1
|
Vanangamudi M, Palaniappan S, Kathiravan MK, Namasivayam V. Strategies in the Design and Development of Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs). Viruses 2023; 15:1992. [PMID: 37896769 PMCID: PMC10610861 DOI: 10.3390/v15101992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/21/2023] [Accepted: 09/22/2023] [Indexed: 10/29/2023] Open
Abstract
AIDS (acquired immunodeficiency syndrome) is a potentially life-threatening infectious disease caused by human immunodeficiency virus (HIV). To date, thousands of people have lost their lives annually due to HIV infection, and it continues to be a big public health issue globally. Since the discovery of the first drug, Zidovudine (AZT), a nucleoside reverse transcriptase inhibitor (NRTI), to date, 30 drugs have been approved by the FDA, primarily targeting reverse transcriptase, integrase, and/or protease enzymes. The majority of these drugs target the catalytic and allosteric sites of the HIV enzyme reverse transcriptase. Compared to the NRTI family of drugs, the diverse chemical class of non-nucleoside reverse transcriptase inhibitors (NNRTIs) has special anti-HIV activity with high specificity and low toxicity. However, current clinical usage of NRTI and NNRTI drugs has limited therapeutic value due to their adverse drug reactions and the emergence of multidrug-resistant (MDR) strains. To overcome drug resistance and efficacy issues, combination therapy is widely prescribed for HIV patients. Combination antiretroviral therapy (cART) includes more than one antiretroviral agent targeting two or more enzymes in the life cycle of the virus. Medicinal chemistry researchers apply different optimization strategies including structure- and fragment-based drug design, prodrug approach, scaffold hopping, molecular/fragment hybridization, bioisosterism, high-throughput screening, covalent-binding, targeting highly hydrophobic channel, targeting dual site, and multi-target-directed ligand to identify and develop novel NNRTIs with high antiviral activity against wild-type (WT) and mutant strains. The formulation experts design various delivery systems with single or combination therapies and long-acting regimens of NNRTIs to improve pharmacokinetic profiles and provide sustained therapeutic effects.
Collapse
Affiliation(s)
- Murugesan Vanangamudi
- Department of Pharmaceutical Chemistry, Amity Institute of Pharmacy, Amity University Madhya Pradesh, Gwalior 474005, Madhya Pradesh, India;
| | - Senthilkumar Palaniappan
- Faculty of Pharmacy, Karpagam Academy of Higher Education, Coimbatore 641021, Tamilnadu, India;
- Center for Active Pharmaceutical Ingredients, Karpagam Academy of Higher Education, Coimbatore 641021, Tamilnadu, India
| | - Muthu Kumaradoss Kathiravan
- Dr. APJ Abdul Kalam Research Lab, SRM College of Pharmacy, SRMIST, Kattankulathur 603203, Tamilnadu, India;
- Department of Pharmaceutical Chemistry, SRM College of Pharmacy, SRMIST, Kattankulathur 603203, Tamilnadu, India
| | - Vigneshwaran Namasivayam
- Pharmaceutical Chemistry, Pharmaceutical Institute, University of Bonn, 53121 Bonn, Germany
- LIED, University of Lübeck and University Medical Center Schleswig-Holstein, Ratzeburger Allee 160, 23538 Lübeck, Germany
| |
Collapse
|
2
|
Chala A, Kitabi EN, Ahmed JH, Tadesse BT, Chaka TE, Makonnen E, Aklillu E. Genetic and non-genetic factors influencing efavirenz population pharmacokinetics among human immunodeficiency virus-1-infected children in Ethiopia. CPT Pharmacometrics Syst Pharmacol 2023; 12:783-794. [PMID: 36840416 PMCID: PMC10272302 DOI: 10.1002/psp4.12951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 02/11/2023] [Accepted: 02/20/2023] [Indexed: 02/26/2023] Open
Abstract
Despite the potential for efavirenz (EFV) to be an effective alternative antiretroviral agent, its sources of wide inter- and intra-individual pharmacokinetic (PK) variability are not well-characterized in children. We investigated the effects of genetic and non-genetic factors, including demographic, treatment duration, baseline clinical, and biochemical characteristics, on the PKs of EFV through population-PK modeling. Antiretroviral therapy (ART) naïve HIV infected children, 3-16 years (n = 100), were enrolled in Ethiopia and received EFV-based combination ART. EFV concentrations after the first dose and at steady-state collected over a span of 1 year were modeled using population-based methods. A one-compartment model with first-order absorption kinetics described the observed EFV data adequately. The CYP2B6*6 and ABCB1c.4036A>G genotypes were identified as major factors influencing EFV clearance. The typical estimates of oral clearance, volume of distribution, and absorption rate constant for typical 22 kg children with CYP2B6 *1/*1 and ABCB1c.4036G/G genotypes were 4.3 L/h, 124 L, and 0.776/h, respectively. Clearance was reduced by 28% and 72% in CYP2B6*1/*6 and CYP2B6*6/*6 genotypes, respectively. Compared to week 1, clearance was higher from weeks 8 and 12 in CYP2B6*1/*6 and CYP2B6*1/*1 genotypes, respectively. Simulations indicated that EFV 12-h concentrations were comparable across weight bands, but more than 80% of subjects with CYP2B6*6/*6 had EFV concentrations greater than 4 μg/mL. EFV PK variability among children is partly explained by body weight, treatment duration, CYP2B6*6, and ABCB1 rs3842 genotypes. Therefore, in addition to body weight, pediatric dosing of EFV should consider pharmacogenetic variability, duration of therapy, and individual treatment outcomes.
Collapse
Affiliation(s)
- Adugna Chala
- Department of Pharmacology and Clinical Pharmacy, College of Health SciencesAddis Ababa UniversityAddis AbabaEthiopia
- Department of Global Public HealthKarolinska Institutet, Widerströmska HusetStockholmSweden
| | - Eliford Ngaimisi Kitabi
- Division of PharmacometricsOffice of Clinical Pharmacology, Food and Drugs AdministrationSilver SpringMarylandUSA
| | | | - Birkneh Tilahun Tadesse
- Department of Global Public HealthKarolinska Institutet, Widerströmska HusetStockholmSweden
- Department of Pediatrics, College of Medicine and Health SciencesHawassa UniversityHawassaEthiopia
| | - Tolossa Eticha Chaka
- Department of Pediatrics and Child HealthAdama Hospital Medical CollegeAdamaEthiopia
| | - Eyasu Makonnen
- Department of Pharmacology and Clinical Pharmacy, College of Health SciencesAddis Ababa UniversityAddis AbabaEthiopia
- Center for Innovative Drug Development and Therapeutic Trials for Africa, College of Health SciencesAddis Ababa UniversityAddis AbabaEthiopia
| | - Eleni Aklillu
- Department of Global Public HealthKarolinska Institutet, Widerströmska HusetStockholmSweden
- Department of Medicine SolnaKarolinska InstituteStockholmSweden
| |
Collapse
|
3
|
Gurjar R, Dickinson L, Carr D, Stöhr W, Bonora S, Owen A, D'Avolio A, Cursley A, De Castro N, Fätkenheuer G, Vandekerckhove L, Di Perri G, Pozniak A, Schwimmer C, Raffi F, Boffito M. Influence of UGT1A1 and SLC22A6 polymorphisms on the population pharmacokinetics and pharmacodynamics of raltegravir in HIV-infected adults: a NEAT001/ANRS143 sub-study. THE PHARMACOGENOMICS JOURNAL 2023; 23:14-20. [PMID: 36266537 PMCID: PMC9584256 DOI: 10.1038/s41397-022-00293-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 09/13/2022] [Accepted: 09/29/2022] [Indexed: 11/04/2022]
Abstract
Using concentration-time data from the NEAT001/ARNS143 study (single sample at week 4 and 24), we determined raltegravir pharmacokinetic parameters using nonlinear mixed effects modelling (NONMEM v.7.3; 602 samples from 349 patients) and investigated the influence of demographics and SNPs (SLC22A6 and UGT1A1) on raltegravir pharmacokinetics and pharmacodynamics. Demographics and SNPs did not influence raltegravir pharmacokinetics and no significant pharmacokinetic/pharmacodynamic relationships were observed. At week 96, UGT1A1*28/*28 was associated with lower virological failure (p = 0.012), even after adjusting for baseline CD4 count (p = 0.048), but not when adjusted for baseline HIV-1 viral load (p = 0.082) or both (p = 0.089). This is the first study to our knowledge to assess the influence of SNPs on raltegravir pharmacodynamics. The lack of a pharmacokinetic/pharmacodynamic relationship is potentially an artefact of raltegravir's characteristic high inter and intra-patient variability and also suggesting single time point sampling schedules are inadequate to thoroughly assess the influence of SNPs on raltegravir pharmacokinetics.
Collapse
Affiliation(s)
- Rohan Gurjar
- Department of Pharmacology & Therapeutics, University of Liverpool, Liverpool, UK
| | - Laura Dickinson
- Department of Pharmacology & Therapeutics, University of Liverpool, Liverpool, UK.
| | - Daniel Carr
- Department of Pharmacology & Therapeutics, University of Liverpool, Liverpool, UK
| | | | - Stefano Bonora
- Unit of Infectious Diseases, University of Turin, Turin, Italy
| | - Andrew Owen
- Department of Pharmacology & Therapeutics, University of Liverpool, Liverpool, UK
| | | | | | - Nathalie De Castro
- Infectious Diseases Department, AP-HP Hôpital Saint-Louis, Paris, France
| | | | - Linos Vandekerckhove
- HIV Translational Research Unit, Ghent University and Ghent University Hospital, Ghent, Belgium
| | | | | | - Christine Schwimmer
- University of Bordeaux, INSERM, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
| | - François Raffi
- Department of Infectious Diseases, Centre Hospitalier Universitaire de Nantes, and CIC 1413, INSERM, Nantes, France
| | - Marta Boffito
- Chelsea and Westminster NHS Trust, London, UK.,Imperial College, London, UK
| | | |
Collapse
|
4
|
Olagunju A, Nwogu J, Eniayewu O, Atoyebi S, Amara A, Kpamor J, Bolaji O, Adejuyigbe E, Owen A, Khoo S. Validation and clinical application of a method to quantify efavirenz in cervicovaginal secretions from flocked swabs using liquid chromatography tandem mass spectrometry. Wellcome Open Res 2022; 6:246. [PMID: 36034058 PMCID: PMC9379332 DOI: 10.12688/wellcomeopenres.17202.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 11/20/2022] Open
Abstract
Background : A liquid chromatography tandem mass spectrometry method to quantify drugs in dried cervicovaginal secretions from flocked swabs was developed and validated using the antiretroviral efavirenz as an example. Methods: Cervicovaginal swabs (CVS) were prepared by submerging flocked swabs in efavirenz-spiked plasma matrix. Time to full saturation, weight uniformity, recovery and room temperature stability were evaluated. Chromatographic separation was on a reverse-phase C18 column by gradient elution using 1mM ammonium acetate in water/acetonitrile at 400 µL/min. Detection and quantification were on a TSQ Quantum Access triple quadrupole mass spectrometer operated in negative ionisation mode. The method was used to quantify efavirenz in CVS samples from human immunodeficiency virus (HIV)-positive women in the VADICT study (NCT03284645). A total of 98 samples (35 paired intensive CVS and DBS pharmacokinetic samples, 14 paired sparse CVS and DBS samples) from 19 participants were available for this analysis. Results: Swabs were fully saturated within 15 seconds, absorbing 128 µL of plasma matrix with coefficient of variation (%CV) below 1.3%. The method was linear with a weighting factor (1/X) in the range of 25-10000 ng/mL with inter- and intra-day precision (% CV) of 7.69-14.9%, and accuracy (% bias) of 99.1-105.3%. Mean recovery of efavirenz from CVS was 83.8% (%CV, 11.2) with no significant matrix effect. Efavirenz remained stable in swabs for at least 35 days after drying and storage at room temperature. Median (range) CVS efavirenz AUC 0-24h was 16370 ng*h/mL (5803-22088), C max was 1618 ng/mL (610-2438) at a T max of 8.0 h (8.0-12), and C min was 399 ng/mL (110-981). Efavirenz CVS:plasma AUC 0-24h ratio was 0.41 (0.20-0.59). Conclusions: Further application of this method will improve our understanding of the pharmacology of other therapeutics in the female genital tract, including in low- and middle-income countries.
Collapse
Affiliation(s)
- Adeniyi Olagunju
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Jacinta Nwogu
- Department of Pharmaceutical Chemistry, University of Ibadan, Ibadan, Nigeria
| | - Oluwasegun Eniayewu
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile-Ife, Nigeria
- Department of Pharmaceutical and Medicinal Chemistry, University of Ilorin, Ilorin, Nigeria
| | - Shakir Atoyebi
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Alieu Amara
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | | | - Oluseye Bolaji
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Ebunoluwa Adejuyigbe
- Department of Paediatrics and Child Health, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Andrew Owen
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Saye Khoo
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| |
Collapse
|
5
|
Olagunju A, Nwogu J, Eniayewu O, Atoyebi S, Amara A, Kpamor J, Bolaji O, Adejuyigbe E, Owen A, Khoo S. Validation and clinical application of a method to quantify efavirenz in cervicovaginal secretions from flocked swabs using liquid chromatography tandem mass spectrometry. Wellcome Open Res 2022; 6:246. [DOI: 10.12688/wellcomeopenres.17202.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 11/20/2022] Open
Abstract
Background : A liquid chromatography tandem mass spectrometry method to quantify drugs in dried cervicovaginal secretions from flocked swabs was developed and validated using the antiretroviral efavirenz as an example. Methods: Cervicovaginal swabs (CVS) were prepared by submerging flocked swabs in efavirenz-spiked plasma matrix. Time to full saturation, weight uniformity, recovery and room temperature stability were evaluated. Chromatographic separation was on a reverse-phase C18 column by gradient elution using 1mM ammonium acetate in water/acetonitrile at 400 µL/min. Detection and quantification were on a TSQ Quantum Access triple quadrupole mass spectrometer operated in negative ionisation mode. The method was used to quantify efavirenz in CVS samples from human immunodeficiency virus (HIV)-positive women in the VADICT study (NCT03284645). A total of 98 samples (35 paired intensive CVS and DBS pharmacokinetic samples, 14 paired sparse CVS and DBS samples) from 19 participants were available for this analysis. Results: Swabs were fully saturated within 15 seconds, absorbing 128 µL of plasma matrix with coefficient of variation (%CV) below 1.3%. The method was linear with a weighting factor (1/X) in the range of 25-10000 ng/mL with inter- and intra-day precision (% CV) of 7.69-14.9%, and accuracy (% bias) of 99.1-105.3%. Mean recovery of efavirenz from CVS was 83.8% (%CV, 11.2) with no significant matrix effect. Efavirenz remained stable in swabs for at least 35 days after drying and storage at room temperature. Median (range) CVS efavirenz AUC 0-24h was 16370 ng*h/mL (5803-22088), C max was 1618 ng/mL (610-2438) at a T max of 8.0 h (8.0-12), and C min was 399 ng/mL (110-981). Efavirenz CVS:plasma AUC 0-24h ratio was 0.41 (0.20-0.59). Conclusions: Further application of this method will improve our understanding of the pharmacology of other therapeutics in the female genital tract, including in low- and middle-income countries.
Collapse
|
6
|
Peng J, Ladumor MK, Unadkat JD. Estimation of fetal-to-maternal unbound steady-state plasma concentration ratio (Kp,uu,fetal ) of P-gp and/or BCRP substrate drugs using a maternal-fetal PBPK model. Drug Metab Dispos 2022; 50:613-623. [PMID: 35149540 PMCID: PMC9073947 DOI: 10.1124/dmd.121.000733] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/18/2022] [Indexed: 11/22/2022] Open
Abstract
Pregnant women are frequently prescribed drugs to treat chronic diseases (e.g., HIV infection), but little is known about the benefits and risks of these drugs to the fetus which are driven by fetal drug exposure. The latter can be estimated by fetal-to-maternal unbound plasma concentration at steady-state (Kp,uu,fetal). For drugs that are substrates of placental efflux transporters (i.e., P-gp or BCRP), is expected to be <1. Here, we estimated the in vivo of selective P-gp and/or BCRP substrate drugs by maternal-fetal (m-f)-PBPK modeling of umbilical vein (UV) plasma and maternal plasma (MP) concentrations obtained simultaneously at term from multiple maternal-fetal dyads. To do so, three drugs were selected: nelfinavir (P-gp substrate), efavirenz (BCRP substrate), and imatinib (P-gp/BCRP substrate). A m-f-PBPK model for each drug was developed and validated for the non-pregnant population and pregnant women using the Simcyp simulator (v20). Then, after incorporating placental passive diffusion clearance, the in vivo of the drug was estimated by adjusting the placental efflux clearance until the predicted UV/MP values best matched the observed data ( nelfinavir=0.41, efavirenz=0.39, imatinib=0.35). Furthermore, of nelfinavir and efavirenz at gestational week (GW) 25 and 15 were predicted to be 0.34, 0.23 and 0.33, 0.27 respectively. These values can be used to adjust dosing regimens of these drugs to optimize maternal-fetal drug therapy throughout pregnancy, to assess fetal benefits and risks of these dosing regimens, and to determine if these estimated in vivo values can be predicted from in vitro studies. Significance Statement The in vivo Kp,uu,fetal of nelfinavir (P-gp substrate), efavirenz (BCRP substrate), and imatinib (P-gp and BCRP substrate) was successfully estimated using m-f- PBPK modeling. These Kp,uu,fetal values can be used to adjust dosing regimens of these drugs to optimize maternal-fetal drug therapy throughout pregnancy, to assess fetal benefits and risks of these dosing regimens, and to determine if these estimated in vivo Kp,uu,fetal values can be predicted from in vitro studies.
Collapse
Affiliation(s)
- Jinfu Peng
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, China
| | | | | |
Collapse
|
7
|
Abstract
Drug--drug interactions (DDIs) have been a clinical challenge in HIV medicine for over two decades. The newer antiretroviral drugs (ARTs) have significantly fewer DDIs than protease inhibitors and boosted integrase inhibitors (INSTIs). The lower propensity of such newer antiretrovirals (e.g. unboosted integrase inhibitors; doravirine) to cause DDIs, has been largely offset by the ageing cohort of patients with multiple comorbidities, who are taking multiple chronic medicines. Furthermore, the introduction of newly marketed drugs into clinical practice needs to be closely monitored, as the new drugs may be perpetrators of DDIs, leading to a potential change in the efficacy or toxicity of the coadministered antiretrovirals.
Collapse
Affiliation(s)
- Phumla Z Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Saye H Khoo
- Department of Pharmacology, University of Liverpool, Liverpool
| | - Marta Boffito
- Chelsea and Westminster Hospital
- Imperial College London, London, United Kingdom
| |
Collapse
|
8
|
Huang WC, Huang CK, Huang SH, Lin SW, Ou ST, Chen YT, Chen YW, Chang SY, Liu WC, Sun HY, Hung CC. Therapeutic drug monitoring study on the switch from coformulated 600-mg efavirenz, tenofovir disoproxil fumarate, and emtricitabine to coformulated 400-mg efavirenz, tenofovir disoproxil fumarate, and lamivudine among HIV-positive patients with viral suppression. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 54:944-951. [PMID: 32675042 DOI: 10.1016/j.jmii.2020.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 06/07/2020] [Accepted: 06/21/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES This study evaluated the efavirenz (EFV) mid-dose plasma concentration (C12), clinical efficacy, and safety after the switch to a single-tablet regimen containing tenofovir disoproxil fumarate (TDF), lamivudine (3TC), and 400-mg EFV in virally suppressed HIV-positive Taiwanese who were receiving co-formulated TDF, emtricitabine (FTC), and 600-mg EFV. METHODS In this single-arm, open-label study, HIV-positive adults who had undetectable plasma HIV RNA load (<50 copies/ml) for 6 months or longer while receiving co-formulated TDF, FTC, and 600-mg EFV with EFV C12 of ≥1 mg/L were enrolled. The participants were switched to co-formulated TDF, 3TC, and 400-mg EFV and followed for 24 weeks. The primary endpoint was the proportion of participants with EFV C12 ≥ 1 mg/L at Week 4. The secondary endpoints included virologic response and change of CD4 lymphocyte count up to Week 24. Specific adverse effects associated with EFV were recorded before and after the switch. RESULTS From December 2018 to January 2019, 50 participants were enrolled. EFV C12 remained ≥1 mg/L in 48 (96.0%) participants with a median reduction of 38.9% (interquartile range 29.0-44.4) at Week 4 after switch. All participants had undetectable plasma HIV RNA by Week 12, whereas 96.0% of them remained so at Week 24. Significant increases of CD4 lymphocyte count were observed at Weeks 12 and 24. Thirty-three participants (66.0%) reported improvement of pre-existing adverse effects. CONCLUSION Switch to coformulated TDF, 3TC, and 400-mg EFV in virally suppressed HIV-positive Taiwanese maintained effective EFV concentration and viral suppression while the adverse effects were reduced.
Collapse
Affiliation(s)
- Wei-Chieh Huang
- School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chun-Kai Huang
- Department of Internal Medicine, I-Da Hospital, Kaohsiung, Taiwan
| | - Sung-Hsi Huang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan; Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shu-Wen Lin
- Department of Pharmacy, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Graduate Institute of Clinical Pharmacy, National Taiwan University College of Medicine, Taipei, Taiwan; School of Pharmacy, National Taiwan University, Taipei, Taiwan
| | - Shyh-Tyan Ou
- Department of Statistics, National Taipei University, Taipei, Taiwan
| | - Yi-Ting Chen
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ya-Wen Chen
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shu-Yuan Chang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wen-Chun Liu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsin-Yun Sun
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Chien-Ching Hung
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| |
Collapse
|
9
|
Olagunju A, Nwogu J, Eniayewu O, Atoyebi S, Amara A, Kpamor J, Bolaji O, Adejuyigbe E, Owen A, Khoo S. Validation and clinical application of a method to quantify efavirenz in cervicovaginal secretions from flocked swabs using liquid chromatography tandem mass spectrometry. Wellcome Open Res 2021; 6:246. [DOI: 10.12688/wellcomeopenres.17202.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 11/20/2022] Open
Abstract
Background: A liquid chromatography tandem mass spectrometry method to quantify drugs in dried cervicovaginal secretions from flocked swabs was developed and validated using the antiretroviral efavirenz as an example. Methods: Cervicovaginal swabs (CVS) were prepared by submerging flocked swabs in efavirenz-spiked matrix. Time to full saturation, weight uniformity, recovery and room temperature stability were evaluated. Chromatographic separation was on a reverse-phase C18 column by gradient elution using 1mM ammonium acetate in water/acetonitrile at 400 µL/min. Detection and quantification were on a TSQ Quantum Access triple quadrupole mass spectrometer operated in negative ionisation mode. The method was used to quantify efavirenz in CVS samples from human immunodeficiency virus (HIV)-positive women in the VADICT study (NCT03284645). A total of 98 samples (35 paired intensive CVS and DBS samples, 14 paired sparse CVS and DBS samples) from 19 participants were available for this analysis. Results: Swabs were fully saturated within 15 seconds, absorbing 128 µL of matrix with coefficient of variation (%CV) below 1.3%. The method was linear with a weighting factor (1/X) in the range of 25-10000 ng/mL with inter- and intra-day precision (% CV) of 7.69-14.9%, and accuracy (% bias) of 99.1-105.3%. Mean recovery of efavirenz from CVS was 83.8% (%CV, 11.2) with no significant matrix effect. Efavirenz remained stable in swabs for at least 35 days after drying and storage at room temperature. Median (range) CVS efavirenz AUC0-24h was 16370 ng*h/mL (5803-22088), Cmax was 1618 ng/mL (610-2438) at a Tmax of 8.0 h (8.0-12), and Cmin was 399 ng/mL (110-981). Efavirenz CVS:plasma AUC0-24 ratio was 0.41 (0.20-0.59). Conclusions: Further application of this method will improve our understanding of the pharmacology of other therapeutics in the female genital tract, including in low- and middle-income countries.
Collapse
|
10
|
Orkin C, Squires KE, Molina JM, Sax PE, Sussmann O, Lin G, Kumar S, Hanna GJ, Hwang C, Martin E, Teppler H. Doravirine/Lamivudine/Tenofovir Disoproxil Fumarate (TDF) Versus Efavirenz/Emtricitabine/TDF in Treatment-naive Adults With Human Immunodeficiency Virus Type 1 Infection: Week 96 Results of the Randomized, Double-blind, Phase 3 DRIVE-AHEAD Noninferiority Trial. Clin Infect Dis 2021; 73:33-42. [PMID: 33336698 PMCID: PMC8246893 DOI: 10.1093/cid/ciaa822] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Indexed: 01/12/2023] Open
Abstract
Background Doravirine (DOR) is a nonnucleoside reverse-transcriptase inhibitor. In the phase 3 DRIVE-AHEAD trial in treatment-naive adults with human immunodeficiency virus type 1 (HIV-1) infection, DOR demonstrated noninferior efficacy compared with efavirenz (EFV) and superior profiles for neuropsychiatric tolerability and lipids at 48 weeks. We present data through week 96. Methods DRIVE-AHEAD is a phase 3, multicenter, double-blind, noninferiority trial in antiretroviral treatment-naive adults with HIV-1 RNA ≥1000 copies/mL. Participants were randomized to a daily fixed-dose tablet of DOR (100 mg), lamivudine (3TC; 300 mg) and tenofovir disoproxil fumarate (TDF; 300 mg) (DOR/3TC/TDF) or EFV (600 mg), emtricitabine (FTC; 200 mg) and TDF (300 mg) (EFV/FTC/TDF). The efficacy end point of interest at week 96 was the proportion of participants with HIV-1 RNA levels <50 copies/mL (Food and Drug Administration Snapshot Approach) with a predefined noninferiority margin of 10% to support week 48 results. Safety end points of interest included prespecified neuropsychiatric adverse events and the mean change in fasting lipids at week 96. Results Of 734 participants randomized, 728 received study drugs and were included in analyses. At week 96, HIV-1 RNA <50 copies/mL was achieved by 77.5% of DOR/3TC/TDF vs 73.6% of EFV/FTC/TDF participants, with a treatment difference of 3.8% (95% confidence interval, –2.4% to 10%). Virologic failure rates were low and similar across treatment arms, with no additional resistance to DOR observed between weeks 48 and 96. Prespecified neuropsychiatric adverse events and rash were less frequent in DOR/3TC/TDF than in EFV/FTC/TDF participants through week 96. At week 96, fasting low-density lipoprotein cholesterol and non–high-density lipoprotein cholesterol (HDL-C) levels increased in the EFV/FTC/TDF group but not in the DOR/3TC/TDF group; the mean changes from baseline in total cholesterol/HDL-C ratio were similar. Clinical Trials Registration NCT02403674.
Collapse
Affiliation(s)
- Chloe Orkin
- Queen Mary University of London, London, United Kingdom
| | - Kathleen E Squires
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Jean-Michel Molina
- University of Paris Diderot, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, INSERM, Paris, France
| | - Paul E Sax
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Otto Sussmann
- Asistencia Cientifica de Alta Complejidad SAS, Bogota, Colombia
| | - Gina Lin
- Merck & Co., Inc., Kenilworth, New Jersey, USA
| | | | | | - Carey Hwang
- Merck & Co., Inc., Kenilworth, New Jersey, USA
| | | | | |
Collapse
|
11
|
Font-Porterias N, Giménez A, Carballo-Mesa A, Calafell F, Comas D. Admixture Has Shaped Romani Genetic Diversity in Clinically Relevant Variants. Front Genet 2021; 12:683880. [PMID: 34220960 PMCID: PMC8244592 DOI: 10.3389/fgene.2021.683880] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/13/2021] [Indexed: 01/04/2023] Open
Abstract
Genetic patterns of inter-population variation are a result of different demographic and adaptive histories, which gradually shape the frequency distribution of the variants. However, the study of clinically relevant mutations has a Eurocentric bias. The Romani, the largest transnational minority ethnic group in Europe, originated in South Asia and received extensive gene flow from West Eurasia. Most medical genetic studies have only explored founder mutations related to Mendelian disorders in this population. Here we analyze exome sequences and genome-wide array data of 89 healthy Spanish Roma individuals to study complex traits and disease. We apply a different framework and focus on variants with both increased and decreased allele frequencies, taking into account their local ancestry. We report several OMIM traits enriched for genes with deleterious variants showing increased frequencies in Roma or in non-Roma (e.g., obesity is enriched in Roma, with an associated variant linked to South Asian ancestry; while non-insulin dependent diabetes is enriched in non-Roma Europeans). In addition, previously reported pathogenic variants also show differences among populations, where some variants segregating at low frequency in non-Roma are virtually absent in the Roma. Lastly, we describe frequency changes in drug-response variation, where many of the variants increased in Roma are clinically associated with metabolic and cardiovascular-related drugs. These results suggest that clinically relevant variation in Roma cannot only be characterized in terms of founder mutations. Instead, we observe frequency differences compared to non-Roma: some variants are absent, while other have drifted to higher frequencies. As a result of the admixture events, these clinically damaging variants can be traced back to both European and South Asian-related ancestries. This can be attributed to a different prevalence of some genetic disorders or to the fact that genetic susceptibility variants are mostly studied in populations of European descent, and can differ in individuals with different ancestries.
Collapse
Affiliation(s)
- Neus Font-Porterias
- Departament de Ciències Experimentals i de la Salut, Institut de Biologia Evolutiva (UPF-CSIC), Universitat Pompeu Fabra, Barcelona, Spain
| | - Aaron Giménez
- Facultat de Sociologia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Francesc Calafell
- Departament de Ciències Experimentals i de la Salut, Institut de Biologia Evolutiva (UPF-CSIC), Universitat Pompeu Fabra, Barcelona, Spain
| | - David Comas
- Departament de Ciències Experimentals i de la Salut, Institut de Biologia Evolutiva (UPF-CSIC), Universitat Pompeu Fabra, Barcelona, Spain
| |
Collapse
|
12
|
Xu L, Peng W, Song X, Li Y, Han Y, Zhu T, Fu Q, Du X, Cao W, Li T. Pharmacodynamics of efavirenz 400 mg in treatment-naïve Chinese HIV-infected patients in a prospective cohort study. BMC Infect Dis 2021; 21:112. [PMID: 33485301 PMCID: PMC7824943 DOI: 10.1186/s12879-021-05802-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/14/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The plasma concentration of patients treated with efavirenz (EFV) 600 mg was found to exceed the upper limit of the proposed therapeutic window in most Chinese HIV-infected individuals; thus, dosage reduction of EFV to 400 mg daily warranted consideration. This study aimed to assess the pharmacodynamics of EFV 400 mg for HIV-1-infected patients in China. METHOD Twenty cART-naïve individuals were enrolled in this study. EFV 400 mg combined with tenofovir (TDF) and lamivudine (3TC) as an initial antiretroviral regimen was administered for 48 weeks. EFV concentration and T cell subsets as well as HIV RNA load were evaluated at baseline and at 4, 12, 24, and 48 weeks. Moreover, neuropsychiatric adverse effects were also assessed by the Hamilton depression (HAMD) scale and Pittsburgh sleep quality index (PSQI). RESULTS Eighteen males and two females whose median age was 26 (interquartile range [IQR]: 23-32) years completed 48 weeks of follow-up. The median EFV concentrations were 1.88 (IQR: 1.54-2.42), 1.74 (IQR: 1.36-1.93), 1.93 (IQR: 1.66-2.22), and 1.85 (IQR: 1.54-2.14) mg/L at weeks 4, 12, 24, and 48, respectively. The viral load was 4.59 (IQR: 4.10-5.19) log10 copies/mL at baseline, and it decreased by 4.6 (IQR: 3.98-5.18) log10 copies/mL from baseline to week 48. Three of 20 (15%), 10 of 20 (50.0%), 17 of 20 (85%), and 18 of 19 (95%) participants had a plasma viral load less than 50 copies/mL at weeks 4, 12, 24, and 48, respectively. The median CD4 cell count was 330 (IQR: 237-410) cells/μL at baseline, and it increased to 473 (IQR: 344-574) cells/μL at 48 weeks. The HAMD score was 5 (IQR: 3-9.8) and 3 (IQR: 2.25-4) at baseline and 48 weeks, respectively. The PSQI score was 4 (IQR: 2-5.8) and 3 (IQR: 2-4) at baseline and 48 weeks, respectively. Dizziness was the most common event, occurring in 70% of patients within the first 2 weeks of treatment. CONCLUSION Patients prescribed with EFV 400 mg-containing agents demonstrated favourable virological and immunological responses. And the plasma EFV concentration was within the recommended therapeutic range, with fewer adverse reactions than with EFV 600 mg. EFV 400 mg was effective and safe in Chinese HIV-infected patients. TRIAL REGISTRATION NCT04596488 ; Registered 21 October, 2020; Retrospectively registered.
Collapse
Affiliation(s)
- Ling Xu
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Wenxiu Peng
- Department of Pharmacy and Pharmacology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaojing Song
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yanling Li
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Han
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ting Zhu
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Qiang Fu
- Department of Pharmacy and Pharmacology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoli Du
- Department of Pharmacy and Pharmacology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Cao
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Taisheng Li
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China. .,Clinical Immunology Center, Chinese Academy of Medical Sciences, Beijing, China. .,Tsinghua University Medical College, Beijing, China.
| |
Collapse
|
13
|
Ayuso P, Neary M, Chiong J, Owen A. Meta-analysis of the effect of CYP2B6, CYP2A6, UGT2B7 and CAR polymorphisms on efavirenz plasma concentrations. J Antimicrob Chemother 2020; 74:3281-3290. [PMID: 31369088 DOI: 10.1093/jac/dkz329] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 06/14/2019] [Accepted: 07/02/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Efavirenz primary metabolism is catalysed by CYP2B6 with minor involvement of CYP2A6. Subsequently, phase I metabolites are conjugated by UGT2B7, and constitutive androstane receptor (CAR) has been shown to transcriptionally regulate many relevant enzymes and transporters. Several polymorphisms occurring in the genes coding for these proteins have been shown to impact efavirenz pharmacokinetics in some but not all studies. OBJECTIVES A meta-analysis was performed to assess the overall effect of CYP2B6 rs3745274, CYP2A6 (rs28399454, rs8192726 and rs28399433), UGT2B7 (rs28365062 and rs7439366) and NR1I3 (rs2307424 and rs3003596) polymorphisms on mid-dose efavirenz plasma concentrations. METHODS Following a literature review, pharmacokinetic parameters were compiled and a meta-analysis for these variants was performed using Review Manager and OpenMetaAnalyst. A total of 28 studies were included. RESULTS Unsurprisingly, the analysis confirmed that individuals homozygous for the T allele for CYP2B6 rs3745274 had significantly higher efavirenz concentrations than those homozygous for the G allele [weighted standard mean difference (WSMD) = 2.98; 95% CI 2.19-3.76; P < 0.00001]. A subgroup analysis confirmed ethnic differences in frequency but with a similar effect size in each ethnic group (P = 0.96). Associations with CYP2A6 and UGT2B7 variants were not statistically significant, but T homozygosity for CAR rs2307424 was associated with significantly lower efavirenz concentrations than in C homozygotes (WSMD = -0.32; 95% CI -0.59 to -0.06; P = 0.02). CONCLUSIONS This meta-analysis provides the overall effect size for the impact of CYP2B6 rs3745274 and NR1I3 rs2307424 on efavirenz pharmacokinetics. The analysis also indicates that some previous associations were not significant when interrogated across studies.
Collapse
Affiliation(s)
- Pedro Ayuso
- Infection Pharmacology Group, University of Liverpool, Liverpool, UK
| | - Megan Neary
- Infection Pharmacology Group, University of Liverpool, Liverpool, UK
| | - Justin Chiong
- Infection Pharmacology Group, University of Liverpool, Liverpool, UK
| | - Andrew Owen
- Infection Pharmacology Group, University of Liverpool, Liverpool, UK
| |
Collapse
|
14
|
Chen R, Chen J, Xun J, Hu Z, Huang Q, Zhang R, Steinhart C, Shen Y, Liu L, Lu H. Pharmacogenomics and pharmacokinetics of efavirenz 400 or 600 mg in 184 treatment-naive HIV-infected patients in China. Pharmacogenomics 2020; 21:945-956. [PMID: 32838647 DOI: 10.2217/pgs-2019-0169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: The pharmacogenomics and pharmacokinetics/pharmacodynamics of 400 mg efavirenz have rarely been reported. Materials & methods: A total of 184 treatment-naive HIV-infected patients were randomly assigned (1:1) to receive a lower dose (tenofovir disoproxil 200 mg, efavirenz 400 mg and lamivudine) or a standard dose regimen. Relationships between pharmacogenomics and efavirenz pharmacokinetics/pharmacodynamics were explored at 48 weeks. Results: There was no relationship between pharmacogenomics and adverse reactions of the central nervous system and antiretoviral efficacy. CYP2B6 516G>T, 785A>G, 18492C>T and ABCB1 3435C>T T/C were associated with higher efavirenz plasma levels in the standard but not the lower dose group. No relationship was found between pharmacogenomics and antiretoviral efficacy. Patients who were <60 kg had higher efavirenz concentration compared with those with weight ≥60 kg when using 600 mg efavirenz, this was not observed with 400 mg efavirenz. Conclusion: The effect of pharmacogenomics and body weight on the efavirenz concentration was significant in the 600 mg group but not in the 400 mg group.
Collapse
Affiliation(s)
- Rong Chen
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China.,Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Jun Chen
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China
| | - Jingna Xun
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China
| | - Zhiliang Hu
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, 210003, China
| | - Qiong Huang
- Yunnan AIDS Care Center (YNACC), Yunnan Provincial Infectious Disease Hospital, Kunming, 650500, China
| | - Renfang Zhang
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China
| | - Corky Steinhart
- CAN Community Health, FL 34232, USA.,Department of Internal Medicine, The University of Central Florida, College of Medicine, FL 32827, USA
| | - Yinzhong Shen
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China
| | - Li Liu
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China
| | - Hongzhou Lu
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China
| |
Collapse
|
15
|
Chaivichacharn P, Avihingsanon A, Manosuthi W, Ubolyam S, Tongkobpetch S, Shotelersuk V, Punyawudho B. Dosage Optimization of Efavirenz Based on a Population Pharmacokinetic-Pharmacogenetic Model of HIV-infected Patients in Thailand. Clin Ther 2020; 42:1234-1245. [PMID: 32451120 DOI: 10.1016/j.clinthera.2020.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 01/11/2023]
Abstract
PURPOSE Efavirenz exhibits high interindividual variability in plasma concentrations, leading to unpredictable efficacy and toxicity. Polymorphism of CYP2B6 516G > T has been found to predominantly contribute to efavirenz variability. However, dosage recommendations incorporating CYP2B6 516G > T polymorphism have not been investigated in the Thai population. This study aimed to develop a population model of the pharmacokinetic properties of efavirenz, and to investigate the impact of patients' characteristics and CYP2B6 516G > T polymorphism on the pharmacokinetic properties of efavirenz. Model-based simulations were performed to provide genotype-based dosage optimization in a Thai population. METHODS Plasma efavirenz concentrations measured at 12 h post-dose in 360 Thai HIV-infected patients with and without tuberculosis were analyzed by the nonlinear mixed-effects modeling approach. A 1-compartment model with first-order absorption and elimination was used for describing the pharmacokinetic properties of efavirenz. FINDINGS The allele frequency of CYP2B6 516G > T was 34.17%. The efavirenz oral clearance were 11.9, 8.0, and 2.8 L/h in patients weighing 57 kg and having the CYP2B6 516 GG, 516 GT, and 516 TT genotypes, respectively. The use of rifampicin increased efavirenz oral clearance by 28%. The results from the simulations suggest that efavirenz dosages of 400, 300, and 100 mg once daily in Thai HIV mono-infected patients, and 800, 600, and 200 mg once daily in HIV/tuberculosis co-infected patients carrying CYP2B6 516 GG, 516 GT, and 516 TT, respectively. IMPLICATION The results from this study provide a rationale for efavirenz dose adjustment based on CYP2B6 516G > T polymorphism in Thai HIV-infected patients, which could help to improve treatment outcomes in this population. ClinicalTrials.gov identifier: NCT01138267.
Collapse
Affiliation(s)
- Piyawat Chaivichacharn
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Anchalee Avihingsanon
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand; Tuberculosis Research Unit, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Weerawat Manosuthi
- Bamrasnaradura Infectious Diseases Institute, Ministry of Public Health, Mueang Nonthaburi, Thailand
| | | | - Siraprapa Tongkobpetch
- Center of Excellence for Medical Genomics, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Center of Excellence for Genomics and Precision Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Vorasuk Shotelersuk
- Center of Excellence for Medical Genomics, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Center of Excellence for Genomics and Precision Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Baralee Punyawudho
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand.
| |
Collapse
|
16
|
Pepperrell T, Hill A, Moorhouse M, Clayden P, McCann K, Sokhela S, Serenata C, Venter WDF. Phase 3 trials of new antiretrovirals are not representative of the global HIV epidemic. J Virus Erad 2020; 6:70-73. [PMID: 32405424 PMCID: PMC7213067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION People living with HIV (PLWH) are mainly African or Asian, the majority female. In contrast, pharmaceutical companies typically conduct phase 3 regulatory randomised controlled trials (RCTs) in high-income countries (HICs), where PLWH are mainly white males. Regulatory authorities can be conservative about including pregnant women in trials, discouraging female participation. Some adverse events occur more frequently by sex or by race because of differing pharmacokinetics. Most drugs have insufficient safety data in pregnancy and non-white people even after regulatory approval. The present study compared race and sex demographics of phase 3 RCTs of dolutegravir (DTG), bictegravir (BIC) and tenofovir alafenamide (TAF) with global HIV epidemic demography. METHODS National epidemic sizes by sex were extracted from UNAIDS 2018 data. National demographics were used to estimate prevalence by race. PLWH by national socio-economic status were calculated from World Bank data. Summary race and sex demographic data for 10 phase 3 trials of DTG (n = 7714), four of BIC (n = 2307), eight of TAF (n = 7573) and two of doravirine (DOR) (n = 1407) were extracted from ClinicalTrials.gov. RESULTS Black females (42%) and black males (30%) have highest prevalence globally. White males comprise 6% of PLWH. Over 60% of PLWH live in low or low-middle-income countries, 68% of whom are black and 23% Asian. Seventy-six per cent of DTG trial centres were in high-income countries (HICs) (5% global burden) and 23% in upper-middle-income countries (UMICs). DTG trials were not representative of PLWH even within the UMIC and HIC setting (49% white male vs 31% income band). White males were overrecruited by 44% to DTG, BIC, TAF and DOR trials in comparison with prevalence. Black females were underrepresented by 35%. CONCLUSION Phase 3 RCT populations for new antiretrovirals comprised 51% white males, vastly disproportionate to the global HIV epidemic (6%). Females and non-white people are underrepresented. Female safety data are insufficient despite drug approval in Europe and USA. HIV trials should be located in regions representing the global epidemic with no sex-based selection. Trials should aim for at least 50% female and 50% non-white recruitment to properly provide safety information.
Collapse
Affiliation(s)
| | - Andrew Hill
- Department of Translational Medicine,
Liverpool University, Pharmacology,
Liverpool,
UK,Corresponding author: Dr Andrew Hill,
Department of
Translational Medicine,
University of Liverpool,
70 Pembroke Place, Liverpool L69 3GF,
UK
| | - Michelle Moorhouse
- Ezintsha,
Wits Reproductive Health and HIV Institute,
Faculty of Health Sciences,
University of the Witwatersrand,
Johannesburg,
South Africa
| | | | | | - Simiso Sokhela
- Ezintsha,
Wits Reproductive Health and HIV Institute,
Faculty of Health Sciences,
University of the Witwatersrand,
Johannesburg,
South Africa
| | - Celicia Serenata
- Wits Reproductive Health and HIV Institute,
Faculty of Health Sciences,
University of the Witwatersrand,
Johannesburg,
South Africa
| | - Willem Daniel Francois Venter
- Ezintsha,
Wits Reproductive Health and HIV Institute,
Faculty of Health Sciences,
University of the Witwatersrand,
Johannesburg,
South Africa
| |
Collapse
|
17
|
Pepperrell T, Hill A, Moorhouse M, Clayden P, McCann K, Sokhela S, Serenata C, Venter WDF. Phase 3 trials of new antiretrovirals are not representative of the global HIV epidemic. J Virus Erad 2020. [DOI: 10.1016/s2055-6640(20)30019-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
18
|
A Comparison of Plasma Efavirenz and Tenofovir, Dried Blood Spot Tenofovir-Diphosphate, and Self-Reported Adherence to Predict Virologic Suppression Among South African Women. J Acquir Immune Defic Syndr 2020; 81:311-318. [PMID: 30893125 DOI: 10.1097/qai.0000000000002032] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Tenofovir-diphosphate (TFV-DP) in dried blood spots (DBS) is an objective long-term adherence measure, but data are limited on its ability to predict virologic suppression (VS) in people on antiretroviral (ARV) treatment. There are also no data comparing DBS TFV-DP with plasma ARV concentrations as predictors of VS. METHODS Women who were on a first-line regimen of tenofovir, emtricitabine, and efavirenz (EFV) were enrolled in a cross-sectional study. Plasma EFV and tenofovir (TFV), DBS TFV-DP assays, and 30-day self-reported adherence were evaluated as predictors of VS (<50 copies/mL) with the area under the curve of receiver operating characteristics and logistic regression. RESULTS We enrolled 137 women; mean age of 33 years; median 4 years on antiretroviral therapy; 88 (64%) had VS. In receiver operating characteristics analyses: DBS TFV-DP [0.926 (95% CI: 0.876 to 0.976)] had a higher area under the curve than plasma TFV [0.864 (0.797 to 0.932); P = 0.006], whereas plasma EFV [0.903 (0.839-0.967)] was not significantly different from DBS TFV-DP (P = 0.138) or plasma TFV (P = 0.140); all ARV assays performed better than self-report. The association of TFV-DP in DBS with VS strengthened with increasing concentrations [reference <350 fmol/punch: 350-699 fmol/punch aOR 37 (8-178); 700-1249 fmol/punch aOR 47 (13-175); ≥1250 fmol/punch aOR 175 (20-1539)]. "White coat adherence" (defined as DBS TFV-DP <350 fmol/punch with detectable plasma TFV) was only detected in 4 women. CONCLUSIONS Plasma EFV, TFV, and DBS TFV-DP were all strong predictors of VS. EFV or TFV assays have potential for development as point-of-care assays for use as objective adherence measures in resource-limited settings.
Collapse
|
19
|
Du X, Peng W, Fu Q, Ma Q, Zhu Z, Li T. A Review of Clinical Pharmacokinetic and Pharmacodynamic Profiles of Select Antiretrovirals: Focus on Differences among Chinese Patients. Pharmacotherapy 2019; 39:1179-1189. [PMID: 31550053 DOI: 10.1002/phar.2333] [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] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To identify the pharmacokinetic differences of antiretroviral drugs between HIV-infected Chinese patients and patients of other race/ethnicities. STUDY DESIGN Results from prospective, open-label pharmacokinetic studies among Chinese and historical data from other race/ethnicities. PATIENTS Pharmacokinetics of six commonly used antiretroviral drugs, including zidovudine, lamivudine, tenofovir disoproxil fumarate, nevirapine, efavirenz and lopinavir/ritonavir, was evaluated in HIV-infected Chinese patients and compared with historical data from other race/ethnicities. ANALYSIS Pharmacokinetic analyses were performed at the steady state among HIV-infected Chinese patients. Safety data were collected during the follow-up. The pharmacokinetic parameters including maximal concentrations (Cmax), area-under-curve (AUC) and clearance (Cl/F) from the Chinese patients were compared to the historic data from other race/ethnicities. RESULTS Current evidence, though limited, suggested that these antiretroviral agents were generally safe and effective among HIV-infected Chinese patients. However, compared with other racial groups, Chinese patients exhibited higher Cmax , AUC and lower Cl/F for most of the agents, and the incidences of adverse reactions, for example, liver toxicity, rash, and bone health, were more frequent. CONCLUSIONS These pharmacokinetic differences suggest that lower dosages for commonly prescribed antiretroviral drugs in China might be appropriate to reduce drug-related adverse reactions, while maintain the antiviral efficacy.
Collapse
Affiliation(s)
- Xiaoli Du
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Wenxiu Peng
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Qiang Fu
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Qing Ma
- Translational Pharmacology Research Core, NYS Center of Excellence in Bioinformatics and Life Sciences, Buffalo, New York
| | - Zhu Zhu
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Taisheng Li
- Department of Infectious Diseases, AIDS Diagnosis and Treatment Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|
20
|
Lamorde M, Wang X, Neary M, Bisdomini E, Nakalema S, Byakika-Kibwika P, Mukonzo JK, Khan W, Owen A, McClure M, Boffito M. Pharmacokinetics, Pharmacodynamics, and Pharmacogenetics of Efavirenz 400 mg Once Daily During Pregnancy and Post-Partum. Clin Infect Dis 2019; 67:785-790. [PMID: 30124823 DOI: 10.1093/cid/ciy161] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 02/22/2018] [Indexed: 12/22/2022] Open
Abstract
Background A clinical trial showed that efavirenz 400 mg once daily (EFV400) is as effective as the standard adult dose. World Health Organization recommends EFV400 as an alternative first-line agent, but data are lacking in the third trimester of pregnancy (TT). We investigated the pharmacokinetics, efficacy, and CYP2B6 pharmacogenetics in HIV-infected women (WLWH) on EFV400 during TT and post-partum (PP). Methods An open-label 2-center study (United Kingdom, Uganda) was conducted in WLWH receiving antiretroviral regimens containing efavirenz 600 mg, who had their efavirenz dose reduced to EFV400. Weekly therapeutic drug monitoring (TDM), steady-state pharmacokinetic profiles (TT and PP), safety, virological efficacy, and CYP2B6 polymorphisms at positions 516 (C > T) and 938 (T > C) were evaluated. Results Twenty-five WLWH of African origin were enrolled. All had viral loads <50 copies/mL at baseline, which were maintained throughout the study. No infant was HIV infected. No WLWH were withdrawn due to low EFV400 TDM results. Geometric mean ratios (TT/PP; 90% confidence interval) for EFV400 maximum observed plasma concentration, area under the curve, and plasma concentration measured 24 hours after the observed dose were 0.97 (.85-1.10), 0.87 (.76-.99), and 0.77 (.65-.91), respectively. Five of 25 WLWH were slow metabolizers. Conclusions Although EFV400 pharmacokinetic parameters were slightly lower for TT compared with PP values, efavirenz concentrations exceeded cutoff levels established by the study and those measured in antiretroviral-naive patients receiving EFV400 in ENCORE1. All subjects maintained a viral load <50 copies/mL, suggesting that EFV400 can be used in pregnant WLWH.
Collapse
Affiliation(s)
- Mohammed Lamorde
- Infectious Diseases Institute, College of Health Science, Makerere University, Kampala, Uganda
| | - Xinzhu Wang
- Jeffriess Research Trust Laboratories, Department of Medicine, Imperial College, St Mary's Campus, London
| | - Megan Neary
- Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool
| | - Elisa Bisdomini
- St Stephen's Clinical Research, Chelsea and Westminster Hospital, London, United Kingdom
| | - Shadia Nakalema
- Infectious Diseases Institute, College of Health Science, Makerere University, Kampala, Uganda
| | - Pauline Byakika-Kibwika
- Infectious Diseases Institute, College of Health Science, Makerere University, Kampala, Uganda
| | - Jackson K Mukonzo
- Department of Pharmacology & Therapeutics, College of Health Science, Makerere University, Kampala, Uganda
| | - Waheed Khan
- St Stephen's Clinical Research, Chelsea and Westminster Hospital, London, United Kingdom
| | - Andrew Owen
- Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool
| | - Myra McClure
- Jeffriess Research Trust Laboratories, Department of Medicine, Imperial College, St Mary's Campus, London
| | - Marta Boffito
- Jeffriess Research Trust Laboratories, Department of Medicine, Imperial College, St Mary's Campus, London.,St Stephen's Clinical Research, Chelsea and Westminster Hospital, London, United Kingdom
| |
Collapse
|
21
|
Cheng L, Wang Y, Li X, Feng W, Weng B, Yuan Q, Xia P, Sun F. Meta-analysis of the associations of CYP2B6-516G>T polymorphisms with efavirenz-induced central nervous system side effects and virological outcome in HIV-infected adults. THE PHARMACOGENOMICS JOURNAL 2019; 20:246-259. [PMID: 31636355 DOI: 10.1038/s41397-019-0112-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 10/06/2019] [Accepted: 10/10/2019] [Indexed: 02/07/2023]
Abstract
Clinical data on the relationships of cytochrome P450 (CYP2) B6 516G>T polymorphisms with efavirenz-induced central nervous system (CNS) side effects and virological response in HIV-infected adults are controversial. We sought to analyze the associations by meta-analysis. To identify eligible studies, we systematically searched PubMed, Embase, ScienceDirect, and Web of Science. The strength of the associations was measured by odds ratio (OR) and effect size (ES) with 95% confidence interval (CI). Seventeen studies comprising a total of 3598 HIV-infected adults were included. The results showed that the CYP2B6-516 GG genotype was significantly associated with a decreased risk of efavirenz-induced CNS side effects compared with the GT and TT genotypes (GG + GT vs. TT: OR = 0.60, 95% CI = 0.41-0.87, P = 0.006; GG vs. GT + TT: OR = 0.68, 95% CI = 0.51-0.91, P = 0.008; GG vs. GT: OR = 0.70, 95% CI = 0.51-0.94, P = 0.018), and there was no significant association between the genetic variants GT and TT (GT vs. TT: OR = 0.82, 95% CI = 0.54-1.26, P = 0.372). However, there was no significant association between CYP2B6-516 GG and GT + TT genotypes in virological response (GT + TT vs. GG: ES = 1.06, 95% CI = 0.95-1.18, P = 0.321; OR = 1.01, 95% CI = 0.65-1.58, P = 0.963). Taken together, our results demonstrated that compared with the normal efavirenz clearance genotype CYP2B6-516 GG, the slow and very slow efavirenz clearance genotypes GT and TT were significantly associated with an increased risk of efavirenz-induced CNS side effects but not an increased virological response. To promote the tolerance of efavirenz, it is better to adjust the dosage of efavirenz according to the polymorphisms of CYP2B6-516 in HIV-infected adults.
Collapse
Affiliation(s)
- Lin Cheng
- Department of Pharmacy, the First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Yu Wang
- Department of Pharmacy, the First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Xiaoyu Li
- Department of Pharmacy, Handan Branch Hospital of the 980th Hospital of PLA, Handan, 056001, China
| | - Wei Feng
- Department of Pharmacy, the First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Bangbi Weng
- Department of Pharmacy, the First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Qian Yuan
- Department of Pharmacy, the First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Peiyuan Xia
- Department of Pharmacy, the First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, 400038, China.
| | - Fengjun Sun
- Department of Pharmacy, the First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, 400038, China.
| |
Collapse
|
22
|
Influence of CYP2B6 activity score on the pharmacokinetics and safety of single dose efavirenz in healthy volunteers. THE PHARMACOGENOMICS JOURNAL 2019; 20:235-245. [PMID: 31628422 DOI: 10.1038/s41397-019-0103-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 09/10/2019] [Accepted: 10/02/2019] [Indexed: 01/11/2023]
Abstract
Efavirenz is a non-nucleoside reverse transcriptase inhibitor used as first-line therapy for the treatment of HIV infection. Cytochrome P450 (CYP) CYP2B6 G516T (rs3745274) is a well-known predictor of efavirenz disposition. Dose adjustment based on G516T variant has been shown to be beneficial. However, this variant cannot explain the entire variability of efavirenz pharmacokinetics. In this study, we evaluated the influence of 11 single-nucleotide polymorphisms (SNPs) in CYP2B6, CYP2A6, CYP3A and ABCB1 (ATP-binding cassette sub-family B member 1) on the pharmacokinetics and safety of efavirenz after single oral dose administration to 47 healthy volunteers. We designed and validated a CYP2B6 activity score model based on two CYP2B6 SNPs (G516T and rs4803419) that predicted efavirenz disposition better than G516T alone.
Collapse
|
23
|
Seden K, Kiiza D, Laker E, Arinaitwe WJ, Waitt C, Lamorde M, Khoo S. High prevalence and long duration of nervous system and psychiatric adverse drug reactions in Ugandan patients taking efavirenz 600 mg daily. J Antimicrob Chemother 2019; 73:3158-3161. [PMID: 30085168 PMCID: PMC6198741 DOI: 10.1093/jac/dky298] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 06/26/2018] [Indexed: 12/01/2022] Open
Abstract
Background Efavirenz-related nervous system or psychiatric adverse drug reactions (ADRs) are conventionally reported to resolve soon after initiation, with incidence of dizziness at 8.5% in large clinical trials. Patients of black ethnicity are genetically at greater risk of elevated efavirenz exposure, which has been linked to nervous system toxicity. Patients and methods The current data derive from a prospective longitudinal observational study of adult HIV-positive outpatients taking current antiretrovirals, at three diverse clinics in central Uganda. As part of an interview about medicine use, patients were asked by trained pharmacy technicians to detail current side effects and to rate their severity on a simple visual analogue scale (1–10). Details of the reported ADRs were verified by case note review. Severity and causality of ADRs were rated by the study team using validated tools. Results A total of 300 patients taking efavirenz were analysed. Of these, 108 (36%, 95% CI 30.6%–41.7%) were affected by persisting nervous system/psychiatric ADRs (median duration 22 months). Dizziness affected 27.3% (95% CI 22.4%–32.8%) of patients taking efavirenz. Severity of the ADRs was rated by patients at ≥5/10 in 76 (58.5%) cases. In 95 (86%) cases, there was no record of the ADRs in the clinical notes. Conclusions Strategies are needed to identify and prioritize patients urgently with persisting efavirenz neurotoxicity for a switch to newer regimens as they become available.
Collapse
Affiliation(s)
- Kay Seden
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Daniel Kiiza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Eva Laker
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Walter J Arinaitwe
- Advanced Treatment Information Centre (ATIC), Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Catriona Waitt
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK.,Infectious Diseases Institute, Makerere University, Kampala, Uganda.,Royal Liverpool University Hospital, Liverpool, UK
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Saye Khoo
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK.,Royal Liverpool University Hospital, Liverpool, UK
| |
Collapse
|
24
|
Atoyebi SA, Rajoli RKR, Adejuyigbe E, Owen A, Bolaji O, Siccardi M, Olagunju A. Using mechanistic physiologically-based pharmacokinetic models to assess prenatal drug exposure: Thalidomide versus efavirenz as case studies. Eur J Pharm Sci 2019; 140:105068. [PMID: 31518681 PMCID: PMC6853277 DOI: 10.1016/j.ejps.2019.105068] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 09/05/2019] [Accepted: 09/05/2019] [Indexed: 11/30/2022]
Abstract
Maternofoetal physiologically-based pharmacokinetic models integrating multi-compartmental maternal and foetal units were developed using Simbiology® to estimate prenatal drug exposure. Processes governing drug disposition were described using differential equations with key system and drug-specific parameters. Transplacental drug transfer was modelled as bidirectional passive diffusion and benchmarked against those for thalidomide as a control. Model-predictions for pharmacokinetic parameters during pregnancy were within acceptable ranges for qualification (two-fold difference of clinically-observed values). Predicted foetal exposure to thalidomide was higher than efavirenz, with median (range) foetal-to-maternal plasma ratios of 4.55 (3.06–9.57) for 400 mg thalidomide versus 0.89 (0.73–1.05) for 400 mg efavirenz at third trimester. Model-predictions indicated foetal exposure consistently above 300% of maternal plasma concentration for thalidomide throughout pregnancy, while exposure to efavirenz increased from under 20% at second trimester to above 100% at third trimester. Further qualification of this approach as a tool in evaluating drug exposure and safety during pregnancy is warranted.
Collapse
Affiliation(s)
| | - Rajith K R Rajoli
- Department of Molecular and Clinical Pharmacology, University of Liverpool, United Kingdom
| | - Ebunoluwa Adejuyigbe
- Department of Paediatrics and Child Health, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, University of Liverpool, United Kingdom
| | - Oluseye Bolaji
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Marco Siccardi
- Department of Molecular and Clinical Pharmacology, University of Liverpool, United Kingdom
| | - Adeniyi Olagunju
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile-Ife, Nigeria; Department of Molecular and Clinical Pharmacology, University of Liverpool, United Kingdom.
| |
Collapse
|
25
|
Mazanderani AH, Murray TY, Sherman GG, Snyman T, George J, Avenant T, Goga AE, Pepper MS, du Plessis N. Non-nucleoside reverse transcriptase inhibitor levels among HIV-exposed uninfected infants at the time of HIV PCR testing - findings from a tertiary healthcare facility in Pretoria, South Africa. J Int AIDS Soc 2019; 22:e25284. [PMID: 31215757 PMCID: PMC6582367 DOI: 10.1002/jia2.25284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 03/29/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION To date, very little programmatic data has been published regarding serial antiretroviral (ARV) levels in infants exposed to maternal treatment and/or infant prophylaxis during the first months of life. Such data provide the opportunity to describe the proportion of infants exposed to virologically suppressive levels of ARVs and to gauge adherence to the prevention of mother-to-child transmission of HIV (PMTCT) programme. METHODS From August 2014 to January 2016, HIV-exposed infants born at Kalafong Provincial Tertiary Hospital in Pretoria, South Africa were enrolled as part of an observational cohort study. Plasma samples from HIV-exposed uninfected infants were obtained at birth, 6-weeks, 10-weeks and 14-weeks of age and quantitative efavirenz (EFV) and nevirapine (NVP) drug level testing performed using liquid chromatography-mass spectrometry, irrespective of maternal ARV regimen. Descriptive analysis of EFV and NVP levels in relation to self-reported maternal and infant ARV exposure was performed. EFV levels >500 ng/mL and NVP levels >100 ng/mL were reported based on studies suggesting that trough levels above these thresholds are associated with virological suppression and PMTCT respectively. RESULTS Among 66 infants exposed to maternal EFVin utero, 29 (44%) had virologically suppressive plasma EFV levels at birth, with a median level of 1665 ng/mL (IQR: 1094 to 3673). Among infants who were exclusively breastfed at 6-, 10- and 14 weeks, 13/48 (27%), 5/25 (25%) and 0/21 (0%) had virologically suppressive EFV levels. Among 64 infants whose mothers reported administering daily infant NVP at time of their 6-week HIV PCR test, only 45 (70%) had NVP levels above the minimum prophylactic trough level. CONCLUSIONS During the first 10-weeks after delivery, a quarter of breastfed infants born to women on an EFV-containing treatment regimen maintained virologically suppressive EFV plasma levels. This finding highlights the importance of both careful monitoring of ARV side effects and repeat HIV PCR after the first few months of life among HIV-exposed uninfected infants. As 30% of infants had inadequate NVP plasma levels at 6-weeks of age, adherence counselling to caregivers regarding infant prophylaxis needs to be enhanced to further reduce mother-to-child transmission of HIV.
Collapse
Affiliation(s)
- Ahmad Haeri Mazanderani
- Centre for HIV & STIsNational Institute for Communicable DiseasesNational Health Laboratory ServiceJohannesburgSouth Africa
- Department of Medical VirologyFaculty of Health SciencesUniversity of PretoriaPretoriaSouth Africa
| | - Tanya Y Murray
- Centre for HIV & STIsNational Institute for Communicable DiseasesNational Health Laboratory ServiceJohannesburgSouth Africa
- Paediatric HIV DiagnosticsWits Health ConsortiumJohannesburgSouth Africa
| | - Gayle G Sherman
- Centre for HIV & STIsNational Institute for Communicable DiseasesNational Health Laboratory ServiceJohannesburgSouth Africa
- Paediatric HIV DiagnosticsWits Health ConsortiumJohannesburgSouth Africa
- Department of Paediatrics & Child HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Tracy Snyman
- Department of Chemical PathologyNational Health Laboratory Service and University of WitwatersrandJohannesburgSouth Africa
| | - Jaya George
- Department of Chemical PathologyNational Health Laboratory Service and University of WitwatersrandJohannesburgSouth Africa
| | - Theunis Avenant
- Paediatric Infectious Diseases DivisionDepartment of PaediatricsKalafong Provincial Tertiary HospitalPretoriaSouth Africa
- Department of Paediatrics and Child HealthFaculty of Health SciencesUniversity of PretoriaPretoriaSouth Africa
| | - Ameena E Goga
- Department of Paediatrics and Child HealthFaculty of Health SciencesUniversity of PretoriaPretoriaSouth Africa
- Health Systems Research UnitSouth African Medical Research CouncilCape TownSouth Africa
| | - Michael S Pepper
- Institute for Cellular and Molecular MedicineDepartment of ImmunologySAMRC Extramural Unit for Stem Cell Research and TherapyFaculty of Health SciencesUniversity of PretoriaPretoriaSouth Africa
| | - Nicolette du Plessis
- Paediatric Infectious Diseases DivisionDepartment of PaediatricsKalafong Provincial Tertiary HospitalPretoriaSouth Africa
- Department of Paediatrics and Child HealthFaculty of Health SciencesUniversity of PretoriaPretoriaSouth Africa
| |
Collapse
|
26
|
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.
Collapse
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
| |
Collapse
|
27
|
Duwal S, Seeler D, Dickinson L, Khoo S, von Kleist M. The Utility of Efavirenz-based Prophylaxis Against HIV Infection. A Systems Pharmacological Analysis. Front Pharmacol 2019; 10:199. [PMID: 30918485 PMCID: PMC6424904 DOI: 10.3389/fphar.2019.00199] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 02/18/2019] [Indexed: 11/13/2022] Open
Abstract
Pre-exposure prophylaxis (PrEP) is considered one of the five “pillars” by UNAIDS to reduce HIV transmission. Moreover, it is a tool for female self-protection against HIV, making it highly relevant to sub-Saharan regions, where women have the highest infection burden. To date, Truvada is the only medication for PrEP. However, the cost of Truvada limits its uptake in resource-constrained countries. Similarly, several currently investigated, patent-protected compounds may be unaffordable in these regions. We set out to explore the potential of the patent-expired antiviral efavirenz (EFV) as a cost-efficient PrEP alternative. A population pharmacokinetic model utilizing data from the ENCORE1 study was developed. The model was refined for metabolic autoinduction. We then explored EFV cellular uptake mechanisms, finding that it is largely determined by plasma protein binding. Next, we predicted the prophylactic efficacy of various EFV dosing schemes after exposure to HIV using a stochastic simulation framework. We predicted that plasma concentrations of 11, 36, 1287 and 1486ng/mL prevent 90% sexual transmissions with wild type and Y181C, K103N and G190S mutants, respectively. Trough concentrations achieved after 600 mg once daily dosing (median: 2017 ng/mL, 95% CI:445–9830) and after reduced dose (400 mg) efavirenz (median: 1349ng/mL, 95% CI: 297–6553) provided complete protection against wild-type virus and the Y181C mutant, and median trough concentrations provided about 90% protection against the K103N and G190S mutants. As reduced dose EFV has a lower toxicity profile, we predicted the reduction in HIV infection when 400 mg EFV-PrEP was poorly adhered to, when it was taken “on demand” and as post-exposure prophylaxis (PEP). Once daily EFV-PrEP provided 99% protection against wild-type virus, if ≥50% of doses were taken. PrEP “on demand” provided complete protection against wild-type virus and prevented ≥81% infections in the mutants. PEP could prevent >98% infection with susceptible virus when initiated within 24 h after virus exposure and continued for at least 9 days. We predict that 400 mg oral EFV may provide superior protection against wild-type HIV. However, further studies are warranted to evaluate EFV as a cost-efficient alternative to Truvada. Predicted prophylactic concentrations may guide release kinetics of EFV long-acting formulations for clinical trial design.
Collapse
Affiliation(s)
- Sulav Duwal
- Department of Mathematics and Computer Science, Systems Pharmacology and Disease Control, Institute of Bioinformatics, Freie Universität Berlin, Berlin, Germany
| | - Daniel Seeler
- Department of Mathematics and Computer Science, Systems Pharmacology and Disease Control, Institute of Bioinformatics, Freie Universität Berlin, Berlin, Germany
| | - Laura Dickinson
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Saye Khoo
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Max von Kleist
- Department of Mathematics and Computer Science, Systems Pharmacology and Disease Control, Institute of Bioinformatics, Freie Universität Berlin, Berlin, Germany
| |
Collapse
|
28
|
Kaboggoza JP, Wang X, Neary M, Ayuso P, Sekaggya-Wiltshire C, Nakalema S, Owen A, McClure M, Lamorde M, Boffito M. A Lower Dose of Efavirenz Can Be Coadministered With Rifampicin and Isoniazid in Tuberculosis Patients. Open Forum Infect Dis 2019; 6:ofz035. [PMID: 30815503 PMCID: PMC6386798 DOI: 10.1093/ofid/ofz035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 01/15/2019] [Indexed: 12/03/2022] Open
Affiliation(s)
- Julian P Kaboggoza
- Infectious Diseases Institute, Makerere University College of Health Sciences, Mulago Hospital Complex, Kampala, Uganda
| | - Xinxhu Wang
- Jeffriess Research Trust Laboratories, Department of Medicine, Imperial College, London, United Kingdom
| | - Megan Neary
- Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Pedro Ayuso
- Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Christine Sekaggya-Wiltshire
- Infectious Diseases Institute, Makerere University College of Health Sciences, Mulago Hospital Complex, Kampala, Uganda
| | - Shadia Nakalema
- Infectious Diseases Institute, Makerere University College of Health Sciences, Mulago Hospital Complex, Kampala, Uganda
| | - Andrew Owen
- Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Myra McClure
- Jeffriess Research Trust Laboratories, Department of Medicine, Imperial College, London, United Kingdom
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Mulago Hospital Complex, Kampala, Uganda
| | - Marta Boffito
- Jeffriess Research Trust Laboratories, Department of Medicine, Imperial College, London, United Kingdom.,St Stephen's Clinical Research, Chelsea and Westminster Hospital, London, United Kingdom
| |
Collapse
|
29
|
Abstract
OBJECTIVE To review the pharmacokinetics, safety, common drug-drug interactions (DDIs), and advantages and disadvantages of new single-tablet regimens (STRs) approved since September 2016 for HIV-1 infection. DATA SOURCES A search using PubMed was conducted (2004 through May 2018) using the following keywords: single tablet regimen AND HIV. Additionally, a PubMed search was conducted for each individual STR using the generic names of the agents. For specific STRs, additional search terms were added to narrow results. Articles were evaluated for content, and additional references were identified from a review of literature citations. Conference abstracts from national and international HIV conferences were also searched. STUDY SELECTION AND DATA EXTRACTION Studies included were published randomized controlled trials and observational studies that evaluated STR approved since September 2016. Relevant conference abstracts were included if the study design was a randomized controlled trial or observational study pertaining to the STRs included. DATA SYNTHESIS Four new STRs are available, including the first dual antiretroviral therapy (ART) regimen for virologically suppressed patients. Of the STRs, only 1 is a new molecular entity, and others include new combinations of existing agents that result in distinct advantages and disadvantages. Relevance to Patient Care and Clinical Practice: The treatment of HIV-1 continues to improve with new agents developed rapidly. These agents should be analyzed in regard to efficacy, safety, DDIs, and appropriateness for specific patients on an individual basis. CONCLUSIONS STRs and agents in the pipeline continue to simplify ART regimens, increase medication adherence, and minimize toxicities.
Collapse
Affiliation(s)
| | - Denise Kelley
- 2 University of Florida, Health Jacksonville, Jacksonville, FL, USA
| |
Collapse
|
30
|
Olagunju A, Schipani A, Bolaji O, Khoo S, Owen A. Evaluation of universal versus genotype-guided efavirenz dose reduction in pregnant women using population pharmacokinetic modelling. J Antimicrob Chemother 2018; 73:165-172. [PMID: 29029267 DOI: 10.1093/jac/dkx334] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 08/17/2017] [Indexed: 01/11/2023] Open
Abstract
Objectives Lack of data on the pharmacokinetics of efavirenz in pregnant women at the 400 mg reduced dose currently prevents universal roll-out. Population pharmacokinetic modelling was used to explore pharmacokinetic endpoints at 200, 400 and 600 mg daily doses in pregnant women stratified by CYP2B6 metabolic status. Methods The analysis was based on 252 plasma efavirenz concentrations from 77 pregnant women (77 sparse, 175 intensive) who received antiretroviral regimens containing 600 mg of efavirenz. The model was developed using NONMEM®. The effect of genetics was investigated and concentration-time courses at steady-state were simulated for individuals (n = 1000 each) classified as CYP2B6 slow, intermediate and fast metabolizers at 200, 400 and 600 mg daily doses. Results At a 400 mg reduced dose, predicted mean (90% CI) mid-dose efavirenz concentration (C12) was 2.24 μg/mL (0.89-4.18) in pregnant women classified as slow metabolizers, compared with 0.87 μg/mL (0.34-1.64) in intermediate metabolizers and 0.78 μg/mL (0.30-1.47) in fast metabolizers. C12 was below the 0.47 μg/mL threshold determined within the ENCORE 1 trial in 10% at 400 mg, 4.6% at 600 mg and 3.4% with genotype-guided dosing. The 4.0 μg/mL toxicity threshold was exceeded in 4.6% at 400 mg, 13.5% at 600 mg and 5.2% with genotype-guided dosing. Conclusions These data provide context for the ongoing debate about reduction in efavirenz dose to 400 mg during pregnancy and should be interpreted alongside the lower toxicity expected with the lower dose. Additional research is required to investigate genotype-guided dose reduction in pregnant women.
Collapse
Affiliation(s)
- Adeniyi Olagunju
- Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria.,Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool L693GF, UK
| | - Alessandro Schipani
- Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool L693GF, UK
| | - Oluseye Bolaji
- Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Saye Khoo
- Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool L693GF, UK
| | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool L693GF, UK
| |
Collapse
|
31
|
Dubrocq G, Rakhmanina N. The pharmacokinetics, pharmacodynamics, and clinical role of fixed dose combination of tenofovir disoproxil fumarate, lamivudine and reduced dose efavirenz (TLE-400) in treating HIV-1 infection. Expert Opin Drug Metab Toxicol 2018; 14:773-779. [PMID: 29985071 DOI: 10.1080/17425255.2018.1498840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Co-formulated fixed dose combination (FDC) of antiretroviral drugs tenofovir disoproxil fumarate, lamivudine, and reduced dose efavirenz [TDF 300 mg/3TC 300mg/EFV400 mg (TLE-400)] is a single daily tablet recently approved for the treatment of HIV-1 infection. Areas covered: An overview of the pharmacokinetics, pharmacodynamics and role of TLE-400 in the treatment of HIV-1 infection based on the publications from Medline and Pubmed as of February, 2018. Expert opinion: Although TLE-400 has not been formally evaluated in a clinical trial as a new formulation, previous studies have evaluated its components individually and in different doses as other FDCs have shown favorable efficacy and safety results to support continuing its approval and indication in the management of HIV-1 infection. Due to the lower dose of EFV, TLE-400 has a lower rate of toxicity and higher tolerability compared to its predecessor, the TLE-600, which contained a higher 600 mg dose of EFV. Given its low cost and ease of administration, TLE-400 is a promising alternative first line FDC in the management of HIV-1.
Collapse
Affiliation(s)
- Gueorgui Dubrocq
- a Division of Pediatric Infectious Diseases , Baylor Scott White McLane Children's Hospital , Temple , TX , USA.,b Department of Pediatrics , Baylor Scott and White, McLane Children's Hospital , Temple , TX , USA
| | - Natella Rakhmanina
- c Division of Pediatric Infectious Diseases , Children's National Health System , Washington , DC , USA.,d Department of Pediatrics , The George Washington University School of Medicine and Health Sciences , Washington , DC , USA.,e Elizabeth Glaser Pediatric AIDS Foundation , Washington , DC , USA
| |
Collapse
|
32
|
Huang SH, Lin SW, Chang SY, Lin YT, Sun HY, Liu WC, Su YC, Hung CC, Chang SC. Effectiveness of half-a-tablet efavirenz plus 2 nucleos(t)ide reverse-transcriptase inhibitors as maintenance therapy with the guidance of therapeutic drug monitoring among virologically suppressed HIV-positive patients: A prospective study. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2018; 53:60-68. [PMID: 29884449 DOI: 10.1016/j.jmii.2018.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 04/29/2018] [Accepted: 05/07/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Optimal efavirenz (EFV) dose that minimizes adverse effects while maintaining efficacy has yet to be elucidated. With a therapeutic drug monitoring (TDM)-guided strategy, we assessed the effectiveness of half-a-tablet EFV plus 2 nucleos(t)ide reverse-transcriptase inhibitors (NRTIs) in HIV-infected Taiwanese who had achieved viral suppression with full-dose (600 mg) EFV. METHODS HIV-infected adults receiving EFV-containing regimens who had plasma mid-dose EFV concentration (C12) ≥2.0 mg/L and had plasma HIV RNA load (PVL) <200 copies/mL were enrolled in this single-arm, open-label study by reducing EFV to half-a-tablet daily. The primary endpoint was PVL <50 copies/ml in an intention-to-treat (ITT) population at week 48. The secondary endpoints were the plasma EFV C12, the proportion of patients with plasma EFV C12 <1.0 mg/L, PVL <50 copies/ml at week 96 and week 144. RESULTS Between April 2013 and September 2016, 203 patients (93.6% male; median age, 39.0 years) were enrolled. The median EFV C12 before switch was 2.80 mg/L (interquartile range (IQR), 2.41-3.73), which decreased to 1.59 mg/L (IQR, 1.23-2.03) after switch with a reduction of 47.4% (IQR, 38.3-55.5%). In ITT analysis, 93.6%, 92.3% and 87.3% of the patients achieved PVL <50 copies/ml at weeks 48, 96 and 144, respectively. More than 70% of the patients reported alleviation of EFV-associated adverse effects following the switch. CONCLUSION Under the guidance of TDM, switch to half-a-tablet EFV plus 2 NRTIs is effective in maintaining viral suppression in HIV-infected Taiwanese with EFV C12 ≥ 2.0 mg/L.
Collapse
Affiliation(s)
- Sung-Hsi Huang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Shu-Wen Lin
- Department of Pharmacy, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Graduate Institute of Clinical Pharmacy, National Taiwan University College of Medicine, Taipei, Taiwan; School of Pharmacy, National Taiwan University, Taipei, Taiwan
| | - Sui-Yuan Chang
- Department of Laboratory Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Clinical Laboratory Sciences and Medical Biotechnology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ya-Ting Lin
- School of Pharmacy, National Taiwan University, Taipei, Taiwan
| | - Hsin-Yun Sun
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wen-Chun Liu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yi-Ching Su
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chien-Ching Hung
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan; China Medical University, Taichung, Taiwan.
| | - Shan-Chwen Chang
- Graduate Institute of Clinical Pharmacy, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| |
Collapse
|
33
|
Stillemans G, Belkhir L, Hesselink DA, Haufroid V, Elens L. Pharmacogenetic associations with cytochrome P450 in antiretroviral therapy: what does the future hold? Expert Opin Drug Metab Toxicol 2018; 14:601-611. [PMID: 29775551 DOI: 10.1080/17425255.2018.1478964] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Several antiretroviral drugs used to treat infection with the human immunodeficiency virus (HIV) are substrates of enzymes belonging to the cytochrome P450 (CYP) superfamily, which are polymorphically expressed. It may therefore be useful to take into account the genetic variation in these enzymes to predict the likelihood of anti-HIV treatment success, toxicity and the potential for drug-drug interactions. Areas covered: In this manuscript, the authors discuss the current state of knowledge regarding pharmacogenetic associations between CYP and all major antiretrovirals, as well as the importance of these associations. Expert opinion: While many pharmacogenetic associations for CYP have been described in the literature, replication studies are sometimes lacking. The implementation of this knowledge in clinical practice also remains difficult. Further efforts are required both to expand this field of knowledge and to enable its use in everyday clinical practice.
Collapse
Affiliation(s)
- Gabriel Stillemans
- a Integrated Pharmacometrics, Pharmacogenomics and Pharmacokinetics , Louvain Drug Research Institute, Université catholique de Louvain , Brussels , Belgium.,b Louvain centre for Toxicology and Applied Pharmacology, Institut de recherche expérimentale et clinique , Université catholique de Louvain , Brussels , Belgium
| | - Leila Belkhir
- b Louvain centre for Toxicology and Applied Pharmacology, Institut de recherche expérimentale et clinique , Université catholique de Louvain , Brussels , Belgium.,c AIDS Reference Center, Department of Internal Medicine , Cliniques universitaires Saint-Luc, Université catholique de Louvain , Brussels , Belgium
| | - Dennis A Hesselink
- d Department of Internal Medicine, Division of Nephrology and Transplantation and Rotterdam Transplant Group. Erasmus MC , University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Vincent Haufroid
- b Louvain centre for Toxicology and Applied Pharmacology, Institut de recherche expérimentale et clinique , Université catholique de Louvain , Brussels , Belgium.,e Department of Clinical Chemistry , Cliniques universitaires Saint-Luc , Brussels , Belgium
| | - Laure Elens
- a Integrated Pharmacometrics, Pharmacogenomics and Pharmacokinetics , Louvain Drug Research Institute, Université catholique de Louvain , Brussels , Belgium.,b Louvain centre for Toxicology and Applied Pharmacology, Institut de recherche expérimentale et clinique , Université catholique de Louvain , Brussels , Belgium
| |
Collapse
|
34
|
Guo F, Cheng X, Hsieh E, Du X, Fu Q, Peng W, Li Y, Song X, Routy JP, Li T. Prospective plasma efavirenz concentration assessment in Chinese HIV-infected adults enrolled in a large multicentre study. HIV Med 2018; 19:10.1111/hiv.12607. [PMID: 29761920 PMCID: PMC6538474 DOI: 10.1111/hiv.12607] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Few studies have explored the optimal dosing for efavirenz in individuals from China. We investigated plasma efavirenz concentrations and their association with efficacy and tolerance of efavirenz 600 mg daily in Chinese HIV-infected adults. METHODS An analysis was performed using plasma samples from 455 patients enrolled in a prospective multicentre trial in China. A total of 1198 plasma samples collected at weeks 4, 24 and 48 following antiretroviral therapy initiation were analysed. The mid-dose interval efavirenz concentrations (C12 ) were determined using high-performance liquid chromatography. RESULTS The median efavirenz concentration (interquartile range) steadily increased over time from 3.02 (2.28-4.23) to 3.71 (2.91-4.91) mg/L from week 4 to 48 (P < 0.001). The proportion of patients with C12 > 4.0 mg/L also rose from 28.0% to 34.2% and 43.8%, measured at 4, 24 and 48 weeks, respectively (P < 0.001). Five patients had efavirenz concentrations < 1.0 mg/L at week 4, 24 or 48. In the multivariable regression analysis, lower body weight and non-Han ethnicities were associated with higher efavirenz concentrations over time. At each time-point, patients with a body weight < 60 kg had significantly higher efavirenz C12 compared with those with body weight ≥ 60 kg (P < 0.05). CONCLUSIONS Efavirenz concentrations increased steadily over 48 weeks, and a substantial proportion of participants had efavirenz C12 above the upper limit of the proposed therapeutic window, especially those with low body weight (< 60 kg). Based upon these findings, a dosage reduction of efavirenz to 400 mg daily may warrant consideration in this population, especially for those with lower body weight.
Collapse
Affiliation(s)
- F Guo
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - X Cheng
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - E Hsieh
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - X Du
- Department of Pharmacy and Pharmacology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Q Fu
- Department of Pharmacy and Pharmacology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - W Peng
- Department of Pharmacy and Pharmacology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Y Li
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - X Song
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - J-P Routy
- Division of Hematology and Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
| | - T Li
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Center for AIDS Research, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
35
|
Compatibility of next-generation first-line antiretrovirals with rifampicin-based antituberculosis therapy in resource limited settings. Curr Opin HIV AIDS 2018; 12:355-358. [PMID: 28403028 DOI: 10.1097/coh.0000000000000376] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Reduced dose efavirenz, dolutegravir, and/or tenofovir alafenamide (TAF) are likely to be used in the next generation of first-line antiretroviral therapy in resource limited settings, where HIV-associated tuberculosis is common. Rifampicin, which is a key component of first-line antituberculosis therapy, is a potent inducer of many drug transporters and metabolising enzymes. We reviewed the literature for potential or actual drug--drug interactions between these antiretrovirals and rifampicin. RECENT FINDINGS Dose adjustments of standard dose efavirenz are not necessary with rifampicin, because auto-induction of CYP2B6 by efavirenz counteracts the induction of rifampicin. However, patients with extensive metabolizer CYP2B6 genotypes have lower efavirenz concentrations and may have less auto-induction of CYP2B6; the additive inducing effects of rifampicin on CYP2B6 could result in clinically significant reductions of efavirenz concentrations. Doubling the dose of dolutegravir overcomes induction by rifampicin. TAF is more prone to be the victim in drug--drug interactions than tenofovir disoproxil fumarate. Interactions between TAF and rifampicin have not been studied, but there is likely to be significant interaction. SUMMARY Further research on drug--drug interactions between rifampicin and the next generation of first-line antiretrovirals will be needed before they can be recommended in patients with HIV-associated tuberculosis.
Collapse
|
36
|
Tanner JA, Tyndale RF. Variation in CYP2A6 Activity and Personalized Medicine. J Pers Med 2017; 7:jpm7040018. [PMID: 29194389 PMCID: PMC5748630 DOI: 10.3390/jpm7040018] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 11/17/2017] [Accepted: 11/27/2017] [Indexed: 12/16/2022] Open
Abstract
The cytochrome P450 2A6 (CYP2A6) enzyme metabolizes several clinically relevant substrates, including nicotine-the primary psychoactive component in cigarette smoke. The gene that encodes the CYP2A6 enzyme is highly polymorphic, resulting in extensive interindividual variation in CYP2A6 enzyme activity and the rate of metabolism of nicotine and other CYP2A6 substrates including cotinine, tegafur, letrozole, efavirenz, valproic acid, pilocarpine, artemisinin, artesunate, SM-12502, caffeine, and tyrosol. CYP2A6 expression and activity are also impacted by non-genetic factors, including induction or inhibition by pharmacological, endogenous, and dietary substances, as well as age-related changes, or interactions with other hepatic enzymes, co-enzymes, and co-factors. As variation in CYP2A6 activity is associated with smoking behavior, smoking cessation, tobacco-related lung cancer risk, and with altered metabolism and resulting clinical responses for several therapeutics, CYP2A6 expression and enzyme activity is an important clinical consideration. This review will discuss sources of variation in CYP2A6 enzyme activity, with a focus on the impact of CYP2A6 genetic variation on metabolism of the CYP2A6 substrates.
Collapse
Affiliation(s)
- Julie-Anne Tanner
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto, ON M5T 1R8, Canada.
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON M5S 1A8, Canada.
| | - Rachel F Tyndale
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto, ON M5T 1R8, Canada.
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON M5S 1A8, Canada.
- Department of Psychiatry, University of Toronto, Toronto, ON M5T 1R8, Canada.
| |
Collapse
|
37
|
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.
Collapse
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
| |
Collapse
|
38
|
Huang SH, Lin SW, Chang SY, Lin YT, Chiang C, Hsiao CF, Sun HY, Liu WC, Su YC, Hung CC, Chang SC. Prediction of plasma efavirenz concentrations among HIV-positive patients taking efavirenz-containing combination antiretroviral therapy. Sci Rep 2017; 7:16187. [PMID: 29170492 PMCID: PMC5701031 DOI: 10.1038/s41598-017-16483-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 11/13/2017] [Indexed: 12/27/2022] Open
Abstract
We investigated the predictors of plasma mid-dose concentrations (C12) of efavirenz by enrolling 456 HIV-positive patients who had received 2 nucleos(t)ide reverse-transcriptase inhibitors plus efavirenz (600 mg daily) for 2 weeks or longer and had their CYP2B6 516G>T polymorphism and efavirenz C12 determined. The median efavirenz C12 was 2.41 mg/L (IQR, 1.93–3.14). In analysis of covariance models, patients with CYP2B6 516GT and TT genotypes compared to those with GG genotype had higher efavirenz C12 (for GT genotype, an increase by 0.976 mg/L [95%CI, 0.765–1.188], and TT genotype, 4.871 mg/L [95%CI, 4.126–5.616]), while per 10-kg increment in weight decreased C12 by 0.199 mg/L (95%CI, 0.111–0.287). Models incorporating CYP2B6 516G>T polymorphism and weight had moderate predictive values in predicting efavirenz C12 ≥ 2 mg/L (ROC area under curve = 0.706 [95%CI, 0.656–0.756]). In the absence of CYP2B6 516G>T polymorphism, weight ≤58 kg provided better predictabilities for efavirenz C12 ≥ 2 mg/L (probability, 77.1% [95%CI, 69.0–83.5%] for weight = 50 kg and 70.6% [95%CI, 64.1–76.4%] for weight = 58 kg).
Collapse
Affiliation(s)
- Sung-Hsi Huang
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Shu-Wen Lin
- Department of Pharmacy, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.,Graduate Institute of Clinical Pharmacy, National Taiwan University College of Medicine, Taipei, Taiwan.,School of Pharmacy, National Taiwan University, Taipei, Taiwan
| | - Sui-Yuan Chang
- Department of Laboratory Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Clinical Laboratory Sciences and Medical Biotechnology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ya-Ting Lin
- Graduate Institute of Clinical Pharmacy, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chieh Chiang
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
| | - Chin-Fu Hsiao
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
| | - Hsin-Yun Sun
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wen-Chun Liu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yi-Ching Su
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chien-Ching Hung
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan. .,Department of Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan. .,Department of Medical Research, China Medical University Hospital, Taichung, Taiwan. .,China Medical University, Taichung, Taiwan.
| | - Shan-Chwen Chang
- Graduate Institute of Clinical Pharmacy, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| |
Collapse
|
39
|
Calcagno A, Cusato J, D'Avolio A, Bonora S. Genetic Polymorphisms Affecting the Pharmacokinetics of Antiretroviral Drugs. Clin Pharmacokinet 2017; 56:355-369. [PMID: 27641153 DOI: 10.1007/s40262-016-0456-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Antiretroviral treatment is highly effective in enhancing HIV-positive patients' survival and quality of life. Despite an increased tolerability in recent years, a substantial amount of patients experience side effects. Antiretrovirals' efficacy and tolerability have been associated with plasma concentrations and single nucleotide polymorphisms in selected genes involved in drug disposition. OBJECTIVE Our aim was to review the current knowledge in genetic polymorphisms affecting plasma, intracellular or compartmental concentrations of antiretrovirals. METHODS A search of the PubMed database was conducted to identify relevant articles, using the following terms: 'pharmacogenetics' or 'pharmacogenomics' or 'single nucleotide polymorphisms' or 'genetic/allelic variants' and 'pharmacokinetics' or 'concentrations' and 'HIV' or 'antiretroviral'. Abstracts from the main HIV conferences during 2015 and 2016 were also searched using the same keywords. Abstracts were manually checked and, if relevant, full papers were obtained. Only articles published in English were selected. RESULTS Several genetic polymorphisms in genes coding enzymes involved in drug metabolism (cytochrome P450 isoenzymes and uridine diphosphate glucuronosyltransferases) and transport (P-glycoprotein, anionic and cationic transporters, other transporters), as well as nuclear receptors (pregnane X receptor and the constitutive androstane receptor), have been associated with concentrations of antiretrovirals. The extent of such influence, the conflicting data, and the potential clinical relevance are discussed in the main section of this article. CONCLUSION Genetic polymorphisms may affect antiretroviral disposition, as well as both efficacy and toxicity. Despite a large amount of data, such precious knowledge has seldom been applied in patients. Studies on the clinical relevance and cost effectiveness of tailoring antiretroviral regimens to patients' genetic assets are lacking, but their importance may grow with the increasing age and complexity of persons living with HIV/AIDS.
Collapse
Affiliation(s)
- Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, c/o Ospedale Amedeo di Savoia, C.so Svizzera 164, 10159, Torino, Italy.
| | - Jessica Cusato
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, c/o Ospedale Amedeo di Savoia, C.so Svizzera 164, 10159, Torino, Italy
| | - Antonio D'Avolio
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, c/o Ospedale Amedeo di Savoia, C.so Svizzera 164, 10159, Torino, Italy
| | - Stefano Bonora
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, c/o Ospedale Amedeo di Savoia, C.so Svizzera 164, 10159, Torino, Italy
| |
Collapse
|
40
|
Abstract
The development of antiretroviral therapy (ART) has dramatically increased the lifespan of HIV patients but treatment is complicated by numerous adverse effects and toxicities. ART complications include neuropsychiatric, metabolic, gastrointestinal, cardiac, and numerous other toxicities, and clinicians often have to choose one toxicity over another to offer the best medication regimen for a patient. Some antiviral drugs cause significant neuropsychiatric complications, including depression, cognitive impairment, and sleep disturbance. Even in careful studies, it may be difficult to determine which effects are related to the virus, the immune system, or the treatment. Of the six currently marketed classes of antiviral drugs, the nucleoside reverse transcriptase inhibitors and the non-nucleoside reverse transcriptase inhibitors have been most commonly associated with neuropsychiatric complications. Within these classes, certain drugs are more likely to cause difficulty than others. We review the contention regarding the central nervous system (CNS) complications of efavirenz, as well as debate about the role of CNS penetration in drug effectiveness and toxicity. A thorough working knowledge of the neuropsychiatric consequences of ART allows clinicians to tailor treatment more successfully to individual patients as well as to identify ART more quickly as the source of a problem or symptom.
Collapse
|
41
|
Brief Report: CYP2B6 516G>T Minor Allele Protective of Late Virologic Failure in Efavirenz-Treated HIV-Infected Patients in Botswana. J Acquir Immune Defic Syndr 2017; 75:488-491. [PMID: 28481785 DOI: 10.1097/qai.0000000000001442] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND CYP2B6 polymorphisms that affect efavirenz (EFV) concentrations are common, but the effect of this polymorphism on HIV virologic failure in clinical practice settings has not fully been elucidated. Our objective was to investigate the relationship between the CYP2B6 516G>T genotype and late virologic failure in patients treated with EFV in Gaborone, Botswana. SETTING We performed a case-control study that included 1338 HIV-infected black Batswana on EFV-based antiretroviral therapy (ART). Patients were approached for enrollment during regular visits at one of the outpatient HIV clinics between July 2013 and April 2014. METHODS Cases experienced late HIV failure, defined as plasma HIV RNA >1000 copies/mL after maintaining viral suppression (<400 copies/mL) for at least 6 months. For each case, a total of 4 control patients were randomly sampled from the same population. Controls had plasma HIV RNA <400 copies/mL on ART for at least 6 months. Logistic regression was used to determine the adjusted odds of late HIV failure by 516G>T genotype. RESULTS After adjustment for the confounding variables age and CD4 count, the CYP2B6 516 T-allele was protective against late HIV virologic breakthrough, adjusted OR 0.70; 95% CI: 0.50 to 0.97. CONCLUSION The CYP2B6 516 T-allele was protective against late virologic breakthrough in patients with initial (6 month) HIV RNA suppression on EFV-based ART. Future studies are needed to assess long-term viral benefits of identifying and offering EFV containing ART to black African HIV-infected patients with CYP2B6 T-alleles, especially given the wider availability of a single pill EFV in this setting.
Collapse
|
42
|
Plasma Efavirenz Exposure, Sex, and Age Predict Virological Response in HIV-Infected African Children. J Acquir Immune Defic Syndr 2017; 73:161-8. [PMID: 27116047 PMCID: PMC5172513 DOI: 10.1097/qai.0000000000001032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Owing to insufficient evidence in children, target plasma concentrations of efavirenz are based on studies in adults. Our analysis aimed to evaluate the pediatric therapeutic thresholds and characterize the determinants of virological suppression in African children. METHODS We analyzed data from 128 African children (aged 1.7-13.5 years) treated with efavirenz, lamivudine, and one among abacavir, stavudine, or zidovudine, and followed up to 36 months. Individual pharmacokinetic (PK) measures [plasma concentration 12 hours after dose (C12h), plasma concentration 24 hours after dose (C24h), and area under the curve (AUC0-24)] were estimated using population PK modeling. Cox multiple failure regression and multivariable fractional polynomials were used to investigate the risks of unsuppressed viral load associated with efavirenz exposure and other factors among 106 initially treatment-naive children, and likelihood profiling was used to identify the most predictive PK thresholds. RESULTS The risk of viral load >100 copies per milliliter decreased by 42% for every 2-fold increase in efavirenz mid-dose concentration [95% confidence interval (CI): 23% to 57%; P < 0.001]. The most predictive PK thresholds for increased risk of unsuppressed viral load were C12h 1.12 mg/L [hazard ratio (HR): 6.14; 95% CI: 2.64 to 14.27], C24h 0.65 mg/L (HR: 6.57; 95% CI: 2.86 to 15.10), and AUC0-24 28 mg·h/L (HR: 5.77; 95% CI: 2.28 to 14.58). Children older than 8 years had a more than 10-fold increased risk of virological nonsuppression (P = 0.005); among children younger than 8 years, boys had a 5.31 times higher risk than girls (P = 0.007). Central nervous system adverse events were infrequently reported. CONCLUSIONS Our analysis suggests that the minimum target C24h and AUC0-24 could be lowered in children. Our findings should be confirmed in a prospective pediatric trial.
Collapse
|