Читать книгу Knowing One's Medical Fate in Advance - Группа авторов - Страница 14

Is the picture too rosy, is there an important aspect missing for knowing one’s medical fate in advance? Yes - as many drugs demonstrate mild but sometimes also severe side effects. However, it is difficult to precisely predict if a specific side effect will affect a specific individual. Nevertheless, progress has been done also in this field. E.g., one drug (abacavir) may lead to severe hypersensitivity in 5% of individuals. Today we can highly predict whether the likelihood of this hypersensitivity reaction is extremely low, i.e. close to 0% or whether it is approximately 50%. It this context the abacavir related hypersensitivity only occurs in HLA B5701 positive individuals, allowing to anticipate this potential life-threatening side effect in predisposed patients.

In conclusion the treatment development is still ongoing and as figure 1 demonstrates we assume that life prolongation is bringing many individuals to a close to normal life expectancy. The change of treatment success had consequences on guidelines and concepts of treatment as shown in figure 2. In 1996, in the upcoming of combination antiretroviral treatment, there were still hopes that the virus could be eradicated. Hence, all patients were treated. Thereafter, when it became clear that this is not possible an early start was recommended to preserve immunity. Afterwards more pessimistic views prevailed becoming aware of the long-term toxicity and co-morbidities of the first line drugs. Following this, the start of treatment was delayed. With better treatments the threshold to initiate treatment earlier decreased. Now treatment concepts change again as it becomes obvious that transmission is significantly reduced with successful combination antiretroviral therapy. Hence, the question is whether to treat all patients as in the mid nineties, but with a different concept.

Fig. 2. This table shows different treatment concepts changing from hope of cure to less optimistic treatment goals. The lower threshold of CD4-T cells depicts a lower degree of immunity. For example, in 2003 treatment was started only late in disease course to prevent long-term toxicity and enable a patient as long as possible to live without treatment. However, with better treatments which are much better tolerable the threshold of CD4-T cells increased, i.e. combination antiretroviral treatment is started much earlier to reduce the remaining morbidity.