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Mulindwa F, Kamal H, Castelnuovo B, Byonanebye DM, Schwarz JM, Bollinger R, Brusselaers N. Association between integrase strand transfer inhibitor use with insulin resistance and incident diabetes mellitus in persons living with HIV: a systematic review and meta-analysis. BMJ Open Diabetes Res Care 2023; 11:11/1/e003136. [PMID: 36754450 PMCID: PMC9923267 DOI: 10.1136/bmjdrc-2022-003136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 01/17/2023] [Indexed: 02/10/2023] Open
Abstract
Whether integrase strand transfer inhibitors (INSTIs) are associated with a higher risk of incident type 2 diabetes mellitus (DM) than other antiretroviral therapies (ART) needs to be established.MEDLINE, Embase, Web of Science, and ClinicalTrials.gov registries were searched for studies published between 1 January 2000 and 15 June 2022. Eligible studies reported incident DM or mean changes in insulin resistance measured by Homeostatic Model for Insulin Resistance (HOMA-IR) in patients on INSTIs compared with other ARTs. We performed random-effects meta-analyses to obtain pooled relative risks (RRs) with 95% CIs.A total of 16 studies were pooled: 13 studies meta-analyzed for incident diabetes with a patient population of 72 404 and 3 for changes in HOMA-IR. INSTI therapy was associated with a lower risk of incident diabetes in 13 studies (RR 0.80, 95% CI 0.67 to 0.96, I2=29%), of which 8 randomized controlled trials demonstrated a 22% reduced risk (RR 0.88, 95% CI 0.81 to 0.96, I2=0%). INSTIs had a lower risk compared with non-nucleoside reverse transcriptase inhibitors (RR 0.75, 95% CI 0.63 to 0.89, I2=0%) but similar to protease inhibitor-based therapy (RR 0.78, 95% CI 0.61 to 1.01, I2=27%). The risk was lower in studies with longer follow-up (RR 0.70, 95% CI 0.53 to 0.94, I2=24%) and among ART-naïve patients (RR 0.78, 95% CI 0.65 to 0.94, I2=3%) but increased in African populations (RR 2.99, 95% CI 2.53 to 3.54, I2=0%).In conclusion, exposure to INSTIs was not associated with increased risk of DM, except in the African population. Stratified analyses suggested reduced risk among ART-naïve patients and studies with longer follow-up.International Prospective Register of Systematic Reviews (PROSPERO) registration number: CRD42021273040.
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Affiliation(s)
- Frank Mulindwa
- Capacity Building Program, Makerere University Infectious Diseases Institute, Kampala, Uganda
- Global Health Institute, University of Antwerp, Antwerpen, Belgium
| | - Habiba Kamal
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Barbara Castelnuovo
- Capacity Building Program, Makerere University Infectious Diseases Institute, Kampala, Uganda
| | - Dathan M Byonanebye
- Biostatistics and Databases Program, Kirby Institute University of New South Wales, Sydney, New South Wales, Australia
- Community and Behavioral Sciences, Makerere University, Kampala, Uganda
| | - Jean-Marc Schwarz
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Robert Bollinger
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nele Brusselaers
- Global Health Institute, University of Antwerp, Antwerpen, Belgium
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden
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De Castro N, Brun A, Sellier P, Hamet G, Mechaï F, Garrait V, Chabrol A, Bouldouyre MA, Froguel E, Troisvallets D, Caraux-Paz P, Delaugerre C, Rozenbaum W, Molina JM. Safety and efficacy of switching to elvitegravir, cobicistat, emtricitabine, tenofovir disoproxil fumarate in treatment-experienced people with HIV: a multicenter cohort study. AIDS Res Ther 2023; 20:1. [PMID: 36597160 PMCID: PMC9809122 DOI: 10.1186/s12981-022-00499-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 12/19/2022] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES We assessed the virologic efficacy of switching to co-formulated elvitegravir, cobicistat, emtricitabine, tenofovir disoproxil fumarate (E/C/F/TDF) in patients with controlled HIV infection. METHODS We conducted a retrospective multicenter observational cohort study including adult patients with controlled HIV-1 infection on any stable antiretroviral (ART) regimen, who switched to E/C/F/TDF. Success was measured by the proportion of patients with plasma viral load < 50 copies/ml at W48 using the FDA snapshot algorithm. We also assessed risk factors associated with virological failure (VF). RESULTS 382 patients with HIV RNA < 50 copies/mL who switched to E/C/F/TDF were included in the study. Most patients (69.9%) were male, with median age 44 years (IQR 38-51), who had been on ART for a median of 7 years (IQR 4-13). Median CD4 count was 614/mm3 and 24.6% of the patients had a history of previous virological failure. The reasons for switching were simplification (67.0%) and tolerance issues (22.0%). At week 48, 314 (82.0% [95% CI 78.4-86.0]) patients had HIV RNA < 50 copies/mL, 13 (3.5% [95% CI 3.64-8.41]) experienced virological failure. Genotype at failure was available in 6/13 patients with detection of resistance-associated mutations to integrase inhibitors and NRTIs in 5/6 (83.3%) patients. We found no predictive factor associated with virological failure except for a borderline significance with the duration of viral suppression before the switch. Tolerability of E/C/F/TDF was good with 23/382 (6.0%) patients experiencing mild adverse reactions. CONCLUSION In our cohort, switching well-suppressed patients to E/C/F/TDF resulted in few virologic failures and was well tolerated. However, resistance to integrase inhibitors emerged in patients with virological failure.
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Affiliation(s)
- Nathalie De Castro
- grid.413328.f0000 0001 2300 6614Infectious Diseases Department, APHP-Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
| | | | - Pierre Sellier
- grid.411296.90000 0000 9725 279XAPHP-Hôpital Lariboisière, Paris, France
| | | | - Frédéric Mechaï
- grid.413780.90000 0000 8715 2621APHP-Hôpital Avicenne, Bobigny, France
| | - Valérie Garrait
- grid.414145.10000 0004 1765 2136Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Amélie Chabrol
- grid.477082.e0000 0004 0641 0297Centre Hospitalier Sud-Francilien, Corbeil-Essonnes, France
| | | | - Eric Froguel
- Grand Hôpital de l’Est Francilien, Jossigny, France
| | - Didier Troisvallets
- grid.460749.80000 0004 0634 6424Centre Hospitalier de Gonesse, Gonesse, France
| | - Pauline Caraux-Paz
- Centre Hospitalier de Villeneuve St. Georges, Villeneuve Saint-Georges, France
| | - Constance Delaugerre
- grid.413328.f0000 0001 2300 6614Infectious Diseases Department, APHP-Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France ,grid.5842.b0000 0001 2171 2558Université de Paris, Paris, France
| | - Willy Rozenbaum
- grid.413328.f0000 0001 2300 6614Infectious Diseases Department, APHP-Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France ,COREVIH Ile-de-France Est, Paris, France
| | - Jean-Michel Molina
- grid.413328.f0000 0001 2300 6614Infectious Diseases Department, APHP-Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France ,grid.5842.b0000 0001 2171 2558Université de Paris, Paris, France
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Fabbiani M, Rossetti B, Ciccullo A, Oreni L, Lagi F, Celani L, Colafigli M, De Vito A, Mazzitelli M, Dusina A, Durante M, Montagnani F, Rusconi S, Capetti A, Sterrantino G, D'Ettorre G, Di Giambenedetto S. Efficacy and durability of two- vs. three-drug integrase inhibitor-based regimens in virologically suppressed HIV-infected patients: Data from real-life ODOACRE cohort. HIV Med 2021; 22:843-853. [PMID: 34318591 DOI: 10.1111/hiv.13146] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 07/05/2021] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The aim of the present study was to compare the efficacy and durability of treatment switch to two-drug (2DR) vs. three-drug (3DR) integrase inhibitor (InSTI)-based regimens in a real-life setting. METHODS Within the ODOACRE cohort, we selected adult patients with HIV RNA < 50 copies/mL switching to an InSTI-based 2DR or 3DR. Survival analyses were performed to estimate the probability of virological failure (VF, defined as one HIV RNA > 1000 copies/mL or two consecutive HIV RNA > 50 copies/mL) and treatment discontinuation (TD, defined as any modification, intensification or interruption of the regimen), and to evaluate their predictors. RESULTS Overall, 1666 patients were included, of whom 1334 (80%) were treated with a 3DR (19.9%, 25.0% and 55.1% elvitegravir-, raltegravir- and dolutegravir-based, respectively) and 332 (20%) with a 2DR (79.2% dolutegravir + lamivudine and 20.8% dolutegravir + rilpivirine). Over a median (interquartile range) follow-up of 100 (52-150) weeks, 52 (3.1%) patients experienced VF with an incidence of 1.5/100 person-year of follow-up (PYFU). The estimated 96-week probability of VF was similar for the 2DR and 3DR groups (2.3% vs. 2.8%, P = 0.53), but it was higher for elvitegravir (4.9%) and raltegravir (5.0%) than for dolutegravir (1.5%) (P = 0.04). Four hundred (24%) patients discontinued their InSTI-based regimen, with an incidence of 11.3/100 PYFU. At 96 weeks, 3DRs showed a higher probability of TD for any reason (20.6% vs. 11.2%, P < 0.001) and TD for toxicity (9.0% vs. 6.6%, P = 0.02) when compared with 2DRs. A higher risk of TD for central nervous system toxicity was observed for dolutegravir than for elvitegravir and raltegravir (4.0% vs. 2.5% vs. 0.6%, P = 0.005). CONCLUSIONS In virologically suppressed HIV-infected patients, 2DRs showed an efficacy similar to 3DRs but with better tolerability.
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Affiliation(s)
- Massimiliano Fabbiani
- UOC Malattie Infettive e Tropicali, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Barbara Rossetti
- UOC Malattie Infettive e Tropicali, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Arturo Ciccullo
- UOC Malattie Infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Letizia Oreni
- Infectious Diseases Unit, DIBIC Luigi Sacco, University of Milan, Milan, Italy
| | - Filippo Lagi
- Malattie Infettive e Tropicali, Dipartimento di Medicina Clinica e Sperimentale, Università di Firenze, Firenze, Italy
| | - Luigi Celani
- Department of Public Health and Infectious Diseases - "Sapienza" University of Rome, Rome, Italy
| | - Manuela Colafigli
- Infectious Dermatology and Allergology Unit, IFO S. Gallicano Institute (IRCCS), Rome, Italy
| | - Andrea De Vito
- Unit of Infectious Diseases, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Maria Mazzitelli
- Infectious and Tropical Diseases Unit, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Alex Dusina
- UOC Malattie Infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Miriam Durante
- Dipartimento di Biotecnologie Mediche, Università degli Studi di Siena, Siena, Italy
| | - Francesca Montagnani
- UOC Malattie Infettive e Tropicali, Azienda Ospedaliero-Universitaria Senese, Siena, Italy.,Dipartimento di Biotecnologie Mediche, Università degli Studi di Siena, Siena, Italy
| | - Stefano Rusconi
- Infectious Diseases Unit, DIBIC Luigi Sacco, University of Milan, Milan, Italy
| | - Amedeo Capetti
- Division of Infectious Diseases, Department of Infectious Diseases, Luigi Sacco University Hospital, Milan, Italy
| | - Gaetana Sterrantino
- Malattie Infettive e Tropicali, Dipartimento di Medicina Clinica e Sperimentale, Università di Firenze, Firenze, Italy
| | - Gabriella D'Ettorre
- Department of Public Health and Infectious Diseases - "Sapienza" University of Rome, Rome, Italy
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Virologic Failure Among People Living With HIV Initiating Dolutegravir-Based Versus Other Recommended Regimens in Real-World Clinical Care Settings. J Acquir Immune Defic Syndr 2020; 81:572-577. [PMID: 31107299 DOI: 10.1097/qai.0000000000002075] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Guidelines for initial antiretroviral treatment (ART) regimens have evolved, with integrase strand transfer inhibitors (INSTIs) increasingly prominent. Research on virologic failure (VF) with INSTI therapy is predominantly from clinical trials not care settings, especially for recently approved medications including dolutegravir. We compared outcomes among people living with HIV (PLWH) who initiated recommended regimens in clinical care across the United States. SETTING We examined 2 groups of PLWH at 8 clinics who initiated ART regimens (August 1, 2013-March 31, 2017): those ART treatment-naive at initiation, and those treatment-experienced. METHODS The outcome in this longitudinal cohort study was VF, defined as a viral load of ≥400 copies/mL ≥6 months after ART initiation. We examined the proportion of individuals who remained on, switched, or discontinued the regimen. Associations between regimens and outcomes were examined with adjusted Cox proportional hazards models. RESULTS Among 5177 PLWH, a lower proportion experienced VF on dolutegravir- versus other INSTI- or darunavir-based regimens for previously treatment-naive (7% vs. 12% vs. 28%) and treatment-experienced PLWH (6% vs. 10% vs. 21%). In adjusted analyses, hazard ratios were similar across regimens for the combined outcome of regimen discontinuation or treatment switch. The hazard ratios for VF comparing dolutegravir- to darunavir-based regimens was 0.30 (95% CI: 0.2 to 0.6) among previously treatment-naive PLWH and was 0.60 (95% CI: 0.4 to 0.8) among treatment-experienced PLWH. CONCLUSIONS The proportion of previously treatment-naive PLWH remaining on recommended ART regimens did not differ by regimen. The likelihood of VF was lower with dolutegravir- than darunavir-based regimens for previously treatment-naive and treatment-experienced PLWH.
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Effectiveness of integrase strand transfer inhibitors among treatment-experienced patients in a clinical setting. AIDS 2019; 33:1187-1195. [PMID: 30870198 DOI: 10.1097/qad.0000000000002194] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Characterize virologic and immunologic outcomes of INSTI-based antiretroviral therapy (ART) in experienced patients with and without virologic failure. DESIGN Prospective clinical cohort. METHODS ART-experienced, INSTI-naive participants in the University of North Carolina Center for AIDS Research HIV Clinical Cohort (UCHCC) initiating an INSTI-containing regimen 2007-2016 were followed from INSTI initiation (baseline) to the earliest of: outcome of interest, loss to follow-up (LTFU, 1 year without clinical visit), or death. Outcomes of interest were virologic failure (first of two consecutive viral loads at least 200 copies/ml more than 2 weeks apart, or one viral load ≥200 before LTFU) and immune recovery (first CD4 ≥500 cells/μl). Patients with baseline viral load at least 50 copies/ml were given 24 weeks before meeting virologic failure criteria. Kaplan-Meier curves and Cox proportional hazards models compared INSTI regimens and patient characteristics. RESULTS Of 773 patients, 32% were women, 59% African-American, and 42% had a viral load at least 50 copies/ml at INSTI initiation. After 2 years, 5% of patients with baseline viral load less than 50 copies/ml experienced virologic failure, compared with 35% of patients with baseline viral load at least 50 copies/ml (P < 0.01). Among patients with baseline viral load less than 50 copies/ml, dolutegravir/NRTIs was associated with longer time to virologic failure [adjusted hazard ratio (aHR) 0.11, 95% confidence interval (CI) 0.01-0.80], whereas among patients with baseline viral load at least 50 copies/ml, raltegravir/NRTIs was associated with longer time to virologic failure (aHR 0.35, 95% CI 0.18-0.68), both compared with elvitegravir/NRTIs. After 5 years suppressed, irrespective of baseline viral load, 61% of patients experienced immune recovery. CONCLUSION In this cohort, INSTI-containing regimens led to low virologic failure rates in patients switching ART while suppressed. Viremic patients initiating INSTIs were at high risk of virologic failure during follow-up.
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