Atazanavir Used in Combination With Other Anti-HIV Drugs in HIV-Infected Infants, Children, and Adolescents
Condition: HIV Infections
MeSH terms: HIV Infections
Study type: Interventional
Phase: Phase 1/Phase 2

Summary: 
      The purpose of this study was to find a safe and tolerable dose of the protease inhibitor
      (PI) atazanavir (ATV), with or without a low-dose boost of the PI ritonavir (RTV), when taken
      with other anti-HIV drugs in HIV infected infants, children, and adolescents.

      Advancements in anti-HIV drugs for HIV infected children and adolescents have been hard to
      make, in part because these patients often do not take the drugs as prescribed. ATV may be a
      better option because it is available in the form of powder which children and adolescents
      may be more willing to take regularly. Using a low dose of RTV as a boosting agent for ATV
      may also increase the chances of virologic response of highly active antiretroviral treatment
      (HAART)-experienced patients. This study aimed to find safe and tolerable doses of ATV with
      or without low-dose RTV boost in infants, children, and adolescents. For this study,
      participants were enrolled in the United States and South Africa.
    

Detailed description: 
      Advancements in HAART for HIV-infected children and adolescents are hindered by patient
      nonadherence. The availability of a powder formulation and the once-daily dosing schedule
      make ATV an attractive agent for improved adherence in pediatric treatment regimens. This
      study was designed to provide pharmacokinetic (PK) data to guide dosing recommendations for
      ATV, when given concurrently with or without low-dose RTV boost, in infants, children, and
      adolescents. During the study, the safety and tolerance of ATV (with or without low-dose RTV)
      were closely monitored, and virologic efficacy data were obtained.

      There were two parts to this study. Step I took place in the United States and South Africa,
      and were further divided into two sets of groups, Parts A and B. Part A participants received
      ATV only and Part B participants received ATV with low-dose RTV boost. All participants
      received ATV once a day with 2 other antiretroviral drugs (not provided by the study). In
      Part B only, participants received ATV with a low dose of RTV. Participants were placed into
      1 of 8 groups (Groups 1 to 4 for Part A; Groups 5 to 8 for Part B) with respect to age and
      study drug formulation. Participants in Groups 1 and 5 were infants between ages 3 months and
      1 day (91 days) and 2 years (less than or exactly 730 days) and took ATV in powder form.
      Participants in Groups 2, 3, 6, and 7 were children between 2 years and 1 day (731 days) old
      and 13 years old. Groups 2 and 6 received ATV in powder form, while Groups 3 and 7 received
      the capsule form. Patients in Groups 4 and 8 were adolescents between 13 years and 1 day old
      and 21 years old (not including the 22nd birthday) and took ATV in capsule form. As of
      01/02/2008 a new group, 5A was opened for enrollment. Participants in Group 5A were between 3
      months and 6 months old and took ATV in powder form plus a low-dose RTV booster.

      For each group, enrollment started with five participants per group. All participants were
      evaluated for PK and safety criteria, adjusting the dose of ATV until one was found that
      passes both sets of criteria. Then five additional participants were enrolled, with
      enrollment continuing for each group once all participants within that group meet the PK
      criteria. For groups receiving RTV (Groups 5 to 8), additional criteria must be met for each
      dose of ATV studied. In addition to the PK and safety evaluations, 24-hour post-dose
      concentrations (Cmin) were monitored in the first 10 participants enrolled for a dose of ATV
      before more participants were enrolled and studied at that same dose. Note that in Protocol
      Version 5.0, South African (S.A.) sites were allowed to enroll patients in study groups
      3,4,5,6,7,8. As a result, the study design has been modified to further stratify study groups
      3, 4, 5, 6, 7, 8 (at the final recommended dose), by country, i.e., U.S.A. versus S.A., such
      that 10 evaluable study subjects will be accrued in parallel to each study group-country
      cohort.

      Clinic visits will be every 4 weeks through Week 48, then every 8 weeks until the last
      participant to enroll in the study has reached Week 96 of his/her treatment. If, after 56
      weeks, a participant has a toxic reaction to a nucleoside/tide reverse transcriptase
      inhibitor (NRTI) in their medication regimen, the regimen may be changed to a different NRTI.
      At every visit, participants will undergo a complete medical history and physical exam,
      cardiac conduction evaluation, and urine and blood collection. Participants of childbearing
      age will have a pregnancy test performed at each visit.

      Step II will only be open to South African subjects who are virologically responding to
      treatment when the last enrollee into either part of Step I (Part A or Part B) has completed
      96 weeks of treatment (end of Step I) . All such participants will be given ATV in capsule
      form at the same dose they received at the end of Step I, as well as the other
      antiretrovirals they were receiving during Step I. Step II will continue until ATV is
      approved in South Africa and readily available by individual prescription, and participants
      will have a study visit every 12 weeks.

      Note that the following ATV doses were independently evaluated for each group during the
      dose-finding stage based on the description above: Group 1 ATV Powder (310mg/m^2, 620mg/m^2);
      Group 2 ATV Powder (310mg/m^2, 620mg/m^2); Group 3 ATV Capsule (310mg/m^2, 415mg/m^2,
      520mg/m^2); Group 4 ATV Capsule (310mg/m^2, 520mg/m^2, 620mg/m^2); Group 5 ATV Powder + RTV
      (310mg/m^2); Group 6 ATV Powder +RTV (310mg/m^2); Group 7 ATV Capsule + RTV (310mg/m^2,
      205mg/m^2); Group 8 ATV Capsule + RTV (310mg/m^2, 205mg/m^2); Group 5A ATV Powder + RTV
      (310mg/m^2). All these dosing groups are presented in Participant Flow groups to show the
      total number of participants enrolled, but only the participants enrolled at the final group
      doses are presented in the subsequent results.

      The following groups satisfied the safety and PK guidelines specified in the protocol: Groups
      3,4,6,7,8. Groups 5 and 5A did not satisfy the protocol-defined pharmacokinetic criteria.
      There was considerable inter-subject variability in systemic exposures in this age group,
      such that a dose escalation to 415mg/m^2 may have resulted in ATV exposures greater than
      90,000 ng*hr/mL in some children. Thus, a further dose increase in Groups 5 and 5A was not
      attempted.

      These are the final dose for each group: Groups 1 and 2 (Final dose was not established);
      Group 3 ATV Capsule (520mg/m^2); Group 4 ATV Capsule (620mg/m^2); Group 5 ATV Powder
      (310mg/m^2) + RTV; Group 6 ATV Powder (310mg/m^2) +RTV; Group 7 ATV Capsule (205mg/m^2) +
      RTV; Group 8 ATV Capsule (205mg/m^2) + RTV; Group 5A ATV Powder (310mg/m^2) + RTV.
    

Intervention name(s): ATV; Ritonavir
Intervention type(s): Drug; Drug
Intervention description(s): Participants received varying doses of ATV, depending on their age and weight. The medication was administered as 50 mg, 100 mg, or 200 mg capsules or a powder formulation, depending on which study arm participants were in.; Administered as 100 mg capsules or oral solution.
Intervention MeSH terms: Ritonavir
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Dose-Response Relationship, Drug; Drug Therapy, Combination; Drug Administration Schedule; HIV Protease Inhibitors; Reverse Transcriptase Inhibitors; Anti-HIV Agents; Pharmacokinetics; Treatment Experienced; Treatment Naive