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Weld ED, Ogasawara K, Fuchs EJ, Louissaint N, Caffo B, Hendrix CW. Mapping Colorectal Distribution of Cell-free and Cell-associated HIV Surrogates Following Simulated Anal Intercourse to Aid Rectal Microbicide Development. J Acquir Immune Defic Syndr 2024; 96:00126334-990000000-00383. [PMID: 38346420 PMCID: PMC11317546 DOI: 10.1097/qai.0000000000003401] [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: 05/07/2023] [Accepted: 01/19/2024] [Indexed: 08/31/2024]
Abstract
BACKGROUND Anal sex remains the greatest HIV transmission risk for men who have sex with men and carries substantial population attributable risk among women. Despite a growing array of HIV pre-exposure prophylaxis (PrEP) options, rectal microbicides remain desirable as on demand, non-systemic PrEP. Rectal microbicide product development for PrEP requires understanding the spatiotemporal distribution of HIV infectious elements in the rectosigmoid to optimize formulation development. SETTING Outpatient setting with healthy research participants. METHODS Six healthy men underwent simulated receptive anal sex with an artificial phallus fitted with a triple lumen catheter in the urethral position. To simulate ejaculation of HIV-infected semen, autologous seminal plasma laden with autologous blood lymphocytes from apheresis labeled with 111Indium-oxine (cell-associated) and 99mTechnetium-sulfur colloid (cell-free) as HIV surrogates were injected into the rectal lumen through the phallic urethra. Spatiotemporal distribution of each radioisotope was assessed using SPECT/CT over eight hours. Analysis of radiolabel distribution used a flexible principal curve algorithm to quantitatively estimate rectal lumen distribution. RESULTS Cell-free and cell-associated HIV surrogates distributed to a maximal distance of 15 and 16 cm, respectively, from the anorectal junction (∼19 and ∼20 cm from the anal verge), with a maximal signal intensity located 6 and 7 cm, respectively. There were no significant differences in any distribution parameters between cell-free and cell-associated HIV surrogate. CONCLUSIONS Cell-free and cell-associated HIV surrogate distribution in the rectosigmoid can be quantified with spatiotemporal pharmacokinetic methods. These results describe the ideal luminal target distribution to guide rectal microbicide development.
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Affiliation(s)
- Ethel D Weld
- Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ken Ogasawara
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Edward J Fuchs
- Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Brian Caffo
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Craig W Hendrix
- Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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2
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Pharmacokinetics and efficacy of topical inserts containing tenofovir alafenamide fumarate and elvitegravir administered rectally in macaques. EBioMedicine 2022; 86:104338. [DOI: 10.1016/j.ebiom.2022.104338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 10/05/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
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Al-Khouja A, Shieh E, Fuchs EJ, Marzinke MA, Bakshi RP, Hummert P, Ham AS, Buckheit KW, Breakey J, Weld ED, Chen H, Caffo BS, Buckheit RW, Hendrix CW. Examining the Safety, Pharmacokinetics, and Pharmacodynamics of a Rectally Administered IQP-0528 Gel for HIV Pre-Exposure Prophylaxis: A First-In-Human Study. AIDS Res Hum Retroviruses 2021; 37:444-452. [PMID: 33371779 DOI: 10.1089/aid.2020.0188] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A lubricating microbicide gel designed for rectal and vaginal use would provide a behaviorally congruent strategy to enhance pre-exposure prophylaxis adherence and reduce HIV infection risk. In this study, we report the first-in-human evaluation of such a gel containing 1% IQP-0528, an investigational antiretroviral. Seven HIV-1-negative participants received one 10 mL rectal dose of radiolabeled 1% IQP-0528 gel. We assessed safety; IQP-0528 pharmacokinetics in plasma, and rectal and vaginal tissue; ex vivo local pharmacodynamics (PD); and colorectal distribution. The 1% gel was determined to be safe with one mild event attributed to study product and no effects on rectal tissue histology. All concentrations measured in plasma and vaginal tissue were below the limit of quantitation. Median IQP-0528 concentrations in rectal tissue exceeded the in vitro EC95 against HIV-1 (0.07 ng/mg) by 3-5 h of dosing and remained above this concentration for at least 24 h, despite a 3-log reduction in concentration over this duration of time. Rectal tissue PD-assessed by ex vivo HIV challenge-demonstrated significant p24 antigen reduction 3-5 h postdose compared with baseline (p = .05), but not 24-26 h postdose (p = .75). Single-photon emission computed tomography/computed tomography imaging revealed that product distribution was localized to the rectosigmoid. The IQP-0528 gel possesses desirable features for a topical microbicide including: local safety with no systemic absorption, delivery of locally high IQP-0528 concentrations, and significant reductions in ex vivo HIV infectivity. However, the gel is limited by its rapid clearance and inability to penetrate vaginal tissues following rectal dosing. Clinical Trial Registration number: NCT03082690.
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Affiliation(s)
- Amer Al-Khouja
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eugenie Shieh
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Edward J. Fuchs
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mark A. Marzinke
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rahul P. Bakshi
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pamela Hummert
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - Jennifer Breakey
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ethel D. Weld
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Huan Chen
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Brian S. Caffo
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Craig W. Hendrix
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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4
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Taylor RA, Xiao S, Carias AM, McRaven MD, Thakkar DN, Araínga M, Allen EJ, Rogers KA, Kumarapperuma SC, Gong S, Fought AJ, Anderson MR, Thomas Y, Schneider JR, Goins B, Fox P, Villinger FJ, Ruprecht RM, Hope TJ. PET/CT targeted tissue sampling reveals virus specific dIgA can alter the distribution and localization of HIV after rectal exposure. PLoS Pathog 2021; 17:e1009632. [PMID: 34061907 PMCID: PMC8195437 DOI: 10.1371/journal.ppat.1009632] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 06/11/2021] [Accepted: 05/11/2021] [Indexed: 12/19/2022] Open
Abstract
Human immunodeficiency virus (HIV) vaccines have not been successful in clinical trials. Dimeric IgA (dIgA) in the form of secretory IgA is the most abundant antibody class in mucosal tissues, making dIgA a prime candidate for potential HIV vaccines. We coupled Positron Emission Tomography (PET) imaging and fluorescent microscopy of 64Cu-labeled, photoactivatable-GFP HIV (PA-GFP-BaL) and fluorescently labeled dIgA to determine how dIgA antibodies influence virus interaction with mucosal barriers and viral penetration in colorectal tissue. Our results show that HIV virions rapidly disseminate throughout the colon two hours after exposure. The presence of dIgA resulted in an increase in virions and penetration depth in the transverse colon. Moreover, virions were found in the mesenteric lymph nodes two hours after viral exposure, and the presence of dIgA led to an increase in virions in mesenteric lymph nodes. Taken together, these technologies enable in vivo and in situ visualization of antibody-virus interactions and detailed investigations of early events in HIV infection.
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Affiliation(s)
- Roslyn A. Taylor
- Department of Cell and Developmental Biology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Sixia Xiao
- Department of Cell and Developmental Biology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Ann M. Carias
- Department of Cell and Developmental Biology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Michael D. McRaven
- Department of Cell and Developmental Biology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Divya N. Thakkar
- Department of Cell and Developmental Biology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Mariluz Araínga
- New Iberia Research Center, University of Louisiana at Lafayette, Lafayette, Louisiana, United States of America
| | - Edward J. Allen
- Department of Cell and Developmental Biology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Kenneth A. Rogers
- New Iberia Research Center, University of Louisiana at Lafayette, Lafayette, Louisiana, United States of America
- Department of Biology, University of Louisiana at Lafayette, Lafayette, Louisiana, United States of America
| | - Sidath C. Kumarapperuma
- Research Imaging Institute, University of Texas Health San Antonio, San Antonio, Texas, United States of America
| | - Siqi Gong
- New Iberia Research Center, University of Louisiana at Lafayette, Lafayette, Louisiana, United States of America
- Department of Microbiology, Immunology, and Molecular Genetics, University of Texas Health San Antonio, San Antonio, Texas, United States of America
- Texas Biomedical Research Institute and Southwest National Primate Research Center, San Antonio, Texas, United States of America
| | - Angela J. Fought
- Department of Preventative Medicine, Division of Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Meegan R. Anderson
- Department of Cell and Developmental Biology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Yanique Thomas
- Department of Cell and Developmental Biology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Jeffrey R. Schneider
- Department of Cell and Developmental Biology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Beth Goins
- Research Imaging Institute, University of Texas Health San Antonio, San Antonio, Texas, United States of America
| | - Peter Fox
- Research Imaging Institute, University of Texas Health San Antonio, San Antonio, Texas, United States of America
| | - Francois J. Villinger
- New Iberia Research Center, University of Louisiana at Lafayette, Lafayette, Louisiana, United States of America
- Department of Biology, University of Louisiana at Lafayette, Lafayette, Louisiana, United States of America
| | - Ruth M. Ruprecht
- New Iberia Research Center, University of Louisiana at Lafayette, Lafayette, Louisiana, United States of America
- Department of Biology, University of Louisiana at Lafayette, Lafayette, Louisiana, United States of America
- Department of Microbiology, Immunology, and Molecular Genetics, University of Texas Health San Antonio, San Antonio, Texas, United States of America
- Texas Biomedical Research Institute and Southwest National Primate Research Center, San Antonio, Texas, United States of America
| | - Thomas J. Hope
- Department of Cell and Developmental Biology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
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5
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Hendrix CW. HIV Antiretroviral Pre-Exposure Prophylaxis: Development Challenges and Pipeline Promise. Clin Pharmacol Ther 2018; 104:1082-1097. [PMID: 30199098 PMCID: PMC6925668 DOI: 10.1002/cpt.1227] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/20/2018] [Indexed: 12/17/2022]
Abstract
The US Food and Drug Administration (FDA) approved oral daily tenofovir/emtricitabine (Truvada) for pre-exposure prophylaxis of human immunodeficiency virus (HIV) infection in 2012 on the basis of two randomized controlled trials (RCTs), one in men who have sex with men (MSM) and another in HIV serodiscordant heterosexual couples. Subsequently, even greater efficacy has been demonstrated in MSM with rapid population-level incidence reductions in some locations. In contrast, studies of antiretroviral pre-exposure prophylaxis (PrEP) in heterosexual women showed only modest or no efficacy, largely attributed to low adherence. The mixed results of antiretroviral-based PrEP bear witness to unique drug development challenges at this complicated intersection of sexual behavior, public health, and drug development. Multiple innovative methods and formulation strategies followed to address unmet medical needs of persons struggling with daily oral PrEP adherence or preference for nonsystemic PrEP options. Clinical pharmacology plays essential roles throughout this PrEP development process, especially in early product development and through pharmacologically informed enhancement and interpretation of clinical trials.
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Affiliation(s)
- Craig W Hendrix
- 1Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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6
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Abstract
Despite a long history of use for rectal and vaginal drug delivery, the current worldwide market for suppositories is limited primarily due to a lack of user acceptability. Therefore, virtually no rational pharmaceutical development of antiviral suppositories has been performed. However, suppositories offer several advantages over other antiviral dosage forms. Current suppository designs have integrated active pharmaceutical ingredients into existing formulation designs without optimization. As such, emerging suppository development has been focused on improving upon the existing classical design to enhance drug delivery and is poised to open suppository drug delivery to a broader range of drugs, including antiretroviral products. Thus, with continuing research into rational suppository design and development, there is significant potential for antiretroviral suppository drug delivery.
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7
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Wu TJ, Chiu HY, Yu J, Cautela MP, Sarmento B, das Neves J, Catala C, Pazos-Perez N, Guerrini L, Alvarez-Puebla RA, Vranješ-Đurić S, Ignjatović NL. Nanotechnologies for early diagnosis, in situ disease monitoring, and prevention. NANOTECHNOLOGIES IN PREVENTIVE AND REGENERATIVE MEDICINE 2018. [PMCID: PMC7156018 DOI: 10.1016/b978-0-323-48063-5.00001-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Nanotechnology is an enabling technology with great potential for applications in stem cell research and regenerative medicine. Fluorescent nanodiamond (FND), an inherently biocompatible and nontoxic nanoparticle, is well suited for such applications. We had developed a prospective isolation method using CD157, CD45, and CD54 to obtain lung stem cells. Labeling of CD45−CD54+CD157+ cells with FNDs did not eliminate their abilities for self-renewal and differentiation. The FND labeling in combination with cell sorting, fluorescence lifetime imaging microscopy, and immunostaining identified transplanted stem cells allowed tracking of their engraftment and regenerative capabilities with single-cell resolution. Time-gated fluorescence (TGF) imaging in mouse tissue sections indicated that they reside preferentially at the bronchoalveolar junctions of lungs, especially in naphthalene-injured mice. Our results presented in Subchapter 1.1 demonstrate not only the remarkable homing capacity and regenerative potential of the isolated stem cells, but also the ability of finding rare lung stem cells in vivo using FNDs. The topical use of antiretroviral-based microbicides, namely of a dapivirine ring, has been recently shown to partially prevent transmission of HIV through the vaginal route. Among different formulation approaches, nanotechnology tools and principles have been used for the development of tentative vaginal and rectal microbicide products. Subchapter 1.2 provides an overview of antiretroviral drug nanocarriers as novel microbicide candidates and discusses recent and relevant research on the topic. Furthermore, advances in developing vaginal delivery platforms for the administration of promising antiretroviral drug nanocarriers are reviewed. Although mostly dedicated to the discussion of nanosystems for vaginal use, the development of rectal nanomicrobicides is also addressed. Infectious diseases are currently responsible for over 8 million deaths per year. Efficient treatments require accurate recognition of pathogens at low concentrations, which in the case of blood infection (septicemia) can go as low as 1 mL–1. Detecting and quantifying bacteria at such low concentrations is challenging and typically demands cultures of large samples of blood (∼1 mL) extending over 24–72 h. This delay seriously compromises the health of patients and is largely responsible for the death toll of bacterial infections. Recent advances in nanoscience, spectroscopy, plasmonics, and microfluidics allow for the development of optical devices capable of monitoring minute amounts of analytes in liquid samples. In Subchapter 1.3 we critically discuss these recent developments that will, in the future, enable the multiplex identification and quantification of microorganisms directly on their biological matrix with unprecedented speed, low cost, and sensitivity. Radiolabeled nanoparticles (NPs) are finding an increasing interest in a broad range of biomedical applications. They may be used to detect and characterize diseases, to deliver relevant therapeutics, and to study the pharmacokinetic/pharmacodynamic parameters of nanomaterials. The use of radiotracer techniques in the research of novel NPs offers many advantages, but there are still some limitations. The binding of radionuclides to NPs has to be irreversible to prevent their escape to other tissues or organs. Due to the short half-lives of radionuclides, the manufacturing process is time limited and difficult, and there is also a risk of contamination. Subchapter 1.4 presents the main selection criteria for radionuclides and applicable radiolabeling procedures used for the radiolabeling of various NPs. Also, an overview of different types of NPs that have so far been labeled with radionuclides is presented.
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Affiliation(s)
- Tsai-Jung Wu
- Institute of Stem Cell and Translational Cancer Research, Chang Gung Memorial Hospital, Kuei Shang, Taiwan
| | - Hsiao-Yu Chiu
- Institute of Stem Cell and Translational Cancer Research, Chang Gung Memorial Hospital, Kuei Shang, Taiwan,China Medical University, Taichung, Taiwan
| | - John Yu
- Institute of Stem Cell and Translational Cancer Research, Chang Gung Memorial Hospital, Kuei Shang, Taiwan,Institute of Cellular and Organismic Biology, Taipei, Taiwan
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8
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Weld ED, Hiruy H, Guthrie KM, Fava JL, Vargas SE, Buckheit K, Buckheit R, Spiegel H, Breakey J, Fuchs EJ, Hendrix CW. A Comparative Pre-Phase I Study of the Impact of Gel Vehicle Volume on Distal Colon Distribution, User Experience, and Acceptability. AIDS Res Hum Retroviruses 2017; 33:440-447. [PMID: 27824253 DOI: 10.1089/aid.2016.0167] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
For persons at risk of HIV infection who practice receptive anal intercourse (RAI), topical rectal microbicides represent a promising option for coitally dependent protection. The study compared colorectal distribution and user sensory experiences of two different volumes of rectal gel for suitability as rectal microbicide. Eight HIV-negative men with a history of recent RAI were enrolled into a two-period, sequence-randomized dosing study comparing 3.5 and 10 ml of radiolabeled (1 mCi 99mTc-DTPA) universal placebo, hydroxyethyl cellulose gel. Each participant received two doses in the research unit, one of each volume, separated by a washout period of at least 2 weeks. Each research unit dose was followed by a self-administered take-home dose in the context of preparing for RAI. Safety and gastrointestinal distribution were assessed after the research unit doses, safety, perceptibility, and acceptability, were assessed after take-home doses. There were no adverse effects of Grade 2 or higher and all resolved spontaneously. Both volumes were well tolerated and received high acceptability scores. Perceptibility scores showed meaningful effect size differences ranging from Cohen's d = 0.5 to d = 1.2. The 3.5 and 10 ml gel volumes distributed similarly (p > .2) within the rectosigmoid, ranging from 0.69 to 18.84 cm and 1.21 to 19.01 cm from the anorectal junction, respectively. Both volumes covered the typical gastrointestinal distribution of ejaculate following simulated intercourse based on other studies. Either of these gel volumes could reasonably be pursued for the next phase of development of rectal microbicides.
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Affiliation(s)
- Ethel D Weld
- 1 Department of Medicine (Division of Clinical Pharmacology), The Johns Hopkins University School of Medicine , Baltimore, Maryland
- 2 Department of Medicine (Division of Infectious Diseases), The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Hiwot Hiruy
- 1 Department of Medicine (Division of Clinical Pharmacology), The Johns Hopkins University School of Medicine , Baltimore, Maryland
- 3 Department of Pediatrics (Division of Infectious Diseases), The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Kate Morrow Guthrie
- 4 Centers for Behavioral and Preventive Medicine, The Miriam Hospital , Providence, Rhode Island
- 5 Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University . Providence, Rhode Island
| | - Joseph L Fava
- 4 Centers for Behavioral and Preventive Medicine, The Miriam Hospital , Providence, Rhode Island
| | - Sara E Vargas
- 4 Centers for Behavioral and Preventive Medicine, The Miriam Hospital , Providence, Rhode Island
- 5 Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University . Providence, Rhode Island
| | | | | | | | - Jennifer Breakey
- 1 Department of Medicine (Division of Clinical Pharmacology), The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Edward J Fuchs
- 1 Department of Medicine (Division of Clinical Pharmacology), The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Craig W Hendrix
- 1 Department of Medicine (Division of Clinical Pharmacology), The Johns Hopkins University School of Medicine , Baltimore, Maryland
- 2 Department of Medicine (Division of Infectious Diseases), The Johns Hopkins University School of Medicine , Baltimore, Maryland
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9
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Gao Y, Katz DF. Multicompartmental Pharmacokinetic Model of Tenofovir Delivery to the Rectal Mucosa by an Enema. PLoS One 2017; 12:e0167696. [PMID: 28114388 PMCID: PMC5256988 DOI: 10.1371/journal.pone.0167696] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 10/28/2016] [Indexed: 02/07/2023] Open
Abstract
Rectal enemas that contain prophylactic levels of anti-HIV microbicides such as tenofovir have emerged as a promising dosage form to prevent sexually transmitted HIV infections. The enema vehicle is promising due to its likely ability to deliver a large amount of drug along the length of the rectal canal. Computational models of microbicide drug delivery by enemas can help their design process by determining key factors governing drug transport and, more specifically, the time history and degree of protection. They can also inform interpretations of experimental pharmacokinetic measures such as drug concentrations in biopsies. The present work begins rectal microbicide PK modeling, for enema vehicles. Results here show that a paramount factor in drug transport is the time of enema retention; direct connectivity between enema fluid and the fluid within rectal crypts is also important. Computations of the percentage of stromal volume protected by a single enema dose indicate that even with only a minute of enema retention, protection of 100% can be achieved after around 14 minutes post dose. Concentrations in biopsies are dependent on biopsy thickness; and control and/or knowledge of thickness could improve accuracy and decrease variability in biopsy measurements. Results here provide evidence that enemas are a promising dosage form for rectal microbicide delivery, and offer insights into their rational design.
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Affiliation(s)
- Yajing Gao
- Department of Biomedical Engineering, Duke University, Durham, NC, United States of America
| | - David F. Katz
- Department of Biomedical Engineering, Duke University, Durham, NC, United States of America
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States of America
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10
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das Neves J, Nunes R, Rodrigues F, Sarmento B. Nanomedicine in the development of anti-HIV microbicides. Adv Drug Deliv Rev 2016; 103:57-75. [PMID: 26829288 DOI: 10.1016/j.addr.2016.01.017] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 01/21/2016] [Accepted: 01/21/2016] [Indexed: 12/20/2022]
Abstract
Prevention plays an invaluable role in the fight against HIV/AIDS. The use of microbicides is considered an interesting potential approach for topical pre-exposure prophylaxis of HIV sexual transmission. The prospects of having an effective product available are expected to be fulfilled in the near future as driven by recent and forthcoming results of clinical trials. Different dosage forms and delivery strategies have been proposed and tested for multiple microbicide drug candidates presently at different stages of the development pipeline. One particularly interesting approach comprises the application of nanomedicine principles to the development of novel anti-HIV microbicides, but its implications to efficacy and safety are not yet fully understood. Nanotechnology-based systems, either presenting inherent anti-HIV activity or acting as drug nanocarriers, may significantly influence features such as drug solubility, stability of active payloads, drug release, interactions between active moieties and virus/cells, intracellular drug delivery, drug targeting, safety, antiviral activity, mucoadhesive behavior, drug distribution and tissue penetration, and pharmacokinetics. The present manuscript provides a comprehensive and holistic overview of these topics as relevant to the development of vaginal and rectal microbicides. In particular, recent advances pertaining inherently active microbicide nanosystems and microbicide drug nanocarriers are discussed.
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Affiliation(s)
- José das Neves
- i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal; INEB-Instituto de Engenharia Biomédica, Universidade do Porto, Porto, Portugal; CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde & Instituto Universitário de Ciências da Saúde, Gandra, Portugal.
| | - Rute Nunes
- i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal; INEB-Instituto de Engenharia Biomédica, Universidade do Porto, Porto, Portugal; ICBAS-Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Francisca Rodrigues
- REQUIMTE, Departamento de Ciências Químicas, Faculdade de Farmácia, Universidade do Porto, Porto, Portugal
| | - Bruno Sarmento
- i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal; INEB-Instituto de Engenharia Biomédica, Universidade do Porto, Porto, Portugal; CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde & Instituto Universitário de Ciências da Saúde, Gandra, Portugal.
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In Vivo Rectal Mucosal Barrier Function Imaging in a Large-Animal Model by Using Confocal Endomicroscopy: Implications for Injury Assessment and Use in HIV Prevention Studies. Antimicrob Agents Chemother 2016; 60:4600-9. [PMID: 27185807 DOI: 10.1128/aac.00134-16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 05/09/2016] [Indexed: 12/16/2022] Open
Abstract
Injury occurring on the surface of the rectal mucosal lining that causes defects in barrier function may result in increased risk for transmission of infection by HIV and other pathogens. Such injury could occur from microbicidal or other topical agents, mechanical trauma during consensual or nonconsensual intercourse, or inflammatory conditions. Tools for evaluation of rectal mucosal barrier function for assessing the mucosa under these conditions are lacking, particularly those that can provide in vivo structural and functional barrier integrity assessment and are adaptable to longitudinal imaging. We investigated confocal endomicroscopy (CE) as a means for in vivo imaging of the rectal epithelial barrier in the ovine model following spatially confined injury to the surface at a controlled site using a topical application of the microbicide test agent benzalkonium chloride. Topical and intravenous (i.v.) fluorescent probes were used with CE to provide subcellular resolution imaging of the mucosal surface and assessment of barrier function loss. A 3-point CE grading system based on cellular structure integrity and leakage of dye through the mucosa showed significant differences in score between untreated (1.19 ± 0.53) and treated (2.55 ± 0.75) tissue (P < 0.0001). Histological grading confirmed findings of barrier compromise. The results indicate that CE is an effective means for detecting epithelial injury and barrier loss following localized trauma in a large-animal model. CE is promising for real-time rectal mucosal evaluation after injury or trauma or topical application of emerging biomedical prevention strategies designed to combat HIV.
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12
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Nelson AG, Zhang X, Ganapathi U, Szekely Z, Flexner CW, Owen A, Sinko PJ. Drug delivery strategies and systems for HIV/AIDS pre-exposure prophylaxis and treatment. J Control Release 2015; 219:669-680. [PMID: 26315816 PMCID: PMC4879940 DOI: 10.1016/j.jconrel.2015.08.042] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 08/20/2015] [Accepted: 08/20/2015] [Indexed: 01/08/2023]
Abstract
The year 2016 will mark an important milestone - the 35th anniversary of the first reported cases of HIV/AIDS. Antiretroviral Therapy (ART) including Highly Active Antiretroviral Therapy (HAART) drug regimens is widely considered to be one of the greatest achievements in therapeutic drug research having transformed HIV infection into a chronically managed disease. Unfortunately, the lack of widespread preventive measures and the inability to eradicate HIV from infected cells highlight the significant challenges remaining today. Moving forward there are at least three high priority goals for anti-HIV drug delivery (DD) research: (1) to prevent new HIV infections from occurring, (2) to facilitate a functional cure, i.e., when HIV is present but the body controls it without drugs and (3) to eradicate established infection. Pre-exposure Prophylaxis (PrEP) represents a significant step forward in preventing the establishment of chronic HIV infection. However, the ultimate success of PrEP will depend on achieving sustained antiretroviral (ARV) tissue concentrations and will require strict patient adherence to the regimen. While first generation long acting/extended release (LA/ER) DD Systems (DDS) currently in development show considerable promise, significant DD treatment and prevention challenges persist. First, there is a critical need to improve cell specificity through targeting in order to selectively achieve efficacious drug concentrations in HIV reservoir sites to control/eradicate HIV as well as mitigate systemic side effects. In addition, approaches for reducing cellular efflux and metabolism of ARV drugs to prolong effective concentrations in target cells need to be developed. Finally, given the current understanding of HIV pathogenesis, next generation anti-HIV DDS need to address selective DD to the gut mucosa and lymph nodes. The current review focuses on the DDS technologies, critical challenges, opportunities, strategies, and approaches by which novel delivery systems will help iterate towards prevention, functional cure and eventually the eradication of HIV infection.
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Affiliation(s)
- Antoinette G Nelson
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA.
| | - Xiaoping Zhang
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA.
| | - Usha Ganapathi
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA.
| | - Zoltan Szekely
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA.
| | - Charles W Flexner
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA.
| | - Andrew Owen
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA.
| | - Patrick J Sinko
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA.
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Hiruy H, Fuchs EJ, Marzinke MA, Bakshi RP, Breakey JC, Aung WS, Manohar M, Yue C, Caffo BS, Du Y, Abebe KZ, Spiegel HM, Rohan LC, McGowan I, Hendrix CW. A Phase 1 Randomized, Blinded Comparison of the Pharmacokinetics and Colonic Distribution of Three Candidate Rectal Microbicide Formulations of Tenofovir 1% Gel with Simulated Unprotected Sex (CHARM-02). AIDS Res Hum Retroviruses 2015; 31:1098-108. [PMID: 26227279 DOI: 10.1089/aid.2015.0098] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
CHARM-02 is a crossover, double-blind, randomized trial to compare the safety and pharmacokinetics of three rectally applied tenofovir 1% gel candidate rectal microbicides of varying osmolalities: vaginal formulation (VF) (3111 mOsmol/kg), the reduced glycerin vaginal formulation (RGVF) (836 mOsmol/kg), and an isoosmolal rectal-specific formulation (RF) (479 mOsmol/kg). Participants (n = 9) received a single, 4 ml, radiolabeled dose of each gel twice, once with and once without simulated unprotected receptive anal intercourse (RAI). The safety, plasma tenofovir pharmacokinetics, colonic small molecule permeability, and SPECT/CT imaging of lower gastrointestinal distribution of drug and virus surrogate were assessed. There were no Grade 3 or 4 adverse events reported for any of the products. Overall, there were more Grade 2 adverse events in the VF group compared to RF (p = 0.006) and RGVF (p = 0.048). In the absence of simulated unprotected RAI, VF had up to 3.8-fold greater systemic tenofovir exposure, 26- to 234-fold higher colonic permeability of the drug surrogate, and 1.5- to 2-fold greater proximal migration in the colonic lumen, when compared to RF and RGVF. Similar trends were observed with simulated unprotected RAI, but most did not reach statistical significance. SPECT analysis showed 86% (standard deviation 19%) of the drug surrogate colocalized with the virus surrogate in the colonic lumen. There were no significant differences between the RGVF and RF formulation, with the exception of a higher plasma tenofovir concentration of RGVF in the absence of simulated unprotected RAI. VF had the most adverse events, highest plasma tenofovir concentrations, greater mucosal permeability of the drug surrogate, and most proximal colonic luminal migration compared to RF and RGVF formulations. There were no major differences between RF and RGVF formulations. Simultaneous assessment of toxicity, systemic and luminal pharmacokinetics, and colocalization of drug and viral surrogates substantially informs rectal microbicide product development.
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Affiliation(s)
- Hiwot Hiruy
- Department of Medicine (Clinical Pharmacology), Johns Hopkins University, Baltimore, Maryland
| | - Edward J. Fuchs
- Department of Medicine (Clinical Pharmacology), Johns Hopkins University, Baltimore, Maryland
| | - Mark A. Marzinke
- Department of Medicine (Clinical Pharmacology), Johns Hopkins University, Baltimore, Maryland
| | - Rahul P. Bakshi
- Department of Medicine (Clinical Pharmacology), Johns Hopkins University, Baltimore, Maryland
| | - Jennifer C. Breakey
- Department of Medicine (Clinical Pharmacology), Johns Hopkins University, Baltimore, Maryland
| | - Wutyi S. Aung
- Department of Medicine (Clinical Pharmacology), Johns Hopkins University, Baltimore, Maryland
| | - Madhuri Manohar
- Department of Medicine (Clinical Pharmacology), Johns Hopkins University, Baltimore, Maryland
| | - Chen Yue
- Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Brian S. Caffo
- Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Yong Du
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kaleab Z. Abebe
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hans M.L. Spiegel
- HJF-DAIDS, a Division of The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Contractor to National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland
| | - Lisa C. Rohan
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | - Ian McGowan
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | - Craig W. Hendrix
- Department of Medicine (Clinical Pharmacology), Johns Hopkins University, Baltimore, Maryland
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Leyva F, Fuchs EJ, Bakshi R, Carballo-Dieguez A, Ventuneac A, Yue C, Caffo B, Du Y, Torbenson M, Li L, Mullin G, Lee L, Rohan L, Anton PA, Hendrix CW. Simultaneous Evaluation of Safety, Acceptability, Pericoital Kinetics, and Ex Vivo Pharmacodynamics Comparing Four Rectal Microbicide Vehicle Candidates. AIDS Res Hum Retroviruses 2015; 31:1089-97. [PMID: 26066390 DOI: 10.1089/aid.2015.0086] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Preexposure prophylaxis (PrEP) of HIV infection with tenofovir-containing regimens is effective, but plagued by poor adherence in some studies. Options for safe, effective, and acceptable PrEP products, especially for men and women at risk of HIV via receptive anal intercourse (RAI), are needed. We performed a randomized, partially blinded, first-in-human evaluation of four candidate rectal microbicide vehicles-aqueous gel, aqueous fluid, lipid gel, and lipid fluid-to select a prototype for further clinical development. Eight seronegative participants received three doses of each product with each dose separated by at least 2 weeks: one dose was given alone without simulated RAI in clinic, another dose was followed by simulated RAI in clinic, and another dose was self-administered at home in the context of RAI with a partner. Assessments included safety, acceptability, colon histology, ex vivo HIV infectivity of colon tissue explants, and colonic luminal distribution of vehicle and HIV surrogates. Adverse events were all mild and mainly sigmoidoscopy associated. There were minor differences in colon distribution of products and little effect of RAI. Vehicle distribution covered 95% (±7% standard deviation) of the distribution of an HIV surrogate in the colonic lumen. The lipid fluid vehicle increased HIV colon tissue infectability 5-fold [log10 p24 0.68 (95% confidence interval 0.08, 1.28)] and aqueous gel provided 6-fold protection [log10 p24 0.80 (95% confidence interval 0.20, 1.41)] compared to no product baseline. Colon permeability of lipid vehicles was more than 10-fold greater than aqueous vehicles. All products received similar acceptability ratings, though trends favored the gel products. Intensive simultaneous assessment of safety and toxicity, luminal and tissue distribution, ex vivo HIV infectivity, and product acceptability in relevant sexual contexts provided clear differentiation among candidate gels very early in product development. We selected the aqueous gel for further development as a rectal microbicide vehicle.
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Affiliation(s)
- Francisco Leyva
- Department of Medicine (Clinical Pharmacology), The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Edward J. Fuchs
- Department of Medicine (Clinical Pharmacology), The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rahul Bakshi
- Department of Medicine (Clinical Pharmacology), The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alex Carballo-Dieguez
- Department of Medicine (Gastroenterology), The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ana Ventuneac
- Department of Medicine (Gastroenterology), The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chen Yue
- Department of Biostatistics, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Brian Caffo
- Department of Biostatistics, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Yong Du
- Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Liye Li
- Department of Medicine (Clinical Pharmacology), The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gerald Mullin
- HIV Center for Clinical and Behavioral Studies, Columbia University, New York, New York
| | - Linda Lee
- HIV Center for Clinical and Behavioral Studies, Columbia University, New York, New York
| | - Lisa Rohan
- Magee Womens Research Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Peter A. Anton
- UCLA Center for HIV Prevention Research, UCLA AIDS Institute, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Craig W. Hendrix
- Department of Medicine (Clinical Pharmacology), The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Fuchs EJ, Schwartz JL, Friend DR, Coleman JS, Hendrix CW. A Pilot Study Measuring the Distribution and Permeability of a Vaginal HIV Microbicide Gel Vehicle Using Magnetic Resonance Imaging, Single Photon Emission Computed Tomography/Computed Tomography, and a Radiolabeled Small Molecule. AIDS Res Hum Retroviruses 2015; 31:1109-15. [PMID: 26077739 DOI: 10.1089/aid.2015.0054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Vaginal microbicide gels containing tenofovir have proven effective in HIV prevention, offering the advantage of reduced systemic toxicity. We studied the vaginal distribution and effect on mucosal permeability of a gel vehicle. Six premenopausal women were enrolled. In Phase 1, a spreading gel containing (99m)technetium-DTPA ((99m)Tc) radiolabel and gadolinium contrast for magnetic resonance imaging (MRI) was dosed intravaginally. MRI was obtained at 0.5, 4, and 24 h, and single photon emission computed tomography with conventional computed tomography (SPECT/CT) at 1.5, 5, and 25 h postdosing. Pads and tissues were measured for activity to determine gel loss. In Phase 2, nonoxynol-9 (N-9), containing (99m)Tc-DTPA, was dosed as a permeability control; permeability was measured in blood and urine for both phases. SPECT/CT showed the distribution of spreading gel throughout the vagina with the highest concentration of radiosignal in the fornices and ectocervix; signal intensity diminished over 25 h. MRI showed the greatest signal accumulation in the fornices, most notably 1-4 h postdosing. The median (interquartile range) isotope signal loss from the vagina through 6 h was 29.1% (15.8-39.9%). Mucosal permeability to (99m)Tc-DTPA following spreading gel was negligible, in contrast to N-9, with detectable radiosignal in plasma, peaking at 8 h (5-12). Following spreading gel dosing, 0.004% (0.001-2.04%) of the radiosignal accumulated in urine over 12 h compared to 8.31% (7.07-11.01%) with N-9, (p=0.043). Spreading gel distributed variably throughout the vagina, persisting for 24 h, with signal concentrating in the fornices and ectocervix. The spreading gel had no significant effect on vaginal mucosal permeability.
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Affiliation(s)
- Edward J. Fuchs
- The Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jill L. Schwartz
- CONRAD, Eastern Virginia Medical School (EVMS), Arlington, Virginia
| | - David R. Friend
- CONRAD, Eastern Virginia Medical School (EVMS), Arlington, Virginia
| | - Jenell S. Coleman
- The Division of Gynecologic Specialties, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Craig W. Hendrix
- The Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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16
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Mukhopadhya I, Murray GI, Berry S, Thomson J, Frank B, Gwozdz G, Ekeruche-Makinde J, Shattock R, Kelly C, Iannelli F, Pozzi G, El-Omar EM, Hold GL, Hijazi K. Drug transporter gene expression in human colorectal tissue and cell lines: modulation with antiretrovirals for microbicide optimization. J Antimicrob Chemother 2015; 71:372-86. [PMID: 26514157 DOI: 10.1093/jac/dkv335] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/15/2015] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES The objectives of this study were to comprehensively assess mRNA expression of 84 drug transporters in human colorectal biopsies and six representative cell lines, and to investigate the alteration of drug transporter gene expression after exposure to three candidate microbicidal antiretroviral (ARV) drugs (tenofovir, darunavir and dapivirine) in the colorectal epithelium. The outcome of the objectives informs development of optimal ARV-based microbicidal formulations for prevention of HIV-1 infection. METHODS Drug transporter mRNA expression was quantified from colorectal biopsies and cell lines by quantitative real-time PCR. Relative mRNA expression was quantified in Caco-2 cells and colorectal explants after induction with ARVs. Data were analysed using Pearson's product moment correlation (r), hierarchical clustering and principal component analysis (PCA). RESULTS Expression of 58 of the 84 transporters was documented in colorectal biopsies, with genes for CNT2, P-glycoprotein (P-gp) and MRP3 showing the highest expression. No difference was noted between individual subjects when analysed by age, gender or anatomical site (rectum or recto-sigmoid) (r = 0.95-0.99). High expression of P-gp and CNT2 proteins was confirmed by immunohistochemical staining. Similarity between colorectal tissue and cell-line drug transporter gene expression was variable (r = 0.64-0.84). PCA showed distinct clustering of human colorectal biopsy samples, with the Caco-2 cells defined as the best surrogate system. Induction of Caco-2 cell lines with ARV drugs suggests that darunavir-based microbicides incorporating tenofovir may result in drug-drug interactions likely to affect distribution of individual drugs to sub-epithelial target cells. CONCLUSIONS These findings will help optimize complex formulations of rectal microbicides to realize their full potential as an effective approach for pre-exposure prophylaxis against HIV-1 infection.
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Affiliation(s)
| | - Graeme I Murray
- Department of Pathology, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - Susan Berry
- School of Medicine & Dentistry, University of Aberdeen, Aberdeen, UK
| | - John Thomson
- Department of Gastroenterology, Aberdeen Royal Infirmary, Aberdeen, UK
| | | | | | - Julia Ekeruche-Makinde
- Mucosal Infection & Immunity Group, Section of Infectious Diseases, Imperial College, London, UK
| | - Robin Shattock
- Mucosal Infection & Immunity Group, Section of Infectious Diseases, Imperial College, London, UK
| | - Charles Kelly
- Mucosal & Salivary Biology, Dental Institute, King's College London, London, UK
| | - Francesco Iannelli
- Laboratory of Molecular Microbiology and Biotechnology, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Gianni Pozzi
- Laboratory of Molecular Microbiology and Biotechnology, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Emad M El-Omar
- School of Medicine & Dentistry, University of Aberdeen, Aberdeen, UK
| | - Georgina L Hold
- School of Medicine & Dentistry, University of Aberdeen, Aberdeen, UK
| | - Karolin Hijazi
- School of Medicine & Dentistry, University of Aberdeen, Aberdeen, UK
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Nunes R, Sarmento B, das Neves J. Formulation and delivery of anti-HIV rectal microbicides: advances and challenges. J Control Release 2014; 194:278-94. [PMID: 25229988 DOI: 10.1016/j.jconrel.2014.09.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 09/08/2014] [Indexed: 12/24/2022]
Abstract
Men and women engaged in unprotected receptive anal intercourse (RAI) are at higher risk of acquiring HIV from infected partners. The implementation of preventive strategies is urgent and rectal microbicides may be a useful tool in reducing the sexual transmission of HIV. However, pre-clinical and first clinical trials have been able to identify limitations of candidate products, mostly related with safety issues, which can in turn enhance viral infection. Indeed, the development of suitable formulations for the rectal delivery of promising antiretroviral drugs is not an easy task, and has been mostly based on products specifically intended for vaginal delivery, but these have been shown to provide sub-optimal outcomes when administered rectally. Research and development in the rectal microbicide field are now charting their own path and important information is now available. In particular, specific formulation requirements of rectal microbicide products that need to be met have just recently been acknowledged despite additional work being still required. Desirable rectal microbicide product features regarding characteristics such as pH, osmolality, excipients, dosage forms, volume to be administered and the need for applicator use have been studied and defined in recent years, and specific guidance is now possible. This review provides a synopsis of the field of rectal microbicides, namely past and ongoing clinical studies, and details on formulation and drug delivery issues regarding the specific development of rectal microbicide products. Also, future work, as required for the advancement of the field, is discussed.
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Affiliation(s)
- Rute Nunes
- INEB - Instituto de Engenharia Biomédica, University of Porto, Porto, Portugal; CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Gandra PRD, Portugal
| | - Bruno Sarmento
- INEB - Instituto de Engenharia Biomédica, University of Porto, Porto, Portugal; CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Gandra PRD, Portugal
| | - José das Neves
- INEB - Instituto de Engenharia Biomédica, University of Porto, Porto, Portugal; CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Gandra PRD, Portugal.
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18
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Image-based noninvasive evaluation of colorectal mucosal injury in sheep after topical application of microbicides. Sex Transm Dis 2014; 40:854-9. [PMID: 24113407 DOI: 10.1097/olq.0000000000000039] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Successful development of topical rectal microbicides requires preclinical evaluation in suitable large animal models. Our previous studies have demonstrated the benefits of high-resolution optical coherence tomography (OCT) to visualize subclinical microbicide toxicity in the sheep vagina. In the current study, we evaluated the potential application of colonoscopy and OCT to visualize and quantify the effects of topical products on sheep colorectal tissue, as assessed by advanced imaging techniques. METHODS Yearling virginal female sheep were treated rectally with a single 8-mL dose of 0.2% benzalkonium chloride (BZK) solution or phosphate-buffered saline control. Imaging was performed before and 30 minutes after treatment. Colonoscopy findings were evaluated based on mucosal disruption. Optical coherence tomography images were graded based on the integrity of the mucosal layer. Biopsies collected after treatment were evaluated by histology for validation of OCT scoring. RESULTS Mucosal disruption was observed by colonoscopy in BZK-treated animals, whereas none was present in controls. In contrast to colonoscopy, high-resolution in-depth OCT imaging provided visualization of the morphology of the mucosal layer and underlying muscularis, thus enabling detection of microscopic abnormalities. Noninvasive quantification of drug-induced injury after validation of the scoring system (categories 1, 2, 3) showed increased scores after treatment with BZK (P < 0.001), indicating mucosal injury. CONCLUSIONS High-resolution OCT can be used as highly sensitive tool to evaluate rectal microbicide effects. Because the sheep rectum has both gross and microscopic similarities to the human, this model is a useful addition to current methods of rectal product toxicity.
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Galea JT, Kinsler JJ, Imrie J, Nureña CR, Ruiz L, Galarza LF, Sánchez J, Cunningham WE. Preparing for rectal microbicides: sociocultural factors affecting product uptake among potential South American users. Am J Public Health 2014; 104:e113-20. [PMID: 24825222 DOI: 10.2105/ajph.2013.301731] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined views on rectal microbicides (RMs), a potential HIV prevention option, among men who have sex with men and transgender women in 3 South American cities. METHODS During September 2009 to September 2010, we conducted 10 focus groups and 36 in-depth interviews (n = 140) in Lima and Iquitos, Peru, and Guayaquil, Ecuador, to examine 5 RM domains: knowledge, thoughts and opinions about RM as an HIV prevention tool, use, condoms, and social concerns. We coded emergent themes in recorded and transcribed data sets and extracted representative quotes. We collected sociodemographic information with a self-administered questionnaire. RESULTS RM issues identified included limited knowledge; concerns regarding plausibility, side effects, and efficacy; impact on condom use; target users (insertive vs receptive partners); and access concerns. CONCLUSIONS Understanding the sociocultural issues affecting RMs is critical to their uptake and should be addressed prior to product launch.
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Affiliation(s)
- Jerome T Galea
- Jerome T. Galea is with the Program in Global Health; Janni J. Kinsler is with the Department of Community Health Sciences, School of Public Health; and William E. Cunningham is with the Department of Medicine, Division of General Internal Medicine and Health Services Research, School of Medicine, University of California, Los Angeles. John Imrie is with the Centre for Sexual Health and HIV Research, Faculty of Population Health, University College London, London, UK. César R. Nureña is with the Escuela de Antropología, Universidad Nacional Mayor de San Marcos, and Jorge Sánchez is with the Asociación Civil Impacta Salud y Educación, Lima, Peru. Lucía Ruiz is with the Asociación Civil Selva Amazónica, Iquitos, Peru. Luis Fernando Galarza is with the Fundación Ecuatoriana Equidad, Guayaquil, Ecuador
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Abstract
INTRODUCTION Individuals practicing unprotected receptive anal intercourse are at particularly high risk of HIV infection. Men who have sex with men in the developed and developing world continue to have disproportionate and increasing levels of HIV infection. The last few years have seen important progress in demonstrating the efficacy of oral antiretroviral pre-exposure prophylaxis, vaginal microbicides, and treatment as prevention, but there has also been significant progress in the development of rectal microbicides for HIV prevention. AREAS COVERED The purpose of this review is to summarize the status of rectal microbicide research and to identify opportunities, challenges, and future directions in this important field of HIV prevention research. The design of completed and ongoing Phase I rectal microbicide studies that include the generation of comprehensive pharmacokinetic/pharmacodynamic data may allow for more rational decisions about which rectal microbicides should be advanced to later stage development. EXPERT OPINION There is a strong rationale for the development of rectal microbicides for HIV prevention. Preclinical data provide supportive evidence for the feasibility of this approach, and there is significant interest in rectal microbicide development from communities at risk of HIV acquisition through unprotected receptive anal intercourse in both the developed and developing world. Demonstration of sustained safety, acceptability, and product adherence in the MTN-017 Phase II study of tenofovir 1% gel will be an important step in rectal microbicide development and will hopefully lead to Phase III effectiveness testing of this novel HIV prevention strategy.
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Affiliation(s)
- Ian McGowan
- University of Pittsburgh, Department of Medicine , Pittsburgh , USA
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21
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Leyva FJ, Bakshi RP, Fuchs EJ, Li L, Caffo BS, Goldsmith AJ, Ventuneac A, Carballo-Diéguez A, Du Y, Leal JP, Lee LA, Torbenson MS, Hendrix CW. Isoosmolar enemas demonstrate preferential gastrointestinal distribution, safety, and acceptability compared with hyperosmolar and hypoosmolar enemas as a potential delivery vehicle for rectal microbicides. AIDS Res Hum Retroviruses 2013; 29:1487-95. [PMID: 23885722 DOI: 10.1089/aid.2013.0189] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Rectally applied antiretroviral microbicides for preexposure prophylaxis (PrEP) of HIV infection are currently in development. Since enemas (rectal douches) are commonly used by men who have sex with men prior to receptive anal intercourse, a microbicide enema could enhance PrEP adherence by fitting seamlessly within the usual sexual practices. We assessed the distribution, safety, and acceptability of three enema types-hyperosmolar (Fleet), hypoosmolar (distilled water), and isoosmolar (Normosol-R)-in a crossover design. Nine men received each enema type in random order. Enemas were radiolabeled [(99m)Tc-diethylene triamine pentaacetic acid (DTPA)] to assess enema distribution in the colon using single photon emission computed tomography/computed tomography (SPECT/CT) imaging. Plasma (99m)Tc-DTPA indicated mucosal permeability. Sigmoidoscopic colon tissue biopsies were taken to assess injury as well as tissue penetration of the (99m)Tc-DTPA. Acceptability was assessed after each product use and at the end of the study. SPECT/CT imaging showed that the isoosmolar enema had greater proximal colonic distribution (up to the splenic flexure) and greater luminal and colon tissue concentrations of (99m)Tc-DTPA when compared to the other enemas (p<0.01). Colon biopsies also showed that only the hyperosmolar enema caused sloughing of the colonic epithelium (p<0.05). In permeability testing, the hypoosmolar enema had higher plasma (99m)Tc-DTPA 24-h area under the concentration-time curve and peak concentration compared to the hyperosmolar and isoosmolar enemas, respectively. Acceptability was generally good with no clear preferences among the three enema types. The isoosmolar enema was superior or similar to the other enemas in all categories and is a good candidate for further development as a rectal microbicide vehicle.
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Affiliation(s)
- Francisco J. Leyva
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rahul P. Bakshi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Edward J. Fuchs
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Liye Li
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brian S. Caffo
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Arthur J. Goldsmith
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Ana Ventuneac
- Department of Infectious Diseases Division, HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, New York
| | - Alex Carballo-Diéguez
- Department of Infectious Diseases Division, HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, New York
| | - Yong Du
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeffrey P. Leal
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Linda A. Lee
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael S. Torbenson
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Craig W. Hendrix
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Rectal pre-exposure prophylaxis (PrEP). Antiviral Res 2013; 100 Suppl:S17-24. [PMID: 24188705 DOI: 10.1016/j.antiviral.2013.09.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 09/09/2013] [Accepted: 09/21/2013] [Indexed: 01/19/2023]
Abstract
Rectal pre-exposure prophylaxis (PrEP) will be a critical component of HIV prevention products due to the prevalence of unprotected receptive anal intercourse among men who have sex with men and heterosexual couples. Given the biological considerations of this compartment and the complexity of HIV infection, design of a successful rectal microbicide product faces a number of challenges. Important information is being compiled to begin to address deficits in knowledge toward design of rectal PrEP products for men and women. Aspects of formulation development and preclinical and clinical evaluation of rectal products studied to date are summarized in this review. This article is based on a presentation at the "Product Development Workshop 2013: HIV and Multipurpose Prevention Technologies," held in Arlington, Virginia on February 21-22, 2013. It forms part of a special supplement to Antiviral Research.
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Cao YJ, Caffo BS, Fuchs EJ, Lee LA, Du Y, Li L, Bakshi RP, Macura K, Khan WA, Wahl RL, Grohskopf LA, Hendrix CW. Quantification of the spatial distribution of rectally applied surrogates for microbicide and semen in colon with SPECT and magnetic resonance imaging. Br J Clin Pharmacol 2012; 74:1013-22. [PMID: 22404308 PMCID: PMC3522815 DOI: 10.1111/j.1365-2125.2012.04267.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Accepted: 02/23/2012] [Indexed: 11/29/2022] Open
Abstract
AIMS We sought to describe quantitatively the distribution of rectally administered gels and seminal fluid surrogates using novel concentration-distance parameters that could be repeated over time. These methods are needed to develop rationally rectal microbicides to target and prevent HIV infection. METHODS Eight subjects were dosed rectally with radiolabelled and gadolinium-labelled gels to simulate microbicide gel and seminal fluid. Rectal doses were given with and without simulated receptive anal intercourse. Twenty-four hour distribution was assessed with indirect single photon emission computed tomography (SPECT)/computed tomography (CT) and magnetic resonance imaging (MRI), and direct assessment via sigmoidoscopic brushes. Concentration-distance curves were generated using an algorithm for fitting SPECT data in three dimensions. Three novel concentration-distance parameters were defined to describe quantitatively the distribution of radiolabels: maximal distance (D(max) ), distance at maximal concentration (D(Cmax) ) and mean residence distance (D(ave) ). RESULTS The SPECT/CT distribution of microbicide and semen surrogates was similar. Between 1 h and 24 h post dose, the surrogates migrated retrograde in all three parameters (relative to coccygeal level; geometric mean [95% confidence interval]): maximal distance (D(max) ), 10 cm (8.6-12) to 18 cm (13-26), distance at maximal concentration (D(Cmax) ), 3.8 cm (2.7-5.3) to 4.2 cm (2.8-6.3) and mean residence distance (D(ave) ), 4.3 cm (3.5-5.1) to 7.6 cm (5.3-11). Sigmoidoscopy and MRI correlated only roughly with SPECT/CT. CONCLUSIONS Rectal microbicide surrogates migrated retrograde during the 24 h following dosing. Spatial kinetic parameters estimated using three dimensional curve fitting of distribution data should prove useful for evaluating rectal formulations of drugs for HIV prevention and other indications.
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Affiliation(s)
- Ying J Cao
- Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Factors Important to the Prioritization and Development of Successful Topical Microbicides for HIV-1. Mol Biol Int 2012; 2012:781305. [PMID: 22848826 PMCID: PMC3403474 DOI: 10.1155/2012/781305] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 05/11/2012] [Indexed: 12/20/2022] Open
Abstract
Significant advancements in topical microbicide development have occurred since the prevention strategy was first described as a means to inhibit the sexual transmission of HIV-1. The lack of clinical efficacy of the first generation microbicide products has focused development attention on specific antiretroviral agents, and these agents have proven partially successful in human clinical trials. With greater understanding of vaginal and rectal virus infection, replication, and dissemination, better microbicide products and delivery strategies should result in products with enhanced potency. However, a variety of development gaps exist which relate to product dosing, formulation and delivery, and pharmacokinetics and pharmacodynamics which must be better understood in order to prioritize microbicide products for clinical development. In vitro, ex vivo, and in vivo models must be optimized with regard to these development gaps in order to put the right product at the right place, at the right time, and at the right concentration for effective inhibition of virus transmission. As the microbicide field continues to evolve, we must harness the knowledge gained from unsuccessful and successful clinical trials and development programs to continuously enhance our preclinical development algorithms.
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Abstract
There is an urgent need control the spread of the global HIV pandemic. A microbicide, or topical drug applied to the mucosal environment to block transmission, is a promising HIV prevention strategy. The development of a safe and efficacious microbicide requires a thorough understanding of the mucosal environment and its role in HIV transmission. Knowledge of the key events in viral infection identifies points at which the virus might be most effectively targeted by a microbicide. The cervicovaginal and rectal mucosa play an important role in the innate defense against HIV, and microbicides must not interfere with these functions. In this review, we discuss the current research on HIV microbicide development.
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Distribution of cell-free and cell-associated HIV surrogates in the colon after simulated receptive anal intercourse in men who have sex with men. J Acquir Immune Defic Syndr 2012; 59:10-7. [PMID: 21937920 DOI: 10.1097/qai.0b013e3182373b5e] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Describing the distribution and clearance of HIV surrogates within the gastrointestinal tract to inform rectal microbicide development. DESIGN Radiolabeled simulated HIV-infected semen was administered, imaged, and biopsied to simulate and measure colonic HIV distribution after anal intercourse. METHODS Healthy male subjects with a history of receptive anal intercourse and experience with the use of anal sex toys were recruited to this study. Apheresis isolated leukocytes were collected before simulated intercourse. These autologous leukocytes, radiolabeled with 9.25 MBq (111)Indium-oxine (cell-associated HIV surrogate), and sulfur colloid particles, labeled with 37 MBq (99m)Technectium (cell-free HIV surrogate), were mixed in 3 mL autologous seminal plasma. This simulated HIV-infected semen was administered to subjects via an artificial phallus with urethra after 5 minutes of simulated intercourse. Postdosing dual isotope Single photon emission computed tomography coupled with traditional computed tomography (SPECT/CT) images were acquired at 1, 4, 8, and 24 hours. At 5 hours postdosing, colon biopsies were collected, CD4 cells were extracted, and samples analyzed for radioactivity. RESULTS SPECT/CT images showed similar luminal distribution for both surrogates, with migration limited to the rectosigmoid colon in all subjects. SPECT showed at least 75% overlap in distribution of both surrogates up to 4 hours after dosing. Biopsies indicate that 2.4% of CD4 cells extracted from rectosigmoid colon tissue were exogenously administered. CONCLUSIONS Our HIV surrogates stayed within the rectosigmoid colon for 24 hours. Exogenously dosed autologous lymphocytes and HIV-sized particles migrate to similar locations and associate with the colonic tissue in the lumen.
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Louissaint NA, Fuchs EJ, Bakshi RP, Nimmagadda S, Du Y, Macura KJ, King KE, Wahl R, Goldsmith AJ, Caffo B, Cao YJ, Anderson J, Hendrix CW. Distribution of cell-free and cell-associated HIV surrogates in the female genital tract after simulated vaginal intercourse. J Infect Dis 2012; 205:725-32. [PMID: 22279121 DOI: 10.1093/infdis/jir841] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Rational development of drugs to prevent human immunodeficiency virus (HIV) transmission benefits from an understanding HIV distribution in the female genital tract after intercourse. This study describes HIV distribution using surrogates of cell-free and cell-associated HIV and semen. METHODS Apheresis-derived, autologous, lymphocyte-rich cells radiolabeled with 3.7-MBq (100-μCi) indium 111 ((111)In)-oxine (cell-associated HIV surrogate) and 18.5-MBq (500-μCi) technetium 99m ((99m)Tc)-sulfur colloid (HIV-sized 100-nm particle, cell-free HIV surrogate) were resuspended in 3 mL of hydroxyethylcellulose gel (semen simulant) with gadoteridol and dosed via artificial phallus after simulated intercourse. Postdosing dual-isotope single photon emission computed tomography with computed tomography (SPECT/CT) and magnetic resonance (MR) images were acquired to determine the surrogates' distribution. Seven hours after dosing, vaginal biopsy and luminal samples were collected at discrete locations in 8 subjects. RESULTS SPECT/CT and MR analysis showed HIV and semen surrogate distribution with highest signal intensity in the vaginal pericervical area, without detectable signal in the uterus. One-third of the administered dose was retained in the female genital tract after 4 hours. Cell-free and cell-associated surrogate distribution coincided. CONCLUSIONS We demonstrate the feasibility of dual-isotope SPECT/CT and MR imaging to determine the distribution of HIV and semen surrogates after simulated intercourse without disrupting vaginal contents. Surrogate distribution suggests topical microbicides do not need to reach the uterus for efficacy.
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Anton PA, Saunders T, Elliott J, Khanukhova E, Dennis R, Adler A, Cortina G, Tanner K, Boscardin J, Cumberland WG, Zhou Y, Ventuneac A, Carballo-Diéguez A, Rabe L, McCormick T, Gabelnick H, Mauck C, McGowan I. First phase 1 double-blind, placebo-controlled, randomized rectal microbicide trial using UC781 gel with a novel index of ex vivo efficacy. PLoS One 2011; 6:e23243. [PMID: 21969851 PMCID: PMC3182160 DOI: 10.1371/journal.pone.0023243] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 07/11/2011] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Successful control of the HIV/AIDS pandemic requires reduction of HIV-1 transmission at sexually-exposed mucosae. No prevention studies of the higher-risk rectal compartment exist. We report the first-in-field Phase 1 trial of a rectally-applied, vaginally-formulated microbicide gel with the RT-inhibitor UC781 measuring clinical and mucosal safety, acceptability and plasma drug levels. A first-in-Phase 1 assessment of preliminary pharmacodynamics was included by measuring changes in ex vivo HIV-1 suppression in rectal biopsy tissue after exposure to product in vivo. METHODS HIV-1 seronegative, sexually-abstinent men and women (N = 36) were randomized in a double-blind, placebo-controlled trial comparing UC781 gel at two concentrations (0.1%, 0.25%) with placebo gel (1∶1∶1). Baseline, single-dose exposure and a separate, 7-day at-home dosing were assessed. Safety and acceptability were primary endpoints. Changes in colorectal mucosal markers and UC781 plasma drug levels were secondary endpoints; ex vivo biopsy infectibility was an ancillary endpoint. RESULTS All 36 subjects enrolled completed the 7-14 week trial (100% retention) including 3 flexible sigmoidoscopies, each with 28 biopsies (14 at 10 cm; 14 at 30 cm). There were 81 Grade 1 adverse events (AEs) and 8 Grade 2; no Grade 3, 4 or procedure-related AEs were reported. Acceptability was high, including likelihood of future use. No changes in mucosal immunoinflammatory markers were identified. Plasma levels of UC781 were not detected. Ex vivo infection of biopsies using two titers of HIV-1(BaL) showed marked suppression of p24 in tissues exposed in vivo to 0.25% UC781; strong trends of suppression were seen with the lower 0.1% UC781 concentration. CONCLUSIONS Single and 7-day topical rectal exposure to both concentrations of UC781 were safe with no significant AEs, high acceptability, no detected plasma drug levels and no significant mucosal changes. Ex vivo biopsy infections demonstrated marked suppression of HIV infectibility, identifying a potential early biomarker of efficacy. (Registered at ClinicalTrials.gov; #NCT00408538).
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Affiliation(s)
- Peter A Anton
- Center for HIV Prevention Research, UCLA AIDS Institute, Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, United States of America.
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Abstract
More than 7000 new HIV infections are documented each day worldwide. In this Perspective, we dissect new results from a large clinical trial showing that genital and plasma HIV-1 RNA loads predict the risk of heterosexual transmission and that genital tract viral RNA load does so independently of plasma viral load. Furthermore, beyond its defined study end points, this well-conducted trial identified new research directions that should be pursued in smaller intensive basic and translational studies.
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Affiliation(s)
- Peter Anton
- Center for HIV Prevention Research, Division of Digestive Diseases and UCLA AIDS Institute, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA.
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Abstract
The results of the CAPRISA 004 and iPrEx HIV prevention studies have demonstrated that topical or systemic use of antiretroviral agents can significantly reduce the risk of HIV acquisition associated with unprotected vaginal or anal sexual intercourse. However, the effect size in these studies was relatively modest and product adherence was generally poor. These observations suggest the need for new approaches to HIV prevention, especially for high risk MSM. Rates of lubricant use are high in MSM practicing receptive anal sex. Consequently, the development of an antiretroviral rectal microbicide gel may provide a safe and effective means of preventing HIV infection with an intervention that is likely to have high acceptability among the target population. The purpose of this article is to describe the challenges and progress in the development of rectal microbicides for HIV prevention.
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Wang L, Schnaare RL, Dezzutti C, Anton PA, Rohan LC. Rectal microbicides: clinically relevant approach to the design of rectal specific placebo formulations. AIDS Res Ther 2011; 8:12. [PMID: 21385339 PMCID: PMC3061893 DOI: 10.1186/1742-6405-8-12] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 03/07/2011] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The objective of this study is to identify the critical formulation parameters controlling distribution and function for the rectal administration of microbicides in humans. Four placebo formulations were designed with a wide range of hydrophilic characteristics (aqueous to lipid) and rheological properties (Newtonian, shear thinning, thermal sensitive and thixotropic). Aqueous formulations using typical polymers to control viscosity were iso-osmotic and buffered to pH 7. Lipid formulations were developed from lipid solvent/lipid gelling agent binary mixtures. Testing included pharmaceutical function and stability as well as in vitro and in vivo toxicity. RESULTS The aqueous fluid placebo, based on poloxamer, was fluid at room temperature, thickened and became shear thinning at 37°C. The aqueous gel placebo used carbopol as the gelling agent, was shear thinning at room temperature and showed a typical decrease in viscosity with an increase in temperature. The lipid fluid placebo, myristyl myristate in isopropyl myristate, was relatively thin and temperature independent. The lipid gel placebo, glyceryl stearate and PEG-75 stearate in caprylic/capric triglycerides, was also shear thinning at both room temperature and 37°C but with significant time dependency or thixotropy. All formulations showed no rectal irritation in rabbits and were non-toxic using an ex vivo rectal explant model. CONCLUSIONS Four placebo formulations ranging from fluid to gel in aqueous and lipid formats with a range of rheological properties were developed, tested, scaled-up, manufactured under cGMP conditions and enrolled in a formal stability program. Clinical testing of these formulations as placebos will serve as the basis for further microbicide formulation development with drug-containing products.
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Affiliation(s)
- Lin Wang
- Magee Womens Research Institute, Pittsburgh, PA, USA
| | | | - Charlene Dezzutti
- Magee Womens Research Institute, Pittsburgh, PA, USA
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Peter A Anton
- Center for HIV Prevention Research, UCLA AIDS Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Lisa C Rohan
- Magee Womens Research Institute, Pittsburgh, PA, USA
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
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Goldsmith J, Caffo B, Crainiceanu C, Reich D, Du Y, Hendrix C. NONLINEAR TUBE-FITTING FOR THE ANALYSIS OF ANATOMICAL AND FUNCTIONAL STRUCTURES. Ann Appl Stat 2011; 5:337-363. [PMID: 21709824 DOI: 10.1214/10-aoas384] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We are concerned with the estimation of the exterior surface and interior summaries of tube-shaped anatomical structures. This interest is motivated by two distinct scientific goals, one dealing with the distribution of HIV microbicide in the colon and the other with measuring degradation in white-matter tracts in the brain. Our problem is posed as the estimation of the support of a distribution in three dimensions from a sample from that distribution, possibly measured with error. We propose a novel tube-fitting algorithm to construct such estimators. Further, we conduct a simulation study to aid in the choice of a key parameter of the algorithm, and we test our algorithm with validation study tailored to the motivating data sets. Finally, we apply the tube-fitting algorithm to a colon image produced by single photon emission computed tomography (SPECT) and to a white-matter tract image produced using diffusion tensor imaging (DTI).
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Affiliation(s)
- Jeff Goldsmith
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Bloomberg School of Public Health, National Institutes of Health, Johns Hopkins School of Medicine and Johns Hopkins School of Medicine
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Suwannateep N, Banlunara W, Wanichwecharungruang SP, Chiablaem K, Lirdprapamongkol K, Svasti J. Mucoadhesive curcumin nanospheres: biological activity, adhesion to stomach mucosa and release of curcumin into the circulation. J Control Release 2011; 151:176-82. [PMID: 21241751 DOI: 10.1016/j.jconrel.2011.01.011] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 12/14/2010] [Accepted: 01/09/2011] [Indexed: 11/19/2022]
Abstract
Although mucoadhesive drug carriers for the gastro-intestinal tract (GIT) have been reported, the mucoadhesive property and drug release characteristics have never been evaluated separately, whilst the adherence of the carriers to the surface of GIT has not been directly visualized. Here, a monopolymeric carrier made from ethylcellulose (EC) and a dipolymeric carrier made from a blend of methylcellulose (MC) and EC (ECMC) were easily fabricated through a self-assembling process and yielded the highest reported curcumin loading of ~48-49%. Both curcumin loaded ECMC (C-ECMC) and curcumin loaded EC (C-EC) particles showed an in vitro free radical scavenging activity and a dose-dependent in vitro cytotoxic effect towards MCF-7 human breast adenocarcinoma and HepG2 hepatoblastoma cells in tissue culture. The in vivo evaluation of their adherence to stomach mucosa and their ability to release curcumin into the circulation were carried out through quantification of curcumin levels in the stomach tissue and in blood of mice orally administered with the two spheres. Direct evidence of the adherence of the C-EC and C-ECMC particles along the mucosal epithelia of the stomach is also presented for the first time through SEM images. The mucoadhesive property of self-assembled C-EC nanoparticles is discussed.
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Morrow KM, Hendrix C. Clinical evaluation of microbicide formulations. Antiviral Res 2010; 88 Suppl 1:S40-6. [PMID: 21109067 PMCID: PMC3053029 DOI: 10.1016/j.antiviral.2010.09.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 09/08/2010] [Accepted: 09/14/2010] [Indexed: 11/25/2022]
Abstract
The clinical evaluation of microbicide formulations presents variable and interacting challenges. Specific domains of acceptability, pharmacokinetics, and toxicity interact with each other to potentially inhibit or enhance a microbicide's efficacy. Each of these is further influenced by application and use parameters in the relative presence (or absence) of vaginal and/or seminal fluids, ultimately impacting effectiveness. Historically, acceptability of formulation and use parameters, and their concomitant behavioral influences, have been considered separately from pharmacokinetics and toxicity. While independent evaluation of these elements is necessary in some respects, we must acknowledge that this approach is not sufficient for the successful development of microbicides. Each needs to be considered in an integrated clinical evaluation strategy. This article presents the rationale for such an approach. This article forms part of a special supplement covering two presentations on clinical evaluation of microbicides from the symposium on "Recent Trends in Microbicide Formulations" held on 25 and 26 January 2010, Arlington, VA.
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Affiliation(s)
- Kathleen M Morrow
- The Miriam Hospital and The Warren Alpert Medical School of Brown University, CBPM, Coro West, 1 Hoppin Street, Providence, RI 02903, USA.
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36
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Youth-specific considerations in the development of preexposure prophylaxis, microbicide, and vaccine research trials. J Acquir Immune Defic Syndr 2010; 54 Suppl 1:S31-42. [PMID: 20571421 DOI: 10.1097/qai.0b013e3181e3a922] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Preventing HIV infection in adolescents and young adults will require a multimodal targeted approach, including individual-directed behavioral risk reduction, community-level structural change, and biomedical interventions to prevent sexual transmission. Trials testing biomedical interventions to prevent HIV transmission will require special attention in this population due to the unique psychosocial and physiologic characteristics that differentiate them from older populations. For example, microbicide research will need to consider acceptability, dosing requirements, and coinfection rates that are unique to this population. Preexposure prophylaxis studies also will need to consider potential unique psychosocial issues such as sexual disinhibition and acceptability as well as unique pharmacokinetic parameters of antiretroviral agents. Vaccine trials also face unique issues with this population, including attitudes toward vaccines, risks related to false-positive HIV tests related to vaccine, and different immune responses based on more robust immunity. In this article, we will discuss issues around implementing each of these biomedical prevention modalities in trials among adolescents and young adults to help to guide future successful research targeting this population.
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Di Mascio M, Srinivasula S, Bhattacharjee A, Cheng L, Martiniova L, Herscovitch P, Lertora J, Kiesewetter D. Antiretroviral tissue kinetics: in vivo imaging using positron emission tomography. Antimicrob Agents Chemother 2009; 53:4086-95. [PMID: 19667288 PMCID: PMC2764156 DOI: 10.1128/aac.00419-09] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Revised: 05/28/2009] [Accepted: 07/31/2009] [Indexed: 11/20/2022] Open
Abstract
Our current knowledge on the antiviral efficacy, dosing, and toxicity of available highly active antiretroviral therapy regimens is mostly derived from plasma or blood kinetics of anti-human immunodeficiency virus (anti-HIV) drugs. However, the blood comprises only 2% of the total target cells in the body. Tissue drug levels may differ substantially from corresponding plasma levels, and drug distribution processes may be characterized by high intertissue variability, leading to suboptimal target site concentrations and the potential risk for therapeutic failures. Positron emission tomography has greatly expanded the scope of the pharmacokinetic measurements that can be performed noninvasively in animal models or humans. We have prepared [18F]FPMPA, a fluorine-18-radiolabeled analogue of tenofovir, to study antiretroviral tissue kinetics in vivo noninvasively and tested the imaging probe in rats. The biodistribution of the fluorine-18 analogue closely follows that of nonfluorinated tenofovir. Compared to that in the blood, the levels of penetration of the antiretroviral drug were found to be significantly reduced in the spleen and submandibular lymph nodes (approximately 2-fold), in the mesenteric lymph nodes and the testes (approximately 4-fold), and in the brain compartment (approximately 25-fold). Intersubject variability of the trough drug concentration (measured at 120 min) in certain tissues, like the colon (coefficient of variation, >100%), is not reflected by the intersubject variability in the blood compartment (coefficient of variation, 24%). Positron emission tomography imaging of the fluorine-18 analogue revealed the accumulation of the antiretroviral drug in the cortex of the kidneys, a potential correlate of tenofovir-induced nephrotoxicity observed in HIV-1-infected treated patients. Thus, [18F]FPMPA is a promising radiotracer for evaluation of tenofovir biodistribution under carefully controlled drug administration protocols.
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Affiliation(s)
- Michele Di Mascio
- Division of Clinical Research, Biostatistics Research Branch, National Institue of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA.
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Hendrix CW, Cao YJ, Fuchs EJ. Topical microbicides to prevent HIV: clinical drug development challenges. Annu Rev Pharmacol Toxicol 2009; 49:349-75. [PMID: 19006450 DOI: 10.1146/annurev.pharmtox.48.113006.094906] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Microbicides, substances applied topically to prevent sexual HIV infection, are needed to empower receptive sexual partners with effective prevention methods. Several large microbicide trials, however, failed to demonstrate efficacy, thus motivating a reevaluation of the current microbicide development paradigm, which has been largely empirically based. Microbicide use occurs in a highly complex environment involving multi-level interactions, behavioral and biochemical, among host, virus, and drug, yet many details of these interactions remain unknown. Fundamental information regarding virus and drug distribution over time in sexually receptive body compartments that is necessary to design a microbicide able to outdistance and outlast the virus is largely absent. Recent efforts have been made to establish a simple conceptual framework for obtaining the knowledge that is likely to inform a more mechanistic, model-based development paradigm. These efforts have also advanced the development of numerous methodological approaches to obtain the knowledge needed to improve microbicide development.
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Affiliation(s)
- Craig W Hendrix
- Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, USA.
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Seo Y, Mari C, Hasegawa BH. Technological development and advances in single-photon emission computed tomography/computed tomography. Semin Nucl Med 2008; 38:177-98. [PMID: 18396178 DOI: 10.1053/j.semnuclmed.2008.01.001] [Citation(s) in RCA: 139] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Single-photon emission computed tomography/computed tomography (SPECT/CT) has emerged during the past decade as a means of correlating anatomical information from CT with functional information from SPECT. The integration of SPECT and CT in a single imaging device facilitates anatomical localization of the radiopharmaceutical to differentiate physiological uptake from that associated with disease and patient-specific attenuation correction to improve the visual quality and quantitative accuracy of the SPECT image. The first clinically available SPECT/CT systems performed emission-transmission imaging using a dual-headed SPECT camera and a low-power x-ray CT subsystem. Newer SPECT/CT systems are available with high-power CT subsystems suitable for detailed anatomical diagnosis, including CT coronary angiography and coronary calcification that can be correlated with myocardial perfusion measurements. The high-performance CT capabilities also offer the potential to improve compensation of partial volume errors for more accurate quantitation of radionuclide measurement of myocardial blood flow and other physiological processes and for radiation dosimetry for radionuclide therapy. In addition, new SPECT technologies are being developed that significantly improve the detection efficiency and spatial resolution for radionuclide imaging of small organs including the heart, brain, and breast, and therefore may provide new capabilities for SPECT/CT imaging in these important clinical applications.
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Affiliation(s)
- Youngho Seo
- Department of Radiology, University of California, San Francisco, San Francisco, CA, USA
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