SciCombinator

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Concept: Integrase inhibitor

171

Failure of antiretroviral regimens containing elvitegravir (EVG) and raltegravir (RAL) can result in the appearance of integrase inhibitor (INI) drug-resistance mutations (DRMs). While several INI DRMs have been identified, the evolution of EVG DRMs and the linkage of these DRMs with protease inhibitor (PI) and reverse transcriptase inhibitor (RTI) DRMs have not been studied at the clonal level. We examined the development of INI DRMs in 10 patients failing EVG-containing regimens over time, and the linkage of INI DRMs with PI and RTI DRMs in these patients plus 6 RAL-treated patients. A one-step RT-nested PCR protocol was used to generate a 2.7 kB amplicon that included the PR, RT, and IN coding region, and standard cloning and sequencing techniques were used to determine DRMs in 1,277 clones (mean 21 clones per time point). Results showed all patients had multiple PI, NRTI, and/or NNRTI DRMs at baseline, but no primary INI DRM. EVG-treated patients developed from 2 to 6 strains with different primary INI DRMs as early as 2 weeks after initiation of treatment, predominantly as single mutations. The prevalence of these strains fluctuated and new strains, and/or strains with new combinations of INI DRMs, developed over time. Final failure samples (weeks 14 to 48) typically showed a dominant strain with multiple mutations or N155H alone. Single N155H or multiple mutations were also observed in RAL-treated patients at virologic failure. All patient strains showed evidence of INI DRM co-located with single or multiple PI and/or RTI DRMs on the same viral strand. Our study shows that EVG treatment can select for a number of distinct INI-resistant strains whose prevalence fluctuates over time. Continued appearance of new INI DRMs after initial INI failure suggests a potent, highly dynamic selection of INI resistant strains that is unaffected by co-location with PI and RTI DRMs.

Concepts: Antiretroviral drug, HIV, Reverse transcriptase inhibitor, Reverse transcriptase, Zidovudine, Antiretroviral drugs, Integrase inhibitor, Integrase

170

Human immunodeficiency virus type 2 (HIV-2) is intrinsically resistant to non-nucleoside reverse transcriptase inhibitors and exhibits reduced susceptibility to several of the protease inhibitors used for antiretroviral therapy of HIV-1. Thus, there is a pressing need to identify new classes of antiretroviral agents that are active against HIV-2. Although recent data suggest that the integrase strand transfer inhibitors raltegravir and elvitegravir may be beneficial, mutations that are known to confer resistance to these drugs in HIV-1 have been reported in HIV-2 sequences from patients receiving raltegravir-containing regimens. To examine the phenotypic effects of mutations that emerge during raltegravir treatment, we constructed a panel of HIV-2 integrase variants using site-directed mutagenesis and measured the susceptibilities of the mutant strains to raltegravir and elvitegravir in culture. The effects of single and multiple amino acid changes on HIV-2 replication capacity were also evaluated. Our results demonstrate that secondary replacements in the integrase protein play key roles in the development of integrase inhibitor resistance in HIV-2. Collectively, our data define three major mutational pathways to high-level raltegravir and elvitegravir resistance: i) E92Q+Y143C or T97A+Y143C, ii) G140S+Q148R, and iii) E92Q+N155H. These findings preclude the sequential use of raltegravir and elvitegravir (or vice versa) for HIV-2 treatment and provide important information for clinical monitoring of integrase inhibitor resistance in HIV-2-infected individuals.

Concepts: Antiretroviral drug, HIV, AIDS, Reverse transcriptase inhibitor, Reverse transcriptase, Integrase inhibitor, Raltegravir, Integrase

169

HIV-1 integrase (IN) is an important target for contemporary antiretroviral drug design research. Historically, efforts at inactivating the enzyme have focused upon blocking its active site. However, it has become apparent that new classes of allosteric inhibitors will be necessary to advance the antiretroviral field in light of the emergence of viral strains resistant to contemporary clinically used IN drugs. In this study we have characterized the importance of a close network of IN residues, distant from the active site, as important for the obligatory multimerization of the enzyme and viral replication as a whole. Specifically, we have determined that the configuration of six residues within a highly symmetrical region at the IN dimerization interface, composed of a four-tiered aromatic interaction flanked by two salt bridges, significantly contributes to proper HIV-1 replication. Additionally, we have utilized a quantitative luminescence assay to examine IN oligomerization and have determined that there is a very low tolerance for amino acid substitutions along this region. Even conservative residue substitutions negatively impacted IN multimerization, resulting in an inactive viral enzyme and a non-replicative virus. We have shown that there is a very low tolerance for amino acid variation at the symmetrical dimeric interface region characterized in this study, and therefore drugs designed to target the amino acid network detailed here could be expected to yield a significantly reduced number of drug-resistant escape mutations compared to contemporary clinically-evaluated antiretrovirals.

Concepts: Antiretroviral drug, HIV, AIDS, Protein, Acid, Amine, Enzyme inhibitor, Integrase inhibitor

168

Two integrases inhibitors, raltegravir and elvitegravir, have now been approved by regulatory agencies for use in the treatment of HIV-infected patients; and the approval of a third such drug, dolutegravir, is expected during 2013 on the basis of several phase 3 clinical trials. The advent of this new class of antiretroviral (ARV) medications represents a major advance in the management of HIV infection, and each of these three drugs can be expected to continue to be an important component of ARV combination regimens.

Concepts: Antiretroviral drug, HIV, Pharmacology, Reverse transcriptase, Retrovirus, Integrase inhibitor, Raltegravir, Integrase

28

The quinolone HL(1) and the hydroxypyrimidine-carboxamide HL(2) were designed and synthesized as models of the HIV integrase strand transfer inhibitors Elvitegravir and Raltegravir (brand name Isentress), with the aim to study their complexing behavior and their biological activity. The Ru(arene) complexes [RuCl(η(6)-p-cym)L(1)], [RuCl(η(6)-p-cym)L(2)] and [RuCl(hexamethylbenzene)L(2)] were also synthesized and spectroscopically characterized and their X-ray diffraction structures were discussed. The ligands and the complexes showed inhibition potency in the sub/low-micromolar concentration range in anti-HIV-1 integrase enzymatic assays, with selectivity toward strand transfer catalytic process, without any significant cytotoxicity on cancer cells.

Concepts: HIV, DNA, X-ray, Reverse transcriptase, Retrovirus, Integrase inhibitor, Raltegravir, Integrase

28

This review focuses on the topic of HIV integrase inhibitors that are potent antiretroviral drugs that efficiently decrease viral load in patients. However, emergence of resistance mutations against this new class of drugs represents a threat to their long-term efficacy. Here, we provide new information about the most recent mutations identified and other mutations that confer resistance to several integrase inhibitors, such as new resistance mutations-for example, G118R, R263K, and S153Y-that have been identified through in vitro selection studies with second-generation integrase strand transfer inhibitors (INSTIs). These add to the three main resistance pathways involving mutations at positions Y143, N155, and Q148. Deep sequencing, structural modeling, and biochemical analyses are methods that currently help in the understanding of the mechanisms of resistance conferred by these mutations. Although the new resistance mutations appear to confer only low levels of cross-resistance to second-generation drugs, the Q148 pathway with numerous secondary mutations has the potential to significantly decrease susceptibility to all drugs of the INSTI family of compounds.

Concepts: Antiretroviral drug, HIV, Viral load, Reverse transcriptase, Antiretroviral drugs, Integrase inhibitor, Raltegravir, Integrase

28

Integration of the HIV-1 DNA is required and essential to maintain the viral DNA in the infected cell. Integration process occurs in several events, mainly endonucleolytic processing of the 3' ends of the viral DNA and strand transfer or joining of the viral and cellular DNA. The design and discovery of integrase inhibitors were first focused at targeting the catalytic site of IN with a specific effect on strand transfer. Several integrase inhibitors were developed clinically, two first generation inhibitors, raltegravir and elvitegravir and then two second-generation inhibitors, dolutegravir and MK-2058. Recently, allosteric integrase inhibitors intended to interfere with the integrase-LEDGF/p75 interaction have been designed. These new inhibitors called LEDGINs have an effect on 3' processing and strand transfer. Thus, integrase inhibitors present a real added value in combined treatment for naive and experienced HIV infected patients. Combination experiments of LEDGINs and raltegravir suggest that these inhibitors could act additively despite sharing the same viral target. Future therapy could involve combinations of inhibitors of IN function acting though different binding pockets within IN. The place of this class on HIV inhibitors and their future role in perspective of novel therapies to eliminate latent HIV reservoirs and infection for cure should also be explored.

Concepts: Antiretroviral drug, HIV, Value added, Reverse transcriptase, Retrovirus, Integrase inhibitor, Raltegravir, Integrase

28

Although all HIV drugs developed to date are prone to the problem of drug resistance, there is hope that second generation integrase inhibitors may prove to be relatively resilient to this problem and to retain efficacy over long periods. This review summarizes information about the integrase mutations identified to date and about why the most recently developed members of this drug class may be superior to earlier drugs. Several newly identified resistance mutations, such as G118R, R263K and S153Y, have been identified through tissue culture selection studies with second-generation integrase strand-transfer inhibitors (INSTIs). These new mutations add to our understanding of the three previously identified resistance pathways involving mutations at positions Y143, N155 and Q148. Biochemical analyses structural modeling, and deep sequencing are methods that currently help in the understanding of the mechanisms of resistance conferred by these various substitutions. Despite the fact that these new resistance mutations confer only low-level cross-resistance to second-generation drugs, the Q148 pathway with numerous secondary mutations has the potential to significantly decrease susceptibility to all members of the INSTI family of drugs. Selection of mutations in vitro with second-generation INSTIs suggests that only low level cross-resistance may exist between these new drugs and first-generation members of this class. The emergence of mutations at position Q148 should be monitored whenever possible and more data are needed to assess the long-term efficacy of second-generation INSTIs in patients who may have failed older INSTIs such as elvitegravir and raltegravir.

Concepts: Antiretroviral drug, HIV, Pharmacology, Reverse transcriptase, Integrase inhibitor, Raltegravir, Integrase, Elvitegravir

26

Raltegravir is an HIV-1 integrase inhibitor approved for use in adults, children, and infants ≥4 weeks of age. As alternatives to the original film-coated tablet, a chewable ethylcellulose (EC) tablet and granules for oral suspension (GFS) have been developed for use in children. The purpose of this study was to evaluate these formulations in adults prior to use in pediatric studies.

Concepts: HIV, Pharmacology, Pharmaceutical formulation, Integrase inhibitor, Raltegravir, Integrase

6

Coitally delivered microbicide gels containing antiretroviral drugs are important for HIV prevention. However, to date, microbicides have contained entry or reverse transcriptase inhibitors that block early steps in virus infection and thus need to be given as a preexposure dose that interferes with sexual practices and may limit compliance. Integrase inhibitors block late steps after virus infection and therefore are more suitable for post-coital dosing. We first determined the kinetics of strand transfer in vitro and confirmed that integration begins about 6 hours after infection. We then used a repeat-challenge macaque model to assess efficacy of vaginal gels containing integrase strand transfer inhibitors when applied before or after simian/human immunodeficiency virus (SHIV) challenge. We showed that gel containing the strand transfer inhibitor L-870812 protected two of three macaques when applied 30 min before SHIV challenge. We next evaluated the efficacy of 1% raltegravir gel and demonstrated its ability to protect macaques when applied 3 hours after SHIV exposure (five of six protected; P < 0.05, Fisher's exact test). Breakthrough infections showed no evidence of drug resistance in plasma or vaginal secretions despite continued gel dosing after infection. We documented rapid vaginal absorption reflecting a short pharmacological lag time and noted that vaginal, but not plasma, virus load was substantially reduced in the breakthrough infection after raltegravir gel treatment. We provide a proof of concept that topically applied integrase inhibitors protect against vaginal SHIV infection when administered shortly before or 3 hours after virus exposure.

Concepts: Antiretroviral drug, HIV, Reverse transcriptase inhibitor, Sexual intercourse, Reverse transcriptase, Fisher's exact test, Integrase inhibitor, Raltegravir