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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