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Barday Z, Manning K, Freercks R, Bertels L, Wearne N, Muller E. Retrospective Review of ART Regimens in HIV-Positive to HIV-Positive Kidney Transplant Recipients. Kidney Int Rep 2022; 7:2039-2046. [PMID: 36090493 PMCID: PMC9459070 DOI: 10.1016/j.ekir.2022.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 05/10/2022] [Revised: 06/14/2022] [Accepted: 06/20/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction The management of complex interactions between antiretroviral therapy (ART) and calcineurin inhibitor (CNI) immunosuppression regimens in HIV-positive to HIV-positive renal transplant recipients can be challenging. Literature describing ART regimens and indications for regimen switching in these patients is limited. Methods This retrospective review included 53 HIV-positive to HIV-positive renal transplant recipients. Data on ART regimens, reasons for ART switching, and timing of switches were described from day of transplant to study endpoint (end of study date, death, or graft failure). The association between rejection and ART regimen (protease inhibitor [PI] -based vs. non-PI-based regimen) was analyzed using negative binomial regression. Results There were a total of 46 switches in 31 of 53 patients (58%). Protocol switches (n = 17 of 46, 37%) accounted for most switches, of which the majority were from non-nucleoside reverse transcriptase inhibitors (NNRTIs) to PIs. Other common reasons for switching include cytochrome P450 enzyme induction from efavirenz (EFV) (9 of 46, 20%), tenofovir disoproxil fumarate (TDF) nephrotoxicity (8 of 46, 17%) or side effects (6 of 46, 13%). Of the 46 switches, nearly half (n = 21, 46%) occurred during the transplant admission period, and approximately two-thirds (n = 28, 62%) were during the first year post-transplantation. There was an association between rejection and being maintained on a PI-based regimen (incidence rate ratio 2.77 (95% confidence interval 1.03-7.48), P = 0.044). Conclusion Despite frequent switching of ART regimens, HIV viral loads remained supressed and graft function remained stable in most HIV-positive kidney transplant recipients in our cohort. There was however a concerning signal for increased rejection rates in those on a PI-based regimen.
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Affiliation(s)
- Zunaid Barday
- Department of Medicine, University of Cape Town, Faculty of Health Sciences, Groote Schuur Hospital, South Africa,Correspondence: Zunaid Barday, Department of Medicine, University of Cape Town, Faculty of Health Sciences, Groote Schuur Hospital, South Africa.
| | - Kathryn Manning
- Department of Surgery, University of Cape Town, Faculty of Health Sciences, Groote Schuur Hospital, South Africa
| | - Robert Freercks
- Department of Medicine, University of Cape Town, Livingstone Hospital, Port Elizabeth, South Africa
| | - Laurie Bertels
- Department of Surgery, University of Cape Town, Faculty of Health Sciences, Groote Schuur Hospital, South Africa
| | - Nicola Wearne
- Department of Medicine, University of Cape Town, Faculty of Health Sciences, Groote Schuur Hospital, South Africa
| | - Elmi Muller
- Department of Surgery, University of Cape Town, Faculty of Health Sciences, Groote Schuur Hospital, South Africa
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Chaparala S, Da Silva RC, Papadopoulos JP. Severe Lactic Acidosis Due to Acute Intoxication by Emtricitabine/Tenofovir Alafenamide. Cureus 2021; 13:e19008. [PMID: 34824925 PMCID: PMC8610206 DOI: 10.7759/cureus.19008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Academic Contribution Register] [Accepted: 10/24/2021] [Indexed: 11/28/2022] Open
Abstract
A 46-year-old female with a history of generalized anxiety disorder was admitted after intentional ingestion of an unknown amount of emtricitabine/tenofovir alafenamide (Descovy®) in a suicidal attempt. Patient was emergently intubated secondary to severe agitation and inability to protect airways. Patient developed severe lactic acidosis early in the admission, secondary as to a possible mitochondrial toxicity. Failed attempts to fluid resuscitation with Lactate Ringer®, eventually warranted to start the patient on norepinephrine infusion. Metabolic acidosis remained refractory to bicarbonate bolus and infusion. Hypothermia and hypoglycemia were corrected. Despite the initial approach, the patient remained acidotic, and the nephrology was consulted for emergent continuous renal replacement therapy (CRRT). After three days of intensive care unit stay and CRRT, the patient improved and was successfully decannulated. Her metabolic profile also showed remarkable improvement and the metabolic lactic acidosis resolved. The previous formulation of tenofovir with disoproxil fumarate is associated with severe lactic acidosis due to inhibition of mammalian mitochondrial DNA polymerase. Risk factors include liver cirrhosis, chronic kidney disease, hepatitis B and C coinfection, and metformin use. The new pharmaceutical formulation of tenofovir with alafenamide (TAF) has caused a significant decrease in the incidence of lactic acidosis. However, its real incidence and the usual plasma level to induce toxicity and mitochondrial dysfunction are unknown. The aim of this report is to highlight the risk of severe lactic acidosis with the use of TAF.
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Affiliation(s)
| | - Rafael C Da Silva
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
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DNA polymerase-γ hypothesis in nucleoside reverse transcriptase-induced mitochondrial toxicity revisited: A potentially protective role for citrus fruit-derived naringenin? Eur J Pharmacol 2019; 852:159-166. [PMID: 30876974 DOI: 10.1016/j.ejphar.2019.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 12/11/2018] [Revised: 03/11/2019] [Accepted: 03/11/2019] [Indexed: 12/23/2022]
Abstract
Nucleoside reverse transcriptase inhibitors (NRTIs) form the backbone in combination antiretroviral therapy (cARVs). They halt chain elongation of the viral cDNA by acting as false substrates in counterfeit incorporation mechanism to viral RNA-dependent DNA polymerase. In the process genomic DNA polymerase as well as mitochondrial DNA (mtDNA) polymerase-γ (which has a much higher affinity for these drugs at therapeutic doses) are also impaired. This leads to mitochondrial toxicity that manifests clinically as mitochondrial myopathy, peripheral neuropathy, hyperlactatemia or lactic acidosis and lipoatrophy. This has led to the revision of clinical guidelines by World Health Organization to remove stavudine from first-line listing in the treatment of HIV infections. Recent reports have implicated oxidative stress besides mtDNA polymerase-γ hypothesis in NRTI-induced metabolic complications. Reduced plasma antioxidant concentrations have been reported in HIV positive patients on cARVs but clinical intervention with antioxidant supplements have not been successful either due to low efficacy or poor experimental designs. Citrus fruit-derived naringenin has previously been demonstrated to possess antioxidant and free radical scavenging properties which could prevent mitochondrial toxicity associated with these drugs. This review revisits the controversy surrounding mtDNA polymerase-γ hypothesis and evaluates the potential benefits of naringenin as a potent anti-oxidant and free radical scavenger which as a nutritional supplement or therapeutic adjunct could mitigate the development of mitochondrial toxicity associated with these drugs.
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Abstract
OBJECTIVE Hepatitis C virus (HCV), cirrhosis, and HCV medications including direct-acting antivirals (DAAs) ±ribavirin may all influence the metabolic milieu. While interferon-based regimens improve glucose tolerance, evidence is limited on DAAs. Cases of elevated lactate have recently been reported in patients treated with DAAs, and lactic acidosis is a known complication of antivirals used to treat hepatitis B virus and HIV. PATIENTS AND METHODS Measures were evaluated at baseline, week 4, end of treatment, and 12-24 weeks after treatment. Mixed-effects modeling was used to determine factors influencing glucose and lactate over time. RESULTS In total, 442 patients were treated (mean age 56, 65% male, 72% genotype 1, 48% cirrhotic). Glucose did not change on or after DAA treatment from baseline (P=0.51) aside from those with untreated diabetes, which declined (P=0.02). Overall, there was a decline in lactate following HCV treatment (mean 2.4-2.1 mmol/l; P<0.001). Lactate initially increased on treatment and then decreased after treatment completion in male patients treated with ribavirin. This pattern was not observed in other groups. There was no evidence of lactic acidosis with HCV nucleotide use. CONCLUSION Distinct glucose and lactate trajectories were identified without evidence of DAA metabolic toxicity. HCV treatment does not improve random glucose levels aside from perhaps in untreated diabetic patients.
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Zidovudine-Mediated Autophagy Inhibition Enhances Mitochondrial Toxicity in Muscle Cells. Antimicrob Agents Chemother 2018; 63:AAC.01443-18. [PMID: 30373793 DOI: 10.1128/aac.01443-18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 07/10/2018] [Accepted: 10/15/2018] [Indexed: 11/20/2022] Open
Abstract
Nucleoside reverse transcriptase inhibitors (NRTI), such as zidovudine (AZT), are constituents of HIV-1 therapy and are used for the prevention of mother-to-child transmission. Prolonged thymidine analogue exposure has been associated with mitochondrial toxicities to heart, liver, and skeletal muscle. We hypothesized that the thymidine analogue AZT might interfere with autophagy in myocytes, a lysosomal degradation pathway implicated in the regulation of mitochondrial recycling, cell survival, and the pathogenesis of myodegenerative diseases. The impact of AZT and lamivudine (3TC) on C2C12 myocyte autophagy was studied using various methods based on LC3-green fluorescent protein overexpression or LC3 staining in combination with Western blotting, flow cytometry, and confocal and electron microscopy. Lysosomal and mitochondrial functions were studied using appropriate staining for lysosomal mass, acidity, cathepsin activity, as well as mitochondrial mass and membrane potential in combination with flow cytometry and confocal microscopy. AZT, but not 3TC, exerted a significant dose- and time-dependent inhibitory effect on late stages of autophagosome maturation, which was reversible upon mTOR inhibition. Inhibition of late autophagy at therapeutic drug concentrations led to dysfunctional mitochondrial accumulation with membrane hyperpolarization and increased reactive oxygen species (ROS) generation and, ultimately, compromised cell viability. These AZT effects could be readily replicated by pharmacological and genetic inhibition of myocyte autophagy and, most importantly, could be rescued by pharmacological stimulation of autophagolysosomal biogenesis. Our data suggest that the thymidine analogue AZT inhibits autophagy in myocytes, which in turn leads to the accumulation of dysfunctional mitochondria with increased ROS generation and compromised cell viability. This novel mechanism could contribute to our understanding of the long-term side effects of antiviral agents.
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Masyeni S, Sintya E, Megawati D, Sukmawati NMH, Budiyasa DG, Aryastuti SA, Khairunisa SQ, Arijana I, Nasronudin N. Evaluation of antiretroviral effect on mitochondrial DNA depletion among HIV-infected patients in Bali. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2018; 10:145-150. [PMID: 30104903 PMCID: PMC6072679 DOI: 10.2147/hiv.s166245] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Academic Contribution Register] [Indexed: 11/23/2022]
Abstract
Background Nucleoside reverse transcriptase inhibitors (NRTIs) are the cornerstone of highly active antiretroviral therapy combination regimens for HIV infection. Unfortunately, NRTIs have been noticeably associated with many adverse effects related to mitochondrial toxicity leading to mitochondrial deoxyribonucleic acid (mtDNA) depletion. However, similar mitochondrial dysfunction has recently been found even in antiretroviral therapy-naïve patients, suggesting HIV itself could contribute to this abnormality. In this study, we determine whether mtDNA depletion was present in either antiretroviral therapy-naïve or NRTI-treated patients at Sanjiwani Hospital, Bali, Indonesia. Patients and methods A cross-sectional study was conducted from the peripheral blood mononuclear cells of HIV patients. Specifically, the relative content of mtDNA (mtRNR1 gene) to nuclear DNA (ASPOLG gene) was determined by real-time polymerase chain reaction. Data were analyzed with SPSS 16.0 software and GraphPad Prism 7.02. Results A total of 84 samples (67 on NRTIs and 17 HIV-naïve) were suitable for analysis. We identified 21.4% of the samples (18/84) with mtDNA:nDNA ratio <1. Although it was not significant (P=0.121), the median mtDNA:nDNA ratio of HIV-naïve group was slightly higher (median 1.8; interquartile range [IQR]: 1.1-2.1) than NRTI-treated patients (median 1.5; IQR: 1.3-2.85). Tenofovir-based NRTI was more frequently used (73.13%) than zidovudine-based NRTI (26.86%). The period for which NRTI was used probably contributed to the ratio of mtDNA:nDNA. The median ratio of mtDNA:nDNA zidovudine-treated patients was slightly lower (median 1.2; IQR: 1.08-1.98) when compared to tenofovir-based NRTI (median 1.6; IQR: 1.05-2.10), with the median period of former treatment being significantly longer (P<0.001). Although these data overall indicate that NRTI treatment had no effect on mtDNA:nDNA ratios, patients who undergo more than 12 months of NRTIs treatment show a decrease in the ratio; however, further study is required. Conclusion Almost one-fourth of the samples showed a lower mtDNA:nDNA ratio. The decreasing of the ratio mtDNA:nDNA was most likely present after 12 months of NRTI treatment.
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Affiliation(s)
- Sri Masyeni
- Faculty of Medicine and Health Sciences, University of Warmadewa, Denpasar, Bali, Indonesia,
| | - Erly Sintya
- Faculty of Medicine and Health Sciences, University of Warmadewa, Denpasar, Bali, Indonesia,
| | - Dewi Megawati
- Faculty of Medicine and Health Sciences, University of Warmadewa, Denpasar, Bali, Indonesia,
| | | | - Dewa Ga Budiyasa
- Internal Medicine Department, Sanjiwani Hospital, Gianyar, Bali, Indonesia
| | - Sri Agung Aryastuti
- Faculty of Medicine and Health Sciences, University of Warmadewa, Denpasar, Bali, Indonesia,
| | - Siti Qamariyah Khairunisa
- Indonesia-Japan Collaborative Research Center for Emerging and Reemerging Infectious Diseases, Institute of Tropical Disease, Airlangga University, Surabaya, Indonesia
| | - Igkn Arijana
- Histology Department of Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia
| | - N Nasronudin
- Indonesia-Japan Collaborative Research Center for Emerging and Reemerging Infectious Diseases, Institute of Tropical Disease, Airlangga University, Surabaya, Indonesia
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Nansseu JRN, Bigna JJR. Antiretroviral therapy related adverse effects: Can sub-Saharan Africa cope with the new "test and treat" policy of the World Health Organization? Infect Dis Poverty 2017; 6:24. [PMID: 28196511 PMCID: PMC5310075 DOI: 10.1186/s40249-017-0240-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 09/06/2016] [Accepted: 01/10/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recent studies have shown that early antiretroviral therapy (ART) initiation results in significant HIV transmission reduction. This is the rationale behind the "test and treat" policy of the World Health Organization (WHO). Implementation of this policy will lead to an increased incidence of ART-related adverse effects, especially in sub-Saharan Africa (SSA). Is the region yet ready to cope with such a challenging issue? MAIN BODY The introduction and widespread use of ART have drastically changed the natural history of HIV/AIDS, but exposure to ART leads to serious medication-related adverse effects mainly explained by mitochondrial toxicities, and the situation will get worse in the near future. Indeed, ART is associated with an increased risk of developing cardiovascular disease, lipodystrophy, prediabetes and overt diabetes, insulin resistance and hyperlactatemia/lactic acidosis. The prevalence of these disorders is already high in SSA, and the situation will be exacerbated by the implementation of the new WHO recommendations. Most SSA countries are characterized by (extreme) poverty, very weak health systems, inadequate and low quality of health services, inaccessibility to existing health facilities, lack of (qualified) health personnel, lack of adequate equipment, inaccessibility and unaffordability of medicines, and heavy workload in a context of a double burden of disease. Additionally, there is dearth of data on the incidence and predictive factors of ART-related adverse effects in SSA, to anticipate on strategies that should be put in place to prevent the occurrence of these conditions or properly estimate the upcoming burden and prepare an adequate response plan. These are required if we are to anticipate and effectively prevent this upcoming burden. CONCLUSION While SSA would be the first region to experience the huge benefits of implementing the "test and treat" policy of the WHO, the region is not yet prepared to manage the consequential increased burden of ART-related toxic and metabolic complications. Urgent measures should be taken to fill the lacunae if SSA is not to become over-burdened by the consequences of the "test and treat" policy.
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Affiliation(s)
- Jobert Richie N Nansseu
- Department of Public Health, Faculty of Medicine and Biomedical Sciences of the University of Yaoundé I, PO Box 1364, Yaoundé, Cameroon. .,Sickle Cell Disease Unit, Mother and Child Centre of the Chantal Biya Foundation, Yaoundé, Cameroon.
| | - Jean Joel R Bigna
- Department of Epidemiology and Public Health, Centre Pasteur of Cameroon, Yaoundé, Cameroon.,Faculty of Medicine, University of Paris Sud XI, Le Kremlin Bicêtre, Paris, France
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Massart J, Begriche K, Moreau C, Fromenty B. Role of nonalcoholic fatty liver disease as risk factor for drug-induced hepatotoxicity. J Clin Transl Res 2017; 3:212-232. [PMID: 28691103 PMCID: PMC5500243 DOI: 10.18053/jctres.03.2017s1.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Obesity is often associated with nonalcoholic fatty liver disease (NAFLD), which refers to a large spectrum of hepatic lesions including fatty liver, nonalcoholic steatohepatitis (NASH) and cirrhosis. Different investigations showed or suggested that obesity and NAFLD are able to increase the risk of hepatotoxicity of different drugs. Some of these drugs could induce more frequently an acute hepatitis in obese individuals whereas others could worsen pre-existing NAFLD. AIM The main objective of the present review was to collect the available information regarding the role of NAFLD as risk factor for drug-induced hepatotoxicity. For this purpose, we performed a data-mining analysis using different queries including drug-induced liver injury (or DILI), drug-induced hepatotoxicity, fatty liver, nonalcoholic fatty liver disease (or NAFLD), steatosis and obesity. The main data from the collected articles are reported in this review and when available, some pathophysiological hypotheses are put forward. RELEVANCE FOR PATIENTS Drugs that could pose a potential risk in obese patients include compounds belonging to different pharmacological classes such as acetaminophen, halothane, methotrexate, rosiglitazone, stavudine and tamoxifen. For some of these drugs, experimental investigations in obese rodents confirmed the clinical observations and unveiled different pathophysiological mechanisms which could explain why these pharmaceuticals are particularly hepatotoxic in obesity and NAFLD. Other drugs such as pentoxifylline, phenobarbital and omeprazole might also pose a risk but more investigations are required to determine whether this risk is significant or not. Because obese people often take several drugs for the treatment of different obesity-related diseases such as type 2 diabetes, hyperlipidemia and coronary heart disease, it is urgent to identify the main pharmaceuticals that can cause acute hepatitis on a fatty liver background or induce NAFLD worsening.
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Affiliation(s)
- Julie Massart
- Department of Molecular Medicine and Surgery, Karolinska University Hospital, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | | | - Caroline Moreau
- INSERM, U991, Université de Rennes 1, Rennes, France.,Service de Biochimie et Toxicologie, CHU Pontchaillou, Rennes, France
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The impact of highly active antiretroviral therapy on obstetric conditions: A review. Eur J Obstet Gynecol Reprod Biol 2016; 210:126-131. [PMID: 28013100 DOI: 10.1016/j.ejogrb.2016.12.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 09/20/2016] [Revised: 12/01/2016] [Accepted: 12/08/2016] [Indexed: 01/05/2023]
Abstract
HIV is the leading cause of maternal and neonatal morbidity and mortality in resource constrained countries. Highly active antiretroviral treatment (HAART) initiated in pregnancy has now almost eliminated mother to child transmission of the virus, and is beginning to show the desired effect of reducing HIV related maternal mortality. By modulating host immunological responses HAART has the potential to alter infections during pregnancy, in addition to modifying clinical conditions such as preeclampsia. There is increasing evidence of the benefits of HAART given to pregnant women, however there is paucity of data that distinguishes HIV or HAART as the cause or exacerbation of pre-existing medical conditions or conditions specific to pregnancy. Anaemia is the commonest haematological disorder seen in HIV infected women and is more pronounced during pregnancy. The use of HAART has the potential to reduce the incidence and severity of the disease. Tuberculosis (TB) is the commonest chest infection amongst HIV infected people, being more common amongst pregnant than non-pregnant women. It is the leading cause of death from infectious diseases amongst women of reproductive age, and accounts for at least a quarter of all cases of maternal deaths associated with non-pregnancy related infections (NPRI). TB can manifest at any stage of the HIV infection, including during treatment with HAART. The latter (ie TB manifestation during HAART treatment) is thought to be the commonest manifestation of what is now known as immune reconstitution inflammatory syndrome (IRIS). In a South African report on maternal deaths, 55% of women who died of TB were on HAART, and a further 35% of women in the NPRI category died from other pneumoniae, notably pneumocystis jorevicci, which is also related to HIV infection. With regards to puerperal sepsis, studies are yet to show the impact of HAART independent of antibiotics in reducing infectious morbidity in HIV infected women. Preeclampsia has been associated with HIV infection, where most studies point towards a reduced risk in HIV infected women. There is increasing evidence that this reduced risk is reversed in the presence of HAART, with women accessing HAART having almost the same risk as HIV uninfected women. HIV or its treatment may be associated with increased risk of obstetric haemorrhage, and an increasing trend of obstetric haemorrhage as a cause of maternal deaths has been recently reported, proportionally in line with the introduction and increasing availability of HAART for pregnant women The mechanism by which this may occur remains elusive since pregnancy is a pro-thrombotic state, however, HIV-related thrombocytopenia or vasculitis could account for the association, if found. HAART would then be expected to reverse this. HAART especially protease inhibitor containing combinations, have been associated with preterm deliveries and low birth weight, particularly when initiated prior to the index pregnancy. With these overall findings of the effect of HAART on obstetric conditions, this review is intended to encourage heightened surveillance of adverse events associated with HAART use in pregnant women.
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First-line antiretroviral therapy durability in a 10-year cohort of naïve adults started on treatment in Uganda. J Int AIDS Soc 2016; 19:20773. [PMID: 27319742 PMCID: PMC4913145 DOI: 10.7448/ias.19.1.20773] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 10/28/2015] [Revised: 04/27/2016] [Accepted: 05/12/2016] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION The majority of studies from resource-limited settings only report short-term virological outcomes of patients on antiretroviral treatment (ART). We aim to describe the long-term durability of first-line ART and identify factors associated with long-term virological outcomes. METHODS At the Infectious Diseases Institute in Kampala, Uganda, 559 adult patients starting ART in 2004 were enrolled into a research cohort and monitored with viral load (VL) testing every six months for 10 years. We report the proportion and cumulative probability of 1) achieving virologic suppression (at least one VL <400 copies/ml); 2) experiencing virologic failure in patients who achieved suppression (two consecutive VLs >1000 copies/ml or one VL >5000, for those without a subsequent one); 3) treatment failure (not attaining virologic suppression or experiencing virologic failure). We used Cox regression methods to determine the characteristics associated with treatment failure. We included gender, baseline age, WHO stage, body mass index, CD4 count, propensity score for initial ART regimen, VL, time-dependent CD4 count and adherence. RESULTS Of the 559 patients enrolled, 472 (84.8%) had at least one VL (67 died, 13 were lost to follow-up, 4 transferred, 2 had no VL available); 73.6% started on d4T/3TC/nevirapine and 26.4% on AZT/3TC/efavirenz. Patients in the two groups had similar characteristics, except for the higher proportion of patients in WHO Stage 3/4 and higher VL in the efavirenz-based group. Four hundred thirty-nine (93%) patients achieved virologic suppression with a cumulative probability of 0.94 (confidence interval (CI): 0.92-0.96); 74/439 (16.9%) experienced virologic failure with a cumulative probability of 0.18 (CI: 0.15-0.22). In the multivariate analysis, initial d4T/3TC/nevirapine regimen (hazard ratio (HR): 3.02; CI: 3.02 (1.66-5.44, p<0.001)) and baseline VL ≥5 log10 copies/ml (HR: 2.29; CI: 1.29-4.04) were associated with treatment failures; patients of older age (HR: 0.87 per five-year increase; CI: 0.77-0.99), with adherence >95% (HR: 0.04; CI: 0.02-0.11) and with higher time-dependent CD4 count (HR: 0.94 per 50 cells/µl increase; CI: 0.92-0.99, p<0.001) were less likely to experience treatment failure. CONCLUSIONS The long-term virological outcomes from this cohort are promising and comparable to those from research-rich settings. Our results provide further evidence that efavirenz is associated with better virological outcomes.
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Oreagba IA, Usman SO, Olayemi SO, Oshikoya KA, Opanuga O, Adeyemo TA, Lesi OA, Dodoo AN, Akanmu AS. Pharmacoepidemiology of antiretroviral drugs in a teaching hospital in Lagos, Nigeria. Ghana Med J 2015; 48:194-203. [PMID: 25709134 DOI: 10.4314/gmj.v48i4.5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Prescribing, adherence, and adverse drug events to HAART in a large antiretroviral programme in Lagos was evaluated. DESIGN A retrospective 5 year open cohort study. SETTING The AIDS Prevention Initiative in Nigeria (APIN) clinic at LUTH is one of the United States Presidential Emergency Plan for AIDS Relief (PEP-FAR) funded centers for HIV relief program in Nigeria Participants The case files of 390 patients on HAART and attending the APIN clinic were reviewed sequel to random selection. MAIN OUTCOME MEASURES Demographics of the patients and pattern of antiretroviral (ARV) combination drugs prescribed were extracted from their case files. The details of the adverse drug events (ADEs) were extracted from drug toxicity forms regularly filled for each patient. A Chi-square test with Yates correction was used to determine the association between adherence and therapeutic outcome. RESULTS A total of 2944 prescriptions were assessed. Zidovudine + lamivudine + nevirapine (35.87%) and stavudine + lamivudine + nevirapine (35.63%) were the most frequently prescribed combinations. Over 2000 ADEs were reported with cough (13.3%), fever (8.75%) and skin rashes (8.01%) being the most frequently reported. Drug adherence was associated with good therapeutic outcome (χ(2) = 115.60, p<0.0001). CONCLUSIONS Zidovudine + lamivudine + nevirapine was the most frequently prescribed ARV combination. Cough was the most frequently reported ADE. Interventions aimed at rational prescribing of ARV drugs and improving adherence to antiretroviral drugs is essential for good therapeutic outcome in the treatment of HIV infection.
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Affiliation(s)
- I A Oreagba
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine, University of Lagos, Lagos, Nigeria, 12003 ; National Pharmacovigilance Centre, National Agency for Food and Drug Administration and Control, Abuja, Nigeria
| | - S O Usman
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine, University of Lagos, Lagos, Nigeria, 12003
| | - S O Olayemi
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine, University of Lagos, Lagos, Nigeria, 12003
| | - K A Oshikoya
- Department of Pharmacology, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria
| | - O Opanuga
- AIDS Prevention Initiative in Nigeria (APIN) Clinic, Lagos University Teaching Hospital, Lagos, Nigeria, 12003
| | - T A Adeyemo
- AIDS Prevention Initiative in Nigeria (APIN) Clinic, Lagos University Teaching Hospital, Lagos, Nigeria, 12003 ; Department of Haematology and Blood Transfusion, University of Lagos, Lagos, Nigeria
| | - O A Lesi
- AIDS Prevention Initiative in Nigeria (APIN) Clinic, Lagos University Teaching Hospital, Lagos, Nigeria, 12003
| | - A N Dodoo
- Centre for Clinical Pharmacology and Therapeutics University of Ghana Medical School Accra Ghana
| | - A S Akanmu
- AIDS Prevention Initiative in Nigeria (APIN) Clinic, Lagos University Teaching Hospital, Lagos, Nigeria, 12003 ; Department of Haematology and Blood Transfusion, University of Lagos, Lagos, Nigeria
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Kupiec KE, Johnson JW, Barroso LF, Wrenn RH, Williamson JC. Zidovudine as modern day salvage therapy for HIV infection. AIDS Patient Care STDS 2014; 28:570-4. [PMID: 25365419 DOI: 10.1089/apc.2014.0151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 11/12/2022] Open
Abstract
Resistance to the first-line NRTIs, tenofovir and emtricitabine, does not generally confer resistance to zidovudine. The objective of this study was to describe the efficacy of zidovudine as modern day salvage antiretroviral therapy. This was a single-center, retrospective, observational, cohort study. Adult HIV-positive patients prescribed a zidovudine-containing regimen between 2005 and 2010 were identified from a computer database. All patients had failed at least one prior antiretroviral regimen before zidovudine. The primary outcome measure was virologic success at 24 weeks. Other efficacy and safety outcomes were determined, including virologic success at 48 and 96 weeks, CD4 count change from baseline, and incidence of adverse effects. Sixty-nine subjects were enrolled. The mean age was 43 years, 70% were male, and 85.5% were black. Most patients were highly antiretroviral experienced. At 24 weeks, 63.8% and 72.5% of patients achieved HIV RNA less than 50 and 400 c/mL, respectively. The median change in CD4 count from baseline to week 24 was +70 cells/mm(3). The percent of patients who discontinued zidovudine due to adverse effects was 10%. In this highly treatment-experienced population, zidovudine as part of a salvage regimen appeared effective. Gastrointestinal adverse effects were reported, but zidovudine-associated metabolic effects were uncommon, suggesting zidovudine was generally well tolerated.
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Affiliation(s)
- Katherine E. Kupiec
- Department of Pharmacy, Section on Infectious Diseases, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - James W. Johnson
- Department of Pharmacy, Section on Infectious Diseases, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Luis F. Barroso
- Department of Internal Medicine, Section on Infectious Diseases, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | | | - John C. Williamson
- Department of Pharmacy, Section on Infectious Diseases, Wake Forest Baptist Health, Winston-Salem, North Carolina
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Mausumee G, Frank S, Shawn C, Dara H, Zhao Y, Soleil PM, Sanderson TP, Michael G, Marc D. Nonclinical Safety Profile of BMS-986001, a Nucleoside Transcriptase Inhibitor for Combination Retroviral Therapy. Int J Toxicol 2014; 33:204-218. [PMID: 24846376 DOI: 10.1177/1091581814529309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 11/16/2022]
Abstract
Nucleoside reverse transcriptase inhibitors (NRTIs)/nucleotide reverse transcriptase inhibitors are key components of combination antiretroviral therapy for HIV infection. First-generation NRTIs are associated with mitochondrial toxicity in patients, mainly due to inhibition of human DNA polymerase γ (hDNA polγ) that manifests as adverse events such as lipodystrophy, lactic acidosis, myopathy, cardiomyopathy, or nephropathy in patients. In chronic nonclinical studies in rodents and nonrodents, eukaryotic (host) mitochondrial toxicity manifests as some drug-specific toxicities similar to human toxicity. BMS-986001, a novel thymidine analog with minimal hDNA polγ inhibition, has demonstrated antiretroviral activity in early clinical studies. The primary toxicity of BMS-986001 in rats and monkeys is bone marrow dyserythropoiesis with associated decreases in red blood cell mass. Additionally, at high doses, severe platelet reductions accompanied by cutaneous petechiae began during weeks 8 and 11 in 3 of 60 monkeys in chronic toxicity studies. In a 6-month study, platelet reductions required euthanasia of the 2 affected monkeys (300 mg/kg/d) at week 14, but with dose reduction (200 mg/kg/d) remaining monkeys had no platelet changes. One affected monkey (200 mg/kg/d) in a 9-month study completed dosing and its platelet counts recovered during a 1-month recovery. Formation of platelet-bound immunoglobulin in the presence of BMS-986001, together with rapid and complete platelet recovery in the absence of BMS-986001, suggested that platelet decreases in monkeys may be immune mediated. No findings indicative of mitochondrial toxicity were observed in rats or monkeys given BMS-986001, suggesting an improved safety profile compared to marketed NRTI or tenofovir disoproxil fumarate.
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Affiliation(s)
- Guha Mausumee
- Research and Development, Bristol-Myers Squibb Company, Mt Vernon, IN, USA
| | - Simutis Frank
- Research and Development, Bristol-Myers Squibb Company, Mt Vernon, IN, USA
| | - Clark Shawn
- Research and Development, Bristol-Myers Squibb Company, Mt Vernon, IN, USA
| | - Hawthorne Dara
- Research and Development, Bristol-Myers Squibb Company Lawrenceville, NJ, USA
| | - Yue Zhao
- Research and Development, Bristol-Myers Squibb Company Lawrenceville, NJ, USA
| | | | - Thomas P Sanderson
- Research and Development, Bristol-Myers Squibb Company, Mt Vernon, IN, USA
| | - Graziano Michael
- Research and Development, Bristol-Myers Squibb Company Lawrenceville, NJ, USA
| | - Davies Marc
- Research and Development, Bristol-Myers Squibb Company Lawrenceville, NJ, USA
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Inzaule S, Otieno J, Kalyango J, Nafisa L, Kabugo C, Nalusiba J, Kwaro D, Zeh C, Karamagi C. Incidence and predictors of first line antiretroviral regimen modification in western Kenya. PLoS One 2014; 9:e93106. [PMID: 24695108 PMCID: PMC3973699 DOI: 10.1371/journal.pone.0093106] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 08/06/2013] [Accepted: 03/03/2014] [Indexed: 02/04/2023] Open
Abstract
Background Limited antiretroviral treatment regimens in resource-limited settings require long-term sustainability of patients on the few available options. We evaluated the incidence and predictors of combined antiretroviral treatment (cART) modifications, in an outpatient cohort of 955 patients who initiated cART between January 2009 and January 2011 in western Kenya. Methods cART modification was defined as either first time single drug substitution or switch. Incidence rates were determined by Poisson regression and risk factor analysis assessed using multivariate Cox regression modeling. Results Over a median follow-up period of 10.7 months, 178 (18.7%) patients modified regimens (incidence rate (IR); 18.6 per 100 person years [95% CI: 16.2–21.8]). Toxicity was the most common cited reason (66.3%). In adjusted multivariate Cox piecewise regression model, WHO disease stage III/IV (aHR; 1.82, 95%CI: 1.25–2.66), stavudine (d4T) use (aHR; 2.21 95%CI: 1.49–3.30) and increase in age (aHR; 1.02, 95%CI: 1.0–1.04) were associated with increased risk of treatment modification within the first year post-cART. Zidovudine (AZT) and tenofovir (TDF) use had a reduced risk for modification (aHR; 0.60 95%CI: 0.38–0.96 and aHR; 0.51 95%CI: 0.29–0.91 respectively). Beyond one year of treatment, d4T use (aHR; 2.75, 95% CI: 1.25–6.05), baseline CD4 counts ≤350 cells/mm3 (aHR; 2.45, 95%CI: 1.14–5.26), increase in age (aHR; 1.05 95%CI: 1.02–1.07) and high baseline weight >60kg aHR; 2.69 95% CI: 1.58–4.59) were associated with risk of cART modification. Conclusions Early treatment initiation at higher CD4 counts and avoiding d4T use may reduce treatment modification and subsequently improve sustainability of patients on the available limited options.
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Affiliation(s)
- Seth Inzaule
- Kenya Medical Research Institute, Kisumu, Kenya; Makerere University Medical School, Clinical Epidemiology Unit, Kampala, Uganda
| | - Juliana Otieno
- Jaramogi Oginga Odinga teaching and Referral Hospital, Kisumu, Kenya
| | - Joan Kalyango
- Makerere University Medical School, Clinical Epidemiology Unit, Kampala, Uganda
| | | | - Charles Kabugo
- Makerere University Medical School, Clinical Epidemiology Unit, Kampala, Uganda
| | - Josephine Nalusiba
- Makerere University Medical School, Clinical Epidemiology Unit, Kampala, Uganda
| | - Daniel Kwaro
- Kenya Medical Research Institute, Kisumu, Kenya; US Centers for Disease Control and Prevention, HIV-Research Branch, Kisumu, Kenya
| | - Clement Zeh
- US Centers for Disease Control and Prevention, HIV-Research Branch, Kisumu, Kenya; Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Charles Karamagi
- Makerere University Medical School, Clinical Epidemiology Unit, Kampala, Uganda
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Mamiafo CT, Moor VJA, Nansseu JRN, Pieme CA, Tayou C, Yonkeu JN. Hyperlactatemia in a group of HIV patients living in Yaounde-Cameroon. AIDS Res Ther 2014; 11:2. [PMID: 24428886 PMCID: PMC3899605 DOI: 10.1186/1742-6405-11-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 06/17/2013] [Accepted: 01/10/2014] [Indexed: 01/09/2023] Open
Abstract
Background and aim Prolonged exposure to highly active antiretroviral therapy (HAART) is associated with adverse effects such as hyperlactatemia. We determined the prevalence and risk factors for developing hyperlactatemia among human immunodeficiency virus (HIV)-infected cameroonians on antiretroviral therapy (ART). Methods We conducted a cross-sectional study from January to April 2012 involving 91 HIV-infected patients receiving ART for at least 12 months and 30 HIV-infected patients who have never received ART (ART-naïve patients). Plasma lactate levels were determined after at least 12 hours of overnight fasting and hyperlactatemia defined as lactate concentrations ≥ 3 mmol/L. The prevalence of hyperlactatemia was determined and the risk factors were analyzed by a multivariate logistic regression model. Results The mean lactataemia was significantly higher in the group of HIV patients currently taking ART than in the ART-naïve one (2.3 ± 1.3 and 1.7 ± 0.7 mmol/L respectively, p = 0.002). Patients on first line ART regimens had significantly higher lactatemia than those on second line regimens (2.5 ± 1.5 and 1.9 ± 0.7 mmol/L respectively, p = 0.014). The prevalence of hyperlactatemia in HIV patients receiving ART and in ART-naïve HIV patients was respectively 18.7 and 6.7% (p = 0.095). ART-exposure (adjusted odds ratio (aOR) 5.44, 95% confidence interval (CI) 1.06 – 27.84; p = 0.042) and being on a first line regimen (aOR 16.22, 95% CI 1.57 – 167.91; p = 0.019) were independent strong predictors of hyperlactatemia. Conclusion Hyperlactatemia was not rare in our study population. Being on a first line regimen constitutes an important risk factor for developing hyperlactatemia. Measurement of plasma lactate may be useful in optimizing the management of HIV-positive persons on ART.
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Stenehjem E, Shlay JC. Sex-specific differences in treatment outcomes for patients with HIV and AIDS. Expert Rev Pharmacoecon Outcomes Res 2014; 8:51-63. [DOI: 10.1586/14737167.8.1.51] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 12/21/2022]
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Luke CA, Moosa MYS, Esterhuizen TM, Knight SE, Saman S, Ross A. Lactic acidosis, risk factors and predictive laboratory markers: a nested case control study in South Africa. S Afr Fam Pract (2004) 2014. [DOI: 10.1080/20786204.2014.10844585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- CA Luke
- Discipline of Family Medicine, University of KwaZulu-Natal, Durban
| | - MYS Moosa
- ,Department of Infectious Disease, University of KwaZulu-Natal, Durban
| | - TM Esterhuizen
- Program of Bio Research Ethics and Medical Law, Division of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban
| | - SE Knight
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban
| | - S Saman
- Port Shepstone Hospital, Port Shepstone
| | - A Ross
- Discipline of Family Medicine, University of KwaZulu-Natal, Durban
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Andersen LW, Mackenhauer J, Roberts JC, Berg KM, Cocchi MN, Donnino MW. Etiology and therapeutic approach to elevated lactate levels. Mayo Clin Proc 2013; 88:1127-40. [PMID: 24079682 PMCID: PMC3975915 DOI: 10.1016/j.mayocp.2013.06.012] [Citation(s) in RCA: 439] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 11/14/2012] [Revised: 05/31/2013] [Accepted: 06/26/2013] [Indexed: 02/07/2023]
Abstract
Lactate levels are commonly evaluated in acutely ill patients. Although most often used in the context of evaluating shock, lactate levels can be elevated for many reasons. While tissue hypoperfusion may be the most common cause of elevation, many other etiologies or contributing factors exist. Clinicians need to be aware of the many potential causes of lactate level elevation as the clinical and prognostic importance of an elevated lactate level varies widely by disease state. Moreover, specific therapy may need to be tailored to the underlying cause of elevation. The present review is based on a comprehensive PubMed search between the dates of January 1, 1960, to April 30, 2013, using the search term lactate or lactic acidosis combined with known associations, such as shock, sepsis, cardiac arrest, trauma, seizure, ischemia, diabetic ketoacidosis, thiamine, malignancy, liver, toxins, overdose, and medication. We provide an overview of the pathogenesis of lactate level elevation followed by an in-depth look at the varied etiologies, including medication-related causes. The strengths and weaknesses of lactate as a diagnostic/prognostic tool and its potential use as a clinical end point of resuscitation are discussed. The review ends with some general recommendations on the management of patients with elevated lactate levels.
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Affiliation(s)
- Lars W. Andersen
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Julie Mackenhauer
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark
| | - Jonathan C. Roberts
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Katherine M. Berg
- Department of Medicine, Division of Pulmonary Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Michael N. Cocchi
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Anesthesia Critical Care, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Michael W. Donnino
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Medicine, Division of Pulmonary Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
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Chagoma N, Mallewa J, Kaunda S, Njalale Y, Kampira E, Mukaka M, Heyderman RS, van Oosterhout JJ. Longitudinal lactate levels from routine point-of-care monitoring in adult Malawian antiretroviral therapy patients: associations with stavudine toxicities. Trans R Soc Trop Med Hyg 2013; 107:615-9. [PMID: 23926161 PMCID: PMC4023278 DOI: 10.1093/trstmh/trt074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 11/18/2022] Open
Abstract
Introduction Stavudine is still widely used in under-resourced settings such as Malawi due to its low price. It frequently causes peripheral neuropathy and lipodystrophy and increases the risk of lactic acidosis and other high lactate syndromes. Methods We studied the association of longitudinal lactate levels, obtained by routine, 3-monthly point-of-care monitoring, with peripheral neuropathy, lipodystrophy and high lactate syndromes in adult Malawians who were in the second year of stavudine containing antiretroviral therapy (ART). Results Point-of-care lactate measurements were feasible in a busy urban ART clinic. Of 1170 lactate levels collected from 253 patients over the course of one year, 487 (41.8%) were elevated (>2.2mg/dl), 58 (5.0%) were highly elevated (>3.5mg/dl). At least one elevated lactate level occurred in 210 (83.0%) of patients and sustained hyperlactatemia in 65 (26.4%). In random effects analyses lipodystrophy and peripheral neuropathy were associated with higher lactate levels. Only five patients developed high lactate syndromes (one lactic acidosis) of whom no preceding lactate measurements were available because events had started before enrolment. Lactate levels significantly decreased over time and no high lactate syndromes were observed after the 15th month on ART. Conclusion Lipodystrophy and peripheral neuropathy were associated with higher lactate levels. Lactate levels decreased over time, coinciding with absence of new high lactate syndromes after the 15th month on ART.
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Affiliation(s)
- Newton Chagoma
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine
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Shah I. Lactic acidosis in HIV-exposed infants with perinatal exposure to antiretroviral therapy. ACTA ACUST UNITED AC 2013; 29:257-61. [DOI: 10.1179/027249309x12547917868880] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 10/31/2022]
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Abstract
Nucleoside reverse transcriptase inhibitors (NRTIs) remain a critical component of therapy for HIV-infected patients. The drugs are effective, relatively inexpensive and an important component of antiretroviral therapy (ART), particularly in areas where the introduction of effective therapy has been delayed. They are an essential part of initial therapy for HIV and for prevention of mother-to-child transmission; however, toxicities and resistance may limit their use. The role for pre-exposure prophylaxis (PrEP) to reduce sexual transmission of HIV is still undefined, but this use may have a significant impact on NRTI resistance worldwide, most particularly in areas where subtype C predominates. With increasing prevalence of resistant HIV, the approval of new agents that are effective against resistant virus, and those that use novel cellular targets, are essential. Large studies are now in progress examining the safety and efficacy of NRTI-sparing regimens, but results are not currently available. NRTIs may lose relevance in the not distant future unless steps are put in place to reduce the development and spread of NRTI-resistant viruses, and new NRTIs with minimal toxicity are developed that have a novel resistance profile. This article describes the principal NRTIs, their mechanism of action, and resistance and selected toxicities of the class and of the individual drugs.
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Affiliation(s)
- Randall Tressler
- HJF, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MA 20892, USA
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Autophagy inhibition due to thymidine analogues as novel mechanism leading to hepatocyte dysfunction and lipid accumulation. AIDS 2012; 26:1995-2006. [PMID: 22914580 DOI: 10.1097/qad.0b013e32835804f9] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Prolonged nucleoside reverse transcriptase inhibitors (NRTI) exposure can lead to microvesicular steatosis. We hypothesized that thymidine analogues might interfere with autophagy in hepatocytes, a lysosomal degradation pathway implicated in cell survival and regulation of hepatocyte lipid metabolism. DESIGN Using HepG2 and HUH7 cell lines and primary human hepatocytes, we performed a comprehensive analysis of NRTI-mediated effects on autophagy. METHODS The impact of zidovudine (ZDV), stavudine (d4T) and lamivudine (3TC) on constitutive and induced autophagy was analyzed by fluorescent and electron microscopy, western blotting and flow cytometry. Effects on hepatocyte autophagy were correlated to cellular viability, mitochondrial dysfunction and intracellular lipid accumulation. RESULTS ZDV and d4T, but not 3TC, significantly inhibited both constitutive as well as stimulated autophagic activity in a dose-dependent and time-dependent manner. Inhibition of autophagy at therapeutic drug concentrations led to accumulation of dysfunctional mitochondria, increased ROS production, increased apoptosis, decreased proliferation and increased intracellular lipid accumulation. These NRTI effects could be readily resembled by pharmacological and genetic inhibition of hepatocyte autophagy. CONCLUSION Our data suggest that thymidine analogues inhibit autophagy in hepatocytes, which in turn leads to increased ROS production, lipid accumulation and hepatic dysfunction. This novel mechanism could contribute to nonalcoholic fatty liver disease in HIV-infected patients.
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O'Connor E, Fraser JF. The interpretation of perioperative lactate abnormalities in patients undergoing cardiac surgery. Anaesth Intensive Care 2012; 40:598-603. [PMID: 22813486 DOI: 10.1177/0310057x1204000404] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 12/18/2022]
Abstract
Hyperlactataemia and lactic acidosis are commonly encountered during and after cardiac surgery. Perioperative lactate production increases in the myocardium, skeletal muscle, lungs and in the splanchnic circulation during cardiopulmonary bypass. Hyperlactataemia has a bimodal distribution in the perioperative period. An early increase in lactate levels, arising intraoperatively or soon after intensive care unit admission, is a familiar and concerning finding for most clinicians. It is highly suggestive of tissue ischaemia and is associated with a prolonged intensive care unit stay, a prolonged requirement for respiratory and cardiovascular support and increased postoperative mortality. Its presence should prompt a thorough search for potential causes of tissue hypoxia. In contrast, late-onset hyperlactataemia, a less well recognised complication, occurs 4 to 24 hours after completion of surgery and is typically associated with preserved cardiac output and oxygen delivery. Risk factors for late-onset hyperlactataemia include hyperglycaemia, long cardiopulmonary bypass time and elevated endogenous catecholamines. Although patients with this complication may have a longer duration of ventilation and intensive care unit length of stay than those with normolactataemia, an association with increased mortality has not been demonstrated. The discovery of late-onset hyperlactataemia should not delay the postoperative progress of an otherwise stable patient following cardiac surgery.
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Affiliation(s)
- E O'Connor
- Adult Intensive Care Services, Prince Charles Hospital, Chermside, Queensland, Australia.
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Wester CW, Eden SK, Shepherd BE, Bussmann H, Novitsky V, Samuels DC, Hendrickson SL, Winkler CA, O'Brien SJ, Essex M, D'Aquila RT, deGruttola V, Marlink RG. Risk factors for symptomatic hyperlactatemia and lactic acidosis among combination antiretroviral therapy-treated adults in Botswana: results from a clinical trial. AIDS Res Hum Retroviruses 2012; 28:759-65. [PMID: 22540188 DOI: 10.1089/aid.2011.0303] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 11/12/2022] Open
Abstract
Nucleoside analogue reverse transcriptase inhibitors are an integral component of combination antiretroviral treatment regimens. However, their ability to inhibit polymerase-γ has been associated with several mitochondrial toxicities, including potentially life-threatening lactic acidosis. A total of 650 antiretroviral-naive adults (69% female) initiated combination antiretroviral therapy (cART) and were intensively screened for toxicities including lactic acidosis as part of a 3-year clinical trial in Botswana. Patients were categorized as no lactic acidosis symptoms, minor symptoms but lactate <4.4 mmol/liter, and symptoms with lactate ≥ 4.4 mmol/liter [moderate to severe symptomatic hyperlactatemia (SH) or lactic acidosis (LA)]. Of 650 participants 111 (17.1%) developed symptoms and/or laboratory results suggestive of lactic acidosis and had a serum lactate drawn; 97 (87.4%) of these were female. There were 20 events, 13 having SH and 7 with LA; all 20 (100%) were female (p<0.001). Cox proportional hazard analysis limited to the 451 females revealed that having a higher baseline BMI was predictive for the development of SH/LA [aHR=1.17 per one-unit increase (1.08-1.25), p<0.0001]. Ordered logistic regression performed among all 650 patients revealed that having a lower baseline hemoglobin [aOR=1.28 per one-unit decrease (1.1-1.49), p=0.002] and being randomized to d4T/3TC-based cART [aOR=1.76 relative to ZDV/3TC (1.03-3.01), p=0.04] were predictive of the symptoms and/or the development of SH/LA. cART-treated women in sub-Saharan Africa, especially those having higher body mass indices, should receive additional monitoring for SH/LA. Women presently receiving d4T/3TC-based cART in such settings also warrant more intensive monitoring.
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Affiliation(s)
- C. William Wester
- Harvard School of Public Health, Boston, Massachusetts
- Vanderbilt University School of Medicine, Nashville, Tennessee
- Vanderbilt Institute for Global Health (VIGH), Nashville, Tennessee
| | | | | | - Hermann Bussmann
- Harvard School of Public Health, Boston, Massachusetts
- Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education (BHP), Gaborone, Botswana
| | - Vladimir Novitsky
- Harvard School of Public Health, Boston, Massachusetts
- Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education (BHP), Gaborone, Botswana
| | - David C. Samuels
- Vanderbilt University School of Medicine, Center for Human Genetics Research, Department of Molecular Physiology and Biophysics, Nashville, Tennessee
| | - Sher L. Hendrickson
- Laboratory of Genomic Diversity, SAIC-Frederick Inc., National Cancer Institute, Frederick, Maryland
| | - Cheryl A. Winkler
- Laboratory of Genomic Diversity, SAIC-Frederick Inc., National Cancer Institute, Frederick, Maryland
| | - Stephen J. O'Brien
- Laboratory of Genomic Diversity, SAIC-Frederick Inc., National Cancer Institute, Frederick, Maryland
| | - Max Essex
- Harvard School of Public Health, Boston, Massachusetts
- Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education (BHP), Gaborone, Botswana
| | | | | | - Richard G. Marlink
- Harvard School of Public Health, Boston, Massachusetts
- Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education (BHP), Gaborone, Botswana
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van Oosterhout JJ, Mallewa J, Kaunda S, Chagoma N, Njalale Y, Kampira E, Mukaka M, Heyderman RS. Stavudine toxicity in adult longer-term ART patients in Blantyre, Malawi. PLoS One 2012; 7:e42029. [PMID: 22848696 PMCID: PMC3406059 DOI: 10.1371/journal.pone.0042029] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 04/20/2012] [Accepted: 06/29/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Stavudine is an effective and inexpensive antiretroviral drug, but no longer recommended by WHO for first-line antiretroviral regimens in resource-limited settings due to toxicity concerns. Because of the high cost of alternative drugs, it has not been feasible to replace stavudine in most adults in the Malawi ART programme. We aimed to provide policy makers with a detailed picture of stavudine toxicities in Malawians on longer-term ART, in order to facilitate prioritization of stavudine replacement among other measures to improve the quality of ART programmes. METHODS Prospective cohort of Malawian adults who had just completed one year of stavudine containing ART in an urban clinic, studying peripheral neuropathy, lipodystrophy, diabetes mellitus, high lactate syndromes, pancreatitis and dyslipidemia during 12 months follow up. Stavudine dosage was 30 mg irrespective of weight. Cox regression was used to determine associations with incident toxicities. RESULTS 253 patients were enrolled, median age 36 years, 62.5% females. Prevalence rates (95%-confidence interval) of toxicities after one year on stavudine were: peripheral neuropathy 21.3% (16.5-26.9), lipodystrophy 14.7% (2.4-8.1), high lactate syndromes 0.0% (0-1.4), diabetes mellitus 0.8% (0-2.8), pancreatitis 0.0% (0-1.5). Incidence rates per 100 person-years (95%-confidence interval) during the second year on stavudine were: peripheral neuropathy 19.8 (14.3-26.6), lipodystrophy 11.4 (7.5-16.3), high lactate syndromes 2.1 (0.7-4.9), diabetes mellitus 0.4 (0.0-1.4), pancreatitis 0.0 (0.0-0.2). Prevalence of hypercholesterolemia and hypertriglyceridemia increased from 12.1% to 21.1% and from 29.5% to 37.6% respectively between 12 and 24 months. 5.5% stopped stavudine, 1.3% died and 4.0% defaulted during follow up. Higher age was an independent risk factor for incident peripheral neuropathy and lipodystrophy. CONCLUSION Stavudine associated toxicities continued to accumulate during the second year of ART, especially peripheral neuropathy and lipodystrophy and more so at increasing age. Our findings support investments for replacing stavudine in first-line regimens in sub-Saharan Africa.
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Affiliation(s)
- Joep J van Oosterhout
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.
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Macrocytosis is a predictor of resting lactate concentrations in persons on dideoxynucleoside therapy for HIV infection. Int J Infect Dis 2012; 16:e225-7. [DOI: 10.1016/j.ijid.2011.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 05/11/2011] [Accepted: 11/30/2011] [Indexed: 11/19/2022] Open
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Leung GPH. Iatrogenic mitochondriopathies: a recent lesson from nucleoside/nucleotide reverse transcriptase inhibitors. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 942:347-69. [PMID: 22399431 DOI: 10.1007/978-94-007-2869-1_16] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Academic Contribution Register] [Indexed: 12/12/2022]
Abstract
The use of nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) has revolutionized the treatment of infection by human immunodeficiency virus (HIV) and hepatitis-B virus. NRTIs can suppress viral replication in the long-term, but possess significant toxicity that can seriously compromise treatment effectiveness. The major toxicity of NRTIs is mitochondrial toxicity. This manifests as serious side effects such as myopathy, peripheral neuropathy and lactic acidosis. In general, it is believed that the mitochondrial pathogenesis is closely related to the effect of NRTIs on mitochondrial DNA polymerase-γ. Depletion and mutation of mitochondrial DNA during chronic NRTI therapy may lead to cellular respiratory dysfunction and release of reactive oxidative species, resulting in cellular damage. It is now apparent that the etiology is far more complex than originally thought. It appears to involve multiple mechanisms as well as host factors such as HIV per se, inborn mitochondrial mutation, and sex. Management of mitochondrial toxicity during NRTI therapy remains a challenge. Interruption of NRTI therapy and substitution of the causative agents with alternative better-tolerated NRTIs represents the mainstay of management for mitochondrial toxicity and its clinical manifestations. A range of pharmacological approaches has been proposed as treatments and prophylaxes.
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Affiliation(s)
- George P H Leung
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, China.
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Point-of-care capillary blood lactate measurements in human immunodeficiency virus-uninfected children with in utero exposure to human immunodeficiency virus and antiretroviral medications. Pediatr Infect Dis J 2011; 30:1069-74. [PMID: 22051859 PMCID: PMC3242409 DOI: 10.1097/inf.0b013e318234c886] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To estimate the prevalence of elevated point-of-care (POC) capillary blood lactate concentrations in human immunodeficiency virus (HIV)-exposed, uninfected children (HEU) and to determine if POC lactate varies with in utero antiretroviral (ARV) exposure. METHODS The Surveillance Monitoring for Antiretroviral Therapy Toxicities protocol of the Pediatric HIV/AIDS Cohort Study enrolled 1934 children between 2007 and 2009, 0 to 12 years of age, born to HIV-infected mothers. POC lactate was measured annually on capillary blood using the Lactate Pro device. Associations of POC lactate with in utero ARV exposure and other characteristics were evaluated using logistic regression models, adjusting for maternal characteristics and other confounders. RESULTS Of 1641 children with POC measurements (median age, 3.0 years), 3.4% had POC lactate >3 mmol/L. Median POC lactate level decreased with age (1.9 mmol/L, 1.7 mmol/L, and 1.6 mmol/L for children 0-<6 months [99% ≤6 weeks of life], 6-<24 months, and ≥24 months of age, respectively; P < 0.001). Prevalence of elevated POC lactate did not differ by in utero ARV exposure drug class, but was significantly higher in children exposed in utero to emtricitabine or efavirenz, cocaine or opiates, and those of white race. CONCLUSIONS POC lactate testing is a useful rapid laboratory screening assay for HEU children with ARV exposure. ARV use during pregnancy has resulted in a dramatic decrease in mother-to-child transmission of HIV, and the risk of elevated lactate in HEU children is low. However, as new ARVs and more complex regimens are used during pregnancy by HIV-infected women, continued monitoring for infant toxicities is essential.
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Leung L, Wilson D, Manini AF. Fatal toxicity from symptomatic hyperlactataemia: a retrospective cohort study of factors implicated with long-term nucleoside reverse transcriptase inhibitor use in a South African hospital. Drug Saf 2011; 34:521-7. [PMID: 21488705 DOI: 10.2165/11588240-000000000-00000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND In many Sub-Saharan African countries, first-line therapy for HIV may include a nucleoside reverse transcriptase inhibitor (NRTI). Long-term NRTI use is associated with symptomatic hyperlactataemia due to inhibition of mitochondrial DNA polymerase γ, a potentially fatal complication. OBJECTIVE The purpose of the study was to evaluate the factors associated with inhospital fatality for HIV inpatients prescribed NRTIs long term who presented with symptomatic hyperlactataemia. METHODS We performed a retrospective cohort study at a 900-bed university hospital in South Africa over 4 years (2005-2008). We included HIV inpatients prescribed NRTIs long term who presented with symptomatic hyperlactataemia (long-term NRTI use; lactate >4.0 mmol/L; absence of infectious source; symptoms requiring admission). Data included demographics, medical history, NRTI duration, blood pressure, symptom duration and relevant laboratory data. RESULTS Of 79 patients who met inclusion criteria (mean age 38.2 ± 10.5 years, 97% female) there were 46 fatalities (58%). Factors significantly associated with fatality were presence of diabetes mellitus (p = 0.04), lactate ≥10 mmol/L (p = 0.003), pH <7.2 (p = 0.002), creatinine ≥200 μmol/L (p = 0.03) and altered mental status (p = 0.03). CONCLUSIONS In this study, NRTI-related symptomatic hyperlactataemia occurred predominantly in females. Mortality was associated with severely elevated lactate (≥10 mmol/L), the degree of acidosis, elevated creatinine, history of diabetes and altered mental status on presentation.
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Affiliation(s)
- Liza Leung
- Department of Emergency Medicine, Mt Sinai School of Medicine, New York, New York 10029, USA.
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Feeney ER, Chazallon C, O'Brien N, Meiffrédy V, Goodall RL, Aboulker JP, Cooper DA, Yeni P, Mallon PWG. Hyperlactataemia in HIV-infected subjects initiating antiretroviral therapy in a large randomized study (a substudy of the INITIO trial). HIV Med 2011; 12:602-9. [PMID: 21599820 DOI: 10.1111/j.1468-1293.2011.00934.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the predictive value of clinical and molecular risk factors, including peripheral blood mononuclear cell (PBMC) mitochondrial DNA (mtDNA) and mitochondrial RNA (mtRNA), for the development of lactic acidosis (LA) and symptomatic hyperlactataemia (SHL). METHODS In a substudy of a large multicentre, randomized trial of three antiretroviral regimens, all containing didanosine (ddI) and stavudine (d4T), in antiretroviralnaïve, HIV-1-infected patients, patients with LA/SHL ('cases') were compared with those without LA/SHL in a univariate analysis, with significant parameters analysed in a multivariate model. In a molecular substudy, PBMC mtDNA and mtRNA from cases and matched controls at baseline and time of event were examined. RESULTS In 911 subjects followed for a median of 192 weeks, 24 cases were identified (14 SHL and 10 LA). In univariate analysis, cases were more likely to be female (P=0.05) and to have a high body mass index (BMI) (P=0.02). In multivariate analyses, only BMI remained an independent predictor of the development of LA/SHL (P=0.03). Between cases and controls there was no significant difference in mtDNA copy number at baseline (389 vs. 411 copies/cell, respectively; P=0.60) or at time of event (329 vs. 474 copies/cell, respectively; P=0.21), in the change in mtDNA copy number from baseline to event (-65 vs. +113 copies/cell, respectively; P=0.12), in mtRNA expression at baseline or time of event, or in the change in mtRNA expression from baseline to event. CONCLUSION The development of LA/SHL was associated with increased BMI, but PBMC mtDNA and mtRNA did not predict LA/SHL. This demonstrates the ineffectiveness of routine measurement of PBMC mtDNA in patients on ddI and d4T as a means of predicting development of LA/SHL.
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Affiliation(s)
- E R Feeney
- HIV Molecular Research Group, School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland.
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Matthews LT, Giddy J, Ghebremichael M, Hampton J, Guarino AJ, Ewusi A, Carver E, Axten K, Geary MC, Gandhi RT, Bangsberg DR. A risk-factor guided approach to reducing lactic acidosis and hyperlactatemia in patients on antiretroviral therapy. PLoS One 2011; 6:e18736. [PMID: 21494566 PMCID: PMC3073990 DOI: 10.1371/journal.pone.0018736] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 11/30/2010] [Accepted: 03/12/2011] [Indexed: 11/18/2022] Open
Abstract
Background Stavudine continues to be used in antiretroviral treatment (ART) regimens in
many resource-limited settings. The use of zidovudine instead of stavudine
in higher-risk patients to reduce the likelihood of lactic acidosis and
hyperlactatemia (LAHL) has not been examined. Methods Antiretroviral-naïve, HIV-infected adults initiating ART between 2004
and 2007 were divided into cohorts of those initiated on stavudine- or
zidovudine-containing therapy. We evaluated stavudine or zidovudine use,
age, sex, body mass index (BMI), baseline CD4 cell count, creatinine,
hemoglobin, alanine aminotransferase, and albumin as predictors of time to
LAHL with Cox Proportional Hazards (PH) regression models. Results Among 2062 patients contributing 2747 patient years (PY), the combined
incidence of LAHL was 3.2/100 PY in those initiating stavudine- and 0.34/100
PY in those initiating zidovudine-containing ART (RR 9.26, 95% CI:
1.28–66.93). In multivariable Cox PH analysis, stavudine exposure (HR
14.31, 95% CI: 5.79–35.30), female sex (HR 3.41, 95% CI:
1.89–6.19), higher BMI (HR 3.21, 95% CI: 2.16–4.77),
higher creatinine (1.63, 95% CI: 1.12–2.36), higher albumin (HR
1.04, 95% CI: 1.01–1.07), and lower CD4 cell count (HR 0.96,
95% CI: 0.92–1.0) at baseline were associated with higher LAHL
rates. Among participants who started on stavudine, switching to zidovudine
was associated with lower LAHL rates (HR 0.15, 95% CI:
0.06–0.35). Subgroup analysis limited to women with higher BMI≥25
kg/m2 initiated on stavudine also showed that switch to zidovudine was
protective when controlling for other risk factors (HR 0.21, 95% CI
.07–0.64). Conclusions Stavudine exposure, female sex, and higher BMI are strong, independent
predictors for developing LAHL. Patients with risk factors for lactic
acidosis have less LAHL while on zidovudine- rather than
stavudine-containing ART. Switching patients from stavudine to zidovudine is
protective. Countries continuing to use stavudine should avoid this drug in
women and patients with higher BMI.
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Affiliation(s)
- Lynn T Matthews
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America.
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Dlamini J, Ledwaba L, Mokwena N, Mokhathi T, Orsega S, Tsoku M, Kowo H, Proschan M, Khabo P, Maja P, Hadigan C. Lactic acidosis and symptomatic hyperlactataemia in a randomized trial of first-line therapy in HIV-infected adults in South Africa. Antivir Ther 2011; 16:605-9. [DOI: 10.3851/imp1790] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 10/18/2022]
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Arenas-Pinto A, Weller I, Ekong R, Grant A, Karstaedt A, Reiss P, Telisinghe L, Weber R, Bolhaar M, Bradman N, Ingram C. Common inherited mitochondrial DNA mutations and nucleoside reverse transcriptase inhibitor-induced severe hyperlactataemia in HIV-infected adults: an exploratory study. Antivir Ther 2011; 17:275-82. [DOI: 10.3851/imp1947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Accepted: 05/15/2011] [Indexed: 10/15/2022]
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Arenas-Pinto A, Grant A, Bhaskaran K, Copas A, Carr A, Worm SW, Martinez E, Reiss P, Dunn D, Weber R, Hoy J, Weller I. Risk factors for fatality in HIV-infected patients with dideoxynucleoside-induced severe hyperlactataemia or lactic acidosis. Antivir Ther 2011; 16:219-26. [PMID: 21447871 DOI: 10.3851/imp1739] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Lactic acidosis (LA) and severe hyperlactataemia (HL) are infrequent but serious complications of antiretroviral therapy that have been associated with a high fatality rate. METHODS In a multinational retrospective cohort study, LA was defined as arterial blood pH<7.35, bicarbonate <20 mmol/l and lactate above normal, and HL as confirmed blood lactate >5 mmol/l. Logistic regression was used to identify factors associated with fatality. Sensitivity and specificity of different case definitions as predictors of death were compared. RESULTS The overall case-fatality rate was 19/110 (17.3%), but among acidotic patients it was 33% (16/49 cases). There were 10 asymptomatic patients and none of them died as a consequence of the event. The median lactate for fatal, non-fatal and all patients was 8.3 mmol/l (IQR 7.2-13.1), 6.4 mmol/l (IQR 5.4-7.8) and 6.7 mmol/l (IQR 5.5-8.1), respectively. After adjusting for age and current CD4(+) T-cell count, lactate >7 mmol/l (OR 6.27, 95% CI 1.13-34.93), blood bicarbonate <12 mmol/l (OR 10.02 relative to >18 mmol/l, 95% CI 1.33-75.65) and concurrent opportunistic infections (OR 8.69, 95% CI 1.45-52.22) were independently associated with case fatality. Blood lactate >7 mmol/l showed a sensitivity of 84% for fatality with a specificity of 60%, whereas bicarbonate <12 mmol/l showed a better specificity (85%) but a poorer sensitivity (42%). Bicarbonate <18 mmol/l appears to be as good as lactate <7 mmol/l at predicting death (sensitivity 90% and specificity 54%). CONCLUSIONS Our data suggest that blood lactate >7 mmol/l and blood bicarbonate <18 mmol/l appear to predict death and might help clinicians in selecting patients who may benefit from more intense monitoring.
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Fielder J, Rambiki K. Occurrence of stavudine-induced lactic acidosis in 3 members of an African family. ACTA ACUST UNITED AC 2010; 9:236-9. [PMID: 20798404 DOI: 10.1177/1545109710373830] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 11/16/2022]
Abstract
Fixed-dose combinations containing stavudine have played a critical role in the worldwide scale-up of antiretroviral therapy, but increasing concern exists regarding adverse events due to mitochondrial toxicity. We describe the first reported occurrence of lactic acidosis within a family of 3 HIV-infected individuals. This report is only the second of lactic acidosis affecting an African child. Further research is indicated to identify possible genetic and other risk factors underlying mitochondrial toxicity in African populations, especially among pediatric cohorts.
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Affiliation(s)
- Jon Fielder
- Partners in Hope Medical Center, Lilongwe, Malawi, Africa.
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Ratsela A, Polis M, Dhlomo S, Emery S, Grandits G, Khabo P, Khanyile T, Komati S, Neaton JD, Naidoo LCD, Magongoa D, Qolohle D. A randomized factorial trial comparing 4 treatment regimens in treatment-naive HIV-infected persons with AIDS and/or a CD4 cell count <200 cells/μL in South Africa. J Infect Dis 2010; 202:1529-37. [PMID: 20942650 DOI: 10.1086/656718] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Few randomized trials comparing antiretroviral therapy (ART) regimens have been conducted in resource-limited settings. METHODS In the Republic of South Africa, antiretroviral-naive human immunodeficiency virus (HIV)-infected individuals >14 years old with a CD4 cell count <200 cells/μL or a prior AIDS diagnosis were randomized to receive efavirenz (EFV) or lopinavir/ritonavir (LPV/r) with either zidovudine (ZDV) plus didanosine (ddI) or stavudine (d4T) plus lamivudine (3TC) in an open-label, 2-by-2 factorial study and followed up for the primary outcome of AIDS or death and prespecified secondary outcomes, including CD4 cell count and viral load changes, treatment discontinuation, and grade 4 events. RESULTS In total, 1771 persons were randomized and followed up for a median of 24.7 months. AIDS or death occurred in (1) 163 participants assigned EFV and 157 assigned LPV/r (hazard ratio [HR], 1.04 [95% confidence interval {CI}, 0.84-1.30]) and in (2) 170 participants assigned ZDV+ddI and 150 assigned d4T+3TC (HR, 1.15 [95% CI, 0.93-1.44]). HIV RNA levels were lower (P < .001) and CD4 cell counts were greater (P < .01) over follow-up for d4T+3TC versus ZDV+ddI. Rates of potentially life-threatening adverse events and overall treatment discontinuation were similar for d4T+3TC and ZDV+ddI; however, more participants discontinued d4T because of toxicity (12.6%) than other treatments (<5%). CONCLUSION EFV and LPV/r are effective components of first-line ART. The poorer viral and immune responses with ZDV+ddI and the greater toxicity-associated discontinuation rate with d4T+3TC suggest that these treatments be used cautiously as initial therapy. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00342355.
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Yazdanpanah Y, Wolf LL, Anglaret X, Gabillard D, Walensky RP, Moh R, Danel C, Sloan CE, Losina E, Freedberg KA. CD4+ T-cell-guided structured treatment interruptions of antiretroviral therapy in HIV disease: projecting beyond clinical trials. Antivir Ther 2010; 15:351-61. [PMID: 20516555 DOI: 10.3851/imp1542] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND International trials have shown that CD4+ T-cell-guided structured treatment interruptions (STI) of antiretroviral therapy (ART) lead to worse outcomes than continuous treatment. We simulated continuous ART and STI strategies with higher CD4+ T-cell interruption/reintroduction thresholds than those assessed in actual trials. METHODS Using a model of HIV, we simulated cohorts of African adults with different baseline CD4+ T-cell counts (< or = 200; 201-350; and 351-500 cells/microl). We varied ART initiation criteria (immediate; CD4+ T-cell count < 350 cells/microl or > or = 350 cells/microl with severe HIV-related disease; and CD4+ T-cell count <200 cells/microl or > or = 200 cells/microl with severe HIV-related disease), and ART interruption/reintroduction thresholds (350/250; 500/350; and 700/500 cells/microl). First-line therapy was non-nucleoside reverse transcriptase inhibitor (NNRTI)-based and second-line therapy was protease inhibitor (PI)-based. RESULTS STI generally reduced life expectancy compared with continuous ART. Life expectancy increased with earlier ART initiation and higher interruption/reintroduction thresholds. STI reduced life expectancy by 48-69 and 11-30 months compared with continuous ART when interruption/reintroduction thresholds were 350/250 and 500/350 cells/microl, depending on ART initiation criteria. When patients interrupted/reintroduced ART at 700/500 cells/microl, life expectancies ranged from 2 months lower to 1 month higher than continuous ART. STI-related life expectancy increased with decreased risk of virological resistance after ART interruptions. CONCLUSIONS STI with NNRTI-based regimens was almost always less effective than continuous treatment, regardless of interruption/reintroduction thresholds. The risks associated with STI decrease only if patients start ART earlier, interrupt/reintroduce treatment at very high CD4+ T-cell thresholds (700/500 cells/microl) and use first-line medications with higher resistance barriers, such as PIs.
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Affiliation(s)
- Yazdan Yazdanpanah
- Service Universitaire des Maladies Infectieuses et du Voyageur, Centre Hospitalier de Tourcoing, Tourcoing, France.
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Minga A, Lewden C, Dohoun L, Abo Y, Emieme A, Coulibaly A, Salamon R, Eholié S, Anglaret X, Danel C. Short communication: Severe symptomatic hyperlactatemia among HIV type 1-infected adults on antiretroviral therapy in Côte d'Ivoire. AIDS Res Hum Retroviruses 2010; 26:991-5. [PMID: 20707728 DOI: 10.1089/aid.2009.0309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 12/20/2022] Open
Abstract
Stavudine is no longer recommended for use in first-line antiretroviral therapy (ART), but it remains in high demand worldwide because it is affordable. We report the clinical presentation and incidence of severe hyperlactatemia (SL) in HIV-infected adults who initiated ART between April 2005 and May 2009 in Côte d'Ivoire, West Africa. In a prospective cohort study at the HIV care center affiliated with the National Centre for Blood Transfusion, we used standardized forms to record baseline and follow-up data. We measured serum lactate levels for all adults on ART who showed signs of hyperlactatemia. SL was defined as serum lactate >2.5 mmol/liter. Overall, 806 adults initiated ART. Among the 591 patients (73%) on stavudine-containing regimens, 394 were women (67%); the median pre-ART CD4 count was 150/mm3 and the median body mass index was 20.9 kg/m2. These patients were followed for a median of 28 months. We detected SL only among patients taking stavudine. The incidence of SL was 0.55/100 person-years (PY) (95% CI 0.47-0.63) overall and 0.85/100 PY among women (95% CI 0.75-0.95). Among the eight patients with SL, 100% lost >9% of body weight before diagnosis, 100% had serum lactate >4 mmol/liter (range 4.2-12.1), 50% had pre-ART BMI >25 kg/m2, and three patients died (38%), accounting for 6.4% of deaths among patients taking stavudine. As long as HIV clinicians continue to use stavudine in sub-Saharan Africa, they should watch out for acute unexplained weight loss in patients taking ART, particularly among women and patients with high pre-ART BMI.
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Affiliation(s)
- Albert Minga
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- INSERM, U897, Bordeaux, France
- Université Victor Segalen Bordeaux 2, Bordeaux, France
| | - Charlotte Lewden
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- INSERM, U897, Bordeaux, France
- Université Victor Segalen Bordeaux 2, Bordeaux, France
| | | | - Yao Abo
- Programme PAC-CI, Abidjan, Côte d'Ivoire
| | | | - Ali Coulibaly
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Abidjan, Côte d'Ivoire
| | - Roger Salamon
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- INSERM, U897, Bordeaux, France
- Université Victor Segalen Bordeaux 2, Bordeaux, France
| | - Serge Eholié
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- Service des Maladies Infectieuses et Tropicales, CHU de Treichville, Abidjan, Côte d'Ivoire
| | - Xavier Anglaret
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- INSERM, U897, Bordeaux, France
- Université Victor Segalen Bordeaux 2, Bordeaux, France
| | - Christine Danel
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- INSERM, U897, Bordeaux, France
- Université Victor Segalen Bordeaux 2, Bordeaux, France
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Hernández Pérez E, Dawood H. Stavudine-induced hyperlactatemia/lactic acidosis at a tertiary communicable diseases clinic in South Africa. ACTA ACUST UNITED AC 2010; 9:109-12. [PMID: 20484736 DOI: 10.1177/1545109710361536] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine the incidence, presentation, and outcome of hyperlactatemia and lactic acidosis. DESIGN AND METHODS SETTING: Grey's Hospital, a tertiary level referral institution. STUDY POPULATION A chart review of 1719 patients commenced on highly active antiretroviral therapy (HAART) between August 1, 2004, and July 31, 2006. A total of 1000 patients (615 females) received stavudine (d4T)/lamivudine (3TC)/efavirenz (EFV), 719 patients (598 females) received d4T/ 3TC/nevirapine (NVP). RESULTS Of the 1719 patients, 152 (8.84%) had an elevated plasma venous lactate (>2.2 mmol/L), 45 patients required admission for lactic acidosis. The overall incidence rate was 13.5 cases per 1000 patient years. The most common presenting symptoms were loss of weight (95%), abdominal pain (78.9%), loss of appetite, and paresthesias (63.8%). The median body mass index (BMI) at commencement of HAART and at onset of symptoms was 24.5 and 26, respectively. A median serum lactate level of 6.08 mmol/L (range 2.3-19.7 mmol/L) was observed at the onset of symptoms. CONCLUSIONS High BMI at treatment initiation did not always predict hyperlactatemia. All patients who died had a baseline CD4 count <10 cells/mm(3) at HAART initiation.
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Affiliation(s)
- Ernesto Hernández Pérez
- Infectious Diseases Unit, Department of Medicine, Grey's Hospital, Pietermaritzburg, South Africa
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Schutz C, Boulle A, Stead D, Rebe K, Osler M, Meintjes G. Reduced referral and case fatality rates for severe symptomatic hyperlactataemia in a South African public sector antiretroviral programme: a retrospective observational study. AIDS Res Ther 2010; 7:13. [PMID: 20500901 PMCID: PMC2898658 DOI: 10.1186/1742-6405-7-13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 01/12/2010] [Accepted: 05/26/2010] [Indexed: 11/29/2022] Open
Abstract
Background Interventions to promote prevention and earlier diagnosis of severe symptomatic hyperlactataemia (SHL) were implemented in the Western Cape provincial antiretroviral programme (South Africa) from 2004. Interventions included clinician education, point-of-care lactate meters, switch from stavudine to zidovudine in high risk patients and stavudine dose reduction. This study assessed trends in referral rate, severity at presentation and case fatality rate for severe SHL. Methods Retrospective study of severe SHL cases diagnosed at a referral facility from 1 January 2003 to 31 December 2008. Severe SHL was defined as patients with compatible symptoms and serum lactate ≥ 5 mmol/l attributable to antiretroviral therapy (ART). Cumulative ART exposure at referring ART clinics was used to calculate referral rates. Results There were 254 severe SHL cases. The referral rate (per thousand patient years [py] ART exposure) peaked in 2005 (20.4/1000py), but fell to 1.3/1000py by 2008 (incidence rate ratio [IRR] = 0.07, 95%CI 0.04-0.11). In 2003, 66.7% of cases presented with a standard bicarbonate (SHCO3) level <15 mmol/l, but this fell to 12.5% by 2008 (p for trend < 0.001). Case fatality rate fell from a peak of 33.3% in 2004 to 0% in 2008 (p for trend = 0.002). Conclusions These trends suggest the interventions were associated with reduced referral, less severe metabolic acidosis at presentation and improved survival.
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Hooker DJ, Cherry CL. Apoptosis: a clinically useful measure of antiretroviral drug toxicity? Expert Opin Drug Metab Toxicol 2010; 5:1543-53. [PMID: 19785516 DOI: 10.1517/17425250903282781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 11/05/2022]
Abstract
Antiretroviral therapy (ART) has improved life expectancy with HIV infection, but long-term toxicities associated with these medications are now a major global disease burden. There is a clear need to develop useful methods for monitoring patients on antiretroviral drugs for early signs of toxicity. Assays with predictive utility -- allowing therapy to be changed before serious end organ damage occurs -- would be ideal. Attempts to develop biochemical methods of monitoring ART toxicity have concentrated on the mitochondrial toxicity of nucleoside analogue reverse transcriptase inhibitors and have not generally lead to assays with widespread clinical applications. For example, plasma lactate and peripheral blood measurements of mitochondrial DNA associate with exposure to potentially toxic nucleoside analogue reverse transcriptase inhibitors but have not reliably predicted clinical toxicity. Better assays are needed, including markers of toxicity from additional drug classes. Apoptosis may be a potential marker of ART toxicity. Increased apoptosis has been demonstrated both in vitro and in vivo in association with various antiretroviral drug classes and a range of clinical toxicities. However, quantifying apoptosis on biopsy specimens of tissue (such as adipose tissue) is impractical for patient monitoring. Novel assays have been described that can quantify apoptosis using minute tissue samples and initial results from clinical samples suggest peripheral blood may have utility in predicting ART toxicities. The limitations and potential of such techniques for monitoring patients for drug side effects will be discussed.
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Abstract
PURPOSE OF REVIEW This review summarizes recent developments regarding the unique clinical pharmacologic profile of nucleoside analog reverse transcriptase inhibitors for management of HIV. RECENT FINDINGS First, intracellular data in patients suggest that nucleoside reverse transcriptase inhibitor-triphosphates are compartmentalized in different cell types. Additionally, intracellular drug-drug interactions were identified, which were undetectable in plasma. Second, extracellular data illustrate multiple bidirectional plasma drug-drug interactions between renally eliminated tenofovir and liver-metabolized drugs. Definitive mechanistic details for these interactions are lacking but they appear to involve renal and/or enteric drug transporters. Furthermore, the plasma versus female genital tract disposition of these agents was recently elucidated, which is important for currently investigated indications for pre-exposure and post-exposure prophylaxis. Finally, tenofovir/emtricitabine and abacavir (using a promising human leukocyte antigen-B*5701 genetic test for hypersensitivity)/lamivudine have emerged as common first-line nucleoside analog reverse transcriptase inhibitors because of co-formulations, once-daily dosing, and favorable tolerability and adverse effect profiles. Nevertheless, elucidating the long-term safety profile for all nucleoside analog reverse transcriptase inhibitors remains a priority. SUMMARY Knowledge of nucleoside analog reverse transcriptase inhibitor disposition intracellularly and extracellularly has expanded. This provides a basis for rational use of these agents clinically and adds new perspectives for future research.
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Maagaard A, Kvale D. Long term adverse effects related to nucleoside reverse transcriptase inhibitors: Clinical impact of mitochondrial toxicity. ACTA ACUST UNITED AC 2009; 41:808-17. [DOI: 10.3109/00365540903186181] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 12/24/2022]
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Maagaard A, Kvale D. Mitochondrial toxicity in HIV-infected patients both off and on antiretroviral treatment: a continuum or distinct underlying mechanisms? J Antimicrob Chemother 2009; 64:901-9. [DOI: 10.1093/jac/dkp316] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 01/05/2023] Open
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Stavudine- and nevirapine-related drug toxicity while on generic fixed-dose antiretroviral treatment: incidence, timing and risk factors in a three-year cohort in Kigali, Rwanda. Trans R Soc Trop Med Hyg 2009; 104:148-53. [PMID: 19732926 DOI: 10.1016/j.trstmh.2009.07.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 02/06/2009] [Revised: 07/06/2009] [Accepted: 07/06/2009] [Indexed: 11/21/2022] Open
Abstract
This cohort study was conducted to report on the incidence, timing and risk factors for stavudine (d4T)- and nevirapine (NVP)-related severe drug toxicity (requiring substitution) with a generic fixed-dose combination under program conditions in Kigali, Rwanda. Probability of 'time to first toxicity-related drug substitution' was estimated using the Kaplan-Meier method and Cox-proportional hazards modeling was used to identify risk factors. Out of 2190 adults (median follow-up: 1.5 years), d4T was replaced in 175 patients (8.0%) for neuropathy, 69 (3.1%) for lactic acidosis and 157 (7.2%) for lipoatrophy, which was the most frequent toxicity by 3 years of antiretroviral treatment (ART). NVP was substituted in 4.9 and 1.3% of patients for skin rash and hepatotoxicity, respectively. Use of d4T 40 mg was associated with increased risk of lipoatrophy and early (<6 months) neuropathy. Significant risk factors associated with lactic acidosis and late neuropathy included higher baseline body weight. Older age and advanced HIV disease increased the risk of neuropathy. Elevated baseline liver tests and older age were identified as risk factors for NVP-related hepatotoxicity. d4T is associated with significant long-term toxicity. d4T-dose reduction, increased access to safer ART in low-income countries and close monitoring for those at risk are all relevant strategies.
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Osler M, Stead D, Rebe K, Meintjes G, Boulle A. Risk factors for and clinical characteristics of severe hyperlactataemia in patients receiving antiretroviral therapy: a case-control study. HIV Med 2009; 11:121-9. [PMID: 19702629 DOI: 10.1111/j.1468-1293.2009.00754.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Symptomatic hyperlactataemia and lactic acidosis (SHLA) are potentially life-threatening complications associated with stavudine (d4T), an antiretroviral therapy (ART) drug widely used in developing countries. METHODS Cases comprised all symptomatic patients with measured lactates >or= 5 mmol/L referred to a South African hospital between August 2003 and November 2005. Matched controls were selected according to facility and duration on ART. RESULTS Seventy-one cases and 142 controls were included in the study. The majority of cases presented between 6 and 18 months on ART. Female sex [adjusted odds ratio (AOR) 23.4; 95% confidence interval (CI) 4.0-136.6], a baseline weight between 60 and 75 kg (AOR 4.5; 95% CI 1.4-14.1) or, in particular, >or= 75 kg (AOR 19.4; 95% CI 4.1-82.5) at ART initiation and gaining >or= 6 kg in the first 3 months on therapy (AOR 3.5; 95% CI 1.3-9.5) were independent risk factors identifying patients who may subsequently develop SHLA. Weight loss of >or= 2 kg (AOR 6.1; 95% CI 2.0-18.3), a rise in alanine aminotransferase (ALT) >or= 10 U/L (AOR 3.1; 95% CI 1.1-8.9), the presence of at least one of three major symptoms (vomiting, nausea and abdominal pains) of SHLA (AOR 12.6; 95% CI 3.3-47.2) and peripheral neuropathy (AOR 3.4; 95% CI 1.1-9.8) were the clinical parameters that were most able to identify patients with early manifestations of SHLA. CONCLUSIONS This is the first case-control study for SHLA in Southern Africa. Given these findings, we advise that stavudine is avoided in overweight women. Weight loss, a rise in ALT, peripheral neuropathy and/or gastrointestinal symptoms should prompt healthcare workers to assess for SHLA, especially at between 6 and 18 months on ART.
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Affiliation(s)
- Meg Osler
- Infectious Disease Epidemiology Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
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George JA, Venter WD, Van Deventer HE, Crowther NJ. A longitudinal study of the changes in body fat and metabolic parameters in a South African population of HIV-positive patients receiving an antiretroviral therapeutic regimen containing stavudine. AIDS Res Hum Retroviruses 2009; 25:771-81. [PMID: 19619010 DOI: 10.1089/aid.2008.0308] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 02/01/2023] Open
Abstract
The aim of this study was to determine the patterns of change in body fat and metabolic parameters in a South African cohort on a first line ART regimen containing stavudine. Fasting lipogram, blood glucose and insulin levels, CD4 cell count, viral load, BMI, waist-to-hip ratio (WHR), and skinfold thickness at the triceps, scapula, and iliac crest were measured before starting ART in 42 (27 female) subjects. Repeat measurements were performed at four monthly intervals for 2 years. Lipodystrophy was diagnosed using patient perception and assessment by a physician. At baseline, subjects who went on to develop lipodystrophy (LD group) were fatter and had higher skinfold thickness at all three sites and higher insulin levels than subjects who never developed lipodystrophy (NLD group). The WHR increased to a greater extent while hip circumference and tricep skinfolds fell more significantly in the LD than NLD group. Triglyceride and cholesterol levels increased significantly in both groups while lactate and glucose levels increased more and insulin levels increased less in the LD than the NLD group. Neither viral load nor CD4 count differed between the groups during the study. Viral load correlated positively with insulin levels at baseline. Thus, lipodystrophy in the South African population is characterized by a higher BMI before initiation of ART and lipoatrophy of the arms and hips, lipohypertrophy of the waist, and increased lactate production. When compared to the NLD group, the LD subjects display attenuated insulin secretory output in response to a higher weight gain.
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Affiliation(s)
- Jaya A. George
- Department of Chemical Pathology, National Health Laboratory Service, University of the Witwatersrand Medical School, Johannesburg, South Africa
| | - Willem D.F. Venter
- Reproductive Health and HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Hendrick E. Van Deventer
- Department of Chemical Pathology, National Health Laboratory Service, University of the Witwatersrand Medical School, Johannesburg, South Africa
| | - Nigel J. Crowther
- Department of Chemical Pathology, National Health Laboratory Service, University of the Witwatersrand Medical School, Johannesburg, South Africa
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Westreich DJ, Sanne I, Maskew M, Malope-Kgokong B, Conradie F, Majuba P, Funk MJ, Kaufman JS, Van Rie A, Macphail P. Tuberculosis treatment and risk of stavudine substitution in first-line antiretroviral therapy. Clin Infect Dis 2009; 48:1617-23. [PMID: 19385733 DOI: 10.1086/598977] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Treatment for tuberculosis (TB) is common among individuals receiving stavudine-containing highly active antiretroviral therapy (HAART), but the effect of TB treatment on stavudine toxicity has received little attention. We estimated the effect of TB treatment on risk of stavudine substitution among individuals receiving first-line HAART. METHODS We evaluated a cohort of 7066 patients who initiated HAART from April 2004 through March 2007 in Johannesburg, South Africa. Three exposure categories were considered: ongoing TB treatment at HAART initiation, concurrent initiation of TB treatment and HAART, and incident TB treatment after HAART initiation. The outcome was single-drug stavudine substitution. Adjusted hazard ratios (aHRs) were estimated using marginal structural models to control for confounding, loss to follow-up, and competing risks. RESULTS Individuals with ongoing and concurrent TB treatment were at increased risk of stavudine substitution, irrespective of stavudine dosage. For ongoing TB treatment, aHR was 3.18 (95% confidence interval [CI], 1.82-5.56) in the first 2 months of HAART, 2.51 (95% CI, 1.77-3.54) in months 3-6, and 1.19 (95% CI, 0.94-1.52) thereafter. For concurrent TB treatment, aHR was 6.60 (95% CI, 3.03-14.37) in the first 2 months, 1.88 (95% CI, 0.87-4.09) in months 3-6, and 1.07 (95% CI, 0.65-1.76) thereafter. There was no effect of incident TB on stavudine substitution risk. CONCLUSIONS Risk of stavudine substitution was increased among patients who received TB treatment and was especially elevated during the period soon after HAART initiation. In settings in which alternative antiretroviral drugs are available, initiation of stavudine therapy in patients receiving TB treatment may need to be reconsidered.
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Affiliation(s)
- Daniel J Westreich
- Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill, NC 27599-7435, USA.
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