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Galindo Puerto MJ, Puig J, Pérez-Molina JA, Fuster-Ruiz de Apodaca MJ. Perspectives of people with HIV and HIV clinicians on characteristics of antiretroviral treatment and HIV-related symptoms. HIV Med 2024; 25:565-576. [PMID: 38214438 DOI: 10.1111/hiv.13609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 12/20/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVES We aimed to assess HIV symptoms from the perspective of both patients and HIV specialists and the impact of discontinuing antiretroviral treatment (ART) on symptomology. We gathered opinions from HIV specialists and people living with HIV about ideal ART parameters and treatment satisfaction. METHODS Ex post-facto cross-sectional surveys were administered to 502 people living with HIV and 101 HIV clinicians in Spain (18 sites). RESULTS The median age of participants with HIV was 43.2 years, 74.5% were male, and 91.6% had an undetectable viral load. The mean time since initiation of ART was 10.2 years. Between 54% and 67% of people living with HIV reported experiencing nervousness or anxiety, sadness, fatigue, sleep problems, or muscle/joint pain during the preceding 4 weeks. However, only 22%-27% of specialists acknowledged the presence of these symptoms. The most bothersome symptoms were related to mental health or the central nervous system. There were significant differences between the burden of symptoms reported by people living with HIV and those acknowledged by specialists. The symptoms that more frequently caused ART discontinuation were depression, dizziness, and sleep problems. Both people living with HIV and specialists prioritized ART efficacy and low toxicity, but their importance ratings differed for 5 of the 11 ART characteristics assessed. People living with HIV rated their satisfaction with ART at a mean (± standard deviation) of 8.9 ± 1.5 out of 10, whereas HIV specialists rated it lower, at 8.3 ± 0.7 (p < 0.001). CONCLUSIONS Despite advances in HIV care and treatment, a large proportion of patients still experience symptoms. HIV specialists may not be fully aware of these. People living with HIV and HIV specialists are, overall, satisfied with ART. However, the importance they place on different ART characteristics may vary.
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Affiliation(s)
- M José Galindo Puerto
- Spanish AIDS Interdisciplinary Society (SEISIDA), Madrid, Spain
- Unit of Infectious Diseases, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - J Puig
- Spanish AIDS Interdisciplinary Society (SEISIDA), Madrid, Spain
- Fundación Llucha contra las Infecciones, Nurecare-IGTP, Hospital Germans Trias, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - J A Pérez-Molina
- Spanish AIDS Interdisciplinary Society (SEISIDA), Madrid, Spain
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - M J Fuster-Ruiz de Apodaca
- Spanish AIDS Interdisciplinary Society (SEISIDA), Madrid, Spain
- Facultad de Psicología, Universidad Nacional de Educación a Distancia (UNED), Madrid, Spain
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Bibas M. Plasmablastic Lymphoma. A State-of-the-Art Review: Part 2-Focus on Therapy. Mediterr J Hematol Infect Dis 2024; 16:e2024015. [PMID: 38468838 PMCID: PMC10927196 DOI: 10.4084/mjhid.2024.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/14/2024] [Indexed: 03/13/2024] Open
Abstract
The objective of this two-part review is to present a current and comprehensive understanding of the diagnosis and management of plasmablastic lymphoma. The first part, which was published previously, focused on the study of epidemiology, etiology, clinicopathological characteristics, differential diagnosis, prognostic variables, and the impact of plasmablastic lymphoma on specific populations. This second part addresses the difficult topic of the treatment of plasmablastic lymphoma, specifically examining both the conventional, consolidated approach and the novel therapeutic strategy.
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Affiliation(s)
- Michele Bibas
- Department of Clinical Research, Hematology. National Institute for Infectious Diseases "Lazzaro Spallanzani" I.R.C.S.S. Via Portuense 292 00148 Rome Italy
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3
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Ji X, Li Y, Wang Z, Gao Y, Wang L. Population Pharmacokinetics of Tenofovir Alafenamide Fumarate and Its Metabolite Tenofovir in Healthy Chinese Volunteers. Clin Pharmacol Drug Dev 2024; 13:168-179. [PMID: 37953690 DOI: 10.1002/cpdd.1340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 10/01/2023] [Indexed: 11/14/2023]
Abstract
Tenofovir alafenamide fumarate (TAF) is a first-line drug for treating hepatitis B virus infection. This study aimed to establish the prodrug-metabolite population pharmacokinetic (PK) model for TAF and its metabolite tenofovir (TFV) in healthy Chinese volunteers and evaluate the factors affecting the PK. Using 1043 TAF and 1198 TFV plasma sample concentrations collected from 67 healthy volunteers, a population PK model was developed using the nonlinear mixed-effects model. The 1-compartment model containing 4 transit compartments and the 2-compartment model accurately described the PK of TAF and TFV, respectively. Covariates such as meal state and sex were found to be statistically significant and potentially clinically relevant. Both internal and external validations demonstrated good stability and predictive performance of the connected model. This study elucidated the PK process by which TAF was absorbed, converted, and finally metabolized and eliminated as TFV, and explored the sources of interindividual variability between TAF and TFV.
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Affiliation(s)
- Xingfang Ji
- School of Pharmacy, Lanzhou University, Lanzhou, Gansu, China
| | - Yunfei Li
- Department of Ophthalmology, West China Hospital of Sichuan University, Sichuan, China
| | - Zhipeng Wang
- School of Pharmacy, Lanzhou University, Lanzhou, Gansu, China
| | - Yuan Gao
- School of Pharmacy, Lanzhou University, Lanzhou, Gansu, China
| | - Ling Wang
- Department of Clinical Pharmacy and Pharmacy Administration, West China School of Pharmacy, Sichuan University, Sichuan, China
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Hikasa S, Shimabukuro S, Hideta K, Higasa S, Sawada A, Tokugawa T, Tanaka K, Yanai M, Kimura T. Comparison between the impact of tenofovir alafenamide and that of abacavir on rapid kidney function decline: A retrospective observational study. HIV Med 2022; 24:422-430. [PMID: 36127309 DOI: 10.1111/hiv.13408] [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: 02/18/2022] [Accepted: 08/30/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare the impact of tenofovir alafenamide (TAF) on the slope of the estimated glomerular filtration rate (eGFR) with that of abacavir in Japanese patients living with HIV infection. METHODS The participants in this single-centre, retrospective, observational study were Japanese patients with HIV infection who started antiretroviral therapy with TAF/emtricitabine or abacavir/lamivudine or were switched from tenofovir disoproxil fumarate/emtricitabine to TAF/emtricitabine or abacavir/lamivudine (anchor drugs remained constant) between January 2012 and December 2020. The eGFR slope was defined as the regression coefficient between eGFR and time. The study outcome was rapid kidney function decline (RKFD; eGFR slope < -5 mL/min/1.73 m2 /year). The adjusted effect of TAF on the eGFR slope was compared with that of abacavir using multivariate logistic regression analysis. RESULTS The study included 184 patients (with 2835 eGFR data points). The median duration of exposure to TAF or abacavir was 2.6 years [interquartile range (IQR): 1.7-3.3], and the median eGFR slope was -4.1 mL/min/1.73 m2 /year (IQR: -6.4 to -1.2). In all, 72 patients (39%) experienced RKFD. Patients receiving TAF were more likely to experience RKFD (adjusted odds ratio = 3.74) than those receiving abacavir. There was a significant independent association between baseline eGFR and RKFD. CONCLUSIONS These findings suggest that renal function should be monitored carefully after the initiation of TAF in Japanese patients with HIV infection.
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Affiliation(s)
- Shinichi Hikasa
- Department of Pharmacy, Hyogo Medical University Hospital, Nishinomiya, Japan
| | - Shota Shimabukuro
- Department of Pharmacy, Hyogo Medical University Hospital, Nishinomiya, Japan
| | - Kyoko Hideta
- Department of Pharmacy, Hyogo Medical University Hospital, Nishinomiya, Japan
| | - Satoshi Higasa
- Department of Respiratory Medicine and Hematology, Hyogo Medical University, Nishinomiya, Japan
| | - Akihiro Sawada
- Department of Respiratory Medicine and Hematology, Hyogo Medical University, Nishinomiya, Japan
| | - Tazuko Tokugawa
- Department of Respiratory Medicine and Hematology, Hyogo Medical University, Nishinomiya, Japan
| | - Kuniyoshi Tanaka
- Department of Pharmacy, Hyogo Medical University Hospital, Nishinomiya, Japan
| | - Mina Yanai
- Department of Pharmacy, Hyogo Medical University Hospital, Nishinomiya, Japan
| | - Takeshi Kimura
- Department of Pharmacy, Hyogo Medical University Hospital, Nishinomiya, Japan
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Hikasa S, Shimabukuro S, Hideta K, Higasa S, Sawada A, Tokugawa T, Tanaka K, Yanai M, Kimura T. Effect of switching from tenofovir disoproxil fumarate to tenofovir alafenamide on estimated glomerular filtration rate slope in patients with HIV: A retrospective observational study. J Infect Chemother 2021; 28:396-400. [PMID: 34896027 DOI: 10.1016/j.jiac.2021.11.016] [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: 09/19/2021] [Revised: 11/09/2021] [Accepted: 11/18/2021] [Indexed: 01/04/2023]
Abstract
INTRODUCTION There is limited data on the effects of switching from tenofovir disoproxil fumarate (TDF) to tenofovir alafenamide (TAF) on estimated glomerular filtration rates (eGFR) slope in patients with human immunodeficiency virus (HIV) infection. This study aimed to compare the eGFR slope when administering TDF and TAF and to investigate the predictors of improvement in eGFR slope after switching from TDF to TAF. METHODS We conducted a single-center, retrospective, observational study in Japanese patients with HIV infection who switched the antiretroviral drug from TDF to TAF. eGFR was calculated using serum cystatin C. The eGFR slope was defined as the regression coefficient between eGFR and time. Differences between eGFR slope during TDF and TAF administration were compared using Wilcoxon signed rank test. A stepwise logistic regression model was used to examine the associations between improvement of eGFR slope after switching from TDF to TAF and various parameters. RESULTS Overall, 63 patients (656 eGFR) were included in the analysis. The median analyzed durations of TDF and TAF exposures were 1.6 and 1.5 years, respectively. There were no significant differences between eGFR slope during TDF and TAF periods (median: 0.6 vs. 4.0 mL/min/1.73 m2/year, p = 0.165). The eGFR slopes during the TDF period and while switching from TDF to TAF were independent predictors of improvement in eGFR slope after switching from TDF to TAF. CONCLUSIONS The results suggest that patients with poor renal function and those with progressive worsening during TDF administration would benefit from switching to TAF.
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Affiliation(s)
- Shinichi Hikasa
- Department of Pharmacy, Hyogo College of Medicine College Hospital, Address: 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.
| | - Shota Shimabukuro
- Department of Pharmacy, Hyogo College of Medicine College Hospital, Address: 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Kyoko Hideta
- Department of Pharmacy, Hyogo College of Medicine College Hospital, Address: 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Satoshi Higasa
- Department of Respiratory Medicine and Hematology, Hyogo College of Medicine, Address: 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Akihiro Sawada
- Department of Respiratory Medicine and Hematology, Hyogo College of Medicine, Address: 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Tazuko Tokugawa
- Department of Respiratory Medicine and Hematology, Hyogo College of Medicine, Address: 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Kuniyoshi Tanaka
- Department of Pharmacy, Hyogo College of Medicine College Hospital, Address: 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Mina Yanai
- Department of Pharmacy, Hyogo College of Medicine College Hospital, Address: 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Takeshi Kimura
- Department of Pharmacy, Hyogo College of Medicine College Hospital, Address: 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
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Chaparala S, Da Silva RC, Papadopoulos JP. Severe Lactic Acidosis Due to Acute Intoxication by Emtricitabine/Tenofovir Alafenamide. Cureus 2021; 13:e19008. [PMID: 34824925 PMCID: PMC8610206 DOI: 10.7759/cureus.19008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 11/28/2022] Open
Abstract
A 46-year-old female with a history of generalized anxiety disorder was admitted after intentional ingestion of an unknown amount of emtricitabine/tenofovir alafenamide (Descovy®) in a suicidal attempt. Patient was emergently intubated secondary to severe agitation and inability to protect airways. Patient developed severe lactic acidosis early in the admission, secondary as to a possible mitochondrial toxicity. Failed attempts to fluid resuscitation with Lactate Ringer®, eventually warranted to start the patient on norepinephrine infusion. Metabolic acidosis remained refractory to bicarbonate bolus and infusion. Hypothermia and hypoglycemia were corrected. Despite the initial approach, the patient remained acidotic, and the nephrology was consulted for emergent continuous renal replacement therapy (CRRT). After three days of intensive care unit stay and CRRT, the patient improved and was successfully decannulated. Her metabolic profile also showed remarkable improvement and the metabolic lactic acidosis resolved. The previous formulation of tenofovir with disoproxil fumarate is associated with severe lactic acidosis due to inhibition of mammalian mitochondrial DNA polymerase. Risk factors include liver cirrhosis, chronic kidney disease, hepatitis B and C coinfection, and metformin use. The new pharmaceutical formulation of tenofovir with alafenamide (TAF) has caused a significant decrease in the incidence of lactic acidosis. However, its real incidence and the usual plasma level to induce toxicity and mitochondrial dysfunction are unknown. The aim of this report is to highlight the risk of severe lactic acidosis with the use of TAF.
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Affiliation(s)
| | - Rafael C Da Silva
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
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Abstract
PURPOSE OF REVIEW People living with HIV (PWH) are at greater risk of low bone mineral density (BMD) and fractures compared to the general population. This narrative review summarises recent literature in the field, including the relative contribution of antiretroviral therapy and frailty to low BMD and fractures in PWH. RECENT FINDINGS The body of evidence indicating less impact on BMD from the use of tenofovir alafenamide compared to tenofovir disoproxil fumarate continues to grow, although this has not yet translated into data supporting a reduction in fracture incidence. Frailty, common in PWH, is associated with both fractures and alterations in renal-bone metabolism, but is an area that is understudied in relation to interventions to reduce fracture risk in PWH. SUMMARY Although a maturing field, research into interventions to reduce fracture incidence in PWH is lacking in both quantity and scope. Development of core outcome datasets for clinical trials along with trials focused on reducing or reversing frailty are required to guide improvements overall bone health outcomes in PWH.
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Impact of Therapeutic Drug Monitoring of Antiretroviral Drugs in Routine Clinical Management of People Living With HIV: A Narrative Review. Ther Drug Monit 2021; 42:64-74. [PMID: 31393332 DOI: 10.1097/ftd.0000000000000684] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The treatment of HIV infection has evolved significantly since the advent of highly active antiretroviral therapy. As a result, a response rate of 90%-95% now represents a realistically achievable target. Given this background, it is difficult to imagine the additional benefits that therapeutic drug monitoring (TDM) could provide in the management of HIV infection. METHODS This article is not intended to provide a systematic literature review on TDM of antiretroviral agents; rather, the authors aim to discuss the potential added value of TDM in the optimal management of people living with HIV (PLWH) in selected real-life clinical scenarios based on data collected over 10 years by their TDM service. RESULTS Some clinical situations, in which the selection of the optimal antiretroviral therapy is challenging, have been identified. These include poorly compliant patients, suboptimal antiretroviral therapies (in terms of both efficacy and toxicity), polypharmacy with a high risk of drug-drug interactions, and different patient populations, such as pregnant women. CONCLUSIONS The transformation of HIV infection from a near-universally fatal illness to a lifelong chronic disease has resulted in an HIV population that is growing and aging, placing new and increasing demands on public programs and health services. Increasingly, the management of comorbidities, polypharmacy, and drug-drug interaction, and their impact on antiretroviral therapy will have to be undertaken. These clinical settings represent some of the new frontiers for the use of TDM with the goal of achieving optimal prescription and outcome for PLWH.
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Ma Q, Ocque AJ, Morse GD, Sanders C, Burgi A, Little SJ, Letendre SL. Switching to Tenofovir Alafenamide in Elvitegravir-Based Regimens: Pharmacokinetics and Antiviral Activity in Cerebrospinal Fluid. Clin Infect Dis 2021; 71:982-988. [PMID: 31560741 DOI: 10.1093/cid/ciz926] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 09/16/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Tenofovir alafenamide fumarate (TAF) co-formulated with elvitegravir (EVG; E), cobicistat (C), and emtricitabine (F), a recommended antiretroviral regimen, was evaluated for distribution and antiviral activity in cerebrospinal fluid (CSF) as well as neurocognitive (NC) performance change in participants switching from E/C/F/tenofovir disoproxil fumarate (TDF) to E/C/F/TAF. METHODS This was a 24-week, single-arm, open-label study in treatment-experienced adults living with human immunodeficiency virus (HIV). Nine participants switched from E/C/F/TDF (150/150/200/300 mg once daily) to E/C/F/TAF (150/150/200/10 mg once daily) at week 12. CSF and total plasma concentrations of EVG, TDF, TAF, tenofovir (TFV), and HIV RNA levels were measured at baseline and week 24. NC performance was estimated by the Montreal Cognitive Assessment. RESULTS EVG concentrations in CSF and the CSF:plasma ratio remained stable (P = .203) over time. Following the switch, TFV concentrations in CSF and plasma declined (P = .004), although the TFV CSF:plasma ratio increased (P = .004). At week 24, median TAF plasma concentration was 11.05 ng/mL (range, 2.84-147.1 ng/mL) 2 hours postdose but was below assay sensitivity 6 hours after dosing. TAF was below assay sensitivity in all CSF specimens. HIV RNA was ≤40 copies/mL in all CSF and plasma specimens. Three participants (33%) had NC impairment at baseline and 2 (22%) remained impaired at week 24. CONCLUSIONS Switch to E/C/F/TAF was associated with reductions in TFV concentrations in CSF but stable EVG concentrations that exceeded the 50% inhibitory concentration for wild-type HIV, suggesting that EVG achieves therapeutic concentrations in the central nervous system. No virologic failure or significant NC changes were detected following the switch. CLINICAL TRIALS REGISTRATION NCT02251236.
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Affiliation(s)
- Qing Ma
- University at Buffalo, Buffalo, New York, USA
| | | | | | - Chelsea Sanders
- University of California, San Diego, La Jolla, California, USA
| | - Alina Burgi
- University of California, San Diego, La Jolla, California, USA
| | - Susan J Little
- University of California, San Diego, La Jolla, California, USA
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HTA and HIV: The Case of Dual NRTI Backbones in the Italian Setting. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17239010. [PMID: 33287274 PMCID: PMC7729444 DOI: 10.3390/ijerph17239010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/30/2020] [Accepted: 12/02/2020] [Indexed: 11/17/2022]
Abstract
The aim of this study is to analyze the potential advantages of emtricitabine/tenofovir alafenamide (FTC/TAF) introduction, creating evidence-based information to orient strategies to reduce costs, thus preserving effectiveness and appropriateness. An Health Technology Assessment (HTA) was implemented in the years 2017–2018 comparing the dual backbones available in the Italian market: FTC/TAF, FTC/TDF (tenofovir disoproxil fumarate/emtricitabine) and ABC/3TC (abacavir/lamivudine). From an efficacy point of view, FTC/TAF ensured a higher percentage of virologic control and a better safety impact than FTC/TDF (improving the renal and bone safety profile, as well as the lipid picture). From an economic point of view, the results revealed a 4% cost saving for the Italian National Healthcare Service NHS with FTC/TAF introduction compared with the baseline scenario. Qualitative perceptions’ results showed that FTC/TAF would decrease the burden of adverse events management, increasing the accessibility of patients to healthcare providers (FTC/TAF: 0.95, FTC/TDF: 0.10, ABC/3TC: 0.28; p-value: 0.016) and social costs (FTC/TDF: −0.23, FTC/TAF: 1.04, ABC/3TC: 0.23; p-value < 0.001), improving patient quality of life (FTC/TDF: 0.31, FTC/TAF: 1.85, ABC/3TC: 0.38; p-value < 0.001). Healthcare services may consider the evidence provided by the present study as an opportunity to include HIV patients in a more adequate antiretroviral treatment arm, guaranteeing a personalized clinical pathway, thus becoming more efficient and effective over time.
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Ibrahim F, Campbell L, Bailey AC, Stockwell S, Waters L, Orkin C, Johnson M, Gompels M, De Burgh-Thomas A, Jones R, Schembri G, Mallon PW, Post FA. Estimated glomerular filtration rate slopes on tenofovir alafenamide. HIV Med 2020; 21:607-612. [PMID: 33021067 DOI: 10.1111/hiv.12899] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of the study was to analyse and compare estimated glomerular filtration rate (eGFR) slopes during exposure to tenofovir disoproxil fumarate (TDF) and tenofovir alafenamide (TAF) in individuals who initiated TAF, regardless of prior regimen, before October 2016. METHODS An observational cohort study was conducted at 11 clinics in the UK and Ireland. Mixed effects models with random intercept and time terms fitted were used to generate and compare eGFR slopes while participants were exposed to TDF and TAF, with adjustment for age, eGFR at TDF/TAF initiation, gender, ethnicity, and time-updated CD4 cell count and HIV RNA measurements. RESULTS Data were available for 357 subjects (median age 50 years; 80% male; 82% white/other ethnicity; 51% men who have sex with men; median nadir CD4 count 216 cells/µL). The median duration of exposure to TAF was 2.0 (interquartile range 1.6, 2.3) years. At TAF initiation, the median CD4 count was 557 cells/µL, the median eGFR was 80 mL/min/1.73 m2, and 86% had suppressed HIV infection. The mean adjusted eGFR slope during TDF and TAF exposure was -2.08 [95% confidence interval (CI) -2.24, -1.92] and 1.18 (95% CI 0.20, 1.52) mL/min/1.73 m2/year, respectively (P < 0.001). Individuals who experienced rapid eGFR decline (> 3 or 5 mL/min/1.73 m2/year) while receiving TDF experienced significant eGFR recovery while on TAF (P < 0.001). CONCLUSIONS Significant improvement in eGFR slope was observed in patients who switched from TDF- to TAF-containing antiretroviral regimens. These data provide further support for the renal safety of TAF, and for switching those who experience progressive worsening of renal function from TDF to TAF.
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Affiliation(s)
| | - L Campbell
- King's College Hospital NHS Foundation Trust, London, UK
| | | | | | - L Waters
- Mortimer Market Centre, London, UK
| | - C Orkin
- Barts Health NHS Trust, London, UK
| | - M Johnson
- Royal Free Hospital NHS Foundation Trust, London, UK
| | - M Gompels
- North Bristol NHS Trust, Bristol, UK
| | | | - R Jones
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - G Schembri
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - P W Mallon
- University College Dublin, Dublin, Ireland
| | - F A Post
- King's College London, London, UK.,King's College Hospital NHS Foundation Trust, London, UK
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Pierra Rouviere C, Dousson CB, Tavis JE. HBV replication inhibitors. Antiviral Res 2020; 179:104815. [PMID: 32380149 PMCID: PMC7293572 DOI: 10.1016/j.antiviral.2020.104815] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/22/2020] [Accepted: 04/28/2020] [Indexed: 12/21/2022]
Abstract
Chronic Hepatitis B Virus infections afflict >250 million people and kill nearly 1 million annually. Current non-curative therapies are dominated by nucleos(t)ide analogs (NAs) that profoundly but incompletely suppress DNA synthesis by the viral reverse transcriptase. Residual HBV replication during NA therapy contributes to maintenance of the critical nuclear reservoir of the HBV genome, the covalently-closed circular DNA, and to ongoing infection of naive cells. Identification of next-generation NAs with improved efficacy and safety profiles, often through novel prodrug approaches, is the primary thrust of ongoing efforts to improve HBV replication inhibitors. Inhibitors of the HBV ribonuclease H, the other viral enzymatic activity essential for viral genomic replication, are in preclinical development. The complexity of HBV's reverse transcription pathway offers many other potential targets. HBV's protein-priming of reverse transcription has been briefly explored as a potential target, as have the host chaperones necessary for function of the HBV reverse transcriptase. Improved inhibitors of HBV reverse transcription would reduce HBV's replication-dependent persistence mechanisms and are therefore expected to become a backbone of future curative combination anti-HBV therapies.
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Affiliation(s)
| | - Cyril B Dousson
- Ai-biopharma, Medicinal Chemistry Department, Montpellier, France.
| | - John E Tavis
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, Saint Louis, MO, USA.
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Moreno S, Perno CF, Mallon PW, Behrens G, Corbeau P, Routy JP, Darcis G. Two-drug vs. three-drug combinations for HIV-1: Do we have enough data to make the switch? HIV Med 2020; 20 Suppl 4:2-12. [PMID: 30821898 DOI: 10.1111/hiv.12716] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2019] [Indexed: 01/01/2023]
Abstract
Three-drug combination antiretroviral therapy (ART) became available in 1996, dramatically improving the prognosis of people living with HIV. The clinical benefits of ART are due to the sustained viral load suppression and CD4 T cell gains. Major drawbacks of the first ART regimens were adverse events, and high pill burden, which led to the reduction of drug adherence resulting in frequent treatment discontinuations and the development of drug resistance. Due to increased viral potency of new antiretroviral drugs consideration of a two-drug combination therapy repositioning occurred in an effort to reduce adverse events, drug-drug interactions and cost, while maintaining a sustained antiviral effect. Various combinations of two-drug regimens have been studied, and non-inferiority compared to a three-drug regimen has been shown only for some of them. In addition, a two-drug combination regimen may not be suitable for every patient, especially those who are pregnant, those with tuberculosis or coexisting HBV infection. Furthermore no information has been generated concerning the secondary transmission of HIV from patients who have undetectable plasma viral load on two-drug regimens. Additional studies of two-drug combinations are also necessary to evaluate the debated existence of low viral replication in tissues and on immune activation. While there is no urgent need to routinely switch patients to two-drug combination therapy, due to the availability of drug combinations without significant toxicities, dual regimens represent a suitable option that deserve long-term evaluation before being introduced to clinical practice.
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Affiliation(s)
- S Moreno
- Department of Infectious Diseases, University Hospital Ramón y Cajal, Alcalá University, IRYCIS, Madrid, Spain
| | - C F Perno
- Department of Laboratory Medicine, ASST Niguarda Hospital, University of Milan, Milan, Italy
| | - P W Mallon
- HIV Molecular Research Group, School of Medicine, University College Dublin, Dublin, Ireland
| | - G Behrens
- Department for Rheumatology and Clinical Immunology, Hannover Medical School, Hannover, Germany
| | - P Corbeau
- Institute for Human Genetics, CNRS-Montpellier University UMR9002, Montpellier, France.,Immunology Department, University Hospital, Nîmes, France
| | - J-P Routy
- Division of Hematology and Chronic Viral Infection Service, McGill University Health Centre, Montréal, QC, Canada
| | - G Darcis
- Department of Infectious Diseases, Liege University Hospital, University of Liege, Liège, Belgium
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14
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Shafran SD, Di Perri G, Esser S, Lelièvre JD, Parczewski M. Planning HIV therapy to prevent future comorbidities: patient years for tenofovir alafenamide. HIV Med 2020; 20 Suppl 7:1-16. [PMID: 31099116 DOI: 10.1111/hiv.12755] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2019] [Indexed: 11/28/2022]
Abstract
Since the introduction of suppressive antiretroviral therapy (ART), HIV has become a chronic disease, with infected people in high-income countries approaching similar life expectancy to the general population. As this population ages, an increasing number of people with HIV are living with age-, treatment-, and disease-related comorbidities. Lifestyle factors such as smoking, alcohol abuse, and substance misuse have a role in age-related comorbidity. Some degree of immune dysfunction is suggested by the presence of markers of immune activation/inflammation despite effective suppression of HIV replication. Cumulative exposure to some antiretroviral drugs contributes to HIV-associated comorbidities, with risk increasing with age. Specifically, tenofovir disoproxil fumarate (TDF), ritonavir-boosted atazanavir, and ritonavir-boosted lopinavir are associated with renal impairment, and TDF is known to cause loss of bone mineral density. Tenofovir alafenamide (TAF) was developed to improve on the safety profile of TDF, while maintaining its efficacy. TAF has better stability in plasma, and higher intracellular accumulation of tenofovir diphosphate in target cells, which has resulted in improved antiviral activity at lower doses with improved renal and bone safety. TAF has been studied extensively in randomized clinical trials and real-world studies. TAF-based regimens are recommended over TDF-containing regimens for the improved safety profile.
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Affiliation(s)
- S D Shafran
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - G Di Perri
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - S Esser
- Department of Dermatology, University of Duisburg-Essen, Essen, Germany
| | - J-D Lelièvre
- Department of Clinical Immunopathology, Faculté de Médecine de Créteil, Université Paris Est Créteil, Créteil, France
| | - M Parczewski
- Department of Infectious, Tropical Diseases and Immune Deficiency, Pomeranian Medical University, Szczecin, Poland
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15
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Najjar A, Najjar A, Karaman R. Newly Developed Prodrugs and Prodrugs in Development; an Insight of the Recent Years. Molecules 2020; 25:E884. [PMID: 32079289 PMCID: PMC7070911 DOI: 10.3390/molecules25040884] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/06/2020] [Accepted: 02/10/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The design and development of prodrugs is the most common and effective strategy to overcome pharmacokinetic and pharmacodynamic drawbacks of active drugs. A respected number of prodrugs have been reached the drugs market throughout history and the recent years have witnessed a significant increase in the use of prodrugs as a replacement of their parent drugs for an efficient treatment of various ailment. METHODS A Scan conducted to find recent approved prodrugs and prodrugs in development. RESULTS Selected prodrugs were reported and categorized in accordance to their target systems. CONCLUSIONS the prodrug approach has shown many successes and still remains a viable and effective approach to deliver new active agents. This conclusion is supported by the recent approved prodrugs and the scan of clinical trials conducted between 2013-2018.
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Affiliation(s)
- Anas Najjar
- Faculty of Pharmacy, Department of Bioorganic & Pharmaceutical Chemistry, Al-Quds University, Jerusalem P.O. Box 20002, Palestine;
| | - Abderrahman Najjar
- Institute of Pathology, Rabin Medical Centre, PetachTikva 49100, Israel;
| | - Rafik Karaman
- Faculty of Pharmacy, Department of Bioorganic & Pharmaceutical Chemistry, Al-Quds University, Jerusalem P.O. Box 20002, Palestine;
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16
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Morales-Alvarez MC. Nephrotoxicity of Antimicrobials and Antibiotics. Adv Chronic Kidney Dis 2020; 27:31-37. [PMID: 32146999 DOI: 10.1053/j.ackd.2019.08.001] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 08/01/2019] [Indexed: 01/05/2023]
Abstract
Medication-induced nephrotoxicity remains one of the most common causes of acute kidney injury (AKI) among hospitalized patients. Within the extensive group of medications associated with AKI, antibiotics and other antimicrobials are well recognized triggers of structural and functional renal impairment. Clinical manifestations range from mild forms of tubular injury to significant deterioration of kidney function requiring acute renal replacement therapy. Several mechanisms are described, although the most frequent are acute interstitial nephritis, acute tubular necrosis, intratubular crystal deposition, and proximal/distal tubulopathy with electrolyte wasting abnormalities. General risk factors for antimicrobial-induced AKI include pre-existing chronic kidney disease, and concomitant use of medication with nephrotoxic potential. Prevention and early recognition of AKI represent the standard approach to mitigate AKI and avoid morbidity.
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17
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Hikasa S, Shimabukuro S, Hideta K, Nishida S, Higasa S, Sawada A, Tokugawa T, Tanaka K, Yanai M, Kimura T. Decreased levels of urinary liver-type fatty acid-binding protein after switching from tenofovir disoproxil fumarate to tenofovir alafenamide: a prospective observational study. Int J STD AIDS 2019; 30:1311-1317. [PMID: 31726929 DOI: 10.1177/0956462419873772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A single-center, prospective, observational study was conducted between September 2016 and August 2018 in 33 HIV-positive Japanese patients who switched antiretroviral drug regimens from tenofovir disoproxil fumarate (TDF) to tenofovir alafenamide (TAF). The study assessed changes in urinary levels of liver-type fatty acid-binding protein (L-FABP) after switching from TDF to TAF and determined the potential of renal parameters to predict improvement in estimated glomerular filtration rate (eGFR). Median urinary levels of L-FABP were found to be 2.0, 1.4, and 1.3 µg/g creatinine before, at 6 months, and at 12 months after switching to TAF, respectively. The urinary levels of L-FABP, β2 microglobulin (β2MG), and eGFR and the protein-to-creatinine ratio (PCR) were not significantly related to the annual change in eGFR after switching from TDF to TAF. Our results demonstrate a significant decrease in urinary levels of L-FABP after switching from TDF to TAF. However, neither urinary L-FABP, β2MG, PCR, nor eGFR predicted the annual change in eGFR after the change in medication.
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Affiliation(s)
- Shinichi Hikasa
- Department of Pharmacy, The Hospital of Hyogo College of Medicine, Nishinomiya, Japan
| | - Shota Shimabukuro
- Department of Pharmacy, The Hospital of Hyogo College of Medicine, Nishinomiya, Japan
| | - Kyoko Hideta
- Department of Pharmacy, The Hospital of Hyogo College of Medicine, Nishinomiya, Japan
| | - Sakurako Nishida
- Department of Pharmacy, The Hospital of Hyogo College of Medicine, Nishinomiya, Japan
| | - Satoshi Higasa
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Akihiro Sawada
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Tazuko Tokugawa
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kuniyoshi Tanaka
- Department of Pharmacy, The Hospital of Hyogo College of Medicine, Nishinomiya, Japan
| | - Mina Yanai
- Department of Pharmacy, The Hospital of Hyogo College of Medicine, Nishinomiya, Japan
| | - Takeshi Kimura
- Department of Pharmacy, The Hospital of Hyogo College of Medicine, Nishinomiya, Japan
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18
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Smith DE, Woolley IJ, Russell DB, Bisshop F, Furner V. HIV in practice: current approaches and challenges in the diagnosis, treatment and management of HIV infection in Australia. HIV Med 2019; 19 Suppl 3:5-23. [PMID: 29927516 DOI: 10.1111/hiv.12637] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2018] [Indexed: 11/29/2022]
Abstract
As treatment improves, people living with HIV (PLWHIV) can now expect to live longer, which means that the foci of HIV-related care for them and their medical practitioners continue to change. With an increasingly older cohort of patients with HIV infection, practitioners' key considerations are shifting from issues of acute treatment and patient survival to multiple comorbidities, toxicities associated with chronic therapy, and ongoing health maintenance. Within this context, this paper explores the current standard of practice for the management of HIV infection in Australia. We surveyed 56 Australian practitioners currently involved in managing HIV infection: 'HIV section 100' (HIV therapy-prescribing) general practitioners (s100 GPs; n = 26), sexual health physicians (SHPs; n = 24) and hospital-based physicians (HBPs; n = 6). Survey results for practice approaches and challenges were broadly consistent across the three practitioner specialties, apart from a few key areas. s100 GPs reported less prophylaxis use among patients whom they deemed at risk of HIV infection in comparison with SHPs, which may reflect differences in patient populations. Further, a higher proportion of s100 GPs nominated older HIV treatment regimens as their preferred therapy choices compared with the other specialties. In contrast with SHPs, s100 GPs were less likely to switch HIV therapies to simplify the treatment protocol, and to immediately initiate treatment upon patient request in those newly diagnosed with HIV infection. Considerably lower levels of satisfaction with current HIV practice guidelines were also reported by s100 GPs. It appears that greater support for s100 GPs may be needed to address these identified challenges and enhance approaches to HIV practice. Across all specialties, increasing access to mental health services for patients with HIV infection was reported as a key management issue. A renewed focus on providing improved mental health and wellbeing supports is recommended, particularly in the face of an ageing HIV-infected population.
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Affiliation(s)
- D E Smith
- Albion Centre, South Eastern Sydney Local Hospital Network, Sydney, NSW, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
| | - I J Woolley
- Monash Infectious Diseases, Monash Health, Melbourne, VIC, Australia.,Centre for Inflammatory Diseases, Monash University, Melbourne, VIC, Australia
| | - D B Russell
- Cairns Sexual Health Service, Cairns, QLD, Australia.,College of Medicine and Dentistry, James Cook University, Cairns, QLD, Australia
| | - F Bisshop
- Holdsworth House Medical Practice, Brisbane, QLD, Australia
| | - V Furner
- Albion Centre, South Eastern Sydney Local Hospital Network, Sydney, NSW, Australia
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19
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Pomeisl K, Pohl R, Snoeck R, Andrei G, Krečmerová M. Utilization of 1,3-Dioxolanes in the Synthesis of α-branched Alkyl and Aryl 9-[2-(Phosphonomethoxy)Ethyl]Purines and Study of the Influence of α-branched Substitution for Potential Biological Activity. NUCLEOSIDES NUCLEOTIDES & NUCLEIC ACIDS 2018; 38:119-156. [PMID: 30526265 DOI: 10.1080/15257770.2018.1506884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Syntheses of α-branched alkyl and aryl substituted 9-[2-(phosphonomethoxy)ethyl]purines from substituted 1,3-dioxolanes have been developed. Key synthetic precursors, α-substituted dialkyl [(2-hydroxyethoxy)methyl]phosphonates were prepared via Lewis acid mediated cleavage of 1,3-dioxolanes followed by reaction with dialkyl or trialkyl phosphites. The best preparative yields were achieved under conditions utilizing tin tetrachloride as Lewis acid and triisopropyl phosphite. Attachment of purine bases to dialkyl [(2-hydroxyethoxy)methyl]phosphonates was performed by Mitsunobu reaction. Final α-branched 9-[2-(phosphonomethoxy)ethyl]purines were tested for antiviral, cytostatic and antiparasitic activity, the latter one determined as inhibitory activity towards Plasmodium falciparum enzyme hypoxanthine-guanine-xanthine phosphoribosyltransfesase. In most cases biological activity was only marginal.
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Affiliation(s)
- Karel Pomeisl
- a Institute of Organic Chemistry and Biochemistry , Czech Academy of Sciences , Prague , Czech Republic.,b Institute of Physics , Czech Academy of Sciences , Prague , Czech Republic
| | - Radek Pohl
- a Institute of Organic Chemistry and Biochemistry , Czech Academy of Sciences , Prague , Czech Republic
| | - Robert Snoeck
- c Rega Institute for Medical Research , Katholieke Universiteit Leuven , Belgium
| | - Graciela Andrei
- c Rega Institute for Medical Research , Katholieke Universiteit Leuven , Belgium
| | - Marcela Krečmerová
- a Institute of Organic Chemistry and Biochemistry , Czech Academy of Sciences , Prague , Czech Republic
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20
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Blindauer CA, Griesser R, Holý A, Operschall BP, Sigel A, Song B, Sigel H. Intramolecular π-stacks in mixed-ligand copper(II) complexes formed by heteroaromatic amines and antivirally active acyclic nucleotide analogs carrying a hydroxy-2-(phosphonomethoxy)propyl residue ‡. J COORD CHEM 2018. [DOI: 10.1080/00958972.2018.1490019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Claudia A. Blindauer
- Department of Chemistry, Inorganic Chemistry, University of Basel, Basel, Switzerland
- Department of Chemistry, University of Warwick, Coventry, UK
| | - Rolf Griesser
- Department of Chemistry, Inorganic Chemistry, University of Basel, Basel, Switzerland
| | - Antonín Holý
- Institute of Organic Chemistry and Biochemistry, Centre of Novel Antivirals and Antineoplastics, Academy of Sciences, Prague, Czech Republic
| | - Bert P. Operschall
- Department of Chemistry, Inorganic Chemistry, University of Basel, Basel, Switzerland
| | - Astrid Sigel
- Department of Chemistry, Inorganic Chemistry, University of Basel, Basel, Switzerland
| | - Bin Song
- Department of Chemistry, Inorganic Chemistry, University of Basel, Basel, Switzerland
- Vertex Pharmaceuticals Inc., Boston, MA, USA
| | - Helmut Sigel
- Department of Chemistry, Inorganic Chemistry, University of Basel, Basel, Switzerland
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21
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Gallagher A, Quan D, Gracey DM. Improvement in renal function and resolution of proteinuria in an HIV-infected patient switched from tenofovir disoproxil fumarate to tenofovir alafenamide. Intern Med J 2018; 47:826-827. [PMID: 28677314 DOI: 10.1111/imj.13468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 09/04/2016] [Accepted: 09/14/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Alexandra Gallagher
- Renal Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Dick Quan
- Holdsworth House Medical Practice, Sydney, New South Wales, Australia
| | - David M Gracey
- Renal Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Holdsworth House Medical Practice, Sydney, New South Wales, Australia.,Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
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22
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Serota DP, Franch HA, Cartwright EJ. Acute Kidney Injury in a Patient on Tenofovir Alafenamide Fumarate After Initiation of Treatment for Hepatitis C Virus Infection. Open Forum Infect Dis 2018; 5:ofy189. [PMID: 30151414 PMCID: PMC6101585 DOI: 10.1093/ofid/ofy189] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 07/29/2018] [Indexed: 12/27/2022] Open
Abstract
HIV treatment with tenofovir alafenamide fumarate (TAF) has decreased renal toxicity compared with tenofovir disoproxil fumarate in clinical trials. We report the case of a patient with HIV/HCV coinfection who was started on a TAF-based HIV regimen and developed acute kidney injury that worsened with the addition of sofosbuvir-ledipasvir.
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Affiliation(s)
- David P Serota
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, Georgia
| | - Harold A Franch
- Atlanta VA Medical Center, Veterans Health Administration, Atlanta, Georgia.,Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, Georgia
| | - Emily J Cartwright
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, Georgia.,Atlanta VA Medical Center, Veterans Health Administration, Atlanta, Georgia
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23
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Development and validation of an LC-MS/MS assay for tenofovir and tenofovir alafenamide in human plasma and cerebrospinal fluid. J Pharm Biomed Anal 2018; 156:163-169. [PMID: 29709783 DOI: 10.1016/j.jpba.2018.04.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 04/16/2018] [Accepted: 04/22/2018] [Indexed: 11/20/2022]
Abstract
A liquid chromatography with triple quadrupole mass spectrometry method was developed and validated for the determination of tenofovir and tenofovir alafenamide concentrations in human plasma and cerebrospinal fluid. Tenofovir and tenofovir alafenamide were extracted from matrix by solid phase extraction. The dried extraction eluents were dissolved in water for LC-MS/MS analysis. Separation was achieved with a Phenomenex Synergi 4 μm Polar-RP 80A column (50 × 2 mm) with a gradient elution of 0.1% formic acid in water and acetonitrile. The total run time was 5 min. Detection of analytes was achieved using electrospray ionization (positive mode) and triple quadrupole selected reaction monitoring. Standard curve concentrations ranged from 0.5 to 500 ng/mL for the plasma assay and 0.1-50 ng/mL for the cerebrospinal fluid assay. The intra- and inter-day accuracy and precision were less than 12% in low, medium, and high quality control samples for both matrices. The validated methods were applied to the analysis of plasma and cerebrospinal fluid samples of a patient undergoing tenofovir therapy which involved the switch from Stribild® (elvitegravir 150 mg/cobicistat 150 mg/emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg) to Genvoya® (elvitegravir 150 mg/cobicistat 150 mg/emtricitabine 200 mg/tenofovir alafenamide 10 mg).
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24
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Miralles P, Navarro JT, Berenguer J, Gómez Codina J, Kwon M, Serrano D, Díez-Martín JL, Villà S, Rubio R, Menárguez J, Ribera Santasusana JM. GESIDA/PETHEMA recommendations on the diagnosis and treatment of lymphomas in patients infected by the human immunodeficiency virus. Med Clin (Barc) 2018; 151:39.e1-39.e17. [PMID: 29357988 DOI: 10.1016/j.medcli.2017.11.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/21/2017] [Accepted: 11/02/2017] [Indexed: 01/20/2023]
Abstract
The incidence of non-Hodgkin's lymphoma and Hodgkin's lymphoma is higher in patients with HIV infection than in the general population. Following the introduction of combination antiretroviral therapy (cART), the prognostic significance of HIV-related variables has decreased, and lymphoma-related factors have become more pronounced. Currently, treatments for lymphomas in HIV-infected patients do not differ from those used in the general population. However, differentiating characteristics of seropositive patients, such as the need for cART and specific prophylaxis and treatment of certain opportunistic infections, should be considered. This document updates recommendations on the diagnosis and treatment of lymphomas in HIV infected patients published by GESIDA/PETHEMA in 2008.
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Affiliation(s)
- Pilar Miralles
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, España.
| | - José Tomás Navarro
- Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Institut de Recerca Josep Carreras, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - Juan Berenguer
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, España
| | | | - Mi Kwon
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, España
| | - David Serrano
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, España
| | - José Luis Díez-Martín
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, España
| | - Salvador Villà
- Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Institut de Recerca Josep Carreras, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | | | - Javier Menárguez
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, España
| | - José-María Ribera Santasusana
- Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Institut de Recerca Josep Carreras, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
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25
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Effect of Cobicistat on Tenofovir Disoproxil Fumarate (TDF): What Is True for TAF May Also Be True for TDF. J Acquir Immune Defic Syndr 2017; 77:86-92. [PMID: 28961682 DOI: 10.1097/qai.0000000000001558] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The dose of tenofovir alafenamide is reduced from 25 to 10 mg daily when given with boosting agents. However, such dose reduction has never been adopted for tenofovir disoproxil fumarate (TDF). In this study, we aim to quantify the effect of cobicistat (COBI) both on tenofovir concentrations and TDF durability in real life setting. METHODS HIV-positive patients receiving TDF-containing antiretroviral therapies with at least 1 assessment of tenofovir plasma trough concentrations were included in the study. Univariate and multivariate regression analyses were performed considering tenofovir concentration as the dependent variable and clinical characteristics as independent covariates. Subsequently, survival and Cox analyses were performed considering as the primary outcome TDF discontinuation for any reasons. RESULTS Patients were given TDF with protease inhibitors/ritonavir (n = 212), non-nucleoside reverse transcriptase inhibitors (n = 176), integrase inhibitors (dolutegravir or raltegravir, n = 46), or with elvitegravir/COBI (ELV/COBI) (n = 76). By multivariate analysis, concomitant antiretroviral therapies resulted significantly associated with tenofovir levels, with the highest drug concentrations measured in patients given ELV/COBI. By survival analysis, we found that patients given TDF with ELV/COBI had the lowest rate of drug durability. Overall, these patients had a 2.3-fold increased risk to experience TDF discontinuation. CONCLUSIONS Coadministration with COBI resulted in significantly higher tenofovir concentrations and higher TDF discontinuation compared with other antiretroviral regimens. Accordingly, the possibility that the lack of proper dose adjustment for TDF when given with COBI might have biased the safety comparisons with tenofovir alafenamide during registrative trials cannot be ruled out.
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26
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De Clercq E. Role of tenofovir alafenamide (TAF) in the treatment and prophylaxis of HIV and HBV infections. Biochem Pharmacol 2017; 153:2-11. [PMID: 29225131 DOI: 10.1016/j.bcp.2017.11.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 11/28/2017] [Indexed: 02/07/2023]
Abstract
Tenofovir (TFV) is the cornerstone of the treatment and prophylaxis of HIV infections. It has been routinely used in its prodrug form TDF (tenofovir disoproxil fumarate) combined with emtricitabine ((-)FTC) and other antiretroviral agents. TDF has now been replaced by TAF (tenofovir alafenamide) which allows better uptake by the lymphoid tissue. In combination with elvitegravir (E), cobicistat (C), emtricitabine (F), TAF can be advocated as an STR (single tablet regimen, Genvoya®) for the treatment of HIV infections. In this combination, E and C may in the future be replaced by bictegravir. The prophylaxis of HIV infection is momentarily based upon Truvada®, the combination of F with TDF, which in the future may also be replaced by TAF. TAF (Vemlidy®) has also replaced TDF (Viread®) for the treatment of hepatitis B virus (HBV) infections. Both TDF and TAF offer little or no risk for virus-drug resistance. As compared to TDF, TAF limits the risk for nephrotoxicity and loss of bone mineral density. What remains to be settled, however, before the universal use of TAF could be recommended, is its safety during pregnancy and its applicability in the treatment of tuberculosis, in combination with rifampicin.
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Affiliation(s)
- Erik De Clercq
- KU Leuven, Department of Microbiology and Immunology, Rega Institute for Medical Research, Herestraat 49, B-3000 Leuven, Belgium.
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27
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Chastain DB, Franco-Paredes C, Stover KR. Addressing Antiretroviral Therapy-Associated Drug-Drug Interactions in Patients Requiring Treatment for Opportunistic Infections in Low-Income and Resource-Limited Settings. J Clin Pharmacol 2017; 57:1387-1399. [PMID: 28884831 DOI: 10.1002/jcph.978] [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] [Received: 04/21/2017] [Accepted: 06/14/2017] [Indexed: 12/17/2022]
Abstract
An increasing number of human immunodeficiency virus (HIV)-infected patients are achieving virologic suppression on antiretroviral therapy (ART) limiting the use of primary and secondary antimicrobial prophylaxis. However, in low-income and resource-limited settings, half of those infected with HIV are unaware of their diagnosis, and fewer than 50% of patients on ART achieve virologic suppression. Management of comorbidities and opportunistic infections among patients on ART may lead to inevitable drug-drug interactions (DDIs) and even toxicities. Elderly patients, individuals with multiple comorbidities, those receiving complex ART, and patients living in low-income settings experience higher rates of DDIs. Management of these cytochrome P450-mediated, nonmediated, and drug transport system DDIs is critical in HIV-infected patients, particularly those in resource-limited settings with few options for ART. This article critically analyzes and provides recommendations to manage significant DDIs and drug toxicities in HIV-infected patients receiving ART.
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Affiliation(s)
- Daniel B Chastain
- University of Georgia College of Pharmacy, Albany, GA, USA.,Phoebe Putney Memorial Hospital, Albany, GA, USA
| | - Carlos Franco-Paredes
- Infectious Diseases Physician, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA.,Hospital Infantil de Mexico Federico Gomez, Mexico City, Mexico
| | - Kayla R Stover
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS, USA
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28
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Medland NA, Chow EP, Walker RG, Chen M, Read TR, Fairley CK. Incidence of renal Fanconi syndrome in patients taking antiretroviral therapy including tenofovir disoproxil fumarate. Int J STD AIDS 2017; 29:227-236. [PMID: 28764611 DOI: 10.1177/0956462417722133] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The objective of this study was to determine the incidence and predictors of Fanconi Syndrome (FS) in a cohort of patients taking tenofovir disoproxil fumarate (TDF). Clinical records and laboratory investigations from patients receiving TDF between 2002 and 2016 were extracted. FS was defined as normoglycaemic glycosuria and proteinuria and at least one other marker of renal dysfunction. Regression analysis was performed with time to development of FS and the following covariates: ritonavir co-administration, age, gender, co-morbidities (hypertension, hyperlipidaemia, diabetes, viral hepatitis), CD4 cell count nadir and baseline eGFR. One thousand and forty-four patients received TDF without ritonavir and 398 patients with ritonavir. Thirteen cases of FS were identified with a mean duration of exposure of 55 months. The incidence of FS was 1.09/1000PY (0.54-1.63) of TDF exposure (without ritonavir) and 5.50/1000PY (3.66-7.33) of TDF-ritonavir co-administration (p=0.0057). The adjusted hazards ratio for ritonavir co-administration was 4.71 (1.37-16.14, p=0.014). Known risk factors for chronic kidney disease were not associated with development of FS. Ritonavir co-administration, but not other factors, is associated with a greater risk of FS. FS developed late. Known risk factors for chronic kidney disease and length of treatment are not useful for identifying patients most at risk of developing FS in patients taking TDF.
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Affiliation(s)
| | - Eric Pf Chow
- 1 Monash University Central Clinical School, Carlton, Australia
| | | | - Marcus Chen
- 3 Melbourne Sexual Health Centre, Carlton, Australia
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Orkin C, Llibre JM, Gallien S, Antinori A, Behrens G, Carr A. Nucleoside reverse transcriptase inhibitor-reducing strategies in HIV treatment: assessing the evidence. HIV Med 2017; 19:18-32. [PMID: 28737291 DOI: 10.1111/hiv.12534] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2017] [Indexed: 01/22/2023]
Abstract
Antiretroviral (ARV) therapy, comprising a backbone of two nucleos(t)ide reverse transcriptase inhibitors (NRTIs) plus another ARV, is the recognized standard of care (SOC), which has helped extend life expectancy in people living with HIV. In a quest to reduce lifelong drug exposure and minimize or avoid the toxicity of NRTIs, "NRTI-reducing" regimens have been investigated. This descriptive review assessing the results of NRTI-reducing strategies from the largest randomized trials focuses on virological efficacy, resistance, regimen safety (in terms of bone mineral density, renal function, lipids and central nervous system function) and simplicity. The review considers efficacy across various NRTI-sparing strategies, for example an integrase strand transfer inhibitor (INSTI) plus a ritonavir-boosted protease inhibitor (PI/r) or PI/r + lamivudine (3TC), in both naïve and switch regimes. Of 10 key studies in treatment-naïve adults assessing five NRTI-reducing strategies, only four studies demonstrated noninferiority vs. SOC [GARDEL, NEAT 001, AIDS Clinical Trials Group 5142 and PROGRESS]. In switch settings, 17 studies (10 randomized) were reviewed that used four strategies, including three studies assessing an INSTI plus a nonnucleoside reverse transcriptase inhibitor . Noninferiority of the NRTI-reducing arm was shown in six of 10 studies (ATLAS-M, SALT, DUAL, OLE, LATTE-2 and SWORD). In general, NRTI-reducing therapy did not always result in an improvement in short- or long-term adverse events; however, in many cases, these endpoints were not reported. Some of these studies reported higher virological failure rates with more frequent emergence of resistance mutations. None of these NRTI-reducing strategies has been compared against a single-pill regimen, including those containing tenofovir alafenamide. Only strategies demonstrating noninferior efficacy, a benefit in safety/tolerability, and a favourable cost-efficacy ratio, preferably in a single pill, will eventually match the current SOC of triple ARV therapy.
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Affiliation(s)
- C Orkin
- Infection and Immunity, Barts Health NHS Trust, London, UK
| | - J M Llibre
- University Hospital Germans Trias i Pujol, Infectious Diseases and "Fight AIDS" Foundation, Badalona, Barcelona, Spain
| | - S Gallien
- Immunology and Infectious Diseases, Henri Mondor Hospital, Paris Est Créteil University, Créteil, France
| | - A Antinori
- HIV/AIDS Department, National Institute for Infectious Diseases "Lazzaro Spallanzani", Rome, Italy
| | - Gmn Behrens
- Department for Clinical Immunology and Rheumatology, Hannover Medical School, Hannover, Germany.,German Center for Infection Research, St Vincent's Hospital, Sydney, Australia
| | - A Carr
- Centre for Applied Medical Research, St Vincent's Hospital, Sydney, Australia
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Lesniewska-Kowiel MA, Muszalska I. Strategies in the designing of prodrugs, taking into account the antiviral and anticancer compounds. Eur J Med Chem 2017; 129:53-71. [DOI: 10.1016/j.ejmech.2017.02.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 01/13/2017] [Accepted: 02/05/2017] [Indexed: 12/22/2022]
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Ripa M, Chiappetta S, Tambussi G. Immunosenescence and hurdles in the clinical management of older HIV-patients. Virulence 2017; 8:508-528. [PMID: 28276994 DOI: 10.1080/21505594.2017.1292197] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
People living with HIV (PLWH) who are treated with effective highly active antiretroviral therapy (HAART) have a similar life expectancy to the general population. Moreover, an increasing proportion of new HIV diagnoses are made in people older than 50 y. The number of older HIV-infected patients is thus constantly growing and it is expected that by 2030 around 70% of PLWH will be more than 50 y old. On the other hand, HIV infection itself is responsible for accelerated immunosenescence, a progressive decline of immune system function in both the adaptive and the innate arm, which impairs the ability of an individual to respond to infections and to give rise to long-term immunity; furthermore, older patients tend to have a worse immunological response to HAART. In this review we focus on the pathogenesis of HIV-induced immunosenescence and on the clinical management of older HIV-infected patients.
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Affiliation(s)
- Marco Ripa
- a Department of Infectious and Tropical Diseases , Ospedale San Raffaele , Milan , Italy
| | - Stefania Chiappetta
- a Department of Infectious and Tropical Diseases , Ospedale San Raffaele , Milan , Italy
| | - Giuseppe Tambussi
- a Department of Infectious and Tropical Diseases , Ospedale San Raffaele , Milan , Italy
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Dumond JB, Collins JW, Cottrell ML, Trezza CR, Prince H, Sykes C, Torrice C, White N, Malone S, Wang R, Patterson KB, Sharpless NE, Forrest A. p16 INK4a , a Senescence Marker, Influences Tenofovir/Emtricitabine Metabolite Disposition in HIV-Infected Subjects. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2016; 6:120-127. [PMID: 28019088 PMCID: PMC5321809 DOI: 10.1002/psp4.12150] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 10/07/2016] [Accepted: 10/19/2016] [Indexed: 12/21/2022]
Abstract
The goal of this study was to explore the relationships between tenofovir (TFV) and emtricitabine (FTC) disposition and markers of biologic aging, such as the frailty phenotype and p16INK4a gene expression. Chronologic age is often explored in population pharmacokinetic (PK) analyses, and can be uninformative in capturing the impact of aging on physiology, particularly in human immunodeficiency virus (HIV)‐infected patients. Ninety‐one HIV‐infected participants provided samples to quantify plasma concentrations of TFV/FTC, as well as peripheral blood mononuclear cell (PBMC) samples for intracellular metabolite concentrations; 12 participants provided 11 samples, and 79 participants provided 4 samples, over a dosing interval. Nonlinear mixed effects modeling of TFV/FTC and their metabolites suggests a relationship between TFV/FTC metabolite clearance (CL) from PBMCs and the expression of p16INK4a, a marker of cellular senescence. This novel approach to quantifying the influence of aging on PKs provides rationale for further work investigating the relationships between senescence and nucleoside phosphorylation and transport.
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Affiliation(s)
- J B Dumond
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - J W Collins
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - M L Cottrell
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - C R Trezza
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Hma Prince
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - C Sykes
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - C Torrice
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - N White
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - S Malone
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - R Wang
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - K B Patterson
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - N E Sharpless
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - A Forrest
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Kandil S, Balzarini J, Rat S, Brancale A, Westwell AD, McGuigan C. ProTides of BVdU as potential anticancer agents upon efficient intracellular delivery of their activated metabolites. Bioorg Med Chem Lett 2016; 26:5618-5623. [PMID: 27818111 PMCID: PMC5131913 DOI: 10.1016/j.bmcl.2016.10.077] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/24/2016] [Accepted: 10/25/2016] [Indexed: 12/04/2022]
Abstract
Nucleosides represent a major chemotherapeutic class for treating cancer, however their limitations in terms of cellular uptake, nucleoside kinase-mediated activation and catabolism are well-documented. The monophosphate pro-nucleotides known as ProTides represents a powerful strategy for bypassing the dependence on active transport and nucleoside kinase-mediated activation. Herein, we report the structural tuning of BVdU ProTides. Forty six phosphoramidates were prepared and biologically evaluated against three different cancer cell lines; murine leukemia (L1210), human CD4+ T-lymphocyte (CEM) and human cervical carcinoma (HeLa). Twenty-fold potency enhancement compared to BVdU was achieved against L1210 cells. Interestingly, a number of ProTides showed low micromolar activity against CEM and HeLa cells compared to the inactive parent BVdU. The ProTides showed poor, if any measurable toxicity to non-tumourigenic human lung fibroblast cell cultures. Separation of four pairs of the diastereoisomeric mixtures and comparison of their spectral properties, biological activities and enzymatic activation rate is reported.
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Affiliation(s)
- Sahar Kandil
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, King Edward VII Avenue, Cardiff CF10 3NB, UK.
| | - Jan Balzarini
- Rega Institute for Medical Research, KU Leuven, Minderbroedersstraat 10, B-3000 Leuven, Belgium
| | - Stephanie Rat
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, King Edward VII Avenue, Cardiff CF10 3NB, UK
| | - Andrea Brancale
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, King Edward VII Avenue, Cardiff CF10 3NB, UK
| | - Andrew D Westwell
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, King Edward VII Avenue, Cardiff CF10 3NB, UK
| | - Christopher McGuigan
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, King Edward VII Avenue, Cardiff CF10 3NB, UK
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Fernando Bernal Q. FARMACOLOGÍA DE LOS ANTIRRETROVIRALES. REVISTA MÉDICA CLÍNICA LAS CONDES 2016. [DOI: 10.1016/j.rmclc.2016.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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