Antiviral Therapy 2014; 19: (doi: /IMP2721)

Transcription

1 Antivirl Therpy 2014; 19: (doi: /IMP2721) Originl rticle Chnge in vitmin D levels nd risk of severe vitmin D deficiency over 48 weeks mong HIV 1 infected, tretment-nive dults receiving rilpivirine or efvirenz in Phse III tril (ECHO) Dvid A Wohl 1 *, Chloe Orkin 2, Mnuel Doron 3, José H Pilotto 4, Somnuek Sungknuprph 5, Ptrick Yeni 6, Simon Vnveggel 7, Henri Deckx 7, Kti Boven 8 1 The University of North Crolin t Chpel Hill, Chpel Hill, NC, USA 2 Brts Helth NHS Trust, London, UK 3 Hospitl de Snt Mri, Lisbon, Portugl 4 Hospitl Gerl de Nov Iguçu & Lbortorio de AIDS e Imunologi Moleculr/IOC, Rio de Jneiro, Brzil 5 Fculty of Medicine, Rmthibodi Hospitl, Mhidol University, Bngkok, Thilnd 6 Hôpitl Bicht Clude Bernrd, Pris, Frnce 7 Jnssen Infectious Diseses BVBA, Beerse, Belgium 8 Jnssen R&D, LLC, Titusville, NJ, USA *Corresponding uthor e-mil: wohl@med.unc.edu Bckground: This nlysis ssessed chnges in serum 25-hydroxyvitmin D (25[OH]D; the precursor form of ctive vitmin D) in ntiretrovirl-nive dults receiving rilpivirine or efvirenz over 48 weeks in rndomized, double-blind, Phse III tril (ECHO). Methods: ECHO included 690 ptients rndomized 1:1 to receive rilpivirine 25 mg once dily (n=346) or efvirenz 600 mg once dily (n=344), plus tenofovir disoproxil fumrte/emtricitbine. 25(OH)D ws mesured in stored serum smples collected t bseline, nd weeks 24 nd 48. Proportions of ptients with optiml/sufficient ( 30 ng/ml), insufficient (21 29 ng/ml), deficient (10 20 ng/ml) nd severely deficient (<10 ng/ml) 25(OH) D levels were determined. Dt re presented for ptients with pired bseline nd week 48 25(OH)D dt (rilpivirine, n=292; efvirenz, n=290). Results: After 48 weeks, men 25(OH)D levels remined lrgely unchnged from bseline with rilpivirine (-0.2 ng/ml; P=0.57 versus no chnge), but were significntly reduced with efvirenz (-2.5 ng/ml; P< versus no chnge). When djusting for seson of rndomiztion nd the combined vrible of rce (Blck/Africn Americn, White/Cucsin, Asin, other rce) nd ethnicity (Hispnic or Ltino nd not Hispnic or not Ltino), the conclusion bout the tretment difference between the rilpivirine nd efvirenz tretment groups remined vlid. At bseline the proportion of ptients with severe 25(OH)D deficiency ws similr in both groups (5%) but ws significntly lower with rilpivirine thn efvirenz t week 48 (5% versus 9%, respectively; P=0.032). Furthermore, of the ptients with 25(OH)D insufficiency/deficiency t bseline, the proportion who developed severe 25(OH)D deficiency t week 48 ws significntly lower with rilpivirine thn efvirenz (2% versus 8%, respectively; P=0.0079). Conclusions: Rilpivirine hd little effect on 25(OH)D, wheres efvirenz resulted in significnt reduction in 25(OH)D levels nd n increse in the risk of severe 25(OH)D deficiency. Introduction Low levels of vitmin D re common in the generl popultion nd re lso prevlent mong those living with HIV infection [1 11]. Although trditionl risks, such s ge, suboptiml sunlight exposure nd obesity contribute to low vitmin D levels in both the HIVinfected nd -uninfected popultions [12,13], fctors relted to HIV, including ntiretrovirl (ARV) therpy, my influence vitmin D sttus in those infected with the virus [14 17]. Severl studies hve demonstrted link between non-nucleoside reverse trnscriptse inhibitor (NNRTI)-bsed tretment nd vitmin D deficiency, 2014 Interntionl Medicl Press (print) (online) 191

2 DA Wohl et l. prticulrly with efvirenz, mong ptients with HIV infection [2,3,8 11,15 27]. In the MONET tril, in ptients with virl lod <50 HIV-1 RNA copies/ml who were receiving combintion ARV therpy t screening, mesured vitmin D levels were significntly lower mong those entering the study on efvirenz compred to those receiving other ARVs [9]. Additionlly, switching from n efvirenz-bsed combintion to drunvir/ ritonvir monotherpy led to significnt increses in vitmin D levels over time [9]. There is less informtion describing the effects of other NNRTIs on vitmin D sttus. Most studies found no ssocition between nevirpine nd low levels of vitmin D [9,10,15,25]. One recent tril reported similr decreses in 25-hydroxyvitmin D (25[OH]D) levels fter 6 months with efvirenz nd etrvirine [28], while prospective cohort of HIV-infected dults in Frnce found n incresed risk of vitmin D deficiency in ptients receiving efvirenz, but not with etrvirine, drunvir or rltegrvir [17]. Rilpivirine is once-dily NNRTI pproved for the tretment of HIV infection bsed on the results of two interntionl, Phse III, double-blind controlled trils, including the ECHO Tril (Efficcy Comprison in Tretment-nive HIV-infected Subjects of TMC278 nd Efvirenz; CliniclTrils.gov registry number NCT ) [29 31]. In ECHO, 690 HIV-1-infected dults nive to ARV therpy were enrolled. Serum smples were stored frozen during the tril nd used in this nlysis to compre the vitmin D sttus of ptients receiving rilpivirine versus efvirenz. As is stndrd clinicl prctice, serum levels of 25(OH)D, the primry metbolite of vitmin D3 nd vitmin D2 in the liver, were mesured s n indictor of vitmin D sttus [32]. Methods Ptients nd study design As described previously, ECHO ws 96-week, rndomized, double-blind, double-dummy, ctive-controlled, Phse III tril designed to ssess the efficcy, sfety nd tolerbility of rilpivirine versus efvirenz, when used in combintion with the nucleoside/nucleotide reverse trnscriptse inhibitors tenofovir disoproxil fumrte (TDF) nd emtricitbine (FTC), in tretmentnive, HIV-1-infected dults [29]. All ptients hd to hve plsm virl lod 5,000 HIV-1 RNA copies/ml t screening nd confirmed virl sensitivity to TDF nd FTC. Ptients with certin NNRTI resistnce-ssocited muttions were excluded, s were those with renl or heptic impirment [29]. The study ws conducted over 112 sites cross 21 countries: the USA, Cnd, Austrli, South Afric, 10 countries in Europe, 3 in Asi nd 4 in Ltin Americ. Ptients were rndomized 1:1 to receive rilpivirine 25 mg once dily or efvirenz 600 mg once dily, in combintion with fixed-dose regimen of TDF 300 mg dily nd FTC 200 mg dily [29]. In ddition to the primry virologicl end point nd sfety nlyses, severl prospective explortory nlyses were lso undertken, including ssessment of serum 25(OH)D levels during the course of the tril. Assessment of serum 25(OH)D This explortory nlysis compred serum levels of 25(OH)D nd 25(OH)D deficiency sttus in ptients receiving rilpivirine or efvirenz plus TDF/FTC over 48 weeks in the ECHO tril. An dditionl objective ws to compre the proportions of ptients with 25(OH)D insufficiency/deficiency t bseline who progressed to severe deficiency t week 48 between the two tretment groups. 25(OH)D levels were mesured in centrl lbortory using the DiSorin LIAISON 25 OH Vitmin D Totl Assy (DiSorin Assy; Stillwter, MN, USA; lower limit of quntifiction =6.8 ng/ml) in stored serum smples obtined from ECHO ptients t bseline, nd weeks 24 nd 48. The proportions of ptients with 25(OH)D levels within defined ctegories were determined ccording to estblished criteri [1,33 35]. These ctegories included optiml/sufficient ( 30 ng/ml), insufficient (21 29 ng/ml), deficient (10 20 ng/ml) nd severely deficient (<10 ng/ml). Sttisticl nlyses This nlysis ws undertken in ll treted ptients (tht is, the intent-to-tret [ITT] popultion) with pired bseline nd week-48 25(OH)D dt. Student s t-test (5% significnce level) ws used to evlute the chnge from bseline in men serum 25(OH)D levels t week 48 (t-test of significnce versus no chnge) nd to ssess the between-group differences in the men chnge in serum 25(OH)D levels from bseline to week 48. Fisher s exct test (5% significnce level) ws used to evlute the between-group differences in the proportion of ptients with severe 25(OH)D deficiency t week 48 irrespective of bseline, nd the proportion of ptients with 25(OH)D insufficiency/ deficiency t bseline who progressed to severe deficiency t week 48. Results Ptients Overll, 346 ptients in the rilpivirine group nd 344 in the efvirenz group received t lest one dose of study mediction nd were included in the ITT popultion. Of these ptients, 292 (84.4%) nd 290 (84.3%) in the rilpivirine nd efvirenz tretment groups, respectively, hd pired bseline nd week 48 25(OH)D dt nd were included in the present nlysis Interntionl Medicl Press

3 Effect of rilpivirine or efvirenz on vitmin D The tretment groups were well blnced t bseline for ge, gender, rce (Blck/Africn Americn, White/ Cucsin, Asin, other rce) nd ethnicity (Hispnic or Ltino nd not Hispnic or not Ltino), geogrphic region, body mss index, HIV durtion, bseline HIV-1 RNA count, CD4 + T-cell count, serum lbumin, serum clcium, serum phosphte nd 25(OH)D levels, s well s use of vitmin D supplements during the study (Tble 1). Approximtely three-qurters of the ptients in ech group were of non-blck/non-africn-americn ethnic origin, nd 80% were from Northern or Southern hemisphere countries (65% in Northern nd 15% in Southern hemisphere) with four sesons resulting in different sunlight exposures nd hence 25(OH)D levels; 80% of Blck/Africn-Americn ptients were rndomized during the spring nd summer sesons. The proportion of ptients rndomized per seson ws lso similr in both tretment groups (Tble 1); similr number of ptients in both groups were rndomized during the spring nd summer (n=143 for efvirenz nd n=138 for rilpivirine) when 25(OH)D levels were the highest, versus utumn nd winter when 25(OH)D levels were lowest. However, medin 25(OH)D levels t bseline (23.6 ng/ml for rilpivirine nd 24.0 ng/ml for efvirenz) were in the insufficient (21 29 ng/ml) ctegory. At bseline, 5% of ptients in the rilpivirine group were severely 25(OH)D deficient, 25% were deficient, 45% were insufficient nd 25% were optiml/sufficient. In the efvirenz-treted ptients 5% of ptients were severely 25(OH)D deficient, 24% were deficient, Tble 1. Bseline chrcteristics of ptients Bseline prmeter Rilpivirine 25 mg once dily (n=292) Efvirenz 600 mg once dily (n=290) Medin ge, yers (rnge) 36 (18 78) 37 (19 67) Femle, n (%) 66 (23) 51 (18) Rcil group b White/Cucsin, n (%) 184 (63) 176 (61) Blck/Africn-Americn, n (%) 68 (23) 62 (21) Asin, n (%) 31 (11) 43 (15) Other rce, n (%) 3 (1) 4 (1) Ethnic group Hispnic or Ltino, n (%) 64 (22) 81 (28) Not Hispnic or not Ltino, n (%) 225 (77) 207 (71) Region USA, Cnd, Europe, Austrli, n (%) 166 (57) 154 (53) Afric, n (%) 29 (10) 25 (9) Asi, n (%) 43 (15) 46 (16) Ltin Americ, n (%) 54 (18) 65 (22) Bseline seson Spring, n (%) 19 (7) 31 (11) Summer, n (%) 119 (41) 112 (39) Autumn, n (%) 70 (24) 60 (21) Winter, n (%) 84 (29) 87 (30) Medin body mss index, kg/m 2 (rnge) c 24 (16 44) 24 (17 42) Medin durtion of HIV-1 infection t 1.3 (0 22) 1.2 (0 25) screening, yers (rnge) Medin log 10 HIV-1 RNA, copies/ml (rnge) 4.9 ( ) 5.0 ( ) Medin CD4 + T-cell count, cells/mm 3 (rnge) 245 (1 888) 250 (1 693) Medin lbumin level, g/l (rnge) 40 (23 49) 40 (28 51) Medin clcium level, mmol/l (rnge) 2.4 (2 3) 2.4 (2 3) Medin phosphorus level, mmol/l (rnge) 1.1 (1 2) 1.1 (1 2) Medin 25(OH)D level Overll, ng/ml (rnge) 23.6 ( ) 24.0 ( ) Spring, ng/ml (rnge) 24.0 ( ) 26.4 ( ) Summer, ng/ml (rnge) 28.8 ( ) 28.8 ( ) Autumn, ng/ml (rnge) 21.6 ( ) 22.2 ( ) Winter, ng/ml (rnge) 20.0 ( ) 20.8 ( ) Use of vitmin D supplements, n (%) 40 (14) 34 (12) Dt presented only for ptients with pired bseline nd week 48 dt. b In some countries reporting of rce ws disllowed. c n=291 for rilpivirine, n=288 for efvirenz. 25(OH)D, 25-hydroxyvitmin D. Antivirl Therpy

4 DA Wohl et l. 40% were insufficient nd 31% were optiml/sufficient. Thus, 75% of rilpivirine-treted ptients nd 69% of efvirenz-treted ptients hd suboptiml 25(OH)D levels t bseline (Figure 1). Chnge in 25(OH)D levels In the rilpivirine group, for ptients with pired smples, the men chnge from bseline in 25(OH)D levels t week 48 ws smll nd non-significnt (men ± stndrd devition; -0.2 ±7.2 ng/ml; t-test: P=0.57 versus no chnge; Figure 2). By contrst, in the efvirenz group with pired smples, 25(OH)D levels declined significntly from bseline to week 48 (-2.5 ±7.2 ng ml; t-test: P< versus no chnge). The difference between the men chnges in the two tretment groups t week 48 ws sttisticlly significnt (t-test: P=0.0002, efvirenz versus rilpivirine). In both tretment groups, the reduction in men 25(OH)D levels from bseline Figure 1. Chnge in 25(OH)D sttus from bseline to week 48 25(OH)D sttus Optiml/sufficient ( 30 ng/ml) Insufficient (21 29 ng/ml) Deficient (10 20 ng/ml) Severely deficient (<10 ng/ml) 25% n=74 24% n=71 31% n=89 24% n=71 45% n=131 42% n=123 40% n=115 37% n=106 25% n=73 29% n=85 24% n=71 30% n=87 5% n=15 4% n=13 5% n=15 9% n=26 Bseline (n=292) Week 48 (n=292) Bseline (n=290) Week 48 (n=290) RPV EFV P=0.032 (Fisher s exct test) for tretment comprison in severe 25-hydroxyvitmin D (25[OH]D) deficiency t week 48, irrespective of bseline. EFV, efvirenz; RPV, rilpivirine Interntionl Medicl Press

5 Effect of rilpivirine or efvirenz on vitmin D Figure 2. Men chnge in 25(OH)D levels from bseline to week 48 1 RPV (n=292) EFV (n=290) Men chnge in 25(OH)D levels from bseline, ng/ml (95% CI) Time, weeks 48 =-0.2 ng/ml P=0.57 versus no chnge =-2.5 ng/ml P< versus no chnge -6 P= (t-test) for efvirenz (EFV) versus rilpivirine (RPV) t week 48. D, chnge; 25(OH)D, 25-hydroxyvitmin D. ws greter t week 24 thn t week 48 (Figure 2). The decline in men 25(OH)D levels from bseline to week 24 in ptients rndomized in the spring nd summer ws lrger, on verge, thn the increse in men 25(OH)D levels for ptients rndomized in the utumn nd winter, resulting in net decrese in men 25(OH) D levels t week 24, which ws greter in the efvirenz group thn in the rilpivirine group (Tble 2). In the rilpivirine group, men 25(OH)D levels t week 48 returned to levels similr to those t bseline while in the efvirenz group, men 25(OH)D levels remined below the bseline vlues (Figure 2 nd Tble 2). An nlysis conducted djusting for seson nd the combined vrible rce (Blck/Africn Americn, White/Cucsin, Asin, other rce) nd ethnicity (Hispnic or Ltino nd not Hispnic or not Ltino) showed tht the conclusion bout the tretment difference between the rilpivirine nd efvirenz tretment groups remined vlid. The lest squres mens for tretment by time point in this nlysis re shown in Tble 3. Progression to severe 25(OH)D deficiency By week 48, the severity of 25(OH)D deficiency hd incresed to lesser extent in rilpivirine-treted ptients thn in efvirenz-treted ptients (Figure 1). A comprison of the proportion of ptients with severe 25(OH)D deficiency t week 48, irrespective of bseline sttus, demonstrted sttisticlly significnt difference between the rilpivirine nd efvirenz tretment groups (4% versus 9%, respectively; Fisher s Exct test: P=0.032). Of the ptients with 25(OH)D insufficiency or deficiency t bseline (tht is, not optiml/sufficient), the proportion who developed severe 25(OH)D deficiency t week 48 ws significntly lower with rilpivirine thn efvirenz (Fisher s Exct test: P=0.0079; Figure 3). Likewise, of the ptients with 25(OH)D deficiency t bseline (tht is, not severely deficient but with levels <21 ng/ml), the percentge of ptients who developed severe 25(OH)D deficiency t week 48 ws significntly lower with rilpivirine thn efvirenz (Fisher s Exct test: P=0.0042; Figure 3). Discussion In this double-blind, rndomized, controlled tril compring rilpivirine nd efvirenz s initil HIV tretment, study ptients treted with efvirenz, but not those ssigned to rilpivirine, experienced sttisticlly significnt decline in 25(OH)D levels t 48 weeks. Furthermore, efvirenz ws ssocited with greter likelihood of progression to more severe 25(OH)D deficiency compred to rilpivirine, especilly mong those with suboptiml vitmin D sttus t bseline. The results from this study, the first double-blind rndomized comprison between NNRTIs of the effect on vitmin D levels, dd to previous reports of reduced vitmin D levels during tretment with efvirenz [2,3,8 11,15 27], nd indicte tht rilpivirine does not shre this effect. The mechnism by which efvirenz lters vitmin D sttus is uncler. However, it is hypothesized tht induction of the cytochrome P450 enzyme Antivirl Therpy

6 DA Wohl et l. Tble 2. Men chnge in 25(OH)D levels from bseline to weeks 24 nd 48 by seson t bseline Rilpivirine 25 mg once dily (n=292) Efvirenz 600 mg once dily (n=290) n b Men chnge, ng/ml (95% CI) n b Men chnge, ng/ml (95% CI) Week 24 Overll (-3.0, -0.8) (-5.0, -2.9) Spring (-7.0, -1.0) (-8.3, -1.8) Summer (-9.3, -6.4) (-11.0, -8.2) Autumn (-3.3, 0.2) (-5.5, -1.9) Winter (4.9, 8.1) (1.8, 4.9) Week 48 Overll (-1.1, 0.6) (-3.3, -1.6) Spring (-5.8, -0.3) (-8.7, -1.1) Summer (-3.7, -0.9) (-4.9, -2.2) Autumn (0.8, 3.9) (-1.3, 2.1) Winter (-0.2, 2.5) (-3.3, -1.0) Number of evluble ptients in ech tretment group. b Number of ptients nlysed. 25(OH)D, 25-hydroxyvitmin D. Tble 3. Lest squres mens for tretment by time point djusting for seson, rce nd ethnicity b Estimte for chnge in bseline in 25(OH)D Tretment Week level, ng/ml Error t-vlue Probbility >t Efvirenz < Rilpivirine Efvirenz < Rilpivirine Blck/Africn-Americn, White/Cucsin, Asin, other rce. b Hispnic or Ltino nd not Hispnic or Ltino. In some countries reporting of rce ws disllowed. 25(OH) D, 25-hydroxyvitmin D. D-24-hydroxylse (CYP24A), responsible for ctlysing the brekdown of ctive vitmin D (1,25-dihydroxyvitmin D [1,25-(OH) 2 D]) nd 25(OH)D, the primry metbolite of vitmin D to inctive metbolites, is responsible [15,16,24,27]. Less induction of CYP24A by NNRTIs other thn efvirenz my explin why chnges in 25(OH)D re less often observed with these drugs. Severl trends in 25(OH)D levels observed during the course of the study re notble. Foremost, following initition of therpy there ws decline in men 25(OH)D levels t week 24 in both tretment groups. In the cse of rilpivirine, this reduction in vitmin D ws trnsient with the men 25(OH)D level t week 48 not significntly different from bseline. In ptients treted with efvirenz, lthough lso there ws n increse in the men 25(OH)D level from week 24 to 48, the week 48 level remined significntly below the men bseline level. A previous study in ptients with HIV hs noted differences in 25(OH)D levels with exposure to ultrviolet light nd sesonl vribility in 1,25-(OH) 2 D levels [15]. In our study, however, becuse similr number of ptients in both groups were rndomized during the spring/summer nd during the utumn/winter sesons, the trnsient decrese we describe t week 24 cnnot be explined by sesonl vrition only. Two lterntive resons for this vitmin D decline t week 24 cn be hypothesized: the imblnce in ptients of Blck/Africn-Americn origin rndomized in the spring/summer sesons (80%) nd greter effect of the NNRTI when initited during the spring/summer sesons. In Blck/Africn-Americn ptients both tretment groups showed lrge (>5 ng/ ml) decrese in plsm 25(OH)D concentrtions t 24 weeks (dt not shown). Blck rce nd greter degree of skin pigmenttion in generl, hve been ssocited with reduced vitmin D levels in persons with nd without HIV infection [14]. It could be tht the seson-relted effects (decline or increse) on vitmin D levels is lrger for Blck/Africn-Americn rce thn other rces. Also, previous dt hve demonstrted tht individuls with drker skin colour presented n incresed risk of hving lower plsm 25(OH)D concentrtions following initition of ntiretrovirl therpy [8]. As with the non-blck/africn-americn ptients, in the rilpivirine group, this chnge ws Interntionl Medicl Press

7 Effect of rilpivirine or efvirenz on vitmin D Figure 3. Effect of RPV or EFV on deficiency sttus between bseline nd week 48 25(OH)D sttus Optiml/sufficient ( 30 ng/ml) 25% n=74 31% n=89 Insufficient (21 29 ng/ml) Deficient (10 20 ng/ml) Severely deficient (<10 ng/ml) 45% 204 Insufficient n=131 40% or deficient t 4/204 (2.0%) n=115 bseline Progressed to severely deficient t week Insufficient or deficient t bseline 15/186 (8.0%) P= Progressed to severely deficient t 8.0 week 48 25% n=73 3/73 (4.0%) Progressed to severely deficient t week 48 24% n=71 14/71 (19.7%) P= Progressed to severely deficient t week 48 5% n=14 5% n=15 Bseline (n=292) Week 48 Bseline Week 48 (n=290) RPV EFV P-vlues versus rilpivirine (RPV) t week 48 (Fisher s exct test). EFV, efvirenz; 25(OH)D, 25-hydroxyvitmin D. trnsient in Blck/Africn-Americn ptients. However, in the efvirenz group, while plsm 25(OH D concentrtions hd incresed from week 24 to week 48, there still remined significnt reduction from bseline in both the Blck/Africn-Americn ptients nd in the in the non-blck/africn-americn ptients. However, it should be noted tht mny cusl fctors hve been identified for vitmin D deficiency (sunlight exposure, skin colour, ethnicity, ge, gender, body mss index, hypertension, renl insufficiency, ARV drug clss nd lck of HIV suppression) [12,13]. The popultion in our study is heterogeneous, with prticipnts recruited throughout the world. Hence, given this heterogeneity in bseline chrcteristics, it is difficult to fully ttribute the cuses of the decrese t week 24 in our study. Nevertheless, while the popultions in both tretment groups were well-blnced for these potentil cusl fctors, exmintion of the chnge from bseline to week 48, when the seson of enrolment returns, likely provides the best ssessment of the effect of ARV therpy on vitmin D sttus. In ddition, fter djusting for seson, rce (Blck/Africn Americn, White/Cucsin, Asin, other rce) combined with ethnicity (Hispnic or Ltino nd not Hispnic or not Ltino), the conclusion bout the tretment difference t week 48 between the rilpivirine nd efvirenz tretment groups remined vlid. As described in previous reports in HIV-infected ptients, vitmin D deficiency ws common t bseline in this study with 72% hving level <30 ng/ml. The potentil clinicl significnce of the reductions in vitmin D levels observed during the study ws considered with exmintion of progression of the severity of 25(OH)D deficiency. At the extreme end of the Antivirl Therpy

8 DA Wohl et l. spectrum of deficiency, significntly more ptients receiving efvirenz thn those receiving rilpivirine hd levels of 25(OH)D t week 48 meeting the definition for severe deficiency, though the bsolute numbers were smll. Among those with some degree of deficiency/ insufficiency in 25(OH)D t bseline, progression to more severe deficiency ws lso significntly more likely with efvirenz (8.0% versus 2.0%; P=0.079). This ws prticulrly striking for ptients with 25(OH)D levels between 10 nd 20 ng/ml (tht is, clssified s vitmin D deficient) t bseline: 20% of such ptients receiving efvirenz progressed to severe deficiency (<10 ng/ml) t week 48 compred with only 4% of those in the rilpivirine group (P=0.0042). The clinicl significnce of less profound depletion of vitmin D is uncler. Vitmin D is importnt for the mintennce of dequte serum clcium nd phosphte concentrtions, to enble norml bone minerliztion nd prevent hypoclcemi [32]. It is lso required for bone growth/remodelling nd hs other functions in the body, such s modultion of cell growth, mintennce of neuromusculr nd immune function, nd reduction of inflmmtion [32]. As such, vitmin D deficiency hs been estblished s custive fctor for rnge of potentilly serious complictions of the skeletl system, including defective bone minerliztion (osteomlci) nd decresed bone minerl density (BMD; osteopeni/ osteoporosis). Among HIV-infected individuls, there is reported ssocition between vitmin D deficiency nd risk of rise in HIV virl lod [5], nd incresed risk of disese progression, AIDS events nd ll-cuse mortlity [5,6,36]. Therefore, lthough our understnding of the role of vitmin D in helth is evolving, there is bsis for concerns regrding low levels of this vitmin in both the HIV-uninfected nd -infected popultions. In ddition to the heterogeneous ptient popultion, there re limittions to this investigtion. Foremost, pired serum smples from bseline nd week 24/48 were not vilble for ll ECHO ptients. The lck of smple vilbility ppered to be rndom nd occurred t similrly low rtes in ech tretment group. In ddition, levels of 1,25(OH) 2 D, the ctive form of vitmin D, were not evluted. Levels of 1,25(OH) 2 D re more difficult to mesure thn 25(OH)D due to its reltively shorter hlf-life. However, levels of 25(OH) D re used cliniclly to determine vitmin D sttus nd response to therpy, nd therefore, re more redily interpretble. Still it is uncler which form of vitmin D is the most importnt in terms of non-skeletl effects. In ddition, the Disorin 25(OH)D ssy, lthough n FDA-pproved, in vitro ssy tht hs been used in multiple trils, seems to bis results towrds lower 25(OH)D vlues. Vitmin D supplementtion ws not prohibited during this study, nd while there ws very little reported use of vitmin D supplementtion, it is possible tht some ptients did so without informing study stff. It is expected tht the rndomized nd double-blind nture of the study would minimize the risk of differentil vitmin D supplementtion by tretment group. The reltionship between vitmin D sttus nd BMD is complex nd low BMD cn be cused by number of fctors. BMD ws ssessed by whole body dul energy X-ry bsorptiometry (DEXA) in substudies of ECHO [37], but the primry end point ws t 96 weeks, while the vitmin D nlysis in ECHO ws t 48 weeks. However, in ptients receiving TDF/FTC in pooled nlysis of the DEXA substudies, BMD decreses from bseline to week 48 were similr in ech tretment group (1.4% in the rilpivirine group [n=158] nd 1.5% in the efvirenz group [n=156]). Furthermore, while TDF is ssocited with decrese in BMD [37 39], TDF hs not been clerly ssocited with reductions in 25(OH)D levels. In conclusion, mong HIV-infected individuls rndomized to initite therpy with rilpivirine or efvirenz long with TDF/FTC, we found no significnt chnge in men 25(OH)D levels t 48 weeks of therpy mong those ssigned rilpivirine, but significnt decline in vitmin D levels mong those ssigned efvirenz. Given the known consequences of vitmin D deficiency, the clinicl implictions of diminished vitmin D levels during tretment with efvirenz, prticulrly for Blcks/Africn-Americns living with HIV infection, requires greter inquiry. Physicins should be vigilnt for this spect of the mngement of HIV infection in these ptients. Acknowledgements We thnk the ptients nd their fmilies for their prticiption nd support during the study, s well s study centre stff nd Jnssen study personnel. We lso cknowledge In Woolveridge (Principl Writer t Grdiner-Cldwell Communictions Ltd, Mcclesfield, UK) for his ssistnce in creting n initil drft introduction, methods nd results of the mnuscript, nd coordinting nd collting uthor contributions, funded by Jnssen. Additionlly, we thnk the following Jnssen people for providing their comments on the first drft of the mnuscript: Mrit Stevens, Peter Willims nd Eric Wong. Disclosure sttement DAW hs received funding for clinicl reserch from Giled Sciences, GlxoSmithKline (GSK), Merck nd Jnssen tht hve been wrded to the University of North Crolin, hs served s n dvisor to Giled Sciences, Jnssen nd Bristol Myers Squibb (BMS). CO hs served s speker nd received honorri from Interntionl Medicl Press

9 Effect of rilpivirine or efvirenz on vitmin D Johnson & Johnson, BMS, Boehringer Ingelheim, GSK, Giled Sciences, ViiV Helthcre nd Abbott Lbortories. PY hs received reserch grnts from Jnssen nd Giled Sciences. SV, HD nd KB re full-time employees of Jnssen. MD, JHP nd SS declre no conflicts of interest. References 1. Holick MF. Vitmin D deficiency. N Engl J Med 2007; 357: Kwn CK, Eckhrdt B, Bghddi J, Aberg JA. Hyperprthyroidism nd complictions ssocited with vitmin D deficiency in HIV-infected dults in New York City, NY. AIDS Res Hum Retroviruses 2012; 28: Childs K, Welz T, Smrwickrm A, Post FA. Effects of vitmin D deficiency nd combintion ntiretrovirl therpy on bone in HIV-positive ptients. AIDS 2012; 26: Vescini F, Cozzi-Lepri A, Borderi M, et l. Prevlence of hypovitminosis D nd fctors ssocited with vitmin D deficiency nd morbidity mong HIV-infected ptients enrolled in lrge Itlin cohort. J Acquir Immune Defic Syndr 2011; 58: Kim JH, Gndhi V, Psevdos G, et l. Evlution of vitmin D levels mong HIV-infected ptients in New York City. AIDS Res Hum Retroviruses 2012; 28: Vird JP, Souberbielle JC, Kirk O, et l. EuroSIDA Study Group. Vitmin D nd clinicl disese progression in HIV infection: results from the EuroSIDA study. AIDS 2011; 25: Adeyemi OM, Agniel D, French AL, et l. Vitmin D deficiency in HIV-infected nd HIV-uninfected women in the United Sttes. J Acquir Immune Defic Syndr 2011; 57: Cones-Botell A, Florence E, Lynen L, et l. Decrese of vitmin D concentrtion in ptients with HIV infection on non nucleoside reverse trnscriptse inhibitor-contining regimen. AIDS Res Ther 2010; 7: Fox J, Peters B, Prksh M, et l. Improvement in vitmin D deficiency following ntiretrovirl regime chnge: results from the MONET tril. AIDS Res Hum Retroviruses 2011; 27: Welz T, Childs K, Ibrhim F, et l. Efvirenz is ssocited with severe vitmin D deficiency nd incresed lkline phosphtse. AIDS 2010; 24: Wssermn P, Rubin DS. Highly prevlent vitmin D deficiency nd insufficiency in n urbn cohort of HIVinfected men under cre. AIDS Ptient Cre STDS 2010; 24: Tsirs WG, Weinstock MA. Fctors influencing vitmin D sttus. Act Derm Venereol 2011; 91: Forrest KY, Stuhldreher WL. Prevlence nd correltes of vitmin D deficiency in US dults. Nutr Res 2011; 31: Crutchley RD, Gthe J, Myberry C, et l. Risk fctors for vitmin D deficiency in HIV-infected ptients in the South Centrl United Sttes. AIDS Res Hum Retroviruses 2012; 28: Do CN, Ptel P, Overton ET, et l. Low vitmin D mong HIV-infected dults: prevlence of nd risk fctors for low vitmin D Levels in cohort of HIV-infected dults nd comprison to prevlence mong dults in the US generl popultion. Clin Infect Dis 2011; 52: Lke JE, Adms JS. Vitmin D in HIV-infected ptients. Curr HIV/AIDS Rep 2011; 8: Allven C, Delpierre C, Cuzin L, et l. High frequency of vitmin D deficiency in HIV-infected ptients: effects of HIV-relted fctors nd ntiretrovirl drugs. J Antimicrob Chemother 2012; 67: Fux CA, Bumnn S, Furrer H, Mueller NJ. Is lower serum 25-hydroxy vitmin D ssocited with efvirenz or the nonnucleoside reverse trnscriptse inhibitor clss? AIDS 2011; 25: Welz T, Childs K, Post FA. Do nevirpine nd efvirenz ffect vitmin D homeostsis similrly? AIDS 2011; 25: Psquet A, Viget N, Ajn F, et l. Vitmin D deficiency in HIV-infected ptients: ssocited with non-nucleoside reverse trnscriptse inhibitor or efvirenz use? AIDS 2011; 25: Vn Den Bout-Vn Den Beukel CJ, Fievez L, Michels M, et l. Vitmin D deficiency mong HIV type 1-infected individuls in the Netherlnds: effects of ntiretrovirl therpy. AIDS Res Hum Retroviruses 2008; 24: Mueller NJ, Fux CA, Ledergerber B, et l. Swiss HIV Cohort Study. High prevlence of severe vitmin D deficiency in combined ntiretrovirl therpy-nive nd successfully treted Swiss HIV ptients. AIDS 2010; 24: Rodríguez M, Dniels B, Gunwrdene S, Robbins GK. High frequency of vitmin D deficiency in mbultory HIV-positive ptients. AIDS Res Hum Retroviruses 2009; 25: Brown TT, McComsey GA. Assocition between initition of ntiretrovirl therpy with efvirenz nd decreses in 25-hydroxyvitmin D. Antivir Ther 2010; 15: Lttud E, Lnzfme M, Zoppini G, et l. No influence of nevirpine on vitmin D deficiency in HIV-infected ptients. AIDS Res Hum Retroviruses 2009; 25: Gyllensten K, Josephson F, Lidmn K, Sääf M. Severe vitmin D deficiency dignosed fter introduction of ntiretrovirl therpy including efvirenz in ptient living t ltitude 59 degrees N. AIDS 2006; 20: Herzmnn C, Arstéh K. Efvirenz-induced osteomlci. AIDS 2009; 23: Rockstroh J, Stoehr A, Duiculescu D, et l. Anlysis of vitmin D nd prthyroid hormone in the SENSE tril: etrvirine versus efvirenz in tretment-nive HIV-1 infected ptients. Antivirl Therpy 2010; 15 Suppl 4:A Molin J-M, Chn P, Grinsztejn B, et l. Rilpivirine versus efvirenz with tenofovir nd emtricitbine in tretmentnive dults infected with HIV-1 (ECHO): Phse 3 rndomised double-blind ctive-controlled tril. Lncet 2011; 378: EDURANT. 25mg film-coted tblets. Summry of product chrcteristics. Jnssen-Cilg Interntionl NV, November (Updted December Accessed 28 Jnury 2013). Avilble from medicine/25490/spc/edurnt+25+mg/. 31. EDURANT (rilpivirine) tblets. Full prescribing informtion. Jnssen, Inc., (Updted June Accessed 28 Jnury 2013). Avilble from edurnt-info.com/sites/defult/files/edurant-pi.pdf. 32. Ntionl Institutes of Helth (NIH), Office of Dietry Supplements. Dietry supplement fct sheet: vitmin D, 24 June (Accessed 28 Jnury 2013). Avilble from Hyppönen E, Power C. Hypovitminosis D in British dults t ge 45 y: ntionwide cohort study of dietry nd lifestyle predictors. Am J Clin Nutr 2007; 85: Dwson-Hughes B, Heney RP, Holick MF, et l. Estimtes of optiml vitmin D sttus. Osteoporos Int 2005; 16: Perce SH, Cheethm TD. Dignosis nd mngement of vitmin D deficiency. BMJ 2010; 340:b Meht S, Mugusi FM, Spiegelmn D, et l. Vitmin D sttus nd its ssocition with morbidity including wsting nd opportunistic illnesses in HIV-infected women in Tnzni. AIDS Ptient Cre STDS 2011; 25: Tebs P, Henry K, Nelson M, et l. Results from the pooled DEXA substudies of the double-blind, rndomised, Phse III trils compring rilpivirine (RPV,TMC278) versus efvirenz (EFV) in tretment-nive, HIV-1-infected dults. Antivir Ther 2011; 16 Suppl 2:A19. Antivirl Therpy

10 DA Wohl et l. 38. Gfni RI, Hzr R, Reynolds JC, et l. Tenofovir disoproxil fumrte nd n optimized bckground regimen of ntiretrovirl gents s slvge therpy: impct on bone minerl density in HIV-infected children. Peditrics 2006; 118:e711 e Cssetti I, Mdrug JV, Suleimn JM, et l. The sfety nd efficcy of tenofovir DF in combintion with lmivudine nd efvirenz through 6 yers in ntiretrovirl-nive HIV-1- infected ptients. HIV Clin Trils 2007; 8: Accepted 30 September 2013; published online 16 Jnury Interntionl Medicl Press