Lopinavir/r no longer recommended as a first-line regimen: a comparative effectiveness analysis

Treatment outcomes of initial differential antiretroviral regimens among HIV patients in Southwest China: comparison from an observational cohort study

OBJECTIVES

China has continued to expand antiretroviral therapy (ART) services and optimise ART guidelines in an effort to significantly reduce and prevent mortality and transmission rates among HIV patients. However, no study to date has compared treatment outcomes of initial differential antiretroviral regimens among HIV patients in a real-world setting in China. This study aimed to compare the effects of different ART regimens on treatment outcomes among adults.

DESIGN

Observational retrospective cohort study.

SETTING

Data from 2011 to 2013 in Guangxi, China.

PARTICIPANTS

Patients aged ≥18 years (n=25 732) were selected.

RESULTS

A total of 25 732 patients were included in this study. The average mortality and attrition rate were 2.64 and 4.98, respectively, per 100 person-years. Using Cox proportional hazard models, zidovudine-based (AZT-based) regimen versus stavudine-based (D4T-based) regimen had an adjusted HR (AHR) for death of 0.65 (95% CI 0.58 to 0.73); the AHR of tenofovir-based (TDF-based) versus D4T-based regimens was 0.81 (95% CI 0.71 to 0.92), and of lopinavir-ritonavir-based (LPV/r-based) versus D4T-based regimens, 1.19 (95% CI 1.04 to 1.37). AZT-based versus D4T-based regimens had an AHR for dropout of 0.89 (95% CI 0.81 to 0.97); this ratio for TDF-based versus D4T-based regimens was 0.88 (95% CI 0.80 to 0.98), and for LPV/r-based versus D4T-based regimens, 1.42 (95% CI 1.27 to 1.58). AZT-based and TDF-based regimens had a lower risk compared with D4T-based regimens, while LPV/r-based regimens had a higher risk. High gastrointestinal reactions and poor adherence were observed among HIV patients whose initial ART regimen was LPV/r-based.

CONCLUSIONS

Our study found that the treatment outcomes of initial ART regimens that were AZT-based or TDF-based were significantly better than D4T-based or LPV/r-based regimens. This finding could be related to the higher rates of gastrointestinal reactions and poorer adherence associated with the LPV/r-based regimens compared with other initial ART regimens.

[Survival in HIV-1 patients receiving antiretroviral therapy in Morocco]

BACKGROUND

The purpose was to study factors associated with the survival of HIV-1 patients receiving antiretroviral therapy in Morocco.

MATERIAL AND METHOD

This was a retrospective study of a cohort of 182 HIV-1 patients receiving antiretroviral therapy in the department of dermatology venereology at the Military Instruction Hospital Mohamed V in Rabat during the period from 1 January 2006 to 1 January 2017. Death of any cause during the study period was considered to be the result of HIV infection. The log-rank test was used to compare the survival curves based on determinants. The Cox regression model analyzed the determinants of survival since induction of antiretroviral therapy.

RESULTS

The median follow-up time was 4.7 years (IQR: 1.97-8.18). The mortality rate was 75 deaths per 1000 person-years. Advanced clinical stage CDC C (RR: 2.72; CI 95%: 1.33-5.56) and treatment with indinavir (RR: 1.41; CI 95%: 0.77-2.59) were significantly associated with death.

CONCLUSION

Initiation of antiretroviral therapy in the early stage of the disease and use of less toxic molecules are recommended to reduce mortality.

Lopinavir/Ritonavir Treatment Induces Oxidative Stress and Caspaseindependent Apoptosis in Human Glioblastoma U-87 MG Cell Line

Background:

Lopinavir and Ritonavir (LPV/r) treatment is widely used to prevent HIV mother-to-child transmission. Nevertheless, studies related to the impact of these compounds on patients, in particular in the foetus and newborns, are strictly required due to the controversial findings reported in the literature concerning possible neurologic side effects following the administration of these drugs.

Objectives:

In our study, we evaluated the impact of LPV/r treatment on the human glioblastoma U- 87 MG cell line.

Methods:

In order to evaluate the influence of Lopinavir and Ritonavir in terms of oxidative stress (ROS production), mitochondrial morphology and apoptotic cell death, the latter either in the presence or in the absence of caspase-3 and -9 inhibitors, we treated U-87 MG with increasing doses (0.1-1-10-25-50 µM) of Lopinavir and Ritonavir for 24h, either in single formulation or in combination. ROS production was measured by flow cytometry using H2DCFDA dye, mitochondrial morphology was evaluated using MitoRed dye and apoptotic cell death was monitored by flow cytometry using Annexin V-FITC and Propidium Iodide.

Results:

We observed that co-treatment with Lopinavir and Ritonavir (25 and 50 µM) promoted a significant increase in ROS production, caused mitochondrial network damage and induced apoptosis in a caspase-independent manner.

Conclusion:

Based on our findings, concordant with others reported in the literature, we hypothesize that LPV/r treatment could not be entirely free from side effects, being aware of the need of validation in in vivo models, necessary to confirm our results.

Prediction of area under the concentration-time curve for lopinavir from peak or trough lopinavir concentrations in patients receiving lopinavir-ritonavir therapy

PURPOSE

A "single time point" strategy for predicting the area under the concentration-time curve (AUC) for lopinavir in patients receiving ritonavir-boosted lopinavir therapy was investigated.

METHODS

Linear regression equations describing the relationships of lopinavir peak and trough concentrations to lopinavir AUC values were established using pharmacokinetic data from published studies of patients or healthy subjects receiving lopinavir and ritonavir at standard dosages. The resulting "trough-AUC model" and "peak-AUC model" were used to predict lopinavir AUC values in the evaluated study populations (total n = 479); those values were then compared with reported AUC values.

RESULTS

Lopinavir peak or trough concentrations were strongly correlated with lopinavir AUC values (r = 0.9947 and r = 0.9541, respectively). For about 94% of calculations using the peak-AUC model and 87% of calculations using the trough-AUC model, differences between predicted and observed AUC values were in the range of 0.76-1.5 fold; the associated r values were 0.9514 (p < 0.001) and 0.9345 (p < 0.001), respectively. The mean absolute predictive error was less than 6% with the use of either the peak-AUC model or the trough-AUC model, with corresponding values for root-mean-square error of 17.6% and 23.5%, respectively.

CONCLUSION

Equations incorporating lopinavir peak and trough concentrations were found to satisfactorily predict lopinavir AUC values in data sets describing patients receiving lopinavir with ritonavir boosting. Variability in predictions was higher with use of the trough-AUC model.

[Choice of initial regimen for antiretroviral-naïve HIV patients: Analysis of motivation]

OBJECTIVE

Several therapeutic combination antiretroviral therapy regimen are available for initial treatment in naïve HIV infected patients. The choice of a particular regimen remains often subjective. The aim of this study was to determine factors associated with the choice of molecules in initial ARV prescriptions.

METHODS

From 01/01 to 30/10/2014, every initial cART prescription was analyzed regarding patients and physicians characteristics. Then, prescriptions were evaluated by an independent committee of ART prescribers.

RESULTS

One hundred and thirty two consecutive initial prescriptions by 34 physicians of 11 medical centers were included: 71 M, migrants: 57 %, MSM: 21 %, CD4<200/mm³: 26 %, HIV RNA>100 000 cp/mL (33 %). cART regimen were: NRTI/PI (43 %), NRTI/NNRTI (29.5 %), NRTI/integrase inhibitor (23 %). 75 % of initial cART regimen were consistent with expert guidelines recommendations. The choice of initial cART was not influenced by the type of HIV contamination risk group, patient's geographic origin, CD4 levels. In contrast, working or not (P=0.007), pregnancy wish (P=0.07), pregnancy (P=0.001), HIV RNA levels (P=0.02) and HIV primary infection (P=0.049) influenced the initial choice. Neither physician's age, nor physician's experience influenced this choice. The prescription's non accordance to 2013 French guidelines was mainly related to integrase inhibitor utilisation (P= 0.0001).

CONCLUSION

Overall, cART initial choice is mostly consistent with guidelines. Primary HIV infection, procreation features and high viral load are the main factors influencing this choice. New regimen with better tolerability is prescribed even if it is not yet included in the guidelines.

Efficacy and safety of once-daily ritonavir-boosted atazanavir or darunavir in combination with a dual nucleos(t)ide analogue backbone in HIV-1-infected combined ART (cART)-naive patients with severe immunosuppression: a 48 week, non-comparative, randomized, multicentre trial (IMEA 040 DATA trial)

OBJECTIVES

Boosted PIs are commonly prescribed in patients presenting with advanced HIV infection. We assessed the efficacy and tolerability of once-daily ritonavir-boosted atazanavir or darunavir plus two NRTIs in HIV-1-infected ART-naive patients with severe immunosuppression, targeting at least an 85% success rate at week 48.

METHODS

This 48 week, open-label, non-comparative, randomized, multicentre trial included ART-naive patients with CD4 cell counts <200 cells/mm(3), with plasma HIV-1 RNA >1000 copies/mL and without genotypic mutations conferring resistance to the study drugs. Patients were randomized (1:1) to receive once-daily atazanavir/ritonavir (300/100 mg) or darunavir/ritonavir (800/100 mg) plus tenofovir disoproxil fumarate/emtricitabine or abacavir/lamivudine. The primary endpoint was treatment success, defined as plasma HIV-1 RNA ≤50 copies/mL at week 48 and no permanent PI/ritonavir discontinuation. The study was registered with ClinicalTrials.gov (NCT01928407).

RESULTS

One hundred and twenty patients were enrolled: 77% were men, 30% were born in Africa and 39% had AIDS. The median baseline CD4 and plasma HIV-RNA values were 69 cells/mm(3) and 5.4 log10 copies/mL. All but four patients received tenofovir disoproxil fumarate/emtricitabine. The week 48 treatment success rate was 66% (95% CI 54%-78%) with atazanavir/ritonavir and 80% (95% CI 68%-89%) with darunavir/ritonavir. The median CD4 cell count increased similarly in the two groups (Δweek 48 to week 0: +194 cells/mm(3)). Adverse events occurred in 23 and 18 patients, respectively.

CONCLUSIONS

Despite good adherence, neither study regimen reached the predefined objective, suggesting a need for more potent regimens for patients with advanced HIV infection.