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Methadone and restarting HAART

Posted: Jan 21, 2008

QUESTION:

We have a patient who has been off HAART since 2/05 and is now willing to restart meds. She is in a methadone program and is currently on 200 mg daily (in split doses due to her being a "high metabolizer"). Prior to starting HAART, she was on 80 mg but had to increase up to her current dose of 200 mg after starting meds and has been unable to bring it down again. Her treatment history is as follows:

1998 Combivir/Crixivan - discontinued after three months due to severe anemia 1998 Videx/Zerit/Crixivan - discontinued in 12/02 due to lipoatrophy 12/02 Epivir/Ziagen/Kaletra - discontinued due to "meds ate up my methadone" 1/03 Epivir/Ziagen/Viracept - discontinued in 11/03 for no reason other than STI 10/04 Truvada/boosted Lexiva - discontinued 2/05 due to intractable vomiting

Her current CD4 is 265/17% and viral load is 10,900. Resistance testing was done in 10/04 and 8/07 and shows she is pan sensitive (although both tests done off meds).

She is unwilling to take Norvir. We are considering starting unboosted Crixivan, unboosted Reyataz or Isentress with a backbone of Truvada or Epzicom.

What are your thoughts particularly regarding unboosted Reyataz (in a treatment-experienced patient) and Isentress (in a patient without any documented resistance)?


  

RESPONSE FROM:   

    Thank you for your post.

    Your patient is one of the significant minority of persons who does not seem to tolerate ritonavir.

    Fortunately, while she is formally "treatment-experienced", the lack of demonstrable or historical suspicion of drug resistance implies that first-line options will apply.

    For this reason (as well as her treatment history), I'd think that either Truvada or Epzicom would be acceptable. If staying with PIs is the first choice (a reasonable one to me), then Epzicom with unboosted atazanavir is reasonable, especially in light of her low viral load. We have a number of patients on this combination and the tolerability and effectiveness have been excellent.

    While raltegravir (Isentress) has been showing remarkable results, the medication is still not yet FDA approved, nor guideline-recommended for first-line patients (or those without significant resistance). For this reason, it would be reasonable to relegate raltegravir to an alternative position for now.

    I hope that this is helpful. Let us know what you decide. BY




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