extensive research on NVP, as few limiting factors in the use of NVP are still not fully clarified. One of them is that virologic failure may occur because underlying resistant strain was present and not detected by the resistance test (if you have done one)

It is quite unlikely , but not 100% impossible that your system harbours a NVP resistant minority virus. Actually, even successful patients under NVP may evelop a resistant variant at some point during treatment, but since the 2 other drugs are powerfull enough, the resistant variant does not succeed in taking over.

So, it is just as if it had never happened.

While I do sympathize with the economical burden, I do think a successful NVP switch would do you great, clinically and financially.

If you are considering it seriously, then you should put all the reasonably favorable factors on your side. This factors are not 'scientifically proven', but, as a NVP user, this is what I would recommend

- NVP has a ramp up period where you take only 1 pill per day for ca. 2 weeks then move to 2 pills. do not neglect this. This safeguard has been implemented (and proven efficient) as some patients did die upon to fast initiation
- Liver monitoring should be taken very seriously in the first 2-3-6 months. Do not neglect this
- after a while, a good number of users take the 2 pills at the same time (once daily, 2 pills). it is proven safe, but I would consider this only after being under NVP for a few months.
- NVP is not as permissive as EFV on timing. Me, I take it off label 2 pills at the same time but always sharp on the designated hour.
- drink lots of water at the beginning
- lastly, you may not underestimate that there may be already some NVP resistant variants in your body. You would increase your chances of being virologically successful if you would leave the virus 'suppressed' by EFV as little bit longer. If you can financially afford, try to stay another 6 months under current regimen. then do the switch. I can not provide a solid rationale for this, but the virus is tricky, nasty and NVP a little risky. risk management is really worth at stake here. switch too early and loose that nice financial relief opportunity would be too bad...

I do not know how the switch is best organized. Should you continue EFV a little while as you are starting NVP or stop EFV right away, I would not know.

So take you time to learn more about NVP, decide if you want to switch or not, then decide for the best timing. Since the risk for the rash is not zero, switch when the timing is most favorable (work/school schedule) , when feeling in good shape. etc.

NVP has been doing great for me and millions of users , so why not you.

BTW, I did start with CD4 at 440-500 level, this is a bit outside of the guidelines.
It worked fine, but I still suffer for the intense stress it has put on me.

Best if you do the switch when you feel real comfortable about it.

Wishing you the best

Eric



   

[Anqueetas]

Thank you Eric and newt for your reply.

[northernguy]

I switched at 1,000 cd4 from Atripla to Truvada+Viramune with no ill effects.  The impression I got from my doctor and pharmacists was that the liver scare was overblown and they had seen it happen less than a handful of times over the years.

 

[eric48]

Hi,

Resistance test can be done on a stored sample, therefore, hte that that you are UV now, does not prevent the resistance test. Any stored sample with VL > 1000 will do.

You obviously have not been resistant to EFV

The resistance mutations for NVP are almost the same as those for EFV.there are 2 exception (as per my genotype report, which is now 2 years old...)
A98 confers resistance to NVP but not to EFV
P225 confers resistance to EFV but not to NVP
M230, G190, Y188, Y181, V106, K103, K101, L100 confer resistance to both.

So, with the sole exception of A98, your home made in vivo resistance test (taking EFV and suppress the virus is a proof of non resistance, so to speak)
chances that you are resistant to NVP is low.

Should you be resistant to NVP, htat would be because of a hiidden A98 mutation and then a switch back to EFV should do the trick.
Beware of Y181, this is a dreaded one since it onfers resistance to EFV, NVP, ETR (therefore, the entire class)

Initiation to NVP will require extra care. close monitoring for side effect, liver, etc. although adverse effect are rare, they are real bad. A NVP experienced doctor might be recommended.

You will find NVP experienced doctors where you live. I have received PMs from people in same country who iniated on NVP and have been very happy with doc and follow up.

Simply asking on this forum should also give you the answer pretty quick. Support groups can also be of help in finding a NVP trained doctor.

Your risk is low, but, since you kind of imply that the switch to ETR was mistake, you already know for a fact that shit happens. Having a good monitoring is a must.

Do not dismiss your doctors recommendation about the ramp up,the dosing and timing. If your switch to NVP is successful you will save you life and budget. Otherwise you are stuck with expensive alternatives.

Hope everything will go fine

Eric