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Combined Angiotensin Receptor Antagonism and Neprilysin Inhibition.
Hubers SA, Brown NJ
(2016) Circulation 133: 1115-24
MeSH Terms: Abnormalities, Drug-Induced, Aminobutyrates, Angioedema, Angiotensin Receptor Antagonists, Biphenyl Compounds, Bradykinin, Contraindications, Drug Combinations, Drug Costs, Drug Synergism, Enalapril, Enzyme Inhibitors, Female, Follow-Up Studies, Heart Failure, Humans, Hyperkalemia, Hypertension, Kidney, Multicenter Studies as Topic, Natriuretic Peptides, Neprilysin, Pregnancy, Prodrugs, Prospective Studies, Pyridines, Randomized Controlled Trials as Topic, Stroke Volume, Tetrazoles, Thiazepines, Valsartan
Show Abstract · Added April 6, 2017
Heart failure affects ≈5.7 million people in the United States alone. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, and aldosterone antagonists have improved mortality in patients with heart failure and reduced ejection fraction, but mortality remains high. In July 2015, the US Food and Drug Administration approved the first of a new class of drugs for the treatment of heart failure: Valsartan/sacubitril (formerly known as LCZ696 and currently marketed by Novartis as Entresto) combines the angiotensin receptor blocker valsartan and the neprilysin inhibitor prodrug sacubitril in a 1:1 ratio in a sodium supramolecular complex. Sacubitril is converted by esterases to LBQ657, which inhibits neprilysin, the enzyme responsible for the degradation of the natriuretic peptides and many other vasoactive peptides. Thus, this combined angiotensin receptor antagonist and neprilysin inhibitor addresses 2 of the pathophysiological mechanisms of heart failure: activation of the renin-angiotensin-aldosterone system and decreased sensitivity to natriuretic peptides. In the Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial, valsartan/sacubitril significantly reduced mortality and hospitalization for heart failure, as well as blood pressure, compared with enalapril in patients with heart failure, reduced ejection fraction, and an elevated circulating level of brain natriuretic peptide or N-terminal pro-brain natriuretic peptide. Ongoing clinical trials are evaluating the role of valsartan/sacubitril in the treatment of heart failure with preserved ejection fraction and hypertension. We review here the mechanisms of action of valsartan/sacubitril, the pharmacological properties of the drug, and its efficacy and safety in the treatment of heart failure and hypertension.
© 2016 American Heart Association, Inc.
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31 MeSH Terms
A peptide immunization approach to counteract a Staphylococcus aureus protease defense against host immunity.
Jordan RE, Fernandez J, Brezski RJ, Greenplate AR, Knight DM, Raju TS, Lynch AS
(2016) Immunol Lett 172: 29-39
MeSH Terms: Abscess, Animals, Bacterial Load, Disease Models, Animal, Drug Combinations, Freund's Adjuvant, Hemocyanins, Humans, Immune Evasion, Immunity, Humoral, Immunization, Immunoglobulin G, Peptide Fragments, Plant Extracts, Proteolysis, Rabbits, Recombinant Fusion Proteins, Staphylococcal Infections, Staphylococcus aureus
Show Abstract · Added April 22, 2016
Pathogens that induce acute and chronic infections, as well as certain cancers, employ numerous strategies to thwart host cellular and humoral immune defenses. One proposed evasion mechanism against humoral immunity is a localized expression of extracellular proteases that cleave the IgG hinge and disable host IgG functions. Host immunity appears to be prepared to counter such a proteolytic tactic by providing a group of autoantibodies, denoted anti-hinge antibodies that specifically bind to cleaved IgGs and provide compensating functional restoration in vitro. These respective counter-measures highlight the complex interrelationships among pathogens and host immunity and suggested to us a possible means for therapeutic intervention. In this study, we combined an investigation of pathogen-mediated proteolysis of host IgGs with an immunization strategy to boost host anti-hinge antibodies. In a Staphylococcus aureus infection model using an artificial tissue cage (wiffle ball) implanted into rabbits, cleaved rabbit IgGs were detected in abundance in the abscesses of untreated animals early after infection. However, in animals previously immunized with peptide analogs of the cleaved IgG hinge to generate substantial anti-hinge antibody titers, S. aureus colony formation was markedly reduced compared to control animals or those similarly immunized with a scrambled peptide sequence. The results of this study demonstrate that extensive local proteolysis of IgGs occurs in a test abscess setting and that immunization to increase host anti-hinge antibodies provided substantial acute protection against bacterial growth.
Copyright © 2016 European Federation of Immunological Societies. Published by Elsevier B.V. All rights reserved.
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19 MeSH Terms
Matrices for combined delivery of proteins and synthetic molecules.
Gilmore KA, Lampley MW, Boyer C, Harth E
(2016) Adv Drug Deliv Rev 98: 77-85
MeSH Terms: Animals, Drug Combinations, Drug Delivery Systems, Hydrogels, Nanoparticles, Pharmaceutical Preparations, Polymers, Proteins
Show Abstract · Added February 15, 2016
With the increasing advancement of synergistic, multimodal approaches to influence the treatment of infectious and non-infectious diseases, we witness the development of enabling techniques merging necessary complexity with leaner designs and effectiveness. Systems- and polypharmacology ask for multi-potent drug combinations with many targets to engage with the biological system. These demand drug delivery designs for one single drug, dual drug release systems and multiple release matrices in which the macromolecular structure allows for higher solubilization, protection and sequential or combined release profiles. As a result, nano- and micromaterials have been evolved from mono- to dual drug carriers but are also an essential part to establish multimodality in polymeric matrices. Surface dynamics of particles creating interfaces between polymer chains and hydrogels inspired the development not only of biomedical adhesives but also of injectable hydrogels in which the nanoscale material is both, adhesive and delivery tool. These complex delivery systems are segmented into two delivery subunits, a polymer matrix and nanocarrier, to allow for an even higher tolerance of the incorporated drugs without adding further synthetic demands to the nanocarrier alone. The opportunities in these quite novel approaches for the delivery of small and biological therapeutics are remarkable and selected examples for applications in cancer and bone treatments are discussed.
Copyright © 2015 Elsevier B.V. All rights reserved.
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8 MeSH Terms
Matrigel Mattress: A Method for the Generation of Single Contracting Human-Induced Pluripotent Stem Cell-Derived Cardiomyocytes.
Feaster TK, Cadar AG, Wang L, Williams CH, Chun YW, Hempel JE, Bloodworth N, Merryman WD, Lim CC, Wu JC, Knollmann BC, Hong CC
(2015) Circ Res 117: 995-1000
MeSH Terms: Cell Differentiation, Cells, Cultured, Collagen, Drug Combinations, Humans, Induced Pluripotent Stem Cells, Laminin, Myocardial Contraction, Myocytes, Cardiac, Pluripotent Stem Cells, Proteoglycans
Show Abstract · Added October 4, 2015
RATIONALE - The lack of measurable single-cell contractility of human-induced pluripotent stem cell-derived cardiac myocytes (hiPSC-CMs) currently limits the utility of hiPSC-CMs for evaluating contractile performance for both basic research and drug discovery.
OBJECTIVE - To develop a culture method that rapidly generates contracting single hiPSC-CMs and allows quantification of cell shortening with standard equipment used for studying adult CMs.
METHODS AND RESULTS - Single hiPSC-CMs were cultured for 5 to 7 days on a 0.4- to 0.8-mm thick mattress of undiluted Matrigel (mattress hiPSC-CMs) and compared with hiPSC-CMs maintained on a control substrate (<0.1-mm thick 1:60 diluted Matrigel, control hiPSC-CMs). Compared with control hiPSC-CMs, mattress hiPSC-CMs had more rod-shape morphology and significantly increased sarcomere length. Contractile parameters of mattress hiPSC-CMs measured with video-based edge detection were comparable with those of freshly isolated adult rabbit ventricular CMs. Morphological and contractile properties of mattress hiPSC-CMs were consistent across cryopreserved hiPSC-CMs generated independently at another institution. Unlike control hiPSC-CMs, mattress hiPSC-CMs display robust contractile responses to positive inotropic agents, such as myofilament calcium sensitizers. Mattress hiPSC-CMs exhibit molecular changes that include increased expression of the maturation marker cardiac troponin I and significantly increased action potential upstroke velocity because of a 2-fold increase in sodium current (INa).
CONCLUSIONS - The Matrigel mattress method enables the rapid generation of robustly contracting hiPSC-CMs and enhances maturation. This new method allows quantification of contractile performance at the single-cell level, which should be valuable to disease modeling, drug discovery, and preclinical cardiotoxicity testing.
© 2015 American Heart Association, Inc.
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Monophosphoryl lipid A inhibits the cytokine response of endothelial cells challenged with LPS.
Stark R, Choi H, Koch S, Lamb F, Sherwood E
(2015) Innate Immun 21: 565-74
MeSH Terms: Cells, Cultured, Chemokine CCL5, Chemokine CXCL10, Down-Regulation, Drug Combinations, Endothelial Cells, Humans, Immunity, Innate, Immunomodulation, Interleukin-6, Lipid A, Lipopolysaccharides, Signal Transduction, Toll-Like Receptor 4, Umbilical Veins
Show Abstract · Added July 28, 2015
Monophosphoryl lipid A (MPLA) is a TLR4 agonist that is used as an immunomodulator in human vaccines; additionally, it has been shown to be protective in models of sepsis. As endothelial cells regulate inflammation, we hypothesized that MPLA would decrease activation of human umbilical vein endothelial cells (HUVECs) to LPS. We studied HUVECs challenged with LPS (100 ng/ml), MPLA (0.001-100 µg/ml) or a combination. Secretion of IL-6, RANTES (CCL5) and IP-10 (CXCL10) were assessed by ELISA. Activation of MAPK phosphorylation and cytokine transcription were assessed by Western blot analysis and PCR, respectively. MPLA alone was a weak stimulator of myeloid differentiation primary response protein 88-dependent IL-6 and did not induce TIR-domain-containing adapter-inducing IFN-β (TRIF)-dependent chemokine responses. MPLA significantly reduced LPS-mediated IL-6 production. This inhibitory effect was also conferred for the TRIF-dependent chemokines RANTES and IP-10. Inhibition of LPS-mediated activation by MPLA was associated with reduced p38 phosphorylation and mRNAs encoding inflammatory cytokines. MPLA inhibition of LPS signaling appeared to be at the level of the TLR4 receptor, acting as a receptor antagonist with weak agonistic properties. This study provides evidence of a novel mechanism for the inhibitory effect of MPLA on LPS-induced endothelial activation.
© The Author(s) 2014.
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15 MeSH Terms
Efficacy and tolerability of 3 nonnucleoside reverse transcriptase inhibitor-sparing antiretroviral regimens for treatment-naive volunteers infected with HIV-1: a randomized, controlled equivalence trial.
Lennox JL, Landovitz RJ, Ribaudo HJ, Ofotokun I, Na LH, Godfrey C, Kuritzkes DR, Sagar M, Brown TT, Cohn SE, McComsey GA, Aweeka F, Fichtenbaum CJ, Presti RM, Koletar SL, Haas DW, Patterson KB, Benson CA, Baugh BP, Leavitt RY, Rooney JF, Seekins D, Currier JS, ACTG A5257 Team
(2014) Ann Intern Med 161: 461-71
MeSH Terms: Adenine, Adult, Atazanavir Sulfate, Darunavir, Deoxycytidine, Drug Combinations, Drug Therapy, Combination, Emtricitabine, Female, HIV Infections, HIV Protease Inhibitors, HIV-1, Humans, Male, Oligopeptides, Organophosphonates, Pyridines, RNA, Viral, Reverse Transcriptase Inhibitors, Sulfonamides, Tenofovir, Therapeutic Equivalency, Viral Load
Show Abstract · Added March 13, 2015
BACKGROUND - Nonnucleoside reverse transcriptase inhibitor-based antiretroviral therapy is not suitable for all treatment-naive HIV-infected persons.
OBJECTIVE - To evaluate 3 nonnucleoside reverse transcriptase inhibitor-sparing initial antiretroviral regimens to show equivalence for virologic efficacy and tolerability.
DESIGN - A phase 3, open-label study randomized in a 1:1:1 ratio with follow-up for at least 96 weeks. (ClinicalTrials.gov: NCT00811954).
SETTING - 57 sites in the United States and Puerto Rico.
PATIENTS - Treatment-naive persons aged 18 years or older with HIV-1 RNA levels greater than 1000 copies/mL without resistance to nucleoside reverse transcriptase inhibitors or protease inhibitors.
INTERVENTION - Atazanavir, 300 mg/d, with ritonavir, 100 mg/d; raltegravir, 400 mg twice daily; or darunavir, 800 mg/d, with ritonavir, 100 mg/d, plus combination emtricitabine, 200 mg/d, and tenofovir disoproxil fumarate, 300 mg/d.
MEASUREMENTS - Virologic failure, defined as a confirmed HIV-1 RNA level greater than 1000 copies/mL at or after 16 weeks and before 24 weeks or greater than 200 copies/mL at or after 24 weeks, and tolerability failure, defined as discontinuation of atazanavir, raltegravir, or darunavir for toxicity. A secondary end point was a combination of virologic efficacy and tolerability.
RESULTS - Among 1809 participants, all pairwise comparisons of incidence of virologic failure over 96 weeks showed equivalence within a margin of equivalence defined as -10% to 10%. Raltegravir and ritonavir-boosted darunavir were equivalent for tolerability, whereas ritonavir-boosted atazanavir resulted in a 12.7% and 9.2% higher incidence of tolerability discontinuation than raltegravir and ritonavir-boosted darunavir, respectively, primarily because of hyperbilirubinemia. For combined virologic efficacy and tolerability, ritonavir-boosted darunavir was superior to ritonavir-boosted atazanavir, and raltegravir was superior to both protease inhibitors. Antiretroviral resistance at the time of virologic failure was rare but more frequent with raltegravir.
LIMITATION - The trial was open-label, and ritonavir was not provided.
CONCLUSION - Over 2 years, all 3 regimens attained high and equivalent rates of virologic control. Tolerability of regimens containing raltegravir or ritonavir-boosted darunavir was superior to that of the ritonavir-boosted atazanavir regimen.
PRIMARY FUNDING SOURCE - National Institute of Allergy and Infectious Diseases.
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23 MeSH Terms
Phase I safety, pharmacokinetics, and pharmacogenetics study of the antituberculosis drug PA-824 with concomitant lopinavir-ritonavir, efavirenz, or rifampin.
Dooley KE, Luetkemeyer AF, Park JG, Allen R, Cramer Y, Murray S, Sutherland D, Aweeka F, Koletar SL, Marzan F, Bao J, Savic R, Haas DW, AIDS Clinical Trials Group A5306 Study Team
(2014) Antimicrob Agents Chemother 58: 5245-52
MeSH Terms: Adult, Antitubercular Agents, Antiviral Agents, Benzoxazines, Drug Combinations, Drug Therapy, Combination, Female, Humans, Lopinavir, Male, Middle Aged, Nitroimidazoles, Pharmacogenetics, Rifampin, Ritonavir, Young Adult
Show Abstract · Added March 13, 2015
There is an urgent need for new antituberculosis (anti-TB) drugs, including agents that are safe and effective with concomitant antiretrovirals (ARV) and first-line TB drugs. PA-824 is a novel antituberculosis nitroimidazole in late-phase clinical development. Cytochrome P450 (CYP) 3A, which can be induced or inhibited by ARV and antituberculosis drugs, is a minor (∼20%) metabolic pathway for PA-824. In a phase I clinical trial, we characterized interactions between PA-824 and efavirenz (arm 1), lopinavir/ritonavir (arm 2), and rifampin (arm 3) in healthy, HIV-uninfected volunteers without TB disease. Participants in arms 1 and 2 were randomized to receive drugs via sequence 1 (PA-824 alone, washout, ARV, and ARV plus PA-824) or sequence 2 (ARV, ARV with PA-824, washout, and PA-824 alone). In arm 3, participants received PA-824 and then rifampin and then both. Pharmacokinetic sampling occurred at the end of each dosing period. Fifty-two individuals participated. Compared to PA-824 alone, plasma PA-824 values (based on geometric mean ratios) for maximum concentration (Cmax), area under the concentration-time curve from 0 to 24 h (AUC0-24), and trough concentration (Cmin) were reduced 28%, 35%, and 46% with efavirenz, 13%, 17%, and 21% with lopinavir-ritonavir (lopinavir/r) and 53%, 66%, and 85% with rifampin, respectively. Medications were well tolerated. In conclusion, lopinavir/r had minimal effect on PA-824 exposures, supporting PA-824 use with lopinavir/r without dose adjustment. PA-824 exposures, though, were reduced more than expected when given with efavirenz or rifampin. The clinical implications of these reductions will depend upon data from current clinical trials defining PA-824 concentration-effect relationships. (This study has been registered at ClinicalTrials.gov under registration no. NCT01571414.).
Copyright © 2014, American Society for Microbiology. All Rights Reserved.
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16 MeSH Terms
Genome-wide association study of peripheral neuropathy with D-drug-containing regimens in AIDS Clinical Trials Group protocol 384.
Leger PD, Johnson DH, Robbins GK, Shafer RW, Clifford DB, Li J, McLaren PJ, Haas DW
(2014) J Neurovirol 20: 304-8
MeSH Terms: Acquired Immunodeficiency Syndrome, Anti-HIV Agents, Case-Control Studies, Drug Combinations, Drug Therapy, Combination, Genome-Wide Association Study, Genotype, Humans, Lamivudine, Multicenter Studies as Topic, Peripheral Nervous System Diseases, Polymorphism, Genetic, Principal Component Analysis, Randomized Controlled Trials as Topic, Retrospective Studies, Stavudine, Treatment Outcome, Zidovudine
Show Abstract · Added March 13, 2015
Stavudine (d4T) was, until recently, one of the most widely prescribed antiretroviral drugs worldwide. While there has been a major shift away from d4T use in resource-limited countries, a large number of patients have previously received (or continue to receive) d4T, and many have developed peripheral neuropathy. The identification of genetic predictors of increased risk might suggest novel therapeutic targets for such patients. In AIDS Clinical Trials Group protocol 384, antiretroviral-naïve patients were randomized to d4T/didanosine (ddI)- or zidovudine/lamivudine-containing regimens. Data from d4T/ddI recipients were analyzed for genome-wide associations (approximately 1 million genetic loci) with new onset distal sensory peripheral neuropathy. Analyses involved 254 patients (49 % White, 34 % Black, 17 % Hispanic), comprising 90 peripheral neuropathy cases (32 grade 1, 35 grade 2, 23 grade 3) and 164 controls. After correcting for multiple comparisons, no polymorphism was consistently associated with neuropathy among all patients, among White, Black, and Hispanic patients analyzed separately, both in genome-wide analyses (threshold, P < 5.0 × 10(-8)) and focused on 46 neuropathy-associated genes (threshold, P < 3.5 × 10(-5)). In the latter analyses, the lowest P values were in KIF1A among Whites (rs10199388, P = 8.4 × 10(-4)), in LITAF among Blacks (rs13333308, P = 6.0 × 10(-6)), and in NEFL among Hispanics (rs17763685, P = 5.6 × 10(-6)). Susceptibility to d4T/ddI-associated neuropathy is not explained by a single genetic variant with a marked effect.
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18 MeSH Terms
Omega-3 PUFA supplementation and the response to evoked endotoxemia in healthy volunteers.
Ferguson JF, Mulvey CK, Patel PN, Shah RY, Doveikis J, Zhang W, Tabita-Martinez J, Terembula K, Eiden M, Koulman A, Griffin JL, Mehta NN, Shah R, Propert KJ, Song WL, Reilly MP
(2014) Mol Nutr Food Res 58: 601-13
MeSH Terms: Adolescent, Adult, Dietary Supplements, Docosahexaenoic Acids, Dose-Response Relationship, Drug, Drug Combinations, Eicosapentaenoic Acid, Endotoxemia, Fatty Acids, Omega-3, Female, Fish Oils, Healthy Volunteers, Humans, Inflammation, Isoprostanes, Lipopolysaccharides, Lipoproteins, Male, Middle Aged, Young Adult
Show Abstract · Added January 20, 2015
SCOPE - Fish oil-derived n-3 PUFA may improve cardiometabolic health through modulation of innate immunity. However, findings in clinical studies are conflicting. We hypothesized that n-3 PUFA supplementation would dose-dependently reduce the systemic inflammatory response to experimental endotoxemia in healthy humans.
METHODS AND RESULTS - The Fenofibrate and omega-3 Fatty Acid Modulation of Endotoxemia (FFAME) study was an 8-wk randomized double-blind trial of placebo or n-3 PUFA supplementation (Lovaza 465 mg eicosapentaenoic acid (EPA) + 375 mg docosahexaenoic acid (DHA)) at "low" (1/day, 900 mg) or "high" (4/day, 3600 mg) dose in healthy individuals (N = 60; age 18-45; BMI 18-30; 43% female; 65% European-, 20% African-, 15% Asian-ancestry) before a low-dose endotoxin challenge (LPS 0.6 ng/kg intravenous bolus). The endotoxemia-induced temperature increase was significantly reduced with high-dose (p = 0.03) but not low-dose EPA + DHA compared to placebo. Although there was no statistically significant impact of EPA + DHA on individual inflammatory responses (tumor necrosis factor-α (TNF-α), IL-6, monocyte chemotactic protein (MCP-1), IL-1 receptor agonist (IL-1RA), IL-10, C-reactive protein (CRP), serum amyloid A (SAA)), there was a pattern of lower responses across all biomarkers with high-dose (nine of nine observed), but not low-dose EPA + DHA.
CONCLUSION - EPA + DHA at 3600 mg/day, but not 900 mg/day, reduced fever and had a pattern of attenuated LPS induction of plasma inflammatory markers during endotoxemia. Clinically and nutritionally relevant long-chain n-3 PUFA regimens may have specific, dose-dependent, anti-inflammatory actions.
© 2013 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.
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20 MeSH Terms
Durability of first ART regimen and risk factors for modification, interruption or death in HIV-positive patients starting ART in Europe and North America 2002-2009.
Abgrall S, Ingle SM, May MT, Costagliola D, Mercie P, Cavassini M, Reekie J, Samji H, Gill MJ, Crane HM, Tate J, Sterling TR, Antinori A, Reiss P, Saag MS, Mugavero MJ, Phillips A, Manzardo C, Wasmuth JC, Stephan C, Guest JL, Gomez Sirvent JL, Sterne JA, Antiretroviral Therapy Cohort Collaboration (ART-CC)
(2013) AIDS 27: 803-13
MeSH Terms: Adenine, Anti-HIV Agents, Antiretroviral Therapy, Highly Active, Benzoxazines, Cohort Studies, Deoxycytidine, Dideoxynucleosides, Drug Combinations, Emtricitabine, Europe, HIV Infections, HIV Protease Inhibitors, HIV Seropositivity, HIV-1, Humans, Lamivudine, Lopinavir, Nevirapine, Organophosphonates, Reverse Transcriptase Inhibitors, Risk Factors, Tenofovir, Time Factors, United States
Show Abstract · Added February 17, 2016
OBJECTIVES - To estimate the incidence of and risk factors for modifications to first antiretroviral therapy (ART) regimen, treatment interruption and death.
METHODS - A total of 21 801 patients from 18 cohorts in Europe and North America starting ART on regimens including at least two nucleoside reverse transcriptase inhibitors and boosted protease inhibitor or non-nucleoside reverse transcriptase inhibitor during 2002-2009 were included. Incidence of modifications (change of drug class, substitution/addition within class, or switch to nonstandard regimen), interruption or death and associations with patient characteristics were estimated using competing-risks methods.
RESULTS - During median 28 months follow-up, 8786 (40.3%) patients modified first ART, 2346 (10.8%) interrupted and 427 (2.0%) died before changing regimen. Three-year cumulative percentages of modification, interruption and death were 47, 12 and 2%, respectively. After adjustment, rates of interruption were highest for IDUs and lowest for MSM, and higher for patients starting ART with CD4 cell count above 350 cells/μl than other patients. Compared to efavirenz, patients on lopinavir and other protease inhibitors had higher rates of modification and interruption, on atazanavir had lower rates of class change, and on nevirapine higher rates of interruption. Those on tenofovir/emtricitabine backbone had lowest rates of substitutions and switches to nonstandard regimen, and on abacavir/lamivudine lowest rates of interruption. Rates of substitution and switches to nonstandard regimen were lower in 2006-2009.
CONCLUSION - Rates of modification and interruption were high, particularly in the first year of ART. Decreased rates of substitutions or switches to nonstandard regimen in recent years may be linked to greater use of well tolerated once-daily drugs.
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24 MeSH Terms