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Conference
"Second Line Therapy" Dr. Frank J. Palella (biography) English - 2003-03-29 - 41 minutes
Summary : The optimal selection of antiretroviral agents for inclusion in second line therapy and beyond must include consideration of several important factors. These include :
- reasons for discontinuation of first line HAART therapy (ie. efficacy versus tolerability)
- - viral susceptibility data (genotype, phenotype, virtual phenotype, replication capacity)
- underlying/preexisting patient diagnoses or comorbid conditions
- known history of drug toxicity
- patient preference
- likelihood of medication adherence
- drugs option remaining for inclusion in a second line (or beyond) regimen
- whether or not complete viral suppression is a realistic option
- fear of development of metabolic complications
feasibility and advisability of an interruption in therapy
Learning objectives : The participant will learn that it is important to use the following guidelines in optimizing second line HAART therapy:
- Use at least 2 or 3 active agents as determined by genotype or phenotype
- Switch treatment as early on in the course of virologic failure as possible to minimize additional resistance, and to increase the chance of successful salvage
- Simplify regimens when possible to enhance adherence and tolerability
- Communicate effectively with patients
Bibliographic references : Factors associated with the successful modification of antiretroviral therapy. HIV Outpatient Study Investigators.
Weidle PJ, Lichtenstein KA, Moorman AC, Von Bargen JC, Greenberg KS, Palella FJ Jr, Holmberg SD.
Epidemiology Branch, Division of HIV/AIDS Prevention Surveillance and Epidemiology, National Center for HIV, STD, and TB Prevention, Centers for Disease Control, Atlanta, GA 30333, USA. pew6@cdc.gov
OBJECTIVES: To assess the characteristics of medication regimen modification and the influence of a commercial genotypic resistance assay on the short-term (3-12 weeks) viral load response (> or = 0.5 log reduction) in HIV-1-infected patients extensively treated with antiretroviral therapy (ART). METHODS: A nested cohort study was performed in two clinics from the HIV Outpatient Study of 96 persons with a HIV-1 viral load of 10(4) log copies/ml or greater taking at least two antiretroviral medications. RESULTS: Successful modification was associated with adding at least two new medications [relative risk (RR), 1.5; 95% confidence interval (CI), 1.1-2.2], adding a drug from a previously unused class of agents (RR, 2.0; CI, 1.4-2.9), the initiation of a non-nucleoside reverse transcriptase inhibitor (NNRTI) (RR, 1.7; CI, 1.2-2.4), but not substituting a protease inhibitor or the use of a commercial genotypic resistance assay. CONCLUSION: Incorporating a drug from a previously unused class or changing at least two new medications, but, within the confines of this study, not using a commercial genotypic resistance assay, was associated with the successful modification of ART as measured by a reduction in viral load.
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