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Should We Mess with Success?

• patients,1,2,3
• Should We Mess with Success?
• Don"t fix what isn't broken.
• Changing treatments
• Changing treatment
• Three patients stable on ARV

patients,1,2,3

Alvin M., 30 Jun 2009 4:56 PM EST

Competing interests: None declared

patient (1) good therapy leave alone. patient (2) start with lyrica 75mg b.i.d.< to 500 to 600 mg as tolerated.start flovent 220 mg b.i.d. patient (3) need more info with labs .

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Should We Mess with Success?

Helen C. Azzam, 30 Jun 2009 4:56 PM EST

Competing interests: None declared

Patient 1: Given the risk of MI with abacavir and this patient's risk factors (lipids, famHx), I would change the abacavir and 3TC to emtricitabine and tenofovir. This way, he could take Atripla (which is a combo of emtricitabine, tenofovir and efavirenz) which is one pill once /day.

Patient 2: The worry here is that fluticasone, in particular, is not good to start when a patient is on ritonavir (PIs in general but ritonavir more than the others), since the ritonavir decreases the metabolism of the inhaled steroids and you can get opportunistic lung infections like PCP, atypical mycobacteria, as well as Cushing's syndrome. I would see which inhaled corticosteroid his insurance covers, and if it's only those that react with PI's, I would change his lopinivir/ritonavir to one of the "newer" combo NRTI regimens (truvada or epzicom) which shouldn't give him neuropathy like the older NRTIs. However, I would first check a resistance phenotype to make sure he's still susceptible to these drugs.

Patient 3: Her adherence is not ideal, so we could change her fosamprenavir to boosted atazanavir (once daily vs. twice daily). However, if she's had an undetectable viral load while still missing a few doses a week of this regimen, I'd just let her be...

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Don"t fix what isn't broken.

William J. DeMedio, private practice, 30 Jun 2009 4:56 PM EST

Competing interests: None declared

The current goal in HIV therapy is to eliminate viral load, minimize disease progression, prevent opportunistic infections, and minimize antiretroviral side effects (mainly "metabolic syndrome" and its sequelae). When these goals are achieved, you have a well treated disease, like an optimized diabetic. Until any new treatments come out, eg a cure, optimize the parameters and keep them there.

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Changing treatments

Antoine. M Donot, Belgian prison, 30 Jun 2009 4:56 PM EST

Competing interests: None declared

Pt 1: CV risk, so I would recommend switching ABC to TDF. PT 2 : no change. PT 3: Because of poor compliance, I would recommend a QD treatment (ABC+3TC+ATZ/r).

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Changing treatment

Alastair Miller, Royal Liverpool University Hospital, Liverpool L22 8QP, 2 Jul 2009 12:47 PM EST

Competing interests: HAve served on ad boards. speakers bureau and travelled to conferences with GSK, BMS, Gilead, BI, Tibotec and Abbott

Case 1 - need to know more about him to make a good CV risk assessment but at 50 it will be almost certainly significant. However therapy is working well and if he is happy I would strenuously address CV risk factors but probably leave him on this therapy

Case 2 - again if it is working would probably leave it but would have low threshold for switch/addition if any significant blips. Truvada is unlikely to worsen neuropathy so could add that and then drop either the Kaletra or efavirenz

Case 3 - ths issue here is poor adherence so I would explore this and see if she would adhere better to an OD regimen such as boosted darunavir or atazanavir

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Three patients stable on ARV

Dr. J.J. Ongole, Specialist; Head, HIV and TB Programs, Piet Retief, South Africa, 2 Jul 2009 1:40 PM EST

Competing interests: None declared

The three patients are clinically stable on treatment with full viral load suppression and good immune response measured by CD4 counts.

At this point in time, I suggest all the three patients remain on the current regimen and do not change:

1. The patients are meeting the clinical goal of treatment. 2. Changing will bring:

a. New side effects which may lead to poor compliance and adherence

b. Treatment failure after short time period

c. May trigger a series of regimen change for various reasons

d. There is possibility of developing resistance to the successful regimen if changed prematurely. This in time will limit treatment options if you practice in Africa with limited choice.

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