Week 48 Results of EMERALD: A Phase 3, Randomized, Non-inferiority Study Evaluating the Efficacy and Safety of Switching from Boosted-protease Inhibitors (bPI) Plus Emtricitabine (FTC)/Tenofovir Disoproxil Fumarate (TDF) Regimens to the Once Daily (QD), Single-tablet Regimen (STR) of Darunavir/Cobicistat/Emtricitabine/Tenofovir Alafenamide (D/C/F/TAF) in Virologically Suppressed, HIV-1-infected Adults
Authors: Orkin Chloe , Molina Jean-Michel , Gallant Joel , Negredo Eugenia , Gathe Joseph , Eron Joseph , Van Landuyt Erika , Lathouwers Erkki , Hufkens Veerle , Petrovic Romana , Opsomer Magda ,   EMERALD Study Group
Published: March 2018

Abstract

Background
EMERALD is evaluating the efficacy and safety of switching from bPI + FTC/TDF regimens (control) to D/C/F/TAF 800/150/200/10 mg in virologically suppressed, HIV-1-infected adults. We present Week 48 primary results.

Method
EMERALD (NCT02269917) is a randomized, active-controlled, open-label, international, multicenter, parallel-group, non-inferiority trial. Virologically suppressed (viral load [VL] &lt; 50 c/mL for ≥2 months), HIV-1-infected adults were randomized (2:1) to switch to D/C/F/TAF or continue control. The FDA-stipulated primary endpoint was non-inferiority of D/C/F/TAF vs. control regarding % virologic rebound (confirmed VL ≥ 50 c/mL or premature discontinuations with last VL ≥ 50 c/mL) cumulative through Week 48 (4% margin).

Result
1141 patients were randomized and treated (N = 763 D/C/F/TAF; N = 378 control); median age 46; 18% women; 76% white; 58% on &gt;2 previous ARVs (prior to screening regimen); 15% with previous non-DRV virologic failure (VF). Virologic rebound through Week 48 was non-inferior for D/C/F/TAF (2.5%; n = 19) vs. control (2.1%; n = 8) (Δ0.4%, 95% CI: –1.5%; 2.2%; P &lt; 0.001). Most rebounders (12/19 [63%] vs. 4/8 [50%]) resuppressed by Week 48 without change in therapy. Week 48 virologic suppression rates (VL &lt; 50 c/mL; FDA Snapshot) were 94.9% vs. 93.7% (Δ1.2%, 95% CI: −1.7%;4.1%) and VF rates (VL ≥ 50 c/mL; Snapshot) were 0.8% vs. 0.5% (Δ0.3%, 95% CI: −0.7%;1.2%), with no discontinuations for VF. No resistance-associated mutations related to any study drug were observed.
Adverse events (AEs) were similar between arms: AE-related discontinuations (1.4% vs. 1.3%); grade 3–4 AEs (6.8% vs. 8.2%); serious AEs (4.6% vs. 4.8%); and no deaths. Renal and bone parameters favored D/C/F/TAF vs. control. TC and LDL-C slightly favored control vs. D/C/F/TAF, with no clinically significant difference in TC/HDL-C ratio between arms (Table 1).

Conclusion
Percentage of virologic rebound after switching to D/C/F/TAF was non-inferior to control cumulative through Week 48, with high suppression rates (94.9%), no resistance development, better bone and renal safety parameters and similar TC/HDL-C ratio. D/C/F/TAF maintains the high genetic barrier to resistance of darunavir with the safety advantages of TAF, even in patients with a history of non-DRV VF.

Disclosures
C. Orkin, Janssen Pharmaceuticals: Grant Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research grant, Speaker honorarium and Travel bursary to attend conference. MSD: Grant Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research grant, Speaker honorarium and Travel bursary to attend conference. Viiv Healthcare: Grant Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research grant, Speaker honorarium and Travel bursary to attend conference. Gilead Sciences: Grant Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research grant, Speaker honorarium and Travel bursary to attend conference. J. M. Molina, Merck / Gilead: Scientific Advisor, Research grant. Janssen / Viiv / BMS / Teva: Scientific Advisor, Speaker honorarium. Gilead: Speaker’s Bureau, Speaker honorarium. J. Gallant, Janssen Therapeutics: Investigator, Research support. E. Negredo, Janssen: Board Member, Scientific Advisor and Speaker’s Bureau, Speaker honorarium. J. Gathe, Janssen: Consultant and Investigator, Research grant and Speaker honorarium. J. Eron, Janssen: Consultant and Grant Investigator, Consulting fee and Grant recipient. E. Van Landuyt, Janssen: Employee and Shareholder, Salary. E. Lathouwers, Janssen: Employee and Shareholder, Salary. V. Hufkens, Janssen: Employee and Shareholder, Salary. R. Petrovic, Janssen: Employee and Shareholder, Salary. M. Opsomer, Janssen: Employee and Shareholder, Salary.