1 00:00:00,000 --> 00:00:12,480 Thanks for joining us again at the Canadian Breakpoint, a Canadian infectious diseases 2 00:00:12,480 --> 00:00:16,560 podcast by Canadian infectious diseases physicians. 3 00:00:16,560 --> 00:00:21,480 I'm Summer Stewart, here with Dr. Rupeena Purewal, pediatric infectious diseases specialist 4 00:00:21,480 --> 00:00:23,120 from Saskatoon. 5 00:00:23,120 --> 00:00:29,840 In this episode, we welcome infectious diseases pediatrician Dr. Jason Brophy to review Dolutegra 6 00:00:29,840 --> 00:00:31,720 Vir Disperseable Tab. 7 00:00:31,720 --> 00:00:32,960 Dr. Purewal. 8 00:00:32,960 --> 00:00:37,600 All right, welcome to another episode of our podcast the Canadian Breakpoint. 9 00:00:37,600 --> 00:00:43,400 Today, we have a very special guest with us, Dr. Brophy, who is a pediatric infectious 10 00:00:43,400 --> 00:00:48,680 disease specialist and researcher at the Children's Hospital of Eastern Ontario, and an associate 11 00:00:48,680 --> 00:00:52,840 professor of pediatrics at the University of Ottawa. 12 00:00:52,840 --> 00:00:58,880 His research interests are in pediatric and perinatal HIV and other congenital infections. 13 00:00:58,880 --> 00:01:05,640 He is the current chair of the Canadian Pediatric and Perinatal HIV and AIDS Research Group, 14 00:01:05,640 --> 00:01:11,840 CPARCH, and co-lead of the Clinical Care and Management Research Corps of the Canadian 15 00:01:11,840 --> 00:01:14,160 HIV Trials Network. 16 00:01:14,160 --> 00:01:21,960 He works part-time as a pediatric HIV clinical advisor with the Clinton Health Access Initiative, 17 00:01:21,960 --> 00:01:27,680 supporting the uptake of optimal pediatric HIV care in West Central Africa and Southeast 18 00:01:27,680 --> 00:01:28,920 Asia. 19 00:01:28,920 --> 00:01:29,920 So welcome, Dr. Brophy. 20 00:01:29,920 --> 00:01:30,920 Thanks. 21 00:01:30,920 --> 00:01:32,920 Great to be here. 22 00:01:32,920 --> 00:01:33,920 Perfect. 23 00:01:33,920 --> 00:01:38,640 So today, we have a very exciting episode because we're talking about Dolutegra Vir. 24 00:01:38,640 --> 00:01:44,400 And so for some of our listeners who manage adult HIV, they're probably quite familiar 25 00:01:44,400 --> 00:01:50,320 with Dolutegra Vir and its mechanism of action, uses, and indications. 26 00:01:50,320 --> 00:01:56,040 But we're very fortunate that there's been new formulary in pediatrics, so the disperseable 27 00:01:56,040 --> 00:02:00,160 tabs that are now available. 28 00:02:00,160 --> 00:02:06,200 And you have some clinical experience and research experience with Dolutegra Vir. 29 00:02:06,200 --> 00:02:09,880 So it's really a pleasure to have you here today. 30 00:02:09,880 --> 00:02:12,880 Yeah, no, I agree. 31 00:02:12,880 --> 00:02:18,120 It's nice to have some new drugs for kids because for a long time, we've been without 32 00:02:18,120 --> 00:02:24,160 the poor cousin to the adult HIV crowd. 33 00:02:24,160 --> 00:02:28,840 So it's nice to have new modern drugs to offer our kids here in Canada. 34 00:02:28,840 --> 00:02:30,800 Yeah, no, very fair. 35 00:02:30,800 --> 00:02:31,800 Yeah. 36 00:02:31,800 --> 00:02:36,480 So I think in terms of what I would like to start with today is for a lot of our listeners. 37 00:02:36,480 --> 00:02:43,240 So we have listeners across the globe, definitely, you know, first, like family physicians, we 38 00:02:43,240 --> 00:02:50,180 have pediatric physicians, we have infectious disease physicians across the globe. 39 00:02:50,180 --> 00:02:54,520 And so it would be nice to kind of maybe not everybody is aware of Dolutegra Vir. 40 00:02:54,520 --> 00:03:01,380 So can we just kind of introduce maybe what Dolutegra Vir is and its common uses and mechanism 41 00:03:01,380 --> 00:03:02,380 of action? 42 00:03:02,380 --> 00:03:05,400 Sure, happy to do that. 43 00:03:05,400 --> 00:03:06,400 Thanks. 44 00:03:06,400 --> 00:03:11,980 So Dolutegra Vir is in the integrase strand inhibitor family or INSTEE family. 45 00:03:11,980 --> 00:03:19,120 And its mechanism of action is that it prevents the HIV enzyme integrase from integrating 46 00:03:19,120 --> 00:03:24,960 the viral DNA into the host CD4 cell DNA. 47 00:03:24,960 --> 00:03:28,920 And so it's one of the newer families of drugs. 48 00:03:28,920 --> 00:03:37,320 So back in the old, old days, we had the NRTIs first, like AZT, 3TC. 49 00:03:37,320 --> 00:03:41,620 And we had NRTIs like nevirapine and afavron. 50 00:03:41,620 --> 00:03:47,640 And then the protease inhibitors came out and they really were kind of the linchpin 51 00:03:47,640 --> 00:03:49,960 that helped move us ahead. 52 00:03:49,960 --> 00:03:59,080 And in 1996, we learned that using them in combination, like two NRTIs plus one NRTI 53 00:03:59,080 --> 00:04:04,120 or PEI protease inhibitor, that was what we called highly active antiretroviral therapy 54 00:04:04,120 --> 00:04:05,720 or HEART. 55 00:04:05,720 --> 00:04:09,840 And so for years, we were working with those three families. 56 00:04:09,840 --> 00:04:13,880 And now we're up to five families that are commercially available. 57 00:04:13,880 --> 00:04:19,240 And there's other ones that are coming out, which is really nice. 58 00:04:19,240 --> 00:04:25,440 But the integrase inhibitors or INSTEE family really have kind of taken over in terms of 59 00:04:25,440 --> 00:04:29,920 being the main ones that we're using nowadays as their anchor drugs. 60 00:04:29,920 --> 00:04:34,320 So two NRTI drugs plus one third drug. 61 00:04:34,320 --> 00:04:39,760 And the third drug is increasingly becoming something from the INSTEE family. 62 00:04:39,760 --> 00:04:41,720 And so dolutegra Vir is one of those. 63 00:04:41,720 --> 00:04:46,960 There are five that we have available for use in Canada right now. 64 00:04:46,960 --> 00:04:54,600 Rauhtegra Vir, Elvitegra Vir, Bictegra Vir, Cabotegra Vir, and dolutegra Vir. 65 00:04:54,600 --> 00:05:02,160 And then we have three of those that have pediatric formulations available. 66 00:05:02,160 --> 00:05:08,680 And so the kind of advantages of these drugs are that they tend to be really well tolerated 67 00:05:08,680 --> 00:05:15,440 and that they don't have the same nasty side effects that some of the earlier ones had. 68 00:05:15,440 --> 00:05:22,520 Like, Favrons caused a lot of neuropsychiatric stuff, like nightmares or made people really 69 00:05:22,520 --> 00:05:25,240 groggy or sleepy or dizzy. 70 00:05:25,240 --> 00:05:29,560 And then the protease inhibitors, the older ones at least, that we had in the liquid ones 71 00:05:29,560 --> 00:05:36,800 that we used for kids, caused a lot of GI upset, diarrhea, vomiting, nausea, especially 72 00:05:36,800 --> 00:05:44,160 for the little babies, like the main one that we always use, dolpenevir, ritonavir. 73 00:05:44,160 --> 00:05:48,920 We did taste tests of it when I was a trainee many years ago. 74 00:05:48,920 --> 00:05:50,640 And I'll never forget that day. 75 00:05:50,640 --> 00:05:56,720 It was like taking a shot of kerosene and it really just stuck with you the whole day. 76 00:05:56,720 --> 00:05:59,400 But like really bad reflux and burning. 77 00:05:59,400 --> 00:06:05,040 And so every time I heard a mom come in saying how hard it was to give this medicine, I was 78 00:06:05,040 --> 00:06:06,040 like, yeah, I know why. 79 00:06:06,040 --> 00:06:07,040 Right. 80 00:06:07,040 --> 00:06:12,800 So yeah, we're all hoping for newer, better drugs. 81 00:06:12,800 --> 00:06:17,720 And so this family has kind of allowed that to happen, which is great. 82 00:06:17,720 --> 00:06:18,720 That's awesome. 83 00:06:18,720 --> 00:06:19,720 Yeah. 84 00:06:19,720 --> 00:06:23,160 So definitely, as you talked about, I mean, there's not too many options in pediatrics. 85 00:06:23,160 --> 00:06:30,020 So for dolpenevir specifically, when we talk about pediatric meds in general, we always 86 00:06:30,020 --> 00:06:35,200 have weight cutoffs or age cutoffs that we can use them. 87 00:06:35,200 --> 00:06:42,180 So for this new formulation of dolutegravir, how young can we be giving that or adding 88 00:06:42,180 --> 00:06:43,180 it to the regimen? 89 00:06:43,180 --> 00:06:49,560 Yeah, there have been a few really, really good studies that have helped inform how we 90 00:06:49,560 --> 00:06:50,560 use dolutegravir. 91 00:06:50,560 --> 00:06:53,440 So they add out tablet, which is actually pretty tiny. 92 00:06:53,440 --> 00:06:59,200 It's about the size of an ibuprofen tablet, the 50 milligram one. 93 00:06:59,200 --> 00:07:04,200 We know from the Odyssey trial that we can actually use that down to 20 kilos of weight, 94 00:07:04,200 --> 00:07:06,560 regardless of the age. 95 00:07:06,560 --> 00:07:13,280 And then with the pediatric dispersable tablet, which is strawberry flavored and you drop 96 00:07:13,280 --> 00:07:18,800 it in water and it dissolves pretty quickly, and then the kid can just drink it. 97 00:07:18,800 --> 00:07:24,740 That one is approved for age one month and up and three kilos and up. 98 00:07:24,740 --> 00:07:30,680 And so that makes pretty much all the kids that we would want to be treating eligible 99 00:07:30,680 --> 00:07:31,680 for it. 100 00:07:31,680 --> 00:07:36,840 There's actually neonatal studies that are planned or starting up now. 101 00:07:36,840 --> 00:07:41,120 And so hopefully we'll even be able to be using it in younger age groups. 102 00:07:41,120 --> 00:07:46,040 But the metabolism is tricky in the first month, especially the first week. 103 00:07:46,040 --> 00:07:50,000 And so they tend to clear things more slowly. 104 00:07:50,000 --> 00:07:54,240 And so we'll learn more about that as the studies progress. 105 00:07:54,240 --> 00:08:00,840 But yeah, the dispersable tablet's making her lives a lot easier here. 106 00:08:00,840 --> 00:08:07,400 Unfortunately, the NRTIs still don't come in similar dispersable formulations in North 107 00:08:07,400 --> 00:08:09,280 America. 108 00:08:09,280 --> 00:08:21,240 But it's interesting, like in my global work with the chai, the chai kind of made its name 109 00:08:21,240 --> 00:08:27,880 in the HIV game by working with generic companies to produce generic versions of the drugs that 110 00:08:27,880 --> 00:08:31,000 we have in the West. 111 00:08:31,000 --> 00:08:38,280 And they actually have had dispersable formulations of the NRTIs, like abacagran, limididine together, 112 00:08:38,280 --> 00:08:42,120 or sadavidine, limididine together. 113 00:08:42,120 --> 00:08:48,840 And then the other tablet, the other ones like the NRTIs, they've had them for years. 114 00:08:48,840 --> 00:08:54,400 And so the pediatric dialyutegibir came out a couple of years ago as a generic product 115 00:08:54,400 --> 00:08:59,320 just after it was released here in North America. 116 00:08:59,320 --> 00:09:04,360 And so when I go and do my teaching in these other countries, I tell them, you're actually 117 00:09:04,360 --> 00:09:10,840 luckier than me in that I don't have access to all of these same formulations of dispersable 118 00:09:10,840 --> 00:09:19,000 tablets, which makes them feel a bit better that they have some advantages over us here. 119 00:09:19,000 --> 00:09:20,000 Right. 120 00:09:20,000 --> 00:09:21,000 Yeah. 121 00:09:21,000 --> 00:09:22,000 No, I mean, it makes a huge difference. 122 00:09:22,000 --> 00:09:29,480 And so I guess clinically, in my practice, there's definitely been indications. 123 00:09:29,480 --> 00:09:33,840 For instance, you mentioned with some of the other medications that we commonly use, they 124 00:09:33,840 --> 00:09:36,040 don't taste very good. 125 00:09:36,040 --> 00:09:40,960 So the compliance gets poor and poor, especially as children are getting older and they're 126 00:09:40,960 --> 00:09:44,800 actually involved in the process of taking their meds. 127 00:09:44,800 --> 00:09:48,320 And they now are starting to decline them because of taste or a lot of reflux. 128 00:09:48,320 --> 00:09:54,480 And so I think having a medication like dialyutegibir where it's disperable, and ideally only in 129 00:09:54,480 --> 00:10:00,160 very small amount of MLs of fluid, like clear fluid that you can disperse it in. 130 00:10:00,160 --> 00:10:04,360 And so it's not a huge volume that they're taking. 131 00:10:04,360 --> 00:10:05,360 Yeah. 132 00:10:05,360 --> 00:10:08,920 So that's probably where I've used it clinically. 133 00:10:08,920 --> 00:10:10,640 So are there other indications? 134 00:10:10,640 --> 00:10:14,000 Is it something like you would... 135 00:10:14,000 --> 00:10:17,680 Are the studies showing that it's something that we would be starting off as a primary 136 00:10:17,680 --> 00:10:20,520 regimen as opposed to like second line? 137 00:10:20,520 --> 00:10:22,520 Kind of what I was saying. 138 00:10:22,520 --> 00:10:23,520 Yeah. 139 00:10:23,520 --> 00:10:32,080 So the WHO actually recommended it as their first line preferred therapy, even before 140 00:10:32,080 --> 00:10:38,000 there was a pediatric formulation available, just because there was a big move globally 141 00:10:38,000 --> 00:10:41,360 to kind of embrace integrase inhibitors. 142 00:10:41,360 --> 00:10:45,920 The only one that was really coming to market was dialyutegibir. 143 00:10:45,920 --> 00:10:50,400 So even before the pediatric formulation was available, it was already recommended. 144 00:10:50,400 --> 00:10:57,960 But in North America, we've had like raltegibir in pediatric formulations for a while. 145 00:10:57,960 --> 00:11:05,000 And then the other ones like alvitegibir, which is in a fixed dose combination tablet 146 00:11:05,000 --> 00:11:12,440 called Genfoya, and triimek, which is the dialyutegibir, back of your lamedidine, comes 147 00:11:12,440 --> 00:11:14,080 in a fixed dose combination. 148 00:11:14,080 --> 00:11:19,360 So those were approved for kids 25 kilos and older. 149 00:11:19,360 --> 00:11:24,880 But these new dispersable ones for the younger kids are the ones that are newer. 150 00:11:24,880 --> 00:11:30,360 But they've really, as soon as the formulations were available and the studies showing that 151 00:11:30,360 --> 00:11:38,320 they were effective either as new therapy or switch therapy, then they became the first 152 00:11:38,320 --> 00:11:41,240 line regimens of choice. 153 00:11:41,240 --> 00:11:44,480 So yeah, this is what we should be starting people on. 154 00:11:44,480 --> 00:11:52,840 I guess the other benefit that is worth mentioning is dialyutegibir is once a day, whereas raltegibir, 155 00:11:52,840 --> 00:11:58,060 which we've had for a while, is twice a day, has a lower barrier to resistance. 156 00:11:58,060 --> 00:12:05,480 So if kids are missing any or their drug levels are low for missing doses or vomiting doses, 157 00:12:05,480 --> 00:12:11,160 then there's a higher chance of getting resistance because there's a lower genetic barrier. 158 00:12:11,160 --> 00:12:16,720 It's a developing resistance with the first generation integrates inhibitor raltegibir. 159 00:12:16,720 --> 00:12:23,400 So dialyutegibir is well tolerated, easy to take once a day. 160 00:12:23,400 --> 00:12:32,520 And we know it's really potent that this family suppresses HIV usually within a month in adults. 161 00:12:32,520 --> 00:12:37,840 Kids often start with a higher viral load than adults, especially in the younger kids. 162 00:12:37,840 --> 00:12:40,280 And so it can take a bit longer than that. 163 00:12:40,280 --> 00:12:42,600 But generally it works pretty fast. 164 00:12:42,600 --> 00:12:48,640 So yeah, there's not a lot of downsides except for occasional drug interactions to think 165 00:12:48,640 --> 00:12:49,640 about. 166 00:12:49,640 --> 00:12:50,640 Right. 167 00:12:50,640 --> 00:12:51,640 Yeah. 168 00:12:51,640 --> 00:12:53,000 So one of those would be like probably a contraindication. 169 00:12:53,000 --> 00:12:54,920 So as you mentioned, there aren't any drawbacks. 170 00:12:54,920 --> 00:13:00,320 Are there any main contraindications that where, you know, sometimes we worry about, 171 00:13:00,320 --> 00:13:08,600 is there any maybe like renal issues or liver issues if a child is having those and has 172 00:13:08,600 --> 00:13:12,440 obviously like comorbidity? 173 00:13:12,440 --> 00:13:18,600 Is there a strong contraindication to when not to use dialyutegibir? 174 00:13:18,600 --> 00:13:26,560 So that it is contraindicated in kids or adults with severe renal impairment or severe liver 175 00:13:26,560 --> 00:13:27,560 impairment. 176 00:13:27,560 --> 00:13:33,000 But mild to moderate, it's okay to use for both. 177 00:13:33,000 --> 00:13:40,560 And then in terms of drug-drug interactions, we know it's metabolized mostly by the cytochrome 178 00:13:40,560 --> 00:13:48,840 P450-3a as well as the UGT1A1. 179 00:13:48,840 --> 00:13:57,680 And so those are the ones that kind of get induced by things like rifampin and some of 180 00:13:57,680 --> 00:14:00,520 the anti-epileptic drugs like phenyton or phenobarb. 181 00:14:00,520 --> 00:14:09,560 So because rifampin is such a big drug to treat TB globally, there's been a fair amount 182 00:14:09,560 --> 00:14:14,600 of work looking at how we can overcome that interaction. 183 00:14:14,600 --> 00:14:18,960 So we know if you double the dose of dialyutegibir, like give it twice a day instead of once a 184 00:14:18,960 --> 00:14:22,520 day, then that should overcome that drug-drug interaction. 185 00:14:22,520 --> 00:14:30,280 But for other ones like phenyton or phenobarb, those are too potent in terms of inducing. 186 00:14:30,280 --> 00:14:35,240 So it's recommended not to use those with dialyutegibir. 187 00:14:35,240 --> 00:14:39,720 But there are other anti-epileptic choices. 188 00:14:39,720 --> 00:14:43,980 And so that would be an option to move them to a different anti-epileptic if you wanted 189 00:14:43,980 --> 00:14:49,360 to use the NHGRACE inhibitor or vice versa if you wanted to use those anti-epileptics 190 00:14:49,360 --> 00:14:51,640 and pick a different antiretroviral. 191 00:14:51,640 --> 00:14:54,000 Yeah, that's fair. 192 00:14:54,000 --> 00:14:55,000 Thank you. 193 00:14:55,000 --> 00:14:56,000 Yeah. 194 00:14:56,000 --> 00:14:59,280 I think these are important things because we, you know, if we're commonly seeing patients, 195 00:14:59,280 --> 00:15:02,960 especially the, you know, some of the younger patients and then over time, if they're, let's 196 00:15:02,960 --> 00:15:07,120 say on a regimen and then they're developing other conditions, then we should be probably 197 00:15:07,120 --> 00:15:08,120 well aware of those. 198 00:15:08,120 --> 00:15:13,400 So if I have a patient on dialyutegibir, I mean, a lot of the NHGRACE inhibitor is not 199 00:15:13,400 --> 00:15:16,040 too much monitoring they have to do regularly. 200 00:15:16,040 --> 00:15:21,480 Whereas like some of our other drugs, there's like neutropenia risks. 201 00:15:21,480 --> 00:15:24,800 They definitely have a lot of bone marrow suppression. 202 00:15:24,800 --> 00:15:29,760 Are there any routine labs that a child, like, I mean, outside of our normal every three 203 00:15:29,760 --> 00:15:31,680 months that we would be following them? 204 00:15:31,680 --> 00:15:37,400 Is there anything specific to dialyutegibir that we would need to be monitoring? 205 00:15:37,400 --> 00:15:40,680 So the NHGRACE inhibitors generally can cause myositis. 206 00:15:40,680 --> 00:15:45,120 So we're recommended to monitor CK. 207 00:15:45,120 --> 00:15:50,200 And then they can really cause some like biochemical hepatitis. 208 00:15:50,200 --> 00:15:53,120 And so monitoring of the enzymes as well. 209 00:15:53,120 --> 00:15:58,560 In my experience, I really haven't seen either of those things. 210 00:15:58,560 --> 00:16:02,560 The other main side effects that they talk about with intergastin inhibitors generally 211 00:16:02,560 --> 00:16:10,000 and dialyutegibir in particular are included, I should say, is insomnia, which I'd say 212 00:16:10,000 --> 00:16:15,440 the very first patient ever treated with dialyutegibir had wicked insomnia. 213 00:16:15,440 --> 00:16:22,880 He came back and was saying he was like not able to sleep at night and he was falling 214 00:16:22,880 --> 00:16:25,280 asleep on the bus on the way home from school. 215 00:16:25,280 --> 00:16:26,280 Oh no. 216 00:16:26,280 --> 00:16:27,280 Poor guy. 217 00:16:27,280 --> 00:16:29,920 But he really didn't like his twice a day regimen before that. 218 00:16:29,920 --> 00:16:33,320 And so I said, well, it's supposed to resolve within a month or two. 219 00:16:33,320 --> 00:16:35,200 So if you want to stick it out. 220 00:16:35,200 --> 00:16:39,000 And so he stuck it out and it completely resolved within two months. 221 00:16:39,000 --> 00:16:45,200 And so that was a really good learning point for me to just see that, oh yeah, these like 222 00:16:45,200 --> 00:16:49,520 uncommon side effects reported in trials can actually happen in people. 223 00:16:49,520 --> 00:16:54,520 Funnily enough, he's like the only patient I've ever had get that side effect. 224 00:16:54,520 --> 00:16:55,520 First one. 225 00:16:55,520 --> 00:16:59,880 So I usually I usually warn people that it definitely can happen. 226 00:16:59,880 --> 00:17:01,960 But if you stick it out, it should go away. 227 00:17:01,960 --> 00:17:05,880 Like most side effects with antiretrovirals. 228 00:17:05,880 --> 00:17:08,000 Then GI stuff can happen. 229 00:17:08,000 --> 00:17:09,440 Headache can happen. 230 00:17:09,440 --> 00:17:17,520 They say that if your drug levels are really high, that it can cause neuropsychiatric side 231 00:17:17,520 --> 00:17:23,160 effects, like if you had depression, it can worsen it or stuff like that. 232 00:17:23,160 --> 00:17:28,680 But again, my experience has been with pediatrics. 233 00:17:28,680 --> 00:17:32,960 All the side effects that you see in adults are much less common in children. 234 00:17:32,960 --> 00:17:34,720 That is true. 235 00:17:34,720 --> 00:17:40,000 I usually say I think kids are just tougher than adults or maybe we as adults tend to 236 00:17:40,000 --> 00:17:41,840 complain a bit more. 237 00:17:41,840 --> 00:17:42,840 But that's fair. 238 00:17:42,840 --> 00:17:49,520 But yeah, I usually find that it's a really well tolerated drug. 239 00:17:49,520 --> 00:17:51,840 Yeah, no, that's great. 240 00:17:51,840 --> 00:17:59,160 So in terms of, I guess if we're starting to use it more in our clinical practice, what 241 00:17:59,160 --> 00:18:04,560 are some of the costs or the cost to the patient in terms of the health care system, just kind 242 00:18:04,560 --> 00:18:10,820 of looking at from a health care standpoint to is this something that's more affordable 243 00:18:10,820 --> 00:18:14,200 than other drugs and is the access quite easy? 244 00:18:14,200 --> 00:18:19,560 So if a physician would want to start it, how do they go about ordering that in Canada 245 00:18:19,560 --> 00:18:21,560 or the US? 246 00:18:21,560 --> 00:18:27,720 Yeah, so Canada, our health system needs to be a bit better unified. 247 00:18:27,720 --> 00:18:34,760 It's like we have 13 different countries and 13 different systems for how we do health 248 00:18:34,760 --> 00:18:37,800 care and fund it and provide it. 249 00:18:37,800 --> 00:18:44,200 But generally in most provinces, ARVs are covered by provincial programs. 250 00:18:44,200 --> 00:18:51,640 And then the main people I find who have difficulty with paying for ARVs are the ones who have 251 00:18:51,640 --> 00:18:52,640 partial insurance. 252 00:18:52,640 --> 00:18:58,680 So it's kind of like the folks in the lower middle class who have jobs and have private 253 00:18:58,680 --> 00:19:01,040 insurance, but it's not 100%. 254 00:19:01,040 --> 00:19:07,120 And so all the ARVs are still pretty expensive, like running in between like $1,500, $2,000 255 00:19:07,120 --> 00:19:08,800 a month. 256 00:19:08,800 --> 00:19:16,720 So if you only have 80% coverage, like 20% of that is still a fair amount of money. 257 00:19:16,720 --> 00:19:25,320 So the nice thing is that most of the big antiretroviral manufacturers do have support 258 00:19:25,320 --> 00:19:26,320 programs. 259 00:19:26,320 --> 00:19:34,760 And so if people are, say, new to Canada and don't have their health care, like their OHIP 260 00:19:34,760 --> 00:19:42,040 or the provincial coverage set up, or don't have their private insurance or their other 261 00:19:42,040 --> 00:19:48,280 forms of insurance set up, then they'll usually pay for the medications for up to six months. 262 00:19:48,280 --> 00:19:56,440 And then Veev that makes pediatric dolly type of care has a program that will provide partial 263 00:19:56,440 --> 00:20:01,080 coverage as well if people have coverage, but not 100% coverage through their insurance. 264 00:20:01,080 --> 00:20:08,200 So I always tell people that no kid and really no adult in Canada should go without ARVs. 265 00:20:08,200 --> 00:20:12,680 We have lots of options and we have good support programs in place. 266 00:20:12,680 --> 00:20:15,880 That's ideal. 267 00:20:15,880 --> 00:20:24,600 In the global setting though, it's very interesting to work on both sides of the globe with HIV, 268 00:20:24,600 --> 00:20:30,880 because we know that, like I said, most ARV combinations for adults cost somewhere between 269 00:20:30,880 --> 00:20:33,000 $1,500 to $2,000 a month. 270 00:20:33,000 --> 00:20:36,560 So it's $24,000 a year about. 271 00:20:36,560 --> 00:20:42,240 And the same medications for the most part, when they're produced generically, are significantly 272 00:20:42,240 --> 00:20:43,240 cheaper. 273 00:20:43,240 --> 00:20:50,840 And so the adult treatment of choice like TLD, it's not very limiting, which comes as 274 00:20:50,840 --> 00:20:53,760 a single pill. 275 00:20:53,760 --> 00:21:01,680 The price for that has been brought down to about $50 to $60 per patient per year. 276 00:21:01,680 --> 00:21:05,680 So pretty significant reduction, right? 277 00:21:05,680 --> 00:21:11,960 And then for kids, the pediatric value tag of your tablet is a fraction of the cost of 278 00:21:11,960 --> 00:21:17,760 the previous recommended regimen, which is lopinavir, ritonavir tablets. 279 00:21:17,760 --> 00:21:23,640 Those costs, I believe somewhere around 200 to 300 per patient per year. 280 00:21:23,640 --> 00:21:29,480 Because on the kid, how many tablets are taking, the pediatric value tag of your is a fraction 281 00:21:29,480 --> 00:21:30,480 of that. 282 00:21:30,480 --> 00:21:39,640 So really part of why the WHO moved to recommend it was not only the fact that there's increasing 283 00:21:39,640 --> 00:21:45,640 NNRTI resistance to favorens and the barium pain, because it's pretty low bariatric resistance. 284 00:21:45,640 --> 00:21:49,960 You only need one mutation to become resistant to those. 285 00:21:49,960 --> 00:21:54,160 Whereas with value tag of your, it's a lot higher barrier to resistance. 286 00:21:54,160 --> 00:22:01,060 So they're wanting to move away from NNRTI-based first line treatment, especially in countries 287 00:22:01,060 --> 00:22:09,240 that have had reached like the 10% resistance kind of threshold at baseline to NNRTI. 288 00:22:09,240 --> 00:22:14,600 And so there was that, there was the cost part coming down, there was the side effects 289 00:22:14,600 --> 00:22:15,600 profile. 290 00:22:15,600 --> 00:22:21,400 We knew the people on a favorens, which is the main drug used before, at a higher rate 291 00:22:21,400 --> 00:22:27,980 of neuropsychiatric side effects, depression, higher risk of suicide, higher risk of people 292 00:22:27,980 --> 00:22:29,960 going off medications over time. 293 00:22:29,960 --> 00:22:37,400 And so really the kind of coalesced around getting behind this new drug and regimen. 294 00:22:37,400 --> 00:22:41,320 And so that extended down to kids too, which is great. 295 00:22:41,320 --> 00:22:49,480 Especially they're stuck on the old Kalitra or Lopinavir, which we can't complain, right? 296 00:22:49,480 --> 00:22:55,080 It's a good antiretroviral, it treats the HIV well, and it saved a lot of people's lives. 297 00:22:55,080 --> 00:22:59,180 And we can't be too down on these old drugs. 298 00:22:59,180 --> 00:23:04,960 They got us to where we are today and saved a lot of our patients' lives. 299 00:23:04,960 --> 00:23:11,080 Long-term usage and having people be able to stay on them in the long-term, it's better 300 00:23:11,080 --> 00:23:13,520 to have drugs that are better tolerated. 301 00:23:13,520 --> 00:23:14,520 Yeah, definitely. 302 00:23:14,520 --> 00:23:15,520 Yeah. 303 00:23:15,520 --> 00:23:20,240 And it's nice because most of these kids then can remain on that once they get into their 304 00:23:20,240 --> 00:23:24,120 tablet forms and it's a really easy switch over. 305 00:23:24,120 --> 00:23:30,960 It's a whole new drug for them, which is really nice because I think, especially us who are 306 00:23:30,960 --> 00:23:37,160 managing pediatric patients and they grow with you, you're definitely transitioning 307 00:23:37,160 --> 00:23:44,120 them to that adult care even or even the adolescent age group, you always want to make it as streamlined 308 00:23:44,120 --> 00:23:45,120 as possible. 309 00:23:45,120 --> 00:23:48,200 So if it's something that's familiar to them already, then they may feel better. 310 00:23:48,200 --> 00:23:54,280 Whereas coming off of some of the older drugs and switching to a drug that they've never 311 00:23:54,280 --> 00:23:57,080 heard of, they sometimes are a little bit nervous too. 312 00:23:57,080 --> 00:24:00,440 So I've definitely seen that. 313 00:24:00,440 --> 00:24:01,800 Yeah. 314 00:24:01,800 --> 00:24:07,800 And then the great thing that is happening is that these companies are really getting 315 00:24:07,800 --> 00:24:12,120 on board with being more sensitive to kids' needs. 316 00:24:12,120 --> 00:24:17,800 And so we have the disperseable Diuretegavir single tablet, but now they've come out with 317 00:24:17,800 --> 00:24:18,800 a three-in-one. 318 00:24:18,800 --> 00:24:26,920 I call it baby Triomec, which is like a baccalaurelamidine and Diuretegavir all in one disperseable tablet, 319 00:24:26,920 --> 00:24:30,760 which can be used down to younger kids. 320 00:24:30,760 --> 00:24:36,840 And that generic version is also coming out in our plan to be coming out for low middle 321 00:24:36,840 --> 00:24:38,240 income countries. 322 00:24:38,240 --> 00:24:44,120 So that's my next job to get countries to move over to that, which will make life even 323 00:24:44,120 --> 00:24:49,800 easier instead of like two separate medications that need to be dispensed down to just one 324 00:24:49,800 --> 00:24:56,240 single tablet regimen or single disperseable tablet regimen, which we'll have here in North 325 00:24:56,240 --> 00:25:02,480 America as well as in low middle income countries for the majority of kids with HIV or living. 326 00:25:02,480 --> 00:25:03,480 Yeah. 327 00:25:03,480 --> 00:25:04,480 That'll be really fantastic. 328 00:25:04,480 --> 00:25:10,960 I mean, one of the most difficult parts about treating HIV is make insuring compliance, 329 00:25:10,960 --> 00:25:11,960 right? 330 00:25:11,960 --> 00:25:17,360 Because if they're not on their meds, then those are when the complications start and 331 00:25:17,360 --> 00:25:19,200 then their viral load is not suppressed. 332 00:25:19,200 --> 00:25:21,880 And so I think that's probably one of the... 333 00:25:21,880 --> 00:25:27,160 So if we can make the patient's life easier by not having to take so many meds, I think 334 00:25:27,160 --> 00:25:31,080 we can probably achieve undetectable viral loads too. 335 00:25:31,080 --> 00:25:32,440 So yeah, so that'll be... 336 00:25:32,440 --> 00:25:33,440 That's great. 337 00:25:33,440 --> 00:25:34,440 Nice to hear. 338 00:25:34,440 --> 00:25:41,000 So when we first got in touch about Diuretegavir and we were talking about you coming on the 339 00:25:41,000 --> 00:25:46,040 podcast, you mentioned your awesome work with the Clinton Health Initiative. 340 00:25:46,040 --> 00:25:51,080 So I guess I wanted to touch base with you about some of the work that you're doing out 341 00:25:51,080 --> 00:25:52,080 there. 342 00:25:52,080 --> 00:25:54,080 And if you wanted to highlight for some of... 343 00:25:54,080 --> 00:25:58,720 I know some of the audience members who are interested in global health for sure would 344 00:25:58,720 --> 00:26:04,320 find this a very, very intriguing conversation for sure. 345 00:26:04,320 --> 00:26:06,080 Yeah. 346 00:26:06,080 --> 00:26:10,800 So when I was back in my training days, I was like, when I grow up, I wanted to do global 347 00:26:10,800 --> 00:26:13,560 health and do global HIV work. 348 00:26:13,560 --> 00:26:18,080 And it was a bit of a rough slog to figure out how to do that. 349 00:26:18,080 --> 00:26:25,640 But I'm very lucky that I get to mix my job here in Canada, looking after kids at an academic 350 00:26:25,640 --> 00:26:29,440 pediatric hospital, and then also work part time abroad. 351 00:26:29,440 --> 00:26:35,640 And so with CHI, Clinton Health Access Initiative, it used to be the Clinton Foundation, but 352 00:26:35,640 --> 00:26:42,680 then they started doing a lot of different things, including environmental work and political 353 00:26:42,680 --> 00:26:43,680 advocacy. 354 00:26:43,680 --> 00:26:48,680 So they carved up all the health stuff and put it into this CHI, or Clinton Health Access 355 00:26:48,680 --> 00:26:50,680 Initiative. 356 00:26:50,680 --> 00:27:00,680 And so they made their name on HIV and getting generic products for HIV care and treatment. 357 00:27:00,680 --> 00:27:07,800 But now they do a lot of other stuff, TB, cryptococcal meningitis, hepatitis C, maternal 358 00:27:07,800 --> 00:27:13,040 newborn child health, lots of other stuff, COVID now. 359 00:27:13,040 --> 00:27:17,600 And so who's not doing COVID? 360 00:27:17,600 --> 00:27:25,000 But my stuff is still predominantly focused on HIV and then advanced HIV disease like 361 00:27:25,000 --> 00:27:28,360 TB and other opportunistic infections. 362 00:27:28,360 --> 00:27:38,640 So what I do is we have products like this that we're trying to get countries to take 363 00:27:38,640 --> 00:27:45,400 up to modernize their approaches. 364 00:27:45,400 --> 00:27:51,480 And so we work directly with ministries of health across Sub-Saharan Africa and Southeast 365 00:27:51,480 --> 00:27:58,560 Asia and Southern Asia, India, parts of the Caribbean and South America as well. 366 00:27:58,560 --> 00:28:03,840 So my work is working directly with ministries of health, kind of going through with them 367 00:28:03,840 --> 00:28:11,160 what are the WHO guidance recommendations, how can they make changes to their guidance 368 00:28:11,160 --> 00:28:15,040 in accordance with WHO, if it fits, right? 369 00:28:15,040 --> 00:28:20,800 Like it really needs to be tailored to their needs and what they're ready to do. 370 00:28:20,800 --> 00:28:29,960 And then making, ordering these products more available, negotiating pricing agreements 371 00:28:29,960 --> 00:28:34,560 to get the best use for money possible. 372 00:28:34,560 --> 00:28:39,280 So it's been great that people think I go and work in hospitals abroad, but I don't 373 00:28:39,280 --> 00:28:40,280 really do that. 374 00:28:40,280 --> 00:28:45,320 I go and do workshops with clinicians, talk just about all the stuff I've talked about 375 00:28:45,320 --> 00:28:51,560 with you, but kind of translate it into what is important for them and tell them how to 376 00:28:51,560 --> 00:28:55,880 use these drugs and how you would monitor them. 377 00:28:55,880 --> 00:29:01,720 We make a knowledge translation and educational materials both for the clinicians as well 378 00:29:01,720 --> 00:29:04,560 as the patients and their families. 379 00:29:04,560 --> 00:29:09,160 And so really try to make life easier for them to be able to do their job well. 380 00:29:09,160 --> 00:29:10,960 So it's a lot of fun. 381 00:29:10,960 --> 00:29:18,800 I get to see a lot of the world and know that even this pediatric value tag of your product 382 00:29:18,800 --> 00:29:22,640 only came out. 383 00:29:22,640 --> 00:29:29,480 The first countries had access to it back in the second half of last year. 384 00:29:29,480 --> 00:29:37,160 And now the majority of countries with high HIV burden have transitioned or are in the 385 00:29:37,160 --> 00:29:43,480 process of transitioning their patients over to pediatric value tag of your, and some countries 386 00:29:43,480 --> 00:29:48,740 are up to like over 90% of kids on this product within a year of it coming out. 387 00:29:48,740 --> 00:29:50,440 So it's really, really nice. 388 00:29:50,440 --> 00:29:52,240 Yeah, it's great. 389 00:29:52,240 --> 00:29:56,800 It's probably nice to see that comparison and between different countries, and then 390 00:29:56,800 --> 00:30:01,760 you can kind of bring that experience even back to North America, but not only that, 391 00:30:01,760 --> 00:30:05,280 but to like their neighboring countries too. 392 00:30:05,280 --> 00:30:10,360 Because I think one thing with using newer drugs and newer medications is just people 393 00:30:10,360 --> 00:30:13,360 want experience. 394 00:30:13,360 --> 00:30:20,360 And it's nice to have, oh yes, like this was used in this case and we saw really good, 395 00:30:20,360 --> 00:30:24,880 we achieved really good undetectable viral loads, that type of thing, or this is an indication. 396 00:30:24,880 --> 00:30:32,360 And so I think just kind of having that comfort in a way that it's used and is frequently 397 00:30:32,360 --> 00:30:35,320 used kind of helps in the HIV world. 398 00:30:35,320 --> 00:30:39,240 So would you say like that's kind of what your experience has been? 399 00:30:39,240 --> 00:30:41,240 For sure, for sure. 400 00:30:41,240 --> 00:30:47,760 When I go to countries and have workshops with clinicians, they usually bring like one 401 00:30:47,760 --> 00:30:52,040 or two hard cases and want to get our advice. 402 00:30:52,040 --> 00:30:58,120 And being able to say you've used this product and this is your experience with it, and you 403 00:30:58,120 --> 00:31:08,600 had cases with wrinkles, X, Y, Z, they really appreciate hearing those experiences and knowing 404 00:31:08,600 --> 00:31:13,120 that they're not alone and knowing that they have access to what are really considered 405 00:31:13,120 --> 00:31:21,120 the treatments of choice and that their patients are not behind or underprivileged like they 406 00:31:21,120 --> 00:31:23,360 definitely used to be. 407 00:31:23,360 --> 00:31:29,400 But one of the things that we have tried with pediatric diet, check your rollout, is to 408 00:31:29,400 --> 00:31:31,600 incorporate some operational research. 409 00:31:31,600 --> 00:31:41,080 And so we negotiated for six countries across Africa to have what we called a catalytic 410 00:31:41,080 --> 00:31:47,560 procurement of drugs, so they got an early shipment of this drug to roll it out, gain 411 00:31:47,560 --> 00:31:52,760 experience in their countries to be able to kind of inform how they would roll it out 412 00:31:52,760 --> 00:31:53,760 more broadly. 413 00:31:53,760 --> 00:32:02,360 And in three of those countries, Uganda, Nigeria, and Benin, we incorporated a research component 414 00:32:02,360 --> 00:32:07,840 to that where we interviewed the families and the clinicians and if they're old enough 415 00:32:07,840 --> 00:32:16,560 kids to ask them, like, compare to your old regimen, how does this new one compare to 416 00:32:16,560 --> 00:32:22,000 the parents, did you see any side effects, to the clinicians, did you see any side effects? 417 00:32:22,000 --> 00:32:27,240 And then just having really overall very, very positive results and being able to share 418 00:32:27,240 --> 00:32:32,400 that with people within those countries but also across the regions. 419 00:32:32,400 --> 00:32:39,400 Because one thing I noticed when I was working in Vietnam in particular, some years ago with 420 00:32:39,400 --> 00:32:47,720 Chai, and then working across West Africa, is they really feel like their population 421 00:32:47,720 --> 00:32:52,560 is distinct and they want to know that the product will work in their country with their 422 00:32:52,560 --> 00:32:53,560 country's children. 423 00:32:53,560 --> 00:32:54,560 Right. 424 00:32:54,560 --> 00:32:57,600 So I always think it's like, well, children are children. 425 00:32:57,600 --> 00:32:58,600 Yeah. 426 00:32:58,600 --> 00:33:05,040 We're not so genetically distinct from each other, but they really sometimes become fixated 427 00:33:05,040 --> 00:33:06,040 on that. 428 00:33:06,040 --> 00:33:10,880 And so being able to say, no, this was research done in your region or done in your country 429 00:33:10,880 --> 00:33:16,800 and we showed that it was really well tolerated and had XYZ results, then they really appreciate 430 00:33:16,800 --> 00:33:22,640 that and it really facilitates the acceptability and uptake. 431 00:33:22,640 --> 00:33:25,640 And then sometimes you learn things that maybe you weren't expecting. 432 00:33:25,640 --> 00:33:30,880 One of the things that really comes up frequently with Dalu Taggiver is there's been some adult 433 00:33:30,880 --> 00:33:36,480 research showing weight gain as a potential longer-term complication with integrates and 434 00:33:36,480 --> 00:33:37,480 inhibitors generally. 435 00:33:37,480 --> 00:33:45,200 But Dalu Taggiver, because it's been the most rapidly used one in low-middle income 436 00:33:45,200 --> 00:33:53,120 countries, and so people are concerned about that because they don't want to have the problems 437 00:33:53,120 --> 00:33:54,120 of the West. 438 00:33:54,120 --> 00:34:01,440 They're concerned about obesity, epidemics, and so having some work around that with this 439 00:34:01,440 --> 00:34:09,120 pediatric operational research has been helpful too to show that we're monitoring for this. 440 00:34:09,120 --> 00:34:13,000 Generally, it doesn't seem like a big deal. 441 00:34:13,000 --> 00:34:18,080 Children are supposed to gain weight because that's the job to grow. 442 00:34:18,080 --> 00:34:24,760 So those are the things that really have been helpful to be able to share across countries. 443 00:34:24,760 --> 00:34:29,920 And even coming back here to Canada, because a lot of our patients, our HIV patients in 444 00:34:29,920 --> 00:34:36,040 Canada in the pediatric sphere at least, are migrants from other countries. 445 00:34:36,040 --> 00:34:44,160 So being able to say, I'm actually doing the same work and providing the same advice to 446 00:34:44,160 --> 00:34:50,360 people in Sub-Saharan Africa or Southeast Asia as what you're getting here in Canada, 447 00:34:50,360 --> 00:34:52,800 that's also in reverse reassuring. 448 00:34:52,800 --> 00:34:53,800 Yeah. 449 00:34:53,800 --> 00:34:54,800 No, that's fair. 450 00:34:54,800 --> 00:34:55,800 Yeah. 451 00:34:55,800 --> 00:34:59,000 And so are there currently, so that's one of the operational trials out there. 452 00:34:59,000 --> 00:35:04,040 Are there currently trials ongoing in North America with Dalu Taggiver in this disperseable 453 00:35:04,040 --> 00:35:12,120 tab that we could enter patients into or anything that you're aware of in that regard? 454 00:35:12,120 --> 00:35:19,040 I don't think there's anything going on new that there was an impact to trial looking 455 00:35:19,040 --> 00:35:27,120 at pediatric Dalu Taggiver that was done that led to its licensure. 456 00:35:27,120 --> 00:35:29,480 And then they're following kids out longer term. 457 00:35:29,480 --> 00:35:34,880 But it's interesting, those studies were quite small compared to the volumes who are starting 458 00:35:34,880 --> 00:35:35,960 it globally. 459 00:35:35,960 --> 00:35:36,960 Right. 460 00:35:36,960 --> 00:35:44,640 And as I mentioned, there is a neonatal study that is, I believe it's just started. 461 00:35:44,640 --> 00:35:49,720 It's in North America and multiple international sites. 462 00:35:49,720 --> 00:35:54,000 But yeah, in terms of enrolling patients, not so much. 463 00:35:54,000 --> 00:36:00,720 But in our pediatric studies in Canada, we have been kind of looking at things like weight 464 00:36:00,720 --> 00:36:04,060 gain with integrase inhibitors over time. 465 00:36:04,060 --> 00:36:08,440 And also looking at the experience of integrase inhibitors in pregnancy, like if moms are 466 00:36:08,440 --> 00:36:09,920 on them in pregnancy. 467 00:36:09,920 --> 00:36:16,440 There's a big scare that a lot of people in HIV probably remember that when they first 468 00:36:16,440 --> 00:36:20,640 started using it in Botswana, there was some concern about maybe an increased risk of neural 469 00:36:20,640 --> 00:36:23,640 tube defects to find the evidence for that. 470 00:36:23,640 --> 00:36:30,640 Which I think was just one of those like 95% confidence interval thing. 471 00:36:30,640 --> 00:36:35,320 So 5% of the time things will happen by chance. 472 00:36:35,320 --> 00:36:38,440 And so they found this slight increased risk. 473 00:36:38,440 --> 00:36:41,680 But then over time that increased risk seemed to go away. 474 00:36:41,680 --> 00:36:46,320 And it was just that they had a number of cases up front. 475 00:36:46,320 --> 00:36:50,040 That risk certainly doesn't seem to be real at this point. 476 00:36:50,040 --> 00:36:51,720 Yeah, that's fair. 477 00:36:51,720 --> 00:36:52,720 Yeah, exactly. 478 00:36:52,720 --> 00:36:58,440 Yeah, it makes it better for our kind of adult or adolescent use too. 479 00:36:58,440 --> 00:37:02,640 Because some things you can't really predict and then you don't want to... 480 00:37:02,640 --> 00:37:08,880 And then having an undetectable HIV viral load we know has a better outcome for those 481 00:37:08,880 --> 00:37:10,000 neonates too. 482 00:37:10,000 --> 00:37:14,120 So it's almost like is this risk versus benefit, right? 483 00:37:14,120 --> 00:37:16,440 So yeah, that's fair. 484 00:37:16,440 --> 00:37:21,080 So in terms of yeah, I think lately in my practice, I think we're slowly becoming more 485 00:37:21,080 --> 00:37:23,640 and more comfortable with this dispersable tab. 486 00:37:23,640 --> 00:37:27,520 And it's always nice to have newer formulation. 487 00:37:27,520 --> 00:37:32,000 So do you foresee any changes to this formulation? 488 00:37:32,000 --> 00:37:36,920 Or do we think that currently what's out there will remain? 489 00:37:36,920 --> 00:37:38,400 And are there... 490 00:37:38,400 --> 00:37:41,280 You talked about having a combo tab, right? 491 00:37:41,280 --> 00:37:42,320 And that coming out. 492 00:37:42,320 --> 00:37:48,680 So I guess is there anything else that you foresee with any changes with this Dolly Tiger 493 00:37:48,680 --> 00:37:51,560 Veer Dispersable Tab in the near future? 494 00:37:51,560 --> 00:37:58,440 Yeah, so the Avaka Veer Limit Veerine Dolly Tiger Veer 3M1 Dispersable Tablet is available 495 00:37:58,440 --> 00:38:03,680 in the US just in the last six months. 496 00:38:03,680 --> 00:38:08,320 Forgetting exactly when it was licensed, but it's recently out. 497 00:38:08,320 --> 00:38:12,920 And so hopefully we'll have access to that here in Canada too. 498 00:38:12,920 --> 00:38:20,480 And that was only licensed I think for 14 kilos and a half. 499 00:38:20,480 --> 00:38:26,760 And then there's work going on looking at the younger or smaller kids. 500 00:38:26,760 --> 00:38:35,080 But hopefully that will be available and we'll be able to use those here in Canada. 501 00:38:35,080 --> 00:38:38,720 I think the next big thing is the injectables. 502 00:38:38,720 --> 00:38:47,240 And so the Integress Inhibitor Cabotegravir is available for adults and adolescents as 503 00:38:47,240 --> 00:38:51,280 an injection, but it's interesting using it for kids. 504 00:38:51,280 --> 00:38:56,200 And then there's even interesting work looking at things like patch delivery. 505 00:38:56,200 --> 00:39:01,760 So just like there's a contraceptive patch that you just put on your skin, but there'll 506 00:39:01,760 --> 00:39:06,640 be a patch version of these injectable ARVs. 507 00:39:06,640 --> 00:39:07,640 Oh wow. 508 00:39:07,640 --> 00:39:11,320 Those are still far off in the future I think overall. 509 00:39:11,320 --> 00:39:17,240 But I don't know, when patients come to you, they want to know what's coming. 510 00:39:17,240 --> 00:39:19,760 They want to know what they can have hope about. 511 00:39:19,760 --> 00:39:23,240 And like you said, most people are like, this works for me. 512 00:39:23,240 --> 00:39:24,520 I'm happy with it. 513 00:39:24,520 --> 00:39:29,880 We don't need to go messing with the formula. 514 00:39:29,880 --> 00:39:32,840 But other people really struggle with taking a pill every day. 515 00:39:32,840 --> 00:39:35,720 Even just like one pill a day. 516 00:39:35,720 --> 00:39:40,560 We can talk about how like 10 years ago people were on like a handful of pills or multiple 517 00:39:40,560 --> 00:39:42,560 pills twice a day. 518 00:39:42,560 --> 00:39:44,040 And now we're down to one pill a day. 519 00:39:44,040 --> 00:39:46,600 And it seems like that's a lot better. 520 00:39:46,600 --> 00:39:50,840 But if you're the person having to take one pill a day, sometimes it's still pretty hard. 521 00:39:50,840 --> 00:39:51,840 Yeah, exactly. 522 00:39:51,840 --> 00:39:56,560 I mean, I always tell my patients, like, I can't even sometimes take vitamins in a day. 523 00:39:56,560 --> 00:40:02,360 So I commend them for sticking to their regimen and taking their pills. 524 00:40:02,360 --> 00:40:03,360 And it's a difficult task. 525 00:40:03,360 --> 00:40:07,280 Like if you think about the pediatric patients that we see, they go through so many changes 526 00:40:07,280 --> 00:40:10,120 in their life. 527 00:40:10,120 --> 00:40:14,320 Even going through your teenage years, having to do all of this. 528 00:40:14,320 --> 00:40:19,000 So I think whatever we can make, you know, anything that you can make that's easier for 529 00:40:19,000 --> 00:40:23,400 them, I think always improves compliance, especially in that age group. 530 00:40:23,400 --> 00:40:27,080 So yeah, but definitely. 531 00:40:27,080 --> 00:40:34,120 And then I find like with adherence issues in teenagers, like sometimes it's about difficulty 532 00:40:34,120 --> 00:40:39,080 with like remembering or having to take a bunch of pills and feeling like you're having 533 00:40:39,080 --> 00:40:41,200 side effects. 534 00:40:41,200 --> 00:40:46,080 But a good chunk of people just don't like being reminded of HIV. 535 00:40:46,080 --> 00:40:51,280 And taking that pill every day is like a reminder that you have this problem. 536 00:40:51,280 --> 00:40:57,160 And so I think for some people, like the injectables once a month, like there's even orals that 537 00:40:57,160 --> 00:41:02,920 will be available in the not distant future that can be taken weekly or monthly or even 538 00:41:02,920 --> 00:41:03,920 less frequently. 539 00:41:03,920 --> 00:41:11,360 Like I think being able to just put HIV kind of on the shelf and not think about it, or 540 00:41:11,360 --> 00:41:16,360 put it in the back of your mind and not think about it is going to be helpful for some people. 541 00:41:16,360 --> 00:41:18,320 Yeah, no, I agree. 542 00:41:18,320 --> 00:41:19,680 Yeah, definitely. 543 00:41:19,680 --> 00:41:25,360 So that was, I mean, so much information definitely bringing into like my clinical practice. 544 00:41:25,360 --> 00:41:30,800 So in terms of some take home points for some of our listeners who, you know, may be seeing 545 00:41:30,800 --> 00:41:37,480 HIV patients who are on older regimens or struggling to, you know, ensure compliance. 546 00:41:37,480 --> 00:41:41,720 What are some take home points for them for Dolutegravir that you would kind of highlight 547 00:41:41,720 --> 00:41:42,720 today? 548 00:41:42,720 --> 00:41:52,400 I mean, I think I would start by saying this is like probably the one of two or three main 549 00:41:52,400 --> 00:41:59,440 drugs that we use in pediatrics and in adults and definitely in pediatrics nowadays. 550 00:41:59,440 --> 00:42:05,680 It's one of the first line recommended products and if your patients are on older products, 551 00:42:05,680 --> 00:42:08,960 it's very reasonable to offer this as a switch. 552 00:42:08,960 --> 00:42:17,760 I think in the old days, we used to say, oh, we'll save this for later just in case. 553 00:42:17,760 --> 00:42:24,200 If your current ones don't work or have issues, but we know that having people on the best 554 00:42:24,200 --> 00:42:29,000 drugs from the start is going to allow them to stay on those best drugs for longer. 555 00:42:29,000 --> 00:42:35,760 So don't be afraid to try something new when we know that it's a good drug. 556 00:42:35,760 --> 00:42:39,400 It's very well tolerated of anything. 557 00:42:39,400 --> 00:42:44,880 I think insomnia for the first month is the main thing to warn about, but only one in 558 00:42:44,880 --> 00:42:48,440 10 adult patients will get that. 559 00:42:48,440 --> 00:42:55,200 And so even less common in kids and very few drug interactions to worry about. 560 00:42:55,200 --> 00:43:02,280 So yeah, hard to find a lot of problems with this medication. 561 00:43:02,280 --> 00:43:11,120 And yeah, I think it's really helped a lot of people achieve undetectable, which is our 562 00:43:11,120 --> 00:43:14,320 goal in addition to a good quality of life. 563 00:43:14,320 --> 00:43:15,700 Yeah, it's there. 564 00:43:15,700 --> 00:43:22,040 And I think as we use more and more drugs that are being authorized for that age group, 565 00:43:22,040 --> 00:43:24,960 they become more accessible in our communities as well. 566 00:43:24,960 --> 00:43:30,320 And then so it makes it easier to actually use these medications then as well, because 567 00:43:30,320 --> 00:43:37,520 even if you have a patient that may be out in a pharmacy, they usually have the older 568 00:43:37,520 --> 00:43:40,480 drugs in our regimens easily accessible. 569 00:43:40,480 --> 00:43:44,600 And so sometimes we resort to use those if we can't find other drugs. 570 00:43:44,600 --> 00:43:51,280 But I think everything in terms of health care has changed and we can get lots of things 571 00:43:51,280 --> 00:43:53,960 approved and sent to different pharmacies. 572 00:43:53,960 --> 00:43:59,160 And so I think as use increases that also increases our chances of getting meds like 573 00:43:59,160 --> 00:44:02,880 Dalu Tegravir out in community pharmacies and that type of thing. 574 00:44:02,880 --> 00:44:07,360 So I've definitely seen some of that in my clinical practice too. 575 00:44:07,360 --> 00:44:10,440 Yeah, no, that's fantastic. 576 00:44:10,440 --> 00:44:16,560 So is there anything else that you feel that our audience should know about Dalu Tegravir 577 00:44:16,560 --> 00:44:21,880 before we kind of close off today's episode, which was like fantastic knowledge for myself. 578 00:44:21,880 --> 00:44:28,680 And I think viewers would appreciate, you know, are going to appreciate having somebody 579 00:44:28,680 --> 00:44:34,240 to not only like reach out to as a clinical expert, but also just have more information 580 00:44:34,240 --> 00:44:37,880 about Dalu Tegravir today. 581 00:44:37,880 --> 00:44:44,440 I think I just closed by saying that this is probably going to be, if not already, going 582 00:44:44,440 --> 00:44:49,160 to be the most commonly used ARV globally. 583 00:44:49,160 --> 00:44:57,520 The vast majority, like 90% plus of adults around the world who have HIV and are on treatment 584 00:44:57,520 --> 00:45:03,160 are going to be on this for first or even second line or third line. 585 00:45:03,160 --> 00:45:06,600 Soon enough, the majority of kids in the world will be on it. 586 00:45:06,600 --> 00:45:13,880 So if you're studying for the exam, this is a good one to fold up on. 587 00:45:13,880 --> 00:45:14,880 There you go. 588 00:45:14,880 --> 00:45:15,880 Perfect. 589 00:45:15,880 --> 00:45:16,880 Yeah. 590 00:45:16,880 --> 00:45:21,440 And then I always like to give everybody a disclaimer that this was an informational 591 00:45:21,440 --> 00:45:29,040 podcast and in by no means is a replacement for an infectious disease console, but definitely 592 00:45:29,040 --> 00:45:35,080 very informative, you know, presentation today regarding Dalu Tegravir. 593 00:45:35,080 --> 00:45:40,880 And I think it'll be nice to see how these, you know, if more trials come up in pediatrics 594 00:45:40,880 --> 00:45:45,880 and just see, you know, even with Z parched is to see other people's experience and their 595 00:45:45,880 --> 00:45:48,320 clinical experience with the use of Dalu Tegravir. 596 00:45:48,320 --> 00:45:56,280 So pediatric HIV, I think is always evolving and there's like so many changes. 597 00:45:56,280 --> 00:46:01,760 And so, and like you said, you know, a few years back even, we didn't have so many meds 598 00:46:01,760 --> 00:46:07,600 and there weren't, there wasn't a lot of research and now we're seeing more of that. 599 00:46:07,600 --> 00:46:12,280 And I don't know about personally, like in Saskatchewan, we've had an uptick in our vertical 600 00:46:12,280 --> 00:46:17,720 transmission as well and so having access to some of these newer drugs is really helping 601 00:46:17,720 --> 00:46:19,720 our practice out here. 602 00:46:19,720 --> 00:46:20,720 Yeah. 603 00:46:20,720 --> 00:46:21,720 I agree. 604 00:46:21,720 --> 00:46:27,680 Caring for the little, those little ones, especially can be really difficult, especially 605 00:46:27,680 --> 00:46:33,840 when they hit the terrible twos and saying no to everything. 606 00:46:33,840 --> 00:46:39,200 Having a drug that doesn't taste like kerosene actually tastes like strawberry cream and 607 00:46:39,200 --> 00:46:43,080 you only have to take once a day can be a lifesaver. 608 00:46:43,080 --> 00:46:44,080 So it's a good thing. 609 00:46:44,080 --> 00:46:45,080 That's great. 610 00:46:45,080 --> 00:46:46,080 All right. 611 00:46:46,080 --> 00:46:47,080 Well, thank you so much, Dr. Brophy. 612 00:46:47,080 --> 00:46:52,000 We really appreciate you coming on the podcast and it would be nice to have you back for 613 00:46:52,000 --> 00:46:53,000 future episodes. 614 00:46:53,000 --> 00:46:59,520 You know, even if it's regarding HIV or with your Clinton Health Initiative work, it's 615 00:46:59,520 --> 00:47:05,240 fantastic what you're doing out there and it's fantastic what you do out at CHEO too. 616 00:47:05,240 --> 00:47:06,240 So thank you so much. 617 00:47:06,240 --> 00:47:07,240 We really appreciate it. 618 00:47:07,240 --> 00:47:08,240 Thanks for having me. 619 00:47:08,240 --> 00:47:13,960 Thank you, Dr. Pirwal and thank you, Dr. Brophy, for joining us. 620 00:47:13,960 --> 00:47:15,320 Have a topic suggestion? 621 00:47:15,320 --> 00:47:22,400 Email us at thecanadianbreakpoint at gmail.com and follow us on Twitter at CABbreakpoint. 622 00:47:22,400 --> 00:47:39,200 See you then soon at the Canadian Breakpoint.