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4 Responses to “M184V: So many options, but does that include TDF/FTC/EFV?”
Paul E. Sax, MD
Associate Editor
NEJM Clinician
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What about treating her once daily with Atripla + Ziagen —
Would adding abacavir give her the necessary “third drug” in this case and allow her to use Atripla as she desires?
Would the 184V affect the efficacy of the abacavir too much to make it worthwhile?
I would check the hl b 5701 and the trofle assay. If the b 5701 was negative, I would offer her atripla and ziagen. If positive, I would explore twice-daily regimens with her, including isentress, intelence and selzentry as possibilities.
I like Dr. Gallant’s response of ritonavir-boosted PI with tenofovir/FTC even with the M184V. However, instead of a “two-drug regimen,” I would call it a “two and 1/2 drug regimen,” and it makes a lot of sense to me. Perhaps more patients could benefit from this simple regimen.
I would urge the patient to restart therapy using a boosted protease inhibitor based regimen that would be simple (once a day) and relatively fat friendly (such as ritonavir/fosamprenavir or ritonavir/atazanavir or ritonavir/darunavir + Truvada or Epzicom -the latter if HLA B5701 negative). I would be tempted (if the patient was willing) to initially recommend use of another agent (such as raltegravir) to rapidly suppress HIV RNA levels to the detection level and then stop it out of concern about the presence of more extensive NRTI resistance than detected by the genotypic results available and not wanting to use potential monotherapy (just a boosted PI) in a treatment experienced patient with underlying NRTI resistance.