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Carvalho S, Sheehan NL, Valois S, Kakkar F, Boucher M, Ferreira E, Boucoiran I. Relationship between raltegravir trough plasma concentration and virologic response and the impact of therapeutic drug monitoring during pregnancy. Int J STD AIDS 2023; 34:175-182. [PMID: 36529684 PMCID: PMC9925909 DOI: 10.1177/09564624221144489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Limited data is available on raltegravir (RAL) pharmacokinetics during pregnancy and the value of therapeutic drug monitoring (TDM) in pregnancy is unknown. This study aims to describe RAL trough plasma concentrations (Ctrough) during pregnancy and review the impact of RAL TDM on outcomes. METHODS Women from the prospective mother-infant HIV cohort of Mother and Children's Infectious Diseases Center who received RAL during their pregnancy between 2011-2020 were included. TDM reports were reviewed and Ctrough values estimated when possible, using historical RAL half-lives. RESULTS We included 76 pregnant women of which 47 underwent TDM. We observed a significant association between virological response and Ctrough (p-value .034) with an increase of 0.1 mg/L corresponding to a 2.96 reduction in the risk of having a detectable viral load. The results indicated that in pregnant women a RAL Ctrough threshold of 0.04 mg/L has a higher specificity (75%) as compared to our current Ctrough target value of 0.02 mg/L (25%) and an acceptable sensitivity (77%). No significant differences were observed between Ctrough at each trimester. When comparing pregnancies with and without TDM, no statistically significant differences were observed in the virologic response during pregnancy and at delivery, or with the need for triple antiretroviral prophylaxis in newborns. CONCLUSIONS An association between RAL Ctrough and viral load was observed and achieving a RAL Ctrough of 0.04 mg/L or greater is a predictor of virologic response in pregnant women. The impact of TDM in pregnancy, however, could not be demonstrated.
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Affiliation(s)
- Sabrina Carvalho
- Faculty of Pharmacy, Université de Montréal, Montréal, QC, Canada,Mother and Children’s Infectious
Diseases Center, Centre Hospitalier Universitaire
Sainte-Justine, Montréal, QC, Canada
| | - Nancy L. Sheehan
- Faculty of Pharmacy, Université de Montréal, Montréal, QC, Canada,Pharmacy Department and Chronic
Viral Illness Service, McGill University Health
Centre, Montréal, QC, Canada
| | - Silvie Valois
- Mother and Children’s Infectious
Diseases Center, Centre Hospitalier Universitaire
Sainte-Justine, Montréal, QC, Canada
| | - Fatima Kakkar
- Mother and Children’s Infectious
Diseases Center, Centre Hospitalier Universitaire
Sainte-Justine, Montréal, QC, Canada,Department of Pediatrics, Université de Montréal, Montréal, QC, Canada
| | - Marc Boucher
- Mother and Children’s Infectious
Diseases Center, Centre Hospitalier Universitaire
Sainte-Justine, Montréal, QC, Canada,Department of Obstetrics and
Gynecology, Université de Montréal, Montréal, QC, Canada
| | - Ema Ferreira
- Faculty of Pharmacy, Université de Montréal, Montréal, QC, Canada,Department of Pharmacy, Centre Hospitalier Universitaire
Sainte-Justine, Montréal, Québec, Canada
| | - Isabelle Boucoiran
- Mother and Children’s Infectious
Diseases Center, Centre Hospitalier Universitaire
Sainte-Justine, Montréal, QC, Canada,Department of Obstetrics and
Gynecology, Université de Montréal, Montréal, QC, Canada,School of Public Health, Université de Montréal, Montréal, QC, Canada,Dr. Isabelle Boucoiran, Research Centre of
the Sainte-Justine University Hospital, Department of Obstetrics and Gynecology
3175, Chemin de la Côte-Sainte-Catherine, Bur. 4804, Montréal, QC H3T 1C.
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2
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Poliektov NE, Badell ML. Antiretroviral Options and Treatment Decisions During Pregnancy. Paediatr Drugs 2023; 25:267-282. [PMID: 36729360 DOI: 10.1007/s40272-023-00559-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 02/03/2023]
Abstract
The majority of pediatric human immunodeficiency virus (HIV) infections are the result of vertical transmissions that occur during pregnancy, childbirth, and breastfeeding. The treatment of all pregnant persons living with HIV remains a global health initiative. Early and consistent use of antiretroviral therapy throughout pregnancy and childbirth drastically reduces the risk of perinatal transmission of HIV, resulting in fewer children living with the disease worldwide. Given that the maternal HIV viral load is the strongest predictor of perinatal transmission, suppressive antiretroviral treatment during pregnancy is the principal means to eliminate transmission of HIV from mother to child. With the use of combined antiretroviral therapy, typically with dual-nucleoside reverse transcriptase inhibitors plus an integrase strand transfer inhibitor or a ritonavir-boosted protease inhibitor, HIV-infected mothers can now achieve virologic suppression to undetectable levels and yield a perinatal transmission rate of less than 2%. Important considerations of HIV treatment in pregnancy include the safety and efficacy of antiretroviral drugs, altered pregnancy-related pharmacokinetics, potential for birth defects or adverse neonatal outcomes, and individualized delivery planning based on maternal viral load. This practical review article summarizes the options, considerations, and recommendations for antiretroviral treatment in pregnancy to reduce perinatal HIV transmission and optimize health outcomes for mothers and infants worldwide.
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Affiliation(s)
- Natalie E Poliektov
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Martina L Badell
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA.
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3
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Nissim O, Lazenby GB. The Use of Integrase Strand Transfer Inhibitors to Treat HIV in Pregnancy. J Midwifery Womens Health 2021; 66:403-406. [PMID: 34166578 DOI: 10.1111/jmwh.13249] [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] [Received: 10/12/2020] [Revised: 04/22/2021] [Accepted: 05/01/2021] [Indexed: 11/27/2022]
Abstract
For pregnant women with HIV, antiretroviral therapy (ART) plays a key role in prevention of perinatal transmission. Newer antiretroviral regimens now contain integrase strand transfer inhibitors, which have been found to rapidly suppress HIV viral load in nonpregnant women; however, there are limited data for use in pregnancy. Here, we present the case of a pregnant woman with well-controlled HIV on a well-tolerated prepregnancy regimen of bictegravir, emtricitabine, and tenofovir alafenamide. As there are limited safety data on bictegravir in pregnancy, this ART regimen was changed to a preferred regimen for pregnancy. In the second trimester, because of adverse effects from the new ART regimen and after a risk-benefit discussion, the patient restarted the original regimen. She was able to maintain viral suppression until giving birth.
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Affiliation(s)
- Oriel Nissim
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina
| | - Gweneth B Lazenby
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina
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4
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Mounce ML, Pontiggia L, Adams JL. A Single-Center Retrospective Cohort Analysis of Maternal and Infant Outcomes in HIV-Infected Mothers Treated with Integrase Inhibitors During Pregnancy. Infect Dis Ther 2017; 6:531-544. [PMID: 28905222 PMCID: PMC5700890 DOI: 10.1007/s40121-017-0170-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Indexed: 11/29/2022] Open
Abstract
Introduction Integrase strand transfer inhibitors (INSTI) are currently being investigated for the treatment of HIV in pregnancy. The purpose of this study is to evaluate the differences in maternal and infant outcomes in HIV-positive mothers treated with INSTI-containing antiretroviral therapy (ART) during pregnancy compared to protease inhibitor (PI)-containing ART. Methods A retrospective, cohort study of INSTI- and PI-based ART used in pregnancy between 2007 and 2015 was performed. The primary objective was to evaluate the differences in viral load (VL) suppression prior to delivery. Secondary endpoints included time to and duration of VL suppression and safety parameters in both mothers and infants. For the primary analysis, the two arms were matched 1:2 INSTI to PI based on the presence or absence of viremia at the time of pregnancy determination. Additional analysis was performed on the entire matched and unmatched dataset. Results Twenty-one patients were matched (7 INSTI and 14 PI). There were no significant differences between groups with respect to the proportion of patients with VL suppression prior to delivery (71.4% INSTI vs. 92.9% PI, p = 0.247), and there were no significant differences in any of the secondary endpoints. Patients with documented adherence issues were statistically more likely to not be virologically suppressed prior to delivery (p = 0.002). Conclusion No differences in efficacy or safety were found between patients treated with INSTIs compared to PIs. This study supports the further investigation of the use of INSTIs during pregnancy to reduce HIV transmission.
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Affiliation(s)
- Monique L Mounce
- Cooper University Hospital, Camden, NJ, USA.,Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA, USA.,Notre Dame of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Laura Pontiggia
- Misher College of Arts and Sciences, University of the Sciences, Philadelphia, PA, USA
| | - Jessica L Adams
- Cooper University Hospital, Camden, NJ, USA. .,Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA, USA.
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Cecchini DM, Martinez MG, Morganti LM, Rodriguez CG. Antiretroviral Therapy Containing Raltegravir to Prevent Mother-to-Child Transmission of HIV in Infected Pregnant Women. Infect Dis Rep 2017; 9:7017. [PMID: 28663779 PMCID: PMC5477474 DOI: 10.4081/idr.2017.7017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 03/13/2017] [Accepted: 03/17/2017] [Indexed: 11/23/2022] Open
Abstract
We conducted a retrospective study in a general hospital in Buenos Aires, Argentina (2009-2015) aimed at evaluating outcomes in HIV-infected pregnant women (HIPW), who were prescribed raltegravir (RAL)-containing antiretroviral therapy (ART). A total of 239 HIPW were enrolled in our study; among them 31 received RAL (12.9%) at different clinical stages: i) intensification (INS): addition of RAL to current ART because of detectable antepartum viral load, 13 (41.9%); ii) late presenter (LP): standard ART + RAL as fourth drug, 15 (48.4%); iii) treatment of resistant-HIV: 3 (9.7%). Median gestational age at RAL initiation was 34 weeks and median exposure was 30 days. In INS-group, median viral load (VL) decrease was 1.48 log10. In LP-group, median VL decline was 2.15 log10. No clinical adverse events or maternal intolerance attributable to RAL were observed. Elective cesarean section was done in 51.7%; mild elevation of transaminases was observed in 35% of neonates. No vertical transmission was documented.
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Affiliation(s)
- Diego M. Cecchini
- Hospital General de Agudos “Cosme Argerich”, Buenos Aires, Argentina
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6
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Critical Review: Review of the Efficacy, Safety, and Pharmacokinetics of Raltegravir in Pregnancy. J Acquir Immune Defic Syndr 2017; 72:153-61. [PMID: 27183177 DOI: 10.1097/qai.0000000000000932] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Raltegravir was previously considered an alternative antiretroviral in pregnancy because of limited data, but recent pregnancy guidelines recommend raltegravir as a preferred integrase treatment option. Data from published articles and preliminary meeting reports between 2001 and July 2015 are reviewed. The literature includes a total of 278 maternal-infant pairs who received raltegravir during pregnancy. The standard raltegravir dose seems safe and effective in preventing mother-to-child transmission in late pregnancy presenters with unknown or unsuppressed viral load, or in multidrug resistance. Viral decay was rapid allowing most women to deliver at undetectable viral levels. Raltegravir was well tolerated, with the exception of a few cases of transient increases in maternal transaminases. No infant adverse effect was consistently reported. Existing data support the use of raltegravir in antiretroviral-naive and experienced pregnant women.
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7
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Lolekha R, Chokephaibulkit K, Phanuphak N, Chaithongwongwatthana S, Kiertiburanakul S, Chetchotisakd P, Boonsuk S. Thai national guidelines for the prevention of mother-to-child transmission of human immunodeficiency virus 2017. ASIAN BIOMED 2017; 11:145-159. [PMID: 29861798 PMCID: PMC5978732 DOI: 10.5372/1905-7415.1102.547] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Thailand has made progress in reducing perinatal HIV transmission rates to levels that meet the World Health Organization targets for so-called "elimination" (<2%) of mother-to-child transmission (MTCT). OBJECTIVES To highlight the Thailand National Guidelines on HIV/AIDS Treatment Prevention Working Group issued a new version of its National Prevention of MTCT guidelines in March 2017 aimed to reduce MTCT rate to <1% by 2020. DISCUSSION OF GUIDELINES The guidelines include recommending initiation of antepartum antiretroviral therapy (ART) containing tenofovir disoproxil fumarate (TDF) plus lamivudine (3TC)/emtricitabine (FTC) plus efavirenz regardless of CD4 cell count as soon as HIV is diagnosed for ART naïve HIV-infected pregnant women. An alternative regimen is TDF or zidovudine (AZT) plus 3TC/FTC plus lopinavir/ritonavir (LPV/r) for HIV-infected pregnant women suspected resistant to non-nucleoside reverse transcriptase inhibitors. Treatment should be started immediately irrespective of gestational age and continued after delivery for life. Raltegravir is recommended in addition to the ART regimen for HIV-infected pregnant women who present late (gestational age (GA) ≥32 weeks) or those who have a viral load (VL) >1000 copies/mL at GA ≥32 weeks. HIV-infected pregnant women who conceive while receiving ART should continue their treatment regimen during pregnancy. HIV-infected pregnant women who present in labor and are not receiving ART should receive single-dose nevirapine immediately along with oral AZT, and continue ART for life. Infants born to HIV-infected mothers are categorized as high or standard risk for MTCT. High MTCT risk is defined as an infant whose mother has a viral load (VL) > 50 copies/mL at GA > 36 weeks or has received ART <12 weeks before delivery, or has poor ART adherence. These infants should be started on AZT plus 3TC plus NVP for 6 weeks after delivery. Infants with standard MTCT risk should receive AZT for 4 weeks. Formula feeding exclusively is recommended for all HIV-exposed infants.
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Affiliation(s)
- Rangsima Lolekha
- Division of Global HIV and TB, Thailand Ministry of Public Health — U.S. CDC Collaboration, Nonthaburi 11000, Thailand
| | - Kulkanya Chokephaibulkit
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | | | | | - Sasisopin Kiertiburanakul
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Pleonchan Chetchotisakd
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Sarawut Boonsuk
- Department of Health, Thailand Ministry of Public Health, Nonthaburi 11000, Thailand
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8
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Rahangdale L, Cates J, Potter J, Badell ML, Seidman D, Miller ES, Coleman JS, Lazenby GB, Levison J, Short WR, Yawetz S, Ciaranello A, Livingston E, Duthely L, Rimawi BH, Anderson JR, Stringer EM. Integrase inhibitors in late pregnancy and rapid HIV viral load reduction. Am J Obstet Gynecol 2016; 214:385.e1-7. [PMID: 26928154 PMCID: PMC4995881 DOI: 10.1016/j.ajog.2015.12.052] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 12/21/2015] [Accepted: 12/29/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND Minimizing time to HIV viral suppression is critical in pregnancy. Integrase strand transfer inhibitors (INSTIs), like raltegravir, are known to rapidly suppress plasma HIV RNA in nonpregnant adults. There are limited data in pregnant women. OBJECTIVE We describe time to clinically relevant reduction in HIV RNA in pregnant women using INSTI-containing and non-INSTI-containing antiretroviral therapy (ART) options. STUDY DESIGN We conducted a retrospective cohort study of pregnant HIV-infected women in the United States from 2009 through 2015. We included women who initiated ART, intensified their regimen, or switched to a new regimen due to detectable viremia (HIV RNA >40 copies/mL) at ≥20 weeks gestation. Among women with a baseline HIV RNA permitting 1-log reduction, we estimated time to 1-log RNA reduction using the Kaplan-Meier estimator comparing women starting/adding an INSTI in their regimen vs other ART. To compare groups with similar follow-up time, we also conducted a subgroup analysis limited to women with ≤14 days between baseline and follow-up RNA data. RESULTS This study describes 101 HIV-infected pregnant women from 11 US clinics. In all, 75% (76/101) of women were not taking ART at baseline; 24 were taking non-INSTI containing ART, and 1 received zidovudine monotherapy. In all, 39% (39/101) of women started an INSTI-containing regimen or added an INSTI to their ART regimen. Among 90 women with a baseline HIV RNA permitting 1-log reduction, the median time to 1-log RNA reduction was 8 days (interquartile range [IQR], 7-14) in the INSTI group vs 35 days (IQR, 20-53) in the non-INSTI ART group (P < .01). In a subgroup of 39 women with first and last RNA measurements ≤14 days apart, median time to 1-log reduction was 7 days (IQR, 6-10) in the INSTI group vs 11 days (IQR, 10-14) in the non-INSTI group (P < .01). CONCLUSION ART that includes INSTIs appears to induce more rapid viral suppression than other ART regimens in pregnancy. Inclusion of an INSTI may play a role in optimal reduction of HIV RNA for HIV-infected pregnant women presenting late to care or failing initial therapy. Larger studies are urgently needed to assess the safety and effectiveness of this approach.
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Affiliation(s)
- Lisa Rahangdale
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC.
| | - Jordan Cates
- Department of Epidemiology, University of North Carolina Gillings School of Public Health, Chapel Hill, NC
| | - JoNell Potter
- Department of Obstetrics and Gynecology, Divison of Research, University of Miami Miller School of Medicine, Miami, FL
| | - Martina L Badell
- Department of Gynecology and Obstetrics, Division of Maternal-Fetal Medicine, Emory University, Atlanta, GA
| | - Dominika Seidman
- Department of Obstetrics, Gynecology, and Reproductive Sciences; University of California-San Francisco, San Francisco, CA
| | - Emilly S Miller
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jenell S Coleman
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD
| | - Gweneth B Lazenby
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC
| | - Judy Levison
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - William R Short
- Department of Medicine, University of Pennsylvania Perelmen School of Medicine, Philadelphia, PA (formerly at Sidney Kimmel Medical College at Thomas Jefferson University)
| | - Sigal Yawetz
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Andrea Ciaranello
- Medical Practice Evaluation Center, Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
| | | | - Lunthita Duthely
- Department of Obstetrics and Gynecology, Divison of Research, University of Miami Miller School of Medicine, Miami, FL
| | - Bassam H Rimawi
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA
| | - Jean R Anderson
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD
| | - Elizabeth M Stringer
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
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Yaita K, Inoue S, Horinouchi T, Kinoshita M, Unno M, Iwata O, Tanaka Y, Gotoh K, Ishibashi M, Sakai Y, Masunaga K, Watanabe H, Tominaga M. An HIV-infected Pregnant Woman Treated with the Long-term Administration of Antiretroviral Therapy Including Raltegravir. Intern Med 2016; 55:2727-30. [PMID: 27629976 DOI: 10.2169/internalmedicine.55.6653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 27-year-old HIV-infected pregnant Japanese woman was admitted to our hospital at gestational week 14. The patient's HIV viral load was 71,000 copies/mL, and her CD4 cell count was 147 cells/mm(3). Zidovudine, lamivudine, and lopinavir/ritonavir were administered at gestational week 18. Because the viral load increased to 222,000 copies/mL at the initiation of antiretroviral therapy, we added raltegravir. The decrease in the viral load was satisfactory, and a caesarean delivery was performed. Although the plasma concentration of raltegravir in the neonate was significantly high (2,482 ng/mL), no adverse event was confirmed. There was no evidence of the mother-to-child transmission of HIV.
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Affiliation(s)
- Kenichiro Yaita
- Department of Infection Control and Prevention, Kurume University School of Medicine, Japan
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A case series of third-trimester raltegravir initiation: Impact on maternal HIV-1 viral load and obstetrical outcomes. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2015; 26:145-50. [PMID: 26236356 PMCID: PMC4507840 DOI: 10.1155/2015/731043] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To describe the impact of initiating raltegravir (RAL)-containing combination antiretroviral therapy (cART) regimens on HIV viral load (VL) in pregnant women who have high or suboptimal VL suppression late in pregnancy. METHODS HIV-infected pregnant women who started RAL-containing cART after 28 weeks' gestation from 2007 to 2013 were identified in two university hospital centres. RESULTS AND DISCUSSION Eleven HIV-infected women started RAL at a median gestational age of 35.7 weeks (range 31.1 to 38.0 weeks). Indications for RAL initiation were late presentation in pregnancy (n=4) and suboptimal VL suppression secondary to poor adherence or viral resistance (n=7). Mean VL at the time of RAL initiation was 73,959 copies/mL (range <40 to 523,975 copies/mL). Patients received RAL for a median of 20 days (range one to 71 days). The mean decline in VL from the time of RAL initiation to delivery was 1.93 log, excluding one patient who received only one RAL dose and one patient with undetectable VL at the time of RAL initiation. After eight days on RAL, 50% of the women achieved a VL <1000 copies/mL (the threshold for recommended Caesarean section to reduce the risk for perinatal transmission). There were no cases of perinatal HIV transmission. CONCLUSION The present study provides preliminary data to support the use of RAL-containing cART to expedite HIV-1 VL reduction in women who have a high VL or suboptimal VL suppression late in pregnancy, and to decrease the risk of HIV perinatal transmission while avoiding Caesarean section. Further assessment of RAL safety during pregnancy is warranted.
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Watts DH, Stek A, Best BM, Wang J, Capparelli EV, Cressey TR, Aweeka F, Lizak P, Kreitchmann R, Burchett SK, Shapiro DE, Hawkins E, Smith E, Mirochnick M. Raltegravir pharmacokinetics during pregnancy. J Acquir Immune Defic Syndr 2014; 67:375-81. [PMID: 25162818 PMCID: PMC4213295 DOI: 10.1097/qai.0000000000000318] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We evaluated the pharmacokinetics (PK) of raltegravir in HIV-infected women during pregnancy and postpartum. METHODS International Maternal Pediatric Adolescent AIDS Clinical Trials 1026s is an ongoing prospective study of antiretroviral PK during pregnancy (NCT00042289). Women receiving 400 mg raltegravir twice daily in combination antiretroviral therapy had intensive steady-state 12-hour PK profiles performed during pregnancy and at 6- to 12-week postpartum. Targets were trough concentration above 0.035 μg/mL, the estimated 10th percentile in nonpregnant historical controls. RESULTS Median raltegravir area under the curve was 6.6 μg·h/mL for second trimester (n = 16), 5.4 μg·h/mL for third trimester (n = 41), and 11.6 μg·h/mL postpartum (n = 38) (P = 0.03 postpartum vs second trimester, P = 0.001 pp vs third trimester). Trough concentrations were above the target in 69%, 80%, and 79% of second trimester, third trimester, and postpartum subjects, respectively, with wide variability (<0.010-0.917 μg/mL), and no significant difference between third trimester and postpartum trough concentrations was detected. The median ratio of cord blood/maternal raltegravir concentrations was 1.5. HIV RNA levels were <400 copies per milliliter in 92% of women at delivery. Adverse events included elevated liver transaminases in 1 woman and vomiting in 1. All infants with known status are HIV uninfected. CONCLUSIONS Median raltegravir area under the curve was reduced by approximately 50% during pregnancy; trough concentrations were frequently below target both during late pregnancy and postpartum. Raltegravir readily crossed the placenta. High rates of viral suppression at delivery and the lack of a clear relationship between raltegravir concentration and virologic effect in nonpregnant adults suggest that despite the decreased exposure during pregnancy, a higher dose is not necessary.
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Affiliation(s)
- D. Heather Watts
- Office of the Global AIDS Coordinator, U.S. Department of State, Washington, DC
| | - Alice Stek
- University of Southern California School of Medicine, Department of Obstetrics and Gynecology, Los Angeles, CA
| | - Brookie M. Best
- University of California, San Diego School of Medicine and Skaggs School of Pharmacy & Pharmaceutical Sciences, San Diego, CA
| | - Jiajia Wang
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, MA
| | - Edmund V. Capparelli
- University of California, San Diego School of Medicine and Skaggs School of Pharmacy & Pharmaceutical Sciences, San Diego, CA
| | - Tim R. Cressey
- Program for HIV Prevention and Treatment (IRD URI 174), Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Francesca Aweeka
- Department of Clinical Pharmacy, Drug Research Unit, University of California, San Francisco, San Francisco, CA
| | - Patty Lizak
- Department of Clinical Pharmacy, Drug Research Unit, University of California, San Francisco, San Francisco, CA
| | - Regis Kreitchmann
- HIV/AIDS Research Department, Irmandade da Santa Casa de Misericordia de Porto Alegre, RS, Brazil
| | | | - David E. Shapiro
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, MA
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Cecchini D, Martinez M, Morganti L, Rodriguez C. Uso de raltegravir en embarazadas infectadas por VIH-1: experiencia en diferentes escenarios clínicos. Enferm Infecc Microbiol Clin 2014; 32:616-8. [DOI: 10.1016/j.eimc.2014.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 11/29/2013] [Accepted: 01/14/2014] [Indexed: 11/30/2022]
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13
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Abstract
PURPOSE OF REVIEW Treatment with combination antiretroviral therapy during pregnancy reduces the chance of mother to child transmission of HIV. Physiological changes during pregnancy can lead to lower exposure to antiretrovirals, possibly resulting in virological failure. For most antiretrovirals, data on exposure during pregnancy and transplacental passage are limited. This review summarizes the most recent information on pharmacokinetics (including transplacental passage), efficacy, as well as the safety of antiretrovirals during pregnancy. RECENT FINDINGS Intensive-sampling pharmacokinetic studies as well as observational studies using sparse sampling were performed to explore the exposure to antiretrovirals during pregnancy. Transplacental passage, efficacy (viral load at delivery and infection status of the newborn) and safety information were evaluated for several antiretrovirals. SUMMARY For most nucleoside/nucleotide reverse transcriptase inhibitors and protease inhibitors, recent research shows a decreased exposure during pregnancy. However, the advantage of a general dose increase during pregnancy still remains unclear. For newer compounds and efavirenz, limited or no data on pharmacokinetics during pregnancy or transplacentally are available, while the mechanisms of transplacental passage also remain unknown. For safety reasons, it will be important to monitor pregnancy outcomes in resource-limited settings during the implementation of the WHO guidelines (including the use of efavirenz during pregnancy).
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