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Academic in ServiceManagement of HIV drugs resistance
นางสาวฐชานันท อิสริยะชัยกุล 53010710053
นิสิตเภสัชศาสตรชั้นปที่ 6
มหาวิทยาลัยมหาสารคาม ปการศึกษา 2558
ผลัด 2 โรงพยาบาลศูนยขอนแกน
Outline
❖ Introduction❖ Definition❖ HIV Resistance Testing
- Genotypic assay- Phenotypic assay- Virtual genotypic assay
❖ HIV-1 Drug Resistance Mutations❖ Regimen Switching (2nd regimen)
HIV
HIV-1
HIV-2
❏ M (major) 90%● Subtype
○ A-H○ J-K
❏ O (outlier) ❏ N(non-major-non-
outlier)
Introduction
Ref : http://www.avert.org/hiv-types.htm
Viral structural proteins ❏ GAG❏ POL❏ ENV
Introduction
Ref : http://www.hiv.lanl.gov/content/sequence/HIV/MAP/landmark.html
GAG :The genomic region encoding the capsid
proteins (group specific antigens) The precursor is the p55 myristoylated
protein, which is processed to - p17 (MAtrix)- p24 (CApsid)- p7 (NucleoCapsid)- p6 proteins, by the viral protease.
Gag associates with the plasma membrane, where virus assembly takes place.
Introduction
Ref : http://www.hiv.lanl.gov/content/sequence/HIV/MAP/landmark.html
POL :The genomic region encoding the viral
- enzymes proteasecleave the precursor Gag
polyprotein to produce structural proteins
- reverse transcriptaserequired to transcribe DNA from
RNA template- integrase.
integrate the double-stranded viral DNA into the host genome
Introduction
Ref : http://www.hiv.lanl.gov/content/sequence/HIV/MAP/landmark.html
ENV :a precursor (gp160), which is processed to
give a - noncovalent complex of the external
glycoprotein gp120 - the transmembrane glycoprotein gp41.
The mature gp120-gp41 proteins are bound by non-covalent interactions and are associated as a trimer on the cell surface. gp120 contains the binding site for the CD4 receptor
Introduction
Ref : http://www.hiv.lanl.gov/content/sequence/HIV/MAP/landmark.html
Ref : http://www.ubooks.pub/Books/ON/B0/E22R2222/05MHIV.html
➢ Viral DNA is a code for RNA ,Which in turn codes for protein.➢ Each codon encodes a particular amino acid➢ Change in the codon may result in the incorporation of a different
amino acid (mutation).
Introduction
Ref : http://www.thaiaidssociety.org/images/PDF/10thHIVDR/12Feb/0830somnuek.pdf
Definition
WHO (World Health Organization)
❏ Virological failure❏ Immunological failure❏ Clinical failure❏
Virological failure
Plasma viral load > 200 copies/ ml after 6 months
Immunological failure
Adults and adolescents- CD4 count falls to the
baseline (or below) or Persistent CD4 levels < 100 cells/mm3
Children- < 5 years
Persistent CD4 levels < 200 cells/mm3
- > 5 yearsPersistent CD4 levels < 100 cells/mm3
Clinical failureAdults and adolescents
- severe immunodeficiency (WHO clinical stage 4 ) a after 6 months of effective treatment
Children- advanced or severe
immunodefiency (WHO clinical stage 3 and 4 exception of TB) after 6 months of effective treatment
Ref : http://www.who.int/hiv/pub/guidelines/arv2013/art/WHO_CG_table_7.15.pdf
HIV Resistance Testing
Genotypic assay
Phenotypic assay
Virtual phenotypic assay
Ref : http://hivinsite.ucsf.edu/InSite?page=kb-02-02-03http://www.aidsinfonet.org/fact_sheets/view/126#_WHAT_IS_RESISTANCE_http://www.thaiaidssociety.org/images/PDF/10thHIVDR/13Feb/0830ekawat.pdf
Investigate the nucleotide sequence of an HIV on the region that control the Protease and reverse transcriptase enzyme
Comparing with nucleotide sequence of HIV wild-type
HIV Resistance Testing
Genotypic assay
Ref : http://hivinsite.ucsf.edu/InSite?page=kb-02-02-03http://www.aidsinfonet.org/fact_sheets/view/126#_WHAT_IS_RESISTANCE_http://www.thaiaidssociety.org/images/PDF/10thHIVDR/13Feb/0830ekawat.pdf
HIV Resistance Testing
1. the TruGene HIV-1 genotyping assay 2. the Viroseq genotyping assay 3. in house Genotypic assay
Genotypic assay
Ref : http://hivinsite.ucsf.edu/InSite?page=kb-02-02-03http://www.aidsinfonet.org/fact_sheets/view/126#_WHAT_IS_RESISTANCE_http://www.thaiaidssociety.org/images/PDF/10thHIVDR/13Feb/0830ekawat.pdf
1.the TruGene HIV-1
genotyping assay
Genotypic assay
Ref : http://www.medscape.org/viewarticle/429693_4
Results :the TruGene HIV-1 genotypic assaythe Viroseq genotypic assay
➢ No evidence of resistance
➢ Possible resistance
➢ Resistance
➢ Insufficient evidence
HIV Resistance Testing
Genotypic assay
Ref : http://www.medscape.org/viewarticle/429693_4
HIV Resistance Testing
3.in house Genotypic assay
Genotypic assay
Ref : http://i-base.info/appendix-9-example-of-a-resistance-report/
HIV Resistance Testing
Genotypic assay
in house Genotypic assay
Ref : hivdb.stanford.edu/DR/asi/releaseNotes/index.html#hivalg_algorithmsavailable
A sample of HIV is grown in the laboratory. A dose of one ARV is added. The growth rate of the HIV is compared to the rate of wild type virus. If the sample grows more than normal, it is resistant to the medication.
HIV Resistance Testing
Phenotypic assay
Ref : http://www.aidsinfonet.org/fact_sheets/view/126
HIV Resistance TestingPhenotypic assay
Ref : http://hiv.uw.edu/arvres/case2/discussion.html
HIV Resistance Testing
susceptible
hypersusceptible
resistant
Phenotypic assay
Ref : http://hiv.uw.edu/arvres/case2/discussion.html
HIV Resistance Testing
Virtual phenotyping is a combination of genotypic and phenotypic assays
If the fold change is below the lower cut-off the drug is sensitive. If it is between this range the drug is intermediate with a reduced response. If it is above the upper cut-off it is resistant.
Virtual phenotypic assay
Ref : http://i-base.info/appendix-9-example-of-a-resistance-report/
HIV Resistance TestingVirtual phenotypic assay
Ref : http://i-base.info/appendix-9-example-of-a-resistance-report/
HIV-1 Drug Resistance Mutations
K65R - K หมายถึง กรดอะมิโน lysine- ตัวเลข 65 หมายถึง ตําแหนงกรดอะมิโนตําแหนงที่ 65 - โดยมีการเปลี่ยนแปลงของกรดอะมิโนจากปกติ คือ
K (lysine) ไปเปน R (arginine)
Ref : https://www.iasusa.org/sites/default/files/tam/22-3-642.pdf
HIV-1 Drug Resistance Mutations
NRTI ResistanceNucleotide Reverse Transcriptase Inhibitors
HIV-1 Drug Resistance Mutations
Ref : https://www.iasusa.org/sites/default/files/tam/22-3-642.pdf
HIV-1 Drug Resistance Mutations
69 Insertion Complex➢ Insertion of 2 or more amino acids➢ Resistance to all NRTIs➢ 69 insertions usually occur in combination with
multiple TAMs (41,210 or 215)
Ref : http://hivdb.stanford.edu/DR/NRTIResiNote.html
HIV-1 Drug Resistance Mutations
Multi-Nucleoside RT Inhibitor Resistance Mutations- A62V- V75I- F77L- F116Y- Q151M
➢ Q151M usually occurs in combination with two or more of the following four accessory mutations.
➢ Q151M alone causes high-level resistance to AZT, d4T, ddI and ABC.
Ref : http://hivdb.stanford.edu/DR/NRTIResiNote.html
HIV-1 Drug Resistance Mutations
Thymidine Analog Mutations (TAMs)- M41L- D67N- K70R- L210W- T215Y ,T215F- K219Q ,K219E
Ref : http://hivdb.stanford.edu/DR/NRTIResiNote.html
HIV-1 Drug Resistance MutationsThymidine Analog Mutations (TAMs)
- Type 1 : M41L, L210W, and T215Y- Type 2 : D67N, K70R, T215F, and K219Q/E
➢ Type 1 TAMs have a greater negative impact on virological response to an ABC-, ddI-, or TDF-containing regimen than do Type 2 TAMs.
Ref : http://hivdb.stanford.edu/DR/NRTIResiNote.html
HIV-1 Drug Resistance Mutations- M41L usually occurs in combination with T215Y. Together, M41L and T215Y
confer high-level resistance to AZT and d4T and intermediate-level resistance to ABC, ddI and TDF
- D67N reduces susceptibility primarily to AZT and d4T. When present with other TAMs it is also associated with reduced susceptibility to ABC, ddI and TDF
- K70R confers intermediate-level resistance to AZT and low-level resistance to d4T and TDF.
- L210W usually occurs in combination with M41L and T215Y. Together, M41L, L210W and T215Y confer high-level resistance to AZT and d4T and intermediate to high-level resistance to ABC, ddI and TDF
- T215Y/F confer intermediate-level resistance to AZT and d4T and low-level resistance to ABC, ddI and TDF.
- K219Q/E reduce susceptibility to AZT and d4T when present with other TAMs.
Ref : http://hivdb.stanford.edu/DR/NRTIResiNote.html
HIV-1 Drug Resistance Mutations
Ref : https://www.iasusa.org/sites/default/files/tam/22-3-642.pdf
HIV-1 Drug Resistance Mutations
Ref : http://hivdb.stanford.edu/DR/NRTIResiNote.html
M184V - selected by 3TC/FTC and reduces susceptibility to these drugs >100-fold. - causes low-level resistance to, ABC and ddI . - increases susceptibility to AZT, d4T and TDF and slows the emergence of
AZT, d4T, and TDF resistance . - M184V is also associated with reduced viral replication in vitro and in
vivo. A combination of TDF, AZT or d4T plus 3TC/FTC often partially inhibits viruses with M184V.
HIV-1 Drug Resistance Mutations
Ref : http://hivdb.stanford.edu/DR/NRTIResiNote.html
L74V/I- L74V is selected by ABC and ddI. Together, - L74V and M184V are the most common mutations to develop in patients
receiving ABC/3TC . - In combination, they reduce ABC susceptibility by >5-fold and ddI
susceptibility >2-fold. - L74V increases susceptibility to AZT and AZT treatment selects against
the development of this mutation . In contrast, TDF treatment does not select against L74V even though this mutation increases susceptibility to TDF in vitro .
- L74I is selected primarily by ddI and ABC, and occasionally by TDF . It is less effective than L74V in reducing susceptibility to ABC and ddI. It does not appear to significantly increase AZT and TDF susceptibility
HIV-1 Drug Resistance Mutations
Ref : http://www.thaiaidssociety.org/images/PDF/10thHIVDR/13Feb/0830ekawat.pdf
HIV-1 Drug Resistance Mutations
K65R ,K65E ,K65N
K65E ,K65N
เปรียบเทียบ2007 กับ 2014
Ref : https://www.iasusa.org/sites/default/files/tam/22-3-642.pdf
HIV-1 Drug Resistance Mutations
NNRTIsNon-Nucleoside Reverse Transcriptase Inhibitors
HIV-1 Drug Resistance Mutations
เปรียบเทียบ2007 กับ 2014
Ref : https://www.iasusa.org/sites/default/files/tam/22-3-642.pdf
HIV-1 Drug Resistance Mutations
Cross-resistanceRef : http://www.thaiaidssociety.org/images/PDF/10thHIVDR/12Feb/1030weerawat.pdf
HIV-1 Drug Resistance Mutations
➢ K103N ○ It reduces NVP and EFV susceptibility by about 50 and
20-fold➢ Y181C
○ about >50-fold reduced susceptibility to NVP ○ about 5-fold reduced susceptibility to ETR ○ about 3-fold reduced susceptibility to RPV ○ about 2-fold reduced susceptibility to EFV
➢ Y188L○ It confers high-level resistance (>50-fold reduction in
susceptibility) to NVP and EFV
Ref : http://hivdb.stanford.edu/DR/NNRTIResiNote.html
HIV-1 Drug Resistance Mutations
เปรียบเทียบ2007 กับ 2014
Ref : https://www.iasusa.org/sites/default/files/tam/22-3-642.pdf
HIV-1 Drug Resistance Mutations
เปรียบเทียบ2007 กับ 2014
Ref : https://www.iasusa.org/sites/default/files/tam/22-3-642.pdf
Regimen Switching (2nd regimen)
Failing an NNRTI plus NRTI regimen. - Second-line ART for adults should consist of two nucleoside reverse-
transcriptase inhibitors (NRTIs) + a ritonavir-boosted protease inhibitor (PI).
- The following sequence of second-line NRTI options is recommended:- After failure on a TDF + 3TC (or FTC) -based first-line regimen,
use AZT + 3TC as the NRTI backbone in second-line regimens.- After failure on an AZT or d4T + 3TC-based first-line regimen, use
TDF + 3TC (or FTC) as the NRTI backbone in second-line regimens.
Ref : http://www.who.int/hiv/pub/guidelines/arv2013/intro/rag/en/index6.html
Case I ผูปวยหญิงอายุ 45 ป ไดรับการวินิจฉัย HIV infection วันที่ 27/09/55เริ่มยาตานไวรัสครั้งแรกดวยสูตร
stavudine (d4T) 20 mg. 1x2 (8.00,20.00)lamivudine (3TC) 150 mg. 1x2 (8.00,20.00)efavirenz (EFV) 600 mg. 1x1 (8.00)
มีประวัติขาดยาประมาณ 5 เดือนRestart ยาตานไวรัส วันที่ 13/01/57 ดวยสูตร
Lastavir (d4T 30 mg.+3TC 150 mg.) 1x2Nevirapine 200 mg. 1x2
และเปลี่ยนยาที่ใหวันที่ 27/01/57 เปนGPO virS30 (d4T 30 mg.+3TC 150 mg.+NVP 200 mg.) 1x2 (7.00,19.00)
วันที่ 26/02/58 ตรวจ VL=32,035 ,CD4=242(17%) หลังจากตรวจ VL,CD4 ไดรับยาสูตรเดิมอีก 1 นัด คือ วันที่ 19/03/58
Case I
ผลดื้อยาวันที่6/5/58
Case I เมื่อพิจารณาจากผลดื้อยา ผูปวยสามารถใชยาใดไดบาง
Case I เมื่อพิจารณาจากผลดื้อยา ผูปวยสามารถใชยาใดไดบาง
TDF 300 mg. 1x13TC 300 mg. 1x1ATV 300 mg. 1x1RTV 100 mg. 1x1
Case II ผูปวยชาย อายุ 57 ป Refer จาก รพ.หนองเรือ เมื่อวันที่ 6/08/58
ดวยอาการดื้อยาตานไวรัส มีประวัติรับประทานยาไมสมํ่าเสมอ เคยใชยา TDF,3TC,EFV
ผล VL,CD4 วันที่ 14/03/58 VL=85,626CD4= 174 (12%)
จากผลดื้อยา ผูปวยสามารถใชยาใดไดบาง
Case II
Case II ผูปวยชาย อายุ 57 ป Refer จาก รพ.หนองเรือ เมื่อวันที่ 6/08/58
ดวยอาการดื้อยาตานไวรัส มีประวัติรับประทานยาไมสมํ่าเสมอ เคยใชยา TDF,3TC,EFV
ผล VL,CD4 วันที่ 14/03/58 VL=85,626CD4= 174 (12%)
จากผลดื้อยา ผูปวยสามารถใชยาใดไดบางAZT 100 mg. 2x23TC 150 mg. 1x2LPV/RTV 2x2
Case IIIผูปวยชาย อายุ 36 ป ไดรับการวินิจฉัย HIV infection วันที่ 2/02/52เริ่มยาตานไวรัสครั้งแรกดวยสูตร
GPO virS30 (d4T 30 mg.+3TC 150 mg.+NVP 200 mg.) 1x2(8.00,20.00)
วันที่ 4/05/53 ผูปวยเกิด ADR จึงเปลี่ยนยามาเปนGPO virZ250 (AZT 250 mg.+3TC 150 mg.+NVP 200 mg.) 1x2(7.00,19.00)
วันที่ 10/01/54 ผูปวย Imp. HBVTenofovir (TDF) 1x1Lamivudine (3TC) 150 mg. 1x2Nevirapine (NVP) 1x2
ผล VL,CD4 วันที่ 14/05/55 VL=102,000 CD4=107
(8.00,20.00)
Case III
Case III เมื่อพิจารณาจากผลดื้อยา ผูปวยสามารถใชยาใดไดบาง
Case III เมื่อพิจารณาจากผลดื้อยา ผูปวยสามารถใชยาใดไดบาง
TDF 300 mg. 1x1Zilavir (AZT 300 mg.+3TC 150 mg) 1x2
LPV/RTV 2x2
Case III
Ref : http://www.thaiaidssociety.org/images/PDF/hiv_guideline_2557.pdf
Case IV ผูปวยหญิง อายุ 42 ป มีประวัติ loss F/U 1 เดือน หลังจากนั้น
restart ยา ARV โดยใชยาตัวเดิม เมื่อเดือน พฤศจิกายน 57TDF 300 mg. 1x13TC 150 mg. 1x2NVP 200 mg. 1x2
ผล VL,CD4 วันที่ 18/05/58 VL=9,395CD4= 283 (13%)
จากผลดื้อยา ผูปวยสามารถใชยาใดไดบาง
Case IV
Case IV
● Susceptible: Total score 0 to 9● Potential low-level resistance: Total score 10 to 14● Low-level resistance: Total score 15 to 29● Intermediate resistance: Total score 30 to 59● High-level resistance: Total score >= 60
Ref : http://hivdb.stanford.edu/DR/asi/releaseNotes/index.html#hivdb
Case IV
Zilavir (AZT 300 mg.+3TC 150 mg) 1x2LPV/RTV 2x2
Case IV
Ref : http://www.thaiaidssociety.org/images/PDF/hiv_guideline_2557.pdf