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48-week results of once-daily maraviroc (MVC) 150 mg in combination with ritonavir-boosted atazanavir (ATV/r) compared to emtricitabine/tenofovir (FTC/TDF) + ATV/r in treatment-naïve patients infected with R5 HIV-1 (Study A4001078).
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48-week results of once-daily maraviroc (MVC) 150 mg in combination with ritonavir-boosted atazanavir (ATV/r) compared to emtricitabine/tenofovir (FTC/TDF) + ATV/r in treatment-naïve patients infected with R5 HIV-1 (Study A4001078) Simon Portsmouth,1 Charles Craig,2 Anthony Mills,3Donna Mildvan,4 Daniel Podzamczer,5Gerd Fätkenheuer,6 Manuel Leal,7 Hernan Valdez,1SrinivasRao Valluri,1Jayvant Heera1 1Pfizer Inc., New York, NY, USA; 2Pfizer, Sandwich, Kent, UK; 3Anthony Mills MD, Los Angeles, CA, USA; 4Beth Israel Medical Center Division of Infectious Diseases, New York, NY, USA; 5HIV Unit, Infectious Disease Service, Hospital Universitari de Bellvitge, Barcelona, Spain; 6University Hospital of Cologne Köln, Germany; 7Laboratory of Immunovirology, Biomedicine Institute of Seville (IBIS), Infectious Disease Service, Virgen del Rocio University Hospital, Seville, Spain
Rationale for MVC + boosted PI regimen • Potential for early use: prevalence of CCR5 tropic virus is greatest in treatment-naïve individuals1 • Nucleoside-sparing regimen • Good penetration of MVC in CSF and genital secretions2-4 • MOTIVATE and PK studies support use of MVC 150 mg QD with selected ritonavir-boosted PIs Study A4001078: an exploratory pilot study of a low pill burden QD dual-therapy regimen, MVC + ATV/r 1. Hoffmann, Eur J Med Res, 2007. 2. Tiraboschi et al, J Acquir Immune Defic Syndr, 20103. Dumond et al, J Acquir Immune Defic Syndr, 2009. 4. Brown et al, J Infect Dis, 2011
Study designOpen-label, 48-week Phase 2b pilot study Randomization 1:1N=121 • Patient eligibility criteria • R5 HIV (ESTA) at screening • ≥16 years of age • HIV-1RNA ≥1000 copies/mL • CD4 ≥100 cells/mm3 • No evidence of resistance to ATV/r, TDF, or FTC • Study has iDMC • Ongoing study: USA, Spain, Germany • Extended to 96 weeks • Study is not powered to show a treatment difference and no formal comparative statistics will be performed FTC/TDF + ATV/r (300/100 mg QD) MVC (150 mg QD) + ATV/r (300/100 mg QD) Screening(6 weeks) 0 16 wk 24 wk 48 wk Interim analyses Primary analysis Week 2 First 15 US patients Serial PK of MVC *Sparse PK sampling on all patients at Weeks 2 (non-PK substudy), 12 and 24 (Vourvahis. Abstract 37 IWCPHIV, 2010)
Study disposition Screening n=220 Enrolled into study n=121 MVC + ATV/r n=60 FTC/TDF + ATV/r n=61 • Discontinued n=7 • 2 AE (vomiting, jaundice) • 3 lost to follow-up • 1 withdrew consent • 1 insufficient clinical response (VL 934 copies/mL) • Discontinued n=7 • 2 lost to follow-up • 1 withdrew consent • 2 protocol violations • 1 pregnancy • 1 other: possible TDF-related kidney failure Continuing in study n=53 Continuing in study n=54 • Two patients in each arm experienced protocol defined treatment failure VL, HIV-1 RNA, viral load
HIV-1 RNA <400 copies/mL at Week 48 89.8% 86.9% Patients with HIV-1 RNA <400 copies/mL (%) MVC + ATV/r (N=59) FTC/TDF + ATV/r (N=61) Study week Intent-to-treat. Missing=failure
HIV-1 RNA <50 copies/mL at Week 48 83.6% 74.6% Patients with HIV-1 RNA <50 copies/mL (%) MVC + ATV/r (N=59) FTC/TDF + ATV/r (N=61) Study week Intent-to-treat. Missing=failure
HIV-1 RNA <50 copies/mL at Week 24 and Week 48 according to baseline viral load 100 MVC + ATV/r Patients with HIV-1 RNA <50 copies/mL (%) 94.9 FTC/TDF + ATV/r 90 37/39 81.3 81.4 80 77.3 35/43 13/16 17/22 70 60 50 40 30 20 10 0 Week 24 Week 48 Week 24 Week 48 <100,000 copies/mL ≥100,000 copies/mL Baseline HIV-1 RNA Intent-to-treat. Missing=failure
HIV-1 RNA <50 copies/mL at Week 24 and Week 48 according to baseline viral load 100 MVC + ATV/r Patients with HIV-1 RNA <50 copies/mL (%) 94.9 FTC/TDF + ATV/r 90 37/39 87.2 81.3 81.4 34/39 80 77.3 76.7 77.3 35/43 13/16 17/22 17/22 33/43 70 68.8 11/16 60 50 40 30 20 10 0 Week 24 Week 48 Week 24 Week 48 <100,000 copies/mL ≥100,000 copies/mL Baseline HIV-1 RNA Intent-to-treat. Missing=failure
HIV-1 RNA <400 copies/mL at Week 24 and Week 48 according to baseline viral load MVC + ATV/r 94.9 100 93.8 Patients with HIV-1 RNA <400 copies/mL (%) FTC/TDF + ATV/r 90.7 90.9 37/39 15/16 20/22 39/43 90 80 70 60 50 40 30 20 10 0 Week 24 Week 48 Week 24 Week 48 <100,000 copies/mL ≥100,000 copies/mL Baseline HIV-1 RNA Intent-to-treat. Missing=failure
HIV-1 RNA <400 copies/mL at Week 24 and Week 48 according to baseline viral load MVC + ATV/r 94.9 100 93.8 93.8 Patients with HIV-1 RNA <400 copies/mL (%) FTC/TDF + ATV/r 90.7 90.9 37/39 88.4 15/16 15/16 87.2 86.4 20/22 39/43 90 38/43 34/39 19/22 80 70 60 50 40 30 20 10 0 Week 24 Week 48 Week 24 Week 48 <100,000 copies/mL ≥100,000 copies/mL Baseline HIV-1 RNA Intent-to-treat. Missing=failure
Outcomes for all patients with VL >50 copies/mL at Week 48 HIV-1 RNA, copies/mL Week 48 Post Week 48 MVC+ATV/r AaBCDEFbGHI FTC/TDF+ATV/r JKL 69144578116787615158 5278055 497 (W84)<50 (W96)<50 (W72)<50 (W84)<50 (W96)274 (W96)<50 (W72)<50 (W84)<50 (W84) <50 (W84)<50 (W96)<50 (W84) aPatient discontinued at Week 84 due to insufficient clinical response bPatient discontinued at Week 96
Change in median CD4+ cell count over time (LOCF) 187 173 Median change from baselinein CD4 cell count (cells/μL) MVC + ATV/r (N=59) FTC/TDF + ATV/r (N=61) Study week Intent-to-treat. LOCF, last observation carried forward
No genotypic or phenotypic resistance observed through Week 48 • 3 patients in the MVC arm and 3 patients in the FTC/TDF arm were identified for virologic analysesa aPatients who discontinued from the study early with sufficient VL (≥500 copies/mL). Assays (ESTA, Monogram GenoSeq and/or PhenoSenseGT) performed at screening/baseline and at the last on-treatment time point were available
Safety • 7 patients in the MVC + ATV/r group and 3 patients in the FTC/TDF group switched off of ATV/r therapy per protocol due to either tolerability or unconjugated hyperbilirubinemia *DAIDS grading
Modern dual-therapy studies: 48-week results No. of patients with post-BL resistance mutations/no. of virologicfailuresa HIV-1 RNA <50 copies/mL ACTG 51421N=500 22/46 39/56 16/78 EFV + 2 NRTI EFV + LPV/r LPV/r + 2 NRTI COOL2N=143 EFV + TDF/3TC 0/03/3 EFV +TDF afrom evaluable samples BL, baseline % of patients 1. Riddler et al, N Engl J Med, 2008. 2. Girard et al, J Antimicrob Chemother, 2009.
Modern dual-therapy studies: 48-week results No. of patients with post-BL resistance mutations/no. of virologicfailuresa HIV-1 RNA <50 copies/mL ACTG 51421N=500 22/46 39/56 16/78 EFV + 2 NRTI EFV + LPV/r LPV/r + 2 NRTI COOL2N=143 EFV + TDF/3TC 0/03/3 EFV +TDF SPARTAN3N=94 (2:1) 0/8 4/11 ATV/r QD + FTC/TDF ATV BID + RAL BID PROGRESS4N=206 LPV/r BID + FTC/TDF 1/3 1/4 LPV/r BID + RAL BID ACTG 52625N=112 DRV/r QD + RAL DRV/r QD + RAL BID 5/28 afrom evaluable samples BL, baseline % of patients 1. Riddler et al, N Engl J Med, 2008. 2. Girard et al, J Antimicrob Chemother, 2009. 3. Kozal THLBB204, IAS 2010. 4. Reynes MOAB0101, IAS, 2010. 5. Taiwo Abstract 551, CROI, 2011.
Modern dual-therapy studies: 48-week results No. of patients with post-BL resistance mutations/no. of virologicfailuresa HIV-1 RNA <50 copies/mL ACTG 51421N=500 22/46 39/56 16/78 EFV + 2 NRTI EFV + LPV/r LPV/r + 2 NRTI COOL2N=143 EFV + TDF/3TC 0/03/3 EFV +TDF SPARTAN3N=94 (2:1) 0/8 4/11 ATV/r QD + FTC/TDF ATV BID + RAL BID PROGRESS4N=206 LPV/r BID + FTC/TDF 1/3 1/4 LPV/r BID + RAL BID ACTG 52625N=112 DRV/r QD + RAL DRV/r QD + RAL BID 5/28 VEMAN6N=37 0/0 0/0 LPV/r BID + FTC/TDF LPV/r BID + MVC QD 1078N=121 0/2 0/2 ATV/r QD + FTC/TDF ATV/r QD + MVC QD afrom evaluable samples BL, baseline % of patients 1. Riddler et al, N Engl J Med, 2008. 2. Girard et al, J Antimicrob Chemother, 2009. 3. Kozal THLBB204, IAS 2010. 4. Reynes MOAB0101, IAS, 2010. 5. Taiwo Abstract 551, CROI, 2011. 6. Nozza CDB325, IAS, 2011
Conclusions • 48-week results of this pilot study of MVC + ATV/r support the antiviral activity of this once-daily, two-drug combination in treatment-naïve patients • No resistance nor change in phenotypic tropism was observed • No new unexpected safety events • A Phase III study (A4001095; NCT01345630) will start in Q3/4 2011 • MVC + DRV/r QD vs FTC/TDF + DRV/r QD • Estimated enrollment of 804
Acknowledgments • Thanks to the patients and investigators who participated in this study • Editorial support was provided by Clemence Hindley of Complete Medical Communications and was funded by ViiV Healthcare
Creatinine clearance Study week Mean change from baseline in creatinine clearance (mL/min) MVC + ATV/r (N=60) FTC/TDF + ATV/r (N=61)
Pharmacokinetics 10,000 * 1000 100 MVC concentration (ng/mL) 10 7.65 ng/mL (in vivo IC50)1 1 0 4 8 12 16 20 24 Hours • All 15 patients had plasma MVC concentrations above the in vivo IC50 across the dosing Interval (150 mg QD + ATV/r)2 • There were 139 sparse PK samples with full dose and time data collected at the 2,12 and 24 week visits yielding concentrations from 13.7 to 933 ng/mL with samples taken from 0-32 hours after dose3 1. Rosario et al, J Acquir Immune DeficSyndr, 2006.2. Vourvahis, Abstract 37 IWCPHIV, 2010. 3. Weatherley, Abstract P_05 IWCPHIV, 2011 * One patient accidentally dosed with MVC prior to the 24-hour sample draw
Definition of Virologic Failure • HIV-1 RNA <1.0 log10 decrease from Baseline at Week 4 or thereafter (confirmed by a second measurement taken no more than 14 days after the first measurement); or • Failure to achieve HIV-1 RNA <400 copies/mL at Week 24, (confirmed by asecond measurement taken no more than 14 days after the first measurement); • An increase in HIV-1 RNA to detectable levels (1,000 copies/mL on 2 consecutive measurements taken no more than 14 days apart) in subjects previously confirmed to have undetectable levels of <400 copies/mL on 2 consecutive visits.
Patients switching from ATV/r • 10 patients switched from ATV/r (7 in the MVC arm and 3 in the FTC/TDF arm) due to either tolerability issues or unconjugated hyperbilirubinemia • 8 switched to DRV/r • 2 switched to LPV/r • All 10 patients had reached HIV-1 RNA <50 copies/mL prior to switching
HIV-1 RNA <50 copies/mL at Week 24 and Week 48 according to baseline CD4 count n/N 4/5 5/5 40/48 46/49
Median CD4+ cell count over time (LOCF) Week 48MVC + ATV/r = 580 FTC/TDF + ATV/r = 580 Week 24MVC + ATV/r = 537 FTC/TDF + ATV/r = 536 Median CD4 cell count (cells/mm3) MVC + ATV/r (N=59) FTC/TDF + ATV/r (N=61) Study week Intent-to-treat. LOCF, last observation carried forward
Responders at Week 24 but not Week 48 N/A, not available; W, week aPatient discontinued prior to Week 48 bResult of repeat test 13 days later was <50 copies/mL
Responders at Week 24 but not Week 48 N/A, not available; W, week aPatient discontinued prior to Week 48 bResult of repeat test 13 days later was <50 copies/mL • 7/9 (MVC + ATV/r) and 3/3 (FTC/TDF + ATV/r) patients with HIV-1 RNA ≥50 copies/mL at Week 48 had HIV-1 RNA <50 copies/mL at their latest visit. HIV-1 RNA levels for the remaining 2 patients were 274 copies/mL (W96), and 497 copies/mL (W84)