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PubMed2003

Simple and rapid method for the simultaneous determination of the non-nucleoside reverse transcriptase inhibitors efavirenz and nevirapine in human plasma using liquid chromatography.

Efavirenz and nevirapine are non-nucleoside reverse transcriptase inhibitors for the treatment of HIV-1-infected individuals. A simple and rapid high-performance liquid chromatographic method for the simultaneous quantification of efavirenz and nevirapine in human plasma suitable for therapeutic drug monitoring is described. Sample pre-treatment consisted of protein precipitation with acetonitrile and subsequently dilution with distilled water. The drugs were separated from endogenous compounds by isocratic reversed-phase high-performance liquid chromatography with ultraviolet detection at 275 nm. The method was validated over the therapeutically relevant concentration range of 0.05-15.0 mg l(-1) and 0.25-15.0 mg l(-1) for efavirenz and nevirapine, respectively, using a volume of 100 microl of plasma. The calibration curves were linear over this concentration range. Carbamazepine was used as internal standard. The assay proved to be accurate (accuracies varied between -12.7 and 8.5%) and precise (intra- and inter-assay precisions were less then 5.9%). The tested batches of control human plasma and frequently co-administered drugs did not interfere with the described methodology. Efavirenz and nevirapine were stable under various relevant storage conditions. This validated assay is suited for use in pharmacokinetic studies with efavirenz and nevirapine and can readily be implemented in the setting of a hospital laboratory for the monitoring of efavirenz and nevirapine concentrations.

Alkynes↗

PubMed2005

Do non-nucleoside reverse transcriptase inhibitors contribute to lipodystrophy?

Lipodystrophy complications, including lipoatrophy (pathological fat loss) and metabolic complications, have emerged as important long-term toxicities associated with antiretroviral therapy in the current era. The wealth of data that has accumulated over the past 6 years has now clarified the contribution of specific antiretroviral drugs to the risk of these clinical endpoints, with evidence that lipoatrophy is strongly associated with the choice of nucleoside reverse transcriptase inhibitor therapy (specifically, stavudine and to a lesser extent zidovudine). The aetiological basis of metabolic complications of antiretroviral therapy has proven to be complex, in that the risk appears to be modulated by a number of lifestyle factors that have made the metabolic syndrome highly prevalent in the general population, with additional contributions from HIV disease status itself, as well as from individual drugs within the HIV protease inhibitor class. The currently licensed non-nucleoside reverse transcriptase inhibitor (NNRTI) drugs, efavirenz and nevirapine, have been proven to have a favourable safety profile in terms of lipodystrophy complications. However, it must be noted that NNRTI drugs also have individual toxicity profiles that must be accounted for when considering and/or monitoring their use in the treatment of HIV infection.

Alkynes↗

PubMed2003

Comparison of metabolic abnormalities 48 weeks after switching from highly active antiretroviral therapy containing a non-nucleoside reverse transcriptase inhibitor to Trizivir versus continued highly active antiretroviral therapy.

Forty patients participating in the TRIZAL study were treated with a non-nucleoside reverse transcriptase inhibitor (NNRTI)-containing regimen before being randomly assigned either to continue their baseline therapy or to switch to a triple nucleoside regimen. No difference was observed in treatment efficacy between the two groups, and total cholesterol was observed to improve significantly in the switch group. Switch maintenance may be an appropriate strategy in patients treated with an NNRTI.

Antiretroviral Therapy, Highly Active↗

PubMed2001

Increased risk of lipodystrophy when nucleoside analogue reverse transcriptase inhibitors are included with protease inhibitors in the treatment of HIV-1 infection.

BACKGROUND: Changes in body fat distribution are an adverse effect of therapy with HIV protease inhibitors (PI). It has been suggested that nucleoside analogue reverse transcriptase inhibitors (NRTI) may also contribute to this so-called lipodystrophy syndrome, but the relative contribution of the two drug classes is unclear as they are usually administered concomitantly. METHOD: The occurrence of lipodystrophy, as reported by physicians using no standardized criteria, was followed in patients randomly assigned to treatment with either a PI alone or a PI combined with an NRTI. The patients were part of a multicenter, open-label, randomized comparison of ritonavir (RTV)/saquinavir (SQV) with or without the addition of stavudine (d4T) in HIV-1-infected patients without prior PI and d4T experience (the Prometheus study). RESULTS: Lipodystrophy was reported in 29 of 175 (17%) patients during 96 weeks of follow up. Overall, it was reported significantly more frequently in patients who were randomized to RTV/SQV/d4T (22/88; 25%), than in patients randomized to RTV/SQV alone (7/87; 8%) (P = 0.003). When the analysis was limited to patients without any prior antiretroviral experience, lipodystrophy likewise was significantly more frequent in patients randomized to RTV/SQV/d4T (12/50; 24%) than in those randomized to RTV/SQV (2/44; 5%) (P = 0.008). CONCLUSION: This randomized clinical trial, in spite of not having been blinded, supports a contributory role of NRTI in the development of antiretroviral therapy-associated lipodystrophy. The low incidence of lipodystrophy in patients with no or limited NRTI exposure supports further evaluation of NRTI-sparing regimens as alternatives to current antiretroviral regimens.

Anti-HIV Agents↗

PubMed2000

Clinical evaluation of the efficacy and tolerability of ritonavir in combination with two reverse transcriptase inhibitors.

A retrospective study of 76 patients was carried out using ritonavir in an antiretroviral regimen combined with two reverse transcriptase inhibitors to treat outpatients from July, 1996, to April, 1998, with the objective of evaluating clinical efficacy and tolerability. Seventy-six percent of the patients had been diagnosed with AIDS, an average number of CD(4) cells = 233.7 cells/mm(3) and viral load = 144, 084 RNA copies/mm(3). The majority of patients (76.3% )were antiretroviral treatment-experienced, 21.4% having taken protease inhibitors. A positive clinical response was found in 86.7% (including an average weight gain of 4.4 kg in 58.5% ), an average CD(4) count increase of 169.5 cells/mm(3) in 83.3% and an average viral load decrease of approximately 2.28 log in 75% of patients. A high percentage of adverse effects (76.3% ) was detected, with most slight or moderate, but they significantly impacted adherence to treatment as 31.6% stopped taking the drug as a result. We conclude that this antiretroviral regimen has good clinical efficacy, but relatively poor tolerability.

Adult↗

PubMed2006

Next-generation HIV-1 non-nucleoside reverse transcriptase inhibitors.

This review discusses the desired attributes of a next-generation HIV-1 non-nucleoside reverse transcriptase inhibitor (NNRTI) and highlights the properties of compounds currently or recently in clinical development. TMC-125 is currently in phase III clinical trials and on track to become the first NNRTI suitable for use in NNRTI-experienced patients. TMC-278 is structurally related to TMC-125, but is more potent in vitro and has pharmacokinetics suitable for once-daily administration. It is currently undergoing phase II clinical trials. BILR-355 BS, a dipyridodiazepinone compound, is in early phase II clinical trials. It requires ritonavir as a booster and has reduced inhibitory activity against several key NNRTI-resistant HIV-1 strains. Development of the NNRTIs capravirine and GW-695634 has been discontinued because of lack of efficacy and safety issues, respectively.

Animals↗

PubMed1994

Swertifrancheside, an HIV-reverse transcriptase inhibitor and the first flavone-xanthone dimer, from Swertia franchetiana.

The first flavone-xanthone C-glucoside, swertifrancheside, was isolated from Swertia franchetiana, and its structure was elucidated on the basis of spectroscopic analysis as 1,5,8-trihydroxy-3-methoxy-7-(5',7',3'',4''- tetrahydroxy-6'-C-beta-D-glucopyranosyl-4'-oxy-8'-flavyl)-xanthone . This compound was a moderately potent inhibitor of HIV reverse transcriptase.

Antimalarials↗

PubMedDate not supplied

Higher rates of viral suppression with nonnucleoside reverse transcriptase inhibitors compared to single protease inhibitors are not explained by better adherence.

BACKGROUND: Although evidence suggests that antiretroviral (ARV) regimens containing nonnucleoside reverse transcriptase inhibitors (NNRTIs) are superior to single-protease inhibitor (PI)-based regimens at suppressing viral load, it is unclear how much of the improved viral suppression is due to intrinsic drug potency versus higher levels of adherence to simpler regimens. We therefore examined adherence and viral suppression in NNRTI and single-PI regimens in a cohort of largely ARV-experienced participants by using objective measures of adherence. METHOD: Participants were recruited from the Research on Access to Care in the Homeless (REACH) Cohort and were included in the study if they were on single-PI-based or NNRTI-based highly active antiretroviral therapy (HAART) regimens for at least 3 months prior to study entry. Adherence was measured by unannounced pill counts at the participant's usual place of residence. The primary outcome was suppression of HIV viral RNA to <50 copies/mL. RESULTS: Among 109 individuals who were followed for a median of 8.7 months, the odds of virologic suppression were approximately 8 times higher (p < .01) for participants on NNRTI-based regimens (n = 53) compared with those using single-PI-based regimens (n = 56) when controlling for adherence, as well as other potential confounders in a multivariable analysis. The only other independent predictors of viral suppression in multivariable modeling were ARV adherence (p < .01), CD4 nadir (p = .02), and continuous months on current regimen prior to the start of adherence monitoring (p < .01). There was no significant difference in adherence by unannounced pill counts in participants receiving NNRTI- versus single-PI-containing regimens. CONCLUSION: A higher proportion of individuals using NNRTI-based regimens had viral suppression when compared to those taking single-PI-containing regimens, and this association was not confounded by higher levels of adherence. These results suggest that improved viral suppression on NNRTI regimens compared to single-PI regimens is more closely associated with regimen potency than higher levels of adherence.

Adult↗

PubMedDate not supplied

Effect of antimetabolite drugs of nucleotide metabolism on the anti-human immunodeficiency virus activity of nucleoside reverse transcriptase inhibitors.

A number of attempts are currently underway to combine antimetabolite drugs of nucleotide metabolism with a nucleoside reverse transcriptase inhibitor (NRTI) targeting human immunodeficiency virus (HIV) to improve the antiviral efficacy of the NRTIs and to better control HIV drug resistance. Hydroxyurea, a ribonucleotide reductase inhibitor, is currently combined with the NRTI didanosine (2',3'-dideoxyinosine) in clinical trials. However, other cellular target enzymes, including thymidylate synthase, inosinate dehydrogenase, cytidine-5'-triphosphate synthetase, and other enzymes from the de novo nucleotide biosynthesis pathway, can also be considered to potentiate the antiviral action of NRTIs. The underlying reasons for the potentiation of the antiviral activity of the NRTIs by antimetabolite drugs of nucleotide metabolism can be multiple. Decreased endogenous 2'-deoxynucleoside-5'-triphosphate (dNTP) pools result in a better competition of the NRTI (as its triphosphate derivative), with the dNTPs for the virus-encoded reverse transcriptase to be recognized as a substrate for the DNA polymerization reaction and subsequently to be incorporated into the growing viral DNA chain. Also, an increased metabolism (phosphorylation) of the NRTI by stimulatory enzyme feedback mechanisms may result in the production of higher levels of NRTI triphosphate. Thus, higher intracellular ratios of NRTI-triphosphate/dNTP created by well-defined combinations of NRTIs and antimetabolite drugs enable a more profound inhibitory effect of the NRTI against the reverse transcriptase (and thus, against the virus) and a better suppression of resistant (mutant) virus strains. A profound evaluation of this relatively new concept in the clinical setting will reveal whether this approach will establish a place in future treatment modalities of HIV infections.

Antimetabolites↗

PubMed2002

Insertions in the reverse transcriptase increase both drug resistance and viral fitness in a human immunodeficiency virus type 1 isolate harboring the multi-nucleoside reverse transcriptase inhibitor resistance 69 insertion complex mutation.

Recent studies have shown that the accumulation of multiple mutations associated with nucleoside reverse transcriptase inhibitor (NRTI) resistance may be grouped as multi-NRTI resistance (MNR) complexes. In this study, we have examined the viral fitness of recombinant viruses carrying the reverse transcriptase (RT) of a human immunodeficiency virus type 1 (HIV-1) primary isolate harboring mutations comprising the MNR 69 insertion complex. Different RT mutants were prepared in the sequence context of either the wild-type RT sequence of the HIV-1(BH10) isolate or the sequence found in a clinical HIV-1 isolate with the MNR 69 insertion mutation. As expected, in the presence of zidovudine, recombinant viruses harboring the MNR RT from the patient were more fit than wild-type viruses. However, in the absence of drug, the virus with the RT from the original clinical isolate (SS) was more fit than (i) the wild-type virus with an engineered serine insertion between residues 69 and 70 (T69SSS) and (ii) the recombinant virus with the MNR RT where the insertion was removed (2S0S). These results suggest that RT insertions, in the right sequence context (i.e., additional mutations contained in the MNR 69 insertion complex), enhance NRTI resistance and may improve viral fitness. Thus, comparing complex mutation patterns with viral fitness may help to elucidate the role of uncharacterized drug resistance mutations in antiretroviral treatment failure.

Adult↗

PubMed1995

Rationale and experience with reverse transcriptase inhibitors and protease inhibitors.

The majority of antiretroviral agents used in the treatment of HIV are targeted at the HIV reverse transcriptase (RT) enzyme. In a continuing effort to develop more effective antiviral regimens, drugs that target other specific enzymes in the virus replication cycle are under development. A promising new class of drugs is the protease inhibitors. These antiviral agents are potent and highly specific, giving excellent inhibition of viral replication. Unfortunately, the high level of inhibition may not be maintained in vivo because of the rapid emergence of resistance to these agents when they are used as monotherapy. However, the combination of protease inhibitors with reverse transcriptase inhibitors may represent a major advance in the treatment of HIV infection.

Drug Therapy, Combination↗

PubMed2002

Induction of apoptosis by a nonnucleoside human immunodeficiency virus type 1 reverse transcriptase inhibitor.

Inhibition of human immunodeficiency virus type 1 reverse transcriptase (RT) by both nucleoside and nonnucleoside RT inhibitors profoundly inhibits virus replication. Nucleoside RT inhibitors are known to be toxic, but there is little information regarding the toxicities of nonnucleoside RT inhibitors (NNRTI). We demonstrate that efavirenz (an NNRTI) induces caspase- and mitochondrion-dependent apoptosis of Jurkat T cells and human peripheral blood mononuclear cells. The clinical relevance of these observations is not yet clear.

Alkynes↗

PubMed1994

Human pharmacokinetics and tolerability of L-697,639, a non-nucleoside HIV-1 reverse transcriptase inhibitor.

L-697,639, a potent and selective non-nucleoside inhibitor of HIV-1 reverse transcriptase and HIV-1 replication in vitro, was administered to healthy male volunteers to investigate the pharmacokinetics and tolerability of single and multiple oral doses. Single doses ranging from 25 to 500 mg, and multiple doses of up to 100 mg every 12 h for ten days, produced no clinically important adverse events. Dose proportionality with respect to AUC was seen over the range of 25-100 mg administered as a single dose. Single doses of 200 mg and 500 mg resulted in an increase in AUC and Cmax that was less than proportional to the increase in dose. The mean Cmax after single doses of 25 and 500 mg were 0.9 and 5.8 microM respectively. Mean Tmax values ranged from 1.7-3 h. Mean AUCs (0-48 h) were from 6.05 to 50.3 microM h after doses from 25 to 500 mg respectively. After the 500-mg dose less than 0.7% appeared unchanged in the urine over 48 hours. During multiple doses, steady-state was reached on day 3 and slight accumulation occurred (approximately 1.5-fold). L-697,639 was well tolerated for up to ten days at doses that resulted in mean steady-state trough concentrations that exceed their in-vitro susceptibilities.

Adult↗

PubMed1991

Viral resistance to human immunodeficiency virus type 1-specific pyridinone reverse transcriptase inhibitors.

Human immunodeficiency virus type 1 (HIV-1)-specific pyridinone reverse transcriptase (RT) inhibitors prevent HIV-1 replication in cell culture (M. E. Goldman, J. H. Nunberg, J. A. O'Brien, J.C. Quintero, W. A. Schleif, K. F. Freund, S. L. Gaul, W. S. Saari, J. S. Wai, J. M. Hoffman, P. S. Anderson, D. J. Hupe, E. A. Emini, and A. M. Stern, Proc. Natl. Acad. Sci. USA 88:6863-6867, 1991). In contrast to nucleoside analog inhibitors, such as AZT, which need to be converted to triphosphates by host cells, these compounds act directly to inhibit RT via a mechanism which is noncompetitive with respect to deoxynucleoside triphosphates. As one approach to define the mechanism of action of pyridinone inhibitors, we isolated resistant mutants of HIV-1 in cell culture. Serial passage in the presence of inhibitor yielded virus which was 1,000-fold resistant to compounds of this class. Bacterially expressed RTs molecularly cloned from resistant viruses were also resistant. The resistant RT genes encoded two amino acid changes, K-103 to N and Y-181 to C, each of which contributed partial resistance. The mutation at amino acid 181 lies adjacent to the conserved YG/MDD motif found in most DNA and RNA polymerases. The mutation at amino acid 103 lies within a region of RT which may be involved in PPi binding. The resistant viruses, although sensitive to nucleoside analogs, were cross-resistant to the structurally unrelated RT inhibitors TIBO R82150 (R. Pauwels, K. Andries, J. Desmyter, D. Schols, M. J. Kukla, H. J. Breslin, A. Raeymaeckers, J. Van Gelder, R. Woestenborghs, J. Heykanti, K. Schellekens, M. A. C. Janssen, E. De Clercq, and P. A. J. Janssen, Nature [London] 343:470-474, 1990) and BI-RG-587 (V. J. Merluzzi, K. D. Hargrave, M. Labadia, K. Grozinger, M. Skoog, J. C. Wu, C.-K. Shih, K. Eckner, S. Hattox, J. Adams, A. S. Rosenthal, R. Faanes, R. J. Eckner, R. A. Koup, and J. L. Sullivan, Science 250:1411-1413, 1990). Thus, these nonnucleoside analog inhibitors may share a common binding site on RT and may all make up a single pharmacologic class of RT inhibitor. This observation may have important implications for the clinical development of these compounds.

Amino Acid Sequence↗

PubMed1993

Kinetics of different human immunodeficiency virus type 1 reverse transcriptases resistant to human immunodeficiency virus type 1-specific reverse transcriptase inhibitors.

The human immunodeficiency virus type 1 (HIV-1)-specific reverse transcriptase (RT) inhibitors [tetrahydroimidazo[4,5,1-jk] [1,4]benzodiazepin-2(1H)-one and -thione (TIBO), 1-[(2-hydroxyethoxy)methyl]-6-(phenylthio)thymine, nevirapine, pyridinone, bis(heteroaryl)piperazine, etc.] are potent inhibitors of HIV-1 replication in cell culture. The rapid emergence of drug-resistant escape mutants in vitro (cell culture) and in vivo (patients) is predominantly linked to the Y181C mutation. Because amino acids Y181 and Y188 appear to be located within the drug binding site of the enzyme, we studied the impact of mutations of both amino acids on the enzyme kinetics and on the susceptibility of the enzyme to different HIV-1-specific RT inhibitors. Mutations Y181C, Y181I, and Y188L led to reduced sensitivity, albeit of varying extents, to all HIV-1-specific RT inhibitors. No resistance was observed to 2',3'-dideoxyguanosine 5'-triphosphate or phosphonoformic acid. The kcat of the Y181C mutant was similar to that of the wild-type RT (18 sec-1 x 10(-3)). The catalytic constant of the Y181I mutant was 6-fold higher and that of the Y188L mutant was 6-fold lower. Whereas TIBO displayed a linear mixed-type (noncompetitive) inhibition with respect to the deoxynucleotide substrate when wild-type p66/p51 was used, the pattern of inhibition became competitive or uncompetitive with Y181C or Y181I, respectively. Thus, the TIBO binding site of HIV-1 RT seems to be functionally and/or spatially related to the natural deoxynucleoside triphosphate binding site.

Amino Acid Sequence↗

PubMed2003

Response to efavirenz plus two nucleoside reverse-transcriptase inhibitors in patients with advanced stage human immunodeficiency virus-1 infection in Taiwan.

From July 1, 1999 to April 30, 2002, 111 consecutive human immunodeficiency virus-infected, antiretroviral-naïve Taiwan patients initiated highly active antiretroviral therapy with efavirenz plus 2 nucleoside reverse-transcriptase inhibitors. Their median baseline CD4+ count was 50 x 10(6)/L (0-559 x 10(6)/L) and plasma viral load was 5.51 log10 copies/mL (3.09 to > 5.88 log10) as assessed by reverse-transcriptase polymerase chain reaction. Of the patients, 52.3% had a CD4+ count of < or = 50 x 10(6)/L, 74.8% had plasma viral load over 5 log10 copies/mL, and 58.5% had active AIDS-defining opportunistic illnesses. The median observation duration of antiretroviral therapy was 350 days (range, 28-991 days). At week 48 to 52 following the initiation of highly active antiretroviral therapy, 81. 8% (45/55) and 91.8% (45/49) of the patients achieved undetectable plasma viral load by intent-to-treat and ontreat analysis, respectively. At week 80 to 84, these percentage decreased to 69.7% (23/33) and 85.2% (23/27), respectively. Median CD4+ count increased from baseline to week 48 to 52 by 147 x 10(6)/L and to week 80 to 84 by 227 x 10(6)/L. The virologic and immunologic responses at each time period by intention-to-treat or on-treat analysis were similar between patients with baseline plasma viral load over or < or = 5 log10, CD4+ count over or < or = 50 x 10(6)/L, and with or without active AIDS-defining opportunistic illnesses. After initiation of highly active antiretroviral therapy for a median duration of 57 days (range, 2-638 days), 11 episodes of AIDS-defining and 11 non-AIDS opportunistic illnesses occurred. The results of this study suggest that efavirenz plus 2 nucleoside reverse-transcriptase inhibitors is a potent antiretroviral combination regardless of whether the patient has a high baseline plasma viral load, low CD4+ count, or AIDS-defining opportunistic illnesses.

Adult↗

PubMed1997

Efficacy, pharmacokinetics, and in vivo antiviral activity of UC781, a highly potent, orally bioavailable nonnucleoside reverse transcriptase inhibitor of HIV type 1.

A series of compounds related to oxathiin carboxanilide has been identified as nonnucleoside reverse transcriptase inhibitors (NNRTIs) of HIV-1, and structure-activity relationships have been described (Buckheit RW, et al.: Antimicrob Agents Chemother 1995;39:2718-2727). Three new analogs (UC040, UC82, and UC781) inhibited laboratory and clinical isolates of HIV-1, including isolates representative of the various clades of HIV-1 found worldwide, in both established and fresh human cells. Virus isolates with the amino acid changes L100I, K103N, V106I, and Y181C in the reverse transcriptase were partially resistant to these compounds. However, UC781 inhibited these virus isolates at low nontoxic concentrations, presenting a broad in vitro therapeutic index. As with other NNRTIs, each of the compounds synergistically interacted with AZT to inhibit HIV-1 replication. UC781 possesses a favorable pharmacokinetic profile in mice with a high level of oral bioavailability. Plasma concentrations reached maximum levels within 2 to 4 hr of oral administration and remained in excess of those required for in vitro anti-HIV activity for at least 24 hr after a single oral dose. When evaluated in a murine hollow fiber implant model of HIV infection, UC781 dosed orally or parenterally was able to suppress HIV replication completely in this model system, providing evidence of the in vivo efficacy of the compound.

Administration, Oral↗

PubMed2003

Immune reconstitution is comparable in antiretroviral-naive subjects after 1 year of successful therapy with a nucleoside reverse-transcriptase inhibitor- or protease inhibitor-containing antiretroviral regimen.

We compared immune restoration in patients who suppressed human immunodeficiency virus type 1 replication after treatment with a protease inhibitor (PI) plus nevirapine or with 3 nucleoside reverse-transcriptase inhibitors (NRTIs) plus nevirapine. Changes in total and memory CD4 and CD8 cells were similar in the groups, as were decreases in immune activation (e.g., CD38 and HLA-DR) and increases in CD28 expression. Increases in naive CD4 and CD8 cells tended to be greater in the NRTI-treated group, with differences in naive CD4 cells significant at weeks 8 and 12 (P<.05) but not at week 48. Lymphocyte apoptosis decreased in both groups, but the week-1 decrease was greater in the PI-treated group (P<.02). Lymphocyte proliferation and skin-test responses were comparable. We find little evidence for differences in the major direct immunologic effect of PI versus NRTI regimens and propose that effects observed elsewhere were indirect, mediated through antiviral activity or adaptation of the virus to selection pressure.

Adult↗