Resistance to novel integrase inhibitors

Transcription

1 Resistance to novel integrase inhibitors Dr Anne-Geneviève Marcelin Virology - Pitié-Salpêtrière Hospital INSERM U943, UPMC HIV integrase Dr Anne-Geneviève Marcelin 1

2 HIV Integration: A Six Step Process Step 4: Preintegration Complex- Host DNA Binding Dr Anne-Geneviève Marcelin 2

3 Step 5: Strand Transfer of HIV DNA into the Host DNA Dr Anne-Geneviève Marcelin 3

4 DTG and RAL as Mg2+ chelators Dr Anne-Geneviève Marcelin 4

5 In vitro passages DTG, RAL and EVL Mean FC against RAL & ELV-related Single Mutation SDMs Dr Anne-Geneviève Marcelin 5

6 Integrase Inhibitors and Dissociation Integrase Inhibitors and Dissociation Dr Anne-Geneviève Marcelin 6

7 Dissociative Half-lives for INIs with IN Mutants In vivo Resistance to RAL Relatively low genetic barrier to resistance Resistance mutations in 40-50% of virological failures Sometimes very rapidly and at low level of VL (Malet, JAC 2009) Resistance profiles Mutations at positions Y143, Q148 and N155 Evolution of profiles: N155 => Q148 Q148 selected more frequently in B vs non B subtypes (Geretti, IHHDRW 2010; Maiga, Antiviral Ther 2009) New resistance pathways G118R (FC to RAL = 25), H121Y (FC to RAL = 29) (Malet, JAC 2012) Dr Anne-Geneviève Marcelin 7

8 - N = 468 patients - VL < 50 copies/ml at M6 in 71% of cases - Nbr of active drugs failures (43% with known RAL resistance mutations) IJAA 2013 JAC 2012 Dr Anne-Geneviève Marcelin 8

9 What do we have learned with RAL? To use RAL in combination with at least to active drugs To manage very carefully failures to RAL To stop RAL in case of failure To avoid selection of resistance mutation and evolution towards 2 nd generation INI resistance (Q148 profile) Evolution of RAL resistance profiles between 2008 and 2012 Percent Single primary mutations alone Y143C Y143H Y143R Q148H a Q148K Q148R N155H -0,34 0,3 3,35-10,37-1,7-1,31 2,99 Secondary (S) Q148H/K/R + S or P b mutations G140 A, C, S < 1 S 2 S 2 S 3 S 2 P -13,08-6,66-5,45-4,49-0,96-1,17 Aug Dec 2009 (n = 273) Aug Feb 2012 (n = 806) Change in prevalence (%) a Q148 pathway count columns bolded b S denotes secondary mutations and P denotes primary mutations; eg, «2S» indicates 2 secondary mutations, «3 S» indicates 3 secondary mutations Decrease of the Q148 frequency between 2008 and 2012 Underwood M, IWHHVDR 2013, Abs 85 Dr Anne-Geneviève Marcelin 9

10 Quad vs EFV or ATV/r (with TDF/FTC) Pre-specified pooled analysis of GS 102 and 103 Resistance Analysis Population % (n) Emergent drug resistance through W96 (integrated analysis 0102 and 0103) Developed Any primary Resistance to Study Drugs % (n) Baseline to week 48 > week 48 to week 96 Emergent primary Resistance Mutations % (n) NRTI-R 3rd agent Primary PI-R STB (n = 701) ATR (n = 352) ATV/r + TVD (n = 355) 5,1% (36) 6,5% (23) 4,5% (16) 2,3% (16) 2,8% (10) 0% (0) 1,9% (13) 0,4% (3) FTC/TDF 2,1% (15) M184V/I 2,1% (15) K65R 0,7% (5) EVG (INSTI) 2,0% (14) E92Q 1,3%(9) N155H 0,7%(5) Q148R 0,4% (3) T66I 0,3% (2) 2,3% (8) 0,6% (2) FTC/TDF 0,9% (3) M184V/I 0,9% (3) K65R 0,9% (3) EFV (NNRTI) 2,8% (10) K103N 2,6% (9) K101E 0,9% (3) V108I 0,6% (2) Y188F/H/L 0,6% (2) M230L 0,6% (2) V90I 0,3% (1) G190A 0,3% (1) P225H 0,3% (1) 0% (0) 0% (0) FTC/TDF 0% (0) M184V/I 0 K65R 0 ATV/r (PI/r) 0% (0) I50L 0 I84V 0 N88S 0 0% (0) 0,6% (2) 0% (0) White K, IWHHVDR 2013, Abs 80 Dr Anne-Geneviève Marcelin 10

11 HIV-1 Integrase Phenotypes Show Concordant Susceptibility for EVG and RAL (>biological cut-off) (Matched Baseline and Virologic Failure Samples from 0102 and 0103) RAL Susceptibility (Fold-change vs. WT) 100 Sensitive to EVG and RAL 10 1 EVG cut-off Baseline Integrase Samples Post-Baseline Integrase Samples Reduced Susceptibility to EVG and RAL EVG Susceptibility (fold change vs. WT) RAL cut-off Biological cut-offs for EVG and RAL are 2.5 and 1.5, respectively (PhenoSense assay) Mead fold change value for HIV-1 from patients with reduced susceptibility to EVG was 64-fold and mean fold change value for RAL was 8-fold Y143 mutations to RAL : cross resistance to EVG (1) Phenotypic tests of 77 patients viruses with Y143X mutations selected by RAL, SDM variants with Y143X alone or associated with secondary mutation(s) RAL phenotype (n = 77), FC CI Y143R (n = 44) Y143C Y143A/H/G/S (n = 23) (n = 10) EVG phenotype, FC CI FC médiane (extrêmes) vs souche sauvage NL43: Y143R FC > 150 (13-150) Y143C FC = 100 (3,9 - > 150) Y143A/H/G/S = 115 (42 - > 150) FC médiane (extrêmes) vs souche sauvage NL43: Y143R FC = 20 (2,8-93) Y143C FC = 14 (1,9 - > 150) Y143A/H/G/S = 27 (7,3 - > 150) EVG phenotype, FC CI 50 Y143H Y143C Y143S Y143G Y143A Y143R Y143X Y143X+L74M Y143X+L74I Y143X+G163R Y143X+T97A Y143X+S230R Y143X+T97A+ L74M Y143X+T97A+ L74I Y143X+T97A+ G163R Y143X+T97A+ S230R Y143X+T97A+ S230R+L74M Y143X+T97A+ S230R+L74I 1 Y143R (n = 44) Y143C Y143A/H/G/S (n = 23) (n = 10) Huang W, IWHHVDR 2013, Abs. 89 Dr Anne-Geneviève Marcelin 11

12 Y143 mutations to RAL : cross resistance to EVG (2) Patients viruses 100 Mutated viruses (SDM) FC EVG FC EVG FC RAL FC RAL Conclusion Virus with Y143 mutations selected by RAL are cross resistant to EVG Secondary mutations strongly impact cross resistance RAL- EVG Huang W, IWHHVDR 2013, Abs. 89 What do we know about EVG resistance? Similar resistance behavior to RAL Cross resistance with RAL No possible sequencing of RAL and EVG Dr Anne-Geneviève Marcelin 12

13 Protocol-Defined Virologic Failure (PDVF): Genotype Amongst DTG-treated subjects, no integrase nor NRTI mutations were detected through Week 48 DTG 50 mg QD n=411 RAL 400 mg BID n=411 Subjects with PDVF 20 (5%) 28 (7%) IN genotypic results at BL and time of PDVF 8 18 INI-r mutations 0 1/18 (6%) a PR/RT genotypic results at BL and time of PDVF NRTI-r mutations 0 4/19 (21%) a,b,c,d Mutations by subject in the RAL 400 mg BID arm: a T97T/A, E138E/D, V151V/I, N155H + A62A/V, K65K/R, K70K/E, M184V b, c, d A62A/V (n=1), M184M/I (n=1), M184M/V (n=1) XIX International AIDS Conference July 22-27, 2012; Washington, DC Raffi F et al. 19th IAC Jul Abstract THLBB04. Virology: Resistance DTG 50mg +ABC/3TC QD (N=414) Atripla QD (N=419) Subjects with PDVF 18 (4%) 17 (4%) PDVF genotypic population 11 9 PDVF Genotypic (RT Results at Baseline and PDVF) 9 9 NRTI tmt-emergent major mutations 0 1(K65R) NNRTI tmt-emergent major mutations 0 4 (K101E, K103N, G190A)* PDVF Genotypic (IN Results at Baseline and PDVF) 7 7 INI-r tmt-emergent major substitution 0** 0 * n=1 with K101E, n=1 with K103N, n=1 with G190A and n=1 with K103N+G190A **E157Q/P polymorphism detected with no significant change in IN phenotypic susceptibility Walmsley S, et al. 52 nd ICAAC Sept Abstract H-556b. XIX International AIDS Conference July 22-27, 2012; Washington, DC Dr Anne-Geneviève Marcelin 13

14 PDVF and Treatment-Emergent Resistance PDVF was defined as 2 consecutive HIV-1 RNA values >200 c/ml, on or after Week 24 DTG 50 mg QD DRV/r 800 mg/100 mg QD PDVF, n (%) 2 (<1) 2 (<1) Treatment-emergent primary mutations (INI, NRTI, PI) 0 a 0 a One individual in the DTG treatment group had phenotypic resistance to nelfinavir. This individual had secondary PI resistance mutations L10V, I13V, K20R, E35D, M36I, I62I/V, L63T and L89M at baseline and at PDVF. PDVF, protocol-defined virologic failure Feinberg et al. ICAAC 2013; Denver, CO. Abstract H-1464a. 53rd Interscience Conference on Antimicrobial Agents and Chemotherapy; September 10-13, 2013; Denver, CO DTG in naïve patients To date, no INIs or NRTIs resistance mutations detected at VF in the DTG arms: SPRING: 2NRTIs + DTG vs. RAL SINGLE: ABC/3TC + DTG vs. ATR Flamingo: 2NRTI + DTF vs. DRV/r But: Very few failures, sequences performed on the first plasma samples at failure (clinical studies vs. routine practice), only known INIs resistance mutations analyzed Dr Anne-Geneviève Marcelin 14

15 SAILING (ING ) HIV-1 treatmentexperienced, INI-naive HIV-1 RNA > 400 c/ml (2x) or > 1000 c/ml (1x) 1:1Randomization Stratified by VL, DRV.r use without primary PI resistance # of fully active drugs Randomized phase DTG 50 mg QD + RAL PBO + background regimen DTG PBO + RAL 400 mg BID background regimen 2 class resistant at screening Investigator selected regimen At least 1 fully active, 2 max drugs in background regimen Randomization Week 24 Week 48 *At screening and a second consecutive test > 400 c/ml within 4 months prior to screening (if screening HIV-1 RNA > 1000 c/ml, no additional HIV-2 RNA assessment was needed). **PBO = Placebo Underwood M, IWHHVDR 2013, Abs 21 SAILING (ING ) Emergence of INI mutations through W24 DTG 50 mg QD n (%) RAL 400 mg BID n (%) PDVF week 24 (VL > 400 cp/ml) 14 (4) 34 (9) BL and PDVF data 9 (64) 27 (80) No emergent IN substitutions 7 (78) 18 (67) Any emergent IN substitutions 2 (22) 9 (33) Emergence of IN mutations associated with development of resistance to INI class L68L/V, L74L/M, E92E/Q, T97A, T97T/A, G140A, G140S, Y143Y/C, Y143R, Y143Y/R/H/C, Q148H, Q148Q/R, V151I, V151V/I, N155H, N155N/H, E157E/Q, G163K 0 9 (33) R263K, R263R/K 2 (22) 0 Less selected mutations at W24 in DTG vs RAL arm Selection of the R263K mutation in the DTG arm (n = 2) 2 more patients at W48: E138T/A + T97A (Q148 at baseline) and V151V/I Underwood M, IWHHVDR 2013, Abs 21 Dr Anne-Geneviève Marcelin 15

16 SAILING (ING ) DTG, RAL and EVG FC in simple et double mutants (SDM) R263K/V260I DTG, RAL and EVG fold change IC 50 versus site-directed mutant HIV-1 Strain IN substitution / FC IC 50 DTG RAL EVG NL432 a R263K 1,5 0,8 1,3 HXB2 V260I 1,0 0,7 5,3 RVA b R263K 2,1 0,6 10,6 a HeLa-CD4 cells, 3-day assay, B-gal readout b MT4 cells, 5-day assay, cell tier glow readout V260I/R263K 2,0 0,5 6,3 Underwood M, IWHHVDR 2013, Abs 21 SAILING (ING ) V260I/R263K and Dissociation Relative Binding 1,0 0,5 WT V260I R263K V260I_R263K 0, Heures DTG dissociation is more rapid with simple mutant R263K or double mutant V260I/R263K vs. WT virus (T1/2: 50H vs 71H) V260I mutation does not increase DTG dissociation Underwood M, IWHHVDR 2013, Abs 21 Dr Anne-Geneviève Marcelin 16

17 Antiviral Activity of Dolutegravir in Subjects With Failure on an Integrase Inhibitor Based Regimen: Week 24 Phase 3 Results From VIKING-3 HIV-1 RNA 500 copies/ml *Resistance to RAL and/or EVG *Resistance to 2 ART classes other than INIs Functional monotherapy phase DTG 50 mg BID and continue failing regimen Optimised phase DTG 50 mg BID + optimised background regimen with OSS 1 Screening period up to a maximum of 42 days Screening visit ~Day -35 Day 1 Day 8 Week 24 analysis *Screening or documented historical evidence Week 48 analysis OSS (overall susceptibility score) determined by Monogram Biosciences net assessment Nichols, G. et al. HIV11, Glasgow, UK November Abstract O232. VIKING-3 : Relationship between baseline INI resistance and efficacy through D8 (DTG functional monotherapy) 0,5 Change from baseline in plasma HIV-1 RNA at day 8 (log 10 c/ml) 0,0-0,5-1,0-1,5-2,0-2,5-3,0-3,5 Baseline INI resistant mutation category Q148 + > 2 Q N155 Y143 0, Baseline FC IN IC 95 relative to wild type virus for DTG > 2 primary mutations Primary not detected Vavro CL, IWHHVDR 2013, Abs 29 Dr Anne-Geneviève Marcelin 17

18 VIKING-3 Impact of INIs mutations on virologic response Results of multivariate linear regression model for derivation of IN mutation groups Effect Estimate SE p Q148H/K/R a 0,47 0,094 < 0,001 L74I 0,27 0,131 0,037 E138A/K/T 0,25 0,130 0,052 L68I 0,58 0,372 0,118 E92Q -0,58 0,380 0,129 a G140A/C/S is highly correlated with Q148H/K/R Mutations Q148H/K/R, L74I et E138A/K/T have the strongest impact on VR Mutations L68I et E92Q did not retained beacause of low frequency Derived IN mutations groups No Q148 Q : Q148H/K/R with 1 mutation (G140A/C/S, L74I, E138A/K/T) Q148 + > 2 : Q148H/K/R with 2 or 3 mutations (G140A/C/S, L74I, E138A/K/T) Vavro CL, IWHHVDR 2013, Abs 29 VIKING-3 D8 and D24 response regarding baseline INIs mutations Day 8 response Week 24 response IN mutation group Decline in VL (log 10 c/ml) Full response a < 50 c/ml n Median n (%) n n (%) No Q , (92 %) (79 %) Q b 35-1,10 25 (71 %) 20 9 (45 %) Q148 +>2 b 20-0,74 9 (45 %) 9 1 (11 %) a Full response: decline in HIV-1 RNA > 1 log 10 c/ml or 50 c/ml at D8 b L74I, E138A/K/T and G140A/C/S Vavro CL, IWHHVDR 2013, Abs 29 Dr Anne-Geneviève Marcelin 18

19 Viking 3 Baseline phenotype/genotype correlation DTG 50 mg BID (n = 176 a ) Q148 +> 2 b Q148 + < 1 b N155 Y143 > 2 primary c Primary not detected Subjects, n (%) 21 (11) 31 (17) 30 (18) 28 (15) 7 (4) 59 (32) Median DTG FC 10,00 4,60 1,49 1,10 4,57 0,89 Q1 4,47 3,39 1,29 0,91 1,68 0,80 Q3 13,00 6,27 1,76 1,18 20,00 1,04 Min 2,56 0,47 0,82 0,78 1,46 0,45 Max 37,00 12,00 3,89 2,01 27,00 3,97 a 176/183 with paired DTG FC and IN genotype at Baseline b Q and Q148 + > 2 groups have 1 or 2 or more In secondary mutations (see Methods) c n = 3 containing Q148 pathway virus Highest FC observed with Q148 + > 2 secondary mutations Vavro CL, IWHHVDR 2013, Abs 81 Viking 3 Treatment-Emergent INI genotypic resistance detected at VF Codon Genotype at PDVF PDVF genotypic population (n = 31) Any 15 (48 %) 97 T97T/A, T97A 6 (19 %) 138 E138A, E138E/K, E138K 5 (16 %) 148 Q148H, Q148Q/H, Q148Q/R/K 4 (13 %) 92 E92E/Q 2 (6 %) 140 G140G/S, G140S 2 (6 %) 155 N155H 2 (6 %) 157 E157E/Q 1 (3 %) 147 S147G 1 (3 %) 143 Y143Y/H 1 (3 %) a 3 subjects with historic evidence of Q148 mutations prior to start of DTG. Fourth subject with Q148R at baseline and Q148Q/R/K at PDVF Emergence of INI mutations in 48 % of patients with VF 13/15 (87 %) of patients with mutated viruses at VF had Q148 profile at baseline or in pre inclusion compiled genotypes Vavro CL, IWHHVDR 2013, Abs 81 Dr Anne-Geneviève Marcelin 19

20 What do we know about DTG? High genetic barrier to resistance To date no emergence of INIs mutations in naïve patients (impact of long term LLV? PI resistance profile?) Emergence of R263K in experienced patients, INI naïve (cross resistance with EVG, not with RAL) Resistance profile No impact of N155H and Y143 Q148 profile has the strongest impact on VR Dr Anne-Geneviève Marcelin 20

21 GS Antiviral activity on a panel of SDM GSK RAL EVG *Monogram data RAL FC > 1,5 from Jan 2010 to Mar 2012 GS retains antiviral activity on most of INIs resistant mutants, except Q148K and Q148R mutants (FCx5) Yoshinoga T, IWHHVDR 2013, Abs 22 GS Virological efficacy and PK A Mean change from Baseline HIV-1 RNA (log 10 copies/ml) 0,5 0-0,5-1,0-1,5-2,0-2,5 5 mg 30 mg placebo B Plasma GSK (µg/ml) 1 0,1 100 mg IM 200 mg IM 400 mg IM 800 mg IM (split) 100 mg SC 200 mg SC 400 mg SC (split) 4 x PA-IC 90 (0,664 mg/ml) 1 x PA-IC 90 (0,165 mg/ml) 4 x PA-IC 90 PA-IC 90-3, Day Time (weeks) A : 5 or 30 mg p.o in monotherapy: VL decrease > 2 log copies/ml B : plasma concentration > CI90 after 3 months or more than 1 injection (IM or SC) of 200 mg to 800 mg Yoshinoga T, IWHHVDR 2013, Abs 22 Dr Anne-Geneviève Marcelin 21

22 Université Pierre et Marie Curie INSERM U943 Résistance aux antirétroviraux Pr Vincent Calvez Dr AG Marcelin Dr L Morand-Joubert Dr Marc Wirden Dr Isabelle Malet Dr Cathia Soulié Dr Sidonie Lambert Dr Slim Fourati Dr Djénéba Fofana Sophie Sayon Stratégie thérapeutique Pr Christine Katlama Dr Marc-Antoine Valantin Dr Roland Tubiana Dr Luminata Schneider Dr Hocine Aït Mohand Dr Fabienne Caby Rachid Agher Epidémiologie et statistiques Dr Dominique Costagliola Dr Philippe Flandre Immunologie PSL Pr Brigitte Autran Dr Guislaine Carcelain Médecine interne PSL Dr Manuela Bonmarchand Dr Anne Simon Maladies infectieuses St Antoine Pr PM Girard Dr JL Meynard Dr N Valin Pharmacologie BCB Dr Gilles Peytavin Biochimie TNN Pr J Capeau Dr JP Bastard AC 5 : ANRS essais thérapeutiques AC 11: ANRS virologie médicale Dr Anne-Geneviève Marcelin 22