A clinical review of HIV integrase strand transfer inhibitors (INSTIs) for the prevention and treatment of HIV-1 infection

Integrase strand transfer inhibitors (INSTIs) have improved the treatment of human immunodeficiency virus (HIV). There are currently four approved for use in treatment-naïve individuals living with HIV; these include first generation raltegravir, elvitegravir, and second generation dolutegravir and bictegravir. The most recent INSTI, cabotegravir, is approved for (1) treatment of HIV infection in adults to replace current antiretroviral therapy in individuals who maintain virologic suppression on a stable antiretroviral regimen without history of treatment failure and no known resistance to its components and (2) pre-exposure prophylaxis in individuals at risk of acquiring HIV-1 infection. Cabotegravir can be administered intramuscularly as a monthly or bi-monthly injection depending on the indication. This long-acting combination has been associated with treatment satisfaction in clinical studies and may be helpful for individuals who have difficulty taking daily oral medications. Worldwide, second generation INSTIs are preferred for treatment-naïve individuals. Advantages of these INSTIs include their high genetic barrier to resistance, limited drug-drug interactions, excellent rates of virologic suppression, and favorable tolerability. Few INSTI resistance-associated mutations have been reported in clinical trials involving dolutegravir, bictegravir and cabotegravir. Other advantages of specific INSTIs include their use in various populations such as infants and children, acute HIV infection, and individuals of childbearing potential. The most common adverse events observed in clinical studies involving INSTIs included diarrhea, nausea, insomnia, fatigue, and headache, with very low rates of treatment discontinuation versus comparator groups. The long-term clinical implications of weight gain associated with second generation INSTIs dolutegravir and bictegravir warrants further study. This review summarizes key clinical considerations of INSTIs in terms of clinical pharmacology, drug-drug interactions, resistance, and provides perspective on clinical decision-making. Additionally, we summarize major clinical trials evaluating the efficacy and safety of INSTIs in treatment-naïve patients living with HIV as well as individuals at risk of acquiring HIV infection.

Crushed bictegravir/emtricitabine/tenofovir alafenamide in a human immunodeficiency virus-positive patient with pancreatic cancer

We present the case of a 78-year-old African American man with a history of human immunodeficiency virus diagnosed in 2007 who was newly diagnosed with pancreatic cancer. A percutaneous endoscopic gastrostomy tube was placed during the initial inpatient visit of pancreatic cancer diagnosis due to persistent dysphagia. Due to PEG placement and the patient's wish to continue his previous antiretroviral therapy, the patient crushed his fixed-dose bictegravir/emtricitabine/tenofovir alafenamide under the direction of a physician and has maintained virologic suppression.

Antiretroviral Therapy Management in Adults With HIV During ICU Admission

The extended lifespan of people living with human immunodeficiency (HIV) and acquired immune deficiency syndrome (AIDS) (PLWHA) has increased the potential for ICU admissions unrelated to HIV infection. The objective of this review is to guide continued management of antiretroviral therapy (ART) recommended by the United States Department of Health and Human Services Antiretroviral Guidelines in critically ill adult PLWHA admitted to the intensive care unit (ICU). Pharmacists are uniquely positioned to mitigate these concerns, including whether to continue ART in the ICU, drug interactions with common ICU drugs, renal and hepatic dosing considerations, and alternative methods of administration. Despite these concerns, the original ART regimen should be continued or modified in conjunction with an HIV specialist. Discontinuation greater than 2 weeks should be avoided due to potential resistance and future HIV treatment failure. Use of ART in critically ill patients presents challenges that pharmacists are best equipped to address to prevent adverse events, administration errors, and treatment failure.