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Bordin Andriguetti N, Van Schalkwyk HK, Barratt DT, Tucci J, Pumuye P, Somogyi AA. Large variability in plasma efavirenz concentration in Papua New Guinea HIV/AIDS patients associated with high frequency of CYP2B6 516T allele. Clin Transl Sci 2021; 14:2521-2531. [PMID: 34415664 PMCID: PMC8604234 DOI: 10.1111/cts.13120] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/20/2021] [Accepted: 07/02/2021] [Indexed: 12/14/2022] Open
Abstract
Papua New Guinea (PNG) has a high HIV/AIDS prevalence and very high frequency of the CYP2B6 c.516G>T (rs3745274) variant. We have conducted the first investigation of the impact of c.516G>T and patient demographics on plasma efavirenz (EFV) and 8‐hydroxyefavirenz (8OH‐EFV) concentrations, metabolic ratio (8OH‐EFV/EFV) (MR), and their association with adverse effects, in PNG patients with HIV/AIDS. For 156 PNG patients with HIV/AIDS taking EFV 600 mg/day (for 3–156 months), plasma EFV and 8OH‐EFV concentrations were quantified, CYP2B6 c.516G>T genotyped, and demographic and self‐reported adverse effects data recorded. Genotype differences in EFV and 8OH‐EFV concentrations, MR, and percent within therapeutic range (1000–4000 ng/ml) were examined, in addition to EFV and 8OH‐EFV concentration differences between patients experiencing adverse effects. CYP2B6 c.516T allele frequency was 53%. Plasma EFV (p < 0.0001), 8OH‐EFV (p < 0.01), and MR (p < 0.0001) differed significantly between genotypes, with genotype explaining 38%, 10%, and 50% of variability, respectively. Plasma EFV concentrations were significantly higher in T/T (median = 5168 ng/ml) than G/G (1036 ng/ml, post hoc p < 0.0001) and G/T (1502 ng/ml, p < 0.0001) genotypes, with all patients above therapeutic range (n = 23) being T/T genotype (p < 0.0001). EFV and 8OH‐EFV concentrations were not significantly higher in patients experiencing adverse effects. In PNG HIV/AIDS population where the 516T frequency is very high, it explains a substantial portion of variability (38%) in EFV disposition; however, at least for the patients receiving EFV long term, this does not translate into significant side effects.
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Affiliation(s)
| | | | - Daniel Thomas Barratt
- Discipline of Physiology, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Joseph Tucci
- Department of Pharmacy & Biomedical Sciences, La Trobe University Bendigo Campus, Bendigo, Victoria, Australia
| | - Paul Pumuye
- School of Medicine and Health Sciences, University of Papua New Guinea, National Capital District, Papua New Guinea
| | - Andrew Alexander Somogyi
- Discipline of Pharmacology, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
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Chen R, Chen J, Xun J, Hu Z, Huang Q, Zhang R, Steinhart C, Shen Y, Liu L, Lu H. Pharmacogenomics and pharmacokinetics of efavirenz 400 or 600 mg in 184 treatment-naive HIV-infected patients in China. Pharmacogenomics 2020; 21:945-956. [PMID: 32838647 DOI: 10.2217/pgs-2019-0169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: The pharmacogenomics and pharmacokinetics/pharmacodynamics of 400 mg efavirenz have rarely been reported. Materials & methods: A total of 184 treatment-naive HIV-infected patients were randomly assigned (1:1) to receive a lower dose (tenofovir disoproxil 200 mg, efavirenz 400 mg and lamivudine) or a standard dose regimen. Relationships between pharmacogenomics and efavirenz pharmacokinetics/pharmacodynamics were explored at 48 weeks. Results: There was no relationship between pharmacogenomics and adverse reactions of the central nervous system and antiretoviral efficacy. CYP2B6 516G>T, 785A>G, 18492C>T and ABCB1 3435C>T T/C were associated with higher efavirenz plasma levels in the standard but not the lower dose group. No relationship was found between pharmacogenomics and antiretoviral efficacy. Patients who were <60 kg had higher efavirenz concentration compared with those with weight ≥60 kg when using 600 mg efavirenz, this was not observed with 400 mg efavirenz. Conclusion: The effect of pharmacogenomics and body weight on the efavirenz concentration was significant in the 600 mg group but not in the 400 mg group.
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Affiliation(s)
- Rong Chen
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China.,Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Jun Chen
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China
| | - Jingna Xun
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China
| | - Zhiliang Hu
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, 210003, China
| | - Qiong Huang
- Yunnan AIDS Care Center (YNACC), Yunnan Provincial Infectious Disease Hospital, Kunming, 650500, China
| | - Renfang Zhang
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China
| | - Corky Steinhart
- CAN Community Health, FL 34232, USA.,Department of Internal Medicine, The University of Central Florida, College of Medicine, FL 32827, USA
| | - Yinzhong Shen
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China
| | - Li Liu
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China
| | - Hongzhou Lu
- Department of Infection & Immunology, Shanghai Public Health Clinical Center, Fudan University. Shanghai, 201508, China
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Dos Santos Martins E, Oliveira JA, Franchin TB, Silva BCU, Cândido CD, Peccinini RG. Simple and Rapid Method by Ultra High-Performance Liquid Chromatography (UHPLC) with Ultraviolet Detection for Determination of Efavirenz in Plasma: Application in a Preclinical Pharmacokinetic Study. J Chromatogr Sci 2020; 57:874-880. [PMID: 31602469 DOI: 10.1093/chromsci/bmz078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/15/2019] [Accepted: 08/27/2019] [Indexed: 11/14/2022]
Abstract
A simple and rapid ultra-high-performance liquid chromatography (UHPLC) method for determination of efavirenz (EFV) in plasma was developed and applied in a preclinical pharmacokinetic study. The method involves only addition of acetonitrile to precipitation of plasma proteins followed by solvent evaporation. The mobile phase consisted of methanol, acetonitrile and 0.1 M formic acid (20:50:30) at a flow rate of 0.3 mL/min with run time of 5 min. A CSH C18 column and a UHPLC-UV system operating at 245 nm were used. There was a linear response in the range of 0.078 to 10 μg/mL, and the equation was obtained by weighting (1/x2) with r2 = 0.9965. The pharmacokinetic disposition of EFV was investigated in rabbits (two groups, n = 7) following a single intravenous administration (IV group) at a dose of 2.7 mg/kg and a single oral administration (oral group) of EFV co-administered with lamivudine (3TC) and tenofovir (TNF) at a dose of 50, 25 and 25 mg, respectively. The study demonstrated the applicability of the method for determination of EFV in plasma without interference from other co-administered drugs, and the pharmacokinetic parameters were calculated. The method showed advantages over other methods in the literature, such as simplicity of sample processing and fast results.
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Affiliation(s)
- Evelin Dos Santos Martins
- Department of Natural Active Principles and Toxicology, School of Pharmaceutical Sciences, Universidade Estadual Paulista ``Júlio de Mesquita Filho''-UNESP, Araraquara, São Paulo, Brazil
| | - Jonata Augusto Oliveira
- Department of Natural Active Principles and Toxicology, School of Pharmaceutical Sciences, Universidade Estadual Paulista ``Júlio de Mesquita Filho''-UNESP, Araraquara, São Paulo, Brazil
| | - Taísa Busaranho Franchin
- Department of Natural Active Principles and Toxicology, School of Pharmaceutical Sciences, Universidade Estadual Paulista ``Júlio de Mesquita Filho''-UNESP, Araraquara, São Paulo, Brazil
| | - Bruna Cristina Ulian Silva
- Department of Natural Active Principles and Toxicology, School of Pharmaceutical Sciences, Universidade Estadual Paulista ``Júlio de Mesquita Filho''-UNESP, Araraquara, São Paulo, Brazil
| | - Caroline Damico Cândido
- Department of Natural Active Principles and Toxicology, School of Pharmaceutical Sciences, Universidade Estadual Paulista ``Júlio de Mesquita Filho''-UNESP, Araraquara, São Paulo, Brazil
| | - Rosângela Gonçalves Peccinini
- Department of Natural Active Principles and Toxicology, School of Pharmaceutical Sciences, Universidade Estadual Paulista ``Júlio de Mesquita Filho''-UNESP, Araraquara, São Paulo, Brazil
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Bednasz CJ, Venuto CS, Ma Q, Daar ES, Sax PE, Fischl MA, Collier AC, Smith KY, Tierney C, Yang Y, Wilding GE, Morse GD. Efavirenz Therapeutic Range in HIV-1 Treatment-Naive Participants. Ther Drug Monit 2017; 39:596-603. [PMID: 29135907 PMCID: PMC5718358 DOI: 10.1097/ftd.0000000000000443] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Efavirenz is currently suggested as an alternative to recommended antiretroviral (ARV) regimens by the Department of Health and Human Services for the treatment of HIV-1 in ARV-naive patients. A mid-dosing interval therapeutic range between 1000 and 4000 ng/mL for efavirenz has been proposed in the literature, with patients more likely to experience virologic failure below this range and adverse effects above. The current study reports an analysis of virologic outcome between those above, below, or within the reported efavirenz therapeutic range (1000-4000 ng/mL) and within subgroups. METHODS This analysis examined efavirenz plasma concentrations obtained from participants enrolled in AIDS Clinical Trials Group Study A5202. This investigation divided subjects into those who experienced virologic failure and those who did not. These subjects were further separated to investigate those who had "high," "within," or "low" plasma concentrations, based on the therapeutic range. The association between virologic failure and plasma concentration was statistically examined in addition to the variables: race/ethnicity, sex, assigned nucleos(t)ide reverse transcriptase inhibitor backbone, age at study entry, history of intravenous drug use, weight, and screening HIV-1 RNA stratification level. RESULTS In univariate analyses, a statistically significant difference was found when comparing the efavirenz concentration groups, (22 failures among the "low" concentration group [19%], 65 failures among the "within" concentration group [12%], and 11 failures among the "high" concentration group [9%]) when evaluating virologic failure as an outcome (P = 0.04). In addition, the proportion of participants with virologic failure differed across race/ethnicity groups (P = 0.03) with black non-Hispanic participants observed to have the highest rate (17%). Efavirenz concentration group, race/ethnicity, age, weight, and the interaction between efavirenz concentration group and weight were found to be significantly associated with virologic failure in multivariable logistic regression analysis. CONCLUSIONS The proposed efavirenz therapeutic range, combined with the impact of a patient's weight, is associated with virologic failure in HIV-infected ARV-naive individuals in the United States. Additional analysis is recommended to determine the most appropriate concentration value that defines the lower limit of the efavirenz therapeutic range.
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Affiliation(s)
- Cindy J. Bednasz
- AIDS Clinical Trials Group Pharmacology Specialty Laboratory, New York State Center of Excellence in Bioinformatics
and Life Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Charles S. Venuto
- AIDS Clinical Trials Group Pharmacology Specialty Laboratory, New York State Center of Excellence in Bioinformatics
and Life Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
- Center for Human Experimental Therapeutics, University of Rochester, Rochester, NY, USA
| | - Qing Ma
- AIDS Clinical Trials Group Pharmacology Specialty Laboratory, New York State Center of Excellence in Bioinformatics
and Life Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Eric S. Daar
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center and the University of California, Los Angeles,
CA, USA
| | - Paul E. Sax
- Division of Infectious Diseases and Department of Medicine, Brigham and Women’s Hospital and Harvard Medical
School, Boston, MA, USA
| | | | - Ann C. Collier
- University of Washington School of Medicine and Harborview Medical Center, Seattle, WA, USA
| | | | - Camlin Tierney
- Statistical Data Analysis Center, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Yang Yang
- Department of Biostatistics, University at Buffalo, Buffalo, NY, USA
| | | | - Gene D. Morse
- AIDS Clinical Trials Group Pharmacology Specialty Laboratory, New York State Center of Excellence in Bioinformatics
and Life Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
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Grilo NM, Correia MJ, Sequeira C, Harjivan SG, Caixas U, Diogo LN, Marques MM, Monteiro EC, Antunes AMM, Pereira SA. Efavirenz biotransformation as an up-stream event of mood changes in HIV-infected patients. Toxicol Lett 2016; 260:28-35. [PMID: 27543169 DOI: 10.1016/j.toxlet.2016.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/09/2016] [Accepted: 08/13/2016] [Indexed: 01/21/2023]
Abstract
Efavirenz is a drug of choice for adults and children infected with the human immunodeficiency virus. Notably, up to 35% of patients on efavirenz suffer from mood changes. This work aimed to investigate efavirenz biotransformation into 8-hydroxy-efavirenz as an up-stream event of mood changes and to evaluate the suitability of 8-hydroxy-efavirenz biomonitoring for the minimization of these manifestations. A case-control study with two age-matched groups of HIV-infected male patients was performed in a group without adverse central nervous system complaints (28 patients) and a group presenting mood changes (14 patients). The plasma concentration of non-conjugated 8-hydroxy-efavirenz was higher in patients with mood changes (p=0.020). An association between efavirenz and 8-hydroxy-efavirenz-glucuronide was found (Spearman r=0.414, p<0.010), only within therapeutic efavirenz concentrations. This correlation was not observed in patients with toxic (>4mg/L) plasma concentrations of the parent drug. We conclude that metabolism to 8-hydroxy-efavirenz is associated with efavirenz-related mood changes, which suggests that the concentration of this metabolite is a suitable parameter for therapeutic drug monitoring aimed at controlling these manifestations. Moreover, our data suggest that 8-hydroxy-efavirenz is able to cross the blood-brain barrier and that the peripheral detoxification of 8-hydroxy-efavirenz by glucuronidation may be inhibited by toxic efavirenz concentrations.
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Affiliation(s)
- Nádia M Grilo
- Centro de Estudos de Doenças Crónicas (CEDOC), NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1150-052, Lisboa, Portugal
| | - M João Correia
- Centro de Estudos de Doenças Crónicas (CEDOC), NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1150-052, Lisboa, Portugal
| | - Catarina Sequeira
- Centro de Estudos de Doenças Crónicas (CEDOC), NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1150-052, Lisboa, Portugal
| | - Shrika G Harjivan
- Centro de Química Estrutural (CQE), Instituto Superior Técnico, Universidade de Lisboa, 1049-001, Lisboa, Portugal
| | - Umbelina Caixas
- Centro de Estudos de Doenças Crónicas (CEDOC), NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1150-052, Lisboa, Portugal; Centro Hospitalar de Lisboa Central, Lisboa, EPE, 1150-199, Lisboa, Portugal
| | - Lucília N Diogo
- Centro de Estudos de Doenças Crónicas (CEDOC), NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1150-052, Lisboa, Portugal
| | - M Matilde Marques
- Centro de Química Estrutural (CQE), Instituto Superior Técnico, Universidade de Lisboa, 1049-001, Lisboa, Portugal
| | - Emília C Monteiro
- Centro de Estudos de Doenças Crónicas (CEDOC), NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1150-052, Lisboa, Portugal
| | - Alexandra M M Antunes
- Centro de Química Estrutural (CQE), Instituto Superior Técnico, Universidade de Lisboa, 1049-001, Lisboa, Portugal
| | - Sofia A Pereira
- Centro de Estudos de Doenças Crónicas (CEDOC), NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1150-052, Lisboa, Portugal.
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Lavra ZMM, Pereira de Santana D, Ré MI. Solubility and dissolution performances of spray-dried solid dispersion of Efavirenz in Soluplus. Drug Dev Ind Pharm 2016; 43:42-54. [DOI: 10.1080/03639045.2016.1205598] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Zênia Maria Maciel Lavra
- Mines Albi, CNRS, Centre RAPSODEE, Campus Jarlard, Université de Toulouse, Albi, France
- Department of Pharmaceutics Sciences, Faculty of Pharmacy, Federal University of Pernambuco, Pernambuco, PE, Brazil
| | - Davi Pereira de Santana
- Department of Pharmaceutics Sciences, Faculty of Pharmacy, Federal University of Pernambuco, Pernambuco, PE, Brazil
| | - Maria Inês Ré
- Mines Albi, CNRS, Centre RAPSODEE, Campus Jarlard, Université de Toulouse, Albi, France
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Gene-gene interactions between DRD3, MRP4 and CYP2B6 polymorphisms and its influence on the pharmacokinetic parameters of efavirenz in HIV infected patients. Drug Metab Pharmacokinet 2016; 31:349-355. [PMID: 27665700 DOI: 10.1016/j.dmpk.2016.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 05/23/2016] [Accepted: 06/19/2016] [Indexed: 01/11/2023]
Abstract
Genetic factors have a significant impact on the PK variability of EFV, much higher than other non-genetic factors, such as demography. In this work we have performed a comprehensive PG analysis of genes encoding the major metabolizing enzymes and transporters of EFV, establishing a clear relationship between the PK parameters and genetic factors, which explain 50% of the variability in EFV PK parameters. The most relevant associations for metabolizing enzymes were found in CYP2B6 (rs3745274), in agreement with previous studies. The influence of transporters on the kinetics of EFV was also proved with significant correlations between the PK parameters of EFV and MRP4 (rs1751034, rs2274407). Analysis of gene-gene interactions with CYP2B6 was particularly useful to reinforce the role of MRP4 and to reveal unknown associations, such as that of DRD3. However, the role of DRD3 cannot be a direct effect but an indirect one due to physical proximity of NAT and the DRD3 locus in the genome.
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Biomarkers and biometric measures of adherence to use of ARV-based vaginal rings. J Int AIDS Soc 2016; 19:20746. [PMID: 27142091 PMCID: PMC4854848 DOI: 10.7448/ias.19.1.20746] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 03/21/2016] [Accepted: 03/31/2016] [Indexed: 11/13/2022] Open
Abstract
Introduction Poor adherence to product use has been observed in recent trials of antiretroviral (ARV)-based oral and vaginal gel HIV prevention products, resulting in an inability to determine product efficacy. The delivery of microbicides through vaginal rings is widely perceived as a way to achieve better adherence but vaginal rings do not eliminate the adherence challenges exhibited in clinical trials. Improved objective measures of adherence are needed as new ARV-based vaginal ring products enter the clinical trial stage. Methods To identify technologies that have potential future application for vaginal ring adherence measurement, a comprehensive literature search was conducted that covered a number of biomedical and public health databases, including PubMed, Embase, POPLINE and the Web of Science. Published patents and patent applications were also searched. Technical experts were also consulted to gather more information and help evaluate identified technologies. Approaches were evaluated as to feasibility of development and clinical trial implementation, cost and technical strength. Results Numerous approaches were identified through our landscape analysis and classified as either point measures or cumulative measures of vaginal ring adherence. Point measurements are those that give a measure of adherence at a particular point in time. Cumulative measures attempt to measure ring adherence over a period of time. Discussion Approaches that require modifications to an existing ring product are at a significant disadvantage, as this will likely introduce additional regulatory barriers to the development process and increase manufacturing costs. From the point of view of clinical trial implementation, desirable attributes would be high acceptance by trial participants, and little or no additional time or training requirements on the part of participants or clinic staff. We have identified four promising approaches as being high priority for further development based on the following measurements: intracellular drug levels, drug levels in hair, the accumulation of a vaginal analyte that diffuses into the ring, and the depletion of an intrinsic ring constituent. Conclusions While some approaches show significant promise over others, it is recommended that a strategy of using complementary biometric and behavioural approaches be adopted to best understand participants’ adherence to ARV-based ring products in clinical trials.
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Abstract
We document our experience with therapeutic drug monitoring (TDM) of antiretroviral agents (1807 determinations) carried out as day-by-day clinical practice for the optimization of drug dosing in HIV-infected patients. A significant proportion of patients had lopinavir, atazanavir and nevirapine trough concentrations exceeding the upper therapeutic threshold. Further studies are needed to identify good candidates/drugs for TDM, eventually allowing the selection of patients who may benefit from TDM-driven adjustments in antiretrovirals dosage.
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Pharmacometric characterization of efavirenz developmental pharmacokinetics and pharmacogenetics in HIV-infected children. Antimicrob Agents Chemother 2013; 58:136-43. [PMID: 24145522 DOI: 10.1128/aac.01738-13] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The aim of this analysis was to create a pharmacometric model of efavirenz developmental pharmacokinetics and pharmacogenetics in HIV-infected children. The data consisted of 3,172 plasma concentrations from 96 HIV-1-infected children who participated in the Pediatric AIDS Clinical Trials Group 382 (PACTG382) study. Analyses were performed using NONMEM, and the impacts of body weight, age, race, sex, formulation, liver function, and cytochrome P450 2B6 (CYP2B6)-G516T and multidrug-resistance transporter gene (MDR1)-C3435T polymorphisms were assessed. A one-compartment model using weight-based allometry on oral clearance and apparent volume of distribution adequately described the data. A sigmoid maximum-effect (Emax) maturation model demonstrated an increase in oral clearance with age to reach 90% of its mature level by the age of 9 months. The liquid formulation bioavailability relative to the capsule was found to increase with age to reach 90% of its mature value by the age of 8 years. The CYP2B6-G516T polymorphism decreased oral clearance, while the MDR1-C3435T polymorphism demonstrated no effect.
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Mid-dosing interval efavirenz plasma concentrations in HIV-1-infected children in Rwanda: treatment efficacy, tolerability, adherence, and the influence of CYP2B6 polymorphisms. J Acquir Immune Defic Syndr 2012; 60:400-4. [PMID: 22481606 DOI: 10.1097/qai.0b013e3182569f57] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
This study evaluated mid-dosing interval efavirenz plasma concentrations and the influence of CYP2B6 polymorphisms in relation to efficacy, tolerability, and adherence in 97 Rwandan HIV-infected children (3-16 years). Plasma drug concentrations and CYP2B6 polymorphisms were determined. Ten children were excluded for nonadherence. Large intersubject variability in efavirenz plasma concentrations was found. Of the 87 remaining, efavirenz concentrations were therapeutic, supratherapeutic, and subtherapeutic in 67%, 20%, and 14%, respectively. No associations were found between efavirenz concentrations and central nervous system disturbances or virologic failure. Minor allele frequencies were 0.32 (516G>T), 0.33 (785A>G), and 0.09 (983T>C). Polymorphisms in CYP2B6 were strongly associated with high efavirenz levels.
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Long-Term Efficacy and Safety of Efavirenz Dose Reduction to 200 mg Once Daily in a Caucasian Patient with HIV. Clin Drug Investig 2012; 30:405-11. [DOI: 10.1007/bf03256910] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Nanzigu S, Eriksen J, Makumbi F, Lanke S, Mahindi M, Kiguba R, Beck O, Ma Q, Morse GD, Gustafsson LL, Waako P. Pharmacokinetics of the nonnucleoside reverse transcriptase inhibitor efavirenz among HIV-infected Ugandans. HIV Med 2011; 13:193-201. [PMID: 22107359 DOI: 10.1111/j.1468-1293.2011.00952.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Pharmacokinetic variability of the nonnucleoside reverse transcriptase inhibitor efavirenz has been documented, and high variation in trough concentrations or clearance has been found to be a risk for virological failure. Africans population exhibits greater variability in efavirenz concentrations than other ethnic groups, and so a better understanding of the pharmacokinetics of the drug is needed in this population. This study characterized efavirenz pharmacokinetics in HIV-infected Ugandans. METHODS Efavirenz plasma concentrations were obtained for 66 HIV-infected Ugandans initiating efavirenz- based regimens, with blood samples collected at eight time-points over 24 h on day 1 of treatment, and at a further eight time-points on day 14. Noncompartmental analysis was used to describe the pharmacokinetics of efavirenz. RESULTS The mean steady-state minimum plasma concentration (C(min) ) of efavirenz was 2.9 µg/mL, the mean area under the curve (AUC) was 278.5 h µg/mL, and mean efavirenz clearance was 7.4 L/h. Although overall mean clearance did not change over the 2 weeks, 41.9% of participants showed an average 95.8% increase in clearance. On day 14, the maximum concentration (C(max) ) of efavirenz was >4 µg/mL in 96.6% of participants, while C(min) was <1 µg/mL in only 4.5%. Overall, 69% of participants experienced adverse central nervous system (CNS) symptoms attributable to efavirenz during the 2-week period, and 95% of these participants were found to have efavirenz plasma concentrations >4 µg/mL, although only half maintained a high concentration until at least 8 h after dosing. CONCLUSION The findings of this study show that HIV-infected patients on efavirenz may exhibit autoinduction to various extents, and this needs to be taken into consideration in the clinical management of individual patients. Efavirenz CNS toxicity during the initial phase of treatment may be related to C(max) , regardless of the sampling time.
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Affiliation(s)
- S Nanzigu
- Department of Pharmacology and Therapeutics, Makerere University College of Health Sciences, Kampala, Uganda.
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Viljoen M, Karlsson MO, Meyers TM, Gous H, Dandara C, Rheeders M. Influence of CYP2B6 516G>T polymorphism and interoccasion variability (IOV) on the population pharmacokinetics of efavirenz in HIV-infected South African children. Eur J Clin Pharmacol 2011; 68:339-47. [PMID: 22057858 DOI: 10.1007/s00228-011-1148-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 10/14/2011] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To investigate the influence of CYP2B6 516G>T polymorphism, as a covariate, and of interoccasion variability (IOV) on the oral clearance (CL/F) of efavirenz (EFV) in treatment-naïve black South African children over a period of 24 months post-antiretroviral therapy (ART) initiation. METHODS HIV-infected black children (n = 60, aged 3-16 years), with no prior exposure to ART, eligible to commence ART and attending an outpatient clinic were enrolled into this study. Blood samples were taken at mid-dose interval at 1, 3, 6, 12, 18 and 24 months post-ART initiation. EFV plasma samples were determined with an adapted and validated LC/MS/MS method. Genotyping of the CYP2B6 G516T single nucleotide polymorphism (SNP) was performed using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). NONMEM was used for the population pharmacokinetic modelling. RESULTS EFV concentrations below 1 μg/mL accounted for 18% (116/649), EFV concentrations >4 μg/mL accounted for 29.5% (192/649) and concentrations within the therapeutic range (1-4 μg/mL) represented 52.5% (341/649) of all the samples determined. The covariates age, weight and CYP2B6 G516Tgenotype were included in the final model with population estimates for CL/F determined as 2.46, 4.60 and 7.33 L/h for the T/T, G/T and G/G genotype groups respectively. CONCLUSIONS The inclusion of both age and weight to predict accurate EFV CL values for the respective genotype groups within this paediatric population was required, whereas the addition of gender and body surface area did not improve the predictions. The importance of introducing IOV in a PK model for a longitudinal study with sparsely collected data was again highlighted by this investigation.
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Affiliation(s)
- M Viljoen
- Unit for Drug Research and Development, Division of Pharmacology, School of Pharmacy, North-West University, Potchefstroom, South Africa.
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15
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Population pharmacokinetic/pharmacogenetic model for optimization of efavirenz therapy in Caucasian HIV-infected patients. Antimicrob Agents Chemother 2011; 55:5314-24. [PMID: 21896912 DOI: 10.1128/aac.00194-11] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Despite extensive clinical experience with efavirenz (EFV), unpredictable interindividual variabilities in efficacy and toxicity remain important limitations associated with the use of this antiretroviral. The purpose of this study was to determine the factors affecting EFV pharmacokinetics and to develop a pharmacokinetic/pharmacogenetic (PK/PG) model in a Caucasian population of HIV-infected patients. In total, 869 EFV plasma concentrations from 128 HIV-infected patients treated with EFV were quantitatively assessed using a validated high-performance liquid chromatography technique. All patients were genotyped for 90 single nucleotide polymorphisms (SNPs) in genes coding for proteins involved in the metabolism and transport of EFV, using a MassArray platform provided by Sequenom. The influence of these polymorphisms on EFV pharmacokinetics and the effects of demographic, clinical, biochemical, lifestyle, and concurrent drug covariates were evaluated. Plasma concentrations were fitted by a one-compartment model, with first-order absorption and elimination using nonlinear mixed-effect modeling (NONMEM program). The CYP2B6*6 allele, multidrug resistance-associated protein 4 (MRP4) 1497C → T, and gamma-glutamyltranspeptidase (GGT) were identified as major factors influencing the apparent EFV oral clearance (CL/F), reducing the initial interindividual variability by 54.8%, according to the model CL/F = (12.2 - 0.00279 · GGT) · 0.602(CYP2B6*6 [G/T]) · 0.354(CYP2B6*6 [T/T]) · 0.793(MRP4 1497C → T), where CYP2B6*6 [G/T], CYP2B6*6 [T/T], and MRP4 1497C → T take values of 0 or 1 to indicate the absence or presence of polymorphisms. The detailed genetic analysis conducted in this study identified two of 90 SNPs that significantly impacted CL/F, which might indicate that the remaining SNPs analyzed do not influence this PK parameter, at least in Caucasian populations with characteristics similar to those of our study population.
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Sun J, Chen J, Yao Y, Zhang R, Zheng Y, Liu L, Zhang L, Shen Y, Lu H. Minimum effective plasma concentration of efavirenz in treatment-naïve Chinese HIV-infected patients. Int J STD AIDS 2011; 21:810-3. [PMID: 21297088 DOI: 10.1258/ijsa.2010.010114] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
To assess the relationship between mean efavirenz (EFV) plasma concentration and clinical effect during the first 48 weeks of combination antiretroviral therapy (cART), the baseline CD4 cell count was recorded and plasma EFV concentration and CD4 cell count were measured every 12 weeks. HIV-RNA viral load was determined in the 48th week of cART. In total, 42 subjects were recruited and grouped according to their mean concentration of EFV during the study period: groups A, B and C with EFV concentrations (mean) <2 mg/L (1.8 mg/L), 2-4 mg/L (2.9 mg/L) and >4 mg/L (5.5 mg/L), respectively. The CD4 cell counts in group C increased more quickly than in groups B and A, although this was not statistically significant (211 ± 176/μL versus 151 ± 145/μL and 172 ± 105/μL, respectively; P = 0.799). Groups B and C had higher rates of HIV viral load suppression than group A (P = 0.017). For treatment-naïve Chinese HIV-infected patients, EFV plasma concentrations above 2 mg/L appear to suppress HIV replication more effectively than concentrations below 2 mg/L.
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Affiliation(s)
- J Sun
- Department of Infectious Diseases, Shanghai Public Health Clinical Center affiliated to Fudan University, Shanghai, China
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Liu X, Ma Q, Zhang F. Therapeutic drug monitoring in highly active antiretroviral therapy. Expert Opin Drug Saf 2011; 9:743-58. [PMID: 20350281 DOI: 10.1517/14740331003767395] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE OF THE FIELD Despite the efficacy of combination antiretroviral therapy (ART), a large proportion of patients living with HIV/AIDS on ART does not achieve or maintain adequate virological suppression. Therapeutic drug monitoring (TDM) has been utilised to improve treatment outcomes of ART. AREAS COVERED IN THE REVIEW The potential incorporation of TDM into the clinical HIV management is supported by the existing relationship between drug exposure and efficacy/toxicity, the high inter-patient variability pharmacokinetics, and the accurate, specific and rapid method for drug level determination. The current status of TDM in ART is reviewed in this article with discussions on its feasibility, potential use and limitations. WHAT THE READER WILL GAIN Mounting evidence from clinical trials has indicated the potential use of TDM in reducing the rates of treatment failure and adverse effect, avoiding the drug interactions, and special populations, such as children, pregnant women and patients with co-infections. TDM may play an important role even in resource-limited settings, to safeguard expanded use of bioequivalent generic antiretroviral drugs and avoid drug interactions with traditional Chinese medicines. TAKE HOME MESSAGE TDM is still in the centre of controversy in that several critical issues need to be addressed, such as limited adherence assessment, inappropriate response predictors, insufficient validation of target concentration windows and lack of the quality control of assay. The utility of TDM will remain experimental until more data are obtained from large clinical trials showing the benefit of TDM.
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Affiliation(s)
- Xia Liu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nan Wei Road, Beijing 100050, China.
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Pereira SA, Batuca JR, Caixas U, Branco T, Delgado-Alves J, Germano I, Lampreia F, Monteiro EC. Effect of efavirenz on high-density lipoprotein antioxidant properties in HIV-infected patients. Br J Clin Pharmacol 2010; 68:891-7. [PMID: 20002083 DOI: 10.1111/j.1365-2125.2009.03535.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT * In previous work, we showed a long-term and concentration-dependent beneficial effect of the non-nucleoside reverse transcriptase inhibitor efavirenz (EFV) on high-density lipoproteins (HDL) in human immunodeficiency virus (HIV)-infected patients. * Furthermore, it has been suggested that instead of the current practice of only measuring HDL-chelesterol values, the evaluation of HDL function, namely its antioxidant properties, might be an improved tool for identifying subjects at increased risk for cardiovascular events. * Paraoxonase-1 (PON-1) is an enzyme associated with HDL that is responsible for HDL antioxidant function. WHAT THIS STUDY ADDS * In the present work, we studied the effect of EFV on the activity of PON-1 and showed, for the first time, that EFV-based antiretroviral therapy is associated with a better antioxidant function, i.e. with a higher PON-1 activity. AIMS A long-term and concentration-dependent beneficial effect of efavirenz (EFV) on cholesterol associated with high-density lipoprotein (HDL-c) in human immunodeficiency virus (HIV)-infected patients has been documented. Furthermore, it has been suggested that, instead of the current practice of only measuring HDL-c values, the evaluation of HDL quality might be an improved tool for identifying subjects at increased risk of cardiovascular events. Paraoxonase-1 (PON-1) is an enzyme associated with HDL that is involved in the onset of cardiovascular disease and responsible for HDL antioxidant function. The aim of the present study was to investigate the effect of EFV on the circulating activity of PON-1 in HIV-infected patients. METHODS The patients included were adults with a documented HIV-1 infection, nontreated or treated with antiretroviral regimens including EFV 600 mg once daily as first therapeutic regimen for at least 3 months. The influence of treatment with EFV, HDL-c and CD4 cell count on PON-1 activity was analysed. RESULTS HIV-infected White patients treated with EFV had higher PON-1 activity [77.35 U l(-1) (65.66, 89.04)] (P < 0.05) and higher PON-1 activity : HDL-c ratio [1.88 (1.49, 2.28)] (P < 0.01) than untreated patients. PON-1 activity was higher in Black patients (P < 0.001) and in patients with a CD4 cell count >500 cells ml(-1) (P= 0.0120). CONCLUSIONS EFV-based antiretroviral regimens are associated with HDL particles with a better antioxidant function, i.e. with a higher PON-1 activity. The PON-1 activity of Black patients is higher than that found in Whites regardless of treatment. Ethnicity should be taken into consideration when studying drug effects on PON-1 activity.
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Affiliation(s)
- S A Pereira
- Department of Pharmacology, Faculty of Medical Sciences, New University of Lisbon, Lisbon, Portugal.
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Viljoen M, Gous H, Kruger HS, Riddick A, Meyers TM, Rheeders M. Efavirenz plasma concentrations at 1, 3, and 6 months post-antiretroviral therapy initiation in HIV type 1-infected South African children. AIDS Res Hum Retroviruses 2010; 26:613-9. [PMID: 20507205 DOI: 10.1089/aid.2009.0200] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The aim of this study was to quantify the plasma efavirenz concentrations over 6 months in black HIV-1-infected South African children (3-14 years), from resource-limited households, attending an outpatient clinic. The children were antiretroviral treatment (ART) naive and received efavirenz in combination with two nucleoside reverse transcriptase inhibitors according to South African national guidelines. Two blood samples were taken between 12 and 20 h after the last efavirenz dose at 1 (n = 58), 3 (n = 54), and 6 (n = 54) months post-ART initiation. A total of 328 efavirenz mid-dose plasma samples from 58 patients was determined with a validated liquid chromatography tandem mass spectrometry method. Viral suppression (<25 copies/ml) was achieved in 95% of the children after 6 months on ART. The median (range) plasma concentration at time points 1 and 2 were 2.06 (0.10-11.14) and 1.80 (0.14-10.70) microg/ml with respective mean (+/-SD) blood sampling times of 15.24 (2.03) and 16.91 (2.03) h post-evening dose. Efavirenz plasma samples within the therapeutic range of 1-4 microg/ml accounted for 58%; 17% were <1 microg/ml and 25% were >4 microg/ml over the 6 months. Efavirenz levels persistently >4 microg/ml were recorded for 13 (23%) children and 3 (5%) children had persistent efavirenz levels <1 microg/ml. Possible reasons for efavirenz plasma levels outside the accepted therapeutic range include genetic variation in drug metabolism, incorrect dosing, drug-drug interactions, and nonadherence. However, these need to be further explored and the importance of sequential plasma levels has been highlighted in this study.
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Affiliation(s)
- Michelle Viljoen
- Department of Pharmacology, North-West University, Potchefstroom, South Africa
| | - Hermien Gous
- ECHO, Harriet Shezi Children's Clinic, Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - Herculina S. Kruger
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
| | - Alison Riddick
- ECHO, Harriet Shezi Children's Clinic, Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - Tammy M. Meyers
- ECHO, Harriet Shezi Children's Clinic, Chris Hani Baragwanath Hospital, Soweto, South Africa
- Department of Paediatrics, University of the Witwatersrand, Johannesburg, South Africa
| | - Malie Rheeders
- Department of Pharmacology, North-West University, Potchefstroom, South Africa
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Pereira SA, Caixas U, Branco T, Germano I, Lampreia F, Papoila AL, Monteiro EC. Efavirenz concentrations in HIV-infected patients with and without viral hepatitis. Br J Clin Pharmacol 2008; 66:551-5. [PMID: 18662298 DOI: 10.1111/j.1365-2125.2008.03238.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AIMS Data on efavirenz in HIV/viral hepatitis co-infected patients is non-consensual, probably due to liver function heterogeneity in the patients included. METHODS A case control study was performed on 27 HIV-infected patients, with controlled and homogenous markers of hepatic function, either mono-infected or co-infected with HBV/HCV, to ascertain the influence of viral hepatitis on efavirenz concentrations over a 2-year follow-up period. RESULTS No differences were found in efavirenz concentrations between groups both during and at the end of the follow-up period: control (2.43 +/- 1.91 mg l(-1)) vs. co-infected individuals (2.37 +/- 0.37 mg l(-1)). CONCLUSION It was concluded that HBV/HCV infections in themselves do not predispose to an overexposure to efavirenz.
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Affiliation(s)
- Sofia A Pereira
- Department of Pharmacology, Faculty of Medical Sciences, New University of Lisbon, Lisbon, Portugal
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