Safety, Pharmacokinetics, and Antiretroviral Activity of the Potent, Specific Human Immunodeficiency Virus Protease Inhibitor Nelfinavir: Results of a Phase I/II Trial and Extended Follow‐up in Patients Infected with Human Immunodeficiency Virus

Abstract

The safety, antiretroviral activity, and pharmacokinetic profile of nelfinavir, a potent and specific inhibitor of human immunodeficiency virus (HIV) protease, were assessed in a small open-label phase I/II dose-ranging study in protease inhibitor-naive HIV-positive men. A total of 22 patients with baseline plasma HIV RNA > or = 20,000 copies/mL and CD4+ counts between 200 and 500 cells/mm3 were enrolled in the study. Of the 22 patients, 20 were evaluated for activity; 10 patients assigned to 771 mg/day base equivalent (300 mg three times daily) and 10 patients assigned to 1,026 mg/day base equivalent (600 mg twice daily) given monotherapy. A capsule formulation of nelfinavir was used. The initial study period was 28 days; patients showing a virologic response of 1 log10 reduction were eligible for enrollment in an extension phase and addition of nucleoside analogues. A maximally tolerated dose of nelfinavir was not established. A dose-response relationship was observed for four (40%) patients in the 771-mg group and six (60%) patients in the 1,026-mg group experiencing a reduction from baseline in plasma HIV RNA of at lest 1 log during the 28-day study. Of these patients, five sustained the reduction in plasma HIV RNA beyond day 28 (2 patients receiving 771 mg/day and 3 patients receiving 1,026 mg/day). Median increases from baseline in CD4+ counts at day 28 were 216 cell/mm3 and 86 cell/mm3 in the 771-mg and 1,026-mg groups, respectively. After oral administration, median nelfinavir plasma concentrations on day 28 reached a maximum at 1 hour (2,966 ng/mL) in the 771-mg group and at 3 hours (3,157 ng/mL) in the 1,026-mg group. Data for 22 patients were included in the safety analysis; 12 patients (55%) reported at least one grade 2 or worse (moderate, severe, or very severe) adverse event. The most common grade 2 or worse adverse event was diarrhea, reported by two patients (20%) receiving 771 mg/day and seven patients (70%) receiving 1,026 mg/day; followed by nausea, flatulence, asthenia, and headache (each reported in 1 patient [10%] in the 771-mg group) and dizziness (reported in 1 patient [10%] receiving 1,026 mg/day). In the small subgroup (n = 6) who continued taking nelfinavir for longer periods (between 8 and 15 months), virologic responses were sustained in the majority of patients with good tolerability. Nelfinavir is an active HIV-protease inhibitor with favorable pharmacokinetics, good tolerability, and sustained antiviral effects. Results of this early phase I/II dose-ranging study provided data for the safety and antiretroviral activity of nelfinavir and led to the selection of higher doses for phase II/III trials to further optimize virologic and immunologic responses.

Timing of the Components of the HIV Life Cycle in Productively Infected CD4 + T Cells in a Population of HIV-Infected Individuals

“…a Estimates of the mean delays assume the same first-phase decay rate across all drugs. The PK estimates for the following drugs are taken from the literature: raltegravir (24), rilpivirine (7), abacavir (19), tenofovir (1), maraviroc (6), ritonavir (30), and nelfinavir (25). The PK delay for enfuvirtide was calculated as described in Materials and Methods from data in Kilby et al (17).…”

“…In order for the calculation of the initial delay (determined by fitting a delayed decay curve to HIV RNA data) to be reasonably accurate, we also required data that had been obtained by frequent sampling of plasma following the commencement of drug dosing. We obtained longitudinal data of the number of HIV RNA copies per ml of plasma for individual patients from previously published monotherapy doseranging or viral dynamics studies from each of the following drug classes: INI, raltegravir (RAL) (26); NNRTI, rilpivirine (RIL) (7); NRTI, abacavir (ABC) and tenofovir disoproxil fumarate (TDF) (8); FI, enfuvirtide (T20) (17); CCR5-I, maraviroc (MVC) (17); PI, ritonavir (RTV) (30) and nelfinavir (NFV) (25).…”

Circulating Metabolites of the Human Immunodeficiency Virus Protease Inhibitor Nelfinavir in Humans: Structural Identification, Levels in Plasma, and Antiviral Activities

“…Nelfinavir mesylate {Viracept; [3S-(3R*, 4aR*, 8aR*, 2ЈS*, 3ЈS*)]-2-(2Ј-hydroxy-3Ј-phenylthiomethyl-4Ј-aza-5Ј-oxo-5Ј-(2Љ-methyl-3Љ-hydroxy-phenyl)-decahydroisoquinoline-3-N-t-butylcarboxamide methanesulfonic acid} is a potent and orally available HIV protease inhibitor that has been shown in phase III controlled clinical trials to significantly reduce viral load and increase CD4 ϩ cell counts in patients when used in combination with RT inhibitors (16)(17)(18). This agent is currently being widely prescribed as part of triple-drug combination therapy for the treatment of HIV infection.…”

Retracing the Evolutionary Pathways of Human Immunodeficiency Virus Type 1 Resistance to Protease Inhibitors: Virus Fitness in the Absence and in the Presence of Drug

“…In individuals receiving antiretroviral therapy, the concentration of drug in peripheral blood can vary greatly over time during a single day, the result of discontinuous oral drug intake by patients and of more or less rapid drug inactivation by the natural clearance systems of the body (28,34,44). Drug concentrations are also presumed to vary widely from one anatomical compartment to another, with some compartments often considered possible sanctuaries for virus replication in spite of therapy (2,13,48).…”