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Emerging comorbidities in the setting of long- term virological suppression

Emerging comorbidities in the setting of long- term virological suppression. Antonella Castagna San Raffaele Scientific Institute , Milan. Comorbidities in HIV Infection: a tangible problem.

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Emerging comorbidities in the setting of long- term virological suppression

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  1. Emerging comorbidities in the setting of long- term virological suppression Antonella Castagna San Raffaele ScientificInstitute, Milan

  2. Comorbidities in HIV Infection: a tangible problem HIV-infected patients exhibit a worse cardiovascular risk profile after a first episode of acute coronary syndrome. Final results of long term follow up in the PACS-HIV study. F. Boccara How much do smoking, hypertension and diabetes contribute to acute coronary syndrome in HIV-infected patients relative to uninfected patients? MC Sanchez Development of a definition for Rapid Progression of renal disease in HIV-positive persons LeneRyom (Nielsen) Prevalence and risk factors of subclinical vertebral fractures in a cohort of HIV positive patients K. Luzi

  3. ARV and comorbidities • Bone Mineral Density (BMD) Analysis in Antiretroviral (ART)-Naïve Subjects Taking Lopinavir/ritonavir (LPV/r) Combined with Raltegravir (RAL) or Tenofovir/Emtricitabine (TDF/FTC) for 96 weeks in the PROGRESS Study Roula Qaqish • Raltegravir as Replacement for PI- or NNRTI-Based ART in HIV-Infected Women with Lipohypertrophy: The Women, Integrase, and Fat Accumulation Trial Jordan E. Lake

  4. Long-termimmunologicalsuppression • Comorbiditiesas a KeyIssue • Reasonsfor switching • Questions to face • Patient management

  5. ARV switches in 12% of the undetectablepatientssince 2010 Virological Suppression (years)

  6. Pooled ECHO and THRIVE Week 48 analysis:Most frequent treatment-related* grade ≥2 AEs† *Occurring in at least 2% of patients in either treatment group and excluding laboratory abnormalities reported as an AE; †Safety analyses performed using all available data, including beyond Week 48; ‡Fisher’s Exact test, predefined analysis for these AEs; ¶Fisher’s Exact test, post-hoc analysis; #Not determined because not predefined in this analysis Significantly fewer grade 3 or 4 laboratory abnormalities for RPV (11%) vs EFV (18%)1 1Cohen C, et al. XVIIIth IAC 2010; Abstract THLBB206

  7. Reasons for switching ARV

  8. Cardiovascularriskassociated with abacavir and tenofovirexposure in HIV-infectedpatients ANY CARDIOVASCULAREVENT PERIPHERAL ARTERIAL DISEASE HEARTH FAILURE CORONARY DISEASE CEREBROVASCULAR DISEASE * P values were<0.01 compared to use of other ART Choi AI. et al, AIDS 2011, 25: 1289-1298

  9. No associationof MyocardialInfarction with Abacavir use: an FDA meta-analysis Ding X, CROI 2011

  10. Long-termglucosetolerance in highlyexperiencedpatientsreceiving NRTI-sparingregimens RED (15 pts) = RAL, ETR, DRV/r REM ( 24 pts)= RAL, ETR, DRV/r Diabetes diagnoses by OGTT in 5/39 patients A.Bigoloni, abstract TUPE257 IAS 2011

  11. Percent changes in Lumbar Spine and Hip BMD for 4 Treatment Arms (substudy of ACTG A5202) McComsey GA. et al, JID 2011: 203: 1791-1801

  12. 96 weeks Bone Mineral Density (BMD) Analysis /Emtricitabine (TDF/FTC in the PROGRESS STUDY

  13. CG, male, 48 years, HIV infectionsince 1988, DRV/r+TDF/FTC • An ARV switchmay be an opportunity for the patient • Thereis a need to sign a new patientcontract

  14. Switches: questions to face • Risksinvolved in continuingexistingregimen • Risk of encountering new toxicity • Risk of virologicalfailure • Risk of resistance • Risk of viralescape in reservoirs • Rescue regimens in the case of failure • Patient management costs

  15. Management of switch Evaluate the weight of the potential comorbidity in the context of the patient’s global prognosis and the possible risk of developing other comorbidities Discuss the risks/benefits of continuing the ongoing regimen or introducing a new regimen Consider the active/proactive switch as part of the global treatment of the patient in terms of interventions and timing Explain the expected outcome, and measure the observed effect in the right manner and at the right time

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