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  • 1.  Deciding ARV with multiple resistances.

    Posted 16 days ago
    Hello Everyone,
     
    I have a new patient who presented to me and I need suggestions on changing his ARV.  Pt is a 28 YO AAM who was diagnosed with HIV last year. Otherwise no PMH.  He was started on Triumeq but has been off ARV x 8 months due to a recent move.  His CD4 count is 66 and VL 124k.   He really hates the size of triumeq.  Initially, I wanted to switch him to Biktarvy, but he is resistant to emtricitabine w/M184 mutation.  I then thought about Julica but this would not be an option since he is not virologically suppressed or on stable regimen x 6 months.   I would input/suggestions.     Kindly, Myra S., FNP-C
    HIV genosure archive
    comment
    final
    02
    Pol gene amplicon adequate for sequencing
    HIV genosure archive
    comment
    final
    02
    The HIV-1 GenoSure Archive(R) for this specimen has been completed.
    HIV-1 Subtype: B
    
    Drug                         Genotypic
    Generic Name    Brand Name   Assessment           Comments
    --------------------------   ----------           --------
    NRTI
    Abacavir        Ziagen       Sensitive
       RAMs*: M184M/V
    Didanosine      Videx         Resistance Possible
       RAMs*: M184M/V
    Emtricitabine   Emtriva       Resistant
       RAMs*: M184M/V
    Lamivudine      Epivir        Resistant
       RAMs*: M184M/V
    Stavudine       Zerit        Sensitive                   1
       RAMs*: None
    Tenofovir       Viread       Sensitive                   1
       RAMs*: None
    Zidovudine      Retrovir     Sensitive                   1
       RAMs*: None
    
    NNRTI
    Doravirine      Pifeltro     Sensitive
       RAMs*: Q207E
    Efavirenz       Sustiva      Sensitive
       RAMs*: None
    Etravirine      Intelence    Sensitive
       RAMs*: None
    Nevirapine      Viramune     Sensitive
       RAMs*: None
    Rilpivirine     Edurant      Sensitive
       RAMs*: None
    
    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*: L10L/I, M36I, I62V
    Darunavir/r     Prezista / r Sensitive
       RAMs*: L10L/I
    Fosamprenavir/r Lexiva / r   Sensitive
       RAMs*: L10L/I
    Indinavir/r     Crixivan / r Sensitive
       RAMs*: L10L/I, M36I
    Lopinavir       Kaletra      Sensitive
       RAMs*: L10L/I
    Nelfinavir      Viracept     Sensitive
       RAMs*: L10L/I, M36I
    Ritonavir       Norvir       Sensitive
       RAMs*: L10L/I
    Saquinavir/r    Invirase / r Sensitive
       RAMs*: L10L/I, I62V
    Tipranavir/r    Aptivus / r  Sensitive
       RAMs*: M36I
    
    *RAMs = Resistance Associated Mutations observed
    
    Summary of Mutations Observed:
    
    RT: T27S, V35V/I, Q102K, K122E, D123E, I135V, Q174K,
        M184M/V, G196E, T200T/I, Q207E, V245M, E248Q, D250E,
        A272P, R277K, T286A, E291E/A, E297E/A/K/T, R356K,
        M357M/T, K358R, G359S, A376S, K390K/R, E399E/D, A400S
    
    IN: S24S/N, V31I, V72V/I, V113I, S119S/P, T122T/I, T124A,
        T125A, V165V/I, I182I/V, E198Q, V201I, K219N, N222K,
        V234L, S283S/D/G/N
    
    PR: L10L/I, I15I/V, L19I, M36I, N37D, R41K, I62V, L63P,
        I64L, I93L
    
    Assessment of drug susceptibility is based upon detected
    mutations and interpreted using an advanced proprietary
    algorithm (version 18).
    
    Comments:
    
     1 - Assessment for this drug was derived considering the
    sensitizing effect of mutation M184V.
    
    HIV genosure archive interp
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    final
    02


    ------------------------------
    Myra Sikwata
    Burns Harbor IN
    ------------------------------


  • 2.  RE: Deciding ARV with multiple resistances.

    Posted 15 days ago
    There's no reason not to use Triumeq or Biktarvy. While the M184 takes a single component off the table, the fact you are considering Juluca shows that you are actively considering an INSTI based 2-drug regimen. My bias is toward dolutegravir and if he can tolerate the pill size and is committed to greater adherence then it's reasonable to restart triumeq. If you're willing to wander a little further afield with multiple tablet 2 drug regimens, there are lots of options for dolutegravir plus another agent that are available to you even with the archived resistance.

    Regardless, you can dangle promises of something injectable should he get to full suppression and start there for a while.

    ------------------------------
    Warren Magnus
    Aids Healthcare Foundation
    Henderson NV
    ------------------------------



  • 3.  RE: Deciding ARV with multiple resistances.

    Posted 15 days ago
    Biktarvy would be fine.  Thanks for presenting!

    ------------------------------
    James Adams
    Rancho Mirage CA
    ------------------------------



  • 4.  RE: Deciding ARV with multiple resistances.

    Posted 14 days ago
    Edited by Angel Ribó 14 days ago
    It is important to remember that the M184V mutation has a large impact in reducing the fitness of viral replication thus from that aspect it is one of the best mutations to have. Additionally, its presence does not totally wipe out the suppression activity  of lamivudine over viral replication remaining about .7 still active. Finally, it also helps with hypersensitization of Tenofovir and/or AZT increasing their activity in viral suppression.

    ------------------------------
    Angel Ribó
    Peninsula Research
    Palm Coast FL
    ------------------------------



  • 5.  RE: Deciding ARV with multiple resistances.

    Posted 14 days ago
    Just to be complete, Symtuza would also work in this case, and currently is the only med with the FDA indication in presence of the M184V mutation.  That being said, Biktarvy, Tivicay/Descovy, and Juluca, as others have mentioned, should work fine.  Thanks!

    ------------------------------
    Adam Zweig
    AIDS Healthcare Foundation
    San Diego CA
    ------------------------------



  • 6.  RE: Deciding ARV with multiple resistances.

    Posted 14 days ago

    Good evening everyone,

    Thank you so much for you input.  So I went with Biktarvy because of its size, and pill size was one of his main concerns with ARV.   Can someone please explain M184 mutation with regards to ARV.   Also, given his CD4 count is 60, I put him on PCP prophylaxis. I used atovaquone because he has g6pd deficiency.  


    Thanks again!

    Myra.  



    ------------------------------
    Myra Sikwata
    Burns Harbor IN
    ------------------------------



  • 7.  RE: Deciding ARV with multiple resistances.

    Posted 14 days ago
    Is he sulfa allergic?   If not, we usually go with TMP/SMX first for PJP prophylaxis.

    The thinking with the presence of M184V is that we can get away with a regimen that has only two active drugs, as long as one of them has a high genetic barrier to resistance, such as Biktarvy, Symtuza, or Tivicay/Descovy.  You are right in that Juluca would not be appropriate in this case, because it is indicated for suppressed patients.  Hope this helps!

    ------------------------------
    Adam Zweig
    AIDS Healthcare Foundation
    San Diego CA
    ------------------------------



  • 8.  RE: Deciding ARV with multiple resistances.

    Posted 14 days ago

    Thank you so much! This makes sense!  I used atovaquone because he has a G6PD deficiency and thought we should not use sulfa with this deficiency.   Again, I really appreciate your input. This group is awesome!