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Low efficacy and high frequency of adverse events in a randomized trial of the triple nucleoside regimen abacavir, stavudine and didanosine

Gerstoft, Jana; Kirk, Oleb,c; Obel, Nielsd; Pedersen, Courte; Mathiesen, Larsb; Nielsen, Henrikf; Katzenstein, Terese La; Lundgren, Jens Db,c

Clinical Science

Background: Highly active antiretroviral therapy containing three nucleoside reverse transcriptase inhibitors has been somewhat successful, but the clinical efficacy is unclear.

Methods: Randomized, controlled, open-label trial of 180 antiretroviral drug-naive HIV-infected patients allocated to a regimen of abacavir, stavudine and didanosine (A/S/D, n = 60), ritonavir and saquinavir (R/S 400/400 mg twice daily; n = 60) or nelfinavir and nevirapine (N/N 1250/200 mg twice daily; n = 60); the latter two in combination with lamivudine and zidovudine. The primary endpoint was HIV plasma RNA ≤ 20 copies/ml after 48 weeks.

Results: At baseline, the median CD4 cell count was 161 × 106 cells/l (range, 0–920) and the HIV RNA was 5.0 log10 copies/ml (range, 2.7–6.7). At 48 weeks, 43% in the A/S/D arm had a HIV RNA ≤ 20 copies/ml, compared with 69% in the N/N arm (P < 0.01) and 62% in the R/S arm (P < 0.05). In a multivariate analysis, the A/S/D arm had an odds ratio of obtaining a viral load of ≤ 20 copies/ml at week 48 of 0.25 [95% confidence interval (CI) 0.10–0.59] versus N/N and 0.53 (95% CI, 0.33–0.83) versus R/S. The A/S/D arm had a particularly poor outcome in patients with higher viral load and AIDS at baseline: 63% had to discontinue A/S/D (any drug). Side effects were more frequent in the A/S/D arm and included neuropathy 27%, suspicion of hypersensitivity 12%, and increase in lactate accompanied by systemic symptoms 8%.

Conclusion: The A/S/D regimen had a low efficacy and a high frequency of adverse events and cannot be recommended.

From the Department of Infectious Diseases at aRigshospitalet, Copenhagen, the bDepartment of Infectious Diseases and the cCopenhagen HIV Programme, Hvidovre University Hospital, Hvidovre, and the Departments of Infectious Diseases at dSkejby Hospital, Aarhus, eOdense University Hospital, Odense and fAalborg Hospital, Aalborg, Denmark.

Requests for reprints to: Dr J. Gerstoft, Copenhagen University Hospital Rigshospitalet, Department of Infectious Diseases M 5132, Blegdamsvej 9, 2100 Copenhagen, Denmark.

Received: 24 October 2002; revised: 20 February 2003; accepted: 24 March 2003.

© 2003 Lippincott Williams & Wilkins, Inc.