Discontiuation of HAART due to Lipoatrophy
Posted: Aug 1, 2004
QUESTION:
Dear Dr.,
One of my patient Is HIV positivesince August 1997.In July,1998 HAART therapy startedwith Lamividine-150,Staudine-40,Nelfinavir-1250 BD continued till December,2002 with strict adherence.Values were viral load Less than 20 and CD4-659 cells.Then treatment discontinued abruptly due to lipoatrophy and 14 pills a day was disliked by patient.Since then Patient is under regular monitoring,Readings are-On 2nd April,2003-VL-945 and CD4-624,On 17th July,2003--VL-2552 and CD4-571 cells--And on 24thApril,2004--VL-11320 andCD4 is 249--Patient is asymptomatic and doing well.Shall I observe some more time or Should I restart the therapy immediately? If so, Which is the ideal combination to avoid lipoatrophy and with less number of pills a day.
Please suggest--- Dr.G.R.Linga Murthy
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RESPONSE FROM: 
It may not be necessary to restart therapy immediately. Some of the CD4 decline that occurs after a treatment interruption seems to be related to compartmental dynamics. After several months there is often a favorable change in the slope of decline and a relative stabilization of CD4 counts. However, since both patient and clinician may get nervous upon witnessing a drop from over 600 CD4 cells to 249 in a 4 month time interval, there is nothing wrong with restarting at this point.
I don't think we yet know the ideal combination to prevent lipoatrophy, but clearly the stavudine needs to go. A reasonable choice for the second regimen would be Viread, Epivir (or Emtriva), and Sustiva (or Viramune). Eventually, there will be a 3 in one combination of Viread, Sustiva, and Emtriva which will allow therapy to be prescribed as one pill once a day. For now, the above regimens will be 3 or 4 pills per day. Thanks for posting.
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