John, thanks for your posts. However, you've ruined my evening by giving me all that reading material...
Reading Dr. Deeks article gives me the impression he likes Crixivan. For example, when talking about Crix (indinavir), he assesses the failure of salvage therapy as follows:
"Comment: The strategy of switching to a ritonavir/saquinavir regimen
after indinavir failure appears to result in a potent but transient
effect on viral load. Considering the cross-resistance among these
agents, the lack of a durable response is not surprising. More
aggressive regimens, containing experimental therapies, will likely be
necessary in order to achieve complete viral suppression in patients no
longer responding to indinavir."
/* actually the data don't support even a transient, potent effect on viral load
e.g., once indinavir fails, nothing seems to work, so let's try some experimental therapies ...
Then talking about Viracept (nelfinavir),
"Although some experience suggests that salvage therapy after nelfinavir
failure may be possible in some patients, other data indicate that
nelfinavir failure confers cross-resistance to other protease
inhibitors. Large prospective studies must address the question of
whether protease inhibitors can be used sequentially."
So, there's data supporting a conclusion that salvage therapy after indinavir failure doesn't work, and there's data supporting a conclusion that salvage therapy after nelfinavir failure may work ... but his assessment of the situation with respect to salvage therapy for both is the same ... inconclusive data requiring further study.
Now, I agree with Dr. Deeks that the data is minimal, and warrants further study, and I also agree that the data do indicate that salvage therapy is at best that, salvage ... hence hit hard, hit fast with the most potent, most tolerated PI in combination therapy since that's your best chance to achieve a lasting anti-viral (and clinical) response. However, he seems to under-emphasize Crix's problems as salvage therapy, and under-estimate Viracept's potential.
Maybe his admiration for Crixivan has something to do with the problems in compliance that show up in his retrospective study he presented at ICAAC? If all the UCSF patients that failed to comply were taking Crix, what's there to wonder about : )
Seriously, I'm not qualified to make judgements in this area, and this is a lot of typing to support a minor observation, but I just wanted to pass it along.
Peter |
