How to Determine When HIV Patients Should Switch ART Regimens

Identifying patients who need to switch from one antiretroviral therapy (ART) regimen to another depends on several factors that vary depending on each patient’s unique needs.

In a recent Peer Exchange held at MD Magazine’s state-of-the-art studio in Cranbury, NJ, 5 leading physicians discussed their methodology for identifying these patients, and the key scenarios that help them understand when a therapy switch is in order.

Here are the switch-worthy patients and scenarios they identified:

Patients who take outdated therapies.

When a simpler or more effective treatment regimen is available, it may be time to switch, according to Paul E Sax, MD, clinical director of the HIV Program and Division of Infectious Diseases at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School.

“I was recently contacted about [a patient’s] refills, and he’s taking old tenofovir — so, the more nephrotoxic one. I could easily ask him ‘Do you want to take 2 pills a day instead of 3 pills a day, and you want to take a safer medication?’” Sax said.

Offering a simpler and safer treatment solution often works, but there will be some patients who are hesitant to make the switch because their current treatments help them achieve HIV suppression. In these cases, it’s the physician’s responsibility to switch the patient — especially if they’re taking a medication that’s harmful to them.

Patients with clinical tolerability issues.

When patients are having side effects because of their ART regimens, it’s a sure sign that a switch may be in order.

“I have a patient on rilpivrine-based treatment right now,” Sax said. “She’s having terrible esophageal reflux.”

In this case, Sax put the patient on a proton pump inhibitor and changed her rilpivirine treatment. In many similar cases, he said, physicians should be making sure current treatments — even ones that helped patients achieve viral suppression – are not too toxic and are tolerated well.

Patients who fail with resistance.

Many patients will have resistant virus deep below the surface, according to Joseph Eron, MD, Professor of Medicine at the University of North Carolina at Chapel Hill.

“We need to consider the number of people that actually fail with resistance. We have patients that we’ve treated since the 1990s that have a lot of resistant virus below the surface. But people who are started on therapy now really suppress or they don’t take it very well,” Eron said.

Avoid the “if it ain’t broke, don’t fix it” approach

Sometimes patients are receiving therapy well, but they have intolerances that could still be improved upon.

“I think to ignore these, just because the viral load is undetectable, is a mistake,” said Ian Frank, MD, Director of Anti-Retroviral Clinical Research at Penn Medicine.

Patients should understand that switching from one ART to another is not a permanent move, and returning to an old treatment usually remains a viable option if no resistance issues develop after the switch.

“You’ve got to convince them that it’s saving their life, that we’ve got something better, and that this older drug may be doing something that’s shortening their life,” said Peter Salgo, MD.

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