Switching treatment feature
If the side effects are hell or lipo threatens, don’t wait until your
treatment fails to switch, writes Susan Cole
“I used to believe you could only switch HIV treatment if your drugs
weren’t
controlling the virus. I was surprised when my doctor suggested I switch my
current combination because of my side effects, even though my viral load
was undetectable and my CD4 count over 500.” Mary
Mary’s experience is no longer unusual. More and more
people living with HIV now have the option to switch from their existing HIV
medications to an alternative combination, because the range of HIV drugs
available is expanding. These days people switch from their existing combo
for various reasons, not just because of treatment failure; wanting an easier-to-take
combo, an attempt to counter short- and long-term side effects, and, in some
cases, to avoid potential side effects associated with certain drugs before
they’ve actually happened.
Switching to an easier-to-take combo or one with fewer side effects can prevent
you developing them, improve your adherence and consequently reduce the risk
of you developing resistance from being unable to take or tolerate your medication.
Lasting lipo
Lipodystrophy is often seen as the most stigmatising side effect of combination
therapy. It’s a syndrome characterised by body fat redistribution leading
to wasting, usually in the face or limbs, and fat increasing abnormally in
others, usually the trunk. In one study, two thirds of people living with
HIV said that they would rather give up a year of life gained on treatment
than get lipodystrophy.
At first it was assumed lipodystrophy was caused by protease inhibitors, but
now it is thought it is also associated with some nucleoside drugs (nukes),
especially the thymidine analogues d4T and AZT. The British HIV Association
(BHIVA) guidelines no longer recommend use of d4T in first-line combination
therapy, and the draft 2005 BHIVA guidelines suggest people currently taking
AZT should be offered a switch to alternative nukes such as abacavir or tenofovir.
Dr John Wright, senior registrar at Charing Cross Hospital’s Nkosi Johnson
Unit, has switched several patients to avoid the risk of lipo. “I’ve
recently switched three of my female patients who were on d4T for about three
years
Fear of lipo
“I was on Combivir and efavirenz for a couple of years. I hadn’t
actually started getting lipodystrophy, but I was worried I would develop
it because of what I’d read about long-term use of AZT. I spoke to my
doctor about my worries and decided to switch to tenofovir, FTC and efavirenz.
So far I haven’t really experienced any side effects and my CD4 count
and viral load are both fine.” John to another combination, usually
tenofovir or abacavir and an NNRTI.”
Other culprits
That said, many people still do well on thymidine analogues, without developing
lipo. But switching to a non-thymidine drug, like abacavir or tenofovir, appears
to reduce the risk. Reversing the effects of lipo is thought to be very hard
and it may take years for the body to recover. However, a recent UK study,
the RAVE study presented at the 2005 Conference on Retroviruses and Opportunistic
Infections in Boston,
indicated that patients with lipodystrophy taking a thymidine nuke experienced
significant but modest increases in limb fat after 48 weeks of switching to
tenofovir or abacavir.
Lipodystrophy can include increased fats in the blood, leading to abnormally
high cholesterol and triglyceride levels. This in turn may lead to an increased
risk of heart disease. Protease inhibitors (PIs), associated with lipid abnormalities,
have been linked to an increased risk of heart disease. However, the PI atazanavir
does not seem to elevate blood fats in the same way as others. A number of
studies indicate switching from a PI to an NNRTI such as efavirenz or nevirapine
appears to reduce the risk of heart disease. NNRTIs also often simplify therapy,
with fewer pills to take and a once-daily regime.
Non-nuke nightmares
But NNRTIs can also cause side effects, which for some people are so intolerable
they may consider switching therapy. Some, like Stevens-Johnson syndrome (PN
113, June/July), a severe hypersen-stivity reaction, are very rare, occurring
in less than three in 1,000 people treated with nevirapine and one in 1,000
treated with efavirenz. But like all hypersensitivity reactions, they cannot
be reliably predicted. Once you get the reaction, you need to switch medication
immediately.
Other side effects like central nervous system disturbances (CNS), associated
with efavirenz, are common. Trials show between 14 and 50 per cent of people
who take efavirenz develop CNS
disturbances in the first few weeks including disrupted sleep, vivid dreams,
impaired concentration, feeling ‘spaced out’ and depression. These
are likely to stop after a couple of weeks, but for some people the effects
persist. If they are intolerable, you should discuss an alternative regime
with your doctor.
Freudian nightmares
“I wanted to switch therapy because of lipodystrophy, peripheral neuropathy
and five years of madness on efavirenz. It’s an effective drug but I
kept getting unnecessarily angry, depressed and often experienced very disturbing
Freudian nightmares. My viral load remained undetectable for five years and
I always had a CD4 count over 600, but I wanted therapy that was easier to
take with fewer side effects.
I discussed switching with my doctor, had a resistance test (I was only resistant
to 3TC and FTC) and decided to drop efavirenz and ddI and start taking tenofovir
with Trizivir. Since switching I’ve put on weight, my CD4 count remains
in the 600s and my viral load is still undetectable.” Martin
Don’t suffer in silence
As you may know from experience, people with HIV can encounter many other
side effects linked to their meds including nausea, diarrhoea, stomach cramps,
kidney and liver problems and nerve damage. Some peak within the first couple
of months of starting therapy and may decrease or disappear. Others may remain
or worsen. All HIV meds can potentially cause side effects. Individuals differ
signif-icantly in their reaction to drugs; some people may experience intolerable
side effects to a particular drug whereas others experience little or no adverse
reaction.
Fourteen pills a day
“I’ve been taking nelfinavir, abacavir and 3TC since 1998 and
so far it’s worked. My viral load has been undetectable for the last
seven years and my CD4 count has never been below 750. My lipids, liver and
heart are all fine, although I do get a bit of diarrhoea. I take 14 pills
a day, seven in the morning and seven at night, but I’m used to it and
for me it’s as easy as taking one pill as I swallow them all in one
go. My doctor gave me the option to switch to another regime, but I can’t
see the point of changing for the sake of it. I have every viable option if
I need to switch in the future.” Michael
If you think you would benefit from switching one or more of your HIV drugs,
talk to your doctor. If you struggle
to stick to your meds, try to find a
combination that is simpler to take, and if side effects are getting you down
or you’re worried about potential
side effects, find out what else
you could switch to.
