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TDF and ddI and HEPC

Posted: Sep 5, 2006

QUESTION:

TDF, ddI and Hepatitis C.

Another patient:

AIDS in 2000 Broke through CBV/NLV and d4T/ddI/NVP

Has the following mutations since 2001:

M41L, L74L/V K219H/N/Q, M184V, K103N Y181C

L63P V77I N88D

He is coinfected with HepC refused therapy in 2000. Now with persistently elevated ALTs X 12 months.

He is Non detectable for year on ddI, TDF,3TC and boosted Reyataz but CD4 counts are only 230 - 330.

I am sending him back to GI for re eval for HepC - if we decide to treat I am concerned about the ddI in his regimen. Is there anything else you think can give him or should I just stop the ddI and add T20?


  

RESPONSE FROM:   

    I am not so sure the ddI is doing much and it could be surpressing the CD4 cell count. The L74V is a major resistance mutation for ddI and M41L and 219Q also reduce viral susceptibility to this med. So, stopping ddI may not make a difference and is necessary given the adverse interaction with HCV therapy.

    Certainly, ddI resistance may be limiting the viruses fittness or replication capacity and maintaining these mutations could provide some advantages. But, it is hard to do if HCV treatment is planned. AZT could be co-administered but the risk of anemia with ribavirin makes this unattractive. Abacavir would not do the trick and I would worry about risk of new NRTI mutations.

    You could stop the ddI and monitor the viral load closely (after first week and then again a couple of weeks later). If viral laod pops up you could intensify with T-20 or consider trying to get expanded access to the Merck integrase inhibitor if you live in the US (or could just wait a little bit until this drug is approved in US so you can have it available if needed).

    DW




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