Safety and Efficacy of Switching a Stable Combined Antiretroviral Therapeutic Regimen to Atazanavir With Ritonavir Plus Lamivudine in Treatment Experienced HIV Positive Patients With Full and Stable Virological Suppression (ATLAS)

This study is ongoing, but not recruiting participants.
Sponsor:
Information provided by (Responsible Party):
Simona Di Giambenedetto, Catholic University of the Sacred Heart
ClinicalTrials.gov Identifier:
NCT01599364
First received: May 14, 2012
Last updated: July 31, 2014
Last verified: July 2014

May 14, 2012
July 31, 2014
July 2011
May 2016   (final data collection date for primary outcome measure)
Proportion of patients with viral load < 50 copies/mL [ Time Frame: at week 48 ] [ Designated as safety issue: No ]
Proportion of patients with viral load < 50 copies/mL at week 48 at the intention-to-treat with switch = failure analysis
Same as current
Complete list of historical versions of study NCT01599364 on ClinicalTrials.gov Archive Site
Efficacy and the safety of atazanavir with ritonavir combined with lamivudine in treatment experienced HIV positive patients with full and stable virological suppression [ Time Frame: 48 and 96 weeks ] [ Designated as safety issue: No ]
Not Provided
Not Provided
Not Provided
 
Safety and Efficacy of Switching a Stable Combined Antiretroviral Therapeutic Regimen to Atazanavir With Ritonavir Plus Lamivudine in Treatment Experienced HIV Positive Patients With Full and Stable Virological Suppression
Safety and Efficacy of Switching a Stable Combined Antiretroviral Therapeutic Regimen to Atazanavir With Ritonavir Plus Lamivudine in Treatment Experienced HIV Positive Patients With Full and Stable Virological Suppression

The purpose of this study is to evaluate the virological efficacy of maintenance therapy with atazanavir with ritonavir combined with lamivudine in treatment experienced HIV positive patients with full and stable virological suppression.

The introduction of combined antiretroviral therapy (cART) dramatically improved the prognosis of HIV infection [1]; nowadays, virological suppression (viral load < 50 copies/mL) can be obtained in the vast majority of patients receiving cART. Nevertheless, antiretroviral drugs have short- and long-term side effects mainly regarding mitochondrial toxicity, impaired lipid and glucose metabolism, impairment of renal function and bone density and may contribute to increase the patients' cardiovascular risk.

Current treatment guidelines recommend three drug regimens with a "backbone" of 2 nucleos(t)ide reverse transcriptase inhibitors (N(t)RTIs) and a "third drug" to be chosen among non-nucleoside reverse transcriptase inhibitors (NNRTIs) and ritonavir-boosted protease inhibitors (PIr). Regimens containing less than three antiretroviral drugs are currently not recommended based on the high risk of virological failure and selection of drug resistance mutations (DRM) with previous experience of NRTI-only based approaches with the exception of boosted PIs monotherapy which is optional in patients with intolerance to NRTIs or requiring treatment simplification provided that they never experienced virological failures or admitted in exceptional circumstances.

Nevertheless, the investigation of possible new treatment paradigms remains attractive due to the high potency and low risk of selection of drug resistance mutations with PIr based therapies and the established long term toxicity of even newer and currently preferred N(t)RTIs, in particular the renal and bone toxicity of tenofovir and the debated potential association with increased cardiovascular risk of abacavir, which has been described in some cohort studies. Studies evaluating N(t)RTI-sparing treatment strategies are thus increasing in order to try to respond to the unmet medical needs of HIV-infected patients with metabolic complications and increasing risk of cardiovascular or renal diseases.

These studies will need to investigate the safety and efficacy of these alternative strategies, also evaluating their possible effects on renal function, bone mass density and risk of premature osteoporosis.

Atazanavir with ritonavir is a generally well tolerated lipid-friendly protease inhibitor with mild effects on lipid metabolism even when combined with low-dose ritonavir and is the only drug who achieved a non-significant difference in virological efficacy compared to efavirenz; like all other PIr-based regimens, failure of an atazanavir/ritonavir containing cART seems to protect against the development of drug resistance mutations to both the PI and the backbone. Lamivudine is a well tolerated NRTI which showed no significant toxicity in the short and long term and, together with its analog emtricitabine, is now a preferred option in most of the major international treatment guidelines; it has a good CNS penetration score and its only signature resistance mutation (M184V) deeply impairs the viral fitness and does not compromise the future treatment options.

The combination of these two drugs could therefore be an appealing possibility for treatment switch in stably virologically suppressed treatment-experienced patients with toxicity-related issues. The results of a previously planned 24 weeks interim analysis of a monocentric 48 weeks Italian pilot study evaluating this strategy in 40 patients has recently been presented at IAS conference in Vienna and showed no virologic failures without any "blip" and good tolerability with a significant improvement of renal function as measured by MDRD. These data look very promising and allow us to be confident in designing a randomized study in order to confirm these findings.

Interventional
Phase 4
Allocation: Randomized
Endpoint Classification: Efficacy Study
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Treatment
Human Immunodeficiency Virus
Drug: Atazanavir, ritonavir, lamivudine
Lamivudine 300 mg 1 pill once-a-day, atazanavir 300 mg 1 pill with ritonavir 100 mg 1 pill once-a-day, taken together orally with a light meal
Other Name: Lamivudine (Epivir, GSK), Atazanavir (Reyataz, BMS), Ritonavir (Norvir, Abbott)
  • Experimental: Switch
    Switch to Atazanavir 300 mg with ritonavir 100 mg plus lamivudine 300 mg
    Intervention: Drug: Atazanavir, ritonavir, lamivudine
  • No Intervention: continue
    Continue Atazanavir 300 mg with ritonavir 100 mg with the same NRTI backbone
Not Provided

*   Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
 
Active, not recruiting
266
November 2016
May 2016   (final data collection date for primary outcome measure)

Inclusion Criteria

  • HIV positive patients 18 years of age or older who signed an informed consent form
  • Already on cART, without any treatment interruption.
  • Treated with a cART regimen containing atazanavir boosted with ritonavir since at least 3 months
  • With full virological suppression (VL<50 copies/mL) for a minimum of six months and in at least in two consecutive determination 3 months +/-2 weeks apart from each other
  • With CD4 cell count >200 since at least 6 months and without opportunistic infections or other AIDS-related events since at least one year before screening

Exclusion Criteria:

  • Previous virological failure on a lamivudine- or PI-containing regimen or previous exposure to lamivudine-containing suboptimal antiretroviral regimens
  • Patients with at least a single viral load blip over 200 copies/mL
  • Patients with M184V or major atazanavir resistance mutation at previous genotypic resistance test (historical genotype)
  • Pregnancy or lactation, planned pregnancy in the short-term
  • Patients with HBsAg positive chronic HBV infection
  • Patients who experienced major toxicities related to any of the study drugs in the past
  • Patients with grade 4 laboratory abnormalities at baseline (excluding lipid profile and plasma bilirubin concentration).
  • Patients with non-AIDS related illnesses which could, in the Clinician's judgement, jeopardize the patient's compliance to the study procedures (i.e. Child-Pugh B or higher liver cirrhosis, active cancers on treatment…).
  • Patients treated with proton-pump inhibitors or other concomitant medication with potential for interactions reducing exposure to atazanavir
Both
18 Years to 80 Years
No
Contact information is only displayed when the study is recruiting subjects
Italy
 
NCT01599364
ATLAS 2, 2011-001060-21
Yes
Simona Di Giambenedetto, Catholic University of the Sacred Heart
Catholic University of the Sacred Heart
Not Provided
Study Chair: Mauro MM Moroni, MD Università di Milano Direttore clinica Malattie infettive
Study Chair: Pierluigi PZ Zoccolotti, MD Università di Roma La Sapienza Dipartimento di Psicologia
Study Chair: Stafano SV Vella, MD Dipartimento del farmaco all'Istituto Superiore della Sanità
Principal Investigator: Roberto RC Cauda, MD Università Cattolica del S. Cuore Policlinico Universitario A. Gemelli
Catholic University of the Sacred Heart
July 2014

ICMJE     Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP