3 PIs in HIV Therapy?

[MindOverMatter]

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So I'm doing a rotation in a specialty pharmacy right now, and was reviewing a patient's profile to find something that I thought was odd. Is it common to have multiple protease inhibitors on board like this in HIV patients?

Prezista (Darunavir) 600 mg bid
Lexiva (Fosamprenavir) 700 mg bid
Norvir (Ritonavir) 100 mg bid

Patient is also taking Sustiva (Efaviranz) 600 mg qhs, Isentress (Raltegravir) 400 mg bid, and Acyclovir 400 mg bid for prophylaxis.

I mean obviously the Norvir is on board to boost the other PIs, but why would you need both? Seems like overkill to me, and something that would place the patient at an increased risk for adverse effects. I've been looking through the guidelines, and can't find anything that supports this regimen. Any help?

 

[rxlynn]

Do you have a genotype and/or phenotype available for the patient? That might give you some insight into what the physician was thinking.

 

[rxlynn]

After thinking about this a bit more, my thought is that they are just doing this combo as salvage therapy because they have exhausted other options.

I did find one paper that looked at using amprenavir (Lexiva is the prodrug for this) plus Kaletra (lopinavir/ritonavir boost) in deep salvage patients.

 

[MindOverMatter]

No, no genotype/phenotype info. He's been on ART for a long time though.

I just bring this up because his triglycerides are through the roof, despite years of trying to get them down, and if there's not a good reason for him to be on duplicate therapy like this, I'd like to see him off one of them.

 

[DrugDealer]

The inclusion of Isentress in this patient's regimen makes me think there is some resistance and they are indeed doing some salvage therapy, trying any combination until something works. What's left to lose at this point?