Integrated Population Exposure–Response of Dolutegravir in HIV‐1 Supports Bridging of Clinical Response Influenced by Relevant Intrinsic and Extrinsic Patient Characteristics

Dolutegravir (DTG) is a human immunodeficiency virus type 1 (HIV‐1) integrase strand transfer inhibitor indicated in combination with other antiretroviral agents for the treatment of HIV‐1 infection in adults and pediatric subjects aged at least 4 weeks. The present work aimed to characterize the viral response based on a pooled analysis of exposure–response (E–R) from five studies in treatment‐experienced and integrase‐resistant (INI‐r) patients infected with HIV‐1. Importantly, model‐based simulations of the E–R relationships with DTG provided insight into the clinical relevance of known intrinsic (e.g., sub‐population with Q148‐driven integrase mutation) and extrinsic (food, enzyme inducers, and metal cation‐containing products) factors expected to influence the DTG E–R relationship. Model‐based post hoc exposure metrics (C min and C avg) were incorporated into a mechanistic population viral dynamic model describing the short‐term effect of DTG on log10 HIV‐1 RNA viral load over 8 or 10 days. In addition, the impact of DTG in combination with background ARTs on the 24‐week HIV RNA response was also assessed using logistic regression. There was good concordance between model‐based predictions and observed virologic response on day 10 and week 24. The E–R model‐based simulations exploring the potential impact of a higher dose (100 mg b.i.d.) of DTG in subpopulations experiencing exposure changes due to covariates did not show clinically relevant changes in virological response compared with the approved 50 mg b.i.d. clinical dose. Overall, our study confirmed the current recommendation of dolutegravir 50 mg b.i.d. in the integrase inhibitor‐resistant (INI‐r) population.