myositis and meds
Posted: Jun 4, 2004
QUESTION:
Despite durable excelllent immunologic and virologic response to Nevirapine/Crix/3TC (not my choice) 50 yo male pt developed myopathy/myositis on this with CPK >1000. Now suffering with consequence of the disease as well as chronic prednisone therapy. Muscle bx not c/w medication induced myopathy. After much hand wringing meds were stopped and CPK nearly normalized. Back on meds the CPK again over 1500. Given previous response I'd like to target one med for change. What's the likely culprit-3TC? If so, what to substitute? Meanwhile he's also go DM, lipodystrophy, lactic acidosis, HCV, aspetic necrosis of the femoral head etc, etc, etc. A real mess, but no virus! You can't win.
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RESPONSE FROM: 
In a situation like this it seems likely that medication-related side effects likely outweigh the benefits of antiretroviral therapy my instinct would be to stop everything and let him recover fully. You did not mention his CD4 count, but if the counts are very low he will need to go back on treatment sooner rather than later. Also, although not stated, I suspect that the lipodystrophy is of the lipohypertrophy variety based on the components of this regimen.
Once he does recover and it is time to construct a new regimen it makes sense to revamp everything. A combination of ritonavir-boosted atazanavir (Reyataz) along with Viread and FTC (Emtriva) might be a reasonable choice.
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