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Bishop MD, Korutaro V, Boyce CL, Beck IA, Styrchak SM, Knowles K, Ziemba L, Brummel SS, Coletti A, Jean-Philippe P, Chakhtoura N, Vhembo T, Cassim H, Owor M, Fairlie L, Moyo S, Chinula L, Lockman S, Frenkel LM. Characterizing HIV drug resistance in cases of vertical transmission in the VESTED randomized antiretroviral treatment trial. J Acquir Immune Defic Syndr 2024; 96:385-392. [PMID: 39175843 PMCID: PMC11338623 DOI: 10.1097/qai.0000000000003435] [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: 08/22/2023] [Accepted: 03/04/2024] [Indexed: 08/24/2024]
Abstract
Introduction VESTED (NCT03048422) compared the safety and efficacy of three antiretroviral treatment (ART) regimens in pregnant and postpartum women: dolutegravir+emtricitabine/tenofovir alafenamide fumarate; dolutegravir+emtricitabine/tenofovir disoproxil fumarate (TDF); efavirenz/emtricitabine/TDF. Vertical HIV transmission (VT) occurred to 4/617 (0.60%) live-born infants, who were evaluated for HIV drug resistance (HIVDR) and other risk factors. Setting In 2018-2020, pregnant (weeks-14-28) women living with HIV and ≤14 days of ART were enrolled at 22 international sites and followed with their infants through 50 weeks postpartum. Methods HIV sequences derived by single genome amplification (SGA) from longitudinally collected specimens were assessed from VT Cases for HIVDR in protease, reverse transcriptase, integrase, and the nef 3'polypurine tract (3'PPT). Results The four Case mothers were prescribed efavirenz-based-ART for 1-7 days prior to randomization to study ART. Their infants received postnatal nevirapine+/-zidovudine prophylaxis and were breastfed. A total of 833 SGA sequences were derived. The "major" (Stanford HIVDR Score ≥60) non-nucleoside reverse transcriptase inhibitor (NNRTI) mutation (K103N) was detected persistently in one viremic mother, and likely contributed to VT of HIVDR. Major NNRTI HIVDR mutations were detected in all three surviving infants. No integrase, nor high frequencies of 3'PPT mutations conferring dolutegravir HIVDR were detected. The timing of HIV infant diagnosis, plasma HIV RNA levels and HIVDR suggests one in utero, one peripartum, one early, and one late breastfeeding transmission. Conclusions VT was rare. New-onset NNRTI HIVDR in Case mothers was likely from efavirenz-ART prescribed prior to study dolutegravir-ART, and in one case appeared transmitted to the infant despite nevirapine prophylaxis.
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Affiliation(s)
- Marley D. Bishop
- Department of Global Infectious Diseases, Seattle Children’s Research Institute, 307 Westlake Ave N, Seattle, 98109, Washington, USA
| | - Violet Korutaro
- Children’s Foundation Uganda, Baylor College of Medicine, Block 5 Mulago Hospital, P. O. BOX 72052, Kampala 72052, Kamutarpala Uganda
| | - Ceejay L. Boyce
- Department of Global Infectious Diseases, Seattle Children’s Research Institute, 307 Westlake Ave N, Seattle, 98109, Washington, USA
| | - Ingrid A. Beck
- Department of Global Infectious Diseases, Seattle Children’s Research Institute, 307 Westlake Ave N, Seattle, 98109, Washington, USA
| | - Sheila M. Styrchak
- Department of Global Infectious Diseases, Seattle Children’s Research Institute, 307 Westlake Ave N, Seattle, 98109, Washington, USA
| | - Kevin Knowles
- Frontier Science and Technology Research Foundation, 4033 Maple Road Amherst, Buffalo, 14226, NY, USA
| | - Lauren Ziemba
- Centre for Biostatistics in AIDS Research Center for Biostatistics in AIDS Research, Harvard University T.H. Chan School of Public Health, FXB 507 677 Huntington Ave Center for Biostatistics in AIDS Research, Boston, 02115, MA, USA
| | - Sean S. Brummel
- Centre for Biostatistics in AIDS Research Center for Biostatistics in AIDS Research, Harvard University T.H. Chan School of Public Health, FXB 507 677 Huntington Ave Center for Biostatistics in AIDS Research, Boston, 02115, MA, USA
| | - Anne Coletti
- FHI 360, 359 Blackwell St. Suite 200, Durham, 27713, NC, USA
| | - Patrick Jean-Philippe
- Division of AIDS; Maternal Adolescent Pediatric Research Branch; Prevention Sciences Program, National Institute of Allergy and Infectious Diseases, 5601 Fishers Lane Room 8B21, MSC 9831, Bethesda, 20892, MD, USA
| | - Nahida Chakhtoura
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Maternal and Pediatric Infectious Disease Branch, 6710B Rockledge Drive, Bethesda, MD, USA 20892
| | - Tichaona Vhembo
- University of Zimbabwe-University of California San Francisco Collaborative Research Program (UZ-UCSF), 15 Phillips Ave, Belgravia Harare, Zimbabwe
| | - Haseena Cassim
- Perinatal HIV Research Unit, University of the Witwatersrand Johannesburg, Chris Hani Baragwanath Hospital P.O. Box 114, Diepkloof, 1864, Johannesburg, 2050, Gauteng, South Africa
| | - Maxensia Owor
- Makerere University –John Hopkins University Research Collaboration (MUJHU CARE LTD), CRS Upper Mulago Hill Road PO Box 23491, Kampala, Uganda
| | - Lee Fairlie
- Wits RHI, Maternal and Child Health, 22 Esselen Street Hillbrow, Johannesburg, Gauteng, South Africa 2001
| | - Sikhulile Moyo
- Botswana-Harvard AIDS Institute Partnership, Plot 1836 N Ring Rd, Gaborone, Botswana
- Division of Infectious Disease, Brigham and Women’s Hospital, 15 Francis St 2nd Floor, Boston, 02115, MA, USA
| | - Lameck Chinula
- Division of Global Women’s Health; Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill, 3009 Old Clinic Building Campus Box 7570, Chapel Hill, 27599, NC, USA
| | - Shahin Lockman
- Botswana-Harvard AIDS Institute Partnership, Plot 1836 N Ring Rd, Gaborone, Botswana
- Division of Infectious Disease, Brigham and Women’s Hospital, 15 Francis St 2nd Floor, Boston, 02115, MA, USA
- Harvard University T.H. Chan School of Public Health, Department of Immunology and Infectious Diseases School of Public Health, 655 Huntington Ave, Boston, 02115, MA, USA
| | - Lisa M. Frenkel
- Department of Global Infectious Diseases, Seattle Children’s Research Institute, 307 Westlake Ave N, Seattle, 98109, Washington, USA
- University of Washington, Department of Global Health, Medicine, Epidemiology and Pediatrics, 1959 NE Pacific St. Seattle 98195 WA
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Aebi-Popp K, Kahlert CR, Crisinel PA, Decosterd L, Saldanha SA, Hoesli I, Martinez De Tejada B, Duppenthaler A, Rauch A, Marzolini C. Transfer of antiretroviral drugs into breastmilk: a prospective study from the Swiss Mother and Child HIV Cohort Study. J Antimicrob Chemother 2022; 77:3436-3442. [PMID: 36177836 PMCID: PMC9704434 DOI: 10.1093/jac/dkac337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/13/2022] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION In 2018, Switzerland changed its guidelines to support women living with HIV wishing to breastfeed. The exposure of antiretroviral drugs (ARVs) in breastmilk and the ingested daily dose by the breastfed infant are understudied, notably for newer ARVs. This study aimed to quantify ARV concentrations in maternal plasma and breastmilk to determine the milk/plasma ratio, to estimate daily infant ARV dose from breastfeeding and to measure ARV concentrations in infants. METHODS All women wishing to breastfeed were included, regardless of their ARV treatment. Breastmilk and maternal plasma samples were mostly collected at mid-dosing interval. RESULTS Twenty-one mother/child pairs were enrolled; of those several were on newer ARVs including 10 raltegravir, 1 bictegravir, 2 rilpivirine, 2 darunavir/ritonavir and 3 tenofovir alafenamide. No vertical HIV transmission was detected (one infant still breastfed). The median milk/plasma ratios were 0.96/0.39 for raltegravir once/twice daily, 0.01 for bictegravir, 1.08 for rilpivirine, 0.12 for darunavir/ritonavir and 4.09 for tenofovir alafenamide. The median estimated infant daily dose (mg/kg) from breastfeeding was 0.02/0.25 for raltegravir once/twice daily, 0.01 for bictegravir, 0.02 for rilpivirine, 0.05 for darunavir/ritonavir and 0.007 for tenofovir alafenamide, resulting in relative infant dose <10% exposure index for all ARVs. CONCLUSIONS ARVs were transferred to a variable extent in breastmilk. Nevertheless, the estimated daily ARV dose from breastfeeding remained low. Differential ARV exposure was observed in breastfed infants with some ARVs being below/above their effective concentrations raising the concern of resistance development if HIV infection occurs. More data on this potential risk are warranted to better support breastfeeding.
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Affiliation(s)
- Karoline Aebi-Popp
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern 3010, Switzerland
- Department of Obstetrics and Gynecology, Lindenhofspital, Bern 3012, Switzerland
| | - Christian R Kahlert
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen 9000, Switzerland
| | - Pierre-Alex Crisinel
- Unit of Pediatric Infectious Diseases and Vaccinology, Service of Pediatrics, Women and Mother Child Department, Lausanne University Hospital and University of Lausanne, Lausanne 1011, Switzerland
| | - Laurent Decosterd
- Department of Laboratory Medicine and Pathology, Service and Laboratory of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne 1011, Switzerland
| | - Susana Alves Saldanha
- Department of Laboratory Medicine and Pathology, Service and Laboratory of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne 1011, Switzerland
| | - Irene Hoesli
- Department of Obstetrics and Gynecology, University Hospital Basel and University of Basel, Basel 4031, Switzerland
| | - Begona Martinez De Tejada
- Department of Pediatrics, Gynecology and Obstetrics, Obstetrics Division, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Geneva 1211, Switzerland
| | - Andrea Duppenthaler
- Division of Infectious Diseases, University Children’s Hospital, Bern 3010, Switzerland
| | - Andri Rauch
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern 3010, Switzerland
| | - Catia Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital and University of Basel, Basel 4031, Switzerland
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool L693GF, UK
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Vanangamudi M, Kurup S, Namasivayam V. Non-nucleoside reverse transcriptase inhibitors (NNRTIs): a brief overview of clinically approved drugs and combination regimens. Curr Opin Pharmacol 2020; 54:179-187. [PMID: 33202360 DOI: 10.1016/j.coph.2020.10.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 10/07/2020] [Accepted: 10/09/2020] [Indexed: 12/27/2022]
Abstract
The non-nucleoside reverse transcriptase inhibitors (NNRTIs) are allosteric inhibitors of HIV-1 reverse transcriptase and are classified into generations depending on their discovery and resistance profiles. The NNRTIs are used in combination regimens with antiretroviral agents that target two or more enzymes in the viral life cycle. The combination regimens usually include a backbone of two nucleoside or nucleotide reverse transcriptase inhibitors and a third core agent among the NNRTIs or protease inhibitors. The combination regimens are maintained over long durations and consequently lead to long-term problems, including toxicity, drug-drug interactions, and increasing costs. This brief overview summarizes the pharmacokinetic profiles for NNRTIs and NNRTI-based combination regimens.
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Affiliation(s)
- Murugesan Vanangamudi
- Department of Medicinal and Pharmaceutical Chemistry, Sree Vidyanikethan College of Pharmacy, Tirupathi, Andhra Pradesh 517102, India
| | - Sonali Kurup
- College of Pharmacy, Ferris State University, 220 Ferris Drive, Big Rapids, MI 49301, USA
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San C, Lê MP, Matheron S, Mourvillier B, Caseris M, Timsit JF, Wolff M, Yazdanpanah Y, Descamps D, Peytavin G. Management of oral antiretroviral administration in patients with swallowing disorders or with an enteral feeding tube. Med Mal Infect 2019; 50:537-544. [PMID: 31722864 DOI: 10.1016/j.medmal.2019.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 12/14/2018] [Accepted: 10/18/2019] [Indexed: 02/07/2023]
Abstract
HIV infection has evolved into a chronic disease with comorbidities since the combination antiretroviral therapy era. Complications still occur and patients may need to be admitted to an intensive care unit. Acute respiratory failure is the first cause of these admissions, questioning the administration of solid oral dosage formulations. This issue is also observed in geriatric units where the prevalence of dysphagia is high and underestimated. The problem of antiretroviral administration is critical: altered solid oral dosage formulations and/or administration via enteral feeding tubes are sometimes the only option. The aim is to help manage antiretroviral treatment in unconscious or intubated patients and those with swallowing disorders who are hospitalized in intensive care units or geriatric units. This review provides information on the main antiretroviral regimens and on practical and legal aspects of manipulating solid oral dosage formulations and administration via enteral feeding tubes. Alternatives to the solid formulation are available for most of the 27 oral antiretrovirals available, or manufacturers provide recommendations for patients who are unable to swallow. Manipulation of solid oral dosage formulations such as crushing tablets or opening capsules and administration via feeding tubes are frequently reported but should be the last option for safety and liability issues. Before any off-label administration of a drug, physicians should consider alternatives to the solid oral dosage formulation and check whether the drug can be altered. Therapeutic monitoring is important in this particular setting as the pharmacokinetic profile of drugs is difficult to predict.
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Affiliation(s)
- Carine San
- Laboratoire de pharmacologie-toxicologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - M P Lê
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Laboratoire de pharmacologie-toxicologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France.
| | - S Matheron
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Service de maladies infectieuses et tropicales, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - B Mourvillier
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Réanimation médicale et infectieuse, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - M Caseris
- Service de pédiatrie, AP-HP, Hôpital Robert Debré, 75019 Paris, France
| | - J-F Timsit
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Réanimation médicale et infectieuse, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - M Wolff
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Réanimation médicale et infectieuse, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - Y Yazdanpanah
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Service de maladies infectieuses et tropicales, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - D Descamps
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Laboratoire de virologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - G Peytavin
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Laboratoire de pharmacologie-toxicologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
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5
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Investigating time dependent brain distribution of nevirapine via mass spectrometric imaging. J Mol Histol 2019; 50:593-599. [DOI: 10.1007/s10735-019-09852-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 10/28/2019] [Indexed: 01/29/2023]
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6
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Mugusi SF, Mopei N, Minzi O. Adherence to combination antiretroviral therapy among orphaned children in Dar es Salaam, Tanzania. South Afr J HIV Med 2019; 20:954. [PMID: 31534787 PMCID: PMC6739535 DOI: 10.4102/sajhivmed.v20i1.954] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 05/05/2019] [Indexed: 11/03/2022] Open
Abstract
Background Adherence to combination antiretroviral therapy (cART) among HIV-infected children is often complicated by various factors including medication formulation, dosing frequency, drug toxicities, age and developmental stage, psychosocial and behavioural characteristics of both children and caregivers and can additionally be complicated by being an orphan. Objectives This study was aimed at determining the factors and the extent of their influence on cART adherence among HIV-infected orphaned children attending Care and Treatment Centres (CTCs) in Dar es Salaam, Tanzania. Methods A cross-sectional study was performed, which assessed adherence in HIV-positive orphaned children aged 2–14 years receiving nevirapine (NVP) based cART for at least 6 months. Data was collected using questionnaires administered to primary caregivers of HIV-infected orphaned children, the review of medical files, and the laboratory measurement of NVP plasma concentrations and CD4 counts. Adherence to cART was determined based on caregivers’ self-report, consistency of clinic attendance and NVP plasma concentrations. Results Among the 216 enrolled orphaned children, adherence to cART was found to be 79.6%, 82.9% and 72.2% respectively based on caregivers’ self-report, clinic attendance and NVP plasma levels. Significant reductions in NVP concentrations (< 3 µg/mL) were seen among children with poor immunological outcomes, poor clinic attendance (p < 0.05) and were suggested by caregivers’ self-reported adherence (p = 0.06). Adherence challenges identified by caregivers included financial constraints (87.5%), lengthy waiting times at clinics (75.5% spent > 2 h at the clinic) and low HIV knowledge among caregivers. Conclusion Significant numbers of HIV-infected orphans have poor adherence to cART ranging between 17% and 28% based on different assessment methods. Inadequate caregiver knowledge of HIV/AIDS, long clinic waiting times and forgetfulness were identified as barriers to cART adherence in these orphans.
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Affiliation(s)
- Sabina F Mugusi
- Department of Clinical Pharmacology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Nassoro Mopei
- Local Government Authority, Dar es Salaam, United Republic of Tanzania
| | - Omary Minzi
- Department of Clinical Pharmacology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
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Alassane OA, Carlos DPM, Mamoudou M, Sounkalo D, Etienne C, Peggy G. Estimation of Drug Pharmacokinetics from Breast Feeding: A Simple Method Based on Meta-analysis. ACTA ACUST UNITED AC 2019; 21. [PMID: 32457926 PMCID: PMC7250461 DOI: 10.9734/jamps/2019/v21i230126] [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] [Indexed: 11/30/2022]
Abstract
Background: In resource-limited settings, breastfeeding is the healthiest source of nutrition for newborns. For economic/cultural reasons, breastfeeding is the preferred option for the majority of mothers, including HIV-positive mothers. Objective: The objective of this review is to document parameters characterizing antiretroviral therapy (ARV) diffusion into breast milk associated with the estimated ARV amount ingested by breastfed infant and clinical/biological abnormalities. Data Source and Eligibility Criteria: Twenty seven (27) published articles on the aspects of Pharmacokinetic parameters on ARV diffusion into breast milk have shown a large variability without clear interpretation on drugs diffusion. Using PubMed and Embase, we conducted a search to identify all published studies at 2015 that characterized antiretroviral drug diffusion from mother to infant via breast milk. We identified 27 published studies that characterized antiretroviral drug passage from mother to infant (drug concentrations in mother’s milk and breastfed plasma). Information was sufficiently complete for inclusion in the present analysis for only six antiretroviral drugs. Results: Finally, only data for nevirapine and efavirenz were exploitable because some of the studies found null or non-detectable levels, which were not suitable for simulations. Median (IQR) nevirapine CL/F were 0.022 (0.013–0.038) for newborns, 0.121 (0.116–0.125) for children and 0.056 (0.045–0.070) for mothers, all in L/h/kg. Efavirenz CL/F were 0.025 (0.016–0.039) for newborns, 0.273 (0.261–0.285) for children and 0.160 (0.153–0.167) for mothers, also in L/h/kg. Conclusion: Pharmacokinetics parameters of efavirenz and nevirapine are important to be determined in breastfed newborns.
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Affiliation(s)
- Oumar Aboubacar Alassane
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan University Hospital, Toulouse, France.,Pharmacology and Pharmacogenetic Laboratory, University Institute of Cancer Oncopôle, Toulouse, France.,HIV/TB Research and Training Center, University of Science, Techniques and Technologies in Bamako, Mali
| | - De Pablos-Martinez Carlos
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan University Hospital, Toulouse, France
| | - Maiga Mamoudou
- Northwestern University, Division of Infectious Diseases, Chicago, USA
| | - Dao Sounkalo
- HIV/TB Research and Training Center, University of Science, Techniques and Technologies in Bamako, Mali
| | - Chatelut Etienne
- Pharmacology and Pharmacogenetic Laboratory, University Institute of Cancer Oncopôle, Toulouse, France
| | - Gandia Peggy
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan University Hospital, Toulouse, France
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Huang L, Carey V, Lindsey JC, Marzan F, Gingrich D, Graham B, Barlow-Mosha L, Ssemambo PK, Kamthunzi P, Nachman S, Parikh S, Aweeka FT. Concomitant nevirapine impacts pharmacokinetic exposure to the antimalarial artemether-lumefantrine in African children. PLoS One 2017; 12:e0186589. [PMID: 29065172 PMCID: PMC5655345 DOI: 10.1371/journal.pone.0186589] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 10/04/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The antiretroviral drug nevirapine and the antimalarial artemisinin-based combination therapy artemether-lumefantrine are commonly co-administered to treat malaria in the context of HIV. Nevirapine is a known inhibitor of cytochrome P450 3A4, which metabolizes artemether and lumefantrine. To address the concern that the antiretroviral nevirapine impacts the antimalarial artemether-lumefantrine pharmacokinetics, a prospective non-randomized controlled study in children presenting with uncomplicated malaria and HIV in sub-Saharan Africa was carried out. METHODS Participants received artemether-lumefantrine (20/120 mg weight-based BID) for 3 days during nevirapine-based antiretroviral therapy (ART) co-administration (158-266 mg/m2 QD). HIV positive participants who were not yet on ART drugs were also enrolled as the control group. The target enrollment was children aged 3-12 years (n = 24 in each group). Intensive pharmacokinetics after the last artemether-lumefantrine dose was assessed for artemether, its active metabolite dihydroartemisinin, and lumefantrine. Pharmacokinetic parameters (area under the plasma concentration vs. time curve (AUC), maximum concentration and day 7 lumefantrine concentrations) were estimated using non-compartmental methods and compared to controls. RESULTS Nineteen children (16 on nevirapine and three not on ART) enrolled. Fifteen of the 16 (aged 4 to 11 years) on nevirapine-based ART were included in the pharmacokinetic analysis. Due to evolving WHO HIV treatment guidelines, insufficient children were enrolled in the control group (n = 3), so the pharmacokinetic data were compared to a historical control group of 20 HIV-uninfected children 5-12 years of age who also presented with malaria and underwent identical study procedures. Decreases of pharmacokinetic exposure [as estimated by AUC (AUC0-8hr)] were marginally significant for artemether (by -46%, p = 0.08) and dihydroartemisinin (-22%, p = 0.06) in the children on nevirapine-based ART, compared to when artemether-lumefantrine was administered alone. Similarly, peak concentration was decreased by 50% (p = 0.07) for artemether and 36% (p = 0.01) for dihydroartemisinin. In contrast, exposure to lumefantrine increased significantly in the context of nevirapine [AUC0-120hr:123% (p<0.001); Cday7:116% (p<0.001), Cmax: 95% (p<0.001)]. CONCLUSIONS Nevirapine-based ART increases the exposure to lumefantrine in pre-pubescent children with a trend toward diminished artemether and dihydroartemisinin exposure. These findings contrast with other studies indicating NVP reduces or results in no change in exposure of antimalarial drugs, and may be specific to this age group (4-12 years). Considering the excellent safety profile of artemether-lumefantrine, the increase in lumefantrine is not of concern. However, the reduction in artemisinin exposure may warrant further study, and suggests that dosage adjustment of artemether-lumefantrine with nevirapine-based ART in children is likely warranted.
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Affiliation(s)
- Liusheng Huang
- Drug Research Unit, Department of Clinical Pharmacy, University of California, San Francisco, CA, United States of America
| | - Vincent Carey
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, MA, United States of America
| | - Jane C. Lindsey
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, MA, United States of America
| | - Florence Marzan
- Drug Research Unit, Department of Clinical Pharmacy, University of California, San Francisco, CA, United States of America
| | - David Gingrich
- Drug Research Unit, Department of Clinical Pharmacy, University of California, San Francisco, CA, United States of America
| | - Bobbie Graham
- Frontier Science and Technology Research Foundation, Buffalo, NY, United States of America
| | | | | | | | - Sharon Nachman
- School of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Sunil Parikh
- Yale School of Public Health, New Haven, CT, United States of America
| | - Francesca T. Aweeka
- Drug Research Unit, Department of Clinical Pharmacy, University of California, San Francisco, CA, United States of America
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Bolaris MA, Keller MA, Robbins BL, Podany AT, Fletcher CV. Nevirapine Plasma Concentrations in Human Immunodeficiency Virus-Exposed Neonates Receiving High-Dose Nevirapine Prophylaxis as Part of 3-Drug Regimen. J Pediatric Infect Dis Soc 2017; 6:102-104. [PMID: 26803329 DOI: 10.1093/jpids/piv084] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 11/29/2015] [Indexed: 11/13/2022]
Affiliation(s)
- Michael A Bolaris
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles County Harbor UCLA Medical Center, Torrance, California
| | - Margaret A Keller
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles County Harbor UCLA Medical Center, Torrance, California
| | - Brian L Robbins
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, Omaha
| | - Anthony T Podany
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, Omaha
| | - Courtney V Fletcher
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, Omaha
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Mbuagbaw L, Mursleen S, Irlam JH, Spaulding AB, Rutherford GW, Siegfried N. Efavirenz or nevirapine in three-drug combination therapy with two nucleoside or nucleotide-reverse transcriptase inhibitors for initial treatment of HIV infection in antiretroviral-naïve individuals. Cochrane Database Syst Rev 2016; 12:CD004246. [PMID: 27943261 PMCID: PMC5450880 DOI: 10.1002/14651858.cd004246.pub4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The advent of highly active antiretroviral therapy (ART) has reduced the morbidity and mortality due to HIV infection. The World Health Organization (WHO) ART guidelines focus on three classes of antiretroviral drugs, namely nucleoside or nucleotide reverse transcriptase inhibitors (NRTI), non-nucleoside reverse transcriptase inhibitors (NNRTI) and protease inhibitors. Two of the most common medications given as first-line treatment are the NNRTIs, efavirenz (EFV) and nevirapine (NVP). It is unclear which NNRTI is more efficacious for initial therapy. This systematic review was first published in 2010. OBJECTIVES To determine which non-nucleoside reverse transcriptase inhibitor, either EFV or NVP, is more effective in suppressing viral load when given in combination with two nucleoside reverse transcriptase inhibitors as part of initial antiretroviral therapy for HIV infection in adults and children. SEARCH METHODS We attempted to identify all relevant studies, regardless of language or publication status, in electronic databases and conference proceedings up to 12 August 2016. We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov to 12 August 2016. We searched LILACS (Latin American and Caribbean Health Sciences Literature) and the Web of Science from 1996 to 12 August 2016. We checked the National Library of Medicine (NLM) Gateway from 1996 to 2009, as it was no longer available after 2009. SELECTION CRITERIA We included all randomized controlled trials (RCTs) that compared EFV to NVP in people with HIV without prior exposure to ART, irrespective of the dosage or NRTI's given in combination.The primary outcome of interest was virological success. Other primary outcomes included mortality, clinical progression to AIDS, severe adverse events, and discontinuation of therapy for any reason. Secondary outcomes were change in CD4 count, treatment failure, development of ART drug resistance, and prevention of sexual transmission of HIV. DATA COLLECTION AND ANALYSIS Two review authors assessed each reference for inclusion using exclusion criteria that we had established a priori. Two review authors independently extracted data from each included trial using a standardized data extraction form. We analysed data on an intention-to-treat basis. We performed subgroup analyses for concurrent treatment for tuberculosis and dosage of NVP. We followed standard Cochrane methodological procedures. MAIN RESULTS Twelve RCTs, which included 3278 participants, met our inclusion criteria. None of these trials included children. The length of follow-up time, study settings, and NRTI combination drugs varied greatly. In five included trials, participants were receiving concurrent treatment for tuberculosis.There was little or no difference between EFV and NVP in virological success (RR 1.04, 95% CI 0.99 to 1.09; 10 trials, 2438 participants; high quality evidence), probably little or no difference in mortality (RR 0.84, 95% CI 0.59 to 1.19; 8 trials, 2317 participants; moderate quality evidence) and progression to AIDS (RR 1.23, 95% CI 0.72 to 2.11; 5 trials, 2005 participants; moderate quality evidence). We are uncertain whether there is a difference in all severe adverse events (RR 0.91, 95% CI 0.71 to 1.18; 8 trials, 2329 participants; very low quality evidence). There is probably little or no difference in discontinuation rate (RR 0.93, 95% CI 0.69 to 1.25; 9 trials, 2384 participants; moderate quality evidence) and change in CD4 count (MD -3.03; 95% CI -17.41 to 11.35; 9 trials, 1829 participants; moderate quality evidence). There may be little or no difference in treatment failure (RR 0.97, 95% CI 0.76 to 1.24; 5 trials, 737 participants; low quality evidence). Development of drug resistance is probably slightly less in the EFV arms (RR 0.76, 95% CI 0.60 to 0.95; 4 trials, 988 participants; moderate quality evidence). No studies were found that looked at sexual transmission of HIV.When we examined the adverse events individually, EFV probably is associated with more people with impaired mental function (7 per 1000) compared to NVP (2 per 1000; RR 4.46, 95% CI 1.65 to 12.03; 6 trials, 2049 participants; moderate quality evidence) but fewer people with elevated transaminases (RR 0.52, 95% CI 0.35 to 0.78; 3 trials, 1299 participants; high quality evidence), fewer people with neutropenia (RR 0.48, 95% CI 0.28 to 0.82; 3 trials, 1799 participants; high quality evidence), and probably fewer people withrash (229 per 100 with NVP versus 133 per 1000 with EFV; RR 0.58, 95% CI 0.34 to 1.00; 7 trials, 2277 participants; moderate quality evidence). We found that there may be little or no difference in gastrointestinal adverse events (RR 0.76, 95% CI 0.48 to 1.21; 6 trials, 2049 participants; low quality evidence), pyrexia (RR 0.65, 95% CI 0.15 to 2.73; 3 trials, 1799 participants; low quality evidence), raised alkaline phosphatase (RR 0.65, 95% CI 0.17 to 2.50; 1 trial, 1007 participants; low quality evidence), raised amylase (RR 1.40, 95% CI 0.72 to 2.73; 2 trials, 1071 participants; low quality evidence) and raised triglycerides (RR 1.10, 95% CI 0.39 to 3.13; 2 trials, 1071 participants; low quality evidence). There was probably little or no difference in serum glutamic oxaloacetic transaminase (SGOT; MD 3.3, 95% CI -2.06 to 8.66; 1 trial, 135 participants; moderate quality evidence), serum glutamic- pyruvic transaminase (SGPT; MD 5.7, 95% CI -4.23 to 15.63; 1 trial, 135 participants; moderate quality evidence) and raised cholesterol (RR 6.03, 95% CI 0.75 to 48.78; 1 trial, 64 participants; moderate quality evidence).Our subgroup analyses revealed that NVP slightly increases mortality when given once daily (RR 0.34, 95% CI 0.13 to 0.90; 3 trials, 678 participants; high quality evidence). There were little or no differences in the primary outcomes for patients who were concurrently receiving treatment for tuberculosis. AUTHORS' CONCLUSIONS Both drugs have similar benefits in initial treatment of HIV infection when combined with two NRTIs. The adverse events encountered affect different systems, with EFV more likely to cause central nervous system adverse events and NVP more likely to raise transaminases, cause neutropenia and rash.
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Affiliation(s)
- Lawrence Mbuagbaw
- Yaoundé Central HospitalCentre for the Development of Best Practices in Health (CDBPH)Henri Dunant AvenuePO Box 87YaoundéCameroon
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamiltonONCanada
| | - Sara Mursleen
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamiltonONCanada
| | - James H Irlam
- University of Cape TownPrimary Health Care DirectorateE47 OMBGroote Schuur HospitalCape TownWestern CapeSouth Africa7925
| | - Alicen B Spaulding
- National Institute of Allergy and Infectious DiseasesLaboratory of Clinical Infectious Diseases2953 TERRACE DRBethesdaMDUSA20892
| | - George W Rutherford
- University of California, San FranciscoGlobal Health Sciences50 Beale StreetSuite 1200San FranciscoCaliforniaUSA94105
| | - Nandi Siegfried
- Cape TownSouth Africa
- Medical Research CouncilAlcohol, Tobacco and Other Drug Research UnitFrancie van Zijl DriveTygerbergSouth Africa7505
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Transcriptional profiling suggests that Nevirapine and Ritonavir cause drug induced liver injury through distinct mechanisms in primary human hepatocytes. Chem Biol Interact 2015; 255:31-44. [PMID: 26626330 DOI: 10.1016/j.cbi.2015.11.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 10/28/2015] [Accepted: 11/20/2015] [Indexed: 12/25/2022]
Abstract
Drug induced liver injury (DILI), a major cause of pre- and post-approval failure, is challenging to predict pre-clinically due to varied underlying direct and indirect mechanisms. Nevirapine, a non-nucleoside reverse transcriptase inhibitor (NNRTI) and Ritonavir, a protease inhibitor, are antiviral drugs that cause clinical DILI with different phenotypes via different mechanisms. Assessing DILI in vitro in hepatocyte cultures typically requires drug exposures significantly higher than clinical plasma Cmax concentrations, making clinical interpretations of mechanistic pathway changes challenging. We previously described a system that uses liver-derived hemodynamic blood flow and transport parameters to restore primary human hepatocyte biology, and drug responses at concentrations relevant to in vivo or clinical exposure levels. Using this system, primary hepatocytes from 5 human donors were exposed to concentrations approximating clinical therapeutic and supra-therapeutic levels of Nevirapine (11.3 and 175.0 μM) and Ritonavir (3.5 and 62.4 μM) for 48 h. Whole genome transcriptomics was performed by RNAseq along with functional assays for metabolic activity and function. We observed effects at both doses, but a greater number of genes were differentially expressed with higher probability at the toxic concentrations. At the toxic doses, both drugs showed direct cholestatic potential with Nevirapine increasing bile synthesis and Ritonavir inhibiting bile acid transport. Clear differences in antigen presentation were noted, with marked activation of MHC Class I by Nevirapine and suppression by Ritonavir. This suggests CD8+ T cell involvement for Nevirapine and possibly NK Killer cells for Ritonavir. Both compounds induced several drug metabolizing genes (including CYP2B6, CYP3A4 and UGT1A1), mediated by CAR activation in Nevirapine and PXR in Ritonavir. Unlike Ritonavir, Nevirapine did not increase fatty acid synthesis or activate the respiratory electron chain with simultaneous mitochondrial uncoupling supporting clinical reports of a lower propensity for steatosis. This in vitro study offers insights into the disparate direct and immune-mediated toxicity mechanisms underlying Nevirapine and Ritonavir toxicity in the clinic.
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Beg S, Chaudhary V, Sharma G, Garg B, Panda SS, Singh B. QbD-oriented development and validation of a bioanalytical method for nevirapine with enhanced liquid-liquid extraction and chromatographic separation. Biomed Chromatogr 2015; 30:818-28. [DOI: 10.1002/bmc.3613] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 08/14/2015] [Accepted: 09/07/2015] [Indexed: 11/07/2022]
Affiliation(s)
- Sarwar Beg
- University Institute of Pharmaceutical Sciences, UGC Centre of Advanced Studies; Panjab University; Chandigarh 160 014 India
| | - Vandna Chaudhary
- University Institute of Pharmaceutical Sciences, UGC Centre of Advanced Studies; Panjab University; Chandigarh 160 014 India
| | - Gajanand Sharma
- University Institute of Pharmaceutical Sciences, UGC Centre of Advanced Studies; Panjab University; Chandigarh 160 014 India
- Formulation Research and Tech Transfer; IPCA Laboratories Limited; Kadhivali (W) Mumbai 400 067 India
| | - Babita Garg
- University Institute of Pharmaceutical Sciences, UGC Centre of Advanced Studies; Panjab University; Chandigarh 160 014 India
| | - Sagar Suman Panda
- Department of Pharmaceutical Analysis and Quality Assurance; Roland Institute of Pharmaceutical Sciences; Berhampur Odisha 760 010 India
| | - Bhupinder Singh
- University Institute of Pharmaceutical Sciences, UGC Centre of Advanced Studies; Panjab University; Chandigarh 160 014 India
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Schipani A, Back D, Owen A, Davies G, Khoo S, Siccardi M. Use of in vitro to in vivo extrapolation to predict the optimal strategy for patients switching from efavirenz to maraviroc or nevirapine. Clin Pharmacokinet 2015; 54:107-16. [PMID: 25245943 DOI: 10.1007/s40262-014-0184-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVES In clinical practice, antiretroviral regimens are often interrupted or modified for intolerance and toxicity. The objective of this study was to develop an in vitro to in vivo extrapolation (IVIVE) approach to describe the interaction when efavirenz is switched to either maraviroc or nevirapine and to test different switching scenarios to identify the best strategy. METHODS In vitro data describing the chemical and absorption, tissue distribution, metabolism and excretion (ADME) characteristics of efavirenz, maraviroc and nevirapine were obtained from the literature, and used to simulate plasma exposures of these drugs using the Simcyp Population-Based Simulator. The predicted maraviroc and nevirapine exposures were compared with data from clinical studies evaluating their exposures following a switch from efavirenz. RESULTS Model predictions for maraviroc and nevirapine exposure were in agreement with observed data. The simulations suggest that the waning efavirenz induction effect following discontinuation necessitated increasing maraviroc to 600 mg twice daily for 1 week after efavirenz cessation. Alternatively, adequate exposure of maraviroc was shown with a dose of 450 mg for 2 weeks. Efavirenz waning induction did not affect nevirapine exposure. CONCLUSION IVIVE modelling successfully predicted patient drug exposure. This modelling technique is able to inform the design of clinical studies, and allows assessment of pragmatic dosing strategies under complex therapeutic scenarios.
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Affiliation(s)
- Alessandro Schipani
- Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool, L69 3GF, UK,
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Lepik KJ, Yip B, McGovern RA, Ding E, Nohpal A, Watson BE, Toy J, Akagi L, Harrigan PR, Moore DM, Hogg RS, Montaner JSG, Barrios R. Post-marketing experience with nevirapine extended release (XR) tablets: effectiveness and tolerability in a population-based cohort in British Columbia, Canada. Antivir Ther 2014; 20:721-30. [PMID: 25960569 DOI: 10.3851/imp2908] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND Nevirapine 400 mg extended release tablets (nevirapine-XR) are a once-daily alternative to nevirapine 200 mg immediate release tablets (nevirapine-IR). Study objectives were to describe the effectiveness and tolerability of nevirapine-XR in clinical practice and, for patients who switched from once daily 2×200 mg nevirapine-IR to nevirapine-XR, compare virological suppression and plasma nevirapine concentrations during each treatment period. METHODS HIV-1-infected adults entered the study cohort if they initiated nevirapine-XR in British Columbia (BC) Canada between 1 April 2012 and 30 September 2012 and were followed until 30 September 2013. Demographic and clinical variables were abstracted from the BC Centre for Excellence in HIV/AIDS databases. Patients who switched from once daily nevirapine-IR to nevirapine-XR were monitored for 6 months pre- and post-switch with comparison of virological suppression (McNeamer's test) and median random plasma nevirapine concentrations (Wilcoxon-Mann-Whitney test) in each period. RESULTS The 536 nevirapine-XR-treated patients were 96% male, median (IQR) age 49.9 (44.0-56.9) years. Median follow-up was 15.6 (14.7-16.5) months, with 474/536 (88%) maintaining virological suppression. Emergent drug resistance developed in 5/536 (1%), adverse drug reactions in 17/536 (3%) and, although 31/536 (6%) reported 'whole' tablets in their stools, this was not associated with adverse outcomes. Among the 305 patients who switched from nevirapine-IR to nevirapine-XR, median (IQR) random plasma nevirapine concentration was higher during nevirapine-IR 5,000 (3,690-6,090) ng/ml than nevirapine-XR 3,930 (3,050-5,150) ng/ml (P<0.001), but there was no difference in virological suppression, 89% and 87% respectively (P=0.414). CONCLUSIONS This post-marketing study affirms the effectiveness and tolerability of nevirapine-XR as an alternative to nevirapine-IR in adults.
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Orden S, De Pablo C, Rios-Navarro C, Martinez-Cuesta MA, Peris JE, Barrachina MD, Esplugues JV, Alvarez A. Efavirenz induces interactions between leucocytes and endothelium through the activation of Mac-1 and gp150,95. J Antimicrob Chemother 2013; 69:995-1004. [PMID: 24275118 DOI: 10.1093/jac/dkt468] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES The potential cardiovascular (CV) toxicity associated with combined antiretroviral therapy (cART) has been attributed mainly to the nucleoside reverse transcriptase inhibitors abacavir and didanosine. However, the other two components of cART--non-nucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors (PIs)--may also be implicated, either directly or by influencing the action of the other drugs. This study evaluates the acute direct effects of the NNRTIs efavirenz and nevirapine and one of the most widely employed PIs, lopinavir, on leucocyte-endothelium interactions, a hallmark of CV disease. METHODS Drugs were analysed in vitro in human cells (interactions of peripheral blood polymorphonuclear or mononuclear cells with human umbilical vein endothelial cells) using a flow chamber system, and in vivo in rat mesenteric vessels by means of intravital microscopy. The expression of adhesion molecules in leucocytes and endothelial cells was studied by flow cytometry, and the role of these molecules in white cell recruitment was evaluated by pre-treating human cells or rats with blocking antibodies. RESULTS Efavirenz and nevirapine, but not lopinavir, increased the rolling flux and adhesion of leucocytes in vitro and in vivo while inducing emigration in rat venules. Efavirenz, but not nevirapine, augmented the levels of CD11b, CD11c and CD18 in neutrophils and monocytes. The actions of efavirenz, but not of nevirapine, were reversed by antibodies against Mac-1 (CD11b/CD18), gp150,95 (CD11c/CD18) or ICAM-1 (CD54). CONCLUSIONS NNRTIs, but not PIs, interfere with leucocyte-endothelial interactions. However, differences between efavirenz and nevirapine suggest a specific CV profile for each compound.
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Affiliation(s)
- Samuel Orden
- Departamento de Farmacología and CIBERehd, Facultad de Medicina, Universidad de Valencia, Valencia, Spain
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Micheli JE, Chinn LW, Shugarts SB, Patel A, Martin JN, Bangsberg DR, Kroetz DL. Measuring the overall genetic component of nevirapine pharmacokinetics and the role of selected polymorphisms: towards addressing the missing heritability in pharmacogenetic phenotypes? Pharmacogenet Genomics 2013; 23:591-6. [PMID: 23982262 PMCID: PMC4048019 DOI: 10.1097/fpc.0b013e32836533a5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Nevirapine is an important component of highly active antiretroviral therapy used in the treatment of HIV infection. There is a considerable variation in the pharmacokinetics of nevirapine and this variation can impact the efficacy and toxicity of nevirapine. Although some of this variation can be attributed to environmental factors, the degree to which heritability influences nevirapine pharmacokinetics is unknown. This study aims to estimate how much variation in nevirapine pharmacokinetics is due to genetic factors and to investigate the contribution of selected polymorphisms to this variability. METHODS Two doses of immediate-release nevirapine were administered to European (n=11) and African American (n=6) participants recruited from the Research in Access to Care in the Homeless cohort. A repeated drug administration method was then used to determine the relative genetic contribution (r(GC)) to variability in nevirapine AUC(0-6 h). Nevirapine plasma levels were quantified using LC/MS/MS. Patients were also genotyped for selected polymorphisms in candidate genes that may influence nevirapine pharmacokinetics. RESULTS A significant r(GC) for nevirapine AUC(0-6 h) was found in Europeans (P=0.02) and African Americans (P=0.01). A trend toward higher nevirapine AUC(0-6 h) for the CYP2B6 516TT (rs3745274; Q172H) genotype was observed in European Americans (P=0.19). CONCLUSION This study demonstrates that there is a significant genetic component to variability in nevirapine pharmacokinetics. Although genetic variants such as CYP2B6 polymorphisms attributed to some of this variation, these data suggest that there may be additional genetic factors that influence nevirapine pharmacokinetics.
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Affiliation(s)
- Janine E Micheli
- Departments of aBioengineering and Therapeutic Sciences bEpidemiology cMedicine dThe Institute for Human Genetics, University of California, San Francisco, California eRagon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, Massachusetts General Hospital Center for Global Health, Harvard Medical School, Boston, Massachusetts, USA
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Bhatti L, Gladstein J. Once-daily nevirapine XR: a brief overview of the safety and efficacy of a new formulation. ACTA ACUST UNITED AC 2012; 11:369-73. [PMID: 22930796 DOI: 10.1177/1545109712456427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Nevirapine (NVP) was the first nonnucleoside reverse transcriptase inhibitor (NNRTI) approved by the US Food and Drug Administration (FDA) in 1996, for the treatment of HIV infection. Current treatment guidelines include NVP as a component of a recommended alternative NNRTI regimen, which may be the preferred regimen for patients with established cardiovascular risk factors since NVP has minimal untoward effects on serum lipids. Two randomized and controlled clinical trials established the noninferior virologic efficacy of twice-daily NVP versus ritonavir-boosted atazanavir (ATV/r), a protease inhibitor with limited effects on serum lipids, each drug on a background regimen of once-daily (QD) tenofovir (TDF)/emtricitabine (FTC). An extended-release (XR) formulation of NVP was developed since QD dosing and reduced pill burdens have been shown to improve regimen adherence. This formulation (Viramune XR 400 mg) was recently FDA approved based on the results of 2 randomized, controlled clinical trials. The XR formulation will provide additional treatment options for patients who may benefit from NVP-based regimens.
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Nevirapine exposure with WHO pediatric weight band dosing: enhanced therapeutic concentrations predicted based on extensive international pharmacokinetic experience. Antimicrob Agents Chemother 2012; 56:5374-80. [PMID: 22869579 DOI: 10.1128/aac.00842-12] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Nevirapine (NVP) is a nonnucleoside reverse transcriptase inhibitor (NNRTI) used worldwide as part of combination antiretroviral therapy in infants and children to treat HIV infection. Dosing based on either weight or body surface area has been approved by the U.S. Food and Drug Administration (FDA) but can be difficult to implement in resource-limited settings. The World Health Organization (WHO) has developed simplified weight band dosing for NVP, but it has not been critically evaluated. NVP pharmacokinetic data were combined from eight pediatric clinical trials (Pediatric AIDS Clinical Trials Group [PACTG] studies 245, 356, 366, 377, 403, 1056, and 1069 and Children with HIV in Africa Pharmacokinetics and Adherence of Simple Antiretroviral Regimens [CHAPAS]) representing subjects from multiple continents and across the pediatric age continuum. A population pharmacokinetic model was developed to characterize developmental changes in NVP disposition, identify potential sources of NVP pharmacokinetic variability, and assess various pediatric dosing strategies and their impact on NVP exposure. Age, CYP2B6 genotype, and ritonavir were independent predictors of oral NVP clearance. The Triomune fixed-dose tablet was an independent predictor of bioavailability compared to the liquid and other tablet formulations. Monte Carlo simulations of the final model were used to assess WHO weight band dosing recommendations. The final pharmacokinetic model indicated that WHO weight band dosing is likely to result in a percentage of children with NVP exposure within the target range similar to that obtained with FDA dosing. Weight band dosing of NVP proposed by the WHO has the potential to provide a simple and effective dosing strategy for resource limited settings.
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Tang MW, Kanki PJ, Shafer RW. A review of the virological efficacy of the 4 World Health Organization-recommended tenofovir-containing regimens for initial HIV therapy. Clin Infect Dis 2012; 54:862-75. [PMID: 22357809 PMCID: PMC3284210 DOI: 10.1093/cid/cir1034] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
We systematically reviewed studies of the virological efficacy of the 4 new tenofovir (TDF)-containing regimens recommended for initial antiretroviral (ARV) therapy in the 2010 World Health Organization ARV Treatment Guidelines. Thirty-three studies assessed the efficacy of 1 or more TDF-containing regimens: TDF/lamivudine (3TC)/nevirapine (NVP) (n = 3), TDF/ emtricitabine (FTC)/NVP (n = 9), TDF/3TC/efavirenz (EFV) (n = 6), and TDF/FTC/EFV (n = 19). TDF/3TC/NVP was the least well-studied and appeared the least efficacious of the 4 regimens. In 2 comparative studies, TDF/3TC/NVP was associated with significantly more virological failure than AZT/3TC/NVP; a third study was terminated prematurely because of early virological failure. TDF/FTC/NVP was either equivalent or inferior to its comparator arms. TDF/3TC/EFV was equivalent to its comparator arms. TDF/FTC/EFV was equivalent or superior to its comparator arms. Possible explanations for these findings include the greater antiviral activity of EFV versus NVP and longer intracellular half-life of FTC-triphosphate versus 3TC-triphosphate. Further study of TDF/3TC/NVP is required before it is widely deployed for initial ARV therapy.
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Affiliation(s)
- Michele W Tang
- Department of Medicine, Division of Infectious Diseases, Stanford University, California 94305-5107, USA.
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Hemodiafiltration with online regeneration of ultrafiltrate for severe nevirapine intoxication in a HIV-infected patient. AIDS 2012; 26:653-5. [PMID: 22398572 DOI: 10.1097/qad.0b013e3283509770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Frank M, von Kleist M, Kunz A, Harms G, Schütte C, Kloft C. Quantifying the impact of nevirapine-based prophylaxis strategies to prevent mother-to-child transmission of HIV-1: a combined pharmacokinetic, pharmacodynamic, and viral dynamic analysis to predict clinical outcomes. Antimicrob Agents Chemother 2011; 55:5529-40. [PMID: 21947390 PMCID: PMC3232796 DOI: 10.1128/aac.00741-11] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2011] [Accepted: 09/14/2011] [Indexed: 12/30/2022] Open
Abstract
Single-dose nevirapine (sd-NVP) and extended NVP prophylaxis are widely used in resource-constrained settings to prevent vertical HIV-1 transmission. We assessed the pharmacokinetics of sd-NVP in 62 HIV-1-positive pregnant Ugandan woman and their newborns who were receiving sd-NVP prophylaxis to prevent mother-to-child HIV-1 transmission. Based on these data, we developed a mathematical model system to quantify the impact of different sd-NVP regimens at delivery and of extended infant NVP prophylaxis (6, 14, 21, 26, 52, 78, and 102 weeks) on the 2-year risk of HIV-1 transmission and development of drug resistance in mothers and their breast-fed infants. Pharmacokinetic parameter estimates and model-predicted HIV-1 transmission rates were very consistent with other studies. Predicted 2-year HIV-1 transmission risks were 35.8% without prophylaxis, 31.6% for newborn sd-NVP, 19.1% for maternal sd-NVP, and 19.7% for maternal/newborn sd-NVP. Maternal sd-NVP reduced newborn infection predominately by transplacental exchange, providing protective NVP concentrations to the newborn at delivery, rather than by maternal viral load reduction. Drug resistance was frequently selected in HIV-1-positive mothers after maternal sd-NVP. Extended newborn NVP prophylaxis further decreased HIV-1 transmission risks, but an overall decline in cost-effectiveness for increasing durations of newborn prophylaxis was indicated. The total number of infections with resistant virus in newborns was not increased by extended newborn NVP prophylaxis. The developed mathematical modeling framework successfully predicted the risk of HIV-1 transmission and resistance development and can be adapted to other drugs/drug combinations to a priori assess their potential in reducing vertical HIV-1 transmission and resistance spread.
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Affiliation(s)
- M. Frank
- Department of Clinical Pharmacy, Institute of Pharmacy, Martin-Luther-Universitaet Halle-Wittenberg, Wolfgang-Langenbeck-Str. 4, 06120 Halle, Germany
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany
| | - M. von Kleist
- Department of Mathematics and Computer Science, Freie Universitaet Berlin, Arnimallee 6, 14195 Berlin, Germany
| | - A. Kunz
- Institute of Tropical Medicine and International Health, Charité Universitätsmedizin Berlin, Spandauer Damm 130, 14050 Berlin, Germany
| | - G. Harms
- Institute of Tropical Medicine and International Health, Charité Universitätsmedizin Berlin, Spandauer Damm 130, 14050 Berlin, Germany
| | - C. Schütte
- Department of Mathematics and Computer Science, Freie Universitaet Berlin, Arnimallee 6, 14195 Berlin, Germany
| | - C. Kloft
- Department of Clinical Pharmacy, Institute of Pharmacy, Martin-Luther-Universitaet Halle-Wittenberg, Wolfgang-Langenbeck-Str. 4, 06120 Halle, Germany
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany
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Schipani A, Wyen C, Mahungu T, Hendra H, Egan D, Siccardi M, Davies G, Khoo S, Fätkenheuer G, Youle M, Rockstroh J, Brockmeyer NH, Johnson MA, Owen A, Back DJ. Integration of population pharmacokinetics and pharmacogenetics: an aid to optimal nevirapine dose selection in HIV-infected individuals. J Antimicrob Chemother 2011; 66:1332-9. [PMID: 21441248 PMCID: PMC3092713 DOI: 10.1093/jac/dkr087] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 02/07/2011] [Accepted: 02/10/2011] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Nevirapine is metabolized by CYP2B6 and polymorphisms within the CYP2B6 gene partly explain inter-patient variability in pharmacokinetics. The aim of this study was to model the complex relationship between nevirapine exposure, weight and genetics (based on combined analysis of CYP2B6 516G > T and 983T > C single nucleotide polymorphisms). METHODS Non-linear mixed-effects modelling was used to estimate pharmacokinetic parameters from 275 patients. Simulations of the nevirapine concentration profile were performed with dosing regimens of 200 mg twice daily and 400 mg once daily for individuals with body weights of 50, 70 and 90 kg in combination with CYP2B6 genetic variation. RESULTS A one-compartment model with first-order absorption best described the data. Population clearance was 3.5 L/h with inter-patient variability of 24.6%. 516T homozygosity and 983C heterozygosity were associated with 37% and 40% lower clearance, respectively. Body weight was the only significant demographic factor influencing clearance, which increased by 5% for every 10 kg increase. For individuals with higher body weight, once-daily nevirapine was associated with a greater risk of sub-therapeutic drug exposure than a twice-daily regimen. This risk was offset in individuals who were 516T homozygous or 983C heterozygous in which drug exposure was optimal for > 95% of patients with body weight of ≤ 70 kg. CONCLUSIONS The data suggest that a 400 mg once-daily dose could be implemented in accordance with CYP2B6 polymorphism and body weight. However, the use of nevirapine once daily (immediate release; off-label) in the absence of therapeutic drug monitoring is not recommended due to the risk of inadequate exposure to nevirapine in a high proportion of patients. There are different considerations for the extended-release formulation (nevirapine XR) that demonstrate minimal peak-to-trough fluctuations in plasma nevirapine levels.
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Affiliation(s)
- Alessandro Schipani
- Department of Pharmacology and Therapeutics, School of Biomedical Sciences, University of Liverpool, Liverpool, UK
| | - Christoph Wyen
- Department of Internal Medicine, University of Cologne, Germany
| | - Tabitha Mahungu
- Department of Pharmacology and Therapeutics, School of Biomedical Sciences, University of Liverpool, Liverpool, UK
- Department of HIV Medicine, Royal Free NHS Trust, London, UK
| | - Heidy Hendra
- Department of Internal Medicine, University of Cologne, Germany
| | - Deirdre Egan
- Department of Pharmacology and Therapeutics, School of Biomedical Sciences, University of Liverpool, Liverpool, UK
| | - Marco Siccardi
- Department of Pharmacology and Therapeutics, School of Biomedical Sciences, University of Liverpool, Liverpool, UK
- Department of Infectious Diseases, University of Turin, Amedeo di Savoia Hospital, Turin, Italy
| | - Gerry Davies
- Department of Pharmacology and Therapeutics, School of Biomedical Sciences, University of Liverpool, Liverpool, UK
| | - Saye Khoo
- Department of Pharmacology and Therapeutics, School of Biomedical Sciences, University of Liverpool, Liverpool, UK
| | | | - Michael Youle
- Department of HIV Medicine, Royal Free NHS Trust, London, UK
| | - Jürgen Rockstroh
- Department of Internal Medicine, University of Bonn, Bonn, Germany
| | - Norbert H. Brockmeyer
- Department of Dermatology, Venerology and Allergology Ruhr-Universität Bochum, Bochum, Germany
| | | | - Andrew Owen
- Department of Pharmacology and Therapeutics, School of Biomedical Sciences, University of Liverpool, Liverpool, UK
| | - David J. Back
- Department of Pharmacology and Therapeutics, School of Biomedical Sciences, University of Liverpool, Liverpool, UK
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Díaz-Delfín J, del Mar Gutiérrez M, Gallego-Escuredo JM, Domingo JC, Gracia Mateo M, Villarroya F, Domingo P, Giralt M. Effects of nevirapine and efavirenz on human adipocyte differentiation, gene expression, and release of adipokines and cytokines. Antiviral Res 2011; 91:112-9. [PMID: 21619898 DOI: 10.1016/j.antiviral.2011.04.018] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Revised: 02/10/2011] [Accepted: 04/19/2011] [Indexed: 12/25/2022]
Abstract
The non-nucleoside reverse transcriptase inhibitors (NNRTIs) nevirapine and efavirenz are drugs of choice for initial antiretroviral treatment for HIV-1 infection. Although NNRTIs have not traditionally been associated with the appearance of adipose alterations, recent data suggest that efavirenz may contribute to adipose tissue alterations in antiretroviral-treated patients, consistent with its ability to impair differentiation of adipocytes in cell cultures. No such effects have been reported for nevirapine, the other most commonly used NNRTI. In this study, we determined the effects of nevirapine on differentiation, gene expression and release of regulatory proteins (adipokines and cytokines) in differentiating human adipocytes, and compared them with those of efavirenz. Efavirenz caused a dose-dependent repression of adipocyte differentiation that was associated with down-regulation of the master adipogenesis regulator genes SREBP-1, PPARγ and C/EBPα, and their target genes encoding lipoprotein lipase, leptin and adiponectin, which are key proteins in adipocyte function. In contrast, nevirapine does not affect adipogenesis and causes a modest but significant coordinate increase in the expression of SREBP-1, PPARγ and C/EBPα and their target genes only at a concentration of 20 μM. Whereas efavirenz caused a significant increase in the release of pro-inflammatory cytokines (interleukin [IL]-8, IL-6, monocyte chemoattractant protein-1), plasminogen activator inhibitor type-1 and hepatocyte growth factor (HGF), nevirapine either had no effect on these factors or decreased their release (IL-6 and HGF). Nevirapine significantly increased adiponectin release, whereas efavirenz strongly repressed it. Moreover, nevirapine inhibited preadipocyte endogenous reverse transcriptase activity, whereas efavirenz did not alter it. It is concluded that, in contrast with the profound anti-adipogenic and pro-inflammatory response elicited by efavirenz, nevirapine does not impair adipogenesis.
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Affiliation(s)
- Julieta Díaz-Delfín
- Department of Biochemistry and Molecular Biology and Institut de Biomedicina (IBUB), University of Barcelona and CIBER Fisiopatología de la Obesidad y Nutrición, Spain
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Mbuagbaw LC, Irlam JH, Spaulding A, Rutherford GW, Siegfried N. Efavirenz or nevirapine in three-drug combination therapy with two nucleoside-reverse transcriptase inhibitors for initial treatment of HIV infection in antiretroviral-naïve individuals. Cochrane Database Syst Rev 2010:CD004246. [PMID: 21154355 DOI: 10.1002/14651858.cd004246.pub3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The advent of highly active antiretroviral therapy (HAART) has reduced the morbidity and mortality due to HIV. The World Health Organisation (WHO) antiretroviral treatment (ART) guidelines focus on three classes of antiretroviral drugs, namely: nucleoside/nucleotide reverse transcriptase inhibitors (NRTI), non-nucleoside reverse transcriptase inhibitors (NNRTI) and protease inhibitors (PI). Two of the most common medications given in first-line treatment are the NNRTIs, efavirenz (EFV) and nevirapine (NVP). It is unclear which NNRTI is more efficacious for initial therapy. OBJECTIVES To determine which NNRTI, EFV or NVP, is more efficacious when given in combination with two NRTIs as part of initial ART for HIV infection in adults and children. SEARCH STRATEGY We used a comprehensive and exhaustive strategy in an attempt to identify all relevant studies, regardless of language or publication status, in electronic databases and conference proceedings from 1996 to 2009. SELECTION CRITERIA All randomised controlled trials comparing EFV to NVP in HIV-infected individuals without prior exposure to ART, irrespective of the dosage or NRTI backbone.The primary outcome of interest was virologic response to ART. Other primary outcomes included mortality, clinical progression, severe adverse events, and discontinuation of therapy for any reason. Secondary outcomes were immunologic response to ART, treatment failure, development of ART drug resistance, and prevention of sexual transmission of HIV. DATA COLLECTION AND ANALYSIS Two authors assessed each reference for inclusion and exclusion criteria established a priori. Data were abstracted independently using a standardised abstraction form. Data were analysed on an intention-to-treat basis and reported as per dosage of NVP. MAIN RESULTS We identified seven randomised controlled trials that met our inclusion criteria.The trials were pooled as per dosage of NVP. None of these trials included children.The seven trials enrolled 1,688 participants and found no critical differences between EFV and NVP, except for different toxicity profiles. EFV is more likely to cause central nervous system side-effects, while NVP is more likely to result in raised transaminases and neutropoenia. There was a higher mortality rate in the NVP 400mg once daily arm.The quality of literature to support these conclusions is moderate to high. Drug resistance was slightly less common with EFV than NVP, but the quality of this literature is low since only one of the seven studies reported on this outcome. No studies reported on sexual transmission of HIV. The length of follow-up time, study settings, and NRTI backbone varied greatly. AUTHORS' CONCLUSIONS Both drugs have equivalent efficacies in initial treatment of HIV infection when combined with two NRTIs, but different side effects.
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Population pharmacokinetics of nevirapine in HIV-1-infected pregnant women and their neonates. Antimicrob Agents Chemother 2010; 55:331-7. [PMID: 20956588 DOI: 10.1128/aac.00631-10] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The aim of the present study was to describe the nevirapine (NVP) pharmacokinetics (PK) in pregnant women and their neonates and to evaluate the transplacental drug transfer and administration scheme for the prevention of mother-to-child transmission. Thirty-eight HIV-1-infected pregnant women were administered one tablet of NVP (200 mg) and two tablets of tenofovir-emtricitabine (Truvada) at the initiation of labor. Children were given NVP syrup (2 mg/kg of body weight) as a single dose (sdNVP) on the first day of life. By pair, NVP concentrations were measured in 11 maternal, 1 cord blood, and 2 neonatal plasma samples and analyzed by a population approach. A one-compartment model was used for mothers and neonates; the absorption rate constants for mothers and neonates were 0.95 h(-1) (intersubject variability, 111%) and 0.39 h(-1), respectively; the apparent elimination clearances were 1.42 liter·h(-1) (intersubject variability, 22%) and 0.035 liter·h(-1), respectively; and apparent volumes of distribution were 87.3 liters (intersubject variability, 25%) and 5.65 liters, respectively. An effect compartment was linked to maternal circulation by mother-to-cord and cord-to-mother rate constants of 1.10 h(-1) and 1.43 h(-1), respectively. Placental transfer, expressed as the fetal-to-maternal area under the curve ratio, was 75%. Neonates had a very long half-lives (110 h) compared to adults. In the 38 mothers, the simulated median individual predicted time during which the NVP concentration remained above the half-maximal inhibitory concentration (IC(50)) was 13.2 days (range, 12 to 19.2 days). Thus, the administration of tenofovir-emtricitabine for at least 3 weeks after delivery should be considered to prevent the emergence of resistant viruses. The neonate must receive sdNVP immediately after birth when the infant is born less than 30 min after maternal drug intake to keep NVP concentrations above the IC(50).
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Reliquet V, Allavena C, Morineau-Le Houssine P, Mounoury O, Raffi F. Twelve-year experience of nevirapine use: benefits and convenience for long-term management in a French cohort of HIV-1-infected patients. HIV CLINICAL TRIALS 2010; 11:110-7. [PMID: 20542847 DOI: 10.1310/hct1102-110] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To describe safety and long-term efficacy of nevirapine (NVP) in a real-life setting. RESULTS From 1996 to 2008, among the 745 patients who received NVP, 592 were still followed in our center; of these, 231 had stopped NVP because of failure (42%), side effects (28%), other causes (30%). Twenty-seven percent of discontinuations occurred in the first 3 months; 68% were related to adverse events. In June 2008, 361/592 patients (61%) were still on NVP for a median duration of 176 weeks (range, 0.3-600), including 18% of naïve patients, 15% of patients who initiated NVP in the context of virologic failure, and 66% of patients with an undetectable viral load (switch strategy). Median CD4 cell count increased from 377/microL (range, 8-1449) to 549/microL (range, 144-1621). Viral load was below 200 copies/mL at the latest visit in 97%, 96%, and 100% of the patients in the naïve, failure, and switch groups, respectively. Over a 5-year period, the rate of antiretroviral drug persistence was 60.9% for NVP, 41.4% for efavirenz, and 23% for lopinavir/ritonavir (P < .0001). CONCLUSIONS In a real-life setting, NVP demonstrates sustained efficacy and good safety and is very convenient to use as reflected by a high rate of persistency.
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Chimsuntorn S, Sungkanuparph S, Manosuthi W. Successful viral suppression with subsequent efavirenz-based regimen in HIV-1-infected patients who stop nevirapine prior to discontinuation of the NRTI backbone. ACTA ACUST UNITED AC 2010; 9:43-5. [PMID: 20071597 DOI: 10.1177/1545109709355827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To study antiviral response of efavirenz (EFV)-based antiretroviral therapy (ART) in HIV-1-infected patients who had previously discontinued nevirapine (NVP) and continued the nucleoside reverse transcriptase inhibitor (NRTI) backbone for 7 to 14 days after stopping NVP. METHODS A retrospective cohort study was conducted in patients who discontinued NVP. CD4 count and plasma HIV-1 RNA levels were monitored through 48 weeks of EFV-based regimen. RESULTS Forty-five patients were eligible with a mean +/- SD age of 37 +/- 11 years; 60% were males. Median (interquartile range [IQR]) baseline CD4 count was 43 (19-150) cells/mm³ and median (IQR) plasma HIV-1 RNA was 5.7 (5.3-5.9) log copies/mL. Median (IQR) duration from stopping NVP to initiating EFV was 13 (7-18) days. At 48 week, 33 (73.3%) of 45 patients achieved plasma HIV-1 RNA <50 copies/mL. At week 12, 24, and 48, median CD4 counts were 193, 238, and 268 cells/mm³, respectively (P < .05). No studied risk factor was associated with achieving HIV-1 RNA <50 copies/mL at 48 weeks (P > .05). CONCLUSION The strategy of extended short half-life NRTIs in the regimen after discontinuation of NVP is justified.
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Affiliation(s)
- Sukanya Chimsuntorn
- Bamrasnaradura Infectious Diseases Institute, Ministry of Public Health, Tiwanon Road, Nonthaburi, Thailand
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Atkinson MJ, Petrozzino JJ. An evidence-based review of treatment-related determinants of patients' nonadherence to HIV medications. AIDS Patient Care STDS 2009; 23:903-14. [PMID: 19642921 DOI: 10.1089/apc.2009.0024] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Patients' adherence to antiretroviral medications is a primary determinant of both the effectiveness of treatment and the clinical course of HIV/AIDS. This empirical review is intended to compare the relative importance of patient and treatment characteristics on nonadherence behavior and the impact of nonadherence on treatment failure. Articles cited in PubMed and published between 2006 and June 2008 (n = 200) were reviewed to select those that address patient or treatment characteristics associated with nonadherence. Twenty-two articles were selected that provided odds ratio or hazard ratio statistics that quantified predictors of patients' level of nonadherence (e.g., <80%, 80%-95% and >95%). Results were summarized using random effects meta-analytic models. Predictors of nonadherence were divided into four predictive clusters (clinical predictors, comorbid predictors, treatment competence predictors, and dosing predictors). The summary odds ratios (ORs) of nonadherence for each cluster (in order of strength) were treatment competence 2.0 (95% confidence interval [CI]: 1.6-2.6), clinical predictors 1.6 (95% CI: 1.4-1.8), comorbid predictors 1.6 (95% CI: 1.4-1.8), and dosing predictors 1.5 (95% CI: 1.3-1.7). The effect of nonadherence on treatment failure supported the findings of two prior empirical reviews (OR 2.0, 95% CI: 1.6-2.5). Within dosing predictors, a pill burden of more versus less than 10 pills per day was associated with a much higher odds of nonadherence than twice versus once daily dosing or small differences in the number of types of antiretroviral treatments in a regimen. These results provide insight into the relative importance of various determinants of patient nonadherence that may inform the design of patient educational initiatives and initiatives to simplify treatment regimens.
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Affiliation(s)
- Mark J. Atkinson
- PRO-Spectus LLC, San Diego, California
- Health Services Research Center, University of California at San Diego, San Diego, California
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Safety of Switching Nevirapine Twice Daily to Nevirapine Once Daily in Virologically Suppressed Patients. J Acquir Immune Defic Syndr 2009; 50:390-6. [PMID: 19214120 DOI: 10.1097/qai.0b013e318198a0cc] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The strategy of switching nevirapine (NVP) twice daily to once daily was evaluated. METHODS Forty-eight-week randomized, open, multicenter trial. Stable HIV-infected patients on NVP twice daily for >12-18 weeks with alanine aminotransferase (ALT) <2.5, the upper normal limit were randomized to continue their regimen or switch to NVP 400 mg once daily. Primary end point was the proportion of ALT/aspartate transaminase (AST) > or =grade 3. RESULTS Two hundred eighty-nine patients were included, mean CD4 620 cells per microliter. Noninferiority was demonstrated in the per protocol analysis, with 97.9% (once daily) and 99.3% (twice daily) of patients event free (difference, 1.4%; 95% confidence interval, -1.95% to 5.4%), whereas 81.8% vs. 93.8% were event free by intent-to-treat switch = toxicity analysis (difference, 12%; 95% confidence interval, 4.6% to 19.4%). Only 4 patients (3 once daily, 1 twice daily) had NVP-related grade 3/4 ALT/AST increases, but in 2 of them (once daily), transaminases decreased despite continuation with NVP. Two other once daily patients presented grade 3/4 ALT/AST increase due to well-documented acute hepatitis A virus or hepatitis C virus infection. Grade 2 ALT/AST increases occurred in 11.2% (once daily) vs. 10.3% (twice daily) of patients (P = 0.80). A larger number of once daily patients were lost to follow-up/violated protocol (15% vs. 5%). CONCLUSIONS In patients on standard twice daily NVP-containing regimens for at least 12-18 weeks, per protocol analysis showed that switching to once daily NVP was not inferior to continued twice daily NVP in terms of the predefined noninferiority margin of 10% for hepatotoxicity.
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Calmy A, Vallier N, Nguyen A, Lange JMA, Battegay M, de Wolf F, Reiss P, Lima VD, Hirschel B, Hogg RS, Yip B, Montaner JSG, Wit FW. Safety and efficacy of once-daily nevirapine dosing: a multicohort study. Antivir Ther 2009; 14:931-8. [DOI: 10.3851/imp1418] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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