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Antiretroviral Recommendations For Initiation of Therapy in Treatment-Nave Patients

 

Antiretroviral Combination Therapy
Putting It All Together

Recommended regimens for initial therapy of HIV (with rationale)

Author's Order of Preference

Regimen

Rationale

Other
Dosing
Frequency
per day
Pill
 Burden
per day
Potency Tolerance Barrier
to Resistance
1 efavirenz/tenofovir/emtricitabine (Atripla) 1 1 +++++ +++ ++  
  rilpivirine/tenofovir/emtricitabine (Complera) 1 1 ++++ ++++ ++  
  elvitegravir/cobicistat/tenofovir/emtricitabine (Stribild) 1 1 ++++ ++++ +  
  atazanavir/ritonavir + emtricitabine/tenofovir (Truvada) 1 4 +++++ ++++ +++  
  atazanavir/ritonavir + abacavir/lamivudine (Epzicom) 1 4 +++++ +++ +++  
  atazanavir/ritonavir + tenofovir + didanosine-EC 1 5 +++++ +++++ ++++ L
  NNRTI-qd + zidovudine/lamivudine/abacavir (Trizivir) 2 3-4 +++++ ++++ +++ H,C
  atazanavir + Trizivir 2 4 +++++ ++++ +++  
  fosamprenavir-qd + emtricitabine/tenofovir (Truvada) 1 5 +++++ ++++ +++  
  fosamprenavir-qd + abacavir/lamivudine (Epzicom) 1 5 +++++ ++++ +++  
  fosamprenavir-qd + didanosine-EC + tenofovir 1 6 +++++ ++++ ++++ L
  fosamprenavir-qd + Trizivir 2 6 +++++ ++++ +++ L
2 atazanavir + zidovudine/lamivudine (Combivir) 2 4 ++++ ++++ +++  
  NNRTI-qd + Combivir 2 3-4 ++++ ++++ +++ H,C
  lopinavir/ritonavir + Combivir 2 8 +++++ +++ +++++ L
  lopinavir/ritonavir + didanosine-EC + tenofovir1 2 8 +++++ +++ +++++ L
  NNRTI-qd + didanosine-EC + lamivudine-qd or emtricitabine 1 3-5 +++++ ++++ +++ H,C
  fosamprenavir-qd + Combivir 2 6 ++++ ++++ ++++ L
3 PI-B +  or (tenofovir + didanosine-EC) 2 8-12 +++++ +++ +++++ L
4 atazanavir or NNRTI-qd  + stavudine-XR + emtricitabine 2 3-4 +++++ +++ +++/++++ M,H
5 PI-B + stavudine-XR + emtricitabine 2 8-12 +++++ ++ ++++ M,L
6 Trizivir and other triple NRTI regimens 2 2 +++ +++ +++ W

 

Key

NNRTI-qd efavirenz or nevirapine using single daily dosing; pregnancy is a contraindication to the use of efavirenz
PI-B single protease inhibitor at usual dosing or ritonavir-boosted PI dosing
lamivudine-qd 300 mg single daily dosing of lamivudine
didanosine-EC Enteric-coated didanosine (Videx-EC)
fosamprenavir-qd ritonavir-boosted single daily dosing of fosamprenavir
L potential for fat redistribution, hyperlipidemia, Type 2 diabetes mellitus
M moderate or greater probability of mitochondrial toxicity possible including lipoatrophy, peripheral neuropathy
H if nevirapine single daily dosing is used, monitor closely for hepatotoxicity; avoid nevirapine when initiating therapy in women with CD4 > 250
C CNS stimulation is likely with efavirenz-containing regimens
1 lopinavir may significantly increase tenofovir levels: monitor for possible toxicity especially renal especially in individuals with lower than average BMI
W(arning) Warning: Trizivir therapy should not be used without a NNRTI or PI unless circumstances dictate that this is the only practical therapy for a particular client.  In particular patients with advanced disease or higher viral loads should be treated with an alternative regimen until further information becomes available.


 

Antiretroviral Recommendations For Therapy in Treatment-Experienced Patients

 

Antiretroviral Salvage Therapy Considerations

Recommended components of regimens for salvage therapy of HIV (with rationale)
Complete regimens will be determined by resistance profile of patient's HIV strain, patient's history of antiretroviral exposure, and tolerance to particular antiretroviral agents

Component(s)

Rationale

Other
mechanism
of
action
Pill
 Burden
per day
Potency Tolerance Advantage
enfuvirtide FI 2
subcutaneous
injections
per
day
+++++ ++ Unique
mechanism
 of
action
injection site reactions; must be used with other active drugs or resistance develops rapidly
lopinavir / ritonavir
or
boosted lopinavir / ritonavir
boosted
PI
6-8 +++++ +++ Active in setting of multiple resistance mutations lipids, hepatitis, nausea, diarrhea
lopinavir / ritonavir + indinavir double
PI
10 +++++ ++ Supported by
small amounts
of salvage trial data

Active in setting of multiple resistance mutations
lipids, hepatitis, nausea, diarrhea nephrolithiasis
tipranavir / ritonavir boosted
PI
8 +++++ ++/+ Investigational
Active in setting of multiple resistance mutations
lipids, hepatitis, nausea, diarrhea
atazanavir + ritonavir boosted
PI
3 ++++ ++++ Possible activity in setting of multiple resistance mutations? lipids, hepatitis, jaundice; less data on this option as salvage drug
tenofovir NtRTI 1 +++++ +++++ Active in setting of multiple
NRTI resistance mutations?
 
didanosine NRTI 1 +++++ +++++ Active in setting of multiple
NRTI resistance mutations?
pancreatitis, peripheral neuropathy
fosamprenavir + ritonavir boosted
PI
10 +++ +++ Active in setting of multiple resistance mutations? nausea, lipids, hepatitis
saquinavir + ritonavir boosted
PI
12 ++++ +++ classic salvage regimen but not active with L90M nausea, lipids, hepatitis, diarrhea
capavirine NNRTI ? ? ? Investigational
May overcome resistance mutations to other 1st generation
NNRTIs
 

 

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Click HERE for Information on Investigational Forms of HIV Therapy
 
Links to Antiretroviral Sections
Nucleoside & Nucleotide Reverse Transcriptase Inhibitors (NRTI)
AZT  |  ddI  |  d4T  |  3TC  |  ABC  |  FTC  |  TDF  ||| Coformulation NRTI:  Combivir  |  Trizivir  |  Epzicom  |  Truvada
Nonnucleoside Reverse Transcriptase Inhibitors (NNRTI)
efavirenz  |  nevirapine  |  delavirdine  |  etravirine  |  rilpivirine
Protease Inhibitors (PI)  |  Boosted Protease Inhibitors
saquinavir  indinavir  |  ritonavir  |  nelfinavir  |  lopinavir + ritonavir  |  atazanavir  |  fosamprenavir  | tipranavir
Co-receptor Inhibitors
maraviroc
Fusion Inhibitors
enfuvirtide
Integrase Inhibitors
raltegravir  |  elvitegravir
Antiretroviral Metabolic Inhibitors
cobicistat  |  ritonavir
Coformulations
Atripla (efavirenz/tenofovir/emtricitabine)  |  Complera (rilpivirine/tenofovir/emtricitabine)  | Stribild (elvitegravir/cobicistat/tenofovir/emtricitabine)

 

 

 

Updated 1/17/2013