Hepatic safety profile of fosamprenavir-containing regimens in HIV-1-infected patients with or without hepatitis B or C coinfection

PURPOSE

This post hoc analysis investigated the hepatic safety profile of fosampre-navir (FPV) in patients monoinfected with HIV or coinfected with HIV and hepatitis B (HbsAg positive) and/or hepatitis C (anti-HCV antibody positive).

METHODS

Data were pooled from 7 prospective, randomized clinical trials of FPV.

RESULTS

Baseline demographics were generally well-matched between the 205 coinfected (72% HCV, 24% HBV, 3% both) and 1,114 monoinfected patients in this analysis. At baseline, most regimens included ritonavir 100 mg (58%) or 200 mg (38%), and 73% of subjects were ART-naïve. Over 48 weeks, the rate of treatment-related serious adverse events was similar between the coinfected (8%; 16/205) and monoinfected (6%; 62/1114) groups, and the rate of treatment-related grade 2-4 adverse events was higher in the coinfected (38%; 77/205) compared with the monoinfected (29%; 320/1114) group. The percentage of patients with grade 3/4 liver enzyme elevations at any time through week 48 was 14% (ALT) and 12% (AST) in the coinfected group and 1% (both ALT and AST) in the monoinfected group. Median AST to platelet ratio index (APRI) scores decreased by 29% in both groups.

CONCLUSION

Liver enzyme elevations in coinfected patients treated with FPV with or without ritonavir appear generally similar to those reported for other second-generation protease inhibitors.

Thymidine-analog and multi-nucleoside resistance mutations are observed in both zidovudine-naive and zidovudine-experienced subjects with viremia after treatment with stavudine-containing regimens

OBJECTIVE

The type and frequency of mutations in the human immunodeficiency virus type 1 (HIV-1) reverse transcriptase coding region observed in virus from antiretroviral therapy (ART)-experienced, zidovudine (ZDV)-naive subjects receiving stavudine (d4T)-based therapies were compared with mutations observed in virus from ART-experienced subjects with previous ZDV exposure.

METHODS

Plasma HIV-1 RNA was isolated from 67 ART-experienced subjects. Reverse transcriptase mutations were assessed by sequencing polymerase chain reaction products.

RESULTS

Thirty-four subjects (51%) were ZDV-experienced (Z(exp)) and 33 (49%) were ZDV-naive and d4T-experienced (d(exp)Z(naive)). Human immunodeficiency virus type 1 from 16 of 33 (48%) d(exp)Z(naive) subjects and from 16 of 34 (47%) Z(exp) subjects had thymidine analog mutations (TAMs). Multi-nucleoside resistance (MNR) mutations were observed in virus from 5 of 33 (15%) d(exp)Z(naive) subjects and 3 of 34 (9%) Z(exp) subjects. At least one TAM or MNR mutation was identified in 18 of 33 (55%) of the former and in 19 of 34 (56%) of the latter group.

CONCLUSIONS

These results confirm recent reports that TAMs and MNR mutations can arise in subjects receiving d4T-based therapy who are naive with respect to ZDV.

Viral genetic heterogeneity in HIV-1-infected individuals is associated with increasing use of HAART and higher viremia

OBJECTIVE

To assess the correlation between the outgrowth of mutant viruses (viral genetic heterogeneity), highly active antiretroviral therapy (HAART), and plasma HIV-1 RNA in a population-based observational cohort study.

DESIGN

The study population consisted of 42 HIV-1-infected individuals receiving at least two nucleotide reverse transcriptase (RT) inhibitors and one or more protease inhibitors at study entry. There were no restrictions on antiretroviral therapy after enrollment.

METHODS

Plasma samples were obtained from subjects at baseline, at therapy changes, and at quarterly intervals for quantitation of HIV-1 RNA levels and for sequence determination of the entire protease coding region and the first 235 codons of the reverse transcriptase coding region. Data were analyzed using the generalized estimating equation method for longitudinal data and using linear regression analysis.

RESULTS

With increased time on HAART there were significant increases in the number of total HIV-1 mutations in the regions sequenced (P = 0.010). There were significant correlations between the increases in the plasma HIV-1 RNA levels and the numbers of total mutations and reverse transcriptase mutations (P = 0.007 and 0.021, respectively).

CONCLUSIONS

The number of HIV-1 mutations increased over time. Failure of HAART in this study population was correlated with outgrowth of virus with numerous mutations in the reverse transcriptase and protease coding regions. Phenotypic results correlated with genotypic results, showing decreased susceptibility to antiretrovirals over time in the majority of this population during HAART. Both synonymous and non-synonymous mutations were observed, with a higher incidence of non-synonymous mutations occurring at codons associated with drug resistance.

Deletions in the beta3-beta4 hairpin loop of HIV-1 reverse transcriptase are observed in HIV-1 isolated from subjects during long-term antiretroviral therapy

OBJECTIVES

To examine the effect of in-frame deletions in human immunodeficiency virus type 1 (HIV-1) reverse transcriptase (RT) on plasma viremia and phenotypic resistance to antiretroviral drugs.

STUDY DESIGN/METHODS

Plasma HIV-1 RNA was isolated from 168 antiretroviral therapy-experienced subjects for quantification of plasma viremia, RT sequence analysis, and phenotypic resistance assays.

RESULTS

Four patients were found to harbor HIV-1 strains possessing in-frame, 3-nucleotide deletions at RT codons 67, 69, and 70. In these subjects, phenotypic resistance and high plasma viremia were observed only in a background of multiple resistance mutations. A recombinant virus engineered with an in-frame deletion of RT codon 67 did not have increased resistance to nucleoside reverse transcriptase inhibitors (NRTIs).

CONCLUSIONS

Selection for deletions within the beta3-beta4 hairpin loop of the HIV-1 RT is an uncommon event most likely to occur in subjects with long-term antiretroviral experience. The codon 67 deletion does not appear to cause increased phenotypic resistance or increased viremia in the absence of concomitant RT mutations.

The reverse transcriptase codon 69 insertion is observed in nucleoside reverse transcriptase inhibitor-experienced HIV-1-infected individuals, including those without prior or concurrent zidovudine therapy

OBJECTIVES

This study was undertaken to examine 6-bp insertions following codon 69 in the reverse transcriptase (RT) coding region of human immunodeficiency virus type 1 (HIV-1) mutations in terms of incidence, presence of additional RT mutations, phenotypic drug resistance, HIV-1 RNA levels, and antiretroviral treatment history.

STUDY DESIGN/METHODS

A retrospective study of 121 nucleoside reverse transcriptase inhibitor (NRTI)-experienced subjects infected with HIV-1 was performed. Methods included quantitation of HIV-1 RNA levels, genotypic analyses of the RT and protease coding regions, and determination of phenotypic drug resistance.

RESULTS

A 6-bp insertion following RT codon 69 was observed in viral isolates from 4 subjects. Two subjects had a history of zidovudine (ZDV)-based therapy, and two subjects had a history of stavudine (D4T)-based therapy without prior exposure to ZDV. The T69S mutation and the 6-bp insertion following RT codon 69 were the only RT mutations observed in the 2 subjects with a history of D4T-based therapy.

CONCLUSIONS

Six-basepair insertions occurred in virus from 4 of 121 (3%) NRTI-experienced subjects, including those without prior ZDV treatment, and was observed in the absence of the T215Y mutation. There was no apparent correlation between insertion incidence and HIV-1 viremia.

Nursing implications of immunosuppression in transplantation

The numbers and survival rates of patients undergoing solid organ transplantation have increased over the past decade. The use of immunosuppressive drugs has contributed greatly to the success of transplantation. Drugs such as cyclosporine, steroids, azathioprine, ATG/ALG, OKT3, and new drugs under investigation such as FK506 are being used on a daily basis by nurses who care for organ transplant patients. This article reviews these medications and the implications for nurses administering these drugs.