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Dragović G, Dimitrijević B, Kušić J, Soldatović I, Jevtović D, Olagunju A, Owen A. Influence of SLCO1B1 polymorphisms on lopinavir C trough in Serbian HIV/AIDS patients. Br J Clin Pharmacol 2020; 86:1289-1295. [PMID: 32022294 DOI: 10.1111/bcp.14230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 12/31/2019] [Accepted: 01/21/2020] [Indexed: 12/20/2022] Open
Abstract
AIMS Lopinavir (LPV) is not a first-line regimen. According to recent WHO data, LPV usage in low- and middle-income countries accounted for approximately 52% of the adult and 23% of the paediatric protease inhibitor market in 2017. Since LPV is a substrate for the SLCO1B1 (OATP1B1) transporter, the aim of this study was to assess the impact of SLCO1B1 polymorphisms (rs11045819, rs4149032 and rs4149056) on LPV trough plasma concentrations (Ctrough ) in Serbian patients. METHODS Plasma samples from 104 HIV/AIDS Caucasians were collected. LPV Ctrough was quantified using liquid-chromatography-mass spectrometry. Genotyping was carried out using real-time-PCR-based allelic discrimination. One-way analysis of variance, t test and linear regression were used for data analysis. RESULTS The overall mean (SD) LPV Ctrough was 5885 ± 2755 ng/mL. Significant differences were between patients with different rs11045819 genotypes: CC (LPV median Ctrough = 6072 ng/mL, interquartile range (IQR) = 4318-7617 ng/mL), CA (LPV median Ctrough = 4987 ng/mL, IQR = 4300-6295 ng/mL) and AA (LPV median Ctrough = 3648 ng/mL, IQR = 1949-4072 ng/mL) (P = .005). Significant differences were also observed according to rs4149032 genotype: CC (LPV median Ctrough = 6027 ng/mL, IQR =4548-8250 ng/mL), CT (LPV median Ctrough = 5553 ng/mL, IQR = 4300-6888 ng/mL) and TT (LPV median Ctrough = 4408 ng/mL, IQR = 3361-5233 ng/mL) (P = .007). For rs4149056 a statistically significant difference between T-homozygotes (LPV median Ctrough = 5434 ng/mL, IQR = 3855-6830 ng/mL), heterozygotes (LPV median Ctrough = 6707 ng/mL, IQR = 5088-8063 ng/mL) and C-homozygotes (LPV median Ctrough = 13906 ng/mL, IQR = 12946-14866 ng/mL) was observed (P = .002). In multivariate regression analysis, only the SLCO1B1 rs4149056 polymorphism was independently associated with higher LPV Ctrough (β = 2834.5 [1442-4226.9] ng/mL [P = .001]). CONCLUSIONS Our results demonstrate a statistically significant influence of the SLCO1B1 rs4149056 polymorphism on higher LPV Ctrough in Caucasian HIV/AIDS patients.
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Affiliation(s)
- Gordana Dragović
- Department of Pharmacology, Clinical Pharmacology and Toxicology, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Božana Dimitrijević
- Department of Pharmacology, Clinical Pharmacology and Toxicology, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jovana Kušić
- Department of Pharmacology, Clinical Pharmacology and Toxicology, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivan Soldatović
- Institute for Biomedical Statistics, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Djordje Jevtović
- Infectious and Tropical Diseases Hospital, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Adeniyi Olagunju
- Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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Bienczak A, Cook A, Wiesner L, Mulenga V, Kityo C, Kekitiinwa A, Walker AS, Owen A, Gibb DM, Burger D, McIlleron H, Denti P. Effect of diurnal variation, CYP2B6 genotype and age on the pharmacokinetics of nevirapine in African children. J Antimicrob Chemother 2017; 72:190-199. [PMID: 27707991 PMCID: PMC5161049 DOI: 10.1093/jac/dkw388] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 08/16/2016] [Accepted: 08/17/2016] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To characterize the effects of CYP2B6 polymorphisms, diurnal variation and demographic factors on nevirapine pharmacokinetics in African children. METHODS Non-linear mixed-effects modelling conducted in NONMEM 7.3 described nevirapine plasma concentration-time data from 414 children aged 0.3-15 years. RESULTS Nevirapine pharmacokinetics was best described using a one-compartment disposition model with elimination through a well-stirred liver model accounting for a first-pass effect and transit-compartment absorption. Intrinsic clearance was affected by diurnal variation (characterized using a cosine function with peak amplitude 29% at 12 noon) and CYP2B6 metabolizer status [extensive metabolizer (EM) 516GG|983TT, reference; intermediate metabolizer (IM) 516GT|983TT or 516GG|983TC, 17% lower; slow metabolizer (SM) 516TT|983TT or 516GT|983TC, 50% lower; ultra-slow metabolizer (USM) 516GG|983CC, 68% lower]. Age was found to affect pre-hepatic bioavailability: 31.7% lower at birth and increasing exponentially. Median (90% CI) evening Cmin values in the different metabolizer groups were 5.01 (3.01-7.47), 6.55 (3.65-13.32), 11.59 (5.44-22.71) and 12.32 (12.32-27.25) mg/L, respectively. Evening Cmin values were <3 mg/L in 43% of EM weighing <6 kg and 26% of IM weighing <6 kg, while 73% of SM and 88% of USM in all weight-bands had evening Cmin values >8 mg/L. Cmin was not markedly affected by administration time, but was altered by unequal splitting of the daily dose. CONCLUSIONS Diurnal variation does not greatly affect nevirapine exposure. However, when daily doses cannot be split equally, the larger dose should be given in the morning. To achieve homogeneous exposures, nevirapine doses for SM and USM should be reduced by 50%, and children weighing <6 kg with EM or IM metabolizer status should receive the same dose as children weighing 6-10 kg.
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Affiliation(s)
- Andrzej Bienczak
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Adrian Cook
- MRC Clinical Trials Unit at University College London, London, UK
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Veronica Mulenga
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - Addy Kekitiinwa
- Baylor College of Medicine Bristol-Myers Squibb Children's Clinical Centre of Excellence, Kampala, Uganda/Gulu Regional Centre of Excellence, Gulu, Uganda
| | - A Sarah Walker
- MRC Clinical Trials Unit at University College London, London, UK
| | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Diana M Gibb
- MRC Clinical Trials Unit at University College London, London, UK
| | - David Burger
- Department of Pharmacy, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Zhang C, Denti P, Decloedt E, Maartens G, Karlsson MO, Simonsson USH, McIlleron H. Model-based approach to dose optimization of lopinavir/ritonavir when co-administered with rifampicin. Br J Clin Pharmacol 2012; 73:758-67. [PMID: 22126409 PMCID: PMC3403203 DOI: 10.1111/j.1365-2125.2011.04154.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AIMS Rifampicin, a key component of antitubercular treatment, profoundly reduces lopinavir concentrations. The aim of this study was to develop an integrated population pharmacokinetic model accounting for the drug-drug interactions between lopinavir, ritonavir and rifampicin, and to evaluate optimal doses of lopinavir/ritonavir when co-administered with rifampicin. METHODS Steady-state pharmacokinetics of lopinavir and ritonavir were sequentially evaluated after the introduction of rifampicin and gradually escalating the dose in a cohort of 21 HIV-infected adults. Intensive pharmacokinetic sampling was performed after each dose adjustment following a morning dose administered after fasting overnight. A population pharmacokinetic analysis was conducted using NONMEM 7. RESULTS A simultaneous integrated model was built. Rifampicin reduced the oral bioavailability of lopinavir and ritonavir by 20% and 45% respectively, and it increased their clearance by 71% and 36% respectively. With increasing concentrations of ritonavir, clearance of lopinavir decreased in an E(max) relationship. Bioavailability was 42% and 45% higher for evening doses compared with morning doses for lopinavir and ritonavir, respectively, while oral clearance of both drugs was 33% lower overnight. Simulations predicted that 99.5% of our patients receiving doubled doses of lopinavir/ritonavir achieve morning trough concentrations of lopinavir > 1 mg l(-1) during rifampicin co-administration, and 95% of those weighing less than 50 kg achieve this target already with 600/150 mg doses of lopinavir/ritonavir. CONCLUSIONS The model describes the drug-drug interactions between lopinavir, ritonavir and rifampicin in adults. The higher trough concentrations observed in the morning were explained by both higher bioavailability with the evening meal and lower clearance overnight.
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Affiliation(s)
- Chao Zhang
- Division of Clinical Pharmacology, Department of Medicine, University of Cape TownCape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape TownCape Town, South Africa
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, University of Cape TownCape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape TownCape Town, South Africa
| | - Mats O Karlsson
- Department of Pharmaceutical Biosciences, Uppsala UniversityUppsala, Sweden
| | | | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape TownCape Town, South Africa
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Yakasai AM, Muhammad H, Babashani M, Jumare J, Abdulmumini M, Habib AG. Once-daily antiretroviral therapy among treatment-experienced Muslim patients fasting for the month of Ramadan. Trop Doct 2011; 41:233-5. [PMID: 21914677 DOI: 10.1258/td.2011.110130] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Many countries with a considerable burden of human immunodeficiency virus (HIV) infection in Africa and Asia also have a substantial Muslim population. Anti-retroviral therapy (ART) has led to reductions in HIV morbidity and mortality in those areas. However, for ART to remain durably effective its provision should be adapted to local and religious customary practices such as Ramadan fasting. The fasting is often observed by Muslims with HIV infection and ART might be compromised by sub-optimal adherence during fasting as it precludes the ingestion of oral substances during the daytime and is often associated with an alteration of meals/sleeping patterns. We studied once-daily compared to twice-daily dosed ritonovir boosted lopinavir with fixed-dose tenofovir-emtricitabine once-daily among 17 heavily treatment-experienced stable FT patients in Nigeria. No changes in adherence, diarrhoea, CD4 cell counts, viral load, haematocrit, kidney, liver and lipid tests were observed. Effectiveness, safety and tolerability appeared unaffected by the changes.
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Affiliation(s)
- Ahmed M Yakasai
- Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
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Pharmacokinetics of lopinavir in HIV-infected adults receiving rifampin with adjusted doses of lopinavir-ritonavir tablets. Antimicrob Agents Chemother 2011; 55:3195-200. [PMID: 21537021 DOI: 10.1128/aac.01598-10] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Rifampin coadministration dramatically reduces plasma lopinavir (LPV) concentrations. In healthy volunteers, doubling the dose of a lopinavir-ritonavir (LPV/r) capsule formulation overcame this interaction, but a subsequent study of double doses of the tablet formulation was stopped early owing to hepatotoxicity. However, healthy-volunteer study findings may not apply to HIV-infected adults. We evaluated the steady-state pharmacokinetics of LPV in HIV-infected adults virologically suppressed on an LPV/r regimen who were given rifampin, and the dose of the LPV/r tablet formulation was gradually increased. The steady-state pharmacokinetics of LPV/r were evaluated at baseline, a week after commencing rifampin, a week after the LPV/r dose was increased 1.5 times, and a week after the LPV/r dose was doubled. Twenty-one participants were enrolled. The median [interquartile range (IQR)] predose LPV concentrations (C(0)) were 8.1 (6.2 to 9.8) mg/liter at baseline, 1.7 (0.3 to 3.0) mg/liter after 7 days of rifampin, 5.9 (2.1 to 9.9) mg/liter with 1.5 times the dose of LPV/r, and 10.8 (7.0 to 13.1) mg/liter with double-dose LPV/r. There were no significant differences in the LPV area under the plasma concentration-time curve from 0 to 12 h (AUC(0-12)), C(0), C(12), maximum concentration of drug in serum (C(max)), or half-life (t(1/2)) between the baseline and double-dose LPV/r time points. Treatment was generally well tolerated, with two participants developing asymptomatic grade 3/4 transaminitis. Doubling the dose of the tablet formulation of LPV/r overcomes induction by rifampin. Less hepatotoxicity occurred in our cohort of HIV-infected participants than was reported in healthy-volunteer studies.
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Mathiesen S, Justesen US, Von Lüttichau HR, Hansen ABE. Genotyping of CYP2B6 and therapeutic drug monitoring in an HIV-infected patient with high efavirenz plasma concentrations and severe CNS side-effects. ACTA ACUST UNITED AC 2009; 38:733-5. [PMID: 16857630 DOI: 10.1080/00365540500504109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We present a case with important pharmacogenetic and pharmacokinetic aspects of antiretroviral therapy in a patient with high efavirenz concentrations, severe CNS side-effects and low lopinavir concentrations. Despite therapeutic drug monitoring and subsequent efavirenz dosage reductions, side-effects did not resolve completely and lopinavir concentrations remained relatively low.
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Affiliation(s)
- Sofie Mathiesen
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen.
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Habib AG, Shepherd JC, Eng MKL, Babashani M, Jumare J, Yakubu U, Gebi UI, Saad M, Ibrahim H, Blattner WA. Adherence to anti retroviral therapy (ART) during Muslim Ramadan fasting. AIDS Behav 2009; 13:42-5. [PMID: 18521736 DOI: 10.1007/s10461-008-9412-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2007] [Accepted: 05/12/2008] [Indexed: 11/27/2022]
Abstract
Annual fasting during the month of Ramadan is observed in Muslim countries, some of which have widespread HIV infection. We studied treatment adherence and customary practices among 142 fasting 'FT' and 101 non-fasting 'NFT' patients on anti-retroviral therapy (ART) in Nigeria. Adherence on ART among FT and NFT patients was similar during Ramadan, 96% and 98%, and ever since commencement of ART, 80% and 88%, respectively. FT patients altered their typical daily behaviors by advancing morning and delaying evening doses thereby prolonging dosing intervals, eating heavier meals pre-dawn and on breakfast at sunset (78%), and changing or reducing their sleeping and waking times (40%). This preliminary study suggests that adherence and drug taking frequency appear uncompromised in FT HIV infected patients on ARVs.
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Affiliation(s)
- A G Habib
- Institute of Human Virology, Nigeria, Pent House, Maina Court, Plot 252 Herbert Macaulay Way, Central Business District, PO Box 9396, Garki, Abuja, Nigeria.
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Pharmacokinetics of BILR 355 after multiple oral doses coadministered with a low dose of ritonavir. Antimicrob Agents Chemother 2008; 53:95-103. [PMID: 18955519 DOI: 10.1128/aac.00752-08] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The pharmacokinetics and safety of BILR 355 following oral repeated dosing coadministered with low doses of ritonavir (RTV) were investigated in 12 cohorts of healthy male volunteers with a ratio of 6 to 2 for BILR 355 versus the placebo. BILR 355 was given once a day (QD) coadministered with 100 mg RTV (BILR 355/r) at 5 to 50 mg in a polyethylene glycol solution or at 50 to 250 mg as tablets. BILR 355 tablets were also dosed at 150 mg twice a day (BID) coadministered with 100 mg RTV QD or BID. Following oral dosing, BILR 355 was rapidly absorbed, with the mean time to maximum concentration of drug in serum reached within 1.3 to 5 h and a mean half-life of 16 to 20 h. BILR 355 exhibited an approximately linear pharmacokinetics for doses of 5 to 50 mg when given as a solution; in contrast, when given as tablets, BILR 355 displayed a dose-proportional pharmacokinetics, with a dose range of 50 to 100 mg; from 100 to 150 mg, a slightly downward nonlinear pharmacokinetics occurred. The exposure to BILR 355 was maximized at 150 mg and higher due to a saturated dissolution/absorption process. After oral dosing of BILR 355/r, 150/100 mg BID, the values for the maximum concentration of drug in plasma at steady state, the area under the concentration-time curve from 0 to the dose interval at steady state, and the minimum concentration of drug in serum at steady state were 1,500 ng/ml, 12,500 h.ng/ml, and 570 ng/ml, respectively, providing sufficient suppressive concentration toward human immunodeficiency virus type 1. Based on pharmacokinetic modeling along with the in vitro virologic data, several BILR 355 doses were selected for phase II trials using Monte Carlo simulations. Throughout the study, BILR 355 was safe and well tolerated.
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Pharmacokinetics of high-dose lopinavir-ritonavir with and without saquinavir or nonnucleoside reverse transcriptase inhibitors in human immunodeficiency virus-infected pediatric and adolescent patients previously treated with protease inhibitors. Antimicrob Agents Chemother 2008; 52:3276-83. [PMID: 18625762 DOI: 10.1128/aac.00224-08] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Human immunodeficiency virus (HIV)-infected children and adolescents who are failing antiretrovirals may have a better virologic response when drug exposures are increased, using higher protease inhibitor doses or ritonavir boosting. We studied the pharmacokinetics and safety of high-dose lopinavir-ritonavir (LPV/r) in treatment-experienced patients, using an LPV/r dose of 400/100 mg/m(2) orally every 12 h (p.o. q12h) (without nonnucleoside reverse transcriptase inhibitor [NNRTI]), or 480/120 mg/m(2) p.o. q12h (with NNRTI). We calculated the LPV inhibitory quotient (IQ), and when the IQ was <15, saquinavir (SQV) 750 mg/m(2) p.o. q12h was added to the regimen. We studied 26 HIV-infected patients. The median age was 15 years (range, 7 to 17), with 11.5 prior antiretroviral medications, 197 CD4 cells/ml, viral load of 75,577 copies/ml, and a 133-fold change in LPV resistance. By treatment week 2, 14 patients had a viral-load decrease of >0.75 log(10), with a median maximal decrease in viral load of -1.57 log(10) copies/ml at week 8. At week 2, 19 subjects showed a median LPV area under the concentration-time curve (AUC) of 157.2 (range, 62.8 to 305.5) microg x h/ml and median LPV trough concentration (C(trough)) of 10.8 (range, 4.1 to 25.3) microg/ml. In 16 subjects with SQV added, the SQV median AUC was 33.7 (range, 4.4 to 76.5) microg x h/ml and the median SQV C(trough) was 2.1 (range, 0.2 to 4.1) microg/ml. At week 24, 18 of 26 (69%) subjects remained in the study. Between weeks 24 and 48, one subject withdrew for nonadherence and nine withdrew for persistently high virus load. In antiretroviral-experienced children and adolescents with HIV, high doses of LPV/r with or without SQV offer safe options for salvage therapy, but the modest virologic response and the challenge of adherence to a regimen with a high pill burden may limit the usefulness of this approach.
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Tenero DM, Henderson LS, Baidoo CA, Harter AH, Campanile AM, Danoff TM, Boyle D. Pharmacokinetic properties of a new controlled-release formulation of carvedilol. Am J Cardiol 2006; 98:5L-16L. [PMID: 17023227 DOI: 10.1016/j.amjcard.2006.07.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This review summarizes the pharmacokinetics (PK) of carvedilol after administration of a new once-daily controlled-release (CR) formulation. The plasma concentration-time profiles for both R(+)- and S(-)-carvedilol indicate that carvedilol CR will provide coverage over a 24-hour period similar to the current immediate-release (IR) twice-daily formulation. Exposures for both enantiomers, based on area under the curve (AUC), maximum plasma concentrations (C(max)), and trough concentrations, are equivalent for carvedilol CR compared with carvedilol IR. C(max) and AUC of the enantiomers of carvedilol increase in an approximate dose-proportional manner after administration of carvedilol CR over the dose range of 10-80 mg, indicating that the formulation provides consistent PK performance across the dose strengths proposed for marketing. The intrasubject and intersubject variability of carvedilol CR was comparable to carvedilol IR. For carvedilol CR, mean AUC and C(max) were increased <20% after a high-fat meal compared with a standard meal. The CR and IR formulations of carvedilol exhibited equivalent steady-state PK characteristics in the target hypertension and heart failure populations. The availability of once-daily dosing is expected to improve treatment adherence and thereby enhance the effectiveness of carvedilol in routine clinical use.
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Affiliation(s)
- David M Tenero
- Department of Clinical Pharmacokinetics, Modeling, and Simulation, GlaxoSmithKline, King of Prussia, Pennsylvania 19406, USA.
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van Heeswijk RPG, Bourbeau M, Seguin I, Giguere P, Garber GE, Cameron DW. Absence of circadian variation in the pharmacokinetics of lopinavir/ritonavir given as a once daily dosing regimen in HIV-1-infected patients. Br J Clin Pharmacol 2005; 59:398-404. [PMID: 15801934 PMCID: PMC1884801 DOI: 10.1111/j.1365-2125.2005.02337.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AIMS To compare the pharmacokinetics of lopinavir/ritonavir (LPV/r) 800/200 mg administered once daily in the morning compared with the evening. METHODS This was a randomized, two-way, cross-over study in HIV+ subjects. In each subject the pharmacokinetics of each drug were characterized after 2 weeks of LPV/r 800/200 mg administered once daily at 08.00 h and 19.00 h. On study days, LPV/r was taken with a standardized meal (800 kCal, 25% from fat) after fasting for at least 5 h. LPV/r concentrations were measured by LC-MS/MS, and the data were analyzed by noncompartmental pharmacokinetic analysis. RESULTS Fourteen subjects completed the study (all men, mean age/weight 44 year/81 kg). The median (interquartile range) LPV AUC(0,24 h), maximum plasma concentration (C(max)) and concentration at the end of the dosing interval (C(24 h)) after am and pm dosing was, respectively, 143 (116-214) mg l(-1) h, 12.8 (10.3-17.2) mg l(-1), 1.34 (0.58-3.25) mg l(-1), and 171 (120-232) mg l(-1) h, 12.9 (8.22-16.3) mg l(-1), 1.15 (0.59-1.98) mg l(-1). The geometric mean ratio (GMR, am : pm) and 95% CI of the LPV AUC(0,24 h), C(max), and C(24 h) was 0.91 (0.79, 1.06), 1.11 (0.94, 1.32), and 1.19 (0.72, 1.96), respectively. The median ritonavir C(max) after am and pm dosing was 1.05 and 0.90 mg l(-1), respectively. The GMR (95% CI) of the RTV AUC(0,24 h), C(max), and C(24 h) was 0.93 (0.80, 1.08), 1.27 (1.00, 1.63), and 1.04 (0.68, 1.60), respectively. Administration of LPV/r in a once-daily regimen was generally well tolerated. CONCLUSIONS No differences were observed in the pharmacokinetics of LPV/r after am or pm dosing with food, which suggests that this once daily combination, can be taken in the morning or evening. Such flexibility in dosing may improve adherence.
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Affiliation(s)
- R P G van Heeswijk
- The Ottawa Hospital, Division of Infectious Diseases, Ottawa, ON, Canada.
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Ribera E, Fernando López-Cortés L, Soriano V, Luis Casado J, Mallolas J. Therapeutic drug monitoring and the inhibitory quotient of antiretroviral drugs: can they be applied to the current situation? Enferm Infecc Microbiol Clin 2005. [DOI: 10.1016/s0213-005x(05)75161-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Ribera E, Fernando López-Cortés L, Soriano V, Luis Casado J, Mallolas J. Monitorización terapéutica y cociente inhibitorio de los fármacos antirretrovirales: ¿son aplicables a nuestra realidad? Enferm Infecc Microbiol Clin 2005. [DOI: 10.1016/s0213-005x(05)75160-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Boyd M, Mootsikapun P, Burger D, Chuenyam T, Ubolyam S, Mahanontharit A, Sangkote J, Bunyaprawit P, Horsakulchai M, Lange J, Cooper D, Phanuphak P, Ruxrungtham K. Pharmacokinetics of Reduced-Dose Indinavir/Ritonavir 400/100 Mg Twice Daily in HIV-1-Infected Thai Patients. Antivir Ther 2005. [DOI: 10.1177/135965350501000213] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To study the pharmacokinetics of indinavir/ ritonavir 400/100 mg twice daily in antiretroviral-naive patients at Srinagarind Hospital in Khon Kaen, Thailand. Methods This was a steady-state, open-label pharmacokinetic study of 19 patients. A 12 h pharmacokinetic curve was recorded after an overnight fast. Plasma levels of indinavir and ritonavir were determined by a validated HPLC method. Virological failure was defined according to the most recent US Department of Health and Human Services guidelines as a viral load above 400 copies/ml at week 24. Results Median baseline values for CD4 and viral load were 13 cells/mm3 and 167000 copies/ml, respectively. The median (interquartile ranges) for indinavir AUC, Cmax and Cmin were 18.1 (15.3–23.8) mg/l•h, 4.1 (3.6–4.8) mg/l and 0.17 (0.12–0.30) mg/l, respectively. These values represent 37%, 39% and 24% of the AUC, Cmax and Cmin values found, respectively, for the indinavir/ritonavir 800/100 mg dose in HIV-1-infected Thai patients. Short-term virological response was satisfactory. There were three subjects with an indinavir Cmin below the target value of 0.10 mg/l, of whom one had virological failure (33%). Among the other 16 subjects with an indinavir Cmin above 0.10 mg/l, there was also one virological failure (6%) ( P=0.30). Conclusions Indinavir exposure in this reduced-dose regimen of 400 mg with 100 mg ritonavir twice daily was more than dose-proportionally lower than previously observed with the indinavir/ritonavir 800/100 mg twice daily regimen. Therapeutic Cmin levels of indinavir were achieved in >80% of the subjects and short-term virological response was satisfactory in this cohort of patients starting highly active antiretroviral therapy at an advanced disease stage with high baseline viral loads.
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Affiliation(s)
- Mark Boyd
- HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, Australia
| | | | - David Burger
- Department of Clinical Pharmacy & Nijmegen University Centre for Infectious Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Theshinee Chuenyam
- HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Sasiwimol Ubolyam
- HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Apicha Mahanontharit
- HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Jongkol Sangkote
- HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | | | | | - Joep Lange
- International AIDS Therapy Evaluation Centre and Department of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Centre, Amsterdam, The Netherlands
| | - David Cooper
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, Australia
| | - Praphan Phanuphak
- HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kiat Ruxrungtham
- HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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15
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Ribera E, Lopez RM, Diaz M, Pou L, Ruiz L, Falcó V, Crespo M, Azuaje C, Ruiz I, Ocaña I, Clotet B, Pahissa A. Steady-state pharmacokinetics of a double-boosting regimen of saquinavir soft gel plus lopinavir plus minidose ritonavir in human immunodeficiency virus-infected adults. Antimicrob Agents Chemother 2004; 48:4256-62. [PMID: 15504850 PMCID: PMC525389 DOI: 10.1128/aac.48.11.4256-4262.2004] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Management of treatment-experienced human immunodeficiency virus patients has become complex, and therapy may need to include two protease inhibitors at therapeutic doses. The objective of this study was to characterize the pharmacokinetics in serum of saquinavir (1,000 mg twice daily [b.i.d.]), lopinavir (400 mg b.i.d.), and ritonavir (100 mg b.i.d.) in a multidrug rescue therapy study and to investigate whether steady-state pharmacokinetics of lopinavir-ritonavir are affected by coadministration of saquinavir. Forty patients were included (25 given ritonavir, lopinavir, and saquinavir and 15 given ritonavir and lopinavir). The median pharmacokinetic parameters of lopinavir were as follows: area under the concentration-time curve from 0 to 12 h (AUC(0-12)), 85.1 microg/ml . h; maximum concentration of drug in serum (C(max)), 10.0 microg/ml; trough concentration of drug in serum (C(trough)), 7.3 microg/ml; and minimum concentration of drug in serum (C(min)), 5.5 microg/ml. Lopinavir concentrations were similar in patients with and without saquinavir. The median pharmacokinetic parameters for saquinavir were as follows: AUC(0-12), 22.9 microg/ml . h; C(max), 2.9 microg/ml; C(trough), 1.6 microg/ml; and C(min), 1.4 microg/ml. There was a strong linear correlation between lopinavir and ritonavir and between saquinavir and ritonavir concentrations in plasma. The correlation between lopinavir and saquinavir levels was weaker. We found higher saquinavir concentrations in women than in men, with no difference in lopinavir levels. Only patients with very high body weight presented lopinavir and saquinavir concentrations lower than the overall group. Ritonavir has a double-boosting function for both lopinavir and saquinavir, and in terms of pharmacokinetics, the drug doses selected seemed appropriate for combining these agents in a dual protease inhibitor-based antiretroviral regimen for patients with several prior virologic failures.
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Affiliation(s)
- Esteban Ribera
- Servicio de Enfermedades Infecciosas, Hospital Universitari Vall d'Hebron, Paseo Vall Hebron 119-129, 08035 Barcelona, Spain.
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16
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Lee LS, Panchalingam A, Yap MC, Paton NI. Pharmacokinetics of indinavir at 800, 600, and 400 milligrams administered with ritonavir at 100 milligrams and efavirenz in ethnic chinese patients infected with human immunodeficiency virus. Antimicrob Agents Chemother 2004; 48:4476-8. [PMID: 15504888 PMCID: PMC525429 DOI: 10.1128/aac.48.11.4476-4478.2004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We assessed the pharmacokinetics of three different doses of indinavir in five patients. All doses achieved trough concentrations above efficacy thresholds. Toxic trough concentrations were observed in all patients receiving 800 mg, in two patients receiving 600 mg, and in none receiving 400 mg. Indinavir at 400 mg may be efficacious and less toxic in patients taking ritonavir and efavirenz.
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Affiliation(s)
- Lawrence S Lee
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University, 600 N. Wolfe St., Osler 527, Baltimore, MD 21287, USA.
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17
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Crommentuyn KML, Mulder JW, Mairuhu ATA, van Gorp ECM, Meenhorst PL, Huitema ADR, Beijnen JH. The Plasma and Intracellular Steady-State Pharmacokinetics of Lopinavir/Ritonavir in HIV-1-Infected Patients. Antivir Ther 2004. [DOI: 10.1177/135965350400900520] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Therapeutic drug monitoring of protease inhibitors (PIs) is usually performed on plasma samples although their antiretroviral effect takes place inside cells. Little is known, however, about the intracellular accumulation and related plasma pharmacokinetics of PIs such as lopinavir/ritonavir (LPV/RTV). Therefore, we studied the plasma and intracellular (cell-associated) steady-state pharmacokinetics of this PI combination in a dosage of 400/100 mg twice daily in a non-randomized cohort of HIV-1-infected individuals. Plasma (0–12 h) and peripheral blood mononuclear cell (PBMC; 0–8 h) samples were drawn during a 12-h dosing interval in 11 subjects. The plasma concentrations versus time curves of LPV and RTV were characterized by an irregular absorption phase showing double-peaks (Cmax) in most subjects and single-peaks in the remaining patients between 1 and 3 h after drug intake. Pre-dose concentrations of both agents in plasma were significantly higher than the concentrations at the end of the dosing interval indicating the presence of a circadian rhythm in their pharmacokinetics. The course of the intracellular concentrations versus time curves appeared to be similar to the plasma concentration curves, with the highest intracellular concentration measured 3 h after drug intake. The intracellular RTV concentrations were higher than reported in vitro EC50 values and might therefore contribute to the antiretroviral effect of LPV/RTV. The median intracellular-to-plasma concentration ratios (interquartile range) were 1.18 (0.74–2.06) and 4.59 (3.20–7.70) for LPV and RTV, respectively. In conclusion, both LPV and RTV accumulate to potential therapeutic concentrations in PBMCs. Irregular absorption and circadian plasma clearance patterns were observed for the PI combination LPV/RTV.
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Affiliation(s)
| | - Jan W Mulder
- Department of Internal Medicine, Slotervaart Hospital, Amsterdam, The Netherlands
| | - Albert TA Mairuhu
- Department of Internal Medicine, Slotervaart Hospital, Amsterdam, The Netherlands
| | - Eric CM van Gorp
- Department of Internal Medicine, Slotervaart Hospital, Amsterdam, The Netherlands
| | - Pieter L Meenhorst
- Department of Internal Medicine, Slotervaart Hospital, Amsterdam, The Netherlands
| | - Alwin DR Huitema
- Department of Pharmacy & Pharmacology, Amsterdam, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, Amsterdam, The Netherlands
- Faculty of Pharmaceutical Sciences, Department of Biomedical Analysis, Division of Drug Toxicology, Utrecht, The Netherlands
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18
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Ford J, Cornforth D, Hoggard PG, Cuthbertson Z, Meaden ER, Williams I, Johnson M, Daniels E, Hsyu P, Back DJ, Khoo SH. Intracellular and Plasma Pharmacokinetics of Nelfinavir and M8 in HIV-Infected Patients: Relationship with P-Glycoprotein Expression. Antivir Ther 2004. [DOI: 10.1177/135965350400900101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
One of the targets of antiretroviral therapy is within cells infected with HIV. In order to improve therapeutic efficacy, it is therefore important that the intracellular pharmacokinetics of drugs, such as nelfinavir mesylate and its active metabolite M8, are studied in addition to plasma pharmacokinetics. Previously, the intracellular accumulation of protease inhibitors has been reported in vivo, displaying the following hierarchy: nelfinavir > saquinavir > ritonavir > indinavir. Multidrug resistance transporters, such as P-glycoprotein (P-gp), may result in a lower intracellular concentration of drug via an efflux mechanism, thus contributing to sanctuary site formation. The objective of this study was to determine concentrations of nelfinavir and M8 in plasma and peripheral blood mononuclear cells from HIV-infected patients, and to ascertain the relationship between intracellular accumulation and lymphocyte P-gp expression. Venous blood samples from 12 HIV-infected patients (viral load <50 copies/ml) receiving nelfinavir (1250 mg twice daily) and dual nucleoside reverse transcriptase inhibitor therapy were collected over a full dosage interval (0, 2, 4, 8 and 12 h). Plasma and intracellular (cell-associated) drug concentrations were measured by HPLC-MS/MS. Drug exposure in plasma and cells was expressed as the area under the concentration–time curve (AUC0-12h), derived from non-compartmental modelling. The ratio of intracellular AUC0-12h/total plasma AUC0-12h was calculated to determine cellular drug accumulation. P-gp expression on lymphocytes was determined by flow cytometry. The median (range) AUC0-12h of nelfinavir in plasma and cellular compartments was 21.8 mg.h.l-1 (5.64–50.8) and 104.6 mg.h.l-1 (23.1–265.7), respectively. Corresponding values for M8 in plasma and cells were 6.60 mg.h.l–1 (2.16–17.3) and 19.6 mg.h.l–1 (5.14–60.8). A ratio of plasma M8/plasma nelfinavir (AUC0–12h) and intracellular M8/intracellular nelfinavir (AUC0–12h) gave median values of 0.32 and 0.17, respectively. The cellular accumulations [median; (range)] of nelfinavir and M8 were 5.30 (2.28–16.2) and 2.32 (1.01–10.7), respectively. A significant correlation between plasma and intracellular nelfinavir minimum concentration (Cmin) (r2=0.34; P=0.049), but not between plasma and intracellular M8 Cmin was observed. C0h concentrations were higher than C12h for both nelfinavir and M8. No relationship was observed between nelfinavir or M8 accumulation and lymphocyte cell surface expression of P-gp. This study illustrates that intracellular concentrations were higher than plasma concentrations for both nelfinavir and M8, suggesting lymphocyte accumulation. The mechanism of differential intracellular accumulation of nelfinavir and M8 remains to be elucidated. It may be that affinities for influx transporters or fundamental drug characteristics play a major role in the greater accumulation of nelfinavir than M8.
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Affiliation(s)
- Jennifer Ford
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - David Cornforth
- Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, University College London, London, UK
| | - Patrick G Hoggard
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Zoe Cuthbertson
- Department of Thoracic Medicine, Royal Free Hospital, London, UK
| | - E Rhiannon Meaden
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Ian Williams
- Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, University College London, London, UK
| | - Margaret Johnson
- Department of Thoracic Medicine, Royal Free Hospital, London, UK
| | | | - Poe Hsyu
- Agouron Pharmaceuticals, Inc., San Diego, Calif., USA
| | - David J Back
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Saye H Khoo
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
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19
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Aarnoutse RE, Schapiro JM, Boucher CAB, Hekster YA, Burger DM. Therapeutic drug monitoring: an aid to optimising response to antiretroviral drugs? Drugs 2003; 63:741-53. [PMID: 12662123 DOI: 10.2165/00003495-200363080-00002] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Therapeutic drug monitoring (TDM) has been proposed as a means to optimise response to highly active antiretroviral therapy (HAART) in HIV infection. Protease inhibitors (PIs) and the non-nucleoside reverse transcriptase inhibitors (NNRTIs) efavirenz and nevirapine satisfy many criteria for TDM. Nucleoside reverse transcriptase inhibitors (NRTIs) are not suitable candidates for TDM, since no clear plasma concentration-effect relationships have been established for these drugs. Several important limitations to the application of TDM for antiretroviral drugs should be recognised, including uncertainty about the best pharmacokinetic predictor of response and insufficient validation of target concentrations for individual PIs and NNRTIs. Data from two clinical trials support the use of TDM in treatment-naive HIV-infected patients who start with an indinavir- or nelfinavir-based regimen. TDM either prevented virological failures (presumably by preventing the development of resistance) or treatment discontinuations due to concentration-related toxicity. Application of routine TDM in other patient groups (treatment-experienced patients) or for drugs other than indinavir or nelfinavir (NNRTIs, other PIs, combination of PIs) is speculative at this moment. However, TDM can be used in selected patient groups (children, pregnant women, patients with renal or hepatic dysfunction) to confirm adequate drug concentrations, and for management of drug-drug interactions.TDM in treatment-experienced patients may be optimally used in conjunction with resistance testing. The integration of pharmacological and virological measures in the inhibitory quotient (IQ) needs to be standardised and elaborated further. TDM should be accompanied by careful assessment of adherence and can itself help identify non-adherence, although a drug concentration only reflects the last few drug doses taken by a patient. Additional clinical trials are needed before routine TDM can be adopted as standard of care in the treatment of HIV infection.
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Affiliation(s)
- Rob E Aarnoutse
- Department of Clinical Pharmacy, University Medical Center Nijmegen, Nijmegen, The Netherlands.
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20
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Justesen US, Levring AM, Thomsen A, Lindberg JA, Pedersen C, Tauris P. Low-dose indinavir in combination with low-dose ritonavir: steady-state pharmacokinetics and long-term clinical outcome follow-up. HIV Med 2003; 4:250-4. [PMID: 12859324 DOI: 10.1046/j.1468-1293.2003.00153.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To evaluate the long-term efficacy and pharmacokinetics of indinavir (IDV)/ritonavir (RTV) 400/100 mg twice a day in combination with two nucleoside reverse transcriptase inhibitors. METHODS The study was retrospective with a prospective pharmacokinetic study at a single centre. All HIV-1-infected patients who started the regimen in the period from January 1999 to February 2001 were included in the study. Plasma HIV RNA and CD4 cell counts were recorded from baseline to week 120. Results were evaluated as intention-to-treat and on-treatment analyses with separate analyses for protease inhibitor naive and experienced patients. Patients who were still on the regimen by August 2001 were asked to participate in a pharmacokinetic evaluation. RESULTS Twenty-one patients started treatment with the regimen (median follow-up: 116 weeks). The percentage of patients with below 20 HIV-1 RNA copies/mL was 70.0% at week 120 and the median CD4 cell count increased from 320 to 607 cells/microL (P=0.062). The median IDV morning and evening Cmin were 434 ng/mL and 220 ng/mL, respectively. CONCLUSIONS Treatment with the IDV/RTV 400/100 mg regimen appears to be efficacious for up to 2 years. However, rather low IDV Cmin suggests that the regimen should be evaluated further before its widespread use and that the regimen probably should be guided by pharmacokinetic evaluation.
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Affiliation(s)
- U S Justesen
- Institute of Public Health, Clinical Pharmacology, University of Southern Denmark, Odense.
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