151
|
Hernandez AV, Pasupuleti V, Deshpande A, Thota P, Collins JA, Vidal JE. Deficient reporting and interpretation of non-inferiority randomized clinical trials in HIV patients: a systematic review. PLoS One 2013; 8:e63272. [PMID: 23658818 PMCID: PMC3643946 DOI: 10.1371/journal.pone.0063272] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 04/03/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Non-inferiority (NI) randomized clinical trials (RCTs) commonly evaluate efficacy of new antiretroviral (ARV) drugs in human immunodeficiency virus (HIV) patients. Their reporting and interpretation have not been systematically evaluated. We evaluated the reporting of NI RCTs in HIV patients according to the CONSORT statement and assessed the degree of misinterpretation of RCTs when NI was inconclusive or not established. DESIGN Systematic review. METHODS PubMed, Web of Science, and Scopus were reviewed until December 2011. Selection and extraction was performed independently by three reviewers. RESULTS Of the 42 RCTs (n = 21,919; range 41-3,316) selected, 23 were in ARV-naïve and 19 in ARV-experienced patients. Twenty-seven (64%) RCTs provided information about prior RCTs of the active comparator, and 37 (88%) used 2-sided CIs. Two thirds of trials used a NI margin between 10 and 12%, although only 12 explained the method to determine it. Blinding was used in 9 studies only. The main conclusion was based on both intention-to-treat (ITT) and per protocol (PP) analyses in 5 trials, on PP analysis only in 4 studies, and on ITT only in 31 studies. Eleven of 16 studies with NI inconclusive or not established highlighted NI or equivalence, and distracted readers with positive secondary results. CONCLUSIONS There is poor reporting and interpretation of NI RCTs performed in HIV patients. Maximizing the reporting of the method of NI margin determination, use of blinding and both ITT and PP analyses, and interpreting negative NI according to actual primary findings will improve the understanding of results and their translation into clinical practice.
Collapse
Affiliation(s)
- Adrian V. Hernandez
- Health Outcomes and Clinical Epidemiology Section, Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
- Postgraduate School, Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru
- * E-mail:
| | - Vinay Pasupuleti
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Abhishek Deshpande
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Priyaleela Thota
- Health Outcomes and Clinical Epidemiology Section, Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Jaime A. Collins
- HIV/AIDS Unit, Department of Internal Medicine, Guillermo Almenara General Hospital, EsSalud, Lima, Peru
| | - Jose E. Vidal
- Department of Infectious Diseases, Emilio Ribas Institute of Infectious Diseases, São Paulo, Brazil
| |
Collapse
|
152
|
Casado JL, de la Calle C, del Palacio M, Perez-Elías MJ, Moreno A, Moreno S. Short communication: lamivudine plus a boosted-protease inhibitor as simplification strategy in HIV-infected patients: proof of concept. AIDS Res Hum Retroviruses 2013; 29:588-91. [PMID: 23163811 DOI: 10.1089/aid.2012.0280] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There are scarce data about the use of a dual therapy with lamivudine plus a ritonavir-boosted protease inhibitor (PI/r) as simplification strategy. We performed a retrospective cohort study of 44 HIV-infected patients on suppressive triple therapy PI/r-based HAART, HBV negative, who discontinued one nucleoside analogue (NA) due to toxicity, and continued dual therapy with lamivudine plus the PI/r. The median time of HIV infection was 18.6 years, and CD4(+) count nadir was 150 cells/μl (6-470). They had received a mean of four regimens before (2-20), and 55% had a previous AIDS diagnosis. In eight cases, a previous resistance test showed two to seven secondary mutations in the protease gene, without resistance to the PI/r. The 184V mutation was not observed, but previous failure with a lamivudine-including regimen had been observed in four patients (9%). At baseline, patients had viral suppression (<50 copies/ml) for a median time of 794 days (235-2344), while receiving atazanavir/r in five cases, lopinavir/r in 14, and darunavir/r in 25. They discontinued mainly tenofovir (19, 43%) and didanosine (15, 34%). During 101.5 patient-years of follow-up, only two patients failed (5%), because of incomplete adherence. CD4(+) count increase at 48 weeks was 55 cells/μl. No new adverse events were observed, although total cholesterol and triglycerides increased significantly during the first 6 months after simplification. In conclusion, dual therapy with lamivudine plus a boosted PI was safe and effective as simplification strategy in patients with toxicity to NA. This combination could be an alternative to mono or triple therapy in hard-to-treat patients.
Collapse
Affiliation(s)
- José L. Casado
- Department of Infectious Diseases, Ramon y Cajal Hospital, Madrid, Spain
| | | | - María del Palacio
- Department of Infectious Diseases, Ramon y Cajal Hospital, Madrid, Spain
| | | | - Ana Moreno
- Department of Infectious Diseases, Ramon y Cajal Hospital, Madrid, Spain
| | - Santiago Moreno
- Department of Infectious Diseases, Ramon y Cajal Hospital, Madrid, Spain
| |
Collapse
|
153
|
|
154
|
Quashie PK, Mesplède T, Wainberg MA. HIV Drug Resistance and the Advent of Integrase Inhibitors. Curr Infect Dis Rep 2013. [PMID: 23180144 DOI: 10.1007/s11908-012-0305-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This review focuses on the topic of HIV integrase inhibitors that are potent antiretroviral drugs that efficiently decrease viral load in patients. However, emergence of resistance mutations against this new class of drugs represents a threat to their long-term efficacy. Here, we provide new information about the most recent mutations identified and other mutations that confer resistance to several integrase inhibitors, such as new resistance mutations-for example, G118R, R263K, and S153Y-that have been identified through in vitro selection studies with second-generation integrase strand transfer inhibitors (INSTIs). These add to the three main resistance pathways involving mutations at positions Y143, N155, and Q148. Deep sequencing, structural modeling, and biochemical analyses are methods that currently help in the understanding of the mechanisms of resistance conferred by these mutations. Although the new resistance mutations appear to confer only low levels of cross-resistance to second-generation drugs, the Q148 pathway with numerous secondary mutations has the potential to significantly decrease susceptibility to all drugs of the INSTI family of compounds.
Collapse
Affiliation(s)
- Peter K Quashie
- McGill University AIDS Centre, Lady Davis for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
| | | | | |
Collapse
|
155
|
Messiaen P, Wensing AMJ, Fun A, Nijhuis M, Brusselaers N, Vandekerckhove L. Clinical use of HIV integrase inhibitors: a systematic review and meta-analysis. PLoS One 2013; 8:e52562. [PMID: 23341902 PMCID: PMC3541389 DOI: 10.1371/journal.pone.0052562] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 11/19/2012] [Indexed: 01/05/2023] Open
Abstract
Background Optimal regimen choice of antiretroviral therapy is essential to achieve long-term clinical success. Integrase inhibitors have swiftly been adopted as part of current antiretroviral regimens. The purpose of this study was to review the evidence for integrase inhibitor use in clinical settings. Methods MEDLINE and Web-of-Science were screened from April 2006 until November 2012, as were hand-searched scientific meeting proceedings. Multiple reviewers independently screened 1323 citations in duplicate to identify randomized controlled trials, nonrandomized controlled trials and cohort studies on integrase inhibitor use in clinical practice. Independent, duplicate data extraction and quality assessment were conducted. Results 48 unique studies were included on the use of integrase inhibitors in antiretroviral therapy-naive patients and treatment-experienced patients with either virological failure or switching to integrase inhibitors while virologically suppressed. On the selected studies with comparable outcome measures and indication (n = 16), a meta-analysis was performed based on modified intention-to-treat (mITT), on-treatment (OT) and as-treated (AT) virological outcome data. In therapy-naive patients, favorable odds ratios (OR) for integrase inhibitor-based regimens were observed, (mITT OR 0.71, 95% CI 0.59–0.86). However, integrase inhibitors combined with protease inhibitors only did not result in a significant better virological outcome. Evidence further supported integrase inhibitor use following virological failure (mITT OR 0.27; 95% CI 0.11–0.66), but switching to integrase inhibitors from a high genetic barrier drug during successful treatment was not supported (mITT OR 1.43; 95% CI 0.89–2.31). Integrase inhibitor-based regimens result in similar immunological responses compared to other regimens. A low genetic barrier to drug-resistance development was observed for raltegravir and elvitegravir, but not for dolutegravir. Conclusion In first-line therapy, integrase inhibitors are superior to other regimens. Integrase inhibitor use after virological failure is supported as well by the meta-analysis. Careful use is however warranted when replacing a high genetic barrier drug in treatment-experienced patients switching successful treatment.
Collapse
Affiliation(s)
- Peter Messiaen
- General Internal Medicine and Infectious Diseases, Ghent University Hospital, Ghent, Belgium
| | - Annemarie M. J. Wensing
- Virology, Department of Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Axel Fun
- Virology, Department of Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Monique Nijhuis
- Virology, Department of Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nele Brusselaers
- General Internal Medicine and Infectious Diseases, Ghent University Hospital, Ghent, Belgium
| | - Linos Vandekerckhove
- General Internal Medicine and Infectious Diseases, Ghent University Hospital, Ghent, Belgium
- * E-mail:
| |
Collapse
|
156
|
Abstract
PURPOSE OF REVIEW We review the most recent clinical trials of integrase inhibitors (INIs) in antiretroviral therapy (ART)-experienced patients, including trails of new strategies such as intensification and simplification therapy with this new class of compounds. RECENT FINDINGS After the excellent results of the first-generation INIs [raltegravir (RAL) and elvitegravir] in the treatment of ART-experienced patients, dolutegravir--a new second-generation compound in this drug class--adds the possibility of rescuing ART-experienced patients after virologic failure to first-generation INIs like RAL. RAL may have a role in an intensification strategy--adding RAL to a suppressive ART therapy--that could have an effect in avoiding new cycles of infection and cellular activation. On the contrary, RAL has clearly shown efficacy in switching away from boosted protease inhibitors (PI/r). This simplification strategy may be an interesting option in patients suffering from side effects of boosted protease inhibitors. In simplification, the length of time of HIV suppression before the switch may be used as a marker of probable success. SUMMARY In ART-experienced patients INIs are a new and exciting part of the armamentarium for the control of HIV replication. INIs could play an interesting role in strategies such as intensification or simplification.
Collapse
|
157
|
Hull M, Klein M, Shafran S, Tseng A, Giguère P, Côté P, Poliquin M, Cooper C. CIHR Canadian HIV Trials Network Coinfection and Concurrent Diseases Core: Canadian guidelines for management and treatment of HIV/hepatitis C coinfection in adults. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2013; 24:217-38. [PMID: 24489565 PMCID: PMC3905006 DOI: 10.1155/2013/781410] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hepatitis C virus (HCV) coinfection occurs in 20% to 30% of Canadians living with HIV, and is responsible for a heavy burden of morbidity and mortality. HIV-HCV management is more complex due to the accelerated progression of liver disease, the timing and nature of antiretroviral and HCV therapy, mental health and addictions management, socioeconomic obstacles and drug-drug interactions between new HCV direct-acting antiviral therapies and antiretroviral regimens. OBJECTIVE To develop national standards for the management of HCV-HIV coinfected adults in the Canadian context. METHODS A panel with specific clinical expertise in HIV-HCV co-infection was convened by The CIHR HIV Trials Network to review current literature, existing guidelines and protocols. Following broad solicitation for input, consensus recommendations were approved by the working group, and were characterized using a Class (benefit verses harm) and Level (strength of certainty) quality-of-evidence scale. RESULTS All HIV-HCV coinfected individuals should be assessed for HCV therapy. Individuals unable to initiate HCV therapy should initiate antiretroviral therapy to slow liver disease progression. Standard of care for genotype 1 is pegylated interferon and weight-based ribavirin dosing plus an HCV protease inhibitor; traditional dual therapy for 24 weeks (for genotype 2/3 with virological clearance at week 4); or 48 weeks (for genotypes 2-6). Therapy deferral for individuals with mild liver disease may be considered. HIV should not be considered a barrier to liver transplantation in coinfected patients. DISCUSSION Recommendations may not supersede individual clinical judgement.
Collapse
Affiliation(s)
- Mark Hull
- University of British Columbia, British Columbia Centre for Excellent in HIV/AIDS, Vancouver, British Columbia
| | | | | | | | | | - Pierre Côté
- Clinique médicale du Quartier Latin, Montréal, Quebec
| | - Marc Poliquin
- Clinique médicale du Quartier Latin, Montréal, Quebec
| | | |
Collapse
|
158
|
Wainberg MA. The Need for Development of New HIV-1 Reverse Transcriptase and Integrase Inhibitors in the Aftermath of Antiviral Drug Resistance. SCIENTIFICA 2012; 2012:238278. [PMID: 24278679 PMCID: PMC3820659 DOI: 10.6064/2012/238278] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 11/01/2012] [Indexed: 05/20/2023]
Abstract
The use of highly active antiretroviral therapy (HAART) involves combinations of drugs to achieve maximal virological response and reduce the potential for the emergence of antiviral resistance. There are two broad classes of reverse transcriptase inhibitors, the nucleoside reverse transcriptase inhibitors (NRTIs) and nonnucleoside reverse transcriptase inhibitors (NNRTIs). Since the first classes of such compounds were developed, viral resistance against them has necessitated the continuous development of novel compounds within each class. This paper considers the NRTIs and NNRTIs currently in both preclinical and clinical development or approved for second line therapy and describes the patterns of resistance associated with their use, as well as the underlying mechanisms that have been described. Due to reasons of both affordability and availability, some reverse transcriptase inhibitors with low genetic barrier are more commonly used in resource-limited settings. Their use results to the emergence of specific patterns of antiviral resistance and so may require specific actions to preserve therapeutic options for patients in such settings. More recently, the advent of integrase strand transfer inhibitors represents another major step forward toward control of HIV infection, but these compounds are also susceptible to problems of HIV drug resistance.
Collapse
Affiliation(s)
- Mark A. Wainberg
- Lady Davis Institute, McGill University AIDS Centre, Jewish General Hospital, Montreal, QC, Canada H3T 1E2
| |
Collapse
|
159
|
Lichterfeld M, Zachary KC. Treating HIV-1 Infection: What Might the Future Hold? Ther Adv Chronic Dis 2012; 2:293-305. [PMID: 23251756 DOI: 10.1177/2040622311411601] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Advances in antiretroviral combination therapy lasting the past two decades have transformed HIV-1 infection from a fatal disease into a chronic medical condition that in many cases does not compromise life quality. There are 25 different antiretroviral agents available currently, allowing for patient-centered, individualized management of HIV-1 infection, and ongoing progress in HIV-1 virology and antiretroviral pharmacology is likely to expand treatment options further in the future. Nevertheless, antiretroviral therapy continues to have limitations, including insufficient immunological reconstitution, selection of drug resistance, ongoing abnormal immune activation despite effective suppression of HIV-1 viremia, and the inability to target latently infected cells that are responsible for long-term viral persistence. Owing to these shortcomings, the theoretical ability of antiretroviral therapy to extend life expectancy to normal levels is not realized in many cases. Strategies to address these limitations are a matter of active ongoing research and will be summarized in this article.
Collapse
Affiliation(s)
- Mathias Lichterfeld
- Infectious Disease Division, Massachusetts General Hospital, 55 Fruit Street, Cox 5, Boston, MA 02114, USA
| | | |
Collapse
|
160
|
Overton ET, Arathoon E, Baraldi E, Tomaka F. Effect of darunavir on lipid profile in HIV-infected patients. HIV CLINICAL TRIALS 2012; 13:256-70. [PMID: 23134626 DOI: 10.1310/hct1305-256] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Highly active antiretroviral therapy regimens, consisting of a ritonavir-boosted protease inhibitor (PI) and 2 nucleoside reverse transcriptase inhibitors, are established first-line regimens for HIV-infected patients. However, a common adverse effect in patients receiving PIs is dyslipidemia, characterized by increases in plasma levels of triglycerides, low-density lipoprotein cholesterol, and total cholesterol (TC). These lipid changes, as well as other well-described risk factors, may predispose patients to the development of cardiovascular disease, an important comorbidity, especially as the lifespan of HIV-infected patients has increased dramatically in recent years. Among PIs, ritonavir-boosted atazanavir (ATV/r) and, more recently, ritonavir-boosted darunavir (DRV/r) have demonstrated potent antiviral efficacy with more favorable lipid profiles than other PIs. This review provides an overview of the lipid effects of DRV/r. Studies with DRV/r in healthy volunteers and in both treatment-naïve and -experienced patients have demonstrated that changes in tri-glycerides and TC are comparable to those seen with ATV/r.
Collapse
|
161
|
Klein MB, Rollet KC, Hull M, Cooper C, Walmsley S, Conway B, Pick N. Who needs direct-acting antivirals for HCV? Challenges faced in advancing HCV therapy for HIV-HCV-coinfected individuals. Antivir Ther 2012; 18:717-21. [PMID: 23211632 DOI: 10.3851/imp2484] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2012] [Indexed: 01/20/2023]
Abstract
BACKGROUND The recent availability of new direct-acting antivirals (DAAs) for HCV treatment, which significantly increase sustained virological response rates for genotype 1 HCV infection, has brought new optimism with respect to curative HCV treatment for HIV-HCV-coinfected patients. We describe the characteristics of coinfected patients who could be eligible for DAAs to determine potential challenges facing clinicians and patients hoping to take advantage of these new therapies. METHODS We evaluated the sociodemographic and clinical characteristics of the genotype 1 HCV-HIV-infected participants in a Canadian prospective multicentre cohort study at their most recent visit to assess potential eligibility for combination HCV treatment with boceprevir or telaprevir. RESULTS Of the 1,020 coinfected participants enrolled in the cohort, 707 (85%) had evidence of chronic HCV infection (HCV-RNA-positive), of whom 497 (70%) were infected with genotype 1; 375 (75%) were naive to HCV treatment and 122 (25%) had previously received therapy and failed. Only 143 (38%) of HCV treatment-naive and 39 (32%) of treatment-experienced participants had no absolute contraindications for treatment. Alcohol abuse, active depression and decompensated liver disease were the most frequent reasons for treatment ineligibility. The majority would require alterations in antiretroviral regimens to avoid important drug-drug interactions. CONCLUSIONS Although the need for curative HCV therapy in HIV-HCV coinfection is great, the actual number of patients who could be eligible for DAAs at the present time may be quite low. There remains an urgent need to develop safe, simple and interferon-sparing treatments for coinfected individuals.
Collapse
Affiliation(s)
- Marina B Klein
- Department of Medicine, Division of Infectious Diseases/Chronic Viral Illness Service, McGill University Health Centre, Montreal, Canada.
| | | | | | | | | | | | | | | |
Collapse
|
162
|
Changes in cardiovascular biomarkers in HIV-infected patients switching from ritonavir-boosted protease inhibitors to raltegravir. AIDS 2012; 26:2315-26. [PMID: 23018438 DOI: 10.1097/qad.0b013e328359f29c] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND : Switching from boosted protease inhibitors (PI/r) to raltegravir (RAL) results in a better plasma lipid profile than continuing PI/r. Whether this strategy affects plasma biomarkers associated with atherosclerosis is unknown. METHODS : We assessed 48-week changes in fasting lipids and several biomarkers including serum high-sensitivity C-reactive protein (hsCRP), monocyte chemoattractant protein 1 (MCP-1), osteoprotegerin, interleukin (IL) 6, IL-10, tumor necrosis factor alpha (TNF-α), intercellular adhesion molecule 1 (ICAM-1), vascular cell adhesion molecule 1 (VCAM-1), E-selectin and P-selectin, adiponectin, insulin, and D-dimer in otherwise healthy, virologically suppressed HIV-infected patients treated with PI/r who randomly switched from PI/r to RAL or continued with PI/r in the SPIRAL trial. Biomarkers and lipids at baseline and 48-week changes between both study arms were compared. Correlations between changes in biomarkers and changes in lipids were also evaluated. RESULTS : Of 273 patients initiating study drugs in the SPIRAL trial, 233 (119 RAL, 114 PI/r) remained on allocated therapy for 48 weeks and had sera available for the purpose of this substudy. Triglycerides (-28%, P < 0.0001), total (-14%, P < 0.0001), low-density lipoprotein (-9%, P = 0.0069), and high-density lipoprotein (-10%, P = 0.0017) cholesterol decreased in RAL relative to the PI/r group. Among biomarkers, hsCRP (-40%, P < 0.0001), MCP-1 (-20%, P = 0.0003), osteoprotegerin (-13%, P = 0.0024), IL-6 (-46%,P < 0.0001), TNF-α (-27%, P = 0.0011), insulin (-26%, P < 0.0001), and D-dimer (-8%, P = 0.0187) decreased in RAL relative to PI/r group, whereas IL-10 (+1%, P = 0.7773), ICAM-1 (-6%, P = 0.1255), VCAM-1(0%, P = 0.8671), E-selectin (-9%, P = 0.2174), P-selectin (-6%, P = 0.3865), and adiponectin (+8%, P = 0.2028) remained unchanged. Biomarkers and lipids changes at 48 weeks were weakly correlated. CONCLUSION : Switching from PI/r to RAL induced significant changes in several cardiovascular biomarkers that were not completely explained by lipid changes.
Collapse
|
163
|
Grant PM, Zolopa AR. When to start ART in the setting of acute AIDS-related opportunistic infections: the time is now! Curr HIV/AIDS Rep 2012; 9:251-8. [PMID: 22733609 DOI: 10.1007/s11904-012-0126-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Despite the substantial benefits of combination antiretroviral therapy (ART), a significant proportion of HIV-infected individuals still present with advanced disease and active AIDS-related opportunistic infections (OIs). The weight of evidence from recent studies supports the early initiation of ART (ie, within 2 weeks of initiating treatment for the acute OIs). Initiating ART early in acutely ill patients can reduce AIDS-related progression and death. Early ART has not been associated with increased rates of immune reconstitution inflammatory syndrome in prospective studies of non-tuberculosis OIs, although this concern is frequently cited as a reason to delay ART. Nor has early ART been associated with increased adverse outcomes. Nonetheless, initiating ART early in acute care settings can be challenging to implement and requires a well-coordinated multidisciplinary team with expertise in ART management.
Collapse
|
164
|
Cost-Effectiveness of Antiretroviral Therapy for Multidrug-Resistant HIV: Past, Present, and Future. AIDS Res Treat 2012; 2012:595762. [PMID: 23193464 PMCID: PMC3502757 DOI: 10.1155/2012/595762] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 10/01/2012] [Accepted: 10/02/2012] [Indexed: 11/18/2022] Open
Abstract
In the early years of the highly active antiretroviral therapy (HAART) era, HIV with resistance to two or more agents in different antiretroviral classes posed a significant clinical challenge. Multidrug-resistant (MDR) HIV was an important cause of treatment failure, morbidity, and mortality. Treatment options at the time were limited; multiple drug regimens with or without enfuvirtide were used with some success but proved to be difficult to sustain for reasons of tolerability, toxicity, and cost. Starting in 2006, data began to emerge supporting the use of new drugs from the original antiretroviral classes (tipranavir, darunavir, and etravirine) and drugs from new classes (raltegravir and maraviroc) for the treatment of MDR HIV. Their availability has enabled patients with MDR HIV to achieve full and durable viral suppression with more compact and cost-effective regimens including at least two and often three fully active agents. The emergence of drug-resistant HIV is expected to continue to become less frequent in the future, driven by improvements in the convenience, tolerability, efficacy, and durability of first-line HAART regimens. To continue this trend, the optimal rollout of HAART in both rich and resource-limited settings will require careful planning and strategic use of antiretroviral drugs and monitoring technologies.
Collapse
|
165
|
DiNubile MJ, Sklar P, Lupinacci RJ, Eron Jr JJ. Paradoxical interpretations of noninferiority studies: violating the excluded middle. Future Virol 2012. [DOI: 10.2217/fvl.12.101] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background: The noninferiority of a novel therapy compared with a standard of care is customarily defined by a noninferiority margin derived from an assessment of what would constitute a clinically relevant decrement in efficacy while preserving some of the treatment effect over placebo. Conundrum: If the one-sided 97.5% CI around the difference in the point estimates of efficacy between the two treatments (investigational drug minus comparator drug) does not extend below the prespecified threshold, noninferiority of the new agent to the comparator is typically concluded. In some cases, the corresponding two-sided 95% CI will fall entirely between zero and the noninferiority delta, technically implying inferiority and noninferiority concurrently. Solution: Stipulating that the upper bound of the two-sided confidence interval reach or exceed zero (as well as fall entirely above the noninferiority limit) to establish statistical noninferiority versus the comparator would avoid paradoxical interpretations.
Collapse
Affiliation(s)
- Mark J DiNubile
- Global Scientific & Medical Publications, Merck Sharp & Dohme, UG3C-06, 351 North Sumneytown Pike, North Wales, PA 19454-2502, USA
| | - Peter Sklar
- Merck Research Laboratories, West Point, PA, USA
| | | | | |
Collapse
|
166
|
Masiá M, Martínez E, Padilla S, Gatell JM, Gutiérrez F. Endothelial function in HIV-infected patients switching from a boosted protease inhibitor-based regimen to raltegravir: a substudy of the SPIRAL study. J Antimicrob Chemother 2012; 68:409-13. [PMID: 23075691 DOI: 10.1093/jac/dks412] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Raltegravir has been demonstrated to have a favourable impact on several metabolic parameters, including a lack of changes in lipid and glucose concentrations. We aimed to assess the effect on endothelial function of switching from a ritonavir-boosted protease inhibitor (PI/r)-based regimen to raltegravir. METHODS This is a substudy of the SPIRAL study, a multicentre, randomized, open-label clinical trial including HIV-infected patients on a stable PI/r-based antiretroviral regimen and virologically suppressed for at least the previous 6 months. Endothelial function was prospectively evaluated through flow-mediated dilatation (FMD) of the brachial artery at baseline and at weeks 24 and 48. RESULTS Thirty-five HIV-infected patients were included. Sixteen patients were randomly assigned to continue their current PI/r regimen and 19 to switch the PI/r to raltegravir. Total cholesterol, low-density lipoprotein cholesterol and triglycerides decreased at weeks 16 and 32 in the raltegravir-switch arm, while no changes were observed in the PI/r arm. Triglyceride levels were significantly lower in the raltegravir arm than in the PI/r arm at weeks 16, 32 and 48. No significant changes from baseline occurred in FMD at weeks 24 and 48 within or between the raltegravir and PI/r arms. Adjustment for baseline artery diameter did not have a significant effect on the FMD differences. CONCLUSIONS Switching from a PI/r-based antiretroviral regimen to raltegravir in patients with virological suppression has a beneficial impact on the lipid profile, but it does not seem to have a clear impact on endothelial function after a 1 year follow-up.
Collapse
Affiliation(s)
- Mar Masiá
- Infectious Diseases Unit, Hospital General Universitario de Elche, University Miguel Hernández, Alicante, Spain.
| | | | | | | | | |
Collapse
|
167
|
Wellek S, Blettner M. Establishing equivalence or non-inferiority in clinical trials: part 20 of a series on evaluation of scientific publications. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:674-9. [PMID: 23264808 DOI: 10.3238/arztebl.2012.0674] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 07/04/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND An increasing number of clinical trials are being performed to show the absence of relevant differences between the effects of two treatments. The primary care physician makes use of the results of so-called equivalence studies, at least indirectly, practically every day. Equally important are active control clinical trials in which the efficacy of a new treatment has to be proven through demonstrating non-inferiority as compared to a standard treatment. METHODS Explanation of basic principles and statistical techniques with reference to the original literature; selective searches in the medical literature. RESULTS First of all, a suitable distributional parameter must be chosen that can be considered a reasonable measure of dissimilarity of the population effects of the treatments under comparison. The simplest approach to the statistical demonstration of equivalence or non-inferiority is to calculate confidence intervals for that parameter. To keep the required number of subjects for equivalence and non-inferiority studies as low as possible, statistical tests should be used which are optimized with respect to power. CONCLUSION Data from equivalence and non-inferiority studies need to be assessed for statistical significance no less than data that are generated to show that two treatments have different effects. A negative result in a traditional two-sided test does not suffice for statistically proving equivalence.
Collapse
Affiliation(s)
- Stefan Wellek
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University Mainz
| | | |
Collapse
|
168
|
Stephan C. Virological efficacy and safety of antiretroviral therapy-switch to atazanavir-based regimen: a review of the literature. Expert Opin Pharmacother 2012; 13:2355-67. [DOI: 10.1517/14656566.2012.734296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
169
|
Focà E, Ripamonti D, Motta D, Torti C. Unboosted atazanavir for treatment of HIV infection: rationale and recommendations for use. Drugs 2012; 72:1161-73. [PMID: 22646049 DOI: 10.2165/11631070-000000000-00000] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Atazanavir (Reyataz®) is a protease inhibitor (PI) for the treatment of HIV infection. Several trials have demonstrated the good efficacy and toxicity profile of atazanavir boosted by ritonavir (atazanavir/r). However, several toxicity events and pharmacokinetic issues due to drug-to-drug interactions (partly related to ritonavir) may complicate atazanavir/r therapy. This is why regimens with unboosted atazanavir have been experimented with and are used in clinical practice. The aim of this article is to identify the clinical settings in which unboosted atazanavir may be a safe and effective option for the long-term control of HIV replication. Despite the fact that a favourable lipid profile and good gastrointestinal tolerability have been reported in comparative trials, unboosted atazanavir should not be considered an optimal choice for treatment-naive patients. In fact, boosting with ritonavir produces higher atazanavir plasma levels, which are beneficial in terms of efficacy, especially in untreated patients with high plasma HIV RNA. Clinical data indicate that, in patients with sustained undetectable HIV RNA and without previous virological failure or HIV drug resistance-associated mutations, a switch to unboosted atazanavir-based regimens is a feasible option to control and prevent toxicity events, especially in patients who cannot tolerate ritonavir and in those with severe hyperbilirubinaemia on atazanavir/r. Moreover, while unboosted atazanavir must not be used in pregnant women, it is a recommended option in special populations, such as patients with moderate liver insufficiency. Lastly, unboosted atazanavir in combination with raltegravir may allow the construction of a well tolerated and effective regimen without nucleoside reverse transcriptase inhibitors in patients for whom these drugs are contraindicated. In conclusion, there is a good rationale, significant clinical interest and accumulating clinical experience with unboosted atazanavir-based regimens, although this formulation should be used only in specific situations and as a maintenance strategy. Moreover, therapeutic drug monitoring could be useful in specific circumstances (such as in patients with liver impairment or in case of potential drug-drug interactions).
Collapse
Affiliation(s)
- Emanuele Focà
- Department for Infectious and Tropical Diseases, University of Brescia, Brescia, Italy
| | | | | | | |
Collapse
|
170
|
Ofotokun I, Sheth AN, Sanford SE, Easley KA, Shenvi N, White K, Eaton ME, Del Rio C, Lennox JL. A switch in therapy to a reverse transcriptase inhibitor sparing combination of lopinavir/ritonavir and raltegravir in virologically suppressed HIV-infected patients: a pilot randomized trial to assess efficacy and safety profile: the KITE study. AIDS Res Hum Retroviruses 2012; 28:1196-206. [PMID: 22364141 DOI: 10.1089/aid.2011.0336] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A nucleoside reverse transcriptase inhibitor (NRTI) backbone is a recommended component of standard highly active antiretroviral therapy (sHAART). However, long-term NRTI exposure can be limited by toxicities. NRTI class-sparing alternatives are warranted in select patient populations. This is a 48-week single-center, open-label pilot study in which 60 HIV-infected adults with plasma HIV-1 RNA (<50 copies/ml) on sHAART were randomized (2:1) to lopinavir/ritonavir (LPV/r) 400/100 mg BID+raltegravir (RAL) 400 mg BID switch (LPV-r/RAL arm) or to continue on sHAART. The primary endpoint was the proportion of subjects with HIV-RNA<50 copies/ml at week 48. Secondary efficacy and immunologic and safety endpoints were evaluated. Demographics and baseline lipid profile were similar across arms. Mean entry CD4 T cell count was 493 cells/mm(3). At week 48, 92% [95% confidence interval (CI): 83-100%] of the LPV-r/RAL arm and 88% (95% CI: 75-100%) of the sHAART arm had HIV-RNA<50 copies/ml (p=0.70). Lipid profile (mean ± SEM, mg/dl, LPV-r/RAL vs. sHAART) at week 24 was total-cholesterol 194 ± 5 vs. 176 ± 9 (p=0.07), triglycerides 234 ± 30 vs. 133 ± 27 (p=0.003), and LDL-cholesterol 121 ± 6 vs. 110 ± 8 (p=0.27). There were no serious adverse events (AEs) in either arm. Regimen change occurred in three LPV-r/RAL subjects (n=1, due to LPV-r/RAL-related AEs) vs. 0 in sHAART. There were no differences between arms in bone mineral density, total body fat composition, creatinine clearance, or CD4 T cell counts at week 48. In virologically suppressed patients on HAART, switching therapy to the NRTI-sparing LPV-r/RAL combination produced similar sustained virologic suppression and immunologic profile as sHAART. AEs were comparable between arms, but the LPV-r/RAL arm experienced higher triglyceridemia.
Collapse
Affiliation(s)
- Ighovwerha Ofotokun
- Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, Atlanta, Georgia
- Emory University Center for AIDS Research, Atlanta, Georgia
| | - Anandi N. Sheth
- Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, Atlanta, Georgia
| | - Sara E. Sanford
- Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, Atlanta, Georgia
| | - Kirk A. Easley
- Emory University Center for AIDS Research, Atlanta, Georgia
- Emory University School of Public Health, Biostatistics and Bioinformatics, Atlanta, Georgia
| | - Neeta Shenvi
- Emory University School of Public Health, Biostatistics and Bioinformatics, Atlanta, Georgia
| | | | - Molly E. Eaton
- Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, Atlanta, Georgia
- Emory University Center for AIDS Research, Atlanta, Georgia
| | - Carlos Del Rio
- Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, Atlanta, Georgia
- Emory University Center for AIDS Research, Atlanta, Georgia
- Emory University School of Public Health, Global Health, Atlanta, Georgia
| | - Jeffrey L. Lennox
- Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, Atlanta, Georgia
- Emory University Center for AIDS Research, Atlanta, Georgia
| |
Collapse
|
171
|
The future of integrase inhibitors of HIV-1. Curr Opin Virol 2012; 2:580-7. [PMID: 22980926 DOI: 10.1016/j.coviro.2012.08.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 08/20/2012] [Accepted: 08/21/2012] [Indexed: 11/21/2022]
Abstract
Integration of the HIV-1 DNA is required and essential to maintain the viral DNA in the infected cell. Integration process occurs in several events, mainly endonucleolytic processing of the 3' ends of the viral DNA and strand transfer or joining of the viral and cellular DNA. The design and discovery of integrase inhibitors were first focused at targeting the catalytic site of IN with a specific effect on strand transfer. Several integrase inhibitors were developed clinically, two first generation inhibitors, raltegravir and elvitegravir and then two second-generation inhibitors, dolutegravir and MK-2058. Recently, allosteric integrase inhibitors intended to interfere with the integrase-LEDGF/p75 interaction have been designed. These new inhibitors called LEDGINs have an effect on 3' processing and strand transfer. Thus, integrase inhibitors present a real added value in combined treatment for naive and experienced HIV infected patients. Combination experiments of LEDGINs and raltegravir suggest that these inhibitors could act additively despite sharing the same viral target. Future therapy could involve combinations of inhibitors of IN function acting though different binding pockets within IN. The place of this class on HIV inhibitors and their future role in perspective of novel therapies to eliminate latent HIV reservoirs and infection for cure should also be explored.
Collapse
|
172
|
Comparison of the in vivo pharmacokinetics and in vitro dissolution of raltegravir in HIV patients receiving the drug by swallowing or by chewing. Antimicrob Agents Chemother 2012; 56:6132-6. [PMID: 22964253 DOI: 10.1128/aac.00942-12] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The pharmacokinetics of raltegravir (RAL) in HIV patients is characterized by high interpatient/intrapatient variability. We investigated the potential contribution of the drug pharmaceutical formulation to RAL pharmacokinetics. We first compared in vivo the pharmacokinetics of RAL for 67 patients to whom the drug was administered by swallowing the intact tablet with those obtained from 13 HIV-infected patients who chewed the RAL tablet due to swallowing difficulties. Subsequently, we evaluated in vitro the dissolution of RAL tablets under different conditions. In the in vivo study, we found that patients given RAL by chewing the tablets presented pharmacokinetic profiles characterized by significantly higher RAL absorption than did patients receiving the drug by swallowing. The in vitro studies showed that when the whole tablets were exposed to an acidic medium, the release of RAL was very low, whereas when the tablets were crushed, the profiles presented significantly higher concentrations of RAL. Crushed tablets tested in water or in a pH 6.8 buffer exhibited prompt and complete dissolution of RAL. HIV-infected patients receiving RAL by chewing the tablet showed higher drug absorption and reduced pharmacokinetic variability compared with patients swallowing the intact tablet. This is related to problems in tablet disintegration and to erratic drug absorption. The amelioration of the RAL pharmaceutical formulation could improve drug pharmacokinetics.
Collapse
|
173
|
Saumoy M, Sánchez-Quesada JL, Martínez E, Llibre JM, Ribera E, Knobel H, Gatell JM, Clotet B, Curran A, Curto J, Masó M, Ordoñez-Llanos J, Podzamczer D. LDL subclasses and lipoprotein-phospholipase A2 activity in suppressed HIV-infected patients switching to raltegravir: Spiral substudy. Atherosclerosis 2012; 225:200-7. [PMID: 23017355 DOI: 10.1016/j.atherosclerosis.2012.08.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 08/02/2012] [Accepted: 08/09/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To analyze the effect of switching the ritonavir-boosted protease inhibitor (PI/r) in a stable combined antiretroviral therapy (cART) regimen to raltegravir on low-density lipoprotein (LDL) particles, and lipoprotein-associated phospholipase A2 (Lp-PLA2). DESIGN Substudy of a multicenter randomized trial that compared the efficacy of switching a PI/r to raltegravir-based cART in stable HIV-infected patients. METHODS LDL size and phenotype (by gel-gradient electrophoresis), Lp-PLA2 (by 2-thio-PAF [Cayman]), proprotein convertase subtilisin/kexin type 9 (PCSK9) (by ELISA), and standard lipid parameters were measured at baseline and week 48. RESULTS Eighty-one (PI/r n = 41 and raltegravir n = 40) patients were evaluated. No differences in baseline demographic and metabolic variables between arms were found except in apolipoprotein (Apo) B (p = 0.042). At week 48, total cholesterol (TC) (p < 0.001), LDL-c (p = 0.023), non-high density lipoprotein cholesterol non-high-density lipoprotein cholesterol (non-HDL-c) (p < 0.001), TC/HDL (p = 0.026), triglyceride (p < 0.001), Apo B (p < 0.001), Apo A-I (p = 0.004) and Lp (a) (p = 0.005) decreased in raltegravir arm compared to PI/r arm. At week 48, a shift from LDL phenotype B to the less atherogenic phenotype A was observed only in raltegravir arm (p < 0.001). LDL size increased (PI/r 2.1 nm, p = 0.019; raltegravir 3.8 nm, p = 0.001) and cholesterol content in small and dense LDL subfractions (LDL 4,5,6) decreased (PI/r p = 0.007, raltegravir p = 0.006) at week 48 in both arms. Total Lp-PLA2 activity (PI/r p = 0.037 and raltegravir p = 0.051) and PCSK9 plasma concentration decreased in both arms (PI/r p = 0.034 and raltegravir p < 0.001). CONCLUSIONS Switching a PI/r to a raltegravir-based cART in virologically suppressed HIV-infected patients was associated with an overall improvement in lipid profile, including a shift to a less atherogenic LDL phenotype.
Collapse
Affiliation(s)
- Maria Saumoy
- HIV Unit, Infectious Disease Service, Bellvitge University Hospital, Bellvitge Biomedical Research Institute, C/ Feixa Llarga s/n., Hospitalet de Llobregat, 08907 Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
174
|
Calin R, Paris L, Simon A, Peytavin G, Wirden M, Schneider L, Valantin MA, Tubiana R, Agher R, Katlama C. Dual raltegravir/etravirine combination in virologically suppressed HIV-1-infected patients on antiretroviral therapy. Antivir Ther 2012; 17:1601-4. [PMID: 22941896 DOI: 10.3851/imp2344] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The combination of raltegravir (RAL) and etravirine (ETR) represents a novel antiretroviral treatment option in patients with toxicity or long-term exposure to standard therapies including protease inhibitors (PI) and nucleoside reverse transcriptase inhibitors (NRTI). The objective of this study was to evaluate the capacity of dual RAL/ETR therapy to maintain virological suppression in HIV-1 patients under effective antiretroviral therapy (ART). METHODS Using the Nadis database we retrospectively identified all patients in our centre who were switched from different ART regimens to ETR 200 mg twice daily plus RAL 400 mg twice daily prior to February 2010, having a suppressed HIV-1 plasma viral load (pVL<200 copies/ml) at the moment of switch. Patients already on RAL or ETR at baseline were not excluded from the study. Treatment failure was defined as two consecutive pVL>50 copies/ml or discontinuation of RAL/ETR for any reason. RESULTS A total of 18 patients were included. Median baseline characteristics were: age 48 years (IQR 45-56), duration of ART 14 years (IQR 13-16), duration of viral suppression 6 years (IQR 5-9), duration of NRTI exposure 11 years (IQR 8-14) and PI exposure 6 years (IQR 3-9). In intent-to-treat analysis, the efficacy at 6 months of follow-up was 94.4% (n=17/18, 95% CI 74.2, 99%) and 83.3% (n=15/18, 95% CI 60.7, 94.1%) at 12 months. In per-protocol analysis, the efficacy at 12 months was 100% (n=15/15, 95% CI 80.6, 100%). No tolerability-related treatment discontinuation was recorded. CONCLUSIONS This study, although on a limited number of patients, suggests that raltegravir plus etravirine represents a potential option of NRTI/PI-sparing strategy, deserving further investigation in randomized studies.
Collapse
Affiliation(s)
- Ruxandra Calin
- Infectious Diseases Department, Hôpital Pitié-Salpêtrière, Paris, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
175
|
Lake JE, McComsey GA, Hulgan TM, Wanke CA, Mangili A, Walmsley SL, Boger MS, Turner RR, McCreath HE, Currier JS. A randomized trial of Raltegravir replacement for protease inhibitor or non-nucleoside reverse transcriptase inhibitor in HIV-infected women with lipohypertrophy. AIDS Patient Care STDS 2012; 26:532-40. [PMID: 22823027 DOI: 10.1089/apc.2012.0135] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Lipohypertrophy in HIV-infected patients is associated with metabolic abnormalities. Raltegravir (RAL) is not known to induce fat changes or severe metabolic perturbations. HIV-infected women with central adiposity and HIV-1 RNA less than 50 copies per milliliter on non-nucleoside reverse transcriptase inhibitor (NNRTI)- or protease inhibitor (PI)-based antiretroviral therapy (ART) continued their nucleoside reverse transcriptase inhibitor (NRTI) backbone and were randomized to switch to open label RAL immediately or after 24 weeks. The primary end point was 24-week between-group change in computed tomography (CT)-quantified visceral adipose tissue (AT) volume. Fasting lipids, glucose, C-reactive protein (CRP), anthropometric measurements, and patient-reported quality of life assessments were also measured. Thirty-six subjects provided 80% power to detect a 10% between-group difference in visceral AT over 24 weeks. Thirty-seven of 39 enrolled subjects completed week 24. At entry, subjects were 75% black or Hispanic, and on 62% PI-based and 38% NNRTI-based regimens. The median age was 43 years, CD4 count 558 cells per microliter, and body mass index (BMI) 32 kg/m(2). After 24 weeks, no statistically significant changes in visceral or subcutaneous AT, anthropometrics, BMI, glucose, or CRP were observed. In subjects receiving RAL, significant improvements in total and LDL cholesterol (p=0.04), self-reported belly size (p=0.02) and composite body size (p=0.02) were observed. Body size changes correlated well with percent visceral AT change. No RAL-related adverse events occurred. Compared to continued PI or NNRTI, switch to RAL was associated with statistically significant 24-week improvements in total and LDL cholesterol but not AT volumes. Additional insights into AT and metabolic changes in women on RAL will be provided by 48-week follow-up of the immediate-switch arm.
Collapse
Affiliation(s)
- Jordan E. Lake
- Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Grace A. McComsey
- Department of Pediatrics and Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Todd M. Hulgan
- Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | | | | | | | - M. Sean Boger
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | | | - Heather E. McCreath
- Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Judith S. Currier
- Department of Medicine, University of California, Los Angeles, Los Angeles, California
| |
Collapse
|
176
|
6.0 Supporting patients on therapy. HIV Med 2012. [DOI: 10.1111/j.1468-1293.2012.01029_7.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
177
|
Schrijvers R, Debyser Z. Combinational therapies for HIV: a focus on EVG/COBI/FTC/TDF. Expert Opin Pharmacother 2012; 13:1969-83. [DOI: 10.1517/14656566.2012.712514] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
178
|
7.0 Managing virological failure. HIV Med 2012. [DOI: 10.1111/j.1468-1293.2012.01029_8.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
179
|
Abstract
Using the SWITCHMRK and MONET trials as examples, Andrew Carr and colleagues question the ethics and motives of switch or simplification trials of anti-retroviral therapy.
Collapse
Affiliation(s)
- Andrew Carr
- Clinical Research Program, Centre for Applied Medical Research, St Vincent's Hospital, Sydney, Australia.
| | | | | |
Collapse
|
180
|
Update on raltegravir and the development of new integrase strand transfer inhibitors. South Med J 2012; 105:370-8. [PMID: 22766666 DOI: 10.1097/smj.0b013e318258c847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Raltegravir (RAL) is the first antiretroviral in the integrase strand transfer inhibitors (INSTI) class. The use of RAL has expanded since its approval in October 2007 for multidrug-resistant human immunodeficiency virus type 1 infection in adults. RAL is now a guideline-preferred treatment option for antiretroviral-naïve patients, indicated for treatment in adolescents, and is being studied as an integral part of nucleoside sparing regimens. The development of resistance and the need for a once-daily dosing option has led to the development of new INSTIs, including elvitegravir and dolutegravir. Elvitegravir is being studied in a promising once-daily single-tablet regimen with tenofovir, emtricitabine, and the investigational pharmacoenhancer cobicistat. The development of cobicistat and the new once-daily INSTIs may revolutionize the treatment of human immunodeficiency virus type 1 infection. This article reviews the current literature on raltegravir and new developments in the INSTI class.
Collapse
|
181
|
Malet I, Fourati S, Morand-Joubert L, Flandre P, Wirden M, Haim-Boukobza S, Sayon S, Pattery T, Simon A, Katlama C, Girard PM, Calvez V, Marcelin AG. Risk factors for raltegravir resistance development in clinical practice. J Antimicrob Chemother 2012; 67:2494-500. [PMID: 22763565 DOI: 10.1093/jac/dks254] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To investigate the best conditions of raltegravir use to avoid the selection of resistance mutations in the three main genetic pathways: 148, 155 and 143. METHODS A total of 161 patients failing on raltegravir with two consecutive HIV-1 viral loads >20 copies/mL were studied. Ten parameters [HIV-1 RNA and CD4 at baseline and failure, genotypic sensitivity score (GSS) of treatment associated with raltegravir, protease inhibitors used, time spent on raltegravir, subtype, sex and age] were tested in univariate and multivariate logistic regression analyses and compared with the emergence of resistance mutations to raltegravir at failure. Phenotypic susceptibility to raltegravir was studied in 16 patients without the main resistance mutations to raltegravir at failure. RESULTS At raltegravir failure, 46/161 patients (28.6%) had integrase resistance mutations, whereas 115/161 (71.4%) had no resistance mutations. High HIV-1 viral load level at failure (OR = 2.81, 95% CI 1.8-4.6, P < 0.001) and low GSS of treatment associated with raltegravir (OR = 11.6, 95% CI 4.5-36.4, P < 0.001) were independently associated with the selection of raltegravir mutations. The percentages of patients with integrase resistance mutations were 7.7% (6/78) versus 48.1% (40/83) when viral load is ≤200 or >200 copies/mL and 47.5% (39/82) versus 8.9% (7/79) when GSS is <2 or ≥2. Among patients without main resistance mutations, two patients showed raltegravir phenotypic resistance, one naturally with F121Y at baseline and the other acquiring G118R at failure. CONCLUSIONS Our results show that to avoid the selection of raltegravir resistance mutations, patients have to be treated with at least two active drugs in combination with raltegravir and to maintain a viral load ≤200 copies/mL.
Collapse
Affiliation(s)
- Isabelle Malet
- Laboratoire de Virologie, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, UPMC Université Pierre et Marie Curie, INSERM U943, Paris, France.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
182
|
[Consensus document of Gesida and Spanish Secretariat for the National Plan on AIDS (SPNS) regarding combined antiretroviral treatment in adults infected by the human immunodeficiency virus (January 2012)]. Enferm Infecc Microbiol Clin 2012; 30:e1-89. [PMID: 22633764 DOI: 10.1016/j.eimc.2012.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 03/19/2012] [Indexed: 11/20/2022]
Abstract
This consensus document has been prepared by a panel consisting of members of the AIDS Study Group (Gesida) and the Spanish Secretariat for the National Plan on AIDS (SPNS) after reviewing the efficacy and safety results of clinical trials, cohort and pharmacokinetic studies published in medical journals, or presented in medical scientific meetings. Gesida has prepared an objective and structured method to prioritise combined antiretroviral treatment (cART) in naïve patients. Recommendations strength (A, B, C) and the evidence which supports them (I, II, III) are based on a modification of the Infectious Diseases Society of America criteria. The current antiretroviral treatment (ART) of choice for chronic HIV infection is the combination of three drugs. ART is recommended in patients with symptomatic HIV infection, in pregnancy, in serodiscordant couples with high transmission risk, hepatitis B fulfilling treatment criteria, and HIV nephropathy. Guidelines on ART treatment in patients with concurrent diagnosis of HIV infection and an opportunistic type C infection are included. In asymptomatic patients 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 <350 cells/μL; 2) when CD4 counts are between 350 and 500 cells/μL, therapy will be recommended and only delayed if patient is reluctant to take it, the CD4 are stabilised, and the plasma viral load is low; 3) therapy could be deferred when CD4 counts are above 500 cells/μL, but should be considered in cases of cirrhosis, chronic hepatitis C, high cardiovascular risk, plasma viral load >10(5) copies/mL, proportion of CD4 cells <14%, and in people aged >55 years. ART should include 2 reverse transcriptase inhibitors nucleoside analogues and a third drug (non-analogue reverse transcriptase inhibitor, ritonavir boosted protease inhibitor or integrase inhibitor). The panel has consensually selected and given priority to using the Gesida score for some drug combinations, some of them co-formulated. 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 an undetectable viral load may be possible nowadays. Adverse events are a fading problem of ART. Guidelines in acute HIV infection, in women, in pregnancy, and to prevent mother-to-child transmission and pre- and post-exposition prophylaxis are commented upon. Management of hepatitis B or C co-infection, other co-morbidities, and the characteristics of ART in HIV-2 infection are included.
Collapse
|
183
|
Desai M, Iyer G, Dikshit RK. Antiretroviral drugs: critical issues and recent advances. Indian J Pharmacol 2012; 44:288-98. [PMID: 22701234 PMCID: PMC3371447 DOI: 10.4103/0253-7613.96296] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 03/05/2012] [Accepted: 03/10/2012] [Indexed: 12/18/2022] Open
Abstract
Human immunodeficiency virus (HIV) infection is now recognized as a chronic illness. Although the success of highly active antiretroviral therapy is beyond question, several issues still persist. Since the drugs cannot eradicate the virus, cure is not yet possible, and patients have to maintain a lifelong adherence with the risk of toxic effects, drug-drug interactions and drug resistance. A clear understanding of the viral replication and its interaction with host cell factors has led to the development of a large number of effective antiretroviral drugs (ARVs). New drugs in the existing class such as apricitabine, elvucitabine and etravirine have shown promising results against HIV isolates resistant to first line drugs. These drugs have offered a new choice for patients with drug resistant disease. However, the impact of their long term use on safety is yet to be assessed. Novel drugs with unique mechanism of action such as CD4 receptor attachment inhibitors, maturation inhibitors, pharmacokinetic enhancers, capsid assembly inhibitors and lens epithelium derived growth factor inhibitors are still under development. Currently, ARVs, especially tenofovir and emtricitabine, are also being evaluated for prevention of sexual transmission of HIV-1. The initial results of an HIV prevention trial network are encouraging and have recommended the use of ARVs for pre-exposure prophylaxis. Thus, ARVs form the key component of HIV prevention and treatment strategy. This article discusses the challenges associated with HIV-1 treatment and updates several major advances in the development of ARVs.
Collapse
Affiliation(s)
- Mira Desai
- Department of Pharmacology, B J Medical College, Ahmedabad, India.
| | | | | |
Collapse
|
184
|
Quashie PK, Sloan RD, Wainberg MA. Novel therapeutic strategies targeting HIV integrase. BMC Med 2012; 10:34. [PMID: 22498430 PMCID: PMC3348091 DOI: 10.1186/1741-7015-10-34] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 04/12/2012] [Indexed: 01/17/2023] Open
Abstract
Integration of the viral genome into host cell chromatin is a pivotal and unique step in the replication cycle of retroviruses, including HIV. Inhibiting HIV replication by specifically blocking the viral integrase enzyme that mediates this step is an obvious and attractive therapeutic strategy. After concerted efforts, the first viable integrase inhibitors were developed in the early 2000s, ultimately leading to the clinical licensure of the first integrase strand transfer inhibitor, raltegravir. Similarly structured compounds and derivative second generation integrase strand transfer inhibitors, such as elvitegravir and dolutegravir, are now in various stages of clinical development. Furthermore, other mechanisms aimed at the inhibition of viral integration are being explored in numerous preclinical studies, which include inhibition of 3' processing and chromatin targeting. The development of new clinically useful compounds will be aided by the characterization of the retroviral intasome crystal structure. This review considers the history of the clinical development of HIV integrase inhibitors, the development of antiviral drug resistance and the need for new antiviral compounds.
Collapse
Affiliation(s)
- Peter K Quashie
- McGill University AIDS Centre, Lady Davis Institute, Montreal, Canada
| | | | | |
Collapse
|
185
|
Rokas KEE, Bookstaver PB, Shamroe CL, Sutton SS, Millisor VE, Bryant JE, Weissman SB. Role of raltegravir in HIV-1 management. Ann Pharmacother 2012; 46:578-89. [PMID: 22496475 DOI: 10.1345/aph.1q616] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To review the literature concerning the role of raltegravir in the treatment of HIV-1 in antiretroviral (ARV)-experienced and ARV-naïve patients. DATA SOURCES A PubMed search was conducted for published data through March 2012 using the search terms raltegravir, MK-0518, and integrase strand transfer inhibitor. An additional search of International Pharmaceutical Abstracts for unpublished data, including data from the Infectious Diseases Society of America, the Conference on Retroviruses and Opportunistic Infections, the International AIDS Society, and the Interscience Conference on Antimicrobial Agents and Chemotherapy, was conducted using similar search terms. STUDY SELECTION AND DATA EXTRACTION In vitro and in vivo Phase 2, Phase 3, and postmarketing studies available in English, evaluating antiretroviral regimens that contain raltegravir for the treatment of HIV-1 infection in both ARV-naïve and ARV-experienced patients, were evaluated. Studies assessing raltegravir pharmacokinetics and pharmacodynamics were included for review. DATA SYNTHESIS The nucleoside-based regimen of raltegravir with tenofovir/emtricitabine provides an effective first-line treatment option. However, nucleoside-sparing regimens appear unfavorable in ARV-naïve subjects and should be reserved for patients with limited treatment options. Raltegravir used with optimized background therapy provides an alternative regimen for ARV-experienced patients. This review describes the available in vitro and in vivo data on raltegravir potency, defined as the ability to achieve undetectable viral load, and safety profile, as well as comparison to standard HIV-1 therapies. CONCLUSIONS Raltegravir has demonstrated potent antiretroviral activity against HIV-1 in both ARV-naïve and ARV-experienced subjects, with the benefits of a favorable adverse effect profile and minimal drug interactions. Raltegravir must be dosed twice daily, as once daily raltegravir displays decreased virologic efficacy compared to twice daily dosing. However, the ongoing development of new integrase strand transfer inhibitors may provide potent once daily regimens.
Collapse
Affiliation(s)
- Kristina E E Rokas
- South Carolina College of Pharmacy, University of South Carolina Campus, Columbia, USA
| | | | | | | | | | | | | |
Collapse
|
186
|
Chaudhary MA, Elbasha EH, Kumar RN, Nathanson EC. Cost-effectiveness of raltegravir in HIV/AIDS. Expert Rev Pharmacoecon Outcomes Res 2012; 11:627-39. [PMID: 22098278 DOI: 10.1586/erp.11.79] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Raltegravir is a first-in-class HIV-1 integrase inhibitor with established antiviral efficacy in treatment-naive and treatment-experienced patients with multidrug-resistant HIV-1 infection. In this article, we summarize pharmacoeconomic evaluations of raltegravir-based treatment regimens, compared with alternative therapies, in the treatment of patients with HIV infection and/or AIDS. Cost-effectiveness evaluations of raltegravir in treatment-experienced patients conducted using a continuous-time, state-transition Markov cohort model suggest that raltegravir, combined with optimized background therapy, falls within the range that would generally be considered cost effective compared with optimized therapy alone in Spanish, Swiss and UK health systems. In treatment-naive populations, raltegravir was evaluated using a three-stage continuous-time state-transition cohort model. Raltegravir-based initiation treatment strategies (first-line raltegravir) were compared with protease inhibitor and non-nucleoside reverse-transcriptase inhibitor initiation strategies, in which raltegravir was retained for salvage therapy. First-line raltegravir was cost-effective versus retaining raltegravir for salvage therapy in several European populations. A separate economic model was used to evaluate first-line raltegravir against two alternative initiation regimens representing standard clinical practice in Australia; raltegravir proved to be cost effective in both scenarios. In all studies examined, results were sensitive to factors including treatment duration, mortality rate, analytic time horizon, health utility weights, cost of raltegravir and optimized therapy, incidence of opportunistic infection and discount rates. Nonetheless, raltegravir remained cost effective under most scenarios.
Collapse
|
187
|
Delaugerre C, Braun J, Charreau I, Delarue S, Nere ML, de Castro N, May T, Marchou B, Simon F, Molina JM, Aboulker JP. Comparison of resistance mutation patterns in historical plasma HIV RNA genotypes with those in current proviral HIV DNA genotypes among extensively treated patients with suppressed replication. HIV Med 2012; 13:517-25. [PMID: 22416781 DOI: 10.1111/j.1468-1293.2012.01002.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Heavily treatment-experienced patients with good virological control could be at risk of virological failure on switching to a new regimen if pre-existing drug resistance is not taken into account. We examined whether genotyping based on cellular HIV-1 DNA during controlled viraemia identifies resistance mutations detected in plasma HIV-1 RNA during treatment with previous antiretroviral regimens. PATIENTS AND METHODS All 169 patients enrolled in the Agence Nationale de Recherche sur le SIDA (ANRS) 138-intEgrase inhibitor MK_0518 to Avoid Subcutaneous Injections of EnfuviRtide (EASIER) trial had already received three antiretroviral drug classes [nucleoside reverse transcriptase inhibitor (NRTI), nonnucleoside reverse transcriptase inhibitor (NNRTI) and protease inhibitor (PI)] and had plasma HIV-1 RNA<400 copies/ml at baseline. The results of previous resistance genotyping of plasma HIV-1 RNA in individual patients were compared with those of resistance genotyping of whole-blood HIV-1 DNA at randomization. RESULTS A median of 4 plasma RNA genotypes were available for the 169 patients. The median numbers of resistance mutations in HIV-1 RNA and DNA were, respectively, 5 and 4 for NRTIs, 2 and 1 for NNRTIs, and 10 and 8 for PIs. The difference was significant for all three drug classes (P=0.001). Resistance to at least one antiretroviral drug was detected exclusively in HIV-1 RNA or in DNA in 63% and 13% of patients for NRTI, 47% and 1% of patients for NNRTI, and 50% and 7% of patients for PI, respectively. CONCLUSION This study shows that, among highly treatment-experienced patients on effective highly active antiretroviral therapy, resistance genotyping of HIV-1 DNA detects fewer resistance mutations than previous analyses of HIV-1 RNA. These results have implications for patient management and for the design of switch studies.
Collapse
Affiliation(s)
- C Delaugerre
- Virology Department, Saint-Louis Hospital-APHP, Inserm U941-Paris 7 Diderot University, Paris, France.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
188
|
Abstract
BACKGROUND CD4 gains in HIV patients on HAART result from release of T cells recently migrated from the thymus, redistribution from lymphoid tissues, proliferation in the periphery and/or reduced apoptosis. The relative contribution of each mechanism in CD4 restoration in patients with suppressed viremia switching antiretrovirals is unclear. METHODS HIV patients with undetectable viremia on HAART were identified at our clinic. A subset switched to raltegravir was compared with another group that kept therapy unmodified. Naive and memory CD4 T-cells were measured by flow cytometry using CD45RA and CD27, respectively. Activation was examined using CD38 and recent thymic emigrants using CD31. Apoptosis was analyzed measuring soluble tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) and Fas ligand (FasL). RESULTS Thirty-seven patients were examined, 19 switched to raltegravir and 18 controls, after a median of 26 months of suppressed viremia. At 6 months, mean CD4 cell counts significantly increased in raltegravir patients from 322 to 448 cells/μl (P = 0.026) but not in controls (from 312 to 330 cells/μl; P = 0.813). No significant changes were recognized in activation or CD31 expression in any group. In raltegravir patients, however, the proportion of naive CD4 T cells significantly increased (P = 0.014) as well as CD38 expression in these cells (P = 0.036). A positive correlation was found between CD38 and CD31 expression in naive CD4 T cells (R = 0.51, P < 0.001). TRAIL and FasL did not decline significantly in any group. CONCLUSION HIV patients with prolonged undetectable viremia on HAART experience more pronounced CD4 gains after raltegravir switching than keeping the same regimen. An increased production of naive CD4 T cells largely explains this effect.
Collapse
|
189
|
Incidence of acute pancreatitis in human immunodeficiency virus-positive patients with hypertriglyceridemia: is it really high? Pancreas 2012; 41:283-9. [PMID: 22343978 DOI: 10.1097/mpa.0b013e3182267fc0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE To assess the incidence of acute pancreatitis in human immunodeficiency virus-positive patients with triglyceride (TG) greater than 500 mg/dL after highly active antiretroviral therapy. METHODS Sequential TG levels during follow-up and episodes of acute pancreatitis were retrospectively reviewed in 347, 417, and 571 patients enrolled in periods 1 (2000-2002), 2 (2003-2005), and 3 (2006-2008), respectively. The incidence of acute pancreatitis, defined as consistent clinical symptoms and elevated amylase and/or lipase levels, was estimated. RESULTS A total of 5356 TG measurements were performed during the follow-up for 698.22, 884.14, and 1215.69 person-years in periods 1, 2, and 3, respectively. Overall, 9.89% of patients had at least one TG greater than 500 mg/dL. Five patients with TG less than 500 mg/dL developed acute pancreatitis. The crude incidences of acute pancreatitis were 0.6%, 0.5%, and 0.2%, and the incidence rates were 2.86, 2.26, and 0.82/1000 person-years in periods 1, 2 and 3, respectively (all, P > 0.05). The incidence rates of acute pancreatitis when TG levels were less than 500, less than 1000, and less than 1500 mg/dL ranged from 1.2 to 4.9/1000 person-years, whereas it was 0/1000 person-years when TG levels were greater than 500, greater than 1000, and greater than 1500 mg/dL, respectively. CONCLUSION The risk of acute pancreatitis was low among human immunodeficiency virus-positive patients who developed hypertriglyceridemia after receiving highly active antiretroviral therapy.
Collapse
|
190
|
Body composition changes after switching from protease inhibitors to raltegravir: SPIRAL-LIP substudy. AIDS 2012; 26:475-81. [PMID: 22112606 DOI: 10.1097/qad.0b013e32834f3507] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare 48-week changes in body fat distribution and bone mineral density (BMD) between patients switching from a ritonavir-boosted protease inhibitor (PI/r) to raltegravir (RAL) and patients continuing with PI/r. DESIGN Substudy of the prospective, randomized, open-label, multicenter SPIRAL study. METHODS Patients were randomized (1 : 1) to continue with the PI/r-based regimen or switch to RAL, maintaining the rest of the treatment unchanged. Dual-energy X-ray absorptiometry and computed tomography scans were performed at baseline and after 48 weeks to measure body fat and bone composition, analyzing intragroup and intergroup differences. RESULTS Eighty-six patients were included and 74 patients (39 RAL, 35 PI/r) completed the substudy. Significant increases in median [interquartile range (IQR)] visceral adipose tissue (VAT) [20.7 (-2.4 to 45.6) cm(2), P = 0.002] and total adipose tissue (TAT) [21.4 (-1.3 to 55.4) cm(2), P = 0.013] were seen within the PI/r group. No significant changes in body fat were seen with RAL or between treatment groups. Regarding bone composition, total BMD [0.01 (0 to 0.02) g/cm(2), P = 0.002], total hip BMD [0.01 (0 to 0.03) g/cm(2), P = 0.015] and total hip T score [0.12 (-0.05 to 0.21) SD, P = 0.004] significantly increased with RAL, with no significant changes within the PI/r group. Differences between treatment groups were significant in femoral neck BMD [0.01 (-0.02 to 0.02) g/cm(2), P = 0.032] and T score [0.01 (-0.18 to 0.18) SD, P = 0.016]. CONCLUSION Although there were no significant changes in body fat between groups, maintaining a PI/r-based regimen was associated with a significant increase in VAT and TAT. Switching to RAL led to a significant increase in femoral neck BMD when comparing between groups.
Collapse
|
191
|
Olalla J, Del Arco A, de la Torre J, Salas D, Prada JL, García-Alegría J. [Raltegravir in HIV-infected patients with high vascular risk]. Med Clin (Barc) 2012; 138:107-9. [PMID: 21561631 DOI: 10.1016/j.medcli.2011.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Revised: 02/15/2011] [Accepted: 02/17/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To record the experience with use of raltegravir (RTG) for devising highly active antiretroviral therapy (HAART) regimens based on RTG in high vascular risk patients. METHODS A retrospective study was conducted on high vascular risk patients taking RTG. Case was a patient who, at the time raltegravir was started, had ≥ 20% 10-year risk of cardiovascular disease, estimated by the algorithm of the European AIDS Clinical Society. Patients should have been on stable HAART including RTG for at least six months. A matched control with ≥ 20% risk of cardiovascular disease, was selected for each case. RESULTS Ten controls and ten cases were selected. After six months using RTG, a significant decreased was seen in levels of HDL cholesterol (median -2,5mg/dL in controls versus 2,5mg/dL in cases, p=0.015), triglycerides (10mg/dL versus -101 mg/dL, p=0.009), and TC/HDL-C ratio (0.17 versus -0.73, p=0.002). Ten-year risk of cardiovascular disease was -4.85% in cases versus -0.05% in controls (p=0.07). CONCLUSIONS RTG shows a good profile to be used in people with high vascular risk, with a decrease in TC/HDL-C ratio and vascular risk.
Collapse
Affiliation(s)
- Julián Olalla
- Unidad de Medicina Interna, Hospital Costa del Sol, Marbella, Málaga, España.
| | | | | | | | | | | |
Collapse
|
192
|
Cattaneo D, Gervasoni C, Meraviglia P, Landonio S, Fucile S, Cozzi V, Baldelli S, Pellegrini M, Galli M, Clementi E. Inter- and intra-patient variability of raltegravir pharmacokinetics in HIV-1-infected subjects. J Antimicrob Chemother 2012; 67:460-464. [DOI: 10.1093/jac/dkr498] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
|
193
|
Garrido C, de Mendoza C, Álvarez E, García F, Morello J, Garcia S, Ribera E, Rodríguez-Novoa S, Gutierrez F, Soriano, on behalf of the SinRES Te V. Plasma raltegravir exposure influences the antiviral activity and selection of resistance mutations. AIDS Res Hum Retroviruses 2012; 28:156-64. [PMID: 21457126 DOI: 10.1089/aid.2010.0370] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Raltegravir (RAL) resistance is associated with the selection of integrase mutations at positions 92, 143, 148, and/or 155. A substantial proportion of RAL failures, however, occurs in the absence of these changes. An examination of RAL plasma concentrations may help in interpreting this observation. All early RAL virological failures seen at 22 clinics in Spain during 2009 were identified. HIV integrase sequences and RAL plasma trough concentrations (C(t)) were examined. A total of 106 patients experiencing virological failure on RAL were identified. Only the earliest sample on failure was examined. Integrase sequences could be obtained for 89 (84%), of whom 30 (33.7%) depicted primary RAL resistance mutations (15 N155H, eight Q148H/R, three Y143R, one E92Q, and three more than one of them). Another nine (10.1%) patients showed only secondary changes. The remaining 50 RAL early failures (56.2%) did not select any integrase change. RAL C(t) could be measured in 66 patients at failure and in 21 of them before failure. In a control group of 37 patients with viral suppression on RAL, detectable plasma levels were seen in all cases, with greater median RAL C(t) than in failures, either at the time of viral rebound (p<0.001) or before it (p=0.055). Moreover, median C(t) at the time of failure was greater in patients selecting primary RAL resistance mutations than in the rest of the failures (p<0.001). Undetectable RAL C(t) was seen only in patients failing RAL without integrase resistance mutations (64.1% of them). RAL failures in the absence of integrase resistance mutations mainly reflect poor drug compliance.
Collapse
Affiliation(s)
- Carolina Garrido
- Infectious Diseases Department, Hospital Carlos III, Madrid, Spain
| | | | - Elena Álvarez
- Infectious Diseases Department, Hospital Carlos III, Madrid, Spain
| | - Federico García
- Microbiology Department, Hospital Clínico Universitario San Cecilio, Granada, Spain
| | - Judit Morello
- Infectious Diseases Department, Hospital Carlos III, Madrid, Spain
| | - Silvia Garcia
- Microbiology Department, Hospital La Paz, Madrid, Spain
| | | | | | | | | | | |
Collapse
|
194
|
Huesgen E, Burgos R, Goldstein DA, Max B, Jarrett OD. Severe dyslipidaemia after the addition of raltegravir to a lopinavir/ritonavir-containing regimen. Antivir Ther 2012; 17:1385-8. [DOI: 10.3851/imp2182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2012] [Indexed: 10/28/2022]
|
195
|
Characterization of the R263K mutation in HIV-1 integrase that confers low-level resistance to the second-generation integrase strand transfer inhibitor dolutegravir. J Virol 2011; 86:2696-705. [PMID: 22205735 DOI: 10.1128/jvi.06591-11] [Citation(s) in RCA: 200] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Integrase (IN) strand transfer inhibitors (INSTIs) have been developed to inhibit the ability of HIV-1 integrase to irreversibly link the reverse-transcribed viral DNA to the host genome. INSTIs have proven their high efficiency in inhibiting viral replication in vitro and in patients. However, first-generation INSTIs have only a modest genetic barrier to resistance, allowing the virus to escape these powerful drugs through several resistance pathways. Second-generation INSTIs, such as dolutegravir (DTG, S/GSK1349572), have been reported to have a higher resistance barrier, and no novel drug resistance mutation has yet been described for this drug. Therefore, we performed in vitro selection experiments with DTG using viruses of subtypes B, C, and A/G and showed that the most common mutation to emerge was R263K. Further analysis by site-directed mutagenesis showed that R263K does confer low-level resistance to DTG and decreased integration in cell culture without altering reverse transcription. Biochemical cell-free assays performed with purified IN enzyme containing R263K confirmed the absence of major resistance against DTG and showed a slight decrease in 3' processing and strand transfer activities compared to the wild type. Structural modeling suggested and in vitro IN-DNA binding assays show that the R263K mutation affects IN-DNA interactions.
Collapse
|
196
|
Pandey KK. Raltegravir in HIV-1 infection: Safety and Efficacy in Treatment-naïve Patients. ACTA ACUST UNITED AC 2011; 2012:13-30. [PMID: 22389581 DOI: 10.4137/cmrt.s5022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The hunt for a compound which inhibits the HIV-1 integrase had been painstakingly difficult. Integrase is essential for viral replication as it mediates the integration of the viral DNA genome into the host DNA resulting in the establishment of the permanent provirus. Persistent efforts have resulted in the discovery of Raltegravir (Isentress, MK-0518), the first integrase inhibitor approved by US Food and Drug Administration for the treatment in HIV-1 infected patients. Numerous clinical studies with raltegravir have found it to be safe and effective in treatment naïve as well as treatment experienced patients. Adverse events associated with raltegravir based therapy are milder compared to previously available regimens. Raltegravir is metabolized primarily via glucuronidation mediated by uridine diphosphate glucuronosyltransferase and has a favorable pharmacokinetics independent of age, gender, race, food, and drug-drug interactions. Within a short period of time of its introduction, raltegravir has been included as one of DHHS recommended preferred regimen for the treatment of HIV-1 infection in treatment naïve patients.
Collapse
Affiliation(s)
- Krishan K Pandey
- 1100 South Grand Boulevard, E. A. Doisy Research Center, Institute for Molecular Virology Saint Louis University Health Sciences Center, Saint Louis, MO 63104 USA
| |
Collapse
|
197
|
Phenotypic susceptibility of HIV-2 to raltegravir: integrase mutations Q148R and N155H confer raltegravir resistance. AIDS 2011; 25:2235-41. [PMID: 21971360 DOI: 10.1097/qad.0b013e32834d8e52] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Raltegravir is the first integrase strand transfer inhibitor approved for treating HIV-1 infection. Although emerging data suggest that raltegravir may also be useful for HIV-2 treatment, studies addressing the in-vitro susceptibility of HIV-2 to raltegravir are scarce, and the genetic pathways leading to raltegravir resistance in HIV-2 have not been adequately characterized. Our objectives were to directly compare the susceptibilities of HIV-1 and HIV-2 to raltegravir and to examine the role of mutations in HIV-2 integrase in emergent raltegravir resistance. MATERIALS AND METHODS Single-cycle and spreading infection assays were used to quantify the sensitivities of wild-type HIV-1 and HIV-2 strains to raltegravir. HIV-2 integrase mutants were constructed by site-directed mutagenesis, and the replication capacities and raltegravir susceptibilities of the resultant variants were analyzed in single-cycle assays. RESULTS Raltegravir showed comparable activity against wild-type HIV-1 and HIV-2 in both single-cycle and spreading infections, with EC(50) values in the low nanomolar range. Amino acid changes Q148R and N155H individually conferred resistance to raltegravir (14-fold and seven-fold, respectively), whereas the Y143C replacement had no statistically significant effect on raltegravir sensitivity. The combination of Q148R with N155H resulted in high-level raltegravir resistance (>1000-fold). In addition, all HIV-2 integrase variants tested showed impairments in replication capacity. CONCLUSION Our data support clinical studies of raltegravir for treating HIV-2 infection and show that the Q148R and N155H changes alone are sufficient for raltegravir resistance in HIV-2. Further efforts are needed to improve access to HIV-2-active antiretrovirals, including raltegravir, in resource-limited areas where HIV-2 is endemic.
Collapse
|
198
|
Clinical management and follow-up of hypercholesterolemia among perinatally HIV-infected children enrolled in the PACTG 219C study. J Acquir Immune Defic Syndr 2011; 57:413-20. [PMID: 21602698 DOI: 10.1097/qai.0b013e31822203f5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hypercholesterolemia is common in perinatally HIV-infected (HIV+) children, but little is known about the clinical course and management in this population. METHODS We studied HIV+ children in a multisite prospective cohort study (Pediatric AIDS Clinical Trials Group 219C) and considered follow-up for 2 years after development of hypercholesterolemia. We estimated the time and factors associated with resolution of hypercholesterolemia and described changes in antiretroviral regimen and use of lipid-lowering medications. We defined incident hypercholesterolemia as entry total cholesterol (cholesterol) <220 mg/dL and 2 subsequent consecutive cholesterol ≥ 220 mg/dL and defined resolution of hypercholesterolemia as 2 consecutive cholesterol <200 mg/dL after incident hypercholesterolemia. RESULTS Among 240 incident hypercholesterolemia cases, 81 (34%) had resolution to normal cholesterol within 2 years of follow-up (median follow-up = 1.9 years). The median age of cases was 10.3 years with 54% non-Hispanic black and 53% male. Resolution to normal cholesterol was more likely in children who changed antiretroviral regimen (adjusted hazard ratio = 2.37, 95% confidence interval: 1.45 to 3.88) and who were 13 years and older (aHR = 2.39, 95% confidence interval: 1.33 to 4.27). Types of regimen changes varied greatly, and 15 children began statins. CONCLUSION The majority of children who develop hypercholesterolemia maintain elevated levels over time, potentially placing them at risk for premature cardiovascular morbidity.
Collapse
|
199
|
Siliciano RF. Measurement of antiviral activity in drugs for HIV-1. THE LANCET. INFECTIOUS DISEASES 2011; 11:888-9. [PMID: 21933753 DOI: 10.1016/s1473-3099(11)70250-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
200
|
Abstract
Morphologic and metabolic abnormalities, including subcutaneous adipose tissue wasting, central adipose tissue accumulation, dyslipidemia and disorders of glucose metabolism are common among HIV-infected patients receiving highly active antiretroviral therapy (HAART) and contribute to the risk of cardiovascular disease in this population. The pathogenesis of these disorders is due to complicated interactions between effects of chronic HIV infection, HAART medications and patient factors, including genetic susceptibility. HAART has transformed HIV into a chronic condition for many patients and as a result the majority of HIV-infected patients in many areas of the developed world will soon be aged ≥50 years. Given that metabolic and cardiovascular diseases increase with aging, knowledge of the optimal management of these conditions is essential for practitioners caring for HIV-infected patients, including endocrine subspecialists. This Review highlights the clinical management of these disorders, focusing on the latest evidence regarding the efficacy of treatment strategies, newly available medications and potential interactions between HAART medications and medications used to treat metabolic disorders.
Collapse
Affiliation(s)
- Todd T Brown
- Division of Endocrinology and Metabolism, Johns Hopkins University, 1830 East Monument Street, Baltimore, MD 21287, USA.
| | | |
Collapse
|