title: Resistance-related mutations in the HIV-1 protease gene of patients treated for 1 year with the protease inhibitor ritonavir (ABT-538).
abstract: OBJECTIVE
  To define genotypic and phenotypic resistance patterns following prolonged therapy with the protease inhibitor ritonavir (ABT-538).
  
  
  METHODS
  Seven HIV-1-infected patients, all but one previously treated with dideoxynucleoside analogues (zidovudine, didanosine, zalcitabine), were treated for 1 year with ritonavir.
  
  
  METHODS
  Direct solid-phase sequencing of the protease gene starting from plasma derived viral RNA followed by comparison to phenotypic drug resistance data.
  
  
  RESULTS
  The most frequent amino-acid substitutions occurring upon administration of the protease inhibitor were V82A/F (substrate binding site), I54V (flap region), A71V and L10I. Additional mutations found in more than one patient were I15V, M36I, I84V and I93L. Mutation L63P was found both in pre- and post-ritonavir samples. Phenotypic drug resistance assays confirmed resistance to ritonavir in post-treatment samples (approximately 170-fold) and showed cross-resistance to indinavir (approximately 30-fold) and partially to saquinavir (approximately fivefold). At 1 year of treatment, one patient without known resistance-associated mutations in the protease gene still showed a substantial rise in CD4 cell count accompanied by a more than 2.4 log decrease in RNA viral load. However, at week 78, mutations R8Q, E34K, R57K, L63P and I84V were detected and the treatment benefit was partially lost.
  
  
  CONCLUSIONS
  Long-term treatment with ritonavir is associated with the emergence of multiple mutations in the HIV-1 protease gene. The mutations L10I, I54V, L63P, A71V, V82A/F and I84V correspond to known drug-resistance mutations for ritonavir and other protease inhibitors. Phenotypic resistance to ritonavir was detected in a majority of ritonavir-treated patients at 1 year of treatment. In addition, long-term ritonavir treatment selects for cross-resistance to the protease inhibitors indinavir and saquinavir. This argues against sequential therapy with several protease inhibitors. Delayed resistance in one patient was accompanied with a prolonged increase in CD4 cell count and decrease in viral load suggesting a temporary benefit of treatment.
authors.affiliation: Rega Institute for Medical Research, Catholic University of Leuven, Belgium.
authors.forename: J C
authors.initials: JC
authors.lastname: Schmit
authors.forename: L
authors.initials: L
authors.lastname: Ruiz
authors.forename: B
authors.initials: B
authors.lastname: Clotet
authors.forename: A
authors.initials: A
authors.lastname: Raventos
authors.forename: J
authors.initials: J
authors.lastname: Tor
authors.forename: J
authors.initials: J
authors.lastname: Leonard
authors.forename: J
authors.initials: J
authors.lastname: Desmyter
authors.forename: E
authors.initials: E
authors.lastname: De Clercq
authors.forename: A M
authors.initials: AM
authors.lastname: Vandamme
mesh_terms: D000595:Amino Acid Sequence; D004351:Drug Resistance / Q000235:genetics; D015658:HIV Infections / Q000188:drug therapy* / Q000378:metabolism; D016333:HIV Protease / Q000235:genetics*; D017320:HIV Protease Inhibitors / Q000494:pharmacology* / Q000627:therapeutic use; D015497:HIV-1 / Q000187:drug effects* / Q000235:genetics / Q000302:isolation & purification; D006801:Humans; D008969:Molecular Sequence Data; D009154:Mutation / Q000187:drug effects; D019438:Ritonavir / Q000494:pharmacology* / Q000627:therapeutic use; D017421:Sequence Analysis
chemical_list: D017320:HIV Protease Inhibitors; D016333:HIV Protease; D019438:Ritonavir