An ongoing dialogue on HIV/AIDS, infectious diseases,
May 19th, 2009
Time for a Switch? Room for Debate
With first-line therapy for HIV being so astonishingly successful, much of what we do in practice is tweak regimens that are by virologic and immunologic standards, working just fine: Viral load undetectable, CD4 stable.
But not so fast — while one of my colleagues said that if he didn’t change his patients’ regimens, then he’d have nothing to do, the other said he NEVER changed a regimen that was working unless he absolutely had to.
Who’s right? Both of them, of course. The regimen might improve in convenience, tolerability, safety, etc, but new side effects could also occur, as well as virologic failure.
So consider these virologically suppressed, clinically stable patients (all recently seen) — would you switch?
- 50 year old man on ABC/3TC, EFV since 2000. No renal disease. Hyperlipidemia, on atorvastatin 80 mg a day. Father died of an MI age 48.
- 63 year old man, on EFV + LPV/r for years; past history of neuropathy on d4T and 3TC. Needs to go on inhaled steroids (preferably fluticasone) to help manage increasingly refractory asthma.
- 35 year old woman, on TDF/FTC, FPV/r BID — doing ok but missing some PM doses.
Keep in mind, all are doing fine — would you switch? If so, to what? Thanks in advance* for the consult.
(*ahem.)
Categories: Antiretroviral Rounds, HIV, Infectious Diseases, Patient Care
You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.
3 Responses to “Time for a Switch? Room for Debate”

Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
Learn more about HIV and ID Observations.
Search this Blog
Follow HIV and ID Observations Posts via Email
Archives
-
-
From the Blog — Most Recent Articles
- My Dog Louie, the Best Dog Ever, Is Seriously Ill September 26, 2025
- Two Drugs, Not Three: The DOLCE Study in Advanced HIV Disease September 19, 2025
- When Required Learning Modules Surprise You (In a Good Way) September 10, 2025
- End-of-Summer Musings — Hepatitis B, Dalbavancin, Alpha-Gal, and More September 4, 2025
- Watching the Chaos at the CDC — with Sadness and Alarm August 29, 2025
NEJM Journal Watch — Recent Infectious Disease Articles
- Can Recombinant Technology Improve Rabies Prevention?
- Is the High-Dose Flu Vaccine Better Than the Standard Dose for Preventing Severe Outcomes?
- Observations from ID and Beyond: Two Drugs, Not Three — The DOLCE Study in Advanced HIV Disease
- Marburg Outbreak! Can Rapid Response Minimize Mortality and Halt Spread?
- The Ryan White HIV/AIDS Program: Critical to Efforts to End the HIV Epidemic
-
Tag Cloud
- Abacavir AIDS antibiotics antiretroviral therapy ART atazanavir baseball Brush with Greatness CDC C diff COVID-19 CROI darunavir dolutegravir elvitegravir etravirine FDA HCV hepatitis C HIV HIV cure HIV testing ID fellowship ID Learning Unit Infectious Diseases influenza Link-o-Rama lyme disease medical education MRSA PEP PrEP prevention primary care raltegravir Really Rapid Review resistance Retrovirus Conference rilpivirine sofosbuvir TDF/FTC tenofovir Thanksgiving vaccines zoster
Assuming no resistance mutations
1. Recommend a switch to tdf/ftc/efv w/ concern for potential for cardiovascular disease (abacavir) and potential for easier dosing w/ daily fixed dose atripla
2. Recommend switch to tdf/ftc/efv again. Not aware of any long term data to support this efv/lpv/r regimen and have concern for possible break through w/ only two drug regimen despite recent success. Doubt tdf/ftc would exacerbate neuropathy. Would avoid ritonavir boosted PI if the inhaled steroids are really needed.
3. Assuming a k103 is the reason for fpv/r would recommend switch to tdf/ftc/Atazanavir/r for ease of daily dosing. Also potential to lose darunavir if resistance occurs to fpv/r. If no k103 then tdf/ftc/efv would be simplest regimen and would potentially eliminate the pm missed doses
CM,
These are all very reasonable (some would say great) recommendations. For the sake of discussion, here are the counter views:
1. He’s over 60, he’s had NO side effects for 9 years on this current regimen, why risk renal/bone issues?
2. Back in the old days, I definitely had pts with bad neuropathy that worsened on 3TC … and it’s known to cause neuropathy in kids.
3. Why risk the EFV CNS side effects, and switching to a new class?
Keep in mind this isn’t necessarily what I believe on these cases … just a countering view.
I’ll let you know what I did in a separate post.
Well, the counter-arguments make some sense, but I would give my listed recommendations to the patients in question, discuss the pros and cons, and make a decision together. Having said that, I would like to get #3 off fpv/r and would feel okay about atazanavir or efv in it’s place.
I look forward to the denouement.