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Lewis R, Niazi-Ali S, McIvor A, Kanj SS, Maertens J, Bassetti M, Levine D, Groll AH, Denning DW. Triazole antifungal drug interactions-practical considerations for excellent prescribing. J Antimicrob Chemother 2024; 79:1203-1217. [PMID: 38629250 DOI: 10.1093/jac/dkae103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024] Open
Abstract
Systemic antifungal therapy is critical for reducing the mortality from many invasive and chronic fungal infections. Triazole antifungals are the most frequently prescribed antifungals but require attention to dosing and drug interactions. Nearly 600 severe drug-drug interactions and over 1100 moderate interactions requiring dose modifications are described or anticipated with systemic antifungal agents (see https://www.aspergillus.org.uk/antifungal-drug-interactions/). In this article, we address the common and less common, but serious, drug interactions observed in clinical practice with triazole antifungals, including a group of drugs that cannot be prescribed with all or most triazole antifungals (ivabradine, ranolazine, eplerenone, fentanyl, apomorphine, quetiapine, bedaquiline, rifampicin, rifabutin, sirolimus, phenytoin and carbamazepine). We highlight interactions with drugs used in children and new agents introduced for the treatment of haematological malignancies or graft versus host disease (midostaurin, ibrutinib, ruxolitinib and venetoclax). We also summarize the multiple interactions between oral and inhaled corticosteroids and triazole antifungals, and the strategies needed to optimize the therapeutic benefits of triazole antifungal therapy while minimizing potential harm to patients.
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Affiliation(s)
- Russell Lewis
- Department of Molecular Medicine, University of Padua, Padua, Italy
| | - Saarah Niazi-Ali
- Antifungal Database Consultancy Pharmacist, Fungal Infection Trust, PO Box 482, Macclesfield, Cheshire SK10 9AR, UK
| | - Andrew McIvor
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Souha S Kanj
- Division of Infectious Diseases, Department of Internal Medicine and Center for Infectious Diseases Research, American University of Beirut Medical Center, Beirut, Lebanon
| | - Johan Maertens
- Department of Microbiology, Immunology, and Transplantation, Department of Haematology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Matteo Bassetti
- Department of Health Sciences, Infectious Diseases Clinic, University of Genoa and Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Deborah Levine
- Lung Transplant Program, Division of Pulmonary Critical Care and Allergy, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, Children's University Hospital, Albert-Schweitzer-Campus 1, Building A1, Münster, 48149, Germany
| | - David W Denning
- Manchester Fungal Infection Group, The University of Manchester and Manchester Academic Health Science Centre, Manchester, UK
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Nyangulu W, Mungwira RG, Divala TH, Nampota-Nkomba N, Nyirenda OM, Buchwald AG, Miller J, Earland DE, Adams M, Plowe CV, Taylor TE, Mallewa JE, van Oosterhout JJ, Parikh S, Laurens MB, Laufer MK. Artemether-lumefantrine efficacy among adults on antiretroviral therapy in Malawi. Malar J 2023; 22:32. [PMID: 36707795 PMCID: PMC9881508 DOI: 10.1186/s12936-023-04466-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 01/20/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND When people with human immunodeficiency virus (HIV) infection (PWH) develop malaria, they are at risk of poor anti-malarial treatment efficacy resulting from impairment in the immune response and/or drug-drug interactions that alter anti-malarial metabolism. The therapeutic efficacy of artemether-lumefantrine was evaluated in a cohort of PWH on antiretroviral therapy (ART) and included measurement of day 7 lumefantrine levels in a subset to evaluate for associations between lumefantrine exposure and treatment response. METHODS Adults living with HIV (≥ 18 years), on ART for ≥ 6 months with undetectable HIV RNA viral load and CD4 count ≥ 250/mm3 were randomized to daily trimethoprim-sulfamethoxazole (TS), weekly chloroquine (CQ) or no prophylaxis. After diagnosis of uncomplicated Plasmodium falciparum malaria, a therapeutic efficacy monitoring was conducted with PCR-correction according to WHO guidelines. The plasma lumefantrine levels on day 7 in 100 episodes of uncomplicated malaria was measured. A frailty proportional hazards model with random effects models to account for clustering examined the relationship between participant characteristics and malaria treatment failure within 28 days. Pearson's Chi-squared test was used to compare lumefantrine concentrations among patients with treatment failure and adequate clinical and parasitological response (ACPR). RESULTS 411 malaria episodes were observed among 186 participants over 5 years. The unadjusted ACPR rate was 81% (95% CI 77-86). However, after PCR correction to exclude new infections, ACPR rate was 94% (95% CI 92-97). Increasing age and living in Ndirande were associated with decreased hazard of treatment failure. In this population of adults with HIV on ART, 54% (51/94) had levels below a previously defined optimal day 7 lumefantrine level of 200 ng/ml. This occurred more commonly among participants who were receiving an efavirenz-based ART compared to other ART regimens (OR 5.09 [95% CI 1.52-7.9]). Participants who experienced treatment failure had lower day 7 median lumefantrine levels (91 ng/ml [95% CI 48-231]) than participants who experienced ACPR (190 ng/ml [95% CI 101-378], p-value < 0.008). CONCLUSION Recurrent malaria infections are frequent in this population of PWH on ART. The PCR-adjusted efficacy of AL meets the WHO criteria for acceptable treatment efficacy. Nevertheless, lumefantrine levels tend to be low in this population, particularly in those on efavirenz-based regimens, with lower concentrations associated with more frequent malaria infections following treatment. These results highlight the importance of understanding drug-drug interactions when diseases commonly co-occur.
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Affiliation(s)
- Wongani Nyangulu
- Dignitas International, Zomba, Malawi
- Public Health and Nutrition Research Group, Kamuzu University of Health Sciences, Mangochi, Malawi
| | - Randy G Mungwira
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | | | - Osward M Nyirenda
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Andrea G Buchwald
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, 685 W. Baltimore St., Baltimore, MD, 21201, USA
| | - Jernelle Miller
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, 685 W. Baltimore St., Baltimore, MD, 21201, USA
| | - Dominique E Earland
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, 685 W. Baltimore St., Baltimore, MD, 21201, USA
| | - Matthew Adams
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, 685 W. Baltimore St., Baltimore, MD, 21201, USA
| | - Christopher V Plowe
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, 685 W. Baltimore St., Baltimore, MD, 21201, USA
| | - Terrie E Taylor
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Michigan State University, East Lansing, USA
| | - Jane E Mallewa
- Department of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi
- Partners in Hope, Lilongwe Malawi and David Geffen School of Medicine, University of California, Los Angeles, USA
| | | | - Matthew B Laurens
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, 685 W. Baltimore St., Baltimore, MD, 21201, USA
| | - Miriam K Laufer
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, 685 W. Baltimore St., Baltimore, MD, 21201, USA.
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Gaur AH, Panetta JC, Smith AM, Dallas RH, Freeman BB, Stewart TB, Tang L, John E, Branum KC, Patel ND, Ost S, Heine RN, Richardson JL, Hammill JT, Bebrevska L, Gusovsky F, Maki N, Yanagi T, Flynn PM, McCarthy JS, Chalon S, Guy RK. Combining SJ733, an oral ATP4 inhibitor of Plasmodium falciparum, with the pharmacokinetic enhancer cobicistat: An innovative approach in antimalarial drug development. EBioMedicine 2022; 80:104065. [PMID: 35598441 PMCID: PMC9127571 DOI: 10.1016/j.ebiom.2022.104065] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/07/2022] [Accepted: 05/04/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND SJ733, a newly developed inhibitor of P. falciparum ATP4, has a favorable safety profile and rapid antiparasitic effect but insufficient duration to deliver a single-dose cure of malaria. We investigated the safety, tolerability, and pharmacokinetics of a multidose SJ733 regimen and a single-dose pharmacoboost approach using cobicistat to inhibit CYP3A4, thereby increasing exposure. METHODS Two multidose unboosted cohorts (n = 9) (SJ733, 300 mg and 600 mg daily for 3 days) followed by three single-dose boosted cohorts combining SJ733 (n = 18) (75-, 300-, or 600-mg single dose) with cobicistat (150-mg single dose) as a pharmacokinetic booster were evaluated in healthy volunteers (ClinicalTrials.gov: NCT02661373). FINDINGS All participants tolerated SJ733 well, with no serious adverse events (AEs), dose-limiting toxicity, or clinically significant electrocardiogram or laboratory test findings. All reported AEs were Grade 1, clinically insignificant, and considered unlikely or unrelated to SJ733. Compared to unboosted cohorts, the SJ733/cobicistat-boosted cohorts showed a median increase in area under the curve and maximum concentration of 3·9 × and 2·6 ×, respectively, and a median decrease in the ratio of the major CYP3A-produced metabolite SJ506 to parent drug of 4·6 × . Incorporating these data in a model of parasite dynamics indicated that a 3-day regimen of SJ733/cobicistat (600 mg/150 mg daily) relative to a single 600-mg dose ± cobicistat would increase parasite clearance from 106 to 1012 parasites/µL. INTERPRETATION The multidose and pharmacoboosted approaches to delivering SJ733 were well-tolerated and significantly increased drug exposure and prediction of cure. This study supports the further development of SJ733 and demonstrates an innovative pharmacoboost approach for an antimalarial. FUNDING Global Health Innovative Technology Fund, Medicines for Malaria Venture, National Institutes of Health, and American Lebanese Syrian Associated Charities.
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Affiliation(s)
- Aditya H Gaur
- Translational Trials Unit, MS 600, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, United States.
| | - John C Panetta
- Translational Trials Unit, MS 600, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, United States
| | - Amber M Smith
- University of Tennessee Health Science Center, Memphis, TN, United States
| | - Ronald H Dallas
- Translational Trials Unit, MS 600, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, United States
| | - Burgess B Freeman
- Translational Trials Unit, MS 600, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, United States
| | - Tracy B Stewart
- Translational Trials Unit, MS 600, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, United States
| | - Li Tang
- Translational Trials Unit, MS 600, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, United States
| | | | - Kristen C Branum
- Translational Trials Unit, MS 600, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, United States
| | - Nehali D Patel
- Translational Trials Unit, MS 600, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, United States
| | - Shelley Ost
- University of Tennessee Health Science Center, Memphis, TN, United States
| | - Ryan N Heine
- Translational Trials Unit, MS 600, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, United States
| | - Julie L Richardson
- Translational Trials Unit, MS 600, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, United States
| | - Jared T Hammill
- University of Kentucky College of Pharmacy, Lexington, KY, United States
| | | | | | | | | | - Patricia M Flynn
- Translational Trials Unit, MS 600, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, United States
| | - James S McCarthy
- Department of Clinical Tropical Medicine, QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | | | - R Kiplin Guy
- University of Kentucky College of Pharmacy, Lexington, KY, United States
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Sugiarto SR, Page-Sharp M, Drinkwater JJ, Davis WA, Salman S, Davis TME. Pharmacokinetic properties of the antimalarial combination therapy artemether-lumefantrine in normal-weight, overweight and obese healthy male adults. Int J Antimicrob Agents 2021; 59:106482. [PMID: 34818520 DOI: 10.1016/j.ijantimicag.2021.106482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/09/2021] [Accepted: 11/13/2021] [Indexed: 11/26/2022]
Abstract
The component drugs in the widely used antimalarial artemisinin combination therapy artemether-lumefantrine are lipophilic, with the possibility that recommended fixed doses in adults may lead to subtherapeutic concentrations and consequent treatment failure in overweight/obese individuals with malaria. The aim of this study was to investigate the pharmacokinetic properties of artemether, lumefantrine and their active metabolites dihydroartemisinin and desbutyl-lumefantrine in 16 normal-weight, overweight and obese healthy male volunteers [body mass index (BMI) categories ≤25 kg/m², >25-≤30 kg/m² and >30 kg/m², respectively; absolute range 19.3-37.2 kg/m²]. Participants received the conventional six doses of artemether-lumefantrine over 3 days, each dose comprising 80 mg artemether plus 480 mg lumefantrine administered with 6.7 g fat, and blood samples were collected at pre-specified time-points over 14 days. Plasma drug/metabolite concentrations were measured using liquid chromatography-mass spectrometry and included in multi-compartmental population pharmacokinetic models. There was a non-significant trend to a lower area under the plasma concentration-time curve with a higher body weight or BMI for dihydroartemisinin and especially artemether which was attenuated when normalized for mg/kg dose, but this relationship was not evident in the case of the more lipophilic lumefantrine and its metabolite desbutyl-lumefantrine. Simulated Day 7 plasma lumefantrine concentrations were >200 µg/L (the threshold at which Plasmodium falciparum recrudescences are minimized) in all participants. These results indicate that there is no need for artemether-lumefantrine dose modification in overweight and obese patients with malaria.
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Affiliation(s)
- Sri Riyati Sugiarto
- University of Western Australia, Medical School, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Madhu Page-Sharp
- Curtin University, School of Pharmacy and Biomedical Sciences, Bentley, Western Australia, Australia
| | - Jocelyn J Drinkwater
- University of Western Australia, Medical School, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Wendy A Davis
- University of Western Australia, Medical School, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Sam Salman
- University of Western Australia, Medical School, Fremantle Hospital, Fremantle, Western Australia, Australia; Clinical Pharmacology and Toxicology Unit, PathWest, Western Australia, Australia
| | - Timothy M E Davis
- University of Western Australia, Medical School, Fremantle Hospital, Fremantle, Western Australia, Australia.
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Hughes E, Wallender E, Mohamed Ali A, Jagannathan P, Savic RM. Malaria PK/PD and the Role Pharmacometrics Can Play in the Global Health Arena: Malaria Treatment Regimens for Vulnerable Populations. Clin Pharmacol Ther 2021; 110:926-940. [PMID: 33763871 PMCID: PMC8518425 DOI: 10.1002/cpt.2238] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/05/2021] [Indexed: 12/23/2022]
Abstract
Malaria is an infectious disease which disproportionately effects children and pregnant women. These vulnerable populations are often excluded from clinical trials resulting in one‐size‐fits‐all treatment regimens based on those established for a nonpregnant adult population. Pharmacokinetic/pharmacodynamic (PK/PD) models can be used to optimize dose selection as they define the drug exposure‐response relationship. Additionally, these models are able to identify patient characteristics that cause alterations in the expected PK/PD profiles and through simulations can recommend changes to dosing which compensate for the differences. In this review, we examine how PK/PD models have been applied to optimize antimalarial dosing recommendations for young children, including those who are malnourished, pregnant women, and individuals receiving concomitant therapies such as those for HIV treatment. The malaria field has had great success in utilizing PK/PD models as a foundation to update treatment guidelines and propose the next generation of dosing regimens to investigate in clinical trials. We propose how the malaria field can continue to use modeling to improve therapies by further integrating PK data into clinical studies and including data on drug resistance and host immunity in PK/PD models. Finally, we suggest that other disease areas can achieve similar success in applying pharmacometrics to improve outcomes by implementing three key principals.
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Affiliation(s)
- Emma Hughes
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Erika Wallender
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Ali Mohamed Ali
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | | | - Radojka M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
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Usman SO, Oreagba IA, Kadri MR, Adewumi OO, Akinyede A, Agbaje EO, Abideen G, Busari AA, Hassan OO, Akinleye MO, Akanmu AS. Evaluation of the effects of atazanavir-ritonavir on the pharmacokinetics of lumefantrine in patients living with HIV in Lagos University Teaching Hospital, South-Western Nigeria. Eur J Clin Pharmacol 2021; 77:1341-1348. [PMID: 33755736 DOI: 10.1007/s00228-021-03116-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/16/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Atazanavir-ritonavir (ATVr)-based antiretroviral therapy and artemether-lumefantrine (AL) are commonly used drugs for the treatment of human immune deficiency virus (HIV) infection and malaria respectively. However, interaction of both drugs, with Cytochrome P 3A4 (CYP 3A4) isoenzyme, may spawn clinically significant pharmacokinetic interactions. This study evaluated the effects of atazanavir-ritonavir on the pharmacokinetics of lumefantrine. METHOD In a case-control study, twenty participants having Plasmodium falciparum malaria were recruited and divided into two groups (ATVr-arm, n=10; and control-arm, n= 10). All the participants were administered six oral doses of AL 80-480 mg (Coartem). Thereafter, their blood samples were collected at different time intervals over seven days. The concentration of lumefantrine in each sample was quantified with high-performance liquid chromatography (HPLC) and used to determine its pharmacokinetic parameters which were compared between the test and control groups. RESULTS ATVr increased the mean day 7 concentration of lumefantrine (ATVr 3847.09 ± 893.35 ng/mL, control 1374.53 ± 265.55 ng/mL, p = 0.016) and the area under its plasma concentration-time curve (ATVr 670529.57 ± 157172.93 ng.h/mL, control 447976.28 ± 80886.99 ng.h/mL, p = 0.224) by 179.88 % and 49.68 %, respectively, but decreased its mean maximum plasma drug concentration (Cmax) (ATVr 13725.70 ± 2658.44 ng/mL, control 15380.48 ± 2332.62 ng/mL, p = 0.645) by 10.76 %. CONCLUSION ATVr increased drug exposure and day 7 plasma concentration of lumefantrine. AL is therefore considered effective for the treatment of malaria in patients taking ATVr-based regimen. However, the safety associated with the interaction requires further elucidation. TRIAL REGISTRATION Clin ClinicalTrials.gov Identifier: NCT04531072, August 27, 2020. "Retrospectively registered".
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Affiliation(s)
- Sikiru Olatunji Usman
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria.
| | - Ibrahim Adekunle Oreagba
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Michael Rotimi Kadri
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Ololade Oluwatosin Adewumi
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Akinwumi Akinyede
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Esther Oluwatoyin Agbaje
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Ganiyu Abideen
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - AbdulWasiu Adeniyi Busari
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | | | - Moshood Olusola Akinleye
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Alani Sulaimon Akanmu
- Department of Haematology and Blood Transfusion, Faculty of Clinical Science, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria.,Apin Clinic, Lagos University Teaching Hospital, Idi-Araba, Lagos State, Nigeria
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Influence of selected polymorphisms in disposition genes on lumefantrine pharmacokinetics when coadministered with efavirenz. Pharmacogenet Genomics 2021; 30:96-106. [PMID: 32209837 DOI: 10.1097/fpc.0000000000000401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Coadministration of artemether-lumefantrine and efavirenz has been shown to result in significant interactions. The influence of functional genetic polymorphisms in selected CYPs on the magnitude of this interaction was investigated in pregnant and nonpregnant adults. METHOD A standard 3-day regimen of artemether-lumefantrine was administered to each patient on steady-state efavirenz-based antiretroviral therapy (ART). Pharmacokinetic parameters were obtained from intensive plasma concentration-time data. Genotyping data were tested for compliance with Hardy-Weinberg equilibrium by Chi-square test. Linear regressions, Mann-Whitney U-test or Kruskal-Wallis tests were conducted to examine the association of lumefantrine plasma level with CYP2B6 c.516G>T, NR1I3 152c-1089T>C, CYP2B6 c.983T>C, CYP3A5*3 and CYP3A4*22. RESULTS Among a total of 69 malaria-HIV coinfected patients (34 nonpregnant and 35 pregnant), median (interquartile range) age was 33 (27-36.5) years and body weight was 59.5 (50-67.5) kg. In nonpregnant group, CYP2B6 c.516G>T was significantly associated with lower log Cday 7 of lumefantrine using multivariate linear regressions (β = -0.239; P = 0.013). In 59% of women with CYP2B6 c.516T, Cday 7 of lumefantrine was below the target of 280 ng/mL compared to 47% in the noncarriers. CYP2B6 c.983T>C significantly associated with higher log Cday 7 of desbutyl lumefantrine in both pregnant (β = 0.383; P = 0.033) and nonpregnant (β = 0.395; P = 0.023) groups. Composite genotypes for both CYP2B6 Single-nucleotide polymorphisms strongly associated with lumefantrine plasma concentration. An associative trend between lumefantrine pharmacokinetics and NR1I3 152c-1089T>C genotypes indicated that 70% of the Cday 7 of lumefantrine in those with NR1I3 152c-1089TT genotype was below 280 ng/mL compared to 53% in those with NR1I3 152c-1089CC or CT genotype. CONCLUSION The findings revealed that the efavirenz-lumefantrine interaction was accentuated in the group with CYP2B6 c.516T, c.983C and NR1I3 152c-1089T alleles. This warrants further investigations of other drug-drug interactions for optimising dosing in genetically defined subgroups, particularly during drug development.
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Determination of lumefantrine as an effective drug against Toxoplasma gondii infection - in vitro and in vivo study. Parasitology 2020; 148:122-128. [PMID: 33087183 PMCID: PMC7808861 DOI: 10.1017/s0031182020002036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Toxoplasma gondii is an obligate intracellular protozoan parasite, which can infect almost all warm-blooded animals, including humans, leading to toxoplasmosis. Currently, the effective treatment for human toxoplasmosis is the combination of sulphadiazine and pyrimethamine. However, both drugs have serious side-effects and toxicity in the host. Therefore, there is an urgent need for the discovery of new anti-T. gondii drugs with high potency and less or no side-effects. Our findings suggest that lumefantrine exerts activity against T. gondii by inhibiting its proliferation in Vero cells in vitro without being toxic to Vero cells (P ≤ 0.01). Lumefantrine prolonged mice infected with T. gondii from death for 3 days at the concentration of 50 μg L−1 than negative control (phosphate-buffered saline treated only), and reduced the parasite burden in mouse tissues in vivo (P ≤ 0.01; P ≤ 0.05). In addition, a significant increase in interferon gamma (IFN-γ) production was observed in high-dose lumefantrine-treated mice (P ≤ 0.01), whereas interleukin 10 (IL-10) and IL-4 levels increased in low-dose lumefantrine-treated mice (P ≤ 0.01). The results demonstrated that lumefantrine may be a promising agent to treat toxoplasmosis, and more experiments on the protective mechanism of lumefantrine should be undertaken in further studies.
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Ashley EA, Poespoprodjo JR. Treatment and prevention of malaria in children. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:775-789. [PMID: 32946831 DOI: 10.1016/s2352-4642(20)30127-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/11/2020] [Accepted: 03/25/2020] [Indexed: 10/23/2022]
Abstract
Malaria disproportionately affects children younger than 5 years. Falciparum malaria is responsible for more than 200 000 child deaths per year in Africa and vivax malaria is well documented as a cause of severe anaemia and excess mortality in children in Asia and Oceania. For the treatment of malaria in children, paediatric dosing recommendations for several agents, including parenteral artesunate and dihydroartemisinin-piperaquine, have belatedly been shown to be suboptimal. Worsening antimalarial resistance in Plasmodium falciparum in the Greater Mekong Subregion threatens to undermine global efforts to control malaria. Triple antimalarial combination therapies are being evaluated to try to impede this threat. The RTS,S/AS01 vaccine gives partial protection against falciparum malaria and is being evaluated in large, pilot studies in Ghana, Malawi, and Kenya as a complementary tool to other preventive measures. Seasonal malaria chemoprevention in west Africa has resulted in declines in malaria incidence and deaths and there is interest in scaling up efforts by expanding the age range of eligible recipients. Preventing relapse in Plasmodium vivax infection with primaquine is challenging because treating children who have G6PD deficiency with primaquine can cause acute haemolytic anaemia. The safety of escalating dose regimens for primaquine is being studied to mitigate this risk.
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Affiliation(s)
- Elizabeth A Ashley
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Jeanne Rini Poespoprodjo
- Timika Research Facility, Papuan Health and Community Development Foundation, Timika, Indonesia; Department of Child Health, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta, Indonesia
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Efavirenz-Based Antiretroviral Therapy Reduces Artemether-Lumefantrine Exposure for Malaria Treatment in HIV-Infected Pregnant Women. J Acquir Immune Defic Syndr 2020; 83:140-147. [PMID: 31929402 DOI: 10.1097/qai.0000000000002237] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The choice of malaria treatment for HIV-infected pregnant women receiving efavirenz-based antiretroviral therapy must consider the potential impact of drug interactions on antimalarial exposure and clinical response. The aim of this study was to investigate the effects of efavirenz on artemether-lumefantrine (AL) because no studies have isolated the impact of efavirenz for HIV-infected pregnant women. METHODS A prospective clinical pharmacokinetic (PK) study compared HIV-infected, efavirenz-treated pregnant women with HIV-uninfected pregnant women in Tororo, Uganda. All women received the standard 6-dose AL treatment regimen for Plasmodium falciparum malaria with intensive PK samples collected over 21 days and 42-days of clinical follow-up. PK exposure parameters were calculated for artemether, its active metabolite dihydroartemisinin (DHA), and lumefantrine to determine the impact of efavirenz. RESULTS Nine HIV-infected and 30 HIV-uninfected pregnant women completed intensive PK evaluations. Relative to controls, concomitant efavirenz therapy lowered the 8-hour artemether concentration by 76% (P = 0.013), DHA peak concentration by 46% (P = 0.033), and day 7 and 14 lumefantrine concentration by 61% and 81% (P = 0.046 and 0.023), respectively. In addition, there were nonsignificant reductions in DHA area under the concentration-time curve0-8hr (35%, P = 0.057) and lumefantrine area under the concentration-time curve0-∞ (34%, P = 0.063) with efavirenz therapy. CONCLUSIONS Pregnant HIV-infected women receiving efavirenz-based antiretroviral therapy during malaria treatment with AL showed reduced exposure to both the artemisinin and lumefantrine. These data suggest that malaria and HIV coinfected pregnant women may require adjustments in AL dosage or treatment duration to achieve exposure comparable with HIV-uninfected pregnant women.
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An Individual Participant Data Population Pharmacokinetic Meta-analysis of Drug-Drug Interactions between Lumefantrine and Commonly Used Antiretroviral Treatment. Antimicrob Agents Chemother 2020; 64:AAC.02394-19. [PMID: 32071050 PMCID: PMC7179577 DOI: 10.1128/aac.02394-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 02/04/2020] [Indexed: 11/20/2022] Open
Abstract
Treating malaria in HIV-coinfected individuals should consider potential drug-drug interactions. Artemether-lumefantrine is the most widely recommended treatment for uncomplicated malaria globally. Lumefantrine is metabolized by CYP3A4, an enzyme that commonly used antiretrovirals often induce or inhibit. A population pharmacokinetic meta-analysis was conducted using individual participant data from 10 studies with 6,100 lumefantrine concentrations from 793 nonpregnant adult participants (41% HIV-malaria-coinfected, 36% malaria-infected, 20% HIV-infected, and 3% healthy volunteers). Treating malaria in HIV-coinfected individuals should consider potential drug-drug interactions. Artemether-lumefantrine is the most widely recommended treatment for uncomplicated malaria globally. Lumefantrine is metabolized by CYP3A4, an enzyme that commonly used antiretrovirals often induce or inhibit. A population pharmacokinetic meta-analysis was conducted using individual participant data from 10 studies with 6,100 lumefantrine concentrations from 793 nonpregnant adult participants (41% HIV-malaria-coinfected, 36% malaria-infected, 20% HIV-infected, and 3% healthy volunteers). Lumefantrine exposure increased 3.4-fold with coadministration of lopinavir-ritonavir-based antiretroviral therapy (ART), while it decreased by 47% with efavirenz-based ART and by 59% in the patients with rifampin-based antituberculosis treatment. Nevirapine- or dolutegravir-based ART and malaria or HIV infection were not associated with significant effects. Monte Carlo simulations showed that those on concomitant efavirenz or rifampin have 49% and 80% probability of day 7 concentrations <200 ng/ml, respectively, a threshold associated with an increased risk of treatment failure. The risk of achieving subtherapeutic concentrations increases with larger body weight. An extended 5-day and 6-day artemether-lumefantrine regimen is predicted to overcome these drug-drug interactions with efavirenz and rifampin, respectively.
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12
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Chotsiri P, Denoeud‐Ndam L, Baudin E, Guindo O, Diawara H, Attaher O, Smit M, Guerin PJ, Doumbo OK, Wiesner L, Barnes KI, Hoglund RM, Dicko A, Etard J, Tarning J. Severe Acute Malnutrition Results in Lower Lumefantrine Exposure in Children Treated With Artemether-Lumefantrine for Uncomplicated Malaria. Clin Pharmacol Ther 2019; 106:1299-1309. [PMID: 31152555 PMCID: PMC6896236 DOI: 10.1002/cpt.1531] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 05/08/2019] [Indexed: 01/28/2023]
Abstract
Severe acute malnutrition (SAM) has been reported to be associated with increased malaria morbidity in Sub-Saharan African children and may affect the pharmacology of antimalarial drugs. This population pharmacokinetic (PK)-pharmacodynamic study included 131 SAM and 266 non-SAM children administered artemether-lumefantrine twice daily for 3 days. Lumefantrine capillary plasma concentrations were adequately described by two transit-absorption compartments followed by two distribution compartments. Allometrically scaled body weight and an enzymatic maturation effect were included in the PK model. Mid-upper arm circumference was associated with decreased absorption of lumefantrine (25.4% decreased absorption per 1 cm reduction). Risk of recurrent malaria episodes (i.e., reinfection) were characterized by an interval-censored time-to-event model with a sigmoid maximum-effect model describing the effect of lumefantrine. SAM children were at risk of underexposure to lumefantrine and an increased risk of malaria reinfection compared with well-nourished children. Research on optimized regimens should be considered for malaria treatment in malnourished children.
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Affiliation(s)
- Palang Chotsiri
- Mahidol‐Oxford Tropical Medicine Research UnitFaculty of Tropical MedicineMahidol UniversityBangkokThailand
| | | | | | | | - Halimatou Diawara
- Malaria Research and Training CentreFaculty of Medicine Pharmacy and DentistryUniversity of BamakoBamakoMali
| | - Oumar Attaher
- Malaria Research and Training CentreFaculty of Medicine Pharmacy and DentistryUniversity of BamakoBamakoMali
| | - Michiel Smit
- Division of Clinical PharmacologyDepartment of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Philippe J. Guerin
- WorldWide Antimalarial Resistance Network (WWARN)OxfordUK
- Centre for Tropical Medicine and Global HealthNuffield Department of MedicineOxford UniversityOxfordUK
| | - Ogobara K. Doumbo
- Malaria Research and Training CenterFaculté de Médecine et d'Odonto‐stomatologie et Faculté de PharmacieUniversité des Sciences Techniques et Technologies de BamakoBamakoMali
| | - Lubbe Wiesner
- Division of Clinical PharmacologyDepartment of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Karen I. Barnes
- Division of Clinical PharmacologyDepartment of MedicineUniversity of Cape TownCape TownSouth Africa
- WorldWide Antimalarial Resistance Network (WWARN)OxfordUK
| | - Richard M. Hoglund
- Mahidol‐Oxford Tropical Medicine Research UnitFaculty of Tropical MedicineMahidol UniversityBangkokThailand
- Centre for Tropical Medicine and Global HealthNuffield Department of MedicineOxford UniversityOxfordUK
| | - Alassane Dicko
- Malaria Research and Training CenterFaculté de Médecine et d'Odonto‐stomatologie et Faculté de PharmacieUniversité des Sciences Techniques et Technologies de BamakoBamakoMali
| | - Jean‐Francois Etard
- EpicentreParisFrance
- TransVIHMI UMI 233Institut de recherche pour le développement (IRD)Inserm U 1175Montpellier 1 UniversityMontpellierFrance
| | - Joel Tarning
- Mahidol‐Oxford Tropical Medicine Research UnitFaculty of Tropical MedicineMahidol UniversityBangkokThailand
- WorldWide Antimalarial Resistance Network (WWARN)OxfordUK
- Centre for Tropical Medicine and Global HealthNuffield Department of MedicineOxford UniversityOxfordUK
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13
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Sevene E, Banda CG, Mukaka M, Maculuve S, Macuacua S, Vala A, Piqueras M, Kalilani-Phiri L, Mallewa J, Terlouw DJ, Khoo SH, Lalloo DG, Mwapasa V. Efficacy and safety of dihydroartemisinin-piperaquine for treatment of Plasmodium falciparum uncomplicated malaria in adult patients on antiretroviral therapy in Malawi and Mozambique: an open label non-randomized interventional trial. Malar J 2019; 18:277. [PMID: 31429785 PMCID: PMC6700797 DOI: 10.1186/s12936-019-2909-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 08/12/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND HIV-infected individuals on antiretroviral therapy (ART) require treatment with artemisinin-based combination therapy (ACT) when infected with malaria. Dihydroartemisinin-piperaquine (DPQ) is recommended for treatment of Plasmodium falciparum malaria, but its efficacy and safety has not been evaluated in HIV-infected individuals on ART, among whom drug-drug interactions are expected. Day-42 adequate clinical and parasitological response (ACPR) and incidence of adverse events were assessed in HIV-infected individuals on non-nucleoside reverse transcriptase inhibitor-based ART (efavirenz and nevirapine) with uncomplicated P. falciparum malaria treated with dihydroartemisinin-piperaquine. METHODS An open label single arm clinical trial was conducted in Malawi (Blantyre and Chikhwawa districts) and Mozambique (Manhiça district) involving patients aged 15-65 years with uncomplicated P. falciparum malaria who were on efavirenz-based or nevirapine-based ART. They received a directly-observed 3-day standard treatment of DPQ and were followed up until day 63 for malaria infection and adverse events. Day-42 PCR-corrected-ACPRs (95% confidence interval [CI]) were calculated for the intention-to-treat (ITT) population. RESULTS The study enrolled 160 and 61 patients on efavirenz and nevirapine-based ART, with a baseline geometric mean (95% CI) parasite density of 2681 (1964-3661) and 9819 (6606-14,593) parasites/µL, respectively. The day-42 PCR-corrected ACPR (95% CI) was 99.4% (95.6-99.9%) in the efavirenz group and 100% in the nevirapine group. Serious adverse events occurred in 5.0% (8/160) and 3.3% (2/61) of the participants in the efavirenz and nevirapine group, respectively, but none were definitively attributable to DPQ. Cases of prolonged QT interval (> 60 ms from baseline) occurred in 31.2% (48/154) and 13.3% (8/60) of the patients on the efavirenz and nevirapine ART groups, respectively. These were not clinically significant and resolved spontaneously over time. As this study was not designed to compare the efficacy and safety of DPQ in the two ART groups, no formal statistical comparisons were made between the two ART groups. CONCLUSIONS DPQ was highly efficacious and safe for the treatment of malaria in HIV-infected patients concurrently taking efavirenz- or nevirapine-based ART, despite known pharmacokinetic interactions between dihydroartemisinin-piperaquine and efavirenz- or nevirapine-based ART regimens. Trial registration Pan African Clinical Trials Registry (PACTR): PACTR201311000659400. Registered on 4 October 2013, https://pactr.samrc.ac.za/Search.aspx.
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Affiliation(s)
- Esperança Sevene
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.
- Eduardo Mondlane University, Maputo, Mozambique.
| | - Clifford G Banda
- University of Malawi, College of Medicine, Blantyre, Malawi
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Mavuto Mukaka
- University of Malawi, College of Medicine, Blantyre, Malawi
- Oxford Centre for Tropical Medicine and Global Health, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Sonia Maculuve
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Salésio Macuacua
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Anifa Vala
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Mireia Piqueras
- Institute for Global Health, Universitat de Barcelona, Barcelona, Spain
| | | | - Jane Mallewa
- University of Malawi, College of Medicine, Blantyre, Malawi
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Dianne J Terlouw
- University of Malawi, College of Medicine, Blantyre, Malawi
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Saye H Khoo
- University of Liverpool, Liverpool, UK
- Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - David G Lalloo
- Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Victor Mwapasa
- University of Malawi, College of Medicine, Blantyre, Malawi.
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
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Walimbwa SI, Lamorde M, Waitt C, Kaboggoza J, Else L, Byakika-Kibwika P, Amara A, Gini J, Winterberg M, Chiong J, Tarning J, Khoo SH. Drug Interactions between Dolutegravir and Artemether-Lumefantrine or Artesunate-Amodiaquine. Antimicrob Agents Chemother 2019; 63:e01310-18. [PMID: 30420479 PMCID: PMC6355558 DOI: 10.1128/aac.01310-18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 10/10/2018] [Indexed: 11/20/2022] Open
Abstract
Across sub-Saharan Africa, patients with HIV on antiretrovirals often get malaria and need cotreatment with artemisinin-containing therapies. We undertook two pharmacokinetic studies in healthy volunteers, using standard adult doses of artemether-lumefantrine or artesunate-amodiaquine given with 50 mg once daily dolutegravir (DTG) to investigate the drug-drug interaction between artemether-lumefantrine or artesunate-amodiaquine and dolutegravir. The dolutegravir/artemether-lumefantrine interaction was evaluated in a two-way crossover study and measured artemether, dihydroartemisinin, lumefantrine, and desbutyl-lumefantrine over 264 h. The dolutegravir/artesunate-amodiaquine interaction was investigated using a parallel study design due to long half-life of the amodiaquine metabolite, desethylamodiaquine and measured artesunate, amodiaquine, and desethylamodiaquine over 624 h. Noncompartmental analysis was performed, and geometric mean ratios and 90% confidence intervals were generated for evaluation of both interactions. Dolutegravir did not significantly change the maximum concentration in plasma, the time to maximum concentration, and the area under the concentration-time curve (AUC) for artemether, dihydroartemisinin, lumefantrine, and desbutyl-lumefantrine, nor did it significantly alter the AUC for artesunate, dihydroartemisinin, amodiaquine, and desethylamodiaquine. Coadministration of dolutegravir with artemether-lumefantrine resulted in a 37% decrease in DTG trough concentrations. Coadministration of dolutegravir with artesunate-amodiaquine resulted in 42 and 24% approximate decreases in the DTG trough concentrations and the AUC, respectively. The significant decreases in DTG trough concentrations with artemether-lumefantrine and artesunate-amodiaquine and dolutegravir exposure with artesunate-amodiaquine are unlikely to be of clinical significance since the DTG trough concentrations were above dolutegravir target concentrations of 300 ng/ml. Study drugs were well tolerated with no serious adverse events. Standard doses of artemether-lumefantrine and artesunate-amodiaquine should be used in patients receiving dolutegravir. (This study has been registered at ClinicalTrials.gov under identifier NCT02242799.).
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Affiliation(s)
- Stephen I Walimbwa
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Catriona Waitt
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Julian Kaboggoza
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Laura Else
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | | | - Alieu Amara
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Joshua Gini
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Markus Winterberg
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Justin Chiong
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Joel Tarning
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Saye H Khoo
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
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15
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Ndagije HB, Nambasa V, Manirakiza L, Kusemererwa D, Kajungu D, Olsson S, Speybroeck N. The Burden of Adverse Drug Reactions Due to Artemisinin-Based Antimalarial Treatment in Selected Ugandan Health Facilities: An Active Follow-Up Study. Drug Saf 2018; 41:753-765. [PMID: 29627926 PMCID: PMC6061396 DOI: 10.1007/s40264-018-0659-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Introduction Uganda has rapidly increased access to antimalarial medicines in an effort to address the huge malaria disease burden. Pharmacovigilance information is important to guide policy decisions. Objectives The purpose of this study was to establish the burden of adverse drug reactions (ADRs) and associated risk factors for developing ADRs to artemisinin-based antimalarial treatment in Uganda. Methods An active follow-up study was conducted between April and July 2017 in a cohort of patients receiving treatment for uncomplicated malaria in the Iganga, Mayuge, and Kampala districts. Results A total of 782 patients with a median age of 22 years (58.6% females) were recruited into this study, with the majority recruited from public health facilities (97%). Diagnostic tests before treatment were performed for 76% of patients, and 97% of patients received artemether/lumefantrine. The prevalence of ADRs was 22.5% (176/782); however, the total number of ADRs was 245 since some patients reported more than one ADR. The most commonly reported reactions were general body weakness (24%), headache (13%), and dizziness (11%). Women were more likely to develop an ADR (adjusted odds ratio [aOR] 1.8, 95% confidence interval [CI] 1.1–2.9), urban dwellers were more likely to develop an ADR than rural residents (aOR 9.9, 95% CI 5.4–17.9), and patients with comorbidities were more likely to develop an ADR than those without (aOR 7.4, 95% CI 4.4–12.3). Conclusion The burden of ADRs is high among women and in patients from urban settings and those with comorbidities. Such risk factors need to be considered in order to optimise therapy. Close monitoring of ADRs is key in implementation of the malaria treatment policy. Electronic supplementary material The online version of this article (10.1007/s40264-018-0659-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Victoria Nambasa
- National Pharmacovigilance Centre, National Drug Authority, Kampala, Uganda
| | - Leonard Manirakiza
- National Pharmacovigilance Centre, National Drug Authority, Kampala, Uganda
| | - Donna Kusemererwa
- National Pharmacovigilance Centre, National Drug Authority, Kampala, Uganda
| | - Dan Kajungu
- Makerere University Centre for Health and Population Research (MUCHAP), Iganga, Kampala, Uganda
| | - Sten Olsson
- Sten Olsson Pharmacovigilance Consulting, Uppsala, Sweden
| | - Niko Speybroeck
- Institute of Health and Society (IRSS), Université Catholique de Louvain, Brussels, Belgium
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16
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Impact of Efavirenz-, Ritonavir-Boosted Lopinavir-, and Nevirapine-Based Antiretroviral Regimens on the Pharmacokinetics of Lumefantrine and Safety of Artemether-Lumefantrine in Plasmodium falciparum-Negative HIV-Infected Malawian Adults Stabilized on Antiretroviral Therapy. Antimicrob Agents Chemother 2018; 62:AAC.01162-18. [PMID: 30150465 PMCID: PMC6201074 DOI: 10.1128/aac.01162-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 08/11/2018] [Indexed: 01/27/2023] Open
Abstract
There is conflicting evidence of the impact of commonly used antiretroviral therapies (ARTs) on the pharmacokinetics of lumefantrine and the safety profile of artemether-lumefantrine. We compared the area under the concentration-time curve from 0 h to 14 days (AUC0-14 days) of lumefantrine and the safety profile of artemether-lumefantrine in malaria-negative human immunodeficiency virus (HIV)-infected adults in two steps. In step 1, a half-dose adult course of artemether-lumefantrine was administered as a safety check in four groups (n = 6/group): (i) antiretroviral naive, (ii) nevirapine-based ART, (iii) efavirenz-based ART, and (iv) ritonavir-boosted lopinavir-based ART. In step 2, a standard-dose adult course of artemether-lumefantrine was administered to a different cohort in three groups (n = 10 to 15/group): (i) antiretroviral naive, (ii) efavirenz-based ART, and (iii) ritonavir-boosted lopinavir-based ART. In step 1, lumefantrine's AUC0-14 days was 53% (95% confidence interval [CI], 0.27 to 0.82) lower in the efavirenz-based ART group than in the ART-naive group and was 2.4 (95% CI, 1.58 to 3.62) and 2.9(95% CI, 1.75 to 4.72) times higher in the nevirapine- and ritonavir-boosted lopinavir groups, respectively. In step 2, lumefantrine's AUC0-14 days was 1.9 (95% CI, 1.26 to 3.00) times higher in the ritonavir-boosted lopinavir group and not significantly different between the efavirenz- and ART-naive groups (0.99 [95% CI, 0.63 to 1.57]). Frequent cases of hematological abnormalities (thrombocytopenia and neutropenia) were observed in the nevirapine group in step 1, leading to a recommendation from the data and safety monitoring board not to include a nevirapine group in step 2. Artemether-lumefantrine was well tolerated in the other groups. The therapeutic implications of these findings need to be evaluated among HIV-malaria-coinfected adults. (This study has been registered at the Pan African Clinical Trials Registry under numbers PACTR2010030001871293 and PACTR2010030001971409.).
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17
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Effect of Pregnancy on the Pharmacokinetic Interaction between Efavirenz and Lumefantrine in HIV-Malaria Coinfection. Antimicrob Agents Chemother 2018; 62:AAC.01252-18. [PMID: 30082286 DOI: 10.1128/aac.01252-18] [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: 06/13/2018] [Accepted: 07/26/2018] [Indexed: 01/10/2023] Open
Abstract
Artemether-lumefantrine is often coadministered with efavirenz-based antiretroviral therapy for malaria treatment in HIV-infected women during pregnancy. Previous studies showed changes in lumefantrine pharmacokinetics due to interaction with efavirenz in nonpregnant adults. The influence of pregnancy on this interaction has not been reported. This pharmacokinetic study involved 35 pregnant and 34 nonpregnant HIV-malaria-coinfected women receiving efavirenz-based antiretroviral therapy and was conducted in four health facilities in Nigeria. Participants received a 3-day standard regimen of artemether-lumefantrine for malaria treatment, and intensive pharmacokinetic sampling was conducted from 0.5 to 96 h after the last dose. Plasma efavirenz, lumefantrine, and desbutyl-lumefantrine were quantified using validated assays, and pharmacokinetic parameters were derived using noncompartmental analysis. The median middose plasma concentrations of efavirenz were significantly lower in pregnant women (n = 32) than in nonpregnant women (n = 32) at 1,820 ng/ml (interquartile range, 1,300 to 2,610 ng/ml) versus 2,760 ng/ml (interquartile range, 2,020 to 5,640 ng/ml), respectively (P = 0.006). The lumefantrine area under the concentration-time curve from 0 to 96 h was significantly higher in pregnant women (n = 27) at 155,832 ng · h/ml (interquartile range, 102,400 to 214,011 ng · h/ml) than nonpregnant women at 90,594 ng · h/ml (interquartile range, 58,869 to 149,775 ng · h/ml) (P = 0.03). A similar trend was observed for the lumefantrine concentration at 12 h after the last dose of lumefantrine, which was 2,870 ng/ml (interquartile range, 2,180 to 4,880 ng/ml) versus 2,080 ng/ml (interquartile range, 1,190 to 2,970 ng/ml) in pregnant and nonpregnant women, respectively (P = 0.02). The lumefantrine-to-desbutyl-lumefantrine ratio also tended to be lower in pregnant women than in nonpregnant women (P = 0.076). Overall, pregnancy tempered the extent of efavirenz-lumefantrine interactions, resulting in increased lumefantrine exposure. However, any consideration of dosage adjustment for artemether-lumefantrine to enhance exposure in this population needs to be based on data from a prospective study with safety and efficacy endpoints.
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18
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Hecht M, Veigure R, Couchman L, S Barker CI, Standing JF, Takkis K, Evard H, Johnston A, Herodes K, Leito I, Kipper K. Utilization of data below the analytical limit of quantitation in pharmacokinetic analysis and modeling: promoting interdisciplinary debate. Bioanalysis 2018; 10:1229-1248. [PMID: 30033744 DOI: 10.4155/bio-2018-0078] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Traditionally, bioanalytical laboratories do not report actual concentrations for samples with results below the LOQ (BLQ) in pharmacokinetic studies. BLQ values are outside the method calibration range established during validation and no data are available to support the reliability of these values. However, ignoring BLQ data can contribute to bias and imprecision in model-based pharmacokinetic analyses. From this perspective, routine use of BLQ data would be advantageous. We would like to initiate an interdisciplinary debate on this important topic by summarizing the current concepts and use of BLQ data by regulators, pharmacometricians and bioanalysts. Through introducing the limit of detection and evaluating its variability, BLQ data could be released and utilized appropriately for pharmacokinetic research.
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Affiliation(s)
- Max Hecht
- Chair of Analytical Chemistry, Institute of Chemistry, University of Tartu, 14a Ravila Street, 50411 Tartu, Estonia
- Analytical Services International, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Rūta Veigure
- Chair of Analytical Chemistry, Institute of Chemistry, University of Tartu, 14a Ravila Street, 50411 Tartu, Estonia
| | - Lewis Couchman
- Analytical Services International, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Charlotte I S Barker
- Paediatric Infectious Diseases Research Group, Institute for Infection & Immunity, St George's University of London, London, SW17 0RE, UK
- Inflammation, Infection & Rheumatology Section, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Paediatric Infectious Diseases Unit, St George's University Hospitals NHS Foundation Trust, London, SW17 0RE, UK
| | - Joseph F Standing
- Paediatric Infectious Diseases Research Group, Institute for Infection & Immunity, St George's University of London, London, SW17 0RE, UK
- Inflammation, Infection & Rheumatology Section, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
| | - Kalev Takkis
- Analytical Services International, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Hanno Evard
- Chair of Analytical Chemistry, Institute of Chemistry, University of Tartu, 14a Ravila Street, 50411 Tartu, Estonia
| | - Atholl Johnston
- Analytical Services International, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
- Clinical Pharmacology, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
| | - Koit Herodes
- Chair of Analytical Chemistry, Institute of Chemistry, University of Tartu, 14a Ravila Street, 50411 Tartu, Estonia
| | - Ivo Leito
- Chair of Analytical Chemistry, Institute of Chemistry, University of Tartu, 14a Ravila Street, 50411 Tartu, Estonia
| | - Karin Kipper
- Chair of Analytical Chemistry, Institute of Chemistry, University of Tartu, 14a Ravila Street, 50411 Tartu, Estonia
- Analytical Services International, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
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Abstract
Following unsuccessful eradication attempts there was a resurgence of malaria towards the end of the 20th century. Renewed control efforts using a range of improved tools, such as long-lasting insecticide-treated bednets and artemisinin-based combination therapies, have more than halved the global burden of disease, but it remains high with 445 000 deaths and more than 200 million cases in 2016. Pitfalls in individual patient management are delayed diagnosis and overzealous fluid resuscitation in severe malaria. Even in the absence of drug resistance, parasite recurrence can occur, owing to high parasite densities, low host immunity, or suboptimal drug concentrations. Malaria elimination is firmly back as a mainstream policy but resistance to the artemisinin derivatives, their partner drugs, and insecticides present major challenges. Vaccine development continues on several fronts but none of the candidates developed to date have been shown to provide long-lasting benefits at a population level. Increased resources and unprecedented levels of regional cooperation and societal commitment will be needed if further substantial inroads into the malaria burden are to be made.
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Affiliation(s)
- Elizabeth A Ashley
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Aung Pyae Phyo
- Shoklo Malaria Research Unit, Mae Sot, Thailand; Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Charles J Woodrow
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Zakaria Z, Badhan RKS. The impact of CYP2B6 polymorphisms on the interactions of efavirenz with lumefantrine: Implications for paediatric antimalarial therapy. Eur J Pharm Sci 2018; 119:90-101. [PMID: 29635009 DOI: 10.1016/j.ejps.2018.04.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 02/08/2018] [Accepted: 04/05/2018] [Indexed: 12/20/2022]
Abstract
Lumefantrine is a widely used antimalarial in children in sub-Saharan Africa and is predominantly metabolised by CYP3A4. The concomitant use of lumefantrine with the antiretroviral efavirenz, which is metabolised by CYP2B6 and is an inducer of CYP3A4, increases the risk of lumefantrine failure and can result in an increased recrudescence rate in HIV-infected children. This is further confounded by CYP2B6 being highly polymorphic resulting in a 2-3 fold higher efavirenz plasma concentration in polymorphic subjects, which enhances the potential for an efavirenz-lumefantrine drug-drug interaction (DDI). This study developed a population-based PBPK model capable of predicting the impact of efavirenz-mediated DDIs on lumefantrine pharmacokinetics in African paediatric population groups, which also considered the polymorphic nature of CYP2B6. The validated model demonstrated a significant difference in lumefantrine target day 7 concentrations (Cd7) in the presence and absence of efavirenz and confirmed the capability of efavirenz to initiate this DDI. This was more apparent in the *6/*6 compared to *1/*1 population group and resulted in a significantly lower (P < 0.001) lumefantrine Cd7. A prospective change in dosing schedule from 3-days to 7-days resulted in a greater number of *6/*6 subjects (28-57%) attaining the target Cd7 across age bands (0.25-13 years), with the greatest increase evident in the 1-4 year old group (3-day: 1%; 7-day: 28%).
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Affiliation(s)
- Zaril Zakaria
- Aston Health Research Group, Aston Pharmacy School, Aston University, Birmingham B4 7ET, United Kingdom; Ministry Of Health Malaysia, Block E1, E3, E6, E7 & E10, Parcel E, Federal Government Administration Centre, 62590 Putrajaya, Malaysia
| | - Raj K S Badhan
- Aston Health Research Group, Aston Pharmacy School, Aston University, Birmingham B4 7ET, United Kingdom; Aston Pharmacy School, Aston University, Birmingham B4 7ET, United Kingdom.
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21
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Zautner AE, Herchenröder O, Moussi AE, Schwarz NG, Wiemer DF, Groß U, Frickmann H. Pharmaceutical interactions between antiretroviral and antimalarial drugs used in chemoprophylaxis. Acta Trop 2018; 179:25-35. [PMID: 29273442 DOI: 10.1016/j.actatropica.2017.12.021] [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: 07/31/2017] [Revised: 12/08/2017] [Accepted: 12/17/2017] [Indexed: 10/18/2022]
Abstract
Human immunodeficiency virus (HIV) is the causative agent of the Acquired Immunodeficiency Syndrome (AIDS). The pandemic is believed to have originated within the Northern Congo basin covering large parts of the Democratic Republic of Congo, the Republic of Congo, the Central African Republic, Cameroon and Gabon. Although over decades, HIV-1 has spread throughout the World leaving no country unaffected, sub-Saharan Africa remains the region with more than 80% of all infected individuals. The HIV-2 epidemic has largely remained restricted to West Africa along the Upper Guinean forests. Co-incident with these regions of highest HIV distribution is a part of the malaria belt and therefore, co-infections are common. In this review we carve out the consequences of HIV transmission prevention and synchronous malaria prophylaxis during occupational or leisure travelling activities within this World region. In particular, we elaborate on considering pre-existing drug resistances of both, the malaria parasites and the immunodeficiency viruses, when determining a combination for prophylactic and, if necessary, post-expositional measures with a focus on the compatibility of both medications.
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Huang L, Carey V, Lindsey JC, Marzan F, Gingrich D, Graham B, Barlow-Mosha L, Ssemambo PK, Kamthunzi P, Nachman S, Parikh S, Aweeka FT. Concomitant nevirapine impacts pharmacokinetic exposure to the antimalarial artemether-lumefantrine in African children. PLoS One 2017; 12:e0186589. [PMID: 29065172 PMCID: PMC5655345 DOI: 10.1371/journal.pone.0186589] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 10/04/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The antiretroviral drug nevirapine and the antimalarial artemisinin-based combination therapy artemether-lumefantrine are commonly co-administered to treat malaria in the context of HIV. Nevirapine is a known inhibitor of cytochrome P450 3A4, which metabolizes artemether and lumefantrine. To address the concern that the antiretroviral nevirapine impacts the antimalarial artemether-lumefantrine pharmacokinetics, a prospective non-randomized controlled study in children presenting with uncomplicated malaria and HIV in sub-Saharan Africa was carried out. METHODS Participants received artemether-lumefantrine (20/120 mg weight-based BID) for 3 days during nevirapine-based antiretroviral therapy (ART) co-administration (158-266 mg/m2 QD). HIV positive participants who were not yet on ART drugs were also enrolled as the control group. The target enrollment was children aged 3-12 years (n = 24 in each group). Intensive pharmacokinetics after the last artemether-lumefantrine dose was assessed for artemether, its active metabolite dihydroartemisinin, and lumefantrine. Pharmacokinetic parameters (area under the plasma concentration vs. time curve (AUC), maximum concentration and day 7 lumefantrine concentrations) were estimated using non-compartmental methods and compared to controls. RESULTS Nineteen children (16 on nevirapine and three not on ART) enrolled. Fifteen of the 16 (aged 4 to 11 years) on nevirapine-based ART were included in the pharmacokinetic analysis. Due to evolving WHO HIV treatment guidelines, insufficient children were enrolled in the control group (n = 3), so the pharmacokinetic data were compared to a historical control group of 20 HIV-uninfected children 5-12 years of age who also presented with malaria and underwent identical study procedures. Decreases of pharmacokinetic exposure [as estimated by AUC (AUC0-8hr)] were marginally significant for artemether (by -46%, p = 0.08) and dihydroartemisinin (-22%, p = 0.06) in the children on nevirapine-based ART, compared to when artemether-lumefantrine was administered alone. Similarly, peak concentration was decreased by 50% (p = 0.07) for artemether and 36% (p = 0.01) for dihydroartemisinin. In contrast, exposure to lumefantrine increased significantly in the context of nevirapine [AUC0-120hr:123% (p<0.001); Cday7:116% (p<0.001), Cmax: 95% (p<0.001)]. CONCLUSIONS Nevirapine-based ART increases the exposure to lumefantrine in pre-pubescent children with a trend toward diminished artemether and dihydroartemisinin exposure. These findings contrast with other studies indicating NVP reduces or results in no change in exposure of antimalarial drugs, and may be specific to this age group (4-12 years). Considering the excellent safety profile of artemether-lumefantrine, the increase in lumefantrine is not of concern. However, the reduction in artemisinin exposure may warrant further study, and suggests that dosage adjustment of artemether-lumefantrine with nevirapine-based ART in children is likely warranted.
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Affiliation(s)
- Liusheng Huang
- Drug Research Unit, Department of Clinical Pharmacy, University of California, San Francisco, CA, United States of America
| | - Vincent Carey
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, MA, United States of America
| | - Jane C. Lindsey
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, MA, United States of America
| | - Florence Marzan
- Drug Research Unit, Department of Clinical Pharmacy, University of California, San Francisco, CA, United States of America
| | - David Gingrich
- Drug Research Unit, Department of Clinical Pharmacy, University of California, San Francisco, CA, United States of America
| | - Bobbie Graham
- Frontier Science and Technology Research Foundation, Buffalo, NY, United States of America
| | | | | | | | - Sharon Nachman
- School of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Sunil Parikh
- Yale School of Public Health, New Haven, CT, United States of America
| | - Francesca T. Aweeka
- Drug Research Unit, Department of Clinical Pharmacy, University of California, San Francisco, CA, United States of America
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Sugiarto SR, Davis TME, Salman S. Pharmacokinetic considerations for use of artemisinin-based combination therapies against falciparum malaria in different ethnic populations. Expert Opin Drug Metab Toxicol 2017; 13:1115-1133. [PMID: 29027504 DOI: 10.1080/17425255.2017.1391212] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Artemisinin-based combination therapy (ACT) is used extensively as first-line treatment for uncomplicated falciparum malaria. There has been no rigorous assessment of the potential for racial/ethnic differences in the pharmacokinetic properties of ACTs that might influence their efficacy. Areas covered: A comprehensive literature search was performed that identified 72 publications in which the geographical origin of the patients could be ascertained and the key pharmacokinetic parameters maximum drug concentration (Cmax), area under the plasma concentration-time curve (AUC) and elimination half-life (t½β) were available for one or more of the five WHO-recommended ACTs (artemether-lumefantrine, artesunate-amodiaquine, artesunate-mefloquine, dihydroartemisinin-piperaquine and artesunate-sulfadoxine-pyrimethamine). Comparisons of each of the three pharmacokinetic parameters of interest were made by drug (artemisinin derivative and long half-life partner), race/ethnicity (African, Asian, Caucasian, Melanesian, South American) and patient categories based on age and pregnancy status. Expert opinion: The review identified no evidence of a clinically significant influence of race/ethnicity on the pharmacokinetic properties of the nine component drugs in the five ACTs currently recommended by WHO for first-line treatment of uncomplicated falciparum malaria. This provides reassurance for health workers in malaria-endemic regions that ACTs can be given in recommended doses with the expectation of adequate blood concentrations regardless of race/ethnicity.
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Affiliation(s)
- Sri Riyati Sugiarto
- a Medical School , University of Western Australia, Fremantle Hospital , Fremantle , Australia
| | - Timothy M E Davis
- a Medical School , University of Western Australia, Fremantle Hospital , Fremantle , Australia
| | - Sam Salman
- a Medical School , University of Western Australia, Fremantle Hospital , Fremantle , Australia
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Drug interactions and the role of pharmacokinetic trials in guiding choices in first-line HIV therapy in low-income and middle-income countries. Curr Opin HIV AIDS 2017; 12:377-382. [PMID: 28570369 DOI: 10.1097/coh.0000000000000384] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE OF REVIEW Low- and middle-income countries (LMICs) face specific challenges in the treatment of people living with HIV. Drug-drug interactions (DDIs) involving antiretrovirals (ARVs) are prevalent in all settings and have considerable potential to cause clinical harm to patients via toxicity or reduced efficacy of treatment. Differing comorbidities, endemic infections and traditional medicines may complicate ARV therapy (ART) in LMICs, which usually takes a public health approach in these settings, with fewer alternative regimens available. This review discusses the issues surrounding pharmacokinetic DDI studies and their application to ART in LMICs, with particular reference to first-line ART regimens. RECENT FINDINGS Pharmacokinetic studies with clinical endpoints are the gold standard for informing management of DDIs; however, data relevant to LMICs are sparse and of low quality. There is significant potential for clinically relevant DDIs between ARVs and antimalarials, antimycobacterials and drugs used in the treatment of neglected tropical diseases. SUMMARY Many pharmacokinetic studies are difficult to interpret in LMICs due to differences in patient factors including weight, disease state and genetic polymorphisms. DDI studies relevant to LMICs may also be lacking due to the neglected nature of relevant comorbidities. The ARVs currently available as first-line ART in LMICs are among those with highest propensity for DDIs.
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Nyangulu WJ, Mwinjiwa E, Divala TH, Mungwira RG, Nyirenda O, Kanjala M, Mbambo G, Mallewa J, Taylor TE, Laurens MB, Laufer MK, van Oosterhout JJ. Frequent malaria illness episodes in two Malawian patients on antiretroviral therapy soon after stopping cotrimoxazole preventive therapy. Malawi Med J 2017; 29:57-60. [PMID: 28567199 DOI: 10.4314/mmj.v29i1.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
We describe two Malawian adults on successful antiretroviral therapy who experienced frequent malaria episodes after stopping cotrimoxazole prophylaxis. We argue that, in addition to stopping cotrimoxazole, diminished malaria immunity and drug interactions between efavirenz and artemether-lumefantrine may have played a causative role in the recurrent malaria our patients experienced.
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Affiliation(s)
| | | | - Titus H Divala
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Randy G Mungwira
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Osward Nyirenda
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Maxwell Kanjala
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Gillian Mbambo
- Division of Malaria Research, Institute for Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jane Mallewa
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Terrie E Taylor
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Matthew B Laurens
- Division of Malaria Research, Institute for Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Miriam K Laufer
- Division of Malaria Research, Institute for Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi.,Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
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Olafuyi O, Coleman M, Badhan RKS. Development of a paediatric physiologically based pharmacokinetic model to assess the impact of drug-drug interactions in tuberculosis co-infected malaria subjects: A case study with artemether-lumefantrine and the CYP3A4-inducer rifampicin. Eur J Pharm Sci 2017; 106:20-33. [PMID: 28546104 DOI: 10.1016/j.ejps.2017.05.043] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 04/27/2017] [Accepted: 05/20/2017] [Indexed: 12/13/2022]
Abstract
The fixed dosed combination of artemether and lumefantrine (AL) is widely used for the treatment of malaria in adults and children in sub-Sahara Africa, with lumefantrine day 7 concentrations being widely used as a marker for clinical efficacy. Both are substrates for CYP3A4 and susceptible to drug-drug interactions (DDIs); indeed, knowledge of the impact of these factors is currently sparse in paediatric population groups. Confounding malaria treatment is the co-infection of patients with tuberculosis. The concomitant treatment of AL with tuberculosis chemotherapy, which includes the CYP3A4 inducer rifampicin, increases the risk of parasite recrudescence and malaria treatment failure. This study developed a population-based PBPK model for AL in adults capable of predicting the pharmacokinetics of AL under non-DDI and DDI conditions, as well as predicting AL pharmacokinetics in paediatrics of 2-12years of age. The validated model was utilised to assess the concomitant treatment of rifampicin and lumefantrine under standard body-weight based treatment regimens for 2-5year olds, and demonstrated that no subjects attained the target day 7 concentration (Cd7) of 280ng/mL, highlighting the importance of this DDI and the potential risk of malaria-TB based DDIs. An adapted 7-day treatment regimen was simulated and resulted in 63% and 74.5% of subjects attaining the target Cd7 for 1-tablet and 2-tablet regimens respectively.
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Affiliation(s)
- Olusola Olafuyi
- Aston Healthy Research Group, Aston Pharmacy School, Aston University, Birmingham B4 7ET, United Kingdom
| | - Michael Coleman
- Aston Pharmacy School, Aston University, Birmingham B4 7ET, United Kingdom
| | - Raj K S Badhan
- Aston Healthy Research Group, Aston Pharmacy School, Aston University, Birmingham B4 7ET, United Kingdom; Aston Pharmacy School, Aston University, Birmingham B4 7ET, United Kingdom.
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Seden K, Gibbons S, Marzolini C, Schapiro JM, Burger DM, Back DJ, Khoo SH. Development of an evidence evaluation and synthesis system for drug-drug interactions, and its application to a systematic review of HIV and malaria co-infection. PLoS One 2017; 12:e0173509. [PMID: 28334018 PMCID: PMC5363796 DOI: 10.1371/journal.pone.0173509] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 02/21/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND In all settings, there are challenges associated with safely treating patients with multimorbidity and polypharmacy. The need to characterise, understand and limit harms resulting from medication use is therefore increasingly important. Drug-drug interactions (DDIs) are prevalent in patients taking antiretrovirals (ARVs) and if unmanaged, may pose considerable risk to treatment outcome. One of the biggest challenges in preventing DDIs is the substantial gap between theory and clinical practice. There are no robust methods published for formally assessing quality of evidence relating to DDIs, despite the diverse sources of information. We defined a transparent, structured process for developing evidence quality summaries in order to guide therapeutic decision making. This was applied to a systematic review of DDI data with considerable public health significance: HIV and malaria. METHODS AND FINDINGS This was a systematic review of DDI data between antiretrovirals and drugs used in prophylaxis and treatment of malaria. The data comprised all original research in humans that evaluated pharmacokinetic data and/or related adverse events when antiretroviral agents were combined with antimalarial agents, including healthy volunteers, patients with HIV and/or malaria, observational studies, and case reports. The data synthesis included 36 articles and conference presentations published via PubMed and conference websites/abstract books between 1987-August 2016. There is significant risk of DDIs between HIV protease inhibitors, or NNRTIs and artemesinin-containing antimalarial regimens. For many antiretrovirals, DDI studies with antimalarials were lacking, and the majority were of moderate to very low quality. Quality of evidence and strength of recommendation categories were defined and developed specifically for recommendations concerning DDIs. CONCLUSIONS There is significant potential for DDIs between antiretrovirals and antimalarials. The application of quality of evidence and strength of recommendation criteria to DDI data is feasible, and allows the assessment of DDIs to be robust, consistent, transparent and evidence-based.
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Affiliation(s)
- Kay Seden
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Sara Gibbons
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Catia Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital of Basel, Basel, Switzerland
| | | | - David M. Burger
- Department of Pharmacy & Radboud Institute of Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - David J. Back
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Saye H. Khoo
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
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Abstract
INTRODUCTION Using the data of a trial on cotrimoxazole (CTX) cessation, we investigated the effect of different antiretroviral therapy (ART) regimens on the incidence of clinical malaria. METHODS During the cotrimoxazole cessation trial (ISRCTN44723643), HIV-infected Ugandan adults with CD4 at least 250 cells/μl were randomized to receive either CTX prophylaxis or placebo and were followed for a median of 2.5 years. Blood slides for malaria microscopy were examined at scheduled visits and at unscheduled visits when the participant felt unwell. CD4 cell counts were done 6-monthly. Malaria was defined as fever with a positive blood slide. ART regimens were categorized as nucleoside reverse transcriptase inhibitor (NRTI) only, non-nucleoside reverse transcriptase inhibitor (NNRTI)-containing or protease inhibitor containing. Malaria incidence was calculated using random effects Poisson regression to account for clustering of events. RESULTS Malaria incidence in the three ART regimen groups was 9.9 (3.6-27.4), 9.3 (8.3-10.4), and 3.5 (1.6-7.6) per 100 person-years, respectively. Incidence on protease inhibitors was lower than that on the other regimens with the results just reaching significance (adjusted rate ratio 0.4, 95% confidence interval = 0.2-1.0, comparing with NNRTI regimens). Stratification by CTX/placebo use gave similar results, without evidence of an interaction between the effects of CTX/placebo use and ART regimen. There was no evidence of an interaction between ART regimen and CD4 cell count. CONCLUSION There was some evidence that protease inhibitor-containing ART regimens may be associated with a lower clinical malaria incidence compared with other regimens. This effect was not modified by CTX use or CD4 cell count. The antimalarial properties of protease inhibitors may have clinical and public health importance.
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Tchaparian E, Sambol NC, Arinaitwe E, McCormack SA, Bigira V, Wanzira H, Muhindo M, Creek DJ, Sukumar N, Blessborn D, Tappero JW, Kakuru A, Bergqvist Y, Aweeka FT, Parikh S. Population Pharmacokinetics and Pharmacodynamics of Lumefantrine in Young Ugandan Children Treated With Artemether-Lumefantrine for Uncomplicated Malaria. J Infect Dis 2016; 214:1243-51. [PMID: 27471317 PMCID: PMC5034953 DOI: 10.1093/infdis/jiw338] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 07/23/2016] [Indexed: 12/21/2022] Open
Abstract
Background. The pharmacokinetics and pharmacodynamics of lumefantrine, a component of the most widely used treatment for malaria, artemether-lumefantrine, has not been adequately characterized in young children. Methods. Capillary whole-blood lumefantrine concentration and treatment outcomes were determined in 105 Ugandan children, ages 6 months to 2 years, who were treated for 249 episodes of Plasmodium falciparum malaria with artemether-lumefantrine. Results. Population pharmacokinetics for lumefantrine used a 2-compartment open model with first-order absorption. Age had a significant positive correlation with bioavailability in a model that included allometric scaling. Children not receiving trimethoprim-sulfamethoxazole with capillary whole blood concentrations <200 ng/mL had a 3-fold higher hazard of 28-day recurrent parasitemia, compared with those with concentrations >200 ng/mL (P = .0007). However, for children receiving trimethoprim-sulfamethoxazole, the risk of recurrent parasitemia did not differ significantly on the basis of this threshold. Day 3 concentrations were a stronger predictor of 28-day recurrence than day 7 concentrations. Conclusions. We demonstrate that age, in addition to weight, is a determinant of lumefantrine exposure, and in the absence of trimethoprim-sulfamethoxazole, lumefantrine exposure is a determinant of recurrent parasitemia. Exposure levels in children aged 6 months to 2 years was generally lower than levels published for older children and adults. Further refinement of artemether-lumefantrine dosing to improve exposure in infants and very young children may be warranted.
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Affiliation(s)
- Eskouhie Tchaparian
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco
| | - Nancy C Sambol
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco
| | | | - Shelley A McCormack
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco
| | - Victor Bigira
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Mary Muhindo
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Darren J Creek
- Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Nitin Sukumar
- Yale School of Public Health, New Haven, Connecticut
| | | | - Jordan W Tappero
- Centers for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Abel Kakuru
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | - Sunil Parikh
- Yale School of Public Health, New Haven, Connecticut
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Parikh S, Kajubi R, Huang L, Ssebuliba J, Kiconco S, Gao Q, Li F, Were M, Kakuru A, Achan J, Mwebaza N, Aweeka FT. Antiretroviral Choice for HIV Impacts Antimalarial Exposure and Treatment Outcomes in Ugandan Children. Clin Infect Dis 2016; 63:414-22. [PMID: 27143666 PMCID: PMC4946019 DOI: 10.1093/cid/ciw291] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/03/2016] [Indexed: 02/06/2023] Open
Abstract
Pharmacokinetic/pharmacodynamic studies of artemether-lumefantrine and 3 antiretroviral regimens were conducted in malaria-infected Ugandan children. Efavirenz-based treatment was associated with significant reductions in antimalarial exposure and higher risks of recurrent malaria. Caution in their concurrent use is warranted. Background. The optimal treatment of malaria in human immunodeficiency virus (HIV)–infected children requires consideration of critical drug–drug interactions in coinfected children, as these may significantly impact drug exposure and clinical outcomes. Methods. We conducted an intensive and sparse pharmacokinetic/pharmacodynamic study in Uganda of the most widely adopted artemisinin-based combination therapy, artemether-lumefantrine. HIV-infected children on 3 different first-line antiretroviral therapy (ART) regimens were compared to HIV-uninfected children not on ART, all of whom required treatment for Plasmodium falciparum malaria. Pharmacokinetic sampling for artemether, dihydroartemisinin, and lumefantrine exposure was conducted through day 21, and associations between drug exposure and outcomes through day 42 were investigated. Results. One hundred forty-five and 225 children were included in the intensive and sparse pharmacokinetic analyses, respectively. Compared with no ART, efavirenz (EFV) reduced exposure to all antimalarial components by 2.1- to 3.4-fold; lopinavir/ritonavir (LPV/r) increased lumefantrine exposure by 2.1-fold; and nevirapine reduced artemether exposure only. Day 7 concentrations of lumefantrine were 10-fold lower in children on EFV vs LPV/r-based ART, changes that were associated with an approximate 4-fold higher odds of recurrent malaria by day 28 in those on EFV vs LPV/r-based ART. Conclusions. The choice of ART in children living in a malaria-endemic region has highly significant impacts on the pharmacokinetics and pharmacodynamics of artemether-lumefantrine treatment. EFV-based ART reduces all antimalarial components and is associated with the highest risk of recurrent malaria following treatment. For those on EFV, close clinical follow-up for recurrent malaria following artemether-lumefantrine treatment, along with the study of modified dosing regimens that provide higher exposure, is warranted.
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Affiliation(s)
- Sunil Parikh
- Yale School of Public Health, New Haven, Connecticut
| | - Richard Kajubi
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Liusheng Huang
- University of California, San Francisco, and San Francisco General Hospital
| | | | - Sylvia Kiconco
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Qin Gao
- University of California, San Francisco, and San Francisco General Hospital
| | - Fangyong Li
- University of California, San Francisco, and San Francisco General Hospital
| | - Moses Were
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Abel Kakuru
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Jane Achan
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Norah Mwebaza
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Francesca T Aweeka
- University of California, San Francisco, and San Francisco General Hospital
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Kredo T, Mauff K, Workman L, Van der Walt JS, Wiesner L, Smith PJ, Maartens G, Cohen K, Barnes KI. The interaction between artemether-lumefantrine and lopinavir/ritonavir-based antiretroviral therapy in HIV-1 infected patients. BMC Infect Dis 2016; 16:30. [PMID: 26818566 PMCID: PMC4728832 DOI: 10.1186/s12879-016-1345-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 01/12/2016] [Indexed: 12/16/2022] Open
Abstract
Background Artemether-lumefantrine is currently the most widely recommended treatment of uncomplicated malaria. Lopinavir–based antiretroviral therapy is the commonly recommended second-line HIV treatment. Artemether and lumefantrine are metabolised by cytochrome P450 isoenzyme CYP3A4, which lopinavir/ritonavir inhibits, potentially causing clinically important drug-drug interactions. Methods An adaptive, parallel-design safety and pharmacokinetic study was conducted in HIV-infected (malaria-negative) patients: antiretroviral-naïve and those stable on lopinavir/ritonavir-based antiretrovirals. Both groups received the recommended six-dose artemether-lumefantrine treatment. The primary outcome was day-7 lumefantrine concentrations, as these correlate with antimalarial efficacy. Adverse events were solicited throughout the study, recording the onset, duration, severity, and relationship to artemether-lumefantrine. Results We enrolled 34 patients. Median day-7 lumefantrine concentrations were almost 10-fold higher in the lopinavir than the antiretroviral-naïve group [3170 versus 336 ng/mL; p = 0.0001], with AUC(0-inf) and Cmax increased five-fold [2478 versus 445 μg.h/mL; p = 0.0001], and three-fold [28.2 versus 8.8 μg/mL; p < 0.0001], respectively. Lumefantrine Cmax, and AUC(0-inf) increased significantly with mg/kg dose in the lopinavir, but not the antiretroviral-naïve group. While artemether exposure was similar between groups, Cmax and AUC(0-8h) of its active metabolite dihydroartemisinin were initially two-fold higher in the lopinavir group [p = 0.004 and p = 0.0013, respectively]. However, this difference was no longer apparent after the last artemether-lumefantrine dose. Within 21 days of starting artemether-lumefantrine there were similar numbers of treatment emergent adverse events (42 vs. 35) and adverse reactions (12 vs. 15, p = 0.21) in the lopinavir and antiretroviral-naïve groups, respectively. There were no serious adverse events and no difference in electrocardiographic QTcF- and PR-intervals, at the predicted lumefantrine Tmax. Conclusion Despite substantially higher lumefantrine exposure, intensive monitoring in our relatively small study raised no safety concerns in HIV-infected patients stable on lopinavir-based antiretroviral therapy given the recommended artemether-lumefantrine dosage. Increased day-7 lumefantrine concentrations have been shown previously to reduce the risk of malaria treatment failure, but further evidence in adult patients co-infected with malaria and HIV is needed to assess the artemether-lumefantrine risk : benefit profile in this vulnerable population fully. Our antiretroviral-naïve patients confirmed previous findings that lumefantrine absorption is almost saturated at currently recommended doses, but this dose-limited absorption was overcome in the lopinavir group. Trial registration Clinical Trial Registration number NCT00869700. Registered on clinicaltrials.gov 25 March 2009 Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1345-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- T Kredo
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa. .,Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa.
| | - K Mauff
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa.
| | - L Workman
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - J S Van der Walt
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - L Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - P J Smith
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - G Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - K Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - K I Barnes
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa. .,WorlldWide Antimalarial Resistance Network (WWARN), Oxford, UK.
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Russo G, Paganotti GM, Soeria-Atmadja S, Haverkamp M, Ramogola-Masire D, Vullo V, Gustafsson LL. Pharmacogenetics of non-nucleoside reverse transcriptase inhibitors (NNRTIs) in resource-limited settings: Influence on antiretroviral therapy response and concomitant anti-tubercular, antimalarial and contraceptive treatments. INFECTION GENETICS AND EVOLUTION 2015; 37:192-207. [PMID: 26602158 DOI: 10.1016/j.meegid.2015.11.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 11/13/2015] [Accepted: 11/16/2015] [Indexed: 01/11/2023]
Abstract
The burden of human immunodeficiency virus (HIV) is mainly concentrated to resources-limited countries where the response to available antiretroviral therapy is often limited by the occurrence of toxicity or by the emergence of HIV drug resistance. Efavirenz and nevirapine are the antiretroviral drugs most prescribed in resources-limited countries as part of antiretroviral combination therapy. Their metabolism and conjugation are largely influenced by enzymatic genetic polymorphisms. The genetic variability of their metabolism could be associated to different metabolic phenotypes causing reduced patients' adherence because of toxicity or drug-drug interactions with concomitant therapies. The purpose of this review is to summarize published evidence on pharmacogenetic and pharmacokinetic aspects related to efavirenz and nevirapine, the influence of concomitant anti-tubercular, anti-malarial or contraceptive treatments, and the impact of human genetic variation and drug-drug interaction on the virologic and immunologic response to antiretroviral therapy in resources-limited countries.
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Affiliation(s)
- Gianluca Russo
- Department of Public Health and Infectious Diseases, University "La Sapienza", P.le Aldo Moro 5, 00185 Rome, Italy
| | - Giacomo Maria Paganotti
- Botswana-University of Pennsylvania Partnership, P.O. Box AC 157 ACH, Gaborone, Botswana; Medical Education Partnership Laboratory, c/o Faculty of Medicine, University of Botswana, Pvt Bag 00713, Gaborone, Botswana.
| | - Sandra Soeria-Atmadja
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, B57, SE-141 86, Stockholm, Sweden
| | - Miriam Haverkamp
- Botswana-University of Pennsylvania Partnership, P.O. Box AC 157 ACH, Gaborone, Botswana
| | - Doreen Ramogola-Masire
- Botswana-University of Pennsylvania Partnership, P.O. Box AC 157 ACH, Gaborone, Botswana
| | - Vincenzo Vullo
- Department of Public Health and Infectious Diseases, University "La Sapienza", P.le Aldo Moro 5, 00185 Rome, Italy
| | - Lars Lennart Gustafsson
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, SE-141 86, Stockholm, Sweden
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Silva A, Mwebaza N, Ntale M, Gustafsson L, Pohanka A. A fast and sensitive method for quantifying lumefantrine and desbutyl-lumefantrine using LC–MS/MS. J Chromatogr B Analyt Technol Biomed Life Sci 2015; 1004:60-6. [DOI: 10.1016/j.jchromb.2015.09.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/17/2015] [Accepted: 09/18/2015] [Indexed: 11/30/2022]
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du Plessis LH, Govender K, Denti P, Wiesner L. In vivo efficacy and bioavailability of lumefantrine: Evaluating the application of Pheroid technology. Eur J Pharm Biopharm 2015; 97:68-77. [DOI: 10.1016/j.ejpb.2015.10.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 09/30/2015] [Accepted: 10/01/2015] [Indexed: 11/27/2022]
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Artemether-Lumefantrine Exposure in HIV-Infected Nigerian Subjects on Nevirapine-Containing Antiretroviral Therapy. Antimicrob Agents Chemother 2015; 59:7852-6. [PMID: 26392500 DOI: 10.1128/aac.01153-15] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/16/2015] [Indexed: 11/20/2022] Open
Abstract
Coadministration of nevirapine-based antiretroviral therapy (ART) and artemether-lumefantrine is reported to result in variable changes in lumefantrine exposure. We conducted an intensive pharmacokinetic study with 11 HIV-infected adults who were receiving artemether-lumefantrine plus nevirapine-based ART, and we compared the results with those for 16 HIV-negative adult historical controls. Exposure to artemether and lumefantrine was significantly lower and dihydroartemisinin exposure was unchanged in subjects receiving nevirapine-based ART, compared with controls. Nevirapine exposure was unchanged before and after artemether-lumefantrine administration.
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CYP2B6*6 genotype and high efavirenz plasma concentration but not nevirapine are associated with low lumefantrine plasma exposure and poor treatment response in HIV-malaria-coinfected patients. THE PHARMACOGENOMICS JOURNAL 2015; 16:88-95. [PMID: 25963334 DOI: 10.1038/tpj.2015.37] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 02/12/2015] [Accepted: 04/07/2015] [Indexed: 01/03/2023]
Abstract
We investigated the influence of efavirenz (EFV)- or nevirapine (NVP)-based antiretroviral therapy (ART) on lumefantrine plasma exposure in HIV-malaria-coinfected patients and implication of pharmacogenetic variations. A total of 269 HIV patients with uncomplicated falciparum malaria on NVP-based ART (NVP-arm), EFV-based ART (EFV-arm) or not receiving ART (control-arm) were enrolled and treated with artemether-lumefantrine. Day-7 lumefantrine, baseline EFV and NVP plasma concentrations, and CYP2B6*6,*18, CYP3A4*1B, CYP3A5*3,*6,*7, ABCB1 c.3435C>T and ABCB1 c.4036A>G genotypes were determined. The median day-7 lumefantrine plasma concentration was significantly lower in the EFV-arm compared with that in NVP- and control-arm. High EFV plasma concentrations and CYP2B6*6/*6 genotype significantly correlated with low lumefantrine plasma concentrations and high rate of recurrent parasitemia. No significant effect of NVP-based ART on lumefantrine exposure was observed. In conclusion, owing to long-term CYP3A induction, EFV-based ART cotreatment significantly reduces lumefantrine plasma exposure leading to poor malaria treatment response, which is more pronounced in CYP2B6 slow metabolizers.
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Maganda BA, Ngaimisi E, Kamuhabwa AAR, Aklillu E, Minzi OMS. The influence of nevirapine and efavirenz-based anti-retroviral therapy on the pharmacokinetics of lumefantrine and anti-malarial dose recommendation in HIV-malaria co-treatment. Malar J 2015; 14:179. [PMID: 25906774 PMCID: PMC4424554 DOI: 10.1186/s12936-015-0695-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 04/14/2015] [Indexed: 01/29/2023] Open
Abstract
Background HIV-malaria co-infected patients in most parts of sub-Saharan Africa are treated with both artemether-lumefantrine (AL) and efavirenz (EFV) or nevirapine (NVP)-based antiretroviral therapy (ART). EFV, NVP, artemether and lumefantrine are substrates, inhibitors or inducers of CYP3A4 and CYP2B6, creating a potential for drug-drug interactions. The effect of EFV and/or NVP on lumefantrine pharmacokinetic profile among HIV-malaria co-infected patients on ART and treated with AL was investigated. Optimal lumefantrine dosage regimen for patients on EFV-based ART was determined by population pharmacokinetics and simulation. Methods This was a non-randomized, open label, parallel, prospective cohort study in which 128, 66 and 75 HIV-malaria co-infected patients on NVP-based ART (NVP-arm), EFV-based ART (EFV-arm) and ART naïve (control-am) were enrolled, respectively. Patients were treated with AL and contributed sparse venous plasma samples. Pharmacokinetic analysis of lumefantrine was done using non-linear mixed effect modelling. Results Of the evaluated models, a two-compartment pharmacokinetic model with first order absorption and lag-time described well lumefantrine plasma concentrations time profile. Patients in the EFV-arm but not in the NVP-arm had significantly lower lumefantrine bioavailability compared to that in the control-arm. Equally, 32% of patients in the EFV-arm had day-7 lumefantrine plasma concentrations below 280 ng/ml compared to only 4% in the control-arm and 3% in the NVP-arm. Upon post hoc simulation of lumefantrine exposure, patients in the EFV-arm had lower exposure (median (IQR)) compared to that in the control-arm; AUC0-inf; was 303,130 (211,080–431,962) versus 784,830 (547,405–1,116,250); day-7 lumefantrine plasma concentrations was: 335.5 (215.8-519.5) versus 858.7 (562.3-1,333.8), respectively. The predictive model through simulation of lumefantrine exposure at different dosage regimen scenarios for patients on EFV-based ART, suggest that AL taken twice daily for five days using the current dose could improve lumefantrine exposure and consequently malaria treatment outcomes. Conclusions Co-treatment of AL with EFV-based ART but not NVP-based ART significantly reduces lumefantrine bioavailability and consequently total exposure. To ensure adequate lumefantrine exposure and malaria treatment success in HIV-malaria co-infected patients on EFV-based ART, an extension of the duration of AL treatment to five days using the current dose is proposed.
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Affiliation(s)
- Betty A Maganda
- Department of Pharmaceutics, School of Pharmacy, Muhimbili University of Health and Allied Sciences, PO Box 65013, Dar es Salaam, Tanzania. .,Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, C-168, SE- 141 86, Stockholm, Sweden.
| | - Eliford Ngaimisi
- Unit of Pharmacology and Therapeutics, School of Pharmacy, Muhimbili University of Health and Allied Sciences, PO Box 65013, Dar es Salaam, Tanzania.
| | - Appolinary A R Kamuhabwa
- Unit of Pharmacology and Therapeutics, School of Pharmacy, Muhimbili University of Health and Allied Sciences, PO Box 65013, Dar es Salaam, Tanzania.
| | - Eleni Aklillu
- Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, C-168, SE- 141 86, Stockholm, Sweden.
| | - Omary M S Minzi
- Unit of Pharmacology and Therapeutics, School of Pharmacy, Muhimbili University of Health and Allied Sciences, PO Box 65013, Dar es Salaam, Tanzania.
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