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Todd CS, Lorenzetti L, Mussa A, Ridgeway K, Morroni C, Nanda K. Drug-drug interactions between antiretrovirals and hormonal contraception: An updated systematic review. Contraception 2024; 138:110490. [PMID: 38762199 DOI: 10.1016/j.contraception.2024.110490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/13/2024] [Accepted: 05/13/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVE To summarize and update information regarding drug-drug interactions (DDIs) between antiretrovirals (ARVs) and hormonal contraceptives (HCs). STUDY DESIGN Systematic review. RESULTS We included 49 articles, with clinical, ARV, or HC PK outcomes reported by 39, 25, and 30 articles, respectively, with some articles reporting outcomes in two or more categories. Fifteen of 18 articles assessing DDIs between efavirenz and progestin implants, emergency contraception, or combined hormonal intravaginal rings found higher pregnancy rates, luteal progesterone levels suggesting ovulation, or reduced progestin PK values. Five studies documented that CYP2B6 single nucleotide polymorphisms exacerbated this DDI. One cohort detected doubled bone density loss with concomitant depot medroxyprogesterone acetate (DMPA) and tenofovir disoproxil fumarate (TDF)-containing ART use versus TDF alone. No other studies described DDIs impacting clinical outcomes. Few adverse events were attributed to ARV-HC use with none exceeding Grade 2. Evidence quality was generally moderate, with dis-similar treatment and control groups, identifying and controlling for confounding, and minimizing attrition bias in the study design being the most frequent limitations. CONCLUSION TDF-DMPA DDIs warrant longer-term study on bone health and consideration of alternate combinations. For efavirenz-based ART, client counseling on relative risks, including both potential increase in pregnancy rate with concomitant efavirenz and implant use and lower pregnancy rates compared to other HCs even with concomitant efavirenz use, should continue to allow users comprehensive method choice. IMPLICATIONS Most ARVs and HCs may be used safely and effectively together. Efavirenz-based ART requires careful counseling and data for possible interactions between HCs and new ARV classes are anticipated.
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Affiliation(s)
- Catherine S Todd
- Global Health, Population, and Nutrition, FHI 360, Durham, NC, United States.
| | - Lara Lorenzetti
- Global Health, Population, and Nutrition, FHI 360, Durham, NC, United States
| | - Aamirah Mussa
- Botswana Harvard Health Partnership, Gaborone, Botswana; Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
| | - Kathleen Ridgeway
- Global Health, Population, and Nutrition, FHI 360, Durham, NC, United States
| | | | - Kavita Nanda
- Global Health, Population, and Nutrition, FHI 360, Durham, NC, United States
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Adeojo LW, Patel RC, Sambol NC. A Physiologically-Based Pharmacokinetic Simulation to Evaluate Approaches to Mitigate Efavirenz-Induced Decrease in Levonorgestrel Exposure with a Contraceptive Implant. Pharmaceutics 2024; 16:1050. [PMID: 39204395 PMCID: PMC11359785 DOI: 10.3390/pharmaceutics16081050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 07/06/2024] [Accepted: 07/29/2024] [Indexed: 09/04/2024] Open
Abstract
Background: Levonorgestrel implant is a highly effective hormonal contraceptive, but its efficacy may be compromised when used with cytochrome enzyme inducers such as efavirenz. The primary aim of this study was to evaluate methods of mitigating the drug interaction. Methods: Using a physiologically-based pharmacokinetic (PBPK) model for levonorgestrel that we developed within the Simcyp® program, we evaluated a higher dose of levonorgestrel implant, a lower dose of efavirenz, and the combination of both, as possible methods to mitigate the interaction. In addition, we investigated the impact on levonorgestrel total and unbound concentrations of other events likely to be associated with efavirenz coadministration: changes in plasma protein binding of levonorgestrel (as with displacement) and high variability of efavirenz exposure (as with genetic polymorphism of its metabolism). The range of fraction unbound tested was 0.6% to 2.6%, and the range of efavirenz exposure ranged from the equivalent of 200 mg to 4800 mg doses. Results: Levonorgestrel plasma concentrations at any given time with a standard 150 mg implant dose are predicted to be approximately 68% of those of control when given with efavirenz 600 mg and 72% of control with efavirenz 400 mg. With double-dose levonorgestrel, the predictions are 136% and 145% of control, respectively. A decrease in levonorgestrel plasma protein binding is predicted to primarily decrease total levonorgestrel plasma concentrations, whereas higher efavirenz exposure is predicted to decrease total and unbound concentrations. Conclusions: Simulations suggest that doubling the dose of levonorgestrel, particularly in combination with 400 mg daily efavirenz, may mitigate the drug interaction. Changes in levonorgestrel plasma protein binding and efavirenz genetic polymorphism may help explain differences between model predictions and clinical data but need to be studied further.
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Affiliation(s)
- Lilian W. Adeojo
- Department of Bioengineering and Therapeutic Sciences, School of Pharmacy, University of California San Francisco, San Francisco, CA 94143-0912, USA;
| | - Rena C. Patel
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35233, USA;
| | - Nancy C. Sambol
- Department of Bioengineering and Therapeutic Sciences, School of Pharmacy, University of California San Francisco, San Francisco, CA 94143-0912, USA;
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Chappell CA, Lamorde M, Nakalema S, Kyohairwe I, Byakika-Kibwika P, Meyn LA, Pham MM, Scarsi KK. A randomized trial of double vs single-dose etonogestrel implant to overcome the interaction with efavirenz-based antiretroviral therapy. Am J Obstet Gynecol 2024; 231:242.e1-242.e9. [PMID: 38458408 DOI: 10.1016/j.ajog.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Concomitant use of efavirenz-based antiretroviral therapy and a standard-dose etonogestrel contraceptive implant led to 82% lower etonogestrel exposure when compared with women who do not receive antiretroviral therapy. The clinical impact of this reduced exposure is supported by retrospective cohort evaluations that demonstrated higher rates of unintended pregnancies when contraceptive implants were combined with efavirenz. We hypothesized that placement of 2 etonogestrel implants in those taking efavirenz-based antiretroviral therapy could increase etonogestrel exposure and improve measures of contraceptive efficacy. OBJECTIVE This study compared the rate of ovulation and etonogestrel pharmacokinetics among women on efavirenz-based antiretroviral therapy who received 2 etonogestrel implants (136 mg; double implant group) in comparison with those who received 1 etonogestrel implant (68 mg; control group). STUDY DESIGN This randomized, open-label study enrolled Ugandan women with regular menstrual periods who were receiving efavirenz-based antiretroviral therapy for the treatment of HIV. Participants were randomized 1:1 to the double implant or control group, and the etonogestrel implant(s) were placed in the same arm at enrollment. All participants used a copper intrauterine device to prevent pregnancy. Ovulation was evaluated by weekly serum progesterone concentrations measured over 4 consecutive weeks at months 3 (weeks 9-12), 6 (weeks 21-24), and 12 (weeks 45-48). Progesterone concentrations >3 ng/mL were interpreted as ovulation. The ovulation rate in each group was compared using Fisher's exact tests for each month and generalized estimating equations over 48 weeks. Plasma was collected at day 3 and weeks 1, 4, 12, 24, 36, and 48 after implant placement and analyzed using a validated liquid chromatography-triple quadrupole mass spectrometry method for etonogestrel. Etonogestrel concentrations were summarized as median (interquartile range) and compared between groups by geometric mean ratio with 90% confidence intervals. RESULTS All participants (n=72) were cisgender Ugandan women with a median age of 31 years (interquartile range, 29-36), and 36 participants were enrolled in each study group. Two participants in the control group discontinued the trial; 1 at week 1 because of undetected pregnancy at entry and another at week 45 because of clinically significant depression. There were 47 ovulations over 104 person-months (45%) in 25 of 34 participants in the control group, and 2 ovulations over 108 person-months (2%) in 2 of 36 participants in the double implant group (month 3: 11 [31%] vs 0 [0%]; month 6: 17 [49%] vs 0 [0%]; month 12: 19 [56%] vs 2 [6%], respectively; all P<.001). The odds of ovulation were reduced by 97.7% (95% confidence interval, 90.1-99.5) in the double implant group over 48 weeks. At each time point, etonogestrel concentration was more than 2-fold higher in the double implant group than in the controls (geometric mean ratio, 2.30-2.83) with a geometric mean ratio of 2.83 (90% confidence interval, 1.89-3.35) at week 48. There were no differences in the adverse events between groups and no participant discontinued because of adverse events. CONCLUSION Over 48 weeks of combined use, placing 2 etonogestrel implants suppressed ovulation and increased plasma etonogestrel exposure when compared with 1 etonogestrel implant among women on efavirenz-based antiretroviral therapy. Doubling the dose of etonogestrel during efavirenz-based antiretroviral therapy could improve contraceptive effectiveness.
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Affiliation(s)
- Catherine A Chappell
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA; Magee-Womens Research Institute, Pittsburgh, PA.
| | - Mohammed Lamorde
- Infectious Diseases Institute, Kampala, Uganda; Department of Medicine, Makerere University, Kampala, Uganda
| | - Shadia Nakalema
- Infectious Diseases Institute, Kampala, Uganda; Department of Medicine, Makerere University, Kampala, Uganda
| | | | - Pauline Byakika-Kibwika
- Infectious Diseases Institute, Kampala, Uganda; Department of Medicine, Makerere University, Kampala, Uganda
| | - Leslie A Meyn
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Michelle M Pham
- Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, NE; Quantitative Pharmacology and Pharmacometrics, Merch & Co., Rahway, NJ
| | - Kimberly K Scarsi
- Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, NE; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
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Amariles P, Rivera-Cadavid M, Ceballos M. Clinical Relevance of Drug Interactions in People Living with Human Immunodeficiency Virus on Antiretroviral Therapy-Update 2022: Systematic Review. Pharmaceutics 2023; 15:2488. [PMID: 37896248 PMCID: PMC10610003 DOI: 10.3390/pharmaceutics15102488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/25/2023] [Accepted: 09/29/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND The clinical outcomes of antiretroviral drugs may be modified through drug interactions; thus, it is important to update the drug interactions in people living with HIV (PLHIV). AIM To update clinically relevant drug interactions in PLHIV on antiretroviral therapy with novel drug interactions published from 2017 to 2022. METHODS A systematic review in Medline/PubMed database from July 2017 to December 2022 using the Mesh terms antiretroviral agents and drug interactions or herb-drug interactions or food-drug interactions. Publications with drug interactions in humans, in English or Spanish, and with full-text access were retrieved. The clinical relevance of drug interactions was grouped into five levels according to the gravity and probability of occurrence. RESULTS A total of 366 articles were identified, with 219 (including 87 citation lists) were included, which allowed for the identification of 471 drug interaction pairs; among them, 291 were systematically reported for the first time. In total 42 (14.4%) and 137 (47.1%) were level one and two, respectively, and 233 (80.1%) pairs were explained with the pharmacokinetic mechanism. Among these 291 pairs, protease inhibitors (PIs) and ritonavir/cobicistat-boosted PIs, as well as integrase strand transfer inhibitors (InSTIs), with 70 (24.1%) and 65 (22.3%) drug interaction pairs of levels one and two, respectively, were more frequent. CONCLUSIONS In PLHIV on antiretroviral therapy, we identify 291 drug interaction pairs systematically reported for the first time, with 179 (61.5%) being assessed as clinically relevant (levels one and two). The pharmacokinetic mechanism was the most frequently identified. PIs, ritonavir/cobicistat-boosted PIs, and InSTIs were the antiretroviral groups with the highest number of clinically relevant drug interaction pairs (levels one and two).
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Affiliation(s)
- Pedro Amariles
- Research Group on Pharmaceutical Promotion and Prevention, University of Antioquia, UdeA, AA 1226, Medellin 050010, Colombia; (M.R.-C.); (M.C.)
- Research Group on Pharmaceutical Care, University of Granada, 18071 Granada, Spain
| | - Mónica Rivera-Cadavid
- Research Group on Pharmaceutical Promotion and Prevention, University of Antioquia, UdeA, AA 1226, Medellin 050010, Colombia; (M.R.-C.); (M.C.)
| | - Mauricio Ceballos
- Research Group on Pharmaceutical Promotion and Prevention, University of Antioquia, UdeA, AA 1226, Medellin 050010, Colombia; (M.R.-C.); (M.C.)
- Research Group on Pharmacy Regency Technology, University of Antioquia, Medellin 050010, Colombia
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Effect of double-dose levonorgestrel subdermal implant in women taking efavirenz-based antiretroviral therapy: The DoubLNG pharmacokinetic study. Contraception 2023; 122:109975. [PMID: 36787829 PMCID: PMC10149595 DOI: 10.1016/j.contraception.2023.109975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 01/22/2023] [Accepted: 01/30/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE We evaluated the pharmacokinetics of double-dose levonorgestrel (LNG) implants to overcome the drug-drug interaction with efavirenz-based antiretroviral therapy (ART). STUDY DESIGN We conducted a nonrandomized, open-label, parallel-group, longitudinal pharmacokinetic study among Ugandan women ages 18-45 years. Participants with HIV on ART containing efavirenz 600 mg received 300 mg of LNG implants (Jadelle®, Bayer, New Zealand): 300LNG+ART group. We compared our outcomes with women without HIV using standard dose, 150 mg of LNG implants: 150LNG group. The implant was placed on day zero in both groups, and we quantified plasma LNG concentrations over 48 weeks post implant insertion. LNG pharmacokinetic parameters were estimated using noncompartmental techniques. Our primary outcome was the geometric mean ratio with 90% confidence intervals of LNG area under the concentration-time curve over 24 weeks (AUC0-24w) between groups. Demographic data were described as median (interquartile range). A secondary outcome compared between-group percent of LNG concentrations ≥300 pg/mL, a minimum threshold selected a priori based on observed pregnancies in Ugandan women on standard-dose LNG implants plus efavirenz. RESULTS We enrolled 27 women in the 300LNG+ART group (34 [28.0 to 40.5] years and 61.0 [49.8-66.0] kg) and 19 women in the 150LNG group (33 [30.0 to 34.5] years and 64.9 [59.0 to 74.5] kg). LNG AUC0-24w was 34% lower for 300LNG+ART versus 150LNG (geometric mean 9998 vs. 15,231 pg*week/mL, respectively [geometric mean ratio 0.66 (90% confidence intervals, 0.54 to 0.80)]). The percentage of participants with LNG concentrations ≥300 pg/mL was not statistically different between groups at week 24 (300LNG+ART: 74.1%; 150LNG: 89.5%; p = 0.27). CONCLUSION Double-dose LNG implant did not completely overcome the drug-drug interaction with efavirenz. IMPLICATION In women using ART containing efavirenz, placing two implant systems (300 mg) did not normalize LNG pharmacokinetics compared with the standard-dose implant (150 mg), and some women had evidence of ovulatory activity. Alternative ART without drug-drug interactions, such as dolutegravir, is recommended with contraceptive implants.
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Stalter RM, Amorim G, Mocello AR, Jakait B, Shepherd BE, Musick B, Bernard C, Bukusi EA, Wools-Kaloustian K, Cohen CR, Yiannoutsos CT, Patel RC. Contraceptive implant use duration is not associated with breakthrough pregnancy among women living with HIV and using efavirenz: a retrospective, longitudinal analysis. J Int AIDS Soc 2022; 25:e26001. [PMID: 36073977 PMCID: PMC9454412 DOI: 10.1002/jia2.26001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 08/05/2022] [Indexed: 12/01/2022] Open
Abstract
Introduction Contraceptive implants containing etonogestrel and levonorgestrel have emerged as popular contraceptive options among women in areas of high HIV burden in sub‐Saharan Africa. However, recent pharmacokinetic data have shown drug–drug interactions between implants and efavirenz‐containing antiretroviral therapy (ART), reducing the effectiveness of the implants. Here, we evaluated pregnancy incidence in 6‐month intervals following implant initiation among women using efavirenz and contraceptive implants to assess whether the risk of breakthrough pregnancy is higher after specific periods of implant use. Methods We used data from a retrospective longitudinal analysis of women living with HIV ages 18–45 years in western Kenya who attended HIV‐care facilities between 2011 and 2015. We used Cox proportional hazard models to compute hazard ratios (HRs) for breakthrough pregnancy by implant type and ART regimen. Depending on the model, we adjusted for socio‐demographic and clinical factors, programme, site and interaction between calendar time and ART regimen. We utilized inverse probability weights (IPWs) to account for three sampling phases (electronic medical record [EMR], chart review and phone interview) and calculated overall parameter estimates. Results Women contributed 14,768 woman‐years from the largest sampling phase (EMR). The median age was 31 years. Women used etonogestrel implants for 26–69% of the time and levonorgestrel implants for 7–31% of the time, depending on the sampling phase. Women used efavirenz, nevirapine or no ART for 27–33%, 40–46% and 15–26% of follow‐ups, respectively. When combining sampling phases, there was little evidence to suggest that the relative hazard of pregnancy among efavirenz‐containing ART users relative to nevirapine‐containing ART changed with length of time on implants: IPW‐adjusted HR of 3.1 (CI: [1.5; 6.4]) at 12 months, 3.4 (CI: [1.8; 6.3]) at 24 months, 3.8 (CI: [1.9; 7.7]) at 36 months and 4.2 (CI: [1.6; 11.1]) at 48 months (interaction p‐value = 0.88). Similarly, no significant change in HRs over time was found when comparing women not using ART to nevirapine‐containing ART users (interaction p‐value = 0.49). Conclusions We did not find evidence to suggest implants being more fallible from drug–drug interactions with efavirenz at later time intervals of implant use. Thus, we would not recommend shortening the duration of implant use or replacing implants sooner when concomitantly used with efavirenz.
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Affiliation(s)
- Randy M Stalter
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Gustavo Amorim
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - A Rain Mocello
- Bixby Center for Global Reproductive Health and Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
| | - Beatrice Jakait
- Moi Teaching & Referral Hospital/Moi University & Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Bryan E Shepherd
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Beverly Musick
- Department of Biostatistics and Health Data Science, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Caitlin Bernard
- Division of Family Planning, Department of Obstetrics & Gynecology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Kara Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Craig R Cohen
- Bixby Center for Global Reproductive Health and Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
| | - Constantin T Yiannoutsos
- Department of Biostatistics and Health Data Science, R.M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Rena C Patel
- Division of Allergy and Infectious Diseases, Department of Medicine and Department of Global Health, University of Washington, Seattle, Washington, USA
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- Department of Epidemiology, University of Washington, Seattle, Washington, USA
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Lazorwitz A, Pena M, Sheeder J, Teal S. Effect of Topiramate on Serum Etonogestrel Concentrations Among Contraceptive Implant Users. Obstet Gynecol 2022; 139:579-587. [PMID: 35594123 PMCID: PMC9140306 DOI: 10.1097/aog.0000000000004697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/16/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate topiramate and etonogestrel pharmacokinetic interactions in contraceptive implant users. METHODS We conducted a prospective, noninferiority study with healthy women using etonogestrel implants continuously for 12-36 months. We measured baseline serum etonogestrel concentrations and then began a 6-week titrated topiramate regimen to standard migraine (100 mg/day) and epilepsy (400 mg/day) dosages. We repeated serum etonogestrel concentrations at 3 weeks (100 mg/day), 4 weeks (200 mg/day), and 6 weeks (400 mg/day) of topiramate therapy. We measured etonogestrel using a validated liquid chromatography-tandem, mass-spectrometry assay and tested for noninferiority (less than 30% decrease) in serum etonogestrel concentrations from baseline. RESULTS We enrolled 48 total participants; 32 completed 3 weeks, 31 completed 4 weeks, and 27 completed all follow-up visits. Participants' median age was 25.3 years (range 18.3-37.2), median body mass index (BMI) was 25.5 kg/m2 (range 18.7-42.2), and median duration of implant use was 24 months (range 12-36). Median etonogestrel concentrations were 142 pg/mL (range 76.2-771) at baseline, 126 pg/mL (range 72.4-585) at 3 weeks, 119 pg/mL (range 65.6-542) at 4 weeks, and 105 pg/mL (46.2-859) at 6 weeks. The 95% CIs for mean percent change in serum etonogestrel concentrations from baseline were [-37.3%+16.9%], [-45.4%+5.2%], and [-66.8%+24.8%] at 3 weeks, 4 weeks, and 6 weeks, respectively. Excluding one participant who had a serum etonogestrel concentration less than 90 pg/mL at baseline, 30.8% of participants (8/26, 95% CI 14.3-51.8%) had a serum etonogestrel concentration less than 90 pg/mL at 6 weeks. CONCLUSION Though only a mild enzyme-inducing antiepileptic drug, concomitant topiramate use led to inferior serum etonogestrel concentrations among implant users, with a significant proportion reaching etonogestrel concentrations below the threshold for ovulatory suppression when taking antiepileptic dosages of topiramate. FUNDING SOURCE This study was primarily funded through an Investigator-Initiated Study grant from Merck Sharp & Dohme Corp [MISP#57073]. This work was also supported by NIH/NCATS CTSA Grant Number UL1 TR001082 and NICHD K12 Women's Reproductive Health Research Scholar Program (grant number 5K12HD001271-18). CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT03335163.
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Affiliation(s)
- Aaron Lazorwitz
- University of Colorado Anschutz Medical Campus, Department of Obstetrics and Gynecology, Division of Family Planning
| | - Morgan Pena
- University of Colorado Anschutz Medical Campus, Department of Obstetrics and Gynecology, Division of Family Planning
| | - Jeanelle Sheeder
- University of Colorado Anschutz Medical Campus, Department of Obstetrics and Gynecology, Division of Family Planning
| | - Stephanie Teal
- University Hospitals Cleveland Medical Center and Case Western Reserve University, Department of Obstetrics and Gynecology
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Kreitchmann R, Stek A, Best BM, Capparelli E, Wang J, Shapiro D, Chakhtoura N, Mirochnick M, Eke AC. Interactions between etonogestrel-releasing contraceptive implant and 3 antiretroviral regimens. Contraception 2022; 105:67-74. [PMID: 34407424 PMCID: PMC8678338 DOI: 10.1016/j.contraception.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 08/05/2021] [Accepted: 08/09/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Long-acting reversible contraceptives are effective contraceptives for women with HIV, but there are limited data on etonogestrel implant and antiretroviral therapy pharmacokinetic drug-drug interactions. We evaluated etonogestrel/antiretroviral therapy drug-drug interactions, and the effects of etonogestrel on ritonavir-boosted-atazanavir, ritonavir-boosted-lopinavir, and efavirenz pharmacokinetics. STUDY DESIGN We enrolled postpartum women using etonogestrel implants and receiving ritonavir-boosted-atazanavir, ritonavir-boosted-lopinavir, or efavirenz-based regimens between 2012 and 2015. Etonogestrel implants were inserted 2 to 12 weeks postpartum. We performed pharmacokinetic sampling pre-etonogestrel insertion and 6 to 7 weeks postinsertion. We measured antiretroviral concentrations pre and postetonogestrel insertion, and compared etonogestrel concentrations between antiretroviral regimens. We considered a minimum serum etonogestrel concentration of 90 pg/mL adequate for ovulation suppression. RESULTS We collected pharmacokinetic data for 74 postpartum women, 22 on ritonavir-boosted-atazanavir, 26 on ritonavir-boosted-lopinavir, and 26 on efavirenz. The median serum concentrations of etonogestrel when co-administered were highest with etonogestrel/ritonavir-boosted-atazanavir (604 pg/mL) and etonogestrel/ritonavir-boosted-lopinavir (428 pg/mL), and lowest with etonogestrel/efavirenz (125 pg/mL); p < 0.001. Minimum concentration (Cmin) of ritonavir-boosted-atazanavir and ritonavir-boosted-lopinavir were lower after etonogestrel implant insertion, but overall exposure, predose concentrations, clearance, and half-lives were unchanged. We found no significant change in efavirenz exposure after etonogestrel insertion. CONCLUSIONS Unlike efavirenz, ritonavir-boosted-atazanavir and ritonavir-boosted-lopinavir were not associated with significant decreases in etonogestrel concentrations. Efavirenz was associated with a significant decrease in etonogestrel concentrations. IMPLICATIONS The findings demonstrate no interactions between etonogestrel and ritonavir-boosted-lopinavir or ritonavir-boosted-atazanavir, but confirm the decreased efficacy of etonogestrel with efavirenz-based antiretrovirals. This information should be used to counsel women with HIV who desire long-acting reversible contraceptives.
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Affiliation(s)
- Regis Kreitchmann
- Irmandade da Santa Casa de Misericordia de Porto Alegre, Porto Alegre, Brazil,Federal University of Health Sciences of Porto Alegre, Brazil
| | - Alice Stek
- University of Southern California School of Medicine, Los Angeles, CA, USA
| | | | | | - JiaJia Wang
- Harvard T.H Chan School of Public Health, Center for Biostatistics in AIDS Research, Boston, MA, USA
| | - David Shapiro
- Harvard T.H Chan School of Public Health, Center for Biostatistics in AIDS Research, Boston, MA, USA
| | - Nahida Chakhtoura
- Maternal and Pediatric Infectious Diseases Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, MD, USA
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Tuthill EL, Maltby AE, Odhiambo BC, Akama E, Pellowski JA, Cohen CR, Weiser SD, Conroy AA. "I Found Out I was Pregnant, and I Started Feeling Stressed": A Longitudinal Qualitative Perspective of Mental Health Experiences Among Perinatal Women Living with HIV. AIDS Behav 2021; 25:4154-4168. [PMID: 33997940 PMCID: PMC8126180 DOI: 10.1007/s10461-021-03283-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 11/03/2022]
Abstract
Globally, depressive symptoms among pregnant and postpartum (i.e., perinatal) women living with HIV (WLWH) are alarmingly high and associated with poor outcomes such as suboptimal adherence to antiretroviral therapy (ART), and early cessation of exclusive breastfeeding (EBF). Few qualitative studies have described the experience of perinatal depression among WLWH to identify the underlying social-structural determinants of poor mental health and potential strategies to intervene. We conducted a longitudinal qualitative study applying semi-structured interviews with 30 WLWH at three timepoints (28-38 weeks pregnant, 6-weeks postpartum and 5-7 months postpartum) to understand mental health experiences of perinatal WLWH in western Kenya. Financial insecurity emerged as the central theme impacting the mental health of women across time. Financial insecurity was often attributed to the loss of employment, related to pregnancy and the demands of breastfeeding and caring for an infant, as well as a lack of support from male partners. The loss of income and subsequent financial strain contributed to worsening levels of food insecurity and relationship stress and challenged engagement in HIV care. In this way, increased financial strain during the perinatal period negatively impacted the mental health of perinatal WLWH. Our findings suggest support to meet basic needs and remain engaged in HIV care during pregnancy and postpartum could improve perinatal mental health for WLWH in this setting.
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Affiliation(s)
- Emily L Tuthill
- Department of Community Health Systems, School of Nursing, University of California, 2 Koret Way, San Francisco, CA, 94143, USA.
| | - Ann E Maltby
- Department of Community Health Systems, School of Nursing, University of California, 2 Koret Way, San Francisco, CA, 94143, USA
| | - Belinda C Odhiambo
- Department of Community Health Systems, School of Nursing, University of California, 2 Koret Way, San Francisco, CA, 94143, USA
- Global Programs, University of California, San Francisco, CA, USA
| | - Eliud Akama
- Kenya Medical Research Institute- Center for Microbiology Research, Nairobi, Kenya
| | - Jennifer A Pellowski
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
- International Health Institute, Brown University School of Public Health, Providence, RI, USA
- Department of Epidemiology and Biostatistics, University of Cape Town, Cape Town, South Africa
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Sheri D Weiser
- Division of HIV, Infectious Disease, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Amy A Conroy
- Division of Prevention Sciences, Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, USA
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10
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Tang JH, Davis NL, Corbett AH, Chinula L, Cottrell ML, Zia Y, Tegha G, Stanczyk FZ, Hurst S, Hosseinipour MC, Haddad LB, Kourtis AP. Effect of efavirenz on levonorgestrel concentrations among Malawian levonorgestrel implant users for up to 30 months of concomitant use: a subanalysis of a randomized clinical trial. Contracept X 2020; 2:100027. [PMID: 33364598 PMCID: PMC7752709 DOI: 10.1016/j.conx.2020.100027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 11/25/2022] Open
Abstract
Objectives Our primary objective was to compare geometric mean levonorgestrel concentrations between levonorgestrel implant users who were or were not taking the antiretroviral efavirenz, for up to 30 months after implant initiation. Our secondary objective was to evaluate the pregnancy rate among levonorgestrel implant users on efavirenz. Study design We performed a subanalysis of 42 Malawian women randomized to initiate the levonorgestrel implant as part of a parent randomized clinical trial. Our subset included 30 HIV-infected women taking efavirenz and 12 HIV-uninfected women not taking efavirenz. They underwent urine pregnancy testing every 3 months and serum levonorgestrel testing at day 3 and months 1, 3, 6, 12, 18, 24, 27 and 30 after implant initiation. Geometric mean levonorgestrel concentrations were calculated for efavirenz users and non-efavirenz users at each time point. Results The geometric mean levonorgestrel concentrations were lower for efavirenz users than non-efavirenz users at every time point; the geometric mean ratio for efavirenz users:non-efavirenz users ranged from 0.60 [90% confidence interval (CI) 0.46–0.79] at 1 month to 0.27 (90% CI 0.12–0.61) at 30 months after implant insertion. No pregnancies occurred over 60 woman-years of concomitant levonorgestrel implant and efavirenz use, although 11 women had levonorgestrel concentrations < 180 pg/mL (the previously suggested minimum threshold concentration for efficacy). Conclusions Efavirenz users had lower levonorgestrel concentrations than non-efavirenz users, and one third of our concomitant efavirenz and levonorgestrel implant users had concentrations < 180 pg/mL. Continued evaluation of the contraceptive efficacy of the levonorgestrel implant may be needed for efavirenz users. Implications Among 42 Malawian women using the levonorgestrel implant for contraception, women who were taking the antiretroviral efavirenz had lower serum levonorgestrel concentrations than women who were not taking efavirenz. However, none of the women who were taking efavirenz became pregnant over 60 women-years of follow-up.
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Affiliation(s)
- Jennifer H Tang
- University of North Carolina at Chapel Hill, 111 Mason Farm Road, CB #7577; Chapel Hill, NC, 27599-7577, USA.,UNC Project Malawi, 100 Mzimba Drive, Private Bag A104, Lilongwe, Malawi
| | - Nicole L Davis
- US Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - Amanda H Corbett
- University of North Carolina at Chapel Hill, 111 Mason Farm Road, CB #7577; Chapel Hill, NC, 27599-7577, USA
| | - Lameck Chinula
- University of North Carolina at Chapel Hill, 111 Mason Farm Road, CB #7577; Chapel Hill, NC, 27599-7577, USA.,UNC Project Malawi, 100 Mzimba Drive, Private Bag A104, Lilongwe, Malawi
| | - Mackenzie L Cottrell
- University of North Carolina at Chapel Hill, 111 Mason Farm Road, CB #7577; Chapel Hill, NC, 27599-7577, USA
| | - Yasaman Zia
- US Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - Gerald Tegha
- UNC Project Malawi, 100 Mzimba Drive, Private Bag A104, Lilongwe, Malawi
| | - Frank Z Stanczyk
- University of Southern California, Keck School of Medicine, Reproductive Endocrine Research Laboratory, 1321 N. Mission Road, Los Angeles, CA, 90033, USA
| | - Stacey Hurst
- US Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - Mina C Hosseinipour
- University of North Carolina at Chapel Hill, 111 Mason Farm Road, CB #7577; Chapel Hill, NC, 27599-7577, USA.,UNC Project Malawi, 100 Mzimba Drive, Private Bag A104, Lilongwe, Malawi
| | - Lisa B Haddad
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA, 30322, USA
| | - Athena P Kourtis
- US Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA
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11
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Krishna GR, Haddad LB. Interactions between Hormonal Contraception and Anti-Retroviral Therapy: An Updated Review. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2020; 9:98-104. [PMID: 33552676 DOI: 10.1007/s13669-020-00289-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose of review Hormonal contraception provides women living with HIV the ability to control their fertility and avoid pregnancy-related morbidity. Due to shared metabolic pathways, there has been concern over drug-drug interactions between hormonal contraception and anti-retroviral therapy, which may affect the drugs' safety and efficacy. This article aims to provide an updated review of the most recent data around hormonal contraceptives and anti-retroviral therapy. Recent findings Prior data have suggested possible pharmacologic interactions between certain hormonal contraceptives and anti-retroviral therapy. The most significant interactions implicated include those between progestin-based contraceptive implants and efavirenz as well as between combined hormonal contraceptives and protease inhibitors. Most past studies, however, feature small sample sizes with few clinical outcomes reported. Summary Recent data since 2017 have largely affirmed prior studies on this topic, showing possible pharmacokinetic relationships between certain contraceptives and anti-retrovirals. Notably, while the effectiveness of progestin-based contraceptives, specifically the implant, appears reduced with efavirenz use, the overall effectiveness may remain higher than most other contraceptive methods. Larger studies are needed to provide further guidance before contraceptive-prescribing recommendations can be changed.
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Affiliation(s)
- Gopika R Krishna
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, GA, USA
| | - Lisa B Haddad
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, GA, USA
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