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Hurbans N, Naidoo P. Efficacy, safety, and tolerability of dolutegravir-based ART regimen in Durban, South Africa: a cohort study. BMC Infect Dis 2024; 24:343. [PMID: 38515041 PMCID: PMC10958909 DOI: 10.1186/s12879-024-09202-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 03/06/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Dolutegravir is an integrase strand transfer inhibitor that has been recommended for use in first-line antiretroviral regimens by the World Health Organisation and is currently being rolled out globally. There has been safety concerns with dolutegravir which has caused concern about its use in the general population. Dolutegravir first-line regimens have been used in South Africa since early 2020. Therefore, the aim of the present study was to assess the efficacy, safety, and tolerability of first-line dolutegravir-based antiretrovirals amongst adults living with HIV in Durban, South Africa. METHODS This was a mixed-methods study, which comprised a cross-sectional survey and longitudinal retrospective follow-up of medical records. The study was conducted between October 2020 and January 2022. Data were described using descriptive and summary statistics. Bivariate logistic regression was applied to socio-demographic and clinical variables and crude odds ratios with a 95% confidence interval was calculated. Pearson chi-square tests, paired sample T-tests, and cross-tabulations were performed on selected variables. RESULTS A total of 461 participants were enrolled in the study. There was a significant change in immunological outcomes (p < 0.001) after dolutegravir initiation. Furthermore, an assessment of laboratory parameters showed that there was a significant decrease in cholesterol (p < 0.001) and increase in creatinine (p < 0.001) levels. Increased weight was shown by 60.7% of the participants but was not associated with age, gender, CD4 counts, and previous antiretroviral usage. The study found that 43.6% of the participants experienced at least one side-effect. A total of 21.6% and 23.2% of the participants experienced neuropsychiatric and central nervous system side-effects, respectively. In the bivariate analyses, only gender was shown to be associated with side-effects, and only 1.7% of the participants discontinued the study due to side-effects. CONCLUSION Our results suggest that dolutegravir is effective, safe, and well tolerated in the study population.
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Affiliation(s)
- Nivriti Hurbans
- Discipline of Pharmaceutical Sciences, School of Health Sciences, College of Health Science, University of KwaZulu-Natal, Westville, Durban, 4001, South Africa.
- South African Medical Research Council, HIV and Other Infectious Diseases Research Unit, Durban, South Africa.
| | - Panjasaram Naidoo
- Discipline of Pharmaceutical Sciences, School of Health Sciences, College of Health Science, University of KwaZulu-Natal, Westville, Durban, 4001, South Africa
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Ellis RJ, Marquine MJ, Kaul M, Fields JA, Schlachetzki JCM. Mechanisms underlying HIV-associated cognitive impairment and emerging therapies for its management. Nat Rev Neurol 2023; 19:668-687. [PMID: 37816937 PMCID: PMC11052664 DOI: 10.1038/s41582-023-00879-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2023] [Indexed: 10/12/2023]
Abstract
People living with HIV are affected by the chronic consequences of neurocognitive impairment (NCI) despite antiretroviral therapies that suppress viral replication, improve health and extend life. Furthermore, viral suppression does not eliminate the virus, and remaining infected cells may continue to produce viral proteins that trigger neurodegeneration. Comorbidities such as diabetes mellitus are likely to contribute substantially to CNS injury in people living with HIV, and some components of antiretroviral therapy exert undesirable side effects on the nervous system. No treatment for HIV-associated NCI has been approved by the European Medicines Agency or the US Food and Drug Administration. Historically, roadblocks to developing effective treatments have included a limited understanding of the pathophysiology of HIV-associated NCI and heterogeneity in its clinical manifestations. This heterogeneity might reflect multiple underlying causes that differ among individuals, rather than a single unifying neuropathogenesis. Despite these complexities, accelerating discoveries in HIV neuropathogenesis are yielding potentially druggable targets, including excessive immune activation, metabolic alterations culminating in mitochondrial dysfunction, dysregulation of metal ion homeostasis and lysosomal function, and microbiome alterations. In addition to drug treatments, we also highlight the importance of non-pharmacological interventions. By revisiting mechanisms implicated in NCI and potential interventions addressing these mechanisms, we hope to supply reasons for optimism in people living with HIV affected by NCI and their care providers.
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Affiliation(s)
- Ronald J Ellis
- Department of Neurosciences, University of California San Diego, La Jolla, CA, USA.
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA.
| | - María J Marquine
- Department of Medicine, Duke University, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Marcus Kaul
- School of Medicine, Division of Biomedical Sciences, University of California Riverside, Riverside, CA, USA
| | - Jerel Adam Fields
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Johannes C M Schlachetzki
- Department of Cellular and Molecular Medicine, University of California San Diego, La Jolla, CA, USA
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Chen DC, Potok OA, Rifkin D, Estrella MM. Advantages, Limitations, and Clinical Considerations in Using Cystatin C to Estimate GFR. Kidney360 2022; 3:1807-1814. [PMID: 36514729 PMCID: PMC9717651 DOI: 10.34067/kid.0003202022] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/17/2022] [Indexed: 01/12/2023]
Abstract
Cystatin C has been shown to be a reliable and accurate marker of kidney function across diverse populations. The 2012 Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommended using cystatin C to confirm the diagnosis of chronic kidney disease (CKD) determined by creatinine-based estimated glomerular filtration rate (eGFR) and to estimate kidney function when accurate eGFR estimates are needed for clinical decision-making. In the efforts to remove race from eGFR calculations in the United States, the National Kidney Foundation (NKF) and American Society of Nephrology (ASN) Joint Task Force recommended increasing availability and clinical adoption of cystatin C to assess kidney function. This review summarizes the key advantages and limitations of cystatin C use in clinical practice. Our goals were to review and discuss the literature on cystatin C; understand the evidence behind the recommendations for its use as a marker of kidney function to diagnose CKD and risk stratify patients for adverse outcomes; discuss the challenges of its use in clinical practice; and guide clinicians on its interpretation.
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Affiliation(s)
- Debbie C. Chen
- Kidney Health Research Collaborative, University of California, San Francisco and San Francisco VA Health Care System, San Francisco, California
| | - O. Alison Potok
- University of California, San Diego and San Diego VA Health Care System, San Francisco, California
| | - Dena Rifkin
- University of California, San Diego and San Diego VA Health Care System, San Francisco, California
| | - Michelle M. Estrella
- Kidney Health Research Collaborative, University of California, San Francisco and San Francisco VA Health Care System, San Francisco, California
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4
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Martínez E. CNS Considerations in ART Simplification Strategies. Curr HIV/AIDS Rep 2021. [PMID: 34739699 DOI: 10.1007/s11904-021-00580-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE OF THE REVIEW This review summarizes current knowledge on central nervous system (CNS) considerations in ART simplification strategies. RECENT FINDINGS Antiretroviral therapies (ART) showing efficacy in plasma will usually show efficacy in the cerebrospinal fluid (CSF). ART simplification may virologically fail if the new regimen has less than two active drugs, the genetic barrier of drugs is not high, and the patient may harbour archived resistance. Dual therapies including a boosted protease inhibitor (PI) or dolutegravir (DTG) are generally effective from the CNS perspective. In cases of related neurotoxicity, switching from either efavirenz (EFV) or DTG to another equally effective drug with better CNS tolerability usually leads to complete resolution of CNS symptoms. However, improvement may be incomplete when factors other than ART that cannot be easily modified are involved.
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Rava M, Bisbal O, Domínguez-Domínguez L, Aleman MR, Rivero M, Antela A, Estrada V, Ribera E, Muñoz A, Iribarren JA, Moreno S, Rubio R, Jarrín I. Late presentation for HIV impairs immunological but not virological response to antiretroviral treatment. AIDS 2021; 35:1283-1293. [PMID: 33813554 DOI: 10.1097/qad.0000000000002891] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to examine the impact of late presentation (CD4+ cell count <350 cells/μl or an AIDS-defining event) on effectiveness and safety of initial antiretroviral therapy (ART) and to evaluate whether treatment response depends on first-line ART regimen in late presenters. DESIGN ART-naive adults from the Cohort of the Spanish HIV/AIDS Research Network (CoRIS) starting triple ART between 2010 and 2018. METHODS We used multivariable models to assess differences in viral suppression (viral load <50 copies/ml), immunological response (change in CD4+ cell count, CD4% (>29%) and CD4/CD8 normalization (>0.4 and >1) multiple T-cell marker recovery (MTMR): CD4+ cell count more than 500 cells/μl and CD4% >29% and CD4/CD8 >1), and treatment discontinuation due to adverse events (TDAE) at 48 weeks from ART initiation. RESULTS Out of 8002 participants, 48.7% were late presenters. Of them, 45.8% initiated ART with a NNRTI- (mostly TDF/FTC/EFV), 33.9% with a protease inhibitor (mostly TDF/FTC+boosted DRV) and 20.3% with an INI-based regimen (mostly ABC/3TC/DTG). At 48 weeks, late presenters had similar viral suppression, but worse immunological response, than non-late presenters with no difference on TDAE. Late presenters initiating with NNRTI-based regimens were more likely to achieve viral suppression than those starting with INI-based, due to the higher chance of achieving viral suppression observed with TDF/FTC/RPV compared to ABC/3TC/DTG. Initial treatment with NNRTI or protease inhibitor based showed similar immunological response than the INI-based regimens, which showed lower rates of TDAE than NNRTI- and protease inhibitor based regimens. CONCLUSION Despite safety and effectiveness of initial ART in terms of viral suppression, late presenters may not experience complete immunological response. In late presenters, effectiveness and safety depends on both the class and the specific first-line ART regimen.
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Affiliation(s)
- Marta Rava
- Unit AIDS Research Network Cohort (CoRIS), National Center of Epidemiology (CNE), Health Institute Carlos III (ISCIII)
| | - Otilia Bisbal
- Hospital Universitario 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, Madrid
| | | | - Ma Remedios Aleman
- Hospital Universitario de Canarias, Universidad de La Laguna, Canary Islands
| | - María Rivero
- Infectious Diseases Unit, Complejo Hospitalario de Navarra - IdiSNA, Pamplona
| | - Antonio Antela
- Hospital Clínico Universitario de Santiago, Santiago de Compostela
| | | | - Esteban Ribera
- Department of Infectious Diseases, Hospital Universitario Valle de Hebrón, Barcelona
| | - Adolfo Muñoz
- Research Unit on Digital Health. Health Institute Carlos III (ISCIII), Madrid
| | | | | | - Rafael Rubio
- Hospital Universitario 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, Madrid
| | - Inmaculada Jarrín
- Unit AIDS Research Network Cohort (CoRIS), National Center of Epidemiology (CNE), Health Institute Carlos III (ISCIII)
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Raciti CG, Enane LA, MacDonald KR, Whipple EC, Ott MA, McHenry MS. Ethical considerations for research involving pregnant women living with HIV and their young children: a systematic review of the empiric literature and discussion. BMC Med Ethics 2021; 22:38. [PMID: 33794891 PMCID: PMC8017748 DOI: 10.1186/s12910-021-00601-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The proper and ethical inclusion of PWLHIV and their young children in research is paramount to ensure valid evidence is generated to optimize treatment and care. Little empirical data exists to inform ethical considerations deemed most critical to these populations. Our study aimed to systematically review the empiric literature regarding ethical considerations for research participation of PWLHIV and their young children. METHODS We conducted this systematic review in partnership with a medical librarian. A search strategy was designed and performed within the following electronic databases: Ovid MEDLINE, Embase and CINAHL. We screened titles and abstracts using the following inclusion criteria: (1) a study population of PWLHIV or children under 5 years of age; and (2) collection of qualitative or quantitative data regarding ethics of research participation. Excluded were reviews, commentaries, policy statements, clinical care-related ethics concerns, abstracts, case studies, or studies unrelated to HIV research. Studies were appraised for quality, data were extracted, and studies were qualitatively analyzed using a principle-based ethical framework within the Belmont Report. RESULTS Of the 7470 titles identified, 538 full-text articles were reviewed for eligibility and only three articles met full criteria for inclusion within this review. While we allowed for inclusion of studies involving young children born to mothers with HIV, only articles focused on PWLHIV were identified. Within the results of these studies, four themes emerged: (1) adequacy of informed consent; (2) consideration of paternal involvement; (3) balancing risks; and (4) access to research and treatment. A strength of this review is that it included perspectives of international research investigators, community leaders, and male partners. However, only two studies collected empiric data from PWLHIV regarding their experiences participating in research CONCLUSION: Researchers and funding agencies should be aware of these considerations and appreciate the value of and critical need for formative research to ensure clinical trials involving PWLHIV promote ethical, well-informed research participation and, ultimately, improve care outcomes. More research is needed to create a comprehensive ethical framework for researchers when conducting studies with PWLHIV.
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Affiliation(s)
- Catherine G Raciti
- Indiana University-Purdue University - Indianapolis, Indianapolis, IN, USA
| | - Leslie A Enane
- Department of Pediatrics, The Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 5853, Indianapolis, IN, 46202, USA
| | - Katherine R MacDonald
- Department of Adolescent and Young Adult Medicine, Children's National Hospital, Washington, DC, USA
| | - Elizabeth C Whipple
- Indiana University School of Medicine, Ruth Lilly Medical Library, Indianapolis, IN, USA
| | - Mary A Ott
- Division of Adolescent Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Megan S McHenry
- Department of Pediatrics, The Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 5853, Indianapolis, IN, 46202, USA.
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Abstract
The development of novel antiretroviral treatments has led to a significant turning point in the fight against HIV. Although therapy leads to virologic suppression and prolonged life expectancies, HIV-associated neurocognitive disorder (HAND) remains prevalent. While various hypotheses have been proposed to explain this phenomenon, a growing body of literature explores the neurotoxic effects of antiretroviral therapy. Research to date brings into question the potential role of such medications in neurocognitive and neuropsychiatric impairment seen in HIV-positive patients. This review highlights recent findings and controversies in cellular, molecular, and clinical neurotoxicity of antiretrovirals. It explores the pathogenesis of such toxicity and relates it to clinical manifestations in each medication class. The concept of accelerated aging in persons living with HIV (PLWH) as well as potential treatments for HAND are also discussed. Ultimately, this article hopes to educate clinicians and basic scientists about the neurotoxic effects of antiretrovirals and spur future scientific investigation into this important topic. Graphical Abstract.
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Affiliation(s)
- Tyler Lanman
- Department of Neurosciences, University of California San Diego School of Medicine, 200 W Arbor Dr, San Diego, La Jolla, CA, 92103, USA
| | - Scott Letendre
- Department of Infectious Diseases, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Qing Ma
- Pharmacotherapy Research Center, University of Buffalo, School of Pharmacy & Pharmaceutical Sciences, Buffalo, NY, USA
| | - Anne Bang
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Ronald Ellis
- Department of Neurosciences, University of California San Diego School of Medicine, 200 W Arbor Dr, San Diego, La Jolla, CA, 92103, USA.
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Abstract
The newest class of antiretrovirals for all persons living with HIV are the integrase strand transfer inhibitors (INSTIs). Since 2007, five INSTIs have been introduced: raltegravir, elvitegravir, dolutegravir, bictegravir, and cabotegravir. The INSTIs have favorable pharmacokinetic and pharmacodynamic properties, which contribute to both their effectiveness and their ease of use. With the exception of cabotegravir, each INSTI is US Food and Drug Administration approved for treatment-naïve individuals initiating antiretroviral therapy. All of the INSTIs, except raltegravir, are approved for antiretroviral treatment simplification for virologically suppressed patients without INSTI resistance. Data also support the use of dolutegravir and raltegravir in individuals with antiretroviral resistance as part of an optimized antiretroviral regimen. INSTIs are generally well tolerated by people living with HIV compared with older classes of antiretrovirals, but emerging data suggest that some INSTIs contribute to weight gain. Due to their efficacy, safety, and ease of use, HIV treatment guidelines recommend oral INSTIs as preferred components of antiretroviral therapy for individuals initiating therapy. The newest INSTI, cabotegravir, represents an alternative to oral administration of life-long antiretroviral therapy with the availability of a long-acting injectable formulation. This review summarizes the current use of INSTIs in adults living with HIV, highlighting the similarities and differences within the class related to pharmacodynamics, pharmacokinetics, safety, dosing, and administration that contribute to their role in modern antiretroviral therapy.
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Affiliation(s)
- Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA.
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Joshua P Havens
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Anthony T Podany
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
| | - Sean N Avedissian
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
| | - Courtney V Fletcher
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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Taramasso L, Lorenzini P, Di Biagio A, Lichtner M, Marchetti G, Rossotti R, Lapadula G, Cozzi-Lepri A, Vichi F, Antinori A, Bonora S, d'Arminio Monforte A. Incidence and risk factors for liver enzyme elevation among naive HIV-1-infected patients receiving ART in the ICONA cohort. J Antimicrob Chemother 2020; 74:3295-3304. [PMID: 31504633 DOI: 10.1093/jac/dkz353] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 05/17/2019] [Accepted: 07/16/2019] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES To evaluate the incidence and risk factors for liver enzyme elevations (LEE) in patients initiating first-line ART in the ICONA prospective observational cohort, between June 2009 and December 2017. PATIENTS AND METHODS In total, 6575 ART-naive patients were selected, initiating two NRTIs with the third drug being a boosted PI (n=2436; 37.0%), an NNRTI (n=2384; 36.3%) or an integrase strand transfer inhibitor (INSTI) (n=1755; 26.7%). HBV surface antigen and HCV RNA were detected in 3.9% and 5.8% of the study population. Inverse probability weighted Cox regression analysis was used to calculate the HRs, according to first-line regimen, for LEE, defined as ALT or AST increases of ≥2.5× upper limit of normal (ULN) for patients with normal baseline values or ≥2.5× baseline for patients with higher baseline values. RESULTS One hundred and eighty-three LEE occurred over 20722 patient-years of follow-up. After adjusting for the main confounders, the risk of LEE halved with INSTIs compared with NNRTIs (HR 0.46, 95% CI 0.25-0.86), with a significant reduction in the raltegravir group (HR 0.11, 95% CI 0.02-0.84 using the NNRTI class as reference). HRs for LEE were significantly higher in subjects with HBV or HCV coinfection, in patients with poorly controlled HIV infection and in those who acquired HIV through homosexual transmission. CONCLUSIONS In our study, INSTI use almost halved the risk of LEE compared with other regimens. This finding could be particularly important for choosing ART in patients with risk factors for liver toxicity such as HCV and HBV coinfections.
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Affiliation(s)
- Lucia Taramasso
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Infectious Diseases Unit, Department of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Patrizia Lorenzini
- HIV/AIDS Clinical Department, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
| | - Antonio Di Biagio
- Infectious Diseases Clinic, Policlinico San Martino Hospital, Genoa, Italy
| | - Miriam Lichtner
- Department of Infectious Diseases, La Sapienza University, Polo Pontino, Latina, Italy
| | - Giulia Marchetti
- Department of Health Sciences, Clinic of Infectious and Tropical Diseases, University of Milan, Milan, Italy
| | | | | | | | - Francesca Vichi
- Unit of Infectious Diseases, Santa Maria Annunziata Hospital, Florence, Italy
| | - Andrea Antinori
- HIV/AIDS Clinical Department, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
| | - Stefano Bonora
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
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Thomas SJ, Kilgore JT, Becken BA, Cunningham CK, Thompson AB. Raltegravir-associated Drug-Reaction With Eosinophilia and Systemic Symptoms Syndrome in a Pediatric Patient Without Characteristic Human Leukocyte Antigen B*57:01 or B*53:01 alleles. J Pediatric Infect Dis Soc 2020; 10:363-366. [PMID: 32766769 PMCID: PMC8023309 DOI: 10.1093/jpids/piaa089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022]
Abstract
We present the first published case of raltegravir-associated drug-reaction with eosinophilia and systemic symptoms (DRESS) syndrome in a child without characteristic human leukocyte antigen haplotypes HLA-B*57:01 or HLA-B*53:01. A 4-year-old African American female with perinatally acquired human immunodeficiency virus infection was hospitalized for DRESS after starting a raltegravir-based antiretroviral regimen.
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Affiliation(s)
- Sanya J Thomas
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA,Correspondence: S. J. Thomas, Duke University School of Medicine, T915 Children’s Health Center, DUMC Box 3499, Durham, NC 27710 ()
| | - Jacob T Kilgore
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Bradford A Becken
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Coleen K Cunningham
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA,Duke Global Health Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amelia B Thompson
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA,Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
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11
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Abstract
The adverse events of antiviral drugs are dose-dependent and often reversible. The nervous system is often affected and to date, many studies have been published regarding the central nervous system toxicity of antiviral agents. They may cause significant neuropsychiatric complications, which range from mild symptoms such as irritability and difficulty sleeping to severe complications such as depression, psychosis, and painful peripheral neuropathy, side effects which may necessitate discontinuation of treatment. The pathogenetic mechanisms may involve molecular targets common to other centrally active drugs, including human monoamine oxidase‐A (MAO‐A), serotonin receptors, gamma-aminobutyric acid (GABA) GABA-A receptors, 5-HT2A and 5-HT2C receptors and others. Notable examples include oseltamivir which may act as MAO inhibitor and efavirenz, which has an affinity for serotonin 5-HT2 and GABA-A receptors, the serotonin transporter, the MAO enzyme, and the vesicular monoamine transporter, with subjective effects which may be similar to those of the psychedelic hallucinogen lysergic acid diethylamide (LSD). Other antiviral drugs with prominent nervous system effects include nucleoside reverse transcriptase inhibitors, which are associated with the development of peripheral neuropathy after prolonged use (an effect strongly associated with older drugs which have since fallen into disfavor such as stavudine) and interferons, which may cause depression. Clinicians should be familiar with such adverse effects in order to recognise them promptly once they occur and manage them appropriately.
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Affiliation(s)
| | - Maria Lagadinou
- Emergency Department, General University Hospital of Patras, Patras, GRC
| | - Anastasia Karela
- Emergency Department, General University Hospital of Patras, Patras, GRC
| | | | - Dimitrios Velissaris
- Department of Internal Medicine, University of Patras, School of Health Sciences, Patras, GRC.,Emergency Department, General University Hospital of Patras, Patras, GRC
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12
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Brooks KM, George JM, Pau AK, Rupert A, Mehaffy C, De P, Dobos KM, Kellogg A, McLaughlin M, McManus M, Alfaro RM, Hadigan C, Kovacs JA, Kumar P. Cytokine-Mediated Systemic Adverse Drug Reactions in a Drug-Drug Interaction Study of Dolutegravir With Once-Weekly Isoniazid and Rifapentine. Clin Infect Dis 2019; 67:193-201. [PMID: 29415190 DOI: 10.1093/cid/ciy082] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 02/01/2018] [Indexed: 12/18/2022] Open
Abstract
Background Once-weekly isoniazid and rifapentine for 3 months is a treatment option in persons with human immunodeficiency virus and latent tuberculosis infection. This study aimed to examine pharmacokinetic drug-drug interactions between this regimen and dolutegravir, a first-line antiretroviral medication. Methods This was a single-center, open-label, fixed-sequence, drug-drug interaction study in healthy volunteers. Subjects received oral dolutegravir 50 mg once daily alone (days 1-4) and concomitantly with once-weekly isoniazid 900 mg, rifapentine 900 mg, and pyridoxine 50 mg (days 5-19). Dolutegravir concentrations were measured on days 4, 14, and 19, and rifapentine, 25-desacetyl-rifapentine, and isoniazid concentrations were measured on day 19. Cytokines and antidrug antibodies to isoniazid and rifapentine were examined at select time points. Results The study was terminated following the development of flu-like syndrome and elevated aminotransferase levels in 2 of 4 subjects after the third isoniazid-rifapentine dose. Markedly elevated levels of interferon-γ, CXCL10, C-reactive protein, and other cytokines were temporally associated with symptoms. Antidrug antibodies were infrequently detected. Dolutegravir area under the curve (AUC) was decreased by 46% (90% confidence interval, 27-110%; P = .13) on day 14. Rifapentine and 25-desacetyl rifapentine levels on day 19 were comparable to reference data, whereas isoniazid AUCs were approximately 67%-92% higher in the subjects who developed toxicities. Conclusions The combined use of dolutegravir with once-weekly isoniazid-rifapentine resulted in unexpected and serious toxicities that were mediated by endogenous cytokine release. Additional investigations are necessary to examine the safety and efficacy of coadministering these medications. Clinical Trials Registration NCT02771249.
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Affiliation(s)
- Kristina M Brooks
- Clinical Pharmacokinetics Research Unit, Pharmacy Department, Clinical Center, National Institutes of Health (NIH), Frederick, Maryland
| | - Jomy M George
- Clinical Pharmacokinetics Research Unit, Pharmacy Department, Clinical Center, National Institutes of Health (NIH), Frederick, Maryland
| | - Alice K Pau
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Frederick, Maryland
| | - Adam Rupert
- AIDS Monitoring Laboratory, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc, Frederick, Maryland
| | - Carolina Mehaffy
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins
| | - Prithwiraj De
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins
| | - Karen M Dobos
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins
| | - Anela Kellogg
- Clinical Monitoring Research Program, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc, Frederick, Bethesda, Maryland
| | | | - Maryellen McManus
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland
| | - Raul M Alfaro
- Clinical Pharmacokinetics Research Unit, Pharmacy Department, Clinical Center, National Institutes of Health (NIH), Frederick, Maryland
| | | | - Joseph A Kovacs
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland
| | - Parag Kumar
- Clinical Pharmacokinetics Research Unit, Pharmacy Department, Clinical Center, National Institutes of Health (NIH), Frederick, Maryland
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Vieira TDS, Vieira IDS, Bresser M, Moura LCL, Moura MDA. O papel do dolutegravir na terapia antiretroviral. HU Rev 2019. [DOI: 10.34019/1982-8047.2018.v44.13945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Os inibidores da integrase são a mais nova classe de antirretroviral aprovada, que agem impedindo a incorporação do DNA do HIV no genoma do linfócito T CD4+ (LTCD4+) do hospedeiro, limitando a propagação do vírus. O Dolutegravir e o inibidor da integrase mais moderno e como os demais inibidores apresenta de alta performance, boa tolerância; alta barreira genética para mutações de resistência, além de apresentar eficácia em pacientes já submetidos a tratamento antirretroviral anterior. Neste contexto o presente estudo trata-se de um estudo de revisão bibliográfica realizada de janeiro a junho de 2018, de artigos científicos de artigos científicos que abordam aspectos exclusivos do dolutegravir na terapia antirretroviral em comparação com outros esquemas terapêuticos. Concluindo que o tratamento com dolutegravir apresenta como principais vantagens à rápida supressão virológica; boa tolerância e alta barreira genética para mutações de resistência.
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Stainsby CM, Perger TM, Vannappagari V, Mounzer KC, Hsu RK, Henegar CE, Oyee J, Urbaityte R, Lane CE, Carter LM, Pakes GE, Shaefer MS. Abacavir Hypersensitivity Reaction Reporting Rates During a Decade of HLA-B*5701 Screening as a Risk-Mitigation Measure. Pharmacotherapy 2018; 39:40-54. [PMID: 30414209 PMCID: PMC6590466 DOI: 10.1002/phar.2196] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Human leukocyte antigen (HLA)-B*5701 screening identifies patients at increased risk for abacavir (ABC) hypersensitivity reaction (HSR). Screening was adopted in GlaxoSmithKline and ViiV Healthcare clinical trials in 2007 and human immunodeficiency virus treatment guidelines in 2008. Company meta-analyses of trials pre-HLA-B*5701 screening reported HSR rates of 4-8%. We analyzed the effectiveness of HLA-B*5701 screening on reducing HSR rates using clinical trial, Observational Pharmaco-Epidemiology Research & Analysis (OPERA) cohort, and spontaneous reporting data. METHODS A meta-analysis examined 12 trials in 3063 HLA-B*5701-negative patients receiving an ABC-containing regimen from April 9, 2007, to September 22, 2015. Potential cases were identified using prespecified Medical Dictionary for Regulatory Activities (MedDRA) preferred terms (drug hypersensitivity, hypersensitivity, anaphylactic reaction, anaphylaxis) and adjudicated against a Company ABC HSR case definition. Investigator-diagnosed cases were identified and rates were calculated. In the OPERA cohort, 9619 patients initiating their first ABC-containing regimen from January 1, 1999, to January 1, 2016, were identified. Patients were observed from regimen start until the earliest-following censoring event: ABC discontinuation, loss to follow-up, death, or study end (July 31, 2016). OPERA physicians evaluated events against OPERA definitions for definite/probable cases of ABC HSR; rates were calculated pre- and post-2008. The Company case definition was used to identify spontaneously reported cases for four marketed ABC-containing products; reporting rates were calculated using estimated exposure from sales data, through December 31, 2016. RESULTS Suspected ABC HSR rates were 1.3% or less in the meta-analysis. In the OPERA cohort, the rate was 0.4% among patients initiating ABC post-2008 versus 1.3% pre-2008 (p<0.0001). Spontaneous reporting rates were low post-2008 (54 to 22 cases per 100,000 patient-years exposure [PYE]) versus pre-2008 (618 to 55 cases per 100,000 PYE). CONCLUSIONS Clinically suspected ABC HSR rates were 1.3% or less in HLA-B*5701-negative patients. Recognizing their limitations, data from the OPERA cohort and spontaneous reporting indicate that HLA-B*5701 screening has reduced reporting rates of suspected HSR in clinical practice. Where screening for HLA-B*5701 is standard care, patients should be confirmed negative for this allele before starting ABC treatment.
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Affiliation(s)
- Chris M Stainsby
- Global Clinical Safety and Pharmacovigilance, GlaxoSmithKline, London, UK
| | | | - Vani Vannappagari
- Epidemiology and Real World Evidence, ViiV Healthcare, Research Triangle Park, North Carolina
| | - Karam C Mounzer
- Infectious Diseases, Philadelphia FIGHT, Philadelphia, Pennsylvania
| | - Ricky K Hsu
- Internal Medicine, AIDS Healthcare Foundation, New York, New York.,Internal Medicine, NYU Langone Medical Center, New York, New York
| | - Cassidy E Henegar
- Epidemiology and Real World Evidence, ViiV Healthcare, Research Triangle Park, North Carolina
| | - James Oyee
- Statistics, Programming and Data Strategy, GlaxoSmithKline, London, UK
| | | | - Charlotte E Lane
- Global Clinical Safety and Pharmacovigilance, GlaxoSmithKline, London, UK
| | - Lindsay M Carter
- Global Medical Sciences, ViiV Healthcare, Research Triangle Park, North Carolina
| | - Gary E Pakes
- Global Medical Sciences, ViiV Healthcare, Research Triangle Park, North Carolina
| | - Mark S Shaefer
- Global Medical Sciences, ViiV Healthcare, Research Triangle Park, North Carolina
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15
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Abstract
As people live longer with HIV infection, there has been a resurgence of interest in challenging the use of three-drug therapy, including two nucleoside reverse transcriptase inhibitors plus a third drug, as initial treatment of HIV infection or for maintenance therapy in virologically suppressed individuals. Although initial studies showed poor efficacy and/or substantial toxicity, more recent regimens have held greater promise. The SWORD-1 and -2 studies were pivotal trials of dolutegravir plus rilpivirine as maintenance therapy in virologically suppressed patients with no history of drug resistance, leading to the US Food and Drug Administration’s approval of the regimen as a small, single tablet. More recently, the GEMINI-1 and -2 studies demonstrated that dolutegravir plus lamivudine is as safe and effective as the same regimen when combined with tenofovir disoproxil fumarate in treatment-naïve individuals. Together, these and other studies of novel two-drug regimens offer the potential for improved tolerability and simplicity, as well as a reduction in cost. We will review historical and recent trials of two-drug therapy for the treatment of HIV-1 infection.
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Affiliation(s)
- Katya C Corado
- Department of Medicine, Division of HIV Medicine, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, CA, USA,
| | - Margaret R Caplan
- Department of Medicine, Division of HIV Medicine, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, CA, USA,
| | - Eric S Daar
- Department of Medicine, Division of HIV Medicine, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, CA, USA,
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16
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Casado JL, Monsalvo M, Rojo AM, Fontecha M, Rodriguez-Sagrado MA. Dolutegravir and rilpivirine for the maintenance treatment of virologically suppressed HIV-1 infection. Expert Rev Clin Pharmacol 2018; 11:561-570. [PMID: 29775399 DOI: 10.1080/17512433.2018.1478726] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Triple combinations of antiretroviral therapy (ART) drugs are the standard treatment for human immunodeficiency virus (HIV) infection, but the challenges include long-term side effects, high costs, and adherence. The recent advent of potent and well-tolerated ART has renewed the interest for newer ART strategies. A dual regimen with the combination of dolutegravir (DTG) and rilpivirine (RPV), two well-tolerated, metabolic-friendly, and potent drugs could offer additional benefits. Areas covered: A review of recent randomized trials and observational cohorts concerning the use of a dual therapy with DTG plus RPV as a switching strategy in patients with viral suppression. Expert commentary: Currently, data of more of 900 patients switched to this dual regimen are available. This combination shows a high rate of virological suppression, above 90% at 48 weeks, few discontinuations due to adverse events, improvement in bone and kidney parameters for patients discontinuing tenofovir disoproxil fumarate, lack of loss of the inflammatory control achieved with triple therapy, and a neutral effect on lipid parameters. Thus, for the first time, a dual regimen without protease inhibitors is effective, avoiding metabolic side effects and drug interactions. Longer follow-up is needed, but this dual regimen appears as a promising strategy for aging HIV-infected patients.
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Affiliation(s)
- Jose L Casado
- a Department of Infectious Diseases, HIV Unit, and Pharmacy , Ramón y Cajal Hospital , Madrid , Spain
| | - Marta Monsalvo
- a Department of Infectious Diseases, HIV Unit, and Pharmacy , Ramón y Cajal Hospital , Madrid , Spain
| | - Aurora M Rojo
- a Department of Infectious Diseases, HIV Unit, and Pharmacy , Ramón y Cajal Hospital , Madrid , Spain
| | - María Fontecha
- a Department of Infectious Diseases, HIV Unit, and Pharmacy , Ramón y Cajal Hospital , Madrid , Spain
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17
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Abstract
Dolutegravir is an increasingly-used second-generation human immunodeficiency virus integrase strand transfer inhibitor. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome has been described in several patients treated with raltegravir but to our knowledge, there is no previous report of DRESS syndrome associated with dolutegravir.
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Affiliation(s)
- Charlotte Martin
- Department of Infectious Diseases, Saint-Pierre University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Marie-Christine Payen
- Department of Infectious Diseases, Saint-Pierre University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Stephane De Wit
- Department of Infectious Diseases, Saint-Pierre University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
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18
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Bornhede R, Soeria-Atmadja S, Westling K, Pettersson K, Navér L. Dolutegravir in pregnancy-effects on HIV-positive women and their infants. Eur J Clin Microbiol Infect Dis 2018; 37:495-500. [PMID: 29396773 DOI: 10.1007/s10096-018-3195-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 01/18/2018] [Indexed: 10/18/2022]
Abstract
The development of new drugs for treatment of HIV has increased the efficacy and the quality of life together with decreased unwanted side-effect for people living with HIV. The integrase inhibitor dolutegravir has in short time become part of the first-line treatment in many countries, but is not a recommended first-line drug in pregnancy. As there are few publications of dolutegravir use during pregnancy, we found it valuable to analyze the Stockholm pregnancy cohort. A retrospective analysis of all pregnant women and their infants exposed to dolutegravir at Karolinska University Hospital, 2014-August 2017. Information about maternal health, treatment, pregnancy, and child outcome were collected. Thirty-six women with singleton pregnancies were included. Four early spontaneous abortions occurred. One late termination was performed and one was lost to follow-up. Fourteen were on dolutegravir before and 22 started during pregnancy. Eighteen delivered by caesarean section, three of them because of HIV RNA > 50 copies/mL. The preeclampsia rate and the maternal liver function were normal. One infant was delivered in GW 34 on maternal indication and the rest in full term. No gross malformations were noted. All infants received antiretroviral prophylaxis and have tested negative on follow-up. No increased maternal or infant morbidity was detected in this retrospective study of dolutegravir during pregnancy. This is so far one of the largest observational studies of dolutegravir treatment during pregnancy, but the number is indeed small, and further studies are needed to evaluate the safety and efficacy.
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Abstract
INTRODUCTION The HIV-infected population is aging and comorbidities and polypharmacological regimens are increasing. To reduce toxicity and drug burden researchers are evaluating the efficacy, safety and durability of dual therapies as a switch option in subjects who have achieved stable virologic suppression. Initially effective dual combinations relied on protease inhibitors but when dolutegravir, the first integrase inhibitor to display a high genetic barrier, became commercially available, many physicians began to use it in a variety of dual regimens, generating several observational cohorts. Areas covered: This review covers the most recent data from observational cohorts and randomized clinical trials concerning the switch to the dual combination of dolutegravir plus rilpivirine and the reasons that lead to consider this option. Also, viral failures, due to poor adherence or to other factors, and drug resistance are investigated. Articles which are searchable on MEDLINE/PubMed and from the main national/international congresses in the field of HIV therapy are reviewed. Expert opinion: The observation period for this regimen is getting longer and data showing its efficacy in maintaining HIV-1 RNA < 50 copies/mL are now consolidated. Metabolic data suggest some benefit in the lipid profile, improvement in bone mineral density and reduced bone reabsorption.
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Affiliation(s)
- Amedeo F Capetti
- a First Division of Infectious Diseases , ASST Fatebenefratelli-Sacco , Milano , Italy
| | - Maria V Cossu
- a First Division of Infectious Diseases , ASST Fatebenefratelli-Sacco , Milano , Italy
| | - Laura Paladini
- a First Division of Infectious Diseases , ASST Fatebenefratelli-Sacco , Milano , Italy
| | - Giuliano Rizzardini
- a First Division of Infectious Diseases , ASST Fatebenefratelli-Sacco , Milano , Italy.,b School of Clinical Medicine, Faculty of Health Sciences , Whitwaterstrand University , Johannesburg , South Africa
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20
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Achhra AC, Nugent M, Mocroft A, Ryom L, Wyatt CM. Chronic Kidney Disease and Antiretroviral Therapy in HIV-Positive Individuals: Recent Developments. Curr HIV/AIDS Rep 2017; 13:149-57. [PMID: 27130284 DOI: 10.1007/s11904-016-0315-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Chronic kidney disease (CKD) has emerged as an important health concern in HIV-positive individuals. Preventing long-term kidney toxicity from an antiretroviral therapy is therefore critical. Selected antiretroviral agents, especially tenofovir disoproxil fumarate (TDF) and some ritonavir-boosted protease inhibitors (PI/rs), have been associated with increased risk of CKD. However, the CKD risk attributable to these agents is overall small, especially in those with low baseline risk of CKD and normal renal function. CKD risk in HIV-positive individuals can be further minimized by timely identification of those with worsening renal function and discontinuation of potentially nephrotoxic agents. Clinicians can use several monitoring tools, including the D:A:D risk score and routine measurements of estimated glomerular filtration (eGFR) and proteinuria, to identify high-risk individuals who may require an intervention. Tenofovir alafenamide (TAF), a TDF alternative, promises to be safer in terms of TDF-associated kidney and bone toxicity. While the short-term data on TAF does indicate lower eGFR decline and lower risk of proteinuria (vs. TDF), long-term data on renal safety of TAF are still awaited. Promising results have also emerged from recent trials on alternative dual-therapy antiretroviral regimens which exclude the nucleoside(tide) reverse transcriptase class as well as possibly the PI/rs, thereby reducing the drug burden, and possibly the toxicity. However, long-term safety or benefits of these dual-therapy regimens are still unclear and will need to be studied in future prospective studies. Finally, addressing risk factors such as hypertension and diabetes will continue to be important in this population.
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Affiliation(s)
| | - Melinda Nugent
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Lene Ryom
- Department of Infectious Diseases, CHIP, Section 8632 Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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21
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Abstract
The development of antiretroviral therapy (ART) has dramatically increased the lifespan of HIV patients but treatment is complicated by numerous adverse effects and toxicities. ART complications include neuropsychiatric, metabolic, gastrointestinal, cardiac, and numerous other toxicities, and clinicians often have to choose one toxicity over another to offer the best medication regimen for a patient. Some antiviral drugs cause significant neuropsychiatric complications, including depression, cognitive impairment, and sleep disturbance. Even in careful studies, it may be difficult to determine which effects are related to the virus, the immune system, or the treatment. Of the six currently marketed classes of antiviral drugs, the nucleoside reverse transcriptase inhibitors and the non-nucleoside reverse transcriptase inhibitors have been most commonly associated with neuropsychiatric complications. Within these classes, certain drugs are more likely to cause difficulty than others. We review the contention regarding the central nervous system (CNS) complications of efavirenz, as well as debate about the role of CNS penetration in drug effectiveness and toxicity. A thorough working knowledge of the neuropsychiatric consequences of ART allows clinicians to tailor treatment more successfully to individual patients as well as to identify ART more quickly as the source of a problem or symptom.
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22
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Cahn P, Rolón MJ, Figueroa MI, Gun A, Patterson P, Sued O. Dolutegravir-lamivudine as initial therapy in HIV-1 infected, ARV-naive patients, 48-week results of the PADDLE (Pilot Antiretroviral Design with Dolutegravir LamivudinE) study. J Int AIDS Soc 2017; 20:21678. [PMID: 28537061 DOI: 10.7448/IAS.20.01.21678] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introduction: A proof-of-concept study was designed to evaluate the antiviral efficacy, safety and tolerability of a two-drug regimen with dolutegravir 50 mg once daily (QD) plus lamivudine 300 mg once daily as initial highly active antiretroviral therapy (HAART) among antiretroviral (ARV)-naive patients. Methods: PADDLE is a pilot study including 20 treatment-naive adults. To be selected, participants had no IAS-USA-defined resistance, HIV-1 RNA ≤100,000 copies/mL at screening and negative HBsAg. Plasma viral load (pVL) was measured at baseline; days 2, 4, 7, 10, 14, 21 and 28; weeks 6, 8 and 12; and thereafter every 12 weeks up to 96 weeks. Primary endpoint was the proportion of patients with HIV-1 RNA <50 copies/mL in an intention to treat (ITT)-exposed analysis at 48 weeks (the FDA snapshot algorithm). Results: Median HIV-1 RNA at entry was 24,128 copies/mL (interquartile range (IQR): 11,686–36,794). Albeit as per protocol, all patients had pVL ≤100,000 copies/mL at screening as required by inclusion criteria, four patients had ≥100,000 copies/mL at baseline. Median baseline CD4+ T-cell count was 507 per cubic millimetre (IQR: 296–517). A rapid decline in pVL was observed (median VL decay from baseline to week 12 was 2.74 logs). All patients were suppressed at week 8 onwards up to week 24. At week 48, 90% (18/20) reached the primary endpoint of a pVL <50 copies/mL. Median change in CD4 cell count between baseline and week 48 was 267 cells/mm3 (IQR: 180–462). No major tolerability/toxicity issues were observed. Nineteen patients completed 48 weeks of the study, and one patient (with undetectable VL at last visit) committed suicide. One patient presented a low-level protocol-defined confirmed virological failure at week 36, being the only observed failure. This patient had pVL <50 copies/mL at the end-of-study visit without having changed the two-drug regimen. Observed failure rate was 5%. This is the first report of integrase strand transfer inhibitor/lamivudine dual regimen in ARV-naive patients. Conclusions: This novel dual regimen of dolutegravir and lamivudine warrants further clinical research and consideration as a potential therapeutic option for ARV-therapy-naive patients. ClinicalTrials.gov Identifier: NCT02211482.
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23
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Abstract
: HIV infection has a significant impact on the natural history of chronic hepatitis B virus (HBV) infection, with increased levels of HBV DNA, accelerated progression of liver disease and increased liver-associated mortality compared with HBV monoinfection. Widespread uptake and early initiation of HBV-active antiretroviral therapy has substantially improved the natural history of HIV-HBV coinfection but the prevalence of liver disease remains elevated in this population. In this paper, we review recent studies examining the natural history and pathogenesis of liver disease and seroconversion in HIV-HBV coinfection in the era of HBV-active antiretroviral therapy and the effects of HIV directly on liver disease. We also review novel therapeutics for the management of HBV with a particular emphasis on clinical strategies being developed for an HBV cure and an HIV cure and their impact on HIV-HBV coinfected individuals.
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Affiliation(s)
- Kasha P Singh
- aThe Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital bVictorian Infectious Diseases Service, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity cDepartment of Infectious Diseases, Alfred Hospital and Monash University, Melbourne Australia dThai Red Cross AIDS Research Center and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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24
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Capetti AF, Astuti N, Cattaneo D, Rizzardini G. Pharmacokinetic drug evaluation of dolutegravir plus rilpivirine for the treatment of HIV. Expert Opin Drug Metab Toxicol 2017; 13:1183-1192. [PMID: 28854832 DOI: 10.1080/17425255.2017.1361929] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The search for simple, potent, metabolic-friendly and nucleoside/nucleotide sparing antiretroviral regimens has led clinical investigators to move steps towards dual therapies. Among these the association of rilpivirine and dolutegravir is emerging as a twin randomized clinical trial (SWORD1&2) and at least three observational cohort describe it as a safe and highly effective regimen for switch from other therapies Areas covered: We review the evidence supporting the use of dolutegravir plus rilpivirine for the treatment of HIV in virologically suppressed patients taking other antiretroviral regimens. The reasons for the switch in clinical practice may range from simplification to tolerability/toxicity issues, to the prevention of future metabolic damage, to predicted drug-drug interactions when treatment of HCV co-infection is planned. Articles searchable on MEDLINE/PubMed and from the main international congresses in the field of HIV therapy were reviewed to provide context for use of dolutegravir plus rilpivirine Expert opinion: This treatment is highly effective in maintaining HIV-1 RNA <50 copies/mL. Although the studies up to date requested patient to switch to drugs they had no experience of, a predictable 'radical change' effect did not impact negatively on the results. Further data from these studies may help elucidate the possible advantage in terms of safety and metabolic effect in the next few months.
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Affiliation(s)
- Amedeo F Capetti
- a 1st Division of Infectious Diseases , ASST Fatebenefratelli-Sacco , Milano , Italy
| | - Noemi Astuti
- a 1st Division of Infectious Diseases , ASST Fatebenefratelli-Sacco , Milano , Italy
| | - Dario Cattaneo
- b Clinical Pharmacology Unit , ASST Fatebenefratelli-Sacco , Milano , Italy
| | - Giuliano Rizzardini
- a 1st Division of Infectious Diseases , ASST Fatebenefratelli-Sacco , Milano , Italy.,c Whitwaterstrand University , Johannesburg , South Africa
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25
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Christensen ES, Jain R, Roxby AC. Abacavir/Dolutegravir/Lamivudine (Triumeq)-Induced Liver Toxicity in a Human Immunodeficiency Virus-Infected Patient. Open Forum Infect Dis 2017; 4:ofx122. [PMID: 28748198 PMCID: PMC5522577 DOI: 10.1093/ofid/ofx122] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 06/09/2017] [Indexed: 11/13/2022] Open
Abstract
Drug-induced liver injury related to Triumeq (abacavir/lamivudine/dolutegravir) has not been reported in clinical trials. We report a case of hepatotoxicity related to Triumeq exposure in a human immunodeficiency virus–infected patient. Clinicians should remain aware of the risk for acute and late-onset hepatitis with these agents. Close monitoring is recommended.
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Affiliation(s)
| | | | - Alison C Roxby
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle
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26
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Fettiplace A, Stainsby C, Winston A, Givens N, Puccini S, Vannappagari V, Hsu R, Fusco J, Quercia R, Aboud M, Curtis L. Psychiatric Symptoms in Patients Receiving Dolutegravir. J Acquir Immune Defic Syndr 2017; 74:423-31. [PMID: 27984559 DOI: 10.1097/QAI.0000000000001269] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Psychiatric symptoms (PSs) are reported to occur frequently in people living with HIV and may be associated with specific antiretrovirals. We analyzed PSs observed with dolutegravir (DTG) and other frequently prescribed anchor drugs. METHODS Selected PSs (insomnia, anxiety, depression, and suicidality) occurring in HIV-positive patients during DTG treatment across 5 randomized clinical trials (3 double-blind), in the Observational Pharmaco-Epidemiology Research & Analysis (OPERA) cohort, and among cases spontaneously reported to ViiV Healthcare were analyzed. RESULTS In clinical trials, PSs were reported at low and similar rates in patients receiving DTG or comparators [atazanavir, darunavir, efavirenz, or raltegravir (RAL)]. Insomnia was most commonly reported. The highest rates were observed in SINGLE (DTG 17%, efavirenz 12%), with consistently lower rates in the other trials (DTG: 3%-8% versus comparator: 3%-7%). More efavirenz-treated patients withdrew because of PSs than patients treated with other anchor drugs. In OPERA, history of PSs at baseline was lowest in efavirenz-treated patients compared with patients treated with DTG, RAL, or darunavir. Despite baseline differences, prevalence and incidence during treatment were similar across the 4 anchor drugs. Withdrawal rates for PSs were lowest for DTG (0%-0.6%) and highest for RAL (0%-2.5%). Spontaneously reported events were similar in nature to clinical trial data. CONCLUSIONS Analysis of 3 different data sources shows that, similar to other frequently prescribed anchor drugs to treat HIV infection, PSs are also reported in DTG-treated patients. These events are reported with low frequency and rarely necessitate DTG discontinuation.
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Waqas S, O'Connor M, Levey C, Mallon P, Sheehan G, Patel A, Avramovic G, Lambert JS. Experience of dolutegravir in HIV-infected treatment-naive patients from a tertiary care University Hospital in Ireland. SAGE Open Med 2016; 4:2050312116675813. [PMID: 27826447 PMCID: PMC5084612 DOI: 10.1177/2050312116675813] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 09/28/2016] [Indexed: 11/30/2022] Open
Abstract
Objective: Dolutegravir, an HIV integrase inhibitor, is a relatively new treatment option. To assess the tolerability, side effects, and time to viral decline to non-detectable in patients newly started on dolutegravir. Methods: Retrospective health care record of 61 consecutive HIV treatment-naive patients started on dolutegravir was reviewed and analysed on SPSS. Results: The mean initial viral load was 160826.05 copies/mL (range, 79–1,126,617 copies/mL). HIV viral load became non-detectable in 63.9% of patients on dolutegravir within 3 months. In all, 60.7% of patients reported no side effects on dolutegravir; 98.4% of the patients claimed full compliance to their antiretrovirals. Conclusion: Dolutegravir was found to be efficacious and well tolerated in HIV-infected treatment-naive patients.
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Affiliation(s)
- Sarmad Waqas
- Infectious Diseases Department, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Mairead O'Connor
- Pharmacy Department, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ciara Levey
- Pharmacy Department, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Paddy Mallon
- Infectious Diseases Department, Mater Misericordiae University Hospital, Dublin, Ireland; University College Dublin, Dublin, Ireland
| | - Gerard Sheehan
- Infectious Diseases Department, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Anjali Patel
- Catherine McAuley Education & Research Centre, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Gordana Avramovic
- Catherine McAuley Education & Research Centre, Mater Misericordiae University Hospital, Dublin, Ireland
| | - John S Lambert
- Infectious Diseases Department, Mater Misericordiae University Hospital, Dublin, Ireland; University College Dublin, Dublin, Ireland; Rotunda Hospital, Dublin, Ireland
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Rutherford GW, Horvath H. Dolutegravir Plus Two Nucleoside Reverse Transcriptase Inhibitors versus Efavirenz Plus Two Nucleoside Reverse Transcriptase Inhibitors As Initial Antiretroviral Therapy for People with HIV: A Systematic Review. PLoS One 2016; 11:e0162775. [PMID: 27736859 PMCID: PMC5063380 DOI: 10.1371/journal.pone.0162775] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 08/29/2016] [Indexed: 01/08/2023] Open
Abstract
Background Dolutegravir (DTG) is a once-daily unboosted second-generation integrase-inhibitor that along with two nucleoside reverse transcriptase inhibitors is one of several regimens recommended by the United States, United Kingdom and European Union for first-line antiretroviral treatment of people with HIV infection. Our objective was to review the evidence for the efficacy and safety of DTG-based first-line regimens compared to efavirenz (EFV)-based regimens. Methods We conducted a systematic review. We comprehensively searched a range of databases as well as conference abstracts and a trials registry. We used Cochrane methods in screening and data collection and assessed each study’s risk of bias with the Cochrane tool. We meta-analyzed data using a fixed-effects model. We used GRADE to assess evidence quality. Results From 492 search results, we identified two randomized controlled trials, reported in five peer-reviewed articles and one conference abstract. One trial tested two DTG-based regimens (DTG + abacavir (ABC) + lamivudine (3TC) or DTG + tenofovir + emtricitabine) against an EFV-based regimen (EFV+ ABC+3TC). The other trial tested DTG+ABC+3TC against EFV+ABC+3TC. In meta-analysis, DTG-containing regimens were superior to EFV-containing regimens at 48 weeks and at 96 weeks (RR = 1.10, 95% CI 1.04–1.16; and RR = 1.12, 95% CI 1.04–1.21, respectively). In one trial, the DTG-containing regimen was superior at 144 weeks (RR = 1.13, 95% CI 1.02–1.24). DTG-containing regimens were superior in reducing treatment discontinuation compared to those containing EFV at 96 weeks and at 144 weeks (RR = 0.27, 95% CI 0.15–0.50; and RR = 0.28, 95% CI 0.16–0.48, respectively). Risk of serious adverse events was similar in each regimen at 96 weeks (RR = 1.15, 95% CI 0.80–1.63) and 144 weeks (RR = 0.93, 95% CI 0.68–1.29). Risk of bias was moderate overall, as was GRADE evidence quality. Conclusions DTG-based regimens should be considered in future World Health Organization guidelines for initial HIV treatment.
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Affiliation(s)
- George W. Rutherford
- Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Hacsi Horvath
- Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
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Abstract
INTRODUCTION Since the last revision of both European and American guidelines (EACS and DHHS), new data from clinical trials and cohort studies, as well as experience in clinical practice, have prompted significant changes to the list of recommended/preferred options for the treatment of HIV infected patients, highlighted the role of INSTI-based regimens. Dolutegravir (DTG) in combination with abacavir/lamivudine (ABC/3TC) is one of these preferred regimens in multiple clinical scenarios, including treatment-naive and treatment-experienced patients. AREAS COVERED In this article we describe the coformulation of ABC/3TC/DTG in a fixed-dose combination (FDC) approved in September 2014 for the treatment of HIV infection. We focused our research on the efficacy and safety data resulting from phase 2 and 3 clinical study, particularly on the results of both SPRING (1 and 2) and SINGLE studies. EXPERT OPINION Triple combination therapy with ABC/3TC/DTG should be considered among the initial options for treatment-naive patients, being effective, well tolerated, with a high genetic barrier to resistance along with a convenient once-daily administration. In treatment-experienced patients the single-tablet regimen (STR) based on ABC/3TC/DTG could be used as simplification strategy in subjects with sustained viral suppression, as the high genetic barrier of DTG should ensure a safe switch from both NNRTI or PI based regimens.
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Affiliation(s)
- Laura Comi
- a USC Malattie Infettive , Azienda Ospedaliera Papa Giovanni XXIII Ringgold standard institution , Bergamo , Italy
| | - Franco Maggiolo
- a USC Malattie Infettive , Azienda Ospedaliera Papa Giovanni XXIII Ringgold standard institution , Bergamo , Italy
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Bares SH, Sandkovsky US, Talmon GA, Hutchins GF, Swindells S, Scarsi KK. Dolutegravir-induced colitis in an HIV-infected patient. J Antimicrob Chemother 2015; 71:281-2. [PMID: 26410169 DOI: 10.1093/jac/dkv296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Sara H Bares
- Department of Internal Medicine/Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Uriel S Sandkovsky
- Department of Internal Medicine/Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Geoffrey A Talmon
- Department of Pathology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Grant F Hutchins
- Department of Internal Medicine/Gastroenterology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Susan Swindells
- Department of Internal Medicine/Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kimberly K Scarsi
- Department of Pharmacy Practice, University of Nebraska Medical Center, Omaha, NE, USA
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Park TE, Mohamed A, Kalabalik J, Sharma R. Review of integrase strand transfer inhibitors for the treatment of human immunodeficiency virus infection. Expert Rev Anti Infect Ther 2015; 13:1195-212. [PMID: 26293294 DOI: 10.1586/14787210.2015.1075393] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Integrase strand transfer inhibitors (INSTIs) are oral antiretroviral agents used against HIV infection. There are three agents available, including raltegravir, elvitegravir and dolutegravir, some of which are available as combination medications with other antiretroviral drugs. The efficacy and safety of INSTIs in treatment-naïve and experienced HIV-infected patients have been established by multiple studies. Based on the current practice guidelines, INSTI-based regimens are considered as one of the first-line therapies for treatment-naïve HIV-infected patients. There are new INSTIs in development to improve the resistance profile and to decrease the frequency of drug administration.
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Affiliation(s)
- Tae Eun Park
- a 1 Fairleigh Dickinson University, School of Pharmacy, 230 Park Avenue, M-SP1-01, Florham Park, NJ 07901, USA
| | - Abdilahi Mohamed
- a 1 Fairleigh Dickinson University, School of Pharmacy, 230 Park Avenue, M-SP1-01, Florham Park, NJ 07901, USA
| | - Julie Kalabalik
- a 1 Fairleigh Dickinson University, School of Pharmacy, 230 Park Avenue, M-SP1-01, Florham Park, NJ 07901, USA
| | - Roopali Sharma
- b 2 Long Island University Arnold & Marie Schwartz College of Pharmacy and Health Sciences, 450 Clarkson Avenue Box 36, Brooklyn, NY 11203, USA
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Abstract
Dolutegravir is the newest integrase strand transfer inhibitor to be approved for the treatment of human immunodeficiency virus (HIV) infection. Dolutegravir is equivalent or superior to existing treatment regimens in both treatment-naïve and treatment-experienced patients including those with previous raltegravir or elvitegravir failure. The consistent efficacy coupled with excellent tolerability and infrequent drug–drug interactions makes the co-formulation of dolutegravir with two nucleotide reverse-transcriptase inhibitors an attractive treatment option. This review summarizes the pharmacokinetics, adverse event profile, and efficacy of dolutegravir in the treatment of HIV.
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Affiliation(s)
| | - Sharon L Walmsley
- Department of Medicine, University of Toronto, Toronto, ON, Canada ; Division of Infectious Diseases, University Health Network, Toronto, ON, Canada
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Bollen P, Reiss P, Schapiro J, Burger D. Clinical pharmacokinetics and pharmacodynamics of dolutegravir used as a single tablet regimen for the treatment of HIV-1 infection. Expert Opin Drug Saf 2015; 14:1457-72. [PMID: 26134478 DOI: 10.1517/14740338.2015.1059818] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION With the introduction of the coformulated dolutegravir, abacavir and lamivudine , a new single tablet regimen (STR) is made available for the use in treatment-naive and treatment-experienced HIV-infected patients. This drug combination is the fourth STR that will be positioned next to the STRs with efavirenz, rilpivirine or elvitegravir as third agents, respectively. AREAS COVERED The objective of this review is to provide an overview of the efficacy and safety of the combined dolutegravir/abacavir/lamivudine coformulation. The review will focus on dolutegravir and includes both published data as well as data presented at recent major international HIV/AIDS conferences. EXPERT OPINION The dolutegravir/abacavir/lamivudine regimen is highly effective in achieving sustained suppression of HIV-1 RNA plasma concentrations. The STR has a favorable safety profile and a low potential for drug interactions, which will contribute to a prominent role in therapy. As this STR contains abacavir as backbone component, the use requires patients to be HLA-B*5701 negative, with good hepatic function. Other first-line treatment combinations are preferred for patients with hepatitis B co-infection or with a high cardiovascular risk.
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Affiliation(s)
- Pauline Bollen
- a 1 Radboud University Medical Center, Department of Pharmacy , Geert Grooteplein-Zuid 10 6525 GA Nijmegen, The Netherlands
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Calcagno A, Nozza S, Muss C, Celesia BM, Carli F, Piconi S, De Socio GV, Cattelan AM, Orofino G, Ripamonti D, Riva A, Di Perri G. Ageing with HIV: a multidisciplinary review. Infection 2015; 43:509-22. [PMID: 25987480 DOI: 10.1007/s15010-015-0795-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 05/07/2015] [Indexed: 02/08/2023]
Abstract
INTRODUCTION After the introduction of highly active antiretroviral treatment, the course of HIV infection turned into a chronic disease and most of HIV-positive patients will soon be over 50 years old. MATERIAL AND METHODS This paper reviews the multiple aspects that physicians have to face while taking care of HIV-positive ageing patients including the definitions of frailty and the prevalence and risk factors of concomitant diseases. From a therapeutic point of view pharmacokinetic changes and antiretroviral-specific toxicities associated with ageing are discussed; finally therapeutic approaches to frailty are reviewed both in HIV-positive and negative patients. CONCLUSION AND DISCUSSION We conclude by suggesting that the combined use of drugs with the least toxicity potential and the promotion of healthy behaviours (including appropriate nutrition and exercise) might be the best practice for ageing HIV-positive subjects.
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