A five-year evaluation of reports of overdose with indinavir sulfate

Final report on exposure during pregnancy from a pregnancy registry for quadrivalent human papillomavirus vaccine

OBJECTIVE

To better describe the safety profile of pregnancy exposures to the qHPV vaccine by acquiring and analyzing post-marketing data on pregnancy outcomes.

METHODS

This is a voluntary, post-marketing prenatal vaccine exposure registry. Enrollment criteria included an identifiable patient and health care provider from the United States, France, or Canada and exposure within 1 month before the date of onset of the last menstrual period or at any time during pregnancy. Outcomes of interest were pregnancy outcomes and birth defects. Prospectively reported cases were used for rate calculations.

RESULTS

For the 1752 prospective reports with known outcome, 1518 (86.6%) were live births, including ten twin pregnancies. Of 1527 neonates, 1444 (94.6%) had no congenital anomalies. The overall rate of spontaneous abortion was 6.7 per 100 outcomes (95% confidence interval [CI] 5.5-8.2). The prevalence of major birth defects was 2.4 per 100 live-born neonates (95% CI 1.7-3.3). There were 12 fetal deaths (0.8 per 100 outcomes, 95% CI 0.4-1.4).

CONCLUSION

Rates of spontaneous abortions and major birth defects were not greater than the general population rates. Although no adverse signals have been identified to date, the qHPV vaccine is not recommended for use in pregnant women.

A review of the toxicity of HIV medications

Antiretroviral therapy has changed human immunodeficiency virus (HIV) infection from a near-certainly fatal illness to one that can be managed chronically. More patients are taking antiretroviral drugs (ARVs) for longer periods of time, which naturally results in more observed toxicity. Overdose with ARVs is not commonly reported. The most serious overdose outcomes have been reported in neonates who were inadvertently administered supratherapeutic doses of HIV prophylaxis medications. Typical ARV regimens include a "backbone" of two nucleoside reverse transcriptase inhibitors (NRTI) and a "base" of either a protease inhibitor (PI) or nonnucleoside reverse transcriptase inhibitor. New classes of drugs called entry inhibitors and integrase inhibitors have also emerged. Older NRTIs were associated with mitochondrial toxicity, but this is less common in the newer drugs, emtricitabine, lamivudine, and tenofovir. Mitochondrial toxicity results from NRTI inhibition of a mitochondrial DNA polymerase. Mitochondrial toxicity manifests as myopathy, neuropathy, hepatic failure, and lactic acidosis. Routine lactate assessment in asymptomatic patients is not indicated. Lactate concentration should be obtained in patients taking NRTIs who have fatigue, nausea, vomiting, or vague abdominal pain. Mitochondrial toxicity can be fatal and is treated by supportive care and discontinuing NRTIs. Metabolic cofactors like thiamine, carnitine, and riboflavin may be helpful in managing mitochondrial toxicity. Lipodystrophy describes changes in fat distribution and lipid metabolism that have been attributed to both PIs and NRTIs. Lipodystrophy consists of loss of fat around the face (lipoatrophy), increase in truncal fat, and hypertriglyceridemia. There is no specific treatment of lipodystrophy. Clinicians should be able to recognize effects of chronic toxicity of ARVs, especially mitochondrial toxicity.

Renal complications in HIV

Highly Active Antiretroviral Therapy has revolutionised the care of individuals living with HIV-1. As the prognosis for this population has improved, there is an increased risk of other major causes of morbidity and mortality, including renal disease. This review discusses the frequency and causes of renal pathology, how to make the diagnosis and monitor for renal disease in HIV-infected individuals. The review was conducted having examined the key evidence focussing upon HIV and renal complications obtained from peer-reviewed journals (level of evidence I-IV). As the population of individuals living with HIV increases, so too does the prevalence of renal disease. Physicians should be vigilant and recognise individuals at risk of renal complications, and be aware of how to monitor, investigate and treat those affected.

Adjusting and censoring electronic monitoring device data. Implications for study outcomes

Electronic monitoring device (EMD) data are widely used to measure adherence in HIV medication adherence research. EMD data represent an objective measure of adherence and arguably provide more valid data than other methods such as self-reported measures, pill counts, and drug level concentration. Moreover, EMD data are longitudinal, include many measurements, and yield a rich data set. This article illustrates potential pitfalls associated with this measurement technique, including lack of clarity associated with EMD data, and the extent to which adherence outcomes are affected by data management decisions. Recommendations are given regarding what information should be included in publications that report results based on EMD data so as to facilitate comparisons between studies.