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Molina JM, Yazdanpanah Y, Afani Saud A, Bettacchi C, Chahin Anania C, DeJesus E, Olsen Klopfer S, Grandhi A, Eves K, Robertson MN, Correll T, Hwang C, Hanna GJ, Sklar P. Islatravir in combination with doravirine for treatment-naive adults with HIV-1 infection receiving initial treatment with islatravir, doravirine, and lamivudine: a phase 2b, randomised, double-blind, dose-ranging trial. Lancet HIV 2021; 8:e324-e333. [PMID: 34000227 DOI: 10.1016/s2352-3018(21)00021-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Islatravir is a nucleoside reverse transcriptase translocation inhibitor in development for the treatment and prevention of HIV-1 infection. We aimed to assess the efficacy and safety of islatravir-based regimens for the treatment of HIV-1. METHODS We did a phase 2b, randomised, double-blind, comparator-controlled, dose-ranging trial at 24 clinics or hospitals in four countries (Chile, France, the UK, and the USA). Treatment-naive adults (≥18 years) with plasma HIV-1 RNA concentrations of at least 1000 copies per mL, CD4 T-cell counts of at least 200 cells per mL, and a calculated creatinine clearance of at least 50 mL/min (all within 60 days before study treatment) were eligible for inclusion. Participants were randomly assigned (1:1:1:1) with a block size of four via an interactive voice and web response system to receive oral treatment with one of three doses of islatravir (0·25 mg, 0·75 mg, or 2·25 mg) plus doravirine (100 mg) and lamivudine (300 mg) or to doravirine (100 mg) plus lamivudine (300 mg) plus tenofovir disoproxil fumarate (TDF; 300 mg) once daily with placebo (part 1). Treatment groups were stratified according to screening HIV-1 RNA concentration (≤100 000 copies per mL or >100 000 copies per mL). After at least 24 weeks of treatment, participants taking islatravir who achieved an HIV-1 RNA concentration lower than 50 copies per mL switched to a two-drug regimen of islatravir and doravirine (part 2). All participants and study investigators were masked to treatment in part 1; in part 2, the islatravir dose was masked to all participants and investigators, but the other drugs were given open label. The primary efficacy outcomes were the proportions of participants with an HIV-1 RNA concentration lower than 50 copies per mL at weeks 24 and 48 (US Food and Drug Administration snapshot approach). The primary safety outcomes were the number of participants experiencing adverse events and the number of participants discontinuing study drug owing to adverse events. All participants who received at least one dose of any study drug were included in the analyses. This trial is ongoing, but closed to enrolment of new participants; herein, we report study findings through 48 weeks of treatment. This trial is registered with ClinicalTrials.gov, NCT03272347. FINDINGS Between Nov 27, 2017, and April 25, 2019, 121 participants (mean age 31 years [SD 10·9], 112 [93%] male, 92 [76%] white, 27 [22%] with HIV-1 RNA concentration >100 000 copies per mL) were randomly assigned: 29 to the 0·25 mg, 30 to the 0·75 mg, and 31 to the 2·25 mg islatravir groups, and 31 to the doravirine, lamivudine, and TDF group. At week 24, 26 (90%) of 29 participants in the 0·25 mg islatravir group, 30 (100%) of 30 in the 0·75 mg islatravir group, and 27 (87%) of 31 in the 2·25 mg islatravir group achieved HIV-1 RNA concentrations lower than 50 copies per mL compared with 27 (87%) of 31 in the doravirine plus lamivudine plus TDF group (difference 2·8%, 95% CI -14·9 to 20·4, for the 0·25 mg islatravir group; 12·9%, -1·6 to 27·5, for the 0·75 mg islatravir group; and 0·3%, -17·9 to 18·5, for the 2·25 mg islatravir group). At week 48, these data were 26 (90%) of 29 in the 0·25 mg islatravir group, 27 (90%) of 30 in the 0·75 mg islatravir group, and 24 (77%) of 31 in the 2·25 mg islatravir group compared with 26 (84%) of 31 in the doravirine plus lamivudine plus TDF group (difference 6·1%, 95% CI -12·4 to 24·4, for the 0·25 mg islatravir group; 6·2%, -12·2 to 24·6, for the 0·75 mg islatravir group; and -6·1%, -27·1 to 14·8, for the 2·75 mg islatravir group). 66 (73%) of participants in the islatravir groups combined and 24 (77%) of those in the doravirine plus lamivudine plus TDF group reported at least one adverse event. Two participants in the 2·25 mg islatravir group and one participant in the doravirine plus lamivudine plus TDF group discontinued owing to an adverse event. No deaths were reported up to week 48. INTERPRETATION Treatment regimens containing islatravir and doravirine showed antiviral efficacy and were well tolerated regardless of dose. Doravirine in combination with islatravir has the potential to be a potent two-drug regimen that warrants further clinical development. FUNDING Merck, Sharp, & Dohme Corp, a subsidiary of Merck & Co., Inc.
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Affiliation(s)
- Jean-Michel Molina
- Department of Infectious Diseases, St-Louis and Lariboisière Hospitals, APHP, University of Paris, Inserm U944, Paris, France
| | - Yazdan Yazdanpanah
- Infectious Diseases Department, Bichat Claude Barnard Hospital, APHP, University of Paris, Inserm U1137, Paris, France
| | | | | | - Carolina Chahin Anania
- Department of Infectious Diseases, Hospital Hernán Henríquez Aravena of Temuco, Temuco, Chile
| | - Edwin DeJesus
- Department of Infectious Diseases, Orlando Immunology Center, Orlando, FL, USA
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Furtado Dos Santos S, Almeida-Brasil CC, Costa JDO, Reis EA, Afonso Cruz M, Silveira MR, Ceccato MDGB. Does switching from multiple to single-tablet regimen containing the same antiretroviral drugs improve adherence? A group-based trajectory modeling analysis. AIDS Care 2020; 32:1268-1276. [PMID: 32148071 DOI: 10.1080/09540121.2020.1736258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Combination Antiretroviral Therapy (cART) in single-tablet regimens (STR) is a simplification strategy that can potentially improve medication adherence and clinical outcomes. We conducted a retrospective cohort study of 1206 patients using efavirenz, tenofovir and lamivudine in multiple-tablet regimen who switched to the STR containing the same active ingredients in a southeast metropolis in Brazil. We measured adherence using the proportion of days covered (PDC≥95%) and evaluated this outcome before and after the switch using paired non-parametric statistics. Additionally, we used group-based trajectory modeling to identify adherence patterns to cART for each period and evaluate the migration behavior of patients between the trajectory groups. We observed a 14% increase in the proportion of adherent patients after switching to STR and a 6.2% increase in the proportion of patients with CD4 count>500 cells/μl (p < 0.001), without changes in viral load outcomes. We identified four adherence trajectories in each period. Most patients (60%, n = 722) migrated towards a group with better adherence trajectory or remained in the trajectory group with the highest probability of adherence after the switch. Our findings suggest that the implementation of the STR had a positive impact on adherence and CD4 count. This may potentially improve virologic outcomes later on treatment.
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Affiliation(s)
- Simone Furtado Dos Santos
- Department of Social Pharmacy, School of Pharmacy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Celline Cardoso Almeida-Brasil
- Department of Social Pharmacy, School of Pharmacy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Juliana de Oliveira Costa
- Department of Social and Preventive Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Centre for Big Data Research in Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Edna Afonso Reis
- Department of Statistics, Institute of Exact Sciences, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Márcio Afonso Cruz
- Graduation in Information Systems and Knowledge Management, Fundação Mineira de Educação e Cultura, Brazil
| | - Micheline Rosa Silveira
- Departamento de Farmácia Social - Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Simões NS, de Oliveira HL, da Silva RCS, Teixeira LS, Sales TLS, de Castro WV, de Paiva MJN, Sanches C, Borges KB. Hollow mesoporous structured molecularly imprinted polymer as adsorbent in pipette-tip solid-phase extraction for the determination of antiretrovirals from plasma of HIV-infected patients. Electrophoresis 2018; 39:2581-2589. [PMID: 29772601 DOI: 10.1002/elps.201800165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 05/01/2018] [Accepted: 05/03/2018] [Indexed: 11/07/2022]
Abstract
In this work a hollow mesoporous structured molecularly imprinted polymer was synthetized and used as adsorbent in pipette-tip solid-phase extraction for the determination of lamivudine (3TC), zidovudine (AZT) and efavirenz (EFZ) from plasma of human immunodeficiency virus (HIV) infected patients by high-performance liquid chromatography (HPLC). All parameters that influence the recovery of the pipette tip based on hollow mesoporous molecularly imprinted polymer solid-phase extraction (PT-HM-MIP-SPE) method were systematically studied and discussed in detail. The adsorbent material was prepared using methacrylic acid and 4-vinylpyridine as functional monomers, ethylene glycol dimethacrylate as crosslinker, acetonitrile as solvent, 4,4'-azobis(4-cyanovaleric acid) as radical initiator, benzalkonium chloride as surfactant, 3TC, and AZT as templates. The simultaneous separation of 3TC, AZT and EFZ by HPLC-UV was performed using a Gemini C18 Phenomenex® column (250 mm × 4.6 mm, 5 μm) and mobile phase consisting of acetonitrile: water pH 3.2 (68:32, v/v), flow rate of 1.0 mL/min and λ = 260 nm. The method was linear over the concentration range from 0.25 to 10 μg/mL for 3TC and EFZ, and 0.05 to 2.0 μg mL-1 for AZT, with correlation coefficients larger than 0.99 for all analytes. Recovery ± relative standard deviations (RSDs %) were 41.99 ± 2.38%, 82.29 ± 1.63%, and 83.72 ± 7.52% for 3TC, AZT, and EFZ, respectively. The RSDs and relative errors (REs) were lower than 15% for intra and interday assays. The method has been successfully applied for monitoring HIV-infected patients outside the therapeutic dosage.
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Affiliation(s)
- Nathália Soares Simões
- Departamento de Ciências Naturais, Universidade Federal de São João del-Rei, Campus Dom Bosco, São João del-Rei, Minas Gerais, Brazil.,Universidade Federal de São João del-Rei, Campus Centro Oeste, Divinópolis, Minas Gerais, Brazil
| | - Hanna Leijoto de Oliveira
- Departamento de Ciências Naturais, Universidade Federal de São João del-Rei, Campus Dom Bosco, São João del-Rei, Minas Gerais, Brazil
| | - Ricky Cássio Santos da Silva
- Departamento de Ciências Naturais, Universidade Federal de São João del-Rei, Campus Dom Bosco, São João del-Rei, Minas Gerais, Brazil
| | - Leila Suleimara Teixeira
- Departamento de Ciências Naturais, Universidade Federal de São João del-Rei, Campus Dom Bosco, São João del-Rei, Minas Gerais, Brazil
| | | | - Whocely Victor de Castro
- Universidade Federal de São João del-Rei, Campus Centro Oeste, Divinópolis, Minas Gerais, Brazil
| | - Maria José Nunes de Paiva
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Farmácia, Universidade Federal de Minas Gerais, Campus Pampulha, Belo Horizonte, Minas Gerais, Brazil
| | - Cristina Sanches
- Universidade Federal de São João del-Rei, Campus Centro Oeste, Divinópolis, Minas Gerais, Brazil
| | - Keyller Bastos Borges
- Departamento de Ciências Naturais, Universidade Federal de São João del-Rei, Campus Dom Bosco, São João del-Rei, Minas Gerais, Brazil
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Abstract
BACKGROUND Barriers to HIV medication adherence may differ by levels of dosing schedules. PURPOSE The current study examined adherence barriers associated with medication regimen complexity and simplification. METHODS A total of 755 people living with HIV currently taking anti-retroviral therapy were recruited from community services in Atlanta, Georgia. Participants completed audio-computer-assisted self-interviews that assessed demographic and behavioral characteristics, provided their HIV viral load obtained from their health care provider, and completed unannounced phone-based pill counts to monitor medication adherence over 1 month. RESULTS Participants taking a single-tablet regimen (STR) were more likely to be adherent than those taking multi-tablets in a single-dose regimen (single-dose MTR) and those taking multi-tablets in a multi-dose regimen (multi-dose MTR), with no difference between the latter two. Regarding barriers to adherence, individuals taking STR were least likely to report scheduling issues and confusion as reasons for missing doses, but they were equally likely to report multiple lifestyle and logistical barriers to adherence. CONCLUSIONS Adherence interventions may need tailoring to address barriers that are specific to dosing regimens.
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Naccarato MJ, Yoong DM, Fong IW, Gough KA, Ostrowski MA, Tan DHS. Combination Therapy with Tenofovir Disoproxil Fumarate/Emtricitabine/Elvitegravir/Cobicistat Plus Darunavir Once Daily in Antiretroviral-Naive and Treatment-Experienced Patients: A Retrospective Review. J Int Assoc Provid AIDS Care 2018; 17:2325957417752260. [PMID: 29385867 PMCID: PMC6748498 DOI: 10.1177/2325957417752260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Patients with drug-resistant HIV often require complex antiretroviral regimens. However, combining fixed-dose combination tablets such as tenofovir-disoproxil-fumarate, emtricitabine, and cobicistat-boosted elvitegravir (TDF/FTC/EVG/cobi) with darunavir (DRV) can provide a simple, once-daily (QD), 2-tablet regimen for patients with drug-resistant HIV. Primary objective was to determine the percentage of patients with HIV-1 RNA <40 copies/mL at 48 weeks. METHODS We performed a retrospective chart review of patients initiated on TDF/FTC/EVG/cobi plus DRV. RESULTS Among the 21 included patients, prior resistance showed a median of 2 nucleoside reverse transcriptase inhibitor mutations, 1 nonnucleoside reverse transcriptase mutation, and 1 protease inhibitor mutation. At week 48, 14 (67%) patients achieved HIV-1 RNA <40 copies/mL, 1 patient experienced viral rebound, and 6 (29%) had missing data or discontinued therapy. No patient discontinued for adverse events. CONCLUSION According to this observational study, QD TDF/FTC/EVG/cobi plus DRV is considered safe, well tolerated, and generally effective in suppressing HIV drug-resistant virus.
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Affiliation(s)
- Mark J. Naccarato
- Department of Pharmacy, St Michael’s Hospital, Toronto, Ontario,
Canada
- Division of Infectious Diseases, St Michael’s Hospital, Toronto, Ontario,
Canada
| | - Deborah M. Yoong
- Department of Pharmacy, St Michael’s Hospital, Toronto, Ontario,
Canada
- Division of Infectious Diseases, St Michael’s Hospital, Toronto, Ontario,
Canada
| | - Ignatius W. Fong
- Division of Infectious Diseases, St Michael’s Hospital, Toronto, Ontario,
Canada
| | - Kevin A. Gough
- Division of Infectious Diseases, St Michael’s Hospital, Toronto, Ontario,
Canada
- Department of Medicine, University of Toronto, Toronto, Ontario,
Canada
| | - Marian A. Ostrowski
- Division of Infectious Diseases, St Michael’s Hospital, Toronto, Ontario,
Canada
- Department of Medicine, University of Toronto, Toronto, Ontario,
Canada
- Keenan Research Centre for Biomedical Science, St Michael’s Hospital,
Toronto, Ontario, Canada
| | - Darrell H. S. Tan
- Division of Infectious Diseases, St Michael’s Hospital, Toronto, Ontario,
Canada
- Department of Medicine, University of Toronto, Toronto, Ontario,
Canada
- Centre for Research on Inner City Health, St Michael’s Hospital, Toronto,
Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of
Toronto, Toronto, Ontario, Canada
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Bedimo R, Rosenblatt L, Myers J. Systematic review of renal and bone safety of the antiretroviral regimen efavirenz, emtricitabine, and tenofovir disoproxil fumarate in patients with HIV infection. HIV CLINICAL TRIALS 2016; 17:246-266. [PMID: 27809711 DOI: 10.1080/15284336.2016.1243363] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Tenofovir disoproxil fumarate (TDF) is a component of many combinations of antiretroviral treatment (ART) regimens. Although potent and generally well tolerated, TDF may cause renal and bone toxicity. The magnitude of off-target side effects is proposed to be related to tenofovir plasma concentrations, which are affected by food and drug-drug interactions with concomitant antiretrovirals. OBJECTIVE To perform a systematic literature review and qualitatively report on renal and bone safety outcomes associated with efavirenz (EFV), emtricitabine (FTC), and TDF (EFV+FTC+TDF) ART. METHODS Embase and PubMed databases were searched for randomized clinical trials and observational cohort studies reporting on HIV treatment with EFV+FTC+TDF. Relevant articles were hand-searched for renal (Grade 3-4 serum creatinine/estimated glomerular filtration rate elevations, renal adverse events [AEs], discontinuation due to renal AEs, and urinary biomarkers) and bone outcomes (bone mineral density [BMD] reductions, bone turnover markers, and fracture), and results compiled qualitatively. RESULTS Of 337 retrieved articles, 29 reporting renal and 11 reporting bone outcomes met the review criteria. EFV+FTC+TDF was associated with a low frequency of renal AEs and treatment discontinuations due to renal AEs. Renal AEs were more frequent when TDF was taken with protease inhibitor (PI)- or cobicistat-containing ART. EFV+FTC+TDF was associated with reduced BMD and increased bone turnover markers, but BMD reductions were less than with PI-containing ART. No treatment-related bone fractures were identified. CONCLUSIONS EFV+FTC+TDF appeared to have a more favorable renal safety profile than TDF administered with a PI or cobicistat. BMD decreased with EFV+FTC+TDF, but no treatment-related fractures were identified.
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Affiliation(s)
- Roger Bedimo
- a Department of Medicine , VA North Texas Health Care System, University of Texas Southwestern Medical Center , Dallas , TX , USA
| | | | - Joel Myers
- b Bristol-Myers Squibb , Plainsboro , NJ , USA
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Viergever RF, ten Berg MJ, van Solinge WW, Hoepelman AI, Gisolf EH. Changes in Hematological Parameters After Switching Treatment of HIV-Infected Patients from Zidovudine to Abacavir or Tenofovir DF. HIV CLINICAL TRIALS 2015; 10:125-8. [DOI: 10.1310/hct1002-125] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Tennant SJ, Hester EK, Caulder CR, Lu ZK, Bookstaver PB. Adherence among rural HIV-infected patients in the deep south: a comparison between single-tablet and multi-tablet once-daily regimens. J Int Assoc Provid AIDS Care 2014; 14:64-71. [PMID: 25331217 DOI: 10.1177/2325957414555228] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Once-daily (QD), combination antiretroviral therapy (ART) can impact the willingness and ability of patients to take medications as directed. The impact of antiretroviral (ARV) drug adherence influenced by single-tablet (STR) versus multi-tablet regimens (MTR) among patients enrolled in the AIDS Drug Assistance Program (ADAP) in a rural environment has not yet been assessed. MATERIAL AND METHODS A retrospective chart review evaluated adherence and outcomes in adult HIV-infected patients enrolled in the ADAP at 2 ambulatory clinics in the Southeast, taking either a QD STR (efavirenz [EFV]/emtricitabine/tenofovir [TDF]) or a QD protease inhibitor (PI)-based, MTR (atazanavir [ATV], ritonavir [RTV], and emtricitabine/TDF) by evaluating pharmacy refill records, patient self-reported adherence, and virologic response. RESULTS A total of 389 patient records were analyzed (STR, n = 165 versus MTR, n = 224). There were more males, a higher percentage of treatment-naive patients, and more patients with a baseline CD4 count of >200 cells/mm(3) in the MTR group. Based on refill records, more patients on MTR were >90% adherent (61.6% versus 51.5%, P = .047). In a multivariable analysis, being treatment experienced was a negative predictor (odds ratio [OR] = 0.48, 0.29-0.78) for adherence. Regimen choice was not associated with adherence. More patients taking MTR were virologically suppressed at the end of the observation period. Regardless of the regimen, being >90% adherent was a significant predictor of virologic suppression (OR = 3.51, 1.98-6.23). CONCLUSION Treatment-experienced patients enrolled in ADAP are less likely to be adherent. A QD PI-based MTR may result in comparable adherence to an STR in a rural HIV-infected population.
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Affiliation(s)
- Sarah J Tennant
- Pharmacy Services Resident, University of Kentucky HealthCare, Lexington, KY, USA
| | - E Kelly Hester
- Auburn University Harrison School of Pharmacy, Department of Pharmacy Practice Harrison School of Pharmacy, Auburn, AL, USA
| | - Celeste R Caulder
- South Carolina College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - Z Kevin Lu
- South Carolina College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - P Brandon Bookstaver
- South Carolina College of Pharmacy, University of South Carolina, Columbia, SC, USA
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Cost-Effectiveness Studies in HIV Treatment with Lopinavir/Ritonavir: A Review. GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2014. [DOI: 10.5301/grhta.5000184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
Combined antiretroviral therapy (cART) has evolved considerably over the past decades leading to a better control of human immunodeficiency virus replication. Recently, regimens have evolved so as to simplify dosing frequency and reduce pill burden to improve adherence. Several national and international guidelines suggest antiretroviral (ARV) regimen simplification as a method of improving adherence. Decreased cART adherence has been associated with both patient-related factors and regimen-related factors. Adherence rates are statistically higher when simpler, once-daily (OD) regimens are combined with smaller daily regimen pill burdens. The avoidance of selective non-adherence, where a patient takes part of a regimen but not the full regimen, is a further potential benefit offered by single-tablet regimens (STRs). Simplification of cART has been associated with a better quality of life (QoL). Although tempered by other factors, better adherence, higher QoL and patients' preferences are all key points which might combine to assure long-lasting efficacy and durability of cART. All studies underlined the favorable tolerability profile of newer STRs. Three STRs are currently available. Tenofovir (TDF) plus emtricitabine (FTC)/efavirenz (EFV) was the first OD complete ARV regimen available as a STR. TDF plus FTC/rilpivirine is a second-generation STR. The most recently approved STR, TDF plus FTC/cobicistat/elvitegravir, is the first non-nucleoside reverse transcriptase inhibitor-based STR. All of them have shown excellent efficacy; safety and tolerability have been improved by more recent formulations. Several other STRs are anticipated both combining completely different drugs, abacavir (ABC) plus lamivudine (3TC)/dolutegravir, utilizing innovative formulations of older drugs, tenofovir alafenamide fumarate, or taking advance of bioequivalent drugs, lamivudine (3TC) plus ABC/EFV. The future challenge would be to develop completely alternative STRs (including for example protease inhibitors or new molecules) to extend the advantages of simplicity to heavily pre-treated individuals.
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Affiliation(s)
- Noemi Astuti
- Unit of Antiviral Therapy, Division of Infectious Diseases, AO Papa Giovanni XXIII, Bergamo, Italy
| | - Franco Maggiolo
- Unit of Antiviral Therapy, Division of Infectious Diseases, AO Papa Giovanni XXIII, Bergamo, Italy
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Abstract
OBJECTIVES Review of the available data on the currently available single-tablet regimens (STRs), from the analysis of efficacy and safety to the key points of value in terms of adherence, quality of life and pharmacoeconomic evaluation. METHODS For this narrative review, literature searches have been performed in PubMed, IndexRevMed and Cochrane, using the search terms HIV, single-tablet, one-pill, single dose, fixed-dose, and STR. These have been reviewed and complemented with the most recent publications of interest. RESULTS Fixed-dose combinations are a significant advance in antiretroviral treatment simplification, contributing to an increase in compliance with complex chronic therapies, thus improving patients' quality of life. Reducing the number of pills and daily doses is associated with higher adherence and better quality of life. As a fixed-dose combination tablet given once daily, EFV/FTC/TDF was the first available STR combining efficacy, tolerability and convenience, with the simplest dosing schedule and smallest numbers of pills of any ART combination therapy. The RPV/FTC/TDF is a next-generation NNRTI-based STR, a once daily complete ART regimen for the treatment of HIV-1 infection. Recently the combination of EVG/COBI/FTC/TDF was also approved by the European Commission, and is the first integrase inhibitor-based STR. Receiving antiretroviral therapy as once daily STR is associated with both clinical and economic benefits, which confirms previous research. CONCLUSIONS The associated benefits of STRs provide a valid strategy for the treatment of HIV-infected patients.
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Affiliation(s)
- Isabel Aldir
- Centro Hospitalar de Lisboa Ocidental, Hospital Egas Moniz , Lisboa , Portugal
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Comparative efficacy of Lamivudine and emtricitabine: a systematic review and meta-analysis of randomized trials. PLoS One 2013; 8:e79981. [PMID: 24244586 PMCID: PMC3823593 DOI: 10.1371/journal.pone.0079981] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Accepted: 10/05/2013] [Indexed: 12/20/2022] Open
Abstract
Introduction Lamivudine and emtricitabine are considered equivalent by several guidelines, but evidence of comparable efficacy is conflicting. Methods We searched two databases up to June 30 2013 to identify randomized and quasi-randomized trials in which lamivudine and emtricitabine were used as part of combination antiretroviral therapy for treatment-naïve or experienced HIV-positive adult patients. We only included trials where partner drugs in the regimen were identical or could be considered to be comparable. We allowed for comparisons between tenofovir and abacavir provided the study population did not begin treatment with a viral load >100,000 copies/ml. Results 12 trials contributed 15 different randomized comparisons providing data on 2251 patients receiving lamivudine and 2662 patients receiving emtricitabine. Treatment success was not significantly different in any of the 12 trials. In the three trials that directly compared lamivudine and emtricitabine, the relative risk for achieving treatment success was non-significant (RR 1.03 95%CI 0.96-1.10). For all trials combined, the pooled relative risk for treatment success was not significantly different (RR 1.00, 95%CI 0.97–1.02). No heterogeneity was observed (I2 = 0). Similarly, there was no difference in the pooled relative risk for treatment failure (RR 1.08, 95%CI 0.94–1.22, I2 = 3.4%). Conclusions The findings of this systematic review suggest that lamivudine and emtricitabine are clinically equivalent.
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Simpson KN, Hanson KA, Harding G, Haider S, Tawadrous M, Khachatryan A, Pashos CL, Wu AW. Review of the impact of NNRTI-based HIV treatment regimens on patient-reported disease burden. AIDS Care 2013; 26:466-75. [PMID: 24111805 DOI: 10.1080/09540121.2013.841825] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
While the burden of HIV disease is well documented, the value of non-nucleoside reverse transcriptase inhibitor (NNRTI)-based therapy regimens in reducing patient burden is not well understood. The purpose of this study was to examine patient-reported health among those receiving NNRTI-based regimens to understand their incremental value in reducing the burden of HIV. We conducted a structured literature review using PubMed to identify NNRTI trials utilizing validated patient-reported outcome (PRO) instruments during 2005-2011. The search strategy included a PubMed search to identify relevant studies based on disease, instrument, PRO, and NNRTI medication terms; and a manual search of bibliographies of identified papers. Data abstracted from each study included study type, treatment regimen(s), and PRO results. Of 11 trials identified, 8 (73%) reported significance of changes in a PRO over time and 10 (91%) reported significance of PRO changes between groups. Several domains were assessed, with significant findings (between or within groups) observed in: physical health/well-being (n = 5), emotional status/well-being (n = 2), symptoms (n = 2), anxiety (n = 2), gastrointestinal upset (n = 2), psychological health (n = 1), functional and global well-being (n = 1), fatigue/energy (n = 1), depression (n = 1), change in body appearance (n = 1), pain (n = 1), headache (n = 1), bad dreams/nightmares (n = 1), problems having sex (n = 1), and general health perception (n = 1). In conclusion, NNRTIs have been observed most frequently to improve patient-reported physical health and well-being. Treatments are needed that can also reduce patient burden in areas of emotional well-being, cognitive functioning, and overall symptom profile.
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Affiliation(s)
- Kit N Simpson
- a Department of Healthcare Leadership and Management , Medical University of South Carolina , Charleston , SC , USA
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Simpson KN, Hanson KA, Harding G, Haider S, Tawadrous M, Khachatryan A, Pashos CL, Wu AW. Patient reported outcome instruments used in clinical trials of HIV-infected adults on NNRTI-based therapy: a 10-year review. Health Qual Life Outcomes 2013; 11:164. [PMID: 24090055 PMCID: PMC3852266 DOI: 10.1186/1477-7525-11-164] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 09/05/2013] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Patient-reported outcomes (PROs) may provide valuable information to clinicians and patients when choosing initial antiretroviral therapy. OBJECTIVE To identify and classify PRO instruments used to measure treatment effects in clinical trials evaluating NNRTIs. METHODS We conducted a structured literature review using PubMed to identify NNRTI trials published from March 2003 to February 2013. Studies identified--based on disease, instrument, PRO, and NNRTI medication terms were reviewed--to identify PRO instruments. Domains measured within each instrument were recorded to understand key areas of interest in NNRTIs. RESULTS Of 189 articles reviewed, 27 validated instruments were administered in 26 unique trials, with a mean of 1.9 instruments (median: 1; range: 1-7) per trial. The Medical Outcomes Study HIV Health Survey (MOS-HIV) was the most commonly used instrument (n = 8 trials). Seventeen trials (65%) included at least one multidimensional health-related quality of life (HRQL) instrument (HIV-targeted, n = 11; general, n = 8). Other validated instruments measured sleep (n = 5), depression (n = 5), anxiety (n = 4), psychiatric symptoms (n = 2), beliefs about HIV medications (n = 2), HIV symptoms (n = 1), and stress (n = 1). CONCLUSIONS Although review of recent NNRTI trials suggests a lack of consensus on the optimal PRO instruments, a typical battery is comprised of a multidimensional HRQL measure coupled with one or more symptom measures. Further work is needed to clarify advantages and disadvantages of using specific PRO instruments to measure relevant constructs and to identify the most useful batteries of instruments for NNRTI trials.
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Affiliation(s)
- Kit N Simpson
- Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | - Kristin A Hanson
- UBC: An Express Scripts Company, 185 Dorval Ave, Suite 500, Dorval, QC H9S 5J9, Canada
| | - Gale Harding
- Evidera, 7101 Wisconsin Avenue, Suite 600, Bethesda, MD 20814, USA
| | - Seema Haider
- Pfizer Inc., 558 Eastern Point Road, Groton, CT 06340, USA
| | | | | | - Chris L Pashos
- UBC: An Express Scripts Company, 430 Bedford Street, Lexington, MA 02420, USA
| | - Albert W Wu
- Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
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Lai JP, Xie L, Sun H, Chen F. Synthesis and evaluation of molecularly imprinted polymeric microspheres for highly selective extraction of an anti-AIDS drug emtricitabine. Anal Bioanal Chem 2013; 405:4269-75. [DOI: 10.1007/s00216-013-6818-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 02/02/2013] [Accepted: 02/04/2013] [Indexed: 11/29/2022]
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Outcomes after reinitiating antiretroviral therapy in children randomized to planned treatment interruptions. AIDS 2013; 27:579-89. [PMID: 23135172 DOI: 10.1097/qad.0b013e32835c1181] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Excess risks for death/opportunistic disease in adults randomized to CD4-driven planned treatment interruption (PTI) in the Strategies for Management of Antiretroviral Therapy (SMART) trial remained after antiretroviral therapy (ART) re-initiation. Risks for children following PTI were evaluated in long-term follow-up of children in the PENTA 11 trial. METHODS Children with HIV RNA below 50 copies/ml and CD4 at least 30% (2-6 years) or at least 500 cells/μl (7-15 years) were randomized to continuous ART (cART) or PTI in PENTA 11 (ISRCTN 36694210). After the end of the trial, all were recommended to resume ART. Data were collected annually and analysed up to the second year of visit. RESULTS One hundred and one (51 cART, 50 PTI; median baseline age 9.2 years) children had median overall follow-up 4.6 (range 3.7-5.0) years. During 2-year post-trial period, there were no deaths or new Centers for Disease Control and Prevention (CDC) stage B/C events. Rate of clinical grade of at least two events was similar between PTI and cART [relative risk (RR) 1.03; 95% confidence interval (CI) 0.43, 2.50; P = 0.94]. At 2 years, difference in absolute CD4% between PTI and cART was -1.6% (-4.5%; 1.3%; P = 0.27), and proportions with HIV RNA below 50 copies/ml were 82 versus 86% (P = 0.57), respectively; no differences in growth or fasting lipids were observed. Key predictors of greater CD4% recovery after re-initiating ART were higher CD4% at baseline (P < 0.001) and longer time since ART re-initiation (P < 0.001). During overall follow-up, 4 (8%) PTI versus 5 (10%) CT children switched ART for failure (P = 0.75) and 9 (18%) versus 1 (2%) (P = 0.008) substituted ART for simplification. CONCLUSIONS No adverse clinical, immunological or virological consequences of PTI were observed 2 years after the end of PENTA 11 trial. Although ART interruption is not generally recommended, it may be an acceptable option for children, particularly when there is high risk of unplanned treatment interruptions.
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Ribera E, Larrousse M, Curran A, Negredo E, Clotet B, Estrada V, Sanz J, Berenguer J, Rubio R, Pulido F, Ferrer P, Alvarez ML, Arterburn S, Martínez E. Impact of switching from zidovudine/lamivudine to tenofovir/emtricitabine on lipoatrophy: the RECOMB study. HIV Med 2013; 14:327-36. [DOI: 10.1111/hiv.12011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2012] [Indexed: 11/30/2022]
Affiliation(s)
- E Ribera
- Infectious Diseases Division; Hospital Universitari Vall d'Hebron; Autonomous University of Barcelona; Barcelona; Spain
| | - M Larrousse
- Infectious Diseases Unit; Hospital Clinic-IDIBAPS; University of Barcelona; Barcelona; Spain
| | - A Curran
- Infectious Diseases Division; Hospital Universitari Vall d'Hebron; Autonomous University of Barcelona; Barcelona; Spain
| | - E Negredo
- IrsiCaixa Foundation; Institut Germans Trias i Pujol; Diseases Division; Autonomous University of Barcelona; Badalona; Spain
| | - B Clotet
- IrsiCaixa Foundation; Institut Germans Trias i Pujol; Diseases Division; Autonomous University of Barcelona; Badalona; Spain
| | - V Estrada
- Hospital Clínico San Carlos; Madrid; Spain
| | - J Sanz
- Hospital Universitario de la Princesa; Instituto de Investigación Princesa; Madrid; Spain
| | - J Berenguer
- Infectious Diseases/HIV Unit; Hospital General Universitario Gregorio Marañón; Madrid; Spain
| | - R Rubio
- Hospital Universitario 12 de Octubre; Madrid; Spain
| | - F Pulido
- Hospital Universitario 12 de Octubre; Madrid; Spain
| | - P Ferrer
- Gilead Sciences SL; Madrid; Spain
| | | | - S Arterburn
- Gilead Sciences Inc.; Foster City; California; USA
| | - E Martínez
- Infectious Diseases Unit; Hospital Clinic-IDIBAPS; University of Barcelona; Barcelona; Spain
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Behrens G, Maserati R, Rieger A, Domingo P, Abel F, Wang H, Pearce G. Switching to tenofovir/emtricitabine from abacavir/lamivudine in HIV-infected adults with raised cholesterol: effect on lipid profiles. Antivir Ther 2012; 17:1011-20. [PMID: 22910324 DOI: 10.3851/imp2305] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND The aim of this study was to investigate the effect on fasting lipid parameters of switching to tenofovir disoproxil fumarate (TDF) plus emtricitabine (FTC) from abacavir (ABC) plus lamivudine (3TC; both fixed-dose combinations), while maintaining ritonavir-boosted lopinavir (LPV/r). METHODS This was an open-label randomized two-arm 12-week controlled study in virologically suppressed HIV-infected patients with elevated cholesterol (≥5.2 mmol/l). Patients stable on ABC/3TC plus LPV/r either continued treatment or switched to TDF/FTC plus LPV/r for 12 weeks. Standard efficacy and safety end points (including fasting lipids) were assessed. RESULTS In total, 85 subjects were treated (n=42 ABC/FTC and n=43 TDF/3TC). A statistically significant decrease in total cholesterol was observed in the TDF/FTC group: from median (IQR) 6.22 mmol/l (5.91-6.77) at baseline to 5.75 mmol/l (5.04-6.18) at week 12 (median [IQR] change from baseline -0.73 mmol/l [-1.20- -0.18]; P<0.001). No notable change was observed for the ABC/3TC group. The difference between groups at week 12 was -0.82 mmol/l (P<0.001). For TDF/FTC (but not for ABC/3TC), statistically significant reductions (P<0.05) from baseline were observed in total, low-density lipoprotein, high-density lipoprotein (HDL)- and non-HDL cholesterol (at weeks 4 and 12). Statistically significant decreases were observed in median estimated creatinine clearance (Cockcroft-Gault) from baseline to week 12 for patients who switched to TDF/FTC (-5.47 ml/min) versus the ABC/3TC group (-2.15 ml/min; P=0.016 between groups). Virological suppression was maintained in both groups. No new safety issues were identified. CONCLUSIONS Switching to TDF/FTC from ABC/3TC was associated with rapid improvements in fasting lipid parameters and continued virological control in patients receiving LPV/r as the third component of antiretroviral therapy. The effect of these changes on clinical end points remains unclear and would need to be evaluated in a longer-term study.
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Affiliation(s)
- Georg Behrens
- Hannover Medical School, Department for Clinical Immunology and Rheumatology, Hannover, Germany.
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Edelman EJ, Gordon K, Rodriguez-Barradas MC, Justice, for the VACS Project Team AC. Patient-reported symptoms on the antiretroviral regimen efavirenz/emtricitabine/tenofovir. AIDS Patient Care STDS 2012; 26:312-9. [PMID: 22612469 DOI: 10.1089/apc.2012.0044] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Most patients (80-90%) newly diagnosed with HIV are started on the antiretroviral regimen efavirenz, emtricitabine, and tenofovir (EFV/FTC/TDF). Existing studies of patient tolerability, however, are limited. We compared symptom experiences of patients on EFV/FTC/TDF, and the subsequent impact on health-related quality of life, with those of patients on other combination antiretroviral therapy (cART). We conducted a cross-sectional analysis of the Veterans Aging Cohort Study from February 2008 to August 2009 to compare the symptom experiences of patients on EFV/FTC/TDF vs. other cART, unadjusted and then adjusted for treatment characteristics, and comorbid disease severity. We then assessed the association between EFV/FTC/TDF use and health-related quality of life. Among the 1,759 patients in our analytic sample, EFV/FTC/TDF use was associated with fewer symptoms than was other cART. The use of EFV/FTC/TDF was independently associated with health-related quality of life, and this association was at least partially explained by symptom burden.
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Affiliation(s)
- E. Jennifer Edelman
- Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut
- Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
- Section of General Internal Medicine, Department of Medicine, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Kirsha Gordon
- Section of General Internal Medicine, Department of Medicine, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Maria C. Rodriguez-Barradas
- Section of Infectious Diseases, Department of Medicine, Michael E. De Bakey VAMC and Baylor College of Medicine, Houston, Texas
| | - Amy C. Justice, for the VACS Project Team
- Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
- Section of General Internal Medicine, Department of Medicine, VA Connecticut Healthcare System, West Haven, Connecticut
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Ganguli A, Wang J, Gourley DR. Does combining antiretroviral agents in a single dosage form enhance quality of life of HIV/AIDS patients? A cost-utility study. Res Social Adm Pharm 2011; 8:157-65. [PMID: 21712147 DOI: 10.1016/j.sapharm.2010.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Revised: 12/18/2010] [Accepted: 12/18/2010] [Indexed: 11/16/2022]
Abstract
BACKGROUND Combining various antiretroviral agents into one single dosage form has been a strategy to reduce pill burden and enhance medication adherence among human immunodeficiency virus /AIDS (HIV/AIDS) patients. OBJECTIVES This is a cost-utility study from a health care system's perspective comparing coformulated fixed dose (FXD) strategy versus multiple free dose combination (FRC) in antiretroviral therapy. METHOD The Medical Expenditure Panel Survey (MEPS) was used to identify HIV/AIDS patients with ≥2 active antiretroviral medications. Patients on FXD were matched in 1:1 ratio with the FRC group using propensity scores. All medical costs excluding those paid by patients and families were included. Utility was measured using SF-6D scores from the SF-12 questionnaire. Incremental cost-utility ratios (ICURs) were calculated using the mean annual estimates. A cost-effectiveness acceptability curve was determined using a Monte Carlo probabilistic simulation technique. RESULTS Nine FXD antiretroviral formulations approved by the U.S. Food and Drug Administration by 2005 was included in this study. One hundred seventy HIV/AIDS patients with ≥2 antiretroviral agents were identified from the MEPS database, of which 53% (n=92) were on FXD formulation. On matching, 70 patients from FXD had a match from the FRC group. No differences in sociodemographic and health status variables were observed between the matched groups. The mean annual cost was $15,766.15 for FXD patients and $11,875.21 for FRC patients. The mean utility gained by using FXD over FRC was 0.085; however, this difference was not statistically significant. The ICUR for the FXD treatment over FRC treatment was $45,540.49/quality-adjusted life years (QALYs). Probabilistic sensitivity analysis showed FXD to dominate FRC (>50% probability of being cost-effective) above the $40,000 threshold. CONCLUSION Although the cost-effectiveness of a single-pill strategy was within the acceptable willingness-to-pay threshold, the QALY difference were minimal. Further research is recommended to explore the long-term impact of the strategy.
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Affiliation(s)
- Arijit Ganguli
- Health Outcomes and Policy Research, Department of Pharmaceutical Sciences, University of Tennessee College of Pharmacy, 847 Monroe Ave., Memphis, TN 38163, USA.
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Impact of NRTIs on lipid levels among a large HIV-infected cohort initiating antiretroviral therapy in clinical care. AIDS 2011; 25:185-95. [PMID: 21150555 DOI: 10.1097/qad.0b013e328341f925] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE to assess the associations between nucleoside reverse transcriptase inhibitors (NRTIs) and change in lipid levels among a large cohort of HIV-infected patients in routine clinical care initiating their first potent antiretroviral regimen. DESIGN longitudinal observational cohort study from the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort. METHODS we used generalized estimating equations to examine the association between NRTIs and lipids accounting for within-patient correlations between repeated measures and key clinical and demographic characteristics including other antiretroviral medications. RESULTS among 2267 individuals who started their first antiretroviral regimen, tenofovir with emtricitabine or lamivudine was associated with lower levels for total cholesterol, low-density lipoprotein (LDL), triglycerides, non-high-density lipoprotein (HDL), and HDL, compared with other NRTI pairs in adjusted analyses. LDL levels were highest among patients receiving didanosine/lamivudine. Triglyceride levels were highest in stavudine/lamivudine users. HDL levels were highest among patients receiving didanosine/stavudine. Hepatitis C infection and younger age were also associated with lower lipid levels. CONCLUSION we found clinically important heterogeneity within the NRTI class of antiretroviral medications regarding their effect on lipid levels over time. Although the lipid profile of tenofovir with emtricitabine or lamivudine appeared to be less pro-atherogenic in this large longitudinal study of HIV-infected patients in routine clinical care, there was no association with beneficial HDL levels. In general, the change in lipid levels associated with most antiretroviral agents, particularly those NRTI combinations currently in common use, are relatively modest. Additional studies are needed to understand the long-term implications of these findings on cardiovascular disease risk.
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Deeks ED, Perry CM. Efavirenz/Emtricitabine/Tenofovir Disoproxil Fumarate Single-Tablet Regimen (Atripla®). Drugs 2010; 70:2315-38. [DOI: 10.2165/11203800-000000000-00000] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Hodder SL, Mounzer K, DeJesus E, Ebrahimi R, Grimm K, Esker S, Ecker J, Farajallah A, Flaherty JF. Patient-reported outcomes in virologically suppressed, HIV-1-Infected subjects after switching to a simplified, single-tablet regimen of efavirenz, emtricitabine, and tenofovir DF. AIDS Patient Care STDS 2010; 24:87-96. [PMID: 20156091 DOI: 10.1089/apc.2009.0259] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A randomized, open-label, multicenter study was conducted to evaluate the therapeutic switch to a single-tablet formulation of efavirenz/emtricitabine/tenofovir DF (EFV/FTC/TDF) among virologically suppressed, HIV-1-infected subjects. Eligible subjects on stable antiretroviral therapy (ART) with HIV-1 RNA less than 200 copies per milliliter for 3 months or more were stratified by prior protease inhibitor (PI)- or non-nucleoside reverse transcriptase inhibitor (NNRTI)-based therapy and randomized (2:1) to EFV/FTC/TDF or to stay on their baseline regimen (SBR). Patient-reported measures were quality of life (QOL; SF-36 [version 2]), treatment adherence (visual analogue scale), preference of medication (POM), perceived ease of the regimen for condition (PERC), and a 20-item HIV symptom index. Overall, 203 subjects were randomized to EFV/FTC/TDF and 97 to SBR. Fifty-three percent of subjects had previously received a PI-based regimen; 47% an NNRTI-based therapy. Throughout the study, SF-36 summary scores did not differ significantly from baseline, regardless of previous ART or treatment allocation. Adherence was 96% or more in both groups at baseline and all subsequent study visits. At study conclusion, the EFV/FTC/TDF regimen was considered easier to follow than prior regimens by 97% and 96% of subjects previously receiving PI-based and NNRTI-based therapies, respectively. Overall, 91% of subjects switched to EFV/FTC/TDF indicated a preference over their prior therapy. Switching to EFV/FTC/TDF was associated with transient worsening/emergence of dizziness and sustained improvements in several other HIV-related symptoms. In conclusion, switching virologically suppressed, HIV-1-infected subjects from PI-based or NNRTI-based regimens to EFV/FTC/TDF was associated with maintained QOL and treatment adherence, and improved ease of use and treatment satisfaction.
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Affiliation(s)
- Sally L. Hodder
- University of Medicine and Dentistry of New Jersey, Newark, New Jersey
| | - Karam Mounzer
- Philadelphia FIGHT, Philadelphia, Pennsylvania
- University of Pennsylvania, School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | | | - Janet Ecker
- Gilead Sciences, Inc., Foster City, California
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Abstract
Efavirenz, a non-nucleoside reverse transcriptase inhibitor, has been an important component of the treatment of HIV infection for 10 years and has contributed significantly to the evolution of highly active antiretroviral therapy (HAART). The efficacy of efavirenz has been established in numerous randomized trials and observational studies in HAART-naive patients, including those with advanced infection. In the ACTG A5142 study, efavirenz showed greater virological efficacy than the boosted protease inhibitor (PI), lopinavir. Efavirenz is more effective as a third agent than unboosted PIs or the nucleoside analogue abacavir. Some, but not all, studies have suggested that efavirenz (added to two nucleoside reverse transcriptase inhibitors) is more effective than nevirapine. Virological and immunological responses achieved with efavirenz-based HAART have been maintained for 7 years. Dosing convenience predicts adherence, and studies have demonstrated that patients can be switched from PI-based therapy to simplified, once-daily efavirenz-based regimens without losing virological control. The one-pill, once-daily formulation of efavirenz plus tenofovir and emtricitabine offers a particular advantage in this regard. Efavirenz also retains a role after failure of a first PI-based regimen. Efavirenz is generally well tolerated: rash and neuropsychiatric disturbances are the most notable adverse events. Neuropsychiatric disturbances generally develop early in treatment and they tend to resolve with continued administration, but they are persistent and troubling in a minority of patients. Efavirenz has less effect on plasma lipid profiles than some boosted PIs. Lipodystrophy can occur under treatment with efavirenz but it may be reduced if the concurrent use of thymidine analogues is avoided. Efavirenz resistance mutations (especially K103N) can be selected during long-term treatment, underscoring the importance of good adherence. Recent data have confirmed that efavirenz is a cost-effective option for first-line HAART. In light of these features, efavirenz retains a key role in HIV treatment strategies and is the first-line agent recommended in some guidelines.
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Affiliation(s)
- Franco Maggiolo
- Division of Infectious Diseases, Ospedali Riuniti, Largo Barozzi 1, Bergamo, Italy.
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Calza L, Manfredi R, Colangeli V, Pocaterra D, Rosseti N, Pavoni M, Chiodo F. Efficacy and safety of atazanavir-ritonavir plus abacavir-lamivudine or tenofovir-emtricitabine in patients with hyperlipidaemia switched from a stable protease inhibitor-based regimen including one thymidine analogue. AIDS Patient Care STDS 2009; 23:691-7. [PMID: 19739937 DOI: 10.1089/apc.2009.0039] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Randomized, open-label, prospective clinical trial assessing efficacy and safety on hyperlipidemia of a switching from a regimen including one protease inhibitor and one thymidine analogue to atazanavir/ritonavir plus abacavir/lamivudine or tenofovir/emtricitabine. Adult HIV-infected patients on their first antiretroviral therapy (of at least 48-week duration), including one protease inhibitor and zidovudine or stavudine, with stable immunovirologic features, and having diagnosis of persisting hyperlipidemia, were randomized to replace current treatment with atazanavir/ritonavir plus abacavir/lamivudine (arm A) or tenofovir/emtricitabine (arm B), and were followed for 48 weeks. Eighty-nine patients were enrolled: 42 patients were randomized to arm A, and 47 to arm B. At the end of the 48-week follow-up, incidence of virologic failure was comparable in both arms, and associated with a poor drug compliance. Increase in CD4 lymphocyte count was significantly higher in arm A after a 24-week study period (62.5 versus 39.2 x 10(6) cells/L; p < 0.05), while immunologic responses were comparable at the end of 48-week follow-up (91.5 versus 83.6; p > 0.05). A statistically significant reduction (-15.4%) in mean triglyceridaemia versus respective baseline values was reported in both groups (p < 0.05), without statistically significant difference between arm A and B. Similar results were reported for total cholesterol and low-density lipoprotein (LDL) cholesterol levels. Safety and tolerability profiles were comparable in both groups. Switching from a protease inhibitor- and thymidine analogue-based antiretroviral regimen to atazanavir/ritonavir plus abacavir/lamivudine or tenofovir/emtricitabine proved effective in the management of hyperlipidemia, without significant differences in lipid-lowering effect, virologic efficacy, and safety profile between these regimens.
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Affiliation(s)
- Leonardo Calza
- Department of Internal Medicine, Geriatrics and Nephrologic Diseases, Section of Infectious Diseases, “Alma Mater Studiorum” University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Roberto Manfredi
- Department of Internal Medicine, Geriatrics and Nephrologic Diseases, Section of Infectious Diseases, “Alma Mater Studiorum” University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Vincenzo Colangeli
- Department of Internal Medicine, Geriatrics and Nephrologic Diseases, Section of Infectious Diseases, “Alma Mater Studiorum” University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Daria Pocaterra
- Department of Internal Medicine, Geriatrics and Nephrologic Diseases, Section of Infectious Diseases, “Alma Mater Studiorum” University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Nirmala Rosseti
- Department of Internal Medicine, Geriatrics and Nephrologic Diseases, Section of Infectious Diseases, “Alma Mater Studiorum” University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Michele Pavoni
- Department of Internal Medicine, Geriatrics and Nephrologic Diseases, Section of Infectious Diseases, “Alma Mater Studiorum” University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Francesco Chiodo
- Department of Internal Medicine, Geriatrics and Nephrologic Diseases, Section of Infectious Diseases, “Alma Mater Studiorum” University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
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Arasteh K, Weitner L, Fenske S, Kuhlmann B, Freiwald M, Ebrahimi R, Gallo L, Ranneberg R, Mertenskoetter T. Switch from a ZDV/3TC-based regimen to a completely once daily (QD) regimen of emtricitabine/tenofovir DF fixed dose combination plus a third QD agent (SONETT). Eur J Med Res 2009; 14:195-9. [PMID: 19541575 PMCID: PMC3351977 DOI: 10.1186/2047-783x-14-5-195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives To assess the efficacy and safety of a treatment switch from a twice-daily (BID) regimen containing zidovudine (ZDV) and lamivudine (3TC) plus a third agent to a once daily (QD) regimen containing the fixed-dose combination of tenofovir DF/emtricitabine (TDF/FTC, Truvada®) plus a divergent third QD agent in HIV-1 infected patients. Methods Prospective, 48-week, non-randomised, single-group, open-label, study. Fifty-one patients on stable ZDV/3TC-containing HAART, with HIV-1 RNA < 50 copies/ml and CD4+ T-cell count > 50 cells/μl, were switched to TDF/FTC plus a third agent. Plasma HIV-1 RNA, CD4+ and CD8+ T-cell counts were assessed at baseline and weeks 4, 12, 24, 36 and 48 post-switch. Results During the 48-week study, 10 patients discontinued prematurely, including three due to adverse events (AEs). At week 48, plasma HIV-1 RNA was < 50 copies/ml in 40 patients (78.4%). No patient experienced virological failure (defined as HIV-1 RNA ≥50 copies/ml at two consecutive post-baseline measurements) during the study. Immunologic control was maintained, with no significant changes in CD4+ or CD8+ T-cell counts. A statistically significant improvement from baseline in haemoglobin level was observed at week 48 (median change 0.8 g/dl; p < 0.001). There was also a statistically significant decrease in total cholesterol concentration at week 48 (-26.0 mg/dl; p = 0.001) in a subset of patients (n = 22) entering the study with elevated total cholesterol. Treatment was well tolerated and no treatment-related grade 3 or 4 AEs were seen. Conclusions Results from this study support switching from a ZDV/3TC-containing HAART regimen to a completely QD regimen of TDF/FTC plus a third agent. Virologic and immunologic control are maintained, with apparent benefits in haemoglobin.
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Waters L. Considering the individual - principles of treatment choice. Int J STD AIDS 2009. [DOI: 10.1258/ijsa.2009.09s002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Although several antiretroviral agents are available, realistic options for initial therapy remain limited, as many are not licensed for treatment-naive patients, as reflected in national and international guidelines. A variety of factors influence treatment choice. From the physicians’ perspective, it is important to consider age, sex, co-morbid conditions, concomitant drugs and potential for adherence. Meanwhile, patients are concerned about the impact of side-effects on their day-to-day life and long-term future, drug efficacy, future options and time available in clinics. Patients’ concerns may be alleviated by detailed discussion throughout treatment, including the importance of adherence, the pros and cons of different treatments and potential side-effects. Positive outcomes in terms of not just viral load and CD4 counts but also improved duration and quality of life should be emphasized. Treatment must be tailored to each patient to maximize benefits and minimize risks.
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Affiliation(s)
- L Waters
- Chelsea & Westminster Hospital, London, UK
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Simplification of antiretroviral therapy to a single-tablet regimen consisting of efavirenz, emtricitabine, and tenofovir disoproxil fumarate versus unmodified antiretroviral therapy in virologically suppressed HIV-1-infected patients. J Acquir Immune Defic Syndr 2009; 51:163-74. [PMID: 19357529 DOI: 10.1097/qai.0b013e3181a572cf] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate a simplification strategy for HIV-1-infected patients virologically suppressed on antiretroviral therapy (ART) by switching to a single-tablet regimen consisting of efavirenz/emtricitabine/tenofovir disoproxil fumarate (EFV/FTC/TDF). DESIGN : Prospective, randomized, controlled, open-label, multicenter study. METHODS Patients on stable ART with HIV-1 RNA <200 copies per milliliter for > or = 3 months were stratified by prior nonnucleoside reverse transcriptase inhibitor-based or protease inhibitor-based therapy and randomized (2:1) to simplify treatment to EFV/FTC/TDF or to stay on their baseline regimen (SBR). Efficacy and safety assessments were performed at baseline and at weeks 4, 12, 24, 36, and 48. Additional patient-reported outcomes included the following: adherence by visual analog scale, quality of life by SF-36 (v2) survey, HIV Symptom Index, and the Preference of Medication and Perceived Ease of the Regimen for Condition questionnaires. RESULTS Three hundred patients (EFV/FTC/TDF 203, SBR 97) were evaluated (prior protease inhibitor-based ART, 53%; nonnucleoside reverse transcriptase inhibitor-based ART, 47%). The arms were well balanced at baseline with 88% males, 29% blacks, and a mean age of 43 years; CD4 was 540 cells per cubic millimeter, 96% had HIV-1 RNA <50 copies per milliliter, and 88% were on their first ART regimen. Through 48 weeks, 89% vs. 88% in the EFV/FTC/TDF vs. SBR arms, respectively, maintained HIV-1 RNA <200 copies per milliliter by time to loss of virologic response algorithm (intent to treat, noncompleters = failures) with the difference (95% confidence interval) between arms of 1.1% (-6.7% to 8.8%), indicating noninferiority of EFV/FTC/TDF vs. SBR. Similarly, maintenance of HIV-1 RNA <50 copies per milliliter by time to loss of virologic response algorithm was 87% vs. 85% for EFV/FTC/TDF vs. SBR, respectively [difference (95% confidence interval) 2.6% (-5.9% to 11.1%)]. Discontinuation rates were similar (EFV/FTC/TDF 11%, SBR 12%); more discontinuations for adverse events occurred in the EFV/FTC/TDF arm vs. SBR (5% vs. 1%), most commonly for nervous system symptoms. More patients withdrew consent in the SBR arm vs. EFV/FTC/TDF (7% vs. 2%). Estimated glomerular filtration rate (by Modification of Diet in Renal Disease) remained unchanged over 48 weeks in both arms (median change < 1 mL.min.1.73 m). A decrease in fasting triglycerides was observed at 48 weeks in the EFV/FTC/TDF vs. SBR arm (-20 vs. -3.0 mg/dL; P = 0.035). Adherence of > or = 96% was reported by visual analog scale in both arms at baseline and at all study visits. CONCLUSION Simplification to EFV/FTC/TDF maintained high and comparable rates of virologic suppression vs. SBR through 48 weeks.
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HIV replication enhances production of free fatty acids, low density lipoproteins and many key proteins involved in lipid metabolism: a proteomics study. PLoS One 2008; 3:e3003. [PMID: 18714345 PMCID: PMC2500163 DOI: 10.1371/journal.pone.0003003] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Accepted: 07/22/2008] [Indexed: 12/30/2022] Open
Abstract
Background HIV-infected patients develop multiple metabolic abnormalities including insulin resistance, lipodystrophy and dyslipidemia. Although progression of these disorders has been associated with the use of various protease inhibitors and other antiretroviral drugs, HIV-infected individuals who have not received these treatments also develop lipid abnormalities albeit to a lesser extent. How HIV alters lipid metabolism in an infected cell and what molecular changes are affected through protein interaction pathways are not well-understood. Results Since many genetic, epigenetic, dietary and other factors influence lipid metabolism in vivo, we have chosen to study genome-wide changes in the proteomes of a human T-cell line before and after HIV infection in order to circumvent computational problems associated with multiple variables. Four separate experiments were conducted including one that compared 14 different time points over a period of >3 months. By subtractive analyses of protein profiles overtime, several hundred differentially expressed proteins were identified in HIV-infected cells by mass spectrometry and each protein was scrutinized for its biological functions by using various bioinformatics programs. Herein, we report 18 HIV-modulated proteins and their interaction pathways that enhance fatty acid synthesis, increase low density lipoproteins (triglycerides), dysregulate lipid transport, oxidize lipids, and alter cellular lipid metabolism. Conclusions We conclude that HIV replication alone (i.e. without any influence of antiviral drugs, or other human genetic factors), can induce novel cellular enzymes and proteins that are significantly associated with biologically relevant processes involved in lipid synthesis, transport and metabolism (p = <0.0002–0.01). Translational and clinical studies on the newly discovered proteins may now shed light on how some of these proteins may be useful for early diagnosis of individuals who might be at high risk for developing lipid-related disorders. The target proteins could then be used for future studies in the development of inhibitors for preventing lipid-metabolic anomalies. This is the first direct evidence that HIV-modulates production of proteins that are significantly involved in disrupting the normal lipid-metabolic pathways.
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