NRTI sparing regimen in someone failing Biktarvy

Mutations: V35S, K101Q, Q102K, V106I, D123E, C162S, E169D, Q174R, M184V, R211K, F214L, P243T, A272P, K275R, R277K, Q278H, K281R, V293I, E297K, E169D, Q174R, M184V, R211K, F214L, P243T, A272P, K275R, R277K, Q278H, K281R, V293I, E297K
Comorbidities: Chronic Renal (Kidney) Disease GFR less than 15 and/or Acute Kidney Injury
Comedications: None
Treatment history: FTC (Emtricitabine/Emtriva) , TAF (Tenofovir/Vemlidy) , BIC (Bictegravir/Biktarvy)
Current regimen: FTC (Emtricitabine/Emtriva) , TAF (Tenofovir/Vemlidy) , BIC (Bictegravir/Biktarvy)
Adherence: No options selected
CD4: > 200
Viral load: Low (200 - 100,000)
HLA-B5701: Negative
Tropism: Unknown
View results
Submitted by sholzma1 on Thu, 08/26/2021 - 08:36

I have a 43 year old man with CKD (stage IV, prior Cr ~3), treated HCV and HIV (on Biktarvy) who presented after a year w/o follow-up and found to have progressive renal failure, Cr 11. Admitted for initiation of HD. Reports compliance with Biktarvy (started a year ago, reportedly transitioned from Triumeq because wanted smaller pill). VL now 15K. Nephrology worried that tenofovir may have contributed to his progressive kidney disease. I'm concerned he didn't suppress on Biktarvy despite the m184V (no prior INSTI genotype available). Should we be worried about INSTI resistance (though did ok on Triumeq)? Repeat genotype pending, but want to start therapy. That being said, the recommended regimen is DTG+DRV/c, over regimens that includes either DOR or RPV. Do we think we can away w/o a third agent? 

Regimen Weighted Score Active Drugs Total Pills Frequency (x/day)
DTG+DRV/c 1.26 2 2 1
DTG+DRV/r 1.81 2 3 1
DTG+DRV/c+DOR 2.57 3 3 1
DRV/c+DTG/RPV 2.62 3 2 1
DTG+DRV/r+DOR 3.02 3 4 1
Ask on the National Clinical Consultation Center