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Injectable HIV Treatment
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Injectable HIV Treatment
Alexandra Danforth, PharmD, BCACP, AAHIVP
Manager, Clinical Pharmacy
Trillium Health
Rochester, NY
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Disclosures
"This [project/publication/program/website] [is/was] supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $3,879,101 with zero percentage financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government."
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Learning Objectives
Describe injectable antiretroviral therapies in clinical trials for HIV treatment and prevention.
Review patients who might be good candidates for injectable therapy.
Describe challenges that providers might face implementing these new therapies.
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4
2020
Fostemsavir (AI)
2021
Cabotegravir (INSTI)
What to start?
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https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv
https://www.positivelyaware.com/articles/choice-options
Do we even need more new drugs?
Options for heavily treatment experienced patients
More convenience
PrEP options
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New Horizons in Therapy
Patient desires
Freedom from stigma
Decreased pill burden or side effects
Ideal long-acting ARV characteristics
Potent
Extended dosing intervals
Low volume injections
Patient self-administration
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IBALIZUMAB
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HIV Entry Inhibitors
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*FDA approved
Adapted from Moore JP, PNAS 2003; 100: 10598-10602.
*
Ibalizumab-uiyk (IBA, Trogarzo)
Post attachment inhibitor
Binds to CD4 and prevents HIV entry into the cell
IV infusion every 2 weeks
Loading dose of 2000mg; Maintenance dose of 800mg
Observe patient for 1 hr post loading dose, if no reaction can be 15 min for maintenance doses
Need to re-load if more than 3 days late for maintenance
ADRs: diarrhea, dizziness, rash, nausea
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IBA: Phase 3 Trial
Single arm, open-label Phase III study
40 adults with multi-drug resistant HIV, VL>1000 cp/mL
IBA with optimized background regimen with at least 1 fully active agent
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At 24 wks, 43% of patients has VL<50 copies/mL
In 48 wk completer analysis, 67% (16/24) were VL<50 copies/mL
Emu et al. N Engl J Med; 2018; 379:645-654.
Emu et al. Glasgow 2018, #O345
What are nanosuspensions?
Drug nanocrystals suspended in liquid
Varied size of nanoparticles leads to prolonged dissolution
Currently approved drug examples:
Invega Sustenna and Trinza (paliperidone)
Abilify Maintena (aripiprazole)
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Question #1
Which of the following does NOT affect the pharmacokinetics of a long acting injectable nanoformulation?
Nanoparticle size and shape
Injection site (muscle vs fat)
Injection route (IM vs SC)
Lipophilicity of the drug
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CABOTEGRAVIR
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Question #2
Which statement about Cabotegravir (CAB) is TRUE?
CAB is a new nucleoside reverse trascriptase inhibitor (NRTI).
Patients preferred taking oral CAB to injectable CAB.
CAB has been used for both HIV treatment and prevention in clinical trials.
CAB is not effective for PrEP in cis-women.
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Cabotegravir (CAB)
INSTI, similar to dolutegravir
Active against some INSTI resistant strains
Half-life is 21-50 days
Nanosuspension, given IM or SC
ADRs: mild injection site reactions, nodules with SC
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CAB/RPV: FLAIR Study
Multicenter randomized, open-label, Phase 3 trial
Treatment nave adults
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Orkin et al. CROI 2019, #140LB
Slide credit: clinicaloptions.com
CAB/RPV: FLAIR Study
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Orkin et al. CROI 2019, #140LB
Slide credit: clinicaloptions.com
CAB/RPV: ATLAS Study
Multicenter, randomized, open-label Phase 3 switch study
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Swindells et al. CROI 2019, #139
Slide credit: clinicaloptions.com
CAB/RPV: ATLAS Study
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Swindells et al. CROI 2019, #139
Slide credit: clinicaloptions.com
ATLAS Study: Patient Satisfaction
Use of patient reported outcome tools to assess patient views on switching to CAB/RPV injections vs continuing baseline oral ART suggested injectable treatment was well tolerated through Week 48
Health status and QoL were similar between LA and oral ART groups
Treatment acceptance was significantly higher with LA vs oral ART group
90% of patients receiving LA treatment scored ISRs as totally or very acceptable and 86% scored pain as totally or very acceptable
Greater improvement in treatment satisfaction with LA vs oral ART group
97% of patients receiving LA treatment said they preferred LA treatment to daily oral therapy
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Murray et al. IAS 2019, #MOAB0103
ATLAS 2M
Multicenter, randomized, open-label, phase 3 non-inferiority trial
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Overton et al. CROI 2020, #34
Slide credit: clinicaloptions.com
ATLAS 2M
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Overton et al. CROI 2020, #34
Slide credit: clinicaloptions.com
CAB/RPV Treatment Failures
Multivariate post hoc analysis of the confirmed virologic failures in ATLAS, FLAIR, ATLAS-2M (n=13/1039)
About 1% in each study
Four factors were associated with increased odds ratio for CVF
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Margolis et al. HIV Drug Therapy Glasgow 2020, O442
CAB/RPV Treatment Failures
CVF was rare and associated with the presence of at least 2 baseline factors: RPV resistance mutations, BMI>30, HIV-1 subtype A6/A1
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Margolis et al. HIV Drug Therapy Glasgow 2020, O442
CAB/RPV (Cabenuva)Approved 1/21/21!
Approved for switch in stable suppressed patients (VL<50)
No history of treatment failure or known/suspected resistance to CAB or RPV
1 month oral lead in phase with 30mg CAB (Vocabria) and 25mg RPV (Edurant) daily
Initiation dose: 3mL 600mg CAB; 3mL 900mg RPV
Maintenace dose: 2mL 400mg CAB; 2mL 600mg RPV
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CAB/RPV (Cabenuva)Approved 1/21/21!
Contraindicated with
Carbamazepine, oxcarbazepine, phenobarbital, phenytoin
Rifabutin, rifampin, reiapentine
St Johns wort
Dexamethasone (more than a single dose treatment)
ADRs: injection site reactions, fatigue, fever, headache, nausea, musculoskeletal pain
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CAB for PrEP: HPTN 083
Phase 2b/3 randomized, double-blind, double-dummy @ 43 sites globally
MSM/TGW age 18+
Risk: any nCRAI, >5 partners, stimulant drug use, incident rectal or urethral STI (or incident syphilis) in past 6 months; or SexPro Score 16 (US only)
Generally good health
No HBV or HCV
No contraindication to gluteal injections, seizures, gluteal tattoos/skin conditions
Planned enrollment 5000
50% under age 30
10% TGW
50% of US enrollment Black
Primary efficacy endpoint: Incident HIV infections during blinded comparison
Primary safety endpoint: G2 or higher clinical and laboratory AEs
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Landovitz et al. AIDS 2020, #OAXLB01
CAB for PrEP: HPTN 083
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Landovitz et al. AIDS 2020, #OAXLB01
CAB for PrEP: HPTN 083
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Landovitz et al. AIDS 2020, #OAXLB01
66% reduction in risk of HIV infection in CAB group
CAB well tolerated, ISR
CAB for PrEP: HPTN 084
Planned enrollment of 3,200 cis-women in sub-Saharan Africa as risk for HIV acquisition
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https://www.hptn.org/research/studies/hptn084#views-field-field-public-f...
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CAB for PrEP: HPTN 084
Stopped early in November 2020, was designed to go to 2022
3223 cisgender women enrolled
CAB was superior to TDF/FTC at preventing HIV
HIV incidence
0.21% in CAB group, n=4
1.79% in TDF/FTC group, n=38
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https://www.084life.org/study-results/
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Question #3
In HPTN 083 and 084, cabotegravir (CAB) was ___________ to TDF/FTC daily oral tablets for PrEP.
Non-inferior
Inferior
Superior
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New Mechanisms of Action
Translocation inhibitor
Capsid inhibitor
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ISLATRAVIR
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Islatravir (ISL, MK-8591)
Nucleoside reverse transcriptase translocation inhibitor (NRTTI)
Chain terminator and translocation inhibitor
Half-life is 50-60hrs in plasma
Daily or once weekly dosing!
Low doses orally and parenteral formulations
Potent activity with broad coverage for HIV-1 and HIV-2 and NRTI resistant strains
Minimal cross resistance with other NRTIs
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ISL: Activity against NRTI resistant strains
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Grobler et al. CROI 2019, #481
ISL + DOR: Phase 2B
International, randomized, double-blind trial
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Molina et al. HIV Drug Therapy Glasgow 2020, #O415
Slide credit: clinicaloptions.com
ISL + DOR: Phase 2B
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Molina et al. HIV Drug Therapy Glasgow 2020, #O415
Slide credit: clinicaloptions.com
Why implants?
Advantages
Removable
Consistent drug release
PK not dependent on injection site
Can be in place for years
Disadvantages
Need implantation device
Minor procedure to remove
Difficult to bring to market as a generic
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ISL for PrEP: Long acting implant
ISL prototype design based on Nexplanon/Implanon
Uses same applicator and polymer
Removable
Double-blind, placebo-controlled in healthy volunteers
Groups had either54mg or 62mg implant
Placed in upper arm ofnon-dominant hand
Removed after 12 weeks
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Matthews et al. IAS 2019; # TUAC0401LB
ISL for PrEP: Long acting implant
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Modeling suggests 62mg implant would have protective levels at 52 weeks, approximately 16 mo before under PK threshold
Half-life after removal similar to oral ISL
Well tolerated with most implantation site reactions self-resolving
Matthews et al. IAS 2019; # TUAC0401LB
LENACAPAVIR
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HIV Capsid Inhibitor
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Sager et al. CROI 2019, #141
Lenacapavir (LEN): Capsid Inhibitor
First in-class inhibitor of HIV capsid inhibitor with picomolar potency
Given as subcutaneous suspension
Also has oral formulation in trials
In-vitro: active against HIV-1 variants and resistant strains
Low clearance and low solubilityvery long half life
In clinical trials, for both treatment and PrEP
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Sager et al. CROI 2019, #141
LEN: PK Study
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Begley et al. AIDS 2020, #PEB0265
Slide credit: clinicaloptions.com
Phase 1 PK and safety data in healthy volunteers
Potential for every 6-mo dosing, will need oral loading dose
Most ADEs were mild injection site reactions
LEN: HIV Capsid Inhibitor
Phase 1b, double-blind, randomized, placebo controlled, dose ranging study
Single subcutaneous injection, then started B/F/TAF at day 10
Current trials: treatment nave patients, heavily treatment experienced
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Daar et al. CROI 2020, #469
Who might benefit?
Patients who
Have issues with tablet size
Have issues with stigma
Trouble remembering to take their meds
Can commit to attend appointments
Drug interactions
Have resistance to current options
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Challenges
Insurance coverage
Patient factors
Pregnancy potential
Managing adverse effects
Drug drug interactions
Body composition
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Administration
Office visits
Missed appointments
Techniques
Injection vs infusion
Summary
Injectable and implantable ARV therapy have great potential for both HIV treatment and prevention
Patients may face challenges with access and administration but also may prefer this to traditional oral therapy
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HIV - HCV - PrEP - PEP
Clinical Consultations
For Providers in Upstate NY
Call or E-mail for a consultation:
518-262-6864
Monday Friday 8:00 a.m. 4:30 p.m.
[email protected]
If you have experienced an occupational exposure such as a needle stick, please call 518-262-4043. You will be given an opportunity on the telephone menu to speak to a physician 24 hours a day.
www.amc.edu/hiv
Questions?[email protected]
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