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Wiesner A, Skrońska M, Gawlik G, Marcinkowska M, Zagrodzki P, Paśko P. Interactions of Antiretroviral Drugs with Food, Beverages, Dietary Supplements, and Alcohol: A Systematic Review and Meta-analyses. AIDS Behav 2022; 27:1441-1468. [PMID: 36318429 PMCID: PMC10129904 DOI: 10.1007/s10461-022-03880-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2022] [Indexed: 04/28/2023]
Abstract
Multiple factors may affect combined antiretroviral therapy (cART). We investigated the impact of food, beverages, dietary supplements, and alcohol on the pharmacokinetic and pharmacodynamic parameters of 33 antiretroviral drugs. Systematic review in adherence to PRISMA guidelines was performed, with 109 reports of 120 studies included. For each drug, meta-analyses or qualitative analyses were conducted. We have found clinically significant interactions with food for more than half of antiretroviral agents. The following drugs should be taken with or immediately after the meal: tenofovir disoproxil, etravirine, rilpivirine, dolutegravir, elvitegravir, atazanavir, darunavir, lopinavir, nelfinavir, ritonavir, saquinavir. Didanosine, zalcitabine, zidovudine, efavirenz, amprenavir, fosamprenavir, and indinavir should be taken on an empty stomach for maximum patient benefit. Antiretroviral agents not mentioned above can be administered regardless of food. There is insufficient evidence available to make recommendations about consuming juice or alcohol with antiretroviral drugs. Resolving drug-food interactions may contribute to maximized cART effectiveness and safety.
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Affiliation(s)
- Agnieszka Wiesner
- Department of Food Chemistry and Nutrition, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna Str., 30-688, Kraków, Poland
| | - Magdalena Skrońska
- Department of Food Chemistry and Nutrition, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna Str., 30-688, Kraków, Poland
| | - Gabriela Gawlik
- Department of Community and Public Health, Idaho State University, 1311 E Central Dr, Meridian, ID, 83642, USA
| | - Monika Marcinkowska
- Department of Medicinal Chemistry, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna Str., 30-688, Kraków, Poland
| | - Paweł Zagrodzki
- Department of Food Chemistry and Nutrition, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna Str., 30-688, Kraków, Poland
| | - Paweł Paśko
- Department of Food Chemistry and Nutrition, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna Str., 30-688, Kraków, Poland.
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Lenis TL, Botsford BW, Sarraf D, Papakostas TD. Didanosine-Associated Retinal Toxicity in a Patient With a Mutation in the CRB1 Gene. JOURNAL OF VITREORETINAL DISEASES 2022; 6:329-331. [PMID: 37007923 PMCID: PMC9976027 DOI: 10.1177/24741264211044599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: This article describes a case of didanosine (DDI)-associated retinal toxicity in a patient with a heterozygous pathogenic variant in the CRB1 gene. Methods: Case report. Results: A middle-aged patient with HIV controlled on HAART therapy, and a remote 10-year year history of treatment with DDI and tenofivir, presented with external ophthalmoplegia and well-circumscribed, midperipheral patterns of bilateral pigmentary retinopathy and chorioretinal atrophy in both eyes. Genetic testing revealed a heterozygous pathogenic variant in the CRB1 gene that encodes a protein (Crumbs homolog 1) involved in regulation of cell polarity and junctions and is localized adjacent to mitochondria in the ellipsoid and myoid area. Conclusions: This case highlights a potential role for genetic susceptibility to retinal toxicity in DDI-associated retinal toxicity. Large, prospective pharmacogenomics studies may be informative to further elucidate the role of genetic risk factors in drug-induced retinal toxicity.
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Affiliation(s)
- Tamara L. Lenis
- Retina Service, Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
| | - Benjamin W. Botsford
- Retina Service, Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
| | - David Sarraf
- Retinal Disorders and Ophthalmic Genetics Division, Stein Eye Institute, UCLA, Los Angeles, CA, USA
| | - Thanos D. Papakostas
- Retina Service, Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
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Ashok Bhairav B, Jayram Chavan M. Method Development and Validation for Estimation of TinofovirDisproxil Fumarate in Pharmaceutical Preparation by UV-Spectroscopy and HPLC With Force Degradation Study. ASIAN JOURNAL OF PHARMACEUTICAL RESEARCH AND HEALTH CARE 2021. [DOI: 10.18311/ajprhc/2021/26050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Anderson MS, Gilmartin J, Fan L, Yee KL, Kraft WK, Triantafyllou I, Reitmann C, Guo Y, Liu R, Iwamoto M. No meaningful drug interactions with doravirine, lamivudine and tenofovir disoproxil fumarate coadministration. Antivir Ther 2020; 24:443-450. [PMID: 31433304 DOI: 10.3851/imp3324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Doravirine (DOR) is a novel non-nucleoside reverse transcriptase inhibitor available as a single tablet and a three-drug combination with lamivudine (3TC) and tenofovir disoproxil fumarate (TDF) to treat HIV-1 infection. These analyses assessed pharmacokinetic (PK) interactions with coadministration. METHODS Two trials were conducted. Study 1: two-period, fixed-sequence; eight healthy participants; Period 1, DOR 100 mg followed by ≥7-day washout; Period 2, TDF 300 mg once daily for 18 days, coadministration of DOR 100 mg on day 14. Study 2: three-period, crossover, 15 healthy participants; Treatment A, DOR 100 mg; Treatment B, 3TC 300 mg + TDF 300 mg; Treatment C, DOR 100 mg + 3TC 300 mg + TDF 300 mg; ≥7-day washout between periods. RESULTS Study 1: geometric mean ratios (GMRs; 90% confidence interval [CI]) of DOR area under the concentration-time curve from time 0 extrapolated to infinity (AUC0-∞) and observed plasma concentrations at 24 h post-dose (C24 h; DOR+TDF/DOR) were 0.95 (0.80, 1.12) and 0.94 (0.78, 1.12), respectively. Study 2: GMRs (90% CI) of DOR AUC0-∞ and C24 h (DOR+3TC+TDF/DOR) were 0.96 (0.87, 1.06) and 0.94 (0.83, 1.06), respectively. GMRs (90% CI) of 3TC and tenofovir AUC0-∞ (DOR+3TC+TDF/3TC+TDF) were 0.94 (0.88, 1.00) and 1.11 (0.97, 1.28), respectively. Study drugs were generally well tolerated. CONCLUSIONS Multiple doses of TDF did not have a clinically meaningful effect on DOR PK. The PK of DOR were similar when administered alone or in combination with 3TC and TDF. DOR had no meaningful effect on the PK of 3TC and tenofovir.
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Affiliation(s)
- Matt S Anderson
- Merck & Co., Inc., Kenilworth, NJ, USA.,Present address: Certara USA, Inc., Princeton, NJ, USA
| | | | - Li Fan
- Merck & Co., Inc., Kenilworth, NJ, USA
| | | | | | | | | | - Ying Guo
- Merck & Co., Inc., Kenilworth, NJ, USA
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Corradetti G, Violanti S, Au A, Sarraf D. Wide field retinal imaging and the detection of drug associated retinal toxicity. Int J Retina Vitreous 2020; 5:26. [PMID: 31890286 PMCID: PMC6907121 DOI: 10.1186/s40942-019-0172-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background To describe the peripheral retinal findings associated with systemic medication toxicity and to outline the importance of ultra-widefield imaging in the detection, analysis and monitoring of these abnormalities. Main text This review highlights the retinal manifestations associated with the more common drug toxicities, with emphasis on the peripheral features and the indications for wide field imaging. The presenting findings, underlying pathophysiology, and retinal alterations in hydroxychloroquine, thioridazine, didanosine, tamoxifen, MEK-inhibitor, and immune checkpoint inhibitor associated drug toxicity will be described and the importance of wide field imaging in the evaluation of these abnormalities will be emphasized. Conclusions Wide field retinal imaging can improve the detection of peripheral retinal abnormalities associated with drug toxicity and may be an important tool in the diagnosis and management of these disorders.
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Affiliation(s)
- Giulia Corradetti
- 1Retina Disorders and Ophthalmic Genetics, Stein Eye Institute, University of California, Los Angeles, 100 Stein Plaza, Los Angeles, CA 90095 USA
| | - Sara Violanti
- 1Retina Disorders and Ophthalmic Genetics, Stein Eye Institute, University of California, Los Angeles, 100 Stein Plaza, Los Angeles, CA 90095 USA
| | - Adrian Au
- 1Retina Disorders and Ophthalmic Genetics, Stein Eye Institute, University of California, Los Angeles, 100 Stein Plaza, Los Angeles, CA 90095 USA
| | - David Sarraf
- 1Retina Disorders and Ophthalmic Genetics, Stein Eye Institute, University of California, Los Angeles, 100 Stein Plaza, Los Angeles, CA 90095 USA.,Greater Los Angeles VA Healthcare Center, Los Angeles, CA USA
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Hashimoto M, Taguchi K, Ishiguro T, Kohgo S, Imoto S, Yamasaki K, Mitsuya H, Otagiri M. Pharmacokinetic properties of a novel inosine analog, 4'-cyano-2'-deoxyinosine, after oral administration in rats. PLoS One 2018; 13:e0198636. [PMID: 29874291 PMCID: PMC5991393 DOI: 10.1371/journal.pone.0198636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/22/2018] [Indexed: 12/22/2022] Open
Abstract
4′-cyano-2′-deoxyinosine (SK14-061a), a novel nucleoside analog based on inosine, has antiviral activity against the human immunodeficiency virus type 1 that has the ability to acquire resistance against many types of reverse transcriptase inhibitors based on nucleosides. The aim of this study was to investigate the pharmacokinetics studies after its oral administration to rats. For this purpose, we first developed and validated an analytical method for quantitatively determining SK14-061a levels in biological samples by a UPLC system interfaced with a TOF-MS system. A rapid, simple and selective method for the quantification of SK14-061a in biological samples was established using liquid chromatography mass spectrometry (LC-MS) with solid phase extraction. The pharmacokinetic properties of SK14-061a in rats after oral administration were then evaluated using this LC-MS method. SK14-061a was found to be relatively highly bioavailable, is rapidly absorbed from the intestinal tract, and is then mainly distributed to the liver and then ultimately excreted via the urine in an unchanged form. Furthermore, the simultaneous administration of SK14-061a with the nucleoside analog, entecavir, led to a significant alteration in the pharmacokinetics of SK14-061a. These results suggest that the SK14-061a has favorable pharmacokinetic properties with a high bioavailability with the potential for use in oral pharmaceutical formulations, but drug-drug interactions should also be considered.
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Affiliation(s)
- Mai Hashimoto
- Faculty of Pharmaceutical Sciences, Sojo University, Ikeda, Kumamoto, Japan
| | - Kazuaki Taguchi
- Faculty of Pharmaceutical Sciences, Sojo University, Ikeda, Kumamoto, Japan
| | - Takako Ishiguro
- Faculty of Pharmaceutical Sciences, Sojo University, Ikeda, Kumamoto, Japan
| | - Satoru Kohgo
- Center for Clinical Sciences, National Center for Global Health and Medicine, Toyama, Shinjuku, Tokyo, Japan
| | - Shuhei Imoto
- Faculty of Pharmaceutical Sciences, Sojo University, Ikeda, Kumamoto, Japan
| | - Keishi Yamasaki
- Faculty of Pharmaceutical Sciences, Sojo University, Ikeda, Kumamoto, Japan.,DDS Research Institutes, Sojo University, Ikeda, Kumamoto, Japan
| | - Hiroaki Mitsuya
- Center for Clinical Sciences, National Center for Global Health and Medicine, Toyama, Shinjuku, Tokyo, Japan.,Department of Infectious Diseases and Hematology, Kumamoto University, School of Medicine, Kumamoto, Japan.,Experimental Retrovirology Section, HIV and AIDS Malignancy Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Masaki Otagiri
- Faculty of Pharmaceutical Sciences, Sojo University, Ikeda, Kumamoto, Japan.,DDS Research Institutes, Sojo University, Ikeda, Kumamoto, Japan
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Abstract
Transporters in proximal renal tubules contribute to the disposition of numerous drugs. Furthermore, the molecular mechanisms of tubular secretion have been progressively elucidated during the past decades. Organic anions tend to be secreted by the transport proteins OAT1, OAT3 and OATP4C1 on the basolateral side of tubular cells, and multidrug resistance protein (MRP) 2, MRP4, OATP1A2 and breast cancer resistance protein (BCRP) on the apical side. Organic cations are secreted by organic cation transporter (OCT) 2 on the basolateral side, and multidrug and toxic compound extrusion (MATE) proteins MATE1, MATE2/2-K, P-glycoprotein, organic cation and carnitine transporter (OCTN) 1 and OCTN2 on the apical side. Significant drug-drug interactions (DDIs) may affect any of these transporters, altering the clearance and, consequently, the efficacy and/or toxicity of substrate drugs. Interactions at the level of basolateral transporters typically decrease the clearance of the victim drug, causing higher systemic exposure. Interactions at the apical level can also lower drug clearance, but may be associated with higher renal toxicity, due to intracellular accumulation. Whereas the importance of glomerular filtration in drug disposition is largely appreciated among clinicians, DDIs involving renal transporters are less well recognized. This review summarizes current knowledge on the roles, quantitative importance and clinical relevance of these transporters in drug therapy. It proposes an approach based on substrate-inhibitor associations for predicting potential tubular-based DDIs and preventing their adverse consequences. We provide a comprehensive list of known drug interactions with renally-expressed transporters. While many of these interactions have limited clinical consequences, some involving high-risk drugs (e.g. methotrexate) definitely deserve the attention of prescribers.
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Affiliation(s)
- Anton Ivanyuk
- Division of Clinical Pharmacology, Lausanne University Hospital (CHUV), Bugnon 17, 1011, Lausanne, Switzerland.
| | - Françoise Livio
- Division of Clinical Pharmacology, Lausanne University Hospital (CHUV), Bugnon 17, 1011, Lausanne, Switzerland
| | - Jérôme Biollaz
- Division of Clinical Pharmacology, Lausanne University Hospital (CHUV), Bugnon 17, 1011, Lausanne, Switzerland
| | - Thierry Buclin
- Division of Clinical Pharmacology, Lausanne University Hospital (CHUV), Bugnon 17, 1011, Lausanne, Switzerland
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Billat PA, Saint-Marcoux F. Liquid chromatography–mass spectrometry methods for the intracellular determination of drugs and their metabolites: a focus on antiviral drugs. Anal Bioanal Chem 2017; 409:5837-5853. [DOI: 10.1007/s00216-017-0449-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 05/24/2017] [Accepted: 06/01/2017] [Indexed: 01/11/2023]
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Abstract
PURPOSE To report nine new cases of retinal degeneration secondary to didanosine toxicity and to summarize the previously reported cases in the literature. METHODS This was a multicenter, retrospective, observational case study from seven institutions. Medical records of patients who demonstrated well-demarcated severe midperipheral chorioretinal degeneration and who were previously treated with didanosine therapy were collected and the following information was reviewed: age, gender, medical history, detailed medication history including current and previous antiretroviral use, ocular and retinal examination findings, and multimodal imaging findings with optical coherence tomography, fundus photography, wide-field fundus autofluorescence, and wide-field fluorescein angiography. When available, findings with electrophysiology testing and automated perimetry were also collected and reviewed. A literature review was also performed to collect all reported cases of chorioretinal degeneration secondary to didanosine toxicity. RESULTS Nine patients were identified who had findings consistent with peripheral retinal toxicity secondary to didanosine use. Eight of the 9 patients were men, and the median age was 54 years at the time of presentation (mean: 55 years, range, 42-71 years). Snellen distance acuity ranged from 20/20 to 20/32. At least three of the cases in the series demonstrated progression of the peripheral retinal pigment epithelium and photoreceptor atrophy despite didanosine cessation. A review of the literature revealed 10 additional cases of didanosine toxicity. Seven of the 10 cases were in men (70%), and the average age was 26 years with a wide range (2-54 years). Chorioretinal findings were very similar to this cohort. CONCLUSION Herein, we report the largest series of nine cases of peripheral chorioretinal degeneration secondary to didanosine toxicity in adults. When combined with the cases in the literature, 19 cases of didanosine toxicity, 4 of which occurred in children, were collected and analyzed. Three of the new cases presented showed clear progression of degeneration despite didanosine cessation. Newer nucleoside reverse transcriptase inhibitors may potentiate mitochondrial DNA damage and lead to continued chorioretinal degeneration.
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Kovari H, Sabin CA, Ledergerber B, Ryom L, Reiss P, Law M, Pradier C, Dabis F, d'Arminio Monforte A, Smith C, de Wit S, Kirk O, Lundgren JD, Weber R. Antiretroviral Drugs and Risk of Chronic Alanine Aminotransferase Elevation in Human Immunodeficiency Virus (HIV)-Monoinfected Persons: The Data Collection on Adverse Events of Anti-HIV Drugs Study. Open Forum Infect Dis 2016; 3:ofw009. [PMID: 26925429 PMCID: PMC4767274 DOI: 10.1093/ofid/ofw009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 01/11/2016] [Indexed: 12/13/2022] Open
Abstract
Background. Although human immunodeficiency virus (HIV)-positive persons on antiretroviral therapy (ART) frequently have chronic liver enzyme elevation (cLEE), the underlying cause is often unclear. Methods. Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) Study participants without chronic viral hepatitis were observed to the earliest of cLEE (elevated aminotransferase ≥6 months), death, last follow-up, or January 2, 2014. Antiretroviral treatment exposure was categorized as follows: no exposure and ongoing short- and long-term exposure (<2 or ≥2 years) after initiation. Association between development of cLEE and ART exposure was investigated using Poisson regression. Results. Among 21 485 participants observed for 105 413 person-years (PY), 6368 developed cLEE (incidence 6.04/100 PY; 95% confidence interval [CI], 5.89–6.19). Chronic liver enzyme elevation was associated with short-and long-term exposure to didanosine (<2 years rate ratio [RR] = 1.29, 95% CI, 1.11–1.49; >2 years RR = 1.26, 95% CI, 1.13–1.41); stavudine (<2 years RR = 1.51, 95% CI, 1.26–1.81; >2 years RR = 1.17, 95% CI, 1.03–1.32), and tenofovir disoproxil fumarate (<2 years RR = 1.55, 95% CI, 1.40–1.72; >2 years RR = 1.18, 95% CI, 1.05–1.32), but only short-term exposure to nevirapine (<2 years RR = 1.44, 95% CI, 1.29–1.61), efavirenz (<2 years RR = 1.14, 95% CI, 1.03–1.26), emtricitabine (<2 years RR = 1.18, 95% CI, 1.04–1.33), and atazanavir (<2 years RR = 1.20, 95% CI, 1.04–1.38). Chronic liver enzyme elevation was not associated with use of lamivudine, abacavir, and other protease inhibitors. Mortality did not differ between participants with and without cLEE. Conclusions. Although didanosine, stavudine, nevirapine, and efavirenz have been described to be hepatotoxic, we additionally observed a consistent association between tenofovir and cLEE emerging within the first 2 years after drug initiation. This novel tenofovir-cLEE signal should be further investigated.
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Affiliation(s)
- Helen Kovari
- Division of Infectious Diseases and Hospital Epidemiology , University Hospital Zurich , Switzerland
| | - Caroline A Sabin
- Research Department of Infection and Population Health , University College London , United Kingdom
| | - Bruno Ledergerber
- Division of Infectious Diseases and Hospital Epidemiology , University Hospital Zurich , Switzerland
| | - Lene Ryom
- CHIP, Department of Infectious Diseases , Rigshospitalet, University of Copenhagen , København , Denmark
| | - Peter Reiss
- Division of Infectious Diseases and Department of Global Health , Academic Medical Center, University of Amsterdam , Netherlands
| | - Matthew Law
- The Kirby Institute for Infection and Immunity in Society , University of New South Wales , Sydney , Australia
| | | | - Francois Dabis
- Université Bordeaux, ISPED, Centre INSERM U897-Epidémiologie-Biostatistique France
| | | | - Colette Smith
- Research Department of Infection and Population Health , University College London , United Kingdom
| | - Stephane de Wit
- Department of Infectious Diseases , St. Pierre University Hospital , Brussels , Belgium
| | - Ole Kirk
- CHIP, Department of Infectious Diseases , Rigshospitalet, University of Copenhagen , København , Denmark
| | - Jens D Lundgren
- CHIP, Department of Infectious Diseases , Rigshospitalet, University of Copenhagen , København , Denmark
| | - Rainer Weber
- Division of Infectious Diseases and Hospital Epidemiology , University Hospital Zurich , Switzerland
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Abstract
Tenofovir disoproxil fumarate (TDF) is approved by the Food and Drug Administration for use in children ages 2 years and older and is recommended by the World Health Organization for use as a preferred first-line nucleotide reverse transcriptase inhibitor in adults and adolescents ages 10 years and older. The simplicity of once daily dosing, few metabolic side effects and efficacy against hepatitis B virus make TDF suitable for use in a large scale program. Unlike thymidine analoge nucleoside reverse transcriptase inhibitors (NRTIs); tenofovir does not induce multi-NRTI resistance mutations, so more NRTI options are available for future second-line-regimens. Fixed-dose combinations of TDF with other ARVs as a single tablet regimen are now widely available for adults and adolescents, but none are available for young children. Current information on TDF including the pharmacokinetics, safety and tolerability in children and adolescents was reviewed. A dosing regimen according to body-weight-band has been established for pediatric use. Safety concerns of TDF mainly relate to its effects on renal function and bone mineral density. Regular monitoring of renal function in high-risk patients, including those on other nephrotoxic drugs, may be warranted to detect adverse renal effects. Long-term-data on renal and bone outcomes among HIV-infected children is needed. Lessons learned from clinical studies will help clinicians balance the risks and benefits of TDF and design appropriate antiretroviral regimens for children in different circumstances.
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Calza L. Renal toxicity associated with antiretroviral therapy. HIV CLINICAL TRIALS 2012; 13:189-211. [PMID: 22849961 DOI: 10.1310/hct1304-189] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Renal disease is becoming an increasingly prevalent comorbidity in patients with human immunodeficiency virus (HIV) infection. The increase in life expectancy following the introduction of highly active antiretroviral therapy (HAART) and the long-term development of metabolic complications (such as diabetes and dyslipidaemia), hypertension, and vascular diseases can contribute to the increasing frequency in the recognition of renal impairment in HIV-infected patients. Some antiretroviral agents, and particularly tenofovir, have been associated with nephrotoxic drug effects, including decline in glomerular filtration rate, proximal tubular damage, and acute kidney injury. The occurrence of clinically evident renal toxicity in patients treated with HAART seems to be very low, but glomerular or tubular subclinical dysfunction may occur more frequently. Therefore, careful clinical and laboratory monitoring for the early recognition of renal abnormalities is recommended for all subjects receiving antiretroviral treatment. In this article, the current knowledge about the nephrotoxic effects of antiretroviral agents has been reviewed, and an algorithm for screening and management of HAART-related kidney disease is proposed in the light of the most recent clinical studies and international guidelines.
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Affiliation(s)
- Leonardo Calza
- Department of Internal Medicine, Geriatrics and Nephrologic Diseases, Section of Infectious Diseases, S.Orsola-Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy.
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14
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Neely MN, Rakhmanina NY. Pharmacokinetic Optimization of Antiretroviral Therapy in Children and Adolescents. Clin Pharmacokinet 2011; 50:143-89. [DOI: 10.2165/11539260-000000000-00000] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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15
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Cotte L, Bénet T, Billioud C, Miailhes P, Scoazec JY, Ferry T, Brochier C, Boibieux A, Vanhems P, Chevallier M, Zoulim F. The role of nucleoside and nucleotide analogues in nodular regenerative hyperplasia in HIV-infected patients: a case control study. J Hepatol 2011; 54:489-96. [PMID: 21056493 DOI: 10.1016/j.jhep.2010.07.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Revised: 05/29/2010] [Accepted: 07/09/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Nodular regenerative hyperplasia (NRH) leading to non-cirrhotic portal hypertension has been described in HIV-infected patients and has been linked to didanosine. The relation between NRH and other antiretrovirals remains unclear. METHODS A case-control study was performed in 13 patients with NRH and 78 controls matched for time of inclusion, baseline CD4, and duration of follow-up. Univariate and multivariate conditional logistic regression analyses were performed. RESULTS Control patients and patients with NRH were similar at baseline regarding demographics and biological data with the exception of older age for patients with NRH (43.9 vs. 33.5 years, p=0.044). At the time of NRH diagnosis, cases had a lower CD4 count (327 vs. 468/mm(3), p=0.013), a similar CD4 percentage (24 vs. 26.2%, p=0.7), a lower platelet count (169 vs. 228 giga/L, p=0.003) and a higher AST level (33 vs. 26 IU/L, p=0.001) than controls. Univariate analysis demonstrated that patients with NRH had been exposed longer than controls to didanosine, stavudine, tenofovir, didanosine+stavudine, and didanosine+tenofovir. The age at baseline [OR 2.2 (1.0-5.0) per 10 years, p=0.053] and didanosine+stavudine cumulative exposure [OR 3.7 (1.4-10.2) per year, p=0.011] were independently associated with NRH. The age at baseline [OR 2.3 (1.0-5.3) per 10 years, p=0.045], cumulative exposure to didanosine [OR 1.4 (1.1-1.9) per year, p=0.023] and to tenofovir [OR 1.7 (1.0-2.8) per year, p=0.04] were independently associated with NRH when didanosine+stavudine exposure was excluded from the model. CONCLUSIONS NRH in HIV-infected patients seems strongly related to age and the cumulative exposure to didanosine+stavudine, didanosine, and stavudine.
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Intracellular nucleotide levels during coadministration of tenofovir disoproxil fumarate and didanosine in HIV-1-infected patients. Antimicrob Agents Chemother 2011; 55:1549-55. [PMID: 21282432 DOI: 10.1128/aac.00910-10] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Studies were conducted to determine if there is a mechanistic basis for reports of suboptimal virologic responses and concerns regarding the safety of regimens containing the combination of tenofovir (TFV) disoproxil fumarate (TDF) and didanosine (ddI) by assessing the pharmacokinetic consequences of coadministration of these drugs on intracellular nucleotides. This was a prospective and longitudinal study in HIV-1-infected patients of adding either TDF or ddI to a stable antiretroviral regimen containing the other drug. Intracellular concentrations of the nucleotide analogs TFV diphosphate (TFV-DP) and ddATP and the endogenous purine nucleotides dATP and 2'-dGTP in peripheral blood mononuclear cells were measured. A total of 16 patients were enrolled into the two study arms and a study extension. Intracellular TFV-DP concentrations (median, 120 fmol/10(6) cells) and ddATP concentrations (range, 1.50 to 7.54 fmol/10(6) cells in two patients) were unaffected following addition of ddI or TDF to a stable regimen containing the other drug. While coadministration of ddI and TDF for 4 weeks did not appear to impact dATP or dGTP concentrations, cross-sectional analysis suggested that extended therapy with ddI-containing regimens, irrespective of TDF coadministration, may decrease dATP and ddATP concentrations. Addition of TDF or ddI to a stable regimen including the other drug, in the context of ddI dose reduction, did not adversely affect the concentration of dATP, dGTP, TFV-DP, or ddATP. The association between longer-term ddI therapy and reduced intracellular nucleotide concentrations and this observation's implication for the efficacy and toxicity of ddI-containing regimens deserve further study.
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Abstract
Drug development involves learning and confirming in healthy volunteers and ultimately in patients. This approach should apply to drug-drug interactions because requirements to extrapolate pharmacokinetic and pharmacodynamic findings from healthy volunteers to patients are not uniformly met, and the designs of interaction studies often have little relevance to actual clinical use. Guidance to health-care professionals on a safe and effective dose for individual patients should include information from drug-drug interaction studies in the intended patients.
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Lack of interaction between the HIV integrase inhibitor S/GSK1349572 and tenofovir in healthy subjects. J Acquir Immune Defic Syndr 2010; 55:365-7. [PMID: 20585260 DOI: 10.1097/qai.0b013e3181e67909] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The potential for a drug interaction between S/GSK1349572 and tenofovir disoproxil fumarate (TDF) was evaluated in an open-label, repeat dose, 3-period, drug-drug interaction study in healthy subjects. METHODS S/GSK1349572 was administered at 50 mg once daily for 5 days (period 1) followed by a 6-day washout period. TDF 300 mg once daily was then administered for 7 days (period 2). The combination of S/GSK1349572 and TDF was then coadministered for 5 days (period 3). Pharmacokinetic parameters were determined and compared between periods. RESULTS Fifteen subjects completed all periods and follow-up. S/GSK1349572 and TDF were generally well tolerated with few adverse events reported. No clinically significant trends in post-dose laboratory abnormalities, vital signs, or electrocardiogram values were noted. Pharmacokinetic parameters of S/GSK1349572 and tenofovir during combination therapy were similar to those when given alone, demonstrating no significant drug interaction. S/GSK1349572 geometric least squares mean ratios (90% confidence interval) for AUC(0-τ), Cmax, and Cτ were 1.01 (0.908, 1.11), 0.969 (0.867, 1.08), and 0.920 (0.816, 1.04), respectively. Tenofovir geometric least squares mean ratios (90% confidence interval) for AUC(0-τ), Cmax, and Cτ were 1.12 (1.01, 1.24), 1.09 (0.974, 1.23), and 1.19 (1.04, 1.35), respectively. CONCLUSION S/GSK1349572 and TDF can be coadministered without dose adjustment.
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19
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Pau AK, Boyd SD. Recognition and management of significant drug interactions in HIV patients: challenges in using available data to guide therapy. Clin Pharmacol Ther 2010; 88:712-9. [PMID: 20668439 PMCID: PMC2995199 DOI: 10.1038/clpt.2010.130] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Combination antiretroviral therapy (cART) has improved survival rates in HIV-infected patients; however, patients now experience comorbidities that require pharmacological intervention, thereby increasing the risk of drug-drug interactions (DDIs). HIV protease inhibitors (PIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), and the CCR5 antagonist maraviroc are primarily metabolized via the cytochrome P450 (CYP) system and are prone to pharmacokinetic interactions.(1,2) This article addresses some key challenges that prescribers face when using available drug interaction-data resources in making day-to-day clinical decisions.
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Affiliation(s)
- A K Pau
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA.
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20
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Barnas D, Koontz D, Bazmi H, Bixby C, Jemsek J, Mellors JW. Clonal resistance analyses of HIV type-1 after failure of therapy with didanosine, lamivudine and tenofovir. Antivir Ther 2010; 15:437-41. [PMID: 20516563 DOI: 10.3851/imp1539] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The rapid failure of initial therapy with combinations of nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) that exclude zidovudine has not been fully explained by standard virus population analyses of HIV type-1 (HIV-1) drug resistance. We therefore investigated HIV-1 genotype and phenotype at the single genome level in samples from patients on a failing regimen of tenofovir (TNV), didanosine (ddI) and lamivudine (3TC). METHODS Single genome sequencing was performed on 9 failure samples containing both K65R and M184V mutations by standard genotype, either as wild-type/mutant mixtures (6/9) or as mutant only (3/9). Recombinant clones with different combinations of observed mutations were generated and tested for NRTI susceptibility. RESULTS Of the 204 single genome sequences analysed, 50% were K65R/M184V double mutants, 38% were M184V single mutants, 10% were M184I single mutants and only 1% (2 sequences) were K65R single mutants. Phenotypic testing of recombinant clones showed a significant increase in resistance for double mutants: mean fold resistance to abacavir, ddI and TNV was 6.5, 4.3 and 1.6 for K65R/M184V double mutants versus 2.5, 1.9 and 0.6 for M184V single mutants, respectively (P<0.001). CONCLUSIONS Mutants with K65R and M184V linked on the same genome were the most common HIV-1 variants in samples analysed from patients failing TNV, ddI and 3TC with both mutations detected by standard genotype. The double mutant exhibited reduced susceptibility to all three NRTIs in the regimen. This resistant phenotype, resulting from just two linked point mutations, likely contributes to rapid failure of NRTI combinations that exclude zidovudine.
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Affiliation(s)
- Douglas Barnas
- Department of Medicine, Division Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, USA
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21
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Jao J, Wyatt CM. Antiretroviral medications: adverse effects on the kidney. Adv Chronic Kidney Dis 2010; 17:72-82. [PMID: 20005491 DOI: 10.1053/j.ackd.2009.07.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Revised: 07/17/2009] [Accepted: 07/21/2009] [Indexed: 11/11/2022]
Abstract
The widespread introduction of highly active antiretroviral therapy (HAART) in the mid-1990s dramatically altered the course of human immunodeficiency virus (HIV) infection, with improvements in survival and reductions in the incidence of AIDS-defining illnesses. Although antiretroviral therapy has been shown to reduce the incidence of both AIDS-defining and non-AIDS conditions, long-term exposure to HAART may also be associated with significant toxicity. This article reviews the potential nephrotoxicity of specific antiretroviral agents and the impact of antiretroviral therapy on related metabolic disorders. The antiretroviral agents most strongly associated with direct nephrotoxicity include the nucleotide reverse transcriptase inhibitor, tenofovir, and the protease inhibitor indinavir, although other agents have been implicated less frequently. Tenofovir and related nucleotide analogs have primarily been associated with proximal tubular dysfunction and acute kidney injury, whereas indinavir is known to cause nephrolithiasis, obstructive nephropathy, and interstitial nephritis. Kidney damage related to antiretroviral therapy is typically reversible with early recognition and timely discontinuation of the offending agent, and nephrologists should be familiar with the potential toxicity of these agents to avoid delays in diagnosis.
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Abstract
PURPOSE OF REVIEW This review describes the class of nucleotide HIV reverse transcriptase inhibitors and summarises recent findings related to tenofovir and its oral prodrug tenofovir disoproxil fumarate, currently the only nucleotide approved for the treatment of HIV infection. In addition, novel strategies in the design of anti-HIV nucleotides and their prodrugs are discussed. RECENT FINDINGS A number of studies have demonstrated a potent and durable clinical efficacy of tenofovir disoproxil fumarate in combination with other antiretrovirals, particularly lamivudine or emtricitabine and efavirenz. The prophylactic antiretroviral effect of tenofovir and tenofovir disoproxil fumarate has been characterized in various animal models and is currently being evaluated in controlled clinical studies. In addition, efficacy of tenofovir disoproxil fumarate against hepatitis B virus has been established and is currently being explored in phase III trials. The identification of GS-7340, an alternative prodrug of tenofovir has raised the possibility of using phosphonoamidates as novel prodrugs allowing for an effective intracellular delivery of nucleotides. SUMMARY The concept of nucleotides as a novel class of antiretroviral therapeutics has been successfully validated through tenofovir disoproxil fumarate, a nucleotide prodrug that exhibits potent and durable clinical efficacy and favourable safety profile both in treatment-naïve and experienced HIV-infected patients. Several novel nucleotide reverse transcriptase inhibitors such as GS-9148, PMDTA, and PMEO have recently emerged from continuing preclinical drug discovery efforts.
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Costa P, Bozzano F, Fenoglio D, Beltrame A, Cenderello G, Di Biagio A, Ferrea G, Pagano G, De Maria A. Conserved T cell and natural killer cell function in treatment-experienced adults receiving tenofovir plus didanosine as nucleoside reverse transcription inhibitor backbone. Clin Exp Immunol 2009; 158:55-63. [PMID: 19737231 DOI: 10.1111/j.1365-2249.2009.03988.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Anti-retroviral treatment (ART) usually results in efficient control of virus replication and in immune reconstitution. Among potential adverse effects, impairment of immune responses in terms of CD4(+) T cell counts has been attributed to some ART regimens, as with didanosine-tenofovir. We studied the functional integrity of adaptive and innate immunity during didanosine-tenofovir-containing ART. Two groups of extensively pretreated patients completing at least 48 weeks of ART containing either lamivudine-didanosine (n = 21) or tenofovir-didanosine (n = 25) were identified. In addition to standard clinical immune and virological parameters, we performed a flow cytometric analysis of natural killer (NK) cells, of memory and naive CD4(+) T cells and of T cell receptor alphabeta(+) T cells co-expressing inhibitory NK receptors. Functional analysis consisted in specific and total interferon-gamma production by NK cells and of recall antigen proliferation of peripheral blood mononuclear cells. Comparable clinical immunological reconstitution and virological control were confirmed in the two groups of patients in the absence of clinically relevant adverse effects. The proportion of CD4(+)CD45RA(+) T cells and of functionally inhibited killer immunoglobulin-like receptor T cell receptor alphabeta(+) cells, the proliferation to recall antigens as well as NK cell phenotype and function as determined by interferon-gamma production in patients treated with tenofovir-didanosine were comparable to those treated with a different regimen. Thus, no differences in functional innate or adaptive immune reconstitution are detected in drug-experienced human immunodeficiency virus-infected patients on tenofovir-didanosine nucleoside reverse transcription inhibitor regimens.
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Affiliation(s)
- P Costa
- Istituto Giannina Gaslini, Universita' di Genova, Genova, Italy
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Azanza JR, García Quetglas E, Sádaba B, Gómez-Giu A. [Tenofovir: pharmacology and interactions]. Enferm Infecc Microbiol Clin 2009; 26 Suppl 8:2-6. [PMID: 19195431 DOI: 10.1157/13126265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Tenofovir is a nucleotide analogue and consequently its mechanism of action differs from that of nucleoside analogues. This drug is administered orally in the form of disoproxil ester, which is deesterified to achieve a bioavailability of more than 20%. This bioavailability slightly increases if tenofovir is taken with a fat-rich meal. This drug has broad tissue distribution, aided by its small molecular size and very low protein binding, and is eliminated as unchanged drug in the urine through glomerular filtration and active tubular secretion. Because of this latter characteristic, dosage adjustments are required in patients with renal insufficiency. The intracellular half-life of tenofovir is more than 10 times greater than the plasma half-life. Because of the pharmacokinetic profile of tenofovir, interactions with other drugs are scarce. Within the class of antiretroviral agents, an increase in the bioavailability of didanosine has been described, leading to the recommendation that the dose of didanosine be reduced when used in combination with tenofovir. Tenofovir can be used without adjustments with other nucleoside and nonnucleoside reverse transcriptase inhibitors. Equally, tenofovir seems to have no effect on the pharmacokinetics of protease inhibitors although these latter agents may produce a slight increase in the bioavailability of tenofovir, which seems to be of little clinical relevance. The absence of interactions with other non-antiretroviral agents has been reported.
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Affiliation(s)
- José Ramón Azanza
- Servicio de Farmacología Clínica, Clínica Universitaria de Navarra, Facultad de Medicina. Universidad de Navarra, Pamplona, España.
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Pilot pharmacokinetic study of human immunodeficiency virus-infected patients receiving tenofovir disoproxil fumarate (TDF): investigation of systemic and intracellular interactions between TDF and abacavir, lamivudine, or lopinavir-ritonavir. Antimicrob Agents Chemother 2009; 53:1937-43. [PMID: 19273671 DOI: 10.1128/aac.01064-08] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Previous work has demonstrated the existence of systemic interaction between tenofovir (TFV) disoproxil fumarate (TDF) and didanosine as well as between TDF and lopinavir-ritonavir (LPV/r). Here we investigated TDF interactions with the nucleoside reverse transcriptase inhibitors (NRTIs) lamivudine (3TC) and abacavir (ABC), comparing both the concentrations of nucleoside/nucleotide reverse transcriptase inhibitors in plasma and the intracellular concentrations of their triphosphate metabolites (NRTI-TP) for human immunodeficiency virus-infected patients receiving these NRTIs with TDF and after 4 weeks of TDF interruption. We also looked at interactions between TDF-ABC and LPV/r, comparing patients receiving or not receiving LPV/r. Blood samples were taken at baseline and at 1, 2, and 4 h after dosing. Liquid chromatography-tandem mass spectrometry was used to measure NRTIs and NRTI-TPs. Statistical analyses were performed on pharmacokinetic parameters: the area under the concentration-time curve from 0 to 4 h (AUC(0-4)), the maximum concentration of the drug (C(max)), and the residual concentration of the drug at the end of the dosing interval (C(trough)) for plasma and the AUC(0-4) and C(trough) for intracellular data. Among the groups of patient discontinuing TDF, the very long intracellular half-life of elimination (150 h) of TFV-DP (the diphosphorylated metabolite of TFV, corresponding to a triphosphorylated species) was confirmed. Comparison between groups as well as the longitudinal study showed no significant systemic or intracellular interaction between TDF and ABC or 3TC. Significant differences were observed between patients receiving LVP/r and those receiving nevirapine. For ABC, plasma exposure was decreased (40%) under LVP/r, while, in contrast, plasma exposure to TFV was increased by 50% and the intracellular TFV-DP AUC(0-4) was increased by 59%. A trend for a gender effect was observed for TFV-DP at the intracellular level, with higher and C(trough) values for women.
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Tenofovir use in human immunodeficiency virus-1-infected children in the United kingdom and Ireland. Pediatr Infect Dis J 2009; 28:204-9. [PMID: 19209091 DOI: 10.1097/inf.0b013e31818c8d2c] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Tenofovir disoproxil fumarate (TDF) is neither licensed for use nor extensively studied in HIV-infected children. The only available formulation is an adult tablet, introducing the possibility of dosing errors in children. TDF interacts with other antiretrovirals and has been associated with decline in renal function and CD4 count. We describe the use of TDF in a cohort of HIV-1-infected children in the United Kingdom and Ireland. METHODS Children ever prescribed TDF and followed in the Collaborative HIV Pediatric Study cohort since 2001 were included in analyses of dosing, adverse events, and virologic and immunologic response. Suspected adverse drug reactions to TDF reported to the Medicines and Healthcare products Regulatory Agency during the same time were also reviewed. RESULTS One hundred fifty-nine of 1253 children had taken TDF. They were older and had clinically more advanced disease than the rest of the cohort. Eighteen percent received >120% and 37% received <80% of the suggested pediatric dose (8 mg/kg). Thirty-seven percent of new TDF regimens contained didanosine (ddI), though few since 2005. Twelve of 159 (7.5%) children experienced serious adverse events and stopped TDF permanently, 11 taking concurrent lopinavir-ritonavir, and 10 ddI; 5 had renal toxicity. Viral load suppressed to < or =50 copies/mL at 12 months in 38% of those starting TDF. Median increase in CD4 count at 12 months was +110 cells/mL (interquartile range, 9-270), but only 3 cells/mL in those taking concurrent ddI. CONCLUSIONS TDF seems to be an effective antiretroviral drug in this pediatric cohort, although considerable underdosing and overdosing occurs. A small number of children experienced serious adverse events while taking TDF; half were renal toxicity, most associated with concurrent ddI and lopinavir-ritonavir use.
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27
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Zhou SF, Lecureur V, Guillouzo A. Structure, function and regulation of P-glycoprotein and its clinical relevance in drug disposition. Xenobiotica 2008; 38:802-32. [PMID: 18668431 DOI: 10.1080/00498250701867889] [Citation(s) in RCA: 372] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
1. P-glycoprotein (P-gp/MDR1), one of the most clinically important transmembrane transporters in humans, is encoded by the ABCB1/MDR1 gene. Recent insights into the structural features of P-gp/MDR1 enable a re-evaluation of the biochemical evidence on the binding and transport of drugs by P-gp/MDR1. 2. P-gp/MDR1 is found in various human tissues in addition to being expressed in tumours cells. It is located on the apical surface of intestinal epithelial cells, bile canaliculi, renal tubular cells, and placenta and the luminal surface of capillary endothelial cells in the brain and testes. 3. P-gp/MDR1 confers a multi-drug resistance (MDR) phenotype to cancer cells that have developed resistance to chemotherapy drugs. P-gp/MDR1 activity is also of great clinical importance in non-cancer-related drug therapy due to its wide-ranging effects on the absorption and excretion of a variety of drugs. 4. P-gp/MDR1 excretes xenobiotics such as cytotoxic compounds into the gastrointestinal tract, bile and urine. It also participates in the function of the blood-brain barrier. 5. One of the most interesting characteristics of P-gp/MDR1 is that its many substrates vary greatly in their structure and functionality, ranging from small molecules such as organic cations, carbohydrates, amino acids and some antibiotics to macromolecules such as polysaccharides and proteins. 6. Quite a number of single nucleotide polymorphisms have been found for the MDR1 gene. These single nucleotide polymorphisms are associated with altered oral bioavailability of P-gp/MDR1 substrates, drug resistance, and a susceptibility to some human diseases. 7. Altered P-gp/MDR1 activity due to induction and/or inhibition can cause drug-drug interactions with altered drug pharmacokinetics and response. 8. Further studies are warranted to explore the physiological function and pharmacological role of P-gp/MDR1.
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Affiliation(s)
- S-F Zhou
- Division of Chinese Medicine, School of Health Science, WHO Collaborating Centre for Traditional Medicine, RMIT University, Bundoora, Vic., Australia.
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Wenning LA, Friedman EJ, Kost JT, Breidinger SA, Stek JE, Lasseter KC, Gottesdiener KM, Chen J, Teppler H, Wagner JA, Stone JA, Iwamoto M. Lack of a significant drug interaction between raltegravir and tenofovir. Antimicrob Agents Chemother 2008; 52:3253-8. [PMID: 18625763 PMCID: PMC2533504 DOI: 10.1128/aac.00005-08] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2008] [Revised: 05/09/2008] [Accepted: 07/07/2008] [Indexed: 11/20/2022] Open
Abstract
Raltegravir is a novel human immunodeficiency virus type 1 (HIV-1) integrase inhibitor with potent in vitro activity (95% inhibitory concentration of 31 nM in 50% human serum). This article reports the results of an open-label, sequential, three-period study of healthy subjects. Period 1 involved raltegravir at 400 mg twice daily for 4 days, period 2 involved tenofovir disoproxil fumarate (TDF) at 300 mg once daily for 7 days, and period 3 involved raltegravir at 400 mg twice daily plus TDF at 300 mg once daily for 4 days. Pharmacokinetic profiles were also determined in HIV-1-infected patients dosed with raltegravir monotherapy versus raltegravir in combination with TDF and lamivudine. There was no clinically significant effect of TDF on raltegravir. The raltegravir area under the concentration time curve from 0 to 12 h (AUC(0-12)) and peak plasma drug concentration (C(max)) were modestly increased in healthy subjects (geometric mean ratios [GMRs], 1.49 and 1.64, respectively). There was no substantial effect of TDF on raltegravir concentration at 12 h postdose (C(12)) in healthy subjects (GMR [TDF plus raltegravir-raltegravir alone], 1.03; 90% confidence interval [CI], 0.73 to 1.45), while a modest increase (GMR, 1.42; 90% CI, 0.89 to 2.28) was seen in HIV-1-infected patients. Raltegravir had no substantial effect on tenofovir pharmacokinetics: C(24), AUC, and C(max) GMRs were 0.87, 0.90, and 0.77, respectively. Coadministration of raltegravir and TDF does not change the pharmacokinetics of either drug to a clinically meaningful degree. Raltegravir and TDF may be coadministered without dose adjustments.
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Crespo M, Pou L, Esteban JI, Falcó V, Ribera E, Lopez R, Sauleda S, Curran A, Del Saz SV, Feijoo M, Ocaña I, Pahissa A. Early Monitoring of Ribavirin Serum Concentration is not Useful to Optimize Hepatitis C Virus treatment in HIV-Coinfected Patients. Antivir Ther 2007. [DOI: 10.1177/135965350701200815] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Emerging data suggest that higher ribavirin (RBV) exposure could improve early hepatitis C virus (HCV) response. Furthermore, interindividual RBV bioavailability shows high variation, and dose-limiting haemolytic anaemia is a common adverse event. Therefore, it has been suggested that monitoring RBV serum levels could be used to drive dose modification and to optimize management of HCV-infected patients receiving combination treatment. Methods To assess the effect of RBV serum levels on HCV RNA clearance at week 4 and 12 of treatment, and to determine the correlation between RBV serum concentration and haemoglobin decrease, RBV trough levels were measured by HPLC in stored serum samples obtained from 94 HCV-HIV-coinfected patients at week 4 and 12 of treatment with peginterferon-α2b (1.5 μg/kg/weekly) plus ribavirin (800–1,200 mg/day). Results The median RBV levels increased from 1.70 μg/ml at week 4 to 1.97 μg/ml at week 12 of treatment ( P=0.001) and were independently predicted by weight-adjusted dose of RBV and co-administration of tenofovir. Haemoglobin drop was higher among patients who received zidovudine and weakly correlated with RBV level. Although RBV concentration was lower in genotype 1 or 4 HCV-infected patients who cleared the virus at treatment week 4, the ability of this parameter to discriminate between responders and non-responders at treatment week 4 and 12 was poor. Conclusion Intracellular RBV accumulation early in treatment might improve the kinetics of HCV response in difficult to treat patients. Although this hypothesis and the potential interaction between RBV and tenofovir warrant further research, our data do not support RBV serum monitoring as a tool to optimize treatment in HCV-HIV-coinfected patients.
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Affiliation(s)
- Manuel Crespo
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Leonor Pou
- Clinical Biochemistry Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Juan I Esteban
- Liver Unit, Department of Medicine, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Vicenç Falcó
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Esteban Ribera
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Rosa Lopez
- Pharmacy Department, Hospital Universitari Vall d'Hebron, Spain
| | - Silvia Sauleda
- Centre de Transfusió i Banc de Teixits, Institut Catala de la Salut, Spain
| | - Adriá Curran
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Sara Villar Del Saz
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - María Feijoo
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Inma Ocaña
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Albert Pahissa
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
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Venhoff N, Setzer B, Melkaoui K, Walker UA. Mitochondrial Toxicity of Tenofovir, Emtricitabine and Abacavir Alone and in Combination with Additional Nucleoside Reverse Transcriptase Inhibitors. Antivir Ther 2007. [DOI: 10.1177/135965350701200704] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background Some nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) combinations cause additive or synergistic interactions in vitro and in vivo. Methods We evaluated the mitochondrial toxicity of tenofovir (TFV), emtricitabine (FTC) and abacavir as carbovir (CBV) alone, with each other, and in combination with additional NRTIs. HepG2 human hepatoma cells were incubated with TFV, FTC, CBV, didanosine (ddI), stavudine (d4T), lamivudine (3TC) and zidovudine (AZT) at concentrations equivalent to 1 and 10x clinical steady-state peak plasma levels (Cmax). NRTIs were also used in double and triple combinations. Cell growth, lactate production, intracellular lipids, mtDNA and the mtDNA-encoded respiratory chain subunit II of cytochrome c oxidase (COXII) were monitored for 25 days. Results TFV and 3TC had no or minimal toxicity. FTC moderately reduced hepatocyte proliferation independent of effects on mtDNA. ddI and d4T induced a time- and dose-dependent loss of mtDNA and COXII, decreased cell growth and increased levels of lactate and intracellular lipids. CBV and AZT strongly impaired hepatocyte proliferation and increased lactate and lipid production, but did not induce mtDNA depletion. The dual combination of TFV plus 3TC had only minimal toxicity; TFV plus FTC slightly reduced cell proliferation without affecting mitochondrial parameters. All other combinations exhibited more pronounced adverse effects on mitochondrial endpoints. Toxic effects on mitochondrial parameters were observed in all combinations with ddI, d4T, AZT or CBV. TFV and 3TC both attenuated ddI-related cytotoxicity, but worsened the effects of CBV and AZT. Conclusions The data demonstrate unpredicted interactions between NRTIs with respect to toxicological endpoints and provide an argument against the liberal use of NRTI cocktails without first obtaining data from clinical trials.
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Affiliation(s)
- Nils Venhoff
- Medizinische Universitätsklinik, Department of Rheumatology & Clinical Immunology, Freiburg, Germany
| | - Bernhard Setzer
- Medizinische Universitätsklinik, Department of Rheumatology & Clinical Immunology, Freiburg, Germany
| | - Kerstina Melkaoui
- Medizinische Universitätsklinik, Department of Rheumatology & Clinical Immunology, Freiburg, Germany
| | - Ulrich A Walker
- Medizinische Universitätsklinik, Department of Rheumatology & Clinical Immunology, Freiburg, Germany
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Giaquinto C, Rampon O, Penazzato M, Fregonese F, De Rossi A, D'Elia R. Nucleoside and nucleotide reverse transcriptase inhibitors in children. Clin Drug Investig 2007; 27:509-31. [PMID: 17638393 DOI: 10.2165/00044011-200727080-00001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
By the end of 2006, approximately 2.3 million children worldwide were living with HIV infection, representing about 15% of all HIV-infected individuals but only 5-7% of the total population of treated patients worldwide. Despite a general increase in the use of antiretroviral therapy (ART) in resource-limited settings, appropriate care and ART remain inaccessible for most of the world's HIV-infected children. ART of children is challenging because of a general lack of paediatric formulations (including tablets in paediatric strengths), limited options of drugs available for children (some have been approved only for use in adults), different viral and immunological responses, dependency on caregivers for administration of the therapy, and specific issues of toxicity in long-term therapy related to maturation and development. As in adults, nucleoside reverse transcriptase inhibitors (NRTIs) are a key component of any ART schedule in children, being the recommended 'backbone' treatment in US, European and WHO guidelines, and, indeed, NRTIs have been extensively studied in children. NRTIs are the class of antiretroviral drugs that have more drugs licensed for paediatric use and more paediatric formulations.Generally, the dual NRTI backbone treatment of combination with a non-NRTI (NNRTI) or protease inhibitor (PI) should comprise a cytidine analogue (lamivudine, emtricitabine) and a thymidine analogue (stavudine, zidovudine), guanosine analogue (i.e. abacavir), or nucleotide RTI (NtRTI; i.e. tenofovir). European and US guidelines recommend the use of triple NRTI therapy (abacavir/lamivudine/zidovudine) in children with anticipated poor adherence to other treatment regimens because of tablet burden. In conclusion, while use of ART in children needs to be dramatically increased, selecting and administering the best drug combination for children is still limited by a lack of paediatric formulations and knowledge of drug metabolism, safety and efficacy in children. NRTIs are already a key component of paediatric ART, but fixed-dose combinations and specific research in children are needed to optimise their use. In this article we review the available information to facilitate selection of the best NRTI for backbone treatment in combination ART for HIV-infected children.
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Affiliation(s)
- Carlo Giaquinto
- Department of Pediatrics, Università di Padova, Padova, Italy.
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Moreno S, Hernández B, Dronda F. Didanosine enteric-coated capsule: current role in patients with HIV-1 infection. Drugs 2007; 67:1441-62. [PMID: 17600392 DOI: 10.2165/00003495-200767100-00006] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Didanosine, which is a synthetic nucleoside analogue intracellularly phosphorylated to the active metabolite, inhibits the activity of HIV-1 reverse transcriptase by competing with the natural substrate. Currently, didanosine is mainly provided as an enteric-coated capsule. In vitro, the molecule is active against laboratory strains and clinical isolates of HIV-1 in resting and activated T cells and monocyte/macrophages. Didanosine may select for resistance mutations that may render the drug inactive against the virus; L74V and K65R remain as the main didanosine-related mutations. In vitro, phenotypic susceptibility to didanosine was decreased beyond a defined fold change clinical cut-off (1.7), and it is considered that genotypic resistance exists when five thymidine-associated mutations or four plus M184V are present. In vivo, clinical studies have shown that didanosine retains significant antiviral activity in patients who have up to five nucleoside analogue mutations at baseline. Didanosine is useful in patients with no previous therapy, as well as in experienced patients in whom one or more antiretroviral regimens has failed.Enteric-coated didanosine is taken once daily, its co-administration with food has been recently evaluated and a reduction of the efficacy of the antiretroviral treatment was not observed. Administered with lamivudine (or emtricitabine), it can be considered a good alternative for use in the nucleoside analogue backbone included in combination therapies for antiretroviral-naive patients. Didanosine could be used in initial treatments for patients intolerant of zidovudine, abacavir or tenofovir. It can be included in once-daily combination regimens, which are more convenient and patient friendly.Prospective, observational and open-label studies, as well as clinical trials (with durations between 24 and 96 weeks), have demonstrated the safety and efficacy of didanosine plus lamivudine (or emtricitabine) plus efavirenz (or nevirapine) in previously untreated HIV-1-infected patients. The administration of didanosine to treatment-experienced patients has been evaluated in two different contexts: patients in whom previous therapies have failed (rescue therapy) and those with controlled viraemia who are switched to a didanosine-containing regimen for simplification.Adverse events associated with the administration of didanosine have been well known since the initial clinical trials with the drug. Gastrointestinal intolerance, peripheral neuropathy and hyperamylasaemia/pancreatitis were the most frequently reported. In the highly active antiretroviral therapy (HAART) era, the rate of adverse events has decreased. The tolerability of didanosine has been clearly improved with the development of the enteric-coated capsule. Severe manifestations of mitochondrial toxicity, including lactic acidosis and abnormal fat distribution, are rare complications, and occur most frequently when didanosine is used in combination with stavudine.
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Affiliation(s)
- Santiago Moreno
- Department of Infectious Diseases, Ramón y Cajal Hospital, Alcalá University, Madrid, Spain.
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Pham PA, Gallant JE. Tenofovir disoproxil fumarate for the treatment of HIV infection. Expert Opin Drug Metab Toxicol 2007; 2:459-69. [PMID: 16863446 DOI: 10.1517/17425255.2.3.459] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tenofovir disoproxil fumarate is a nucleotide analogue reverse transcriptase inhibitor approved by the FDA for the treatment of HIV infection. It is a potent agent with a long intracellular half-life that allows for once-daily dosing. It has been well tolerated in clinical trials, without evidence of the mitochondrial toxicity that has been associated with long-term treatment of some of the nucleoside analogue reverse transcriptase inhibitors. Because of its demonstrated efficacy and favourable safety profile, tenofovir disoproxil fumarate has quickly become a favoured nucleoside component of antiretroviral regimens for both treatment-naive and -experienced patients.
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Affiliation(s)
- Paul A Pham
- Johns Hopkins University School of Medicine, Division of Infectious Diseases, 1830 E. Monument St. #443, Baltimore, MD 21287, USA.
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Abstract
Despite huge advances in terms of the impact of antiretroviral therapy on HIV-related morbidity and mortality patients continue to fail therapy. We discuss the reasons why failure occurs including primary or transmitted resistance, poor adherence, toxicity and drug potency. We performed a review of PubMed, Medline and recent conference abstracts for information on antiretroviral toxicity, adherence, failure and transmitted resistance. Most first-line regimens are now similar in potency and, assuming susceptibility to the selected regimen determined by genotypic resistance testing, tolerability and toxicity are the key issues differentiating currently available agents. New developments such as pharmacogenomics have already proven useful in predicting toxicity and may play an increasingly important role. With all regimens good adherence remains the key to successful therapy; minimising toxicity and other barriers to adherence wherever possible is crucial.
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Affiliation(s)
- L Waters
- St Stephen's Centre, Chelsea & Westminster Hospital, London, UK.
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Takahashi M, Kudaka Y, Okumura N, Hirano A, Banno K, Kaneda T. Determination of Plasma Tenofovir Concentrations Using a Conventional LC-MS Method. Biol Pharm Bull 2007; 30:1784-6. [PMID: 17827740 DOI: 10.1248/bpb.30.1784] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The quantification of tenofovir, a nucleoside reverse transcriptase inhibitor prescribed once daily, in human plasma is important due to a recent increase in its use. HPLC, however, can not easily detect and quantify tenofovir because of interfering peaks. Therefore, we developed a rapid and conventional LC-MS method, validated by estimating the precision and accuracy for inter- and intraday analysis in the concentration range of 0.019-1.567 microg/ml. The calibration curve was linear in the described concentration range. Average accuracy ranged from 95.9 to 100.7%. Relative standard deviations of both inter- and intraday assays were less than 11.6%. Recovery of tenofovir was more than 80.2%. This novel method provides a conventional, accurate and precise way to determine tenofovir in human plasma samples.
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Affiliation(s)
- Masaaki Takahashi
- Department of Pharmacy, National Hospital Organization Nagoya Medical Center (Tokai Area Central Hospital for AIDS Treatment and Research), Naka-ku, Nagoya, Aichi 460-0001, Japan
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Amariles P, Giraldo N, Faus M. Interacciones medicamentosas en pacientes infectados con el VIH: aproximación para establecer y evaluar su relevancia clínica. FARMACIA HOSPITALARIA 2007; 31:283-302. [DOI: 10.1016/s1130-6343(07)75392-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Rotger M, Colombo S, Furrer H, Décosterd L, Buclin T, Telenti A. Does Tenofovir Influence Efavirenz Pharmacokinetics? Antivir Ther 2007. [DOI: 10.1177/135965350701200115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction A recent report described a possible interaction between tenofovir (TFV) and efavirenz (EFV). Patients developed neuropsychiatric manifestations upon introduction of TFV on a stable EFV-containing regimen. We evaluated the possibility of a pharmacokinetic interaction between TFV and EFV by assessing cross-sectional and longitudinal data in 169 individuals receiving EFV. Results EFV plasma area-under-the-curve (AUC) levels were comparable among individuals receiving ( n=18) or not receiving TFV ( n=151); 57,962 versus 52,293 ng*h/ml. However, under conditions of limited EFV metabolism, that is, the group of 23 individuals carrying two copies of CYP2B6 loss/diminished-function alleles, plasma AUC values were highest among individuals receiving TFV ( n=5, 353,031 ng*h/ml), compared with those not receiving TFV ( n=18, 180,689 ng*h/ml). Statistical analysis identified both a global, sixfold effect of CYP2B6 loss/diminished function ( P<0.0001) and a significant interaction between the number of loss/diminished-function alleles and the co-medication with TFV ( P=0.009). Conclusion Although there is no clear evidence for a pharmacokinetic interaction between TFV and EFV, we cannot rule out an interaction between these drugs restricted to individuals who are slow EFV metabolizers.
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Affiliation(s)
- Margalida Rotger
- Institute of Microbiology, University Hospital, Lausanne, Switzerland
| | - Sara Colombo
- Division of Clinical Pharmacology, University Hospital, Lausanne, Switzerland
| | - Hansjakob Furrer
- Division of Infectious Diseases, University Hospital, Bern, Switzerland
| | - Laurent Décosterd
- Division of Clinical Pharmacology, University Hospital, Lausanne, Switzerland
| | - Thierry Buclin
- Division of Clinical Pharmacology, University Hospital, Lausanne, Switzerland
| | - Amalio Telenti
- Institute of Microbiology, University Hospital, Lausanne, Switzerland
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Weiss J, Theile D, Ketabi-Kiyanvash N, Lindenmaier H, Haefeli WE. Inhibition of MRP1/ABCC1, MRP2/ABCC2, and MRP3/ABCC3 by Nucleoside, Nucleotide, and Non-Nucleoside Reverse Transcriptase Inhibitors. Drug Metab Dispos 2006; 35:340-4. [PMID: 17172311 DOI: 10.1124/dmd.106.012765] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Many drug interactions with drugs used for the therapy of human immunodeficiency virus (HIV) occur at the level of different cytochrome P450 isozymes. Increasing evidence suggests that antiretrovirals may also modify activity and expression of active drug transport systems. Such interactions may alter drug absorption, elimination, and also drug distribution and reach clinical importance if thereby access to the target site is affected. Beyond P-glycoprotein, the family of multidrug resistance-related proteins (MRP/ABCC) substantially contributes to the elimination of numerous drugs and their metabolites. Because the interaction of MRPs with non-HIV protease inhibitor antiretrovirals has not been studied thoroughly, we investigated whether important non-nucleoside reverse transcriptase inhibitors (NNRTI) (delavirdine, efavirenz, and nevirapine), nucleoside reverse transcriptase inhibitors (NRTI) (abacavir, emtricitabine, and lamivudine), and tenofovir as a nonnucleotide reverse transcriptase inhibitor can interact with MRP1, MRP2, and MRP3 in vitro. Inhibition of these ABC transporters was quantified by confocal laser-scanning microscopy using the 5-chloromethylfluorescein diacetate assay. With the exception of abacavir, which had no effect on MRP3, all the test compounds increased intracellular 5-chloromethylfluorescein fluorescence in a concentration-dependent manner, and this effect was observed in all the overexpressing cell lines but not in the parental cell line, indicating inhibition of MRP1, MRP2, and MRP3. In conclusion, the present study provides the first evidence for a significant and concentration-dependent inhibition of MRPs by NNRTI, NRTI, and tenofovir, which was most pronounced for delavirdine, efavirenz, and emtricitabine, suggesting that this might contribute to some of the known drug interactions impairing HIV therapy and also to the superior effectiveness of combination pharmacotherapy.
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Affiliation(s)
- Johanna Weiss
- Department of Internal Medicine VI, Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany.
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