Grand Rounds

Nucleoside Reverse Transcriptase Inhibitor Combinations

Medical Sciences Department, Pediatric Oncall, Mumbai, India

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056, India.

Clinical Problem :
A 12 years old HIV infected orphan was referred for further management. Both parents were also HIV infected and had died due to same. At 3 years, the child had PCP pneumonia. At 4 years, he was treated for pulmonary tuberculosis {TB}. At 6 years, he had herpes zoster ophthalmicus and molluscum contagiosum. At that time, he was treated with 2 drug Antiretroviral therapy {ART} consisting of Zidovudine {AZT} and Lamivudine {3TC}. At 6½ years of age, 2 more drugs – Stavudine {d4t} and Nevirapine {NVP} were added. At that time mantoux was done which was positive and child was retreated with antituberculous therapy {ATT}. At 11½ years of age, his CD4 count was 138 {19.6 percent} and HIV viral load was 294337 copies, ml. He was shifted to Abacavir {ABC} Didanosine {ddI} and Lopinavir-Ritonavir {LPVr}. At 12 years, his viral load was 452 copies, ml and CD4 count was 542 cells, cumm.

Is the present regime likely to work_?

Discussion :
This child has been on multiple NRTI from the age of 6 years, initially 2 drugs and then Stavudine with Zidovudine which are contraindicated. It is quite likely that the child has developed resistance to the nucleoside reverse transcriptase inhibitors {NRTIs} in form of thymidine analog mutations {TAMs} which may cause resistance to other NRTI group. Thus though the child is now on a protease inhibitor {LPVr}, whether Abacavir and Didanosine will work or not is not known. Six months after starting this combination, the viral load has decreased significantly {452 copies, ml} and thus it would need a close monitoring. Ideally a viral resistance testing should be done in this child since there are still viral copies present in the blood. Also there have been reports that ABC and DDI together can cause increased risk of heart disease.

E-published: June 2012 Vol 9 Issue 5 Art No. 40

Correct Answers :  yes 84%
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