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Cheng L, Wang Y, Li X, Feng W, Weng B, Yuan Q, Xia P, Sun F. Meta-analysis of the associations of CYP2B6-516G>T polymorphisms with efavirenz-induced central nervous system side effects and virological outcome in HIV-infected adults. THE PHARMACOGENOMICS JOURNAL 2019; 20:246-259. [PMID: 31636355 DOI: 10.1038/s41397-019-0112-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 10/06/2019] [Accepted: 10/10/2019] [Indexed: 02/07/2023]
Abstract
Clinical data on the relationships of cytochrome P450 (CYP2) B6 516G>T polymorphisms with efavirenz-induced central nervous system (CNS) side effects and virological response in HIV-infected adults are controversial. We sought to analyze the associations by meta-analysis. To identify eligible studies, we systematically searched PubMed, Embase, ScienceDirect, and Web of Science. The strength of the associations was measured by odds ratio (OR) and effect size (ES) with 95% confidence interval (CI). Seventeen studies comprising a total of 3598 HIV-infected adults were included. The results showed that the CYP2B6-516 GG genotype was significantly associated with a decreased risk of efavirenz-induced CNS side effects compared with the GT and TT genotypes (GG + GT vs. TT: OR = 0.60, 95% CI = 0.41-0.87, P = 0.006; GG vs. GT + TT: OR = 0.68, 95% CI = 0.51-0.91, P = 0.008; GG vs. GT: OR = 0.70, 95% CI = 0.51-0.94, P = 0.018), and there was no significant association between the genetic variants GT and TT (GT vs. TT: OR = 0.82, 95% CI = 0.54-1.26, P = 0.372). However, there was no significant association between CYP2B6-516 GG and GT + TT genotypes in virological response (GT + TT vs. GG: ES = 1.06, 95% CI = 0.95-1.18, P = 0.321; OR = 1.01, 95% CI = 0.65-1.58, P = 0.963). Taken together, our results demonstrated that compared with the normal efavirenz clearance genotype CYP2B6-516 GG, the slow and very slow efavirenz clearance genotypes GT and TT were significantly associated with an increased risk of efavirenz-induced CNS side effects but not an increased virological response. To promote the tolerance of efavirenz, it is better to adjust the dosage of efavirenz according to the polymorphisms of CYP2B6-516 in HIV-infected adults.
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Affiliation(s)
- Lin Cheng
- Department of Pharmacy, the First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Yu Wang
- Department of Pharmacy, the First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Xiaoyu Li
- Department of Pharmacy, Handan Branch Hospital of the 980th Hospital of PLA, Handan, 056001, China
| | - Wei Feng
- Department of Pharmacy, the First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Bangbi Weng
- Department of Pharmacy, the First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Qian Yuan
- Department of Pharmacy, the First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Peiyuan Xia
- Department of Pharmacy, the First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, 400038, China.
| | - Fengjun Sun
- Department of Pharmacy, the First Affiliated Hospital of Third Military Medical University (Army Medical University), Chongqing, 400038, China.
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Mugusi S, Ngaimisi E, Janabi M, Mugusi F, Minzi O, Aris E, Bakari M, Bertilsson L, Burhenne J, Sandstrom E, Aklillu E. Neuropsychiatric manifestations among HIV-1 infected African patients receiving efavirenz-based cART with or without tuberculosis treatment containing rifampicin. Eur J Clin Pharmacol 2018; 74:1405-1415. [PMID: 30003275 PMCID: PMC6182598 DOI: 10.1007/s00228-018-2499-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 05/31/2018] [Indexed: 01/11/2023]
Abstract
Purpose Efavirenz-based combination antiretroviral therapy (cART) is associated with neuropsychiatric adverse events. We investigated the time to onset, duration, clinical implications, impact of pharmacogenetic variations, and anti-tuberculosis co-treatment on efavirenz-associated neuropsychiatric manifestations. Methods Prospective cohort study of cART naïve HIV patients with or without tuberculosis (HIV-TB) co-infection treated with efavirenz-based cART. Rifampicin-based anti-tuberculosis therapy was initiated 4 weeks prior to efavirenz-based cART in HIV-TB patients. Data on demographic, clinical, laboratory, and a 29-item questionnaire on neuropsychiatric manifestations were collected for 16 weeks after cART initiation. Genotyping for CYP2B6, CYP3A5, SLCO1B1, and ABCB1 and quantification of efavirenz plasma concentration were done on the 4th and 16th week. Results Data from 458 patients (243 HIV-only and 215 HIV-TB) were analyzed. Overall incidence of neuropsychiatric manifestations was 57.6% being higher in HIV-only (66.7%) compared to HIV-TB patients (47.4%) (p < 0.01). HIV-only patients were more symptomatic, with proportionately higher grades of manifestations compared to HIV-TB patients. Median time to manifestations was 1 week after cART initiation in HIV-only and 6 weeks after anti-TB (i.e., 2 weeks after cART initiation) in HIV-TB patients. HIV-only patients had significantly higher efavirenz plasma concentrations at 4 weeks after cART compared to HIV-TB patients. No association of sex or genotype was seen in relation to neuropsychiatric manifestations. Risk for neuropsychiatric manifestations was three times more in HIV-only patients compared to HIV-TB (p < 0.01). Conclusions Incidence of neuropsychiatric manifestations during early initiation of efavirenz-based cART is high in Tanzanian HIV patients. Risk of neuropsychiatric manifestations is lower in HIV patients co-treated with rifampicin containing anti-TB compared to those treated with efavirenz-based cART only. Electronic supplementary material The online version of this article (10.1007/s00228-018-2499-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sabina Mugusi
- Department of Clinical Pharmacology, School of Medicine, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania.
| | - Eliford Ngaimisi
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Mohammed Janabi
- Department of Internal Medicine, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Ferdinand Mugusi
- Department of Internal Medicine, School of Medicine, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Omary Minzi
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Eric Aris
- Department of Internal Medicine, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Muhammad Bakari
- Department of Internal Medicine, School of Medicine, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Leif Bertilsson
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska University Hospital-Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Juergen Burhenne
- Department of Clinical Pharmacology and Pharmaco-epidemiology, University of Heidelberg, Heidelberg, Germany
| | - Eric Sandstrom
- Department of Clinical Science and Education, Infectious Disease Unit, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Eleni Aklillu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska University Hospital-Huddinge, Karolinska Institute, Stockholm, Sweden
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Orrell C, Bienczak A, Cohen K, Bangsberg D, Wood R, Maartens G, Denti P. Effect of mid-dose efavirenz concentrations and CYP2B6 genotype on viral suppression in patients on first-line antiretroviral therapy. Int J Antimicrob Agents 2016; 47:466-72. [PMID: 27211824 DOI: 10.1016/j.ijantimicag.2016.03.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 03/14/2016] [Accepted: 03/28/2016] [Indexed: 01/11/2023]
Abstract
The therapeutic range for efavirenz plasma concentrations is unclear and some studies found no correlation with viral non-suppression. Efavirenz concentrations are variable, driven in part by polymorphisms in CYP2B6. We hypothesised that efavirenz mid-dosing concentrations, together with CYP2B6 metaboliser genotype, could predict viral non-suppression. Participants starting first-line efavirenz-based antiretroviral therapy were monitored for 48 weeks. HIV-RNA and efavirenz mid-dose interval concentrations were determined at Weeks 16 and 48. CYP2B6 metaboliser genotype status was determined by 516G→T and 983T→C polymorphisms. Cox proportional hazards modelling was used to predict viral non-suppression and to determine the most predictive efavirenz mid-dosing concentration threshold. In total, 180 participants were included. Median efavirenz concentrations were 2.3 mg/L (IQR 1.6-4.6 mg/L) and 2.2 mg/L (IQR 1.5-3.9 mg/L) at Weeks 16 and 48, respectively. Moreover, 49 (27.2%), 84 (46.7%) and 39 (21.7%) participants had extensive, intermediate or slow CYP2B6 metaboliser genotype, respectively. Log2 efavirenz concentrations [adjusted hazard ratio (aHR) = 0.77, 95% CI 0.67-0.89] and baseline CD4 cell count (aHR = 0.994, 95% CI 0.989-0.998), but not CYP2B6 genotype, were predictive of viral non-suppression. For every doubling of efavirenz concentration there was a 23% decrease in the hazard of non-suppression. A threshold of 0.7 mg/L was found to be the efavirenz mid-dosing concentration that was most predictive of non-suppression. Mid-dosing efavirenz concentrations are predictive of viral non-suppression, but the currently recommended lower therapeutic limit (1 mg/L) is higher than our finding. Knowledge of CYP2B6 metaboliser genotype is not required for prediction of virological outcomes.
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Affiliation(s)
- Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - Andrzej Bienczak
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - David Bangsberg
- Harvard Medical School, Boston, MA, USA; Massachusetts General Hospital Center for Global Health, Boston, MA, USA; Ragon Institute of Massachusetts General Hospital, Boston, MA, USA
| | - Robin Wood
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Hui KH, Lee SS, Lam TN. Dose Optimization of Efavirenz Based on Individual CYP2B6 Polymorphisms in Chinese Patients Positive for HIV. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2016; 5:182-91. [PMID: 27299708 PMCID: PMC4846779 DOI: 10.1002/psp4.12067] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 01/29/2016] [Indexed: 02/05/2023]
Abstract
The purpose of this study was to investigate the impact of CYP2B6‐G516T polymorphisms on the pharmacokinetics (PKs) of efavirenz among the Chinese population and to propose doses for different genotypic populations that optimize therapeutic outcomes. Nonlinear mixed‐effect modeling was applied to describe PKs of efavirenz in Chinese patients with human immunodeficiency virus (HIV). Probabilities of successful treatment at different doses were obtained by simulations using the developed model to identify the optimal doses. The model was based on data from 163 individuals. Efavirenz clearance was found to be significantly influenced by CYP2B6‐G516T polymorphisms and body weight. The typical values of oral clearance were 10.2 L/h, 7.33 L/h, and 2.38 L/h and simulation results suggested that the optimal daily oral doses are 550 mg, 350 mg, and 100 mg for the GG, GT, and TT populations, respectively. The effect of CYP2B6‐G516T polymorphisms on efavirenz clearance was successfully quantified. Pharmacogenetics‐based dose individualization of efavirenz may optimize patient outcomes by promoting efficacy while minimizing central nervous system (CNS) side effects.
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Affiliation(s)
- K H Hui
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - S S Lee
- Stanley Ho Centre for Emerging Infectious Diseases, Shatin, New Territories, Hong Kong.,Department of Microbiology, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - T N Lam
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
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Pinillos F, Dandara C, Swart M, Strehlau R, Kuhn L, Patel F, Coovadia A, Abrams E. Case report: Severe central nervous system manifestations associated with aberrant efavirenz metabolism in children: the role of CYP2B6 genetic variation. BMC Infect Dis 2016; 16:56. [PMID: 26831894 PMCID: PMC4735961 DOI: 10.1186/s12879-016-1381-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 01/25/2016] [Indexed: 01/11/2023] Open
Abstract
Background Efavirenz, widely used as part of antiretroviral drug regimens in the treatment of paediatric human immunodeficiency virus infection, has central nervous system side effects. We describe four children presenting with serious, persistent central nervous system adverse events who were found to have elevated plasma efavirenz concentrations as a result of carrying CYP2B6 single nucleotide polymorphisms, known to play a role in the metabolism of EFV. None of the children had a CYP2B6 wildtype haplotype. We believe this is the first case of cerebellar dysfunction associated with efavirenz use to be described in children. Case presentation Four black African children, between the ages of 4 and 8 years presenting between 1 and 20 months post-efavirenz initiation, are described. Cerebellar dysfunction, generalised seizures and absence seizures were the range of presenting abnormalities. Plasma efavirenz levels ranged from 20-60 mg/L, 5–15 times the upper limit of the suggested reference range. All abnormal central nervous system manifestations abated after efavirenz discontinuation. Conclusion Efavirenz toxicity should always be considered in human immunodeficiency virus-infected children with unexplained central nervous system abnormalities. Our findings further our understanding of the impact of genetic variants on antiretroviral pharmacokinetics in children across various ethnic groups. Screening for potential EFV-toxicity based on the CYP2B6 c.516 SNP alone, may not be adequate.
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Affiliation(s)
- Francoise Pinillos
- Empilweni Services and Research Unit (ESRU), Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Collet Dandara
- Pharmacogenetics and Cancer Research Group, Division of Human Genetics, Department of Pathology & Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Marelize Swart
- Pharmacogenetics and Cancer Research Group, Division of Human Genetics, Department of Pathology & Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Renate Strehlau
- Empilweni Services and Research Unit (ESRU), Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Louise Kuhn
- Gertrude H. Sergievsky Center, College of Physicians and Surgeons; and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Faeezah Patel
- Empilweni Services and Research Unit (ESRU), Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ashraf Coovadia
- Empilweni Services and Research Unit (ESRU), Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Elaine Abrams
- ICAP, Mailman School of Public Health, and College of Physicians & Surgeons Columbia University, 722 W168th street, New York, NY, 10032, USA.
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Swart M, Evans J, Skelton M, Castel S, Wiesner L, Smith PJ, Dandara C. An Expanded Analysis of Pharmacogenetics Determinants of Efavirenz Response that Includes 3'-UTR Single Nucleotide Polymorphisms among Black South African HIV/AIDS Patients. Front Genet 2016; 6:356. [PMID: 26779253 PMCID: PMC4703773 DOI: 10.3389/fgene.2015.00356] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 12/10/2015] [Indexed: 01/11/2023] Open
Abstract
Introduction: Efavirenz (EFV) is a non-nucleoside reverse transcriptase inhibitor prescribed as part of first-line highly active antiretroviral therapy (HAART) in South Africa. Despite administration of fixed doses of EFV, inter-individual variability in plasma concentrations has been reported. Poor treatment outcomes such as development of adverse drug reactions or treatment failure have been linked to EFV plasma concentrations outside the therapeutic range (1–4 μg/mL) in some studies. The drug metabolizing enzyme (DME), CYP2B6, is primarily responsible for EFV metabolism with minor contributions by CYP1A2, CYP2A6, CYP3A4, CYP3A5, and UGT2B7. DME coding genes are also regulated by microRNAs through targeting the 3′-untranslated region. Expanded analysis of 30 single nucleotide polymorphisms (SNPs), including those in the 3′-UTR, was performed to identify pharmacogenetics determinants of EFV plasma concentrations in addition to CYP2B6 c.516G>T and c.983T>C SNPs. Methods: SNPs in CYP1A2, CYP2B6, UGT2B7, and NR1I2 (PXR) were selected for genotyping among 222 Bantu-speaking South African HIV-infected patients receiving EFV-containing HAART. This study is a continuation of earlier pharmacogenetics studies emphasizing the role of genetic variation in the 3′-UTR of genes which products are either pharmacokinetic or pharmacodynamic targets of EFV. Results: Despite evaluating thirty SNPs, CYP2B6 c.516G>T and c.983T>C SNPs remain the most prominent predictors of EFV plasma concentration. Conclusion: We have shown that CYP2B6 c.516G>T and c.983T>C SNPs are the most important predictors of EFV plasma concentration after taking into account all other SNPs, including genetic variation in the 3′-UTR, and variables affecting EFV metabolism.
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Affiliation(s)
- Marelize Swart
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Jonathan Evans
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Michelle Skelton
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Sandra Castel
- Division of Clinical Pharmacology, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Peter J Smith
- Division of Clinical Pharmacology, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Collet Dandara
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
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