1
|
Kandel S, Gracey EG, Lampe JN. Consideration of Nevirapine Analogs To Reduce Metabolically Linked Hepatotoxicity: A Cautionary Tale of the Deuteration Approach. Chem Res Toxicol 2023; 36. [PMID: 37769118 PMCID: PMC10583834 DOI: 10.1021/acs.chemrestox.3c00192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Indexed: 09/30/2023]
Abstract
Idiosyncratic drug reactions (IDRs) in their most deleterious form can lead to serious medical complications and potentially fatal events. Nevirapine (NVP), still widely used in developing countries for combinatorial antiretroviral and prophylactic therapies against HIV infection, represents a prototypical example of IDRs causing severe skin rashes and hepatotoxicity. Complex metabolic pathways accompanied by production of multiple reactive metabolites often complicate our understanding of IDR's origin. While assessment of NVP analogs has helped characterize the pathways involved in IDRs for NVP, which are largely driven by metabolism at the 12-methyl position, it has yet to be investigated if some of these analogs could be valuable replacement drugs with reduced reactive metabolite properties and drug-drug interaction (DDI) risks. Here, we evaluated a set of eight NVP analogs, including the deuterated 12-d3-NVP and two NVP metabolites, for their efficacy and inhibitory potencies against HIV reverse transcriptase (HIV-RT). A subset of three analogs, demonstrating >85% inhibition for HIV-RT, was further assessed for their hepatic CYP induction-driven DDI risks. This led to a closer investigation of the inactivation properties of 12-d3-NVP for hepatic CYP3A4 and a comparison of its propensity in generating reactive metabolite species. The metabolic shift triggered with 12-d3-NVP, increasing formation of the 2-hydroxy and glutathione metabolites, emphasized the importance of the dynamic balance between induction and metabolism-dependent inactivation of CYP3A4 and its impact on clearance of NVP during treatment. Unfortunately, the strategy of incorporating deuterium to reduce NVP metabolism and production of the electrophile species elicited opposite results, illustrating the great challenges involved in tackling IDRs through deuteration.
Collapse
Affiliation(s)
| | | | - Jed N. Lampe
- Department of Pharmaceutical
Sciences, Skaggs School of Pharmacy, University
of Colorado, Aurora, Colorado 80045, United States
| |
Collapse
|
2
|
Thangaraju P, Velmurugan H, N K. Current Status of Pharmacokinetic Research in Children: A Systematic Review of Clinical Trial Records. Curr Rev Clin Exp Pharmacol 2022; 19:CRCEP-EPUB-128427. [PMID: 36573054 DOI: 10.2174/2772432818666221223155455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 09/05/2022] [Accepted: 10/18/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Many medications have different pharmacokinetics in children than in adults. Knowledge about the safety and efficacy of medications in children requires research into the pharmacokinetic profiles of children's medicines. By analysing registered clinical trial records, this study determined how frequently pharmacokinetic data is gathered in paediatric drug trials. METHODS We searched for the pharmacokinetic data from clinical trial records for preterm infants and children up to the age of 16 from January 2011 to April 2022. The records of trials involving one or more drugs in preterm infants and children up to the age of 16 were examined for evidence that pharmacokinetic data would be collected. RESULTS In a total of 1483 records of interventional clinical trials, 136 (9.17%) pharmacokinetic data involved adults. Of those 136 records, 60 (44.1%) records were pharmacokinetics trials involving one or more medicines in children up to the age of 16. 20 (33.3 %) in America, followed by 19 (31.6 %) in Europe. Most trials researched medicines in the field of infection or parasitic diseases 20 (33.3%). 27 (48.2%) and 26 (46.4%) trials investigated medicines that were indicated as essential medicine. CONCLUSION The pharmacokinetic characteristics of children's drugs need to be better understood. The current state of pharmacokinetic research appears to address the knowledge gap in this area adequately. Despite slow progress, paediatric clinical trials have experienced a renaissance as the significance of paediatric trials has gained international attention. The outcome of paediatric trials will have an impact on children's health in the future. In recent years, the need for greater availability and access to safe child-size pharmaceuticals has received a lot of attention.
Collapse
Affiliation(s)
- Pugazhenthan Thangaraju
- Department of Pharmacology, All India institute of medical sciences, Raipur, Chhattisgarh, India
| | - Hemasri Velmurugan
- Department of Pharmacology, All India institute of medical sciences, Raipur, Chhattisgarh, India
| | - Krishnapriya N
- Department of Pharmacology, All India institute of medical sciences, Raipur, Chhattisgarh, India
| |
Collapse
|
3
|
Liyanage M, Nikanjam M, McFadyen L, Vourvahis M, Rogg L, Moye J, Chadwick EG, Jean-Philippe P, Mirochnick M, Whitson K, Bradford S, Capparelli EV, Best BM. Maraviroc Population Pharmacokinetics Within the First 6 Weeks of Life. Pediatr Infect Dis J 2022; 41:885-890. [PMID: 35980827 PMCID: PMC9560968 DOI: 10.1097/inf.0000000000003665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Treatment and prophylaxis options for neonatal HIV are limited. This study aimed to develop a population pharmacokinetic model to characterize the disposition of maraviroc in neonates to inform dosing regimens and expand available options. METHODS Using maraviroc concentrations from neonates who received either a single dose or multiple doses of 8 mg/kg of maraviroc in the first 6 weeks of life, a population pharmacokinetic model was developed to determine the effects of age, sex, maternal efavirenz exposure and concomitant ARV therapy on maraviroc disposition. The final model was used in Monte Carlo simulations to generate expected exposures with recommended dosing regimens. RESULTS A total of 396 maraviroc concentrations, collected in the first 4 days of life, at 1 week, at 4 weeks and at 6 weeks, from 44 neonates were included in the analysis. After allometrically scaling for weight, age less than 4 days was associated with a 44% decreased apparent clearance compared with participants 7 days to 6 weeks of life. There were no differences identified in apparent clearance or volume of distribution from ages 7 days to 6 weeks, sex, maternal efavirenz exposure or concomitant nevirapine therapy. Monte Carlo simulations with FDA-approved weight band dosing resulted in the majority of simulated patients (84.3%) achieving an average concentration of ≥75 ng/mL. CONCLUSIONS While maraviroc apparent clearance is decreased in the first few days of life, the current FDA-approved maraviroc weight band dosing provides maraviroc exposures for neonates in the first 6 weeks of life, which were consistent with adult maraviroc exposure range. Maraviroc provides another antiretroviral treatment option for very young infants.
Collapse
Affiliation(s)
- Marlon Liyanage
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Mina Nikanjam
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Lynn McFadyen
- Pharmacometrics, Pfizer Global Research and Development, Sandwich, UK
| | - Manoli Vourvahis
- Clinical Pharmacology, Pfizer Global Research and Development, New York, New York, USA
| | - Luise Rogg
- ViiV Healthcare, Research Triangle, North Carolina, USA
| | - John Moye
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda
| | - Ellen G. Chadwick
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | | | - Mark Mirochnick
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Kyle Whitson
- Frontier Science Foundation, Amherst, New York, USA
| | | | - Edmund V. Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
- Pediatrics Department, School of Medicine, University of California San Diego-Rady Children’s Hospital San Diego, San Diego, CA
| | - Brookie M. Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
- Pediatrics Department, School of Medicine, University of California San Diego-Rady Children’s Hospital San Diego, San Diego, CA
| |
Collapse
|
4
|
Millar JR, Bengu N, Vieira VA, Adland E, Roider J, Muenchhoff M, Fillis R, Sprenger K, Ntlantsana V, Fatti I, Archary M, Groll A, Ismail N, García-Guerrero MC, Matthews PC, Ndung'u T, Puertas MC, Martinez-Picado J, Goulder P. Early initiation of antiretroviral therapy following in utero HIV infection is associated with low viral reservoirs but other factors determine subsequent plasma viral rebound. J Infect Dis 2021; 224:1925-1934. [PMID: 33963757 PMCID: PMC8643423 DOI: 10.1093/infdis/jiab223] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 04/29/2021] [Indexed: 11/17/2022] Open
Abstract
Background Early HIV diagnosis allows combination antiretroviral therapy (cART) initiation in the first days of life following in utero (IU) infection. The impact of early cART initiation on infant viral reservoir size in the setting of high-frequency cART nonadherence is unknown. Methods Peripheral blood total HIV DNA from 164 early treated (day 0–21 of life) IU HIV-infected South African infants was measured using droplet digital PCR at birth and following suppressive cART. We evaluated the impact of cART initiation timing on HIV reservoir size and decay, and on the risk of subsequent plasma viremia in cART-suppressed infants. Results Baseline HIV DNA (median 2.8 log10 copies/million peripheral blood mononuclear cells, range 0.7–4.8) did not correlate with age at cART initiation (0–21 days) but instead with maternal antenatal cART use. In 98 infants with plasma viral suppression on cART, HIV DNA half-life was 28 days. However, the probability of maintenance of plasma aviremia was low (0.46 at 12 months) and not influenced by HIV DNA load. Unexpectedly, longer time to viral suppression was associated with protection against subsequent viral rebound. Conclusions With effective prophylaxis against mother-to-child transmission, cART initiation timing in the first 3 weeks of life is not critical to reservoir size.
Collapse
Affiliation(s)
- Jane R Millar
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa.,Department of Paediatrics, University of Oxford, Oxford, UK
| | - Nomonde Bengu
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | | | - Emily Adland
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Julia Roider
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa.,Department of Paediatrics, University of Oxford, Oxford, UK.,Africa Health Research Institute (AHRI), Durban, South Africa.,German Center for Infection Research (DZIF), Partner site Munich, Germany.,Department of Infectious Diseases, Ludwig-Maximilians-University, Munich
| | - Maximilian Muenchhoff
- German Center for Infection Research (DZIF), Partner site Munich, Germany.,Max von Pettenkofer Institute, Virology, National Reference Center for Retroviruses, Faculty of Medicine, LMU München, Munich, Germany
| | - Rowena Fillis
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | - Kenneth Sprenger
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | - Vuyokazi Ntlantsana
- School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Isabella Fatti
- Umkhuseli Innovation and Research Management, Pietermaritzburg, South Africa
| | - Moherndran Archary
- Department of Paediatrics, King Edward VIII Hospital/University of KwaZulu-Natal, Durban, South Africa
| | - Andreas Groll
- TU Dortmund University, Department of Statistics, Vogelpothsweg, Dortmund
| | - Nasreen Ismail
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | | | - Philippa C Matthews
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Department of Microbiology and Infectious Diseases, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford BRC, John Radcliffe Hospital, Oxford, UK
| | - Thumbi Ndung'u
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa.,Africa Health Research Institute (AHRI), Durban, South Africa.,Ragon Institute of MGH, MIT, and Harvard, Cambridge, Massachusetts, USA.,Max Planck Institute for Infection Biology, Berlin, Germany.,Division of Infection and Immunity, University College London, London, UK
| | | | - Javier Martinez-Picado
- IrsiCaixa AIDS Research Institute, Badalona, Spain.,University of Vic-Central University of Catalonia (UVic-UCC), Vic, Spain.,Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain.,Germans Trias i Pujol Research Institute (IGTP), Badalona, Spain
| | - Philip Goulder
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa.,Department of Paediatrics, University of Oxford, Oxford, UK.,Ragon Institute of MGH, MIT, and Harvard, Cambridge, Massachusetts, USA
| |
Collapse
|
5
|
Maswabi K, Ajibola G, Bennett K, Capparelli EV, Jean-Philippe P, Moyo S, Mohammed T, Batlang O, Sakoi M, Lockman S, Makhema J, Lichterfeld M, Kuritzkes DR, Hughes MD, Shapiro RL. Safety and Efficacy of Starting Antiretroviral Therapy in the First Week of Life. Clin Infect Dis 2021; 72:388-393. [PMID: 31927562 PMCID: PMC7850532 DOI: 10.1093/cid/ciaa028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/10/2020] [Indexed: 01/24/2023] Open
Abstract
Background Early antiretroviral therapy (ART) is recommended for infants with human immunodeficiency virus (HIV) infection. However, few antiretroviral options are available for neonates. Methods The Early Infant Treatment Study in Botswana tested HIV-exposed infants within 96 hours of birth, and HIV-infected infants started nevirapine (NVP) 6 mg/kg twice daily, zidovudine (ZDV), and lamivudine (3TC) at age < 7 days. NVP trough concentrations were tested at 1 and 2 weeks. NVP was switched to ritonavir-boosted lopinavir (LPV/r) at week 2, 3, 4, or 5 according to delivery gestational age. Results Forty HIV-infected infants started ART at median age 2 days (range, 1–5 days). NVP trough concentrations were highly variable and below therapeutic target (3000 ng/mL) for 50% of 2-week measurements; concentrations did not correlate with viral decline at weeks 2, 4, or 12. Two deaths unrelated to ART occurred through 24 weeks. Only 1 unscheduled treatment modification was required. Within 4 weeks of transition to LPV/r, 9 (22.5%) had transient HIV RNA increases, likely due to poor LPV/r palatability. At 12 weeks, 22 (55%) of 40 were <40 copies/mL (93% <400 copies/mL); by 24 weeks, 27 of 38 (71%) were < 40 copies/mL (84% < 400 copies/mL). HIV-1 RNA response at 12 and 24 weeks did not differ by baseline HIV RNA or other factors. Conclusions NVP/ZDV/3TC started in the first week of life was safe and effective, even when trough NVP levels were below target. Transient viral increases occurred following transition to LPV/r, but by 12 and 24 weeks most children achieved and maintained viral suppression. Clinical Trials Registration NCT02369406.
Collapse
Affiliation(s)
- Kenneth Maswabi
- Botswana-Harvard AIDS Institute Partnership, LLC, Gaborone, Botswana
| | - Gbolahan Ajibola
- Botswana-Harvard AIDS Institute Partnership, LLC, Gaborone, Botswana
| | - Kara Bennett
- Bennett Statistical Consulting, Inc, Ballston Lake, New York, USA
| | | | | | - Sikhulile Moyo
- Botswana-Harvard AIDS Institute Partnership, LLC, Gaborone, Botswana.,Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Terence Mohammed
- Botswana-Harvard AIDS Institute Partnership, LLC, Gaborone, Botswana
| | - Oganne Batlang
- Botswana-Harvard AIDS Institute Partnership, LLC, Gaborone, Botswana
| | - Maureen Sakoi
- Botswana-Harvard AIDS Institute Partnership, LLC, Gaborone, Botswana
| | - Shahin Lockman
- Botswana-Harvard AIDS Institute Partnership, LLC, Gaborone, Botswana.,Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph Makhema
- Botswana-Harvard AIDS Institute Partnership, LLC, Gaborone, Botswana.,Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Mathias Lichterfeld
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel R Kuritzkes
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael D Hughes
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Roger L Shapiro
- Botswana-Harvard AIDS Institute Partnership, LLC, Gaborone, Botswana.,Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
6
|
Ruel TD, Capparelli EV, Tierney C, Nelson BS, Coletti A, Bryson Y, Cotton MF, Spector SA, Mirochnick M, LeBlanc R, Reding C, Zimmer B, Persaud D, Bwakura-Dangarembizi M, Naidoo KL, Hazra R, Jean-Philippe P, Chadwick EG. Pharmacokinetics and safety of early nevirapine-based antiretroviral therapy for neonates at high risk for perinatal HIV infection: a phase 1/2 proof of concept study. Lancet HIV 2021; 8:e149-e157. [PMID: 33242457 PMCID: PMC7933083 DOI: 10.1016/s2352-3018(20)30274-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 09/11/2020] [Accepted: 10/02/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND With increasing intention to treat HIV as early as possible, evidence to confirm the safety and therapeutic drug concentrations of a nevirapine-based antiretroviral regimen in the early neonatal period is needed. This study aims to establish dosing of nevirapine for very early treatment of HIV-exposed neonates at high risk of HIV acquisition. METHODS IMPAACT P1115 is a multinational phase 1/2 proof-of-concept study in which presumptive treatment for in-utero HIV infection is initiated within 48 h of birth in HIV-exposed neonates at high risk of HIV acquisition. Participants were neonates who were at least 34 weeks gestational age at birth and enrolled within 48 h of birth, born to women with presumed or confirmed HIV infection who had not received antiretrovirals during this pregnancy. The regimen consisted of two nucleoside reverse transcriptase inhibitors plus nevirapine dosed at 6 mg/kg twice daily for term neonates (≥37 weeks gestational age) or 4 mg/kg twice daily for 1 week and 6 mg/kg twice daily thereafter for preterm neonates (34 to <37 weeks gestational age). Here, we report the secondary outcomes of the study: nevirapine exposures in study weeks 1 and 2 and treatment-associated grade 3 or 4 adverse events at least possibly related to study treatment up to study week 4. A population pharmacokinetic model to assess nevirapine exposure was developed from dried blood spot and plasma nevirapine concentrations at study weeks 1 and 2. Nevirapine exposure was assessed in all patients with available blood samples and safety was assessed in all participants. This trial is registered at ClinicalTrials.gov (NCT02140255). FINDINGS Between Jan 23, 2015, and Sept 4, 2017, 438 neonates were enrolled and included in analyses; 36 had in-utero HIV infection and 389 (89%) were born at term. Neonates without confirmed in-utero HIV infection received nevirapine for a median of 13 days (IQR 7-14). Measured dried blood spot nevirapine concentrations were higher than the minimum HIV treatment target (3 μg/mL) in 314 (90%, 95% CI 86-93) of 349 neonates at week 1 and 174 (87%, 81-91) of 201 at week 2. In Monte-Carlo simulations, week 1 nevirapine concentrations exceeded 3 μg/mL in 80% of term neonates and 82% of preterm neonates. DAIDS grade 3 or 4 adverse events at least possibly related to antiretrovirals occurred in 30 (7%, 95% CI 5-10) of 438 infants but did not lead to nevirapine cessation in any neonates; neutropenia (25 [6%] neonates) and anaemia (six [1%]) were most common. INTERPRETATION Nevirapine at the dose studied was confirmed to be safe and provides therapeutic exposure concentrations. These data support nevirapine as a component of presumptive HIV treatment in high-risk neonates. FUNDING National Institute of Allergy and Infectious Diseases, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Institute of Mental Health.
Collapse
Affiliation(s)
- Theodore D Ruel
- University of California San Francisco, San Francisco, CA, USA.
| | | | - Camlin Tierney
- Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Bryan S Nelson
- Harvard TH Chan School of Public Health, Boston, MA, USA
| | | | | | | | | | | | - Rebecca LeBlanc
- Frontier Science and Technology Research Foundation, Amherst, NY, USA
| | - Christina Reding
- Frontier Science and Technology Research Foundation, Amherst, NY, USA
| | - Bonnie Zimmer
- Frontier Science and Technology Research Foundation, Amherst, NY, USA
| | - Deborah Persaud
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Rohan Hazra
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Patrick Jean-Philippe
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Ellen G Chadwick
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| |
Collapse
|
7
|
Perinatal Antiretroviral Intensification to Prevent Intrapartum HIV Transmission When Antenatal Antiretroviral Therapy Is Initiated Less Than 8 Weeks Before Delivery. J Acquir Immune Defic Syndr 2020; 84:313-322. [PMID: 32205720 PMCID: PMC9741956 DOI: 10.1097/qai.0000000000002350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Infants born to women living with HIV initiating combination antiretroviral therapy (cART) late in pregnancy are at high risk of intrapartum infection. Mother/infant perinatal antiretroviral intensification may substantially reduce this risk. METHODS In this single-arm Bayesian trial, pregnant women with HIV receiving standard of care antiretroviral prophylaxis in Thailand (maternal antenatal lopinavir-based cART; nonbreastfed infants 4 weeks' postnatal zidovudine) were offered "antiretroviral intensification" (labor single-dose nevirapine plus infant zidovudine-lamivudine-nevirapine for 2 weeks followed by zidovudine-lamivudine for 2 weeks) if their antenatal cART was initiated ≤8 weeks before delivery. A negative birth HIV-DNA polymerase chain reaction (PCR) followed by a confirmed positive PCR defined intrapartum transmission. Before study initiation, we modeled intrapartum transmission probabilities using data from 3738 mother/infant pairs enrolled in our previous trials in Thailand using a logistic model, with perinatal maternal/infant antiretroviral regimen and predicted viral load at delivery as main covariates. Using the characteristics of the women enrolled who received intensification, prior intrapartum transmission probabilities (credibility intervals) with/without intensification were estimated. After including the transmission data observed in the current study, the corresponding Bayesian posterior transmission probability was derived. RESULTS No intrapartum transmission of HIV was observed among the 88 mother/infant pairs receiving intensification. The estimated intrapartum transmission probability was 2·2% (95% credibility interval 0·5-6·1) without intensification versus 0·3% (0·0-1·6) with intensification. The probability of superiority of intensification over standard of care was 94·4%. Antiretroviral intensification appeared safe. CONCLUSION Mother/infant antiretroviral intensification was effective in preventing intrapartum transmission of HIV in pregnant women receiving ≤8 weeks antepartum cART.
Collapse
|
8
|
Mazanderani AH, Murray TY, Sherman GG, Snyman T, George J, Avenant T, Goga AE, Pepper MS, du Plessis N. Non-nucleoside reverse transcriptase inhibitor levels among HIV-exposed uninfected infants at the time of HIV PCR testing - findings from a tertiary healthcare facility in Pretoria, South Africa. J Int AIDS Soc 2019; 22:e25284. [PMID: 31215757 PMCID: PMC6582367 DOI: 10.1002/jia2.25284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 03/29/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION To date, very little programmatic data has been published regarding serial antiretroviral (ARV) levels in infants exposed to maternal treatment and/or infant prophylaxis during the first months of life. Such data provide the opportunity to describe the proportion of infants exposed to virologically suppressive levels of ARVs and to gauge adherence to the prevention of mother-to-child transmission of HIV (PMTCT) programme. METHODS From August 2014 to January 2016, HIV-exposed infants born at Kalafong Provincial Tertiary Hospital in Pretoria, South Africa were enrolled as part of an observational cohort study. Plasma samples from HIV-exposed uninfected infants were obtained at birth, 6-weeks, 10-weeks and 14-weeks of age and quantitative efavirenz (EFV) and nevirapine (NVP) drug level testing performed using liquid chromatography-mass spectrometry, irrespective of maternal ARV regimen. Descriptive analysis of EFV and NVP levels in relation to self-reported maternal and infant ARV exposure was performed. EFV levels >500 ng/mL and NVP levels >100 ng/mL were reported based on studies suggesting that trough levels above these thresholds are associated with virological suppression and PMTCT respectively. RESULTS Among 66 infants exposed to maternal EFVin utero, 29 (44%) had virologically suppressive plasma EFV levels at birth, with a median level of 1665 ng/mL (IQR: 1094 to 3673). Among infants who were exclusively breastfed at 6-, 10- and 14 weeks, 13/48 (27%), 5/25 (25%) and 0/21 (0%) had virologically suppressive EFV levels. Among 64 infants whose mothers reported administering daily infant NVP at time of their 6-week HIV PCR test, only 45 (70%) had NVP levels above the minimum prophylactic trough level. CONCLUSIONS During the first 10-weeks after delivery, a quarter of breastfed infants born to women on an EFV-containing treatment regimen maintained virologically suppressive EFV plasma levels. This finding highlights the importance of both careful monitoring of ARV side effects and repeat HIV PCR after the first few months of life among HIV-exposed uninfected infants. As 30% of infants had inadequate NVP plasma levels at 6-weeks of age, adherence counselling to caregivers regarding infant prophylaxis needs to be enhanced to further reduce mother-to-child transmission of HIV.
Collapse
Affiliation(s)
- Ahmad Haeri Mazanderani
- Centre for HIV & STIsNational Institute for Communicable DiseasesNational Health Laboratory ServiceJohannesburgSouth Africa
- Department of Medical VirologyFaculty of Health SciencesUniversity of PretoriaPretoriaSouth Africa
| | - Tanya Y Murray
- Centre for HIV & STIsNational Institute for Communicable DiseasesNational Health Laboratory ServiceJohannesburgSouth Africa
- Paediatric HIV DiagnosticsWits Health ConsortiumJohannesburgSouth Africa
| | - Gayle G Sherman
- Centre for HIV & STIsNational Institute for Communicable DiseasesNational Health Laboratory ServiceJohannesburgSouth Africa
- Paediatric HIV DiagnosticsWits Health ConsortiumJohannesburgSouth Africa
- Department of Paediatrics & Child HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Tracy Snyman
- Department of Chemical PathologyNational Health Laboratory Service and University of WitwatersrandJohannesburgSouth Africa
| | - Jaya George
- Department of Chemical PathologyNational Health Laboratory Service and University of WitwatersrandJohannesburgSouth Africa
| | - Theunis Avenant
- Paediatric Infectious Diseases DivisionDepartment of PaediatricsKalafong Provincial Tertiary HospitalPretoriaSouth Africa
- Department of Paediatrics and Child HealthFaculty of Health SciencesUniversity of PretoriaPretoriaSouth Africa
| | - Ameena E Goga
- Department of Paediatrics and Child HealthFaculty of Health SciencesUniversity of PretoriaPretoriaSouth Africa
- Health Systems Research UnitSouth African Medical Research CouncilCape TownSouth Africa
| | - Michael S Pepper
- Institute for Cellular and Molecular MedicineDepartment of ImmunologySAMRC Extramural Unit for Stem Cell Research and TherapyFaculty of Health SciencesUniversity of PretoriaPretoriaSouth Africa
| | - Nicolette du Plessis
- Paediatric Infectious Diseases DivisionDepartment of PaediatricsKalafong Provincial Tertiary HospitalPretoriaSouth Africa
- Department of Paediatrics and Child HealthFaculty of Health SciencesUniversity of PretoriaPretoriaSouth Africa
| |
Collapse
|
9
|
Nevirapine Concentrations During the First Month of Life and Maternal Efavirenz Washout in High-Risk HIV-Exposed Infants Receiving Triple Antiretroviral Prophylaxis. Pediatr Infect Dis J 2019; 38:152-156. [PMID: 30204660 DOI: 10.1097/inf.0000000000002195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Triple-drug infant antiretroviral prophylaxis containing nevirapine (NVP) is increasingly used to prevent HIV transmission among neonates at high risk of HIV infection. Our aim was to describe NVP concentration from birth through the first month of life. METHODS High-risk HIV-exposed neonates were enrolled in a prospective cohort in Thailand. High-risk neonates defined as maternal HIV RNA >50 copies/mL before delivery or mother received antiretroviral treatment for <12 weeks before delivery. Neonates received zidovudine (4 mg/kg) and lamivudine (2 mg/kg) twice daily, plus NVP (4 mg/kg) once daily (no lead-in) from birth to 6 weeks of life. Infant plasma samples were collected at 1, 2, 14 or 2, 7, 28 days of life. NVP trough concentrations (C24) were estimated using a population pharmacokinetic model and target C24 was ≥0.1 mg/L. "Washout" efavirenz (EFV) concentrations were assessed in infants whose mother received EFV-based antiretroviral treatment. RESULTS A total of 48 infants were included: 25 (52%) were male and 12 (25%) were preterm (gestational age 34-37 weeks). Median (interquartile range) predicted NVP C24 were 1.34 mg/L (1.13-1.84), 2.24 (2.00-2.59), 2.78 (2.61-3.12), 2.20 (1.86-2.44) and 0.81 (0.58-0.98) on days 1, 2, 7, 14 and 28 of life, respectively. NVP C24 was not significantly different between term and preterm infants. All infants maintained NVP C24 ≥0.1 mg/L. EFV via placental transfer remained detectable in infants up to 7 days of life. CONCLUSIONS NVP 4 mg/kg daily from birth provided adequate prophylactic concentrations during the first month of life in high-risk HIV-exposed neonates.
Collapse
|
10
|
Abstract
INTRODUCTION Recent goals of antiretroviral treatment of neonates have expanded from reducing morbidity and mortality to also aiming to facilitate HIV remission. Areas covered: In this review, we present and discuss the rationale and evidence-bases for each of these distinct goals. Next we discuss the challenges of how to identify HIV-infected neonates. Finally, we discuss the specific antiretroviral drugs that are preferred for this group, making distinctions between the use of these agents in prevention and treatment. Expert commentary: The clinical and scientific challenges of pharmacological treatment of acute HIV infection in neonates are complicated by externalities beyond biology. At the same time, these challenges are energized by the unique biological opportunities afforded by investigating this population, including a unique immune profile, ability to study both mother and neonate as well as transmitted and acquired virus, and time period spanning both the period soon after infection as well as the period of viral reservoir establishment and related damage. Given the unique scientific opportunities afforded by study of pharmacologic treatment of acute HIV infection in neonates, we hypothesize that over the next five years breakthroughs may occur that may lead to new interventions effective at achieving HIV remission.
Collapse
Affiliation(s)
- Louise Kuhn
- Professor of Epidemiology, Gertrude H. Sergievsky Center, College of Physicians and Surgeons 622, West 168 Street, PH 19-113 New York, NY, 10032
| | - Stephanie Shiau
- Postdoctoral Research Scientist Gertrude H. Sergievsky Center College of Physicians and Surgeons 622 West 168 Street, PH 19-118 New York, NY, 10032,
| |
Collapse
|
11
|
Clarke DF, Penazzato M, Capparelli E, Cressey TR, Siberry G, Sugandhi N, Mirochnick M. Prevention and treatment of HIV infection in neonates: evidence base for existing WHO dosing recommendations and implementation considerations. Expert Rev Clin Pharmacol 2017; 11:83-93. [PMID: 29039686 DOI: 10.1080/17512433.2018.1393331] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Antiretroviral drugs are used in neonates for prevention and treatment of HIV infection. Use of antiretrovirals to prevent perinatal HIV transmission is well established. Early identification of neonates infected with HIV and rapid initiation of combination antiretroviral treatment during the neonatal period is now recommended by WHO and DHHS. However, few antiretrovirals are available in formulations suitable for neonates and there are limited safety and pharmacokinetic data for most antiretrovirals in neonates. Areas covered: We summarize existing neonatal antiretroviral safety and pharmacokinetic information and discuss implementation considerations for programs providing antiretrovirals to neonates and young infants. Expert commentary: Antiretrovirals currently recommended by WHO for use in neonates are zidovudine, lamivudine, lopinavir/ritonavir, nevirapine, and raltegravir. Significant implementation challenges exist to the widespread use of these antiretrovirals in neonates. Optimal, feasible treatment of HIV-exposed and HIV-infected newborns will require development of practical neonatal dosage forms and their study in neonates for a wide range of antiretrovirals.
Collapse
Affiliation(s)
- Diana F Clarke
- a Department of Pediatric Infectious Diseases , Boston Medical Center , Boston , MA , USA.,b Department of Pediatrics , Boston University School of Medicine , Boston , MA , USA
| | - Martina Penazzato
- c Department of HIV/AIDS , World Health Organization , Geneva , Switzerland
| | - Edmund Capparelli
- d Skaggs School of Pharmacy and Pharmaceutical Sciences , University of California San Diego , La Jolla , CA , USA
| | - Tim R Cressey
- e PHPT-IRD (UMI 174), Faculty of Associated Medical Sciences , Chiang Mai University , Chiang Mai , Thailand.,f Department of Immunology & Infectious Diseases , Harvard T.H. Chan School of Public Health , Boston , MA , USA.,g Department of Molecular & Clinical Pharmacology , University of Liverpool , Liverpool , UK
| | - George Siberry
- h Office of the Global AIDS , U.S. Department of State , Washington , DC , USA
| | | | - Mark Mirochnick
- b Department of Pediatrics , Boston University School of Medicine , Boston , MA , USA
| | | |
Collapse
|
12
|
Canals F, Masiá M, Gutiérrez F. Developments in early diagnosis and therapy of HIV infection in newborns. Expert Opin Pharmacother 2017; 19:13-25. [PMID: 28764578 DOI: 10.1080/14656566.2017.1363180] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Infants who acquire HIV have an exceptionally high risk of morbidity and mortality if they do not receive antiretroviral therapy (ART). AREAS COVERED This review aims to summarize the currently available evidence on ART in HIV-infected neonates. Data were obtained from literature searches from PubMed, abstracts from International Conferences (2000-2017), and authors' files EXPERT OPINION Current evidence favors early diagnosis and prompt ART of HIV infection in newborns. The precise timing of initiation of ART remains undetermined. Very early (close to birth) ART appears to limit the size of the viral reservoir and may restrict replication-competent virus, but the clinical benefit remains unproven. Among the current options for initial therapy, in full term neonates from 2 weeks of life onwards, a lopinavir/ritonavir-based three-drug regimen is preferred. In term infants, younger than 2 weeks a nevirapine-based regimen is recommended, although there are no clinical trial data supporting that initiating treatment before 2 weeks improves outcome compared to starting afterwards. Existing safety information is insufficient to recommend ART in preterm infants, with pharmacokinetic data available for zidovudine only. If ART is considered in this setting, an individual case assessment of the risk/benefit ratio of treatment should be made.
Collapse
Affiliation(s)
- Francisco Canals
- a Department of Infectious Diseases, Hospital General de Elche , Universidad Miguel Hernández , Alicante , Spain.,b Department of Pediatrics , Hospital General de Elche , Alicante , Spain
| | - Mar Masiá
- a Department of Infectious Diseases, Hospital General de Elche , Universidad Miguel Hernández , Alicante , Spain
| | - Félix Gutiérrez
- a Department of Infectious Diseases, Hospital General de Elche , Universidad Miguel Hernández , Alicante , Spain
| |
Collapse
|