Re: A querry on second line drug combination

[Guest guest]

Dear Dr Rakesh Bharti,

Re: /message/10152

Regarding starting second line, the resistance genotyping test is essential.

Without one nobody can assure about the efficacy of the regimen. Wecan discuss

the the present situation without a resistant test.

1. The patient's previous regimen was d4t+3TC+EFV.

2. The first mutation is expected to occur is against 3TC. But a single mutation

is not indicative switch over as the virus are still suceptible and this

mutation sometimes increases the virus succeptibility to certain NRTIs like ZDV.

3. The next mutations are expected to occur with NNRTIs. A single mutation may

likely to render these drugs useless and cross resistance to other NNRTIs are

quiet common as the genetic barrier is very low.

4. As the patient on already on d4T, mutation against THYMIDINE ANALOG could

have occured.Then ZDV, another Thymidine analog may also become useless. But

upto 3 mutations Thymidine analog drugs are sensitive to the virus. So if more

mutations occured ZDV will not be useful. This can be decided only by Resistance

test.

5. Then the right choice of back bone NRTIs for this patient will be TDF+3TC OR

FTC +ABC (IF HLA typing is o.k).

6. As the NNRTIs will not be useful PIs are the next chice among which as the

PGI doctor's chice is better than anything else with LPV/rtv, provided the

individual's hepatic and nephrotic parametres are normal.

Thanking you.

Dr S.Murugan

Senior Consultant HIV Physician,

Tirunelveli

Tamilnadu.

e-mail: <muruganyes@...>

[Guest guest]

Dear all

 

Re: /message/10152

Refence my earlier reply on this, I have enquired into the matter . No Such

patient has been started on such regimen by PGI, Chandigarh.

 

I would request Dr Bharti to send more details on my eamil and not on the forum

to maintian confidentiality of patient. In fact the patients confidentiality has

already been breached as there is a patients by this name as mentioned in Dr

Bhartis email.

 

We should not allow this forum to be used for defaming some one /some

institution without documentation/verification of facts, if any.

This case should have been sent to me in first instance as most of forum members

know that I do respond to their querries.

In case the response was not obtained , than this could have been put on forum

minus the patients name, which is very obvious to those who are involved with

second line in Punjab

 

Dr Bharti, pl send me further details of this patient so that we verify whether

it has been the case and if yes, than to take further course of action

 

Thanks

Dr B.B.Rewari

MD,FICP,FIACM,FIMSA,FGSI

Sr.Physician,Dr RML Hospital &

National Programme Officer (ART)

National AIDS Control Organistion,

6th Floor, Chandralok Building,

36, Janpath, New Delhi-110001

Tel; 011-23731954, 43509999(O)

Mobile ; 91-9811267610

Fax : 011-23731954,23731746

e-mail: <drbbrewari@...>

[Guest guest]

Dear all

 

Re: /message/10152

This is not at all acceptable , may be there is a mistake. I will find out and

inform you

Dr B.B.Rewari

MD,FICP,FIACM,FIMSA,FGSI

Sr.Physician,Dr RML Hospital &

National Programme Officer (ART)

National AIDS Control Organistion,

6th Floor, Chandralok Building,

36, Janpath, New Delhi-110001

Tel; 011-23731954, 43509999(O)

Mobile ; 91-9811267610

Fax : 011-23731954,23731746

e-mail: <drbbrewari@...>

[Guest guest]

[Editor's note follows the main text of this message]

Dear FORUM,

Re: /message/10152

As the nodal officer of the COE at PGIMER, I would like to apprise the readers

in general and Dr Bharti in particular that as per the NACO gudelines the two

recommended second line regime is

Lpv/r , tenofovir, lamivudine with or without Zidovudine depending upon Hb.

As the full name of the patient is not provided, We have on our record one

patient from Amritsar with name as Ms C. K (full name of this patient is removed

by the ediotr) who was also started on the Zidovudine based NACO regime. We have

records to substantiate the same. (just for records ALUVIA is not the brand

available with us).

If Dr bharti is confusing Zidovudine with duovir then the quantum of error is

self explanatory and if he has done it intentionally then it is liable for

defamation suit.

Further to apprise the kind of practices some men do, this was a patient who was

doing well and was on NACO  first line regime and was doing fine, due to some

mishap at home she went to some private practitioner (whether it was Dr Bharti

or someone else can be confirmed when she come for follow up) while she was

clinically asymptomatic, all her previous CD4 could were way above 250. CD4

count was asked and single time report of 10 was obtained, without confirming

such drastic fall in a patient who was asymptomatic and without doing viral load

she was started on second line drugs.

As she could not afford these when she learnt that the same are now being

provided at PGI 4-5 months after she was already on second line, she wanted free

second line drugs from PGI.

As she had already taken drugs for a long time, she was started on second line

NACO ART regime whih is available free of cost as per rules.

It is ironical that in this country, those people who are not even trained to

manage life threatening conditions like Cryptococcal meningitis,

PCP,Toxoplasmosis and AIDS dementia complex are managing all such issues, taking

therapeutic decisions like the ones highlighted in this particular case where we

end up clearing the mess created by them (although reluctantly but without

making any noise)  and then take the altruistic approach and use the medium for

only their advertisement.

Just for record we have documentary proof of wrong prescriptions from AMRITSAR

which can be put on any forum. We generally do not tell the patient as to what

our colleagues have been doing. But from this case it seems that we should not

do that.

Whether at least an apology is warranted from DR BHARTI, I leave to the

judgement of the readers.

The academic points have been very well highlighted by Dr Murugan from Tamil

Nadu for which I am thankful personally.

Best wishes to all the readers,

Dr Aman Sharma,

Nodal Officer, COE, PGIMER, Chandigarh

e-mail: <amansharma74@...>

[The name of the patient supplied by Dr Aman Sharma is with held by the editor.

It is disappointing to see Dr Sharma, is willing to discuss the health condition

of a patient apparently without the permission of the patient on a public FORUM

like this. Please note, this is not a clinical discussion forum. Clinical issues

are discussed, only when it has wider health policy implications. In this case,

the question under discussion has implication on quality of care provided by ART

centres. Editor AIDS INDIA].

[Guest guest]

Dear Dr Sharma and the forum,

Re: /message/10170

My idea was not to malign anyone (individual or institution) and if

some one is hurt ,my unconditional apologies.

In the same breath let me have an oppurtunity to inform that my

credentials can be checked at any time by anyone,although I do not

have to prove anything to anyone.

Regarding patient being asymtomatic when admitted with me-the records

of the hospital (EMC3, Amritsar-where she was admitted )can be

checked,yes the viral load was not done because of affordability.

Aluvia ,I know is not availabnle with you sir,but the combination was

same. And also I did not confuse duovir with Zidovudine--still if that

is the issue and Dr. sharma thinks so,then I become wiser.

Dr.Sharma, with all regards to you,we always point fingers at

others,who are qualified(BTW-I stand qualified to be called an

HIVspecialist by the defination, please check the following by American academy

of HIV medicine What Makes an HIV Specialist?

Being an HIV specialist is not just a matter of a physician calling

him or herself a specialist. There are guidelines and requirements

that have to be met in order to be considered an HIV specialist.

The American Academy of HIV Medicine (AAHIVM) has established a definition of

the HIV specialist that includes three standard criteria for HIV knowledge

measurement. They include:

Experience

The doctor must maintain state licensure and provide direct, on-going,

continuous care for at least 20 HIV patients over the past two years.

This requirement has to be documented every two years and if the

doctor fails to document this requirement, the doctor is no longer

considered an HIV specialist.

Education

The doctor must complete at least 30 credits of HIV related continuing

medical education (CME) every two years or must have completed an

HIV-related internship or fellowship in the last two years.

External Validation

A doctor must be recognized by an external credentialing entity such

as the AAHIVM. This is accomplished by passing an HIV Medicine

Credentialing Exam.

When looking for an HIV doctor, make sure he or she meets these three

criteria. If so, your doctor can be considered an HIV specialist. Now

that you know what an HIV specialist is, let's tell you why having one

is a must.

Dr.Sharma-I fulfill all these criteria.

Finally, whatevevr I have been doing for more than a decade is for the

benefit of patients---my patients are my proof.

Regards Dr.Aman

Dr.Bharti

 

--

Rakesh Bharti

MD,AAHIVS,

BDC Research center,

27-D,Sant Avenue,The Mall,Amritsar.

Punjab,INDIA143001.

TEl-91-183-2277822;E-MAIL:

E-MAIL: <rakesh.bharti1@...>