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Todd CS, Lorenzetti L, Mussa A, Ridgeway K, Morroni C, Nanda K. Drug-Drug Interactions between Antiretrovirals and Hormonal Contraception: An Updated Systematic Review. Contraception 2024:110490. [PMID: 38762199 DOI: 10.1016/j.contraception.2024.110490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/13/2024] [Accepted: 05/13/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVE To summarize and update information regarding drug-drug interactions (DDIs) between antiretrovirals (ARVs) and hormonal contraceptives (HCs). DESIGN Systematic review METHODS: We searched seven databases for peer-reviewed publications from January 1, 2015, through December 31, 2023, including studies of women using ARVs and HCs concurrently with outcomes including therapeutic effectiveness or toxicity, pharmacokinetics (PK), or pharmacodynamics. We summarized findings and used checklists to assess evidence quality. RESULTS We included 49 articles, with clinical, ARV or HC PK outcomes reported by 39, 25, and 30 articles, respectively, with some articles reporting outcomes in two or more categories. Fifteen of 18 articles assessing DDIs between efavirenz and progestin implants, emergency contraception, or combined hormonal intravaginal rings found higher pregnancy rates, luteal progesterone levels suggesting ovulation, or reduced progestin PK values. Five studies documented that CYP2B6 single nucleotide polymorphisms exacerbated this DDI. One cohort detected doubled bone density loss with concomitant depot medroxyprogesterone acetate (DMPA) and tenofovir disoproxil fumarate (TDF)-containing ART use versus TDF alone. No other studies described DDIs impacting clinical outcomes. Few adverse events were attributed to ARV-HC use with none exceeding Grade 2. Evidence quality was generally moderate, with dis-similar treatment and control groups, identifying and controlling for confounding, and minimizing attrition bias in the study design being the most frequent limitations. CONCLUSION Most ARVs and HCs may be used safely and effectively together. TDF-DMPA DDIs warrant longer-term study on bone health and consideration of alternate combinations. For efavirenz-based ART, client counselling on relative risks, including both potential increase in pregnancy rate with concomitant efavirenz and implant use and lower pregnancy rates compared to other HCs even with concomitant efavirenz use, should continue to allow users comprehensive method choice.
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Affiliation(s)
- Catherine S Todd
- Global Health, Population, & Nutrition, FHI 360, Durham, North Carolina, United States.
| | - Lara Lorenzetti
- Global Health, Population, & Nutrition, FHI 360, Durham, North Carolina, United States
| | - Aamirah Mussa
- Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana; Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Kathleen Ridgeway
- Global Health, Population, & Nutrition, FHI 360, Durham, North Carolina, United States
| | - Chelsea Morroni
- Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana; MRC Centre for Reproductive Health and Centre for Global Health, The Queens Medical Research Institute, Edinburgh, United Kingdom
| | - Kavita Nanda
- Global Health, Population, & Nutrition, FHI 360, Durham, North Carolina, United States
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Lewis GJ, Ahire D, Taskar KS. Physiologically-based pharmacokinetic modeling of prominent oral contraceptive agents and applications in drug-drug interactions. CPT Pharmacometrics Syst Pharmacol 2024; 13:563-575. [PMID: 38130003 PMCID: PMC11015076 DOI: 10.1002/psp4.13101] [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: 08/04/2023] [Revised: 11/24/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023] Open
Abstract
Considerable interest remains across the pharmaceutical industry and regulatory landscape in capabilities to model oral contraceptives (OCs), whether combined (COCs) with ethinyl estradiol (EE) or progestin-only pill. Acceptance of COC drug-drug interaction (DDI) assessment using physiologically-based pharmacokinetic (PBPK) is often limited to the estrogen component (EE), requiring further verification, with extrapolation from EE to progestins discouraged. There is a paucity of published progestin component PBPK models to support the regulatory DDI guidance for industry to evaluate a new chemical entity's (NCE's) DDI potential with COCs. Guidance recommends a clinical interaction study to be considered if an investigational drug is a weak or moderate inducer, or a moderate/strong inhibitor, of CYP3A4. Therefore, availability of validated OC PBPK models within one software platform, will be useful in predicting the DDI potential with NCEs earlier in the clinical development. Thus, this work was focused on developing and validating PBPK models for progestins, DNG, DRSP, LNG, and NET, within Simcyp, and assessing the DDI potential with known CYP3A4 inhibitors (e.g., ketoconazole) and inducers (e.g., rifampicin) with published clinical data. In addition, this work demonstrated confidence in the Simcyp EE model for regulatory and clinical applications by extensive verification in 70+ clinical PK and CYP3A4 interaction studies. The results provide greater capability to prospectively model clinical CYP3A4 DDI with COCs using Simcyp PBPK to interrogate the regulatory decision-tree to contextualize the potential interaction by known perpetrators and NCEs, enabling model-informed decision making, clinical study designs, and delivering potential alternative COC options for women of childbearing potential.
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Affiliation(s)
- Gareth J. Lewis
- Drug Metabolism and Pharmacokinetics, In Vitro In Vivo Translation, Research, GlaxoSmithKlineStevenageUK
| | - Deepak Ahire
- Department of Pharmaceutical SciencesWashington State UniversitySpokaneWashingtonUSA
| | - Kunal S. Taskar
- Drug Metabolism and Pharmacokinetics, In Vitro In Vivo Translation, Research, GlaxoSmithKlineStevenageUK
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Yang L, Allen RH, Catherine Cambou M, Nielsen-Saines K, Brown BP. Contraception and Abortion Care for People Living With HIV: A Clinical Guide for Reproductive Health Practitioners. J Midwifery Womens Health 2023; 68:719-727. [PMID: 37903728 PMCID: PMC10872909 DOI: 10.1111/jmwh.13575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/13/2023] [Indexed: 11/01/2023]
Abstract
People capable of pregnancy are disproportionately affected by HIV. Family planning needs and services are often unmet in this population, and clinical care guidelines regarding contraceptive options and abortion care are not well elucidated. Individuals living with HIV often face unique barriers in accessing contraception and abortion services due to internalized stigma, medically complex care (eg, drug-drug interactions, adverse effects of antiretroviral therapy), and distrust of health care providers. There is also a lack of clarity among reproductive health, primary, and infectious disease care providers on best-practice contraceptive counseling and contraceptive care for individuals living with HIV, given limited opportunities to enhance expertise in reproductive infectious disease. In this review, we summarize existing and updated evidence and clinical considerations regarding contraceptive counseling and abortion care in this population.
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Affiliation(s)
- Lanbo Yang
- Department of Obstetrics and Gynecology, Tulane University School of Medicine, New Orleans, Louisiana
| | - Rebecca H. Allen
- Department of Obstetrics and Gynecology, Women and Infants Hospital/Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Mary Catherine Cambou
- Division of Infectious Diseases, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Karin Nielsen-Saines
- Division of Pediatric Infectious Diseases, Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Benjamin P. Brown
- Department of Obstetrics and Gynecology, Women and Infants Hospital/Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Oddie PD, Heskin J, Leung S, Naous N, Garvey L, Cohen CE. Drug-induced liver injury secondary to increased levonorgestrel exposure in a patient taking ritonavir. Int J STD AIDS 2023; 34:903-905. [PMID: 37449366 DOI: 10.1177/09564624231185889] [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] [Indexed: 07/18/2023]
Abstract
We report the first published case of a drug induced liver injury (DILI) presumed secondary to a drug-drug interaction between ritonavir and levonorgestrel progestogen-only emergency contraception (POEC). Our patient is a 25-year-old female living with human immunodeficiency virus (HIV), taking antiretroviral therapy (ART) containing tenofovir alafenamide/emtricitabine and darunavir/ritonavir. She was found to have elevated transaminases at a routine clinic appointment consistent with hepatocellular DILI. Further investigation found the most likely cause of this was a drug-drug interaction (DDI) between the ritonavir component of her ART and recent use of levonorgestrel POEC 3 days earlier. Evidence suggests that ritonavir increases levonorgestrel exposure, yet our patient received double the usual dose as per dispensing guidance at the time. We review the pharmacokinetics of ritonavir-levonorgestrel DDIs and highlight the need for consistent guidelines on this topic.
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Affiliation(s)
- Philip D Oddie
- GUM/HIV Directorate, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Joseph Heskin
- GUM/HIV Directorate, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Suki Leung
- GUM/HIV Directorate, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Nadia Naous
- GUM/HIV Directorate, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Lucy Garvey
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Charlotte E Cohen
- GUM/HIV Directorate, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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Mikus G, I. Foerster K, Terstegen T, Vogt C, Said A, Schulz M, E. Haefeli W. Oral Drugs Against COVID-19. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:263-269. [PMID: 35302484 PMCID: PMC9400198 DOI: 10.3238/arztebl.m2022.0152] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 01/05/2022] [Accepted: 02/16/2022] [Indexed: 05/05/2023]
Abstract
BACKGROUND Five-day oral therapies against early COVID-19 infection have recently been conditionally approved in Europe. In the drug combination nirmatrelvir + ritonavir (nirmatrelvir/r), the active agent, nirmatrelvir, is made bioavailable in clinically adequate amounts by the additional administration of a potent inhibitor of its first-pass metabolism by way of cytochrome P450 [CYP] 3A in the gut and liver. In view of the central role of CYP3A in the clearance of many different kinds of drugs, and the fact that many patients with COVID-19 are taking multiple drugs to treat other conditions, it is important to assess the potential for drug interactions when nirmatrelvir/r is given, and to minimize the risks associated with such interactions. METHODS We defined the interaction profile of ritonavir on the basis of information derived from two databases (Medline, GoogleScholar), three standard electronic texts on drug interactions, and manufacturer-supplied drug information. We compiled a list of drugs and their potentially relevant interactions, developed a risk min - imization algorithm, and applied it to the substances in question. We also compiled a list of commonly prescribed drugs for which there is no risk of interaction with nirmatrelvir/r. RESULTS Out of 190 drugs and drug combinations, 57 do not need any special measures when given in combination with brief, low-dose ritonavir treatment, while 15 require dose modification or a therapeutic alternative, 8 can be temporarily discontinued, 9 contraindicate ritonavir use, and 102 should preferably be combined with a different treatment. CONCLUSION We have proposed measures that are simple to carry out for the main types of drug that can interact with ritonavir. These measures can be implemented under quarantine conditions before starting a 5-day treatment with nirmatrelvir/r.
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Affiliation(s)
- Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kathrin I. Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Theresa Terstegen
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Cathrin Vogt
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - André Said
- Drug Commission of German Pharmacists (AMK), Berlin, Germany
| | - Martin Schulz
- Drug Commission of German Pharmacists (AMK), Berlin, Germany
- Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany: Prof. Dr. rer. nat. Martin Schulz
| | - Walter E. Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
- *Abteilung Klinische Pharmakologie und Pharmakoepidemiologie Universitätsklinikum Heidelberg Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
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Stanczyk FZ, Sriprasert I, Danis R, Pandian R, Matharu H, Bender N, Natavio M. Effect of oral contraceptives on total and bioavailable 25-hydroxyvitamin D. J Steroid Biochem Mol Biol 2021; 211:105879. [PMID: 33757895 DOI: 10.1016/j.jsbmb.2021.105879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 11/30/2022]
Abstract
Studies show an increase in circulating levels of 25-hydroxyvitamin D [25(OH)D] in women using combined oral contraceptives (COCs). 25(OH)D is a quantitatively important metabolite and widely used clinical marker of vitamin D status and is regulated by vitamin D binding protein (VDBP). However, studies have not identified the type of formulations used by the women, and there are no data on the effect of progestins on 25(OH)D levels. Our study objective was to compare the effects of two COC formulations [ethinyl estradiol (EE)/norethindrone acetate (NETA) vs. EE/levonorgestrel (LNG)] as well as LNG alone on total and bioavailable (free plus albumin-bound) 25(OH)D levels in serum samples collected at baseline, mid treatment, and end of treatment. Total 25(OH)D and VDBP were measured by immunoassay, and bioavailable 25(OH)D was calculated. The results show that with the EE/NETA formulation, total and bioavailable 25(OH)D and VDBP levels increased non-significantly by 7.4 %, 14.9 %, and 10 %, respectively, from baseline to end of treatment. In contrast, the corresponding changes with EE/LNG showed an increase of 4.4 % in total 25(OH)D but a significant decrease of 18.2 % in bioavailable 25(OH)D and increase of 19.1 % in VDBP. When LNG was administered alone, no significant changes were observed in total and bioavailable 25(OH)D or VDBP levels during the course of treatment. Our findings show considerably different effects on total and bioavailable 25(OH)D levels, as well as VDBP levels, with different oral contraceptive formulations. LNG may have a suppressive effect on VDBP, similar to its well-known androgenic effect on SHBG. Further studies are needed to determine the effect of hormonal contraceptive formulations on vitamin D status and its potential impact on women's health.
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Affiliation(s)
- Frank Z Stanczyk
- Department of Obstetrics and Gynecology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA; Department of Preventive Medicine, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA.
| | - Intira Sriprasert
- Department of Preventive Medicine, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Rachel Danis
- Department of Obstetrics and Gynecology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | | | - Harpreet Matharu
- Department of Obstetrics and Gynecology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Nicole Bender
- Department of Obstetrics and Gynecology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Melissa Natavio
- Department of Obstetrics and Gynecology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
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Krishna GR, Haddad LB. Interactions between Hormonal Contraception and Anti-Retroviral Therapy: An Updated Review. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2020; 9:98-104. [PMID: 33552676 DOI: 10.1007/s13669-020-00289-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose of review Hormonal contraception provides women living with HIV the ability to control their fertility and avoid pregnancy-related morbidity. Due to shared metabolic pathways, there has been concern over drug-drug interactions between hormonal contraception and anti-retroviral therapy, which may affect the drugs' safety and efficacy. This article aims to provide an updated review of the most recent data around hormonal contraceptives and anti-retroviral therapy. Recent findings Prior data have suggested possible pharmacologic interactions between certain hormonal contraceptives and anti-retroviral therapy. The most significant interactions implicated include those between progestin-based contraceptive implants and efavirenz as well as between combined hormonal contraceptives and protease inhibitors. Most past studies, however, feature small sample sizes with few clinical outcomes reported. Summary Recent data since 2017 have largely affirmed prior studies on this topic, showing possible pharmacokinetic relationships between certain contraceptives and anti-retrovirals. Notably, while the effectiveness of progestin-based contraceptives, specifically the implant, appears reduced with efavirenz use, the overall effectiveness may remain higher than most other contraceptive methods. Larger studies are needed to provide further guidance before contraceptive-prescribing recommendations can be changed.
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Affiliation(s)
- Gopika R Krishna
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, GA, USA
| | - Lisa B Haddad
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, GA, USA
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