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Imaz A, Niubó J, Kashuba AD, Ferrer E, Sykes C, Rozas N, Acerete L, Vila A, Podzamczer D. Elvitegravir concentrations in seminal plasma in HIV-1-infected men. HIV Med 2016; 18:225-230. [PMID: 27477062 DOI: 10.1111/hiv.12417] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The aim of the study was to quantify elvitegravir (EVG) concentrations in the semen of HIV-1-infected men receiving antiretroviral therapy (ART) consisting of an elvitegravir/cobicistat/emtricitabine/tenofovir (EVG/COBI/FTC/TDF) single-tablet regimen. METHODS A phase IV, cross-sectional study was carried out including HIV-1-infected male adults with suppressed plasma HIV-1 RNA who switched ART to EVG/COBI/FTC/TDF. Total EVG concentrations at the end of the dosing interval (C24 h ) and HIV-1 RNA were measured in paired seminal plasma (SP) and blood plasma (BP) samples 4 weeks after switching to EVG/COBI/FTC/TDF. Validated liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used to quantify EVG concentrations, and HIV-1 RNA was determined by real-time polymerase chain reaction (PCR). RESULTS Ten men were included. Their median age was 40 years (range 24-47 years), the median time on ART was 50 months (range 10-186 months), the median time with plasma HIV-1 RNA < 40 copies/mL was 37 months (range 7-113 months), and the median CD4 count was 737 cells/μL (range 190-1122 cells/μL). Four weeks after switching to EVG/COBI/FTC/TDF, all subjects had HIV-1 RNA < 40 copies/mL in both BP and SP. Median EVG C24 h was 277 ng/mL (range 64.8-1790 ng/mL) in BP and 169 ng/mL (range 12.8-792 ng/mL) in SP. A significant correlation was observed between BP and SP EVG concentrations (Spearman rho 0.952; P < 0.001). The median SP:BP EVG concentration ratio was 0.39 (range 0.20-0.92). EVG C24 h in SP was at least 23-fold the in vitro protein-unbound 50% effective response (EC50 ) of HIV-1 clinical isolates (0.04-0.55 ng/mL). In all but one individual, EVG C24 h in SP was also higher than the blood plasma protein binding-adjusted 95% inhibitory concentration (IC95 ) of wild-type HIV-1 (45 ng/mL). CONCLUSIONS Seminal EVG concentrations in HIV-infected men treated with EVG/COBI/FTC/TDF sufficed to contribute to maintaining HIV-1 RNA suppression in this compartment.
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Affiliation(s)
- A Imaz
- HIV and STD Unit, Department of Infectious Diseases, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - J Niubó
- Department of Microbiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - A D Kashuba
- UNC Center for AIDS Research, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - E Ferrer
- HIV and STD Unit, Department of Infectious Diseases, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - C Sykes
- UNC Center for AIDS Research, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - N Rozas
- HIV and STD Unit, Department of Infectious Diseases, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - L Acerete
- HIV and STD Unit, Department of Infectious Diseases, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - A Vila
- HIV and STD Unit, Department of Infectious Diseases, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - D Podzamczer
- HIV and STD Unit, Department of Infectious Diseases, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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Rivero A, Pérez-Molina JA, Blasco AJ, Arribas JR, Crespo M, Domingo P, Estrada V, Iribarren JA, Knobel H, Lázaro P, López-Aldeguer J, Lozano F, Moreno S, Palacios R, Pineda JA, Pulido F, Rubio R, de la Torre J, Tuset M, Gatell JM. Costs and cost-efficacy analysis of the 2016 GESIDA/Spanish AIDS National Plan recommended guidelines for initial antiretroviral therapy in HIV-infected adults. Enferm Infecc Microbiol Clin 2016; 35:88-99. [PMID: 27459919 DOI: 10.1016/j.eimc.2016.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 06/14/2016] [Accepted: 06/14/2016] [Indexed: 11/16/2022]
Abstract
INTRODUCTION GESIDA and the AIDS National Plan panel of experts suggest preferred (PR), alternative (AR), and other regimens (OR) for antiretroviral treatment (ART) as initial therapy in HIV-infected patients for the year 2016. The objective of this study is to evaluate the costs and the efficacy of initiating treatment with these regimens. METHODS Economic assessment of costs and efficiency (cost/efficacy) based on decision tree analyses. Efficacy was defined as the probability of reporting a viral load <50copies/mL at week 48 in an intention-to-treat analysis. Cost of initiating treatment with an ART regimen was defined as the costs of ART and its consequences (adverse effects, changes of ART regimen, and drug resistance studies) during the first 48 weeks. The payer perspective (National Health System) was applied, only taking into account differential direct costs: ART (official prices), management of adverse effects, studies of resistance, and HLA B*5701 testing. The setting is Spain and the costs correspond to those of 2016. A sensitivity deterministic analysis was conducted, building three scenarios for each regimen: base case, most favourable, and least favourable. RESULTS In the base case scenario, the cost of initiating treatment ranges from 4663 Euros for 3TC+LPV/r (OR) to 10,894 Euros for TDF/FTC+RAL (PR). The efficacy varies from 0.66 for ABC/3TC+ATV/r (AR) and ABC/3TC+LPV/r (OR), to 0.89 for TDF/FTC+DTG (PR) and TDF/FTC/EVG/COBI (AR). The efficiency, in terms of cost/efficacy, ranges from 5280 to 12,836 Euros per responder at 48 weeks, for 3TC+LPV/r (OR), and RAL+DRV/r (OR), respectively. CONCLUSION Despite the overall most efficient regimen being 3TC+LPV/r (OR), among the PR and AR, the most efficient regimen was ABC/3TC/DTG (PR). Among the AR regimes, the most efficient was TDF/FTC/RPV.
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Affiliation(s)
- Antonio Rivero
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | | | | | - José Ramón Arribas
- Servicio de Medicina Interna, Unidad de VIH, IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
| | - Manuel Crespo
- Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Pere Domingo
- Hospitals Universitaris Arnau de Vilanova & Santa María, Universitat de Lleida, Institut de Recerca Biomèdica (IRB) de Lleida, Lieida, Spain
| | - Vicente Estrada
- Hospital Clínico San Carlos, IdISSC; Universidad Complutense, Madrid, Spain
| | - José Antonio Iribarren
- Servicio de Enfermedades Infecciosas, Hospital Universitario Donostia, San Sebastián, Spain
| | - Hernando Knobel
- Servicio de Enfermedades Infecciosas, Hospital del Mar, Barcelona, Spain
| | | | - José López-Aldeguer
- Servicio de Medicina Interna y Unidad de Enfermedades Infecciosas, Hospital Universitario La Fe, Valencia, Spain
| | - Fernando Lozano
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario de Valme, Sevilla, Spain
| | - Santiago Moreno
- Servicio de Enfermedades Infecciosas, Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Instituto de Investigación Sanitaria Ramón y Cajal (IRYCIS), Alcalá de Henares, Madrid, Spain
| | - Rosario Palacios
- Unidad de Enfermedades Infecciosas, Hospital Virgen de la Victoria, Málaga, Spain
| | - Juan Antonio Pineda
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario de Valme, Sevilla, Spain
| | - Federico Pulido
- Unidad VIH, i+12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Rafael Rubio
- Unidad VIH, i+12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Javier de la Torre
- Grupo de Enfermedades Infecciosas de la Unidad de Medicina Interna, Hospital Costa del Sol, Marbella, Málaga, Spain
| | | | - Josep M Gatell
- Servicio de Enfermedades Infecciosas, Hospital Clínic-IDIBAPS, Universidad de Barcelona, Barcelona, Spain
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153
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Bello KJ, Mesner O, O'Bryan TA, Won SH, Lalani T, Ganesan A, Agan BK, Okulicz JF. Factors associated with 10 years of continuous viral load suppression on HAART. BMC Infect Dis 2016; 16:351. [PMID: 27449671 PMCID: PMC4957300 DOI: 10.1186/s12879-016-1677-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 06/09/2016] [Indexed: 12/03/2022] Open
Abstract
Background The principal goal of HAART is sustained viral load (VL) suppression resulting in immune reconstitution and improved HIV outcomes. We studied the factors associated with 10 years of continuous VL suppression on HAART in the US Military HIV Natural History Study. Methods Participants with continuous VL suppression (CS, n = 149) were compared to those who did not have continuous viral load suppression (NCS, n = 127) for ≥10 years on HAART. Factors associated with >10 years of VL suppression were evaluated by multivariate logistic regression. Additionally, association between CS and CD4 reconstitution was analyzed with a mixed effects model. Results Compared to NCS participants, a lower proportion of CS participants started HAART in the early HAART era (66 vs 90 %, for years 1996–1999; p < 0.001) and had less antiretroviral use prior to HAART (37 vs 83 %; p < 0.001). At initial HAART, the median CD4 cell count was higher and VL was lower for CS compared to NCS participants (375 cells/uL [256, 499] vs 261 cells/uL [146, 400]; p < 0.001 and 4.4 log10 copies/mL [3.5, 4.9] vs 4.5 log10 copies/mL [3.8, 5.0]; p = 0.048, respectively). New AIDS events were lower during HAART (5 vs 13 %; p = 0.032) and post-HAART CD4 trajectories were greater for the CS compared to NCS group. Factors negatively associated with ≥10 years of VL suppression included log10 VL at first HAART (OR 0.61, 95 % CI 0.4, 0.92; p = 0.020) and antiretroviral use prior to HAART (OR 0.16, 95 % CI 0.06, 0.38; p < .001). Conclusions Sustained VL suppression is a key to long-term health in HIV-infected patients, as demonstrated by the lower proportion of AIDS events observed 10 years after HAART initiation. The current use of more potent and well-tolerated regimens may mitigate the negative factors of pre-HAART VL and prior ARV use encountered by treatment initiated in the early HAART era.
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Affiliation(s)
- Kathryn J Bello
- Internal Medicine Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, 78234, TX, USA
| | - Octavio Mesner
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, 20814, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive #100, Bethesda, 20817, MD, USA
| | - Thomas A O'Bryan
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, 20814, MD, USA.,Infectious Disease Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, 78234, TX, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive #100, Bethesda, 20817, MD, USA
| | - Seung Hyun Won
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, 20814, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive #100, Bethesda, 20817, MD, USA
| | - Tahaniyat Lalani
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, 20814, MD, USA.,Naval Medical Center, 620 John Paul Jones Circle, Portsmouth, 23708, VA, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive #100, Bethesda, 20817, MD, USA
| | - Anuradha Ganesan
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, 20814, MD, USA.,Infectious Disease Service, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, 20889, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive #100, Bethesda, 20817, MD, USA
| | - Brian K Agan
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, 20814, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive #100, Bethesda, 20817, MD, USA
| | - Jason F Okulicz
- Internal Medicine Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, 78234, TX, USA. .,Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, 20814, MD, USA. .,Infectious Disease Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, 78234, TX, USA.
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154
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Brenner BG, Wainberg MA. Clinical benefit of dolutegravir in HIV-1 management related to the high genetic barrier to drug resistance. Virus Res 2016; 239:1-9. [PMID: 27422477 DOI: 10.1016/j.virusres.2016.07.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 07/07/2016] [Accepted: 07/11/2016] [Indexed: 01/08/2023]
Abstract
This manuscript reviews the reasons why Integrase inhibitors should now routinely constitute a part of first line antiretroviral therapy for the treatment of HIV disease. The use of these drugs that are generally well tolerated has resulted in far less drug resistance than was the case with most other categories of antiviral compounds. In addition, the integrase inhibitor family of drugs has been less prone to the problem of transmitted drug resistance which is due to a wide variety of substitutions in the HIV genome that can be sexually transmitted from one person to another. However, the use of integrase inhibitors in first line therapy may unfortunately not soon happen in developing country settings where non-nucleoside reverse transcriptase inhibitors continue to be a mainstay of initial therapy, primarily for reasons of cost. As long as this situation continues, problems of drug resistance and transmitted drug resistance will be common in such settings. Current evidence also suggests that the use of dolutegravir as a first line integrase inhibitor may limit development of drug resistance to an extent that exceeds the use of other members of this family of drugs. This may be due to particular patterns of resistance involving dolutegravir, whereby the mutations that are associated with resistance against this compound may actually diminish both HIV replication capacity as well as integrase enzymatic activity in a far-reaching and unique manner. This gives potential hope that the use of dolutegravir in first line therapy could actually form part of the long-sought goal of attainment of a functional cure for HIV disease.
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Affiliation(s)
- Bluma G Brenner
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
| | - Mark A Wainberg
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada.
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155
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Hull M, Shafran S, Wong A, Tseng A, Giguère P, Barrett L, Haider S, Conway B, Klein M, Cooper C. CIHR Canadian HIV Trials Network Coinfection and Concurrent Diseases Core Research Group: 2016 Updated Canadian HIV/Hepatitis C Adult Guidelines for Management and Treatment. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2016; 2016:4385643. [PMID: 27471521 PMCID: PMC4947683 DOI: 10.1155/2016/4385643] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 12/15/2015] [Indexed: 12/13/2022]
Abstract
Background. Hepatitis C virus (HCV) coinfection occurs in 20-30% of Canadians living with HIV and is responsible for a heavy burden of morbidity and mortality. Purpose. To update national standards for management of HCV-HIV coinfected adults in the Canadian context with evolving evidence for and accessibility of effective and tolerable DAA therapies. The document addresses patient workup and treatment preparation, antiviral recommendations overall and in specific populations, and drug-drug interactions. Methods. A standing working group with HIV-HCV expertise was convened by The Canadian Institute of Health Research HIV Trials Network to review recently published HCV antiviral data and update Canadian HIV-HCV Coinfection Guidelines. Results. The gap in sustained virologic response between HCV monoinfection and HIV-HCV coinfection has been eliminated with newer HCV antiviral regimens. All coinfected individuals should be assessed for interferon-free, Direct Acting Antiviral HCV therapy. Regimens vary in content, duration, and success based largely on genotype. Reimbursement restrictions forcing the use of pegylated interferon is not acceptable if optimal patient care is to be provided. Discussion. Recommendations may not supersede individual clinical judgement. Treatment advances published since December 2015 are not considered in this document.
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Affiliation(s)
- Mark Hull
- British Columbia Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, BC, Canada V6T 1Z4
| | | | - Alex Wong
- Regina Qu'Appelle Health Region, Regina, SK, Canada S4P 1E2
| | - Alice Tseng
- Toronto General Hospital, Toronto, ON, Canada M5G 2C4
| | | | - Lisa Barrett
- Dalhousie University, Halifax, NS, Canada B3H 4R2
| | | | - Brian Conway
- Vancouver Infectious Diseases Centre, Vancouver, BC, Canada V6Z 2C7
| | | | - Curtis Cooper
- The Ottawa Hospital, General Campus, G12, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6
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156
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Hassounah SA, Mesplède T, Wainberg MA. Nonhuman Primates and Humanized Mice for Studies of HIV-1 Integrase Inhibitors: A Review. Pathog Immun 2016; 1:41-67. [PMID: 30993244 PMCID: PMC6423640 DOI: 10.20411/pai.v1i1.104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Since the discovery of the first inhibitors of HIV replication, drug resistance has been a major problem in HIV therapy due in part to the high mutation rate of HIV. Therefore, the development of a predictive animal model is important to identify impending resistance mutations and to possibly inform treatment decisions. Significant advances have been made possible through use of nonhuman primates infected by SIV, SHIV, and simian-tropic HIV-1 (stHIV-1), and use of humanized mouse models of HIV-1 infections. In this review, we describe some of the findings from animal models used for the preclinical testing of integrase strand transfer inhibitors. These models have led to important findings about the potential role of integrase strand transfer inhibitors in both the prevention and treatment of HIV-1 infection.
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Affiliation(s)
- Said A Hassounah
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada.,Division of Experimental Medicine, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Thibault Mesplède
- Division of Experimental Medicine, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Mark A Wainberg
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada.,Division of Experimental Medicine, Faculty of Medicine, McGill University, Montréal, Québec, Canada.,Division of Microbiology and Immunology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
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157
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Derrick CB, Lu ZK, Caulder CR, Hester EK, Wagner TD, Bookstaver PB. Safety and Tolerability of Stribild in the Southeast United States. J Int Assoc Provid AIDS Care 2016; 15:432-9. [PMID: 27225853 DOI: 10.1177/2325957416650260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE The purpose of this study is to assess postmarketing safety and tolerability of Stribild (elvitegravir [EVG]/cobicistat [COBI]/tenofovir disoproxil fumarate [TDF]/emtricitabine [FTC]). METHODS A retrospective, pharmacoepidemiologic study in 2 outpatient HIV clinics in the Southeast United States was conducted among adults receiving EVG/COBI/TDF/FTC. We evaluated incidence and treatment-related adverse events, including change in serum creatinine (SCr). RESULTS Patients were primarily treatment experienced (n = 173, 60%), African American (n = 210, 73%), and males (n = 187, 65%). One hundred ninety-five (68%) patients had any increase in SCr, and 65 (23%) had an increase of ≥0.3 mg/dL. Mean SCr change from baseline to peak was 0.2 mg/dL. Being treatment experienced (odds ratio [OR] = 2.21, 95% confidence interval [CI]: 1.12-4.38) was associated with SCr ≥0.3 mg/dL, while body mass index ≥30 kg/m(2) (OR = 0.41, 95% CI: 0.18-0.93) was protective. Twenty (7%) patients discontinued therapy, 3 due to acute kidney injury. CONCLUSION Our results demonstrate limited adverse events and low discontinuation rates associated with EVG/COBI/TDF/FTC.
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Affiliation(s)
| | - Zhiqiang Kevin Lu
- Department of Clinical Pharmacy and Outcomes Sciences, SC College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - Celeste Rudisill Caulder
- Department of Clinical Pharmacy and Outcomes Sciences, SC College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - Elizabeth Kelly Hester
- Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, AL, USA
| | | | - Paul Brandon Bookstaver
- Department of Clinical Pharmacy and Outcomes Sciences, SC College of Pharmacy, University of South Carolina, Columbia, SC, USA
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158
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Moure R, Domingo P, Gallego-Escuredo JM, Villarroya J, Gutierrez MDM, Mateo MG, Domingo JC, Giralt M, Villarroya F. Impact of elvitegravir on human adipocytes: Alterations in differentiation, gene expression and release of adipokines and cytokines. Antiviral Res 2016; 132:59-65. [PMID: 27216995 DOI: 10.1016/j.antiviral.2016.05.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 04/19/2016] [Accepted: 05/17/2016] [Indexed: 11/28/2022]
Abstract
Elvitegravir is a recently developed integrase inhibitor used for antiretroviral treatment of HIV infection. Secondary effects, including disturbances in lipid metabolism and, ultimately, in adipose tissue distribution and function, are common concerns associated with antiretroviral treatments. Here, we provide the first study of the effects of elvitegravir (in comparison with efavirenz, a non-nucleoside analog inhibitor of reverse transcriptase; and raltegravir, another integrase inhibitor) on human adipocyte differentiation, gene expression and secretion of adipokines and cytokines. Elvitegravir impaired adipogenesis and adipocyte metabolism in human SGBS adipocytes in a concentration-dependent manner (delaying acquisition of adipocyte morphology and reducing the expression of adipogenesis marker genes such as PPARγ, glucose transporter GLUT4, lipoprotein lipase, and the adipokines adiponectin and leptin). Compared with efavirenz, the effects of elvitegravir were similar but tended to occur at higher concentrations than those elicited by efavirenz, or were somewhat less intense than those caused by efavirenz at similar concentration. Elvitegravir tended to cause a more moderate induction of pro-inflammatory cytokines than efavirenz. Efavirenz induced a marked concentration-dependent increase in interleukin-8 expression and release whereas elvitregravir had little effect. Raltegravir had totally neutral actions of adipogenesis, adipocyte metabolism-related gene expression and release of adipokines and cytokines. In conclusion, elvitegravir alters adipocyte differentiation and function and promotes induction of pro-inflammatory cytokines similarly to efavirenz, but several effects were less intense. Further assessment of lipid metabolism and adipose tissue function in patients administered elvitegravir-based regimes is advisable considering that totally neutral effects of elvitegravir on lipid homeostasis cannot be anticipated from the current study in vitro.
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Affiliation(s)
- Ricardo Moure
- Department of Biochemistry and Molecular Biology, Institut de Biomedicina (IBUB), University of Barcelona, CIBER Fisiopatología de la Obesidad y Nutrición, Barcelona, Spain
| | - Pere Domingo
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona and Red de Investigación en SIDA (RIS), Barcelona, Spain
| | - José M Gallego-Escuredo
- Department of Biochemistry and Molecular Biology, Institut de Biomedicina (IBUB), University of Barcelona, CIBER Fisiopatología de la Obesidad y Nutrición, Barcelona, Spain
| | - Joan Villarroya
- Department of Biochemistry and Molecular Biology, Institut de Biomedicina (IBUB), University of Barcelona, CIBER Fisiopatología de la Obesidad y Nutrición, Barcelona, Spain; Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona and Red de Investigación en SIDA (RIS), Barcelona, Spain
| | - Maria Del Mar Gutierrez
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona and Red de Investigación en SIDA (RIS), Barcelona, Spain
| | - Maria G Mateo
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona and Red de Investigación en SIDA (RIS), Barcelona, Spain
| | - Joan C Domingo
- Department of Biochemistry and Molecular Biology, Institut de Biomedicina (IBUB), University of Barcelona, CIBER Fisiopatología de la Obesidad y Nutrición, Barcelona, Spain
| | - Marta Giralt
- Department of Biochemistry and Molecular Biology, Institut de Biomedicina (IBUB), University of Barcelona, CIBER Fisiopatología de la Obesidad y Nutrición, Barcelona, Spain
| | - Francesc Villarroya
- Department of Biochemistry and Molecular Biology, Institut de Biomedicina (IBUB), University of Barcelona, CIBER Fisiopatología de la Obesidad y Nutrición, Barcelona, Spain.
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159
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M. Llibre J, Raffi F, Moyle G, Behrens G, Bouee S, Reilly G, Borg P, Piontkowsky D, Rogatto F. An Indirect Comparison of Efficacy and Safety of Elvitegravir/Cobicistat/Emtricitabine/Tenofovir Disoproxil Fumarate and Abacavir/Lamivudine + Dolutegravir in Initial Therapy. PLoS One 2016; 11:e0155406. [PMID: 27196332 PMCID: PMC4872996 DOI: 10.1371/journal.pone.0155406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 04/28/2016] [Indexed: 11/19/2022] Open
Abstract
Objectives The objective of this analysis is to perform an indirect comparison of elvitegravir, cobicistat, emtricitabine and tenofovir DF (E/C/F/TDF) to abacavir/lamivudine and dolutegravir (ABC/3TC + DTG) by using 2 trials evaluating each of these regimens in comparison to efavirenz, emtricitabine and tenofovir DF (EFV/FTC/TDF). Methods An indirect comparison was performed by using a generalization of Bucher's methodology to calculate risk differences. Two phase III clinical trials (GS-US-236-0102 and SINGLE—described above) were used. Results Results of the indirect comparison showed no statistically significant risk difference of the efficacy endpoint of achieving HIV RNA < 50 copies/mL between E/C/F/TDF and ABC/3TC + DTG for the ITT population at weeks 48, 96 and 144: respectively -3.7% (CI95% = [-10.8%; 3.4%]), -5.2% (CI95% = [-13.2%; 2.8%]) and -3.1% (CI95% = [-12.0%; 5.7%]). There was no statistically significant differences in the risk difference for serious adverse events (5.7% (CI95% = [-2.2%; 12.3%])), drug related adverse event (2.7% (CI95% = [-7.0%;12.4%])), drug related serious adverse event (0.8% (CI95% = [-1.6%;3.2%])) and death (0.5% (CI95% = [-0.8%;1.8%])), respectively, between E/C/F/TDF and ABC/3TC + DTG. A significant difference was found for discontinuation due to adverse events with a higher rate for E/C/F/TDF (difference = 8.6% (CI95% = [3.3%; 13.9%])). There was also no statistically significant risk difference of the viral resistance of 1.2% (CI95% = [-1.2; 3.7]) between E/C/F/TDF and ABC/3TC + DTG at week 48, 1.7% at week 96 (CI95% = [-1.1; 4.5]) and 2.2% (CI95% = [-1.0; 5.4]) at week 144.
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Affiliation(s)
| | | | - Graeme Moyle
- Chelsea and Westminster Hospital, London, United Kingdom
| | | | | | | | - Peter Borg
- Gilead Sciences, Stockley Park, United Kingdom
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Barceló C, Gaspar F, Aouri M, Panchaud A, Rotger M, Guidi M, Cavassini M, Buclin T, Decosterd LA, Csajka C. Population pharmacokinetic analysis of elvitegravir and cobicistat in HIV-1-infected individuals. J Antimicrob Chemother 2016; 71:1933-42. [PMID: 27029846 DOI: 10.1093/jac/dkw050] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 02/05/2016] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Co-formulated elvitegravir, cobicistat, tenofovir disoproxil fumarate and emtricitabine is among the preferred regimens for first-line ART. A population approach was used to characterize the pharmacokinetics of elvitegravir and cobicistat and identify individual factors and co-medications influencing their disposition, taking into consideration the interaction between the two compounds. METHODS The study population included 144 HIV-infected individuals who provided 186 and 167 elvitegravir and cobicistat plasma concentrations, respectively. First, distinct NONMEM(®) analyses were conducted for elvitegravir and cobicistat, including individual demographic, clinical and genetic factors as potential covariates. Elvitegravir and cobicistat interaction was then assessed through different inhibitory models. Simulations based on the final model served to compare expected drug concentrations under standard and alternative dosage regimens. RESULTS Clearance with between-subject variability was 7.6 L/h [coefficient of variation (CV) 16.6%] and volume of distribution 61 L for elvitegravir and 16.0 L/h (CV 41.9%) and 88.3 L, respectively, for cobicistat. Concomitant administration of non-ritonavir-boosted atazanavir decreased elvitegravir clearance by 35%, likely due to UDP-glucuronosyl transferase (UGT) 1A1 inhibition. Concomitant administration of non-ritonavir-boosted atazanavir and ritonavir-boosted darunavir decreased cobicistat clearance by 47% and 27%, respectively. The final interaction model included cobicistat exposure (AUC0-24) on elvitegravir clearance. Simulations confirmed that a reduced elvitegravir dose of 85 mg co-administered with cobicistat and atazanavir produces a concentration-time course comparable to the standard regimen without atazanavir. CONCLUSIONS Elvitegravir and cobicistat pharmacokinetic variability appears to be mainly explained by drug-drug interactions that may be encountered in routine clinical practice. In these cases, therapeutic drug monitoring and surveillance for potential toxicities would be justified.
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Affiliation(s)
- Catalina Barceló
- Division of Clinical Pharmacology, University Hospital Centre and University of Lausanne, Lausanne, Switzerland
| | - Frédéric Gaspar
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Manel Aouri
- Division of Clinical Pharmacology, University Hospital Centre and University of Lausanne, Lausanne, Switzerland
| | - Alice Panchaud
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Margalida Rotger
- Division of Clinical Pharmacology, University Hospital Centre and University of Lausanne, Lausanne, Switzerland Institute of Microbiology, University Hospital Centre and University of Lausanne, Lausanne, Switzerland
| | - Monia Guidi
- Division of Clinical Pharmacology, University Hospital Centre and University of Lausanne, Lausanne, Switzerland School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Matthias Cavassini
- Service of Infectious Diseases, University Hospital Centre and University of Lausanne, Lausanne, Switzerland
| | - Thierry Buclin
- Division of Clinical Pharmacology, University Hospital Centre and University of Lausanne, Lausanne, Switzerland
| | - Laurent A Decosterd
- Innovation & Development, Laboratory of Clinical Pharmacology, Service of Biomedicine, University Hospital Centre and University of Lausanne, Lausanne, Switzerland
| | - Chantal Csajka
- Division of Clinical Pharmacology, University Hospital Centre and University of Lausanne, Lausanne, Switzerland School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
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162
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2-hydroxyisoquinoline-1,3(2H,4H)-diones (HIDs) as human immunodeficiency virus type 1 integrase inhibitors: Influence of the alkylcarboxamide substitution of position 4. Eur J Med Chem 2016; 117:256-68. [PMID: 27105029 DOI: 10.1016/j.ejmech.2016.03.083] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 03/25/2016] [Accepted: 03/26/2016] [Indexed: 11/22/2022]
Abstract
Herein, we report further insight into the biological activities displayed by the 2-hydroxyisoquinoline-1,3(2H,4H)-dione (HID) scaffold. Previous studies have evidenced the marked fruitful effect of substitution of this two-metal binding pharmacophore at position 4 by phenyl and benzyl carboxamido chains. Strong human immunodeficiency virus type 1 integrase (HIV-1 IN) inhibitors in the low nanomolar range with micromolar (even down to low nanomolar) anti-HIV activities were obtained. Keeping this essential 4-carboxamido function, we investigated the influence of the replacement of phenyl and benzyl groups by various alkyl chains. This study shows that the recurrent halogenobenzyl pharmacophore found in the INSTIs can be efficiently replaced by an n-alkyl group. With an optimal length of six carbons, we observed a biological profile and a high barrier to resistance equivalent to those of a previously reported hit compound bearing a 4-fluorobenzyl group.
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163
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Cihlar T, Fordyce M. Current status and prospects of HIV treatment. Curr Opin Virol 2016; 18:50-6. [PMID: 27023283 DOI: 10.1016/j.coviro.2016.03.004] [Citation(s) in RCA: 200] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 03/09/2016] [Indexed: 11/24/2022]
Abstract
Current antiviral treatments can reduce HIV-associated morbidity, prolong survival, and prevent HIV transmission. Combination antiretroviral therapy (cART) containing preferably three active drugs from two or more classes is required for durable virologic suppression. Regimen selection is based on virologic efficacy, potential for adverse effects, pill burden and dosing frequency, drug-drug interaction potential, resistance test results, comorbid conditions, social status, and cost. With prolonged virologic suppression, improved clinical outcomes, and longer survival, patients will be exposed to antiretroviral agents for decades. Therefore, maximizing the safety and tolerability of cART is a high priority. Emergence of resistance and/or lack of tolerability in individual patients require availability of a range of treatment options. Development of new drugs is focused on improving safety (e.g. tenofovir alafenamide) and/or resistance profile (e.g. doravirine) within the existing drug classes, combination therapies with improved adherence (e.g. single-tablet regimens), novel mechanisms of action (e.g. attachment inhibitors, maturation inhibitors, broadly neutralizing antibodies), and treatment simplification with infrequent dosing (e.g. long-acting injectables). In parallel with cART innovations, research and development efforts focused on agents that target persistent HIV reservoirs may lead to prolonged drug-free remission and HIV cure.
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Affiliation(s)
- Tomas Cihlar
- Department of Biology, Gilead Sciences, Inc., Foster City, CA, USA.
| | - Marshall Fordyce
- HIV Clinical Development, Gilead Sciences, Inc., Foster City, CA, USA
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164
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A 48-week randomized phase 2b study evaluating cenicriviroc versus efavirenz in treatment-naive HIV-infected adults with C-C chemokine receptor type 5-tropic virus. AIDS 2016; 30:869-78. [PMID: 26636929 PMCID: PMC4794136 DOI: 10.1097/qad.0000000000000988] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: To compare the efficacy, safety, and anti-inflammatory effects of cenicriviroc (CVC), an oral, once-daily C-C chemokine receptor types 5 and 2 antagonist, with those of efavirenz (EFV) in treatment-naive, HIV-1-infected adults. Design: A 48-week, randomized, double-blind, double-dummy phase 2b trial at 43 institutions (USA and Puerto Rico). Methods: Study participants (HIV-1 RNA ≥1000 copies/ml, CD4+ cell count ≥200 cells/μl, C-C chemokine receptor type 5-tropic virus) were randomized 2 : 2 : 1 to CVC 100 mg (CVC100), CVC 200 mg (CVC200), or EFV 600 mg, each administered with emtricitabine/tenofovir disoproxil fumarate. Key end points were virologic success (HIV-1 RNA <50 copies/ml) at week 24 (primary) and week 48 (secondary), safety/tolerability at weeks 24 and 48. Study sites and patients remained blinded until week 48. Results: A total of 143 patients were randomized (CVC100, n = 59; CVC200, n = 56; EFV, n = 28). Virologic success was obtained at week 24 in 76, 73, and 71% of study participants for CVC100, CVC200, and EFV, respectively (all P > 0.05 versus EFV), and at week 48 in 68, 64, and 50%, respectively (all P > 0.05 versus EFV). Resistance mutations emerged in five and zero CVC and EFV-treated study participants, respectively. Virologic nonresponse and nucleoside reverse transcriptase inhibitor resistance decreased when CVC minimum plasma concentration was at least 47.8 ng/ml. Treatment-related adverse events of at least grade 2 and discontinuations because of adverse events were less frequent in CVC-treated study participants. Total and low-density lipoprotein cholesterol decreased with CVC, but increased with EFV. C-C chemokine ligand type 2 (CCL2) (aka monocyte chemotactic protein-1) increased in a dose-dependent manner, whereas soluble CD14 levels decreased with CVC. Conclusion: CVC showed efficacy and favorable safety in treatment-naive HIV-1-infected study participants, supporting selection of CVC200 for phase 3 studies. Trial registration: NCT01338883.
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165
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Lindeman TA, Duggan JM, Sahloff EG. Evaluation of Serum Creatinine Changes With Integrase Inhibitor Use in Human Immunodeficiency Virus-1 Infected Adults. Open Forum Infect Dis 2016; 3:ofw053. [PMID: 27092314 PMCID: PMC4831579 DOI: 10.1093/ofid/ofw053] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 03/03/2016] [Indexed: 12/21/2022] Open
Abstract
This retrospective chart review evaluated changes in serum creatinine and creatinine clearance (CrCl) after initiation of an integrase inhibitor (INSTI)-based regimen as initial treatment in human immunodeficiency virus-infected adults. Serum creatinine and CrCl changes were similar to those seen in clinical trials for INSTIs. No renal-related serious adverse events or discontinuations occurred.
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Affiliation(s)
- Tara A Lindeman
- PGY-2 Infectious Diseases Pharmacy Resident, VA St. Louis Healthcare System , Missouri
| | - Joan M Duggan
- Division of Infectious Diseases , College of Medicine and Life Sciences
| | - Eric G Sahloff
- College of Pharmacy and Pharmaceutical Sciences, University of Toledo , Ohio
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Runja C, Kumar PR, Avanapu SR. A Validated Stability Indicating RP-HPLC Method for the Determination of Emtricitabine, Tenofovir Disoproxil Fumarate, Elvitegravir and Cobicistat in Pharmaceutical Dosage Form. J Chromatogr Sci 2016; 54:759-64. [PMID: 26865655 DOI: 10.1093/chromsci/bmw004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Indexed: 11/12/2022]
Abstract
A new simple, rapid stability indicating assay method has been developed and validated for the determination of emtricitabine, tenofovir disoproxil fumarate, elvitegravir and cobicistat using reverse-phase high-performance liquid chromatography in their pharmaceutical dosage form. The chromatographic separation was performed on an ODS column (250 × 4.6 mm, 5 µm) using mobile phase A (potassium dihydrogen orthophosphate, pH adjusted to 2.5) and mobile phase B (acetonitrile) in the ratio of 55:45% v/v at a flow rate of 1 mL/min. The analytes were detected at 250 nm. The method was found to be linear in the concentration range of 2-12 µg/mL for EMT, 3-18 µg/mL for TNDF, 1.5-9 µg/mL for ELV and COB, with the coefficient value (R(2)) of >0.9990. The accuracy was measured via recovery studies and found to be acceptable, and the percentage recoveries were found in the range of 99.93-100.08 ± 0.5%. Forced degradation studies were also conducted, and the drugs were subjected to various stress conditions such as acid hydrolysis, base hydrolysis, oxidative, photolytic and thermal degradation. The proposed method was successfully validated and applied for the quantitative estimation of these drugs in both bulk and tablet dosage forms.
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Affiliation(s)
- Chinnalalaiah Runja
- Department of Pharmaceutical Chemistry, Joginpally B.R. Pharmacy College, Moinabad, Hyderabad 500 075, Telangana, India
| | | | - Srinivasa Rao Avanapu
- Department of Pharmacology, Bhaskar Pharmacy College, Moinabad, Hyderabad 500 075, Telangana, India
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167
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Switching to Coformulated Rilpivirine/Emtricitabine/Tenofovir in Virologically Suppressed Patients: Data From a Multicenter Cohort. J Acquir Immune Defic Syndr 2016; 70:e147-50. [PMID: 26090757 DOI: 10.1097/qai.0000000000000727] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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168
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Sweet DE, Altice FL, Cohen CJ, Vandewalle B. Cost-Effectiveness of Single- Versus Generic Multiple-Tablet Regimens for Treatment of HIV-1 Infection in the United States. PLoS One 2016; 11:e0147821. [PMID: 26808503 PMCID: PMC4725959 DOI: 10.1371/journal.pone.0147821] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 01/08/2016] [Indexed: 11/17/2022] Open
Abstract
Background The possibility of incorporating generics into combination antiretroviral therapy and breaking apart once-daily single-tablet regimens (STRs), may result in less efficacious medications and/or more complex regimens with the expectation of marked monetary savings. A modeling approach that assesses the merits of such policies in terms of lifelong costs and health outcomes using adherence and effectiveness data from real-world U.S. settings. Methods A comprehensive computer-based microsimulation model was developed to assess the lifetime health (life expectancy and quality adjusted life-years—QALYs) and economic outcomes in HIV-1 infected patients initiating STRs compared with multiple-table regimens including generic medications where possible (gMTRs). The STRs considered included tenofovir disoproxil fumarate/emtricitabine and efavirenz or rilpivirine or elvitegravir/cobicistat. gMTRs substitutions included each counterpart to STRs, including generic lamivudine for emtricitabine and generic versus branded efavirenz. Results Life expectancy is estimated to be 1.301 years higher (discounted 0.619 QALY gain) in HIV-1 patients initiating a single-tablet regimen in comparison to a generic-based multiple-table regimen. STRs were associated with an average increment of $26,547.43 per patient in medication and $1,824.09 in other medical costs due to longer survival which were partially offset by higher inpatients costs ($12,035.61) with gMTRs treatment. Overall, STRs presented incremental lifetime costs of $16,335.91 compared with gMTRs, resulting in an incremental cost-effectiveness ratio of $26,383.82 per QALY gained. Conclusions STRs continue to represent good value for money under contemporary cost-effectiveness thresholds despite substantial price reductions of generic medications in the U. S.
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Affiliation(s)
- Donna E Sweet
- Internal Medicine, The University of Kansas School of Medicine-Wichita, Wichita, Kansas, United States of America
| | - Frederick L Altice
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Calvin J Cohen
- CRI New England, Boston, Massachusetts, United States of America
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169
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Young CJ. Updates on the Pharmacologic Treatment of Individuals with Human Immunodeficiency Virus. Nurs Clin North Am 2016; 51:45-56. [PMID: 26897423 DOI: 10.1016/j.cnur.2015.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Human immunodeficiency virus has been affecting the human population for more than 30 years. During this time period, more effective, safe, simple, and tolerable pharmacologic agents have been developed. To date, there are 26 antiretroviral agents available that are used either as a single agent or a coformulation in an antiretroviral regimen. The goal of these medications is to achieve viral suppression in individuals infected with human immunodeficiency virus. Evidence continues to support the most effective combinations. It is important that clinicians are knowledgeable of updates so as to provide the best possible medical regimen for this population.
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Affiliation(s)
- Courtney J Young
- Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240, USA.
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170
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Sarfo FS, Sarfo MA, Chadwick D. Incidence and risk factors for neuropsychiatric events among Ghanaian HIV patients on long-term non-nucleoside reverse transcriptase inhibitor-based therapy. eNeurologicalSci 2016; 3:21-25. [PMID: 29430531 PMCID: PMC5803068 DOI: 10.1016/j.ensci.2015.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 12/26/2015] [Accepted: 12/28/2015] [Indexed: 11/29/2022] Open
Abstract
Background Non-nucleoside reverse transcriptase inhibitor (NNRTI)-based antiretroviral therapy (ART) is associated with neuropsychiatric toxicity. Little is known about the risk of short- and long-term neuropsychiatric toxicity in sub-Saharan Africa, where NNRTIs are widely used in first-line combination ART. This observational study assessed the risk of neuropsychiatric toxicity in Ghanaian patients starting first-line ART between 2004 and 2010 at a single centre. Methods In this retrospective observational study, frequencies of documented neuropsychiatric toxicity events were assessed and time to events calculated using a Kaplan–Meier analysis. Associations of neuropsychiatric toxicity with specific NNRTIs and other explanatory variables were examined using Cox proportional hazards modelling. Results Of 3999 patients initiating NNRTI-based ART, who were followed for a median of 30 (0.25–90) months (11,237 person years), 218 (5.5%) reported symptoms of neuropsychiatric toxicity at a rate of 21.4 events per 1000 person-years (95% CI, 18.8–24.2/1000 py). Events were more common with efavirenz than nevirapine (7.6% versus 2.4%), were usually reported within the first 2 months of ART initiation and persisted up to 84 months in a few patients. The most commonly reported neuropsychiatric adverse drug reactions were insomnia (50%), headaches (8%), dizziness (7%) and abnormal dreams (6%). The factors independently associated with neuropsychiatric toxicity were BMI < 16 kg/m2 (aHR of 1.44 [95% CI, 1.02–2.03]) and use of efavirenz (aHR 3.29 [95% CI, 2.32–4.69]). Substitution of NNRTI on account of toxicity was reported in up to 17% of patients experiencing neuropsychiatric events. Conclusions NNRTI-related neuropsychiatric toxicity, mainly due to efavirenz, was infrequently documented in this Ghanaian cohort under routine clinical care settings. Regimens with more favourable tolerability will be needed as first-line agents in sub-Saharan Africa in the coming years. Millions of patients living with HIV AIDS in sub-Saharan Africa are initiated on an efavirenz-based combination antiretroviral therapy which is frequently associated with neuropsychiatric toxicity. In this retrospective study involving 3999 Ghanaian HIV-infected patients initiating therapy between 2004 and 2010, neuropsychiatric toxicity was documented in 5.5% with a higher incidence among efavirenz recipients (7.6%) compared with nevirapine recipients (2.4%). Peak neuropsychiatric adverse events occurred within the first two months upon initiating therapy with some few further events occurring as later on during 90 months of follow-up. Up to 17% of patients reporting neuropsychiatric toxicity had treatment modifications as a result.
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Affiliation(s)
- Fred S Sarfo
- Komfo Anokye Teaching Hospital, Kumasi, Ghana.,Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
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Llibre JM, Walmsley S, Gatell JM. Backbones versus core agents in initial ART regimens: one game, two players. J Antimicrob Chemother 2016; 71:856-61. [PMID: 26747092 DOI: 10.1093/jac/dkv429] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The advances seen in ART during the last 30 years have been outstanding. Treatment has evolved from the initial use of single agents as monotherapy. The ability to use HIV RNA as a surrogate marker for clinical outcomes allowed the more rapid evaluation of new therapies. This led to the understanding that triple-drug regimens, including a core agent (an NNRTI or a boosted PI) and two NRTIs, are optimal. These combinations have demonstrated continued improvements in their efficacy and toxicity as initial therapy. However, the need for pharmacokinetic boosting, with potential drug-drug interactions, or residual issues of efficacy or toxicity have persisted for some agents. Most recently, integrase strand transfer inhibitors, particularly dolutegravir, have shown unparalleled safety and efficacy and are currently the core agents of choice. Regimens that included only core agents or only backbone agents have not been as successful as combined therapy in antiretroviral-naive patients. It appears that at least one NRTI is needed for optimal performance and lamivudine and emtricitabine may be the ideal candidates. Several studies are ongoing of agents with longer dosing intervals, lower cost and new NRTI-saving strategies to address unmet needs.
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Affiliation(s)
- Josep M Llibre
- HIV Unit and 'Lluita contra la SIDA' Foundation, University Hospital Germans Trias I Pujol, Badalona, Spain Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sharon Walmsley
- Infectious Diseases, University Health Network, University of Toronto, Toronto, Canada
| | - Josep M Gatell
- Infectious Diseases & AIDS Units, Hospital Clinic/IDIBAPS, University of Barcelona, Barcelona, Spain
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Kubicka J, Gizińska J, Kowalska J, Siwak E, Swiecki P, Pulik P, Szulborska B, Burkacka-Firlag E, Horban A. Efavirenz as component of initial combination antiretroviral therapy – Data from the Polish Observational Cohort of HIV/AIDS Patients (POLCA) Study Group. HIV & AIDS REVIEW 2016. [DOI: 10.1016/j.hivar.2016.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Custodio JM, Gordi T, Zhong L, Ling KHJ, Ramanathan S. Population Pharmacokinetics of Boosted-Elvitegravir in HIV-Infected Patients. J Clin Pharmacol 2015; 56:723-32. [PMID: 26449283 DOI: 10.1002/jcph.657] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 10/04/2015] [Accepted: 10/05/2015] [Indexed: 11/11/2022]
Abstract
Elvitegravir (EVG) is an HIV strand transfer integrase inhibitor approved for the treatment of HIV infection as a part of antiretroviral regimens containing cobicistat (COBI) or ritonavir (RTV) as a booster. The population pharmacokinetics of EVG in treatment-naive and -experienced HIV patients was determined, and the effects of demographic, biometric, and formulation covariates on EVG pharmacokinetics (PK) were evaluated. Data from 31 clinical studies (25 in healthy subjects, 6 phase 1b to phase 3 in HIV-1-infected patients) with COBI-boosted EVG studies (as EVG/co or EVG/COBI/FTC/TDF single-tablet regimen) or RTV-boosted EVG studies (EVG/r) were analyzed using NONMEM. The effect of the covariates age, sex, race, health status (healthy volunteers vs HIV patients), weight, body mass index (BMI), body surface area (BSA), creatinine clearance (estimated GFR), and formulation were evaluated. EVG PK, with COBI or RTV, was described by a 2-compartment model, with first-order absorption and elimination and an absorption lag time. A statistically significant, but not clinically relevant, effect of BSA on EVG clearance (CL) was observed. Coadministration of atazanavir or lopinavir with EVG/r had an effect on EVG CL consistent with the known interaction with these agents. No other covariate had a meaningful effect on EVG PK. EVG PK was well described in a population PK model with HIV-infected patients, with low PK variability and no relevant effect of demographic or biometric covariates.
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Affiliation(s)
| | - Toufigh Gordi
- Ziba Drug Development Partners, San Carlos, CA, 94070
| | - Lijie Zhong
- Gilead Sciences, Inc, Foster City, CA, 94404
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Garner W, White K, Szwarcberg J, McCallister S, Zhong L, Wulfsohn M. Concordance of HIV-1 RNA Values by Amplicor and TaqMan 2.0 in Patients With Confirmed Suppression in Clinical Trials. Clin Infect Dis 2015; 62:929-934. [PMID: 26689956 DOI: 10.1093/cid/civ1034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 12/04/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The COBAS AMPLICOR HIV-1 MONITOR Test, version 1.5 (Amplicor) has been replaced with the COBAS AmpliPrep/COBAS TaqMan HIV-1 Test, version 2.0 (TaqMan 2.0), a real-time polymerase chain reaction human immunodeficiency virus type 1 (HIV-1) assay with higher sensitivity and broader dynamic range. HIV-1 RNA values at the 50 copies/mL cutoff drive major patient management decisions and clinical study outcomes. METHODS A total of 2217 samples were collected from 1922 HIV-1-infected subjects taking antiretroviral therapy for at least 48 weeks and had at least 2 consecutive samples with HIV-1 RNA <50 copies/mL by Amplicor from 7 recent clinical trials. HIV-1 RNA results were obtained from the Amplicor and TaqMan 2.0 assays in parallel by a reference laboratory. RESULTS The overall concordance between assay results was 96% at the cutoff of 50 copies/mL. However, statistically significant discordance at the 50 copies/mL cutoff was found between the assays for 3.9% of samples (n = 87). By TaqMan 2.0, virologic failure defined as HIV-1 RNA ≥ 50 copies/mL was reported for 2.8% more samples than Amplicor. Of these 87 samples, 68 samples fell within the predicted range of assay variability. Retesting of HIV-1 RNA by TaqMan 2.0 confirmed the discordance in only 28 of the 87 samples. CONCLUSIONS The TaqMan 2.0 assay reports fewer subjects below the clinical endpoint of HIV-1 RNA <50 copies/mL in HIV clinical trials than the Amplicor assay. This difference must be considered when assessing disease progression, designing clinical trials, and comparisons with historical trials that used the Amplicor assay.
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Affiliation(s)
- Will Garner
- Gilead Sciences, Inc, Foster City, California
| | | | | | | | - Lijie Zhong
- Gilead Sciences, Inc, Foster City, California
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Schackman BR, Haas DW, Park SS, Li XC, Freedberg KA. Cost-effectiveness of CYP2B6 genotyping to optimize efavirenz dosing in HIV clinical practice. Pharmacogenomics 2015; 16:2007-18. [PMID: 26607811 PMCID: PMC4832977 DOI: 10.2217/pgs.15.142] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
AIMS To assess the cost-effectiveness of CYP2B6 genotyping to guide efavirenz dosing for initial HIV therapy in the USA. METHODS We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) microsimulation model to project quality-adjusted life expectancy and lifetime costs (2014 US dollars) for efavirenz-based HIV therapy with or without CYP2B6 genotyping. We assumed that with genotyping 60% of patients would be eligible to receive lower doses. RESULTS Current care without CYP2B6 genotyping has an incremental cost-effectiveness ratio >$100,000/QALY compared with genotype-guided dosing, even if lower dosing reduces efficacy. When we assumed generic efavirenz availability, conclusions were similar unless lower dosing reduces efficacy by 6% or more. CONCLUSION CYP2B6 genotyping can inform efavirenz dosing and decrease HIV therapy cost.
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Affiliation(s)
- Bruce R Schackman
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY, USA
| | - David W Haas
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Sanghee S Park
- Medical Practice Evaluation Center, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - X Cynthia Li
- Medical Practice Evaluation Center, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Health Policy & Management, Harvard TH Chan School of Public Health, Boston, MA, USA
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IAPAC Guidelines for Optimizing the HIV Care Continuum for Adults and Adolescents. J Int Assoc Provid AIDS Care 2015; 14 Suppl 1:S3-S34. [PMID: 26527218 DOI: 10.1177/2325957415613442] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND An estimated 50% of people living with HIV (PLHIV) globally are unaware of their status. Among those who know their HIV status, many do not receive antiretroviral therapy (ART) in a timely manner, fail to remain engaged in care, or do not achieve sustained viral suppression. Barriers across the HIV care continuum prevent PLHIV from achieving the therapeutic and preventive effects of ART. METHODS A systematic literature search was conducted, and 6132 articles, including randomized controlled trials, observational studies with or without comparators, cross-sectional studies, and descriptive documents, met the inclusion criteria. Of these, 1047 articles were used to generate 36 recommendations to optimize the HIV care continuum for adults and adolescents. RECOMMENDATIONS Recommendations are provided for interventions to optimize the HIV care environment; increase HIV testing and linkage to care, treatment coverage, retention in care, and viral suppression; and monitor the HIV care continuum.
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Pei PP, Weinstein MC, Li XC, Hughes MD, Paltiel AD, Hou T, Parker RA, Gaynes MR, Sax PE, Freedberg KA, Schackman BR, Walensky RP. Prioritizing HIV comparative effectiveness trials based on value of information: generic versus brand-name ART in the US. HIV CLINICAL TRIALS 2015; 16:207-18. [PMID: 26651525 PMCID: PMC4718767 DOI: 10.1080/15284336.2015.1123942] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Value of Information (VOI) analysis examines whether to acquire information before making a decision. We introduced VOI to the HIV audience, using the example of generic antiretroviral therapy (ART) in the US. METHODS AND FINDINGS We used a mathematical model and probabilistic sensitivity analysis (PSA) to generate probability distributions of survival (in quality-adjusted life years, QALYs) and cost for three potential first-line ART regimens: three-pill generic, two-pill generic, and single-pill branded. These served as input for a comparison of two hypothetical two-arm trials: three-pill generic versus single-pill branded; and two-pill generic versus single-pill branded. We modeled pre-trial uncertainty by defining probability distributions around key inputs, including 24-week HIV-RNA suppression and subsequent ART failure. We assumed that, without a trial, patients received the single-pill branded strategy. Post-trial, we assumed that patients received the most cost-effective strategy. For both trials, we quantified the probability of changing to a generic-based regimen upon trial completion and the expected VOI in terms of improved health outcomes and costs. Assuming a willingness to pay (WTP) threshold of $100 000/QALY, the three-pill trial led to more treatment changes (84%) than the two-pill trial (78%). Estimated VOI was $48 000 (three-pill trial) and $35 700 (two-pill trial) per future patient initiating ART. CONCLUSIONS A three-pill trial of generic ART is more likely to lead to post-trial treatment changes and to provide more value than a two-pill trial if policy decisions are based on cost-effectiveness. Value of Information analysis can identify trials likely to confer the greatest impact and value for HIV care.
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Affiliation(s)
- Pamela P. Pei
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Milton C. Weinstein
- Harvard School of Public Health, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - X. Cynthia Li
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | - Taige Hou
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Robert A. Parker
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Melanie R. Gaynes
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Paul E. Sax
- Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kenneth A. Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
- Harvard School of Public Health, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Bruce R. Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Rochelle P. Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts
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Safety, Pharmacokinetics and Efficacy of Dolutegravir in Treatment-experienced HIV-1 Infected Adolescents: Forty-eight-week Results from IMPAACT P1093. Pediatr Infect Dis J 2015; 34:1207-13. [PMID: 26244832 PMCID: PMC4604048 DOI: 10.1097/inf.0000000000000848] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess the pharmacokinetics (PK), safety and efficacy of dolutegravir plus optimized background regimen in HIV-infected treatment-experienced adolescents. METHODS Children older than 12 to younger than 18 years received dolutegravir weight-based fixed doses at approximately 1.0 mg/kg once daily in a phase I/II multicenter open label 48-week study. Intensive PK evaluation was done at steady state after dolutegravir was added to a failing regimen or started at the end of a treatment interruption. Safety and HIV RNA and CD4 cell count assessments were performed through week 48. RESULTS Twenty-three adolescents were enrolled and 22 (96%) completed the 48-week study visit. Median age and weight were 15 years and 52 kg, respectively. Median [interquartile range (IQR)] baseline CD4+ cell count was 466 cells/μL (297, 771). Median (IQR) baseline HIV-1 RNA log10 was 4.3 log10 copies/mL (3.9, 4.6). Dolutegravir geometric mean of the area under the plasma concentration-time curve from time of administration to 24 hours after dosing (AUC0-24) and 24 hour postdose concentration (C24) were 46.0 μg hours/mL and 0.90 μg/mL, respectively, which were within the study targets based on adult PK ranges. Virologic success with an HIV RNA <400 copies/mL was achieved in 74% [95% confidence interval (CI): 52-90%] at week 48. Additionally, 61% (95% CI: 39-80%) had an HIV RNA <50 copies/mL at week 48. Median (IQR) gain in CD4 cell count at week 48 was 84 cells/μL (-81, 238). Dolutegravir was well tolerated, with no grade 4 adverse events, serious adverse events or discontinuations because of serious adverse events. CONCLUSIONS Dolutegravir achieved target PK exposures in adolescents. Dolutegravir was safe and well tolerated, providing good virologic efficacy through week 48.
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Pontali E, Sotgiu G, Centis R, D’Ambrosio L, Spanevello A, Migliori GB. Management of drug resistantTB in patients with HIV co-infection. Expert Opin Pharmacother 2015; 16:2737-50. [DOI: 10.1517/14656566.2015.1100169] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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181
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Clay PG, Nag S, Graham CM, Narayanan S. Meta-Analysis of Studies Comparing Single and Multi-Tablet Fixed Dose Combination HIV Treatment Regimens. Medicine (Baltimore) 2015; 94:e1677. [PMID: 26496277 PMCID: PMC4620781 DOI: 10.1097/md.0000000000001677] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 08/21/2015] [Accepted: 09/02/2015] [Indexed: 01/08/2023] Open
Abstract
Availability of a single source review of once-daily fixed-dose single tablet regimen (STR) and multiple tablet fixed-dose regimen (MTR) would optimally inform healthcare providers and policy makers involved in the management of population with human immunodeficiency virus (HIV).We conducted a meta-analysis of published literature to compare patient adherence, clinical, and cost outcomes of STR to MTR.Published literature in English between 2005 and 2014 was searched using Embase, PubMed (Medline in-process), and ClinicalTrials.Gov databases. Two-level screening was undertaken by 2 independent researchers to finalize articles for evidence synthesis. Adherence, efficacy, safety, tolerability, healthcare resource use (HRU), and costs were assessed comparing STR to MTR. A random-effects meta-analysis was performed and heterogeneity examined using meta-regression.Thirty-five articles were identified for qualitative evidence synthesis, of which 9 had quantifiable data for meta-analysis (4 randomized controlled trials and 5 observational studies). Patients on STR were significantly more adherent when compared to patients on MTR of any frequency (odds ratio [OR]: 2.37 [95% CI: 1.68, 3.35], P < 0.001; 4 studies), twice-daily MTR (OR: 2.53 [95% CI: 1.13, 5.66], P = 0.02; 2 studies), and once-daily MTR (OR: 1.81 [95% CI: 1.15, 2.84], P = 0.01; 2 studies). The relative risk (RR) for viral load suppression at 48 weeks was higher (RR: 1.09 [95% CI: 1.04, 1.15], P = .0003; 3 studies) while RR of grade 3 to 4 laboratory abnormalities was lower among patients on STR (RR: 0.68 [95% CI: 0.49, 0.94], P = 0.02; 2 studies). Changes in CD4 count at 48 weeks, any severe adverse events (SAEs), grade 3 to 4 AEs, mortality, and tolerability were found comparable between STR and MTR. Several studies reported significant reduction in HRU and costs among STR group versus MTR.Study depicted comparable tolerability, safety (All-SAE and Grade 3-4 AE), and mortality and fewer Grade 3 to 4 lab abnormalities and better viral load suppression and adherence among patients on FDC-containing STR versus MTR; literature depicted favorable HRU and costs for STRs.These findings may help decision makers especially in resource-poor settings to plan for optimal HIV disease management when the choice of both STRs and MTRs are available.
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Affiliation(s)
- P G Clay
- From the University of North Texas System College of Pharmacy, Fort Worth, TX, USA (PGC) and Ipsos Healthcare, Global Evidence, Value and Access Center of Excellence, Washington, DC, USA (SN, CMG, SN)
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Ferrer E, Curto J, Esteve A, Miro JM, Tural C, Murillas J, Segura F, Barrufet P, Casabona J, Podzamczer D. Clinical progression of severely immunosuppressed HIV-infected patients depends on virological and immunological improvement irrespective of baseline status. J Antimicrob Chemother 2015; 70:3332-8. [PMID: 26410171 DOI: 10.1093/jac/dkv272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 08/05/2015] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim of this study was to analyse factors associated with progression to AIDS/death in severely immunosuppressed HIV-infected patients receiving ART. METHODS This study included naive patients from the PISCIS Cohort with CD4 <200 cells/mm(3) at enrolment and who initiated ART consisting of two nucleoside analogues plus either a PI or an NNRTI between 1998 and 2011. The PISCIS Cohort is a multicentre, observational study of HIV-infected individuals aged >18 years followed at 14 participating hospitals in Catalonia and the Balearic Islands (Spain). Clinical and laboratory parameters were assessed every 3-4 months during follow-up. Cox regression models were used to assess the effect of CD4 and viral load on the risk of progression to AIDS/death, adjusting for baseline variables and confounders. RESULTS 2295 patients were included and, after 5 years, 69.9% reached CD4 ≥200 cells/mm(3), 64.4% had an undetectable viral load and 482 (21%) progressed to AIDS/death. The lowest rate of disease progression was found in patients who reached both immunological and viral responses during follow-up, regardless of their baseline situation (1.9% in baseline CD4 >100 cells/mm(3) and viral load <5 log copies/mL; 2.3% in baseline CD4 ≤100 cells/mm(3) and/or viral load >5 log copies/mL). Achieving a CD4 count ≥200 cells/mm(3) was the main predictor of decreased progression to AIDS/death. In those not reaching this CD4 threshold, virological response reduced disease progression by half. CONCLUSIONS Even in the worse baseline scenario of CD4 ≤100 cells/mm(3) and high baseline viral loads, positive virological and immunological responses were associated with dramatic decreases in progression.
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Affiliation(s)
- Elena Ferrer
- HIV Unit, Infectious Disease Service, Hospital Universitari de Bellvitge, L'Hospitalet del Llobregat, 08907 Barcelona, Spain
| | - Jordi Curto
- HIV Unit, Infectious Disease Service, Hospital Universitari de Bellvitge, L'Hospitalet del Llobregat, 08907 Barcelona, Spain Department of Public Health, Mental Health and Perinatal Nursing, University School of Nursing, Campus de Bellvitge-Pavelló de Govern, Feixa Llarga, s/n L'Hospitalet del Llobregat, 08907 Barcelona, Spain
| | - Anna Esteve
- Centre for Epidemiological Studies on HIV/STI in Catalonia (CEEISCAT), Agencia de Salut Publica de Catalunya (ASPC), Generalitat de Catalunya, 08916 Badalona, Spain CIBER Epidemiología y Salud Pública (CIBERESP), 08036 Barcelona, Spain Fundació Institut d'Investigació Germans Trias i Pujol (IGTP), 08916 Badalona, Spain Department of Paediatrics, Obstetrics and Gynaecology, and Preventive Medicine, Universitat Autónoma de Barcelona, 08193 Bellaterra (Cerdanyola del Vallés), Spain
| | - Jose M Miro
- Infectious Diseases Service, Hospital Clinic-IDIBAPS, University of Barcelona, Hospital Clinic, Villarroel, 170, 08036 Barcelona, Spain
| | - Cristina Tural
- Fundació Lluita contra la SIDA, Hospital Universitari Germans Trias i Pujol, 2a planta Maternal, Ctra. de Canyet s/n, 08916 Badalona, Barcelona, Spain
| | - Javier Murillas
- Infectious Diseases Service, Hospital Son Dureta, C/ Andrea Doria, 55, 07014 Palma de Mallorca, Spain
| | - Ferran Segura
- Infectious Diseases Service, Corporació Sanitaria i Universitaria Parc Taulí, 08208 Sabadell, Universitat Autónoma de Barcelona, 08193 Bellaterra (Cerdanyola del Vallés), Spain
| | - Pilar Barrufet
- Internal Medicine Unit, Hospital de Mataró, C/ Cirera sn. Mataró, 08304 Barcelona, Spain
| | - Jordi Casabona
- Centre for Epidemiological Studies on HIV/STI in Catalonia (CEEISCAT), Agencia de Salut Publica de Catalunya (ASPC), Generalitat de Catalunya, 08916 Badalona, Spain CIBER Epidemiología y Salud Pública (CIBERESP), 08036 Barcelona, Spain Fundació Institut d'Investigació Germans Trias i Pujol (IGTP), 08916 Badalona, Spain Department of Paediatrics, Obstetrics and Gynaecology, and Preventive Medicine, Universitat Autónoma de Barcelona, 08193 Bellaterra (Cerdanyola del Vallés), Spain
| | - Daniel Podzamczer
- HIV Unit, Infectious Disease Service, Hospital Universitari de Bellvitge, L'Hospitalet del Llobregat, 08907 Barcelona, Spain
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Characterization of the Drug Resistance Profiles of Integrase Strand Transfer Inhibitors in Simian Immunodeficiency Virus SIVmac239. J Virol 2015; 89:12002-13. [PMID: 26378179 DOI: 10.1128/jvi.02131-15] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 09/11/2015] [Indexed: 11/20/2022] Open
Abstract
UNLABELLED We previously showed that the simian immunodeficiency virus SIVmac239 is susceptible to human immunodeficiency virus (HIV) integrase (IN) strand transfer inhibitors (INSTIs) and that the same IN drug resistance mutations result in similar phenotypes in both viruses. Now we wished to determine whether tissue culture drug selection studies with SIV would yield the same resistance mutations as in HIV. Tissue culture selection experiments were performed using rhesus macaque peripheral blood mononuclear cells (PBMCs) infected with SIVmac239 viruses in the presence of increasing concentrations of dolutegravir (DTG), elvitegravir (EVG), and raltegravir (RAL). We now show that 22 weeks of selection pressure with DTG yielded a mutation at position R263K in SIV, similar to what has been observed in HIV, and that selections with EVG led to emergence of the E92Q substitution, which is a primary INSTI resistance mutation in HIV associated with EVG treatment failure. To study this at a biochemical level, purified recombinant SIVmac239 wild-type (WT) and E92Q, T97A, G118R, Y143R, Q148R, N155H, R263K, E92Q T97A, E92Q Y143R, R263K H51Y, and G140S Q148R recombinant substitution-containing IN enzymes were produced, and each of the characteristics strand transfer, 3'-processing activity, and INSTI inhibitory constants was assessed in cell-free assays. The results show that the G118R and G140S Q148R substitutions decreased Km' and Vmax'/Km' for strand transfer compared to those of the WT. RAL and EVG showed reduced activity against both viruses and against enzymes containing Q148R, E92Q Y143R, and G140S Q148R. Both viruses and enzymes containing Q148R and G140S Q148R showed moderate levels of resistance against DTG. This study further confirms that the same mutations associated with drug resistance in HIV display similar profiles in SIV. IMPORTANCE Our goal was to definitively establish whether HIV and simian immunodeficiency virus (SIV) share similar resistance pathways under tissue culture drug selection pressure with integrase strand transfer inhibitors and to test the effect of HIV-1 integrase resistance-associated mutations on SIV integrase catalytic activity and resistance to integrase strand transfer inhibitors. Clinically relevant HIV integrase resistance-associated mutations were selected in SIV in our tissue culture experiments. Not only do we report on the characterization of SIV recombinant integrase enzyme catalytic activities, we also provide the first research anywhere on the effect of mutations within recombinant integrase SIV enzymes on drug resistance.
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Cuffe R, Barnett C, Granier C, Machida M, Wang C, Roger J. Missing CD4+ cell response in randomized clinical trials of maraviroc and dolutegravir. HIV CLINICAL TRIALS 2015; 16:170-7. [PMID: 26365498 DOI: 10.1179/1945577115y.0000000003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Missing data can compromise inferences from clinical trials, yet the topic has received little attention in the clinical trial community. Shortcomings in commonly used methods used to analyze studies with missing data (complete case, last- or baseline-observation carried forward) have been highlighted in a recent Food and Drug Administration-sponsored report. This report recommends how to mitigate the issues associated with missing data. We present an example of the proposed concepts using data from recent clinical trials. METHODS CD4+ cell count data from the previously reported SINGLE and MOTIVATE studies of dolutegravir and maraviroc were analyzed using a variety of statistical methods to explore the impact of missing data. Four methodologies were used: complete case analysis, simple imputation, mixed models for repeated measures, and multiple imputation. We compared the sensitivity of conclusions to the volume of missing data and to the assumptions underpinning each method. RESULTS Rates of missing data were greater in the MOTIVATE studies (35%-68% premature withdrawal) than in SINGLE (12%-20%). The sensitivity of results to assumptions about missing data was related to volume of missing data. Estimates of treatment differences by various analysis methods ranged across a 61 cells/mm3 window in MOTIVATE and a 22 cells/mm3 window in SINGLE. CONCLUSIONS Where missing data are anticipated, analyses require robust statistical and clinical debate of the necessary but unverifiable underlying statistical assumptions. Multiple imputation makes these assumptions transparent, can accommodate a broad range of scenarios, and is a natural analysis for clinical trials in HIV with missing data.
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Comparative Safety and Neuropsychiatric Adverse Events Associated With Efavirenz Use in First-Line Antiretroviral Therapy: A Systematic Review and Meta-Analysis of Randomized Trials. J Acquir Immune Defic Syndr 2015; 69:422-9. [PMID: 25850607 DOI: 10.1097/qai.0000000000000606] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Efavirenz (EFV) is widely used for the treatment of antiretroviral-naive HIV-positive individuals, but there are concerns about the risk of adverse neuropsychiatric events. We systematically reviewed the safety of EFV in first-line therapy. METHODS Four databases were searched until October 2014 for randomized trials comparing EFV against non-EFV-based regimens for the treatment of antiretroviral-naive HIV-positive adults and children. The primary outcome was drug discontinuation as a result of any adverse event. Relative risks and proportions were pooled using random-effects meta-analysis. RESULTS Forty-two trials were included for review. A lower relative and absolute risk of discontinuations due to adverse drug reactions was seen with EFV compared to nevirapine. The relative and absolute risk of discontinuation was greater for EFV compared with low-dose EFV, rilpivirine, tenofovir, atazanavir, and maraviroc. The relative risk of discontinuation was greater for EFV compared with dolutegravir and raltegravir, but absolute risks were not significantly different. There was no difference in the risk of any severe clinical adverse events for any comparison. With the exception of dizziness, fewer than 10% of patients exposed to EFV experienced any other specific type of neuropsychiatric event. No suicides were reported. CONCLUSIONS This review found that over 90% of patients remained on an EFV-based first-line regimen after an average follow-up time of 78 weeks. The relative risk of discontinuations due to adverse events was higher for EFV compared with most other first-line options, but absolute differences were less than 5% for all comparisons.
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Genome-wide association study of virologic response with efavirenz-containing or abacavir-containing regimens in AIDS clinical trials group protocols. Pharmacogenet Genomics 2015; 25:51-9. [PMID: 25461247 DOI: 10.1097/fpc.0000000000000106] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Efavirenz and abacavir are components of recommended first-line regimens for HIV-1 infection. We used genome-wide genotyping and clinical data to explore genetic associations with virologic failure among patients randomized to efavirenz-containing or abacavir-containing regimens in AIDS Clinical Trials Group (ACTG) protocols. PARTICIPANTS AND METHODS Virologic response and genome-wide genotype data were available from treatment-naive patients randomized to efavirenz-containing (n=1596) or abacavir-containing (n = 786) regimens in ACTG protocols 384, A5142, A5095, and A5202. RESULTS Meta-analysis of association results across race/ethnic groups showed no genome-wide significant associations (P < 5 × 10) with virologic response for either efavirenz or abacavir. Our sample size provided 80% power to detect a genotype relative risk of 1.8 for efavirenz and 2.4 for abacavir. Analyses focused on CYP2B genotypes that define the lowest plasma efavirenz exposure stratum did not show associations nor did analysis limited to gene sets predicted to be relevant to efavirenz and abacavir disposition. CONCLUSION No single polymorphism is associated strongly with virologic failure with efavirenz-containing or abacavir-containing regimens. Analyses to better consider context, and that minimize confounding by nongenetic factors, may show associations not apparent here.
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Suttels V, Florence E, Leys J, Vekemans M, Van den Ende J, Vlieghe E, Kenyon C. A 68-year old male presenting with rhabdomyolysis-associated acute kidney injury following concomitant use of elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate and pravastatin/fenofibrate: a case report. J Med Case Rep 2015; 9:190. [PMID: 26347243 PMCID: PMC4562183 DOI: 10.1186/s13256-015-0671-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 08/11/2015] [Indexed: 01/10/2023] Open
Abstract
Introduction We present what we believe to be the first case in the literature of rhabdomyolysis-induced renal failure caused by a probable drug interaction between elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate (EVG/COBI/FTC/TDF) and pravastatin/fenofibrate. Case presentation A 68-year old Caucasian man presented with progressive pain in both legs two weeks after commencing treatment with EVG/COBI/FTC/TDF. He was found to have biochemical evidence of rhabdomyolysis and acute renal failure. Conclusion We emphasize the need for post marketing surveillance of adverse effects of new products. Pharmacokinetic studies are necessary to investigate the levels of pravastatin in patients taking COBI and fenofibrate with and without other comorbidities. Meanwhile, we suggest that creatine kinase levels should be monitored and patients advised to report myalgias when using concomitant EVG/COBI/FTC/TDF and pravastatin/fenofibrate. This case serves as an important reminder to use estimated glomerular filtration rates rather than serum creatinine levels when choosing new medications. If potentially nephrotoxic combinations are started in patients with borderline estimated glomerular filtration rates, it may be prudent to check these filtration rates more frequently than usual. In patients with reduced estimated glomerular filtration rates, potentially nephrotoxic combinations should be avoided wherever possible.
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Affiliation(s)
- Veronique Suttels
- Tropical Disease Unit, Antwerp University Hospital, Wilrijkstraat 10, Edegem, Belgium.
| | - Eric Florence
- Department of Clinical Sciences, Institute of Tropical Medicine, Kronenburgstraat 43/3, 2000, Antwerp, Belgium.
| | - John Leys
- Department of Pharmacy, Antwerp University Hospital, Wilrijkstraat 10, Edegem, Belgium.
| | - Marc Vekemans
- Department of Clinical Sciences, Institute of Tropical Medicine, Kronenburgstraat 43/3, 2000, Antwerp, Belgium.
| | - Jef Van den Ende
- Tropical Disease Unit, Antwerp University Hospital, Wilrijkstraat 10, Edegem, Belgium. .,Department of Clinical Sciences, Institute of Tropical Medicine, Kronenburgstraat 43/3, 2000, Antwerp, Belgium.
| | - Erika Vlieghe
- Department of Clinical Sciences, Institute of Tropical Medicine, Kronenburgstraat 43/3, 2000, Antwerp, Belgium.
| | - Chris Kenyon
- Department of Clinical Sciences, Institute of Tropical Medicine, Kronenburgstraat 43/3, 2000, Antwerp, Belgium.
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188
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Costs and cost-effectiveness analysis of 2015 GESIDA/Spanish AIDS National Plan recommended guidelines for initial antiretroviral therapy in HIV-infected adults. Enferm Infecc Microbiol Clin 2015; 34:361-71. [PMID: 26321131 DOI: 10.1016/j.eimc.2015.07.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 07/20/2015] [Accepted: 07/20/2015] [Indexed: 11/23/2022]
Abstract
INTRODUCTION GESIDA and the AIDS National Plan panel of experts suggest a preferred (PR), alternative (AR) and other regimens (OR) for antiretroviral treatment (ART) as initial therapy in HIV-infected patients for 2015. The objective of this study is to evaluate the costs and the effectiveness of initiating treatment with these regimens. METHODS Economic assessment of costs and effectiveness (cost/effectiveness) based on decision tree analyses. Effectiveness was defined as the probability of reporting a viral load <50 copies/mL at week 48, in an intention-to-treat analysis. Cost of initiating treatment with an ART regimen was defined as the costs of ART and its consequences (adverse effects, changes of ART regimen, and drug resistance studies) during the first 48 weeks. The payer perspective (National Health System) was applied, only taking into account differential direct costs: ART (official prices), management of adverse effects, studies of resistance, and HLA B*5701 testing. The setting is Spain and the costs correspond to those of 2015. A deterministic sensitivity analysis was conducted, building three scenarios for each regimen: base case, most favourable and least favourable. RESULTS In the base case scenario, the cost of initiating treatment ranges from 4663 Euros for 3TC+LPV/r (OR) to 10,902 Euros for TDF/FTC+RAL (PR). The effectiveness varies from 0.66 for ABC/3TC+ATV/r (AR) and ABC/3TC+LPV/r (OR), to 0.89 for TDF/FTC+DTG (PR) and TDF/FTC/EVG/COBI (AR). The efficiency, in terms of cost/effectiveness, ranges from 5280 to 12,836 Euros per responder at 48 weeks, for 3TC+LPV/r (OR) and RAL+DRV/r (OR), respectively. CONCLUSION The most efficient regimen was 3TC+LPV/r (OR). Among the PR and AR, the most efficient regimen was TDF/FTC/RPV (AR). Among the PR regimes, the most efficient was ABC/3TC+DTG.
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189
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Adams JL, Byrne D, Pepe R, Gray A, Baxter JD. Virological failure in two patients with HIV-1 RNA viral loads >1,000,000 copies/ml initiated on elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate. Antivir Ther 2015; 21:175-80. [PMID: 26308882 DOI: 10.3851/imp2987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2015] [Indexed: 10/23/2022]
Abstract
Very high baseline HIV-1 RNA viral loads require potent and robust antiretroviral regimens to achieve virological suppression. The coformulated single tablet regimen of elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate (EVG/COBI/FTC/TDF) is recommended by the US Department of Health and Human Services for the treatment of HIV-1 in treatment-naive adults and adolescents regardless of baseline CD4(+) T-cell count and viral load. We report two cases of HIV-infected, treatment-naive patients, with baseline HIV-1 RNA viral loads >1,000,000 copies/ml who were initiated on the single tablet regimen EVG/COBI/FTC/TDF, but failed to attain viral load suppression and developed resistance to the components of EVG/COBI/FTC/TDF.
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Affiliation(s)
- Jessica L Adams
- University of the Sciences, Philadelphia College of Pharmacy, Philadelphia, PA, USA.
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190
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Sherman EM, Worley MV, Unger NR, Gauthier TP, Schafer JJ. Cobicistat: Review of a Pharmacokinetic Enhancer for HIV Infection. Clin Ther 2015; 37:1876-93. [PMID: 26319088 DOI: 10.1016/j.clinthera.2015.07.022] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 07/30/2015] [Accepted: 07/30/2015] [Indexed: 12/13/2022]
Abstract
PURPOSE This article reviews the clinical pharmacology, pharmacodynamic and pharmacokinetic (PK) properties, clinical efficacy and tolerability, drug interactions, and dosing and administration of cobicistat. METHODS Searches of MEDLINE and International Pharmaceutical Abstracts from 1964 to February 2015 were conducted using the search terms cobicistat and GS-9350. Relevant information was extracted from the identified clinical trials and review articles. Abstracts from the Conference on Retroviruses and Opportunistic Infections (2014-2015) and the Interscience Conference on Antimicrobial Agents and Chemotherapy (2013-2014) were also searched. FINDINGS Cobicistat is a PK enhancer lacking antiviral activity that, via selective cytochrome P-450 (CYP) 3A inhibition, inhibits the metabolism of certain antiretroviral medications and is used for prolonging their effect. Cobicistat has been studied as a booster of elvitegravir, a second-generation integrase inhibitor, and of the protease inhibitors atazanavir and darunavir. Data on its clinical efficacy and tolerability have been presented in 2 Phase II trials and in 9 Phase III trials, which reported durable efficacy in terms of achievement of sustained suppression of HIV-1 RNA levels to <50 copies/mL for at least 48 weeks. Cobicistat was generally well-tolerated in these studies. Cobicistat may increase serum creatinine levels via the inhibition of proximal renal tubular cell transporters and thus reduce estimated glomerular filtration rate, although it does not appear to affect actual glomerular filtration rate. Given the potent CYP3A inhibition by cobicistat, its coadministration with drugs metabolized by CYP3A may result in increased plasma concentrations of such agents. Moreover, as cobicistat is metabolized predominantly by CYP3A, plasma concentrations may increase or decrease on coadministration with CYP3A inhibitors or inducers, respectively. IMPLICATIONS With potent durability through 48 weeks, a tolerability profile comparable to other first- and second-line antiretroviral therapies, and a convenient dosing schedule with low daily pill burden in fixed-dose combination tablets, cobicistat is a potential addition to the management of HIV infection as a PK enhancer. However, the effects of cobicistat on serum creatinine and its considerable drug-interaction potential may warrant additional monitoring.
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Affiliation(s)
- Elizabeth M Sherman
- College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida;.
| | - Marylee V Worley
- College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida
| | - Nathan R Unger
- College of Pharmacy, Nova Southeastern University, Palm Beach Gardens, Florida
| | - Timothy P Gauthier
- Department of Pharmacy, Miami Veterans Affairs Healthcare System, Miami, Florida
| | - Jason J Schafer
- Jefferson School of Pharmacy, Thomas Jefferson University, Philadelphia, Pennsylvania
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Changes to Initial Postexposure Prophylaxis Regimens Between the Emergency Department and Clinic. J Acquir Immune Defic Syndr 2015; 69:e182-4. [DOI: 10.1097/qai.0000000000000680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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192
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Park TE, Mohamed A, Kalabalik J, Sharma R. Review of integrase strand transfer inhibitors for the treatment of human immunodeficiency virus infection. Expert Rev Anti Infect Ther 2015; 13:1195-212. [PMID: 26293294 DOI: 10.1586/14787210.2015.1075393] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Integrase strand transfer inhibitors (INSTIs) are oral antiretroviral agents used against HIV infection. There are three agents available, including raltegravir, elvitegravir and dolutegravir, some of which are available as combination medications with other antiretroviral drugs. The efficacy and safety of INSTIs in treatment-naïve and experienced HIV-infected patients have been established by multiple studies. Based on the current practice guidelines, INSTI-based regimens are considered as one of the first-line therapies for treatment-naïve HIV-infected patients. There are new INSTIs in development to improve the resistance profile and to decrease the frequency of drug administration.
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Affiliation(s)
- Tae Eun Park
- a 1 Fairleigh Dickinson University, School of Pharmacy, 230 Park Avenue, M-SP1-01, Florham Park, NJ 07901, USA
| | - Abdilahi Mohamed
- a 1 Fairleigh Dickinson University, School of Pharmacy, 230 Park Avenue, M-SP1-01, Florham Park, NJ 07901, USA
| | - Julie Kalabalik
- a 1 Fairleigh Dickinson University, School of Pharmacy, 230 Park Avenue, M-SP1-01, Florham Park, NJ 07901, USA
| | - Roopali Sharma
- b 2 Long Island University Arnold & Marie Schwartz College of Pharmacy and Health Sciences, 450 Clarkson Avenue Box 36, Brooklyn, NY 11203, USA
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Young L, Wohl DA, Hyslop WB, Lee YZ, Napravnik S, Wilkin A. Effects of raltegravir combined with tenofovir/emtricitabine on body shape, bone density, and lipids in African-Americans initiating HIV therapy. HIV CLINICAL TRIALS 2015; 16:163-9. [PMID: 26249671 DOI: 10.1179/1945577115y.0000000002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Raltegravir (RAL) plus tenofovir/emtricitabine (TDF/FTC) is a recommended initial antiretroviral regimen. A substantial proportion of persons diagnosed with HIV infection and starting antiretrovirals in the U.S. are African-American (AA); however, the effects of this regimen on metabolic parameters have largely been studied in white patients. METHODS Single-arm, open-label study of untreated AA HIV-infected patients administered RAL with TDF/FTC for 104 weeks. Changes in fasting lipids, insulin resistance, visceral adipose tissue (VAT), abdominal subcutaneous adipose tissue (SAT), limb and trunk fat, and bone mineral density (BMD) were assessed at weeks 56 and 104. RESULTS Thirty (85% men) participants were included. Median entry characteristics included age of 38 years, CD4 323 cells/mm3, HIV RNA level 29,245 copies/ml, and body mass index 28.1 kg/m2. At 56 and 104 weeks, significant increases in VAT, trunk fat, limb fat, and overall fat were observed. Bone mineral density decreased by 1.5% by week 104.There were no significant changes in non-HDL-cholesterol, fasting triglycerides, or insulin resistance. A median CD4 cell count increase of 318 cells/mm3 (IQR 179, 403; full range 40, 749) (P<0.001) was observed. Assuming missing=failure, 78 and 70% had HIV RNA levels<40 copies/ml at weeks 56 and 104, respectively. There were no treatment-related discontinuations and no new antiretroviral resistance mutations were detected. CONCLUSIONS In this cohort of AAs, initiation of RAL with TDF/FTC was associated with significant general increases in fat. Significant changes in lipids or insulin resistance were not observed and there was a small decline in BMD. Therapy was well tolerated and effective. These results are consistent with findings of studies of initial antiretroviral therapy in racially diverse cohorts and inform treatment selection for AA patients starting therapy for HIV infection.
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194
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Hileman CO, Kinley B, Scharen-Guivel V, Melbourne K, Szwarcberg J, Robinson J, Lederman MM, Mccomsey GA. Differential Reduction in Monocyte Activation and Vascular Inflammation With Integrase Inhibitor-Based Initial Antiretroviral Therapy Among HIV-Infected Individuals. J Infect Dis 2015; 212:345-54. [PMID: 25583168 PMCID: PMC4539910 DOI: 10.1093/infdis/jiv004] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 12/04/2014] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Little is known about how different antiretrovirals effect inflammation and monocyte activation in human immunodeficiency virus (HIV) infection. METHODS We examined plasma specimens obtained during a randomized, double-blinded trial in antiretroviral therapy (ART)-naive HIV-infected adults which compared the efficacy of elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate (EVG/c/FTC/TDF) with that of efavirenz/emtricitabine/tenofovir disoproxil fumarate (EFV/FTC/TDF). From a random sample achieving an HIV type 1 RNA load of <50 copies/mL by week 48, changes over 24 and 48 weeks in levels of biomarkers of monocyte activation (soluble CD14 [sCD14] and soluble CD163 [sCD163]), systemic inflammation (soluble tumor necrosis factor α receptor I [sTNF-RI], interleukin 6 [IL-6], and high-sensitivity C-reactive protein [hsCRP]), and vascular inflammation (lipoprotein-associated phospholipase A2 [Lp-PLA2]) were compared. Multivariable linear regression was used. RESULTS A total of 200 participants were included. Significant differences favoring EVG/c/FTC/TDF were noted for changes in sCD14, hsCRP, and Lp-PLA2 levels. Factors independently associated with a larger decrease in the sCD14 level included random assignment to receive EVG/c/FTC/TDF, higher baseline sCD14 level, and larger decreases in hsCRP and sCD163 levels; factors associated with a larger Lp-PLA2 decrease included higher baseline Lp-PLA2 and IL-6 levels, smaller increases in total cholesterol and triglycerides levels, a larger decrease in the sCD14 level, and a smaller decrease in the sCD163 level. CONCLUSIONS EVG/c/FTC/TDF led to greater decreases in sCD14, hsCRP, and Lp-PLA2 levels, compared with EFV/FTC/TDF. Randomization group independently predicted the change in sCD14 level, and changes in monocyte activation independently predicted the change in Lp-PLA2 level. There appears to be a more favorable effect of the integrase inhibitor EVG over efavirenz on immune activation, which may affect vascular inflammation.
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Affiliation(s)
- Corrilynn O Hileman
- Case Western Reserve University School of Medicine MetroHealth Medical Center
| | - Bruce Kinley
- University Hospitals Case Medical Center, Cleveland, Ohio
| | | | | | | | | | - Michael M Lederman
- Case Western Reserve University School of Medicine University Hospitals Case Medical Center, Cleveland, Ohio
| | - Grace A Mccomsey
- Case Western Reserve University School of Medicine University Hospitals Case Medical Center, Cleveland, Ohio
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Santos JR, Blanco JL, Masiá M, Gutiérrez F, Pérez-Elías MJ, Iribarren JA, Force L, Antela A, Knobel H, Salavert M, López Bernaldo De Quirós JC, Pino M, Paredes R, Clotet B. Virological failure to raltegravir in Spain: incidence, prevalence and clinical consequences. J Antimicrob Chemother 2015; 70:3087-95. [PMID: 26490727 DOI: 10.1093/jac/dkv205] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 06/18/2015] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The objective of this study was to evaluate the incidence, prevalence and clinical consequences of virological failure (VF) to raltegravir-based regimens in Spain. METHODS A multicentre, retrospective, observational study was performed in 10 tertiary hospitals (January 2006 to June 2013). The study included HIV-1-infected patients with loss of virological suppression (LVS; two consecutive HIV-1 RNA ≥50 copies/mL) while receiving raltegravir. VF and low-level viraemia (LLV) were defined as two consecutive HIV-1 RNA ≥200 copies/mL and 50 to <200 copies/mL, respectively. Integrase strand-transfer inhibitor resistance was investigated at LVS. During the 48 weeks following LVS, recorded data included clinical characteristics, treatment discontinuations, AIDS-associated events and deaths. Effectiveness of therapy following LVS was evaluated by ITT and PP. Multivariate regression was used to assess predictors of efficacy. RESULTS Of the 15 009 HIV-infected patients in participating centres, 2782 (18.5%) had received raltegravir-based regimens. Of those, 192 (6.9%), 125 (4.5%) and 67 (2.4%) experienced LVS, VF and LLV, respectively. The incidence of VF was 1.8 (95% CI, 1.5-2.1) per 100 patients/year. The prevalence of VF was 4.5% (95% CI, 3.8%-5.3%). Integrase-associated mutations were found in 78.8% of patients with integrase genotyping results available. High-level resistance to dolutegravir was not observed. Salvage therapy failed in 34.1% of patients; progression to AIDS/death occurred in 8.3% during the first year following LVS. The latter was associated with intravenous drug use, time on raltegravir and lower CD4+ count nadir in patients who started raltegravir-based treatments as salvage regimens. CONCLUSIONS VF with raltegravir is infrequent, but often associated with major clinical complications in treatment-experienced patients.
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Affiliation(s)
- José Ramón Santos
- Lluita contra la SIDA Foundation, Germans Trias i Pujol University Hospital, Barcelona, Spain Universitat Autònoma de Barcelona, Barcelona, Spain
| | - José Luis Blanco
- Hospital Clinic de Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Mar Masiá
- Infectious Diseases Unit, Elche University General Hospital, Elche, Spain Miguel Hernández University, Elche, Spain
| | - Félix Gutiérrez
- Infectious Diseases Unit, Elche University General Hospital, Elche, Spain Miguel Hernández University, Elche, Spain
| | | | | | - Lluis Force
- Infectious Diseases Unit, Mataró Hospital, Mataró, Spain
| | - Antonio Antela
- Infectious Diseases Unit, University Hospital, Santiago de Compostela, Spain
| | - Hernando Knobel
- Service of Infectious Diseases, Hospital del Mar, IMIM (Hospital del Mar Research Institute), Barcelona, Spain
| | - Miguel Salavert
- Infectious Diseases Unit, La Fe University and Polytechnic Hospital, Valencia, Spain
| | | | - María Pino
- IrsiCaixa AIDS Research Institute, Barcelona, Spain
| | - Roger Paredes
- Lluita contra la SIDA Foundation, Germans Trias i Pujol University Hospital, Barcelona, Spain IrsiCaixa AIDS Research Institute, Barcelona, Spain Universitat de Vic-Universitat Central de Catalunya, Vic, Spain
| | - Bonaventura Clotet
- Lluita contra la SIDA Foundation, Germans Trias i Pujol University Hospital, Barcelona, Spain Universitat Autònoma de Barcelona, Barcelona, Spain IrsiCaixa AIDS Research Institute, Barcelona, Spain Universitat de Vic-Universitat Central de Catalunya, Vic, Spain
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Kandel CE, Walmsley SL. Dolutegravir - a review of the pharmacology, efficacy, and safety in the treatment of HIV. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:3547-55. [PMID: 26185421 PMCID: PMC4500604 DOI: 10.2147/dddt.s84850] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Dolutegravir is the newest integrase strand transfer inhibitor to be approved for the treatment of human immunodeficiency virus (HIV) infection. Dolutegravir is equivalent or superior to existing treatment regimens in both treatment-naïve and treatment-experienced patients including those with previous raltegravir or elvitegravir failure. The consistent efficacy coupled with excellent tolerability and infrequent drug–drug interactions makes the co-formulation of dolutegravir with two nucleotide reverse-transcriptase inhibitors an attractive treatment option. This review summarizes the pharmacokinetics, adverse event profile, and efficacy of dolutegravir in the treatment of HIV.
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Affiliation(s)
| | - Sharon L Walmsley
- Department of Medicine, University of Toronto, Toronto, ON, Canada ; Division of Infectious Diseases, University Health Network, Toronto, ON, Canada
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Abstract
Drug resistance prevents the successful treatment of HIV-positive individuals by decreasing viral sensitivity to a drug or a class of drugs. In addition to transmitted resistant viruses, treatment-naïve individuals can be confronted with the problem of drug resistance through de novo emergence of such variants. Resistant viruses have been reported for every antiretroviral drug tested so far, including the integrase strand transfer inhibitors raltegravir, elvitegravir and dolutegravir. However, de novo resistant variants against dolutegravir have been found in treatment-experienced but not in treatment-naïve individuals, a characteristic that is unique amongst antiretroviral drugs. We review here the issue of drug resistance against integrase strand transfer inhibitors as well as both pre-clinical and clinical studies that have led to the identification of the R263K mutation in integrase as a signature resistance substitution for dolutegravir. We also discuss how the topic of drug resistance against integrase strand transfer inhibitors may have relevance in regard to the nature of the HIV reservoir and possible HIV curative strategies.
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198
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White K, Kulkarni R, Miller MD. Analysis of early resistance development at the first failure timepoint in elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate-treated patients. J Antimicrob Chemother 2015; 70:2632-8. [PMID: 26108607 DOI: 10.1093/jac/dkv149] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 05/11/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The patterns of emergent HIV-1 drug resistance in patients failing a single-tablet regimen consisting of elvitegravir, boosted by cobicistat, plus emtricitabine and tenofovir disoproxil fumarate (EVG/COBI/FTC/TDF) include mutations in HIV-1 reverse transcriptase (RT) and integrase (IN). The order of development of mutations at early virological failure has not been described. The aim of this study was to determine the first resistance mutations to emerge during virological failure on EVG/COBI/FTC/TDF. PATIENTS AND METHODS Population sequencing was conducted at the first virological failure timepoint with HIV-1 RNA ≥400 copies/mL for each of the 18 patients with emergent resistance in the EVG/COBI/FTC/TDF arms of two randomized, double-blind, Phase 3 studies of EVG/COBI/FTC/TDF through Week 144. RESULTS At first failure compared with confirmed virological failure, 4 of the 18 patients had no detectable resistance mutation in their virus and only 51% of the RT and IN mutations were detected overall. M184V/I in RT was the first mutation to appear in many cases (n = 6) and was then followed by additional mutations in RT and IN. No case with development of resistance to the IN strand-transfer inhibitor prior to the development of M184V/I was detected. CONCLUSIONS The analysis of first failure found fewer patients with emergent resistance and fewer resistance mutations than the standard analysis at the later confirmation of virological failure. The early detection of resistance may preserve later treatment options.
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Affiliation(s)
- Kirsten White
- Gilead Sciences, Inc., 333 Lakeside Dr., Foster City, CA 94404, USA
| | - Rima Kulkarni
- Gilead Sciences, Inc., 333 Lakeside Dr., Foster City, CA 94404, USA
| | - Michael D Miller
- Gilead Sciences, Inc., 333 Lakeside Dr., Foster City, CA 94404, USA
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Cory TJ, Midde NM, Rao P, Kumar S. Investigational reverse transcriptase inhibitors for the treatment of HIV. Expert Opin Investig Drugs 2015; 24:1219-28. [PMID: 26088266 DOI: 10.1517/13543784.2015.1058357] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION While considerable advances have been made in the development of antiretroviral agents, there is still work to be done. Reverse transcriptase inhibitors are important drugs for the treatment of HIV, and considerable research is currently ongoing to develop new agents and to modify currently existing agents. AREAS COVERED Herein, the authors discuss both investigational nucleoside reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs), including agents that are in various stages of development. They also discuss novel formulations that are being investigated for currently available drugs, and discuss the advantages that these new formulations may provide. EXPERT OPINION New formulations and co-formulations of currently existing antiretrovirals will represent an important area of development, as a means to improve adherence for HIV-positive individuals. New formulations will continue to be developed, with a focus on allowing for less-frequent administration, as well increasing drug concentrations at local sites such as vaginal tissue, rectal tissue and sites in the immune system.
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Affiliation(s)
- Theodore J Cory
- University of Tennessee Health Science Center College of Pharmacy, Department of Clinical Pharmacy , 881 Madison Avenue, Memphis, TN 38163 , USA +1 901 448 7216 ; +1 901 448 1741 ;
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Tenofovir: What We Have Learnt After 7.5 Million Person-Years of Use. Infect Dis Ther 2015; 4:145-57. [PMID: 26032649 PMCID: PMC4471058 DOI: 10.1007/s40121-015-0070-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Indexed: 01/09/2023] Open
Abstract
Tenofovir was licensed for use in patients with HIV in 2001 and since then has become a firmly established anti-retroviral in both guidelines and routine practice. Data have been presented from many pivotal studies—informing on its efficacy, use, and adverse features—and there are also over 7.5 million patient-years of experience to date. We explore the data on this nucleotide reverse transcriptase inhibitor in HIV presented since 2008—focusing on efficacy, side effects, and utility.
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