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Kariyawasam D, Peries M, Foissac F, Eymard-Duvernay S, Tylleskär T, Singata-Madliki M, Kankasa C, Meda N, Tumwine J, Mwiya M, Engebretsen I, Flück CE, Hartmann MF, Wudy SA, Hirt D, Treluyer JM, Molès JP, Blanche S, Van De Perre P, Polak M, Nagot N. Lopinavir-Ritonavir Impairs Adrenal Function in Infants. Clin Infect Dis 2021; 71:1030-1039. [PMID: 31633158 DOI: 10.1093/cid/ciz888] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 09/05/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Perinatal treatment with lopinavir boosted by ritonavir (LPV/r) is associated with steroidogenic abnormalities. Long-term effects in infants have not been studied. METHODS Adrenal-hormone profiles were compared at weeks 6 and 26 between human immunodeficiency virus (HIV)-1-exposed but uninfected infants randomly assigned at 7 days of life to prophylaxis with LPV/r or lamivudine (3TC) to prevent transmission during breastfeeding. LPV/r in vitro effect on steroidogenesis was assessed in H295R cells. RESULTS At week 6, 159 frozen plasma samples from Burkina Faso and South Africa were assessed (LPV/r group: n = 92; 3TC group: n = 67) and at week 26, 95 samples from Burkina Faso (LPV/r group: n = 47; 3TC group: n = 48). At week 6, LPV/r-treated infants had a higher median dehydroepiandrosterone (DHEA) level than infants from the 3TC arm: 3.91 versus 1.48 ng/mL (P < .001). Higher DHEA levels (>5 ng/mL) at week 6 were associated with higher 17-OH-pregnenolone (7.78 vs 3.71 ng/mL, P = .0004) and lower testosterone (0.05 vs 1.34 ng/mL, P = .009) levels in LPV/r-exposed children. There was a significant correlation between the DHEA and LPV/r AUC levels (ρ = 0.40, P = .019) and Ctrough (ρ = 0.40, P = .017). At week 26, DHEA levels remained higher in the LPV/r arm: 0.45 versus 0.13 ng/mL (P = .002). Lopinavir, but not ritonavir, inhibited CYP17A1 and CYP21A2 activity in H295R cells. CONCLUSIONS Lopinavir was associated with dose-dependent adrenal dysfunction in infants. The impact of long-term exposure and potential clinical consequences require evaluation. CLINICAL TRIALS REGISTRATION NCT00640263.
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Affiliation(s)
- Dulanjalee Kariyawasam
- Pediatric Endocrinology, Gynecology, and Diabetology Unit, Hopital Universitaire Necker-Enfants Malades, Assistance Publique-Hopitaux de Paris (AP-HP), Paris, France.,INSERM U1016, Faculte de Medecine, Universite Paris Descartes, Sorbonne Paris Cite, Paris, France.,IMAGINE Institute, Paris, France
| | - Marianne Peries
- Pathogenesis and Control of Chronic Infections, INSERM U1058, Universite de Montpellier, Etablissement Francais du Sang, Montpellier, France
| | - Frantz Foissac
- Service de Pharmacologie Clinique, Hopital Cochin, AP-HP, Groupe Hospitalier Paris Centre, France.,Universite Paris Descartes, EA7323, Sorbonne Paris Cite, France
| | - Sabrina Eymard-Duvernay
- Pathogenesis and Control of Chronic Infections, INSERM U1058, Universite de Montpellier, Etablissement Francais du Sang, Montpellier, France
| | | | - Mandisa Singata-Madliki
- Effective Care Research Unit, University of Fort Hare, Cecilia Makiwane Hospital, East London, South Africa
| | - Chipepo Kankasa
- University of Zambia, School of Medicine, Department of Pediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Nicolas Meda
- Center of International Research for Health, Faculty of Health Sciences, University of Ouagadougou, Ouagadougou, Burkina Faso
| | - James Tumwine
- Department of Pediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mwiya Mwiya
- University of Zambia, School of Medicine, Department of Pediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | | | - Christa E Flück
- Pediatric Endocrinology, Diabetology, and Metabolism, Department of Pediatrics and Department of BioMedical Research, University Hospital Inselspital Bern, University of Bern, Bern, Switzerland
| | - Michaela F Hartmann
- Steroid Research and Mass Spectrometry Unit, Division of Pediatric Endocrinology and Diabetology, Center of Child and Adolescent Medicine, Justus-Liebig-University, Giessen, Germany
| | - Stefan A Wudy
- Steroid Research and Mass Spectrometry Unit, Division of Pediatric Endocrinology and Diabetology, Center of Child and Adolescent Medicine, Justus-Liebig-University, Giessen, Germany
| | - Deborah Hirt
- Service de Pharmacologie Clinique, Hopital Cochin, AP-HP, Groupe Hospitalier Paris Centre, France.,Universite Paris Descartes, EA7323, Sorbonne Paris Cite, France
| | - Jean Marc Treluyer
- Service de Pharmacologie Clinique, Hopital Cochin, AP-HP, Groupe Hospitalier Paris Centre, France.,Universite Paris Descartes, EA7323, Sorbonne Paris Cite, France
| | - Jean-Pierre Molès
- Pathogenesis and Control of Chronic Infections, INSERM U1058, Universite de Montpellier, Etablissement Francais du Sang, Montpellier, France
| | - Stéphane Blanche
- Pediatric Immunology-Hematology and Rheumatology Unit, Hopital Universitaire Necker-Enfants Malades, AP-HP, Paris, France
| | - Philippe Van De Perre
- Service de Pharmacologie Clinique, Hopital Cochin, AP-HP, Groupe Hospitalier Paris Centre, France.,Centre Hospitalo-Universitaire (CHU) de Montpellier, Montpellier, France
| | - Michel Polak
- Pediatric Endocrinology, Gynecology, and Diabetology Unit, Hopital Universitaire Necker-Enfants Malades, Assistance Publique-Hopitaux de Paris (AP-HP), Paris, France.,INSERM U1016, Faculte de Medecine, Universite Paris Descartes, Sorbonne Paris Cite, Paris, France.,IMAGINE Institute, Paris, France
| | - Nicolas Nagot
- Pathogenesis and Control of Chronic Infections, INSERM U1058, Universite de Montpellier, Etablissement Francais du Sang, Montpellier, France.,Centre Hospitalo-Universitaire (CHU) de Montpellier, Montpellier, France
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Néant N, Solas C, Bouazza N, Lê MP, Yazdanpanah Y, Dhiver C, Bregigeon S, Mokhtari S, Peytavin G, Tamalet C, Descamps D, Lacarelle B, Gattacceca F. Concentration-response model of rilpivirine in a cohort of HIV-1-infected naive and pre-treated patients. J Antimicrob Chemother 2020; 74:1992-2002. [PMID: 31225609 DOI: 10.1093/jac/dkz141] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Rilpivirine is widely prescribed in people living with HIV. Although trough plasma concentrations have been associated with virological response, the drug pharmacodynamics remain incompletely characterized. OBJECTIVES To develop the first pharmacodynamic model of rilpivirine in order to establish the rilpivirine concentration-response relationship for future treatment optimization. METHODS A retrospective observational study was conducted in patients receiving the once-daily rilpivirine/tenofovir disoproxil fumarate/emtricitabine regimen. Individual rilpivirine trough plasma concentrations over time were predicted using a previous pharmacokinetic model. An established susceptible, infected, recovered model was used to describe HIV dynamics without assuming disease steady-state. Population analysis was performed with MONOLIX 2018 software. Simulations of the viral load evolution as a function of time and rilpivirine trough plasma concentration were performed. RESULTS Overall, 60 naive and 39 pre-treated patients were included with a follow-up ranging from 2 to 37 months. The final model adequately described the data and the pharmacodynamic parameters were estimated with a good precision. The population typical value of rilpivirine EC50 was estimated at 65 ng/mL. A higher infection rate constant of CD4 cells for HIV-1 was obtained in pre-treated patients. Consequently, the time to obtain virological suppression was longer in pre-treated than in naive patients. CONCLUSIONS The concentration-response relationship of rilpivirine was satisfactorily described for the first time using an original population pharmacodynamic model. Simulations performed using the final model showed that the currently used 50 ng/mL rilpivirine trough plasma concentration efficacy target might need revision upwards, particularly in pre-treated patients.
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Affiliation(s)
- Nadège Néant
- Aix Marseille Université, APHM, INSERM, CNRS, CRCM SMARTc, Hôpital La Timone, Laboratoire de Pharmacocinétique et Toxicologie, Marseille, France
| | - Caroline Solas
- Aix Marseille Université, APHM, INSERM, CNRS, CRCM SMARTc, Hôpital La Timone, Laboratoire de Pharmacocinétique et Toxicologie, Marseille, France
| | - Naïm Bouazza
- Université Paris Descartes, EA7323 Sorbonne Paris Cité, Paris, France.,Unité de Recherche Clinique Paris Descartes Necker Cochin, AP-HP, Paris, France.,CIC-1419 Inserm, Cochin-Necker, Paris, France
| | - Minh Patrick Lê
- APHP, Hôpital Bichat-Claude Bernard, Laboratoire de Pharmaco-Toxicologie, IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité and INSERM, Paris, France
| | - Yazdan Yazdanpanah
- Université Paris Diderot, APHP, IAME-UMR 1137, Hôpital Bichat-Claude Bernard, Service des Maladies Infectieuses et Tropicales, Paris, France
| | - Catherine Dhiver
- IHU Méditerranée Infection, Aix-Marseille Université, AP-HM, URMITE UM 63 CNRS 7278 IRD 198 INSERM 1095, Marseille, France
| | - Sylvie Bregigeon
- APHM, Hôpital Sainte-Marguerite, Service d'Immuno-hématologie clinique, Marseille, France
| | - Saadia Mokhtari
- IHU Méditerranée Infection, Aix-Marseille Université, AP-HM, URMITE UM 63 CNRS 7278 IRD 198 INSERM 1095, Marseille, France
| | - Gilles Peytavin
- APHP, Hôpital Bichat-Claude Bernard, Laboratoire de Pharmaco-Toxicologie, IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité and INSERM, Paris, France
| | - Catherine Tamalet
- IHU Méditerranée Infection, Aix-Marseille Université, AP-HM, URMITE UM 63 CNRS 7278 IRD 198 INSERM 1095, Marseille, France
| | - Diane Descamps
- APHP, Hôpital Bichat-Claude Bernard, Laboratoire de Virologie, IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité and INSERM, Paris, France
| | - Bruno Lacarelle
- Aix Marseille Université, APHM, INSERM, CNRS, CRCM SMARTc, Hôpital La Timone, Laboratoire de Pharmacocinétique et Toxicologie, Marseille, France
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Engelbrecht AE, Wiesner L, Norman J, Rabie H, Decloedt EH. Pediatric Antiretroviral Therapeutic Drug Monitoring: A Five and a Half Year Experience from a South African Tertiary Hospital. J Trop Pediatr 2020; 66:385-394. [PMID: 31754710 DOI: 10.1093/tropej/fmz077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Antiretroviral therapeutic drug monitoring (TDM) is not routinely used in the management of human immunodeficiency virus, but may be useful in pediatric patients who are prone to altered pharmacokinetics. Data on the routine use of antiretroviral TDM in pediatrics are sparse especially data from sub-Saharan Africa. METHODS We retrospectively reviewed the antiretroviral TDM indications at Tygerberg Children's Hospital, identified pediatric patients who had antiretroviral TDM requests from January 2012 until June 2017 and reviewed their clinical records. RESULTS Fifty-nine patients were identified who presented with 64 clinical problems for which TDM was requested. TDM was requested for lopinavir, efavirenz and nevirapine in 83% (53/64), 14% (9/64) and 3% (2/64) of clinical problems, respectively. Lopinavir was mostly requested in patients when adherence measures did not correlate with the clinical picture, suspected non-adherence, lopinavir-rifampicin interactions and for neonatal safety monitoring. Efavirenz was requested when toxicity was suspected and nevirapine in patients receiving rifampicin. Lopinavir TDM confirmed non-adherence in 25% (4/16) of cases when adherence measures did not correlate with the clinical picture and in 43% (3/7) of cases when non-adherence was suspected by the clinician. Efavirenz TDM confirmed toxicity in 100% (6/6) of patients. CONCLUSIONS Lopinavir TDM was mostly requested when adherence measures did not correlate with the clinical picture, when rifampicin was co-administered and for perinatal safety monitoring. Lopinavir TDM excluded pharmacokinetic reasons for failure in patients failing treatment when lopinavir dosing was supervised. Efavirenz TDM was requested for suspected toxicity with a 100% positive predictive value.
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Affiliation(s)
- Anton E Engelbrecht
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Jennifer Norman
- Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Helena Rabie
- Division of Infectious Diseases, Department of Pediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
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Optimizing Pediatric Dosing Recommendations and Treatment Management of Antiretroviral Drugs Using Therapeutic Drug Monitoring Data in Children Living With HIV. Ther Drug Monit 2020; 41:431-443. [PMID: 31008997 PMCID: PMC6636807 DOI: 10.1097/ftd.0000000000000637] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Supplemental Digital Content is Available in the Text. Introduction: This review summarizes the current dosing recommendations for antiretroviral (ARV) drugs in the international pediatric guidelines of the World Health Organization (WHO), US Department of Health and Human Services (DHHS), and Pediatric European Network for Treatment of AIDS (PENTA), and evaluates the research that informed these approaches. We further explore the role of data generated through therapeutic drug monitoring in optimizing the dosing of ARVs in children. Methods: A PubMed search was conducted for the literature on ARV dosing published in English. In addition, the registration documentation of European Medicines Agency and the US Food and Drug Administration for currently used ARVs and studies referenced by the WHO, DHHS, and EMA guidelines were screened. Resulting publications were screened for papers containing data on the area under the concentration–time curve, trough concentration, and peak concentration. Studies with enrolled participants with a median or mean age of ≥18 years were excluded. No restriction on publishing date was applied. Discussion and conclusion: Pediatric ARV dosing is frequently based on data obtained from small studies and is often simplified to facilitate dosing in the context of a public health approach. Pharmacokinetic parameters of pediatric ARVs are subject to high interpatient variation and this leads to a potential risk of underdosing or overdosing when drugs are used in real life. To ensure optimal use of ARVs and validate dosing recommendations for children, it is essential to monitor ARV dosing more thoroughly with larger sample sizes and to include diverse subpopulations. Therapeutic drug monitoring data generated in children, where available and affordable, have the potential to enhance our understanding of the appropriateness of simplified pediatric dosing strategies recommended using a public health approach and to uncover suboptimal dosing or other unanticipated issues postmarketing, further facilitating the ultimate goal of optimizing pediatric ARV treatment.
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Rabie H, Denti P, Lee J, Masango M, Coovadia A, Pillay S, Liberty A, Simon F, McIlleron H, Cotton MF, Lallemant M. Lopinavir-ritonavir super-boosting in young HIV-infected children on rifampicin-based tuberculosis therapy compared with lopinavir-ritonavir without rifampicin: a pharmacokinetic modelling and clinical study. Lancet HIV 2018; 6:S2352-3018(18)30293-5. [PMID: 30529029 DOI: 10.1016/s2352-3018(18)30293-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/08/2018] [Accepted: 10/12/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Rifampicin reduces lopinavir concentrations in HIV and tuberculosis co-treated patients. We hypothesised that adding ritonavir to co-formulated lopinavir-ritonavir (4:1) to achieve a one-to-one ratio would overcome this drug-drug interaction in young children. METHODS We did a prospective, open-label, one-group, one-sequence study at five sites in three South African provinces. We included HIV-infected children with tuberculosis, a bodyweight of 3-15 kg, and a post-conceptional age of more than 42 weeks. Children received the standard four-to-one ratio of lopinavir-ritonavir in the absence of rifampicin-based anti-tuberculosis treatment, whereas super-boosting of lopinavir-ritonavir with additional ritonavir was given orally twice a day to achieve a one-to-one ratio during rifampicin treatment. The primary outcome was the comparison of the proportion of children with predicted lopinavir morning minimum concentrations (Cmin) of more than 1·0 mg/L during super-boosting with the proportion of more than 1·0 mg/L during standard lopinavir-ritonavir treatment without rifampicin. Lopinavir concentrations were determined before and at 1, 2, 4, 6, and 10 h after the morning dose during the second and the last month of tuberculosis co-treatment, and 4-6 weeks after stopping rifampicin. A non-linear mixed-effects model was implemented to interpret the data and Monte Carlo simulations were used to compare the percentage of lopinavir with morning Cmin values of less than 1·0 mg/L for the two dosing schemes. A non-inferiority margin of 10% was used. This study is registered with ClinicalTrials.gov, number NCT02348177. FINDINGS Between Jan 30, 2013, and Nov 9, 2015, 96 children with a median age of 18·2 months (IQR 9·6-26·8) were enrolled. Of these 96 children, 80 (83%) completed the first three pharmacokinetic evaluations. Tuberculosis therapy was started before antiretrovirals in 70 (73%) children. The model-predicted percentage of morning Cmin of less than 1·0 mg/L after tuberculosis treatment without super-boosting was 8·8% (95% CI 0·6-19·8) versus 7·6% (0·4-16·2) during super-boosting and tuberculosis treatment. The difference of -1·1% (95% CI -6·9 to 3·2), at a non-inferiority margin of 10%, confirmed the non-inferiority of lopinavir trough concentrations during rifampicin co-treatment. 19 serious adverse events were reported in 12 participants. Three deaths and a temporary treatment interruption due to jaundice were unrelated to study treatment. INTERPRETATION Lopinavir exposure with ritonavir super-boosting in a one-to-one ratio during rifampicin-based tuberculosis treatment was non-inferior to the exposure with lopinavir-ritonavir without rifampicin. Safe and effective, field application of super-boosting is limited by poor acceptability. Access to better adapted solid formulations will most likely facilitate public health implementation of this strategy. FUNDING DNDi, French Development Agency, UBS Optimus Foundation, and Unitaid.
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Affiliation(s)
- Helena Rabie
- Department of Pediatrics and Child Health and Family Clinical Research Unit, University of Stellenbosch, Cape Town, South Africa.
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Janice Lee
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Mhleli Masango
- Shandukani Research Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Ashraf Coovadia
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Sandy Pillay
- Enhancing Care Foundation-Durban International Clinical Research, Wentworth Hospital, Durban, South Africa
| | - Afaaf Liberty
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - François Simon
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mark F Cotton
- Department of Pediatrics and Child Health and Family Clinical Research Unit, University of Stellenbosch, Cape Town, South Africa
| | - Marc Lallemant
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
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Archary M, Mcllleron H, Bobat R, La Russa P, Sibaya T, Wiesner L, Hennig S. Population Pharmacokinetics of Lopinavir in Severely Malnourished HIV-infected Children and the Effect on Treatment Outcomes. Pediatr Infect Dis J 2018; 37:349-355. [PMID: 29227461 PMCID: PMC5849509 DOI: 10.1097/inf.0000000000001867] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In developing countries, malnutrition remains a common clinical syndrome at antiretroviral treatment (ART) initiation. Physiologic changes because of malnutrition and during nutritional recovery could affect the pharmacokinetics of antiretroviral drugs. METHODS HIV-infected children admitted with severe acute malnutrition were randomized to early or delayed initiation of lopinavir (LPV)/ritonavir, abacavir and lamivudine using World Health Organization weight band dosage charts. LPV concentrations were measured on day 1 and day 14. Thereafter, patients were followed-up to week 48. The population pharmacokinetics of LPV was described using NONMEM v7.3. Covariates were screened to assess their influence on the pharmacokinetics of LPV, and the relationship between pharmacokinetic variability and treatment outcomes were assessed. RESULTS Five hundred and two LPV concentrations were collected from 62 pediatric patients 0.1-3.9 years of age (median: 0.9 years). Rifampin-based antituberculosis treatment and "super-boosted" LPV/ritonavir were prescribed in 20 patients. LPV disposition was well described by a one-compartment model with first-order elimination. Neither randomization to early or delayed ART, tuberculosis comedications nor anthropometrical measurements explained the pharmcokinetic variability. Allometrically scaled fat-free mass influenced apparent clearance (CL/F) and volume of distribution (Vd/F). Pharmacokinetic exposure did not correlate with virologic outcomes or death at 12 or 48 weeks. CONCLUSIONS LPV pharmacokinetics was influenced by fat-free mass and not by timing of ART initiation or tuberculosis comedication in severely malnourished HIV-infected children. LPV pharmacokinetics was found to be highly variable and bioavailability greatly reduced, resulting in a high CL estimate in this population. The role of LPV dose adjustment should be further evaluated in severely malnourished children initiating ART.
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Pharmacokinetics and Drug-Drug Interactions of Lopinavir-Ritonavir Administered with First- and Second-Line Antituberculosis Drugs in HIV-Infected Children Treated for Multidrug-Resistant Tuberculosis. Antimicrob Agents Chemother 2018; 62:AAC.00420-17. [PMID: 29133558 DOI: 10.1128/aac.00420-17] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 10/13/2017] [Indexed: 11/20/2022] Open
Abstract
Lopinavir-ritonavir forms the backbone of current first-line antiretroviral regimens in young HIV-infected children. As multidrug-resistant (MDR) tuberculosis (TB) frequently occurs in young children in high-burden TB settings, it is important to identify potential interactions between MDR-TB treatment and lopinavir-ritonavir. We describe the pharmacokinetics of and potential drug-drug interactions between lopinavir-ritonavir and drugs routinely used for MDR-TB treatment in HIV-infected children. A combined population pharmacokinetic model was developed to jointly describe the pharmacokinetics of lopinavir and ritonavir in 32 HIV-infected children (16 with MDR-TB receiving treatment with combinations of high-dose isoniazid, pyrazinamide, ethambutol, ethionamide, terizidone, a fluoroquinolone, and amikacin and 16 without TB) who were established on a lopinavir-ritonavir-containing antiretroviral regimen. One-compartment models with first-order absorption and elimination for both lopinavir and ritonavir were combined into an integrated model. The dynamic inhibitory effect of the ritonavir concentration on lopinavir clearance was described using a maximum inhibition model. Even after adjustment for the effect of body weight with allometric scaling, a large variability in lopinavir and ritonavir exposure, together with strong correlations between the pharmacokinetic parameters of lopinavir and ritonavir, was detected. MDR-TB treatment did not have a significant effect on the bioavailability, clearance, or absorption rate constants of lopinavir or ritonavir. Most children (81% of children with MDR-TB, 88% of controls) achieved therapeutic lopinavir trough concentrations (>1 mg/liter). The coadministration of lopinavir-ritonavir with drugs routinely used for the treatment of MDR-TB was found to have no significant effect on the key pharmacokinetic parameters of lopinavir or ritonavir. These findings should be considered in the context of the large interpatient variability found in the present study and the study's modest sample size.
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Are Prophylactic and Therapeutic Target Concentrations Different?: the Case of Lopinavir-Ritonavir or Lamivudine Administered to Infants for Prevention of Mother-to-Child HIV-1 Transmission during Breastfeeding. Antimicrob Agents Chemother 2017; 61:AAC.01869-16. [PMID: 27895016 DOI: 10.1128/aac.01869-16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 11/18/2016] [Indexed: 11/20/2022] Open
Abstract
The ANRS 12174 trial assessed the efficacy and tolerance of lopinavir (LPV)-ritonavir (LPV/r) prophylaxis versus those of lamivudine (3TC) prophylaxis administered to breastfed infants whose HIV-infected mothers were not on antiretroviral therapy. In this substudy, we assessed LPV/r and 3TC pharmacokinetics to evaluate the percentage of infants with therapeutic plasma concentrations and to discuss these data in the context of a prophylactic treatment. Infants from the South African trial site underwent blood sampling for pharmacokinetic study at weeks 6, 26, and 38 of life. We applied a Bayesian approach to derive the 3TC and LPV pharmacokinetic parameters on the basis of previously published pharmacokinetic models for HIV-infected children. We analyzed 114 LPV and 180 3TC plasma concentrations from 69 infants and 92 infants, respectively. A total of 30 LPV and 20 3TC observations were considered missing doses and discarded from the Bayesian analysis. The overall population analysis showed that 30 to 40% of the infants did not reach therapeutic targets, regardless of treatment group. The median LPV trough concentrations at weeks 6, 26, and 38 were 2.8 mg/liter (interquartile range [IQR], 1.7 to 4.4 mg/liter), 5.6 mg/liter (IQR, 3.2 to 7.7 mg/liter), and 3.4 mg/liter (IQR, 2.3 to 7.3 mg/liter), respectively. The median 3TC area under the curve from 0 to 12 h after the last drug intake were 5.6 mg · h/liter (IQR, 4.1 to 7.8 mg · h/liter), 5.9 mg · h/liter (IQR, 5.1 to 7.5 mg · h/liter), and 7.3 mg · h/liter (IQR, 4.9 to 8.5 mg · h/liter) at weeks 6, 26, and 38, respectively. Use of the therapeutic doses recommended by the WHO would have resulted in a higher proportion of infants achieving the targets. However, no HIV-1 infection was reported among these infants. These results suggest that the prophylactic targets for both 3TC and LPV may be lower than the therapeutic ones. For treatment, the WHO dosing guidelines should be suitable to maintain values above the therapeutic pharmacokinetic targets in most infants. (This study has been registered at ClinicalTrials.gov under identifier NCT00640263.).
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Yang W, Xiao Q, Wang D, Yao C, Yang J. Evaluation of pharmacokinetic interactions between long-acting HIV-1 fusion inhibitor albuvirtide and lopinavir/ritonavir, in HIV-infected subjects, combined with clinical study and simulation results. Xenobiotica 2016; 47:133-143. [PMID: 27052428 DOI: 10.3109/00498254.2016.1166532] [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] [Indexed: 11/13/2022]
Abstract
1. A clinical study to assess the interactions between albuvirtide (320 mg) and lopinavir/ritonavir (400/100 mg) was conducted in 10 HIV-1-infected subjects. Because albuvirtide requires a long period to achieve steady state, and extended monotherapy may lead to early resistance, it is unethical to take albuvirtide alone to achieve steady state. Therefore, a population pharmacokinetic model was developed to predict steady-state concentration-time curve of solely administered albuvirtide. 2. When albuvirtide and lopinavir/ritonavir were co-administered, the plasma concentration of albuvirtide when the infusion ended (Cend) increased by about 34%, but the geometric mean ratios and 90% confidence intervals (90% CIs) of AUC(0-t) [1.09 (0.96-1.24)] and Ctrough [1.00 (0.83-1.20)] were within the range of 0.8-1.25. For lopinavir, the ratios (90% CIs) of AUC(0-t), Cmax and Ctrough were 0.63 (0.49-0.82), 0.67 (0.53-0.86) and 0.65 (0.46-0.91); for ritonavir, those ratios (90% CIs) were 0.62 (0.42-0.91), 0.61 (0.38-0.99) and 0.72 (0.40-1.26), respectively. 3. Co-administration of albuvirtide with lopinavir/ritonavir has little effect on albuvirtide exposure, but it decreases the plasma exposures of lopinavir/ritonavir. However, the drug-drug interactions may not reduce the effectiveness of this co-therapy, the trough concentration of lopinavir may be sufficient and this combination could achieve similar clinical efficacy with marketed drugs. So, a phase 3 clinical trial without dose adjustment is underway to validate their effectiveness and safety.
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Affiliation(s)
- Wanqiu Yang
- a Center of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University , Nanjing , China
| | - Qingqing Xiao
- b Department of Clinical Pharmacy , School of Pharmacy, China Pharmaceutical University , Nanjing , China , and
| | - Dan Wang
- a Center of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University , Nanjing , China
| | - Cheng Yao
- c Nanjing Frontier Biotechnologies Co , Nanjing , China
| | - Jin Yang
- a Center of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University , Nanjing , China
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Overgaard RV, Ingwersen SH, Tornøe CW. Establishing Good Practices for Exposure-Response Analysis of Clinical Endpoints in Drug Development. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2015; 4:565-75. [PMID: 26535157 PMCID: PMC4625861 DOI: 10.1002/psp4.12015] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 07/12/2015] [Indexed: 01/24/2023]
Abstract
This tutorial aims at promoting good practices for exposure–response (E-R) analyses of clinical endpoints in drug development. The focus is on practical aspects of E-R analyses to assist modeling scientists with a process of performing such analyses in a consistent manner across individuals and projects and tailored to typical clinical drug development decisions. This includes general considerations for planning, conducting, and visualizing E-R analyses, and how these are linked to key questions.
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Affiliation(s)
- R V Overgaard
- Quantitative Clinical Pharmacology, Novo Nordisk A/S Søborg, Denmark
| | - S H Ingwersen
- Quantitative Clinical Pharmacology, Novo Nordisk A/S Søborg, Denmark
| | - C W Tornøe
- Quantitative Clinical Pharmacology, Novo Nordisk A/S Søborg, Denmark
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