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Dallmann A, van den Anker J, Ahmadzia HK, Rakhmanina N. Mechanistic Modeling of the Drug-Drug Interaction Between Efavirenz and Dolutegravir: Is This Interaction Clinically Relevant When Switching From Efavirenz to Dolutegravir During Pregnancy? J Clin Pharmacol 2023; 63 Suppl 1:S81-S95. [PMID: 37317489 DOI: 10.1002/jcph.2225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/08/2023] [Indexed: 06/16/2023]
Abstract
Following the 2021 World Health Organization's updated recommendations on the management of HIV infection, millions of people living with HIV are currently switched from efavirenz-based antiretroviral therapy to dolutegravir-based antiretroviral therapy. Pregnant individuals transitioning from efavirenz to dolutegravir might be at increased risk of insufficient viral suppression in the immediate postswitch period because both efavirenz- and pregnancy-related increases in hormone levels induce enzymes involved in dolutegravir metabolism, namely, cytochrome P450 3A4 and uridine 5'-diphospho-glucuronosyltransferase 1A1. This study aimed at developing physiologically based pharmacokinetic models to simulate the switch from efavirenz to dolutegravir in the late second and third trimester. To this end, the drug-drug interaction between efavirenz and the uridine 5'-diphospho-glucuronosyltransferase 1A1 substrates dolutegravir and raltegravir was first simulated in nonpregnant subjects. After successful validation, the physiologically based pharmacokinetic models were translated to pregnancy and dolutegravir pharmacokinetics following efavirenz discontinuation were predicted. Modeling results indicated that, at the end of the second trimester, both efavirenz concentrations and dolutegravir trough concentrations fell below respective pharmacokinetic target thresholds (defined as reported thresholds producing 90%-95% of the maximum effect) during the time interval from 9.75 to 11 days after dolutegravir initiation. At the end of the third trimester, this time interval spanned from 10.3 days to >4 weeks after dolutegravir initiation. These findings suggest that dolutegravir exposure in the immediate post-efavirenz switch period during pregnancy may be suboptimal, leading to HIV viremia and, potentially, resistance. The clinical implications of these findings remain to be substantiated by future studies.
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Affiliation(s)
- André Dallmann
- Pharmacometrics/Modeling & Simulation, Research & Development, Pharmaceuticals, Bayer AG, Germany
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, District of Columbia, USA
- Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Homa K Ahmadzia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Natella Rakhmanina
- Division of Pediatric Infectious Diseases, Children's National Hospital, Washington, District of Columbia, USA
- The George Washington University, School of Medicine and Health Sciences, Washington, District of Columbia, USA
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia, USA
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2
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Angle ED, Cox PM. Multidisciplinary Insights into the Structure-Function Relationship of the CYP2B6 Active Site. Drug Metab Dispos 2023; 51:369-384. [PMID: 36418184 DOI: 10.1124/dmd.122.000853] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 10/12/2022] [Accepted: 11/04/2022] [Indexed: 11/27/2022] Open
Abstract
Cytochrome P450 2B6 (CYP2B6) is a highly polymorphic human enzyme involved in the metabolism of many clinically relevant drugs, environmental toxins, and endogenous molecules with disparate structures. Over the last 20-plus years, in silico and in vitro studies of CYP2B6 using various ligands have provided foundational information regarding the substrate specificity and structure-function relationship of this enzyme. Approaches such as homology modeling, X-ray crystallography, molecular docking, and kinetic activity assays coupled with CYP2B6 mutagenesis have done much to characterize this originally neglected monooxygenase. However, a complete understanding of the structural details that make new chemical entities substrates of CYP2B6 is still lacking. Surprisingly little in vitro data has been obtained about the structure-function relationship of amino acids identified to be in the CYP2B6 active site. Since much attention has already been devoted to elucidating the function of CYP2B6 allelic variants, here we review the salient findings of in silico and in vitro studies of the CYP2B6 structure-function relationship with a deliberate focus on the active site. In addition to summarizing these complementary approaches to studying structure-function relationships, we note gaps/challenges in existing data such as the need for more CYP2B6 crystal structures, molecular docking results with various ligands, and data coupling CYP2B6 active site mutagenesis with kinetic parameter measurement under standard expression conditions. Harnessing in silico and in vitro techniques in tandem to understand the CYP2B6 structure-function relationship will likely offer further insights into CYP2B6-mediated metabolism. SIGNIFICANCE STATEMENT: The apparent importance of cytochrome P450 2B6 (CYP2B6) in the metabolism of various xenobiotics and endogenous molecules has grown since its discovery with many in silico and in vitro studies offering a partial description of its structure-function relationship. Determining the structure-function relationship of CYP2B6 is difficult but may be aided by thorough biochemical investigations of the CYP2B6 active site that provide a more complete pharmacological understanding of this important enzyme.
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Affiliation(s)
- Ethan D Angle
- Department of Biology and Chemistry, College of Liberal Arts and Sciences, Azusa Pacific University, Azusa, California (E.D.A., P.M.C.) and Roy J. and Lucille A. Carver College of Medicine University of Iowa, Iowa City, Iowa (E.D.A.)
| | - Philip M Cox
- Department of Biology and Chemistry, College of Liberal Arts and Sciences, Azusa Pacific University, Azusa, California (E.D.A., P.M.C.) and Roy J. and Lucille A. Carver College of Medicine University of Iowa, Iowa City, Iowa (E.D.A.)
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3
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Protein Abundance of Drug Metabolizing Enzymes in Human Hepatitis C Livers. Int J Mol Sci 2023; 24:ijms24054543. [PMID: 36901973 PMCID: PMC10002520 DOI: 10.3390/ijms24054543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/22/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023] Open
Abstract
Hepatic drug metabolizing enzymes (DMEs), whose activity may be affected by liver diseases, are major determinants of drug pharmacokinetics. Hepatitis C liver samples in different functional states, i.e., the Child-Pugh class A (n = 30), B (n = 21) and C (n = 7) were analyzed for protein abundances (LC-MS/MS) and mRNA levels (qRT-PCR) of 9 CYPs and 4 UGTs enzymes. The protein levels of CYP1A1, CYP2B6, CYP2C8, CYP2C9, and CYP2D6 were not affected by the disease. In the Child-Pugh class A livers, a significant up-regulation of UGT1A1 (to 163% of the controls) was observed. The Child-Pugh class B was associated with down-regulation of the protein abundance of CYP2C19 (to 38% of the controls), CYP2E1 (to 54%), CYP3A4 (to 33%), UGT1A3 (to 69%), and UGT2B7 (to 56%). In the Child-Pugh class C livers, CYP1A2 was found to be reduced (to 52%). A significant trend in down-regulation of the protein abundance was documented for CYP1A2, CYP2C9, CYP3A4, CYP2E1, UGT2B7, and UGT2B15. The results of the study demonstrate that DMEs protein abundances in the liver are affected by hepatitis C virus infection and depend on the severity of the disease.
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4
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Mouterde M, Daali Y, Rollason V, Čížková M, Mulugeta A, Al Balushi KA, Fakis G, Constantinidis TC, Al-Thihli K, Černá M, Makonnen E, Boukouvala S, Al-Yahyaee S, Yimer G, Černý V, Desmeules J, Poloni ES. Joint Analysis of Phenotypic and Genomic Diversity Sheds Light on the Evolution of Xenobiotic Metabolism in Humans. Genome Biol Evol 2022; 14:6852765. [PMID: 36445690 PMCID: PMC9750130 DOI: 10.1093/gbe/evac167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 11/03/2022] [Accepted: 11/22/2022] [Indexed: 11/30/2022] Open
Abstract
Variation in genes involved in the absorption, distribution, metabolism, and excretion of drugs (ADME) can influence individual response to a therapeutic treatment. The study of ADME genetic diversity in human populations has led to evolutionary hypotheses of adaptation to distinct chemical environments. Population differentiation in measured drug metabolism phenotypes is, however, scarcely documented, often indirectly estimated via genotype-predicted phenotypes. We administered seven probe compounds devised to target six cytochrome P450 enzymes and the P-glycoprotein (P-gp) activity to assess phenotypic variation in four populations along a latitudinal transect spanning over Africa, the Middle East, and Europe (349 healthy Ethiopian, Omani, Greek, and Czech volunteers). We demonstrate significant population differentiation for all phenotypes except the one measuring CYP2D6 activity. Genome-wide association studies (GWAS) evidenced that the variability of phenotypes measuring CYP2B6, CYP2C9, CYP2C19, and CYP2D6 activity was associated with genetic variants linked to the corresponding encoding genes, and additional genes for the latter three. Instead, GWAS did not indicate any association between genetic diversity and the phenotypes measuring CYP1A2, CYP3A4, and P-gp activity. Genome scans of selection highlighted multiple candidate regions, a few of which included ADME genes, but none overlapped with the GWAS candidates. Our results suggest that different mechanisms have been shaping the evolution of these phenotypes, including phenotypic plasticity, and possibly some form of balancing selection. We discuss how these contrasting results highlight the diverse evolutionary trajectories of ADME genes and proteins, consistent with the wide spectrum of both endogenous and exogenous molecules that are their substrates.
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Affiliation(s)
| | - Youssef Daali
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Victoria Rollason
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Martina Čížková
- Institute of Archaeology of the Academy of Sciences of the Czech Republic, Prague, Czech Republic
| | - Anwar Mulugeta
- Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Khalid A Al Balushi
- College of Pharmacy, National University of Science and Technology, Muscat, Sultanate of Oman
| | - Giannoulis Fakis
- Department of Molecular Biology and Genetics, Democritus University of Thrace, Alexandroupolis, Greece
| | | | - Khalid Al-Thihli
- Department of Genetics, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Marie Černá
- Department of Medical Genetics, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Eyasu Makonnen
- Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia,Center for Innovative Drug Development and Therapeutic Trials for Africa, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Sotiria Boukouvala
- Department of Molecular Biology and Genetics, Democritus University of Thrace, Alexandroupolis, Greece
| | - Said Al-Yahyaee
- Department of Genetics, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Sultanate of Oman
| | - Getnet Yimer
- Center for Global Genomics & Health Equity, Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Viktor Černý
- Department of Anthropology and Human Genetics, Faculty of Science, Charles University, Prague, Czech Republic
| | - Jules Desmeules
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
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5
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Wiesner A, Skrońska M, Gawlik G, Marcinkowska M, Zagrodzki P, Paśko P. Interactions of Antiretroviral Drugs with Food, Beverages, Dietary Supplements, and Alcohol: A Systematic Review and Meta-analyses. AIDS Behav 2022; 27:1441-1468. [PMID: 36318429 PMCID: PMC10129904 DOI: 10.1007/s10461-022-03880-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2022] [Indexed: 04/28/2023]
Abstract
Multiple factors may affect combined antiretroviral therapy (cART). We investigated the impact of food, beverages, dietary supplements, and alcohol on the pharmacokinetic and pharmacodynamic parameters of 33 antiretroviral drugs. Systematic review in adherence to PRISMA guidelines was performed, with 109 reports of 120 studies included. For each drug, meta-analyses or qualitative analyses were conducted. We have found clinically significant interactions with food for more than half of antiretroviral agents. The following drugs should be taken with or immediately after the meal: tenofovir disoproxil, etravirine, rilpivirine, dolutegravir, elvitegravir, atazanavir, darunavir, lopinavir, nelfinavir, ritonavir, saquinavir. Didanosine, zalcitabine, zidovudine, efavirenz, amprenavir, fosamprenavir, and indinavir should be taken on an empty stomach for maximum patient benefit. Antiretroviral agents not mentioned above can be administered regardless of food. There is insufficient evidence available to make recommendations about consuming juice or alcohol with antiretroviral drugs. Resolving drug-food interactions may contribute to maximized cART effectiveness and safety.
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Affiliation(s)
- Agnieszka Wiesner
- Department of Food Chemistry and Nutrition, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna Str., 30-688, Kraków, Poland
| | - Magdalena Skrońska
- Department of Food Chemistry and Nutrition, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna Str., 30-688, Kraków, Poland
| | - Gabriela Gawlik
- Department of Community and Public Health, Idaho State University, 1311 E Central Dr, Meridian, ID, 83642, USA
| | - Monika Marcinkowska
- Department of Medicinal Chemistry, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna Str., 30-688, Kraków, Poland
| | - Paweł Zagrodzki
- Department of Food Chemistry and Nutrition, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna Str., 30-688, Kraków, Poland
| | - Paweł Paśko
- Department of Food Chemistry and Nutrition, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna Str., 30-688, Kraków, Poland.
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6
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Olafuyi O, Parekh N, Wright J, Koenig J. Inter-ethnic differences in pharmacokinetics-is there more that unites than divides? Pharmacol Res Perspect 2021; 9:e00890. [PMID: 34725944 PMCID: PMC8561230 DOI: 10.1002/prp2.890] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/19/2021] [Indexed: 12/31/2022] Open
Abstract
Inter-ethnic variability in pharmacokinetics (PK) has been attributed to several factors ranging from genetic to environmental. It is not clear how current teaching in higher education (HE) reflects what published literature suggests on this subject. This study aims to gain insights into current knowledge about inter-ethnic differences in PK based on reports from published literature and current teaching practices in HE. A systematic literature search was conducted on PubMed and Scopus to identify suitable literature to be reviewed. Insights into inter-ethnic differences in PK teaching among educators in HE and industry were determined using a questionnaire. Thirty-one percent of the studies reviewed reported inter-ethnic differences in PK, of these, 37% of authors suggested genetic polymorphism as possible explanation for the inter-ethnic differences observed. Other factors authors proposed included diet and weight differences between ethnicities. Most respondents (80%) who taught inter-ethnic difference in PK attributed inter-ethnic differences to genetic polymorphism. While genetic polymorphism is one source of variability in PK, the teaching of genetic polymorphism is better associated with interindividual variabilities rather than inter-ethnic differences in PK as there are no genes with PK implications specific to any one ethnic group. Nongenetic factors such as diet, weight, and environmental factors, should be highlighted as potential sources of interindividual variation in the PK of drugs.
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Affiliation(s)
- Olusola Olafuyi
- Division of Physiology, Pharmacology and NeurosciencesSchool of Life SciencesUniversity of NottinghamNottinghamUK
| | - Nikita Parekh
- Department of Pharmacology and TherapeuticsKing’s College LondonLondonUK
| | - Jacob Wright
- Centre for Bioscience EducationKing’s College LondonLondonUK
| | - Jennifer Koenig
- Division of Medical Sciences & Graduate Entry MedicineSchool of MedicineUniversity of NottinghamNottinghamUK
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7
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Togao M, Tajima S, Kurakawa T, Wagai G, Otsuka J, Kado S, Kawakami K. Normal variation of the gut microbiota affects hepatic cytochrome P450 activity in mice. Pharmacol Res Perspect 2021; 9:e00893. [PMID: 34747570 PMCID: PMC8573722 DOI: 10.1002/prp2.893] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 10/21/2021] [Indexed: 12/12/2022] Open
Abstract
Several studies revealed that substantial artificial changes in the gut microbiota resulted in modification of hepatic cytochrome P450 3a (Cyp3a) in mice. Consequently, we hypothesized that "normal" variation of the gut microbiota might also alter hepatic Cyp activity and lead to individual differences in drug metabolism. Therefore, this study investigated the effects of normal gut microbiota variation on hepatic Cyp activity under the same genetic and environmental conditions using ex-germ-free mice. Using the feces of three breeder BALB/c mice (Jcl, Slc, and Crj), germ-free BALB/cYit mice were conventionalized (Yit-Jcl, Yit-Slc, and Yit-Crj). The gut microbiota composition and hepatic Cyp activity of these donors and recipients were evaluated. 16S rRNA sequencing revealed clear differences of the gut microbiota among donors and among recipients. Cyp3a activity was significantly higher in Slc mice than in Jcl and Crj mice. Notably, among recipients, Cyp3a activity was significantly higher in Yit-Slc and Yit-Crj mice than in Yit-Jcl mice. Cyp2b activity was significantly higher in Slc mice than in Jcl and Crj mice. Cyp2b activity was significantly higher in Yit-Slc mice than in Yit-Jcl mice. Additionally, in correlation analysis, some genera displayed significant positive or negative correlations with Cyp activity, particular the strong positive correlation between Clostridium sensu stricto 1 with Cyp3a activity. In conclusion, this study demonstrated that normal variation of the gut microbiota affected hepatic Cyp3a and Cyp2b activity, which might result in individual differences of drug metabolism.
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Affiliation(s)
- Masao Togao
- Safety Research DepartmentYakult Central InstituteKunitachi‐shiTokyoJapan
| | - Shinnosuke Tajima
- Safety Research DepartmentYakult Central InstituteKunitachi‐shiTokyoJapan
| | - Takashi Kurakawa
- Basic Research DepartmentYakult Central InstituteKunitachi‐shiTokyoJapan
| | - Gaku Wagai
- Safety Research DepartmentYakult Central InstituteKunitachi‐shiTokyoJapan
| | - Jun Otsuka
- Safety Research DepartmentYakult Central InstituteKunitachi‐shiTokyoJapan
| | - Shoichi Kado
- Safety Research DepartmentYakult Central InstituteKunitachi‐shiTokyoJapan
| | - Koji Kawakami
- Safety Research DepartmentYakult Central InstituteKunitachi‐shiTokyoJapan
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8
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OpenCYP: An open source database exploring human variability in activities and frequencies of polymophisms for major cytochrome P-450 isoforms across world populations. Toxicol Lett 2021; 350:267-282. [PMID: 34352333 DOI: 10.1016/j.toxlet.2021.07.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/22/2021] [Accepted: 07/27/2021] [Indexed: 12/12/2022]
Abstract
The open source database "OpenCYP database" has been developed based on the results of extensive literature searches from the peer-reviewed literature. OpenCYP provides data on human variability on baseline of activities and polymophism frequencies for selected cytochrome P-450 isoforms (CYP1A2, CYP2A6, CYP2D6, CYP3A4/3A5 and CYP3A7) in healthy adult populations from world populations. CYP enzymatic activities were generally expressed as the metabolic ratio (MR) between an unchanged probe drug and its metabolite(s) in urine or plasma measured in healthy adults. Data on other age groups were very limited and fragmented, constituting an important data gap. Quantitative comparisons were often hampered by the different experimental conditions used. However, variability was quite limited for CYP1A2, using caffeine as a probe substrate, with a symmetrical distribution of metabolic activity values. For CYP3A4, human variability was dependent on the probe substrate itself with low variability when data considering the dextromethorphan/demethilathed metabolite MR were used and large variability when the urinary 6β-hydroxycortisol/cortisol ratio was used. The largest variability in CYP activity was shown for CYP2D6 activity, after oral dosing of dextromethorphan, for which genetic polymorphisms are well characterised and constitute a significant source of variability. It is foreseen that the OpenCYP database can contribute to promising tools to support the further development of QIVIVE and PBK models for human risk assessment of chemicals particularly when combined with information on isoform-specific content in cells using proteomic approaches.
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9
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Tang JH, Davis NL, Corbett AH, Chinula L, Cottrell ML, Zia Y, Tegha G, Stanczyk FZ, Hurst S, Hosseinipour MC, Haddad LB, Kourtis AP. Effect of efavirenz on levonorgestrel concentrations among Malawian levonorgestrel implant users for up to 30 months of concomitant use: a subanalysis of a randomized clinical trial. Contracept X 2020; 2:100027. [PMID: 33364598 PMCID: PMC7752709 DOI: 10.1016/j.conx.2020.100027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 11/25/2022] Open
Abstract
Objectives Our primary objective was to compare geometric mean levonorgestrel concentrations between levonorgestrel implant users who were or were not taking the antiretroviral efavirenz, for up to 30 months after implant initiation. Our secondary objective was to evaluate the pregnancy rate among levonorgestrel implant users on efavirenz. Study design We performed a subanalysis of 42 Malawian women randomized to initiate the levonorgestrel implant as part of a parent randomized clinical trial. Our subset included 30 HIV-infected women taking efavirenz and 12 HIV-uninfected women not taking efavirenz. They underwent urine pregnancy testing every 3 months and serum levonorgestrel testing at day 3 and months 1, 3, 6, 12, 18, 24, 27 and 30 after implant initiation. Geometric mean levonorgestrel concentrations were calculated for efavirenz users and non-efavirenz users at each time point. Results The geometric mean levonorgestrel concentrations were lower for efavirenz users than non-efavirenz users at every time point; the geometric mean ratio for efavirenz users:non-efavirenz users ranged from 0.60 [90% confidence interval (CI) 0.46–0.79] at 1 month to 0.27 (90% CI 0.12–0.61) at 30 months after implant insertion. No pregnancies occurred over 60 woman-years of concomitant levonorgestrel implant and efavirenz use, although 11 women had levonorgestrel concentrations < 180 pg/mL (the previously suggested minimum threshold concentration for efficacy). Conclusions Efavirenz users had lower levonorgestrel concentrations than non-efavirenz users, and one third of our concomitant efavirenz and levonorgestrel implant users had concentrations < 180 pg/mL. Continued evaluation of the contraceptive efficacy of the levonorgestrel implant may be needed for efavirenz users. Implications Among 42 Malawian women using the levonorgestrel implant for contraception, women who were taking the antiretroviral efavirenz had lower serum levonorgestrel concentrations than women who were not taking efavirenz. However, none of the women who were taking efavirenz became pregnant over 60 women-years of follow-up.
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Affiliation(s)
- Jennifer H Tang
- University of North Carolina at Chapel Hill, 111 Mason Farm Road, CB #7577; Chapel Hill, NC, 27599-7577, USA.,UNC Project Malawi, 100 Mzimba Drive, Private Bag A104, Lilongwe, Malawi
| | - Nicole L Davis
- US Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - Amanda H Corbett
- University of North Carolina at Chapel Hill, 111 Mason Farm Road, CB #7577; Chapel Hill, NC, 27599-7577, USA
| | - Lameck Chinula
- University of North Carolina at Chapel Hill, 111 Mason Farm Road, CB #7577; Chapel Hill, NC, 27599-7577, USA.,UNC Project Malawi, 100 Mzimba Drive, Private Bag A104, Lilongwe, Malawi
| | - Mackenzie L Cottrell
- University of North Carolina at Chapel Hill, 111 Mason Farm Road, CB #7577; Chapel Hill, NC, 27599-7577, USA
| | - Yasaman Zia
- US Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - Gerald Tegha
- UNC Project Malawi, 100 Mzimba Drive, Private Bag A104, Lilongwe, Malawi
| | - Frank Z Stanczyk
- University of Southern California, Keck School of Medicine, Reproductive Endocrine Research Laboratory, 1321 N. Mission Road, Los Angeles, CA, 90033, USA
| | - Stacey Hurst
- US Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - Mina C Hosseinipour
- University of North Carolina at Chapel Hill, 111 Mason Farm Road, CB #7577; Chapel Hill, NC, 27599-7577, USA.,UNC Project Malawi, 100 Mzimba Drive, Private Bag A104, Lilongwe, Malawi
| | - Lisa B Haddad
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA, 30322, USA
| | - Athena P Kourtis
- US Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA
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10
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Li AP, Ho MD, Alam N, Mitchell W, Wong S, Yan Z, Kenny JR, E. C. A. Hop C. Inter-individual and inter-regional variations in enteric drug metabolizing enzyme activities: Results with cryopreserved human intestinal mucosal epithelia (CHIM) from the small intestines of 14 donors. Pharmacol Res Perspect 2020; 8:e00645. [PMID: 32851819 PMCID: PMC7449955 DOI: 10.1002/prp2.645] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 07/22/2020] [Indexed: 11/10/2022] Open
Abstract
We have previously reported successful isolation and cryopreservation of human intestinal mucosa (CHIM) with retention of viability and drug metabolizing enzyme activities. Here we report the results of the quantification of drug metabolizing enzyme activities in CHIM from different regions of the small intestines from 14 individual donors. CHIM were isolated from the duodenum, jejunum, and ileum of 10 individuals, and from 10 consecutive 12-inch segments starting from the pyloric sphincter of human small intestines from four additional individuals. P450 and non-P450 drug metabolizing enzyme activities (CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP2E1, CYP3A, UGT, SULT, FMO, MAO, AO, NAT1, and NAT2) were quantified via incubation with pathway-selective substrates. Quantifiable activities were observed for all pathways except for CYP2A6. Comparison of the duodenum, jejunum, and ileum in 10 donors shows jejunum had higher activities for CYP2C9, CYP3A, UGT, SULT, MAO, and NAT1. Further definition of regional variations with CHIM from ten 12-inch segments of the proximal small intestine shows that the segments immediately after the first 12-inch segment (duodenum) had the highest activity for most of the drug metabolizing enzymes but with substantial differences among the four donors. Our overall results demonstrate that there are substantial individual differences in drug metabolizing enzymes and that jejunum, especially the regions immediately after the duodenum, had the highest drug metabolizing enzyme activities.
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Affiliation(s)
| | | | - Novera Alam
- In Vitro ADMET Laboratories, Inc.ColumbiaMDUSA
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11
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Hakkers CS, Hermans AM, van Maarseveen EM, Teunissen CE, Verberk IMW, Arends JE, Hoepelman AIM. High efavirenz levels but not neurofilament light plasma levels are associated with poor neurocognitive functioning in asymptomatic HIV patients. J Neurovirol 2020; 26:572-580. [PMID: 32524424 PMCID: PMC7438296 DOI: 10.1007/s13365-020-00860-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 05/10/2020] [Accepted: 05/19/2020] [Indexed: 11/29/2022]
Abstract
The aim of this study is to assess the effect of efavirenz exposure on neurocognitive functioning and investigate plasma neurofilament light (Nfl) as a biomarker for neurocognitive damage. Sub-analysis of the ESCAPE-study, a randomised controlled trial where virologically suppressed, cognitively asymptomatic HIV patients were randomised (2:1) to switch to rilpivirine or continue on efavirenz. At baseline and week 12, patients underwent an extensive neuropsychological assessment (NPA), and serum efavirenz concentration and plasma Nfl levels were measured. Subgroups of elevated (≥ 4.0 mg/L) and therapeutic (0.74 to< 4.0 mg/L) baseline efavirenz concentration were made. Differences between these groups in baseline NPA Z-scores and in delta scores after efavirenz discontinuation were assessed. Nfl level was measured using an ELISA analysis using single molecule array (Simoa) technology. Correlation of plasma NFL with NPA Z-scores was evaluated using a linear mixed model. The elevated group consisted of 6 patients and the therapeutic group of 48. At baseline, the elevated group showed lower composite Z-scores (median - 1.03; IQR 0.87 versus 0.27; 0.79. p 0.02). This effect was also seen on the subdomains verbal (p 0.01), executive functioning (p 0.02), attention (p < 0.01) and speed (p 0.01). In the switch group, the elevated group improved more on composite scores after discontinuing efavirenz (mean 0.58; SD 0.32 versus 0.22; 0.54, p 0.15). No association between plasma Nfl and composite Z-score was found. High efavirenz exposure is associated with worse cognitive functioning compared with patients with therapeutic concentrations. Plasma Nfl is not a suitable biomarker to measure cognitive damage in this group.
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Affiliation(s)
- Charlotte S Hakkers
- Department of Internal Medicine, section Infectious Diseases, University Medical Center (UMC) Utrecht, Utrecht University, PO Box 85500, 3508, GA, Utrecht, the Netherlands.
| | - Anne Marie Hermans
- Department of Internal Medicine, section Infectious Diseases, University Medical Center (UMC) Utrecht, Utrecht University, PO Box 85500, 3508, GA, Utrecht, the Netherlands
| | - Erik M van Maarseveen
- Division of Laboratory and Pharmacy, Clinical Pharmacy, University Medical Center (UMC) Utrecht, Utrecht, the Netherlands
| | - Charlotte E Teunissen
- Department of Clinical Chemistry, Amsterdam Neuroscience Neurochemistry laboratory, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Inge M W Verberk
- Department of Clinical Chemistry, Amsterdam Neuroscience Neurochemistry laboratory, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Joop E Arends
- Department of Internal Medicine, section Infectious Diseases, University Medical Center (UMC) Utrecht, Utrecht University, PO Box 85500, 3508, GA, Utrecht, the Netherlands
| | - Andy I M Hoepelman
- Department of Internal Medicine, section Infectious Diseases, University Medical Center (UMC) Utrecht, Utrecht University, PO Box 85500, 3508, GA, Utrecht, the Netherlands
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12
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Chetty M, Danckwerts MP, Julsing A. Prediction of the exposure to a 400-mg daily dose of efavirenz in pregnancy: is this dose adequate in extensive metabolisers of CYP2B6? Eur J Clin Pharmacol 2020; 76:1143-1150. [DOI: 10.1007/s00228-020-02890-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 05/01/2020] [Indexed: 12/26/2022]
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Darney K, Testai E, Buratti FM, Di Consiglio E, Kasteel EE, Kramer N, Turco L, Vichi S, Roudot AC, Dorne JL, Béchaux C. Inter-ethnic differences in CYP3A4 metabolism: A Bayesian meta-analysis for the refinement of uncertainty factors in chemical risk assessment. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.comtox.2019.100092] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Hammond CK, Eley B, Ing N, Wilmshurst JM. Neuropsychiatric and Neurocognitive Manifestations in HIV-Infected Children Treated With Efavirenz in South Africa-A Retrospective Case Series. Front Neurol 2019; 10:742. [PMID: 31338063 PMCID: PMC6629903 DOI: 10.3389/fneur.2019.00742] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 06/24/2019] [Indexed: 01/01/2023] Open
Abstract
Background: Efavirenz is associated with transient neuropsychiatric manifestations but the impact on neurocognition in children is unknown. Genetically slow metabolizers of efavirenz may be at risk of toxicity. This study describes neuropsychiatric and neurocognitive manifestations of South African children with suspected efavirenz neurotoxicity. Method: This retrospective study describes clinical features of 12 children with features consistent with efavirenz neurotoxicity between 2008 and 2014. Results: Twelve children (4 males, 8 females) aged 3–12 years (median 8.4 years) were referred to a dedicated pediatric neuroHIV service. Eight were of indigenous African (black) ancestry and 4 were of mixed ancestry. The total duration on efavirenz-containing ART at the time of referral was 6–72 (mean 31) months. Two children (both of black ancestry) were phenotypically slow metabolizers and presented with acute manifestations and high plasma efavirenz concentrations above normal range resulting in discontinuation of efavirenz. Ten other children had clinical presentations compatible with efavirenz neurotoxicity but had normal or sub-therapeutic plasma efavirenz concentrations and continued treatment with efavirenz. The acute neuropsychiatric manifestations reported included drowsiness, seizures, sleep disturbances, personality changes, ataxia, and slurred speech. These were noticed 2–8 weeks (mean 5 weeks) after commencing efavirenz and resolved over a few weeks. Nine children had neurocognitive deficits and showed poor performance in all neurocognitive domains that were tested. Interpretation: Efavirenz causes transient neuropsychiatric adverse effects and may contribute to poor long-term neurocognitive outcomes in HIV-infected children. Prospective studies comparing efavirenz-treated and efavirenz-naïve children are needed to further elucidate the manifestations of efavirenz toxicity.
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Affiliation(s)
- Charles K Hammond
- Department of Paediatric Neurology, Neuroscience Institute, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.,Department of Child Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Brian Eley
- Paediatric Infectious Diseases Unit, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Natalia Ing
- Department of Psychology, Paediatric Neuropsychology Clinic, University of Cape Town, Cape Town, South Africa
| | - Jo M Wilmshurst
- Department of Paediatric Neurology, Neuroscience Institute, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
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Homkham N, Cressey TR, Bouazza N, Ingsrisawang L, Techakunakorn P, Mekmullica J, Borkird T, Puangsombat A, Na-Rajsima S, Treluyer JM, Urien S, Jourdain G. Role of efavirenz plasma concentrations on long-term HIV suppression and immune restoration in HIV-infected children. PLoS One 2019; 14:e0216868. [PMID: 31095608 PMCID: PMC6521995 DOI: 10.1371/journal.pone.0216868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 04/30/2019] [Indexed: 11/24/2022] Open
Abstract
Background To access the long term relationship between efavirenz plasma concentrations and evolution of HIV RNA loads and CD4 cell counts in children. Methods Retrospective analysis of data from HIV-infected children on first line efavirenz-containing regimen. A population pharmacokinetic-pharmacodynamic (PK-PD) model was developed to describe the evolution of HIV RNA load and CD4 cell count (efficacy outcomes) in relation to efavirenz plasma concentration. Individual CYP2B6 516 G>T genotype data were not available for this analysis. A score (ISEFV) quantifying the effect of efavirenz concentrations on the long-term HIV replication was calculated from efavirenz concentrations and PD parameters and, a value of ISEFV below which HIV replication is likely not suppressed was determined. Cox proportional hazards regression models were used to assess the association of the risk of viral replication with ISEFV, and with efavirenz mid-dose concentration(C12). Results At treatment initiation, median (interquartile range, IQR) age was 8 years (5 to 10), body weight 17 kg (14 to 23), HIV RNA load 5.1 log10 copies/mL (4.6 to 5.4), and CD4 cell count 71 cells/mm3. A model of PK-PD viral dynamics assuming that efavirenz decreases the rate of infected host cells adequately described the relationship of interest. After adjusting for age, baseline HIV RNA load and CD4 cell counts an ISEFV <85% was significantly associated with a higher risk of viral replication (p-value <0.001) while no significant association was observed with C12 <1.0 mg/L. Conclusion The ISEFV score was a good predictor of viral replication in children on efavirenz-based treatment.
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Affiliation(s)
- Nontiya Homkham
- Institut de recherche pour le développement (IRD UMI 174), Marseille, France
- Ecole Doctorale de Santé Publique, Université Paris Saclay, Paris, France
- Department of Statistics, Faculty of Science, Kasetsart University, Bangkok, Thailand
- Faculty of Public Health, Thammasat University, Bangkok, Thailand
- * E-mail:
| | - Tim R. Cressey
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Naim Bouazza
- Unité de Recherche Clinique Paris Centre, Assistance Publique-Hôpitaux de Paris, Paris, France
- CIC1419, INSERM & APHP, EAU08 Université Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Lily Ingsrisawang
- Department of Statistics, Faculty of Science, Kasetsart University, Bangkok, Thailand
| | | | | | | | | | | | - Jean Marc Treluyer
- Unité de Recherche Clinique Paris Centre, Assistance Publique-Hôpitaux de Paris, Paris, France
- CIC1419, INSERM & APHP, EAU08 Université Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Saik Urien
- Unité de Recherche Clinique Paris Centre, Assistance Publique-Hôpitaux de Paris, Paris, France
- CIC1419, INSERM & APHP, EAU08 Université Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Gonzague Jourdain
- Institut de recherche pour le développement (IRD UMI 174), Marseille, France
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Ota R, Ishii H, Tsuda M, Higuchi Y, Yamashita F. A model-based comparative meta-analysis of the efficacy of dolutegravir-based and efavirenz-based regimens in HIV-infected patients. J Infect Chemother 2019; 25:687-694. [PMID: 30982724 DOI: 10.1016/j.jiac.2019.03.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 02/12/2019] [Accepted: 03/18/2019] [Indexed: 11/25/2022]
Abstract
Currently, combinations of typical types of antiretroviral agents have been adopted as chemotherapy for human immunodeficiency virus (HIV) infection, comprising two nucleoside analogue reverse transcriptase inhibitors plus one of a non-nucleoside reverse transcriptase inhibitor, an integrase strand-transfer inhibitor, and a protease inhibitor. Although several meta-analyses have been conducted to determine first-line combination antiretroviral therapy, this has yet to be confirmed due to the technical limitation associated. In the present study, we applied a model-based meta-analysis (MBMA) approach, because it allows integration of information from clinical trials with varying dosing, duration, and sampling time points, resulting in enlargement of available data sources. We performed a bibliographic search to identify clinical trials involving dolutegravir (DTG)-based and efavirenz (EFV)-based regimens in HIV-infected, antiretroviral therapy-naïve adults, and then identified 30 independent trial data. The time course of drug effect was described by a consecutive first-order kinetic model and analyzed using the nonlinear mixed effect modeling approach. The developed model suggests that the DTG-based regimen provides a faster-acting and more sustainable drug effect than the EFV-based regimen. Moreover, the drug effect tends to appear more slowly and decay faster in severe patients having higher viral load or smaller baseline CD4 count.
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Affiliation(s)
- Ryosaku Ota
- Department of Drug Delivery Research, Graduate School of Pharmaceutical Sciences, Kyoto University, 46-29 Yoshidashimoadachi-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Hiromu Ishii
- Department of Drug Delivery Research, Graduate School of Pharmaceutical Sciences, Kyoto University, 46-29 Yoshidashimoadachi-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Masahiro Tsuda
- Department of Applied Pharmaceutics and Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Kyoto University, 46-29 Yoshidashimoadachi-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Yuriko Higuchi
- Department of Drug Delivery Research, Graduate School of Pharmaceutical Sciences, Kyoto University, 46-29 Yoshidashimoadachi-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Fumiyoshi Yamashita
- Department of Drug Delivery Research, Graduate School of Pharmaceutical Sciences, Kyoto University, 46-29 Yoshidashimoadachi-cho, Sakyo-ku, Kyoto, 606-8501, Japan; Department of Applied Pharmaceutics and Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Kyoto University, 46-29 Yoshidashimoadachi-cho, Sakyo-ku, Kyoto, 606-8501, Japan.
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He C, Wan H. Drug metabolism and metabolite safety assessment in drug discovery and development. Expert Opin Drug Metab Toxicol 2018; 14:1071-1085. [DOI: 10.1080/17425255.2018.1519546] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Chunyong He
- Department of DMPK/Tox, Shanghai Hengrui Pharmaceutical Co., Ltd., Shanghai, P. R. China
| | - Hong Wan
- Department of DMPK/Tox, Shanghai Hengrui Pharmaceutical Co., Ltd., Shanghai, P. R. China
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18
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Priming the body to receive the therapeutic agent to redefine treatment benefit/risk profile. Sci Rep 2018; 8:4797. [PMID: 29556068 PMCID: PMC5859131 DOI: 10.1038/s41598-018-23140-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 03/06/2018] [Indexed: 12/16/2022] Open
Abstract
Many therapeutic agents offer a low useful dose (dose responsible for efficacy)/useless dose (dose eliminated or responsible for toxicity) ratio, mainly due to the fact that therapeutic agents must ensure in one single object all the functions required to deliver the treatment, which leads to compromises in their physico-chemical design. Here we introduce the concept of priming the body to receive the treatment by uncorrelating these functions into two distinct objects sequentially administered: a nanoprimer occupying transiently the main pathway responsible for therapeutic agent limited benefit/risk ratio followed by the therapeutic agent. The concept was evaluated for different nature of therapeutic agents: For nanomedicines we designed a liposomal nanoprimer presenting preferential hepatic accumulation without sign of acute toxicity. This nanoprimer was able to increase the blood bioavailability of nanomedicine correlated with a lower hepatic accumulation. Finally this nanoprimer markedly enhanced anti-tumor efficacy of irinotecan loaded liposomes in the HT-29 tumor model when compared to the nanomedicine alone. Then, for small molecules we demonstrated the ability of a cytochrome inhibitor loaded nanoprimer to increase efficacy of docetaxel treatment. These results shown that specific nanoprimers could be designed for each family of therapeutic agents to answer to their specific needs.
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Drury A, Gleadow-Ware S, Gilfillan S, Ahrens J. HIV and mental illness in Malawi and the neuropsychiatric sequelae of efavirenz. Malawi Med J 2018; 30:40-45. [PMID: 29868159 PMCID: PMC5974386 DOI: 10.4314/mmj.v30i1.9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 10/18/2017] [Accepted: 11/05/2017] [Indexed: 01/01/2023] Open
Abstract
Introduction Little is published about mental disorders in Malawi, specifically in relation to Human Immunodeficiency Virus (HIV) and it's treatment. Efavirenz is a medication commonly used as part of triple therapy for HIV treatment. Indeed, in 2013, Malawi introduced 5A with Efavirenz as part of it's 1st line treatment for HIV. There exists some literature documenting known psychiatric side effects of Efavirenz, which include anxiety, mood changes, nightmares, psychosis and suicidal ideation. Little is known about what features are most common in the presentation and what factors in the patient and drug which may make this reaction more likely. Aim The aim of this commentary is to review the association between HIV and psychiatric disorder, and consider the neuropsychiatric side-effects of Efavirenz. Method An evaluative literature review was completed by means of multiple electronic database search as well as an additional manual search to obtain published works identified through the electronic search. Search terms used were: Efavirenz, Acquired Immunodeficiency Syndrome, Africa, Antiretroviral Therapy, Developing Countries, Malawi, Mental Disorders, Public Health, and Psychiatry. Conclusion This is an important area of study, as potentially large numbers of individuals with HIV are being placed on Efavirenz as first line treatment, yet 60% may experience some form of neuropsychiatric side effects.
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Affiliation(s)
- Andrew Drury
- South London and Maudsley NHS Foundation Trust
- Scotland Malawi Mental Health Education Project
| | - Selena Gleadow-Ware
- Scotland Malawi Mental Health Education Project
- Honorary lecturer in psychiatry, University of Aberdeen
| | - Sheila Gilfillan
- Scotland Malawi Mental Health Education Project
- Herdmanflat Hospital, NHS Lothian
| | - Jen Ahrens
- Scotland Malawi Mental Health Education Project
- College of Medicine, Blantyre, Malawi
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Bednasz CJ, Venuto CS, Ma Q, Daar ES, Sax PE, Fischl MA, Collier AC, Smith KY, Tierney C, Yang Y, Wilding GE, Morse GD. Efavirenz Therapeutic Range in HIV-1 Treatment-Naive Participants. Ther Drug Monit 2017; 39:596-603. [PMID: 29135907 PMCID: PMC5718358 DOI: 10.1097/ftd.0000000000000443] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Efavirenz is currently suggested as an alternative to recommended antiretroviral (ARV) regimens by the Department of Health and Human Services for the treatment of HIV-1 in ARV-naive patients. A mid-dosing interval therapeutic range between 1000 and 4000 ng/mL for efavirenz has been proposed in the literature, with patients more likely to experience virologic failure below this range and adverse effects above. The current study reports an analysis of virologic outcome between those above, below, or within the reported efavirenz therapeutic range (1000-4000 ng/mL) and within subgroups. METHODS This analysis examined efavirenz plasma concentrations obtained from participants enrolled in AIDS Clinical Trials Group Study A5202. This investigation divided subjects into those who experienced virologic failure and those who did not. These subjects were further separated to investigate those who had "high," "within," or "low" plasma concentrations, based on the therapeutic range. The association between virologic failure and plasma concentration was statistically examined in addition to the variables: race/ethnicity, sex, assigned nucleos(t)ide reverse transcriptase inhibitor backbone, age at study entry, history of intravenous drug use, weight, and screening HIV-1 RNA stratification level. RESULTS In univariate analyses, a statistically significant difference was found when comparing the efavirenz concentration groups, (22 failures among the "low" concentration group [19%], 65 failures among the "within" concentration group [12%], and 11 failures among the "high" concentration group [9%]) when evaluating virologic failure as an outcome (P = 0.04). In addition, the proportion of participants with virologic failure differed across race/ethnicity groups (P = 0.03) with black non-Hispanic participants observed to have the highest rate (17%). Efavirenz concentration group, race/ethnicity, age, weight, and the interaction between efavirenz concentration group and weight were found to be significantly associated with virologic failure in multivariable logistic regression analysis. CONCLUSIONS The proposed efavirenz therapeutic range, combined with the impact of a patient's weight, is associated with virologic failure in HIV-infected ARV-naive individuals in the United States. Additional analysis is recommended to determine the most appropriate concentration value that defines the lower limit of the efavirenz therapeutic range.
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Affiliation(s)
- Cindy J. Bednasz
- AIDS Clinical Trials Group Pharmacology Specialty Laboratory, New York State Center of Excellence in Bioinformatics
and Life Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Charles S. Venuto
- AIDS Clinical Trials Group Pharmacology Specialty Laboratory, New York State Center of Excellence in Bioinformatics
and Life Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
- Center for Human Experimental Therapeutics, University of Rochester, Rochester, NY, USA
| | - Qing Ma
- AIDS Clinical Trials Group Pharmacology Specialty Laboratory, New York State Center of Excellence in Bioinformatics
and Life Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Eric S. Daar
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center and the University of California, Los Angeles,
CA, USA
| | - Paul E. Sax
- Division of Infectious Diseases and Department of Medicine, Brigham and Women’s Hospital and Harvard Medical
School, Boston, MA, USA
| | | | - Ann C. Collier
- University of Washington School of Medicine and Harborview Medical Center, Seattle, WA, USA
| | | | - Camlin Tierney
- Statistical Data Analysis Center, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Yang Yang
- Department of Biostatistics, University at Buffalo, Buffalo, NY, USA
| | | | - Gene D. Morse
- AIDS Clinical Trials Group Pharmacology Specialty Laboratory, New York State Center of Excellence in Bioinformatics
and Life Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
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Soeria-Atmadja S, Österberg E, Gustafsson LL, Dahl ML, Eriksen J, Rubin J, Navér L. Genetic variants in CYP2B6 and CYP2A6 explain interindividual variation in efavirenz plasma concentrations of HIV-infected children with diverse ethnic origin. PLoS One 2017; 12:e0181316. [PMID: 28886044 PMCID: PMC5590735 DOI: 10.1371/journal.pone.0181316] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 06/29/2017] [Indexed: 12/13/2022] Open
Abstract
Background Approximately 2.6 million children live with HIV globally, and efavirenz (EFV) is one of the most widely used antiretroviral agents for HIV treatment in children and adults. There are concerns about the appropriateness of current EFV dosing and it has been discussed whether EFV dosing should be adapted according to genotype in children as suggested for adults. Aim To investigate if pediatric EFV dosing should be guided by genetic variation in drug metabolizing enzymes rather than by body weight. Method EFV plasma concentrations measured for clinical purposes from all children less than 18 years old at Karolinska University Hospital, Stockholm, Sweden, treated with EFV were collected retrospectively. They were genotyped for eleven polymorphisms in genes coding for drug-metabolizing enzymes and P-glycoprotein, of potential importance for EFV disposition. Data on country of origin, sex, age, weight, HIV RNA, viral resistance patterns, CD4 cells, adherence to treatment, subjective health status and adverse events were collected from their medical records. Results Thirty-six patients and 182 (mean 5 samples/patient) EFV plasma concentration measurements from children of African, Asian and Latin American origin were included. EFV plasma concentration varied 21-fold between measurements (n = 182) (0.85–19.3 mg/L) and 9-fold measured as mean EFV plasma concentration across the subjects (1.55–13.4 mg/L). A multivariate mixed-effects restricted maximum likelihood regression model, including multiple gene polymorphisms, identified CYP2B6*6 T/T (p < 0.0005), CYP2B6*11 G/G (p < 0.0005), CYP2A6*9 A/C (p = 0.001) genotypes, age at treatment initiation (p = 0.002) and time from treatment initiation (p < 0.0005) as independent factors significantly related to loge concentration/(dose/weight). The contribution of the model to the intra- and interindividual variation were 6 and 75%, respectively (Bryk/Raudenbush R-squared level). Conclusion Genetic polymorphisms in CYP2B6 and CYP2A6 explained a significant proportion of variability in EFV plasma concentration in HIV-infected children in a multi-ethnic outpatient clinic. Knowledge about individual variants in key drug metabolizing enzyme genes could improve clinical safety and genotype directed dosing could achieve more predictable EFV plasma concentrations in HIV-infected children.
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Affiliation(s)
- Sandra Soeria-Atmadja
- Department of Pediatrics, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Emma Österberg
- Department of Pediatrics, Karolinska University Hospital, Stockholm, Sweden
| | - Lars L Gustafsson
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marja-Liisa Dahl
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jaran Eriksen
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Johanna Rubin
- Department of Pediatrics, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Lars Navér
- Department of Pediatrics, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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Segarra I, Modamio P, Fernández C, Mariño EL. Sex-Divergent Clinical Outcomes and Precision Medicine: An Important New Role for Institutional Review Boards and Research Ethics Committees. Front Pharmacol 2017; 8:488. [PMID: 28785221 PMCID: PMC5519571 DOI: 10.3389/fphar.2017.00488] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 07/10/2017] [Indexed: 12/22/2022] Open
Abstract
The efforts toward individualized medicine have constantly increased in an attempt to improve treatment options. These efforts have led to the development of small molecules which target specific molecular pathways involved in cancer progression. We have reviewed preclinical studies of sunitinib that incorporate sex as a covariate to explore possible sex-based differences in pharmacokinetics and drug–drug interactions (DDI) to attempt a relationship with published clinical outputs. We observed that covariate sex is lacking in most clinical outcome reports and suggest a series of ethic-based proposals to improve research activities and identify relevant different sex outcomes. We propose a deeper integration of preclinical, clinical, and translational research addressing statistical and clinical significance jointly; to embed specific sex-divergent endpoints to evaluate possible gender differences objectively during all stages of research; to pay greater attention to sex-divergent outcomes in polypharmacy scenarios, DDI and bioequivalence studies; the clear reporting of preclinical and clinical findings regarding sex-divergent outcomes; as well as to encourage the active role of scientists and the pharmaceutical industry to foster a new scientific culture through their research programs, practice, and participation in editorial boards and Institutional Ethics Review Boards (IRBs) and Research Ethics Committees (RECs). We establish the IRB/REC as the centerpiece for the implementation of these proposals. We suggest the expansion of its competence to follow up clinical trials to ensure that sex differences are addressed and recognized; to engage in data monitoring committees to improve clinical research cooperation and ethically address those potential clinical outcome differences between male and female patients to analyze their social and clinical implications in research and healthcare policies.
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Affiliation(s)
- Ignacio Segarra
- Clinical Pharmacy and Pharmacotherapy Unit, Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of BarcelonaBarcelona, Spain
| | - Pilar Modamio
- Clinical Pharmacy and Pharmacotherapy Unit, Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of BarcelonaBarcelona, Spain
| | - Cecilia Fernández
- Clinical Pharmacy and Pharmacotherapy Unit, Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of BarcelonaBarcelona, Spain
| | - Eduardo L Mariño
- Clinical Pharmacy and Pharmacotherapy Unit, Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of BarcelonaBarcelona, Spain
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24
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Gutierrez MM, Pillai G, Felix S, Romero F, Onyango KO, Owusu-Agyei S, Asante KP, Barnes KI, Sinxadi P, Allen E, Abdulla S, Masimirembwa C, Munyoro M, Yimer G, Gebre-Mariam T, Spector J, Ogutu B. Building Capability for Clinical Pharmacology Research in Sub-Saharan Africa. Clin Pharmacol Ther 2017; 102:786-795. [PMID: 28378903 DOI: 10.1002/cpt.695] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 02/28/2017] [Accepted: 03/22/2017] [Indexed: 01/13/2023]
Abstract
A strong scientific rationale exists for conducting clinical pharmacology studies in target populations because local factors such as genetics, environment, comorbidities, and diet can affect variability in drug responses. However, clinical pharmacology studies are not widely conducted in sub-Saharan Africa, in part due to limitations in technical expertise and infrastructure. Since 2012, a novel public-private partnership model involving research institutions and a pharmaceutical company has been applied to developing increased capability for clinical pharmacology research in multiple African countries.
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Affiliation(s)
- M M Gutierrez
- Novartis Pharma and Novartis Institutes for Biomedical Research, Basel, Switzerland and Cambridge, Massachusetts, USA
| | - G Pillai
- Novartis Pharma and Novartis Institutes for Biomedical Research, Basel, Switzerland and Cambridge, Massachusetts, USA
| | - S Felix
- Novartis Pharma and Novartis Institutes for Biomedical Research, Basel, Switzerland and Cambridge, Massachusetts, USA
| | - F Romero
- Novartis Pharma and Novartis Institutes for Biomedical Research, Basel, Switzerland and Cambridge, Massachusetts, USA
| | - K O Onyango
- Kenya Medical Research Institute (KEMRI)/Strathmore University (SU), Nairobi, Kenya
| | | | - K P Asante
- Kintampo Health Research Center, Kintampo, Ghana
| | - K I Barnes
- University of Cape Town, Cape Town, South Africa
| | - P Sinxadi
- University of Cape Town, Cape Town, South Africa
| | - E Allen
- University of Cape Town, Cape Town, South Africa
| | - S Abdulla
- Ifakara Health Institute, Bagamoyo, Tanzania
| | - C Masimirembwa
- African Institute of Biomedical Science & Technology, Harare, Zimbabwe
| | - M Munyoro
- African Institute of Biomedical Science & Technology, Harare, Zimbabwe
| | - G Yimer
- Addis Ababa University/Regional Bioequivalence Center, Addis Ababa, Ethiopia
| | - T Gebre-Mariam
- Addis Ababa University/Regional Bioequivalence Center, Addis Ababa, Ethiopia
| | - J Spector
- Novartis Pharma and Novartis Institutes for Biomedical Research, Basel, Switzerland and Cambridge, Massachusetts, USA
| | - B Ogutu
- Kenya Medical Research Institute (KEMRI)/Strathmore University (SU), Nairobi, Kenya
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25
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Gaida R, Truter I, Grobler C, Kotze T, Godman B. A review of trials investigating efavirenz-induced neuropsychiatric side effects and the implications. Expert Rev Anti Infect Ther 2016; 14:377-88. [PMID: 26900637 DOI: 10.1586/14787210.2016.1157469] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Efavirenz is part of the first-line treatment for HIV patients including those in South Africa with approximately 50% experiencing neuropsychiatric side effects. A systematic review of papers reporting neuropsychiatric side effects with efavirenz published between January 2001 and December 2014 was performed, to provide guidance. 13 articles were reviewed. Patient ages ranged between 37 to 41 years, with a high percentage males. Scales used to measure incidence and severity of side effects were varied; with disease severity or stage not reported. Patients with psychoses were excluded. Most commonly reported side effects were a reduction in sleep quality, depression, dizziness and anxiety. These were generally mild and not warranting discontinuation of efavirenz. It is difficult to directly compare the studies. Standardised methods need to be introduced and all patient groups represented including the elderly, children, patients with active symptomatic illness and more women especially among the African population.
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Affiliation(s)
- Razia Gaida
- a Department of Pharmacy , Nelson Mandela Metropolitan University , Port Elizabeth , South Africa
| | - Ilse Truter
- b Department of Pharmacy and Leader of Drug Utilisation Research Unit, Faculty of Health Sciences , Nelson Mandela Metropolitan University , Port Elizabeth , South Africa
| | - Christoffel Grobler
- c Elizabeth Donkin Hospital , Port Elizabeth , South Africa.,d Department of Psychology, Faculty of Health Sciences , Nelson Mandela Metropolitan University , Port Elizabeth , South Africa
| | - Theunis Kotze
- e Drug Utilisation Research Unit, Faculty of Health Sciences , Nelson Mandela Metropolitan University , Port Elizabeth , South Africa
| | - Brian Godman
- f Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet , Karolinska University Hospital Huddinge , Stockholm , Sweden.,g Strathclyde Institute of Pharmacy and Biomedical Sciences , University of Strathclyde , Glasgow , United Kingdom
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26
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Vo TT, Varghese Gupta S. Role of Cytochrome P450 2B6 Pharmacogenomics in Determining Efavirenz-Mediated Central Nervous System Toxicity, Treatment Outcomes, and Dosage Adjustments in Patients with Human Immunodeficiency Virus Infection. Pharmacotherapy 2016; 36:1245-1254. [PMID: 27779789 DOI: 10.1002/phar.1852] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
For treatment-naive patients with human immunodeficiency virus infection, efavirenz (EFV), together with tenofovir and emtricitabine, was once widely prescribed given its efficacy and ease of administration in a combination pill. However, the high rate of central nervous system (CNS) toxicities from EFV prompted the U.S. Department of Health and Human Services to move the EFV-based regimen from the recommended to the alternative category. For patients who do meet the criteria for newer recommended antiretroviral treatments, EFV is a viable option and often the mainstay of treatment outside the United States because newer antiretroviral treatments are more expensive. CNS toxicity occurring with the recommended standard dose of EFV remains a challenge and may in part be attributable to polymorphisms in cytochrome P450 (CYP) 2B6, the enzyme involved in the major metabolic pathway for converting EFV to inactive metabolites. Functionally deficient alleles of CYP2B6 such as CYP2B6*6, *18, and *22 may be responsible for significantly higher therapeutic concentrations of EFV at a standard dose of 600 mg/day. We conducted a thorough review of the reported studies to elucidate the relationship between polymorphisms in CYP2B6 with adverse events and treatment response, including virologic suppression, immunologic response, resistance, and discontinuation of treatment. Compelling evidence exists to support the case for CYP2B6 genotype-guided EFV therapy while acknowledging the need for prospective controlled clinical trials to evaluate its clinical utility.
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Affiliation(s)
- Teresa T Vo
- College of Pharmacy, University of South Florida, Tampa, Florida
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27
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Abstract
Simeprevir is an NS3/4A protease inhibitor approved for the treatment of hepatitis C infection, as a component of combination therapy. Simeprevir is metabolized by the cytochrome P450 (CYP) system, primarily CYP3A, and is a substrate for several drug transporters, including the organic anion transporting polypeptides (OATPs). It is susceptible to metabolic drug–drug interactions with drugs that are moderate or strong CYP3A inhibitors (e.g. ritonavir and erythromycin) or CYP3A inducers (e.g. rifampin and efavirenz); coadministration of these drugs may increase or decrease plasma concentrations of simeprevir, respectively, and should be avoided. Clinical studies have shown that simeprevir is a mild inhibitor of CYP1A2 and intestinal CYP3A but does not inhibit hepatic CYP3A. The effects of simeprevir on these enzymes are of clinical relevance only for narrow-therapeutic-index drugs that are metabolized solely by these enzymes (e.g. oral midazolam). Simeprevir does not have a clinically relevant effect on the pharmacokinetics of rilpivirine, tacrolimus, oral contraceptives and several other drugs metabolized by CYP enzymes. Simeprevir is a substrate and inhibitor of the transporters P-glycoprotein (P-gp), breast cancer resistance protein (BCRP) and OATP1B1/3. Cyclosporine is an inhibitor of OATP1B1/3, BCRP and P-gp, and a mild inhibitor of CYP3A; cyclosporine causes a significant increase in simeprevir plasma concentrations, and coadministration is not recommended. Clinical studies have demonstrated increases in coadministered drug concentrations for drugs that are substrates of the OATP1B1/3, BRCP (e.g. rosuvastatin) and P-gp (e.g. digoxin) transporters; these drugs should be administered with dose titration and or/close monitoring.
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28
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Pearce RE, Gaedigk R, Twist GP, Dai H, Riffel AK, Leeder JS, Gaedigk A. Developmental Expression of CYP2B6: A Comprehensive Analysis of mRNA Expression, Protein Content and Bupropion Hydroxylase Activity and the Impact of Genetic Variation. Drug Metab Dispos 2016; 44:948-58. [PMID: 26608082 PMCID: PMC4931886 DOI: 10.1124/dmd.115.067546] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 11/19/2015] [Indexed: 01/11/2023] Open
Abstract
Although CYP2B6 catalyzes the biotransformation of many drugs used clinically for children and adults, information regarding the effects of development on CYP2B6 expression and activity are scarce. Utilizing a large panel of human liver samples (201 donors: 24 fetal, 141 pediatric, and 36 adult), we quantified CYP2B6 mRNA and protein expression levels, characterized CYP2B6 (bupropion hydroxylase) activity in human liver microsomes (HLMs), and performed an extensive genotype analysis to differentiate CYP2B6 haplotypes such that the impact of genetic variation on these parameters could be assessed. Fetal livers contained extremely low levels of CYP2B6 mRNA relative to postnatal samples and fetal HLMs did not appear to catalyze bupropion hydroxylation; however, fetal CYP2B6 protein levels were not significantly different from postnatal levels. Considerable interindividual variation in CYP2B6 mRNA expression, protein levels, and activity was observed in postnatal HLMs (mRNA, ∼40,000-fold; protein, ∼300-fold; activity, ∼600-fold). The extremely wide range of interindividual variability in CYP2B6 expression and activity was significantly associated with age (P < 0.01) following log transformation of the data. Our data suggest that CYP2B6 activity appears as early as the first day of life, increases through infancy, and by 1 year of age, CYP2B6 levels and activity may approach those of adults. Surprisingly, CYP2B6 interindividual variability was not significantly associated with genetic variation in CYP2B6, nor was it associated with differences in gender or ethnicity, suggesting that factors other than these are largely responsible for the wide range of variability in CYP2B6 expression and activity observed among a large group of individuals/samples.
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Affiliation(s)
- Robin E Pearce
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation (R.E.P., R.G., G.P.T., A.K.R., J.S.L., A.G.), and Health Services and Outcomes Research (H.D.), Children's Mercy Kansas City, Kansas City, Missouri; and Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri (R.E.P., R.G., H.D., J.S.L., A.G.)
| | - Roger Gaedigk
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation (R.E.P., R.G., G.P.T., A.K.R., J.S.L., A.G.), and Health Services and Outcomes Research (H.D.), Children's Mercy Kansas City, Kansas City, Missouri; and Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri (R.E.P., R.G., H.D., J.S.L., A.G.)
| | - Greyson P Twist
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation (R.E.P., R.G., G.P.T., A.K.R., J.S.L., A.G.), and Health Services and Outcomes Research (H.D.), Children's Mercy Kansas City, Kansas City, Missouri; and Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri (R.E.P., R.G., H.D., J.S.L., A.G.)
| | - Hongying Dai
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation (R.E.P., R.G., G.P.T., A.K.R., J.S.L., A.G.), and Health Services and Outcomes Research (H.D.), Children's Mercy Kansas City, Kansas City, Missouri; and Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri (R.E.P., R.G., H.D., J.S.L., A.G.)
| | - Amanda K Riffel
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation (R.E.P., R.G., G.P.T., A.K.R., J.S.L., A.G.), and Health Services and Outcomes Research (H.D.), Children's Mercy Kansas City, Kansas City, Missouri; and Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri (R.E.P., R.G., H.D., J.S.L., A.G.)
| | - J Steven Leeder
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation (R.E.P., R.G., G.P.T., A.K.R., J.S.L., A.G.), and Health Services and Outcomes Research (H.D.), Children's Mercy Kansas City, Kansas City, Missouri; and Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri (R.E.P., R.G., H.D., J.S.L., A.G.)
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation (R.E.P., R.G., G.P.T., A.K.R., J.S.L., A.G.), and Health Services and Outcomes Research (H.D.), Children's Mercy Kansas City, Kansas City, Missouri; and Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri (R.E.P., R.G., H.D., J.S.L., A.G.)
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29
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Hammond CK, Eley B, Wilmshurst JM. Neuropsychiatric complications of efavirenz in children with HIV infection. Future Virol 2016. [DOI: 10.2217/fvl-2016-0030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Efavirenz is an effective antiretroviral agent widely used as part of first-line regimen in HIV1-infected children and adults. Neuropsychiatric adverse effects are reported in up to 50% of users. These include dizziness, insomnia, abnormal dreams, headache and impaired concentration. The plasma level of efavirenz may be key in the development of these adverse effects. Even among individuals taking recommended doses for weight, the plasma levels vary widely. Genetic polymorphisms leading to different allelic variants of the CYP2B6 enzyme, making some individuals slow metabolizers may play a role. These allelic variants are highest in people of African descent. This report examines the neuropsychiatric adverse effects of efavirenz, and the strength of the data that the product may result in neuronal damage.
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Affiliation(s)
- Charles K Hammond
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa
| | - Brian Eley
- Paediatric Infectious Diseases Unit, Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa
| | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa
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30
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Röhrich CR, Drögemöller BI, Ikediobi O, van der Merwe L, Grobbelaar N, Wright GE, McGregor N, Warnich L. CYP2B6*6 and CYP2B6*18 Predict Long-Term Efavirenz Exposure Measured in Hair Samples in HIV-Positive South African Women. AIDS Res Hum Retroviruses 2016; 32:529-38. [PMID: 26655325 DOI: 10.1089/aid.2015.0048] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Long-term exposure to efavirenz (EFV) measured in hair samples may predict response to antiretroviral treatment (ART). Polymorphisms in CYP2B6 are known to alter EFV levels. The aim of this study was to assess the relationship between CYP2B6 genotype, EFV levels measured in hair, and virological outcomes on ART in a real-world setting. We measured EFV levels in hair from HIV-positive South African females who had been receiving EFV-based treatment for at least 3 months from the South African Black (SAB) (n = 81) and Cape Mixed Ancestry (CMA) (n = 53) populations. Common genetic variation in CYP2B6 was determined in 15 individuals from each population using bidirectional Sanger sequencing. Prioritized variants (n = 16) were subsequently genotyped in the entire patient cohort (n = 134). The predictive value of EFV levels in hair and selected variants in CYP2B6 on virological treatment outcomes was assessed. Previously described alleles (CYP2B6*2, CYP2B6*5, CYP2B6*6, CYP2B6*17, and CYP2B6*18), as well as two novel alleles (CYP2B6*31 and CYP2B6*32), were detected in this study. Compared to noncarriers, individuals homozygous for CYP2B6*6 had ∼109% increased EFV levels in hair (p = .016) and CYP2B6*18 heterozygotes demonstrated 82% higher EFV hair levels (p = .0006). This study confirmed that alleles affecting CYP2B6 metabolism and subsequent EFV exposure are present at significant frequencies in both the SAB and CMA populations. Furthermore, this study demonstrated that the use of hair samples for testing EFV concentrations may be a useful tool in determining long-term drug exposure in resource-limited countries.
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Affiliation(s)
- Carola R. Röhrich
- Department of Genetics, Stellenbosch University, Stellenbosch, South Africa
| | | | - Ogechi Ikediobi
- Departments of Pharmacy, University of California San Francisco, UCSF, San Francisco, California
| | - Lize van der Merwe
- Department of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
- Department of Statistics, University of Western Cape, Bellville, South Africa
| | | | - Galen E.B. Wright
- Department of Genetics, Stellenbosch University, Stellenbosch, South Africa
| | - Nathaniel McGregor
- Department of Genetics, Stellenbosch University, Stellenbosch, South Africa
- Department of Psychiatry, Stellenbosch University, Tygerberg, South Africa
| | - Louise Warnich
- Department of Genetics, Stellenbosch University, Stellenbosch, South Africa
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31
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Swart M, Evans J, Skelton M, Castel S, Wiesner L, Smith PJ, Dandara C. An Expanded Analysis of Pharmacogenetics Determinants of Efavirenz Response that Includes 3'-UTR Single Nucleotide Polymorphisms among Black South African HIV/AIDS Patients. Front Genet 2016; 6:356. [PMID: 26779253 PMCID: PMC4703773 DOI: 10.3389/fgene.2015.00356] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 12/10/2015] [Indexed: 01/11/2023] Open
Abstract
Introduction: Efavirenz (EFV) is a non-nucleoside reverse transcriptase inhibitor prescribed as part of first-line highly active antiretroviral therapy (HAART) in South Africa. Despite administration of fixed doses of EFV, inter-individual variability in plasma concentrations has been reported. Poor treatment outcomes such as development of adverse drug reactions or treatment failure have been linked to EFV plasma concentrations outside the therapeutic range (1–4 μg/mL) in some studies. The drug metabolizing enzyme (DME), CYP2B6, is primarily responsible for EFV metabolism with minor contributions by CYP1A2, CYP2A6, CYP3A4, CYP3A5, and UGT2B7. DME coding genes are also regulated by microRNAs through targeting the 3′-untranslated region. Expanded analysis of 30 single nucleotide polymorphisms (SNPs), including those in the 3′-UTR, was performed to identify pharmacogenetics determinants of EFV plasma concentrations in addition to CYP2B6 c.516G>T and c.983T>C SNPs. Methods: SNPs in CYP1A2, CYP2B6, UGT2B7, and NR1I2 (PXR) were selected for genotyping among 222 Bantu-speaking South African HIV-infected patients receiving EFV-containing HAART. This study is a continuation of earlier pharmacogenetics studies emphasizing the role of genetic variation in the 3′-UTR of genes which products are either pharmacokinetic or pharmacodynamic targets of EFV. Results: Despite evaluating thirty SNPs, CYP2B6 c.516G>T and c.983T>C SNPs remain the most prominent predictors of EFV plasma concentration. Conclusion: We have shown that CYP2B6 c.516G>T and c.983T>C SNPs are the most important predictors of EFV plasma concentration after taking into account all other SNPs, including genetic variation in the 3′-UTR, and variables affecting EFV metabolism.
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Affiliation(s)
- Marelize Swart
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Jonathan Evans
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Michelle Skelton
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Sandra Castel
- Division of Clinical Pharmacology, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Peter J Smith
- Division of Clinical Pharmacology, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Collet Dandara
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
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32
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Kharasch ED, Regina KJ, Blood J, Friedel C. Methadone Pharmacogenetics: CYP2B6 Polymorphisms Determine Plasma Concentrations, Clearance, and Metabolism. Anesthesiology 2015; 123:1142-53. [PMID: 26389554 PMCID: PMC4667947 DOI: 10.1097/aln.0000000000000867] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Interindividual variability in methadone disposition remains unexplained, and methadone accidental overdose in pain therapy is a significant public health problem. Cytochrome P4502B6 (CYP2B6) is the principle determinant of clinical methadone elimination. The CYP2B6 gene is highly polymorphic, with several variant alleles. CYP2B6.6, the protein encoded by the CYP2B6*6 polymorphism, deficiently catalyzes methadone metabolism in vitro. This investigation determined the influence of CYP2B6*6, and other allelic variants encountered, on methadone concentrations, clearance, and metabolism. METHODS Healthy volunteers in genotype cohorts CYP2B6*1/*1 (n = 21), CYP2B6*1/*6 (n = 20), and CYP2B6*6/*6 (n = 17), and also CYP2B6*1/*4 (n = 1), CYP2B6*4/*6 (n = 3), and CYP2B6*5/*5 (n = 2) subjects, received single doses of IV and oral methadone. Plasma and urine methadone and metabolite concentrations were determined by tandem mass spectrometry. RESULTS Average S-methadone apparent oral clearance was 35 and 45% lower in CYP2B6*1/*6 and CYP2B6*6/*6 genotypes, respectively, compared with CYP2B6*1/*1. R-methadone apparent oral clearance was 25 and 35% lower in CYP2B6*1/*6 and CYP2B6*6/*6 genotypes, respectively, compared with CYP2B6*1/*1. R- and S-methadone apparent oral clearance was threefold and fourfold greater in CYP2B6*4 carriers. IV and oral R- and S-methadone metabolism was significantly lower in CYP2B6*6 carriers compared with that of CYP2B6*1 homozygotes and greater in CYP2B6*4 carriers. Methadone metabolism and clearance were lower in African Americans in part because of the CYP2B6*6 genetic polymorphism. CONCLUSIONS CYP2B6 polymorphisms influence methadone plasma concentrations, because of altered methadone metabolism and thus clearance. Genetic influence is greater for oral than IV methadone and S- than R-methadone. CYP2B6 pharmacogenetics explains, in part, interindividual variability in methadone elimination. CYP2B6 genetic effects on methadone metabolism and clearance may identify subjects at risk for methadone toxicity and drug interactions.
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Affiliation(s)
- Evan D. Kharasch
- Department of Anesthesiology, Division of Clinical and Translational Research, Washington University in St. Louis, St. Louis, MO
- Department of Biochemistry and Molecular Biophysics, Washington University in St. Louis, St. Louis, MO
| | - Karen J. Regina
- Department of Anesthesiology, Division of Clinical and Translational Research, Washington University in St. Louis, St. Louis, MO
| | - Jane Blood
- Department of Anesthesiology, Division of Clinical and Translational Research, Washington University in St. Louis, St. Louis, MO
| | - Christina Friedel
- Department of Anesthesiology, Division of Clinical and Translational Research, Washington University in St. Louis, St. Louis, MO
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