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Orkin C, Oka S, Philibert P, Brinson C, Bassa A, Gusev D, Degen O, García JG, Morell EB, Tan DHS, D'Amico R, Dorey D, Griffith S, Thiagarajah S, St Clair M, Van Solingen-Ristea R, Crauwels H, Ford SL, Patel P, Chounta V, Vanveggel S, Cutrell A, Van Eygen V, Vandermeulen K, Margolis DA, Smith KY, Spreen WR. Long-acting cabotegravir plus rilpivirine for treatment in adults with HIV-1 infection: 96-week results of the randomised, open-label, phase 3 FLAIR study. Lancet HIV 2021; 8:e185-e196. [PMID: 33794181 DOI: 10.1016/s2352-3018(20)30340-4] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/04/2020] [Accepted: 12/10/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is a need for more convenient, less frequent treatment to help address challenges associated with daily oral HIV treatment in people living with HIV, including stigma, pill burden, drug-food interactions, and adherence. The phase 3 ATLAS and FLAIR studies showed non-inferiority of long-acting cabotegravir and rilpivirine dosed every 4 weeks compared with standard oral therapy for the maintenance of virological suppression in adults with HIV-1 over 48 weeks. We present the 96-week findings. METHODS FLAIR is a randomised, phase 3, open-label, multicentre study done in 11 countries investigating whether switching to long-acting cabotegravir and rilpivirine is non-inferior to daily dolutegravir, abacavir, and lamivudine in virologically suppressed adults living with HIV-1. Antiretroviral therapy (ART)-naive participants received induction therapy with daily oral dolutegravir (50 mg), abacavir (600 mg), and lamivudine (300 mg) for 20 weeks. After 16 weeks, participants with less than 50 HIV-1 RNA copies per mL were randomly assigned (1:1) to continue the standard of care regimen (standard care group) or switch to receive daily oral cabotegravir 30 mg and rilpivirine 25 mg for at least 4 weeks followed by long-acting cabotegravir 400 mg and rilpivirine 600 mg, administered as two 2 mL intramuscular injections, every 4 weeks for at least 96 weeks (long-acting group). Randomisation was stratified by baseline (preinduction) HIV-1 RNA (<100 000 or ≥100 000 copies per mL) and sex at birth and used GlaxoSmithKline-verified randomisation software (RandAll NG, version 1.3.3) for treatment assignment. The primary endpoint was the proportion of participants with plasma HIV-1 RNA of 50 copies per mL or more assessed as per the US Food and Drug Administration (FDA) Snapshot algorithm at week 48, which has been reported previously. Here, we report the proportion of participants with 50 or more HIV-1 RNA copies per mL using the FDA Snapshot algorithm at week 96 (intention-to-treat population; non-inferiority margin 6%). The trial is registered with ClinicalTrials.gov, NCT02938520. FINDINGS Between Oct 27, 2016, and March 24, 2017, 809 participants were screened. 631 (78%) participants entered the induction phase and 566 (70%) were randomly assigned to either the standard care group (283 [50%] participants) or the long-acting group (283 [50%]). Median age was 34 years (IQR 29 to 43), 62 (11%) were 50 years or older, 127 (22%) were women (sex at birth), and 419 (74%) were white. At week 96, nine (3%) participants in each arm had 50 or more HIV-1 RNA copies per mL, with an adjusted difference of 0·0 (95% CI -2·9 to 2·9), consistent with non-inferiority established at week 48. Across both treatment groups, adverse events leading to withdrawal were infrequent (14 [5%] participants in the long-acting group and four [1%] in the standard care group). Injection site reactions were the most common adverse event, reported by 245 (88%) participants in the long-acting group; their frequency decreased over time. Median injection site reaction duration was 3 days (IQR 2 to 4), and 3082 (99%) of 3100 reactions were grade 1 or 2. No deaths occurred during the maintenance phase. INTERPRETATION The 96-week results reaffirm the 48-week results, showing long-acting cabotegravir and rilpivirine continued to be non-inferior compared with continuing a standard care regimen in adults with HIV-1 for the maintenance of viral suppression. These results support the durability of long-acting cabotegravir and rilpivirine, over an almost 2-year-long period, as a therapeutic option for virally suppressed adults with HIV-1. FUNDING ViiV Healthcare and Janssen Research and Development.
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Affiliation(s)
- Chloe Orkin
- Department of Immunobiology, Queen Mary University, London, UK.
| | - Shinichi Oka
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Patrick Philibert
- Department for Internal Medicine and Infectious Diseases, Hôpital Européen, Marseille, France
| | | | - Ayesha Bassa
- Mzansi Ethical Research Centre, Middelburg, South Africa
| | - Denis Gusev
- State Medical Center for the Prevention and Control of AIDS and Infectious Diseases, St Petersburg, Russia; St Petersburg State Budgetary Health Care Institution, St Petersburg, Russia
| | - Olaf Degen
- Infectious Diseases Unit, Outpatient Center, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Juan González García
- Department for Internal Medicine, Hospital La Paz Institute for Health Research, Hospital Universitario La Paz, Madrid, Spain
| | - Enrique Bernal Morell
- Sección de Enfermedades Infecciosas, Hospital General Universitario Reina Sofía, Murcia, Spain
| | - Darrell H S Tan
- Division of Infectious Diseases, Department of Medicine, St Michael's Hospital, Toronto, ON, Canada
| | - Ronald D'Amico
- Research and Development, ViiV Healthcare, Research Triangle Park, NC, USA
| | - David Dorey
- Biostatistics, GlaxoSmithKline, Mississauga, ON, Canada
| | - Sandy Griffith
- Research and Development, ViiV Healthcare, Research Triangle Park, NC, USA
| | | | - Marty St Clair
- Translational Medical Research, ViiV Healthcare, Research Triangle Park, NC, USA
| | | | - Herta Crauwels
- Infectious Diseases & Vaccines, Janssen Research & Development, Beerse, Belgium
| | - Susan L Ford
- Clinical Pharmacology, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Parul Patel
- Research and Development, ViiV Healthcare, Research Triangle Park, NC, USA
| | | | - Simon Vanveggel
- Global Development, Janssen Research & Development, Beerse, Belgium
| | - Amy Cutrell
- Research Statistics, ViiV Healthcare, Research Triangle Park, NC, USA
| | - Veerle Van Eygen
- Infectious Diseases & Vaccines, Janssen Research & Development, Beerse, Belgium
| | - Kati Vandermeulen
- Infectious Diseases & Vaccines, Janssen Research & Development, Beerse, Belgium
| | - David A Margolis
- Research and Development, ViiV Healthcare, Research Triangle Park, NC, USA
| | - Kimberly Y Smith
- Research and Development, ViiV Healthcare, Research Triangle Park, NC, USA
| | - William R Spreen
- Research and Development, ViiV Healthcare, Research Triangle Park, NC, USA
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Nelson M, Winston A, Hill A, Mngqibisa R, Bassa A, Orkin C, Rassool M, Rodgers A, Teal V, Kumar S, Teppler H. Efficacy, safety and central nervous system effects after switch from efavirenz/tenofovir/emtricitabine to doravirine/tenofovir/lamivudine. AIDS 2021; 35:759-767. [PMID: 33587439 DOI: 10.1097/qad.0000000000002804] [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: 02/05/2023]
Abstract
OBJECTIVE Doravirine is an alternative treatment option for individuals who do not tolerate efavirenz. We assessed efficacy, safety, and CNS effects in adults with HIV-1 and CNS complaints who switched from an efavirenz-based regimen to a doravirine-based regimen. DESIGN Multicenter, double-blind, randomized trial (NCT02652260). METHODS Virologically suppressed adults receiving efavirenz/emtricitabine/tenofovir (EFV/FTC/TDF), or its components, with ongoing EFV-associated CNS toxicity grade 2 or higher (DAIDS criteria) were switched to doravirine/lamivudine/tenofovir (DOR/3TC/TDF) on day 1 (Immediate Switch Group [ISG]) or after 12 weeks (Deferred Switch Group [DSG]). CNS toxicity data were collected by self-administered questionnaire. The primary endpoint was the proportion of participants with any grade 2 or higher CNS toxicity at week 12. Secondary endpoints included virologic response and effect on fasting lipids. RESULTS Eighty-six participants (58% men, 56% black, median age 41 years, median 4 years on prior EFV regimen) were enrolled (43 ISG, 43 DSG) and included in the analyses. At week 12, 42% of ISG and 37% of DSG had at least 1 grade 2 or higher CNS toxicity [difference 4.7%, 95% CI (-16 to 25%); P = 0.33]. At 24 weeks postswitch, HIV-1 RNA less than 50 copies/ml was maintained in 95.3% of participants, and fasting lipids were significantly decreased (LDL-cholesterol -11.0, non-HDL-cholesterol -13.2, HDL-cholesterol -7.7, total cholesterol -20.9, and triglycerides -13.0 mg/dl). CONCLUSION In participants who had CNS complaints while receiving EFV/FTC/TDF, improvement in CNS toxicities attributable to EFV was not significantly different after switching to DOR/3TC/TDF compared with remaining on EFV/FTC/TDF. Virologic efficacy was maintained and lipid profiles improved after switching to DOR/3TC/TDF.
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Affiliation(s)
- Mark Nelson
- Department of HIV Medicine, Chelsea and Westminster Hospital NHS Foundation Trust
- Imperial College London, London
| | | | - Andrew Hill
- Department of Translational Medicine, University of Liverpool, Liverpool, UK
| | | | - Ayesha Bassa
- Mzansi Ethical Research Centre, Middleburg, South Africa
| | | | - Mohammed Rassool
- University of Witwatersrand, Clinical HIV Research Unit, Helen Joseph Hospital, Johannesburg, South Africa
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Abstract
OBJECTIVES A retrospective study to confirm the clinical impression of an increasing prevalence of granuloma inguinale (GI) in women, and to evaluate its association with pregnancy and HIV infection. METHODS Clinical records of all patients with a definitive diagnosis of GI attending the gynecology and antenatal clinics at King Edward VIII Hospital, Durban, South Africa, over a period of 36 months (January 1991-December 1993). RESULTS A total of 123 women were diagnosed with GI. The diagnosis was made by tissue smear alone in 21% (n = 26), histology 43% (n = 53) and by a combination of smear and histology in the rest. Forty-two percent (n = 52) were pregnant. The only difference between pregnant and non-pregnant women were the presence of rectal and pelvic lesions in the latter. Sixty-nine percent (n = 36) delivered vaginally while the remaining (n = 16) were delivered by cesarean section. The indications for cesarean section were obstetric except for a patient in labor with extensive untreated vulval granuloma. In the majority (85%) GI had no influence on pregnancy outcome. There was no evidence of congenital GI in the neonates. Twenty-seven percent (30/113) had positive syphilis serology and 16% (18/110) had antibody to HIV. There were no differences in the clinical features and outcome of HIV positive and negative women. CONCLUSION This study shows that GI is increasing in pregnancy in Durban, South Africa. Despite the concern that pregnancy promotes dissemination of GI, such an effect could not be established as the clinical response to treatment and outcome were similar in both pregnant and non-pregnant women. Infection with HIV also did not alter the clinical presentation and outcome of the disease in the patients studied.
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Affiliation(s)
- A A Hoosen
- Department of Medical Microbiology, Faculty of Medicine, University of Natal, Durban, South Africa
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Abstract
Pseudomonas paucimobilis (formerly CDC group IIK, biotype 1) is a strictly aerobic, nonfermenting, oxidase- and catalase-positive, gram-negative bacillus that is widely distributed in water and soil. Its name derives from the difficulty encountered in demonstrating its motility, even in liquid media. This microorganism is responsible for two types of infection in humans: sporadic or community-acquired infections, probably of endogenous or environmental origin (bacteremia, meningitis, urinary tract infection, and wound infection); and outbreaks of nosocomial infection associated with the contamination of sterile fluids employed in hospitals. We present four cases of infection caused by P. paucimobilis (two of bacteremia, one of leg ulcer infection, and one of cervical adenitis). The majority of infections produced by P. paucimobilis have a good prognosis; no deaths related to this entity have been reported in the literature. The published results of susceptibility tests suggest that the aminoglycosides (either alone or in combination with a beta-lactam antibiotic) or the quinolone may be the agents of choice in the treatment of these infections.
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Affiliation(s)
- J Reina
- Service of Clinical Microbiology, Hospital Son Dureta, Palma de Mallorca, Spain
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Reñé R, Mas A, Villabona CM, Ricart MC, Bassa A, Tolosa F. [Otitis externa maligna and cranial neuropathy]. Neurologia 1990; 5:222-7. [PMID: 2288752] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Malignant external otitis (MEO) is a disease of the external auditive channel (EAC) due to Pseudomonas aeruginosa which usually involves individuals with diabetes mellitus. It may result in the invasion of the cranial base with cranial neuropathy and a high mortality rate despite therapy. We report the clinical features, diagnostic procedures, evolution and therapy of 8 patients with MEO, seven of which had cranial neuropathy. All patients have diabetes except one who had acquired immunodeficiency syndrome. All had otalgia, otorrhea and headache lasting for several months. Six patients had homolateral (as related to the MEO) facial palsy. One patient with bilateral MEO developed bilateral facial palsy and lesion of the cranial nerves VI (unilaterally) and IX through XII (bilaterally). In all patients P. aeruginosa was cultured from the EAC exudate scintigraphy with 99Tc showed uptake at medium ear and mastoid level in all 8 patients, suggesting a possible osteomyelitis. Scintigraphy with 67Ga was positive in the 6 cases where it was carried out, showing uptake in the soft tissues of the cranial base. Computed tomography was carried out in 6 patients, and it was useful to define the anatomical extent of the disease. The patients received different therapeutic schedules, particularly the combination of a betalactamic and aminoglucoside antibiotics. Follow up was characterized by common recurrences, and one patient died. The importance of early diagnosis and treatment to prevent the extension and recurrence of MEO are discussed. Cranial neuropathy is considered as a poor prognostic finding.
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Affiliation(s)
- R Reñé
- Sección de Neurología, Otorrinolaringología, Hospital de Son Dureta, Palma de Mallorca
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