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Atkinson A, Tulloch K, Boucoiran I, Money D. Guideline No. 450: Care of Pregnant Women Living with HIV and Interventions to Reduce Perinatal Transmission. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102551. [PMID: 38734074 DOI: 10.1016/j.jogc.2024.102551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
OBJECTIVE This guideline provides an update on the care of pregnant women living with HIV and the prevention of perinatal HIV transmission. This guideline is a revision of the previous guideline, No. 310 Guidelines for the Care of Pregnant Women Living With HIV and Interventions to Reduce Perinatal Transmission, and includes an updated review of the literature with contemporary recommendations. TARGET POPULATION Pregnant women newly diagnosed with HIV during antenatal screening and women living with HIV who become pregnant. This guideline does not include specific guidance for girls/women of reproductive age living with HIV who are not pregnant. OUTCOMES Prevention of perinatal HIV transmission is a key indicator of the success of a health care system and requires multidisciplinary care of pregnant women living with HIV. Intended outcomes include guidance on best practice in perinatal management for Canadian health care providers for pregnant women living with HIV; reduction of perinatal transmission of HIV toward a target of eradication of perinatal transmission; provision of optimal antenatal care for pregnant women to ensure the best maternal health outcomes and HIV suppression; and evidence-based support and recommendations for pregnant women living with HIV, maintaining awareness and consideration of the complex psychosocial impacts of living with HIV. BENEFITS, HARMS, AND COSTS The perinatal transmission of HIV has significant morbidity and mortality implications for the child, with associated lifelong health care costs. Pregnancy presents an emotionally and physically vulnerable time for pregnant women as well as an opportunity to engage them in health promotion. This guidance does not include recommendations with additional costs to health care facilities compared with the previous guideline. Application of the recommendations is aimed at health benefits to both mother and child by optimizing maternal health and preventing perinatal HIV transmission. EVIDENCE Published and unpublished literature was reviewed with a focus on publications post-2013. OVID-Medline, Embase, PubMed and the Cochrane Library databases were searched for relevant publications available in English or French for each section of this guideline. Results included systematic reviews, randomized controlled trials, and observational studies published from 2012 to 2022. Searches were updated on a regular basis and incorporated in the guideline until May 2023. Unpublished literature, protocols, and international guidelines were identified by accessing the websites of health-related agencies, clinical practice guideline collections, and national and international medical specialty societies. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional recommendations). INTENDED AUDIENCE The intended users of this guideline include obstetric care providers and infectious disease clinicians who provide care for pregnant women living with HIV. SOCIAL MEDIA SUMMARY Updated Canadian HIV in pregnancy guideline informed by global research and tailored to Canadian healthcare needs and goals for pregnant women living with HIV and their families. SUMMARY STATEMENTS RECOMMENDATIONS.
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Atoyebi S, Bunglawala F, Cottura N, Grañana-Castillo S, Montanha MC, Olagunju A, Siccardi M, Waitt C. Physiologically-based pharmacokinetic modelling of long-acting injectable cabotegravir and rilpivirine in pregnancy. Br J Clin Pharmacol 2024. [PMID: 38340019 DOI: 10.1111/bcp.16006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 11/25/2023] [Accepted: 01/06/2024] [Indexed: 02/12/2024] Open
Abstract
AIMS Long-acting cabotegravir and rilpivirine have been approved to manage HIV in adults, but data regarding safe use in pregnancy are limited. Physiologically-based pharmacokinetic (PBPK) modelling was used to simulate the approved dosing regimens in pregnancy and explore if Ctrough was maintained above cabotegravir and rilpivirine target concentrations (664 and 50 ng/mL, respectively). METHODS An adult PBPK model was validated using clinical data of cabotegravir and rilpivirine in nonpregnant adults. This was modified by incorporating pregnancy-induced metabolic and physiological changes. The pregnancy PBPK model was validated with data on oral rilpivirine and raltegravir (UGT1A1 probe substrate) in pregnancy. Twelve weeks' disposition of monthly and bimonthly dosing of long-acting cabotegravir and rilpivirine was simulated at different trimesters and foetal exposure was also estimated. RESULTS Predicted Ctrough at week 12 for monthly long-acting cabotegravir was above 664 ng/mL throughout pregnancy, but below the target in 0.5% of the pregnant population in the third trimester with bimonthly long-acting cabotegravir. Predicted Ctrough at week 12 for monthly and bimonthly long-acting rilpivirine was below 50 ng/mL in at least 40% and over 90% of the pregnant population, respectively, throughout pregnancy. Predicted medians (range) of cord-to-maternal blood ratios were 1.71 (range, 1.55-1.79) for cabotegravir and 0.88 (0.78-0.93) for rilpivirine between weeks 38 and 40. CONCLUSIONS Model predictions suggest that monthly long-acting cabotegravir could maintain antiviral efficacy throughout pregnancy, but that bimonthly administration may require careful clinical evaluation. Both monthly and bimonthly long-acting rilpivirine may not adequately maintain antiviral efficacy in pregnancy.
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Goulding AN, Meeks K, Shay L, Casey S, Applegarth C, McKinney J. Antiretroviral Therapy in Pregnancy: A 2023 Review of the Literature. Curr HIV/AIDS Rep 2024; 21:1-10. [PMID: 38277098 PMCID: PMC11095844 DOI: 10.1007/s11904-024-00688-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 01/27/2024]
Abstract
PURPOSE OF REVIEW Selection of antiretroviral therapy during pregnancy must consider maternal physiology and resulting pharmacokinetic changes in pregnancy, resistance and efficacy profiles, tolerability and frequency of adverse effects, teratogenicity, and maternal, neonatal, and pregnancy outcomes. The objective of this review is to summarize the underlying data that informs the current clinical perinatal guidelines in the USA. RECENT FINDINGS Data now supports the use of dolutegravir at all stages of pregnancy with no significant increase in neural tube defects. Safety and pharmacokinetic data on newer antiretroviral medications in pregnancy continue to lag behind the general population. While there are multiple safety and tolerability concerns with older regimens, there are now multiple options of regimens that are highly efficacious and have good safety data in pregnancy. Most pregnant patients who are virally suppressed on a well-tolerated regimen are able to safely continue those medications during pregnancy.
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Affiliation(s)
- Alison N Goulding
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Kasey Meeks
- School of Medicine, Saint Louis University, Saint Louis, MO, USA
| | - Lena Shay
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Sarah Casey
- School of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Colton Applegarth
- School of Medicine, University of California San Diego, San Diego, CA, USA
| | - Jennifer McKinney
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA.
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Brooks KM, Scott RK, Best BM, Capparelli E, Momper JD. Translating Clinical Pharmacology Data in Pregnancy to Evidence-Based Guideline Recommendations: Perspectives From the HIV Field. J Clin Pharmacol 2023; 63 Suppl 1:S188-S196. [PMID: 37317495 DOI: 10.1002/jcph.2240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/28/2023] [Indexed: 06/16/2023]
Abstract
Pharmacokinetic (PK) studies in pregnant, postpartum, and breastfeeding people are critical to informing appropriate medication use and dosing. A key component of translating PK results in these complex populations into clinical practice involves the systematic review and interpretation of data by guideline panels, composed of clinicians, scientists, and community members, to leverage available data for informed decision making by clinicians and patients and offer clinical best practices. Interpretation of PK data in pregnancy involves evaluation of multiple factors such as the study design, target population, and type of sampling performed. Assessments of fetal and infant drug exposure while in utero or during breastfeeding, respectively, are also critical for informing whether medications are safe to use during pregnancy and throughout postpartum in lactating people. This review will provide an overview of this translational process, discussion of the various factors considered by guideline panels, and practical aspects of implementing certain recommendations, using the HIV field as an example.
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Affiliation(s)
- Kristina M Brooks
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Rachel K Scott
- Division of Women's Health Research, MedStar Health Research Institute, Washington, District of Columbia, USA
| | - Brookie M Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, California, USA
- Pediatrics Department, University of California San Diego School of Medicine-Rady Children's Hospital San Diego, San Diego, California, USA
| | - Edmund Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, California, USA
- Pediatrics Department, University of California San Diego School of Medicine-Rady Children's Hospital San Diego, San Diego, California, USA
| | - Jeremiah D Momper
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, California, USA
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Nachega JB, Scarsi KK, Gandhi M, Scott RK, Mofenson LM, Archary M, Nachman S, Decloedt E, Geng EH, Wilson L, Rawat A, Mellors JW. Long-acting antiretrovirals and HIV treatment adherence. Lancet HIV 2023; 10:e332-e342. [PMID: 37062293 PMCID: PMC10734401 DOI: 10.1016/s2352-3018(23)00051-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/26/2023] [Accepted: 02/10/2023] [Indexed: 04/18/2023]
Abstract
Intramuscular injection of long-acting cabotegravir and rilpivirine is a novel, long-acting antiretroviral therapy (ART) combination approved for use as a fully suppressive regimen for people living with HIV. Long-acting cabotegravir with rilpivirine ART has reduced required dosing frequency from once daily to once every month or every 2 months injections. This new era of long-acting ART, which includes other antiretrovirals and formulations in various stages of clinical development, holds tremendous promise to change the standard of HIV treatment. Although long-acting ART has high potential to be revolutionary in the landscape of HIV care, prevention, and treatment cascade, more data are needed to substantiate its efficacy and cost-effectiveness among patients at risk of non-adherence and across age groups, pregnancy, and post partum. Advocacy efforts and policy changes to optimise a sustained, high-quality, equitable reach of long-acting ART, especially in low-income and middle-income countries where most people living with HIV reside, are needed to realise the full benefits of long-acting ART.
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Affiliation(s)
- Jean B Nachega
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA; Department of Infectious Diseases and Microbiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA; Center for Global Health, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA; Department of Epidemiology and Department International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, and Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Rachel K Scott
- MedStar Health Research Institute and MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC, USA
| | | | - Moherndran Archary
- Department of Pediatrics, King Edward VIII Hospital, University of Kwa Zulu Natal, Durban, South Africa
| | - Sharon Nachman
- Department of Pediatrics, Stony Brook Children's, SUNY Stony Brook University, Stony Brook, NY, USA
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elvin H Geng
- Division of Infectious Diseases, Department of Medicine, and Institute for Public Health, Washington University, St Louis, MO, USA
| | | | - Angeli Rawat
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; School of Population and Public Heath, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John W Mellors
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
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Poliektov NE, Badell ML. Antiretroviral Options and Treatment Decisions During Pregnancy. Paediatr Drugs 2023; 25:267-282. [PMID: 36729360 DOI: 10.1007/s40272-023-00559-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 02/03/2023]
Abstract
The majority of pediatric human immunodeficiency virus (HIV) infections are the result of vertical transmissions that occur during pregnancy, childbirth, and breastfeeding. The treatment of all pregnant persons living with HIV remains a global health initiative. Early and consistent use of antiretroviral therapy throughout pregnancy and childbirth drastically reduces the risk of perinatal transmission of HIV, resulting in fewer children living with the disease worldwide. Given that the maternal HIV viral load is the strongest predictor of perinatal transmission, suppressive antiretroviral treatment during pregnancy is the principal means to eliminate transmission of HIV from mother to child. With the use of combined antiretroviral therapy, typically with dual-nucleoside reverse transcriptase inhibitors plus an integrase strand transfer inhibitor or a ritonavir-boosted protease inhibitor, HIV-infected mothers can now achieve virologic suppression to undetectable levels and yield a perinatal transmission rate of less than 2%. Important considerations of HIV treatment in pregnancy include the safety and efficacy of antiretroviral drugs, altered pregnancy-related pharmacokinetics, potential for birth defects or adverse neonatal outcomes, and individualized delivery planning based on maternal viral load. This practical review article summarizes the options, considerations, and recommendations for antiretroviral treatment in pregnancy to reduce perinatal HIV transmission and optimize health outcomes for mothers and infants worldwide.
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Affiliation(s)
- Natalie E Poliektov
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Martina L Badell
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA.
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Olagunju A, Mathad J, Eke A, Delaney-Moretlwe S, Lockman S. Considerations for the Use of Long-Acting and Extended-Release Agents During Pregnancy and Lactation. Clin Infect Dis 2022; 75:S571-S578. [PMID: 36410383 PMCID: PMC10200321 DOI: 10.1093/cid/ciac659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Long-acting agents hold significant promise for treating and preventing common illnesses, including infections. Pharmacokinetic and safety data during pregnancy and lactation are often unavailable for new drugs; these data are vital to facilitate optimal drug use by pregnant and lactating women and women who may conceive. In this commentary, we summarize the circumstances in which pregnant and lactating women are likely to use and benefit from long-acting agents. We focus on long-acting formulations of small molecules (rather than biologics such as monoclonal antibodies) and on several infections of global importance (human immunodeficiency virus, tuberculosis, malaria, and hepatitis C). We discuss pregnancy pharmacokinetic/pharmacodynamic and potential safety and efficacy considerations pertaining to the use of long-acting agents in pregnancy and lactation. Finally, we summarize existing preclinical and pregnancy pharmacokinetic data that are available (or expected in the near future) for several agents that are under development or approved, and how key research gaps may be addressed.
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Affiliation(s)
- Adeniyi Olagunju
- Centre of Excellence for Long-acting Therapeutics, Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Jyoti Mathad
- Department of Medicine and Obstetrics and Gynecology, Center for Global Health, Weill Cornell Medicine, New York, New York, USA
| | - Ahizechukwu Eke
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sinead Delaney-Moretlwe
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Shahin Lockman
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
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Patel P, Ford SL, Baker M, Meyer C, Garside L, D'Amico R, Van Solingen‐Ristea R, Crauwels H, Polli JW, Seal C, Yagüe Muñoz I, Thiagarajah S, Birmingham E, Spreen WR, Baugh B, van Wyk J, Vannappagari V. Pregnancy outcomes and pharmacokinetics in pregnant women living with
HIV
exposed to long‐acting cabotegravir and rilpivirine in clinical trials. HIV Med 2022; 24:568-579. [PMID: 36411596 DOI: 10.1111/hiv.13439] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/19/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Limited data exist on pregnant women living with HIV exposed to cabotegravir + rilpivirine (CAB + RPV). Outcomes in pregnant participants exposed to CAB + RPV, and pharmacokinetic washout data in those exposed to CAB + RPV long-acting (LA) with live births, are presented. METHODS Women exposed to one or more doses of CAB + RPV (oral/LA) from ViiV Healthcare-sponsored phase 2b/3/3b clinical trials and the compassionate use programme who became pregnant were included. Upon pregnancy in the trial programme, CAB + RPV was discontinued, an alternative antiretroviral regimen was initiated, and quarterly pharmacokinetic sampling for 52 weeks post-last injection was obtained. CAB + RPV continuation or alternative antiretroviral regimen initiation was decided by pregnant compassionate use programme participants and their treating physicians. RESULTS As of 31 March 2021, 25 pregnancies following CAB + RPV exposure at conception were reported (five oral, 20 LA), including four who conceived during pharmacokinetic washout following treatment discontinuation. There were eight elective abortions, six miscarriages (five in first trimester), one ectopic pregnancy, and 10 live births (one oral, nine LA), including one infant born with congenital ptosis. Among participants exposed to CAB + RPV LA at conception with live births, plasma CAB and RPV washout concentrations during pregnancy were within the range of those observed in non-pregnant women. CONCLUSION In this first analysis of pregnancy outcomes following CAB + RPV exposure at conception, 10 live births, including one with congenital anomaly, were reported. Plasma CAB and RPV washout concentrations during pregnancy were within the range of those in non-pregnant women. Pregnancy surveillance within ViiV Healthcare-sponsored clinical trials is ongoing, with dedicated pregnancy studies planned.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Ciara Seal
- GlaxoSmithKline Collegeville Pennsylvania USA
| | | | | | | | | | - Bryan Baugh
- Janssen Research & Development Titusville New Jersey USA
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Cerveny L, Murthi P, Staud F. HIV in pregnancy: Mother-to-child transmission, pharmacotherapy, and toxicity. Biochim Biophys Acta Mol Basis Dis 2021; 1867:166206. [PMID: 34197912 DOI: 10.1016/j.bbadis.2021.166206] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/18/2021] [Accepted: 06/11/2021] [Indexed: 12/15/2022]
Abstract
An estimated 1.3 million pregnant women were living with HIV in 2018. HIV infection is associated with adverse pregnancy outcomes and all HIV-positive pregnant women, regardless of their clinical stage, should receive a combination of antiretroviral drugs to suppress maternal viral load and prevent vertical fetal infection. Although antiretroviral treatment in pregnant women has undoubtedly minimized mother-to-child transmission of HIV, several uncertainties remain. For example, while pregnancy is accompanied by changes in pharmacokinetic parameters, relevant data from clinical studies are lacking. Similarly, long-term adverse effects of exposure to antiretrovirals on fetuses have not been studied in detail. Here, we review current knowledge on HIV effects on the placenta and developing fetus, recommended antiretroviral regimens, and pharmacokinetic considerations with particular focus on placental transport. We also discuss recent advances in antiretroviral research and potential effects of antiretroviral treatment on placental/fetal development and programming.
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Affiliation(s)
- Lukas Cerveny
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Padma Murthi
- Department of Medicine, School of Clinical Sciences, and Department of Pharmacology, Monash Biomedicine Discovery Institute Monash University, Clayton, Victoria, Australia; Hudson Institute of Medical Research, The Ritchie Centre, Clayton, Victoria, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
| | - Frantisek Staud
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic.
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Frange P, Tubiana R, Sibiude J, Canestri A, Arvieux C, Brunet-Cartier C, Cotte L, Reynes J, Mandelbrot L, Warszawski J, Le Chenadec J. Rilpivirine in HIV-1-positive women initiating pregnancy: to switch or not to switch? J Antimicrob Chemother 2021; 75:1324-1331. [PMID: 32157283 DOI: 10.1093/jac/dkaa017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/09/2020] [Accepted: 01/12/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Safety data about rilpivirine use during pregnancy remain scarce, and rilpivirine plasma concentrations are reduced during second/third trimesters, with a potential risk of viral breakthroughs. Thus, French guidelines recommend switching to rilpivirine-free combinations (RFCs) during pregnancy. OBJECTIVES To describe the characteristics of women initiating pregnancy while on rilpivirine and to compare the outcomes for virologically suppressed subjects continuing rilpivirine until delivery versus switching to an RFC. METHODS In the ANRS-EPF French Perinatal cohort, we included women on rilpivirine at conception in 2010-18. Pregnancy outcomes were compared between patients continuing versus interrupting rilpivirine. In women with documented viral suppression (<50 copies/mL) before 14 weeks of gestation (WG) while on rilpivirine, we compared the probability of viral rebound (≥50 copies/mL) during pregnancy between subjects continuing rilpivirine versus those switching to RFC. RESULTS Among 247 women included, 88.7% had viral suppression at the beginning of pregnancy. Overall, 184 women (74.5%) switched to an RFC (mostly PI/ritonavir-based regimens) at a median gestational age of 8.0 WG. Plasma HIV-1 RNA nearest delivery was <50 copies/mL in 95.6% of women. Among 69 women with documented viral suppression before 14 WG, the risk of viral rebound was higher when switching to RFCs than when continuing rilpivirine (20.0% versus 0.0%, P = 0.046). Delivery outcomes were similar between groups (overall birth defects, 3.8/100 live births; pregnancy losses, 2.0%; preterm deliveries, 10.6%). No HIV transmission occurred. CONCLUSIONS In virologically suppressed women initiating pregnancy, continuing rilpivirine was associated with better virological outcome than changing regimen. We did not observe a higher risk of adverse pregnancy outcomes.
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Affiliation(s)
- Pierre Frange
- Laboratoire de Microbiologie clinique, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Necker-Enfants malades, Paris, France.,EA7328 PACT, Institut Imagine, Université de Paris, Paris, France
| | - Roland Tubiana
- Service de Maladies infectieuses et tropicales, APHP, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Paris, France.,INSERM, Sorbonne Université, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
| | - Jeanne Sibiude
- Service de Gynécologie-Obstétrique, APHP, Hôpital Louis Mourier, Colombes, France.,INSERM UMR1137 IAME, Université de Paris, Paris, France
| | - Ana Canestri
- Service de Maladies infectieuses et tropicales, APHP, Hôpital Tenon, Paris, France
| | - Cédric Arvieux
- Service des maladies infectieuses et réanimation médicale, Centre hospitalier universitaire, Rennes, France
| | - Cécile Brunet-Cartier
- Service de Maladies infectieuses et tropicales, Centre hospitalier universitaire de Nantes, Nantes, France
| | - Laurent Cotte
- Service de Maladies infectieuses, Hôpital de La Croix Rousse, Hospices Civils de Lyon, Lyon, France
| | - Jacques Reynes
- Département de Maladies infectieuses, UMI 233 INSERM U1175, CHU de Montpellier, Montpellier, France
| | - Laurent Mandelbrot
- Service de Gynécologie-Obstétrique, APHP, Hôpital Louis Mourier, Colombes, France.,INSERM UMR1137 IAME, Université de Paris, Paris, France
| | - Josiane Warszawski
- Département d'Epidémiologie, Centre de Recherche en Épidémiologie et Santé des Populations, INSERM U1018, Université Paris-Saclay, APHP Public Health Department, Le Kremlin-Bicêtre, France.,Université Paris Saclay, Le Kremlin-Bicêtre, France.,Service de Santé publique, APHP, Le Kremlin Bicêtre, France
| | - Jérôme Le Chenadec
- Département d'Epidémiologie, Centre de Recherche en Épidémiologie et Santé des Populations, INSERM U1018, Université Paris-Saclay, APHP Public Health Department, Le Kremlin-Bicêtre, France
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Impact of Therapeutic Drug Monitoring of Antiretroviral Drugs in Routine Clinical Management of People Living With HIV: A Narrative Review. Ther Drug Monit 2021; 42:64-74. [PMID: 31393332 DOI: 10.1097/ftd.0000000000000684] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The treatment of HIV infection has evolved significantly since the advent of highly active antiretroviral therapy. As a result, a response rate of 90%-95% now represents a realistically achievable target. Given this background, it is difficult to imagine the additional benefits that therapeutic drug monitoring (TDM) could provide in the management of HIV infection. METHODS This article is not intended to provide a systematic literature review on TDM of antiretroviral agents; rather, the authors aim to discuss the potential added value of TDM in the optimal management of people living with HIV (PLWH) in selected real-life clinical scenarios based on data collected over 10 years by their TDM service. RESULTS Some clinical situations, in which the selection of the optimal antiretroviral therapy is challenging, have been identified. These include poorly compliant patients, suboptimal antiretroviral therapies (in terms of both efficacy and toxicity), polypharmacy with a high risk of drug-drug interactions, and different patient populations, such as pregnant women. CONCLUSIONS The transformation of HIV infection from a near-universally fatal illness to a lifelong chronic disease has resulted in an HIV population that is growing and aging, placing new and increasing demands on public programs and health services. Increasingly, the management of comorbidities, polypharmacy, and drug-drug interaction, and their impact on antiretroviral therapy will have to be undertaken. These clinical settings represent some of the new frontiers for the use of TDM with the goal of achieving optimal prescription and outcome for PLWH.
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Shenkoya B, Atoyebi S, Eniayewu I, Akinloye A, Olagunju A. Mechanistic Modeling of Maternal Lymphoid and Fetal Plasma Antiretroviral Exposure During the Third Trimester. Front Pediatr 2021; 9:734122. [PMID: 34616699 PMCID: PMC8488224 DOI: 10.3389/fped.2021.734122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/23/2021] [Indexed: 12/17/2022] Open
Abstract
Pregnancy-induced changes in plasma pharmacokinetics of many antiretrovirals (ARV) are well-established. Current knowledge about the extent of ARV exposure in lymphoid tissues of pregnant women and within the fetal compartment is limited due to their inaccessibility. Subtherapeutic ARV concentrations in HIV reservoirs like lymphoid tissues during pregnancy may constitute a barrier to adequate virological suppression and increase the risk of mother-to-child transmission (MTCT). The present study describes the pharmacokinetics of three ARVs (efavirenz, dolutegravir, and rilpivirine) in lymphoid tissues and fetal plasma during pregnancy using materno-fetal physiologically-based pharmacokinetic models (m-f-PBPK). Lymphatic and fetal compartments were integrated into our previously validated adult PBPK model. Physiological and drug disposition processes were described using ordinary differential equations. For each drug, virtual pregnant women (n = 50 per simulation) received the standard dose during the third trimester. Essential pharmacokinetic parameters, including Cmax, Cmin, and AUC (0-24), were computed from the concentration-time data at steady state for lymph and fetal plasma. Models were qualified by comparison of predictions with published clinical data, the acceptance threshold being an absolute average fold-error (AAFE) within 2.0. AAFE for all model predictions was within 1.08-1.99 for all three drugs. Maternal lymph concentration 24 h after dose exceeded the reported minimum effective concentration (MEC) for efavirenz (11,514 vs. 800 ng/ml) and rilpivirine (118.8 vs. 50 ng/ml), but was substantially lower for dolutegravir (16.96 vs. 300 ng/ml). In addition, predicted maternal lymph-to-plasma AUC ratios vary considerably (6.431-efavirenz, 0.016-dolutegravir, 1.717-rilpivirine). Furthermore, fetal plasma-to-maternal plasma AUC ratios were 0.59 for efavirenz, 0.78 for dolutegravir, and 0.57 for rilpivirine. Compared with rilpivirine (0 h), longer dose forgiveness was observed for dolutegravir in fetal plasma (42 h), and for efavirenz in maternal lymph (12 h). The predicted low lymphoid tissue penetration of dolutegravir appears to be significantly offset by its extended dose forgiveness and adequate fetal compartment exposure. Hence, it is unlikely to be a predictor of maternal virological failure or MTCT risks. Predictions from our m-f-PBPK models align with recommendations of no dose adjustment despite moderate changes in exposure during pregnancy for these drugs. This is an important new application of PBPK modeling to evaluate the adequacy of drug exposure in otherwise inaccessible compartments.
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Affiliation(s)
- Babajide Shenkoya
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Shakir Atoyebi
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile-Ife, Nigeria.,Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Ibrahim Eniayewu
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile-Ife, Nigeria.,Department of Pharmaceutical and Medicinal Chemistry, University of Ilorin, Ilorin, Nigeria
| | - Abdulafeez Akinloye
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Adeniyi Olagunju
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile-Ife, Nigeria.,Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
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13
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Fink JB, Ehrmann S, Li J, Dailey P, McKiernan P, Darquenne C, Martin AR, Rothen-Rutishauser B, Kuehl PJ, Häussermann S, MacLoughlin R, Smaldone GC, Muellinger B, Corcoran TE, Dhand R. Reducing Aerosol-Related Risk of Transmission in the Era of COVID-19: An Interim Guidance Endorsed by the International Society of Aerosols in Medicine. J Aerosol Med Pulm Drug Deliv 2020; 33:300-304. [PMID: 32783675 PMCID: PMC7757542 DOI: 10.1089/jamp.2020.1615] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/14/2020] [Indexed: 12/12/2022] Open
Abstract
National and international guidelines recommend droplet/airborne transmission and contact precautions for those caring for coronavirus disease 2019 (COVID-19) patients in ambulatory and acute care settings. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, an acute respiratory infectious agent, is primarily transmitted between people through respiratory droplets and contact routes. A recognized key to transmission of COVID-19, and droplet infections generally, is the dispersion of bioaerosols from the patient. Increased risk of transmission has been associated with aerosol generating procedures that include endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, noninvasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation. The knowledge that COVID-19 subjects can be asymptomatic and still shed virus, producing infectious droplets during breathing, suggests that health care workers (HCWs) should assume every patient is potentially infectious during this pandemic. Taking actions to reduce risk of transmission to HCWs is, therefore, a vital consideration for safe delivery of all medical aerosols. Guidelines for use of personal protective equipment (glove, gowns, masks, shield, and/or powered air purifying respiratory) during high-risk procedures are essential and should be considered for use with lower risk procedures such as administration of uncontaminated medical aerosols. Bioaerosols generated by infected patients are a major source of transmission for SARS CoV-2, and other infectious agents. In contrast, therapeutic aerosols do not add to the risk of disease transmission unless contaminated by patients or HCWs.
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Affiliation(s)
- James B. Fink
- Aerogen Pharma Corp., San Mateo, California, USA
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Stephan Ehrmann
- CHRU Tours, Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSep Research Network, Tours, France
- INSERM, Centre d'étude des Pathologies Respiratoires, U1100, Université de Tours, Tours, France
| | - Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | | | | | - Chantal Darquenne
- Department of Medicine, University of California, San Diego, California, USA
| | | | | | | | | | - Ronan MacLoughlin
- Aerogen Limited, Galway, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland
| | - Gerald C. Smaldone
- Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, State University of New York at Stony Brook, Stony Brook, New York, USA
| | | | - Timothy E. Corcoran
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rajiv Dhand
- Department of Medicine, Graduate School of Medicine, University of Tennessee Health Science Center, Knoxville, Tennessee, USA
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14
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Kaur R, Weiss TT, Perez A, Fink JB, Chen R, Luo F, Liang Z, Mirza S, Li J. Practical strategies to reduce nosocomial transmission to healthcare professionals providing respiratory care to patients with COVID-19. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:571. [PMID: 32967700 PMCID: PMC7509502 DOI: 10.1186/s13054-020-03231-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/07/2020] [Indexed: 02/07/2023]
Abstract
Coronavirus disease (COVID-19) is an emerging viral infection that is rapidly spreading across the globe. SARS-CoV-2 belongs to the same coronavirus class that caused respiratory illnesses such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). During the SARS and MERS outbreaks, many frontline healthcare workers were infected when performing high-risk aerosol-generating medical procedures as well as when providing basic patient care. Similarly, COVID-19 disease has been reported to infect healthcare workers at a rate of ~ 3% of cases treated in the USA. In this review, we conducted an extensive literature search to develop practical strategies that can be implemented when providing respiratory treatments to COVID-19 patients, with the aim to help prevent nosocomial transmission to the frontline workers.
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Affiliation(s)
- Ramandeep Kaur
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA
| | - Tyler T Weiss
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA
| | - Andrew Perez
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA
| | - James B Fink
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA
| | - Rongchang Chen
- Shenzhen Institute of Respiratory Disease, Shenzhen People's Hospital (First Affiliated Hospital of South University of Science and Technology of China), Shenzhen, China
| | - Fengming Luo
- Department of Respiratory and Critical Care Medicine, West China Medical Center of Sichuan University, Chengdu, China
| | - Zongan Liang
- Department of Respiratory and Critical Care Medicine, West China Medical Center of Sichuan University, Chengdu, China
| | - Sara Mirza
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA
| | - Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA.
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15
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O'Mahony HR, Martin DS. An anaesthetic and intensive care perspective on infection control measures for the prevention of airborne transmission of SARS-CoV-2. Br J Hosp Med (Lond) 2020; 81:1-9. [PMID: 32990080 DOI: 10.12968/hmed.2020.0538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Guidance regarding appropriate use of personal protective equipment in hospitals is in constant flux as research into SARS-COV-2 transmission continues to develop our understanding of the virus. The risk associated with procedures classed as 'aerosol generating' is under constant debate. Current guidance is largely based on pragmatic and cautious logic, as there is little scientific evidence of aerosolization and transmission of respiratory viruses associated with procedures. The physical properties of aerosol particles which may contain viable virus have implications for the safe use of personal protective equipment and infection control protocols. As elective work in the NHS is reinstated, it is important that the implications of the possibility of airborne transmission of the virus in hospitals are more widely understood. This will facilitate appropriate use of personal protective equipment and help direct further research into the true risks of aerosolization during these procedures to allow safe streamlining of services for staff and patients.
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Affiliation(s)
| | - Daniel S Martin
- Intensive Care Unit, Royal Free Hospital, London, UK.,Peninsula Medical School, University of Plymouth, Plymouth, UK
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16
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Abduljalil K, Pansari A, Jamei M. Prediction of maternal pharmacokinetics using physiologically based pharmacokinetic models: assessing the impact of the longitudinal changes in the activity of CYP1A2, CYP2D6 and CYP3A4 enzymes during pregnancy. J Pharmacokinet Pharmacodyn 2020; 47:361-383. [DOI: 10.1007/s10928-020-09711-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 08/11/2020] [Indexed: 12/19/2022]
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17
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Bukkems VE, Colbers A, Marzolini C, Molto J, Burger DM. Drug-Drug Interactions with Antiretroviral Drugs in Pregnant Women Living with HIV: Are They Different from Non-Pregnant Individuals? Clin Pharmacokinet 2020; 59:1217-1236. [PMID: 32696442 PMCID: PMC7550380 DOI: 10.1007/s40262-020-00914-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background and Objective Although the separate effects of drug–drug interactions and pregnancy on antiretroviral drug pharmacokinetics have been widely studied and described, their combined effect is largely unknown. Physiological changes during pregnancy may change the extent or clinical relevance of a drug–drug interaction in a pregnant woman. This review aims to provide a detailed overview of the mechanisms, magnitude, and clinical significance of antiretroviral drug–drug interactions in pregnant women. Methods We performed a literature search and selected studies that compared the magnitude of drug–drug interactions with antiretroviral drugs in pregnant vs non-pregnant women. Results Forty-eight papers examining drug–drug interactions during pregnancy were selected, of which the majority focused on pharmacokinetic boosting. Other selected studies examined the drug–drug interactions between efavirenz and lumefantrine, efavirenz and tuberculosis drugs, etravirine and tenofovir disoproxil fumarate, atazanavir and tenofovir disoproxil, and mefloquine and nevirapine in pregnant compared to non-pregnant women. The clinical significance of antiretroviral drug–drug interactions changed during pregnancy from a minimal effect to a contra-indication. In almost all cases, the clinical significance of a drug–drug interaction was more relevant in pregnant women, owing to the combined effects of pregnancy-induced physiological changes and drug–drug interactions leading to a lower absolute drug exposure. Conclusions Multiple studies show that the clinical relevance of a drug–drug interaction can change during pregnancy. Unfortunately, many potential interactions have not been studied in pregnancy, which may place pregnant women living with human immunodeficiency virus and their newborns at risk.
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Affiliation(s)
- Vera E Bukkems
- Department of Pharmacy, Radboud University Medical Center and Radboud Institute for Health Sciences (RIHS), Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Angela Colbers
- Department of Pharmacy, Radboud University Medical Center and Radboud Institute for Health Sciences (RIHS), Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands.
| | - Catia Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital of Basel and University of Basel, Basel, Switzerland.,Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Jose Molto
- Fundació Lluita Contra La Sida, Badalona, Spain.,Infectious Diseases Department, Hospital Universitari Germans Trias I Pujol, Badalona, Spain.,Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - David M Burger
- Department of Pharmacy, Radboud University Medical Center and Radboud Institute for Health Sciences (RIHS), Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
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18
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Sommerstein R, Fux CA, Vuichard-Gysin D, Abbas M, Marschall J, Balmelli C, Troillet N, Harbarth S, Schlegel M, Widmer A. Risk of SARS-CoV-2 transmission by aerosols, the rational use of masks, and protection of healthcare workers from COVID-19. Antimicrob Resist Infect Control 2020; 9:100. [PMID: 32631450 PMCID: PMC7336106 DOI: 10.1186/s13756-020-00763-0] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/23/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To determine the risk of SARS-CoV-2 transmission by aerosols, to provide evidence on the rational use of masks, and to discuss additional measures important for the protection of healthcare workers from COVID-19. METHODS Literature review and expert opinion. SHORT CONCLUSION SARS-CoV-2, the pathogen causing COVID-19, is considered to be transmitted via droplets rather than aerosols, but droplets with strong directional airflow support may spread further than 2 m. High rates of COVID-19 infections in healthcare-workers (HCWs) have been reported from several countries. Respirators such as filtering face piece (FFP) 2 masks were designed to protect HCWs, while surgical masks were originally intended to protect patients (e.g., during surgery). Nevertheless, high quality standard surgical masks (type II/IIR according to European Norm EN 14683) appear to be as effective as FFP2 masks in preventing droplet-associated viral infections of HCWs as reported from influenza or SARS. So far, no head-to-head trials with these masks have been published for COVID-19. Neither mask type completely prevents transmission, which may be due to inappropriate handling and alternative transmission pathways. Therefore, compliance with a bundle of infection control measures including thorough hand hygiene is key. During high-risk procedures, both droplets and aerosols may be produced, reason why respirators are indicated for these interventions.
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Affiliation(s)
- Rami Sommerstein
- Department of Infectious, Diseases and Hospital Hygiene, Freiburgstrasse, 3010, Bern, Switzerland.
- Swissnoso, the National Center for Infection Control, Bern, Switzerland.
| | - Christoph Andreas Fux
- Department of Infectious Diseases and Hospital Hygiene, Aarau Cantonal Hospital, Aarau, Switzerland
| | - Danielle Vuichard-Gysin
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Department of Infectious Diseases, Thurgau Cantonal Hospital, Thurgau, Switzerland
| | - Mohamed Abbas
- Infection Control Programme and Division of Infectious Diseases, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Jonas Marschall
- Department of Infectious, Diseases and Hospital Hygiene, Freiburgstrasse, 3010, Bern, Switzerland
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
| | - Carlo Balmelli
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Infection Control Programme, EOC Hospitals, Ticino, Switzerland
| | - Nicolas Troillet
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Service of Infectious Diseases, Central Institute, Valais Hospitals, Sion, Switzerland
| | - Stephan Harbarth
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Infection Control Programme and Division of Infectious Diseases, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Matthias Schlegel
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Andreas Widmer
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Department of Infectious Diseases, University Hospital Basel, Basel, Switzerland
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19
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Sommerstein R, Fux CA, Vuichard-Gysin D, Abbas M, Marschall J, Balmelli C, Troillet N, Harbarth S, Schlegel M, Widmer A. Risk of SARS-CoV-2 transmission by aerosols, the rational use of masks, and protection of healthcare workers from COVID-19. Antimicrob Resist Infect Control 2020. [PMID: 32631450 DOI: 10.1186/s13756-020-00763-] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023] Open
Abstract
OBJECTIVES To determine the risk of SARS-CoV-2 transmission by aerosols, to provide evidence on the rational use of masks, and to discuss additional measures important for the protection of healthcare workers from COVID-19. METHODS Literature review and expert opinion. SHORT CONCLUSION SARS-CoV-2, the pathogen causing COVID-19, is considered to be transmitted via droplets rather than aerosols, but droplets with strong directional airflow support may spread further than 2 m. High rates of COVID-19 infections in healthcare-workers (HCWs) have been reported from several countries. Respirators such as filtering face piece (FFP) 2 masks were designed to protect HCWs, while surgical masks were originally intended to protect patients (e.g., during surgery). Nevertheless, high quality standard surgical masks (type II/IIR according to European Norm EN 14683) appear to be as effective as FFP2 masks in preventing droplet-associated viral infections of HCWs as reported from influenza or SARS. So far, no head-to-head trials with these masks have been published for COVID-19. Neither mask type completely prevents transmission, which may be due to inappropriate handling and alternative transmission pathways. Therefore, compliance with a bundle of infection control measures including thorough hand hygiene is key. During high-risk procedures, both droplets and aerosols may be produced, reason why respirators are indicated for these interventions.
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Affiliation(s)
- Rami Sommerstein
- Department of Infectious, Diseases and Hospital Hygiene, Freiburgstrasse, 3010, Bern, Switzerland.
- Swissnoso, the National Center for Infection Control, Bern, Switzerland.
| | - Christoph Andreas Fux
- Department of Infectious Diseases and Hospital Hygiene, Aarau Cantonal Hospital, Aarau, Switzerland
| | - Danielle Vuichard-Gysin
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Department of Infectious Diseases, Thurgau Cantonal Hospital, Thurgau, Switzerland
| | - Mohamed Abbas
- Infection Control Programme and Division of Infectious Diseases, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Jonas Marschall
- Department of Infectious, Diseases and Hospital Hygiene, Freiburgstrasse, 3010, Bern, Switzerland
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
| | - Carlo Balmelli
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Infection Control Programme, EOC Hospitals, Ticino, Switzerland
| | - Nicolas Troillet
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Service of Infectious Diseases, Central Institute, Valais Hospitals, Sion, Switzerland
| | - Stephan Harbarth
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Infection Control Programme and Division of Infectious Diseases, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Matthias Schlegel
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Andreas Widmer
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Department of Infectious Diseases, University Hospital Basel, Basel, Switzerland
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20
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Hodel EM, Marzolini C, Waitt C, Rakhmanina N. Pharmacokinetics, Placental and Breast Milk Transfer of Antiretroviral Drugs in Pregnant and Lactating Women Living with HIV. Curr Pharm Des 2020; 25:556-576. [PMID: 30894103 DOI: 10.2174/1381612825666190320162507] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/18/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Remarkable progress has been achieved in the identification of HIV infection in pregnant women and in the prevention of vertical HIV transmission through maternal antiretroviral treatment (ART) and neonatal antiretroviral drug (ARV) prophylaxis in the last two decades. Millions of women globally are receiving combination ART throughout pregnancy and breastfeeding, periods associated with significant biological and physiological changes affecting the pharmacokinetics (PK) and pharmacodynamics (PD) of ARVs. The objective of this review was to summarize currently available knowledge on the PK of ARVs during pregnancy and transport of maternal ARVs through the placenta and into the breast milk. We also summarized main safety considerations for in utero and breast milk ARVs exposures in infants. METHODS We conducted a review of the pharmacological profiles of ARVs in pregnancy and during breastfeeding obtained from published clinical studies. Selected maternal PK studies used a relatively rich sampling approach at each ante- and postnatal sampling time point. For placental and breast milk transport of ARVs, we selected the studies that provided ratios of maternal to the cord (M:C) plasma and breast milk to maternal plasma (M:P) concentrations, respectively. RESULTS We provide an overview of the physiological changes during pregnancy and their effect on the PK parameters of ARVs by drug class in pregnancy, which were gathered from 45 published studies. The PK changes during pregnancy affect the dosing of several protease inhibitors during pregnancy and limit the use of several ARVs, including three single tablet regimens with integrase inhibitors or protease inhibitors co-formulated with cobicistat due to suboptimal exposures. We further analysed the currently available data on the mechanism of the transport of ARVs from maternal plasma across the placenta and into the breast milk and summarized the effect of pregnancy on placental and of breastfeeding on mammal gland drug transporters, as well as physicochemical properties, C:M and M:P ratios of individual ARVs by drug class. Finally, we discussed the major safety issues of fetal and infant exposure to maternal ARVs. CONCLUSIONS Available pharmacological data provide evidence that physiological changes during pregnancy affect maternal, and consequently, fetal ARV exposure. Limited available data suggest that the expression of drug transporters may vary throughout pregnancy and breastfeeding thereby possibly impacting the amount of ARV crossing the placenta and secreted into the breast milk. The drug transporter's role in the fetal/child exposure to maternal ARVs needs to be better understood. Our analysis underscores the need for more pharmacological studies with innovative study design, sparse PK sampling, improved study data reporting and PK modelling in pregnant and breastfeeding women living with HIV to optimize their treatment choices and maternal and child health outcomes.
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Affiliation(s)
- E M Hodel
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Molecular & Clinical Pharmacology, Liverpool, United Kingdom.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom.,Division of Paediatric Pharmacology & Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - C Marzolini
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Molecular & Clinical Pharmacology, Liverpool, United Kingdom.,Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - C Waitt
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Molecular & Clinical Pharmacology, Liverpool, United Kingdom.,Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - N Rakhmanina
- Department of Pediatrics, The George Washington University, School of Medicine & Health Sciences, Washington, DC, United States.,Division of Infectious Diseases, Children's National Medical Center, Washington, DC, United States.,Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States
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21
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Zietsman M, Phan LT, Jones RM. Potential for occupational exposures to pathogens during bronchoscopy procedures. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2019; 16:707-716. [PMID: 31407954 PMCID: PMC7157954 DOI: 10.1080/15459624.2019.1649414] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Bronchoscopy is classified as an aerosol-generating procedure, but it is unclear what drives the elevated infection risk observed among healthcare personnel performing the procedure. The objective of this study was to characterize pathways through which bronchoscopists may be exposed to infectious agents during bronchoscopy procedures. Aerosol number concentrations (0.2-1 µm aerodynamic diameter) were measured using a P-Trak Ultrafine Particle Counter 8525 and mass concentrations (<10 µm) were measured using a SidePak Personal Aerosol Monitor AM510 near the head of patients during bronchoscopy procedures. Procedure pathway, number of patient coughs, number of suctioning events, number of contacts with different surfaces by the pulmonologist, and the use and doffing of personal protective equipment were recorded by the investigator on a specially designed form. Any pulmonologist performing a bronchoscopy procedure was eligible to participate. A total of 18 procedures were observed. Mean particle number and mass concentrations were not elevated during procedures relative to those measured before or after the procedure, on average, but the concentrations were highly variable, exhibiting high levels periodically. Patients frequently coughed during procedures (median 65 coughs, range: 0-565 coughs), and suctioning was commonly performed (median 6.5 suctioning events, range: 0-42). In all procedures, pulmonologists contacted the patient (mean 22.3 contacts, range: 1-48), bronchoscope (mean 19.4 contacts, range: 1-46), and at least one environmental surface (mean 31.2 contacts, range: 3-62). In the majority of procedures, the participant contacted his or her body or personal protective equipment (PPE), with a mean of 17.3 contacts (range: 4-48). More often than not, the observed PPE doffing practices differed from those recommended. Bronchoscopy procedures were associated with short-term increased ultrafine or respirable aerosol concentrations, and there were opportunities for contact transmission.
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Affiliation(s)
- Maryshe Zietsman
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Linh T. Phan
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Rachael M. Jones
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois
- CONTACT Rachael M. Jones Rocky Mount Center for Occupational and Environmental Health, Department of Family and Preventive Medicine, School of Medicine, University of Utah, 391 Chipeta Way, Suite C, Salt Lake City, UT 84108
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Inojosa WO, Giobbia M, Muffato G, Minniti G, Baldasso F, Carniato A, Farina F, Forner G, Rossi MC, Formentini S, Rigoli R, Scotton PG. Mycobacterium chimaera infections following cardiac surgery in Treviso Hospital, Italy, from 2016 to 2019: Cases report. World J Clin Cases 2019; 7:2776-2786. [PMID: 31616692 PMCID: PMC6789390 DOI: 10.12998/wjcc.v7.i18.2776] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 08/19/2019] [Accepted: 09/09/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND An epidemic of Mycobacterium chimaera (M. chimaera) infections following cardiac surgery is ongoing worldwide. The outbreak was first discovered in 2011, and it has been traced to a point source contamination of the LivaNova 3T heater-cooler unit, which is used also in Italy. International data are advocated to clarify the spectrum of clinical features of the disease as well as treatment options and outcome. We report a series of M. chimaera infections diagnosed in Treviso Hospital, including the first cases notified in Italy in 2016.
CASE SUMMARY Since June 2016, we diagnosed a M. chimaera infection in nine patient who had undergone cardiac valve surgery between February 2011 and November 2016. The time between cardiac surgery and developing symptoms ranged from 6 to 97 mo. Unexplained fever, psychophysical decay, weight loss, and neurological symptoms were common complaints. The median duration of symptoms was 32 wk, and the longest was almost two years. A new cardiac murmur, splenomegaly, choroidoretinitis, anaemia or lymphopenia, abnormal liver function tests and hyponatremia were common findings. All the patients presented a prosthetic valve endocarditis, frequently associated to an ascending aortic pseudoneurysm or spondylodiscitis. M. chimaera was cultured from blood, bioprosthetic tissue, pericardial abscess, vertebral tissue, and bone marrow. Mortality is high in our series, reflecting the poor outcome observed in other reports. Three patients have undergone repeat cardiac surgery. Five patients are being treated with a targeted multidrug antimycobacterial regimen.
CONCLUSION Patients who have undergone cardiac surgery in Italy and presenting with signs and symptoms of endocarditis must be tested for M. chimaera.
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Affiliation(s)
- Walter O Inojosa
- Infectious Diseases Unit, Treviso Hospital, Treviso 31100, Italy
| | - Mario Giobbia
- Infectious Diseases Unit, Treviso Hospital, Treviso 31100, Italy
| | | | | | | | | | - Francesca Farina
- Infectious Diseases Unit, Treviso Hospital, Treviso 31100, Italy
| | - Gabriella Forner
- Infectious Diseases Unit, Treviso Hospital, Treviso 31100, Italy
| | - Maria C Rossi
- Infectious Diseases Unit, Treviso Hospital, Treviso 31100, Italy
| | | | - Roberto Rigoli
- Microbiology Unit, Treviso Hospital, Treviso 31100, Italy
| | - Pier G Scotton
- Infectious Diseases Unit, Treviso Hospital, Treviso 31100, Italy
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Fairlie L, Waitt C, Lockman S, Moorhouse M, Abrams EJ, Clayden P, Boffito M, Khoo S, Rees H, Cournil A, Venter WF, Serenata C, Chersich M. Inclusion of pregnant women in antiretroviral drug research: what is needed to move forwards? J Int AIDS Soc 2019; 22:e25372. [PMID: 31529598 PMCID: PMC6747006 DOI: 10.1002/jia2.25372] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 07/21/2019] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION To adequately ascertain drug safety and efficacy, drug trials need to include participants from all groups likely to receive the medication following approval. Pregnant women, however, are mostly excluded from trials, and women participating are often required to use highly effective contraception and taken off study product (even off study) if they conceive. There is little commercial incentive for including pregnant women in clinical trials, even when preclinical animal and human pharmacokinetic and safety data appear reassuring. With this conservative approach, large numbers of pregnant women are exposed to drug postlicensing with little known about drug safety and efficacy, and little done to systematically monitor outcomes of pregnancy exposure. DISCUSSION The article focuses on antiretrovirals for treating and preventing HIV, and presents potential approaches which could extend to other therapeutic areas, to obtaining adequate and timely data to inform use of these drugs in this population. Most importantly the pregnancy risk profile of investigational agents can be systematically stratified from low to high risk, based on guidelines from regulatory bodies. This stratification can determine the progress through preclinical work with animals and non-pregnant women to opportunistic studies among women who become pregnant on a clinical trial or within routine clinical treatment. Stratification can include pregnant women in clinical trials, concurrent with Phase II/III trials in non-pregnant adults, and ultimately to postmarketing surveillance for outcomes in pregnant women and their infants. Each step can be enabled by clear criteria from international and local regulatory bodies on progression through study phases, standardized protocols for collecting relevant data, collaborative data sharing, pregnancy outcomes surveillance systems supported by committed funding for these endeavours. CONCLUSIONS A formalized step-wise approach to including pregnant women in antiretroviral drug research should become the new norm. Systematic implementation of this approach would yield more timely and higher quality pregnancy dosing, safety and efficacy data. Through more vigorous action, regulatory bodies could responsibly overcome reluctance to include pregnant women in drug trials. Funders, researchers and programme implementers need to be galvanized to progressively include pregnant women in research - the use of newer, more effective drugs in women is at stake (349).
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Affiliation(s)
- Lee Fairlie
- Wits Reproductive Health and HIV InstituteFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Catriona Waitt
- Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
- Infectious Diseases InstituteMakerere University College of Health SciencesKampalaUganda
| | - Shahin Lockman
- Brigham and Women's HospitalHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Michelle Moorhouse
- Wits Reproductive Health and HIV InstituteFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Elaine J. Abrams
- ICAP at Columbia UniversityMailman School of Public Health and Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | | | | | - Saye Khoo
- Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Helen Rees
- Wits Reproductive Health and HIV InstituteFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Amandine Cournil
- Unité Mixte Internationale 233Institut de Recherche pour le DéveloppementU1175‐INSERMUniversity of MontpellierMontpellierFrance
| | - Willem Francois Venter
- Wits Reproductive Health and HIV InstituteFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Celicia Serenata
- Wits Reproductive Health and HIV InstituteFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Matthew Chersich
- Wits Reproductive Health and HIV InstituteFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
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Moorhouse MA, Cohen K. The role of rilpivirine in Southern Africa. South Afr J HIV Med 2019; 20:825. [PMID: 31205774 PMCID: PMC6556917 DOI: 10.4102/sajhivmed.v20i1.825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 04/03/2019] [Indexed: 11/10/2022] Open
Abstract
Rilpivirine, a second-generation non-nucleoside reverse transcriptase inhibitor (NNRTI), is included as an option in first-line antiretroviral therapy (ART) for antiretroviral-naïve individuals in treatment guidelines in high-income countries, including the United States and many European countries. Rilpivirine is available in a single-tablet fixed-dose combination, has a favourable tolerability profile and is of relatively low cost. However, rilpivirine has reduced efficacy in patients commencing ART at high viral loads. Therefore, baseline viral load testing is required before commencing rilpivirine, and it is not recommended for patients commencing therapy with a viral load greater than 100 000 copies/mL. Rilpivirine is not included in the treatment regimens recommended by the World Health Organization (WHO), which form the basis of treatment guidelines in many lower- and middle-income countries. Some patients commencing standard first-line regimens experience treatment-limiting toxicity. A low-cost rilpivirine-containing fixed-dose combination would potentially be a useful addition to treatment options available in South Africa and other countries in the region, for patients who do not tolerate standard first-line ART. In this article, we explore the utility of rilpivirine as an option in ART in South Africa and the region in the context of current public-sector regimens. We consider what role rilpivirine might play if first-line therapy moves to a dolutegravir-based regimen, as has already happened in some lower- and middle-income countries, including Botswana, Kenya and Brazil. Finally, we describe emerging evidence for rilpivirine in the prevention of HIV transmission.
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Affiliation(s)
- Michelle A Moorhouse
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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25
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HIV treatment in pregnancy. Lancet HIV 2018; 5:e457-e467. [PMID: 29958853 DOI: 10.1016/s2352-3018(18)30059-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/27/2018] [Accepted: 03/29/2018] [Indexed: 01/15/2023]
Abstract
Almost 25 years since antiretroviral therapy (ART) was first shown to prevent mother-to-child transmission of HIV, 76% of pregnant women living with HIV (over 1 million women) receive ART annually. This number is the result of successes in universal ART scale-up in low-income and middle-income countries. Despite unprecedented ART-related benefits to maternal and child health, challenges remain related to ART adherence, retention in care, and unequal access to ART. Implementation research is ongoing to understand and to address obstacles that lead to loss to follow-up. The biological mechanisms that underlie observed associations between antenatal ART and adverse outcomes in pregnancy and birth are not completely understood, with further research needed as well as strengthening of the systems to assess safety of antiretroviral drugs for the mother and HIV-exposed child. In the treat-all era, as duration of treatment and options for ART expand, pregnant women will remain a priority population for treatment optimisation to promote their health and that of their ART-exposed children.
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Pharmacokinetics, Antiviral Activity, and Safety of Rilpivirine in Pregnant Women with HIV-1 Infection: Results of a Phase 3b, Multicenter, Open-Label Study. Infect Dis Ther 2018; 7:147-159. [PMID: 29335895 PMCID: PMC5840103 DOI: 10.1007/s40121-017-0184-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Physiologic changes during pregnancy may impact the pharmacokinetics of drugs. In addition, efficacy and safety/tolerability concerns have been identified for some antiretroviral agents. METHODS Human immunodeficiency virus (HIV)-1-infected pregnant women (18-26 weeks gestation) receiving the non-nucleoside reverse transcriptase inhibitor rilpivirine 25 mg once daily were enrolled in this phase 3b, open-label study examining the impact of pregnancy on the pharmacokinetics of rilpivirine when it is given in combination with other antiretroviral agents. Blood samples (collected over the 24-h dosing interval) to assess total and unbound rilpivirine plasma concentrations were obtained during the second and third trimesters (24-28 and 34-38 weeks gestation, respectively) and 6-12 weeks postpartum. Pharmacokinetic parameters were derived using noncompartmental analysis and compared (pregnancy versus postpartum) using linear mixed effects modeling. Antiviral and immunologic response and safety were assessed. RESULTS Nineteen women were enrolled; 15 had evaluable pharmacokinetic results. Total rilpivirine exposure was 29-31% lower during pregnancy versus postpartum; differences were less pronounced for unbound (pharmacodynamically active) rilpivirine. At study entry, 12/19 (63.2%) women were virologically suppressed; 10/12 (83.3%) women were suppressed at the postpartum visit. Twelve infants were born to the 12 women who completed the study (7 discontinued); no perinatal viral transmission was observed among 10 infants with available data. Rilpivirine was generally safe and well tolerated in women and infants exposed in utero. CONCLUSION Despite decreased rilpivirine exposure during pregnancy, treatment was effective in preventing mother-to-child transmission and suppressing HIV-1 RNA in pregnant women. Results suggest that rilpivirine 25 mg once daily, as part of individualized combination antiretroviral therapy, may be an appropriate option for HIV-1-infected pregnant women. TRIAL REGISTRATION ClinicalTrials.gov Identifier, NCT00855335.
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