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Lakkis H, Lakkis A. Analysis of two binomial proportions in noninferiority confirmatory trials. Pharm Stat 2024; 23:257-275. [PMID: 38083906 DOI: 10.1002/pst.2351] [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: 04/05/2022] [Revised: 09/24/2023] [Accepted: 11/13/2023] [Indexed: 03/08/2024]
Abstract
In this article, we propose considering an approximate exact score (AES) test for noninferiority comparisons and we derive its test-based confidence interval for the difference between two independent binomial proportions. This test was published in the literature, but not its associated confidence interval. The p-value for this test is obtained by using exact binomial probabilities with the nuisance parameter being replaced by its restricted maximum likelihood estimate. Calculated type I errors revealed that the AES method has important advantages for noninferiority comparisons over popular asymptotic methods for adequately powered confirmatory clinical trials, at 80% or 90% statistical power. For unbalanced sample sizes of the compared groups, type I errors for the asymptotic score method were shown to be higher than the nominal level in a systematic pattern over a range of true proportions, but the AES method did not suffer from such a problem. On average, the true type I error of the AES method was closer to the nominal level than all considered methods in the empirical comparisons. In rare cases, type I errors of the AES test exceeded the nominal level, but only by a small amount. Presented examples showed that the AES method can be more attractive in practice than practical exact methods. In addition, p-value and confidence interval of the AES method can be obtained in <30 s of computer time for most confirmatory trials. Theoretical arguments, combined with empirical evidence and fast computation time should make the AES method attractive in statistical practice.
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Affiliation(s)
- Hassan Lakkis
- Biostatistics, Intra-Cellular Therapies, Inc, New York, New York, USA
| | - Andrew Lakkis
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Hui L, Xiaoxu H, Yuqi W, Peng W, Xin W, Yunyun Y, Xin L. Effectiveness and Safety Analysis of PIs/r Based Dual Therapy in Treatment-Naïve, HIV/AIDS Patients: A Network Meta Analysis of Randomized Controlled Trials. Front Pharmacol 2022; 13:811357. [PMID: 35308227 PMCID: PMC8931831 DOI: 10.3389/fphar.2022.811357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Dual anti-retroviral therapy is the main proven valuable intervention type for treating naïve HIV/AIDS. Currently, no high-quality evidence is available regarding the best dual schemes.Objectives: The aim of this study is to evaluate the effectiveness and safety of PIs/r-based dual therapy in treatment-naïve HIV/AIDS patients by using network meta-analysis.Methods: Randomized controlled trials of PIs/r-based dual therapy in treatment-naïve HIV/AIDS were searched based on Embase, PubMed and Cochrane library database from January 2006 to June 2021. Taking viral suppression rate, CD4+T cell count changes from baseline as the primary indicator and adverse events rate as secondary indicator, the network meta-analysis was performed on Review Manager and STATA software. Heterogeneity was assessed by the Q statistic and I2. We registered our protocol in Prospero with ID CRD42021275466.Results: Among 15 randomized controlled trials (3,497 patients and 7 PIs/r-based dual therapy) were reviewed in this study. According to the forest map, DRV/r + INSTIs was more effective compared to triple therapy (TT) in viral suppression [OR 0.82, 95% CI (0.61–1.11)], in CD4+T cell count changes from baseline [MD 1.9, 95% CI (0.7, 3.1), I2 86%], in adverse events [OR 0.98, 95% CI (0.68–1.39)]. Furthermore, SUCRA ranking analysis indicated that DRV/r + INSTIs was superior to TT in viral suppression (DRV/r + INSTIs 75.5% > TT 41.2%) and in immune construction (DRV/r + INSTIs 67% > TT 42%). In addition, DRV/r + INSTIs was similar to TT in adverse events (DRV/r + INSTIs 54.9% ≈ TT 54.7%).Conclusion: DRV/r + INSTIs was obviously superior to TT in viral suppression and immune reconstruction, and was not higher than TT in adverse events.Systematic Review Registration:https://www.crd.york.ac.uk/prospero/, identifier CRD42021275466
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Uddin E, Islam R, Ashrafuzzaman, Bitu NA, Hossain MS, Islam AN, Asraf A, Hossen F, Mohapatra RK, Kudrat-E-Zahan M. Potential Drugs for the Treatment of COVID-19: Synthesis, Brief History and Application. Curr Drug Res Rev 2021; 13:184-202. [PMID: 34126913 DOI: 10.2174/2589977513666210611155426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 02/02/2021] [Accepted: 03/04/2021] [Indexed: 11/22/2022]
Abstract
Coronaviruses (CoVs) belonging to the Betacoronavirus group, an unusually large RNA genome, are characterized by club-like spikes that project from their surface. An outbreak of a novel coronavirus 2019 (nCOVID-19) showing a unique replication strategy and infection has posed a significant threat to international health and the economy around the globe. Scientists around the world are investigating few previously used clinical drugs for the treatment of COVID-19. This review provides synthesis and mode of action of recently investigated drugs like Chloroquine, Hydroxychloroquine, Ivermectin, Selamectin, Remdesivir, Baricitinib, Darunavir, Favipiravir, Lopinavir/ritonavir and Mefloquine hydrochloride that constitute an option for COVID-19 treatment.
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Affiliation(s)
- Ekhlass Uddin
- Department of chemistry, Rajshahi University, Rajshahi 6205, Bangladesh
| | - Raisul Islam
- Department of chemistry, Rajshahi University, Rajshahi 6205, Bangladesh
| | - Ashrafuzzaman
- Department of chemistry, Rajshahi University, Rajshahi 6205, Bangladesh
| | - Nur Amin Bitu
- Department of chemistry, Rajshahi University, Rajshahi 6205, Bangladesh
| | - Md Saddam Hossain
- Department of Chemistry, Begum Rokeya University, Rangpur, Bangladesh
| | - Abm Nazmul Islam
- Chemistry Discipline, Khulna University, Khulna-9208, Bangladesh
| | - Ali Asraf
- Department of chemistry, Rajshahi University, Rajshahi 6205, Bangladesh
| | - Faruk Hossen
- Department of chemistry, Rajshahi University, Rajshahi 6205, Bangladesh
| | - Ranjan K Mohapatra
- Department of Chemistry, Government College of Engineering, Keonjhar, Odisha, India
| | - Md Kudrat-E-Zahan
- Department of chemistry, Rajshahi University, Rajshahi 6205, Bangladesh
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Pisaturo M, Onorato L, Russo A, Martini S, Chiodini P, Signoriello S, Maggi P, Coppola N. Risk of failure in dual therapy versus triple therapy in naïve HIV patients: a systematic review and meta-analysis. Clin Microbiol Infect 2020; 27:28-35. [PMID: 33031949 DOI: 10.1016/j.cmi.2020.09.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/31/2020] [Accepted: 09/25/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Several attempts have been made to test different drug-sparing strategies to reduce the drug-burden and drug-related toxicities. The objective of this meta-analysis was to evaluate the relative risk (RR) of failure of dual therapies compared to triple therapies in HIV-naïve patients. METHODS We searched MEDLINE, Google Scholar and the Cochrane Library. The following criteria were used: present data from original articles comparing the two treatment regimens; published from January 2007 up to January, 2020. No language or study design restriction was applied. Subjects were HIV-positive naïve patients treated with dual or triple antiretroviral therapy (ART). A systematic review and meta-analysis was performed. Treatment failure (TF) was the primary outcome evaluated; heterogeneity was assessed using the Q statistic and I2. RESULTS Fourteen studies were included, allowing a meta-analysis on 5205 patients. The meta-analysis performed on studies that presented data at 48 weeks showed that the RR of TF (RR > 1 favouring triple therapy) in 10 studies was 1.20 (95% confidence interval (CI): 0.91-1.59, I2: 49.2%); the RR of virological failure (VF) in eight studies was 1.54 (95% CI: 0.84-2.86, I2: 54%); the RR of adverse drug reaction leading to discontinuation of the regimen at 48 weeks in eight studies was 0.76 (95% CI: 0.43-1.33, I2: 17.7%). In patients with less than 200 CD4+, the RR of TF in two studies without maraviroc was 2.09 (95% CI: 1.05-4.17, I2: 0.0%). Regarding the studies at 96 weeks there was no difference except in rate of development of resistance, RR 1.94 (95% CI: 1.06-3.53, I2: 6.2%). CONCLUSION Dual therapies are as effective as those with three drugs, showing no difference according to the different dual therapies, except in patients with less than 200 CD4; however, they are associated with a higher selection of resistance-associated mutations at 96 weeks of therapy.
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Affiliation(s)
- Mariantonietta Pisaturo
- Department of Mental Health and Public Medicine - Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Lorenzo Onorato
- Department of Mental Health and Public Medicine - Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Antonio Russo
- Department of Mental Health and Public Medicine - Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Salvatore Martini
- Infectious Disease Unit, University Hospital Luigi Vanvitelli, Naples, Italy
| | - Paolo Chiodini
- Medical Statistics Unit, Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Simona Signoriello
- Medical Statistics Unit, Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Paolo Maggi
- Department of Mental Health and Public Medicine - Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Nicola Coppola
- Department of Mental Health and Public Medicine - Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy; Infectious Disease Unit, University Hospital Luigi Vanvitelli, Naples, Italy.
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Huang Y, Huang X, Chen H, Wu H, Chen Y. Efficacy and Safety of Raltegravir-Based Dual Therapy in AIDS Patients: A Meta-Analysis of Randomized Controlled Trials. Front Pharmacol 2019; 10:1225. [PMID: 31749699 PMCID: PMC6842978 DOI: 10.3389/fphar.2019.01225] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/23/2019] [Indexed: 11/13/2022] Open
Abstract
Background: The life expectancy for HIV-infected individuals has improved dramatically because of improvements in antiretroviral therapy (ART). Today, a simplified two-drug regimen enhances adherence and treatment satisfaction by reducing adverse effects. Therefore, we need more evidence to show the benefits and risks of simplified ART regimens from randomized controlled trials (RCTs). We compared the efficacy and safety of raltegravir-based simplified dual therapy (DT) and of traditional triple therapy (TT) for people living with HIV/AIDS (PLWHA). Methods: We carried out a systematic review of RCTs. After using a combination of the key words "HIV," "raltegravir," and "protease inhibitor" to search the English-language electronic databases from January 1, 2004, to September 11, 2019, we pooled data across eligible studies and estimated the summary effect sizes with Review Manager (version 5.3). Results: We included eight RCTs involving 4420 PLWHA: 2187 (49.5%) received raltegravir-based simplified DT, and 2144 (48.5%) received traditional TT. The proportion of viral suppression was 79% at 48 weeks and 74% at 96 weeks in the simplified regimen, and the proportion of viral suppression was 78% at 48 weeks and 71% at 96 weeks in the traditional TT group. Furthermore, the proportion of viral suppression in the simplified DT group was greater than that in the TT group at 24 weeks (risk ratio 1.11, 95% confidence interval 1.02-1.21; p = 0.01). The CD4 cell counts in the simplified DT group were significantly higher at 48 weeks and 96 weeks than those in the group that received the traditional TT. Regarding adverse events and mortality rates, the DT and TT groups were similar. However, there was better adherence in the DT group than in the TT group. Conclusion: We found that the simplified regimen was noninferior to TT regimen in regard to viral suppression. Furthermore, the simplified DT regimen had a better CD4 cell count and lower adverse events than the TT regimen.
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Affiliation(s)
- Yinqiu Huang
- National Key Laboratory for Infectious Diseases Prevention and Treatment with Traditional Chinese Medicine, Chongqing Public Health Medical Center, Chongqing, China.,Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Xiaojie Huang
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Hui Chen
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Hao Wu
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Yaokai Chen
- National Key Laboratory for Infectious Diseases Prevention and Treatment with Traditional Chinese Medicine, Chongqing Public Health Medical Center, Chongqing, China.,Department of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
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Huang Y, Huang X, Chen H, Wu H, Chen Y. Efficacy and Safety of Raltegravir-Based Dual Therapy in AIDS Patients: A Meta-Analysis of Randomized Controlled Trials. Front Pharmacol 2019. [PMID: 31749699 DOI: 10.3389/fphar.2019.01225/bibtex] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2023] Open
Abstract
Background: The life expectancy for HIV-infected individuals has improved dramatically because of improvements in antiretroviral therapy (ART). Today, a simplified two-drug regimen enhances adherence and treatment satisfaction by reducing adverse effects. Therefore, we need more evidence to show the benefits and risks of simplified ART regimens from randomized controlled trials (RCTs). We compared the efficacy and safety of raltegravir-based simplified dual therapy (DT) and of traditional triple therapy (TT) for people living with HIV/AIDS (PLWHA). Methods: We carried out a systematic review of RCTs. After using a combination of the key words "HIV," "raltegravir," and "protease inhibitor" to search the English-language electronic databases from January 1, 2004, to September 11, 2019, we pooled data across eligible studies and estimated the summary effect sizes with Review Manager (version 5.3). Results: We included eight RCTs involving 4420 PLWHA: 2187 (49.5%) received raltegravir-based simplified DT, and 2144 (48.5%) received traditional TT. The proportion of viral suppression was 79% at 48 weeks and 74% at 96 weeks in the simplified regimen, and the proportion of viral suppression was 78% at 48 weeks and 71% at 96 weeks in the traditional TT group. Furthermore, the proportion of viral suppression in the simplified DT group was greater than that in the TT group at 24 weeks (risk ratio 1.11, 95% confidence interval 1.02-1.21; p = 0.01). The CD4 cell counts in the simplified DT group were significantly higher at 48 weeks and 96 weeks than those in the group that received the traditional TT. Regarding adverse events and mortality rates, the DT and TT groups were similar. However, there was better adherence in the DT group than in the TT group. Conclusion: We found that the simplified regimen was noninferior to TT regimen in regard to viral suppression. Furthermore, the simplified DT regimen had a better CD4 cell count and lower adverse events than the TT regimen.
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Affiliation(s)
- Yinqiu Huang
- National Key Laboratory for Infectious Diseases Prevention and Treatment with Traditional Chinese Medicine, Chongqing Public Health Medical Center, Chongqing, China
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Xiaojie Huang
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Hui Chen
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Hao Wu
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Yaokai Chen
- National Key Laboratory for Infectious Diseases Prevention and Treatment with Traditional Chinese Medicine, Chongqing Public Health Medical Center, Chongqing, China
- Department of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
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Churchill D, Waters L, Ahmed N, Angus B, Boffito M, Bower M, Dunn D, Edwards S, Emerson C, Fidler S, Fisher M, Horne R, Khoo S, Leen C, Mackie N, Marshall N, Monteiro F, Nelson M, Orkin C, Palfreeman A, Pett S, Phillips A, Post F, Pozniak A, Reeves I, Sabin C, Trevelion R, Walsh J, Wilkins E, Williams I, Winston A. British HIV Association guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2015. HIV Med 2018; 17 Suppl 4:s2-s104. [PMID: 27568911 DOI: 10.1111/hiv.12426] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | | | | | - Mark Bower
- Chelsea and Westminster Hospital, London, UK
| | | | - Simon Edwards
- Central and North West London NHS Foundation Trust, UK
| | | | - Sarah Fidler
- Imperial College School of Medicine at St Mary's, London, UK
| | | | | | | | | | | | | | | | - Mark Nelson
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | | | | | | | | | - Anton Pozniak
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Caroline Sabin
- Royal Free and University College Medical School, London, UK
| | | | - John Walsh
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Ian Williams
- Royal Free and University College Medical School, London, UK
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Gallien S, Massetti M, Flandre P, Leleu H, Descamps D, Lazaro E. Comparison of 48-week efficacies of elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide and nucleoside/nucleotide reverse transcriptase inhibitor-sparing regimens: a systematic review and network meta-analysis. HIV Med 2018; 19:559-571. [PMID: 30004176 DOI: 10.1111/hiv.12643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2018] [Indexed: 02/01/2023]
Abstract
OBJECTIVES To compare nucleoside/nucleotide reverse transcriptase inhibitor (NRTI)-sparing regimens with tenofovir alafenamide (TAF)-based combinations in HIV-1-infected adults, we performed a network meta-analysis (NMA) to provide estimates of relative efficacy for these two regimens. METHODS A systematic literature review (SLR) was performed to identify phase 3/4 randomized controlled clinical trials evaluating the efficacy of commonly used combination antiretroviral therapy (cART) including an NRTI backbone or that of commonly used NRTI-sparing regimens. A Bayesian random-effect model was used to compare virological suppression rates at 48 weeks for NRTI-sparing regimens and elvitegravir/cobicistat/emtricitabine/TAF (E/C/F/TAF). RESULTS Twenty-three studies in treatment-naïve patients identified by the SLR were included in the NMA, including four studies assessing NRTI-sparing regimens. In treatment-naïve patients, the probability of achieving virological suppression at 48 weeks was between 40% and 60% higher with E/C/F/TAF than with NRTI-sparing strategies. The credible interval vs. darunavir/ritonavir (DVR/r) + raltegravir (RAL) and LPV/r monotherapy did not include 1. In the subgroup of naïve patients with viral load < 100 000 HIV-1 RNA copies/mL, a credible difference was found between NRTI-sparing treatments and E/C/F/TAF. Studies in treatment-experienced patients were too heterogeneous to allow for an NMA. CONCLUSIONS The NMA results suggest that E/C/F/TAF represents a more effective option than NRTI-sparing regimens in terms of 48-week efficacy in treatment-naïve patients. Furthermore, TAF pharmacological properties, as well as tolerability results in clinical studies, suggest a safety profile similar to that of NRTI-sparing regimens. Thus, the E/C/F/TAF combination might represent a more appropriate option than NRTI-sparing regimens for initiation of antiretroviral therapy in treatment-naïve HIV-infected patients.
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Affiliation(s)
- S Gallien
- Henri Mondor University Hospital, Créteil, France
- University of Paris-Est Créteil Val de Marne Medical School, Créteil, France
| | | | - P Flandre
- INSERM Sorbonne University, UPMC University Paris 06, UMR-S 1136, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
| | - H Leleu
- Public Health Expertise, Paris, France
| | - D Descamps
- Bichat Claude Bernard University Hospital, Paris, France
- University Paris Diderot Medical School, Paris, France
| | - E Lazaro
- Bordeaux University Hospital, Bordeaux, France
- University of Bordeaux, Bordeaux, France
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Rossetti B, Montagnani F, De Luca A. Current and emerging two-drug approaches for HIV-1 therapy in ART-naïve and ART-experienced, virologically suppressed patients. Expert Opin Pharmacother 2018; 19:713-738. [PMID: 29676935 DOI: 10.1080/14656566.2018.1457648] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Current guidelines recommend a 2-drug antiretroviral regimen as an alternative to triple antiretroviral therapy (ART) in selected patients to reduce long-term toxicity and costs. AREAS COVERED This review is intended to provide insight into the efficacy, safety and tolerability of 2-drug versus 3-drug ART in naïve and in treatment-experienced virologically-suppressed patients. EXPERT OPINION Dual therapy regimens are not feasible in HBV-coinfected individuals and should not be applied during pregnancy. Positive data on 2-drug ART in drug naïve patients are still limited, while, in virologically-suppressed individuals, several regimens have shown non-inferiority as compared to 3-drug regimens. The strongest evidence of efficacy applies to ritonavir-boosted PI regimens combined with lamivudine and to dolutegravir with rilpivirine. Dual therapies showed improved renal function and bone mineral density over tenofovir disoproxil fumarate-based 3-drug regimens. There are also great expectations for ongoing phase 3 trials testing dolutegravir with lamivudine. New and future single tablet co-formulations of dual regimens are expected to improve their suitability. Despite the lack of comparison with tenofovir alafenamide-based 3-drug regimens, the 2-drug regimens showing consistent non-inferiority and safety versus 3-drug regimens will challenge the current paradigm of 3-drug ART.
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Affiliation(s)
- Barbara Rossetti
- a Infectious Diseases Unit, Hospital Department of Specialized and Internal Medicine , University Hospital of Siena , Siena , Italy.,b Clinic of Infectious Diseases , Catholic University of Sacred Heart , Rome , Italy
| | - Francesca Montagnani
- a Infectious Diseases Unit, Hospital Department of Specialized and Internal Medicine , University Hospital of Siena , Siena , Italy.,c Department of Medical Biotechnologies, Infectious Diseases Division , University of Siena , Siena , Italy
| | - Andrea De Luca
- a Infectious Diseases Unit, Hospital Department of Specialized and Internal Medicine , University Hospital of Siena , Siena , Italy.,c Department of Medical Biotechnologies, Infectious Diseases Division , University of Siena , Siena , Italy
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10
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Fewer pills do not mean fewer drug-drug interactions: severe rhabdomyolysis on Elvitegravir/Cobicistat and statin treatment. AIDS 2018; 32:676-678. [PMID: 29494427 DOI: 10.1097/qad.0000000000001746] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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11
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Hakim JG, Thompson J, Kityo C, Hoppe A, Kambugu A, van Oosterhout JJ, Lugemwa A, Siika A, Mwebaze R, Mweemba A, Abongomera G, Thomason MJ, Easterbrook P, Mugyenyi P, Walker AS, Paton NI. Lopinavir plus nucleoside reverse-transcriptase inhibitors, lopinavir plus raltegravir, or lopinavir monotherapy for second-line treatment of HIV (EARNEST): 144-week follow-up results from a randomised controlled trial. THE LANCET. INFECTIOUS DISEASES 2018; 18:47-57. [PMID: 29108797 PMCID: PMC5739875 DOI: 10.1016/s1473-3099(17)30630-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 09/05/2017] [Accepted: 09/26/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Millions of HIV-infected people worldwide receive antiretroviral therapy (ART) in programmes using WHO-recommended standardised regimens. Recent WHO guidelines recommend a boosted protease inhibitor plus raltegravir as an alternative second-line combination. We assessed whether this treatment option offers any advantage over the standard protease inhibitor plus two nucleoside reverse-transcriptase inhibitors (NRTIs) second-line combination after 144 weeks of follow-up in typical programme settings. METHODS We analysed the 144-week outcomes at the completion of the EARNEST trial, a randomised controlled trial done in HIV-infected adults or adolescents in 14 sites in five sub-Saharan African countries (Uganda, Zimbabwe, Malawi, Kenya, Zambia). Participants were those who were no longer responding to non-NRTI-based first-line ART, as assessed with WHO criteria, confirmed by viral-load testing. Participants were randomly assigned to receive a ritonavir-boosted protease inhibitor (lopinavir 400 mg with ritonavir 100 mg, twice per day) plus two or three clinician-selected NRTIs (protease inhibitor plus NRTI group), protease inhibitor plus raltegravir (400 mg twice per day; protease inhibitor plus raltegravir group), or protease inhibitor monotherapy (plus raltegravir induction for first 12 weeks, re-intensified to combination therapy after week 96; protease inhibitor monotherapy group). Randomisation was by computer-generated randomisation sequence, with variable block size. The primary outcome was viral load of less than 400 copies per mL at week 144, for which we assessed non-inferiority with a one-sided α of 0·025, and superiority with a two-sided α of 0·025. The EARNEST trial is registered with ISRCTN, number 37737787. FINDINGS Between April 12, 2010, and April 29, 2011, 1837 patients were screened for eligibility, of whom 1277 patients were randomly assigned to an intervention group. In the primary (complete-case) analysis at 144 weeks, 317 (86%) of 367 in the protease inhibitor plus NRTI group had viral loads of less than 400 copies per mL compared with 312 (81%) of 383 in the protease inhibitor plus raltegravir group (p=0·07; lower 95% confidence limit for difference 10·2% vs specified non-inferiority margin 10%). In the protease inhibitor monotherapy group, 292 (78%) of 375 had viral loads of less than 400 copies per mL; p=0·003 versus the protease inhibitor plus NRTI group at 144 weeks. There was no difference between groups in serious adverse events, grade 3 or 4 adverse events (total or ART-related), or events that resulted in treatment modification. INTERPRETATION Protease inhibitor plus raltegravir offered no advantage over protease inhibitor plus NRTI in virological efficacy or safety. In the primary analysis, protease inhibitor plus raltegravir did not meet non-inferiority criteria. A regimen of protease inhibitor with NRTIs remains the best standardised second-line regimen for use in programmes in resource-limited settings. FUNDING European and Developing Countries Clinical Trials Partnership (EDCTP), UK Medical Research Council, Instituto de Salud Carlos III, Irish Aid, Swedish International Development Cooperation Agency, Instituto Superiore di Sanita, Merck, ViiV Healthcare, WHO.
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Affiliation(s)
- James G Hakim
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | - Cissy Kityo
- Joint Clinical Research Centre (JCRC) Kampala, Kampala, Uganda
| | - Anne Hoppe
- MRC Clinical Trials Unit at University College London, London, UK
| | | | - Joep J van Oosterhout
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi; Dignitas International, Zomba, Malawi
| | | | | | | | | | | | | | | | - Peter Mugyenyi
- Joint Clinical Research Centre (JCRC) Kampala, Kampala, Uganda
| | - A Sarah Walker
- MRC Clinical Trials Unit at University College London, London, UK
| | - Nicholas I Paton
- MRC Clinical Trials Unit at University College London, London, UK; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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Orkin C, Llibre JM, Gallien S, Antinori A, Behrens G, Carr A. Nucleoside reverse transcriptase inhibitor-reducing strategies in HIV treatment: assessing the evidence. HIV Med 2017; 19:18-32. [PMID: 28737291 DOI: 10.1111/hiv.12534] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2017] [Indexed: 01/22/2023]
Abstract
Antiretroviral (ARV) therapy, comprising a backbone of two nucleos(t)ide reverse transcriptase inhibitors (NRTIs) plus another ARV, is the recognized standard of care (SOC), which has helped extend life expectancy in people living with HIV. In a quest to reduce lifelong drug exposure and minimize or avoid the toxicity of NRTIs, "NRTI-reducing" regimens have been investigated. This descriptive review assessing the results of NRTI-reducing strategies from the largest randomized trials focuses on virological efficacy, resistance, regimen safety (in terms of bone mineral density, renal function, lipids and central nervous system function) and simplicity. The review considers efficacy across various NRTI-sparing strategies, for example an integrase strand transfer inhibitor (INSTI) plus a ritonavir-boosted protease inhibitor (PI/r) or PI/r + lamivudine (3TC), in both naïve and switch regimes. Of 10 key studies in treatment-naïve adults assessing five NRTI-reducing strategies, only four studies demonstrated noninferiority vs. SOC [GARDEL, NEAT 001, AIDS Clinical Trials Group 5142 and PROGRESS]. In switch settings, 17 studies (10 randomized) were reviewed that used four strategies, including three studies assessing an INSTI plus a nonnucleoside reverse transcriptase inhibitor . Noninferiority of the NRTI-reducing arm was shown in six of 10 studies (ATLAS-M, SALT, DUAL, OLE, LATTE-2 and SWORD). In general, NRTI-reducing therapy did not always result in an improvement in short- or long-term adverse events; however, in many cases, these endpoints were not reported. Some of these studies reported higher virological failure rates with more frequent emergence of resistance mutations. None of these NRTI-reducing strategies has been compared against a single-pill regimen, including those containing tenofovir alafenamide. Only strategies demonstrating noninferior efficacy, a benefit in safety/tolerability, and a favourable cost-efficacy ratio, preferably in a single pill, will eventually match the current SOC of triple ARV therapy.
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Affiliation(s)
- C Orkin
- Infection and Immunity, Barts Health NHS Trust, London, UK
| | - J M Llibre
- University Hospital Germans Trias i Pujol, Infectious Diseases and "Fight AIDS" Foundation, Badalona, Barcelona, Spain
| | - S Gallien
- Immunology and Infectious Diseases, Henri Mondor Hospital, Paris Est Créteil University, Créteil, France
| | - A Antinori
- HIV/AIDS Department, National Institute for Infectious Diseases "Lazzaro Spallanzani", Rome, Italy
| | - Gmn Behrens
- Department for Clinical Immunology and Rheumatology, Hannover Medical School, Hannover, Germany.,German Center for Infection Research, St Vincent's Hospital, Sydney, Australia
| | - A Carr
- Centre for Applied Medical Research, St Vincent's Hospital, Sydney, Australia
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Soriano V, Fernandez-Montero JV, Benitez-Gutierrez L, Mendoza CD, Arias A, Barreiro P, Peña JM, Labarga P. Dual antiretroviral therapy for HIV infection. Expert Opin Drug Saf 2017. [PMID: 28621159 DOI: 10.1080/14740338.2017.1343300] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION For two decades, triple combinations of antiretrovirals have been the standard treatment for HIV infection. The challenges of such lifelong therapy include long-term side effects, high costs and reduced drug adherence. The recent advent of more potent and safer antiretrovirals has renewed the interest for simpler HIV regimens. Areas covered: We discuss the pros and cons of dual antiretroviral therapies in both drug-naïve and in treatment-experienced patients with viral suppression (switch strategy). Expert opinion: Some dual antiretroviral regimens are safe and efficacious, particularly as maintenance therapy. At this time, combinations of dolutegravir plus rilpivirine represent the best dual regimen. Longer follow-up and larger study populations are needed before supporting dolutegravir plus lamivudine. In contrast, dual therapy based on maraviroc is less effective. Although dual regimens with boosted protease inhibitors plus either lamivudine or raltegravir may be effective, they are penalized by metabolic side effects and risk for drug interactions. The newest dual regimens could save money, reduce toxicity and spare drug options for the future. For the first time in HIV therapeutics, less can be more. Dual therapy switching has set up a new paradigm in HIV treatment that uses induction-maintenance.
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Affiliation(s)
- Vicente Soriano
- a Infectious Diseases Unit , La Paz University Hospital & Autonomous University , Madrid , Spain
| | | | | | - Carmen de Mendoza
- c Internal Medicine Department , Puerta de Hierro Research Institute , Majadahonda , Spain
| | - Ana Arias
- c Internal Medicine Department , Puerta de Hierro Research Institute , Majadahonda , Spain
| | - Pablo Barreiro
- a Infectious Diseases Unit , La Paz University Hospital & Autonomous University , Madrid , Spain
| | - José M Peña
- a Infectious Diseases Unit , La Paz University Hospital & Autonomous University , Madrid , Spain
| | - Pablo Labarga
- d Internal Medicine Department , Nuestra Señora de la Paz Hospital , Madrid , Spain
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Karris MY, Jain S, Day TRC, Pérez-Santiago J, Goicoechea M, Dubé MP, Sun X, Spina C, Daar ES, Haubrich RH, Morris S. HIV viral kinetics and T cell dynamics in antiretroviral naïve persons starting an integrase strand transfer inhibitor and protease inhibitor regimen. HIV CLINICAL TRIALS 2017; 18:67-74. [PMID: 28134057 DOI: 10.1080/15284336.2017.1282578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Nucleos(t)ide reverse transcriptase inhibitor (NRTI)-sparing regimens may potentially minimize antiretroviral (ART) toxicities, but demonstrate mixed efficacy and toxicity results. The impact of an integrase strand transfer inhibitor (INSTI) and protease inhibitor (PI) regimen on HIV viral dynamics and T cell kinetics remains underdescribed. OBJECTIVE To compare the effect of raltegravir + ritonavir boosted lopinavir (RAL + LPV/r) to efavirenz/tenofovir disoproxil fumarate/emtricitabine (EFV/TDF/FTC) on HIV kinetics and T cell dynamics. METHODS Fifty participants naïve to ART underwent HIV viral kinetic sampling evaluated using biexponential mixed effects modeling. A subset of 28 subjects (with complete viral suppression) underwent flow cytometry and evaluation of soluble markers of inflammation at weeks 0, 4, and 48 of ART. RESULTS RAL + LPV/r compared to EFV/TDF/FTC resulted in a prolonged first phase viral decay rate (18 vs. 13 days p < 0.01). From weeks 0 to 4, RAL + LPV/r was associated with a trend toward greater decreases in activated CD4+ T cells (-3.81 vs. -1.18 p = 0.09) and less decreases in activated effector memory CD4+ T cells (-0.63 vs. -2.69 p-0.07). These trends did not persist to week 48. No differences were noted at any time point for soluble markers of immune activation. CONCLUSIONS The prolonged first phase viral decay observed with RAL + LPV/r in persons starting ART did not result in differences in viral suppression at week 48. We also observed trends in declines in certain cellular markers of immune activation but it remains unclear if this could translate to long-term immunologic benefits in persons on an INSTI + PI.
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Affiliation(s)
- Maile Y Karris
- a Department of Medicine , University California San Diego , San Diego , CA , USA
| | - Sonia Jain
- b Department of Family and Preventive Medicine , University California San Diego , San Diego , CA , USA
| | - Tyler R C Day
- c Department of Medicine , Washington University , Saint Louis , MO , USA
| | - Josué Pérez-Santiago
- a Department of Medicine , University California San Diego , San Diego , CA , USA
| | | | - Michael P Dubé
- e Department of Medicine , University Southern California Keck School of Medicine , Los Angeles , CA , USA
| | - Xiaoying Sun
- b Department of Family and Preventive Medicine , University California San Diego , San Diego , CA , USA
| | - Celsa Spina
- f Department of Pathology , Veterans Affairs San Diego Healthcare System , San Diego , CA , USA
| | - Eric S Daar
- g Los Angeles Biomedical Research Institute , Harbor-UCLA Medical Center , Los Angeles , CA , USA.,h David Geffen School of Medicine , UCLA , Los Angeles , CA , USA
| | | | - Sheldon Morris
- a Department of Medicine , University California San Diego , San Diego , CA , USA.,b Department of Family and Preventive Medicine , University California San Diego , San Diego , CA , USA
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Pulido I, Genebat M, Alvarez-Rios AI, De Pablo-Bernal RS, Rafii-El-Idrissi Benhnia M, Pacheco YM, Ruiz-Mateos E, Leal M. Immunovirological Efficacy of Once-Daily Maraviroc Plus Ritonavir-Boosted Atazanavir After 48 Weeks in Naive HIV-Infected Patients. Viral Immunol 2016; 29:471-477. [PMID: 27689417 DOI: 10.1089/vim.2016.0046] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Toxicities related to the use of nucleoside analogues have increased the interest in developing nucleoside-sparing regimens, mainly combining protease inhibitors with raltegravir. However, data regarding the use of CCR5-antagonists in this setting and in the naive scenario are scarce. The main objective was to analyze the immunovirological efficacy and tolerability of a low-dose, once-daily, maraviroc (MVC)-containing, nucleoside reverse transcriptase inhibitor-sparing dual therapy compared with standard triple therapy after 48 weeks for naive HIV-infected patients in the routine clinical practice setting. All naive HIV-infected patients with stable clinical condition that started antiretroviral treatment since February 1, 2008 to May 30,h 2012 were included. MVC clinical test was used to select candidate subjects to MVC therapy. Thirty-two subjects with MVC + atazanavir/ritonavir (ATV/r) and 66 with standard triple therapy were analyzed. A comparable virological efficacy between groups was found after 48 weeks (87.5% vs. 80.3% of HIV undetectability, p = 0.37, MVC + ATV/r and triple therapy groups, respectively). The CD4 recovery after 48 weeks was similar and more than 200 cells/mm3 in both groups. No need of therapy changes or treatment discontinuations was observed in the MVC + ATV/r group. Effect on lipid profile, high-sensitivity C reactive protein, and β2-microglobulin was similar for both groups. Noteworthy, a significant increase of erythrocyte mean corpuscular volume was observed only in the triple therapy group. A nucleoside-sparing MVC-containing dual therapy showed similar immunovirological efficacy and tolerability than standard triple therapy in naive HIV-infected patients.
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Affiliation(s)
- Ildefonso Pulido
- 1 Laboratory of Immunovirology, Infectious Diseases, Microbiology and Preventive Medicine Clinical Unit, Institute of Biomedicine of Seville (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville , Seville, Spain
| | - Miguel Genebat
- 1 Laboratory of Immunovirology, Infectious Diseases, Microbiology and Preventive Medicine Clinical Unit, Institute of Biomedicine of Seville (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville , Seville, Spain
| | - Ana I Alvarez-Rios
- 2 Department of Clinical Biochemistry, Virgen del Rocio University Hospital (IBiS/CSIC/SAS/University of Seville) , Seville, Spain
| | - Rebeca S De Pablo-Bernal
- 1 Laboratory of Immunovirology, Infectious Diseases, Microbiology and Preventive Medicine Clinical Unit, Institute of Biomedicine of Seville (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville , Seville, Spain
| | - Mohammed Rafii-El-Idrissi Benhnia
- 1 Laboratory of Immunovirology, Infectious Diseases, Microbiology and Preventive Medicine Clinical Unit, Institute of Biomedicine of Seville (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville , Seville, Spain .,3 Department of Biochemistry, Molecular Biology and Immunology, Medical School, University of Seville , Seville, Spain
| | - Yolanda M Pacheco
- 1 Laboratory of Immunovirology, Infectious Diseases, Microbiology and Preventive Medicine Clinical Unit, Institute of Biomedicine of Seville (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville , Seville, Spain
| | - Ezequiel Ruiz-Mateos
- 1 Laboratory of Immunovirology, Infectious Diseases, Microbiology and Preventive Medicine Clinical Unit, Institute of Biomedicine of Seville (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville , Seville, Spain
| | - Manuel Leal
- 1 Laboratory of Immunovirology, Infectious Diseases, Microbiology and Preventive Medicine Clinical Unit, Institute of Biomedicine of Seville (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville , Seville, Spain
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NRTI Sparing Therapy in Virologically Controlled HIV-1 Infected Subjects: Results of a Controlled, Randomized Trial (Probe). J Acquir Immune Defic Syndr 2016; 72:46-51. [PMID: 26910503 DOI: 10.1097/qai.0000000000000966] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Dual treatments could help clinicians to avoid drawbacks and toxicities due to the nucleosidic backbone, while maintaining the efficacy and convenience of robust combination antiretroviral therapy (cART). We explored the combination of rilpivirine plus boosted darunavir (DRV) as an option when switching from standard cART in patients who are virologically suppressed. In this randomized, open-label, proof-of-concept, noninferiority trial, we recruited patients aged 18 years or older with chronic HIV-1 infection and on a stable, effective (>6 months) protease inhibitor-based cART including a nucleosidic backbone. The primary endpoint was noninferiority of the virological response between treatment groups, according to FDA snapshot approach. Sixty patients were randomly allocated to dual treatment with rilpivirine plus boosted DRV or to continue their ongoing triple treatment. Noninferiority was shown at the prespecified level of -12% both at 24 and 48 weeks. At week 24, 100% of patients in the dual arm presented a blood HIV-RNA level <50 copies per milliliter compared with 90.1% in the triple drug arm (difference 9.9%, 95% CI: -0.7 to 20.7), whereas, at 48 weeks, the same proportions were 96.7% and 93.4%, respectively (difference 3.3%, 95% CI: -7.15 to 13.5). The mean change in CD4 cell count from baseline was 6.0 cells per microliter (SD, 184) for dual treatment and 16.5 cells per microliter (SD, 142) for triple treatment. A relevant decrement in CD838HLADR cells was observed in both arms. The reduction was, however, significantly more pronounced in the dual-therapy arm. At week 48, the CD838HLADR cell count was 3.4% (SD, 2.2) in the dual-therapy arm and 5.2% (SD, 3.1) in the triple arm (P = 0.018). None of the patients developed severe adverse events nor had to stop treatment because of adverse events or presented grade 3-4 laboratory abnormalities. A greater reduction of bone stiffness (-2.25; SD, 7.1) was observed in patients randomized to continue triple therapy compared with patients switched to dual therapy (-0.32; SD, 8.8). Finally, baseline HIV-DNA content directly correlated with pre-cART viral load of patients (P = 0.021), but not with time on cART or time with HIV-RNA below 50 copies per milliliter. Independently of the study arm, patients with a n HIV-RNA level constantly above 3 copies per milliliter or showing viral blips had baseline HIV-DNA levels significantly higher (64,656 copies per 10 cells; SD, 93057) compared with patients who constantly presented a HIV-RNA level below the detection limit of 3 copies per milliliter (14,457 copies per 10 cells; SD, 14098) (P = 0.001). A rilpivirine-boosted plus ritonavir-boosted DRV therapy was not inferior over 48 weeks to a standard boosted protease inhibitor-based triple cART. The dual therapy did not negatively affect lipid profile and renal function and was more friendly on bone metabolism. This approach constitutes an alternative for patients experiencing nucleoside reverse transcriptase inhibitor-related toxicities.
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Achhra AC, Mwasakifwa G, Amin J, Boyd MA. Efficacy and safety of contemporary dual-drug antiretroviral regimens as first-line treatment or as a simplification strategy: a systematic review and meta-analysis. LANCET HIV 2016; 3:e351-e360. [DOI: 10.1016/s2352-3018(16)30015-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 03/31/2016] [Accepted: 03/31/2016] [Indexed: 12/01/2022]
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Rivero A, Pérez-Molina JA, Blasco AJ, Arribas JR, Crespo M, Domingo P, Estrada V, Iribarren JA, Knobel H, Lázaro P, López-Aldeguer J, Lozano F, Moreno S, Palacios R, Pineda JA, Pulido F, Rubio R, de la Torre J, Tuset M, Gatell JM. Costs and cost-efficacy analysis of the 2016 GESIDA/Spanish AIDS National Plan recommended guidelines for initial antiretroviral therapy in HIV-infected adults. Enferm Infecc Microbiol Clin 2016; 35:88-99. [PMID: 27459919 DOI: 10.1016/j.eimc.2016.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 06/14/2016] [Accepted: 06/14/2016] [Indexed: 11/16/2022]
Abstract
INTRODUCTION GESIDA and the AIDS National Plan panel of experts suggest preferred (PR), alternative (AR), and other regimens (OR) for antiretroviral treatment (ART) as initial therapy in HIV-infected patients for the year 2016. The objective of this study is to evaluate the costs and the efficacy of initiating treatment with these regimens. METHODS Economic assessment of costs and efficiency (cost/efficacy) based on decision tree analyses. Efficacy was defined as the probability of reporting a viral load <50copies/mL at week 48 in an intention-to-treat analysis. Cost of initiating treatment with an ART regimen was defined as the costs of ART and its consequences (adverse effects, changes of ART regimen, and drug resistance studies) during the first 48 weeks. The payer perspective (National Health System) was applied, only taking into account differential direct costs: ART (official prices), management of adverse effects, studies of resistance, and HLA B*5701 testing. The setting is Spain and the costs correspond to those of 2016. A sensitivity deterministic analysis was conducted, building three scenarios for each regimen: base case, most favourable, and least favourable. RESULTS In the base case scenario, the cost of initiating treatment ranges from 4663 Euros for 3TC+LPV/r (OR) to 10,894 Euros for TDF/FTC+RAL (PR). The efficacy varies from 0.66 for ABC/3TC+ATV/r (AR) and ABC/3TC+LPV/r (OR), to 0.89 for TDF/FTC+DTG (PR) and TDF/FTC/EVG/COBI (AR). The efficiency, in terms of cost/efficacy, ranges from 5280 to 12,836 Euros per responder at 48 weeks, for 3TC+LPV/r (OR), and RAL+DRV/r (OR), respectively. CONCLUSION Despite the overall most efficient regimen being 3TC+LPV/r (OR), among the PR and AR, the most efficient regimen was ABC/3TC/DTG (PR). Among the AR regimes, the most efficient was TDF/FTC/RPV.
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Affiliation(s)
- Antonio Rivero
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | | | | | - José Ramón Arribas
- Servicio de Medicina Interna, Unidad de VIH, IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
| | - Manuel Crespo
- Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Pere Domingo
- Hospitals Universitaris Arnau de Vilanova & Santa María, Universitat de Lleida, Institut de Recerca Biomèdica (IRB) de Lleida, Lieida, Spain
| | - Vicente Estrada
- Hospital Clínico San Carlos, IdISSC; Universidad Complutense, Madrid, Spain
| | - José Antonio Iribarren
- Servicio de Enfermedades Infecciosas, Hospital Universitario Donostia, San Sebastián, Spain
| | - Hernando Knobel
- Servicio de Enfermedades Infecciosas, Hospital del Mar, Barcelona, Spain
| | | | - José López-Aldeguer
- Servicio de Medicina Interna y Unidad de Enfermedades Infecciosas, Hospital Universitario La Fe, Valencia, Spain
| | - Fernando Lozano
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario de Valme, Sevilla, Spain
| | - Santiago Moreno
- Servicio de Enfermedades Infecciosas, Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Instituto de Investigación Sanitaria Ramón y Cajal (IRYCIS), Alcalá de Henares, Madrid, Spain
| | - Rosario Palacios
- Unidad de Enfermedades Infecciosas, Hospital Virgen de la Victoria, Málaga, Spain
| | - Juan Antonio Pineda
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario de Valme, Sevilla, Spain
| | - Federico Pulido
- Unidad VIH, i+12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Rafael Rubio
- Unidad VIH, i+12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Javier de la Torre
- Grupo de Enfermedades Infecciosas de la Unidad de Medicina Interna, Hospital Costa del Sol, Marbella, Málaga, Spain
| | | | - Josep M Gatell
- Servicio de Enfermedades Infecciosas, Hospital Clínic-IDIBAPS, Universidad de Barcelona, Barcelona, Spain
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Dehority W, Abadi J, Wiznia A, Viani RM. Use of Integrase Inhibitors in HIV-Infected Children and Adolescents. Drugs 2016; 75:1483-97. [PMID: 26242765 DOI: 10.1007/s40265-015-0446-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Resistance to antiretroviral drugs is an increasingly prevalent challenge affecting both the adult and pediatric HIV-infected populations. Though data on the safety, pharmacokinetics, and efficacy of newer antiretroviral agents in children typically lags behind adult data, newer agents are becoming available for use in HIV-infected children who are failing to respond to or are experiencing toxicities with traditional antiretroviral regimens. Integrase strand transfer inhibitors are one such new class of antiretrovirals. Raltegravir has been US Food and Drug Administration (FDA) approved for use in patients over the age of 4 weeks. Elvitegravir is a second member of this class, and has the potential for use in children but does not yet have a Pediatric FDA indication. Dolutegravir, a second-generation integrase inhibitor, is approved for those older than 12 years. This review summarizes the use of integrase inhibitors in children and adolescents, and highlights the results of recent clinical trials.
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Affiliation(s)
- Walter Dehority
- Division of Infectious Diseases, Department of Pediatrics, The University of New Mexico, MSC10 5590, 1 University of New Mexico, Albuquerque, NM, 87131-0001, USA,
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Podzamczer D, Imaz A. Dual antiretroviral therapy: finding a place in the battle. Lancet HIV 2016; 3:e335-e336. [PMID: 27470021 DOI: 10.1016/s2352-3018(16)30021-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 04/11/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Daniel Podzamczer
- HIV Unit, Infectious Disease Service, Hospital Universitari de Bellvitge, L'Hospitalet 08907 Barcelona, Spain.
| | - Arkaitz Imaz
- HIV Unit, Infectious Disease Service, Hospital Universitari de Bellvitge, L'Hospitalet 08907 Barcelona, Spain
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van Lunzen J, Pozniak A, Gatell JM, Antinori A, Klauck I, Serrano O, Baakili A, Osiyemi O, Sevinsky H, Girard PM. Brief Report: Switch to Ritonavir-Boosted Atazanavir Plus Raltegravir in Virologically Suppressed Patients With HIV-1 Infection: A Randomized Pilot Study. J Acquir Immune Defic Syndr 2016; 71:538-43. [PMID: 26605505 PMCID: PMC4804741 DOI: 10.1097/qai.0000000000000904] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 10/26/2015] [Indexed: 11/26/2022]
Abstract
This open-label, multinational, pilot study randomized (1:2 ratio) adults with HIV-1 RNA <40 copies per milliliter and nucleos(t)ide-related safety/tolerability issues to switch to ritonavir-boosted atazanavir (ATV/r) plus tenofovir disoproxil fumarate/emtricitabine (n = 37) or the nucleos(t)ide reverse transcriptase inhibitor-sparing regimen of ATV/r plus raltegravir (RAL) (n = 72). At 24 weeks, 35/37 (94.6%) and 58/72 (80.6%) of patients, respectively, maintained virological suppression, the primary endpoint, and 1 (2.7%) and 7 (9.7%), respectively, experienced virological rebound. Corresponding 48-week proportions were 86.5%, 69.4%, 2.7%, and 12.5%, respectively. Adherence was lower and treatment discontinuation was higher with ATV/r+RAL. In conclusion, switching to ATV/r+RAL resulted in a higher virological rebound rate than switching to ATV/r plus tenofovir disoproxil fumarate/emtricitabine.
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Affiliation(s)
- Jan van Lunzen
- Infectious Diseases Unit, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- ViiV Healthcare, Brentford, United Kingdom
| | - Anton Pozniak
- Chelsea and Westminster NHS Foundation Trust Hospital, London, United Kingdom
| | - Jose M. Gatell
- Infectious Diseases & AIDS Units, Clinical Institute of Medicine & Dermatology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Andrea Antinori
- National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Roma, Italy
| | | | | | - Adyb Baakili
- Bristol-Myers Squibb, Rueil-Malmaison, France
- Bristol-Myers Squibb, Uxbridge, United Kingdom
| | | | | | - Pierre-Marie Girard
- Department of Infectious and Tropical Diseases, Hôpital St Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France; and
- Institut Pierre-Louis d'Epidémiologie et Santé Publique, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche en Santé n°1136, Paris, France
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Calcagno A, D'Avolio A, Bonora S. Pharmacokinetic and pharmacodynamic evaluation of raltegravir and experience from clinical trials in HIV-positive patients. Expert Opin Drug Metab Toxicol 2016; 11:1167-76. [PMID: 26073580 DOI: 10.1517/17425255.2015.1056732] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Raltegravir was the first available integrase inhibitor for treating HIV-positive patients. This review aims to provide an overview of its role in the management of HIV-1 infection, highlighting its key pharmacokinetic and pharmacodynamic properties. AREAS COVERED This review covers material searched and obtained through Medline and PubMed up to April 2015. EXPERT OPINION Raltegravir for its tolerability, efficacy, few drug-to-drug interactions and for the amount of available data in difficult subgroups of patients is a key drug in the antiretroviral armamentarium. For its weak genetic barrier to resistance and erratic pharmacokinetic profile, it should be administered twice daily and with fully active companion antiretrovirals.
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Affiliation(s)
- Andrea Calcagno
- University of Torino, Amedeo di Savoia Hospital, Unit of Infectious Diseases, Department of Medical Sciences , C.so Svizzera 164 - 10149, Torino , Italy + 39 011 439 3884 ; + 39 011 439 3942 ;
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Abstract
PURPOSE OF REVIEW We aim to review the strengths and weaknesses of current antiretroviral therapy (ART), and describe ongoing research to address limitations to current therapy. RECENT FINDINGS Current ART is highly effective and well tolerated. As a result of a decrease in medication side-effects and pill burden, and the known health effects of uncontrolled viremia, ART is now recommended at all CD4 cell counts in the USA. Novel medications are being developed to further decrease side-effects and offer alternative options for patients with multiclass resistance. New combination pills will further decrease pill burden. SUMMARY Current treatment for HIV is characterized by highly potent oral antiretroviral medications, which are well tolerated, resulting in outstanding rates of virologic suppression in patients who are adherent to therapy. Despite the marked improvement in therapeutic options, limitations to therapy still exist including reliance on daily adherence, long-term toxicity of medications, drug-drug interactions, long-term effects of HIV even in the setting of viral suppression, high lifetime cost of treatment, and limited options for some patients with multiclass resistance. Emerging alternative treatment strategies include nucleoside reverse transcriptase inhibitor-sparing or limiting regimens and long-acting injectable combination therapy.
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Baril JG, Angel JB, Gill MJ, Gathe J, Cahn P, van Wyk J, Walmsley S. Dual Therapy Treatment Strategies for the Management of Patients Infected with HIV: A Systematic Review of Current Evidence in ARV-Naive or ARV-Experienced, Virologically Suppressed Patients. PLoS One 2016; 11:e0148231. [PMID: 26849060 PMCID: PMC4746196 DOI: 10.1371/journal.pone.0148231] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 01/14/2016] [Indexed: 12/13/2022] Open
Abstract
Objective We reviewed the current literature regarding antiretroviral (ARV)-sparing therapy strategies to determine whether these novel regimens can be considered appropriate alternatives to standard regimens for the initial treatment of ARV-naive patients or as switch therapy for those patients with virologically suppressed HIV infection. Methods A search for studies related to HIV dual therapy published from January 2000 through April 2014 was performed using Biosis, Derwent Drug File, Embase, International Pharmaceutical Abstracts, Medline, Pascal, SciSearch, and TOXNET databases; seven major trial registries, and the abstracts of major conferences. Using predetermined criteria for inclusion, an expert review committee critically reviewed and qualitatively evaluated all identified trials for efficacy and safety results and potential limitations. Results Sixteen studies of dual therapy regimens were critiqued for the ARV-naive population. Studies of a protease inhibitor/ritonavir in combination with the integrase inhibitor raltegravir or the nucleoside reverse transcriptase inhibitor lamivudine provided the most definitive evidence supporting a role for dual therapy. In particular, lopinavir/ritonavir or darunavir/ritonavir combined with raltegravir and lopinavir/ritonavir combined with lamivudine demonstrated noninferiority to standard of care triple therapy after 48 weeks of treatment. Thirteen trials were critiqued in ARV-experienced, virologically suppressed patients. The virologic efficacy outcomes were mixed. Although overall data regarding toxicity are limited, when compared with standard triple therapy, certain dual therapy regimens may offer advantages in renal function, bone mineral density, and limb fat changes; however, some dual combinations may elevate lipid or bilirubin levels. Conclusions The potential benefits of dual therapy regimens include reduced toxicity, improved tolerability and adherence, and reduced cost. Although the data reviewed here provide valuable insights into the effectiveness and tolerability of dual therapy regimens, it remains unclear whether these potential benefits can be maintained long-term. Appropriately powered studies with longer follow-up periods are needed to more definitively assess potential toxicity reduction advantages with dual therapy.
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Affiliation(s)
- Jean-Guy Baril
- Clinique médicale du Quartier latin, Montreal, Quebec, Canada
- * E-mail:
| | - Jonathan B. Angel
- Division of Infectious Diseases, University of Ottawa and the Ottawa Hospital, Ottawa, Ontario, Canada
| | - M. John Gill
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joseph Gathe
- Therapeutic Concepts, Houston, Texas, United States of America
| | - Pedro Cahn
- Fundación Huesped, Buenos Aires, Argentina
| | - Jean van Wyk
- AbbVie Inc., North Chicago, Illinois, United States of America
| | - Sharon Walmsley
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
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Hemkens LG, Ewald H, Santini-Oliveira M, Bühler JE, Vuichard D, Schandelmaier S, Stöckle M, Briel M, Bucher HC. Comparative effectiveness of tenofovir in treatment-naïve HIV-infected patients: systematic review and meta-analysis. HIV CLINICAL TRIALS 2016; 16:178-89. [PMID: 26395328 DOI: 10.1179/1945577115y.0000000004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Benefits and harms of tenofovir disoproxil fumarate (TDF) in HIV-infected, antiretroviral treatment (ART)-naïve patients of any age have not been systematically reviewed since recent milestone trials were published. METHODS We searched MEDLINE, EMBASE, CENTRAL, SCI, LILACS, WHO GHL, and ClinicalTrials.gov for randomized controlled trials (RCTs) comparing TDF-based treatments with any other ART-regimen (last search 01/2015). Trial characteristics and results were extracted, risks of bias systematically assessed, and treatment effects synthesized in meta-analyses using random-effects models. RESULTS We included 22 RCTs (8297 patients). We found no differences between groups for mortality, AIDS, fractures, CD4 cell count, and virological failure; and inconclusive information due to inadequate reporting for cardiovascular events, renal failure, proteinuria, rash, and quality of life. Tenofovir disoproxil fumarate-based regimens significantly reduced total cholesterol (mean difference -18.42 mg/dl; 95% confidence interval [CI] -22.80 to -14.0), LDL-cholesterol (-9.53 mg/dl; -12.16 to -6.89), HDL-cholesterol (-2.97 mg/dl; -4.41 to -1.53), and triglycerides (-29.77 mg/dl; -38.61 to -20.92), bone mineral density (BMD) (hip: -1.41%; -1.87 to -0.94), and glomerular filtration rate (eGFR) (-3.47 ml/minute; -5.89 to -1.06) over 48 weeks of follow-up. Effects were similar in trials comparing fixed-dose TDF/FTC-based regimens with ABC/3TC-based regimens. We found no influence of baseline viral load on virological failure. DISCUSSION Moderate-quality evidence suggests similar effects of TDF-based treatment regimens and other ART on virological failure. Tenofovir disoproxil fumarate-based regimens are associated with a more favorable lipid profile, but with increased risk of reduced BMD and eGFR. Improved reporting quality is vital to allow assessment of clinical outcomes in future trials.
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Llibre JM, Walmsley S, Gatell JM. Backbones versus core agents in initial ART regimens: one game, two players. J Antimicrob Chemother 2016; 71:856-61. [PMID: 26747092 DOI: 10.1093/jac/dkv429] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The advances seen in ART during the last 30 years have been outstanding. Treatment has evolved from the initial use of single agents as monotherapy. The ability to use HIV RNA as a surrogate marker for clinical outcomes allowed the more rapid evaluation of new therapies. This led to the understanding that triple-drug regimens, including a core agent (an NNRTI or a boosted PI) and two NRTIs, are optimal. These combinations have demonstrated continued improvements in their efficacy and toxicity as initial therapy. However, the need for pharmacokinetic boosting, with potential drug-drug interactions, or residual issues of efficacy or toxicity have persisted for some agents. Most recently, integrase strand transfer inhibitors, particularly dolutegravir, have shown unparalleled safety and efficacy and are currently the core agents of choice. Regimens that included only core agents or only backbone agents have not been as successful as combined therapy in antiretroviral-naive patients. It appears that at least one NRTI is needed for optimal performance and lamivudine and emtricitabine may be the ideal candidates. Several studies are ongoing of agents with longer dosing intervals, lower cost and new NRTI-saving strategies to address unmet needs.
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Affiliation(s)
- Josep M Llibre
- HIV Unit and 'Lluita contra la SIDA' Foundation, University Hospital Germans Trias I Pujol, Badalona, Spain Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sharon Walmsley
- Infectious Diseases, University Health Network, University of Toronto, Toronto, Canada
| | - Josep M Gatell
- Infectious Diseases & AIDS Units, Hospital Clinic/IDIBAPS, University of Barcelona, Barcelona, Spain
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Jaeckle M, Khaykin P, Haberl A, De Leuw P, Schüttfort G, Stephan C, Wolf T. Efficacy of raltegravir-containing regimens in antiretroviral-naïve and -experienced individuals in routine clinical practice. Int J STD AIDS 2015; 27:1170-1179. [PMID: 26429890 DOI: 10.1177/0956462415610678] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 09/16/2015] [Indexed: 11/15/2022]
Abstract
Raltegravir is one of the standard antiretroviral therapy (ART) options in treatment-experienced and -naïve patients. However, efficacy data from clinical practice are scarce. Therefore, the efficacy of raltegravir-containing ART in clinical practice was investigated retrospectively. In all, 295 treatment-naïve and -experienced patients were analysed using two different cut-offs for virological failure (200 or 50 copies/ml). The response at week 24 and onwards was evaluated as a 'time to loss of virological response' analysis and estimated as a survival function. Additionally, dual therapy regimens (raltegravir plus boosted protease inhibitor) were compared to standard combinations in experienced patients performing a snapshot analysis at weeks 24 and 48, as well as a time to loss of virological response analysis. A total of 86.2% of the 64 treatment-naïve patients maintained virological suppression using a cut-off of 200 copies/ml (c/ml), while 67.7% maintained virological suppression with a 50 copies/ml cut-off from week 24 until the end of observation. Among the 231 treatment-experienced patients, 84.8% maintained virological suppression from week 24 onwards using a cut-off of 200 copies/ml; and 71.0% using 50 copies/ml, respectively. In the subgroup snapshot analysis at week 24, 98.3% (86.7% using a cut-off of 50 copies/ml) and at week 48, 93.3% (80.0%) of patients responded to dual therapy. Patients who were receiving a standard background therapy responded in 88.3% (81.3%) at week 24 and in 86.0% (80.7%) at week 48. Differences were not significant. This study shows again the overall long-term efficacy of raltegravir-based ART and furthermore gives reference for a comparable efficacy of dual and standard nucleos(t)ide reverse transcriptase inhibitor-backbone regimens in experienced patients on raltegravir over a period of 48 weeks in a real-life cohort where patients with severe comorbidities were included.
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Affiliation(s)
- M Jaeckle
- HIV Center, Department of Infectious Diseases, University Hospital, Frankfurt, Germany
| | - P Khaykin
- MainFachArzt, Specialist Practice for Infectious Diseases and Primary Care, Frankfurt, Germany
| | - A Haberl
- HIV Center, Department of Infectious Diseases, University Hospital, Frankfurt, Germany
| | - P De Leuw
- HIV Center, Department of Infectious Diseases, University Hospital, Frankfurt, Germany
| | - G Schüttfort
- HIV Center, Department of Infectious Diseases, University Hospital, Frankfurt, Germany
| | - C Stephan
- HIV Center, Department of Infectious Diseases, University Hospital, Frankfurt, Germany
| | - T Wolf
- HIV Center, Department of Infectious Diseases, University Hospital, Frankfurt, Germany
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Costs and cost-effectiveness analysis of 2015 GESIDA/Spanish AIDS National Plan recommended guidelines for initial antiretroviral therapy in HIV-infected adults. Enferm Infecc Microbiol Clin 2015; 34:361-71. [PMID: 26321131 DOI: 10.1016/j.eimc.2015.07.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 07/20/2015] [Accepted: 07/20/2015] [Indexed: 11/23/2022]
Abstract
INTRODUCTION GESIDA and the AIDS National Plan panel of experts suggest a preferred (PR), alternative (AR) and other regimens (OR) for antiretroviral treatment (ART) as initial therapy in HIV-infected patients for 2015. The objective of this study is to evaluate the costs and the effectiveness of initiating treatment with these regimens. METHODS Economic assessment of costs and effectiveness (cost/effectiveness) based on decision tree analyses. Effectiveness was defined as the probability of reporting a viral load <50 copies/mL at week 48, in an intention-to-treat analysis. Cost of initiating treatment with an ART regimen was defined as the costs of ART and its consequences (adverse effects, changes of ART regimen, and drug resistance studies) during the first 48 weeks. The payer perspective (National Health System) was applied, only taking into account differential direct costs: ART (official prices), management of adverse effects, studies of resistance, and HLA B*5701 testing. The setting is Spain and the costs correspond to those of 2015. A deterministic sensitivity analysis was conducted, building three scenarios for each regimen: base case, most favourable and least favourable. RESULTS In the base case scenario, the cost of initiating treatment ranges from 4663 Euros for 3TC+LPV/r (OR) to 10,902 Euros for TDF/FTC+RAL (PR). The effectiveness varies from 0.66 for ABC/3TC+ATV/r (AR) and ABC/3TC+LPV/r (OR), to 0.89 for TDF/FTC+DTG (PR) and TDF/FTC/EVG/COBI (AR). The efficiency, in terms of cost/effectiveness, ranges from 5280 to 12,836 Euros per responder at 48 weeks, for 3TC+LPV/r (OR) and RAL+DRV/r (OR), respectively. CONCLUSION The most efficient regimen was 3TC+LPV/r (OR). Among the PR and AR, the most efficient regimen was TDF/FTC/RPV (AR). Among the PR regimes, the most efficient was ABC/3TC+DTG.
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Mondi A, Fabbiani M, Ciccarelli N, Colafigli M, D'Avino A, Borghetti A, Gagliardini R, Cauda R, De Luca A, Di Giambenedetto S. Efficacy and safety of treatment simplification to atazanavir/ritonavir + lamivudine in HIV-infected patients with virological suppression: 144 week follow-up of the AtLaS pilot study. J Antimicrob Chemother 2015; 70:1843-9. [PMID: 25885326 DOI: 10.1093/jac/dkv037] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 01/25/2015] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES AtLaS was a single-arm pilot study that demonstrated promising efficacy and safety of treatment simplification to a dual regimen with atazanavir/ritonavir + lamivudine in virologically suppressed HIV-positive patients. Here, we report data from the 144 week follow-up. METHODS At baseline, patients treated with a three-drug atazanavir/ritonavir-based regimen were switched to 300/100 mg of atazanavir/ritonavir plus 300 mg of lamivudine once daily. Major clinical events, laboratory parameters, neurocognitive performance, bone composition and body fat distribution were monitored. Treatment failure was defined as a discontinuation/switch of the regimen or virological failure (HIV-RNA >50 copies/mL in two consecutive determinations or a single level above 1000 copies/mL). RESULTS After 144 weeks, 9/40 (22.5%) treatment failures occurred, including two virological failures (Weeks 48 and 53, without resistance). A significant increase in the CD4 count was observed at Week 96 (+124 cells/mm(3); P = 0.002) and Week 144 (+94 cells/mm(3); P = 0.008). After 144 weeks, a significant increase in total cholesterol (+25 mg/dL; P = 0.001), HDL cholesterol (+6 mg/dL; P = 0.024) and LDL cholesterol (+12 mg/dL; P = 0.008) was observed, without any change in triglyceride levels, total cholesterol/HDL ratio or LDL/HDL ratio. A significant increase in the estimated glomerular filtration rate (+25 mL/min/1.73 m(2); P < 0.001) and lumbar spine T-score and Z-score (+0.2, P = 0.011; and +0.35, P = 0.001, respectively) and a decrease in trunk fat (-1.898 g; P = 0.005) were also observed. Neurocognitive function did not decline over time. Concerning safety, 10 moderate to severe adverse events were recorded in eight patients; overall seven cases of renal colic (possibly treatment related) were observed, leading to a discontinuation of treatment in two patients. CONCLUSIONS Data from the 144 week follow-up suggested good long-term efficacy of the simplification strategy that was investigated, with rare virological failure and a potential for improvement of the CD4 count, renal function and bone mineral density. This strategy warrants further investigation in a randomized trial.
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Affiliation(s)
- A Mondi
- Institute of Clinical Infectious Diseases, Catholic University of the Sacred Heart, Rome, Italy
| | - M Fabbiani
- Institute of Clinical Infectious Diseases, Catholic University of the Sacred Heart, Rome, Italy
| | - N Ciccarelli
- Institute of Clinical Infectious Diseases, Catholic University of the Sacred Heart, Rome, Italy
| | - M Colafigli
- Institute of Clinical Infectious Diseases, Catholic University of the Sacred Heart, Rome, Italy
| | - A D'Avino
- Institute of Clinical Infectious Diseases, Catholic University of the Sacred Heart, Rome, Italy
| | - A Borghetti
- Institute of Clinical Infectious Diseases, Catholic University of the Sacred Heart, Rome, Italy
| | - R Gagliardini
- Institute of Clinical Infectious Diseases, Catholic University of the Sacred Heart, Rome, Italy
| | - R Cauda
- Institute of Clinical Infectious Diseases, Catholic University of the Sacred Heart, Rome, Italy
| | - A De Luca
- Infectious Diseases Unit, Siena University Hospital, Siena, Italy
| | - S Di Giambenedetto
- Institute of Clinical Infectious Diseases, Catholic University of the Sacred Heart, Rome, Italy
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Calza L, Danese I, Colangeli V, Vandi G, Manfredi R, Girometti N, Borderi M, Appolloni L, Puggioli C, Viale P. Skeletal muscle toxicity in HIV-1-infected patients treated with a raltegravir-containing antiretroviral therapy: a cohort study. AIDS Res Hum Retroviruses 2014; 30:1162-9. [PMID: 25369244 DOI: 10.1089/aid.2014.0113] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
To evaluate the frequency of myopathy and serum creatine kinase (CK) elevation associated with the use of the integrase inhibitor raltegravir we conducted a retrospective, cohort analysis assessing the incidence of skeletal muscle toxicity among HIV-infected patients treated with raltegravir. Adult HIV-infected patients who started a raltegravir-containing therapy were enrolled into the study. The skeletal muscle toxicity was defined by the presence of one or more of the following parameters: (1) isolated and significant CK elevation without signs or symptoms; (2) diffuse myalgia without weakness; (3) proximal muscle weakness; (4) rhabdomyolysis. On the whole, 155 patients were included in the study, with a mean age of 49.2 years; the median duration of the raltegravir treatment was 30.7 months. The overall frequency of skeletal muscle toxicity was 23.9%, with an incidence of 4.7/100 person-years. An isolated CK elevation was reported in 21.3% of cases, while less than 3% of patients complained of myalgia or muscle weakness. The CK elevation was usually of grade 1 or 2 and self-limiting, and laboratory or clinical abnormalities did not require discontinuation of raltegravir in any patient. Factors significantly associated with skeletal muscle toxicity were previous use of zidovudine, higher baseline CK levels, previous increase of the CK levels, and a higher body mass index. Skeletal muscle toxicity is not an unusual adverse event in subjects receiving raltegravir, but it is usually represented by a mild-to-moderate increase in CK concentration, while clinical symptoms of myopathy are very uncommon.
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Affiliation(s)
- Leonardo Calza
- Department of Medical and Surgical Sciences, Infectious Diseases Unit, S. Orsola-Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Ilaria Danese
- Department of Medical and Surgical Sciences, Infectious Diseases Unit, S. Orsola-Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Vincenzo Colangeli
- Department of Medical and Surgical Sciences, Infectious Diseases Unit, S. Orsola-Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giacomo Vandi
- Department of Medical and Surgical Sciences, Infectious Diseases Unit, S. Orsola-Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Roberto Manfredi
- Department of Medical and Surgical Sciences, Infectious Diseases Unit, S. Orsola-Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Nicolò Girometti
- Department of Medical and Surgical Sciences, Infectious Diseases Unit, S. Orsola-Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Marco Borderi
- Department of Medical and Surgical Sciences, Infectious Diseases Unit, S. Orsola-Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Lucia Appolloni
- Department of Medical and Surgical Sciences, Infectious Diseases Unit, S. Orsola-Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Cristina Puggioli
- Department of Medical and Surgical Sciences, Infectious Diseases Unit, S. Orsola-Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Infectious Diseases Unit, S. Orsola-Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
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Affiliation(s)
- Manuel Battegay
- Departments of Medicine and Clinical Research, Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel 4031, Switzerland.
| | - Luigia Elzi
- Departments of Medicine and Clinical Research, Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel 4031, Switzerland
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Raffi F, Babiker AG, Richert L, Molina JM, George EC, Antinori A, Arribas JR, Grarup J, Hudson F, Schwimmer C, Saillard J, Wallet C, Jansson PO, Allavena C, Van Leeuwen R, Delfraissy JF, Vella S, Chêne G, Pozniak A. Ritonavir-boosted darunavir combined with raltegravir or tenofovir-emtricitabine in antiretroviral-naive adults infected with HIV-1: 96 week results from the NEAT001/ANRS143 randomised non-inferiority trial. Lancet 2014; 384:1942-51. [PMID: 25103176 DOI: 10.1016/s0140-6736(14)61170-3] [Citation(s) in RCA: 146] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Standard first-line antiretroviral therapy for HIV-1 infection includes two nucleoside or nucleotide reverse transcriptase inhibitors (NtRTIs), but these drugs have limitations. We assessed the 96 week efficacy and safety of an NtRTI-sparing regimen. METHODS Between August, 2010, and September, 2011, we enrolled treatment-naive adults into this randomised, open-label, non-inferiority trial in treatment-naive adults in 15 European countries. The composite primary outcome was change to randomised treatment before week 32 because of insufficient virological response, no virological response by week 32, HIV-1 RNA concentration 50 copies per mL or higher at any time after week 32; death from any cause; any new or recurrent AIDS event; or any serious non-AIDS event. Patients were randomised in a 1:1 ratio to receive oral treatment with 400 mg raltegravir twice daily plus 800 mg darunavir and 100 mg ritonavir once daily (NtRTI-sparing regimen) or tenofovir-emtricitabine in a 245 mg and 200 mg fixed-dose combination once daily, plus 800 mg darunavir and 100 mg ritonavir once daily (standard regimen). This trial was registered with ClinicalTrials.gov, number NCT01066962. FINDINGS Of 805 patients enrolled, 401 received the NtRTI-sparing regimen and 404 the standard regimen, with median follow-up of 123 weeks (IQR 112-133). Treatment failure was seen in 77 (19%) in the NtRTI-sparing group and 61 (15%) in the standard group. Kaplan-Meier estimated proportions of treatment failure by week 96 were 17·8% and 13·8%, respectively (difference 4·0%, 95% CI -0·8 to 8·8). The frequency of serious or treatment-modifying adverse events were similar (10·2 vs 8·3 per 100 person-years and 3·9 vs 4·2 per 100 person-years, respectively). INTERPRETATION Our NtRTI-sparing regimen was non-inferior to standard treatment and represents a treatment option for patients with CD4 cell counts higher than 200 cells per μL. FUNDING European Union Sixth Framework Programme, Inserm-ANRS, Gilead Sciences, Janssen Pharmaceuticals, Merck Laboratories.
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Affiliation(s)
- François Raffi
- Infectious Diseases Department, University of Nantes, Nantes, France.
| | - Abdel G Babiker
- MRC Clinical Trials Unit at University College London, London, UK
| | - Laura Richert
- Inserm U897 Epidemiologie-Biostatistique, University of Bordeaux, Bordeaux, France
| | - Jean-Michel Molina
- Department of Infectious Diseases, Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris and University of Paris Diderot, Paris, France
| | | | - Andrea Antinori
- Clinical Department, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Jose R Arribas
- HIV Unit, Internal Medicine Service, Hospital La Paz, Madrid, Spain
| | - Jesper Grarup
- CHIP Department of Infectious Diseases and Rheumatology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Fleur Hudson
- MRC Clinical Trials Unit at University College London, London, UK
| | - Christine Schwimmer
- Inserm U897 Epidemiologie-Biostatistique, University of Bordeaux, Bordeaux, France
| | | | - Cédrick Wallet
- Inserm U897 Epidemiologie-Biostatistique, University of Bordeaux, Bordeaux, France
| | - Per O Jansson
- CHIP Department of Infectious Diseases and Rheumatology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Clotilde Allavena
- Infectious Diseases Department, University of Nantes, Nantes, France
| | - Remko Van Leeuwen
- Academic Medical Centre, Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | | | | | - Geneviève Chêne
- Inserm U897 Epidemiologie-Biostatistique, University of Bordeaux, Bordeaux, France
| | - Anton Pozniak
- Chelsea and Westminster NHS Foundation Trust, London, UK
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Lucas GM, Ross MJ, Stock PG, Shlipak MG, Wyatt CM, Gupta SK, Atta MG, Wools-Kaloustian KK, Pham PA, Bruggeman LA, Lennox JL, Ray PE, Kalayjian RC. Clinical practice guideline for the management of chronic kidney disease in patients infected with HIV: 2014 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:e96-138. [PMID: 25234519 PMCID: PMC4271038 DOI: 10.1093/cid/ciu617] [Citation(s) in RCA: 201] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 07/25/2014] [Indexed: 12/15/2022] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Paul A. Pham
- Johns HopkinsSchool of Medicine, Baltimore, Maryland
| | - Leslie A. Bruggeman
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | | | | | - Robert C. Kalayjian
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
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The RADAR study: week 48 safety and efficacy of RAltegravir combined with boosted DARunavir compared to tenofovir/emtricitabine combined with boosted darunavir in antiretroviral-naive patients. Impact on bone health. PLoS One 2014; 9:e106221. [PMID: 25170938 PMCID: PMC4149560 DOI: 10.1371/journal.pone.0106221] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 07/29/2014] [Indexed: 11/19/2022] Open
Abstract
Background NRTI-sparing regimens may avoid long-term mitochondrial, bone and renal toxicities and maintain viral suppression. Methods In the RADAR study, 85 antiretroviral-naïve HIV-infected patients were randomized to receive either raltegravir (RAL) (n = 42) or tenofovir/emtricitabine (TDF/FTC) (n = 43), each with ritonavir-boosted darunavir (DRV/r). Virologic efficacy was assessed at weeks 24 and 48. Bone mineral density (BMD) was assessed by dual energy X-ray absorptiometry (DXA) scan at baseline and week 48, and bone turnover markers (BTM) assessed at weeks 0, 16 and 48. Results Using an intention-to-treat analysis, 62.5% of RAL subjects and 83.7% of TDF/FTC subjects were responders (VL<48 copies/mL) at week 48 (p = 0.045; chi-square test). The proportions of patients achieving VL<200 copies/mL were similar: 72.5% and 86.0% (p = 0.175). Premature treatment discontinuation was the main cause for failure. No treatment-emergent resistance was observed. Changes from baseline in RAL vs. TDF/FTC for CD4+ (+199 vs. +216 cells/µL, p = 0.63), total cholesterol/HDL (−0.25 vs. −0.71 mg/dL (p = 0.270), and eGFR (−4.4 vs. −7.9 ml/min, p = 0.44) were comparable between groups. Changes in subtotal BMD to week 48 were: +9.2 with RAL vs. −7 g/cm2 with TDF/FTC (p = 0.002). Mean CTX changes were +0.04 vs. +0.24 ng/mL (p = 0.001), and mean P1NP changes were +3.59 vs. +30.09 ng/mL (p = 0.023). BTM changes at week 16 predicted change in BMD by week 48 (R = −0.394, p = 0.003 for CTX; and R = −0.477, p<0.001 for P1NP). Conclusion The NRTI-sparing regimen RAL+DRV/r did not achieve similar week 48 virologic efficacy compared with TDF/FTC+DRV/r, but was better with regard to markers of bone health. Trial Registration ClinicalTrials.gov NCT 00677300
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Blasco AJ, Llibre JM, Berenguer J, González-García J, Knobel H, Lozano F, Podzamczer D, Pulido F, Rivero A, Tuset M, Lázaro P, Gatell JM. Costs and cost-efficacy analysis of the 2014 GESIDA/Spanish National AIDS Plan recommended guidelines for initial antiretroviral therapy in HIV-infected adults. Enferm Infecc Microbiol Clin 2014; 33:156-65. [PMID: 25175171 DOI: 10.1016/j.eimc.2014.05.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 05/19/2014] [Accepted: 05/25/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION GESIDA and the National AIDS Plan panel of experts suggest preferred (PR) and alternative (AR) regimens of antiretroviral treatment (ART) as initial therapy in HIV-infected patients for 2014. The objective of this study is to evaluate the costs and the efficiency of initiating treatment with these regimens. METHODS An economic assessment was made of costs and efficiency (cost/efficacy) based on decision tree analyses. Efficacy was defined as the probability of reporting a viral load <50 copies/mL at week 48, in an intention-to-treat analysis. Cost of initiating treatment with an ART regimen was defined as the costs of ART and its consequences (adverse effects, changes of ART regimen, and drug resistance studies) during the first 48 weeks. The payer perspective (National Health System) was applied by considering only differential direct costs: ART (official prices), management of adverse effects, studies of resistance, and HLA B*5701 testing. The setting is Spain and costs correspond to those of 2014. A sensitivity deterministic analysis was conducted, building three scenarios for each regimen: base case, most favourable and least favourable. RESULTS In the base case scenario, the cost of initiating treatment ranges from 5133 Euros for ABC/3TC+EFV to 11,949 Euros for TDF/FTC+RAL. The efficacy varies between 0.66 for ABC/3TC+LPV/r and ABC/3TC+ATV/r, and 0.89 for TDF/FTC/EVG/COBI. Efficiency, in terms of cost/efficacy, ranges from 7546 to 13,802 Euros per responder at 48 weeks, for ABC/3TC+EFV and TDF/FTC+RAL respectively. CONCLUSION Considering ART official prices, the most efficient regimen was ABC/3TC+EFV (AR), followed by the non-nucleoside containing PR (TDF/FTC/RPV and TDF/FTC/EFV). The sensitivity analysis confirms the robustness of these findings.
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Affiliation(s)
| | - Josep M Llibre
- Fundació Lluita contra la Sida, Unitat VIH, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - Juan Berenguer
- Unidad de Enfermedades Infecciosas/VIH, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Juan González-García
- Servicio de Medicina Interna, Unidad de VIH, IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
| | - Hernando Knobel
- Servicio de Enfermedades Infecciosas, Hospital del Mar, Barcelona, Spain
| | - Fernando Lozano
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario de Valme, Sevilla, Spain
| | - Daniel Podzamczer
- Unidad VIH, Servicio de Enfermedades Infecciosas, Hospital Universitari de Bellvitge, ĹHospitalet de Llobregat, Barcelona, Spain
| | - Federico Pulido
- Unidad de VIH, Hospital Universitario 12 de Octubre, i+12, Madrid, Spain
| | - Antonio Rivero
- Sección de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Córdoba, Spain
| | | | - Pablo Lázaro
- Técnicas Avanzadas de Investigación en Servicios de Salud (TAISS), Madrid, Spain
| | - Josep M Gatell
- Servicio de Enfermedades Infecciosas, Hospital Clinic-IDIBAPS, Universidad de Barcelona, Barcelona, Spain.
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Girard PM, Cotte L, Gathe J, Renjifo B, Argyropoulos C, Trinh R, Fredrick LM, Norton M, Nilius A. Comparison of renal changes with lopinavir/ritonavir plus raltegravir or tenofovir/emtricitabine in the PROGRESS study. Future Virol 2014. [DOI: 10.2217/fvl.14.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT Aim: To assess renal function changes among 172 treatment-naive subjects treated with lopinavir/ritonavir (LPV/r) plus raltegravir (RAL) or LPV/r plus tenofovir/emtricitabine in the PROGRESS study, a prospective, randomized controlled trial. Patients & methods: Serum creatinine, creatinine clearance and chronic kidney disease category were compared between groups. Results: Mean change from baseline to week 96 in creatinine clearance was smaller with LPV/r plus RAL versus LPV/r plus tenofovir/emtricitabine (-1.4 vs -7.3 ml/min; p = 0.035). Chronic kidney disease category improvement was more frequent and the mean increase in serum creatinine was smaller for the LPV/r plus RAL group. Differences in estimated renal function were also detected when the analysis was performed according to baseline demographics. Conclusion: Smaller renal function declines were observed with LPV/r plus RAL. The results from this study warrant further evaluation of the renal safety profile of nucleotide reverse transcriptase inhibitor-sparing regimens.
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Affiliation(s)
- Pierre-Marie Girard
- Department of Infectious Disease, Saint Antoine Hospital, UPMC, Univ-Paris 6, AP-HP & INSERM, UMR-S 1136, Institut Pierre Louis d’Epidémiologie et de Santé Publique, F-75013 Paris, France
| | - Laurent Cotte
- Department of Infectious Diseases, Hospices Civils de Lyon, Lyon, France
- INSERM U1052, Lyon, France
| | - Joseph Gathe
- Therapeutic Concepts, 4900 Fannin, Houston, TX 77004, USA
| | - Boris Renjifo
- AbbVie, Inc., Global Pharmaceutical Research & Development, 1 North Waukegan Road, North Chicago, IL 60064, USA
| | - Christos Argyropoulos
- AbbVie Pharmaceuticals SA, Medical Department, 41–45 Marinou Antypa Str, 141 21 Neo Irakleio, Greece
| | - Roger Trinh
- AbbVie, Inc., Global Pharmaceutical Research & Development, 1 North Waukegan Road, North Chicago, IL 60064, USA
| | - Linda M Fredrick
- AbbVie, Inc., Global Pharmaceutical Research & Development, 1 North Waukegan Road, North Chicago, IL 60064, USA
| | - Michael Norton
- AbbVie, Inc., Global Pharmaceutical Research & Development, 1 North Waukegan Road, North Chicago, IL 60064, USA
| | - Angela Nilius
- AbbVie, Inc., Global Pharmaceutical Research & Development, 1 North Waukegan Road, North Chicago, IL 60064, USA
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Van den Eynde E, Podzamczer D. Switch strategies in antiretroviral therapy regimens. Expert Rev Anti Infect Ther 2014; 12:1055-74. [PMID: 25075752 DOI: 10.1586/14787210.2014.944506] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite great advances in antiretroviral therapy in the last decade, several limitations still remain such as adverse effects, lack of adherence and drug-drug interactions. Switching antiretroviral therapy in stable, virologically suppressed patients with the aim of improving tolerability and convenience is an expanding strategy in clinical practice. Several factors need to be taken into consideration when switching a suppressive regimen, such as previous virologic failure, genetic barrier of the new regimen, prior duration of virologic suppression and expected level of adherence. The most frequently used strategies include reductions in the number of pills, drugs or doses. Although switching strategies may be useful, not all the regimens used in clinical practice are based on data from randomized clinical trials and some may not be the best option for certain patients; therefore, therapy should be individualized taking into consideration available information as well as patient and drug characteristics.
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Affiliation(s)
- Eva Van den Eynde
- HIV Unit, Infectious Disease Service, Hospital Universitari de Bellvitge, c/Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907 Barcelona, Spain
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Dual therapy with lopinavir and ritonavir plus lamivudine versus triple therapy with lopinavir and ritonavir plus two nucleoside reverse transcriptase inhibitors in antiretroviral-therapy-naive adults with HIV-1 infection: 48 week results of the randomised, open label, non-inferiority GARDEL trial. THE LANCET. INFECTIOUS DISEASES 2014; 14:572-80. [DOI: 10.1016/s1473-3099(14)70736-4] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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40
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Mesplède T, Osman N, Wares M, Quashie PK, Hassounah S, Anstett K, Han Y, Singhroy DN, Wainberg MA. Addition of E138K to R263K in HIV integrase increases resistance to dolutegravir, but fails to restore activity of the HIV integrase enzyme and viral replication capacity. J Antimicrob Chemother 2014; 69:2733-40. [PMID: 24917583 DOI: 10.1093/jac/dku199] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The results of several clinical trials suggest that the integrase inhibitor dolutegravir may be less prone than other drugs to the emergence of HIV drug resistance mutations in treatment-naive patients. We have shown that the R263K mutation commonly emerged during tissue culture selection studies with dolutegravir and conferred low levels of resistance to this drug while simultaneously diminishing both HIV replication capacity and integrase enzymatic activity. E138K has been identified as a secondary mutation for dolutegravir in selection studies and has also been observed as a secondary mutation in the clinic for the integrase inhibitors raltegravir and elvitegravir. METHODS We used biochemical cell-free strand-transfer assays and tissue culture assays to characterize the effects of the E138K/R263K combination of mutations on resistance to dolutegravir, integrase enzyme activity and HIV-1 replication capacity. RESULTS We show here that the addition of the E138K substitution to R263K increased the resistance of HIV-1 to dolutegravir but failed to restore viral replication capacity, integrase strand-transfer activity and integration within cellular DNA. We also show that the addition of E138K to R263K did not increase the resistance to raltegravir or elvitegravir. The addition of the E138K substitution to R263K was also less detrimental to integrase strand-transfer activity and integration than a different secondary mutation at position H51Y that had also been selected in culture. CONCLUSIONS The E138K substitution failed to restore the defect in viral replication capacity that is associated with R263K, confirming previous selection studies that failed to identify compensatory mutation(s) for the latter primary mutation. This study suggests that the R263K resistance pathway may represent an evolutionary dead end for HIV in treatment-naive individuals who are treated with dolutegravir and will need to be confirmed by the long-term use of dolutegravir in the clinic.
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Affiliation(s)
- Thibault Mesplède
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada
| | - Nathan Osman
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada Department of Microbiology and Immunology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Melissa Wares
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada Department of Microbiology and Immunology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Peter K Quashie
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada Division of Experimental Medicine, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Said Hassounah
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada Division of Experimental Medicine, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Kaitlin Anstett
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada Department of Microbiology and Immunology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Yingshan Han
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada
| | - Diane N Singhroy
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada Department of Microbiology and Immunology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Mark A Wainberg
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada Department of Microbiology and Immunology, Faculty of Medicine, McGill University, Montréal, Québec, Canada Division of Experimental Medicine, Faculty of Medicine, McGill University, Montréal, Québec, Canada
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de la Torre P, George J, Baxter JD. Nucleoside-sparing antiretroviral regimens. Curr Infect Dis Rep 2014; 16:410. [PMID: 24880455 DOI: 10.1007/s11908-014-0410-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Nucleoside reverse transcriptase inhibitors (NRTIs) were the first drugs approved for use as antiretroviral therapy in patients infected with HIV. Despite the introduction of other classes of antiretroviral drugs, they remain an important component of combination regimens as recommended by many treatment guidelines. They also continue to be used in prevention of disease from mother to child, postexposure prophylaxis, and more recently for preexposure prophylaxis. Unfortunately, the toxicities associated with this class of drugs can limit their use. Although NRTI-sparing regimens are not currently recommended for first-line therapy there is an increasing amount of data supporting their use in both treatment-naive and in treatment-experienced patients.
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Affiliation(s)
- Pola de la Torre
- Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, USA,
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Figueroa MI, Sued O, Cahn P. What to do Next? Second-line Antiretroviral Therapy. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2014. [DOI: 10.1007/s40506-014-0013-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fisher M, Norton M, Saget B, Fredrick L, Wyk JV. Safety and efficacy of lopinavir/ritonavir-containing antiretroviral therapy in patients aged <50 versus ≥50 years from randomized trials. Future Virol 2014. [DOI: 10.2217/fvl.14.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT: Aim: Data describing the safety and efficacy of antiretroviral therapy (ART) in HIV-infected patients aged ≥50 years are limited. We evaluated the effect of age on safety, efficacy and tolerability in patients aged <50 and ≥50 years receiving lopinavir/ritonavir (LPV/r)-containing ART. Methods: End points from AbbVie Inc. (IL, USA) or AIDS Clinical Trials Group randomized clinical trials in adults using LPV/r 800/200 mg/day as part of a three-drug regimen (follow-up ≥48 weeks) were evaluated using a random-effects meta-analysis (virologic efficacy; intent-to-treat; noncompleter = failure) or pooled data (other end points). Results: A total of 2608 patients (2294.3 patient-years of follow-up) from ten trials were included: 2248 patients (86.2%) <50 years of age and 360 (13.8%) ≥50 years of age. Demographics and baseline characteristics were similar between age groups. At week 48, 64.9 and 67.8% of patients <50 and ≥50 years, respectively, had plasma HIV-1 RNA <50 copies/ml (random effects meta-analysis p = 0.992). Mean change from baseline in CD4+ T-cell count was +193.9 and +163.5 cells/μl (<50 and ≥50 years, respectively; p < 0.001). Smaller proportions of patients <50 years of age discontinued due to adverse events (AEs)/HIV-related events (4.9 vs 9.4%; p = 0.001) and reported moderate-to-severe treatment-related AEs (30.5 vs 36.4%; p = 0.027) compared with patients ≥50 years of age. Conclusion: This analysis suggests LPV/r-anchored three-drug therapy in patients ≥50 years of age leads to comparable rates of virologic suppression, with a smaller increase in absolute CD4+ T cells and increased AEs, including discontinuations associated with AEs compared with patients <50 years of age.
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Affiliation(s)
- Martin Fisher
- Brighton & Sussex Medical School & University Hospitals, Eastern Road, Brighton, BN2 5BE, UK
| | | | - Brad Saget
- AbbVie Inc., North Chicago, IL 60064, USA
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5.0 What to start. HIV Med 2013. [DOI: 10.1111/hiv.12119_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Mesplède T, Wainberg MA. Integrase Strand Transfer Inhibitors in HIV Therapy. Infect Dis Ther 2013; 2:83-93. [PMID: 25134473 PMCID: PMC4108112 DOI: 10.1007/s40121-013-0020-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Indexed: 11/22/2022] Open
Abstract
HIV drug resistance has been one of the major obstacles to HIV eradication and has contributed to the need for the constant development of new antiretroviral drugs over the past 25 years. With the recent approval of dolutegravir for human therapy by the U.S. Food and Drug Administration, health practitioners may soon have access to three integrase strand transfer inhibitors to treat individuals living with HIV. Here, we review the use of raltegravir, elvitegravir, and dolutegravir for use in first- and second-line HIV treatment regimens and the issue of HIV resistance against integrase inhibitors.
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Affiliation(s)
- Thibault Mesplède
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, QC, Canada
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Martin A, Moore CL, Mallon PWG, Hoy JF, Emery S, Belloso WH, Phanuphak P, Ferret S, Cooper DA, Boyd MA. HIV lipodystrophy in participants randomised to lopinavir/ritonavir (LPV/r) +2-3 nucleoside/nucleotide reverse transcriptase inhibitors (N(t)RTI) or LPV/r + raltegravir as second-line antiretroviral therapy. PLoS One 2013; 8:e77138. [PMID: 24204757 PMCID: PMC3813715 DOI: 10.1371/journal.pone.0077138] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 08/27/2013] [Indexed: 12/29/2022] Open
Abstract
Objective To compare changes over 48 weeks in body fat, lipids, Metabolic Syndrome and cardiovascular disease risk between patients randomised 1∶1 to lopinavir/ritonavir (r/LPV) plus raltegravir (RAL) compared to r/LPV plus 2–3 nucleoside/nucleotide reverse transcriptase inhibitors (N(t)RTIs) as second-line therapy. Methods Participants were HIV-1 positive (>16 years) failing first-line treatment (2 consecutive HIV RNA >500 copies/mL) of NNRTI +2N(t)RTI. Whole body dual energy x-ray absorptiometry was performed at baseline and week 48. Data were obtained to calculate the Metabolic Syndrome and Framingham cardiovascular disease (CVD) risk score. Linear regression was used to compare mean differences between arms. Logistic regression compared incidence of metabolic syndrome. Associations between percent limb fat changes at 48 weeks with baseline variables were assessed by backward stepwise multivariate linear regression. Analyses were adjusted for gender, body mass index and smoking status. Results 210 participants were randomised. The mean (95% CI) increase in limb fat over 48 weeks was 15.7% (5.3, 25.9) or 0.9 kg (0.2, 1.5) in the r/LPV+N(t)RTI arm and 21.1% (11.1, 31,1) or 1.3 kg (0.7, 1.9) in the r/LPV+RAL arm, with no significant difference between treatment arms (−5.4% [−0.4 kg], p>0.1). Increases in total body fat mass (kg) and trunk fat mass (kg) were also similar between groups. Total:HDL cholesterol ratio was significantly higher in the RAL arm (mean difference −0.4 (1.4); p = 0.03), there were no other differences in lipid parameters between treatment arms. There were no statistically significant differences in CVD risk or incidence of Metabolic Syndrome between the two treatment arms. The baseline predictors of increased limb fat were high viral load, high insulin and participant's not taking lipid lowering treatment. Conclusion In patients switching to second line therapy, r/LPV combined with RAL demonstrated similar improvements in limb fat as an N(t)RTI + r/LPV regimen, but a worse total:HDL cholesterol ratio over 48 weeks. Trial Registration This clinical trial is registered on Clinicaltrials.gov, registry number NCT00931463.
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Affiliation(s)
- Allison Martin
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- * E-mail:
| | - Cecilia L. Moore
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Patrick W. G. Mallon
- University College Dublin School of Medicine and Medical Science, Dublin, Ireland
| | - Jennifer F. Hoy
- The Alfred Hospital and Monash University, Victoria, Melbourne, Australia
| | - Sean Emery
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Waldo H. Belloso
- Coordinación de Investigación Clínica Académica en Latinoamérica, Buenos Aires, Argentina
| | | | | | - David A. Cooper
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Mark A. Boyd
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
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[Consensus Statement by GeSIDA/National AIDS Plan Secretariat on antiretroviral treatment in adults infected by the human immunodeficiency virus (Updated January 2013)]. Enferm Infecc Microbiol Clin 2013; 31:602.e1-602.e98. [PMID: 24161378 DOI: 10.1016/j.eimc.2013.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 04/08/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVE This consensus document is an update of combined antiretroviral therapy (cART) guidelines for HIV-1 infected adult patients. METHODS To formulate these recommendations a panel composed of members of the GeSIDA/National AIDS Plan Secretariat (Grupo de Estudio de Sida and the Secretaría del Plan Nacional sobre el Sida) reviewed the efficacy and safety advances in clinical trials, cohort and pharmacokinetic studies published in medical journals (PubMed and Embase) or presented in medical scientific meetings. The strength of the recommendations and the evidence which support them are based on a modification of the criteria of Infectious Diseases Society of America. RESULTS cART is recommended in patients with symptoms of HIV infection, in pregnant women, in serodiscordant couples with high risk of transmission, in hepatitisB co-infection requiring treatment, and in HIV nephropathy. cART is recommended in asymptomatic patients if CD4 is <500cells/μl. If CD4 are >500cells/μl cART should be considered in the case of chronic hepatitisC, cirrhosis, high cardiovascular risk, plasma viral load >100.000 copies/ml, proportion of CD4 cells <14%, neurocognitive deficits, and in people aged >55years. The objective of cART is to achieve an undetectable viral load. The first cART should include 2 reverse transcriptase inhibitors (RTI) nucleoside analogs and a third drug (a non-analog RTI, a ritonavir boosted protease inhibitor, or an integrase inhibitor). The panel has consensually selected some drug combinations, for the first cART and specific criteria for cART in acute HIV infection, in tuberculosis and other HIV related opportunistic infections, for the women and in pregnancy, in hepatitisB or C co-infection, in HIV-2 infection, and in post-exposure prophylaxis. CONCLUSIONS These new guidelines update previous recommendations related to first cART (when to begin and what drugs should be used), how to monitor, and what to do in case of viral failure or adverse drug reactions. cART specific criteria in comorbid patients and special situations are similarly updated.
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Blasco AJ, Llibre JM, Arribas JR, Boix V, Clotet B, Domingo P, González-García J, Knobel H, López JC, Lozano F, Miró JM, Podzamczer D, Santamaría JM, Tuset M, Zamora L, Lázaro P, Gatell JM. [Analysis of costs and cost-effectiveness of preferred GESIDA/National AIDS Plan regimens for initial antiretroviral therapy in human immunodeficiency virus infected adult patients in 2013]. Enferm Infecc Microbiol Clin 2013; 31:568-78. [PMID: 23969276 DOI: 10.1016/j.eimc.2013.06.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 05/28/2013] [Accepted: 06/02/2013] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The GESIDA and National AIDS Plan panel of experts have proposed "preferred regimens" of antiretroviral treatment (ART) as initial therapy in HIV infected patients for 2013. The objective of this study is to evaluate the costs and effectiveness of initiating treatment with these "preferred regimens". METHODS An economic assessment of costs and effectiveness (cost/effectiveness) was performed using decision tree analysis models. Effectiveness was defined as the probability of having viral load <50copies/mL at week48, in an intention-to-treat analysis. Cost of initiating treatment with an ART regime was defined as the costs of ART and its consequences (adverse effects, changes of ART regime and drug resistance analyses) during the first 48weeks. The perspective of the analysis is that of the National Health System was applied, only taking into account differential direct costs: ART (official prices), management of adverse effects, resistance studies, and determination of HLA B*5701. The setting is Spain and the costs are those of 2013. A sensitivity deterministic analysis was performed, constructing three scenarios for each regimen: baseline, most favourable, and most unfavourable cases. RESULTS In the baseline case scenario, the cost of initiating treatment ranges from 6,747euros for TDF/FTC+NVP to 12,059euros for TDF/FTC+RAL. The effectiveness ranges between 0.66 for ABC/3TC+LPV/r and ABC/3TC+ATV/r, and 0.87 for TDF/FTC+RAL and ABC/3TC+RAL. Effectiveness, in terms of cost/effectiveness, varies between 8,396euros and 13,930euros per responder at 48weeks, for TDF/FTC/RPV and TDF/FTC+RAL, respectively. CONCLUSIONS Taking ART at official prices, the most effective regimen was TDF/FTC/RPV, followed by the rest of non-nucleoside containing regimens. The sensitivity analysis confirms the robustness of these findings.
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Pallikkuth S, Fischl MA, Pahwa S. Combination antiretroviral therapy with raltegravir leads to rapid immunologic reconstitution in treatment-naive patients with chronic HIV infection. J Infect Dis 2013; 208:1613-23. [PMID: 23922374 DOI: 10.1093/infdis/jit387] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In treatment-naive, human immunodeficiency virus (HIV)-infected persons, combination antiretroviral therapy (cART) incorporating raltegravir (RAL) is highly effective for virologic suppression, but characteristics of immunologic recovery have not been described. METHODS We performed a 48-week substudy of 15 patients, median age 40 years, within a phase 2 randomized trial of RAL-cART in treatment-naive patients with chronic HIV infection. RESULTS Plasma viral load decreased from 5.2 ± 5.3 log10 HIV RNA copies/mL to 2.2 ± 2.4 log10 copies/mL at week 4, reaching <50 copies/mL at week 8 in 13 of 15 patients. Total CD4 T cells increased at week 4, as did central memory CD4 T cells in association with reduction of the immune activation markers HLA-DR and CD38 and immune exhaustion marker PD1 in CD4 and CD8 T cells. Naive CD4 T cells increased at week 24 with appearance of HIV gag-specific interleukin 2, interferon-γ, and CD107a responses in CD4 and CD8 T cells at week 48. Plasma lipopolysaccharide and soluble CD14 decreased, but at week 48 were elevated as compared to healthy volunteers. Altogether, the week 48 immune profile was more favorable in patients taking RAL-cART than in patients treated with non-RAL-cART. CONCLUSIONS RAL in first-line treatment regimens results in rapid immune reconstitution with residual low-level microbial translocation.
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Boyd MA, Kumarasamy N, Moore CL, Nwizu C, Losso MH, Mohapi L, Martin A, Kerr S, Sohn AH, Teppler H, Van de Steen O, Molina JM, Emery S, Cooper DA. Ritonavir-boosted lopinavir plus nucleoside or nucleotide reverse transcriptase inhibitors versus ritonavir-boosted lopinavir plus raltegravir for treatment of HIV-1 infection in adults with virological failure of a standard first-line ART regimen (SECOND-LINE): a randomised, open-label, non-inferiority study. Lancet 2013; 381:2091-9. [PMID: 23769235 DOI: 10.1016/s0140-6736(13)61164-2] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Uncertainty exists about the best treatment for people with HIV-1 who have virological failure with first-line combination antiretroviral therapy of a non-nucleoside analogue (NNRTI) plus two nucleoside or nucleotide analogue reverse transcriptase inhibitors (NtRTI). We compared a second-line regimen combining two new classes of drug with a WHO-recommended regimen. METHODS We did this 96-week, phase 3b/4, randomised, open-label non-inferiority trial at 37 sites worldwide. Adults with HIV-1 who had confirmed virological failure (plasma viral load >500 copies per mL) after 24 weeks or more of first-line treatment were randomly assigned (1:1) to receive ritonavir-boosted lopinavir plus two or three NtRTIs (control group) or ritonavir-boosted lopinavir plus raltegravir (raltegravir group). The randomisation sequence was computer generated with block randomisation (block size four). Neither participants nor investigators were masked to allocation. The primary endpoint was the proportion of participants with plasma viral load less than 200 copies per mL at 48 weeks in the modified intention-to-treat population, with a non-inferiority margin of 12%. This study is registered with ClinicalTrials.gov, number NCT00931463. FINDINGS We enrolled 558 patients, of whom 541 (271 in the control group, 270 in the raltegravir group) were included in the primary analysis. At 48 weeks, 219 (81%) patients in the control group compared with 223 (83%) in the raltegravir group met the primary endpoint (difference 1·8%, 95% CI -4·7 to 8·3), fulfilling the criterion for non-inferiority. 993 adverse events occurred in 271 participants in the control group versus 895 in 270 participants in the raltegravir group, the most common being gastrointestinal. INTERPRETATION The raltegravir regimen was no less efficacious than the standard of care and was safe and well tolerated. This simple NtRTI-free treatment strategy might extend the successful public health approach to management of HIV by providing simple, easy to administer, effective, safe, and tolerable second-line combination antiretroviral therapy. FUNDING University of New South Wales, Merck, AbbVie, the Foundation for AIDS Research.
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