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Gibas KM, Kelly SG, Arribas JR, Cahn P, Orkin C, Daar ES, Sax PE, Taiwo BO. Two-drug regimens for HIV treatment. Lancet HIV 2022; 9:e868-e883. [PMID: 36309038 PMCID: PMC10015554 DOI: 10.1016/s2352-3018(22)00249-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 08/16/2022] [Accepted: 08/22/2022] [Indexed: 12/05/2022]
Abstract
Combination therapy with three antiretroviral agents has been integral to successful HIV-1 treatment since 1996. Although the efficacy, adverse effects, and toxicities of contemporary three-drug regimens have improved, even the newest therapies have potential adverse effects. The use of two-drug regimens is one way to reduce lifetime exposure to antiretroviral drugs while maintaining the benefits of viral suppression. Multiple large, randomised trials have shown the virological non-inferiority of certain two-drug regimens versus three-drug comparators, including adverse effect differences that reflect known profiles of the antiretroviral drugs in the respective regimens. Two-drug combinations are now recommended in treatment guidelines and include the first long-acting antiretroviral regimen for the treatment of HIV-1. Recommended two-drug regimens differ in their risks for, and factors associated with, virological failure and emergent resistance. The tolerability, safety, metabolic profiles, and drug interactions of two-drug regimens also vary by the constituent drugs. No current two-drug regimen is recommended for people with chronic hepatitis B virus as none include tenofovir. Two-drug regimens have increased options for individualised care.
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Affiliation(s)
- Kevin M Gibas
- Division of Infectious Diseases, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN, USA
| | - Sean G Kelly
- Division of Infectious Diseases, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN, USA
| | - Jose R Arribas
- Infectious Diseases Unit, La Paz University Hospital, Hospital La Paz Institute for Health Research, Madrid, Spain; School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Madrid, Spain
| | - Pedro Cahn
- Fundación Huésped, Buenos Aires, Argentina
| | - Chloe Orkin
- Department of Immunobiology, Queen Mary University of London, London, UK
| | - Eric S Daar
- The Lundquist Institute, Harbor University of California, Los Angeles, Torrence, CA, USA
| | - Paul E Sax
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | - Babafemi O Taiwo
- Division of Infectious Diseases, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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Shorter Time to Discontinuation Due to Treatment Failure in People Living with HIV Switched to Dolutegravir Plus Either Rilpivirine or Lamivudine Compared with Integrase Inhibitor-Based Triple Therapy in a Large Spanish Cohort. Infect Dis Ther 2022; 11:1177-1192. [PMID: 35399147 PMCID: PMC9124284 DOI: 10.1007/s40121-022-00630-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 03/18/2022] [Indexed: 11/27/2022] Open
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Badowski M, Pérez SE, Silva D, Lee A. Two's a Company, Three's a Crowd: A Review of Initiating or Switching to a Two-Drug Antiretroviral Regimen in Treatment-Naïve and Treatment-Experienced Patients Living with HIV-1. Infect Dis Ther 2020; 9:185-208. [PMID: 32193799 PMCID: PMC7237600 DOI: 10.1007/s40121-020-00290-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION As HIV has become a manageable chronic condition, a renewed and increased interest in challenging traditional three-drug HIV therapies and moving toward two-drug regimens (2DR) for initial or maintenance treatment in people living with HIV (PLWH) has developed. As PLWH are living longer, continual advancements in antiretroviral regimens have been a focus to provide optimal life-long therapy options. Although early studies may have shown poor outcomes in virologic suppression with 2DR, newer studies and treatment options have emerged to show promise in the management of HIV. The purpose of this review is to evaluate current literature and assess the efficacy of two-drug (2DR) antiretroviral therapy in treatment-naïve and -experienced people living with HIV. METHODS A systematic search was performed between January 2009 to January 2020, using EMBASE, MEDLINE, Google Scholar, and bibliographies. Combinations of the following search terms were used: HIV-1 infection, antiretroviral therapy, dual therapy, two-drug regimen, two-drug therapy, two-drug regimen, and 2DR. Included studies were those in the adult population with at least one active comparator, outcomes assessing HIV-1 RNA viral load while on treatment, and written in English. RESULTS Thirty-three studies were included, 13 where 2DRs were evaluated as initial therapy (3 studies with extension data) and 15 where 2DRs were evaluated as maintenance or switch therapy (2 studies with extension data). CONCLUSION Although 2DRs may not be appropriate in all patient populations, they are being utilized more frequently and have the potential to reduce costs, adverse effects, and drug interactions.
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Affiliation(s)
| | - Sarah E Pérez
- College of Pharmacy, University of New Mexico, Albuquerque, NM, USA
| | - David Silva
- College of Pharmacy, University of Illinois, Chicago, IL, USA
| | - Andrea Lee
- College of Pharmacy, University of Illinois, Chicago, IL, USA
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Perez-Molina JA, Pulido F, Di Giambenedetto S, Ribera E, Moreno S, Zamora J, Coscia C, Alejos B, Pitch J, Gatell JM, De Luca A, Arribas JR. Individual patient data meta-analysis of randomized controlled trials of dual therapy with a boosted PI plus lamivudine for maintenance of virological suppression: GeSIDA study 9717. J Antimicrob Chemother 2019; 73:2927-2935. [PMID: 30085184 DOI: 10.1093/jac/dky299] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/26/2018] [Indexed: 12/24/2022] Open
Abstract
Background Dual therapy (DT) with a ritonavir-boosted PI (PI/r) plus lamivudine has proven non-inferior (12% margin) to triple therapy (TT) with PI/r plus two nucleos(t)ide reverse transcriptase inhibitors [N(t)RTIs] in four clinical trials. It remains unclear whether DT is non-inferior based on the US FDA endpoint (virological failure with a margin of 4%) or in specific subgroups. Methods We performed a systematic search (January 1990 to March 2017) of randomized controlled trials that compared switching of maintenance ART from TT to DT. The principal investigators were contacted and agreed to share study databases. The primary endpoint was non-inferiority of DT to TT based on the current FDA endpoint (4% non-inferiority margin for virological failure at week 48). We also analysed whether efficacy was modified by gender, active HCV infection and type of PI. Effect estimates and 95% CIs were calculated using generalized estimating equation-based models. Results We found 881 references that yielded eight articles corresponding to four clinical trials (1051 patients). At week 48, 4% of patients on DT versus 3.04% on TT had experienced virological failure (difference 0.9%; 95% CI -1.2% to 3.1%), and 84.7% of patients on DT versus 83.2% on TT had <50 copies of HIV RNA/mL (FDA snapshot algorithm) (difference 1.4%; 95% CI -2.8% to 5.8%). Gender, active HCV infection and type of PI had no effect on differences in treatment efficacy between DT and TT. Conclusions DT was non-inferior to TT using both current and past FDA endpoints. The efficacy of DT was not influenced by gender, active HCV infection status, or type of PI.
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Affiliation(s)
- J A Perez-Molina
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - F Pulido
- HIV Unit, Hospital Universitario Doce de Octubre, imas12, UCM, Madrid, Spain
| | - S Di Giambenedetto
- Institute of Clinical Infectious Diseases, Catholic University of Sacred Heart, Rome, Italy
| | - E Ribera
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - S Moreno
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - J Zamora
- Clinical Biostatistics Unit and CIBERESP, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain.,Queen Mary University, London, UK
| | - C Coscia
- Clinical Biostatistics Unit and CIBERESP, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - B Alejos
- Centro Nacional de Epidemiología, Instituto Carlos III, Madrid, Spain
| | - J Pitch
- Hospital Clínic/Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - J M Gatell
- Hospital Clínic/Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - A De Luca
- UOC Malattie Infettive, Azienda Ospedaliera Universitaria Senese, and Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - J R Arribas
- Hospital Universitario La Paz, IDIPAZ, Madrid, Spain
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Cento V, Perno CF. Two-drug regimens with dolutegravir plus rilpivirine or lamivudine in HIV-1 treatment-naïve, virologically-suppressed patients: Latest evidence from the literature on their efficacy and safety. J Glob Antimicrob Resist 2019; 20:228-237. [PMID: 31446092 DOI: 10.1016/j.jgar.2019.08.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 08/15/2019] [Accepted: 08/15/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES In the HIV-1-positive population, a paradigm shift from three-drug regimens (3DRs) to dolutegravir-based two-drug regimens (2DRs) both as initial and switch treatment is beginning to take place, supported virologically by the availability of new potent drugs with high genetic barrier to overcome, at least in certain conditions, the dogma of 3DRs in effective HIV-1 therapy. This manuscript reviews the increasing evidence on their excellent and sustained long-term effectiveness and safety. METHODS This review includes the most recent results on dolutegravir plus rilpivirine or lamivudine 2DRs from randomised clinical trials, meta-analyses and real-life studies, including relevant data presented at international conferences up to August 2019. RESULTS As an initial treatment strategy, dolutegravir plus lamivudine showed high efficacy and safety over 96 weeks in 1441 patients from the GEMINI-1&2 phase III non-inferiority trials. In the SWORD 1&2 trials in virologically-suppressed patients, switching to once-daily dolutegravir plus rilpivirine maintained efficacy over 148 weeks. Similarly, in the TANGO trial, no confirmed virological withdrawals were observed with dolutegravir/lamivudine through Week 48. Consistent results were observed in real-life cohorts. No emergent dolutegravir-resistant virus has ever been reported in a patient in whom dolutegravir was prescribed in the context of such 2DRs. Switching to once-daily dolutegravir plus rilpivirine or lamivudine was generally well tolerated and was associated with favourable renal and bone safety. CONCLUSION The results available so far support dolutegravir-based 2DRs as excellent treatment options for adults with HIV-1 infection, either naïve or already virologically suppressed on their current antiretroviral regimen.
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Affiliation(s)
- Valeria Cento
- Residency in Microbiology and Virology, Università degli Studi di Milano, Milan, Italy
| | - Carlo Federico Perno
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milan, Italy.
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Switch to dolutegravir and unboosted atazanavir in HIV-1 infected patients with undetectable viral load and long exposure to antiretroviral therapy. AIDS 2019; 33:1256-1260. [PMID: 30870194 DOI: 10.1097/qad.0000000000002188] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
: We evaluated the efficacy and safety of a two-drug regimen including dolutegravir (DTG) and unboosted atazanavir (uATV) in 151 HIV-1 infected patients with HIV-RNA of more than 50 copies/ml. During a median follow-up of 62 (42-97) weeks, two virological failures (1%) and 13 treatment discontinuations (9%) occurred; the 48-week probability of virological failure was 0.8% (95% confidence interval 0.2-5.6%). Switch to DTG + uATV may represent a boosting and transcriptase reverse inhibitors sparing otion in individuals with long exposure to antiretroviral therapy and risk of cardiovascular disease.
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Pasquau J, de Jesus SE, Arazo P, Crusells MJ, Ríos MJ, Lozano F, de la Torre J, Galindo MJ, Carmena J, Santos J, Tornero C, Verdejo G, Samperiz G, Palacios Z, Hidalgo-Tenorio C. Effectiveness and safety of dual therapy with rilpivirine and boosted darunavir in treatment-experienced patients with advanced HIV infection: a preliminary 24 week analysis (RIDAR study). BMC Infect Dis 2019; 19:207. [PMID: 30819101 PMCID: PMC6396540 DOI: 10.1186/s12879-019-3817-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 02/13/2019] [Indexed: 01/01/2023] Open
Abstract
Background The objective was to analyze the effectiveness and safety of dual therapy with rilpivirine plus boosted-darunavir (RPV + bDRV) in real-life patients. Methods Observational, retrospective, multi-center study in HIV+ patients who had received RPV + bDRV for 24 weeks to optimize/simplify their previous antiretroviral treatment. We determined the percentage of patients without virologic failure (2 consecutive viral loads > 50 copies/mL) at 24 weeks of treatment. Results The study included 161 patients from 15 hospitals with median age of 49 years; 29.3% had previous AIDS stage and median CD4+ lymphocyte nadir of 170 cells/uL. They had been diagnosed with HIV for a median of 17 years and had received 14 years of ART, with five previous treatment combinations, and 36.6% had a history of virological failure. The reasons for the switch were simplification/optimization (49.7%), toxicity/intolerance (17.4%), or inadequate effectiveness of previous ART (10.6%). Baseline VL of 50–1000 copies/mL was recorded in 25.5% of the patients. In the“intention-to-treat” analysis at 24 weeks, 87.6% of 161 patients continued the study treatment without virologic failure criteria. In the “on treatment” analysis (excluding patients who discontinued treatment with dual therapy for any reason other than virologic failure) the efficacy was 94.6% (141/149 patients). Conclusions Dual therapy with RPV + DRVb proved to be effective and safe in patients with advanced HIV infection, long exposure to ART, low CD4 nadir, previous virologic failure, and/or history of ineffective ART.
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Affiliation(s)
- Juan Pasquau
- Hospital Universitario Virgen de las Nieves, Granada, Spain.
| | | | | | | | | | | | | | | | - Jorge Carmena
- Hospital Universitario Doctor Peset, Valencia, Spain
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Barrier to Resistance of Dolutegravir in Two-Drug Combinations. Antimicrob Agents Chemother 2019; 63:AAC.02104-18. [PMID: 30602514 DOI: 10.1128/aac.02104-18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 12/04/2018] [Indexed: 01/18/2023] Open
Abstract
A major concern when using two-drug anti-HIV regimens is the risk of viral resistance. However, no techniques to evaluate the barrier to resistance of two-drug combinations in vitro have been reported. We evaluated the emergence of drug-resistant mutants in a passage study with constant concentrations of two drugs simultaneously. The barrier to resistance of dolutegravir-containing two-drug combinations was higher than the other combinations evaluated in this study.
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Chastain D, Badowski M, Huesgen E, Pandit NS, Pallotta A, Michienzi S. Optimizing Antiretroviral Therapy in Treatment-Experienced Patients Living with HIV: A Critical Review of Switch and Simplification Strategies. An Opinion of the HIV Practice and Research Network of the American College of Clinical Pharmacy. J Int Assoc Provid AIDS Care 2019; 18:2325958219867325. [PMID: 31516088 PMCID: PMC6900586 DOI: 10.1177/2325958219867325] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/11/2019] [Accepted: 07/02/2019] [Indexed: 12/28/2022] Open
Abstract
Simplifying or switching antiretroviral therapy (ART) in treatment-experienced people living with HIV (PLWH) may improve adherence, tolerability, toxicities, and/or drug-drug interactions. The purpose of this review is to critically evaluate the literature for efficacy and safety associated with switching or simplifying ART in treatment-experienced PLWH. A systematic literature search using MEDLINE was performed from January 1, 2010 to April 30, 2018. References within articles of interest, the Department of Health and Human Services guidelines, and conference abstracts were also reviewed. Switch/simplification strategies were categorized as those supported by high-level clinical evidence and those with emerging data. Rates of virologic suppression were noninferior for several switch/simplification strategies when compared to baseline ART. Potential for reducing adverse events was also seen. Additional evidence for some strategies, including most 2-drug regimens, is needed before they can be recommended.
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Affiliation(s)
| | - Melissa Badowski
- Department of Pharmacy Practice, University of Illinois at Chicago, College
of Pharmacy, Chicago, IL, USA
| | | | - Neha Sheth Pandit
- Department of Pharmacy Practice and Science, University of Maryland School
of Pharmacy, Baltimore, MD, USA
| | - Andrea Pallotta
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Sarah Michienzi
- Department of Pharmacy Practice, University of Illinois at Chicago, College
of Pharmacy, Chicago, IL, USA
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Corado KC, Caplan MR, Daar ES. Two-drug regimens for treatment of naïve HIV-1 infection and as maintenance therapy. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:3731-3740. [PMID: 30464404 PMCID: PMC6219414 DOI: 10.2147/dddt.s140767] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
As people live longer with HIV infection, there has been a resurgence of interest in challenging the use of three-drug therapy, including two nucleoside reverse transcriptase inhibitors plus a third drug, as initial treatment of HIV infection or for maintenance therapy in virologically suppressed individuals. Although initial studies showed poor efficacy and/or substantial toxicity, more recent regimens have held greater promise. The SWORD-1 and -2 studies were pivotal trials of dolutegravir plus rilpivirine as maintenance therapy in virologically suppressed patients with no history of drug resistance, leading to the US Food and Drug Administration’s approval of the regimen as a small, single tablet. More recently, the GEMINI-1 and -2 studies demonstrated that dolutegravir plus lamivudine is as safe and effective as the same regimen when combined with tenofovir disoproxil fumarate in treatment-naïve individuals. Together, these and other studies of novel two-drug regimens offer the potential for improved tolerability and simplicity, as well as a reduction in cost. We will review historical and recent trials of two-drug therapy for the treatment of HIV-1 infection.
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Affiliation(s)
- Katya C Corado
- Department of Medicine, Division of HIV Medicine, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, CA, USA,
| | - Margaret R Caplan
- Department of Medicine, Division of HIV Medicine, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, CA, USA,
| | - Eric S Daar
- Department of Medicine, Division of HIV Medicine, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, CA, USA,
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Chawla A, Wang C, Patton C, Murray M, Punekar Y, de Ruiter A, Steinhart C. A Review of Long-Term Toxicity of Antiretroviral Treatment Regimens and Implications for an Aging Population. Infect Dis Ther 2018; 7:183-195. [PMID: 29761330 PMCID: PMC5986685 DOI: 10.1007/s40121-018-0201-6] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Indexed: 02/07/2023] Open
Abstract
Human immunodeficiency virus (HIV) is a chronic infectious disease currently requiring lifelong antiretroviral therapy (ART). People living with HIV (PLWH) face an increased risk of comorbidities associated with aging, chronic HIV, and the toxicity arising from long-term ART. A literature review was conducted to identify the most recent evidence documenting toxicities associated with long-term ART, particularly among aging PLWH. In general, PLWH are at a greater risk of developing fractures, osteoporosis, renal and metabolic disorders, central nervous system disorders, cardiovascular disease, and liver disease. There remains limited evidence describing the economic burden of long-term ART. Overall, an aging HIV population treated with long-term ART presents a scenario in which the clinical, humanistic, and economic burden for healthcare systems will demand thoughtful policy solutions that preserve access to treatment. Newer treatment regimens with fewer drugs may mitigate some of the cumulative toxicity burden of long-term ART. Funding: ViiV Healthcare.
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Rossetti B, Montagnani F, De Luca A. Current and emerging two-drug approaches for HIV-1 therapy in ART-naïve and ART-experienced, virologically suppressed patients. Expert Opin Pharmacother 2018; 19:713-738. [PMID: 29676935 DOI: 10.1080/14656566.2018.1457648] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Current guidelines recommend a 2-drug antiretroviral regimen as an alternative to triple antiretroviral therapy (ART) in selected patients to reduce long-term toxicity and costs. AREAS COVERED This review is intended to provide insight into the efficacy, safety and tolerability of 2-drug versus 3-drug ART in naïve and in treatment-experienced virologically-suppressed patients. EXPERT OPINION Dual therapy regimens are not feasible in HBV-coinfected individuals and should not be applied during pregnancy. Positive data on 2-drug ART in drug naïve patients are still limited, while, in virologically-suppressed individuals, several regimens have shown non-inferiority as compared to 3-drug regimens. The strongest evidence of efficacy applies to ritonavir-boosted PI regimens combined with lamivudine and to dolutegravir with rilpivirine. Dual therapies showed improved renal function and bone mineral density over tenofovir disoproxil fumarate-based 3-drug regimens. There are also great expectations for ongoing phase 3 trials testing dolutegravir with lamivudine. New and future single tablet co-formulations of dual regimens are expected to improve their suitability. Despite the lack of comparison with tenofovir alafenamide-based 3-drug regimens, the 2-drug regimens showing consistent non-inferiority and safety versus 3-drug regimens will challenge the current paradigm of 3-drug ART.
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Affiliation(s)
- Barbara Rossetti
- a Infectious Diseases Unit, Hospital Department of Specialized and Internal Medicine , University Hospital of Siena , Siena , Italy.,b Clinic of Infectious Diseases , Catholic University of Sacred Heart , Rome , Italy
| | - Francesca Montagnani
- a Infectious Diseases Unit, Hospital Department of Specialized and Internal Medicine , University Hospital of Siena , Siena , Italy.,c Department of Medical Biotechnologies, Infectious Diseases Division , University of Siena , Siena , Italy
| | - Andrea De Luca
- a Infectious Diseases Unit, Hospital Department of Specialized and Internal Medicine , University Hospital of Siena , Siena , Italy.,c Department of Medical Biotechnologies, Infectious Diseases Division , University of Siena , Siena , Italy
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Nucleoside-Sparing Regimens With Raltegravir and a Boosted Protease Inhibitor: An Unsettled Issue. J Acquir Immune Defic Syndr 2018; 72:e48-50. [PMID: 26977746 DOI: 10.1097/qai.0000000000000990] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Di Giambenedetto S, Fabbiani M, Quiros Roldan E, Latini A, D'Ettorre G, Antinori A, Castagna A, Orofino G, Francisci D, Chinello P, Madeddu G, Grima P, Rusconi S, Di Pietro M, Mondi A, Ciccarelli N, Borghetti A, Focà E, Colafigli M, De Luca A, Cauda R. Treatment simplification to atazanavir/ritonavir + lamivudine versus maintenance of atazanavir/ritonavir + two NRTIs in virologically suppressed HIV-1-infected patients: 48 week results from a randomized trial (ATLAS-M). J Antimicrob Chemother 2017; 72:1163-1171. [PMID: 28093483 DOI: 10.1093/jac/dkw557] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 11/27/2016] [Indexed: 11/14/2022] Open
Abstract
Background Combination ART (cART)-related toxicities and costs have prompted the need for treatment simplification. The ATLAS-M trial explored 48 week non-inferior efficacy of simplification to atazanavir/ritonavir + lamivudine versus maintaining three-drug atazanavir/ritonavir-based cART in virologically suppressed patients. Methods We performed an open-label, multicentre, randomized, non-inferiority study, enrolling HIV-infected adults on atazanavir/ritonavir + two NRTIs, with stable HIV-RNA <50 copies/mL and CD4 + >200 cells/mm 3 . Main exclusion criteria were hepatitis B virus coinfection, past virological failure on or resistance to study drugs, recent AIDS and pregnancy. Patients were randomly assigned 1:1 to either switch to 300 mg of atazanavir/100 mg of ritonavir once daily and 300 mg of lamivudine once daily (atazanavir/ritonavir + lamivudine arm) or to continue the previous regimen (atazanavir/ritonavir + two NRTIs arm). The primary study outcome was the maintenance of HIV-RNA <50 copies/mL at week 48 of the ITT-exposed (ITT-e) analysis with switch = failure. The non-inferiority margin was 12%. This study is registered at ClinicalTrials.gov, number NCT01599364. Results Between July 2011 and June 2014, 266 patients were randomized (133 to each arm). After 48 weeks, the primary study outcome was met by 119 of 133 patients (89.5%) in the atazanavir/ritonavir + lamivudine arm and 106 of 133 patients (79.7%) in the atazanavir/ritonavir + two NRTIs arm [difference atazanavir/ritonavir + lamivudine versus atazanavir/ritonavir + two NRTIs arm: +9.8% (95% CI + 1.2 to + 18.4)], demonstrating non-inferiority and superior efficacy of the atazanavir/ritonavir + lamivudine arm. Virological failure occurred in two (1.5%) patients in the atazanavir/ritonavir + lamivudine arm and six (4.5%) patients in the atazanavir/ritonavir + two NRTIs arm, without resistance selection. A similar proportion of adverse events occurred in both arms. Conclusions Treatment simplification to atazanavir/ritonavir + lamivudine showed non-inferior efficacy (superiority on post-hoc analysis) and a comparable safety profile over continuing atazanavir/ritonavir + two NRTIs in virologically suppressed patients.
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Affiliation(s)
| | - Massimiliano Fabbiani
- Institute of Clinical Infectious Diseases, Catholic University of Sacred Heart, Rome, Italy
| | - Eugenia Quiros Roldan
- University Division of Infectious and Tropical Diseases, University of Brescia, Brescia, Italy
| | - Alessandra Latini
- Infectious Dermatology and Allergology Unit, IFO S. Gallicano Institute (IRCCS), Rome, Italy
| | | | - Andrea Antinori
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' IRCCS, Rome, Italy
| | - Antonella Castagna
- Department of Infectious and Tropical Diseases, Vita-Salute San Raffaele University, San Raffaele Hospital, Milan, Italy
| | - Giancarlo Orofino
- Infectious and Tropical Diseases Unit, Amedeo di Savoia Hospital, Torino, Italy
| | | | - Pierangelo Chinello
- Systemic Infections and Immunodeficiency Unit, National Institute for Infectious Diseases 'Lazzaro Spallanzani' IRCCS, Rome, Italy
| | - Giordano Madeddu
- Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy
| | | | - Stefano Rusconi
- Infectious Diseases Unit, DIBIC Luigi Sacco, University of Milan, Milan, Italy
| | - Massimo Di Pietro
- Unit of Infectious Diseases, S.M. Annunziata Hospital, Florence, Italy
| | - Annalisa Mondi
- Institute of Clinical Infectious Diseases, Catholic University of Sacred Heart, Rome, Italy
| | - Nicoletta Ciccarelli
- Institute of Clinical Infectious Diseases, Catholic University of Sacred Heart, Rome, Italy
| | - Alberto Borghetti
- Institute of Clinical Infectious Diseases, Catholic University of Sacred Heart, Rome, Italy
| | - Emanuele Focà
- University Division of Infectious and Tropical Diseases, University of Brescia, Brescia, Italy
| | - Manuela Colafigli
- Infectious Dermatology and Allergology Unit, IFO S. Gallicano Institute (IRCCS), Rome, Italy
| | - Andrea De Luca
- UOC Malattie Infettive, Azienda Ospedaliera Universitaria Senese, Siena, Italy.,Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Roberto Cauda
- Institute of Clinical Infectious Diseases, Catholic University of Sacred Heart, Rome, Italy
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15
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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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Soriano V, Fernandez-Montero JV, Benitez-Gutierrez L, Mendoza CD, Arias A, Barreiro P, Peña JM, Labarga P. Dual antiretroviral therapy for HIV infection. Expert Opin Drug Saf 2017. [PMID: 28621159 DOI: 10.1080/14740338.2017.1343300] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION For two decades, triple combinations of antiretrovirals have been the standard treatment for HIV infection. The challenges of such lifelong therapy include long-term side effects, high costs and reduced drug adherence. The recent advent of more potent and safer antiretrovirals has renewed the interest for simpler HIV regimens. Areas covered: We discuss the pros and cons of dual antiretroviral therapies in both drug-naïve and in treatment-experienced patients with viral suppression (switch strategy). Expert opinion: Some dual antiretroviral regimens are safe and efficacious, particularly as maintenance therapy. At this time, combinations of dolutegravir plus rilpivirine represent the best dual regimen. Longer follow-up and larger study populations are needed before supporting dolutegravir plus lamivudine. In contrast, dual therapy based on maraviroc is less effective. Although dual regimens with boosted protease inhibitors plus either lamivudine or raltegravir may be effective, they are penalized by metabolic side effects and risk for drug interactions. The newest dual regimens could save money, reduce toxicity and spare drug options for the future. For the first time in HIV therapeutics, less can be more. Dual therapy switching has set up a new paradigm in HIV treatment that uses induction-maintenance.
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Affiliation(s)
- Vicente Soriano
- a Infectious Diseases Unit , La Paz University Hospital & Autonomous University , Madrid , Spain
| | | | | | - Carmen de Mendoza
- c Internal Medicine Department , Puerta de Hierro Research Institute , Majadahonda , Spain
| | - Ana Arias
- c Internal Medicine Department , Puerta de Hierro Research Institute , Majadahonda , Spain
| | - Pablo Barreiro
- a Infectious Diseases Unit , La Paz University Hospital & Autonomous University , Madrid , Spain
| | - José M Peña
- a Infectious Diseases Unit , La Paz University Hospital & Autonomous University , Madrid , Spain
| | - Pablo Labarga
- d Internal Medicine Department , Nuestra Señora de la Paz Hospital , Madrid , Spain
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19
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Switch to Ritonavir-Boosted versus Unboosted Atazanavir plus Raltegravir Dual-Drug Therapy Leads to Similar Efficacy and Safety Outcomes in Clinical Practice. PLoS One 2016; 11:e0164240. [PMID: 27798641 PMCID: PMC5087881 DOI: 10.1371/journal.pone.0164240] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 09/21/2016] [Indexed: 01/08/2023] Open
Abstract
Objectives To assess immunovirological response, safety and pharmacokinetic of NRTI-sparing regimen dual therapy of atazanavir (ATV) and raltegravir (RAL) in maintenance strategy. Methods A retrospective analysis was conducted on a cohort of HIV-infected adults followed in French centers (Dat’AIDS cohort), comparing the proportions of virological and therapeutic failures between ATV + RAL and ATV/ritonavir + RAL dual therapy regimens. Results 283 patients were assessed: 185 switched for ATV + RAL and 98 for ATV/ritonavir + RAL dual therapy. Virological failure rate at week 96 was 13.8% (95% CI, 9.8–17.8), without difference between the two groups (Log-rank Test, p = 0.87). The cumulative percentages of patients remaining free of therapeutic failure at week 24, 48 and 96 of dual therapy were 74.9% (95% CI, 69.9–80.0), 65.4% (95% CI, 59.8–70.9) and 53.4% (95% CI, 47.5–59.2), respectively. Four out of 39 confirmed virological failures developed RAL resistance. By multivariate analysis, virological failure was associated with high HIV-1 RNA zenith (p = 0.02), low CD4+ T-cell count at baseline (p<0.001) and short duration on antiretroviral therapy (p<0.001). Before week 96, dual therapy was discontinued in 44 patients (16%) because of various adverse events, with no difference between the two groups. Minimal plasma levels were targeted in 84% and 87% of patients for ATV and RAL, respectively, and both were significantly higher in ritonavir-boosted regimen. Conclusions Emerging RAL-resistance and discontinuations for adverse events resulted in moderate efficacy rates of ATV and RAL dual therapy in heavily pretreated patients.
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Achhra AC, Mwasakifwa G, Amin J, Boyd MA. Efficacy and safety of contemporary dual-drug antiretroviral regimens as first-line treatment or as a simplification strategy: a systematic review and meta-analysis. LANCET HIV 2016; 3:e351-e360. [DOI: 10.1016/s2352-3018(16)30015-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 03/31/2016] [Accepted: 03/31/2016] [Indexed: 12/01/2022]
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