151
|
Jain V, Liegler T, Vittinghoff E, Hartogensis W, Bacchetti P, Poole L, Loeb L, Pilcher CD, Grant RM, Deeks SG, Hecht FM. Transmitted drug resistance in persons with acute/early HIV-1 in San Francisco, 2002-2009. PLoS One 2010; 5:e15510. [PMID: 21170322 PMCID: PMC3000814 DOI: 10.1371/journal.pone.0015510] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 10/06/2010] [Indexed: 11/18/2022] Open
Abstract
Background Transmitted HIV-1 drug resistance (TDR) is an ongoing public health problem, representing 10–20% of new HIV infections in many geographic areas. TDR usually arises from two main sources: individuals on antiretroviral therapy (ART) who are failing to achieve virologic suppression, and individuals who acquired TDR and transmit it while still ART-naïve. TDR rates can be impacted when novel antiretroviral medications are introduced that allow for greater virologic suppression of source patients. Although several new HIV medications were introduced starting in late 2007, including raltegravir, maraviroc, and etravirine, it is not known whether the prevalence of TDR was subsequently affected in 2008–2009. Methodology/Principal Findings We performed population sequence genotyping on individuals who were diagnosed with acute or early HIV (<6 months duration) and who enrolled in the Options Project, a prospective cohort, between 2002 and 2009. We used logistic regression to compare the odds of acquiring drug-resistant HIV before versus after the arrival of new ART (2005–2007 vs. 2008–2009). From 2003–2007, TDR rose from 7% to 24%. Prevalence of TDR was then 15% in 2008 and in 2009. While the odds of acquiring TDR were lower in 2008–2009 compared to 2005–2007, this was not statistically significant (odds ratio 0.65, 95% CI 0.31–1.38; p = 0.27). Conclusions Our study suggests that transmitted drug resistance rose from 2003–2007, but this upward trend did not continue in 2008 and 2009. Nevertheless, the TDR prevalence in 2008–2009 remained substantial, emphasizing that improved management strategies for drug-resistant HIV are needed if TDR is to be further reduced. Continued surveillance for TDR will be important in understanding the full impact of new antiretroviral medications.
Collapse
Affiliation(s)
- Vivek Jain
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Teri Liegler
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Wendy Hartogensis
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Peter Bacchetti
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Lauren Poole
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Lisa Loeb
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Christopher D. Pilcher
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Robert M. Grant
- Gladstone Institute for Virology, University of California San Francisco, San Francisco, California, United States of America
| | - Steven G. Deeks
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Frederick M. Hecht
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| |
Collapse
|
152
|
Taiwo B, Murphy RL, Katlama C. Novel antiretroviral combinations in treatment-experienced patients with HIV infection: rationale and results. Drugs 2010; 70:1629-42. [PMID: 20731472 DOI: 10.2165/11538020-000000000-00000] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Novel antiretroviral drugs offer different degrees of improvement in activity against drug-resistant HIV, short- and long-term tolerability, and dosing convenience compared with earlier drugs. Those drugs approved more recently and commonly used in treatment-experienced patients include the entry inhibitor enfuvirtide, protease inhibitors (PIs) [darunavir and tipranavir], a C-C chemokine receptor (CCR) type 5 antagonist (maraviroc), an integrase inhibitor (raltegravir) and etravirine, a non-nucleoside reverse transcriptase inhibitor (NNRTI). Novel agents in earlier stages of development include a CCR5 monoclonal antibody (PRO 140) administered subcutaneously once weekly, once-daily integrase inhibitors (elvitegravir and S/GSK1349572), and several nucleoside (nucleotide) reverse transcriptase inhibitors and NNRTIs. Bevirimat, a maturation inhibitor, has compromised activity in the presence of relatively common Gag polymorphisms. Viral suppression is necessary to control the evolution of drug resistance, reduce chronic immune activation that probably underlies the excess morbidity and mortality in HIV-infected patients, and reduce viral transmission, including transmitted drug resistance. In general, the proportion of viraemic patients who achieve suppression increases with the number of active pharmacokinetically compatible antiretroviral drugs in the regimen. In the ANRS139-TRIO trial, 86% of highly treatment-experienced patients treated with darunavir-ritonavir, etravirine and raltegravir had HIV RNA <50 copies/mL at 48 weeks. In patients who had received at least 12 weeks of a stable regimen and had no darunavir resistance-associated mutations, once-daily darunavir boosted with ritonavir 100 mg was virologically noninferior with better lipid effects than with the twice-daily dosing, which requires a 200 mg total daily dose of ritonavir. Raltegravir plus a boosted PI is being investigated for second-line therapy in patients not responding to NNRTI-based first-line treatment in resource-limited settings (RLS). However, concerns about this potential strategy include the low barrier against resistance of raltegravir, limited penetration of some PIs into the CNS and the unknown impact of integrase polymorphisms seen more commonly in non-B subtype HIV-1. In patients who have already achieved viral suppression, novel agents may be used to simplify the dosing schedule, lower costs (such as by switching to boosted PI monotherapy), reduce adverse events or preserve antiretroviral drug options, especially since the absence of an HIV eradication strategy implies the need for life-long combination antiretroviral therapy. Switching enfuvirtide to raltegravir eliminated painful injection-site reactions without compromising virological suppression. Two studies found different virological outcomes when patients were switched from lopinavir/ritonavir to raltegravir, but there was an improvement in the lipid profile. Simplifying to darunavir-ritonavir monotherapy after suppression of plasma HIV RNA to <50 copies/mL has been found to be safe with no emergence of resistance in cases of viral rebound, but longer-term data are needed. The initial suggestion that maraviroc may possess unique CD4+ T-cell boosting effects was not confirmed in several clinical trials. Improved understanding of HIV pathogenesis has opened new frontiers for research such as identifying the sources, consequences and optimal management of residual viraemia in those with plasma HIV RNA <50 copies/mL. Globally, however, one of the most urgent priorities is providing the increasing number of treatment-experienced virologically failing patients in RLS with access to optimal treatment, including those treatments based on novel antiretroviral agents.
Collapse
Affiliation(s)
- Babafemi Taiwo
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | | |
Collapse
|
153
|
Willig JH, Aban I, Nevin CR, Ye J, Raper JL, McKinnel JA, DeLaitsch LL, Mrus JM, De La Rosa GR, Mugavero MJ, Saag MS. Darunavir outcomes study: comparative effectiveness of virologic suppression, regimen durability, and discontinuation reasons for three-class experienced patients at 48 weeks. AIDS Res Hum Retroviruses 2010; 26:1279-85. [PMID: 20961276 DOI: 10.1089/aid.2010.0059] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Several new antiretroviral (ARV) agents for treatment experienced HIV-infected patients have been approved since June 2006, including darunavir (DRV) and raltegravir (RAL). While efficacious in clinical trials, the effectiveness, durability, and tolerability of these new ARVs remains understudied in the context of routine clinical care. The Darunavir Outcomes Study is a prospective cohort study of three-class ARV-experienced patients changing regimens at the 1917 Clinic after 1/7/2006. All treatment decisions were at the discretion of primary providers. Multivariate (MV) logistic regression for 48 week VL < 400c/ml and Cox models for regimen durability were completed. Propensity score methods controlled for sociodemographics. Among 108 patients, mean age of 46, 48% were white, 80% male, with prior exposure to a mean 10.5 ARVs. Overall, 64% of patients achieved 48-week VL < 400 c/ml. In MV modeling DRV/rll (OR = 5.77;95%CI = 1.62-20.58) and RAL (OR = 3.84;95%CI = 1.23-11.95) use increased odds of 48-week suppression. Use of these agents exhibited a trend towards prolonged regimen durability in Cox models. Among those highly ARV-experienced, regimens containing DRV/r and/or RAL were more likely to achieve 48-week VL < 400 c/ml and exhibited a trend towards prolonged durability. New agents have transformed the treatment landscape for ARV-experienced patients, with effectiveness in routine clinical care mirroring efficacy in clinical trials.
Collapse
Affiliation(s)
- James H. Willig
- Division of Infectious Diseases, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Inmaculada Aban
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Christa R. Nevin
- Division of Infectious Diseases, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jiatao Ye
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - James L. Raper
- Division of Infectious Diseases, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - James A. McKinnel
- Division of Infectious Diseases, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | | | - Michael J. Mugavero
- Division of Infectious Diseases, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael S. Saag
- Division of Infectious Diseases, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| |
Collapse
|
154
|
Resistance analyses in highly experienced patients failing raltegravir, etravirine and darunavir/ritonavir regimen. AIDS 2010; 24:2651-6. [PMID: 20802293 DOI: 10.1097/qad.0b013e32833ed2a7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES ANRS 139 TRIO trial was a phase II noncomparative trial that evaluated in highly experienced patients, a combination of raltegravir, etravirine and darunavir boosted with ritonavir. We analyzed emergence of resistant viruses at the time of virological failure and investigated the impact of baseline integrase polymorphisms on virological failure occurrence. METHODS Bulk sequencing of protease, reverse transcriptase and integrase genes was performed for 103 patients at baseline and 14 patients at the time of virological failure. Additionally, integrase clonal analyses were performed at baseline and at virological failure in patients with successful integrase gene amplification. Impact of baseline integrase polymorphisms on virological failure occurrence was analyzed using Fisher exact and Wilcoxon tests. RESULTS In the 14 failing patients median viral load at virological failure was 90 copies/ml (interquartile range = 60-783). Emergence of darunavir and etravirine resistance mutations was observed at virological failure in only one and three patients, respectively. Raltegravir resistance mutations were found neither at baseline nor at the time of virologic failure. Integrase clonal analyses showed neither the presence nor the selection of minority variants carrying raltegravir resistance mutations at baseline or at virological failure. No impact of baseline integrase polymorphisms was observed on virological failure either at week 24 or at week 48. CONCLUSION Virological failure occurred in a small proportion of patients with low viral load. No raltegravir resistance mutations were observed using bulk sequencing or clonal analyses, and darunavir and etravirine resistance-associated mutations were detected in only one and three patients, respectively at virological failure. No impact of baseline integrase polymorphism was observed on virological failure occurrence.
Collapse
|
155
|
Tambuyzer L, Vingerhoets J, Azijn H, Daems B, Nijs S, Béthune MD, Picchio G. Characterization of genotypic and phenotypic changes in HIV-1-infected patients with virologic failure on an etravirine-containing regimen in the DUET-1 and DUET-2 clinical studies. AIDS Res Hum Retroviruses 2010; 26:1197-205. [PMID: 20854144 DOI: 10.1089/aid.2009.0302] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The randomized, placebo-controlled Phase III DUET studies enrolled treatment-experienced, HIV-1-infected patients. We examined the genotypic and phenotypic changes at endpoint relative to baseline, including the emergence of individual reverse transcriptase (RT) mutations, in patients who received the non-nucleoside reverse transcriptase inhibitor (NNRTI) etravirine and experienced virologic failure by rebound by the time of the Week 96 analysis. Patients received etravirine 200 mg twice-daily in combination with a background regimen containing darunavir/ritonavir, investigator-selected nucleoside reverse transcriptase inhibitors, and optional enfuvirtide. Virologic failure by rebound occurred in 93 (15.5%) etravirine-treated patients (compared with 170 [28.1%] placebo-treated patients). Patients experiencing virologic failure had more baseline antiretroviral resistance and lower activity of the background regimen relative to those not experiencing failure. Emergence of NNRTI resistance-associated mutations was observed in 55 of 93 patients. The most frequently emerging RT mutations were V179F, V179I, and Y181C, with positions K101 and E138 also showing frequent changes. Mutations usually emerged in a background of multiple other NNRTI mutations and were, in most cases, associated with a decrease in phenotypic sensitivity to etravirine at endpoint. Further analysis is needed to clarify the role of mutations at position 138 as determinants of etravirine resistance.
Collapse
|
156
|
Osih RB, Taffé P, Rickenbach M, Gayet–Ageron A, Elzi L, Fux C, Opravil M, Bernasconi E, Schmid P, Günthard HF, Cavassini M. Outcomes of patients on dual-boosted PI regimens: experience of the Swiss HIV cohort study. AIDS Res Hum Retroviruses 2010; 26:1239-46. [PMID: 20929393 DOI: 10.1089/aid.2010.0070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Dual-boosted protease inhibitors (DBPI) are an option for salvage therapy for HIV-1 resistant patients. Patients receiving a DBPI in the Swiss HIV Cohort Study between January1996 and March 2007 were studied. Outcomes of interest were viral suppression at 24 weeks. 295 patients (72.5%) were on DBPI for over 6 months. The median duration was 2.2 years. Of 287 patients who had HIV-RNA >400 copies/ml at the start of the regimen, 184 (64.1%) were ever suppressed while on DBPI and 156 (54.4%) were suppressed within 24 weeks. The median time to suppression was 101 days (95% confidence interval 90-125 days). The median number of past regimens was 6 (IQR, 3-8). The main reasons for discontinuing the regimen were patient's wish (48.3%), treatment failure (22.5%), and toxicity (15.8%). Acquisition of HIV through intravenous drug use and the use of lopinavir in combination with saquinavir or atazanavir were associated with an increased likelihood of suppression within 6 months. Patients on DBPI are heavily treatment experienced. Viral suppression within 6 months was achieved in more than half of the patients. There may be a place for DBPI regimens in settings where more expensive alternates are not available.
Collapse
Affiliation(s)
- Regina B. Osih
- Infectious Diseases Service, Department of Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Switzerland
- The Reproductive Health and HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Patrick Taffé
- Data Coordination Center for the Swiss HIV Cohort, Lausanne, Switzerland
| | - Martin Rickenbach
- Data Coordination Center for the Swiss HIV Cohort, Lausanne, Switzerland
| | - Angèle Gayet–Ageron
- Hopital Cantonal et Universitaire de Genève, Service des Maladies Infectieuses, Geneva, Switzerland
| | - Luigia Elzi
- University of Basel, Medicine, Division of Infectious Diseases, Basel, Switzerland
| | - Christoph Fux
- Universitätsspital Bern, Klinik und Poliklinik für Infektiologie, Bern, Switzerland
| | - Milos Opravil
- University Hospital Zürich, Division of Infectious Diseases and Hospital Epidemiology, University of Zürich, Switzerland
| | - Enos Bernasconi
- Ospedale, Civico, Department of Medicine, Division of Infectious Diseases, Lugano, Switzerland
| | | | - Huldrych F Günthard
- University Hospital Zürich, Division of Infectious Diseases and Hospital Epidemiology, University of Zürich, Switzerland
| | - Matthias Cavassini
- Infectious Diseases Service, Department of Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Switzerland
| | | |
Collapse
|
157
|
Ruane P, Alas B, Ryan R, Perniciaro A, Witek J. A 48-week pilot study switching suppressed patients to darunavir/ritonavir and etravirine from enfuvirtide, protease inhibitor(s), and non-nucleoside reverse transcriptase inhibitor(s). AIDS Res Hum Retroviruses 2010; 26:1215-9. [PMID: 21083412 DOI: 10.1089/aid.2009.0285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Treatment options for HIV-infected patients can be limited due to viral drug resistance to antiretroviral agents. Enfuvirtide (ENF) is an injectable entry/fusion inhibitor that is effective in achieving viral suppression when used in combination with protease inhibitors (PIs) in patients with pre-existing resistance. However, ENF treatment is associated with injection site reactions and dosing fatigue. This multicenter, open-label, Phase IIIb, 48-week pilot study assessed safety, tolerability, and effectiveness of the PI darunavir (DRV), boosted with ritonavir (DRV/r), and the non-nucleoside reverse transcriptase inhibitor (NNRTI) etravirine (ETR), when substituted for ENF/PI (±NNRTI)-based therapy. Ten virologically suppressed (HIV RNA less than 50 copies/ml) men who were intolerant to ENF were enrolled. Median (range) CD4+ count was 301 (187-663) cells/mm(3). Two patients discontinued the study; all remaining patients maintained a viral load of less than 50 copies/ml at Week 48. Viral load increased to greater than 50 copies/ml in two patients, but was eventually re-suppressed without the need for changes in treatment. Median (range) increase (last observation carried forward) in CD4+ count from baseline to Week 48 was 64 (-53-100) cells/mm(3). Two grade 3 adverse events (AEs), nausea and weight loss, and one serious AE, acute cholecystitis, were reported; each AE resolved without treatment interruption. Most common AEs related to study drug were fatigue, rash, headache, and diarrhea. Decreases in triglycerides, low-density lipoprotein, and high-density lipoprotein, were observed. This study suggests that a DRV/r- and ETR-based regimen can be substituted for an ENF-based regimen while maintaining virologic suppression.
Collapse
Affiliation(s)
- Peter Ruane
- Light Source Medical, Los Angeles, California
| | - Brian Alas
- Light Source Medical, Los Angeles, California
| | | | | | - James Witek
- Tibotec Therapeutics, Titusville, New Jersey
| |
Collapse
|
158
|
Gonzalez de Requena D, Bonora S, Vigano O, Calcagno A, Cometto C, D'Avolio A, Baietto L, Ghisetti V, Magnani S, Ferramosca S, Vitiello P, Galli M, Rusconi S, Di Perri G. Comparative evaluation of seven resistance interpretation algorithms and their derived genotypic inhibitory quotients for the prediction of 48 week virological response to darunavir-based salvage regimens. J Antimicrob Chemother 2010; 66:192-200. [DOI: 10.1093/jac/dkq384] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
|
159
|
Fullerton DS, Watson MJ, Anderson D, Witek J, Martin SC, Mrus JM. Pharmacoeconomics of etravirine. Expert Rev Pharmacoecon Outcomes Res 2010; 10:485-95. [PMID: 20950062 DOI: 10.1586/erp.10.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
HIV infection, particularly multidrug-resistant HIV, continues to be a major societal and economic challenge worldwide. Etravirine, a new (US FDA approved in 2008) non-nucleoside reverse transcriptase inhibitor, has been shown to be very effective in treating patients who have failed prior antiretroviral therapy. Clinical studies demonstrated that etravirine in combination with other antiretrovirals achieved superior levels of undetectable plasma HIV RNA and CD4 cell count increases that led to reductions in risk of death and development of AIDS-defining illnesses when compared with placebo. Etravirine was also shown to be generally well tolerated, with favorable CNS and psychiatric tolerability profiles. In addition, etravirine in combination with other antiretrovirals has been shown to improve quality of life and quality-adjusted life expectancy. Economic evaluations showed that the addition of etravirine to a regimen was associated with lower costs per person with an undetectable viral load and lower hospital-related costs compared with placebo.
Collapse
Affiliation(s)
- D S Fullerton
- School of Pharmacy, University of Washington, Seattle, WA, USA.
| | | | | | | | | | | |
Collapse
|
160
|
Tang G, Kertesz DJ, Yang M, Lin X, Wang Z, Li W, Qiu Z, Chen J, Mei J, Chen L, Mirzadegan T, Harris SF, Villaseñor AG, Fretland J, Fitch WL, Hang JQ, Heilek G, Klumpp K. Exploration of piperidine-4-yl-aminopyrimidines as HIV-1 reverse transcriptase inhibitors. N-Phenyl derivatives with broad potency against resistant mutant viruses. Bioorg Med Chem Lett 2010; 20:6020-3. [DOI: 10.1016/j.bmcl.2010.08.068] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 07/29/2010] [Accepted: 08/13/2010] [Indexed: 10/19/2022]
|
161
|
Pharmacokinetics and Pharmacodynamics of the Non-Nucleoside Reverse-Transcriptase Inhibitor Etravirine in Treatment-Experienced HIV-1-Infected Patients. Clin Pharmacol Ther 2010; 88:695-703. [DOI: 10.1038/clpt.2010.181] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
|
162
|
Evaluation and Pharmacologic Management of the HIV-Infected Patient With Dyslipidemia. J Assoc Nurses AIDS Care 2010; 21:429-38. [DOI: 10.1016/j.jana.2009.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Accepted: 12/11/2009] [Indexed: 11/22/2022]
|
163
|
Cahn P, Haubrich R, Katlama C, Goebel F, Suter F, Peeters M, Vingerhoets J, Sinha R, Witek J. The impact of baseline characteristics on virologic response to etravirine: 48-week pooled analysis of DUET-1 and DUET-2. ACTA ACUST UNITED AC 2010. [DOI: 10.2217/hiv.10.41] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aims: The impact of baseline characteristics on response to the non-nucleoside reverse transcriptase inhibitor etravirine was investigated at 48 weeks in the Phase III DUET trials. Methods: Logistic regression was used to examine the effect of baseline demographics, disease characteristics and characteristics of antiretroviral therapy on virologic response (viral load <50 HIV-1 RNA copies/ml) to etravirine in pre-specified pooled subgroup analyses. Results: Several nondemographic characteristics were significant predictors of response in univariate analyses. Baseline viral load, adherence to study medication and use of enfuvirtide were predictive of response in the multivariate analysis. Patients treated with etravirine consistently achieved higher response rates than placebo-treated patients. Conclusions: The clinical benefits of etravirine in the DUET trials were observed irrespective of baseline characteristics.
Collapse
Affiliation(s)
- Pedro Cahn
- Fundación Huesped, Angel Peluffo 3932, Buenos Aires, C1202ABB, Argentina
| | | | - Christine Katlama
- Université Pierre et Marie Curie, Paris VI, and Hôpital Pitié-Salpêtrière, Paris, France
| | | | - Fredy Suter
- Division of Infectious Diseases, Ospedali Riuniti, Bergamo, Italy
| | | | | | | | | |
Collapse
|
164
|
Distinct mutation pathways of non-subtype B HIV-1 during in vitro resistance selection with nonnucleoside reverse transcriptase inhibitors. Antimicrob Agents Chemother 2010; 54:4812-24. [PMID: 20805392 DOI: 10.1128/aac.00829-10] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Studies were conducted to investigate mutation pathways among subtypes A, B, and C of human immunodeficiency virus type 1 (HIV-1) during resistance selection with nonnucleoside reverse transcriptase inhibitors (NNRTIs) in cell culture under low-multiplicity of infection (MOI) conditions. The results showed that distinct pathways were selected by different virus subtypes under increasing selective pressure of NNRTIs. F227C and Y181C were the major mutations selected by MK-4965 in subtype A and C viruses during resistance selection. With efavirenz (EFV), F227C and V106M were the major mutations responsible for viral breakthrough in subtype A viruses, whereas a single pathway (G190A/V106M) accounted for mutation development in subtype C viruses. Y181C was the dominant mutation in the resistance selection with etravirine (ETV) in subtype A, and E138K/H221Y were the mutations detected in the breakthrough viruses from subtype C viruses with ETV. In subtype B viruses, on the other hand, known NNRTI-associated mutations (e.g., Y181C, P236L, L100I, V179D, and K103N) were selected by the NNRTIs. The susceptibility of the subtype A and B mutant viruses to NNRTIs was determined in order to gain insight into the potential mechanisms of mutation development. Collectively, these results suggest that minor differences may exist in conformation of the residues within the NNRTI binding pocket (NNRTIBP) of reverse transcriptase (RT) among the three subtypes of viruses. Thus, the interactions between NNRTIs and the residues in the NNRTIBPs of different subtypes may not be identical, leading to distinct mutation pathways during resistance selection in cell culture.
Collapse
|
165
|
Lima VD, Harrigan PR, Sénécal M, Yip B, Druyts E, Hogg RS, Montaner JSG. Epidemiology of antiretroviral multiclass resistance. Am J Epidemiol 2010; 172:460-8. [PMID: 20667931 DOI: 10.1093/aje/kwq101] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Given the recent evolution of therapeutic trends, the frequency and determinants of multiclass-resistant HIV infection in the modern combination highly active antiretroviral therapy (HAART) era are less well understood. In this study, the authors characterize the epidemiology of antiretroviral multiclass resistance among HAART-naïve patients enrolled in a province-wide HAART distribution program in British Columbia, Canada. HAART and resistance testing are free to eligible individuals in British Columbia. This study was based on patients who initiated naïve on HAART and were followed during January 1, 2000-June 30, 2007. Explanatory logistic and survival models were built to identify those factors most influential in the emergence of multiclass resistance. Among the 1,820 individuals in our study, 833 (46%) were tested for antiretroviral resistance at least once during their follow-up. Multiclass resistance was observed in 142 individuals (n = 833; 17%) during a median follow-up of 14 months (interquartile range, 3-34 months) (incidence rate, 0.8 cases/1,000 person-months). The authors found that initial nonnucleoside reverse transcriptase inhibitor-based HAART was the main determinant of multiclass resistance. Given that these inhibitors are still widely used, priority should be given to make resistance testing and viral load monitoring a standard part of human immunodeficiency virus care to maximize the long-term efficacy and efficiency of HAART.
Collapse
Affiliation(s)
- Viviane D Lima
- St. Paul's Hospital, 1081 Burrard Street, Room 608, Vancouver, British Columbia V6Z 1Y6, Canada.
| | | | | | | | | | | | | |
Collapse
|
166
|
Abstract
IMPORTANCE OF THE FIELD Acquired immunodeficiency syndrome (AIDS) is one of the leading causes of death worldwide. Although the combination therapies of highly active antiretroviral therapy (HAART) have significantly contributed to virological suppression, improved immune function and quality of life, issues such as tolerability, drug-drug interactions and cross-resistance amongst members of a particular drug class still pose a significant barrier to long-term successful treatment. There is a constant need for newer anti HIV drugs with increased potency and improved pharmacokinetic properties either in the existing classes or drugs from new classes that target several new steps in HIV replication cycle. AREAS COVERED IN THIS REVIEW The authors have discussed newer antiretroviral drugs belonging to second-generation nucleoside analog reverse transcriptase inhibitors (amdoxovir, elvucitabine, apricitabine, racivir), non-nucleoside analog reverse transcriptase inhibitors (etravirine, rilpivirine), protease inhibitors (darunavir, tipranavir) as well as emerging new classes, i.e., fusion inhibitors (enfuvirtide, sifuvirtide), CCR5 inhibitors (maraviroc, vicriviroc, PRO 140, PRO 542), CD4-receptor inhibitors (ibalizumab), integrase inhibitors (raltegravir, elvitegravir, GSK-1349572), maturation inhibitors (bevirimat), cobicistat (pharmacoenhancer), lens epithelium-derived growth factor inhibitors and capsid assembly inhibitors. WHAT THE READER WILL GAIN The reader will gain an understanding of the mechanism of action, mechanism of resistance, stages of development and important clinical trials related to the newer antiretroviral drugs and future potential of these drugs. TAKE HOME MESSAGE The initial clinical trial data of these newer drugs are very encouraging for the long-term successful control of HIV in both treatment-naïve and treatment-experienced patients.
Collapse
Affiliation(s)
- Raktim Kumar Ghosh
- Department of Pharmacology, Maulana Azad Medical College, New Delhi, India.
| | | | | |
Collapse
|
167
|
Wilkin TJ, Su Z, Krambrink A, Long J, Greaves W, Gross R, Hughes MD, Flexner C, Skolnik PR, Coakley E, Godfrey C, Hirsch M, Kuritzkes DR, Gulick RM. Three-year safety and efficacy of vicriviroc, a CCR5 antagonist, in HIV-1-infected treatment-experienced patients. J Acquir Immune Defic Syndr 2010; 54:470-6. [PMID: 20672447 PMCID: PMC2917795 DOI: 10.1097/qai.0b013e3181e2cba0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Vicriviroc, an investigational CCR5 antagonist, demonstrated short-term safety and antiretroviral activity. METHODS Phase 2, double-blind, randomized study of vicriviroc in treatment-experienced subjects with CCR5-using HIV-1. Vicriviroc (5, 10, or 15 mg) or placebo was added to a failing regimen with optimization of background antiretroviral medications at day 14. Subjects experiencing virologic failure and subjects completing 48 weeks were offered open-label vicriviroc. RESULTS One hundred eighteen subjects were randomized. Virologic failure (<1 log10 decline in HIV-1 RNA > or =16 weeks postrandomization) occurred by week 48 in 24 of 28 (86%), 12 of 30 (40%), 8 of 30 (27%), 10 of 30 (33%) of subjects randomized to placebo, 5, 10, and 15 mg, respectively. Overall, 113 subjects received vicriviroc at randomization or after virologic failure, and 52 (46%) achieved HIV-1 RNA <50 copies per milliliter within 24 weeks. Through 3 years, 49% of those achieving suppression did not experience confirmed viral rebound. Dual or mixed-tropic HIV-1 was detected in 33 (29%). Vicriviroc resistance (progressive decrease in maximal percentage inhibition on phenotypic testing) was detected in 6 subjects. Nine subjects discontinued vicriviroc due to adverse events. CONCLUSIONS Vicriviroc seems safe and demonstrates sustained virologic suppression through 3 years of follow-up. Further trials of vicriviroc will establish its clinical utility for the treatment of HIV-1 infection.
Collapse
Affiliation(s)
- Timothy J Wilkin
- Division of Infectious Diseases Weill Cornell Medical College, New York, NY, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
168
|
Hull MW, Montaner JSG. Etravirine in combination with darunavir/ritonavir and optimized background regimen results in suppression of HIV replication in treatment-experienced patients. Evaluation of Katlama C, Haubrich R, Lalezari J, et al. Efficacy and safety of etravirine in treatment-experienced HIV-1 patients: pooled 48-week analysis of two randomized, controlled trials. AIDS 2009; 23: 2289-300. Expert Opin Pharmacother 2010; 11:1433-7. [PMID: 20367279 DOI: 10.1517/14656561003724754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Therapeutic options for treatment-experienced HIV-infected patients have been limited. The DUET trial evaluated the use of etravirine, a second-generation non-nucleoside reverse transcriptase inhibitor (NNRTI), or placebo, in 1203 treatment-experienced, HIV-infected patients. Eligible patients had to have evidence of NNRTI and protease inhibitor resistance-associated mutations, and evidence of virologic failure, as defined as a plasma viral load > 5000 copies/ml on antiretroviral therapy at the time of screening. Patients in both arms received an optimized background regimen including darunavir/ritonavir. DUET demonstrated superior outcomes in virologic suppression (plasma viral load < 50 copies/ml) and clinical end points including new AIDS-defining illnesses and death, in those randomized to receive etravirine. These results were maintained at 48 weeks of follow-up. Furthermore, etravirine was shown to be safe and well-tolerated over this period. In exploratory analyses, patients in the DUET study with greater number of active agents within the background regimen were more likely to have a fully suppressive response. Taken together, the DUET results highlight the high rates of virological success that can be achieved using new active agents, such as ritonavir-boosted darunavir and etravirine, in treatment-experienced patients with underlying drug-resistant HIV infection.
Collapse
Affiliation(s)
- Mark W Hull
- Faculty of Medicine, University of British Columbia, 1081 Burrard St., Vancouver, BC, Canada
| | | |
Collapse
|
169
|
HIV-1 protease mutations and protease inhibitor cross-resistance. Antimicrob Agents Chemother 2010; 54:4253-61. [PMID: 20660676 DOI: 10.1128/aac.00574-10] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The effects of many protease inhibitor (PI)-selected mutations on the susceptibility to individual PIs are unknown. We analyzed in vitro susceptibility test results on 2,725 HIV-1 protease isolates. More than 2,400 isolates had been tested for susceptibility to fosamprenavir, indinavir, nelfinavir, and saquinavir; 2,130 isolates had been tested for susceptibility to lopinavir; 1,644 isolates had been tested for susceptibility to atazanavir; 1,265 isolates had been tested for susceptibility to tipranavir; and 642 isolates had been tested for susceptibility to darunavir. We applied least-angle regression (LARS) to the 200 most common mutations in the data set and identified a set of 46 mutations associated with decreased PI susceptibility of which 40 were not polymorphic in the eight most common HIV-1 group M subtypes. We then used least-squares regression to ascertain the relative contribution of each of these 46 mutations. The median number of mutations associated with decreased susceptibility to each PI was 28 (range, 19 to 32), and the median number of mutations associated with increased susceptibility to each PI was 2.5 (range, 1 to 8). Of the mutations with the greatest effect on PI susceptibility, I84AV was associated with decreased susceptibility to eight PIs; V32I, G48V, I54ALMSTV, V82F, and L90M were associated with decreased susceptibility to six to seven PIs; I47A, G48M, I50V, L76V, V82ST, and N88S were associated with decreased susceptibility to four to five PIs; and D30N, I50L, and V82AL were associated with decreased susceptibility to fewer than four PIs. This study underscores the greater impact of nonpolymorphic mutations compared with polymorphic mutations on decreased PI susceptibility and provides a comprehensive quantitative assessment of the effects of individual mutations on susceptibility to the eight clinically available PIs.
Collapse
|
170
|
Grinsztejn B, Di Perri G, Towner W, Woodfall B, De Smedt G, Peeters M. A review of the safety and tolerability profile of the next-generation NNRTI etravirine. AIDS Res Hum Retroviruses 2010; 26:725-33. [PMID: 20624073 DOI: 10.1089/aid.2009.0293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The next-generation nonnucleoside reverse transcriptase inhibitor (NNRTI) etravirine (TMC125) has demonstrated durable virologic efficacy in clinical trials involving >1000 treatment-experienced, NNRTI-resistant, HIV-1-infected patients. In this clinical safety review, we show etravirine to be well tolerated with a proven safety record. The nature and magnitude of adverse events observed during treatment suggest that etravirine may offer improved tolerability over existing antiretrovirals, including NNRTIs. Notably, adverse events reported with etravirine treatment are generally mild to moderate in severity. Rash has been shown to occur with a higher incidence in etravirine-treated patients versus placebo, but cases are generally mild to moderate, occur within the first few weeks, and resolve with continued use. In addition, the rate of adverse event-related discontinuations is low with etravirine. In summary, the safety and tolerability profile of etravirine, combined with its virologic efficacy, suggest that the drug may be a valuable option for treatment-experienced patients with HIV-1 infection.
Collapse
Affiliation(s)
- Beatriz Grinsztejn
- Instituto de Pesquisa Clinica Evandro Chagas-Fiocruz, Rio de Janeiro, Brazil
| | | | | | | | | | | |
Collapse
|
171
|
Oumar AA, Jnaoui K, Kabamba-Mukadi B, Yombi JC, Vandercam B, Goubau P, Ruelle J. Genotypic evaluation of etravirine sensitivity of clinical human immunodeficiency virus type 1 (HIV-1) isolates carrying resistance mutations to nevirapine and efavirenz. Acta Clin Belg 2010; 65:242-4. [PMID: 20954462 DOI: 10.1179/acb.2010.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Etravirine is a second-generation non-nucleoside reverse transcriptase inhibitor (NNRTI) with a pattern of resistance mutations quite distinct from the current NNRTIs. METHODS We collected all routine samples of HIV-1 patients followed in the AIDS reference laboratory of UCLouvain (in 2006 and 2007) carrying resistance-associated mutations to nevirapine (NVP) or efavirenz (EFV). The sensitivity to Etravirine was estimated using three different drug resistance algorithms: ANRS (July 2008), IAS (December 2008) and Stanford (November 2008). We also verified whether the mutations described as resistance mutations are not due to virus polymorphisms by the study of 58 genotypes of NNRTI-naive patients. RESULTS Sixty one samples harboured resistance to NVP and EFV: 41/61 had at least one resistance mutation to Etravirine according to ANRS-IAS algorithms; 42/61 samples had at least one resistance mutation to Etravirine according to the Stanford algorithm. 48 and 53 cases were fully sensitive to Etravirine according to ANRS-IAS and Stanford algorithms, respectively. Three cases harboured more than three mutations and presented a pattern of high-degree resistance to Etravirine according to ANRS-IAS algorithm, while one case harboured more than three mutations and presented high degree resistance to Etravirine according to the Stanford algorithm. The V1061 and V179D mutations were more frequent in the ARV-naive group than in the NNRTI-experienced one. CONCLUSIONS According to the currently available algorithms, Etravirine can still be used in the majority of patients with virus showing resistance to NVP and/or EFV, if a combination of other active drugs is included.
Collapse
Affiliation(s)
- A A Oumar
- AIDS Reference Laboratory, Université Catholique de Louvain, Louvain-la-Neuve, Belgique
| | | | | | | | | | | | | |
Collapse
|
172
|
Abstract
The biggest challenge facing highly antiretroviral-experienced patients and their caregivers is the diminishing number of therapeutic options available that sustain activity despite increasing numbers of drug-resistance mutations. New options in antiretroviral treatment have been introduced: two new members of traditional antiretroviral classes (darunavir and etravirine) and two drugs with novel mechanisms of action (raltegravir and maraviroc). Each was approved for use in treatment-experienced patients. A fifth drug-containing efavirenz, tenofovir, and emtricitabine (Atripla; Bristol-Myers Squibb, New York, NY, and Gilead Sciences, Foster City, CA)-is a novel coformulation of existing drugs from two different classes, simplifying administration with the intent of increasing adherence. Because successful management of HIV infection requires the simultaneous use of three or more drugs, understanding the pharmacologic aspects of coadministration is critical. This review summarizes the pharmacokinetic properties affecting the administration of these recently approved drugs in light of highly active antiretroviral treatment guidelines.
Collapse
|
173
|
Vingerhoets J, Azijn H, Tambuyzer L, Dierynck I, De Meyer S, Rimsky L, Nijs S, De Smedt G, de Béthune MP, Picchio G. Short communication: activity of etravirine on different HIV type 1 subtypes: in vitro susceptibility in treatment-naive patients and week 48 pooled DUET study data. AIDS Res Hum Retroviruses 2010; 26:621-4. [PMID: 20507207 DOI: 10.1089/aid.2009.0239] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Etravirine (ETR) has previously shown potent in vitro activity against different primary HIV-1 isolates and demonstrated durable efficacy in treatment-experienced, HIV-1-infected patients in the Phase III DUET studies. The antiviral activity and efficacy of ETR against HIV-1 subtypes B and non-B were further investigated. The effect of HIV-1 subtype on ETR fold change in EC(50) value (FC) was analyzed in HIV-1 recombinant clinical isolates from 673 treatment-naive patients enrolled in other Tibotec studies. Subgroup analyses from the DUET studies of the effect of HIV-1 subtype on the proportion of patients with viral load (VL) <50 HIV-1 RNA copies/ml were also conducted using pooled week 48 data. Genotype/subtype and phenotype determinations were performed using the vircoTYPE HIV-1 and Antivirogram assays, respectively. In vitro results from treatment-naive patients indicated comparable median ETR FC in virus isolates from patients infected with subtype B or non-B (1.1 vs. 1.2, respectively). HIV-1 subtype data were available for 594 and 595 patients in the ETR and placebo groups of the DUET studies, respectively; 94% of patients harbored subtype B. Baseline characteristics were similar across the different subtypes, with the exception of a higher number of sensitive NRTIs used in patients with subtype non-B. At week 48, virological responses in the ETR group were higher in patients with subtype non-B versus B (73% vs. 60%, respectively). ETR was equally effective in suppressing viral replication in patients infected with HIV-1 subtype B or various HIV-1 non-B subtypes.
Collapse
|
174
|
Manosuthi W, Butler DM, Chantratita W, Sukasem C, Richman DD, Smith DM. Patients infected with HIV type 1 subtype CRF01_AE and failing first-line nevirapine- and efavirenz-based regimens demonstrate considerable cross-resistance to etravirine. AIDS Res Hum Retroviruses 2010; 26:609-11. [PMID: 20507208 PMCID: PMC2982719 DOI: 10.1089/aid.2009.0107] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Weerawat Manosuthi
- Bamrasnaradura Infectious Diseases Institute, Ministry of Public Health, Nonthaburi, Thailand
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Wasun Chantratita
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chonlaphat Sukasem
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Douglas D. Richman
- University of California San Diego, La Jolla, California
- Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Davey M. Smith
- University of California San Diego, La Jolla, California
- Veterans Affairs San Diego Healthcare System, San Diego, California
| |
Collapse
|
175
|
[AIDS Study Group/Spanish AIDS Plan consensus document on antiretroviral therapy in adults with human immunodeficiency virus infection (updated January 2010)]. Enferm Infecc Microbiol Clin 2010; 28:362.e1-91. [PMID: 20554079 DOI: 10.1016/j.eimc.2010.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 03/14/2010] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This consensus document is an update of antiretroviral therapy recommendations for adult patients with human immunodeficiency virus infection. METHODS To formulate these recommendations a panel made up of members of the Grupo de Estudio de Sida (Gesida, AIDS Study Group) and the Plan Nacional sobre el Sida (PNS, Spanish AIDS Plan) reviewed the advances in the current understanding of the pathophysiology of human immunodeficiency virus (HIV) infection, the efficacy and safety of clinical trials, and cohort and pharmacokinetic studies published in biomedical journals or presented at scientific meetings. Three levels of evidence were defined according to the data source: randomized studies (level A), cohort or case-control studies (level B), and expert opinion (level C). The decision to recommend, consider or not to recommend ART was established in each situation. RESULTS Currently, the treatment of choice for chronic HIV infection is the combination of three drugs of two different classes, including 2 nucleosides or nucleotide analogs (NRTI) plus 1 non-nucleoside (NNRTI) or 1 boosted protease inhibitor (PI/r), but other combinations are possible. Initiation of ART is recommended in patients with symptomatic HIV infection. In asymptomatic patients, initiation of ART is recommended on the basis of CD4 lymphocyte counts, plasma viral load and patient co-morbidities, as follows: 1) therapy should be started in patients with CD4 counts below 350 cells/microl; 2) When CD4 counts are between 350 and 500 cells/microl, therapy should be started in case of cirrhosis, chronic hepatitis C, high cardiovascular risk, HIV nephropathy, HIV viral load above 100,000 copies/ml, proportion of CD4 cells under 14%, and in people aged over 55; 3) Therapy should be deferred when CD4 are above 500 cells/microl, but could be considered if any of previous considerations concurs. Treatment should be initiated in case of hepatitis B requiring treatment and should be considered for reduce sexual transmission. The objective of ART is to achieve an undetectable viral load. Adherence to therapy plays an essential role in maintaining antiviral response. Therapeutic options are limited after ART failures but undetectable viral loads maybe possible with the new drugs even in highly drug experienced patients. Genotype studies are useful in these situations. Drug toxicity of ART therapy is losing importance as benefits exceed adverse effects. Criteria for antiretroviral treatment in acute infection, pregnancy and post-exposure prophylaxis are mentioned as well as the management of HIV co-infection with hepatitis B or C. CONCLUSIONS CD4 cells counts, viral load and patient co-morbidities are the most important reference factors to consider when initiating ART in asymptomatic patients. The large number of available drugs, the increased sensitivity of tests to monitor viral load, and the ability to determine viral resistance is leading to a more individualized therapy approach in order to achieve undetectable viral load under any circumstances.
Collapse
|
176
|
Schöller-Gyüre M, Kakuda TN, De Smedt G, Woodfall B, Berckmans C, Peeters M, Hoetelmans RMW. Effects of hepatic impairment on the steady-state pharmacokinetics of etravirine 200 mg BID: an open-label, multiple-dose, controlled Phase I study in adults. Clin Ther 2010; 32:328-37. [PMID: 20206790 DOI: 10.1016/j.clinthera.2010.02.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND Etravirine is a non-nucleoside reverse transcriptase inhibitor (NNRTI) with activity against both wild-type HIV and viruses harboring NNRTI resistance. Etravirine is mainly eliminated via the hepatobiliary route. OBJECTIVES This study in HIV- patients with mild or moderate hepatic impairment and healthy matched controls was conducted to explore the effects of mild and moderate hepatic impairment on the steady-state pharmacokinetics of etravirine and to provide guidance for the treatment of HIV+ patients with hepatic impairment. METHODS This open-label, multiple-dose study enrolled HIV- patients aged 18 to 65 years with mild or moderate hepatic impairment (Child-Pugh score, 5-6 or 7-9, respectively) and healthy volunteers matched for age, sex, race, and body mass index (BMI). All subjects received etravirine 200 mg BID with food for 7 days and a morning dose on day 8. Etravirine pharmacokinetics over a period of 12 hours on days 1 and 8 were determined using noncompartmental methods and analyzed using linear mixed-effects modeling. Tolerability of etravirine was assessed based on the reported adverse events, laboratory investigations, ECG, and physical examination. RESULTS Each group comprised 8 subjects (mild hepatic impairment patients: 5 men, 3 women; median age, 57 years [range, 41-65 years]; BMI, 26 kg/m(2) [range, 20-32 kg/m(2)]; moderate hepatic impairment patients: 6 men, 2 women; age, 54 years [range, 44-64 years]; BMI, 26 kg/m(2) [range, 22-32 kg/m(2)]). All patients were white and light smokers. On day 8, the least squares mean ratios (90% CIs) of the log transformed pharmacokinetic properties in patients with mild and moderate hepatic impairment were, respectively: C(min), 0.87 (0.65-1.17) and 0.98 (0.68-1.42) microg/mL; C(max), 0.79 (0.63-1.00) and 0.72 (0.54-0.96) ug/mL; and AUC(0-12), 0.87 (0.69-1.09) and 0.82 (0.60-1.11) microg/mL/h. All treatment-emergent adverse events were considered mild to moderate; the most common were headache (50% in healthy controls) and fatigue and nausea (both 25% in patients with mild hepatic impairment). No clinically significant changes in laboratory parameters, physical examination including vital signs, or ECG were observed. One serious adverse event was reported during the follow-up period in a patient with moderate hepatic impairment due to hepatic cirrhosis secondary to alcoholism. This patient presented at screening with dilated cardiomyopathy and cardiac arrhythmia. CONCLUSIONS In this Phase I pharmacokinetic study, no clinically relevant differences were observed between patients with mild or moderate hepatic impairment and healthy matched subjects with regard to the pharmacokinetics of etravirine. Based on these findings in these HIV- volunteers, no dose adjustment of etravirine appears to be necessary in patients with mild or moderate hepatic impairment. Etravirine was generally well tolerated.
Collapse
|
177
|
Psychometric evaluation of the functional assessment of HIV Infection (FAHI) questionnaire and its usefulness in clinical trials. Qual Life Res 2010; 19:1215-27. [DOI: 10.1007/s11136-010-9674-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2010] [Indexed: 10/19/2022]
|
178
|
Wittkop L, Smith C, Fox Z, Sabin C, Richert L, Aboulker JP, Phillips A, Chêne G, Babiker A, Thiébaut R. Methodological issues in the use of composite endpoints in clinical trials: examples from the HIV field. Clin Trials 2010; 7:19-35. [PMID: 20156955 DOI: 10.1177/1740774509356117] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In many fields, the choice of a primary endpoint for a trial is not always the ultimate clinical endpoint of interest, but rather some surrogate endpoint believed to be relevant for predicting the effect of the intervention on the clinical endpoint. The classic example of such a field is clinical HIV treatment research, where a variety of primary endpoints are used to evaluate the efficacy of new antiretroviral drugs or new combinations of existing drugs. The choice of endpoint reflects either the goal of therapy as recommended by treatment guidelines (e.g. rapid virological suppression) or the licensing requirements of official drug approval organizations (e.g. time to loss of virological response [TLOVR]). PURPOSE To review the diversity of endpoints used in recent clinical trials in HIV infection and highlight the methodological issues. METHODS We identified articles relating to antiretroviral therapy by searching PubMed and through hand searches of relevant conference abstracts. We restricted the search to randomized controlled trials conducted in HIV-infected adults published/presented from January 2005 until March 2008. RESULTS We identified 28 trials in antiretroviral-naive patients (i.e. patients who were starting antiretroviral therapy for the first time at the time of randomization) and 23 trials in antiretroviral-experienced patients. Most trials were performed for purposes of drug licensing, but others were focused on strategies of using approved drugs. Most trials (40 of 51) used a composite primary endpoint (TLOVR in 13). Of note, 22 of these 40 studies reported that they had used a purely virological efficacy endpoint, but the primary endpoint was actually a composite one due to the way in which missing data and treatment switches were considered as failures. LIMITATIONS Examples are restricted to HIV clinical trials. CONCLUSIONS Whilst most current HIV clinical trials use composite primary endpoints, there are substantial differences in the components that make up these endpoints. In HIV and other fields where precise definitions are variable, guidelines for standardization of definition and reporting would greatly improve the ability to compare trial results.
Collapse
Affiliation(s)
- Linda Wittkop
- Inserm U897, Research Centre for Epidemiology and Biostatistics, Bordeaux, France.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
179
|
Kertesz DJ, Brotherton-Pleiss C, Yang M, Wang Z, Lin X, Qiu Z, Hirschfeld DR, Gleason S, Mirzadegan T, Dunten PW, Harris SF, Villaseñor AG, Hang JQ, Heilek GM, Klumpp K. Discovery of piperidin-4-yl-aminopyrimidines as HIV-1 reverse transcriptase inhibitors. N-benzyl derivatives with broad potency against resistant mutant viruses. Bioorg Med Chem Lett 2010; 20:4215-8. [PMID: 20538456 DOI: 10.1016/j.bmcl.2010.05.040] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Revised: 05/10/2010] [Accepted: 05/12/2010] [Indexed: 11/17/2022]
Abstract
An analysis of the binding motifs of known HIV-1 non-nucleoside reverse transcriptase inhibitors has led to discovery of novel piperidine-linked aminopyrimidine derivatives with broad activity against wild-type as well as drug-resistant mutant viruses. Notably, the series retains potency against the K103N/Y181C and Y188L mutants, among others. Thus, the N-benzyl compound 5k has a particularly attractive profile. Synthesis and SAR are presented and discussed, as well as crystal structures relating to the binding motifs.
Collapse
Affiliation(s)
- Denis J Kertesz
- Roche Palo Alto LLC, 3431 Hillview Avenue, Palo Alto, CA 94304, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
180
|
Antiretroviral monotherapy: should we abandon the principles of successful antiretroviral therapy? AIDS 2010; 24:1057-9. [PMID: 20032771 DOI: 10.1097/qad.0b013e32833609a2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
181
|
|
182
|
Abstract
Raltegravir, the first approved HIV-1 integrase inhibitor, is able to block the strand transfer step of the HIV proviral DNA integration process into the cellular host DNA. The selected dosage for the pivotal phase III studies (subsequently approved by the regulatory agencies) was 400 mg bid by oral route with or without food. Raltegravir has a week effect (either inhibition or induction) on the hepatic cytochrone P450 activity. There is not need of dose adjustments in renal insufficiency or in mild-to-moderate hepatic impairment. The emerging paradigm in the field of salvage therapy was to achieve a viral load below limit of detection in almost all patients. Pretty soon it became apparent that this was feasible in more than 70-90% of patients. Raltegravir proved to be pivotal for this new paradigm. Raltegravir vs placebo both with an optimized background therapy has been tested for salvage therapy in the 005 and in the BENCHMRK studies (018 and 019). In all three studies proved to be superior to the placebo at 24, 48 and 96 weeks. Tolerance was remarkably good and virological failure was often associated with selection of integrase gene resistance mutations following the Y143C/H/R, Q148H/K/R o less frequently the NI55H paths. Finally, in the two SWITCHMRK studies non-inferiority vs Lopinavir/r could not be demonstrated in virogically suppressed patients with an stable cART containing Lopinavir/r. Most likely explanation was the presence of archived resistance mutationts to background therapy leading to a functional monotherapy with raltegravir.
Collapse
Affiliation(s)
- Jose M Gatell
- Hospital Clinic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain.
| |
Collapse
|
183
|
A validated high-performance liquid chromatography-ultraviolet method for quantification of the CCR5 inhibitor maraviroc in plasma of HIV-infected patients. Ther Drug Monit 2010; 32:86-92. [PMID: 20040898 DOI: 10.1097/ftd.0b013e3181cacbd0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Maraviroc is the first commercialized CCR5 inhibitor for HIV therapy. A new high-performance liquid chromatography-ultraviolet method to quantify maraviroc concentrations in human plasma was developed and validated. The method is based on a protein precipitation procedure, with an acidic solution of acetonitrile (trifluoroacetic acid 0.1%) and quinoxaline as internal standard. The analytes were eluted using a gradient run in 15 minutes on an analytical C18 Luna column (150 mm x 4.6 mm ID) with a particle size of 5 mum. Maraviroc and internal standard were detected by UV at 193 nm and 352 nm, respectively. The calibration curve was linear up to 2500 ng/mL. The mean recovery of maraviroc was 96%. All validation data were in accordance with U.S. Food and Drug Administration requirements. The new high-performance liquid chromatography-ultraviolet method reported here could be used routinely to monitor plasma concentrations of maraviroc in healthy volunteers and HIV-infected patients.
Collapse
|
184
|
Using of nevirapine is associated with intermediate and reduced response to etravirine among HIV-infected patients who experienced virologic failure in a resource-limited setting. J Clin Virol 2010; 47:330-4. [DOI: 10.1016/j.jcv.2010.01.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2009] [Revised: 12/15/2009] [Accepted: 01/28/2010] [Indexed: 11/23/2022]
|
185
|
Varied Patterns of HIV-1 Drug Resistance on Failing First-Line Antiretroviral Therapy in South Africa. J Acquir Immune Defic Syndr 2010; 53:480-4. [DOI: 10.1097/qai.0b013e3181bc478b] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
186
|
Santos JR, Llibre JM, Ferrer E, Domingo P, Imaz A, Moltó J, Martin-Iguacel R, Caum C, Podzamczer D, Clotet B. Efficacy and safety of switching from enfuvirtide to raltegravir in patients with virological suppression. HIV CLINICAL TRIALS 2010; 10:432-8. [PMID: 20133273 DOI: 10.1310/hct1006-432] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To assess the Efficacy and safety of switching from HAART containing enfuvirtide to raltegravir as a simplification strategy in patients with viral suppression and intolerance to enfuvirtide. METHODS Thirty-six patients with sustained plasma HIV RNA levels <50 copies/mL for at least 3 months with injection site reactions and/or injection fatigue while receiving an enfuvirtide-containing optimized background regimen switched from enfuvirtide to raltegravir (400 mg bid). RESULTS Patientshad received enfuvirtide for a median of 96 weeks and had sustained HIV RNA <50 copies/ mL for a median of 95 weeks. One patient discontinued raltegravir due to the appearance of cutaneous rash (grade 2) unresponsive to antihistamines after 19 days of starting raltegravir. The remaining 35 patients were followed for 24 weeks and 18 of them for 48 weeks. All patients maintained virological suppression <50 copies/mL at Weeks 24 and 48. No patient had blips in their viral load after switching to raltegravir. There were no grade 3 or 4 adverse events related to raltegravir. CONCLUSIONS A switch from enfuvirtide to raltegravir in virologically suppressed patients who are highly treatment-experienced maintained both virologic and immunologic efficacy up to 48 weeks.
Collapse
Affiliation(s)
- José R Santos
- Lluita contra la SIDA, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain Universitat Autònoma de Barcelona, Barcelona, Spain.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
187
|
Scherrer AU, von Wyl V, Fux CA, Opravil M, Bucher HC, Fayet A, Decosterd LA, Hirschel B, Khanlari B, Yerly S, Klimkait T, Furrer H, Ledergerber B, Günthard HF. Implementation of raltegravir in routine clinical practice: selection criteria for choosing this drug, virologic response rates, and characteristics of failures. J Acquir Immune Defic Syndr 2010; 53:464-71. [PMID: 19841590 DOI: 10.1097/qai.0b013e3181bca4ec] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Raltegravir (RAL) achieved remarkable virologic suppression rates in randomized-clinical trials, but today efficacy data and factors for treatment failures in a routine clinical care setting are limited. METHODS First, factors associated with a switch to RAL were identified with a logistic regression including patients from the Swiss HIV Cohort Study with a history of 3 class failure (n = 423). Second, predictors for virologic outcome were identified in an intent-to-treat analysis including all patients who received RAL. Last observation carried forward imputation was used to determine week 24 response rate (HIV-1 RNA >or= 50 copies/mL). RESULTS The predominant factor associated with a switch to RAL in patients with suppressed baseline RNA was a regimen containing enfuvirtide [odds ratio 41.9 (95% confidence interval: 11.6-151.6)]. Efficacy analysis showed an overall response rate of 80.9% (152/188), whereas 71.8% (84/117) and 95.8% (68/71) showed viral suppression when stratified for detectable and undetectable RNA at baseline, respectively. Overall CD4 cell counts increased significantly by 42 cells/microL (P < 0.001). Characteristics of failures were a genotypic sensitivity score of the background regimen <or=1, very low RAL plasma concentrations, poor adherence, and high viral load at baseline. CONCLUSIONS Virologic suppression rates in our routine clinical care setting were promising and comparable with data from previously published randomized-controlled trials.
Collapse
Affiliation(s)
- Alexandra U Scherrer
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
188
|
Raltegravir, maraviroc, etravirine: an effective protease inhibitor and nucleoside reverse transcriptase inhibitor-sparing regimen for salvage therapy in HIV-infected patients with triple-class experience. AIDS 2010; 24:924-8. [PMID: 20154578 DOI: 10.1097/qad.0b013e3283372d76] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We prospectively evaluated 28 triple-class experienced HIV-1-infected patients harbouring R5 virus, who received maraviroc, raltegravir and etravirine. By on-treatment analysis, 26 (92%) had less than 50 copies HIV-RNA/ml at week 48. The median (interquartile range) 48-week increase in CD4 cell counts was 267 (136-355) cells/microl. Three serious adverse events occurred: one recurrence of mycobacterial spondylodiscitis, one anal cancer, one Hodgkin lymphoma. Although long-term safety needs further study, this protease inhibitor and nucleoside analogue-sparing regimen showed sustained efficacy.
Collapse
|
189
|
Abstract
PURPOSE OF REVIEW New antiretroviral agents have recently become available within existing and new drug classes, increasing treatment options for patients with multidrug-resistant virus. This review discusses the challenges that these new agents pose for the management of treatment-experienced patients. RECENT FINDINGS Recent studies of the efficacy and safety of new antiretroviral drugs illustrate that drug regimens containing new agents are well tolerated and can suppress viremia in even the most drug-resistant patients. The goal of any new regimen should therefore be suppression of plasma HIV RNA levels to less than 50 copies/ml, even in treatment-experienced patients. Patients should be given a regimen with at least two, or preferably three, fully active drugs after careful consideration of their treatment and adherence history, current and prior genotype tests, comorbidities, and concomitant medications. Newer and more tolerable agents also offer the possibility of regimen simplification among patients with multidrug-resistant HIV who are virologically suppressed. SUMMARY Clinicians must optimize the pairing and sequencing of recently available antiretroviral agents. Future studies should continue to investigate the optimal use of new agents in order to further improve long-term treatment efficacy in patients with multidrug-resistant HIV infection.
Collapse
|
190
|
Abstract
PURPOSE OF REVIEW As antiretroviral therapy has been refined with the development of more potent agents and simpler regimens, fewer individuals experience treatment failure. This review will highlight recent trends in treatment failure and virologic resistance in the developed world and resource-limited settings. RECENT FINDINGS The goal of antiretroviral therapy in all individuals, regardless of prior treatment exposure or HIV drug resistance, is to achieve full suppression of viral replication with a viral load of less than 50 copies/ml. This goal has been made a reality by the development of newer agents and simpler, better tolerated regimens. Recent cohort studies have demonstrated improved virologic outcomes in the current antiretroviral era, with decreased rates of virologic failure and associated resistance. Improved tolerability has aided adherence, which remains a key determinant of treatment success. Cohorts in resource-limited settings report improved clinical and virologic outcomes as rollout of highly active antiretroviral therapy programs continues. SUMMARY There has been a reassuring decrease in the frequency of virological failure and drug resistance in the modern highly active antiretroviral therapy era. This observation provides an important incentive to strengthen support of antiretroviral therapy programs to optimize virological outcomes, particularly in resource-limited settings in which access to newer agents and laboratory monitoring may be needed to ensure sustainable success.
Collapse
|
191
|
Abstract
PURPOSE OF REVIEW To define treatment failure in resource-rich settings; summarizing current guidelines, assays, the significance of detectable viremia, and definitions of treatment failure in clinical and research settings. RECENT FINDINGS The goal of treatment should be full viral suppression, even in highly treatment-experienced patients. SUMMARY Treatment failure is defined as repeated HIV RNA values above the lower limit of detection of a sensitive assay (usually 50 copies/ml). This criterion is based on evidence that the maximum clinical benefit of antiretroviral therapy is derived by keeping the viral load as low as possible. Full viral suppression should be achievable in all patients, both treatment-naïve and experienced. Transient, low-detectable viremia ('blips') may not predict virologic breakthrough. However, consecutive or higher-level transient viremia is associated with risk of treatment failure. Defining failure by a confirmed HIV RNA more than 50 copies/ml is the most conservative approach, but the use of such low limits of detection in clinical trials may lead to a high false-positive 'failure' rate, thus a definition of 200 copies/ml may be preferable. Variation in clinical trial endpoint definitions creates a challenge for comparing results between studies. For example, using a composite endpoint to define treatment failure may result in a high proportion of 'failures' that are not related to poor virologic response.
Collapse
|
192
|
Drugs in traditional drug classes (nucleoside reverse transcriptase inhibitor/nonnucleoside reverse transcriptase inhibitor/protease inhibitors) with activity against drug-resistant virus (tipranavir, darunavir, etravirine). Curr Opin HIV AIDS 2010; 4:507-12. [PMID: 20048718 DOI: 10.1097/coh.0b013e328331b911] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review focuses on the use of tipranavir/ritonavir, darunavir/ritonavir and etravirine for the treatment of HIV infection that has become resistant to protease inhibitors and/or nonnucleoside reverse transcriptase inhibitors. RECENT FINDINGS Tipranavir/ritonavir and darunavir/ritonavir are boosted protease inhibitors highly active against HIV that has developed mutations that confer resistance to other protease inhibitors. For both drugs, there are scores to predict activity based on a combination of mutations. Best results are obtained when each drug is combined with one and preferably two other completely active antiretrovirals. The interaction profile and toxicity profile is better for darunavir/ritonavir, which in addition has shown positive outcomes in clinical trials of patients with early failure.Etravirine is a nonnucleoside reverse transcriptase inhibitor highly active against HIV that has developed mutations that confer resistance to nevirapine or efavirenz. Clinical trials results suggest that etravirine should be used with other active antiretrovirals. Best results for etravirine have been obtained in combination with darunavir/ritonavir in patients with extensive protease inhibitor and nonnucleoside reverse transcriptase inhibitor resistance. The role of etravirine for the treatment of early failure of efavirenz-based or nevirapine-based regimens remains to be elucidated. Resistance to etravirine requires the accumulation of multiple reverse transcriptase mutations different from K103N, which has no impact on activity. SUMMARY Tipranavir/ritonavir, darunavir/ritonavir and etravirine are very important additions to the therapeutic armamentarium against HIV that has become resistant to protease inhibitors and nonnucleoside reverse transcriptase inhibitors.
Collapse
|
193
|
Di Vincenzo P, Rusconi S, Adorni F, Vitiello P, Maggiolo F, Francisci D, Di Biagio A, Monno L, Antinori A, Boeri E, Punzi G, Perno CF, Callegaro A, Bruzzone B, Zazzi M. Prevalence of mutations and determinants of genotypic resistance to etravirine (TMC125) in a large Italian resistance database (ARCA). HIV Med 2010; 11:530-4. [PMID: 20236364 DOI: 10.1111/j.1468-1293.2009.00819.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate whether etravirine (TMC125) might be effective in patients failing therapy with current nonnucleoside reverse transcriptase inhibitors (NNRTIs), we analysed the prevalence of TMC125 mutations and the possible determinants of genotypic resistance to this drug among sequences reported to a large database in Italy [Antiretroviral Resistance Cohort Analysis (ARCA)]. METHODS We analysed the prevalence of TMC125 resistance-associated mutations (RAMs) and the TMC125 weighted genotypic score (WGS) together with the determinants of genotypic resistance. A total of 5011 sequences from 2955 patients failing NNRTI therapy were evaluated. RESULTS Among the sequences in ARCA, 68% had at least one and 9.8% at least three TMC125 RAMs, whereas 31% had a WGS>2. Frequent RAMs were Y181C, G190A, K101E and A98G, whereas V179F, Y181V and G190S appeared in <5% of sequences. Multivariate analysis revealed a higher risk of developing at least three TMC125 RAMs associated with both nevirapine and efavirenz exposure, whereas CD4 counts > or = 200 cells/microL retained their protective effect. An increased risk of WGS>2 was linked to higher HIV RNA values (maximum risk at >5 log(10) copies/mL) and nevirapine exposure; CD4 counts > or = 200 cells/microL were protective. CONCLUSIONS The prevalence of TMC125 resistance mutations in the ARCA cohort was 68%. The DUET studies showed that at least three TMC125-associated mutations were required to impair the efficacy of the drug and Y181C/V, V179F and G190S had the greatest effect on response. The prevalence of these mutations among the patients examined in our study was low. However, WGS>2 was found for one-third of our sequences. Previous nevirapine exposure was associated with an increased risk of having WGS>2 (adjusted odds ratio 1.76).
Collapse
Affiliation(s)
- P Di Vincenzo
- Sezione Malattie Infettive e Immunopatologia, Dipartimento di Scienze Cliniche 'Luigi Sacco', Universita' degli Studi, Milan, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
194
|
Josephson F, Albert J, Flamholc L, Gisslén M, Karlström O, Moberg L, Navér L, Svedhem V, Svennerholm B, Sönnerborg A. Treatment of HIV infection: Swedish recommendations 2009. ACTA ACUST UNITED AC 2010; 41:788-807. [PMID: 19922061 DOI: 10.3109/00365540903214322] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
On 4 previous occasions, in 2002, 2003, 2005 and 2007, the Swedish Medical Products Agency (Läkemedelsverket) and the Swedish Reference Group for Antiviral Therapy (RAV) have jointly published recommendations for the treatment of HIV infection. In November 2008, an expert group under the guidance of RAV once more revised the guidelines, of which this is a translation into English. The most important updates in the present guidelines include the following: (a) treatment initiation is now recommended at a CD4 cell count of approximately 350/microl; (b) new recommendations for first-line therapy: abacavir/lamivudine or tenofovir/emtricitabine in combination with efavirenz or a boosted protease inhibitor (PI/r); (c) an increased focus on reducing the use of antiretroviral drugs that may cause lipoatrophy; (d) an emphasis on quality assurance of HIV care through the use of InfCare HIV; (e) considerably altered recommendations for the initiation of antiretroviral therapy in children. All infants (<1 y) should start antiretroviral therapy, regardless of immune status. Also, absolute CD4+ cell counts, rather than percentage, may be used to guide treatment initiation in children above the age of 5 y.
Collapse
Affiliation(s)
- Filip Josephson
- Department of Clinical Pharmacology, Karolinska University Hospital, Sweden.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
195
|
Resistance profile of etravirine: combined analysis of baseline genotypic and phenotypic data from the randomized, controlled Phase III clinical studies. AIDS 2010; 24:503-14. [PMID: 20051805 DOI: 10.1097/qad.0b013e32833677ac] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To refine the genotypic and phenotypic correlates of response to the nonnucleoside reverse transcriptase inhibitor etravirine. DESIGN Initial analyses identified 13 etravirine resistance-associated mutations (RAMs) and clinical cutoffs (CCOs) for etravirine. A multivariate analysis was performed to refine the initial etravirine RAM list and improve the predictive value of genotypic resistance testing with regard to virologic response and relationship to phenotypic data. METHODS Week 24 data were pooled from the phase III studies with TMC125 to Demonstrate Undetectable viral load in patients Experienced with ARV Therapy (DUET). The effect of baseline resistance to etravirine on virologic response (<50 HIV-1 RNA copies/ml) was studied in patients not using de-novo enfuvirtide and excluding discontinuations for reasons other than virologic failure (n = 406). Clinical cutoffs for etravirine were established by analysis of covariance models and sliding fold change in 50% effective concentration (EC50) windows (Antivirogram; Virco BVBA, Mechelen, Belgium). Etravirine RAMs were identified as those associated with decreased virologic response/increased etravirine fold change in EC50. Relative weight factors were assigned to the etravirine RAMs using random forest and linear modeling techniques. RESULTS Baseline etravirine fold change in EC50 predicted virologic response at week 24, with lower and preliminary upper clinical cutoffs of 3.0 and 13.0, respectively. A fold change in EC50 value above which etravirine provided little or no additional efficacy benefit could not be established. Seventeen etravirine RAMs were identified and attributed a relative weight factor accounting for the differential impact on etravirine fold change in EC50. Virologic response was a function of etravirine-weighted genotypic score. CONCLUSION The weighted genotypic scoring algorithm optimizes resistance interpretations for etravirine and guides treatment decisions regarding its use in treatment-experienced patients.
Collapse
|
196
|
Tseng A, MacArthur RD. Profile of etravirine for the treatment of HIV infection. Ther Clin Risk Manag 2010; 6:49-58. [PMID: 20169036 PMCID: PMC2817788 DOI: 10.2147/tcrm.s3128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Indexed: 11/24/2022] Open
Abstract
Etravirine is a second-generation non-nucleoside reverse transcriptase inhibitor (NNRTI) with the advantages of in vitro potency against many strains of virus resistant to efavirenz and nevirapine, as well as a higher genetic barrier to resistance. Etravirine is indicated for use in treatment-experienced patients, and the approved dose in adults is 200 mg twice daily. Etravirine should be administered after a meal as bioavailability is significantly reduced when taken in the fasting state. Etravirine is a substrate of CYP3A4, CYP2C9, CYP2C19, and uridine diphosphate glucuronyltransferase, and induces CYP3A4, weakly inhibits CYP2C9 and moderately inhibits CYP2C19. Etravirine may be coadministered with nucleoside/tide reverse transcriptase inhibitors, raltegravir and boosted darunavir, lopinavir, and saquinavir without dosage adjustment. Etravirine should not be given with other NNRTIs, unboosted protease inhibitors, and atazanavir/ritonavir, tipranavir/ritonavir, and fosamprenavir/ritonavir due to unfavorable drug interactions. In randomized, controlled trials, twice daily etravirine combined with darunavir/ritonavir plus optimized background therapy demonstrated better efficacy compared to darunavir/ritonavir plus optimized background therapy alone in treatment-experienced populations out to 96 weeks follow-up. The main etravirine-associated toxicity is mild to moderate self-limiting rash, although severe and sometimes fatal hypersensitivity reactions have been reported. Etravirine offers a potent sequencing option after the development of resistance to first-line NNRTIs, and is a welcome addition to this established drug class.
Collapse
Affiliation(s)
- Alice Tseng
- Toronto General Hospital, Toronto, ON, Canada
| | - Rodger D MacArthur
- Division of Infectious Diseases, Wayne State University, Detroit, Michigan, USA
| |
Collapse
|
197
|
Deeks SG, Gange SJ, Kitahata MM, Saag MS, Justice AC, Hogg RS, Eron JJ, Brooks JT, Rourke SB, Gill MJ, Bosch RJ, Benson CA, Collier AC, Martin JN, Klein MB, Jacobson LP, Rodriguez B, Sterling TR, Kirk GD, Napravnik S, Rachlis AR, Calzavara LM, Horberg MA, Silverberg MJ, Gebo KA, Kushel MB, Goedert JJ, McKaig RG, Moore RD. Trends in multidrug treatment failure and subsequent mortality among antiretroviral therapy-experienced patients with HIV infection in North America. Clin Infect Dis 2010; 49:1582-90. [PMID: 19845473 DOI: 10.1086/644768] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Although combination antiretroviral therapy continues to evolve, with potentially more effective options emerging each year, the ability of therapy to prevent multiple regimen failure and mortality in clinical practice remains poorly defined. METHODS Sixteen cohorts representing over 60 sites contributed data on all individuals who initiated combination antiretroviral therapy. We identified those individuals who experienced virologic failure (defined as a human immunodeficiency virus [HIV] RNA level >1000 copies/mL), received modified therapy, and subsequently had a second episode of virologic failure. Multivariate Cox regression was used to assess factors associated with time to second regimen failure and the time to death after the onset of second regimen failure. RESULTS Of the 42,790 individuals who received therapy, 7159 experienced a second virologic failure. The risk of second virologic failure decreased from 1996 (56 cases per 100 person-years) through 2005 (16 cases per 100 person-years; P < .001). The cumulative mortality after onset of second virologic failure was 26% at 5 years and decreased over time. A history of AIDS, a lower CD4(+) T cell count, and a higher plasma HIV RNA level were each independently associated with mortality. Similar trends were observed when analysis was limited to the subset of previously treatment-naive patients CONCLUSIONS Although the rates of multiple regimen failure have decreased dramatically over the past decade, mortality rates for those who have experienced failure of at least 2 regimens have remained high. Plasma HIV RNA levels, CD4(+) T cell counts at time of treatment failure, and a history of AIDS remain independent risk factors for death, which emphasizes that these factors remain important targets for those in need of more-aggressive therapeutic interventions.
Collapse
Affiliation(s)
- Steven G Deeks
- University of California-San Francisco, San Francisco, San Diego, CA 94110, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
198
|
Domingo P. [Role of etravirine in combination antiretroviral therapy]. Enferm Infecc Microbiol Clin 2010; 27 Suppl 2:46-51. [PMID: 20116628 DOI: 10.1016/s0213-005x(09)73219-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Etravirine (ETR) is a new antiretroviral drug of the non-nucleoside reverse transcriptase inhibitor (NNRTI) family that has recently been approved by the regulatory agencies for the treatment of patients with prior experience with antiretrovirals, evidence of active viral replication, and who harbor multidrug resistant HIV-1 strains. In this context, in Europe, the use of this drug has been authorized combined with boosted protease inhibitors and nucleoside reverse transcriptase inhibitors. This approval was based on the results of the randomized double-blind DUET studies, in which the ETR arm was statistically superior to the placebo arms in terms of virological efficacy, immunological recovery, clinical progression and health- related quality of life. These studies showed that ETR was as well-tolerated as placebo, except for the appearance of rash, which was more common in the ETR arm. However, rash was usually mild or moderate and caused discontinuation of ETR in only 2% of the patients. The characteristics of ETR, i.e., potency, benign safety profile, resistance profile, pharmacokinetic characteristics, and drug interactions suggest that the use of this drug may go beyond its currently approved indications. Nevertheless, the evidence supporting these alternative uses is still scarce, although a randomized, double-blind, placebo controlled trial (SENSE) is under way in treatment-naïve patients. In this trial ETR will be administered once daily and the principal objective is to show that ETR has better tolerability in the central nervous system (CNS) than efavirenz. Moreover, the tolerability profile in the CNS, liver, and even skin suggest that ETR may be a good option when there are toxicity problems, or a risk of toxicity, with first-generation NNRTIs. When there is virological failure with an initial first-generation NNRTI-based regimen, the differential resistance profile of ETR may allow this drug to be used to construct a rescue combination. ETR is not teratogenic and can therefore be safely used in pregnant or fertile women. Finally, ETR has an excellent drug-drug interaction profile, which may be useful in patients administered other medications. This interaction profile may be especially important in areas with a high prevalence of methadone treatment, as both drugs can be coadministered safely. ETR has received approval as advanced rescue therapy. However, the characteristics of this drug suggest that it may be useful in a series of potential indications, due to its antiviral potency, differential resistance profile, safety, tolerability and drug-drug interaction profile.
Collapse
Affiliation(s)
- Pere Domingo
- Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, España.
| |
Collapse
|
199
|
Palter DP, Corbera EF, Tiraboschi JM. [Etravirine in highly treatment-experienced patients]. Enferm Infecc Microbiol Clin 2010; 27 Suppl 2:6-11. [PMID: 20116622 DOI: 10.1016/s0213-005x(09)73213-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Etravirine (ETR) has demonstrated efficacy in patients with multiple prior treatments with prior virological failure and resistance mutations to various families of antiretroviral drugs. Most of the evidence concerning this drug has been drawn from the DUET studies, consisting of two multicenter, randomized, double-blind clinical trials with identical designs that included 1,200 patients. These trials showed that ETR obtained a superior virological and immunological response to placebo, reducing the incidence of hospital admissions and progression to AIDS/death. The most frequent adverse effect was rash, which was generally mild to moderate and required treatment discontinuation in only 2%. There were no differences in gastrointestinal, liver or lipid toxicities compared with the placebo arm. Because of the recent development of new drugs, effective regimens are now available for multi-treated patients. The TRIO study evaluated the efficacy and tolerability of one of the regimens most widely used today (ETR/raltegravir/darunavir/r) with excellent virological and immunological response (86% of viral load < 50 copies and CD4 +108 at 48 weeks) and excellent tolerance. ETR is effective and well tolerated and is the first non-nucleoside reverse transcriptase inhibitor (NNRTI) that allows the sequential use of drugs in this family, due to its high genetic barrier compared with firstgeneration NNRTI. Moreover, its long half-life allows once daily administration in patients requiring a QD regimen.
Collapse
|
200
|
Santos Gil IDL. [Etravirine in special populations]. Enferm Infecc Microbiol Clin 2010; 27 Suppl 2:40-5. [PMID: 20116627 DOI: 10.1016/s0213-005x(09)73218-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The choice of antiretroviral treatment in comorbidities requires thorough knowledge of the interactions, pharmacokinetics and adverse effects of the drug to be used. Most drugs carry some risk in certain processes associated or not with HIV infection and drugs that can be used in these situations are of great interest. The development of etravirine, a new non-nucleoside reverse transcriptase inhibitor, will allow its use in these processes, with a lower risk of secondary effects and therefore of worsening the course of the disease and of treatment withdrawal. This is the case of patients coinfected with active hepatitis B and/or C virus and patients with a history of psychiatric disorders or receiving psychotropic drugs. The possible use of etravirine in women of fertile age is also of interest, due to the lower risk of teratogenicity if pregnancy occurs during treatment. Other collectives, such as patients with renal insufficiency or children and adolescents should not be forgotten; although these populations are less well studied, data are beginning to become available.
Collapse
|