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Moore BR, Davis TM. Updated pharmacokinetic considerations for the use of antimalarial drugs in pregnant women. Expert Opin Drug Metab Toxicol 2020; 16:741-758. [PMID: 32729740 DOI: 10.1080/17425255.2020.1802425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The association between pregnancy and altered drug pharmacokinetic (PK) properties is acknowledged, as is its impact on drug plasma concentrations and thus therapeutic efficacy. However, there have been few robust PK studies of antimalarial use in pregnancy. Given that inadequate dosing for prevention or treatment of malaria in pregnancy can result in negative maternal/infant outcomes, along with the potential to select for parasite drug resistance, it is imperative that reliable pregnancy-specific dosing recommendations are established. AREAS COVERED PK studies of antimalarial drugs in pregnancy. The present review summarizes the efficacy and PK properties of WHO-recommended therapies used in pregnancy, with a focus on PK studies published since 2014. EXPERT OPINION Changes in antimalarial drug disposition in pregnancy are well described, yet pregnant women continue to receive treatment regimens optimized for non-pregnant adults. Contemporary in silico modeling has recently identified a series of alternative dosing regimens that are predicted to provide optimal therapeutic efficacy for pregnant women.
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Affiliation(s)
- Brioni R Moore
- School of Pharmacy and Biomedical Sciences, Curtin University , Bentley, Western Australia, Australia.,Medical School, University of Western Australia , Crawley, Western Australia, Australia
| | - Timothy M Davis
- Medical School, University of Western Australia , Crawley, Western Australia, Australia
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Abduljalil K, Badhan RKS. Drug dosing during pregnancy-opportunities for physiologically based pharmacokinetic models. J Pharmacokinet Pharmacodyn 2020; 47:319-340. [PMID: 32592111 DOI: 10.1007/s10928-020-09698-w] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/20/2020] [Indexed: 12/15/2022]
Abstract
Drugs can have harmful effects on the embryo or the fetus at any point during pregnancy. Not all the damaging effects of intrauterine exposure to drugs are obvious at birth, some may only manifest later in life. Thus, drugs should be prescribed in pregnancy only if the expected benefit to the mother is thought to be greater than the risk to the fetus. Dosing of drugs during pregnancy is often empirically determined and based upon evidence from studies of non-pregnant subjects, which may lead to suboptimal dosing, particularly during the third trimester. This review collates examples of drugs with known recommendations for dose adjustment during pregnancy, in addition to providing an example of the potential use of PBPK models in dose adjustment recommendation during pregnancy within the context of drug-drug interactions. For many drugs, such as antidepressants and antiretroviral drugs, dose adjustment has been recommended based on pharmacokinetic studies demonstrating a reduction in drug concentrations. However, there is relatively limited (and sometimes inconsistent) information regarding the clinical impact of these pharmacokinetic changes during pregnancy and the effect of subsequent dose adjustments. Examples of using pregnancy PBPK models to predict feto-maternal drug exposures and their applications to facilitate and guide dose assessment throughout gestation are discussed.
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Affiliation(s)
- Khaled Abduljalil
- Certara UK Limited, Simcyp Division, Level 2-Acero, 1 Concourse Way, Sheffield, S1 2BJ, UK.
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Olafuyi O, Badhan RKS. Dose Optimization of Chloroquine by Pharmacokinetic Modeling During Pregnancy for the Treatment of Zika Virus Infection. J Pharm Sci 2018; 108:661-673. [PMID: 30399360 DOI: 10.1016/j.xphs.2018.10.056] [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: 08/20/2018] [Revised: 10/01/2018] [Accepted: 10/30/2018] [Indexed: 01/01/2023]
Abstract
The insidious nature of Zika virus (ZIKV) infections can have a devastating consequence for fetal development. Recent reports have highlighted that chloroquine (CQ) is capable of inhibiting ZIKV endocytosis in brain cells. We applied pharmacokinetic modeling to develop a predictive model for CQ exposure to identify an optimal maternal/fetal dosing regimen to prevent ZIKV endocytosis in brain cells. Model validation used 13 nonpregnancy and 3 pregnancy clinical studies, and a therapeutic CQ plasma window of 0.3-2 μM was derived. Dosing regimens used in rheumatoid arthritis, systemic lupus erythematosus, and malaria were assessed for their ability to target this window. Dosing regimen identified that weekly doses used in malaria were not sufficient to reach the lower therapeutic window; however, daily doses of 150 mg achieved this therapeutic window. The impact of gestational age was further assessed and culminated in a final proposed regimen of 600 mg on day 1, 300 mg on day 2 and 3, and 150 mg thereafter until the end of trimester 2, which resulted in maintaining 65% and 94% of subjects with a trough plasma concentration above the lower therapeutic window on day 6 and at term, respectively.
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Affiliation(s)
- Olusola Olafuyi
- Aston Health Research Group, Aston Pharmacy School, Aston University, Birmingham B4 7ET, UK
| | - Raj K S Badhan
- Aston Health Research Group, Aston Pharmacy School, Aston University, Birmingham B4 7ET, UK; Aston Pharmacy School, Aston University, Birmingham B4 7ET, UK.
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Moore BR, Davis TME. Pharmacotherapy for the prevention of malaria in pregnant women: currently available drugs and challenges. Expert Opin Pharmacother 2018; 19:1779-1796. [PMID: 30289730 DOI: 10.1080/14656566.2018.1526923] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Malaria in pregnancy continues to be a significant public health burden globally, with over 100 million women at risk each year. Sulfadoxine-pyrimethamine (SP) is the only antimalarial recommended for intermittent preventive therapy in pregnancy (IPTp) but increasing parasite resistance threatens its viability. There are few other available antimalarial therapies that currently have sufficient evidence of tolerability, safety, and efficacy to replace SP. AREAS COVERED Novel antimalarial combinations are under investigation for potential use as chemoprophylaxis and in IPTp regimens. The present review summarizes currently available therapies, emerging candidate combination therapies, and the potential challenges to integrating these into mainstream policy. EXPERT OPINION Alternative drugs or combination therapies to SP for IPTp are desperately required. Dihydroartemisinin-piperaquine and azithromycin-based combinations are showing great promise as potential candidates for IPTp but pharmacokinetic data suggest that dose modification may be required to ensure adequate prophylactic efficacy. If a suitable candidate regimen is not identified in the near future, the success of chemopreventive strategies such as IPTp may be in jeopardy.
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Affiliation(s)
- Brioni R Moore
- a School of Pharmacy and Biomedical Sciences , Curtin University , Bentley , Western Australia , Australia.,b Medical School , University of Western Australia , Crawley , Western Australia , Australia
| | - Timothy M E Davis
- b Medical School , University of Western Australia , Crawley , Western Australia , Australia
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Salman S, Baiwog F, Page-Sharp M, Kose K, Karunajeewa HA, Mueller I, Rogerson SJ, Siba PM, Ilett KF, Davis TME. Optimal antimalarial dose regimens for chloroquine in pregnancy based on population pharmacokinetic modelling. Int J Antimicrob Agents 2017; 50:542-551. [PMID: 28669839 DOI: 10.1016/j.ijantimicag.2017.05.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/22/2017] [Accepted: 05/25/2017] [Indexed: 12/25/2022]
Abstract
Despite extensive use and accumulated evidence of safety, there have been few pharmacokinetic studies from which appropriate chloroquine (CQ) dosing regimens could be developed specifically for pregnant women. Such optimised CQ-based regimens, used as treatment for acute malaria or as intermittent preventive treatment in pregnancy (IPTp), may have a valuable role if parasite CQ sensitivity returns following reduced drug pressure. In this study, population pharmacokinetic/pharmacodynamic modelling was used to simultaneously analyse plasma concentration-time data for CQ and its active metabolite desethylchloroquine (DCQ) in 44 non-pregnant and 45 pregnant Papua New Guinean women treated with CQ and sulfadoxine/pyrimethamine or azithromycin (AZM). Pregnancy was associated with 16% and 49% increases in CQ and DCQ clearance, respectively, as well as a 24% reduction in CQ relative bioavailability. Clearance of DCQ was 22% lower in those who received AZM in both groups. Simulations based on the final multicompartmental model demonstrated that a 33% CQ dose increase may be suitable for acute treatment for malaria in pregnancy as it resulted in equivalent exposure to that in non-pregnant women receiving recommended doses, whilst a double dose would likely be required for an effective duration of post-treatment prophylaxis when used as IPTp especially in areas of CQ resistance. The impact of co-administered AZM was clinically insignificant in simulations. The results of past/ongoing trials employing recommended adult doses of CQ-based regimens in pregnant women should be interpreted in light of these findings, and consideration should be given to using increased doses in future trials.
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Affiliation(s)
- Sam Salman
- School of Medicine and Pharmacology, University of Western Australia, 35 Stirling Hwy, Crawley, WA 6009, Australia
| | - Francesca Baiwog
- Papua New Guinea Institute of Medical Research, P.O. Box 378, Madang, Madang Province, Papua New Guinea
| | - Madhu Page-Sharp
- School of Pharmacy, Curtin University of Technology, Kent Street, Bentley, WA 6102, Australia
| | - Kay Kose
- Papua New Guinea Institute of Medical Research, P.O. Box 378, Madang, Madang Province, Papua New Guinea
| | - Harin A Karunajeewa
- Population Health and Immunity, Walter and Eliza Hall Institute, 1G Royal Parade, Parkville, VIC 3052, Australia
| | - Ivo Mueller
- Population Health and Immunity, Walter and Eliza Hall Institute, 1G Royal Parade, Parkville, VIC 3052, Australia; Barcelona Institute for Global Health (ISGlobal), Carrer del Rosselló 132, 08036 Barcelona, Spain
| | - Stephen J Rogerson
- Department of Medicine (RMH), The University of Melbourne, 300 Grattan Street, Parkville, VIC 3050, Australia
| | - Peter M Siba
- Papua New Guinea Institute of Medical Research, P.O. Box 378, Madang, Madang Province, Papua New Guinea
| | - Kenneth F Ilett
- School of Medicine and Pharmacology, University of Western Australia, 35 Stirling Hwy, Crawley, WA 6009, Australia
| | - Timothy M E Davis
- School of Medicine and Pharmacology, University of Western Australia, 35 Stirling Hwy, Crawley, WA 6009, Australia.
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Abstract
BACKGROUND Women are commonly prescribed a variety of medications during pregnancy. As most organ systems are affected by the substantial anatomical and physiological changes that occur during pregnancy, it is expected that pharmacokinetics (PK) (absorption, distribution, metabolism, and excretion of drugs) would also be affected in ways that may necessitate changes in dosing schedules. The objective of this study was to systematically identify existing clinically relevant evidence on PK changes during pregnancy. METHODS AND FINDINGS Systematic searches were conducted in MEDLINE (Ovid), Embase (Ovid), Cochrane Central Register of Controlled Trials (Ovid), and Web of Science (Thomson Reuters), from database inception to August 31, 2015. An update of the search from September 1, 2015, to May 20, 2016, was performed, and relevant data were added to the present review. No language or date restrictions were applied. All publications of clinical PK studies involving a group of pregnant women with a comparison to nonpregnant participants or nonpregnant population data were eligible to be included in this review. A total of 198 studies involving 121 different medications fulfilled the inclusion criteria. In these studies, commonly investigated drug classes included antiretrovirals (54 studies), antiepileptic drugs (27 studies), antibiotics (23 studies), antimalarial drugs (22 studies), and cardiovascular drugs (17 studies). Overall, pregnancy-associated changes in PK parameters were often observed as consistent findings among many studies, particularly enhanced drug elimination and decreased exposure to total drugs (bound and unbound to plasma proteins) at a given dose. However, associated alterations in clinical responses and outcomes, or lack thereof, remain largely unknown. CONCLUSION This systematic review of pregnancy-associated PK changes identifies a significant gap between the accumulating knowledge of PK changes in pregnant women and our understanding of their clinical impact for both mother and fetus. It is essential for clinicians to be aware of these unique pregnancy-related changes in PK, and to critically examine their clinical implications.
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Finaurini S, Basilico N, Corbett Y, D’Alessandro S, Parapini S, Olliaro P, Haynes RK, Taramelli D. Dihydroartemisinin inhibits the human erythroid cell differentiation by altering the cell cycle. Toxicology 2012; 300:57-66. [DOI: 10.1016/j.tox.2012.05.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Revised: 05/26/2012] [Accepted: 05/26/2012] [Indexed: 11/16/2022]
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Wilby KJ, Ensom MHH. Pharmacokinetics of antimalarials in pregnancy: a systematic review. Clin Pharmacokinet 2012; 50:705-23. [PMID: 21973268 DOI: 10.2165/11594550-000000000-00000] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Malaria is a serious parasitic infection, which affects millions of people worldwide. As pregnancy has been shown to alter the pharmacokinetics of many medications, the efficacy and safety of antimalarial drug regimens may be compromised in pregnant women. The objective of this review is to systematically review published literature on the pharmacokinetics of antimalarial agents in pregnant women. A search of MEDLINE (1948-May 2011), EMBASE (1980-May 2011), International Pharmaceutical Abstracts (1970-May 2011), Google and Google Scholar was conducted for articles describing the pharmacokinetics of antimalarials in pregnancy (and supplemented by a bibliographic review of all relevant articles); all identified studies were summarized and evaluated according to the level of evidence, based on the classification system developed by the US Preventive Services Task Force. Identified articles were included in the review if the study had at least one group that reported at least one pharmacokinetic parameter of interest in pregnant women. Articles were excluded from the review if no pharmacokinetic information was reported or if both pregnant and non-pregnant women were analysed within the same group. For quinine and its metabolites, there were three articles (one level II-1 and two level III); for artemisinin compounds, two articles (both level III); for lumefantrine, two articles (both level III); for atovaquone, two articles (both level III); for proguanil, three articles (one level II-1 and two level III); for sulfadoxine, three articles (all level II-1); for pyrimethamine, three articles (all level II-1); for chloroquine and its metabolite, four articles (three level II-1 and one level II-3); for mefloquine, two articles (one level II-1 and one level III); and for azithromycin, two articles (one level II-1 and one level III). Although comparative trials were identified, most of these studies were descriptive and classified as level III evidence. The main findings showed that pharmacokinetic parameters are commonly altered in pregnancy for the majority of recommended agents. Importantly, first-line regimens of artemisinin-based compounds, lumefantrine, chloroquine and pyrimethamine/sulfadoxine may undergo significant changes that could decrease therapeutic efficacy. These changes are usually due to increases in the apparent oral clearance and volume of distribution that commonly occur in pregnant women, and may result in decreased exposure and increased therapeutic failure. In order to assess the clinical implications of these changes and to provide safe and effective dosage regimens, there is an immediate need for dose-optimization studies of all recommended first- and second-line agents used in pregnant women with malaria.
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Affiliation(s)
- Kyle J Wilby
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
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Davis TME, Mueller I, Rogerson SJ. Prevention and treatment of malaria in pregnancy. Future Microbiol 2011; 5:1599-613. [PMID: 21073316 DOI: 10.2217/fmb.10.113] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Malaria in pregnancy is a substantial public health issue in many tropical countries. However, its prevention and treatment have been hindered because of fears of adverse drug effects in pregnant women recruited to intervention studies. This article details the pharmacological agents and management strategies currently or potentially available for use in pregnant women with or at risk of malaria. There are deficiencies in pharmacokinetic, tolerability, safety and efficacy data for even well-established drugs and combinations. This can have serious implications for the design of rational dose regimens. Approaches such as intermittent preventive treatment are increasingly employed in endemic areas with proven benefits, but the emergence of parasite drug resistance means that new strategies and drug regimens should be continually evaluated.
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Affiliation(s)
- Timothy M E Davis
- School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia.
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Sevene E, González R, Menéndez C. Current knowledge and challenges of antimalarial drugs for treatment and prevention in pregnancy. Expert Opin Pharmacother 2010; 11:1277-93. [PMID: 20408744 DOI: 10.1517/14656561003733599] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE OF THE FIELD Malaria infection during pregnancy is a major public health problem worldwide, with 50 million pregnancies exposed to the infection every year. Approximately 25,000 maternal deaths and between 75,000 and 200,000 infant deaths could be prevented each year by effective malaria control in pregnancy. Antimalarial drug treatment and prevention has been hampered by the appearance of drug resistance, which has been a particular problem in pregnancy due to the inherent safety issues. AREAS COVERED IN THIS REVIEW New antimalarial drugs and combinations are being studied but there is not yet sufficient information on their efficacy or, more importantly, on their safety in pregnancy. This article provides an overview of the relevance of the topic and reviews the current antimalarial drugs recommended for pregnancy, as well as the guidelines for both treatment and prevention in women living in endemic areas and for travellers. WHAT THE READER WILL GAIN Updated information on the drugs currently used for malaria treatment and prevention in pregnancy, including new drugs under development, is provided. The gaps on efficacy and safety information for use during pregnancy are also discussed. TAKE HOME MESSAGE Prevention and case management of malaria during pregnancy is based on risk-benefit criteria and poses one of the greatest challenges to current malaria control.
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Affiliation(s)
- Esperança Sevene
- Eduardo Mondlane University, Faculty of Medicine, CIMed, Maputo, Mozambique.
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Pharmacokinetics of chloroquine and monodesethylchloroquine in pregnancy. Antimicrob Agents Chemother 2010; 54:1186-92. [PMID: 20086162 DOI: 10.1128/aac.01269-09] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In order to determine the pharmacokinetic disposition of chloroquine (CQ) and its active metabolite, desethylchloroquine (DECQ), when administered as intermittent presumptive treatment in pregnancy (IPTp) for malaria, 30 Papua New Guinean women in the second or third trimester of pregnancy and 30 age-matched nonpregnant women were administered three daily doses of 450 mg CQ (8.5 mg/kg of body weight/day) in addition to a single dose of sulfadoxine-pyrimethamine. For all women, blood was taken at baseline; at 1, 2, 4, 6, 12, 18, 24, 30, 48, and 72 h posttreatment; and at 7, 10, 14, 28, and 42 days posttreatment. Plasma was subsequently assayed for CQ and DECQ by high-performance liquid chromatography, and population pharmacokinetic modeling was performed. Pregnant subjects had significantly lower area under the plasma concentration-time curve for both CQ (35,750 versus 47,892 microg.h/liter, P < 0.001) and DECQ (23,073 versus 41,584 microg.h/liter, P < 0.001), reflecting significant differences in elimination half-lives and in volumes of distribution and clearances relative to bioavailability. Reduced plasma concentrations of both CQ and DECQ could compromise both curative efficacy and posttreatment prophylactic properties in pregnant patients. Higher IPTp CQ doses may be desirable but could increase the risk of adverse hemodynamic effects.
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Lee SJ, McGready R, Fernandez C, Stepniewska K, Paw MK, Viladpai-nguen SJ, Thwai KL, Villegas L, Singhasivanon P, Greenwood BM, White NJ, Nosten F. Chloroquine pharmacokinetics in pregnant and nonpregnant women with vivax malaria. Eur J Clin Pharmacol 2008; 64:987-92. [DOI: 10.1007/s00228-008-0500-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Accepted: 04/22/2008] [Indexed: 10/21/2022]
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Ward SA, Sevene EJP, Hastings IM, Nosten F, McGready R. Antimalarial drugs and pregnancy: safety, pharmacokinetics, and pharmacovigilance. THE LANCET. INFECTIOUS DISEASES 2007; 7:136-44. [PMID: 17251084 DOI: 10.1016/s1473-3099(07)70025-7] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Before a recommendation for antimalarial drug use in pregnancy is made, it is essential that we understand the potential risks involved and have mechanisms in place to monitor risk during treatment. This requires data on drug disposition during pregnancy and potential toxicological liabilities to the developing fetus and mother. In most cases this information is not available. We review the reproductive toxicology of the main antimalarial drug classes in use or under development. Preclinical data are presented if appropriate, but as human experience overrides such data, in instances in which preclinical studies do not correlate with the human experience the data are reviewed only briefly. Additionally, we highlight the lack of appropriate drug disposition data in pregnancy and suggest mechanisms that can be used to capture data on risk after drug treatment in pregnancy.
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