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Kendall MA, Lalloo U, Fletcher CV, Wu X, Podany AT, Cardoso SW, Ive P, Benson CA. Safety and Pharmacokinetics of Double-Dose Lopinavir/Ritonavir + Rifampin Versus Lopinavir/Ritonavir + Daily Rifabutin for Treatment of Human Immunodeficiency Virus-Tuberculosis Coinfection. Clin Infect Dis 2021; 73:706-715. [PMID: 34398956 PMCID: PMC8366816 DOI: 10.1093/cid/ciab097] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 02/02/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Protease inhibitor-based antiretroviral therapy may be used in resource-limited settings in persons with human immunodeficiency virus and tuberculosis (HIV-TB). Data on safety, pharmacokinetics/pharmacodynamics (PK/PD), and HIV-TB outcomes for lopinavir/ritonavir (LPV/r) used with rifampin (RIF) or rifabutin (RBT) are limited. METHODS We randomized adults with HIV-TB from July 2013 to February 2016 to arm A, LPV/r 400 mg/100 mg twice daily + RBT 150 mg/day; arm B, LPV/r 800 mg/200 mg twice daily + RIF 600 mg/day; or arm C, LPV/r 400 mg/100 mg twice daily + raltegravir (RAL) 400 mg twice daily + RBT 150 mg/day. All received two nucleoside reverse transcriptase inhibitors and other TB drugs. PK visits occurred on day 12 ± 2. Within-arm HIV-TB outcomes were summarized using proportions and 95% CIs; PK were compared using Wilcoxon tests. RESULTS Among 71 participants, 52% were women; 72% Black; 46% Hispanic; median age, 37 years; median CD4+ count, 130 cells/mm3; median HIV-1 RNA, 4.6 log10 copies/mL; 46% had confirmed TB. LPV concentrations were similar across arms. Pooled LPV AUC12 (157 203 hours × ng/mL) and Ctrough (9876 ng/mL) were similar to historical controls; RBT AUC24 (7374 hours × ng/mL) and Ctrough (208 ng/mL) were higher, although 3 participants in arm C had RBT Cmax <250 ng/mL. Proportions with week 48 HIV-1 RNA <400 copies/mL were 58%, 67%, and 61%, respectively, in arms A, B, and C. CONCLUSIONS Double-dose LPV/r+RIF and LPV/r+RBT 150mg/day had acceptable safety, PK and TB outcomes; HIV suppression was suboptimal but unrelated to PK. Faster RBT clearance and low Cmax in 3 participants on RBT+RAL requires further study.
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Affiliation(s)
- Michelle A Kendall
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Umesh Lalloo
- Enhancing Care Foundation, Durban International Clinical Research Site (CRS), Durban, South Africa
| | - Courtney V Fletcher
- UNMC Center for Drug Discovery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Xingye Wu
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Anthony T Podany
- UNMC Center for Drug Discovery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Sandra W Cardoso
- Instituto de Pesquisa Clinica Evandro Chagas (IPEC) CRS, Rio de Janeiro, Brazil
| | - Prudence Ive
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Constance A Benson
- Antiviral Research Center, University of California, San Diego, San Diego, California, USA
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Duwal S, Dickinson L, Khoo S, von Kleist M. Mechanistic framework predicts drug-class specific utility of antiretrovirals for HIV prophylaxis. PLoS Comput Biol 2019; 15:e1006740. [PMID: 30699105 PMCID: PMC6370240 DOI: 10.1371/journal.pcbi.1006740] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 02/11/2019] [Accepted: 12/20/2018] [Indexed: 11/21/2022] Open
Abstract
Currently, there is no effective vaccine to halt HIV transmission. However, pre-exposure prophylaxis (PrEP) with the drug combination Truvada can substantially decrease HIV transmission in individuals at risk. Despite its benefits, Truvada-based PrEP is expensive and needs to be taken once-daily, which often leads to inadequate adherence and incomplete protection. These deficits may be overcome by next-generation PrEP regimen, including currently investigated long-acting formulations, or patent-expired drugs. However, poor translatability of animal- and ex vivo/in vitro experiments, and the necessity to conduct long-term (several years) human trials involving considerable sample sizes (N>1000 individuals) are major obstacles to rationalize drug-candidate selection. We developed a prophylaxis modelling tool that mechanistically considers the mode-of-action of all available drugs. We used the tool to screen antivirals for their prophylactic utility and identify lower bound effective concentrations that can guide dose selection in PrEP trials. While in vitro measurable drug potency usually guides PrEP trial design, we found that it may over-predict PrEP potency for all drug classes except reverse transcriptase inhibitors. While most drugs displayed graded concentration-prophylaxis profiles, protease inhibitors tended to switch between none- and complete protection. While several treatment-approved drugs could be ruled out as PrEP candidates based on lack-of-prophylactic efficacy, darunavir, efavirenz, nevirapine, etravirine and rilpivirine could more potently prevent infection than existing PrEP regimen (Truvada). Notably, some drugs from this candidate set are patent-expired and currently neglected for PrEP repurposing. A next step is to further trim this candidate set by ruling out compounds with ominous safety profiles, to assess different administration schemes in silico and to test the remaining candidates in human trials. Pre-exposure prophylaxis (PrEP) is a novel, promising strategy to halt HIV transmission. PrEP with Truvada can substantially decrease the risk of infection. However, individuals often inadequately adhere to the once-daily regimen and the drug is expensive. These shortcomings may be overcome by next-generation PrEP compounds, including long-acting formulations. However, poor translatability of animal- and ex vivo/in vitro experiments, and difficulties in conducting long-term trials involving considerable sample sizes (N > 1000 individuals) make drug-candidate selection and optimization of administration schemes costly and often infeasible. We developed a simulation tool that mechanistically considers the mode-of-action of all antivirals. We used the tool to screen all available antivirals for their prophylactic utility and identified lower bound effective concentrations for designing PrEP dosing regimen in clinical trials. We found that in vitro measured drug potency may over-predict PrEP potency, for all antiviral classes except reverse transcriptase inhibitors. We could rule out a number of antivirals for PrEP repurposing and predicted that darunavir, efavirenz, nevirapine, etravirine and rilpivirine provide complete protection at clinically relevant concentrations. Further trimming of this candidate set by compound-safety and by assessing different implementation schemes is envisaged.
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Affiliation(s)
- Sulav Duwal
- Department of Mathematics & Computer Science, Freie Universität Berlin, Germany
- * E-mail: (SD); (MvK)
| | - Laura Dickinson
- Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Saye Khoo
- Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Max von Kleist
- Department of Mathematics & Computer Science, Freie Universität Berlin, Germany
- * E-mail: (SD); (MvK)
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Rothenberger M, Wagner JE, Haase A, Richman D, Grzywacz B, Strain M, Lada S, Estes J, Fletcher CV, Podany AT, Anderson J, Schmidt T, Wietgrefe S, Schacker T, Verneris MR. Transplantation of CCR5∆32 Homozygous Umbilical Cord Blood in a Child With Acute Lymphoblastic Leukemia and Perinatally Acquired HIV Infection. Open Forum Infect Dis 2018; 5:ofy090. [PMID: 29868623 PMCID: PMC5965100 DOI: 10.1093/ofid/ofy090] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 05/09/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Allogeneic hematopoietic cell transplantation (allo-HCT) in a CCR5∆32 homozygous donor resulted in HIV cure. Understanding how allo-HCT impacts the HIV reservoir will inform cure strategies. METHODS A 12-year-old with perinatally acquired, CCR5-tropic HIV and acute lymphoblastic leukemia underwent myeloablative conditioning and umbilical cord blood (UCB) transplantation from a CCR5∆32 homozygous donor. Peripheral blood mononuclear cells (PBMCs) and the rectum were sampled pre- and post-transplant. The brain, lung, lymph node (LN), stomach, duodenum, ileum, and colon were sampled 73 days after transplantation (day +73), when the patient died from graft-vs-host disease. Droplet digital polymerase chain reaction (ddPCR) and in situ hybridization (ISH) were used detect the HIV reservoir in tissues. CCR5 and CD3 expression in the LN was assessed using immunohistochemistry (IHC). RESULTS HIV DNA (vDNA) was detected in PBMCs by ddPCR pretransplant but not post-transplant. vDNA was detected by ISH in the rectum at days -8 and +22, and in the LN, colon, lung, and brain day +73. vDNA was also detected in the lung by ddPCR. IHC revealed CCR5+CD3+ cells in the LN postmortem. CONCLUSIONS HIV was detected in multiple tissues 73 days after CCR5∆32 homozygous UCB allo-HCT despite myeloablative conditioning and complete donor marrow engraftment. These results highlight the importance of analyzing tissue during HIV cure interventions and inform the choice of assay used to detect HIV in tissue reservoirs.
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Affiliation(s)
| | - John E Wagner
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Ashley Haase
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, Minnesota
| | - Douglas Richman
- Department of Pathology and Lab Medicine, University of Minnesota, Minneapolis, Minnesota
- Veteran’s Affairs (VA) San Diego Healthcare System, San Diego, California
| | - Bartosz Grzywacz
- Center for AIDS Research, University of California San Diego, La Jolla, California
| | - Matthew Strain
- Veteran’s Affairs (VA) San Diego Healthcare System, San Diego, California
| | - Steven Lada
- Department of Pathology and Lab Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Jacob Estes
- AIDS and Cancer Virus Program and Laboratory Animal Science Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | | | - Anthony T Podany
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska
| | - Jodi Anderson
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Thomas Schmidt
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Steve Wietgrefe
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, Minnesota
| | - Timothy Schacker
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Michael R Verneris
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
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Uemura H, Tsukada K, Mizushima D, Aoki T, Watanabe K, Kinai E, Teruya K, Gatanaga H, Kikuchi Y, Sugiyama M, Mizokami M, Oka S. Interferon-free therapy with direct acting antivirals for HCV/HIV-1 co-infected Japanese patients with inherited bleeding disorders. PLoS One 2017; 12:e0186255. [PMID: 29045448 PMCID: PMC5646795 DOI: 10.1371/journal.pone.0186255] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 09/27/2017] [Indexed: 02/07/2023] Open
Abstract
Introduction Almost 30 years ago, about 30% of Japanese hemophiliacs became infected with HIV-1 and hepatitis C virus (HCV) after receiving contaminated blood products. While several studies have reported the high efficacy and safety of direct acting antivirals (DAA) in HIV-1 co-infected patients, such data are limited in hemophiliacs. Methods We conducted a single-center, open-label study involving 27 Japanese patients (median age; 45 years) with inherited bleeding disorders who were co-infected with HCV/HIV-1. Patients with HCV genotype 1 (GT1) and GT4 received ledipasvir (90 mg) plus sofosbuvir (400 mg), those with HCV GT2 received sofosbuvir plus weight-based ribavirin, and those with HCV GT3 received daclatasvir (60 mg) plus sofosbuvir. Treatment was continued for 12 weeks in all patients. The primary endpoints were rate of sustained virologic response at 12 weeks after end of therapy (SVR12) and occurrence of adverse events during DAA therapy. Results Eighteen (67%) patients had had received interferon-based therapy, and 11 (41%) had compensated cirrhosis. HCV genotypes were GT1a 4 (15%), GT1b 16 (59%), GT1 undetermined 2 (7%), GT2a 1 (4%), GT3a 3 (11%) and GT4a 1 (4%). All patients were on combination antiretroviral therapy (cART) and had undetectable HIV-1 viral load (<20 copies/μL) at baseline. All patients achieved SVR12. Serious adverse events were observed in 3 patients: arteritis of the leg, which resolved after completion of DAA therapy, asymptomatic QT prolongation and gastrointestinal hemorrhage. cART failure was noted in one patient due to emergence of raltegravir resistance during ledipasvir/sofosbuvir treatment. Although α-fetoprotein, Mac-2 binding protein glycosylation isomer (M2BPGi), and Fibro Scan (FS) scores decreased in most patients during DAA therapy, M2BPGi (>2.0 cutoff index) and FS scores (>15.0 kPa) were still high in 6 patients at week 36. Conclusions DAA therapy is effective in all patients. However, adverse events and efficacy of cART should be monitored closely.
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Affiliation(s)
- Haruka Uemura
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
- Center for AIDS Research, Kumamoto University, Kumamoto, Japan
- * E-mail:
| | - Kunihisa Tsukada
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Daisuke Mizushima
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takahiro Aoki
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Koji Watanabe
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Ei Kinai
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Katsuji Teruya
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hiroyuki Gatanaga
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
- Center for AIDS Research, Kumamoto University, Kumamoto, Japan
| | - Yoshimi Kikuchi
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masaya Sugiyama
- Genome Medical Sciences Project, Research Institute, National Center for Global Health and Medicine, Chiba, Japan
| | - Masashi Mizokami
- Genome Medical Sciences Project, Research Institute, National Center for Global Health and Medicine, Chiba, Japan
| | - Shinichi Oka
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
- Center for AIDS Research, Kumamoto University, Kumamoto, Japan
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A rapid spin through oil results in higher cell-associated concentrations of antiretrovirals compared with conventional cell washing. Bioanalysis 2016; 7:1447-55. [PMID: 26168252 DOI: 10.4155/bio.15.70] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Determination of cell-associated antiretroviral drug concentrations is necessary for research into reservoirs of HIV. Variation exists in cell-associated drug concentrations among research groups. One cause for this may be washing cells during processing. We explored spinning cells through oil to minimize this variability. METHODS & RESULTS Raltegravir, atazanavir, darunavir, efavirenz, lopinavir and ritonavir concentrations were assessed in CEM.ss T cells washed with HBSS and oil-spun cells. Oil-spun cells had significantly higher concentrations for all drugs compared with samples washed with HBSS. CONCLUSION The decline in cell-associated drug concentrations with saline washes compared with a single spin through oil shows the utility of a spin through oil. Oil centrifugation results in high cell-associated drug concentrations, and can be done in a fast, efficient manner.
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Raltegravir is safely used with long-term viral suppression for HIV-infected patients on hemodialysis: a pharmacokinetic study. AIDS 2016; 30:970-2. [PMID: 26959356 DOI: 10.1097/qad.0000000000001012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Veselinovic M, Yang KH, Sykes C, Remling-Mulder L, Kashuba ADM, Akkina R. Mucosal tissue pharmacokinetics of the integrase inhibitor raltegravir in a humanized mouse model: Implications for HIV pre-exposure prophylaxis. Virology 2016; 489:173-8. [PMID: 26771889 DOI: 10.1016/j.virol.2015.12.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 12/09/2015] [Accepted: 12/22/2015] [Indexed: 12/26/2022]
Abstract
Orally administered anti-retroviral drugs show considerable promise for HIV/AIDS pre-exposure prophylaxis (PrEP). For the success of these strategies, pharmacokinetic (PK) data defining the optimal concentration of the drug needed for protection in relevant mucosal exposure sites is essential. Here we employed a humanized mouse model to derive comprehensive PK data on the HIV integrase inhibitor raltegravir (RAL), a leading PrEP drug candidate. Under steady state conditions following oral dosing, plasma and multiple mucosal tissues were sampled simultaneously. RAL exhibited higher drug exposure in mucosal tissues relative to that in plasma with one log higher exposure in vaginal and rectal tissue and two logs higher exposure in intestinal mucosa reflecting the trends seen in the human studies. These data demonstrate the suitability of RAL for HIV PrEP and validate the utility of humanized mouse models for deriving important preclinical PK-PD data.
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Affiliation(s)
- Milena Veselinovic
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, USA
| | | | | | - Leila Remling-Mulder
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, USA
| | - Angela D M Kashuba
- Eshelman School of Pharmacy, NC, USA; School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Ramesh Akkina
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, USA.
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Correlation between plasma, intracellular, and cervical tissue levels of raltegravir at steady-state dosing in healthy women. Antimicrob Agents Chemother 2014; 58:3360-5. [PMID: 24687503 DOI: 10.1128/aac.02757-13] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Raltegravir is an antiretroviral with potential value for preexposure prophylaxis (PrEP) against HIV, but the intracellular pharmacokinetics in genital tissue have not been described. In this study, healthy, HIV-uninfected nonpregnant women took 400 mg of raltegravir twice daily for 22 days. On day 8, 15, and 22, blood was collected 0, 4, 6, 8, and 12 h and cervical biopsy specimens taken 0, 6, and 12 h after raltegravir dosing. Plasma and intracellular raltegravir concentrations in peripheral blood mononuclear cells (PBMC) and cervical tissue were measured by tandem mass spectrometry. Linear mixed effects models evaluated correlations between different sample types, as well as differences in concentration between phases of the menstrual cycle. Ten women were enrolled: 9 completed all three visits and 1 completed two visits. The age (mean ± standard deviation) of participants was 30 ± 8 years. Trough plasma concentrations of raltegravir 12 h after a directly observed dose were above the HIV 95% inhibitory concentration (IC95) of 33 nM (14.6 ng/ml) in 96% of measurements, compared to 67% of PBMC and 89% of cervical tissue trough values. Across all measurements, only 2% (3/135) of plasma values fell below the IC95, compared to 10% (13/135) for PBMC and 6% (5/81) for cervical tissue. There was no impact of menstrual phase on raltegravir concentrations. In conclusion, cervical tissue raltegravir concentrations were no greater than plasma concentrations, and ∼10% of all cervical tissue trough values were below the IC95, making the current twice-daily formulation of raltegravir impractical for PrEP.
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Larson KB, King JR, Acosta EP. Raltegravir for HIV-1 infected children and adolescents: efficacy, safety, and pharmacokinetics. ADOLESCENT HEALTH MEDICINE AND THERAPEUTICS 2013; 4:79-87. [PMID: 24600298 PMCID: PMC3912854 DOI: 10.2147/ahmt.s29462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Raltegravir was the first HIV integrase strand-transfer inhibitor to be approved by the US FDA, in October 2007, for the treatment of HIV-1 infection in combination with other antiretroviral agents. Raltegravir can be used in treatment-naïve and -experienced patients, as well as for the treatment of multidrug-resistant infection. Raltegravir exists in two formulations: a film-coated tablet administered orally at 400 mg twice daily, and a chewable tablet administered orally at 300 mg twice daily. In 2011, raltegravir was also approved for the treatment of children and adolescents, ages 2–18 years. For adolescents (ages 12–18 years), the recommended dose is 400 mg twice daily (film-coated tablet). If children (ages 6–12 years) weigh at least 25 kg, the film-coated tablet is recommended at 400 mg twice daily. Otherwise, patients receive the chewable tablet according to weight-based dosing at approximately 6 mg/kg/dose. Studies are ongoing for children ages 4 weeks to 2 years, and preliminary efficacy and safety data are promising. This article reviews current studies on the efficacy, safety, and pharmacokinetics of raltegravir in the pediatric population and the challenges of treating HIV in children and adolescents.
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Affiliation(s)
- Kajal B Larson
- Department of Pharmacology and Toxicology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jennifer R King
- Department of Pharmacology and Toxicology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Edward P Acosta
- Department of Pharmacology and Toxicology, University of Alabama at Birmingham, Birmingham, AL, USA
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