ECC Cases
Case Vignettes: Avoiding and Managing Drug Resistance in HIV-Infected Patients
Interactive Cases
Managing the Clinically and Immunologically Stable HIV-Infected Patient With Multidrug-Resistant Virus
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 In a case-based discussion, Eric S. Daar, MD, reviews considerations influencing management strategies in patients with virologic failure and multidrug-resistant virus but stable clinical condition Learning Objectives
Upon completion of this activity, participants should be able to:
- Recount the goals of therapy in HIV-infected patients with detectable viral load on antiretroviral therapy
- Discuss management considerations specific to patients with relatively high CD4+ cell counts and stable clinical condition despite virologic failure
- Review strategies for the optimal use of antiretroviral agents in a new regimen for a treatment-experienced patient
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Selecting a First-Line Regimen: Balancing Efficacy and Resistance Considerations
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In a case-based discussion, Paul E. Sax, MD, reviews recent data from comparative studies of first-line therapy and the implications of increasing transmission of NNRTI resistance for treatment choices. Learning Objectives
Upon completion of this activity, participants should be able to:
- Discuss data that outline the levels of primary resistance to different classes of drugs in population studies
- Recount data from ACTG 5142 that detail the comparative efficacy of lopinavir/ritonavir-based and efavirenz-based regimens
- Review the resistance consequences of failure as detailed in ACTG 5142
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Virologic Failure With M184V: What Is the Next Optimal NRTI Combination?
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In a case-based discussion, Paul E. Sax, MD, reviews data from clinical studies that help guide the selection of NRTIs after emergence of the M184V mutation. Learning Objectives
Upon completion of this activity, participants should be able to:
- Discuss data that outline the emergence of M184V after virologic failure of initial lamivudine- or emtricitabine-containing NNRTI-based regimens
- Compare data on the emergence of M184V after virologic failure of initial regimens that contain boosted vs unboosted PIs
- List potential NRTI combinations for second-line regimens after emergence of M184V
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Utilization of Antiretroviral Drug Resistance Testing in Clinical Practice
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Eric S. Daar, MD, describes criteria influencing the choice of the genotype vs phenotype resistance assay in this case-based discussion involving a treatment-experienced patient presenting for therapy. Learning Objectives
Upon completion of this activity, participants should be able to:
- List the types of drug resistance tests available to the practicing physician today
- Discuss the advantages and disadvantages of the genotype and phenotype resistance tests
- Describe the appropriate setting for the use of each test
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The Resistance Consequences of Virologic Failure on a Boosted PI Regimen
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In a case-based discussion, Paul E. Sax, MD, discusses resistance development after failure of a boosted PI regimen and implications for the choice of a next regimen. Learning Objectives
Upon completion of this activity, participants should be able to:
- Describe data on the emergence of PI resistance mutations after virologic failure on boosted vs unboosted PIs
- List elements of the assessment of patients with failure of a boosted PI regimen
- Discuss implications for second-line therapy after failure of a boosted PI regimen
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Managing HIV-Infected Patients With the K65R Mutation
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Eric S. Daar, MD, discusses in this case-based presentation the emergence of the K65R mutation in patients treated with contemporary regimens and implications for clinical management. Learning Objectives
Upon completion of this activity, participants should be able to:
- Describe the clinical situations in which the K65R mutation has been found to emerge
- List NRTIs to which K65R confers resistance
- Discuss how components of the background regimen may affect emergence of K65R
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Activity of NNRTI-Based Regimens in Patients With NRTI Resistance Mutations
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Paul E. Sax, MD, discusses in this case-based presentation the dilemma of using an NNRTI-based regimen in treatment-experienced patients when background NRTI resistance is present. Learning Objectives
Upon completion of this activity, participants should be able to:
- Discuss clinical trial data about activity of NNRTI-based regimens when background NRTI resistance is present
- Compare data about activity of PI-based regimens when background NRTI resistance is present
- Describe implications for therapy when background NRTI resistance is present
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The Consequences of Stopping Antiretroviral Therapy in a Treatment-Experienced Patient With Detectable Viremia on Therapy
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Eric S. Daar, MD, discusses in this case-based presentation the circumstances under which stopping therapy may be reasonable and what clinical trials have shown us about this strategy. Learning Objectives
Upon completion of this activity, participants should be able to:
- Identify the goals of therapy for treatment-experienced patients
- Describe the clinical situations in which stopping therapy may be an acceptable alternative to treatment
- Discuss results of controlled clinical trials that have investigated therapy interruption
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Treatment Options for an HIV-Infected Patient With Highly Drug–Resistant Virus
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In a case-based discussion, Paul E. Sax, MD, discusses how new classes of antiretrovirals may be utilized in a patient with multidrug-resistant virus. Learning Objectives
Upon completion of this activity, participants should be able to:
- Identify treatment goals for treatment-experienced patients
- Summarize data on antiretroviral agents that are in late stages of clinical development and for which data are available in treatment-experienced patients
- Discuss limitations of treatment with chemokine receptor antagonists
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Is It Safe to Stop Enfuvirtide?
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Eric S. Daar, MD, discusses in this case-based presentation about stopping enfuvirtide the process that one must undergo when making decisions that are not fully supported by clinical trial data. Learning Objectives
Upon completion of this activity, participants should be able to:
- Describe how resistance testing can be used to help guide decisions about construction of a new regimen
- Name antiretroviral agents that have been shown to be active in highly treatment–experienced patients
- Discuss the limitations of using maraviroc when it is not possible to obtain a tropism assay
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Disclaimer: The materials published on the Clinical Care Options Web site reflect the views of the reviewers or authors of the CCO material, not those of Clinical Care Options, LLC, the CME provider, or the companies providing educational grants. The materials may discuss uses and dosages for therapeutic products that have not been approved by the United States Food and Drug Administration. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or using any therapies described in these materials.
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