Weight changes and adverse pregnancy outcomes with dolutegravir- and tenofovir alafenamide fumarate-containing antiretroviral treatment regimens during pregnancy and postpartum

BACKGROUND

We evaluated associations between antepartum weight change and adverse pregnancy outcomes and between antiretroviral therapy (ART) regimens and week-50 postpartum body mass index in IMPAACT 2010.

METHODS

Women with HIV-1 in 9 countries were randomized 1:1:1 at 14-28 weeks gestational age (GA) to start dolutegravir(DTG)+emtricitabine(FTC)/tenofovir alafenamide fumarate(TAF) versus DTG+FTC/tenofovir disoproxil fumarate(TDF) versus efavirenz (EFV)/FTC/TDF. Insufficient antepartum weight gain was defined using IOM guidelines. Cox-proportional hazards regression models were used to evaluate the association between antepartum weight change and adverse pregnancy outcomes: stillbirth (≥20 weeks GA), preterm delivery (<37 weeks GA), small for gestational age (SGA<10th percentile), and a composite of these endpoints.

RESULTS

643 participants were randomized: 217 in DTG+FTC/TAF, 215 in DTG+FTC/TDF, and 211 in EFV/FTC/TDF arms. Baseline medians were: GA 21.9 weeks, HIV RNA 903 copies/mL, CD4 count 466 cells/uL. Insufficient weight gain was least frequent with DTG+FTC/TAF (15.0%) versus DTG+FTC/TDF (23.6%) and EFV/FTC/TDF (30.4%). Women in the DTG+FTC/TAF arm had the lowest rate of composite adverse pregnancy outcome. Low antepartum weight gain was associated with higher hazard of composite adverse pregnancy outcome (HR 1.44, 95%CI 1.04, 2.00) and SGA (HR 1.48, 95%CI 0.99, 2.22). More women in the DTG+FTC/TAF arm had body mass index ≥25 kg/m2 at 50 weeks postpartum (54.7%) versus the DTG+FTC/TDF (45.2%) and EFV/FTC/TDF (34.2%) arms.

CONCLUSIONS

Antepartum weight gain on DTG regimens was protective against adverse pregnancy outcomes traditionally associated with insufficient weight gain, supportive of guidelines recommending DTG-based ART for women starting ART during pregnancy. Interventions to mitigate postpartum weight gain are needed.

69. Incidence of metabolic complications among treatment-naïve adults living with HIV-1 randomized to B/F/TAF, DTG/ABC/3TC or DTG+F/TAF after 144 Weeks

Background

Metabolic comorbidities including diabetes (DM) and dyslipidemia pose challenges to the long-term care of people with HIV (PWH). Incidence of cardiovascular disease and DM are reported at higher rates in PWH than the general population. Obesity is broadly prevalent in both the general population and PWH, and higher body mass index (BMI) can contribute to metabolic complications. Here we present longer-term follow up on incidence of DM, hypertension (HTN), BMI categorical shifts, and lipid changes over 144 weeks of blinded treatment from two trials of PWH initiating antiretroviral therapy.

Methods

We assessed incidence of metabolic complications in adult PWH in Study 1489: bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) vs dolutegravir/abacavir/ lamivudine (DTG/ABC/3TC) and Study 1490: B/F/TAF vs DTG+F/TAF. Treatment-emergent (TE) metabolic comorbidities were defined by standard MedDRA search lists. CDC-defined BMI categories were compared from baseline (BL) to Week 144. Analyses by sex at birth and race were performed, as well as for lipid changes.

Results

Among 1,274 total participants, median (range) age was 33 years (18-77), 90% men, 33% black. In study 1489, BL prevalence of DM and HTN was 4.5 and 12.1% with TE DM and HTN in B/F/TAF being 0.7% and 10%, and for DTG/ABC/3TC 1.3% and 6.9%, respectively. In study 1490, BL prevalence of DM and HTN was 6.8 and 18.8% with TE DM and HTN in B/F/TAF being 2.1 and 5.8%, and for DTG+F/TAF 2.3 and 6.5%, respectively. BMI shift from Normal to Obese: B/F/TAF 0%, DTG/ABC/3TC 3.2%, p=0.12 (1489) (Table 1); B/F/TAF 2.5%, DTG+F/TAF 2.9% p=1.00 (1490) (Table 2). Subgroup analyses by gender/race showed similar findings for TE DM, HTN, and BMI changes. Median changes from BL fasted lipids were small (Table 1).

Table 1§. Studies 1489 and 1490: Metabolic Outcomes from Baseline to Week 144

Table 2±. Shift Table of BMI Category at Week 144 by Baseline BMI Category – Overall

Conclusion

Through over 144 weeks of follow up, PWH randomized to initiate B/F/TAF, DTG/ABC/3TC or DTG+F/TAF had low rates of incident DM or HTN-related AEs, with no statistically significant differences by treatment group. BMI changes/categorical shifts from BL did not significantly differ by regimen, and no clinically significant change or difference by regimen in lipids were observed. While data are limited by three years of follow up, they are strengthened by randomized study design of three widely used initial ART regimens.

Disclosures

Eric Daar, MD, Bristol-Myers Squibb (Consultant)Gilead Sciences Inc. (Consultant, Scientific Research Study Investigator, Advisor or Review Panel member, Research Grant or Support)Janssen (Consultant, Advisor or Review Panel member, Research Grant or Support)Merck (Consultant, Advisor or Review Panel member, Research Grant or Support)Teva (Consultant, Advisor or Review Panel member)ViiV Healthcare (Consultant, Advisor or Review Panel member, Research Grant or Support) Chloe Orkin, MD, Gilead Sciences Inc. (Grant/Research Support, Scientific Research Study Investigator, Other Financial or Material Support)Janssen (Research Grant or Support, Other Financial or Material Support)Merck (Research Grant or Support, Other Financial or Material Support)ViiV Healthcare (Research Grant or Support, Other Financial or Material Support) Paul Sax, MD, Gilead Sciences (Consultant, Grant/Research Support)Janssen (Consultant)Merck (Consultant, Research Grant or Support)ViiV (Consultant, Research Grant or Support) Jeffrey L. Stephens, MD, Gilead Sciences Inc. (Scientific Research Study Investigator, Research Grant or Support) Ellen Koenig, MD, Gilead Sciences Inc. (Scientific Research Study Investigator) Amanda Clarke, MD, Gilead Sciences Inc. (Consultant, Scientific Research Study Investigator, Other Financial or Material Support, Conference attendance sponsorship)ViiV Healthcare (Consultant, Other Financial or Material Support, Conference travel sponsorship) Axel Baumgarten, MD, AbbVie (Advisor or Review Panel member, Speaker’s Bureau)Bristol-Myers Squibb (Advisor or Review Panel member, Speaker's Bureau)Gilead Sciences Inc. (Scientific Research Study Investigator, Advisor or Review Panel member, Speaker's Bureau)Janssen (Speaker’s Bureau)Merck (Advisor or Review Panel member) Cynthia Brinson, MD, Abbvie (Scientific Research Study Investigator)BI (Scientific Research Study Investigator)Gilead Sciences Inc. (Scientific Research Study Investigator, Advisor or Review Panel member, Speaker's Bureau, Personal fees)GSK (Scientific Research Study Investigator)Novo Nordisk (Scientific Research Study Investigator)ViiV Healthcare (Scientific Research Study Investigator, Advisor or Review Panel member, Speaker's Bureau) Moti Ramgopal, MD FIDSA, Abbvie (Scientific Research Study Investigator, Speaker's Bureau)Gilead (Consultant, Scientific Research Study Investigator, Speaker's Bureau)Janssen (Consultant, Scientific Research Study Investigator, Research Grant or Support, Speaker's Bureau)Merck (Consultant, Scientific Research Study Investigator)ViiV (Consultant, Scientific Research Study Investigator, Speaker's Bureau) Hailin Huang, PhD, Gilead Sciences Inc. (Employee, Shareholder) Terry Farrow, MD, Gilead Sciences Inc. (Employee, Shareholder) Jared Baeten, MD, PHD, Gilead Sciences Inc. (Employee, Shareholder) Jason Hindman, PharmD, Gilead Sciences Inc. (Employee, Shareholder) Hal Martin, MD, MPH, Gilead Sciences Inc. (Employee, Shareholder) Kimberly Workowski, MD, Nothing to disclose

38. Remdesivir Treatment in Patients Hospitalized with COVID-19: A Comparative Analysis of In-Hospital All-Cause Mortality

Background

Remdesivir (RDV) reduced time to recovery and mortality in some subgroups of hospitalized patients in the NIAID ACTT-1 RCT compared to placebo. Comparative effectiveness data in clinical practice are limited.

Methods

Using the Premier Healthcare Database, we compared survival for adult non-mechanically ventilated hospitalized COVID-19 patients between Aug-Nov 2020 and treated with RDV within 2 days of hospitalization vs. those who did not receive RDV. Preferential within-hospital propensity score matching with replacement was used. Patients were matched on baseline O2 and 2-month admission period and were excluded if discharged within 3 days of RDV initiation (to exclude anticipated discharges/transfers within 72 hrs consistent with ACTT-1 study). Time to 14- and 28-day mortality was examined separately for patients on high-flow/non-invasive ventilation (NIV), low-flow, and no supplemental O2 using Cox Proportional Hazards models.

Results

RDV patients (n=27,559) were matched to unique non-RDV patients (n=15,617) (Fig 1). The two groups were balanced; median age 66 yrs and 73% white (RDV); 68 yrs and 74% white (non-RDV), and 55% male. At baseline, 21% required high-flow O2, 50% low-flow O2, and 29% no O2, overall.

Mortality in RDV patients was 9.6% and 13.8% on days 14 and 28, respectively. For non-RDV patients, mortality was 14.0% and 17.3% on days 14 and 28, respectively. Kaplan-Meier curves for time to mortality are shown in Fig 2. After adjusting for baseline and clinical covariates, RDV patients on no O2 and low-flow O2 had a significantly lower risk of death within 14 days (no O2, HR: 0.69, 95% CI: 0.57—0.83; low-flow, HR: 0.67, 95% CI: 0.59—0.77) and 28 days (no O2, HR: 0.80, 95% CI: 0.68—0.94; low-flow, HR: 0.76, 95% CI: 0.68—0.86). Additionally, RDV patients on high-flow O2/NIV had a significantly lower risk of death within 14 days (HR: 0.81, 95% CI: 0.70—0.93); but not at 28 days (Fig 3).

Fig 1. Study Population

Conclusion

In this large study of patients in clinical care hospitalized with COVID-19, we observed a significant reduction of mortality in RDV vs. non-RDV treated patients in those on no O2 or low-flow O2. Mortality reduction was also seen in patients on high-flow O2 at day 14, but not day 28. These data support the use of RDV early in the course of COVID-19 in hospitalized patients.

Disclosures

Essy Mozaffari, PharmD, MPH, MBA, Gilead Sciences (Employee, Shareholder) Aastha Chandak, PhD, Gilead Sciences (Other Financial or Material Support, Employee of Certara (contracted by Gilead to conduct this study)) Zhiji Zhang, MS, Gilead Sciences (Other Financial or Material Support, Employee of Certara (contracted by Gilead to conduct this study)) Shuting Liang, MPH, Gilead Sciences (Employee) Mark Thrun, MD, Gilead Sciences (Employee, Shareholder) Robert L. Gottlieb, MD, Eli Lilly (Scientific Research Study Investigator, Advisor or Review Panel member)Gilead Sciences (Scientific Research Study Investigator, Advisor or Review Panel member, Other Financial or Material Support, Gift in kind to Baylor Scott and White Research Institute for NCT03383419)GSK (Advisor or Review Panel member)Johnson and Johnson (Scientific Research Study Investigator)Kinevant (Scientific Research Study Investigator)Roche/Genentech (Scientific Research Study Investigator) Daniel R. Kuritzkes, MD, Abpro (Consultant)Atea (Consultant, Scientific Research Study Investigator)Decoy (Consultant)Gilead Sciences (Consultant, Grant/Research Support)GSK (Consultant)Janssen (Consultant)Merck (Consultant, Grant/Research Support)Novartis (Scientific Research Study Investigator)Rigel (Consultant)ViiV (Consultant, Grant/Research Support) Paul Sax, MD, Gilead Sciences (Consultant, Grant/Research Support)Janssen (Consultant)Merck (Consultant, Research Grant or Support)ViiV (Consultant, Research Grant or Support) David Wohl, MD, Gilead Sciences (Consultant, Grant/Research Support, Advisor or Review Panel member)Janssen (Consultant, Advisor or Review Panel member)Merck (Consultant, Grant/Research Support, Advisor or Review Panel member)ViiV (Consultant, Grant/Research Support, Advisor or Review Panel member) Roman Casciano, M.Eng, Gilead Sciences (Other Financial or Material Support, Employee of Certara (contracted by Gilead to conduct this study)) Paul Hodgkins, PhD, MSc, Gilead Sciences (Employee, Shareholder) Richard Haubrich, MD, Gilead Sciences (Employee, Shareholder)

Once-daily Doravirine for Initial Treatment of Adults Living With Human Immunodeficiency Virus-1: An Integrated Safety Analysis

BACKGROUND

A prespecified integrated safety analysis was conducted for 3 doravirine (DOR) double-blind trials (Phase IIb: P007 [NCT01632345]; Phase III: DRIVE-FORWARD [NCT02275780] and DRIVE-AHEAD [NCT02403674]).

METHODS

DOR (100 mg) arms from these trials were compared with darunavir plus ritonavir (DRV+r) in DRIVE-FORWARD and efavirenz (EFV) in P007 and DRIVE-AHEAD. Background therapies were emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) in P007; abacavir/lamivudine (ABC/3TC) or FTC/TDF in DRIVE-FORWARD; and 3TC/TDF for DOR and FTC/TDF for EFV in DRIVE-AHEAD. The primary endpoint was the proportion of participants discontinuing due to adverse events (AEs) through Week 48.

RESULTS

Discontinuation rates due to AEs were similar for participants on DOR and DRV+r (2.5% vs 3.1%, respectively) and lower for those on DOR than for those on EFV (2.5% vs 6.6%, respectively). Rates of drug-related AEs for DOR, DRV+r, and EFV were 30.9%, 32.1%, and 61.4%, respectively. In an analysis of DOR versus EFV, the treatment difference for discontinuations due to AEs was -3.4%, favoring DOR (95% confidence interval -6.2 to -0.8; P = .012). Fewer participants experienced neuropsychiatric AEs on DOR than on EFV (25.0% vs 55.9%, respectively), and fewer experienced diarrhea on DOR than on DRV+r (12.4% vs 22.5%, respectively). Changes from baseline in most lipid parameters also favored DOR.

CONCLUSIONS

At Week 48, DOR at 100 mg had a favorable safety profile compared with EFV or DRV+r and a favorable tolerability profile compared with EFV.

CLINICAL TRIALS REGISTRATION

NCT01632345; NCT02275780 and NCT02403674.

LB-7. Weight Change in Suppressed People with HIV (PWH) Switched from Either Tenofovir Disoproxil Fumarate (TDF) or Abacavir (ABC) to Tenofovir Alafenamide (TAF)

Background

Weight gain in PWH occurred in both naïve and switch studies and is linked to use of integrase inhibitors (INSTIs) with varying associations with nucleoside reverse transcriptase inhibitors (NRTIs). One hypothesis is that gain associated with TAF when switching from TDF is a result of cessation of TDF-induced weight suppression.

Methods

The study evaluated weight change in suppressed PWH on INSTI+NRTIs switched from ABC or TDF to TAF. Eligible pts had HIV, were ≥ 18 yrs at index (date of switch), treatment-experienced with known prior regimen, suppressed at index (-12 to +1 mo) and 1 yr, ≥ 6 mo pre-index history, with weight measures at index and 1 yr, no current or pre-index use of protease inhibitor or non-nucleoside reverse transcriptase inhibitor. Univariate comparisons were performed using Χ2 for categorical and t-test for continuous variables; negative binomial model with log link function evaluated risk of gain ≥ 3% of body weight between groups accounting for age, gender, race, body mass index (BMI), CD4. Linear mixed effects model was used to estimate mean weight at index and 1 yr post switch.

Results

Of 970 pts, 828 (85%) switched from TDF to TAF and 142 (15%) from ABC to TAF. Groups were balanced by race, gender, index BMI [Table 1]. Figures 1a-b describe pre- and post-switch INSTI use. At 1 yr, mean unadjusted weight change was 1.4 kg in TDF and 0.2 in ABC group p=0.039. TDF to TAF had higher proportion of PWH with gain ≥ 3% vs ABC to TAF (40% vs 27% p=0.003); differences in gain ≥ 5% and ≥ 10% were not statistically significant (26% vs 22% p=0.323 and 10% vs 6% p=0.220). Pts who gained ≥ 3% were younger, with greater proportion of females, non-obese, with 1 prior regimen, and prior elvitegravir (EVG) use. In adjusted analysis TDF to TAF had higher risk of gain ≥ 3% vs ABC to TAF [Figure 2]. In sensitivity analysis accounting for EVG or dolutegravir (DTG) use, TDF to TAF also had higher risk of ≥ 3% gain vs ABC to TAF: adjusted risk ratio (aRR)= 1.38 [1.01–1.89] and aRR= 1.42 [1.02–1.97].

Table 1. Baseline (index) characteristics.

Conclusion

Switching from TDF to TAF in INSTI-based regimens had a greater risk of weight gain vs ABC to TAF. This difference persisted when accounting for impact of the INSTI agent in the current regimen. These data suggest that differences in weight gain between TAF and TDF are driven by removal of TDF-associated weight suppression.

Disclosures

Paul Sax, MD, Gilead (Consultant, Research Grant or Support)Janssen (Consultant)Merck (Consultant, Research Grant or Support)ViiV Healthcare (Consultant, Research Grant or Support) Keri N. Althoff, PhD, MPH, Gilead (Advisor or Review Panel member) Keri N. Althoff, PhD, MPH, All of Us Study (NIH) (Individual(s) Involved: Self): Consultant; MedIQ (Individual(s) Involved: Self): Consultant; TrioHealth (Individual(s) Involved: Self): Advisor or Review Panel member Todd T. Brown, MD, PhD, Gilead (Consultant)Merck (Consultant)Theratechnologies (Consultant)ViiV Healthcare (Consultant) Janna Radtchenko, MBA, Trio Health (Employee) Helena Diaz Cuervo, PhD, Gilead Sciences (Employee) Steven Santiago, MD, Gilead (Advisor or Review Panel member, Speaker's Bureau)Janssen (Speaker's Bureau) Graeme Moyle, MD, Theratechnologies (Consultant) Karam Mounzer, MD, Epividian (Advisor or Review Panel member)Gilead (Advisor or Review Panel member, Research Grant or Support, Speaker's Bureau)Janssen (Advisor or Review Panel member, Research Grant or Support, Speaker's Bureau)Merck (Advisor or Review Panel member, Research Grant or Support, Speaker's Bureau)ViiV Healthcare (Advisor or Review Panel member, Research Grant or Support, Speaker's Bureau) Richard Elion, MD, Gilead (Advisor or Review Panel member, Research Grant or Support, Speaker's Bureau)Janssen (Speaker's Bureau)Proteus (Research Grant or Support)ViiV Healthcare (Advisor or Review Panel member, Research Grant or Support)

2510. Systematic Literature Review of Multiclass Resistance in Heavily Treatment Experienced Persons with HIV

Background

Methods

Results

Conclusion

Disclosures

2503. Differences Between Experts and Community Clinicians in Selecting HIV Switch Regimens for Patients With Viral Suppression

Background

Patients and clinicians may consider switching suppressive HIV regimens for a variety of reasons, including simplification, improved safety and tolerability, drug interactions, or cost. Because switching treatment is a common clinical dilemma in current HIV care, we developed an online treatment decision support tool to assist providers on selecting a new regimen in a variety of patient scenarios.

Methods

In March 2018, 5 HIV experts provided treatment recommendations for more than 1300 unique HIV switch case scenarios based on a simplified set of variables: CVD, HLA-B*5701, HBV, drug resistance, current ART, and component requiring a switch. We then developed a decision support tool that enabled clinicians to specify a patient scenario using these variables and to select their currently intended approach. The experts’ recommendations for that specific case were then shown, and clinicians were asked if the recommendations changed their planned treatment.

Results

In the 5 months following release of the tool, healthcare providers (HCPs) entered 932 patient case scenarios. A comparison of HCPs treatment plans vs expert selections in select patient case scenarios is shown in Tables 1 and 2. The data demonstrated several key areas of discordance, including the more frequent selection of the following options by HCPs vs. experts across a wide range of case scenarios: (a) Boosted regimens: 18% to 31% vs. 0% to 4% of cases; (b) TDF-containing regimens: 7% to 25% vs. 0% of cases; and (c) PI-based regimens: 9% to 23% vs. 0% to 4% of cases. In a subset of 88 patient case scenarios where HCPs’ intended treatment differed from experts and HCPs also self-identified the impact of the tool, 48% indicated that their treatment plan would change/agreed with experts after using the tool.

Conclusion

This online HIV switch decision support tool shows substantial differences between experts’ and HCPs’ treatment choices for switching therapy in multiple case scenarios. Moreover, consensus expert selections in this online tool resulted in a change to the intended treatment plan for approximately one half of users, suggesting use of the tool can help optimize selection of a new ART regimen for patients switching in the setting of virologic suppression.

Disclosures

All authors: No reported disclosures.

LB1. Doravirine/Lamivudine/Tenofovir DF Continues to Be NonInferior to Efavirenz/Emtricitabine/Tenofovir DF in Treatment-Naïve Adults With HIV-1 Infection: Week 96 Results of the DRIVE-AHEAD Trial

Background

Doravirine (DOR) is a novel non-nucleoside reverse-transcriptase inhibitor (NNRTI). In the phase 3 DRIVE-AHEAD trial in HIV-1-infected treatment-naïve adults, DOR demonstrated noninferior efficacy to efavirenz (EFV) and favorable profiles for neuropsychiatric tolerability and lipids at 48 weeks. We present data through week 96.

Methods

DRIVE- AHEAD (Clinical Trials Registration: NCT02403674) is a phase 3, multicenter, double-blind, noninferiority trial that compared DOR with EFV. Eligible participants were HIV-1-infected treatment-naïve adults with pre-treatment HIV-1 RNA ≥1,000 copies/mL. Participants were randomized (1:1) to a fixed-dose regimen of DOR 100 mg, lamivudine 300 mg and tenofovir disoproxil fumarate 300 mg (DOR/3TC/TDF) QD or EFV 600 mg, emtricitabine 200 mg and TDF 300 mg (EFV/FTC/TDF) QD for up to 96 weeks. Randomization was stratified by screening HIV-1 RNA (≤/>100,000 copies/mL) and hepatitis B/C co-infection (yes/no). The efficacy endpoint of interest at week 96 was HIV-1 RNA <50 copies/mL with predefined noninferiority margin of 10%. Safety endpoints of interest included occurrence of pre-specified neuropsychiatric adverse events and mean change from baseline in fasting lipid levels at week 96.

Results

Of 734 participants randomized, 728 received study drug and were included in analyses (mean age 33 years, 85% male, 48% white, 19% black, 34% Hispanic). At week 96, HIV-1 RNA <50 copies/mL was achieved by 77.5% of DOR/3TC/TDF recipients vs. 73.6% of EFV/FTC/TDF recipients (difference 3.8%, 95%CI [−2.4, 10.0]). No additional phenotypic resistance to DOR was observed between weeks 48 and 96, while two additional participants in the EFV/FTC/TDF group developed resistance to EFV. Dizziness, sleep disorders/disturbances, altered sensorium, and rash were less frequent in DOR/3TC/TDF recipients than in EFV/FTC/TDF recipients. Fasting LDL-C and non-HDL-C increased in the EFV/FTC/TDF group but not in the DOR/3TC/TDF group, while change in total cholesterol/HDL-C ratio was similar.

Conclusion

Week 96 results support non-inferiority of DOR/3TC/TFD to EFV/FTC/TDF established at Week 48 with no additional DOR resistance between week 48 and 96. DOR/3TC/TDF was safe and well-tolerated with fewer neuropsychiatric and rash events and favorable lipid profile compared with EFV/FTC/TDF.

Disclosures

C. Orkin, AbbVie, Abbott, Boehringer Ingelheim, BMS, Gilead, GSK, Janssen, ViiV: Grant Investigator and Research Contractor, Research grant and Research support. K. Squires, Merck & Co., Inc.: Ad Board, Ad Board. Gilead Sciences: Grant, Ad Board. VIIV: Ad Board, Ad Board. Bristol Myers Squibb: Ad Board, Ad Board. Janssen: Ad Board, Ad Board. J. M. Molina, Gilead: Scientific Advisor, Consulting fee. Merck: Scientific Advisor, Consulting fee. ViiV: Scientific Advisor, Consulting fee. Teva: Scientific Advisor, Consulting fee. P. Sax, Gilead: Consultant and Grant Investigator, Consulting fee, Grant recipient and Research grant. ViiV Healthcare: Consultant and Grant Investigator, Consulting fee, Grant recipient and Research grant. Merck: Consultant and Grant Investigator, Consulting fee, Grant recipient and Research grant. Janssen: Consultant, Consulting fee. BMS: Grant Investigator, Grant recipient and Research grant. W. Wong, Merck & Co., Inc.: Research Contractor, Research grant. G. Lin, Merck Sharp & Dohme, a subsidiary of Merck & Co., Inc.: Employee and Shareholder, May hold stock/stock options in the company and Salary. S. Kumar, Merck & Co., Inc.: Employee and Shareholder, Salary. G. Hanna, Merck & Co., Inc.: Employee and Shareholder, Salary. C. Hwang, Merck & Co., Inc.: Employee and Shareholder, Salary. E. Martin, Merck & Co., Inc.: Employee and Shareholder, Salary. H. Teppler, Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA: Employee, May hold stock/stock options in the company and Salary.

543. An Integrated Safety Analysis Comparing Once-Daily Doravirine (DOR) to Darunavir+Ritonavir (DRV+r) and Efavirenz (EFV) in HIV-1-Infected, Antiretroviral Therapy (ART)-Naïve Adults

Background

DOR is a novel NNRTI that has shown noninferior efficacy to DRV+r- and EFV-based regimens in phase 3 trials (DRIVE-FORWARD [NCT02275780] and DRIVE-AHEAD [NCT02403674]). A prespecified integrated analysis of those trials plus a completed phase 2 trial (P007; NCT01632345) was performed to evaluate the overall safety and tolerability of DOR.

Methods

In this integrated analysis, DOR (100 mg QD) arms from P007, DRIVE-FORWARD, and DRIVE-AHEAD were compared with DRV+r in DRIVE-FORWARD and EFV in P007 and DRIVE-AHEAD for treatment of HIV-1 in ART-naïve adults. The NRTI background included FTC/TDF in P007, ABC/3TC or FTC/TDF in DRIVE-FORWARD, and 3TC/TDF for DOR and FTC/TDF for EFV in DRIVE-AHEAD. The primary safety endpoint was the proportion of participants discontinuing due to adverse events (AEs) through Week 48.

Results

A total of 1,710 treated participants were included in the analysis (table). Similar proportions of DOR− and DRV+r-treated participants, and fewer of those treated with DOR than with EFV discontinued due to AEs (2.5% vs. 3.1%, DOR vs. DRV+r; 2.5% vs. 6.6%, DOR vs. EFV). Drug-related AEs (DRAEs) were similar for DOR (30.9%) and DRV+r (32.1%), and higher for EFV (61.4%). The most common DRAEs (≥10% any group, any grade) were dizziness (4.9%, 1.8%, and 30.7%) diarrhea (4.0%, 12.8%, and 5.7%), and abnormal dreams (3.2%, 0.3%, and 10.6%) for DOR, DRV+r, and EFV, respectively. Higher rates of central nervous system (CNS) AEs were reported for DOR when EFV was the comparator, while similar low rates of CNS AEs were reported for DOR when DRV+r was the comparator. In two prespecified analyses combining the DOR 100-mg arms and EFV arms from P007 and DRIVE-AHEAD, 2.8% vs. 6.1% discontinued due to AEs on the DOR- and EFV-treated arms, respectively, for a treatment difference of −3.4% (95% CI: −6.2, −0.8; P = 0.012); 25.0% vs. 55.9% of participants experienced ≥1 neuropsychiatric AE in DOR and EFV arms, respectively.

Conclusion

At Week 48, DOR was generally safe and well tolerated in ART-naïve adults with HIV-1. Statistically significantly lower proportions of DOR- than EFV-treated participants discontinued due to AEs supported by a lower proportion that discontinued due to DRAEs. Those on DOR had fewer CNS AEs compared with those on EFV, and less diarrhea than those on DRV+r.

Disclosures

M. Thompson, Merck & Co., Inc.: Research funding to AIDS Research Consortium of Atlanta; no funds to me personally, Research funding to AIDS Research Consortium of Atlanta; no funds to me personally. Bristol Myers Squibb: Research funding to AIDS Research Consortium of Atlanta; no funds to me personally, Research funding to AIDS Research Consortium of Atlanta; no funds to me personally. CytoDyn, Inc.: Research funding to AIDS Research Consortium of Atlanta; no funds to me personally, Research funding to AIDS Research Consortium of Atlanta; no funds to me personally. Gilead Sciences, Inc.: Research funding to AIDS Research Consortium of Atlanta; no funds to me personally, Research funding to AIDS Research Consortium of Atlanta; no funds to me personally. GlaxoSmithKline: Research funding to AIDS Research Consortium of Atlanta; no funds to me personally, Research funding to AIDS Research Consortium of Atlanta; no funds to me personally. Roche Laboratories: Research Funding, Research funding to AIDS Research Consortium of Atlanta; no funds to me personally and Research grant. TaiMed, Inc.: Research Funding, Research funding to AIDS Research Consortium of Atlanta; no funds to me personally and Research grant. ViiV Healthcare: Research Funding, Research funding to AIDS Research Consortium of Atlanta; no funds to me personally. C. Orkin, AbbVie, Abbott, Boehringer Ingelheim, BMS, Gilead, GSK, Janssen, ViiV: Ad Board, Grant Investigator and Research Contractor, Research grant and Research support. J. M. Molina, Merck GIlead ViiV Janssen Teva: Ad Board and Speaker’s Bureau, Consulting fee. Gilead Sciences: Grant Investigator, Research support. J. Gatell, Gilead Sciences: Grant and Independent Contractor, Consulting fee and Educational grant. Janssen: Grant and Independent Contractor, Consulting fee. ViiV Healthcare: Grant and Independent Contractor, Consulting fee. MSD: Grant and Independent Contractor, Consulting fee. P. Sax, Gilead: Consultant and Grant Investigator, Consulting fee, Grant recipient and Research grant. ViiV Healthcare: Consultant and Grant Investigator, Consulting fee, Grant recipient and Research grant. Merck: Consultant and Grant Investigator, Consulting fee, Grant recipient and Research grant. Janssen: Consultant, Consulting fee. BMS, Gilead, Merck, GSK/ViiV: Grant Investigator, Grant recipient and Research grant. P. Cahn, Abbvie: Grant, Research grant. Merck: Grant, Advisory Board. ViiV Healthcare: Grant, Advisory Board. K. Squires, Merck & Co., Inc.: Ad Board, Ad Board. Gilead Sciences: Grant, Ad Board. VIIV: Ad Board, Ad Board. Bristol Myers Squibb: Ad Board, Ad Board. Janssen: Ad Board, Ad Board. Y. Zhou, Merck & Co., Inc.: Employee, Salary. X. Xu, Merck & Co., Inc.: Employee, Salary. A. Rodgers, Merck & Co., Inc.: Employee and Shareholder, Salary. S. Kumar, Merck & Co., Inc.: Employee and Shareholder, Salary. H. Teppler, Merck & Co., Inc.: Employee and Shareholder, Salary. E. Martin, Merck & Co., Inc.: Employee and Shareholder, Salary. G. Hanna, Merck & Co., Inc.: Employee and Shareholder, Salary. C. Hwang, Merck & Co., Inc.: Employee and Shareholder, Salary.

550. Adherence and Persistency With Modern Single vs. Multi-Tablet Antiretroviral (ARV) Regimens in First Treatment of HIV in Clinical Practice

Background

Prior studies have reported improved adherence, persistency, virologic outcomes and lower risk of hospitalizations with single tablet (STR) vs. multi-tablet regimens (MTR) in HIV treatment. However, most studies were conducted using prescription and medical claims data limited to EFV-based therapies. In this study, we utilized EMR, prescription, and pharmacy dispensing data to assess STR and MTR adherence and persistency as observed in a network of clinical practices.

Methods

Data were collected for HIV-infected patients in care at six US-based HIV treatment centers. Patients eligible for the study initiated their first ARV between January 2015 and December 2016. First ARV regimen was assigned based on absence of prior ARV prescriptions and a 30-day pre-treatment period with no ARV dispensed or for rapid starts, a high baseline viral load (≥10,000 copies/mL). Adherence was assessed using proportion of days covered (PDC). Follow-up was ≥365 days with duration capped at 365 days for persistency comparisons.

Results

A total of 1,499 patients met the criteria for the study; 66% (982/1,499) received STR and 34% (517/1,499) MTR. Top STRs were EVG/c/TDF/FTC (265/982, 27%), EVG/c/TAF/FTC (250/982, 26%), and DTG/ABC/3TC (171/982, 17%). Top MTRs were DTG + TDF/FTC (69/517, 13%), DRV + RTV + TDF/FTC (60/517, 12%), and DRV/c + TDF/FTC (40/517, 8%). Average persistency for STRs was significantly longer at 252 days vs. 233 days for MTRs (P = 0.002). Average PDC adherence rates were significantly higher for STRs at 91% vs. 83% for MTRs (P < 0.001). Within the STR group, older age was significantly associated with greater adherence (average age: 45 in 80%+ adherent group vs. 42 in <80% adherent group, P = 0.012). In both the STR and MTR groups, the percentage of black patients was significantly higher in the non-adherent group (45% in STR, 42% in MTR) compared with the adherent group (24% in STR, 32% in MTR) (P < 0.001 in STR, P = 0.027 in MTR).

Conclusion

This study of adherence with STR vs. MTR HIV therapy is novel, as it uses more currently relevant HIV regimens and was conducted utilizing EMR, prescription, and dispensing data. The results of better adherence and persistency with STR ART underscore the ongoing importance of simpler treatment for HIV care.

Disclosures

A. Mills, ViiV: Investigator and Scientific Advisor, Consulting fee and Research support. Gilead: Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research support and Speaker honorarium. Merck: Investigator and Scientific Advisor, Consulting fee and Research support. J. Priest, ViiV Healthcare: Employee, Salary. A. Musallam, Trio Health: Employee, Salary. K. Althoff, Gilead: Scientific Advisor, Consulting fee. J. Eron, ViiV Healthcare: Consultant and Investigator, Consulting fee and Research support. Gilead: Consultant and Investigator, Consulting fee and Research support. Janssen: Consultant and Investigator, Consulting fee and Research support. G. Huhn, Gilead: Grant Investigator and Scientific Advisor, Consulting fee and Grant recipient. ViiV Healthcare: Grant Investigator and Scientific Advisor, Consulting fee and Grant recipient. Janssen: Grant Investigator and Scientific Advisor, Consulting fee and Grant recipient. Theratechnologies: Scientific Advisor, Consulting fee. Proteus: Grant Investigator, Grant recipient. D. Jayaweera, Gilead: Grant Investigator, Research grant. ViiV Healthcare: Grant Investigator, Research grant. Janssen: Grant Investigator, Research grant. K. Mounzer, Gilead: Grant Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. ViiV Healthcare: Grant Investigator and Scientific Advisor, Consulting fee and Research grant. Janssen: Grant Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. Merck: Grant Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. G. Moyle, Merck: Scientific Advisor and Speaker’s Bureau, Consulting fee and Speaker honorarium. Gilead: Scientific Advisor and Speaker’s Bureau, Consulting fee and Speaker honorarium. Janssen: Scientific Advisor and Speaker’s Bureau, Consulting fee and Speaker honorarium. TheraTechnologies: Scientific Advisor and Speaker’s Bureau, Consulting fee and Speaker honorarium. J. Mrus, ViiV Healthcare: Employee, Salary. M. Rampogal, Gilead: Consultant, Grant Investigator and Speaker’s Bureau, Consulting fee, Research grant and Speaker honorarium. Janssen: Speaker’s Bureau, Speaker honorarium. Allergen: Speaker’s Bureau, Speaker honorarium. ViiV Healthcare: Consultant and Grant Investigator, Consulting fee and Grant recipient. Merck: Consultant, Consulting fee. S. Santiago, Gilead: Scientific Advisor and Speaker’s Bureau, Consulting fee and Speaker honorarium. Janssen: Speaker’s Bureau, Speaker honorarium. P. Sax, Gilead: Consultant and Grant Investigator, Consulting fee, Grant recipient and Research grant. ViiV Healthcare: Consultant and Grant Investigator, Consulting fee, Grant recipient and Research grant. Merck: Consultant and Grant Investigator, Consulting fee, Grant recipient and Research grant. Janssen: Consultant, Consulting fee. BMS: Grant Investigator, Grant recipient and Research grant. G. Voskuhl, Gilead: Grant Investigator and Scientific Advisor, Consulting fee, Grant recipient and Research grant. ViiV Healthcare: Grant Investigator, Grant recipient and Research grant. Merck: Grant Investigator, Grant recipient and Research grant. Janssen: Grant Investigator, Grant recipient and Research grant. A. Oglesby, ViiV Healthcare: Employee and Shareholder, Salary. R. Elion, Gilead: Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research support and Speaker honorarium. ViiV: Consultant, Consulting fee. Trio Health: Consultant, Consulting fee.

Transcriptional Changes during Naturally Acquired Zika Virus Infection Render Dendritic Cells Highly Conducive to Viral Replication

Although dendritic cells are among the human cell population best equipped for cell-intrinsic antiviral immune defense, they seem highly susceptible to infection with the Zika virus (ZIKV). Using highly purified myeloid dendritic cells isolated from individuals with naturally acquired acute infection, we here show that ZIKV induces profound perturbations of transcriptional signatures relative to healthy donors. Interestingly, we noted a remarkable downregulation of antiviral interferon-stimulated genes and innate immune sensors, suggesting that ZIKV can actively suppress interferon-dependent immune responses. In contrast, several host factors known to support ZIKV infection were strongly upregulated during natural ZIKV infection; these transcripts included AXL, the main entry receptor for ZIKV; SOCS3, a negative regulator of ISG expression; and IDO-1, a recognized inducer of regulatory T cell responses. Thus, during in vivo infection, ZIKV can transform the transcriptome of dendritic cells in favor of the virus to render these cells highly conducive to ZIKV infection.

Efficacy and Safety of Elvitegravir/Cobicistat/Emtricitabine/Tenofovir Disoproxil Fumarate in Asian Subjects with Human Immunodeficiency Virus 1 Infection: A Sub-Analysis of Phase 3 Clinical Trials

The efficacy and safety of a single tablet regimen (STR) of elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate (E/C/F/TDF) were analyzed in Phase 3 clinical trials in antiretroviral therapy (ART)-naïve and ART-experienced Asian subjects infected with human immunodeficiency virus (HIV)-1. Studies GS-US-236-102 and GS-US-236-103 were randomized, double-blind, placebo-controlled, 144-week studies conducted in ART-naïve subjects, comparing E/C/F/TDF versus efavirenz (EFV)/F/TDF or ritonavir-boosted atazanavir (ATV+RTV) plus emtricitabine/tenofovir DF (F/TDF), respectively. Studies GS-US-236-115 and GS-US-236-121 were randomized, open-label, 96-week long conducted in ART-experienced subjects, who switched to E/C/F/TDF from ritonavir-boosted protease inhibitors (PI+RTV)+F/TDF, or non-nucleoside reverse transcriptase inhibitors (NNRTI)+F/TDF regimens. The E/C/F/TDF appeared to have sustained efficacy and safety and was well tolerated in the small number of ART-naïve and ART-experienced Asian subjects.

Outcomes by sex following treatment initiation with atazanavir plus ritonavir or efavirenz with abacavir/lamivudine or tenofovir/emtricitabine

BACKGROUND

We aimed to evaluate treatment responses to atazanavir plus ritonavir (ATV/r) or efavirenz (EFV) in initial antiretroviral regimens among women and men, and determine if treatment outcomes differ by sex.

METHODS

We performed a randomized trial of open-label ATV/r or EFV combined with abacavir/lamivudine (ABC/3TC) or tenofovir/emtricitabine (TDF/FTC) in 1857 human immunodeficiency virus type 1-infected, treatment-naive persons enrolled between September 2005 and November 2007 at 59 sites in the United States and Puerto Rico. Associations of sex with 3 primary study endpoints of time to virologic failure, safety, and tolerability events were analyzed using Cox proportional hazards models. Model-based population pharmacokinetic analysis was performed using nonlinear mixed effects modeling (NONMEM version VII).

RESULTS

Of 1857 participants, 322 were women. Women assigned to ATV/r had a higher risk of virologic failure with either nucleoside reverse transcriptase inhibitor backbone than women assigned to EFV, or men assigned to ATV/r. The effects of ATV/r and EFV upon safety and tolerability risk did not differ significantly by sex. With ABC/3TC, women had a significantly higher (32%) safety risk compared to men; with TDF/FTC, the safety risk was 20% larger for women compared to men, but not statistically significant. Women had slower ATV clearance and higher predose levels of ATV compared to men. Self-reported adherence did not differ significantly by sex.

CONCLUSIONS

This is the first randomized clinical trial to identify a significantly earlier time to virologic failure in women randomized to ATV/r compared to women randomized to EFV. This finding has important clinical implications given that boosted protease inhibitors are often favored over EFV in women of childbearing potential.

CLINICAL TRIALS REGISTRATION

NCT00118898.

Comparison of cardiovascular disease risk markers in HIV-infected patients receiving abacavir and tenofovir: the nucleoside inflammation, coagulation and endothelial function (NICE) study

BACKGROUND

The association between abacavir (ABC) and cardiovascular disease (CVD) risk in HIV-infected individuals is unclear. Putative mechanisms for an effect of ABC on CVD risk including endothelial dysfunction have been proposed; however, a biological mechanism has not been established.

METHODS

This was a cross-sectional study of HIV-infected subjects with HIV RNA levels <400 copies/ml, who were randomly assigned to ABC or tenofovir (TDF) as initial therapy during a prior clinical trial. A small cohort of subjects on zidovudine (AZT; not randomly assigned) were studied to explore long-term exposure to this agent. All underwent brachial artery ultrasound for flow-mediated dilation (FMD), and D-dimer, high-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6) and fasting lipids were measured. Between-arm differences were evaluated by multivariable linear or logistic regression modelling.

RESULTS

There were 148 subjects (46 on ABC, 72 on TDF and 30 on AZT). Demographic characteristics were balanced across the groups except, as expected, AZT-treated participants were older, had higher CD4(+) T-cell counts, and longer antiretroviral therapy duration. After adjusting for age, brachial artery diameter, and treatment duration, FMD was similar in those on ABC (3.9%) and TDF (5.4%; P=0.181). FMD was higher in those on AZT (6.1%; P<0.005). Levels of IL-6, hsCRP and detectable D-dimer were similar between groups.

CONCLUSIONS

Among individuals assigned to ABC or TDF in randomized clinical trials there were no significant differences in FMD or markers of inflammation and coagulation. Whether ABC contributes to risk of CVD remains unclear, but our results suggest that endothelial dysfunction, heightened inflammation, and altered coagulation are unlikely to be mechanisms by which the drug could increase CVD risk above that seen with TDF.

Current management challenges in HIV: tolerability of antiretrovirals and metabolic complications

The use of antiretroviral therapy for HIV infection has led to substantial reductions in morbidity and mortality. Many regimens, such as those combining three or more antiretroviral agents, result in near-complete suppression of HIV replication. Increased attention to short- and long-term toxicities of antiretroviral therapy reflects a number of factors including the indefinite duration of antiretroviral therapy required to preserve clinical benefit, the variety of antiretrovirals available, the use of antiretrovirals in combinations, and the declining incidence of HIV-associated opportunistic disease. Long-term success requires therapy to be individualized, carefully balancing toxicities with efficacy and resistance.

Changes in drug economy in Israel's health maintenance organizations in the wake of the National Health Insurance Law

BACKGROUND

It is not clear to what extent the drug economy in Israel's health maintenance organizations is responsive to major healthcare reforms.

OBJECTIVE

To provide information on how drug expenditures, revenues, net costs and drug utilization have changed in the wake of the 1995 National Health Insurance Law in Israel.

METHODS

This study compares trends in aggregate sick fund expenditures, revenues (patient co-payment) and net costs (expenditures less revenues) in Israel's four health maintenance organizations for the 3 year period 1992-1994 prior to the introduction in 1995 of the NHI Law, with that of the 4 year period 1995-1998 following its introduction. This analysis is similarly carried out for Israel's largest HMO, Clalit Health Services, and for the three smaller HMOs combined.

RESULTS

The pace of growth in the pre-NHI era in drug expenditures and particularly in drug revenues was drastically reduced in the NHI era--whether measured as totals or as per insured person (age-adjusted) or in real terms at constant medicine prices. These trends were mirrored to a large extent in Clalit and in the other HMOs, with some important differences noted between the HMOs. Despite declining growth rates in drug expenditures and net costs, the proportion of these measures of the total HMO economy actually increased in the NHI era, reversing the trend seen in the pre-NHI era.

CONCLUSIONS

The impact of the NHI Law on the HMO drug economy has been substantial. The evidence suggests a decline in both the qualitative (basket of drugs consumed) and quantitative (volume of drugs consumed) elements of growth. These changes in expenditure and revenue trends are discussed in the light of the evolving involvement of the Israel Ministry of Health in drug policy within the framework of the NHI, with emphasis on the basket of drugs reimbursed and co-payments for prescriptions.

Metabolic abnormalities and cardiovascular disease risk factors in adults with human immunodeficiency virus infection and lipodystrophy

We evaluated metabolic and clinical features of 71 HIV-infected patients with lipodystrophy by comparing them with 213 healthy control subjects, matched for age and body mass index, from the Framingham Offspring Study. Thirty HIV-infected patients without fat redistribution were compared separately with 90 matched control subjects from the Framingham Offspring Study. Fasting glucose, insulin, and lipid levels; glucose and insulin response to standard oral glucose challenge; and anthropometric measurements were determined. HIV-infected patients with lipodystrophy demonstrated significantly increased waist-to-hip ratios, fasting insulin levels, and diastolic blood pressure compared with controls. Patients with lipodystrophy were more likely to have impaired glucose tolerance, diabetes, hypertriglyceridemia, and reduced levels of high-density lipoprotein (HDL) cholesterol than were controls. With the exception of HDL cholesterol level, these risk factors for cardiovascular disease (CVD) were markedly attenuated in patients without lipodystrophy and were not significantly different in comparison with controls. These data demonstrate a metabolic syndrome characterized by profound insulin resistance and hyperlipidemia. CVD risk factors are markedly elevated in HIV-infected patients with fat redistribution.

Metformin in the treatment of HIV lipodystrophy syndrome: A randomized controlled trial

CONTEXT

A syndrome of lipodystrophy, characterized by fat redistribution and insulin resistance, has been estimated to affect the majority of human immunodeficiency virus (HIV)-infected individuals who are treated with combination antiretroviral therapy. There are no proven therapies for the metabolic disturbances associated with HIV lipodystrophy syndrome.

OBJECTIVE

To determine the safety and efficacy of metformin therapy in HIV-infected patients with fat redistribution and abnormal glucose homeostasis.

DESIGN AND SETTING

Randomized, double-blind, placebo-controlled pilot study conducted in a university hospital between December 1998 and January 2000.

PATIENTS

Twenty-six HIV-infected, nondiabetic patients with fat redistribution and abnormal oral glucose tolerance test (OGTT) results, hyperinsulinemia, or both.

INTERVENTIONS

Patients were randomly assigned to receive metformin, 500 mg twice daily (n = 14), or identical placebo (n = 12), for 3 months.

MAIN OUTCOME MEASURES

Insulin area under the curve (AUC), calculated 120 minutes following a 75-g OGTT at baseline vs at 3-month follow-up and compared between treatment groups.

RESULTS

Patients treated with metformin demonstrated significant reductions in mean (SEM) insulin AUC 120 minutes after OGTT (-2930 [912] vs -414 [432] microIU/mL [-20349 6334 vs -2875 3000 pmol/L]; P =.01), weight (-1.3 [0.6] vs 1.1 [0.4] kg; P =.005), and diastolic blood pressure (-5 [4] vs 5 [2] mm Hg; P =.009) vs controls, respectively. Metformin therapy was associated with a decrease in visceral abdominal fat (VAT; -1115 [819] vs 1191 [699] mm(2); P =.08) and a proportional reduction in subcutaneous abdominal fat (SAT); the VAT-SAT ratio was unchanged in metformin-treated vs placebo-treated patients. No increase in lactate or liver transaminase levels was observed with metformin treatment. Mild diarrhea was the most common adverse effect of metformin. No patient discontinued therapy because of adverse effects.

CONCLUSIONS

This study suggests that a relatively low dosage of metformin reduces insulin resistance and related cardiovascular risk parameters in HIV-infected patients with lipodystrophy. JAMA. 2000;284:472-477

Improved Survival and Reduced Clinical Progression in HIV-Infected Patients with Advanced Disease Treated with Saquinavir plus Zalcitabine

The objective of this randomized, double-blind, controlled multicentre study was to evaluate the efficacy of saquinavir alone or in combination with zalcitabine compared to zalcitabine monotherapy in reducing progression of human immunodeficiency virus (HIV) disease. Nine hundred and forty HIV-infected patients with more than 16 weeks of prior zidovudine therapy and pre-study entry CD4 cell counts between 50 and 300 cells/mm3 were randomized to saquinavir 600 mg every 8 h, zalcitabine 0.75 mg every 8 h or the combination of both drugs. In an intent-to-treat analysis, the treatment arms were balanced with respect to demographics, baseline HIV RNA (mean 5.0 log10 copies/ml) and CD4 lymphocyte count (mean 170 cells/mm3). More patients in the zalcitabine arm stopped therapy because of toxicity than in the other two arms (25% versus 16%; P=0.005). Peripheral neuropathy was the most common treatment-limiting toxicity. Fifty-one patients in the saquinavir plus zalcitabine group developed an AIDS-defining event or died compared to 84 and 88 in the saquinavir and zalcitabine monotherapy groups respectively. Combination treatment with saquinavir plus zalcitabine reduced the risk of progression to AIDS by 49% (95% confidence interval 0.36 to 0.72, P=0.0001) and reduced death by 68% (95% confidence interval 0.16 to 0.64, P=0.001) compared to zalcitabine monotherapy. The addition of saquinavir to zalcitabine resulted in a significant reduction in progression to AIDS or death compared with zalcitabine alone.

Recent trends in drug utilization in Israel

There has been a considerable increase in the rate of medicine expenditure and consumption in Israel in the latter half of the 1980s in dollar terms compared to the previous decade both in total and per capita expenditure. At constant medicine prices there has been only a slight increase, reaching an average 9.4% annual growth in per capita consumption in the latter half of the 1980s. From the late 1970s to the late 1980s Israel had one of the highest rates of growth in total expenditure and per capita consumption at constant prices compared to OECD countries (Organization for Economic Cooperation and Development). The driving forces behind the real growth in overall expenditure continue to be the introduction of new drugs and changes in drug therapy. However, mainly as a result of substantial quantitative growth in per capita consumption in the private pharmacy sector, there was a greater growth in this sector than in Kupat Holim Klalit (Medical Insurance Scheme of the General Federation of Labor). An attempt to break down the aggregate into private pharmacy and Kupat Holim Klalit, according to expenditure, prices and consumption, indicate that although the latter has a much lower per capita expenditure, the price adjusted per capita consumption is similar in both sectors. Price adjusted per capita consumption is well below that of France and Italy, and close to that of the USA, the UK, West Germany and Switzerland. These findings are briefly discussed in terms of demographic differences.

Cost-effectiveness of misoprostol for prophylaxis against nonsteroidal anti-inflammatory drug-induced gastrointestinal tract bleeding

Patients who take nonsteroidal anti-inflammatory drugs (NSAIDs) are at increased risk of upper gastrointestinal tract bleeding, which may be prevented with prophylactic prescription of misoprostol. Using data from the literature, we estimated rates of gastrointestinal tract bleeding in NSAID users, direct medical costs, years of life lost, and cost-effectiveness of a 1-year course of misoprostol in three clinical populations of NSAID users: all users, users aged 60 years or older, and users with rheumatoid arthritis. The incremental cost-effectiveness ratios for misoprostol as primary prevention were $667,400 per year of life saved for all NSAID users; $186,700 per year of life saved for users aged 60 years or older; and $95,600 per year of life saved for users with rheumatoid arthritis. Misoprostol as secondary prevention for those who continued to take NSAIDs despite having had an episode of gastrointestinal tract bleeding in the previous year was associated with incremental cost-effectiveness ratios less than $40,000 per year of life saved in all patient groups. We conclude that misoprostol is costly as primary prevention for NSAID-induced gastrointestinal tract bleeding in the groups examined but may be cost-effective as secondary prevention in patients with a proved history of gastrointestinal tract bleeding.

Availability and timing of new drugs in Israel: analysis and international comparison

Whereas the latest data suggest that the number of new chemical entities (NCE) launches worldwide may be on the increase, both recent and longer term data show a decline in the rate of NCE introductions into Israel. In terms of percentage availability, only 30% of NCEs available worldwide during 1978-1987 were introduced in Israel during the same period, compared with 42% for the U.S.A. In both countries there has been a decreasing percentage availability since 1983/84. The percentage availability of commercially significant NCEs was greater (47%) compared to all NCEs introduced in Israel. Whereas in the U.S.A. the lower the therapeutic rating the higher the proportion of NCEs, in Israel the B- and C-rated drugs were equally represented. NCEs with an A-rating had a similar share of all NCEs (ca 15%) in both countries. The average time lag for NCEs launched worldwide to reach Israel during 1978-1987 was 4 to 5 years, but in recent years there has been a considerable decline. Commercially significant NCEs introduced in Israel had on average a shorter time lag of 0.5 years than the average for all NCEs introduced. In spite of a preponderance of NCEs first launched in the U.S.A. there was on average a slight relative lag into the U.S.A. compared to Israel. This was probably due to there being a number of NCEs first introduced in Israel with a long delay before they were subsequently approved in the U.S.A.(ABSTRACT TRUNCATED AT 250 WORDS)

Expenditure and consumption of medicines in Israel 1975-85: analysis of trends and elements of growth

Data on the annual expenditure on medicines and medical supplies have been collected and used to provide the expenditure on medicines only, by the main purchasing sectors for each of the fiscal years from 1975/76 to 1984/85 inclusive. During the decade total expenditure at constant prices increased by 145% with an average annual growth of 10.7%; on a per capita basis the growth was 107 and 8.7%, respectively. The average annual growth decreased during the later years. The real average cost of all medicines actually consumed at constant prices was derived from a pharmaceutical audit. The changes in this cost element are an indication of qualitative changes in drug therapy and in the introduction of new drugs. The analysis shows that this structural change is more significant than changes in quantity of drugs consumed per capita and changes derived from the increase in population. Comparing cross-national per capita expenditure in common units of currency, Israel had one of the lowest levels of consumption among the developed countries. Nevertheless, from 1975 to 1982 Israel had one of the highest rates of growth in per capita consumption at constant medicine prices. A discussion of environmental factors leads to the conclusion that the quality of therapeutic advantage gained by a (decreasing) number of innovative products, coupled with an increase in demand from the unprecedented growth in the number of the elderly and chronically ill, has resulted in a significant growth in consumption during the decade.

Thermodynamic parameters of molecular complexes in aqueous solution: enthalpy-entropy compensation in a series of complexes of caffeine with beta- naphthoxyacetic acid and drug-related aromatic compounds

Stability constants and thermodynamic parameters have been evaluated for the complexation reaction in aqueous solution of caffeine with beta-naphthoxy acetic acid. The values were higher than those previously reported for the complexation of other ligands with methyl xanthines. In nearly all aromatic ligands complexing with caffeine and theophylline for which data are available, both entropy and free energy of complexation were linearly related to the enthalpy, giving an isoequilibrium relationship. Salicylamide, sodium benzoate and cis-methyl cinnamate exhibited slight deviations on the delta G-delta H plot; the non-aromatic dehydroacetic acid showed the largest deviation. The isoequilibrium relationship was shown to be valid statistically (349-365 K, caffeine systems; 353-372 K, caffeine and theophylline systems) indicating underlying chemical causation. Thermodynamic equations are presented for analysis of the factor involved, which are attributed to a combination of substrate-ligand interactions and solvent effects. The substrate-ligand overlap area is considered as a common parameter through which the solvent and interaction forces might cooperate to give rise to linearity in the isoequilibrium relationship. The increasingly negative experimental values of the enthalpy and entropy with increase in ligand planar overlap area are discussed in relation to the underlying forces involved in the complexation.