July 11th, 2008

M184V: So many options, but does that include TDF/FTC/EFV?

Co-formulated TDF/FTC/EFV (Atripla) is a nifty bit of pharmacologic packaging (ever so much more so since it involves collaboration between two different pharmaceutical companies, ahem) — and our patients have noticed.  All of us who practice HIV medicine have been asked for the “one pill” treatment; often these requests make sense, sometimes they don’t.

It’s easy to say when it’s a bad idea (known NNRTI resistance, for example), but sometimes it’s not so clear.

We presented a case in AIDS Clinical Care of someone with documented M184V several years previously (before a treatment interruption) who now needed to go back on treatment.  Her request:  the “one pill” treatment.  One of our clinical experts (Joel Gallant) said he wouldn’t do it; the other (Jose Arribas) said he would.  Not surprisingly, there were good reasons provided by both for their decisions.

We also asked if they’d order a viral tropism test.  Joel — no.  Jose — yes.

Thoughts?  What do you do for patients who only have M184V?

4 Responses to “M184V: So many options, but does that include TDF/FTC/EFV?”

  1. Jonna Gaberman says:

    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?

  2. William Shay says:

    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.

  3. Don Tayloe says:

    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.

  4. Keith Henry, MD says:

    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.

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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