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Asif M, Qusty NF, Alghamdi S. An Overview of Various Rifampicin Analogs against Mycobacterium tuberculosis and their Drug Interactions. Med Chem 2024; 20:268-292. [PMID: 37855280 DOI: 10.2174/0115734064260853230926080134] [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] [Received: 06/10/2023] [Revised: 07/14/2023] [Accepted: 08/12/2023] [Indexed: 10/20/2023]
Abstract
The success of the TB control program is hampered by the major issue of drug-resistant tuberculosis (DR-TB). The situation has undoubtedly been made more difficult by the widespread and multidrug-resistant (XDR) strains of TB. The modification of existing anti-TB medications to produce derivatives that can function on resistant TB bacilli is one of the potential techniques to overcome drug resistance affordably and straightforwardly. In comparison to novel pharmaceuticals for drug research and progress, these may have a better half-life and greater bioavailability, be more efficient, and serve as inexpensive alternatives. Mycobacterium tuberculosis, which is drugsusceptible or drug-resistant, is effectively treated by several already prescribed medications and their derivatives. Due to this, the current review attempts to give a brief overview of the rifampicin derivatives that can overcome the parent drug's resistance and could, hence, act as useful substitutes. It has been found that one-third of the global population is affected by M. tuberculosis. The most common cause of infection-related death can range from latent TB to TB illness. Antibiotics in the rifamycin class, including rifampicin or rifampin (RIF), rifapentine (RPT), and others, have a special sterilizing effect on M. tuberculosis. We examine research focused on evaluating the safety, effectiveness, pharmacokinetics, pharmacodynamics, risk of medication interactions, and other characteristics of RIF analogs. Drug interactions are especially difficult with RIF because it must be taken every day for four months to treat latent TB infection. RIF continues to be the gold standard of treatment for drug-sensitive TB illness. RIF's safety profile is well known, and the two medicines' adverse reactions have varying degrees of frequency. The authorized once-weekly RPT regimen is insufficient, but greater dosages of either medication may reduce the amount of time needed to treat TB effectively.
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Affiliation(s)
- Mohammad Asif
- Department of Pharmaceutical Chemistry, Era College of Pharmacy, Era University, Lucknow, 226003, Uttar Pradesh, India
| | - Naeem F Qusty
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al‒Qura University, Makkah, 21955, Saudi Arabia
| | - Saad Alghamdi
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al‒Qura University, Makkah, 21955, Saudi Arabia
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2
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Ernest JP, Goh JJN, Strydom N, Wang Q, van Wijk RC, Zhang N, Deitchman A, Nuermberger E, Savic RM. Translational predictions of phase 2a first-in-patient efficacy studies for antituberculosis drugs. Eur Respir J 2023; 62:2300165. [PMID: 37321622 PMCID: PMC10469274 DOI: 10.1183/13993003.00165-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/02/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Phase 2a trials in tuberculosis typically use early bactericidal activity (EBA), the decline in sputum CFU over 14 days, as the primary end-point for testing the efficacy of drugs as monotherapy. However, the cost of phase 2a trials can range from USD 7 million to USD 19.6 million on average, while >30% of drugs fail to progress to phase 3. Better utilising pre-clinical data to predict and prioritise the most likely drugs to succeed will thus help to accelerate drug development and reduce costs. We aim to predict clinical EBA using pre-clinical in vivo pharmacokinetic (PK)-pharmacodynamic (PD) data and a model-based translational pharmacology approach. METHODS AND FINDINGS First, mouse PK, PD and clinical PK models were compiled. Second, mouse PK-PD models were built to derive an exposure-response relationship. Third, translational prediction of clinical EBA studies was performed using mouse PK-PD relationships and informed by clinical PK models and species-specific protein binding. Presence or absence of clinical efficacy was accurately predicted from the mouse model. Predicted daily decreases of CFU in the first 2 days of treatment and between day 2 and day 14 were consistent with clinical observations. CONCLUSION This platform provides an innovative solution to inform or even replace phase 2a EBA trials, to bridge the gap between mouse efficacy studies and phase 2b and phase 3 trials, and to substantially accelerate drug development.
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Affiliation(s)
- Jacqueline P Ernest
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
- Shared authorship ordered alphabetically
| | - Janice Jia Ni Goh
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
- Shared authorship ordered alphabetically
| | - Natasha Strydom
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
- Shared authorship ordered alphabetically
| | - Qianwen Wang
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
- Shared authorship ordered alphabetically
| | - Rob C van Wijk
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
- Shared authorship ordered alphabetically
| | - Nan Zhang
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
- Shared authorship ordered alphabetically
| | - Amelia Deitchman
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Eric Nuermberger
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MA, USA
| | - Rada M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, USA
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3
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Kumar G, C A. Natural products and their analogues acting against Mycobacterium tuberculosis: A recent update. Drug Dev Res 2023; 84:779-804. [PMID: 37086027 DOI: 10.1002/ddr.22063] [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: 11/25/2022] [Revised: 02/28/2023] [Accepted: 04/01/2023] [Indexed: 04/23/2023]
Abstract
Tuberculosis (TB) remains one of the deadliest infectious diseases caused by Mycobacterium tuberculosis (M.tb). It is responsible for significant causes of mortality and morbidity worldwide. M.tb possesses robust defense mechanisms against most antibiotic drugs and host responses due to their complex cell membranes with unique lipid molecules. Thus, the efficacy of existing front-line drugs is diminishing, and new and recurring cases of TB arising from multidrug-resistant M.tb are increasing. TB begs the scientific community to explore novel therapeutic avenues. A precise knowledge of the compounds with their mode of action could aid in developing new anti-TB agents that can kill latent and actively multiplying M.tb. This can help in the shortening of the anti-TB regimen and can improve the outcome of treatment strategies. Natural products have contributed several antibiotics for TB treatment. The sources of anti-TB drugs/inhibitors discussed in this work are target-based identification/cell-based and phenotypic screening from natural products. Some of the recently identified natural products derived leads have reached clinical stages of TB drug development, which include rifapentine, CPZEN-45, spectinamide-1599 and 1810. We believe these anti-TB agents could emerge as superior therapeutic compounds to treat TB over known Food and Drug Administration drugs.
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Affiliation(s)
- Gautam Kumar
- Department of Natural Products, Chemical Sciences, National Institute of Pharmaceutical Education and Research-Hyderabad, Hyderabad, Telangana, India
| | - Amrutha C
- Department of Natural Products, Chemical Sciences, National Institute of Pharmaceutical Education and Research-Hyderabad, Hyderabad, Telangana, India
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4
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Feng Z, Miao Y, Peng Y, Sun F, Zhang Y, Li R, Ge S, Chen X, Song L, Li Y, Wang X, Zhang W. Optimizing (O) rifapentine-based (RI) regimen and shortening (EN) the treatment of drug-susceptible tuberculosis (T) (ORIENT) using an adaptive seamless design: study protocol of a multicenter randomized controlled trial. BMC Infect Dis 2023; 23:300. [PMID: 37158831 PMCID: PMC10165810 DOI: 10.1186/s12879-023-08264-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 04/18/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Standard treatment for drug-susceptible tuberculosis (DS-TB) includes a multidrug regimen requiring at least 6 months of treatment, and this lengthy treatment easily leads to poor adherence. There is an urgent need to simplify and shorten treatment regimens to reduce interruption and adverse event rates, improve compliance, and reduce costs. METHODS ORIENT is a multicenter, randomized controlled, open-label, phase II/III, non-inferiority trial involving DS-TB patients to evaluate the safety and efficacy of short-term regimens compared with the standardized six-month treatment regimen. In stage 1, corresponding to a phase II trial, a total of 400 patients are randomly divided into four arms, stratified by site and the presence of lung cavitation. Investigational arms include 3 short-term regimens with rifapentine 10 mg/kg, 15 mg/kg, and 20 mg/kg, while the control arm uses the standardized six-month treatment regimen. A combination of rifapentine, isoniazid, pyrazinamide, and moxifloxacin is administered for 17 or 26 weeks in rifapentine arms, while a 26-week regimen containing rifampicin, isoniazid, pyrazinamide, and ethambutol is applied in the control arm. After the safety and preliminary effectiveness analysis of patients in stage 1, the control arm and the investigational arm meeting the conditions will enter into stage 2, which is equivalent to a phase III trial and will be expanded to recruit DS-TB patients. If all investigational arms do not meet the safety conditions, stage 2 will be canceled. In stage 1, the primary safety endpoint is permanent regimen discontinuation at 8 weeks after the first dose. The primary efficacy endpoint is the proportion of favorable outcomes at 78 weeks after the first dose for both two stages. DISCUSSION This trial will contribute to the optimal dose of rifapentine in the Chinese population and suggest the feasibility of the short-course treatment regimen containing high-dose rifapentine and moxifloxacin for DS-TB. TRIAL REGISTRATION The trial has been registered on ClinicalTrials.gov on 28 May 2022 with the identifier NCT05401071.
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Affiliation(s)
- Zhen Feng
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yan Miao
- Shanghai Huashen Institute of Microbes and Infections, Shanghai, China
| | - Ying Peng
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Zhejiang Province, Hangzhou, People's Republic of China
| | - Feng Sun
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yilin Zhang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Rong Li
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Shijia Ge
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xinchang Chen
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Lingyun Song
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yang Li
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.
| | - Xiaomeng Wang
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Zhejiang Province, Hangzhou, People's Republic of China.
| | - Wenhong Zhang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.
- Shanghai Huashen Institute of Microbes and Infections, Shanghai, China.
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5
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Aguilar Diaz JM, Abulfathi AA, te Brake LHM, van Ingen J, Kuipers S, Magis-Escurra C, Raaijmakers J, Svensson EM, Boeree MJ. New and Repurposed Drugs for the Treatment of Active Tuberculosis: An Update for Clinicians. Respiration 2023; 102:83-100. [PMID: 36516792 PMCID: PMC9932851 DOI: 10.1159/000528274] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/28/2022] [Indexed: 12/15/2022] Open
Abstract
Although tuberculosis (TB) is preventable and curable, the lengthy treatment (generally 6 months), poor patient adherence, high inter-individual variability in pharmacokinetics (PK), emergence of drug resistance, presence of comorbidities, and adverse drug reactions complicate TB therapy and drive the need for new drugs and/or regimens. Hence, new compounds are being developed, available drugs are repurposed, and the dosing of existing drugs is optimized, resulting in the largest drug development portfolio in TB history. This review highlights a selection of clinically available drug candidates that could be part of future TB regimens, including bedaquiline, delamanid, pretomanid, linezolid, clofazimine, optimized (high dose) rifampicin, rifapentine, and para-aminosalicylic acid. The review covers drug development history, preclinical data, PK, and current clinical development.
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Affiliation(s)
- Jessica M Aguilar Diaz
- Radboudumc Center for Infectious Diseases, Department of Pulmonary Diseases, TB Expert Center Dekkerswald, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ahmed A Abulfathi
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, Lake Nona (Orlando), University of Florida, Gainesville, Florida, USA,Department of Clinical Pharmacology and Therapeutics, Faculty of Basic Clinical Sciences, College of Medical Sciences, University of Maiduguri, Maiduguri, Nigeria,Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine & Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Lindsey HM te Brake
- Radboudumc Center for Infectious Diseases, Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jakko van Ingen
- Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Saskia Kuipers
- Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cecile Magis-Escurra
- Radboudumc Center for Infectious Diseases, Department of Pulmonary Diseases, TB Expert Center Dekkerswald, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jelmer Raaijmakers
- Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Elin M Svensson
- Radboudumc Center for Infectious Diseases, Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands,Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Martin J Boeree
- Radboudumc Center for Infectious Diseases, Department of Pulmonary Diseases, TB Expert Center Dekkerswald, Radboud University Medical Center, Nijmegen, The Netherlands,*Martin J. Boeree,
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6
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Ge Q, Ma Y, Zhang L, Ma L, Zhao C, Chen Y, Huang X, Shu W, Chen S, Wang F, Li B, Han X, Shi L, Wang X, Li Y, Yang S, Cao W, Liu Q, Chen L, Wu C, Ouyang B, Wang F, Li P, Wu X, Xi X, Leng X, Zhang H, Li H, Li J, Yang C, Zhang P, Cui H, Liu Y, Kong C, Sun Z, Du J, Gao W. Effect of a modified regimen on drug-sensitive retreated pulmonary tuberculosis: A multicenter study in China. Front Public Health 2023; 11:1039399. [PMID: 36778546 PMCID: PMC9909400 DOI: 10.3389/fpubh.2023.1039399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/06/2023] [Indexed: 01/27/2023] Open
Abstract
Background and objective Retreatment pulmonary tuberculosis (PTB) still accounts for a large proportion of tuberculosis, and the treatment outcome is unfavorable. The recurrence of retreatment PTB based on long-term follow-up has not been well demonstrated. This study aimed to evaluate effect of a modified regimen on drug-sensitive retreated pulmonary tuberculosis. Methods This multicenter cohort study was conducted in 29 hospitals from 23 regions of China from July 1, 2009, to December 31, 2020. Patients were divided into two treatment regimen groups including experimental group [modified regimen (4H-Rt2-E-Z-S(Lfx)/4H-Rt2-E)]and control group [standard regimen (2H-R-E-Z-S/6H-R-E or 3H-R-E-Z/6H-R-E)]. The patients enrolled were followed up of 56 months after successful treatment. We compared the treatment success rate, treatment failure rate, adverse reaction rate, and recurrence rate between two regimens. Multivariate Cox regression model was used to identify the potential risk factors for recurrence after successful treatment with proportional hazards assumptions tested for all variables. Results A total of 381 patients with retreatment PTB were enrolled, including 244 (64.0%) in the experimental group and 137 (36.0%) in the control group. Overall, the treatment success rate was significant higher in the experimental group than control group (84.0 vs. 74.5%, P = 0.024); no difference was observed in adverse reactions between the two groups (25.8 vs. 21.2%, P > 0.05). A total of 307 patients completed the 56 months of follow-up, including 205 with the modified regimen and 102 with the standard regimen. Among these, 10 cases (3.3%) relapsed, including 3 in the experimental group and 7 in the control group (1.5% vs 6.9%, P = 0.035). Reduced risks of recurrence were observed in patients treated with the modified regimen compared with the standard regimen, and the adjusted hazard ratio was 0.19 (0.04-0.77). Conclusion The modified retreatment regimen had more favorable treatment effects, including higher treatment success rate and lower recurrence rate in patients with retreated drug-sensitive PTB.
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Affiliation(s)
- Qiping Ge
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Yan Ma
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China,Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Lijie Zhang
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China,Administration Office, Clinical Center on Tuberculosis, China CDC, Beijing, China
| | - Liping Ma
- Department of TB Control, Henan Center for Disease Control and Prevention, Zhengzhou, Henan, China
| | - Caiyan Zhao
- Department of Tuberculosis, Haerbin Chest Hospital, Haerbin, China
| | - Yuhui Chen
- Department of Outpatients, Center for Tuberculosis Control of Guangdong Province, Guangzhou, Guangdong, China
| | - Xuerui Huang
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Wei Shu
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China,Administration Office, Clinical Center on Tuberculosis, China CDC, Beijing, China
| | - Shengyu Chen
- Department of Outpatients, Center for Tuberculosis Control of Tianjin, Tianjin, China
| | - Fei Wang
- Department of TB Control, Zhejiang Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
| | - Bo Li
- Department of Outpatients, Beijing Center for Disease Control and Prevention, Beijing, China
| | - Xiqin Han
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Lian Shi
- Department of Tuberculosis, Shenyang Chest Hospital, Shenyang, Liaoning, China
| | - Xin Wang
- Department of TB Control, Heilongjiang Center for Disease Control and Prevention, Haerbin, Heilongjiang, China
| | - Youlun Li
- Department of Tuberculosis, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shangpeng Yang
- Department of Tuberculosis, Jingzhou Hospital for Infectious Diseases, Jingzhou, Hubei, China
| | - Wenli Cao
- Department of Infectious Disease, Beijing Geriatric Hospital, Beijing, China
| | - Qianying Liu
- Department of Tuberculosis, 8th Medical Center, PLA General Hospital, Beijing, China
| | - Ling Chen
- Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Chao Wu
- Department of Tuberculosis, The 3rd People's Hospital of Zhenjiang, Zhenjiang, Jiangsu, China
| | - Bing Ouyang
- Department of Tuberculosis, Kunming 3rd People's Hospital, Kunming, Yunnan, China
| | - Furong Wang
- Department of Medicine, The 4th Hospital of Inner Mongolia Autonomous Region, Huhehaote, China
| | - Po Li
- Department of Tuberculosis, The 3rd Hospital of Baotou, Baotou, China
| | - Xiang Wu
- Department of Tuberculosis, Jingmen Center for Disease Control and Prevention, Jingmen, Hubei, China
| | - Xiue Xi
- Department of Tuberculosis, The First Affiliated Hospital of Xinxiang Medical College, Xinxiang, China
| | - Xueyan Leng
- Department of Tuberculosis, The 3rd Hospital of Qinhuangdao, Qinhuangdao, Hebei, China
| | - Haiqing Zhang
- Department of Tuberculosis, Xuzhou Hospital for Infectious Diseases, Xuzhou, Jiangsu, China
| | - Hua Li
- Department of Tuberculosis, Linfen 3rd People's Hospital, Linfen, Shanxi, China
| | - Juan Li
- Department of TB Control, Guangxi Zhuang Autonomous Region Center for Disease Control and Prevention, Nangning, China
| | - Chengqing Yang
- Department of Respiratory and Critical Care Medicine of Wuhan Tuberculosis Institute, Wuhan, Hubei, China
| | - Peng Zhang
- Department of Tuberculosis, 4th Hospital of Tangshan City, Tangshan, Hebei, China
| | - Hongzhe Cui
- Department of Tuberculosis Control, Yanbian Institute of Tuberculosis Prevention and Control, Yanbian, Jilin, China
| | - Yuhong Liu
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Chengcheng Kong
- Translational Medicine Center, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Zhaogang Sun
- Translational Medicine Center, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China,*Correspondence: Zhaogang Sun ✉
| | - Jian Du
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China,Jian Du ✉
| | - Weiwei Gao
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China,Weiwei Gao ✉
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7
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Grañana-Castillo S, Montanha MC, Bearon R, Khoo S, Siccardi M. Evaluation of drug-drug interaction between rilpivirine and rifapentine using PBPK modelling. Front Pharmacol 2022; 13:1076266. [PMID: 36588698 PMCID: PMC9797969 DOI: 10.3389/fphar.2022.1076266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
Tuberculosis remains the leading cause of death among people living with HIV. Rifapentine is increasingly used to treat active disease or prevent reactivation, in both cases given either as weekly or daily therapy. However, rifapentine is an inducer of CYP3A4, potentially interacting with antiretrovirals like rilpivirine. This in silico study investigates the drug-drug interaction (DDI) magnitude between daily oral rilpivirine 25 mg with either daily 600 mg or weekly 900 mg rifapentine. A physiologically based pharmacokinetic (PBPK) model was built in Simbiology (Matlab R2018a) to simulate the drug-drug interaction. The simulated PK parameters from the PBPK model were verified against reported clinical data for rilpivirine and rifapentine separately, daily rifapentine with midazolam, and weekly rifapentine with doravirine. The simulations of concomitant administration of rifapentine with rilpivirine at steady-state lead to a maximum decrease on AUC0-24 and Ctrough by 83% and 92% on day 5 for the daily rifapentine regimen and 68% and 92% for the weekly regimen on day 3. In the weekly regimen, prior to the following dose, AUC0-24 and Ctrough were still reduced by 47% and 53%. In both simulations, the induction effect ceased 2 weeks after the interruption of rifapentine's treatment. A daily double dose of rilpivirine after initiating rifapentine 900 mg weekly was simulated but failed to compensate the drug-drug interaction. The drug-drug interaction model suggested a significant decrease on rilpivirine exposure which is unlikely to be corrected by dose increment, thus coadministration should be avoided.
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Affiliation(s)
- Sandra Grañana-Castillo
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom,*Correspondence: Sandra Grañana-Castillo,
| | - Maiara Camotti Montanha
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Rachel Bearon
- Department of Mathematical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Saye Khoo
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Marco Siccardi
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
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8
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Edwards BD, Field SK. The Struggle to End a Millennia-Long Pandemic: Novel Candidate and Repurposed Drugs for the Treatment of Tuberculosis. Drugs 2022; 82:1695-1715. [PMID: 36479687 PMCID: PMC9734533 DOI: 10.1007/s40265-022-01817-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2022] [Indexed: 12/12/2022]
Abstract
This article provides an encompassing review of the current pipeline of putative and developed treatments for tuberculosis, including multidrug-resistant strains. The review has organized each compound according to its site of activity. To provide context, mention of drugs within current recommended treatment regimens is made, thereafter followed by discussion on recently developed and upcoming molecules at established and novel targets. The review is designed to provide a clinically applicable understanding of the compounds that are deemed most currently relevant, including those already under clinical study and those that have shown promising pre-clinical results. An extensive review of the efficacy and safety data for key contemporary drugs already incorporated into treatment regimens, such as bedaquiline, pretomanid, and linezolid, is provided. The three levels of the bacterial cell wall (mycolic acid, arabinogalactan, and peptidoglycan layers) are highlighted and important compounds designed to target each layer are delineated. Amongst others, the highly optimistic and potent anti-mycobacterial activity of agents such as BTZ-043, PBTZ 169, and OPC-167832 are emphasized. The evolving spectrum of oxazolidinones, such as sutezolid, delpazolid, and TBI-223, all aiming to exceed the efficacy achieved with linezolid yet offer a safer alternative to the potential toxicity, are reviewed. New and exciting prospective agents with novel mechanisms of impact against TB, including 3-aminomethyl benzoxaboroles and telacebec, are underscored. We describe new diaryloquinolines in development, striving to build on the immense success of bedaquiline. Finally, we discuss some of these compounds that have shown encouraging additive or synergistic benefit when used in combination, providing some promise for the future in treating this ancient scourge.
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Affiliation(s)
- Brett D Edwards
- Division of Infectious Diseases and Tuberculosis Services, Alberta Health Services, Department of Medicine, Cumming School of Medicine, University of Calgary, Peter Lougheed Centre, 3500, 26 Avenue NE, Calgary, AB, T1Y6J4, Canada.
| | - Stephen K Field
- Division of Infectious Diseases and Tuberculosis Services, Alberta Health Services, Department of Medicine, Cumming School of Medicine, University of Calgary, Peter Lougheed Centre, 3500, 26 Avenue NE, Calgary, AB, T1Y6J4, Canada
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9
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Bolleddula J, Gopalakrishnan S, Hu P, Dong J, Venkatakrishnan K. Alternatives to rifampicin: A review and perspectives on the choice of strong CYP3A inducers for clinical drug-drug interaction studies. Clin Transl Sci 2022; 15:2075-2095. [PMID: 35722783 PMCID: PMC9468573 DOI: 10.1111/cts.13357] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/27/2022] [Accepted: 06/08/2022] [Indexed: 01/25/2023] Open
Abstract
N-Nitrosamine (NA) impurities are considered genotoxic and have gained attention due to the recall of several marketed drug products associated with higher-than-permitted limits of these impurities. Rifampicin is an index inducer of multiple cytochrome P450s (CYPs) including CYP2B6, 2C8, 2C9, 2C19, and 3A4/5 and an inhibitor of OATP1B transporters (single dose). Hence, rifampicin is used extensively in clinical studies to assess drug-drug interactions (DDIs). Despite NA impurities being reported in rifampicin and rifapentine above the acceptable limits, these critical anti-infective drugs are available for therapeutic use considering their benefit-risk profile. Reports of NA impurities in rifampicin products have created uncertainty around using rifampicin in clinical DDI studies, especially in healthy volunteers. Hence, a systematic investigation through a literature search was performed to determine possible alternative index inducer(s) to rifampicin. The available strong CYP3A inducers were selected from the University of Washington DDI Database and their in vivo DDI potential assessed using the data from clinical DDI studies with sensitive CYP3A substrates. To propose potential alternative CYP3A inducers, factors including lack of genotoxic potential, adequate safety, feasibility of multiple dose administration to healthy volunteers, and robust in vivo evidence of induction of CYP3A were considered. Based on the qualifying criteria, carbamazepine, phenytoin, and lumacaftor were identified to be the most promising alternatives to rifampicin for conducting CYP3A induction DDI studies. Strengths and limitations of the proposed alternative CYP3A inducers, the magnitude of in vivo CYP3A induction, appropriate study designs for each alternative inducer, and future perspectives are presented in this paper.
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Affiliation(s)
- Jayaprakasam Bolleddula
- Quantitative PharmacologyEMD Serono Research & Development Institute, Inc.BillericaMassachusettsUSA
| | | | - Ping Hu
- Quantitative PharmacologyEMD Serono Research & Development Institute, Inc.BillericaMassachusettsUSA
| | - Jennifer Dong
- Quantitative PharmacologyEMD Serono Research & Development Institute, Inc.BillericaMassachusettsUSA
| | - Karthik Venkatakrishnan
- Quantitative PharmacologyEMD Serono Research & Development Institute, Inc.BillericaMassachusettsUSA
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10
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Mkhize B, Kellermann T, Norman J, Castel S, Joubert A, van der Merwe M, Dooley KE, Mathad JS, Wiesner L. Validation and application of a quantitative liquid chromatography tandem mass spectrometry assay for the analysis of rifapentine and 25-O-desacetyl rifapentine in human milk. J Pharm Biomed Anal 2022; 215:114774. [PMID: 35462285 PMCID: PMC9871952 DOI: 10.1016/j.jpba.2022.114774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/28/2022] [Accepted: 04/14/2022] [Indexed: 01/27/2023]
Abstract
A robust analytical method based on liquid chromatography coupled to tandem mass spectrometry was developed and validated to quantify rifapentine and 25-O-desacetyl rifapentine in human breast milk to aid in determining the breastfed infant risk to the excreted drug in human milk. Samples were extracted by a combination of protein precipitation and solid phase extraction using rifampicin-d3 as an internal standard. An Agilent® Poroshell 120 EC-C18 (4.6 mm × 50 mm, 2.7 µm) column was used for chromatographic separation employing an isocratic mobile phase consisting of acetonitrile: methanol: 0.1% formic acid (55/5/40, v/v/v) at a flow rate of 450 µL/min, and with a total run time of four minutes. Mass detection was on an AB Sciex API 4000 mass spectrometer using electrospray ionization in the positive mode and based on multiple reaction monitoring data acquisition. Rifapentine was accurately quantified across a concentration range of 2.00-2000 ng/mL and 25-O-desacetyl rifapentine from 4.00 to 2000 ng/mL. During validation, the inter- and intra-day accuracy and precision at the tested QC concentrations (N = 18) for rifapentine were between 97.4% and 100.6%, and 3.1% and 8.3%, respectively. The inter- and intra-day accuracy and precision for 25-O-desacetyl rifapentine were between 96.4% and 106.3%, and 6.7% and 11.8%, respectively. No significant matrix effects were observed, and the method was shown to be specific for rifapentine and 25-O-desacetyl rifapentine. Human milk samples (N = 22) generated during a phase I/II clinical trial were successfully analysed for rifapentine and 25-O-desacetyl rifapentine using this validated method. Concentrations for rifapentine and 25-O-desacetyl rifapentine in human milk samples (N = 22) ranged from 11.2-1180 ng/mL and 7.11-573 ng/mL, respectively.
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Affiliation(s)
- Buyisile Mkhize
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Tracy Kellermann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - Jennifer Norman
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sandra Castel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anton Joubert
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marthinus van der Merwe
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jyoti S Mathad
- Department of Medicine and Obstetrics and Gynecology, Center for Global Health, Weill Cornell Medicine, New York, NY, USA
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
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11
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MacDougall C, Canonica T, Keh C, P. Phan BA, Louie J. Systematic review of drug–drug interactions between rifamycins and anticoagulant and antiplatelet agents and considerations for management. Pharmacotherapy 2022; 42:343-361. [DOI: 10.1002/phar.2672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Conan MacDougall
- Department of Clinical Pharmacy University of California San Francisco School of Pharmacy San Francisco California USA
| | - Theora Canonica
- Department of Clinical Pharmacy San Francisco Veterans' Affairs Medical Center San Francisco California USA
| | - Chris Keh
- Division of Infectious Disease University of California, San Francisco San Francisco California USA
| | - Binh An P. Phan
- Division of Cardiology San Francisco General Hospital University of California, San Francisco San Francisco California USA
| | - Janice Louie
- Division of Infectious Diseases San Francisco Department of Public Health Tuberculosis Clinic University of California, San Francisco San Francisco California USA
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12
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Naidoo A, Naidoo K, Padayatchi N, Dooley KE. Use of integrase inhibitors in HIV-associated tuberculosis in high-burden settings: implementation challenges and research gaps. Lancet HIV 2022; 9:e130-e138. [PMID: 35120633 PMCID: PMC8970050 DOI: 10.1016/s2352-3018(21)00324-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/24/2021] [Accepted: 11/24/2021] [Indexed: 02/03/2023]
Abstract
People living with HIV have a higher risk of developing tuberculosis, and tuberculosis is one of the leading causes of death among people living with HIV globally. Treating HIV and tuberculosis concurrently has morbidity and mortality benefits. However, HIV and tuberculosis co-treatment is challenging due to drug-drug interactions, overlapping toxicities, tuberculosis-associated immune reconstitution syndrome, and concerns for treatment failure or drug resistance. Drug-drug interactions between antiretrovirals and tuberculosis drugs are driven mainly by the rifamycins (for example, the first-line tuberculosis drug rifampicin), and dose adjustments or drug switches during co-treatment are commonly required. Several implementation challenges and research gaps exist when combining the integrase strand transfer inhibitors (INSTIs), highly potent antiretroviral drugs recommended as first-line treatment of HIV, and drugs used for the treatment and prevention of tuberculosis. Ongoing and planned studies will address some critical questions on the use of INSTIs in settings with a high tuberculosis burden, including dosing of dolutegravir, bictegravir, and cabotegravir when used with the rifamycins for both tuberculosis treatment and prevention. Failure, in the past, to include people with tuberculosis in HIV clinical treatment trials has been responsible for some of the research gaps still evident for informing optimisation of HIV and tuberculosis co-treatment.
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13
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OUP accepted manuscript. J Pharm Pharmacol 2022; 74:905-917. [DOI: 10.1093/jpp/rgac004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/01/2022] [Indexed: 11/13/2022]
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14
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Humphries H, Almond L, Berg A, Gardner I, Hatley O, Pan X, Small B, Zhang M, Jamei M, Romero K. Development of physiologically-based pharmacokinetic models for standard of care and newer tuberculosis drugs. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2021; 10:1382-1395. [PMID: 34623770 PMCID: PMC8592506 DOI: 10.1002/psp4.12707] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 08/12/2021] [Accepted: 08/22/2021] [Indexed: 12/19/2022]
Abstract
Tuberculosis (TB) remains a global health problem and there is an ongoing effort to develop more effective therapies and new combination regimes that can reduce duration of treatment. The purpose of this study was to demonstrate utility of a physiologically‐based pharmacokinetic modeling approach to predict plasma and lung concentrations of 11 compounds used or under development as TB therapies (bedaquiline [and N‐desmethyl bedaquiline], clofazimine, cycloserine, ethambutol, ethionamide, isoniazid, kanamycin, linezolid, pyrazinamide, rifampicin, and rifapentine). Model accuracy was assessed by comparison of simulated plasma pharmacokinetic parameters with healthy volunteer data for compounds administered alone or in combination. Eighty‐four percent (area under the curve [AUC]) and 91% (maximum concentration [Cmax]) of simulated mean values were within 1.5‐fold of the observed data and the simulated drug‐drug interaction ratios were within 1.5‐fold (AUC) and twofold (Cmax) of the observed data for nine (AUC) and eight (Cmax) of the 10 cases. Following satisfactory recovery of plasma concentrations in healthy volunteers, model accuracy was assessed further (where patients’ with TB data were available) by comparing clinical data with simulated lung concentrations (9 compounds) and simulated lung: plasma concentration ratios (7 compounds). The 5th–95th percentiles for the simulated lung concentration data recovered between 13% (isoniazid and pyrazinamide) and 88% (pyrazinamide) of the observed data points (Am J Respir Crit Care Med, 198, 2018, 1208; Nat Med, 21, 2015, 1223; PLoS Med, 16, 2019, e1002773). The impact of uncertain model parameters, such as the fraction of drug unbound in lung tissue mass (fumass), is discussed. Additionally, the variability associated with the patient lung concentration data, which was sparse and included extensive within‐subject, interlaboratory, and experimental variability (as well interindividual variability) is reviewed. All presented models are transparently documented and are available as open‐source to aid further research.
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Affiliation(s)
| | - Lisa Almond
- Certara UK Limited, Simcyp Division, Sheffield, UK
| | | | - Iain Gardner
- Certara UK Limited, Simcyp Division, Sheffield, UK
| | | | - Xian Pan
- Certara UK Limited, Simcyp Division, Sheffield, UK
| | - Ben Small
- Certara UK Limited, Simcyp Division, Sheffield, UK
| | - Mian Zhang
- Certara UK Limited, Simcyp Division, Sheffield, UK
| | - Masoud Jamei
- Certara UK Limited, Simcyp Division, Sheffield, UK
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15
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Nazli A, He D, Xu H, Wang ZP, He Y. A Comparative Insight on the Newly Emerging Rifamycins: Rifametane, Rifalazil, TNP-2092 and TNP-2198. Curr Med Chem 2021; 29:2846-2862. [PMID: 34365945 DOI: 10.2174/0929867328666210806114949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 11/22/2022]
Abstract
Rifamycins are considered a milestone for tuberculosis (TB) treatment because of their proficient sterilizing ability. Currently, available TB treatments are complicated and need a long duration, which ultimately leads to failure of patient compliance. Some new rifamycin derivatives, i.e., rifametane, TNP-2092 (rifamycin-quinolizinonehybrid), and TNP-2198 (rifamycin-nitromidazole hybrid) are under clinical trials, which are attempting to overcome the problems associated with TB treatment. The undertaken review is intended to compare the pharmacokinetics, pharmacodynamics and safety profiles of these rifamycins, including rifalazil, another derivative terminated in phase II trials, and already approved rifamycins. The emerging resistance of microbes is an imperative consideration associated with antibiotics. Resistance development potential of microbial strains against rifamycins and an overview of chemistry, as well as structure-activity relationship (SAR) of rifamycins, are briefly described. Moreover, issues associated with rifamycins are discussed as well. We expect that newly emerging rifamycins shall appear as potential tools for TB treatment in the near future.
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Affiliation(s)
- Adila Nazli
- Chongqing Key Laboratory of Natural Product Synthesis and Drug Research, School of Pharmaceutical Sciences, Chongqing University, Chongqing. China
| | - David He
- Chongqing Key Laboratory of Natural Product Synthesis and Drug Research, School of Pharmaceutical Sciences, Chongqing University, Chongqing. China
| | - Huacheng Xu
- Chongqing Key Laboratory of Natural Product Synthesis and Drug Research, School of Pharmaceutical Sciences, Chongqing University, Chongqing. China
| | - Zhi-Peng Wang
- Chongqing Key Laboratory of Natural Product Synthesis and Drug Research, School of Pharmaceutical Sciences, Chongqing University, Chongqing. China
| | - Yun He
- Chongqing Key Laboratory of Natural Product Synthesis and Drug Research, School of Pharmaceutical Sciences, Chongqing University, Chongqing. China
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16
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Mehtani NJ, Puryear S, Pham P, Dooley KE, Shah M. Infectious Diseases Learning Unit: Understanding Advances in the Treatment of Latent Tuberculosis Infection Among People With Human Immunodeficiency Virus. Open Forum Infect Dis 2021; 8:ofab319. [PMID: 34395707 PMCID: PMC8361237 DOI: 10.1093/ofid/ofab319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/15/2021] [Indexed: 12/04/2022] Open
Abstract
Tuberculosis (TB) remains the leading cause of death among people with human immunodeficiency virus (PWH). The diagnosis of latent TB infection (LTBI) and treatment with TB preventative therapy (TPT) can reduce morbidity and mortality in this population. Historically, isoniazid has been recommended for TPT in PWH due to the absence of drug-drug interactions with most antiretroviral therapy (ART). However, newer rifamycin-based regimens are safer, shorter in duration, associated with improved adherence, and may be as or more effective than isoniazid TPT. Current guidelines have significant heterogeneity in their recommendations for TPT regimens and acceptability of drug interactions with modern ART. In this Infectious Diseases learning unit, we review common questions on diagnosis, treatment, and drug interactions related to the management of LTBI among PWH.
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Affiliation(s)
- Nicky J Mehtani
- University of California, San Francisco, Department of Medicine, Division of HIV, Infectious Diseases, and Global Medicine, San Francisco, California, USA
| | - Sarah Puryear
- University of California, San Francisco, Department of Medicine, Division of HIV, Infectious Diseases, and Global Medicine, San Francisco, California, USA
| | - Paul Pham
- Johns Hopkins University, Department of Medicine, Division of Infectious Diseases, Baltimore, Maryland, USA
| | - Kelly E Dooley
- Johns Hopkins University, Department of Medicine, Division of Clinical Pharmacology, Baltimore, Maryland, USA
| | - Maunank Shah
- Johns Hopkins University, Department of Medicine, Division of Infectious Diseases, Baltimore, Maryland, USA
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17
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Podany AT, Leon-Cruz J, Hakim J, Supparatpinyo K, Omoz-Oarhe A, Langat D, Mwelase N, Kanyama C, Gupta A, Benson CA, Chaisson RE, Swindells S, Fletcher CV. Nevirapine pharmacokinetics in HIV-infected persons receiving rifapentine and isoniazid for TB prevention. J Antimicrob Chemother 2021; 76:718-721. [PMID: 33241266 DOI: 10.1093/jac/dkaa470] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/19/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The use of rifamycin antibiotics for TB prevention carries a risk of detrimental drug-drug interactions with concomitantly used ART. OBJECTIVES To evaluate the interaction of the antiretroviral drug nevirapine in combination with 4 weeks of daily rifapentine and isoniazid for TB prevention in people living with HIV. METHODS Participants were individuals enrolled in the BRIEF-TB study receiving nevirapine and randomized to the rifapentine/isoniazid arm of the study. Participants provided sparse pharmacokinetic (PK) sampling at baseline and weeks 2 and 4 for trough nevirapine determination. Nevirapine apparent oral clearance (CL/F) was estimated and the geometric mean ratio (GMR) of CL/F prior to and during rifapentine/isoniazid was calculated. RESULTS Seventy-eight participants had evaluable PK data: 61 (78%) female, 51 (65%) black non-Hispanic and median (range) age of 40 (13-66) years. Median (IQR) nevirapine trough concentrations were: week 0, 7322 (5266-9302) ng/mL; week 2, 5537 (3552-8462) ng/mL; and week 4, 5388 (3516-8243) ng/mL. Sixty out of 78 participants (77%) had nevirapine concentrations ≥3000 ng/mL at both week 2 and 4. Median (IQR) nevirapine CL/F values were: week 0 pre-rifapentine/isoniazid, 2.03 (1.58-2.58) L/h; and during rifapentine/isoniazid, 2.62 (1.81-3.42) L/h. The GMR (90% CI) for nevirapine CL/F was 1.30 (1.26-1.33). CONCLUSIONS The CL/F of nevirapine significantly increased with concomitant rifapentine/isoniazid. The decrease in nevirapine trough concentrations during rifapentine/isoniazid therapy suggests induction of nevirapine metabolism, consistent with known rifapentine effects. The magnitude of this drug-drug interaction suggests daily rifapentine/isoniazid for TB prevention should not be co-administered with nevirapine-containing ART.
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Affiliation(s)
- A T Podany
- University of Nebraska Medical Center, Omaha, NE, USA
| | - J Leon-Cruz
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - J Hakim
- Parirenyatwa CRS, Harare, Zimbabwe
| | - K Supparatpinyo
- Chiang Mai University HIV Treatment CRS, Chiang Mai, Thailand
| | - A Omoz-Oarhe
- Molepolole Clinical Research Site, Molepolole, Botswana
| | - D Langat
- Kenya Medical Research Institute/Walter Reed Project Clinical Research Center CRS, Kericho, Kenya
| | - N Mwelase
- University of the Witwatersrand Helen Joseph CRS, Johannesburg, South Africa
| | | | - A Gupta
- Johns Hopkins Hospital, Baltimore, MD, USA
| | - C A Benson
- University of California San Diego, San Diego, CA, USA
| | | | - S Swindells
- University of Nebraska Medical Center, Omaha, NE, USA
| | - C V Fletcher
- University of Nebraska Medical Center, Omaha, NE, USA
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18
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Boorgula GD, Jakkula LUMR, Gumbo T, Jung B, Srivastava S. Comparison of Rifamycins for Efficacy Against Mycobacterium avium Complex and Resistance Emergence in the Hollow Fiber Model System. Front Pharmacol 2021; 12:645264. [PMID: 33935740 PMCID: PMC8085489 DOI: 10.3389/fphar.2021.645264] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/04/2021] [Indexed: 11/13/2022] Open
Abstract
Rifamycins are integral part of the combination regimen for treatment of pulmonary Mycobacterium avium-complex [MAC] infection, but different practitioners prefer different rifamycins. The objective of the study was to compare microbial kill and resistance emergence of rifamycins using principles of pharmacokinetics/pharmacodynamics. First, we identified rifamycin MICs in 20 MAC isolates from patients followed by concentration-response studies in test-tubes. Next, we examined efficacy and resistance suppression of three doses of each rifamycin in the hollow fiber system model of pulmonary MAC [HFS-MAC], mimicking human like concentration-time profile of the drugs. HFS-MAC units were repetitively sampled for total and drug-resistant MAC burden and for drug concentration measurements. Inhibitory sigmoid E max model, linear regression, and analysis of variance was used for data analysis. For rifabutin 90% of isolates had MIC ≤ 0.125 mg/L while for both rifampin and rifapentine this was ≤2.0 mg/L. There was no statistically significant difference (p > 0.05) in maximal kill and effective concentration mediating 50% of the bacterial kill among three rifamycins in the static concentration experiment. In the HFS-MAC, the bactericidal kill (day 0-4) for rifampin was 0.89 (95% Confidence Interval (CI): 0.43-1.35), for rifapentine was 1.05 (95% CI: 0.08-1.23), and for rifabutin was 0.92 (95% CI: 0.61-1.24) log10 CFU/ml, respectively. Rifamycins monotherapy failed after just 4-days of treatment and entire MAC population was drug resistant on day 26 of the study. There was no dose dependent difference in MAC kill or resistance suppression among the three rifamycins tested in the HFS-MAC. Therefore, replacing one rifamycin, due to emergence of drug-resistance, with other may not be beneficial in clinical setting.
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Affiliation(s)
- Gunavanthi D. Boorgula
- Department of Pulmonary Immunology, University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Laxmi U. M. R. Jakkula
- Department of Pulmonary Immunology, University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Tawanda Gumbo
- Quantitative Preclinical and Clinical Sciences Department, Praedicare Inc., Dallas, TX, United States
| | - Bockgie Jung
- Department of Pulmonary Immunology, University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Shashikant Srivastava
- Department of Pulmonary Immunology, University of Texas Health Science Center at Tyler, Tyler, TX, United States
- Department of Immunology, UT Southwestern Medical Center, Dallas, TX, United States
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Tsutsui H, Kuramoto S, Ozeki K. Evaluation of Methods to Assess CYP3A Induction Risk in Clinical Practice Using in Vitro Induction Parameters. Biol Pharm Bull 2021; 44:338-349. [PMID: 33642543 DOI: 10.1248/bpb.b20-00578] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Established guidelines have recommended a number of methods based on in vitro data to assess the CYP3A induction risk of new chemical entities in clinical practice. In this study, we evaluated the predictability of various assessment methods. We collected in vitro parameters from a variety of literature that includes data on 19 batches of hepatocytes. Clinical CYP3A induction was predicted using 3 direct approaches-the fold-change, basic model, and mechanistic static models-as well as 5 correlation approaches, including the relative induction score (RIS) and the relative factor (RF) method. These predictions were then compared with data from 30 clinical inductions. Collected in vitro parameters varied greatly between hepatocyte batches. Direct assessment methods using fixed cut-off values provided a lot of false predictions due to hepatocyte variability, which can overlook induction risk or lead to needless clinical drug-drug interaction (DDI) studies. On the other hand, correlation methods with the cut-off values set for each batch of hepatocytes accurately predicted the induction risk. Among these, the AUCu/inducer concentrations for half the maximum induction (EC50) and the RF methods which use the area under the curve (AUC) of the unbound inducers for calculating induction potential showed an especially good correlation with clinical induction. Correlation methods were better at predicting clinical induction risk than the other methods, regardless of hepatocyte variability. The AUCu/EC50 and the RF methods in particular had a small number of false predictions, and can therefore be used to assess induction risk along with the other correlation methods recommended in guidelines.
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20
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Ultra-short-course and intermittent TB47-containing oral regimens produce stable cure against Buruli ulcer in a murine model and prevent the emergence of resistance for Mycobacterium ulcerans. Acta Pharm Sin B 2021; 11:738-749. [PMID: 33777679 PMCID: PMC7982501 DOI: 10.1016/j.apsb.2020.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/01/2020] [Accepted: 09/07/2020] [Indexed: 12/13/2022] Open
Abstract
Buruli ulcer (BU), caused by Mycobacterium ulcerans, is currently treated with rifampin-streptomycin or rifampin-clarithromycin daily for 8 weeks recommended by World Health Organization (WHO). These options are lengthy with severe side effects. A new anti-tuberculosis drug, TB47, targeting QcrB in cytochrome bc1:aa3 complex is being developed in China. TB47-containing regimens were evaluated in a well-established murine model using an autoluminescent M. ulcerans strain. High-level TB47-resistant spontaneous M. ulcerans mutants were selected and their qcrB genes were sequenced. The in vivo activities of TB47 against both low-level and high-level TB47-resistant mutants were tested in BU murine model. Here, we show that TB47-containing oral 3-drug regimens can completely cure BU in ≤2 weeks for daily use or in ≤3 weeks given twice per week (6 doses in total). All high-level TB47-resistant mutants could only be selected using the low-level mutants which were still sensitive to TB47 in mice. This is the first report of double mutations in QcrB in mycobacteria. In summary, TB47-containing regimens have promise to cure BU highly effectively and prevent the emergence of drug resistance. Novel QcrB mutations found here may guide the potential clinical molecular diagnosis of resistance and the discovery of new drugs against the high-level resistant mutants.
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21
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Weiner M, Gelfond J, Johnson-Pais TL, Engle M, Johnson JL, Whitworth WC, Bliven-Sizemore E, Nsubuga P, Dorman SE, Savic R. Decreased plasma rifapentine concentrations associated with AADAC single nucleotide polymorphism in adults with tuberculosis. J Antimicrob Chemother 2021; 76:582-586. [PMID: 33374006 DOI: 10.1093/jac/dkaa490] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/29/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Rifapentine exposure is associated with bactericidal activity against Mycobacterium tuberculosis, but high interindividual variation in plasma concentrations is encountered. OBJECTIVES To investigate a genomic association with interindividual variation of rifapentine exposure, SNPs of six human genes involving rifamycin metabolism (AADAC, CES2), drug transport (SLCO1B1, SLCO1B3) and gene regulation (HNF4A, PXR) were evaluated. METHODS We characterized these genes in 173 adult participants in treatment trials of the Tuberculosis Trials Consortium. Participants were stratified by self-identified race (black or non-black), and rifapentine AUC from 0 to 24 h (AUC0-24) was adjusted by analysis of covariance for SNPs, rifapentine dose, sex, food and HIV coinfection. This study was registered at ClinicalTrials.gov under identifier NCT01043575. RESULTS The effect on rifapentine least squares mean AUC0-24 in black participants overall decreased by -10.2% for AADAC rs1803155 G versus A allele (Wald test: P = 0.03; false discovery rate, 0.10). Black participants with one G allele in AADAC rs1803155 were three times as likely to have below target bactericidal rifapentine exposure than black participants with the A allele (OR, 2.97; 95% CI: 1.16, 7.58). With two G alleles, the OR was greater. In non-black participants, AADAC rs1803155 SNP was not associated with rifapentine exposure. In both black and non-black participants, other evaluated genes were not associated with rifapentine exposure (P > 0.05; false discovery rate > 0.10). CONCLUSIONS Rifapentine exposure in black participants varied with AADAC rs1803155 genotype and the G allele was more likely to be associated with below bactericidal target rifapentine exposure. Further pharmacogenomic study is needed to characterize the association of the AADAC rs1803155 with inadequate rifapentine exposure in different patient groups.
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Affiliation(s)
- Marc Weiner
- University of Texas Health Science Center San Antonio, San Antonio, TX, USA.,South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Jon Gelfond
- University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | | | - Melissa Engle
- University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - John L Johnson
- Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - William C Whitworth
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Erin Bliven-Sizemore
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Pheona Nsubuga
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Susan E Dorman
- Medical University of South Carolina, Charleston, SC, USA
| | - Rada Savic
- University of California San Francisco, San Francisco, CA, USA
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22
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Miura M, Uchida S, Tanaka S, Kamiya C, Katayama N, Hakamata A, Odagiri K, Inui N, Kawakami J, Watanabe H, Namiki N. Verification of a cocktail approach for quantitative drug-drug interaction assessment: a comparative analysis between the results of a single drug and a cocktail drug. Xenobiotica 2021; 51:404-412. [PMID: 33393430 DOI: 10.1080/00498254.2020.1867330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
A cocktail approach is a method to comprehensively evaluate the activity of cytochrome P450 enzymes (CYPs) by co-administering multiple CYP substrates. This is the first report that compares the results from a cocktail study to a single substrate separate administration study (single study) with concomitant administration of CYP inducers/inhibitors. The validity of a cocktail study for use as a quantitative drug-drug interactions (DDIs) assessment was evaluated.We administered a cocktail drug (caffeine, losartan, omeprazole, dextromethorphan, midazolam) with rifampicin, cimetidine or fluvoxamine. A comparative analysis was performed between the results of a cocktail study and single studies. The results of single studies were obtained from a literature review and the trials of single substrate separate administration.A strong positive correlation of the AUC ratio of all drugs between single studies and the cocktail study was obtained. The ratio of AUC change of 12 combinations converged to 0.82-1.09, and 2 combinations ranged between 0.74-1.32.The differences in the degree of interaction between the single studies and cocktail study are acceptable to evaluate DDIs for almost all combinations. Our results indicate that a cocktail study is an adequate and quantitative evaluation method for DDIs.
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Affiliation(s)
- Motoyasu Miura
- Departments of Pharmacy Practice and Science, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan.,Hospital Pharmacy, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Shinya Uchida
- Departments of Pharmacy Practice and Science, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Shimako Tanaka
- Departments of Pharmacy Practice and Science, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Chiaki Kamiya
- Department of Clinical Pharmacology and Therapeutics, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Naoki Katayama
- Department of Clinical Pharmacology and Therapeutics, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Akio Hakamata
- Department of Clinical Pharmacology and Therapeutics, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Keiichi Odagiri
- Department of Clinical Pharmacology and Therapeutics, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Naoki Inui
- Department of Clinical Pharmacology and Therapeutics, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Junichi Kawakami
- Hospital Pharmacy, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hiroshi Watanabe
- Department of Clinical Pharmacology and Therapeutics, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Noriyuki Namiki
- Departments of Pharmacy Practice and Science, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
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23
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Haas DW, Podany AT, Bao Y, Swindells S, Chaisson RE, Mwelase N, Supparatpinyo K, Mohapi L, Gupta A, Benson CA, Baker P, Fletcher CV. Pharmacogenetic interactions of rifapentine plus isoniazid with efavirenz or nevirapine. Pharmacogenet Genomics 2021; 31:17-27. [PMID: 32815870 PMCID: PMC7655626 DOI: 10.1097/fpc.0000000000000417] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES The effect of rifapentine plus isoniazid on efavirenz pharmacokinetics was characterized in AIDS Clinical Trials Group protocol A5279 (NCT01404312). The present analyses characterize pharmacogenetic interactions between these drugs, and with nevirapine. METHODS A subset of HIV-positive individuals receiving efavirenz- or nevirapine-containing antiretroviral therapy in A5279 underwent pharmacokinetic evaluations at baseline, and again weeks 2 and 4 after initiating daily rifapentine plus isoniazid. Associations with polymorphisms relevant to efavirenz, nevirapine, isoniazid, and rifapentine pharmacokinetics were assessed. RESULTS Of 128 participants, 101 were evaluable for associations with rifapentine and its active 25-desacetyl metabolite, 87 with efavirenz, and 38 with nevirapine. In multivariable analyses, NAT2 slow acetylators had greater week 4 plasma concentrations of rifapentine (P = 2.6 × 10) and 25-desacetyl rifapentine (P = 7.0 × 10) among all participants, and in efavirenz and nevirapine subgroups. NAT2 slow acetylators also had greater plasma efavirenz and nevirapine concentration increases from baseline to week 4, and greater decreases from baseline in clearance. CYP2B6 poor metabolizers had greater efavirenz concentrations at all weeks and greater nevirapine concentrations at baseline. None of 47 additional polymorphisms in 11 genes were significantly associated with pharmacokinetics. CONCLUSIONS Among HIV-positive individuals receiving efavirenz or nevirapine, and who then initiated rifapentine plus isoniazid in A5279, NAT2 slow acetylators had greater rifapentine and 25-desacetyl rifapentine concentrations, and greater increases from baseline in plasma efavirenz and nevirapine concentrations. These associations are likely mediated by greater isoniazid exposure in NAT2 slow acetylators.
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Affiliation(s)
- David W Haas
- Department of Medicine, Vanderbilt University School of Medicine
| | - Anthony T Podany
- Department of Pharmacy Practice and Science, Antiviral Pharmacology Laboratory, UNMC Center for Drug Discovery, University of Nebraska Medical Center, Omaha
| | - Yajing Bao
- Statistical and Data Analysis Center, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Susan Swindells
- Infectious Diseases, Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Richard E Chaisson
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Noluthando Mwelase
- Helen Joseph Hospital, University of Witwatersrand University, Johannesburg, South Africa
| | - Khuanchai Supparatpinyo
- Department of Medicine, Research Institute for Health Sciences and Faculty of Medicine, Chiang Mai University, Thailand
| | - Lerato Mohapi
- Perinatal HIV Research Unit, University of the Witwatersrand and Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - Amita Gupta
- Department of Medicine, Center for Clinical Global Health Education, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Constance A Benson
- Departments of Medicine and Global Public Health, Antiviral Research Center, University of California, San Diego
| | - Paxton Baker
- Vanderbilt Technologies for Advanced Genomics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Courtney V Fletcher
- Department of Pharmacy Practice and Science, Antiviral Pharmacology Laboratory, UNMC Center for Drug Discovery, University of Nebraska Medical Center, Omaha; for the AIDS Clinical Trials Group A5279 Study Team
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24
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Hibma JE, Radtke KK, Dorman SE, Jindani A, Dooley KE, Weiner M, McIlleron HM, Savic RM. Rifapentine Population Pharmacokinetics and Dosing Recommendations for Latent Tuberculosis Infection. Am J Respir Crit Care Med 2020; 202:866-877. [PMID: 32412342 DOI: 10.1164/rccm.201912-2489oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Rifapentine has been investigated at various doses, frequencies, and dosing algorithms, but clarity on the optimal dosing approach is lacking.Objectives: To characterize rifapentine population pharmacokinetics, including autoinduction, and determine optimal dosing strategies for short-course rifapentine-based regimens for latent tuberculosis infection.Methods: Rifapentine pharmacokinetic studies were identified though a systematic review of literature. Individual plasma concentrations were pooled, and nonlinear mixed-effects modeling was performed. A subset of data was reserved for external validation. Simulations were performed under various dosing conditions, including current weight-based methods; and alternative methods driven by identified covariates.Measurements and Main Results: We identified nine clinical studies with a total of 863 participants with pharmacokinetic data (n = 4,301 plasma samples). Rifapentine population pharmacokinetics were described successfully with a one-compartment distribution model. Autoinduction of clearance was driven by rifapentine plasma concentrations. The maximum effect was a 72% increase in clearance and was reached after 21 days. Drug bioavailability decreased by 27% with HIV infection, decreased by 28% with fasting, and increased by 49% with a high-fat meal. Body weight was not a clinically relevant predictor of clearance. Pharmacokinetic simulations showed that current weight-based dosing leads to lower exposures in individuals with low weight, which can be overcome with flat dosing. In HIV-positive patients, 30% higher doses are required to match drug exposure in HIV-negative patients.Conclusions: Weight-based dosing of rifapentine should be removed from clinical guidelines, and higher doses for HIV-positive patients should be considered to provide equivalent efficacy.
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Affiliation(s)
- Jennifer E Hibma
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California
| | - Kendra K Radtke
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California
| | - Susan E Dorman
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Amina Jindani
- St. George's, University of London, London, United Kingdom
| | - Kelly E Dooley
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Marc Weiner
- Department of Medicine, University of Texas Health Science Center, San Antonio, Texas.,South Texas Veterans Administration Medical Center, San Antonio, Texas; and
| | - Helen M McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Radojka M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California
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25
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Dorman SE, Nahid P, Kurbatova EV, Goldberg SV, Bozeman L, Burman WJ, Chang KC, Chen M, Cotton M, Dooley KE, Engle M, Feng PJ, Fletcher CV, Ha P, Heilig CM, Johnson JL, Lessem E, Metchock B, Miro JM, Nhung NV, Pettit AC, Phillips PPJ, Podany AT, Purfield AE, Robergeau K, Samaneka W, Scott NA, Sizemore E, Vernon A, Weiner M, Swindells S, Chaisson RE. High-dose rifapentine with or without moxifloxacin for shortening treatment of pulmonary tuberculosis: Study protocol for TBTC study 31/ACTG A5349 phase 3 clinical trial. Contemp Clin Trials 2020; 90:105938. [PMID: 31981713 PMCID: PMC7307310 DOI: 10.1016/j.cct.2020.105938] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/17/2020] [Accepted: 01/20/2020] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Phase 2 clinical trials of tuberculosis treatment have shown that once-daily regimens in which rifampin is replaced by high dose rifapentine have potent antimicrobial activity that may be sufficient to shorten overall treatment duration. Herein we describe the design of an ongoing phase 3 clinical trial testing the hypothesis that once-daily regimens containing high dose rifapentine in combination with other anti-tuberculosis drugs administered for four months can achieve cure rates not worse than the conventional six-month treatment regimen. METHODS/DESIGN S31/A5349 is a multicenter randomized controlled phase 3 non-inferiority trial that compares two four-month regimens with the standard six-month regimen for treating drug-susceptible pulmonary tuberculosis in HIV-negative and HIV-positive patients. Both of the four-month regimens contain high-dose rifapentine instead of rifampin, with ethambutol replaced by moxifloxacin in one regimen. All drugs are administered seven days per week, and under direct observation at least five days per week. The primary outcome is tuberculosis disease-free survival at twelve months after study treatment assignment. A total of 2500 participants will be randomized; this gives 90% power to show non-inferiority with a 6.6% margin of non-inferiority. DISCUSSION This phase 3 trial formally tests the hypothesis that augmentation of rifamycin exposures can shorten tuberculosis treatment to four months. Trial design and standardized implementation optimize the likelihood of obtaining valid results. Results of this trial may have important implications for clinical management of tuberculosis at both individual and programmatic levels. TRIAL REGISTRATION NCT02410772. Registered 8 April 2015,https://www.clinicaltrials.gov/ct2/show/NCT02410772?term=02410772&rank=1.
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Affiliation(s)
- Susan E Dorman
- Medical University of South Carolina, Charleston, SC, USA.
| | - Payam Nahid
- University of California, San Francisco, California, USA
| | | | | | - Lorna Bozeman
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Kwok-Chiu Chang
- Tuberculosis and Chest Service, Department of Health, Hong Kong
| | - Michael Chen
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mark Cotton
- Stellenbosch University, Cape Town, South Africa
| | - Kelly E Dooley
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Melissa Engle
- Audie L. Murphy Veterans Affairs Medical Center / University of Texas Health Science Center, San Antonio, TX, USA
| | - Pei-Jean Feng
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Phan Ha
- Vietnam National TB Program (NTP)/UCSF Research Collaboration, Hanoi, Viet Nam
| | | | - John L Johnson
- Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda
| | | | | | - Jose M Miro
- Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Nguyen Viet Nhung
- Vietnam National TB Program (NTP)/UCSF Research Collaboration, Hanoi, Viet Nam
| | - April C Pettit
- Vanderbilt University Medical Center, Department of Medicine, Division of Infectious Diseases, Nashville, TN, USA
| | | | | | - Anne E Purfield
- US Centers for Disease Control and Prevention, Atlanta, GA, USA; U.S. Public Health Service Commissioned Corps, Rockville, MD, USA
| | | | | | - Nigel A Scott
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Erin Sizemore
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Andrew Vernon
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Marc Weiner
- Audie L. Murphy Veterans Affairs Medical Center / University of Texas Health Science Center, San Antonio, TX, USA
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26
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Cerrone M, Bracchi M, Wasserman S, Pozniak A, Meintjes G, Cohen K, Wilkinson RJ. Safety implications of combined antiretroviral and anti-tuberculosis drugs. Expert Opin Drug Saf 2020; 19:23-41. [PMID: 31809218 PMCID: PMC6938542 DOI: 10.1080/14740338.2020.1694901] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/15/2019] [Indexed: 01/01/2023]
Abstract
Introduction: Antiretroviral and anti-tuberculosis (TB) drugs are often co-administered in people living with HIV (PLWH). Early initiation of antiretroviral therapy (ART) during TB treatment improves survival in patients with advanced HIV disease. However, safety concerns related to clinically significant changes in drug exposure resulting from drug-drug interactions, development of overlapping toxicities and specific challenges related to co-administration during pregnancy represent barriers to successful combined treatment for HIV and TB.Areas covered: Pharmacokinetic interactions of different classes of ART when combined with anti-TB drugs used for sensitive-, drug-resistant (DR) and latent TB are discussed. Overlapping drug toxicities, implications of immune reconstitution inflammatory syndrome (IRIS), safety in pregnancy and research gaps are also explored.Expert opinion: New antiretroviral and anti-tuberculosis drugs have been recently introduced and international guidelines updated. A number of effective molecules and clinical data are now available to build treatment regimens for PLWH with latent or active TB. Adopting a systematic approach that also takes into account the need for individualized variations based on the available evidence is the key to successfully integrate ART and TB treatment and improve treatment outcomes.
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Affiliation(s)
- Maddalena Cerrone
- Department of Medicine, Imperial College London, W2 1PG, UK
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory 7925, South Africa
- Department of HIV, Chelsea and Westminster Hospital NHS Trust, London, UK
- Francis Crick Institute, London, NW1 1AT, UK
| | - Margherita Bracchi
- Department of HIV, Chelsea and Westminster Hospital NHS Trust, London, UK
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory 7925, South Africa
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anton Pozniak
- Department of HIV, Chelsea and Westminster Hospital NHS Trust, London, UK
- The London School of Hygiene & Tropical Medicine
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory 7925, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Robert J Wilkinson
- Department of Medicine, Imperial College London, W2 1PG, UK
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory 7925, South Africa
- Francis Crick Institute, London, NW1 1AT, UK
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27
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Brooks KM, George JM, Pau AK, Rupert A, Mehaffy C, De P, Dobos KM, Kellogg A, McLaughlin M, McManus M, Alfaro RM, Hadigan C, Kovacs JA, Kumar P. Cytokine-Mediated Systemic Adverse Drug Reactions in a Drug-Drug Interaction Study of Dolutegravir With Once-Weekly Isoniazid and Rifapentine. Clin Infect Dis 2019; 67:193-201. [PMID: 29415190 DOI: 10.1093/cid/ciy082] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 02/01/2018] [Indexed: 12/18/2022] Open
Abstract
Background Once-weekly isoniazid and rifapentine for 3 months is a treatment option in persons with human immunodeficiency virus and latent tuberculosis infection. This study aimed to examine pharmacokinetic drug-drug interactions between this regimen and dolutegravir, a first-line antiretroviral medication. Methods This was a single-center, open-label, fixed-sequence, drug-drug interaction study in healthy volunteers. Subjects received oral dolutegravir 50 mg once daily alone (days 1-4) and concomitantly with once-weekly isoniazid 900 mg, rifapentine 900 mg, and pyridoxine 50 mg (days 5-19). Dolutegravir concentrations were measured on days 4, 14, and 19, and rifapentine, 25-desacetyl-rifapentine, and isoniazid concentrations were measured on day 19. Cytokines and antidrug antibodies to isoniazid and rifapentine were examined at select time points. Results The study was terminated following the development of flu-like syndrome and elevated aminotransferase levels in 2 of 4 subjects after the third isoniazid-rifapentine dose. Markedly elevated levels of interferon-γ, CXCL10, C-reactive protein, and other cytokines were temporally associated with symptoms. Antidrug antibodies were infrequently detected. Dolutegravir area under the curve (AUC) was decreased by 46% (90% confidence interval, 27-110%; P = .13) on day 14. Rifapentine and 25-desacetyl rifapentine levels on day 19 were comparable to reference data, whereas isoniazid AUCs were approximately 67%-92% higher in the subjects who developed toxicities. Conclusions The combined use of dolutegravir with once-weekly isoniazid-rifapentine resulted in unexpected and serious toxicities that were mediated by endogenous cytokine release. Additional investigations are necessary to examine the safety and efficacy of coadministering these medications. Clinical Trials Registration NCT02771249.
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Affiliation(s)
- Kristina M Brooks
- Clinical Pharmacokinetics Research Unit, Pharmacy Department, Clinical Center, National Institutes of Health (NIH), Frederick, Maryland
| | - Jomy M George
- Clinical Pharmacokinetics Research Unit, Pharmacy Department, Clinical Center, National Institutes of Health (NIH), Frederick, Maryland
| | - Alice K Pau
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Frederick, Maryland
| | - Adam Rupert
- AIDS Monitoring Laboratory, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc, Frederick, Maryland
| | - Carolina Mehaffy
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins
| | - Prithwiraj De
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins
| | - Karen M Dobos
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins
| | - Anela Kellogg
- Clinical Monitoring Research Program, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc, Frederick, Bethesda, Maryland
| | | | - Maryellen McManus
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland
| | - Raul M Alfaro
- Clinical Pharmacokinetics Research Unit, Pharmacy Department, Clinical Center, National Institutes of Health (NIH), Frederick, Maryland
| | | | - Joseph A Kovacs
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland
| | - Parag Kumar
- Clinical Pharmacokinetics Research Unit, Pharmacy Department, Clinical Center, National Institutes of Health (NIH), Frederick, Maryland
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28
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A Pharmacology Perspective of Simultaneous Tuberculosis and Hepatitis C Treatment. Antimicrob Agents Chemother 2019:AAC.01215-19. [PMID: 31591118 DOI: 10.1128/aac.01215-19] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Tuberculosis (TB) and hepatitis C virus (HCV) infection are both major public health problems. Despite high rates of co-infection there is scarce literature addressing the convergence of the two diseases. One particularly unexplored area is the potential for simultaneous treatment of TB and HCV which would allow for leveraging an extensive global TB treatment infrastructure to help scale up HCV treatment. We review the drug metabolism of anti-TB and HCV drugs and the known and potential drug-drug interactions between recommended HCV regimens and individual anti-TB drugs. Rifampin is the only anti-TB drug to have been formally studied for potential drug interactions with anti-HCV direct-acting antivirals (DAAs) and existing data precludes these combinations. However, based on known pathways of drug metabolism and enzyme effects, the combination of HCV DAA regimens with all other anti-TB drugs may be feasible. Pharmacokinetic studies are needed next to help move co treatment regimens forward for clinical use among patients coinfected with TB and HCV.
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29
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Rifat D, Prideaux B, Savic RM, Urbanowski ME, Parsons TL, Luna B, Marzinke MA, Ordonez AA, DeMarco VP, Jain SK, Dartois V, Bishai WR, Dooley KE. Pharmacokinetics of rifapentine and rifampin in a rabbit model of tuberculosis and correlation with clinical trial data. Sci Transl Med 2019; 10:10/435/eaai7786. [PMID: 29618565 DOI: 10.1126/scitranslmed.aai7786] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 12/20/2016] [Accepted: 09/29/2017] [Indexed: 12/18/2022]
Abstract
In clinical trials of two rifamycin antibiotics (rifampin and rifapentine) for treating tuberculosis (TB), patients with cavitary lung lesions did not appear to derive benefit from rifapentine. Rifapentine was found not to outperform rifampin, despite a lower minimum inhibitory concentration against Mycobacterium tuberculosis in mouse models of TB. To understand these findings, we have developed a rabbit model of TB that reliably develops lung cavities with features similar to those of patients with pulmonary cavitary TB. After single or multiple doses of rifampin or rifapentine that produced human-equivalent plasma exposures, rabbits were sacrificed at different time points after dosing. We measured site-of-disease drug pharmacokinetics and tissue drug distribution. We used pharmacokinetic-pharmacodynamic (PK/PD) modeling to estimate drug penetration into different types of tubercular lesions. Both drugs penetrated rabbit lung cellular lesions, as well as the fibrotic cavity wall of cavitary lesions (penetration coefficients ≥1 compared to plasma). For the necrotic liquefied material inside cavitary lesions known as caseum (which contains high numbers of bacteria), the penetration coefficient was 1.0 for rifampin but only 0.25 for rifapentine. When estimates of site-of-disease drug PK were substituted into clinical PK/PD models, the relationship between site-of-action exposure and sputum culture conversion was significant (P < 10-7). We propose that poor penetration of rifapentine into lung cavitary lesions explains, in part, why rifapentine doses required to improve treatment outcomes in two phase 2 clinical trials were four times higher in TB patients with large cavities compared to TB patients without cavitary lung disease.
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Affiliation(s)
- Dalin Rifat
- Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Brendan Prideaux
- Rutgers New Jersey Medical School, Public Health Research Institute, Newark, NJ 07103, USA
| | - Radojka M Savic
- Department of Bioengineering, University of California at San Francisco School of Pharmacy, San Francisco, CA 94117, USA
| | | | - Teresa L Parsons
- Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Brian Luna
- Department of Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA
| | - Mark A Marzinke
- Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Alvaro A Ordonez
- Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Vincent P DeMarco
- Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Sanjay K Jain
- Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Veronique Dartois
- Rutgers New Jersey Medical School, Public Health Research Institute, Newark, NJ 07103, USA
| | - William R Bishai
- Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Kelly E Dooley
- Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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Rajoli RKR, Podany AT, Moss DM, Swindells S, Flexner C, Owen A, Siccardi M. Modelling the long-acting administration of anti-tuberculosis agents using PBPK: a proof of concept study. Int J Tuberc Lung Dis 2019; 22:937-944. [PMID: 29991405 DOI: 10.5588/ijtld.17.0515] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Anti-tuberculosis formulations necessitate uninterrupted treatment to cure tuberculosis (TB), but are characterised by suboptimal adherence, which jeopardises therapeutic efficacy. Long-acting injectable (LAI) formulations or implants could address these associated issues. OBJECTIVE niazid, rifapentine, bedaquiline and delamanid-in adults for treatment for latent tuberculous infection (LTBI). DESIGN PBPK models were developed and qualified against available clinical data by integrating drug physicochemical properties and in vitro and population pharmacokinetic data into a mechanistic description of drug distribution. Combinations of optimal dose and release rates were simulated such that plasma concentrations were maintained over the epidemiological cut-off or minimum inhibitory concentration for the dosing interval. RESULTS The PBPK model identified 1500 mg of delamanid and 250 mg of rifapentine as sufficient doses for monthly intramuscular administration, if a formulation or device can deliver the required release kinetics of 0.001-0.0025 h-1 and 0.0015-0.0025 h-1, respectively. Bedaquiline and isoniazid would require weekly to biweekly intramuscular dosing. CONCLUSION We identified the theoretical doses and release rates of LAI anti-tuberculosis formulations. Such a strategy could ease the problem of suboptimal adherence provided the associated technological complexities for LTBI treatment are addressed.
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Affiliation(s)
- R K R Rajoli
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - A T Podany
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - D M Moss
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK, School of Pharmacy, Keele University, Newcastle, UK
| | - S Swindells
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - C Flexner
- Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - A Owen
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - M Siccardi
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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High-Dose Rifamycins Enable Shorter Oral Treatment in a Murine Model of Mycobacterium ulcerans Disease. Antimicrob Agents Chemother 2019; 63:AAC.01478-18. [PMID: 30455239 DOI: 10.1128/aac.01478-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/06/2018] [Indexed: 10/27/2022] Open
Abstract
Buruli ulcer (BU), caused by Mycobacterium ulcerans, is a neglected tropical skin and soft tissue infection that is associated with disability and social stigma. The mainstay of BU treatment is an 8-week course of rifampin (RIF) at 10 mg/kg of body weight and 150 mg/kg streptomycin (STR). Recently, the injectable STR has been shown to be replaceable with oral clarithromycin (CLR) for smaller lesions for the last 4 weeks of treatment. A shorter, all-oral, highly efficient regimen for BU is needed, as the long treatment duration and indirect costs currently burden patients and health systems. Increasing the dose of RIF or replacing it with the more potent rifamycin drug rifapentine (RPT) could provide such a regimen. Here, we performed a dose-ranging experiment of RIF and RPT in combination with CLR over 4 weeks of treatment in a mouse model of M. ulcerans disease. A clear dose-dependent effect of RIF on both clinical and microbiological outcomes was found, with no ceiling effect observed with tested doses up to 40 mg/kg. RPT-containing regimens were more effective on M. ulcerans All RPT-containing regimens achieved culture negativity after only 4 weeks, while only the regimen with the highest RIF dose (40 mg/kg) did so. We conclude that there is dose-dependent efficacy of both RIF and RPT and that a ceiling effect is not reached with the current standard regimen used in the clinic. A regimen based on higher rifamycin doses than are currently being evaluated against tuberculosis in clinical trials could shorten and improve therapy of Buruli ulcer.
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Winslow CJ, Nichols BL, Novo DC, Mosquera-Giraldo LI, Taylor LS, Edgar KJ, Neilson AP. Cellulose-based amorphous solid dispersions enhance rifapentine delivery characteristics in vitro. Carbohydr Polym 2018; 182:149-158. [DOI: 10.1016/j.carbpol.2017.11.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 11/05/2017] [Accepted: 11/06/2017] [Indexed: 11/26/2022]
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Zheng C, Hu X, Zhao L, Hu M, Gao F. Clinical and pharmacological hallmarks of rifapentine's use in diabetes patients with active and latent tuberculosis: do we know enough? DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:2957-2968. [PMID: 29066867 PMCID: PMC5644564 DOI: 10.2147/dddt.s146506] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Rifapentine is a rifamycin derivate approved by the US Food and Drug Administration in 1998 for the treatment of active, drug-susceptible tuberculosis (TB). In 2014, rifapentine was approved for the treatment of latent TB infection in patients at high risk of progression to active disease and is currently under evaluation by the European Medicines Agency. Expanding indications of rifapentine largely affect diabetes patients, since about one-third of them harbor latent TB. Clinical consequences of rifapentine use in this population and potentially harmful interactions with hypoglycemic agents are widely underexplored and generally considered similar to the ones of rifampicin. Indeed, rifapentine too may decrease blood levels of many oral antidiabetics and compete with them for protein-binding sites and/or transporters. However, the two drugs differ in protein-binding degree, the magnitude of cytochrome P450 induction and auto-induction, the degree of renal elimination, and so on. Rifapentine seems to be more suitable for use in diabetes patients with renal impairment, owing to the fact that it does not cause renal toxicity, and it is eliminated via kidneys in smaller proportions than rifampicin. On the other hand, there are no data related to rifapentine use in patients >65 years, and hypoalbuminemia associated with diabetic kidney disease may affect a free fraction of rifapentine to a greater extent than that of rifampicin. Until more pharmacokinetic information and information on the safety of rifapentine use in diabetic patients and drug–drug interactions are available, diabetes in TB patients treated with rifapentine should be managed with insulin analogs, and glucose and rifapentine plasma levels should be closely monitored.
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Affiliation(s)
- Chunlan Zheng
- Department of Internal Medicine - Section 5, Wuhan Pulmonary Hospital (Wuhan Tuberculosis Control Institute)
| | - Xiufen Hu
- Department of Paediatrics, Tongji Hospital
| | - Li Zhao
- Department of Internal Medicine - Section 5, Wuhan Pulmonary Hospital (Wuhan Tuberculosis Control Institute)
| | - Minhui Hu
- Department of Internal Medicine - Section 5, Wuhan Pulmonary Hospital (Wuhan Tuberculosis Control Institute)
| | - Feng Gao
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
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Mishra SK, Tripathi G, Kishore N, Singh RK, Singh A, Tiwari VK. Drug development against tuberculosis: Impact of alkaloids. Eur J Med Chem 2017. [DOI: 10.1016/j.ejmech.2017.06.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Alfarisi O, Alghamdi WA, Al-Shaer MH, Dooley KE, Peloquin CA. Rifampin vs. rifapentine: what is the preferred rifamycin for tuberculosis? Expert Rev Clin Pharmacol 2017; 10:1027-1036. [PMID: 28803492 DOI: 10.1080/17512433.2017.1366311] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION One-third of the world's population is infected with Mycobacterium tuberculosis (M.tb.). Latent tuberculosis infection (LTBI) can progress to tuberculosis disease, the leading cause of death by infection. Rifamycin antibiotics, like rifampin and rifapentine, have unique sterilizing activity against M.tb. What are the advantages of each for LTBI or tuberculosis treatment? Areas covered: We review studies assessing the pharmacokinetics (PK), pharmacodynamics (PD), drug interaction risk, safety, and efficacy of rifampin and rifapentine and provide basis for comparing them. Expert commentary: Rifampin has shorter half-life, higher MIC against M.tb, lower protein binding, and better distribution into cavitary contents than rifapentine. Drug interactions for the two drugs maybe similar in magnitude. For LTBI, rifapentine is effective as convenient, once-weekly, 12-week course of treatment. Rifampin is also effective for LTBI, but must be given daily for four months, therefore, drug interactions are more problematic. For drug-sensitive tuberculosis disease, rifampin remains the standard of care. Safety profile of rifampin is better-described; adverse events differ somewhat for the two drugs. The registered once-weekly rifapentine regimen is inadequate, but higher doses of either drugs may shorten the treatment duration required for effective management of TB. Results of clinical trials evaluating high-dose rifamycin regimens are eagerly awaited.
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Affiliation(s)
- Omamah Alfarisi
- a Department of Medicine , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Wael A Alghamdi
- b Department of Pharmacotherapy and Translational Research , University of Florida, College of Pharmacy , Gainesville , FL , USA.,c Infectious Disease Pharmacokinetics Laboratory , University of Florida , Gainesville , FL , USA
| | - Mohammad H Al-Shaer
- b Department of Pharmacotherapy and Translational Research , University of Florida, College of Pharmacy , Gainesville , FL , USA.,c Infectious Disease Pharmacokinetics Laboratory , University of Florida , Gainesville , FL , USA
| | - Kelly E Dooley
- a Department of Medicine , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Charles A Peloquin
- b Department of Pharmacotherapy and Translational Research , University of Florida, College of Pharmacy , Gainesville , FL , USA.,c Infectious Disease Pharmacokinetics Laboratory , University of Florida , Gainesville , FL , USA
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The importance of clinical pharmacokinetic-pharmacodynamic studies in unraveling the determinants of early and late tuberculosis outcomes. ACTA ACUST UNITED AC 2017; 2:195-212. [PMID: 30283633 PMCID: PMC6161803 DOI: 10.4155/ipk-2017-0004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 05/16/2017] [Indexed: 12/17/2022]
Abstract
Tuberculosis remains a major infectious cause of morbidity and mortality worldwide. Current antibiotic regimens, constructed prior to the development of modern pharmacokinetic-pharmacodynamic (PK–PD) tools, are based on incomplete understanding of exposure–response relationships in drug susceptible and multidrug resistant tuberculosis. Preclinical and population PK data suggest that clinical PK–PD studies may enable therapeutic drug monitoring for some agents and revised dosing for others. Future clinical PK–PD challenges include: incorporation of PK methods to assay free concentrations for all active metabolites; selection of appropriate early outcome measures which reflect therapeutic response; elucidation of genetic contributors to interindividual PK variability; conduct of targeted studies on special populations (including children); and measurement of PK–PD parameters at the site of disease.
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Parumasivam T, Ashhurst AS, Nagalingam G, Britton WJ, Chan HK. Inhalation of Respirable Crystalline Rifapentine Particles Induces Pulmonary Inflammation. Mol Pharm 2016; 14:328-335. [PMID: 27977216 DOI: 10.1021/acs.molpharmaceut.6b00905] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Rifapentine is an anti-tuberculosis (anti-TB) drug with a prolonged half-life, but oral delivery results in low concentrations in the lungs because of its high binding (98%) to plasma proteins. We have shown that inhalation of crystalline rifapentine overcomes the limitations of oral delivery by significantly enhancing and prolonging the drug concentration in the lungs. The delivery of crystalline particles to the lungs may promote inflammation. This in vivo study characterizes the inflammatory response caused by pulmonary deposition of the rifapentine particles. The rifapentine powder was delivered to BALB/c mice by intratracheal insufflation at a dose of 20 mg/kg. The inflammatory response in the lungs and bronchoalveolar lavage (BAL) was examined at 12 h, 24 h, and 7 days post-treatment by flow cytometry and histopathology. At 12 and 24 h post-treatment, there was a significant influx of neutrophils into the lungs, and this returned to normal by day 7. A significant recruitment of macrophages occurred in the BAL at 24 h. Consistent with these findings, histopathological analysis demonstrated pulmonary vascular congestion and significant macrophage recruitment at 12 and 24 h post-treatment. In conclusion, the pulmonary delivery of crystalline rifapentine caused a transient neutrophil-associated inflammatory response in the lungs that resolved over 7 days. This observation may limit pulmonary delivery of rifapentine to once a week at a dose of 20 mg/kg or less. The effectiveness of weekly dosing with inhalable rifapentine will be assessed in murine Mycobacterium tuberculosis infection.
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Affiliation(s)
- Thaigarajan Parumasivam
- Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney , Sydney, New South Wales 2006, Australia.,School of Pharmaceutical Sciences, Universiti Sains Malaysia , Pulau Pinang 11800, Malaysia
| | - Anneliese S Ashhurst
- Tuberculosis Research Program, Centenary Institute , Sydney, New South Wales 2042, Australia.,Discipline of Infectious Diseases and Immunology, Sydney Medical School, The University of Sydney , Sydney, New South Wales 2006, Australia
| | - Gayathri Nagalingam
- Tuberculosis Research Program, Centenary Institute , Sydney, New South Wales 2042, Australia.,Discipline of Infectious Diseases and Immunology, Sydney Medical School, The University of Sydney , Sydney, New South Wales 2006, Australia
| | - Warwick J Britton
- Tuberculosis Research Program, Centenary Institute , Sydney, New South Wales 2042, Australia.,Discipline of Infectious Diseases and Immunology, Sydney Medical School, The University of Sydney , Sydney, New South Wales 2006, Australia
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney , Sydney, New South Wales 2006, Australia
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Abstract
INTRODUCTION The goal of this article is to review the use of rifapentine in the treatment of latent tuberculosis infection (LTBI). Controlling LTBI is an important part of the global strategy to end the spread of tuberculosis. Rifapentine's potent sterilizing effect against Mycobacterium tuberculosis combined with its long half-life make it an attractive LTBI treatment option. Areas covered: A systematic literature search of Pubmed using the terms 'rifapentine' and 'tuberculosis' was performed. Articles identified were cross-referenced for other relevant publications. The mechanisms of action and resistance, pharmacokinetic and pharmacodynamics, potential drug interactions and side effects are discussed. Expert commentary: Rifapentine in combination with isoniazid for twelve weeks is the best available option for treating latent TB in the majority of patients in the United States due to its favorable safety profile and the increased likelihood of completing therapy. Currently, rifapentine is not registered or available in other countries.
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Affiliation(s)
- Eric F Egelund
- a Department of Pharmacotherapy and Translational Research, College of Pharmacy , University of Florida , Gainesville , FL , USA.,b Infectious Disease Pharmacokinetics Laboratory , University of Florida , Gainesville , FL , USA
| | - Charles A Peloquin
- a Department of Pharmacotherapy and Translational Research, College of Pharmacy , University of Florida , Gainesville , FL , USA.,b Infectious Disease Pharmacokinetics Laboratory , University of Florida , Gainesville , FL , USA.,c Emerging Pathogens Institute , University of Florida , Gainesville , FL , USA
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Zhang Z, Wu L, Li H, Long Z, Song X. Drug Release Characteristics and Tissue Distribution of Rifapentine Polylactic Acid Sustained-Release Microspheres in Rabbits after Paravertebral Implantation. IRANIAN RED CRESCENT MEDICAL JOURNAL 2016; 18:e38661. [PMID: 28210500 PMCID: PMC5301995 DOI: 10.5812/ircmj.38661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 05/24/2016] [Accepted: 06/14/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Rates of drug-resistant tuberculosis (TB) and TB associated with human immunodeficiency virus (HIV) infection have increased dramatically, intensifying challenges in TB control. New formulations of TB treatment drugs that control drug release and increase local drug concentrations will have a significant impact on mitigating the toxic side effects and increasing the clinical efficacy of anti-TB drugs. OBJECTIVES The aim was to observe the sustained release characteristics of rifapentine polylactic acid sustained-release microspheres in vivo and the accumulation of rifapentine in other tissues following paravertebral implantation. METHODS This study is a basic animal experimental study that began on July 17, 2014 in the Fifth Affiliated hospital of Xinjiang Medical University. One hundred and eight New Zealand white rabbits (weighing 2.8 - 3.0 kg, male and female, China) were randomly divided into three groups of 36 rabbits each. Blood and tissue samples from the liver, lungs, kidneys, vertebrae, and paravertebral muscle were collected at different time points post-surgery. High performance liquid chromatography (HPLC) analysis with a biological internal standard was used to determine the drug concentrations in samples. RESULTS In group A, no significant differences in rifapentine concentrations in the liver were detected between any two time points (P > 0.05). However, the differences in rifapentine concentrations between day 10 and day 21 were statistically significant (P < 0.05); for days 21, 35, 46, and 60, the differences in rifapentine concentrations between two sequential time points were not statistically significant (P > 0.05). In group B, the differences in rifapentine concentration between days 3 and 10 in vertebral bone and in paravertebral muscles were statistically significant (P < 0.05). Rifapentine was detected in the vertebral bone tissue in the group C animals. The rifapentine concentrations between two sequential time points were statistically significant (P < 0.05). Rifapentine could not be detected in the paravertebral muscles 46 days after the operation. The differences in rifapentine concentrations between two sequential time points among days 3, 10, 21, and 35 were statistically significant (P < 0.05). CONCLUSIONS After paravertebral implantation of rifapentine polylactic acid sustained-release microspheres, the concentration of rifapentine in local vertebral bone tissues was maintained above the TB minimum inhibitory concentration for up to 60 days with no apparent accumulation of the drug in other tissues.
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Affiliation(s)
- Zheng Zhang
- Orthopedics Department, Fifth Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Linbo Wu
- Bone Tumor Surgery, First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Haijian Li
- Bone Tumor Surgery, First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Zhicheng Long
- Bone Tumor Surgery, First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Xinghua Song
- Bone Tumor Surgery, First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
- Corresponding Author: Xinghua Song, Bone Tumor Surgery, First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China. Tel: +86-18599084077, Fax: +86-9913835298, E-mail:
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Physiologically Based Pharmacokinetic Model of Rifapentine and 25-Desacetyl Rifapentine Disposition in Humans. Antimicrob Agents Chemother 2016; 60:4860-8. [PMID: 27270284 DOI: 10.1128/aac.00031-16] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 05/25/2016] [Indexed: 01/21/2023] Open
Abstract
Rifapentine (RPT) is a rifamycin antimycobacterial and, as part of a combination therapy, is indicated for the treatment of pulmonary tuberculosis (TB) caused by Mycobacterium tuberculosis Although the results from a number of studies indicate that rifapentine has the potential to shorten treatment duration and enhance completion rates compared to other rifamycin agents utilized in antituberculosis drug regimens (i.e., regimens 1 to 4), its optimal dose and exposure in humans are unknown. To help inform such an optimization, a physiologically based pharmacokinetic (PBPK) model was developed to predict time course, tissue-specific concentrations of RPT and its active metabolite, 25-desacetyl rifapentine (dRPT), in humans after specified administration schedules for RPT. Starting with the development and verification of a PBPK model for rats, the model was extrapolated and then tested using human pharmacokinetic data. Testing and verification of the models included comparisons of predictions to experimental data in several rat tissues and time course RPT and dRPT plasma concentrations in humans from several single- and repeated-dosing studies. Finally, the model was used to predict RPT concentrations in the lung during the intensive and continuation phases of a current recommended TB treatment regimen. Based on these results, it is anticipated that the PBPK model developed in this study will be useful in evaluating dosing regimens for RPT and for characterizing tissue-level doses that could be predictors of problems related to efficacy or safety.
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Boeree MJ, Diacon AH, Dawson R, Narunsky K, du Bois J, Venter A, Phillips PPJ, Gillespie SH, McHugh TD, Hoelscher M, Heinrich N, Rehal S, van Soolingen D, van Ingen J, Magis-Escurra C, Burger D, Plemper van Balen G, Aarnoutse RE. A dose-ranging trial to optimize the dose of rifampin in the treatment of tuberculosis. Am J Respir Crit Care Med 2015; 191:1058-65. [PMID: 25654354 DOI: 10.1164/rccm.201407-1264oc] [Citation(s) in RCA: 225] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Rifampin at a dose of 10 mg/kg was introduced in 1971 based on pharmacokinetic, toxicity, and cost considerations. Available data in mice and humans showed that an increase in dose may shorten the duration of tuberculosis treatment. OBJECTIVES To evaluate the safety and tolerability, the pharmacokinetics, and the extended early bactericidal activity of increasing doses of rifampin. METHODS Patients with drug-susceptible tuberculosis were enrolled into a control group of eight patients receiving the standard dose of 10 mg/kg rifampin, followed by consecutive experimental groups with 15 patients each receiving rifampin 20, 25, 30, and 35 mg/kg, respectively, for 14 days. In all patients isoniazid, pyrazinamide, and ethambutol were added in standard doses for the second 7 days of treatment. Safety, pharmacokinetics of rifampin, and fall in bacterial load were assessed. MEASUREMENTS AND MAIN RESULTS Grade 1 and 2 adverse events were equally distributed between the five dose groups; there were five grade 3 events of which one was a possibly related hepatotoxicity. Areas under the time-concentration curves and peak serum concentrations of rifampin showed a more than proportional increase with dose. The daily fall in bacterial load over 14 days was 0.176, 0.168, 0.167, 0.265, and 0.261 log10 colony-forming units/ml sputum in the 10, 20, 25, 30, and 35 mg/kg groups, respectively. CONCLUSIONS Two weeks of rifampin up to 35 mg/kg was safe and well tolerated. There was a nonlinear increase in exposure to rifampin without an apparent ceiling effect and a greater estimated fall in bacterial load in the higher dosing groups. Clinical trial registered with www.clinicaltrials.gov (NCT 01392911).
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Nguta JM, Appiah-Opong R, Nyarko AK, Yeboah-Manu D, Addo PGA. Current perspectives in drug discovery against tuberculosis from natural products. Int J Mycobacteriol 2015; 4:165-83. [PMID: 27649863 DOI: 10.1016/j.ijmyco.2015.05.004] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 05/03/2015] [Accepted: 05/06/2015] [Indexed: 10/23/2022] Open
Abstract
Currently, one third of the world's population is latently infected with Mycobacterium tuberculosis (MTB), while 8.9-9.9 million new and relapse cases of tuberculosis (TB) are reported yearly. The renewed research interests in natural products in the hope of discovering new and novel antitubercular leads have been driven partly by the increased incidence of multidrug-resistant strains of MTB and the adverse effects associated with the first- and second-line antitubercular drugs. Natural products have been, and will continue to be a rich source of new drugs against many diseases. The depth and breadth of therapeutic agents that have their origins in the secondary metabolites produced by living organisms cannot be compared with any other source of therapeutic agents. Discovery of new chemical molecules against active and latent TB from natural products requires an interdisciplinary approach, which is a major challenge facing scientists in this field. In order to overcome this challenge, cutting edge techniques in mycobacteriology and innovative natural product chemistry tools need to be developed and used in tandem. The present review provides a cross-linkage to the most recent literature in both fields and their potential to impact the early phase of drug discovery against TB if seamlessly combined.
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Affiliation(s)
- Joseph Mwanzia Nguta
- Department of Clinical Pathology, Noguchi Memorial Institute for Medical Research, University of Ghana, Ghana; Department of Public Health, Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Nairobi, Kenya
| | - Regina Appiah-Opong
- Department of Clinical Pathology, Noguchi Memorial Institute for Medical Research, University of Ghana, Ghana
| | - Alexander K Nyarko
- Department of Clinical Pathology, Noguchi Memorial Institute for Medical Research, University of Ghana, Ghana
| | - Dorothy Yeboah-Manu
- Department of Bacteriology, Noguchi Memorial Institute for Medical Research, University of Ghana, Ghana
| | - Phyllis G A Addo
- Department of Animal Experimentation, Noguchi Memorial Institute for Medical Research, University of Ghana, Ghana
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Dorman SE, Savic RM, Goldberg S, Stout JE, Schluger N, Muzanyi G, Johnson JL, Nahid P, Hecker EJ, Heilig CM, Bozeman L, Feng PJI, Moro RN, MacKenzie W, Dooley KE, Nuermberger EL, Vernon A, Weiner M. Daily rifapentine for treatment of pulmonary tuberculosis. A randomized, dose-ranging trial. Am J Respir Crit Care Med 2015; 191:333-43. [PMID: 25489785 DOI: 10.1164/rccm.201410-1843oc] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Rifapentine has potent activity in mouse models of tuberculosis chemotherapy but its optimal dose and exposure in humans are unknown. OBJECTIVES We conducted a randomized, partially blinded dose-ranging study to determine tolerability, safety, and antimicrobial activity of daily rifapentine for pulmonary tuberculosis treatment. METHODS Adults with sputum smear-positive pulmonary tuberculosis were assigned rifapentine 10, 15, or 20 mg/kg or rifampin 10 mg/kg daily for 8 weeks (intensive phase), with isoniazid, pyrazinamide, and ethambutol. The primary tolerability end point was treatment discontinuation. The primary efficacy end point was negative sputum cultures at completion of intensive phase. MEASUREMENTS AND MAIN RESULTS A total of 334 participants were enrolled. At completion of intensive phase, cultures on solid media were negative in 81.3% of participants in the rifampin group versus 92.5% (P = 0.097), 89.4% (P = 0.29), and 94.7% (P = 0.049) in the rifapentine 10, 15, and 20 mg/kg groups. Liquid cultures were negative in 56.3% (rifampin group) versus 74.6% (P = 0.042), 69.7% (P = 0.16), and 82.5% (P = 0.004), respectively. Compared with the rifampin group, the proportion negative at the end of intensive phase was higher among rifapentine recipients who had high rifapentine areas under the concentration-time curve. Percentages of participants discontinuing assigned treatment for reasons other than microbiologic ineligibility were similar across groups (rifampin, 8.2%; rifapentine 10, 15, or 20 mg/kg, 3.4, 2.5, and 7.4%, respectively). CONCLUSIONS Daily rifapentine was well-tolerated and safe. High rifapentine exposures were associated with high levels of sputum sterilization at completion of intensive phase. Further studies are warranted to determine if regimens that deliver high rifapentine exposures can shorten treatment duration to less than 6 months. Clinical trial registered with www.clinicaltrials.gov (NCT 00694629).
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Affiliation(s)
- Susan E Dorman
- 1 Johns Hopkins University School of Medicine, Baltimore, Maryland
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Novel dosing strategies increase exposures of the potent antituberculosis drug rifapentine but are poorly tolerated in healthy volunteers. Antimicrob Agents Chemother 2015; 59:3399-405. [PMID: 25824215 DOI: 10.1128/aac.05128-14] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 03/20/2015] [Indexed: 11/20/2022] Open
Abstract
Rifapentine is a potent antituberculosis drug currently in phase III trials. Bioavailability decreases with increasing dose, yet high daily exposures are likely needed to improve efficacy and shorten the tuberculosis treatment duration. Further, the limits of tolerability are poorly defined. The phase I multicenter trial in healthy adults described here investigated two strategies to increase rifapentine exposures: dividing the dose or giving the drug with a high-fat meal. In arm 1, rifapentine was administered at 10 mg/kg of body weight twice daily and 20 mg/kg once daily, each for 14 days, separated by a 28-day washout; the dosing sequence was randomized. In arm 2, 15 mg/kg rifapentine once daily was given with a high-fat versus a low-fat breakfast. Sampling for pharmacokinetic analysis was performed on days 1 and 14. Population pharmacokinetic analyses were performed. This trial was stopped early for poor tolerability and because of safety concerns. Of 44 subjects, 20 discontinued prematurely; 11 of these discontinued for protocol-defined toxicity (a grade 3 or higher adverse event or grade 2 or higher rifamycin hypersensitivity). Taking rifapentine with a high-fat meal increased the median steady-state area under the concentration-time curve from time zero to 24 h (AUC0-24ss) by 31% (relative standard error, 6%) compared to that obtained when the drug was taken with a low-fat breakfast. Dividing the dose increased exposures substantially (e.g., 38% with 1,500 mg/day). AUC0-24ss was uniformly higher in our study than in recent tuberculosis treatment trials, in which toxicity was rare. In conclusion, two strategies to increase rifapentine exposures, dividing the dose or giving it with a high-fat breakfast, successfully increased exposures, but toxicity was common in healthy adults. The limits of tolerability in patients with tuberculosis remain to be defined. (AIDS Clinical Trials Group study A5311 has been registered at ClinicalTrials.gov under registration no. NCT01574638.).
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Murine pharmacokinetics of rifapentine delivered as an inhalable dry powder. Int J Antimicrob Agents 2015; 45:319-23. [DOI: 10.1016/j.ijantimicag.2014.11.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 11/08/2014] [Accepted: 11/10/2014] [Indexed: 11/19/2022]
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Svensson EM, Murray S, Karlsson MO, Dooley KE. Rifampicin and rifapentine significantly reduce concentrations of bedaquiline, a new anti-TB drug. J Antimicrob Chemother 2014; 70:1106-14. [PMID: 25535219 PMCID: PMC4356204 DOI: 10.1093/jac/dku504] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objectives Bedaquiline is the first drug of a new class approved for the treatment of TB in decades. Bedaquiline is metabolized by cytochrome P450 (CYP) 3A4 to a less-active M2 metabolite. Its terminal half-life is extremely long (5–6 months), complicating evaluations of drug–drug interactions. Rifampicin and rifapentine, two anti-TB drugs now being optimized to shorten TB treatment duration, are potent inducers of CYP3A4. This analysis aimed to predict the effect of repeated doses of rifampicin or rifapentine on the steady-state pharmacokinetics of bedaquiline and its M2 metabolite from single-dose data using a model-based approach. Methods Pharmacokinetic data for bedaquiline and M2 were obtained from a Phase I study involving 32 individuals each receiving two doses of bedaquiline, alone or together with multiple-dose rifampicin or rifapentine. Sampling was performed over 14 days following each bedaquiline dose. Pharmacokinetic analyses were performed using non-linear mixed-effects modelling. Models were used to simulate potential dose adjustments. Results Rifamycin co-administration increased bedaquiline clearance substantially: 4.78-fold [relative standard error (RSE) 9.10%] with rifampicin and 3.96-fold (RSE 5.00%) with rifapentine. Induction of M2 clearance was equally strong. Average steady-state concentrations of bedaquiline and M2 are predicted to decrease by 79% and 75% when given with rifampicin or rifapentine, respectively. Simulations indicated that increasing the bedaquiline dosage to mitigate the interaction would yield elevated M2 concentrations during the first treatment weeks. Conclusions Rifamycin antibiotics reduce bedaquiline concentrations substantially. In line with current treatment guidelines for drug-susceptible TB, concomitant use is not recommended, even with dose adjustment.
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Affiliation(s)
- Elin M Svensson
- Department of Pharmaceutical Biosciences, Uppsala University, PO Box 591, 751 24 Uppsala, Sweden
| | - Stephen Murray
- Department of Clinical Research, Global Alliance for TB Drug Development, New York, NY, USA
| | - Mats O Karlsson
- Department of Pharmaceutical Biosciences, Uppsala University, PO Box 591, 751 24 Uppsala, Sweden
| | - Kelly E Dooley
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Evaluation of the pharmacokinetic interaction between repeated doses of rifapentine or rifampin and a single dose of bedaquiline in healthy adult subjects. Antimicrob Agents Chemother 2014; 59:1219-24. [PMID: 25512422 DOI: 10.1128/aac.04171-14] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study assessed the effects of rifapentine or rifampin on the pharmacokinetics of a single dose of bedaquiline and its M2 metabolite in healthy subjects using a two-period single-sequence design. In period 1, subjects received a single dose of bedaquiline (400 mg), followed by a 28-day washout. In period 2, subjects received either rifapentine (600 mg) or rifampin (600 mg) from day 20 to day 41, as well as a single bedaquiline dose (400 mg) on day 29. The pharmacokinetic profiles of bedaquiline and M2 were compared over 336 h after the administration of bedaquiline alone and in combination with steady-state rifapentine or rifampin. Coadministration of bedaquiline with rifapentine or rifampin resulted in lower bedaquiline exposures. The geometric mean ratios (GMRs) and 90% confidence intervals (CIs) for the maximum observed concentration (Cmax), area under the concentration-time curve to the last available concentration time point (AUC0-t), and AUC extrapolated to infinity (AUC0-inf) of bedaquiline were 62.19% (53.37 to 72.47), 42.79% (37.77 to 48.49), and 44.52% (40.12 to 49.39), respectively, when coadministered with rifapentine. Similarly, the GMRs and 90% CIs for the Cmax, AUC0-t, and AUC0-inf of bedaquiline were 60.24% (51.96 to 69.84), 41.36% (37.70 to 45.36), and 47.32% (41.49 to 53.97), respectively, when coadministered with rifampin. The Cmax, AUC0-t, and AUC0-inf of M2 were also altered when bedaquiline was coadministered with rifapentine or rifampin. Single doses of bedaquiline, administered alone or with multiple doses of rifapentine or rifampin, were well tolerated, with no safety concerns related to coadministration. Daily administration of rifapentine to patients with tuberculosis presents the same drug interaction challenges as rifampin and other rifamycins. Strong inducers of the cytochrome P450 isoenzyme CYP3A4 should be avoided when considering the use of bedaquiline. (This study is registered at clinicaltrials.gov under identifier NCT02216331.).
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Quantification of rifapentine, a potent antituberculosis drug, from dried blood spot samples using liquid chromatographic-tandem mass spectrometric analysis. Antimicrob Agents Chemother 2014; 58:6747-57. [PMID: 25182637 DOI: 10.1128/aac.03607-14] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
The quantification of antituberculosis drug concentrations in multinational trials currently requires the collection of modest blood volumes, centrifugation, aliquoting of plasma, freezing, and keeping samples frozen during shipping. We prospectively enrolled healthy individuals into the Tuberculosis Trials Consortium Study 29B, a phase I dose escalation study of rifapentine, a rifamycin under evaluation in tuberculosis treatment trials. We developed a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for quantifying rifapentine in whole blood on dried blood spots (DBS) to facilitate pharmacokinetic/pharmacodynamic analyses in clinical trials. Paired plasma and whole-blood samples were collected by venipuncture, and whole blood was spotted on Whatman protein saver 903 cards. The methods were optimized for plasma and then validated for DBS. The analytical measuring range for quantification of rifapentine and its metabolite was 50 to 80,000 ng/ml in whole-blood DBS. The analyte was stable on the cards for 11 weeks with a desiccant at room temperature and protected from light. The method concordance for paired plasma and whole-blood DBS samples was determined after correcting for participant hematocrit or population-based estimates of bias from Bland-Altman plots. The application of either correction factor resulted in acceptable correlation between plasma and whole-blood DBS (Passing-Bablok regression corrected for hematocrit; y = 0.98x + 356). Concentrations of rifapentine may be determined from whole-blood DBS collected via venipuncture after normalization in order to account for the dilutional effects of red blood cells. Additional studies are focused on the application of this methodology to capillary blood collected by finger stick. The simplicity of processing, storage, shipping, and low blood volume makes whole-blood DBS attractive for rifapentine pharmacokinetic evaluations, especially in international and pediatric trials.
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Trends in discovery of new drugs for tuberculosis therapy. J Antibiot (Tokyo) 2014; 67:655-9. [PMID: 25095807 DOI: 10.1038/ja.2014.109] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 07/18/2014] [Accepted: 07/18/2014] [Indexed: 11/09/2022]
Abstract
After the introduction of isoniazid and rifampicin, the second one discovered in the Lepetit Research Laboratories (Milan, Italy), under the supervision of Professor Piero Sensi, tuberculosis (TB) was considered an illness of the past. Unfortunately, this infectious disease is still a global health fear, due to the multidrug-resistant Mycobacterium tuberculosis and extensively circulating drug-resistant strains, as well as the unrecognized TB transmission, especially in regions with high HIV incidence. In the last few years, new antitubercular molecules appeared on the horizon both in preclinical and clinical stage of evaluation. In this review, we focus on a few of them and on their mechanism of action. Two new promising drug targets, DprE1 and MmpL3, are also discussed.
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Dooley KE, Nuermberger EL, Diacon AH. Pipeline of drugs for related diseases: tuberculosis. Curr Opin HIV AIDS 2014; 8:579-85. [PMID: 24100880 DOI: 10.1097/coh.0000000000000009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW For the first time in decades, there are multiple new drugs in the pipeline for the treatment of tuberculosis (TB). In addition, existing drugs are being repurposed or optimized for TB with the goal of shortened treatment duration for drug-sensitive TB and safer, shorter treatments for multidrug-resistant (MDR) TB. In this review, the results of recent trials evaluating novel combination regimens for TB disease and latent TB infection are described. RECENT FINDINGS High-dose rifamycins (rifampin and rifapentine) and fluoroquinolones directly observed have treatment-shortening potential when used for drug-sensitive TB disease, and a 12-dose once-weekly regimen of rifapentine along with isoniazid effectively treats latent TB. Bedaquiline, an anti-TB drug with a novel mechanism of action, and delamanid, a nitroimidazole, are entering phase 3 trials. Both improve rates of sputum culture conversion among patients with MDR-TB. Other nitroimidazoles and oxazolidinones are in Phase 2 testing, as are combinations involving multiple new chemical entities. SUMMARY With the resurgence of anti-TB drug discovery efforts, we now have a modestly robust pipeline of new anti-TB drugs. Several promising new regimens involving investigational and existing drugs that may be capable of shortening treatment for drug-sensitive TB and improving management of drug-resistant TB are in late-phase clinical evaluation.
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Affiliation(s)
- Kelly E Dooley
- aJohns Hopkins University School of Medicine, Baltimore, Maryland, USA bStellenbosch University, Tygerberg, South Africa
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