Indication:
- Documented toxicity
- Side-effects
- Planned pregnancy
- Wish to simplify regimen
- Actual regimen no longer recommended
- Prevention of long-term toxicity (pre-emptive switch)
- Aging and/or co-morbidity with a possible negative impact of drug(s) in current regimen eg on CVS risk, metabolic parameters.
- Management of potential drug interactions
- Management of TB, HBV or HCV infection
Principles:
- Intra-class switch if drug-specific related adverse event
- Bid to qd NRTI switch for simplification, prevention of long-term toxicity
- PI/r to NNRTI switch for simplification, prevention or improvement of metabolic abnormalities, adherence facilitation. NVP has the advantage of its metabolic profile. EFV has the advantage of possible FDC of 3 drugs (Atripla®).
- Switching from PI/r to NNRTI or raltegravir only possible if 1) no history of prior virological failure; and 2) NRTI backbone fully active.
- PI/r or enfuvirtide to raltegravir switch for simplification, prevention or improvement of metabolic abnormalities, adherence facilitation.
- Simplification of a complex multi-drug regimen in antiretroviral-experienced patients with 1) substitution of drugs difficult to administer (enfuvirtide) and/or with poor activity (NRTI in case of multiple NRTI resistance) and/or poor tolerability and 2) addition of new well-tolerable, simpler and active agent(s).
Strategies not recommended:
- a. Intermittent therapy, sequential or prolonged treatment interruptions
- b. 2 drug combination,i.e. 1 NRTI + 1 NNRTI or 1 NRTI + 1 PI without ritonavir or 1 NRTI + RAL, or 2 NRTIs
- c. NRTI-sparing regimen except if documented intolerance to all NRTIs
- d. Triple NRTIs combinations
Other strategy:
PI/r monotherapy with bid LPV/r ,or qd DRV/r, might represent an option in patients with intolerance to NRTI or for treatment simplification. Such strategy only applies to patients without history of failure on prior PI-based therapy and who have had viral load < 50 c/ml in at least the past 6 months.
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