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Podany AT, Scarsi KK, Pham MM, Fletcher CV. Comparative Clinical Pharmacokinetics and Pharmacodynamics of HIV-1 Integrase Strand Transfer Inhibitors: An Updated Review. Clin Pharmacokinet 2021; 59:1085-1107. [PMID: 32462541 DOI: 10.1007/s40262-020-00898-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Bictegravir, cabotegravir, dolutegravir, elvitegravir, and raltegravir are members of the latest class of antiretrovirals available to treat human immunodeficiency virus (HIV) infection, the integrase strand transfer inhibitors. Integrase strand transfer inhibitors are potent inhibitors of the HIV integrase enzyme with IC90/95 values in the low nanogram per milliliter range and they retain antiviral activity against strains of HIV with acquired resistance to other classes of antiretrovirals. Each of the integrase strand transfer inhibitors have unique pharmacokinetic/pharmacodynamic properties, influencing their role in clinical use in specific subsets of patients. Cabotegravir, approved for use in Canada but not yet by the US Food and Drug Administration, is formulated in both oral and intramuscular formulations; the latter of which has shown efficacy as a long-acting extended-release formulation. Cabotegravir, raltegravir, and dolutegravir have minimal drug-drug interaction profiles, as their metabolism has minimal cytochrome P450 involvement. Conversely, elvitegravir metabolism occurs primarily via cytochrome P450 3A4 and requires pharmacokinetic boosting to achieve systemic exposures amenable to once-daily dosing. Bictegravir metabolism has similar contributions from both cytochrome P450 3A4 and uridine 5'-diphospho-glucuronosyltransferase 1A1. Bictegravir, dolutegravir, and raltegravir are recommended components of initial regimens for most people with HIV in the US adult and adolescent HIV treatment guidelines. This review summarizes and compares the pharmacokinetics and pharmacodynamics of the integrase strand transfer inhibitor agents, and describes specific pharmacokinetic considerations for persons with hepatic impairment, renal dysfunction, pregnancy, and co-infections.
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Affiliation(s)
- Anthony T Podany
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, PDD Rm 3019, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA.
| | - Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, PDD Rm 3019, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
| | - Michelle M Pham
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, PDD Rm 3019, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
| | - Courtney V Fletcher
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, PDD Rm 3019, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
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Podany AT, Scarsi KK, Fletcher CV. Comparative Clinical Pharmacokinetics and Pharmacodynamics of HIV-1 Integrase Strand Transfer Inhibitors. Clin Pharmacokinet 2017; 56:25-40. [PMID: 27317415 PMCID: PMC5164870 DOI: 10.1007/s40262-016-0424-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Dolutegravir (DTG), elvitegravir (EVG) and raltegravir (RAL) are members of the latest class of antiretrovirals (ARVs) that have become available to treat human immunodeficiency virus (HIV) infection: integrase strand transfer inhibitors (INSTIs). INSTIs are potent inhibitors of the HIV integrase enzyme, with protein binding-adjusted concentration inhibiting viral replication by 90/95 % [IC90/95] values in the low nanogram per millilitre range, and they retain antiviral activity against strains of HIV with acquired resistance to other classes of ARVs. Each of the INSTIs has unique pharmacokinetic/pharmacodynamic properties, influencing its role in clinical use in specific subsets of patients. RAL and DTG have minimal drug-drug interaction profiles, as their metabolism has minimal cytochrome P450 (CYP) involvement. Conversely, EVG metabolism occurs primarily via CYP3A4 and requires pharmacokinetic boosting to achieve systemic exposures amenable to once-daily dosing. EVG and DTG have the added benefit of availability of fixed-dose combination tablets, allowing for convenient and simplified ARV regimens. RAL is the only INSTI to be listed as a preferred agent in the current US perinatal treatment guidelines. All three INSTIs are recommended regimens for treatment-naïve individuals in the US adult and adolescent HIV treatment guidelines. This review summarizes and compares the pharmacokinetics and pharmacodynamics of the INSTIs, and describes specific pharmacokinetic considerations for special patient conditions: hepatic impairment, renal dysfunction, pregnancy and co-infections.
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Affiliation(s)
- Anthony T Podany
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986000 Nebraska Medical Center, Omaha, NE, 68198-6000, USA
| | - Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986000 Nebraska Medical Center, Omaha, NE, 68198-6000, USA
| | - Courtney V Fletcher
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986000 Nebraska Medical Center, Omaha, NE, 68198-6000, USA.
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Apostolova N, Funes HA, Blas-Garcia A, Galindo MJ, Alvarez A, Esplugues JV. Efavirenz and the CNS: what we already know and questions that need to be answered. J Antimicrob Chemother 2015. [PMID: 26203180 DOI: 10.1093/jac/dkv183] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The NNRTI efavirenz has long been one of the most frequently employed antiretroviral drugs in the multidrug regimens used to treat HIV infection, in accordance with its well-demonstrated antiretroviral efficacy and favourable pharmacokinetics. However, growing concern about its adverse effects has sometimes led to efavirenz being replaced by other drugs in the initial treatment selection or to switching of therapy to efavirenz-free regimens in experienced patients. Neurological and neuropsychiatric reactions are the manifestations most frequently experienced by efavirenz-treated patients and range from transitory effects, such as nightmares, dizziness, insomnia, nervousness and lack of concentration, to more severe symptoms including depression, suicidal ideation or even psychosis. In addition, efavirenz has recently been associated with mild/moderate neurocognitive impairment, which is of specific relevance given that half of the patients receiving ART eventually suffer some form of HIV-associated neurocognitive disorder. The mechanisms responsible for efavirenz-induced neurotoxicity are unclear, although growing evidence points to disturbances in brain mitochondrial function and bioenergetics. This review offers a comprehensive overview of the current evidence on the interaction that efavirenz displays with the CNS, including the penetration and concentration of the drug in the brain. We discuss the prevalence, types and specificities of its side effects and recently uncovered cellular mechanisms that may be involved in their development.
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Affiliation(s)
- Nadezda Apostolova
- Departamento de Farmacología, Facultad de Medicina, Universidad de Valencia, Valencia, Spain Facultad de Ciencias de la Salud, Universitat Jaume I, Castellón de la Plana, Spain CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Valencia, Spain
| | - Haryes A Funes
- Departamento de Farmacología, Facultad de Medicina, Universidad de Valencia, Valencia, Spain
| | - Ana Blas-Garcia
- Departamento de Farmacología, Facultad de Medicina, Universidad de Valencia, Valencia, Spain CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Valencia, Spain FISABIO-Hospital Universitario Dr Peset, Valencia, Spain
| | - Maria J Galindo
- Unidad de Enfermedades Infecciosas-Medicina Interna, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Angeles Alvarez
- Departamento de Farmacología, Facultad de Medicina, Universidad de Valencia, Valencia, Spain CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Valencia, Spain
| | - Juan V Esplugues
- Departamento de Farmacología, Facultad de Medicina, Universidad de Valencia, Valencia, Spain CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Valencia, Spain FISABIO-Hospital Universitario Dr Peset, Valencia, Spain
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