Neurobehavioral and pregnancy effects of prenatal zidovudine exposure in Sprague-Dawley rats: preliminary findings

In utero exposure to HIV and/or antiretroviral therapy: a systematic review of preclinical and clinical evidence of cognitive outcomes

INTRODUCION

With the increasing number of children exposed to HIV or antiretroviral therapy in utero, there are concerns that this population may have worse neurodevelopmental outcomes compared to those who are unexposed. The objective of this study was to systematically review the clinical and preclinical literature on the effects of in utero exposure to HIV and/or antiretroviral therapy (ART) on neurodevelopment.

METHODS

We systematically searched OVID Medline, PsycINFO and Embase, as well as the Cochrane Collaborative Database, Google Scholar and bibliographies of pertinent articles. Titles, abstracts, and full texts were assessed independently by two reviewers. Data from included studies were extracted. Results are summarized qualitatively.

RESULTS

The search yielded 3027 unique titles. Of the 255 critically reviewed full-text articles, 25 met inclusion criteria for the systematic review. Five articles studied human subjects and looked at brain structure and function. The remaining 20 articles were preclinical studies that mostly focused on behavioural assessments in animal models. The few clinical studies had mixed results. Some clinical studies found no difference in white matter while others noted higher fractional anisotropy and lower mean diffusivity in the brains of HIV-exposed uninfected children compared to HIV-unexposed uninfected children, correlating with abnormal neurobehavioral scores. Preclinical studies focused primarily on neurobehavioral changes resulting from monotherapy with either zidovudine or lamivudine. Various developmental and behavioural changes were noted in preclinical studies with ART exposure, including decreased grooming, decreased attention, memory deficits and fewer behaviours associated with appropriate social interaction.

CONCLUSIONS

While the existing literature suggests that there may be some neurobehavioral differences associated with HIV and ART exposure, limited data are available to substantially support these claims. More research is needed comparing neurobiological factors between HIV-exposed uninfected and HIV-unexposed uninfected children and using exposures consistent with current clinical care.

Perinatal AZT exposure alters the acoustic and tactile startle response to 8-OH-DPAT and apomorphine in adult rats

The present study was designed to assess the dopaminergic and serotonergic contributions of the acoustic startle response (ASR) and the tactile startle response (TSR) in adult rats that had been perinatally exposed to AZT (azidothymidine, zidovudine; an antiretroviral agent). Each dam was randomly assigned to a treatment group: non-treated, AZT0, 100 or 150 mg/kg. Once daily gastric intubation began prenatally on gestational day (G) 19 and continued to G22 and then the pups were intubated between postnatal day (PND) 2-20. On PND60, animals were tested for responses to both acoustic and tactile stimuli following a challenge of vehicle, 0.25 or 0.5 mg/kg 8-OH-DPAT, a 5-HT(1A) agonist, or 0.75 or 2.0 mg/kg apomorphine (APO, a dopaminergic agonist) IP. Both DPAT and APO increased startle magnitude as expected. Additionally, perinatal AZT exposure enhanced startle responses following both DPAT and APO, an effect not due to perinatal handling or intubation. Similarly, perinatal AZT increased tactile responses following drug challenge in a gender-specific manner. Perinatal AZT also prolonged startle latencies, a change which may indicate that perinatal AZT alters conduction velocity. Therefore, the administration of AZT during the perinatal period results in long-term functional alterations within the startle reflex pathways.

Neurobehavioral effects of prenatal exposure to AZT: a preliminary investigation with the D1 receptor agonist SKF 38393 in mice

Zidovudine (AZT) is the main therapeutic agent against HIV vertical transmission and is routinely administered to seropositive pregnant women and their newborns. Toxicity after chronic administration as well as citogenetic effects following developmental AZT exposure has been reported. Furthermore, recent animal data indicate alterations of several behavioral endpoints during the entire lifespan of mice and rats after developmental AZT exposure. In this study, we investigated specific central nervous system (CNS) effects of AZT administration during pregnancy on the offspring. CD-1 mouse females were administered twice daily from day 10 of pregnancy until delivery with either AZT (160 mg/kg) or saline (0.9% NaCl). On PND, 60 male offsprings received an intraperitoneal injection of the D1 receptor agonist 2,3,4,5-tetra-hydro-7,8-diol-1-phenyl-(1H)-3-benzazepine (SKF 38393) (0, 3, and 10 mg/kg), and spontaneous behavior was assessed in an automated activity chamber for 40 min. At variance from what observed in control mice that displayed excessive grooming when administered the higher dose of the D1 agonist, SKF 38393 failed to increase duration of grooming in AZT-treated mice. These data suggest that the D1 receptorial dopaminergic subsystem might be hyporesponsive in mice prenatally exposed to AZT.

Prolonged perinatal AZT administration and early maternal separation: effects on social and emotional behaviour of periadolescent mice

Zidovudine (AZT) is an effective treatment in preventing perinatal transmission of HIV-1; however, a continuous re-evaluation of the risk-benefit ratio of human exposure to this drug is suggested by both clinical and animal studies. The objective of this study was to assess the medium and long-term effects of pre-postnatal AZT treatment on mouse social and emotional behaviour and the possible interactions between AZT exposure and disruptions in the mother-infant relationship. Pregnant CD-1 mice were administered per os with AZT (160 mg/kg) from pregnancy day 10, throughout delivery, to lactation day 10. In half of the litters, the offspring was separated from the mother for 3 h from postnatal days 2 (PND2) to PND14. On PND35, a 30-min social interaction test was performed and corticosterone levels were measured at the end of the session. On PND80, long-term effects of AZT on emotionality were assess by means of an elevated plus-maze. Results indicate that, on PND35, previous AZT exposure affected social behaviour of the experimental subjects, reducing aggressive interactions in males, while decreasing investigative behaviours in females. At adulthood, AZT inhibited exploratory behaviour in the plus-maze while increasing the frequency of risk-assessment postures in male mice. As for maternal deprivation, this early manipulation exerted a pro-aggressive effect in adolescent male mice, deprived subjects being overall characterised by higher activity levels and a deficit in habituation, an effect also observed in the plus-maze. A significant interaction between AZT and maternal deprivation was found for affiliative behaviours. As for corticosterone levels, no AZT effect was found, while maternal deprivation tended to reduce elevations of this hormone in response to stressful stimuli. Overall results from this study indicate that both AZT exposure and maternal deprivation induced gender-dependent changes in social and emotional behaviour both during adolescence and at adulthood.

The effects of perinatal AZT exposure on the acoustic startle response in adult rats

AZT (azidothymidine, zidovudine, ZDV) has become the standard medication to prevent the transmission of the human immunodeficiency virus from mother to fetus. The present study was designed to assess the acoustic startle response (ASR) in adult rats that had been perinatally exposed to AZT. Each litter was randomly assigned to a treatment group: nontreated, AZT 0, 50, 100 or 150 mg/kg. Once daily gastric intubation began prenatally between gestational day (G) 19 and 22 and then continued postnatally between postnatal day (PND) 2 and 20. Between PND75 and PND80, animals were tested for habituation to the acoustic stimuli and prepulse inhibition following a challenge of either saline or 1.0 mg/kg amphetamine (AMP) intraperitoneally. Amphetamine increased ASR and startle latencies throughout the session. The AZT100 dose increased ASR habituation. AZT treatment did not affect prepulse inhibition. Females treated with AZT150 continued to show high ASRs at the end of the startle session. AZT-treated animals showed a dose-dependent increase in peak latency, suggesting a possible abnormal conduction velocity. These effects are independent of handling and intubation effects. Therefore, perinatal AZT treatment results in long-term changes within the primary acoustic startle pathway.

Long-term effects of developmental exposure to zidovudine on exploratory behavior and novelty discrimination in CD-1 mice

Long-term changes in exploratory, social and agonistic behavior have been reported in rodents following developmental exposure to zidovudine (AZT), an agent commonly administered to pregnant seropositive women and their neonates to prevent HIV-1 transmission. The present study evaluates the effects of either prenatal or prolonged AZT treatment on spatial and nonspatial novelty discrimination in mice, using an open-field test with four objects, in which responses to both spatial rearrangement of familiar objects and object novelty are assessed. AZT (160 mg/kg) or Saline was given orally twice daily to pregnant mice from gestational days (GD) 10 to 19 (Experiment 1) or from GD 10 to lactation day 10 (Experiment 2). Offspring of both sexes were tested on postnatal day (PND) 28, 45 or 70. Depending on treatment schedule, AZT altered different behavioral responses, males being more affected than females. The prenatal treatment (Experiment 1) reduced exploration of the objects at all ages considered and increased wall and top rearing at ages 45 and 70. Following prolonged treatment (Experiment 2), AZT offspring were markedly more active than controls and displayed more wall rearing at age 70 while showing lower grooming frequency at all ages. Both AZT and control mice failed to respond to object rearrangement at adulthood, a discrepancy from previous data, which is discussed in relation to perinatal stress effects.

Fetal pharmacotherapy

Rapid progress has recently been encountered in pharmacologically treating the unborn baby. This unique area of drug therapy raises new methodological and ethical questions. This article is a systematic review of known modalities of fetal pharmacotherapy, and aims to highlight essential principles, difficulties and controversies in fetal pharmacotherapy. Unique pharmacokinetic features of pregnancy, the placenta and the fetus govern maternal-to-fetal drug transfer. Ethically, it is important that the mother and family are appropriately informed about the evidence in favour of specific fetal therapy, its risks and alternatives. Antenatal use of corticosteroids for lung maturation is an example of adequate methodology, leading to clear results. In contrast, the initial hopes in antenatal use of phenobarbital were based on less than optimal methodology. Folic acid for the prevention of neural tube defects is the first instance of fetal therapy that has led to the prevention of a major malformation. Serious infections, such as HIV, Group B streptococcus and toxoplasmosis highlight the need for controlled, randomised studies to prevent fetal infection. With scores of new modalities of fetal therapy likely to be introduced in the next few years, it will be important to adhere to the best possible methodology and execution, in order to address optimally the needs of the fetus.

Animal models of anti-HIV drugs exposure during pregnancy: effects on neurobehavioral development

In the last 10 years, zidovudine (AZT) has become the main prophylactic therapy against vertical HIV-1 transmission. AIDS Clinical Trials Group (ACTG) 076 have demonstrated that the administration of AZT to HIV-infected women during their third trimester of pregnancy, trough labor and given orally to babies for 6 weeks, reduced by two-thirds the rate of vertical infection. Although the rapid diffusion of this regimen into clinical practice together with the implementation of HIV counseling and testing practices have dramatically reduced the vertical transmission rate in the US and Western Europe, there is a growing concern on the adverse effects of antiretroviral therapy on the fetus and the newborn. In fact, even though shorter regimen therapies that are less complex and expensive to implement in poor countries have been demonstrated as effective as ACTG 076 regimen, the distribution of the risk of vertical transmission in the developing countries is still very high. Consequently, a large number of unborns will be a candidate to developmental exposure to antiretroviral agents. To date, data on the transplacental mutagenicity, carcinogenicity and mitochondrial dysfunction induced by developmental exposure to AZT have been reported in several animal models. Furthermore, one study reported severe yet few human cases of cardiomyopathy and neurological disease likely associated with mitochondrial dysfunction in uninfected infants of seropositive mothers perinatally exposed to AZT. For all of these reasons, many investigations have been focusing on the assessment of the potential adverse effects of nucleoside reverse transcriptase (RT) inhibitors (NRTI) administration during development. A survey of the main results derived from clinical and animal studies is reported here, focusing on those neurobehavioral studies that have been looking for specific and/or aspecific changes in the nervous system induced by NRTI exposure in utero.

AZT distribution in the fetal and postnatal rat central nervous system

The distribution of 3'-azido-3'-deoxythymidine (AZT, zidovudine), an antiviral drug used in the treatment of human immunodeficiency virus, was investigated in gestation day-20 (G-20) fetuses and in postnatal day-20 (PND-20) rats. At both ages, a single dose of 150 mg/kg (1.78 mmol/kg) AZT was administered orally along with tracer amounts of 14C-AZT, and rats were randomly killed at 15, 30, 60, 120, or 240 min after dosing. The fetuses, brains, and spinal cords were processed for autoradiography. The peak concentrations of AZT in plasma of G-20 and PND-20 rats were 92.2 microg/mL (0.345 micromol/mL) and 56.6 microg/mL (0.21 micromol/mL) at 15 and 30 min after intubation, respectively. The peak concentration of fetal tissue occurred in the colon at 60 min and was 205.8 microg/g tissue. In the G-20 rats, the brain showed higher levels of AZT than spinal cord only at the 30-min sample time, whereas in the PND-20 rats, greater radioactivity was found in the spinal cord up to the 240-min sample time. This pattern of AZT distribution in the central nervous system may hypothetically be attributed to the postnatal development of an organic anion carrier system believed to be responsible for transporting AZT from the brain to the blood, resulting in relatively greater overall exposure of the spinal cord to AZT than observed in the brain.

Prenatal exposure to anti-HIV drugs: neurobehavioral effects of zidovudine (AZT) + lamivudine (3TC) treatment in mice

BACKGROUND

The new antiretroviral treatments that combine the zidovudine (AZT) regimen with lamivudine (3TC) appear as a cost-effective alternative to the current AZT monotherapy to prevent mother-to-fetus transmission of the HIV-1 virus. Recent evidence in uninfected children raised concern about the long-term effects of perinatal exposure to AZT and 3TC, especially when used in combination. Animal studies indicated behavioral changes in offspring exposed perinatally to both AZT and 3TC, whereas no animal data are available on the effects of the perinatal exposure to the AZT + 3TC combination on neurodevelopment.

METHODS

Pregnant CD-1 mice received p.o. AZT + 3TC (160 and 500 mg/kg, respectively) or vehicle solution (NaCl 0.9%) twice daily from gestational day 10 to delivery. Maternal reproductive endpoints such as pregnancy length, abortion, litter size, sex ratio, and offspring viability were assessed. Pups were scored for different somatic and behavioral endpoints, including sensorimotor development, homing performance on postnatal day (PND) 10, passive-avoidance testing (PND 22-23), locomotor activity (PND 23), and social interaction (PND 35).

RESULTS

While no effects were observed on maternal reproductive endpoints, treated pups showed a long-lasting reduction of body weight and a slightly delayed maturation of placing and grasping reflexes and pole grasping. No effects on passive-avoidance or locomotor activity were found. AZT + 3TC-treated mice showed selective alterations in the social interaction test; the treated female offspring also displayed a significant reduction of affiliative interactions.

CONCLUSIONS

The combination of AZT and 3TC (1) induced small, but more marked, effects on somatic and sensorimotor development than either of these drugs administered separately; and (2) affected juvenile social behavior.

Effects of prenatal AZT+3TC treatment on open field behavior and responsiveness to scopolamine in adult mice

Treatment of pregnant seropositive women and their neonates with the nucleoside analogs (reverse transcriptase inhibitors) zidovudine (AZT), lamivudine (3TC) and their combination has become a standard of care in industrialized countries to prevent transmission of the HIV-1 virus. Animal studies indicated limited but significant behavioral changes in AZT or 3TC-prenatally exposed offspring, whereas data on the potential neurobehavioral outcomes of AZT+3TC combination are still lacking. The aim of the present study was to assess in mice prenatally exposed to AZT+3TC the functional state of cholinergic muscarinic neuroregulation at adulthood. Pregnant CD-1 mice received per orem twice daily AZT+3TC (160 and 500 mg/kg, respectively) or vehicle solution (NaCl 0.9%) from gestational day (GD) 10 to delivery (GD 19). Locomotor activity, exploratory behavior and responsiveness to the muscarinic cholinergic blocker scopolamine (2 mg/kg) were analyzed at adulthood (PND 70) in offspring of both sexes in an open field test. Results indicated that prenatal AZT+3TC exposure does not influence responsiveness to the muscarinic cholinergic antagonist as measured by analysis of the drug's effects on locomotor and exploratory activity and different behavioral items. However, AZT+3TC-treated mice displayed higher frequency of rearing, and lower frequency and duration of self-grooming behavior, consistent with an effect on dopaminergic neurotransmission. However, this would need confirmatory experiments.

Prenatal exposure to anti-HIV drugs. long-term neurobehavioral effects of lamivudine (3TC) in CD-1 mice

The present study was aimed at investigating the long-term effects of prenatal exposure to lamivudine (3TC), an antiretroviral drug used in clinical practice alone or in combination with zidovudine (AZT) to prevent mother-to-child transmission of the HIV virus. Pregnant CD-1 mice were given per os twice daily either 3TC at different doses (125, 250, or 500 mg/kg) or vehicle solution (NaCl 0. 9%) from pregnancy day 10 to delivery. Offspring behavior was examined on postnatal day 35 in a 20-min social interaction test. At adulthood different behavioral endpoints were analyzed, including locomotor activity and exploration in an open field following administration of the muscarinic antagonist scopolamine (2 mg/kg), spatial learning in either radial arm or Morris water maze, virgin female behavior in a maternal induction test, and pain sensitivity in a hot-plate test (52 +/- 0.1 degrees C). Our findings confirm the low neurotoxicity of 3TC in comparison to AZT. However some significant behavioral alterations were found, namely (1) a decrease in immobility in the open field test, (2) an increase in the responsiveness to scopolamine shown by the 500-mg/kg 3TC mice (sniffing behavior) in the open field, and (3) a longer escape latency in the first day of the reversal phase in the Morris task (particularly marked in the 250-mg/kg treatment group). No significant changes in either pain sensitivity, social/affiliative, or maternal behavior were found, although a higher occurrence of aggressive behavior toward foster pups was noted in both 125- and 500-mg/kg 3TC females.

Management of HIV-infected pregnant patients in malaria-endemic areas: therapeutic and safety considerations in concomitant use of antiretroviral and antimalarial agents

Chemotherapy in pregnancy is an intricate process requiring prudent use of pharmacologic agents. Malarial infection during pregnancy is often fatal, and prophylaxis against the causative parasite necessitates rational therapeutic intervention. Various agents have been used for prophylaxis against malaria during pregnancy, including chloroquine, mefloquine, proguanil, pyrimethamine, and pyrimethamine-sulfadoxine. Use of these agents has been based on a risk-benefit criterion, without appropriate toxicologic or teratologic evaluation. Some of the aforementioned prophylactic agents have been shown to alter glutathione levels and may exacerbate the oxidation-reduction imbalance attendant on HIV infection. HIV-infected patients traveling to or residing in malaria-endemic areas require protection from malarial infection to avoid placing themselves in double jeopardy. Zidovudine (AZT) is recommended for the prevention of vertical transmission of HIV-1 from mother to child. Other agents, such as lamivudine alone or in combination with AZT, nevirapine, or the HIV-1 protease inhibitors, are either being considered or are currently undergoing trials for use in preventing vertical transmission of HIV-1 or managing HIV infection in infants and children. Although the potential for antimalarial agents to cause congenital malformations is low when they are used alone, their ability to cause problems when combined with antiretroviral drugs needs to be evaluated. In developing countries that have high birth rates, a high endemicity of malaria, and alarming rates of new cases of HIV, prophylaxis against both diseases with combination agents during pregnancy is a challenge.

Neurobehavioral effects of prenatal lamivudine (3TC) exposure in preweaning mice

The present study provides a characterization of the behavioral changes induced in preweaning mice by prenatal exposure to lamivudine (3TC), an antiviral drug recently entered in the clinical practice to treat HIV patients. Pregnant CD1 mice were given per os bidaily either 3TC at different doses (125, 250, or 500 mg/kg) or vehicle solution (saline 0.9%) from pregnancy day 10 to delivery. Data on reproductive performance, such as gestation length, litter size, and offspring viability, were collected. Offspring were then examined for a series of different somatic and behavioral end points, including sensorimotor development, ontogenetic pattern of ultrasonic vocalization, passive avoidance learning, and locomotor activity. In the absence of gross changes in somatic and sensorimotor development, a slight change in ultrasound emission was found on postnatal day (PND) 3, with 125 and 500 mg/kg 3TC-treated offspring emitting a lower number of ultrasounds. Learning and retention performances of a passive-avoidance task on PND 20-21 were unaffected by 3TC treatment, while decreased habituation in an automated locomotor activity test was evident in male offspring exposed to 250 and 500 mg/kg 3TC.

Neurobehavioral effects of perinatal AZT exposure in Sprague-Dawley adult rats

Since AZT (azidothymidine, zidovudine, ZDV) has become the standard of care for preventing human immunodeficiency virus transmission during pregnancy, we conducted a study to assess the possible long-term neurobehavioral effects of AZT, using a rat model. Each litter was randomly assigned to a treatment group: no treatment, vehicle or AZT 50, 100, or 150 mg/kg. Treatments were administered once daily via gastric intubation, prenatally from gestation day (G) 19-22 and then from postnatal day (PND) 2-20. Between PND 59-65, each rat was given a single dose of amphetamine (0.1, 0.5, 1.0, or 2.0 mg/kg) or saline and placed in the Accuscan activity chamber for 1 h of data collection and video taping. There was a significant interaction between perinatal treatment and amphetamine challenge drug for one behavioral category, distance traveled, which was due to differences in the nontreated control group compared to all treated groups. These data indicate that chronic AZT treatment at three dose levels during the perinatal period produces no lasting changes in response to amphetamine in the open field in the rat.