Denosumab: an update.

Denosumab is a fully human monoclonal antibody that inhibits the formation, function and survival of osteoclasts, preventing the interaction of tumor necrosis factor ligand superfamily member 11 (receptor activator of nuclear factor kappa-B ligand, RANKL) with the tumor necrosis factor receptor superfamily member 11A (osteoclast differentiation factor receptor, ODFR, receptor activator of NF-KB, RANK). This results in a reduction in bone resorption and an increase in bone mineral density. In clinical studies, denosumab has been shown to decrease the risk for vertebral, hip and nonvertebral fractures in women with postmenopausal osteoporosis and the risk for new vertebral fractures in men with nonmetastatic prostate cancer receiving androgen deprivation therapy, with a rate of side effects similar to placebo. A number of clinical trials with denosumab are ongoing to demonstrate its value for other indications and to further characterize its effects on immunomodulation. Denosumab is a new alternative for the prevention and treatment of postmenopausal osteoporosis and a promising agent for the treatment of other bone diseases associated with bone loss.

Genetic correlates of in vivo viral resistance to indinavir, a human immunodeficiency virus type 1 protease inhibitor.

Indinavir (IDV) (also called CRIXIVAN, MK-639, or L-735,524) is a potent and selective inhibitor of the human immunodeficiency virus type 1 (HIV-1) protease. During early clinical trials, in which patients initiated therapy with suboptimal dosages of IDV, we monitored the emergence of viral resistance to the inhibitor by genotypic and phenotypic characterization of primary HIV-1 isolates. Development of resistance coincided with variable patterns of multiple substitutions among at least 11 protease amino acid residues. No single substitution was present in all resistant isolates, indicating that resistance evolves through multiple genetic pathways. Despite this complexity, all of 29 resistant isolates tested exhibited alteration of residues M-46 (to I or L) and/or V-82 (to A, F, or T), suggesting that screening of these residues may be useful in predicting the emergence of resistance. We also extended our previous finding that IDV-resistant viral variants exhibit various patterns of cross-resistance to a diverse panel of HIV-1 protease inhibitors. Finally, we noted an association between the number of protease amino acid substitutions and the observed level of IDV resistance. No single substitution or pair of substitutions tested gave rise to measurable viral resistance to IDV. The evolution of this resistance was found to be cumulative, indicating the need for ongoing viral replication in this process. These observations strongly suggest that therapy should be initiated with the most efficacious regimen available, both to suppress viral spread and to inhibit the replication that is required for the evolution of resistance.

Combination therapy with zidovudine prevents selection of human immunodeficiency virus type 1 variants expressing high-level resistance to L-697,661, a nonnucleoside reverse transcriptase inhibitor.

L-697,661 is a human immunodeficiency virus type 1 (HIV-1)-specific nonnucleoside reverse transcriptase (RT) inhibitor. Its tolerability and activity in combination with zidovudine were evaluated in a 48-week double-blind study. One hundred nineteen zidovudine-naive HIV-1-infected patients with CD4 cell counts of 200-500/mm3 received either combination therapy, L-697,661 alone, or zidovudine alone. Activity was assessed by CD4 cell count changes. Selection for L-697,661-resistant virus was monitored by susceptibility testing of RT expressed by circulating viral RNA. Therapy was generally well tolerated. All groups receiving zidovudine exhibited transient increases in CD4 cell counts, while the L-697,661 monotherapy group showed a significant decline and yielded RT > 100-fold resistant to L-697,661 and associated with substitutions at RT residue 181. The RT from patients receiving combination therapy was maximally 15-fold less susceptible to L-697,661. Hence, cotreatment with zidovudine prevents selection of HIV-1 variants that are highly resistant to L-697,661 in patients naive to both compounds.

In vivo T lymphocyte origin of macrophage-tropic strains of HIV. Role of monocytes during in vitro isolation and in vivo infection.

Previously published isolation techniques with T cell blasts and monocyte-derived macrophages (MDM) were used to recover HIV from the PBMC of a group of 23 asymptomatic seropositive individuals. Viral isolation was more readily accomplished by MDM coculture resulting in 9 isolates being obtained exclusively by this method (macrophage tropic strains). To determine the in vivo cellular source of these isolates we separated PBMC from 5 of these 9 patients into T lymphocyte and monocyte fractions by flow microfluorometry. These fractions were then analyzed by polymerase chain reaction (PCR) for the presence of HIV-1 proviral DNA. In 4 out of these 5 patients HIV-1 proviral DNA could be detected exclusively in T lymphocytes but not in monocytes, although the virus could be isolated only by MDM coculture. In the remaining patient HIV could be amplified in both T lymphocytes and monocytes. Further phenotypic analysis revealed that, among T lymphocytes, only the CD4+ subset was infected with HIV. We conclude that among PBMC the most common in vivo source of HIV strains which preferentially infect macrophages in vitro is the CD4+ T lymphocyte. These data also suggest that the macrophage tropism characteristic of some HIV strains reflects predominantly an in vitro phenomenon.

Efficient macrophage isolation of human immunodeficiency virus from peripheral blood leukocytes from healthy seropositive individuals: implications for cell tropism.

We investigated the efficiency of HIV isolation from the PBL of 23 healthy, HIV-seropositive individuals with high (600-700/mm3) CD4+ T cell counts. Cocultivations of patients' PBL with allogeneic T lymphocyte blasts or monocytes were performed. T lymphocyte blasts allowed recovery of 4/23 (17%) HIV isolates, whereas monocytes allowed recovery of 12/23 (52%) isolates. Monocyte cultures sustained release of viral antigen for up to 70 days. Nine of the viral isolations could be accomplished only with this monocyte coculture technique. To determine the in vivo source of the macrophage-tropic HIV isolates we separated PBL from 5 of these 9 patients into T lymphocyte and monocyte fractions by cell sorting; then, we analyzed the fractions by PCR to amplify HIV proviral DNA. In 4 out of 5 patients studied HIV-1 proviral DNA was detected only in T lymphocytes but not in monocytes, although the virus was isolated exclusively by monocyte coculture technique. In the remaining patient, HIV DNA was found to be present in both T cells and monocytes. Thus, HIV can be more efficiently isolated in healthy seropositive individuals by coculture of their PBL with normal monocytes rather than T cell blasts. Of note, the most common in vivo source of viral isolates which preferentially infect monocytes in vitro ("macrophage-tropic strains") is the circulating CD4+ T lymphocyte.