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Mykris TM, Weinhold J, Winchester LC, Scarsi KK, Fletcher CV, Podany AT, Avedissian SN. Quantification of nine antiretroviral drugs in cerebrospinal fluid: An approach to overcome sample collection tube adsorption. J Chromatogr B Analyt Technol Biomed Life Sci 2023; 1227:123810. [PMID: 37429153 PMCID: PMC10529871 DOI: 10.1016/j.jchromb.2023.123810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/20/2023] [Accepted: 06/23/2023] [Indexed: 07/12/2023]
Abstract
A highly sensitive LC-MS/MS methods were developed and validated to quantify nine antiretrovirals (atazanavir [ATV], tenofovir [TFV], emtricitabine [FTC], darunavir [DRV], dolutegravir [DTG], efavirenz [EFV], lamivudine [3TC], raltegravir [RAL], and ritonavir [RTV]) in human cerebral spinal fluid (CSF). The approach remedies adsorption issues caused by polypropylene based sample collection tubes. 1% ammonium hydroxide in methanol was added in an amount equal to the volume of each quality control (QC) or patient sample. Protein precipitation was utilized with a CSF sample volume of 100 μL and a 100 μL of methanol:ACN and vortexed. Chromatographic separation was achieved with a 3 × 100 ACE® C18 column for ATV, DRV, DTG, EFV, RTV and RAL, and a 2 × 100 Polar RP column for TFV/FTC/3TC. Mobile phase was methanol:water:formic acid (70:30:0.1, v/v/v) for ATV, DRV, DTG, EFV and RTV (10 uL injection, flow rate: 1.00 mL/min), ACN:water:formic acid (35:65:0.1, v/v/v) for RAL (50 uL injection, flow rate: 1.00 mL/min), ACN:water:formic acid (2:98:0.1, v/v/v) for TFV, FTC and 3TC (50 uL injection, flow rate: 0.35 mL/min). Column temperature was 40° C across all assays. The mass spectrometer was operated in positive, multiple-reaction-monitoring (MRM) mode with electrospray ionization (ESI) for all analytes with the exception of EFV, which was operated in negative, MRM mode with ESI. The assay was linear over the calibration range of 1 to 250 ng/mL for all analytes. The addition of 1% ammonium hydroxide in sample tubes overcame up to 44% negative bias in QC samples and allowed the methods to meet full validation criteria.
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Affiliation(s)
- Timothy M Mykris
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center. Omaha, NE, USA
| | - Jonathan Weinhold
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center. Omaha, NE, USA
| | - Lee C Winchester
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center. Omaha, NE, USA
| | - Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center. Omaha, NE, USA; Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center. Omaha, NE, USA
| | - Courtney V Fletcher
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center. Omaha, NE, USA; Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center. Omaha, NE, USA
| | - Anthony T Podany
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center. Omaha, NE, USA.
| | - Sean N Avedissian
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center. Omaha, NE, USA.
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2
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Abstract
Etravirine is a second-generation non-nucleoside reverse transcriptase inhibitor (NNRTI) for the treatment of human immunodeficiency virus type 1 infection. It is a potent inhibitor of HIV reverse transcriptase and retains activity against wild-type and most NNRTI-resistant HIV. The pharmacokinetic profile of etravirine and clinical data support twice-daily dosing, although once-daily dosing has been investigated in treatment-naïve and treatment-experienced persons. Despite similar pharmacokinetic and pharmacodynamic results compared with twice-daily dosing, larger studies are needed to fully support once-daily etravirine dosing in treatment-naïve individuals. Etravirine is reserved for use in third- or fourth-line antiretroviral treatment regimens, as recommended, for example, in treatment guidelines by the US Department of Health and Human Services-Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV. Etravirine exhibits the potential for bi-directional drug-drug interactions with other antiretrovirals and concomitant medications through its interactions with cytochrome P450 (CYP) isozymes: CYP3A4, CYP2C9, and CYP2C19. This review summarizes the pharmacokinetic and pharmacodynamic parameters of etravirine, with particular attention to information on drug-drug interactions and use in special patient populations, including children/adolescents, women, persons with organ dysfunction, and during pregnancy.
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3
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Fulco PP. Crushed bictegravir/emtricitabine/tenofovir alafenamide in a human immunodeficiency virus–positive patient with esophageal cancer. Am J Health Syst Pharm 2020; 77:509-510. [DOI: 10.1093/ajhp/zxaa017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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4
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San C, Lê MP, Matheron S, Mourvillier B, Caseris M, Timsit JF, Wolff M, Yazdanpanah Y, Descamps D, Peytavin G. Management of oral antiretroviral administration in patients with swallowing disorders or with an enteral feeding tube. Med Mal Infect 2019; 50:537-544. [PMID: 31722864 DOI: 10.1016/j.medmal.2019.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 12/14/2018] [Accepted: 10/18/2019] [Indexed: 02/07/2023]
Abstract
HIV infection has evolved into a chronic disease with comorbidities since the combination antiretroviral therapy era. Complications still occur and patients may need to be admitted to an intensive care unit. Acute respiratory failure is the first cause of these admissions, questioning the administration of solid oral dosage formulations. This issue is also observed in geriatric units where the prevalence of dysphagia is high and underestimated. The problem of antiretroviral administration is critical: altered solid oral dosage formulations and/or administration via enteral feeding tubes are sometimes the only option. The aim is to help manage antiretroviral treatment in unconscious or intubated patients and those with swallowing disorders who are hospitalized in intensive care units or geriatric units. This review provides information on the main antiretroviral regimens and on practical and legal aspects of manipulating solid oral dosage formulations and administration via enteral feeding tubes. Alternatives to the solid formulation are available for most of the 27 oral antiretrovirals available, or manufacturers provide recommendations for patients who are unable to swallow. Manipulation of solid oral dosage formulations such as crushing tablets or opening capsules and administration via feeding tubes are frequently reported but should be the last option for safety and liability issues. Before any off-label administration of a drug, physicians should consider alternatives to the solid oral dosage formulation and check whether the drug can be altered. Therapeutic monitoring is important in this particular setting as the pharmacokinetic profile of drugs is difficult to predict.
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Affiliation(s)
- Carine San
- Laboratoire de pharmacologie-toxicologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - M P Lê
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Laboratoire de pharmacologie-toxicologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France.
| | - S Matheron
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Service de maladies infectieuses et tropicales, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - B Mourvillier
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Réanimation médicale et infectieuse, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - M Caseris
- Service de pédiatrie, AP-HP, Hôpital Robert Debré, 75019 Paris, France
| | - J-F Timsit
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Réanimation médicale et infectieuse, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - M Wolff
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Réanimation médicale et infectieuse, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - Y Yazdanpanah
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Service de maladies infectieuses et tropicales, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - D Descamps
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Laboratoire de virologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - G Peytavin
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Laboratoire de pharmacologie-toxicologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
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5
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Fulco PP, Sterling RK, Lavoie SR. Administration of crushed ledipasvir-sofosbuvir tablets via gastrostomy button in a patient coinfected with HIV and hepatitis C virus. Am J Health Syst Pharm 2019; 74:1761-1762. [PMID: 29070496 DOI: 10.2146/ajhp170452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Patricia Pecora Fulco
- Division of Infectious Diseases and Department of PharmacyVirginia Commonwealth University HealthRichmond,
| | - Richard K Sterling
- Department of Internal MedicineDivision of GastroenterologyVirginia Commonwealth University HealthRichmond, VA
| | - Suzanne R Lavoie
- Department of PediatricsDivision of Infectious DiseasesVirginia Commonwealth University HealthRichmond, VA
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6
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Pecora Fulco P, Gatesman TL. Administration of crushed maraviroc via percutaneous gastrostomy tube in a patient with human immunodeficiency virus and progressive multifocal leukoencephalopathy. Am J Health Syst Pharm 2019; 76:265-267. [DOI: 10.1093/ajhp/zxy046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Travis L Gatesman
- Department of Pharmacy Virginia Commonwealth University Health Richmond, VA
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7
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Fulco PP, Higginson RT. Enhanced HIV viral load suppression with crushed combination tablets containing tenofovir alafenamide and emtricitabine. Am J Health Syst Pharm 2018; 75:594-595. [DOI: 10.2146/180090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Patricia Pecora Fulco
- Division of Infectious Diseases and Department of Pharmacy Virginia Commonwealth University Health Richmond, VA
| | - Robert T. Higginson
- Division of Infectious Diseases Virginia Commonwealth University Health Richmond, VA
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Brooks KM, Garrett KL, Kuriakose SS, George JM, Balba G, Bailey B, Anderson M, Lane HC, Maldarelli F, Pau AK. Decreased Absorption of Dolutegravir and Tenofovir Disoproxil Fumarate, But Not Emtricitabine, in an HIV-Infected Patient Following Oral and Jejunostomy-Tube Administration. Pharmacotherapy 2017; 37:e82-e89. [PMID: 28556353 PMCID: PMC5559318 DOI: 10.1002/phar.1960] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The use of enteral feeding tubes to administer antiretroviral medications is necessary in certain patients with human immunodeficiency virus (HIV) infection. However, adequacy of drug exposures after these administration routes are largely unknown, making dosing recommendations and the attainment of viral suppression challenging in this patient population. This report describes a patient with advanced HIV infection and a complicated medical history including long-term intractable nausea/vomiting necessitating antiretroviral medication administration via a Roux-en-Y jejunostomy (J)-tube. Pharmacokinetic assessments were performed to compare differences in antiretroviral drug absorption and plasma exposure following oral and J-tube administration of dolutegravir, tenofovir disoproxil fumarate, and emtricitabine. Results were also compared with published pharmacokinetic data in HIV-infected individuals. Exposure to dolutegravir and tenofovir were similar between J-tube and oral administration routes, whereas emtricitabine exposure was 38% lower when administered via J-tube. However, in comparison with reference data in HIV-infected individuals taking these medications orally, exposure to dolutegravir and tenofovir was 75-76% and 55-61% lower, respectively, following both routes of administration. Emtricitabine exposure was similar to and 71% higher than reference data following J-tube and oral administration, respectively. This report highlights the importance of performing pharmacokinetic assessments in patients with the potential for impaired drug absorption to ensure antiretroviral treatment success.
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Affiliation(s)
- Kristina M Brooks
- Clinical Pharmacokinetics Research Unit, Clinical Center Pharmacy Department, National Institutes of Health (NIH), Bethesda, Maryland
| | - Katy L Garrett
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina at Chapel Hill-Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Safia S Kuriakose
- Clinical Research Directorate/Clinical Monitoring Research Program, Leidos Biomedical Research, Inc., Frederick, Maryland
| | - Jomy M George
- Clinical Pharmacokinetics Research Unit, Clinical Center Pharmacy Department, National Institutes of Health (NIH), Bethesda, Maryland
| | - Gayle Balba
- Division of Infectious Diseases, Georgetown University Hospital, Washington, DC
| | - Bria Bailey
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland
| | - Megan Anderson
- Division of Intramural Research, NIAID, NIH, Bethesda, Maryland
| | - H Clifford Lane
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland
- Division of Intramural Research, NIAID, NIH, Bethesda, Maryland
| | - Frank Maldarelli
- Host Virus Interaction Branch, National Cancer Institute, NIH, Bethesda, Maryland
| | - Alice K Pau
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland
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9
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A Complete Guide on Crushing Tablets and/or Opening Capsules of Human Immunodeficiency Virus Medications. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2017. [DOI: 10.1097/ipc.0000000000000505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Durham SH, Badowski ME, Liedtke MD, Rathbun RC, Pecora Fulco P. Acute Care Management of the HIV-Infected Patient: A Report from the HIV Practice and Research Network of the American College of Clinical Pharmacy. Pharmacotherapy 2017; 37:611-629. [PMID: 28273373 DOI: 10.1002/phar.1921] [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] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients infected with human immunodeficiency virus (HIV) admitted to the hospital have complex antiretroviral therapy (ART) regimens with an increased medication error rate upon admission. This report provides a resource for clinicians managing HIV-infected patients and ART in the inpatient setting. METHODS A survey of the authors was conducted to evaluate common issues that arise during an acute hospitalization for HIV-infected patients. After a group consensus, a review of the medical literature was performed to determine the supporting evidence for the following HIV-associated hospital queries: admission/discharge orders, antiretroviral hospital formularies, laboratory monitoring, altered hepatic/renal function, drug-drug interactions (DDIs), enteral administration, and therapeutic drug monitoring. RESULTS With any hospital admission for an HIV-infected patient, a specific set of procedures should be followed including a thorough admission medication history and communication with the ambulatory HIV provider to avoid omissions or substitutions in the ART regimen. DDIs are common and should be reviewed at all transitions of care during the hospital admission. ART may be continued if enteral nutrition with a feeding tube is deemed necessary, but the entire regimen should be discontinued if no oral access is available for a prolonged period. Therapeutic drug monitoring is not generally recommended but, if available, should be considered in unique clinical scenarios where antiretroviral pharmacokinetics are difficult to predict. ART may need adjustment if hepatic or renal insufficiency ensues. CONCLUSIONS Treatment of hospitalized patients with HIV is highly complex. HIV-infected patients are at high risk for medication errors during various transitions of care. Baseline knowledge of the principles of antiretroviral pharmacotherapy is necessary for clinicians managing acutely ill HIV-infected patients to avoid medication errors, identify DDIs, and correctly dose medications if organ dysfunction arises. Timely ambulatory follow-up is essential to prevent readmissions and facilitate improved transitions of care.
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Affiliation(s)
- Spencer H Durham
- Department Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, Alabama
| | - Melissa E Badowski
- Section of Infectious Diseases, Department of Pharmacy Practice, University of Illinois at Chicago, College of Pharmacy, Chicago, Illinois
| | - Michelle D Liedtke
- Department of Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - R Chris Rathbun
- Department of Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Lalley-Chareczko L, Clark D, Zuppa AF, Moorthy G, Conyngham C, Mounzer K, Koenig H. A case study of chewed Truvada ® for PrEP maintaining protective drug levels as measured by a novel urine tenofovir assay. Antivir Ther 2017; 22:639-641. [PMID: 28260694 DOI: 10.3851/imp3151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2017] [Indexed: 10/20/2022]
Abstract
Emtricitabine/tenofovir disoproxil fumarate (FTC/TDF; Truvada®) given as pre-exposure prophylaxis (PrEP) successfully blocks HIV when taken once daily prior to potential HIV exposure. A 22-year-old male reported difficulty swallowing FTC/TDF for PrEP and subsequently began chewing the FTC/TDF tablets. Monthly urine samples assessed using liquid chromatography-tandem mass spectrometry (LC-MS/MS) indicated tenofovir levels >1,000 ng/ml, indicative of protection from HIV acquisition, over a 48-week period. Data from observational studies of HIV-positive patients details the successful treatment of HIV using crushed FTC/TDF delivered via feeding and gastronomy tubes while small, randomized trials of healthy volunteers demonstrate bioequivalence between whole and crushed FTC/TDF.
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Affiliation(s)
| | - Devon Clark
- Philadelphia FIGHT Community Health Centers, Philadelphia, PA, USA
| | - Athena F Zuppa
- Division of Pediatric Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ganesh Moorthy
- Division of Clinical Pharmacology & Therapeutics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Karam Mounzer
- Philadelphia FIGHT Community Health Centers, Philadelphia, PA, USA
| | - Helen Koenig
- Philadelphia FIGHT Community Health Centers, Philadelphia, PA, USA.,Division of Infectious Diseases, MacGregor Infectious Diseases Clinic, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Huesgen E, DeSear KE, Egelund EF, Smith R, Max B, Janelle J. A HAART-Breaking Review of Alternative Antiretroviral Administration: Practical Considerations with Crushing and Enteral Tube Scenarios. Pharmacotherapy 2016; 36:1145-1165. [PMID: 27636237 DOI: 10.1002/phar.1835] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Selection of an appropriate antiretroviral regimen for the patient infected with human immunodeficiency virus can be challenging, as various considerations must be taken into account including viral resistance mutations, patient comorbidities, drug interactions, and the potential for drug-related adverse effects and toxicities. Treatment is further complicated when a clinical scenario arises requiring an alteration in the dosage form. Factors ranging from dysphagia to administration through an enteral feeding tube can affect decisions regarding antiretroviral dosage forms. Limited pharmacokinetic data exist regarding the alteration of antiretroviral medications from their original form. Bioavailability may vary substantially between dosage forms, which can lead to unpredictable drug concentrations. Supratherapeutic or subtherapeutic antiretroviral drug concentrations can result in increased toxicity, virologic failure, or the emergence of drug resistance. We performed a systematic literature search to review the available antiretroviral literature on the modification of solid dosage forms as well as alternative routes of administration of oral antiretroviral agents and their application to clinical practice.
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Affiliation(s)
- Emily Huesgen
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Kathryn E DeSear
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Eric F Egelund
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Renata Smith
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois
| | - Blake Max
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois.,Ruth M. Rothstein CORE Center, Cook County Health & Hospital System, Chicago, Illinois
| | - Jennifer Janelle
- Department of Medicine, University of Florida, Gainesville, Florida
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13
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Larson KB, Cressey TR, Yogev R, Wiznia A, Hazra R, Jean-Philippe P, Graham B, Gonzalez A, Britto P, Carey VJ, Acosta EP. Pharmacokinetics of Once-Daily Darunavir/Ritonavir With and Without Etravirine in Human Immunodeficiency Virus-Infected Children, Adolescents, and Young Adults. J Pediatric Infect Dis Soc 2016; 5:131-7. [PMID: 27199469 PMCID: PMC5407125 DOI: 10.1093/jpids/piu142] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 12/18/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Limited data are available for once-daily (QD) darunavir (DRV)/ritonavir (r) in the pediatric population. Coadministration of etravirine (ETR) may alter the pharmacokinetics (PK) of DRV. We evaluated the PK interactions between DRV/r (QD) and ETR QD or twice-daily (BID) in children, adolescents, and young adults. METHODS Human immunodeficiency virus-infected subjects 9 to < 24 years old on optimized background therapy including DRV/r 800/100 mg QD alone or combined with ETR 200 mg BID or ETR 400 mg QD were enrolled. Protocol-defined target drug exposure ranges based on adult data were used to assess the adequacy of each regimen. Intensive 24-hour blood sampling was performed, and PK parameters were determined using noncompartmental analysis. RESULTS Thirty-one subjects (14 males) completed the study; 16 received DRV/r QD alone (group 1), 6 received DRV/r plus ETR BID (group 2A), and 9 received DRV/r plus ETR QD (group 2B). The geometric mean (90% confidence interval [CI] geometric mean) for DRV area under the curve at 24 hours (AUC24) was 57.9 (49.6-67.6), 74.9 (44.4-126.5), and 66.4 (50.8-86.9) mg × h/L for patients in groups 1, 2A, and 2B, respectively. The increased DRV exposure when coadministered with ETR was not statistically significant. The geometric mean (90% CI geometric mean) of ETR AUC24 was 8.6 (4.4-16.8) and 11.9 (7.5-18.9) mg × h/L for groups 2A and 2B, respectively, with comparable C24. CONCLUSIONS The results suggest that DRV/r QD with ETR 400 mg QD or 200 mg BID is appropriate and support further evaluation of the safety and efficacy of the once-daily regimen in older children, adolescents, and young adults.
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Affiliation(s)
| | - Tim R. Cressey
- Program for HIV Prevention and Treatment, Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Thailand,Harvard School of Public Health, Boston, Massachusetts
| | - Ram Yogev
- Children's Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Rohan Hazra
- National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Maternal and Pediatric Infectious Disease Branch, Bethesda, Maryland
| | - Patrick Jean-Philippe
- HJF-DAIDS, a Division of The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc
| | | | - Amy Gonzalez
- Frontier Science & Technology, Amherst, New York
| | - Paula Britto
- Harvard School of Public Health, Boston, Massachusetts
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14
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Fulco PP, Ayala-Sims VA. Sustained virological response after taking crushed elvitegravir–cobicistat–emtricitabine–tenofovir tablets. Am J Health Syst Pharm 2014; 71:784, 786. [DOI: 10.2146/ajhp130737] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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15
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Kim CH, Muzevich KM, Fulco PP. Orogastric administration of crushed darunavir tablets for a critically ill patient. Can J Hosp Pharm 2014; 67:39-42. [PMID: 24634526 PMCID: PMC3952907 DOI: 10.4212/cjhp.v67i1.1321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Catherine H Kim
- , PharmD, BCPS, was, at the time of this case, a Postgraduate Year Two Pharmacy Resident in Critical Care, Virginia Commonwealth University Health System, Richmond, Virginia. She is now a Unit-Based Clinical Pharmacist in the Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Katie M Muzevich
- , PharmD, BCPS, is a Clinical Pharmacy Specialist in Critical Care and Clinical Assistant Professor of Pharmacy, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Patricia P Fulco
- , PharmD, BCPS, FASHP, AAHIVP, is a Clinical Pharmacy Specialist in Internal Medicine/HIV and a Clinical Associate Professor of Pharmacy and Clinical Assistant Professor of Internal Medicine in the Division of Infectious Diseases, Virginia Commonwealth University Health System, Richmond, Virginia
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16
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Monteiro P, Perez I, Laguno M, Martínez-Rebollar M, González-Cordon A, Lonca M, Mallolas J, Blanco JL, Gatell JM, Martínez E. Dual therapy with etravirine plus raltegravir for virologically suppressed HIV-infected patients: a pilot study. J Antimicrob Chemother 2013; 69:742-8. [PMID: 24128667 DOI: 10.1093/jac/dkt406] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinical use of protease inhibitors (PIs) and nucleoside reverse transcriptase inhibitors (NRTIs) may be hampered by toxicity, interactions or resistance issues. Simple and effective antiretroviral regimens avoiding both drug classes may be needed for selected patients. METHODS This was a prospective cohort study. Virologically suppressed patients on PI or NRTI regimens, with problems of tolerability, safety concerns due to comorbidities or risk of drug interactions for both PIs and NRTIs, were given the opportunity to switch their regimen to etravirine plus raltegravir. Patients were required not to have prior virological failure to raltegravir and if there was prior non-nucleoside reverse transcriptase inhibitor (NNRTI) virological failure, only patients in whom efficacy of etravirine could be anticipated through the Stanford Drug Resistance Database were included. Follow-up was scheduled for at least 48 weeks, unless the patient was lost to follow-up or discontinued therapy. RESULTS Twenty-five patients were included. Their median age was 54 years; they had a median of 16 years on antiretroviral therapy and a median of nine previous regimens; 21 (84%) patients had previous virological failure; and 15 (60%) patients had a genotypic test that showed three or more NRTI mutations in 9 (36%), four or more PI mutations in 11 (44%) and at least one NNRTI mutation in 8 (32%) patients. At 48 weeks efficacy was 84% (95% CI 65.3%-93.6%) by intent-to-treat analysis and 91.3% (95% CI 73.2%-97.6%) by per-protocol analysis. One (4%) patient died, two (8%) discontinued due to intolerance and one (4%) experienced virological failure. The CD4/CD8 ratio and plasma lipids improved. CONCLUSIONS Dual therapy with etravirine plus raltegravir was well tolerated and maintained durable viral suppression in selected virologically suppressed patients for whom both PI and NRTI therapy was challenging.
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Affiliation(s)
- Polyana Monteiro
- Infectious Diseases Unit, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
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Prohaska ES, King AR. Administration of antiretroviral medication via enteral tubes. Am J Health Syst Pharm 2013; 69:2140-6. [PMID: 23230036 DOI: 10.2146/ajhp120106] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Case reports and other published or manufacturer-provided data on the administration of antiretroviral agents through enteral feeding tubes are reviewed. SUMMARY There is very limited published evidence to guide clinicians in the delivery of therapies for human immunodeficiency virus (HIV) infection by feeding tubes, especially crushed tablets and capsule contents. A search of the primary literature (through February 2012) identified a total of nine articles describing the delivery of highly active antiretroviral therapy (HAART) agents via gastrostomy (G), jejunostomy, and other feeding tubes; correspondence with pharmaceutical manufacturers yielded additional information. Most of the published evidence (from two prospective studies, one retrospective study, and six case reports) pertains to the treatment of HIV-infected children (33 of 40 cases). Although not a primary endpoint of any of the reviewed studies, viral suppression was documented in 29 of the 40 patients referenced in the reviewed articles. Manufacturer-provided information indicates that crushed darunavir tablets in suspension, as well as oral solutions of ritonavir and lopinavir-ritonavir, can be administered through G-tubes without significant loss of therapeutic efficacy. CONCLUSION Data regarding enteral feeding tube administration are available for 63% of commercially available oral HAART agents and are primarily limited to case reports specific to the pediatric population.
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