Antiretroviral Combination Therapy Summary and Recommendations

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Antiretroviral Recommendations For Initiation of Therapy in Treatment-Naïve 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
Author's Order of Preference	Regimen	Dosing Frequency per day	Pill Burden per day	Potency	Tolerance	Barrier to Resistance	Other
1	atazanavir/ritonavir + emtricitabine/tenofovir (Truvada)	1	4	+++++	++++	+++
	atazanavir/ritonavir + abacavir/lamivudine (Epzicom)	1	4	+++++	+++	+++
	efavirenz + emtricitabine + tenofovir (Atripla)	1	1	++++	++++	+++	C
	fosamprenavir-qd + emtricitabine/tenofovir (Truvada)	1	5	+++++	++++	+++
	fosamprenavir-qd + abacavir/lamivudine (Epzicom)	1	5	+++++	++++	+++
2	atazanavir + zidovudine/lamivudine (Combivir)	2	4	++++	++++	+++	M
	NNRTI-qd + zidovudine/lamivudine (Combivir)	2	3-4	++++	++++	+++	H,C
	lopinavir/ritonavir + abacavir/lamivuding (Epzicom)	2	5	+++++	+++	++++	L
	lopinavir/ritonavir + zidovudine/lamivudine (Combivir)	2	8	+++++	+++	+++++	L,M
	lopinavir/ritonavir + didanosine-EC + tenofovir¹	2	8	+++++	+++	+++++	L,M
	NNRTI-qd + didanosine-EC + lamivudine-qd or emtricitabine	1	3-5	+++++	++++	+++	H,C
	fosamprenavir-qd + zidovudine/lamivudine (Combivir)	2	6	++++	++++	++++	L,M
	atazanavir/ritonavir + tenofovir + didanosine-EC	1	4	++++	+++	++++	M
	fosamprenavir-qd + didanosine-EC + tenofovir	1	6	++++	+++	++++	M
3	PI-B + or (tenofovir + didanosine-EC)	2	8-12	+++++	+++	+++++	L
4	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
Component(s)	mechanism of action	Pill Burden per day	Potency	Tolerance	Advantage	Other
raltegravir	integrase inhibitor	2	++++?	+++++	Unique mechanism of action	contraindicated with rifampin
maraviroc	CCR5 coreceptor inhibition	2	++++	++++	Unique mechanism of action	possible orthostatic hypotension
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; injection fatigue
lopinavir / ritonavir or boosted lopinavir / ritonavir	boosted PI	6-8	+++++	+++	Active in setting of multiple resistance mutations	lipids, rare 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, rare hepatitis, nausea, diarrhea nephrolithiasis
tipranavir / ritonavir	boosted PI	8	+++++	++/+	Active in setting of multiple resistance mutations	lipids, rare hepatitis, nausea, diarrhea
atazanavir + ritonavir	boosted PI	3	++++	++++	Possible activity in setting of multiple resistance mutations?	lipids, rare hepatitis, jaundice; less data on this option as salvage drug
tenofovir	NtRTI	1	+++++	+++++	Active in setting of multiple NRTI resistance mutations?	nephrotoxicity
didanosine	NRTI	1	+++++	+++	Active in setting of multiple NRTI resistance mutations?	pancreatitis, peripheral neuropathy, other mitochondrial toxicity
fosamprenavir + ritonavir	boosted PI	10	+++	+++	Active in setting of multiple resistance mutations?	nausea, diarrhea, lipids, rare hepatitis
saquinavir + ritonavir	boosted PI	12	++++	+++	classic salvage regimen but not active with L90M	nausea, lipids, rare hepatitis, diarrhea
durunavir + ritonavir	boosted PI	4	+++++	++++	May overcome resistance mutations to other PIs	nausea, diarrhea, lipids, rare hepatitis

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Nucleoside & Nucleotide Reverse Transcriptase Inhibitors (NRTI)

AZT | ddC | ddI | d4T | 3TC | ABC | FTC | TDF | Combivir | Trizivir | Epzicom | Truvada | Atripla

Nonnucleoside Reverse Transcriptase Inhibitors (NNRTI)

efavirenz | nevirapine | delavirdine | etravirine

Protease Inhibitors (PI) | Boosted Protease Inhibitors

Fusion Inhibitors

enfuvirtide

Co-Receptor Inhibitors

maraviroc

Integrase inhibitors

raltegravir

Quick Menu / Table of Contents
Introduction	Principles	Management	NRTI Info	NNRTI Info
PI Info	Fusion Inhibitors	Coreceptor Inhibitors	Integrase Inhibitors	Drug Summary
Investigational	Adherence	Lab Evaluation	Resistance Tests	PEP
Antiretroviral Tables	OI Prevention	Vaccinations	TB Therapy	Hepatitis Therapy
OI Diagnosis	OI Therapy	Bibliography	Links	Palliative Therapy

Updated 10.26.2007