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Gibas KM, Kelly SG, Arribas JR, Cahn P, Orkin C, Daar ES, Sax PE, Taiwo BO. Two-drug regimens for HIV treatment. Lancet HIV 2022; 9:e868-e883. [PMID: 36309038 PMCID: PMC10015554 DOI: 10.1016/s2352-3018(22)00249-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 08/16/2022] [Accepted: 08/22/2022] [Indexed: 12/05/2022]
Abstract
Combination therapy with three antiretroviral agents has been integral to successful HIV-1 treatment since 1996. Although the efficacy, adverse effects, and toxicities of contemporary three-drug regimens have improved, even the newest therapies have potential adverse effects. The use of two-drug regimens is one way to reduce lifetime exposure to antiretroviral drugs while maintaining the benefits of viral suppression. Multiple large, randomised trials have shown the virological non-inferiority of certain two-drug regimens versus three-drug comparators, including adverse effect differences that reflect known profiles of the antiretroviral drugs in the respective regimens. Two-drug combinations are now recommended in treatment guidelines and include the first long-acting antiretroviral regimen for the treatment of HIV-1. Recommended two-drug regimens differ in their risks for, and factors associated with, virological failure and emergent resistance. The tolerability, safety, metabolic profiles, and drug interactions of two-drug regimens also vary by the constituent drugs. No current two-drug regimen is recommended for people with chronic hepatitis B virus as none include tenofovir. Two-drug regimens have increased options for individualised care.
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Affiliation(s)
- Kevin M Gibas
- Division of Infectious Diseases, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN, USA
| | - Sean G Kelly
- Division of Infectious Diseases, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN, USA
| | - Jose R Arribas
- Infectious Diseases Unit, La Paz University Hospital, Hospital La Paz Institute for Health Research, Madrid, Spain; School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Madrid, Spain
| | - Pedro Cahn
- Fundación Huésped, Buenos Aires, Argentina
| | - Chloe Orkin
- Department of Immunobiology, Queen Mary University of London, London, UK
| | - Eric S Daar
- The Lundquist Institute, Harbor University of California, Los Angeles, Torrence, CA, USA
| | - Paul E Sax
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | - Babafemi O Taiwo
- Division of Infectious Diseases, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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Shorter Time to Discontinuation Due to Treatment Failure in People Living with HIV Switched to Dolutegravir Plus Either Rilpivirine or Lamivudine Compared with Integrase Inhibitor-Based Triple Therapy in a Large Spanish Cohort. Infect Dis Ther 2022; 11:1177-1192. [PMID: 35399147 PMCID: PMC9124284 DOI: 10.1007/s40121-022-00630-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 03/18/2022] [Indexed: 11/27/2022] Open
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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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Zeng J, Ye P, Wei D, Li L, Ma W. Tenofovir-induced osteopenia and hyperparathyroidism: A case report and literature review. Front Endocrinol (Lausanne) 2022; 13:1043954. [PMID: 36714555 PMCID: PMC9875041 DOI: 10.3389/fendo.2022.1043954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/19/2022] [Indexed: 01/13/2023] Open
Abstract
Tenofovir disoproxil fumarate is the first-line antiviral therapy for chronic viral hepatitis B, but long-term use is associated with renal failure and hypophosphatemic osteomalacia. Tenofovir disoproxil fumarate-induced osteoporosis and secondary hyperparathyroidism are less commonly reported. Herein, we describe the case of a patient with bone and multijoint pain who was initially misdiagnosed as having normocalcemic primary hyperparathyroidism associated with prolonged exposure to tenofovir disoproxil fumarate. The patient's 24-h urinary calcium and phosphorus excretion levels and serum calcium levels were at the lower end of the normal range. After reviewing these findings, the diagnosis was amended to osteoporosis and secondary hyperparathyroidism caused by tenofovir disoproxil fumarate. In this report, we describe the differences in clinical and laboratory manifestations of hyperparathyroidism induced by tenofovir disoproxil fumarate and normocalcemic primary hyperparathyroidism. We also discuss relevant pathophysiological mechanisms and propose a feasible treatment strategy.
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Katzenstein TL, Wessman M, Moseholm E, Sandholdt H, Hansen ABE, Lebech AM, Jørgensen NR, Weis N. Prevalence of low bone mineral density among people living with HIV. COGENT MEDICINE 2021. [DOI: 10.1080/2331205x.2021.1920667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Terese L. Katzenstein
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Maria Wessman
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre Hospital, Copenhagen, Denmark
| | - Ellen Moseholm
- Department of Clinical Biochemistry, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Haakon Sandholdt
- Department of Clinical Biochemistry, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Ann-Brit E Hansen
- Department of Clinical Biochemistry, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre Hospital, Copenhagen, Denmark
| | - Niklas R Jørgensen
- Department of Clinical Biochemistry, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Nina Weis
- Department of Clinical Biochemistry, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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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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Abstract
PLHIV have an increased risk of osteoporosis and fractures when compared with people of the same age and sex. In this review, we address the epidemiology and the pathophysiology of bone disease and fractures in PLHIV. The assessment of fracture risk and fracture prevention in these subjects is also discussed. The spectrum of HIV-associated disease has changed dramatically since the introduction of potent antiretroviral drugs. Today, the survival of people living with HIV (PLHIV) is close to that of the general population. However, the longer life-span in PLHIV is accompanied by an increased prevalence of chronic diseases. Detrimental effects on bone health are well recognised, with an increased risk of osteoporosis and fractures, including vertebral fractures, compared to the general population. The causes of bone disease in PLHIV are not fully understood, but include HIV-specific risk factors such as use of antiretrovirals and the presence of chronic inflammation, as well as traditional risk factors for fracture. Current guidelines recommend the use of FRAX to assess fracture probability in PLHIV age ≥ 40 years and measurement of bone mineral density in those at increased fracture risk. Vitamin D deficiency, if present, should be treated. Bisphosphonates have been shown to increase bone density in PLHIV although fracture outcomes are not available.
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Affiliation(s)
- M O Premaor
- Department of Clinical Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.
| | - J E Compston
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
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Bonfanti P, De Vito A, Ricci E, Menzaghi B, Orofino G, Squillace N, Molteni C, De Socio GV, Salomoni E, Celesia BM, Dentone C, Colombo V, Madeddu G. Bone Safety of Dolutegravir-Containing Regimens in People Living with HIV: Results from a Real-World Cohort. Infect Drug Resist 2020; 13:2291-2300. [PMID: 32765005 PMCID: PMC7368553 DOI: 10.2147/idr.s260449] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/27/2020] [Indexed: 12/30/2022] Open
Abstract
Objective Few data exist about the effect of dolutegravir (DTG) on bone mineral density (BMD) in real life. The aim of this study was to determine rates of change in BMD over time in people living with HIV (PLWH) treated with DTG. Design The SCOLTA project is a multicenter observational study enrolling HIV-infected people who start newly commercialized drugs prospectively, with the aim of identifying toxicities and adverse events (AE) in a real-life setting. Methods Dual-energy X-ray absorptiometry at the femoral neck (FN) and lumbar spine (LS) was performed at study entry (baseline, BL) and after 96 weeks. Percentage BMD change from BL was evaluated using a general linear model, including factors potentially associated with bone loss. Results One hundred and sixty PLWH were enrolled (26.3% female, mean age 49.9 ± 11.2 years) from April 2015 to April 2017. Overall, we could calculate BMD change from baseline, for at least one site, in 133 subjects (83.1%). After a median of 102 weeks (IQR: 90–110), mean FN BMD increased, but not significantly, whereas LS BMD showed a significant mean increase of 13.1 (95% confidence interval, CI: 1.7–24.6) mg/cm3 (+1.6%, 95% CI: 0.3%, 2.8%) after a median time of 102 weeks (IQR: 84–110). As regards LS BMD, patients with osteopenia/osteoporosis at study entry experienced a high increase from baseline (20.6, 95% CI: 3.1, 38.1 mg/cm3), as well as experienced subjects (16.9, 95% CI: 4.7, 29.2 mg/cm3) and those on vitamin D supplementation (26.8, 95% CI: 7.7, 45.9 mg/cm3). Conclusion Dolutegravir-containing regimens could reduce the negative impact of antiretroviral therapy on bone, especially in patients with low BMD.
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Affiliation(s)
- Paolo Bonfanti
- Infectious Diseases Unit ASST-MONZA, San Gerardo Hospital-University of Milano-Bicocca, Milan, Italy
| | - Andrea De Vito
- Unit of Infectious Diseases, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Elena Ricci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Barbara Menzaghi
- Unit of Infectious Diseases, ASST della Valle Olona - Busto Arsizio (VA), Busto Arsizio, Italy
| | - Giancarlo Orofino
- Division I of Infectious and Tropical Diseases, ASL Città di Torino, Turin, Italy
| | - Nicola Squillace
- Infectious Diseases Unit ASST-MONZA, San Gerardo Hospital-University of Milano-Bicocca, Milan, Italy
| | - Chiara Molteni
- Unit of Infectious Diseases, A. Manzoni Hospital, Lecco, Italy
| | - Giuseppe Vittorio De Socio
- Department of Internal Medicine 2, Infectious Diseases Unit, Perugia "Santa Maria della Misericordia" General Hospital, Perugia, Italy
| | - Elena Salomoni
- Infectious Diseases Unit 1, Santa Maria Annunziata Hospital, Azienda USL Toscana Centro, Florence, Italy
| | | | - Chiara Dentone
- Division of Infectious Diseases, Department of Health Sciences, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Valeria Colombo
- Infectious Disease Unit, DIBC "Luigi Sacco", University of Milan, Milan, Italy
| | - Giordano Madeddu
- Unit of Infectious Diseases, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
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Mwasakifwa GE, Amin J, White CP, Center JR, Kelleher A, Boyd MA. Early changes in bone turnover and inflammatory biomarkers and clinically significant bone mineral density loss over 48 weeks among HIV-infected patients with virological failure of a standard first-line antiretroviral therapy regimen in the SECOND-LINE study. HIV Med 2020; 21:492-504. [PMID: 32573910 DOI: 10.1111/hiv.12882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 01/31/2020] [Accepted: 04/28/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES We assessed whether changes at week 12 in markers of bone turnover, inflammation, and immune activation were associated with clinically important (≥ 5%) bone mineral density (BMD) loss from baseline to week 48 at the proximal femur (hip) and lumbar spine in the SECOND-LINE study. METHODS We measured concentrations of procollagen type 1 pro-peptide (P1NP), carboxyl-terminal collagen crosslinks (CTX), high-sensitivity C-reactive protein (hs-CRP), D-dimer, interleukin (IL)-6, tumor necrosis factor (TNF), neopterin, and soluble CD14 and 163 at weeks 0, 12, and 48 in 123 SECOND-LINE dual-energy X-ray absorptiometry (DXA) substudy participants. Linear regression was used to compare changes in biomarkers. Predictors of ≥ 5% BMD loss were examined using multivariable regression. RESULTS The mean age was 38 years, the mean CD4 T-cell count was 252 cells/µL and the mean viral load was 4.2 log HIV-1 RNA copies/mL; 56% of participants were female and 47% were randomized to receive a nucleos(t)ide reverse transcriptase inhibitor [N(t)RTI]-based regimen [91% (53/58) were randomized to receive a tenofovir disoproxil fumarate (TDF)-containing regimen]. Over 48 weeks, 71% in the N(t)RTI arm experienced ≥ 5% hip BMD loss vs. 29% in the raltegravir arm (P = 0.001). Week 12 changes in P1NP and CTX were significantly greater among patients experiencing ≥ 5% hip BMD loss, patients randomized to N(t)RTI, and male patients. Predictors of ≥ 5% hip BMD loss at week 48 were P1NP increase [odds ratio (OR) 5.0; 95% confidence interval (CI) 1.1-27; P < 0.043]; N(t)RTI randomization (OR 6.7; 95% CI 2.0-27.1; P < 0.003), being African, higher baseline CD4 T cell count , and smoking. CONCLUSIONS In a diverse cohort of viraemic HIV-infected patients, switching to second-line antiretroviral therapy (ART) was associated with clinically significant BMD loss, which was correlated with an early increase in P1NP. Measurement of P1NP may facilitate timely interventions to reduce rapid BMD loss among at-risk patients.
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Affiliation(s)
- G E Mwasakifwa
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - J Amin
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia.,Department of Health Systems and Populations, Macquarie University, Sydney, NSW, Australia
| | - C P White
- Department of Endocrinology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - J R Center
- The Garvan Institute of Medical Research, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - A Kelleher
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - M A Boyd
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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Badowski M, Pérez SE, Silva D, Lee A. Two's a Company, Three's a Crowd: A Review of Initiating or Switching to a Two-Drug Antiretroviral Regimen in Treatment-Naïve and Treatment-Experienced Patients Living with HIV-1. Infect Dis Ther 2020; 9:185-208. [PMID: 32193799 PMCID: PMC7237600 DOI: 10.1007/s40121-020-00290-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION As HIV has become a manageable chronic condition, a renewed and increased interest in challenging traditional three-drug HIV therapies and moving toward two-drug regimens (2DR) for initial or maintenance treatment in people living with HIV (PLWH) has developed. As PLWH are living longer, continual advancements in antiretroviral regimens have been a focus to provide optimal life-long therapy options. Although early studies may have shown poor outcomes in virologic suppression with 2DR, newer studies and treatment options have emerged to show promise in the management of HIV. The purpose of this review is to evaluate current literature and assess the efficacy of two-drug (2DR) antiretroviral therapy in treatment-naïve and -experienced people living with HIV. METHODS A systematic search was performed between January 2009 to January 2020, using EMBASE, MEDLINE, Google Scholar, and bibliographies. Combinations of the following search terms were used: HIV-1 infection, antiretroviral therapy, dual therapy, two-drug regimen, two-drug therapy, two-drug regimen, and 2DR. Included studies were those in the adult population with at least one active comparator, outcomes assessing HIV-1 RNA viral load while on treatment, and written in English. RESULTS Thirty-three studies were included, 13 where 2DRs were evaluated as initial therapy (3 studies with extension data) and 15 where 2DRs were evaluated as maintenance or switch therapy (2 studies with extension data). CONCLUSION Although 2DRs may not be appropriate in all patient populations, they are being utilized more frequently and have the potential to reduce costs, adverse effects, and drug interactions.
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Affiliation(s)
| | - Sarah E Pérez
- College of Pharmacy, University of New Mexico, Albuquerque, NM, USA
| | - David Silva
- College of Pharmacy, University of Illinois, Chicago, IL, USA
| | - Andrea Lee
- College of Pharmacy, University of Illinois, Chicago, IL, USA
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11
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Baranek B, Wang S, Cheung AM, Mishra S, Tan DH. The effect of tenofovir disoproxil fumarate on bone mineral density: a systematic review and meta-analysis. Antivir Ther 2020; 25:21-32. [PMID: 32077867 DOI: 10.3851/imp3346] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND We conducted a systematic review and meta-analysis (CRD#42017070552) to quantify the impact of oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) on bone mineral density (BMD) and the risk of osteoporosis, low bone mass and fractures, among people taking it as pre-exposure prophylaxis (PrEP), HIV treatment and HBV treatment. METHODS We searched MEDLINE and EMBASE for randomized controlled trials published from 1997-2018 reporting BMD, osteoporosis, low bone mass and/or fractures in treatment-naive patients taking compared with not taking TDF for 48 ±4 weeks. We pooled outcomes using DerSimonian random-effects models. RESULTS Our search yielded 5,178 abstracts, representing 3,865 articles, with 25 meeting the inclusion criteria. TDF was associated with greater BMD decline when taken as PrEP (lumbar spine: mean difference [MD]=-0.82%, 95% CI=-1.28, -0.37%, I2=38%; total hip: MD=-0.81%, 95% CI=-1.22, -0.40%, I2=48%) and HIV treatment (lumbar spine: MD=-1.62%, 95% CI=-2.30, -0.95%, I2=93%; total hip: MD=-1.75%, 95% CI=-2.08, -1.42%, I2=83%; femoral neck: MD=-1.26%, 95% CI=-2.15, -0.38%, I2=43%) in comparison to those not taking TDF. Eight studies reported on incident osteoporosis or low bone mass, with variable results. Pooled results from five PrEP studies showed that TDF was not associated with increased fractures compared with no PrEP (RR=1.12, 95% CI=0.752, 1.74, I2=26%). CONCLUSIONS TDF caused greater decreases in BMD than did comparators when used for all three indications and the magnitude of this decrease was larger for HIV treatment compared with PrEP. Fractures were not increased among PrEP patients. The clinically significant BMD decline caused by TDF and current expansion of PrEP use suggest attention to the adverse bone effects of TDF will increase in importance.
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Affiliation(s)
| | - Shaoyuan Wang
- Division of Infectious Diseases, St. Michael's Hospital, Toronto, ON, Canada
| | - Angela M Cheung
- Centre for Excellence in Skeletal Health Assessment, University of Toronto, Toronto, ON, Canada.,Department of Medicine and Osteoporosis Program, University Health Network, Toronto, ON, Canada
| | - Sharmistha Mishra
- Division of Infectious Diseases, St. Michael's Hospital, Toronto, ON, Canada.,Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada.,Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
| | - Darrell Hs Tan
- Division of Infectious Diseases, St. Michael's Hospital, Toronto, ON, Canada.,Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada.,Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
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Abstract
PURPOSE OF REVIEW Simplification of antiretroviral therapy is a strategy aiming to reduce pill burden, drug interactions, and toxicity. This review focuses on the most recent and important studies evaluating a reduction on the number of drugs for HIV treatment, both in naive and virologically suppressed patients. RECENT FINDINGS Interesting studies have been performed in the past years testing dual therapy and monotherapy, with variable rates of virological control. Novel therapeutics like immunotherapy or long-acting antiretrovirals can also be considered for simplification. Reducing the number of drugs for HIV treatment can be an option for selected patients. Current available evidence favors dual therapy over monotherapy. Future research should seek to identify the best candidates for simplification.
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13
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Gutierrez MDM, Mateo MG, Vidal F, Domingo P. Does choice of antiretroviral drugs matter for inflammation? Expert Rev Clin Pharmacol 2019; 12:389-396. [PMID: 31017494 DOI: 10.1080/17512433.2019.1605902] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The massive implementation of combination antiretroviral therapy (cART) has forever changed the landscape of HIV infection. This unprecedented success has turned HIV infection into a manageable chronic disease. The increased survival of people living with HIV is, however, shadowed by a high burden of aging-related comorbidities. The pathogenic basis underlying this excess of co-morbid conditions is most likely a persistent inflammatory and immune activation state, despite an optimal control of HIV replication, which in turn has largely been attributed to bacterial or bacterial products translocation from the gut. Area covered: This review is focused on the relationship between cART and the chronic inflammatory and immune activation status in otherwise virologically well-controlled people living with HIV (PLWH). Particular focus will be placed on the differences, if any, between distinct cART modalities, with emphasis on less-drug cART regimens, and especially on dual therapies. Expert opinion: Research to address the increased inflammatory and immune activation status of cART-treated, HIV-infected patients, should focus on adjuvant means of therapy, rather than on the cART regime itself. With current antiretrovirals, no difference between dual and triple regimens has been demonstrated, provided that virological and immunological outcomes be non-inferior.
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Affiliation(s)
- María Del Mar Gutierrez
- a HIV Infection Unit, Infectious Diseases Department , Hospital de la Santa Creu i Sant Pau Institut de Recerca del Hospital de la Santa Creu i Sant Pau , Barcelona , Spain
| | - María Gracia Mateo
- a HIV Infection Unit, Infectious Diseases Department , Hospital de la Santa Creu i Sant Pau Institut de Recerca del Hospital de la Santa Creu i Sant Pau , Barcelona , Spain
| | - Francesc Vidal
- b HIV Unit, Department of Internal Medicine , Hospital Universitari Joan XXIII, Universitat Rovira I Virgili, Institut de Recerca Rovira I Virgili , Tarragona , Spain
| | - Pere Domingo
- a HIV Infection Unit, Infectious Diseases Department , Hospital de la Santa Creu i Sant Pau Institut de Recerca del Hospital de la Santa Creu i Sant Pau , Barcelona , Spain
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Brooks KM, Sherman EM, Egelund EF, Brotherton A, Durham S, Badowski ME, Cluck DB. Integrase Inhibitors: After 10 Years of Experience, Is the Best Yet to Come? Pharmacotherapy 2019; 39:576-598. [PMID: 30860610 DOI: 10.1002/phar.2246] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The era of the integrase strand transfer inhibitors (INSTIs) for the treatment of human immunodeficiency virus (HIV) infection began with raltegravir in 2007. Since that time, several other INSTIs have been introduced including elvitegravir, dolutegravir, and, most recently, bictegravir, that have shown great utility as part of antiretroviral regimens in both treatment-naive and treatment-experienced patients. At present, antiretroviral guidelines fully endorse the INSTI class as part of all first-line treatment regimens. After 10 years of experience with INSTIs, newer agents are on the horizon such as cabotegravir and MK-2048 for potential use as either HIV pre-exposure prophylaxis or maintenance therapy. This review provides a brief overview of the INSTI class including agents currently available and those still in development, reviews available data from both completed and ongoing clinical trials, and outlines simplification strategies using INSTIs.
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Affiliation(s)
- Kristina M Brooks
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Elizabeth M Sherman
- Department of Pharmacy Practice, Nova Southeastern University, Fort Lauderdale, Florida
| | - Eric F Egelund
- Department of Pharmacotherapy & Translational Research, University of Florida College of Pharmacy, Jacksonville, Florida
| | - Amy Brotherton
- Department of Pharmacy, The Miriam Hospital, Providence, Rhode Island
| | - Spencer Durham
- Department Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, Alabama
| | - Melissa E Badowski
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - David B Cluck
- Department of Pharmacy Practice, East Tennessee State University Gatton College of Pharmacy, Johnson City, Tennessee
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Bernardino JI, Mocroft A, Wallet C, de Wit S, Katlama C, Reiss P, Mallon PW, Richert L, Molina JM, Knobel H, Morlat P, Babiker A, Pozniac A, Raffi F, Arribas JR. Body composition and adipokines changes after initial treatment with darunavir-ritonavir plus either raltegravir or tenofovir disoproxil fumarate-emtricitabine: A substudy of the NEAT001/ANRS143 randomised trial. PLoS One 2019; 14:e0209911. [PMID: 30689664 PMCID: PMC6349314 DOI: 10.1371/journal.pone.0209911] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 12/06/2018] [Indexed: 01/03/2023] Open
Abstract
Background Comparison of changes in body composition, adipokines and inflammatory markers after initial therapy with a nucleos(t)ide reverse transcriptase inhibitor (N(t)RTI)- sparing or containing regimen are scarce. Design Randomised Clinical Trial. Methods This is the body composition substudy of NEAT 001/ANRS 143, a randomised trial comparing darunavir/ritonavir (DRV/r) plus either raltegravir (RAL) or tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) in 805 ART naïve HIV-infected adults. The primary endpoint was percentage change in limb fat at week 96. Secondary endpoints were associations among these changes and metabolic markers (IL-6, insulin, leptin, adiponectin, FGF-23). Results 126 subjects (61 DRV/r + RAL and 65 DRV/r + TDF/FTC) were included. The rate of change in BMI between groups for RAL versus TDF/FTC at week 96 was 1.5% per 48-week period (p = 0.015). The rate of change in limb fat mass, trunk fat mass, total body fat and total lean mass was for RAL versus TDF/FTC at week 96 was 2.5% (p = 0.38), 7.3% ((p = 0.021), 4.9% (p = 0.061) and 1.3% (p = 0.12) respectively. Baseline insulin and leptin levels were correlated with baseline limb fat and trunk fat mass [r = 0.31 (p = 0.0043)/r = 0.28 (p = 0.0011) for limb fat, and r = 0.63 (p<0.0001)/r = 0.50(p<0.0001) for trunk fat]. After adjustment, a 10% faster increase in leptin between baseline and week 48 was associated with a more rapid increase in limb fat at week 48 (0.5% per 48 weeks, p<0.001), total body fat mass (0.6% per 48 weeks, p<0.001), and trunk fat mass (0.3% per 48 weeks, p = 0.0026). Conclusions After week 96 a N(t)RTI sparing regimen of DRV/r + RAL produced a numerically greater percentage increase in body composition variables with only change in trunk fat mass and BMI being significant.
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Affiliation(s)
- Jose I. Bernardino
- Department of Internal Medicine, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
- * E-mail:
| | | | - Cedrick Wallet
- University of Bordeaux INSERM, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
| | - Stéphane de Wit
- CHU Saint Pierre, Université Libre de Bruxeles, Brussels, Belgium
| | - Christine Katlama
- Hôpital Pitié Salpétrière, Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d’Epidémiologie et de Santé Publique, Paris, France
| | - Peter Reiss
- Department of Global Health and Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Laura Richert
- University of Bordeaux INSERM, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
| | - Jean-Michel Molina
- Hôpital Saint-Louis, University of Paris Diderot, Paris, INSERM U941, France
| | - Hernando Knobel
- Department of Infectious Diseases, Hospital del Mar, Universidad Autónoma de Barcelona, Spain
| | - Philippe Morlat
- Service de Medicine Interne et Maladies Infectieuses, CHU Bordeaux, Université de Bordeaux, Inserm U 1219, Bourdeaux, France
| | - Abdel Babiker
- MRC Clinical Trials Unit at UCL, London, United Kingdom
| | - Anton Pozniac
- Chelsea and Westminster hospital NHS Foundation Trust, London, United Kingdom
| | - Francois Raffi
- Department of infectious diseases, CHU de Nantes and CIC 1413, INSERM, Nantes, France
| | - Jose R. Arribas
- Department of Internal Medicine, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
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Baseline Hepatitis B Virus Titer Predicts Initial Postpartum Hepatic Flare: A Multicenter Prospective Study. J Clin Gastroenterol 2018; 52:902-907. [PMID: 28654554 DOI: 10.1097/mcg.0000000000000877] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND GOALS A series of changes in the immune system occur during pregnancy and puerperium. Currently, we aim to characterize both the natural changes in liver inflammation and its association with hepatitis B viremia during this special period. PATIENTS AND METHODS Chronic hepatitis B (CHB) gravidas were recruited and followed up to 52 weeks postpartum. Virological and biochemical parameters were assessed throughout the period. RESULTS A total of 1097 CHB mothers had finished the entire follow-up including 451 accepting telbivudine, 178 accepting tenofovir, and 468 without antiviral therapy. Among the mothers, 11.94% went through hepatic flare in the first trimester and the rate decreased to 2.1% at the time of delivery. Nevertheless, a much higher frequency (19.78%) was observed in the early postpartum. Interestingly, alanine aminotransferase level decreased along with the development of pregnancy and then suddenly increased in the first month of puerperium. In addition, a downward trend was observed on the titer of HBsAg and HBeAg after delivery. Of note, an obvious higher frequency of alanine aminotransferase flare was revealed in mothers with high viremia (>6 log10 IU/mL). With multivariate analysis, only hepatitis B virus titer at baseline was strongly associated with hepatic flare during early postpartum (95% confidence interval, 1.012-3.049, P=0.045). The predictive rates of hepatic flare at baseline viral load of 6, 7, and 8 log10 IU/mL were 16.67%, 28.30%, and 30.60%, respectively. CONCLUSIONS CHB gravidas with high viremia should be monitored closely during entire pregnancy, and extended antiviral therapy is recommend to those mothers with baseline viremia >7 log10 IU/mL.
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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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18
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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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Premaor MO, Compston JE. The Hidden Burden of Fractures in People Living With HIV. JBMR Plus 2018; 2:247-256. [PMID: 30283906 PMCID: PMC6139727 DOI: 10.1002/jbm4.10055] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/02/2018] [Accepted: 04/11/2018] [Indexed: 02/06/2023] Open
Abstract
The survival of people living with human immunodeficiency virus (HIV) has increased markedly since the advent of antiretroviral therapy (ART). However, other morbidities have emerged, including osteoporosis. The estimated incidence of fractures at any site in people living with HIV ranges from 0.1 per 1000 person‐years to 8.4 per 1000 person‐years: at least twice that of people without HIV. This increased risk seems to be related to HIV itself and its treatment. Risk factors for bone disease in HIV‐positive (HIV+) subjects include both classical risk factors for osteoporosis and fracture and factors linked to HIV itself, such as inflammation, reconstitution syndrome, low CD4, ART, and co‐infection with hepatitis B and C viruses. The risk of fractures in these individuals can be at least partially assessed by measurement of BMD and the Fracture Risk Assessment Tool (FRAX™). Only alendronate and zoledronic acid have been studied in HIV+ individuals; both show beneficial effects on BMD, although data on fracture reduction are not available. © 2018 The Authors. JBMR Plus Published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Melissa O Premaor
- Department of Clinical Medicine Health Sciences Center Federal University of Santa Maria Santa Maria Brazil
| | - Juliet E Compston
- Department of Medicine Cambridge Biomedical Campus Cambridge United Kingdom
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Abstract
INTRODUCTION Darunavir (DRV) was the last approved protease inhibitor (PI) and has been extensively used for the treatment of HIV in both naïve and experienced subjects due to its high genetic barrier and efficacy. The introduction in clinical practice of integrase strand transfer inhibitors limited its role in the management of naïve subjects and in antiretroviral treatment simplification strategies. However, recent data from trials that have investigated the new DRV/cobicistat/emtricitabine/tenofovir alafenamide (D/C/F/TAF) combination showed an excellent efficacy and tolerability of this coformulation both in naïve patients and in those with viral suppression, making D/C/F/TAF a new option for the treatment of HIV infection. Areas covered: The authors present and discuss the efficacy and safety data of DRV when used in antiretroviral-naïve, multiexperienced subjects and in the setting of treatment deintensification in subjects with viral suppression. Moreover, the authors evaluate the recent data from two different Phase III trials on D/C/F/TAF both in treatment-naïve and virologically suppressed subjects. Expert opinion: Although novel antiretroviral drugs may become available over time, DRV continues to represent a valuable option for multiexperienced subjects and has a role in simplification regimens. In addition, the convenience of D/C/F/TAF coformulation may be useful for the future management of HIV-infected subjects.
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Affiliation(s)
- Vincenzo Spagnuolo
- a Faculty of Medicine and Surgery , Vita-Salute San Raffaele University , Milan , Italy.,b Unit of Management and Antiretroviral Treatment of HIV Infection, Division of Immunology, Transplantation and Infectious Diseases , IRCCS San Raffaele Hospital , Milan , Italy
| | - Antonella Castagna
- a Faculty of Medicine and Surgery , Vita-Salute San Raffaele University , Milan , Italy.,b Unit of Management and Antiretroviral Treatment of HIV Infection, Division of Immunology, Transplantation and Infectious Diseases , IRCCS San Raffaele Hospital , Milan , Italy
| | - Adriano Lazzarin
- b Unit of Management and Antiretroviral Treatment of HIV Infection, Division of Immunology, Transplantation and Infectious Diseases , IRCCS San Raffaele Hospital , Milan , Italy
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Jabłonowska E, Pulik P, Kalinowska A, Gąsiorowski J, Parczewski M, Bociąga-Jasik M, Mularska E, Pulik Ł, Siwak E, Wójcik K. Dual therapy based on raltegravir and boosted protease inhibitors - the experience of Polish centers. Arch Med Sci 2018; 14:860-864. [PMID: 30002705 PMCID: PMC6040130 DOI: 10.5114/aoms.2016.62445] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 07/03/2016] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The aim of the study was to present the experience of Polish centers regarding dual therapy based on the integrase inhibitor raltegravir (RAL) and ritonavir-boosted protease inhibitors (PI/r) for treating treatment-naïve and -experienced HIV-infected patients. MATERIAL AND METHODS The paper concerns a retrospective multicenter study. The medical databases of six main Polish HIV centers from January 2009 to December 2014 were analyzed for the use of combined antiretroviral treatment consisting of RAL + PI/r. This study included 126 HIV-infected patients receiving RAL + PI/r therapy, of whom 17 patients were treatment-naive and 109 patients were treatment-experienced. RESULTS In treatment-experienced patients, the most common reasons for the introduction of a RAL + PI/r regimen were virologic failure and impaired renal function (45 of 109 patients). In the treatment-naïve group kidney disease was the cause of the RAL + PI/r regimen in 3 of 17 participants. In treatment-experienced patients, 80% of individuals still were on RAL + PI/r treatment after 12 months, 65% after 24 months and 53% of subjects after 60 months. In both groups, the simplification of the antiretroviral regimen was the most common reason for discontinuation of RAL + PI/r based therapy. CONCLUSIONS In antiretroviral-experienced patients the dual therapy based on RAL + PI/s is safe and effective. In antiretroviral-naïve patients the RAL + PI/r regimen is rarely used in Poland.
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Affiliation(s)
- Elżbieta Jabłonowska
- Clinic of Infectious Diseases and Hepatology, Medical University of Lodz, Lodz, Poland
| | - Piotr Pulik
- Hospital for Infectious Diseases, HIV Out-Patient Clinic, Warsaw, Poland
| | - Anna Kalinowska
- Department of Infectious Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Jacek Gąsiorowski
- Department of Infectious Diseases, Hepatology and Acquired Immune Deficiencies, Wroclaw Medical University, Wroclaw, Poland
| | - Miłosz Parczewski
- Department of Infectious and Tropical Diseases and Immune Deficiency, Pomeranian Medical University, Szczecin, Poland
| | - Monika Bociąga-Jasik
- Department of Infectious Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Elżbieta Mularska
- Outpatient Clinic for AIDS Diagnostics and Therapy Specialistic Hospital, Chorzow, Poland
| | - Łukasz Pulik
- Hospital for Infectious Diseases, HIV Out-Patient Clinic, Warsaw, Poland
| | - Ewa Siwak
- Hospital for Infectious Diseases, HIV Out-Patient Clinic, Warsaw, Poland
| | - Kamila Wójcik
- Clinic of Infectious Diseases and Hepatology, Medical University of Lodz, Lodz, Poland
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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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de Miguel R, Montejano R, Stella-Ascariz N, Arribas JR. A safety evaluation of raltegravir for the treatment of HIV. Expert Opin Drug Saf 2017; 17:217-223. [PMID: 29199485 DOI: 10.1080/14740338.2018.1411903] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Raltegravir (RAL) was the first commercialized agent from a new drug class with an innovative target, the integrase. Since its introduction in clinical practice RAL has become widely used for the treatment of HIV-1 infected patients. A decade after its approval, this article reviews key evidence from RAL with a special interest on safety outcomes. Areas covered: Pharmacologic, safety and efficacy data of RAL from clinical trials and post-commercialization published reports are hereby summarized after a literature review including PubMed search, relating proceedings and abstracts from relevant international HIV conferences, assessment reports from European and United States regulatory agencies and treatment guidelines (World Health Organization, United States Department of Health and Human Services and European AIDS Clinical Society), up to October 2017. Most frequent search terms were 'raltegravir', 'safety', 'adverse events', 'efficacy' and 'integrase-inhibitors'. Expert opinion: Despite the arrival of new integrase strand transfer inhibitors (INSTIs) with advantages in terms of dosing convenience (elvitegravir, ELV) and higher genetic barrier (dolutegravir, DTG), RAL has stood the test of time and its overall favourable safety profile, without significant appearance of unexpected adverse events, vouch for its relevance in the antiretroviral armamentarium.
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Affiliation(s)
- Rosa de Miguel
- a HIV Unit, Internal Medicine Service , Hospital Universitario La Paz-IdiPAZ , Madrid , Spain
| | - Rocio Montejano
- a HIV Unit, Internal Medicine Service , Hospital Universitario La Paz-IdiPAZ , Madrid , Spain
| | - Natalia Stella-Ascariz
- a HIV Unit, Internal Medicine Service , Hospital Universitario La Paz-IdiPAZ , Madrid , Spain
| | - Jose R Arribas
- a HIV Unit, Internal Medicine Service , Hospital Universitario La Paz-IdiPAZ , Madrid , Spain
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McGinty T, Mallon P. Protecting bone in long-term HIV positive patients receiving antiretrovirals. Expert Rev Anti Infect Ther 2017; 14:587-99. [PMID: 27189695 DOI: 10.1080/14787210.2016.1184570] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION As the population of people living with HIV ages, the increase in non-AIDs morbidities is expected to increase in parallel. Maintaining bone health in those with HIV will be an important area of focus for the HIV clinician to prevent the morbidity and mortality associated with fragility fractures, the principal clinical sequela of low bone mineral density (BMD). Rates of fractures and prevalence of low bone mineral density, a risk factor for future fragility fractures, are already increased in the HIV positive population. AREAS COVERED This review examines the strategies to maintain bone health in those living with HIV from screening through to managing those with established low BMD or fracture, including the role for choice of or modification of antiretroviral therapy to maintain bone health. Expert commentary: The increasing complexity of managing bone health in the age of succesful antiretroviral therapy and an aging patient population as well as future perspectives which may help achieve the long term aim of minimising the impact of low BMD in those with HIV are discussed and explored.
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Affiliation(s)
- Tara McGinty
- a School of Medicine , University College Dublin , Dublin , Ireland
| | - Patrick Mallon
- a School of Medicine , University College Dublin , Dublin , Ireland
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25
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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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Abstract
Human immunodeficiency virus (HIV) infection is an established risk factor for low bone mineral density (BMD) and subsequent fracture, and treatment with combination antiretroviral therapy (cART) leads to additional BMD loss, particularly in the first 1-2 years of therapy. The prevalence of low BMD and fragility fracture is expected to increase as the HIV-infected population ages with successful treatment with cART. Mechanisms of bone loss in the setting of HIV infection are likely multifactorial, and include viral, host, and immune effects, as well as direct and indirect effects of cART, particularly tenofovir disoproxil fumarate (TDF) and the protease inhibitors (PIs). Emerging data indicate that BMD loss following cART initiation can be mitigated by prophylaxis with either long-acting bisphosphonates or vitamin D and calcium supplementation. In addition, newer antiretrovirals, particularly the integrase strand transfer inhibitors and tenofovir alafenamide (TAF), are associated with less intense bone loss than PIs and TDF. However, further studies are needed to establish optimal bone sparing cART regimens, appropriate screening intervals, and preventive measures to address the rising prevalence of fragility bone disease in the HIV population.
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Abstract
The advent of combination antiretroviral therapy (ART) has significantly decreased AIDS-related morbidity and mortality. Nevertheless, the benefits of ART are only realized through adherence to lifelong treatment. Though contemporary antiretroviral (ARV) drugs have fewer adverse effects in comparison to older ARV drugs, many agents are associated with negative or unknown long-term effects. There is increasing evidence that two-drug (dual-therapy) regimens may be an effective alternative to the currently recommended three-drug (triple-therapy) regimens. In this review, we provide a comprehensive and critical review of recently completed and ongoing trials of dual-therapy regimens in treatment-naïve and treatment-experienced HIV-1-infected patients. We also review current HIV/AIDS society recommendations regarding dual therapy as well as future therapeutic possibilities.
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Affiliation(s)
- Sean G Kelly
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, 645 N Michigan Ave, Suite 900, Chicago, IL, 60611, USA
| | - Amesika N Nyaku
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, 645 N Michigan Ave, Suite 900, Chicago, IL, 60611, USA
| | - Babafemi O Taiwo
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, 645 N Michigan Ave, Suite 900, Chicago, IL, 60611, USA. .,Center for Global Health, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Abstract
PURPOSE OF REVIEW With continued improvements to the antiviral efficacy and tolerability of antiretroviral therapy, long-term safety of antiretroviral therapy has become paramount. Low bone mineral density and fragility fractures are more common in HIV-infected individuals than in the general population. The aims of this review are to describe potential mechanisms underlying the adverse effects of tenofovir on bone, clinical studies of tenofovir disoproxil fumarate (TDF) and bone, and more recent bone data on tenofovir alafenamide. RECENT FINDING Several studies have demonstrated an approximately 1-3% greater bone mineral density loss with TDF compared with other agents. Recent studies with tenofovir alafenamide have shown improved bone (and renal) safety with similar virologic efficacy when compared to TDF. SUMMARY Given these findings, TDF-containing regimens may be gradually replaced with non-TDF containing regimens for the treatment of HIV infection, especially in those at higher risk for fragility fracture.
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Abstract
PURPOSE OF REVIEW There is increasing evidence pointing toward an important role of heightened immune activation and inflammation in people living with HIV contributing to the development of non-AIDS comorbidities. This review aims to explore low bone mineral density (BMD) in HIV with a focus on the underlying mechanisms and relationships between the immune and skeletal systems. RECENT FINDINGS Baseline immune activation and inflammation negatively impact BMD at antiretroviral therapy (ART) initiation. B- and T-cell alterations in HIV lead to an imbalance in the osteoblastic osteoprotegerin (OPG) and osteoclastic receptor activator of NF-κB ligand (RANKL) cytokines which favours osteoclastogenesis and bone resorption. These findings suggest an important role for immune-mediated mechanisms in the pathogenesis of low BMD in HIV. SUMMARY Bone homeostasis is in part regulated by cells of the immune system through complex interactions with the RANK/RANKL/OPG axis. Disturbances in the normal functioning of T, B cells, and monocytes in HIV and the resulting proinflammatory state may contribute to dysregulation of this finely controlled balance leading to increased bone loss. Pre-ART levels of immune activation and inflammation have a consistently negative effect on BMD and further suggest the immunocentric basis of bone loss in HIV alongside supporting the benefits of earlier ART initiation. Further longitudinal studies will help determine the effect this will have on fracture risk in people living with HIV.
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Abstract
The success of antiretroviral therapy in treating HIV infection has greatly prolonged life expectancy in affected individuals, transforming the disease into a chronic condition. A number of HIV-associated non-AIDS comorbidities have emerged in the ageing HIV-infected population, including osteoporosis and increased risk of fracture. The pathogenesis of fracture is multifactorial with contributions from both traditional and HIV-specific risk factors. Significant bone loss occurs on initiation of antiretroviral therapy but stabilizes on long-term therapy. Fracture risk assessment should be performed in HIV-infected individuals and bone mineral density measured when indicated. Lifestyle measures to optimize bone health should be advised and, in individuals at high risk of fracture, treatment with bisphosphonates considered.
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Affiliation(s)
- J Compston
- Dept of Medicine, Cambridge Biomedical Campus Francis Crick Ave, Cambridge CB2 0SL, UK.
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Latini A, Fabbiani M, Borghi V, Sterrantino G, Giannetti A, Lorenzini P, Loiacono L, Ammassari A, Bellagamba R, Colafigli M, D’Ettorre G, Di Giambenedetto S, Antinori A, Zaccarelli M. Switching to boosted protease inhibitor plus a second antiretroviral drug (dual therapy) for treatment simplification: a multicenter observational study. BMC Infect Dis 2016; 16:401. [PMID: 27515949 PMCID: PMC4982404 DOI: 10.1186/s12879-016-1703-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 07/08/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Aim of the study was to assess predictors of discontinuation/toxicity of boosted PI-based (PI/r) dual therapy (DT). METHODS Observational, retrospective switch study in patients successfully treated with triple drugs regimen. Patients switched to PI/r based DT [darunavir (DRV/r), lopinavir (LPV/r) or atazanavir (ATV/r)] plus a second drug: [raltegravir (RAL), maraviroc (MVC) etravirine (ETR), lamivudine (3TC) or tenofovir (TDF)] between 2009 and 2014 were included. The effect of each drug as well as other clinical and virological cofactors over treatment discontinuation (TD) was assessed using survival analysis. RESULTS Overall, 376 patients were included with mean follow-up of 73 weeks. The most commonly used drugs in DT were DRV/r (63.0 %) and RAL (53.7 %). TD was observed in 77 (20,4 %) patients: 38 (10,1 %) virological failure, 35 (9,3 %) toxicity/intolerance (4 deaths) and 4 (1 %) interruptions for patients decision. At Cox Model, adjusted by demographic and laboratory variables, DRV/r and ATV/r significantly reduced the likelihood of TD and longer treatment was associated with lower risk, while low CD4 count at baseline and number of previous regimens with a higher risk. Moreover, RAL and 3TC use were significantly associated with lower TD by toxicity. CONCLUSIONS In our clinical practice experience, switching virologically suppressed patients to PI/r based DT showed adequate safety and efficacy, so that it may be used in selected patients with specific medical needs.
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Affiliation(s)
- Alessandra Latini
- San Gallicano Dermatologic Institute (IRCCS), Clinic of Dermatology and Infectious Diseases, Rome, Italy
| | - Massimiliano Fabbiani
- Department of Infectious Diseases, Catholic University of the Sacred Heart, Rome, Italy
- Division of Infectious Diseases, Department of Internal Medicine, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Vanni Borghi
- Azienda Ospedaliero Universitaria, Clinic of Infectious Diseases, Modena, Italy
| | | | - Alberto Giannetti
- Clinical Department, National Institute for the Infectious Diseases “Lazzaro Spallanzani”, Rome, Italy
| | - Patrizia Lorenzini
- Clinical Department, National Institute for the Infectious Diseases “Lazzaro Spallanzani”, Rome, Italy
| | - Laura Loiacono
- Clinical Department, National Institute for the Infectious Diseases “Lazzaro Spallanzani”, Rome, Italy
| | - Adriana Ammassari
- Clinical Department, National Institute for the Infectious Diseases “Lazzaro Spallanzani”, Rome, Italy
| | - Rita Bellagamba
- Clinical Department, National Institute for the Infectious Diseases “Lazzaro Spallanzani”, Rome, Italy
| | - Manuela Colafigli
- San Gallicano Dermatologic Institute (IRCCS), Clinic of Dermatology and Infectious Diseases, Rome, Italy
| | - Gabriella D’Ettorre
- Policlinico Universitario “Umberto I”, Clinic of Infectious Diseases, Rome, Italy
| | | | - Andrea Antinori
- Clinical Department, National Institute for the Infectious Diseases “Lazzaro Spallanzani”, Rome, Italy
| | - Mauro Zaccarelli
- Clinical Department, National Institute for the Infectious Diseases “Lazzaro Spallanzani”, Rome, Italy
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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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Bone Mineral Density Changes Among Young, Healthy African Women Receiving Oral Tenofovir for HIV Preexposure Prophylaxis. J Acquir Immune Defic Syndr 2016; 71:287-94. [PMID: 26866954 PMCID: PMC4755358 DOI: 10.1097/qai.0000000000000858] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Limited data exist on effect of tenofovir disoproxil fumarate (TDF) when used for preexposure prophylaxis (PrEP) on bone mineral density (BMD) in HIV-negative women. We evaluated the effect of daily oral TDF and emtricitabine/TDF compared with placebo on BMD among women enrolled in an HIV-1 PrEP trial. METHODS HIV-uninfected women in Uganda and Zimbabwe had BMD measurements of lumbar spine (LS) and total hip (TH) by dual-energy x-ray absorptiometry at baseline and every 24 weeks for 48 weeks of active treatment and for 48 weeks after discontinuation of study medication. Plasma tenofovir levels were assessed every 12 weeks for the first 48 weeks. RESULTS Of 518 women enrolled, 432 had dual-energy x-ray absorptiometry results at baseline and week 48. In the primary analysis, no significant differences in percent BMD change in hip or spine between arms observed, likely because of low product adherence. Among the subset with tenofovir detection in 75%-100% of plasma samples, the mean percent BMD change from baseline to week 48 in the LS was 1.4% lower for TDF or emtricitabine/TDF recipients than for placebo (P = 0.002) and TH BMD was 0.9% lower (P = 0.018). BMD changes from end of active treatment to 48 weeks were significantly greater in the active arm participants compared with placebo participants with a net difference of approximately +0.9% at the LS (P = 0.007) and +0.7% (P = 0.003) at the TH. CONCLUSIONS TDF-containing oral PrEP resulted in small but significant reversible decreases in hip and spine BMD among young African women.
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Stellbrink HJ, Le Fevre E, Carr A, Saag MS, Mukwaya G, Nozza S, Valluri SR, Vourvahis M, Rinehart AR, McFadyen L, Fichtenbaum C, Clark A, Craig C, Fang AF, Heera J. Once-daily maraviroc versus tenofovir/emtricitabine each combined with darunavir/ritonavir for initial HIV-1 treatment. AIDS 2016; 30:1229-38. [PMID: 26854810 PMCID: PMC4856180 DOI: 10.1097/qad.0000000000001058] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Objective: The aim of this study was to evaluate the efficacy of maraviroc along with darunavir/ritonavir, all once daily, for the treatment of antiretroviral-naive HIV-1 infected individuals. Design: MODERN was a multicentre, double-blind, noninferiority, phase III study in HIV-1 infected, antiretroviral-naive adults with plasma HIV-1 RNA at least 1000 copies/ml and no evidence of reduced susceptibility to study drugs. Methods: At screening, participants were randomized 1 : 1 to undergo either genotypic or phenotypic tropism testing. Participants with CCR5-tropic HIV-1 were randomized 1 : 1 to receive maraviroc 150 mg once daily or tenofovir/emtricitabine once daily each with darunavir/ritonavir once daily for 96 weeks. The primary endpoint was the proportion of participants with HIV-1 RNA less than 50 copies/ml (Food and Drug Administration snapshot algorithm) at Week 48. A substudy evaluated bone mineral density, body fat distribution and serum bone turnover markers. Results: Seven hundred and ninety-seven participants were dosed (maraviroc, n = 396; tenofovir/emtricitabine, n = 401). The Data Monitoring Committee recommended early study termination due to inferior efficacy in the maraviroc group. At Week 48, the proportion of participants with HIV-1 RNA less than 50 copies/ml was 77.3% for maraviroc and 86.8% for tenofovir/emtricitabine [difference of −9.54% (95% confidence interval: −14.83 to −4.24)]. More maraviroc participants discontinued for lack of efficacy, which was not associated with non-R5 tropism or resistance. Discontinuations for adverse events, Category C events, Grade 3/4 adverse events and laboratory abnormalities were similar between groups. Conclusion: A once-daily nucleos(t)ide-sparing two-drug regimen of maraviroc and darunavir/ritonavir was inferior to a three-drug regimen of tenofovir/emtricitabine and darunavir/ritonavir in antiretroviral-naive adults.
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Liu J, Feng Y, Wang J, Li X, Lei C, Jin D, Feng W, Yang Y, He Y, Li Y, Du D, Zhang X, Jin L, Yan T, Chen T, Zhao Y. An "immune barrier" is formed in the placenta by hepatitis B immunoglobulin to protect the fetus from hepatitis B virus infection from the mother. Hum Vaccin Immunother 2016; 11:2068-76. [PMID: 26126021 PMCID: PMC4635728 DOI: 10.1080/21645515.2015.1010890] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The effect of hepatitis B immunoglobulin (HBIG) on hepatitis B virus (HBV) DNA load and its protective mechanism are not well understood. Twenty-eight hepatitis B surface antigen (HBsAg)–positive pregnant women and their newborns were assigned to an experimental (n = 12) or control group (n = 16) according to whether they received HBIG during pregnancy. HBV DNA load and markers titer of the mothers and newborns were tested. These markers and HBV DNA load in mothers of the experimental group did not fluctuate significantly and were comparable to the control. In the experimental group, there was a positive correlation between mothers and their newborns with regard to hepatitis B surface antibody titer. Immunohistochemical staining of placenta sections showed that HBsAg-positive areas mainly included trophoblastic cells and villous mesenchymal cells without HBIG colocalization, whereas HBIG-positive areas principally included villous capillary endothelial cells and villous mesenchymal cells. Additionally, compared with the control group, the positive rate and mean density of HBIG in the experimental group were remarkably higher. HBIG deposition was seen in Hofbauer cells. Thus, rather than influencing virus replication, HBIG forms an immune barrier between the mother and fetus to prevent HBV transmission.
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Affiliation(s)
- Jinfeng Liu
- a Department of Infectious Diseases ; the First Affiliated Hospital of Medical College; Xi'an Jiaotong University ; Xi'an , Shaanxi Province , China
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Abstract
PURPOSE OF REVIEW HIV infection is an established risk factor for osteoporosis and bone fracture. Combination antiretroviral therapy (cART) increases bone resorption leading to an additional 2-6% bone mineral density (BMD) loss within the first 1-2 years of therapy. Although tenofovir disoproxil fumarate is often blamed for antiretroviral drug-associated bone loss, evidence abounds to suggest that other agents, including the protease inhibitors (PIs), have adverse bone effects. In the current review, we examine bone loss associated with protease inhibitor use, describing the relative magnitude of bone loss reported for individual protease inhibitors. We also review the potential mechanisms associated with protease inhibitor-induced bone loss. RECENT FINDINGS As a class, protease inhibitors contribute to a greater degree of bone loss than other anchor drugs. HIV disease reversal and the associated immune reconstitution following cART initiation play an important role in protease inhibitor-mediated bone loss in addition to plausible direct effects of protease inhibitors on bone cells. SUMMARY Protease inhibitors remain an important component of cART despite their adverse effects on bone. A better understanding of factors that drive HIV/cART-induced bone loss is needed to stem the rising rate of fracture in the HIV-infected population.
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Affiliation(s)
- Caitlin A. Moran
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA USA
- Grady Healthcare System, Atlanta, GA USA
| | - M. Neale Weitzmann
- Division of Endocrinology & Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA USA
- Atlanta Department of Veterans Affairs Medical Center, Decatur, GA USA
| | - Ighovwerha Ofotokun
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA USA
- Grady Healthcare System, Atlanta, GA USA
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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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Yang W, Xiao Q, Wang D, Yao C, Yang J. Evaluation of pharmacokinetic interactions between long-acting HIV-1 fusion inhibitor albuvirtide and lopinavir/ritonavir, in HIV-infected subjects, combined with clinical study and simulation results. Xenobiotica 2016; 47:133-143. [PMID: 27052428 DOI: 10.3109/00498254.2016.1166532] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
1. A clinical study to assess the interactions between albuvirtide (320 mg) and lopinavir/ritonavir (400/100 mg) was conducted in 10 HIV-1-infected subjects. Because albuvirtide requires a long period to achieve steady state, and extended monotherapy may lead to early resistance, it is unethical to take albuvirtide alone to achieve steady state. Therefore, a population pharmacokinetic model was developed to predict steady-state concentration-time curve of solely administered albuvirtide. 2. When albuvirtide and lopinavir/ritonavir were co-administered, the plasma concentration of albuvirtide when the infusion ended (Cend) increased by about 34%, but the geometric mean ratios and 90% confidence intervals (90% CIs) of AUC(0-t) [1.09 (0.96-1.24)] and Ctrough [1.00 (0.83-1.20)] were within the range of 0.8-1.25. For lopinavir, the ratios (90% CIs) of AUC(0-t), Cmax and Ctrough were 0.63 (0.49-0.82), 0.67 (0.53-0.86) and 0.65 (0.46-0.91); for ritonavir, those ratios (90% CIs) were 0.62 (0.42-0.91), 0.61 (0.38-0.99) and 0.72 (0.40-1.26), respectively. 3. Co-administration of albuvirtide with lopinavir/ritonavir has little effect on albuvirtide exposure, but it decreases the plasma exposures of lopinavir/ritonavir. However, the drug-drug interactions may not reduce the effectiveness of this co-therapy, the trough concentration of lopinavir may be sufficient and this combination could achieve similar clinical efficacy with marketed drugs. So, a phase 3 clinical trial without dose adjustment is underway to validate their effectiveness and safety.
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Affiliation(s)
- Wanqiu Yang
- a Center of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University , Nanjing , China
| | - Qingqing Xiao
- b Department of Clinical Pharmacy , School of Pharmacy, China Pharmaceutical University , Nanjing , China , and
| | - Dan Wang
- a Center of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University , Nanjing , China
| | - Cheng Yao
- c Nanjing Frontier Biotechnologies Co , Nanjing , China
| | - Jin Yang
- a Center of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University , Nanjing , China
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Cutrell J, Bedimo R. Single-Tablet Regimens in the Treatment of HIV-1 Infection. Fed Pract 2016; 33:24S-30S. [PMID: 30766212 PMCID: PMC6375416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The emergence of highly active antiretroviral therapies has decreased mortality, increased viral suppression, and significantly reduced the risk of the sexual transmission of HIV.
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Affiliation(s)
- James Cutrell
- is a staff physician, and is the chief of the Infectious Diseases Section, both at the VA North Texas Health Care System in Dallas, Texas. Dr. Cutrell is assistant professor of medicine, and Dr. Bedimo is associate professor of medicine, both at the University of Texas Southwestern Medical Center in Dallas
| | - Roger Bedimo
- is a staff physician, and is the chief of the Infectious Diseases Section, both at the VA North Texas Health Care System in Dallas, Texas. Dr. Cutrell is assistant professor of medicine, and Dr. Bedimo is associate professor of medicine, both at the University of Texas Southwestern Medical Center in Dallas
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Crespo M, Navarro J, Martinez-Rebollar M, Podzamczer D, Domingo P, Mallolas J, Saumoy M, Mateo GM, Curran A, Gatell J, Ribera E. Improvement of BMD after Switching from Lopinavir/R Plus Two Nucleos(T)ide Reverse Transcriptase Inhibitors to Lopinavir/R Plus Lamivudine: OLE-LIP Substudy. HIV CLINICAL TRIALS 2016; 17:89-95. [PMID: 27125363 DOI: 10.1080/15284336.2016.1149929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To compare 48-week changes in bone mineral density (BMD) and body fat distribution between patients continuing lopinavir/ritonavir and two NRTIs and those switching to lopinavir/ritonavir and lamivudine. METHODS Substudy of a randomized, open-label, multicenter OLE study was carried out. Adult HIV-infected patients with <50 copies/mL for ≥6 months were randomized (1:1) to continue lopinavir/ritonavir and two NRTIs or switching to lopinavir/ritonavir and lamivudine. Dual-energy X-ray absorptiometry (DXA) was performed at baseline and after 48 weeks to measure bone composition and body fat distribution in both the groups. RESULTS Forty-one patients (dual-therapy, n = 23; triple-therapy, n = 18) of 239, who received at least one dose of study medication, completed the study: median age, 42 years, 71% male, 73% Caucasian. At week 48, total BMD increased by 1.04% (95% CI, 0.06 to 2.01%) among patients switching to dual-therapy, whereas no significant changes occurred in patients maintaining triple-therapy. Dual-therapy and older age were independently associated with total BMD increase. Among patients discontinuing tenofovir-DF, a significant increase was seen in total BMD (1.43; 95% CI, -0.04 to 2.91) and total hip (1.33%; 95% CI, 0.44 to 2.22%). A non-statistically significant decrease in femoral and spinal BMD was observed in patients who discontinued abacavir and in those continuing triple-therapy. Regarding fat distribution, no significant changes were seen in both the treatment groups. DISCUSSION BMD increased following switching to lopinavir/ritonavir plus lamivudine in HIV-infected patients on suppressive triple-therapy with lopinavir/ritonavir and two NRTIs including tenofovir-DF.
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Affiliation(s)
- M Crespo
- a Hospital Universitari Vall d'Hebrón , Autonomous University of Barcelona , Barcelona , Spain.,b Vall d'Hebron Research Institute , Barcelona , Spain
| | - J Navarro
- a Hospital Universitari Vall d'Hebrón , Autonomous University of Barcelona , Barcelona , Spain.,b Vall d'Hebron Research Institute , Barcelona , Spain
| | | | - D Podzamczer
- d Hospital Universitario de Bellvitge , Barcelona , Spain
| | - P Domingo
- e Hospital de la Santa Creu i Sant Pau , Barcelona , Spain
| | - J Mallolas
- c Hospital Clínic/IDIBAPS , University of Barcelona , Barcelona , Spain
| | - M Saumoy
- d Hospital Universitario de Bellvitge , Barcelona , Spain
| | - G M Mateo
- e Hospital de la Santa Creu i Sant Pau , Barcelona , Spain
| | - A Curran
- a Hospital Universitari Vall d'Hebrón , Autonomous University of Barcelona , Barcelona , Spain
| | - J Gatell
- c Hospital Clínic/IDIBAPS , University of Barcelona , Barcelona , Spain
| | - E Ribera
- a Hospital Universitari Vall d'Hebrón , Autonomous University of Barcelona , Barcelona , Spain
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Negredo E, Bonjoch A, Clotet B. Management of bone mineral density in HIV-infected patients. Expert Opin Pharmacother 2016; 17:845-52. [PMID: 26809940 DOI: 10.1517/14656566.2016.1146690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Loss of bone mineral density is an emerging problem in persons living with HIV infection. Earlier and more rapid bone demineralization has been attributed not only to the high prevalence of traditional risk factors, but also to specific HIV-related factors. The aim of this guidance is to stimulate an appropriate management of osteoporosis in this population, to identify patients at risk and to better manage them. AREAS COVERED Appropriate screening of HIV-infected subjects to identify those at risk for bone fractures is described, as well as the recommended interventions. American and European recommendations in HIV-infected and non-infected populations were considered. As the etiology of bone loss is multifactorial, many factors have to be addressed. Overall, recommendations on traditional risk factors are the same for HIV-infected and non-HIV-infected subjects. However, we should consider some specific factors in the HIV-infected population, including an appropriate antiretroviral therapy in patients with low bone mineral density, and probably novel strategies that could provide an additional benefit, such as anti-inflammatory drugs, although data supporting this approach are scant. EXPERT OPINION Some personal opinions are highlighted on the management of bone health in HIV-infected subjects, mainly on the use of FRAX(®) score and DXA scans. In addition, the need to implement new strategies to delay demineralization is remarked upon.
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Affiliation(s)
- Eugenia Negredo
- a Unitat VIH, Fundació Lluita contra la SIDA, Hospital Germans Trias i Pujol , Universitat Autònoma de Barcelona , Badalona , Barcelona , Spain.,b Universitat de Vic-Universitat Central de Catalunya , Barcelona , Spain
| | - Anna Bonjoch
- a Unitat VIH, Fundació Lluita contra la SIDA, Hospital Germans Trias i Pujol , Universitat Autònoma de Barcelona , Badalona , Barcelona , Spain
| | - Bonaventura Clotet
- a Unitat VIH, Fundació Lluita contra la SIDA, Hospital Germans Trias i Pujol , Universitat Autònoma de Barcelona , Badalona , Barcelona , Spain.,b Universitat de Vic-Universitat Central de Catalunya , Barcelona , Spain.,c Fundació IrsiCaixa, Hospital Germans Trias i Pujol , Universitat Autònoma de Barcelona , Badalona , Barcelona , Spain
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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
| | - 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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Calza L, Danese I, Magistrelli E, Colangeli V, Manfredi R, Bon I, Re MC, Conti M, Viale P. Dual Raltegravir-Darunavir/Ritonavir Combination in Virologically Suppressed HIV-1-Infected Patients on Antiretroviral Therapy Including a Ritonavir-Boosted Protease Inhibitor Plus Two Nucleoside/Nucleotide Reverse Transcriptase Inhibitors. HIV CLINICAL TRIALS 2016; 17:38-47. [PMID: 26728706 DOI: 10.1080/15284336.2015.1122874] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Nucleoside reverse transcriptase inhibitor (NRTI)-sparing antiretroviral therapies may be useful in HIV-infected patients with resistance or intolerance to this class. METHODS We performed an observational study of patients on suppressive antiretroviral therapy containing two NRTIs plus one ritonavir-boosted protease inhibitor who switched to a dual regimen containing raltegravir (400 mg twice daily) and darunavir/ritonavir (800/100 mg once daily) and were followed-up for 48 weeks. RESULTS As a whole, 82 patients were enrolled. Mean duration of current regimen was 4.6 years and mean duration of plasma HIV RNA < 50 copies/mL before the switch was 46.2 months. Reason for simplification was toxicity in 76 patients and resistance to NRTIs in 13. After switching, the percentage of patients with HIV RNA < 50 copies/mL at week 48 was 92.7% in the intent-to-treat-exposed analysis and 97.6% in the per-protocol analysis. The switch led to a significant reduction in the mean triglyceride value (-85.2 mg/dL), in the prevalence of tubular proteinuria (-56%) and in the mean level of interleukin-6 (-0.94 pg/mL), with a significant increase in the mean phosphoremia (+0.58 mg/dL). Mean trough concentrations of both raltegravir and darunavir were within the therapeutic range. Two patients (2.4%) had virological failure due to suboptimal adherence and 4 subjects (4.9%) discontinued treatment due to adverse events, but no patients experienced Grade 3 or 4 adverse events. CONCLUSION In our study, simplification to a dual therapy containing raltegravir plus darunavir/ritonavir after 48 weeks maintained viral suppression in more than 90% of patients and showed a good tolerability with a favourable effect on proteinuria, ipophosphoremia, and lipid metabolism.
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Affiliation(s)
- Leonardo Calza
- 1 Department of Medical and Surgical Sciences, Clinics of Infectious Diseases, "Alma Mater Studiorum" University of Bologna, S. Orsola-Malpighi Hospital , Bologna, Italy
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Abstract
PURPOSE OF REVIEW Because of antiretroviral therapy (ART), people are living with HIV infection longer than ever before. As this patient group ages, it is expected that medical comorbidities such as osteoporosis and fragility fractures will increase. The purpose of this review is to address the epidemiology and what is known regarding the pathogenesis of bone loss in people living with HIV infection with a focus on recently published literature. RECENT FINDINGS HIV-infected individuals are at increased risk for low bone mineral density and bone fractures. The cause of bone loss in HIV is multifactorial including traditional risk factors some of which disproportionately affect HIV-infected individuals and alterations in bone metabolism due to ART, HIV viral proteins and chronic inflammation. Lifestyle modification, changing ART, calcium and vitamin D supplementation and pharmacologic treatment for osteoporosis may all be employed to abrogate bone loss in this patient group. SUMMARY Clinicians should be aware of the contributors to bone loss in people living with HIV in order to recognize high-risk individuals and to take appropriate steps to address modifiable risk factors to prevent future fracture.
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Affiliation(s)
- Corrilynn O Hileman
- Metrohealth Medical Center, Cleveland, Ohio, USA
- Case Western Reserve School of Medicine, Cleveland, Ohio, USA
| | | | - Grace A McComsey
- Case Western Reserve School of Medicine, Cleveland, Ohio, USA
- University Hospitals Case Medical Center, Cleveland, Ohio, USA
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Greater change in bone turnover markers for efavirenz/emtricitabine/tenofovir disoproxil fumarate versus dolutegravir + abacavir/lamivudine in antiretroviral therapy-naive adults over 144 weeks. AIDS 2015; 29:2459-64. [PMID: 26355674 PMCID: PMC4645955 DOI: 10.1097/qad.0000000000000863] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Antiretroviral therapy initiation has been linked to bone mineral density and bone biomarker changes. We assessed long-term bone turnover biomarker effects over 144 weeks in patients initiating dolutegravir (DTG) + abacavir/lamivudine (ABC/3TC) versus efavirenz/emtricitabine/tenofovir disoproxil fumarate (EFV/FTC/TDF). METHODS Patients randomized in SINGLE received DTG (50 mg once daily) + ABC/3TC or fixed-dose combination EFV/FTC/TDF. We evaluated vitamin D serum levels and bone turnover markers (BTMs), including type 1 collagen cross-linked C-telopeptide (CTx), osteocalcin, bone-specific alkaline phosphatase (BSAP), and procollagen type 1 N-terminal propeptide (P1NP), at baseline and weeks 48, 96, and 144. RESULTS Among the 833 enrolled patients (68% white, 85% men), baseline median age was 35 years (range 18-85), median CD4 was 338 cells/μl, and median BMI was 24 kg/m. Fifty-three percent of patients smoked, and 6% reported baseline vitamin D use, with no meaningful differences between groups. Relative to baseline, CTx, osteocalcin, BSAP, and P1NP increased; vitamin D decreased in both groups at weeks 48, 96, and 144. Changes from baseline typically peaked at weeks 48 or 96 and for the four analytes, excluding vitamin D, with the EFV/FTC/TDF group having significantly greater changes from baseline at all time points. CONCLUSION DTG + ABC/3TC in antiretroviral therapy-naive patients resulted in significantly lower increases in BTMs (CTx, osteocalcin, BSAP, P1NP) compared with EFV/FTC/TDF over 144 weeks. The observed changes are consistent with results from other smaller, randomized trials. These differences in BTMs likely correlate with changes in bone mineral density over time.
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Capetti A, Cossu MV, Rizzardini G. Darunavir/cobicistat for the treatment of HIV-1: a new era for compact drugs with high genetic barrier to resistance. Expert Opin Pharmacother 2015; 16:2689-702. [PMID: 26612518 DOI: 10.1517/14656566.2015.1109632] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Cobicistat-boosted darunavir is a boosted protease inhibitor in a fixed-dose combination to be approved for the treatment of human immunodeficiency virus type1 infection. It contains darunavir, a well-known protease inhibitor with a good efficacy and safety profile, and the new pharmacokinetic enhancer cobicistat. The convenience of this combination in a single pill makes this compound easier to take, thus improving adherence. AREAS COVERED PubMed and www.clinicaltrials.gov were searched with the term "darunavir/cobicistat" for all clinical trials conducted up to date, as well as for those ongoing and to be opened in the near future as well as for pharmacology data. A review of abstracts from major infectious diseases (particularly those dedicated to human immunodeficiency disease) and pharmacology conferences from 2010 to 2015 was also conducted. EXPERT OPINION improving adherence, particularly by minimizing pill burden with convenient formulations (i.e., fixed-dose combination), is one of the major objectives of modern antiretroviral treatment of patients with human immunodeficiency virus disease. Cobicistat is an alternative agent to ritonavir for boosting plasma drug levels for several antiretrovirals. Darunavir co-administered with low-dose ritonavir, in combination with other antiretrovirals, is recommended in several guidelines for treatment of patients with human immunodeficiency disease. Darunavir/cobicistat fixed-dose combination allows for a once-daily treatment regimen with a reduced pill burden. This new co formulation makes this compound easier to take, thus improving adherence.
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Affiliation(s)
- Amedeo Capetti
- a 1st Division of Infectious Diseases, Department of Infectious Diseases , Luigi Sacco University Hospital , GB Grassi 74, Milan 20157 , Italy
| | - Maria Vittoria Cossu
- a 1st Division of Infectious Diseases, Department of Infectious Diseases , Luigi Sacco University Hospital , GB Grassi 74, Milan 20157 , Italy
| | - Giuliano Rizzardini
- a 1st Division of Infectious Diseases, Department of Infectious Diseases , Luigi Sacco University Hospital , GB Grassi 74, Milan 20157 , Italy.,b School of Clinical Medicine, Faculty of Health Science , University of the Witwaterstrand , Johannesburg , South Africa
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NtRTI sparing in patients at risk of bone disease. Lancet HIV 2015; 2:e452-3. [PMID: 26520920 DOI: 10.1016/s2352-3018(15)00187-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 09/07/2015] [Indexed: 11/20/2022]
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Bone mineral density and inflammatory and bone biomarkers after darunavir-ritonavir combined with either raltegravir or tenofovir-emtricitabine in antiretroviral-naive adults with HIV-1: a substudy of the NEAT001/ANRS143 randomised trial. Lancet HIV 2015; 2:e464-73. [PMID: 26520926 DOI: 10.1016/s2352-3018(15)00181-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 08/25/2015] [Accepted: 08/25/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Osteopenia, osteoporosis, and low bone mineral density are frequent in patients with HIV. We assessed the 96 week loss of bone mineral density associated with a nucleoside or nucleotide reverse transcriptase inhibitor (NtRTI)-sparing regimen. METHODS Antiretroviral-naive adults with HIV were enrolled in 78 clinical sites in 15 European countries into a randomised (1:1), open-label, non-inferiority trial (NEAT001/ANRS143) assessing the efficacy and safety of darunavir (800 mg once per day) and ritonavir (100 mg once per day) plus either raltegravir (400 mg twice per day; NtRTI-sparing regimen) or tenofovir (245 mg once per day) and emtricitabine (200 mg once per day; standard regimen). For this bone-health substudy, 20 of the original sites in six countries participated, and any patient enrolled at one of these sites who met the following criteria was eligible: plasma viral loads greater than 1000 HIV RNA copies per mL and CD4 cell counts of fewer than 500 cells per μL, except in those with symptomatic HIV infection. Exclusion criteria included treatment for malignant disease, testing positive for hepatitis B virus surface antigen, pregnancy, creatinine clearance less than 60 mL per min, treatment for osteoporosis, systemic steroids, or oestrogen-replacement therapy. The two primary endpoints were the mean percentage changes in lumbar spine and total hip bone mineral density at week 48, assessed by dual energy x-ray absorptiometry (DXA) scans. We did the analysis with an intention-to-treat-exposed approach with antiretroviral modifications ignored. The parent trial is registered with ClinicalTrials.gov, number NCT01066962, and is closed to new participants. FINDINGS Between Aug 2, 2010, and April 18, 2011, we recruited 146 patients to the substudy, 70 assigned to the NtRTI-sparing regimen and 76 to the standard regimen. DXA data were available for 129, 121 and 107 patients at baseline, 48 and 96 weeks respectively. At week 48, the mean percentage loss in bone mineral density in the lumbar spine was greater in the standard group than in the NtRTI-sparing group (mean percentage change -2.49% vs -1.00%, mean percentage difference -1.49, 95% CI -2.94 to -0.04; p=0.046). Total hip bone mineral density loss was similarly greater at week 48 in the standard group than in the NtRTI-sparing group (mean percentage change -3.30% vs -0.73%; mean percentage difference -2.57, 95% CI -3.75 to -1.35; p<0.0001). Seven new fractures occurred during the trial (two in the NtRTI-sparing group and five in the standard group). INTERPRETATION A raltegravir-based regimen was associated with significantly less loss of bone mineral density than a standard regimen containing tenofovir disoproxil fumarate, and might be a treatment option for patients at high risk of osteopenia or osteoporosis who are not suitable for NtRTIs such as abacavir or tenofovir alafenamide. FUNDING The European Union Sixth Framework Programme, Inserm-ANRS, Ministerio de Sanidad y Asuntos Sociales de España, Gilead Sciences, Janssen Pharmaceuticals, and Merck Laboratories.
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