Pharmacokinetic interactions of modern antiretroviral therapy

Pharmacokinetics of tecovirimat in subjects with Mpox

OBJECTIVE

To investigate the pharmacokinetics (PK) of tecovirimat in subjects with Mpox.

METHODS

This monocentric, prospective, observational study enrolled subjects with Mpox who received standard treatment with oral tecovirimat. Plasma samples for PK assessment were collected at steady state (5-8 days after initiation of antiviral therapy), before and 3, 5, 7 and 12 h after tecovirimat administration. Drug concentrations were determined by validated liquid chromatography coupled with tandem mass spectrometry. PK parameters were calculated using Phoenix 8.1.

RESULTS

Overall, 14 male patients hospitalized for severe Mpox with ongoing tecovirimat treatment were enrolled in this study. Six of the 14 patients were living with human immunodeficiency virus (HIV), all of whom were on antiretroviral therapy (ART) and virologically suppressed at the time of hospitalization. Significant differences in tecovirimat PK were observed in subjects without HIV compared with subjects with HIV. In subjects with HIV, the maximum tecovirimat plasma concentration (39%, P≤0.0001), minimum tecovirimat plasma concentration (42%, P=0.0079) and area under the curve from zero to the last measured time-point (40%, P≤0.0001) were significantly lower compared with subjects without HIV, but all concentrations remained above the in-vitro calculated 90% inhibitory concentration. No significant associations were found between demographic/clinical data and tecovirimat PK. All patients recovered completely within 14 (range 6-36) days of treatment initiation.

CONCLUSIONS

This study found a significant decrease in plasma exposure of tecovirimat in Mpox patients with HIV on effective ART compared with those without HIV, with no evident impact on clinical outcomes. Although these results need to be confirmed in larger studies, they may provide useful information on the PK of tecovirimat.

Clinical Relevance of Drug Interactions in People Living with Human Immunodeficiency Virus on Antiretroviral Therapy-Update 2022: Systematic Review

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).

Improving measurement-based care implementation in adult ambulatory psychiatry: a virtual focus group interview with multidisciplinary healthcare professionals

BACKGROUND

Measurement-Based Care (MBC) is an evidence-based practice shown to enhance patient care. Despite being efficacious, MBC is not commonly used in practice. While barriers and facilitators of MBC implementation have been described in the literature, the type of clinicians and populations studied vary widely, even within the same practice setting. The current study aims to improve MBC implementation in adult ambulatory psychiatry by conducting focus group interviews while utilizing a novel virtual brainwriting premortem method.

METHODS

Semi-structured focus group interviews were conducted with clinicians (n = 18) and staff (n = 7) to identify their current attitudes, facilitators, and barriers of MBC implementation in their healthcare setting. Virtual video-conferencing software was used to conduct focus groups, and based on transcribed verbatin, emergent barriers/facilitators and four themes were identified. Mixed methods approach was utilized for this study. Specifically, qualitative data was aggregated and re-coded separately by three doctoral-level coders. Quantitative analyses were conducted from a follow-up questionnaire surveying clinician attitudes and satisfaction with MBC.

RESULTS

The clinician and staff focus groups resulted in 291 and 91 unique codes, respectively. While clinicians identified a similar number of barriers (40.9%) and facilitators (44.3%), staff identified more barriers (67%) than facilitators (24.7%) for MBC. Four themes emerged from the analysis; (1) a description of current status/neutral opinion on MBC; (2) positive themes that include benefits of MBC, facilitators, enablers, or reasons on why they conduct MBC in their practice, (3) negative themes that include barriers or issues that hinder them from incorporating MBC into their practice, and (4) requests and suggestions for future MBC implementation. Both participant groups raised more negative themes highlighting critical challenges to MBC implementation than positive themes. The follow-up questionnaire regarding MBC attitudes showed the areas that clinicians emphasized the most and the least in their clinical practice.

CONCLUSION

The virtual brainwriting premortem focus groups provided critical information on the shortcomings and strengths of MBC in adult ambulatory psychiatry. Our findings underscore implementation challenges in healthcare settings and provide insight for both research and clinical practice in mental health fields. The barriers and facilitators identified in this study can inform future training to increase sustainability and better integrate MBC with positive downstream outcomes in patient care.

Long-term success for people living with HIV: A framework to guide practice

OBJECTIVES

In recent decades, the needs of people living with HIV have evolved as life expectancy has greatly improved. Now, a new definition of long-term success (LTS) is necessary to help address the multifaceted needs of all people living with HIV.

METHODS

We conducted a two-phase research programme to delineate the range of experiences of people living with HIV. The insights garnered from these research phases were explored in a series of expert-led workshops, which led to the development and refinement of the LTS framework.

RESULTS

The insights generated from the research phases identified a series of themes that form a part of LTS. These themes were subsequently incorporated into the LTS framework, which includes five outcome pillars: sustained undetectable viral load, minimal impact of treatment and clinical monitoring, optimized health-related quality of life, lifelong integration of healthcare, and freedom from stigma and discrimination. A series of supporting statements were also developed by the expert panel to help in the achievement of each of the LTS pillars.

CONCLUSIONS

The LTS framework offers a comprehensive and person-centric approach that, if achieved, could help improve the long-term well-being of people living with HIV and support the LTS vision of 'every person living with HIV being able to live their best life'.