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Question 1

Question 1. Do the data demonstrate that tipranavir/ritonavir (TPV/r) is safe and effective for the multi-drug resistant HIV-1 infected population? If no, what additional data are needed to provide evidence of safety and efficacy?

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Question 1

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  1. Question 1 Do the data demonstrate that tipranavir/ritonavir (TPV/r) is safe and effective for the multi-drug resistant HIV-1 infected population? • If no, what additional data are needed to provide evidence of safety and efficacy? • If yes, please address the appropriate population for TPV/r use considering the following: • limited inclusion criteria of the RESIST trials • drug-drug interactions • resistance information and patterns associated with optimal use • safety considerations FDA Antiviral Drugs Advisory Committee Meeting

  2. Question 2 Given the data on transaminase elevations, please provide your recommendations for: • TPV/r use in patients with underlying liver disease • Monitoring and management of hepatotoxicity during clinical use • Future studies FDA Antiviral Drugs Advisory Committee Meeting

  3. Question 3 • The limited amount of data in females with HIV infection in the TPV program shows an increased incidence of rash in females. Please provide your recommendations for: • Investigation of this safety signal in future studies with TPV FDA Antiviral Drugs Advisory Committee Meeting

  4. Question 4 • Current information indicates the net effect of TPV/r on substrates of CYP1A2, CYP2C9, CYP2C19 and CYP2D6 is not known, and there are competing effects of TPV/r on CYP3A (inhibition) and P-glycoprotein (induction). Please comment on additional post-marketing drug interaction studies. FDA Antiviral Drugs Advisory Committee Meeting

  5. Question 5 • Given the high inter-patient variability in TPV exposures following fixed doses and exposure (blood levels)-virologic response relationships, could a biomarker such as Cmin/IC50 be used for the individualization of TPV/r therapy? Please discuss the studies that would supplement the data presented today. FDA Antiviral Drugs Advisory Committee Meeting

  6. Question 6 • Please provide your recommendations regarding the display of TPV/r resistance data/analyses in the TPV package insert that would be useful to clinicians. FDA Antiviral Drugs Advisory Committee Meeting

  7. Examples • Baseline Outcome Analyses • Baseline Number of PI Mutations • Type of PI Mutation • Baseline Phenotype • TPV score • Key mutations • Endpoints • Primary endpoint (proportion of responders) • Change from Baseline (e.g. median, average) • +/-T20 use FDA Antiviral Drugs Advisory Committee Meeting

  8. Response by Baseline Number of PI Mutations Proportion of Responders (confirmed >1 log decrease at Week 24) # Any change at positions 30, 32, 36, 46, 47, 48, 50, 53, 54, 82, 84, 88 and 90 FDA Antiviral Drugs Advisory Committee Meeting

  9. Response by Baseline PI MutationsMedian Change from Baseline - Overall 0 2 4 8 16 24 Week FDA Antiviral Drugs Advisory Committee Meeting

  10. Question 7 • Please discuss and recommend future study designs /data acquisition for the heavily pretreated population. FDA Antiviral Drugs Advisory Committee Meeting

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