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Atkinson A, Tulloch K, Boucoiran I, Money D. Guideline No. 450: Care of Pregnant Women Living with HIV and Interventions to Reduce Perinatal Transmission. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102551. [PMID: 38734074 DOI: 10.1016/j.jogc.2024.102551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
OBJECTIVE This guideline provides an update on the care of pregnant women living with HIV and the prevention of perinatal HIV transmission. This guideline is a revision of the previous guideline, No. 310 Guidelines for the Care of Pregnant Women Living With HIV and Interventions to Reduce Perinatal Transmission, and includes an updated review of the literature with contemporary recommendations. TARGET POPULATION Pregnant women newly diagnosed with HIV during antenatal screening and women living with HIV who become pregnant. This guideline does not include specific guidance for girls/women of reproductive age living with HIV who are not pregnant. OUTCOMES Prevention of perinatal HIV transmission is a key indicator of the success of a health care system and requires multidisciplinary care of pregnant women living with HIV. Intended outcomes include guidance on best practice in perinatal management for Canadian health care providers for pregnant women living with HIV; reduction of perinatal transmission of HIV toward a target of eradication of perinatal transmission; provision of optimal antenatal care for pregnant women to ensure the best maternal health outcomes and HIV suppression; and evidence-based support and recommendations for pregnant women living with HIV, maintaining awareness and consideration of the complex psychosocial impacts of living with HIV. BENEFITS, HARMS, AND COSTS The perinatal transmission of HIV has significant morbidity and mortality implications for the child, with associated lifelong health care costs. Pregnancy presents an emotionally and physically vulnerable time for pregnant women as well as an opportunity to engage them in health promotion. This guidance does not include recommendations with additional costs to health care facilities compared with the previous guideline. Application of the recommendations is aimed at health benefits to both mother and child by optimizing maternal health and preventing perinatal HIV transmission. EVIDENCE Published and unpublished literature was reviewed with a focus on publications post-2013. OVID-Medline, Embase, PubMed and the Cochrane Library databases were searched for relevant publications available in English or French for each section of this guideline. Results included systematic reviews, randomized controlled trials, and observational studies published from 2012 to 2022. Searches were updated on a regular basis and incorporated in the guideline until May 2023. Unpublished literature, protocols, and international guidelines were identified by accessing the websites of health-related agencies, clinical practice guideline collections, and national and international medical specialty societies. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional recommendations). INTENDED AUDIENCE The intended users of this guideline include obstetric care providers and infectious disease clinicians who provide care for pregnant women living with HIV. SOCIAL MEDIA SUMMARY Updated Canadian HIV in pregnancy guideline informed by global research and tailored to Canadian healthcare needs and goals for pregnant women living with HIV and their families. SUMMARY STATEMENTS RECOMMENDATIONS.
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Todorović Z, Dragović G, Lukić R. Pharmacokinetic and toxicological considerations affecting antiretroviral drug dosing in pregnant women. Expert Opin Drug Metab Toxicol 2024:1-19. [PMID: 38738389 DOI: 10.1080/17425255.2024.2353762] [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: 11/23/2023] [Accepted: 05/07/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION To prevent mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV) during pregnancy, the appropriate dosing regimens of antiretroviral (ARV) drugs need to be determined. Reliable data about pharmacokinetic (PK) characteristics of ARVs from randomized clinical trials (RCTs) are lacking, and post-marketing observational studies may offer valuable, but sometimes insufficient data, especially in pregnant people living with HIV (PLWHIV). This review article is focused PK and toxicological considerations affecting ARV dosing in pregnant PLWHIV. AREAS COVERED In our search, we included studies focused on PKs of ARVs in pregnancy available on PubMed, abstracts from recent global conferences and data from modeling studies. There are no significant changes in PKs of nucleoside/nucleotide reverse transcriptase inhibitors and non-nucleoside reverse transcriptase inhibitors throughout pregnancy. In contrast, the PKs of PIs and INSTIs are more variable, especially in the second and third trimesters. EXPERT OPINION Pregnant women are left out of RCTs. To the greatest extent possible, future research should include pregnant persons in RCTs, including PK studies, strictly considering maternal and fetal safety. Alternative innovative approaches/models need to be developed to obtain reliable data about rational pharmacotherapy of ARVs in the effective PMTCT of HIV, with maximum safety.
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Affiliation(s)
- Zoran Todorović
- Faculty of Medicine, Department of Pharmacology, Clinical Pharmacology and Toxicology, University of Belgrade, Belgrade, Serbia
| | - Gordana Dragović
- Faculty of Medicine, Department of Pharmacology, Clinical Pharmacology and Toxicology, University of Belgrade, Belgrade, Serbia
| | - Relja Lukić
- Faculty of Medicine, Obstetrics and Gynaecology Clinic GAK "Narodni Front", University of Belgrade, Belgrade, Serbia
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Brooks KM, Scarsi KK, Mirochnick M. Antiretrovirals for Human Immunodeficiency Virus Treatment and Prevention in Pregnancy. Obstet Gynecol Clin North Am 2023; 50:205-218. [PMID: 36822704 DOI: 10.1016/j.ogc.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Safe and effective antiretroviral medications are needed during pregnancy to reduce maternal morbidity and mortality associated with untreated human immunodeficiency virus (HIV) infection and to prevent viral transmission to the infant. Pharmacokinetic studies have helped inform the appropriate dosing of antiretroviral medications during pregnancy. However, data from these studies consistently become available years after initial regulatory approvals in nonpregnant adults. In this article, the authors provide an overview of considerations in use of antiretroviral medications in pregnant people with or at risk for HIV, pharmacokinetic studies that helped support recommended options, and therapies either under active investigation or in need of prospective study.
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Affiliation(s)
- Kristina M Brooks
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
| | - Kimberly K Scarsi
- Department of Pharmacy Practice and Science, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Room 3021, Omaha, NE 68198, USA.
| | - Mark Mirochnick
- Boston University School of Medicine, 801 Albany Street, Room 2021, Boston, MA 20118, USA
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Stika CS. Principles of Obstetric Pharmacology: Maternal Physiologic and Hepatic Metabolism Changes. Obstet Gynecol Clin North Am 2023; 50:1-15. [PMID: 36822695 DOI: 10.1016/j.ogc.2022.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Since the recognition of pregnancy as a special pharmacokinetic population in the late 1990s, investigations have expanded our understanding of obstetric pharmacology. Many of the basic physiologic changes that occur during pregnancy impact on drug absorption, distribution, or clearance. Activities of hepatic metabolizing enzymes are variably altered by pregnancy, resulting in concentrations sufficiently different for some drugs that efficacy or toxicity may be affected. Understanding these unique pharmacologic changes will better inform our use of medications for our pregnant patients.
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Affiliation(s)
- Catherine S Stika
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 East Superior Street, Suite 03-2303, Chicago, IL 60611, USA.
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Magnitude of Drug–Drug Interactions in Special Populations. Pharmaceutics 2022; 14:pharmaceutics14040789. [PMID: 35456623 PMCID: PMC9027396 DOI: 10.3390/pharmaceutics14040789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/28/2022] [Accepted: 04/01/2022] [Indexed: 02/05/2023] Open
Abstract
Drug–drug interactions (DDIs) are one of the most frequent causes of adverse drug reactions or loss of treatment efficacy. The risk of DDIs increases with polypharmacy and is therefore of particular concern in individuals likely to present comorbidities (i.e., elderly or obese individuals). These special populations, and the population of pregnant women, are characterized by physiological changes that can impact drug pharmacokinetics and consequently the magnitude of DDIs. This review compiles existing DDI studies in elderly, obese, and pregnant populations that include a control group without the condition of interest. The impact of physiological changes on the magnitude of DDIs was then analyzed by comparing the exposure of a medication in presence and absence of an interacting drug for the special population relative to the control population. Aging does not alter the magnitude of DDIs as the related physiological changes impact the victim and perpetrator drugs to a similar extent, regardless of their elimination pathway. Conversely, the magnitude of DDIs can be changed in obese individuals or pregnant women, as these conditions impact drugs to different extents depending on their metabolic pathway.
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Momper JD, Wang J, Stek A, Shapiro DE, Powis KM, Paul ME, Badell ML, Browning R, Chakhtoura N, Denson K, Rungruengthanakit K, George K, Capparelli EV, Mirochnick M, Best BM. Pharmacokinetics of Atazanavir Boosted With Cobicistat in Pregnant and Postpartum Women With HIV. J Acquir Immune Defic Syndr 2022; 89:303-309. [PMID: 34732682 PMCID: PMC8837686 DOI: 10.1097/qai.0000000000002856] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/11/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study evaluated atazanavir and cobicistat pharmacokinetics during pregnancy compared with postpartum and in infant washout samples. SETTING A nonrandomized, open-label, parallel-group, multicenter prospective study of atazanavir and cobicistat pharmacokinetics in pregnant women with HIV and their children. METHODS Intensive steady-state 24-hour pharmacokinetic profiles were performed after administration of 300 mg of atazanavir and 150 mg of cobicistat orally in fixed-dose combination once daily during the second trimester, third trimester, and postpartum. Infant washout samples were collected after birth. Atazanavir and cobicistat were measured in plasma by validated high-performance liquid chromatography-ultraviolet and liquid chromatography-tandem mass spectrometry assays, respectively. A 2-tailed Wilcoxon signed-rank test (α = 0.10) was used for paired within-participant comparisons. RESULTS A total of 11 pregnant women enrolled in the study. Compared with paired postpartum data, atazanavir AUC0-24 was 26% lower in the second trimester [n = 5, P = 0.1875, geometric mean of ratio (GMR) = 0.739, 90% CI: 0.527 to 1.035] and 54% lower in the third trimester (n = 6, GMR = 0.459, P = 0.1563, 90% CI: 0.190 to 1.109), whereas cobicistat AUC0-24 was 35% lower in the second trimester (n = 5, P = 0.0625, GMR = 0.650, 90% CI: 0.493 to 0.858) and 52% lower in the third trimester (n = 7, P = 0.0156, GMR = 0.480, 90% CI: 0.299 to 0.772). The median (interquartile range) 24-hour atazanavir trough concentration was 0.21 μg/mL (0.16-0.28) in the second trimester, 0.21 μg/mL (0.11-0.56) in the third trimester, and 0.61 μg/mL (0.42-1.03) in postpartum. Placental transfer of atazanavir and cobicistat was limited. CONCLUSIONS Standard atazanavir/cobicistat dosing during pregnancy results in lower exposure which may increase the risk of virologic failure and perinatal transmission.
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Affiliation(s)
| | - Jiajia Wang
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alice Stek
- University of Southern California, Los Angeles, CA, USA
| | - David E. Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Kathleen M. Powis
- Departments of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Renee Browning
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Nahida Chakhtoura
- National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Kayla Denson
- Frontier Science & Technology Research Foundation, Inc, Amherst, NY, USA
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Gilmore JC, Zhang G, Cameron DW, Serghides L, Bendayan R. Impact of in-utero antiretroviral drug exposure on expression of membrane-associated transporters in mouse placenta and fetal brain. AIDS 2021; 35:2249-2258. [PMID: 34175869 DOI: 10.1097/qad.0000000000003009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Although antiretroviral therapy (ART) during pregnancy is effective in limiting vertical HIV transmission, adverse outcomes persist amongst uninfected children exposed to antiretroviral drugs in utero. Membrane-associated drug transporters, metabolic enzymes, and tight junction proteins play important roles in adult antiretroviral drug disposition and toxicity; however, the fetal expression of these proteins in the context of ART, and their impact on in-utero antiretroviral drug distribution remain poorly understood. This study aimed to characterize the role of these proteins in modulating in-utero antiretroviral drug exposure. METHODS Pregnant mice were exposed to an ART regimen consisting of lamivudine, abacavir, atazanavir, and ritonavir, at clinically relevant doses. Fetal brain, liver, placenta amniotic fluid, and maternal plasma were collected on gestational day 18.5 and concentration of antiretroviral drugs in fetal tissues was measured by LC/MS/MS, whereas transporter expression was assessed by qPCR. RESULTS Abacavir and lamivudine were detected in fetal brain and amniotic fluid, whereas atazanavir and ritonavir were detected in amniotic fluid only. Robust mRNA expression of key transporters was observed in adult and fetal tissues, and sex differences were identified in the expression of Abcc1 and Slc29a1 in the placenta. Antiretroviral drug exposure was associated with a reduction in relative placental Abcg2, Abcc1, and Slc29a1 expression. CONCLUSION These findings identify a novel effect of fetal sex and antiretroviral drug treatment on the expression of placental transporters in a mouse model, and characterize the penetration of lamivudine and abacavir into fetal brain, uncovering a potential role of transporters in modulating fetal exposure to antiretroviral drugs.
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Affiliation(s)
- Julian C Gilmore
- Department of Pharmaceutical Sciences, University of Toronto, Toronto
| | - Guijun Zhang
- Clinical Investigation Unit, University of Ottawa at the Ottawa Hospital/Research Institute, Ottawa
| | - D William Cameron
- Clinical Investigation Unit, University of Ottawa at the Ottawa Hospital/Research Institute, Ottawa
| | - Lena Serghides
- Department of Immunology and Institute of Medical Sciences, University of Toronto
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Reina Bendayan
- Department of Pharmaceutical Sciences, University of Toronto, Toronto
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Cerveny L, Murthi P, Staud F. HIV in pregnancy: Mother-to-child transmission, pharmacotherapy, and toxicity. Biochim Biophys Acta Mol Basis Dis 2021; 1867:166206. [PMID: 34197912 DOI: 10.1016/j.bbadis.2021.166206] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/18/2021] [Accepted: 06/11/2021] [Indexed: 12/15/2022]
Abstract
An estimated 1.3 million pregnant women were living with HIV in 2018. HIV infection is associated with adverse pregnancy outcomes and all HIV-positive pregnant women, regardless of their clinical stage, should receive a combination of antiretroviral drugs to suppress maternal viral load and prevent vertical fetal infection. Although antiretroviral treatment in pregnant women has undoubtedly minimized mother-to-child transmission of HIV, several uncertainties remain. For example, while pregnancy is accompanied by changes in pharmacokinetic parameters, relevant data from clinical studies are lacking. Similarly, long-term adverse effects of exposure to antiretrovirals on fetuses have not been studied in detail. Here, we review current knowledge on HIV effects on the placenta and developing fetus, recommended antiretroviral regimens, and pharmacokinetic considerations with particular focus on placental transport. We also discuss recent advances in antiretroviral research and potential effects of antiretroviral treatment on placental/fetal development and programming.
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Affiliation(s)
- Lukas Cerveny
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Padma Murthi
- Department of Medicine, School of Clinical Sciences, and Department of Pharmacology, Monash Biomedicine Discovery Institute Monash University, Clayton, Victoria, Australia; Hudson Institute of Medical Research, The Ritchie Centre, Clayton, Victoria, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
| | - Frantisek Staud
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic.
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9
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Therapeutic Drug Monitoring of HIV Antiretroviral Drugs in Pregnancy: A Narrative Review. Ther Drug Monit 2021; 42:229-244. [PMID: 32004247 DOI: 10.1097/ftd.0000000000000735] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To date, therapeutic drug monitoring (TDM) has played an important role in the management of pregnant HIV patients on highly active antiretroviral therapy. Historically, in pregnant women living with HIV, the third agent in triple therapy has been either non-nucleoside reverse transcriptase inhibitors or protease inhibitors (PIs). PIs have been the preferred agents because of their robustness from the perspective of viral resistance and the dominant drug class for the management of HIV during pregnancy for the previous decade. As with many drugs used during pregnancy, pharmacokinetic changes decrease exposure to these agents as the pregnancy progresses. This can lead to viral escape at the time of pregnancy and ultimately increase the risk of mother-to-child transmission (MTCT) of HIV. TDM has been well-established for this class of highly active antiretroviral therapy, and appropriate dose adjustment studies have been performed. At present, there is a shift from the traditional treatment paradigm in pregnancy to a new drug class, integrase strand transfer inhibitors (INSTIs). Although INSTIs are affected by pharmacokinetic changes during pregnancy, they do not harbor the same issues with viral escape as seen with PIs at birth and in general eliminate the need for boosting with additional agents like ritonavir (r) and cobicistat (c) [bar elvitegravir (EVG)] that can lead to interactions with treatment of other common infections in HIV, including tuberculosis. Furthermore, INSTIs are the most successful medication for rapidly reducing the viral load (VL) in HIV patients, a useful factor where VL may be unknown, or in late presenters. These merits make INSTIs the best choice in pregnancy, although their use has been hindered in recent years by a report of neural tube defects from a large African study with dolutegravir (DTG). New data from Botswana and Brazil indicate that this risk is less significant than previously reported, necessitating further data to shed light on this critical issue. Current international guidelines including DHHS, EACS, WHO, and BHIVA (for patients with VLs >100,000 copies/mL or late presenters) now recommend INSTIs as first-line agents. The role of TDM in INSTIs shifts to cases of insufficient viral suppression with standard adherence measures, cases of drug-drug interactions, or cases where EVG/c is continued throughout pregnancy, and thus remains an important aspect of HIV care in pregnancy.
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Abstract
BACKGROUND This study aims to evaluate the pharmacokinetics of an increased dose of darunavir (800 mg twice daily) with 100 mg ritonavir during pregnancy and postpartum. METHODS Darunavir (DRV) and ritonavir (RTV; r) intensive pharmacokinetic evaluations were performed at steady state during the second and third trimesters of pregnancy (DRV/r 800/100 mg bid) and 2-3 weeks postpartum (DRV/r 600/100 mg twice daily). Plasma concentrations of darunavir and ritonavir were measured using high-performance liquid chromatography. Target darunavir area under the concentration time curve (AUC) was >70% (43.6 μg × h/mL) of median AUC (62.3 μg × h/mL) in nonpregnant adults on twice daily darunavir-ritonavir 600/100 mg. RESULTS Twenty-four women were included in the analysis. Darunavir AUC0-12 was lower with the increased dose during the second {[geometric mean ratio (GMR) of 0.62 (IQR 0.44-0.88); P = 0.055]} and third trimesters [GMR 0.64 (IQR 0.55-0.73); P = <0.001] compared with postpartum. Darunavir apparent clearance was higher during the second [GMR 1.77 (IQR 1.24-2.51); P = 0.039] and third trimesters [GMR 2.01 (IQR 1.17-2.35); P = <0.001] compared with postpartum. Similarly, ritonavir AUC0-12 was lower during the third trimester [GMR 0.65 (IQR 0.52-0.82); P = 0.007] compared with postpartum, whereas its apparent clearance was higher during the third trimester [GMR 1.53 (IQR 1.22-1.92); P = 0.008] compared with postpartum. No major drug-related safety concerns were noted. CONCLUSIONS Increasing darunavir dose to 800 mg BID failed to significantly increase darunavir exposure compared with 600 mg BID. Other strategies, such as increasing the ritonavir dose should be investigated.
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11
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Salama E, Eke AC, Best BM, Mirochnick M, Momper JD. Pharmacokinetic Enhancement of HIV Antiretroviral Therapy During Pregnancy. J Clin Pharmacol 2020; 60:1537-1550. [PMID: 32798276 DOI: 10.1002/jcph.1714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/21/2020] [Indexed: 12/21/2022]
Abstract
Pharmacokinetic boosting of antiretroviral (ARV) therapies with either ritonavir or cobicistat is used to achieve target drug exposure, lower pill burden, and provide simplified dosing schedules. Several ARVs require boosting, including the integrase inhibitor elvitegravir as well as protease inhibitors such as darunavir, atazanavir, and lopinavir. The use of boosted regimens in pregnant women living with HIV has been studied for a variety of ARVs; however, a recent recommendation by the US Food and Drug Administration advised against cobicistat-boosted regimens in pregnancy due to substantially lower drug exposures observed in clinical pharmacokinetic studies. The objectives of this article are to review pharmacokinetic enhancement of ARVs with ritonavir and cobicistat during pregnancy and postpartum, describe clinical implications, and provide recommendations for future research.
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Affiliation(s)
- Engie Salama
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California, USA
| | - Ahizechukwu C Eke
- Division of Maternal Fetal Medicine & Clinical Pharmacology, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Doctoral Training Program (PhD), Graduate Training Program in Clinical Investigation (GTPCI), Johns Hopkins University School of Public Health, Baltimore, Maryland, USA
| | - Brookie M Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California, USA.,Department of Pediatrics, University of California San Diego - Rady Children's Hospital San Diego, San Diego, California, USA
| | - Mark Mirochnick
- Division of Neonatology, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jeremiah D Momper
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California, USA
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Bukkems VE, Colbers A, Marzolini C, Molto J, Burger DM. Drug-Drug Interactions with Antiretroviral Drugs in Pregnant Women Living with HIV: Are They Different from Non-Pregnant Individuals? Clin Pharmacokinet 2020; 59:1217-1236. [PMID: 32696442 PMCID: PMC7550380 DOI: 10.1007/s40262-020-00914-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background and Objective Although the separate effects of drug–drug interactions and pregnancy on antiretroviral drug pharmacokinetics have been widely studied and described, their combined effect is largely unknown. Physiological changes during pregnancy may change the extent or clinical relevance of a drug–drug interaction in a pregnant woman. This review aims to provide a detailed overview of the mechanisms, magnitude, and clinical significance of antiretroviral drug–drug interactions in pregnant women. Methods We performed a literature search and selected studies that compared the magnitude of drug–drug interactions with antiretroviral drugs in pregnant vs non-pregnant women. Results Forty-eight papers examining drug–drug interactions during pregnancy were selected, of which the majority focused on pharmacokinetic boosting. Other selected studies examined the drug–drug interactions between efavirenz and lumefantrine, efavirenz and tuberculosis drugs, etravirine and tenofovir disoproxil fumarate, atazanavir and tenofovir disoproxil, and mefloquine and nevirapine in pregnant compared to non-pregnant women. The clinical significance of antiretroviral drug–drug interactions changed during pregnancy from a minimal effect to a contra-indication. In almost all cases, the clinical significance of a drug–drug interaction was more relevant in pregnant women, owing to the combined effects of pregnancy-induced physiological changes and drug–drug interactions leading to a lower absolute drug exposure. Conclusions Multiple studies show that the clinical relevance of a drug–drug interaction can change during pregnancy. Unfortunately, many potential interactions have not been studied in pregnancy, which may place pregnant women living with human immunodeficiency virus and their newborns at risk.
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Affiliation(s)
- Vera E Bukkems
- Department of Pharmacy, Radboud University Medical Center and Radboud Institute for Health Sciences (RIHS), Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Angela Colbers
- Department of Pharmacy, Radboud University Medical Center and Radboud Institute for Health Sciences (RIHS), Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands.
| | - Catia Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital of Basel and University of Basel, Basel, Switzerland.,Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Jose Molto
- Fundació Lluita Contra La Sida, Badalona, Spain.,Infectious Diseases Department, Hospital Universitari Germans Trias I Pujol, Badalona, Spain.,Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - David M Burger
- Department of Pharmacy, Radboud University Medical Center and Radboud Institute for Health Sciences (RIHS), Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
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Maitre T, Muret P, Blot M, Waldner A, Duong M, Si-Mohammed A, Chavanet P, Aho S, Piroth L. Benefits and Limits of Antiretroviral Drug Monitoring in Routine Practice. Curr HIV Res 2020; 17:190-197. [PMID: 31490758 DOI: 10.2174/1570162x17666190903232053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/26/2019] [Accepted: 08/20/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND HIV infection is a chronic disease for which therapeutic adherence and tolerance require particular attention. OBJECTIVE This study aimed to assess whether and when therapeutic drug monitoring (TDM) could be associated with a benefit in routine practice. METHODS All HIV-infected patients who underwent at least one TDM at the University Hospital of Dijon (France) between 1st January 2009 and 31st December 2012 were retrospectively included. Compliance with the recommendations, the results (antiretroviral concentrations), any subsequent therapeutic modifications, and the virological results at 4-8 months were analysed each time TDM was performed. TDM was defined as "practically relevant" when low or high antiretroviral concentrations led to a change in therapy. RESULTS Of the 571 patients who followed-up, 43.4% underwent TDM. TDM complying with recommendations (120 patients) was associated with a higher proportion of antiretroviral concentrations outside the therapeutic range (p=0.03). Antiretroviral treatment was modified after TDM in 22.6% of patients. Protease inhibitors, non-nucleoside reverse transcriptase inhibitors and raltegravir were more significantly modified when the measured concentration was outside the therapeutic range (p=0.008, p=0.05 and p=0.02, respectively). Overall, 11.7% of TDM was considered "practically relevant", though there was no significant correlation between subsequent changes in antiretroviral treatment and undetectable final HIV viral load. CONCLUSION TDM may be a useful tool in the management of HIV infection in specific situations, but the overall benefit seems moderate in routine practice. TDM cannot be systematic and/or a decision tool per se, but should be included in a comprehensive approach in certain clinical situations.
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Affiliation(s)
- Thomas Maitre
- Department of Infectious Diseases, University Hospital, Dijon, France
| | - Patrice Muret
- Laboratory of Clinical Pharmacology, University Hospital, Besancon, France.,UMR1098, University of Franche-Comte, Besançon, France
| | - Mathieu Blot
- Department of Infectious Diseases, University Hospital, Dijon, France
| | - Anne Waldner
- Department of Infectious Diseases, University Hospital, Dijon, France
| | - Michel Duong
- Department of Infectious Diseases, University Hospital, Dijon, France
| | | | - Pascal Chavanet
- Department of Infectious Diseases, University Hospital, Dijon, France.,UMR1347, University of Burgundy, Dijon, France
| | - Serge Aho
- Department of Hospital Hygiene, University Hospital, Dijon, France
| | - Lionel Piroth
- Department of Infectious Diseases, University Hospital, Dijon, France.,UMR1347, University of Burgundy, Dijon, France
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14
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Giacomelli A, Pezzati L, Rusconi S. The crosstalk between antiretrovirals pharmacology and HIV drug resistance. Expert Rev Clin Pharmacol 2020; 13:739-760. [PMID: 32538221 DOI: 10.1080/17512433.2020.1782737] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The clinical development of antiretroviral drugs has been followed by a rapid and concomitant development of HIV drug resistance. The development and spread of HIV drug resistance is due on the one hand to the within-host intrinsic HIV evolutionary rate and on the other to the wide use of low genetic barrier antiretrovirals. AREAS COVERED We searched PubMed and Embase on 31 January 2020, for studies reporting antiretroviral resistance and pharmacology. In this review, we assessed the molecular target and mechanism of drug resistance development of the different antiretroviral classes focusing on the currently approved antiretroviral drugs. Then, we assessed the main pharmacokinetic/pharmacodynamic of the antiretrovirals. Finally, we retraced the history of antiretroviral treatment and its interconnection with antiretroviral worldwide resistance development both in , and middle-income countries in the perspective of 90-90-90 World Health Organization target. EXPERT OPINION Drug resistance development is an invariably evolutionary driven phenomenon, which challenge the 90-90-90 target. In high-income countries, the antiretroviral drug resistance seems to be stable since the last decade. On the contrary, multi-intervention strategies comprehensive of broad availability of high genetic barrier regimens should be implemented in resource-limited setting to curb the rise of drug resistance.
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Affiliation(s)
- Andrea Giacomelli
- III Infectious Disease Unit, ASST-FBF-Sacco , Milan, Italy.,Department of Biomedical and Clinical Sciences DIBIC L. Sacco, University of Milan , Milan, Italy
| | - Laura Pezzati
- III Infectious Disease Unit, ASST-FBF-Sacco , Milan, Italy.,Department of Biomedical and Clinical Sciences DIBIC L. Sacco, University of Milan , Milan, Italy
| | - Stefano Rusconi
- III Infectious Disease Unit, ASST-FBF-Sacco , Milan, Italy.,Department of Biomedical and Clinical Sciences DIBIC L. Sacco, University of Milan , Milan, Italy
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15
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Gilleece DY, Tariq DS, Bamford DA, Bhagani DS, Byrne DL, Clarke DE, Clayden MP, Lyall DH, Metcalfe DR, Palfreeman DA, Rubinstein DL, Sonecha MS, Thorley DL, Tookey DP, Tosswill MJ, Utting MD, Welch DS, Wright MA. British HIV Association guidelines for the management of HIV in pregnancy and postpartum 2018. HIV Med 2020; 20 Suppl 3:s2-s85. [PMID: 30869192 DOI: 10.1111/hiv.12720] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Dr Yvonne Gilleece
- Honorary Clinical Senior Lecturer and Consultant Physician in HIV and Genitourinary Medicine, Brighton and Sussex University Hospitals NHS Trust
| | - Dr Shema Tariq
- Postdoctoral Clinical Research Fellow, University College London, and Honorary Consultant Physician in HIV, Central and North West London NHS Foundation Trust
| | - Dr Alasdair Bamford
- Consultant in Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | - Dr Sanjay Bhagani
- Consultant Physician in Infectious Diseases, Royal Free Hospital NHS Trust, London
| | - Dr Laura Byrne
- Locum Consultant in HIV Medicine, St George's University Hospitals NHS Foundation Trust, London
| | - Dr Emily Clarke
- Consultant in Genitourinary Medicine, Royal Liverpool and Broadgreen University Hospitals NHS Trust
| | - Ms Polly Clayden
- UK Community Advisory Board representative/HIV treatment advocates network
| | - Dr Hermione Lyall
- Clinical Director for Children's Services and Consultant Paediatrician in Infectious Diseases, Imperial College Healthcare NHS Trust, London
| | | | - Dr Adrian Palfreeman
- Consultant in Genitourinary Medicine, University Hospitals of Leicester NHS Trust
| | - Dr Luciana Rubinstein
- Consultant in Genitourinary Medicine, London North West Healthcare University NHS Trust, London
| | - Ms Sonali Sonecha
- Lead Directorate Pharmacist HIV/GUM, Chelsea and Westminster Healthcare NHS Foundation Trust, London
| | | | - Dr Pat Tookey
- Honorary Senior Lecturer and Co-Investigator National Study of HIV in Pregnancy and Childhood, UCL Great Ormond Street Institute of Child Health, London
| | | | - Mr David Utting
- Consultant Obstetrician and Gynaecologist, Brighton and Sussex University Hospitals NHS Trust
| | - Dr Steven Welch
- Consultant in Paediatric Infectious Diseases, Heart of England NHS Foundation Trust, Birmingham
| | - Ms Alison Wright
- Consultant Obstetrician and Gynaecologist, Royal Free Hospitals NHS Foundation Trust, London
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16
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Fosamprenavir with Ritonavir Pharmacokinetics during Pregnancy. Antimicrob Agents Chemother 2020; 64:AAC.02260-19. [PMID: 32015036 DOI: 10.1128/aac.02260-19] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 01/07/2020] [Indexed: 12/17/2022] Open
Abstract
The purpose of this study was to evaluate the pharmacokinetics of ritonavir-boosted fosamprenavir during pregnancy and postpartum. Amprenavir (the active moiety of fosamprenavir) and ritonavir intensive pharmacokinetic evaluations were performed at steady state during the second and third trimesters of pregnancy and postpartum. Plasma concentrations of amprenavir and ritonavir were measured using high-performance liquid chromatography. The target amprenavir area under the concentration-versus-time curve (AUC) was higher than the 10th percentile (27.7 μg · h/ml) of the median area under the curve for ritonavir-boosted fosamprenavir in adults receiving twice-daily fosamprenavir-ritonavir at 700 mg/100 mg. Twenty-nine women were included in the analysis. The amprenavir AUC from time zero to 12 h (AUC0-12) was lower (geometric mean ratio [GMR], 0.60 [confidence interval {CI}, 0.49 to 0.72] [P < 0.001]) while its apparent oral clearance was higher (GMR, 1.68 [CI, 1.38 to 2.03] [P < 0.001]) in the third trimester than postpartum. Similarly, the ritonavir AUC0-12 was lower in the second (GMR, 0.51 [CI, 0.28 to 0.91] [P = 0.09]) and third (GMR, 0.72 [CI, 0.55 to 0.95] [P = 0.005]) trimesters than postpartum, while its apparent oral clearance was higher in the second (GMR, 1.98 [CI, 1.10 to 3.56] [P = 0.06]) and third (GMR, 1.38 [CI, 1.05 to 1.82] [P = 0.009]) trimesters than postpartum. The amprenavir area under the curve exceeded the target for 6/8 (75%) women in the 2nd trimester, 18/28 (64%) in the 3rd trimester, and 19/22 (86.4%) postpartum, and the trough concentrations (C min) of amprenavir were 4- to 16-fold above the mean amprenavir-protein-adjusted 50% inhibitory concentration (IC50) of 0.146 μg/ml. Although amprenavir plasma concentrations in women receiving ritonavir-boosted fosamprenavir were lower during pregnancy than postpartum, the reduced amprenavir concentrations were still above the exposures needed for viral suppression.
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17
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Development and validation of a UPLC-MS method for determination of atazanavir sulfate by the "analytical quality by design" approach. ACTA PHARMACEUTICA (ZAGREB, CROATIA) 2020; 70:17-33. [PMID: 31677371 DOI: 10.2478/acph-2020-0008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/20/2019] [Indexed: 01/19/2023]
Abstract
A UPLC-MS method for the estimation of atazanavir sulfate was developed using the "analytical quality by design" approach. The critical chromatographic quality attributes identified were retention time, theoretical plates and peak tailing. The critical method parameters established were percent of organic modifier, flow rate and injection volume. Optimization performed using Box-Behnken Design (BBD) established 10 % organic modifier, 0.4 mL min-1 flow rate and 6-µL injection volume as the optimum method conditions. Atazanavir sulfate eluted at 5.19 min without any interference. Method validation followed international guidelines. The method has proven linearity in the range of 10-90 µg mL-1. Recovery was between 100.2-101.0 % and precision within the accepted limits (RSD 0.2-0.7 %). LOD and LOQ were 2.68 and 8.14 µg mL-1, resp. Stress testing stability studies showed atazanavir sulfate to degrade under acidic and basic conditions. The suggested technique is simple, rapid and sustainable. It is, therefore, suggested for routine analysis of atazanavir sulfate.
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18
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Hodel EM, Marzolini C, Waitt C, Rakhmanina N. Pharmacokinetics, Placental and Breast Milk Transfer of Antiretroviral Drugs in Pregnant and Lactating Women Living with HIV. Curr Pharm Des 2020; 25:556-576. [PMID: 30894103 DOI: 10.2174/1381612825666190320162507] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/18/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Remarkable progress has been achieved in the identification of HIV infection in pregnant women and in the prevention of vertical HIV transmission through maternal antiretroviral treatment (ART) and neonatal antiretroviral drug (ARV) prophylaxis in the last two decades. Millions of women globally are receiving combination ART throughout pregnancy and breastfeeding, periods associated with significant biological and physiological changes affecting the pharmacokinetics (PK) and pharmacodynamics (PD) of ARVs. The objective of this review was to summarize currently available knowledge on the PK of ARVs during pregnancy and transport of maternal ARVs through the placenta and into the breast milk. We also summarized main safety considerations for in utero and breast milk ARVs exposures in infants. METHODS We conducted a review of the pharmacological profiles of ARVs in pregnancy and during breastfeeding obtained from published clinical studies. Selected maternal PK studies used a relatively rich sampling approach at each ante- and postnatal sampling time point. For placental and breast milk transport of ARVs, we selected the studies that provided ratios of maternal to the cord (M:C) plasma and breast milk to maternal plasma (M:P) concentrations, respectively. RESULTS We provide an overview of the physiological changes during pregnancy and their effect on the PK parameters of ARVs by drug class in pregnancy, which were gathered from 45 published studies. The PK changes during pregnancy affect the dosing of several protease inhibitors during pregnancy and limit the use of several ARVs, including three single tablet regimens with integrase inhibitors or protease inhibitors co-formulated with cobicistat due to suboptimal exposures. We further analysed the currently available data on the mechanism of the transport of ARVs from maternal plasma across the placenta and into the breast milk and summarized the effect of pregnancy on placental and of breastfeeding on mammal gland drug transporters, as well as physicochemical properties, C:M and M:P ratios of individual ARVs by drug class. Finally, we discussed the major safety issues of fetal and infant exposure to maternal ARVs. CONCLUSIONS Available pharmacological data provide evidence that physiological changes during pregnancy affect maternal, and consequently, fetal ARV exposure. Limited available data suggest that the expression of drug transporters may vary throughout pregnancy and breastfeeding thereby possibly impacting the amount of ARV crossing the placenta and secreted into the breast milk. The drug transporter's role in the fetal/child exposure to maternal ARVs needs to be better understood. Our analysis underscores the need for more pharmacological studies with innovative study design, sparse PK sampling, improved study data reporting and PK modelling in pregnant and breastfeeding women living with HIV to optimize their treatment choices and maternal and child health outcomes.
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Affiliation(s)
- E M Hodel
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Molecular & Clinical Pharmacology, Liverpool, United Kingdom.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom.,Division of Paediatric Pharmacology & Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - C Marzolini
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Molecular & Clinical Pharmacology, Liverpool, United Kingdom.,Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - C Waitt
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Molecular & Clinical Pharmacology, Liverpool, United Kingdom.,Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - N Rakhmanina
- Department of Pediatrics, The George Washington University, School of Medicine & Health Sciences, Washington, DC, United States.,Division of Infectious Diseases, Children's National Medical Center, Washington, DC, United States.,Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States
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19
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Fairlie L, Waitt C, Lockman S, Moorhouse M, Abrams EJ, Clayden P, Boffito M, Khoo S, Rees H, Cournil A, Venter WF, Serenata C, Chersich M. Inclusion of pregnant women in antiretroviral drug research: what is needed to move forwards? J Int AIDS Soc 2019; 22:e25372. [PMID: 31529598 PMCID: PMC6747006 DOI: 10.1002/jia2.25372] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 07/21/2019] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION To adequately ascertain drug safety and efficacy, drug trials need to include participants from all groups likely to receive the medication following approval. Pregnant women, however, are mostly excluded from trials, and women participating are often required to use highly effective contraception and taken off study product (even off study) if they conceive. There is little commercial incentive for including pregnant women in clinical trials, even when preclinical animal and human pharmacokinetic and safety data appear reassuring. With this conservative approach, large numbers of pregnant women are exposed to drug postlicensing with little known about drug safety and efficacy, and little done to systematically monitor outcomes of pregnancy exposure. DISCUSSION The article focuses on antiretrovirals for treating and preventing HIV, and presents potential approaches which could extend to other therapeutic areas, to obtaining adequate and timely data to inform use of these drugs in this population. Most importantly the pregnancy risk profile of investigational agents can be systematically stratified from low to high risk, based on guidelines from regulatory bodies. This stratification can determine the progress through preclinical work with animals and non-pregnant women to opportunistic studies among women who become pregnant on a clinical trial or within routine clinical treatment. Stratification can include pregnant women in clinical trials, concurrent with Phase II/III trials in non-pregnant adults, and ultimately to postmarketing surveillance for outcomes in pregnant women and their infants. Each step can be enabled by clear criteria from international and local regulatory bodies on progression through study phases, standardized protocols for collecting relevant data, collaborative data sharing, pregnancy outcomes surveillance systems supported by committed funding for these endeavours. CONCLUSIONS A formalized step-wise approach to including pregnant women in antiretroviral drug research should become the new norm. Systematic implementation of this approach would yield more timely and higher quality pregnancy dosing, safety and efficacy data. Through more vigorous action, regulatory bodies could responsibly overcome reluctance to include pregnant women in drug trials. Funders, researchers and programme implementers need to be galvanized to progressively include pregnant women in research - the use of newer, more effective drugs in women is at stake (349).
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Affiliation(s)
- Lee Fairlie
- Wits Reproductive Health and HIV InstituteFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Catriona Waitt
- Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
- Infectious Diseases InstituteMakerere University College of Health SciencesKampalaUganda
| | - Shahin Lockman
- Brigham and Women's HospitalHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Michelle Moorhouse
- Wits Reproductive Health and HIV InstituteFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Elaine J. Abrams
- ICAP at Columbia UniversityMailman School of Public Health and Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | | | | | - Saye Khoo
- Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Helen Rees
- Wits Reproductive Health and HIV InstituteFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Amandine Cournil
- Unité Mixte Internationale 233Institut de Recherche pour le DéveloppementU1175‐INSERMUniversity of MontpellierMontpellierFrance
| | - Willem Francois Venter
- Wits Reproductive Health and HIV InstituteFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Celicia Serenata
- Wits Reproductive Health and HIV InstituteFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Matthew Chersich
- Wits Reproductive Health and HIV InstituteFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
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20
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21
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Eke AC, McCormack SA, Best BM, Stek AM, Wang J, Kreitchmann R, Shapiro D, Smith E, Mofenson LM, Capparelli EV, Mirochnick M. Pharmacokinetics of Increased Nelfinavir Plasma Concentrations in Women During Pregnancy and Postpartum. J Clin Pharmacol 2018; 59:386-393. [PMID: 30358179 DOI: 10.1002/jcph.1331] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 10/02/2018] [Indexed: 11/05/2022]
Abstract
This study aims to evaluate the safety, acceptability, and pharmacokinetics (PK) of an increased dose of nelfinavir (NFV) during the third trimester of pregnancy. The study was registered as part of the International Maternal Pediatric Adolescent AIDS Clinical Trials network (IMPAACT-P1026s), an ongoing multicenter prospective cohort study of antiretroviral PK during pregnancy (NCT00042289). NFV intensive PK evaluations were performed at steady state during the third trimester of pregnancy and 2-3 weeks postpartum. Plasma concentrations of NFV and its active metabolite, hydroxyl-tert-butylamide (M8) were measured using high-performance liquid chromatography with ultraviolet detection. A total of 18 women are included in the analysis. NFV area under the concentration-time curve (AUC) with the increased dose during the third trimester was nearly identical to the standard dose postpartum, with a geometric mean ratio for third trimester to postpartum AUC of 0.98 (90%CI 0.71-1.35). Despite the increased dose, M8 AUC was lower during the third trimester compared to postpartum (0.53, IQR [0.38-0.75]), as was the M8/NFV AUC ratio (0.51, IQR [0.42-0.63]). NFV AUC0-12 was above target in 15 of 18 (83%) of participants during the third trimester compared to 14 of 16 (88%) postpartum. No major safety concerns were noted. Increasing the NFV dose to 1875 mg twice daily during the third trimester achieved similar concentrations postpartum compared to standard dosing (1250 mg twice daily). Increased NFV dose regimens may still have some benefit to human immunodeficiency virus (HIV)-positive pregnant women living in countries where novel protease inhibitors are currently unavailable or in individuals who are intolerant to ritonavir-boosted HIV medications.
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Affiliation(s)
- Ahizechukwu C Eke
- Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Brookie M Best
- University of California San Diego School of Medicine, San Diego, CA, USA.,University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego, CA, USA
| | - Alice M Stek
- University of Southern California School of Medicine, Los Angeles, CA, USA
| | - Jiajia Wang
- Harvard School of Public Health, Center for Biostatistics in AIDS Research, Boston, MA, USA
| | - Regis Kreitchmann
- Irmandade da Santa Casa de Misericórdia de Porto Alegre, HIV/AIDS Research Department, Porto Alegre, Rio Grande do Sul, Brazil
| | - David Shapiro
- Harvard School of Public Health, Center for Biostatistics in AIDS Research, Boston, MA, USA
| | - Elizabeth Smith
- National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD, USA
| | - Lynne M Mofenson
- National Institute of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, MD, USA
| | - Edmund V Capparelli
- University of California San Diego School of Medicine, San Diego, CA, USA.,University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego, CA, USA
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- Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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22
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Kala S, Watson B, Zhang JG, Papp E, Guzman Lenis M, Dennehy M, Cameron DW, Harrigan PR, Serghides L. Improving the clinical relevance of a mouse pregnancy model of antiretroviral toxicity; a pharmacokinetic dosing-optimization study of current HIV antiretroviral regimens. Antiviral Res 2018; 159:45-54. [PMID: 30236532 DOI: 10.1016/j.antiviral.2018.09.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 09/05/2018] [Accepted: 09/14/2018] [Indexed: 12/16/2022]
Abstract
Animal models can be useful tools for the study of HIV antiretroviral (ARV) safety/toxicity in pregnancy and the mechanisms that underlie ARV-associated adverse events. The utility and translatability of animal model-based ARV safety/toxicity data is improved if ARVs are tested in clinically relevant concentrations. The objective of this work was to improve the clinical relevance of our mouse pregnancy model of ARV toxicity, by determining the doses of currently prescribed ARV regimens that would yield human therapeutic plasma concentrations. Pregnant mice were administered increasing doses of ARV combinations by oral gavage, followed by measurement of drug concentrations in the maternal plasma and amniotic fluid. Concentrations of ten different ARVs in maternal plasma and amniotic fluid samples of pregnant mice are presented, with dosing optimization to yield human pregnancy-relevant plasma drug concentrations. We have proposed optimal dosing for different regimen component drugs to achieve human therapeutic plasma levels, so that a clinically relevant standard dosing is established. A review of related ARV pharmacokinetic studies in (pregnant/non-pregnant) rodents and human pregnancy is also shown. We hope these data will inform and encourage the use of mouse pregnancy models in the study of ARV safety/toxicity.
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Affiliation(s)
- Smriti Kala
- Toronto General Hospital Research Institute, University Health Network (UHN), Toronto, Canada
| | - Birgit Watson
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Jeremy Guijun Zhang
- Clinical Investigation Unit at the Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine, University of Ottawa at the Ottawa Hospital / Research Institute, Ottawa, Canada
| | - Eszter Papp
- Toronto General Hospital Research Institute, University Health Network (UHN), Toronto, Canada
| | - Monica Guzman Lenis
- Toronto General Hospital Research Institute, University Health Network (UHN), Toronto, Canada
| | - Michelle Dennehy
- Clinical Investigation Unit at the Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine, University of Ottawa at the Ottawa Hospital / Research Institute, Ottawa, Canada
| | - D William Cameron
- Clinical Investigation Unit at the Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine, University of Ottawa at the Ottawa Hospital / Research Institute, Ottawa, Canada
| | - P Richard Harrigan
- Division of AIDS, Department of Medicine, University of British Columbia, Vancouver Canada
| | - Lena Serghides
- Toronto General Hospital Research Institute, University Health Network (UHN), Toronto, Canada; Department of Immunology and Institute of Medical Sciences, University of Toronto, Toronto, Canada; Women's College Research Institute, Women's College Hospital, Toronto, Canada.
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23
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Focà E, Calcagno A, Bonito A, Simiele M, Domenighini E, D'Avolio A, Quiros Roldan E, Trentini L, Casari S, Di Perri G, Castelli F, Bonora S. Atazanavir intracellular concentrations remain stable during pregnancy in HIV-infected patients. J Antimicrob Chemother 2018; 72:3163-3166. [PMID: 28961777 DOI: 10.1093/jac/dkx274] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 07/07/2017] [Indexed: 11/13/2022] Open
Abstract
Background Atazanavir (300 mg) boosted by ritonavir (100 mg) is the preferred third drug in pregnancy. However, there is still discordance on atazanavir dose increase during the third trimester. Objectives To evaluate plasma and intracellular atazanavir and ritonavir concentrations in HIV-infected women during pregnancy and after delivery. Methods This was an observational study. HIV-infected pregnant patients treated with atazanavir/ritonavir plus either tenofovir/emtricitabine or abacavir/lamivudine had been prospectively enrolled after having signed a written informed consent form. Plasma and intracellular atazanavir and ritonavir Ctrough (24 ± 3 h after drug intake) were measured at each visit during the first, second and third trimesters and post-partum using validated HPLC-MS and HPLC-photodiode array methods (with direct evaluation of cellular volume). Data are described as median (IQR) and compared through non-parametric tests. Results Twenty-five patients were enrolled; at baseline, the median age was 32 years (27-35). All patients had plasma HIV RNA <50 copies/mL; the median CD4+ count was 736 cells/mm3 (542-779). Atazanavir plasma concentrations were 441 ng/mL (261-1557), 710 ng/mL (338-1085), 556 ng/mL (334-1022) and 837 ng/mL (608-1757) during the first, second and third trimesters and post-partum, respectively; intracellular concentrations were 743 ng/mL (610-1928), 808 ng/mL (569-1620), 756 ng/mL (384-1074) and 706 ng/mL (467-2688), respectively. Atazanavir intracellular/plasma ratios were 1.32 (0.98-2.77), 1.34 (1.13-1.88), 1.38 (0.61-2.63) and 1.07 (0.56-2.69), respectively. Atazanavir intracellular concentrations and intracellular/plasma ratios showed non-significant changes over time (P > 0.05). Conclusions This is the first demonstration that intracellular atazanavir exposure remains unchanged during pregnancy supporting the standard 300/100 mg atazanavir/ritonavir dosing throughout pregnancy.
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Affiliation(s)
- Emanuele Focà
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, University of Brescia and Spedali Civili General Hospital, Brescia, Italy
| | - Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Andrea Bonito
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, University of Brescia and Spedali Civili General Hospital, Brescia, Italy
| | - Marco Simiele
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Elisabetta Domenighini
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, University of Brescia and Spedali Civili General Hospital, Brescia, Italy
| | - Antonio D'Avolio
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | | | - Laura Trentini
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Salvatore Casari
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, University of Brescia and Spedali Civili General Hospital, Brescia, Italy
| | - Giovanni Di Perri
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Francesco Castelli
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, University of Brescia and Spedali Civili General Hospital, Brescia, Italy
| | - Stefano Bonora
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
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24
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Cerveny L, Ptackova Z, Durisova M, Staud F. Interactions of protease inhibitors atazanavir and ritonavir with ABCB1, ABCG2, and ABCC2 transporters: Effect on transplacental disposition in rats. Reprod Toxicol 2018; 79:57-65. [PMID: 29859254 DOI: 10.1016/j.reprotox.2018.05.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 05/08/2018] [Accepted: 05/29/2018] [Indexed: 12/11/2022]
Abstract
Atazanavir and ritonavir are preferred protease inhibitors frequently used in combination antiretroviral therapy for prevention of HIV mother-to-child transmission. Although their use is associated with higher risk of congenital anomalies, factors affecting atazanavir and ritonavir placental transfer are not known. This study is the first attempt to evaluate whether the placental drug efflux ATP-binding cassette (ABC) transporters, p-glycoprotein (ABCB1), breast cancer resistance protein (ABCG2), and/or multidrug resistance-associated proteins 2 (ABCC2), affect placental pharmacokinetics of atazanavir or ritonavir. Transport experiments across MDCKII cells expressing respective human ABC carrier showed that atazanavir is a substrate of ABCB1 and dual perfusion studies in a rat placenta confirmed this finding. In conclusion, we suggest that placental ABCB1 might reduce ATV maternal-to-fetal transfer and therefore represent a site for pharmacokinetic drug-drug interactions of ATV. Further studies in human placenta models are necessary to provide additional data closer to clinical environment.
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Affiliation(s)
- Lukas Cerveny
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Kralove, Charles University, Akademika Heyrovskeho 1203, Hradec Kralove 500 05, Czech Republic
| | - Zuzana Ptackova
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Kralove, Charles University, Akademika Heyrovskeho 1203, Hradec Kralove 500 05, Czech Republic
| | - Marketa Durisova
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Kralove, Charles University, Akademika Heyrovskeho 1203, Hradec Kralove 500 05, Czech Republic
| | - Frantisek Staud
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Kralove, Charles University, Akademika Heyrovskeho 1203, Hradec Kralove 500 05, Czech Republic.
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Metsu D, Toutain PL, Chatelut E, Delobel P, Gandia P. Antiretroviral unbound concentration during pregnancy: piece of interest in the puzzle? J Antimicrob Chemother 2018; 72:2407-2409. [PMID: 28595364 DOI: 10.1093/jac/dkx176] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Atazanavir and darunavir total concentrations (drug bound to plasma proteins plus unbound drug) progressively decrease during pregnancy. This pharmacokinetic variation leads physicians to recommend increasing doses. Conversely, the unbound concentration (Cu), i.e. the pharmacologically active form of the drug, remains unchanged. The explanation of this desynchronization lies in the fact that the clearance of the unbound form, corresponding to the intrinsic metabolic capacity of the hepatocytes, is the only factor driving Cu, and is constant during pregnancy. The attention of HIV physicians should be attracted to this aspect of pharmacokinetics, which is often incompletely understood and could lead to inadequate dose adjustment, which could then cause overexposure of the foetus for many months, with unknown consequences.
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Affiliation(s)
- D Metsu
- Laboratoire de Pharmacocinétique et de Toxicologie, CHU Toulouse, Toulouse, France.,CRCT, Université de Toulouse, INSERM, UPS, Toulouse, France
| | - P L Toutain
- Toxalim, Université de Toulouse, INRA, INP-ENVT, Toulouse, France
| | - E Chatelut
- CRCT, Université de Toulouse, INSERM, UPS, Toulouse, France.,Institut Claudius-Regaud, IUCT-Oncopole, Toulouse, France
| | - P Delobel
- Service des Maladies Infectieuses et Tropicales, CHU Toulouse, Toulouse, France.,INSERM, UMR1043, Toulouse, France
| | - P Gandia
- Laboratoire de Pharmacocinétique et de Toxicologie, CHU Toulouse, Toulouse, France.,Toxalim, Université de Toulouse, INRA, INP-ENVT, Toulouse, France
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Safety of Tenofovir Disoproxil Fumarate-Based Antiretroviral Therapy Regimens in Pregnancy for HIV-Infected Women and Their Infants: A Systematic Review and Meta-Analysis. J Acquir Immune Defic Syndr 2017; 76:1-12. [PMID: 28291053 PMCID: PMC5553236 DOI: 10.1097/qai.0000000000001359] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Supplemental Digital Content is Available in the Text. Background: There are limited data on adverse effects of tenofovir disoproxil fumarate (TDF)-based antiretroviral therapy (ART) on pregnant women and their infants. Methods: We conducted a systematic review of studies published between January 1980 and January 2017 that compared adverse outcomes in HIV-infected women receiving TDF- vs. non–TDF-based ART during pregnancy. The risk ratio (RR) for associations was pooled using a fixed-effects model. Results: Seventeen studies met the study inclusion criteria. We found that the rate of preterm (<37 weeks gestation) delivery (RR = 0.90, 95% confidence interval [CI]: 0.81 to 0.99, I2 = 59%) and stillbirth (RR = 0.60, 95% CI: 0.43 to 0.84, I2 = 72.0%) were significantly lower in women exposed (vs. not) to TDF-based ART regimen. We found no increased risk in maternal severe (grade 3) or potentially life-threatening (grade 4) adverse events (RR = 0.62; 95% CI: 0.30 to 1.29), miscarriage (RR = 1.09; 95% CI: 0.80 to 1.48), very preterm (<34 weeks gestation) delivery (RR = 1.08, 95% CI: 0.72 to 1.62), small for gestational age (RR = 0.87, 95% CI: 0.67 to 1.13), low birth weight (RR = 0.91; 95% CI: 0.80 to 1.04), very low birth weight (RR = 3.18; 95% CI: 0.65 to 15.63), congenital anomalies (RR = 1.03; 95% CI: 0.83 to 1.28), infant adverse outcomes or infant mortality (age >14 days) (RR = 0.65; 95% CI: 0.23 to 1.85), but increased neonatal mortality (age <14 days) risk (RR = 5.64, 95% CI: 1.70 to 18.79) with TDR-based ART exposure. No differences were found for anthropomorphic parameters at birth; one study reported minor differences in z-scores for length and head circumference at age 1 year. Conclusions: TDF-based ART in pregnancy seems generally safe for women and their infants. However, data remain limited and further studies are needed, particularly to assess neonatal mortality and infant growth/bone effects.
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Colbers A, Greupink R, Litjens C, Burger D, Russel FGM. Physiologically Based Modelling of Darunavir/Ritonavir Pharmacokinetics During Pregnancy. Clin Pharmacokinet 2016; 55:381-96. [PMID: 26369773 PMCID: PMC4761019 DOI: 10.1007/s40262-015-0325-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pregnant women are usually excluded from clinical trials. Physiologically based pharmacokinetic (PBPK) modelling may provide a method to predict pharmacokinetics in pregnant women, without the need to perform extensive in vivo clinical trials. Here, we used mechanistic modelling to delineate the potential impact of drug transporters on darunavir pharmacokinetics and to identify current knowledge gaps that limit accurate PBPK modelling of darunavir/ritonavir (darunavir/r) exposure in pregnancy. Simcyp (version 13.2) was used for PBPK modelling, using physicochemical and in vitro pharmacokinetic parameters of darunavir and ritonavir from the literature. The Michaelis-Menten constant (K m) and the maximum rate of metabolite formation (V max) for cytochrome P450 3A4-mediated darunavir biotransformation and inhibition by ritonavir were determined experimentally, while the contributions of hepatocyte influx and efflux transporters were assessed by sensitivity analysis. The simulations were compared with previously published clinical pharmacokinetic data. We found that use of a well-stirred liver model overestimated darunavir exposure substantially. A permeability-limited liver model, including hepatic uptake and efflux transporters and an efficient enterohepatic circulation step, resulted in an acceptable description of darunavir/r exposure. For the 600/100 mg darunavir/r twice-daily dose and the 800/100 mg once-daily dose, the estimated pharmacokinetic parameters were within a 2-fold range of the reported data. The predicted decreases in the area under the concentration-time curve (AUC) values during pregnancy for the twice- and once-daily doses were 27 and 41%, respectively, which were in line with the observed decreases of 17-22 and 33%. In conclusion, our data support a clinically relevant role of hepatic transporters in darunavir pharmacokinetics. By including them in our model, we successfully approximated the increase in darunavir exposure mediated by ritonavir co-administration and the decrease in darunavir exposure observed during pregnancy.
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Affiliation(s)
- Angela Colbers
- Department of Pharmacy, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Rick Greupink
- Department of Pharmacology and Toxicology (149), Radboud University Medical Centre, Radboud Institute for Molecular Life Sciences, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Carlijn Litjens
- Department of Pharmacy, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Department of Pharmacology and Toxicology (149), Radboud University Medical Centre, Radboud Institute for Molecular Life Sciences, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - David Burger
- Department of Pharmacy, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Frans G M Russel
- Department of Pharmacology and Toxicology (149), Radboud University Medical Centre, Radboud Institute for Molecular Life Sciences, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
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Abstract
BACKGROUND Women are commonly prescribed a variety of medications during pregnancy. As most organ systems are affected by the substantial anatomical and physiological changes that occur during pregnancy, it is expected that pharmacokinetics (PK) (absorption, distribution, metabolism, and excretion of drugs) would also be affected in ways that may necessitate changes in dosing schedules. The objective of this study was to systematically identify existing clinically relevant evidence on PK changes during pregnancy. METHODS AND FINDINGS Systematic searches were conducted in MEDLINE (Ovid), Embase (Ovid), Cochrane Central Register of Controlled Trials (Ovid), and Web of Science (Thomson Reuters), from database inception to August 31, 2015. An update of the search from September 1, 2015, to May 20, 2016, was performed, and relevant data were added to the present review. No language or date restrictions were applied. All publications of clinical PK studies involving a group of pregnant women with a comparison to nonpregnant participants or nonpregnant population data were eligible to be included in this review. A total of 198 studies involving 121 different medications fulfilled the inclusion criteria. In these studies, commonly investigated drug classes included antiretrovirals (54 studies), antiepileptic drugs (27 studies), antibiotics (23 studies), antimalarial drugs (22 studies), and cardiovascular drugs (17 studies). Overall, pregnancy-associated changes in PK parameters were often observed as consistent findings among many studies, particularly enhanced drug elimination and decreased exposure to total drugs (bound and unbound to plasma proteins) at a given dose. However, associated alterations in clinical responses and outcomes, or lack thereof, remain largely unknown. CONCLUSION This systematic review of pregnancy-associated PK changes identifies a significant gap between the accumulating knowledge of PK changes in pregnant women and our understanding of their clinical impact for both mother and fetus. It is essential for clinicians to be aware of these unique pregnancy-related changes in PK, and to critically examine their clinical implications.
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Punyawudho B, Singkham N, Thammajaruk N, Dalodom T, Kerr SJ, Burger DM, Ruxrungtham K. Therapeutic drug monitoring of antiretroviral drugs in HIV-infected patients. Expert Rev Clin Pharmacol 2016; 9:1583-1595. [PMID: 27626677 DOI: 10.1080/17512433.2016.1235972] [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: 12/18/2022]
Abstract
INTRODUCTION Therapeutic drug monitoring (TDM) may be beneficial when applied to antiretroviral (ARV). Even though TDM can be a valuable strategy in HIV management, its role remains controversial. Areas covered: This review provides a comprehensive update on important issues relating to TDM of ARV drugs in HIV-infected patients. Articles from PubMed with keywords relevant to each topic section were reviewed. Search strategies limited to articles published in English. Expert commentary: There is evidence supporting the use of TDM in HIV treatment. However, some limitations need to be considered. The evidence supporting the use of routine TDM for all patients is limited, as it is not clear that this strategy offers any advantages over TDM for selected indications. Selected groups of patients including patients with physiological changes, patients with drug-drug interactions or toxicity, and the elderly could potentially benefit from TDM, as optimized dosing is challenging in these populations.
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Affiliation(s)
- Baralee Punyawudho
- a Department of Pharmaceutical Care, Faculty of Pharmacy , Chiang Mai University , Chiang Mai , Thailand
| | - Noppaket Singkham
- a Department of Pharmaceutical Care, Faculty of Pharmacy , Chiang Mai University , Chiang Mai , Thailand
| | | | - Theera Dalodom
- b HIV-NAT , Thai Red Cross AIDS Research Centre , Bangkok , Thailand
| | - Stephen J Kerr
- b HIV-NAT , Thai Red Cross AIDS Research Centre , Bangkok , Thailand.,c The Kirby Institute, University of New South Wales , Sydney , Australia.,d Department of Global Health, Academic Medical Center , University of Amsterdam, Amsterdam Institute for Global Health and Development , Amsterdam , The Netherlands
| | - David M Burger
- e Radbound University Medical Center , Nijmegen , The Netherlands
| | - Kiat Ruxrungtham
- b HIV-NAT , Thai Red Cross AIDS Research Centre , Bangkok , Thailand.,f Faculty of Medicine , Chulalongkorn University , Bangkok , Thailand
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Tran AH, Best BM, Stek A, Wang J, Capparelli EV, Burchett SK, Kreitchmann R, Rungruengthanakit K, George K, Cressey TR, Chakhtoura N, Smith E, Shapiro DE, Mirochnick M. Pharmacokinetics of Rilpivirine in HIV-Infected Pregnant Women. J Acquir Immune Defic Syndr 2016; 72:289-96. [PMID: 26918544 PMCID: PMC4911231 DOI: 10.1097/qai.0000000000000968] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Rilpivirine pharmacokinetics is defined by its absorption, distribution, metabolism, and excretion. Pregnancy can affect these factors by changes in cardiac output, protein binding, volume of distribution, and cytochrome P450 (CYP) 3A4 activity. Rilpivirine is metabolized by CYP3A4. The impact of pregnancy on rilpivirine pharmacokinetics is largely unknown. METHODS International Maternal Pediatric Adolescent AIDS Clinical Trials P1026s is a multicenter, nonblinded, prospective study evaluating antiretroviral pharmacokinetics in HIV-infected pregnant women that included a cohort receiving rilpivirine 25 mg once daily as part of their combination antiretrovirals for clinical care. Thirty-two women were enrolled in this study. Intensive pharmacokinetic sampling was performed at steady state during the second trimester, the third trimester, and postpartum. Maternal and umbilical cord blood samples were obtained at delivery. Plasma rilpivirine concentration was measured using liquid chromatography-mass spectrometry; lower limit of quantitation was 10 ng/mL. RESULTS Median (range) AUC0-24 were 1969 (867-4987, n = 15), 1669 (556-4312, n = 28), and 2387 (188-6736, n = 28) ng·h/mL in the second trimester, the third trimester, and postpartum, respectively (P < 0.05 for either trimester vs postpartum). Median (range) C24 were 63 (37-225, n = 17), 56 (<10-181, n = 30), and 81 (<10-299, n = 28) ng/mL (P < 0.05 for either trimester vs postpartum). High variability in pharmacokinetic parameters was observed between subjects. Median (range) cord blood/maternal concentration ratio was 0.55 (0.3-0.8, n = 21). Delivery HIV-1 RNA was ≤50 copies per milliliter in 70% and ≤400 copies per milliliter in 90% of women. Cmin were significantly lower at 15 visits with detectable HIV-1 RNA compared with 61 visits with undetectable HIV-1 RNA, 29 (<10-93) vs 63 (15-200) ng/mL (P = 0.0001). Cmin was below the protein binding-adjusted EC90 concentration (12.2 ng/mL) at 4 visits in 3 of 31 women (10%). CONCLUSIONS Rilpivirine exposure is lower during pregnancy compared with postpartum and highly variable. Ninety percent of women had minimum concentrations above the protein binding-adjusted EC90 for rilpivirine.
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Affiliation(s)
- Anna H Tran
- *Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, CA; †Skaggs School of Pharmacy and Pharmaceutical Sciences, Pediatrics Department-Rady Children's Hospital, University of California, San Diego, CA; ‡Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA; §Department of Biostatistics, Harvard School of Public Health, Boston, MA; ‖Department of Medicine, Children's Hospital Boston, Boston, MA; ¶Irmandade da Santa Casa de Misericordia de Porto Alegre, HIV/AIDS Research Department, Porto Alegre, Brazil; #Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand; **FHI 360, IMPAACT Operations Office, Durham, NC; ††Program for HIV Prevention and Treatment, Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand; ‡‡Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institute of Health, DHHS, Bethesda, MD; §§National Institute of Allergy and Infectious Diseases, Bethesda, MD; and ‖‖Department of Pediatrics, Boston University School of Medicine, Boston, MA
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Crauwels HM, Kakuda TN, Ryan B, Zorrilla C, Osiyemi OO, Yasin S, Brown K, Verboven P, Hillewaert V, Baugh B. Pharmacokinetics of once-daily darunavir/ritonavir in HIV-1-infected pregnant women. HIV Med 2016; 17:643-52. [PMID: 27187894 DOI: 10.1111/hiv.12366] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES HIV antiretroviral therapy during pregnancy is recommended to reduce the risk of mother-to-child transmission and for maternal care. Physiological changes during pregnancy can affect pharmacokinetics. The impact of pregnancy was evaluated for once-daily (qd) darunavir/ritonavir. METHODS HIV-1-infected pregnant women on an antiretroviral regimen that includes darunavir were enrolled in the study and further treated with darunavir/ritonavir 800/100 mg qd. Plasma concentrations were assessed over 24 h during the second and third trimesters and postpartum using a validated high-performance liquid chromatography tandem mass spectrometry assay for total darunavir and ritonavir, and using (14) C-darunavir-fortified plasma for unbound darunavir. Pharmacokinetic parameters were derived using noncompartmental analysis. Safety and antiviral response were assessed at all visits. RESULTS Data were available for 16 women. The area under the plasma concentration-time curve from 0 to 24 h (AUC24h ) for total darunavir was 34-35% lower during pregnancy vs. postpartum. Unbound darunavir AUC24h was 20-24% lower during pregnancy vs. postpartum. The minimum plasma concentration of total and unbound darunavir was 32-50% and 13-38% lower, respectively, during pregnancy vs. postpartum. The antiviral response (< 50 HIV-1 RNA copies/mL) was 59% at baseline and increased to 87-100% during the trial; the CD4 count increased over time. One serious adverse event (gestational diabetes) was judged as possibly related to study medication. All 16 infants born to women remaining in the study at delivery were HIV-1 negative (two were premature). CONCLUSIONS Total darunavir exposure decreased during pregnancy, but the decrease was less for unbound (active) darunavir. These changes are not considered clinically relevant. Darunavir/ritonavir 800/100 mg qd may therefore be a treatment option for HIV-1-infected pregnant women.
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Affiliation(s)
| | - T N Kakuda
- Janssen Research & Development, LLC, Titusville, NJ, USA
| | - B Ryan
- Janssen Research & Development, LLC, Titusville, NJ, USA
| | - C Zorrilla
- University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| | - O O Osiyemi
- Triple O Research Institute PA, West Palm Beach, FL, USA
| | - S Yasin
- University of Miami School of Medicine, Miami, FL, USA
| | - K Brown
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - P Verboven
- Janssen Research & Development, Beerse, Belgium
| | | | - B Baugh
- Janssen Research & Development, LLC, Raritan, NJ, USA
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Pharmacokinetics of Once Versus Twice Daily Darunavir in Pregnant HIV-Infected Women. J Acquir Immune Defic Syndr 2015; 70:33-41. [PMID: 25950206 DOI: 10.1097/qai.0000000000000668] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe darunavir (DRV) pharmacokinetics with once-and twice-daily dosing during pregnancy and postpartum in HIV-infected women. DESIGN Women were enrolled in International Maternal Pediatric Adolescent AIDS Clinical Trials Network Protocol P1026s, a prospective nonblinded study of antiretroviral pharmacokinetics in HIV-infected pregnant women that included separate cohorts receiving DRV/ritonavir dosed at either 800 mg/100 mg once daily or 600 mg/100 mg twice daily. METHODS Intensive steady-state 12- or 24-hour pharmacokinetic profiles were performed during the second trimester, third trimester, and postpartum. DRV was measured using high-performance liquid chromatography (detection limit: 0.09 μg/mL). RESULTS Pharmacokinetic data were available for 64 women (30 once daily and 34 twice daily dosing). Median DRV area under the concentration-time curve (AUC) and maximum concentration were significantly reduced during pregnancy with both dosing regimens compared with postpartum, whereas the last measurable concentration (Clast) was also reduced during pregnancy with once daily DRV. DRV AUC with once daily dosing was reduced by 38% during the second trimester and by 39% during the third trimester. With twice daily dosing, DRV AUC was reduced by 26% in both trimesters. The median (range) ratio of cord blood/maternal delivery DRV concentration in 32 paired samples was 0.18 (range: 0-0.82). CONCLUSIONS DRV exposure is reduced by pregnancy. To achieve DRV plasma concentrations during pregnancy equivalent to those seen in nonpregnant adults, an increased twice daily dose may be necessary. This may be especially important for treatment-experienced women who may have developed antiretroviral resistance mutations.
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Siberry GK, Jacobson DL, Kalkwarf HJ, Wu JW, DiMeglio LA, Yogev R, Knapp KM, Wheeler JJ, Butler L, Hazra R, Miller TL, Seage GR, Van Dyke RB, Barr E, Davtyan M, Mofenson LM, Rich KC. Lower Newborn Bone Mineral Content Associated With Maternal Use of Tenofovir Disoproxil Fumarate During Pregnancy. Clin Infect Dis 2015; 61:996-1003. [PMID: 26060285 PMCID: PMC4551007 DOI: 10.1093/cid/civ437] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 05/30/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fetal bone effects of maternal tenofovir use have not been well studied. We sought to compare whole-body bone mineral content (BMC) of newborns exposed vs not exposed to tenofovir in utero. METHODS We enrolled participants from April 2011 to June 2013 at 14 US clinical sites. Singleton infants of women with human immunodeficiency virus (HIV) infection who took tenofovir in late pregnancy (tenofovir-exposed) or no tenofovir during pregnancy (tenofovir-unexposed) were enrolled during late pregnancy or within 72 hours of birth. Infants born before 36 weeks gestation or with confirmed HIV infection were excluded. Whole-body BMC was measured in the first month of life and compared with that of the tenofovir-exposed and tenofovir-unexposed newborns, unadjusted and adjusted for covariates. RESULTS Seventy-four tenofovir-exposed and 69 tenofovir-unexposed infants had evaluable BMC measurements. Tenofovir-exposed mothers were more likely to be married (31% vs 22%; P = .04) and to use boosted protease inhibitors (84% vs 62%; P = .004). Tenofovir-exposed newborns did not differ from unexposed newborns on mean gestational age (38.2 vs 38.1 weeks) or mean length (-0.41 vs -0.18) or weight (-0.71 vs -0.48) Z-scores. The mean (standard deviation) BMC of tenofovir-exposed infants was 12% lower than for unexposed infants (56.0 [11.8] vs 63.8 [16.6] g; P = .002). The adjusted mean bone mineral content was 5.3 g lower (95% confidence interval, -9.5, -1.2; P = .013) in the tenofovir-exposed infants. CONCLUSIONS Maternal tenofovir use is associated with significantly lower neonatal BMC. The duration and clinical significance of this finding should be evaluated in longitudinal studies. CLINICAL TRIALS REGISTRATION ClinicalTrials.gov NCT01310023.
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Affiliation(s)
- George K. Siberry
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Denise L. Jacobson
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Heidi J. Kalkwarf
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Ohio
| | - Julia W. Wu
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Linda A. DiMeglio
- Section of Pediatric Endocrinology/Diabetology, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis
| | - Ram Yogev
- Lurie Children's Hospital, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Katherine M. Knapp
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Justin J. Wheeler
- Tufts University Body Composition Analysis Center, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Boston, Massachusetts
| | - Laurie Butler
- Frontier Science Technology and Research Foundation, Amherst, New York
| | - Rohan Hazra
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Tracie L. Miller
- Department of Pediatrics, Miller School of Medicine at the University of Miami, Florida
| | - George R. Seage
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Russell B. Van Dyke
- Department of Pediatrics, Tulane University School of Medicine, New Orleans, Louisiana
| | - Emily Barr
- Children's Hospital Colorado, Department of Infectious Disease, University of Colorado, Denver
| | - Mariam Davtyan
- LAC+USC Maternal, Child & Adolescent Center for Infectious Diseases and Virology, Los Angeles, California
| | - Lynne M. Mofenson
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Gilbert EM, Darin KM, Scarsi KK, McLaughlin MM. Antiretroviral Pharmacokinetics in Pregnant Women. Pharmacotherapy 2015; 35:838-55. [DOI: 10.1002/phar.1626] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Elise M. Gilbert
- Department of Pharmacy; Northwestern Memorial Hospital; Chicago Illinois
- Department of Pharmacy Practice; Chicago State University College of Pharmacy; Chicago Illinois
| | - Kristin M. Darin
- Feinberg School of Medicine; Division of Infectious Diseases and Center for Global Health; Northwestern University; Chicago Illinois
| | - Kimberly K. Scarsi
- Department of Pharmacy Practice; College of Pharmacy; University of Nebraska Medical Center; Omaha Nebraska
| | - Milena M. McLaughlin
- Department of Pharmacy; Northwestern Memorial Hospital; Chicago Illinois
- Department of Pharmacy Practice; Chicago College of Pharmacy; Midwestern University; Downers Grove Illinois
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Meconium Atazanavir Concentrations and Early Language Outcomes in HIV-Exposed Uninfected Infants With Prenatal Atazanavir Exposure. J Acquir Immune Defic Syndr 2015; 69:178-86. [PMID: 26009830 DOI: 10.1097/qai.0000000000000558] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate whether prenatal atazanavir (ATV) exposure, assessed by meconium antiretroviral (ARV) quantification, predicts early child language outcomes. Prenatal ATV exposure previously was associated with poorer language development in 1-year olds. METHODS Pregnant women with HIV and their uninfected infants enrolled in the Surveillance Monitoring of Antiretroviral Therapy Toxicities study. Meconium ARV concentrations were quantified by liquid chromatography-tandem mass spectrometry. Language development at 1 year was assessed with MacArthur-Bates Communicative Development Inventory (CDI) and Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III). Late language emergence was defined as ≥ 1 of 4 CDI scores ≤ 10th percentile for age. Associations between fetal ATV exposure timing and duration, meconium ATV concentration, and language outcomes were evaluated, adjusting for potential confounders. RESULTS Through 2013, meconium samples were available from 175 of 432 infants with prenatal ATV exposure. Valid Bayley-III (n = 93) and CDI (n = 106) assessments also were available. After adjustment for potential confounders, higher ATV meconium concentrations were associated with lower late language emergence risk (P = 0.04) and cumulative ATV exposure duration also was associated with higher Bayley-III Language scores (P = 0.03). Maternal ATV duration and initiation week correlated with ATV meconium concentrations (positively and negatively, respectively). CONCLUSIONS Higher meconium ATV concentrations were protective against developmental language delays at 1 year, suggesting the importance of fetal ATV detoxification into meconium. This information supports ATV exposure safety for infant language development. ATV is a preferred ARV for pregnant women with HIV, suggesting the importance of ATV safety investigations. Additionally, further pursuit of the influences on language development in HIV-exposed uninfected infants is required.
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de Ruiter A, Taylor GP, Clayden P, Dhar J, Gandhi K, Gilleece Y, Harding K, Hay P, Kennedy J, Low-Beer N, Lyall H, Palfreeman A, O'Shea S, Tookey P, Tosswill J, Welch S, Wilkins E. British HIV Association guidelines for the management of HIV infection in pregnant women 2012 (2014 interim review). HIV Med 2015; 15 Suppl 4:1-77. [PMID: 25604045 DOI: 10.1111/hiv.12185] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Protecting the fetus against HIV infection: a systematic review of placental transfer of antiretrovirals. Clin Pharmacokinet 2015; 53:989-1004. [PMID: 25223699 DOI: 10.1007/s40262-014-0185-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Maternal-to-fetal transfer of antiretroviral drugs contributes to prevention of vertical transmission of HIV. OBJECTIVE This systematic review discusses published studies containing data pertaining to the pharmacokinetics of placental transfer of antiretrovirals in humans, including paired cord and maternal plasma samples collected at the time of delivery as well as ex vivo placental perfusion models. METHODS Articles pertaining to placental transfer of antiretrovirals were identified from PubMed, from references of included articles, and from US Department of Health and Human Services Panel on Treatment of HIV-infected Pregnant Women and Prevention of Perinatal Transmission guidelines. Articles from non-human animal models or that had no original maternal-to-fetal transfer data were excluded. PRISMA guidelines were followed. RESULTS A total of 103 published studies were identified. Data across studies appeared relatively consistent for the nucleoside reverse transcriptase inhibitors (NRTIs) and the non-nucleotide reverse transcriptase inhibitors (NNRTIs), with cord to maternal ratios approaching 1 for many of these agents. The protease inhibitors atazanavir and lopinavir exhibited consistent maternal-to-fetal transfer across studies, although the transfer may be influenced by variations in drug-binding proteins. The protease inhibitors indinavir, nelfinavir, and saquinavir exhibited unreliable placental transport, with cord blood concentrations that were frequently undetectable. Limited data, primarily from case reports, indicate that darunavir and raltegravir provide detectable placental transfer. CONCLUSION These findings appear consistent with current guidelines of using two NRTIs plus an NNRTI, atazanavir/ritonavir, or lopinavir/ritonavir to maximize placental transfer as well as to optimally suppress maternal viral load. Darunavir/ritonavir and raltegravir may reasonably serve as second-line agents.
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Waqas S, Lambert JS. Therapeutic drug monitoring in HIV-infected pregnant women with a focus on protease inhibitors. Future Virol 2015. [DOI: 10.2217/fvl.15.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The goals of HIV therapy in pregnant patients are to ensure health of mother and to prevent mother to child transmission of HIV to the unborn child. Pregnancy is a time of significant physiological alterations that affect all pharmacological aspects of the antiretroviral (ARV) drugs. Studies point toward lower levels of ARVs in maternal blood especially during late stages of pregnancy. Therapeutic drug monitoring is a strategy to ensure that maternal blood contains adequate level of ARVs to achieve these targets. Pharmacokinetics and therapeutic drug monitoring studies of protease inhibitors are reviewed in this article with emphasis on darunavir which is a newer protease inhibitor gaining popularity as a therapeutic choice in pregnant patients.
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Affiliation(s)
- Sarmad Waqas
- Infectious Diseases Department, Mater Misericordiae University Hospital, Dublin, Ireland
| | - John S Lambert
- Infectious Diseases Medicine & Sexual Health (GUM) Department, Mater, Rotunda & University College Dublin, Dublin, Ireland
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Aweeka FT, Hu C, Huang L, Best BM, Stek A, Lizak P, Burchett SK, Read JS, Watts H, Mirochnick M, Capparelli EV. Alteration in cytochrome P450 3A4 activity as measured by a urine cortisol assay in HIV-1-infected pregnant women and relationship to antiretroviral pharmacokinetics. HIV Med 2015; 16:176-83. [PMID: 25407158 PMCID: PMC4320673 DOI: 10.1111/hiv.12195] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Pregnancy results in physiological changes altering the pharmacokinetics of drugs metabolized by cytochrome P450 3A4 (CYP3A4). The urinary ratio of 6-β hydroxycortisol to cortisol (6βHF : F) is a marker of CYP3A4 induction. We sought to evaluate its change in antiretroviral (ARV)-treated HIV-1-infected women and to relate this change to ARV pharmacokinetics. METHODS Women receiving various ARVs had pharmacokinetic evaluations during the third trimester of pregnancy (>30 weeks) and postpartum with determination of 6βHF : F carried out on the same days. The Wilcoxon signed rank test was used to compare the ratio antepartum to postpartum. The relationship between the change in ratio and the change in pharmacokinetics was analysed using Kendall's tau. RESULTS 6βHF : F ratios were available for 107 women antepartum, with 54 having postpartum values. The ratio was higher antepartum (P=0.033) (median comparison 1.35; 95% confidence interval 1.01, 1.81). For 71 women taking a protease inhibitor (PI), the antepartum vs. postpartum 6βHF : F comparison was marginally significant (P=0.058). When the change in the 6βHF : F ratio was related to the change in the dose-adjusted ARV area under the plasma concentration vs. time curve (AUC) between antepartum and postpartum, the 35 subjects in the lopinavir/ritonavir (LPV/r) arms demonstrated an inverse relationship (P=0.125), albeit this correlation did not reach statistical significance. CONCLUSIONS A 35% increase in the urinary 6βHF : F ratio was measured during late pregnancy compared with postpartum, indicating that CYP3A induction occurs during pregnancy. The trend towards an inverse relationship between the change in the 6βHF : F ratio and the change in the LPV AUC antepartum vs. postpartum suggests that CYP3A induction may be one mechanism behind altered LPV exposure during pregnancy.
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Affiliation(s)
- F T Aweeka
- University of California, San Francisco, CA, USA
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Genomewide association study of atazanavir pharmacokinetics and hyperbilirubinemia in AIDS Clinical Trials Group protocol A5202. Pharmacogenet Genomics 2015; 24:195-203. [PMID: 24557078 DOI: 10.1097/fpc.0000000000000034] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Atazanavir-associated hyperbilirubinemia can cause premature discontinuation of atazanavir and avoidance of its initial prescription. We used genomewide genotyping and clinical data to characterize determinants of atazanavir pharmacokinetics and hyperbilirubinemia in AIDS Clinical Trials Group protocol A5202. METHODS Plasma atazanavir pharmacokinetics and indirect bilirubin concentrations were characterized in HIV-1-infected patients randomized to atazanavir/ritonavir-containing regimens. A subset had genomewide genotype data available. RESULTS Genomewide assay data were available from 542 participants, of whom 475 also had data on estimated atazanavir clearance and relevant covariates available. Peak bilirubin concentration and relevant covariates were available for 443 participants. By multivariate analysis, higher peak on-treatment bilirubin levels were found to be associated with the UGT1A1 rs887829 T allele (P=6.4×10(-12)), higher baseline hemoglobin levels (P=4.9×10(-13)), higher baseline bilirubin levels (P=6.7×10(-12)), and slower plasma atazanavir clearance (P=8.6×10(-11)). For peak bilirubin levels greater than 3.0 mg/dl, the positive predictive value of a baseline bilirubin level of 0.5 mg/dl or higher with hemoglobin concentrations of 14 g/dl or higher was 0.51, which increased to 0.85 with rs887829 TT homozygosity. For peak bilirubin levels of 3.0 mg/dl or lower, the positive predictive value of a baseline bilirubin level less than 0.5 mg/dl with a hemoglobin concentration less than 14 g/dl was 0.91, which increased to 0.96 with rs887829 CC homozygosity. No polymorphism predicted atazanavir pharmacokinetics at genomewide significance. CONCLUSION Atazanavir-associated hyperbilirubinemia is best predicted by considering UGT1A1 genotype, baseline bilirubin level, and baseline hemoglobin level in combination. Use of ritonavir as a pharmacokinetic enhancer may have abrogated genetic associations with atazanavir pharmacokinetics.
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Lê MP, Mandelbrot L, Descamps D, Soulié C, Ichou H, Bourgeois-Moine A, Damond F, Lariven S, Valantin MA, Landman R, Faucher P, Tubiana R, Duro D, Meier F, Legac S, Bourse P, Mortier E, Dommergues M, Calvez V, Matheron S, Peytavin G. Pharmacokinetics, safety and efficacy of ritonavir-boosted atazanavir (300/100 mg once daily) in HIV-1-infected pregnant women. Antivir Ther 2015; 20:507-13. [PMID: 25599649 DOI: 10.3851/imp2936] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Atazanavir/ritonavir (ATV/r) is a boosted protease inhibitor recommended to minimize the risk of mother-to-child HIV-1 transmission (MTCT). We aimed to assess the pharmacokinetics, safety and efficacy of ATV/r in HIV-1-infected pregnant women and their neonates. METHODS A multicentre, cross-sectional, non-interventional cohort of HIV-1-infected pregnant women receiving ATV/r (300/100 mg once daily) who delivered in three Paris hospitals from 2006 to 2013 was designed. We determined antiretroviral trough plasma concentrations using liquid chromatography-mass spectrometry at each of the three trimesters, delivery and post-partum. ATV concentrations at 24 h (C24h) were interpreted by the 150-850 ng/ml efficacy-tolerance thresholds. Safety data and newborn HIV status were recorded. A mother's virological failure was defined as two successive measurements of plasma HIV-1 RNA>50 copies/ml within the 2 months before delivery. RESULTS 103 pregnant women were included, mostly from sub-Saharan Africa (88%). ATV C24h at each of the three trimesters and delivery remained similar to post-partum values. No dose adjustment was needed during pregnancy. The median plasma ratio of fetal/maternal ATV level was 0.19 (n=28). Only three patients showed two successive detectable viral loads but <400 copies/ml. Among 82 available newborn data, 16 were born preterm. Three in utero deaths occurred. Tolerance was good with one case of maternal grade 3 hyperbilirubinaemia, no cases in neonates at delivery and no clinically relevant adverse event. No case of MTCT was reported. CONCLUSIONS In this population, an ATV/r-containing antiretroviral regimen demonstrated good pharmacokinetics, virological efficacy and safety. No significant impact of pregnancy on ATV C24h was found. No dose adjustment was required.
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Affiliation(s)
- Minh P Lê
- APHP, Bichat-Claude Bernard Hospital, Clinical Pharmaco-Toxicology Department, Hôpitaux Universitaires Paris Nord Val de Seine, Paris, France.
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Olagunju A, Bolaji O, Amara A, Else L, Okafor O, Adejuyigbe E, Oyigboja J, Back D, Khoo S, Owen A. Pharmacogenetics of pregnancy-induced changes in efavirenz pharmacokinetics. Clin Pharmacol Ther 2015; 97:298-306. [PMID: 25669165 DOI: 10.1002/cpt.43] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 11/21/2014] [Accepted: 11/25/2014] [Indexed: 01/06/2023]
Abstract
Pregnancy-induced physiological changes alter many drugs' pharmacokinetics. We investigated pregnancy-induced changes in efavirenz pharmacokinetics in 25 pregnant and 19 different postpartum women stratified from 211 HIV-positive women in whom a preliminary pharmacogenetic study had been undertaken. Despite significant changes in CL/F during pregnancy (42.6% increase; P = 0.023), median (range) Cmin was 1,000 ng/mL (429-5,190) with no significant change in Cmax (P = 0.072). However, when stratified for CYP2B6 516G>T (rs3745274) genotype, efavirenz AUC0-24 , Cmax and Cmin were 50.6% (P = 0.0013), 17.2% (P = 0.14), and 61.6% (P = 0.0027) lower during pregnancy (n = 8) compared with postpartum (n = 6) in 516G homozygotes, with values of 25,900 ng.h/mL (21,700-32,600), 2,640 ng/mL (1,260-3,490), and 592 ng/mL (429-917), respectively, and CL/F was 100% higher (P = 0.0013). No changes were apparent in CYP2B6 516 heterozygotes (14 pregnant vs. 7 postpartum). The clinical implications of these findings warrant further investigation.
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Affiliation(s)
- A Olagunju
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK; Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria
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Padberg S. Anti-infective Agents. DRUGS DURING PREGNANCY AND LACTATION 2015. [PMCID: PMC7150338 DOI: 10.1016/b978-0-12-408078-2.00007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
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Quantitative determination of free/bound atazanavir via high-throughput equilibrium dialysis and LC-MS/MS, and the application in ex vivo samples. Bioanalysis 2014; 6:3169-82. [DOI: 10.4155/bio.14.251] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Aim: The determination of drug–protein binding is important in the pharmaceutical development process because of the impact of protein binding on both the pharmacokinetics and pharmacodynamics of drugs. Equilibrium dialysis is the preferred method to measure the free drug fraction because it is considered to be more accurate. The throughput of equilibrium dialysis has recently been improved by implementing a 96-well format plate. Results/methodology: This manuscript illustrates the successful application of a 96-well rapid equilibrium dialysis (RED) device in the determination of atazanavir plasma–protein binding. Discussion/conclusion: This RED method of measuring free fraction was successfully validated and then applied to the analysis of clinical plasma samples taken from HIV-infected pregnant women administered atazanavir. Combined with LC-MS/MS detection, the 96-well format equilibrium dialysis device was suitable for measuring the free and bound concentration of pharmaceutical molecules in a high-throughput mode.
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Colbers A, Moltó J, Ivanovic J, Kabeya K, Hawkins D, Gingelmaier A, Taylor G, Weizsäcker K, Sadiq ST, Van der Ende M, Giaquinto C, Burger D. Pharmacokinetics of total and unbound darunavir in HIV-1-infected pregnant women. J Antimicrob Chemother 2014; 70:534-42. [PMID: 25326090 DOI: 10.1093/jac/dku400] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To describe the pharmacokinetics of darunavir in pregnant HIV-infected women in the third trimester and post-partum. PATIENTS AND METHODS This was a non-randomized, open-label, multicentre, Phase IV study in HIV-infected pregnant women recruited from HIV treatment centres in Europe. HIV-infected pregnant women treated with darunavir (800/100 mg once daily or 600/100 mg twice daily) as part of their combination ART were included. Pharmacokinetic curves were recorded in the third trimester and post-partum. A cord blood sample and maternal sample were collected. The study is registered at ClinicalTrials.gov under number NCT00825929. RESULTS Twenty-four women were included in the analysis [darunavir/ritonavir: 600/100 mg twice daily (n=6); 800/100 mg once daily (n=17); and 600/100 mg once daily (n=1)]. Geometric mean ratios of third trimester versus post-partum (90% CI) were 0.78 (0.60-1.00) for total darunavir AUC0-tau after 600/100 mg twice-daily dosing and 0.67 (0.56-0.82) for total darunavir AUC0-tau after 800/100 mg once-daily dosing. The unbound fraction of darunavir was not different during pregnancy (12%) compared with post-partum (10%). The median (range) ratio of darunavir cord blood/maternal blood was 0.13 (0.08-0.35). Viral load close to delivery was <300 copies/mL in all but two patients. All children were tested HIV-negative and no congenital abnormalities were reported. CONCLUSIONS Darunavir AUC and Cmax were substantially decreased in pregnancy for both darunavir/ritonavir regimens. This decrease in exposure did not result in mother-to-child transmission. For antiretroviral-naive patients, who are adherent, take darunavir with food and are not using concomitant medication reducing darunavir concentrations, 800/100 mg of darunavir/ritonavir once daily is adequate in pregnancy. For all other patients 600/100 mg of darunavir/ritonavir twice daily is recommended during pregnancy.
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Affiliation(s)
- Angela Colbers
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - José Moltó
- Hospital Universitari Germans Trias I Pujol, Badalona, Spain
| | - Jelena Ivanovic
- National Institute for Infectious Diseases 'L. Spallanzani', Rome, Italy
| | | | | | - Andrea Gingelmaier
- Klinikum der Universität München, Frauenklinik Innenstadt, München, Germany
| | | | | | - S Tariq Sadiq
- Institution for Infection and Immunity, St George's, University of London, London, UK
| | | | | | - David Burger
- Radboud University Medical Center, Nijmegen, The Netherlands
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Antenatal atazanavir: a retrospective analysis of pregnancies exposed to atazanavir. Infect Dis Obstet Gynecol 2014; 2014:961375. [PMID: 25328370 PMCID: PMC4190692 DOI: 10.1155/2014/961375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 08/15/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION There are few data regarding the tolerability, safety, or efficacy of antenatal atazanavir. We report our clinical experience of atazanavir use in pregnancy. METHODS A retrospective medical records review of atazanavir-exposed pregnancies in 12 London centres between 2004 and 2010. RESULTS There were 145 pregnancies in 135 women: 89 conceived whilst taking atazanavir-based combination antiretroviral therapy (cART), "preconception" atazanavir exposure; 27 started atazanavir-based cART as "first-line" during the pregnancy; and 29 "switched" to an atazanavir-based regimen from another cART regimen during pregnancy. Gastrointestinal intolerance requiring atazanavir cessation occurred in five pregnancies. Self-limiting, new-onset transaminitis was most common in first-line use, occurring in 11.0%. Atazanavir was commenced in five switch pregnancies in the presence of transaminitis, two of which discontinued atazanavir with persistent transaminitis. HIV-VL < 50 copies/mL was achieved in 89.3% preconception, 56.5% first-line, and 72.0% switch exposures. Singleton preterm delivery (<37 weeks) occurred in 11.7% preconception, 9.1% first-line, and 7.7% switch exposures. Four infants required phototherapy. There was one mother-to-child transmission in a poorly adherent woman. CONCLUSIONS These data suggest that atazanavir is well tolerated and can be safely prescribed as a component of combination antiretroviral therapy in pregnancy.
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Colbers A, Hawkins D, Hidalgo-Tenorio C, van der Ende M, Gingelmaier A, Weizsäcker K, Kabeya K, Taylor G, Rockstroh J, Lambert J, Moltó J, Wyen C, Sadiq ST, Ivanovic J, Giaquinto C, Burger D. Atazanavir exposure is effective during pregnancy regardless of tenofovir use. Antivir Ther 2014; 20:57-64. [PMID: 24992294 DOI: 10.3851/imp2820] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND We studied the effect of pregnancy on atazanavir pharmacokinetics in the presence and absence of tenofovir. METHODS This was a non-randomized, open-label, multicentre Phase IV study in HIV-infected pregnant women recruited from European HIV treatment centres. HIV-infected pregnant women treated with boosted atazanavir (300/100 mg or 400/100 mg atazanavir/ritonavir) as part of their combination antiretroviral therapy (cART) were included in the study. 24 h pharmacokinetic curves were recorded in the third trimester and postpartum. Collection of a cord blood and maternal sample at delivery was optional. RESULTS 31 patients were included in the analysis, 21/31 patients used tenofovir as part of cART. Median (range) gestational age at delivery was 39 weeks (36-42). Approaching delivery 81% (25 patients) had an HIV viral load <50 copies/ml, all <1,000 copies/ml. Least squares means ratios (90% CI) of atazanavir pharmacokinetic parameters third trimester/postpartum were: 0.66 (0.57, 0.75) for AUC0-24h, 0.70 (0.61, 0.80) for Cmax and 0.59 (0.48, 0.72) for C24h. No statistical difference in pharmacokinetic parameters was found between patients using tenofovir versus no tenofovir. None of the patients showed atazanavir concentrations <0.15 mg/l (target for treatment-naive patients). One baby had a congenital abnormality, which was not likely to be related to atazanavir/ritonavir use. None of the children were HIV-infected. CONCLUSIONS Despite 34% lower atazanavir exposure during pregnancy, atazanavir/ritonavir 300/100 mg once daily generates effective concentrations for protease inhibitor (PI)-naive patients, even if co-administered with tenofovir. For treatment-experienced patients (with relevant PI resistance mutations) therapeutic drug monitoring of atazanavir should be considered to adapt the atazanavir/ritonavir dose on an individual basis.
ClinicalTrials.gov number NCT00825929.
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Affiliation(s)
- Angela Colbers
- Radboud University Medical Center, Nijmegen, the Netherlands.
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Else LJ, Jackson V, Brennan M, Back DJ, Khoo SH, Coulter-Smith S, Lambert JS. Therapeutic drug monitoring of atazanavir/ritonavir in pregnancy. HIV Med 2014; 15:604-10. [PMID: 24825070 DOI: 10.1111/hiv.12164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Pregnant women experience physiological changes during pregnancy that can have a significant impact on antiretroviral pharmacokinetics. Ensuring optimal plasma concentrations of antiretrovirals is essential for maternal health and to minimize the risk of vertical transmission. Here we describe atazanavir/ritonavir (ATV/r) plasma concentrations in a cohort of pregnant women undergoing routine therapeutic drug monitoring (TDM). METHODS Pregnant HIV-positive women received ATV/r as part of their routine pre-natal care. Demographic and clinical data were collected. ATV plasma concentrations ([ATV]) were determined in the first (T1), second (T2) and third (T3) trimesters and at postpartum (PP) using liquid chromatography-tandem mass spectrometry (LC-MS/MS). RESULTS From January 2007, 44 women (37 black African) were enrolled in the study. All received ATV/r at a dose of 300/100 mg once a day. Twenty-four had received antiretroviral therapy (ART) prior to pregnancy, and 20 initiated ATV/r in pregnancy. At the time nearest to delivery, 36 patients had undetectable plasma viral loads. [ATV] values were determined in 11 (T1), 25 (T2), 34 (T3) and 28 (PP) patients. [ATV] at 24 hours post-dose (C24) values significantly lower at T2/T3 relative to PP. CONCLUSIONS This study was carried out in one of the larger cohorts of women undergoing TDM for ATV in pregnancy. Lower [ATV] values were seen in T2/T3 compared with T1/PP. However, [ATV] were not associated with a lack of virologic suppression at delivery. Nonetheless, careful monitoring of women in pregnancy is required, and dose adjustment of ATV to 400 mg may be an option.
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Affiliation(s)
- L J Else
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
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Cressey TR, Best BM, Achalapong J, Stek A, Wang J, Chotivanich N, Yuthavisuthi P, Suriyachai P, Prommas S, Shapiro DE, Watts DH, Smith E, Capparelli E, Kreitchmann R, Mirochnick M. Reduced indinavir exposure during pregnancy. Br J Clin Pharmacol 2014; 76:475-83. [PMID: 23305215 DOI: 10.1111/bcp.12078] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 12/23/2012] [Indexed: 11/28/2022] Open
Abstract
AIM To describe the pharmacokinetics and safety of indinavir boosted with ritonavir (IDV/r) during the second and third trimesters of pregnancy and in the post-partum period. METHODS IMPAACT P1026s is an on-going, prospective, non-blinded study of antiretroviral pharmacokinetics (PK) in HIV-infected pregnant women with a Thai cohort receiving IDV/r 400/100 mg twice daily during pregnancy through to 6-12 weeks post-partum as part of clinical care. Steady-state PK profiles were performed during the second (optional) and third trimesters and at 6-12 weeks post-partum. PK targets were the estimated 10(th) percentile IDV AUC (12.9 μg ml(-1)h) in non-pregnant historical Thai adults and a trough concentration of 0.1 μg ml(-1), the suggested minimum target. RESULTS Twenty-six pregnant women were enrolled; thirteen entered during the second trimester. Median (range) age was 29.8 (18.9-40.8) years and weight 60.5 (50.0-85.0) kg at the third trimester PK visit. The 90% confidence limits for the geometric mean ratio of the indinavir AUC(0,12 h) and Cmax during the second trimester and post-partum (ante : post ratios) were 0.58 (0.49, 0.68) and 0.73 (0.59, 0.91), respectively; third trimester/post-partum AUC(0,12 h) and Cmax ratios were 0.60 (0.53, 0.68) and 0.63 (0.55, 0.72), respectively. IDV/r was well tolerated and 21/26 women had a HIV-1 viral load < 40 copies ml(-1) at delivery. All 26 infants were confirmed HIV negative. CONCLUSION Indinavir exposure during the second and third trimesters was significantly reduced compared with post-partum and ∼30% of women failed to achieve a target trough concentration. Increasing the dose of IDV/r during pregnancy to 600/100 mg twice daily may be preferable to ensure adequate drug concentrations.
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Affiliation(s)
- Tim R Cressey
- Program for HIV Prevention and Treatment (IRD URI 174), Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand; Harvard School of Public Health, Boston, MA, USA; Institut de Recherché pour le Développement (IRD), UMI 174-PHPT, Marseille, France
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