doi:10.1093/jac/dkn471
Advance Access publication 25 November 2008
Received 21 July 2008; returned 11 September 2008; revised 14 October 2008; accepted 18 October 2008
Background: The combination of one non-nucleoside reverse transcriptase inhibitor (NNRTI) with two
nucleoside reverse transcriptase inhibitors is a validated first-line antiretroviral (ARV) therapy. The
once-daily combination of lamivudine, tenofovirDF and nevirapine has not been evaluated in a clinical
trial.
Methods: Randomized, open-label, multicentre, non-inferiority trial comparing lamivudine, tenofovirDF
and nevirapine once daily (Group 2) with zidovudine/lamivudine and nevirapine twice daily (Group 1),
in naive HIV-1-infected patients with a CD4 count <350/mm3. We planned to enrol 250 patients.
Results: As of May 2006, 71 patients had been enrolled (35 in Group 1 and 36 in Group 2) and an
unplanned interim analysis was done. The groups were comparable at baseline: median CD4 count
was 195 and 191/mm3 and median plasma viral load was 4.9 log10 and 5.01 log10, respectively, in
Groups 1 and 2. Eight early non-responses (22.2%) were observed, all in Group 2, while two later viral
rebounds occurred. Resistance genotypes for the nine Group 2 failing patients showed the mutations
M184V/I (n 5 3), K65R (n 5 6), one or more NNRTI resistance mutations in all cases. At baseline, the
nine Group 2 patients who failed had higher median plasma viral load (5.4 log10) and lower median
CD4 count (110/mm3) than the other Group 2 patients (4.7 log10, P 5 0.002 and 223/mm3, P 5 0.004).
Nevirapine trough concentrations were not different between the two groups, nor between patients
with full viral suppression or those who failed in Group 2. Due to slow recruitment, and those results,
the steering committee decided to stop the trial at 12 months.
Conclusions: In ARV-naive HIV-1-infected patients, the once-daily lamivudine, tenofovirDF and nevira-
pine regimen resulted in a high rate of early virological failures. The reasons for the failures remain
unclear.
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*Corresponding author. COREVIH, Clinique Médicale A, Hôpitaux Universitaires, 1 place de l’Hôpital, 67091 Strasbourg Cedex, France.
Tel: þ33-3-88-11-63-33; Fax: þ33-3-88-11-64-51; E-mail: david.rey@chru-strasbourg.fr
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Early virological failure with once-daily tenofovir/lamivudine/nevirapine
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Genotypic analysis
Endpoints and statistical analysis Table 2 shows drug resistance mutation results, viral load
The primary endpoint was the proportion of patients with HIV RNA change and viral subtype in the 10 patients who experienced vir-
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Early virological failure with once-daily tenofovir/lamivudine/nevirapine
Excluded (n = 21)
Figure 1. CONSORT flow diagram. ZDV, zidovudine; 3TC, lamivudine; NVP, nevirapine; TDF, tenofovirDF.
week 12 (Figure 4). Comparison of nevirapine plasma concen- There was no significant difference at week 8: 15/22 (68%) and
trations, restricted to these 24 patients, was also not different 20/26 (77%) adherent subjects in Groups 1 and 2, respectively
(data not shown). (P ¼ 0.53). The only difference was seen after 24 weeks of treat-
ment, with a higher number of adherent patients on once-a-day
Safety treatment (13/18¼72%) compared with twice-a-day treatment
(4/13 ¼ 31%, P ¼ 0.03). Due to premature study discontinu-
Grade 3 or 4 adverse events, leading to study discontinuation,
ation, next visits were not analysed.
were more frequent in Group 1 compared with Group 2, with
10 and 6 subjects, respectively. Hepatic or cutaneous toxicity
was similar in the two groups: two grade 3 or 4 transaminase
increases in each group, and three and four skin rashes in Discussion
Groups 1 and 2, respectively. The difference was mainly due
to zidovudine-related anaemia (four in Group 1 versus none This randomized, multicentre study showed a high rate of early
in Group 2). virological failures with a once-daily combination of lamivu-
dine, tenofovirDF and nevirapine, in ARV-naive HIV-infected
patients, while the validated comparator (twice-daily combi-
Adherence nation of zidovudine/lamivudine and nevirapine) induced a viro-
At week 4 of treatment, 16/27 (59%) patients were adherent in logical response rate in the expected range. Moreover, the
Group 1, compared with 22/31 (71%) in Group 2 (P ¼ 0.41). broad-spectrum resistance profile, to both NNRTIs and NRTIs,
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Rey et al.
Group 1 (ZDV/3TC þ NVP, twice daily) Group 2 (3TC þ TDF þ NVP, once daily) P
n 35 36
Mean age, years (range) 41.2 (24–56) 41.6 (25–74) 0.87
Sex, males/females 25/10 28/8 0.53
CDC classification, A/B/C 26/6/3 25/8/3 0.86
HIV risk group, MSM/hetero/IVDU/other 9/19/1/6 13/17/0/6 0.86
3
Median CD4/mm (range) 195 (13–464) 191 (9– 373) 0.55
3
CD4 ,200/mm 18/35 (51%) 20/36 (56%) 0.85
Median HIV RNA, copies/mL (range) 86 492 (3973–1 793 938) 103 062 (865 –6 844 820) 0.20
HIV RNA 5 log10 15/35 (43%) 18/36 (50%) 0.25
which was selected, was cause for concern. These results were NNRTI therapy in subtype C viruses.27 A rapid selection
highly unexpected. of K65R has also been described in subtype C following
To our knowledge, the DAUFIN study is the first to show such tenofovirDF treatment,28 but only in vitro, and has not been
a high and early proportion of failures, with this once-a-day found in vivo.29 As 67% of the patients who failed in Group 1
regimen. However, Towner et al.21 showed comparable results in of the DAUFIN study were infected with a B subtype, it is
a small group of 23 ARV-naive patients, in a study only presented highly unlikely to be the explanation of the high rate of virologi-
in a meeting: seven virological failures (30%) occurred, five of cal failures.
whom developed the Y181C mutation. More recently, an Italian From a pharmacokinetic standpoint, nevirapine trough
study22 also showed a high rate of early viral failures (3/7) with plasma concentrations of 4 mg/L or higher are accepted as
tenofovirDF/emtricitabine once a day combined with nevirapine appropriate for wild-type viruses.4,30 In this study, mean nevira-
twice a day. All three patients developed NNRTI mutations, pine trough concentrations were above the 4 mg/L threshold in
including Y181C, plus M184V (n ¼ 2) and K65R (n ¼ 1). both groups and not significantly different between the two
Thus, two studies recently showed similar poor outcomes groups. Moreover, nevirapine concentrations were not lower in
with nevirapine þ tenofovirDF and lamivudine or emtricitabine, subjects who failed than in those with full viral suppression of
as reported in our trial. Although the reasons for the high rate of the same once daily group. In conclusion, underexposure to
virological failure of this once-daily regimen are unclear, several nevirapine is very unlikely to explain our findings.
potential hypotheses may be considered: pre-existing resistance The expected tenofovir trough plasma concentration following
mutations, high baseline viral load, non-B subtypes, underexpo- tenofovirDF 300 mg once daily is 66 ng/mL.31 This concentration
sure to one of the studied drugs and, lastly, poor adherence was reached in our Group 2 patients and, although lower in
despite a simplified regimen. patients who failed, the concentrations were not significantly
Regarding the first hypothesis, only one patient harboured a different when compared with subjects with viral suppression.
pre-existent mutation (K101E). One could hypothesize that some Analysis of variance for repeated measures was used for this
of these patients had archived NNRTI-resistant viruses, non- analysis, which has a strong power (a patient is withdrawn
detectable with standard genotyping, but even with a small from analysis when a single measure is lacking). As for nevira-
number of patients, this should also have occurred in the other pine, no underexposure to tenofovirDF was identified.
group. Also, global adherence could appear to be low in our study,
In our study, the only significant differences shown in failing as 77% was the best result achieved. Mean adherence to treat-
subjects, compared with those with success, were a higher base- ment, for example, was better in the 934 trial with efavirenz:32
line viral load, as well as lower initial CD4 cell counts. The 90% among patients receiving tenofovirDF þ emtricitabine and
same observation was made by Lapadula et al.22 It has already efavirenz, and 87% among those receiving zidovudine/lamivu-
been shown that such factors (HIV RNA .100 000 copies/mL, dine and efavirenz (P ¼ 0.04 in favour of the once-daily combi-
and CD4 ,200/mm3) are strong predictors of clinical evolution nation), but adherence was assessed on the basis of pill counts at
to AIDS or death,23 and more recently of increased risk of viro- each visit, and potential variation from visit to visit was not indi-
logical failure with both efavirenz and nevirapine in the 2NN cated. In addition, we used a very strict definition for good
study.24 adherence, as a patient was considered to be non-adherent if a
Virological response to the first-line ARV therapy is thought single question, out of four, identified suboptimal adherence. It
to be not significantly different for B and non-B subtypes.25,26 has also been shown that ,95% adherence to NNRTI therapy
However, the V106M mutation may be selected following (but .75%) could lead to viral suppression.33 Even if some of
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Early virological failure with once-daily tenofovir/lamivudine/nevirapine
Table 2. Viral subtype, drug resistance mutations (GT) and viral load (VL) change on study treatment, in 10 patients who failed
Group 2
1 (B) VL 5.9 2.7 3.7
GT K101E K101E þ K101E þ
G190G/A Y181Y/C þ
G190G/A þ
M184M/I þ
K65R
2 (B) VL 6.8 6.4 6.5
GT WT Y181Y/C þ
G190G/A þ
M184M/V
3 (B) VL 5.8 3.4 4.8
GT WT Y181Y/C K103N þ
WT, wild-type.
a
Treatment interruption at week 8.
the failures observed in our study clearly appeared to be the con- compared with twice-a-day intake. The 2NN trial showed higher
sequence of poor adherence (complete lack of viral load hepatic toxicity with nevirapine once a day, compared with a
decrease in three subjects), it is highly unlikely that suboptimal twice-a-day regimen,13 but in the NEFA study,34 patients with
adherence difficulties would solely explain our results (as no high CD4 cell counts were switched to a nevirapine-containing
differences were observed between the two groups). regimen without hepatotoxicity increase.
Once-a-day nevirapine appeared to be rather safe, at least as The main limitation of the DAUFIN trial is the small number
well tolerated as twice-a-day administration. In the DAUFIN of patients. It has been claimed that some of our results could be
study, we did not observe more cutaneous or hepatic side effects attributable to chance, and there were criticisms relating to
385
Rey et al.
Table 3. Comparison of mean nevirapine trough (12 or 24 h) Table 4. Comparison of nevirapine trough plasma concentrations
plasma concentrations (mg/L) between treatment arms (mg/L) in Group 2 patients
Group 1 (n) 4.22 (29) 6.27 (27) 5.79 (19) 6.99 (17) 5.69 (14) Patients with full viral 3.39 (23) 4.73 (24) 4.48 (21) 4.44 (17)
suppression (n)
Group 2 (n) 3.43 (31) 4.49 (32) 4.40 (28) 4.45 (20) 3.99 (13)
Patients who failed (n) 3.53 (8) 3.76 (8) 4.16 (7) 4.5 (3)
P 0.31 0.13 0.25 0.12 0.19
P 0.9 0.27 0.74 0.97
Group
1 2
12
Week 2 Week 4 Week 12 Week 24 Week 36 Week 2 Week 4 Week 12 Week 24 Week 36
Figure 2. Comparison of nevirapine (NVP) trough concentrations between treatment arms using box-plot (variability around the median).
Failure
0 1
12
10
NVP concentration (mg/L), Group 2
Figure 3. Comparison of nevirapine (NVP) trough concentrations between patients with viral suppression (0) and those who failed (1) in Group 2, using
box-plot (variability around the median).
386
Early virological failure with once-daily tenofovir/lamivudine/nevirapine
Failure
0 1
125
TFV concentration (ng/mL)
100
75
50
25
Figure 4. Comparison of tenofovir (TFV) trough concentrations between patients with viral suppression (0) and those who failed (1) in Group 2, using
pharmacological (low nevirapine plasma trough concentrations) C. Jacomet (CHU Clermont-Ferrand), N. Plaisance (CH
or virological (non-B subtypes) grounds.35 We have ruled these Colmar), A. Devidas (CH Corbeil-Essones), M. Duong,
out as discussed earlier. We acknowledge that we were far from P. Chavanet (CHU Dijon), P. Del Giudice (CH Fréjus
the initial enrolment goal, and we had neither planned an Saint-Raphaël), E. Brottier-Mancini (CH La Rochelle), L. Cotte
interim analysis nor predefined criteria for study cessation. (Hôtel Dieu, Lyon), J. M. Livrozet (Hôpital Edouard Herriot,
However, the steering committee unanimously decided to stop Lyon), I. Ravaux (CHU Marseille), L. Fournier (CH Melun),
the trial, and we strongly think that continuing the trial would B. Christian (CH Metz), J. M. Jobard (CH Montbéliard),
have been unethical. Actually, the failures we observed were C. Allavena, V. Reliquet-Guesnier (CHU Nantes), J. C. Lebas
associated with mutations that dramatically reduced the remain- de Lacour (Nevers), M. A. Serini, J. Durant (Maladies
ing therapeutic options. Infectieuses, CHU Nice), E. Rosenthal (Médecine Interne, CHU
In conclusion, the DAUFIN trial showed an unexpected and Nice), T. Prazuck (CH Orléans), A. Simon (Hôpital La Pitié
high rate of early virological failures in patients treated with Salpétrière, Paris), M. Diemer (Hôpital Lariboisière, Paris),
tenofovirDF þ lamivudine and nevirapine once daily, with a C. Pintado (Hôpital St-Louis, Paris), M. T. Goeger-Sow (CHU
high incidence of resistance mutations to NNRTIs, and K65R Pointe à Pitre, Guadeloupe), Y. Welker (CHI Poissy
conferring broad cross-resistance to nucleoside analogues. At Saint-Germain en Laye), G. Le Moal (CHU Poitiers), I. Rouger
baseline, failing patients had higher viral loads and lower CD4 (CHU Reims), C. Gaud (Saint-Denis, La Réunion), P. Poubeau
cell counts than subjects with success. But adherence to treat- (Saint-Pierre, La Réunion), V. Nasser (CH Saint-Laurent du
ment was similar in the two groups and we failed to identify any Maroni, Guyanne), F. Bissuel (Saint-Martin), D. Rey, J. M. Lang
pharmacological explanation for virological failures. Whatever (COREVIH, Hôpitaux Universitaires Strasbourg), H. Lalanne
the mechanism that led to the high viral failure rate, we deem it (Immunologie Clinique, Hôpitaux Universitaires Strasbourg),
essential to alert that the once-daily combination of tenofovirDF, J. Pouaha (CH Thionville), T. May (CHU Vandoeuvre), O. Patey
lamivudine and nevirapine should not be given as a first-line (CH Intercommunal Villeneuve St Georges).
ARV therapy.
Funding
Acknowledgements The study was financially supported by Boehringer-Ingelheim.
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