Department of Medicine, University Health Network, University of Toronto, Ontario, Canada.
Curr Opin HIV AIDS. 2009 Nov;4(6):493-8. doi: 10.1097/COH.0b013e328331b5e2.
To provide a clinical approach for choosing an appropriate second-line antiretroviral (ARV) regimen in HIV-positive patients with virologic failure.
Patients should be carefully evaluated as to why failure occurred and undergo HIV resistance testing to guide second-line treatment options. The new regimen should be initiated as soon as possible to avoid evolution of resistance. There is a paucity of clinical trial data to make recommendations for optimal second-line regimens. With failure, a member of the alternative class nonnucleoside reverse transcriptase inhibitor or ritonavir protease inhibitor] is traditionally combined with two active nucleoside reverse transcriptase inhibitors. Etravirine may be effective, if adequately supported, depending upon the resistance profile. If protease inhibitor resistance is detected, second-generation agents such as darunavir/r or tipranavir/r are preferred. Integrase or entry inhibitors may be added if there is protease inhibitor intolerance or if an active NRTI backbone cannot be constructed
Many options are available for second-line regimens. Decisions should be tailored to patients' needs and results of resistance testing. Two to three active agents must be included. Although the absolute number of agents is not critical, the goal is to develop a regimen that maximally suppresses HIV viral replication and provides an adequate barrier to prevent the emergence of resistance.
为 HIV 阳性、病毒学失败患者提供选择适当二线抗逆转录病毒（ARV）治疗方案的临床方法。
应仔细评估患者失败的原因，并进行 HIV 耐药性检测，以指导二线治疗选择。应尽快开始新的治疗方案，以避免耐药性的进化。缺乏临床试验数据来推荐最佳二线治疗方案。出现失败时，传统上会将替代类别中非核苷类逆转录酶抑制剂或利托那韦蛋白酶抑制剂与两种有效的核苷类逆转录酶抑制剂联合使用。如果得到充分支持，依曲韦林可能有效，具体取决于耐药谱。如果检测到蛋白酶抑制剂耐药性，则首选第二代药物，如达芦那韦/利托那韦或替普那韦/利托那韦。如果存在蛋白酶抑制剂不耐受或无法构建有效的 NRTI 骨架，则可添加整合酶或进入抑制剂。
二线治疗方案有多种选择。决策应根据患者的需求和耐药性检测结果进行调整。必须包含两种或三种有效药物。尽管药物数量绝对不是关键，但目标是制定最大限度抑制 HIV 病毒复制并提供足够屏障以防止耐药性出现的方案。
