Perspectivesconcernantles InhibiteursNon Nucléosidiquesde la Transcriptase Inverse (INNTI) Gianni Di Perri Dept. de Maladies Infectieuses Universitè de Turin Ospedale Amedeo di Savoia
Fusion inhibitors HIV CYCLE co-receptors inhibitors CD4 BINDING CCR5 CXCR4 BUDDING REVERSE TRANSCRIPTION UNCOATING genomic RNA integrase inhibitors double stranded DNA INTEGRATION genomic RNA ASSEMBLY proviral RNA viral proteins TRANSLATION cell membrane PROTEASE Protease Inhibitors viral mrna RT Inhibitors N/tRTIs NNRTIs TRANSCRIPTION cell nucleus
NNRTIs: Common Properties Direct on site enzymatic inibition(non-competitors) Substrates and inducers ofcyp 3A Low genetic barrier Long eliminaton half-life Responsible of cutaneous rash
NNRTIs: pharmacological features Mol. weight g/mol Oral bioav. (%) VD Protein binding( %) Plasma T/2 (h) Clearance (main route) EFV 315.68 nd 2.4 L/Kg > 99 45 NVP 266.3 93 1.21 L/Kg 60 25-30 ETR 435.28 nd nd 99.9 41
Antiretroviral Therapy for Treatment-Naïve Patients Recommendation Preferred NNRTI Alternative NNRTI Recommendation Preferred PIs Alternative PIs Recommendation Preferred dual N/NtRTIs Alternative dual N/NtRTIs NNRTI Efavirenz(AI) Nevirapine(BI) PI ATV/r QD (AI) DRV/r QD (AI) fosapv/r bid(bi) LPV/rQD or bid(ai) ATV QD (BI) fosapv/rqd or fosapvbid(bi) SQV/r bid(bi) Dual N/NtRTIs TDF-FTC (AI) ABV-3TC (BI) Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents
NNRTIs: New drugs under development
TMC278-C204: Rilpivirine vs EFV in Treatment-Naive Patients Stratified by NRTI backbone and location (Asia/Africa, US/Europe/Russia, or Latin America) Week 48: primary analysis Week 96: current analysis HIV-infected treatment-naive patients, HIV-1 RNA 5000 copies/ml, susceptible to NRTIs, no major NNRTI resistance mutations (N = 368) EFV 600 mg QD (open label) + ZDV/3TC or TDF/FTC (n = 89) Rilpivirine 25 mg QD (blinded) + ZDV/3TC or TDF/FTC (n = 93) Rilpivirine 75 mg QD (blinded) + ZDV/3TC or TDF/FTC (n = 95) Rilpivirine 150 mg QD (blinded) + ZDV/3TC or TDF/FTC (n = 91) Results at 96 Weeks Molina JM, et al. Glasgow 2008. Abstract P002. Rilpivirine 25 mg (n = 93) Rilpivirine 75 mg (n = 95) Rilpivirine 150 mg (n = 91) EFV 600 mg (n = 89) Viral load < 50 copies/ml, % 76 72 71 71 Mean in CD4+ count, cells/mm 3 146 172 159 160
Antiviral Activity With Varying Doses of UK-453,061 NC CN 0.5 Last day of dosing O N In vitro characteristics IC 90 of ~12 nmagainst WT HIV Phase I pharmacokinetics Elimination half-life: 7-11 hours N OH Change in HIV-1 RNA (log 10 copies/ml) 0.0-0.5-1.0-1.5-2.0-2.5 Metabolized by CYP3A and glucuronidation 0 5 10 15 20 25 28 Time (Day) Placebo 10 mg BID 30 mg BID 100 mg BID 500 mg BID 100 mg QD 500 mg QD 750 mg QD Corbau R, et al. ICAAC 2007. Abstract 2751. Fätkenheuer G, et al. IAS 2007. Abstract WESS202.
Novel NNRTI IDX899 Safe, Effective In HIV- Infected, Treatment-Naive Patients IDX899, a novel NNRTI with potent, selective activity against wild-type and NNRTI-resistant HIV in vitro High genetic barrier to resistance in vitro QD dosing feasible N Adverse events mild and similar to placebo-treated group Mean HIV-1 RNA level declined by ~ 1.8 log 10 copies/ml from BL to Day 8 with all 3 doses tested Current proof-of-concept study assessed safety, activity, and PK of IDX899 monotherapyvsplacebo for 7 days in treatment-naive HIV-infected patients Zala C, et al. IAC 2008. Abstract THAB0402. CI O P O NH2 N H O Mean VL ΔFrom BL (log 10 copies/ml) Placebo (n = 6) 800 mg IDX899 (n = 8) 0.5 0.0 -.5-1.0-1.5-2.0-2.5 400 mg IDX899 (n = 8) 200 mg IDX899 (n = 8) 0.05-1.78-1.81-1.84 1 2 3 4 5 6 7 8 Study Day
Novel NNRTI RDEA806 Safe, Effective in Pilot Study in HIV-Infected Patients RDEA806, an investigational NNRTI with in vitro activity against NNRTI-resistant mutants, including K103N Preclinical studies show high barrier to resistance No reproductive toxicity in animals Does not inhibit/induce of CYP450 Br N N N S HN Current study explored safety, efficacy, and PK of RDEA806 monotherapy vs placebo in treatment-naive HIVinfected pts Moyle G, et al. IAC 2008. Abstract THAB0403. O CI O OK No serious, grade 3/4 advers events, significant laboratory toxicities or discontinuations Potentially drug related AEs of moderate severity reported in 6 of 36 pts receiving RDEA806 vs 1 of 12 receiving placebo Median -1.3 to -1.8 log 10 copies/ml VL reduction at Day 8 0.5 0.0-0.5-1.0-1.5 Mean VL Δfrom BL (log 10 copies/ml) -2.0 Last dose 0 5 10 15 Days 20 Placebo 400mg BID 600mg QD 800mg QD 1000mg QD
NNRTIs: Update on existingdrugs EFV
VirologicResponse, According to Study Group ACTG 5142 Percent of patients with virological failure* 100 Percent of patients 80 60 40 20 24% P = 0.006 37% 29% 0 EFV LPV/r LPV/r + EFV Riddler S et al. N Engl J Med 2008;358:2095-2106
Successful Efavirenz dose reduction in HIV Type 1-Infected Individuals with Cytochrome P450 2B6 *6 and *26 Gatanaga H, et al. Clin Infect Dis 2007; 45: 1230-7 EFV (ng/ml) 15000 12000 9000 *1/*26 *6/*6 *6/*26 PHARMACOGENOMICS CYP2B6 genotypes determined in 456 HIV-1-infected EFV recipients CYP2B6 516G>Twas identified in the *6allele (17.9% of patients) and a novel allele, *26(1.3% of patients). 6000 3000 Genotype-based dose reduction of EFV 1000 EFV dosage 600 mg 400 mg 200 mg 12000 9000 6000 3000 1000 *6/*6 *6/*26 EFV-associated CNS symptoms improved in 10/14 EFV dosage 400 mg 200 mg
FOTO: 5-Days-On, 2-Days-Off vsdaily Therapy in Suppressed Pts (week end interruption) Wk 24 primary endpoint* Wk 48 HIV-infected pts on TDF/FTC + EFV with HIV-1 RNA < 50 c/ml (N = 60) TDF/FTC + EFV FOTO (n = 30) TDF/FTC + EFV QD (n =30) TDF/FTC + EFV FOTO (n = 23) Switch to TDF/FTC + EFV FOTO (n = 27) *Cross-over from daily to FOTO arm if HIV-1 RNA < 50 c/ml Cohen C, et al. IAS 2009. Abstract MOPEB063.
FOTO: 48-Wk Results of 5-Days-On, 2-Days-Off vs Daily Therapy Pts on FOTO strategy maintained virologic suppression through Wk 48 No virologic failure noted in either arm 10 pts stopped before Wk 48 (all HIV-1 RNA < 50 c/ml at d/c); 5 on FOTO; 4 on daily (1 before randomization) n = 5 lost to follow-up n = 4 withdrew consent n = 1 pregnancy 54 pts reported strong preference for FOTO schedule at 4 wks following switch to FOTO HIV-1 RNA < 50 c/ml (%) 100 90 80 70 60 50 40 30 20 100 86 As-Treated Analysis 90 FOTO (n = 25)* Daily (n = 28)* 90 10 0 Wk 24* Wk 36 Wk 48 *After Wk 24, all pts on FOTO. P<.001 to reject inferiority of FOTO vs daily strategy to maintain suppression. Cohen C, et al. IAS 2009. Abstract MOPEB063.
NNRTIs: Update on existingdrugs ETR
Pooled DUET: more etravirinepatients with viral load < 50 copies/mlat week 48 Responders (%) ±95% CIs 100 90 80 70 60 50 40 30 20 10 ETR + BR (n = 599) Placebo + BR (n = 604) 61% ITT TLOVR analysis 40% p < 0.0001* 0 0 2 4 8 12 16 20 24 32 40 48 Time (weeks) *Logistic regression model CI = confidence interval; TLOVR = time to loss of virological response. Trottier B, et al. 17th CAHR 2008 [Poster P167].
Pooled DUET 96-Wk Results: ETR + DRV/RTV-Containing OBR in Exp d Pts Randomized trial of ETR vs placebo, both with DRV/RTV-containing OBR in multiclass-resistant pts 100 ETR (n = 599) Placebo (n = 604) Superior virologic suppression with ETR at Wks 24 (primary endpoint) and 48 Superior virologic suppression maintained at Wk 96 in ETR vs placebo arm [1] Higher response with ETR irrespective of number of active agents, baseline ETR FC, weighted score, sex, race, and age Greater mean change in CD4+ cell count with ETR vs placebo HIV-1 RNA < 50 c/ml (%) (ITT-TLOVR) 80 60 40 20 P <.0001 60 39 P <.0001 57 36 +123 vs +86 cells/mm³(p <.0001) 0 Wk 48 Wk 96 1. Mills A, et al. IAS 2009. Abstract MOPEB036. 2. Nelson T, et al. IAS 2009. Abstract MOPEB038. No new safety signals in Wks 48-96 [2] New rash in < 1% of pts CNS adverse effects similar between arms in Wks 48-96
NNRTIs: Update on existingdrugs NVP
TheARTEN study Open-label(due to hyperbilirubinaemia) Treatment-naivepatientswithCD4+ Tcells< 400/mL(male) or 250 (females) Genotype report Week 2: up-titration to 400 mg NVP/day n=188 Screening Nevirapinebid+ FTC/TDF = 188 Cont. or new n=188 Screening Nevirapineqd+ FTC/TDF = 188 Cont. or new n=193 Screening Atazanavir/rqd+ FTC/TDF = 193 Cont. or new Week -4 02 48 144 or EOT Posttrial Primary endpoint Soriano et al. IAS 2009, Cape Town, South Africa, Poster LBPE07.
ARTEN included a more stringent primary endpoint Study period Week 0 24 36 48 Primary endpoint HIV RNA <50: TLOVR algorithm: HIV RNA <50: - (sensitivity analysis) Primary analysis:95% CI for difference between the combined NVP groups and ATZ/rin proportion of responders (primary endpoint); non-inferiority margin -12% Soriano et al. IAS 2009, Cape Town, South Africa, Poster LBPE07.
ARTEN: ITT analyses (Week 48) Soriano et al. IAS 2009, Cape Town, South Africa, Poster LBPE07 Treatment response by primary endpoint (ITT) (two visits prior Wk 48) Treatment response by sensitivity analysis: TLOVR algorithm (ITT) 100 95% CI= -5.9% to 9.8%; p=0.63 100 95% CI= -10.4% to 4.5%; p=0.44 Patients achieving treatment response (%) 80 60 40 20 67 65 Patients achieving treatment response (%) 80 60 40 20 70 74 0 NVP qd + bid ATZ/r Suppression to HIV-RNA <50 copies/mlat two visits priorto Week 48 (e.g. suppression at weeks24, 36 and 48) 0 NVP qd + bid ATZ/r Suppression at two visits up to Week 48 (including week 48; eg at weeks 36 and 48, based on the TLOVR algorithm)
Nevirapineqdand bid were similarly effective Treatment response by primary endpoint (ITT): by nevirapine dose schedule 100 Nevirapine qd vs ATZ/r Nevirapine bid vs ATZ/r 95% CI= -6.5%to 11.5%; p=0.58 95% CI= -7.7%to 10.7%; p=0.75 100 Patients achieving treatment response (%) 80 60 40 20 67 65 NVP qd ATZ/r Patients achieving treatment response (%) 80 60 40 20 66 65 NVP bid ATZ/r 0 0 Soriano et al. IAS 2009, Cape Town, South Africa, Poster LBPE07.
OT analysis over time (single measurement) HIV-RNA <50 copies/ml over time (OT) CD4 cell count improvement to Week 48 Patients (%) 100 90 80 70 60 50 40 30 20 10 0 NVP qd NVP bid NVP qd + bid ATZ/r 4 8 24 48 Weeks CD4+ increase (mean) NVP qd + bid (n=269) ATZ/r (n=173) 170 185 95% CI -39.3 to 7.4 p value 0.18 HIV-RNA <50 copies/ml at 48 weeks, n (%) NVP qd NVP bid NVP qd + bid ATZ/r 132/144 (91.7) 124/130 (95.4) 256/274 (93.4) 154/175 (88.0) Total excluding missing data, based on pre-defined time windows, numbers differ from TLOVR endpoint values. Soriano et al. IAS 2009, Cape Town, South Africa, Poster LBPE07.
Response according to baseline viral load Patients achieving treatment response (%) 100 80 60 40 20 0 77 Response by screening viral load (primary endpoint analysis; Wk 48) 60 NVP qd + bid 85 230 ATZ/r 52 n=146 n=230 n=78 n=115 NVP 100K NVP >100K ATZ/r 100K ATZ/r >100K Soriano et al. IAS 2009, Cape Town, South Africa, Poster LBPE07.
Non-inferiority was reached despite a higher premature discontinuation rate in the NVP arm up to Week 48 Any premature discontinuation, up to Week 48, n (%) Discontinuations due to AEs, n (%) NVP qd (n=188) NVP bid (n=188) ATZ/r (n=193) 41 (21.8) 53 (28.2) 18 (9.3) 20 (10.6) 27 (14.4) 5 (2.6) Lost to follow-up, n (%) 6 (3.1) 2 (1.1) 4 (2.1) Lack of efficacy *, n (%) 11 (5.9) 21 (11.2) 3 (1.6) *As defined by the investigator Other, n (%) 4 (2.1) 3 (1.6) 6 (3.2) NVP qd (n=188) NVP bid (n=188) ATZ/r (n=193) Virologic failure, n (%) 21 (11.2) 24 (12.8) 27 (14.0) Lack of efficacy (investigator defined VF) 11 (5.9) 21 (11.2) 3 (1.6) No confirmed response at Wk 48=VF 10 (5.3) 3 (1.6) 24 (12.4) Soriano et al. IAS 2009, Cape Town, South Africa, Poster LBPE07.Data under media embargo until 20 th July, 08.00 h
Overall incidence of adverse events was similar between groups 100 80 85.9 86.5 NVP qd + bid ATZ/r Adverse events (%) 60 40 20 34.6 48.7 9.6 8.8 0 Any Drugrelated Serious Soriano et al. IAS 2009, Cape Town, South Africa, Poster LBPE07.
Low rate of rash or hepatic events with NVP used as in label Any degree Grade 3 4 Leading to discontinuation % NVP qd NVP bid ATZ/r NVP qd NVP bid ATZ/r NVP qd NVP bid ATZ/r Rash (including during lead-in phase) Hepatitis (excl.viral) LEE (coded as AE, excluding hyperbilirubinaemia) 14.9 17.0 12.4 1.6 1.6 0.0 3.7 6.4 0.0 1.6 2.1 0.0 1.0 1.6 0.0 1.6 2.1 0.0 5.9 7.4 1.6 3.2 4.8 1.5 2.1 3.2 1.0 DAIDS Grade (% patients) NVP qd NVP bid ATZ/r G3 G4 G3 G4 G3 G4 ALT 3.2 2.7 4.3 4.3 2.1 0 AST 4.3 1.6 4.3 2.7 2.6 0.5 Total bilirubin 1.1 1.6 2.1 1.6 45.6* 8.8 Soriano et al. IAS 2009, Cape Town, South Africa, Poster LBPE07.Data under media embargo until 20 th July, 08.00 h
ARTEN: lipid profile(week 48) Change in lipid and cardiovascular risk parameters from baseline to Week 48 Change from baseline (mg/dl) 30 25 20 15 10 5 0-5 p=0.041 Total cholesterol p=0.011 LDL-c NVP ATZ/r p<0.0001 HDL-c p<0.0001 Triglycerides Change in ratio from baseline 0.2 0.15 0.1 0.05-0.05-0.1-0.15-0.2-0.25 0 p=0.0001 TC:HDL-c Soriano et al. IAS 2009, Cape Town, South Africa, Poster LBPE07.
Summary Nevirapine is a potent first-line choice Efficacy non-inferior to ATZ/r Effective in combination with Truvada Effective in patients with high screening viral load (>100,000 c/ml) Efficacy of qdand bid NVP/Truvada regimens similar Nevirapine/Truvada demonstrates a morefavourable lipid profile than ATZ/r Low rate of hepatic adverse events in ARTEN in which the CD4 count guidance was applied Most rashes occurred in the early treatment phase when patients are being closely monitored (thus avoiding grade 4 events) Soriano et al. IAS 2009, Cape Town, South Africa, Poster LBPE07.Data under media embargo until 20 th July, 08.00 h
Ultrasensitive AssessmentofResidualHIV Viraemiain HAART-Treated Patients With Persistently Undetectable Plasma HIV-RNA: A Cross- Sectional Evaluation 154 HIV-infected patients All taking 3-drug ART HIV RNA in blood <50 c/ml HIV RNA measured using a more sensitive assay (2.5 c/ml) NVP: 60% <2.5 c/ml EFV: 42% <2.5 c/ml LPV/r: 29% <2.5 c/ml NVP was the only factor associated with undetectable HIV RNA on multivariate analysis Bonora et al. J Med Virol 2009;81:400 405 HIV RNA (copies/ml) 50 40 30 20 10 p<0.05 p<0.05 0 NVP EFV LPV/r n 48 57 49
Conclusions NNRTIs remain the most successful and recommended treatment choiceaftermore than10 yearsofclinicaluse, and new options are in development NNRTIs have unique pharmacologic properties accounting for the possibility of QD dosing and a reasonable degree of forgiveness in clinical practice, thus well combining the highest standard of antiretroviral efficacy with a reduced interference with normal life activities and long-term toxicity Specific features like co-formulation(e.g. EFV), good penetrationintosanctuaries(e.g. NVP), reducedlipidimpact (e.g. NVP) and activityin treatment-experiencedpatients(e.g. ETR) make NNRTIs a truly attractive choice for long-term antiretroviral therapy