Jenny,
You didn't say whether her injections have been given with the longer needles, which would be indicated based on her BMI. She didn't have RPV resistance, but the NNRTI resistance in combination with her obesity would still make me nervous about Cabenuva. Now she's failing that regimen. I wouldn't wait for reconfirmation, because you've already confirmed it. Waiting longer would increase the risk of DTG and BIC resistance.
According to DHHS guidelines, you should use Symtuza until you're sure that there's no resistance to the 2nd generation INSTIs. That being said, she's on a lot of other medications, and avoiding drug interactions would be desirable. The other option would be to try Biktarvy, since her VL is still very low, follow her closely, and see what happens.
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Joel Gallant, MD, MPH
Johns Hopkins University
Baltimore, MD
AXCES Research Group
Santa Fe, NM
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Original Message:
Sent: 04-07-2025 14:32
From: Jenny Tan
Subject: Detectable viremia on Cabenuva
58 y/o female hx of HIV, stroke, DM, HTN, CKD3, obese with a BMI of 30.66, was previously controlled on Biktarvy and was switched to Cabenuva that was started 9/3/2024. She has been consistently on time with her subsequent doses without late or missed doses. She last received dose on 4/1/2025.
Labs since switching to Cabenuva
10/2024: <20
2/2025: 116
4/2025: 223, pending resistance test if able to result with the low VL
Meds:
Taking- Vitamin D 25 MCG (1000 UT) Tablet 1 tablet Orally Once a day
|
- Aspirin 81 mg Tablet Delayed Release 1 tablet Orally Once a day
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- Ozempic (0.25 or 0.5 MG/DOSE) 2 MG/3ML Solution Pen-injector 0.25mg Subcutaneous WEEKLY
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- Basaglar KwikPen 100 UNIT/ML Solution Pen-injector 15 units Subcutaneous at night
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- Cabenuva 600 & 900 MG/3ML Suspension Extended Release 6 mL Intramuscular every 2 months
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- Escitalopram Oxalate 10 MG Tablet 1 tablet Orally Once a day , Notes to Pharmacist: by neuro
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- amLODIPine Besylate 10 mg Tablet 1 tablet Orally Once a day
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- Crestor 40 MG Tablet 1 tablet Orally Once a day
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- Zetia 10 MG Tablet 1 tablet Orally Once a day
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- Jardiance 25 MG Tablet 1 tablet Orally Once a day
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- Losartan Potassium 100 MG Tablet 1 tablet Orally Once a day
|
Reviewed GT on file, has K103N, V245E/K; NRTI: M184V, T69NDA, Y115F and multiple PI mutations. I've attached a copy of the Stanford Database interpretation based on all her previous resistance tests we have on file.
Questions:
With the increasing trend in VL, now above 200, should I put her back on the Biktarvy again now, pending resistance test, or should I switch her to Symtuza assuming she has Integrase resistance?
Should I repeat the VL again in 2 weeks to confirm first?
I'm not really sure what to do and would appreciate your help.
Thank you.
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Jenny Tan
CA
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