Resistance Testing Case Studies

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Resistance Testing Case Studies

• D.T.Jayaweera M.D.
• Associate Professor in Medicine
• University of Miami School of Medicine
• Division of Infectious Diseases

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Disclosure of Financial RelationshipsThis
speaker has the following significant financial
relationships with commercial entities to
disclose

• Advisory Board GSK, BMS, Tibotec, Roche,
  Achillion, Abbott, BIPI, Idenix
• Consultant GSK, BMS, Tibotec, Roche, Achillion,
  Abbott, BIPI, Idenix
• Grants/Research Support GSK, BMS, Tibotec,
  Roche, Achillion, Abbott, BIPI
• Speakers Bureau GSK, BMS, Tibotec, Roche,
  Abbott, BIPI, Gilead

This slide set has been peer-reviewed to ensure
that there are no conflicts of interest
represented in the presentation.
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Case Study 1

• Mr. JC is a 37 year old white man who is an
  administrator in an institution. He acquired HIV,
  hepatitis C and B from multiple blood
  transfusions and factor transfusions for
  hemophilia. Diagnosed through transfusion safety
  study in 1983.
• He was treated with multiple regimens. He failed
  all the current ARV regimens.

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Case Study 1

• Medications
• Videx EC 250mg PO QD, D4T 40mg PO BID, Fuzeon
  90mg SQ BID
• His Hepatitis C was not treated as he was too
  advanced to tolerate Peg interferon and
  Ribavirin.
• Patient met all the criteria for transplant
  except HIV control. His HIV VL was 141,000/mm3
  and CD4 cell count was 91 cells/mm3 and resistant
  to all agents.

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Case Study 1

• Lexiva/r with Zerit 30mg twice a day, 3TC 300mg
  a day, Tenofovir 300mg / day and Fuzeon.
• Patient had severe GI symptoms and had to stop in
  5 days.
• Changed to Reyataz/r with 3TC 300mg a day,
  Tenofovir 300mg / day and Fuzeon, despite
  resistance.
• The HIV VL decrease from 140,000 to 1200 in 2
  weeks

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Case Study 1

• Patients transplanted on Aug 5th of 2005.
• Patients is tolerating Reyataz well but current
  medications
• Valcyte, prograft, medrol, Protonix and many
  other meds
• The PI changed to Invirase and ritonavir twice a
  day and vircotype was done.
• HIV VL increased to 47,800/mm3

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Case Study 1

• Patients medications were changed to LPV/r
  tablets 3 tablets twice a day (not two) with 3TC
  and Viread.
• Patient tolerating meds, but has significant
  diarrhea.
• Change to Darunavir/r with tenofovir,
  emtricitabine and fuzeon.
• Gained over 30 lbs.
• Patient is back at work.

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Case Study 2

• 48 year old white male diagnosed in 1994
• Between 1994-2001 took abacavir, ddI, d4T, ddC,
  ritonavir, efavirenz, nevirapine, indinavir, and
  nelfinavir.
• From 2001-8/25/04 took tenofovir, lopinavir/r,
  and lamivudine
• In Dec. 2002 documented resistance to NNRTIs
  (K103N)
• In June 2004 presents VL26,050 c/mL, CD4 3,
  absolute CD472 cells/?l
• vircoTYPE ordered (VirtualPhenotype)

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Guess which PI is more active
10I, 23I, 33F, 46I, 54V, 60E, 63P, 71V, 76V,
82F,90M, 93L
Lets look at 2 genotype interpretation systems
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Guess which PI is more active
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vircoTYPE resistance results
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• The clinical case
• On 9/20/04 changes to Invirase (SQV) 1000 mg
  BID, Norvir (RTV) 100 mg BID, Viread (TDF) QD,
  Sustiva (EFV) 600 mg QD, Fuzeon 90 mg BID.
• On 12/13/04 VL lt50 c/mL, CD4 13, and absolute
  CD4 179 cells/?l