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Chaivichacharn P, Avihingsanon A, Gatechompol S, Ubolyam S, Punyawudho B. Dose optimization with population pharmacokinetics of ritonavir-boosted lopinavir for Thai people living with HIV with and without active tuberculosis. Drug Metab Pharmacokinet 2022; 47:100478. [DOI: 10.1016/j.dmpk.2022.100478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 09/11/2022] [Accepted: 10/11/2022] [Indexed: 11/28/2022]
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Waalewijn H, Turkova A, Rakhmanina N, Cressey TR, Penazzato M, Colbers A, Burger DM. Optimizing Pediatric Dosing Recommendations and Treatment Management of Antiretroviral Drugs Using Therapeutic Drug Monitoring Data in Children Living With HIV. Ther Drug Monit 2019; 41:431-443. [PMID: 31008997 PMCID: PMC6636807 DOI: 10.1097/ftd.0000000000000637] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/03/2019] [Indexed: 12/27/2022]
Abstract
INTRODUCTION This review summarizes the current dosing recommendations for antiretroviral (ARV) drugs in the international pediatric guidelines of the World Health Organization (WHO), US Department of Health and Human Services (DHHS), and Pediatric European Network for Treatment of AIDS (PENTA), and evaluates the research that informed these approaches. We further explore the role of data generated through therapeutic drug monitoring in optimizing the dosing of ARVs in children. METHODS A PubMed search was conducted for the literature on ARV dosing published in English. In addition, the registration documentation of European Medicines Agency and the US Food and Drug Administration for currently used ARVs and studies referenced by the WHO, DHHS, and EMA guidelines were screened. Resulting publications were screened for papers containing data on the area under the concentration-time curve, trough concentration, and peak concentration. Studies with enrolled participants with a median or mean age of ≥18 years were excluded. No restriction on publishing date was applied. DISCUSSION AND CONCLUSION Pediatric ARV dosing is frequently based on data obtained from small studies and is often simplified to facilitate dosing in the context of a public health approach. Pharmacokinetic parameters of pediatric ARVs are subject to high interpatient variation and this leads to a potential risk of underdosing or overdosing when drugs are used in real life. To ensure optimal use of ARVs and validate dosing recommendations for children, it is essential to monitor ARV dosing more thoroughly with larger sample sizes and to include diverse subpopulations. Therapeutic drug monitoring data generated in children, where available and affordable, have the potential to enhance our understanding of the appropriateness of simplified pediatric dosing strategies recommended using a public health approach and to uncover suboptimal dosing or other unanticipated issues postmarketing, further facilitating the ultimate goal of optimizing pediatric ARV treatment.
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Affiliation(s)
- Hylke Waalewijn
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Anna Turkova
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Natella Rakhmanina
- Department of Pediatrics, School of Medicine and Health Sciences, The George Washington University
- Division of Infectious Diseases, Children's National Medical Center
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia
| | - Tim R. Cressey
- PHPT/IRD UMI 174, Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Immunology and Infectious Diseases, Harvard T.H Chan School of Public Health, Boston, Massachusetts
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom; and
| | - Martina Penazzato
- Treatment and Care, Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Angela Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - David M. Burger
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
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Landry S, Chen CN, Patel N, Tseng A, Lalonde RG, Thibeault D, Sanche S, Sheehan NL. Therapeutic drug monitoring in treatment-experienced HIV-infected patients receiving darunavir-based salvage regimens: A case series. Antiviral Res 2018; 152:111-116. [PMID: 29458132 DOI: 10.1016/j.antiviral.2018.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 02/10/2018] [Accepted: 02/12/2018] [Indexed: 12/19/2022]
Abstract
Therapeutic drug monitoring (TDM) constitutes a compelling approach for the optimization of antiretroviral therapy in treatment-experienced HIV-1 patients. While various inhibitory indices have been proposed to predict virologic outcome, there is a lack of consensus on the clinical value of TDM. Here, we report the comparative results of TDM in 14 HIV-1-infected patients who had previously received at least two different PI-based regimens and who initiated darunavir (DRV)-based salvage therapy. Pharmacokinetic/pharmacodynamics (PK/PD) parameters were calculated for each subject. Seventy-nine percent of subjects had a viral load <50 copies/mL at 48 weeks. The only subject with two consecutive viral loads >50 copies/mL at the end of the study period was the patient with the lowest instantaneous inhibitory potential (IIP). The sample size was insufficient to show an association between any of the PK/PD parameters and virologic response. Based on our observations, we suggest that the utility of IIP for antiretroviral combinations for the prediction of virologic outcome in HIV-1 drug-experienced patients should be studied further.
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Affiliation(s)
- Sébastien Landry
- Faculté de pharmacie, Université de Montréal, C.P. 6128, succ. Centre-ville, Montréal, Québec, H3C 3J7, Canada; Chronic Viral Illness Service, McGill University Health Centre, 1001 boulevard Décarie, D02.4110, Montréal, Québec, H4A 3J1, Canada
| | - Chi-Nan Chen
- Chronic Viral Illness Service, McGill University Health Centre, 1001 boulevard Décarie, D02.4110, Montréal, Québec, H4A 3J1, Canada
| | - Nimish Patel
- Department of Pharmacy Practice, Albany College of Pharmacy & Health Sciences, 106 New Scotland Avenue, Albany, NY, 12208, USA
| | - Alice Tseng
- Immunodeficiency Clinic, University Health Network, 585 University Avenue, Toronto, ON, M5G 2N2, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, M5S 3M2, Canada
| | - Richard G Lalonde
- Chronic Viral Illness Service, McGill University Health Centre, 1001 boulevard Décarie, D02.4110, Montréal, Québec, H4A 3J1, Canada
| | - Denis Thibeault
- Biochemistry Laboratory, McGill University Health Center, 1001 boul. Décarie, E04.1510, Montréal, Québec, H4A 3J1, Canada
| | - Steven Sanche
- Faculté de pharmacie, Université de Montréal, C.P. 6128, succ. Centre-ville, Montréal, Québec, H3C 3J7, Canada
| | - Nancy L Sheehan
- Faculté de pharmacie, Université de Montréal, C.P. 6128, succ. Centre-ville, Montréal, Québec, H3C 3J7, Canada; Chronic Viral Illness Service, McGill University Health Centre, 1001 boulevard Décarie, D02.4110, Montréal, Québec, H4A 3J1, Canada; Pharmacy Department, McGill University Health Centre, 1001 boulevard Décarie, CRC.6004, Montréal, Québec, H4A 3J1, Canada.
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Punyawudho B, Singkham N, Thammajaruk N, Dalodom T, Kerr SJ, Burger DM, Ruxrungtham K. Therapeutic drug monitoring of antiretroviral drugs in HIV-infected patients. Expert Rev Clin Pharmacol 2016; 9:1583-1595. [PMID: 27626677 DOI: 10.1080/17512433.2016.1235972] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Therapeutic drug monitoring (TDM) may be beneficial when applied to antiretroviral (ARV). Even though TDM can be a valuable strategy in HIV management, its role remains controversial. Areas covered: This review provides a comprehensive update on important issues relating to TDM of ARV drugs in HIV-infected patients. Articles from PubMed with keywords relevant to each topic section were reviewed. Search strategies limited to articles published in English. Expert commentary: There is evidence supporting the use of TDM in HIV treatment. However, some limitations need to be considered. The evidence supporting the use of routine TDM for all patients is limited, as it is not clear that this strategy offers any advantages over TDM for selected indications. Selected groups of patients including patients with physiological changes, patients with drug-drug interactions or toxicity, and the elderly could potentially benefit from TDM, as optimized dosing is challenging in these populations.
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Affiliation(s)
- Baralee Punyawudho
- a Department of Pharmaceutical Care, Faculty of Pharmacy , Chiang Mai University , Chiang Mai , Thailand
| | - Noppaket Singkham
- a Department of Pharmaceutical Care, Faculty of Pharmacy , Chiang Mai University , Chiang Mai , Thailand
| | | | - Theera Dalodom
- b HIV-NAT , Thai Red Cross AIDS Research Centre , Bangkok , Thailand
| | - Stephen J Kerr
- b HIV-NAT , Thai Red Cross AIDS Research Centre , Bangkok , Thailand.,c The Kirby Institute, University of New South Wales , Sydney , Australia.,d Department of Global Health, Academic Medical Center , University of Amsterdam, Amsterdam Institute for Global Health and Development , Amsterdam , The Netherlands
| | - David M Burger
- e Radbound University Medical Center , Nijmegen , The Netherlands
| | - Kiat Ruxrungtham
- b HIV-NAT , Thai Red Cross AIDS Research Centre , Bangkok , Thailand.,f Faculty of Medicine , Chulalongkorn University , Bangkok , Thailand
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Pharmacokinetics of Etravirine Combined with Atazanavir/Ritonavir and a Nucleoside Reverse Transcriptase Inhibitor in Antiretroviral Treatment-Experienced, HIV-1-Infected Patients. AIDS Res Treat 2015; 2015:938628. [PMID: 25664185 PMCID: PMC4312629 DOI: 10.1155/2015/938628] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 11/26/2014] [Accepted: 12/09/2014] [Indexed: 01/10/2023] Open
Abstract
Objectives. TEACH (NCT00896051) was a randomized, open-label, two-arm Phase II trial to investigate the pharmacokinetic interaction between etravirine and atazanavir/ritonavir and safety and efficacy in treatment-experienced, HIV-1-infected patients. Methods. After a two-week lead-in of two nucleoside reverse transcriptase inhibitors (NRTIs) and atazanavir/ritonavir 300/100 mg, 44 patients received etravirine 200 mg bid with one NRTI, plus atazanavir/ritonavir 300/100 mg or 400/100 mg qd (n = 22 each group) over 48 weeks. Results. At steady-state etravirine with atazanavir/ritonavir 300/100 mg qd or 400/100 mg qd decreased atazanavir C min by 18% and 9%, respectively, with no change in AUC24 h or C max versus atazanavir/ritonavir 300/100 mg qd alone (Day -1). Etravirine AUC12 h was 24% higher and 16% lower with atazanavir/ritonavir 300/100 or 400/100 mg qd, respectively, versus historical controls. At Week 48, no significant differences were seen between the atazanavir/ritonavir groups in discontinuations due to adverse events (9.1% each group) and other safety parameters, the proportion of patients with viral load <50 copies/mL (intent-to-treat population, noncompleter = failure) (50.0%, atazanavir/ritonavir 300/100 mg qd versus 45.5%, 400/100 mg qd), and virologic failures (31.8% versus 27.3%, resp.). Conclusions. Etravirine 200 mg bid can be combined with atazanavir/ritonavir 300/100 mg qd and an NRTI in HIV-1-infected, treatment-experienced patients without dose adjustment.
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Hull MW, Harris M, Lima V, Guillemi S, Harrigan PR, Montaner JSG. Lopinavir/Ritonavir Pharmacokinetics in a Substitution of High-Dose Soft-Gelatin Capsule to Tablet Formulation. J Clin Pharmacol 2013; 49:155-61. [DOI: 10.1177/0091270008329550] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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López Aspiroz E, Cabrera Figueroa SE, Domínguez-Gil Hurlé A, García Sánchez MJ. [New strategies in the optimisation of lopinavir/ritonavir doses in human immunodeficiency virus-infected patients]. Enferm Infecc Microbiol Clin 2012; 31:36-43. [PMID: 22280562 DOI: 10.1016/j.eimc.2011.11.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 11/21/2011] [Accepted: 11/28/2011] [Indexed: 01/11/2023]
Abstract
Lopinavir/ritonavir (LPV/r) has demonstrated virological and immunological efficacy in the combined antiretroviral treatment (cART), in both naïve and experienced patients. Furthermore, LPV/r showed a high barrier to the development of resistance. Although generally well tolerated, adverse gastrointestinal side effects and metabolic disorders are frequent. The different tools used to optimise the cART with this drug combination in the daily clinical practice, emphasising the therapeutic drug monitoring (TDM) of LPV/r and the genetic analysis of the main enzymes responsible for the metabolism and transport, are reviewed. The relationship between phenotype and genotype, established through TDM, could be useful for the physician to improve the clinical management of the HIV infection, due to the possibility of individualising the dose with this drug. Monotherapy is also reviewed as a new strategy used in the simplification of the treatment with this drug, which could increase safety and reduce costs.
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Affiliation(s)
- Elena López Aspiroz
- Servicio de Farmacia, Hospital Universitario de Salamanca, Salamanca, España
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Neither Branded Nor Generic Lopinavir/Ritonavir Produces Adequate Lopinavir Concentrations at a Reduced Dose of 200/50 mg Twice Daily. J Acquir Immune Defic Syndr 2012; 59:55-8. [DOI: 10.1097/qai.0b013e31823ba736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Albrecht M, Mukherjee AL, Tierney C, Morse GD, Dykes C, Klingman KL, Demeter LM. A randomized clinical trial evaluating therapeutic drug monitoring (TDM) for protease inhibitor-based regimens in antiretroviral-experienced HIV-infected individuals: week 48 results of the A5146 study. HIV CLINICAL TRIALS 2011; 12:201-14. [PMID: 22044856 DOI: 10.1310/hct1204-201] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND We devised an open-label, randomized trial to evaluate whether therapeutic drug monitoring (TDM) of protease inhibitors (PIs) and dose escalation based upon a normalized inhibitory quotient (NIQ), which integrates PI trough concentration and drug resistance, could improve virologic outcome in PI-experienced patients with treatment failure. Secondary analyses through 48 weeks are presented. METHODS Eligible HIV-infected subjects with a screening viral load of ≥ 1000 copies/mL initiated a new PI-based regimen at entry and had NIQ performed at week 2. Subjects with an NIQ ≤1 were randomized at week 4 to a standard-of-care (SOC) arm or TDM arm featuring PI dose escalation. RESULTS One hundred and eighty-three subjects were randomized. There was no significant treatment difference in change from randomization to week 48 in HIV-1 RNA [ P = .13, median (25th, 75th percentile log10 copies/mL change): -0.03 (-0.74, 0.62) with TDM and 0.11 (-2.3, 0.82) with SOC]. In subgroup analysis, patients with ≥ 0.69 active PIs benefited from TDM compared to those with <0.69 active PIs ( P = .05). CONCLUSIONS While the TDM strategy of PI dose escalation did not improve virologic response at week 48 overall, in subgroup analysis, TDM favorably impacted virologic outcome in subjects taking PI-based regimens with moderate antiviral activity.
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Affiliation(s)
- Mary Albrecht
- Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Cozzi-Lepri A, Prosperi MCF, Kjær J, Dunn D, Paredes R, Sabin CA, Lundgren JD, Phillips AN, Pillay D. Can linear regression modeling help clinicians in the interpretation of genotypic resistance data? An application to derive a lopinavir-score. PLoS One 2011; 6:e25665. [PMID: 22110581 PMCID: PMC3217925 DOI: 10.1371/journal.pone.0025665] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Accepted: 09/07/2011] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The question of whether a score for a specific antiretroviral (e.g. lopinavir/r in this analysis) that improves prediction of viral load response given by existing expert-based interpretation systems (IS) could be derived from analyzing the correlation between genotypic data and virological response using statistical methods remains largely unanswered. METHODS AND FINDINGS We used the data of the patients from the UK Collaborative HIV Cohort (UK CHIC) Study for whom genotypic data were stored in the UK HIV Drug Resistance Database (UK HDRD) to construct a training/validation dataset of treatment change episodes (TCE). We used the average square error (ASE) on a 10-fold cross-validation and on a test dataset (the EuroSIDA TCE database) to compare the performance of a newly derived lopinavir/r score with that of the 3 most widely used expert-based interpretation rules (ANRS, HIVDB and Rega). Our analysis identified mutations V82A, I54V, K20I and I62V, which were associated with reduced viral response and mutations I15V and V91S which determined lopinavir/r hypersensitivity. All models performed equally well (ASE on test ranging between 1.1 and 1.3, p = 0.34). CONCLUSIONS We fully explored the potential of linear regression to construct a simple predictive model for lopinavir/r-based TCE. Although, the performance of our proposed score was similar to that of already existing IS, previously unrecognized lopinavir/r-associated mutations were identified. The analysis illustrates an approach of validation of expert-based IS that could be used in the future for other antiretrovirals and in other settings outside HIV research.
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Affiliation(s)
- Alessandro Cozzi-Lepri
- Department of Infection and Population Health, Division of Population Health, UCL Medical School, Royal Free Campus, London, United Kingdom.
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Barrail-Tran A, Taburet AM, Poirier JM. [Evidence-based therapeutic drug monitoring of lopinavir]. Therapie 2011; 66:231-8. [PMID: 21819807 DOI: 10.2515/therapie/2011034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 03/22/2011] [Indexed: 11/20/2022]
Abstract
The HIV protease inhibitor lopinavir presents a wide inter-individual variability related to liver and intestinal metabolism involving CYP3A. Published studies were analyzed to establish whether there is evidence that therapeutic drug monitoring of lopinavir could improve patient care. In naïve or pretreated HIV-infected patients, no relationship could be evidenced between virological efficacy and trough lopinavir concentration, most likely because concentrations are above inhibitory concentrations. Although data are limited, patients with elevated triglycerides and cholesterol had trough lopinavir concentrations >8 000 ng/mL. These data suggest that the level of evidence of interest of lopinavir therapeutic drug monitoring is may be recommended in some situations such as children, pregnant women, pretreated patients if the number of mutations is <5, when coadministration with drug with metabolizing enzyme inducing properties is warranted and toxicity.
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Quality assessment for therapeutic drug monitoring in AIDS Clinical Trials Group (ACTG 5146): a multicenter clinical trial. Ther Drug Monit 2010; 32:458-66. [PMID: 20592644 DOI: 10.1097/ftd.0b013e3181e4427a] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In a randomized trial, AIDS Clinical Trials Group (ACTG) protocol 5146 (A5146) investigated the use of therapeutic drug monitoring (TDM) to adjust doses of HIV-1 protease inhibitors (PIs) in patients with prior virologic failure on PI-based therapy who were starting a new PI-based regimen. The overall percentage of "PI trough repeats" such as rescheduled visits or redrawn PI trough specimens increased from 2% to 5% to 10% as the process progressed from the clinical sites, the pharmacology specialty laboratory, and the study team, respectively. Cumulatively, this represents a 17% rate of failure to obtain adequate PI trough sample. While targeting a turnaround of 7 days or less from sample receipt to a drug concentration report, 12% of the received specimens required a longer period to report concentrations. The implementation of dosing changes in the TDM arm were achieved within 7 days or less for 56% of the dose change events and within 14 days or less for 77% of dose change events. This quality assurance analysis provides a valuable summary of the specific points in the TDM process that could be improved during a multicenter clinical trial including: 1) shortening the timeline of sample shipment from clinical site to the laboratory; 2) performing the collection of PI trough specimen within the targeted sampling window by careful monitoring of the last dose times and collection times by the clinicians; 3) increasing patient adherence counseling to reduce the number of samples that are redrawn due to suspecting inconsistent adherence; and 4) decreasing the time to successful TDM-based dose adjustment. The application of some of these findings may also be relevant to single-center studies or clinical TDM programs within a hospital.
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Gonzalez de Requena D, Bonora S, Vigano O, Calcagno A, Cometto C, D'Avolio A, Baietto L, Ghisetti V, Magnani S, Ferramosca S, Vitiello P, Galli M, Rusconi S, Di Perri G. Comparative evaluation of seven resistance interpretation algorithms and their derived genotypic inhibitory quotients for the prediction of 48 week virological response to darunavir-based salvage regimens. J Antimicrob Chemother 2010; 66:192-200. [DOI: 10.1093/jac/dkq384] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Dominguez S, Ghosn J, Peytavin G, Guiguet M, Tubiana R, Valantin MA, Murphy R, Bricaire F, Benhamou Y, Katlama C. Impact of hepatitis C and liver fibrosis on antiretroviral plasma drug concentrations in HIV-HCV co-infected patients: the HEPADOSE study. J Antimicrob Chemother 2010; 65:2445-9. [DOI: 10.1093/jac/dkq320] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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[AIDS Study Group/Spanish AIDS Plan consensus document on antiretroviral therapy in adults with human immunodeficiency virus infection (updated January 2010)]. Enferm Infecc Microbiol Clin 2010; 28:362.e1-91. [PMID: 20554079 DOI: 10.1016/j.eimc.2010.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 03/14/2010] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This consensus document is an update of antiretroviral therapy recommendations for adult patients with human immunodeficiency virus infection. METHODS To formulate these recommendations a panel made up of members of the Grupo de Estudio de Sida (Gesida, AIDS Study Group) and the Plan Nacional sobre el Sida (PNS, Spanish AIDS Plan) reviewed the advances in the current understanding of the pathophysiology of human immunodeficiency virus (HIV) infection, the efficacy and safety of clinical trials, and cohort and pharmacokinetic studies published in biomedical journals or presented at scientific meetings. Three levels of evidence were defined according to the data source: randomized studies (level A), cohort or case-control studies (level B), and expert opinion (level C). The decision to recommend, consider or not to recommend ART was established in each situation. RESULTS Currently, the treatment of choice for chronic HIV infection is the combination of three drugs of two different classes, including 2 nucleosides or nucleotide analogs (NRTI) plus 1 non-nucleoside (NNRTI) or 1 boosted protease inhibitor (PI/r), but other combinations are possible. Initiation of ART is recommended in patients with symptomatic HIV infection. In asymptomatic patients, initiation of ART is recommended on the basis of CD4 lymphocyte counts, plasma viral load and patient co-morbidities, as follows: 1) therapy should be started in patients with CD4 counts below 350 cells/microl; 2) When CD4 counts are between 350 and 500 cells/microl, therapy should be started in case of cirrhosis, chronic hepatitis C, high cardiovascular risk, HIV nephropathy, HIV viral load above 100,000 copies/ml, proportion of CD4 cells under 14%, and in people aged over 55; 3) Therapy should be deferred when CD4 are above 500 cells/microl, but could be considered if any of previous considerations concurs. Treatment should be initiated in case of hepatitis B requiring treatment and should be considered for reduce sexual transmission. The objective of ART is to achieve an undetectable viral load. Adherence to therapy plays an essential role in maintaining antiviral response. Therapeutic options are limited after ART failures but undetectable viral loads maybe possible with the new drugs even in highly drug experienced patients. Genotype studies are useful in these situations. Drug toxicity of ART therapy is losing importance as benefits exceed adverse effects. Criteria for antiretroviral treatment in acute infection, pregnancy and post-exposure prophylaxis are mentioned as well as the management of HIV co-infection with hepatitis B or C. CONCLUSIONS CD4 cells counts, viral load and patient co-morbidities are the most important reference factors to consider when initiating ART in asymptomatic patients. The large number of available drugs, the increased sensitivity of tests to monitor viral load, and the ability to determine viral resistance is leading to a more individualized therapy approach in order to achieve undetectable viral load under any circumstances.
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Abstract
PURPOSE OF REVIEW This review discusses the use of the inhibitory quotient in light of therapeutic drug monitoring of antiretroviral drugs. The inhibitory quotient is a parameter that combines viral resistance data with drug exposure data, and has its main role in therapeutic drug monitoring of protease inhibitors in experienced patients. Data from recent clinical studies investigating inhibitory quotient cutoffs to be used in therapeutic drug monitoring will be reviewed. In addition points for discussion regarding the use and study of inhibitory quotients will be presented. RECENT FINDINGS A number of studies generated data on the use of the inhibitory quotient in general and the genotypic inhibitory quotient in particular. Most of these studies define a cutoff inhibitory quotient value, above which the virological response rate is higher. These cutoff values can be used in therapeutic drug monitoring and give guidance to the clinician on dose adjustments. Genotypic inhibitory quotient cutoff values are available for amprenavir, atazanavir, darunavir, lopinavir, saquinavir and tipranavir. SUMMARY The inhibitory quotient is becoming a valuable tool in therapeutic drug monitoring. At this moment most data are available for the genotypic inhibitory quotient. Nevertheless, a consensus needs to be reached on a number of items, including the methods to study inhibitory quotient as well as the mathematical and virological background.
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Bouillon-Pichault M, Jullien V, Azria E, Pannier E, Firtion G, Krivine A, Compagnucci A, Taulera O, Finkielsztejn L, Chhun S, Pons G, Launay O, Treluyer JM. Population analysis of the pregnancy-related modifications in lopinavir pharmacokinetics and their possible consequences for dose adjustment. J Antimicrob Chemother 2009; 63:1223-32. [PMID: 19389715 DOI: 10.1093/jac/dkp123] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To investigate the possible necessity of an increase in lopinavir dose during pregnancy in order to achieve the concentrations previously defined as predictive of virological efficacy. PATIENTS AND METHODS Lopinavir pharmacokinetics were investigated by a population approach performed on 145 HIV-infected women, including 74 pregnant women. The final model was used to determine the probability of achievement of the target trough concentrations by Monte Carlo simulations. RESULTS The typical population estimates (inter-individual variability %) of apparent clearance (CL/F) and volume of distribution were 4.38 L/h (24%) and 58.4 L (59%), respectively. Pregnancy associated with a gestational age >15 weeks and delivery were found to increase lopinavir CL/F by 39% and 58%, respectively. With the standard 400 mg twice-a-day regimen, the probability of reaching the 1 mg/L target trough concentration for protease inhibitor (PI)-naive patients was 99% and 96% for non-pregnant and pregnant women, respectively. An important decrease in the probability of achieving the 5.7 mg/L target trough concentration for salvage therapy was observed for non-pregnant women (55%), this decrease being even greater for pregnant women (21%). Raising the lopinavir dose to 600 mg twice daily increased these probabilities to 87% and 53% for non-pregnant and pregnant women, respectively. CONCLUSIONS Modification of the lopinavir dose is unlikely to be required for PI-naive pregnant women; however, in pregnant women who have previously received a PI, therapeutic drug monitoring and/or empirical increasing of the dose should be considered.
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A randomized trial of therapeutic drug monitoring of protease inhibitors in antiretroviral-experienced, HIV-1-infected patients. AIDS 2009; 23:357-68. [PMID: 19114860 DOI: 10.1097/qad.0b013e32831f9148] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Whether therapeutic drug monitoring of protease inhibitors improves outcomes in HIV-infected patients is controversial. We evaluated this strategy in a randomized, open-label clinical trial, using a normalized inhibitory quotient (NIQ), which incorporates drug exposure and viral drug resistance. NIQs < or = 1 may predict poor outcome and identify patients who could benefit from dose escalation. DESIGN/METHODS Eligible patients had a viral load > or =1000 copies/ml on a failing regimen, and began a new protease inhibitor containing regimen at entry. All FDA-approved protease inhibitors available during the study recruitment (June 2002-May 2006) were allowed. One hundred and eighty-three participants with NIQ < or = 1, on the basis of their week 2 protease inhibitor trough concentration and pre-entry drug resistance test, were randomized at week 4 to standard of care (SOC) or protease inhibitor dose escalation (TDM). The primary endpoint was change in log10 plasma HIV-1 RNA concentration from randomization to 20 weeks later. RESULTS Ninety-one patients were randomized to SOC and 92 to TDM. NIQs increased more in the TDM arm compared to SOC (+69 versus +25%, P = 0.01). Despite this, TDM and SOC arms showed no difference in outcome (+0.09 versus +0.02 log10, P = 0.17). In retrospective subgroup analyses, patients with less HIV resistance to their protease inhibitors benefited from TDM (P = 0.002), as did black and Hispanic patients (P = 0.035 and 0.05, respectively). Differences between black and white patients persisted when accounting for protease inhibitor susceptibility. CONCLUSIONS There was no overall benefit of TDM. In post hoc subgroup analyses, TDM appeared beneficial in black and Hispanic patients, and in patients whose virus retained some susceptibility to the protease inhibitors in their regimen.
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Moltó J, Barbanoj MJ, Miranda C, Blanco A, Santos JR, Negredo E, Costa J, Domingo P, Clotet B, Valle M. Simultaneous population pharmacokinetic model for lopinavir and ritonavir in HIV-infected adults. Clin Pharmacokinet 2009; 47:681-92. [PMID: 18783298 DOI: 10.2165/00003088-200847100-00005] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Lopinavir is a protease inhibitor indicated for the treatment of HIV infection. It is coformulated with low doses of ritonavir in order to enhance its pharmacokinetic profile. After oral administration, plasma concentrations of lopinavir can vary widely between different HIV-infected patients. OBJECTIVE To develop and validate a population pharmacokinetic model for lopinavir and ritonavir administered simultaneously in a population of HIV-infected adults. The model sought was to incorporate patient characteristics influencing variability in the drug concentration and the interaction between the two compounds. METHODS HIV-infected adults on stable therapy with oral lopinavir/ritonavir in routine clinical practice for at least 4 weeks were included. A concentration-time profile was obtained for each patient, and blood samples were collected immediately before and 1, 2, 4, 6, 8, 10 and 12 hours after a morning lopinavir/ritonavir dose. Lopinavir and ritonavir concentrations in plasma were determined by high-performance liquid chromatography. First, a population pharmacokinetic model was developed for lopinavir and for ritonavir separately. The pharmacokinetic parameters, interindividual variability and residual error were estimated, and the influence of different patient characteristics on the pharmacokinetics of lopinavir and ritonavir was explored. Then, a simultaneous model estimating the pharmacokinetics of both drugs together and incorporating the influence of ritonavir exposure on oral clearance (CL/F) of lopinavir was developed. Population analysis was performed using nonlinear mixed-effects modelling (NONMEM version V software). The bias and precision of the final model were assessed through Monte Carlo simulations and data-splitting techniques. RESULTS A total of 53 and 25 Caucasian patients were included in two datasets for model building and model validation, respectively. Lopinavir and ritonavir pharmacokinetics were described by one-compartment models with first-order absorption and elimination. The presence of advanced liver fibrosis decreased CL/F of ritonavir by nearly half. The volume of distribution after oral administration (Vd/F) and CL/F of lopinavir were reduced as alpha1-acid glycoprotein (AAG) concentrations increased. CL/F of lopinavir was inhibited by ritonavir concentrations following a maximum-effect model (maximum inhibition [Imax] = 1, concentration producing 50% of the I(max) [IC50] = 0.36 mg/L). The final model appropriately predicted plasma concentrations in the model-validation dataset with no systematic bias and adequate precision. CONCLUSION A population model to simultaneously describe the pharmacokinetics of lopinavir and ritonavir was developed and validated in HIV-infected patients. Bayesian estimates of the individual parameters of ritonavir and lopinavir could be useful to predict lopinavir exposure based on the presence of advanced liver fibrosis and the AAG concentration in an individual manner, with the aim of maximizing the chances of treatment success.
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Affiliation(s)
- José Moltó
- "Lluita contra la SIDA" Foundation, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.
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Bouillon-Pichault M, Jullien V, Piketty C, Viard JP, Morini JP, Chhun S, Krivine A, Salmon D, Dupin N, Weiss L, Lortholary O, Pons G, Launay O, Treluyer JM. A population analysis of weight-related differences in lopinavir pharmacokinetics and possible consequences for protease inhibitor-naive and -experienced patients. Antivir Ther 2009; 14:923-9. [DOI: 10.3851/imp1414] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
This review provides an overview of the development of viral protease inhibitors as antiviral drugs. We concentrate on HIV-1 protease inhibitors, as these have made the most significant advances in the recent past. Thus, we discuss the biochemistry of HIV-1 protease, inhibitor development, clinical use of inhibitors, and evolution of resistance. Since many different viruses encode essential proteases, it is possible to envision the development of a potent protease inhibitor for other viruses if the processing site sequence and the catalytic mechanism are known. At this time, interest in developing inhibitors is limited to viruses that cause chronic disease, viruses that have the potential to cause large-scale epidemics, or viruses that are sufficiently ubiquitous that treating an acute infection would be beneficial even if the infection was ultimately self-limiting. Protease inhibitor development is most advanced for hepatitis C virus (HCV), and we also provide a review of HCV NS3/4A serine protease inhibitor development, including combination therapy and resistance. Finally, we discuss other viral proteases as potential drug targets, including those from Dengue virus, cytomegalovirus, rhinovirus, and coronavirus.
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Affiliation(s)
- Hans-Georg Kräusslich
- Hygiene Institute Department of Virology, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 324, Heidelberg, 69120 Germany
| | - Ralf Bartenschlager
- Hygiene Institute Department of Virology, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 324, Heidelberg, 69120 Germany
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Roustit M, Jlaiel M, Leclercq P, Stanke-Labesque F. Pharmacokinetics and therapeutic drug monitoring of antiretrovirals in pregnant women. Br J Clin Pharmacol 2008; 66:179-95. [PMID: 18537960 PMCID: PMC2492933 DOI: 10.1111/j.1365-2125.2008.03220.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Accepted: 05/06/2008] [Indexed: 01/07/2023] Open
Abstract
Highly active antiretroviral therapy is recommended for HIV-infected pregnant women to prevent mother-to-child transmission. The specific physiological background induced by pregnancy leads to significant changes in maternal pharmacokinetics, suggesting potential variability in plasma concentrations of antiretrovirals during gestation. Therapeutic drug monitoring (TDM) of protease inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs) is recommended in certain situations, including pregnancy, but its systematic use in HIV-infected pregnant women remains controversial. This review provides an update of the pharmacokinetic data available for PIs and NNRTIs in pregnant women and highlights the clinical interest of systematic TDM of certain antiretroviral drugs during pregnancy, including nevirapine, nelfinavir, saquinavir, indinavir and lopinavir.
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Affiliation(s)
- Matthieu Roustit
- CHU de Grenoble, Laboratoire de PharmacologieBP217, Grenoble, France
- INSERM ERI 17, Laboratoire HP2BP217, Grenoble, France
| | - Malik Jlaiel
- CHU de Grenoble, Laboratoire de PharmacologieBP217, Grenoble, France
| | - Pascale Leclercq
- CHU de Grenoble, Clinique Infectiologie–CISIHBP217, Grenoble, France
| | - Françoise Stanke-Labesque
- CHU de Grenoble, Laboratoire de PharmacologieBP217, Grenoble, France
- INSERM ERI 17, Laboratoire HP2BP217, Grenoble, France
- Université Joseph Fourier, Faculté de Médecine IFR1BP217, Grenoble, France
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Demeter LM, Mukherjee AL, DiFrancesco R, Jiang H, DiCenzo R, Bastow B, Rinehart AR, Morse GD, Albrecht M. The design and implementation of A5146, a prospective trial assessing the utility of therapeutic drug monitoring using an inhibitory quotient in antiretroviral-experienced HIV-infected patients. HIV CLINICAL TRIALS 2008; 9:61-72. [PMID: 18215983 DOI: 10.1310/hct0901-61] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The AIDS Clinical Trials Group designed and implemented a prospective, randomized, strategy trial in antiretroviral-experienced, HIV-infected patients to evaluate the virologic impact of protease inhibitor dose escalation in response to therapeutic drug monitoring (TDM) with an inhibitory quotient, which integrates both drug exposure and viral drug resistance. In the process of developing this clinical trial, several unique challenges were identified that required innovative solutions. The major challenge was the need to integrate resistance testing, pharmacokinetic data, medication adherence, toxicity data, clinical assessments, randomization assignment, and protocol-specified clinical management in a way that could be utilized in real time by the protocol team, communicated promptly to the clinical sites, and transmitted accurately to the study database. In addition, the protocol team had to address the relative lack of commercially available TDM laboratories in the United States that were experienced in antiretroviral drug assays and a lack of familiarity with the principles of pharmacokinetic monitoring at participating clinical sites. This article outlines the rationale for the design of this strategy trial, specific barriers to implementation that were identified, and solutions that were developed with the hope that these experiences will facilitate the design and conduct of future trials of TDM.
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Affiliation(s)
- Lisa M Demeter
- Infectious Diseases Division, University of Rochester School of Medicine and Dentistry, Rochester, New York 14642, USA.
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Predictive values of the human immunodeficiency virus phenotype and genotype and of amprenavir and lopinavir inhibitory quotients in heavily pretreated patients on a ritonavir-boosted dual-protease-inhibitor regimen. Antimicrob Agents Chemother 2008; 52:1642-6. [PMID: 18285478 DOI: 10.1128/aac.01314-07] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The inhibitory quotient (IQ) of human immunodeficiency virus (HIV) protease inhibitors (PIs), which is the ratio of drug concentration to viral susceptibility, is considered to be predictive of the virological response. We used several approaches to calculate the IQs of amprenavir and lopinavir in a subset of heavily pretreated patients participating in the French National Agency for AIDS Research (ANRS) 104 trial and then compared their potentials for predicting changes in the plasma HIV RNA level. Thirty-seven patients were randomly assigned to receive either amprenavir (600 mg twice a day [BID]) or lopinavir (400 mg BID) plus ritonavir (100 or 200 mg BID) for 2 weeks before combining the two PIs. The 90% inhibitory concentration (IC(90)) was measured using a recombinant assay without or with additional human serum (IC(90+serum)). Total and unbound PI concentrations in plasma were measured. Univariate linear regression was used to estimate the relation between the change in viral load and the IC(90) or IQ values. The amprenavir phenotypic IQ values were very similar when measured with the standard and protein binding-adjusted IC(90)s. No relationship was found between the viral load decline and the lopinavir IQ. During combination therapy, the amprenavir and lopinavir genotypic IQ values were predictive of the viral response at week 6 (P = 0.03). The number of protease mutations (< 5 or > or = 5) was related to the virological response throughout the study. These findings suggest that the combined genotypic IQ and the number of protease mutations are the best predictors of virological response. High amprenavir and lopinavir concentrations in these patients might explain why plasma concentrations and the phenotypic IQ have poor predictive value.
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Pellegrin I, Wittkop L, Joubert LM, Neau D, Bollens D, Bonarek M, Girard PM, Fleury H, Winters B, Saux MC, Pellegrin JL, Thiébaut R, Breilh D. Virological Response to Darunavir/Ritonavir-Based Regimens in Antiretroviral-Experienced Patients (PREDIZISTA Study). Antivir Ther 2008. [DOI: 10.1177/135965350801300214] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background We assessed the association of baseline HIV-1 mutations, phenotypic sensitivity and pharmacokinetics with virological failure (VF) at week 12 (W12) after onset of a darunavir/ritonavir (DRV/r)-based regimen in a cohort of 67 antiretroviral-experienced HIV-patients failing on highly active antiretroviral therapy (HAART). Methods VF was defined as HIV RNA >2.3 log10copies/ml at W12. HIV reverse transcriptase and protease sequencing was performed at W0; mutations with a P-value <0.25 in univariable analyses were used for a backward selection to find the best mutation set for VF prediction. Genotypic and phenotypic sensitivity scores were calculated and virtual phenotype predicted fold change (FC) assessed. DRV Cmin, Cmax, AUC0→12 h and genotypic inhibitory quotient (GIQ) were determined. Results Patients had a median of 15 previous treatments for 10 years. Median W0 values included a T-cell count of 129 cells/μl, 4.7 log10 HIV RNA copies/ml, four major protease and six nucleoside reverse transcriptase inhibitor resistance mutations. At W12, median HIV RNA decrease was -2.1 log10 copies/ml with a gain of +67 CD4+ T-cells/μl; 40% of patients failed. We determined the genotypic score I13V+V32I+L33F/I/V+E35D+ M36I/L/V+I47V+F53L+I62V According to <4, 4–5 and >5 mutations, failure occurred in 11%, 48% and 100% of patients. Failure was associated with CDC stage, baseline CD4+ T-cell count, number of major protease inhibitor resistance mutations, FC and DRV/r score. Pharmacokinetics were not associated with failure, but GIQ was. Conclusion At W12, 60% of heavily pretreated patients responded on DRV/r-based HAART. Genotypic and phenotypic information constituted the main virological response determinant in patients with optimal drug concentrations.
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Affiliation(s)
| | | | - Linda Wittkop
- INSERM U875 (Biostatistics) and U593, Bordeaux, France
| | | | - Didier Neau
- Internal Medicine and Infectious Diseases Departments, Bordeaux University Hospital, Bordeaux, France
| | - Diane Bollens
- Department of Virology, Hopital Saint-Antoine, Paris, France
| | - Mojgan Bonarek
- Internal Medicine and Infectious Diseases Departments, Bordeaux University Hospital, Bordeaux, France
| | | | - Hervé Fleury
- Department of Virology, Bordeaux University Hospital, Bordeaux, France
| | | | - Marie-Claude Saux
- Clinical Pharmacokinetics and Pharmacy Department, Bordeaux University Hospital, Bordeaux, France
| | - Jean-Luc Pellegrin
- Internal Medicine and Infectious Diseases Departments, Bordeaux University Hospital, Bordeaux, France
| | | | - Dominique Breilh
- Clinical Pharmacokinetics and Pharmacy Department, Bordeaux University Hospital, Bordeaux, France
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Tipranavir (TPV) genotypic inhibitory quotient predicts virological response at 48 weeks to TPV-based salvage regimens. Antimicrob Agents Chemother 2007; 52:1066-71. [PMID: 18160524 DOI: 10.1128/aac.01063-07] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The virological response (VR) to a tipranavir-ritonavir (TPV-RTV)-based regimen had been shown to be associated with a number of mutations in the protease gene, the use of enfuvirtide (T20), and the TPV phenotypic inhibitory quotient (IQ). The role of the TPV genotypic IQ (gIQ) has not yet been fully investigated. The aim of our study was to evaluate the relationship between the TPV gIQ and the VR at 48 weeks to TPV-based salvage regimens. Patients placed on regimens containing two nucleoside reverse transcriptase inhibitors plus TPV-RTV 500/200 mg twice a day with or without T20 were prospectively studied. Regular follow-up was performed over the study period. VR, considered a viral load (VL) decrease of >or=1 log unit and/or the achievement of <50 copies/ml with no VL rebound of >0.5 log unit compared to the maximal VL decrease at week 48, was assessed. Thirty-eight patients who had received multiple drugs were included. At week 48 the VL decrease was -1.48 (interquartile range [IQR], -2.88 to -0.48), 15 patients (39.5%) had VLs of <50 copies/ml, and the CD4+ cell count increase was 37 cells/mm3 (IQR, -30 to +175). Twenty subjects (52.6%) achieved VRs. The TPV gIQ and optimized background score (OBS) were independently associated with higher VL decreases. The TPV gIQ and OBS were also independent predictors of a VR at week 48. TPV gIQ and OBS cutoff values of 14,500 and 2, respectively, were associated with a higher rate of VR. The TPV gIQ was shown to be able to predict the VR at 48 weeks to TPV-containing salvage regimens better than the TPV trough concentration or TPV-associated mutations alone. A possible TPV gIQ cutoff value of 14,500 for reaching a VR at week 48 was suggested. Further studies are needed in order to evaluate the calculation of TPV gIQ as a new tool for the optimization of TPV-based salvage therapy.
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Pellegrin I, Breilh D, Coureau G, Boucher S, Neau D, Merel P, Lacoste D, Fleury H, Saux MC, Pellegrin JL, Lazaro E, Dabis F, Thiébaut R. Interpretation of genotype and pharmacokinetics for resistance to fosamprenavir-ritonavir-based regimens in antiretroviral-experienced patients. Antimicrob Agents Chemother 2007; 51:1473-80. [PMID: 17296739 PMCID: PMC1855517 DOI: 10.1128/aac.00481-06] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In this study, named the Zephir study (Telzir-pharmacokinetics), 121 antiretroviral-experienced human immunodeficiency virus (HIV) patients failing on highly active antiretroviral therapy (HAART) were included in a prospective cohort and received a fosamprenavir-ritonavir (700 mg/100 mg twice a day)-based regimen. The impact of baseline HIV type 1 (HIV-1) mutations, pharmacokinetic (PK) parameters, and genotype inhibitory quotient (GIQ) on the virological response at week 12 (W12) was assessed. HIV reverse transcriptase and protease were sequenced at W0. The response at W12 was defined as<2.3 log10 HIV-1 RNA copies/ml or a virus load decrease of>or=1 log10 copies/ml. W4 amprenavir PK were determined by high-performance liquid chromatography. Patients had a median of nine previous treatments over 8 years. Median W0 values were as follows: 295 CD4+/microl, 4.4 log10 HIV-1 RNA copies/ml, and 6 protease- and 5 nucleotide reverse transcription inhibitor-related mutations. Respective values for minimum concentration of drug in serum (Cmin) and area under the concentration-time curve (AUC) from 0 to 24 h were 1,400 ng/ml and 35 mg.h/ml. At W12, 52% of the patients were successes, with a median decrease of -0.7 log10 HIV-1 RNA copies/ml. The Zephir mutation score included 12 IAS protease mutations associated with poorer virological response: L10I/F/R/V, L33F, M36I, M46I/L, I54L/M/T/V, I62V, L63P, A71I/L/V/T, G73A/C/F/T, V82A/F/S/T, I84V, L90M, and polymorphism mutations I13V, L19I, K55R, and L89M. Comparing<4 versus>or=4 mutations, HIV-1 RNA decreases were -2.3 log10 copies/ml versus -0.1 log10 copies/ml (P<10(-4)) with 93% versus 19% successes (P<10(-4)), respectively. This score predicted W12 failure with 94% sensitivity, versus 31% for the ANRS 2005 algorithm. Cmin (<1,600 ng/ml), AUC (<40 mg.h/ml), and GIQ (<300) values were associated with failure (all P values were <10(-4)). The need to test genotype-based algorithms using different patient databases before their implementation in clinical practice is highlighted. Specific mutations, PK and GIQ, provide relevant information for monitoring fosamprenavir-ritonavir-based HAART.
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Affiliation(s)
- Isabelle Pellegrin
- Department of Virology, INSERM U593, Bordeaux University Hospital, France.
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Maillard A, Chapplain JM, Tribut O, Bentué-Ferrer D, Tattevin P, Arvieux C, Michelet C, Ruffault A. The use of drug resistance algorithms and genotypic inhibitory quotient in prediction of lopinavir–ritonavir treatment response in human immunodeficiency virus type 1 protease inhibitor-experienced patients. J Clin Virol 2007; 38:131-8. [PMID: 17208042 DOI: 10.1016/j.jcv.2006.11.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2005] [Revised: 08/16/2006] [Accepted: 11/23/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND Different approaches using genotypic, pharmacokinetic parameters or combination of both have been recently developed to monitor antiretroviral treatment in HIV-1-infected individuals. Their uses in clinical practice may improve the benefit of protease inhibitor-based salvage therapy while reducing treatment toxicity and emergence of viral resistance. OBJECTIVES To assess the prediction of genotypic inhibitory quotient (GIQ) using different genotypic drug resistance interpretation's algorithms and lopinavir plasma concentration in PI-experienced patients treated by lopinavir/ritonavir (LPV/r). Genotypic susceptibility score (GSS) was also evaluated. STUDY DESIGN Forty-seven HIV-1 PI-experienced, but LPV naïve patients were included in a retrospective cohort study. Plasma HIV-1 viral load (VL), CD4 cell count and LPV plasma concentrations were assessed at weeks (W) 12 and 24. Interpretation of baseline resistance genotype was achieved according to four different algorithms and GSS calculated using two expert systems. GIQ was defined as the ratio of LPV concentration to the number of LPV resistance mutations at day 0 (D0) and patients classified by units of GIQ. The end point of the study was the virological response expressed in HIV VL median decrease from D0 to W24. RESULTS The overall median VL decrease from D0 to W24 was -2.42 log(10)copies/mL and 60% of patients had VL below 400 copies/mL. The LPV mutation score was predictive of response for all algorithms whereas plasma concentrations of LPV were not. Mean VL decrease was greater for higher GIQ classes and difference reached statistical significance at W24. When considering virological response at W24, GSS calculated with ANRS and Stanford system were good predictor scores as areas under the receiver operating characteristics (ROC) curves were 0.76 for both. CONCLUSION GIQ was found to be a useful drug-monitoring tool which could be helpful in targeting LPV concentrations in order to achieve long-term undetectable viral load, particularly in genotypic resistant patients.
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Affiliation(s)
- Anne Maillard
- Laboratoire de Virologie, Hôpital Pontchaillou, 2 rue Henri Le Guilloux, 35 033 Rennes, France.
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van der Leur MR, Burger DM, la Porte CJL, Koopmans PP. A retrospective TDM database analysis of interpatient variability in the pharmacokinetics of lopinavir in HIV-infected adults. Ther Drug Monit 2007; 28:650-3. [PMID: 17038880 DOI: 10.1097/01.ftd.0000245681.12092.d6] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Lopinavir is one of the most-widely used protease inhibitors in the treatment of HIV-1 infected patients. Concentration-effect relationships have been described for both antiviral activity and toxicity. Less is known about patient characteristics that may determine interpatient variability in lopinavir plasma concentrations. A database was created containing all Therapeutic Drug Monitoring (TDM) results collected at our Department. Patients were included if they were using lopinavir twice daily for at least two weeks; subjects who were known to be nonadherent (based on either a lopinavir concentration <0.2 mg/L or suspected by the physician) were excluded. Demographic data were collected from TDM application forms and patient charts. Patients attending one of the 22 HIV treatment centers in The Netherlands. The Department of Clinical Pharmacy is a national referral center for TDM of antiretroviral agents. Lopinavir concentration ratios (CRs) were calculated for each patient by dividing the individual plasma concentration by the time-adjusted population value. Relationships with lopinavir CRs were tested using regression analysis and analysis of variance. A total of 802 patients were included (607 males; 150 females; 45 unknown). The age and body weight of the patients ranged from 18 to 74 years (mean 42) and 42 to 121 kg (mean 72), respectively. Race was known for 756 persons: Caucasian 76%, African 18% and Asian 6%. The median (+ interquartile range, IQR) lopinavir CR was 0.98 (IQR: 0.67-1.31). Body weight showed an inverse relationship with lopinavir CR (F = 23.1; P < 0.001). Age was not related with lopinavir CR (P = 0.99). Female patients had a significantly higher lopinavir CR than males: 1.18 vs. 1.03 (P = 0.005); race was not associated with differences in lopinavir CR. In a multivariate regression analysis body weight, but not gender, remained significantly related to lopinavir CR. Body weight is the only demographic factor that could be related to lopinavir exposure; clinicians should be alert for an increased risk of suboptimal antiviral efficacy in patients with high body weight, and for an increased risk of toxicity in patients with a low body weight.
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Affiliation(s)
- Martijn R van der Leur
- Department of Clinical Pharmacy, Radboud University Medical Center Nijmegen, the Netherlands
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Temesgen Z, Cainelli F, Poeschla EM, Vlahakis SAR, Vento S. Approach to salvage antiretroviral therapy in heavily antiretroviral-experienced HIV-positive adults. THE LANCET. INFECTIOUS DISEASES 2006; 6:496-507. [PMID: 16870528 DOI: 10.1016/s1473-3099(06)70550-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Despite dramatic declines in HIV-associated morbidity and mortality as a result of highly active antiretroviral therapy, management of heavily treatment-experienced patients remains complex and challenging. Treatment response rates with subsequent antiretroviral regimens are lower than with initial antiretroviral therapy. Additionally, increased mortality has been associated with multidrug-resistant HIV. We review data relevant to management of such patients and offer a systematic approach to constructing a salvage antiretroviral regimen.
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Affiliation(s)
- Zelalem Temesgen
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Abstract
There is an increasing uptake of TDM of antiretroviral drugs, particularly in Europe. There is consensus that current antiretroviral drugs meet most of the criteria of drugs that can be considered as candidates for a TDM strategy. This review examines the pharmacokinetic-pharmacodynamic relationship for protease inibitors and non nucleoside reverse transcriptase inhibitor, give an overview of the published randomised clinical trials and then summarises the scenarios for use of TDM. Finally the development of the inhibitory quotient (IQ) concept is discussed.
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Affiliation(s)
- David Back
- Pharmacology Research Laboratories, University of Liverpool, 70 Pembroke Street, Liverpool, USA.
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de Mendoza C, Valer L, Bacheler L, Pattery T, Corral A, Soriano V. Prevalence of the HIV-1 protease mutation I47A in clinical practice and association with lopinavir resistance. AIDS 2006; 20:1071-4. [PMID: 16603864 DOI: 10.1097/01.aids.0000222084.44411.cc] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Mutation proI47A has recently been associated with lopinavir/ritonavir (LPV/r) resistance. Only four out of 1859 specimens (0.2%) sent for drug resistance testing (219 drug-naive and 1650 antiretroviral-experienced) showed I47A. All belonged to patients failing LPV/r. The prevalence among protease inhibitor-experienced patients was 0.6%. Phenotypic testing showed that proI47A caused high-level lopinavir resistance (> 100-fold) and cross-resistance to amprenavir, whereas it caused hypersusceptibility to saquinavir. ProI47A should thus be considered the primary lopinavir resistance mutation.
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Hoefnagel JGM, van der Lee MJ, Koopmans PP, Schuurman R, Jurriaans S, van Sighem AI, Gras L, de Wolf F, Galama JMD, Burger DM. The genotypic inhibitory quotient and the (cumulative) number of mutations predict the response to lopinavir therapy. AIDS 2006; 20:1069-71. [PMID: 16603863 DOI: 10.1097/01.aids.0000222083.44411.02] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
For 95 protease inhibitor-experienced HIV-1-infected patients, the genotypic inhibitory quotient (GIQ; trough level/number of mutations) was calculated for lopinavir. Three different sets of mutations showed equal predictive value. However, the use of cumulative numbers of mutations for calculation of the GIQ showed significantly better association with the virological response. Furthermore, the predictive value of the GIQ was no different from that of the number of mutations alone.
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Affiliation(s)
- Jolanda G M Hoefnagel
- Department of Medical Microbiology, Nijmegen University Centre for Infectious Diseases, the Netherlands
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35
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Winston A, Patel N, Back D, Khoo S, Bulbeck S, Mandalia S, Pozniak AL, Nelson M, Moyle G, Gazzard B, Boffito M. Different Methods to Calculate the Inhibitory Qoutient of Boosted Single Protease Inhibitors and Their Association With Virological Response. J Acquir Immune Defic Syndr 2006; 41:675-6. [PMID: 16652044 DOI: 10.1097/01.qui.0000209910.27997.d9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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36
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Luca AD, Giambenedetto SD, Cingolani A, Bacarelli A, Ammassari A, Cauda R. Three-Year Clinical Outcomes of Resistance Genotyping and Expert Advice: Extended follow-up of the Argenta Trial. Antivir Ther 2006. [DOI: 10.1177/135965350601100312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To investigate the influence of genotypic resistance-guided HIV-treatment decisions on long-term clinical and virological outcomes in patients failing anti-retroviral therapy by a prospective 30-month observation following a 6-month randomized study (Argenta trial). Methods Patients ( n=174) with virological failure on highly active antiretroviral therapy (HAART) were initially randomized (1:1) to receive empirical therapy or guidance by genotypic resistance results. After month 6, all patients with HIV RNA >1,000 copies/ml received genotypic resistance tests and expert advice. Predictors of virological and clinical outcomes were analysed by logistic regression and Cox's regression models. Results There was a gradual increase in the proportion of patients with HIV RNA <400 copies/ml with 29.3% at 36 months (intent-to-treat) without differences between initial randomization arms. Independent predictors of 36-month virological response were the use of a salvage therapy with less daily doses and a more pronounced 3-month viral load drop. At 36 months, 84% survived without new AIDS events/death. Independent predictors of new AIDS events/death were previous AIDS events, higher baseline viral load, less pronounced 3-month viral load drop and, in a separate model, baseline protease substitutions K20M/R and I84V Conclusions The virological benefit of genotype-guided treatment decisions was continuously appreciable over time. Short-term virological response and viral cross-resistance were independent predictors of long-term outcomes.
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Affiliation(s)
- Andrea De Luca
- Istituto di Clinica delle Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simona Di Giambenedetto
- Istituto di Clinica delle Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonella Cingolani
- Istituto di Clinica delle Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandra Bacarelli
- Istituto di Clinica delle Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Adriana Ammassari
- Istituto di Clinica delle Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Roberto Cauda
- Istituto di Clinica delle Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy
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37
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Wateba MI, Billaud E, Dailly E, Jolliet P, Raffi F. Low initial trough plasma concentrations of lopinavir are associated with an impairment of virological response in an unselected cohort of HIV-1-infected patients. HIV Med 2006; 7:197-9. [PMID: 16494635 DOI: 10.1111/j.1468-1293.2006.00354.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The relationship between lopinavir trough plasma concentration at baseline and virological efficacy 3 months after the beginning of the therapy was investigated in an unselected cohort of HIV-1-infected patients METHODS According to initial trough lopinavir plasma level, patients were classified into three groups: the subtherapeutic group (<3 mg/L, n=18), the therapeutic group (between 3 and 8 mg/L, n=50) and the toxic group (>8 mg/L, n=16). The virological response after 3 months of lopinavir treatment, defined as a viral load <200 HIV-1 RNA copies/mL, was compared amongst these groups. RESULTS The virological response was significantly different (P<0.05) between the subtherapeutic group (22.% of patients with viral load<200 copies/mL) and the other groups (56.0% of patients with a viral load<200 copies/mL in the therapeutic group and 56.2% in the toxic group). CONCLUSIONS A lower virological efficacy should be expected for experienced or naive patients with plasma trough lopinavir concentrations<3 mg/L at the beginning of treatment.
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Affiliation(s)
- M I Wateba
- Department of Infectious Diseases, Hôtel Dieu, Nantes, France
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38
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Morse GD, Catanzaro LM, Acosta EP. Clinical pharmacodynamics of HIV-1 protease inhibitors: use of inhibitory quotients to optimise pharmacotherapy. THE LANCET. INFECTIOUS DISEASES 2006; 6:215-25. [PMID: 16554246 DOI: 10.1016/s1473-3099(06)70436-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The introduction of HIV-1 protease inhibitors and non-nucleoside reverse transcriptase inhibitors in 1996 began an era described as that of highly active antiretroviral therapy. In addition, the more recent development and availability of HIV-1 genotypic and phenotypic resistance tests and advances in pharmacological assays that support therapeutic drug monitoring (TDM) have created tools that may help clinicians to provide more individualised treatment with HIV-1 protease inhibitors. All current treatment guidelines provide fixed doses of protease inhibitors with vague recommendations for the use of TDM in selected clinical situations. In patients with resistance to protease inhibitors, the combined use of resistance tests with TDM provide a mechanism for individualising the clinical pharmacodynamics of protease inhibitors. Current therapeutic approaches seek to include the monitoring of protease-inhibitor concentrations as part of a TDM programme with phenotypic assays to calculate an inhibitory quotient, virtual inhibitory quotient, or normalised inhibitory quotient, whereas genotypic tests are used with TDM to calculate a genotypic inhibitory quotient. Current investigation is focused on examining the predictive value of this approach for clinical monitoring.
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Affiliation(s)
- Gene D Morse
- Department of Pharmacy Practice, University at Buffalo, State University of New York, Amherst 14260, USA.
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39
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Fraaij PLA, van Kampen JJA, Burger DM, de Groot R. Pharmacokinetics of antiretroviral therapy in HIV-1-infected children. Clin Pharmacokinet 2005; 44:935-56. [PMID: 16122281 DOI: 10.2165/00003088-200544090-00004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The initiation of antiretroviral therapy has resulted in an impressive reduction in the rate of disease progression in AIDS and HIV-1-related deaths in children; however, there are still several major challenges to be faced in order to improve therapy. A major topic that needs to be dealt with is the establishment of the optimal dosage of antiretroviral therapy for children. This review presents the currently available peer-reviewed data on the pharmacokinetics of nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs) and fusion inhibitors (FIs) in children. In addition, the data are discussed in relation to the currently available European and US guidelines and the US FDA-approved drug labels. High intra- and interpatient variability in pharmacokinetics are often observed for all antiretroviral drugs. The number of children included in the pharmacokinetic studies is often small and children are often divided into divergent groups using different dosage levels and/or drug formulations. For a substantial number of antiretroviral drugs, dosage recommendations, especially for young children, are still absent in the European and US guidelines. The recommended drug dosages in the guidelines are often different from that in the officially approved drug product label. In addition, the recommended drug dosages may deviate between the European and US guidelines. Thus, while practioners aim to meet the recommendations in the official guidelines, patients may receive highly divergent dosages of medication. The high intra- and interpatient variability in pharmacokinetics of antiretroviral drugs in children hampers the application of fixed dosages of antiretroviral drugs. For PIs and NNRTIs, plasma drug levels correlate with viral suppression and drug toxicity. NRTIs are prodrugs that are intracellularly converted to their active triphosphate form and, therefore, plasma NRTI levels correlate poorly with viral suppression. Therapeutic drug monitoring of PIs and NNRTIs should be considered to optimise HIV therapy in children.
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Affiliation(s)
- Pieter L A Fraaij
- Department of Pediatrics, Erasmus MC/Sophia Children's Hospital, Rotterdam, The Netherlands
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40
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Hoefnagel JGM, Koopmans PP, Burger DM, Schuurman R, Galama JMD. Role of the Inhibitory Quotient in HIV Therapy. Antivir Ther 2005. [DOI: 10.1177/135965350501000802] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A systemic review is presented of all studies that have evaluated the inhibitory quotient (IQ). The IQ is defined as the ratio between (trough) drug concentration and level of drug resistance of the HIV isolate. From the studies presented, it can be concluded that for protease inhibitors (PIs) and efavirenz, the phenotypic IQ is associated with virological response. The genotypic IQ (GIQ) for PIs was also demonstrated to be associated with virological response. An intrinsic limitation of the GIQ is that it is only applicable for PIs, of which resistance is based on the cumulative effect of mutations. As the IQ can be modified by adjustment of the drug dosage, it may be of clinical value. Its application in patient care should therefore be further investigated.
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Affiliation(s)
- Jolanda GM Hoefnagel
- Department of Medical Microbiology, Radboud University Nijmegen Medical Centre, the Netherlands
- Nijmegen University Centre for Infectious diseases (NUCI), The Netherlands
| | - Peter P Koopmans
- Nijmegen University Centre for Infectious diseases (NUCI), The Netherlands
- Department of General Internal Medicine, Radboud University Nijmegen Medical Centre, The Netherlands
| | - David M Burger
- Nijmegen University Centre for Infectious diseases (NUCI), The Netherlands
- Department of Clinical Pharmacy, Radboud University Nijmegen Medical Centre, The Netherlands
| | - Rob Schuurman
- Department of Virology, University Medical Centre Utrecht, The Netherlands
| | - Jochem MD Galama
- Department of Medical Microbiology, Radboud University Nijmegen Medical Centre, the Netherlands
- Nijmegen University Centre for Infectious diseases (NUCI), The Netherlands
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41
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Winston A, Hales G, Amin J, van Schaick E, Cooper DA, Emery S. The normalized inhibitory quotient of boosted protease inhibitors is predictive of viral load response in treatment-experienced HIV-1-infected individuals. AIDS 2005; 19:1393-9. [PMID: 16103770 DOI: 10.1097/01.aids.0000181009.77632.36] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The normalized inhibitory quotient (NIQ) has been proposed as a measure for refining the precision of HIV resistance testing when selecting antiretroviral therapy (ART). We undertook an assessment of NIQ and 48-week virological outcome in patients commencing ritonavir-boosted protease inhibitor (PI) regimens. DESIGN A cohort of 87 HIV-infected individuals who all had extensive prior exposure to ART were assigned a new boosted PI regimen following resistance testing. PI therapy consisted of lopinavir, indinavir, saquinavir and amprenavir at 50, 32, 11 and 6%, respectively. Fold change (FC) for each PI was determined from the resistance test at baseline. Trough drug concentration (Cmin) was determined at week 4. METHODS NIQ was derived individually by taking the logarithm of the ratio of Cmin/FC divided by the fixed ratio of population mean trough drug concentration/clinical cut off. Associations between viral load (VL) response over 48 weeks with baseline VL, FC, Cmin, NIQ and selected PI were assessed. RESULTS Mean change from baseline VL reduced by 0.83 log at week 48. In multivariate analyses, baseline VL and NIQ were the parameters most associated with change from baseline VL at week 48 (P = 0.012 and 0.003, respectively). FC, Cmin and selected PI were not significantly associated with VL changes. CONCLUSION In this cohort of highly treatment-experienced individuals treated with boosted PI regimens, baseline VL and NIQ were significantly predictive of virological response over 48 weeks whereas FC and Cmin were not. These results support the use of a NIQ at week 4, as a tool for predicting response to therapy in this setting.
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Affiliation(s)
- Alan Winston
- National Centre for HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW 2010, Australia.
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42
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Ribera E, Fernando López-Cortés L, Soriano V, Luis Casado J, Mallolas J. Therapeutic drug monitoring and the inhibitory quotient of antiretroviral drugs: can they be applied to the current situation? Enferm Infecc Microbiol Clin 2005. [DOI: 10.1016/s0213-005x(05)75161-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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43
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Gazzard B. British HIV Association (BHIVA) guidelines for the treatment of HIV-infected adults with antiretroviral therapy (2005). HIV Med 2005; 6 Suppl 2:1-61. [PMID: 16011536 DOI: 10.1111/j.1468-1293.2005.0311b.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- B Gazzard
- Chelsea and Westimnster Hospital, London, UK.
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44
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Ribera E, Fernando López-Cortés L, Soriano V, Luis Casado J, Mallolas J. Monitorización terapéutica y cociente inhibitorio de los fármacos antirretrovirales: ¿son aplicables a nuestra realidad? Enferm Infecc Microbiol Clin 2005. [DOI: 10.1016/s0213-005x(05)75160-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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45
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Mo H, King MS, King K, Molla A, Brun S, Kempf DJ. Selection of resistance in protease inhibitor-experienced, human immunodeficiency virus type 1-infected subjects failing lopinavir- and ritonavir-based therapy: mutation patterns and baseline correlates. J Virol 2005; 79:3329-38. [PMID: 15731227 PMCID: PMC1075714 DOI: 10.1128/jvi.79.6.3329-3338.2005] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The selection of in vivo resistance to lopinavir was characterized by analyzing the longitudinal isolates from 54 protease inhibitor-experienced subjects who either experienced incomplete virologic response or viral rebound subsequent to initial response while on treatment with lopinavir-ritonavir in Phase II and III studies. The evolution of incremental resistance to lopinavir (emergence of new mutation[s] and/or at least a twofold increase in phenotypic resistance compared to baseline isolates) was highly dependent on the baseline phenotype and genotype. Among the subjects demonstrating evolution of lopinavir resistance, mutations at positions 82, 54, and 46 in human immunodeficiency virus protease emerged frequently, suggesting that these mutations are important for conferring high-level resistance. Less common mutations, such as L33F, I50V, and V32I together with I47V/A, were also selected; however, new mutations at positions 84, 90, and 71 were not observed. The emergence of incremental resistance contrasts greatly with the low incidence of resistance observed after initiating lopinavir-ritonavir therapy in antiretroviral-naive patients, suggesting that partial resistance accumulated during prior protease inhibitor therapy can compromise the genetic barrier to resistance to lopinavir-ritonavir. The emergence of incremental resistance was uncommon in subjects whose baseline isolates contained eight or more mutations associated with lopinavir resistance and/or displayed >60-fold-reduced susceptibility to lopinavir, providing insight into suitable upper genotypic and phenotypic breakpoints for lopinavir-ritonavir.
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Affiliation(s)
- Hongmei Mo
- Department R47D, Building AP52N, Abbott Laboratories, 200 Abbott Park Rd., Abbott Park, IL 60064-6217, USA.
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46
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Boffito M, Acosta E, Burger D, Fletcher CV, Flexner C, Garaffo R, Gatti G, Kurowski M, Perno CF, Peytavin G, Regazzi M, Back D. Current Status and Future Prospects of Therapeutic Drug Monitoring and Applied Clinical Pharmacology in Antiretroviral Therapy. Antivir Ther 2005. [DOI: 10.1177/135965350501000307] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The consensus of current international guidelines for the treatment of HIV infection is that data on therapeutic drug monitoring (TDM) of non-nucleoside reverse transcriptase inhibitors and protease inhibitors provide a framework for the implementation of TDM in certain defined scenarios in clinical practice. However, the utility of TDM is considered to be on an individual basis until more data are obtained from large clinical trials showing the benefit of TDM. In April 2004, a panel of experts met in Rome, Italy. This followed an inaugural meeting in Perugia, Italy, in October 2000, which resulted in the article published in AIDS 2002, 16(Suppl 1):S5–S37. The objectives of this second meeting were to review the questions surrounding TDM of antiretroviral drugs and discuss the clinical utility, current concerns and future prospects of drug concentration monitoring in the care of HIV-1-infected individuals. This report, which has been updated to include material published or presented at international conferences up to the end of September 2004, reviews pharmacokinetic and pharmacodynamic data and reports the issues discussed by the panel, offering advice to clinical care providers who may be currently, or are considering incorporating TDM into the routine care of their patients. In addition, the panel formulated a series of position statements that are relevant to the interpretation of current data and can aid the design of future clinical trials. Part 2 of this Special article, Therapeutic drug monitoring and drug–drug interactions involving antiretroviral drugs, will be published in Antiviral Therapy 10(4).
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Affiliation(s)
- Marta Boffito
- Chelsea and Westminster Hospital, London, UK
- University of Turin, Department of Infectious Diseases, Turin, Italy
| | - Edward Acosta
- Division of Clinical Pharmacology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David Burger
- Department of Clinical Pharmacy & Nijmegen University Centre for Infectious Diseases, University Medical Centre, Nijmegen, The Netherlands
| | - Courtney V Fletcher
- Department of Clinical Pharmacy, University of Colorado Health Sciences Center, Denver, CO, USA
| | - Charles Flexner
- Johns Hopkins University, School of Medicine, Division of Clinical Pharmacology, Baltimore, MD, USA
| | - Rodolphe Garaffo
- Unité de Pharmacocinetique Clinique, Pasteur University Hospital, Nice, France
| | - Giorgio Gatti
- Vertex Pharmaceuticals (Europe) Ltd, Genoa, Italy and University of Genoa, c/o San Martino Hospital, Genoa, Italy
| | | | | | - Gilles Peytavin
- Département de Pharmacocinétique Clinique, Hôpital Bichat-Claude Bernard, Paris, France
| | - Mario Regazzi
- Service of Clinical Pharmacology, IRCCS Policlinico S Matteo, Pavia, Italy
| | - David Back
- Department of Pharmacology, University of Liverpool, Liverpool, UK
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47
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Valer L, de Mendoza C, Soriano V. Predictive value of drug levels, HIV genotyping, and the genotypic inhibitory quotient (GIQ) on response to saquinavir/ritonavir in antiretroviral-experienced HIV-infected patients. J Med Virol 2005; 77:460-4. [PMID: 16254964 DOI: 10.1002/jmv.20477] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Plasma levels of HIV protease inhibitors (PI) are often close to IC50 values of wild-type viruses when administered without ritonavir boosting. The impact of drug levels, resistance mutations, and the genotypic inhibitory quotient (GIQ) were examined on the response to saquinavir/ritonavir (SQV/r)-based salvage therapy. Patients with prior exposure to PI other than SQV and currently failing virologically were recruited prospectively in a multicenter trial. All patients began SQV/r 1000/100 mg bid plus another two antiretrovirals. A total of 139 patients was enrolled. At month 12, virological response (VR), defined as plasma HIV-RNA decline >1 log, was recorded in 68.2% of patients on treatment (41.7% in the intent-to-treat analysis). The median baseline number of protease resistance mutations was three. The VR was significantly lower in patients with >5 protease resistance mutations and in those with plasma SQV Cmin<0.1 microg/ml. At week 48, the VR was seen in 77.1% of patients with a GIQ>0.04 compared to 18.2% of those with a lower GIQ (P=0.001). In the multivariate analysis, <or=5 protease resistance mutations and SQV Cmin>0.1 microg/ml were independently associated with VR. Interestingly, drug levels had their highest predictive value of the VR at week 12, since low SQV plasma levels often permitted ruling out poorly adherent patients. In contrast, the number of protease resistance mutations had the highest impact on the VR at week 24, suggesting that for those taking the drugs, the VR is highly dependent of the presence of resistance mutations. At any time, nevertheless, the GIQ provided the most accurate prediction of the VR.
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Affiliation(s)
- Luisa Valer
- Service of Infectious Diseases, Hospital Carlos III, Madrid, Spain
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48
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Torti C, Quiros-Roldan E, Tirelli V, Regazzi-Bonora M, Moretti F, Pierotti P, Orani A, Maggi P, Cargnel A, Patroni A, De Luca A, Carosi G. Lopinavir plasma levels in salvage regimes by a population of highly active antiretroviral therapy-treated HIV-1-positive patients. AIDS Patient Care STDS 2004; 18:629-34. [PMID: 15633260 DOI: 10.1089/apc.2004.18.629] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Increased lopinavir (LPV) exposure obtained in vivo through combination with low-dose ritonavir may overcome a certain grade of resistance but not all. We sought to analyze LPV variability and possible risk factors. LPV trough plasma concentrations were determined by high-performance liquid chromatography after 1, 4, and 12 weeks from salvage regimens and tested in both univariate and multivariate regression analyses with age, gender, weight, risk factors for HIV acquisition, hepatitis C virus reactivity, hepatitis B surface antigen positivity, baseline aspartate transferase (AST) or alanine transferase (ALT) levels, creatinine, non-nucleoside reverse transcriptase inhibitors (NNRTIs) or tenofovir as concomitant drugs, and NNRTIs administered in the previous regimen. Fifty-six patients were included into the study. Among them, 8 of 56 (14.3%) at week 1, 12 of 56 (21.4%) at week 4, and 9 of 56 (16.1%) at week 12 had suboptimal LPV plasma concentrations, defined as trough concentration less than 4 microg/mL. No correlation was found between LPV trough concentrations and assessed variables. In conclusion, pharmacokinetic variability and low LPV concentrations have been found, supporting the use of therapeutic drug monitoring in those starting this drug.
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Affiliation(s)
- C Torti
- Institute of Infectious and Tropical Diseases, University of Brescia, Brescia, Italy.
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