| Clinical Use|
Raltegravir must be used in combination with other antiretroviral medications.
| Use in Initial vs Subsequent Therapy|
Current adult and adolescent treatment guidelines of the U.S. Department of Health and Human Services state that the combination of raltegravir plus tenofovir/emtricitabine is a "preferred" regimen for initial treatment of HIV infection, and raltegravir plus abacavir/lamivudine is an "alternative" regimen.
In initial therapy, a randomized double-blind noninferiority comparison of raltegravir and efavirenz, each in combination with tenofovir + emtricitabine, found similar rates of virologic suppression to <50 copies/mL at 48 weeks: 86% in the raltegravir arm and 82% in the efavirenz group.(2) CD4 increases also were similar in the two groups: 189 cells/µL and 163 cells/µL, respectively.
In treatment-naive individuals, raltegravir was compared with darunavir + ritonavir and with atazanavir + ritonavir; each was given in combination with tenofovir/emtricitabine. At week 96 (the primary endpoint), by intention to treat (snapshot) analysis, the rate of virologic suppression to <50 copies/mL was 80% in the raltegravir group, 73% in the darunavir + ritonavir group, and 63% in the atazanavir + ritonavir group; the difference with each comparator was statistically significant. The differences in efficacy were driven primarily by higher rates of adverse effects in the comparator groups. Mean increases in CD4 cell counts were similar in all treatment groups.(3)
Also in initial therapy, a randomized double-blind study compared raltegravir and dolutegravir, each given in combination with investigator-selected nucleoside analogues, either tenofovir + emtricitabine or abacavir + lamivudine. At 48 weeks, by snapshot analysis, 85% of the raltegravir group and 88% of the dolutegravir group achieved HIV RNA suppression to <50 copies/mL; this difference was not statistically significant. In subjects with HIV RNA >100,000 copies/mL at baseline, HIV RNA suppression rates were 75% and 82%, respectively. The median CD4 increase was 230 cells/µL in each group.(4)
In treatment-experienced patients with resistance to at least 2 classes of antiretrovirals but no previous exposure to integrase inhibitors, a randomized controlled study compared raltegravir and dolutegravir (50 mg once daily) each in combination with other antiretrovirals as selected by investigators (background regimens were required to include at least 1 agent with full activity against HIV). At 48 weeks, higher rates of virologic failure were seen in the raltegravir group: 64% of patients in the raltegravir group and 71% of patients in the dolutegravir group had HIV RNA levels of <50 copies/mL (p = .03). Mean CD4 count increases were 153 and 162 cells/µL cells/µL, respectively.(5)
In treatment-experienced patients with resistance to 3 classes of antiretrovirals (nucleoside analogues, nonnucleoside reverse transcriptase inhibitors, and protease inhibitors) and ongoing viral replication, 2 Phase III studies (described above in "Approval") compared raltegravir with placebo, each given in combination with an optimized background regimen. In combined analysis, the groups that received raltegravir had higher rates of virologic suppression at 24 and 48 weeks than the groups that received placebo (at 48 weeks, HIV RNA was <400 copies/mL in 73% of raltegravir recipients vs 37% of placebo recipients, and <50 copies/mL in 62% vs 33%, respectively).(1) These differences were statistically significant (p < .001). Virologic suppression was closely correlated with having at least 1 active agent in the background antiretroviral regimen, and the inclusion of enfuvirtide or darunavir in the regimen of those without previous exposure to these drugs substantially improved the rates of virologic response. In the raltegravir treatment groups, the mean increase in CD4 count was higher than in the placebo group (109 cells/µL vs 45 cells/µL at 48 weeks; p < .001).(1,6)
A smaller Phase II randomized controlled trial, also involving patients with advanced HIV disease, extensive treatment experience, and resistance to at least 1 agent in each of 3 classes, compared 3 dosages of raltegravir (200 mg, 400 mg, and 600 mg, administered twice daily) with placebo. All participants were also given an optimized background regimen (tipranavir and darunavir were not available for use). At 24 weeks, by intention-to-treat analysis, the proportion of patients with HIV RNA levels of <50 copies/mL was 56-67% in the raltegravir groups and 13% in the placebo group (p < .0001 for comparison of each raltegravir dose with placebo). All participants were continued on open-label raltegravir (at the 400 mg twice daily dosage) to 48 weeks; at this time point, the proportion with HIV RNA levels of <50 copies/mL was 46-64%. As in the Phase III studies, the presence of other active antiretroviral agents (including enfuvirtide) in the background regimen substantially increased the rates of virologic suppression. The raltegravir groups had greater increases in CD4 cell counts at 24 weeks (60-102 cells/µL) than the placebo group (8 cells/µL).(7,8)
| Potential Adverse Effects|
Symptomatic adverse effects of raltegravir are uncommon but include nausea, headache, fatigue, and muscle aches. Rash and hypersensitivity reactions have been reported. Laboratory abnormalities include increases in pancreatic amylase and hepatic transaminase levels.(6,7,9) In one study, raltegravir caused less adverse impact on lipid levels and on bone mineral density than did atazanavir + ritonavir or darunavir + ritonavir.(3)
It is important to assess patient motivation and discuss possible adverse effects and strategies for their management before treatment with raltegravir is initiated.
Raltegravir has not been studied extensively in pregnant women; it is classified as an FDA Pregnancy Category C drug.
| Interactions with Other Drugs|
Raltegravir interacts with several medications, including other antiretroviral agents. Raltegravir does not interact with the hepatic cytochrome P450 enzyme system. It is metabolized primarily by glucuronidation, particularly by uridine diphosphate glucuronosyltransferase (UGT) 1A1. Inducers or inhibitors of UGT 1A1 may affect serum levels of raltegravir. For example, rifampin induces raltegravir glucuronidation and substantially decreases raltegravir concentrations; the dosage of raltegravir must be increased if given concomitantly with rifampin. The nonnucleoside analogues efavirenz and etravirine and the protease inhibitor combination of tipranavir + ritonavir also lower raltegravir concentrations by this mechanism; however, the therapeutic significance of these interactions has not been defined. Other strong UGT 1A1 inducers such as phenobarbital and phenytoin have not been studied in combination with raltegravir.(6,10)
Inhibitors of UGT 1A1, including atazanavir, may increase raltegravir levels; the interaction with atazanavir does not appear to be clinically significant.(6)
Divalent cations (such as magnesium, calcium, and iron) may bind integrase inhibitors and interfere with their absorption and activity. Administration of an antacid containing aluminum and/or magnesium hydroxide with raltegravir or within 2 hours before or after raltegravir can reduce plasma raltegravir levels by 50%; these agents should not be taken within 2 hours of raltegravir. Simultaneous administration of calcium carbonate antacid with raltegravir results in 30% reduction in raltegravir trough levels, but dosage adjustment is not currently recommended. Proton pump inhibitors and H2 receptor antagonists do not affect raltegravir concentrations.(6)
Information on drug interactions should be consulted, as dosage adjustments are frequently required and some combinations are contraindicated.
Resistance to raltegravir is associated with the selection of 1 or more of several resistance mutations; however, the resistance profile of raltegravir in human subjects has not been characterized fully. In vitro and in vivo studies of raltegravir show the emergence of a number of integrase mutations. In the clinical data currently available, three main genetic pathways to resistance have been identified. These involve Y143C/H/R plus additional mutations (L74M, T97A, G163R, S230R), Q148H/K/R plus additional mutations (E138K, G140A/S), or N155H plus additional mutations (L74M, T92Q, T97A, V151I, G163R). Increasing numbers of these mutations, as well as specific combinations, appear to be associated with greater degrees of reduced susceptibility to raltegravir and to other integrase inhibitors.(9,11)
In studies of initial therapy, emergent resistance to raltegravir also usually involved development of the reverse transcriptase mutations M184I or M184V (which confer resistance to lamivudine and emtricitabine), with or without mutations related to other components of the antiretroviral regimen.
| Implications of raltegravir resistance for treatment with other antiretrovirals|
Resistance mutations selected by raltegravir may confer resistance to other integrase inhibitors. Raltegravir-resistant HIV strains generally exhibit cross-resistance to elvitegravir.(12,13,14) The efficacy of dolutegravir may be sharply reduced by certain mutations, notably by Q148H/R in conjunction with 1 or more other integrase inhibitor mutations.(15,16)
Raltegravir mutations are not expected to affect sensitivity to other classes of antiretroviral agents.
| Implications of resistance to other antiretrovirals for raltegravir treatment|
Resistance mutations selected by other integrase inhibitors may contribute to raltegravir resistance; cross-resistance with elvitegravir is common, and cross-resistance with dolutegravir is likely.(13,14) Additional data from studies of integrase inhibitors will be needed to define resistance in this class of medications.
Resistance mutations selected by other classes of antiretrovirals are not expected to contribute to raltegravir resistance.
|| || Steigbigel RT, Cooper DA, Kumar PN, et al; BENCMRK Study Teams. Raltegravir with optimized background therapy for resistant HIV-1 infection. N Engl J Med. 2008 Jul 24;359(4):339-54.|
|| || Lennox JL, DeJesus E, Lazzarin A, et al; STARTMRK investigators. Safety and efficacy of raltegravir-based versus efavirenz-based combination therapy in treatment-naive patients with HIV-1 infection: a multicentre, double-blind randomised controlled trial. Lancet. 2009 Sep 5;374(9692):796-806.|
|| ||Landovitz RJ, Ribaudo HJ, Ofotokun I, et al. Efficacy and tolerability of atazanvir, raltegravir, or darunavir with FTC/Tenofovir: ACTG 5257. In: Program and abstracts of the 21st Conference on Retroviruses and Opportunistic Infections; March 3-6, 2014; Boston. Abstract 85.|
|| || Raffi F, Rachlis A, Stellbrink HJ, et al; SPRING-2 Study Group. Once-daily dolutegravir versus raltegravir in antiretroviral-naive adults with HIV-1 infection: 48 week results from the randomised, double-blind, non-inferiority SPRING-2 study. Lancet. 2013 Mar 2;381(9868):735-43.|
|| || Cahn P, Pozniak AL, Mingrone H, et al; SAILING Study Team. Dolutegravir versus raltegravir in antiretroviral-experienced, integrase-inhibitor-naive adults with HIV: week 48 results from the randomised, double-blind, non-inferiority SAILING study. Lancet. 2013 Aug 24;382(9893):700-8.|
|| ||Isentress Prescribing Information. Whitehouse Station, New Jersey: Merck & Co.|
|| || Grinsztejn B, Nguyen BY, Katlama C, et al. Safety and efficacy of the HIV-1 integrase inhibitor raltegravir (MK-0518) in treatment-experienced patients with multidrug-resistant virus: a phase II randomised controlled trial. Lancet. 2007 Apr 14;369(9569):1261-9.|
|| ||Grinsztejn B, Nguyen B, Katlama C, et al. 48 week efficacy and safety of MK-0518, a novel HIV-1 integrase inhibitor, in patients with triple-class resistant virus. In: Program and abstracts of the 47th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 17-20, 2007; Chicago. Abstract H-713.|
|| || Markowitz M, Nguyen BY, Gotuzzo E, et al. Rapid and durable antiretroviral effect of the HIV-1 Integrase inhibitor raltegravir as part of combination therapy in treatment-naive patients with HIV-1 infection: results of a 48-week controlled study. J Acquir Immune Defic Syndr. 2007 Oct 1;46(2):125-33. |
|| ||Anderson MS, Kakuda TN, Miller JL, et al. Pharmacokinetic evaluation of non-nucleoside reverse transcriptase inhibitor (NNRTI) TMC125 and integrase inhibitor (InSTI) raltegravir (RAL) in healthy subjects. In: Program and abstract of the 4th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention; July 22-25, 2007; Sydney, Australia. Abstract TUPDB02|
|| || Cooper DA, Steigbigel RT, Gatell JM, et al; BENCHMRK Study Teams. Subgroup and resistance analyses of raltegravir for resistant HIV-1 infection. N Engl J Med. 2008 Jul 24;359(4):355-65.|
|| ||Hazuda DJ, Miller MD, Nguyen BY, et al, Resistance to the HIV-integrase inhibitor raltegravir: analysis of protocol 005, a phase II study in patients with triple-class resistant HIV-1 infection. In: Program and abstracts of the XVI International HIV Drug Resistance Workshop; June 12-16, 2007; St. Michael, Barbados. Abstract 8.|
|| || Hatano H, Lampiris H, Fransen S, et al. Evolution of integrase resistance during failure of integrase inhibitor-based antiretroviral therapy. J Acquir Immune Defic Syndr. 2010 Aug;54(4):389-93|
|| || Abram ME, Hluhanich RM, Goodman DD, et al. Impact of primary elvitegravir resistance-associated mutations in HIV-1 integrase on drug susceptibility and viral replication fitness. Antimicrob Agents Chemother. 2013 Jun;57(6):2654-63.|
|| || Underwood MR, Johns BA, Sato A, et al. The activity of the integrase inhibitor dolutegravir against HIV-1 variants isolated from raltegravir-treated adults. J Acquir Immune Defic Syndr. 2012 Nov 1;61(3):297-301.|
|| || Castagna A, Maggiolo F, Penco G, et al; VIKING-3 Study Group. Dolutegravir in antiretroviral-experienced patients with raltegravir- and/or elvitegravir-resistant HIV-1: 24-week results of the phase III VIKING-3 study. J Infect Dis. 2014 Aug 1;210(3):354-62.|