Managing HIV/AIDS Therapy in Treatment-Experienced Patients How do you handle a patient with limited prior treatment and a low viral load?
	Enlarged Version of Graphics Below	Dr. Kwakwa (OC): A patient who has had an inadequate virologic response, or a rising viral load, on any initial regimen can be considered a treatment failure, and because of that reason, the therapy may be switched... Dr. Kwakwa (VO): ...what it is switched to really is dependent on what they are on at the time of the rising viral load. I will say that it is incredibly important to include in the assessment a thorough assessment of how the patient is taking the medication, and how adherent they are not only to taking all the doses of the medication, but also taking the medication as prescribed, and whether they are taking any herbal preparations in association with the medication that they may not think to mention spontaneously.   See Slide Dr. Wohlfeiler (OC): In a situation where you've got someone who doesn't have a lot of antiretroviral experience. They're on their first regimen, for instance. And they're failing with a low viral load. Dr. Wohlfeiler (VO): One of the options actually might be not to completely switch the regimen, but simply to intensify the regimen. And that's a situation where a medication like tenofovir has proven to be often very effective. And given the fact that often, as I mentioned, the reason for failure is frequently due to the development of an M184V mutation, tenofovir seems to work particularly well in that situation in the presence of an M184V. So that would be a situation where I would probably first consider intensification rather than actually switching the regimen. The other thing is that part of what drives the decision is how low that viral load is at the time that you're looking to make the switch. If the viral load is above 1,000, and maybe even above 500, there's a high likelihood that you'll be able to get results back in you send a resistance tested genotype or phenotype. And then you can use that data to guide your decision.   See Slide Dr. Wohlfeiler (OC): If you're talking about failure with a viral load of less than 500 or 1,000, then you really just have to use your best guess. And that's when I use rules like the idea that if they're on 3TC or FTC, that's probably where they've developed the mutation because there's a low genetic barrier. And studies have shown that that's likely the first mutation to develop. Dr. Kwakwa (OC): Intensification in such a patient as you describe is certainly an option. I would use it as an option if there were good data showing what their resistance is at the time of intensification. Dr. Bellos (OC): With limited prior treatment, and a low viral load, again, it would depend on what they were doing immunologically. Dr. Bellos (VO): If that were a patient who was immunologically maintaining, then, at that juncture, I would probably continue to observe. If that was a patient who was experiencing immunologic decline, that's someone we need to look at for potentially altering their regimen, because again, we go back to that issue that our goal is to maintain immunologic competence, because if we can maintain immunologic competence, we are actually avoiding the opportunistic infections and other complications that can occur as T-cells fall.   See Slide Dr. Wohlfeiler (OC): I would consider PK enhancement. That's mostly going to be with protease inhibitor based regimens. And the fact of the matter is that I use almost all boosted proteases to begin with. Certainly with medications like Reyataz or fosamprenavir you have options for using them boosted or unboosted. But I'm always going to have a preference to use them boosted unless there's some reason that a patient can't take ritonavir or something like that, which is not likely to be the case because it's such low dose ritonavir. So if I'm already starting from a boosted regimen, then there's probably not much room for me to do PK enhancement. But certainly if I've got somebody on an unboosted PI, one of the first things I would do would be to switch to add ritonavir-boosted.
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