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Sizovs A, Pons-Faudoa FP, Malgir G, Shelton KA, Bushman LR, Chua CYX, Anderson PL, Nehete PN, Sastry KJ, Grattoni A. Trans-urocanic acid enhances tenofovir alafenamide stability for long-acting HIV applications. Int J Pharm 2020; 587:119623. [PMID: 32663582 PMCID: PMC7484042 DOI: 10.1016/j.ijpharm.2020.119623] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/30/2020] [Accepted: 07/04/2020] [Indexed: 12/30/2022]
Abstract
Long-acting (LA) pre-exposure prophylaxis (PrEP) for HIV prevention is poised to address non-adherence and implementation challenges by alleviating the burden of user-dependent dosing. Due to its potency, tenofovir alafenamide (TAF) is a viable candidate for LA PrEP. However, the inherent hydrolytic instability of TAF presents a challenge for application in LA systems. In this work, we examined the mechanism of TAF hydrolysis in a reservoir-based implant system and characterized TAF degradation kinetics as a function of the solution pH. We determined a pH "stability window" between pH 4.8 - 5.8 in which TAF degradation is substantially mitigated, with minimal degradation at pH 5.3. In a pursuit of a TAF formulation suitable for LA PrEP, we studied trans-urocanic acid (UA) as a buffer excipient. Here we show that UA can maintain the pH of TAF free base (TAFfb) solution inside a surrogate implant model at approximately pH 5.4. Through in vitro analysis, we demonstrated preservation of released TAF purity above 90% for over 9 months. Further, we performed an in vivo assessment of TAFfb-UA formulation in a reservoir-based nanofluidic implant inserted subcutaneously in non-human primates. Preventive levels of tenofovir diphosphate above 100 fmol/106 peripheral blood mononuclear cells were achieved in 2 days and sustained over 35 days. Fluid retrieved from implants after 60 days of implantation showed that UA preserved the aqueous phase in the implant at ~ pH 5.5, effectively counteracting the neutralizing action of interstitial fluids. Moreover, residual TAF in the implants maintained > 98% purity. Overall, TAF-UA represents a viable formulation applicable for LA HIV PrEP.
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Affiliation(s)
- Antons Sizovs
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA
| | - Fernanda P Pons-Faudoa
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA; Tecnologico de Monterrey, School of Medicine and Health Sciences, Monterrey, NL, Mexico
| | - Gulsah Malgir
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA; Department of Biomedical Engineering, University of Houston, Houston, TX 77204, USA
| | - Kathryn A Shelton
- Department of Comparative Medicine, Michael E. Keeling Center for Comparative Medicine and Research, MD Anderson Cancer Center, Bastrop, TX 78602, USA
| | - Lane R Bushman
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado- Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Corrine Ying Xuan Chua
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA
| | - Peter L Anderson
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado- Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Pramod N Nehete
- Department of Comparative Medicine, Michael E. Keeling Center for Comparative Medicine and Research, MD Anderson Cancer Center, Bastrop, TX 78602, USA; The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX 77030, USA
| | - K Jagannadha Sastry
- Department of Comparative Medicine, Michael E. Keeling Center for Comparative Medicine and Research, MD Anderson Cancer Center, Bastrop, TX 78602, USA; Department of Thoracic Head and Neck Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences at Houston, Houston, TX 77030, USA
| | - Alessandro Grattoni
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA; Department of Surgery, Houston Methodist Research Institute, Houston, TX 77030, USA; Department of Radiation Oncology, Houston Methodist Research Institute, Houston, TX 77030, USA.
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Cobb DA, Smith NA, Edagwa BJ, McMillan JM. Long-acting approaches for delivery of antiretroviral drugs for prevention and treatment of HIV: a review of recent research. Expert Opin Drug Deliv 2020; 17:1227-1238. [PMID: 32552187 PMCID: PMC7442675 DOI: 10.1080/17425247.2020.1783233] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/12/2020] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Despite significant advances in treatment and prevention of HIV-1 infection, poor adherence to daily combination antiretroviral therapy (ART) regimens remains a major obstacle toward achieving sustained viral suppression and prevention. Adherence to ART could also be compromised by adverse drug reactions and societal factors that limit access to therapy. Therefore, medicines that aim to improve adherence by limiting ART side effects, frequency of dosing and socially acceptable regimens are becoming more attractive. AREAS COVERED This review highlights recent advances and challenges in the development of long-acting drug delivery strategies for HIV prevention and treatment. Approaches for extended oral and transdermal deliveries, microbicides, broadly neutralizing antibodies, and long-acting implantable and injectable deliveries are reviewed. EXPERT OPINION Emerging approaches on long-acting antiretroviral therapies and broadly neutralizing antibody technologies are currently at various stages of development. Such efforts, if successful and become broadly accepted by clinicians and users, will provide newer and simpler options for prevention and treatment of HIV infection.
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Affiliation(s)
- Denise A. Cobb
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center; Omaha, NE, USA
| | - Nathan A. Smith
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center; Omaha, NE, USA
| | - Benson J. Edagwa
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center; Omaha, NE, USA
| | - JoEllyn M. McMillan
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center; Omaha, NE, USA
- Department of Environmental, Agricultural and Occupational Health; University of Nebraska Medical Center; Omaha, NE, USA
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53
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Interspecies Differences in Tenofovir Alafenamide Fumarate Stability in Plasma. Antimicrob Agents Chemother 2020; 64:AAC.00930-20. [PMID: 32540983 DOI: 10.1128/aac.00930-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 06/10/2020] [Indexed: 12/29/2022] Open
Abstract
Tenofovir (TFV) alafenamide fumarate (TAF) is an antiretroviral that has been evaluated in alternative drug delivery systems in several species. The ex vivo stability of TAF was evaluated, and TAF was stable in dog-, sheep-, and macaque-spiked plasma. A negative bias was observed in TAF recovery in rabbit-spiked plasma; there was complete loss of TAF and corresponding overestimation of TFV in rodent-spiked plasma. These data highlight considerations when evaluating TAF and TFV concentrations in preclinical studies.
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54
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Kulkarni TA, Bade AN, Sillman B, Shetty BLD, Wojtkiewicz MS, Gautam N, Hilaire JR, Sravanam S, Szlachetka A, Lamberty BG, Morsey BM, Fox HS, Alnouti Y, McMillan JM, Mosley RL, Meza J, Domanico PL, Yue TY, Moore G, Edagwa BJ, Gendelman HE. A year-long extended release nanoformulated cabotegravir prodrug. NATURE MATERIALS 2020; 19:910-920. [PMID: 32341511 PMCID: PMC7384935 DOI: 10.1038/s41563-020-0674-z] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/31/2020] [Indexed: 05/21/2023]
Abstract
Long-acting cabotegravir (CAB) extends antiretroviral drug administration from daily to monthly. However, dosing volumes, injection site reactions and health-care oversight are obstacles towards a broad usage. The creation of poloxamer-coated hydrophobic and lipophilic CAB prodrugs with controlled hydrolysis and tissue penetrance can overcome these obstacles. To such ends, fatty acid ester CAB nanocrystal prodrugs with 14, 18 and 22 added carbon chains were encased in biocompatible surfactants named NMCAB, NM2CAB and NM3CAB and tested for drug release, activation, cytotoxicity, antiretroviral activities, pharmacokinetics and biodistribution. Pharmacokinetics studies, performed in mice and rhesus macaques, with the lead 18-carbon ester chain NM2CAB, showed plasma CAB levels above the protein-adjusted 90% inhibitory concentration for up to a year. NM2CAB, compared with NMCAB and NM3CAB, demonstrated a prolonged drug release, plasma circulation time and tissue drug concentrations after a single 45 mg per kg body weight intramuscular injection. These prodrug modifications could substantially improve CAB's effectiveness.
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Affiliation(s)
- Tanmay A Kulkarni
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Aditya N Bade
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, USA
| | - Brady Sillman
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, USA
| | - Bhagya Laxmi Dyavar Shetty
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, USA
| | - Melinda S Wojtkiewicz
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, USA
| | - Nagsen Gautam
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - James R Hilaire
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sruthi Sravanam
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, USA
| | - Adam Szlachetka
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, USA
| | - Benjamin G Lamberty
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, USA
| | - Brenda M Morsey
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, USA
| | - Howard S Fox
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, USA
| | - Yazen Alnouti
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - JoEllyn M McMillan
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, USA
| | - R Lee Mosley
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jane Meza
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Paul L Domanico
- Department of Global Health Sciences, The Clinton Health Access Initiative, Boston, MA, USA
| | - Tai-Yuen Yue
- Department of Global Health Sciences, The Clinton Health Access Initiative, Boston, MA, USA
| | - Gary Moore
- Department of Global Health Sciences, The Clinton Health Access Initiative, Boston, MA, USA
| | - Benson J Edagwa
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Howard E Gendelman
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, USA.
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE, USA.
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Predicting Pharmacokinetics of a Tenofovir Alafenamide Subcutaneous Implant Using Physiologically Based Pharmacokinetic Modelling. Antimicrob Agents Chemother 2020; 64:AAC.00155-20. [PMID: 32423957 DOI: 10.1128/aac.00155-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/09/2020] [Indexed: 02/06/2023] Open
Abstract
Long-acting (LA) administration using a subcutaneous (s.c.) implant presents opportunities to simplify administration of antiretroviral drugs, improve pharmacological profiles, and overcome suboptimal adherence associated with daily oral formulations. Tenofovir alafenamide (TAF) is a highly potent nucleoside reverse transcriptase inhibitor (NRTI) and an attractive agent for LA delivery, with a high potency and long intracellular half-life. The aim of this study was to predict minimum TAF doses required to achieve concentrations effective for HIV preexposure prophylaxis (PrEP). Daily drug release requirements were then ascertained by averaging across the dosing interval. A TAF physiologically based pharmacokinetic (PBPK) model was developed and partially qualified against available oral single- and multiple-dose pharmacokinetics. The models were assumed to be qualified when simulated values were within 2-fold of the observed mean. TAF s.c. implants were simulated in five hundred individuals, reporting predicted TAF plasma and tenofovir (TFV) plasma concentrations for various release rates. Intracellular TFV diphosphate (TFV-DP) concentrations were also simulated in peripheral blood cells and cervical and rectal tissues. The minimum dose predicted to achieve intracellular TFV-DP levels above a target concentration of 48 fmol/106 cells for a month was identified. TAF, TFV, and TFV-DP concentrations for release rates between 1.0 and 1.6 mg/day were simulated. The PBPK model indicated that a minimum release of 1.4 mg/day TAF is necessary to achieve TFV-DP concentrations above the identified target in peripheral blood mononuclear cells (PBMCs). TFV-DP cervical and rectal tissue concentrations were predicted to be between 1.5 and 2.0 fmol/106 cells and 0.9 and 1.1 fmol/106 cells, respectively, for release rates between 1.3 and 1.6 mg/day. These simulations provide target minimum doses for LA TAF PrEP in humans. Based on the generated results, multiple implants delivering a total of 1.4 mg/day of TAF subcutaneously could provide protection levels for approximately 6 months to 1 year. This modeling may inform future design of s.c. implants to mitigate adherence issues for effective PrEP applications.
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56
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Massud I, Cong ME, Ruone S, Holder A, Dinh C, Nishiura K, Khalil G, Pan Y, Lipscomb J, Johnson R, Deyounks F, Rooney JF, Babusis D, Park Y, McCallister S, Callebaut C, Heneine W, García-Lerma JG. Efficacy of Oral Tenofovir Alafenamide/Emtricitabine Combination or Single-Agent Tenofovir Alafenamide Against Vaginal Simian Human Immunodeficiency Virus Infection in Macaques. J Infect Dis 2020; 220:1826-1833. [PMID: 31362305 DOI: 10.1093/infdis/jiz383] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/18/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Tenofovir alafenamide (TAF)-based regimens are being evaluated for pre-exposure prophylaxis (PrEP). We used a macaque model of repeated exposures to simian human immunodeficiency virus (SHIV) to investigate whether TAF alone or the combination of TAF and emtricitabine (FTC) can prevent vaginal infection. METHODS Pigtail macaques were exposed vaginally to SHIV162p3 once a week for up to 15 weeks. Animals received clinical doses of FTC/TAF (n = 6) or TAF (n = 9) orally 24 hours before and 2 hours after each weekly virus exposure. Infection was compared with 21 untreated controls. RESULTS Five of the 6 animals in the FTC/TAF and 4 of the 9 animals in the TAF alone group were protected against infection (P = .001 and P = .049, respectively). The calculated efficacy of FTC/TAF and TAF was 91% (95% confidence interval [CI], 34.9%-98.8%) and 57.8% (95% CI, -8.7% to 83.6%), respectively. Infection in FTC/TAF but not TAF-treated macaques was delayed relative to controls (P = .005 and P = .114). Median tenofovir diphosphate (TFV-DP) levels in peripheral blood mononuclear cells (PBMCs) were similar among infected and uninfected macaques receiving TAF PrEP (351 and 143 fmols/106 cells, respectively; P = .921). CONCLUSIONS Emtricitabine/TAF provided a level of protection against vaginal challenge similar to FTC/TFV disoproxil fumarate combination in the macaque model. Our results support the clinical evaluation of FTC/TAF for PrEP in women.
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Affiliation(s)
- Ivana Massud
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mian-Er Cong
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Susan Ruone
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Angela Holder
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Chuong Dinh
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kenji Nishiura
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - George Khalil
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Yi Pan
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jonathan Lipscomb
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ryan Johnson
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Frank Deyounks
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Yeojin Park
- Gilead Sciences, Inc., Foster City, California
| | | | | | - Walid Heneine
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - J Gerardo García-Lerma
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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57
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Dandachi D, Dang BN, Lucari B, Swindells S, Giordano TP. Acceptability and preferences for long-acting antiretroviral formulations among people with HIV infection. AIDS Care 2020; 33:801-809. [PMID: 32408771 DOI: 10.1080/09540121.2020.1764906] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The study evaluates the acceptability and preferences for long-acting antiretroviral therapy (LA-ART) among a diverse cohort of people with HIV infection (PWH). It consists of a self-administered survey and chart review of PWH presenting to an HIV clinic in Houston, Texas, between February and June 2018; 374 participants were included; 61% indicated that they were likely or very likely to use LA-ART formulations. When asked about preference, 41% preferred pills, 40% preferred injections, and 18% preferred an implant. The most common benefit reported was eliminating the need to remember taking daily HIV pills (74%); 43% were worried that LA-ART will not be as effective as pills. Participants with a college degree, men who have sex with men, and ART-experienced were more willing to use LA-ART. Participants who reported poor or fair health, or who screened positive for depression or anxiety were significantly less willing to use LA-ART. The likelihood of using LA-ART did not correlate with self-reported adherence and HIV suppression. Patients with difficulty scheduling and attending clinic visits preferred injections and implant over pills. Most participants indicated a willingness to use new LA ART formulations. However, 41% still prefers pills, and those more interested in LA-ART were not less adherent.
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Affiliation(s)
- Dima Dandachi
- Division of Infectious Diseases, Department of Medicine, University of Missouri, Columbia, MO, USA.,Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Bich N Dang
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,VA Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,School of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Brandon Lucari
- School of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Susan Swindells
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Thomas P Giordano
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,VA Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,School of Medicine, Baylor College of Medicine, Houston, TX, USA
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Rael CT, Martinez M, Giguere R, Bockting W, MacCrate C, Mellman W, Valente P, Greene GJ, Sherman SG, Footer KHA, D'Aquila RT, Carballo-Diéguez A, Hope TJ. Transgender Women's Concerns and Preferences on Potential Future Long-Acting Biomedical HIV Prevention Strategies: The Case of Injections and Implanted Medication Delivery Devices (IMDDs). AIDS Behav 2020; 24:1452-1462. [PMID: 31654172 PMCID: PMC7181384 DOI: 10.1007/s10461-019-02703-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
There are several long-acting biomedical HIV prevention products in the development pipeline, including injections and implanted medication delivery devices (IMDDs). It is critical to understand concerns and preferences on the use of these products in populations that shoulder a disproportionate burden of the HIV epidemic, such as transgender women. This will allow researchers and public health professionals to construct interventions tailored to the needs of these women to promote optimal use of these tools. In studies of other biomedical HIV prevention products (e.g., oral PrEP) it is clear that transgender women have unique concerns related to the use of these strategies. This may have an impact on this group's uptake and sustained use of longacting HIV prevention products. This study conducted four focus groups with N = 18 transgender women in New York City to understand their concerns and preferences on long-acting PrEP injections and IMDDs. Findings showed that participants were overwhelmingly positive about long-acting HIV prevention strategies, though they had some apprehensions. Overall, participants felt that injections and IMDDs could help address adherence challenges, and that transgender-specific needs should be addressed during clinical trials. Also, there were concerns related to injection or IMDD logistics, concerns about injections' or IMDDs' presence in the body, and familiarity with these products affected participants' opinions on them. Findings from this work can be used to inform protocols, measures, materials, and adherence interventions in future initiatives for transgender women using PrEP injections or IMDDs.
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Affiliation(s)
- Christine Tagliaferri Rael
- HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University, 1051 Riverside Dr., New York, NY, 10032, USA.
| | - Michelle Martinez
- Program for the Study of LGBT Health at the New York State Psychiatric Institute/Columbia Psychiatry and the Columbia University School of Nursing, New York, NY, USA
- Columbia University Mailman School of Public Health, New York, NY, USA
| | - Rebecca Giguere
- HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University, 1051 Riverside Dr., New York, NY, 10032, USA
| | - Walter Bockting
- Program for the Study of LGBT Health at the New York State Psychiatric Institute/Columbia Psychiatry and the Columbia University School of Nursing, New York, NY, USA
| | - Caitlin MacCrate
- Program for the Study of LGBT Health at the New York State Psychiatric Institute/Columbia Psychiatry and the Columbia University School of Nursing, New York, NY, USA
- CUNY School of Public Health, New York, NY, USA
| | - Will Mellman
- Program for the Study of LGBT Health at the New York State Psychiatric Institute/Columbia Psychiatry and the Columbia University School of Nursing, New York, NY, USA
| | - Pablo Valente
- Program for the Study of LGBT Health at the New York State Psychiatric Institute/Columbia Psychiatry and the Columbia University School of Nursing, New York, NY, USA
- Columbia University Mailman School of Public Health, New York, NY, USA
| | - George J Greene
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Susan G Sherman
- Department of Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Katherine H A Footer
- Department of Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Richard T D'Aquila
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alex Carballo-Diéguez
- HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University, 1051 Riverside Dr., New York, NY, 10032, USA
| | - Thomas J Hope
- Northwestern University Feinberg School of Medicine, and Biomedical Engineering in the McCormick School of Engineering and Applied Sciences, Chicago, IL, USA
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Jiang Y, Gao X, Singh ON, Zhang W, Agrahari V, Peet MM, Clark MR, Doncel GF, Banga AK. Pharmacokinetics of a weekly transdermal delivery system of tenofovir alafenamide in hairless rats. Int J Pharm 2020; 582:119342. [PMID: 32315746 DOI: 10.1016/j.ijpharm.2020.119342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/06/2020] [Accepted: 04/14/2020] [Indexed: 02/06/2023]
Abstract
Tenofovir alafenamide (TAF) is a potent prodrug of tenofovir (TFV) for HIV prophylaxis, and HIV and HBV treatment. Compared to oral daily doses, transdermal administration of TAF may be more advantageous for long-term adherence by offering sustained drug delivery and reduced dosing frequency. Here, we described the plasma pharmacokinetics (PK) of an optimized once-weekly suspension transdermal delivery system (TDS) for TAF (96 mg/25 cm2 of TDS) in female hairless rats. Over the study period, the TAF TDS delivered an overall low level of TAF (median: 1.43 [0.02-3.28] ng/mL) and a sustained level of the stable metabolite and parent drug, TFV. Relative to the projected exposure corresponding to six-day oral daily doses, a comparable TAF exposure but a substantially lower TFV exposure was resulted from the TAF TDS, suggesting a lower risk of TFV-associated adverse effects. TAF, TFV, and phosphorylated TFVs (TFV-monophosphate and diphosphate) were found distributed in vaginal tissue, the portal of entry for HIV during male-to-female sexual transmission. Skin adhesion and tolerance were acceptable given the animal model used. PK evaluation of the TAF TDS in hairless rats demonstrates the proof of concept that transdermal delivery can be an alternative route for a sustained, once-weekly systemic delivery of TAF.
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Affiliation(s)
- Ying Jiang
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA 30341, United States
| | - Xinyi Gao
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA 30341, United States
| | - Onkar N Singh
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Arlington, VA 22209, United States
| | - Wei Zhang
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Arlington, VA 22209, United States
| | - Vivek Agrahari
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Arlington, VA 22209, United States
| | - M Melissa Peet
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Arlington, VA 22209, United States
| | - Meredith R Clark
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Arlington, VA 22209, United States
| | - Gustavo F Doncel
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Arlington, VA 22209, United States
| | - Ajay K Banga
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA 30341, United States.
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Simpson SM, Widanapathirana L, Su JT, Sung S, Watrous D, Qiu J, Pearson E, Evanoff A, Karunakaran D, Chacon JE, Kiser PF. Design of a Drug-Eluting Subcutaneous Implant of the Antiretroviral Tenofovir Alafenamide Fumarate. Pharm Res 2020; 37:83. [PMID: 32296951 PMCID: PMC7160069 DOI: 10.1007/s11095-020-2777-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 02/02/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE Sexual transmission of HIV has been clinically proven to be preventable with a once-daily oral tablet; however, missed doses dramatically increase the risk of HIV infection. Long-acting subcutaneous implants do not allow the user to miss a dose. A desirable long-acting drug-eluting implant can deliver a constant amount of drug, adjust the delivered dose, and be readily manufactured. We present a long-acting, subcutaneous implant design composed of tenofovir alafenamide hemifumarate (TAF) pellets loaded in a sealed polyether urethane tube for the prevention of HIV transmission. METHODS Implants were prepared with pressed drug pellets and extruded polyurethane tubing. In vitro release rate of implants using different pellet formulations, rate-controlling membranes, and geometries were measured. RESULTS Tenofovir alafenamide release appeared to be governed by a pseudo-steady state and followed a mass transport model of release from a cylindrical drug reservoir. Implant seal integrity was tested and confirmed using mechanical testing. The inclusion of sodium chloride in the pellet increased the release rate and reduced initial lag. The release was sustained for 100 days. CONCLUSIONS The release rate of tenofovir alafenamide mechanistically varied with geometry and rate controlling membrane composition. The polyether urethane implant presented herein is modular and tunable to adjust the release rate and duration of the TAF release.
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Affiliation(s)
- Solange M Simpson
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
| | | | - Jonathan T Su
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
- Department of Physics and Engineering, Elon University, Elon, North Carolina, USA
| | - Samuel Sung
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
| | - David Watrous
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
| | - Jiang Qiu
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
| | - Elizabeth Pearson
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
| | - Alex Evanoff
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
| | - Dipu Karunakaran
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
| | - Jorge E Chacon
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
| | - Patrick F Kiser
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA.
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61
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Rial-Crestelo D, Pinto-Martínez A, Pulido F. Cabotegravir and rilpivirine for the treatment of HIV. Expert Rev Anti Infect Ther 2020; 18:393-404. [PMID: 32164474 DOI: 10.1080/14787210.2020.1736561] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: Antiretroviral treatment (ART) has led to improved control of HIV infection, giving the opportunity of exploring therapeutic alternatives as new long-acting (LA) regimens, that might improve the quality of life of people living with HIV (PLWH).Areas covered: This article overviews the pharmacokinetic and pharmacodynamic properties of LA cabotegravir and rilpivirine (CR), two nanoformulated drugs of intramuscular administration and focuses on assessing its role on the treatment of HIV infection.Expert opinion: In addition to the advantage of treatment simplification, which could be especially beneficial for population subgroups with significant HIV-related stigma, it also reduces the number of drugs, and probably, the risk of treatment-related toxicity. The similar efficacy when compared to oral triple therapies in clinical trials and the high satisfaction rates among both professionals and patients make LA CR a suitable alternative for the control of HIV infection in the modern era.
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Affiliation(s)
| | | | - Federico Pulido
- HIV Unit, Hospital Universitario 12 De Octubre - Imas12, Madrid, Spain
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A Subcutaneous Implant of Tenofovir Alafenamide Fumarate Causes Local Inflammation and Tissue Necrosis in Rabbits and Macaques. Antimicrob Agents Chemother 2020; 64:AAC.01893-19. [PMID: 31871073 PMCID: PMC7038301 DOI: 10.1128/aac.01893-19] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/08/2019] [Indexed: 12/22/2022] Open
Abstract
We describe the in vitro and in vivo evaluation of a subcutaneous reservoir implant delivering tenofovir alafenamide hemifumarate (TAF) for the prevention of HIV infection. These long-acting reservoir implants were able to deliver antiretroviral drug for over 90 days in vitro and in vivo. We evaluated the implants for implantation site histopathology and pharmacokinetics in plasma and tissues for up to 12 weeks in New Zealand White rabbit and rhesus macaque models. We describe the in vitro and in vivo evaluation of a subcutaneous reservoir implant delivering tenofovir alafenamide hemifumarate (TAF) for the prevention of HIV infection. These long-acting reservoir implants were able to deliver antiretroviral drug for over 90 days in vitro and in vivo. We evaluated the implants for implantation site histopathology and pharmacokinetics in plasma and tissues for up to 12 weeks in New Zealand White rabbit and rhesus macaque models. A dose-ranging study in rabbits demonstrated dose-dependent pharmacokinetics and local inflammation up to severe necrosis around the active implants. The matched placebos showed normal wound healing and fibrous tissue encapsulation of the implant. We designed a second implant with a lower release rate and flux of TAF and achieved a median cellular level of tenofovir diphosphate of 42 fmol per 106 rhesus macaque peripheral blood mononuclear cells at a TAF dose of 10 μg/kg/day. This dose and flux of TAF also resulted in adverse local inflammation and necrosis near the implant in rhesus macaques. The level of inflammation in the primates was markedly lower in the placebo group than in the active-implant group. The histological inflammatory response to the TAF implant at 4 and 12 weeks in primates was graded as a severe reaction. Thus, while we were able to achieve a sustained target dose, we observed an unacceptable inflammatory response locally at the implant tissue interface.
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63
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Stewart SA, Domínguez-Robles J, McIlorum VJ, Mancuso E, Lamprou DA, Donnelly RF, Larrañeta E. Development of a Biodegradable Subcutaneous Implant for Prolonged Drug Delivery Using 3D Printing. Pharmaceutics 2020; 12:E105. [PMID: 32013052 PMCID: PMC7076405 DOI: 10.3390/pharmaceutics12020105] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 01/20/2020] [Accepted: 01/24/2020] [Indexed: 12/31/2022] Open
Abstract
Implantable drug delivery devices offer many advantages over other routes of drug delivery. Most significantly, the delivery of lower doses of drug, thus, potentially reducing side-effects and improving patient compliance. Three dimensional (3D) printing is a flexible technique, which has been subject to increasing interest in the past few years, especially in the area of medical devices. The present work focussed on the use of 3D printing as a tool to manufacture implantable drug delivery devices to deliver a range of model compounds (methylene blue, ibuprofen sodium and ibuprofen acid) in two in vitro models. Five implant designs were produced, and the release rate varied, depending on the implant design and the drug properties. Additionally, a rate controlling membrane was produced, which further prolonged the release from the produced implants, signalling the potential use of these devices for chronic conditions.
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Affiliation(s)
- Sarah A. Stewart
- School of Pharmacy, Queen’s University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK; (S.A.S.); (V.J.M.); (D.A.L.); (R.F.D.)
| | - Juan Domínguez-Robles
- School of Pharmacy, Queen’s University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK; (S.A.S.); (V.J.M.); (D.A.L.); (R.F.D.)
| | - Victoria J. McIlorum
- School of Pharmacy, Queen’s University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK; (S.A.S.); (V.J.M.); (D.A.L.); (R.F.D.)
| | - Elena Mancuso
- Nanotechnology and Integrated Bio-Engineering Centre (NIBEC), Ulster University, Jordanstown BT37 0QB, UK;
| | - Dimitrios A. Lamprou
- School of Pharmacy, Queen’s University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK; (S.A.S.); (V.J.M.); (D.A.L.); (R.F.D.)
| | - Ryan F. Donnelly
- School of Pharmacy, Queen’s University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK; (S.A.S.); (V.J.M.); (D.A.L.); (R.F.D.)
| | - Eneko Larrañeta
- School of Pharmacy, Queen’s University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK; (S.A.S.); (V.J.M.); (D.A.L.); (R.F.D.)
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64
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Flexner C. Modern Human Immunodeficiency Virus Therapy: Progress and Prospects. Clin Pharmacol Ther 2019; 105:61-70. [PMID: 30411787 DOI: 10.1002/cpt.1284] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 10/31/2018] [Indexed: 01/05/2023]
Abstract
Safe and effective lifelong treatment to control human immunodeficiency virus (HIV) infection is one of the greatest scientific and public health achievements of the past century. The majority of infected individuals able to maintain a daily oral regimen now have a normal or near-normal life expectancy. More than 30 approved drugs and dozens of formulations have produced thousands of possible drug combinations used clinically in the past, but today most patients receive only a handful of high priority and rigorously tested regimens. Unique features of antiretroviral therapy include the need for lifelong treatment to control virus replication and the possibility of rapid emergence of permanent drug resistance if these agents are not properly used. Although three-drug combination oral regimens have radically altered the course of this epidemic, the future will include long-acting injectable and implantable drugs and devices to treat and prevent infection.
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Affiliation(s)
- Charles Flexner
- Divisions of Clinical Pharmacology and Infectious Diseases, Departments of Medicine, Pharmacology and Molecular Sciences, and International Health, School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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65
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Coelho LE, Torres TS, Veloso VG, Landovitz RJ, Grinsztejn B. Pre-exposure prophylaxis 2.0: new drugs and technologies in the pipeline. Lancet HIV 2019; 6:e788-e799. [PMID: 31558423 DOI: 10.1016/s2352-3018(19)30238-3] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 06/28/2019] [Accepted: 07/02/2019] [Indexed: 01/17/2023]
Abstract
Pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate and emtricitabine was adopted by WHO as a strategy to reduce HIV incidence. Although shown to be highly effective in reducing HIV acquisition, the protective efficacy of oral tenofovir disoproxil fumarate and emtricitabine relies on optimal adherence, which poses a challenge for a key portion of the most at-risk populations (women, young individuals [15-24 years], racial and ethnic minority men who have sex with men, and transgender women). New PrEP agents in clinical development include novel oral agents (eg, tenofovir alafenamide and islatravir [also known as MK-8591]), long-acting injectables (eg, cabotegravir), vaginal rings, broadly neutralising monoclonal antibodies, topical products (including gels, films, and enemas), and multipurpose technologies. In addition, new drug delivery systems, such as implants and transdermal devices, are promising strategies that are being developed for HIV prevention. The ultimate goal of this new PrEP research agenda is to expand the available PrEP regimens and offer preventive technologies that will appeal to a wide variety of individuals with different needs over the course of their sexually active lifespan.
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Affiliation(s)
- Lara Esteves Coelho
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Thiago Silva Torres
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Valdiléa Gonçalves Veloso
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Raphael J Landovitz
- UCLA Center for Clinical AIDS Research and Education, University of California, Los Angeles, Los Angeles, CA, USA
| | - Beatriz Grinsztejn
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil.
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66
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Creation of a long-acting rilpivirine prodrug nanoformulation. J Control Release 2019; 311-312:201-211. [PMID: 31491432 DOI: 10.1016/j.jconrel.2019.09.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/28/2019] [Accepted: 09/02/2019] [Indexed: 11/20/2022]
Abstract
Antiretroviral therapy requires lifelong daily dosing to attain viral suppression, restore immune function, and improve quality of life. As a treatment alternative, long-acting (LA) antiretrovirals can sustain therapeutic drug concentrations in blood for prolonged time periods. The success of recent clinical trials for LA parenteral cabotegravir and rilpivirine highlight the emergence of these new therapeutic options. Further optimization can improve dosing frequency, lower injection volumes, and facilitate drug-tissue distributions. To this end, we report the synthesis of a library of RPV prodrugs designed to sustain drug plasma concentrations and improved tissue biodistribution. The lead prodrug M3RPV was nanoformulated into the stable LA injectable NM3RPV. NM3RPV treatment led to RPV plasma concentrations above the protein-adjusted 90% inhibitory concentration for 25 weeks with substantial tissue depots after a single intramuscular injection in BALB/cJ mice. NM3RPV elicited 13- and 26-fold increases in the RPV apparent half-life and mean residence time compared to native drug formulation. Taken together, proof-of-concept is provided that nanoformulated RPV prodrugs can extend the apparent drug half-life and improve tissue biodistribution. These results warrant further development for human use.
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67
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Lowinger MB, Ormes JD, Su Y, Small JH, Williams RO, Zhang F. How broadly can poly(urethane)-based implants be applied to drugs of varied properties? Int J Pharm 2019; 568:118550. [DOI: 10.1016/j.ijpharm.2019.118550] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/18/2019] [Accepted: 07/19/2019] [Indexed: 01/02/2023]
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68
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Soni D, Bade AN, Gautam N, Herskovitz J, Ibrahim IM, Smith N, Wojtkiewicz MS, Dyavar Shetty BL, Alnouti Y, McMillan J, Gendelman HE, Edagwa BJ. Synthesis of a long acting nanoformulated emtricitabine ProTide. Biomaterials 2019; 222:119441. [PMID: 31472458 DOI: 10.1016/j.biomaterials.2019.119441] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 08/04/2019] [Accepted: 08/19/2019] [Indexed: 01/20/2023]
Abstract
While antiretroviral therapy (ART) has revolutionized treatment and prevention of human immunodeficiency virus type one (HIV-1) infection, regimen adherence, viral mutations, drug toxicities and access stigma and fatigue are treatment limitations. These have led to new opportunities for the development of long acting (LA) ART including implantable devices and chemical drug modifications. Herein, medicinal and formulation chemistry were used to develop LA prodrug nanoformulations of emtricitabine (FTC). A potent lipophilic FTC phosphoramidate prodrug (M2FTC) was synthesized then encapsulated into a poloxamer surfactant (NM2FTC). These modifications extended the biology, apparent drug half-life and antiretroviral activities of the formulations. NM2FTC demonstrated a >30-fold increase in macrophage and CD4+ T cell drug uptake with efficient conversion to triphosphates (FTC-TP). Intracellular FTC-TP protected macrophages against an HIV-1 challenge for 30 days. A single intramuscular injection of NM2FTC, at 45 mg/kg native drug equivalents, into Sprague Dawley rats resulted in sustained prodrug levels in blood, liver, spleen and lymph nodes and FTC-TP in lymph node and spleen cells at one month. In contrast, native FTC-TPs was present for one day. These results are an advance in the transformation of FTC into a LA agent.
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Affiliation(s)
- Dhruvkumar Soni
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE 68198, USA; Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Aditya N Bade
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Nagsen Gautam
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Jonathan Herskovitz
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Ibrahim M Ibrahim
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Nathan Smith
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Melinda S Wojtkiewicz
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Bhagya Laxmi Dyavar Shetty
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Yazen Alnouti
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - JoEllyn McMillan
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Howard E Gendelman
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE 68198, USA; Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA.
| | - Benson J Edagwa
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA.
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69
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Topical Inserts: A Versatile Delivery Form for HIV Prevention. Pharmaceutics 2019; 11:pharmaceutics11080374. [PMID: 31374941 PMCID: PMC6723036 DOI: 10.3390/pharmaceutics11080374] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 07/21/2019] [Accepted: 07/23/2019] [Indexed: 11/16/2022] Open
Abstract
The development of topical inserts for the prevention of sexually transmitted infections (STIs), particularly human immunodeficiency virus (HIV), represents a promising alternative to oral and parenteral pre-exposure prophylaxis (PrEP) dosage forms. They may be used for vaginal and/or rectal administration of a variety of agents with antiviral activity. Topical inserts deliver drugs to the portal of viral entry, i.e., the genital or rectal mucosa, with low systemic exposure, and therefore are safer and have fewer side effects than systemic PrEP agents. They may dissolve fast, releasing the active drugs within minutes of insertion, or slowly for long-acting drug delivery. Furthermore, they are user-friendly being easy to administer, discreet and highly portable. They are also economical and easy to manufacture at scale and to distribute, with excellent stability and shelf-life. Altogether, topical inserts represent a particularly promising form of drug delivery for HIV and STI prevention. Highlighted within this review are end-user acceptability research dedicated to understanding preferred attributes for this form of drug delivery, advantages and disadvantages of the formulation platform options, considerations for their development, clinical assessment of select placebo prototypes, future directions, and the potential impact of this dosage form on the HIV prevention landscape.
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70
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Beymer MR, Holloway IW, Pulsipher C, Landovitz RJ. Current and Future PrEP Medications and Modalities: On-demand, Injectables, and Topicals. Curr HIV/AIDS Rep 2019; 16:349-358. [PMID: 31222499 PMCID: PMC6719717 DOI: 10.1007/s11904-019-00450-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW Pre-exposure prophylaxis (PrEP) is a potent HIV prevention strategy, but uptake of daily oral PrEP remains low. This review covers PrEP agents currently available and agents and modalities under investigation. RECENT FINDINGS Injectable ARV preparations have high acceptability among users but are likely to require adherence to 8-week interval injections. Topical microbicide gels and vaginal rings have underperformed by intention-to-treat analyses in efficacy studies, at least in large part due to challenges with adherence and/or sustained use. However, daily oral TDF-FTC also underperformed in randomized, placebo-controlled trials compared to expectations and subsequent real-world pragmatic use. On-demand (2-1-1 dosing strategy for MSM) and injectable PrEP appear to be acceptable among participants in clinical trials. These modalities are particularly compelling alternatives for individuals who either do not want to take a daily medication (both on-demand and injectable) and/or want to take PrEP without a long commitment (on-demand). Emerging modalities such as vaginal films, microneedles, and subdermal implants have numerous advantages but are still in early stages of development.
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Affiliation(s)
- Matthew R Beymer
- Department of Health and Mental Health Services, Los Angeles LGBT Center, McDonald/Wright Building, 1625 N Schrader Blvd, Room 114-E, Los Angeles, CA, 90028, USA.
| | - Ian W Holloway
- Department of Social Welfare, Luskin School of Public Affairs, University of California, Los Angeles, 337 Charles E Young Drive East, Los Angeles, CA, 90095, USA
| | | | - Raphael J Landovitz
- David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA, 90095, USA
- UCLA Center for Clinical AIDS Research & Education (CARE), 11075 Santa Monica Blvd, Suite 100, Los Angeles, CA, 90024, USA
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71
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Johnson LM, Krovi SA, Li L, Girouard N, Demkovich ZR, Myers D, Creelman B, van der Straten A. Characterization of a Reservoir-Style Implant for Sustained Release of Tenofovir Alafenamide (TAF) for HIV Pre-Exposure Prophylaxis (PrEP). Pharmaceutics 2019; 11:pharmaceutics11070315. [PMID: 31277461 PMCID: PMC6680758 DOI: 10.3390/pharmaceutics11070315] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 06/21/2019] [Accepted: 06/29/2019] [Indexed: 11/29/2022] Open
Abstract
Long-acting (LA) HIV pre-exposure prophylaxis (PrEP) offers the potential to improve adherence by lowering the burden of daily or on-demand regimens of antiretroviral (ARV) drugs. This paper details the fabrication and in vitro performance of a subcutaneous and trocar-compatible implant for the LA delivery of tenofovir alafenamide (TAF). The reservoir-style implant comprises an extruded tube of a biodegradable polymer, poly(ε-caprolactone) (PCL), filled with a formulation of TAF and castor oil excipient. Parameters that affect the daily release rates of TAF are described, including the surface area of the implant, the thickness of the PCL tube walls (between 45 and 200 µm), and the properties of the PCL (e.g., crystallinity). In vitro studies show a linear relationship between daily release rates and surface area, demonstrating a membrane-controlled release mechanism from extruded PCL tubes. Release rates of TAF from the implant are inversely proportional to the wall thickness, with release rates between approximately 0.91 and 0.15 mg/day for 45 and 200 µm, respectively. The sustained release of TAF at 0.28 ± 0.06 mg/day over the course of 180 days in vitro was achieved. Progress in the development of this implant platform addresses the need for new biomedical approaches to the LA delivery of ARV drugs.
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Affiliation(s)
- Leah M Johnson
- Engineered Systems, RTI International, 3040 E. Cornwallis Road, Research Triangle Park, NC 27709, USA.
| | - Sai Archana Krovi
- Engineered Systems, RTI International, 3040 E. Cornwallis Road, Research Triangle Park, NC 27709, USA
| | - Linying Li
- Engineered Systems, RTI International, 3040 E. Cornwallis Road, Research Triangle Park, NC 27709, USA
| | - Natalie Girouard
- Engineered Systems, RTI International, 3040 E. Cornwallis Road, Research Triangle Park, NC 27709, USA
| | - Zach R Demkovich
- Women's Global Health Imperative, RTI International, 351 California Street, Suite 500, San Francisco, CA 94104, USA
| | - Daniel Myers
- PATH, 2201 Westlake Ave, Suite 200, Seattle, WA 98121, USA
| | - Ben Creelman
- PATH, 2201 Westlake Ave, Suite 200, Seattle, WA 98121, USA
| | - Ariane van der Straten
- Women's Global Health Imperative, RTI International, 351 California Street, Suite 500, San Francisco, CA 94104, USA
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72
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2-Hydroxypropyl-β-cyclodextrin-enhanced pharmacokinetics of cabotegravir from a nanofluidic implant for HIV pre-exposure prophylaxis. J Control Release 2019; 306:89-96. [PMID: 31136811 DOI: 10.1016/j.jconrel.2019.05.037] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/14/2019] [Accepted: 05/23/2019] [Indexed: 12/12/2022]
Abstract
Preexposure prophylaxis (PrEP) with antiretrovirals (ARV) can prevent human immunodeficiency virus (HIV) transmission, but its efficacy is highly dependent on strict patient adherence to daily dosing regimen. Long-acting (LA) ARV formulations or delivery systems that reduce dosing frequency may increase adherence and thus PrEP efficacy. While cabotegravir (CAB) long-acting injectable (CAB LA), an integrase strand transfer inhibitor (INSTI), reduces dosing frequency to bimonthly injections, variable pharmacokinetics (PK) between patients and various adverse reactions necessitate improvement in delivery methods. Here we developed a subcutaneously implantable nanofluidic device for the sustained delivery of CAB formulated with 2-hydroxypropyl-β-cyclodextrin (βCAB) and examined the pharmacokinetics (PK) in Sprague-Dawley rats for 3 months in comparison to CAB. Our study demonstrated βCAB treatment group maintained clinically-relevant plasma CAB concentrations 2 times above the protein-adjusted concentration that inhibits viral replication by 90% (2 × PA-IC90) and drug penetration into tissues relevant to HIV-1 transmission. Further, we successfully fitted plasma CAB concentrations into a PK model (R2 = 0.9999) and determined CAB apparent elimination half-life of 47 days. Overall, our data shows the potential of sustained release of βCAB via a nanofluidic implant for long-term PrEP delivery, warranting further investigation for efficacy against HIV infections.
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73
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Tatham LM, Savage AC, Dwyer A, Siccardi M, Scott T, Vourvahis M, Clark A, Rannard SP, Owen A. Towards a Maraviroc long-acting injectable nanoformulation. Eur J Pharm Biopharm 2019; 138:92-98. [DOI: 10.1016/j.ejpb.2018.04.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/09/2018] [Accepted: 04/12/2018] [Indexed: 10/17/2022]
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74
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Singh K, Sarafianos SG, Sönnerborg A. Long-Acting Anti-HIV Drugs Targeting HIV-1 Reverse Transcriptase and Integrase. Pharmaceuticals (Basel) 2019; 12:E62. [PMID: 31010004 PMCID: PMC6631967 DOI: 10.3390/ph12020062] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 04/16/2019] [Accepted: 04/18/2019] [Indexed: 12/20/2022] Open
Abstract
One of the major factors contributing to HIV-1 drug resistance is suboptimal adherence to combination antiretroviral therapy (cART). Currently, recommended cART for HIV-1 treatment is a three-drug combination, whereas the pre-exposure prophylaxis (PrEP) regimens consist of one or two antivirals. Treatment regimens require adherence to a once or twice (in a subset of patients) daily dose. Long-acting formulations such as injections administered monthly could improve adherence and convenience, and thereby have potential to enhance the chances of expected outcomes, although long-lasting drug concentrations can also contribute to clinical issues like adverse events and development of drug resistance. Globally, two long-acting antivirals have been approved, and fifteen are in clinical trials. More than half of investigational long-acting antivirals target HIV-1 reverse transcriptase (HIV-1 RT) and/or integrase (HIV-1 IN). Here, we discuss the status and potential of long-acting inhibitors, including rilpivirine (RPV), dapivirine (DPV), and 4-ethynyl-2-fluoro-2-deoxyadenosine (EFdA; also known as MK-8591), which target RT, and cabotegravir (CAB), which targets IN. The outcomes of various clinical trials appear quite satisfactory, and the future of long-acting HIV-1 regimens appears bright.
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Affiliation(s)
- Kamal Singh
- Department of Molecular Microbiology and Immunology, University of Missouri, Columbia, MO 65211, USA.
- Bond Life Sciences Center, University of Missouri, Columbia, MO 65211, USA.
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute, Huddinge 14186, Stockholm, Sweden.
| | - Stefan G Sarafianos
- Laboratory of Biochemical Pharmacology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Anders Sönnerborg
- Department of Molecular Microbiology and Immunology, University of Missouri, Columbia, MO 65211, USA.
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute, Huddinge 14186, Stockholm, Sweden.
- Division of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institute, Huddinge 14186, Stockholm, Sweden.
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75
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Gendelman HE, McMillan J, Bade AN, Edagwa B, Kevadiya BD. The Promise of Long-Acting Antiretroviral Therapies: From Need to Manufacture. Trends Microbiol 2019; 27:593-606. [PMID: 30981593 DOI: 10.1016/j.tim.2019.02.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/19/2019] [Accepted: 02/27/2019] [Indexed: 12/30/2022]
Abstract
Antiretroviral therapy has transformed human immunodeficiency virus infections from certain death to a manageable chronic disease. Achieving strict adherence to drug regimens that limit toxicities and viral resistance is an achievable goal. Success is defined by halting viral transmission and by continuous viral restriction. A step towards improving treatment outcomes is in long-acting antiretrovirals. While early results remain encouraging there remain opportunities for improvement. These rest, in part, on the required large drug dosing volumes, local injection-site reactions, and frequency of injections. Thus, implantable devices and long-acting parenteral prodrugs have emerged which may provide more effective clinical outcomes. The recent successes in transforming native antiretrovirals into lipophilic and hydrophobic prodrugs stabilized into biocompatible surfactants can positively affect both. Formulating antiretroviral prodrugs demonstrates improvements in cell and tissue targeting, in drug-dosing intervals, and in the administered volumes of nanosuspensions. As such, the newer formulations also hold the potential to suppress viral loads beyond more conventional therapies with the ultimate goal of HIV-1 elimination when combined with other modalities.
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Affiliation(s)
- Howard E Gendelman
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198-5880, USA.
| | - JoEllyn McMillan
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198-5880, USA
| | - Aditya N Bade
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198-5880, USA
| | - Benson Edagwa
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198-5880, USA
| | - Bhavesh D Kevadiya
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198-5880, USA
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76
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Puri A, Bhattaccharjee SA, Zhang W, Clark M, Singh O, Doncel GF, Banga AK. Development of a Transdermal Delivery System for Tenofovir Alafenamide, a Prodrug of Tenofovir with Potent Antiviral Activity Against HIV and HBV. Pharmaceutics 2019; 11:pharmaceutics11040173. [PMID: 30970630 PMCID: PMC6523937 DOI: 10.3390/pharmaceutics11040173] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 11/16/2022] Open
Abstract
Tenofovir alafenamide (TAF) is an effective nucleotide reverse transcriptase inhibitor that is used in the treatment of HIV-1 and HBV. Currently, it is being investigated for HIV prophylaxis. Oral TAF regimens require daily intake, which hampers adherence and increases the possibility of viral resistance. Long-acting formulations would significantly reduce this problem. Therefore, the aim of this study was to develop a transdermal patch containing TAF and investigate its performance in vitro through human epidermis. Two types of TAF patches were manufactured. Transparent patches were prepared using acrylate adhesive (DURO-TAK 87-2516), and suspension patches were prepared using silicone (BIO-PSA 7-4301) and polyisobutylene (DURO-TAK 87-6908) adhesives. In vitro permeation studies were performed while using vertical Franz diffusion cells for seven days. An optimized silicone-based patch was characterized for its adhesive properties and tested for skin irritation. The acrylate-based patches, comprising 2% w/w TAF and a combination of chemical enhancers, showed a maximum flux of 0.60 ± 0.09 µg/cm²/h. However, the silicone-based patch comprising of 15% w/w TAF showed the highest permeation (7.24 ± 0.47 μg/cm²/h). This study demonstrates the feasibility of developing silicone-based transdermal patches that can deliver a therapeutically relevant dose of TAF for the control of HIV and HBV infections.
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Affiliation(s)
- Ashana Puri
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA 30341, USA.
| | - Sonalika A Bhattaccharjee
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA 30341, USA.
| | - Wei Zhang
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Arlington, VA 22209, USA.
| | - Meredith Clark
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Arlington, VA 22209, USA.
| | - Onkar Singh
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Arlington, VA 22209, USA.
| | - Gustavo F Doncel
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Arlington, VA 22209, USA.
| | - Ajay K Banga
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA 30341, USA.
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Abstract
PURPOSE OF REVIEW Poor adherence to oral antiretroviral formulations remains the major barrier to the success of long-term treatment and prevention strategies. Although a number of approaches have been developed for long-acting parenteral delivery of antiretroviral drugs, subcutaneous implants are a particularly promising technology as they may be able to provide protective drugs concentrations for a year or longer following a single implant. This review addresses the current status of preclinical and clinical development of antiretroviral implants. RECENT FINDINGS Subcutaneous implants have been widely used for hormonal contraception and the treatment of hormonally driven malignancies for more than 3 decades. These implants are economical to manufacture and deliver, but require special procedures for insertion and removal. They are generally well tolerated and can remain in place for as long as 5 years. A small number of investigational implants are under development for the delivery of antiretroviral drugs. The most advanced of these, containing the investigational antiretroviral MK-8591 (4'-ethynyl-2-fluoro-2'-deoxyadenosine), a potent nucleoside analog reverse transcriptase translocation inhibitor that demonstrates particular promise for subcutaneous implantation, is closest to testing in human subjects. Investigational implants containing tenofovir alafenamide and nevirapine have also been developed and tested in animal models. SUMMARY Long-acting antiretroviral implants are a promising new technology, but are in very early stages of development. Potential advantages of these systems include more consistent and predictable drug release than intramuscular injections, and the fact that implants can be removed in the case of adverse events or the desire to stop treatment.
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Krogstad EA, Montgomery ET, Atujuna M, Minnis AM, O'Rourke S, Ahmed K, Bekker LG, van der Straten A. Design of an Implant for Long-Acting HIV Pre-Exposure Prophylaxis: Input from South African Health Care Providers. AIDS Patient Care STDS 2019; 33:157-166. [PMID: 30932697 DOI: 10.1089/apc.2018.0177] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Implants are in the pre-clinical stage for long-acting HIV pre-exposure prophylaxis (PrEP), with an opportunity to solicit end-users' feedback early in development. Health care providers (HCPs) have been key gatekeepers for contraceptive implant uptake, and uniquely understand both technical considerations and the social context of use. Given their influential role, we gathered South African HCP perspectives on contraceptive implant implementation and features of PrEP implant prototypes that may influence future provider and patient acceptability. We conducted in-depth interviews with 30 HCPs (20 nurses and 10 doctors) in Cape Town and Soshanguve, South Africa. Interviews were conducted by a bioengineer and later transcribed, coded, and analyzed for key themes. HCPs described health system barriers such as understaffed clinics and inadequate training on contraceptive implant removal as major influences to their PrEP implant design preferences. They preferred a PrEP implant that is long lasting (>6 months) to minimize patient-clinic interactions, biodegradable to avoid need for removal, and flexible (but still palpable in case of removal). Commenting on negative experiences with contraceptive implant rollout, they recommended prioritizing both HCP and community education on the PrEP implant, with emphasis on expected side effects, and planning ahead for adequate training of HCPs before rollout. Challenges experienced with past contraceptive implant rollout may taint perspectives on future PrEP implants and must be carefully considered during product development and planning for clinical studies. Particular consideration should be given to the health system context of future distribution, including staff who would be providing and monitoring implants.
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Affiliation(s)
- Emily A. Krogstad
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
- RTI International, Women's Global Health Imperative, San Francisco, California
| | | | - Millicent Atujuna
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Alexandra M. Minnis
- RTI International, Women's Global Health Imperative, San Francisco, California
| | - Shannon O'Rourke
- RTI International, Women's Global Health Imperative, San Francisco, California
| | | | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Ariane van der Straten
- RTI International, Women's Global Health Imperative, San Francisco, California
- Center for AIDS Prevention Studies, University of California—San Francisco, San Francisco, California
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79
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Pre-exposure Prophylaxis for HIV Infection in the Older Patient: What can be Recommended? Drugs Aging 2019; 35:485-491. [PMID: 29736816 DOI: 10.1007/s40266-018-0553-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Over the past 15 years, a significant increase in new HIV/AIDS diagnoses has been observed in the elderly population. This new epidemiological shift has been attributed to a longer sex life, lifestyle and changes in sexual behavior, poor sexual health education, and misconceptions about the absence of sexually transmitted disease in later life. Although many biomedical and behavioral interventions have proven useful to prevent sexually transmitted infections and HIV, pre-exposure prophylaxis (PrEP) has been shown to be the most successful biomedical intervention to prevent HIV in high-risk individuals. This approach is based on delivering a fixed dose of tenofovir disoproxil fumarate (300 mg), alone or combined with emtricitabine (300/200 mg) daily or on demand, before and after sexual intercourse. Despite the consistent number of clinical trials proving the effectiveness and safety of this strategy, no studies have focused specifically on elderly people. These individuals, who may benefit substantially from (PrEP), are at a higher risk of experiencing side effects secondary to tenofovir exposure. This review critically discusses the efficacy and safety of PrEP in people aged over 50 years and translates the knowledge of tenofovir management in patients with HIV into monitoring and stopping rules to be used in this special population. We provide practical recommendations to properly identify PrEP candidates among older adults. Furthermore, we define correct case management before and during PrEP delivery, and we suggest stopping rules and alternative sexually transmitted infection prevention strategies.
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80
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Can drug release rate from implants be tailored using poly(urethane) mixtures? Int J Pharm 2019; 557:390-401. [DOI: 10.1016/j.ijpharm.2018.11.067] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/23/2018] [Accepted: 11/24/2018] [Indexed: 12/14/2022]
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Hamlin AN, Tillotson J, Bumpus NN. Genetic variation of kinases and activation of nucleotide analog reverse transcriptase inhibitor tenofovir. Pharmacogenomics 2019; 20:105-111. [PMID: 30628547 DOI: 10.2217/pgs-2018-0140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
As antiretroviral therapy has become more accessible across the world and coformulations have improved patient compliance; the morbidity and mortality of HIV/AIDS has decreased. However, there is still a substantial gap in knowledge regarding the impact of genetic variation on the metabolism of and response to some of the most commonly prescribed antiretrovirals, including the nucleotide reverse transcriptase inhibitor tenofovir. While it has been scientifically established that tenofovir must be activated to be efficacious against HIV, the enzymes responsible for this activation have not been well characterized. The purpose of this review is to summarize and clarify the scientific knowledge regarding the enzymes that phosphorylate and activate this clinically important drug.
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Affiliation(s)
- Allyson N Hamlin
- Department of Medicine (Division of Clinical Pharmacology), Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Joseph Tillotson
- Department of Medicine (Division of Clinical Pharmacology), Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Namandjé N Bumpus
- Department of Medicine (Division of Clinical Pharmacology), Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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82
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Creating demand for long-acting formulations for the treatment and prevention of HIV, tuberculosis, and viral hepatitis. Curr Opin HIV AIDS 2019; 14:13-20. [PMID: 30394948 DOI: 10.1097/coh.0000000000000510] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW Long-acting parenteral drug delivery is an established and widely accepted solution to the problem of poor adherence when daily oral medications are used to treat or prevent chronic medical conditions. Poor adherence to oral formulations remains a major barrier to successfully treating or preventing HIV, tuberculosis (TB), and viral hepatitis. The uptake of long-acting formulations developed for these infections is uncertain, despite their promise. This review addresses the current state of development of long-acting and extended-release approaches to HIV, TB, and viral hepatitis in the context of creating market demand for such products. RECENT FINDINGS Two nanoformulated long-acting injectable antiretroviral compounds, cabotegravir and rilpivirine, recently completed Phase 2 clinical trials demonstrating safety, tolerability, and antiretroviral activity, and should be available in high income countries following completion of ongoing Phase 3 trials. Long-acting polymer implants of the antiretroviral nucleosides tenofovir alafenamide and 4'-ethynyl-2-fluoro-2'-deoxyadenosine are being tested in animals and should soon enter human studies; tenofovir alafenamide also has activity against hepatitis B virus. Long-acting versions of several broadly neutralizing monoclonal antibodies are in advanced clinical trials for HIV prevention and treatment. Long-acting formulations for TB are in preclinical development. There is no evidence that comparable formulations for viral hepatitis are being developed at present. SUMMARY Long-acting and extended release formulations are promising approaches to the treatment and prevention of common infectious diseases, but their availability is limited at this time. These products hold great promise for the global control of important human infections. Based on experience with other diseases, it is likely that their use will become more widespread if they are cost competitive with generic oral formulations.
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83
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Stewart SA, Domínguez-Robles J, Donnelly RF, Larrañeta E. Implantable Polymeric Drug Delivery Devices: Classification, Manufacture, Materials, and Clinical Applications. Polymers (Basel) 2018; 10:E1379. [PMID: 30961303 PMCID: PMC6401754 DOI: 10.3390/polym10121379] [Citation(s) in RCA: 182] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 12/10/2018] [Indexed: 12/27/2022] Open
Abstract
The oral route is a popular and convenient means of drug delivery. However, despite its advantages, it also has challenges. Many drugs are not suitable for oral delivery due to: first pass metabolism; less than ideal properties; and side-effects of treatment. Additionally, oral delivery relies heavily on patient compliance. Implantable drug delivery devices are an alternative system that can achieve effective delivery with lower drug concentrations, and as a result, minimise side-effects whilst increasing patient compliance. This article gives an overview of classification of these drug delivery devices; the mechanism of drug release; the materials used for manufacture; the various methods of manufacture; and examples of clinical applications of implantable drug delivery devices.
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Affiliation(s)
- Sarah A Stewart
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK.
| | - Juan Domínguez-Robles
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK.
| | - Ryan F Donnelly
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK.
| | - Eneko Larrañeta
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK.
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84
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Hendrix CW. HIV Antiretroviral Pre-Exposure Prophylaxis: Development Challenges and Pipeline Promise. Clin Pharmacol Ther 2018; 104:1082-1097. [PMID: 30199098 PMCID: PMC6925668 DOI: 10.1002/cpt.1227] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/20/2018] [Indexed: 12/17/2022]
Abstract
The US Food and Drug Administration (FDA) approved oral daily tenofovir/emtricitabine (Truvada) for pre-exposure prophylaxis of human immunodeficiency virus (HIV) infection in 2012 on the basis of two randomized controlled trials (RCTs), one in men who have sex with men (MSM) and another in HIV serodiscordant heterosexual couples. Subsequently, even greater efficacy has been demonstrated in MSM with rapid population-level incidence reductions in some locations. In contrast, studies of antiretroviral pre-exposure prophylaxis (PrEP) in heterosexual women showed only modest or no efficacy, largely attributed to low adherence. The mixed results of antiretroviral-based PrEP bear witness to unique drug development challenges at this complicated intersection of sexual behavior, public health, and drug development. Multiple innovative methods and formulation strategies followed to address unmet medical needs of persons struggling with daily oral PrEP adherence or preference for nonsystemic PrEP options. Clinical pharmacology plays essential roles throughout this PrEP development process, especially in early product development and through pharmacologically informed enhancement and interpretation of clinical trials.
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Affiliation(s)
- Craig W Hendrix
- 1Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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85
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A three-in-one, long-acting, nanosuspension reformulation of off-patent antiretrovirals for low-income and middle-income countries. AIDS 2018; 32:2625-2627. [PMID: 30379688 DOI: 10.1097/qad.0000000000001970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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86
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Landovitz RJ, Li S, Grinsztejn B, Dawood H, Liu AY, Magnus M, Hosseinipour MC, Panchia R, Cottle L, Chau G, Richardson P, Marzinke MA, Hendrix CW, Eshleman SH, Zhang Y, Tolley E, Sugarman J, Kofron R, Adeyeye A, Burns D, Rinehart AR, Margolis D, Spreen WR, Cohen MS, McCauley M, Eron JJ. Safety, tolerability, and pharmacokinetics of long-acting injectable cabotegravir in low-risk HIV-uninfected individuals: HPTN 077, a phase 2a randomized controlled trial. PLoS Med 2018; 15:e1002690. [PMID: 30408115 PMCID: PMC6224042 DOI: 10.1371/journal.pmed.1002690] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 10/08/2018] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Cabotegravir (CAB) is a novel strand-transfer integrase inhibitor being developed for HIV treatment and prevention. CAB is formulated both as an immediate-release oral tablet for daily administration and as a long-acting injectable suspension (long-acting CAB [CAB LA]) for intramuscular (IM) administration, which delivers prolonged plasma exposure to the drug after IM injection. HIV Prevention Trials Network study 077 (HPTN 077) evaluated the safety, tolerability, and pharmacokinetics of CAB LA in HIV-uninfected males and females at 8 sites in Brazil, Malawi, South Africa, and the United States. METHODS AND FINDINGS HPTN 077 was a double-blind, placebo-controlled phase 2a trial. Healthy individuals age 18-65 years at low HIV risk were randomized (3:1) to receive CAB or placebo (PBO). In the initial oral phase, participants received 1 daily oral tablet (CAB or PBO) for 4 weeks. Those without safety concerns in the oral phase continued and received injections in the injection phase (Cohort 1: 3 injections of CAB LA 800 mg or 0.9% saline as PBO IM every 12 weeks for 3 injection cycles; Cohort 2: CAB LA 600 mg or PBO IM for 5 injection cycles; the first 2 injections in Cohort 2 were separated by 4 weeks, the rest by 8 weeks). The primary analysis included weeks 5 to 41 of study participation, encompassing the injection phase. The cohorts were enrolled sequentially. Primary outcomes were safety and tolerability. Secondary outcomes included pharmacokinetics and events occurring during the oral and injection phases. Between February 9, 2015, and May 27, 2016, the study screened 443 individuals and enrolled 110 participants in Cohort 1 and 89 eligible participants in Cohort 2. Participant population characteristics were as follows: 66% female at birth; median age 31 years; 27% non-Hispanic white, 41% non-Hispanic black, 24% Hispanic/Latino, 3% Asian, and 6% mixed/other; and 6 transgender men and 1 transgender woman. Twenty-two (11%) participants discontinued the oral study product; 6 of these were for clinical or laboratory adverse events (AEs). Of those who received at least 1 CAB LA injection, 80% of Cohort 1 and 92% of Cohort 2 participants completed all injections; injection course completion rates were not different from those in the PBO arm. Injection site reactions (ISRs) were common (92% of Cohort 1 and 88% of Cohort 2 participants who received CAB LA reported any ISR). ISRs were mostly Grade 1 (mild) to Grade 2 (moderate), and 1 ISR event (Cohort 1) led to product discontinuation. Grade 2 or higher ISRs were the only AEs reported more commonly among CAB LA recipients than PBO recipients. Two Grade 3 (severe) ISRs occurred in CAB recipients, 1 in each cohort, but did not lead to product discontinuation in either case. Seven incident sexually transmitted infections were diagnosed in 6 participants. One HIV infection occurred in a participant 48 weeks after last injection of CAB LA: CAB was not detectable in plasma both at the time of first reactive HIV test and at the study visit 12 weeks prior to the first reactive test. Participants in Cohort 2 (unlike Cohort 1) consistently met prespecified pharmacokinetic targets of at least 95% of participants maintaining CAB trough concentrations above PA-IC90, and 80% maintaining trough concentrations above 4× PA-IC90. Study limitations include a modest sample size, a short course of injections, and a low-risk study population. CONCLUSIONS In this study, CAB LA was well tolerated at the doses and dosing intervals used. ISRs were common, but infrequently led to product discontinuation. CAB LA 600 mg every 8 weeks met pharmacokinetic targets for both male and female study participants. The safety and pharmacokinetic results observed support the further development of CAB LA, and efficacy studies of CAB LA for HIV treatment and prevention are in progress. TRIAL REGISTRATION ClinicalTrials.gov Registry: ClinicalTrials.gov Trial number: NCT02178800.
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Affiliation(s)
- Raphael J. Landovitz
- UCLA Center for Clinical AIDS Research and Education, Los Angeles, California, United States of America
| | - Sue Li
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Beatriz Grinsztejn
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Halima Dawood
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu Natal, Durban, South Africa
| | - Albert Y. Liu
- Bridge HIV, Population Health Division, San Francisco Department of Health, San Francisco, California, United States of America
| | - Manya Magnus
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia, United States of America
| | | | - Ravindre Panchia
- Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - Leslie Cottle
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Gordon Chau
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Paul Richardson
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Mark A. Marzinke
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Craig W. Hendrix
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Susan H. Eshleman
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Yinfeng Zhang
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | | | - Jeremy Sugarman
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Ryan Kofron
- UCLA Center for Clinical AIDS Research and Education, Los Angeles, California, United States of America
| | - Adeola Adeyeye
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - David Burns
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Alex R. Rinehart
- ViiV Healthcare, Durham, North Carolina, United States of America
| | - David Margolis
- ViiV Healthcare, Durham, North Carolina, United States of America
| | | | - Myron S. Cohen
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | - Joseph J. Eron
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Abstract
Antiretroviral drugs have revolutionized the treatment and prevention of HIV infection; however, adherence is critical for sustained efficacy. Current HIV treatment consists of three-drug regimens, and current HIV pre-exposure prophylaxis (PrEP) consists of a two-drug regimen; both generally require adherence to once-daily dosing. Long-acting formulations are useful in the treatment and prevention of other conditions (e.g., contraceptives, antipsychotics) and help promote adherence. Newer long-acting formulations of approved and investigational antiretroviral drugs in existing and newer mechanistic classes are under study for HIV treatment and prevention, including some phase III trials. Although long-acting antiretroviral drugs hold promise, some clinical challenges exist, including managing side effects, drug-drug interactions, pregnancy, and long-lasting drug concentrations that could lead to the development of drug resistance. This review aims to summarize currently available information on long-acting antiretroviral drugs for HIV treatment and prevention.
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Affiliation(s)
- Roy M Gulick
- Division of Infectious Diseases, Weill Cornell Medicine, New York, NY 10065, USA;
| | - Charles Flexner
- Divisions of Clinical Pharmacology and Infectious Diseases, Long Acting/Extended Release Antiretroviral Resource Program, School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland 21287-5554, USA;
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Derrick CB, Ostermann J, Weissman SB, Hobbie A, Alshareef N, Weinhold A, Yelverton V, Thielman NM. Who Wants to Switch? Gauging Patient Interest in Novel Antiretroviral Therapies. Open Forum Infect Dis 2018; 5:ofy247. [PMID: 30364593 PMCID: PMC6197380 DOI: 10.1093/ofid/ofy247] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 09/21/2018] [Indexed: 11/13/2022] Open
Abstract
Study participants were asked about their interest in switching to novel drug delivery systems that reduce the dosing frequency of antiretroviral regimens. Across a diverse, treatment-experienced cohort, we describe greatest interest in switching to an oral regimen taken once weekly, followed by injections taken every other month and twice-annual implants.
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Affiliation(s)
- Caroline B Derrick
- Department of Medicine, School of Medicine, University of South Carolina, Columbia, South Carolina
| | - Jan Ostermann
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.,Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Sharon B Weissman
- Department of Medicine, School of Medicine, University of South Carolina, Columbia, South Carolina
| | - Amy Hobbie
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Noor Alshareef
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Andrew Weinhold
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Valerie Yelverton
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.,Fachbereich Gesundheit, Pflege, Management, Hochschule Neubrandenburg, Neubrandenburg, Germany
| | - Nathan M Thielman
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Durham, North Carolina.,Department of Medicine, School of Medicine, Duke University, Durham, North Carolina
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89
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Extended-Duration MK-8591-Eluting Implant as a Candidate for HIV Treatment and Prevention. Antimicrob Agents Chemother 2018; 62:AAC.01058-18. [PMID: 30012772 DOI: 10.1128/aac.01058-18] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 07/03/2018] [Indexed: 11/20/2022] Open
Abstract
Regimen adherence remains a major hurdle to the success of daily oral drug regimens for the treatment and prevention of human immunodeficiency virus (HIV) infection. Long-acting drug formulations requiring less-frequent dosing offer an opportunity to improve adherence and allow for more forgiving options with regard to missed doses. The administration of long-acting formulations in a clinical setting enables health care providers to directly track adherence. MK-8591 (4'-ethynyl-2-fluoro-2'-deoxyadenosine [EFdA]) is an investigational nucleoside reverse transcriptase translocation inhibitor (NRTTI) drug candidate under investigation as part of a regimen for HIV treatment, with potential utility as a single agent for preexposure prophylaxis (PrEP). The active triphosphate of MK-8591 (MK-8591-TP) exhibits protracted intracellular persistence and, together with the potency of MK-8591, supports its consideration for extended-duration dosing. Toward this end, drug-eluting implant devices were designed to provide prolonged MK-8591 release in vitro and in vivo Implants, administered subcutaneously, were studied in rodents and nonhuman primates to establish MK-8591 pharmacokinetics and intracellular levels of MK-8591-TP. These data were evaluated against pharmacokinetic and pharmacodynamic models, as well as data generated in phase 1a (Ph1a) and Ph1b clinical studies with once-weekly oral administration of MK-8591. After a single administration in animals, MK-8591 implants achieved clinically relevant drug exposures and sustained drug release, with plasma levels maintained for greater than 6 months that correspond to efficacious MK-8591-TP levels, resulting in a 1.6-log reduction in viral load. Additional studies of MK-8591 implants for HIV treatment and prevention are warranted.
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90
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Reed JB, Patel RR, Baggaley R. Lessons from a decade of voluntary medical male circumcision implementation and their application to HIV pre-exposure prophylaxis scale up. Int J STD AIDS 2018; 29:1432-1443. [PMID: 30114997 PMCID: PMC6287252 DOI: 10.1177/0956462418787896] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Oral pre-exposure prophylaxis (PrEP) has the ability to curb HIV incidence worldwide and bring us closer to ending the HIV epidemic. Scale up of PrEP service delivery has many similar challenges to those faced by voluntary medical male circumcision (VMMC) services roll-out. This article outlines ten important lessons learned during the scale up of VMMC services in sub-Saharan Africa and their application to current oral PrEP implementation efforts to promote faster expansion for public health impact.
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Affiliation(s)
- Jason B Reed
- HIV-Malaria-Infectious Diseases, Jhpiego, Baltimore, MD, USA
| | - Rupa R Patel
- Division of Infectious Diseases, Washington University in St. Louis, St Louis, MO, USA
| | - Rachel Baggaley
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
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91
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Transcutaneously refillable nanofluidic implant achieves sustained level of tenofovir diphosphate for HIV pre-exposure prophylaxis. J Control Release 2018; 286:315-325. [PMID: 30092254 DOI: 10.1016/j.jconrel.2018.08.010] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 06/20/2018] [Accepted: 08/03/2018] [Indexed: 02/07/2023]
Abstract
Pre-exposure prophylaxis (PrEP) with antiretroviral (ARV) drugs are effective at preventing human immunodeficiency virus (HIV) transmission. However, implementation of PrEP presents significant challenges due to poor user adherence, low accessibility to ARVs and multiple routes of HIV exposure. To address these challenges, we developed the nanochannel delivery implant (NDI), a subcutaneously implantable device for sustained and constant delivery of tenofovir alafenamide (TAF) and emtricitabine (FTC) for HIV PrEP. Unlike existing drug delivery platforms with finite depots, the NDI incorporates ports allowing for transcutaneous refilling upon drug exhaustion. NDI-mediated drug delivery in rhesus macaques resulted in sustained release of both TAF and FTC for 83 days, as indicated by concentrations of TAF, FTC and their respectively metabolites in plasma, PBMCs, rectal mononuclear cells and tissues associated with HIV transmission. Notably, clinically relevant preventative levels of tenofovir diphosphate were achieved as early as 3 days after NDI implantation. We also demonstrated the feasibility of transcutaneous drug refilling to extend the duration of PrEP drug delivery in NHPs. Overall, the NDI represents an innovative strategy for long-term HIV PrEP administration in both developed and developing countries.
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92
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Krogstad EA, Atujuna M, Montgomery ET, Minnis A, Ndwayana S, Malapane T, Shapley‐Quinn MK, Manenzhe K, Bekker L, van der Straten A. Perspectives of South African youth in the development of an implant for HIV prevention. J Int AIDS Soc 2018; 21:e25170. [PMID: 30152004 PMCID: PMC6111144 DOI: 10.1002/jia2.25170] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 07/13/2018] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Implants are a new dosage form in development for HIV pre-exposure prophylaxis (PrEP) with potential for high adherence given that they are provider-administered and are intended for long-acting protection. Integrating end-user preference into early stage product development may further overcome challenges with future product uptake and adherence. Hence, we sought to optimize the design of a PrEP implant in early-stage development by gathering opinions about implant attributes from potential end-users in South Africa. METHODS We conducted 14 focus group discussions (FGDs) with young women and men aged 18 to 24 in Cape Town and Soshanguve, South Africa, inviting participants into discussion as co-designers. FGDs were homogenous by gender and previous implant experience. During FGDs, we showed prototype devices and followed a semi-structured guide with questions on history of contraceptive implant use, preferences for physical characteristics of an implant, implant biodegradability, insertion process, participant-driven ideas for implant design, and social adoption considerations. FGDs were facilitated in English, isiXhosa, Tswana, isiZulu, or Tsonga, audio-recorded, transcribed into English, and qualitatively coded and analysed. RESULTS In this qualitative sample of 105 youth (68 women and 37 men), 58 participants were from Soshanguve and 47 from Cape Town, and 23% had previously used contraceptive implants. Participants expressed preferences for several implant design features; specifically, longer duration (≥6 months) was more important to most participants than the size or number of devices implanted. A majority preferred a flexible versus stiff implant to minimize palpability, thereby increasing discreetness and comfort. Nearly all participants favoured a biodegradable implant to avoid removal and thus reduce clinic visits. Concerns about the implant centred on its possible side effects and the "plastic" look of the prototype displayed for demonstration. CONCLUSIONS This study offers preliminary insights into an implant for HIV prevention that provides long-lasting protection may be well received among young South Africans. Additionally, flexibility, discreetness, and biodegradability may increase acceptability of the implant. Such end-user feedback is being incorporated into current implant designs in the hope of creating an effective long-acting PrEP product that is likely to achieve high uptake and adherence in target populations.
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Affiliation(s)
- Emily A Krogstad
- Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
- RTI InternationalWomen's Global Health ImperativeSan FranciscoCaliforniaUSA
| | | | | | - Alexandra Minnis
- RTI InternationalWomen's Global Health ImperativeSan FranciscoCaliforniaUSA
| | - Sheily Ndwayana
- Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
| | | | | | | | | | - Ariane van der Straten
- RTI InternationalWomen's Global Health ImperativeSan FranciscoCaliforniaUSA
- Center for AIDS Prevention StudiesUniversity of California – San FranciscoSan FranciscoCaliforniaUSA
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93
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Monroe M, Flexner C, Cui H. Harnessing nanostructured systems for improved treatment and prevention of HIV disease. Bioeng Transl Med 2018; 3:102-123. [PMID: 30065966 PMCID: PMC6063869 DOI: 10.1002/btm2.10096] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 05/15/2018] [Accepted: 05/17/2018] [Indexed: 12/12/2022] Open
Abstract
Combination antiretroviral therapy effectively controls human immunodeficiency virus (HIV) viral replication, delaying the progression to acquired immune deficiency syndrome and improving and extending quality of life of patients. However, the inability of antiretroviral therapeutics to target latent virus and their poor penetration of viral reserve tissues result in the need for continued treatment for the life of the patient. Side effects from long-term antiretroviral use and the development of drug resistance due to patient noncompliance are also continuing problems. Nanostructured systems of antiretroviral therapeutics have the potential to improve targeted delivery to viral reservoirs, reduce drug toxicity, and increase dosing intervals, thereby improving treatment outcomes and enhancing patient adherence. Despite these advantages, very few nanostructured antiretroviral delivery systems have made it to clinical trials due to challenges in preclinical and clinical development. In this context, we review the current challenges in HIV disease management, and the recent progress in leveraging the unique performance of nanostructured systems in therapeutic delivery for improved treatment and prevention of this incurable human disease.
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Affiliation(s)
- Maya Monroe
- Dept. of Chemical and Biomolecular Engineering The Johns Hopkins University, 3400 N Charles Street Baltimore MD 21218.,Institute for NanoBioTechnology The Johns Hopkins University, 3400 N Charles Street Baltimore MD 21218
| | - Charles Flexner
- Div. of Clinical Pharmacology and Infectious Diseases Johns Hopkins University School of Medicine and Bloomberg School of Public Health Baltimore MD 21205
| | - Honggang Cui
- Dept. of Chemical and Biomolecular Engineering The Johns Hopkins University, 3400 N Charles Street Baltimore MD 21218.,Institute for NanoBioTechnology The Johns Hopkins University, 3400 N Charles Street Baltimore MD 21218.,Dept. of Oncology, Sidney Kimmel Comprehensive Cancer Center The Johns Hopkins University School of Medicine Baltimore MD 21205.,Center for Nanomedicine The Wilmer Eye Institute, The Johns Hopkins University School of Medicine Baltimore MD 21231
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94
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[Long-acting shot against HIV]. MMW Fortschr Med 2018; 159:36-38. [PMID: 28597266 DOI: 10.1007/s15006-017-9734-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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95
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Blakney AK, Jiang Y, Woodrow KA. Application of electrospun fibers for female reproductive health. Drug Deliv Transl Res 2018; 7:796-804. [PMID: 28497376 DOI: 10.1007/s13346-017-0386-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Here, we present the current challenges in women's reproductive health and the current state-of-the-art treatment and prevention options for STI prevention, contraception, and treatment of infections. We discuss how the versatile platform of electrospun fibers can be applied to each challenge, and postulate at how these technologies could be improved. The void of approved electrospun fiber-based products yields the potential to apply this useful technology to a number of medical applications, many of which are relevant to women's reproductive health. Given the ability to tune drug delivery characteristics and three-dimensional geometry, there are many opportunities to pursue new product designs and routes of administration for electrospun fibers. For each application, we provide an overview of the versatility of electrospun fibers as a novel dosage form and summarize their advantages in clinical applications. We also provide a perspective on why electrospun fibers are well-suited for a variety of applications within women's reproductive health and identify areas that could greatly benefit from innovations with electrospun fiber-based approaches.
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Affiliation(s)
- Anna K Blakney
- Department of Bioengineering, University of Washington, Seattle, WA, USA
| | - Yonghou Jiang
- Department of Bioengineering, University of Washington, Seattle, WA, USA
| | - Kim A Woodrow
- Department of Bioengineering, University of Washington, Seattle, WA, USA.
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96
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Abstract
Oral pre-exposure prophylaxis for the prevention of HIV-1 transmission (HIV PrEP) has been widely successful as demonstrated by a number of clinical trials. However, studies have also demonstrated the need for patients to tightly adhere to oral dosing regimens in order to maintain protective plasma and tissue concentrations. This is especially true for women, who experience less forgiveness from dose skipping than men in clinical trials of HIV PrEP. There is increasing interest in long-acting (LA), user-independent forms of HIV PrEP that could overcome this adherence challenge. These technologies have taken multiple forms including LA injectables and implantables. Phase III efficacy trials are ongoing for a LA injectable candidate for HIV PrEP. This review will focus on the design considerations for both LA injectable and implantable platforms for HIV PrEP. Additionally, we have summarized the existing LA technologies currently in clinical and pre-clinical studies for HIV PrEP as well as other technologies that have been applied to HIV PrEP and contraceptives. Our discussion will focus on the potential application of these technologies in low resource areas, and their use in global women's health.
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97
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Abstract
INTRODUCTION There are 36.7 million people living with HIV with 20.9 million having access to antiretroviral therapy (ART). Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) remain the 'backbone' of ART. However, the currently available nine NRTIs and five non-nucleoside reverse transcriptase inhibitors (NNRTIs) have significant side effects and resistance profiles. Areas covered: We summarize the mechanisms of resistance and other limitations of the existing NRTIs/NNRTIs. GS-9131, MK-8591, Elsulfavirine and Doravirine are four new agents that are furthest along in development. Expert opinion: ART development has evolved with several new promising agents. Longer-acting agents, like MK-8591 are extremely attractive to enhance drug adherence and patient satisfaction. Doravirine offers an NNRTI effective against common mutations that has fewer side effects, limitations on dosing and drug interactions. GS-9131 is very potent and active against a variety of NRTI mutants but it is too early in its development to understand its full risks and benefits. Finally, Elsulfavirine has a long half-life and preliminary data suggests fewer side effects than the most commonly used NNRTI, efavirenz. Each of these new agents shows promise and potential to improve ART in the future. The newer generation of reverse transcriptase inhibitors have longer half-lives, more favorable adverse effect profiles, and fewer drug interactions.
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Affiliation(s)
- Mohammad A Rai
- a Department of Internal Medicine , University of Cincinnati Medical Center , Cincinnati , OH , USA
| | - Sam Pannek
- a Department of Internal Medicine , University of Cincinnati Medical Center , Cincinnati , OH , USA
| | - Carl J Fichtenbaum
- a Department of Internal Medicine , University of Cincinnati Medical Center , Cincinnati , OH , USA
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98
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Benítez-Gutiérrez L, Soriano V, Requena S, Arias A, Barreiro P, de Mendoza C. Treatment and prevention of HIV infection with long-acting antiretrovirals. Expert Rev Clin Pharmacol 2018; 11:507-517. [PMID: 29595351 DOI: 10.1080/17512433.2018.1453805] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Current antiretroviral therapy allows to achieve and sustain maximal suppression of HIV replication in most treated patients. As result, the life expectancy of HIV-infected persons has improved dramatically and is nowadays similar to that of the HIV-negative population. However, oral antiretrovirals have to be taken daily and indefinitely to avoid resumption of HIV replication and selection of drug resistance. Unfortunately, drug adherence is often suboptimal and tends to decline over time. Areas covered: New drugs, formulations and delivery systems are being developed for extended-release of antiretrovirals. At this time, intramuscular cabotegravir and rilpivirine, dapivirine vaginal rings and tenofovir alafenamide subdermal implants are the products in more advanced stages of clinical development. Their pharmacokinetics/dynamics and safety/efficacy are reviewed. Expert commentary: In the absence of eradicative therapy for individuals with HIV infection and protective vaccines for persons at risk, long-term antiretroviral therapy is the best approach for preventing disease progression in patients and halting transmissions, either as result of 'treatment as prevention' for HIV carriers or 'pre-exposure prophylaxis' for uninfected individuals at risk. In all these scenarios, the advent of long-acting antiretrovirals will expand options for overcoming the challenge of suboptimal drug adherence and reduce the burden of HIV infection.
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Affiliation(s)
- Laura Benítez-Gutiérrez
- a Internal Medicine Department , Puerta de Hierro University Hospital , Majadahonda , Spain.,b Laboratory of Internal Medicine , Puerta de Hierro Research Institute , Majadahonda , Spain
| | - Vicente Soriano
- c Infectious Diseases Unit , La Paz University Hospital & Autonomous University , Madrid , Spain
| | - Silvia Requena
- b Laboratory of Internal Medicine , Puerta de Hierro Research Institute , Majadahonda , Spain
| | - Ana Arias
- a Internal Medicine Department , Puerta de Hierro University Hospital , Majadahonda , Spain
| | - Pablo Barreiro
- c Infectious Diseases Unit , La Paz University Hospital & Autonomous University , Madrid , Spain
| | - Carmen de Mendoza
- b Laboratory of Internal Medicine , Puerta de Hierro Research Institute , Majadahonda , Spain
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99
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Zhou T, Lin Z, Puligujja P, Palandri D, Hilaire J, Araínga M, Smith N, Gautam N, McMillan J, Alnouti Y, Liu X, Edagwa B, Gendelman HE. Optimizing the preparation and stability of decorated antiretroviral drug nanocrystals. Nanomedicine (Lond) 2018; 13:871-885. [PMID: 29553879 PMCID: PMC5992566 DOI: 10.2217/nnm-2017-0381] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Aim: While the therapeutic potential for current long-acting (LA) antiretroviral therapy (ART) is undeniable, ligand-decorated nanoformulated LA-ART could optimize drug delivery to viral reservoirs. The development of decorated ART hinges, however, on formulation processes and manufacture efficiencies. To this end, we compared manufacture and purification techniques for ligand-decorated antiretroviral drug nanocrystals. Materials & methods: Ligand-decorated nanoparticle manufacturing was tested using folic acid (FA) nanoformulated cabotegravir. Results: Direct manufacturing of FA-cabotegravir resulted in stable particles with high drug loading and monocyte–macrophage targeting. A one step ‘direct’ scheme proved superior over differential centrifugation or tangential flow filtration facilitating particle stability and preparation simplicity and efficiency. Conclusion: Direct manufacturing of FA nanoparticles provides a path toward large-scale clinical grade manufacturing of cell-targeted LA-ART.
Folic acid (FA) decoration on the surface of nanocrystals can be achieved by mixing FA conjugated poloxamer 407 (FA-P407) and native P407 in varied ratios followed by size reduction by homogenization and differential centrifugation or tangential flow filtration to remove excess unbound polymers. The optimized manufacturing scheme is by direct homogenization with predetermined quantity of FA conjugated P407. Direct manufacturing method yields stable homogenous nanoparticles with high drug loading.
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Affiliation(s)
- Tian Zhou
- Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA.,Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Zhiyi Lin
- Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA.,Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Pavan Puligujja
- Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Diana Palandri
- Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - James Hilaire
- Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Mariluz Araínga
- Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Nathan Smith
- Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Nagsen Gautam
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - JoEllyn McMillan
- Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Yazen Alnouti
- Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Xinming Liu
- Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Benson Edagwa
- Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Howard E Gendelman
- Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA.,Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE 68198, USA
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100
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Hummert P, Parsons TL, Ensign LM, Hoang T, Marzinke MA. Validation and implementation of liquid chromatographic-mass spectrometric (LC-MS) methods for the quantification of tenofovir prodrugs. J Pharm Biomed Anal 2018; 152:248-256. [PMID: 29433097 DOI: 10.1016/j.jpba.2018.02.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/01/2018] [Accepted: 02/04/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The nucleotide reverse transcriptase inhibitor tenofovir (TFV) is widely administered in a disoproxil prodrug form (tenofovir disoproxil fumarate, TDF) for HIV management and prevention. Recently, novel prodrugs tenofovir alafenamide fumarate (TAF) and hexadecyloxypropyl tenofovir (CMX157) have been pursued for HIV treatment while minimizing adverse effects associated with systemic TFV exposure. Dynamic and sensitive bioanalytical tools are required to characterize the pharmacokinetics of these prodrugs in systemic circulation. Two parallel methods have been developed, one to combinatorially quantify TAF and TFV, and a second method for CMX157 quantification, in plasma. METHODS K2EDTA plasma was spiked with TAF and TFV, or CMX157. Following the addition of isotopically labeled internal standards and sample extraction via solid phase extraction (TAF and TFV) or protein precipitation (CMX157), samples were subjected to liquid chromatographic-tandem mass spectrometric (LC-MS/MS) analysis. For TAF and TFV, separation occurred using a Zorbax Eclipse Plus C18 Narrow Bore RR, 2.1 × 50 mm, 3.5 μm column and analytes were detected on an API5000 mass analyzer; CMX157 was separated using a Kinetex C8, 2.1 × 50 mm, 2.6 μm column and quantified using an API4500 mass spectrometer. Methods were validated according to FDA Bioanalytical Method Validation guidelines. RESULTS Analytical methods: were optimized for the multiplexed monitoring of TAF and TFV, and CMX157 in plasma. The lower limits of quantification (LLOQs) for TAF, TFV, and CMX157 were 0.03, 1.0, and 0.25 ng/mL, respectively. Calibration curves were generated via weighted linear regression of standards. Intra- and inter-assay precision and accuracy studies demonstrated %CVs ≤ 14.4% and %DEVs ≤ ± 7.95%, respectively. Stability and matrix effects studies were also performed. All results were acceptable and in accordance with the recommended guidelines for bioanalytical methods. Assays were also applied to quantify in vivo concentrations of prodrugs and TFV in a preclinical study post-rectal administration. CONCLUSIONS Sensitive, specific, and dynamic LC-MS/MS assays have been developed and validated for the multiplexed quantification TAF and TFV, as well as an independent assay for CMX157 quantification, in plasma. The described methods meet sufficient throughput criteria to support large research trials.
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Affiliation(s)
- Pamela Hummert
- Department of Medicine, Baltimore, MD, 21287, USA; Johns Hopkins University School of Medicine, 4940 Eastern Avenue, Mason F. Lord Center Tower, Baltimore, MD, 21224, USA
| | - Teresa L Parsons
- Department of Medicine, Baltimore, MD, 21287, USA; Johns Hopkins University School of Medicine, 4940 Eastern Avenue, Mason F. Lord Center Tower, Baltimore, MD, 21224, USA
| | | | - Thuy Hoang
- Department of Pharmacology and Molecular Sciences, Baltimore, MD, 21287, USA
| | - Mark A Marzinke
- Department of Medicine, Baltimore, MD, 21287, USA; Department of Pathology, Baltimore, MD, 21287, USA; Johns Hopkins University School of Medicine, 1800 Orleans Street, Sheikh Zayed Tower, B1020-G, Baltimore, MD, 21287, USA.
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