Increased risk of IRIS with integrase inhibitors?


In a French cohort 2,287 patients that had less than 200 in CD4 cell count and who started antiretroviral therapy (ART) between 2010 and 2015 were identified. Data were prospectively collected. 398 patients started therapy with Integrase inhibitors (INSTI) and 1,889 patients started with ART not containing INSTI. All cases of Immune Reconstitution Inflammatory Syndrome (IRIS) requiring hospital care were registered. 3 % of the patients that received INSTI versus 1.5 % of the patients receiving ART without INSTI developed IRIS requiring hospitalization. Pre-ART viral loads were comparable but viral loads at three months were significantly lower in patients receiving INSTI. The authors suggest that the risk of severe IRIS requiring hospitalization is increased in INSTI based ART compared to other treatments.

Dutertre et al. JAcquir Immune Syndr 2017;76:e23-e26

Comment: It is well known that the viral load declines faster with ART containing INSTIs compared to treatment combinations with non-nucleoside reverse transcriptase inhibitors or protease inhibitors. It is not unlikely that this may lead to a faster immune recovery and an increased likelihood of IRIS. However, it is doubtful whether this possible increased risk of IRIS should influence our choice of first line treatment in patients with low CD4 counts.