Resistencias a los ARVs - fai.org.co · PDF fileMargot NA et al. Anti Res 2016 Margot NA et...

José Luis BlancoServicio de Enfermedades Infecciosas

Hospital Clinic. Barcelona

Resistencias a los ARVs

Medellin, 1 de Julio del 2017

Presenter Disclosure Information

– Research Support: ViiV, BMS, MSD, Jansen

– Speaker’s Bureau: Abbvie, Bristol-Myers Squibb, Merck,Jansen, ViiV Healthcare, Stendhal

– Advisory Panel: Gilead, Stendhal, Gador,Jansens, ViiV

Agenda

• Introducción: conceptos básicos

• Test de resistencias: nuevas herramientas

• Resistencias en el paciente naïve

• Resistencias a los ANITI/ANNITI/PI: qué debemos saber

• INIs: datos de resistencias

• Conclusiones

0 2-6 w

Virological Failure (VF)

VL<50 cop/mL

VF

“Blip”

VL<200 cop/mL

• Check again patient’s adherence

• Rule out DDI

• Infections/vaccinations

Resistance: more than “Genetic barrier”

VL

Limit of Detection

VF

ART: A+B+C+D

week/sdays yearsmonths

mutation to B

mutation to A

mutation to C

time

drug A: very low robustness(GB)

drug B: low robustnessdrug C: moderate robustness

drug D: high robustness

mutation to D

i.e.: EFV, NEV

i.e.: d4t, PI/r

i.e. : IP non boostedi.e.: 3TC

INIs

RAL,EGV/COBI

DGV (?)*

*from in vitro data

“Robustedness”: in vivo concept

High Level of Resistance

“Genetic Barrier-GB”: concept

Drug A: low GB

Drug B: moderate GB

Drug C: high GB

3TC

i.e.: EFV, NEV, RPV, 3TC

i.e. : IP/r

i.e.: ETR

INIs

RAL,EGV/COBI

DGV (?)*

each step = 1 mutation ABC*d4T*, TDF*

1 mutationDrug CDrug A Drug B

2-3 mutations >3 mutations

* : depends on the pathway of scape

ETR DRV/r

M184V G190A

Y181C

I84V

L33F

V32I

I47V

I54L

TDF

K65R

TDF

K70R

K219Q

T215F

M41L

T210W

Agenda






• Conclusiones

Standard Sanger Sequencing Detects the Most Common Circulating HIV-1 Variants

Standard

Cloning

Allele-specific PCR Parallel Allele-Specific

Sequencing (PASS)

Single

Genome

sequencing

Ultra deep sequencing

(454 life sciences/Roche)

Concept Analysis of

single CFUs

with indiviual

clones

Differential

amplification of

mutants vs WT in

real-time PCR

Single-base allele

sequencing of polonies

fixed to an acrylamide

surface

Massive

sequencing of

single genome

molecules

Massively parallel

microfluidic solid-surface

sequencing of single

molecules (105 reads)

Sensitivity > 10% 0.003 - 0.4% 0.1% 2% 0.5 – 1%

# mutations multiple 1 1 per round (up to 22

rounds)

Multiple within 300 bp

Linked

mutations

Yes No Yes Yes Yes

Labor

Intensity

Cost

Best Experience,

PPV

S, PPV, NPV,

Affordable

S, linkage of muts Linkage Linkage, Accuracy, S, NPV,

Labor intensity, Rapidity

of results

Worst S, NPV Only 1 mutant,

Sp, effect of

polymorphisms,

Cost, Labor intensity Cost, time and

labor

consuming

Short sequence,

background noise, Sp

TOOLS TO STUDY MINORITY VARIANTS

Secuenciación masiva…..

Agenda






• Conclusiones

Avila-Ríos et al., unpublished

Publications on HIV TDR in the Andean Region, 2000-2015

Colombia

Peru

Venezuela

Low level HIVDRModerate level HIVDRHigh level HIVDR

Special populationsPregnant women

TDRprevalence(%)

AuthorsYearof

publicationCountryandarea

Samplingyears

StudyPopulation NAnydrug

classNRTI NNRTI PI

DiazGranadoset

al.

2010 Colombia(Bogotá/

Cundinamarca,Valle

delCauca,Antioquia,

Atlantico/Bolivar,Santander,Caldas/

Risaralda)

2006-2008Mixed 103 5.8 2.9 4.9 1.0

MSM 326 3.4 2.1 0.6 1.8Lamaetal. 2006 Peru(Lima,Sullana,

Piura,Arequipa,

Iuitos,Pucallpa)

2002-2003

RecentlyinfectedMSM(DetunedEIA)

33 3.0 3.0 3.0 3.0

Guaniraetal. 2009 Perú(Lima,Arequipa,

Ica,Sullana)and

Ecuador(Guayaquil)

2006 MSM 117 4.3 0.6 2.6 0.6

Soriaetal. 2011 Peru(Lima) 2007-2009 Mixed 96 1.0 0 1.0 0

Delgadoetal. 2001 Venezuela 1999 Mixed 31 3.2 3.2 0 0

Bouchardetal. 2007 Venezuela(Caracas,

CentralVenezuela)

2003 Mixed 20 5.0 5.0 0 0

Rangeletal. 2009 Venezuela(Caracas) 2004-2007 Mixed 63 11.0 9.5 3.2 1.6

Castilloetal. 2009 Venezuela(Caracas) 2008 Mixed 62 6.5 3.2 1.6 1.6

No KEY InSTIs mutations

DEPARTAMENTO DE INVESTIGACIÓN EN ENFERMEDADES INFECCIOSAS

INI TDR survey in Mexico

17.3%

52.1 %26.5 %

No data 4.1 %

Major INI TDR mutations

INI TDR1.0%

Accessory INI TDR mutations

Atypical polymorphisms in IN positions associated with DR

Agenda






• Conclusiones

RESISTENCIAS a los ANITI

Mutaciones seleccionadasInicialmente por el fármaco

Mutaciones existentesque condicionan resistencia

cruzada al fármaco

AZT: 215YddI: 74V3TC: 184Vd4T: 75VFTC: 184VTDF: 65RABA: 74V/65R

En monoterapia En combinación

Depende:

-NRTI acompañante

-Niveles PK??

-Otros F

acompañantes

- TAMs

- 41L,210W, 215Y (via 1)

- 67N,70R,215F,219Q (via 2)

- 184V

- Otras : 65R,74V, 44D,118I

- Patrones multi-R: 151Q,69SSS

21 - GILEAD CONFIDENTIAL AND PROPRIETARY DRAFT. FOR INTERNAL USE ONLY. NOT FOR DISTRIBUTION OR PROMOTION.21 - GILEAD CONFIDENTIAL AND PROPRIETARY DRAFT. FOR INTERNAL USE ONLY. NOT FOR DISTRIBUTION OR PROMOTION.

LYMPHOCYTE

TFV

OAT

1 & 3

OAT

1 & 3

RENAL

TUBULAR

CELL

TFV

RENAL

TUBULAR

CELL

PLASMA

TFV

ESTER

AMIDATE

DIANION

TDF(tenofovir

disoproxil

fumarate)

300 mg

TAF(tenofovir

alafenamide)

25 mg

TFV(tenofovir)

PRO

DRUGLONGER PLASMA HALF-LIFE † - GREATER PLASMA

STABILITY

SHORT PLASMA

HALF-LIFE†

TFV HIV

GI TRACT

TAF – A Novel Prodrug of Tenofovir

Prodrug Pharmacology‡

OAT, organic anion transporter; TAF, tenofovir alafenamide; TDF, tenofovir disoproxil fumarate; TFV, tenofovir.

TAF results in 80-90% lower TFV plasma levels compared to TDF

1. Sax P, et al. Lancet 2014 2. Ruane P, et al. J Acquir Immune Defic Syndr 2013; 63:449-5. 3. Data on file

0

20

40

60

80

100

120

TDF(300 mg)

TAF(25 mg)

Pla

sma

TFV

(%

of

TDF

valu

e)

~90% less TFV in

plasma

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

TDF(300 mg)

TAF(25 mg)

HIV

RN

A r

ed

uct

ion

; Day

11

(Lo

g10

c/m

L)

~ 0.5 Log more in VL

reduction

Ruane P et al. JAIDS 2013;63:449–455

P=0.024

Phase Ib, randomised, dose ranging study, evaluating antiviral activity, safety and pharmacokinetics/pharmacodynamics of 10 day monotherapy with TAF (N=38)

In comparison to TDF, antiviral activity was increased with TAF and TFV exposure was decreased at an approximately 90% lower dose

Study GS-US-120-0104

Virological and PK comparison of TAF and TDF

Ruane P, et al. JAIDS 2013;63:449-455.

Study GS-US-120-0104M

ed

ian

ch

an

ge

fro

m B

as

eli

ne

H

IV-1

RN

A (

log

10

c/m

L)

0.5

0.0

-0.5

-1.0

-1.5

-2.07 14 21

Placebo (N =7)

TDF 300mg (N =6)

TAF 8mg (N =9)

TAF 25mg (N =8)

TAF 40mg (N =8)

Day

Dosing period

Resistance

• 2 participants on E/C/F/TAF and 4 on E/C/F/TDF had newly detected

genotypic resistance between Weeks 96 and 144

• In participants with genotypic resistance, there was no significant difference

in median baseline VL between E/C/F/TAF and E/C/F/TDF (HIV-RNA

252,200 vs 115,500 copies/mL; p=0.27)

2

4

INSTI, integrase strand transfer inhibitor; VF, virologic failure.

Participants, % (n)

VF With

Resistance

INSTI + NRTI

Resistance

NRTI

Resistance Only

INSTI

Resistance Only

E/C/F/TAF 1.4 (12) 8 4 0

E/C/F/TDF 1.4 (12) 7 4 1

Margot NA et al. Anti Res 2016Margot NA et al. AAC 2015

NEV

EFV

RPV

ETR

103N

181C

138K

138K, 181C, 101E??

RPV, ETR

ETR

EFV, NEV, ETR

190A, 181C

190A, 103N

181C, 101E

EFV, NEV, ETR

26

Resistencias a los ANNITI: DOR, qué aporta?

DOR ??

NNRTI activos

No diferencias “valorables” por subgrupos

Resistencias a DOR

AAC 2015

High Level of Resistance

DRV/r Robustness and Genetic Barrier

high GB

each step = 1 mutation

DRV/r

>3 mutations

DRV/r

I84V

L33F

V32I

I47V

I54L

VL

VF

week/sdays years

mutation to DRV

High Robustness

DRV/r

DRV: ratio Cmin/IC50 y t1/2d.

Van Lunzen J. Lancet Infect Dis 2012; 12: 111–18.

DRV/r: t1/2 disociativa: 240 hDRV/r: Cmin/ IC50: 35

Dierynck I, et al. Journal of virol. 2007;81(24):13845-13851

Cahn P, et al. AIDS 2011

Posología de Darunavir/ritonavir

Paciente naïve osin DRV-RAMs

Paciente con DRV-RAMs

800/100 qd 600/100 bid

FC>4 3-4 2-3 <2

50V 54M

76V

84V

32I

33F

47V

74P

11I

54L 89V

De Meyer S. Abst 54. EU DRW. Budapest 2008

Agenda






• Conclusiones

EGV

RAL

DTG

155H (+92Q+74M)

148R/H/K

66I/A/K + 92Q

[2DR/3DR]

148R/H/K

?? 263K /148R/H/K

INSTI Pathways of resistance

Blanco JL, personal comunication

143R/H/C (+92Q+97A)

140A/S (+138A/K)

148R/H/K

148R/H/K 140A/S (+138A/K)

[1DR] All the same than RAL,EGVmainly 148X and others 118R

SECUENCIAR OR NOT SECUENCIAR

De Souza, et al. JAC 2015; Fourati S, et al JAC 2015

32/92= 35%

Is it “correct” sequencing INSTIs?

Resistance to DTG

In vivo :(naïves)

No data yet….

SPRING-21 96 sem SINGLE2 96 sem FLAMINGO3 48 sem

n (%) DTG 50 mg (n=411)

DTG 50 mg +ABC/3TC (n=414)

DTG 50 mg(n=234)

Pacientes con FVDP 20 (5) 18 (4) 2 (<1)

Mutaciones de resistencia a ITIAN 0 0 0

Mutaciones de resistencia a INI 0 0¶ 0a

??

Why these“Robustness”and GB?

PK and Inhibitory Quotient(IQ):

Plasma levels at 24 h post-dose

IC-DTG90

0 5

Time post-dose (hours)

10.0

1.0

DT

G p

lasm

a co

ncent

rati

ons

(µg/

mL)

0.1

10 15 20 25

50 mg QD

PA-IC90 0.064 µg/mL*

19 folds

= 19

DTG disassociation from IN-DNA

Comprehensive Assessment of Resistance Mutations Selected by Dolutegravir (DTG) in Subjects Failing DTG-Monotherapy after Switching from other Therapies (Redomo

Study)

Blanco JL1, Oldenbuettel C2, Thomas R3, Mallolas J1, Wolf E2,

Brenner BG4,Spinner CD2, Wainberg MA4, Martinez E1

1 Hospital Clinic, Barcelona, Spain. 2 MVZ Karlsplatz, HIV Research and Clinical Care Centre, Munich, Germany. 3 Clinique Actuel, Montreal,

Quebec, Canada. 4 McGill AIDS Centre Montreal, Quebec, Canada

Susceptible ReducedSusceptibility

Resistance

<2.5-fold ≥2.5-10-fold >10-fold

Susceptibility to INSTIs

Q148H/R + G140A/S (n=12)

WT

BIC

DTG

EVG

RAL

143Q148H

G140S

143Q148H

G140S

143Q148R

G140A

143Q148H

G140S

143

143Q148H

G140SQ148H

G140S

Q148H

G140S

143Q148H

G140S

Q148H

G140S

Q148H

G140SQ148R

G140S

Q148R

G140S

14th European Workshop on HIV & Hepatitis. Abstract O-01Poster 497. CROI 2017

Conclusiones• La Barrera a las Resistencias (BR) es una combinación de

“Robusted” y “Barrera genética”

• Los estudios de secuenciación masiva detectan resistencias en poblaciones minoritarias que tenemos que aprender a interpretar.

• Los niveles de TFV intracelular que se alcanzan con TAF incrementan su IQ y conceptualmente su barrera a las resistencias

• Doravirine es un ANNITI con un perfil de resistencias “diferente”

• Darunavir es el IP con mayor BR

• Dolutegravir (DTG) es el INsTI comercializado con mayor BR

Gracias!

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