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Comparison of PI vs PI ATV vs ATV/r BMS 089 LPV/r mono vs LPV/r + ZDV/3TCMONARK LPV/r QD vs BIDM02-418 M05-730 A5073 LPV/r + 3TC vs LPV/r + 2 NRTIGARDEL ATV/r vs FPV/rALERT ATV/r vs DRV/rATADAR FPV/r vs LPV/rKLEAN SQV/r vs LPV/rGEMINI ATV/r vs LPV/rCASTLE DRV/r vs LPV/rARTEMIS
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ARTEMIS Study: DRV/r QD vs LPV/r (BID or QD), in combination with TDF/FTC ARTEMIS Design N = 346 N = 343 Objective –Non inferiority of DRV/r vs LPV/r at W48: % HIV RNA < 50 c/mL by per-protocol TLOVR analysis (lower margin of the 2-sided 95% CI for the difference = - 12%, 90% power). Superiority tested by ITT if non inferiority established DRV/r 800/100 mg QD TDF/FTC fdc QD LPV/r 400/100 mg BID or 800/200 mg QD TDF/FTC fdc QD Randomisation* 1 : 1 Open-label W192 > 18 years ARV-naïve HIV RNA > 5,000 c/mL Any CD4 cell count *Randomisation was stratified by HIV RNA ( 100,000 c/mL) and CD4 ( 200/mm 3 ) at screening W48 Ortiz R. AIDS 2008;22:1389-97
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ARTEMIS Study: DRV/r QD vs LPV/r (BID or QD), in combination with TDF/FTC DRV/r N = 343 * LPV/r ** N = 346 Mean age, years3635 Female30% Caucasian/Hispanic/Other40% / 23% / 37%44% / 21% / 35% HIV RNA (log 10 c/mL), mean4.86 + 0.644.84 + 0.60 CD4 cell count (/mm 3 ), median228218 Hepatitis B and/or C coinfection13%14% Discontinuation by W4812%16% For virologic failure2 (< 1%)6 (2%) For adverse event12 (3%)24 (7%) Ortiz R. AIDS 2008;22:1389-97 * 3 patients excluded for the per-protocol analysis (did not received study medication or received disallowed therapy for more than 1 week) ** LPV/r was administered BID or QD according to investigator and/or patient preference (77% received BID, 15% QD and 8% both; 15% received soft-gel capsules, 2% tablets and 83% switched from SGC to tablets) Baseline characteristics and patient disposition ARTEMIS
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ARTEMIS Study: DRV/r QD vs LPV/r (BID or QD), in combination with TDF/FTC Baseline DRV/r (%) LPV/r (%) RNA < 5 log 10 c/mL RNA > 5 log 10 c/mL 86 79 * 85 67 * CD4 > 200/mm 3 CD4 < 200/mm 3 87 79 84 70 HIV RNA < 50 c/mL at W48 (per-protocol, TLOVR) by baseline stratification factors Response to treatment at week 48 * P < 0.05 Ortiz R. AIDS 2008;22:1389-97 Median CD4/mm 3 increase at W48 (ITT, NC = F): 137 (DRV/r) vs 141 (LPV/r) HIV RNA < 50 c/mL (TLOVR) 25 50 100 75 84 78 343 % DRV/rLPV/r 346 95% CI for the difference = (- 0.1; 11) (P < 0.001) Non inferiority 84 78 343 DRV/rLPV/r 346 Per protocolITT 95% CI for the difference = (- 0.3; 11) Test for superiority (P = 0.062) 0 N = ARTEMIS
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ARTEMIS Study: DRV/r QD vs LPV/r (BID or QD), in combination with TDF/FTC Virologic failure at Week 48 –Definition: HIV RNA never suppressed below 50 c/mL at W24 or confirmed HIV RNA > 50 c/mL after achieving < 50 c/mL or last observed HIV RNA > 50 c/mL followed by discontinuation DRV/r N = 343 LPV/r N = 346 Virologic failure34 (10%)49 (14%) Patients in genotypic analysis (HIV RNA > 1,000 c/mL)10 *18 Protease inhibitor resistance mutation emergence01 ** M184I/V12 * 1 patient with HIV RNA > 1,000 c/mL did not have genotype available ** A71T and V77I Resistance data Ortiz R. AIDS 2008;22:1389-97 ARTEMIS
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ARTEMIS Study: DRV/r QD vs LPV/r (BID or QD), in combination with TDF/FTC W48 Safety: DRV/r vs LPV/r –Discontinuations for adverse events (AE) were significantly less frequent in the DRV/r group: 3% vs 7% (P < 0.05) –Rate of serious AE was not significantly different: 7% vs 12% –Incidence of grade 2 to 4 gastrointestinal AE was significantly lower in the DRV/r group: 7% vs 14% (P < 0.01); these were mainly diarrhoea: 4% vs 10% (P < 0.01) –Rash incidence was not significantly different: 3% vs 1%; 1 case of Stevens-Johnson occurred in the DRV/r group –No patients discontinued because of renal events –Mean increases in triglycerides and total cholesterol were less pronounced with DRV/r; grade 2 to 4 elevations in triglycerides and total cholesterol were significantly less frequent with DRV/r: 3% vs 11% and 13% vs 23%, respectively –Hepatic safety was similar in both groups Ortiz R. AIDS 2008;22:1389-97 ARTEMIS
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ARTEMIS Study: DRV/r QD vs LPV/r (BID or QD), in combination with TDF/FTC Summary – Conclusion (W48) –DRV/r QD is non inferior to LPV/r, when co-administered with TDF/FTC (1) –Greater virologic response, at W48 (HIV RNA < 50 c/mL), of DRV/r as compared with LPV/r in patients with high pre treatment HIV RNA (significant difference) or low CD4 count –Lower incidence of diarrhoea with DRV/r vs LPV/r –Lipid elevations were less pronounced with DRV/r Ortiz R. AIDS 2008;22:1389-97
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ARTEMIS Study: DRV/r QD vs LPV/r (BID or QD), in combination with TDF/FTC Overview at week 96 –At W96 (2), significantly more DRV/r (79%) than LPV/r (71%) patients had HIV RNA < 50 c/mL confirming non inferiority and superiority (P = 0.012; ITT) in virologic response –Safety outcomes confirmed W48 results: more favourable gastrointestinal and lipid profile of DRV/r QD Lipid-lowering agents use by W96: 8% LPV/r vs 7% DRV/r –Overall, discontinuation for adverse events occurred in 4% of DRV/r patients vs 9% of LPV/r patients Mills AM. AIDS 2009;23:1679-88
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DRV/r N = 343 LPV/r N = 346 p Discontinuation by W4812%16% For virologic failure2 (< 1%)6 (2%) For adverse event12 (3%)24 (7%) Discontinuation by W9617.2%23.4% Discontinuation by W19224.8%32.9% For virologic failure59 For adverse event16 (4.7%)44 (12.7%)0.005 For pregnancy96 Lost to follow-up2117 Withdrew consent/non compliance26 Other812 Patient disposition at W96 and W192 Ortiz R. AIDS 2008;22:1389-97 ; Mills AM. AIDS 2009;23:1679-88 ; Orkin C. HIV Med 2012;14:49-59 ARTEMIS Study: DRV/r QD vs LPV/r (BID or QD), in combination with TDF/FTC ARTEMIS
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ARTEMIS Study: DRV/r QD vs LPV/r (BID or QD), in combination with TDF/FTC HIV RNA < 50 c/mL (TLOVR) Baseline DRV/ r (%) LPV/r (%) p RNA < 5 log 10 c/mL RNA > 5 log 10 c/mL 69.5 67.5 60.2 51.7 0.038 0.012 CD4 > 200/mm 3 CD4 < 200/mm 3 71.3 65.2 59.6 54.1 0.014 0.052 HIV RNA < 50 c/mL (ITT, TLOVR) by baseline stratification factors Final (week 192) analysis Orkin C. HIV Med 2012;14:49-59 Median CD4/mm 3 increase at W192 (ITT, NC = F): + 258 (DRV/r) vs + 263 (LPV/r) ARTEMIS 25 50 100 75 69.1 57.1 340 % DRV/rLPV/r 345 Difference (95% CI) = 12.0% (4.8 ; 19.2) (P < 0.001) Superiority 68.8 57.2 343 DRV/rLPV/r 346 Per protocolITT 0 N = Difference (95% CI) = 11.6% (4.4 ; 18.8) (P < 0.001) Superiority
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DRV/r N = 343 LPV/r N = 346 Virologic failure55 (16.0%)71 (20.5%) Never suppressed1622 Rebounders3949 Resistance testing (HIV RNA > 50 c/mL)4357 Protease inhibitor resistance mutation emergence* Major PI mutation 4** 0 9090 NRTI resistance mutations * 4 M184I/V = 4 K70E = 1 7 M184I/V Resistance data at W192 * At endpoint = last time point : with available genotype ** L10V, N = 1 ; V11I, N = 1 ; I13V, N = 1 ; I13V + G16E, N = 1 ARTEMIS Study: DRV/r QD vs LPV/r (BID or QD), in combination with TDF/FTC Orkin C. HIV Med 2012;14:49-59 ARTEMIS
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Safety – W192 analysis –Data similar to that seen at W96 –No new emerging AE with longer-term follow-up –Grade 2-4 treatment-related diarrhoea was significantly less frequent with DRV/r than with LPV/r (5.0% vs. 11.3%, respectively; P = 0.003) –DRV/r was associated with smaller median increases in total cholesterol and triglyceride levels than LPV/r. Changes in low- and high-density lipoprotein cholesterol were similar between groups –Similar increases in aspartate aminotransferase and alanine aminotransferase for DRV/r and LPV/r were observed ARTEMIS Study: DRV/r QD vs LPV/r (BID or QD), in combination with TDF/FTC Orkin C. HIV Med 2012;14:49-59 ARTEMIS
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