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Lepage MA, Rozza N, Kremer R, Grunbaum A. Safety and effectiveness concerns of lopinavir/ritonavir in COVID-19 affected patients: a retrospective series. Clin Toxicol (Phila) 2021; 59:644-647. [PMID: 33641562 PMCID: PMC7919102 DOI: 10.1080/15563650.2020.1842882] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Context Originally developed for treatment of human immunodeficiency virus (HIV), the antiviral combination lopinavir/ritonavir (LPV/r) is being repurposed for treating the novel coronavirus disease (COVID-19) despite minimal experience in this markedly different population and an in-vitro derived EC50 against SARS-CoV-2 several hundred-fold greater than for HIV. We present a case series including a case of severe hyponatremia and a 32-fold overdose raising safety and effectiveness concerns in COVID-19 patients. Methods We measured LPV trough concentrations in 12 patients and reviewed their clinical charts for side effects known to occur in HIV patients. Findings Compared to established LPV trough concentrations in HIV patients, concentrations in COVID-19 patients were 3-fold greater (19.37 ± 10.12 mcg/mL versus 6.25 mcg/mL). In addition, cholestasis and dyslipidemia toxicity thresholds were exceeded in 12/12 and 11/12 patients respectively. No patients achieved the presumed therapeutic concentration. Side effects included gastrointestinal symptoms (5/12), electrolyte imbalances (4/12), liver enzyme disturbances (5/12) and triglyceride elevations (2/12). Conclusion No patients reached presumed therapeutic LPV concentrations despite experiencing side effects and exceeding cholestasis and dyslipidemia toxicity thresholds. This raises concerns for the safety and effectiveness of LPV/r. Clinicians should consider closely monitoring for side effects and not necessarily attribute them to COVID-19.
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Affiliation(s)
- Marc-Antoine Lepage
- McGill University Health Centre, Montreal, Canada.,McGill Faculty of Medecine and Health Sciences, Montreal, Canada
| | - Nicholas Rozza
- McGill Faculty of Medecine and Health Sciences, Montreal, Canada
| | - Richard Kremer
- McGill University Health Centre, Montreal, Canada.,McGill Faculty of Medecine and Health Sciences, Montreal, Canada
| | - Ami Grunbaum
- McGill University Health Centre, Montreal, Canada.,McGill Faculty of Medecine and Health Sciences, Montreal, Canada
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2
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Batteux B, Bodeau S, Gras-Champel V, Liabeuf S, Lanoix JP, Schmit JL, Andréjak C, Zerbib Y, Haye G, Masmoudi K, Lemaire-Hurtel AS, Bennis Y. Abnormal laboratory findings and plasma concentration monitoring of lopinavir and ritonavir in COVID-19. Br J Clin Pharmacol 2020; 87:1547-1553. [PMID: 32692462 DOI: 10.1111/bcp.14489] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/22/2020] [Accepted: 07/13/2020] [Indexed: 12/15/2022] Open
Abstract
It is not known whether the adverse events (AEs) associated with the administration of lopinavir and ritonavir (LPV/r) in the treatment of COVID-19 are concentration-dependent. In a retrospective study of 65 patients treated with LPV/r and therapeutic drug monitoring (TDM) for severe forms of COVID-19 (median age: 67; males: 41 [63.1%]), 33 (50.8%) displayed a grade ≥2 increase in plasma levels of hepatobiliary markers, lipase and/or triglycerides. A causal relationship between LPV/r and the AE was suspected in 9 of the 65 patients (13.8%). At 400 mg b.i.d., the plasma trough concentrations of LPV/r were high and showed marked interindividual variability (median [interquartile range]: 16,600 [11,430-20,842] ng/ml for lopinavir and 501 [247-891] ng/ml for ritonavir). The trough lopinavir concentration was negatively correlated with body mass index, while the trough ritonavir concentration was positively correlated with age and negatively correlated with prothrombin activity. However, the occurrence of abnormal laboratory values was not associated with higher trough plasma concentrations of LPV/r. Further studies will be needed to determine the value of TDM in LPV/r-treated patients with COVID-19.
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Affiliation(s)
- Benjamin Batteux
- Department of Clinical Pharmacology, Amiens University Hospital, Amiens, France.,MP3CV laboratory, EA 7517, Jules Verne University of Picardie, Amiens, France
| | - Sandra Bodeau
- Department of Clinical Pharmacology, Amiens University Hospital, Amiens, France.,MP3CV laboratory, EA 7517, Jules Verne University of Picardie, Amiens, France
| | - Valérie Gras-Champel
- Department of Clinical Pharmacology, Amiens University Hospital, Amiens, France.,MP3CV laboratory, EA 7517, Jules Verne University of Picardie, Amiens, France
| | - Sophie Liabeuf
- Department of Clinical Pharmacology, Amiens University Hospital, Amiens, France.,MP3CV laboratory, EA 7517, Jules Verne University of Picardie, Amiens, France.,Department of Clinical Research, Amiens University Hospital, Amiens, France
| | - Jean-Philippe Lanoix
- Department of Infectious Diseases, Amiens University Hospital, Amiens, France.,AGIR, EA 4294, Jules Verne University of Picardie, Amiens, France
| | - Jean-Luc Schmit
- Department of Infectious Diseases, Amiens University Hospital, Amiens, France.,AGIR, EA 4294, Jules Verne University of Picardie, Amiens, France
| | - Claire Andréjak
- AGIR, EA 4294, Jules Verne University of Picardie, Amiens, France.,Department of Pulmonology, Amiens University Hospital, Amiens, France
| | - Yoann Zerbib
- Department of Intensive Care and BoReal study group, Amiens University Hospital, Amiens, France
| | - Guillaume Haye
- Department of Anaesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Kamel Masmoudi
- Department of Clinical Pharmacology, Amiens University Hospital, Amiens, France
| | | | - Youssef Bennis
- Department of Clinical Pharmacology, Amiens University Hospital, Amiens, France.,MP3CV laboratory, EA 7517, Jules Verne University of Picardie, Amiens, France
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4
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Chen FC, Liao YC, Huang JM, Lin CH, Chen YY, Dou HY, Hsiung CA. Pros and cons of the tuberculosis drugome approach--an empirical analysis. PLoS One 2014; 9:e100829. [PMID: 24971632 PMCID: PMC4074101 DOI: 10.1371/journal.pone.0100829] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 05/27/2014] [Indexed: 01/20/2023] Open
Abstract
Drug-resistant Mycobacterium tuberculosis (MTB), the causative pathogen of tuberculosis (TB), has become a serious threat to global public health. Yet the development of novel drugs against MTB has been lagging. One potentially powerful approach to drug development is computation-aided repositioning of current drugs. However, the effectiveness of this approach has rarely been examined. Here we select the "TB drugome" approach--a protein structure-based method for drug repositioning for tuberculosis treatment--to (1) experimentally validate the efficacy of the identified drug candidates for inhibiting MTB growth, and (2) computationally examine how consistently drug candidates are prioritized, considering changes in input data. Twenty three drugs in the TB drugome were tested. Of them, only two drugs (tamoxifen and 4-hydroxytamoxifen) effectively suppressed MTB growth at relatively high concentrations. Both drugs significantly enhanced the inhibitory effects of three first-line anti-TB drugs (rifampin, isoniazid, and ethambutol). However, tamoxifen is not a top-listed drug in the TB drugome, and 4-hydroxytamoxifen is not approved for use in humans. Computational re-examination of the TB drugome indicated that the rankings were subject to technical and data-related biases. Thus, although our results support the effectiveness of the TB drugome approach for identifying drugs that can potentially be repositioned for stand-alone applications or for combination treatments for TB, the approach requires further refinements via incorporation of additional biological information. Our findings can also be extended to other structure-based drug repositioning methods.
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Affiliation(s)
- Feng-Chi Chen
- Division of Biostatistics and Bioinformatics, Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli County, Taiwan
- Department of Life Sciences, National Chiao-Tung University, Hsinchu, Taiwan
- Department of Dentistry, China Medical University, Taichung, Taiwan
| | - Yu-Chieh Liao
- Division of Biostatistics and Bioinformatics, Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli County, Taiwan
| | - Jie-Mao Huang
- Division of Biostatistics and Bioinformatics, Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli County, Taiwan
| | - Chieh-Hua Lin
- Division of Biostatistics and Bioinformatics, Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli County, Taiwan
- Institute of Bioinformatics and Structural Biology, National Tsing Hua University, Hsinchu, Taiwan
| | - Yih-Yuan Chen
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan, Miaoli County, Taiwan
| | - Horng-Yunn Dou
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan, Miaoli County, Taiwan
| | - Chao Agnes Hsiung
- Division of Biostatistics and Bioinformatics, Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli County, Taiwan
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Milazzo L, Ebranati E, Cattaneo D, Gabanelli E, Lai A, Zehender G, Gervasoni C. Recurrence of another hepatitis B virus escape mutant comes back in a patient infected with HIV and low CD4+ count. J Med Virol 2013; 86:97-101. [DOI: 10.1002/jmv.23721] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2013] [Indexed: 01/24/2023]
Affiliation(s)
- Laura Milazzo
- III Division of Infectious Diseases; Luigi Sacco University Hospital; Milan Italy
| | - Erika Ebranati
- Department of Clinical Sciences ‘L Sacco’ Hospital, Section of Infectious Diseases and Immunopathology; University of Milan; Milan Italy
| | - Dario Cattaneo
- Unit of Clinical Pharmacology; Luigi Sacco University Hospital; Milan Italy
| | - Elena Gabanelli
- Department of Clinical Sciences ‘L Sacco’ Hospital, Section of Infectious Diseases and Immunopathology; University of Milan; Milan Italy
| | - Alessia Lai
- Department of Clinical Sciences ‘L Sacco’ Hospital, Section of Infectious Diseases and Immunopathology; University of Milan; Milan Italy
| | - Gianguglielmo Zehender
- Department of Clinical Sciences ‘L Sacco’ Hospital, Section of Infectious Diseases and Immunopathology; University of Milan; Milan Italy
| | - Cristina Gervasoni
- III Division of Infectious Diseases; Luigi Sacco University Hospital; Milan Italy
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6
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Nies AT, Niemi M, Burk O, Winter S, Zanger UM, Stieger B, Schwab M, Schaeffeler E. Genetics is a major determinant of expression of the human hepatic uptake transporter OATP1B1, but not of OATP1B3 and OATP2B1. Genome Med 2013; 5:1. [PMID: 23311897 PMCID: PMC3706890 DOI: 10.1186/gm405] [Citation(s) in RCA: 145] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 01/04/2013] [Accepted: 01/11/2013] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Organic anion transporting polypeptide (OATP) 1B1, OATP1B3, and OATP2B1 (encoded by SLCO1B1, SLCO1B3, SLCO2B1) mediate the hepatic uptake of endogenous compounds like bile acids and of drugs, for example, the lipid-lowering atorvastatin, thereby influencing hepatobiliary elimination. Here we systematically elucidated the contribution of SLCO variants on expression of the three hepatic OATPs under consideration of additional important covariates. METHODS Expression was quantified by RT-PCR and immunoblotting in 143 Caucasian liver samples. A total of 109 rare and common variants in the SLCO1B3-SLCO1B1 genomic region and the SLCO2B1 gene were genotyped by MALDI-TOF mass spectrometry and genome-wide SNP microarray technology. SLCO1B1 haplotypes affecting hepatic OATP1B1 expression were associated with pharmacokinetic data of the OATP1B1 substrate atorvastatin (n = 82). RESULTS Expression of OATP1B1, OATP1B3, and OATP2B1 at the mRNA and protein levels showed marked interindividual variability. All three OATPs were expressed in a coordinated fashion. By a multivariate regression analysis adjusted for non-genetic and transcription covariates, increased OATP1B1 expression was associated with the coding SLCO1B1 variant c.388A > G (rs2306283) even after correction for multiple testing (P = 0.00034). This held true for haplotypes harboring c.388A > G but not the functional variant c.521T > C (rs4149056) associated with statin-related myopathy. c.388A > G also significantly affected atorvastatin pharmacokinetics. SLCO variants and non-genetic and regulatory covariates together accounted for 59% of variability of OATP1B1 expression. CONCLUSIONS Our results show that expression of OATP1B1, but not of OATP1B3 and OATP2B1, is significantly affected by genetic variants. The SLCO1B1 variant c.388A > G is the major determinant with additional consequences on atorvastatin plasma levels.
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Affiliation(s)
- Anne T Nies
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Auerbachstrasse 112, 70376 Stuttgart, Germany, and University of Tübingen
| | - Mikko Niemi
- Department of Clinical Pharmacology, University of Helsinki and HUSLAB Helsinki University Central Hospital, FI-00014 Helsinki, Finland
| | - Oliver Burk
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Auerbachstrasse 112, 70376 Stuttgart, Germany, and University of Tübingen
| | - Stefan Winter
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Auerbachstrasse 112, 70376 Stuttgart, Germany, and University of Tübingen
| | - Ulrich M Zanger
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Auerbachstrasse 112, 70376 Stuttgart, Germany, and University of Tübingen
| | - Bruno Stieger
- Division of Clinical Pharmacology and Toxicology, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Auerbachstrasse 112, 70376 Stuttgart, Germany, and University of Tübingen
- Department of Clinical Pharmacology, Institute of Experimental and Clinical Pharmacology and Toxicology, University of Tübingen, Otfried-Müller-Strasse 45, 72076 Tübingen, Germany
| | - Elke Schaeffeler
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Auerbachstrasse 112, 70376 Stuttgart, Germany, and University of Tübingen
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7
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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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8
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Caswell RJ, Phillips D, Chaponda M, Khoo SH, Taylor GP, Ghanem M, Poulton M, Welch J, Gibbons S, Jackson V, Lambert JS. Utility of therapeutic drug monitoring in the management of HIV-infected pregnant women in receipt of lopinavir. Int J STD AIDS 2011; 22:11-4. [PMID: 21364060 PMCID: PMC3594887 DOI: 10.1258/ijsa.2009.009184] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The pharmacokinetics of antiretroviral drugs in pregnancy is poorly understood. We reviewed the use of therapeutic drug monitoring (TDM) in clinical settings to document plasma concentrations of lopinavir during pregnancy and investigated how clinicians acted upon TDM results. A retrospective review was carried out of all HIV-infected pregnant women taking boosted lopinavir-based highly active antiretroviral therapy (HAART) at five National Health Service (NHS) centres in the UK between May 2004 and March 2007. Seventy-three women in receipt of lopinavir were identified, of whom 89% had plasma lopinavir concentrations above the suggested minimum recommended for wild-type HIV. Initial TDM results prompted dosage change in 10% and assessment of adherence and/or pharmacist review in 11%. TDM was repeated in 29%. TDM can play an important role in the clinical management of HIV-positive pregnant women, allowing informed dose modification and an alternative measure of adherence.
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Affiliation(s)
- R J Caswell
- Department of GU Medicine and Teaching Primary Care Trust, Coventry PCT, Coventry
| | | | - M Chaponda
- Department of Pharmacology, University of Liverpool, Liverpool
| | - S H Khoo
- Department of Pharmacology, University of Liverpool, Liverpool
| | - G P Taylor
- Department GU Medicine, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London
| | - M Ghanem
- Summers Unit, Northamptonshire Healthcare NHS Trust, Northampton
| | - M Poulton
- Caldecot Centre, King’s College Hospital, London, UK
| | - J Welch
- Department of Infectious Diseases, The Rotunda Hospital, Dublin
| | | | - V Jackson
- Department of Infectious Diseases, The Rotunda Hospital, Dublin
| | - J S Lambert
- Department of Medicine (Infectious Diseases), Catherine McAuley Research Centre, Mater Misericordiae University Hospital, Dublin
- Department of Medicine, University College Dublin, Dublin, Ireland
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9
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Else L, Watson V, Tjia J, Hughes A, Siccardi M, Khoo S, Back D. Validation of a rapid and sensitive high-performance liquid chromatography–tandem mass spectrometry (HPLC–MS/MS) assay for the simultaneous determination of existing and new antiretroviral compounds. J Chromatogr B Analyt Technol Biomed Life Sci 2010; 878:1455-65. [DOI: 10.1016/j.jchromb.2010.03.036] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 03/12/2010] [Accepted: 03/17/2010] [Indexed: 10/19/2022]
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10
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Risk factors for grade 3 or 4 gamma-glutamyl transferase elevation in HIV/hepatitis C virus-coinfected patients. AIDS 2008; 22:1234-6. [PMID: 18525274 DOI: 10.1097/qad.0b013e3282fbd203] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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