Penetración en reservorios

Pasquau Liaño, Juan

doi:10.1016/S0213-005X(08)76610-2

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La monoterapia de mantenimiento con lopinavir potenciado con ritonavir (LPV/r) es una estrategia segura y efectiva a corto y medio plazo. Para afrontar su efectividad a largo plazo, necesitamos despejar la incógnita de si una teórica disminución de la potencia del tratamiento puede reducir la capacidad de suprimir la actividad replicativa del virus de la inmunodeficiencia humana (VIH) en los reservorios o compartimentos biológicos, donde LPV/r tiene más dificultades de difundirse.

Hemos aprendido que el LPV/r penetra bastante bien en el peor de los reservorios, el sistema nervioso central. Pero, sobre todo, hemos aprendido que la capacidad de difundirse en los reservorios no es una condición crítica para conseguir la eficacia. Y es que el principal escenario de la batalla frente al VIH es el compartimento plasmático. Lo que allí conseguimos con el tratamiento antirretroviral puede extrapolarse fielmente al líquido cefalorraquídeo y casi siempre al líquido seminal. Lo que ocurre en el tejido linfoide y en la mucosa intestinal, cuya fisiopatología se inicia con intensidad desde el comienzo de la enfermedad, es más oscuro y más difícil de interpretar.

En cualquier caso, los problemas marginales que unos reservorios repletos del VIH y relativamente impermeables a LPV/r pudieran generar serían poco relevantes en el escenario del tratamiento de simplificación, en el que sólo se ofrece monoterapia de mantenimiento con LPV/r a pacientes estables y con buen control inmunovirológico de la enfermedad.

Palabras clave:

VIH

Monoterapia

Lopinavir potenciado con ritonavir

Reservorios

Maintenance monotherapy with lopinavir/ritonavir (LPV/r) is a safe and effective strategy in the short and medium term. To evaluate its effectiveness in the long term, the question of whether a theoretical decrease in the potency of treatment could reduce suppression of viral replication in reservoirs or in biological compartments where LPV/r penetration is lower must be answered. LPV/r penetrates fairly well in the most impenetrable reservoir, the central nervous system. However, the ability to penetrate reservoirs is not essential to achieve efficacy, since the main battlefield in the fight against HIV is the plasma compartment. What can be achieved in this compartment with antiretroviral therapy can be faithfully extrapolated to cerebrospinal fluid and almost always to seminal fluid.

What occurs in lymphoid tissue and in intestinal mucosa, whose physiopathology is intensely initiated at the beginning of the disease, is more obscure and difficult to interpret. The marginal problems that might be generated by some reservoirs that harbor HIV and are relatively impermeable to LPV/r would be of little importance in simplification therapy, which is only offered as maintenance monotherapy with LPV/r to clinically stable patients with good immunological and virological control.

Key words:

HIV

Monotherapy

Lopinavir/ritonavir

Reservoirs

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