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Chiu ML, Liang WM, Li JP, Cheng CF, Chiou JS, Ho MW, Wu YC, Lin TH, Liao CC, Huang SM, Tsai FJ, Lin YJ. Timing, Dosage, and Adherence of Antiretroviral Therapy and Risk of Osteoporosis in Patients With Human Immunodeficiency Virus Infection in Taiwan: A Nested Case-Control Study. Front Pharmacol 2021; 12:631480. [PMID: 33995032 PMCID: PMC8121495 DOI: 10.3389/fphar.2021.631480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 04/21/2021] [Indexed: 11/27/2022] Open
Abstract
The progression of acquired immunodeficiency syndrome is delayed in patients with human immunodeficiency virus (HIV) infection receiving antiretroviral therapy (ART). However, long-term ART is associated with adverse effects. Osteoporosis is one of the adverse effects and is a multifactorial systemic skeletal disease associated with bone fragility and an increased risk of fracture. We performed a longitudinal, comprehensive, nested case-control study to explore the effect of ART on the risk of osteoporosis in 104 osteoporotic and 416 non-osteoporotic patients with HIV infection at their average age about 29 years old in Taiwan. Patients with history of ART, current exposure to ART, higher cumulative defined daily doses (DDDs), or higher ART adherence were at a higher risk of osteoporosis (p < 0.05). Patients receiving nucleoside/nucleotide reverse transcriptase inhibitor (NRTI)-containing regimen (zidovudine-lamivudine combination, lamivudine-abacavir combination, and abacavir alone) and protease inhibitor (PI)-containing regimen (lopinavir-ritonavir combination, ritonavir, and atazanavir) had a higher risk of osteoporosis (p < 0.05). Especially, patients receiving high doses of the PIs lopinavir-ritonavir combination had an increased risk of osteoporosis (p < 0.05). In conclusion, history of ART, current exposure to ART, higher cumulative DDDs, and higher ART adherence were associated with an increased risk of osteoporosis. Furthermore, NRTI- and PI-containing regimens and high doses of PIs lopinavir-ritonavir combination may be associated with an increased risk of osteoporosis in patients with HIV infection in Taiwan.
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Affiliation(s)
- Mu-Lin Chiu
- Genetic Center, Department of Medical Research, China Medical University Hospital, Taichung, Taiwan.,School of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Wen-Miin Liang
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Ju-Pi Li
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chi-Fung Cheng
- Genetic Center, Department of Medical Research, China Medical University Hospital, Taichung, Taiwan.,Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Jian-Shiun Chiou
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Mao-Wang Ho
- Section of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Yang-Chang Wu
- Department of Biotechnology and Bioinformatics, Asia University, Taichung, Taiwan.,Graduate Institute of Integrated Medicine and Chinese Medicine Research and Development Center, China Medical University and Hospital, Taichung, Taiwan
| | - Ting-Hsu Lin
- Genetic Center, Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Chiu-Chu Liao
- Genetic Center, Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Shao-Mei Huang
- Genetic Center, Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Fuu-Jen Tsai
- Genetic Center, Department of Medical Research, China Medical University Hospital, Taichung, Taiwan.,School of Chinese Medicine, China Medical University, Taichung, Taiwan.,Department of Biotechnology and Bioinformatics, Asia University, Taichung, Taiwan
| | - Ying-Ju Lin
- Genetic Center, Department of Medical Research, China Medical University Hospital, Taichung, Taiwan.,School of Chinese Medicine, China Medical University, Taichung, Taiwan
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Mdanda S, Ntshangase S, Singh SD, Naicker T, Kruger HG, Baijnath S, Govender T. Mass spectrometric investigations into the brain delivery of abacavir, stavudine and didanosine in a rodent model. Xenobiotica 2019; 50:570-579. [PMID: 31403353 DOI: 10.1080/00498254.2019.1655605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
HIV replication in the brain is unopposed due to reduced antiretroviral drug penetration into the central nervous system (CNS). Prevalence of HIV-associated neurocognitive disorder (HAND) has increased severely in patients living with HIV despite current treatments. The aims of this study were to evaluate the brain bio-distribution of alternative nucleoside reverse transcriptase inhibitors, abacavir, stavudine and didanosine in the CNS and to determine their localization patterns in the brain.Sprague-Dawley rats received 50 mg kg-1 single i.p dose of each drug. Mass spectrometric techniques were then used to investigate the pharmacokinetics and localization patterns of these drugs in the brain using LC-MS/MS and mass spectrometric imaging (MSI), respectively.Abacavir, stavudine and didanosine reached the Brain Cmax with concentration of 831.2, 1300 and 43.37 ngmL-1, respectively. Based on MSI analysis Abacavir and Stavudine were located in brain regions that are strongly implicated in the progression of HAND.Abacavir and Stavudine penetrated into CNS, reaching a Cmax that was above the IC50 for HIV (457.6 and 112.0 ngmL-1, respectively), however, it was noted ddI showed poor entry within the brain, therefore, it is recommended that this drug cannot be considered for treating CNS-HIV.
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Affiliation(s)
- Sipho Mdanda
- Catalysis and Peptide Research Unit, University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Sphamandla Ntshangase
- Catalysis and Peptide Research Unit, University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | | | - Tricia Naicker
- Catalysis and Peptide Research Unit, University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Hendrik G Kruger
- Catalysis and Peptide Research Unit, University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Sooraj Baijnath
- Catalysis and Peptide Research Unit, University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Thavendran Govender
- Catalysis and Peptide Research Unit, University of KwaZulu-Natal, Westville Campus, Durban, South Africa.,Biomedical Resource Unit, University of KwaZulu-Natal, Westville Campus, Durban, South Africa
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3
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Khuder SS, Chen S, Letendre S, Marcotte T, Grant I, Franklin D, Rubin LH, Margolick JB, Jacobson LP, Sacktor N, D'Souza G, Stosor V, Lake JE, Rapocciolo G, McArthur JC, Dickens AM, Haughey NJ. Impaired insulin sensitivity is associated with worsening cognition in HIV-infected patients. Neurology 2019; 92:e1344-e1353. [PMID: 30787163 DOI: 10.1212/wnl.0000000000007125] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 11/08/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the association of insulin sensitivity and metabolic status with declining cognition in HIV-infected individuals. METHODS We conducted targeted clinical and metabolic measures in longitudinal plasma samples obtained from HIV-infected patients enrolled in the Central Nervous System HIV Anti-Retroviral Therapy Effects Research Study (CHARTER). Findings were validated with plasma samples from the Multicenter AIDS Cohort Study (MACS). Patients were grouped according to longitudinally and serially assessed cognitive performance as having stably normal or declining cognition. RESULTS Patients with declining cognition exhibited baseline hyperinsulinemia and elevated plasma c-peptide levels with normal c-peptide/insulin ratios, suggesting that insulin production was increased, but insulin clearance was normal. The association of hyperinsulinemia with worsening cognition was further supported by low high-density lipoprotein (HDL), high low-density lipoprotein/HDL ratio, and elevated cholesterol/HDL ratio compared to patients with stably normal cognition. CONCLUSIONS These findings suggest that hyperinsulinemia and impaired insulin sensitivity are associated with cognitive decline in antiretroviral therapy-treated HIV-infected patients.
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Affiliation(s)
- Saja S Khuder
- From the Departments of Neurology (S.S.K., S.C., L.H.R., N.S., J.C.M., N.J.H.) and Psychiatry (N.J.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Department of Psychiatry (S.L., T.M., I.G., D.F.), School of Medicine, University of California, San Diego, La Jolla; Department of Epidemiology (J.B.M., L.P.J., G.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine (V.S.), Division of Infectious Diseases, and Department of Surgery (V.S.), Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL; University of Texas Health Sciences Center (J.E.L.), Houston; Infectious Disease and Microbiology (G.R.), University of Pittsburg, PA; and Turku Centre for Biotechnology (A.M.D.), Turku University, Finland
| | - Suming Chen
- From the Departments of Neurology (S.S.K., S.C., L.H.R., N.S., J.C.M., N.J.H.) and Psychiatry (N.J.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Department of Psychiatry (S.L., T.M., I.G., D.F.), School of Medicine, University of California, San Diego, La Jolla; Department of Epidemiology (J.B.M., L.P.J., G.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine (V.S.), Division of Infectious Diseases, and Department of Surgery (V.S.), Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL; University of Texas Health Sciences Center (J.E.L.), Houston; Infectious Disease and Microbiology (G.R.), University of Pittsburg, PA; and Turku Centre for Biotechnology (A.M.D.), Turku University, Finland
| | - Scott Letendre
- From the Departments of Neurology (S.S.K., S.C., L.H.R., N.S., J.C.M., N.J.H.) and Psychiatry (N.J.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Department of Psychiatry (S.L., T.M., I.G., D.F.), School of Medicine, University of California, San Diego, La Jolla; Department of Epidemiology (J.B.M., L.P.J., G.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine (V.S.), Division of Infectious Diseases, and Department of Surgery (V.S.), Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL; University of Texas Health Sciences Center (J.E.L.), Houston; Infectious Disease and Microbiology (G.R.), University of Pittsburg, PA; and Turku Centre for Biotechnology (A.M.D.), Turku University, Finland
| | - Thomas Marcotte
- From the Departments of Neurology (S.S.K., S.C., L.H.R., N.S., J.C.M., N.J.H.) and Psychiatry (N.J.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Department of Psychiatry (S.L., T.M., I.G., D.F.), School of Medicine, University of California, San Diego, La Jolla; Department of Epidemiology (J.B.M., L.P.J., G.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine (V.S.), Division of Infectious Diseases, and Department of Surgery (V.S.), Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL; University of Texas Health Sciences Center (J.E.L.), Houston; Infectious Disease and Microbiology (G.R.), University of Pittsburg, PA; and Turku Centre for Biotechnology (A.M.D.), Turku University, Finland
| | - Igor Grant
- From the Departments of Neurology (S.S.K., S.C., L.H.R., N.S., J.C.M., N.J.H.) and Psychiatry (N.J.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Department of Psychiatry (S.L., T.M., I.G., D.F.), School of Medicine, University of California, San Diego, La Jolla; Department of Epidemiology (J.B.M., L.P.J., G.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine (V.S.), Division of Infectious Diseases, and Department of Surgery (V.S.), Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL; University of Texas Health Sciences Center (J.E.L.), Houston; Infectious Disease and Microbiology (G.R.), University of Pittsburg, PA; and Turku Centre for Biotechnology (A.M.D.), Turku University, Finland
| | - Donald Franklin
- From the Departments of Neurology (S.S.K., S.C., L.H.R., N.S., J.C.M., N.J.H.) and Psychiatry (N.J.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Department of Psychiatry (S.L., T.M., I.G., D.F.), School of Medicine, University of California, San Diego, La Jolla; Department of Epidemiology (J.B.M., L.P.J., G.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine (V.S.), Division of Infectious Diseases, and Department of Surgery (V.S.), Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL; University of Texas Health Sciences Center (J.E.L.), Houston; Infectious Disease and Microbiology (G.R.), University of Pittsburg, PA; and Turku Centre for Biotechnology (A.M.D.), Turku University, Finland
| | - Leah H Rubin
- From the Departments of Neurology (S.S.K., S.C., L.H.R., N.S., J.C.M., N.J.H.) and Psychiatry (N.J.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Department of Psychiatry (S.L., T.M., I.G., D.F.), School of Medicine, University of California, San Diego, La Jolla; Department of Epidemiology (J.B.M., L.P.J., G.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine (V.S.), Division of Infectious Diseases, and Department of Surgery (V.S.), Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL; University of Texas Health Sciences Center (J.E.L.), Houston; Infectious Disease and Microbiology (G.R.), University of Pittsburg, PA; and Turku Centre for Biotechnology (A.M.D.), Turku University, Finland
| | - Joseph B Margolick
- From the Departments of Neurology (S.S.K., S.C., L.H.R., N.S., J.C.M., N.J.H.) and Psychiatry (N.J.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Department of Psychiatry (S.L., T.M., I.G., D.F.), School of Medicine, University of California, San Diego, La Jolla; Department of Epidemiology (J.B.M., L.P.J., G.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine (V.S.), Division of Infectious Diseases, and Department of Surgery (V.S.), Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL; University of Texas Health Sciences Center (J.E.L.), Houston; Infectious Disease and Microbiology (G.R.), University of Pittsburg, PA; and Turku Centre for Biotechnology (A.M.D.), Turku University, Finland
| | - Lisa P Jacobson
- From the Departments of Neurology (S.S.K., S.C., L.H.R., N.S., J.C.M., N.J.H.) and Psychiatry (N.J.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Department of Psychiatry (S.L., T.M., I.G., D.F.), School of Medicine, University of California, San Diego, La Jolla; Department of Epidemiology (J.B.M., L.P.J., G.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine (V.S.), Division of Infectious Diseases, and Department of Surgery (V.S.), Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL; University of Texas Health Sciences Center (J.E.L.), Houston; Infectious Disease and Microbiology (G.R.), University of Pittsburg, PA; and Turku Centre for Biotechnology (A.M.D.), Turku University, Finland
| | - Ned Sacktor
- From the Departments of Neurology (S.S.K., S.C., L.H.R., N.S., J.C.M., N.J.H.) and Psychiatry (N.J.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Department of Psychiatry (S.L., T.M., I.G., D.F.), School of Medicine, University of California, San Diego, La Jolla; Department of Epidemiology (J.B.M., L.P.J., G.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine (V.S.), Division of Infectious Diseases, and Department of Surgery (V.S.), Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL; University of Texas Health Sciences Center (J.E.L.), Houston; Infectious Disease and Microbiology (G.R.), University of Pittsburg, PA; and Turku Centre for Biotechnology (A.M.D.), Turku University, Finland
| | - Gypsyamber D'Souza
- From the Departments of Neurology (S.S.K., S.C., L.H.R., N.S., J.C.M., N.J.H.) and Psychiatry (N.J.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Department of Psychiatry (S.L., T.M., I.G., D.F.), School of Medicine, University of California, San Diego, La Jolla; Department of Epidemiology (J.B.M., L.P.J., G.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine (V.S.), Division of Infectious Diseases, and Department of Surgery (V.S.), Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL; University of Texas Health Sciences Center (J.E.L.), Houston; Infectious Disease and Microbiology (G.R.), University of Pittsburg, PA; and Turku Centre for Biotechnology (A.M.D.), Turku University, Finland
| | - Valentina Stosor
- From the Departments of Neurology (S.S.K., S.C., L.H.R., N.S., J.C.M., N.J.H.) and Psychiatry (N.J.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Department of Psychiatry (S.L., T.M., I.G., D.F.), School of Medicine, University of California, San Diego, La Jolla; Department of Epidemiology (J.B.M., L.P.J., G.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine (V.S.), Division of Infectious Diseases, and Department of Surgery (V.S.), Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL; University of Texas Health Sciences Center (J.E.L.), Houston; Infectious Disease and Microbiology (G.R.), University of Pittsburg, PA; and Turku Centre for Biotechnology (A.M.D.), Turku University, Finland
| | - Jordan E Lake
- From the Departments of Neurology (S.S.K., S.C., L.H.R., N.S., J.C.M., N.J.H.) and Psychiatry (N.J.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Department of Psychiatry (S.L., T.M., I.G., D.F.), School of Medicine, University of California, San Diego, La Jolla; Department of Epidemiology (J.B.M., L.P.J., G.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine (V.S.), Division of Infectious Diseases, and Department of Surgery (V.S.), Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL; University of Texas Health Sciences Center (J.E.L.), Houston; Infectious Disease and Microbiology (G.R.), University of Pittsburg, PA; and Turku Centre for Biotechnology (A.M.D.), Turku University, Finland
| | - Giovanna Rapocciolo
- From the Departments of Neurology (S.S.K., S.C., L.H.R., N.S., J.C.M., N.J.H.) and Psychiatry (N.J.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Department of Psychiatry (S.L., T.M., I.G., D.F.), School of Medicine, University of California, San Diego, La Jolla; Department of Epidemiology (J.B.M., L.P.J., G.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine (V.S.), Division of Infectious Diseases, and Department of Surgery (V.S.), Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL; University of Texas Health Sciences Center (J.E.L.), Houston; Infectious Disease and Microbiology (G.R.), University of Pittsburg, PA; and Turku Centre for Biotechnology (A.M.D.), Turku University, Finland
| | - Justin C McArthur
- From the Departments of Neurology (S.S.K., S.C., L.H.R., N.S., J.C.M., N.J.H.) and Psychiatry (N.J.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Department of Psychiatry (S.L., T.M., I.G., D.F.), School of Medicine, University of California, San Diego, La Jolla; Department of Epidemiology (J.B.M., L.P.J., G.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine (V.S.), Division of Infectious Diseases, and Department of Surgery (V.S.), Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL; University of Texas Health Sciences Center (J.E.L.), Houston; Infectious Disease and Microbiology (G.R.), University of Pittsburg, PA; and Turku Centre for Biotechnology (A.M.D.), Turku University, Finland
| | - Alex M Dickens
- From the Departments of Neurology (S.S.K., S.C., L.H.R., N.S., J.C.M., N.J.H.) and Psychiatry (N.J.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Department of Psychiatry (S.L., T.M., I.G., D.F.), School of Medicine, University of California, San Diego, La Jolla; Department of Epidemiology (J.B.M., L.P.J., G.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine (V.S.), Division of Infectious Diseases, and Department of Surgery (V.S.), Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL; University of Texas Health Sciences Center (J.E.L.), Houston; Infectious Disease and Microbiology (G.R.), University of Pittsburg, PA; and Turku Centre for Biotechnology (A.M.D.), Turku University, Finland.
| | - Norman J Haughey
- From the Departments of Neurology (S.S.K., S.C., L.H.R., N.S., J.C.M., N.J.H.) and Psychiatry (N.J.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Department of Psychiatry (S.L., T.M., I.G., D.F.), School of Medicine, University of California, San Diego, La Jolla; Department of Epidemiology (J.B.M., L.P.J., G.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine (V.S.), Division of Infectious Diseases, and Department of Surgery (V.S.), Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL; University of Texas Health Sciences Center (J.E.L.), Houston; Infectious Disease and Microbiology (G.R.), University of Pittsburg, PA; and Turku Centre for Biotechnology (A.M.D.), Turku University, Finland.
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Venter WDF, Kambugu A, Chersich MF, Becker S, Hill A, Arulappan N, Moorhouse M, Majam M, Akpomiemie G, Sokhela S, Poongulali S, Feldman C, Duncombe C, Ripin DHB, Vos A, Kumarasamy N. Efficacy and Safety of Tenofovir Disoproxil Fumarate Versus Low-Dose Stavudine Over 96 Weeks: A Multicountry Randomized, Noninferiority Trial. J Acquir Immune Defic Syndr 2019; 80:224-233. [PMID: 30640204 PMCID: PMC6358196 DOI: 10.1097/qai.0000000000001908] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/15/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Reducing doses of antiretroviral drugs, including stavudine (d4T), may lower toxicity, while preserving efficacy. There are substantial concerns about renal and bone toxicities of tenofovir disoproxil fumarate (TDF). SETTING HIV-1-infected treatment-naive adults in India, South Africa, and Uganda. METHODS A phase-4, 96-week, randomized, double-blind, noninferiority trial compared d4T 20 mg twice daily and TDF, taken in combination with lamivudine (3TC) and efavirenz (EFV). The primary endpoint was the proportion of participants with HIV-1 RNA <50 copies per milliliter at 48 weeks. Adverse events assessments included measures of bone density and body fat. The trial is registered on Clinicaltrials.gov (NCT02670772). RESULTS Between 2012 and 2014, 536 participants were recruited per arm. At week 96, trial completion rates were 75.7% with d4T/3TC/EFV (n = 406) and 82.1% with TDF/3TC/EFV (n = 440, P = 0.011). Noncompletion was largely due to virological failure [6.2% (33) with d4T/3TC/EFV versus 5.4% (29) with TDF/3TC/EFV; P = 0.60]. For the primary endpoint, d4T/3TC/EFV was noninferior to TDF/3TC/EFV (79.3%, 425/536 versus 80.8% 433/536; difference = -1.49%, 95% CI: -6.3 to 3.3; P < 0.001). Drug-related adverse event discontinuations were higher with d4T (6.7%, 36), than TDF (1.1%, 6; P < 0.001). Lipodystrophy was more common with d4T (5.6%, 30) than TDF (0.2%, 1; P < 0.001). Creatinine clearance increased in both arms, by 18.1 mL/min in the d4T arm and 14.2 mL/min with TDF (P = 0.03). Hip bone density measures, however, showed greater loss with TDF. CONCLUSIONS Low-dose d4T combined with 3TC/EFV demonstrated noninferior virological efficacy compared with TDF/3TC/EFV, but mitochondrial toxicity remained high. Little renal toxicity occurred in either arm. Implications of bone mineral density changes with TDF warrant investigation.
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Affiliation(s)
- Willem Daniel Francois Venter
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew Kambugu
- Infectious Diseases, College of Health Sciences at Makerere University, Kampala, Uganda
| | - Matthew F. Chersich
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Andrew Hill
- Pharmacology Department, University of Liverpool, Liverpool, United Kingdom
| | - Natasha Arulappan
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michelle Moorhouse
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mohammed Majam
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Godspower Akpomiemie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Simiso Sokhela
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Selvamuthu Poongulali
- Chennai Antiviral Research and Treatment Clinical Research Site, YRGCARE Medical Centre, Voluntary Health Services, Chennai, India
| | - Charles Feldman
- Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Alinda Vos
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Nagalingeswaran Kumarasamy
- Chennai Antiviral Research and Treatment Clinical Research Site, YRGCARE Medical Centre, Voluntary Health Services, Chennai, India
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5
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Wulunggono W, Yunihastuti E, Shatri H, Wahyudi ER, Ophinni Y. Frailty among HIV-1 Infected Adults under Antiretroviral Therapy in Indonesia. Curr HIV Res 2019; 17:204-213. [PMID: 31456523 PMCID: PMC7061977 DOI: 10.2174/1570162x17666190828143947] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/12/2019] [Accepted: 08/19/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Increasing age of HIV-1 infected population brought about the risk of frailty as comorbidity, whose prevalence is higher in low and middle-income countries (LMICs). Indonesia as an LMIC also bears a major burden of HIV-1 epidemic with a similarly aging population, but the prevalence of frailty and its predictors are unknown. OBJECTIVES To identify the prevalence of frailty and analyze its associated factors, among HIV-1 infected adults under antiretroviral therapy in Indonesia. METHODS A cross-sectional study was conducted among HIV-infected individuals with inclusion criteria of age ≥30 years old and underwent ART for at least 6 months. The main assessment was done using Fried's frailty phenotype score, which categorizes subjects into non-frail, pre-frail, or frail. Factors associated with frailty were characterized and multiple logistic regression analysis was performed. RESULTS A total of 164 subjects were recruited; male subjects were 118 (72%), the median age was 40.5 years old, and the median CD4 nadir was 53 cells/μl. Frailty was identified among 90 (54.9%) subjects with 84 (51.2%) identified as pre-frail and 6 (3.7%) as frail, with dominant frailty phenotype was weakness in grip strength. The multivariate model showed that depression was the only factor significantly correlated with pre-frailty and frailty (OR 2.14; 95% CI 1.04-4.43, p=0.036). CONCLUSION Frailty is a common occurrence among HIV-infected patients under ART, with depression as an independent predictive factor.
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Affiliation(s)
- Wulunggono Wulunggono
- Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Evy Yunihastuti
- Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Hamzah Shatri
- Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Edy Rizal Wahyudi
- Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Youdiil Ophinni
- Department of Pathology, Graduate School of Medicine, Kobe University, Kobe, Japan
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6
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Vos AG, Chersich MF, Klipstein-Grobusch K, Zuithoff P, Moorhouse MA, Lalla-Edward ST, Kambugu A, Kumarasamy N, Grobbee DE, Barth RE, Venter WD. Lipid levels, insulin resistance and cardiovascular risk over 96 weeks of antiretroviral therapy: a randomised controlled trial comparing low-dose stavudine and tenofovir. Retrovirology 2018; 15:77. [PMID: 30547820 PMCID: PMC6295103 DOI: 10.1186/s12977-018-0460-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 12/07/2018] [Indexed: 01/17/2023] Open
Abstract
Background HIV infection and antiretroviral treatment are associated with changes in lipid levels, insulin resistance and risk of cardiovascular disease (CVD). We investigated these changes in the first 96 weeks of treatment with low-dose stavudine or tenofovir regimens. Methods This is a secondary analysis of a double blind, randomised controlled trial performed in South-Africa, Uganda and India comparing low-dose stavudine (20 mg twice daily) with tenofovir in combination with efavirenz and lamivudine in antiretroviral-naïve adults (n = 1067) (Clinicaltrials.gov, NCT02670772). Over 96 weeks, data were collected on fasting lipids, glucose and insulin. Insulin resistance was assessed with the HOMA-IR index and 10-year CVD risk with the Framingham risk score (FRS). A generalized linear mixed model was used to estimate trends over time. Results Participants were on average 35.3 years old, 57.6% female and 91.8% Black African. All lipid levels increased following treatment initiation, with the sharpest increase in the first 24 weeks of treatment. The increase in all lipid subcomponents over 96 weeks was higher among those in the stavudine than the tenofovir group. Insulin resistance increased steadily with no difference detected between study groups. FRS rose from 1.90% (1.84–1.98%) at baseline to 2.06 (1.98–2.15%) at week 96 for the total group, with no difference between treatment arms (p = 0.144). Lipid changes were more marked in Indian than African participants. Conclusion Lipid levels increased in both groups, with low-dose stavudine resulting in a worse lipid profile compared to tenofovir. Insulin resistance increased, with no difference between regimens. CVD risk increased over time and tended to increase more in the group on stavudine. The low CVD risk across both arms argues against routine lipid and glucose monitoring in the absence of other CVD risk factors. In high risk patients, monitoring may only be appropriate at least a year after treatment initiation. Electronic supplementary material The online version of this article (10.1186/s12977-018-0460-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alinda G Vos
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa. .,Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands. .,Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Matthew F Chersich
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Peter Zuithoff
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Michelle A Moorhouse
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Samanta T Lalla-Edward
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Andrew Kambugu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - N Kumarasamy
- YRGCARE Medical Centre, CART Clinical Research Site, Voluntary Health Services, Chennai, India
| | - Diederick E Grobbee
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roos E Barth
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Willem D Venter
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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7
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Can We Improve Stavudine's Safety Profile in Children? Pharmacokinetics of Intracellular Stavudine Triphosphate with Reduced Dosing. Antimicrob Agents Chemother 2018; 62:AAC.00761-18. [PMID: 30104267 PMCID: PMC6201115 DOI: 10.1128/aac.00761-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 08/06/2018] [Indexed: 01/13/2023] Open
Abstract
Stavudine remains a useful replacement option for treatment for HIV+ children. WHO reduced the adult dose to 30 mg twice daily, which maintains efficacy and lowers mitochondrial toxicity. We explored intracellular stavudine triphosphate levels in children receiving a reduced dose of 0.5 to 0.75 mg/kg of body weight twice daily to investigate whether a similar dose optimization can safely be made. A population pharmacokinetic model was developed to describe the pharmacokinetics of intracellular stavudine triphosphate in 23 HIV+ children and 24 HIV+ adults who received stavudine at 0.5 mg/kg and 20 mg twice daily for 7 days, respectively. Simulations were employed to optimize the pediatric dosing regimen to match exposures in adults receiving the current WHO-recommended dose of 30 mg twice daily. A biphasic disposition model with first-order appearance and disappearance described the pharmacokinetics of stavudine triphosphate. The use of allometric scaling with fat-free mass characterized well the pharmacokinetics in both adults and children, and no other significant effect could be detected. Simulations of 30 mg twice daily in adults predicted median (interquartile range [IQR]) stavudine triphosphate minimum drug concentration (C min) and maximum drug concentration (C max) values of 13 (10 to 19) and 45 (38 to 53) fmol/106 cells, respectively. Targeting this exposure, simulations in HIV+ children were used to identify a suitable weight-band dosing approach (0.5 to 0.75 mg/kg), which was predicted to achieve median (IQR) C min and C max values of 13 (9 to 18) and 49 (40 to 58) fmol/106 cells, respectively. Weight-band dosing using a stavudine dose of 0.5 to 0.75 mg/kg is proposed, and it shows comparable exposures to adults receiving the current WHO-recommended dose of 30 mg twice daily. Our pharmacokinetic results suggest that the decreased stavudine dose in children >2 years would have a reduced toxic effect while retaining antiretroviral efficacy.
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8
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Sharma TS, Somarriba G, Arheart KL, Neri D, Mathew MS, Graham PL, Scott GB, Miller TL. Longitudinal Changes in Body Composition by Dual-energy Radiograph Absorptiometry Among Perinatally HIV-infected and HIV-uninfected Youth: Increased Risk of Adiposity Among HIV-infected Female Youth. Pediatr Infect Dis J 2018; 37:1002-1007. [PMID: 29474262 PMCID: PMC6105572 DOI: 10.1097/inf.0000000000001963] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Combination antiretroviral therapy has allowed youth with perinatal HIV infection (PHIV+) to live into adulthood, but many youth may experience metabolic and body composition changes that predispose to greater cardiovascular disease (CVD) risk. This longitudinal study evaluated changes in body composition measured by dual-energy radiograph absorptiometry (DXA) in a cohort of PHIV+ youth compared with HIV- controls over a 7-year period. METHODS PHIV+ youth and HIV- controls were prospectively enrolled in a single-site study to assess nutrition and CVD risk. Anthropometrics and DXA scans were longitudinally obtained to assess percent body fat and regional fat distribution. Using general linear models, we analyzed differences in body composition and anthropometric measures by sex between PHIV+ youth and controls over time. RESULTS Two hundred thirty-five participants (156 PHIV+ and 79 HIV- controls) with at least 1 DXA performed since study enrollment were included for analysis. During the study period, 471 DXAs were obtained in the PHIV+ group and 95 in HIV- controls. PHIV+ females demonstrated greater increase in weight and body mass index over time compared with HIV- females, and significant increases in total percent body fat [estimate = 1.212 (95% confidence interval: 0.837-1.587) percent per year; P < 0.001) and percent trunk fat [1.3818 (95% confidence interval: 0.922-1.84); P < 0.001] compared with HIV- females and PHIV+ males. CONCLUSIONS PHIV+ females demonstrate an unfavorable change in fat redistribution and percent body fat over time that exceeds the pattern seen in PHIV+ males or HIV- females. Providers should have heightened awareness of body composition changes of PHIV+ females that may eventually lead to increased CVD risk.
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Affiliation(s)
- Tanvi S Sharma
- From the Division of Infectious Diseases, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gabriel Somarriba
- Department of Clinical Education, University of St. Augustine for Health Sciences, St. Augustine, Florida
| | - Kristopher L Arheart
- Division of Biostatistics, Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, Florida
| | - Daniela Neri
- Discipline of Nutrition, Department of Pediatrics, Paulista School of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - M Sunil Mathew
- Division of Pediatric Clinical Research, Department of Pediatrics
| | | | - Gwendolyn B Scott
- Division of Pediatric Infectious Diseases and Immunology, Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, Florida
| | - Tracie L Miller
- Division of Pediatric Clinical Research, Department of Pediatrics
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9
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Strehlau R, Shiau S, Arpadi S, Patel F, Pinillos F, Tsai WY, Coovadia A, Abrams E, Kuhn L. Substituting Abacavir for Stavudine in Children Who Are Virally Suppressed Without Lipodystrophy: Randomized Clinical Trial in Johannesburg, South Africa. J Pediatric Infect Dis Soc 2018; 7:e70-e77. [PMID: 29373687 PMCID: PMC6097575 DOI: 10.1093/jpids/pix110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 12/18/2017] [Indexed: 11/14/2022]
Abstract
OBJECTIVES Abacavir has replaced stavudine in antiretroviral therapy (ART) regimens because it has largely been phased out as a result of toxicity concerns; this loss has reduced further the already-limited drug options for children. Few data regarding virologic and metabolic outcomes among children who undergo substitution of stavudine exist. We evaluated the effects of preemptive substitution of abacavir for stavudine in children initially without lipodystrophy and virally suppressed on a stavudine-containing regimen. METHODS At Rahima Moosa Mother and Child Hospital in Johannesburg, South Africa, virally suppressed human immunodeficiency virus (HIV)-infected children ≥36 months of age without lipodystrophy were randomly assigned to continue taking stavudine as part of their ART regimen (n = 106) or to have abacavir substituted for stavudine (n = 107). The children were followed for 56 weeks after randomization in the context of a larger trial of treatment options for ART-experienced children. RESULTS The mean age of the children was 4.3 years, and the mean duration of ART before random assignment was 3.5 years. No differences in virological outcomes, CD4 response, growth, or dyslipidemia were noted between the stavudine and abacavir groups. By 56 weeks, children in the abacavir group had less clinically detected lipodystrophy (4.7% vs 16%, respectively), a higher proportion of leg fat relative to total fat (0.243 vs 0.230, respectively; P = .006), and a lower trunk/leg-skinfold ratio (0.547 vs 0.569, respectively; P = .003) than the children in the stavudine group. CONCLUSION Substituting abacavir for stavudine did not compromise virological response to treatment and was associated with significantly less lipodystrophy. These results support recommendations that favor abacavir in this population.
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Affiliation(s)
- Renate Strehlau
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Stephanie Shiau
- Gertrude H. Sergievsky Center, Columbia University,ICAP, Mailman School of Public Health, Columbia University
| | - Stephen Arpadi
- Gertrude H. Sergievsky Center, Columbia University,Department of Epidemiology, Columbia University,Department of Biostatistics, Columbia University,ICAP, Mailman School of Public Health, Columbia University
| | - Faeezah Patel
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Francoise Pinillos
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Wei-Yann Tsai
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University
| | - Ashraf Coovadia
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Elaine Abrams
- Department of Epidemiology, Columbia University,Department of Biostatistics, Columbia University,ICAP, Mailman School of Public Health, Columbia University
| | - Louise Kuhn
- Gertrude H. Sergievsky Center, Columbia University,ICAP, Mailman School of Public Health, Columbia University,Correspondence: L. Kuhn, PhD, Gertrude H. Sergievsky Center, Columbia University, 630 W. 168th St, New York, NY, 10032 ()
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10
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Unsal AB, Mattingly AS, Jones SE, Purdy JB, Reynolds JC, Kopp JB, Hazra R, Hadigan CM. Effect of Antiretroviral Therapy on Bone and Renal Health in Young Adults Infected With HIV in Early Life. J Clin Endocrinol Metab 2017; 102:2896-2904. [PMID: 28531309 PMCID: PMC5546869 DOI: 10.1210/jc.2017-00197] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 05/17/2017] [Indexed: 01/01/2023]
Abstract
Context HIV antiretroviral (ARV) therapy is associated with renal and bone toxicity, but little is known about the potential cumulative effects in adults exposed to ARVs from birth. Objective To prospectively evaluate renal and bone health in young adults with lifelong HIV and extensive ARV exposure. Design Cross-sectional comparison of bone mineral density (BMD) by dual-energy X-ray absorptiometry, bone turnover, and renal function in young adults infected with HIV in early life (n = 65) to matched healthy controls (n = 23) and longitudinal evaluation (mean follow-up = 4.4 years) within a subset of the HIV cohort (n = 33). Setting Government outpatient research clinic. Results Albumin/creatinine ratio, protein/creatinine ratio, anion gap, N-terminal telopeptides, and osteocalcin were significantly increased in persons with HIV compared with controls, whereas whole-body BMD and BMD z scores were lower. Within the HIV group, duration of tenofovir disoproxil fumarate (TDF) correlated with higher anion gap but did not correlate with bone parameters. Longer duration of didanosine and stavudine use correlated with lower BMD and BMD z scores. Longitudinal analyses revealed that BMD and bone metabolism significantly improved over time. No subject had an estimated glomerular filtration rate (eGFR) <60, but decline in eGFR correlated with increasing years of TDF exposure. Conclusions Subclinical markers of renal dysfunction were increased in HIV-infected young adults and associated with TDF exposure, whereas lower bone density was associated with didanosine and stavudine exposure. The tendency for improvement in markers of bone health over time and the availability of less toxic ARV alternatives may herald improvements in renal and bone health for perinatally infected patients in adulthood.
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Affiliation(s)
- Aylin B. Unsal
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Disease, Bethesda, Maryland 20892
| | - Aviva S. Mattingly
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Disease, Bethesda, Maryland 20892
| | - Sara E. Jones
- Clinical Research Directorate/Clinical Monitoring Research Program, Leidos Biomedical Research, Inc., NCI Campus at Frederick, Frederick, Maryland 21701
| | - Julia B. Purdy
- Critical Care Medicine Department, Clinical Center, Bethesda, Maryland 20892
| | - James C. Reynolds
- Radiology and Imaging Sciences, Nuclear Medicine Division, National Institutes of Health (NIH) Clinical Center, Bethesda, Maryland 20892
| | - Jeffrey B. Kopp
- Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland 20892
| | - Rohan Hazra
- Maternal and Pediatric Infectious Disease, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland 20892
| | - Colleen M. Hadigan
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Disease, Bethesda, Maryland 20892
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11
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Willig AL, Overton ET. Metabolic Complications and Glucose Metabolism in HIV Infection: A Review of the Evidence. Curr HIV/AIDS Rep 2016; 13:289-96. [PMID: 27541600 PMCID: PMC5425100 DOI: 10.1007/s11904-016-0330-z] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
HIV infection and antiretroviral therapy (ART) use are associated with perturbations in glucose and lipid metabolism. Increasing incidence of diabetes, cardiovascular disease, and obesity highlights the need for early identification and treatment of metabolic dysfunction. Newer ART regimens are less toxic for cellular function and metabolism but have failed to completely eliminate metabolic dysfunction with HIV infection. Additional factors, including viral-host interactions, diet, physical activity, non-ART medications, and aging may further contribute to metabolic disease risk in the HIV setting. We summarize the recent literature regarding the impact on metabolic function of HIV infection, ART, and pharmaceutical or lifestyle prescriptions.
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Affiliation(s)
- Amanda L Willig
- Division of Infectious Diseases. UAB Center for AIDS Research, University of Alabama School of Medicine, 845 19th Street South, BBRB 207, Birmingham, AL, 35294, USA
| | - Edgar Turner Overton
- Division of Infectious Diseases, University of Alabama School of Medicine, 908 20th St, South, CCB Rm 330A, Birmingham, AL, 35294, USA.
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12
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Dai Z, Cai W, Hu F, Lan Y, Li L, Chung C, Caughey B, Zhang K, Tang X. Plasma Mitochondrial DNA Levels as a Biomarker of Lipodystrophy Among HIV-infected Patients Treated with Highly Active Antiretroviral Therapy (HAART). Curr Mol Med 2016; 15:975-9. [PMID: 26592244 PMCID: PMC5403959 DOI: 10.2174/1566524016666151123114401] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 10/28/2015] [Accepted: 11/18/2015] [Indexed: 11/22/2022]
Abstract
Lipodystrophy is a common complication in HIV-infected patients taking highly active antiretroviral therapy. Its early diagnosis is crucial for timely modification of antiretroviral therapy. We hypothesize that mitochondrial DNA in plasma may be a potential marker of LD in HIV-infected individuals. In this study, we compared plasma mitochondrial DNA levels in HIV-infected individuals and non-HIV-infected individuals to investigate its potential diagnostic value. Total plasma DNA was extracted from 67 HIV-infected patients at baseline and 12, 24 and 30 months after initiating antiretroviral therapy. Real-time quantitative PCR was used to determine the mitochondrial DNA levels in plasma. Lipodystrophy was defined by the physician-assessed presence of lipoatrophy or lipohypertrophy in one or more body regions. The mitochondrial DNA levels in plasma were significantly higher at baseline in HIV-infected individuals than in non-HIV-infected individuals (p<0.05). At month 30, 33 out of 67 patients (49.2%) showed at least one sign of lipodystrophy. The mean plasma mitochondrial DNA levels in lipodystrophy patients were significantly higher compared to those without lipodystrophy at month 24 (p<0.001). The receiver operating curve analysis demonstrated that using plasma mitochondrial DNA level (with cut-off value <5.09 log10 copies/ml) as a molecular marker allowed identification of patients with lipodystrophy with a sensitivity of 64.2% and a specificity of 73.0%. Our data suggest that mitochondrial DNA levels may help to guide therapy selection with regards to HIV lipodystrophy risk.
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Affiliation(s)
| | | | | | | | | | | | | | - K Zhang
- Institute for Genomic Medicine, University of California San Diego, La Jolla, CA 92093, USA.
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13
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Escota GV, Mondy K, Bush T, Conley L, Brooks JT, Önen N, Patel P, Kojic EM, Henry K, Hammer J, Wood K, Lichtenstein KA, Overton ET. High Prevalence of Low Bone Mineral Density and Substantial Bone Loss over 4 Years Among HIV-Infected Persons in the Era of Modern Antiretroviral Therapy. AIDS Res Hum Retroviruses 2016; 32:59-67. [PMID: 26366785 DOI: 10.1089/aid.2015.0158] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
HIV-infected persons are living longer on combination antiretroviral therapy (cART) but experiencing more comorbidities including low bone mineral density (BMD). Using data from the Study to Understand the Natural History of HIV and AIDS in the Era of Effective Therapy (SUN Study), we determined the prevalence of low BMD (T-score below one standard deviation of the reference mean) and compared it with matched controls from the National Health and Nutrition Examination Survey (NHANES). We also assessed 4-year longitudinal BMD changes among participants virologically suppressed on cART. Of 653 participants included in this analysis (77% male, 29% black, median age 41 years, median CD4(+) cell count 464 cells/mm(3), 89% with HIV RNA <400 copies/ml), 51% and 10% had baseline osteopenia and osteoporosis, respectively. Low BMD at the femoral neck was significantly more prevalent than for the NHANES controls (47% versus 29%, p<0.001). Lower body mass index, nonwhite race, longer tenofovir exposure, older age, being unemployed or retired, and lower apolipoprotein E were independently associated with baseline osteoporosis. Among 170 participants virologically suppressed on cART and with longitudinal BMD data, 31% experienced substantial bone loss (≥5% BMD decline from baseline) over 4 years. Female sex, current smoking, and longer stavudine use were more common among participants who had substantial bone loss, although these variables failed to reach statistical significance. Low BMD was highly prevalent among HIV-infected persons. One-third of participants experienced substantial bone loss despite cART, suggesting the need for monitoring and potential clinical interventions.
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Affiliation(s)
- Gerome V. Escota
- Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, Missouri
| | - Kristin Mondy
- Central Texas Veterans Healthcare System, Austin, Texas
| | - Tim Bush
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lois Conley
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - John T. Brooks
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nur Önen
- Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, Missouri
| | - Pragna Patel
- Center of Global Health, Non-Communicable Diseases Unit, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Erna Milunka Kojic
- Division of Infectious Diseases, Brown University, Miriam Hospital, Providence, Rhode Island
| | - Keith Henry
- HIV Program, Hennepin County Medical Center and the University of Minnesota, Minneapolis, Minnesota
| | - John Hammer
- Denver Infectious Disease Consultants, Denver, Colorado
| | - K.C. Wood
- Cerner Corporation, Vienna, Virginia
| | | | - Edgar T. Overton
- Division of Infectious Diseases, University of Alabama School of Medicine, Birmingham, Alabama
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14
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Antiretroviral Therapy, Especially Efavirenz, Is Associated with Low Bone Mineral Density in HIV-Infected South Africans. PLoS One 2015; 10:e0144286. [PMID: 26633015 PMCID: PMC4669137 DOI: 10.1371/journal.pone.0144286] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 11/15/2015] [Indexed: 12/12/2022] Open
Abstract
Purpose We determined the prevalence and correlates of low bone mineral density (BMD) in HIV-infected South Africans as there is a paucity of such data from Africa. Methods BMD and serum 25-hydroxyvitamin D were measured in HIV-positive participants on antiretroviral therapy (ART) and in those not yet on ART (ART-naïve). Results We enrolled 444 participants [median age 35(IQR: 30, 40) years; 77% women]. BMD was low (z score <-2SD) in 17% and 5% of participants at the lumbar spine and total hip, respectively. Total hip [0.909 (SD 0.123) vs 0.956 (SD 0.124) g/cm2, p = 0.0001] and neck of femur BMD [0.796 (SD 0.130) vs 0.844 (SD 0.120) g/cm2, p = 0.0001] were lower in the ART, compared to the ART-naïve group. Vitamin D deficiency was present in 15% of participants and was associated with efavirenz use [adjusted OR 2.04 (95% CI 1.01 to 4.13)]. In a multivariate linear regression, exposure to efavirenz or lopinavir-based ART was associated with lower total hip BMD, whereas higher weight, being male and higher vitamin D concentration were associated with higher total hip BMD (adjusted R2 = 0.28). Age, weight, sex, and the use of efavirenz-based ART were independently associated with lumbar spine BMD (adjusted R2 = 0.13). Conclusions Vitamin D status, use of efavirenz or lopinavir/ritonavir, weight, age and sex are significantly associated with lower BMD in this young cohort of HIV-infected South Africans.
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Abstract
BACKGROUND Stavudine remains a component of combination antiretroviral therapy (ART) in resource-constrained countries due to its relatively low cost despite the WHO recommendation for its phasing out as a strategy to reduce stavudine associated toxicities. Where stavudine is still in use, it is recommended at a dose lower than the standard dose in order to reduce stavudine related toxicity. OBJECTIVES To compare the safety and virologic efficacy of low dose versus high dose stavudine for treating HIV-1 infection. SEARCH METHODS The comprehensive search strategy developed by the Cochrane HIV/AIDS Review Group was used to identify randomised controlled trials that compared the use of low dose versus high dose stavudine. The last search was conducted in February 2014 and the searches covered the period 1996 to 2014. SELECTION CRITERIA Randomised controlled trials comparing the use of low dose and high dose stavudine as part of ART combination therapy for treating adults. DATA COLLECTION AND ANALYSIS Two reviewers independently selected eligible trials, assessed methodological quality of the included studies and completed data extraction and analysis. MAIN RESULTS The search identified 3952 abstracts which were scanned for relevance. Three trials met the inclusion criteria (Milinkovic 2007; McComsey 2008; Sanchez-Conde 2005). All three trials were conducted in developed countries, participants were ART experienced and all had sustained virologic suppression at baseline. A total of 157 participants were recruited to the trials. Sample sizes ranged from 24 to 92 and more than 79% of participants were male.The studies were at a high risk of selection, performance/detection and selective outcome reporting biases. Some baseline characteristics differed among the groups, including triglyceride levels in two studies and body mass index in one study. In light of variation in the design and follow-up of the study results, no meta-analysis was performed and the results of single studies are presented. There was no significant difference in virologic suppression in the included studies (Milinkovic 2007; McComsey 2008; Sanchez-Conde 2005); Risk Ratio (RR) 1.09 (95% CI: 0.93 to 1.28), 0.94 (95% CI:0.59 to 1.50) and 1.03 (95% CI: 0.90 to 1.18) respectively. Symptomatic hyperlactatemia was seen in the high dose arm of the Milinkovic 2007 study; RR 0.21 (95% CI: 0.01 to 4.66), in no participants in the McComsey 2008 trial and not reported on in the Sanchez-Conde 2005 trial. McComsey 2008 and Milinkovic 2007 demonstrated a reduction in bone mineral density (BMD), reduction in limb fat and an increase in triglycerides in the high dose arms. The studies did not indicate that any participants discontinued treatment due to adverse events. AUTHORS' CONCLUSIONS This systematic review identified only three small trials that evaluated virologic efficacy and safety of high dose versus low dose stavudine. All three trials were conducted in developed countries and none reported from developing countries yet stavudine remains a component of ART combination therapy in many developing countries. It was not possible to perform a meta-analysis on these trails. Individual results from the trials were imprecise and have not identified a clear advantage in virologic efficacy or safety between low and high dose stavudine. Furthermore, enrolled participants were treatment experienced with sustained virologic suppression and so existing data cannot be generalized to settings where stavudine is currently used in ART naive patients with high viral loads. Stavudine dose reduction trials in ART naive patients, in developing countries where stavudine is still being used are warranted as the phasing out of stavudine that is recommended by WHO may not be immediately universally feasible.
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Affiliation(s)
- Nombulelo Magula
- Nelson R Mandela School of MedicineDurbanKwaZulu‐NatalSouth Africa
| | - Martin Dedicoat
- Birmingham Heartlands HospitalDepartment of InfectionBordesley Green EastBirminghamUKB9 5SS
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Abstract
Concern has been raised that HIV infection, its treatment, or both adversely affect skeletal health. Cross-sectional studies show that bone mineral density (BMD) is 3-5% lower in patients infected with HIV than in uninfected controls, but patients with HIV infection are, on average, 5 kg lighter than uninfected people. After this weight difference is accounted for, BMD differences are smaller and not clinically relevant. Longitudinal studies show short-term BMD loss of 2-4% over 1-2 years when antiretroviral therapy is started, followed by longer periods of BMD increase or stability. Losses are greatest with treatment regimens that contain tenofovir. Patients infected with HIV have slightly higher fracture rates than controls, but the increased risk of fracture is substantially attenuated by adjustment for traditional risk factors for fracture. These reassuring findings suggest that management of skeletal health in HIV should follow guidelines for the general population. In general, effective antiretroviral treatment and avoidance of undernutrition are the two most important factors for maintenance of skeletal health in patients infected with HIV.
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Affiliation(s)
- Mark J Bolland
- Department of Medicine, University of Auckland, Auckland, New Zealand.
| | - Andrew Grey
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Ian R Reid
- Department of Medicine, University of Auckland, Auckland, New Zealand
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Inzaule S, Otieno J, Kalyango J, Nafisa L, Kabugo C, Nalusiba J, Kwaro D, Zeh C, Karamagi C. Incidence and predictors of first line antiretroviral regimen modification in western Kenya. PLoS One 2014; 9:e93106. [PMID: 24695108 PMCID: PMC3973699 DOI: 10.1371/journal.pone.0093106] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 03/03/2014] [Indexed: 02/04/2023] Open
Abstract
Background Limited antiretroviral treatment regimens in resource-limited settings require long-term sustainability of patients on the few available options. We evaluated the incidence and predictors of combined antiretroviral treatment (cART) modifications, in an outpatient cohort of 955 patients who initiated cART between January 2009 and January 2011 in western Kenya. Methods cART modification was defined as either first time single drug substitution or switch. Incidence rates were determined by Poisson regression and risk factor analysis assessed using multivariate Cox regression modeling. Results Over a median follow-up period of 10.7 months, 178 (18.7%) patients modified regimens (incidence rate (IR); 18.6 per 100 person years [95% CI: 16.2–21.8]). Toxicity was the most common cited reason (66.3%). In adjusted multivariate Cox piecewise regression model, WHO disease stage III/IV (aHR; 1.82, 95%CI: 1.25–2.66), stavudine (d4T) use (aHR; 2.21 95%CI: 1.49–3.30) and increase in age (aHR; 1.02, 95%CI: 1.0–1.04) were associated with increased risk of treatment modification within the first year post-cART. Zidovudine (AZT) and tenofovir (TDF) use had a reduced risk for modification (aHR; 0.60 95%CI: 0.38–0.96 and aHR; 0.51 95%CI: 0.29–0.91 respectively). Beyond one year of treatment, d4T use (aHR; 2.75, 95% CI: 1.25–6.05), baseline CD4 counts ≤350 cells/mm3 (aHR; 2.45, 95%CI: 1.14–5.26), increase in age (aHR; 1.05 95%CI: 1.02–1.07) and high baseline weight >60kg aHR; 2.69 95% CI: 1.58–4.59) were associated with risk of cART modification. Conclusions Early treatment initiation at higher CD4 counts and avoiding d4T use may reduce treatment modification and subsequently improve sustainability of patients on the available limited options.
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Affiliation(s)
- Seth Inzaule
- Kenya Medical Research Institute, Kisumu, Kenya; Makerere University Medical School, Clinical Epidemiology Unit, Kampala, Uganda
| | - Juliana Otieno
- Jaramogi Oginga Odinga teaching and Referral Hospital, Kisumu, Kenya
| | - Joan Kalyango
- Makerere University Medical School, Clinical Epidemiology Unit, Kampala, Uganda
| | | | - Charles Kabugo
- Makerere University Medical School, Clinical Epidemiology Unit, Kampala, Uganda
| | - Josephine Nalusiba
- Makerere University Medical School, Clinical Epidemiology Unit, Kampala, Uganda
| | - Daniel Kwaro
- Kenya Medical Research Institute, Kisumu, Kenya; US Centers for Disease Control and Prevention, HIV-Research Branch, Kisumu, Kenya
| | - Clement Zeh
- US Centers for Disease Control and Prevention, HIV-Research Branch, Kisumu, Kenya; Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Charles Karamagi
- Makerere University Medical School, Clinical Epidemiology Unit, Kampala, Uganda
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Huang JS, Hughes MD, Riddler SA, Haubrich RH. Bone mineral density effects of randomized regimen and nucleoside reverse transcriptase inhibitor selection from ACTG A5142. HIV CLINICAL TRIALS 2014; 14:224-34. [PMID: 24144899 DOI: 10.1310/hct1405-224] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare the longitudinal changes in total bone mineral density (TBMD) across antiretroviral (ARV) regimens. METHODS A5142 was an open-label study comparing 3 ARV regimens for the initial treatment of HIV-1. Subjects were randomized equally to efavirenz (EFV) plus 2 nucleoside reverse transcriptase inhibitors (NRTIs), lopinavir/ritonavir (LPV/r) plus 2 NRTIs, or LPV/r plus EFV without NRTI. The NRTI regimen (lamivudine [3TC] plus zidovudine [ZDV], stavudine [d4T], or tenofovir [TDF]) was selected prior to randomization. TBMD was assessed via whole-body dual-energy X-ray absorptiometry (DXA) at baseline and 48 and 96 weeks. Analysis was modified intent-to-treat (ITT) ignoring regimen changes using all evaluations. RESULTS Significant mean declines in TBMD at week 48 were observed among subjects. In repeated-measures analysis of changes (including randomized regimen, NRTI used, and time), there was a significant difference in the NRTI-containing arms in mean percentage change in TBMD at week 48 according to NRTI used (P < .001). Subjects taking ZDV had similar changes to those taking d4T (P = .970), whereas those taking TDF had larger declines (P < .001). There was a nonsignificant trend toward greater mean declines among subjects taking LPV/r versus EFV (P = .080). Overall, TDF-containing regimens demonstrated the greatest losses in TBMD, while EFV regimens without TDF had lesser TBMD reductions even compared to the NRTI-sparing arm. From week 48 to 96, all treatment groups continued to lose TBMD at similar rates. CONCLUSIONS Among NRTI-containing arms, NRTI selection, especially use of TDF, had a greater effect on TBMD change than randomized regimen. The long-term clinical significance remains to be demonstrated.
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Affiliation(s)
- Jeannie S Huang
- Department of Pediatrics, University of California San Diego, La Jolla, California
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19
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Estimation of intracellular concentration of stavudine triphosphate in HIV-infected children given a reduced dose of 0.5 milligrams per kilogram twice daily. Antimicrob Agents Chemother 2013; 58:1084-91. [PMID: 24295968 DOI: 10.1128/aac.01717-13] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The antiviral efficacy of stavudine depends on the trough concentration of its intracellular metabolite, stavudine-triphosphate (d4T-TP), while the degree of stavudine's mitochondrial toxicity depends on its peak concentration. Rates of mitochondrial toxicity are high when stavudine is used at the current standard pediatric dose (1 mg/kg twice daily [BID]). Evidence from adult work suggests that half of the original standard adult dose (i.e., 20 mg BID) may be equally effective, with markedly less mitochondrial toxicity. We present a population pharmacokinetic model to predict intracellular d4T-TP concentrations in pediatric HIV-infected patients administered a dose of 0.5 mg/kg BID. Our model predicted that the reduced pediatric dose would result in a trough intracellular d4T-TP concentration above that of the reduced 20-mg adult dose and a peak concentration below that of the 20-mg adult dose. The simulated pediatric intracellular d4T-TP at 0.5 mg/kg BID resulted in median peak and trough values of approximately 23.9 fmol/10(6) cells (95% prediction interval [PI], 14.2 to 41 fmol/10(6) cells) and 14.8 fmol/10(6) cells (95% PI, 7.2 to 31 fmol/10(6) cells), respectively. The peak and trough concentrations resulting from a 20-mg BID adult dose were 28.4 fmol/10(6) cells (95% PI, 17.3 to 45.5 fmol/10(6) cells) and 13 fmol/10(6) cells (95% PI, 6.8 to 28.6 fmol/10(6) cells), respectively. Halving the current standard pediatric dose should therefore not compromise antiviral efficacy, while markedly reducing mitochondrial toxicity.
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Brennan AT, Maskew M, Ive P, Shearer K, Long L, Sanne I, Fox MP. Increases in regimen durability associated with the introduction of tenofovir at a large public-sector clinic in Johannesburg, South Africa. J Int AIDS Soc 2013; 16:18794. [PMID: 24256692 PMCID: PMC3835788 DOI: 10.7448/ias.16.1.18794] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 09/19/2013] [Accepted: 10/17/2013] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION In April 2010, tenofovir replaced stavudine in public-sector first-line antiretroviral therapy (ART) in South Africa. The association of tenofovir with fewer side effects and toxicities compared to stavudine could translate to increased durability of tenofovir-based regimens. We evaluated changes over time in regimen durability at the Themba Lethu Clinic, Johannesburg, South Africa. METHODS This was a cohort analysis of treatment-naïve, non-pregnant adult patients initiated on ART between April 2004 and December 2011. First-line ART regimens before April 2010 consisted of stavudine or zidovudine with lamivudine and either efavirenz or nevirapine. Tenofovir was substituted for stavudine after April 2010. We evaluated the frequency and type of single-drug substitutions (excluding switches to second-line therapy). Cox models were used to evaluate the association of ART initiation year and antiretroviral drug type with single-drug substitutions in the first 12 months on treatment. RESULTS One thousand nine hundred and sixty-four (10%) substitutions occurred amongst 19,699 patients. Excluding 2004 (year of treatment roll-out), before 2010 one-year single-drug substitutions ranged from 10.0 to 13.1%. In 2011, well after integration of tenofovir, substitutions decreased to 5.6%. Single-drug substitution was lowest amongst patients on tenofovir (5.1%) versus zidovudine (11.3%), 30 mg stavudine (10.5%) or 40 mg stavudine (14.4%). Adjusted Cox models showed that patients initiating treatment between 2005 and 2010 (vs. 2011) had a twofold increased hazard of single-drug substitution, while those on zidovudine or stavudine had a two to threefold increase in single-drug substitution versus tenofovir patients in the first 12 months on ART. CONCLUSIONS The decline in single-drug substitutions is associated with the introduction of tenofovir. Tenofovir use could improve regimen durability and treatment outcomes in resource-limited settings.
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Affiliation(s)
- Alana T Brennan
- Center for Global Health & Development, Boston University, Boston, MA, USA; Health Economics and Epidemiology Research Office, Faculty of Health Sciences, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa;
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Menezes CN, Crowther NJ, Duarte R, Van Amsterdam D, Evans D, Dickens C, Dix-Peek T, Rassool M, Prinsloo A, Raal F, Sanne I. A randomized clinical trial comparing metabolic parameters after 48 weeks of standard- and low-dose stavudine therapy and tenofovir disoproxil fumarate therapy in HIV-infected South African patients. HIV Med 2013; 15:3-12. [PMID: 23980620 DOI: 10.1111/hiv.12074] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2013] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Low-dose stavudine therapy may have a lower toxicity profile compared with standard dose. A randomized controlled trial comparing these two doses of stavudine with tenofovir disoproxil fumarate (tenofovir DF) was performed to assess the effects on anthropometry, markers of inflammation, and lipid and glucose metabolism in Black South African patients. METHODS Sixty patients were randomized 1:1:1 to either standard-dose (30-40 mg) or low-dose (20-30 mg) stavudine or tenofovir DF (300 mg), each combined with lamivudine and efavirenz, for 48 weeks. Anthropometry, markers of inflammation, and lipid and glucose metabolism were assessed using standard techniques. RESULTS In all three treatment arms, there was a significant increase in lipid levels over the study period. At 48 weeks, fasting glucose level (P < 0.005) and homeostasis model assessment (HOMA) score (P < 0.05) increased significantly in the standard-dose stavudine arm, as did insulin and C-peptide levels in both the standard- and low-dose stavudine arms. At week 48, a significant decrease (P < 0.05) in adiponectin was noted in the standard-dose stavudine arm, but there was an increase (P < 0.005) in the tenofovir DF arm. In both the stavudine arms, significant increases in anthropometric measures occurred at 24 weeks but these decreased by week 48. Mitochondrial toxicities occurred in both the stavudine arms. Immunological and virological outcomes were similar for all three arms. CONCLUSIONS This study highlights the occurrence of metabolic abnormalities with both stavudine and tenofovir DF treatment. Awareness of the potential increased cardiovascular risk should be of concern with the use of both these therapies.
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Affiliation(s)
- C N Menezes
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Clinical HIV Research Unit, Department of Internal Medicine, Helen Joseph Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Mora S, Diceglie C, Viganò A, Giacomet V, Manfredini V, Stucchi S, Fabiano V, Mameli C, Coletto S, Zuccotti GV. Antiretroviral therapy and pregnancy: effect on cortical bone status of human immunodeficiency virus-infected Caucasian women as assessed by quantitative ultrasonography. Calcif Tissue Int 2013; 92:394-8. [PMID: 23307187 DOI: 10.1007/s00223-013-9696-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 12/26/2012] [Indexed: 11/28/2022]
Abstract
Treatment with antiretroviral agents (ARVs) during pregnancy is important to prevent mother-to-child transmission of the human immunodeficiency virus (HIV), but their use has been associated with low bone mineral density in adult patients. Currently, there are no data regarding the bone status of HIV-infected women who received ARV during pregnancy. The aim of this study was to evaluate cortical bone status at delivery in a group of HIV-infected women who received ARV during pregnancy and to monitor the changes occurring during the first year postpartum. We studied 33 HIV-infected and 116 HIV-uninfected healthy Caucasian women within 4 days from delivery. Follow-up measurements were performed at 4 and 12 months postpartum in 17 HIV-infected and 55 healthy women. Cortical bone status was evaluated by quantitative ultrasonography at the mid-tibia, and bone measurements were expressed as the speed of sound (SOS). HIV-infected women after delivery had a median SOS of 3,985 (3,567-4,242) m/s, while the median SOS of healthy women was 4,025 (3,643-4,250) m/s. The difference was not significant (t = 0.39, P = 0.69). No significant differences were observed between ARV-exposed and control subjects at 4 and 12 months. Our data suggest that ARV during pregnancy and the first year after delivery does not affect negatively cortical bone status.
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Affiliation(s)
- Stefano Mora
- Laboratory of Pediatric Endocrinology, BoNetwork, Division of Metabolic and Cardiovascular Sciences, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
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Musiime V, Cook A, Kayiwa J, Zangata D, Nansubuga C, Arach B, Kenny J, Wavamunno P, Komunyena J, Kabamba D, Asiimwe AR, Mirembe G, Abongomera G, Mulenga V, Kekitiinwa A, Kityo C, Walker SA, Klein N, Gibb DM. Anthropometric measurements and lipid profiles to detect early lipodystrophy in antiretroviral therapy experienced HIV-infected children in the CHAPAS-3-Trial. Antivir Ther 2013; 19:269-76. [DOI: 10.3851/imp2695] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2013] [Indexed: 10/26/2022]
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Innes S, Cotton MF, Haubrich R, Conradie MM, van Niekerk M, Edson C, Rabie H, Jain S, Sun X, Zöllner EW, Hough S, Browne SH. High prevalence of lipoatrophy in pre-pubertal South African children on antiretroviral therapy: a cross-sectional study. BMC Pediatr 2012; 12:183. [PMID: 23176441 PMCID: PMC3584923 DOI: 10.1186/1471-2431-12-183] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 10/31/2012] [Indexed: 11/10/2022] Open
Abstract
Abstract Background Despite changes in WHO guidelines, stavudine is still used extensively for treatment of pediatric HIV in the developing world. Lipoatrophy in sub-Saharan African children can be stigmatizing and have far-reaching consequences. The severity and extent of lipoatrophy in pre-pubertal children living in sub-Saharan Africa is unknown. Methods In this cross-sectional study, children who were 3-12 years old, on antiretroviral therapy and pre-pubertal were recruited from a Family HIV Clinic in South Africa. Lipoatrophy was identified and graded by consensus between two HIV pediatricians using a standardized grading scale. A professional dietician performed formal dietary assessment and anthropometric measurements of trunk and limb fat. Previous antiretroviral exposures were recorded. In a Dual-Energy X-ray Absorbtiometry (DXA) substudy body composition was determined in 42 participants. Results Among 100 recruits, the prevalence of visually obvious lipoatrophy was 36% (95% CI: 27%–45%). Anthropometry and DXA measurements corroborated the clinical diagnosis of lipoatrophy: Both confirmed significant, substantial extremity fat loss in children with visually obvious lipoatrophy, when adjusted for age and sex. Adjusted odds ratio for developing lipoatrophy was 1.9 (95% CI: 1.3 - 2.9) for each additional year of accumulated exposure to standard dose stavudine. Cumulative time on standard dose stavudine was significantly associated with reductions in biceps and triceps skin-fold thickness (p=0.008). Conclusions The prevalence of visually obvious lipoatrophy in pre-pubertal South African children on antiretroviral therapy is high. The amount of stavudine that children are exposed to needs review. Resources are needed to enable low-and-middle-income countries to provide suitable pediatric-formulated alternatives to stavudine-based pediatric regimens. The standard stavudine dose for children may need to be reduced. Diagnosis of lipoatrophy at an early stage is important to allow timeous antiretroviral switching to arrest progression and avoid stigmatization. Diagnosis using visual grading requires training and experience, and DXA and comprehensive anthropometry are not commonly available. A simple objective screening tool is needed to identify early lipoatrophy in resource-limited settings where specialized skills and equipment are not available.
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Affiliation(s)
- Steve Innes
- Department of Paediatrics, Children's Infectious Diseases Clinical Research Unit (KID CRU), Tygerberg Children's Hospital, Stellenbosch University, Cape Town, South Africa.
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Vento S, Lanzafame M, Lattuada E, Cainelli F, Restelli U, Foglia E. Dose reduction of antiretrovirals: a feasible and testable approach to expand HIV treatment in developing countries. Trop Med Int Health 2012; 18:40-4. [PMID: 23094787 DOI: 10.1111/tmi.12008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hamers RL, Sigaloff KCE, Wensing AM, Wallis CL, Kityo C, Siwale M, Mandaliya K, Ive P, Botes ME, Wellington M, Osibogun A, Stevens WS, Rinke de Wit TF, Schuurman R. Patterns of HIV-1 drug resistance after first-line antiretroviral therapy (ART) failure in 6 sub-Saharan African countries: implications for second-line ART strategies. Clin Infect Dis 2012; 54:1660-9. [PMID: 22474222 DOI: 10.1093/cid/cis254] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus type 1 (HIV-1) drug resistance may limit the benefits of antiretroviral therapy (ART). This cohort study examined patterns of drug-resistance mutations (DRMs) in individuals with virological failure on first-line ART at 13 clinical sites in 6 African countries and predicted their impact on second-line drug susceptibility. METHODS A total of 2588 antiretroviral-naive individuals initiated ART consisting of different nucleoside reverse transcriptase inhibitor (NRTI) backbones (zidovudine, stavudine, tenofovir, or abacavir, plus lamivudine or emtricitabine) with either efavirenz or nevirapine. Population sequencing after 12 months of ART was retrospectively performed if HIV RNA was >1000 copies/mL. The 2010 International Antiviral Society-USA list was used to score major DRMs. The Stanford algorithm was used to predict drug susceptibility. RESULTS HIV-1 sequences were generated for 142 participants who virologically failed ART, of whom 70% carried ≥1 DRM and 49% had dual-class resistance, with an average of 2.4 DRMs per sequence (range, 1-8). The most common DRMs were M184V (53.5%), K103N (28.9%), Y181C (15.5%), and G190A (14.1%). Thymidine analogue mutations were present in 8.5%. K65R was frequently selected by stavudine (15.0%) or tenofovir (27.7%). Among participants with ≥1 DRM, HIV-1 susceptibility was reduced in 93% for efavirenz/nevirapine, in 81% for lamivudine/emtricitabine, in 59% for etravirine/rilpivirine, in 27% for tenofovir, in 18% for stavudine, and in 10% for zidovudine. CONCLUSIONS Early failure detection limited the accumulation of resistance. After stavudine failure in African populations, zidovudine rather than tenofovir may be preferred in second-line ART. Strategies to prevent HIV-1 resistance are a global priority.
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Affiliation(s)
- Raph L Hamers
- PharmAccess Foundation, Academic Medical Center of the University of Amsterdam, The Netherlands.
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Pahuja M, Grobler A, Glesby MJ, Karim F, Parker G, Gumede S, Naidoo K. Effects of a reduced dose of stavudine on the incidence and severity of peripheral neuropathy in HIV-infected adults in South Africa. Antivir Ther 2012; 17:737-43. [PMID: 22414588 DOI: 10.3851/imp2087] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND Although recent World Health Organization (WHO) guidelines recommend withdrawing stavudine (d4T) from first-line antiretroviral therapy (ART), it remains commonly used in resource-limited settings. In 2006, WHO recommended decreasing the dose of d4T from 40 mg to 30 mg to mitigate toxicities. We compared the incidence and severity of peripheral neuropathy by d4T dose in a retrospective cohort study. METHODS Patients' charts from an ART-naive population at a rural clinic in KwaZulu-Natal, South Africa, were retrospectively reviewed for signs and symptoms of incident peripheral neuropathy and were graded for severity using the DAIDS scale. Patients enrolled prior to the WHO guideline change were included in the study if they were on d4T 40 mg for ≥6 months. After the guideline change all patients were initiated on d4T 30 mg. RESULTS A total of 475 patients were analysed, including 235 in the 40 mg cohort (152.7 person-years [py]) and 240 in the 30 mg cohort (244.7 py). Incidence of peripheral neuropathy was 90.4/100 py (95% CI 75.9, 106.8) in the 40 mg cohort versus 40.5/100 py (95% CI 32.9, 49.3) in the 30 mg group (incidence rate ratio 0.45; P<0.0001). There was no difference in proportion of severe peripheral neuropathy cases (grade 3/4) between the cohorts: 8.3% in the 40 mg group and 8.9% in the 30 mg group (P=1.0). In a multivariate analysis, risk of peripheral neuropathy was associated with increasing age (hazard ratio [HR] 1.65, 95% CI 1.24, 2.19), 40 mg dose (HR 2.1, 95% CI 1.61, 2.74) and concurrent tuberculosis therapy (HR 1.41, 95% CI 1.06, 1.87). CONCLUSIONS Incidence of peripheral neuropathy in the 40 mg cohort was extremely high and, although lower, the rate in the 30 mg cohort was nonetheless unacceptably high.
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Affiliation(s)
- Meera Pahuja
- Division of Infectious Diseases, Weill Cornell Medical College, New York, NY, USA.
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Maskew M, Westreich D, Fox MP, Maotoe T, Sanne IM. Effectiveness and safety of 30 mg versus 40 mg stavudine regimens: a cohort study among HIV-infected adults initiating HAART in South Africa. J Int AIDS Soc 2012; 15:13. [PMID: 22410312 PMCID: PMC3313885 DOI: 10.1186/1758-2652-15-13] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 03/12/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As stavudine remains an important and widely prescribed drug in resource-limited settings, the effect of a reduced dose of stavudine (from 40 mg to 30 mg) on outcomes of highly active antiretroviral therapy (HAART) remains an important public health question. METHODS We analyzed prospectively collected data from the Themba Lethu Clinic in Johannesburg, South Africa. We assessed the relationship between stavudine dose and six- and/or 12-month outcomes of stavudine substitution, failure to suppress viral load to below 400 copies/ml, development of peripheral neuropathy, lipoatrophy and hyperlactatemia/lactic acidosis. Since individuals with a baseline weight of less than 60 kg were expected to have received the same dose of stavudine throughout the study period, analysis was restricted to individuals who weighed 60 kg or more at baseline. Data were analyzed using logistic regression. RESULTS Between 1 April 2004 and 30 September 2009, 3910 patients were initiated on antiretroviral therapy (ART) with a recorded stavudine dose and were included in the analysis. Of these, 2445 (62.5%) received a 40 mg stavudine dose while 1565 (37.5%) received 30 mg. In multivariate analysis, patients receiving a 40 mg dose were more likely to discontinue stavudine use (adjusted odds ratio, OR 1.71; 95% confidence limits, CI 1.13-2.57) than those receiving 30 mg by 12 months on ART. Additionally, patients receiving 40 mg doses of stavudine were more likely to report peripheral neuropathy (OR 3.12; 95% CI 1.86-5.25), lipoatrophy (OR 11.8; 95% CI 3.2-43.8) and hyperlactatemia/lactic acidosis (OR 8.37; 95% CI 3.83-18.29) in the same time period. Failure to suppress HIV viral load within 12 months of HAART initiation was somewhat more common among those given 40 mg doses (OR 1.62; 95% CI 0.88, 2.97) although this result lacked precision. Sensitivity analyses accounting for death and loss to follow up generally supported these estimates. CONCLUSIONS Lower stavudine dosage is associated with fewer reports of several stavudine-associated adverse events and also a lower risk of stavudine discontinuation within the first year on ART.
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Affiliation(s)
- Mhairi Maskew
- Clinical HIV Research Unit, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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Akanbi MO, Scarsi KK, Scarci K, Taiwo B, Murphy RL. Combination nucleoside/nucleotide reverse transcriptase inhibitors for treatment of HIV infection. Expert Opin Pharmacother 2012; 13:65-79. [PMID: 22149368 PMCID: PMC3397780 DOI: 10.1517/14656566.2012.642865] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION The combination of two nucleoside/nucleotide reverse transcriptase inhibitors (N(t)RTIs) and a third agent from another antiretroviral class is currently recommended for initial antiretroviral therapy. In general, N(t)RTIs remain relevant in subsequent regimens. There are currently six nucleoside reverse transcriptase inhibitors and one nucleotide reverse transcriptase inhibitor drug entities available, and several formulations that include two or more N(t)RTIs in a fixed-dose combination. These entities have heterogeneous pharmacological and clinical properties. Accordingly, toxicity, pill burden, dosing frequency, potential drug-drug interaction, preexisting antiretroviral drug resistance and comorbid conditions should be considered when constructing a regimen. This approach is critical in order to optimize virologic efficacy and clinical outcomes. AREAS COVERED This article reviews N(t)RTI combinations used in the treatment of HIV-infected adults. The pharmacological properties of each N(t)RTI, and the clinical trials that have influenced treatment guidelines are discussed. EXPERT OPINION It is likely that N(t)RTIs will continue to dominate the global landscape of HIV treatment and prevention, despite emerging interest in N(t)RTI-free combination therapy. Clinical domains where only few alternatives to N(t)RTIs exist include treatment of HIV/HBV coinfection and HIV-2. There is a need for novel N(t)RTIs with enhanced safety and resistance profiles compared with current N(t)RTIs.
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Affiliation(s)
- Maxwell O Akanbi
- Jos University Teaching Hospital, Department of Internal Medicine, P M B 2076, Jos. Plateau State, 930001, Nigeria
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Pujades-Rodríguez M, Dantony E, Pinoges L, Ecochard R, Etard JF, Carrillo-Casas E, Szumilin E. Toxicity associated with stavudine dose reduction from 40 to 30 mg in first-line antiretroviral therapy. PLoS One 2011; 6:e28112. [PMID: 22132226 PMCID: PMC3221698 DOI: 10.1371/journal.pone.0028112] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 11/01/2011] [Indexed: 11/23/2022] Open
Abstract
Background To compare the incidence and timing of toxicity associated with the use of a reduced dose of stavudine from 40 to 30 mg in first-line antiretroviral therapy (ART) for HIV treatment and to investigate associated risk factors. Methods Multicohort study including 23 HIV programs in resource-limited countries. Adults enrolled between January 2005 and December 2009. Four-year rates of all-cause and stavudine-specific toxicity were estimated. Multilevel mixed-effect Poisson and accelerated failure models were used to investigate factors associated with toxicity and timing of diagnosis. Findings A total of 48,785 patients contributed 62,505 person-years of follow-up. Rate of all-cause toxicity was 7.80 (95%CI 7.59–8.03) per 100 person-years, but varied greatly across sites (range 0.41–21.76). Patients treated with stavudine 40 mg had higher rates of toxicity (adjusted rate ratio [aRR] 1.18, 95%CI 1.06–1.30 during the first year of ART; and 1.51, 95%CI 1.32–1.71 during the second year). Women, older age, initial advanced clinical stage, and low CD4 count were associated with increased toxicity rate ratios. Timing of lipodystrophy and peripheral neuropathy diagnosis were 12% and 13% shorter, respectively, in patients treated with stavudine 40 mg than in those receiving 30 mg stavudine dose (P = 0.03 and 0.07, respectively). Insterpretation Higher rates of drug-related toxicity were reported in patients receiving stavudine 40 mg compared with 30 mg, and the time to toxicity diagnosis was shorter in patients treated with the higher dose. Higher rates of toxicity were observed during the first two years of ART.
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Bone mineral density in HIV-infected women taking antiretroviral therapy: a systematic review. ACTA ACUST UNITED AC 2011; 54:133-42. [PMID: 20485901 DOI: 10.1590/s0004-27302010000200008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Accepted: 02/19/2010] [Indexed: 11/22/2022]
Abstract
There is a high prevalence of osteoporosis in HIV-infected patients. Initially described in HIV-positive men, studies have also demonstrated a high prevalence of osteoporosis in HIV-infected women. It would appear that antiretroviral therapy (ART) plays an important role in the pathogenesis of osteoporosis in HIV-infected patients, although little is known about its importance in relation to osteoporosis and fractures in HIV-positive women. The aim of this systematic review was to evaluate the frequency of bone loss, bone mineral density (BMD) and fractures in HIV-positive women taking ART or protease inhibitors (PI). After screening 597 citations from the databases of PubMed, EMBASE and Lilacs, five studies were selected for the review. A difference was demonstrated of over 3% in the BMD at the femoral neck of HIV-positive women taking PI/ART. No difference was registered in the BMD at the lumbar spine between users and non-users of PI/ART. The lack of studies has made it impossible to reach any conclusion regarding the occurrence of fractures.
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Liu X, Ma Q, Zhang F. Therapeutic drug monitoring in highly active antiretroviral therapy. Expert Opin Drug Saf 2011; 9:743-58. [PMID: 20350281 DOI: 10.1517/14740331003767395] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE OF THE FIELD Despite the efficacy of combination antiretroviral therapy (ART), a large proportion of patients living with HIV/AIDS on ART does not achieve or maintain adequate virological suppression. Therapeutic drug monitoring (TDM) has been utilised to improve treatment outcomes of ART. AREAS COVERED IN THE REVIEW The potential incorporation of TDM into the clinical HIV management is supported by the existing relationship between drug exposure and efficacy/toxicity, the high inter-patient variability pharmacokinetics, and the accurate, specific and rapid method for drug level determination. The current status of TDM in ART is reviewed in this article with discussions on its feasibility, potential use and limitations. WHAT THE READER WILL GAIN Mounting evidence from clinical trials has indicated the potential use of TDM in reducing the rates of treatment failure and adverse effect, avoiding the drug interactions, and special populations, such as children, pregnant women and patients with co-infections. TDM may play an important role even in resource-limited settings, to safeguard expanded use of bioequivalent generic antiretroviral drugs and avoid drug interactions with traditional Chinese medicines. TAKE HOME MESSAGE TDM is still in the centre of controversy in that several critical issues need to be addressed, such as limited adherence assessment, inappropriate response predictors, insufficient validation of target concentration windows and lack of the quality control of assay. The utility of TDM will remain experimental until more data are obtained from large clinical trials showing the benefit of TDM.
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Affiliation(s)
- Xia Liu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nan Wei Road, Beijing 100050, China.
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Curran A, Ribera E. From old to new nucleoside reverse transcriptase inhibitors: changes in body fat composition, metabolic parameters and mitochondrial toxicity after the switch from thymidine analogs to tenofovir or abacavir. Expert Opin Drug Saf 2011; 10:389-406. [PMID: 21235431 DOI: 10.1517/14740338.2011.542145] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Thymidine analogs zidovudine (AZT) and stavudine (d4T) have been widely used because of their antiviral activity against HIV, but at the expense of high toxicity, mainly related to mitochondrial damage. Many studies have been performed replacing AZT or d4T with newer nucleoside analogs reverse transcriptase inhibitors (NRTIs) with less toxicity, such as tenofovir (TDF) or abacavir (ABC), maintaining virological efficacy. AREAS COVERED Relevant literature was identified using a PubMed search of articles published up to June 2010. Search terms included: 'thymidine analogs', 'stavudine', 'zidovudine', 'd4T', 'AZT', 'ZDV', 'treatment switch'. Original articles in which d4T or AZT had been replaced by TDF or ABC as switch strategies (with undetectable viral load) were reviewed where information about body fat distribution, mitochondrial functionality and/or plasma lipid parameters were available. Relevant references from these articles were also considered. Only studies performed in adult patients (18 years or older) are included. The readers will gain a better understanding of the toxicity caused by thymidine analogs, the treatment alternatives and the benefits observed after treatment switch to newer NRTIs. EXPERT OPINION Thymidine analogs AZT and d4T yield considerable toxicity and proactive switch to newer NRTIs such as TDF or ABC is necessary in order to avoid or partially reverse such side effects.
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Affiliation(s)
- Adrian Curran
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Institut de Recerca, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain.
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Abstract
The use of antiretroviral therapy has significantly reduced the number of deaths due to HIV/AIDS. However, no current therapy can suppress the virus completely, and as the HIV-infected population continues to live longer new complications are emerging from the persistence of the virus and use of antiretroviral therapy. This review summarizes the clinical evidence linking HIV-associated osteoporosis to direct infection and antiretroviral therapy (ART) use. The purported molecular mechanisms involved in bone loss are also reviewed. Additionally, recommendations regarding the pharmacologic management of HIV/ART-related osteoporosis are given.
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Affiliation(s)
- Shitij Arora
- Department of Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA
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Introcaso CE, Hines JM, Kovarik CL. Cutaneous toxicities of antiretroviral therapy for HIV: part I. Lipodystrophy syndrome, nucleoside reverse transcriptase inhibitors, and protease inhibitors. J Am Acad Dermatol 2010; 63:549-61; quiz 561-2. [PMID: 20846563 DOI: 10.1016/j.jaad.2010.01.061] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Revised: 01/11/2010] [Accepted: 01/15/2010] [Indexed: 11/17/2022]
Abstract
Antiretroviral medications for the treatment of HIV are common drugs with diverse and frequent skin manifestations. Multiple new cutaneous effects have been recognized in the past decade. Dermatologists play an important role in accurately diagnosing and managing the cutaneous toxicities of these medications, thereby ensuring that a patient has as many therapeutic options as possible for life-long viral suppression. Part I of this two-part series on the cutaneous adverse effects of antiretroviral medications will discuss HIV-associated lipodystrophy syndrome, which can be seen as a result of many antiretroviral medications for HIV, and the specific cutaneous effects of the nucleoside reverse transcriptase inhibitors and protease inhibitors.
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Affiliation(s)
- Camille E Introcaso
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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Sinxadi PZ, van der Walt JS, McIlleron HM, Badri M, Smith PJ, Dave JA, Levitt NS, Maartens G. Lack of association between stavudine exposure and lipoatrophy, dysglycaemia, hyperlactataemia and hypertriglyceridaemia: a prospective cross sectional study. AIDS Res Ther 2010; 7:23. [PMID: 20630064 PMCID: PMC2914641 DOI: 10.1186/1742-6405-7-23] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Accepted: 07/14/2010] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Stavudine continues to be widely used in resource poor settings despite its toxicity. Our objective was to determine association between plasma stavudine concentrations and lipoatrophy, concentrations of glucose, lactate and triglycerides. METHODS Participants were enrolled in a cross-sectional study with lipoatrophy assessment, oral glucose tolerance test, fasting triglycerides, finger prick lactate, and stavudine concentrations. Individual predictions of the area under the concentration curve (AUC) were obtained using a population pharmacokinetic approach. Logistic regression models were fitted to assess the association between stavudine geometric mean ratio > 1 and impaired fasting glucose, impaired glucose tolerance, hyperlactataemia, hypertriglyceridaemia, and lipoatrophy. RESULTS There were 47 study participants with a median age of 34 years and 83% were women. The median body mass index and waist:hip ratio was 24.5 kg/m2 and 0.85 respectively. The median duration on stavudine treatment was 14.5 months. The prevalence of lipoatrophy, impaired fasting glucose, impaired glucose tolerance, hyperlactataemia, and hypertriglyceridaemia were 34%, 19%, 4%, 32%, and 23% respectively. Estimated median (interquartile range) stavudine AUC was 2191 (1957 to 2712) ng*h/mL. Twenty two participants had stavudine geometric mean ratio >1. Univariate logistic regression analysis showed no association between stavudine geometric mean ratio >1 and impaired fasting glucose (odds ratio (OR) 2.00, 95% CI 0.44 to 9.19), impaired glucose tolerance (OR 1.14, 95% CI 0.07 to 19.42), hyperlactataemia (OR 2.19, 95%CI 0.63 to 7.66), hypertriglyceridaemia (OR 1.75, 95%CI 0.44 to 7.04), and lipoatrophy (OR 0.83, 95% CI 0.25 to 2.79). CONCLUSIONS There was a high prevalence of metabolic complications of stavudine, but these were not associated with plasma stavudine concentrations. Until there is universal access to safer antiretroviral drugs, there is a need for further studies examining the pathogenesis of stavudine-associated toxicities.
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Affiliation(s)
- Phumla Z Sinxadi
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, K45 Old Main Building, Groote Schuur Hospital, Observatory, 7925, Cape Town, South Africa
| | - Jan-Stefan van der Walt
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, K45 Old Main Building, Groote Schuur Hospital, Observatory, 7925, Cape Town, South Africa
| | - Helen M McIlleron
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, K45 Old Main Building, Groote Schuur Hospital, Observatory, 7925, Cape Town, South Africa
| | - Motasim Badri
- Department of Medicine, Clinical Research Support Unit, University of Cape Town. J45-46 Old Main Building, Groote Schuur Hospital, Observatory, 7925, Cape Town, South Africa
| | - Peter J Smith
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, K45 Old Main Building, Groote Schuur Hospital, Observatory, 7925, Cape Town, South Africa
| | - Joel A Dave
- Department of Medicine, Division of Diabetic Medicine and Endocrinology, University of Cape Town. J47 Old Main Building, Groote Schuur Hospital, Observatory, 7925, Cape Town, South Africa
| | - Naomi S Levitt
- Department of Medicine, Division of Diabetic Medicine and Endocrinology, University of Cape Town. J47 Old Main Building, Groote Schuur Hospital, Observatory, 7925, Cape Town, South Africa
| | - Gary Maartens
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, K45 Old Main Building, Groote Schuur Hospital, Observatory, 7925, Cape Town, South Africa
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Zuccotti G, Viganò A, Gabiano C, Giacomet V, Mignone F, Stucchi S, Manfredini V, Marinacci F, Mora S. Antiretroviral therapy and bone mineral measurements in HIV-infected youths. Bone 2010; 46:1633-8. [PMID: 20211284 DOI: 10.1016/j.bone.2010.02.029] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 02/26/2010] [Accepted: 02/28/2010] [Indexed: 11/30/2022]
Abstract
Reduced bone mass measurements are often found in HIV-infected youths. Both in vitro and human studies demonstrated a role of antiretroviral treatment in determining bone mass alteration. Nevertheless, the data regarding the responsibility of different antiretroviral drugs on bone health in children and adolescents are highly controversial. The purpose of the current study was to relate antiretroviral treatment to bone mass measurements in a large cohort of HIV-infected children and adolescents. Bone mineral content (BMC) was measured in 86 HIV-infected youths (aged 4.8-22.1 years), and in 194 healthy controls (aged 4.9-21.9 years). Fifteen patients were naive to antiretroviral treatment, 11 were receiving a dual nucleoside reverse transcriptase inhibitor (NRTIs) combination, 32 a protease inhibitor (PI)-based antiretroviral treatment, and 28 a non-nucleoside reverse transcriptase inhibitor (NNRTIs)-based regimen. Comparisons between healthy and HIV-infected children and adolescents have been performed by multiple regression analyses to correct for differences in age, sex, and anthropometric measurements. Patients receiving a PI-based treatment had lumbar spine and whole body BMC values significantly lower than healthy children (P<0.05). BMC measurements of patients on other therapeutic regimens or naive to antiretroviral treatment did not differ significantly from those of healthy children. Among patients receiving a PI-based regimen, those receiving full dose Ritonavir had significantly lower lumbar spine BMC values compared to other patients. Lumbar spine and whole body BMC measurements of patients receiving a Stavudine-containing regimen were lower compared to healthy controls, naive patients, and patients on other antiretroviral regimens. Multivariate analyses showed that patients receiving both Stavudine and full dose Ritonavir had significantly lower BMC values both at the lumbar spine (P=0.0033), and in the whole skeleton (P=0.05). In conclusion, antiretroviral treatment may have a detrimental effect on bone health of HIV-infected youths: the use of Ritonavir full dose alone or in combination with Stavudine is associated to lower bone mass measurements. The use of antiretroviral regimens including these drugs should thus be monitored closely in HIV-infected youths.
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Kim RJ, Rutstein RM. Impact of antiretroviral therapy on growth, body composition and metabolism in pediatric HIV patients. Paediatr Drugs 2010; 12:187-99. [PMID: 20481647 DOI: 10.2165/11532520-000000000-00000] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Highly active antiretroviral therapy improves survival and growth in children with HIV infection. However, its use can be associated with adverse changes in body composition and metabolism. Bone mineral density can be adversely affected in HIV-positive children due to nutritional compromise or certain antiretrovirals. HIV-associated lipodystrophy, consisting of redistribution of adipose tissue, insulin resistance, and dyslipidemia, has also been described in children. Pediatric HIV patients may be at greater risk for these problems because of their longer potential lifetime exposure to these agents and because childhood is normally a period of rapid growth and tissue accretion. Healthcare providers for children with HIV infection must be aware of the potential complications associated with HIV antiretrovirals so that their antiviral efficacy can be balanced against their risk for side effects. In this review, we discuss the alterations in childhood growth and body composition that occur in HIV-infected children, and describe the impact of antiretroviral therapy on these outcomes. The problem of HIV-associated lipodystrophy syndrome in children is also discussed. Children with HIV should have their growth and body composition systematically monitored. Antiretroviral regimens should be tailored to optimize adherence and viral suppression while minimizing the potential for adverse side effects.
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Affiliation(s)
- Roy J Kim
- Division of Endocrinology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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Reynolds SJ, Kityo C, Hallahan CW, Kabuye G, Atwiine D, Mbamanya F, Ssali F, Dewar R, Daucher M, Davey RT, Mugyenyi P, Fauci AS, Quinn TC, Dybul MR. A randomized, controlled, trial of short cycle intermittent compared to continuous antiretroviral therapy for the treatment of HIV infection in Uganda. PLoS One 2010; 5:e10307. [PMID: 20442758 PMCID: PMC2860845 DOI: 10.1371/journal.pone.0010307] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Accepted: 03/22/2010] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Short cycle treatment interruption could reduce toxicity and drug costs and contribute to further expansion of antiretroviral therapy (ART) programs. METHODS A 72 week, non-inferiority trial enrolled one hundred forty six HIV positive persons receiving ART (CD4+ cell count > or =125 cells/mm(3) and HIV RNA plasma levels <50 copies/ml) in one of three arms: continuous, 7 days on/7 days off and 5 days on/2 days off treatment. Primary endpoint was ART treatment failure determined by plasma HIV RNA level, CD4+ cell count decrease, death attributed to study participation, or opportunistic infection. RESULTS Following enrollment of 32 participants, the 7 days on/7 days off arm was closed because of a failure rate of 31%. Six of 52 (11.5%) participants in the 5 days on/2 days off arm failed. Five had virologic failure and one participant had immunologic failure. Eleven of 51 (21.6%) participants in the continuous treatment arm failed. Nine had virologic failure with 1 death (lactic acidosis) and 1 clinical failure (extra-pulmonary TB). The upper 97.5% confidence boundary for the difference between the percent of non-failures in the 5 days on/2 days off arm (88.5% non-failure) compared to continuous treatment (78.4% non failure) was 4.8% which is well within the preset non-inferiority margin of 15%. No significant difference was found in time to failure in the 2 study arms (p = 0.39). CONCLUSIONS Short cycle 5 days on/2 days off intermittent ART was at least as effective as continuous therapy. TRIAL REGISTRATION ClinicalTrials.gov NCT00339456.
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Affiliation(s)
- Steven J Reynolds
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America.
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Evaluation of glucose uptake by skeletal muscle tissue and subcutaneous fat in HIV-infected patients with and without lipodystrophy using FDG-PET. Nucl Med Commun 2010; 31:311-4. [DOI: 10.1097/mnm.0b013e3283359058] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cournil A, Coudray M, Kouanfack C, Essomba CN, Tonfack CAD, Biwolé-Sida M, Delaporte E, Bork K, Laurent C. Reduced dose of stavudine and lipoatrophy in
HIV-infected patients in Cameroon. Antivir Ther 2010; 15:1039-43. [DOI: 10.3851/imp1664] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Innes S, Levin L, Cotton M. LIPODYSTROPHY SYNDROME IN HIV-INFECTED CHILDREN ON HAART. South Afr J HIV Med 2009; 10:76-80. [PMID: 20706598 DOI: 10.4102/sajhivmed.v10i4.264] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Lipodystrophy syndrome (LD) is common in HIV-infected children, particularly those taking didanosine, stavudine or zidovudine. Lipo-atrophy in particular causes major stigmatisation and interferes with adherence. In addition, LD may have significant long-term health consequences, particularly cardiovascular. Since the stigmatising fat distribution changes of LD are largely permanent, the focus of management remains on early detection and arresting progression. Practical guidelines for surveillance and avoidance of LD in routine clinical practice are presented. The diagnosis of LD is described and therapeutic options are reviewed. The most important therapeutic intervention is to switch the most likely offending antiretroviral to a non-LD-inducing agent as soon as LD is recognised. Typically, when lipoatrophy or lipohypertrophy is diagnosed the thymidine nucleoside reverse transcriptase inhibitor (NRTI) is switched to a non-thymidine agent such as abacavir (or tenofovir in adults). Where dyslipidaemia is predominant, a dietician review is helpful, and the clinician may consider switching to a protease inhibitor-sparing regimen or to atazanavir.
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Affiliation(s)
- Steve Innes
- KID-CRU (Children's Infectious Diseases Clinical Research Unit), Tygerberg Children's Hospital and Stellenbosch University, Tygerberg, W Cape
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Maagaard A, Kvale D. Long term adverse effects related to nucleoside reverse transcriptase inhibitors: Clinical impact of mitochondrial toxicity. ACTA ACUST UNITED AC 2009; 41:808-17. [DOI: 10.3109/00365540903186181] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Villarroya J, Giralt M, Villarroya F. Mitochondrial DNA: an up-and-coming actor in white adipose tissue pathophysiology. Obesity (Silver Spring) 2009; 17:1814-20. [PMID: 19461585 DOI: 10.1038/oby.2009.152] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Joan Villarroya
- Departament de Bioquimica i Biologia Molecular, i Institut de Biomedicina de la Universitat de Barcelona (IBUB), Barcelona, Spain
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Maagaard A, Kvale D. Mitochondrial toxicity in HIV-infected patients both off and on antiretroviral treatment: a continuum or distinct underlying mechanisms? J Antimicrob Chemother 2009; 64:901-9. [DOI: 10.1093/jac/dkp316] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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Abstract
OBJECTIVES To assess the effects of antiretroviral therapy (ART) on bone mineral density (BMD) DESIGN: Randomized comparison of continuous ART (viral suppression group; VS) with intermittent ART (drug conservation group; DC) SETTING: Outpatient clinics in the United States, Australia, and Spain. PARTICIPANTS Participants in the Strategies for Management of Antiretroviral Therapy (SMART) Body Composition substudy. MAIN OUTCOME MEASURES Annual hip and spine BMD by dual-energy radiographic absorptiometry (DXA) and spine BMD by quantitative computed tomography (qCT). METHODS Comparisons were by intention-to-treat analysis, using longitudinal models for change in BMD. Risk factors for BMD loss were evaluated. RESULTS The 214 participants (median 44 years, 19% female participants, 73% on ART; median T-scores -0.5 total hip, -0.7 spine DXA, -0.9 spine qCT; 98 randomized to VS and 116 to DC) were followed for a mean 2.4 years. With continuous ART, BMD declined per year by 0.8% (hip), 0.4% (spine DXA), and 2.4% (spine qCT). BMD declined significantly less with intermittent ART. Estimated DC minus VS group differences in mean BMD change through follow-up were 1.4% [hip; 95% confidence interval (CI) 0.6-2.3; P = 0.002], 1.3% (spine DXA; 95% CI 0.1-2.4, P = 0.03), and 3.0% (spine qCT; 95% CI 0.8-5.2, P = 0.007). No consistent drug-specific association with BMD decline was found. In the parent study, 10 of 2753 participants in the VS group and two of 2720 in the DC group reported serious fractures (hazard ratio 4.9; 95% CI 1.1-22.5; P = 0.04). CONCLUSION Continuous ART is associated with decline in BMD and possibly more fractures relative to intermittent, CD4 cell count-guided ART.
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First line zidovudine/lamivudine/lopinavir/ritonavir leads to greater bone loss compared to nevirapine/lopinavir/ritonavir. AIDS 2009; 23:1367-76. [PMID: 19424051 DOI: 10.1097/qad.0b013e32832c4947] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We studied changes in bone mineral density (BMD) and bone turnover after initiation of combination antiretroviral therapy (cART) and the contribution of zidovudine/lamivudine (ZDV/3TC) in particular. DESIGN Randomized clinical trial comparing lopinavir/ritonavir(LPV/r) + ZDV/3TC with LPV/r + nevirapine (NVP) in 50 cART-naive men. METHODS Dual energy X-ray absorptiometry (DXA) and quantitative computed tomography scans (QCT) were performed at baseline and 3, 12, and 24 months after cART initiation. Serum 25-hydroxy-vitamin D3, parathyroid hormone (PTH), osteocalcin, and urine deoxypyridinoline (DPD)/creatinine ratio were measured. RESULTS BMD decreased rapidly in both femoral neck and lumbar spine after cART initiation. BMD loss during 24 months measured by DXA, but not by QCT, was greater in the ZDV/3TC/LPV/r group compared to the NVP/LPV/r group [femoral neck: -6.3% +/- 1.0% (P < 0.0001) compared to -2.3% +/- 0.9% (P = 0.01), between-group P = 0.0006); lumbar spine: -5.1% +/- 0.8% (P < 0.0001) compared to -2.6% +/- 0.7% (P = 0.0006), between-group P = 0.07]. Osteocalcin [+1.60 +/- 0.32 (P < 0.0001) and +1.81 +/- 0.29 (P < 0.0001) nmol/l] and the urine DPD/creatinine ratio [+1.35 +/- 0.44 (P = 0.0029) and +1.19 +/- 0.38 nmol/mmol (P = 0.0024)] increased in both groups over 24 months, with no significant difference between groups. PTH increased to a greater degree in the NVP/LPV/r group [+2.0 +/- 0.31 pmol/l (P < 0.0001)] compared to [+0.81 +/- 0.33 pmol/l (P = 0.021) in the ZDV/3TC/LPV/r group]. CONCLUSION BMD in both femoral neck and lumbar spine decreased rapidly after initiation of cART, in parallel to an increase in bone turnover. The greater bone loss in the ZDV/3TC/LPV/r group compared to the NVP/LPV/r group suggests that ZDV/3TC contributes to this process. The PTH increase does not explain this greater bone loss.
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Gatell Artigas JM. [HIV infection. Irreversible mistakes not to be repeated]. Med Clin (Barc) 2009; 134:399-401. [PMID: 19477467 DOI: 10.1016/j.medcli.2009.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2008] [Accepted: 02/26/2009] [Indexed: 10/20/2022]
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Abstract
INTRODUCTION Osteoporosis is among the chronic problems emerging as the human immunodeficiency virus (HIV)-positive population ages. SOURCES OF DATA We reviewed the English language bibliography using Pubmed 2.0, Web of Science and Embase for relevant abstracts and articles. AREAS OF AGREEMENT The prevalence of low bone mineral density (BMD) and fracture is increased in the HIV-positive population. AREAS OF CONTROVERSY The pathogenesis is multifactorial; there is some evidence that HIV infection is an independent risk factor and that highly active antiretroviral therapy has adverse skeletal effects. GROWING POINTS Physicians should routinely review the bone health of all HIV patients. AREAS TIMELY FOR DEVELOPING RESEARCH More studies of the mechanisms of bone loss, the skeletal effects of antiretroviral therapy and the therapeutic outcome of bone-protective therapy in HIV-positive individuals are needed.
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Affiliation(s)
- Emily Pollock
- Clinical School of Medicine, University of Cambridge, Cambridge, UK
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Wanke C. Editorial Commentary:The Effect of Reducing the Dose of Stavudine on Body Composition, Bone Density, and Markers of Mitochondrial Toxicity in HIV‐Infected Subjects: Answers and Questions. Clin Infect Dis 2008; 46:1297-8. [DOI: 10.1086/529383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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