{"id":167,"date":"2008-11-22T14:54:15","date_gmt":"2008-11-22T19:54:15","guid":{"rendered":"http:\/\/blogs.nejm.org\/?p=167"},"modified":"2015-06-04T15:31:39","modified_gmt":"2015-06-04T19:31:39","slug":"salvage-rx-for-hiv-macro-good-news-micro-bad-news","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/salvage-rx-for-hiv-macro-good-news-micro-bad-news\/2008\/11\/22\/","title":{"rendered":"“Salvage” Rx for HIV: Macro Good News, Micro Bad News"},"content":{"rendered":"

\"\"<\/a>I’ve written before <\/a>how the number of treatment experienced patients who have no <\/em>options for successful therapy has dwindled to a tiny — but unfortunate — few. \u00a0Darunavir, maraviroc, raltegravir, and etravirine (in order of FDA approval) are that <\/em>good.<\/p>\n

Two presentations at recent scientific meetings confirmed the staggering efficacy of these newer drugs. Notably, both described response rates that exceeded what was reported in pivotal phase III studies — telling us that if anything, results in clinical practice will be\u00a0better<\/em> than in the trials, likely because a broader range of drugs is now available to the prescribing clinician. \u00a0(By contrast, patients in the MOTIVATE studies of maraviroc couldn’t use darunavir — not yet approved.)\u00a0<\/p>\n

First, this summer at the IAC meeting in Mexico City, a French group described a 90% virologic suppression rate<\/a> (< 50 at 24 weeks) for 103 patients with triple class resistance receiving raltegravir, etravirine, and darunavir (sometimes with other agents). \u00a0Second, more recently at ICAAC, a group from Kaiser Permanente reported that 50 out of 53 patients<\/a> in their etravirine expanded access program were virologically suppressed — many of whom did not even have full susceptibility to darunavir or etravirine.<\/p>\n

Wow.<\/em><\/p>\n

Which brings me to an e-mail I received this week which included the following chilling piece of information:<\/p>\n

He has rather resistant virus, and has been on Truvada,\u00a0Darunavir, Ritonavir, and Raltegravir. His most recent viral loads were 450 then 920 …\u00a0<\/p><\/blockquote>\n

Needless to say, my response included a comment that the rising viral load on a raltegravir-based regimen was “worrisome”.\u00a0<\/p>\n

In addition, a patient who is a typical raltegravir success story from our practice — high-level triple class resistance, never previously virologically suppressed, but HIV RNA undetectable for now 2-plus years — had a viral load come back recently at nearly a thousand. \u00a0(He says he had a cold.) \u00a0Confirmation of this result is pending (I like to wait at least a couple of weeks before repeating these) so of course this could just be a mega-blip, but needless to say I’m worried about him too. \u00a0<\/p>\n

With the disappointing news on bevirimat<\/a> presented at ICAAC — showing that some 40% of individuals harbor a polymorphism in the gag region of HIV that makes their viruses essentially resistant to the drug — we don’t really have promising drugs in the pipeline for this group of individuals, however small that group may be. \u00a0<\/p>\n

Let’s hope this precarious state of affairs is a temporary one.<\/p>\n","protected":false},"excerpt":{"rendered":"

I’ve written before how the number of treatment experienced patients who have no options for successful therapy has dwindled to a tiny — but unfortunate — few. \u00a0Darunavir, maraviroc, raltegravir, and etravirine (in order of FDA approval) are that good. Two presentations at recent scientific meetings confirmed the staggering efficacy of these newer drugs. Notably, […]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[4,5,8],"tags":[77,78,112,244,266,339,423,474,478,779],"class_list":["post-167","post","type-post","status-publish","format-standard","hentry","category-hiv","category-infectious-diseases","category-patient-care","tag-antiretroviral-therapy","tag-antiretrovirals","tag-bevirimat","tag-croi","tag-darunavir","tag-etravirine","tag-hiv","tag-iac","tag-icaac","tag-raltegravir"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/167","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=167"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/167\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=167"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=167"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=167"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}