Managing HIV/AIDS Therapy in Treatment-Experienced Patients What are the treatment goals in treatment-experienced patients?
	Enlarged Version of Graphics Below	Dr. Bellos (OC): In treatment-experienced patients, the issues really are not significantly different for the patient. They still want tolerability of the regimen with few side effects. They want ease of administration, and hopefully lower pill burden, if that's possible with the second or third regimen. Dr. Bellos (VO): For the clinician, I think the issue that comes into play is: How do we choose that regimen, based on particular resistance patterns, phenotypic or genotypic resistance patterns? If that data is not available, treatment history for regimens in the past? Additionally, any potential side effects or toxicities that the patient had with their initial regimens, we would like to try to avoid.   See Slide Dr. Bellos (OC): Generally, most patients who have virologically failed one regimen have a tendency to be a little more tolerant of increased pill burden, but still, if you can keep the regimen to once a day, those patients much prefer taking their drug once a day. In that setting, what we will do in a lot of instances is use protease inhibitors, or boosted protease inhibitors, and I think pretty much the state-of-the-art today is the use of boosted protease inhibitors, although the drugs can be used without boosting. Dr. Wohlfeiler (OC): It partly depends on why you're changing the regimen. If you're changing because of virologic failure then obviously you need to look at what's failing, what would be the next best choice or choices in terms of antiretrovirals to get that virus resuppressed. If you're changing because of side effects or adherence issues, then you've got to explore with the patient what kind of side effects they're having, obviously why it is that they're finding it difficult to adhere to the regimen that they're on. Dr. Kwakwa (OC): For second regimens, the goal is still maximum virus suppression, with optimum reconstitution of the immune system, and also to keep some control on side effect profiles and medication inconvenience. Included in that is pill burden and dosing frequency.   See Slide Dr. Bellos (OC): ...the regimen that you choose at that juncture will be based on some genotypic and phenotypic data, and from that perspective, the regimen may not be as easy or as low a pill burden as the initial regimen was, and patients need to understand that as they move into their second or third regimens. Your goal would be to be able to create a very simple and low pill burden regimen, and sometimes you can't, based on that genotypic information. Announcer (VO): Here are some of the emerging resistance patterns that develop in patients with first virologic failure. Resistance is compared between protease inhibitor-and non-nucleoside based regimens. As can be seen, resistance to 3TC is the first to emerge.   See Slide Dr. Kwakwa (OC): For someone who is heavily treatment-experienced, the virologic, immunologic, and convenience goals change considerably. Dr. Kwakwa (VO): The goal there may be, again, to suppress the virus to some degree, to the maximum degree possible, but generally, not to a level below detection, and to maintain the CD4 count for as long as possible, and to also of course do whatever you can to minimize the inconvenience, but then, the priority really drops a notch at that point.   See Slide Dr. Wohlfeiler (OC): I think resistance testing becomes really critical in those more experienced patients where you probably have multiple resistant mutations and a number of antiretrovirals that the virus is no longer susceptible to. So the balance starts to shift with those patients where, as much as you would like to focus on convenience and side effects, you may not be able to focus on those things as much as you just need to pick the regimen that's going to work. Dr. Bellos (OC): The goals of therapy with the second or third regimen should theoretically be the same as the goals of your initial regimen. Where your goal for therapy really changes is actually in later-stage patients who are in what we refer to as "salvage" or "deep salvage." In those patients, your goal is to really maintain immunological intactness in those individuals compared to necessarily controlling their viral loads. Your goal for initial therapy, as well as for second and third regimens, would potentially be to bring your viral load down as low as you can. Once you get into salvage or deep salvage regimens, then, your goals change a little bit. At that point, your goal becomes, "How immunologically intact can we keep the patient?"
Program Menu		Next