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Sun CK, Kung YY, Lee WH, Lin LC, Yang MH, Tsai TH. Pharmacokinetic analysis of antiviral drug ritonavir across the blood-brain barrier and its interaction with Scutellaria baicalensis using multisite microdialysis in rats. J Pharm Biomed Anal 2024; 245:116162. [PMID: 38678857 DOI: 10.1016/j.jpba.2024.116162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 05/01/2024]
Abstract
Ritonavir, an excellent inhibitor of CYP3A4, has recently been combined with nirmatrelvir to form Paxlovid for the treatment of severe acute respiratory syndrome coronavirus 2 infections. The root of Scutellaria baicalensis Georgi (S. baicalensis), a traditional Chinese medicinal (TCM) herb commonly used to treat heat/inflammation in the lung and digestive tracts, which are major organs targeted by viral infections, contains flavones that can influence the CYP3A metabolism pathway. To investigate the ability of ritonavir to cross the bloodbrain barrier (BBB) and its potential herb-drug interactions with an equivalent TCM clinical dose of S. baicalensis, multisite microdialysis coupled with an LCMS/MS system was developed using rat model. Pretreatment with S. baicalensis extract for 5 days, which contains less flavones than those used in previous studies, had a significant influence on ritonavir, resulting in a 2-fold increase in the total concentration of flavones in the blood and brain. Treatment also boosted the maximum blood concentration of flavones by 1.5-fold and the maximum brain concentration of flavones by 2-fold, all the while exerting no noticeable influence on the transfer ratio across the bloodbrain barrier. These experimental results demonstrated that the use of a typical traditional Chinese medicinal dose of S. baicalensis is sufficient to influence the metabolic pathway and synergistically increase the concentration of ritonavir in rats.
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Affiliation(s)
- Chung-Kai Sun
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Yen-Ying Kung
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; Center for Traditional Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Wan-Hsin Lee
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Lie-Chwen Lin
- National Research Institute of Chinese Medicine, Ministry of Health and Welfare, Taipei 112, Taiwan
| | - Muh-Hwa Yang
- Institute of Clinical Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Tung-Hu Tsai
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; Graduate Institute of Acupuncture Science, China Medical University, Taichung 404, Taiwan; School of Pharmacy, Kaohsiung Medical University, Kaohsiung 807, Taiwan; Graduate Institute of Law and Interdisciplinary Studies, College of Law, National Chengchi University, Taipei 116, Taiwan.
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Scutellaria baicalensis and its constituents baicalin and baicalein as antidotes or protective agents against chemical toxicities: a comprehensive review. Naunyn Schmiedebergs Arch Pharmacol 2022; 395:1297-1329. [PMID: 35676380 DOI: 10.1007/s00210-022-02258-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 05/21/2022] [Indexed: 10/18/2022]
Abstract
Scutellaria baicalensis (SB), also known as the Chinese skullcap, has a long history of being used in Chinese medicine to treat a variety of conditions ranging from microbial infections to metabolic syndrome and malignancies. Numerous studies have reported that treatment with total SB extract or two main flavonoids found in its root and leaves, baicalin (BA) and baicalein (BE), can prevent or alleviate the detrimental toxic effects of exposure to various chemical compounds. It has been shown that BA and BE are generally behind the protective effects of SB against toxicants. This paper aimed to review the protective and therapeutic effects of SB and its main components BA and BE against chemical compounds that can cause intoxication after acute or chronic exposure and seriously affect different vital organs including the brain, heart, liver, and kidneys. In this review paper, we had a look into a total of 221 in vitro and in vivo studies from 1995 to 2021 from the scientific databases PubMed, Scopus, and Web of Science which reported protective or therapeutic effects of BA, BE, or SB against drugs and chemicals that one might be exposed to on a professional or accidental basis and compounds that are primarily used to simulate disease models. In conclusion, the protective effects of SB and its flavonoids can be mainly attributed to increase in antioxidants enzymes, inhibition of lipid peroxidation, reduction of inflammatory cytokines, and suppression of apoptosis pathway.
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Huang YM, Alharbi NS, Sun B, Shantharam CS, Rakesh KP, Qin HL. Synthetic routes and structure-activity relationships (SAR) of anti-HIV agents: A key review. Eur J Med Chem 2019; 181:111566. [PMID: 31401538 DOI: 10.1016/j.ejmech.2019.111566] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 07/25/2019] [Accepted: 07/26/2019] [Indexed: 01/05/2023]
Abstract
The worldwide increase of AIDS, an epidemic infection in constant development has an essential and still requires potent antiretroviral chemotherapeutic agents for reducing the integer of deaths caused by HIV. Thus, there is an urgent need for new anti-HIV drug candidates with increased strength, new targets, superior pharmacokinetic properties, and compact side effects. From this viewpoint, we first review present strategies of anti-HIV drug innovation and the synthesis of heterocyclic or natural compound as anti-HIV agents for facilitating the development of more influential and successful anti-HIV agents.
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Affiliation(s)
- Yu-Mei Huang
- Department of Pharmaceutical Engineering, School of Chemistry, Chemical Engineering and Life Science, Wuhan University of Technology, 205 Luoshi Road, Wuhan, 430070, PR China
| | - Njud S Alharbi
- Biotechnology Research Group, Deportment of Biological Sciences, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Bing Sun
- Department of Pharmaceutical Engineering, School of Chemistry, Chemical Engineering and Life Science, Wuhan University of Technology, 205 Luoshi Road, Wuhan, 430070, PR China.
| | - C S Shantharam
- Department of Chemistry, Pooja Bhagavath Memorial Mahajana Education Centre, Mysuru, 570016, Karnataka, India
| | - K P Rakesh
- Department of Pharmaceutical Engineering, School of Chemistry, Chemical Engineering and Life Science, Wuhan University of Technology, 205 Luoshi Road, Wuhan, 430070, PR China.
| | - Hua-Li Qin
- Department of Pharmaceutical Engineering, School of Chemistry, Chemical Engineering and Life Science, Wuhan University of Technology, 205 Luoshi Road, Wuhan, 430070, PR China.
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Zhao T, Tang H, Xie L, Zheng Y, Ma Z, Sun Q, Li X. Scutellaria baicalensis Georgi. (Lamiaceae): a review of its traditional uses, botany, phytochemistry, pharmacology and toxicology. ACTA ACUST UNITED AC 2019; 71:1353-1369. [PMID: 31236960 DOI: 10.1111/jphp.13129] [Citation(s) in RCA: 238] [Impact Index Per Article: 47.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 05/21/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Scutellaria baicalensis Georgi. (Lamiaceae) is a plant of the genus Lamiaceae, and its root is the main part used as a medicine. In China, Scutellaria baicalensis is still an important traditional Chinese medicine with the functions of clearing away heat and dampness, purging fire and detoxification. This medicinal plant is widely distributed in China, Russia, Mongolia, North Korea and Japan. The purpose of this paper was to provide a systematic and comprehensive overview on the traditional usages, botany, phytochemistry, pharmacology, pharmacokinetics and toxicology of this plant. Furthermore, the possible development trends and perspectives for future research on this medicinal plant are also discussed. KEY FINDINGS So far, over 40 compounds have been isolated and identified from Scutellaria baicalensis, including flavonoids, terpenoids, volatile oils and polysaccharides. The compounds and extracts isolated from Scutellaria baicalensis exhibit a wide range of pharmacological activities, including the effects on the nervous system, effects on the immune system, liver protection, antitumour effects, antibacterial and antiviral effects, antioxidant effects and other pharmacological effects. SUMMARY As a traditional Chinese herbal medicine, Scutellaria baicalensis has shown significant effects on the treatment of various diseases, especially hepatitis, diarrhoea, vomiting and high blood pressure. Numerous traditional uses of Scutellaria baicalensis have been confirmed by current investigations. However, it is also necessary to further study the drug-forming properties and pharmacokinetics of the active constituents of Scutellaria baicalensis, as well as to establish quality control standards for different areas of Scutellaria baicalensis, and to carry out the research at the cellular and molecular levels.
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Affiliation(s)
- Tiantian Zhao
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Hailong Tang
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Long Xie
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yu Zheng
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Zubing Ma
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Qiang Sun
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xiaofang Li
- College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
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Abstract
Much of our knowledge about HIV infection has been obtained from cohort studies, including description of the natural history of infection, identification of CD4 count and viral load as good surrogate markers of clinical progression, identification of co-factors [including older age and viral infections (CMV, HCV)] for progression of HIV-related disease and assessment of impact of highly active antiretroviral therapy on clinical outcomes. The Cologne-Bonn cohort was founded by Gerd Fätkenheuer and Bernd Salzberger after introduction of combination antiretroviral therapy in 1996 and has delivered important findings which have helped to improve treatment strategies as well as quality of overall care in HIV infection in these two cities. Indeed, the first pivotal paper from the cohort reported on an unexpectedly high rate of virological treatment failure of protease inhibitor therapy in an unselected cohort of HIV-infected patients. The subsequent analysis of risk factors for virological failure initiated the development of more potent HIV combination therapy. This review summarizes some of the major findings and contributions from the Cologne-Bonn cohort since 1996.
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Yuan CS, Wang CZ, Mehendale SR, Aung HH, Foo A, Israel RJ. Protease inhibitor-induced nausea and vomiting is attenuated by a peripherally acting, opioid-receptor antagonist in a rat model. AIDS Res Ther 2009; 6:19. [PMID: 19698111 PMCID: PMC2736972 DOI: 10.1186/1742-6405-6-19] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Accepted: 08/21/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Protease inhibitors such as ritonavir can cause nausea and vomiting which is the most common reason for discontinuation. Rats react to nauseous and emetic stimuli by increasing their oral intake of non-nutritive substances like kaolin, known as pica behavior. In this study, we evaluated the effects of methylnaltrexone, a peripherally acting mu-opioid receptor antagonist that does not affect analgesia, on ritonavir-induced nausea and vomiting in a rat pica model. RESULTS We observed that 24 to 48 hr after administration of oral ritonavir 20 mg/kg, kaolin consumption increased significantly in rats (P < 0.01). This increase was attenuated by pretreatment with an intraperitoneal injection of methylnaltrexone (0.3-3.0 mg/kg) in a dose dependent manner (P < 0.01) and also with naloxone (0.1-0.3 mg/kg) (P < 0.01). The areas under the curve for kaolin intake from time 0 to 120 hr were significantly reduced after administration of the opioid antagonists. Food intake was not significantly affected. Plasma naltrexone levels were measured after methylnaltrexone injection, and no detectable levels were found, indicating that methylnaltrexone was not demethylated in our experimental paradigm. CONCLUSION These results suggest that methylnaltrexone may have potential clinical utility in reducing nausea and vomiting in HIV patients who take ritonavir.
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Bertrand J, Treluyer JM, Panhard X, Tran A, Auleley S, Rey E, Salmon-Céron D, Duval X, Mentré F. Influence of pharmacogenetics on indinavir disposition and short-term response in HIV patients initiating HAART. Eur J Clin Pharmacol 2009; 65:667-78. [PMID: 19440701 DOI: 10.1007/s00228-009-0660-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Accepted: 04/07/2009] [Indexed: 01/08/2023]
Abstract
AIMS To assess the relationship between genetic polymorphisms and indinavir pharmacokinetic variability and to study the link between concentrations and short-term response or metabolic safety. METHODS Forty protease inhibitor-naive patients initiating highly active antiretroviral therapy (HAART) including indinavir/ritonavir and enrolled in the COPHAR 2-ANRS 111 trial were studied. At week 2, four blood samples were taken before and up to 6 h following drug intake. A population pharmacokinetic analysis was performed using the stochastic approximation expectation maximization (SAEM) algorithm implemented in MONOLIX software. The area under the concentration-time curve (AUC) and maximum (C(max)) and trough concentrations (C(trough)) of indinavir were derived from the population model and tested for their correlation with short-term viral response and safety measurements, while for ritonavir, these same three parameters were tested for their correlation with short-term biochemical safety RESULTS A one-compartment model with first-order absorption and elimination best described both indinavir and ritonavir concentrations. For indinavir, the estimated clearance and volume of distribution were 22.2 L/h and 97.3 L, respectively. The eight patients with the *1B/*1B genotype for the CYP3A4 gene showed a 70% decrease in absorption compared to those with the *1A/*1B or *1A/*1A genotypes (0.5 vs. 2.1, P = 0.04, likelihood ratio test by permutation). The indinavir AUC and C(trough) were positively correlated with the decrease in human immunodeficiency virus RNA between week 0 and week 2 (r = 0.4, P = 0.03 and r = -0.4, P = 0.03, respectively). Patients with the *1B/*1B genotype also had a significantly lower indinavir C(max) (median 3.6, range 2.1-5.2 ng/mL) than those with the *1A/*1B or *1A/*1A genotypes (median 4.4, range 2.2-8.3 ng/mL) (P = 0.04) and a lower increase in triglycerides during the first 4 weeks of treatment (median 0.1, range -0.7 to 1.4 vs. median 0.6, range -0.5 to 1.7 mmol/L, respectively; P = 0.02). For ritonavir, the estimated clearance and volume of distribution were 8.3 L/h and 60.7 L, respectively, and concentrations were not found to be correlated to biochemical safety. Indinavir and ritonavir absorption rate constants were found to be correlated, as well as their apparent volumes of distribution and clearances, indicating correlated bioavailability of the two drugs. CONCLUSION The CYP3A4*1B polymorphism was found to influence the pharmacokinetics of indinavir and, to some extent, the biochemical safety of indinavir.
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Affiliation(s)
- Julie Bertrand
- UMR 738, INSERM, Université Paris Diderot, UFR de Médecine, 16, rue Henri Huchard, 75018, Paris, France.
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Kappelhoff BS, Huitema ADR, Sankatsing SUC, Meenhorst PL, Van Gorp ECM, Mulder JW, Prins JM, Beijnen JH. Population pharmacokinetics of indinavir alone and in combination with ritonavir in HIV-1-infected patients. Br J Clin Pharmacol 2006; 60:276-86. [PMID: 16120066 PMCID: PMC1884764 DOI: 10.1111/j.1365-2125.2005.02436.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
AIMS The aim of the study was to characterize the population pharmacokinetics of indinavir, define the relationship between the pharmacokinetics of indinavir and ritonavir, and to identify the factors influencing the pharmacokinetics of indinavir alone or when given with ritonavir. METHODS HIV-1-infected patients being treated with an indinavir-containing regimen were included. During regular visits, 102 blood samples were collected for the determination of plasma indinavir and ritonavir concentrations. Full pharmacokinetic curves were available from 45 patients. Concentrations of indinavir and ritonavir were determined by liquid chromatography coupled with electrospray tandem mass spectrometry. Pharmacokinetic analysis was performed using nonlinear mixed effect modelling (NONMEM). RESULTS The disposition of indinavir was best described by a single compartment model with first order absorption and elimination. Values for the clearance, volume of distribution and the absorption rate constant were 46.8 l h(-1) (24.2% IIV), 82.3 l (24.6% IIV) and 02.62 h(-1), respectively. An absorption lag-time of 0.485 h was detected in patients also taking ritonavir. Furthermore this drug, independent of dose (100-400 mg) or plasma concentration, decreased the clearance of indinavir by 64.6%. In contrast, co-administration of efavirenz or nevirapine increased the clearance of indinavir by 41%, irrespective of the presence or absence of ritonavir. Female patients had a 48% higher apparent bioavailability of indinavir than males. CONCLUSIONS The pharmacokinetic parameters of indinavir were adequately described by our population model. Female gender and concomitant use of ritonavir and non-nucleoside reverse transcriptase inhibitors strongly influenced the pharmacokinetics of this drug. The results support the concept of ritonavir boosting, maximum inhibition of indinavir metabolized being observed at 100 mg.
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Affiliation(s)
- Bregt S Kappelhoff
- Slotervaart Hospital, Department of Pharmacy & Pharmacology, Amsterdam, the Netherlands.
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Aung H, Mehendale S, Chang WT, Wang CZ, Xie JT, Yuan CS. Scutellaria baicalensis decreases ritonavir-induced nausea. AIDS Res Ther 2005; 2:12. [PMID: 16368007 PMCID: PMC1352373 DOI: 10.1186/1742-6405-2-12] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2005] [Accepted: 12/20/2005] [Indexed: 12/30/2022] Open
Abstract
Background Protease inhibitors, particularly ritonavir, causes significant gastrointestinal disturbances such as nausea, even at low doses. This ritonavir-induced nausea could be related to its oxidative stress in the gut. Alleviation of drug-induced nausea is important in effectively increasing patients' compliance and improving their quality of life. Conventional anti-emetic drugs can only partially abate the symptoms in these patients, and their cost has also been a concern. Rats respond to nausea-producing emetic stimuli by increasing consumption of non-nutritive substances like kaolin or clay, a phenomenon known as pica. In this study, we used this rat pica model to evaluate the effects of Scutellaria baicalensis, a commonly used oriental herbal medicine, on ritonavir-induced nausea. Results Rats treated with 20 mg/kg ritonavir significant caused increases of kaolin consumption at 24 to 48 hr (P < 0.01). Pretreatment with 0.3 and 3 mg/kg Scutellaria baicalensis extract significantly decreased ritonavir-induced kaolin intake in a dose-related manner (P < 0.01). Compared to vehicle treatment, the extract completely prevented ritonavir-induced kaolin consumption at dose 3 mg/kg. The area under the curves (AUC) for kaolin intake from time 0 to 120 hr for vehicle only, ritonavir only, SbE 0.3 mg/kg plus ritonavir, and SbE 3 mg/kg plus ritonavir were 27.3 g•hr, 146.7 g•hr, 123.2 g•hr, and 32.7 g•hr, respectively. The reduction in area under the curves of kaolin intake from time 0 to 120 hr between ritonavir only and SbE 0.3 mg/kg plus ritonavir, ritonavir only and SbE 3 mg/kg plus ritonavir were 16.0% and 77.7%, respectively. Conclusion Scutellaria baicalensis significantly attenuated ritonavir-induced pica, and demonstrated a potential in treating ritonavir-induced nausea.
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Affiliation(s)
- Han Aung
- Tang Center for Herbal Medicine Research, Pritzker School of Medicine. The University of Chicago, IL 60637, USA
- Departments of Anesthesia & Critical Care. Pritzker School of Medicine. The University of Chicago, IL 60637, USA
| | - Sangeeta Mehendale
- Tang Center for Herbal Medicine Research, Pritzker School of Medicine. The University of Chicago, IL 60637, USA
- Departments of Anesthesia & Critical Care. Pritzker School of Medicine. The University of Chicago, IL 60637, USA
| | - Wei-Tien Chang
- Tang Center for Herbal Medicine Research, Pritzker School of Medicine. The University of Chicago, IL 60637, USA
- Departments of Anesthesia & Critical Care. Pritzker School of Medicine. The University of Chicago, IL 60637, USA
| | - Chong-Zhi Wang
- Tang Center for Herbal Medicine Research, Pritzker School of Medicine. The University of Chicago, IL 60637, USA
- Departments of Anesthesia & Critical Care. Pritzker School of Medicine. The University of Chicago, IL 60637, USA
| | - Jing-Tian Xie
- Tang Center for Herbal Medicine Research, Pritzker School of Medicine. The University of Chicago, IL 60637, USA
- Departments of Anesthesia & Critical Care. Pritzker School of Medicine. The University of Chicago, IL 60637, USA
| | - Chun-Su Yuan
- Tang Center for Herbal Medicine Research, Pritzker School of Medicine. The University of Chicago, IL 60637, USA
- Departments of Anesthesia & Critical Care. Pritzker School of Medicine. The University of Chicago, IL 60637, USA
- Committee on Clinical Pharmacology and Pharmacogenomics. Pritzker School of Medicine. The University of Chicago, IL 60637, USA
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Acosta EP, Wu H, Hammer SM, Yu S, Kuritzkes DR, Walawander A, Eron JJ, Fichtenbaum CJ, Pettinelli C, Neath D, Ferguson E, Saah AJ, Gerber JG. Comparison of two indinavir/ritonavir regimens in the treatment of HIV-infected individuals. J Acquir Immune Defic Syndr 2005; 37:1358-66. [PMID: 15483465 DOI: 10.1097/00126334-200411010-00004] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pharmacokinetic enhancement of protease inhibitors (PIs) with low-dose ritonavir (RTV) for salvage therapy is increasingly common. The purpose of this study was to compare the pharmacokinetics, safety, and tolerability of indinavir (IDV)/RTV at 800/200 mg (arm A) and 400/400 mg (arm B) administered twice daily in HIV-infected subjects failing their first PI-based regimen. METHODS A phase I/II, randomized, open-label, 24-week study was conducted. Formal 12-hour pharmacokinetic evaluations were performed, and study visits occurred at baseline; at weeks 1, 2, and 4; and every 4 week thereafter for 24 weeks. Clinical symptoms and laboratory assessments were collected. Subjects were allowed to switch arms because of toxicity. RESULTS Forty-four subjects were enrolled (22 per arm). IDV predose concentration, maximum plasma concentration and area under the curve were significantly higher in arm A. Fifty-five percent and 45% of subjects in arms A and B responded (<200 copies/mL at week 24; P = 0.76), respectively. CD4 cell responses were similar. All subjects had IDV-sensitive virus at baseline and at virologic failure. Tolerability was comparable, but all grade 3 or higher triglyceride increases occurred in arm B and more subjects in arm B switched because of toxicity (5 vs. 1 triglyceride increases). CONCLUSIONS This is the largest formal pharmacokinetic evaluation of 2 dosage combinations of IDV/RTV in HIV-infected individuals. Pharmacokinetic parameters were consistent with previous results in patients but lower than in seronegative controls. Both regimens exhibited similar tolerability and response rates. High toxicity with a low response suggests that the optimum IDV/RTV combination would include an RTV dose <400 mg and an IDV dose <800 mg in this population.
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Affiliation(s)
- Edward P Acosta
- Division of Clinical Pharmacology, University of Alabama at Birmingham School of Medicine, Birmingham, AL 35294-0019, USA.
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Brendel K, Legrand M, Taburet AM, Baron G, Goujard C, Mentré F. Population pharmacokinetic analysis of indinavir in HIV-infected patient treated with a stable antiretroviral therapy. Fundam Clin Pharmacol 2005; 19:373-83. [PMID: 15910662 DOI: 10.1111/j.1472-8206.2005.00315.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The objectives of this study were to build a population pharmacokinetic model that describe plasma concentrations of indinavir in human immunodeficiency virus (HIV)-infected patients with sustained virological response under a stable antiretroviral combination, and to characterize the effect of covariates and co-medications on indinavir pharmacokinetics. Data were obtained from 45 patients who received different dosages of indinavir: either indinavir alone t.i.d. (mostly 800 mg), either indinavir b.i.d. (mostly 800 mg) with a booster dose of 100 mg of ritonavir. Patients were required to have a baseline plasma HIV RNA <200 copies/mL and to have unchanged antiretroviral treatment for 6 months. Indinavir concentrations were measured at a first visit (one sample before drug administration and five after) and at a second visit 3 months later (before and 1 or 3 h after drug administration). A one-compartment model with first-order absorption and first-order elimination best described indinavir pharmacokinetics. For patients treated with indinavir alone, absorption rate constant was estimated to be 0.43/h, and oral clearance Cl/F was 33 L/h. For patients treated with indinavir plus ritonavir these estimates were 0.25/h and 19 L/h, respectively. Cl/F was found to increase by 1.45-fold in men and by 1.18-fold in patients also receiving zidovudine. Oral volume of distribution (V/F) was 24 L. The inter-individual and intra-individual variability were 117 and 205% for V/F, 42 and 58% for Cl/F, respectively. This population analysis in patients with sustained virological response, quantified the effect of ritonavir on the absorption rate constant and on the clearance of indinavir, showed an increase of Cl/F in men and can be used to draw reference curve for therapeutic drug monitoring.
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Affiliation(s)
- Karl Brendel
- INSERM E0357, Department of Epidemiology, Biostatistics and Clinical Research, AP-HP, Bichat University Hospital, Paris, France.
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Rhame FS, Rawlins SL, Petruschke RA, Erb TA, Winchell GA, Wilson HM, Edelman JM, Abramson MA. Pharmacokinetics of indinavir and ritonavir administered at 667 and 100 milligrams, respectively, every 12 hours compared with indinavir administered at 800 milligrams every 8 hours in human immunodeficiency virus-infected patients. Antimicrob Agents Chemother 2004; 48:4200-8. [PMID: 15504842 PMCID: PMC525412 DOI: 10.1128/aac.48.11.4200-4208.2004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Human immunodeficiency virus (HIV) patients on nucleoside or nucleotide reverse transcriptase inhibitors with HIV RNA at <1,000 copies/ml were randomized in an open-label study to administration of combined indinavir/ritonavir (IDV/RTV) at 667/100 mg every 12 h (q12h) or IDV alone at 800 mg q8h to determine the regimens' pharmacokinetics. On day 14, plasma IDV and RTV levels were determined over 24 h. Noncompartmental pharmacokinetics (minimum concentration of drug in serum [C(min)], area under the concentration-time curve from 0 to 24 h [AUC(0-24)], and maximum concentration of drug in serum [C(max)]) were expressed as geometric mean values with 90% confidence intervals (CI). The primary hypothesis was that the lower bound of the protocol-specified 90% CI for the geometric mean C(min) ratio of the combination compared to IDV alone regimen would be >/=2. Twenty-seven patients were enrolled, and 24 (15 male; average age, 42 years) completed the study. The C(min), AUC(0-24), and C(max) for IDV/RTV compared to IDV alone were 1,511 versus 250 nM, 119,557 versus 77,034 nM . h, and 10,428 versus 10,407 nM, respectively. Corresponding relationships for IDV/RTV compared to IDV alone were a 6.0-fold increase in C(min) (90% CI, 4.0, 9.3), an increase in AUC(0-24) (1.5-fold, 90% CI, 1.2, 2.0), and no increase in C(max). Adverse events were similar and generally mild, with no cases of nephrolithiasis. The geometric mean ratio of IDV C(min) for IDV/RTV compared to IDV was at least 2 by a lower bound of the 90% CI, satisfying the primary hypothesis. The C(max) was not increased, suggesting an IDV/RTV 667/100-mg toxicity profile may be similar to that of unboosted IDV.
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Affiliation(s)
- Frank S Rhame
- Merck & Co., Inc., HM-322, 1 Walnut Grove Dr., Horsham, PA 19044, USA
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Wasmuth JC, la Porte CJL, Schneider K, Burger DM, Rockstroh JK. Comparison of Two Reduced-Dose Regimens of Indinavir (600 Mg Vs 400 Mg Twice Daily) and Ritonavir (100 Mg Twice Daily) in Healthy Volunteers (Coredir). Antivir Ther 2004. [DOI: 10.1177/135965350400900209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To assess the pharmacokinetics and tolerability of reduced dosages of twice daily indinavir (IDV) boosted by low-dose ritonavir (RTV) in healthy volunteers. Methods Pharmacokinetics and tolerability of IDV/RTV twice daily (600/100 mg and 400/100 mg) were assessed in a randomized crossover design in 16 healthy volunteers. Each dosage was taken twice daily for 2 weeks before 12 h pharmacokinetics were obtained. Results Sixteen subjects were included, with a mean age ±SD of 30 ±4 years; seven female, nine male. Fifteen subjects completed the study. After dose reduction of IDV AUC, Cmax and Cmin decreased significantly. In the 400 mg group three out of 15 subjects had IDV levels below 0.10 mg/l vs none in the 600 mg group. All subjects reported mild to moderate side effects throughout the study period, which were more severe in the 600 mg group (mostly renal, dry skin/lips, paresthesias/oral discomfort). In the 600 mg group four subjects reported dysuria and one subject discontinued because of flank pain, whereas two subjects reported dysuria and no subject discontinued in the 400 mg group, respectively. Eight subjects developed crystalluria without a significant difference between both groups. No significant change in serum creatinine was observed. Conclusions IDV/RTV 400/100 mg twice daily resulted in significant lower IDV exposure, with three out of 15 subjects revealing Cmin values below the recommended threshold for wild-type virus of 0.10 mg/l. Tolerability, however, was lower in the 600 mg IDV group. Therapeutic drug monitoring in the individual patient appears to be necessary to guarantee appropriate drug levels and simultaneously minimize toxicity. Presented in part at the 6th International Congress on Drug Therapy in HIV Infection. Glasgow, Scotland, UK, November 2002. Abstract P182.
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Affiliation(s)
| | - Charles JL la Porte
- Department of Clinical Pharmacy and Nijmegen University Centre for Infectious diseases, University of Nijmegen, the Netherlands
| | | | - David M Burger
- Department of Clinical Pharmacy and Nijmegen University Centre for Infectious diseases, University of Nijmegen, the Netherlands
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Colagreco JP. Cardiovascular Considerations in Patients Treated with HIV Protease Inhibitors. J Assoc Nurses AIDS Care 2004; 15:30-41. [PMID: 14983559 DOI: 10.1177/1055329003256922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Highly active antiretroviral therapy (HAART) has dramatically reduced mortality from HIV infection, transforming it in many cases to a chronic condition. However, protease inhibitors (PIs), which are integral components of most HAART regimens, are commonly associated with a host of metabolic disturbances that may increase the risk of cardiovascular disease in patients with HIV infection, potentially counteracting some of the positive health effects of PIs. Dyslipidemia is of particular concern. The Adult AIDS Clinical Trials Group has established preliminary guidelines to evaluate and treat PI-associated dyslipidemia. A number of strategies exist for the management of PI-based dyslipidemia in HAART recipients; their advantages and disadvantages should be considered when treating patients with HIV infection.
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Affiliation(s)
- Joseph P Colagreco
- Division of Nursing, Steinhardt School of Education, New York University, USA
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Justesen US, Levring AM, Thomsen A, Lindberg JA, Pedersen C, Tauris P. Low-dose indinavir in combination with low-dose ritonavir: steady-state pharmacokinetics and long-term clinical outcome follow-up. HIV Med 2003; 4:250-4. [PMID: 12859324 DOI: 10.1046/j.1468-1293.2003.00153.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To evaluate the long-term efficacy and pharmacokinetics of indinavir (IDV)/ritonavir (RTV) 400/100 mg twice a day in combination with two nucleoside reverse transcriptase inhibitors. METHODS The study was retrospective with a prospective pharmacokinetic study at a single centre. All HIV-1-infected patients who started the regimen in the period from January 1999 to February 2001 were included in the study. Plasma HIV RNA and CD4 cell counts were recorded from baseline to week 120. Results were evaluated as intention-to-treat and on-treatment analyses with separate analyses for protease inhibitor naive and experienced patients. Patients who were still on the regimen by August 2001 were asked to participate in a pharmacokinetic evaluation. RESULTS Twenty-one patients started treatment with the regimen (median follow-up: 116 weeks). The percentage of patients with below 20 HIV-1 RNA copies/mL was 70.0% at week 120 and the median CD4 cell count increased from 320 to 607 cells/microL (P=0.062). The median IDV morning and evening Cmin were 434 ng/mL and 220 ng/mL, respectively. CONCLUSIONS Treatment with the IDV/RTV 400/100 mg regimen appears to be efficacious for up to 2 years. However, rather low IDV Cmin suggests that the regimen should be evaluated further before its widespread use and that the regimen probably should be guided by pharmacokinetic evaluation.
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Affiliation(s)
- U S Justesen
- Institute of Public Health, Clinical Pharmacology, University of Southern Denmark, Odense.
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Author Index. HIV Med 2002. [DOI: 10.1046/j.1468-1293.2002.04200.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Aarnoutse RE, Wasmuth JC, Fätkenheuer G, Schneider K, Schmitz K, de Boo TM, Reiss P, Hekster YA, Burger DM, Rockstroh JK. Administration of Indinavir and Low-Dose Ritonavir (800/100 Mg Twice Daily) with Food Reduces Nephrotoxic Peak Plasma Levels of Indinavir. Antivir Ther 2002. [DOI: 10.1177/135965350300800407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The objective of this study was to compare indinavir peak plasma (Cmax) values after administration of indinavir/ritonavir 800/100 mg on an empty stomach or with food. High indinavir Cmax values have been associated with indinavir-related nephrotoxicity. Methods This was an open-label, randomized, two-treatment, two-period, cross-over pharmacokinetic study performed at steady state. HIV-infected patients who had been using indinavir/ritonavir 800/100 mg twice daily for at least 4 weeks were randomized to take this combination with a light breakfast (two filled rolls and 130 ml of fluid) on a first study day, and without food on a second day, or in the reverse order. The pharmacokinetics of indinavir and ritonavir were assessed after plasma and urine sampling during 12 h. Results Data for nine patients were evaluated. Administration of indinavir/ritonavir 800/100 mg on an empty stomach resulted in a higher indinavir Cmax [geometric mean (GM) ratio – fasting/fed and 95% confidence interval (CI): 1.28 (1.08–1.52), P=0.01] and a trend to a shorter indinavir tmax ( P=0.07) compared to administration with food. The mode of administration of indinavir/ritonavir did not affect plasma indinavir Cmin and AUC values, parameters that have been associated with the antiviral efficacy of indinavir, nor the urinary excretion of indinavir. Conclusions Administration of indinavir/ritonavir 800/100 mg on an empty stomach results in a higher indinavir Cmax compared to ingestion with a light meal. Stated the other way round, intake with a light meal reduces indinavir Cmax, which probably reflects a food-induced delay in the absorption of indinavir. It is recommended to administer indinavir/ritonavir 800/100 mg with food, as a possible means to prevent indinavir-related nephrotoxicity in patients who start or continue with this regimen.
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Affiliation(s)
- Rob E Aarnoutse
- Department of Clinical Pharmacy, University Medical Centre Nijmegen, The Netherlands
- Nijmegen University Centre for Infectious Diseases, University Medical Centre Nijmegen, The Netherlands
| | | | | | | | - Karina Schmitz
- Department of Internal Medicine, University of Cologne, Germany
| | - Theo M de Boo
- Department of Epidemiology and Biostatistics, University Medical Centre Nijmegen, The Netherlands
| | - Peter Reiss
- National AIDS Therapy Evaluation Centre & Department of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Centre, Amsterdam, The Netherlands
| | - Yechiel A Hekster
- Department of Clinical Pharmacy, University Medical Centre Nijmegen, The Netherlands
- Nijmegen University Centre for Infectious Diseases, University Medical Centre Nijmegen, The Netherlands
| | - David M Burger
- Department of Clinical Pharmacy, University Medical Centre Nijmegen, The Netherlands
- Nijmegen University Centre for Infectious Diseases, University Medical Centre Nijmegen, The Netherlands
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