UCSF - Complex Case

Mutations: K65R, M184V, K101E, K103N, N155H, I135L, Q207E, I13V
Comorbidities: None
Comedications: None
Treatment history: BIC/TAF/FTC (Biktarvy) , EVG/c/TDF/FTC (Stribild)
Current regimen: None
Adherence: Increase prioritization of at least 3 active drugs, Penalize regimens with IV/IM dosing
CD4: ≤ 200
Viral load: High (100,000 - 500,000)
HLA-B5701: Negative
Tropism: Unknown
View results
Submitted by nicky.mehtani on Sat, 05/23/2020 - 15:55

Patient w/ KS, poor prior control of HIV, seen on street HIV outreach. Based on reported medication history, performed rapid start on DRV/c/TAF/FTC qd + DTG bid on day 1, then changed regimen to DRV/c qd + DTG bid + DOR qd when genotype resulted. Noted to have diffuse lymphadenopathy, s/p LN biopsy, and now with new diagnosis of Castleman's disease. 

Remaining questions: 

1. Will cobi have interaction with impending chemo regimen for Castleman's (suspect ritux + doxil)? 

2. If DOR increases AUC of DTG by 33%, once he becomes undetectable (he is actually now undetectable on this regimen), would it be reasonable to make DTG dosing qd rather than bid? I realize this would not be evidence-based, but I wonder if it's reasonable based on pharmacokinetic properties and initial findings that DTG 25mg is likely as effective at 50mg (but that the higher dose was formulated due to it being the maximum tolerated dose). 

Regimen Weighted Score Active Drugs Total Pills Frequency (x/day)
DTG+FOS+DRV/c+DOR 4.51 3.33 6 2
DTG+FOS+DRV/r+DOR 4.66 3.33 7 2
DTG+FOS+DRV/c/TAF/FTC 4.8 3 5 2
DTG+FOS+DRV/r+TAF/FTC 5.15 3 7 2
DTG+DRV/c+DOR+3TC/AZT 5.31 3.33 6 2
Ask on the National Clinical Consultation Center