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Linfield RY, Nguyen NN, Laprade OH, Holodniy M, Chary A. An update on drug-drug interactions in older adults living with human immunodeficiency virus (HIV). Expert Rev Clin Pharmacol 2024:1-26. [PMID: 38753455 DOI: 10.1080/17512433.2024.2350968] [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: 02/01/2024] [Accepted: 04/30/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION People with HIV are living longer due to advances in antiretroviral therapy. With improved life expectancy comes an increased lifetime risk of comorbid conditions - such as cardiovascular disease and cancer - and polypharmacy. Older adults, particularly those living with HIV, are more vulnerable to drug interactions and adverse effects, resulting in negative health outcomes. AREA COVERED Antiretrovirals are involved in many potential drug interactions with medications used to treat common comorbidities and geriatric conditions in an aging population of people with HIV. We review the mechanisms and management of significant drug-drug interactions involving antiretroviral medications and non-antiretroviral medications commonly used among older people living with HIV. The management of these interactions may require dose adjustments, medication switches to alternatives, enhanced monitoring, and considerations of patient- and disease-specific factors. EXPERT OPINION Clinicians managing comorbid conditions among older people with HIV must be particularly vigilant to side effect profiles, drug-drug interactions, pill burden, and cost when optimizing treatment. To support healthier aging among people living with HIV, there is a growing need for antiretroviral stewardship, multidisciplinary care models, and advances that promote insight into the correlations between an individual, their conditions, and their medications.
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Affiliation(s)
| | - Nancy N Nguyen
- Department of Pharmacy, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy, University of the Pacific, Stockton, CA, USA
| | - Olivia H Laprade
- Department of Pharmacy, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy, University of the Pacific, Stockton, CA, USA
| | - Mark Holodniy
- Stanford University School of Medicine, Stanford, CA, USA
- Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- National Public Health Program Office, Veterans Health Administration, Palo Alto, CA, USA
| | - Aarthi Chary
- Stanford University School of Medicine, Stanford, CA, USA
- Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- National Public Health Program Office, Veterans Health Administration, Palo Alto, CA, USA
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Moodley D, Lombard C, Govender V, Naidoo M, Desmond AC, Naidoo K, Mhlongo O, Sebitloane M, Newell ML, Clark R, Rooney JF, Gray G, Lombard C, Govender V, Naidoo M, Desmond AC, Naidoo KL, Mhlongo O, Sebitloane M, Newell ML, Clark R, Rooney JF, Gray GE, Ngaleka L, Pillay N, Booi S, Samsunder N, Pillay L, Gray R, Gazu R, Nkosi T. Pregnancy and neonatal safety outcomes of timing of initiation of daily oral tenofovir disoproxil fumarate and emtricitabine pre-exposure prophylaxis for HIV prevention (CAP016): an open-label, randomised, non-inferiority trial. Lancet HIV 2023; 10:e154-e163. [PMID: 36746169 DOI: 10.1016/s2352-3018(22)00369-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 11/26/2022] [Accepted: 11/29/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND The safety of tenofovir disoproxil fumarate and emtricitabine as pre-exposure prophylaxis (PrEP) in pregnant women not living with HIV is uncertain. We aimed to compare pregnancy and neonatal outcomes in women exposed and not exposed to PrEP during pregnancy. METHODS In this single-site, open-label, randomised, non-inferiority trial in Durban, South Africa, we evaluated pregnancy and neonatal outcomes in pregnant women aged 18 years or older, not living with HIV, and at 14-28 weeks' gestation at the time of enrolment. Eligible participants were randomly assigned (1:1) using a computer-generated permuted block (block size of ten) randomisation list to immediate initiation or deferred initiation of PrEP until breastfeeding cessation. Participants in the immediate PrEP group received a monthly supply of once daily oral tenofovir disoproxil fumarate 300 mg and emtricitabine 200 mg. Participants in the deferred PrEP group received standard of care for HIV prevention. The primary outcomes were the occurrence of preterm live birth (<37 weeks gestational age) and very preterm birth (<34 weeks gestational age) determined by menstrual dating, low birthweight (<2500 g), very low birthweight (<1500 g), stillbirth (≥20 weeks gestational age), and small for gestational age (birthweight less than the tenth percentile). Post-natal safety outcomes will be reported elsewhere. We used binomial regression models to estimate risk differences and two-sided 90% CIs. Immediate PrEP was non-inferior to deferred PrEP if the upper bound of the 90% CI of the risk difference was less than the upper predefined non-inferiority margin for preterm birth (7·5%), very preterm birth (2·6%), low birthweight (5·5%), very low birthweight (1·2%), stillbirth (1·0%), and small for gestational age (3·7%). All outcomes were analysed in the intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT3227731. FINDINGS Between Sept 25, 2017, and Dec 6, 2019, we screened 693 women, of whom 540 were randomly assigned to immediate PrEP (n=271) or deferred PrEP (n=269). The median gestational age was 19 weeks (IQR 15-23 for immediate PrEP and 16-23 for deferred PrEP). The risk difference between the immediate PrEP group and the deferred PrEP group for preterm birth was -4·7% (90% CI -10·7 to 1·2; immediate PrEP was non-inferior), for very preterm birth was 0·6% (-3·4 to 4·6; upper limit exceeded the non-inferiority margin), for low birthweight was 2·5% (-1·6 to 6·6; upper limit exceeded the non-inferiority margin), for very low birthweight was 0% (-1·4 to 1·4; upper limit exceeded the non-inferiority margin), for stillbirth was 1·2% (-1·5 to 3·8; upper limit exceeded the non-inferiority margin), and for small for gestational age was 0·9% (-1·2 to 2·9; immediate PrEP was non-inferior). INTERPRETATION In our study, PrEP was not associated with preterm birth or small for gestational age infants. Our data support the use of tenofovir disoproxil fumarate and emtricitabine in pregnancy and our reassuring findings can be used to allay safety concerns among pregnant women. FUNDING South African Medical Research Council and Gilead Sciences.
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Affiliation(s)
- Dhayendre Moodley
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa; Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa.
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Tygerberg, South Africa; Division of Epidemiology and Biostatistics, Department of Global Health, University of Stellenbosch, Tygerberg, South Africa
| | - Vani Govender
- Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa
| | - Megeshinee Naidoo
- Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa
| | - Alicia C Desmond
- Centre for the Program of AIDS Research in South Africa (CAPRISA), Durban, South Africa
| | - Kimesh Naidoo
- Department of Paediatrics and Child Health, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Ottacia Mhlongo
- KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa
| | - Motshedisi Sebitloane
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Marie-Louise Newell
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; Human Health and Development, Faculty of Medicine, University of Southampton, Southampton, UK
| | | | | | - Glenda Gray
- South African Medical Research Council, Cape Town, South Africa
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Liegeon G, Assoumou L, Ghosn J, El Mouhebb M, Palich R, Palacios C, Slama L, Surgers L, Genin M, Beniguel L, Goldwirt L, Duvivier C, Rojas Castro D, Costagliola D, Molina JM. Impact on renal function of daily and on-demand HIV pre-exposure prophylaxis in the ANRS-PREVENIR study. J Antimicrob Chemother 2022; 77:3427-3435. [PMID: 36205009 DOI: 10.1093/jac/dkac336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 09/13/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To assess the impact on the estimated glomerular filtration rate (eGFR) of different tenofovir disoproxil/emtricitabine dosing regimens for HIV pre-exposure prophylaxis (PrEP). PATIENTS AND METHODS We included in the study individuals with baseline eGFR > 50 mL/min/1.73 m2 who initiated PrEP in the ongoing ANRS-PREVENIR PrEP cohort. We retrospectively classified PrEP users in three groups: 'on-demand' (reported at ≥75% of study visits), 'daily' (≥75% of study visits) or 'switches'. We compared the area under curve (AUC) of the eGFR variation from baseline (ΔeGFR) between groups using analysis of covariance, and assessed factors associated with a negative AUC of ΔeGFR. RESULTS From May 2017 to October 2020, 1253 PrEP-naïve participants (98% of MSM) were included in the study with a median follow-up of 22 months. 499 (40%), 494 (39%) and 260 (21%) users were in the group daily, on-demand and switches, respectively, for a median number of pills taken per week of 6, 1.7 and 4. The mean AUC of the ΔeGFR was -1.09 mL/min/1.73 m2 in the daily PrEP group, -0.69 mL/min/1.73 m2 in the switches group and +0.18 mL/min/1.73 m2 with on-demand PrEP. In a model adjusted on baseline age and eGFR, the AUC of the ΔeGFR was significantly higher with on-demand PrEP compared to daily PrEP (P = 0.037). Independent factors associated with a negative AUC of ΔeGFR were a daily PrEP regimen, a switches regimen, an age > 40 years and a baseline eGFR≥90 mL/min/1.73 m². CONCLUSIONS On-demand PrEP dosing had a smaller impact on eGFR evolution than daily PrEP, but the difference was not clinically relevant.
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Affiliation(s)
- Geoffroy Liegeon
- Service des maladies infectieuses, Assistance publique - Hôpitaux de Paris (AP-HP), Hôpitaux Saint Louis et Lariboisière, Paris 75010, France.,Université Paris Cité, Paris 75006, France
| | - Lambert Assoumou
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris 75646, France
| | - Jade Ghosn
- Université Paris Cité, Paris 75006, France.,Service des maladies infectieuses, AP-HP, Hôpital Bichat, Paris 75018, France
| | | | - Romain Palich
- Service des maladies infectieuse, AP-HP, Hôpital Pitié Salpetrière, Paris 75013, France
| | - Christia Palacios
- Service des maladies infectieuse, AP-HP, Hôpital Tenon, Paris 75020, France
| | - Laurence Slama
- Service des maladies infectieuses, AP-HP, Hôpital Hôtel Dieu, Paris 75004, France
| | - Laure Surgers
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris 75646, France.,Service des maladies infectieuses, AP-HP, Hôpital Saint Antoine, Paris 75012, France
| | - Michèle Genin
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris 75646, France
| | - Lydie Beniguel
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris 75646, France
| | - Lauriane Goldwirt
- Service de pharmacologie clinique, AP-HP, Hôpital Saint Louis, Paris 75010, France
| | - Claudine Duvivier
- Service des maladies infectieuses, AP-HP, Hôpital Necker-Enfants Malades, Centre d'Infectiologie Necker Pasteur; IHU Imagine, Paris 75015, France.,Institut Cochin - CNRS 8104 - INSERM U1016 - RIL (Retrovirus, Infection, and Latency) Team, Université Paris Cité, Paris 75014, France.,Institut Pasteur, Centre Médical de l'Institut Pasteur, Paris 75015France
| | | | - Dominique Costagliola
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris 75646, France
| | - Jean-Michel Molina
- Service des maladies infectieuses, Assistance publique - Hôpitaux de Paris (AP-HP), Hôpitaux Saint Louis et Lariboisière, Paris 75010, France.,Université Paris Cité, Paris 75006, France.,INSERM UMR 941, Paris 75010, France
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Clinical Considerations in the Selection of Preexposure Prophylaxis for HIV Prevention in Canada. CANADIAN JOURNAL OF INFECTIOUS DISEASES AND MEDICAL MICROBIOLOGY 2022; 2022:3913439. [PMID: 36081603 PMCID: PMC9448580 DOI: 10.1155/2022/3913439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/03/2022] [Indexed: 11/17/2022]
Abstract
According to the Public Health Agency of Canada, approximately 62,050 people were living with HIV in Canada in 2018, and of those, 13% were undiagnosed. Currently, no single strategy provides complete protection or is universally effective across all demographic groups at risk for HIV. However, HIV preexposure prophylaxis (PrEP) is the newest HIV prevention strategy that shows promise. To date, two products have received an indication for PrEP by Health Canada: emtricitabine/tenofovir disoproxil fumarate (Truvada®; FTC/TDF) and emtricitabine/tenofovir alafenamide (Descovy®; FTC/TAF). Despite the high efficacy of these PrEP intervention methods, access to PrEP in Canada remains low. Identifying and addressing barriers to PrEP access, especially in high-risk groups, are necessary to reduce HIV transmission in Canada. While guidelines published by the Center for Disease Control and Prevention (CDC) include FTC/TAF information, the efficacy of FTC/TAF for PrEP has not yet been considered in Canada's clinical practice guidelines. Thus, the current paper reviews data regarding the use of FTC/TDF and FTC/TAF for PrEP, which may be useful for Canadian healthcare providers when counseling and implementing HIV prevention methods. The authors highlight these data in relation to various at-risk populations and review ongoing clinical trials investigating novel PrEP agents. Overall, FTC/TDF PrEP is effective for many populations, including men who have sex with men, transgender women, heterosexuals with partners living with HIV, and people who use drugs. While there is fewer data reported on the efficacy of FTC/TAF to date, recent clinical trials have demonstrated noninferiority of FTC/TAF in comparison to FTC/TDF. Notably, as studies have shown that FTC/TAF maintains renal function and bone mineral density to a greater extent than FTC/TDF, FTC/TAF may be a safer option for patients experiencing renal and/or bone dysfunction, for those at risk of renal and bone complications, and for those who develop FTC/TDF-related adverse events.
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Drak D, Lin J, Gowers A, Gracey DM. Fanconi syndrome in a patient receiving pre-exposure prophylaxis for HIV infection: case report. Sex Health 2022; 19:224-227. [PMID: 35614021 DOI: 10.1071/sh21185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 05/04/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Tenofovir disoproxil is efficacious in the preventing HIV infection as part of a pre-exposure prophylaxis (PrEP) regimen. Although its use has been associated with impaired renal function, instances of Fanconi syndrome are extremely rare. This may change with increased uptake of PrEP. METHODS A 55-year-old male patient (he/him/his) was commenced on PrEP with a baseline estimated glomerular filtration rate (eGFR) of approximately 60mL/min/1.73m2. RESULTS Within 6months, he developed new and worsening proteinuria, glycosuria and aminoaciduria despite no apparent change in eGFR. PrEP was discontinued and his urinary abnormalities rapidly resolved. The patient remains off PrEP. CONCLUSIONS Fanconi syndrome is a rare, but known complication of tenofovir disoproxil. This is the first report related to PrEP in Australia. While tenofovir associated nephrotoxicity in patients taking PrEP is uncommon, the patient's age and pre-existing renal impairment placed him at substantially higher risk. At-risk patients need more frequent monitoring of their eGFR and proteinuria. Urinary protein to creatinine ratio is the preferred to dipstick testing for proteinuria and the latter does not readily detect the low molecular wight proteinuria characteristic of tenofovir toxicity. Early recognition of these patients is essential, as prompt cessation of PrEP can often reverse renal abnormalities.
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Affiliation(s)
- Douglas Drak
- Royal North Shore Hospital, St Leonards, NSW, Australia; and Faculty of Medicine, Central Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Jasper Lin
- Renal Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Andrew Gowers
- Holdsworth House Medical Practice, College Street, Sydney, NSW, Australia
| | - David M Gracey
- Faculty of Medicine, Central Clinical School, University of Sydney, Sydney, NSW, Australia; and Renal Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; and Holdsworth House Medical Practice, College Street, Sydney, NSW, Australia
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Lucas GM, Winslow DL. New onset kidney impairment in a large pre-exposure prophylaxis demonstration project in New South Wales, Australia. AIDS 2021; 35:2395-2397. [PMID: 34723855 PMCID: PMC8982901 DOI: 10.1097/qad.0000000000003077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Gregory M. Lucas
- Johns Hopkins University School of Medicine, Division of Infectious Diseases, Baltimore, Maryland
| | - Dean L. Winslow
- Stanford University School of Medicine, Division of Hospital Medicine and Division of Infectious Diseases and Geographic Medicine, Stanford, California
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