October 28th, 2012

Dolutegravir and the 88% Rule

In the latest treatment-naive trials of elvitegravir and dolutegravir, there’s a striking consistency in the results of the “test” regimen. Here are the studies, with the percentage of responders by treatment arm:

  • Study 102:  TDF/FTC/EFV (84%) vs. TDF/FTC/EVG/c (88%) — non-inferior
  • Study 103:  TDF/FTC + ATV/r (87%) vs. TDF/FTC/EVG/c (90%) — non-inferior
  • SPRING-2:  TDF/FTC or ABC/3TC + RAL (85%) vs. DTG (88%) — non-inferior
  • SINGLE:  TDF/FTC/EFV (81%) vs. ABC/3TC + DTG (88%) — ABC/3TC + DTG — superior

The last of these, the SINGLE study, is the only one where there’s superiority in the primary outcome for the experimental arm, here ABC/3TC + dolutegravir. As the lead investigator Sharon Walmsley note, this favorable result was largely due to a significantly higher proportion of subjects in the TDF/FTC/EFV group discontinuing therapy for adverse events (10% vs 2%), as rates of virologic failure were similar between arms. ABC/3TC + dolutegravir also was better than TDF/FTC/EFV from both the immunologic and resistance perspective.

And though cross study comparisons are frowned upon by purists, we can’t resist. Just a quick glance at all four of the EVG and DTG arms, and you can easily see that an 88% response rate is the new price of admission for any treatment-naive regimen.

Anything shy of the high 80s, and there has to be something else very special about the treatment — for example, better tolerability, much lower cost, better long-term safety, it helps you become a virtuoso violinist — to make it compete with options for therapy we already have, or will have soon.

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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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