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Le X, Shen Y. Advances in Antiretroviral Therapy for Patients with Human Immunodeficiency Virus-Associated Tuberculosis. Viruses 2024; 16:494. [PMID: 38675837 PMCID: PMC11054420 DOI: 10.3390/v16040494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/09/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024] Open
Abstract
Tuberculosis is one of the most common opportunistic infections and a prominent cause of death in patients with human immunodeficiency virus (HIV) infection, in spite of near-universal access to antiretroviral therapy (ART) and tuberculosis preventive therapy. For patients with active tuberculosis but not yet receiving ART, starting ART after anti-tuberculosis treatment can complicate clinical management due to drug toxicities, drug-drug interactions and immune reconstitution inflammatory syndrome (IRIS) events. The timing of ART initiation has a crucial impact on treatment outcomes, especially for patients with tuberculous meningitis. The principles of ART in patients with HIV-associated tuberculosis are specific and relatively complex in comparison to patients with other opportunistic infections or cancers. In this review, we summarize the current progress in the timing of ART initiation, ART regimens, drug-drug interactions between anti-tuberculosis and antiretroviral agents, and IRIS.
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Affiliation(s)
| | - Yinzhong Shen
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China;
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Nightingale S, Ssemmanda S, Tucker LM, Eastman RW, Lee Pan EB. Electroencephalography as a diagnostic tool for late-onset efavirenz neurotoxicity syndrome. PLoS One 2023; 18:e0288055. [PMID: 37948398 PMCID: PMC10637668 DOI: 10.1371/journal.pone.0288055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/18/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION To examine electroencephalogram (EEG) as a diagnostic tool for late-onset efavirenz (EFV) neurotoxicity syndrome (LENS), an uncommon but severe and potentially fatal complication of EFV therapy. METHODS We conducted a Retrospective case-control study. EEGs from confirmed cases of LENS (clinical syndrome and plasma EFV >4ug/mL) recorded from June 2016 to May 2021 were compared with control EEGs from the same time-period. Controls were adults (18-70 years) with a similar indication for EEG (eg. encephalopathy or confusion), dysrhythmia generalised grade II, and LENS excluded. EEGs were reviewed by two blinded interpreters given a description of the characteristic EEG changes, ie. persistent, diffuse, high voltage, bisynchronous, monomorphic 4-7 Hz theta frequency waveforms with transient attenuation on eye opening. Interpreters were asked to determine whether EEGs showed definite, probable or no changes. RESULTS Thirteen LENS cases were compared with 50 control EEGs. Interpreter 1 labelled 11/13 LENS cases as having define or probable changes, and interpreter 2 labelled 10/13. Interpreter 1 labelled probable changes in 1/50 controls and interpreter 2 in 3/50. Neither interpreter labelled any controls as having definite changes. Interrater reliability was good with 95% agreement and a Cohen's kappa of 0.83. Sensitivity of EEG under these conditions for the diagnosis of LENS was 85% and 77% for interpreters 1 and 2 respectively, and specificity was 98% and 94%. CONCLUSIONS EEG is a useful tool in the diagnosis of LENS which can be used to aid clinical decisions while awaiting EFV levels, or in low-resource settings where EFV levels are not available.
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Affiliation(s)
- Sam Nightingale
- Neurology Department, Groote Schuur Hospital, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | | | - Lawrence M. Tucker
- Neurology Department, Groote Schuur Hospital, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Roland W. Eastman
- Neurology Department, Groote Schuur Hospital, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Eddy B. Lee Pan
- Neurology Department, Groote Schuur Hospital, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
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Wang T, Liu Y, Zhu C, Yang S, Yang D, Xiao J, Gao G. Pharmacokinetics of Efavirenz 600mg in Combination with Rifampicin in Chinese HIV/TB Co-Infection Patients. Infect Drug Resist 2023; 16:4659-4666. [PMID: 37484907 PMCID: PMC10361278 DOI: 10.2147/idr.s415749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/01/2023] [Indexed: 07/25/2023] Open
Abstract
Background Rifampicin is a known inducer of the cytochrome P450 (CYP2B6) enzyme, which can lead to a decrease in the concentration of efavirenz. Therefore, we conducted a study to evaluate the effect of daily rifampicin intake on efavirenz 600mg pharmacokinetics and HIV-1 virological suppression. Methods Patients receiving antiretroviral therapy containing efavirenz (600mg daily), and we collected efavirenz concentration at four visit points: ART day 14 (PK1), ART day 42 (PK2), ART day 140 (PK3), and ART day 336 (PK4), and performed pharmacokinetics analysis. Results From February 2017 to November 2020, 29 HIV/TB co-infection patients were included. Ninety percent of patients had a concentration of ≥1000ng/mL of efavirenz during the study. All patients had efavirenz Cmax ≥1000ng/mL, 86% patients showed good virology response. Conclusion Our study shows that the use of rifampicin in HIV/TB co-infection patients does not affect efavirenz drug concentrations, that virological suppression is good and that no efavirenz dose adjustment is required.
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Affiliation(s)
- Tongtong Wang
- Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yingchu Liu
- School of General Practice and Continuing Education, Capital Medical University, Beijing, People’s Republic of China
| | - Chunyu Zhu
- Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Siyuan Yang
- Laboratory of Infectious Diseases Center, Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Di Yang
- Clinical and Research Center of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jiang Xiao
- Clinical and Research Center of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Guiju Gao
- Clinical and Research Center of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, People’s Republic of China
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Munsami L, Schutte CM, de Villiers M, Hiesgen J. Late-onset efavirenz toxicity: A descriptive study from Pretoria, South Africa. South Afr J HIV Med 2023; 24:1439. [PMID: 36751478 PMCID: PMC9900310 DOI: 10.4102/sajhivmed.v24i1.1439] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/16/2022] [Indexed: 02/04/2023] Open
Abstract
Background The neuropsychiatric side effects of efavirenz occur mainly early during treatment and are usually mild. A lesser-known and serious complication is late-onset efavirenz toxicity causing ataxia and encephalopathy. Data regarding this condition are limited. Objectives We describe the clinical picture of late-onset efavirenz toxicity, investigate co-morbidities and report outcomes. Method This descriptive study of all patients with late-onset efavirenz toxicity was conducted over three years at Kalafong Provincial Tertiary Hospital, Pretoria, South Africa. Results Forty consecutive patients were identified. Mean age was 42.1 years, three patients (7.5%) were male and the mean efavirenz level was 49.0 μg/mL (standard deviation [s.d.]: 24.8). Cerebellar ataxia (82.5%) and encephalopathy (47.5%) were the most common presenting features (40.0% had both); four patients presented with psychosis. Presence of encephalopathy and/or cerebellar ataxia was associated with higher efavirenz levels compared with psychosis (52.1 μg/mL, s.d.: 24.1 vs 25.0 μg/mL, s.d.: 17.1). In most patients, symptoms resolved, but four patients (10.0%) died, and one patient remained ataxic. Conclusion Late-onset efavirenz toxicity typically presented with ataxia and encephalopathy, but psychosis can be the presenting feature. The outcome after withdrawal was good, but the mortality of 10.0% is concerning. Recent changes in guidelines favour dolutegravir, but many patients remain on efavirenz, and awareness of the condition is vital. What this study adds This large, single-centre study contributes to the limited data of HIV-positive patients with late-onset efavirenz toxicity and emphasises its ongoing relevance in clinical practice.
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Affiliation(s)
- Lyneshree Munsami
- Department of Neurology, Faculty of Health Science, University of Pretoria, Pretoria, South Africa
| | - Clara M. Schutte
- Department of Neurology, Faculty of Health Science, University of Pretoria, Pretoria, South Africa
| | - Maryke de Villiers
- Department of Internal Medicine, Faculty of Health Science, University of Pretoria, Pretoria, South Africa
| | - Juliane Hiesgen
- Department of Neurology, Faculty of Health Science, University of Pretoria, Pretoria, South Africa
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Munsami L, Schutte CM, de Villiers M, Hiesgen J. Late-onset efavirenz toxicity: A descriptive study from Pretoria, South Africa. South Afr J HIV Med 2022. [DOI: 10.4102/sajhivmed.v23i1.1439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Griesel R, Kawuma AN, Wasmann R, Sokhela S, Akpomiemie G, Venter WDF, Wiesner L, Denti P, Sinxadi P, Maartens G. CONCENTRATION-RESPONSE RELATIONSHIPS OF DOLUTEGRAVIR AND EFAVIRENZ WITH WEIGHT CHANGE AFTER STARTING ANTIRETROVIRAL THERAPY. Br J Clin Pharmacol 2021; 88:883-893. [PMID: 34954840 PMCID: PMC7612404 DOI: 10.1111/bcp.15177] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/28/2021] [Accepted: 12/01/2021] [Indexed: 12/03/2022] Open
Abstract
Aim Dolutegravir is associated with more weight gain than efavirenz in people starting antiretroviral therapy (ART). We investigated the concentration-response relationships of efavirenz and dolutegravir with weight gain. Methods We determined concentration-response relationships of dolutegravir and efavirenz (both combined with tenofovir disoproxil fumarate and emtricitabine) with changes in weight and fat distribution, derived from dual-energy x-ray absorptiometry scans, in a nested study of ART-naïve participants from a randomised controlled trial. Pharmacokinetic parameters used in analyses were efavirenz mid-dosing interval (MDI) concentrations and estimated dolutegravir area under the concentration-time curve (AUC0-24) using a population pharmacokinetic model developed in the study population. Study outcomes were percentage changes from baseline to week 48 in weight, and visceral and subcutaneous adipose tissue (VAT and SAT) mass. Results Pharmacokinetic data were available for 158 and 233 participants in the efavirenz arm and dolutegravir arms respectively; 57.0% were women. On multivariable linear regression there were independent negative associations between efavirenz concentrations and changes in both weight (P <0.001) and SAT mass (P = 0.002). Estimated dolutegravir AUC0-24 was not associated with change in weight (P = 0.109) but was negatively associated with change in VAT mass (P = 0.025). Conclusion We found an independent negative concentration-response relationship between efavirenz concentrations and weight change in ART-naïve participants. Dolutegravir concentrations were not independently associated with weight change. These findings suggest that weight gain differences between efavirenz and dolutegravir are driven by efavirenz toxicity impairing weight gain rather than by off-target effects of dolutegravir causing weight gain.
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Affiliation(s)
- Rulan Griesel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Aida N Kawuma
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Roeland Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Simiso Sokhela
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Godspower Akpomiemie
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - W D Francois Venter
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Phumla Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Griesel R, Maartens G, Chirehwa M, Sokhela S, Akpomiemie G, Moorhouse M, Venter F, Sinxadi P. CYP2B6 Genotype and Weight Gain Differences Between Dolutegravir and Efavirenz. Clin Infect Dis 2021; 73:e3902-e3909. [PMID: 32960272 PMCID: PMC8653639 DOI: 10.1093/cid/ciaa1073] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 07/25/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Dolutegravir is associated with more weight gain than efavirenz. Loss-of-function polymorphisms in CYP2B6 result in higher efavirenz concentrations, which we hypothesized would impair weight gain among people living with human immunodeficiency virus (HIV; PLWH) starting efavirenz-based antiretroviral therapy (ART). METHODS We studied ART-naive participants from the ADVANCE study randomized to the efavirenz /emtricitabine/tenofovir disoproxil fumarate (TDF) and dolutegravir/emtricitabine/TDF arms. We compared changes in weight and regional fat on DXA from baseline to week 48 between CYP2B6 metabolizer genotypes in the efavirenz arm, and with the dolutegravir arm. RESULTS There were 342 participants in the dolutegravir arm and 168 in the efavirenz arm who consented to genotyping. Baseline characteristics were similar. Weight gain was greater in women than men. In the efavirenz arm CYP2B6 metaboliser genotype was associated with weight gain (P = .009), with extensive metabolizers gaining the most weight, and with changes in regional fat in women, but not in men. Weight gain was similar in CYP2B6 extensive metabolizers in the efavirenz arm and in the dolutegravir arm (P = .836). The following variables were independently associated with weight gain in all participants: baseline CD4 count, baseline human immunodeficiency virus type 1 (HIV-1) RNA, and CYP2B6 metaboliser genotype. CONCLUSIONS CYP2B6 metaboliser genotype was associated with weight gain in PLWH starting efavirenz-based ART. Weight gain was similar between CYP2B6 extensive metabolizers in the efavirenz arm and in the dolutegravir arm, suggesting that impaired weight gain among CYP2B6 slow or intermediate metabolizers could explain the increased weight gain on dolutegravir compared with efavirenz observed in ADVANCE and other studies.
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Affiliation(s)
- Rulan Griesel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Maxwell Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Simiso Sokhela
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Godspower Akpomiemie
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michelle Moorhouse
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Francois Venter
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Phumla Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Atwine D, Baudin E, Gelé T, Muyindike W, Mworozi K, Kyohairwe R, Kananura K, Orikiriza P, Nyehangane D, K T Nanjebe D, Furlan V, Verstuyft C, Barrail-Tran A, Taburet AM, Bonnet M. Effect of high-dose rifampicin on efavirenz pharmacokinetics: drug-drug interaction randomized trial. J Antimicrob Chemother 2021; 75:1250-1258. [PMID: 31999314 DOI: 10.1093/jac/dkz557] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 11/09/2019] [Accepted: 12/11/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND High-dose rifampicin is considered to shorten anti-TB treatment duration but its effect on antiretroviral metabolism is unknown. OBJECTIVES To assess the effect of doubling the rifampicin dose (to 20 mg/kg/day, R20) on efavirenz pharmacokinetics (PK) in HIV/TB coinfected patients. METHODS Open-label Phase 2 drug-drug interaction randomized trial. Pulmonary TB, ART-naive adults were randomized to R20 and either efavirenz 600 mg (EFV600) or 800 mg (EFV800), or rifampicin 10 mg/kg/day (R10) and EFV600 with a 1:1:1 ratio. Patients were first started on TB treatment and 2-4 weeks later started on ART. They were switched to R10 and EFV600 after 8 weeks. Full PK sampling was done 4 weeks (on rifampicin) and 24 weeks (off rifampicin) after ART initiation. Transaminases, plasma HIV-1 RNA and sputum cultures were monitored. The efavirenz geometric mean ratio (GMR) of AUC at 4 and 24 weeks after ART initiation within the same patient was calculated in each arm and its 90% CI was compared with a preset range (0.70-1.43). RESULTS Of 98 enrolled patients (32 in the R20EFV600 arm, 33 in the R20EFV800 arm and 33 in the R10EFV600 arm), 87 had full PK sampling. For the R20EFV600, R20EFV800 and R10EFV600 arms, GMRs of efavirenz AUC were 0.87 (90% CI: 0.75-1.00), 1.12 (90% CI: 0.96-1.30) and 0.96 (90% CI: 0.84-1.10). Twelve weeks after ART initiation, 78.6%, 77.4% and 72.4% of patients had HIV-1 RNA below 100 copies/mL and 85.7%, 86.7% and 80.0% had Week 8 culture conversion, respectively. Two patients per arm experienced a severe increase in transaminases. CONCLUSIONS Doubling the rifampicin dose had a small effect on efavirenz concentrations and was well tolerated.
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Affiliation(s)
- Daniel Atwine
- Epicentre, PO Box 1956, Mbarara, Uganda.,Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda.,University Montpellier, Montpellier, France
| | | | - Thibaut Gelé
- Bicêtre hospital, Assistance Publique Hôpitaux de Paris, 78 Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | | | | | | | | | - Patrick Orikiriza
- Epicentre, PO Box 1956, Mbarara, Uganda.,Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda
| | | | | | - Valérie Furlan
- Bicêtre hospital, Assistance Publique Hôpitaux de Paris, 78 Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Céline Verstuyft
- CESP, Team 'Moods', Faculty of Medicine Paris-Saclay, University Paris-Saclay, INSERM, Le Kremlin Bicêtre, France.,Molecular Genetics, Pharmacogenetics and Hormonology department, Paris-Saclay university hospitals, AP-HP, Le Kremlin Bicêtre, F-94275, France
| | - Aurélie Barrail-Tran
- Bicêtre hospital, Assistance Publique Hôpitaux de Paris, 78 Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France.,UMR1184, Université Paris-Sud, France.,Paris Sud university, Faculty of Pharmacy, 5 rue Jean Baptiste Clément, 92290 Chatenay Malabry, France
| | - Anne-Marie Taburet
- Bicêtre hospital, Assistance Publique Hôpitaux de Paris, 78 Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France.,UMR1184, Université Paris-Sud, France
| | - Maryline Bonnet
- Epicentre, PO Box 1956, Mbarara, Uganda.,IRD UMI233, INSERM U1175, University Montpellier, Montpellier, France
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Influence of selected polymorphisms in disposition genes on lumefantrine pharmacokinetics when coadministered with efavirenz. Pharmacogenet Genomics 2021; 30:96-106. [PMID: 32209837 DOI: 10.1097/fpc.0000000000000401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Coadministration of artemether-lumefantrine and efavirenz has been shown to result in significant interactions. The influence of functional genetic polymorphisms in selected CYPs on the magnitude of this interaction was investigated in pregnant and nonpregnant adults. METHOD A standard 3-day regimen of artemether-lumefantrine was administered to each patient on steady-state efavirenz-based antiretroviral therapy (ART). Pharmacokinetic parameters were obtained from intensive plasma concentration-time data. Genotyping data were tested for compliance with Hardy-Weinberg equilibrium by Chi-square test. Linear regressions, Mann-Whitney U-test or Kruskal-Wallis tests were conducted to examine the association of lumefantrine plasma level with CYP2B6 c.516G>T, NR1I3 152c-1089T>C, CYP2B6 c.983T>C, CYP3A5*3 and CYP3A4*22. RESULTS Among a total of 69 malaria-HIV coinfected patients (34 nonpregnant and 35 pregnant), median (interquartile range) age was 33 (27-36.5) years and body weight was 59.5 (50-67.5) kg. In nonpregnant group, CYP2B6 c.516G>T was significantly associated with lower log Cday 7 of lumefantrine using multivariate linear regressions (β = -0.239; P = 0.013). In 59% of women with CYP2B6 c.516T, Cday 7 of lumefantrine was below the target of 280 ng/mL compared to 47% in the noncarriers. CYP2B6 c.983T>C significantly associated with higher log Cday 7 of desbutyl lumefantrine in both pregnant (β = 0.383; P = 0.033) and nonpregnant (β = 0.395; P = 0.023) groups. Composite genotypes for both CYP2B6 Single-nucleotide polymorphisms strongly associated with lumefantrine plasma concentration. An associative trend between lumefantrine pharmacokinetics and NR1I3 152c-1089T>C genotypes indicated that 70% of the Cday 7 of lumefantrine in those with NR1I3 152c-1089TT genotype was below 280 ng/mL compared to 53% in those with NR1I3 152c-1089CC or CT genotype. CONCLUSION The findings revealed that the efavirenz-lumefantrine interaction was accentuated in the group with CYP2B6 c.516T, c.983C and NR1I3 152c-1089T alleles. This warrants further investigations of other drug-drug interactions for optimising dosing in genetically defined subgroups, particularly during drug development.
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Jacobs TG, Svensson EM, Musiime V, Rojo P, Dooley KE, McIlleron H, Aarnoutse RE, Burger DM, Turkova A, Colbers A. Pharmacokinetics of antiretroviral and tuberculosis drugs in children with HIV/TB co-infection: a systematic review. J Antimicrob Chemother 2020; 75:3433-3457. [PMID: 32785712 PMCID: PMC7662174 DOI: 10.1093/jac/dkaa328] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/29/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Management of concomitant use of ART and TB drugs is difficult because of the many drug-drug interactions (DDIs) between the medications. This systematic review provides an overview of the current state of knowledge about the pharmacokinetics (PK) of ART and TB treatment in children with HIV/TB co-infection, and identifies knowledge gaps. METHODS We searched Embase and PubMed, and systematically searched abstract books of relevant conferences, following PRISMA guidelines. Studies not reporting PK parameters, investigating medicines that are not available any longer or not including children with HIV/TB co-infection were excluded. All studies were assessed for quality. RESULTS In total, 47 studies met the inclusion criteria. No dose adjustments are necessary for efavirenz during concomitant first-line TB treatment use, but intersubject PK variability was high, especially in children <3 years of age. Super-boosted lopinavir/ritonavir (ratio 1:1) resulted in adequate lopinavir trough concentrations during rifampicin co-administration. Double-dosed raltegravir can be given with rifampicin in children >4 weeks old as well as twice-daily dolutegravir (instead of once daily) in children older than 6 years. Exposure to some TB drugs (ethambutol and rifampicin) was reduced in the setting of HIV infection, regardless of ART use. Only limited PK data of second-line TB drugs with ART in children who are HIV infected have been published. CONCLUSIONS Whereas integrase inhibitors seem favourable in older children, there are limited options for ART in young children (<3 years) receiving rifampicin-based TB therapy. The PK of TB drugs in HIV-infected children warrants further research.
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Affiliation(s)
- Tom G Jacobs
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - Elin M Svensson
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Victor Musiime
- Research Department, Joint Clinical Research Centre, Kampala, Uganda
- Department of Paediatrics and Child Health, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Pablo Rojo
- Pediatric Infectious Diseases Unit. Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Kelly E Dooley
- Divisions of Clinical Pharmacology and Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rob E Aarnoutse
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - David M Burger
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - Anna Turkova
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Angela Colbers
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
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Alghamdi WA, Antwi S, Enimil A, Yang H, Dompreh A, Wiesner L, Langaee T, Peloquin CA, Kwara A. Population pharmacokinetics of efavirenz in HIV and TB/HIV coinfected children: the significance of genotype-guided dosing. J Antimicrob Chemother 2020; 74:2698-2706. [PMID: 31243456 DOI: 10.1093/jac/dkz238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/12/2019] [Accepted: 05/06/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES The current WHO weight-based dosing recommendations for efavirenz result in a wide variability of drug exposure in children. Our objectives are to characterize the effects of rifampicin- and isoniazid-containing anti-TB therapy and CYP2B6 activity on efavirenz concentrations in children, using non-linear mixed-effects modelling. METHODS This is a pharmacokinetic (PK) substudy of a prospective study that examined the interactions between anti-TB therapy and efavirenz in HIV-infected children with and without TB. PK samples were obtained 4 weeks after starting efavirenz (PK1) and repeated 4 weeks after completing TB therapy (PK2) in TB/HIV coinfected patients. Drug concentrations were measured using LC-MS/MS. Composite CYP2B6 516/983/15582 genotype was determined. Population PK modelling was performed in Monolix. Simulations were performed to obtain the predicted mid-dose concentrations (C12). RESULTS One hundred and five HIV-infected Ghanaian children (46 with TB/HIV) were included. The median age and weight were 7 years and 19 kg. The efavirenz concentrations over time were adequately described using a one-compartment model. Weight, composite CYP2B6 genotype and PK visit had a significant influence on the PK parameters, while TB therapy had no significant effect. Simulations showed adequate C12 for intermediate composite CYP2B6 metabolizers only. CONCLUSIONS Our model showed that rifampicin- and isoniazid-containing anti-TB therapy does not influence efavirenz PK parameters. On the other hand, it describes the effect of efavirenz autoinduction after completing TB treatment. In addition, dosing efavirenz in children based only on weight results in a large variability in drug exposure. We propose dose adjustments for slow and extensive composite CYP2B6 metabolizers.
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Affiliation(s)
- Wael A Alghamdi
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, Saudi Arabia
| | - Sampson Antwi
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana.,Department of Child Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Anthony Enimil
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana.,Department of Child Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Hongmei Yang
- Department of Biostatistics and Computational Biology, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Albert Dompreh
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Taimour Langaee
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Charles A Peloquin
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Awewura Kwara
- College of Medicine and Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
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12
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Meintjes G, Brust JCM, Nuttall J, Maartens G. Management of active tuberculosis in adults with HIV. Lancet HIV 2020; 6:e463-e474. [PMID: 31272663 DOI: 10.1016/s2352-3018(19)30154-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 04/25/2019] [Accepted: 05/08/2019] [Indexed: 12/11/2022]
Abstract
Every year, about 1 million people living with HIV worldwide develop tuberculosis. Although the drug regimens used to treat tuberculosis in these patients are the same as those used in HIV-negative patients, cotreatment of tuberculosis with antiretroviral therapy involves challenges including the optimal timing of antiretroviral initiation, drug-drug interactions, drug tolerability, and the prevention and treatment of tuberculosis-associated immune reconstitution syndrome. Furthermore, mortality is high in people with HIV who are diagnosed with tuberculosis during a hospital admission, and in those with tuberculous meningitis. Studies in this field have better characterised these challenges and informed optimal management and guideline revisions. In patients with tuberculosis, antiretroviral therapy improves survival, is well tolerated, and can be adjusted to manage drug-drug interactions with rifampicin. Prednisone is effective in both preventing and treating the paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome.
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Affiliation(s)
- Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, South Africa; Division of Infectious Diseases and HIV Medicine, Department of Medicine, South Africa.
| | - James C M Brust
- University of Cape Town, Observatory, South Africa; Divisions of General Internal Medicine and Infectious Diseases, Albert Einstein College of Medicine, New York, NY, USA
| | - James Nuttall
- Department of Paediatrics and Child Health, South Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, South Africa; Division of Clinical Pharmacology, Department of Medicine, South Africa
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13
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Cerrone M, Bracchi M, Wasserman S, Pozniak A, Meintjes G, Cohen K, Wilkinson RJ. Safety implications of combined antiretroviral and anti-tuberculosis drugs. Expert Opin Drug Saf 2020; 19:23-41. [PMID: 31809218 PMCID: PMC6938542 DOI: 10.1080/14740338.2020.1694901] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/15/2019] [Indexed: 01/01/2023]
Abstract
Introduction: Antiretroviral and anti-tuberculosis (TB) drugs are often co-administered in people living with HIV (PLWH). Early initiation of antiretroviral therapy (ART) during TB treatment improves survival in patients with advanced HIV disease. However, safety concerns related to clinically significant changes in drug exposure resulting from drug-drug interactions, development of overlapping toxicities and specific challenges related to co-administration during pregnancy represent barriers to successful combined treatment for HIV and TB.Areas covered: Pharmacokinetic interactions of different classes of ART when combined with anti-TB drugs used for sensitive-, drug-resistant (DR) and latent TB are discussed. Overlapping drug toxicities, implications of immune reconstitution inflammatory syndrome (IRIS), safety in pregnancy and research gaps are also explored.Expert opinion: New antiretroviral and anti-tuberculosis drugs have been recently introduced and international guidelines updated. A number of effective molecules and clinical data are now available to build treatment regimens for PLWH with latent or active TB. Adopting a systematic approach that also takes into account the need for individualized variations based on the available evidence is the key to successfully integrate ART and TB treatment and improve treatment outcomes.
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Affiliation(s)
- Maddalena Cerrone
- Department of Medicine, Imperial College London, W2 1PG, UK
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory 7925, South Africa
- Department of HIV, Chelsea and Westminster Hospital NHS Trust, London, UK
- Francis Crick Institute, London, NW1 1AT, UK
| | - Margherita Bracchi
- Department of HIV, Chelsea and Westminster Hospital NHS Trust, London, UK
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory 7925, South Africa
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anton Pozniak
- Department of HIV, Chelsea and Westminster Hospital NHS Trust, London, UK
- The London School of Hygiene & Tropical Medicine
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory 7925, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Robert J Wilkinson
- Department of Medicine, Imperial College London, W2 1PG, UK
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory 7925, South Africa
- Francis Crick Institute, London, NW1 1AT, UK
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14
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Metzger IF, Dave N, Kreutz Y, Lu JB, Galinsky RE, Desta Z. CYP2B6 Genotype-Dependent Inhibition of CYP1A2 and Induction of CYP2A6 by the Antiretroviral Drug Efavirenz in Healthy Volunteers. Clin Transl Sci 2019; 12:657-666. [PMID: 31339646 PMCID: PMC6853154 DOI: 10.1111/cts.12671] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/10/2019] [Indexed: 01/11/2023] Open
Abstract
We investigated the effect of efavirenz on the activities of cytochrome P450 (CYP)1A2, CYP2A6, xanthine oxidase (XO), and N-acetyltransferase 2 (NAT2), using caffeine as a probe. A single 150 mg oral dose of caffeine was administered to healthy volunteers (n = 58) on two separate occasions; with a single 600 mg oral dose of efavirenz and after treatment with 600 mg/day efavirenz for 17 days. Caffeine and its metabolites in plasma and urine were quantified using liquid chromatography/tandem-mass spectrometry. DNA was genotyped for CYP2B6*4 (785A>G), CYP2B6*9 (516G>T), and CYP2B6*18 (983T>C) alleles using TaqMan assays. Relative to single-dose efavirenz treatment, multiple doses of efavirenz decreased CYP1A2 (by 38%) and increased CYP2A6 (by 85%) activities (P < 0.05); XO and NAT2 activities were unaffected. CYP2B6*6*6 genotype was associated with lower CYP1A2 activity following both single and multiple doses of efavirenz. No similar association was noted for CYP2A6 activity. This is the first report showing that efavirenz reduces hepatic CYP1A2 and suggesting chronic efavirenz exposure likely enhances the elimination of CYP2A6 substrates. This is also the first to report the extent of efavirenz-CYP1A2 interaction may be efavirenz exposure-dependent and CYP2B6 genotype-dependent.
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Affiliation(s)
- Ingrid F. Metzger
- Division of Clinical PharmacologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Nimita Dave
- Division of Clinical PharmacologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Blueprint MedicinesCambridgeMassachusettsUSA
| | - Yvonne Kreutz
- Division of Clinical PharmacologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Jessica B.L. Lu
- Division of Clinical PharmacologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Raymond E. Galinsky
- Division of Clinical PharmacologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- School of PharmacyPurdue UniversityWest LafayetteIndianaUSA
| | - Zeruesenay Desta
- Division of Clinical PharmacologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
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15
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Desta Z, Gammal RS, Gong L, Whirl-Carrillo M, Gaur AH, Sukasem C, Hockings J, Myers A, Swart M, Tyndale RF, Masimirembwa C, Iwuchukwu OF, Chirwa S, Lennox J, Gaedigk A, Klein TE, Haas DW. Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for CYP2B6 and Efavirenz-Containing Antiretroviral Therapy. Clin Pharmacol Ther 2019; 106:726-733. [PMID: 31006110 DOI: 10.1002/cpt.1477] [Citation(s) in RCA: 113] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/12/2019] [Indexed: 01/11/2023]
Abstract
The HIV type-1 nonnucleoside reverse transcriptase inhibitor, efavirenz, is widely used to treat HIV type-1 infection. Efavirenz is predominantly metabolized into inactive metabolites by cytochrome P450 (CYP)2B6, and patients with certain CYP2B6 genetic variants may be at increased risk for adverse effects, particularly central nervous system toxicity and treatment discontinuation. We summarize the evidence from the literature and provide therapeutic recommendations for efavirenz prescribing based on CYP2B6 genotypes.
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Affiliation(s)
- Zeruesenay Desta
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Roseann S Gammal
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences University School of Pharmacy, Boston, Massachusetts, USA.,Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Li Gong
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | | | - Aditya H Gaur
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Chonlaphat Sukasem
- Division of Pharmacogenomics and Personalized Medicine, Faculty of Medicine Ramathibodi Hospital, Department of Pathology, Mahidol University, Bangkok, Thailand.,Laboratory for Pharmacogenomics, Faculty of Medicine Ramathibodi Hospital, Somdech Phra Debaratana Medical Center, Bangkok, Thailand
| | - Jennifer Hockings
- Department of Pharmacy and Genomic Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alan Myers
- Department of Diagnostic & Biomedical Sciences, The University of Texas Health Sciences Center School of Dentistry, Houston, Texas, USA
| | - Marelize Swart
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachel F Tyndale
- Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Collen Masimirembwa
- African Institute of Biomedical Science & Technology, Wilkins Hospital, Harare, Zimbabwe
| | - Otito F Iwuchukwu
- Division of Pharmaceutical Sciences, Fairleigh Dickinson University School of Pharmacy, Florham Park, New Jersey, USA
| | - Sanika Chirwa
- Department of Internal Medicine, Meharry Medical College School of Medicine, Nashville, Tennessee, USA
| | - Jeffrey Lennox
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology, & Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - David W Haas
- Department of Internal Medicine, Meharry Medical College School of Medicine, Nashville, Tennessee, USA.,Departments of Medicine, Pharmacology, Pathology, Microbiology, & Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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16
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Charbe NB, Zacconi FC, Amnerkar N, Ramesh B, Tambuwala MM, Clementi E. Bio-analytical Assay Methods used in Therapeutic Drug Monitoring of Antiretroviral Drugs-A Review. CURRENT DRUG THERAPY 2019. [DOI: 10.2174/1574885514666181217125550] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Several clinical trials, as well as observational statistics, have exhibited that the advantages of antiretroviral [ARV] treatment for humans with Human Immunodeficiency Virus / Acquired Immune Deficiency Syndrome HIV/AIDS exceed their risks. Therapeutic drug monitoring [TDM] plays a key role in optimization of ARV therapy. Determination of ARV’s in plasma, blood cells, and other biological matrices frequently requires separation techniques capable of high effectiveness, specific selectivity and high sensitivity. High-performance liquid chromatography [HPLC] coupled with ultraviolet [UV], Photodiode array detectors [PDA], Mass spectrophotometer [MS] detectors etc. are the important quantitative techniques used for the estimation of pharmaceuticals in biological samples. </P><P> Objective: This review article is aimed to give an extensive outline of different bio-analytical techniques which have been reported for direct quantitation of ARV’s. This article aimed to establish an efficient role played by the TDM in the optimum therapeutic outcome of the ARV treatment. It also focused on establishing the prominent role played by the separation techniques like HPLC and UPLC along with the detectors like UV and Mass in TDM. </P><P> Methods: TDM is based on the principle that for certain drugs, a close relationship exists between the plasma level of the drug and its clinical effect. TDM is of no value if the relationship does not exist. The analytical methodology employed in TDM should: 1) distinguish similar compounds; 2) be sensitive and precise and 3) is easy to use. </P><P> Results: This review highlights the advancement of the chromatographic techniques beginning from the HPLC-UV to the more advanced technique like UPLC-MS/MS. TDM is essential to ensure adherence, observe viral resistance and to personalize ARV dose regimens. It is observed that the analytical methods like immunoassays and liquid chromatography with detectors like UV, PDA, Florescent, MS, MS/MS and Ultra performance liquid chromatography (UPLC)-MS/MS have immensely contributed to the clinical outcome of the ARV therapy. Assay methods are not only helping physicians in limiting the side effects and drug interactions but also assisting in monitoring patient’s compliance. </P><P> Conclusion: The present review revealed that HPLC has been the most widely used system irrespective of the availability of more sensitive chromatographic technique like UPLC.
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Affiliation(s)
- Nitin B. Charbe
- Departamento de Quimica Organica, Facultad de Quimica y de Farmacia, Pontificia Universidad Catolica de Chile, Av. Vicuna McKenna 4860, Macul, Santiago 7820436, Chile
| | - Flavia C. Zacconi
- Departamento de Quimica Organica, Facultad de Quimica y de Farmacia, Pontificia Universidad Catolica de Chile, Av. Vicuna McKenna 4860, Macul, Santiago 7820436, Chile
| | - Nikhil Amnerkar
- Adv V. R. Manohar Institute of Diploma in Pharmacy, Wanadongri, Hingna Road, Nagpur, Maharashtra 441110, India
| | - B. Ramesh
- Sri Adichunchunagiri University, Sri Adichunchunagiri College of Pharmacy, BG Nagar, Karnataka 571418, India
| | - Murtaza M. Tambuwala
- School of Pharmacy and Pharmaceutical Science, University of Ulster, Coleraine, County Londonderry, Northern Ireland BT52 1SA, United Kingdom
| | - Emilio Clementi
- Clinical Pharmacology Unit, CNR Institute of Neuroscience, Department of Biomedical and Clinical Sciences, Luigi Sacco University Hospital, Universita di Milano, Milan, Italy
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17
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Kwara A, Yang H, Antwi S, Enimil A, Gillani FS, Dompreh A, Ortsin A, Opoku T, Bosomtwe D, Sarfo A, Wiesner L, Norman J, Alghamdi WA, Langaee T, Peloquin CA, Court MH, Greenblatt DJ. Effect of Rifampin-Isoniazid-Containing Antituberculosis Therapy on Efavirenz Pharmacokinetics in HIV-Infected Children 3 to 14 Years Old. Antimicrob Agents Chemother 2019; 63:e01657-18. [PMID: 30397066 PMCID: PMC6325194 DOI: 10.1128/aac.01657-18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 10/24/2018] [Indexed: 12/23/2022] Open
Abstract
We compared efavirenz pharmacokinetic (PK) parameters in children with tuberculosis (TB)/human immunodeficiency virus (HIV) coinfection on and off first-line antituberculosis therapy to that in HIV-infected children. Children 3 to 14 years old with HIV infection, with and without TB, were treated with standard efavirenz-based antiretroviral therapy without any efavirenz dose adjustments. The new World Health Organization-recommended antituberculosis drug dosages were used in the coinfected participants. Steady-state efavirenz concentrations after 4 weeks of antiretroviral therapy were measured using validated liquid chromatography with tandem mass spectrometry (LC-MS/MS) assays. Pharmacokinetic parameters were calculated using noncompartmental analysis. Between groups, PK parameters were compared by Wilcoxon rank-sum test and within group by signed-rank test. Of the 105 participants, 43 (41.0%) had TB coinfection. Children with TB/HIV coinfection compared to those with HIV infection were younger, had lower median weight-for-age Z score, and received a higher median efavirenz weight-adjusted dose. Geometric mean (GM) efavirenz peak concentration (Cmax), concentration at 12 h (C12h), Cmin, and total area under the curve from time 0 to 24 h (AUC0-24h) values were similar in children with HIV infection and those with TB/HIV coinfection during anti-TB therapy. Geometric mean efavirenz C12h, Cmin, and AUC0-24h values were lower in TB/HIV-coinfected patients off anti-TB therapy than in the children with HIV infection or TB/HIV coinfection on anti-TB therapy. Efavirenz clearance was lower and AUC0-24h was higher on than in patients off anti-TB therapy. Reduced efavirenz clearance by first-line anti-TB therapy at the population level led to similar PK parameters in HIV-infected children with and without TB coinfection. Our findings do not support modification of efavirenz weight-band dosing guidelines based on TB coinfection status in children. (The study was registered with ClinicalTrials.gov under registration number NCT01704144.).
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Affiliation(s)
- Awewura Kwara
- College of Medicine and Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
| | - Hongmei Yang
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sampson Antwi
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
- Department of Child Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Anthony Enimil
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
- Department of Child Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Fizza S Gillani
- Deaprtment of Medicine, The Miriam Hospital, Providence, Rhode Island, USA
| | - Albert Dompreh
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Antoinette Ortsin
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Theresa Opoku
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Dennis Bosomtwe
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Anima Sarfo
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jennifer Norman
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Wael A Alghamdi
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, Saudi Arabia
| | - Taimour Langaee
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Charles A Peloquin
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Michael H Court
- Program in Individualized Medicine, Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington, USA
| | - David J Greenblatt
- Graduate Program in Pharmacology and Experimental Therapeutics, Sackler School of Graduate Biomedical Sciences and Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, Boston, Massachusetts, USA
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18
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Atwine D, Bonnet M, Taburet AM. Pharmacokinetics of efavirenz in patients on antituberculosis treatment in high human immunodeficiency virus and tuberculosis burden countries: A systematic review. Br J Clin Pharmacol 2018; 84:1641-1658. [PMID: 29624706 DOI: 10.1111/bcp.13600] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/07/2018] [Accepted: 03/26/2018] [Indexed: 12/12/2022] Open
Abstract
AIMS Efavirenz (EFV) and rifampicin-isoniazid (RH) are cornerstone drugs in human immunodeficiency virus (HIV)-tuberculosis (TB) coinfection treatment but with complex drug interactions, efficacy and safety challenges. We reviewed recent data on EFV and RH interaction in TB/HIV high-burden countries. METHODS We conducted a systematic review of studies conducted in the high TB/HIV-burden countries between 1990 and 2016 on EFV pharmacokinetics during RH coadministration in coinfected patients. Two reviewers conducted article screening and data collection. RESULTS Of 119 records retrieved, 22 were included (two conducted in children), reporting either EFV mid-dose or pre-dose concentrations. In 19 studies, median or mean concentrations of RH range between 1000 and 4000 ng ml-1 , the so-called therapeutic range. The proportion of patients with subtherapeutic concentration of RH ranged between 3.1 and 72.2%, in 12 studies including one conducted in children. The proportion of patients with supratherapeutic concentration ranged from 19.6 to 48.0% in six adult studies and one child study. Five of eight studies reported virological suppression >80%. The association between any grade hepatic and central nervous system adverse effects with EFV/RH interaction was demonstrated in two and three studies, respectively. The frequency of the CYP2B6 516G > T polymorphism ranged from 10 to 28% and was associated with higher plasma EFV concentrations, irrespective of ethnicity. CONCLUSIONS Anti-TB drug coadministration minimally affect the EFV exposure, efficacy and safety among TB-HIV coinfected African and Asian patients. This supports the current 600 mg EFV dosing when coadministered with anti-TB drugs.
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Affiliation(s)
- Daniel Atwine
- Epicentre Mbarara Research Centre, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda.,University of Montpellier, Montpellier, France
| | - Maryline Bonnet
- Epicentre Mbarara Research Centre, Mbarara, Uganda.,IRD UMI233 TransVIHMI-INSERM U1175, Montpellier, France.,University of Montpellier, Montpellier, France
| | - Anne-Marie Taburet
- Bicetre hospital, Paris, France.,UMR 1184, INSERM, CEA, Université Paris-Sud
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19
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Abstract
BACKGROUND Tuberculosis (TB) is the major cause of mortality in HIV-infected children globally. Current guidelines about the management of antiretroviral therapy in children with TB are based on a limited number of nonrandomized studies involving small numbers of participants. The aim of the study was to systematically retrieve and critically appraise available evidence on the efficacy and safety of different antiretroviral regimens in children with HIV infection who are receiving treatment for active TB. METHODS We conducted a systematic review of the literature according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Records were retrieved through March 2016 from Medline, Embase and manual screening of key conference proceedings. Four specific research questions assessing available treatment options were defined. RESULTS Although 4 independent searches were conducted (1 for each Population, Intervention, Comparator, Outcomes question), results were elaborated and interpreted together because of significant overlap among the retrieved records. Six observational studies were selected for qualitative synthesis while meta-analysis could not be performed. CONCLUSION Evidence for optimal treatment options for HIV/TB coinfected children is limited. As the global community strives to reach the fast-track HIV treatment targets and eliminate childhood TB deaths, it must ensure that coinfected children are included in key treatment studies and expand this neglected but crucial area of research.
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20
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Compatibility of next-generation first-line antiretrovirals with rifampicin-based antituberculosis therapy in resource limited settings. Curr Opin HIV AIDS 2018; 12:355-358. [PMID: 28403028 DOI: 10.1097/coh.0000000000000376] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Reduced dose efavirenz, dolutegravir, and/or tenofovir alafenamide (TAF) are likely to be used in the next generation of first-line antiretroviral therapy in resource limited settings, where HIV-associated tuberculosis is common. Rifampicin, which is a key component of first-line antituberculosis therapy, is a potent inducer of many drug transporters and metabolising enzymes. We reviewed the literature for potential or actual drug--drug interactions between these antiretrovirals and rifampicin. RECENT FINDINGS Dose adjustments of standard dose efavirenz are not necessary with rifampicin, because auto-induction of CYP2B6 by efavirenz counteracts the induction of rifampicin. However, patients with extensive metabolizer CYP2B6 genotypes have lower efavirenz concentrations and may have less auto-induction of CYP2B6; the additive inducing effects of rifampicin on CYP2B6 could result in clinically significant reductions of efavirenz concentrations. Doubling the dose of dolutegravir overcomes induction by rifampicin. TAF is more prone to be the victim in drug--drug interactions than tenofovir disoproxil fumarate. Interactions between TAF and rifampicin have not been studied, but there is likely to be significant interaction. SUMMARY Further research on drug--drug interactions between rifampicin and the next generation of first-line antiretrovirals will be needed before they can be recommended in patients with HIV-associated tuberculosis.
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Multiphenotype association study of patients randomized to initiate antiretroviral regimens in AIDS Clinical Trials Group protocol A5202. Pharmacogenet Genomics 2017; 27:101-111. [PMID: 28099408 PMCID: PMC5285297 DOI: 10.1097/fpc.0000000000000263] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Supplemental Digital Content is available in the text. Background High-throughput approaches are increasingly being used to identify genetic associations across multiple phenotypes simultaneously. Here, we describe a pilot analysis that considered multiple on-treatment laboratory phenotypes from antiretroviral therapy-naive patients who were randomized to initiate antiretroviral regimens in a prospective clinical trial, AIDS Clinical Trials Group protocol A5202. Participants and methods From among 5 9545 294 polymorphisms imputed genome-wide, we analyzed 2544, including 2124 annotated in the PharmGKB, and 420 previously associated with traits in the GWAS Catalog. We derived 774 phenotypes on the basis of context from six variables: plasma atazanavir (ATV) pharmacokinetics, plasma efavirenz (EFV) pharmacokinetics, change in the CD4+ T-cell count, HIV-1 RNA suppression, fasting low-density lipoprotein-cholesterol, and fasting triglycerides. Permutation testing assessed the likelihood of associations being by chance alone. Pleiotropy was assessed for polymorphisms with the lowest P-values. Results This analysis included 1181 patients. At P less than 1.5×10−4, most associations were not by chance alone. Polymorphisms with the lowest P-values for EFV pharmacokinetics (CYPB26 rs3745274), low-density lipoprotein -cholesterol (APOE rs7412), and triglyceride (APOA5 rs651821) phenotypes had been associated previously with those traits in previous studies. The association between triglycerides and rs651821 was present with ATV-containing regimens, but not with EFV-containing regimens. Polymorphisms with the lowest P-values for ATV pharmacokinetics, CD4 T-cell count, and HIV-1 RNA phenotypes had not been reported previously to be associated with that trait. Conclusion Using data from a prospective HIV clinical trial, we identified expected genetic associations, potentially novel associations, and at least one context-dependent association. This study supports high-throughput strategies that simultaneously explore multiple phenotypes from clinical trials’ datasets for genetic associations.
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Plasma Efavirenz Exposure, Sex, and Age Predict Virological Response in HIV-Infected African Children. J Acquir Immune Defic Syndr 2017; 73:161-8. [PMID: 27116047 PMCID: PMC5172513 DOI: 10.1097/qai.0000000000001032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Owing to insufficient evidence in children, target plasma concentrations of efavirenz are based on studies in adults. Our analysis aimed to evaluate the pediatric therapeutic thresholds and characterize the determinants of virological suppression in African children. METHODS We analyzed data from 128 African children (aged 1.7-13.5 years) treated with efavirenz, lamivudine, and one among abacavir, stavudine, or zidovudine, and followed up to 36 months. Individual pharmacokinetic (PK) measures [plasma concentration 12 hours after dose (C12h), plasma concentration 24 hours after dose (C24h), and area under the curve (AUC0-24)] were estimated using population PK modeling. Cox multiple failure regression and multivariable fractional polynomials were used to investigate the risks of unsuppressed viral load associated with efavirenz exposure and other factors among 106 initially treatment-naive children, and likelihood profiling was used to identify the most predictive PK thresholds. RESULTS The risk of viral load >100 copies per milliliter decreased by 42% for every 2-fold increase in efavirenz mid-dose concentration [95% confidence interval (CI): 23% to 57%; P < 0.001]. The most predictive PK thresholds for increased risk of unsuppressed viral load were C12h 1.12 mg/L [hazard ratio (HR): 6.14; 95% CI: 2.64 to 14.27], C24h 0.65 mg/L (HR: 6.57; 95% CI: 2.86 to 15.10), and AUC0-24 28 mg·h/L (HR: 5.77; 95% CI: 2.28 to 14.58). Children older than 8 years had a more than 10-fold increased risk of virological nonsuppression (P = 0.005); among children younger than 8 years, boys had a 5.31 times higher risk than girls (P = 0.007). Central nervous system adverse events were infrequently reported. CONCLUSIONS Our analysis suggests that the minimum target C24h and AUC0-24 could be lowered in children. Our findings should be confirmed in a prospective pediatric trial.
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Wang Y, Xiang X, Wu SQ, Chen G, Zhang MM, Wang MG, Wang FJ, Sandford AJ, He JQ. Association of CYP2B6 gene polymorphisms and anti-tuberculosis drug-induced hepatotoxicity in a Chinese population. INFECTION GENETICS AND EVOLUTION 2017; 51:198-202. [PMID: 28389387 DOI: 10.1016/j.meegid.2017.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 03/25/2017] [Accepted: 04/01/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Antituberculosis drug-induced hepatotoxicity (ATDH) remains a common and severe challenge in tuberculosis (TB) chemotherapy. A growing number of studies have revealed that genetic polymorphisms affect an individual's susceptibility to ATDH. The aim of this study was to explore the role of cytochrome P450 family 2 subfamily B member 6 (CYP2B6) gene polymorphisms in the development of ATDH in Chinese TB patients. METHODS CYP2B6*6 genotypes were determined in TB patients with and without ATDH. Association between polymorphisms and risk of ATDH was estimated by multiple logistic regression analysis. RESULTS A total of 343 eligible TB patients (166 with ATDH; 177 without ATDH) were included in this study. Analysis of all subjects revealed no statistical differences in genotype distribution between the two groups. However, the CYP2B6 *6/*6 genotype was significantly associated with decreased risk of ATDH in the male subgroup (P=0.039, OR=0.097, 95% CI: 0.011-0.885). Furthermore, in male patients, the presence of the CYP2B6*6 allele was significantly higher in the non-ATDH group compared with the ATDH group (26.2% vs. 15.5%, P=0.020, OR=0.522, 95% CI: 0.301-0.903). CONCLUSIONS This study is the first to demonstrate an association between CYP2B6 polymorphisms and the risk of ATDH in the Chinese population. We have shown that males who have the CYP2B6 *6/*6 genotype may be less susceptible to the development of ATDH. Further studies are required to confirm this genetic association result.
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Affiliation(s)
- Yu Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Xi Xiang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Shou-Quan Wu
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Guo Chen
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Miao-Miao Zhang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Ming-Gui Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Feng-Juan Wang
- Department of Hematology and Research Laboratory of Hematology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Andrew J Sandford
- Centre for Heart Lung Innovation, University of British Columbia and St. Paul's Hospital, Vancouver, BC, Canada
| | - Jian-Qing He
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China.
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Rabie H, Decloedt EH, Garcia-Prats AJ, Cotton MF, Frigati L, Lallemant M, Hesseling A, Schaaf HS. Antiretroviral treatment in HIV-infected children who require a rifamycin-containing regimen for tuberculosis. Expert Opin Pharmacother 2017; 18:589-598. [PMID: 28346018 DOI: 10.1080/14656566.2017.1309023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION In high prevalence settings, tuberculosis and HIV dual infection and co-treatment is frequent. Rifamycins, especially rifampicin, in combination with isoniazid, ethambutol and pyrazinamide are key components of short-course antituberculosis therapy. Areas covered: We reviewed available data, for which articles were identified by a Pubmed search, on rifamycin-antiretroviral interactions in HIV-infected children. Rifamycins have potent inducing effects on phase I and II drug metabolising enzymes and transporters. Antiretroviral medications are often metabolised by the enzymes induced by rifamycins or may suppress specific enzyme activity leading to drug-drug interactions with rifamycins. These may cause significant alterations in their phamacokinetic and pharmacodynamic properties, and sometimes that of the rifamycin. Recommended strategies to adapt to these interactions include avoidance and dose adjustment. Expert opinion: Despite the importance and frequency of tuberculosis as an opportunistic disease in HIV-infected children, current data on the management of co-treated children is based on few studies. We need new strategies to rapidly assess the use of rifamycins, new anti-tuberculosis drugs and antiretroviral drugs together as information on safety and dosing of individual drugs becomes available.
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Affiliation(s)
- Helena Rabie
- a Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences , Stellenbosch University and Tygerberg Hospital , Cape Town , South Africa.,b Children's Infectious Diseases Clinical Research Unit , Stellenbosch University , Cape Town , South Africa
| | - Eric H Decloedt
- c Division of Clinical Pharmacology, Faculty of Medicine and Health Sciences , Stellenbosch University and Tygerberg Hospital , Cape Town , South Africa
| | - Anthony J Garcia-Prats
- d Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences , Stellenbosch University , Cape Town , South Africa
| | - Mark F Cotton
- a Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences , Stellenbosch University and Tygerberg Hospital , Cape Town , South Africa.,b Children's Infectious Diseases Clinical Research Unit , Stellenbosch University , Cape Town , South Africa
| | - Lisa Frigati
- a Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences , Stellenbosch University and Tygerberg Hospital , Cape Town , South Africa.,b Children's Infectious Diseases Clinical Research Unit , Stellenbosch University , Cape Town , South Africa
| | - Marc Lallemant
- e Pediatric HIV Program , Drugs for Neglected Diseases Initiative , Geneva , Switzerland
| | - Anneke Hesseling
- d Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences , Stellenbosch University , Cape Town , South Africa
| | - H Simon Schaaf
- a Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences , Stellenbosch University and Tygerberg Hospital , Cape Town , South Africa.,d Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences , Stellenbosch University , Cape Town , South Africa
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Mouton JP, Cohen K, Maartens G. Key toxicity issues with the WHO-recommended first-line antiretroviral therapy regimen. Expert Rev Clin Pharmacol 2016; 9:1493-1503. [PMID: 27498720 DOI: 10.1080/17512433.2016.1221760] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION WHO recommends tenofovir, efavirenz, and lamivudine or emtricitabine for first-line antiretroviral therapy (ART) in adults, which replaced more toxic regimens using stavudine, zidovudine or nevirapine. Areas covered: We searched Pubmed to identify observational studies and randomized controlled trials reporting toxicity of these antiretrovirals published between 2011 and 2016, and hand-searched abstracts presented at major HIV conferences in 2015 and 2016, focusing on data from sub-Saharan Africa. Tenofovir's nephrotoxicity manifests as mild renal tubular dysfunction (common and of uncertain clinical significance), acute kidney injury (rare), and chronic declining glomerular filtration rate (common). African studies, which include high proportions of patients with renal dysfunction from opportunistic diseases, report population improvement in renal function after starting tenofovir-based ART. Tenofovir modestly decreases bone mineral density, and there is emerging data that this increases fracture risk. Efavirenz commonly causes early self-limiting neuropsychiatric toxicity and hypersensitivity rashes. Recent studies have highlighted its long-term neuropsychiatric effects, notably suicidality and neurocognitive impairment, and metabolic toxicities (dyslipidemia, dysglycemia, and lipoatrophy). We point out the challenges clinicians face in the recognition and attribution of adverse drug reactions. Expert commentary: Tenofovir and efavirenz are generally well tolerated, but both are associated with potentially serious toxicities. Pharmacovigilance systems in resource-limited settings with high HIV burden should be strengthened.
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Affiliation(s)
- Johannes P Mouton
- a Division of Clinical Pharmacology, Department of Medicine , University of Cape Town , Cape Town , South Africa
| | - Karen Cohen
- a Division of Clinical Pharmacology, Department of Medicine , University of Cape Town , Cape Town , South Africa
| | - Gary Maartens
- a Division of Clinical Pharmacology, Department of Medicine , University of Cape Town , Cape Town , South Africa
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Hammond CK, Eley B, Wilmshurst JM. Neuropsychiatric complications of efavirenz in children with HIV infection. Future Virol 2016. [DOI: 10.2217/fvl-2016-0030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Efavirenz is an effective antiretroviral agent widely used as part of first-line regimen in HIV1-infected children and adults. Neuropsychiatric adverse effects are reported in up to 50% of users. These include dizziness, insomnia, abnormal dreams, headache and impaired concentration. The plasma level of efavirenz may be key in the development of these adverse effects. Even among individuals taking recommended doses for weight, the plasma levels vary widely. Genetic polymorphisms leading to different allelic variants of the CYP2B6 enzyme, making some individuals slow metabolizers may play a role. These allelic variants are highest in people of African descent. This report examines the neuropsychiatric adverse effects of efavirenz, and the strength of the data that the product may result in neuronal damage.
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Affiliation(s)
- Charles K Hammond
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa
| | - Brian Eley
- Paediatric Infectious Diseases Unit, Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa
| | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa
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Habtewold A, Aklillu E, Makonnen E, Amogne W, Yimer G, Aderaye G, Bertilsson L, Owen JS, Burhenne J. Long-Term Effect of Rifampicin-Based Anti-TB Regimen Coadministration on the Pharmacokinetic Parameters of Efavirenz and 8-Hydroxy-Efavirenz in Ethiopian Patients. J Clin Pharmacol 2016; 56:1538-1549. [PMID: 27125860 DOI: 10.1002/jcph.756] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 04/20/2016] [Accepted: 04/21/2016] [Indexed: 12/29/2022]
Abstract
We compared the pharmacokinetic (PK) exposure parameters of efavirenz (EFV) and its major inactive metabolite, 8-hydroxy-efavirenz (8-OH-EFV), in an open-label, single-sequence, and parallel design of HIV-infected and tuberculosis (TB)-HIV-coinfected Ethiopian patients in the HIV-TB Pharmagene study with 20 and 33 patients, respectively. Both treatment groups underwent PK sampling following oral 600 mg EFV in week 16 of initiating EFV-based combination antiretroviral therapy. The TB-HIV-coinfected group repeated the PK sampling 8 weeks after stopping rifampin (RIF)-based anti-TB treatment. Between-treatment group analysis indicated no significant effect of RIF-based anti-TB cotreatment on PK exposure parameters of EFV, nor was there a significant effect after controlling for sex or CYP2B6 genotype. However, RIF-based therapy in TB-HIV-coinfected patients had significantly increased 8-OH-EFV PK exposure measures and metabolic ratio relative to HIV-only patients, AUC0-24 greater by 79%. The effect was more prominent in women and CYP2B6*6 carriers in within-sex and CYP2B6 genotype comparisons. Within-subject comparisons for AUC0-24 and Cmax when "on" and "off" RIF-based anti-TB cotreatment showed geometric mean ratios (90% confidence intervals) of 100.5% (98.7%-102.3%) and 100.2% (98.1%-102.4%), respectively, for EFV and 98.6% (95.5%-101.7%-) and 97.6% (92.2%-103.0%), respectively, for 8-OH-EFV. We report no significant influence of RIF-based anti-TB cotherapy on the EFV PK exposure measures. The study also calls for caution related to higher exposure to 8-OH-EFV during simultaneous coadministration of EFV and RIF-based anti-TB regimens, which may be associated with neurotoxicity, particularly in female patients and CYP2B6*6 carriers.
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Affiliation(s)
- Abiy Habtewold
- Department of Pharmaceutical Sciences, School of Pharmacy, Union University, Jackson, TN, USA.,Division of Clinical Pharmacology, Department of Lab Medicine, Karolinska Institutet Hospital Huddinge, Stockholm, Sweden.,Department of Pharmacology, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Eleni Aklillu
- Section of Pharmacogenetics, Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Eyasu Makonnen
- Department of Pharmacology, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Wondwossen Amogne
- Department of Internal Medicine, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Getnet Yimer
- Department of Pharmacology, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Getachew Aderaye
- Department of Internal Medicine, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Leif Bertilsson
- Division of Clinical Pharmacology, Department of Lab Medicine, Karolinska Institutet Hospital Huddinge, Stockholm, Sweden
| | - Joel S Owen
- Department of Pharmaceutical Sciences, School of Pharmacy, Union University, Jackson, TN, USA
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital of Heidelberg, Heidelberg, Germany
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Orrell C, Bienczak A, Cohen K, Bangsberg D, Wood R, Maartens G, Denti P. Effect of mid-dose efavirenz concentrations and CYP2B6 genotype on viral suppression in patients on first-line antiretroviral therapy. Int J Antimicrob Agents 2016; 47:466-72. [PMID: 27211824 DOI: 10.1016/j.ijantimicag.2016.03.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 03/14/2016] [Accepted: 03/28/2016] [Indexed: 01/11/2023]
Abstract
The therapeutic range for efavirenz plasma concentrations is unclear and some studies found no correlation with viral non-suppression. Efavirenz concentrations are variable, driven in part by polymorphisms in CYP2B6. We hypothesised that efavirenz mid-dosing concentrations, together with CYP2B6 metaboliser genotype, could predict viral non-suppression. Participants starting first-line efavirenz-based antiretroviral therapy were monitored for 48 weeks. HIV-RNA and efavirenz mid-dose interval concentrations were determined at Weeks 16 and 48. CYP2B6 metaboliser genotype status was determined by 516G→T and 983T→C polymorphisms. Cox proportional hazards modelling was used to predict viral non-suppression and to determine the most predictive efavirenz mid-dosing concentration threshold. In total, 180 participants were included. Median efavirenz concentrations were 2.3 mg/L (IQR 1.6-4.6 mg/L) and 2.2 mg/L (IQR 1.5-3.9 mg/L) at Weeks 16 and 48, respectively. Moreover, 49 (27.2%), 84 (46.7%) and 39 (21.7%) participants had extensive, intermediate or slow CYP2B6 metaboliser genotype, respectively. Log2 efavirenz concentrations [adjusted hazard ratio (aHR) = 0.77, 95% CI 0.67-0.89] and baseline CD4 cell count (aHR = 0.994, 95% CI 0.989-0.998), but not CYP2B6 genotype, were predictive of viral non-suppression. For every doubling of efavirenz concentration there was a 23% decrease in the hazard of non-suppression. A threshold of 0.7 mg/L was found to be the efavirenz mid-dosing concentration that was most predictive of non-suppression. Mid-dosing efavirenz concentrations are predictive of viral non-suppression, but the currently recommended lower therapeutic limit (1 mg/L) is higher than our finding. Knowledge of CYP2B6 metaboliser genotype is not required for prediction of virological outcomes.
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Affiliation(s)
- Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - Andrzej Bienczak
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - David Bangsberg
- Harvard Medical School, Boston, MA, USA; Massachusetts General Hospital Center for Global Health, Boston, MA, USA; Ragon Institute of Massachusetts General Hospital, Boston, MA, USA
| | - Robin Wood
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Bienczak A, Cook A, Wiesner L, Olagunju A, Mulenga V, Kityo C, Kekitiinwa A, Owen A, Walker AS, Gibb DM, McIlleron H, Burger D, Denti P. The impact of genetic polymorphisms on the pharmacokinetics of efavirenz in African children. Br J Clin Pharmacol 2016; 82:185-98. [PMID: 26991336 PMCID: PMC4917805 DOI: 10.1111/bcp.12934] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/07/2016] [Accepted: 03/10/2016] [Indexed: 01/11/2023] Open
Abstract
Aims Using a model‐based approach, the efavirenz steady‐state pharmacokinetics in African children is characterized, quantifying demographic and genotypic effects on the drug's disposition. Simulations are also conducted allowing prediction of optimized doses of efavirenz in this population. Methods We modelled the steady‐state population pharmacokinetics of efavirenz in Ugandan and Zambian children using nonlinear mixed‐effects modelling. Individual mid‐dose efavirenz concentrations were derived and simulations explored genotype‐based dose optimization strategies. Results A two‐compartment model with absorption through transit compartments well described 2086 concentration‐time points in 169 children. The combined effect of single nucleotide polymorphisms (SNPs) 516G>T and 983T>C explained 44.5% and 14.7% of the variability in efavirenz clearance and bioavailability, respectively. The detected frequencies of composite CYP2B6 genotype were 0.33 for 516GG|983TT, 0.35 for 516GT|983TT, 0.06 for 516GG|983TC, 0.18 for 516TT|983TT, 0.07 516GT|983TC and 0.01 for 516GG|983CC. The corresponding estimated clearance rates were 6.94, 4.90, 3.93, 1.92, 1.36, and 0.74 l h−1 for a 15.4 kg child and median (95% CI) observed mid‐dose concentrations 1.55 (0.51–2.94), 2.20 (0.97–4.40), 2.03 (1.19–4.53), 7.55 (2.40–14.74), 7.79 (3.66–24.59) and 18.22 (11.84–22.76) mg l−1, respectively. Simulations showed that wild‐type individuals had exposures at the bottom of therapeutic range, while slower metabolizers were overexposed. Conclusions Dosage guidelines for African children should take into consideration the combined effect of SNPs CYP2B6 516G>T and 983T>C.
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Affiliation(s)
- Andrzej Bienczak
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Adrian Cook
- MRC Clinical Trials Unit at University College London, London, UK
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Adeniyi Olagunju
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Veronica Mulenga
- University Teaching Hospital, Department of Paediatrics and Child Health, Lusaka, Zambia
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - Addy Kekitiinwa
- Baylor College of Medicine Bristol Myers Squibb Children's Clinical Centre of Excellence, Kampala, Uganda / Gulu Regional Centre of Excellence, Gulu, Uganda
| | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - A Sarah Walker
- MRC Clinical Trials Unit at University College London, London, UK
| | - Diana M Gibb
- MRC Clinical Trials Unit at University College London, London, UK
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - David Burger
- Department of Pharmacy, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Tuberculosis: opportunities and challenges for the 90-90-90 targets in HIV-infected children. J Int AIDS Soc 2015; 18:20236. [PMID: 26639110 PMCID: PMC4670842 DOI: 10.7448/ias.18.7.20236] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 09/09/2015] [Accepted: 09/25/2015] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION In 2014 the Joint United Nations Programme on HIV/AIDS defined the ambitious 90-90-90 targets for 2020, in which 90% of people living with HIV must be diagnosed, 90% of those diagnosed should be on sustained therapy and 90% of those on therapy should have an undetectable viral load. Children are considered to be a key focus population for these targets. This review will highlight key components of the epidemiology, prevention and treatment of tuberculosis (TB) in HIV-infected children in the era of increasing access to antiretroviral therapy (ART) and their relation to the 90-90-90 targets. DISCUSSION The majority of HIV-infected children live in countries with a high burden of TB. In settings with a high burden of both diseases such as in sub-Saharan Africa, up to 57% of children diagnosed with and treated for TB are HIV-infected. TB results in substantial morbidity and mortality in HIV-infected children, so preventing TB and optimizing its treatment in HIV-infected children will be important to ensuring good long-term outcomes. Prevention of TB can be achieved by increasing access to ART to both children and adults, and appropriate provision of isoniazid preventative therapy. Co-treatment of HIV and TB is complicated by drug-drug interactions particularly due to the use of rifampicin; these may compromise virologic outcomes if appropriate corrective actions are not taken. There remain substantial operational challenges, and improved integration of paediatric TB and HIV services, including with antenatal and routine under-five care, is an important priority. CONCLUSIONS TB may be an important barrier to achievement of the 90-90-90 targets, but specific attention to TB care in HIV-infected children may provide important opportunities to enhance the care of both TB and HIV in children.
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Lancella L, Galli L, Chiappini E, Montagnani C, Gabiano C, Garazzino S, Principi N, Tadolini M, Matteelli A, Battista Migliori G, Villani A, de Martino M, Esposito S. Recommendations Concerning the Therapeutic Approach to Immunocompromised Children With Tuberculosis. Clin Ther 2015; 38:180-90. [PMID: 26548321 DOI: 10.1016/j.clinthera.2015.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 10/07/2015] [Accepted: 10/09/2015] [Indexed: 11/15/2022]
Abstract
PURPOSE This article describes the recommendations of a group of scientific societies concerning the therapeutic approach to immunocompromised children with tuberculosis (TB). METHODS Using the Consensus Conference method, relevant publications in English were identified by a systematic review of MEDLINE and the Cochrane Database of Systematic Reviews from their inception until December 31, 2014. FINDINGS On the basis of their clinical experience and the published evidence, the group of experts concluded that, although immunosuppressed subjects are at greater risk of developing TB, none of the signs or symptoms is sensitive or specific enough to enable a diagnosis. Immunocompromised patients are at greater risk of developing extrapulmonary forms of TB, especially if they are adolescents, whereas pulmonary forms are more prevalent among younger patients. When TB is suspected, a combination of skin and immunologic tests and other clinical, radiologic, and microbiologic examinations can be used to assess the risk of infection or disease. If the TB diagnosis is confirmed, immunocompromised children should be treated by using a standard regimen with a minimum of 4 drugs for at least 9 to 12 months, during which the tolerability of the drugs and their interactions should be carefully evaluated. IMPLICATIONS It is difficult to diagnose and treat TB in immunocompromised children. Thus, all pediatric patients undergoing immunosuppressive therapy who develop TB should be diagnosed and treated at a TB reference center, which should also be responsible for the recommended follow-up.
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Affiliation(s)
- Laura Lancella
- Unit of General Pediatrics and Pediatric Infectious Diseases, IRCCS Bambino Gesù Hospital, Rome, Italy
| | - Luisa Galli
- Pediatric Clinic, Meyer Hospital, University of Florence, Florence, Italy
| | - Elena Chiappini
- Pediatric Clinic, Meyer Hospital, University of Florence, Florence, Italy
| | | | - Clara Gabiano
- Pediatric Infectious Diseases Unit, Regina Margherita Hospital, University of Turin, Turin, Italy
| | - Silvia Garazzino
- Pediatric Infectious Diseases Unit, Regina Margherita Hospital, University of Turin, Turin, Italy
| | - Nicola Principi
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marina Tadolini
- Section of Infectious Diseases, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Alberto Matteelli
- University Division of Infectious and Tropical Diseases, University of Brescia, Brescia, Italy
| | - Giovanni Battista Migliori
- World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy
| | - Alberto Villani
- Unit of General Pediatrics and Pediatric Infectious Diseases, IRCCS Bambino Gesù Hospital, Rome, Italy
| | | | - Susanna Esposito
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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Mukonzo JK, Nanzigu S, Waako P, Ogwal-Okeng J, Gustafson LL, Aklillu E. CYP2B6 genotype, but not rifampicin-based anti-TB cotreatments, explains variability in long-term efavirenz plasma exposure. Pharmacogenomics 2015; 15:1423-35. [PMID: 25303294 DOI: 10.2217/pgs.14.73] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
AIM We investigated the effects of rifampicin-based anti-TB treatment on plasma efavirenz exposure and the implications of CYP2B6 genotype. PATIENTS & METHODS Antiretroviral therapy-naive Ugandan HIV patients without (n = 157) or with TB coinfection (n = 106) were enrolled and treated with efavirenz-based highly active antiretroviral therapy alone or with rifampicin-based anti-TB therapy, respectively. Efavirenz plasma concentration was determined on day 3 and weeks 1, 2, 8, 12, 16, 20, 24, 28 and 32. RESULTS Rifampicin-based anti-TB cotreatment reduced plasma efavirenz exposure during the first 2 weeks (p < 0.05), but no significant effect was observed afterwards. Although not significant, rifampicin-based anti-TB cotreatment inconsistently increased efavirenz exposure over time, which was reduced immediately after completing anti-TB therapy. CYP2B6*6, *11 and ABCB1 c.4036A>G genotypes were significant predictors of efavirenz plasma exposure. CONCLUSION Plasma efavirenz exposure is mainly influenced by CYP2B6 genotype, but not by rifampicin cotreatment. Therefore, no efavirenz dosage adjustment during rifampicin cotreatment is required in Ugandans.
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Affiliation(s)
- Jackson K Mukonzo
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, C-168 SE-141 86 Stockholm, Sweden
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Gengiah TN, Botha JH, Yende-Zuma N, Naidoo K, Abdool Karim SS. Efavirenz dosing: influence of drug metabolizing enzyme polymorphisms and concurrent tuberculosis treatment. Antivir Ther 2015; 20:297-306. [PMID: 25318122 DOI: 10.3851/imp2877] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Rifampicin-based tuberculosis (TB) treatment alters efavirenz (EFV) clearance. Polymorphisms in important drug metabolizing enzymes and the implications for EFV dosing were investigated. METHODS Trough EFV concentrations (Cmin) were measured in 54 South African black patients. During TB treatment, EFV dose was 600 mg in patients <50 kg or 800 mg if ≥50 kg. Off TB treatment it was 600 mg. Polymorphisms in CYP2B6, CYP2A6 and UGT2B7 enzymes were sequenced. A multivariate generalized estimating equations model was fitted to assess predictors of high median EFV Cmin. RESULTS During TB treatment, median EFV Cmin was 3.2 (IQR 2.6-6.3) µg/ml and 3.3 (2.4-9.5) µg/ml in the 800 mg and 600 mg groups, respectively. After TB treatment EFV Cmin was 2.0 (1.4-3.5) µg/ml. Minor allele frequencies for CYP2B6 516G→T, 785A→G, 983T→C, UGT2B7-372G→A, CYP2A6*9B and CYP2A6*17 were 0.31, 0.33, 0.23, 0.29, 0.10 and 0.02, respectively. Haplotypes CYP2B6*6 and CYP2B6*18 were found in 38.9% and 25.9% of patients, respectively. Polymorphisms in all three CYP2B6 genes studied (516T-785G-983C) were present in 11.1% of patients and in this group median EFV Cmin was 19.2 (IQR 9.5-20) µg/ml during and 4.7 (IQR 3.5-5.6) µg/ml after TB treatment. The presence of TB treatment and composite genotypes CYP2B6 516 GT/TT, CYP2B6 983 TC/CC and CYP2A6*9B carrier status predicted median EFV Cmin>4 µg/ml. Adverse events due to high EFV concentrations were rare. CONCLUSIONS Because polymorphisms of EFV metabolizing enzymes are frequent and are associated with elevated EFV concentrations in this population, EFV dose increases are unnecessary when concomitant rifampicin-containing TB treatment is prescribed.
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Affiliation(s)
- Tanuja N Gengiah
- CAPRISA - Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa.
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Adetokunboh O, Atibioke O, Balogun T, Oluwasanu M. Antiretroviral Treatment and Resistance Patterns in HIV-Infected Children. Curr Infect Dis Rep 2015; 17:502. [DOI: 10.1007/s11908-015-0502-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Cho DY, Shen JHQ, Lemler SM, Skaar TC, Li L, Blievernicht J, Zanger UM, Kim KB, Shin JG, Flockhart DA, Desta Z. Rifampin enhances cytochrome P450 (CYP) 2B6-mediated efavirenz 8-hydroxylation in healthy volunteers. Drug Metab Pharmacokinet 2015; 31:107-16. [PMID: 27053325 DOI: 10.1016/j.dmpk.2015.07.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 06/29/2015] [Accepted: 07/14/2015] [Indexed: 01/11/2023]
Abstract
The effect of rifampin on the in vivo metabolism of the antiretroviral drug efavirenz was evaluated in healthy volunteers. In a cross-over placebo control trial, healthy subjects (n = 20) were administered a single 600 mg oral dose of efavirenz after pretreatment with placebo or rifampin (600 mg/day for 10 days). Plasma and urine concentrations of efavirenz, 8-hydroxyefavirenz and 8,14-dihydroxyefavirenz were measured by LC-MS/MS. Compared to placebo treatment, rifampin increased the oral clearance (by ∼2.5-fold) and decreased maximum plasma concentration (Cmax) and area under the plasma concentration-time curve (AUC0-∞) of efavirenz (by ∼1.6- and ∼2.5-fold respectively) (p < 0.001). Rifampin treatment substantially increased the Cmax and AUC0-12h of 8-hydroxyefavirenz and 8,14-dihydroxyefavirenz, metabolic ratio (AUC0-72h of metabolites to AUC0-72h efavirenz) and the amount of metabolites excreted in urine (Ae0-12hr) (all, p < 0.01). Female subjects had longer elimination half-life (1.6-2.2-fold) and larger weight-adjusted distribution volume (1.6-1.9-fold) of efavirenz than male subjects (p < 0.05) in placebo and rifampin treated groups respectively. In conclusion, rifampin enhances CYP2B6-mediated efavirenz 8-hydroxylation in vivo. The metabolism of a single oral dose of efavirenz may be a suitable in vivo marker of CYP2B6 activity to evaluate induction drug interactions involving this enzyme.
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Affiliation(s)
- Doo-Yeoun Cho
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN 46202, USA
| | - Joan H Q Shen
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN 46202, USA
| | - Suzanne M Lemler
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN 46202, USA
| | - Todd C Skaar
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN 46202, USA
| | - Lang Li
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN 46202, USA
| | - Julia Blievernicht
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
| | - Ulrich M Zanger
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
| | - Kwon-Bok Kim
- Inje University College of Medicine, Inje University Busan Paik Hospital, Busan 614-735, Republic of Korea
| | - Jae-Gook Shin
- Inje University College of Medicine, Inje University Busan Paik Hospital, Busan 614-735, Republic of Korea
| | - David A Flockhart
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN 46202, USA
| | - Zeruesenay Desta
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN 46202, USA.
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Podany AT, Bao Y, Swindells S, Chaisson RE, Andersen JW, Mwelase T, Supparatpinyo K, Mohapi L, Gupta A, Benson CA, Kim P, Fletcher CV. Efavirenz Pharmacokinetics and Pharmacodynamics in HIV-Infected Persons Receiving Rifapentine and Isoniazid for Tuberculosis Prevention. Clin Infect Dis 2015; 61:1322-7. [PMID: 26082504 DOI: 10.1093/cid/civ464] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 06/07/2015] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Concomitant use of rifamycins to treat or prevent tuberculosis can result in subtherapeutic concentrations of antiretroviral drugs. We studied the interaction of efavirenz with daily rifapentine and isoniazid in human immunodeficiency virus (HIV)-infected individuals receiving a 4-week regimen to prevent tuberculosis. METHODS Participants receiving daily rifapentine and isoniazid with efavirenz had pharmacokinetic evaluations at baseline and weeks 2 and 4 of concomitant therapy. Efavirenz apparent oral clearance was estimated and the geometric mean ratio (GMR) of values before and during rifapentine and isoniazid was calculated. HIV type 1 (HIV-1) RNA was measured at baseline and week 8. RESULTS Eighty-seven participants were evaluable: 54% were female, and the median age was 35 years (interquartile range [IQR], 29-44 years). Numbers of participants with efavirenz concentrations ≥1 mg/L were 85 (98%) at week 0; 81 (93%) at week 2; 78 (90%) at week 4; and 75 (86%) at weeks 2 and 4. Median efavirenz apparent oral clearance was 9.3 L/hour (IQR, 6.42-13.22 L/hour) at baseline and 9.8 L/hour (IQR, 7.04-15.59 L/hour) during rifapentine/isoniazid treatment (GMR, 1.04 [90% confidence interval, .97-1.13]). Seventy-nine of 85 (93%) participants had undetectable HIV-1 RNA (<40 copies/mL) at entry; 71 of 75 (95%) participants had undetectable HIV-1 RNA at week 8. Two participants with undetectable HIV-1 RNA at study entry were detectable (43 and 47 copies/mL) at week 8. CONCLUSIONS The proportion of participants with midinterval efavirenz concentrations ≥1 mg/L did not cross below the prespecified threshold of >80%, and virologic suppression was maintained. Four weeks of daily rifapentine plus isoniazid can be coadministered with efavirenz without clinically meaningful reductions in efavirenz mid-dosing concentrations or virologic suppression. CLINICAL TRIALS REGISTRATION NCT 01404312.
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Affiliation(s)
- Anthony T Podany
- College of Pharmacy, University of Nebraska Medical Center, Omaha
| | - Yajing Bao
- Statistical and Data Analysis Center, Harvard School of Public Health, Boston, Massachusetts
| | - Susan Swindells
- Infectious Diseases, Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Richard E Chaisson
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Janet W Andersen
- Statistical and Data Analysis Center, Harvard School of Public Health, Boston, Massachusetts
| | - Thando Mwelase
- University of the Witwatersrand, Johannesburg, South Africa
| | - Khuanchai Supparatpinyo
- Research Institute for Health Sciences and Faculty of Medicine, Chiang Mai University, Thailand
| | - Lerato Mohapi
- University of the Witwatersrand and Baragwanath Hospital, Soweto, South Africa
| | - Amita Gupta
- Center for Clinical Global Health Education, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Peter Kim
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Courtney V Fletcher
- College of Pharmacy, University of Nebraska Medical Center, Omaha Infectious Diseases, Internal Medicine, University of Nebraska Medical Center, Omaha
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Sinxadi PZ, Leger PD, McIlleron HM, Smith PJ, Dave JA, Levitt NS, Maartens G, Haas DW. Pharmacogenetics of plasma efavirenz exposure in HIV-infected adults and children in South Africa. Br J Clin Pharmacol 2015; 80:146-56. [PMID: 25611810 DOI: 10.1111/bcp.12590] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 12/09/2014] [Accepted: 01/06/2015] [Indexed: 12/22/2022] Open
Abstract
AIMS Genetic factors, notably CYP2B6 516G→T [rs3745274] and 983T→C [rs28399499], explain much of the interindividual variability in efavirenz pharmacokinetics, but data from Africa are limited. We characterized relationships between genetic polymorphisms and plasma efavirenz concentrations in HIV-infected Black South African adults and children. METHODS Steady-state mid-dosing interval efavirenz concentrations were measured. We genotyped 241 polymorphisms in genes potentially relevant to efavirenz metabolism and transport, including ABCB1, CYP2A6, CYP2B6, CYP3A4, CYP3A5, NR1I2 and NR1I3. RESULTS Among 113 participants (59 adults and 54 children), minor allele frequencies for CYP2B6 516G→T, 983T→C, and 15582C→T [rs4803419] were 0.36, 0.07, and 0.09, respectively. Based on composite CYP2B6 15582/516/983 genotype, there were 33 extensive metabolizer, 62 intermediate metabolizer and 18 slow metabolizer genotypes. Median (IQR) mid-dose efavirenz concentrations were 1.44 (1.21-1.93) µg ml(-1), 2.08 (1.68-2.94) µg ml(-1) and 7.26 (4.82-8.34) µg ml(-1) for extensive, intermediate and slow metabolizers, respectively. In univariate analyses, a model that included composite genotype best predicted efavirenz concentrations (β = 0.28, 95% CI 0.21, 0.35, P = 2.4 × 10(-11)). Among individual CYP2B6 polymorphisms, 516G→T best predicted efavirenz concentrations (β = 0.22, 95% CI 0.13, 0.30, P = 1.27 × 10(-6)). There was also associations with 983T→C (β = 0.27, 95% CI 0.10, 0.44, P = 0.002) and 15582C→T (β = 0.11, 95% CI 0.01, 0.22, P = 0.04). Associations were consistent in adults and children. No other polymorphisms were independently associated with efavirenz concentrations. CONCLUSIONS Composite CYP2B6 genotype based on CYP2B6 516G→T, 983T→C, and 15582C→T best described efavirenz exposure in HIV-infected Black South African adults and children.
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Affiliation(s)
- Phumla Z Sinxadi
- Division of Clinical of Pharmacology, Division of Exercise and Endocrine Metabolism, University of Cape Town, Cape Town, South Africa
| | - Paul D Leger
- Vanderbilt University Medical Center, Department of Medicine, Nashville, Tennessee, United States of America
| | - Helen M McIlleron
- Division of Clinical of Pharmacology, Division of Exercise and Endocrine Metabolism, University of Cape Town, Cape Town, South Africa
| | - Peter J Smith
- Division of Clinical of Pharmacology, Division of Exercise and Endocrine Metabolism, University of Cape Town, Cape Town, South Africa
| | - Joel A Dave
- Division of Exercise and Endocrine Metabolism, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Naomi S Levitt
- Division of Exercise and Endocrine Metabolism, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical of Pharmacology, Division of Exercise and Endocrine Metabolism, University of Cape Town, Cape Town, South Africa
| | - David W Haas
- Vanderbilt University School of Medicine, Department of Medicine, Nashville, Tennessee, United States of America
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Habtewold A, Makonnen E, Amogne W, Yimer G, Aderaye G, Bertilsson L, Burhenne J, Aklillu E. Is there a need to increase the dose of efavirenz during concomitant rifampicin-based antituberculosis therapy in sub-Saharan Africa? The HIV-TB pharmagene study. Pharmacogenomics 2015; 16:1047-64. [PMID: 25831219 DOI: 10.2217/pgs.15.35] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
AIMS The current HIV treatment guidelines are inconsistent about the need for weight-based efavirenz dose adjustment during rifampicin containing antituberculosis (anti-TB) cotreatment. We investigated effect of rifampicin-based anti-TB cotreatment on plasma efavirenz exposure and treatment outcome, considering effect of CYP2B6 genotype and bodyweight. PATIENTS & METHODS HIV-only (arm 1, n = 285) or TB-HIV (arm 2, n = 208) coinfected patients were enrolled and received efavirenz-based ART alone or with rifampicin-based anti-TB therapy, respectively. Plasma efavirenz concentrations at 4th and 16th weeks, viral load and CD4 cell count at 24th and 48th weeks were determined. RESULTS The mean plasma efavirenz concentration at weeks 4 (p = 0.03) and 16 (p = 0.08) was inconsistently higher in arm 2 than arm 1, mainly in CYP2B6*6 carriers. Effect of bodyweight on efavirenz pharmacokinetics was significant only in arm 1, but not in arm 2. Proportion of patients with nondetectable viral load (≤50 copies/ml) at week 24 was higher in arm 1 than arm 2 patients (91.0 vs 76.3%; p = 0.002), but no significant difference was observed at week 48 (89.5 vs 87.8%; p = 0.22). CONCLUSION Rifampicin-based anti-TB cotreatment has no significant influence on long-term efavirenz plasma exposure and efficacy. Hence, there is no need to increase the dose of efavirenz during concomitant rifampicin-based anti-TB cotreatment in the sub-Saharan African population.
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Affiliation(s)
- Abiy Habtewold
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska University Hospital Huddinge, C-168, Karolinska Institutet, 141 86 Stockholm, Sweden.,Department of Pharmacology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Eyasu Makonnen
- Department of Pharmacology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Wondwossen Amogne
- Department of Internal Medicine, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Medicine, Division of Infectious Diseases, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Getnet Yimer
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska University Hospital Huddinge, C-168, Karolinska Institutet, 141 86 Stockholm, Sweden.,Department of Pharmacology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Getachew Aderaye
- Department of Internal Medicine, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Leif Bertilsson
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska University Hospital Huddinge, C-168, Karolinska Institutet, 141 86 Stockholm, Sweden
| | - Jürgen Burhenne
- Department of Clinical Pharmacology & Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Eleni Aklillu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska University Hospital Huddinge, C-168, Karolinska Institutet, 141 86 Stockholm, Sweden
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Luetkemeyer AF, Rosenkranz SL, Lu D, Grinsztejn B, Sanchez J, Ssemmanda M, Sanne I, McIlleron H, Havlir DV, Haas DW. Combined effect of CYP2B6 and NAT2 genotype on plasma efavirenz exposure during rifampin-based antituberculosis therapy in the STRIDE study. Clin Infect Dis 2015; 60:1860-3. [PMID: 25722197 DOI: 10.1093/cid/civ155] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 02/18/2015] [Indexed: 01/11/2023] Open
Abstract
In STRIDE, slow metabolizer CYP2B6 and NAT2 genotypes were each associated with increased plasma efavirenz concentrations during antituberculosis therapy. Concentrations were greater on therapy than off therapy in 58% with CYP2B6 and 93% with NAT2 slow metabolizer genotypes. Individuals with slow metabolizer genotypes in both genes had markedly elevated concentrations.
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Affiliation(s)
- Anne F Luetkemeyer
- HIV/AIDS Division, San Francisco General Hospital, University of California, San Francisco
| | - Susan L Rosenkranz
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts
| | - Darlene Lu
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts
| | - Beatriz Grinsztejn
- Fundacao Oswaldo Cruz, Instituto de Pesquisa Clinica Evandro Chagas, Rio de Janeiro, Brazil
| | | | | | - Ian Sanne
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Diane V Havlir
- HIV/AIDS Division, San Francisco General Hospital, University of California, San Francisco
| | - David W Haas
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
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Court MH, Almutairi FE, Greenblatt DJ, Hazarika S, Sheng H, Klein K, Zanger UM, Bourgea J, Patten CJ, Kwara A. Isoniazid mediates the CYP2B6*6 genotype-dependent interaction between efavirenz and antituberculosis drug therapy through mechanism-based inactivation of CYP2A6. Antimicrob Agents Chemother 2014; 58:4145-52. [PMID: 24820076 PMCID: PMC4068589 DOI: 10.1128/aac.02532-14] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 05/04/2014] [Indexed: 01/11/2023] Open
Abstract
Efavirenz is commonly used to treat patients coinfected with human immunodeficiency virus and tuberculosis. Previous clinical studies have observed paradoxically elevated efavirenz plasma concentrations in patients with the CYP2B6*6/*6 genotype (but not the CYP2B6*1/*1 genotype) during coadministration with the commonly used four-drug antituberculosis therapy. This study sought to elucidate the mechanism underlying this genotype-dependent drug-drug interaction. In vitro studies were conducted to determine whether one or more of the antituberculosis drugs (rifampin, isoniazid, pyrazinamide, or ethambutol) potently inhibit efavirenz 8-hydroxylation by CYP2B6 or efavirenz 7-hydroxylation by CYP2A6, the main mechanisms of efavirenz clearance. Time- and concentration-dependent kinetics of inhibition by the antituberculosis drugs were determined using genotyped human liver microsomes (HLMs) and recombinant CYP2A6, CYP2B6.1, and CYP2B6.6 enzymes. Although none of the antituberculosis drugs evaluated at up to 10 times clinical plasma concentrations were found to inhibit efavirenz 8-hydroxylation by HLMs, both rifampin (apparent inhibition constant [Ki] = 368 μM) and pyrazinamide (Ki = 637 μM) showed relatively weak inhibition of efavirenz 7-hydroxylation. Importantly, isoniazid demonstrated potent time-dependent inhibition of efavirenz 7-hydroxylation in both HLMs (inhibitor concentration required for half-maximal inactivation [KI] = 30 μM; maximal rate constant of inactivation [kinact] = 0.023 min(-1)) and recombinant CYP2A6 (KI = 15 μM; kinact = 0.024 min(-1)) and also formed a metabolite intermediate complex consistent with mechanism-based inhibition. Selective inhibition of the CYP2B6.6 allozyme could not be demonstrated for any of the antituberculosis drugs using either recombinant enzymes or CYP2B6*6 genotype HLMs. In conclusion, the results of this study identify isoniazid as the most likely perpetrator of this clinically important drug-drug interaction through mechanism-based inactivation of CYP2A6.
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Affiliation(s)
- Michael H Court
- Individualized Medicine Program, Department of Veterinary Clinical Sciences, Washington State University College of Veterinary Medicine, Pullman, Washington, USA
| | - Fawziah E Almutairi
- Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, Boston, Massachusetts, USA Program in Pharmacology and Experimental Therapeutics, Sackler School of Graduate Biomedical Sciences, Tufts University, Boston, Massachusetts, USA
| | - David J Greenblatt
- Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Suwagmani Hazarika
- Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Hongyan Sheng
- Individualized Medicine Program, Department of Veterinary Clinical Sciences, Washington State University College of Veterinary Medicine, Pullman, Washington, USA
| | - Kathrin Klein
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, and University of Tübingen, Tübingen, Germany
| | - Ulrich M Zanger
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, and University of Tübingen, Tübingen, Germany
| | - Joanne Bourgea
- BD Biosciences, Discovery Labware, Woburn, Massachusetts, USA
| | | | - Awewura Kwara
- Warren Alpert Medical School of Brown University and The Miriam Hospital, Providence, Rhode Island, USA
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Larru B, Eby J, Lowenthal ED. Antiretroviral treatment in HIV-1 infected pediatric patients: focus on efavirenz. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2014; 5:29-42. [PMID: 25937791 PMCID: PMC4412603 DOI: 10.2147/phmt.s47794] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Efavirenz is a non-nucleoside reverse transcriptase inhibitor (NNRTI), used for the treatment of human immunodeficiency virus (HIV)-1 infection. Approved by the US Food and Drug Administration in 1998, its indication was recently extended to include children as young as 3 months of age. The World Health Organization and many national guidelines consider efavirenz to be the preferred NNRTI for first-line treatment of children over the age of 3 years. Clinical outcomes of patients on three-drug antiretroviral regimens which include efavirenz are as good as or better than those for patients on all other currently approved HIV medications. Efavirenz is dosed once daily and has pediatric-friendly formulations. It is usually well tolerated, with central nervous system side effects being of greatest concern. Efavirenz increases the risk of neural tube defects in nonhuman primates and therefore its use during the first trimester of pregnancy is limited in some settings. With minimal interactions with antituberculous drugs, efavirenz is preferred for use among patients with HIV/tuberculosis coinfection. Efavirenz can be rendered inactive by a single point mutation in the reverse transcriptase enzyme. Newer NNRTI drugs such as etravirine, not yet approved for use in children under the age of 6 years, may maintain their activity following development of efavirenz resistance. This review highlights key points from the existing literature regarding the use of efavirenz in children and suggests directions for future investigation.
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Affiliation(s)
- Beatriz Larru
- Department of Pediatrics, Division of infectious Diseases, Children's Hospital of Philadelphia, Philadelphia
| | - Jessica Eby
- Department of Pediatrics, Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia ; Villanova University, Villanova
| | - Elizabeth D Lowenthal
- Department of Pediatrics, Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia ; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA ; Department of Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Reynolds J, Heysell SK. Understanding pharmacokinetics to improve tuberculosis treatment outcome. Expert Opin Drug Metab Toxicol 2014; 10:813-23. [PMID: 24597717 DOI: 10.1517/17425255.2014.895813] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Tuberculosis (TB) remains the leading cause of death from a curable infectious disease; drug-resistant TB threatens to dismantle all prior gains in global control. Suboptimal circulating anti-TB drug concentrations can lead to lack of cure and acquired drug resistance. AREAS COVERED This review will introduce pharmacokinetic parameters for key anti-TB drugs, as well as the indications and limitations of measuring these parameters in clinical practice. Current and novel methodologies for delivering anti-TB pharmacokinetic-pharmacodynamic data are highlighted and gaps in operational research described. EXPERT OPINION Individual pharmacokinetic variability is commonplace, underappreciated and difficult to predict without therapeutic drug monitoring (TDM). Pharmacokinetic thresholds associated with poor TB treatment outcome in drug-susceptible TB have recently been described and may now guide the application of TDM, but require validation in a variety of settings and comorbidities. Dried blood spots for TDM and prepackaged multidrug plates for minimum inhibitory concentration testing will overcome barriers of accessibility and represent areas for innovation. Operationalizing pharmacokinetics has the potential to improve TB outcomes in the most difficult-to-treat forms of the disease such as multidrug resistance. Clinical studies in these areas are eagerly anticipated and we expect will better define the rational introduction of novel therapeutics.
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Affiliation(s)
- Jonathan Reynolds
- University of Virginia, School of Medicine , PO Box 801340, Charlottesville, VA 22908-1340 , USA
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Kwara A, Cao L, Yang H, Poethke P, Kurpewski J, Tashima KT, Mahjoub BD, Court MH, Peloquin CA. Factors associated with variability in rifampin plasma pharmacokinetics and the relationship between rifampin concentrations and induction of efavirenz clearance. Pharmacotherapy 2014; 34:265-71. [PMID: 24420746 DOI: 10.1002/phar.1388] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
STUDY OBJECTIVES To identify factors associated with variability in rifampin plasma pharmacokinetics and explore the relationship between rifampin pharmacokinetics and change in efavirenz plasma pharmacokinetics with rifampin coadministration. METHODS In this randomized, cross-over study, 12 healthy volunteers received either efavirenz 600 mg/day or efavirenz 600 mg with rifampin 600 mg/day for 8 days. After a washout period of at least 2 weeks, subjects crossed over to the alternate 8-day regimen. Samples were obtained for pharmacokinetic assessment on day 8 of each study cycle. Drugs concentrations were determined by a validated high-performance liquid chromatography. Pharmacokinetic parameters were calculated using noncompartmental analysis. Multivariate analysis was used to examine factors associated with rifampin pharmacokinetics. Spearman correlation analysis was used to investigate relationship between rifampin pharmacokinetics and change in efavirenz plasma pharmacokinetics with rifampin coadministration. MEASUREMENTS AND MAIN RESULTS Of 11 evaluable subjects, the median interquartile range, rifampin peak concentration (Cmax) , area under the concentration-time curve (AUC0-24 hour ), and weight-normalized clearance were 8.9 (7.3-13.8) μg/ml, 48.8 (29.6-67.4) μg·h/ml, and 0.19 (0.11-0.29) L/h/kg, respectively. Solute carrier organic anion transporter family member 1B1 (SLCO1B1) c.388A→G and SLCO1B1 c.463C→A polymorphisms jointly had significant effect on rifampin Cmax (R(2) = 0.75). Male sex and SLCO1B1 c.463C→A polymorphism together influenced rifampin AUC0-24 hour (R(2) = 0.52) and weight-normalized clearance (R(2) = 0.65). All four volunteers with rifampin Cmax less than 8 μg/ml (lower end of the normal range) had c.463CA genotype. Rifampin Cmax and AUC0-24 hour had no significant relationship with the efavirenz AUC0-24 hour ratio or weight-normalized clearance ratio in the presence versus absence of rifampin (p>0.05). CONCLUSIONS Men with the SLCO1B1c.463CA genotype are at increased risk of lower rifampin plasma exposure. However, plasma rifampin concentrations did not correlate with the extent of induction of efavirenz clearance by rifampin during coadministration.
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Affiliation(s)
- Awewura Kwara
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island; The Miriam Hospital, Providence, Rhode Island
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Lawn SD, Meintjes G, McIlleron H, Harries AD, Wood R. Management of HIV-associated tuberculosis in resource-limited settings: a state-of-the-art review. BMC Med 2013; 11:253. [PMID: 24295487 PMCID: PMC4220801 DOI: 10.1186/1741-7015-11-253] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 11/07/2013] [Indexed: 01/08/2023] Open
Abstract
The HIV-associated tuberculosis (TB) epidemic remains a huge challenge to public health in resource-limited settings. Reducing the nearly 0.5 million deaths that result each year has been identified as a key priority. Major progress has been made over the past 10 years in defining appropriate strategies and policy guidelines for early diagnosis and effective case management. Ascertainment of cases has been improved through a twofold strategy of provider-initiated HIV testing and counseling in TB patients and intensified TB case finding among those living with HIV. Outcomes of rifampicin-based TB treatment are greatly enhanced by concurrent co-trimoxazole prophylaxis and antiretroviral therapy (ART). ART reduces mortality across a spectrum of CD4 counts and randomized controlled trials have defined the optimum time to start ART. Good outcomes can be achieved when combining TB treatment with first-line ART, but use with second-line ART remains challenging due to pharmacokinetic drug interactions and cotoxicity. We review the frequency and spectrum of adverse drug reactions and immune reconstitution inflammatory syndrome (IRIS) resulting from combined treatment, and highlight the challenges of managing HIV-associated drug-resistant TB.
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Affiliation(s)
- Stephen D Lawn
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Anthony D Harries
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
- International Union against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Robin Wood
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Mukonzo JK, Okwera A, Nakasujja N, Luzze H, Sebuwufu D, Ogwal-Okeng J, Waako P, Gustafsson LL, Aklillu E. Influence of efavirenz pharmacokinetics and pharmacogenetics on neuropsychological disorders in Ugandan HIV-positive patients with or without tuberculosis: a prospective cohort study. BMC Infect Dis 2013; 13:261. [PMID: 23734829 PMCID: PMC3680019 DOI: 10.1186/1471-2334-13-261] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 05/25/2013] [Indexed: 01/01/2023] Open
Abstract
Background HIV infection, anti-tuberculosis and efavirenz therapy are associated with neuropsychological effects. We evaluated the influence of rifampicin cotreatment, efavirenz pharmacokinetics and pharmacogenetics on neuropsychiatric disorders in Ugandan HIV patients with or without tuberculosis coinfection. Methods 197 treatment naïve Ugandan HIV patients, of whom 138 were TB co-infected, enrolled prospectively and received efavirenz based HAART. TB-HIV confected patients received concomitant rifampicin based anti-TB therapy. Genotypes for CYP2B6 (*6, *11), CYP3A5 (*3, *6, *7), ABCB1 (c.3435C>T and c.4036 A/G rs3842), CYP2A6 (*9, *17) and NR1I3 rs3003596 T/C were determined. Efavirenz plasma concentrations were serially quantified at 3rd day, 1st, 2nd, 4th, 6th, 8th and 12th weeks during therapy. Efavirenz neuropsychiatric symptoms were evaluated in terms of sleep disorders, hallucinations and cognitive effects at baseline, at two and twelve weeks of efavirenz treatment using a modified Mini Mental State Examination (MMSE) score. Results During the first twelve weeks of ART, 73.6% of the patients experienced at least one efavirenz related neuropsychiatric symptom. Commonest symptoms experienced were sleep disorders 60.5% (n=124) and hallucination 30.7% (n=63). Neuropsychiatric symptoms during HAART were significantly predicted by efavirenz plasma concentrations consistently. Rifampicin cotreatment reduced plasma efavirenz concentrations significantly only during the first week but not afterwards. There was no significant difference in the incidence of neuropsychiatric symptoms between patients receiving efavirenz with or without rifampicin cotreatment. CYP2B6*6 and ABCB1 c.4036 A/G genotype significantly predicted efavirenz concentrations. The tendency of CYP2B6*6 genotype association with higher incidence of having vivid dream (p=0.05), insomnia (p=0.19) and tactile hallucination (p=0.09) was observed mainly at week-2. Conclusions Efavirenz related neuropsychiatric symptoms are common among Ugandan HIV patients receiving ART and is mainly predicted by higher efavirenz plasma concentrations and CYP2B6 genotype but not by rifampicin based anti-TB co-treatment.
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Affiliation(s)
- Jackson K Mukonzo
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, SE- 141 86, Stockholm, Sweden
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