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Henegar C, Letang E, Wang R, Hicks C, Fox D, Jones B, de Ruiter A, Vannappagari V. A Comprehensive Literature Review of Treatment-Emergent Integrase Resistance with Dolutegravir-Based Regimens in Real-World Settings. Viruses 2023; 15:2426. [PMID: 38140667 PMCID: PMC10747437 DOI: 10.3390/v15122426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
After a decade of dolutegravir (DTG) use in various antiretroviral therapy combinations and in diverse populations globally, it is critical to identify HIV strains with reduced drug susceptibility and monitor emergent resistance in people living with HIV who experience virologic failure while on DTG-based regimens. We searched the PubMed, Embase, and Cochrane databases to identify studies that reported DTG resistance-associated mutations (RAMs) emerging under selection pressure. Our review showed that RAMs conferring resistance to DTG were rare in 2-drug and 3-drug regimens used in real-world cohorts, corroborating data from clinical trials. The potency of DTG in maintaining virologic suppression was demonstrated, even in cases of pre-existing resistance to companion drugs in the regimen. Estimates of DTG RAMs depended on the population and certain risk factors, including monotherapy, baseline resistance or lack of genotypic testing, treatment history and prior virologic failure, and suboptimal treatment adherence. The RAMs detected after virologic failure, often in heavily treatment-experienced individuals with prior exposure to integrase strand transfer inhibitors, were G118R, E138K, G140A/C/R/S, Q148H/K/R, N155H, and R263K. Overall, these data highlight the durable effectiveness and high barrier to resistance of DTG as part of combination antiretroviral therapy in a wide variety of settings.
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Affiliation(s)
- Cassidy Henegar
- ViiV Healthcare, 406 Blackwell Street, Suite 300, Durham, NC 27701, USA; (R.W.); (C.H.); (D.F.); (V.V.)
| | - Emilio Letang
- ViiV Healthcare, P.T.M., Severo Ochoa 2, 28760 Tres Cantos, Madrid, Spain
| | - Ruolan Wang
- ViiV Healthcare, 406 Blackwell Street, Suite 300, Durham, NC 27701, USA; (R.W.); (C.H.); (D.F.); (V.V.)
| | - Charles Hicks
- ViiV Healthcare, 406 Blackwell Street, Suite 300, Durham, NC 27701, USA; (R.W.); (C.H.); (D.F.); (V.V.)
| | - Dainielle Fox
- ViiV Healthcare, 406 Blackwell Street, Suite 300, Durham, NC 27701, USA; (R.W.); (C.H.); (D.F.); (V.V.)
| | - Bryn Jones
- ViiV Healthcare, 980 Great West Road, Brentford TW8 9GS, Middlesex, UK
| | | | - Vani Vannappagari
- ViiV Healthcare, 406 Blackwell Street, Suite 300, Durham, NC 27701, USA; (R.W.); (C.H.); (D.F.); (V.V.)
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Integrase Inhibitor Resistance Mechanisms and Structural Characteristics in Antiretroviral Therapy-Experienced, Integrase Inhibitor-Naive Adults with HIV-1 Infection Treated with Dolutegravir plus Two Nucleoside Reverse Transcriptase Inhibitors in the DAWNING Study. Antimicrob Agents Chemother 2022; 66:e0164321. [PMID: 34694877 PMCID: PMC8765460 DOI: 10.1128/aac.01643-21] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
At week 48 in the phase IIIb DAWNING study, the integrase strand transfer inhibitor (INSTI) dolutegravir plus 2 nucleoside reverse transcriptase inhibitors demonstrated superiority to ritonavir-boosted lopinavir in achieving virologic suppression in adults with HIV-1 who failed first-line therapy. Here, we report emergent HIV-1 drug resistance and mechanistic underpinnings among dolutegravir-treated adults in DAWNING. Population viral genotyping, phenotyping, and clonal analyses were performed on participants meeting confirmed virologic withdrawal (CVW) criteria on dolutegravir-containing regimens. Dolutegravir binding to and structural changes in HIV-1 integrase-DNA complexes with INSTI resistance-associated substitutions were evaluated. Of participants who received dolutegravir through week 48 plus an additional 110 weeks for this assessment, 6 met CVW criteria with treatment-emergent INSTI resistance-associated substitutions and 1 had R263R/K at baseline but not at CVW. All 7 achieved HIV-1 RNA levels of <400 copies/mL (5 achieved <50 copies/mL) before CVW. Treatment-emergent G118R was detected in 5 participants, occurring with ≥2 other integrase substitutions, including R263R/K, in 3 participants and without other integrase substitutions in 2 participants. G118R or R263K increased the rate of dolutegravir dissociation from integrase-DNA complexes versus wild-type but retained prolonged binding. Overall, among treatment-experienced adults who received dolutegravir in DAWNING, 6 of 314 participants developed treatment-emergent INSTI resistance-associated substitutions, with a change in in vitro dolutegravir resistance of >10-fold and reduced viral replication capacity versus baseline levels. This study demonstrates that the pathway to dolutegravir resistance is a challenging balance between HIV-1 phenotypic change and associated loss of viral fitness. (This study has been registered at ClinicalTrials.gov under identifier NCT02227238.).
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Engone-Ondo JD, Bignoumba M, Boundzanga Moussavou P, Gafou A, Diane A, Yangawagou LM, Kassa Kassa RF, Onanga R, Mouinga-Ondémé A, Aghokeng AF. OUP accepted manuscript. J Antimicrob Chemother 2022; 77:2035-2037. [PMID: 35474382 PMCID: PMC9244210 DOI: 10.1093/jac/dkac134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jéordy D Engone-Ondo
- Unité des infections rétrovirales et pathologies associées, Centre International de Recherches Médicales de Franceville (CIRMF), Franceville, Gabon
| | - Michelle Bignoumba
- Unité de recherche et d’Analyses Médicales, Laboratoire de Bactériologie, Centre International de Recherches Médicales de Franceville, Franceville, Gabon
| | - Pamela Boundzanga Moussavou
- Unité des infections rétrovirales et pathologies associées, Centre International de Recherches Médicales de Franceville (CIRMF), Franceville, Gabon
- Unité Mixte de Recherche sur le VIH et les Maladies Infectieuses Associées, (CIRMF-SSM), Libreville, Gabon
| | - Amahani Gafou
- Unité de recherche et d’Analyses Médicales, Laboratoire de Bactériologie, Centre International de Recherches Médicales de Franceville, Franceville, Gabon
| | - Abdoulaye Diane
- Unité des infections rétrovirales et pathologies associées, Centre International de Recherches Médicales de Franceville (CIRMF), Franceville, Gabon
| | | | - Roland Fabrice Kassa Kassa
- Unité de recherche et d’Analyses Médicales, Laboratoire de Bactériologie, Centre International de Recherches Médicales de Franceville, Franceville, Gabon
| | - Richard Onanga
- Unité de recherche et d’Analyses Médicales, Laboratoire de Bactériologie, Centre International de Recherches Médicales de Franceville, Franceville, Gabon
| | - Augustin Mouinga-Ondémé
- Unité des infections rétrovirales et pathologies associées, Centre International de Recherches Médicales de Franceville (CIRMF), Franceville, Gabon
- Unité Mixte de Recherche sur le VIH et les Maladies Infectieuses Associées, (CIRMF-SSM), Libreville, Gabon
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Tebano G, Soulié C, Schneider L, Blanc C, Agher R, Seang S, Valantin MA, Palich R, Tubiana R, Peytavin G, Marcelin AG, Assoumou L, Katlama C. Long-term follow-up of HIV-infected patients on dolutegravir monotherapy. J Antimicrob Chemother 2021; 75:675-680. [PMID: 31800056 DOI: 10.1093/jac/dkz478] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/06/2019] [Accepted: 10/21/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In recent years, dolutegravir monotherapy has been explored as a drug-reduced regimen for HIV patients. METHODS This was a retrospective observational study, including patients virologically suppressed for ≥6 months, without previous virological failure (VF) under integrase inhibitors (INIs), who had been switched to dolutegravir monotherapy (50 mg/day). The primary aim was to report the proportion of VF at week 48 (W48) and week 96 (W96) of dolutegravir monotherapy. The evolution from baseline to W48 of residual viraemia on ultra-deep sequencing and HIV DNA was also evaluated. RESULTS Sixty-one patients were included. Prior to switching to dolutegravir monotherapy, they had a median (IQR) of 15.4 (6.5-19.9) years of antiretroviral exposure, 5.8 (3.2-10.3) years of viral suppression and 687 (461-848) CD4+ cells/mm3. They remained on dolutegravir monotherapy for a median (IQR) of 100 (29-148) weeks. Forty-two out of 61 patients (68.9%) reached W48 and 32 out of 61 patients (52.5%) reached W96. VF occurred in three patients, with the emergence of INI resistance. VF occurred before W24 and in patients pre-exposed to INIs. At W48, the probability of VF (Kaplan-Meier analysis) was 5.6% (95% CI = 1.8%-16.4%). The same result was obtained at W96. Detectable residual viraemia did not increase and median HIV DNA did not change significantly (2.4 log/106 cells at baseline and 2.3 log/106 cells at W48). Dolutegravir plasma concentration was above the IC90 in 41/41 samples, from 22 patients. CONCLUSIONS Long-term follow-up showed a low risk of VF under dolutegravir monotherapy, in a selected population of patients with previous long-term virological suppression and low HIV reservoir.
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Affiliation(s)
- G Tebano
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP); AP-HP, Pitié Salpêtrière Hospital, Department of Infectious Diseases, F-75013 Paris, France
| | - C Soulié
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP); AP-HP, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, Laboratoire de Virologie, F75013 Paris, France
| | - L Schneider
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP); AP-HP, Pitié Salpêtrière Hospital, Department of Infectious Diseases, F-75013 Paris, France
| | - C Blanc
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP); AP-HP, Pitié Salpêtrière Hospital, Department of Infectious Diseases, F-75013 Paris, France
| | - R Agher
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP); AP-HP, Pitié Salpêtrière Hospital, Department of Infectious Diseases, F-75013 Paris, France
| | - S Seang
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP); AP-HP, Pitié Salpêtrière Hospital, Department of Infectious Diseases, F-75013 Paris, France
| | - M A Valantin
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP); AP-HP, Pitié Salpêtrière Hospital, Department of Infectious Diseases, F-75013 Paris, France
| | - R Palich
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP); AP-HP, Pitié Salpêtrière Hospital, Department of Infectious Diseases, F-75013 Paris, France
| | - R Tubiana
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP); AP-HP, Pitié Salpêtrière Hospital, Department of Infectious Diseases, F-75013 Paris, France
| | - G Peytavin
- AP-HP, Hôpital Bichat-Claude Bernard, Laboratoire de Pharmacologie-Toxicologie; IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité and INSERM, Paris, France
| | - A G Marcelin
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP); AP-HP, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, Laboratoire de Virologie, F75013 Paris, France
| | - L Assoumou
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), F-75013 Paris, France
| | - C Katlama
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP); AP-HP, Pitié Salpêtrière Hospital, Department of Infectious Diseases, F-75013 Paris, France
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Ndashimye E, Arts EJ. Dolutegravir response in antiretroviral therapy naïve and experienced patients with M184V/I: Impact in low-and middle-income settings. Int J Infect Dis 2021; 105:298-303. [PMID: 33722682 DOI: 10.1016/j.ijid.2021.03.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/05/2021] [Accepted: 03/07/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Dolutegravir (DTG) is now recommended to all HIV infected adults, adolescents, and children of right age by WHO. The low cost of $75 per year for generic DTG-based combination, has allowed 3.9 million people living with HIV (PLWH) in low and middle-income countries (LMICs) access to DTG. Lamivudine and emtricitabine associated M184V/I mutation is highly prevalent in PLWH and the majority of HIV infected individuals receiving DTG regimens may already be carrying M184V/I mutation. DISCUSSION Despite high prevalence of M184V/I in antiretroviral therapy (ART) experienced patients, DTG treatment outcomes will likely not be adversely affected by this mutation. The use of DTG in ART naïve has been largely characterised by rare emergence of resistance and virological failure. DTG-based regimens have to great extent been effective at maintaining viral suppression in treatment experienced PLWH carrying M184V/I. CONCLUSIONS Initiating patients on DTG may help preserve more treatment options for HIV infected individuals living in LMICs. High genetic barrier to the development of resistance associated with DTG and progressive viral suppression in patients switched to DTG-based therapy with M184V/I, may encourage better DTG outcomes and help in curbing increasing levels of HIV drug resistance in LMICs.
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Affiliation(s)
- Emmanuel Ndashimye
- Department of Microbiology and Immunology, Western University, London, Canada; Joint Clinical Research Centre, Center for AIDS Research Uganda Laboratories, Kampala, Uganda.
| | - Eric J Arts
- Department of Microbiology and Immunology, Western University, London, Canada.
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6
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Mulato A, Acosta R, Chang S, Martin R, Yant SR, Cihlar T, White K. Simulating HIV Breakthrough and Resistance Development During Variable Adherence to Antiretroviral Treatment. J Acquir Immune Defic Syndr 2021; 86:369-377. [PMID: 33196554 DOI: 10.1097/qai.0000000000002562] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/26/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Barriers to lifelong HIV-1 suppression by antiretrovirals include poor adherence and drug resistance; regimens with higher tolerance to missed doses (forgiveness) would be beneficial to patients. To model short-term nonadherence, in vitro experiments monitoring viral breakthrough (VB) and resistance development were conducted. METHODS HIV breakthrough experiments simulated drug exposures at full adherence or suboptimal adherence to bictegravir+emtricitabine+tenofovir alafenamide (BIC+FTC+TAF) or dolutegravir + lamivudine (DTG+3TC). MT-2 cells were infected with wild-type or low frequency M184V HIV-1, exposed to drug combinations, monitored for VB, and rebound virus was deep sequenced. Drug concentrations were determined using human plasma-free adjusted clinical trough concentrations (Cmin), at simulated Cmin after missing 1 to 3 consecutive doses (Cmin - 1 or Cmin - 2, and Cmin - 3) based on drug or active metabolite half-lives. RESULTS Cultures infected with wild-type or low frequency M184V HIV-1 showed no VB with BIC+FTC+TAF at drug concentrations corresponding to Cmin, Cmin - 1, or Cmin - 2 but breakthrough did occur in 26 of 36 cultures at Cmin - 3, where the M184V variant emerged in one culture. Experiments using DTG + 3TC prevented most breakthrough at Cmin concentrations (9/60 had breakthrough) but showed more breakthroughs as drug concentrations decreased (up to 36/36) and variants associated with resistance to both drugs emerged in some cases. CONCLUSIONS These in vitro VB results suggest that the high potency, long half-lives, and antiviral synergy provided by the BIC/FTC/TAF triple therapy regimen may protect from viral rebound and resistance development after short-term lapses in drug adherence.
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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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Smith SJ, Zhao XZ, Passos DO, Lyumkis D, Burke TR, Hughes SH. Integrase Strand Transfer Inhibitors Are Effective Anti-HIV Drugs. Viruses 2021; 13:v13020205. [PMID: 33572956 PMCID: PMC7912079 DOI: 10.3390/v13020205] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/20/2021] [Accepted: 01/25/2021] [Indexed: 12/12/2022] Open
Abstract
Integrase strand transfer inhibitors (INSTIs) are currently recommended for the first line treatment of human immunodeficiency virus type one (HIV-1) infection. The first-generation INSTIs are effective but can select for resistant viruses. Recent advances have led to several potent second-generation INSTIs that are effective against both wild-type (WT) HIV-1 integrase and many of the first-generation INSTI-resistant mutants. The emergence of resistance to these new second-generation INSTIs has been minimal, which has resulted in alternative treatment strategies for HIV-1 patients. Moreover, because of their high antiviral potencies and, in some cases, their bioavailability profiles, INSTIs will probably have prominent roles in pre-exposure prophylaxis (PrEP). Herein, we review the current state of the clinically relevant INSTIs and discuss the future outlook for this class of antiretrovirals.
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Affiliation(s)
- Steven J. Smith
- HIV Dynamics and Replication Program, Center for Cancer Research, National Cancer Institute, Frederick, MD 21702, USA;
| | - Xue Zhi Zhao
- Chemical Biology Laboratory, Center for Cancer Research, National Cancer Institute, Frederick, MD 21702, USA; (X.Z.Z.); (T.R.B.J.)
| | - Dario Oliveira Passos
- Laboratory of Genetics, The Salk Institute for Biological Studies, La Jolla, CA 92037, USA; (D.O.P.); (D.L.)
| | - Dmitry Lyumkis
- Laboratory of Genetics, The Salk Institute for Biological Studies, La Jolla, CA 92037, USA; (D.O.P.); (D.L.)
- Department of Integrative Structural and Computational Biology, The Scripps Research Institute, La Jolla, CA 92037, USA
| | - Terrence R. Burke
- Chemical Biology Laboratory, Center for Cancer Research, National Cancer Institute, Frederick, MD 21702, USA; (X.Z.Z.); (T.R.B.J.)
| | - Stephen H. Hughes
- HIV Dynamics and Replication Program, Center for Cancer Research, National Cancer Institute, Frederick, MD 21702, USA;
- Correspondence:
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Andreatta K, Willkom M, Martin R, Chang S, Wei L, Liu H, Liu YP, Graham H, Quirk E, Martin H, White KL. Switching to bictegravir/emtricitabine/tenofovir alafenamide maintained HIV-1 RNA suppression in participants with archived antiretroviral resistance including M184V/I. J Antimicrob Chemother 2020; 74:3555-3564. [PMID: 31430369 PMCID: PMC6857193 DOI: 10.1093/jac/dkz347] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 06/01/2019] [Accepted: 07/16/2019] [Indexed: 12/12/2022] Open
Abstract
Objectives Studies 1878 and 1844 demonstrated non-inferior efficacy of switching suppressed HIV-1-infected adults to bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) versus continuing boosted PI-based triple regimens or dolutegravir/abacavir/lamivudine (DTG/ABC/3TC). Here, detailed analyses of pre-existing resistance in the two BIC/FTC/TAF switch studies and efficacy at week 48 are described. Methods Pre-existing resistance was assessed from historical genotypes (documented resistance to study drugs was excluded) and by retrospective baseline proviral archive DNA genotyping from whole blood. Outcomes were based on HIV-1 RNA at week 48 with missing values imputed using the last on-treatment observation carried forward method. Results Cumulative pre-existing resistance data from historical and proviral genotypes were obtained for 95% (543/570) of participants who switched to BIC/FTC/TAF. Altogether, 40% (217/543) had one or more pre-existing primary resistance substitutions in protease, reverse transcriptase and/or integrase. Pre-switch NRTI resistance was detected in 16% (89/543) of BIC/FTC/TAF-treated participants, with M184V or M184I detected by proviral genotyping in 10% (54/543). At week 48, 98% (561/570) of all BIC/FTC/TAF-treated participants versus 98% (213/217) with pre-existing resistance and 96% (52/54) with archived M184V/I had HIV-1 RNA <50 copies/mL. No BIC/FTC/TAF-treated participants developed treatment-emergent resistance to study drugs. Conclusions Pre-existing resistance substitutions, notably M184V/I, were unexpectedly common among suppressed participants who switched to BIC/FTC/TAF. High rates of virological suppression were maintained in the overall study population and in those with pre-existing resistance, including M184V/I, for up to 48 weeks of BIC/FTC/TAF treatment with no resistance development. These results indicate that BIC/FTC/TAF is an effective treatment option for suppressed patients, including those with evidence of archived NRTI resistance.
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Affiliation(s)
- Kristen Andreatta
- Gilead Sciences, Inc., 333 Lakeside Drive, Foster City, CA 94404, USA
| | - Madeleine Willkom
- Gilead Sciences, Inc., 333 Lakeside Drive, Foster City, CA 94404, USA
| | - Ross Martin
- Gilead Sciences, Inc., 333 Lakeside Drive, Foster City, CA 94404, USA
| | - Silvia Chang
- Gilead Sciences, Inc., 333 Lakeside Drive, Foster City, CA 94404, USA
| | - Lilian Wei
- Gilead Sciences, Inc., 333 Lakeside Drive, Foster City, CA 94404, USA
| | - Hui Liu
- Gilead Sciences, Inc., 333 Lakeside Drive, Foster City, CA 94404, USA
| | - Ya-Pei Liu
- Gilead Sciences, Inc., 333 Lakeside Drive, Foster City, CA 94404, USA
| | - Hiba Graham
- Gilead Sciences, Inc., 333 Lakeside Drive, Foster City, CA 94404, USA
| | - Erin Quirk
- Gilead Sciences, Inc., 333 Lakeside Drive, Foster City, CA 94404, USA
| | - Hal Martin
- Gilead Sciences, Inc., 333 Lakeside Drive, Foster City, CA 94404, USA
| | - Kirsten L White
- Gilead Sciences, Inc., 333 Lakeside Drive, Foster City, CA 94404, USA
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10
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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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11
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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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12
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Kirichenko A, Lapovok I, Baryshev P, van de Vijver DAMC, van Kampen JJA, Boucher CAB, Paraskevis D, Kireev D. Genetic Features of HIV-1 Integrase Sub-Subtype A6 Predominant in Russia and Predicted Susceptibility to INSTIs. Viruses 2020; 12:v12080838. [PMID: 32752001 PMCID: PMC7472261 DOI: 10.3390/v12080838] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/29/2020] [Accepted: 07/29/2020] [Indexed: 02/07/2023] Open
Abstract
The increasing use of the integrase strand transfer inhibitor (INSTI) class for the treatment of HIV-infection has pointed to the importance of analyzing the features of HIV-1 subtypes for an improved understanding of viral genetic variability in the occurrence of drug resistance (DR). In this study, we have described the prevalence of INSTI DR in a Russian cohort and the genetic features of HIV-1 integrase sub-subtype A6. We included 408 HIV infected patients who were not exposed to INSTI. Drug resistance mutations (DRMs) were detected among 1.3% of ART-naïve patients and among 2.7% of INSTI-naïve patients. The prevalence of 12 polymorphic mutations was significantly different between sub-subtypes A6 and A1. Analysis of the genetic barriers determined two positions in which subtype A (A1 and A6) showed a higher genetic barrier (G140C and V151I) compared with subtype B, and one position in which subtypes A1 and B displayed a higher genetic barrier (L74M and L74I) than sub-subtype A6. Additionally, we confirmed that the L74I mutation was selected at the early stage of the epidemic and subsequently spread as a founder effect in Russia. Our data have added to the overall understanding of the genetic features of sub-subtype A6 in the context of drug resistance.
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Affiliation(s)
- Alina Kirichenko
- Central Research Institute of Epidemiology, 111123 Moscow, Russia; (I.L.); (P.B.); (D.K.)
- Correspondence:
| | - Ilya Lapovok
- Central Research Institute of Epidemiology, 111123 Moscow, Russia; (I.L.); (P.B.); (D.K.)
| | - Pavel Baryshev
- Central Research Institute of Epidemiology, 111123 Moscow, Russia; (I.L.); (P.B.); (D.K.)
| | - David A. M. C. van de Vijver
- Viroscience Department, Erasmus Medical Centre, 3015 CE Rotterdam, The Netherlands; (D.A.M.C.v.d.V.); (J.J.A.v.K.); (C.A.B.B.)
| | - Jeroen J. A. van Kampen
- Viroscience Department, Erasmus Medical Centre, 3015 CE Rotterdam, The Netherlands; (D.A.M.C.v.d.V.); (J.J.A.v.K.); (C.A.B.B.)
| | - Charles A. B. Boucher
- Viroscience Department, Erasmus Medical Centre, 3015 CE Rotterdam, The Netherlands; (D.A.M.C.v.d.V.); (J.J.A.v.K.); (C.A.B.B.)
| | - Dimitrios Paraskevis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 11527 Goudi, Athens, Greece;
| | - Dmitry Kireev
- Central Research Institute of Epidemiology, 111123 Moscow, Russia; (I.L.); (P.B.); (D.K.)
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13
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Metsu D, Lanot T, Fraissinet F, Concordet D, Gayrard V, Averseng M, Ressault A, Martin-Blondel G, Levade T, Février F, Chatelut E, Delobel P, Gandia P. Comparing ultrafiltration and equilibrium dialysis to measure unbound plasma dolutegravir concentrations based on a design of experiment approach. Sci Rep 2020; 10:12265. [PMID: 32703975 PMCID: PMC7378073 DOI: 10.1038/s41598-020-69102-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 06/30/2020] [Indexed: 11/30/2022] Open
Abstract
Dolutegravir therapeutic drug monitoring (TDM) could be improved by measuring the unbound dolutegravir plasma concentration (Cu), particularly in patients experiencing virological failure or toxicity despite achieving appropriate DTG total plasma concentrations. Equilibrium dialysis (ED) is the gold standard to measure Cu, but ED is time consuming, precluding its use in clinical practice. In contrast, ultrafiltration is applicable to TDM, but is sensitive to numerous analytical conditions. In order to evaluate measurements of Cu by ultrafiltration, ultrafiltration conditions were validated by comparison with ED. DTG concentrations were measured by LC–MS/MS. Three ultrafiltration factors (temperature, duration and relative centrifugal force [RCF]) were evaluated and compared to ED (25/37 °C), using a design of experiment strategy. Temperature was found to influence Cu results by ED (p = 0.036) and UF (p = 0.002) when results were analysed with ANOVA. Relative centrifugal force (2000 g) and time (20 min) interacted to influence Cu (p = 0.006), while individually they did not influence Cu (p = 0.88 and p = 0.42 for RCF and time). Ultrafiltration conditions which yielded the most comparable results to ED were 37 °C, 1000 g for 20 min. Ultrafiltration results greatly depended on analytical conditions, confirming the need to validate the method by comparison with ED in order to correctly interpret DTG Cu.
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Affiliation(s)
- David Metsu
- Department of Pharmacokinetics and Toxicology, Toulouse University Hospital, Toulouse, France.,INSERM, CRCT, Toulouse University, UPS, Toulouse, France
| | - Thomas Lanot
- Department of Pharmacokinetics and Toxicology, Toulouse University Hospital, Toulouse, France
| | - François Fraissinet
- Department of Pharmacokinetics and Toxicology, Toulouse University Hospital, Toulouse, France
| | | | | | - Manon Averseng
- Department of Pharmacokinetics and Toxicology, Toulouse University Hospital, Toulouse, France
| | - Alice Ressault
- Department of Pharmacokinetics and Toxicology, Toulouse University Hospital, Toulouse, France
| | - Guillaume Martin-Blondel
- Department of Infectious Diseases, University Hospital of Toulouse, Toulouse, France.,Inserm U1043 - CNRS UMR 5282, Toulouse-Purpan Pathophysiology Center, 31173, Toulouse Cedex, France
| | - Thierry Levade
- Department of Biochemistry, Toulouse University Hospital, Toulouse, France.,INSERM UMR1037, CRCT (Cancer Research Centre of Toulouse), Toulouse University, UPS, Toulouse, France
| | - Frédéric Février
- Department of Laboratory Medicine, GCS Ingres-Quercy, Montauban Hospital, Montauban, France
| | - Etienne Chatelut
- INSERM, CRCT, Toulouse University, UPS, Toulouse, France.,Institut Claudius-Regaud, IUCT-Oncopole, Toulouse, France
| | - Pierre Delobel
- Department of Infectious Diseases, University Hospital of Toulouse, Toulouse, France.,Inserm U1043 - CNRS UMR 5282, Toulouse-Purpan Pathophysiology Center, 31173, Toulouse Cedex, France
| | - Peggy Gandia
- Department of Pharmacokinetics and Toxicology, Toulouse University Hospital, Toulouse, France. .,INTHERES, INRA, ENVT, Toulouse University, Toulouse, France. .,Laboratoire de Pharmacocinétique Et Toxicologie (Pharmacokinetics and Toxicology Laboratory), Centre Hospitalo-Universitaire Purpan (Purpan University Medical Centre), 330 avenue de Grande-Bretagne, 31059, Toulouse, France.
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14
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Charpentier C, Peytavin G, Lê MP, Joly V, Cabras O, Perrier M, Le Gac S, Phung B, Yazdanpanah Y, Descamps D, Landman R. High virological suppression regardless of the genotypic susceptibility score after switching to a dolutegravir-based regimen: week 48 results in an observational cohort. J Antimicrob Chemother 2019. [PMID: 29528412 DOI: 10.1093/jac/dky062] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objectives To assess, in a clinical cohort, the efficacy of switching current ART in virologically suppressed patients to a dolutegravir-based regimen, regardless of the genotypic susceptibility score (GSS). Patients and methods This was an observational single-centre study assessing ART-treated patients with plasma viral load (pVL) <50 copies/mL who were switched to a dolutegravir-based regimen with 1 year of follow-up. PCR negative was defined as an undetected PCR signal. Trough plasma concentration (C24) was determined using UPLC-MS/MS. Results Two hundred and thirty-nine patients initiated a dolutegravir-based regimen: 12%, 29% and 59% had a total GSS of 1 or 1.5 (group 1), 2 or 2.5 (group 2) and 3 (group 3), respectively. At switch initiation, the median time since first ART and the median duration with pVL <50 copies/mL were 13 years (IQR = 6-19) and 3 years (IQR = 1-6), respectively. Median times since last genotype were 9, 10 and 5 years for groups 1, 2 and 3, respectively. Twenty patients (8.4%) discontinued the dolutegravir-based regimen due to adverse events. During the study, 96.4% (n = 661/686) of all pVL were <50 copies/mL. Four patients (1.7%) experienced virological failure (two pVL >50 copies/mL) without emergence of resistance; these patients' GSSs were 2, 2.5, 3 and 3. The median dolutegravir C24 was 1545 ng/mL (IQR = 1150-2097). Of the patients with pVL <20 copies/mL, 72% were PCR negative during the follow-up, with no difference between the three groups of patients. Conclusions This observational cohort study showed a high level of virological suppression maintenance in the first year following the switch to a dolutegravir-based regimen, even in patients with GSS ≤2.
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Affiliation(s)
- Charlotte Charpentier
- IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, AP-HP, Laboratoire de Virologie, Hôpital Bichat, AP-HP, Paris, France
| | - Gilles Peytavin
- IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, AP-HP, Laboratoire de Pharmacologie-Toxicologie, Hôpital Bichat, AP-HP, Paris, France
| | - Minh P Lê
- IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, AP-HP, Laboratoire de Pharmacologie-Toxicologie, Hôpital Bichat, AP-HP, Paris, France
| | - Véronique Joly
- IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, AP-HP, Service de Maladies Infectieuses et Tropicales, Hôpital Bichat, AP-HP, Paris, France
| | - Ornella Cabras
- AP-HP, Hôpital Bichat-Claude Bernard, Service de Maladies Infectieuses et Tropicales, 75018 Paris, France
| | - Marine Perrier
- IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, AP-HP, Laboratoire de Virologie, Hôpital Bichat, AP-HP, Paris, France
| | - Sylvie Le Gac
- AP-HP, Hôpital Bichat-Claude Bernard, Service de Maladies Infectieuses et Tropicales, 75018 Paris, France
| | - Bao Phung
- AP-HP, Hôpital Bichat-Claude Bernard, Service de Maladies Infectieuses et Tropicales, 75018 Paris, France
| | - Yazdan Yazdanpanah
- IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, AP-HP, Service de Maladies Infectieuses et Tropicales, Hôpital Bichat, AP-HP, Paris, France
| | - Diane Descamps
- IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, AP-HP, Laboratoire de Virologie, Hôpital Bichat, AP-HP, Paris, France
| | - Roland Landman
- IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, AP-HP, Service de Maladies Infectieuses et Tropicales, Hôpital Bichat, AP-HP, Paris, France
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15
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Pham HT, Labrie L, Wijting IEA, Hassounah S, Lok KY, Portna I, Goring ME, Han Y, Lungu C, van der Ende ME, Brenner BG, Boucher CA, Rijnders BJA, van Kampen JJA, Mesplède T, Wainberg MA. The S230R Integrase Substitution Associated With Virus Load Rebound During Dolutegravir Monotherapy Confers Low-Level Resistance to Integrase Strand-Transfer Inhibitors. J Infect Dis 2019; 218:698-706. [PMID: 29617824 DOI: 10.1093/infdis/jiy175] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 03/27/2018] [Indexed: 01/24/2023] Open
Abstract
Background Dolutegravir (DTG) is an integrase strand-transfer inhibitor (INSTI) used for treatment of human immunodeficiency virus (HIV)-infected individuals. Owing to its high genetic barrier to resistance, DTG has been clinically investigated as maintenance monotherapy to maintain viral suppression and to reduce complication and healthcare costs. Our study aims to explain the underlying mechanism related to the emergence of a S230R substitution in patients who experienced virologic failure while using DTG monotherapy. Methods We evaluated the effect of the S230R substitution in regard to integrase enzyme activity, viral infectivity, replicative capacity, and susceptibility to different INSTIs by biochemical and cell-based assays. Results The S230R substitution conferred a 63% reduction in enzyme efficiency. S230R virus was 1.29-fold less infectious than wild-type virus but could replicate in PM1 cells without significant delay. Resistance levels against DTG, cabotegravir, raltegravir, and elvitegravir in tissue culture were 3.85-, 3.72-, 1.52-, and 1.21-fold, respectively, in virus with the S230R substitution. Conclusions Our data indicate that the S230R substitution is comparable to the previously reported R263K substitution in some respects. Virologic failure during DTG monotherapy can occur through the development of the S230R or R263K mutation, without the need for high-level DTG resistance.
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Affiliation(s)
- Hanh T Pham
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.,Department of Microbiology and Immunology, McGill University, Montreal, Canada
| | - Lydia Labrie
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.,Department of Microbiology and Immunology, McGill University, Montreal, Canada
| | - Ingeborg E A Wijting
- Department of Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, Netherlands
| | - Said Hassounah
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.,Division of Experimental Medicine, Faculty of Medicine, McGill University, Montreal, Canada
| | - Ka Yee Lok
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | - Inna Portna
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.,Department of Microbiology and Immunology, McGill University, Montreal, Canada
| | - Mark E Goring
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.,Division of Experimental Medicine, Faculty of Medicine, McGill University, Montreal, Canada
| | - Yingshan Han
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | - Cynthia Lungu
- Department of Viroscience, Erasmus University, Rotterdam, Netherlands
| | - Marchina E van der Ende
- Department of Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, Netherlands
| | - Bluma G Brenner
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.,Faculty of Surgery, McGill University, Montreal, Canada
| | - Charles A Boucher
- Department of Viroscience, Erasmus University, Rotterdam, Netherlands
| | - Bart J A Rijnders
- Department of Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, Netherlands
| | | | - Thibault Mesplède
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.,Department of Microbiology and Immunology, McGill University, Montreal, Canada.,Division of Experimental Medicine, Faculty of Medicine, McGill University, Montreal, Canada
| | - Mark A Wainberg
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.,Department of Microbiology and Immunology, McGill University, Montreal, Canada.,Division of Experimental Medicine, Faculty of Medicine, McGill University, Montreal, Canada
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16
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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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17
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Engelman AN. Multifaceted HIV integrase functionalities and therapeutic strategies for their inhibition. J Biol Chem 2019; 294:15137-15157. [PMID: 31467082 DOI: 10.1074/jbc.rev119.006901] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Antiretroviral inhibitors that are used to manage HIV infection/AIDS predominantly target three enzymes required for virus replication: reverse transcriptase, protease, and integrase. Although integrase inhibitors were the last among this group to be approved for treating people living with HIV, they have since risen to the forefront of treatment options. Integrase strand transfer inhibitors (INSTIs) are now recommended components of frontline and drug-switch antiretroviral therapy formulations. Integrase catalyzes two successive magnesium-dependent polynucleotidyl transferase reactions, 3' processing and strand transfer, and INSTIs tightly bind the divalent metal ions and viral DNA end after 3' processing, displacing from the integrase active site the DNA 3'-hydroxyl group that is required for strand transfer activity. Although second-generation INSTIs present higher barriers to the development of viral drug resistance than first-generation compounds, the mechanisms underlying these superior barrier profiles are incompletely understood. A separate class of HIV-1 integrase inhibitors, the allosteric integrase inhibitors (ALLINIs), engage integrase distal from the enzyme active site, namely at the binding site for the cellular cofactor lens epithelium-derived growth factor (LEDGF)/p75 that helps to guide integration into host genes. ALLINIs inhibit HIV-1 replication by inducing integrase hypermultimerization, which precludes integrase binding to genomic RNA and perturbs the morphogenesis of new viral particles. Although not yet approved for human use, ALLINIs provide important probes that can be used to investigate the link between HIV-1 integrase and viral particle morphogenesis. Herein, I review the mechanisms of retroviral integration as well as the promises and challenges of using integrase inhibitors for HIV/AIDS management.
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Affiliation(s)
- Alan N Engelman
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, Massachusetts 02215 Department of Medicine, Harvard Medical School, Boston, Massachusetts 02115
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Abstract
PURPOSE OF REVIEW Dolutegravir (DTG) is a second-generation integrase strand transfer inhibitor (InSTI) with an outstanding antiviral potency, good tolerability, good pharmacokinetic profile with a lack of major drug-drug interactions, and a barrier to resistance higher than the other compounds of the class (raltegravir and elvitegravir) and allegedly as high as that of boosted protease inhibitors. For these reasons, DTG, after successful results in a context of triple therapy in various clinical scenarios, has been investigated mostly by independent investigators in less-drug regimens, including dolutegravir monotherapy, in the context of a growing clinical interest for adjusting successful antiretroviral therapy to the increasing number of limitations for standard antiretroviral therapy in some HIV-infected patients. However, the development of genotypic resistance in case of failure to DTG monotherapy was unexpected. RECENT FINDINGS Data on efficacy and resistance from preclinical studies, randomized clinical trials and clinical cohorts of HIV-infected patients treated with DTG monotherapy published in indexed journals or presented at international meetings were reviewed. SUMMARY Monotherapy with dolutegravir has a high rate for resistance selection in the integrase gene through different pathways in case of virological failure.
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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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Pham HT, Mesplède T. Bictegravir in a fixed-dose tablet with emtricitabine and tenofovir alafenamide for the treatment of HIV infection: pharmacology and clinical implications. Expert Opin Pharmacother 2019; 20:385-397. [PMID: 30698467 DOI: 10.1080/14656566.2018.1560423] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Current antiretroviral therapy is more effective and simpler than in previous times due to the development of new drugs with improved pharmacokinetic and pharmacodynamic profiles and the advent of single pill regimens with low toxicity that facilitate long-term adherence. The recent approval of the novel potent integrase strand-transfer inhibitor bictegravir (BIC) co-formulated with emtricitabine (FTC) and tenofovir alafenamide (TAF) in a fixed daily dose pill, B/F/TAF, adds to the list of single-tablet regimens available to treat HIV infection. Areas covered: This review provides an overview of the pharmacological and clinical information obtained from MEDLINE/PubMed publications and the latest international conferences. Expert opinion: BIC is a potent antiretroviral with an improved resistance profile over previous integrase inhibitors. Its combination with the new tenofovir prodrug TAF and FTC creates an effective regimen B/F/TAF for treatment-naïve patients and for those switching from another successful combination. B/F/TAF's favorable pharmacokinetic profile, simple dose, low pill burden, and few drug-drug interactions or treatment-related adverse events, will make it one of the preferred regimens in the future.
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Affiliation(s)
- Hanh Thi Pham
- a Lady Davis Institute for Medical Research, Jewish General Hospital , McGill University AIDS Centre , Montréal , Québec , Canada.,b Department of Microbiology and Immunology, Faculty of Medicine , McGill University , Montréal , Québec , Canada
| | - Thibault Mesplède
- a Lady Davis Institute for Medical Research, Jewish General Hospital , McGill University AIDS Centre , Montréal , Québec , Canada.,b Department of Microbiology and Immunology, Faculty of Medicine , McGill University , Montréal , Québec , Canada.,c Division of Experimental Medicine, Faculty of Medicine , McGill University , Montréal , Québec , Canada.,d Division of Infectious Diseases, Jewish General Hospital , McGill University , Montréal , Québec , Canada
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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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22
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Pham HT, Goring ME, Mesplède T. Reply to Achieng and Riedel. J Infect Dis 2019; 219:167-169. [PMID: 30165488 DOI: 10.1093/infdis/jiy437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Hanh Thi 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
| | - Mark E Goring
- McGill AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada.,Division of Experimental Medicine, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Thibault Mesplède
- 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.,Division of Experimental Medicine, Faculty of Medicine, McGill University, Montréal, Québec, Canada.,Division of Infectious Diseases, Jewish General Hospital, Faculty of Medicine, McGill University, Montréal, Québec, Canada
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Diaco ND, Strickler C, Giezendanner S, Wirz SA, Tarr PE. Systematic De-escalation of Successful Triple Antiretroviral Therapy to Dual Therapy with Dolutegravir plus Emtricitabine or Lamivudine in Swiss HIV-positive Persons. EClinicalMedicine 2018; 6:21-25. [PMID: 31193647 PMCID: PMC6537552 DOI: 10.1016/j.eclinm.2018.11.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 11/01/2018] [Accepted: 11/16/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Studies increasingly suggest that the efficacy of certain dual antiretroviral therapy (ART) combinations is equal to triple ART. Increasing concerns among HIV-positive patients and physicians in Switzerland include ART cost and long-term ART safety and toxicity, i.e. taking only as many ART agents as necessary. The aims of this retrospective analysis are to report on the de-escalation of our entire clinic population of eligible patients with well-controlled HIV-infection to dolutegravir-containing dual ART. METHODS Starting in March 2015, we systematically considered the de-escalation of eligible patients to either dolutegravir/emtricitabine or dolutegravir/lamivudine, by discontinuing tenofovir disoproxil fumarate or abacavir. We report on the virological efficacy, tolerability and patient satisfaction ≥ 48 weeks after de-escalation. FINDINGS Of 106 HIV-positive patients followed in our clinic, 70 patients were de-escalated. Three returned to triple ART (insomnia after dolutegravir start, n = 2; new wish for single tablet regimen, n = 1). All de-escalated patients and all who continued triple ART had suppressed HIV viremia at last follow-up and were satisfied with their ART regimen, except for one patient who had virological failure after ART discontinuation in the setting of major depression. The most common reasons to not de-escalate included hepatitis B co-infection (n = 6), physician's concern about ART adherence (n = 6), patient reluctance to switch from a single tablet to a 2-tablet regimen (n = 7), patient satisfied with current ART (n = 5) and others (n = 12). INTERPRETATION ART de-escalation to dolutegravir/FTC or dolutegravir/3TC is possible in the majority of patients virologically suppressed on triple ART, and may effectively address patient and physician concerns about long-term safety and cost of ART.
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Affiliation(s)
- Natascha D. Diaco
- University Department of Medicine and Infectious Diseases Service, Kantonsspital Baselland, University of Basel, Bruderholz, Switzerland
| | - Claudio Strickler
- University Department of Medicine and Infectious Diseases Service, Kantonsspital Baselland, University of Basel, Bruderholz, Switzerland
| | | | - Sebastian A. Wirz
- University Department of Medicine and Infectious Diseases Service, Kantonsspital Baselland, University of Basel, Bruderholz, Switzerland
| | - Philip E. Tarr
- University Department of Medicine and Infectious Diseases Service, Kantonsspital Baselland, University of Basel, Bruderholz, Switzerland
- Corresponding author at: University Dept. of Medicine, Kantonsspital Baselland, University of Basel, 4101 Bruderholz, Switzerland.
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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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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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Nanoformulated Antiretroviral Therapy Attenuates Brain Metabolic Oxidative Stress. Mol Neurobiol 2018; 56:2896-2907. [PMID: 30069830 PMCID: PMC6403019 DOI: 10.1007/s12035-018-1273-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/16/2018] [Indexed: 12/24/2022]
Abstract
Antiretroviral therapy (ART) restricts human immunodeficiency virus type one (HIV-1) replication and by so doing, improves the quality and longevity of life for infected people. Nonetheless, treatment can also lead to adverse clinical outcomes such as drug resistance and systemic adverse events. Both could be affected by long-acting slow effective release ART. Indeed, maintenance of sustained plasma drug levels, for weeks or months, after a single high-level dosing, could improve regimen adherence but, at the same time, affect systemic toxicities. Of these, the most troubling are those that affect the central nervous system (CNS). To address this, dolutegravir (Tivicay, DTG), a potent and durable HIV integrase inhibitor used effectively in combination ART was tested. Rodents were administered parenteral 45-mg/kg doses. DTG-associated changes in CNS homeostasis were assessed by measuring brain metabolic activities. After antiretroviral treatment, brain subregions were dissected and screened by mass spectrometry-based metabolomics. Metabolic drug-related dysregulation of energy and oxidative stress were readily observed within the cerebellum and frontal cortex following native drug administrations. Each was associated with alterations in neural homeostasis and depleted canonical oxidation protection pools that included glutathione and ascorbic acid. Surprisingly, the oxidative stress-related metabolites were completely attenuated when DTG was administered as nanoformulations. These data demonstrate the importance of formulation design in control of DTG or perhaps other antiretroviral drug-associated CNS events.
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Sculier D, Doco‐Lecompte T, Yerly S, Metzner KJ, Decosterd LA, Calmy A. Stable HIV-1 reservoirs on dolutegravir maintenance monotherapy: the MONODO study. HIV Med 2018; 19:572-577. [PMID: 29932298 PMCID: PMC6120531 DOI: 10.1111/hiv.12626] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Dolutegravir (DTG) is a highly effective integrase inhibitor with a strong genetic resistance barrier and a potential role in simplified HIV maintenance treatment. We assessed the feasibility of DTG maintenance monotherapy and measured HIV reservoirs on DTG monotherapy. METHODS An interventional, open-label, single-arm study including eight virologically suppressed HIV-1-infected patients switched to DTG 50 mg once daily for 24 weeks was performed. HIV-1 RNA levels in plasma and cerebrospinal and seminal fluids were measured at baseline and week 24, as well as HIV-1 DNA in peripheral cells and DTG concentrations in these compartments. RESULTS HIV-1 RNA remained undetectable in all samples of blood, cerebrospinal fluid and sperm throughout the 24 weeks, except for one cerebrospinal fluid sample with a value of 28 HIV-1 RNA copies/mL at week 24. One patient discontinued the study because of a neurological side effect. There was no change in the mean HIV-1 DNA level between baseline and week 24. Plasma and cerebrospinal fluid DTG concentrations reached therapeutic levels in all patients in these two compartments. CONCLUSIONS In this small sample of carefully selected patients, HIV-1 reservoirs were well controlled on DTG monotherapy over a period of 24 weeks. Viral suppression was also maintained throughout follow-up.
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Affiliation(s)
- D Sculier
- Division of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
| | - T Doco‐Lecompte
- Division of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
| | - S Yerly
- Laboratory of VirologyGeneva University HospitalsGenevaSwitzerland
| | - KJ Metzner
- Division of Infectious Diseases and Hospital EpidemiologyUniversity Hospital ZurichZurichSwitzerland
- Institute of Medical VirologyUniversity of ZurichZurichSwitzerland
| | - LA Decosterd
- Division of Clinical PharmacologyUniversity Hospital and University of LausanneLausanneSwitzerland
| | - A Calmy
- Division of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
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Charpentier C, Montes B, Perrier M, Meftah N, Reynes J. HIV-1 DNA ultra-deep sequencing analysis at initiation of the dual therapy dolutegravir + lamivudine in the maintenance DOLULAM pilot study. J Antimicrob Chemother 2018; 72:2831-2836. [PMID: 29091218 DOI: 10.1093/jac/dkx233] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 06/09/2017] [Indexed: 12/12/2022] Open
Abstract
Background The DOLULAM study assessed the efficacy of dolutegravir + lamivudine dual therapy to maintain virological suppression in heavily treatment-experienced HIV-1-infected adults. No virological failure occurred during the first year of the dual therapy. Objectives A virological substudy was conducted to assess the prevalence of M184I/V mutations at dual therapy initiation using historical DNA/RNA genotypes and baseline DNA genotype obtained by next-generation sequencing (NGS). Methods HIV-1 RT sequences were obtained from DNA and/or historical RNA using Sanger technology. HIV-1 DNA RT and integrase NGS was performed using Illumina® technology. Results Among the 27 patients enrolled in the DOLULAM study, historical HIV DNA and RNA Sanger sequences were available in 14 and 18 patients, respectively. At the initiation of DOLULAM, DNA NGS genotypes showed that 45% and 21% of the patients harboured minority resistant variants (MRV) in RT and integrase, respectively. Combining all available genotype data, an M184I/V was observed in 17 of 27 (63%) of the patients. Most M184V were detected in historical RNA genotypes (n = 8 of 11), whereas M184I were exclusively detected in DNA genotypes (n = 10, including 7 as MRV). Ten patients displayed defective viral genomes in cellular reservoirs, all including M184I and stop codons. At the time of DOLULAM initiation, M184V was observed in DNA NGS in five patients, including one as MRV. Conclusions These first NGS data on HIV DNA at initiation of a switch study showed (i) a high proportion of patients harbouring defective viral genomes, whose mutation M184I is a marker, and (ii) a low number of patients in whom M184V remained as a major viral variant in PBMCs.
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Affiliation(s)
- Charlotte Charpentier
- IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, AP-HP, Laboratoire de Virologie, Hôpital Bichat, AP-HP, Paris, France
| | - Brigitte Montes
- Laboratoire de Virologie, CHU de Montpellier, Montpellier, France
| | - Marine Perrier
- IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, AP-HP, Laboratoire de Virologie, Hôpital Bichat, AP-HP, Paris, France
| | - Nadia Meftah
- COREVIH, CHU de Montpellier, Montpellier, France
| | - Jacques Reynes
- Département de Maladies infectieuses et tropicales, CHU de Montpellier, Montpellier, France.,Unité Mixte Internationale 233 IRD-U1175 INSERM-Université de Montpellier, Montpellier, France
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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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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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31
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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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Metsu D, Lanot T, Fraissinet F, Picot M, Concordet D, Cabrol M, Dubois-Galopin F, Chatelut E, Delobel P, Gandia P. Determination of dolutegravir's unbound fraction in human plasma using validated equilibrium dialysis and LC-MS/MS methods. Clin Chim Acta 2017; 479:56-65. [PMID: 29277535 DOI: 10.1016/j.cca.2017.12.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 12/20/2017] [Accepted: 12/21/2017] [Indexed: 01/26/2023]
Abstract
Assessment of the unbound pharmacologically active fraction (fu; as the ratio of unbound to total concentration) of dolutegravir could improve therapeutic drug monitoring (TDM) in patients that experience virological failure or toxicity, despite receiving adequate total concentrations. This study evaluated (i) dolutegravir's fu through equilibrium dialysis (ED), (ii) the pre-analytical parameters that influence fu, and (iii) fu's inter-individual variability in HIV patients. Validation of the LC-MS/MS method followed FDA guidelines. The results, based on coefficients of variation (results from nominal concentrations <15%), allowed accurate measurement of unbound and total dolutegravir concentrations. Equilibrium during ED was obtained in 4h. Sparse non-specific binding (9%) was observed, allowing results interpretation without interference. Steps before analysis (e.g., conservation at +4°C, freeze/thaw cycles) did not influence fu, allowing easy integration of fu analysis within laboratory routines. Anticoagulants from samples (citrated versus heparinized; p<0.001) and hemolysis (p=0.007) influenced fu and could lead to misinterpretation. Developed was then performed to the HIV-patients' plasma (n=54). Results, expressed as median InterQuartile Range [25%;75%] were 0.45% IQR [0.38; 0.55] for fu, 9.26μg/L IQR [4.62; 15.14] for unbound, and 2035μg/L IQR [878.5; 2640] for total concentration. The high inter-individual variability observed in the unbound form from HIV patients was a first step towards integrating dolutegravir TDM.
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Affiliation(s)
- David Metsu
- Department of Pharmacokinetic and Toxicology, Toulouse University Hospital, France; INSERM, CRCT, Toulouse University, UPS, Toulouse, France
| | - Thomas Lanot
- Department of Pharmacokinetic and Toxicology, Toulouse University Hospital, France
| | - François Fraissinet
- Department of Pharmacokinetic and Toxicology, Toulouse University Hospital, France
| | - Mélanie Picot
- Department of Pharmacokinetic and Toxicology, Toulouse University Hospital, France
| | - Didier Concordet
- INRA, Toxalim, INP-ENVT, Toulouse University, UPS, Toulouse, France
| | - Marion Cabrol
- Department of Pharmacokinetic and Toxicology, Toulouse University Hospital, France
| | | | - Etienne Chatelut
- INSERM, CRCT, Toulouse University, UPS, Toulouse, France; Institut Claudius-Regaud, IUCT-Oncopole, Toulouse, France
| | - Pierre Delobel
- INSERM, UMR1043, Toulouse University, UPS, Toulouse, France; Department of Infectious Diseases, University Hospital of Toulouse, France
| | - Peggy Gandia
- Department of Pharmacokinetic and Toxicology, Toulouse University Hospital, France; INRA, Toxalim, INP-ENVT, Toulouse University, UPS, Toulouse, France.
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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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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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Orkin C, Llibre JM, Gallien S, Antinori A, Behrens G, Carr A. Nucleoside reverse transcriptase inhibitor-reducing strategies in HIV treatment: assessing the evidence. HIV Med 2017; 19:18-32. [PMID: 28737291 DOI: 10.1111/hiv.12534] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2017] [Indexed: 01/22/2023]
Abstract
Antiretroviral (ARV) therapy, comprising a backbone of two nucleos(t)ide reverse transcriptase inhibitors (NRTIs) plus another ARV, is the recognized standard of care (SOC), which has helped extend life expectancy in people living with HIV. In a quest to reduce lifelong drug exposure and minimize or avoid the toxicity of NRTIs, "NRTI-reducing" regimens have been investigated. This descriptive review assessing the results of NRTI-reducing strategies from the largest randomized trials focuses on virological efficacy, resistance, regimen safety (in terms of bone mineral density, renal function, lipids and central nervous system function) and simplicity. The review considers efficacy across various NRTI-sparing strategies, for example an integrase strand transfer inhibitor (INSTI) plus a ritonavir-boosted protease inhibitor (PI/r) or PI/r + lamivudine (3TC), in both naïve and switch regimes. Of 10 key studies in treatment-naïve adults assessing five NRTI-reducing strategies, only four studies demonstrated noninferiority vs. SOC [GARDEL, NEAT 001, AIDS Clinical Trials Group 5142 and PROGRESS]. In switch settings, 17 studies (10 randomized) were reviewed that used four strategies, including three studies assessing an INSTI plus a nonnucleoside reverse transcriptase inhibitor . Noninferiority of the NRTI-reducing arm was shown in six of 10 studies (ATLAS-M, SALT, DUAL, OLE, LATTE-2 and SWORD). In general, NRTI-reducing therapy did not always result in an improvement in short- or long-term adverse events; however, in many cases, these endpoints were not reported. Some of these studies reported higher virological failure rates with more frequent emergence of resistance mutations. None of these NRTI-reducing strategies has been compared against a single-pill regimen, including those containing tenofovir alafenamide. Only strategies demonstrating noninferior efficacy, a benefit in safety/tolerability, and a favourable cost-efficacy ratio, preferably in a single pill, will eventually match the current SOC of triple ARV therapy.
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Affiliation(s)
- C Orkin
- Infection and Immunity, Barts Health NHS Trust, London, UK
| | - J M Llibre
- University Hospital Germans Trias i Pujol, Infectious Diseases and "Fight AIDS" Foundation, Badalona, Barcelona, Spain
| | - S Gallien
- Immunology and Infectious Diseases, Henri Mondor Hospital, Paris Est Créteil University, Créteil, France
| | - A Antinori
- HIV/AIDS Department, National Institute for Infectious Diseases "Lazzaro Spallanzani", Rome, Italy
| | - Gmn Behrens
- Department for Clinical Immunology and Rheumatology, Hannover Medical School, Hannover, Germany.,German Center for Infection Research, St Vincent's Hospital, Sydney, Australia
| | - A Carr
- Centre for Applied Medical Research, St Vincent's Hospital, Sydney, Australia
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37
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Gantner P, Cuzin L, Allavena C, Cabie A, Pugliese P, Valantin MA, Bani-Sadr F, Joly V, Ferry T, Poizot-Martin I, Garraffo R, Peytavin G, Fafi-Kremer S, Rey D. Efficacy and safety of dolutegravir and rilpivirine dual therapy as a simplification strategy: a cohort study. HIV Med 2017; 18:704-708. [DOI: 10.1111/hiv.12506] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- P Gantner
- Virology Laboratory; Hôpitaux Universitaires de Strasbourg; Strasbourg France
| | - L Cuzin
- INSERM; UMR 1027; Toulouse France
- Université de Toulouse III; Toulouse France
- CHU Toulouse; COREVIH Toulouse; Toulouse France
| | - C Allavena
- Infectious Diseases Department; CHU de Nantes; Nantes France
| | - A Cabie
- Infectious Diseases Department; CHU de Fort-de-France; Martinique France
| | - P Pugliese
- Infectious Diseases Department; CHU de Nice; Nice France
| | - M-A Valantin
- Infectious Diseases Department; APHP Hôpital Pitié Salpêtrière; Paris France
- Institut Pierre Louis d'épidémiologie et de Santé Publique (UMRS 1136); UPMC Univ Paris 06; INSERM; Sorbonne Universités; Paris France
| | - F Bani-Sadr
- Infectious Diseases Department; CHU de Reims; Reims France
| | - V Joly
- Infectious Diseases Department; APHP Hôpital Bichat; Paris France
| | - T Ferry
- Infectious Diseases Department; Hospices civils de Lyon; Lyon France
| | - I Poizot-Martin
- APHM Hôpital Sainte-Marguerite; Immuno-Hematology Clinic; Aix-Marseille University; Marseille France
| | - R Garraffo
- Pharmacology Laboratory; CHU de Nice; Nice France
| | - G Peytavin
- AP-HP; Pharmacology Laboratory; Hôpital Bichat-Claude Bernard; Paris France
- IAME; UMR 1137; Sorbonne Paris Cité, INSERM; Université Paris Diderot; Paris France
| | - S Fafi-Kremer
- Virology Laboratory; Hôpitaux Universitaires de Strasbourg; Strasbourg France
| | - D Rey
- Le Trait d'Union; HIV-Infection Care Center; Hôpitaux Universitaires de Strasbourg; Strasbourg France
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Abstract
Human immunodeficiency virus (HIV) infection persists despite decades of active antiretroviral therapy (ART), effectively preventing viral eradication. Treatment decreases plasma viral RNA, but viral DNA persists, mostly integrated within the genome of nucleated blood cells. Viral DNA blood levels correlate with comorbidities and the rapidity of viral rebound following treatment interruption. To date, no intervention aiming at decreasing HIV DNA levels below those attained through ART has been successful. This includes use of some integrase inhibitors either as part of ART or in treatment intensification studies. We have argued that using the integrase inhibitor dolutegravir (DTG) in similar studies may yield better results, but this remains to be studied. In treatment-experienced individuals, the most frequent substitution associated with failure with dolutegravir is R263K in integrase. R263K decreases integration both in cell-free and tissue culture assays. We investigated here how integrated DNA levels evolve over time during prolonged infections with R263K viruses. To investigate a potential defect in reverse transcription with R263K, the levels of reverse transcripts were measured by quantitative PCR. We measured HIV type 1 (HIV-1) integration in Jurkat cells over the course of 4-week infections using Alu-mediated quantitative PCR. The results show that R263K did not decrease reverse transcription. Prolonged infections with R263K mutant viruses led to less HIV-1 integrated DNA over time compared to wild-type viruses. These tissue culture results help to explain the absence of the R263K substitution in most individuals experiencing failure with DTG and support studies aiming at longitudinally measuring the levels of integrated DNA in individuals treated with this drug. Antiretroviral treatment decreases plasma viral RNA, but HIV DNA persists for decades within infected cells. Studies of nonhuman primates have suggested that reducing retroviral DNA levels might represent a path to eradication. The integrase inhibitor dolutegravir is less susceptible than any other anti-HIV drug to the emergence of resistance in treatment-naive individuals. In treatment-experienced individuals, in contrast, rare cases of treatment failure were commonly associated with emergence of an R263K integrase substitution that confers low-level resistance to dolutegravir. It is unclear why this substitution is not more common in individuals experiencing failure with dolutegravir. We report here that R263K progressively diminishes the levels of integrated HIV-1 DNA in tissue culture over multiple cycles of infection. Our results help to explain aspects of the clinical efficacy of dolutegravir and suggest that this drug may be able to reduce HIV DNA levels within infected individuals compared to other drugs.
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Maggiolo F, Gulminetti R, Pagnucco L, Digaetano M, Benatti S, Valenti D, Callegaro A, Ripamonti D, Mussini C. Lamivudine/dolutegravir dual therapy in HIV-infected, virologically suppressed patients. BMC Infect Dis 2017; 17:215. [PMID: 28302065 PMCID: PMC5356275 DOI: 10.1186/s12879-017-2311-2] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 03/08/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Little is known about the applicability of dual treatments based on integrase inhibitors. We explored the combination of lamivudine + dolutegravir as an option when switching from standard cART in virologically suppressed patients. METHODS In this prospective cohort we enrolled patients previously switched to 3TC + DTG who were 18 years or older, with no previous resistance mutations to the used drugs, having a HIV-RNA <50 copies/ml for 6 months or longer, negative for HBsAg and on a stable (>6 months) cART. RESULTS Ninety-four individuals were included. They were mostly men (77.7%) with a mean age of 53 years. They presented 159 co-morbidities including cardiovascular, bone, hepatic, kidney, and CNS diseases. Because of these pathologies, they took 207 non-ARV drugs (mean 2.2 per patient). Median duration of viral suppression was 77.5 months (IQR 61). All subjects were prospectively followed up to week 24 and all remained on dual therapy during the whole period. Neither virological failure, nor viral blip was detected. The median CD4 count rose from 658 cells/mcl (IQR 403) to 724 cells/mcl (IQR 401) (P = 0.006) without a significant (P = 0.44) change in the CD4/CD8 ratio. A significant (P < 0.0001) increment of median creatinine from 0.87 mg/dl (IQR 0.34) to 0.95 mg/dl (IQR 0.29) was observed in the first 2 months but thereafter leveled on these values (1.00 mg/dl; IQR 0.35) (P = 0.111 compared to 2 months). The lipid profile slightly improved. The daily cost of cART was significantly (P < 0.0001) reduced of 6.89 euros (SD 6.10). DISCUSSION Switching to a dual cART regimen based on lamivudine + dolutegravir maintains virological efficacy up to week 24, and is associated to slight improvements of the immunologic and metabolic status. The strategy allows to freely using concomitant medications for associated pathologies. The dual therapy is less expensive in economic terms. CONCLUSION Although still limited evidence exists, a dolutegravir-based dual therapy in combination with lamivudine shows promising results to be confirmed in larger controlled trials.
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Affiliation(s)
- Franco Maggiolo
- Division of Infectious Diseases, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy
| | - Roberto Gulminetti
- Division of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Layla Pagnucco
- Division of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Simone Benatti
- Division of Infectious Diseases, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy
| | - Daniela Valenti
- Division of Infectious Diseases, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy
| | - Annapaola Callegaro
- Microbiology and Virology Laboratory, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Diego Ripamonti
- Division of Infectious Diseases, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy
| | - Cristina Mussini
- Division of Infectious Diseases, University of Modena, Modena, Italy
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Gallant J, Sugarman J. Dolutegravir monotherapy: when should clinical practice be clinical research? Antivir Ther 2016; 22:93-95. [PMID: 27977411 DOI: 10.3851/imp3113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Joel Gallant
- Southwest CARE Center, Santa Fe, NM, USA.,Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeremy Sugarman
- Johns Hopkins Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
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Oldenbuettel C, Wolf E, Ritter A, Noe S, Heldwein S, Pascucci R, Wiese C, Von Krosigk A, Jaegel-Guedes E, Jaeger H, Balogh A, Koegl C, Spinner CD. Dolutegravir monotherapy as treatment de-escalation in HIV-infected adults with virological control: DoluMono cohort results. Antivir Ther 2016; 22:169-172. [PMID: 27588613 DOI: 10.3851/imp3082] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The potential toxicity of long-term antiretroviral therapy (ART) requires ongoing investigation of novel strategies for treatment of HIV-infected patients. Monotherapy with the integrase inhibitor (INSTI) dolutegravir (DTG) may offer a favourable safety profile. Additionally, DTG has a high barrier of resistance, crucial for successful maintenance of virological control. However, published data is sparse. METHODS Retrospective, single-centre cohort study. We enrolled patients on suppressive ART who were switched to DTG monotherapy in routine clinical practice and fulfilled the following inclusion criteria: HIV RNA level <50 copies/ml for ≥6 months at time of switch (one blip <200 copies/ml with re-suppression accepted), no known INSTI resistance or prior INSTI failure, no replicative HBV infection and no history of AIDS. RESULTS We identified 31 patients with 24-weeks of follow-up data. Previous ART included a non-nucleoside reverse transcriptase inhibitor, a boosted protease inhibitor or an INSTI in 32%, 6% and 61% of patients, respectively. At week 24, HIV RNA remained <50 copies/ml in all but two patients (94%). One patient chose to discontinue DTG monotherapy and another developed confirmed virological failure (HIV RNA 538 copies/ml) with new INSTI mutations (Q148H/G140S). Immune status and renal and metabolic function showed no statistically significant changes, apart from a significant decrease in gamma-glutamyl transferase. CONCLUSIONS De-escalating to DTG monotherapy in selected patients might be a safe and feasible option. However, in one case evolution of INSTI resistance was observed. Further studies should assess particular risk factors for DTG monotherapy failure. In the meanwhile, caution is warranted.
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Affiliation(s)
| | | | - Ayla Ritter
- Department of Medicine II, University Hospital Klinikum rechts der Isar, Munich, Germany
| | - Sebastian Noe
- MVZ Karlsplatz, HIV Research and Clinical Care Centre, Munich, Germany
| | - Silke Heldwein
- MVZ Karlsplatz, HIV Research and Clinical Care Centre, Munich, Germany
| | - Rita Pascucci
- MVZ Karlsplatz, HIV Research and Clinical Care Centre, Munich, Germany
| | - Carmen Wiese
- MVZ Karlsplatz, HIV Research and Clinical Care Centre, Munich, Germany
| | | | - Eva Jaegel-Guedes
- MVZ Karlsplatz, HIV Research and Clinical Care Centre, Munich, Germany
| | - Hans Jaeger
- MVZ Karlsplatz, HIV Research and Clinical Care Centre, Munich, Germany
| | | | | | - Christoph D Spinner
- MVZ Karlsplatz, HIV Research and Clinical Care Centre, Munich, Germany.,Department of Medicine II, University Hospital Klinikum rechts der Isar, Munich, Germany.,German Center for Infection Research (DZIF), partner site Munich, Munich, Germany
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