{"id":460,"date":"2009-07-10T15:07:45","date_gmt":"2009-07-10T20:07:45","guid":{"rendered":"http:\/\/blogs.nejm.org\/?p=460"},"modified":"2015-06-04T15:30:31","modified_gmt":"2015-06-04T19:30:31","slug":"time-for-a-switch-what-actually-happened","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/time-for-a-switch-what-actually-happened\/2009\/07\/10\/","title":{"rendered":"Time for a Switch? What Actually Happened"},"content":{"rendered":"

\"\"<\/a>A couple of months<\/a> ago, I presented these three clinically stable, virologically suppressed patients — and asked if they should switch treatment:<\/p>\n

    \n
  1. 50 year old man on ABC\/3TC, EFV since 2000.\u00a0 No renal disease.\u00a0 Hyperlipidemia, on atorvastatin 80 mg a day.\u00a0 Father died of an MI age 48.<\/li>\n
  2. 63 year old man, on EFV + LPV\/r for years; past history of neuropathy on d4T and 3TC.\u00a0 Needs to go on inhaled steroids (preferably fluticasone) to help manage increasingly refractory asthma.<\/li>\n
  3. 35 year old woman, on ABC\/FTC, FPV\/r BID \u2014 doing ok but missing some PM doses.<\/li>\n<\/ol>\n

    We also published them in AIDS Clinical Care<\/em><\/a>, inviting both reader and and formal “expert” opinion.<\/p>\n

    Not surprisingly, there was disagreement from both the readers and the experts — some electing to change, some to switch, with various suggested new regimens.\u00a0 It makes interesting reading, as all perspectives are defensible.<\/p>\n

    So what actually happened?\u00a0 I switched them all:\u00a0 Patient 1 is now on TDF\/FTC\/EFV, and Patient 3 on ABC\/3TC, DRV\/r.\u00a0 They are both doing great.<\/p>\n

    Patient 2, um, not so much:\u00a0 After switching to TDF\/FTC\/EFV, he almost immediately noted marked worsening in neuropathic symptoms — reminding me that in the bad old days of d4T and ddI, some patients did <\/em>seem to experience worsening on 3TC.\u00a0 So he went back on EFV + LPV\/r, and the neuropathy returned to baseline over a month or so.<\/p>\n

    But — since he still needed the inhaled steroids for asthma treatment, and the fluticasone\/PI interaction can be troublesome, I tried the combination of etravirine and raltegravir as a novel “NRTI- and PI-sparing” approach.\u00a0 Almost immediately after this switch, he developed fevers, rigors, and malaise, and actually needed to be hospitalized overnight.<\/p>\n

    His current regimen?\u00a0 Back to EFV + LPV\/r — again doing well from the HIV perspective.\u00a0 The pulmonologist managing his asthma is trying to get by with low dose beclomethasone, with some success.<\/p>\n

    Humbled, I’m reminded that this antiretroviral business can be tricky — and that sometimes, it’s better to do nothing than something.<\/p>\n","protected":false},"excerpt":{"rendered":"

    A couple of months ago, I presented these three clinically stable, virologically suppressed patients — and asked if they should switch treatment: 50 year old man on ABC\/3TC, EFV since 2000.\u00a0 No renal disease.\u00a0 Hyperlipidemia, on atorvastatin 80 mg a day.\u00a0 Father died of an MI age 48. 63 year old man, on EFV + […]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2,4,5],"tags":[15,45,84,88,107,261,268,295,309,339,372,473,505,644,768,779,795,796,813,901],"class_list":["post-460","post","type-post","status-publish","format-standard","hentry","category-antiretroviral-rounds","category-hiv","category-infectious-diseases","tag-3tc","tag-aids-clinical-care","tag-asthma-treatment","tag-atorvastatin","tag-beclomethasone","tag-d4t","tag-ddi","tag-drv","tag-efv","tag-etravirine","tag-fpv","tag-hyperlipidemia","tag-inhaled-steroids","tag-neuropathy","tag-pulmonologist","tag-raltegravir","tag-regimens","tag-renal-disease","tag-rigors","tag-tdf"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/460","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=460"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/460\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=460"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=460"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=460"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}