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Kang R, Luo L, Chen H, Zhu Q, Liao L, Xing H, Zhu J, Shen Z, Lan G, Tang Z, Shao Y, Yang W, Ruan Y. Treatment outcomes of initial differential antiretroviral regimens among HIV patients in Southwest China: comparison from an observational cohort study. BMJ Open 2019; 9:e025666. [PMID: 30928945 PMCID: PMC6475164 DOI: 10.1136/bmjopen-2018-025666] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES China has continued to expand antiretroviral therapy (ART) services and optimise ART guidelines in an effort to significantly reduce and prevent mortality and transmission rates among HIV patients. However, no study to date has compared treatment outcomes of initial differential antiretroviral regimens among HIV patients in a real-world setting in China. This study aimed to compare the effects of different ART regimens on treatment outcomes among adults. DESIGN Observational retrospective cohort study. SETTING Data from 2011 to 2013 in Guangxi, China. PARTICIPANTS Patients aged ≥18 years (n=25 732) were selected. RESULTS A total of 25 732 patients were included in this study. The average mortality and attrition rate were 2.64 and 4.98, respectively, per 100 person-years. Using Cox proportional hazard models, zidovudine-based (AZT-based) regimen versus stavudine-based (D4T-based) regimen had an adjusted HR (AHR) for death of 0.65 (95% CI 0.58 to 0.73); the AHR of tenofovir-based (TDF-based) versus D4T-based regimens was 0.81 (95% CI 0.71 to 0.92), and of lopinavir-ritonavir-based (LPV/r-based) versus D4T-based regimens, 1.19 (95% CI 1.04 to 1.37). AZT-based versus D4T-based regimens had an AHR for dropout of 0.89 (95% CI 0.81 to 0.97); this ratio for TDF-based versus D4T-based regimens was 0.88 (95% CI 0.80 to 0.98), and for LPV/r-based versus D4T-based regimens, 1.42 (95% CI 1.27 to 1.58). AZT-based and TDF-based regimens had a lower risk compared with D4T-based regimens, while LPV/r-based regimens had a higher risk. High gastrointestinal reactions and poor adherence were observed among HIV patients whose initial ART regimen was LPV/r-based. CONCLUSIONS Our study found that the treatment outcomes of initial ART regimens that were AZT-based or TDF-based were significantly better than D4T-based or LPV/r-based regimens. This finding could be related to the higher rates of gastrointestinal reactions and poorer adherence associated with the LPV/r-based regimens compared with other initial ART regimens.
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Affiliation(s)
- Ruihua Kang
- State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention (NCAIDS), Chinese Center for Disease Control and Prevention (China CDC), Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing, China
| | - Liuhong Luo
- Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Huanhuan Chen
- Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Qiuying Zhu
- Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Lingjie Liao
- State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention (NCAIDS), Chinese Center for Disease Control and Prevention (China CDC), Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing, China
| | - Hui Xing
- State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention (NCAIDS), Chinese Center for Disease Control and Prevention (China CDC), Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing, China
| | - Jinhui Zhu
- Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Zhiyong Shen
- Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Guanghua Lan
- Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Zhenzhu Tang
- Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Yiming Shao
- State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention (NCAIDS), Chinese Center for Disease Control and Prevention (China CDC), Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing, China
| | - Wenmin Yang
- Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Yuhua Ruan
- State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention (NCAIDS), Chinese Center for Disease Control and Prevention (China CDC), Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing, China
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Torti C, Raffetti E, Donato F, Castelli F, Maggiolo F, Angarano G, Mazzotta F, Gori A, Sighinolfi L, Pan A, Cauda R, Scalzini A, Quiros-Roldan E, Nasta P, Gregis G, Benatti S, Digiambenedetto S, Ladisa N, Giralda M, Saracino A, Castelnuovo F, Di Pietro M, Lo Caputo S, Lapadula G, Costarelli S, Lorenzotti S, Mazzini N, Paraninfo G, Casari S, Focà E, Pezzoli C, Fabbiani M, Monno L, Pierotti P, Ble C, Leone S, Postorino MC, Fornabaio C, Zacchi F, Zoncada A, Carosi G. Cohort Profile: Standardized Management of Antiretroviral Therapy Cohort (MASTER Cohort). Int J Epidemiol 2018; 46:e12. [PMID: 26445966 DOI: 10.1093/ije/dyv192] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2015] [Indexed: 12/14/2022] Open
Affiliation(s)
- Carlo Torti
- Unità di Malattie Infettive e Tropicali, Dipartimento di Scienze Mediche e Chirurgiche, Università Magna Grecia di Catanzaro, Catanzaro, Italia
| | - Elena Raffetti
- Unità di Igiene, Epidemiologia e Sanità Pubblica, Università degli Studi di Brescia, Brescia, Italia
| | - Francesco Donato
- Unità di Igiene, Epidemiologia e Sanità Pubblica, Università degli Studi di Brescia, Brescia, Italia
| | - Francesco Castelli
- Divisione Universitaria di Malattie Infettive Spedali Civili di Brescia-Università degli Studi di Brescia, Brescia, Italia
| | - Franco Maggiolo
- Malattie Infettive Ospedale Papa Giovanni XXIII, Bergamo, Italia
| | | | | | - Andrea Gori
- Malattie Infettive Ospedale San Gerardo di Monza, Monza, Italia
| | - Laura Sighinolfi
- Malattie Infettive Nuovo Polo Ospedaliero di Cona, Ferrara, Italia
| | - Angelo Pan
- Malattie Infettive Istituti Ospitalieri di Cremona, Cremona, Italia
| | - Roberto Cauda
- Clinica di Malattie Infettive Policlinico A. Gemelli-Università Cattolica di Roma, Roma, Italia
| | - Alfredo Scalzini
- Divisione Ospedaliera di Malattie Infettive Spedali Civili, Brescia, Italia and
| | - Eugenia Quiros-Roldan
- Divisione Universitaria di Malattie Infettive Spedali Civili di Brescia-Università degli Studi di Brescia, Brescia, Italia
| | - Paola Nasta
- Divisione Universitaria di Malattie Infettive Spedali Civili di Brescia-Università degli Studi di Brescia, Brescia, Italia
| | | | - Simone Benatti
- Malattie Infettive Ospedale Papa Giovanni XXIII, Bergamo, Italia
| | - Simona Digiambenedetto
- Clinica di Malattie Infettive Policlinico A. Gemelli-Università Cattolica di Roma, Roma, Italia
| | | | - Mariarosaria Giralda
- Divisione Universitaria di Malattie Infettive Spedali Civili di Brescia-Università degli Studi di Brescia, Brescia, Italia
| | | | - Filippo Castelnuovo
- Divisione Ospedaliera di Malattie Infettive Spedali Civili, Brescia, Italia and
| | | | | | | | | | | | - Nicola Mazzini
- Fondazione Malattie Infettive e Salute Internazionale, Brescia, Italia
| | - Giuseppe Paraninfo
- Divisione Universitaria di Malattie Infettive Spedali Civili di Brescia-Università degli Studi di Brescia, Brescia, Italia
| | - Salvatore Casari
- Divisione Universitaria di Malattie Infettive Spedali Civili di Brescia-Università degli Studi di Brescia, Brescia, Italia
| | - Emanuele Focà
- Divisione Universitaria di Malattie Infettive Spedali Civili di Brescia-Università degli Studi di Brescia, Brescia, Italia
| | - Chiara Pezzoli
- Divisione Universitaria di Malattie Infettive Spedali Civili di Brescia-Università degli Studi di Brescia, Brescia, Italia
| | - Massimiliano Fabbiani
- Clinica di Malattie Infettive Policlinico A. Gemelli-Università Cattolica di Roma, Roma, Italia
| | - Laura Monno
- Clinica di Malattie Infettive Policlinico di Bari, Bari, Italia
| | | | - Claudio Ble
- Malattie Infettive S.M. Annunziata, Firenze, Italia
| | | | - Maria Concetta Postorino
- Unità di Malattie Infettive e Tropicali, Dipartimento di Scienze Mediche e Chirurgiche, Università Magna Grecia di Catanzaro, Catanzaro, Italia
| | - Chiara Fornabaio
- Malattie Infettive Istituti Ospitalieri di Cremona, Cremona, Italia
| | - Fabio Zacchi
- Malattie Infettive Istituti Ospitalieri di Cremona, Cremona, Italia
| | - Alessia Zoncada
- Malattie Infettive Istituti Ospitalieri di Cremona, Cremona, Italia
| | - Giampiero Carosi
- Fondazione Malattie Infettive e Salute Internazionale, Brescia, Italia
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Beghin JC, Yombi JC, Ruelle J, Van der Linden D. Moving forward with treatment options for HIV-infected children. Expert Opin Pharmacother 2017; 19:27-37. [PMID: 28879787 DOI: 10.1080/14656566.2017.1377181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Current international guidelines recommend to treat all HIV-1 infected patients regardless of CD4 cell count. Despite the remarkable worldwide progress for universal access to antiretroviral during the last decade, the pediatric population remains fragile due to lack of randomized studies, inappropriate antiretroviral formulations, adherence difficulties, drug toxicity and development of resistance. AREAS COVERED This review summarizes the latest recommendations and advances for the treatment of HIV-infected children and highlights the potential complications of a lifelong antiretroviral treatment initiated early in life. EXPERT OPINION International guidelines recommend to start combination antiretroviral therapy (cART) as fast as possible in all children diagnosed with HIV-1. The principal goal is to improve survival and reduce mortality as well as rapidly decrease HIV reservoirs. This remains a challenge in resource-limited settings were diagnostic tools and treatment access may be limited. Different new strategies are in the pipeline such as immunotherapy in combination with very early cART initiation to seek remission or functional cure. For the time being and awaiting for long term remission or cure, there is a need for further pharmacokinetics studies, more pediatric formulations with improved palatability and implementation of randomized trials for the newer antiretroviral drugs.
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Affiliation(s)
- Jean-Christophe Beghin
- a Hôpital Universitaire des Enfants Reine Fabiola , Université Libre de Bruxelles (ULB) , Brussels , Belgium.,b AIDS Reference Laboratory , Université Catholique de Louvain , Brussels , Belgium.,c Institute of Experimental and Clinical Research (IREC) , Université Catholique de Louvain , Brussels , Belgium
| | - Jean Cyr Yombi
- c Institute of Experimental and Clinical Research (IREC) , Université Catholique de Louvain , Brussels , Belgium.,d Department of Internal Medicine, Infectious Diseases and Tropical Medicine Unit , Cliniques Universitaires St Luc , Brussels , Belgium
| | - Jean Ruelle
- c Institute of Experimental and Clinical Research (IREC) , Université Catholique de Louvain , Brussels , Belgium.,e Medical Molecular Biology Unit , Cliniques Universitaires St Luc , Brussels , Belgium
| | - Dimitri Van der Linden
- c Institute of Experimental and Clinical Research (IREC) , Université Catholique de Louvain , Brussels , Belgium.,f Pediatric Infectious Diseases, General Pediatrics, Pediatric Department , Cliniques Universitaires St Luc , Brussels , Belgium
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Postorino MC, Prosperi M, Quiros-Roldan E, Maggiolo F, Di Giambenedetto S, Saracino A, Costarelli S, Lorenzotti S, Sighinolfi L, Di Pietro M, Torti C. Use of efavirenz or atazanavir/ritonavir is associated with better clinical outcomes of HAART compared to other protease inhibitors: routine evidence from the Italian MASTER Cohort. Clin Microbiol Infect 2014; 21:386.e1-9. [PMID: 25595708 DOI: 10.1016/j.cmi.2014.10.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 10/08/2014] [Accepted: 10/23/2014] [Indexed: 10/24/2022]
Abstract
Randomized trials and observational cohorts reported higher rates of virological suppression after highly active antiretroviral therapy (HAART) including efavirenz (EFV), compared with boosted protease inhibitors (PIs). Correlations with immunological and clinical outcomes are unclear. Patients of the Italian MASTER cohort who started HAART from 2000 to 2010 were selected. Outstanding outcome (composite outcome for success (COS)) was introduced. We evaluated predictors of COS (no AIDS plus CD4+ count >500/mm(3)plus HIV-RNA <500 copies/mL) and of eight single outcomes either at month 6 or at year 3. Multivariable logistic regression was conducted. There were 6259 patients selected. Patients on EFV (43%) were younger, had greater CD4+ count, presented with AIDS less frequently, and more were Italians. At year 3, 90% of patients had HIV RNA <500 copies/mL, but only 41.4% were prescribed EFV, vs. 34.1% prescribed boosted PIs achieved COS (p <0.0001). At multivariable analysis, patients on lopinavir/ritonavir had an odds ratio of 0.70 for COS at year 3 (p <0.0001). Foreign origin and positive hepatitis C virus-Ab were independently associated with worse outcome (OR 0.54, p <0.0001 and OR 0.70, p 0.01, respectively). Patients on boosted PIs developed AIDS more frequently either at month 6 (13.8% vs. 7.6%, p <0.0001) or at year 3 (17.1% vs. 13.8%, p <0.0001). At year 3, deaths of patients starting EFV were 3%, vs. 5% on boosted PIs (p 0.008). In this study, naïve patients on EFV performed better than those on boosted PIs after adjustment for imbalances at baseline. Even when virological control is achieved, COS is relatively rare. Hepatitis C virus-positive patients and those of foreign origin are at risk of not obtaining COS.
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Affiliation(s)
- M C Postorino
- Infectious Diseases Unit, "Magna Graecia" University, Catanzaro, Italy
| | - M Prosperi
- University of Manchester, Manchester, UK
| | - E Quiros-Roldan
- Infectious and Tropical Diseases Institute, University of Brescia, Brescia, Italy
| | | | | | | | | | | | | | - M Di Pietro
- "S. M. Annunziata" Hospital ASL Florence, Bagno a Ripoli, Florence, Italy
| | - C Torti
- Infectious Diseases Unit, "Magna Graecia" University, Catanzaro, Italy; Infectious and Tropical Diseases Institute, University of Brescia, Brescia, Italy.
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Lopinavir/r no longer recommended as a first-line regimen: a comparative effectiveness analysis. J Int AIDS Soc 2014; 17:19070. [PMID: 25261780 PMCID: PMC4176690 DOI: 10.7448/ias.17.1.19070] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 08/04/2014] [Accepted: 08/20/2014] [Indexed: 11/18/2022] Open
Abstract
Introduction We compared the effectiveness of tenofovir/emtricitabine (TDF/FTC) combined with either lopinavir/r (LPV/r) or another recommended third drug in the 2010 French guidelines in antiretroviral-naïve patients starting combination antiretroviral therapy in 2004–2008 in the French Hospital Database on HIV. Methods The outcomes were stop or switch of the third component, viral load (VL) <500 copies/ml, an increase of at least 100 CD4 cells/mm3, AIDS-defining event and non-AIDS-defining hospitalization or death. Propensity scores were estimated by logistic regression based on the clinical centre and other confounders. In each clinical centre, each patient initiating LPV/r was matched with a patient initiating another third drug (efavirenz or atazanavir/r) and having a close propensity score. Cox's proportional hazards models were then used, with treatment as covariate. Time was right-censored at four years. Results 1269 patients started LPV/r plus TDF/FTC, and 890 could be matched to 890 patients receiving another third drug. Baseline characteristics were well balanced between these two groups. LPV/r was associated with a higher risk of third drug stop (hazard ratio (HR): 1.69; 95% confidence interval (CI), 1.42–2.00) and with less rapid viral suppression (HR: 0.83; 95% CI, 0.72–0.95). There was no difference in the time required for a CD4 cell increment of at least 100/mm3, or to the occurrence of an AIDS-defining event. Non-AIDS-defining hospitalizations or deaths were more frequent with LPV/r (HR: 1.79; 95% CI, 1.33–2.39). Conclusions For first-line therapy, in this observational setting, TDF/FTC plus LPV/r were less durable than TDF/FTC plus another recommended third drug, led to a less rapid viral suppression and were associated with a higher risk of non-AIDS morbidity.
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Torres B, Rallón NI, Loncá M, Díaz A, Alós L, Martínez E, Cruceta A, Arnaiz JA, Leal L, Lucero C, León A, Sánchez M, Negredo E, Clotet B, Gatell JM, Benito JM, Garcia F. Immunological function restoration with lopinavir/ritonavir versus efavirenz containing regimens in HIV-infected patients: a randomized clinical trial. AIDS Res Hum Retroviruses 2014; 30:425-33. [PMID: 24380397 DOI: 10.1089/aid.2013.0185] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
CD4(+) count increase has been reported to be different with lopinavir/r (LPV/r) and efavirenz (EFV)-containing regimens. The different effect of these two regimens on other immune function parameters and the relationship with the gain of CD4(+) count have not been assessed in a randomized clinical trial. Fifty antiretroviral treatment (cART) naïve HIV-infected individuals were randomized to receive LPV/r or EFV both with tenofovir/emtricitabine for 48 weeks. A substudy of immunological function restoration was performed in 22 patients (LPV/r n=10 and EFV n=12). Activation, thymic function, apoptosis, senescence, exhaustion, Treg cells, interleukin (IL)-7-receptor/IL-7 system, thymic volume, and lymphoid tissue fibrosis were evaluated at baseline and at week 48. Both groups experienced a CD4(+) count increase that was higher in the EFV group (ΔCD4(+) 88 vs. 315 cells/μl LPV/r vs. EFV, respectively, p<0.001). Despite this difference in CD4(+) gain, the change in other immune function parameters was similar in both treatment groups. Most of parameters evaluated tended to normalize after 48 weeks of cART. A significant decrease in levels of activation, senescence, exhaustion, and apoptosis on CD4(+) and CD8(+) T cells (p<0.001 for all) and a significant increase in markers of thymic function, IL-7 receptor, and in the levels of central memory CD4(+) T cells and naive subsets of CD8(+) T cells (p<0.001 for all) with respect to baseline values were observed without any difference between groups. These data indicate that the differences in CD4(+) gain with different cART regimens are not immunologically meaningful and might explain the similar clinical efficacy of these regimens.
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Affiliation(s)
- Berta Torres
- Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Norma I. Rallón
- Fundación de Investigación Biomédica FIB Hospital Carlos III, Madrid, Spain
| | - Montserrat Loncá
- Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Alba Díaz
- Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Llucia Alós
- Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Esteban Martínez
- Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Anna Cruceta
- Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Lorna Leal
- Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Constanza Lucero
- Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Agathe León
- Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Marcelo Sánchez
- Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | | | - José M. Gatell
- Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - José M. Benito
- Fundación de Investigación Biomédica FIB Hospital Carlos III, Madrid, Spain
| | - Felipe Garcia
- Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
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Jarrin I, Hernández-Novoa B, Alejos B, Santos I, Lopez-Aldeguer J, Riera M, Gutiérrez F, Rubio R, Antela A, Blanco JR, Moreno S. Interpreting the reasons for the choice and changing of two drug regimens in an observational cohort: comparison of a ritonavir-boosted protease inhibitor-based versus a nonnucleoside reverse transcriptase inhibitor-based first-line regimen. HIV Med 2014; 15:547-56. [PMID: 24655804 DOI: 10.1111/hiv.12144] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We compared reasons for the choice of regimen, time to and reasons for third drug modification, virological response and change in CD4 T-cell counts in patients started on atazanavir/ritonavir (ATV/r)- vs. efavirenz (EFV)-based first-line regimens. METHODS We included patients from the Cohort of the Spanish HIV Research Network (CoRIS), a multicentre cohort of HIV-positive treatment-naïve subjects, in the study. We used logistic regression to assess factors associated with choosing ATV/r vs. EFV, proportional hazards models on the subdistribution hazard to estimate subdistribution hazard ratios (sHRs) for third drug modification, logistic regression to estimate odds ratios (ORs) for virological response and linear regression to assess mean differences in CD4 T-cell count increase from baseline. RESULTS Of 2167 patients, 10.7% started on ATV/r. ATV/r was more likely than EFV to be prescribed in injecting drug users [adjusted OR 1.85; 95% confidence interval (CI) 1.03-3.33], in 2009-2010 (adjusted OR 1.63; 95% CI 1.08-2.47) and combined with abacavir plus lamivudine (adjusted OR 1.53; 95% CI 0.98-2.43). Multivariate analyses showed no differences, comparing ATV/r vs. EFV, in the risk of third drug modification (sHR 1.04; 95% CI 0.74-1.46) or in virological response (OR 0.81; 95% CI 0.46-1.41); differences in mean CD4 T-cell count increase from baseline were at the limit of statistical significance (mean difference 29.8 cells/μL; 95% CI -4.1 to 63.6 cells/μL). In patients changing from EFV, 48% of changes were attributable to toxicity/adverse events, 16% to treatment failure/resistance, 3% to simplification, and 8 and 12%, respectively, to patients' and physicians' decisions; these percentages were 24, 6, 12, 14 and 24%, respectively, in those changing from ATV/r. CONCLUSIONS ATV/r- and EFV-based regimens meet the requirements of both efficacy and safety for initial combination antiretroviral regimen, which relate to better durability.
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Affiliation(s)
- I Jarrin
- Institute of Health Carlos III, Madrid, Spain
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Papadopoulos A, Pantazis N, Panagopoulos P, Kourkounti S, Xylomenos G, Chini M, Petrikkos G, Sambatakou H, Ioannidou P, Kordosis T, Panos G, Touloumi G. Effects of first antiretroviral regimen on lipid levels in HIV (+) individuals. J Chemother 2013; 24:38-47. [DOI: 10.1179/1120009x12z.0000000008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Di Biagio A, Prinapori R, Giannarelli D, Maggiolo F, Di Giambenedetto S, Borghi V, Penco G, Cicconi P, Francisci D, Sterrantino G, Zoncada A, Monno L, Capetti A, Giacometti A. Duration of first-line antiretroviral therapy with tenofovir and emtricitabine combined with atazanavir/ritonavir, efavirenz or lopinavir/ritonavir in the Italian ARCA cohort. J Antimicrob Chemother 2012; 68:200-5. [PMID: 22915463 DOI: 10.1093/jac/dks339] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To explore the durability of three first-line tenofovir/emtricitabine-based regimens in combination with atazanavir/ritonavir, efavirenz or lopinavir/ritonavir in HIV-1-infected patients. PATIENTS AND METHODS A retrospective, longitudinal, multicentre analysis of adult patients enrolled in the Antiretroviral Resistance Cohort Analysis (ARCA), a national prospective observational cohort of HIV-1-infected patients followed up at more than 100 clinical and laboratory units in Italy. Patients eligible were those starting first-line antiretroviral therapy between 1 June 2004 and 15 April 2011 and who were followed up for at least 6 months. The primary endpoint was durability, defined as the time from antiretroviral therapy initiation to first treatment modification. Time-dependent events were analysed by the Kaplan-Meier approach and the Cox proportional hazard model. RESULTS There are 26,000 HIV-infected patients in the ARCA database, of whom 1654 met study inclusion criteria. Six hundred and thirty-nine (38.6%) received efavirenz, 321 (19.4%) received atazanavir/ritonavir and 694 (41.9%) received lopinavir/ritonavir as a first-line regimen. Over a total observation period of 88 months, equivalent to more than 2805 person-years of follow-up, 618 patients underwent treatment modification. Lopinavir/ritonavir, given twice daily, was associated with a higher discontinuation rate than efavirenz- and atazanavir-based regimens [hazard ratio (HR) 1.83, 95% confidence interval (CI) 1.56-2.15, P = 0.001]. Comparing the once-daily regimens, the rate of discontinuation of efavirenz was higher than that of atazanavir/ritonavir (HR 1.39, 95% CI 1.06-1.83, P = 0.016). CONCLUSIONS Significant differences in treatment duration were observed among the three studied regimens. Once-daily regimens exhibited greater durability than the twice-daily regimen. Among the specific regimens examined, tenofovir/emtricitabine plus atazanavir/ritonavir showed the greatest durability.
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Siccardi M, Almond L, Schipani A, Csajka C, Marzolini C, Wyen C, Brockmeyer NH, Boffito M, Owen A, Back D. Pharmacokinetic and Pharmacodynamic Analysis of Efavirenz Dose Reduction Using an In Vitro–In Vivo Extrapolation Model. Clin Pharmacol Ther 2012; 92:494-502. [DOI: 10.1038/clpt.2012.61] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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HIV RNA suppression and immune restoration: can we do better? Clin Dev Immunol 2012; 2012:515962. [PMID: 22489250 PMCID: PMC3318265 DOI: 10.1155/2012/515962] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 01/02/2012] [Accepted: 01/15/2012] [Indexed: 11/23/2022]
Abstract
HAART has significantly changed the natural history of HIV infection: patients receiving antiretrovirals are usually able to control viremia, even though not all virological responders adequately recover their CD4+ count. The reasons for poor immune restoration are only partially known and they include genetic, demographic and immunologic factors. A crucial element affecting immune recovery is immune activation, related to residual viremia; indeed, a suboptimal virological control (i.e., low levels of plasma HIV RNA) has been related with higher levels of chronic inflammation and all-cause mortality. The sources of residual viremia are not yet completely known, even though the most important one is represented by latently infected cells. Several methods, including 2-LTR HIV DNA and unspliced HIV RNA measurement, have been developed to estimate residual viremia and predict the outcome of antiretroviral therapy. Considering that poor immunologic responders are exposed to a higher risk of both AIDS-related and non-AIDS-related diseases, there is a need of new therapeutic strategies, including immunomodulators and drugs targeting the latent viral reservoirs, in order to face residual viremia but also to “drive” the host immunologic responses.
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Jung N, Lehmann C, Knispel M, Meuer EK, Fischer J, Fätkenheuer G, Hartmann P, Taubert D. Long-term beneficial effect of protease inhibitors on the intrinsic apoptosis of peripheral blood mononuclear cells in HIV-infected patients. HIV Med 2012; 13:469-78. [PMID: 22414163 DOI: 10.1111/j.1468-1293.2012.00999.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2012] [Indexed: 01/22/2023]
Abstract
BACKGROUND Viral suppression by antiretroviral therapy (ART) inhibits HIV-induced apoptosis and CD4 T-cell loss. It has been suggested that protease inhibitors (PIs) have nonviral antiapoptotic effects by maintaining mitochondrial integrity. Long-term clinical effects of PI-based ART on mitochondrial toxicity and lymphocyte apoptosis beyond viral suppression have not been exploited to date. METHODS We conducted a 7-year study on HIV-1-infected patients from the Cologne HIV cohort with sufficient viral suppression under either a PI-based or nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimen. Eight patients on PI and eight on NNRTI were eligible for inclusion in the analysis. The primary outcome measure was defined as a change in the mitochondrial-to-nuclear DNA ratio in PBMCs. Further key molecules involved in extrinsic [tumour necrosis factor-related apoptosis-inducing ligand (TRAIL), Fas ligand (FasL) and caspase 8], intrinsic [B-cell lymphoma 2 (Bcl-2), Bcl-2-associated X protein (Bax), caspase 9 and lactate-to-pyruvate ratio] and overall apoptosis [Annexin+/7-aminoactinomycin D (7-AAD)- and caspase 3/7] and viral activity [negative regulatory factor (Nef), interferon-α (IFN-α) and myxovirus resistance protein A (MxA)] were measured. RESULTS Demographic and baseline clinical parameters were similar in the two groups, except that patients in the PI group had a higher mean age. After 7 years of treatment, CD4 T-cell count increased and the expression of genes encoding the proapoptotic viral protein Nef and HIV-induced cytokine IFN-α and its downstream effector MxA decreased in both groups. Focusing on the different pathways of apoptosis, only in the PI group intrinsic apoptosis decreased significant and in the inter-group comparison the decrease was significantly higher than in the NNRTI group. CONCLUSIONS Our study provides evidence that long-term therapy with a PI-based regimen may be superior to that with a NNRTI-based regimen with regard to its intrinsic antiapoptotic effect.
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Affiliation(s)
- N Jung
- First Department of Internal Medicine, Medical Hospital of the University of Cologne, Cologne, Germany.
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UPLC-MS/MS quantification of nanoformulated ritonavir, indinavir, atazanavir, and efavirenz in mouse serum and tissues. J Chromatogr B Analyt Technol Biomed Life Sci 2011; 879:2332-8. [PMID: 21752731 DOI: 10.1016/j.jchromb.2011.06.032] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 06/22/2011] [Accepted: 06/23/2011] [Indexed: 01/11/2023]
Abstract
Animal pharmacokinetic and tissue distribution assays of antiretroviral therapeutic drugs require accurate drug quantification in biological fluids and tissues. Here we report a simple, rapid, and sensitive ultra performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method for quantification of commonly used antiretroviral drugs ritonavir (RTV), indinavir (IDV), atazanavir (ATV), and efavirenz (EFV) in mouse serum and tissues (liver, kidney, lung, and spleen). These antiretroviral drugs are currently the cornerstones of common therapeutic regimens for human immunodeficiency virus (HIV) infection. Chromatographic separation was achieved using a gradient mobile phase (5% acetonitrile in methanol and 7.5mM ammonium acetate (pH 4.0)) on an ACQUITY UPLC(®)BEH Shield RP 18 column. All compounds eluted within a 7 min run time. Lopinavir was used as an internal standard. Detection was achieved by dual positive and negative ionization modes on a quadrupole linear ion trap hybrid mass spectrometer with an electrospray ionization (ESI) source. The dynamic range was 0.2-1000 ng/mL for RTV, IDV, and ATV, and 0.5-1000 for EFV. The method was validated and showed high and consistent intra-day and inter-day accuracy and precision for all analytes. This method is used to support the preclinical development studies of targeted- and sustained-release combination ART (nanoART). The current data demonstrate a 1.5-4 fold increase in serum and tissue AUC of nanoformulated ATV, RTV, and EFV administered to mice when compared to native drug. In addition, the tested formulation enhanced exposure of the same anti-HIV drugs in mouse tissues.
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Rajasuriar R, Gouillou M, Spelman T, Read T, Hoy J, Law M, Cameron PU, Petoumenos K, Lewin SR. Clinical predictors of immune reconstitution following combination antiretroviral therapy in patients from the Australian HIV Observational Database. PLoS One 2011; 6:e20713. [PMID: 21674057 PMCID: PMC3107235 DOI: 10.1371/journal.pone.0020713] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 05/08/2011] [Indexed: 12/03/2022] Open
Abstract
Background A small but significant number of patients do not achieve CD4 T-cell counts >500cells/µl despite years of suppressive cART. These patients remain at risk of AIDS and non-AIDS defining illnesses. The aim of this study was to identify clinical factors associated with CD4 T-cell recovery following long-term cART. Methods Patients with the following inclusion criteria were selected from the Australian HIV Observational Database (AHOD): cART as their first regimen initiated at CD4 T-cell count <500cells/µl, HIV RNA<500copies/ml after 6 months of cART and sustained for at least 12 months. The Cox proportional hazards model was used to identify determinants associated with time to achieve CD4 T-cell counts >500cells/µl and >200cells/µl. Results 501 patients were eligible for inclusion from AHOD (n = 2853). The median (IQR) age and baseline CD4 T-cell counts were 39 (32–47) years and 236 (130–350) cells/µl, respectively. A major strength of this study is the long follow-up duration, median (IQR) = 6.5(3–10) years. Most patients (80%) achieved CD4 T-cell counts >500cells/µl, but in 8%, this took >5 years. Among the patients who failed to reach a CD4 T-cell count >500cells/µl, 16% received cART for >10 years. In a multivariate analysis, faster time to achieve a CD4 T-cell count >500cells/µl was associated with higher baseline CD4 T-cell counts (p<0.001), younger age (p = 0.019) and treatment initiation with a protease inhibitor (PI)-based regimen (vs. non-nucleoside reverse transcriptase inhibitor, NNRTI; p = 0.043). Factors associated with achieving CD4 T-cell counts >200cells/µl included higher baseline CD4 T-cell count (p<0.001), not having a prior AIDS-defining illness (p = 0.018) and higher baseline HIV RNA (p<0.001). Conclusion The time taken to achieve a CD4 T-cell count >500cells/µl despite long-term cART is prolonged in a subset of patients in AHOD. Starting cART early with a PI-based regimen (vs. NNRTI-based regimen) is associated with more rapid recovery of a CD4 T-cell count >500cells/µl.
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Affiliation(s)
- Reena Rajasuriar
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
- Faculty of Medicine, University Malaya, Kuala Lumpur, Federal Territory, Malaysia
| | - Maelenn Gouillou
- Centre for Population Health, Burnet Institute, Melbourne, Victoria, Australia
| | - Tim Spelman
- Centre for Population Health, Burnet Institute, Melbourne, Victoria, Australia
| | - Tim Read
- Melbourne Sexual Health Centre, Melbourne, Victoria, Australia
| | - Jennifer Hoy
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
- National Centre in HIV Epidemiology and Clinical Research, Sydney, New South Wales, Australia
- Infectious Disease Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Matthew Law
- National Centre in HIV Epidemiology and Clinical Research, Sydney, New South Wales, Australia
| | - Paul U. Cameron
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
- Infectious Disease Unit, The Alfred Hospital, Melbourne, Victoria, Australia
- Centre for Virology, Burnet Institute, Melbourne, Victoria, Australia
| | - Kathy Petoumenos
- National Centre in HIV Epidemiology and Clinical Research, Sydney, New South Wales, Australia
| | - Sharon R. Lewin
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
- Infectious Disease Unit, The Alfred Hospital, Melbourne, Victoria, Australia
- Centre for Virology, Burnet Institute, Melbourne, Victoria, Australia
- * E-mail:
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Torti C, d'Arminio-Monforte A, Pozniak AL, Lapadula G, Cologni G, Antinori A, De Luca A, Mussini C, Castagna A, Cicconi P, Minoli L, Costantini A, Carosi G, Liang H, Cesana BM. Long-term CD4+ T-cell count evolution after switching from regimens including HIV nucleoside reverse transcriptase inhibitors (NRTI) plus protease inhibitors to regimens containing NRTI plus non-NRTI or only NRTI. BMC Infect Dis 2011; 11:23. [PMID: 21266068 PMCID: PMC3038912 DOI: 10.1186/1471-2334-11-23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 01/25/2011] [Indexed: 12/02/2022] Open
Abstract
Background Data regarding CD4+ recovery after switching from protease inhibitor (PI)-based regimens to regimens not containing PI are scarce. Methods Subjects with virological success on first-PI-regimens who switched to NNRTI therapy (NNRTI group) or to nucleoside reverse transcriptase (NRTI)-only (NRTI group) were studied. The effect of the switch on the ongoing CD4+ trend was assessed by two-phase linear regression (TPLR), allowing us to evaluate whether a change in the CD4+ trend (hinge) occurred and the time of its occurrence. Furthermore, we described the evolution of the frequencies in CD4-count classes across four relevant time-points (baseline, before and immediately after the switch, and last visit). Finally, we explored whether the CD4+ counts evolved differently in patients who switched to NNRTI or NRTI-only regimens by considering: the overall CD4+ trends, the time to CD4+≥ 500/mm3 after the switch, and the area-under-the-curve (AUC) of the CD4+ after the switch. Results Eight hundred and ninety-six patients, followed for a median of 2,121 days, were included. At TPLR, hinges occurred in 581/844 (68.9%), but in only 40/581 (6.9%) within a time interval (180 days) compatible with a possible relationship to the switch; furthermore, in 19/40 cases, CD4+ counts appeared to decrease after the hinges. In comparison with the NNRTI group, the NRTI group showed CD4+ count greater at baseline (P = 0.0234) and before the switch (P ≤ 0.0001), superior CD4+ T-cell increases after HAART was started, lower probability of not achieving CD4+ ≥ 500/mm3 (P = 0.0024), and, finally, no significant differences in the CD4+ T-cell AUC after the switch after adjusting for possible confounders (propensity score and pre-switch AUC). Persistence at CD4+ < 200/mm3 was observed in 34/435 (7.5%) patients, and a decrease below this level was found in only 10/259 (3.9%) with baseline CD4+ ≥ 350/mm3. Conclusions Switching from first-line PI to NNRTI- or NRTI-based regimens did not seem to impair CD4+ trend over long-term follow-up. Although the greater CD4+ increases in patients who switched to the NRTI-only regimen was due to higher CD4+ counts before the switch, several statistical analyses consistently showed that switching to this regimen did not damage the ongoing immune-reconstitution. Lastly, the observation that CD4+ T-cell counts remained low or decreased in the long term despite virological success merits further investigation.
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Echeverría P, Negredo E, Carosi G, Gálvez J, Gómez J, Ocampo A, Portilla J, Prieto A, López J, Rubio R, Mariño A, Pedrol E, Viladés C, del Arco A, Moreno A, Bravo I, López-Blazquez R, Pérez-Alvarez N, Clotet B. Similar antiviral efficacy and tolerability between efavirenz and lopinavir/ritonavir, administered with abacavir/lamivudine (Kivexa®), in antiretroviral-naïve patients: A 48-week, multicentre, randomized study (Lake Study). Antiviral Res 2010; 85:403-8. [DOI: 10.1016/j.antiviral.2009.11.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Revised: 11/16/2009] [Accepted: 11/17/2009] [Indexed: 11/30/2022]
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Young J, Bucher HC, Guenthard HF, Rickenbach M, Fux CA, Hirschel B, Cavassini M, Vernazza P, Bernasconi E, Battegay M. Virological and immunological responses to efavirenz or boosted lopinavir as first-line therapy for patients with HIV. Antivir Ther 2009; 14:771-9. [PMID: 19812439 DOI: 10.3851/imp1291] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Efavirenz and lopinavir boosted with ritonavir are both recommended as first-line therapies for patients with HIV when combined with two nucleoside reverse transcriptase inhibitors. It is uncertain which therapy is more effective for patients starting therapy with an advanced infection. METHODS We estimated the relative effect of these two therapies on rates of virological and immunological failure within the Swiss HIV Cohort Study and considered whether estimates depended on the CD4(+) T-cell count when starting therapy. We defined virological failure as either an incomplete virological response or viral rebound after viral suppression and immunological failure as failure to achieve an expected CD4(+) T-cell increase calculated from EuroSIDA statistics. RESULTS Patients starting efavirenz (n=660) and lopinavir (n=541) were followed for a median of 4.5 and 3.1 years, respectively. Virological failure was less likely for patients on efavirenz, with the adjusted hazard ratio (95% confidence interval) of 0.63 (0.50-0.78) then multiplied by a factor of 1.00 (0.90-1.12) for each 100 cells/mm(3) decrease in CD4(+) T-cell count below the mean when starting therapy. Immunological failure was also less likely for patients on efavirenz, with the adjusted hazard ratio of 0.68 (0.51-0.91) then multiplied by a factor of 1.29 (1.14-1.46) for each 100 cells/mm(3) decrease in CD4(+) T-cell count below the mean when starting therapy. CONCLUSIONS Virological failure is less likely with efavirenz regardless of the CD4(+) T-cell count when starting therapy. Immunological failure is also less likely with efavirenz; however, this advantage disappears if patients start therapy with a low CD4(+) T-cell count.
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Affiliation(s)
- Jim Young
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland.
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Abstract
Efavirenz, a non-nucleoside reverse transcriptase inhibitor, has been an important component of the treatment of HIV infection for 10 years and has contributed significantly to the evolution of highly active antiretroviral therapy (HAART). The efficacy of efavirenz has been established in numerous randomized trials and observational studies in HAART-naive patients, including those with advanced infection. In the ACTG A5142 study, efavirenz showed greater virological efficacy than the boosted protease inhibitor (PI), lopinavir. Efavirenz is more effective as a third agent than unboosted PIs or the nucleoside analogue abacavir. Some, but not all, studies have suggested that efavirenz (added to two nucleoside reverse transcriptase inhibitors) is more effective than nevirapine. Virological and immunological responses achieved with efavirenz-based HAART have been maintained for 7 years. Dosing convenience predicts adherence, and studies have demonstrated that patients can be switched from PI-based therapy to simplified, once-daily efavirenz-based regimens without losing virological control. The one-pill, once-daily formulation of efavirenz plus tenofovir and emtricitabine offers a particular advantage in this regard. Efavirenz also retains a role after failure of a first PI-based regimen. Efavirenz is generally well tolerated: rash and neuropsychiatric disturbances are the most notable adverse events. Neuropsychiatric disturbances generally develop early in treatment and they tend to resolve with continued administration, but they are persistent and troubling in a minority of patients. Efavirenz has less effect on plasma lipid profiles than some boosted PIs. Lipodystrophy can occur under treatment with efavirenz but it may be reduced if the concurrent use of thymidine analogues is avoided. Efavirenz resistance mutations (especially K103N) can be selected during long-term treatment, underscoring the importance of good adherence. Recent data have confirmed that efavirenz is a cost-effective option for first-line HAART. In light of these features, efavirenz retains a key role in HIV treatment strategies and is the first-line agent recommended in some guidelines.
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Affiliation(s)
- Franco Maggiolo
- Division of Infectious Diseases, Ospedali Riuniti, Largo Barozzi 1, Bergamo, Italy.
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Pérez-Elías MJ, Moreno A, Casado JL, Dronda F, Antela A, López D, Quereda C, Navas E, Hermida JM, Del Sol E, Moreno S. Observational study to evaluate clinical outcomes after first-line efavirenz-or lopinavir-ritonavir-based HAART in treatment-naive patients. ACTA ACUST UNITED AC 2009; 8:308-13. [PMID: 19721095 DOI: 10.1177/1545109709343965] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate clinical, immunological, and virological outcomes after first-line highly active antiretroviral therapy (HAART) with a regimen including either efavirenz (EFV) or lopinavir/ritonavir (LPV/r) in treatment-naive adult patients in routine clinical care. METHOD An ongoing prospective, observational follow-up study included all patients starting their first antiretroviral therapy (ART) with any of the studied regimens from July 1998 to July 2004. The follow-up period was finalized in September 2006, when all patients completed an observation of at least 96 weeks. Mortality rates, CD4 counts, viral suppression (HIV RNA below 50 copies/mL), and discontinuation of any component of the regimen were compared at 48 and 96 weeks. RESULTS Despite the worst immunological status of the LPV/r group patients at baseline, this regimen was at least as effective as the one based on EFV not only in terms of treatment durability but also in terms of virological responses, nevertheless with an apparently quicker immune recovery. In general terms, both regimens present similar tolerability and safety outcomes except for the higher risk of increasing triglyceride (TG) levels in the LPV/r group. Low durability was observed in both regimens. CONCLUSION In a routine clinical care setting, initial HAART containing LPV/r seems to present an effectiveness, tolerability, and toxicity similar to the one containing EFV.
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Khanna N, Opravil M, Furrer H, Cavassini M, Vernazza P, Bernasconi E, Weber R, Hirschel B, Battegay M, Kaufmann G. CD4+T Cell Count Recovery in HIV Type 1–Infected Patients Is Independent of Class of Antiretroviral Therapy. Clin Infect Dis 2008; 47:1093-101. [DOI: 10.1086/592113] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Allan G, Davis J, Dickins M, Gardner I, Jenkins T, Jones H, Webster R, Westgate H. Pre-clinical pharmacokinetics of UK-453,061, a novel non-nucleoside reverse transcriptase inhibitor (NNRTI), and use of in silico physiologically based prediction tools to predict the oral pharmacokinetics of UK-453,061 in man. Xenobiotica 2008; 38:620-40. [DOI: 10.1080/00498250802069088] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- G. Allan
- Clinical Pharmacology, Pharmacokinetics, Dynamics and Metabolism , Sandwich, UK
| | - J. Davis
- Clinical Pharmacology, Pharmacokinetics, Dynamics and Metabolism , Sandwich, UK
| | - M. Dickins
- Clinical Pharmacology, Pharmacokinetics, Dynamics and Metabolism , Sandwich, UK
| | - I. Gardner
- Clinical Pharmacology, Pharmacokinetics, Dynamics and Metabolism , Sandwich, UK
| | - T. Jenkins
- Clinical Research, Pfizer Global Research and Development , Sandwich, UK
| | - H. Jones
- Clinical Pharmacology, Pharmacokinetics, Dynamics and Metabolism , Sandwich, UK
| | - R. Webster
- Clinical Pharmacology, Pharmacokinetics, Dynamics and Metabolism , Sandwich, UK
| | - H. Westgate
- Clinical Pharmacology, Pharmacokinetics, Dynamics and Metabolism , Sandwich, UK
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Saitoh A, Fletcher CV, Brundage R, Alvero C, Fenton T, Hsia K, Spector SA. Efavirenz pharmacokinetics in HIV-1-infected children are associated with CYP2B6-G516T polymorphism. J Acquir Immune Defic Syndr 2007; 45:280-5. [PMID: 17356468 DOI: 10.1097/qai.0b013e318040b29e] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The CYP2B6-G516T polymorphism has been shown to alter plasma efavirenz (EFV) concentrations in adults. The impact of CYP2B6-G516T polymorphisms on EFV concentrations may be different in children because of differences in liver maturation and drug dosage. METHODS The CYP2B6-G516T polymorphisms were analyzed in 71 HIV-1-infected children receiving highly active antiretroviral therapy (HAART) containing EFV for >or=6 months. EFV pharmacokinetics, toxicity profiles, and viral resistance data were also evaluated. RESULTS The median oral clearance (CL/F) rate was significantly lower in children with the CYP2B6-516-T/T genotype (3.0 L/h/m2, n=13) than in children with the G/T genotype (5.7 L/h/m2, n=30; P=0.02) or the G/G genotype (7.0 L/h/m2, n=31; P=0.003). In children with the CYP2B6-516-G/G genotype, which is associated with higher expression of hepatic CYP2B6, the clearance rate was significantly higher in younger children (<5 years of age) than in older children (>or=5 years of age) (9.7 L/h/m2 vs. 6.6 L/h/m2; P=0.03). No association was found between CYP2B6-G516T polymorphisms and virologic or immunologic responses, toxicity, or the development of viral resistance against EFV. CONCLUSIONS CYP2B6-G516T polymorphisms significantly affect the CL/F rate of EFV in children. Changes in hepatic enzyme activity by age may need to be considered when evaluating the impact of genetic variants on antiretroviral pharmacokinetics in children.
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Affiliation(s)
- Akihiko Saitoh
- Division of Infectious Diseases, Department of Pediatrics, University of California, San Diego, La Jolla, CA 92093-0672, USA.
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Potard V, Rey D, Mokhtari S, Frixon-Marin V, Pradier C, Rozenbaum W, Brun-Vezinet F, Costagliola D. First-line Highly Active Antiretroviral Regimens in 2001–2002 in the French Hospital Database on HIV: Combination Prescribed and Biological Outcomes. Antivir Ther 2007. [DOI: 10.1177/135965350701200312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction We compared biological outcomes in anti-retroviral-naive patients with viral load (VL) >5,000 copies/ml starting combivir-based, three-drug highly active antiretroviral therapy regimens in 2001–2002 according to the third component, namely abacavir (ABC), nelfinavir (NFV), indinavir/ritonavir (IDV/r), lopinavir/ritonavir (LPV/r), nevirapine (NVP) or efavirenz (EFV). Methods We evaluated virological response (HIV RNA <500 copies/ml) and immunological response (increase of ≥50 CD4+ T-cells/u, l) separately in patients with baseline VL <100,000 copies/ml ( n=992) and ≥100,000 copies/ml ( n=1,048). Hazard ratios (HR) were calculated with Cox models stratified for quintiles of propensity scores, estimated by multinomial regression from baseline characteristics. Results Median follow up was 19 months. EFV had better virological efficacy than NFV and IDV/r among patients with baseline VL <100,000 copies/ml, with respective HRs of 0.71 and 0.72, compared with 0.81 for NVP, 0.89 for ABC and 0.99 for LPV/r. The immunological efficacy of EFV was lower than that of LPV/r (1.37) and similar to that of NFV (0.96), IDV/r (0.81), NVP (1.08) and ABC (1.04). Among patients with baseline VL ≥100,000 copies/ml, the virological efficacy of EFV was similar to that of NVP (0.90) and LPV/r (0.97) and better than that of NFV (0.62), ABC (0.75) and IDV/r (0.78). The immunological results found in these patients were similar to those observed in patients with baseline VL <100,000 copies/ml. Conclusions For first-line therapy, in this observational setting, EFV, LPV/r and NVP, when added to the combivir backbone, were more likely to drive viral load <500 copies/ml. LPV/r showed the best immunological effectiveness.
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Affiliation(s)
- Valérie Potard
- INSERM, UMR S 720, Paris, France; Université Pierre et Marie Curie-Paris 6, Paris, France
| | | | | | | | | | | | | | - Dominique Costagliola
- INSERM, UMR S 720, Paris, France; Université Pierre et Marie Curie-Paris 6, Paris, France
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Abstract
Non-nucleoside reverse transcriptase inhibitors form the backbone of antiretroviral treatment for many HIV-infected individuals. The tolerability, pill burden and efficacy associated with this class of agents make them a frequent choice for first-line therapy. Here we review nevirapine and efavirenz in terms of efficacy, resistance and toxicity, focusing particularly on the use of nevirapine to prevent mother-to-child transmission in developing countries.
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Affiliation(s)
- L Waters
- Department of HIV/GU Medicine, Chelsea & Westminster Hospital, London, UK
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MacArthur RD, Novak RM, Peng G, Chen L, Xiang Y, Hullsiek KH, Kozal MJ, van den Berg-Wolf M, Henely C, Schmetter B, Dehlinger M. A comparison of three highly active antiretroviral treatment strategies consisting of non-nucleoside reverse transcriptase inhibitors, protease inhibitors, or both in the presence of nucleoside reverse transcriptase inhibitors as initial therapy (CPCRA 058 FIRST Study): a long-term randomised trial. Lancet 2006; 368:2125-35. [PMID: 17174704 DOI: 10.1016/s0140-6736(06)69861-9] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Long-term data from randomised trials on the consequences of treatment with a protease inhibitor (PI), non-nucleoside reverse transcriptase inhibitor (NNRTI), or both are lacking. Here, we report results from the FIRST trial, which compared initial treatment strategies for clinical, immunological, and virological outcomes. METHODS Between 1999 and 2002, 1397 antiretroviral-treatment-naive patients, presenting at 18 clinical trial units with 80 research sites in the USA, were randomly assigned in a ratio of 1:1:1 to a protease inhibitor (PI) strategy (PI plus nucleoside reverse transcriptase inhibitor [NRTI]; n=470), a non-nucleoside reverse transcriptase inhibitor (NNRTI) strategy (NNRTI plus NRTI; n=463), or a three-class strategy (PI plus NNRTI plus NRTI; n=464). Primary endpoints were a composite of an AIDS-defining event, death, or CD4 cell count decline to less than 200 cells per mm3 for the PI versus NNRTI comparison, and average change in CD4 cell count at or after 32 months for the three-class versus combined two-class comparison. Analyses were by intention-to-treat. This study is registered ClinicalTrials.gov, number NCT00000922. FINDINGS 1397 patients were assessed for the composite endpoint. A total of 388 participants developed the composite endpoint, 302 developed AIDS or died, and 188 died. NNRTI versus PI hazard ratios (HRs) for the composite endpoint, for AIDS or death, for death, and for virological failure were 1.02 (95% CI 0.79-1.31), 1.07 (0.80-1.41), 0.95 (0.66-1.37), and 0.66 (0.56-0.78), respectively. 1196 patients were assessed for the three-class versus combined two-class primary endpoint. Mean change in CD4 cell count at or after 32 months was +234 cells per mm3 and +227 cells per mm3 for the three-class and the combined two-class strategies (p=0.62), respectively. HRs (three-class vs combined two-class) for AIDS or death and virological failure were 1.15 (0.91-1.45) and 0.87 (0.75-1.00), respectively. HRs (three-class vs combined two-class) for AIDS or death were similar for participants with baseline CD4 cell counts of 200 cells per mm3 or less and of more than 200 cells per mm3 (p=0.38 for interaction), and for participants with baseline HIV RNA concentrations less than 100 000 copies per mL and 100,000 copies per mL or more (p=0.26 for interaction). Participants assigned the three-class strategy were significantly more likely to discontinue treatment because of toxic effects than were those assigned to the two-class strategies (HR 1.58; p<0.0001). INTERPRETATION Initial treatment with either an NNRTI-based regimen or a PI-based regimen, but not both together, is a good strategy for long-term antiretroviral management in treatment-naive patients with HIV.
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Luca AD, Cozzi-Lepri A, Antinori A, Zaccarelli M, Bongiovanni M, Giambenedetto SD, Marconi P, Cicconi P, Resta F, Grisorio B, Ciardi M, Cauda R, Monforte AD. Lopinavir/Ritonavir or Efavirenz plus two Nucleoside Analogues as First-Line Antiretroviral Therapy: A Non-Randomized Comparison. Antivir Ther 2006. [DOI: 10.1177/135965350601100507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Although efavirenz (EFV) and lopinavir/ritonavir (LPV/r) are both recommended antiretroviral agents for combination therapy in drug-naive HIV-infected patients, no randomized comparison of their efficacy and tolerability is available yet. A multi-cohort prospective observational comparative study was performed. Methods Efficacy was examined comparing time to virological failure, CD4 recovery and clinical progression. Tolerability was examined comparing time to treatment discontinuation for any reason and for toxicity and time to liver enzymes or lipid alterations. Survival analysis was conducted by an intent-to-treat principle using the Kaplan–Meier method, and standard and weighted Cox regression models. Results A total of 674 antiretroviral-naive patients starting a two nucleoside reverse transcriptase inhibitor regimen plus either EFV ( n=481) or LPV/r ( n=193) were examined. At baseline, patients starting LPV/r had higher HIV RNA and lower CD4+ T-cell counts. There was no difference in the adjusted hazards of virological failure (LPV/r versus EFV relative hazard [RH] 1.16, 95% confidence intervals [CI]: 0.58–2.32, P=0.67), CD4 recovery (RH=0.93, 95% CI: 0.66–1.30, P=0.66), clinical progression (RH=1.64, 95% CI: 0.70–3.84, P=0.25), drug discontinuation for toxicity (RH=0.92, 95% CI: 0.51–1.64, P=0.76) and for any reason, and rates of liver enzyme and total/low density lipoprotein (LDL) cholesterol elevation. In contrast, the rate of triglycerides elevations (>1 NCEP Adult Treatment Panel III category increase) was higher in the LPV/r group (RH=1.69, 95% CI: 1.14–2.50; P=0.01). Models weighted for the inverse of conditional probability of receiving either drug applied to the efficacy endpoints yielded similar results. CD4 recovery with both drugs was also similar in the lowest CD4 strata. Conclusions Our analysis suggests similar efficacy and tolerability for EFV- or LPV/r-based first-line antiretroviral regimens. LPV/r was associated with higher rates of hypertriglyceridaemia.
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Affiliation(s)
| | - Andrea De Luca
- Institute of Clinical Infectious Diseases, Catholic University of the Sacred Heart, Rome, Italy
| | | | - Andrea Antinori
- National Institute for Infectious Diseases ‘Lazzaro Spallanzani’, Rome, Italy
| | - Mauro Zaccarelli
- National Institute for Infectious Diseases ‘Lazzaro Spallanzani’, Rome, Italy
| | - Marco Bongiovanni
- Institute of Infectious and Tropical Diseases, University of Milan, Milan, Italy
| | - Simona Di Giambenedetto
- Institute of Clinical Infectious Diseases, Catholic University of the Sacred Heart, Rome, Italy
| | - Patrizia Marconi
- National Institute for Infectious Diseases ‘Lazzaro Spallanzani’, Rome, Italy
| | - Paola Cicconi
- Institute of Infectious and Tropical Diseases, University of Milan, Milan, Italy
| | | | | | | | - Roberto Cauda
- Institute of Clinical Infectious Diseases, Catholic University of the Sacred Heart, Rome, Italy
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Panagopoulos P, Tsiodras S, Antoniadou A, Katsarolis I, Papadopoulos A, Poulakou G, Giamarellou H. Efficacy and safety of an anti-retroviral combination regimen including either efavirenz or lopinavir–ritonavir with a backbone of two nucleoside reverse transcriptase inhibitors. Clin Microbiol Infect 2006; 12:486-9. [PMID: 16643529 DOI: 10.1111/j.1469-0691.2006.01372.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The efficacy and safety of a combination regimen including either efavirenz or lopinavir-ritonavir was examined in a cohort of 65 patients positive for human immunodeficiency virus-1 (HIV-1). Both the efavirenz (n = 33, 18 anti-retroviral naive) and lopinavir-ritonavir (n = 32, 15 naive) regimens achieved significant changes from baseline CD4 cell counts and HIV RNA levels after 108 weeks (p < 0.01). Despite diminished immunological and virological parameters at study entry, the lopinavir-ritonavir group showed greater virological effects than the efavirenz group after 108 weeks (median change 3.3 log(10), interquartile range (IQR) 2.2-3.8 log(10) vs. 2.4 log(10), IQR 0.9-3.3 log(10), respectively, p 0.004). Use of lopinavir-ritonavir, in contrast to use of efavirenz, was associated with significant hypertriglyceridaemia.
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Affiliation(s)
- P Panagopoulos
- 4th University Department of Internal Medicine, Attikon University General Hospital, 24 Omirou Street, Melissia, 15127 Athens, Greece.
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