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Editorials |15 July 2003

Is It Time To Proactively Switch Successful Antiretroviral Therapy? Carefully Check Your SWATCH

Michael Saag, MD

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Author, Article, and Disclosure Information
  • From University of Alabama at Birmingham; Birmingham, AL 35294.

    Potential Financial Conflicts of Interest:Consultancies: Abbott, Boehringer-Ingelheim, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Hoffman-LaRoche, OrthoBiotech/Johnson & Johnson, Pfizer/Agouron, Schering-Plough, Shire Pharmaceutical, TherapyEdge, Tibotec/Virco, Trimeris, Virologic; Grants received: Abbott, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Hoffman-LaRoche, Ortho Biotech/Johnson & Johnson, Pfizer/Agouron, Pharmacia & Upjohn, Triangle Pharmaceuticals.

    Requests for Single Reprints: Michael Saag, MD, University of Alabama at Birmingham, CCB Room 178, 908 20th Street South, Birmingham, AL 35294.

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The routine use of triple-drug antiretroviral therapy in the mid-1990s heralded the beginning of the highly active antiretroviral therapy (HAART) era in HIV therapeutics. With these potent regimens, viral replication in lymphatic tissue could be reduced almost completely, leading to levels of virus in plasma below assay detection limits (<50 copies/mL). This resulted in steady increases in CD4 cell counts, reductions in opportunistic infections, and a dramatic reduction in HIV-related mortality rates.
Yet HAART is not always successful. Many patients have trouble tolerating some of the short-term (for example, gastrointestinal) side effects, while others develop longer-term complications, such as hyperlipidemia, insulin resistance, lactic acidosis, or peripheral fat wasting. Other patients experience virologic failure, defined as the inability to achieve HIV RNA levels less than 50 copies/mL or failure to sustain this level of suppression once it has been achieved, a phenomena referred to as viral load rebound. In many instances, viral load rebound is associated with the emergence of resistance-conferring mutations within the viral genome, resulting in virus with reduced susceptibility to one or more of the drugs in the failing regimen. Although there are 17 antiretroviral agents within four drug classes currently approved by the U.S. Food and Drug Administration, many of the resistance-conferring mutations lead to cross-resistance to some or all drugs within the same class, thereby limiting treatment options.
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Saag M. Is It Time To Proactively Switch Successful Antiretroviral Therapy? Carefully Check Your SWATCH. Ann Intern Med. ;139:148–149. doi: 10.7326/0003-4819-139-2-200307150-00014

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Published: Ann Intern Med. 2003;139(2):148-149.

DOI: 10.7326/0003-4819-139-2-200307150-00014

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2003 American College of Physicians
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