Non-nucleoside reverse transcriptase inhibitors (NNRTIs) are widely used as part of combination antiretroviral therapy (ART) for infants and children, but NNRTI resistance is increasing, leading to treatment failure. This study tested the safety, tolerability, and dosing levels of etravirine (ETR), a new NNRTI.
Use of NNRTI-based regimens as initial therapy for HIV-infected children is increasing, especially in areas where newborns exposed to HIV-1 receive single-dose nevirapine (NVP) as part of prevention of mother-to-child transmission (PMTCT) regimens and/or daily NVP for prevention of transmission through breastfeeding. First-generation NNRTIs have a low genetic barrier to the development of resistance; in two of the most widely used NNRTIs, NVP and efavirenz (EFV), even a single amino acid mutation in the virus can lead to a reduction in the drug's effectiveness. Even short-term use of these NNRTIs, including only a single dose of NVP, can cause NNRTI resistance. Second-generation NNRTIs are needed as part of ARV regimens for newly diagnosed infants and children who have been exposed to single-dose NVP or who have failed their current antiretroviral (ARV) regimens. In this study, the second-generation NNRTI ETR was tested for safety, tolerability, and appropriate dosing. Children were assigned to one of three cohorts based on age: * Cohort I: At least 2 but younger than 6 years of age * Cohort II: At least 1 but younger than 2 years of age * Cohort III: At least 2 months but younger than 1 year of age Children in all three cohorts were treatment experienced, defined as being on a failing combination ARV regimen (containing at least 3 ARVs) for at least 8 weeks or having a treatment interruption of at least 4 weeks with a history of virologic failure while on a combination ARV regimen (containing at least 3 ARVs). Children received ETR together with an optimized background regimen (OBR) consisting of at least 2 active agents (a boosted protease inhibitor \[PI\] and at least 1 additional active ARV drug). OBR were based on clinical status, treatment history, resistance data, and availability of appropriate pediatric dosing and formulations. The children received an oral dose of ETR twice daily. Most children had 11 visits: at screening, entry (Day 0), Day 14 (intensive pharmacokinetic \[PK\] visit), and at Weeks 4, 8, 12, 16, 24, 32, 40, and 48. Most visits included a physical exam, giving a medical history, discussion of adherence, and blood and urine collection. The screening and intensive PK visits also included an electrocardiogram (ECG). During the intensive PK visit, the child had blood drawn approximately 7 times over 12 hours. After the Week 48 visit, children entered the long-term follow-up phase of the study and have a visit every 12 weeks for up to 5 years. These follow-up visits included giving a medical history and undergoing a physical exam and blood draw.
Study Type
INTERVENTIONAL
Allocation
NON_RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
26
ETR was administered as 25-mg scored tablets and/or 100-mg tablets swallowed whole or dispersed in an appropriate liquid vehicle following a meal. Children took the specified dose orally twice daily within 30 minutes following a meal. Dose was decided according to dosing tables in protocol.
Pediatric Perinatal HIV Clinical Trials Unit CRS
Miami, Florida, United States
Lurie Children's Hospital of Chicago (LCH) CRS
Chicago, Illinois, United States
Bronx-Lebanon Hospital Center NICHD CRS
The Bronx, New York, United States
Termination From Treatment Due to a Suspected Adverse Drug Reaction (SADR)
Number (%) of participants who discontinued treatment due to a suspected adverse drug reaction (SADR) by Cohort.
Time frame: From baseline to occurrence of event, up to Week 48.
Adverse Events (AEs) of Grade 3 or Higher Severity
Number (%) of participants who experienced a Grade 3 or higher severity adverse event through Week 48 by Cohort, with Clopper-Pearson confidence intervals.
Time frame: From baseline to occurrence of event, up to Week 48.
Death
Number (%) of deaths on study by Cohort.
Time frame: From baseline to occurrence of event, up to Week 48.
Area Under the Plasma Concentration-Time Curve Over 12 Hours of ETR
Geometric Mean (Standard Deviation) of the area under the plasma concentration-time curve over 12 hours (AUC12h) of ETR.
Time frame: Pre-dose, 1, 2, 4, 6, 9, and 12 hours post-dose measured at intensive PK visit (within 7-10 days after last dose of study drug administration)
AEs of Grade 3 or Higher Severity Judged to be at Least Possibly Attributable to the Study Medications
Number (%) of Participants with AEs of Grade 3 or higher severity judged, by the Study Team, to be at least possibly attributable to the study medications by Cohort, including Clopper-Pearson confidence intervals.
Time frame: From baseline to occurrence of event, up to Week 48.
HIV-1 RNA Virologic Failure Status at Weeks 24 and 48
Number (%) of participants with confirmed Virologic Failure, defined as: failure to suppress plasma HIV-1 RNA to fewer than 400 copies/ml and failure to achieve at least a 2-log10 reduction (from baseline) in HIV-1 RNA at Weeks 24 or 48, by Cohort, with Clopper-Pearson confidence intervals. The initial HIV-1 RNA results that met the Virologic Failure definition were each confirmed by a second result obtained within 1 to 4 weeks of the initial result obtained at Week 24 and/or 48.
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Jacobi Med. Ctr. Bronx NICHD CRS
The Bronx, New York, United States
SOM Federal University Minas Gerais Brazil NICHD CRS
Belo Horizonte, Minas Gerais, Brazil
Hospital Federal dos Servidores do Estado NICHD CRS
Rio de Janeiro, Brazil
Instituto de Puericultura e Pediatria Martagao Gesteira - UFRJ NICHD CRS
Rio de Janeiro, Brazil
Hosp. Geral De Nova Igaucu Brazil NICHD CRS
Rio de Janeiro, Brazil
Univ. of Sao Paulo Brazil NICHD CRS
São Paulo, Brazil
Wits RHI Shandukani Research Centre CRS
Johannesburg, Gauteng, South Africa
...and 1 more locations
Time frame: Baseline, Week 24, and Week 48
Treatment Discontinued Due to Toxicity or Virologic Failure
Number (%) of participants who discontinued study treatment (ETR) due to a toxicity or Virologic Failure (VF), by Cohort.
Time frame: From baseline to occurrence of event, up to Week 48.
Change in Optimized Background Regimen Due to Virologic Failure
Number (%) of participants who initiated a change in their optimized background regimen (OBR) due to virologic failure, by Cohort.
Time frame: Measured at entry and at Weeks 8, 12, 24, and 48
New Onset Opportunistic Infection (OI) or AIDS Diagnosis
Number (%) of participants with a new onset opportunistic infection (OI) or AIDS diagnosis, by Cohort.
Time frame: From baseline to occurrence of event, up to Week 48.
Decline in Absolute CD4 Percent of Greater Than 5 Percent Any Time After 12 Weeks of Therapy
Number (%) of participants with a \>5% decline in absolute CD4 percent from baseline at weeks 12, 24, and 48, by Cohort, including Clopper-Pearson confidence intervals.
Time frame: Measured at baseline and at Weeks 12, 24, and 48