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 HIV and Coverage of the
th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC 2009)
September 12-15, 2009, San Francisco, CA
 The material posted on HIV and about the 49th ICAAC is not approved by the American Society for Microbiology
At 96 Weeks, Raltegravir (Isentress) Is as Effective as Efavirenz (Sustiva) in Suppressing HIV Viral Load and Improving Immune Function

When used as part of a combination antiretroviral therapy (ART) regimen for 96 weeks, the entry inhibitor raltegravir (Isentress) is as effective as efavirenz (Sustiva) in suppressing viral load and increasing CD4 cell counts in previously untreated HIV patients, according to data presented at the 49th Annual Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC 2009) this week in San Francisco. These results confirm the data from the 48-week analysis of this ongoing study. In July 2009, the FDA approved the use of raltegravir for treatment-naive HIV patients, in addition to the previous indication for treatment-experienced adults.

Following are excerpts from a press release from Merck about the latest data from the STARTMRK trial:

ISENTRESS (raltegravir) Tablets Studied in Comparison to Efavirenz in Combination Therapy Through 96 Weeks in HIV-1 Treatment-naive Patients

San Francisco -- September 13, 2009 -- ISENTRESS, an integrase inhibitor from Merck & Co., Inc., was studied in comparison to efavirenz in maintaining viral load suppression to undetectable levels (less than 50 copies/mL) and at improving CD4 cell counts in previously untreated (treatment-naive) HIV-1-infected patients through 96 weeks in a Phase III study called STARTMRK. In STARTMRK, ISENTRESS patients received either ISENTRESS or efavirenz in combination therapy. The data was presented today at the 49th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) in San Francisco, CA.

The U.S. Food and Drug Administration on July 8, 2009, to include the treatment of adult patients starting HIV-1 therapy for the first time, as well as treatment-experienced adult patients, in combination with other antiretroviral (ARV) medicines. The expanded indication for ISENTRESS was based on analyses of plasma HIV-1 RNA levels through 48 weeks in three double-blind controlled studies. Two of these studies were conducted in clinically advanced, three-class antiretroviral [nonnucleoside reverse transcriptase inhibitor (NNRTI), nucleoside reverse transcriptase inhibitor (NRTI) and protease inhibitor (PI)] treatment-experienced adults. The third study was a 48-week analysis of the STARTMRK trial in treatment-naive patients.

ISENTRESS is used in combination with other ARV medicines for the treatment of HIV-1 infection in adult patients. The safety and efficacy of ISENTRESS have not been established in pediatric patients. The use of other active agents with ISENTRESS is associated with a greater likelihood of treatment response.

"Results from the 96 week analysis of STARTMRK showed that ISENTRESS in combination therapy was as effective as efavirenz at suppressing HIV viral load and increasing immune system function," said Edwin de Jesus, MD, FACP, medical director of the Orlando Immunology Center in Orlando, Florida. "These results further confirm the findings from the 48 week analysis of this ongoing study."

ISENTRESS studied through 96 weeks in 563 previously untreated adult patients

In this ongoing, multi-center, double-blind, randomized, active-controlled Phase III STARTMRK trial, 563 treatment-naive adult patients received either 400 mg ISENTRESS administered orally twice daily in combination with tenofovir/emtricitabine [Truvada] or 600 mg efavirenz administered orally once daily in combination with the same agents. The primary endpoints were reductions in HIV-1 viral load to less than 50 copies/mL and an evaluation of safety and tolerability at Week 48. Secondary endpoints included ARV activity as measured by the proportion of patients achieving HIV viral load to less than 50 copies/mL, less than 400 copies/mL and change from baseline in CD4 count at Week 96, as well as tolerability and safety at Week 96.

Patients who entered the study were required to have HIV viral loads greater than 5,000 copies/mL. At baseline, geometric mean viral load levels for patients on the regimen including ISENTRESS was 103,205 copies/mL (n=281) and for the efavirenz regimen was 106,215 copies/mL (n=282). Mean baseline CD4 cell counts were 218.9 cells/mm3 and 217.4 cells/mm3 for the groups receiving ISENTRESS and efavirenz, respectively.

Viral load reductions and increase in CD4 cell counts maintained through 96 weeks

After 96 weeks of treatment, the ISENTRESS-based regimen suppressed HIV RNA levels below 50 copies/mL at a rate comparable to the regimen containing efavirenz (81 percent versus 79 percent, respectively); the treatment difference was two percent favoring ISENTRESS with an associated 95 percent confidence interval (CI) of (-4.3, 9.0). Results also showed that patients on the regimen containing ISENTRESS in combination therapy experienced a statistically similar yet numerically greater mean increase in CD4 cell count (240 cells/mm3) than those on the regimen containing efavirenz (225 cells/mm3). The treatment difference was 15 with an associated 95 percent CI of (-13, 42).

Impact on lipid levels and tolerability profile of ISENTRESS

At 96 weeks, ISENTRESS in combination therapy had less impact on lipid levels, including total, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol levels, as well as triglycerides than the regimen containing efavirenz in previously untreated adults:

Mean Changes from Baseline in Lipid Levels at Week 96

Total Cholesterol10 mg/dL38 mg/dL<0.001
LDL Cholesterol7 mg/dL21 mg/dL<0.001
HDL Cholesterol3 mg/dL10 mg/dL<0.001
Triglycerides-4 mg/dL40 mg/dL0.001
Total HDL Cholesterol Ratio-0.18 mg/dL-0.04 mg/dL0.192

Additionally, 47.0 percent of patients taking the regimen containing ISENTRESS experienced drug-related side effects versus 78.0 percent of patients receiving the efavirenz-based regimen; p-value <0.00.

In the study, the most commonly reported clinical adverse experiences (AEs) in the regimens containing ISENTRESS and efavirenz, respectively, were:

Clinical Adverse Experiences Occurring in > 10 percent of patients


ISENTRESS Group (n=281)

Efavirenz Group (n=282)

Raltegravir vs. Efavirenz
Difference from Efavirenz







ients with ≥h ≥ 1 AE






(-6.4, 0.4)

Eye Disorders






(-10.2, -1.4)

Gastrointestinal Disorders






(-13.3, 3.1)

General Disorders and Administration Site Conditions






(-14.6, 0.6)

Infections and Infestations






(-9.7, 5.3)

Injury, Poisoning and Procedural Complications






(-4.6, 6.8)

Metabolism and Nutrition Disorders






(-8.4, 2.0)

Musculoskeletal and Connective Tissue Disorders






(-11.9, 2.8)

Nervous System Disorders






(-30.1, -14.0)

Psychiatric Disorders






(-16.1, -0.6)

Reproductive and Breast Disorders






(-9.0, 0.3)

Respiratory, Thoracic and Mediastinal Disorders






(-3.0, 11.7)

Skin and Subcutaneous Disorders






(-20.8, -5.1)

Additional posters on ISENTRESS presented at ICAAC

Three additional posters being presented at the ICAAC meeting described studies that evaluated the safety profile and efficacy of ISENTRESS in combination therapy. These posters include:

Metabolic analysis and body composition changes from the 48-week findings in STARTMRK (Poster 329)
A review of the effect of ISENTRESS on the pharmacokinetics of methadone (Poster 1295)
The lack of a clinically important effect of rifabutin on raltegravir pharmacokinetics (Poster 29)

Important safety information about ISENTRESS

ISENTRESS does not cure HIV or AIDS and does not prevent passing HIV to others.

Healthcare providers should know that immune reconstitution syndrome has been reported in patients treated with antiretroviral therapy, which may necessitate further evaluation and treatment.

Creatine kinase elevations were observed in subjects who received ISENTRESS. Myopathy and rhabdomyolysis have been reported, however the relationship of ISENTRESS to these events is not known. ISENTRESS should be used with caution in patients at increased risk of myopathy or rhabdomyolysis, such as patients receiving concomitant medication known to cause these conditions.

In STARTMRK, the most commonly (greater than or equal to two percent in either treatment group) reported drug-related clinical AE of moderate or severe intensity in treatment-naive patients receiving ISENTRESS and at a higher incidence compared to efavirenz was insomnia (four percent versus three percent).

In Phase III clinical trials of ISENTRESS, the most commonly (greater than or equal to two percent in either treatment group) reported drug-related clinical AEs of moderate or severe intensity in treatment-experienced patients receiving ISENTRESS and at a higher rate compared to placebo were headache (rate of three versus one, per 100- patient years), nausea (rate of two versus one, per 100- patient years), asthenia/weakness (rate of two versus one, per 100 patient years) and fatigue (rate of two versus one, per 100 patient years).

Dosing and administration

ISENTRESS is a single 400 mg tablet taken twice daily without regard to food. The dose of ISENTRESS should be increased during coadmistration with rifampin to 800 mg twice daily.

Drug interactions

Coadmistration with strong inducers of uridine diphosphate glucuronosyltransferase (UGT) 1A1 may reduce plasma concentrations of ISENTRESS. Based on the results of drug interaction studies and the clinical trials data, no dose adjustment of ISENTRESS is required when coadministered with other ARV agents. Also, preclinical studies show that ISENTRESS is not metabolized by cytochrome P450 enzymes.


ISENTRESS is the first medicine to be approved in a class of ARV drugs called integrase inhibitors. ISENTRESS works by inhibiting the insertion of HIV-1 DNA into human DNA by the integrase enzyme and has demonstrated rapid antiviral activity. Inhibiting integrase from performing this essential function limits the ability of the virus to replicate and infect new cells. Other HIV-1 drugs in use inhibit two other enzymes critical to the HIV-1 replication process - protease and reverse transcriptase -- but ISENTRESS is the only approved drug that inhibits the integrase enzyme.

ISENTRESS is now approved in more than 80 countries worldwide for treatment-experienced adult patients. Merck is continuing to move forward with filings in additional countries around the world for use of ISENTRESS in both treatment-experienced and treatment-naive patients.

Patient assistance programs in the U.S.

Merck recently launched a co-pay assistance program in the U.S. for eligible patients on ISENTRESS who are commercially insured and have co-pays or coinsurance above $30 up to a maximum of $400 per month. With this program, eligible patients can receive savings off their out-of-pocket costs for up to one year. Information about the co-pay assistance program can be obtained by calling 866-350-9232 or at

In addition, for eligible patients with HIV, Merck provides patient assistance to ensure access to ISENTRESS through a program called SUPPORT. The SUPPORT Program helps patients who have been prescribed ISENTRESS by providing personalized support and patient advocacy regarding individual reimbursement issues. The Program can also provide patient assistance which may provide ISENTRESS free of charge to eligible patients. Information about the SUPPORT Program can be obtained by calling 1-800-850-3430 or at

About Merck

Merck & Co., Inc. is a global research-driven pharmaceutical company dedicated to putting patients first. Established in 1891, Merck currently discovers, develops, manufactures and markets vaccines and medicines to address unmet medical needs. The company devotes extensive efforts to increase access to medicines through far-reaching programs that not only donate Merck medicines but help deliver them to the people who need them. Merck also publishes unbiased health information as a not-for-profit service. For more information, visit


J Lennox, E DeJesus, A Lazzarin, and others. Raltegravir Demonstrates Durable Efficacy through 96 Weeks (Wk): Results from STARTMRK, A Phase III Study of Raltegravir (RAL)-based vs Efavirenz (EFV)-based Therapy in Treatment-Naive HIV+ Patients (Pts). 49th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC 2009). San Francisco. September 12-15, 2009. Abstract H-924b.

Other Source
Merck and Company. ISENTRESS (raltegravir) Tablets Studied in Comparison to Efavirenz in Combination Therapy Through 96 Weeks in HIV-1 Treatment-naive Patients. Press Release. September 13, 2009.

























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