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van Hove H, Mathiesen L, Freriksen J, Vähäkangas K, Colbers A, Brownbill P, Greupink R. Placental transfer and vascular effects of pharmaceutical drugs in the human placenta ex vivo: A review. Placenta 2022; 122:29-45. [DOI: 10.1016/j.placenta.2022.03.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/15/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
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Protecting the fetus against HIV infection: a systematic review of placental transfer of antiretrovirals. Clin Pharmacokinet 2015; 53:989-1004. [PMID: 25223699 DOI: 10.1007/s40262-014-0185-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Maternal-to-fetal transfer of antiretroviral drugs contributes to prevention of vertical transmission of HIV. OBJECTIVE This systematic review discusses published studies containing data pertaining to the pharmacokinetics of placental transfer of antiretrovirals in humans, including paired cord and maternal plasma samples collected at the time of delivery as well as ex vivo placental perfusion models. METHODS Articles pertaining to placental transfer of antiretrovirals were identified from PubMed, from references of included articles, and from US Department of Health and Human Services Panel on Treatment of HIV-infected Pregnant Women and Prevention of Perinatal Transmission guidelines. Articles from non-human animal models or that had no original maternal-to-fetal transfer data were excluded. PRISMA guidelines were followed. RESULTS A total of 103 published studies were identified. Data across studies appeared relatively consistent for the nucleoside reverse transcriptase inhibitors (NRTIs) and the non-nucleotide reverse transcriptase inhibitors (NNRTIs), with cord to maternal ratios approaching 1 for many of these agents. The protease inhibitors atazanavir and lopinavir exhibited consistent maternal-to-fetal transfer across studies, although the transfer may be influenced by variations in drug-binding proteins. The protease inhibitors indinavir, nelfinavir, and saquinavir exhibited unreliable placental transport, with cord blood concentrations that were frequently undetectable. Limited data, primarily from case reports, indicate that darunavir and raltegravir provide detectable placental transfer. CONCLUSION These findings appear consistent with current guidelines of using two NRTIs plus an NNRTI, atazanavir/ritonavir, or lopinavir/ritonavir to maximize placental transfer as well as to optimally suppress maternal viral load. Darunavir/ritonavir and raltegravir may reasonably serve as second-line agents.
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Lê MP, Mandelbrot L, Descamps D, Soulié C, Ichou H, Bourgeois-Moine A, Damond F, Lariven S, Valantin MA, Landman R, Faucher P, Tubiana R, Duro D, Meier F, Legac S, Bourse P, Mortier E, Dommergues M, Calvez V, Matheron S, Peytavin G. Pharmacokinetics, safety and efficacy of ritonavir-boosted atazanavir (300/100 mg once daily) in HIV-1-infected pregnant women. Antivir Ther 2015; 20:507-13. [PMID: 25599649 DOI: 10.3851/imp2936] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Atazanavir/ritonavir (ATV/r) is a boosted protease inhibitor recommended to minimize the risk of mother-to-child HIV-1 transmission (MTCT). We aimed to assess the pharmacokinetics, safety and efficacy of ATV/r in HIV-1-infected pregnant women and their neonates. METHODS A multicentre, cross-sectional, non-interventional cohort of HIV-1-infected pregnant women receiving ATV/r (300/100 mg once daily) who delivered in three Paris hospitals from 2006 to 2013 was designed. We determined antiretroviral trough plasma concentrations using liquid chromatography-mass spectrometry at each of the three trimesters, delivery and post-partum. ATV concentrations at 24 h (C24h) were interpreted by the 150-850 ng/ml efficacy-tolerance thresholds. Safety data and newborn HIV status were recorded. A mother's virological failure was defined as two successive measurements of plasma HIV-1 RNA>50 copies/ml within the 2 months before delivery. RESULTS 103 pregnant women were included, mostly from sub-Saharan Africa (88%). ATV C24h at each of the three trimesters and delivery remained similar to post-partum values. No dose adjustment was needed during pregnancy. The median plasma ratio of fetal/maternal ATV level was 0.19 (n=28). Only three patients showed two successive detectable viral loads but <400 copies/ml. Among 82 available newborn data, 16 were born preterm. Three in utero deaths occurred. Tolerance was good with one case of maternal grade 3 hyperbilirubinaemia, no cases in neonates at delivery and no clinically relevant adverse event. No case of MTCT was reported. CONCLUSIONS In this population, an ATV/r-containing antiretroviral regimen demonstrated good pharmacokinetics, virological efficacy and safety. No significant impact of pregnancy on ATV C24h was found. No dose adjustment was required.
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Affiliation(s)
- Minh P Lê
- APHP, Bichat-Claude Bernard Hospital, Clinical Pharmaco-Toxicology Department, Hôpitaux Universitaires Paris Nord Val de Seine, Paris, France.
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Bennetto-Hood C, Bryson YJ, Stek A, King JR, Mirochnick M, Acosta EP. Zidovudine, Lamivudine, and Nelfinavir Concentrations in Amniotic Fluid and Maternal Serum. HIV CLINICAL TRIALS 2015. [DOI: 10.1310/hct1001-41] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Padberg S. Anti-infective Agents. DRUGS DURING PREGNANCY AND LACTATION 2015. [PMCID: PMC7150338 DOI: 10.1016/b978-0-12-408078-2.00007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
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Santini-Oliveira M, Grinsztejn B. Adverse drug reactions associated with antiretroviral therapy during pregnancy. Expert Opin Drug Saf 2014; 13:1623-52. [PMID: 25390463 DOI: 10.1517/14740338.2014.975204] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Antiretroviral (ARV) drug use during pregnancy significantly reduces mother-to-child HIV transmission, delays disease progression in the women and reduces the risk of HIV transmission to HIV-serodiscordant partners. Pregnant women are susceptible to the same adverse reactions to ARVs as nonpregnant adults as well as to specific pregnancy-related reactions. In addition, we should consider adverse pregnancy outcomes and adverse reactions in children exposed to ARVs during intrauterine life. However, studies designed to assess the safety of ARV in pregnant women are rare, usually with few participants and short follow-up periods. AREAS COVERED In this review, we discuss studies reporting adverse reactions to ARV drugs, including maternal toxicity, adverse pregnancy outcomes and the consequences of exposure to ARV in infants. We included results of observational studies, both prospective and retrospective, as well as randomized clinical trials, systematic reviews and meta-analyses. EXPERT OPINION The benefits of ARV use during pregnancy outweigh the risks of adverse reactions identified to date. More studies are needed to assess the adverse effects in the medium- and long term in children exposed to ARVs during pregnancy, as well as pregnant women using lifelong antiretroviral therapy and more recently available drugs.
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Affiliation(s)
- Marilia Santini-Oliveira
- Evandro Chagas National Institute of Infectious Diseases, Clinical Research in STD & AIDS Laboratory, Oswaldo Cruz Foundation , Rio de Janeiro , Brazil
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Mandelbrot L, Duro D, Belissa E, Peytavin G. Placental transfer of darunavir in an ex vivo human cotyledon perfusion model. Antimicrob Agents Chemother 2014; 58:5617-20. [PMID: 24982090 PMCID: PMC4135808 DOI: 10.1128/aac.03184-14] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Accepted: 06/26/2014] [Indexed: 11/20/2022] Open
Abstract
Placental transfer of the HIV protease inhibitor darunavir was investigated in 5 term human cotyledons perfused with darunavir (1,000 ng/ml) in the maternal to fetal direction. The mean (± the standard deviation [SD]) fetal transfer rate (FTR) (fetal/maternal concentration at steady state from 30 to 90 min) was 15.0%±2.1%, and the mean (±SD) clearance index (darunavir FTR/antipyrine FTR) was 40.3%±5.8%. This shows that darunavir crosses the placenta at a relatively low rate, resulting in fetal exposure.
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Affiliation(s)
- Laurent Mandelbrot
- Assistance Publique-Hôpitaux de Paris, Hôpital Louis Mourier, Service de Gynécologie-Obstetrique, Département Hospitalier Universitaire Risque et Grossesse, Colombes, France Université Paris-Diderot, Paris, France
| | - Dominique Duro
- Assistance Publique-Hôpitaux de Paris, Hôpital Louis Mourier, Service de Gynécologie-Obstetrique, Département Hospitalier Universitaire Risque et Grossesse, Colombes, France
| | - Emilie Belissa
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Clinical Pharmaco-Toxicology Department and IAME, INSERM, Paris, France
| | - Gilles Peytavin
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Clinical Pharmaco-Toxicology Department and IAME, INSERM, Paris, France
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Chougrani I, Luton D, Matheron S, Mandelbrot L, Azria E. Safety of protease inhibitors in HIV-infected pregnant women. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2013; 5:253-62. [PMID: 24101883 PMCID: PMC3790874 DOI: 10.2147/hiv.s33058] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The dire conditions of the human immunodeficiency virus/acquired immune deficiency syndrome epidemic and the immense benefits of antiretroviral prophylaxis in prevention of mother-to-child transmission far outweigh the potential for adverse effects and undeniably justify the rapid and widespread use of this therapy, despite incomplete safety data. Highly active antiretroviral therapy has now become standard care, and more than half the validated regimens include protease inhibitors. This paper reviews current knowledge of the safety of these drugs during pregnancy, in terms of maternal and fetal outcomes. Transfer of protease inhibitors across the placenta is known to be minimal, and current data about birth defects and fetal malignancies are reassuring. Maternal liver function and glucose metabolism should be monitored in women treated with protease inhibitor-based regimens, but concerns about the development of maternal resistance, should treatment be discontinued, have been shown to be groundless. Neonates should be screened for hematologic abnormalities, although these are rarely severe or permanent and are not usually related to the protease inhibitor component of the antiretroviral combination. Current findings concerning pre-eclampsia and growth restriction are discordant, and further research is needed to address the question of placental vascular complications. The increased risk of preterm birth attributed to protease inhibitors should be interpreted with caution considering the discrepant results and the multitude of confounding factors often overlooked. Although data are thus far reassuring, further research is needed to shed light on unresolved controversies about the safety of protease inhibitors during pregnancy.
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Affiliation(s)
- Imène Chougrani
- Department of Obstetrics and Gynecology, Bichat Claude Bernard Hospital, Paris Diderot University, Paris
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Abstract
The impact of antiretroviral therapy (ART) on the natural history of HIV-1 infection has resulted in dramatic reductions in disease-associated morbidity and mortality. Additionally, the epidemiology of HIV-1 infection worldwide is changing, as women now represent a substantial proportion of infected adults. As more highly effective and tolerable antiretroviral regimens become available, and as the prevention of mother-to-child transmission becomes an attainable goal in the management of HIV-infected individuals, more and more HIV-positive women are choosing to become pregnant and have children. Consequently, it is important to consider the efficacy and safety of antiretroviral agents in pregnancy. Protease inhibitors are a common class of medication used in the treatment of HIV-1 infection and are increasingly being used in pregnancy. However, several studies have raised concerns regarding pharmacokinetic alterations in pregnancy, particularly in the third trimester, which results in suboptimal drug concentrations and a theoretically higher risk of virologic failure and perinatal transmission. Drug level reductions have been observed with each individual protease inhibitor and dose adjustments in pregnancy are suggested for certain agents. Furthermore, studies have also raised concerns regarding the safety of protease inhibitors in pregnancy, particularly as they may increase the risk of pre-term birth and metabolic disturbances. Overall, protease inhibitors are safe and effective for the treatment of HIV-infected pregnant women. Specifically, ritonavir-boosted lopinavir- and atazanavir-based regimens are preferred in pregnancy, while ritonavir-boosted darunavir- and saquinavir-based therapies are reasonable alternatives. This paper reviews the use of protease inhibitors in pregnancy, focusing on pharmacokinetic and safety considerations, and outlines the recommendations for use of this class of medication in the HIV-1-infected pregnant woman.
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Affiliation(s)
- Nisha Andany
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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Else LJ, Taylor S, Back DJ, Khoo SH. Pharmacokinetics of antiretroviral drugs in anatomical sanctuary sites: the fetal compartment (placenta and amniotic fluid). Antivir Ther 2012; 16:1139-47. [PMID: 22155898 DOI: 10.3851/imp1918] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
HIV resides within anatomical 'sanctuary sites' where local drug exposure and viral dynamics may differ significantly from the systemic compartment. Widespread implementation of antiretroviral therapy has seen a significant decline in the incidence of mother-to-child transmission (MTCT) of HIV. In addition to suppression of maternal plasma/genital viral loads, antiretroviral agents that cross the placenta and achieve adequate concentrations in the fetal compartment may exert a greater prophylactic effect. Penetration of antiretrovirals in the fetal compartment is expressed by accumulation ratios derived from the measurement of drug concentrations in paired maternal plasma and umbilical cord samples. The nucleoside analogues and nevirapine accumulate extensively in cord blood and in the surrounding amniotic fluid, whereas the protease inhibitors (PIs) exhibit low-to-moderate placental accumulation. Early data suggest that high placental/neonatal concentrations are achieved with raltegravir, but to a lesser extent with etravirine and maraviroc (rank order of accumulation: raltegravir/nucleoside reverse transcriptase inhibitor [tenofovir > zidovudine/lamivudine/emtricitabine/stavudine/abacavir] > non-nucleoside reverse transcriptase inhibitor [nevirapine > etravirine] > PI > maraviroc/enfuvirtide). More comprehensive in vivo pharmacokinetic data are required to justify the potential use of these agents as safe and effective options during pregnancy.
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Affiliation(s)
- Laura J Else
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK.
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Spezielle Arzneimitteltherapie in der Schwangerschaft. ARZNEIMITTEL IN SCHWANGERSCHAFT UND STILLZEIT 2012. [PMCID: PMC7271212 DOI: 10.1016/b978-3-437-21203-1.10002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Peixoto MF, Pilotto JH, Stoszek SK, Kreitchmann R, Mussi-Pinhata MM, Melo VH, João EC, Ceriotto M, Souza RDSD, Read J. Lopinavir/ritonavir dosing during pregnancy in Brazil and maternal/infant laboratory abnormalities. Braz J Infect Dis 2011; 15:253-61. [PMID: 21670927 DOI: 10.1016/s1413-8670(11)70185-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Accepted: 11/03/2010] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVES To describe laboratory abnormalities among HIV-infected women and their infants with standard and increased lopinavir/ritonavir (LPV/r) dosing during the third trimester of pregnancy. METHODS We evaluated data on pregnant women from NISDI cohorts (2002-2009) enrolled in Brazil, who received at least 28 days of LPV/r during the third pregnancy trimester and gave birth to singleton infants. RESULTS 164 women received LPV/r standard dosing [(798/198 or 800/200 mg/day) (Group 1)] and 70 increased dosing [(> 800/200 mg/day) (Group 2)]. Group 1 was more likely to have advanced clinical disease and to use ARVs for treatment, and less likely to have CD4 counts > 500 cells/mm³. Mean plasma viral load was higher in Group 2. There were statistically significant, but not clinically meaningful, differences between groups in mean AST, ALT, cholesterol, and triglycerides. The proportion of women with Grade 3 or 4 adverse events was very low, with no statistically significant differences between groups in severe adverse events related to ALT, AST, total bilirubin, cholesterol, or triglycerides. There were statistically significant, but not clinically meaningful, differences between infant groups in ALT and creatinine. The proportion of infants with Grade 3 or 4 adverse events was very low, and there were no statistically significant differences in severe adverse events related to ALT, AST, BUN, or creatinine. CONCLUSION The proportions of women and infants with severe laboratory adverse events were very low. Increased LPV/r dosing during the third trimester of pregnancy appears to be safe for HIV-infected women and their infants.
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Affiliation(s)
- Mario Ferreira Peixoto
- Unidade de Prevenção à Transmissão Vertical, Hospital Femina, Porto Alegre, Rio Grande do Sul, Brazil.
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Anger GJ, Piquette-Miller M. Mechanisms of Reduced Maternal and Fetal Lopinavir Exposure in a Rat Model of Gestational Diabetes. Drug Metab Dispos 2011; 39:1850-9. [DOI: 10.1124/dmd.111.040626] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Conradie F, Zorrilla C, Josipovic D, Botes M, Osiyemi O, Vandeloise E, Eley T, Child M, Bertz R, Hu W, Wirtz V, McGrath D. Safety and exposure of once-daily ritonavir-boosted atazanavir in HIV-infected pregnant women. HIV Med 2011; 12:570-9. [DOI: 10.1111/j.1468-1293.2011.00927.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Use of darunavir/ritonavir once daily in treatment-naive pregnant woman: pharmacokinetics, compartmental exposure, efficacy and safety. AIDS 2010; 24:1083-4. [PMID: 20386380 DOI: 10.1097/qad.0b013e32833653b2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pinnetti C, Tamburrini E, Ragazzoni E, De Luca A, Navarra P. Decreased plasma levels of darunavir/ritonavir in a vertically infected pregnant woman carrying multiclass-resistant HIV type-1. Antivir Ther 2010; 15:127-9. [DOI: 10.3851/imp1473] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
PURPOSE OF REVIEW This review briefly outlines the influences of gender and pregnancy on drug disposition, and describes the available antiretroviral pharmacokinetic data and dosing recommendations in these groups. RECENT FINDINGS Recent studies in pregnant women continue to document altered exposure of different classes of drugs during pregnancy. While new information shows that tenofovir exposure is significantly decreased during pregnancy, the magnitude of the decrease will not likely necessitate dose changes, similar to other nucleoside reverse transcriptase inhibitors. In contrast, standard doses of lopinavir/ritonavir in the third trimester showed markedly decreased exposure, and higher doses of this co-formulated agent should be given to women during the third trimester. Likewise, nelfinavir exposure using the new 625-mg tablets is also decreased during pregnancy, and higher doses should be considered in the third trimester. SUMMARY The majority of antiretrovirals studied have altered pharmacokinetics during pregnancy. Understanding the extent of these changes is necessary to recommend dose changes during pregnancy when appropriate. The correct dose is critical to maintain efficacy and safety of these agents for both the mother and the fetus. Innovative study designs are needed to facilitate the study of antiretrovirals during pregnancy.
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Gavard L, Beghin D, Forestier F, Cayre Y, Peytavin G, Mandelbrot L, Farinotti R, Gil S. Contribution and limit of the model of perfused cotyledon to the study of placental transfer of drugs. Example of a protease inhibitor of HIV: Nelfinavir. Eur J Obstet Gynecol Reprod Biol 2009; 147:157-60. [DOI: 10.1016/j.ejogrb.2009.08.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Revised: 07/01/2009] [Accepted: 08/18/2009] [Indexed: 12/01/2022]
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Buchholz B, Beichert M, Marcus U, Grubert T, Gingelmaier A, Haberl A, Schmied B. German-Austrian recommendations for HIV1-therapy in pregnancy and in HIV1-exposed newborn, update 2008. Eur J Med Res 2009; 14:461-79. [PMID: 19948442 PMCID: PMC3352287 DOI: 10.1186/2047-783x-14-11-461] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
In Germany during the last years about 200-250 HIV1-infected pregnant women delivered a baby each year, a number that is currently increasing. To determine the HIV-status early in pregnancy voluntary HIV-testing of all pregnant women is recommended in Germany and Austria as part of prenatal care. In those cases, where HIV1-infection was known during pregnancy, since 1995 the rate of vertical transmission of HIV1 was reduced to 1-2%. - This low transmission rate has been achieved by the combination of anti-retroviral therapy of pregnant women, caesarean section scheduled before onset of labour, anti-retroviral post exposition prophylaxis in the newborn and refraining from breast-feeding by the HIV1-infected mother. To keep pace with new results in research, approval of new anti-retroviral drugs and changes in the general treatment recommendations for HIV1-infected adults, in 1998, 2001, 2003 and 2005 an interdisciplinary consensus meeting was held. Gynaecologists, infectious disease specialists, paediatricians, pharmacologists, virologists and members of the German AIDS Hilfe (NGO) were participating in this conference to update the prevention strategies. A fifth update became necessary in 2008. The updating process was started in January 2008 and was terminated in September 2008. The guidelines provide new recommendations on the indication and the starting point for HIV-therapy in pregnancies without complications, drugs and drug combinations to be used preferably in these pregnancies and updated information on adverse effects of anti-retroviral drugs. Also the procedures for different scenarios and risk constellations in pregnancy have been specified again. - With these current guidelines in Germany and Austria the low rate of vertical HIV1-transmission should be further maintained.
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Affiliation(s)
- Bernd Buchholz
- University Medical Centre Mannheim, Pediatric Clinic, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
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Gulati A, Gerk PM. Role of placental ATP-binding cassette (ABC) transporters in antiretroviral therapy during pregnancy. J Pharm Sci 2009; 98:2317-35. [PMID: 19067393 DOI: 10.1002/jps.21623] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Highly active anti-retroviral therapy (HAART) is used to treat HIV-infected patients and involves administration of multiple antiretroviral drugs acting at different steps of the HIV life cycle. In treating HIV-infected pregnant patients, the aim of therapy is not only to treat the mother but also to prevent the transmission of the virus to the fetus. Among the antiretroviral drugs used, there are differences in the extent of transfer of these drugs across the placenta; HIV protease inhibitors are particularly poorly transferred. Activities of ABC transporters expressed in the human placenta as well as differences in plasma protein binding may account for the poor transplacental transfer of certain drugs. This review discusses factors affecting the extent of placental transfer of antiretroviral drugs during pregnancy. These issues may also apply to drugs in other therapeutic categories.
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Affiliation(s)
- Abhishek Gulati
- Department of Pharmaceutics, Virginia Commonwealth University, Medical College of Virginia Campus, 410 N. 12th Street, PO Box 980533, Richmond, Virginia 23298-0533, USA
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Baroncelli S, Tamburrini E, Ravizza M, Dalzero S, Tibaldi C, Ferrazzi E, Anzidei G, Fiscon M, Alberico S, Martinelli P, Placido G, Guaraldi G, Pinnetti C, Floridia M. Antiretroviral treatment in pregnancy: a six-year perspective on recent trends in prescription patterns, viral load suppression, and pregnancy outcomes. AIDS Patient Care STDS 2009; 23:513-20. [PMID: 19530956 DOI: 10.1089/apc.2008.0263] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The aim of the study was to describe the recent trends in antiretroviral treatment in late pregnancy and the sociodemographic changes among pregnant women with HIV over the last 6 years. Data from the National Program on Surveillance on Antiretroviral Treatment in Pregnancy in Italy were grouped per calendar year, and changes in antiretroviral treatment, population characteristics, maternal immunovirologic status and newborn clinical parameters were analyzed. A total of 981 HIV-infected mothers who delivered between 2002 and 2008 were evaluated. The proportion of women receiving at least three antiretroviral drugs at delivery increased significantly from 63.0% in 2002 to 95.5% in 2007-2008, paralleled by a similar upward trend in the proportion of women who achieved complete viral suppression at third trimester (from 37.3 in 2002 to 80.9 in 2007-2008; p < 0.001). The co-formulation of zidovudine plus lamivudine remained the most common nucleoside backbone in pregnancy, even if a significant increase in the use of tenofovir plus emtricitabine was observed in more recent years. Starting from 2003, nevirapine prescription declined, paralleled by a significant rise in the use of protease inhibitors (PI), which were present in more than 60% of regimens administered in 2007-2008. Nelfinavir was progressively replaced by ritonavir-boosted PIs, mainly lopinavir. No significant changes in preterm delivery, Apgar score, birth weight, and birth defects were observed during the study period, and the rate of HIV transmission remained below 2%. These data demonstrate a significant evolution in the treatment of HIV in pregnancy. Constant improvements in the rates of HIV suppression were observed, probably driven by the adoption of stronger and more effective regimens and by the increasing options available for combination treatment.
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Affiliation(s)
- Silvia Baroncelli
- Department of Drug Research and Evaluation, Istituto Superiore di Sanità (ISS), Rome, Italy
| | | | - Marina Ravizza
- University of Milan, Dept. Obstet. Gynecol., and S. Paolo Hospital, Milan, Italy
| | - Serena Dalzero
- University of Milan, Dept. Obstet. Gynecol., and S. Paolo Hospital, Milan, Italy
| | - Cecilia Tibaldi
- Department of Obstetrics and Gynecology, University of Turin, and A.O. OIRM S. Anna, Turin, Italy
| | - Enrico Ferrazzi
- University of Milan, Department of Obstetrics and Gynaecology, and Buzzi Hospital, Milan, Italy
| | | | - Marta Fiscon
- University of Padova, Department of Pediatrics, Padova, Italy
| | - Salvatore Alberico
- Department of Obstetrics and Gynaecology, Policlinic Hospital, Trieste, Italy
| | - Pasquale Martinelli
- Department of Obstetrics and Gynecology, University Federico II of Naples, Naples, Italy
| | - Giuseppina Placido
- Unit of Infectious Diseases, Department of Internal Medicine, Spirito Santo Hospital, Pescara, Italy
| | - Giovanni Guaraldi
- Department of Medical Specialties, Infectious Diseases Clinic, University of Modena and Reggio Emilia, Modena, Italy
| | - Carmela Pinnetti
- Department of Infectious Diseases, Catholic University, Rome, Italy
| | - Marco Floridia
- Department of Drug Research and Evaluation, Istituto Superiore di Sanità (ISS), Rome, Italy
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Genital tract, cord blood, and amniotic fluid exposures of seven antiretroviral drugs during and after pregnancy in human immunodeficiency virus type 1-infected women. Antimicrob Agents Chemother 2009; 53:2367-74. [PMID: 19307360 DOI: 10.1128/aac.01523-08] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The objective of the study was to measure antiretroviral exposures in four physiological compartments during pregnancy, delivery, and postpartum. This prospective, open-label, longitudinal study collected paired blood plasma (BP) and genital tract (GT) aspirates antepartum, at delivery, and up to 12 weeks postpartum. Antiretroviral cord BP and amniotic fluid concentrations were also measured. Drug concentrations were analyzed by validated high-performance liquid chromatography/UV and liquid chromatography/tandem mass spectrometry methods, with secondary compartment concentrations presented as the percentage of BP. Fourteen women taking lamivudine plus zidovudine and either lopinavir-ritonavir (n = 7), nelfinavir (n = 6), or nevirapine (n = 1) were enrolled; four also received tenofovir. GT penetration relative to BP was highest for the nucleoside reverse transcriptase inhibitors compared to the protease inhibitors and nevirapine. Only antepartum nelfinavir GT penetration was significantly higher than in the second trimester (geometric mean ratio [GMR], 179.3) or third trimester (GMR, 41.9). Compared to nonpregnant historical controls, antepartum GT penetration was significantly lower (P < 0.05) for zidovudine (GMR, 0.25) and lopinavir (GMR, 0.03); postpartum lopinavir GT penetration continued to be significantly lower (GMR, 0.27). Cord BP exposures were highest for lamivudine and tenofovir (> or = 100%), with cord BP levels of the remaining drugs ranging from 49 to 86% of that of the respective BP level. Amniotic exposures for lamivudine, zidovudine, tenofovir, and nelfinavir were > or = 100%, nevirapine exposure was 53%, and lopinavir and ritonavir exposures were < or = 6% that of BP. We conclude that GT, cord BP, and amniotic fluid exposures vary within and between antiretroviral drug classes and biologic sites. Measurement of antiretroviral exposure in maternal genital secretions, cord BP, and amniotic fluid may be needed to identify signals of subtherapeutic or supratherapeutic drug exposure.
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Abstract
Azatanavir is a protease inhibitor (PI) approved for the treatment of HIV-1 infection. Atazanavir is a substrate and inhibitor of cytochrome P450 isozyme 3A and an inhibitor and inducer of P-glycoprotein. It has similar virologic efficacy as efavirenz and ritonavir-boosted lopinavir in antiretroviral-naive individuals. Its impact on lipids is less than other PIs and it is suitable for those in whom hyperlipidemia is undesirable. Ritonavir boosting of atazanavir enhances the bioavailability of atazanavir but may result in some elevation of lipids and is recommended for treatment-experienced patients and those receiving efavirenz or tenofovir. Ritonavir-boosted atazanavir has similar antiviral activity as ritonavir-boosted lopinavir in both antiretroviral therapy-naive and -experienced patients. Atazanavir causes unconjugated bilirubinemia in over 40% of patients but results in less than 2% discontinuations. Atazanavir is licensed for once-daily use and atazanavir/ritonavir competes with lopinavir/ritonavir as the most commonly prescribed PI.
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Affiliation(s)
- Robin Wood
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town Faculty of Health Sciences, Anzio Road, Observatory 7925, South Africa.
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von Hentig N, Nisius G, Lennemann T, Khaykin P, Stephan C, Babacan E, Staszewski S, Kurowski M, Harder S, Haberl A. Pharmacokinetics, Safety and Efficacy of Saquinavir/ Ritonavir 1,000/100 Mg Twice Daily as HIV Type-1 Therapy and Transmission Prophylaxis in Pregnancy. Antivir Ther 2008. [DOI: 10.1177/135965350801300820] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background A saquinavir/ritonavir-containing regimen is one option for the prevention of mother-to-child transmission of HIV during pregnancy. We evaluated the pharmaco-kinetics, efficacy and safety of saquinavir/ritonavir 1,000/100 mg twice daily plus nucleos(t)ide reverse transcriptase inhibitors in 13 women during late pregnancy and compared the results to those of 15 non-pregnant women. Methods Protease inhibitor plasma concentration profiles were assessed at 12 h using a standardized therapeutic drug monitoring procedure and measured by LC-MS/MS. Minimum and maximum concentrations (Cmin and Cmax), area under the plasma concentration–time curve (AUC0–12 h), and total clearance (CL total) were compared between the groups and correlated to demographic, physiological and clinical cofactors. Antiviral and immunological efficacy and safety were investigated. Results The geometric means (90% confidence interval [CI]) for saquinavir Cmin, Cmax and AUC0–12 h of pregnant versus non-pregnant women were 572 (437–717) versus 765 (485–1,052, P=0.064) ng/ml, 2,168 (1,594–2,807) versus 3,344 (2,429–4,350; P=0.045) ng/ml and 15,512 (11,657–19,943) versus 24,027 (17,454–31,548, P=0.029) ng•h/ml. The geometric means (90% CI) for ritonavir Cmin, Cmax and AUC0–12 h were 190 (148–234) versus 310 (240–381, P=0.011) ng/ml, 781 (580–999) versus 1,552 (1,127–2,007, P=0.004) ng/ml and 5,576 (4,303–7,006) versus 10,528 (8,131–13,177, P=0.003) ng•h/ml. Age, weight, saquinavir dose per weight and body mass index differed significantly; saquinavir Cmin and AUC0–12 h were correlated with ritonavir Cmin and saquinavir dose per weight. After a mean of 11 weeks treatment, 12 of 13 pregnant women had a viral load <400 copies/ml, which was similar to the results of non-pregnant women. Conclusions Although saquinavir plasma concentrations were significantly lower in pregnant women compared with non-pregnant women, all pregnant women displayed a saquinavir AUC0–12 h>10,000 ng•h/ml, 92.3% had a viral load <400 copies/ml at birth. Saquinavir was well tolerated by the mothers and all newborn children were HIV type-1 negative at 18 months of age.
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Affiliation(s)
- Nils von Hentig
- Pharmazentrum Frankfurt, Institute of Clinical Pharmacology, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Gabi Nisius
- HIV Center, Medical HIV Treatment and Research Unit, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Tessa Lennemann
- HIV Center, Medical HIV Treatment and Research Unit, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Pavel Khaykin
- HIV Center, Medical HIV Treatment and Research Unit, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Christoph Stephan
- HIV Center, Medical HIV Treatment and Research Unit, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Errol Babacan
- HIV Center, Medical HIV Treatment and Research Unit, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Schlomo Staszewski
- HIV Center, Medical HIV Treatment and Research Unit, Johann Wolfgang Goethe University, Frankfurt, Germany
| | | | - Sebastian Harder
- Pharmazentrum Frankfurt, Institute of Clinical Pharmacology, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Annette Haberl
- HIV Center, Medical HIV Treatment and Research Unit, Johann Wolfgang Goethe University, Frankfurt, Germany
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Read JS, Best BM, Stek AM, Hu C, Capparelli EV, Holland DT, Burchett SK, Smith ME, Sheeran EC, Shearer WT, Febo I, Mirochnick M. Pharmacokinetics of new 625 mg nelfinavir formulation during pregnancy and postpartum. HIV Med 2008; 9:875-82. [PMID: 18795962 DOI: 10.1111/j.1468-1293.2008.00640.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Our objective was to evaluate the pharmacokinetics of nelfinavir (NFV) (625 mg tablets) 1250 mg twice daily during pregnancy and postpartum. METHODS The participants were HIV-1-infected pregnant women enrolled in P1026s and receiving NFV (625 mg tablets) 1250 mg twice daily as part of routine clinical care. Intensive steady-state 12-h NFV pharmacokinetic profiles were performed during pregnancy and postpartum. The target NFV area under the plasma concentration-time curve (AUC(0-12)) was >or=10th percentile NFV AUC(0-12) in non-pregnant historical controls (18.5 microg h/mL). RESULTS Of 27 patients receiving NFV, pharmacokinetic data were available for four (second trimester), 27 (third trimester) and 22 (postpartum) patients. The NFV maximum concentration (C(max)), 12-h post-dose concentration (C(12)) and AUC(0-12) were significantly lower during the third trimester compared to postpartum (P<or=0.03). The metabolite hydroxyl-tert-butylamide (M8) AUC(0-12) and the M8/NFV AUC ratio were lower during the third trimester compared to postpartum (P<0.01). The NFV AUC(0-12) exceeded the AUC(0-12) target for 15/27 (56%) and 21/22 (95%) of third trimester and postpartum patients, respectively. The minimum concentration (C(min)) was above the suggested minimum trough concentration (0.8 mug/mL) in 15% (third trimester) and 18% (postpartum). The plasma viral load was <400 HIV-1 RNA copies/mL in 81% of patients at delivery. CONCLUSIONS These results suggest that higher doses of NFV should be considered during pregnancy.
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Affiliation(s)
- J S Read
- Pediatric, Adolescent and Maternal AIDS Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892-7510, USA.
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Bryson YJ, Mirochnick M, Stek A, Mofenson LM, Connor J, Capparelli E, Watts DH, Huang S, Hughes MD, Kaiser K, Purdue L, Asfaw Y, Keller M, Smith E. Pharmacokinetics and safety of nelfinavir when used in combination with zidovudine and lamivudine in HIV-infected pregnant women: Pediatric AIDS Clinical Trials Group (PACTG) Protocol 353. HIV CLINICAL TRIALS 2008; 9:115-25. [PMID: 18474496 DOI: 10.1310/hct0902-115] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Combination antiretroviral regimens including nelfinavir (NFV) are commonly used in pregnancy. We studied the safety, antiviral effect, and pharmacokinetics of NFV and its M8 metabolite with two dosing regimens in combination with zidovudine (ZDV) and lamivudine (3TC) in HIV-infected pregnant women. METHOD HIV-infected pregnant women between 14 and 34 weeks gestation received NFV (Cohort 1: 750 mg tid, n = 10; Cohort 2: 1250 mg bid, n = 23) with ZDV and 3TC. Serial blood sampling for NFV concentrations was performed antepartum (AP) and 6 weeks postpartum (PP). Maternal and cord blood samples were also obtained at delivery. NFV and M8 levels were determined by high-performance liquid chromatography. The pharmacokinetic (PK) target was an extrapolated NFV AUC0-24 > 30 mug . h/mL. Mothers were followed frequently for potential clinical and laboratory toxicity. RESULTS Overall, NFV in combination with ZDV and 3TC was well tolerated. The PK target was met in 3/8 AP and 5/7 PP in Cohort 1 and 17/21 AP and 16/17 PP in Cohort 2. When Cohort 2 NFV PK parameters AP and PP were compared, median Cmax (3.90 microg/mL vs. 5.01 microg/mL, p < .05) and AUC0-24 (56.6 vs. 86.8 microg . h/mL, p < .05) were increased PP and oral clearance (Cl/F; 44.2 vs. 28.8 L/h, p < .05) was decreased PP. The average M8/NFV ratio was increased PP compared to AP (0.085 vs. 0.29, p < .001). Placental transfer of NFV was low with a median cord blood:maternal plasma ratio at delivery of 0.05. Maternal mean CD4+ T cell counts increased significantly and plasma HIV-1 RNA levels decreased from entry to delivery and 6 to 12 weeks postpartum. CONCLUSION NFV used in combination with ZDV and 3TC was well tolerated in pregnant HIV-infected women and produced a significant improvement in HIV disease parameters. NFV drug exposure is inadequate in most pregnant women receiving 750 mg tid but is much improved with 1250 mg bid. NFV crosses the placenta poorly. The AP increase in NFV oral clearance and decrease in M8/NFV ratio suggest that CYP3A activity increases relative to CYP2C19 activity during pregnancy.
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Affiliation(s)
- Y J Bryson
- David Geffen School of Medicine at UCLA, Los Angeles, California 90095-1752, USA.
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Hirt D, Urien S, Jullien V, Firtion G, Chappuy H, Rey E, Pons G, Mandelbrot L, Treluyer JM. Pharmacokinetic modelling of the placental transfer of nelfinavir and its M8 metabolite: a population study using 75 maternal-cord plasma samples. Br J Clin Pharmacol 2007; 64:634-44. [PMID: 17892516 PMCID: PMC2203265 DOI: 10.1111/j.1365-2125.2007.02885.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AIMS A population pharmacokinetic model was developed to characterize the transfer of nelfinavir and its active metabolite M8 from maternal to cord plasma and amniotic fluid. METHODS Concentration data were obtained from 75 women on the day of delivery and for whom maternal, umbilical plasma and amniotic fluid samples were collected. Data from 53 pregnant, 61 nonpregnant and seven consecutively pregnant and non pregnant women were then added to the database, the contents of which were analyzed using NONMEM. RESULTS Nelfinavir and M8 concentrations in maternal plasma, umbilical plasma and amniotic fluid were described by six connected compartments. Mean (% intersubject variability) population estimates were: absorption rate 00.67 h(-1), lag time 00.87 h, oral clearance and volume of distribution: 39.5 l h(-1) (53%), and 557 l for non pregnant and pregnant women, respectively, and 115 l h(-1) (132%) and 1626 l, respectively, on the day of delivery, M8 formation clearance 0.77 l h(-1) and M8 elimination rate constant 03.41 h(-1) (74%). For nelfinavir and M8, respectively, the mother-to-cord parameters were 0.058 l h(-1) (34%), and 00.35 h(-1) (76%), the cord-to-amniotic fluid rate constants were 0.23 and 00.59 h(-1), and the elimination rate constants from amniotic fluid were 0.36 and 00.49 h(-1). The nelfinavir fetus : maternal concentration ratio was 25% for maternal concentrations between 0.1 and 2.5 mg l(-1), between the 31 and 41st week of gestation. CONCLUSIONS The low transfer of nelfinavir from the placenta is unlikely to protect the fetus from vertical HIV-1 transmission.
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Affiliation(s)
- Déborah Hirt
- Pharmacologie Clinique, Assistance publique- Hôpitaux de Paris, groupe hospitalier Cochin-Saint-Vincent-de-Paul, Faculté de médecine René Descartes, Université Paris 5, Paris, France.
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Feiterna-Sperling C, Weizsaecker K, Bührer C, Casteleyn S, Loui A, Schmitz T, Wahn V, Obladen M. Hematologic Effects of Maternal Antiretroviral Therapy and Transmission Prophylaxis in HIV-1-Exposed Uninfected Newborn Infants. J Acquir Immune Defic Syndr 2007; 45:43-51. [PMID: 17356471 DOI: 10.1097/qai.0b013e318042d5e3] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE A prospective observational study to investigate hematologic alterations during the first 3 months of life in HIV-exposed uninfected infants subjected to antiretroviral medication before and after birth. METHODS Two hundred twenty-one consecutive uninfected infants born to HIV-positive mothers on antiretroviral medication during pregnancy were included. Perinatal transmission prophylaxis comprised zidovudine (ZDV) administered intravenously intrapartum and 10 days after birth. Blood counts and differentials were determined at birth and at 2, 4, 6, and 12 weeks of age, and hematologic toxicity was graded according to pediatric toxicity scales. Data were analyzed according to the kind of prenatal medication (ZDV alone or with another nucleoside reverse transcriptase inhibitor [NRTI] vs. highly active antiretroviral therapy [HAART]). RESULTS Median hemoglobin was significantly lower in HAART-exposed newborns from birth (P = 0.004) until day 28. During follow-up, 119 (53.8%) infants had anemia grade 2 or higher on at least 1 occasion; 16 (7.2%) received red blood cell transfusion at 23 (range: 1-56) days of age. Neutropenia grade 2 or higher occurred in 106 (48.0%) infants at least once; 8 infants had staphylococcal infections, and 2 infections were severe. After adjustment for possible confounders (prematurity, birth weight, ethnicity, gender, duration of maternal antiretroviral therapy, maternal Centers for Disease Control and Prevention stage, and maternal illicit drug use), HAART exposure was the only independent risk factor for anemia (odds ratio [OR] = 2.22, 95% confidence interval [CI]: 1.06 to 4.64; P = 0.034) and neutropenia (OR = 2.15, CI: 1.02 to 4.55; P = 0.045). CONCLUSIONS Antiretroviral transmission prophylaxis is associated with significant anemia and neutropenia in HIV-uninfected infants during the first 3 months of life. Anemia was more profound in HAART-exposed infants.
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Affiliation(s)
- Cornelia Feiterna-Sperling
- Charité, Department of Pediatric Pneumology and Immunology, University Medicine Berlin, Berlin, Germany.
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Villani P, Floridia M, Pirillo MF, Cusato M, Tamburrini E, Cavaliere AF, Guaraldi G, Vanzini C, Molinari A, degli Antoni A, Regazzi M. Pharmacokinetics of nelfinavir in HIV-1-infected pregnant and nonpregnant women. Br J Clin Pharmacol 2007; 62:309-15. [PMID: 16934047 PMCID: PMC1885131 DOI: 10.1111/j.1365-2125.2006.02669.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AIMS To compare steady-state nelfinavir (NFV) pharmacokinetics in pregnant and nonpregnant HIV-infected women. METHODS Twenty-five pregnant HIV-infected women were selected from an ongoing observational study evaluating the pharmacokinetics of antiretroviral agents during pregnancy. Twenty of them were in the third and five in the second trimester. Data for the control group of 21 HIV-infected nonpregnant women were taken from a previous multicentre pharmacokinetic trial. All the participating women achieved steady-state plasma concentrations while on a highly active antiretroviral therapy (HAART) regimen including NFV (1250 mg bid) and two nucleoside reverse transcriptase inhibitors (NRTIs). Blood samples for NFV measurement were collected predose (C(trough)) and at 0.5, 1, 2, 3, 4, 5, 6, 8 and 12 h post dose. RESULTS During the third trimester of pregnancy NFV AUC(0-12 h) median (range) values were 25.76 (12.61-42.74) microg h(-1) ml(-1), and were 32.49 (19.16-63.81) microg h(-1) ml(-1) in the control group [mean difference - 9.30 microg h(-1) ml(-1); 95% confidence interval (CI) -15.76, -2.83; P < 0.05). Median oral clearance (CL/F) was significantly higher in pregnant women than in the control group (48.5 l h(-1), range 29.3-99.1 l h(-1) vs. 38.5 l h(-1), range 19.6-65.2 l h(-1); mean difference 12.6 l h(-1); 95% CI 3.3, 21.9) but the difference disappeared when CL/F was adjusted for body weight. C(trough) was significantly (P < 0.01) lower in pregnant compared with nonpregnant women (median 0.8 microg ml(-1), range 0-2.6 microg ml(-1) vs. 1.5 microg ml(-1), range 0.5-4.9 microg ml(-1); mean difference -1.0 microg ml(-1); 95% CI -1.7, -0.31). The median elimination half-life of NFV observed during pregnancy was 3.7 h (range 1.4-6.6 h), compared with 5.2 (range 3.1-10.1 h) in the control group (mean difference -1.7; 95% CI -2.8, -0.51). CONCLUSIONS Our results indicate that women in the later stages of pregnancy may be exposed to subtherapeutic concentrations of NFV. Thus, adjustments in drug dosage or frequency of administration may be required.
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Affiliation(s)
- P Villani
- Department of Pharmacology, IRCCS Policlinico S. Matteo, Pavia, Italy
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Stek AM, Mirochnick M, Capparelli E, Best BM, Hu C, Burchett SK, Elgie C, Holland DT, Smith E, Tuomala R, Cotter A, Read JS. Reduced lopinavir exposure during pregnancy. AIDS 2006; 20:1931-9. [PMID: 16988514 DOI: 10.1097/01.aids.0000247114.43714.90] [Citation(s) in RCA: 154] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Optimal antiretroviral exposure during pregnancy is critical for prevention of mother-to-child HIV transmission and for maternal health. Pregnancy can alter antiretroviral pharmacokinetics. Our objective was to describe lopinavir/ritonavir (LPV/r) pharmacokinetics during pregnancy. METHODS We performed intensive steady-state 12-h pharmacokinetic profiles of lopinavir and ritonavir (three capsules: LPV 400 mg/r 100 mg) at 30-36 weeks gestation and 6-12 weeks postpartum. Maternal and umbilical cord blood samples were obtained at delivery. We measured LPV and ritonavir by reverse-phase high-performance liquid chromatography. Target LPV area under concentration versus time curve (AUC) was > or = 52 microg h/ml, the estimated 10th percentile LPV AUC in non-pregnant historical controls (mean AUC = 83 microg h/ml). RESULTS Seventeen women completed antepartum evaluations; average gestational age was 35 weeks. Geometric mean antepartum LPV AUC was 44.4 microg h/ml [90% confidence interval (CI), 38.7-50.9] and 12-h post-dose concentration (C12h) was 1.6 microg/ml (90% CI, 1.1-2.5). Twelve women completed postpartum evaluations; geometric mean LPV AUC was 65.2 microg h/ml (90% CI, 49.7-85.4) and C12h was 4.6 microg/ml (90% CI, 3.7-5.7). The geometric mean ratio of antepartum/postpartum LPV AUC was 0.72 (90% CI, 0.54-0.96). Fourteen of 17 (82%) pregnant and three of 12 (25%) postpartum women did not meet our target LPV AUC. The ratio of cord blood/maternal LPV concentration in ten paired detectable samples was 0.2 +/- 0.13. CONCLUSIONS LPV/r exposure during late pregnancy was lower compared to postpartum and compared to non-pregnant historical controls. Small amounts of lopinavir cross the placenta. The pharmacokinetics, safety, and effectiveness of increased LPV/r dosing during the third trimester of pregnancy should be investigated.
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Affiliation(s)
- Alice M Stek
- Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Los Angeles, CA, USA.
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Gingelmaier A, Kurowski M, Kästner R, Eberle J, Mylonas I, Belohradsky BH, Friese K, Grubert TA. Placental transfer and pharmacokinetics of lopinavir and other protease inhibitors in combination with nevirapine at delivery. AIDS 2006; 20:1737-43. [PMID: 16931938 DOI: 10.1097/01.aids.0000242820.67001.2c] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antiretroviral combination therapies, including nevirapine (NVP) and protease inhibitors (PI), are increasingly used in the treatment and for the prophylaxis of vertical HIV-1 transmission in HIV-1 infected pregnant women. OBJECTIVE To determine pharmacokinetics and placental transfer of NVP and different PI in pregnancy we measured drug levels in maternal and foetal compartments at the day of delivery. DESIGN AND METHODS We conducted a prospective study in 40 eligible HIV-1 infected pregnant women who gave birth in our hospital. A pre-dose to 6 h post-dose steady-state pharmacokinetic analysis (n = 35) of the drugs on the day of the scheduled Caesarean section was performed. In addition cord blood and amniotic fluid drug levels were measured (n = 40). RESULTS In all women NVP plasma concentrations (n = 20) were below the recommended level. PI plasma concentrations (nelfinavir, n = 5; saquinavir, n = 3; lopinavir, n = 10; ritonavir, n = 13) were extremely variable. Cord blood and amniotic fluid drug levels suggested that NVP passes the placenta unrestricted whereas PI were detected in smaller concentrations in the foetal compartment. CONCLUSIONS Because of the changed pharmacokinetics of antiretroviral drugs in pregnancy therapeutic drug monitoring could be important and dose adjustment should be considered. The minimal placental transfer of PI is desirable from the perspective that the foetus is protected from potentially teratogenic agents. However, it is not known if antiretroviral compounds in the foetal compartment contribute to the risk reduction of vertical HIV-1 transmission, and whether the property of missing placental transfer is in fact beneficial for the newborn.
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Affiliation(s)
- Andrea Gingelmaier
- 1st Department of Obstetrics and Gynecology, Ludwig-Maximilians-University of Munich, Maistrasse 11, 80337 Munich, Germany.
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Gavard L, Gil S, Peytavin G, Ceccaldi PF, Ferreira C, Farinotti R, Mandelbrot L. Placental transfer of lopinavir/ritonavir in the ex vivo human cotyledon perfusion model. Am J Obstet Gynecol 2006; 195:296-301. [PMID: 16678781 DOI: 10.1016/j.ajog.2006.01.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2005] [Revised: 12/10/2005] [Accepted: 01/10/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This study was done to determine the placental transfer of the human immunodeficiency virus protease inhibitor lopinavir with ritonavir. STUDY DESIGN Twenty-five human cotyledons that were obtained after uneventful pregnancies and deliveries were perfused in an open double circuit with lopinavir (1099-10,606 microg/L) and ritonavir (254-1147 microg/L) at various albumin concentrations (2, 10, and 40 g/L). RESULTS The fetal transfer rate of lopinavir, when combined with ritonavir, was 23.6% +/- 6.9% at an albumin concentration of 2 g/L. The fetal transfer rate decreased to 20.7% +/- 10% at an albumin concentration of 10 g/L and to 3.3% +/- 0.5% at an albumin concentration of 40 g/L. CONCLUSION The placental transfer of lopinavir, a highly protein-bound molecule, was compatible with passive diffusion of the unbound fraction. Even at physiologic maternal albumin concentrations, the amount of drug transferred into the fetal compartment was well above the 50% inhibitory concentration.
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Affiliation(s)
- Laurent Gavard
- Louis Mourier Hospital, Assistance Publique-Hôpitaux de Paris, Department of Obstetrics and Gynecology, Colombes, and Paris 7 University, Paris, France
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Abstract
The expanded use of multiple antiretroviral drugs during pregnancy has led to a reduction in the occurrence of perinatal transmission of HIV to <2%, but has led to concerns regarding both short-term toxicity and the long-term impact on the woman and her child. Enhanced toxicity of nevirapine has been noted among women with CD4+ lymphocyte counts >250 cells/microL at treatment initiation and among pregnant women on long-term didanosine and stavudine. These drugs should be avoided in such situations if alternatives are available. Efavirenz has been associated with birth defects in monkeys, and several cases of neural tube defects have been reported in humans after first trimester exposure, so treatment with this drug should be avoided during the first trimester. Protease inhibitors have been associated with an increased risk of maternal glucose intolerance, pre-eclampsia and preterm birth in some, but not all, studies. Pregnancies exposed to antiretroviral therapy should be registered with the Antiretroviral Pregnancy Registry as early in pregnancy as possible in order to provide data on the risk of birth defects after exposure. The pharmacokinetics of nucleoside and non-nucleoside reverse transcriptase inhibitors are not significantly changed in pregnancy, so standard dosing may be used. However, concentrations of several protease inhibitors are lower in pregnancy, so ritonavir-boosting or increased doses are required. Of great theoretical concern is the impact of resistance mutations that develop following single-dose nevirapine therapy on the response to later therapy among women and their infected infants. The use of dual nucleoside therapy for 3-7 days after single-dose nevirapine in the mother reduces but does not eliminate the risk of nevirapine resistance; alternative regimens for prevention of resistance are under study, as are the subsequent responses of the mother and her infant to therapy. Short courses of prophylactic zidovudine and nevirapine have been well tolerated in neonates. Concern has been raised, however, that these exposures may lead to persistent mitochondrial dysfunction or later cancers, underscoring the need for long-term surveillance of antiretroviral-exposed, HIV-uninfected infants.
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Affiliation(s)
- D Heather Watts
- Pediatric, Adolescent, and Maternal AIDS Branch, Center for Research for Mothers and Children, National Institute of Child Health and Human Development, Rockville, Maryland, USA.
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Spezielle Arzneimitteltherapie in der Schwangerschaft. ARZNEIVERORDNUNG IN SCHWANGERSCHAFT UND STILLZEIT 2006. [PMCID: PMC7271219 DOI: 10.1016/b978-343721332-8.50004-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Camus M, Deloménie C, Didier N, Faye A, Gil S, Dauge MC, Mabondzo A, Farinotti R. Increased expression of MDR1 mRNAs and P-glycoprotein in placentas from HIV-1 infected women. Placenta 2005; 27:699-706. [PMID: 16165208 DOI: 10.1016/j.placenta.2005.08.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2005] [Revised: 08/02/2005] [Accepted: 08/03/2005] [Indexed: 01/02/2023]
Abstract
P-glycoprotein transports several compounds including protease inhibitors, actually used in the clinical management of HIV-1 infection. Since P-glycoprotein is expressed in placental trophoblasts, its efflux activity could interfere with placental transfer of antiretrovirals. The purpose of this study was to investigate the expression of P-gp-encoding MDR1 gene and P-gp itself in full-term placentas from uninfected (n=35) and HIV-1 infected women (n=24). MDR1 transcripts were quantified by real-time PCR using relative (MDR1 normalized upon 28S levels) and absolute (copy number) determinations. P-glycoprotein localization and expression were evaluated by immunohistochemistry and western blot analysis, respectively. Relative or absolute PCR quantification showed a significant 3.3-fold (p<0.0009) or 3.7-fold (p<0.0002) mean increase in MDR1 placental transcription in HIV-infected compared to non-infected women, respectively. Ratios of individual HIV-positive values to HIV-negative mean ranged from 0.1 to 21.8. Moreover a significant 2.5-fold increased expression of immunoreactive P-glycoprotein was evidenced in placentas from HIV-infected women (p<0.0001). This MDR1 overexpression was observed in a similar extent in placentas from pregnant women treated with Zidovudine alone or in combination with Nelfinavir and/or Lamivudine. Our findings suggest that P-glycoprotein in placentas from HIV-infected women would contribute to modulate the materno-fetal transport of antiretrovirals across the placental barrier and consequently diminish fetal exposure to these compounds.
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Affiliation(s)
- M Camus
- Department of Clinical Pharmacy, UPRES EA 2706, University of Pharmaceutical Sciences, Paris XI, 5 rue Jean-Baptiste Clément, 92296 Châtenay-Malabry, France.
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Pacifici GM. Transfer of antivirals across the human placenta. Early Hum Dev 2005; 81:647-54. [PMID: 15946808 DOI: 10.1016/j.earlhumdev.2005.02.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2004] [Revised: 02/10/2005] [Accepted: 02/14/2005] [Indexed: 11/29/2022]
Abstract
BACKGROUND Viruses cross the placenta and infect the fetus. Antivirals are administered to pregnant women to protect them and the fetus against the viruses. It is necessary to know which antivirals cross the placenta and reach the fetal circulation in pharmacologically significant concentrations in order to plan antiviral therapy. AIMS This article reviews the literature on the placental transfer of antivirals against HIV. The review considers also the placental transfer of acyclovir and ganciclovir, which are used against the herpes simplex virus and the cytomegalovirus, respectively. STUDY DESIGN Firstly, a medline was performed with the following key words "placental transfer of antivirals". Secondly, a medline was performed with the key words "placenta transfer of..." followed by the name of a single antiviral and it was repeated for 20 antivirals. Thirdly, another medline was performed using the following key words "pharmacokinetics of antiviral in newborn" in order to collect those articles which describe in vivo transfer of antivirals. The literature was critically read and a written note was produced. RESULTS The literature on the placental transfer of antivirals includes studies in vitro perfusing the human placenta and studies performed in vivo in which the cord and maternal antiviral plasma concentrations are compared. Both the results obtained in vitro and in vivo show that the protease inhibitors poorly transfer the placenta because of their great molecular weight. With the exception of didanosine, the nucleoside reverse transcriptase inhibitors and nelfinavir, a non-nucleoside reverse transcriptase inhibitor, cross the placenta and the cord, and maternal plasma concentrations equilibrate. CONCLUSIONS In vitro and in vivo results are consistent with the view that the nucleoside reverse transcriptase inhibitors cross the human placenta and produce significant pharmacological concentrations in the fetal circulation. Nevirapine, the only studied non-nucleoside reverse transcriptase inhibitor, reach the equilibrium between the fetal and maternal concentration, whereas the protease inhibitors have a poor transfer across the human placenta.
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Affiliation(s)
- Gian Maria Pacifici
- Department of Neurosciences, Section of Pharmacology, Medical School, Via Roma 55, 56126 Pisa, Italy.
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Sudhakaran S, Ghabrial H, Nation RL, Kong DCM, Gude NM, Angus PW, Rayner CR. Differential bidirectional transfer of indinavir in the isolated perfused human placenta. Antimicrob Agents Chemother 2005; 49:1023-8. [PMID: 15728898 PMCID: PMC549249 DOI: 10.1128/aac.49.3.1023-1028.2005] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The protease inhibitor (PI) indinavir may be used in the management of human immunodeficiency virus (HIV) infection during pregnancy. Poor maternal-to-fetal transfer of indinavir has been reported previously, but the mechanisms of transfer remain unknown. The bidirectional transfer of indinavir was assessed in dually perfused, isolated human placentae. Term placentae (n = 5) were obtained from non-HIV-infected pregnant women. To investigate transport mechanisms, the steady-state transfer of indinavir was compared to those of antipyrine (a marker of passive diffusion) and [(3)H]vinblastine (a marker of P-glycoprotein [P-gp] transport) in the maternal-to-fetal and fetal-to-maternal directions in each placenta. Indinavir and antipyrine perfusate concentrations were determined by using reverse-phase, high-performance liquid chromatography; [(3)H]vinblastine concentrations were measured by liquid scintillation. The antipyrine transfer clearance in each direction did not differ (P = 0.76), a finding consistent with passive diffusion. However, the maternal-to-fetal transfer clearance of vinblastine, normalized to that of antipyrine (clearance index) (0.31 +/- 0.05), was significantly lower than the fetal-to-maternal clearance index of vinblastine (0.67 +/- 0.17; P = 0.017), suggesting the involvement of placental P-gp. Similarly, the maternal-to-fetal clearance index of indinavir (0.39 +/- 0.09) was significantly lower than its fetal-to-maternal clearance index (0.97 +/- 0.12; P < 0.001). These results represent the first evidence for differential transfer of a xenobiotic in the intact human placenta. The use of transport modulators to increase the maternal-to-fetal transfer of PIs as a possible strategy to reduce mother-to-child transmission of HIV warrants investigation.
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Affiliation(s)
- Sreeja Sudhakaran
- Facility for Anti-Infective Drug Development and Innovation, Monash University, 381 Royal Parade, Parkville, 3052, Melbourne, Australia
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Abstract
Continued spread of HIV infection among women has led to the use of antiretrovirals in pregnant women and their newborns. Regional strategies to prevent mother-to-child transmission are evolving. Altered drug disposition during pregnancy may require altered dosing or 'boosted' therapies to avoid treatment failure. Maturing drug elimination pathways in newborns must also be considered for effective therapy. Potential teratogenic effects and increased sensitivity to antiretroviral toxicities might be encountered in this population. Use of highly active antiretroviral therapy (HAART) to suppress viral replication combined with formula feeding can reduce the rate of mother-to-child HIV transmission to less than 2%. In resource-limited settings, less intensive regimens including zidovudine, lamivudine and nevirapine still substantially reduce mother-to-child transmission. Although difficult to perform, clinical trials to determine the safety, pharmacokinetics and optimal dosing of antiretroviral in pregnant women and their newborns are urgently needed.
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Affiliation(s)
- Edmund Capparelli
- University of California, San Diego, Pediatric Pharmacology Research Unit, 4094 Fourth Street #201, San Diego, CA 92103, USA.
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Chappuy H, Tréluyer JM, Rey E, Dimet J, Fouché M, Firtion G, Pons G, Mandelbrot L. Maternal-fetal transfer and amniotic fluid accumulation of protease inhibitors in pregnant women who are infected with human immunodeficiency virus. Am J Obstet Gynecol 2004; 191:558-62. [PMID: 15343237 DOI: 10.1016/j.ajog.2004.01.034] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate placental transfer and amniotic fluid concentrations of protease inhibitors when they are given to pregnant women who are infected with human immunodeficiency virus. STUDY DESIGN Fifty-eight mothers who received antiretroviral therapy that included > or =1 protease inhibitors for clinical indications at the time of delivery were enrolled in the study. Maternal blood samples and amniotic fluid were obtained during delivery or cesarean delivery, and paired cord blood samples were obtained by venipuncture immediately after the delivery. Drug concentrations were measured with high performance liquid chromatography. RESULTS Most maternal protease inhibitor plasma concentrations (38/66 concentrations) were below the trough concentrations that are recommended for therapeutic drug monitoring. Cord blood concentrations were below the assay limit of detection in 10 of 40 samples for nelfinavir and 25 of 40 samples for its metabolite M8, 9 of 11 samples for ritonavir, 4 of 6 samples for indinavir, 5 of 6 samples for saquinavir but were detectable in 3 of 3 samples for amprenavir. Among the 24 amniotic fluid samples that were available, the concentrations below the detection limit were 10 of 16 samples for nelfinavir, 11 of 16 samples for M8, 1 of 3 samples for indinavir, 4 of 4 samples for ritonavir, and 0 of 1 samples for amprenavir. There were significant correlations between cord blood and maternal concentrations of nelfinavir and its metabolite M8. CONCLUSION Placental transfer of the human immunodeficiency virus protease inhibitors is generally low; however, it may differ greatly according to the molecule.
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Affiliation(s)
- Hélène Chappuy
- Pharmacologie Clinique, Université René-Descartes, Hôpital Cochin Saint-Vincent-de-Paul, 82 avenue Denfert Rochereau, 75674 Paris Cedex 14, France
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Ostrea EM, Mantaring JB, Silvestre MA. Drugs that affect the fetus and newborn infant via the placenta or breast milk. Pediatr Clin North Am 2004; 51:539-79, vii. [PMID: 15157585 DOI: 10.1016/j.pcl.2004.01.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In general, drugs that are taken by a mother during pregnancy or after birth may be transferred to the fetus or the infant (through breast milk). Many factors are involved that determine the amount of drugs that are transferred and their potential effects on the fetus or infant. A careful assessment of the risk versus benefit is necessary and should be individualized. In the breastfed infant, many measures can be undertaken further so that the amount of drug transferred to the infant is minimized.
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Affiliation(s)
- Enrique M Ostrea
- Department of Pediatrics, Wayne State University, Detroit, MI 48202, USA.
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Rakhmanina NY, van den Anker JN, Soldin SJ. Safety and Pharmacokinetics of Antiretroviral Therapy During Pregnancy. Ther Drug Monit 2004; 26:110-5. [PMID: 15228149 DOI: 10.1097/00007691-200404000-00004] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Combined antiretroviral therapy can reduce the transmission of human immunodeficiency virus (HIV) to an unborn child to less than two percent. An HIV-infected woman of childbearing age and her medical provider are in the unique position of making treatment decisions that not only will impact the woman's health but also that of her child. Treatment recommendations for pregnant women infected with HIV state that therapies of known benefit to women should not be withheld during pregnancy, unless there are known adverse effects for the mother and fetus, and these adverse effects outweigh the benefit for the women. However, the recommendations of antiretroviral drugs for the treatment of HIV-infected pregnant women are subject to unique considerations, including potential changes in dosing requirement resulting from physiologic changes associated with pregnancy, and potential adverse effects on the development of the fetus and/or newborn. Currently there is a general lack of pharmacokinetic data in pregnant HIV-infected women. The limited available information suggests that pregnant women may be exposed to subtherapeutic drug levels of certain antiretroviral agents during the later stages of pregnancy, which can lead to the failure of virologic suppression, development of resistance and increased risk of vertical transmission of HIV infection. The available pharmacokinetic data regarding the use of antiretroviral therapy in pregnancy is reviewed.
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Affiliation(s)
- Natella Y Rakhmanina
- Special Immunology Program, Children's National Medical Center, Washington, DC 20010-2970, USA.
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Pillay T, Khan M, Moodley J, Adhikari M, Coovadia H. Perinatal tuberculosis and HIV-1: considerations for resource-limited settings. THE LANCET. INFECTIOUS DISEASES 2004; 4:155-65. [PMID: 14998501 DOI: 10.1016/s1473-3099(04)00939-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Tuberculosis is the commonest HIV-1-related disease and the most frequent cause of mortality in young women in endemic regions. Tuberculosis and HIV-1 are independent risk factors for maternal mortality and adverse perinatal outcomes, and in combination have a greater impact on these parameters than their individual effects. In referral health centres in southern Africa around one-sixth of all maternal deaths are due to tuberculosis/HIV-1 coinfection. One-third (37%) of HIV-1-infected mothers with tuberculosis are severely immunocompromised, with CD4 counts of fewer than 200 cells/microL compared with 14-19% in mothers recruited into major mother-to-child intervention trials in Europe. Babies born to mothers with tuberculosis/HIV-1 also have higher rates of prematurity, low birthweight, and intrauterine growth restriction. Transmission rates of HIV-1 from mother to infant are around 25-45% in resource-limited settings, while that for mother-to-child-transmission of tuberculosis is 15% within 3 weeks of birth. We highlight this emergent problem, and discuss the dilemmas associated with diagnosis and management of pregnant HIV-1-infected mothers with tuberculosis, and their newborn babies.
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Affiliation(s)
- T Pillay
- Department of Paediatrics and Child Health, University of Natal, Nelson R Mandela Medical School, KwaZulu Natal, Durban, South Africa.
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Abstract
Antiretroviral treatment of HIV-infected pregnant women is widely used to prevent mother-to-child HIV transmission and as primary therapy of maternal HIV infection. The physiological changes associated with pregnancy have a large impact on drug disposition, and changes in antiretroviral pharmacokinetics during pregnancy must be understood for these drugs to be used safely and effectively in pregnant women. Zidovudine and didanosine, two of the nucleoside reverse transcriptase inhibitors, demonstrate an increase in clearance and decrease in area under the concentration-time curve during pregnancy. The clinical significance of these changes is unknown due to the lack of a clear relationship between plasma concentrations of nucleoside reverse transcriptase inhibitors and clinical effects. Pharmacokinetic parameters of lamivudine, stavudine and abacavir are not significantly changed during pregnancy. There are no data describing the effect of pregnancy on the pharmacokinetics of the other nucleoside/nucleotide analogues (zalcitabine, emtricitabine and tenofovir). Pregnancy does not appear to have a significant effect on the pharmacokinetics of the non-nucleoside reverse transcriptase inhibitor nevirapine and there are no data describing the pharmacokinetics of the other non-nucleoside reverse transcriptase inhibitors (efavirenz and delavirdine) during pregnancy. Reduced plasma concentrations during pregnancy have been described for several of the protease inhibitors, including nelfinavir (with administration of 750 mg three times daily), indinavir, saquinavir and Kaletra (a co-formulation of lopinavir and ritonavir). Plasma concentrations equivalent to those in nonpregnant adults have been reported in pregnant women receiving nelfinavir at doses of 1250 mg twice daily, and the addition of ritonavir to saquinavir greatly increases saquinavir exposure to therapeutic concentrations in pregnant women. No pregnancy pharmacokinetic data are available for the newer protease inhibitors atazanavir and fosamprenavir, or with other dual protease inhibitor combinations that include low dose ritonavir to boost concentrations of the coadministered protease inhibitor. Further investigations of antiretroviral pharmacology during pregnancy, including protein binding studies, are urgently needed.
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Affiliation(s)
- Mark Mirochnick
- Boston University School of Medicine, Boston, Massachusetts 02118, USA.
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Chauvenet M, Rimailho A, Hoog-Labouret N. Methodology for the evaluation of drugs in pregnant women. Therapie 2003; 58:247-58. [PMID: 14655319 DOI: 10.2515/therapie:2003039] [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]
Abstract
Although drugs are prescribed during pregnancy with some reluctance, they fulfill a real need in some circumstances. Adequate drug evaluation is thus essential, either based on efficacy and safety or mainly safety, using available data from non-pregnant women. Evaluation methodology is not fundamentally different during pregnancy. Recommendations for drug development are formulated on the basis of the most common situations as well as specific suggestions, thus raising the awareness of the different partners participating in healthcare (institutions, the pharmaceutical industry and prescribers). In particular, regulatory and economic incentives superimposed upon those recommendations adopted in Europe and the US for orphan diseases should be put into place to assist in the evaluation of drugs used in obstetrics. Medical needs in obstetrics should be better identified, and labelling of drugs for use during pregnancy should be better directed towards prescribers; a national registry of pregnancies should be established in France.
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Affiliation(s)
- Marina Chauvenet
- Agence Française de Sécurité Sanitaire des Produits de Santé, Saint-Denis, France
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Burns-Naas LA, Webber S, Stump DG, Holson JF, Masarjian L, Zorbas M. Absence of embryo-fetal toxicity in rats or rabbits following oral dosing with nelfinavir. Regul Toxicol Pharmacol 2003; 38:291-303. [PMID: 14623480 DOI: 10.1016/s0273-2300(03)00096-5] [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: 11/16/2022]
Abstract
The potential for nelfinavir mesylate (VIRACEPT) to induce maternal and embryo-fetal toxicity was evaluated in rats and rabbits following oral administration. The drug was administered by gavage to rats at doses of 200, 500, or 1000mg/kg/day on days 6-17 of gestation and to rabbits at doses of 200, 400, or 1000mg/kg/day on days 7-20 of gestation. Dams and does were euthanized on GD20 and 29, respectively, and the offspring were weighed and examined for external, visceral, and skeletal alterations. Maximum plasma nelfinavir concentrations (C(max)) in rats were comparable to C(max) values in humans and were 3- to 6-fold higher than the reported human trough levels, while plasma nelfinavir levels in rabbits were approximately 0.13-0.17x the human C(max) and 0.25-0.5x the human trough. In rats, no treatment-related maternal or embryo-fetal toxicity was observed at any dose level and the NOAEL for both maternal and fetal toxicity was considered to be 1000mg/kg/day. Two rabbits in the 400mg/kg/day group died prior to scheduled termination. Because no deaths occurred in the high dose group and there were no other treatment-related signs of clinical toxicity in any dose group, these deaths were considered unrelated to nelfinavir. Group mean body weight loss in rabbits was observed at 1000mg/kg/day on gestation days 7-10. Food consumption was also reduced in this treatment group throughout the dosing period. There were no treatment-related findings in other maternal or fetal parameters. Thus, the no-observed-adverse-effect-level (NOAEL) for maternal toxicity in the rabbit was considered to be 400mg/kg/day (based on maternal body weight loss in the high dose group), while the NOAEL for embryo-fetal toxicity in the rabbit was considered to be 1000mg/kg/day. Thus, under the conditions of this study, nelfinavir was not considered to be toxic to the rat or rabbit conceptus.
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Affiliation(s)
- Leigh Ann Burns-Naas
- Worldwide Safety Sciences, Pfizer Global Research and Development, La Jolla Laboratories, San Diego, CA, USA.
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Burns-Naas LA, Stump DG, Webber S, Holson JF, Masarjian L, Furman G, Zorbas M. Absence of reproductive and developmental toxicity in rats following oral dosing with nelfinavir. Regul Toxicol Pharmacol 2003; 38:304-16. [PMID: 14623481 DOI: 10.1016/s0273-2300(03)00097-7] [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: 11/23/2022]
Abstract
The potential for nelfinavir mesylate (VIRACEPT) to produce reproductive toxicity was evaluated in rats administered oral doses of 200, 500, or 1000mg/kg/day. In the fertility and early embryonic development to implantation study, male rats were treated beginning 28 days prior to mating until necropsy and females for 2 weeks prior to mating and through gestation day (GD) 7. In the pre- and postnatal development study, pregnant rats were treated from GD 6 through lactation day (LD) 20. Selected F(1) pups from this study were evaluated in sensory and behavioral tests and were subsequently mated. Pregnant F(1) females were euthanized on GD 20 and their F(2) fetuses were examined. F(1) animals were not directly dosed with the drug. No treatment-related effects were observed on any male reproductive parameters. Administration of nelfinavir did not produce adverse effects on fertility, pregnancy, embryo-fetal development, parturition, or lactation in the F(0) generation. Similarly, no adverse effects of nelfinavir treatment were observed on pre- and postnatal growth, development, reproductive performance and embryo-fetal development in the F(1) offspring. Based on the results of this study, the no-observed-adverse-effect-level (NOAEL) for developmental and reproductive toxicity in rats was considered to be 1000mg/kg/day, the highest dose tested.
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Affiliation(s)
- Leigh Ann Burns-Naas
- Worldwide Safety Sciences, Pfizer Global Research and Development, 10724 Science Center Drive, San Diego, CA 92064, USA.
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Chauvenet M, Rimailho A, Hoog-Labouret N, Audibert F, Bavoux F, Boutroy M, Brasseur D, Carlier P, Elefant E, Gersberg M, Goffinet F, Jacqz-Aigrain E, Lemery D, Mandelbrot L, Mirelesse V, Saint-Salvi B, Tchinou C, Vial T. Methodology for the Evaluation of Drugs in Pregnant Women. Therapie 2003. [DOI: 10.2515/therapie:2003040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2003; 12:253-68. [PMID: 12733480 DOI: 10.1002/pds.789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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