In the previous episode (see Wes' Drug Decision Process -- Part One), Wes had decided it was time to change his medications around. He did his research. He made his decision. He changed his drugs to include a protease inhibitor called indinavir (Crixivan^tm).

In the two weeks after he started Crixivan^tm, Wes started having growing concerns: Had he made the right choice? There were a few things gnawing at him.

Wes' concerns about Crixivan^tm

• Crixivan^tm turned out to contain anhydrous lactose. (FYI, saquinavir/Invirase^tm also has lactose.) Wes is lactose intolerant. Lactaid^tm partly solved the problem, so it wasn't a big deal. Wes was just disappointed (okay, and a bit gassy). But the other good current protease inhibitor, ritonavir/Norvir^tm, contained no lactose.
• Crixivan^tm is taken every 8 hours on an empty stomach. Wes knew this going in. He didn't expect that it would be a problem, since he could take it at 8:30am, 4:30pm and 12:30am. This fit with his normal schedule. What Wes wasn't expecting was the onset of fairly severe lethargy. (This could be from the Crixivan^tm, adding d4T/Zerit^tm, doubling AZT/Retrovir^tm, an undiagnosed infection, or whatever.) What this lethargy meant in practical terms was that it was hard to stay on the 8-hour-interval dosing schedule (particularly that 12:30am dose). No big deal? Wrong: The virus quickly becomes resistant to a protease inhibitor when exposed to irregular dosing. ritonavir/Norvir^tm only needed to be taken at 12-hour intervals, and taking it with food is recommended.
• If he were to make a change, he needed to decide quickly: Usage of Crixivan^tm creates cross-resistance to ritonavir/Norvir^tm. (Another good alternative, nelfinavir/Viracept^tm is in the pipeline as of this writing.) So, if he didn't change soon, he wouldn't be able to change later.

Would a change to ritonavir/Norvir^tm fit Wes' needs?

• It didn't contain lactose -- a plus.
• It had an easier dosing schedule -- a plus.
• It could be taken with meals (actually the preferred method) -- a plus
• It needs to be refrigerated -- a minor negative
• It has more than 200 documented drug interactions and contraindications -- a major negative. This was the original reason Wes decided against it. Time to look at those drug interactions in detail and see if they were relevant to him.

What Wes mapped out

It took multiple sources to track down all the drug interactions and medical terminology in order to convert them to more understandable terms. (For example, how many people know off the top of their head that "fluoxetine" is the generic name for Prozac^tm? Or that an "antiemetic" is a drug to prevent or relieve nausea and vomiting?) But, armed with his trusty array of research tools (see Wes' Drug Decision Index), he plodded along. Here are two tables from the ritonavir/Norvir^tm drug insert, as transcribed by Wes:

Potential effects on drugs co-administered with ritonavir/Norvir^tm

Drugs that should not be co-administered with ritonavir/Norvir^tm

Drugs that should not be co-administered with indinavir/Crixivan^tm:

• terfenadine
• astemizole
• cisapride
• triazolam
• midazolam.

Additionally, Rifabutin and Ketoconazole require dose modification if co-administered with indinavir/Crixivan^tm.

Wes' decision

Wes reviewed the drug interaction charts and decided that the drug interactions with Norvir^tm outweighed the inconveniences associated with Crixivan^tm. This was based on a several factors:

• Several anti-cancer (eg: anti-KS), anti-MAI, and effective pain suppressants -- as well as Wes' antidepressant -- were on the Norvir^tm interaction chart.
• Wes realized that setting the alarm to take a late or morning dose of Crixivan^tm was not such a big deal.
• Wes was already known as being gassy, so maybe nobody would notice the slight increase due to the Crixivan^tm.

Having just said that for me, however, I do want to caution that not everyone is the same. ritonavir/Norvir^tm also gets good results. In particular, it appears very potent when used in combination with saquinavir. Similarly, I have two friends on it who -- despite an initial two-week adjustment period -- love it. So, this is just my drug decision. Make your own for yourself. This is just here as an example of one way to approach what can seem a life-or-death situation. Good luck!