{"id":8388,"date":"2017-05-21T17:23:32","date_gmt":"2017-05-21T21:23:32","guid":{"rendered":"http:\/\/blogs.nejm.org\/hiv-id-observations\/?p=8388"},"modified":"2018-06-07T08:20:08","modified_gmt":"2018-06-07T12:20:08","slug":"curious-case-m184v-part-1","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/curious-case-m184v-part-1\/2017\/05\/21\/","title":{"rendered":"The Curious Case of M184V, Part 1"},"content":{"rendered":"

\"\"<\/a>Thanks to our sophisticated\u00a0research team here at NEJM Journal Watch<\/em>, we have an excellent idea who reads this thing for its scintillating ID\/HIV content.<\/p>\n

Most of you are clinicians — doctors, nurses, PAs, PharmDs. A smaller proportion are researchers, lab-oriented types\u00a0who wandered over here unexpectedly after an\u00a0errant search, expecting the latest in CRISPR-Cas9 gene editing and instead getting\u00a0an ID Link-o-Rama<\/a>, a rumination on vintage medical photos<\/a>, and a mysteriosis about listeriosis.<\/a><\/p>\n

But another\u00a0divider is whether you consider yourself an HIV specialist or not. A grab bag of ID (mostly), primary care, and other subspecialty clinicians, HIV specialists know and ruminate over lots of the same stuff even though there’s no formally designated HIV specialty by the American Board of Internal Medicine.<\/p>\n

And today’s topic is most definitely an HIV-focused one, triggered by an\u00a0email I received last week from one of my colleagues:<\/p>\n

Subject: M184V<\/p>\n

Paul,<\/p>\n

What’s your go-to regimen in the setting of a solo M184V?<\/p>\n

Jon<\/p>\n

For the non-HIV specialist<\/em> readers, allow me to decipher the code in the above question. “M184V” is the shorthand for methionine replacing valine at position 184 in reverse transcriptase. It is by far the most commonly encountered nucleoside reverse transcriptase inhibitor (NRTI) mutation after failure with regimens containing lamivudine (3TC) or emtricitabine (FTC).<\/p>\n

And with that single paragraph, I’ve hinted\u00a0why HIV drug resistance — and genotypes in particular — baffle some of even the most astute\u00a0and brilliant ID clinicians. It’s like reading about the coagulation cascade or the complement system. You have to work with this stuff frequently\u00a0to understand the lingo.<\/p>\n

But for those seeing HIV patients on a regular basis\u00a0(especially as outpatients), this question — what should be done after M184V? — is both quite relevant clinically and, surprisingly, not readily answerable from the literature.<\/p>\n

Remember, M184V is a special mutation — it does some very weird things:<\/p>\n