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Lowe SH, Wensing AMJ, Hassink EAM, ten Kate RW, Richter C, Schreij G, Koopmans PP, Juttmann JR, van der Tweel I, Lange JMA, Borleffs JCC. Comparison of Two Once-Daily Regimens with a Regimen Consisting of Nelfinavir, Didanosine, and Stavudine in Antiretroviral Therapy-Naïve Adults: 48-Week Results from the Antiretroviral Regimen Evaluation Study (ARES). HIV CLINICAL TRIALS 2015; 6:235-45. [PMID: 16306030 DOI: 10.1310/a686-m37y-j2pt-e9gj] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND To improve the dosing frequency and pill burden of antiretroviral therapy, we compared two once-daily dosed regimens to a twice-daily dosed regimen. METHOD HIV-1-infected, antiretroviral drug-naïve adults were randomized to either twice-daily nelfinavir and stavudine and once-daily didanosine (regimen A) or simplified once-daily dosed antiretroviral regimens consisting of nevirapine, didanosine, and lamivudine (regimen B) or saquinavir, ritonavir, didanosine, and lamivudine (regimen C). RESULTS At 48 weeks of therapy, the proportion of patients with a blood plasma HIV-1 RNA concentration (pVL) <50 copies/mL by intention-to treat analysis was 42.3%, 50.0%, and 56.5% for regimens A (n = 26), B (n = 22), and C (n = 23), respectively. The time to a pVL <50 copies/mL for the first time was significantly shorter in regimen C, and there was significantly more progression to CDC events in regimen B. These differences are possibly due to differences in baseline characteristics. Adverse events were lowest for regimen C; more signs associated with mitochondrial toxicity occurred in regimen A. Increase in CD4 count was comparable between arms. CONCLUSION No statistically significant difference in efficacy was found between the two investigated once-daily dosed treatment regimens (B and C) and the reference (A). Regimen C possibly had a better virological response and less toxicity than regimens A and B.
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Affiliation(s)
- S H Lowe
- International Antiviral Therapy Evaluation Center (IATEC), University of Amsterdam, Amsterdam, The Netherlands.
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Bogner JR. Nevirapine extended-release for the treatment of HIV-1 infection. Expert Rev Anti Infect Ther 2014; 10:21-30. [DOI: 10.1586/eri.11.145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Comparison of nevirapine plasma concentrations between lead-in and steady-state periods in Chinese HIV-infected patients. PLoS One 2013; 8:e52950. [PMID: 23359265 PMCID: PMC3554734 DOI: 10.1371/journal.pone.0052950] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 11/21/2012] [Indexed: 01/11/2023] Open
Abstract
Objectives To investigate the potential of nevirapine 200 mg once-daily regimen and evaluate the influence of patient characteristics on nevirapine concentrations. Methods This was a prospective, multicentre cohort study with 532 HIV-infected patients receiving nevirapine as a part of their initial antiretroviral therapy. Plasma samples were collected at trough or peak time at the end of week 2 (lead-in period) and week 4, 12, 24, 36, and 48 (steady-state period), and nevirapine concentrations were determined using a validated HPLC method. Potential influencing factors associated with nevirapine concentrations were evaluated using univariate and multivariate logistic regression. Results A total of 2348 nevirapine plasma concentrations were collected, including 1510 trough and 838 peak values. The median nevirapine trough and peak concentration during the lead-in period were 4.26 µg/mL (IQR 3.05–5.61) and 5.07 µg/mL (IQR 3.92–6.44) respectively, which both exceeded the recommended thresholds of nevirapine plasma concentrations. Baseline hepatic function had a moderate effect on median nevirapine trough concentrations at week 2 (4.25 µg/mL v.s. 4.86 µg/mL, for ALT <1.5×ULN and ≥1.5×ULN, respectively, P = 0.045). No significant difference was observed in median nevirapine trough concentration between lead-in and steady-state periods in patients with baseline ALT and AST level ≥1.5×ULN (P = 0.171, P = 0.769), which was different from the patients with ALT/AST level <1.5ULN. The median trough concentrations were significantly higher in HIV/HCV co-infected patients than those without HCV at week 48 (8.16 µg/mL v.s. 6.15 µg/mL, P = 0.004). Conclusions The 200 mg once-daily regimen of nevirapine might be comparable to twice-daily in plasma pharmacokinetics in Chinese population. Hepatic function prior to nevirapine treatment and HIV/HCV coinfection were significantly associated with nevirapine concentrations. Registration Clinicaltrial.gov ID: NCT00872417
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López A, van der Lubbe N, Sánchez-Palomino S, Arnedo M, Nomdedeu M, Castro P, Guilà M, Maleno MJ, García F, Gallart T, Gatell JM, Plana M. Phenotypic and functional characteristics of HIV-specific CD8 T cells and gag sequence variability after autologous dendritic cells based therapeutic vaccine. Vaccine 2009; 27:6166-78. [PMID: 19712765 DOI: 10.1016/j.vaccine.2009.08.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Revised: 07/31/2009] [Accepted: 08/06/2009] [Indexed: 12/19/2022]
Abstract
A decrease in HIV-1 specific CD8 T-cell responses associated with a partial control of viral replication occurred in 12 HIV-1-infected patients during autologous dendritic cells vaccination. HIV CD8 T cells were detected in 6/10 patients during immunizations, increasing after HAART discontinuation in 3 of them. Tet+ CD8 cells mainly had an effector phenotype (CD45RA-/+ CCR7- and CD28- and Perf+/-) and maintained IFN-gamma release throughout follow-up. By contrast, patients with CD45RA-/+ CCR7+ Perf+ HIV-specific cells showed a decrease in peptide-specific IFN-gamma production during vaccinations while levels were recovered when off HAART. No major mutations in either Gag p24 and p17 immunodominant epitopes were observed that might have explained the impaired CD8+ T-cell responses. Taken together, heterogeneity in the maturation status of HIV-specific CD8 T cells may be partially involved in the drop of peptide-specific IFN-gamma production during immunizations.
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Affiliation(s)
- Anna López
- Retrovirology and Viral Immunopathology Laboratory, Hospital Clínic, University of Barcelona, Barcelona, Spain
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Chowers MY, Gottesman BS, Leibovici L, Pielmeier U, Andreassen S, Paul M. Reporting of adverse events in randomized controlled trials of highly active antiretroviral therapy: systematic review. J Antimicrob Chemother 2009; 64:239-50. [DOI: 10.1093/jac/dkp191] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Safety of Switching Nevirapine Twice Daily to Nevirapine Once Daily in Virologically Suppressed Patients. J Acquir Immune Defic Syndr 2009; 50:390-6. [PMID: 19214120 DOI: 10.1097/qai.0b013e318198a0cc] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The strategy of switching nevirapine (NVP) twice daily to once daily was evaluated. METHODS Forty-eight-week randomized, open, multicenter trial. Stable HIV-infected patients on NVP twice daily for >12-18 weeks with alanine aminotransferase (ALT) <2.5, the upper normal limit were randomized to continue their regimen or switch to NVP 400 mg once daily. Primary end point was the proportion of ALT/aspartate transaminase (AST) > or =grade 3. RESULTS Two hundred eighty-nine patients were included, mean CD4 620 cells per microliter. Noninferiority was demonstrated in the per protocol analysis, with 97.9% (once daily) and 99.3% (twice daily) of patients event free (difference, 1.4%; 95% confidence interval, -1.95% to 5.4%), whereas 81.8% vs. 93.8% were event free by intent-to-treat switch = toxicity analysis (difference, 12%; 95% confidence interval, 4.6% to 19.4%). Only 4 patients (3 once daily, 1 twice daily) had NVP-related grade 3/4 ALT/AST increases, but in 2 of them (once daily), transaminases decreased despite continuation with NVP. Two other once daily patients presented grade 3/4 ALT/AST increase due to well-documented acute hepatitis A virus or hepatitis C virus infection. Grade 2 ALT/AST increases occurred in 11.2% (once daily) vs. 10.3% (twice daily) of patients (P = 0.80). A larger number of once daily patients were lost to follow-up/violated protocol (15% vs. 5%). CONCLUSIONS In patients on standard twice daily NVP-containing regimens for at least 12-18 weeks, per protocol analysis showed that switching to once daily NVP was not inferior to continued twice daily NVP in terms of the predefined noninferiority margin of 10% for hepatotoxicity.
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Calmy A, Vallier N, Nguyen A, Lange JMA, Battegay M, de Wolf F, Reiss P, Lima VD, Hirschel B, Hogg RS, Yip B, Montaner JSG, Wit FW. Safety and efficacy of once-daily nevirapine dosing: a multicohort study. Antivir Ther 2009; 14:931-8. [DOI: 10.3851/imp1418] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Benzie A, Marett B, Mackie NE, Winston A. High treatment success rates when switching to once daily nevirapine containing antiretroviral therapy. Open AIDS J 2008; 2:89-93. [PMID: 19274065 PMCID: PMC2627512 DOI: 10.2174/1874613600802010089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2008] [Revised: 11/24/2008] [Accepted: 11/25/2008] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Two recent studies have highlighted low rates of virological response to once daily nevirapine containing combination antiretroviral therapy (CART) in treatment naïve HIV-1 infected subjects. AIM We assessed factors associated with treatment responses in a cohort of HIV-1 infected, therapy naïve individuals, commencing nevirapine CART with two nucleoside reverse transcriptase inhibitors (NRTI) containing either lamivudine or emtricitabine. RESULTS Between January 2002 and 2006, 173 subjects (80 female) met the study inclusion criteria. All subjects initially commenced on twice daily nevirapine with six different NRTI backbones. Mean follow up was 802 days. 49 (28%) subjects switched to once daily nevirapine, 23 (13%) within the first year. After 48 weeks of therapy, HIV RNA was < 50 copies/mL in 154/173 subjects (89%). A trend was observed towards improved virological outcome (HIV RNA < 50 copies/mL) and switching to once daily nevirapine during the first year of therapy (p=0.051). CONCLUSION Whilst awaiting the results of prospective studies assessing once daily nevirapine, our data describe high treatment success rates and good safety responses when switching to once daily nevirapine.
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Affiliation(s)
- Andrew Benzie
- Department of GU and HIV Medicine, Imperial College Healthcare NHS Trust, UK
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Canestri A, Sow PS, Vray M, Ngom F, M'boup S, Kane CT, Delaporte E, Gueye M, Peytavin G, Girard PM, Landman R. Poor Efficacy and Tolerability of Stavudine, Didanosine, and Efavirenz-based Regimen in Treatment-Naive Patients in Senegal. J Int AIDS Soc 2007; 9:7. [PMID: 19825141 PMCID: PMC2758902 DOI: 10.1186/1758-2652-9-4-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To study the effectiveness and tolerance of an antiretroviral therapy (ART) regimen composed of the antiretroviral agents (ARVs) stavudine (d4T) plus didanosine (ddI) plus efavirenz (EFV) in patients with advanced HIV infection in Senegal. DESIGN AND METHODS This was an open-label, single-arm, 18-month trial in treatment-naive patients. The primary virologic end point was the percentage of patients with plasma HIV RNA < 500 copies/mL at months 6 (M6), 12 (M12) and 18 (M18). The primary analysis was done as intent-to-treat. RESULTS The staging of HIV disease, performed using the definitions of the US Centers for Disease Control and Prevention (CDC), was CDC stage B or C for all 40 recruited patients. At baseline, the mean CD4+ cell count was 133 +/- 92/mcL (+/- standard deviation [SD]; range 1-346), and 23% of patients had CD4+ cell counts below 50/mcL. The mean baseline plasma HIV RNA level was 5.5 +/- 0.4 log10 copies/mL (+/- SD; range 4.6-5.9). The proportion of patients with plasma HIV-1 RNA below 500 copies/mL fell during the study from 73% (95% CI [56; 85]) at M6 to 56% (95% CI [41; 73]) at M12 and 43% (95% CI [27; 59]) at M18. Plasma HIV-RNA was below 50 copies/mL in 50% of study subjects (95% CI [31; 66]) at M6, 43% (95% CI [27; 59]) at M12, and 33% (95% CI [19; 49]) at M18.The mean increase in the CD4+ cell count was 105 +/- 125/mcL (n = 38) at M3 and 186 +/- 122/mcL (n = 21) at M18. Eight patients died, including 6 because of infectious complications. The last viral load (VL) value before death was < 500 copies/mL in all these patients except 1 nonadherent patient. Fifteen patients (37.5%) had peripheral neuropathy that was severe enough in 5 patients (12.5%) to require ddI and d4T discontinuation. CONCLUSION Virologic efficacy combination therapy with d4T, ddI, and EFV was measured by the percentage of patients with plasma HIV RNA values below 500 copies/mL and 50 copies/mL; for both parameters, virologic efficacy decreased during the study period. This is explained by the high mortality rate (20%) and treatment modifications due to adverse events (13%). These data strengthen the recently revised World Health Organization (WHO) guidelines advocating initiation of highly active antiretroviral therapy (HAART) before profound CD4 lymphocyte depletion occurs and avoiding HAART regimens containing d4T and ddI because of treatment-limiting side effects.
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Affiliation(s)
- Anna Canestri
- Institut de Médecine et d'Epidémiologie Appliquée, Bichat Claude Bernard Hospital, Paris, France
| | - Papa Salif Sow
- Fann University Teaching Hospital and Centre Croix-Rouge de Traitement Ambulatoire, Dakar, Senegal
| | | | - Fatou Ngom
- Fann University Teaching Hospital and Centre Croix-Rouge de Traitement Ambulatoire, Dakar, Senegal
| | | | | | - Eric Delaporte
- Institut de Recherche et Développement, Montpellier, France
| | | | - Gilles Peytavin
- Pharmacology Laboratory Bichat-Claude-Bernard Hospital Paris, France
| | - Pierre Marie Girard
- Institut de Médecine et d'Epidémiologie Appliquée, Bichat Claude Bernard Hospital, Paris, France
| | - Roland Landman
- Institut de Médecine et d'Epidémiologie Appliquée, Bichat Claude Bernard Hospital, Paris, France
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Abstract
In the context of attempts to simplify treatment regimens and enhance adherence, there is great interest in once-daily dosing regimens for the treatment of HIV-1 infection. Nevirapine has a long half-life and achieves high steady-state plasma concentrations relative to the concentration required to inhibit 50% viral replication in vitro (IC(50)) in patients. For this reason, it has been considered as a once-daily antiretroviral. Pharmacokinetic and efficacy data support the use of this dosing approach, but excess rash and lingering concerns over liver toxicity preclude use of once-daily dosed nevirapine at this time. Tolerance to high nevirapine concentrations may develop when dose escalation is used during initiation of therapy. It is theoretically possible that the benefits of once-daily dosing may be achieved without excess toxicity by switching to once-daily nevirapine following several months of twice-daily administration. This dosing strategy is currently under evaluation.
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Affiliation(s)
- C L Cooper
- University of Ottawa, Ottawa Hospital Division of Infectious Diseases, and Health Research Institute, Ottawa, Ontario, Canada.
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Kappelhoff BS, Huitema ADR, van Leth F, Robinson PA, MacGregor TR, Lange JMA, Beijnen JH. Pharmacokinetics of nevirapine: once-daily versus twice-daily dosing in the 2NN study. HIV CLINICAL TRIALS 2006; 6:254-61. [PMID: 16306032 DOI: 10.1310/b5vu-fu5f-qnwc-udck] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE As part of the large international, randomized 2NN trial, the pharmacokinetics of nevirapine in once-daily 400 mg and twice-daily 200 mg dosing regimens were investigated. METHOD Treatment-naive HIV-1-infected patients were randomized to receive nevirapine 400 mg once daily or 200 mg twice daily, in combination with lamivudine and stavudine. Blood samples were collected at several time-points (day 3, weeks 1, 2, 4, 24, and 48). Differences in pharmacokinetics between once- versus twice-daily dosing were investigated with nonlinear mixed effects modelling (NONMEM). RESULTS In total, 2,899 nevirapine plasma concentrations were available from 578 patients. Dosage and dosing frequency did not influence clearance or volume of distribution of nevirapine, indicating linear pharmacokinetic behavior of nevirapine whether given as a single daily dose or as divided doses over 24 hours. During steady state, the Cmin was lower (3.26 mg/L vs. 4.44 mg/L; p < .001) and the Cmax was higher (7.88 mg/L vs. 6.55 mg/L; p < .001) in the once-daily arm. However, compared to total variability in nevirapine levels for both treatments, these differences were minor. During steady state, total exposure, measured as AUC24h, was comparable for both regimens (133 mg/L*h vs. 133 mg/L*h; p = .084). CONCLUSION The daily exposure to nevirapine (AUC24h) was similar for the 400 mg once-daily and the 200 mg twice-daily dosing regimens. The Cmin of nevirapine is lower and the Cmax of nevirapine is higher for the once-daily regimen as compared to the twice-daily regimen. As a result, 200 mg nevirapine dosed twice daily may be preferred over 400 mg nevirapine dosed once daily.
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Affiliation(s)
- Bregt S Kappelhoff
- Slotervaart Hospital, Department of Pharmacy & Pharmacology, Amsterdam, The Netherlands.
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Lange S, Freitag G. Choice of delta: requirements and reality--results of a systematic review. Biom J 2006; 47:12-27; discussion 99-107. [PMID: 16395993 DOI: 10.1002/bimj.200410085] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
An essential problem in planning clinical non-inferiority or equivalence studies is the specification of the 'irrelevant difference' (irrelevance margin; delta). This quantifies the amount of non-inferiority or difference, respectively, between a new test therapy and an established standard treatment which is to be considered as tolerable. In the past, most recommendations and guidelines for clinical non-inferiority and equivalence studies contained only general statements and formulations concerning the specification of delta. The current unsatisfactory situation was the reason for performing a systematic review of published clinical non-inferiority and equivalence studies. It was the aim to gain an overview on the irrelevance margins used in such studies, and on reasons for choosing the particular margins. For the sake of comparability, the irrelevance margins were converted into standardized differences and odds ratios. Overall, there were 332 non-inferiority or equivalence trials obtained by means of an extensive literature search. The results of the systematic review show that current requirements on the choice of delta and the reality of recent clinical non-inferiority and equivalence trials differ substantially. In about one half of the trials a difference of 0.5 standard deviations or more was regarded as 'irrelevant' explicitly or implicitly. Estimates of standard-placebo differences formed the basis of the irrelevance margin in less than every tenth trial. Reasons for this very low proportion might be (1) the possibly resulting very small irrelevance margins, and (2) unsolved problems of the requirements themselves. Overall, it seems that a more global definition of 'irrelevance' might be warranted.
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Affiliation(s)
- S Lange
- Institute for Quality and Efficiency in Health Care, Cologne, Germany.
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Pulido F, Ribera E, Moreno S, Muñoz A, Podzamczer D, del Pozo MA, Rivero A, Rodríguez F, Sanjoaquín I, Teira R, Viciana P, Villalonga C, Antela A, Carmena J, Ena J, Gonzalez E, Kindelán JM, Mallolas J, Márquez M, Martínez E. Once-daily antiretroviral therapy: Spanish Consensus Statement. J Antimicrob Chemother 2005; 56:808-18. [PMID: 16150862 DOI: 10.1093/jac/dki320] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Administration of antiretroviral therapy (ART) once daily is creating extraordinary interest among the members of the scientific community and also among those who receive the therapy. However, in clinical practice, some doubts remain about its use. OBJECTIVES This document examines the characteristics and possibilities of treatment administered once daily. METHODS Consensus of 248 Spanish experts in the field. RESULTS Once-daily dosing is considered an added value which could favour adherence and, therefore, efficacy, as well as the quality of life of certain patients, however, the objective of adequate adherence in the long term is often difficult to achieve regardless of the treatment used. In theory, any patient can receive once-daily therapy, although some patients could particularly benefit from it, e.g. those with unfavourable social or personal circumstances, including drug users, patients whose treatment must be supervised, patients receiving multiple medications, or those who need rescue therapy after multiple treatment failures. At present, it is possible to design once-daily ART using some of the combinations of drugs considered as first-choice in national and international recommendations for antiretroviral therapy, but the options are still limited. The marketing of new drugs with this characteristic could allow us to increase the number and types of patient who can benefit from once-daily regimens, including those patients who need rescue therapy. CONCLUSIONS Once-daily ART is a good alternative to regimens administered several times each day when a potent combination of active drugs is available.
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Affiliation(s)
- F Pulido
- Hospital Universitario 12 de Octubre, 28041 Madrid, Spain.
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Ribera E, Rodríguez-Pardo D, Rubio M, Soler A, Pedrol E, Blanco JL, González A, Crespo M, Falcó V, Ocaña I, Deig E, Miró JM, Pahissa A. Efficacy and Safety of Once-Daily Combination Therapy with Didanosine, Lamivudine and Nevirapine in Antiretroviral-Naive HIV-Infected Patients. Antivir Ther 2005. [DOI: 10.1177/135965350501000509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Simplified antiretroviral regimens are needed to improve patient adherence and quality of life. The purpose of this study was to evaluate the efficacy and safety of a once-daily regimen consisting of didanosine (ddI), lamivudine (3TC) and nevirapine (NVP) for adult antiretroviral-naive patients with HIV-1 infection. Methods This was a prospective, one-arm, multicentre pilot study. Daily drug dosage was 250 or 400 mg didanosine, 300 mg lamivudine and 400 mg nevirapine. The primary outcome measure was the percentage of patients with a plasma HIV-RNA level <50 copies/ml at 12 months on an intention-to-treat (ITT) basis. Results Seventy patients were enrolled in the study. At baseline, mean plasma HIV-1 RNA was 5.10 log10 copies/ml, and mean CD4 cell count was 262 cells/μl. At month 12, 67% (95% CI: 56–78) of patients maintained a viral load of <50 copies/ml in the ITT analysis and CD4 counts increased a median of 201 cells/μl. The treatment was more effective in patients with baseline CD4 counts >100 cells/μl than in those with a poorer immunological status at baseline, although the number of patients with CD4 counts <100 was low. Four patients died during the study period. Therapy was discontinued in 18 patients due to virological failure in 11, adverse events in seven, loss to follow-up or withdrawal of consent in four and death in one. Eight out of nine patients with available genotype after virological failure showed resistance mutations to NVP (Y181C and others) and 3TC (M184V/I), and four of them also had ddI resistance (L74V). The lipid profile was favourable, with a decrease in the ratio of total-to-high density lipoprotein cholesterol. Conclusion A once-daily combination of ddI, 3TC and NVP seems to be an effective, safe and easy-to-take regimen in antiretroviral-naive patients, at least in those who do not have severe immunodepression at baseline.
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Affiliation(s)
- Esteban Ribera
- Infectious Diseases Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Manuel Rubio
- Internal Medicine Service, Hospital Arnau de Vilanova, Lleida, Spain
| | - Anna Soler
- HIV Unit, Department of Internal Medicine, Fundació Hospital de Granollers, Granollers, Barcelona, Spain
| | - Enric Pedrol
- HIV Unit, Department of Internal Medicine, Fundació Hospital de Granollers, Granollers, Barcelona, Spain
| | - José L Blanco
- Infectious Diseases Service, Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Alicia González
- Department of Internal Medicine – Infectious Diseases, Hospital del Mar, Barcelona, Spain
| | - Manel Crespo
- Infectious Diseases Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Vicenç Falcó
- Infectious Diseases Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Imma Ocaña
- Infectious Diseases Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Elisabeth Deig
- HIV Unit, Department of Internal Medicine, Fundació Hospital de Granollers, Granollers, Barcelona, Spain
| | - Jose M Miró
- Infectious Diseases Service, Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Albert Pahissa
- Infectious Diseases Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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Roca B, Lapuebla C, Vidal-Tegedor B. HAART with didanosine once versus twice daily: adherence and efficacy. Int J Infect Dis 2005; 9:195-200. [PMID: 15964537 DOI: 10.1016/j.ijid.2004.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2003] [Revised: 06/17/2004] [Accepted: 07/19/2004] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Highly active antiretroviral therapy (HAART) containing didanosine taken twice daily was compared with HAART containing didanosine taken once daily in terms of adherence and efficacy. METHOD This was a self-controlled prospective cohort study, carried out in a tertiary level hospital. A total of 49 HIV-infected patients were included. They were prescribed HAART according to guidelines. After six months taking HAART containing didanosine twice daily, patients continued with the same regimen of HAART although once daily. Thereafter they were followed up for a further nine months. Adherence and virological efficacy were assessed at three-month intervals, for a total of six times, in every patient. RESULTS Overall, adherence was poor, with only 19 patients (39%) showing adequate adherence for all six visits. Adequate adherence was observed in 29 patients (59%) three months before didanosine switching, and in 37 patients (75%) three months after didanosine switching (P=0.034). Pooled HIV RNA results of the first three visits were higher than the same results of the last three visits (P=0.05). CONCLUSIONS Non-adherence is common among patients who take HAART. Simplification of regimens is useful to improve adherence and efficacy.
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Affiliation(s)
- Bernardino Roca
- Infectious Disease Division, Hospital General of Castellón, Catalunya, 33-A, 4-12004 Castellón, Spain.
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Knobel H, Miró JM, Mahillo B, Domingo P, Rivero A, Ribera E, Gonzalez J, Sanz J, González A, Blanco JL, Boix V, Force L, Llibre JM, Dalmau D, Arroyo JA, De la Torre J, Rodriguez D, Montes ML, Arranz A, Sarasa M. Failure of Cetirizine to Prevent Nevirapine-Associated Rash. J Acquir Immune Defic Syndr 2004; 37:1276-81. [PMID: 15385735 DOI: 10.1097/01.qai.0000137372.18814.34] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Rash is the most frequent adverse event associated with nevirapine. The use of antihistamines remains unclear in this setting. A double-blind placebo-controlled study was performed to evaluate the efficacy of cetirizine in the prevention of nevirapine rash. METHODS A multicenter, randomized, double-blind, placebo-controlled clinical trial with cetirizine (10 mg/d x 30 days) was conducted. Inclusion criteria were HIV-1 infection and nevirapine therapy started with any CD4 cell count or plasma viral load and without simultaneous use of abacavir, cotrimoxazole, or rifampin. Clinical follow-up was performed at 15, 30, and 90 days. RESULTS Two hundred seventeen evaluable patients were enrolled (107 patients receiving cetirizine and 110 patients receiving placebo), 32.3% of whom were women. The median baseline CD4 cell count and plasma viral load were 341 cells/mm and 11,000 copies/mL, respectively. Overall, 29 rashes (13.4%) were detected: 16 (15.0%) in the cetirizine group and 13 (11.8%) in the placebo group (odds ratio [OR] = 1.31, 95% confidence interval [CI]: 0.60-2.88; P = 0.50). The incidence of moderate to severe rashes leading to nevirapine withdrawal was 10.3% (11 of 107 patients) in the cetirizine group and 7.3% (8 of 110 patients) in the placebo group (OR = 1.46, 95% CI: 0.52-4.18; P = 0.43). Adverse events leading to withdrawal of therapy appeared in 14 patients (13.1%) from the cetirizine group and 10 (9.1%) from the placebo group (P = 0.34). CONCLUSION Cetirizine does not prevent the incidence or affect the severity of nevirapine-associated rash.
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Affiliation(s)
- Hernando Knobel
- Department of Internal Medicine, Infectious Diseases, Hospital del Mar, Barcelona, Spain.
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van Leth F, Phanuphak P, Ruxrungtham K, Baraldi E, Miller S, Gazzard B, Cahn P, Lalloo UG, van der Westhuizen IP, Malan DR, Johnson MA, Santos BR, Mulcahy F, Wood R, Levi GC, Reboredo G, Squires K, Cassetti I, Petit D, Raffi F, Katlama C, Murphy RL, Horban A, Dam JP, Hassink E, van Leeuwen R, Robinson P, Wit FW, Lange JMA. Comparison of first-line antiretroviral therapy with regimens including nevirapine, efavirenz, or both drugs, plus stavudine and lamivudine: a randomised open-label trial, the 2NN Study. Lancet 2004; 363:1253-63. [PMID: 15094269 DOI: 10.1016/s0140-6736(04)15997-7] [Citation(s) in RCA: 520] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The 2NN Study was a randomised comparison of the non-nucleoside reverse-transcriptase inhibitors (NNRTI) nevirapine and efavirenz. METHODS In this multicentre, open-label, randomised trial, 1216 antiretroviral-therapy-naive patients were assigned nevirapine 400 mg once daily, nevirapine 200 mg twice daily, efavirenz 600 mg once daily, or nevirapine (400 mg) and efavirenz (800 mg) once daily, plus stavudine and lamivudine, for 48 weeks. The primary endpoint was the proportion of patients with treatment failure (less than 1 log(10) decline in plasma HIV-1 RNA in the first 12 weeks or two consecutive measurements of more than 50 copies per mL from week 24 onwards, disease progression [new Centers for Disease Control and Prevention grade C event or death], or change of allocated treatment). Analyses were by intention to treat. FINDINGS Treatment failure occurred in 96 (43.6%) of 220 patients assigned nevirapine once daily, 169 (43.7%) of 387 assigned nevirapine twice daily, 151 (37.8%) of 400 assigned efavirenz, and 111 (53.1%) of 209 assigned nevirapine plus efavirenz. The difference between nevirapine twice daily and efavirenz was 5.9% (95% CI -0.9 to 12.8). There were no significant differences among the study groups in the proportions with plasma HIV-1 RNA concentrations below 50 copies per mL at week 48 (p=0.193) or the increases in CD4-positive cells (p=0.800). Nevirapine plus efavirenz was associated with the highest frequency of clinical adverse events, and nevirapine once daily with significantly more hepatobiliary laboratory toxicities than efavirenz. Of 25 observed deaths, two were attributed to nevirapine. INTERPRETATION Antiretroviral therapy with nevirapine or efavirenz showed similar efficacy, so triple-drug regimens with either NNRTI are valid for first-line treatment. There are, however, differences in safety profiles. Combination of nevirapine and efavirenz did not improve efficacy but caused more adverse events.
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Affiliation(s)
- F van Leth
- International Antiviral Therapy Evaluation Center, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
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Negredo E, Moltó J, Muñoz-Moreno JA, Pedrol E, Ribera E, Viciana P, Galindo MJ, Miralles C, Burger D, Fumaz CR, Puig J, Gel S, Rodríguez E, Videla S, Ruiz L, Clotet B. Safety and Efficacy of Once-Daily Didanosine, Tenofovir and Nevirapine as a Simplification Antiretroviral Approach. Antivir Ther 2004. [DOI: 10.1177/135965350400900304] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To assess the efficacy and safety of a once-daily antiretroviral regimen in HAART-experienced subjects with long-lasting viral suppression. Methods One-hundred-and-sixty-nine patients with chronically suppressed viral load (limit of detection <50 copies/ml) were recruited. Based on patient willingness to simplify treatment, 84 of them continued receiving their usual treatment (BID Group) and 85 switched to once-daily didanosine/tenofovir/nevirapine (QD Group) in a non-randomized fashion. Results At week 48, the proportion of patients with viral suppression in the QD and in the BID Group, respectively, was 97 vs 100% in the per-protocol analysis ( P=0.497), and 76 vs 86% for the intention-to-treat analysis ( P=0.176). Nevertheless, CD4 count decreased in the QD Group, with a mean decline of 95 cells/mm3 (95% CI: 45–145). Twelve subjects in the QD Group (14%) discontinued treatment due to adverse events, mainly nevirapine-related hepatitis (6%). No significant differences regarding the rate of acute pancreatitis or peripheral neuropathy were observed between both groups. A significant improvement in the lipid profile was only seen in the QD Group. High levels of adherence were observed in both groups during follow-up, as well as a good quality of life. At week 48, a reduction in effort to take medication ( P≤0.001) and an increment in the satisfaction with the treatment ( P<0.001) was only seen in the QD group. No differences were observed in median nevirapine trough levels between patients on twice-daily nevirapine at baseline (4820 ng/ml) and subjects in the QD Group (6090 ng/ml, P=0.30). Conclusion Treatment simplification to a once-daily antiretroviral regimen based on didanosine, tenofovir and nevirapine may be a valid approach in HIV-infected subjects with long-lasting viral suppression. Combination of standard doses of didanosine and tenofovir may have contributed to the CD4 cell decline observed with this QD regimen.
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Affiliation(s)
- Eugènia Negredo
- ‘Lluita Contra la SIDA’ and ‘Irsicaixa’ Foundations, Germans Trias i Pujol Hospital, Badalona, Spain
| | - José Moltó
- ‘Lluita Contra la SIDA’ and ‘Irsicaixa’ Foundations, Germans Trias i Pujol Hospital, Badalona, Spain
| | - José Antonio Muñoz-Moreno
- ‘Lluita Contra la SIDA’ and ‘Irsicaixa’ Foundations, Germans Trias i Pujol Hospital, Badalona, Spain
| | | | | | | | | | | | | | - Carmina Rodriguez Fumaz
- ‘Lluita Contra la SIDA’ and ‘Irsicaixa’ Foundations, Germans Trias i Pujol Hospital, Badalona, Spain
| | - Jordi Puig
- ‘Lluita Contra la SIDA’ and ‘Irsicaixa’ Foundations, Germans Trias i Pujol Hospital, Badalona, Spain
| | - Sílvia Gel
- ‘Lluita Contra la SIDA’ and ‘Irsicaixa’ Foundations, Germans Trias i Pujol Hospital, Badalona, Spain
| | - Eva Rodríguez
- ‘Lluita Contra la SIDA’ and ‘Irsicaixa’ Foundations, Germans Trias i Pujol Hospital, Badalona, Spain
| | - Sebastià Videla
- ‘Lluita Contra la SIDA’ and ‘Irsicaixa’ Foundations, Germans Trias i Pujol Hospital, Badalona, Spain
| | - Lidia Ruiz
- ‘Lluita Contra la SIDA’ and ‘Irsicaixa’ Foundations, Germans Trias i Pujol Hospital, Badalona, Spain
| | - Bonaventura Clotet
- ‘Lluita Contra la SIDA’ and ‘Irsicaixa’ Foundations, Germans Trias i Pujol Hospital, Badalona, Spain
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Plana M, Ferrer E, Martínez C, Podzamczer D, García F, Maleno MJ, Barceló JJ, García A, Barberá MJ, Lacarcel M, Miró JM, Gallart T, Gatell JM. Immune Restoration in HIV-Positive, Antiretroviral-Naive Patients after 1 Year of Zidovudine/Lamivudine plus Nelfinavir or Nevirapine. Antivir Ther 2004. [DOI: 10.1177/135965350400900207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives To evaluate the immunological response in HIV-1-infected, antiretroviral-naive patients receiving highly active antiretroviral therapy regimen of two nucleosides plus a protease inhibitor or a non-nucleoside reverse transcriptase inhibitor. Design and methods Of 142 patients included in a randomized, open, multicentre trial comparing zidovudine/lamivudine plus nelfinavir (NFV) or nevirapine (NVP), 36 patients (16 NFV, 20 NVP) were enrolled in an immunological substudy. Mean baseline CD4 T-cell counts was 360/mm3 (range: 11–679) and mean baseline plasma viral load >50 000 copies/ml (range: 2240–1468210). Viral load (VL), T-cell subsets and T-cell functions were analysed at baseline and after 1 year of treatment. Results After 12 months of follow-up, plasma viral load was reduced similarly in both groups, with 78% (NFV) and 83% (NVP) of patients achieving a VL <200 copies/ml. A significant increase in CD4 T cells was observed in both groups (mean: +182 cells, P=0.001). Both regimens were similarly effective in reducing activated T cells (CD38 and DR). A significant increase of both CD4 and CD8 CD28 T cells occurred in both arms of treatment. Patients of both regimens showed a significant decrease of activated memory (CD45RA–CD45RO+) CD8 T cells and a clear increase of naive (CD45RA+CD45RO-) CD8 T cells. Peripheral blood mononuclear cell proliferative responses to polyclonal stimuli (CD3 and CD3 +CD28) as well as to ubiquitous cytomegalovirus antigen increased significantly in both groups after 12 months of follow-up. Nevertheless, neither at baseline nor after 1 year of treatment, these patients showed any significant T-cell responsiveness to HIV-1 recombinant proteins gp160 or p24. Conclusions Our data indicate that immune restoration achieved after 1 year of therapy with either NFV or NVP was similar. This reinforces the role of NVP-containing regimens as a valid option for initiating antiretroviral therapy. Nevertheless, additional therapeutic approaches should be envisaged to restore HIV-1-specific T-cell responses.
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Affiliation(s)
- Montserrat Plana
- Institut Clínic d'Infeccions i Immunologia (ICII), Immunology, Infectious Diseases and Microbiology Units, Institut de Investigació Biomèdica Agustí Pi i Suñer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Elena Ferrer
- Infectious Diseases Service, Ciutat Sanitària de Bellvitge, Barcelona, Spain
| | - Catalina Martínez
- Institut Clínic d'Infeccions i Immunologia (ICII), Immunology, Infectious Diseases and Microbiology Units, Institut de Investigació Biomèdica Agustí Pi i Suñer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Daniel Podzamczer
- Infectious Diseases Service, Ciutat Sanitària de Bellvitge, Barcelona, Spain
| | - Felipe García
- Institut Clínic d'Infeccions i Immunologia (ICII), Immunology, Infectious Diseases and Microbiology Units, Institut de Investigació Biomèdica Agustí Pi i Suñer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - María J Maleno
- Institut Clínic d'Infeccions i Immunologia (ICII), Immunology, Infectious Diseases and Microbiology Units, Institut de Investigació Biomèdica Agustí Pi i Suñer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Juan J Barceló
- Institut Clínic d'Infeccions i Immunologia (ICII), Immunology, Infectious Diseases and Microbiology Units, Institut de Investigació Biomèdica Agustí Pi i Suñer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Ana García
- Institut Clínic d'Infeccions i Immunologia (ICII), Immunology, Infectious Diseases and Microbiology Units, Institut de Investigació Biomèdica Agustí Pi i Suñer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - María J Barberá
- Infectious Diseases Service, Ciutat Sanitària de Bellvitge, Barcelona, Spain
| | - Montserrat Lacarcel
- Infectious Diseases Service, Ciutat Sanitària de Bellvitge, Barcelona, Spain
| | - José M Miró
- Institut Clínic d'Infeccions i Immunologia (ICII), Immunology, Infectious Diseases and Microbiology Units, Institut de Investigació Biomèdica Agustí Pi i Suñer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Teresa Gallart
- Institut Clínic d'Infeccions i Immunologia (ICII), Immunology, Infectious Diseases and Microbiology Units, Institut de Investigació Biomèdica Agustí Pi i Suñer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - José M Gatell
- Institut Clínic d'Infeccions i Immunologia (ICII), Immunology, Infectious Diseases and Microbiology Units, Institut de Investigació Biomèdica Agustí Pi i Suñer (IDIBAPS), Hospital Clínic, University of Barcelona, Barcelona, Spain
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Recomendaciones de GESIDA/Plan Nacional sobre el Sida respecto al tratamiento antirretroviral en pacientes adultos infectados por el VIH (octubre 2004). Enferm Infecc Microbiol Clin 2004. [DOI: 10.1016/s0213-005x(04)73163-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Lange JMA. Efficacy and durability of nevirapine in antiretroviral drug näive patients. J Acquir Immune Defic Syndr 2003; 34 Suppl 1:S40-52. [PMID: 14562857 DOI: 10.1097/00126334-200309011-00007] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Nevirapine is a non-nucleoside reverse transcriptase inhibitor (NNRTI) that was first reported in the scientific literature in 1990. Varying doses of nevirapine (NVP) and a number of regimens containing this NNRTI have been studied in antiretroviral (ARV) näive patients. Four key studies have compared the efficacy and safety of triple drug regimens containing NVP in ARV näive, HIV-1 infected patients. The INCAS study was the first demonstration of how to use NVP in an effective and durable manner: as a component of a triple drug regimen. The COMBINE Study was a comparison of protease inhibitor (PI)-based and NVP-based triple regimens. The Atlantic Study is comparing the safety and efficacy of three triple drug regimens in ARV näive patients. In this study, treatment consists of a divergent drug regimen (PI and nucleoside reverse transcriptase inhibitors, NRTIs) targeting both HIV-1 protease and reverse transcriptase or a convergent regimen targeting reverse transcriptase alone (three NRTIs or two NRTIs plus a NNRTI). A clinical endpoint study (BI 1090) compared the efficacy and durability of multi-drug regimens in ARV näive patients with high baseline plasma HIV-1 RNA levels (pVLs) and low peripheral blood CD4+ lymphocyte counts. Data from these studies confirm that triple regimens containing NVP suppressed viral replication for up to one year, even when the ARV näive patients had low CD4+ cell counts at baseline. Nevirapine-containing regimens suppressed pVLs to < 50 copies/ mL in approximately 50% of patients in the studies discussed (Intent to Treat analyses). Data from 96 weeks of follow up in the Atlantic Study demonstrates that the regimens containing didanosine and stavudine plus indinavir or NVP were significantly more successful in suppressing pVLs to < 50 copies/mL during this period than a regimen composed of these NRTIs and lamivudine (p < or = 0.001). As with other ARV drugs, NVP should always be used as part of a fully suppressive ARV regimen. When used in this way, it is an effective ARV drug, which contributes to durable virological and immunological responses in approximately half of all treated patients. Nevirapine-containing regimens are effective in patients with advanced HIV-1 infection, i.e., low CD4+ cell counts. Data will soon be available from the 2NN Study that compares the efficacy and safety of four different regimens using NVP once daily, NVP twice daily, efavirenz once daily or a combination of NVP and efavirenz. All four arms of the study include a backbone of stavudine and lamivudine.
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Affiliation(s)
- Joep M A Lange
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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22
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Verweel G, Sharland M, Lyall H, Novelli V, Gibb DM, Dumont G, Ball C, Wilkins E, Walters S, Tudor-Williams G. Nevirapine use in HIV-1-infected children. AIDS 2003; 17:1639-47. [PMID: 12853746 DOI: 10.1097/00002030-200307250-00008] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the safety, efficacy, and clinical, virological, and immunological responses in HIV-1-infected children receiving nevirapine as part of combination antiretroviral therapy (ART). METHODS A review of case notes of all HIV-1-infected children 96 weeks after starting nevirapine, under a national compassionate access scheme between August 1997 and March 1999 in the UK. Nevirapine was dosed according to the manufacturer's guidelines. RESULTS Seventy-four children (36 boys, 28 naive to ART) were enrolled, with a median age of 5.2 years, viral load of 5.1 log copies/ml and CD4 lymphocyte count of 13.5%. The liquid formulation and tablets of nevirapine were well tolerated. The proportions of patients achieving undetectable viral load levels at weeks 12, 24, 48 and 96 were 30, 40, 36 and 33%, respectively (intention-to-treat analysis). Of children not on a protease inhibitor who received more than 300 mg/m2/day of nevirapine, 60% had undetectable viral loads at week 96, compared with 17% on recommended doses. Outcomes were similar for patients receiving nevirapine once or twice daily. CD4 cell count percentages increased significantly, with median values sustained above 25% by week 48 onwards. Z-scores for weight and height increased significantly during 96 weeks of treatment. Rash occurred in 20%, of which four (5%) were severe. There were no cases of Stevens-Johnson syndrome. CONCLUSION Nevirapine was mostly well tolerated, and was associated with encouraging clinical and immunological responses. Virological responses in this cohort support the use of nevirapine doses greater than 300 mg/m2/day, which is higher than currently recommended by the manufacturers.
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van Leeuwen R, Katlama C, Murphy RL, Squires K, Gatell J, Horban A, Clotet B, Staszewski S, van Eeden A, Clumeck N, Moroni M, Pavia AT, Schmidt RE, Gonzalez-Lahoz J, Montaner J, Antunes F, Gulick R, Bánhegyi D, van der Valk M, Reiss P, van Weert L, van Leth F, Johnson VA, Sommadossi JP, Lange JM. A randomized trial to study first-line combination therapy with or without a protease inhibitor in HIV-1-infected patients. AIDS 2003; 17:987-99. [PMID: 12700448 DOI: 10.1097/00002030-200305020-00007] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare one protease inhibitor (PI)-based and two PI-sparing antiretroviral therapy regimens. METHODS International, open label, randomized study of antiretroviral drug-naive patients, with CD4 lymphocyte counts >/= 200 x 106 cells/l and plasma HIV-1 RNA levels > 500 copies/ml. Treatment assignment to stavudine and didanosine plus indinavir or nevirapine or lamivudine. Primary study endpoint was the percentage of patients with plasma HIV-1 RNA levels < 500 copies/ml after 48 weeks in the intention-to-treat analysis (ITT). RESULTS In total, 298 patients were enrolled. After 48 weeks, the percentage of patients in the indinavir, nevirapine and lamivudine arms with HIV-1 RNA < 500 copies/ml was 57.0%, 58.4% and 58.7%, respectively, in an ITT analysis. After 96 weeks of follow-up, these percentages were 50.0%, 59.6% and 45.0%, respectively. The percentage of patients with HIV-1 RNA < 50 copies/ml was significantly less for those allocated to lamivudine in an on-treatment analysis after 48 and 96 weeks of follow-up. Patients in the nevirapine arm experienced a smaller increase in the absolute number of CD4 T lymphocytes. There were no significant differences in the incidence of serious adverse events. CONCLUSIONS A comparable virological response can be achieved with first-line PI-base and PI-sparing regimens. The triple nucleoside regimen utilized may be less likely to result in viral suppression to < 50 copies/ml, while the nevirapine-based regimen is associated with a lower increase in CD4 T lymphocytes.
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Affiliation(s)
- Remko van Leeuwen
- International Antiviral Therapy Evaluation Center, Academic Medical Center, Amsterdam, The Netherlands
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Ananworanich J, Nuesch R, Teeratakulpisarn S, Srasuebkul P, Chuenyam T, Siangphoe U, Ungsedhaphand C, Phanuphak P, Ruxrungtham K. In vivo cell-mediated immunity in subjects with undetectable viral load on protease inhibitor-based versus non-protease inhibitor-based highly active antiretroviral therapy. J Acquir Immune Defic Syndr 2003; 32:570-2. [PMID: 12679711 DOI: 10.1097/00126334-200304150-00016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Jensen-Fangel S, Pedersen C, Larsen CS, Tauris P, Møller A, Obel N. Trends in the use of highly active antiretroviral therapy in western Denmark 1996-2000. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 2003; 34:460-5. [PMID: 12160175 DOI: 10.1080/00365540110080458] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
New antiretroviral drugs, expanding knowledge of their long-term toxic effects and the large number of patients with treatment failure have increased the demand for new strategies in the antiretroviral treatment of HIV-infected patients. The present study was conducted as part of the HIV Cohort Study in western Denmark to reveal trends in the use of antiretrovirals in the region. The cohort includes all patients attached to those centers treating HIV patients in western Denmark. A total of 537 patients who started highly active antiretroviral therapy (HAART) were included. The number of patients receiving HAART increased dramatically in 1996 and 1997 before leveling off, with 45-75 patients initiating treatment annually thereafter. Median follow-up time after initiation of HAART was 151 weeks. An estimated 45.1% of patients had the initial HAART regimen modified during the first year of follow-up. Side-effects and treatment failure were the main reasons for treatment modifications. Major new strategies implemented in the region in 1999 and 2000 included treatment with boosted protease inhibitors and non-nucleoside reverse transcriptase inhibitors.
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Vidal C, Arnedo M, Garcia F, Mestre G, Plana M, Cruceta A, Capon A, Gallart T, Miro JM, Pumarola T, Gatell JM. Genotypic and Phenotypic Resistance Patterns in Early-Stage HIV-1-Infected Patients Failing Initial Therapy with Stavudine, Didanosine and Nevirapine. Antivir Ther 2002. [DOI: 10.1177/135965350200700408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objectives of this study were to determine the genotypic and phenotypic patterns of resistance in a group of early-stage antiretroviral-naive patients failing initial therapy with didanosine, stavudine and nevirapine. These patterns of resistance were determined at baseline and at time of virological failure in 89 antiretroviral-naive patients with CD4 cells >500 cells/ml and viral load >5000 copies/ml who received initial antiretroviral therapy with didanosine plus stavudine and nevirapine as part of the SCAN study, and who failed after having reached undetectable plasma levels (<200 copies/ml). Of the 89 patients recruited in the SCAN study, 14 (16%) developed a virological failure after reaching a viral load below 200 copies/ml after a median of 20 months of follow-up. At baseline, none of these 14 patients had genotypic resistance. At time of failure, six out of 14 (43%) failing patients had wild-type genotype and no phenotypic resistance. Suboptimal compliance could be documented in four of these six patients. Seven patients (50%) had nevirapine resistance mutations (mainly K103N [4/7], Y181C/I [2/7], G190A/S [2/7] and V108I [1/7]) associated with phenotypic high-level resistance to nevirapine, delavirdine and efavirenz (nevirapine >47.4-to 58.1-fold, delavirdine >74.4- to 168.9-fold and efavirenz >56.0- to 347.2-fold). Four of these seven patients also had thymidine analogue-associated mutations (TAM) (T215Y/F [2/4], M41L [1/4], D67N [2/4] and K70R [1/4]). Finally, one patient (7%) had exclusively TAM mutations (M41L). None of the patients developed mutations associated with didanosine resistance or phenotypic resistance to didanosine or stavudine. Suboptimal compliance or selection of nevirapine resistance often with TAM mutations was frequently associated with virological failure in a cohort of early-stage chronic HIV-1-infected patients treated with a protease inhibitor-sparing regimen.
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Affiliation(s)
- Carme Vidal
- Microbiology Laboratory, Institut Clínic de Infeccions i Immunologia, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Hospital Clínic, Faculty of Medicine, University of Barcelona, Spain
| | - Mireia Arnedo
- Microbiology Laboratory, Institut Clínic de Infeccions i Immunologia, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Hospital Clínic, Faculty of Medicine, University of Barcelona, Spain
| | - Felipe Garcia
- Infectious Diseases Unit, Institut Clínic de Infeccions i Immunologia, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Hospital Clínic, Faculty of Medicine, University of Barcelona, Spain
| | - Gabriel Mestre
- Infectious Diseases Unit, Institut Clínic de Infeccions i Immunologia, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Hospital Clínic, Faculty of Medicine, University of Barcelona, Spain
| | - Montserrat Plana
- Immunology Laboratory, Institut Clínic de Infeccions i Immunologia, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Hospital Clínic, Faculty of Medicine, University of Barcelona, Spain
| | - Anna Cruceta
- Infectious Diseases Unit, Institut Clínic de Infeccions i Immunologia, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Hospital Clínic, Faculty of Medicine, University of Barcelona, Spain
| | - Alicia Capon
- Microbiology Laboratory, Institut Clínic de Infeccions i Immunologia, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Hospital Clínic, Faculty of Medicine, University of Barcelona, Spain
| | - Teresa Gallart
- Immunology Laboratory, Institut Clínic de Infeccions i Immunologia, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Hospital Clínic, Faculty of Medicine, University of Barcelona, Spain
| | - José M Miro
- Infectious Diseases Unit, Institut Clínic de Infeccions i Immunologia, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Hospital Clínic, Faculty of Medicine, University of Barcelona, Spain
| | - Tomas Pumarola
- Microbiology Laboratory, Institut Clínic de Infeccions i Immunologia, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Hospital Clínic, Faculty of Medicine, University of Barcelona, Spain
| | - José M Gatell
- Infectious Diseases Unit, Institut Clínic de Infeccions i Immunologia, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Hospital Clínic, Faculty of Medicine, University of Barcelona, Spain
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27
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Immunologic Reconstitution After 1 Year of Highly Active Antiretroviral Therapy, With or Without Protease Inhibitors. J Acquir Immune Defic Syndr 2002. [DOI: 10.1097/00042560-200204150-00001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Armbruster C, Stiegler GM, Vcelar BA, Jäger W, Michael NL, Vetter N, Katinger HWD. A phase I trial with two human monoclonal antibodies (hMAb 2F5, 2G12) against HIV-1. AIDS 2002; 16:227-33. [PMID: 11807307 DOI: 10.1097/00002030-200201250-00012] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To study the safety, immunogenicity and pharmacokinetics of two intravenously administered human monoclonal antibodies (hMAb 2F5, 2G12) against HIV-1 in humans. DESIGN Open label clinical phase I trial. SETTING Primary institutional care. PATIENTS Seven HIV-1-infected healthy volunteers with > or = 500 x 10(6)CD4 cells/l and < or = 10,000 HIV-1 RNA copies/ml, not treated with highly active antiretroviral therapy (HAART), entered and finished the study. INTERVENTIONS and main outcome measures: Eight separate infusions of the hMAb were administered over a 4-week period (total dose 14 g). The safety was assessed by physical examination, blood chemistry, complete blood cell count and recording adverse events. 2F5 and 2G12 plasma levels were determined prior to and at the end of each infusion and during the follow-up period of 22 weeks. RESULTS No clinical or laboratory abnormalities were observed throughout the study. The median distribution half-life (t(1/2 alpha)) of 2F5 and 2G12 was 1.02 (range, 0.77-1.47) days and 2.49 (range, 0.92-4.59) days, respectively. The elimination half-life (t(1/2 beta)) was calculated to be 7.94 (range, 3.46-8.31) days for 2F5 and 16.48 (range, 12.84-24.85) days for 2G12. The median plasma concentration immediately after the first infusion was 216 microg/ml (range, 158-409 microg/ml) for 2F5 and 238 microg/ml (range, 197-402 microg/ml) for 2G12. Multiple infusions resulted in maximum plasma concentrations of 374 microg/ml (range, 304-700 microg/ml) and 605 microg/ml (range, 479-897 microg/ml) for 2F5 and 2G12, respectively. CONCLUSIONS This study showed that the hMAb 2F5 and 2G12 are safe and well tolerated by HIV-1-infected subjects.
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Abstract
Nevirapine (Viramune, Boehringer Ingelheim) is a non-nucleoside reverse transcriptase (RT) inhibitor (NNRTI) effective in the treatment of HIV-1 infected antiretroviral-naive and -experienced patients. Some recent studies have suggested that nevirapine-based regimens may have an efficacy similar to protease inhibitor (PI)-based regimens, at least in naive patients with CD4+ > 200 microl, while it lacks the drawbacks inherent in PI-containing regimens, such as lipodystrophy and metabolic alterations. Switching from a PI-containing regimen to a nevirapine-containing regimen seems to retain the virological response to therapy and it may also limit or reverse the development of some metabolic disorders induced by PIs. Nevirapine is also effective in preventing mother-to-child transmission of HIV-1 disease and in the treatment of HIV-1 infected children. Nevirapine is well-tolerated, rash being the most common severe adverse effect observed. Hepatotoxicity may also appear with nevirapine, mainly in patients with chronic hepatitis C and/or altered liver function tests. This side effect may occasionally be life-threatening but it can be safely managed in most patients.
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Affiliation(s)
- D Podzamczer
- Infectious Disease Service, Ciutat Sanitaria de Bellvitge, Barcelona, Spain.
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30
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Cattelan AM, Trevenzoli M, Sasset L, Sgarabotto D, Lanzafame M, Meneghetti F. Toxic epidermal necrolysis induced by nevirapine therapy: description of two cases and review of the literature. J Infect 2001; 43:246-9. [PMID: 11869062 DOI: 10.1053/jinf.2001.0902] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We describe two cases of toxic epidermal necrolysis developed during an antiretroviral therapy regimen containing nevirapine. It seems likely that the poor adherence to the dose escalation regimen of nevirapine has caused this life-threatening disease. A complete and written information on the scheduled antiretroviral therapy is mandatory, above all for individuals coming from developing countries where language barriers have not yet been successfully overcome.
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Affiliation(s)
- A M Cattelan
- Division of Infectious Diseases, General Hospital of Padua, Italy.
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31
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Podzamczer D, Ferrer E, Consiglio E, Gatell JM, Perez P, Perez JL, Luna E, González A, Pedrol E, Lozano L, Ocaña I, Llibre JM, Casiró A, Aranda M, Barrufet P, Martínez-Lacasa J, Miró JM, Badía X, Casado A, Lupo S, Cahn P, Maños M, Estela J, Barberá MJ, Santín M, Gudiol F, Hidalgo M, Knobel H, Azuaje C, Ribera E, Roget M, Force L, Dalmau D, Suarez C. A Randomized Clinical Trial Comparing Nelfinavir Or Nevirapine Associated to Zidovudine/Lamivudine in HIV-Infected Naive Patients (The Combine Study). Antivir Ther 2001. [DOI: 10.1177/135965350200700202] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Non-nucleoside reverse transcriptase inhibitor-containing regimens may be a valid alternative to protease inhibitor-containing regimens for initial antiretroviral therapy, but to date few studies comparing these two strategies have been performed. Objective To evaluate the efficacy and safety of nelfinavir or nevirapine associated to zidovudine/lamivudine in HIV-infected naive patients. Design Randomized, open-label, multicentre trial. Setting Twelve centres in Spain (9) and Argentina (3). Patients One hundred and forty-two HIV-infected naive patients without AIDS. Interventions Patients received combivir (zidovudine 300 mg/lamivudine 150 mg, twice-daily) plus either nelfinavir (1250 mg) twice-daily (zidovudine/lamivudine/nelfinavir, n=70) or nevirapine (200 mg) twice-daily (zidovudine/lamivudine/nevirapine, n=72), and were followed for 12 months. The primary endpoint was the proportion of patients with a plasma HIV-1 RNA (pVL) of less than 200 copies/ml by PCR at 12 months. pVL of less than 20 copies/ml (PCR), changes in CD4 counts, clinical progression and adverse events were also evaluated. Efficacy was assessed using intent-to-treat (ITT) (missing=failure) and on-treatment analysis. Results At 12 months in the ITT analysis the proportion of patients with pVL below 200 copies/ml was 60% (95% CI 48.5–71.5) in the zidovudine/lamivudine/nelfinavir arm and 75% (95% CI 65–85) in the zidovudine/lamivudine/nevirapine arm ( P=0.06), and the proportion below 20 copies/ml was 50% (95% CI 38.3–61.7) and 65% (95% CI 54.2–76.2), respectively ( P=0.06). No differences were found when comparing the subgroup of patients with baseline pVL of more than 100 000 copies/ml. A gain of +173 and +162 CD4 cells/mm3, respectively, was observed. Zidovudine/lamivudine/nelfinavir was discontinued in 21% of patients, and zidovudine/lamivudine/ nevirapine in 25%, due to toxicity ( P>0.2). Conclusions Our results suggest that zidovudine/ lamivudine/nevirapine is at least as effective as zidovudine/lamivudine/nelfinavir as first-line therapy for HIV disease.
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Affiliation(s)
- Daniel Podzamczer
- Infectious Disease Service, Ciutat Sanitària de Bellvitge, L'Hospitalet, Barcelona, Spain
| | - Elena Ferrer
- Infectious Disease Service, Ciutat Sanitària de Bellvitge, L'Hospitalet, Barcelona, Spain
| | - Ezequiel Consiglio
- Infectious Disease Service, Ciutat Sanitària de Bellvitge, L'Hospitalet, Barcelona, Spain
| | | | - Pepa Perez
- Microbiology Service, Ciutat Sanitària de Bellvitge, L'Hospitalet, Barcelona, Spain
| | - José Luis Perez
- Microbiology Service, Ciutat Sanitària de Bellvitge, L'Hospitalet, Barcelona, Spain
| | - Elena Luna
- Infectious Disease Service, Ciutat Sanitària de Bellvitge, L'Hospitalet, Barcelona, Spain
| | | | - Enric Pedrol
- Internal Medicine Service, Hospital de Granollers, Granollers, Barcelona, Spain
| | - Luisa Lozano
- Infectious Disease Service, Hospital Clínic, Barcelona, Spain
| | - Imma Ocaña
- Infectious Disease Service, Hospital Vall d'Hebron, Barcelona, Spain
| | - Josep María Llibre
- Internal Medicine Service, Hospital de Calella, Calella, Barcelona, Spain
| | - Arnaldo Casiró
- Internal Medicine Service, Hospital Alvarez, Buenos Aires, Argentina
| | - Miquel Aranda
- Internal Medicine Service, Hospital Comarcal de Terrassa, Terrassa, Barcelona, Spain
| | - Pilar Barrufet
- Internal Medicine Service, Hospital de Mataró, Mataró, Barcelona, Spain
| | | | - José María Miró
- Infectious Disease Service, Hospital Clínic, Barcelona, Spain
| | - Xavier Badía
- Iberoamerican Cochrane Center, Hospital de Sant Pau, Barcelona, Spain
| | - Alfonso Casado
- Iberoamerican Cochrane Center, Hospital de Sant Pau, Barcelona, Spain
| | - Sergio Lupo
- Internal Medicine Service, CAICI, Rosario, Argentina
| | - Pedro Cahn
- Fundación Huesped, Buenos Aires, Argentina
| | - Manel Maños
- Otolaringology Service, Ciutat Sanitària de Bellvitge, L'Hospitalet, Barcelona, Spain
| | - Jordi Estela
- Neurology Service, Ciutat Sanitària de Bellvitge, L'Hospitalet, Barcelona, Spain
| | - MJ Barberá
- Ciutat Sanitária de Bellvitge, L'Hospitalet
| | - M Santín
- Ciutat Sanitária de Bellvitge, L'Hospitalet
| | - F Gudiol
- Ciutat Sanitária de Bellvitge, L'Hospitalet
| | - M Hidalgo
- Ciutat Sanitária de Bellvitge, L'Hospitalet
| | - H Knobel
- Hospital del Mar; R Solé, Hospital de Granollers
| | | | | | - M Roget
- Hospital Comarcal de Terrassa
| | | | - D Dalmau
- Mutua de Terrassa, Barcelona, Spain
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