Safety and Pharmacokinetics (PK) of Raltegravir in HIV (Human Immunodeficiency Virus)-Infected Children and Adolescents
- Conditions
- HIV Infections
- Interventions
- Registration Number
- NCT00485264
- Brief Summary
Integrase is 1 of 3 HIV (Human Immunodeficiency Virus)-1 enzymes required for viral replication. Raltegravir is a drug that prevents integrase from working properly. This drug has been tested for safety and efficacy in adults, but this is the first study to examine raltegravir in children and adolescents. The purpose of this study was to determine the appropriate dose for raltegravir across the pediatric age range from 4 weeks to 18 years of age, by acquiring short and long term safety data, intensive and population pharmacokinetic (PK) data, and efficacy experience with raltegravir in HIV-infected children and adolescents.
- Detailed Description
Integrase is one of three enzymes necessary for HIV replication. Integrase allows for the integration of HIV DNA (deoxyribonucleic acid) into the human genome. Raltegravir is a strong and selective inhibitor of HIV integrase. In adults, raltegravir has shown significant antiretroviral activity in clinical trials and is well tolerated. The purpose of this study was to determine the appropriate dose for raltegravir across the pediatric age range from 4 weeks (30 days) to 18 years of age, by acquiring short and long term safety data, intensive and population PK data, and efficacy experience with raltegravir in treatment-experienced, HIV-infected children and adolescents.
The study consisted of two sequential Stages: I and II. The dose finding period of Stage I was intended to examine the pharmacokinetics and short term tolerability and safety of raltegravir in a limited number of participants to permit dose selection for further study in Stage II. The dose finding algorithm required a preliminary assessment of data from the first 4 patients of each cohort (termed a "mini-cohort"). Failure to meet PK targets required dose adjustments, contingent upon the mini-cohort's dose having met safety criteria, followed by reassessment of safety and PK data from the new mini-cohort dose. When a mini-cohort dose had passed both safety and PK criteria, further accrual to and an assessment of results from the full cohort could occur. Again, failure to meet PK targets required dose adjustments contingent upon the full cohort's dose having met safety criteria with subsequent PK and safety evaluation of data from a new cohort taking the new dose.
Chronic dosing, which includes Stage I extension (the period after Stage I dose finding) and Stage II (additional participants enrolled), was intended to provide longer term safety and antiviral activity data in a larger sample of participants. Participants accrued into Stage I and treated only at the dose ultimately selected for their cohorts were combined with those accrued into Stage II, where all patients received only the final selected doses for their respective cohorts. This group is denoted as the Final Dose Population, and results from this group are considered primary, since they reflect only the age-specific doses proposed for commercial use. The group with all participants exposed to raltegravir (at any dose) is denoted as the All Treated Population.
Stage I lasted for a minimum of 48 weeks, Stage II was for 48 weeks, and a long-term follow-up period lasted for 5 years from initial exposure (i.e., 48 weeks of treatment plus 4 years of follow-up). Participants were stratified by age and assigned to one of six cohorts. Participants in Cohort I were between the ages of 12 and 18 years and received poloxamer film coated raltegravir tablets. Participants in Cohort IIA were between the ages of 6 and 11 years, weighed at least 25 kg, and received poloxamer film coated raltegravir tablets. Participants in Cohort IIB were between the ages of 6 and 11 years and received chewable raltegravir tablets. Participants in Cohort III were between the ages of 2 and 5 years and received chewable raltegravir tablets. Participants in Cohort IV were between the ages of 6 months (defined as 180 days) and 23 months and received oral granules for suspension. Participants in Cohort V were between the ages of 4 weeks (defined as 30 days) and 5 months and received oral granules for suspension.
Enrollment for Stage I of this study began with Cohort I and progressed to the other cohorts once preliminary dosage had been determined and safety data were reviewed. When this information had been determined for Cohort I, Cohorts IIA and IIB began enrollment. Once safety and dose data for these cohorts were reviewed, enrollment into Cohort III began. Once safety and dose data for Cohort III were reviewed, enrollment into Cohort IV began and once safety and dose data for Cohort IV were reviewed, enrollment into Cohort V began.
During Stage II of this study, participants took raltegravir at the dosage determined as safe and reaching PK targets based on the the Stage I data. The purpose of Stage II was to determine long-term safety of raltegravir once a safe dose meeting PK targets has been determined.
Participants whose Stage I dose was different from the dose determined for Stage II and who had not had individual dose adjustments because of extreme PK values had their raltegravir dose changed to the selected Stage II dose once it was determined. If individualizing the dose for participants in this manner resulted in a dose increase, these participants had an additional safety visit 4 weeks after the dose modification, and then continued on study visits with no further changes in the visit schedule.
There were at least 9 study visits for participants in this study, occurring during the 48-week raltegravir treatment period. For participants who completed 48 weeks of study and appeared to have benefited from receiving study drug, raltegravir was provided until five years after initial raltegravir exposure. For participants who opted to continue on study-provided raltegravir, extended provision of drug was implemented as part of a protocol extension involving visits every 4 months for five years after initial raltegravir exposure. Participants who did not continue on study-provided raltegravir were followed with annual visits for five years after initial raltegravir exposure (i.e. 48 weeks of raltegravir treatment plus 4 years follow-up). At each visit, a physical exam, blood collection, and determination of treatment adherence occurred. At some visits, urine collection and Tanner staging occurred. Selected cohorts underwent a taste evaluation at 1 of 2 visits. Participants aged 2 to less than 6 years of age were asked to participate in an additional PK substudy in which blood was collected two times over a 12-hour visit (or, if more convenient, this assessment may have been completed in 2 separate visits) in order to collect additional Cmin PK data. Participants were re-registered into the same cohort if a dose change was recommended.
Current pediatric Food and Drug Administration approval and dosing recommendations are based upon evaluations in 122 Final Dose participants aged ≥4 weeks to 18 years enrolled in this study.
The results present safety and efficacy results of the complete 5 year follow up data (primary and key secondary endpoints) of the participants from IMPAACT P1066, the Final Dose Population. By the date on which most of the data were frozen, 24 July 2017, all participants enrolled had Week 24 data (i.e., had either completed the Week 24 visit, or, for those who discontinued before Week 24, had the potential to have experienced the Week 24 visit), had also completed (or had the potential to have experienced) the Week 48 visit, and had either completed 240 weeks of study and were subsequently taken off study, or had prematurely discontinued study and were no longer in follow up.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 153
Not provided
Not provided
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Cohort IIB Raltegravir chewable tablet Participants between the ages of 6 and 11 years; receiving raltegravir chewable tablet: Stage I starting dose: Weight based dose of \~8 mg/kg based on protocol dosing table, taken orally twice daily. Final Selected Dose: Weight based dose of \~6 mg/kg according to the dosing table, to a maximum dose of 300 mg, taken orally twice daily. Cohort III Raltegravir chewable tablet Participants between the ages of 2 and 5 years; receiving raltegravir chewable tablet: Stage I starting dose: Weight based dose of \~6 mg/kg based on protocol dosing table, taken orally twice daily. Final Selected Dose: Weight based dose of \~6 mg/kg according to the dosing table, to a maximum dose of 300 mg, taken orally twice daily. Cohort I Raltegravir poloxamer film coated tablet Participants between the ages of 12 and 18 years; receiving raltegravir poloxamer film coated tablet: Stage I starting dose: Weight based dose of \~6 mg/kg based on protocol dosing table, taken orally twice daily. Final Selected Dose: 400-mg tablet taken orally twice daily. Cohort IIA Raltegravir poloxamer film coated tablet Participants between the ages of 6 and 11 years, receiving raltegravir poloxamer film coated tablet: Stage I starting dose: Weight based dose of \~8 mg/kg based on protocol dosing table, taken orally twice daily. Final Selected Dose: 400-mg tablet taken orally twice daily for participants weighing at least 25 kg. Participants \< 25 kg were switched to a weight-based dose of the chewable tablet. Cohort V Raltegravir oral granules for suspension (20 mg/mL) Participants between the ages of 4 weeks and 5 months; receiving raltegravir oral granules for suspension (20 mg/mL): Stage I starting dose: Weight based dose of \~6 mg/kg orally every 12 hours according to dosing table in protocol or the dose determined by review of all available data. Cohort IV Raltegravir oral granules for suspension (20 mg/mL) Participants between the ages of 6 and 23 months; receiving raltegravir oral granules for suspension (20 mg/mL): Stage I starting dose: Weight based dose of \~6 mg/kg orally every 12 hours according to dosing table in protocol or the dose determined by review of all available data.
- Primary Outcome Measures
Name Time Method Percentage of Participants With Grade 3 or 4 Adverse Events (AEs) From study entry through Week 24 Adverse events were graded using the Division of AIDS (DAIDS) AE Grading Table, Version 1.0. All grade 3 and higher signs, symptoms, and laboratory toxicities were included.
Number of Participants Terminated From Treatment Due to Suspected Adverse Drug Reaction (SADR) Attributable to the Study Medication From study entry through Week 24 The attribution of relationship of serious adverse events to study drug for the purposes of employing the start, stop and pause rules was by consensus among the site investigator, study team (which includes representatives from Merck) and the Division of AIDS medical officer; if unanimous agreement between them cannot be established, the attribution made by the majority of these 3 persons or entities will be used. Gradation of relationship will use the following terminology: Not related, Probably not related, Possibly related, Probably related or Definitely related.
Pharmacokinetic (PK) Parameter: Area Under the Curve (AUC12h) Measured between days 5 and 12 of raltegravir initiation; Blood samples were drawn pre-dose and at 0.5, 1, 2, 3, 4, 6, 8, and 12 hours post dosing. Pharmacokinetic parameters were determined from plasma concentration-time profiles using noncompartmental methods (WinNonlin version 4.01, Pharsight Corp., Mountain View, CA). AUC12h (area-under-the-curve from 0 to 12 hours) were determined using the linear-log trapezoidal rule.
PK Parameter: Concentration at 12 Hours Postdose (C12h) Measured between days 5 and 12 of raltegravir initiation; Blood samples were drawn pre-dose and at 0.5, 1, 2, 3, 4, 6, 8, and 12 hours post dosing. Pharmacokinetic parameters were determined from plasma concentration-time profiles using noncompartmental methods (WinNonlin version 4.01, Pharsight Corp., Mountain View, CA). Plasma concentration at 12 hours postdose (C12h) was taken directly from the observed concentration-time data.
Number of Participants Who Died From study entry through Week 24 Number of participants who died were summarized.
PK Parameter: Maximum Plasma Concentration (Cmax) Measured between days 5 and 12 of raltegravir initiation; Blood samples were drawn pre-dose and at 0.5, 1, 2, 3, 4, 6, 8, and 12 hours post dosing. Pharmacokinetic parameters were determined from plasma concentration-time profiles using noncompartmental methods (WinNonlin version 4.01, Pharsight Corp., Mountain View, CA). Maximum plasma concentration (Cmax) was taken directly from the observed concentration-time data.
PK Parameter: Time to Half of Maximum Plasma Concentration Cmax (T1/2) Measured between days 5 and 12 of raltegravir initiation; Blood samples were drawn pre-dose and at 0.5, 1, 2, 3, 4, 6, 8, and 12 hours post dosing. Pharmacokinetic parameters were determined from plasma concentration-time profiles using noncompartmental methods (WinNonlin version 4.01, Pharsight Corp., Mountain View, CA). Time to half of maximum plasma concentration Cmax (T1/2) was taken directly from the observed concentration-time data.
- Secondary Outcome Measures
Name Time Method Percentage of Participants With Grade 3 or 4 Adverse Events (AEs) From study entry through Week 48 Adverse events were graded using the Division of AIDS (DAIDS) AE Grading Table, Version 1.0. All grade 3 and higher signs, symptoms, and laboratory toxicities were included.
Number of Participants Terminated From Treatment Due to Suspected Adverse Drug Reaction (SADR) Attributable to the Study Medication From study entry through Week 48 The attribution of relationship of serious adverse events to study drug for the purposes of employing the start, stop and pause rules was by consensus among the site investigator, study team (which includes representatives from Merck) and the Division of AIDS medical officer; if unanimous agreement between them cannot be established, the attribution made by the majority of these 3 persons or entities will be used. Gradation of relationship will use the following terminology: Not related, Probably not related, Possibly related, Probably related or Definitely related.
Number of Participants Who Died From study entry through Week 48 Number of participants who died were summarized.
Percentage of Participants With ≥1 log10 Drop From Baseline in HIV RNA or HIV RNA <400 Copies/mL Baseline, Week 24, 48 Plasma HIV RNA concentrations were determined at entry and at regular intervals using the HIV-1 MONITOR Test, version 1.5 (Roche Molecular Diagnostics) or RealTime HIV-1 (Abbott Molecular), and analyses used the Observed Failure Approach.
Change of CD4 Count From Baseline Baseline, Week 24, 48 Change in CD4 cell count from baseline was calculated as the value at later visit minus the value at baseline.
Change of CD4 Percent From Baseline Baseline, Week 24, 48 Change in CD4 percent from baseline was calculated as the value of the later visit minus the value at baseline.
Trial Locations
- Locations (42)
Ann & Robert H. Lurie Children's Hospital of Chicago (LCH) CRS
🇺🇸Chicago, Illinois, United States
Children's Hosp. of Boston NICHD CRS
🇺🇸Boston, Massachusetts, United States
Usc La Nichd Crs
🇺🇸Alhambra, California, United States
Children's Hospital of Los Angeles NICHD CRS
🇺🇸Los Angeles, California, United States
David Geffen School of Medicine at UCLA NICHD CRS
🇺🇸Los Angeles, California, United States
South Florida CDTC Ft Lauderdale NICHD CRS
🇺🇸Fort Lauderdale, Florida, United States
Nyu Ny Nichd Crs
🇺🇸New York, New York, United States
University of California, UC San Diego CRS
🇺🇸La Jolla, California, United States
Johns Hopkins Univ. Baltimore NICHD CRS
🇺🇸Baltimore, Maryland, United States
Gaborone CRS
🇧🇼Gaborone, Botswana
Bronx-Lebanon Hospital Center NICHD CRS
🇺🇸Bronx, New York, United States
Jacobi Med. Ctr. Bronx NICHD CRS
🇺🇸Bronx, New York, United States
Univ. of Sao Paulo Brazil NICHD CRS
🇧🇷Sao Paulo, Brazil
DUMC Ped. CRS
🇺🇸Durham, North Carolina, United States
SOM Federal University Minas Gerais Brazil NICHD CRS
🇧🇷Belo Horizonte, Minas Gerais, Brazil
Hospital Nossa Senhora da Conceicao NICHD CRS
🇧🇷Porto Alegre, Rio Grande Do Sul, Brazil
Durban Paediatric HIV CRS
🇿🇦Durban, KwaZulu-Natal, South Africa
Hosp. General de Agudos Buenos Aires Argentina NICHD CRS
🇦🇷Ciudad de Buenos Aires, Buenos Aires, Argentina
Univ. of California San Francisco NICHD CRS
🇺🇸San Francisco, California, United States
Univ. of Colorado Denver NICHD CRS
🇺🇸Aurora, Colorado, United States
USF - Tampa NICHD CRS
🇺🇸Tampa, Florida, United States
Howard Univ. Washington DC NICHD CRS
🇺🇸Washington, District of Columbia, United States
Children's National Med. Ctr. Washington DC NICHD CRS
🇺🇸Washington, District of Columbia, United States
Univ. of Florida Jacksonville NICHD CRS
🇺🇸Jacksonville, Florida, United States
Boston Medical Center Ped. HIV Program NICHD CRS
🇺🇸Boston, Massachusetts, United States
WNE Maternal Pediatric Adolescent AIDS CRS
🇺🇸Worcester, Massachusetts, United States
Columbia IMPAACT CRS
🇺🇸New York, New York, United States
St. Jude Children's Research Hospital CRS
🇺🇸Memphis, Tennessee, United States
Philadelphia IMPAACT Unit CRS
🇺🇸Philadelphia, Pennsylvania, United States
SUNY Stony Brook NICHD CRS
🇺🇸Stony Brook, New York, United States
Metropolitan Hosp. NICHD CRS
🇺🇸New York, New York, United States
Texas Children's Hospital CRS
🇺🇸Houston, Texas, United States
Hospital Federal dos Servidores do Estado NICHD CRS
🇧🇷Rio de Janeiro, Brazil
Instituto de Puericultura e Pediatria Martagao Gesteira - UFRJ NICHD CRS
🇧🇷Rio de Janeiro, Brazil
Inst de Infectologia Emilio Ribas Sao Paulo Brazil NICHD CRS
🇧🇷Sao Paulo, Brazil
San Juan City Hosp. PR NICHD CRS
🇵🇷San Juan, Puerto Rico
Soweto IMPAACT CRS
🇿🇦Johannesburg, Gauteng, South Africa
Shandukani Research CRS
🇿🇦Johannesburg, Gauteng, South Africa
Family Clinical Research Unit (FAM-CRU) CRS
🇿🇦Tygerberg, Western Cape Province, South Africa
Rush Univ. Cook County Hosp. Chicago NICHD CRS
🇺🇸Chicago, Illinois, United States
Seattle Children's Research Institute CRS
🇺🇸Seattle, Washington, United States
Tulane Univ. New Orleans NICHD CRS
🇺🇸New Orleans, Louisiana, United States