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Chandasana H, Bush M, Ait-Khaled M, Wynne B, Min S, Mehta R. Population Pharmacokinetic Analysis of Dolutegravir in Treatment-Experienced Adults Living with HIV-1. J Clin Pharmacol 2024. [PMID: 39011960 DOI: 10.1002/jcph.2494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 06/06/2024] [Indexed: 07/17/2024]
Abstract
The World Health Organization has recommended the use of dolutegravir (DTG) for both first and second-line antiretroviral treatment in both adults and children down to 4 weeks of age. We developed a population pharmacokinetic(PopPK) model following oral administration of DTG 50 mg QD and 50 mg BID in HIV-infected treatment-experienced adults (607) based on pooled data from four phase 2/3 trials. DTG population pharmacokinetics are described by a one-compartment model with first-order absorption, absorption lag-time, and first-order elimination. The PopPK parameter estimates were apparent oral clearance (CL/F) = 1.00 L/h, apparent volume of distribution (V/F) = 18.9 L, absorption rate constant (Ka) = 1.99 per hour, and absorption lag time = 0.333 h, respectively. The final model included inter-individual and inter-occasion variability on apparent clearance (CL/F). Weight, smoking status, use of metabolic inducers as part of background antiretroviral therapy (ART) classified by their level of induction, use of atazanavir or atazanavir-ritonavir as part of background ART, and albumin level were predictors of CL/F; weight and albumin level were predictors of V/F; and sex and concomitant use of metal cation-containing vitamin/mineral supplements were predictors of relative bioavailability (F). The current model-based analysis suggests that the DTG dose adjustment is not required based on the demographics, laboratory values, smoking status, concomitant use of mild metabolic inducers or inhibitors in the background therapy, or use of metal cation-containing vitamin/mineral supplements because these covariate effects are not predicted to have a clinically relevant impact on safety and efficacy.
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Poliseno M, Mazzitelli M, Narducci A, Ferrara SM, Resnati C, Gervasoni C, Cattelan AM, Lo Caputo S. Doravirine Plus Integrase Strand Transfer Inhibitors as a 2-Drug Treatment-Switch Strategy in People Living with HIV: The Real-Life DORINI Multicentric Cohort Study. J Acquir Immune Defic Syndr 2023; 94:235-243. [PMID: 37757865 DOI: 10.1097/qai.0000000000003248] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 06/20/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Few data are available about the efficacy, durability, and tolerability of doravirine (DOR) + integrase strand inhibitors (INI) as a switching strategy among antiretroviral therapy (ART)-experienced people living with HIV (PLWH). SETTING Retrospective, multicenter cohort study investigating the durability, efficacy, and tolerability of 2 off-label drug associations of DOR + INI among ART-experienced PLWH. METHODS The study included PLWH who switched to DOR combined with either raltegravir (RAL) or dolutegravir (DTG) between June 1, 2020, and December 31, 2021, with at least 1 follow-up (FU) visit. Virologic, biometric, and metabolic parameters were evaluated at baseline (T0) and at 1-3 (T1), 6 (T2), and 12 (T3) months. Univariate and multivariate survival analyses assessed the 28-week probability of persistence on the regimens. Patient satisfaction was measured using the HIV Treatment Satisfaction Questionnaire. RESULTS Ninety-five PLWH were included, 52 in DOR + RAL and 43 in DOR + DTG. Six treatment discontinuations were reported during a mean of 37 (±17) weeks of FU (incidence of 2.7 × 1000 person-weeks FU). Only 2 were the result of virological failure without resistance mutations. DOR + DTG demonstrated significantly higher 28-week persistence than DOR + RAL (HR 1.90, 95% CI: 1.24-2.90, log-rank: P = 0.003). Weight, waist circumference, and fasting lipids reduced considerably at T3 vs T0. Overall, high satisfaction with the new treatment was reported, particularly in the DOR + RAL (68 (64-72)/72), compared with the DOR + DTG group (58 (50-65)/72, P < 0.001). CONCLUSIONS Our experience revealed few treatment discontinuations, improved metabolic parameters, and high patient satisfaction among ART-experienced PLWH switching to DOR combined with INI, irrespective of the specific INI used.
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Affiliation(s)
- Mariacristina Poliseno
- Unit of Infectious Diseases, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Maria Mazzitelli
- Infectious and Tropical Diseases Unit, Padua University Hospital, Padua, Italy
| | - Arianna Narducci
- Unit of Infectious Diseases, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Sergio Maria Ferrara
- Unit of Infectious Diseases, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Chiara Resnati
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy; and
| | - Cristina Gervasoni
- Department of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Anna Maria Cattelan
- Infectious and Tropical Diseases Unit, Padua University Hospital, Padua, Italy
| | - Sergio Lo Caputo
- Unit of Infectious Diseases, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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Chisholm BS, Swart AM, Blockman M. South African healthcare workers' knowledge of dolutegravir's drug-drug interactions in the first year of its rollout: a cross-sectional online survey. J Int AIDS Soc 2022; 25:e25885. [PMID: 35255196 PMCID: PMC8901146 DOI: 10.1002/jia2.25885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 01/19/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION In December 2019, dolutegravir-based treatment was recommended as first-line antiretroviral therapy (ART) in South Africa. Dolutegravir has clinically significant interactions with several commonly used drugs, such as rifampicin, metformin and cation-containing medicines. National guidelines detail these interactions and how to manage them. While previous international studies have shown low healthcare worker knowledge of drug-drug interactions, there is a paucity of information on antiretroviral interaction knowledge in the South African setting, where much ART is nurse-led. The study aimed to determine this knowledge and to describe which variables were associated with gaps in knowledge. METHODS An anonymous online survey of healthcare workers in the field of HIV was conducted in August/September 2020. The survey was designed, tested and piloted, and included sections on demographics, guideline access and training, interaction knowledge, counselling and the effect of COVID-19. Dissemination was via e-mail and social media (convenience sampling). Descriptive and inferential analysis was done using proportions and the 95% confidence interval to determine relationships between independent and dependent variables. Research ethics approval was obtained from the University of Cape Town's Human Research Ethics Committee (HREC Ref: 357/2020). RESULTS AND DISCUSSION In total, 1950 survey responses were included in the analysis - 47.1% nurses, 35.8% doctors and 8.9% pharmacists. When asked whether they were aware that dolutegravir has interactions, 70% said yes, 13.9% said no and 16.1% did not answer. Knowledge of specific interactions and the dosing changes needed was low with a wide range between different drugs: 79.7% knew to double the dolutegravir dose with rifampicin, but with calcium, 5.1% picked both correct dosing options and 33.7% picked one of the two correct options. Access to guidelines and training were positively associated with drug interaction knowledge. CONCLUSIONS There are gaps in the awareness and knowledge of dolutegravir interactions and how to adjust dosing among South African healthcare workers.
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Affiliation(s)
- Briony S. Chisholm
- Division of Clinical PharmacologyNational HIV and TB Healthcare Worker HotlineMedicines Information CentreUniversity of Cape TownCape TownSouth Africa
| | - Annoesjka M. Swart
- Division of Clinical PharmacologyNational HIV and TB Healthcare Worker HotlineMedicines Information CentreUniversity of Cape TownCape TownSouth Africa
| | - Marc Blockman
- Division of Clinical PharmacologyUniversity of Cape TownCape TownSouth Africa
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Rugemalila J, Kamori D, Maokola W, Mizinduko M, Barabona G, Masoud S, Mlunde LB, Mutagonda RF, Ruhago G, Mushi J, Sambu V, Ueno T, Mutayoba B, Njau P, Nagu T, Aboud S, Sunguya BF. Acquired HIV drug resistance among children and adults receiving antiretroviral therapy in Tanzania: a national representative survey protocol. BMJ Open 2021; 11:e054021. [PMID: 34921085 PMCID: PMC8689191 DOI: 10.1136/bmjopen-2021-054021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Tanzania is making an enormous effort in scaling-up of antiretroviral therapy (ART). However, people living with HIV (PLHIV) continue to succumb to the challenge of drug resistance. Evidence on drug resistance for a national survey is unavailable in Tanzania. Therefore, we sought to assess viral suppression (vs) rates and magnitude of acquired drug resistance (ADR) among PLHIV. METHODS AND ANALYSIS A national survey will be conducted from 26 July to 29 October 2021 in 22 regions, recruiting 2160 participants. These will include adults on ART for 9-15 months and ≥48 months and children on ART for 9-15 months and ≥36 months. A standardised questionnaire will capture participants' demographic and clinical data. Plasma and dried blood spot will be prepared for viral load testing and drug resistance genotyping. Statistical analyses to determine the burden of ADR, characteristics and factors associated therewith will be done using STATA V.15. ETHICS AND DISSEMINATION Ethical approval has been obtained from the National Health Research Ethics Committee of Tanzania (NIMR/HQ/R.8a/Vol.IX/3432). Appropriate participant informed consent or parental consent and assent will be obtained. Dissemination will include a survey report, conference presentations, policy briefs and peer-reviewed publications.
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Affiliation(s)
- Joan Rugemalila
- Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Doreen Kamori
- Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Werner Maokola
- Strategic Information Unit, National AIDS Control Program, Dodoma, Tanzania
| | - Mucho Mizinduko
- Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Godfrey Barabona
- Joint Research Center for Human Retrovirus Infection, Kumamoto University, Kumamoto-Shi, Kumamoto, Japan
| | - Salim Masoud
- Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Linda B Mlunde
- Department of Community Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ritah Francis Mutagonda
- Clinical Pharmacy and Pharmacology, Muhimbili University of Health and Allied Sciences, Dar-es-salaam, Tanzania, United Republic of Tanzania
| | - George Ruhago
- Department of Development Studies, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jeremiah Mushi
- Strategic Information Unit, National AIDS Control Program, Dodoma, Tanzania
| | - Veryeh Sambu
- Strategic Information Unit, National AIDS Control Program, Dodoma, Tanzania
| | - Takamasa Ueno
- Joint Research Center for Human Retrovirus Infection, Kumamoto University, Kumamoto-Shi, Kumamoto, Japan
| | - Beatrice Mutayoba
- Administration Department, National AIDS Control Program, Dodoma, Tanzania
| | - Prosper Njau
- Strategic Information Unit, National AIDS Control Program, Dodoma, Tanzania
| | - Tumaini Nagu
- Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Said Aboud
- Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Bruno F Sunguya
- Department of Community Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Pham HT, Alves BM, Yoo S, Xiao MA, Leng J, Quashie PK, Soares EA, Routy JP, Soares MA, Mesplède T. Progressive emergence of an S153F plus R263K combination of integrase mutations in the proviral DNA of one individual successfully treated with dolutegravir. J Antimicrob Chemother 2021; 76:639-647. [PMID: 33184634 DOI: 10.1093/jac/dkaa471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/19/2020] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES The development of HIV drug resistance against the integrase strand transfer inhibitor dolutegravir is rare. We report here the transient detection, by near full-genome ultradeep sequencing, of minority HIV-1 subtype B variants bearing the S153F and R263K integrase substitutions in the proviral DNA from blood cells of one patient who successfully initiated dolutegravir-based ART, over 24 weeks. Our objective was to study the effects of these substitutions. METHODS Strand transfer and DNA-binding activities of recombinant integrase proteins were measured in cell-free assays. Cell-based resistance, infectivity and replicative capacities were measured using molecular clones. Structural modelling was performed to understand experimental results. RESULTS R263K emerged first, followed by the addition of S153F at Week 12. By Week 24, both mutations remained present, but at lower prevalence. We confirmed the coexistence of S153F and R263K on single viral genomes. Combining S153F or S153Y with R263K decreased integration and viral replicative capacity and conferred high levels of drug resistance against all integrase inhibitors. Alone, S153Y and S153F did little to infectivity or dolutegravir resistance. We identified altered DNA binding as a mechanism of resistance. The patient remained with undetectable viral loads at all timepoints. CONCLUSIONS Drug-resistant minority variants have often been reported under suppressive ART. Our study adds to these observations by unravelling a progression towards higher levels of resistance through a novel pathway despite continuous undetectable viral loads. Poorly replicative HIV drug-resistant minority proviral variants did not compromise viral suppression in one individual treated with dolutegravir.
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Affiliation(s)
- Hanh T Pham
- McGill AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada
- Department of Microbiology and Immunology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Brunna M Alves
- Programa de Oncovirologia, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
| | - Sunbin Yoo
- McGill AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada
- Department of Microbiology and Immunology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Meng A Xiao
- McGill AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada
- Department of Microbiology and Immunology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Jing Leng
- McGill AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada
- Department of Microbiology and Immunology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Peter K Quashie
- West African Centre for Cell Biology of Infectious Pathogens, University of Ghana, Accra, Ghana
- The Francis Crick Institute, London, UK
- Department of Virology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Esmeralda A Soares
- Programa de Oncovirologia, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
| | - Jean-Pierre Routy
- For Montreal PHI Cohort Study Group, Division of Hematology, McGill University Health Centre, Montréal, Québec, Canada
| | - Marcelo A Soares
- Programa de Oncovirologia, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
- Departamento de Genética, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Thibault Mesplède
- McGill AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada
- Department of Microbiology and Immunology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
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Rhee SY, Grant PM, Tzou PL, Barrow G, Harrigan PR, Ioannidis JPA, Shafer RW. A systematic review of the genetic mechanisms of dolutegravir resistance. J Antimicrob Chemother 2020; 74:3135-3149. [PMID: 31280314 PMCID: PMC6798839 DOI: 10.1093/jac/dkz256] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 05/06/2019] [Accepted: 05/22/2019] [Indexed: 12/17/2022] Open
Abstract
Background Characterizing the mutations selected by the integrase strand transfer inhibitor (INSTI) dolutegravir and their effects on susceptibility is essential for identifying viruses less likely to respond to dolutegravir therapy and for monitoring persons with virological failure (VF) on dolutegravir therapy. Methods We systematically reviewed dolutegravir resistance studies to identify mutations emerging under dolutegravir selection pressure, the effect of INSTI resistance mutations on in vitro dolutegravir susceptibility, and the virological efficacy of dolutegravir in antiretroviral-experienced persons. Results and conclusions We analysed 14 studies describing 84 in vitro passage experiments, 26 studies describing 63 persons developing VF plus INSTI resistance mutations on a dolutegravir-containing regimen, 41 studies describing dolutegravir susceptibility results, and 22 clinical trials and 16 cohort studies of dolutegravir-containing regimens. The most common INSTI resistance mutations in persons with VF on a dolutegravir-containing regimen were R263K, G118R, N155H and Q148H/R, with R263K and G118R predominating in previously INSTI-naive persons. R263K reduced dolutegravir susceptibility ∼2-fold. G118R generally reduced dolutegravir susceptibility >5-fold. The highest levels of reduced susceptibility occurred in viruses containing Q148 mutations in combination with G140 and/or E138 mutations. Dolutegravir two-drug regimens were highly effective for first-line therapy and for virologically suppressed persons provided dolutegravir’s companion drug was fully active. Dolutegravir three-drug regimens were highly effective for salvage therapy in INSTI-naive persons provided one or more of dolutegravir’s companion drugs was fully active. However, dolutegravir monotherapy in virologically suppressed persons and functional dolutegravir monotherapy in persons with active viral replication were associated with a non-trivial risk of VF plus INSTI resistance mutations.
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Affiliation(s)
- Soo-Yon Rhee
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Philip M Grant
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Philip L Tzou
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Geoffrey Barrow
- Centre for HIV/AIDS Research, Education and Services (CHARES), Department of Medicine, University of the West Indies, Kingston, Jamaica
| | - P Richard Harrigan
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - John P A Ioannidis
- Department of Medicine, Stanford University, Stanford, CA, USA.,Meta-Research Innovation Center at Stanford, Stanford University, Stanford, CA, USA
| | - Robert W Shafer
- Department of Medicine, Stanford University, Stanford, CA, USA
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Braun DL, Turk T, Tschumi F, Grube C, Hampel B, Depmeier C, Schreiber PW, Brugger SD, Greiner M, Steffens D, De Torrenté-Bayard C, Courlet P, Neumann K, Kuster H, Flepp M, Bertisch B, Decosterd L, Böni J, Metzner KJ, Kouyos RD, Günthard HF. Noninferiority of Simplified Dolutegravir Monotherapy Compared to Continued Combination Antiretroviral Therapy That Was Initiated During Primary Human Immunodeficiency Virus Infection: A Randomized, Controlled, Multisite, Open-label, Noninferiority Trial. Clin Infect Dis 2020; 69:1489-1497. [PMID: 30601950 DOI: 10.1093/cid/ciy1131] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/28/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Patients who start combination antiretroviral therapy (cART) during primary human immunodeficiency virus type 1 (HIV-1) infection show a smaller HIV-1 latent reservoir, less immune activation, and less viral diversity compared to patients who start cART during chronic infection. We conducted a pilot study to determine whether these properties would allow sustained virological suppression after simplification of cART to dolutegravir monotherapy. METHODS EARLY-SIMPLIFIED is a randomized, open-label, noninferiority trial. Patients who started cART <180 days after a documented primary HIV-1 infection and had an HIV-1 RNA <50 copies/mL plasma for at least 48 weeks were randomized (2:1) to monotherapy with dolutegravir 50 mg once daily or to continuation of cART. The primary efficacy endpoint was the proportion of patients with <50 HIV-1 RNA copies/mL on or before week 48; noninferiority margin 10%. RESULTS Of the 101 patients randomized, 68 were assigned to simplification to dolutegravir monotherapy and 33 to continuation of cART. At week 48 in the per-protocol population, 67/67 (100%) had virological response in the dolutegravir monotherapy group vs 32/32 (100%) in the cART group (difference, 0.00%; 95% confidence interval, -100%, 4.76%). This showed noninferiority of the dolutegravir monotherapy at the prespecified level. CONCLUSION In this pilot study consisting of patients who initiated cART during primary HIV-1 infection and had <50 HIV-1 RNA copies/mL for at least 48 weeks, monotherapy with once-daily dolutegravir was noninferior to cART. Our results suggest that future simplification studies should use a stratification according to time of HIV infection and start of first cART. CLINICAL TRIALS REGISTRATION NCT02551523.
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Affiliation(s)
- Dominique L Braun
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland.,Institute of Medical Virology, University of Zurich, Switzerland
| | - Teja Turk
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland.,Institute of Medical Virology, University of Zurich, Switzerland
| | - Fabian Tschumi
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland.,Institute of Medical Virology, University of Zurich, Switzerland
| | - Christina Grube
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Benjamin Hampel
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland.,Institute of Medical Virology, University of Zurich, Switzerland
| | - Carsten Depmeier
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Peter W Schreiber
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Silvio D Brugger
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Michael Greiner
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Daniela Steffens
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Cornelia De Torrenté-Bayard
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Perrine Courlet
- Service of Clinical Pharmacology, University Hospital Center, University of Lausanne, Switzerland
| | - Kathrin Neumann
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Herbert Kuster
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Markus Flepp
- Center of Infectious Diseases Zurich, Switzerland
| | - Barbara Bertisch
- Checkpoint Zurich, Switzerland.,Institute of Global Health, University of Geneva, Switzerland
| | - Laurent Decosterd
- Service of Clinical Pharmacology, University Hospital Center, University of Lausanne, Switzerland
| | - Jürg Böni
- Institute of Medical Virology, University of Zurich, Switzerland
| | - Karin J Metzner
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland.,Institute of Medical Virology, University of Zurich, Switzerland
| | - Roger D Kouyos
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland.,Institute of Medical Virology, University of Zurich, Switzerland
| | - Huldrych F Günthard
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland.,Institute of Medical Virology, University of Zurich, Switzerland
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Hocqueloux L, Raffi F, Prazuck T, Bernard L, Sunder S, Esnault JL, Rey D, Le Moal G, Roncato-Saberan M, André M, Billaud E, Valéry A, Avettand-Fènoël V, Parienti JJ, Allavena C. Dolutegravir Monotherapy Versus Dolutegravir/Abacavir/Lamivudine for Virologically Suppressed People Living With Chronic Human Immunodeficiency Virus Infection: The Randomized Noninferiority MONotherapy of TiviCAY Trial. Clin Infect Dis 2020; 69:1498-1505. [PMID: 30601976 DOI: 10.1093/cid/ciy1132] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/29/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We investigated whether dolutegravir (DTG) monotherapy could be used to maintain virological suppression in people living with human immunodeficiency virus (HIV) on a successful dolutegravir-based triple therapy. METHODS MONCAY (MONotherapy of TiviCAY) was a 48-week, multicentric, randomized, open-label, 12% noninferiority margin trial. Patients with CD4 nadir >100/μL, plasma HIV-1 RNA <50 copies/mL for ≥12 months, and stable regimen with DTG/abacavir (ABC)/lamivudine (3TC) were 1:1 randomized to continue their regimen or to DTG monotherapy. The primary endpoint was the proportion of patients with HIV RNA <50 copies/mL at week 24 in intention-to-treat snapshot analysis. Virologic failure (VF) was defined as 2 consecutive HIV RNA >50 copies/mL within 2 weeks apart. RESULTS Seventy-eight patients were assigned to DTG monotherapy and 80 to continue DTG/ABC/3TC. By week 24, 2 patients in the DTG group experienced VF without resistance to the integrase strand transfer inhibitor (INSTI) class; 1 patient discontinued DTG/ABC/3TC due to an adverse event. The success rate at week 24 was 73/78 (93.6%) in the DTG arm and 77/80 (96.3%) in the DTG/ABC/3TC arm (difference, 2.7%; 95% confidence interval [CI], -5.0 to 10.8). During subsequent follow-up, 5 additional VFs occurred in the DTG arm (2 of which harbored emerging resistance mutation to INSTI). The cumulative incidence of VF at week 48 was 9.7% (95% CI, 2.8 to 16.6) in the DTG arm compared with 0% in the DTG/ABC/3TC arm (P = .005 by the log-rank test). The Data Safety Monitoring Board recommended to reintensify the DTG arm with standardized triple therapy. CONCLUSIONS Because the risk of VF with resistance increases over time, we recommend avoiding DTG monotherapy as a maintenance strategy among people living with chronic HIV infection. CLINICAL TRIALS REGISTRATION NCT02596334 and EudraCT 2015-002853-36.
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Affiliation(s)
- Laurent Hocqueloux
- Service des Maladies Infectieuses et Tropicales, CHR d'Orléans-La Source, Tours
| | - François Raffi
- Service des Maladies Infectieuses, CHU Hôtel Dieu and INSERM UIC 1413 Nantes University, Tours
| | - Thierry Prazuck
- Service des Maladies Infectieuses et Tropicales, CHR d'Orléans-La Source, Tours
| | - Louis Bernard
- Service des Maladies Infectieuses, CHU Bretonneau, Tours
| | - Simon Sunder
- Service des Maladies Infectieuses et Tropicales, CHG de Niort
| | - Jean-Luc Esnault
- Service des Maladies Infectieuses, CHD de Vendée, La Roche-sur-Yon
| | - David Rey
- Le Trait d'Union, Hôpitaux Universitaires de Strasbourg
| | - Gwenaël Le Moal
- Service des Maladies Infectieuses, CHU La Milétrie, Poitiers
| | | | - Marie André
- Service des Maladies Infectieuses, CHRU-Brabois, Nancy
| | - Eric Billaud
- Service des Maladies Infectieuses, CHU Hôtel Dieu and INSERM UIC 1413 Nantes University, Tours
| | - Antoine Valéry
- Département d'Informatique Médicale, CHR d'Orléans-La Source, France
| | - Véronique Avettand-Fènoël
- Laboratoire de Microbiologie clinique, CHU Necker and Université Paris Descartes, Sorbonne Paris Cité
| | - Jean-Jacques Parienti
- Unité de Biostatistique et de Recherche Clinique, CHU de Caen; EA2656 Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0), Université Caen Normandie, Caen, France
| | - Clotilde Allavena
- Service des Maladies Infectieuses, CHU Hôtel Dieu and INSERM UIC 1413 Nantes University, Tours
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9
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Wijting IEA, Lungu C, Rijnders BJA, van der Ende ME, Pham HT, Mesplede T, Pas SD, Voermans JJC, Schuurman R, van de Vijver DAMC, Boers PHM, Gruters RA, Boucher CAB, van Kampen JJA. HIV-1 Resistance Dynamics in Patients With Virologic Failure to Dolutegravir Maintenance Monotherapy. J Infect Dis 2019; 218:688-697. [PMID: 29617822 DOI: 10.1093/infdis/jiy176] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 03/18/2018] [Indexed: 11/14/2022] Open
Abstract
Background A high genetic barrier to resistance to the integrase strand transfer inhibitor (INSTI) dolutegravir has been reported in vitro and in vivo. We describe the dynamics of INSTI resistance-associated mutations (INSTI-RAMs) and mutations in the 3'-polypurine tract (3'-PPT) in relation to virologic failure (VF) observed in the randomized Dolutegravir as Maintenance Monotherapy for HIV-1 study (DOMONO, NCT02401828). Methods From 10 patients with VF, plasma samples were collected before the start of cART and during VF, and were used to generate Sanger sequences of integrase, the 5' terminal bases of the 3' long terminal repeat (LTR), and the 3'-PPT. Results Median human immunodeficiency virus RNA load at VF was 3490 copies/mL (interquartile range 1440-4990 copies/mL). INSTI-RAMs (S230R, R263K, N155H, and E92Q+N155H) were detected in 4 patients, no INSTI-RAMs were detected in 4 patients, and sequencing of the integrase gene was unsuccessful in 2 patients. The time to VF ranged from 4 weeks to 72 weeks. In 1 patient, mutations developed in the highly conserved 3'-PPT. No changes in the terminal bases of the 3'-LTR were observed. Conclusions The genetic barrier to resistance is too low to justify dolutegravir maintenance monotherapy because single INSTI-RAMs are sufficient to cause VF. The large variation in time to VF suggests that stochastic reactivation of a preexisting provirus containing a single INSTI-RAM is the mechanism for failure. Changes in the 3'-PPT point to a new dolutegravir resistance mechanism in vivo. Clinical Trials Registration NCT02401828.
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Affiliation(s)
- Ingeborg E A Wijting
- Department of Internal Medicine and Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands
| | - Cynthia Lungu
- Department of Viroscience, Erasmus MC, Rotterdam, the Netherlands
| | - Bart J A Rijnders
- Department of Internal Medicine and Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands
| | - Marchina E van der Ende
- Department of Internal Medicine and Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands
| | - Hanh T Pham
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.,Department of Microbiology and Immunology, Faculty of Medicine, McGill University, Montreal, Canada
| | - Thibault Mesplede
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.,Department of Microbiology and Immunology, Faculty of Medicine, McGill University, Montreal, Canada
| | - Suzan D Pas
- Department of Viroscience, Erasmus MC, Rotterdam, the Netherlands
| | | | - Rob Schuurman
- Division of Virology, Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | | - Rob A Gruters
- Department of Viroscience, Erasmus MC, Rotterdam, the Netherlands
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10
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Brooks KM, Sherman EM, Egelund EF, Brotherton A, Durham S, Badowski ME, Cluck DB. Integrase Inhibitors: After 10 Years of Experience, Is the Best Yet to Come? Pharmacotherapy 2019; 39:576-598. [PMID: 30860610 DOI: 10.1002/phar.2246] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The era of the integrase strand transfer inhibitors (INSTIs) for the treatment of human immunodeficiency virus (HIV) infection began with raltegravir in 2007. Since that time, several other INSTIs have been introduced including elvitegravir, dolutegravir, and, most recently, bictegravir, that have shown great utility as part of antiretroviral regimens in both treatment-naive and treatment-experienced patients. At present, antiretroviral guidelines fully endorse the INSTI class as part of all first-line treatment regimens. After 10 years of experience with INSTIs, newer agents are on the horizon such as cabotegravir and MK-2048 for potential use as either HIV pre-exposure prophylaxis or maintenance therapy. This review provides a brief overview of the INSTI class including agents currently available and those still in development, reviews available data from both completed and ongoing clinical trials, and outlines simplification strategies using INSTIs.
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Affiliation(s)
- Kristina M Brooks
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Elizabeth M Sherman
- Department of Pharmacy Practice, Nova Southeastern University, Fort Lauderdale, Florida
| | - Eric F Egelund
- Department of Pharmacotherapy & Translational Research, University of Florida College of Pharmacy, Jacksonville, Florida
| | - Amy Brotherton
- Department of Pharmacy, The Miriam Hospital, Providence, Rhode Island
| | - Spencer Durham
- Department Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, Alabama
| | - Melissa E Badowski
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - David B Cluck
- Department of Pharmacy Practice, East Tennessee State University Gatton College of Pharmacy, Johnson City, Tennessee
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11
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Van Rompay KKA, Hassounah S, Keele BF, Lifson JD, Ardeshir A, Watanabe J, Pham HT, Chertova E, Sowder R, Balzarini J, Mesplède T, Wainberg MA. Dolutegravir Monotherapy of Simian Immunodeficiency Virus-Infected Macaques Selects for Several Patterns of Resistance Mutations with Variable Virological Outcomes. J Virol 2019; 93:e01189-18. [PMID: 30381490 PMCID: PMC6321921 DOI: 10.1128/jvi.01189-18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 10/24/2018] [Indexed: 12/19/2022] Open
Abstract
Drug resistance remains a major concern for human immunodeficiency virus (HIV) treatment. To date, very few resistance mutations have emerged in first-line combination therapy that includes the integrase strand transfer inhibitor (INSTI) dolutegravir (DTG). In vitro, DTG selects for several primary mutations that induce low-level DTG resistance; secondary mutations, while increasing the level of resistance, however, further impair replication fitness, which raised the idea that DTG monotherapy may be feasible. The simian immunodeficiency virus (SIV) rhesus macaque model of HIV infection can be useful to explore this concept. Nine macaques were infected with virulent SIVmac251 and started on DTG monotherapy during either acute (n = 2) or chronic infection (n = 7). Within 4 weeks of treatment, all animals demonstrated a reduction in viremia of 0.8 to 3.5 log RNA copies/ml plasma. Continued treatment led to overall sustained benefits, but the outcome after 10 to 50 weeks of treatment was highly variable and ranged from viral rebound to near pretreatment levels to sustained suppression, with viremia being 0.5 to 5 logs lower than expected based on pretreatment viremia. A variety of mutations previously described to confer low-level resistance of HIV-1 to DTG or other INSTI were detected, and these were sometimes followed by mutations believed to be compensatory. Some mutations, such as G118R, previously shown to severely impair the replication capacity in vitro, were associated with more sustained virological and immunological benefits of continued DTG therapy, while other mutations, such as E92Q and G140A/Q148K, were associated with more variable outcomes. The observed variability of the outcomes in macaques warrants avoidance of DTG monotherapy in HIV-infected people.IMPORTANCE A growing number of anti-HIV drug combinations are effective in suppressing virus replication in HIV-infected persons. However, to reduce their cost and risk for toxicity, there is considerable interest in simplifying drug regimens. A major concern with single-drug regimens is the emergence of drug-resistant viral mutants. It has been speculated that DTG monotherapy may be a feasible option, because DTG may have a higher genetic barrier for the development of drug resistance than other commonly used antiretrovirals. To explore treatment initiation with DTG monotherapy, we started SIV-infected macaques on DTG during either acute or chronic infection. Although DTG initially reduced virus replication, continued treatment led to the emergence of a variety of viral mutations previously described to confer low-level resistance of HIV-1 to DTG, and this was associated with variable clinical outcomes. This unpredictability of mutational pathways and outcomes warns against using DTG monotherapy as initial treatment for HIV-infected people.
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Affiliation(s)
- Koen K A Van Rompay
- California National Primate Research Center, University of California, Davis, Davis, California, USA
- Department of Pathology, Microbiology and Immunology, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Said Hassounah
- McGill University AIDS Centre Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - Brandon F Keele
- AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Jeffrey D Lifson
- AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Amir Ardeshir
- California National Primate Research Center, University of California, Davis, Davis, California, USA
| | - Jennifer Watanabe
- California National Primate Research Center, University of California, Davis, Davis, California, USA
| | - Hanh Thi Pham
- McGill University AIDS Centre Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
- Department of Microbiology and Immunology, McGill University, Montreal, Quebec, Canada
| | - Elena Chertova
- AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Raymond Sowder
- AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Jan Balzarini
- Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
| | - Thibault Mesplède
- McGill University AIDS Centre Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
- Department of Microbiology and Immunology, McGill University, Montreal, Quebec, Canada
| | - Mark A Wainberg
- McGill University AIDS Centre Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
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12
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Wandeler G, Buzzi M, Anderegg N, Sculier D, Béguelin C, Egger M, Calmy A. Virologic failure and HIV drug resistance on simplified, dolutegravir-based maintenance therapy: Systematic review and meta-analysis. F1000Res 2018; 7:1359. [PMID: 30271590 PMCID: PMC6134332 DOI: 10.12688/f1000research.15995.2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2019] [Indexed: 12/20/2022] Open
Abstract
Background: Dolutegravir-containing maintenance therapy is a promising simplification strategy for virologically suppressed HIV-infected individuals. However, most of the available data to inform this strategy come from small, uncontrolled studies. We estimated the proportion of HIV-infected patients experiencing virological failure (VF) and developing drug resistance on dolutegravir (DTG)-based maintenance therapy. Methods: We searched Medline, Embase, Cochrane Central, Web of Science, and conference abstracts for studies assessing VF on DTG-based maintenance therapy. Studies including ≥5 adults with an undetectable viral load on antiretroviral therapy (ART) who switched to a DTG-based mono- or dual therapy were included. Pooled proportions of VF were estimated using random-intercept logistic meta-regression and acquired drug resistance mutations described for each strategy. Results: Of 1719 studies considered, 21 met our selection criteria, including seven interventional and 14 observational studies. Eight studies including 251 patients assessed VF on DTG monotherapy and fourteen studies including 1670 participants VF on dual therapy. The participant's median age ranged from 43 to 63 years, their median nadir CD4 count from 90 to 399 cells/µl, and 27.6% were female. The proportion of participants experiencing VF on DTG-monotherapy was 3.6% (95% confidence interval [CI] 1.9-6.7) at 24 weeks and 8.9% (95% CI 4.7-16.2) at 48 weeks. Resistance mutations developed in seven (3.6%) participants on DTG-monotherapy. Among patients on dual therapy, ten (0.7%, 95% CI 0.4-1.3) experienced VF by 48 weeks and none developed resistance to DTG. In adjusted analyses, VF at 24 weeks was less likely on dual therapy than on monotherapy (adjusted odds ratio: 0.10, 95% CI 0.03-0.30). Conclusions: Whereas VF is relatively common on DTG maintenance monotherapy, DTG-based dual therapy appears to be a promising simplification strategy for individuals with a suppressed HIV viral load on triple-ART.
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Affiliation(s)
- Gilles Wandeler
- Department of Infectious Diseases, Bern University Hospital, Bern, 3010, Switzerland
- Institute of Social and Preventive Medicine, University of Bern, Bern, 3012, Switzerland
| | - Marta Buzzi
- Division of Infectious Diseases, Geneva University Hospital, Geneva, 1205, Switzerland
| | - Nanina Anderegg
- Institute of Social and Preventive Medicine, University of Bern, Bern, 3012, Switzerland
| | - Delphine Sculier
- Division of Infectious Diseases, Geneva University Hospital, Geneva, 1205, Switzerland
| | - Charles Béguelin
- Department of Infectious Diseases, Bern University Hospital, Bern, 3010, Switzerland
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, 3012, Switzerland
| | - Alexandra Calmy
- Division of Infectious Diseases, Geneva University Hospital, Geneva, 1205, Switzerland
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13
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Wandeler G, Buzzi M, Anderegg N, Sculier D, Béguelin C, Egger M, Calmy A. Virologic failure and HIV drug resistance on simplified, dolutegravir-based maintenance therapy: Systematic review and meta-analysis. F1000Res 2018; 7:1359. [PMID: 30271590 PMCID: PMC6134332 DOI: 10.12688/f1000research.15995.1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2018] [Indexed: 11/20/2022] Open
Abstract
Background: Dolutegravir-containing maintenance therapy is a promising simplification strategy for virologically suppressed HIV-infected individuals. However, most of the available data to inform this strategy come from small, uncontrolled studies. We estimated the proportion of HIV-infected patients experiencing virological failure (VF) and developing drug resistance on dolutegravir (DTG)-based maintenance therapy. Methods: We searched Medline, Embase, Cochrane Central, Web of Science, and conference abstracts for studies assessing VF on DTG-based maintenance therapy. Studies including ≥5 adults with an undetectable viral load on antiretroviral therapy (ART) who switched to a DTG-based mono- or dual therapy were included. Pooled proportions of VF were estimated using random-intercept logistic meta-regression and acquired drug resistance mutations described for each strategy. Results: Of 1719 studies considered, 21 met our selection criteria, including seven interventional and 14 observational studies. Eight studies including 251 patients assessed VF on DTG monotherapy and fourteen studies including 1670 participants VF on dual therapy. The participant's median age ranged from 43 to 63 years, their median nadir CD4 count from 90 to 399 cells/µl, and 27.6% were female. The proportion of participants experiencing VF on DTG-monotherapy was 3.6% (95% confidence interval [CI] 1.9-6.7) at 24 weeks and 8.9% (95% CI 4.7-16.2) at 48 weeks. Resistance mutations developed in seven (3.6%) participants on DTG-monotherapy. Among patients on dual therapy, ten (0.7%, 95% CI 0.4-1.3) experienced VF by 48 weeks and none developed resistance to DTG. In adjusted analyses, VF at 24 weeks was less likely on dual therapy than on monotherapy (adjusted odds ratio: 0.10, 95% CI 0.03-0.30). Conclusions: Whereas VF is relatively common on DTG maintenance monotherapy, DTG-based dual therapy appears to be a promising simplification strategy for individuals with a suppressed HIV viral load on triple-ART.
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Affiliation(s)
- Gilles Wandeler
- Department of Infectious Diseases, Bern University Hospital, Bern, 3010, Switzerland
- Institute of Social and Preventive Medicine, University of Bern, Bern, 3012, Switzerland
| | - Marta Buzzi
- Division of Infectious Diseases, Geneva University Hospital, Geneva, 1205, Switzerland
| | - Nanina Anderegg
- Institute of Social and Preventive Medicine, University of Bern, Bern, 3012, Switzerland
| | - Delphine Sculier
- Division of Infectious Diseases, Geneva University Hospital, Geneva, 1205, Switzerland
| | - Charles Béguelin
- Department of Infectious Diseases, Bern University Hospital, Bern, 3010, Switzerland
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, 3012, Switzerland
| | - Alexandra Calmy
- Division of Infectious Diseases, Geneva University Hospital, Geneva, 1205, Switzerland
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14
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Mason S, Devincenzo JP, Toovey S, Wu JZ, Whitley RJ. Comparison of antiviral resistance across acute and chronic viral infections. Antiviral Res 2018; 158:103-112. [PMID: 30086337 DOI: 10.1016/j.antiviral.2018.07.020] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/24/2018] [Accepted: 07/26/2018] [Indexed: 12/26/2022]
Abstract
Antiviral therapy can lead to drug resistance, but multiple factors determine the frequency of drug resistance mutations and the clinical consequences. When chronic infections caused by Human Immunodeficiency Virus (HIV), Hepatitis C Virus (HCV) and Hepatitis B Virus (HBV) are compared with acute infections such as influenza virus, respiratory syncytial virus (RSV), and other respiratory viruses, there are similarities in how and why antiviral resistance substitutions occur, but the clinical significance can be quite different. Emergence of resistant variants has implications for design of new therapeutics, treatment guidelines, clinical trial design, resistance monitoring, reporting, and interpretation. In this discussion paper, we consider the molecular factors contributing to antiviral drug resistance substitutions, and a comparison is made between chronic and acute infections. The implications of resistance are considered for clinical trial endpoints and public health, as well as the requirements for therapeutic monitoring in clinical practice with acute viral infections.
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Affiliation(s)
- Stephen Mason
- SWM Consulting, 9 Clearview Dr, Wallingford, CT 06492, USA
| | - John P Devincenzo
- Dpt of Pediatrics, College of Medicine, University of Tennessee Center for Health Sciences, Memphis, TN, USA; Dpt of Microbiology, Immunology, and Biochemistry, College of Medicine, University of Tennessee Center for Health Sciences, Memphis, TN, USA; Children's Foundation Research Institute at Le Bonheur Children's Hospital, Memphis, TN, USA
| | | | - Jim Z Wu
- Ark Biosciences Inc, Shanghai, PR China
| | - Richard J Whitley
- Department of Pediatrics, Microbiology, Medicine and Neurosurgery, The University of Alabama at Birmingham, USA
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15
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Heredia A, Hassounah S, Medina-Moreno S, Zapata JC, Le NM, Han Y, Foulke JS, Davis C, Bryant J, Redfield RR, Wainberg MA. Monotherapy with either dolutegravir or raltegravir fails to durably suppress HIV viraemia in humanized mice. J Antimicrob Chemother 2018. [PMID: 28637235 DOI: 10.1093/jac/dkx195] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objectives To compare the effectiveness of HIV integrase inhibitor monotherapy between raltegravir and dolutegravir as an approach to simplify therapy. Methods We evaluated and compared the efficacy of 20 week monotherapy with dolutegravir or raltegravir in humanized mice (HSC-NSG) infected with HIVBaL. Plasma HIV RNA was measured by quantitative RT-PCR (limit of detection of 150 copies/45 μL of plasma) and drug levels by LC-MS/MS. Escape viruses were genotyped and analysed for replication capacity and drug susceptibility in tissue culture. Results Drug-untreated control mice maintained constant viraemia throughout the study. Virus isolates from these mice were susceptible to both raltegravir (EC50 of <8 nM) and dolutegravir (EC50 of <1 nM). Mice treated with raltegravir or dolutegravir had plasma drug levels comparable to those in humans. Monotherapy with raltegravir initially suppressed HIV viraemia, but failed to maintain suppression in 4/4 mice. Viruses from raltegravir failing mice developed mutations G140G/S and Q148H/K, and were resistant to both raltegravir (EC50 values of >100 nM) and dolutegravir (EC50 values ranging from 8.8 to 13.3 nM). Monotherapy with dolutegravir suppressed viraemia in 5/5 of mice, but viraemia rebounded in one animal. The virus from this mouse had mutations E138K, G140S, Q148H, N155H and S230R, was highly resistant to both raltegravir (EC50 of >1000 nM) and dolutegravir (EC50 of 550 nM), and replicated to levels similar to those of control viruses in PBMCs. Conclusions Monotherapy with either raltegravir or dolutegravir does not consistently maintain HIV suppression, suggesting that dual therapy may be required in simplification strategies.
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Affiliation(s)
- Alonso Heredia
- Institute of Human Virology, University of Maryland School of Medicine, Medicine, Baltimore, MD, USA
| | - Said Hassounah
- McGill University AIDS Centre, Lady Davis Institute, Montréal, Quebec, Canada
| | - Sandra Medina-Moreno
- Institute of Human Virology, University of Maryland School of Medicine, Medicine, Baltimore, MD, USA
| | - Juan C Zapata
- Institute of Human Virology, University of Maryland School of Medicine, Medicine, Baltimore, MD, USA
| | - Nhut M Le
- Institute of Human Virology, University of Maryland School of Medicine, Medicine, Baltimore, MD, USA
| | - Yingshan Han
- McGill University AIDS Centre, Lady Davis Institute, Montréal, Quebec, Canada
| | - James S Foulke
- Institute of Human Virology, University of Maryland School of Medicine, Medicine, Baltimore, MD, USA
| | - Charles Davis
- Institute of Human Virology, University of Maryland School of Medicine, Medicine, Baltimore, MD, USA
| | - Joseph Bryant
- Institute of Human Virology, University of Maryland School of Medicine, Medicine, Baltimore, MD, USA
| | - Robert R Redfield
- Institute of Human Virology, University of Maryland School of Medicine, Medicine, Baltimore, MD, USA
| | - Mark A Wainberg
- McGill University AIDS Centre, Lady Davis Institute, Montréal, Quebec, Canada
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16
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Lattuada E, Lanzafame M, Nicolè S, Rigo F, Cucchetto G, Concia E, Vento S. Dolutegravir monotherapy in HIV-1-suppressed patients: A feasible regimen in real life. Int J STD AIDS 2018; 29:206-207. [PMID: 29320967 DOI: 10.1177/0956462417747832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Affiliation(s)
- Emanuela Lattuada
- 1 Infectious Diseases Unit, G.B. Rossi University Hospital, Verona, Italy
| | - Massimiliano Lanzafame
- 1 Infectious Diseases Unit, G.B. Rossi University Hospital, Verona, Italy
- 2 Diagnosis and Therapy of HIV Infection Unit, G.B. Rossi University Hospital, Verona, Italy
| | - Stefano Nicolè
- 1 Infectious Diseases Unit, G.B. Rossi University Hospital, Verona, Italy
| | - Fabio Rigo
- 1 Infectious Diseases Unit, G.B. Rossi University Hospital, Verona, Italy
| | - Giulia Cucchetto
- 1 Infectious Diseases Unit, G.B. Rossi University Hospital, Verona, Italy
| | - Ercole Concia
- 1 Infectious Diseases Unit, G.B. Rossi University Hospital, Verona, Italy
| | - Sandro Vento
- 3 Department of Medicine, School of Medicine, Nazarbayev University, Astana, Kazakhstan
- 4 Nazarbayev University Medical Center, Astana, Kazakhstan
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17
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Sörstedt E, Carlander C, Flamholc L, Hejdeman B, Svedhem V, Sönnerborg A, Gisslén M, Yilmaz A. Effect of dolutegravir in combination with Nucleoside Reverse Transcriptase Inhibitors (NRTIs) on people living with HIV who have pre-existing NRTI mutations. Int J Antimicrob Agents 2018; 51:733-738. [PMID: 29371105 DOI: 10.1016/j.ijantimicag.2018.01.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 12/19/2017] [Accepted: 01/13/2018] [Indexed: 11/25/2022]
Abstract
Until the introduction of dolutegravir (DTG), people living with HIV (PLWH) who have developed nucleoside reverse transcriptase inhibitor (NRTI) mutations have had few other treatment options outside of regimens based on ritonavir-boosted protease inhibitors (PI/r). Here we report treatment results among PLWH in Sweden with pre-existing NRTI mutations on antiretroviral treatment (ART) with DTG and one to two NRTIs. All PLWH on ART with DTG and one to two NRTIs with pre-existing NRTI mutations were retrospectively identified from the National InfCare HIV database. As controls, PLWH on PI/r and one to two NRTIs, matched according to Genotypic Susceptibility Score and observation time, were included. Data were collected as long as the study population was on treatment with DTG; controls were monitored for the same interval. Outcome was classified as either treatment success or failure. In total, 244 participants (122 individuals treated with DTG and 122 individuals treated with PI/r) were included. Median observation time was 78 weeks (interquartile range 50-98 weeks) for participants on DTG and 75 weeks (50-101 weeks) for individuals on PI/r. Viral failure was detected in four individuals treated with DTG and three individuals treated with PI/r, resulting in similar success rates of 96.7% and 97.5%, respectively. No new mutations were found among participants with treatment failure. DTG in combination with one to two NRTIs was as efficient as PI/r in individuals with pre-existing NRTI mutations in this setting. It may be considered an alternative to PI/r-based ART even in the presence of NRTI resistance.
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Affiliation(s)
- Erik Sörstedt
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, 413 90 Gothenburg, Sweden.
| | - Christina Carlander
- Department of Infectious Diseases, Hospital of Västmanland Västerås, 721 89 Västerås, Sweden
| | - Leo Flamholc
- Department of Infectious Diseases, Malmö University Hospital, 205 02 Malmö, Sweden
| | - Bo Hejdeman
- Department of Clinical Science and Education, Sodersjukhuset, Karolinska Institute, 141 86 Stockholm, Sweden; Unit of Infectious Diseases/Venhälsan, Södersjukhuset, SE-118 83 Stockholm, Sweden
| | - Veronica Svedhem
- Department of Infectious Diseases, Karolinska Institute, Karolinska University Hospital, 141 86 Stockholm, Sweden
| | - Anders Sönnerborg
- Department of Infectious Diseases, Karolinska Institute, Karolinska University Hospital, 141 86 Stockholm, Sweden; Department of Clinical Microbiology, Karolinska Institute, Karolinska University Hospital, 141 86 Stockholm, Sweden
| | - Magnus Gisslén
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, 413 90 Gothenburg, Sweden
| | - Aylin Yilmaz
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, 413 90 Gothenburg, Sweden
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18
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Development of an oral once-weekly drug delivery system for HIV antiretroviral therapy. Nat Commun 2018; 9:2. [PMID: 29317618 PMCID: PMC5760734 DOI: 10.1038/s41467-017-02294-6] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 11/16/2017] [Indexed: 01/07/2023] Open
Abstract
The efficacy of antiretroviral therapy is significantly compromised by medication non-adherence. Long-acting enteral systems that can ease the burden of daily adherence have not yet been developed. Here we describe an oral dosage form composed of distinct drug–polymer matrices which achieved week-long systemic drug levels of the antiretrovirals dolutegravir, rilpivirine and cabotegravir in a pig. Simulations of viral dynamics and patient adherence patterns indicate that such systems would significantly reduce therapeutic failures and epidemiological modelling suggests that using such an intervention prophylactically could avert hundreds of thousands of new HIV cases. In sum, weekly administration of long-acting antiretrovirals via a novel oral dosage form is a promising intervention to help control the HIV epidemic worldwide. Poor adherence to daily antiretrovirals can significantly affect treatment efficacy, but oral long-acting antiretrovirals are currently lacking. Here, the authors develop a once-weekly oral dosage form for anti-HIV drugs, assess its pharmacokinetics in pigs, and model its impact on viral resistance and disease epidemics.
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McCoy C, Badowski M, Sherman E, Crutchley R, Smith E, Chastain DB. Strength in Amalgamation: Newer Combination Agents for HIV and Implications for Practice. Pharmacotherapy 2017; 38:86-107. [PMID: 29105160 DOI: 10.1002/phar.2055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Antiretroviral (ART) therapy for the treatment of human immunodeficiency virus (HIV) infection has undergone significant changes over the past 30 years. Many single-tablet regimens (STRs), including newer fixed-dose combination (FDC) tablets, are available, offering patients several options for choosing a treatment regimen that works best for them. Given these changes, patients are more likely to adhere to treatment, achieve better clinical outcomes, and experience both fewer side effects and drug-drug interactions. Newer STRs include dolutegravir (DTG)/lamivudine (3TC)/abacavir (ABC) (Triumeq; Viiv Healthcare, Research Triangle Park, NC), rilpivirine (RPV)/emtricitabine (FTC)/tenofovir alafenamide (TAF) (Odefsey; Gilead, Foster City, CA), RPV/FTC/tenofovir disoproxil fumarate (TDF) (Complera; Gilead), elvitegravir (EVG)/cobicistat (COBI)/FTC/TDF (Stribild; Gilead), and EVG/COBI/FTC/TAF (Genvoya; Gilead). Recently approved FDCs, such as atazanavir (ATV)/COBI (Evotaz; Bristol-Myers Squibb, Princeton, NJ), darunavir (DRV)/COBI (Prezcobix; Janssen Products, Titusville NJ), and FTC/TAF (Descovy; Gilead), are also now available. The Department of Health and Human Services treatment guidelines for HIV recommend many of these integrase strand transfer inhibitor (INSTI) STRs as a preferred choice for initiation of treatment in both ART-naive and -experienced patients because they offer comparably faster rates of virologic suppression, reduced rates of resistance development (especially with DTG), and overall better adherence than protease inhibitors or NNRTIs. Numerous phase 3 clinical trials support these recommendations including several switch or simplification clinical trials. Notably, the novel pharmacokinetic booster COBI, with its water soluble properties, has enabled the development and coformulation of a few of these STRs and FDCs. Also, a newer tenofovir salt formulation, TAF, has an advantageous pharmacokinetic profile, contributing to better overall renal and bone tolerability compared with TDF. Further simplification regimens comprising dual ART therapies are currently being explored. This review provides an overview of the clinical efficacy and safety data for these coformulated agents, highlighting the relative impact on comparative adverse events, assessing the potential for experiencing fewer drug-drug interactions, and discussing the clinical implications regarding adherence to treatment.
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Affiliation(s)
- Christopher McCoy
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Melissa Badowski
- Department of Pharmacy Practice, University of Illinois at Chicago, College of Pharmacy, Chicago, Illinois
| | - Elizabeth Sherman
- Department of Pharmacy Practice, Nova Southeastern University, Fort Lauderdale, Florida
| | - Rustin Crutchley
- Department of Pharmacotherapy, Washington State University, College of Pharmacy, Yakima, Washington
| | - Ethan Smith
- Department of Pharmacy Services, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel B Chastain
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, Georgia
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Wijting I, Rokx C, Boucher C, van Kampen J, Pas S, de Vries-Sluijs T, Schurink C, Bax H, Derksen M, Andrinopoulou ER, van der Ende M, van Gorp E, Nouwen J, Verbon A, Bierman W, Rijnders B. Dolutegravir as maintenance monotherapy for HIV (DOMONO): a phase 2, randomised non-inferiority trial. Lancet HIV 2017; 4:e547-e554. [PMID: 29107562 DOI: 10.1016/s2352-3018(17)30152-2] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 07/19/2017] [Accepted: 07/21/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND The high genetic barrier to resistance of dolutegravir might allow for its use as maintenance monotherapy in patients with HIV. We investigated whether dolutegravir monotherapy was non-inferior to combination antiretroviral therapy (ART) for maintaining virological suppression in patients with HIV-1 infection successfully treated with combination ART. METHODS We did this open-label, phase 2, randomised non-inferiority trial at two medical centres in the Netherlands. Eligible patients (aged ≥18 years) were on combination ART, had been virologically suppressed (HIV RNA <50 copies per mL) for at least 6 months, and had CD4 nadirs of 200 cells per μL or higher, HIV RNA zeniths of 100 000 copies per mL or less, and no history of virological failure. Patients were randomly assigned (1:1), via a web-based block randomisation method (variable block sizes of 4 and 6), to switch to dolutegravir monotherapy (50 mg once a day) either immediately or after a delay of 24 weeks of continued combination ART. Randomisation was stratified by HIV RNA zenith (<50 000 copies per mL vs 50 000-99 999 copies per mL). Investigators and patients were not masked to group allocation. The primary endpoint was the proportion of patients with plasma HIV RNA viral loads of less than 200 copies per mL at week 24, with a non-inferiority margin of 12%. We did analyses in the on-treatment and intention-to-treat populations. This trial is registered with ClinicalTrials.gov, NCT02401828. FINDINGS Between March 10, 2015, and Feb 4, 2016, we randomly assigned 51 patients to the immediate switch group and 53 patients to the delayed switch group. One patient who received immediate monotherapy discontinued treatment at week 12 because of disturbed sleep. At week 24, dolutegravir monotherapy was non-inferior to combination ART, with plasma HIV RNA loads of 200 copies per mL or higher observed in 2% (1/50) of patients in the immediate switch group and in no patients in the delayed switch group (difference 2%, 95% CI -5 to 12). Of patients assigned to the delayed switch group, 47 (89%) switched to dolutegravir monotherapy at week 24, two (4%) of whom subsequently discontinued monotherapy because of headache (n=1) and disturbed sleep (n=1). Eight (8%) of the 95 patients who remained on dolutegravir monotherapy had virological failure; all had therapeutic plasma concentrations of dolutegravir. In three (38%) of the eight patients, mutations associated with resistance were detected in the integrase gene. According to a predefined stopping rule, detection of these mutations led to premature study discontinuation. INTERPRETATION Dolutegravir monotherapy was non-inferior to combination ART at 24 weeks. However, virological failure continued to occur thereafter and led to dolutegravir resistance. Dolutegravir should not be used as maintenance monotherapy. FUNDING Erasmus Trustfonds.
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Affiliation(s)
- Ingeborg Wijting
- Department of Internal Medicine and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Casper Rokx
- Department of Internal Medicine and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Charles Boucher
- Department of Viroscience, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Jeroen van Kampen
- Department of Viroscience, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Suzan Pas
- Department of Viroscience, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Theodora de Vries-Sluijs
- Department of Internal Medicine and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Carolina Schurink
- Department of Internal Medicine and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Hannelore Bax
- Department of Internal Medicine and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Maarten Derksen
- Department of Internal Medicine and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | | | - Marchina van der Ende
- Department of Internal Medicine and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Eric van Gorp
- Department of Internal Medicine and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Viroscience, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Jan Nouwen
- Department of Internal Medicine and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Annelies Verbon
- Department of Internal Medicine and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Wouter Bierman
- Department of Internal Medicine/Infectious Diseases, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Bart Rijnders
- Department of Internal Medicine and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, Netherlands.
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21
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Trevillyan JM, Hoy JF. Dolutegravir monotherapy as maintenance ART bites the dust. Lancet HIV 2017; 4:e531-e532. [PMID: 29107563 DOI: 10.1016/s2352-3018(17)30168-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 08/04/2017] [Indexed: 12/22/2022]
Affiliation(s)
- Janine M Trevillyan
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, VIC 3004, Australia; Clinical AIDS Research and Education Center, University of California Los Angeles, LA, USA
| | - Jennifer F Hoy
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, VIC 3004, Australia.
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Soriano V, Fernandez-Montero JV, Benitez-Gutierrez L, Mendoza CD, Arias A, Barreiro P, Peña JM, Labarga P. Dual antiretroviral therapy for HIV infection. Expert Opin Drug Saf 2017. [PMID: 28621159 DOI: 10.1080/14740338.2017.1343300] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION For two decades, triple combinations of antiretrovirals have been the standard treatment for HIV infection. The challenges of such lifelong therapy include long-term side effects, high costs and reduced drug adherence. The recent advent of more potent and safer antiretrovirals has renewed the interest for simpler HIV regimens. Areas covered: We discuss the pros and cons of dual antiretroviral therapies in both drug-naïve and in treatment-experienced patients with viral suppression (switch strategy). Expert opinion: Some dual antiretroviral regimens are safe and efficacious, particularly as maintenance therapy. At this time, combinations of dolutegravir plus rilpivirine represent the best dual regimen. Longer follow-up and larger study populations are needed before supporting dolutegravir plus lamivudine. In contrast, dual therapy based on maraviroc is less effective. Although dual regimens with boosted protease inhibitors plus either lamivudine or raltegravir may be effective, they are penalized by metabolic side effects and risk for drug interactions. The newest dual regimens could save money, reduce toxicity and spare drug options for the future. For the first time in HIV therapeutics, less can be more. Dual therapy switching has set up a new paradigm in HIV treatment that uses induction-maintenance.
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Affiliation(s)
- Vicente Soriano
- a Infectious Diseases Unit , La Paz University Hospital & Autonomous University , Madrid , Spain
| | | | | | - Carmen de Mendoza
- c Internal Medicine Department , Puerta de Hierro Research Institute , Majadahonda , Spain
| | - Ana Arias
- c Internal Medicine Department , Puerta de Hierro Research Institute , Majadahonda , Spain
| | - Pablo Barreiro
- a Infectious Diseases Unit , La Paz University Hospital & Autonomous University , Madrid , Spain
| | - José M Peña
- a Infectious Diseases Unit , La Paz University Hospital & Autonomous University , Madrid , Spain
| | - Pablo Labarga
- d Internal Medicine Department , Nuestra Señora de la Paz Hospital , Madrid , Spain
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The M184I/V and K65R nucleoside resistance mutations in HIV-1 prevent the emergence of resistance mutations against dolutegravir. AIDS 2016; 30:2267-73. [PMID: 27367488 DOI: 10.1097/qad.0000000000001191] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Recommended treatments for newly diagnosed HIV-positive individuals now focus on the integrase strand transfer inhibitors, raltegravir (RAL), elvitegravir (EVG) and dolutegravir (DTG). In treatment-naive individuals, cases of RAL-based and EVG-based virological failure, although rare, are associated with the occurrence of resistance mutations in integrase and/or reverse transcriptase coding sequences. In such cases, common resistance substitutions in reverse transcriptase that were associated with nucleos(t)ide reverse transcriptase inhibitors included M184I/V and K65R and these occurred together with various mutations in integrase. In some instances, these mutations in reverse transcriptase preceded the emergence of mutations in integrase. In contrast, no resistance substitutions in either integrase or reverse transcriptase have been observed to date in viruses isolated from treatment-naive individuals who experienced treatment failure with DTG-based regimens. DESIGN The objective of this study was to determine the effects of the M184I/V and K65R substitutions in reverse transcriptase on the ability of HIV-1 to become resistant against RAL, EVG or DTG. METHODS We performed tissue culture selection experiments using reverse transcriptase inhibitor-resistant viruses containing resistance substitutions at positions K65R, M184I or M184V in the presence of increasing concentrations of RAL, EVG or DTG and monitored changes in integrase sequences by genotyping. RESULTS Selections using EVG and RAL led to the emergence of resistance mutations in integrase. In contrast, only the wild-type virus was able to acquire resistance mutations for DTG. CONCLUSION Resistance mutations against nucleos(t)ide reverse transcriptase inhibitors antagonized the development of HIV-1 resistance against DTG but not RAL or EVG.
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Abstract
INTRODUCTION Since the last revision of both European and American guidelines (EACS and DHHS), new data from clinical trials and cohort studies, as well as experience in clinical practice, have prompted significant changes to the list of recommended/preferred options for the treatment of HIV infected patients, highlighted the role of INSTI-based regimens. Dolutegravir (DTG) in combination with abacavir/lamivudine (ABC/3TC) is one of these preferred regimens in multiple clinical scenarios, including treatment-naive and treatment-experienced patients. AREAS COVERED In this article we describe the coformulation of ABC/3TC/DTG in a fixed-dose combination (FDC) approved in September 2014 for the treatment of HIV infection. We focused our research on the efficacy and safety data resulting from phase 2 and 3 clinical study, particularly on the results of both SPRING (1 and 2) and SINGLE studies. EXPERT OPINION Triple combination therapy with ABC/3TC/DTG should be considered among the initial options for treatment-naive patients, being effective, well tolerated, with a high genetic barrier to resistance along with a convenient once-daily administration. In treatment-experienced patients the single-tablet regimen (STR) based on ABC/3TC/DTG could be used as simplification strategy in subjects with sustained viral suppression, as the high genetic barrier of DTG should ensure a safe switch from both NNRTI or PI based regimens.
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Affiliation(s)
- Laura Comi
- a USC Malattie Infettive , Azienda Ospedaliera Papa Giovanni XXIII Ringgold standard institution , Bergamo , Italy
| | - Franco Maggiolo
- a USC Malattie Infettive , Azienda Ospedaliera Papa Giovanni XXIII Ringgold standard institution , Bergamo , Italy
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Dolutegravir monotherapy as a simplified strategy in virologically suppressed HIV-1-infected patients: Table 1. J Antimicrob Chemother 2016; 71:2675-6. [DOI: 10.1093/jac/dkw154] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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