Transcript Slide 1

Emerging Patterns of Resistance to
Integrase Inhibitors
Michael D. Miller, Robert M. Danovich, Marc Witmer, Bach-Yen
Nguyen, Hedy Teppler, Jing Zhao, Richard J.O. Barnard , and Daria
Hazuda for the HIV-1 Integrase Inhibitor Development Teams,
Protocol 004 Study Team, and BENCHMRK-1 and -2 Teams.
Merck and Co., Inc., West Point, PA
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
1
Raltegravir Resistance:
Major pathways and longitudinal analysis
 Resistance data from 5 clinical studies are generally consistent:
– 3 studies in treatment-experienced patients( Protocols 005, 018, and 019)
– 2 studies in treatment-naïve patients (Protocols 004 and 021)
 Three pathways defined by primary mutations Y143C/H/R, Q148H/K/R,
and N155H
 Secondary mutations lead to higher resistance
– If not present at VF, evolves at later time
 Q148 pathway is preferred
– Virus population can switch N155 to Q148
– When combined with secondary mutations, Q148 mutants lead to greater
resistance
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
2
Impact of polymorphisms and minority variants?
 Are baseline integrase polymorphisms associated with treatment
success or failure?
– Data from Protocol 018 (BENCHMRK 1)
 Can minority RAL RAMs be detected at baseline, and are they
associated with treatment success or failure?
– Protocol 019 (BENCHMRK 2): patients with GSS = 0
– Protocol 004: patients who received RAL monotherapy followed by
combination therapy
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
3
Are baseline integrase polymorphisms
associated with treatment success or
failure?
Data from Protocol 018
(BENCHMRK-1)
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
4
Acknowledgments
All patients who participated in BENCHMRK-1.
BENCHMRK-1 Investigators: Australia: Allworth A, Anderson J, Bloch M, Cooper DA, Hoy J, Workman C;
Belgium: Clumeck N, Colebunders R, Moutschen M; Denmark: Gerstoft J, Larsen C, Mathiesen L, Pedersen C;
France: Delfraissy JF, Dellamonica P, Katlama C, Molina JM, Raffi F, Reynes J, Vittecoq D, Yeni P; Germany:
Arasteh K, Fatkenheuer G, Jaeger H, Rockstroh J, Stoehr A; Italy: Aiuti F, Carosi G, Cauda R, Chiodo F, Di Perri G,
Filice G, Galli M, Lazzarin A,Vullo V; Peru: Castaneda M, Florez A, Mendo F, Paredes A, Salazar R, Ticona E;
Portugal: Antunes R, Diniz A, Mansinho K, Saraiva da Cunha J, Sarmento R, Teofilo E, Vera J; Spain: Arrizabalaga
J, Clotet Sala B, Domingo Pedrol P, Gatell Artigas J, Moreno Guillen S, Soriano Vazquez V; Switzerland: Hirschel
B, Opravil M; Taiwan: Lin H-H, Sheng W-H, Wang J-H; Thailand: Sungkanuparph S, Suwanagool S.
Merck Research Laboratories: M. Nessly, J. Chen, A. Rodgers, J. Zhao, X. Xu, D. Hazuda, R. Isaacs, M. Miller,
R. Danovich, R. Rhodes, B. Jackson, K. Strohmaier, P. Sklar, R. Leavitt, H. Teppler, B-Y. Nguyen.
Siemens Health Solutions: SD Pandit, H Kapur, D Sebisanovic, AJ Uzgiris
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
5
Like all HIV-1 proteins, integrase is polymorphic
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
6
Integrase polymorphisms do not significantly
affect InSTI antiviral activity in vitro
3.0
Data from Monogram Biosciences PhenoSense assay
Fold-Change IC50
2.5
2.0
1.5
1.0
0.5
0.0
All Isolates
(N = 144)
Non-B Subtype Isolates
(N = 23)
 Polymorphisms do not seem to affect RAL or EVG sensitivity in
vitro, BUT
 No data available regarding possible effect of baseline
polymorphisms on RAL treatment outcome
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
7
Do IN polymorphisms affect RAL treatment
outcome?
 Determine baseline sequences for patients enrolled in BENCHMRK-1
who received RAL + Optimized Background Therapy
– 51 patients who experienced virologic failure by week 48 (35 with RAL
resistance)
– 138 patients who did not experience virologic failure by week 48 (partial data
set)
 Determine the frequency of specific IN polymorphisms found in baseline
sequences from both populations:
– Known RAL resistance mutations (e.g., the secondary mutation T97A)
– Polymorphisms found at a frequency of >10%
– NOT AN EXHAUSTIVE LIST
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
8
Analysis of Baseline RAMs and Treatment
Outcome in BENCHMRK-1
Mutation1
% of Baseline Sequences with
specific mutation
Treatment
Treatment
Successes2
Failures3
Statistical
Significance4
Y143C/H/R
Not detected
Not detected
N/A
N155H
Not detected
Not detected
N/A
Q148H/K/R
Not detected
Not detected
N/A
L74M
Not detected
Not detected
N/A
E92Q
Not detected
Not detected
N/A
T97A
2%
2%
E138A/K
Not detected
Not detected
N/A
G140A/S
Not detected
Not detected
N/A
 Conclusions:
p=1
1 Mutations
in bold yellow are primary RAL RAMs,
others are secondary
2 Partial data: N = 138
– No primary RAMs detected at Baseline
3 Includes patients with and without RAL
– One secondary RAM detected, at baseline,
resistance at VF
no correlation
with
virologic
success/failure
© 2009 Merck & Co., Inc., Whitehouse Station, NJ 4USA. All rights reserved,
Fisher’s exact test 2-sided; N/A, not applicable 9
All polymorphisms analyzed to date (I)
Polymorphism
% of Baseline Sequences with
specific mutation
Treatment
Treatment
1
Successes
Failures2
Statistical
Significance3
E11D
22%
33%
p = 0.136
K14R
17%
18%
p=1
S17N
38%
16%
p = 0.003
R20K
17%
18%
p=1
V31I
33%
33%
p=1
S39C
10%
22%
p = 0.052
M50I
6%
20%
p = 0.009
I72V
36%
29%
p = 0.49
T97A
2%
2%
p=1
L101I
62%
69%
p = 0.496
T112I
20%
10%
p = 0. 13
T112V
14%
12%
p = 0.813
I113V
11%
10%
p=1
S119G
4%
4%1
p=1
S119P,G,R,T,A
29%
20%
p = 0.235
1Partial
data: N = 138
2Includes
patients with and
without RAL resistance at VF
3
Fisher’s exact test 2-sided
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
10
All polymorphisms analyzed to date (II)
Polymorphism
% of Baseline Sequences with
specific mutation
Treatment
Treatment
1
Successes
Failures2
Statistical
Significance3
T122I
12%
10%
p = 0.80
T124A
38%
27%
p = 0.11
T124N
11%
10%
p = 0.602
T124N/S/G/A
55%
41%
p = 0.118
T125A
40%
43%
p = 0.74
M154I
6%
8%
p = 0.737
K160Q
4%
4%
p=1
V201I
54%
57%
p = 0.536
T206S
18%
29%
p = 0.109
S230N
12%
16%
p = 0.42
L234I
14%
16%
p = 0.816
D256E
26%
12%
p = 0.048
S283G
1Partial
data: N = 138
2Includes
patients with and
without RAL resistance at VF
3 Fisher’s exact test 2-sided
20%
14%
p = 0.401
11
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
Conclusions from analysis of baseline
polymorphisms and virologic outcome
 RAL resistance-associated mutations (RAMs):
– No primary RAL RAMs (i.e., 143, 148, 155) detected at baseline
– Secondary RAL RAMs: Only T97A observed at baseline; frequency not
significantly different between patients with and without virologic failure
 25 of 28 baseline polymorphisms analyzed to date had no significant
difference in frequency between virologic failures and treatment
successes
– Frequency of S17N, M50I, and D256E were statistically different between
treatment successes and virologic failures– these need to be characterized
further
– Additional analyses needed on polymorphism frequency by subtype,
association with RAL resistance pathways
 Caveat to all analyses: numbers of patients tested are relatively small
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
12
Can minority RAL resistance variants
be detected at baseline, and are they
associated with treatment success or
failure?
Data from patients in Protocol 019
(BENCHMRK-2) with GSS = 0
See Poster #685, (Liu et al.)
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
13
Acknowledgments
All patients who participated in BENCHMRK-2.
BENCHMRK-2 Investigators: Brazil: Grinsztejn, B., Madruga, JV., Schechter, M. Canada: Baril, J-G., Loutfy,
MR., Montaner, JS., Tremblay, C., Tsoukas, CM., Vezina, S. Colombia: Cortes, JA., Mendoza, H., Velez, J.
Mexico: Quintero Perez, N., Ramos, J., Rodriguez, E. Puerto Rico: Morales-Ramirez, JO., Sepulveda, GE. US:
Aberg, J., Beatty, GW., Benson, P., Bolon, RK., Bredeek, UF., Bruno, C., Campbell, T., Campo, R., Coodley, GO.,
Corales, RB., DeJesus, E., Eron, JJ., Fessel, WJ., Fetchick, RJ., Gonzales, CJ., Hicks, C., Horberg, MA., Klein,
DB., Kozal, MJ., Kumar, PN., LaMarca, A., Lennox, JL., Lichtenstein, KA., Liporace, R., Little, SJ., Luetkemeyer, A.,
Mariuz, P., Markowitz, M., McMahon, DK., Perez, G., Pierone, G., Reichman, RC., Rhame, F., Shalit, P., Short, W.,
Skolnik, PR., Steigbigel, RT., Tedaldi, EM., Ward, DJ., Wiznia, AA., Wright, DP.
Merck Research Laboratories: M. Nessly, J. Chen, A. Rodgers, J. Zhao, X. Xu, D. Hazuda, R. Isaacs, M. Miller,
R. Danovich, R. Rhodes, B. Jackson, K. Strohmaier, P. Sklar, R. Leavitt, H. Teppler, B-Y. Nguyen.
Duke University: Jia Liu, Feng Gao, Charles Hicks, Nathan Vandergrift, Fangping Cai
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
14
Experimental approach
 Use Parallel Allele-Specific Sequencing (PASS) to quantify specific RAL
resistance-associated mutations (RAMs) present in baseline isolates
 Focus on patients in BENCHMRK-2 who took RAL and had GSS = 0
– BENCHMRK-2 had 45 RAL + OBT patients with GSS = 0
– Data obtained for 32 patients: 14 virologic failures, 18 successes (48wk
data)
 Are minority resistant variants present at baseline?
 If so, is their presence correlated with virologic failure?
 Do viruses isolated from patients after virologic failure display the same
mutations observed as minority variants at baseline?
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
15
Detection of RAL resistance mutations in patient
M010 after virologic failure (PASS method)
Green = wild-type
Red = mutant
N155H (66%)
V151I (11%)
Liu, et al., Poster
#685, CROI2009
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
16
Baseline RAL RAM detection in BENCHMRK-2 patients
with
GSS = 0of
– Minority
no correlation
with
success/failure
Frequency
Resistant
Viruses
in Each Patient
Frequency of mutations (%)
10
Liu, et al.,
Poster
#685,
CROI2009
Treatment success
Treatment failure
Average of frequency
1
0.1
0.01
0.001
Q148R
Q148K Q148H
Q148 pathway
G140S
L74M
T97A
G163R
N155 pathway
Y143C
Y143H
Y143 pathway
Mutations
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
17
Minority RAL resistance mutations at baseline generally
did not emerge after virologic failure (BENCHMRK-2
patients with GSS = 0) (Liu, et al., Poster #685, CROI2009)
Treatment
Failure
Success
PID
Viral load No. of genomes
(copies/ml)
analyzed
N155 pathway
N155H L74M
E92Q
Q148 pathway
Y143 pathway
Q148K Q148R Q148H G140S G140A
Y143R Y143C Y143H
Genotype
T97A
G163R
0
1 (0.03)
0
0
0
1 (0.03)
0
0
0
0
N155H, V151I, E157Q
1 (0.03) 4 (0.12)
0
0
0
1 (0.03)
0
0
0
0
E92Q, T97T/A, Y143Y/H, N155N/H
N155H, T97A, L74M, S230R, Y143C
M010
105,000
3,640
0
0
0
M011
172,000
3,347
0
3 (0.09)
0
M017
160,000
2,018
0
1 (0.05)
0
0
3 (0.15)
0
0
0
0
0
0
0
0
M019
8,430
408
0
0
0
0
1 (0.25)
0
0
0
0
0
0
0
0
Q148H, G140S
M020
34,300
836
0
0
0
0
0
0
0
0
0
0
0
0
0
N155N/H, Q148Q/R/H, V151V/I, G140S
M023
36,800
525
0
0
0
0
1 (0.19)
0
0
0
0
0
0
0
0
N155H, Q148H, G140S
M027
34,700
531
0
0
0
0
1 (0.19)
0
0
0
0
0
0
0
0
Q148R, G140S, D167D/N
M031
27,700
621
0
0
0
0
0
0
0
0
1 (0.16)
0
0
0
0
Q148R/H, G140S
M032
12,200
45
0
1 (2.22)
0
0
0
0
0
0
0
0
0
0
0
N155N/H, Q148Q/R, E138E/K
M034
414,000
1,644
0
0
0
0
0
0
0
0
1 (0.06)
0
0
0
0
Q148H, G140S
M035
18,900
349
0
0
0
0
0
0
0
0
0
0
0
0
0
N155N/H, Q148Q/R
M036
132,000
705
0
0
0
0
0
0
0
0
1 (0.14)
0
0
0
0
N155H, Q148H, G140S
M038
41,500
2,529
0
0
0
0
3 (0.12)
0
0
0
0
0
0
0
0
N155H, G163R
M039
109,000
1,019
0
0
0
0
1 (0.10)
0
0
0
0
0
0
0
0
N155N/H, E92E/Q
M001
152,000
1,691
0
0
0
0
2 (0.12)
0
0
0
0
0
0
0
1 (0.06)
Not done
M002
5,710
74
0
0
0
0
0
0
0
0
0
0
0
0
0
Not done
M003
4,090
6
0
0
0
0
0
0
0
0
0
0
0
0
0
Not done
M004
8,160
144
0
0
0
0
0
0
0
0
0
0
0
0
0
Not done
M006
59,900
572
0
0
0
0
1 (0.17)
0
0
0
0
0
0
0
0
Not done
M007
134,000
1,000
0
0
0
1 (0.10)
0
0
0
0
0
0
0
0
0
Not done
M009
30,400
630
0
0
0
0
0
0
0
1 (0.16)
0
0
0
0
0
Not done
M012
750,000
12,015
0
1 (0.01)
0
0
1 (0.01)
0
0
M014
241,000
978
0
0
0
0
3 (0.31)
0
0
0
1 (0.10)
0
0
0
0
Not done
M021
2,880
26
0
0
0
0
0
0
0
0
0
0
0
0
0
Not done
M022
55,000
2,402
0
2 (0.08)
0
0
0
0
0
0
0
0
0
0
0
Not done
M024
5,430
3
0
0
0
0
0
0
0
0
0
0
0
0
0
Not done
M025
99,100
1,551
0
1 (0.06)
0
0
1 (0.06)
0
0
0
1 (0.06)
0
0
0
0
Not done
M028
5,910
107
0
0
0
0
0
0
0
0
0
0
0
0
0
Not done
M029
5,490
87
0
0
0
0
0
0
0
0
0
0
0
0
0
Not done
M030
5,630
10
0
0
0
0
0
0
0
0
0
0
0
0
0
Not done
M033
66,000
492
0
0
0
0
0
0
0
0
0
0
0
0
0
Not done
M037
111,000
14
0
0
0
0
0
0
0
0
0
0
0
0
0
Not done
2 (0.02) 13 (0.11) 1 (0.01) 1 (0.01)
1 (0.01) 1 (0.01)
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
Not done
18
Conclusions from PASS study
 Primary RAL resistance mutations (Y143, N155, Q148) were very
infrequent in baseline viral isolates (<0.2% per patient) and did not
correlate with subsequent virologic failure
 Some secondary RAL resistance mutations were observed infrequently
in baseline samples
– Generally not correlated with virologic failure
– Observed some examples of minority variants becoming more prevalent
after virologic failure
 See poster by Liu, et al. (Poster #685) for complete story
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
19
Can minority RAL resistance variants
be detected at baseline, and are they
associated with treatment success or
failure?
Data from patients in Protocol 004
who received RAL monotherapy
followed by combination therapy
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
20
Acknowledgments
All patients who participated in PN004
Merck
PN004 Investigators
D. Baker
Australia
J. Santana-Bagur
Puerto Rico
H. Teppler
M. Bloch
Australia
S. Brown
USA
B.-Y. Nguyen
N. Bodsworth
Australia
C. Crumpacker
USA
R. Isaacs
D. Cooper
Australia
C. Hicks
USA
J. Zhao
C. Workman
Australia
P. Kumar
USA
H. Wan
C. Kovacs
Canada
K. Lichtenstein
USA
J. Chen
C Tsoukas
Canada
R. Liporace
USA
L. Gilde
A. Afani
Chile
S. Little
USA
L. Wenning
J. Perez
Chile
M. Markowitz
USA
M. Miller
J. Cortes
Colombia
R. Schwartz
USA
D. Hazuda
G. Prada
Colombia
R. Steigbigel
USA
J. Vacca
E. Gotuzzo
Peru
K. Tashima
USA
M. Rowley
F. Mendo
Peru
W. Ratanasuwan
Thailand
V. Summa
J. Morales-Ramirez
Puerto Rico
S. Thitivichianlert
Thailand
M. Iwamoto
Special thanks to B. Taillon, B. Simen, L. Blake, and E. St John.
(Roche/454
for 454
sequence
© 2009 Merck Life
& Co.,Sciences)
Inc., Whitehouse
Station,
NJ USA. analyses
All rights reserved,
21
Protocol 004: Study Design
Interim analysis of Part I before initiating Part II
Part I
Part II
Integrase Monotherapy for 10 days
Combination Therapy
~ 8pts
~ 30 pts
MK-0518 600mg bid
MK-0518 600mg bid + TFV*/3TC
Total
~ 38 pts
~ 30 pts
~ 8pts
~ 8pts
~ 8pts
~ 8pts
MK-0518 400mg bid
MK-0518 400mg bid+ TFV* /3TC
~ 30 pts
MK-0518 200mg bid
MK-0518 200mg bid+ TFV*/ 3TC
~ 30 pts
MK-0518 100mg bid
MK-0518 100mg bid + TFV*/3TC
~ 38 pts
~ 38 pts
~ 38 pts
~ 30 pts
MK-0518 placebo bid
Part I cohort Rx-naïve pts
stratified and randomized
to Integrase monotherapy
or placebo for 10 days
Efavirenz 600mg**
+ TFV*/3TC
~ 38 pts
Part II cohort Rx-naïve pts
stratified and randomized to
combination therapy for 48
weeks
*TFV = tenofovir
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
22
Percent of Patients with
HIV RNA <50 copies/mL
Protocol 004 – 96 weeks
Percent of Patients (95% CI) With HIV RNA <50 Copies/mL
[Non-Completer=Failure]
100
80
60
40
20
0
0 4 8
16
24
Number of Contributing Patients
Raltegravir 100 mg b.i.d.
Raltegravir 200 mg b.i.d.
Raltegravir 400 mg b.i.d.
Raltegravir 600 mg b.i.d.
Efavirenz 600 mg q.d.
39
40
41
40
38
39
40
41
40
37
32
40
48
W eek
39
40
41
40
38
60
72
84
96
160
160
159
160
38
38
38
38
m518p4 r50 7Manu_ July 17, 2008
*After Week 48 patients in all RAL groups continued at 400 mg b.i.d.
All patients received TDF/3TC
Markowitz, et al., 2008,
AIDS2008,
Abstract #TUAB010223
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA.
All rights reserved,
Change from Baseline
in HIV RNA (Log10 copies/mL)
Change From Baseline in Log10 HIV RNA (95% CI)†
(Protocol 004) (Cohort 1; Monotherapy Phase)
1
0
-1
-2
-3
1
2
3
4
5
8
10
7
7
6
8
7
7
7
6
8
7
Day
Number of Contributing Patients
Raltegravir
Raltegravir
Raltegravir
Raltegravir
Placebo
†
Data as observed.
100 mg BID
200 mg BID
400 mg BID
600 mg BID
7
7
6
8
7
7
7
6
8
7
7
7
6
8
7
7
7
6
8
7
5
6
6
7
4
HIV RNA  of 1.7 – 2.2 log10m518p4
copies/mL
RNA10C1 Aug. 7, 2007
(Markowitz et al., 2006 JAIDS 43:509)
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
24
Resistance analysis of patients enrolled in PN004
part I (RAL monotherapy): Ultradeep sequencing
 Ultradeep sequencing (454 technology) used to detect emergence of
low-level RAL resistance mutations before, during and after therapy
 Focused on patients in 100mg and 200mg arms who later enrolled in
part 2: samples available for 9 of 15 patients in these arms
1. Baseline sample (pre-monotherapy)
2. On-therapy sample – balance need for viral suppression (selective
pressure) and need for sufficient virus to obtain meaningful diversity
– VL reduction from baseline: Mean = 1.4 log10; Range = 0.6 to 2.79 log10
– VL at time of testing: Geo Mean = 1912; Range = 364 to 12,700
3. Baseline sample (pre-combination therapy) –
– Time off RAL: Mean = 104 days; Range = 49 to 168 days
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
25
RAL RAMs detected by Ultradeep (454) sequencing in 9
patients receiving RAL monotherapy (100mg or 200mg
bid) in PN004
 RAMs not detected in any sample (LOD = 0.4%):
– N155H, Q148H, Q148K, Y143R, Y143C, L74M, E92Q, E138A, G140A
 RAMs detected in BL samples:
– Secondary mutation E138K in 1 patient (1.83% of sequences)
– Secondary mutation S230R in 1 patient (3.16% of sequences)
 RAMs detected on therapy:
– Primary RAM Q148R detected in 1 patient (0.4% at day 10; VL = 364)
– Secondary RAM G140S detected in 1 patient (3.04% at day 5; VL = 3460)
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
26
Results of Ultradeep (454) sequencing in 10 patients
receiving RAL monotherapy (100mg or 200mg bid) in PN004
% of sequences with this mutation:
PATIENT Rx Group PART 2 FATE
A
200mg
Success
B
200mg
Success
C
200mg
Success
D
100mg
Success
E
100mg
Success
F
100mg
Success
G
100mg
Success
H
100mg
Success
I
200mg
Success
TIME POINT
Baseline
On monotherapy
Pre-Part 2 baseline
Baseline
On monotherapy
Pre-Part 2 baseline
Baseline
On monotherapy
Pre-Part 2 baseline
Baseline
On monotherapy
Pre-Part 2 baseline
Baseline
On monotherapy
Pre-Part 2 baseline
Baseline
On monotherapy
Pre-Part 2 baseline
Baseline
On monotherapy
Pre-Part 2 baseline
Baseline
On monotherapy
Pre-Part 2 baseline
Baseline
On monotherapy
Pre-Part 2 baseline
T97A
E138K
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
4.74
0
0
0
0
0
0
0
0
0
0
0
0
1.83
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
G140S
0
0
0
0
0
0
0
3.04
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Y143H
Q148R
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
V151I
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.4
0
0
0
0
0
0
0
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
S230R
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
3.16
0
0
0
0
0
0
0
0
27
Disposition of patients who participated in PN004
Part I (10d monotherapy) at 96wks
PN004
Part 1 (N = 35)
Part 1
Enrollment
Placebo
N=7
RAL 100mg bid
N=7
RAL 200mg bid
N=7
RAL 400mg bid
N=6
RAL 600mg bid
N=8
Part 2
Enrollment
(N = 29)
EFV
+ 3TC + TDF
N=4
RAL 100mg bid
+ 3TC + TDF
N=6
RAL 200mg bid
+ 3TC + TDF
N=7
RAL 400mg bid
+ 3TC + TDF
N=6
RAL 600mg bid
+ 3TC + TDF
N=6
Part 2
Disposition
VF: 0/4
Discon: 0/4
VF: 0/6
Discon: 1‡/6
VF: 1†/7
Discon: 1‡/7
VF: 0/6
Discon: 2║/6
VF: 0/6
Discon: 1‡/6
†No
resistance to RAL, 3TC, or TDF at virologic failure (VF between 48 and 96 weeks)
load <50 copies/ml at discontinuation (4 patients) – all d/c’d between 48 and 96 weeks
║Discontinued after 2 weeks of combination therapy (1 patient)
‡Viral
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28
PN004 monotherapy conclusions
 24 of 25 patients who received 10d RAL monotherapy were treatment
successes after 48 weeks of RAL+TDF+3TC combination therapy
– The 1 patient with VF had NO resistance to RAL, TDF, or 3TC at VF
– Low-level primary RAL resistance mutations appearing during PN004
monotherapy were rare (ultradeep sequencing) and did not result in virologic
failure during the combination therapy phase.
– 1 patient selected Y143H during monotherapy, but did not enroll in part 2
 RAL monotherapy did not reduce chance of treatment success
 Different from NNRTI monotherapy study (DMP-266-003, cohort 1;
Bacheler, et al., 2000, Antimicrob Agents Chemother. 44(9):2475-84)
– EFV resistance detected in 11 of 16 patients after 2 weeks of EFV
monotherapy
– Higher failure rate among patients who received EFV monotherapy
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
29
Summary
 Polymorphisms
– 25 of 28 baseline polymorphisms analyzed to date had no significant
difference in frequency between virologic failures and treatment successes
(exceptions: S17N, M50I, and D256E)--Further data needed to confirm
 Minority variants
– Primary RAL RAMs were detected at exceedingly low frequencies in
baseline samples: None detected by 454 sequencing (LOQ = 0.4%),
frequencies of <0.2% were detected by PASS
– Primary RAL RAMs detected by PASS at baseline did not emerge in any
patients who experienced virologic failure
– RAL resistance mutations appearing during PN004 monotherapy were rare,
occurred at low levels, and did not result in virologic failure during the
combination therapy phase.
© 2009 Merck & Co., Inc., Whitehouse Station, NJ USA. All rights reserved,
30