#initial regimen

[hivforum]

Hi, Gallant , I'm going to start soon my medication and my Dr. told me that i can take Atripla, Complera, Genvoya, Odefsey, or Stribild, can you tell me pease, which one is your of this medication is less toxic, ? Thanks

I hope your doctor didn’t just give you a list of 5 regimens to choose from without helping you decide. You’d get better advice from a high school graduate at Best Buy when you try to pick a TV! 

Atripla - No. It’s no longer recommended because of its toxicity. 

Complera - No. Why take Complera when you could take the new, improved version, Odefsey?.

Stribild - No. Why take Stribild when you could take the new, improved version, Genvoya? 

Genvoya - A good choice, as long as you’re not takingmedications that interact, including certain inhaled or nasal steroid spraysfor asthma or allergies, among others.

Odefsey - A good choice if (1) your viral load is below 100,000, (2) your CD4 count is above 200, (3) you don’t take medications for heartburn or ulcers, (3) you will be able to take your medications daily with a full meal,  and (4) you don’t intend to miss doses.

He didn’t mention two other excellent, recommended regimens, which in my mind are preferred in people who may sometimes miss doses.

Triumeq - A good single-table regimen for people with a negative HLA B*5701 test who don’t have multiple risk factors for heart disease.

Descovy + Tivicay - Two pills a day, but unlike Genvoya there are few drug interactions, and unlike Triumeq, you don’t have to worry about HLA B*5701 testing or heart issues. This tends to by my choice in people who don’t mind taking two pills a day.

[hivforum]

Hi Dr. Joel. I have been HIV positive for 15+ years and am not on medication yet. My current CD4 is 485 and my viral load is 55,000. I have decided to start treatment but am confused between Genvoya & Tivicay+Truvada. I want a regimen that has the least side effects, most tolerability & no lipoatrophy, that's the side effect I'm most scared of. I am not on any other medication & am healthy otherwise. My husband is on Complera. Can you please help me with my confusion? Thank you so much.

First, let’s dispense with lipoatrophy: it doesn’t happen with any of the regimens we use today.

I’ve discussed the choice of initial therapy a lot lately, but rather than search for my previous answers (which you can do), I’ll give a short recap on the choices you mentioned:

1. Genvoya: 

PROs: A well tolerated single-tablet regimen, taken with food, that does not appear to have the kidney and bone toxicity that we associate with the tenofovir DF contained in Truvada. 

CONs: It’s possible to develop integrase resistance if you don’t take your meds consistently  The cobicistat in Genvoya interacts with many other medications.

2. Truvada + Tivicay: 

PROs: A well tolerated regimen, taken with or without food. It’s hard–maybe even impossible–to develop integrase resistance with this regimen. There are fewer drug interactions than with Genvoya. It has advantages over the single-tablet Triumeq (which you didn’t mention, but they involve advantages of tenofovir over abacavir). 

CONs: It’s a 2-pill regimen. Truvada can cause bone and kidney toxicity, but that shouldn’t be an issue if you switch to the TAF version of Truvada in March.

You didn’t ask about Complera, but since your husband is on it, I’ll remind you that a TAF-containing version of Complera will probably be approved in March.

Good luck.  (And yes, it’s high time you started therapy!)

[hivforum]

Dear Doctor Joel, at with liver, kidney function and HB normal my doctor gave me with she said an "standard regimen" of combivir and viramune. But even after 3 months im still feeling nauseous, occasional vomiting, dizzy and fatigue. I want to change my regimen that have the least side effects. I am an 48kg person with East Asian genetic that hard to gain weight either by fat or muscle. Could.u recommend me a regimen so that i could consult it with my doctor next time? Thanks.

The combination of Combivir and Viramune is not a standard regimen in the U.S., but you didn’t say where you were writing from—a critical piece of information that almost everyone leaves out. Nausea and fatigue are common side effects of the AZT in Combivir. 

In the U.S., four of the five recommended regimens include integrase inhibitors and the fifth is a protease inhibitor-based regimen. Neither Combivir nor Viramune is recommended anymore. 

The WHO guidelines for resource-limited countries now recommend tenofovir + lamivudine + efavirenz as the preferred initial regimen. 

[hivforum]

New DHHS Guidelines: What to Start

The HIV treatment guidelines from the Department of Health and Human Services (DHHS) have just been released and include some important changes, especially on the question of what drugs to start with.  The guidelines now place initial regimens into 3 categories: Recommended, Alternative, and Other. The most notable changes are the “demotion” of Atripla and Reyataz to “alternative” status based on toxicity and tolerability disadvantages compared to the Recommended Regimens. .

There are now only five Recommended Regimens, all but one containing an integrase inhibitor.  The Recommended Regimens are: 

Triumeq —only for people who are HLA-B*5701 negative

Tivicay + Truvada 

Stribild —only for people with estimated GFR (kidney function) above >70 mL/min

Isentress + Truvada

Prezista + Norvir + Truvada

Alternative Regimens are “regimens that are effective and tolerable, but that have potential disadvantages when compared with the Recommended Regimens listed above, have limitations for use in certain patient populations, or have less supporting data from randomized clinical trials. An Alternative Regimen may be the preferred regimen for some patients.” The Alternative Regimens are: 

Atripla 

Complera—only for people with viral loads below 100,000 and CD4 counts above 200

Evotaz + Truvada —only for people with estimated GFR (kidney function) above >70 mL/min

Reyataz + Norvir + Truvada 

Either Prezista/Norvir or Prezcobix + Epzicom —only for people who are HLA-B*5701 negative

Prezcobix + Truvada —only for people with estimated GFR (kidney function) above >70 mL/min

Other Regimens are “regimens that, in comparison with Recommended and Alternative Regimens, may have reduced virologic activity, limited supporting data from large comparative clinical trials, or other factors such as greater toxicities, higher pill burden, drug interaction potential, or limitations for use in certain patient populations.” The Other Regimens are: 

Isentress + Epizcom—only for people who are HLA-B*5701 negative

Sustiva + Epzicom—only for people who are HLA-B*5701 negative and have viral loads below 100,000 

Either Evotaz or Reyataz/Norvir + Epzicom— only for people who are HLA-B*5701 negative and have viral loads below 100,000

Kaletra + Epzicom—only for people who are HLA-B*5701 negative

Kaletra + Truvada:

Prezista/Norvir + Isentress — only for people with viral loads below 100,000 and CD4 counts above >200, when Truvada or Epzicom can’t be used

Kaletra plus lamivudine (3TC)—only for people with viral loads below 100,000 and CD4 counts above >200, when Truvada or Epzicom can’t be used

I’ve used U.S. brand names here to make things clearer, but keep in mind that in the case of Epzicom, you may be taking generic abacavir and lamivudine