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Lemaitre F, Grégoire M, Monchaud C, Bouchet S, Saint-Salvi B, Polard E. Management of drug-drug interactions with nirmatrelvir/ritonavir in patients treated for Covid-19: Guidelines from the French Society of Pharmacology and Therapeutics (SFPT). Therapie 2022; 77:509-521. [PMID: 35618549 PMCID: PMC9020499 DOI: 10.1016/j.therap.2022.03.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 03/17/2022] [Accepted: 03/18/2022] [Indexed: 01/14/2023]
Abstract
Objectives Nirmatrelvir in association with ritonavir (PAXLOVID™, Pfizer) is an antiviral agent targeting the 3-chymotrypsin–like cysteine protease enzyme (3C-like protease or Mpro) which is a key enzyme of the viral cycle of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This combination with a well-known pharmacokinetic enhancer leads to a high risk for drug-drug interactions in a polymedicated elected population for treatment. The aim of this work was to provide recommendations on behalf of the national French society of pharmacology (French Society of Pharmacology and Therapeutics; SFPT), by suggesting optimal and pragmatic therapeutic strategies if nirmatrelvir/ritonavir is to be given together with drugs commonly used, in order to ensure secured physicians’ prescription. Methods Six clinical pharmacologists search the scientific literature to provide a first draft of recommendations. Thereafter, twelve other clinical pharmacologists verified the recommendations and proposed modifications. The final draft was then validated by all 18 participants. Results Five distinct recommendations were issued: i) contra-indications, ii) “PAXLOVID™ not recommended with the comedication”, iii) “PAXLOVID™ possible whether the comedication is discontinued”, iv) “PAXLOVID™ possible only after an expert advice” and v) “PAXLOVID™ possible without modification of the associated treatment”. The final document comprises recommendations for 171 drugs/therapeutic classes aiming to secure prescription. In complex situations, clinicians are advised to contact their pharmacology department to obtain specific recommendations on the management of drug-drug interactions with nirmatrelvir/ritonavir. Conclusion These recommendations intend to be a help for clinicians willing to prescribe nirmatrelvir/ritonavir and to prevent drug-drug interactions leading to adverse drug reactions or loss of efficacy. They constitute a guideline for primary care situations. Of course, some complex situations may require expert advices and here, again, clinical pharmacologists are at the forefront in providing therapeutic advice.
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Affiliation(s)
- Florian Lemaitre
- Université de Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France; Inserm, centre d'investigation clinique, CIC 1414, 35000 Rennes, France.
| | - Matthieu Grégoire
- Clinical pharmacology department, Nantes university hospital, 44000 Nantes, France; UMR Inserm 1235, The Enteric Nervous System in Gut and Brain Disorders, University of Nantes, 44000 Nantes, France
| | - Caroline Monchaud
- Department of pharmacology, toxicology and centre of pharmacovigilance, CHU de Limoges, 87000 Limoges, France; UMR-1248, Inserm, 87000 Limoges, France
| | - Stéphane Bouchet
- Laboratoire de pharmacologie et toxicologie, service de pharmacologie médicale, CHU Pellegrin, Inserm U1219, 33000 Bordeaux, France
| | - Béatrice Saint-Salvi
- Medical interactions unit, Agence nationale de sécurité du médicaments et des produits de santé, 93200 Saint-Denis, France
| | - Elisabeth Polard
- Université de Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France; Inserm, centre d'investigation clinique, CIC 1414, 35000 Rennes, France
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Zhang Q, Duan SX, Harmatz JS, Wei Z, Singleton CA, Greenblatt DJ. Mechanism of dasabuvir inhibition of acetaminophen glucuronidation. J Pharm Pharmacol 2021; 74:131-138. [PMID: 34718654 DOI: 10.1093/jpp/rgab144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/14/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Acetaminophen (APAP) (paracetamol) is a widely used non-prescription drug for pain relief and antipyretic effects. The clearance of APAP is mainly through phase-2 biotransformation catalysed by UDP-glucuronosyl transferases (UGT). Dasabuvir is an anti-hepatitis C drug reported to inhibit several UGT isoforms. The study evaluated the in-vitro inhibitory capacity of dasabuvir versus APAP glucuronidation. METHODS Procedures included human liver microsomal incubations with APAP and isoform-selective probe substrates. KEY FINDINGS Dasabuvir inhibited APAP metabolism by a reversible, mixed-type (competitive and non-competitive) partial inhibition, with an inhibition constant Ki = 3.4 µM. The index constant 'a' was 6.7, indicating the relative contribution of competitive and non-competitive inhibition. The enzyme-inhibitor complex was still able to catalyse the reaction by 12% of the control capacity. Dasabuvir produced strong partial inhibition effect of UGT1A1 and UGT1A9 and relatively complete inhibition of UGT1A6. CONCLUSIONS Consistent with previous reports, dasabuvir inhibits the activity of 3 UGT isoforms associated with APAP metabolism. In-vitro to in-vivo scaling by 2 different approaches showed identical results, predicting an increased AUC of APAP by a factor of 1.3-fold with coadministration of dasabuvir. Until the findings are confirmed in clinical drug interaction studies, APAP dosage should not exceed 3 g per day in dasabuvir-treated patients to avoid potentially hepatotoxic APAP exposures.
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Affiliation(s)
- Qingchen Zhang
- Program in Pharmacology and Drug Development, Tufts University Graduate School of Biomedical Science and School of Medicine, Boston, MA, USA
| | - Su Xiang Duan
- Program in Pharmacology and Drug Development, Tufts University Graduate School of Biomedical Science and School of Medicine, Boston, MA, USA
| | - Jerold S Harmatz
- Program in Pharmacology and Drug Development, Tufts University Graduate School of Biomedical Science and School of Medicine, Boston, MA, USA
| | - Zixuan Wei
- Program in Pharmacology and Drug Development, Tufts University Graduate School of Biomedical Science and School of Medicine, Boston, MA, USA
| | - Christopher A Singleton
- Program in Pharmacology and Drug Development, Tufts University Graduate School of Biomedical Science and School of Medicine, Boston, MA, USA
| | - David J Greenblatt
- Program in Pharmacology and Drug Development, Tufts University Graduate School of Biomedical Science and School of Medicine, Boston, MA, USA
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Yuan NY, Kaul M. Beneficial and Adverse Effects of cART Affect Neurocognitive Function in HIV-1 Infection: Balancing Viral Suppression against Neuronal Stress and Injury. J Neuroimmune Pharmacol 2021; 16:90-112. [PMID: 31385157 PMCID: PMC7233291 DOI: 10.1007/s11481-019-09868-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/23/2019] [Indexed: 02/07/2023]
Abstract
HIV-associated neurocognitive disorders (HAND) persist despite the successful introduction of combination antiretroviral therapy (cART). While insufficient concentration of certain antiretrovirals (ARV) may lead to incomplete viral suppression in the brain, many ARVs are found to cause neuropsychiatric adverse effects, indicating their penetration into the central nervous system (CNS). Several lines of evidence suggest shared critical roles of oxidative and endoplasmic reticulum stress, compromised neuronal energy homeostasis, and autophagy in the promotion of neuronal dysfunction associated with both HIV-1 infection and long-term cART or ARV use. As the lifespans of HIV patients are increased, unique challenges have surfaced. Longer lives convey prolonged exposure of the CNS to viral toxins, neurotoxic ARVs, polypharmacy with prescribed or illicit drug use, and age-related diseases. All of these factors can contribute to increased risks for the development of neuropsychiatric conditions and cognitive impairment, which can significantly impact patient well-being, cART adherence, and overall health outcome. Strategies to increase the penetration of cART into the brain to lower viral toxicity may detrimentally increase ARV neurotoxicity and neuropsychiatric adverse effects. As clinicians attempt to control peripheral viremia in an aging population of HIV-infected patients, they must navigate an increasingly complex myriad of comorbidities, pharmacogenetics, drug-drug interactions, and psychiatric and cognitive dysfunction. Here we review in comparison to the neuropathological effects of HIV-1 the available information on neuropsychiatric adverse effects and neurotoxicity of clinically used ARV and cART. It appears altogether that future cART aiming at controlling HIV-1 in the CNS and preventing HAND will require an intricate balancing act of suppressing viral replication while minimizing neurotoxicity, impairment of neurocognition, and neuropsychiatric adverse effects. Graphical abstract Schematic summary of the effects exerted on the brain and neurocognitive function by HIV-1 infection, comorbidities, psychostimulatory, illicit drugs, therapeutic drugs, such as antiretrovirals, the resulting polypharmacy and aging, as well as the potential interactions of all these factors.
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Affiliation(s)
- Nina Y Yuan
- School of Medicine, Division of Biomedical Sciences, University of California Riverside, 900 University Ave, Riverside, CA, 92521, USA
| | - Marcus Kaul
- School of Medicine, Division of Biomedical Sciences, University of California Riverside, 900 University Ave, Riverside, CA, 92521, USA.
- Sanford Burnham Prebys Medical Discovery Institute, Infectious and Inflammatory Disease Center, 10901 North Torrey Pines Road, La Jolla, CA, 92037, USA.
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Venuto CS, Cramer YS, Rosenkranz SL, Sulkowski M, Wyles DL, Cohen DE, Schmidt J, Alston‐Smith BL, Morse GD. Raltegravir pharmacokinetics before and during treatment with ombitasvir, paritaprevir/ritonavir plus dasabuvir in adults with human immunodeficiency virus-1 and hepatitis C virus coinfection: AIDS Clinical Trials Group sub-study A5334s. Br J Clin Pharmacol 2020; 86:132-142. [PMID: 31656054 PMCID: PMC6983509 DOI: 10.1111/bcp.14148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/23/2019] [Accepted: 10/01/2019] [Indexed: 01/01/2023] Open
Abstract
AIMS AIDS Clinical Trials Group study A5334s evaluated the pharmacokinetics of raltegravir before and during combined administration of ombitasvir, paritaprevir/ritonavir, plus dasabuvir (OBV/PTV/r + DSV) and weight-based ribavirin in human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfected adults. The pharmacokinetics of OBV/PTV/r + DSV during raltegravir coadministration were also characterized. METHODS Adults living with HIV/HCV coinfection receiving steady-state raltegravir (400 mg twice daily) with 2 nucleos(t)ide analogues were enrolled. Pharmacokinetics of raltegravir were assessed prior to HCV therapy, and 4 weeks later following initiation of OBV/PTV/r (25/150/100 mg) once daily + DSV (250 mg) twice daily. Geometric mean ratios (GMRs) and 90% confidence intervals (CIs) were used to compare the following: raltegravir pharmacokinetics with HCV therapy (week 4) vs before HCV therapy (week 0); OBV/PTV/r and DSV pharmacokinetics vs historical healthy controls; raltegravir pharmacokinetics at week 0 vs historical control adults living with HIV. RESULTS Eight of 11 participants had decreased raltegravir exposures after initiation of HCV therapy. The GMRs (90% CI) for maximum concentration and area under the concentration-time curve of raltegravir with vs without HCV therapy were 0.68 (0.38-1.19) and 0.82 (0.58-1.17), respectively. Comparing OBV/PTV/r pharmacokinetics in healthy controls, A5334s study participants demonstrated generally lower maximum concentration and area under the concentration-time curve values by 41-82% and 4-73%, respectively. Raltegravir exposures tended to be higher in A5334s study participants compared to adults living with HIV. CONCLUSIONS The majority of participants' plasma raltegravir exposures were lower after initiation of HCV therapy in coinfected adults; however, confidence intervals were wide.
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Roncero C, Villegas JL, Martínez-Rebollar M, Buti M. The pharmacological interactions between direct-acting antivirals for the treatment of chronic hepatitis c and psychotropic drugs. Expert Rev Clin Pharmacol 2018; 11:999-1030. [PMID: 30199279 DOI: 10.1080/17512433.2018.1519392] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Most direct-acting antivirals (DAAs) and psychotropic drugs are metabolized by or induct/inhibit CYP enzymes and drug transporters. Although they are frequently coadministered, the drug-drug interactions (DDIs) have been little studied. Therefore, the aim of this review is to describe the interactions between the approved DAA or combination regimens and the main psychoactive substances, including legal and illegal drugs of abuse. Areas covered: We performed a literature search on PubMed database on drug interactions with the currently available antivirals for hepatitis C and a review of the information on pharmacokinetics, metabolism, and drug interactions from www.hep-druginteractions.org and from all the Summary of Product Characteristics (SmPC). This review covers the DDI between the DAA regimens approved, such as simeprevir and sofosbuvir, paritaprevir, glecaprevir, voxilaprevir, ombitasvir, ledipasvir, daclatasvir and sofosbuvir, elbasvir and grazoprevir, sofosbuvir and velpatasvir, glecaprevir/pibrentasvir, sofosbuvir and velpatasvir, and main psychotropic agents. Expert Commentary: DAA regimens based on sofosbuvir combination usually have less DDI than protease inhibitor-based regimens. Among protease inhibitors regimens, new combinations, such as glecaprevir/elbasvir and grazoprevir/elbasvir, seemed to have less DDI than the combination POrD (paritaprevir/ombitasvir/ritonavir/dasabuvir). However, the analysis of each interaction is theoretical and further interaction studies would be necessary to confirm actual effect.
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Affiliation(s)
- Carlos Roncero
- a Psychiatric Service , University of Salamanca Health Care Complex (Complejo Asistencial Universitario de Salamanca) , Salamanca , Spain.,b Psyciatric Departament, Institute of Biomedicine of Salamanca (IBSAL) , University of Salamanca , Salamanca , Spain
| | - Jose Luis Villegas
- c Psychiatric Unit Topas Prison, Psychiatric Service , University of Salamanca Health Care Complex , Salamanca , Spain
| | | | - Maria Buti
- e Liver Unit , Hospital Universitario Vall d'Hebron and Ciber-ehd, Instituto Carlos III , Barcelona , Spain
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You Y, Kim HS, Park JW, Keum G, Jang SK, Kim BM. Sulfur(vi) fluoride exchange as a key reaction for synthesizing biaryl sulfate core derivatives as potent hepatitis C virus NS5A inhibitors and their structure-activity relationship studies. RSC Adv 2018; 8:31803-31821. [PMID: 35548241 PMCID: PMC9085918 DOI: 10.1039/c8ra05471a] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 08/28/2018] [Indexed: 12/25/2022] Open
Abstract
Extremely potent, new hepatitis C virus (HCV) nonstructural 5A (NS5A) featuring substituted biaryl sulfate core structures was designed and synthesized. Based on the previously reported novel HCV NS5A inhibitors featuring biaryl sulfate core structures which exhibit two-digit picomolar half-maximal effective concentration (EC50) values against HCV genotype 1b and 2a, the new inhibitors equipped with the sulfate core structures containing diversely substituted aryl groups were explored. In this study, highly efficient, chemoselective coupling reactions between an arylsulfonyl fluoride and an aryl silyl ether, known as the sulfur(vi) fluoride exchange (SuFEx) reaction, were utilized. Among the inhibitors prepared based on the SuFEx chemistry, compounds 14, 15 and 29 exhibited two-digit picomolar EC50 values against GT-1b and single digit or sub nanomolar activities against the HCV GT-2a strain. Nonsymmetrical inhibitors containing an imidazole and amide moieties on each side of the sulfate core structures were also synthesized. In addition, a biotinylated probe targeting NS5A protein was prepared for labeling using the same synthetic methodology.
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Affiliation(s)
- Youngsu You
- Department of Chemistry, College of Natural Sciences, Seoul National University Seoul 08826 South Korea
| | - Hee Sun Kim
- Division of Integrative Biosciences and Biotechnology, Pohang University of Science and Technology Pohang 37673 South Korea
| | - Jung Woo Park
- Supercomputing Modeling & Simulation Center, Division of Data Analysis, Korea Institute of Science and Technology Information (KISTI) 245 Daehak-ro, Yuseong-gu Daejeon 34141 South Korea
| | - Gyochang Keum
- Center for Neuro-Medicine, Brain Science Institute, Korea Institute of Science and Technology (KIST) Hwarangno 14-gil 5, Seongbuk-gu Seoul 02455 South Korea
| | - Sung Key Jang
- Department of Life Sciences, Pohang University of Science and Technology Pohang 37673 South Korea
| | - B Moon Kim
- Department of Chemistry, College of Natural Sciences, Seoul National University Seoul 08826 South Korea
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Schlabe S, Rockstroh JK. Advances in the treatment of HIV/HCV coinfection in adults. Expert Opin Pharmacother 2017; 19:49-64. [DOI: 10.1080/14656566.2017.1419185] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Stefan Schlabe
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
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Alam N, Angeli MG, Greenblatt DJ. Mechanism of in-vitro inhibition of UGT1A1 by paritaprevir. J Pharm Pharmacol 2017; 69:1794-1801. [PMID: 28990653 DOI: 10.1111/jphp.12821] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 08/26/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The direct-acting protease inhibitor paritaprevir is a new pharmaco-logic option available for treatment of chronic hepatitis C (HCV). Paritaprevir is reported to inhibit human UGT 1A1, but the mechanism of inhibition and its possible clinical consequences are not established. Our objective was to evaluate the in-vitro metabolic interaction between paritaprevir and the oral contraceptive steroid ethinyl estradiol (EE), a UGT 1A1 substrate. METHODS Enzyme kinetic parameters were determined using human liver microsomes for the biotransformation of EE to its glucuronide metabolites, and the potency and mechanism of inhibition by paritaprevir. Probenecid was used as a reference inhibitor for purposes of assay validation. KEY FINDINGS The underlying pattern of EE kinetics was complex, with evidence of substrate inhibition. The in-vitro inhibition constant (Ki ) value for paritaprevir vs EE on average was 20 μm and was consistent with a competitive inhibition mechanism. The ratio of in-vivo maximum plasma concentration of paritaprevir to in-vitro Ki was <0.1. CONCLUSIONS Paritaprevir is an in-vitro inhibitor of UGT 1A1. However, the in-vitro Ki value relative to maximum clinical plasma concentrations is below the threshold to trigger a recommendation for pharmacokinetic drug interaction studies.
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Affiliation(s)
- Novera Alam
- Graduate Program in Pharmacology and Drug Development, Sackler School of Graduate Biomedical Sciences, Boston, MA, USA
| | - Mia G Angeli
- Graduate Program in Pharmacology and Drug Development, Sackler School of Graduate Biomedical Sciences, Boston, MA, USA
| | - David J Greenblatt
- Graduate Program in Pharmacology and Drug Development, Sackler School of Graduate Biomedical Sciences, Boston, MA, USA.,Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, Boston, MA, USA
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