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Therapy Switch

  • 1.  Therapy Switch

    Posted 22 days ago
    Edited by Ryan Doyle 22 days ago

    Hello, 

    I have a patient who recently transferred care to me who has been on Genvoya for many years and has been doing well with respect to control of HIV, always virally suppressed and great CD4 count (most recent CD4 >700). Patient does have CKD3a. We were recently discussing switching from Genvoya to Biktarvy as an option as patient may be interested, however patient is also very hesitant to come in for visits more frequently than annually for wellness visits. I am open to switching the patient to Biktarvy, however I am concerned about his willingness to attend closer follow up after the switch to assess for adherence and obtain follow up labs. Curious if others have thoughts? I have discussed with the patient given ongoing adequate control of HIV, there may not be indication/need to make a regimen change. 

    Thanks!

    Ryan



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    Ryan K. Doyle, DO (he/him/his)
    rymed89@gmail.com
    Grand Rapids, MI
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  • 2.  RE: Therapy Switch

    Posted 21 days ago

    Hi Ryan

    from someone who has been providing HIV care since 1989 out of residency, I would say an important piece with a NEW patient is to go gingerly with them when it comes to medication change (ART) - especially when they have been doing well (VL < 20/ CD4 -700) on their current regimen and their prior doctor did not (likely) recommend a change. Biktarvy from a renal perspective makes sense and hopefully something he would understand if explained carefully.  Many of my older long-term patients who used to come in monthly and then q3 or q6 months with simplified safer regimens -  also started requesting yearly visits. Although our Ryan White Clinic has a 6-month visit policy -  I generally agreed to yearly visits for some patients -  with the caveat being they would get "safety/ screening labs) at a 6 month interval but would not need an office visit.  The other challenge with aging HIV patients is then addressing co-morbidities which can be difficult with only once visit a year. "Dance" with them -- and once they have gained trust and confidence you should be able to do what is clinically best for them.



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    Jeffrey T. Kirchner, DO, FAAFP, AAHIVS
    Lancaster PA
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  • 3.  RE: Therapy Switch

    Posted 20 days ago

    Jeffrey, 

    Thank you for your reply, I greatly appreciate it. Great insight. I have seen this patient a couple of times and he expresses interest in a switch but is quite ambivalent about making a change, it may take time to continue developing rapport and trust with him. 

    Thanks again!

    Ryan



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    Ryan K. Doyle, DO (he/him/his)
    rymed89@gmail.com
    Grand Rapids, MI
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  • 4.  RE: Therapy Switch

    Posted 21 days ago

    Hi Ryan,

    Good question.   In a case like this, it is all about the "art" of medicine.  There are no "right" answers.

    For me, I would prefer to have this guy on an unboosted regimen.  As he gets older and accumulates additional morbidities, he will likely need additional medications, and the risk of significant DDIs grows if he stays on Genvoya.  Also, you would want to make sure his lipds are not elevated from this as well. That being said, if he is really attached to this med and is doing well, than I really don't see an overwhelming reason to push it.  That could threaten his trust in you.   If you do end up switching, I am not particularly concerned about the switch to Biktarvy.  You would be switching from a low barrier to resistance regimen to a high one.  Sure.  It would be great to get one visit in a few months after he changes to assure tolerability. But once again, if he is opposed to this, I would not push it that hard.   You could just ask him to call you if he experiences any issues.   Thanks!



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    Adam Zweig
    AIDS Healthcare Foundation
    San Diego CA
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  • 5.  RE: Therapy Switch

    Posted 20 days ago

    Adam, 

    Thank you for your perspective. You have affirmed the thoughts I have had in this case about preference for using an unboosted regimen. I like that idea of just having him call in a few months after the switch, he might go for that. He does not like to come in for visits more than he needs to. 

    Thanks! 

    Ryan



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    Ryan K. Doyle, DO (he/him/his)
    rymed89@gmail.com
    Grand Rapids, MI
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  • 6.  RE: Therapy Switch

    Posted 21 days ago

    Switching the patient off Genvoya is probably a great idea - more to avoid the now unnecessary cobicistat boosting and the increased risk of elvitegravir virologic failure. If this patient already has CKD3a, I would seriously consider a TDF/TAF-sparing regimen, such as DTG/3TC or DTG/RPV to avoid any further exposure to TDF. If he has no prior history of VF, the TANGO study results support this switch.

    David



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    W. David Hardy
    Los Angeles CA
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  • 7.  RE: Therapy Switch

    Posted 20 days ago

    David, 

    Great idea about TDF/TAF sparing regimen, thank you for the suggestion. He is concerned about his kidney function, as am I, and so if I educate him well on the potential benefits of getting away from a TDF/TAF regimen, he may be included to make a switch also. 

    Thanks!

    Ryan



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    Ryan K. Doyle, DO (he/him/his)
    rymed89@gmail.com
    Grand Rapids, MI
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  • 8.  RE: Therapy Switch

    Posted 21 days ago

    Hi - thanks for your question.  I often grapple with this question - I have several pts on genvoya who do not want to switch to BIk or a newer ARV.  If their current labs are stable, they are adherent, and this is no contraindication to stay on genvoya - I keep them on genvoya.   When I see them at their visits - I do raise the issue of switching regimens.  I dont think it is a bad thing to keep the pt on genvoya if s/he is stable and other parameters are wnl.

    Hope this helps.



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    Sara Back
    North Central Bronx Hospital
    New York NY
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  • 9.  RE: Therapy Switch

    Posted 20 days ago

    Sara, 

    Thank you for your insight. I appreciate it! I will continue to bring this up at future visits with him as we continue to develop rapport and hopefully his trust in me.

    Ryan



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    Ryan K. Doyle, DO (he/him/his)
    rymed89@gmail.com
    Grand Rapids, MI
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  • 10.  RE: Therapy Switch

    Posted 21 days ago

    Genvoya was a great regimen in its day, but it has essentially been replaced by Biktarvy for lots of good reasons: Biktarvy is a smaller pill with no food restrictions, fewer gastrointestinal side effects, far fewer drug interactions, and a higher barrier to resistance. In contrast, I can't think of any advantage of Genvoya over Biktarvy, other than that you can get away with lower doses of Viagra.  

    I had a number of patients who only wanted to be seen once a year, but they were willing to get their bloodwork drawn more often (e.g. every 6 months). Would your patient consider that?



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    Joel Gallant, MD, MPH
    Santa Fe, NM
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  • 11.  RE: Therapy Switch

    Posted 20 days ago

    Joel, 

    Great reminders of the benefits of Biktarvy over Genvoya, thank you. He might be willing to get bloodwork more often with keeping visits to annually, I like the idea. 

    Thank you! 

    Ryan



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    Ryan K. Doyle, DO (he/him/his)
    rymed89@gmail.com
    Grand Rapids, MI
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  • 12.  RE: Therapy Switch

    Posted 18 days ago
    Edited by Chiu-Bin Hsiao 18 days ago

    Ryan:

    I think, whoever on Genvoya (TAF/FTC/EVG/cobi) should be switched over to "Biktarvy" or other Bictegravir or Dolutegravir containing regimen. Two reasons, drug-drug interaction issues with Cobicistat and the lower genetic barrier to develop integrase inhibitor resistant mutation of Evitegravir.. When patient has severe renal impairment, two drugs therapy can be used; however, we should carefully review patient's cumulated HIV- drug mutation to make sure both components are fully active. We have great experience with Doravirine plus Dolutegravir, Dolutegravir/3TC and Dolutegravir/Rilpivirine in this setting. We have been doing an investigator-initiated study: CABENUVA PK study in PLHIV with severe renal impairment (e-GFR <= 30), Today, we already have patients completed 12 months study and we have 2 patients received kidney transplantations successfully while they were receiving CABENUVA as their HIV regimen. We have to remember that dolutegravir may boost metformin level double, therefore, we have to be careful about metformin use in patients with CKD 3a while they are on metformin and limited metformin daily dose to 1000 mg if patients are on dolutegravir regimen. I think that Biktarvy does not have significant DDI with Metformin. 



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    Chiu-Bin Hsiao
    Allegheny General Hospital - Positive Health Clinic
    Pittsburgh PA
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