Simposio 9: Terapia Simposio 9: Terapia Antirretroviral. Una Antirretroviral. Una
mirada al futuromirada al futuro
Dr. Luis Enrique Soto RamírezDr. Luis Enrique Soto RamírezProfesor de Medicina Interna, Infectología y VIH/SIDAProfesor de Medicina Interna, Infectología y VIH/SIDA
Jefe Laboratorio de Virología MolecularJefe Laboratorio de Virología MolecularDepartamento InfectologíaDepartamento Infectología
Instituto Nacional de Ciencias Médicas y NutriciónInstituto Nacional de Ciencias Médicas y NutriciónCoordinadorCoordinador
Comité de Atención Integral CONASIDAComité de Atención Integral CONASIDA
Resistencia del VIH a los ARvs
Resistencia:Resistencia:
- Disminución de la Disminución de la susceptibilidad de un virus a susceptibilidad de un virus a un medicamentoun medicamento
- Resistencia fenotípica - Resistencia genotípica
- Resistencia primaria- Resistencia secundaria
- Resistencia cruzada
Resistencia a ARV: DefinicionesResistencia a ARV: Definiciones
Mecanismos de falla a ARV Mecanismos de falla a ARV
Resistencia Pre-existente
Alts. Farma-cocinèticas
Pobre Apego
Replicación Viral Persistente
Desarrollo de resistencia
Falla Virológica
POTENCIA LIMITADA
Consecuencias de la Terapia Consecuencias de la Terapia ARVARV
Corto plazo Largo Plazo
Resistencia
Reacciones de Hipersensibilidad: ABC,NVP
* Partially reversible
Diarrea/Nausea Hiperlipidemia
Efectos de SNC Lipodistrofia*
Reversible
Irreversible
Algunos ejemplos:
““La Resistencia es un continuo” La Resistencia es un continuo”
Susceptible Resistente
Mutaciones
Fold Change
Actividad del Medicamento
DHHS, IAS-USA, EACS
Infección primaria
PEP (Fuente Pt)
Crónica(< 2 años)
Falla al tratamiento
Embarazo
Niños
Recomendaciones para el usode pruebas de resistencia
Importancia del las pruebas de resistencia en Importancia del las pruebas de resistencia en el diagnóstico y abordaje del VIHel diagnóstico y abordaje del VIH
• Resistencia primaria- Determinar tratamiento de inicio
• Tipo• Respuesta
• Resistencia secundaria- Nucleósidos- No Nucleósidos- IPs- I. Integrasa- Falla múltiple
Resistencia Primaria Resistencia Primaria
1 1 XIII IHDRW, Tenerife, June 2004; XIII IHDRW, Tenerife, June 2004; 2 2 Wensing AMJ, XII IHDRW, June 2003, #117; Wensing AMJ, XII IHDRW, June 2003, #117; 3 3 Delfraissy JF,Delfraissy JF, Rapport 2004Rapport 2004
% de nuevas infecciones por VIH con resistencias primarias
USA: ~10%1
Canada~8.5%1
Europe:~112*
UK: ~181†
Mexico: ~7%1
Australia:~131
France: ~123‡
Spain: ~9.51
Argentina 7-15%
Brazil 0-30%
Efecto de la resistencia transmitida sobre el tiempo a supresión virológica
N/A, Not available; NNRTI, non-nucleoside reverse transcriptase inhibitor; NRTI, nucleoside reverse transcriptase inhibitor; PR, protease; RT, reverse transcriptase.aMDR, Multi-drug resistant, defined as the presence of drug-resistant mutations for more than one class of antiretroviral drug.
AIDS:Volume 18 Supplement 3June 2004pp S9-S13
Primary Antiretroviral Resistance in Brazil
Primary Antiretroviral Resistance in Brazil
Recently acquired infection (%)
Long-standing infection (%)
NRTIs T215Y/F M184V M41L
22.79.19.14.5
21.11.73.53.5
NNRTIs 0 15.7
PIs 13.6 8.1
Cumulative 32 29.2
M C A Sucupira. High Levels of Primary Antiretroviral Genotypic Resistance and B/F Recombinants in Santos SP, Brazil. 676, 11th CROI, San Francisco 2004.
Persistence of transmitted resistant virus
1. Little SJ, et al. XII Resistance Workshop, Los Cabos 2003, #115; 2. Ravaux I, et al. 2nd IAS, Paris 2003, #822; 3. Brenner B, et al. J Virology 2002; 766:1753; 4. Chan K, et al. AIDS 2003; 17:1256
n=101
NNRTI (n=9)NRTI (n=3)PI (n=3)
Primary HIVInfection
9-145 1 of 10
Reversions
n=1 PI2 156 None
n=4 MDR3 36-260 None
n=24
MDR (n=1)NNRTI (n=1)
26-156 None
Follow-up (Weeks)
• Reversion of DR is rare even after 1 year
Resistencia secundariaResistencia secundaria
Historia de TARV previo y secuenciación
Medicamentos con pasado
-ITRAN, ITRNN, IPs
-Necesitan de Genotipo a la falla para determinar su actividad
Medicamentos sin pasado
-Inh Integrasa, CCR5 yfusión
-Pueden ser usados sin Genotipo
AZT o d4T
Factores desconocidos
TAMs 141L210W215Y
TAMs 267N70R219Q
Mas alto nivel de resistencia a AZTMayor resistencia cruzada a ITRANs
Mayor decremento en resistencia con M184V
Patrones Dicotómicos de Resistencia
Factores desconocidos
Menor nivel de resistencia a AZTMenor resistencia cruzada a ITRANs
Menor decremento en resistencia con M184V
Factores desconocidos
TAMs 141L210W215Y
Factores desconocidos
TAMs 267N70R219Q+ 215F
Factores desconocidos
TAMs 141L210W215Y+ 67N
Factores desconocidos
Efecto de TAMs, NAMs o ZAMs en la respuesta a Efecto de TAMs, NAMs o ZAMs en la respuesta a otros nucleósidosotros nucleósidos
NARVAL: Brazo de cuidado estándar
Respuesta subsecuente< 3TAMs 3TAMs pa ( log10 CV)
d4T -1.2343 -0.2632 0.036
ABC -1.7636 -0.5891 0.039
ddI -1.1249 -0.2534 0.023
ddI + 3TC -2.40 -0.5197 NS
Costagliola D. Abstract 7. 3rd European Symposium on the Clinical Implications of HIV Drug Resistance, Frankfurt 2001
All Patients
M184V
No TAMs
1-2 TAMs
3+ TAMS w/ 41 or 210
3+ TAMS w/o 41 or 210
-0.9
-0.8
-0.7
-0.6
-0.5
-0.4
-0.3
-0.2
-0.1
0
Cha
nge
in H
IV R
NA
(Log
10 c
/ml)
Response to Tenofovir DF:Effect of TAMs (Gilead 902 & 907)
Miller M, et al. 9th CROI, 2002, Abstract 43
Pocos ITRANs activos en pacientes en falla a primer esquema en Malawi
Pocos ITRANs activos en pacientes en falla a primer esquema en Malawi
Resistencia a ITRANs en pacientes en falla a primer esquema
País Esquema usado/evaluado
% TAMs % M184V
México n=134 [1]
d4T/ZDV + 3TC + EFV
55 58
Vietnam n=136 [2]
d4T/ZDV + 3TC + NVP/EFV
72 75
India n=350 [3]
d4T/ZDV + 3TC + NVP/EFV
62 71
1. Rodríguez-Diaz R. et al. In Press AIDS 2. Truong Giang L, et al. IAC 2008. Abstract TUPDA201. 2. Vidya M, et al. IAC 2008. TUPDA205.
GS934: Resistance Development Through Week 144
1. p=0.037
TDF + FTCTDF + FTC(n = 244)(n = 244)
ZDV/3TCZDV/3TC(n = 243)(n = 243)
Patients genotyped, n (%)Patients genotyped, n (%) 19 (8)19 (8) 2929 (12)(12)
Wild type, nWild type, n 6 6 77
Any resistance, nAny resistance, n 1313 2222
• EFV resistance EFV resistance mutations, nmutations, n 1313 2121
• M184V/I, nM184V/I, n 22 1010**
• TAMs, nTAMs, n 00 22
• K65R, nK65R, n 00 00*P = .02
Arribas JR, et al. IAS 2007. Abstract WEPEB029.
No emergence of K65R during 3 years
Arribas JR, et al. IAS 2007. Abstract WEPEB029.
No emergence of K65R during 3 years
GS 903 (brazoTDF n=299)GS 903 (brazoTDF n=299)Desarrollo de K65R, M184V/I & mutaciones Desarrollo de K65R, M184V/I & mutaciones
relacionadas a EFV en 144 semanasrelacionadas a EFV en 144 semanas
7
10
4
2
12
46
16
0
2
4
6
8
10
12
14
16
18
0-48 Weeks 48-96 Weeks 96-144 Weeks
Nu
mb
er o
f Pat
ien
ts w
ith M
uta
tion
s
K65R
M184V/I
EFV-R
Patrones de Resistencia para ITRNN
K103N
L100I
P225H
Y181C
K101E
G190A
EFAVIRENZ NEVIRAPINA
RESISTENCIA CRUZADA A ETRAVIRINA
§§
Y181IY181IY181VY181VK101PK101PL100IL100IY181CY181CM230LM230LE138AE138AV106IV106IG190SG190SV179FV179FV90IV90I
V179DV179DK101EK101EK101HK101HA98GA98GV179TV179TG190AG190A
§V179F was never present as single INTELENCE RAM (always with Y181C)
Score for individual mutationsScore for individual mutations
Add togetherAdd together Total weighted score
Total weighted score
33
2.52.52.52.51.51.51.51.51111111
Determinación del score genotípico con peso relativo para Etravirina
• Weight for each mutation added together = total weighted score• No single mutation confers a reduced response (≥4)
Pat
ien
ts w
ith
co
nfi
rmed
VL
H
IV-1
RN
A <
50 c
op
ies/
mL
(%
)
Highest response
Intermediateresponse
Reduced response
Highest responses occurred with a weighted score of 2
Relación entre score genotípico basal y respuesta virológica (<50 copias/mL) a semana 24
Hatched bars indicate virologic response for the entire category
74.4%
52.0%
37.7%
4/13 1/33/914/2719/3611/156/1137/53115/148 32/59 2/7 1/5 4/9 2/11N
Response category
2008 weighted mutation score for ETR
TPV weighted score
Mutation Weight
L10V 1
L24I -2
M36I 2
K43T 2
M46L 1
I47V 6
I50L/V -4
I54A/M/V 3
I54L -7
Q58E 5
T74P 6
L76V -2
V82L/T 5
N83D 4
I84V 2
Score Response
≤3 Susceptible
>3 – ≤10 Partially susceptible
>10 Resistant
Scherer et al, EACS 2007
Response by total score
Minor mutation
Major mutation
Increased response
TMC114 (Darunavir) related mutations:
V11I, V32I, L33F, I47V, I50V, I54L/M, G73S (T74P), L76V, I84V, L89V
Different “weight” of these mutations:
FC>4 3-4 2-3 <2
50V(4.5) 54M(3.5)76V(3.5)84V(3.5)T74P(3.5)
32I(2.5) 33F(2.5)47V(2.5)89V(3)
11I(1.5) 54L(1.5) 73S(1.5)
Diminished response to Darunavir when 3 or more of these mutations where present at BL
Antiviral Therapy 2006; 11: S83
Score genotípico para Darunavir
Combined effect of ETR and DRV RAMs on virological response (<50 copies/mL)
Patients with VL <50 copies/mL, % (n)
ETR RAMs weighted score*
[0; 2] [2.5; 3.5] ≥4
DRV RAMs
0 71 (12/17) 83 (5/6) 60 (3/5)1 83 (53/64) 72 (21/29) 53 (8/15)
2 77 (41/53) 64 (14/22) 26 (5/19)
3 74 (40/54) 38 (9/24) 43 (9/21)
>3 59 (23/39) 19 (4/21) 24 (4/17)
Patients with VL<50 copies/mL (%)
Subgroup of patients treated with ETR; not de novo ENF (n=406)
0
20
40
60
80
100
ETR RAMs weighted score
Res
po
nse
at
Wee
k 24
(%
)
DRV RAMs >3
32
10
[0; 2] [2.5; 3.5] ≥4
59
74
77
8371 83
72
64
38
19 24
43
26
53
60
65%
<65%
*from the list of 17 ETR RAMs (Vingerhoets et al. IHDRW 2008) Haubrich et al. XVII WAC, Mexico 2008
ETR RAMs weighted score
Res
po
nse
at
Wee
k 24
(%
)
DRV RAMs >3
32
10
[0; 2] [2.5; 3.5] ≥4
59
74
77
8371 83
72
64
38
19 24
43
26
53
60
ETR RAMs weighted score
Res
po
nse
at
Wee
k 24
(%
)
DRV RAMs >3
32
10
[0; 2] [2.5; 3.5] ≥4
59
74
77
8371 83
72
64
38
19 24
43
26
53
60
ETR RAMs weighted score
Res
po
nse
at
Wee
k 24
(%
)
DRV RAMs >3
32
10
[0; 2] [2.5; 3.5] ≥4
59
74
77
8371 83
72
64
38
19 24
43
26
53
60
ETR RAMs weighted score
Res
po
nse
at
Wee
k 24
(%
)
DRV RAMs >3
32
10
[0; 2] [2.5; 3.5] ≥4
59
74
77
8371 83
72
64
38
19 24
43
26
53
60
ETR RAMs weighted score
Res
po
nse
at
Wee
k 24
(%
)
DRV RAMs >3
32
10
[0; 2] [2.5; 3.5] ≥4
59
74
77
8371 83
72
64
38
19 24
43
26
53
60
ETR RAMs weighted score
Res
po
nse
at
Wee
k 24
(%
)
DRV RAMs >3
32
10
[0; 2] [2.5; 3.5] ≥4
59
74
77
8371 83
72
64
38
19 24
43
26
53
60
ETR RAMs weighted score
Res
po
nse
at
Wee
k 24
(%
)
DRV RAMs >3
32
10
[0; 2] [2.5; 3.5] ≥4
59
74
77
8371 83
72
64
38
19 24
43
26
53
60
ETR RAMs weighted score
Res
po
nse
at
Wee
k 24
(%
)
DRV RAMs >3
32
10
[0; 2] [2.5; 3.5] ≥4
59
74
77
8371 83
72
64
38
19 24
43
26
53
60
ETR RAMs weighted score
Res
po
nse
at
Wee
k 24
(%
)
DRV RAMs >3
32
10
[0; 2] [2.5; 3.5] ≥4
59
74
77
8371 83
72
64
38
19 24
43
26
53
60
ETR RAMs weighted score
Res
po
nse
at
Wee
k 24
(%
)
DRV RAMs >3
32
10
[0; 2] [2.5; 3.5] ≥4
59
74
77
8371 83
72
64
38
19 24
43
26
53
60
Primary protease resistance in naPrimary protease resistance in naїїve ve patients failing boosted-PIspatients failing boosted-PIs
1 Murphy R. et al., 10th EACS, Dublin, Ireland, Nov. 2005; #P7.9/3; 2 Kempf D, et al. J Infect Dis 2004: 189: 51-60; 3 Feinberg J, et al. XIV IAC, Barcelona, July 2002, # B4445, 4Cahn P, et al. 1st IAS, Buenos Aires, Argentina, July 2001, #779, 5Molina JM. et al., 3rd IAS, Rio de Janeiro, Brazil, #WePe16.7B04; 6Malan N, et al., 13th CROI, Denver, #LB107; 7Gathe JC, et al. AIDS 2004, 18:1529-37.
Weeks
0/32 isolates 7
0/3 isolates 6
0/19 isolates 1
0/51 isolates 5
0/13 isolates 4 0/5 isolates 3 0/23 isolates 2
100 200 300 400
ATV/r BMS-089
fosAmp/r SOLO
Kaletra studies
SQV/r GEMINI 0/17 isolates 7
• Adherencia??Adherencia??
• Zona de Presión SelectivaZona de Presión Selectiva
• Alta Ptencia de los IPs/rAlta Ptencia de los IPs/r
• Alta barrera genéticaAlta barrera genética
• Mecanismos alternativos de resistenciaMecanismos alternativos de resistencia- Sitios ruptura de gagSitios ruptura de gag
Como explicar la NO resistencia a IPs/r?Como explicar la NO resistencia a IPs/r?
MONARK Study: LPV/RTV MONARK Study: LPV/RTV Monotherapy vs LPV/RTV + 2 NRTIsMonotherapy vs LPV/RTV + 2 NRTIs
• Primary endpointsPrimary endpoints- HIV-1 RNA < 400 copies/mL at Week 24HIV-1 RNA < 400 copies/mL at Week 24- HIV-1 RNA < 50 copies/mL at Week 48HIV-1 RNA < 50 copies/mL at Week 48
• Patients underwent genotyping when evidence of suboptimal Patients underwent genotyping when evidence of suboptimal response was present or at the treating physician’s requestresponse was present or at the treating physician’s request
Delaugerre C, et al. HIV Resistance Workshop 2007. Abstract 75.
Antiretroviral-naive, HIV-infected patients with
HIV-1 RNA < 105 copies/mL,CD4+ cell count > 100 cells/mm3, andno evidence of resistance at screening
(N = 278)
LPV/RTV SGC 400/100 mg BID (n = 83)
LPV/RTV SGC 400/100 mg +ZDV/3TC 300/150 mg BID
(n = 53)
Week 24 Week 48 Week 96
Ongoing
SGC, soft-gel capsule.
MONARK StudyMONARK Study
• 32 patients in LPV/RTV arm 32 patients in LPV/RTV arm vs 7 in LPV/RTV + ZDV/3TC vs 7 in LPV/RTV + ZDV/3TC arm qualified for genotypic arm qualified for genotypic resistance testingresistance testing- Suboptimal response in 7 vs Suboptimal response in 7 vs
4 subjects, respectively 4 subjects, respectively - 5 vs 2 discontinuations5 vs 2 discontinuations- 20 vs 1 requests for genotyping20 vs 1 requests for genotyping
• 5 patients with major 5 patients with major mutations in monotherapy mutations in monotherapy armarm- L76V mutation in 3 patientsL76V mutation in 3 patients
• All 3 with HIV viral subtype All 3 with HIV viral subtype CRF 02 CRF 02
• LPV/RTV should be LPV/RTV should be administered with an NRTI administered with an NRTI backbone to reduce selection backbone to reduce selection for resistancefor resistance
Delaugerre C, et al. HIV Resistance Workshop 2007. Abstract 75.
LPV/RTVLPV/RTV(n = 32)(n = 32)
LPV/RTV LPV/RTV ++
ZDV/3TCZDV/3TC(n = 7)(n = 7)
No change No change from from screeningscreening
1515 33
Any change Any change in protease in protease genegene
1717 44
IAS minor PI IAS minor PI resistance resistance mutationmutation
55 00
IAS major PI IAS major PI resistance resistance mutationmutation
55 00
Mutaciones Primarias y Secundarias que afectan la Susceptibilidad a RAL
Fo
ld C
han
ge
IC5
0100
200
300
400
500
600Q148HQ148H/G140SQ148KQ148K/E138AQ148K/G140AQ148K/E138A/G140AQ148RQ148R/G140S
Q148 Pathway
Q148 key mutation emerges, associated with secondary mutations
N155 Pathway
N155H key mutation emerges, associated with secondary mutations
Fo
ld C
han
ge
IC5
0
10
203040
50
70 N155HN155H/L74MN155H/T97AN155H/E92Q
60
Hazuda DJ, et al. HIV Resistance Workshop 2007. Abstract 8.
Q148H
Raltegravir Resistance Evolution
N155H + Q148H
N155H N155H + Q148H
Q148H + others
Q148H + others
Q148H + others
Fransen S, et al. Resist Wkshp 2008. Abstract 7.
Cambios en la Susceptibilidad FENOTÍPICA Cambios en la Susceptibilidad FENOTÍPICA a EVG y RAL de mutaciones sitio-dirigidasa EVG y RAL de mutaciones sitio-dirigidas
• Integrase sequenced in patients with virologic failureIntegrase sequenced in patients with virologic failure- Site-directed mutants constructed from those data and used to determine Site-directed mutants constructed from those data and used to determine
susceptibility to EVG, RAL, and 2 antiretroviral controls (TDF and LPV)susceptibility to EVG, RAL, and 2 antiretroviral controls (TDF and LPV)
Fold Change of Mutant Viruses: Single Integrase Mutations
Drug T66I E92Q E138K G140S S147G Q148H Q148K Q148R N155H
EVG 15 33 0.7 5.0 8.0 6.4 67 118 38
RAL 1.4 6.0 0.9 2.0 1.0 20 34 30 23
TDF 0.9 1.0 1.0 0.8 0.8 0.9 0.8 0.7 1.0
LPV 1.0 1.0 0.9 0.8 0.8 0.7 0.9 0.7 1.0
Fold Change of Mutant Viruses: Clinical EVG Mutation Patterns
Drug T66I/S147G
T66I/E92Q
E92Q/N155H
G140S/Q148H
E138K/S147G/Q148R
EVG 46 145 166 > 1000 175
RAL 2.5 33 135 > 1000 34
TDF 1.1 0.9 0.9 0.9 0.9
LPV 1.0 1.0 0.7 0.9 0.8
McColl DJ, et al. HIV Resistance Workshop 2007. Abstract 9.
ARvs recomendados en 212 casos analizados
HIV-1 drug resistance genotyping in treatment-naïve subjects using dried whole blood spots
Silvia Bertagnolio, Luis Soto-Ramirez, Richard Pilon, Richard Harrigan, Roberto Rodriguez, MonicaViveros, Luis Fuentes, Theresa Mo, Don Sutherland, Paul Sandstrom.
Antivir Ther. 2007; 12(1):107-13
Methods: We prospectively collected specimens from newly-diagnosed, treatment-naïve HIV+ subjects in Mexico. Whole blood was spotted onto filter cards, air dried at room temperature and stored with desiccant at 37°C & 85% humidity for 3 months. Genotypes obtained from DBS-extracted nucleic acids using an in-house nested RT-PCR method were compared to genotypes derived from matched plasma.
PDR Surveillance
Results of replicate amplifications of DBS extracts where drug resistance mutations
were detected in either specimen type.
Specimen IDPlasma DBS Mutations from
Replicate RT-PCR (n=11)Mutation Detected in DBS
A2-0229 M41LL210W
11-M41L11-L210W
100%100%
A2-0805 K103NY181CY
8-K103N, 2-K103KN, 1-K103K9-Y181C, 2-Y181CY
90.9%100%
A2-0916 L90MK70RT215FK219E
11-L90M11-K70R11-T215F11-K219E
100%100%100%100%
B5-0054 M41L 11-M41L 100%
B5-0042 M41L 11-M41ML 100%
B1-0015 K103KNV108I
9-K103KN, 2-K103K7-V108I, 4-V108IV
81.8%100%
B5-0119 V108IV 11-V108V 0%
A2-0535 M184M 10-M184M, 1-M184MV 9.1%
B4-0050 D67D 6-D67DN, 5-D67D 54.5%
DBS replicate genotypes were generated from 3 RT-PCR that served as template for 11 nested PCR, except in the case of B5-054 and B1-0015, where only 2 RT-PCR were used as template.All differences between specimen types were partial discordances (mixed bases). In 1 case, B5-0119, a mixed wild type/mutant was detected in plasma and no mutations were detected in matched DBS sequences. Two specimens, A2-0535 and B4-0050, were wild type in plasma and found as mixed wild type/ mutant in 9.1% and 54.5% of replicates in DBS, respectively.
Score del Evaluador 3
3.002.502.001.501.00
Score del Evaluador 3
Fre
qu
en
cy
20
10
0
Std. Dev = .68
Mean = 2.47
N = 34.00
Score del Evaluador 4
3.002.502.001.501.00.500.00
Score del Evaluador 4
Fre
qu
en
cy
14
12
10
8
6
4
2
0
Std. Dev = .83
Mean = 2.26
N = 35.00
Sobreprescripción en base a genotipo
En 30 ocasiones se utilizaron fármacos más potentes de lo requerido según las mutaciones mostradas por el genotipo y la historia de esquemas antiretrovirales previos.
Evaluador 1(2.90): 5/35 (14.28%) Evaluador 2 (2.66): 7/35 (20%) Evaluador 3 (2.47): 17/35 (48.5%) Evaluador 4 (2.26): 1/35 (2.85%)
Los fármacos ARV más sobre prescritos:
Raltegravir 9/30 (30%).
Darunavir 8/30 (26.66%)
T20: 5/30 (16.66%)
Etravirina 5/30 (16.66%)
Tipranavir 3/30 (10%)
LALatin American HIV Resistance Network
Bogotá, ColombiaMayo 6, 2010
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