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Bekker A, Salvadori N, Rabie H, du Toit S, Than-In-At K, Groenewald M, Cressey R, Nielsen J, Capparelli EV, Lallemant M, Cotton MF, Cressey TR. Paediatric abacavir-lamivudine fixed-dose dispersible tablets and ritonavir-boosted lopinavir granules in neonates exposed to HIV (PETITE study): an open-label, two-stage, single-arm, phase 1/2, pharmacokinetic and safety trial. Lancet HIV 2024; 11:e86-e95. [PMID: 38296364 DOI: 10.1016/s2352-3018(23)00289-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/16/2023] [Accepted: 10/26/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Existing solid antiretroviral fixed-dose combination formulations are preferred over liquid formulations in children, but their suitability for neonates is unknown. We evaluated the pharmacokinetics and safety of paediatric abacavir-lamivudine fixed-dose dispersible tablets and ritonavir-boosted lopinavir granules in neonates. METHODS In this open-label, two-stage, single-arm, phase 1/2, pharmacokinetic and safety trial, generic abacavir- lamivudine (120:60 mg) double-scored dispersible tablets and lopinavir boosted with ritonavir (40:10 mg) granules were studied. Neonates exposed to HIV (≥37 weeks gestational age) of no more than 3 days of age with birthweights of 2000-4000 g were identified through routine care in a tertiary hospital in Cape Town, South Africa. In stage 1, the pharmacokinetics and safety of two single doses were assessed to select the multidose strategy for stage 2. Neonates received a single dose of abacavir-lamivudine (30:15 mg, a quarter of a tablet) and lopinavir boosted with ritonavir (40:10 mg - one sachet) orally between 3 days and 14 days of age, and a second dose of a quarter tablet of abacavir-lamivudine and lopinavir boosted with ritonavir (80:20 mg, two sachets) 10-14 days later in stage 1. The multidose strategy selected in stage 2 was a quarter of the abacavir-lamivudine (30:15 mg) fixed-dose dispersible tablet once per day and two sachets of the lopinavir boosted with ritonavir (80:20 mg) granules twice per day from birth to age 28 days. In both stages two intensive pharmacokinetic visits were done, one at less than 14 days of life (pharmacokinetics 1) and another 10-14 days later (pharmacokinetics 2). Safety visits were done 1-2 weeks after each pharmacokinetic visit. Primary objectives were to assess pharmacokinetics and safety of abacavir, lamivudine, and lopinavir. Pharmacokinetic endpoints were area under the concentration time curve (AUC), maximum concentration, and concentration at end of dosing interval in all participants with at least one evaluable pharmacokinetic visit. Safety endpoints included grade 3 or worse adverse events, and grade 3 or worse treatment-related adverse events, occurring between study drug initiation and end of study. This completed trial is registered with the Pan African Clinical Trials Registry (PACTR202007806554538). FINDINGS Between Aug 18, 2021, and Aug 18, 2022, 24 neonates were enrolled into the trial and received study drugs. Eight neonates completed stage 1, meeting interim pharmacokinetic and safety criteria. In stage 2, 16 neonates received study drugs. Geometric mean abacavir and lamivudine exposures (AUC0-24) were higher at 6-14 days (51·7 mg × h/L for abacavir and 17·2 mg × h/L for lamivudine) than at 19-24 days of age (25·0 mg × h/L and 11·3 mg × h/L), whereas they were similar for lopinavir over this period (AUC 0-12 58·5 mg × h/L vs 46·4 mg × h/L). Abacavir geometric mean AUC0-24 crossed the upper reference range at pharmacokinetics 1, but rapidly decreased. Lamivudine and lopinavir AUC0-tau were within range. No grade 2 or worse adverse events were related to study drugs. One neonate had a grade 1 prolonged corrected QT interval using the Fridericia method that spontaneously resolved. INTERPRETATION Abacavir-lamivudine dispersible tablets and ritonavir-boosted lopinavir granules in neonates were safe and provided drug exposures similar to those in young infants. Although further safety data are needed, this regimen presents a new option for HIV prevention and treatment from birth. Accelerating neonatal pharmacokinetic studies of novel antiretroviral therapies is essential for neonates to also benefit from state-of-the-art treatments. FUNDING Unitaid.
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Affiliation(s)
- Adrie Bekker
- Family Centre for Research with Ubuntu, Stellenbosch University, Cape Town, South Africa
| | - Nicolas Salvadori
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand; Department of Statistics, Faculty of Science, Chiang Mai University, Chiang Mai, Thailand
| | - Helena Rabie
- Family Centre for Research with Ubuntu, Stellenbosch University, Cape Town, South Africa
| | - Samantha du Toit
- Family Centre for Research with Ubuntu, Stellenbosch University, Cape Town, South Africa
| | - Kanchana Than-In-At
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Marisa Groenewald
- Family Centre for Research with Ubuntu, Stellenbosch University, Cape Town, South Africa
| | - Ratchada Cressey
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - James Nielsen
- Hassenfield Children's Hospital at NYU Langone, New York, NY, USA
| | - Edmund V Capparelli
- Department of Pediatrics and Skaggs School of Pharmacy and Pharmaceutical Science, University of California San Diego, San Diego, CA, USA
| | - Marc Lallemant
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Mark F Cotton
- Family Centre for Research with Ubuntu, Stellenbosch University, Cape Town, South Africa
| | - Tim R Cressey
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand; Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand.
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Wiesner A, Skrońska M, Gawlik G, Marcinkowska M, Zagrodzki P, Paśko P. Interactions of Antiretroviral Drugs with Food, Beverages, Dietary Supplements, and Alcohol: A Systematic Review and Meta-analyses. AIDS Behav 2022; 27:1441-1468. [PMID: 36318429 PMCID: PMC10129904 DOI: 10.1007/s10461-022-03880-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2022] [Indexed: 04/28/2023]
Abstract
Multiple factors may affect combined antiretroviral therapy (cART). We investigated the impact of food, beverages, dietary supplements, and alcohol on the pharmacokinetic and pharmacodynamic parameters of 33 antiretroviral drugs. Systematic review in adherence to PRISMA guidelines was performed, with 109 reports of 120 studies included. For each drug, meta-analyses or qualitative analyses were conducted. We have found clinically significant interactions with food for more than half of antiretroviral agents. The following drugs should be taken with or immediately after the meal: tenofovir disoproxil, etravirine, rilpivirine, dolutegravir, elvitegravir, atazanavir, darunavir, lopinavir, nelfinavir, ritonavir, saquinavir. Didanosine, zalcitabine, zidovudine, efavirenz, amprenavir, fosamprenavir, and indinavir should be taken on an empty stomach for maximum patient benefit. Antiretroviral agents not mentioned above can be administered regardless of food. There is insufficient evidence available to make recommendations about consuming juice or alcohol with antiretroviral drugs. Resolving drug-food interactions may contribute to maximized cART effectiveness and safety.
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Affiliation(s)
- Agnieszka Wiesner
- Department of Food Chemistry and Nutrition, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna Str., 30-688, Kraków, Poland
| | - Magdalena Skrońska
- Department of Food Chemistry and Nutrition, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna Str., 30-688, Kraków, Poland
| | - Gabriela Gawlik
- Department of Community and Public Health, Idaho State University, 1311 E Central Dr, Meridian, ID, 83642, USA
| | - Monika Marcinkowska
- Department of Medicinal Chemistry, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna Str., 30-688, Kraków, Poland
| | - Paweł Zagrodzki
- Department of Food Chemistry and Nutrition, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna Str., 30-688, Kraków, Poland
| | - Paweł Paśko
- Department of Food Chemistry and Nutrition, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna Str., 30-688, Kraków, Poland.
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Bekker A, Rabie H, Salvadori N, du Toit S, Than-in-at K, Groenewald M, Andrieux-Meyer I, Kumar M, Cressey R, Nielsen J, Capparelli E, Lallemant M, Cotton MF, Cressey TR. Pharmacokinetics and Safety of the Abacavir/Lamivudine/Lopinavir/Ritonavir Fixed-Dose Granule Formulation (4-in-1) in Neonates: PETITE Study. J Acquir Immune Defic Syndr 2022; 89:324-331. [PMID: 34855626 PMCID: PMC8826609 DOI: 10.1097/qai.0000000000002871] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/15/2021] [Indexed: 12/03/2022]
Abstract
BACKGROUND Antiretroviral options for neonates (younger than 28 days) should be expanded. We evaluated the pharmacokinetics, safety, and acceptability of the "4-in-1" fixed-dose pediatric granule formulation of abacavir/lamivudine/lopinavir/ritonavir (30/15/40/10 mg) in neonates. METHODS The PETITE study is an ongoing phase I/II, open-label, single-arm, 2-stage trial conducted in South Africa. In stage 1, term neonates exposed to HIV on standard antiretroviral prophylaxis (nevirapine ± zidovudine) received single dose(s) of the 4-in-1 formulation, followed by intensive pharmacokinetic sampling and safety assessments. At each PK visit, blood was drawn after an observed dose at 1, 2, 4, 8, and 12 hours postdose. In this study, we have reported the planned interim pharmacokinetic and safety analysis after completion of the single-dose administration. RESULTS Sixteen neonates, with a median (range) birth weight of 3130 g (2790-3590 g), completed 24 pharmacokinetic visits. The 4-in-1 formulation imposed relatively high doses of abacavir [8.6 mg/kg (6.6-11.4)] and lamivudine [4.3 mg/kg (3.3-5.7)] but lower doses of lopinavir [11.5 mg/kg (8.8-15.2)]. The geometric means (GM, 90% CI) AUC0-12 of abacavir, lamivudine, and lopinavir were 29.87 (26.29-33.93), 12.61 (10.72-14.83), and 3.49 (2.13-5.72) µg.h/mL, respectively. Lopinavir GM AUC0-12 was below the predefined target (20-100 µg.h/mL), and ritonavir concentrations were only detectable in 4 of the 120 (3%) samples. No adverse events were related to study drugs. No neonate had difficulty swallowing the 4-in-1 formulation. CONCLUSIONS The high doses of abacavir and lamivudine (in mg/kg) and AUCs were safe, and the formulation was well tolerated; however, lopinavir/ritonavir exposures were extremely low, preventing its use in neonates use in neonates. Alternative pediatric solid antiretroviral formulations must be studied in neonates.
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Affiliation(s)
- Adrie Bekker
- Department of Pediatrics and Child Health, Family Centre for Research with Ubuntu, Stellenbosch University, Cape Town, South Africa
| | - Helena Rabie
- Department of Pediatrics and Child Health, Family Centre for Research with Ubuntu, Stellenbosch University, Cape Town, South Africa
| | - Nicolas Salvadori
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- MIVEGEC, University of Montpellier, CNRS, IRD, Montpellier, France
| | - Samantha du Toit
- Department of Pediatrics and Child Health, Family Centre for Research with Ubuntu, Stellenbosch University, Cape Town, South Africa
| | - Kanchana Than-in-at
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Marisa Groenewald
- Department of Pediatrics and Child Health, Family Centre for Research with Ubuntu, Stellenbosch University, Cape Town, South Africa
| | | | | | - Ratchada Cressey
- Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - James Nielsen
- Hassenfield Children's Hospital at NYU Langone, New York, NY
| | | | - Marc Lallemant
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Mark F. Cotton
- Department of Pediatrics and Child Health, Family Centre for Research with Ubuntu, Stellenbosch University, Cape Town, South Africa
| | - Tim R. Cressey
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- MIVEGEC, University of Montpellier, CNRS, IRD, Montpellier, France
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
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Saeed AM, Schmidt JM, Munasinghe WP, Vallabh BK, Jarvis MF, Morris JB, Mostafa NM. Comparative Bioavailability of Two Formulations of Biopharmaceutical Classification System (BCS) Class IV Drugs: A Case Study of Lopinavir/Ritonavir. J Pharm Sci 2021; 110:3963-3968. [PMID: 34530003 DOI: 10.1016/j.xphs.2021.08.037] [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] [Received: 03/19/2021] [Revised: 08/23/2021] [Accepted: 08/23/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Lopinavir/ritonavir (LPV/r-A, Kaletra®), a fixed dose, co-formulated antiviral therapy for the treatment of HIV infection has been used worldwide for over two decades. Both active substances have low solubility in water and low membrane permeability. LPV/r-A tablets contain key excipients critical to ensuring acceptable bioavailability of lopinavir and ritonavir in humans. An established dog pharmacokinetic model demonstrated several generic LPV/r tablet formulations have significant oral bioavailability variability compared to LPV/r-A. METHODS Analytical characterizations of LPV/r-B tablets were performed and a clinical study was conducted to assess the relative bioavailability of Kalidavir® (LPV/r-B) 400/100 mg tablets relative to Kaletra® (LPV/r-A) 400/100 mg tablets under fasting conditions. RESULTS The presence of active substances were confirmed in LPV/r-B tablets in an apparent amorphous state at essentially the labeled amounts, and dissolution profiles were generally similar to LPV/r-A tablets. Excipients in the tablet formulation were found to be variable and deviate from the labeled composition. Lopinavir and ritonavir exposures (AUC) following LPV/r-B administration were approximately 90% and 20% lower compared to that of LPV/r-A. CONCLUSIONS LPV/r-B was not shown to be bioequivalent to LPV/r-A.
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Affiliation(s)
- Ahmed M Saeed
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., North Chicago, IL, USA
| | | | | | | | | | - John B Morris
- Development Sciences, AbbVie, Inc., North Chicago, IL, USA
| | - Nael M Mostafa
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., North Chicago, IL, USA.
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Thakur A, Tan SPF, Chan JCY. Physiologically-Based Pharmacokinetic Modeling to Predict the Clinical Efficacy of the Coadministration of Lopinavir and Ritonavir against SARS-CoV-2. Clin Pharmacol Ther 2020; 108:1176-1184. [PMID: 32767755 PMCID: PMC7436510 DOI: 10.1002/cpt.2014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/28/2020] [Indexed: 12/26/2022]
Abstract
Lopinavir/ritonavir, originally developed for treating HIV, is currently undergoing clinical studies for treating the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Although recent reports suggest that lopinavir exhibits in vitro efficacy against SARS‐CoV‐2, it is a highly protein‐bound drug and it remains unknown if it reaches adequate in vivo unbound (free) concentrations in lung tissue. We built a physiologically‐based pharmacokinetic model of lopinavir/ritonavir in white and Chinese populations. Our aim was to perform pharmacokinetic/pharmacodynamic correlations by comparing simulated free plasma and lung concentration values achieved using different dosing regimens of lopinavir/ritonavir with unbound half‐maximal effective concentration (EC50,unbound) and unbound effective concentration 90% values of lopinavir against SARS‐CoV‐2. The model was validated against multiple observed clinical datasets for single and repeated dosing of lopinavir/ritonavir. Predicted pharmacokinetic parameters, such as the maximum plasma concentration, area under the plasma concentration‐time profile, oral clearance, half‐life, and minimum plasma concentration at steady‐state were within two‐fold of clinical values for both populations. Using the current lopinavir/ritonavir regimen of 400/100 mg twice daily, lopinavir does not achieve sufficient free lung concentrations for efficacy against SARS‐CoV‐2. Although the Chinese population reaches greater plasma and lung concentrations as compared with whites, our simulations suggest that a significant dose increase from the current clinically used dosing regimen is necessary to reach the EC50,unbound value for both populations. Based on safety data, higher doses would likely lead to QT prolongation and gastrointestinal disorders (nausea, vomiting, and diarrhea), thus, any dose adjustment must be carefully weighed alongside these safety concerns.
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Affiliation(s)
- Aarzoo Thakur
- Innovations in Food and Chemical Safety, Agency for Science, Technology, and Research, Singapore City, Singapore.,Skin Research Institute of Singapore, Agency for Science, Technology, and Research, Singapore City, Singapore
| | - Shawn Pei Feng Tan
- Innovations in Food and Chemical Safety, Agency for Science, Technology, and Research, Singapore City, Singapore.,Skin Research Institute of Singapore, Agency for Science, Technology, and Research, Singapore City, Singapore
| | - James Chun Yip Chan
- Innovations in Food and Chemical Safety, Agency for Science, Technology, and Research, Singapore City, Singapore.,Skin Research Institute of Singapore, Agency for Science, Technology, and Research, Singapore City, Singapore.,Singapore Institute of Food and Biotechnology Innovation, Agency for Science, Technology, and Research, Singapore City, Singapore
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Ibarra M, Fagiolino P, Vázquez M, Ruiz S, Vega M, Bellocq B, Pérez M, González B, Goyret A. Impact of food administration on lopinavir-ritonavir bioequivalence studies. Eur J Pharm Sci 2012; 46:516-21. [PMID: 22522225 DOI: 10.1016/j.ejps.2012.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 02/23/2012] [Accepted: 04/03/2012] [Indexed: 10/28/2022]
Abstract
A bioequivalence study in 16 Caucasian healthy volunteers (eight male, eight female), comparing plasma drug concentrations after a single oral dose of lopinavir and ritonavir (400 and 100mg, respectively), was carried out following a two-period, two-sequence, two-treatment, randomized crossover design. Formulations were given 15 min after a moderate-fat breakfast in order to diminish both the intrinsic highly-variable performance and the sex differences observed in bioequivalence trials under fasting conditions. Ninety percent confidence intervals for the Test/Reference (T/R) ratio of geometric means for area under concentration-time curve (AUC) and maximum concentration (C(MAX)), either for lopinavir or ritonavir, were within the range of 0.80-1.25. Coprandial administration of formulations not only reduced the number of subjects required for bioequivalence assessment, reducing both ethical and economic cost of the trial, but also the sex differences in the T/R ratio of means.
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Affiliation(s)
- M Ibarra
- Center of Bioavailability and Bioequivalence for Medicine Evaluation, University of the Republic, Uruguay
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