1
|
Pierone Jr G, Brunet L, Fusco JS, Henegar CE, Sarkar S, Van Wyk J, Vannappagari V, Wohlfeiler MB, Fusco GP. Switching to Dolutegravir/Lamivudine Two-Drug Regimen: Durability and Virologic Outcomes by Age, Sex, and Race in Routine US Clinical Care. HIV AIDS (Auckl) 2024; 16:133-140. [PMID: 38645753 PMCID: PMC11032131 DOI: 10.2147/hiv.s452130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/13/2024] [Indexed: 04/23/2024] Open
Abstract
Purpose Two-drug regimens (2DR) may address drug-drug interactions and toxicity concerns. Dolutegravir/lamivudine (DTG/3TC) 2DR was approved in the US for both treatment-naïve and treatment-experienced individuals with a viral load <50 copies/mL. This study describes real-world DTG/3TC 2DR treatment outcomes among treatment-experienced individuals, stratified by age, sex, and race. Methods From the OPERA® cohort, people with HIV with a viral load <50 copies/mL who switched from a commonly used three-drug regimen to DTG/3TC 2DR as per the label between April 8, 2019 and April 30, 2021 were included. Incidence rates (Poisson regression) for loss of virologic control (first viral load ≥50 copies/mL), confirmed virologic failure (2 viral loads ≥200 copies/mL or discontinuation after 1 viral load ≥200 copies/mL), and DTG/3TC 2DR discontinuation were estimated overall and stratified by age, sex, and race. Results The 787 individuals included were followed for a median of 13.6 months (IQR: 8.2, 22.3). Confirmed virologic failure occurred in ≤5 individuals. Loss of virologic control occurred at a rate of 14.0 per 100 person-years (95% CI: 11.7, 16.8). DTG/3TC 2DR discontinuation occurred at a rate of 17.5 per 100 person-years (95% CI: 15.0, 20.3); 4% discontinued for treatment-related reasons (viremia, adverse diagnosis, side effect, lab abnormality). For all outcomes, incidence rates were comparable across strata of age, sex, and race. Conclusion This descriptive study demonstrates that DTG/3TC 2DR is an effective and well-tolerated treatment option for people with HIV with a viral load <50 copies/mL at switch, regardless of their age, sex, or race.
Collapse
Affiliation(s)
- Gerald Pierone Jr
- Department of Adult Primary Care, Whole Family Health Center, Vero Beach, FL, USA
| | | | | | - Cassidy E Henegar
- Epidemiology and Real World Evidence, ViiV Healthcare, Research Triangle Park, NC, USA
| | - Supriya Sarkar
- Epidemiology and Real World Evidence, ViiV Healthcare, Research Triangle Park, NC, USA
| | | | - Vani Vannappagari
- Epidemiology and Real World Evidence, ViiV Healthcare, Research Triangle Park, NC, USA
| | | | | |
Collapse
|
2
|
Chu C, Tao K, Kouamou V, Avalos A, Scott J, Grant PM, Rhee SY, McCluskey SM, Jordan MR, Morgan RL, Shafer RW. Prevalence of Emergent Dolutegravir Resistance Mutations in People Living with HIV: A Rapid Scoping Review. Viruses 2024; 16:399. [PMID: 38543764 PMCID: PMC10975848 DOI: 10.3390/v16030399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND Dolutegravir (DTG) is a cornerstone of global antiretroviral (ARV) therapy (ART) due to its high efficacy and favorable tolerability. However, limited data exist regarding the risk of emergent integrase strand transfer inhibitor (INSTI) drug-resistance mutations (DRMs) in individuals receiving DTG-containing ART. METHODS We performed a PubMed search using the term "Dolutegravir", last updated 18 December 2023, to estimate the prevalence of VF with emergent INSTI DRMs in people living with HIV (PLWH) without previous VF on an INSTI who received DTG-containing ART. RESULTS Of 2131 retrieved records, 43 clinical trials, 39 cohorts, and 6 cross-sectional studies provided data across 6 clinical scenarios based on ART history, virological status, and co-administered ARVs: (1) ART-naïve PLWH receiving DTG plus two NRTIs; (2) ART-naïve PLWH receiving DTG plus lamivudine; (3) ART-experienced PLWH with VF on a previous regimen receiving DTG plus two NRTIs; (4) ART-experienced PLWH with virological suppression receiving DTG plus two NRTIs; (5) ART-experienced PLWH with virological suppression receiving DTG and a second ARV; and (6) ART-experienced PLWH with virological suppression receiving DTG monotherapy. The median proportion of PLWH in clinical trials with emergent INSTI DRMs was 1.5% for scenario 3 and 3.4% for scenario 6. In the remaining four trial scenarios, VF prevalence with emergent INSTI DRMs was ≤0.1%. Data from cohort studies minimally influenced prevalence estimates from clinical trials, whereas cross-sectional studies yielded prevalence data lacking denominator details. CONCLUSIONS In clinical trials, the prevalence of VF with emergent INSTI DRMs in PLWH receiving DTG-containing regimens has been low. Novel approaches are required to assess VF prevalence with emergent INSTI DRMs in PLWH receiving DTG in real-world settings.
Collapse
Affiliation(s)
- Carolyn Chu
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA 94110, USA;
| | - Kaiming Tao
- Division of Infectious Diseases, Department of Medicine, Stanford University, Stanford, CA 94305, USA (J.S.); (S.-Y.R.)
| | - Vinie Kouamou
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare 00263, Zimbabwe;
| | - Ava Avalos
- Careena Center for Health, Gaborone, Botswana
| | - Jake Scott
- Division of Infectious Diseases, Department of Medicine, Stanford University, Stanford, CA 94305, USA (J.S.); (S.-Y.R.)
| | - Philip M. Grant
- Division of Infectious Diseases, Department of Medicine, Stanford University, Stanford, CA 94305, USA (J.S.); (S.-Y.R.)
| | - Soo-Yon Rhee
- Division of Infectious Diseases, Department of Medicine, Stanford University, Stanford, CA 94305, USA (J.S.); (S.-Y.R.)
| | | | - Michael R. Jordan
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, MA 02111, USA
- Collaboratory for Emerging Infectious Diseases and Response (CEIDR), Tufts University, Medford, MA 02155, USA
| | - Rebecca L. Morgan
- School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Robert W. Shafer
- Division of Infectious Diseases, Department of Medicine, Stanford University, Stanford, CA 94305, USA (J.S.); (S.-Y.R.)
| |
Collapse
|
3
|
Malagnino V, Mulas T, Teti E, Basso M, Giobbia M, Geremia N, Battagin G, Abi Aad Y, Vincensini JP, Iannetta M, Parisi SG, Sarmati L, Lacombe K. HBcAb Positivity as a Risk Factor for Missing HIV RNA Undetectability after the 3TC+DTG Switch. Viruses 2024; 16:348. [PMID: 38543714 PMCID: PMC10974397 DOI: 10.3390/v16030348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/19/2024] [Accepted: 02/21/2024] [Indexed: 05/23/2024] Open
Abstract
Hepatitis B Core antibody (HBcAb) positivity is the surrogate marker of hepatitis B occult infection. This condition is not a contraindication for switching to two-drug (2DR) antiretroviral therapy; however, the removal of tenofovir may contribute to poor control of HBV replication. A multicentre retrospective cohort study investigated the impact of HBcAb positivity on HIV control in patients switching to a 2DR with Lamivudine and Dolutegravir (3TC-DTG). In this study, a comparison analysis was conducted between HBcAb-positive and -negative PLWH regarding HIV-RNA suppression, considering: (1): Target Not Detected (TND) < 20 cp/mL; (2) Target Detected (TD) < 20 cp/mL; and (3) Detectable > 20 cp/mL and <50 cp/mL and >50 copies/mL. A total of 267 patients on 2DR with 3TC-DTG were included. In comparison to HBcAb-negative, HBcAb-positive patients were older (45 years [35-54]) and had a lower CD4+ nadir (248 vs. 349 cells/mmc, p = 0.007). No difference in the maintenance of virological suppression was present in the two groups of patients before the switch. Although no patient had an HIV-RNA > 20 cp/mL after the switch, significantly fewer HBcAb-positive compared with -negative subjects resulted in TND at 12, 24, and 36 months after the switch: 52 (69.3%) versus 164 (85.4%), p = 0.004, 50 [72.5%] versus 143 [89.9%], p = 0.001, and 30 [66.7%] versus 90 [92.8%], p = 0.001, respectively. HBcAb positivity is associated with an increased risk of suboptimal HIV suppression during the 36 months after 3TC/DTG simplification. This finding reinforces the relevance of the OBI condition in PLWH and raises the issue of careful virological monitoring of such cases.
Collapse
Affiliation(s)
- Vincenzo Malagnino
- Infectious Disease Unit, Policlinico Tor Vergata of Rome, 00133 Rome, Italy; (T.M.); (E.T.); (M.I.); (L.S.)
- Department of System Medicine, Tor Vergata University of Rome, 00133 Rome, Italy
| | - Tiziana Mulas
- Infectious Disease Unit, Policlinico Tor Vergata of Rome, 00133 Rome, Italy; (T.M.); (E.T.); (M.I.); (L.S.)
| | - Elisabetta Teti
- Infectious Disease Unit, Policlinico Tor Vergata of Rome, 00133 Rome, Italy; (T.M.); (E.T.); (M.I.); (L.S.)
| | - Monica Basso
- Department of Molecular Medicine, University of Padova, 35128 Padova, Italy; (M.B.); (S.G.P.)
| | - Mario Giobbia
- Infectious Disease Unit, Ospedale di Treviso, 31100 Treviso, Italy;
| | - Nicholas Geremia
- Infectious Disease Unit, Ospedale di Venezia, 30122 Venezia, Italy;
| | | | - Yasmine Abi Aad
- Hôpital Saint-Antoine, Assistance Publique Des Hôpitaux de Paris, Service Des Maladies Infectieuses Et Tropicales, Cedex 12, 75571 Paris, France; (Y.A.A.); (J.-P.V.); (K.L.)
| | - Jean-Paul Vincensini
- Hôpital Saint-Antoine, Assistance Publique Des Hôpitaux de Paris, Service Des Maladies Infectieuses Et Tropicales, Cedex 12, 75571 Paris, France; (Y.A.A.); (J.-P.V.); (K.L.)
| | - Marco Iannetta
- Infectious Disease Unit, Policlinico Tor Vergata of Rome, 00133 Rome, Italy; (T.M.); (E.T.); (M.I.); (L.S.)
- Department of System Medicine, Tor Vergata University of Rome, 00133 Rome, Italy
| | - Saverio Giuseppe Parisi
- Department of Molecular Medicine, University of Padova, 35128 Padova, Italy; (M.B.); (S.G.P.)
| | - Loredana Sarmati
- Infectious Disease Unit, Policlinico Tor Vergata of Rome, 00133 Rome, Italy; (T.M.); (E.T.); (M.I.); (L.S.)
- Department of System Medicine, Tor Vergata University of Rome, 00133 Rome, Italy
| | - Karine Lacombe
- Hôpital Saint-Antoine, Assistance Publique Des Hôpitaux de Paris, Service Des Maladies Infectieuses Et Tropicales, Cedex 12, 75571 Paris, France; (Y.A.A.); (J.-P.V.); (K.L.)
- INSERM, Pierre Louis Institute of Epidemiology and Public Health (IPLESP), Sorbonne University, 75646 Paris, France
| |
Collapse
|
4
|
De Socio GV, Tordi S, Altobelli D, Gidari A, Zoffoli A, Francisci D. Dolutegravir/Lamivudine versus Tenofovir Alafenamide/Emtricitabine/Bictegravir as a Switch Strategy in a Real-Life Cohort of Virogically Suppressed People Living with HIV. J Clin Med 2023; 12:7759. [PMID: 38137828 PMCID: PMC10743626 DOI: 10.3390/jcm12247759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/01/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND The aim of the study is to evaluate the effectiveness, safety, and tolerability of a two-drug regimen (2-DR) dolutegravir/lamivudine (DTG/3TC) versus a three-drug regimen (3-DR) tenofovir alafenamide/emtricitabine/bictegravir (TAF/FTC/BIC) in a real-life cohort of HIV-1 virologically suppressed treatment-experienced (TE) people living with HIV (PLWH). METHODS This was a single-center, retrospective, observational study analyzing adult TE PLWH who started the 2-DR or 3-DR between January 2018 and January 2023. All PLWH with a viral load (VL) <50 copies/mL at the time of switching, and a follow-up of more than 6 months or interruption of treatment at any time, were included. RESULTS A total of 324 PLWH were included; of these, 110 (34%) were on the 2-DR and 214 (66%) were on the 3-DR. Most patients remained on therapy in both groups (93.6% 2-DR versus 90.2% 3-DR) and, at the last control, 99.1% achieved VL < 50 copies/mL with the 2-DR versus 97.2% with the 3-DR (p = 0.260). No virological failures occurred in either group. Adverse events occurred in a few cases: four (3.6%) in the 2-DR group and five (2.3%) in the 3-DR group (p = 0.500). The median follow-up-time was 19.6 months for the 2-DR and 27.5 months for the 3-DR. CONCLUSION Our study shows a similar effectiveness and safety profile in virologically suppressed PLWH switching to DTG/3TC or TAF/FTC/BIC.
Collapse
Affiliation(s)
| | - Sara Tordi
- Correspondence: (G.V.D.S.); (S.T.); Tel.: +39-0755783262 (S.T.)
| | | | | | | | | |
Collapse
|
5
|
Alavian G, Abbasian L, Khalili H, Alinaghi SAS, Hasannezhad M, Ashtiani MF, Manshadi SAD. Tenofovir alafenamide plus dolutegravir as a switch strategy in HIV-infected patients: a pilot randomized controlled trial. Daru 2023; 31:145-153. [PMID: 37540331 PMCID: PMC10624796 DOI: 10.1007/s40199-023-00470-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/05/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Currently, two-drug antiretroviral regimens are emerging fields in life-long treatment in people living with HIV. OBJECTIVES This randomized non-inferiority open-label controlled trial was designed to compare the 48-week efficacy and safety of tenofovir alafenamide plus dolutegravir versus the standard triple therapy in virologically suppressed people living with HIV. To the best of our knowledge this combination has not been studied before. METHODS This open-label randomized controlled trial was conducted in treatment-experienced people with HIV who had HIV-RNA < 47 copies/mL for at least two years. Patients received either tenofovir alafenamide plus dolutegravir combination (26 patients) or a standard three-drug regimen (29 patients). The primary outcome was the proportion of patients maintaining HIV-RNA < 47 copies/mL during 48 weeks, and the secondary outcomes were CD4 cell count changes, the adherence rate, and adverse drug reactions, all over 48 weeks of study. RESULTS HIV viral load remained undetectable (HIV-RNA < 47 copies/mL) during the 48 weeks of the study in both arms. The absolute CD4 cell count change was not significant between the two groups. The overall proportion of adverse effects in each group was comparable. The rate of adherence to treatment was acceptable in both groups, and no significant difference was observed. CONCLUSIONS Treatment simplification with tenofovir alafenamide plus dolutegravir regimen as maintenance therapy was non-inferior in terms of efficacy and safety compared to the standard triple therapy. Comparing efficacy of antiretroviral therapy.
Collapse
Affiliation(s)
- Golbarg Alavian
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Ladan Abbasian
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran.
- Department of Infectious & Tropical Diseases, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Keshavarz Blvd, Tehran, Iran.
| | - Hossein Khalili
- Department of Clinical Pharmacy (Pharmacotherapy), Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Ahmad Seyed Alinaghi
- Iranian Research Center for HIV/AIDS (IRCHA), Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Malihe Hasannezhad
- Department of Infectious Diseases, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoumeh Farrokh Ashtiani
- Department of Infectious Diseases, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Ali Dehghan Manshadi
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
6
|
Cossarizza A, Cozzi-Lepri A, Mattioli M, Paolini A, Neroni A, De Biasi S, Tartaro DL, Borella R, Fidanza L, Gibellini L, Beghetto B, Roncaglia E, Nardini G, Milic J, Menozzi M, Cuomo G, Digaetano M, Orlando G, Borghi V, Guaraldi G, Mussini C. Evaluating immunological and inflammatory changes of treatment-experienced people living with HIV switching from first-line triple cART regimens to DTG/3TC vs. B/F/TAF: the DEBATE trial. Front Immunol 2023; 14:1279390. [PMID: 37908359 PMCID: PMC10613634 DOI: 10.3389/fimmu.2023.1279390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 09/21/2023] [Indexed: 11/02/2023] Open
Abstract
Background The aim of this randomized clinical trial (RCT) was to compare immunological changes in virally suppressed people living with HIV (PLWH) switching from a three-drug regimen (3DR) to a two-drug regimen (2DR). Methods An open-label, prospective RCT enrolling PLWH receiving a 3DR who switched to bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) or dolutegravir/lamivudine (DTG/3TC) was performed. Blood was taken at baseline and months 6 and 12. The primary outcome was the change in CD4+ or CD8+ T-cell counts and CD4/CD8 ratio over time points. The secondary outcomes were the changes in immunological and inflammatory parameters. Parametric mixed-linear models with random intercepts and slopes were fitted separately for each marker after controlling for potential confounders. Results Between the two arms (33 PLWH each), there was no difference in CD4+ or CD8+ T cells, CD4/CD8 ratio, and IL-6 trajectories. PLWH switching to DTG/3TC had increased levels of both transitional memory and terminally differentiated CD4+ T cells (arm-time interaction p-value = 0.02) and to a lesser extent for the corresponding CD8+ T-cell subsets (p = 0.09). Significantly lower levels of non-classical monocytes were detected in the B/F/TAF arm at T6 (diff = -6.7 cells/mm3; 95% CI; -16, +2.6; p-value for interaction between arm and time = 0.03). All differences were attenuated at T12. Conclusion No evidence for a difference in absolute CD4+ and CD8+ T-cell counts, CD4/CD8 ratio, and IL-6 trajectories by study arm over 12 months was found. PLWH on DTG/3TC showed higher levels of terminally differentiated and exhausted CD4+ and CD8+ T lymphocytes and non-classical monocytes at T6. Further studies are warranted to better understand the clinical impact of our results. Clinical Trial Registration https://clinicaltrials.gov, identifier NCT04054089.
Collapse
Affiliation(s)
- Andrea Cossarizza
- Chair of Pathology and Immunology, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Alessandro Cozzi-Lepri
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), Institute for Global Health, University College London (UCL), London, United Kingdom
| | - Marco Mattioli
- Chair of Pathology and Immunology, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Annamaria Paolini
- Chair of Pathology and Immunology, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Anita Neroni
- Chair of Pathology and Immunology, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Sara De Biasi
- Chair of Pathology and Immunology, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Domenico Lo Tartaro
- Chair of Pathology and Immunology, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Rebecca Borella
- Chair of Pathology and Immunology, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Lucia Fidanza
- Chair of Pathology and Immunology, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Lara Gibellini
- Chair of Pathology and Immunology, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Barbara Beghetto
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Enrica Roncaglia
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Giulia Nardini
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Jovana Milic
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Marianna Menozzi
- Clinic of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Gianluca Cuomo
- Clinic of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Margherita Digaetano
- Clinic of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Gabriella Orlando
- Clinic of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Vanni Borghi
- Clinic of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Giovanni Guaraldi
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Clinic of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Cristina Mussini
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Clinic of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| |
Collapse
|
7
|
Chu Y, Wong A, Chen H, Ji L, Qin C, Feng W, Stocks MJ, Gershkovich P. Development of lipophilic ester prodrugs of dolutegravir for intestinal lymphatic transport. Eur J Pharm Biopharm 2023; 191:90-102. [PMID: 37634824 DOI: 10.1016/j.ejpb.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/21/2023] [Accepted: 08/24/2023] [Indexed: 08/29/2023]
Abstract
The establishment of latent cellular and anatomical viral reservoirs is a major obstacle to achieving a cure for people infected by HIV. Mesenteric lymph nodes (MLNs) are one of the most important anatomical reservoirs of HIV. Suboptimal levels of antiretroviral (ARVs) drugs in these difficult-to-penetrate viral reservoirs is one of the limitations of current antiretroviral therapy (ART) regimens. This study aimed to design and assess highly lipophilic ester prodrugs of dolutegravir (DTG) formulated with long-chain triglyceride (LCT) for delivery of DTG to the viral reservoir in mesenteric lymph and MLNs. A number of alkyl ester prodrugs of DTG were designed based on the predicted affinity to chylomicrons (CM), and the six most promising prodrugs were selected and synthesised. The synthesised prodrugs were further assessed for their intestinal lymphatic transport potential and biotransformation in biorelevant media in vitro and ex vivo. DTG and the most promising prodrug (prodrug 5) were then assessed in pharmacokinetic and biodistribution studies in rats. Although oral administration of 5 mg/kg of unmodified DTG (an allometrically scaled dose from humans) with or without lipids achieved concentrations above protein binding-adjusted IC90 (PA-IC90) (64 ng/mL) in most tissues, the drug was not selectively targeted to MLNs. The combination of lipophilic ester prodrug and LCT-based formulation approach improved the targeting selectivity of DTG to MLNs 4.8-fold compared to unmodified DTG. However, systemic exposure to DTG was limited, most likely due to poor intestinal absorption of the prodrug following oral administration. In vitro lipolysis showed a good correlation between micellar solubilisation of the prodrug and systemic exposure to DTG in rats in vivo. Thus, it is prudent to include in vitro lipolysis in the early assessment of orally administered drugs and prodrugs in lipidic formulations, even when intestinal lymphatic transport is involved in the absorption pathway. Further studies are needed to clarify the underlying mechanisms of low systemic bioavailability of DTG following oral administration of the prodrug and potential ways to overcome this limitation.
Collapse
Affiliation(s)
- Yenju Chu
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK; Department of Pharmacy Practice, Tri-Service General Hospital, Taipei 114, Taiwan
| | - Abigail Wong
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - Haojie Chen
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - Liuhang Ji
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - Chaolong Qin
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - Wanshan Feng
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - Michael J Stocks
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - Pavel Gershkovich
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK.
| |
Collapse
|
8
|
Palmier E, De Miguel R, Montejano R, Busca C, Micán R, Ramos L, Cadiñanos J, Serrano L, Bernardino JI, Pérez-Valero I, Valencia E, Arribas JR, Montes ML, González-García J, Martín-Carbonero L. Three-year efficacy of switching to dolutegravir plus lamivudine: A real-world study. HIV Med 2023; 24:1013-1019. [PMID: 37194419 DOI: 10.1111/hiv.13500] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/18/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Dolutegravir (DTG) plus lamivudine (3TC) has proven highly efficacious as a switching strategy in virologically suppressed people with HIV (PWH). As this strategy was introduced relatively recently, real-world, long-term durability studies are lacking. METHODS We performed a retrospective review of treatment-experienced patients who started DTG + 3TC in a cohort of PWH. HIV-RNA <50 copies/mL was analysed at 144 weeks in an intention-to-treat (ITT) analysis (missing = failure) and a per-protocol (PP) analysis (patients with missing data or changes for reasons other than virological failure were excluded). RESULTS The study population comprised 358 PWH (19% women). Median age and time with HIV infection were 51.7 and 13.4 years, respectively. The median number of previous antiretroviral combinations was three. Previous virological failure was reported in 27.1% of patients, and the M184V resistance mutation was detected in 17 patients. At 144 weeks, the percentage of individuals with HIV-RNA <50 copies/mL was 77.4% (277/358) in the ITT analysis and 95.5% (277/290) in the PP analysis. A total of 68 participants were excluded from the PP analysis (data missing, 25, discontinuation due to toxicity, 19; other, 16; death, 8). Two people with virological failure selected resistance-associated mutations (M184V and M184V + R263K). HIV-RNA remained undetectable in 17 patients with a previous history of the M184V mutation. CONCLUSION Our results confirm the real-world, long-term efficacy, tolerability and high genetic barrier of DTG + 3TC in treatment-experienced PWH. Although scarce, mutations causing resistance to nucleosides and integrase can emerge.
Collapse
Affiliation(s)
- E Palmier
- Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - R De Miguel
- Hospital Universitario La Paz, IdiPaz, Madrid, Spain
- CIBER Infectious Diseases (CIBERINFEC), Madrid, Spain
| | - R Montejano
- Hospital Universitario La Paz, IdiPaz, Madrid, Spain
- CIBER Infectious Diseases (CIBERINFEC), Madrid, Spain
| | - C Busca
- Hospital Universitario La Paz, IdiPaz, Madrid, Spain
- CIBER Infectious Diseases (CIBERINFEC), Madrid, Spain
| | - R Micán
- Hospital Universitario La Paz, IdiPaz, Madrid, Spain
- CIBER Infectious Diseases (CIBERINFEC), Madrid, Spain
| | - L Ramos
- Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - J Cadiñanos
- Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - L Serrano
- Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - J I Bernardino
- Hospital Universitario La Paz, IdiPaz, Madrid, Spain
- CIBER Infectious Diseases (CIBERINFEC), Madrid, Spain
| | | | - E Valencia
- Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - J R Arribas
- Hospital Universitario La Paz, IdiPaz, Madrid, Spain
- CIBER Infectious Diseases (CIBERINFEC), Madrid, Spain
| | - M L Montes
- Hospital Universitario La Paz, IdiPaz, Madrid, Spain
- CIBER Infectious Diseases (CIBERINFEC), Madrid, Spain
| | - J González-García
- Hospital Universitario La Paz, IdiPaz, Madrid, Spain
- CIBER Infectious Diseases (CIBERINFEC), Madrid, Spain
| | | |
Collapse
|