Lenacapavir: Playing the Long Game in the New Era of Antiretrovirals

Abstract

The mainstay of antiretroviral therapy (ART) has been combination oral therapy. While oral ART is highly effective, nonadherence remains a chief concern. Addressing this concern in recent years is the emergence of long-acting antiretrovirals for the treatment and prevention of HIV-1 infection. The most recently approved long-acting antiretroviral is the first-in-class capsid inhibitor lenacapavir (LEN) for heavily treatment-experienced adults with multidrug-resistant HIV-1 infection. Due to its biannual subcutaneous dosing scheme to inhibit the HIV-1 capsid, LEN exhibits unique pharmacokinetics and reinforces an evolving era of ART. In this review, we evaluate published and accepted research articles, conference proceedings, and clinical trial records to provide a comprehensive overview of LEN for treatment and preliminary data for the prevention of HIV-1 infection. These data include clinical trials outcomes, in vitro and in vivo resistance profiles, and preclinical data supporting downstream indications. We also discuss the unique clinical pharmacology of LEN with the goal of serving as a resource toward subsequent physiologically based, population-based, and other miscellaneous pharmacometric-focused analyses. Given the dynamic nature of the HIV treatment and prevention research fields, we also discuss ongoing studies related to LEN for treatment-naïve adults and for prevention. Lastly, we discuss important pharmacologic gaps in special populations, drug-drug interactions, and at the sites of action germane to HIV treatment and prevention. The information discussed in this review will provide knowledge and understanding of the unique pharmacologic properties of LEN to assist clinicians and researchers as they navigate the dynamic HIV research landscape.

Figure 1

Chemical structure of lenacapavir (retrieved from PubChem).

Figure 2

Compartmental model of SC lenacapavir injection input and exit rates. Abbreviations (in alphabetical order): CL, clearance out of body (L/h/kg); Frac_direct, fraction of dose released via direct process; Frac_indirect, fraction of dose released via indirect process; F _SC, bioavailability of lenacapavir following SC dose; k _direct, absorption rate constant for direct release fraction (1/h); k _indirect, absorption rate constant for indirect release fraction (1/h); Q, intercompartmental clearance (L/h/kg); V _c, volume of central compartment (L/kg); V _p, volume of peripheral compartment (L/kg). Adapted from Subramanian et al. (https://pubs.acs.org/doi/10.1021/acs.molpharmaceut.3c00626) and the FDA‐Integrated Review for NDA 215973/215974.