Thank You for your input very much !
Original Message:
Sent: 04-14-2022 16:09
From: Angela Kapalko
Subject: switching arv due to multiple resistance mutations
This is actually a real tricky one, because there are so many factors in play. First, this provider who is prescribing meds for this patient is trying to make the best decisions based on their history and resistance pattern. Unfortunately this patient has ruined some options because of how they have taken meds, and even tho complera and odefsey seem to be the only ones that "worked" they didn't really work because they didn't take them all the time, have a high viral load AND developed resistance. So it might be the only regimen they identify as not getting sick from but it didn't work.
Instead of getting specific with this patient I will talk about one of mine to try and relate. I had a patient a number of years ago that ALWAYS had nausea with ANY hiv meds. All of em. But when we dug deeper it was actually a physical manifestation of her depression around her HIV and how it made her feel to think about the meds. Once we got her in therapy to work on that, she never had an issue with nausea again.
there are some patients that are booster intolerant. This is well written about. What this might mean is this patient will be on a multi pill, twice daily regimen Or even some pills but also maybe an infusion (like trogarzo). So I think some things to really talk to this patient about is what is THEIR goal with their HIV. Is it to be healthy? Is it to not have any side effects (who cares about number of pills just as long as no side effects)? Is their goal to never take meds cause they hate them all? What about liquid meds? So I think trying to identify the patients goals might actually help come to some of the reasons this patient is struggling so much with meds. Because something tells me it's not about the pill or pills but the diagnosis itself that might be playing a large part in this and no matter what you try, it's going to end poorly.
if this were my patient, and just looking at the resistance I would be hesitant to do biktarvy because there are multiple NRTI mutations and then bictegravir would be the only real active agent.
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Angela Kapalko
Physician Assistant Chairperson for AAHIVM
Philadelphia FIGHT CommunityHealth Centers
Philadelphia PA
akapalko@fight.org
Original Message:
Sent: 04-14-2022 09:43
From: Deanne Carroll
Subject: switching arv due to multiple resistance mutations
hi everyone,
i am a counselor for a female 62 yr old hiv pos since 2005 with a history of changing meds due to gastric issues . she has only ever been successful on complera and odefsey for any duration due to extreme nausea and vomiting . she has 10800 viral load and 500 t cell but has done so taking 1/2 dose and 3//4 dose now genosure shows mutations . she is requesting Bictarvey but docs recommend cobistat and tivicay ...how do i counsel this woman who has basically looked at the doc and said refer me to hospice i cant live this way...subligual zofran is being utilised also .....would bictarvey be a better bet since she has such history ....here is her data and she has agreed to take the full dose of the bicktarvey .....HIV-1 Subtype: B
Drug Genotypic
Generic Name Brand Name Assessment Comments
-------------------------- ---------- --------
NRTI
Abacavir Ziagen Resistant
RAMs*: M41L, L74I, M184V, K219R
Didanosine Videx Resistant
RAMs*: M41L, L74I, M184V
Emtricitabine Emtriva Resistant
RAMs*: M41L, M184V, K219R
Lamivudine Epivir Resistant
RAMs*: M41L, M184V, K219R
Stavudine Zerit Resistant 1
RAMs*: M41L, K70N, K219R
Tenofovir Viread Resistance Possible 1
RAMs*: M41L, K219R
Zidovudine Retrovir Resistant 1
RAMs*: M41L, K219R
NNRTI
Doravirine Pifeltro Resistance Possible
RAMs*: K101D, V108I, E138Q, E203K, L228R
Efavirenz Sustiva Sensitive
RAMs*: V108I
Etravirine
Intelence Resistant
RAMs*: E138Q, Y181I
Nevirapine Viramune Resistant
RAMs*: V108I, E138Q, Y181I
Rilpivirine Edurant Resistant
RAMs*: E138Q, Y181I
INI
Bictegravir Bictegravir Sensitive
RAMs*: None
Dolutegravir Tivicay Sensitive
RAMs*: None
Elvitegravir Vitekta Sensitive
RAMs*: None
Raltegravir Isentress Sensitive
RAMs*: None
PI
Atazanavir/r Reyataz / r Sensitive
RAMs*: None
Darunavir/r Prezista / r Sensitive
RAMs*: None
Fosamprenavir/r Lexiva / r Sensitive
RAMs*: None
Indinavir/r Crixivan / r Sensitive
RAMs*: None
Lopinavir Kaletra Sensitive
RAMs*: None
Nelfinavir Viracept Sensitive
RAMs*: None
Ritonavir Norvir Sensitive
RAMs*: None
Saquinavir/r Invirase / r Sensitive
RAMs*: None
Tipranavir/r Aptivus / r Sensitive
RAMs*: None
*RAMs = Resistance Associated Mutations observed
Summary of
Mutations Observed:
RT: V35L, M41L, K70N, L74I, K101D, Q102K, V108I, E138Q,
Y181I, M184V, I195L, E203K, R211K, K219R, L228R, E248D,
A272P, T286A, V292I, V293I, E297A
IN: P90A, K111T, V113V/I, T124A, T125A, K173R, I203M,
I208I/L, S230N, V234L, S283G
PR: N37S, R41K, L63P
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Deanne Carroll
Wilmington NC
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