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Méchaï F, Bachelet D, Han L, Dubert M, Parisey M, Cordel H, Bourgarit A, Bertrac C, Chauveau S, Billard-Pomares T, Carbonnelle E, Bouchaud O, Yazdanpanah Y, Vignier N, Laouénan C. Tuberculosis treatment outcomes among precarious patients in France. Infect Dis Now 2022; 52:389-395. [DOI: 10.1016/j.idnow.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/08/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022]
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Towards Improved Management of Tuberculous Bloodstream Infections: Pharmacokinetic Considerations with Suggestions for Better Treatment Outcomes. Antibiotics (Basel) 2022; 11:antibiotics11070895. [PMID: 35884149 PMCID: PMC9311525 DOI: 10.3390/antibiotics11070895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/09/2022] [Accepted: 04/11/2022] [Indexed: 11/17/2022] Open
Abstract
Mycobacterium tuberculosis is the leading cause of sepsis among HIV-infected adults, yet effective treatment remains a challenge. Efficacy of antituberculous drugs is optimized by high Area Under Curve to Minimum Inhibitory Concentration (AUC/MIC) ratios, suggesting that both the drug concentration at the disease site and time above MIC are critical to treatment outcomes. We elaborate on sepsis pathophysiology and show how it adversely affects antituberculous drug kinetics. Expanding distribution volumes secondary to an increased vascular permeability prevents the attainment of target Cmax concentrations for nearly all drugs. Furthermore, sepsis-induced metabolic acidosis promotes protonation, which increases renal clearance of basic drugs such as isoniazid and ethambutol, and hence AUCs are substantially reduced. Compared with the treatment of non-sepsis TB disease, these distorted kinetics underlie the poor treatment outcomes observed with bloodstream infections. In addition to aggressive hemodynamic management, an increase in both the dose and frequency of drug administration are warranted, at least in the early phase of treatment.
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Anderson G, Vinnard C. Diagnostic Accuracy of Therapeutic Drug Monitoring During Tuberculosis Treatment. J Clin Pharmacol 2022; 62:1206-1214. [PMID: 35588142 PMCID: PMC9541759 DOI: 10.1002/jcph.2068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 04/29/2022] [Indexed: 11/06/2022]
Abstract
Tuberculosis (TB) patients co-infected with human immunodeficiency virus (HIV) are more likely to have low blood concentrations of the first-line anti-TB drugs (associated with poor outcomes). Therapeutic drug monitoring (TDM) is recommended for certain TB patient populations at increased risk for a poor outcome. Our objective was to estimate the diagnostic accuracy of a 2-hour TDM serum sample for the first-line anti-TB drugs among HIV/TB patients, and evaluate the information gained by an additional 6-hour sample. We created a virtual (n = 1,000) HIV/TB patient population and performed pharmacokinetic (PK) simulations using published population models for isoniazid, rifampin, pyrazinamide, and ethambutol. We performed receiver-operating-characteristic (ROC) analysis to compare the diagnostic performance of a single 2-hour serum sample with samples obtained at 2- and 6-hours post-dosing. The sensitivity of a single 2-hour serum concentration to identify HIV/TB patients with adequate serum exposures was lowest for rifampin (54.9%, 95% CI 50.79-59.41%) and highest for ethambutol (70.8%, 95% CI 66.06-72.61%) for Cmax targets. Diagnostic accuracy of a single 2-hour serum sample for the AUC0-24 target was highest for isoniazid (93%, 95% CI 90.9-94.1%) and lowest for pyrazinamide (66.3%, 95% CI 62.6-70.0%). In summary, the diagnostic performance of TDM for Cmax and AUC0-24 targets demonstrated variability across the first-line anti-TB drugs. The addition of a 6-hour serum sample lead to the highest statistically significant improvement (p < 0.001) and highest increase in diagnostic accuracy (area under the ROC curve) for rifampin for Cmax and AUC. The other first-line drugs had modest/negligible increases in diagnostic accuracy. This article is protected by copyright. All rights reserved.
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Jacobs TG, Svensson EM, Musiime V, Rojo P, Dooley KE, McIlleron H, Aarnoutse RE, Burger DM, Turkova A, Colbers A. Pharmacokinetics of antiretroviral and tuberculosis drugs in children with HIV/TB co-infection: a systematic review. J Antimicrob Chemother 2020; 75:3433-3457. [PMID: 32785712 PMCID: PMC7662174 DOI: 10.1093/jac/dkaa328] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/29/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Management of concomitant use of ART and TB drugs is difficult because of the many drug-drug interactions (DDIs) between the medications. This systematic review provides an overview of the current state of knowledge about the pharmacokinetics (PK) of ART and TB treatment in children with HIV/TB co-infection, and identifies knowledge gaps. METHODS We searched Embase and PubMed, and systematically searched abstract books of relevant conferences, following PRISMA guidelines. Studies not reporting PK parameters, investigating medicines that are not available any longer or not including children with HIV/TB co-infection were excluded. All studies were assessed for quality. RESULTS In total, 47 studies met the inclusion criteria. No dose adjustments are necessary for efavirenz during concomitant first-line TB treatment use, but intersubject PK variability was high, especially in children <3 years of age. Super-boosted lopinavir/ritonavir (ratio 1:1) resulted in adequate lopinavir trough concentrations during rifampicin co-administration. Double-dosed raltegravir can be given with rifampicin in children >4 weeks old as well as twice-daily dolutegravir (instead of once daily) in children older than 6 years. Exposure to some TB drugs (ethambutol and rifampicin) was reduced in the setting of HIV infection, regardless of ART use. Only limited PK data of second-line TB drugs with ART in children who are HIV infected have been published. CONCLUSIONS Whereas integrase inhibitors seem favourable in older children, there are limited options for ART in young children (<3 years) receiving rifampicin-based TB therapy. The PK of TB drugs in HIV-infected children warrants further research.
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Affiliation(s)
- Tom G Jacobs
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - Elin M Svensson
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Victor Musiime
- Research Department, Joint Clinical Research Centre, Kampala, Uganda
- Department of Paediatrics and Child Health, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Pablo Rojo
- Pediatric Infectious Diseases Unit. Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Kelly E Dooley
- Divisions of Clinical Pharmacology and Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rob E Aarnoutse
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - David M Burger
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - Anna Turkova
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Angela Colbers
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
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Abulfathi AA, Decloedt EH, Svensson EM, Diacon AH, Donald P, Reuter H. Clinical Pharmacokinetics and Pharmacodynamics of Rifampicin in Human Tuberculosis. Clin Pharmacokinet 2020; 58:1103-1129. [PMID: 31049868 DOI: 10.1007/s40262-019-00764-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The introduction of rifampicin (rifampin) into tuberculosis (TB) treatment five decades ago was critical for shortening the treatment duration for patients with pulmonary TB to 6 months when combined with pyrazinamide in the first 2 months. Resistance or hypersensitivity to rifampicin effectively condemns a patient to prolonged, less effective, more toxic, and expensive regimens. Because of cost and fears of toxicity, rifampicin was introduced at an oral daily dose of 600 mg (8-12 mg/kg body weight). At this dose, clinical trials in 1970s found cure rates of ≥ 95% and relapse rates of < 5%. However, recent papers report lower cure rates that might be the consequence of increased emergence of resistance. Several lines of evidence suggest that higher rifampicin doses, if tolerated and safe, could shorten treatment duration even further. We conducted a narrative review of rifampicin pharmacokinetics and pharmacodynamics in adults across a range of doses and highlight variables that influence its pharmacokinetics/pharmacodynamics. Rifampicin exposure has considerable inter- and intra-individual variability that could be reduced by administration during fasting. Several factors including malnutrition, HIV infection, diabetes mellitus, dose size, pharmacogenetic polymorphisms, hepatic cirrhosis, and substandard medicinal products alter rifampicin exposure and/or efficacy. Renal impairment has no influence on rifampicin pharmacokinetics when dosed at 600 mg. Rifampicin maximum (peak) concentration (Cmax) > 8.2 μg/mL is an independent predictor of sterilizing activity and therapeutic drug monitoring at 2, 4, and 6 h post-dose may aid in optimizing dosing to achieve the recommended rifampicin concentration of ≥ 8 µg/mL. A higher rifampicin Cmax is required for severe forms TB such as TB meningitis, with Cmax ≥ 22 μg/mL and area under the concentration-time curve (AUC) from time zero to 6 h (AUC6) ≥ 70 μg·h/mL associated with reduced mortality. More studies are needed to confirm whether doses achieving exposures higher than the current standard dosage could translate into faster sputum conversion, higher cure rates, lower relapse rates, and less mortality. It is encouraging that daily rifampicin doses up to 35 mg/kg were found to be safe and well-tolerated over a period of 12 weeks. High-dose rifampicin should thus be considered in future studies when constructing potentially shorter regimens. The studies should be adequately powered to determine treatment outcomes and should include surrogate markers of efficacy such as Cmax/MIC (minimum inhibitory concentration) and AUC/MIC.
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Affiliation(s)
- Ahmed Aliyu Abulfathi
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa.
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Elin M Svensson
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Andreas H Diacon
- Task Applied Science, Bellville, South Africa.,Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Peter Donald
- Paediatrics and Child Health and Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Helmuth Reuter
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
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6
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A population approach of rifampicin pharmacogenetics and pharmacokinetics in Mexican patients with tuberculosis. Tuberculosis (Edinb) 2020; 124:101982. [PMID: 32810723 DOI: 10.1016/j.tube.2020.101982] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 07/25/2020] [Accepted: 07/27/2020] [Indexed: 11/22/2022]
Abstract
The aim of this study was to develop a population pharmacokinetic model of rifampicin (RMP) in Mexican patients with tuberculosis (TB) to evaluate the influence of anthropometric and clinical covariates, as well as genotypic variants associated with MDR1 and OATP1B1 transporters. A prospective study approved by Research Ethics Committee was performed at Hospital Central in San Luis Potosí, Mexico. TB patients under DOTS scheme and who signed informed consent were consecutively included. Anthropometric and clinical information was retrieved from medical records. Single nucleotide polymorphisms in MDR1 (C3435T) and SLCO1B1 (A388G and T521C) genes were evaluated. RMP plasma concentrations and time data were assessed with NONMEM software. A total of 71 Mexican TB patients from 18 to 72 years old were included for RMP quantification from 0.3 to 12 h after dose; 329 and 97 plasma concentrations were available for model development and validation, respectively. Sequential process includes a typical lag time of 0.25 h prior to absorption start with a Ka of 1.24 h-1 and a zero-order absorption of 0.62 h to characterize the gradual increase in RMP plasma concentrations. Final model includes total body weight in volume of distribution (0.7 L/kg, CV = 26.8%) and a total clearance of 5.96 L/h (CV = 38.5%). Bioavailability was modified according to time under treatment and generic formulation administration. In conclusion, a population pharmacokinetic model was developed to describe the variability in RMP plasma concentrations in Mexican TB patients. Genetic variants evaluated did not showed significant influence on pharmacokinetic parameters. Final model will allow therapeutic drug monitoring at early stages.
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7
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A Systematic Review on the Effect of HIV Infection on the Pharmacokinetics of First-Line Tuberculosis Drugs. Clin Pharmacokinet 2020; 58:747-766. [PMID: 30406475 PMCID: PMC7019645 DOI: 10.1007/s40262-018-0716-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Introduction Contrasting findings have been published regarding the effect of human immunodeficiency virus (HIV) on tuberculosis (TB) drug pharmacokinetics (PK). Objectives The aim of this systematic review was to investigate the effect of HIV infection on the PK of the first-line TB drugs (FLDs) rifampicin, isoniazid, pyrazinamide and ethambutol by assessing all published literature. Methods Searches were performed in MEDLINE (through PubMed) and EMBASE to find original studies evaluating the effect of HIV infection on the PK of FLDs. The included studies were assessed for bias and clinical relevance. PK data were extracted to provide insight into the difference of FLD PK between HIV-positive and HIV-negative TB patients. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and its protocol was registered at PROSPERO (registration number CRD42017067250). Results Overall, 27 studies were eligible for inclusion. The available studies provide a heterogeneous dataset from which consistent results could not be obtained. In both HIV-positive and HIV-negative TB groups, rifampicin (13 of 15) and ethambutol (4 of 8) peak concentration (Cmax) often did not achieve the minimum reference values. More than half of the studies (11 of 20) that included both HIV-positive and HIV-negative TB groups showed statistically significantly altered FLD area under the concentration–time curve and/or Cmax for at least one FLD. Conclusions HIV infection may be one of several factors that reduce FLD exposure. We could not make general recommendations with respect to the role of dosing. There is a need for consistent and homogeneous studies to be conducted.
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Meintjes G, Brust JCM, Nuttall J, Maartens G. Management of active tuberculosis in adults with HIV. Lancet HIV 2020; 6:e463-e474. [PMID: 31272663 DOI: 10.1016/s2352-3018(19)30154-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 04/25/2019] [Accepted: 05/08/2019] [Indexed: 12/11/2022]
Abstract
Every year, about 1 million people living with HIV worldwide develop tuberculosis. Although the drug regimens used to treat tuberculosis in these patients are the same as those used in HIV-negative patients, cotreatment of tuberculosis with antiretroviral therapy involves challenges including the optimal timing of antiretroviral initiation, drug-drug interactions, drug tolerability, and the prevention and treatment of tuberculosis-associated immune reconstitution syndrome. Furthermore, mortality is high in people with HIV who are diagnosed with tuberculosis during a hospital admission, and in those with tuberculous meningitis. Studies in this field have better characterised these challenges and informed optimal management and guideline revisions. In patients with tuberculosis, antiretroviral therapy improves survival, is well tolerated, and can be adjusted to manage drug-drug interactions with rifampicin. Prednisone is effective in both preventing and treating the paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome.
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Affiliation(s)
- Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, South Africa; Division of Infectious Diseases and HIV Medicine, Department of Medicine, South Africa.
| | - James C M Brust
- University of Cape Town, Observatory, South Africa; Divisions of General Internal Medicine and Infectious Diseases, Albert Einstein College of Medicine, New York, NY, USA
| | - James Nuttall
- Department of Paediatrics and Child Health, South Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, South Africa; Division of Clinical Pharmacology, Department of Medicine, South Africa
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Bracchi M, van Halsema C, Post F, Awosusi F, Barbour A, Bradley S, Coyne K, Dixon-Williams E, Freedman A, Jelliman P, Khoo S, Leen C, Lipman M, Lucas S, Miller R, Seden K, Pozniak A. British HIV Association guidelines for the management of tuberculosis in adults living with HIV 2019. HIV Med 2020; 20 Suppl 6:s2-s83. [PMID: 31152481 DOI: 10.1111/hiv.12748] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
| | - Clare van Halsema
- North Manchester General Hospital, Liverpool School of Tropical Medicine
| | - Frank Post
- King's College Hospital NHS Foundation Trust
| | | | | | | | | | | | | | - Pauline Jelliman
- Royal Liverpool and Broadgreen University Hospital Trust, NHIVNA
| | | | | | | | | | | | | | - Anton Pozniak
- Chelsea and Westminster Hospital NHS Foundation Trust, London School of Hygiene and Tropical Medicine
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10
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Sundell J, Bienvenu E, Janzén D, Birgersson S, Äbelö A, Ashton M. Model-Based Assessment of Variability in Isoniazid Pharmacokinetics and Metabolism in Patients Co-Infected With Tuberculosis and HIV: Implications for a Novel Dosing Strategy. Clin Pharmacol Ther 2020; 108:73-80. [PMID: 32017035 DOI: 10.1002/cpt.1806] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/07/2020] [Indexed: 12/11/2022]
Abstract
Tuberculosis is the most common cause of death in HIV-infected patients. Isoniazid is used as a first-line drug to treat tuberculosis infection. However, variability in isoniazid pharmacokinetics can result in hepatotoxicity or treatment failure. Determination of clinical factors affecting isoniazid pharmacokinetics and metabolic pathways in HIV co-infected patients is therefore critical. Plasma levels of isoniazid, acetyl-isoniazid, and isonicotinic acid from 63 patients co-infected with tuberculosis and HIV were analyzed by liquid chromatography with tandem mass spectrometry followed by nonlinear mixed-effects modeling. Patients were genotyped to determine acetylator status. Patients were either on concomitant efavirenz-based antiretroviral therapy or HIV treatment naïve. Clearances of isoniazid were 1.3-fold and 2.3-fold higher in intermediate and rapid acetylators, respectively, compared with slow acetylators. Patients on concomitant efavirenz-based antiretroviral therapy had 64% and 80% higher population predicted clearances of acetyl-isoniazid and isonicotinic acid, respectively, compared with patients who were HIV treatment naïve. Both sex and CD4 cell count affected the bioavailability of isoniazid. Variability in isoniazid exposure could be reduced by dose adaptions based on acetylator type and sex in addition to the currently used weight bands. A novel dosing strategy that has the potential to reduce isoniazid-related toxicity and treatment failure is presented.
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Affiliation(s)
- Jesper Sundell
- Unit for Pharmacokinetics and Drug Metabolism, Department of Pharmacology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Emile Bienvenu
- Department of Pharmacy, School of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
| | - David Janzén
- Drug Metabolism and Pharmacokinetics, Early Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Sofia Birgersson
- Unit for Pharmacokinetics and Drug Metabolism, Department of Pharmacology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Angela Äbelö
- Unit for Pharmacokinetics and Drug Metabolism, Department of Pharmacology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Michael Ashton
- Unit for Pharmacokinetics and Drug Metabolism, Department of Pharmacology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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11
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Stott KE, Pertinez H, Sturkenboom MGG, Boeree MJ, Aarnoutse R, Ramachandran G, Requena-Méndez A, Peloquin C, Koegelenberg CFN, Alffenaar JWC, Ruslami R, Tostmann A, Swaminathan S, McIlleron H, Davies G. Pharmacokinetics of rifampicin in adult TB patients and healthy volunteers: a systematic review and meta-analysis. J Antimicrob Chemother 2019; 73:2305-2313. [PMID: 29701775 PMCID: PMC6105874 DOI: 10.1093/jac/dky152] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/31/2018] [Indexed: 12/29/2022] Open
Abstract
Objectives The objectives of this study were to explore inter-study heterogeneity in the pharmacokinetics (PK) of orally administered rifampicin, to derive summary estimates of rifampicin PK parameters at standard dosages and to compare these with summary estimates for higher dosages. Methods A systematic search was performed for studies of rifampicin PK published in the English language up to May 2017. Data describing the Cmax and AUC were extracted. Meta-analysis provided summary estimates for PK parameter estimates at standard rifampicin dosages. Heterogeneity was assessed by estimation of the I2 statistic and visual inspection of forest plots. Summary AUC estimates at standard and higher dosages were compared graphically and contextualized using preclinical pharmacodynamic (PD) data. Results Substantial heterogeneity in PK parameters was evident and upheld in meta-regression. Treatment duration had a significant impact on the summary estimates for rifampicin PK parameters, with Cmax 8.98 mg/L (SEM 2.19) after a single dose and 5.79 mg/L (SEM 2.14) at steady-state dosing, and AUC 72.56 mg·h/L (SEM 2.60) and 38.73 mg·h/L (SEM 4.33) after single and steady-state dosing, respectively. Rifampicin dosages of at least 25 mg/kg are required to achieve plasma PK/PD targets defined in preclinical studies. Conclusions Vast inter-study heterogeneity exists in rifampicin PK parameter estimates. This is not explained by the available modifying variables. The recommended dosage of rifampicin should be increased to improve efficacy. This study provides an important point of reference for understanding rifampicin PK at standard dosages as efforts to explore higher dosing strategies continue in this field.
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Affiliation(s)
- K E Stott
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - H Pertinez
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - M G G Sturkenboom
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - M J Boeree
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - R Aarnoutse
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - G Ramachandran
- Department of Biochemistry and Clinical Pharmacology, National Institute for Research in Tuberculosis, Chennai, India
| | - A Requena-Méndez
- CRESIB, Barcelona Institute for Global Health, University of Barcelona, Barcelona, Spain
| | - C Peloquin
- College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - C F N Koegelenberg
- Department of Pulmonology, Stellenbosch University & Tygerberg Academic Hospital, Cape Town, South Africa
| | - J W C Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - R Ruslami
- Department of Pharmacology and Therapy, Universitas Padjadjaran, Bandung, Indonesia
| | - A Tostmann
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - S Swaminathan
- Indian Council of Medical Research, New Delhi, India
| | - H McIlleron
- Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - G Davies
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Institute of Global Health, University of Liverpool, Liverpool, UK
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Low Antituberculosis Drug Concentrations in HIV-Tuberculosis-Coinfected Adults with Low Body Weight: Is It Time To Update Dosing Guidelines? Antimicrob Agents Chemother 2019; 63:AAC.02174-18. [PMID: 30910890 DOI: 10.1128/aac.02174-18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 03/12/2019] [Indexed: 01/28/2023] Open
Abstract
Antituberculosis drugs display large pharmacokinetic variability, which may be influenced by several factors, including body size, genetic differences, and drug-drug interactions. We set out to determine these factors, quantify their effect, and determine the dose adjustments necessary for optimal drug concentrations. HIV-infected Ugandan adults with pulmonary tuberculosis treated according to international weight-based dosing guidelines underwent pharmacokinetic sampling (1, 2, and 4 h after drug intake) 2, 8, and 24 weeks after treatment initiation. Between May 2013 and November 2015, we enrolled 268 patients (148 males) with a median weight of 53.5 (interquartile range [IQR], 47.5 to 59.0) kg and a median age of 35 (IQR, 29 to 40) years. Population pharmacokinetic modeling was used to interpret the data and revealed that patients weighing <55 kg achieved lower concentrations than those in higher weight bands for all drugs in the regimen. The models predicted that this imbalance could be solved with a dose increment of one fixed-dose combination (FDC) tablet for the weight bands of 30 to 37 and 38 to 54 kg. Additionally, the concomitant use of efavirenz increased isoniazid clearance by 24.1%, while bioavailability and absorption of rifampin and isoniazid varied up to 30% in patients on different formulations. Current dosing guidelines lead to lower drug exposure in patients in the lower weight bands. Simply adding one FDC tablet to current weight band-based dosing would address these differences in exposure and possibly improve outcomes. Lower isoniazid exposures due to efavirenz deserve further attention, as does the quality of currently used drug formulations of anti-TB drugs. (This study has been registered at ClinicalTrials.gov under identifier NCT01782950.).
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13
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Hatton GB, Madla CM, Rabbie SC, Basit AW. Gut reaction: impact of systemic diseases on gastrointestinal physiology and drug absorption. Drug Discov Today 2018; 24:417-427. [PMID: 30453059 DOI: 10.1016/j.drudis.2018.11.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/25/2018] [Accepted: 11/13/2018] [Indexed: 12/17/2022]
Abstract
It was in 400 BC that Hippocrates reportedly stated that "death sits in the colon". The growth in our knowledge of the intestinal microbiome, the gut-brain axis and their function and imbalance has distinctly uncovered the complex relationship between the gut to disease predisposition and development, heralding the problem and the solution to disease pathology. Human studies of new drug molecules are typically performed in healthy volunteers and their specific disease indication. Approved drugs, however, are used by patients with diverse disease backgrounds. Here, we review the current literature of the gastrointestinal tract reacting to systemic disease pathology that elicits physiological and functional changes that consequently affect oral drug product performance.
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Affiliation(s)
- Grace B Hatton
- UCL School of Pharmacy, University College London, 29-39 Brunswick Square, London, WC1N 1AX, UK
| | - Christine M Madla
- UCL School of Pharmacy, University College London, 29-39 Brunswick Square, London, WC1N 1AX, UK
| | - Sarit C Rabbie
- UCL School of Pharmacy, University College London, 29-39 Brunswick Square, London, WC1N 1AX, UK
| | - Abdul W Basit
- UCL School of Pharmacy, University College London, 29-39 Brunswick Square, London, WC1N 1AX, UK.
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14
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Sekaggya-Wiltshire C, von Braun A, Lamorde M, Ledergerber B, Buzibye A, Henning L, Musaazi J, Gutteck U, Denti P, de Kock M, Jetter A, Byakika-Kibwika P, Eberhard N, Matovu J, Joloba M, Muller D, Manabe YC, Kamya MR, Corti N, Kambugu A, Castelnuovo B, Fehr JS. Delayed Sputum Culture Conversion in Tuberculosis-Human Immunodeficiency Virus-Coinfected Patients With Low Isoniazid and Rifampicin Concentrations. Clin Infect Dis 2018; 67:708-716. [PMID: 29514175 PMCID: PMC6094003 DOI: 10.1093/cid/ciy179] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 03/01/2018] [Indexed: 01/23/2023] Open
Abstract
Background The relationship between concentrations of antituberculosis drugs, sputum culture conversion, and treatment outcome remains unclear. We sought to determine the association between antituberculosis drug concentrations and sputum conversion among patients coinfected with tuberculosis and human immunodeficiency virus (HIV) and receiving first-line antituberculosis drugs. Methods We enrolled HIV-infected Ugandans with pulmonary tuberculosis. Estimation of first-line antituberculosis drug concentrations was performed 1, 2, and 4 hours after drug intake at 2, 8, and 24 weeks of tuberculosis treatment. Serial sputum cultures were performed at each visit. Time-to-event analysis was used to determine factors associated with sputum culture conversion. Results We enrolled 268 HIV-infected patients. Patients with low isoniazid and rifampicin concentrations were less likely to have sputum culture conversion before the end of tuberculosis treatment (hazard ratio, 0.54; 95% confidence interval, .37-.77; P = .001) or by the end of follow-up (0.61; .44-.85; P = .003). Patients in the highest quartile for area under the rifampicin and isoniazid concentration-time curves for were twice as likely to experience sputum conversion than those in the lowest quartile. Rifampicin and isoniazid concentrations below the thresholds and weight <55 kg were both risk factors for unfavorable tuberculosis treatment outcomes. Only 4.4% of the participants had treatment failure. Conclusion Although low antituberculosis drug concentrations did not translate to a high proportion of patients with treatment failure, the association between low concentrations of rifampicin and isoniazid and delayed culture conversion may have implications for tuberculosis transmission. Clinical Trials Registration: NCT01782950.
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Affiliation(s)
| | - Amrei von Braun
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Mohammed Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Bruno Ledergerber
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Allan Buzibye
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Lars Henning
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
- Division of Tropical Health and Medicine, James Cook University, Queensland, Australia
| | - Joseph Musaazi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ursula Gutteck
- Department of Clinical Chemistry, University Hospital Zurich, University of Zurich, Switzerland
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Miné de Kock
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Alexander Jetter
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Switzerland
| | - Pauline Byakika-Kibwika
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- School of Medicine, Makerere University, Kampala, Uganda
| | - Nadia Eberhard
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Joshua Matovu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Moses Joloba
- School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Daniel Muller
- Department of Clinical Chemistry, University Hospital Zurich, University of Zurich, Switzerland
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
| | - Moses R Kamya
- School of Medicine, Makerere University, Kampala, Uganda
| | - Natascia Corti
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Switzerland
| | - Andrew Kambugu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Barbara Castelnuovo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jan S Fehr
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
- Department of Public Health at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
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15
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Gaikwad UN, Gaikwad NR. Modalities to monitor the treatment response in tuberculosis. Indian J Tuberc 2018; 65:109-117. [PMID: 29579423 DOI: 10.1016/j.ijtb.2017.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 10/07/2017] [Accepted: 12/29/2017] [Indexed: 06/08/2023]
Abstract
Considering the global epidemic of drug resistance in Mycobacterium tuberculosis, early and accurate diagnosis as well as prompt initiation of antitubercular therapy (ATT) forms the mainstay of tuberculosis control programs. Patients on ATT may develop treatment failure due to diverse reasons including emergence of drug resistance in the host during the course of therapy. Monitoring the timely response to treatment in such cases has a significant role in rapid identification of drug resistant strains and institution of change of regimen to further decrease the morbidity and mortality associated with the disease. Furthermore, availability of faster surrogate end points to assess treatment efficacy, disease activity, cure, and relapse is one of the crucial requirements for undertaking innovative clinical trials related to TB. The article presents here the compilation of currently available methods for monitoring the treatment response in pulmonary as well as extrapulmonary TB.
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Affiliation(s)
- Ujjwala N Gaikwad
- Associate Professor, Department of Microbiology, All India Institute of Medical Sciences, G. E. Road, Tatibandh, Raipur, Chhattisgarh 492099, India.
| | - Nitin R Gaikwad
- Additional Professor, Department of Pharmacology, All India Institute of Medical Sciences, G.E. Road, Tatibandh, Raipur, Chhattisgarh 492099, India
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16
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The utility of pharmacokinetic studies for the evaluation of exposure-response relationships for standard dose anti-tuberculosis drugs. Tuberculosis (Edinb) 2017. [PMID: 29523331 DOI: 10.1016/j.tube.2017.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Tuberculosis (TB) is a major public health problem. Many countries still fall below the minimum World Health Organization (WHO) TB treatment target success rate. There is conflicting evidence about whether concentrations of anti-tuberculosis drugs given at standard doses have an effect on treatment outcomes. The current data correlating anti-TB drug concentrations and treatment outcome is limited. This article summarized the existing literature and their utility in evaluating the association between each anti-TB drug's concentrations using current target concentrations and treatment outcomes in patients with pulmonary tuberculosis receiving standard WHO-recommended dosing.
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17
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Sekaggya-Wiltshire C, Castelnuovo B, von Braun A, Musaazi J, Muller D, Buzibye A, Gutteck U, Henning L, Ledergerber B, Corti N, Lamorde M, Fehr J, Kambugu A. Cohort profile of a study on outcomes related to tuberculosis and antiretroviral drug concentrations in Uganda: design, methods and patient characteristics of the SOUTH study. BMJ Open 2017; 7:e014679. [PMID: 28928173 PMCID: PMC5623357 DOI: 10.1136/bmjopen-2016-014679] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
PURPOSE Tuberculosis (TB) is a leading cause of death among people living with HIV in sub-Saharan Africa. Several factors influence the efficacy of TB treatment by leading to suboptimal drug concentrations and subsequently affecting treatment outcome. The aim of this cohort is to determine the association between anti-TB drug concentrations and TB treatment outcomes. PARTICIPANTS Patients diagnosed with new pulmonary TB at the integrated TB-HIV outpatient clinic in Kampala, Uganda, were enrolled into the study and started on first-line anti-TB treatment. FINDINGS TO DATE Between April 2013 and April 2015, the cohort enrolled 268 patients coinfected with TB/HIV ; 57.8% are male with a median age of 34 years (IQR 29-40). The median time between the diagnosis of HIV and the diagnosis of TB is 2 months (IQR 0-22.5). The majority of the patients are antiretroviral therapy naive (75.4%). Our population is severely immunosuppressed with a median CD4 cell count at enrolment of 163 cells/µL (IQR 46-298). Ninety-nine per cent of the patients had a diagnosis of pulmonary TB confirmed by sputum microscopy, Xpert/RIF or culture and 203 (75.7%) have completed TB treatment with 5099 aliquots of blood collected for pharmacokinetic analysis. FUTURE PLANS This cohort provides a large database of well-characterised patients coinfected with TB/HIV which will facilitate the description of the association between serum drug concentrations and TB treatment outcomes as well as provide a research platform for future substudies including evaluation of virological outcomes. TRIAL REGISTRATION NUMBER NCT01782950; Pre-results.
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Affiliation(s)
| | - Barbara Castelnuovo
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Amrei von Braun
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Division of Infectious Diseases and Infection Control, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Joseph Musaazi
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Daniel Muller
- Department of Clinical Chemistry, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Allan Buzibye
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ursula Gutteck
- Department of Clinical Chemistry, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Lars Henning
- Division of Infectious Diseases and Infection Control, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Bruno Ledergerber
- Division of Infectious Diseases and Infection Control, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Natascia Corti
- Division of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jan Fehr
- Division of Infectious Diseases and Infection Control, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Andrew Kambugu
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
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18
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Abstract
Tuberculosis (TB) has recently surpassed HIV as the primary infectious disease killer worldwide, but the two diseases continue to display lethal synergy. The burden of TB is disproportionately borne by people living with HIV, particularly where HIV and poverty coexist. The impact of these diseases on one another is bidirectional, with HIV increasing risk of TB infection and disease progression and TB slowing CD4 recovery and increasing progression to AIDS and death among the HIV infected. Both antiretroviral therapy (ART) and latent TB infection (LTBI) treatment mitigate the impact of coinfection, and ART is now recommended for HIV-infected patients independent of CD4 count. LTBI screening should be performed for all HIV-positive people at the time of diagnosis, when their CD4 count rises above 200, and yearly if there is repeated exposure. Tuberculin skin tests (TSTs) may perform better with serial testing than interferon gamma release assays (IGRAs). Any patient with HIV and a TST induration of ≥5 mm should be evaluated for active TB disease and treated for LTBI if active disease is ruled out. Because HIV impairs multiple aspects of immune function, progressive HIV is associated with lower rates of cavitary pulmonary TB and higher rates of disseminated and extrapulmonary disease, so a high index of suspicion is important, and sputum should be obtained for evaluation even if chest radiographs are negative. TB diagnosis is similar in patients with and without TB, relying on smear, culture, and nucleic acid amplification tests, which are the initial tests of choice. TSTs and IGRAs should not be used in the evaluation of active TB disease since these tests are often negative with active disease. Though not always performed in resource-limited settings, drug susceptibility testing should be performed on all TB isolates from HIV-positive patients. Urine lipoarabinomannan testing may also be helpful in HIV-positive patients with disseminated disease. Treatment of TB in HIV-infected patients is similar to that of TB in HIV-negative patients except that daily therapy is required for all coinfected patients, vitamin B6 supplementation should be given to all coinfected patients receiving isoniazid to reduce peripheral neuropathy, and specific attention needs to be paid to drug-drug interactions between rifamycins and many classes of antiretrovirals. In patients requiring ART that contains ritonavir or cobicistat, this can be managed by the use of rifabutin at 150 mg daily in place of rifampin. For newly diagnosed coinfected patients, mortality is lower if treatment is provided in parallel, rather than serially, with treatment initiation within 2 weeks preferred for those with CD4 counts of <50 and within 8 to 12 weeks for those with higher CD4 counts. When TB immune reconstitution inflammatory syndrome occurs, patients can often be treated symptomatically with nonsteroidal anti-inflammatory drugs, but a minority will benefit from steroids. Generally, patients who do not have space-occupying lesions such as occurs in TB meningitis do not require cessation of therapy.
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19
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Antwi S, Yang H, Enimil A, Sarfo AM, Gillani FS, Ansong D, Dompreh A, Orstin A, Opoku T, Bosomtwe D, Wiesner L, Norman J, Peloquin CA, Kwara A. Pharmacokinetics of the First-Line Antituberculosis Drugs in Ghanaian Children with Tuberculosis with or without HIV Coinfection. Antimicrob Agents Chemother 2017; 61:e01701-16. [PMID: 27855070 PMCID: PMC5278726 DOI: 10.1128/aac.01701-16] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 11/05/2016] [Indexed: 11/20/2022] Open
Abstract
Although human immunodeficiency virus (HIV) coinfection is the most important risk factor for a poor antituberculosis (anti-TB) treatment response, its effect on the pharmacokinetics of the first-line drugs in children is understudied. This study examined the pharmacokinetics of the four first-line anti-TB drugs in children with TB with and without HIV coinfection. Ghanaian children with TB on isoniazid, rifampin, pyrazinamide, and ethambutol for at least 4 weeks had blood samples collected predose and at 1, 2, 4, and 8 hours postdose. Drug concentrations were determined by validated liquid chromatography-mass spectrometry methods and pharmacokinetic parameters calculated using noncompartmental analysis. The area under the concentration-time curve from 0 to 8 h (AUC0-8), maximum concentration (Cmax), and apparent oral clearance divided by bioavailability (CL/F) for each drug were compared between children with and without HIV coinfection. Of 113 participants, 59 (52.2%) had HIV coinfection. The baseline characteristics were similar except that the coinfected patients were more likely to have lower weight-for-age and height-for-age Z scores (P < 0.05). Rifampin, pyrazinamide, and ethambutol median body weight-normalized CL/F values were significantly higher, whereas the plasma AUC0-8 values were lower, in the coinfected children than in those with TB alone. In the multivariate analysis, drug dose and HIV coinfection jointly influenced the apparent oral clearance and AUC0-8 for rifampin, pyrazinamide, and ethambutol. Isoniazid pharmacokinetics were not different by HIV coinfection status. HIV coinfection was associated with lower plasma exposure of three of the four first-line anti-TB drugs in children. Whether TB/HIV-coinfected children need higher dosages of rifampin, pyrazinamide, and ethambutol requires further investigation. (This study has been registered at ClinicalTrials.gov under identifier NCT01687504.).
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Affiliation(s)
- Sampson Antwi
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
- Department of Child Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Hongmei Yang
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Anthony Enimil
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
- Department of Child Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Anima M Sarfo
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Fizza S Gillani
- Department of Medicine, The Miriam Hospital, Providence, Rhode Island, USA
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Daniel Ansong
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
- Department of Child Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Albert Dompreh
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Antoinette Orstin
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Theresa Opoku
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Dennis Bosomtwe
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jennifer Norman
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Charles A Peloquin
- College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
| | - Awewura Kwara
- Department of Medicine, The Miriam Hospital, Providence, Rhode Island, USA
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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20
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Egelund EF, Dupree L, Huesgen E, Peloquin CA. The pharmacological challenges of treating tuberculosis and HIV coinfections. Expert Rev Clin Pharmacol 2016; 10:213-223. [PMID: 27828731 DOI: 10.1080/17512433.2017.1259066] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Tuberculosis (TB) is the most prevalent opportunistic infection among HIV patients, and the leading cause of death among HIV patients worldwide. Simultaneous treatment of both diseases is recommended by current guidelines, but can be challenging due to the potential for drug-drug interactions, overlapping toxicities, difficulty adhering to medications, and an increased risk for immune reconstitution inflammatory syndrome (IRIS). Clinical manifestations of TB can also vary between HIV-infected patients and uninfected patients, which can increase the risk for delayed diagnosis. Areas covered: Topics covered in this review include the following: the inter-related pathophysiology of HIV and TB; clinical manifestations and diagnosis; drug-drug interactions, particularly the rifamycins with the antiretrovirals; IRIS presentation and treatment, as well as a discussion on overlapping toxicity between the two disease states. Expert commentary: The complexity of managing these two disease states simultaneously requires a multidisciplinary approach to care and dedicated resources. If properly funded, TB/HIV co-infection will continue to decline over the coming years.
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Affiliation(s)
- Eric F Egelund
- a Department of Pharmacotherapy and Translational Research , College of Pharmacy.,b Infectious Disease Pharmacokinetics Laboratory
| | - Lori Dupree
- a Department of Pharmacotherapy and Translational Research , College of Pharmacy
| | - Emily Huesgen
- a Department of Pharmacotherapy and Translational Research , College of Pharmacy
| | - Charles A Peloquin
- a Department of Pharmacotherapy and Translational Research , College of Pharmacy.,b Infectious Disease Pharmacokinetics Laboratory.,c Emerging Pathogens Institute , University of Florida , Gainesville , FL , USA
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21
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Toure A, Cabral M, Niang A, Diop C, Garat A, Humbert L, Fall M, Diouf A, Broly F, Lhermitte M, Allorge D. Prevention of isoniazid toxicity by NAT2 genotyping in Senegalese tuberculosis patients. Toxicol Rep 2016; 3:826-831. [PMID: 28959610 PMCID: PMC5616082 DOI: 10.1016/j.toxrep.2016.10.004] [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: 08/08/2016] [Revised: 10/14/2016] [Accepted: 10/14/2016] [Indexed: 11/24/2022] Open
Abstract
Isoniazid (INH), recommended by WHO (World Health Organization) in the treatment of tuberculosis (TB), is metabolized primarily by the genetically polymorphic N-acetyltransferase 2 (NAT2) enzyme. The human population is divided into three different phenotypic groups according to acetylation rate: slow, intermediate, and fast acetylators. The objective of this study was to explore the relationship between NAT2 genotypes and the serum concentrations of INH. Blood samples from 96 patients with TB were taken for the analysis. NAT2 polymorphisms on coding region were examined by polymerase chain reaction (PCR) direct sequencing; the acetylation status was obtained by measuring isoniazid (INH) and its metabolite, acetylisoniazid (AcINH) in plasma was obtained by using the liquid chromatography coupled to mass spectrometry. TB patients were distributed into two groups of fast and slow acetylators according to the acetylation index calculated based on the plasma concentration of INH in the 3rd hour (T3) after an oral dose. Our PCR analysis identified several alleles, where NAT2*4, NAT2*5A, NAT2*6A, and NAT2*13A were the most important. The concentrations of INH varied between 1.10 mg/L and 13.10 mg/L at the 3rd hour and between 0.1 and 9.5 mg/L at the 6th hour. The use of the acetylating index I3 allowed the classification of tested patients into two phenotypic groups: slow acetylators (44.3% of TB patients), and rapid acetylators (55.7%). Patient’s acetylation profile provides valuable information on their therapeutic, pharmacological, and toxicological responses.
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Affiliation(s)
- A Toure
- Laboratoire de Toxicologie et Hydrologie, Faculté de Médecine, Pharmacie et d'Odontologie UCAD, Dakar, Senegal.,EA 4483, Faculté de Médecine H. Warembourg, Pôle Recherche, Lille, France
| | - M Cabral
- Laboratoire de Toxicologie et Hydrologie, Faculté de Médecine, Pharmacie et d'Odontologie UCAD, Dakar, Senegal
| | - A Niang
- Service de Pneumophtisiologie, Centre Hospitalier National de Fann, Dakar, Senegal
| | - C Diop
- Laboratoire de Toxicologie et Hydrologie, Faculté de Médecine, Pharmacie et d'Odontologie UCAD, Dakar, Senegal
| | - A Garat
- Laboratoire de Toxicologie, Centre de Biologie Pathologie, Centre Hospitalier Régional et Universitaire, Lille, France.,EA 4483, Faculté de Médecine H. Warembourg, Pôle Recherche, Lille, France
| | - L Humbert
- Laboratoire de Toxicologie, Centre de Biologie Pathologie, Centre Hospitalier Régional et Universitaire, Lille, France
| | - M Fall
- Laboratoire de Toxicologie et Hydrologie, Faculté de Médecine, Pharmacie et d'Odontologie UCAD, Dakar, Senegal
| | - A Diouf
- Laboratoire de Toxicologie et Hydrologie, Faculté de Médecine, Pharmacie et d'Odontologie UCAD, Dakar, Senegal
| | - F Broly
- Laboratoire de Toxicologie, Centre de Biologie Pathologie, Centre Hospitalier Régional et Universitaire, Lille, France.,EA 4483, Faculté de Médecine H. Warembourg, Pôle Recherche, Lille, France
| | - M Lhermitte
- Laboratoire de Toxicologie, Centre de Biologie Pathologie, Centre Hospitalier Régional et Universitaire, Lille, France.,EA 4483, Faculté de Médecine H. Warembourg, Pôle Recherche, Lille, France
| | - D Allorge
- Laboratoire de Toxicologie, Centre de Biologie Pathologie, Centre Hospitalier Régional et Universitaire, Lille, France.,EA 4483, Faculté de Médecine H. Warembourg, Pôle Recherche, Lille, France
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22
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Nahid P, Dorman SE, Alipanah N, Barry PM, Brozek JL, Cattamanchi A, Chaisson LH, Chaisson RE, Daley CL, Grzemska M, Higashi JM, Ho CS, Hopewell PC, Keshavjee SA, Lienhardt C, Menzies R, Merrifield C, Narita M, O'Brien R, Peloquin CA, Raftery A, Saukkonen J, Schaaf HS, Sotgiu G, Starke JR, Migliori GB, Vernon A. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis 2016; 63:e147-e195. [PMID: 27516382 PMCID: PMC6590850 DOI: 10.1093/cid/ciw376] [Citation(s) in RCA: 672] [Impact Index Per Article: 84.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 06/06/2016] [Indexed: 02/06/2023] Open
Abstract
The American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America jointly sponsored the development of this guideline for the treatment of drug-susceptible tuberculosis, which is also endorsed by the European Respiratory Society and the US National Tuberculosis Controllers Association. Representatives from the American Academy of Pediatrics, the Canadian Thoracic Society, the International Union Against Tuberculosis and Lung Disease, and the World Health Organization also participated in the development of the guideline. This guideline provides recommendations on the clinical and public health management of tuberculosis in children and adults in settings in which mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis. For all recommendations, literature reviews were performed, followed by discussion by an expert committee according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. Given the public health implications of prompt diagnosis and effective management of tuberculosis, empiric multidrug treatment is initiated in almost all situations in which active tuberculosis is suspected. Additional characteristics such as presence of comorbidities, severity of disease, and response to treatment influence management decisions. Specific recommendations on the use of case management strategies (including directly observed therapy), regimen and dosing selection in adults and children (daily vs intermittent), treatment of tuberculosis in the presence of HIV infection (duration of tuberculosis treatment and timing of initiation of antiretroviral therapy), as well as treatment of extrapulmonary disease (central nervous system, pericardial among other sites) are provided. The development of more potent and better-tolerated drug regimens, optimization of drug exposure for the component drugs, optimal management of tuberculosis in special populations, identification of accurate biomarkers of treatment effect, and the assessment of new strategies for implementing regimens in the field remain key priority areas for research. See the full-text online version of the document for detailed discussion of the management of tuberculosis and recommendations for practice.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Julie M. Higashi
- Tuberculosis Control Section, San Francisco Department
of Public Health, California
| | - Christine S. Ho
- Division of Tuberculosis Elimination, National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and
Prevention, Atlanta, Georgia
| | | | | | | | | | | | - Masahiro Narita
- Tuberculosis Control Program, Seattle and King County Public Health, and
University of Washington, Seattle
| | - Rick O'Brien
- Ethics Advisory Group, International Union Against TB
and Lung Disease, Paris,
France
| | | | | | | | - H. Simon Schaaf
- Department of Paediatrics and Child Health, Stellenbosch University, Cape
Town, South Africa
| | | | | | - Giovanni Battista Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Fondazione S. Maugeri Care and
Research Institute, Tradate, Italy
| | - Andrew Vernon
- Division of Tuberculosis Elimination, National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and
Prevention, Atlanta, Georgia
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23
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Abstract
Current treatment guidelines advocate the use of triple combination antiretroviral therapy for the management of human immunodeficiency virus (HIV) infection with one protease inhibitor (PI) or nonnucleoside reverse transcriptase inhibitor (NNRTI) plus two nucleoside reverse transcriptase inhibitors (NRTIs). Additionally, patients often receive medications for prophylaxis and treatment of opportunistic infections and comorbid illnesses. Polypharmacy with potent medications places the patient with HIV at significant risk of drug interactions. The purpose of this review is to assist clinicians regarding awareness and management of clinically significant drug interactions frequently encountered in the HIV population. Pharmacodynamic and pharmacokinetic interactions are discussed in depth with several tables of significant interactions encountered in the patient with HIV. Certain combinations of NRTIs have antagonistic antiretroviral action (e.g., zidovudine plus stavudine), and thus should be avoided. All of the currently available PIs and delavirdine are cytochrome (CYP) 450 inhibitors and can cause significant inhibition of concomitant drug metabolism. Nevirapine is a CYP 450 inducer and can cause induction of drug metabolism, whereas efavirenz may cause inhibition or induction. Drug-herbal interactions are reviewed, including the decreased concentrations of indinavir following the administration of St. John’s wort. Additionally, the pharmacist’s role as an integral member of the HIV patient care team is discussed.
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Affiliation(s)
- John M. Conry
- Department of Pharmacy Practice, Nesbitt School of Pharmacy, Wilkes University, P.O. Box 111, Stark Learning Center 336, Wilkes-Barre, PA 18766
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Pharmacokinetics of Antituberculosis Drugs in HIV-Positive and HIV-Negative Adults in Malawi. Antimicrob Agents Chemother 2015; 59:6175-80. [PMID: 26248378 PMCID: PMC4576091 DOI: 10.1128/aac.01193-15] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 07/12/2015] [Indexed: 11/25/2022] Open
Abstract
Limited data address the impact of HIV coinfection on the pharmacokinetics (PK) of antituberculosis drugs in sub-Saharan Africa. A total of 47 Malawian adults underwent rich pharmacokinetic sampling at 0, 0.5, 1, 2, 3, 4, 6, 8, and 24 h postdose. Of the subjects, 51% were male, their mean age was 34 years, and 65% were HIV-positive with a mean CD4 count of 268 cells/μl. Antituberculosis drugs were administered as fixed-dose combinations (150 mg rifampin, 75 mg isoniazid, 400 mg pyrazinamide, and 275 mg ethambutol) according to recommended weight bands. Plasma drug concentrations were determined by high-performance liquid chromatography (rifampin and pyrazinamide) or liquid chromatography-mass spectrometry (isoniazid and ethambutol). Data were analyzed by noncompartmental methods and analysis of variance of log-transformed summary parameters. The pharmacokinetic parameters were as follows (median [interquartile range]): for rifampin, maximum concentration of drug in plasma (Cmax) of 4.129 μg/ml (2.474 to 5.596 μg/ml), area under the curve from 0 to 24 h (AUC0–∞) of 21.32 μg/ml · h (13.57 to 28.60 μg/ml · h), and half-life of 2.45 h (1.86 to 3.08 h); for isoniazid, Cmax of 3.97 μg/ml (2.979 to 4.544 μg/ml), AUC0–24 of 22.5 (14.75 to 34.59 μg/ml · h), and half-life of 3.93 h (3.18 to 4.73 h); for pyrazinamide, Cmax of 34.21 μg/ml (30.00 to 41.60 μg/ml), AUC0–24 of 386.6 μg/ml · h (320.0 to 463.7 μg/ml · h), and half-life of 6.821 h (5.71 to 8.042 h); and for ethambutol, Cmax of 2.278 μg/ml (1.694 to 3.098 μg/ml), AUC0–24 of 20.41 μg/ml · h (16.18 to 26.27 μg/ml · h), and half-life of 7.507 (6.517 to 8.696 h). The isoniazid PK data analysis suggested that around two-thirds of the participants were slow acetylators. Dose, weight, and weight-adjusted dose were not significant predictors of PK exposure, probably due to weight-banded dosing. In this first pharmacokinetic study of antituberculosis drugs in Malawian adults, measures of pharmacokinetic exposure were comparable with those of other studies for all first-line drugs except for rifampin, for which the Cmax and AUC0–24 values were notably lower. Contrary to some earlier observations, HIV status did not significantly affect the AUC of any of the drugs. Increasing the dose of rifampin might be beneficial in African adults, irrespective of HIV status. Current co-trimoxazole prophylaxis was associated with an increase in the half-life of isoniazid of 41% (P = 0.022). Possible competitive interactions between isoniazid and sulfamethoxazole mediated by the N-acetyltransferase pathway should therefore be explored further.
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Baietto L, Calcagno A, Motta I, Baruffi K, Poretti V, Di Perri G, Bonora S, D'Avolio A. A UPLC-MS-MS method for the simultaneous quantification of first-line antituberculars in plasma and in PBMCs. J Antimicrob Chemother 2015; 70:2572-5. [PMID: 26066583 DOI: 10.1093/jac/dkv148] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 05/11/2015] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES TB is currently the second cause of death among patients affected with infectious diseases. Quantification of drug levels in plasma and in cells where Mycobacterium tuberculosis persists and grows may be useful in understanding the appropriateness of dosage regimens. We report a new and fully validated chromatographic method to quantify first-line antituberculars in plasma and PBMCs. The method was used for plasma and cell quantification of antituberculars in patients undergoing treatment with standard oral therapy. METHODS Ethambutol, isoniazid, pyrazinamide and rifampicin were extracted from plasma and PBMCs using two separate and optimized procedures; analysis was performed using UPLC coupled with a mass-mass detector system (UPLC-MS-MS). Antitubercular levels in patients were assayed at the end of the dosing interval (C trough) and 2 h post-dose (C max). RESULTS The method was accurate and precise. Recovery and the matrix effect were reproducible. While rifampicin intracellular concentrations were similar to plasma values (median intra-PBMC C max = 7503 ng/mL versus median plasma C max = 6505 ng/mL), isoniazid and pyrazinamide intracellular concentrations were lower than plasma values (median intra-PBMC C max = 12 ng/mL versus median plasma C max = 3258 ng/mL for isoniazid and median intra-PBMC C max = 2364 ng/mL versus median plasma C max = 26 988 ng/mL for pyrazinamide) and ethambutol intracellular concentrations were significantly higher than plasma values (median intra-PBMC C max = 73 334 ng/mL versus median plasma C max = 2244 ng/mL). CONCLUSIONS The method was suitable for both therapeutic drug monitoring and for pharmacokinetic analysis. Should the clinical usefulness of measuring antitubercular drug intracellular concentrations be confirmed, this method could be useful to enhance the clinical application of intra-PBMC evaluation.
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Affiliation(s)
- Lorena Baietto
- Department of Medical Sciences, University of Turin, Unit of Infectious Diseases, Amedeo di Savoia Hospital, Turin, Italy
| | - Andrea Calcagno
- Department of Medical Sciences, University of Turin, Unit of Infectious Diseases, Amedeo di Savoia Hospital, Turin, Italy
| | - Ilaria Motta
- Department of Medical Sciences, University of Turin, Unit of Infectious Diseases, Amedeo di Savoia Hospital, Turin, Italy
| | - Katia Baruffi
- Department of Medical Sciences, University of Turin, Unit of Infectious Diseases, Amedeo di Savoia Hospital, Turin, Italy
| | - Viviana Poretti
- Department of Medical Sciences, University of Turin, Unit of Infectious Diseases, Amedeo di Savoia Hospital, Turin, Italy
| | - Giovanni Di Perri
- Department of Medical Sciences, University of Turin, Unit of Infectious Diseases, Amedeo di Savoia Hospital, Turin, Italy
| | - Stefano Bonora
- Department of Medical Sciences, University of Turin, Unit of Infectious Diseases, Amedeo di Savoia Hospital, Turin, Italy
| | - Antonio D'Avolio
- Department of Medical Sciences, University of Turin, Unit of Infectious Diseases, Amedeo di Savoia Hospital, Turin, Italy
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Tuffour J, Owusu-Mireku E, Ruf MT, Aboagye S, Kpeli G, Akuoku V, Pereko J, Paintsil A, Bonney K, Ampofo W, Pluschke G, Yeboah-Manu D. Challenges Associated with Management of Buruli Ulcer/Human Immunodeficiency Virus Coinfection in a Treatment Center in Ghana: A Case Series Study. Am J Trop Med Hyg 2015; 93:216-23. [PMID: 26055745 DOI: 10.4269/ajtmh.14-0571] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 03/13/2015] [Indexed: 11/07/2022] Open
Abstract
The synergy between Mycobacterium tuberculosis infection and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome is well established but not so in Buruli ulcer (BU). We screened confirmed BU cases for HIV infection and followed seven BU/HIV-coinfected patients. Management of BU/HIV was based on the World Health Organization guidelines and patient condition. The HIV positivity among BU patients (8.2%; 11/134) was higher compared with that of general patients attending the facility (4.8%; 718/14,863; P = 0.07) and that of pregnant women alone (2.5%; 279/11,125; P = 0.001). All seven BU/HIV-coinfected cases enrolled in the study presented with very large (category III) lesions with four having multiple lesions compared with 54.5% of category III lesions among HIV-negative BU patients. During the recommended BU treatment with streptomycin and rifampicin (SR) all patients developed immune infiltrates including CD4 T cells in their lesions. However, one patient who received antiretroviral therapy (ART) 1 week after beginning SR treatment developed four additional lesions during antibiotic treatment, while two out of the four who did not receive ART died. Further evidence is required to ascertain the most appropriate time to commence ART in relation to SR treatment to minimize paradoxical reactions.
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Affiliation(s)
- Joseph Tuffour
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Evelyn Owusu-Mireku
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Marie-Therese Ruf
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Samuel Aboagye
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Grace Kpeli
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Victor Akuoku
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Janet Pereko
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Albert Paintsil
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Kofi Bonney
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - William Ampofo
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Gerd Pluschke
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | - Dorothy Yeboah-Manu
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana; Ga West Municipal Hospital, Ghana Health Service, Amasaman, Ghana; Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
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Egelund EF, Fennelly KP, Peloquin CA. Medications and Monitoring in Nontuberculous Mycobacteria Infections. Clin Chest Med 2015; 36:55-66. [DOI: 10.1016/j.ccm.2014.11.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Alsultan A, Peloquin CA. Therapeutic Drug Monitoring in the Treatment of Tuberculosis: An Update. Drugs 2014; 74:839-54. [DOI: 10.1007/s40265-014-0222-8] [Citation(s) in RCA: 280] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pharmacokinetics of ofloxacin and levofloxacin for prevention and treatment of multidrug-resistant tuberculosis in children. Antimicrob Agents Chemother 2014; 58:2948-51. [PMID: 24550337 DOI: 10.1128/aac.02755-13] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Limited data on fluoroquinolone pharmacokinetics and cardiac effects in children exist. Among 22 children receiving drug-resistant tuberculosis prophylaxis or treatment, serum concentrations following oral doses of levofloxacin (15 mg/kg of body weight) and ofloxacin (20 mg/kg) were lower than those expected from existing pediatric data, possibly due to differences in the formulations (crushed tablets). Drug exposures were lower than those in adults following standard doses and below the proposed pharmacodynamic targets, likely due to more rapid elimination in children. No QT prolongation was observed.
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Nishanth Kumar S, Mohandas C. Antimycobacterial activity of cyclic dipeptides isolated from Bacillus sp. N strain associated with entomopathogenic nematode. PHARMACEUTICAL BIOLOGY 2014; 52:91-96. [PMID: 24047443 DOI: 10.3109/13880209.2013.815635] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
CONTEXT Tuberculosis (TB) is one of the leading causes of morbidity and mortality with a global mortality rate of two million deaths per year; one-third of the world's population is infected with Mycobacterium tuberculosis. OBJECTIVE The aim of this study was to determine the antimycobacterial activity of six diketopiperazines (DKPs) purified from a Bacillus sp. N strain associated with entomopathogenic nematode Rhabditis (Oscheius) sp. MATERIALS AND METHODS The minimum inhibitory concentration (MIC) and minimum bactericidal concentration of DKPs were determined using the broth dilution method on Middlebrook 7H11 against M. tuberculosis H₃₇Rv. Time-kill assay was used to determine the rate of killing of M. tuberculosis H₃₇Rv by DKPs. The cytotoxicity of the DKPs was determined by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay against the VERO cell line. RESULTS Out of six DKP-tested cyclo-(D-Pro-L-Leu), cyclo-(L-Pro-L-Met) and cyclo-(D-Pro-L-Phe) recorded antimycobacterial activity, the cyclo-(L-Pro-L-Met) showed the highest activity and MIC values of 4 μg/ml for M. tuberculosis H₃₇Rv. The MIC value for rifampicin was 0.06 μg/ml. Growth curve study by the MIC concentration of cyclic dipeptides recorded significant inhibition when compared with control. Time-kill curve showed maximum reduction of colony count was between 3 and 5 weeks. The DKPs are nontoxic to the VERO cell line up to 200 µg/ml. The antimycobacterial activity of cyclo-(D-Pro-L-Leu), cyclo-(L-Pro-L-Met) and cyclo-(D-Pro-L-Phe) is reported in this study for the first time. DISCUSSION AND CONCLUSION In conclusion, the potency, low cytotoxicity and selectivity of these compounds make them valid lead compounds for treatment against TB.
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Affiliation(s)
- S Nishanth Kumar
- Division of Crop Protection/Division of Crop Utilization, Central Tuber Crops Research Institute , Sreekariyam, Thiruvananthapuram, Kerala , India
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Pandey K, Sinha PK, Das VNR, Kumar N, Hassan SM, Verma N, Lal CS, Bimal S, Das P, Bhattacharya SK. HIV-1 infection, visceral leishmaniasis, Koch's chest and tuberculous meningitis in the same patient — a case report. ANNALS OF TROPICAL MEDICINE AND PARASITOLOGY 2013; 99:807-11. [PMID: 16297295 DOI: 10.1179/136485905x75386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- K Pandey
- Rajendra Memorial Research Institute of Medical Sciences (ICMR), Agam Kuan, P.O. Gulzarbagh, Patna - 800007, Bihar, India.
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Pettit AC, Cummins J, Kaltenbach LA, Sterling TR, Warkentin JV. Non-adherence and drug-related interruptions are risk factors for delays in completion of treatment for tuberculosis. Int J Tuberc Lung Dis 2013; 17:486-92. [PMID: 23394818 DOI: 10.5588/ijtld.12.0133] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
SETTING A key program performance objective established by the Centers for Disease Control and Prevention (CDC) is that ≥93% of tuberculosis (TB) cases complete treatment within 12 months. OBJECTIVE To determine the rate of and risk factors for delay in anti-tuberculosis treatment completion. DESIGN Nested case-control study among TB cases reported to the Tennessee Department of Health between 1 January 2000 and 31 December 2010. Time to complete treatment was calculated using treatment start and stop dates documented in the Tuberculosis Information Management System (TIMS). RESULTS Of 2627 cases, 261 (9.9%) required >12 months to complete treatment. In adjusted conditional logistic regression analyses, cavitary disease and positive cultures after 2 months of therapy (OR 5.85, 95%CI 1.98-17.32, P = 0.001), non-adherence (OR 4.13, 95%CI 1.76-9.72, P < 0.001), and interruptions in treatment due to drug-related issues (OR 6.91, 95%CI 3.76-12.70, P < 0.001) were independently associated with delay in completion of TB treatment. CONCLUSION From 2000 to 2010, the proportion of TB cases completing treatment within 12 months increased from 84.6% to 94.9%, and remained above the CDC target during 2009-2010. Efforts to improve patient adherence and reduce interruptions in treatment due to anti-tuberculosis drug-related issues could improve the proportion of TB cases completing treatment within 12 months.
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Affiliation(s)
- A C Pettit
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA. april.pettit@ vanderbilt.edu
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Cohen T, Dye C, Colijn C, Williams B, Murray M. Mathematical models of the epidemiology and control of drug-resistant TB. Expert Rev Respir Med 2012; 3:67-79. [PMID: 20477283 DOI: 10.1586/17476348.3.1.67] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Recent reports of extensively drug-resistant TB in South Africa have renewed concerns that antibiotic resistance may undermine progress in TB control. We review three major questions for which mathematical models elucidate the epidemiology and control of drug-resistant TB. How is multiple drug-resistant Mycobacterium tuberculosis selected for in individuals exposed to combination chemotherapy? What factors determine the prevalence of drug-resistant TB? Which interventions to prevent the spread of drug-resistant TB are effective and feasible? Models offer insight into the acquisition and amplification of drug resistance, reveal the importance of distinguishing the intrinsic and extrinsic determinants of the reproductive capacity of drug-resistant M. tuberculosis, and demonstrate the cost effectiveness of interventions for drug-resistant TB. These models also highlight knowledge gaps for which new research will improve our ability to project trends of drug resistance and develop more effective policies for its control.
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Affiliation(s)
- Ted Cohen
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA and Department of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA.
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Matteelli A, Richardson MD, Sotgiu G, Centis R, Migliori GB. Multidrug- and extensively drug-resistant TB in persons living with HIV. Expert Rev Respir Med 2012; 3:245-54. [PMID: 20477319 DOI: 10.1586/ers.09.15] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) represent an emerging public health problem worldwide. The collision of the HIV epidemic with MDR- and XDR-TB has produced disastrous consequences for individual patients, with very high mortality rates reported in outbreaks among HIV-infected individuals. There is evidence of the importance of primary resistance among HIV-infected persons with XDR-TB, while the relevance of acquired resistance during inappropriate treatment among HIV-infected persons is uncertain, and TB case management of HIV-infected and -uninfected persons is based on similar standard practices to ensure treatment adherence. Current data show a limited geographical overlap of the XDR-TB and HIV epidemics: such data must be interpreted cautiously owing to the lack of adequate testing for both conditions. In fact, there are signs of an evolving epidemiological situation characterized by increased outbreak risk in concentrated areas owing to the extension of the HIV epidemic into areas of high MDR-TB prevalence and of the MDR-TB epidemic into areas of high HIV prevalence. There is a paucity of studies on treatment outcome among HIV-infected XDR-TB patients, and the only available report shows extremely high mortality rate and very short survival. Rapid diagnosis of TB and MDR-TB will be pivotal to reduce mortality among persons co-infected with HIV. However, while rapid diagnosis of MDR-TB is feasible with molecular assays on direct specimens, molecular approaches are still insensitive for XDR-TB diagnosis. There is speculative evidence that effective strategies for early HIV diagnosis and treatment will play a role in limiting the spread, and possibly improving the outcome of XDR-TB. Prevention is currently the mainstay of XDR-TB control in HIV communities. Strategies for infection control based on administrative procedures, environmental control and respiratory protection should be a priority for countries where both XDR-TB and HIV are prevalent. However, only the comprehensive implementation of the full Stop TB Strategy may be expected to curb the devastating impact of XDR-TB on HIV-infected persons.
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Affiliation(s)
- Alberto Matteelli
- Institute of Infectious & Tropical Diseases, University of Brescia, Piazza Spedali Civili, 1-25125 Brescia, Italy.
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Reduced antituberculosis drug concentrations in HIV-infected patients who are men or have low weight: implications for international dosing guidelines. Antimicrob Agents Chemother 2012; 56:3232-8. [PMID: 22411614 DOI: 10.1128/aac.05526-11] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Reduced antituberculosis drug concentrations may contribute to unfavorable treatment outcomes among HIV-infected patients with more advanced immune suppression, and few studies have evaluated pharmacokinetics of the first-line antituberculosis drugs in such patients given fixed-dose combination tablets according to international guidelines using weight bands. In this study, pharmacokinetics were evaluated in 60 patients on 4 occasions during the first month of antituberculosis therapy. Multilevel linear mixed-effects regression analysis was used to examine the effects of age, sex, weight, drug dose/kilogram, CD4(+) lymphocyte count, treatment schedule (5 versus 7 days/week), and concurrent antiretrovirals (efavirenz plus lamivudine plus zidovudine) on the area under the concentration-time curve from 0 to 12 h (AUC(0-12)) of the respective antituberculosis drugs and to compare AUC(0-12)s at day 8, day 15, and day 29 with the day 1 AUC(0-12). Median (range) age, weight, and CD4(+) lymphocyte count were 32 (18 to 47) years, 55.2 (34.4 to 98.7) kg, and 252 (12 to 500)/μl. For every 10-kg increase in body weight, the predicted day 29 AUC(0-12) increased by 14.1% (95% confidence interval [CI], 7.5, 20.8), 14.1% (95% CI, -0.7, 31.1), 6.1% (95% CI, 2.7, 9.6) and 6.0% (95% CI, 0.8, 11.3) for rifampin, isoniazid, pyrazinamide, and ethambutol, respectively. Males had day 29 AUC(0-12)s 19.3% (95% CI, 3.6, 35.1) and 14.0% (95% CI, 5.6, 22.4) lower than females for rifampin and pyrazinamide, respectively. Level of immune suppression and concomitant antiretrovirals had little effect on the concentrations of the antituberculosis agents. As they had reduced drug concentrations, it is important to review treatment responses in patients in the lower weight bands and males to inform future treatment guidelines, and revision of doses in these patients should be considered.
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Pozniak AL, Coyne KM, Miller RF, Lipman MCI, Freedman AR, Ormerod LP, Johnson MA, Collins S, Lucas SB. British HIV Association guidelines for the treatment of TB/HIV coinfection 2011. HIV Med 2011; 12:517-24. [PMID: 21951595 DOI: 10.1111/j.1468-1293.2011.00954.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- A L Pozniak
- British HIV Association (BHIVA), BHIVA Secretariat, Mediscript Ltd, 1 Mountview Court, 310 Friern Barnet Lane, London N20 0LD, UK.
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Wilkins JJ, Langdon G, McIlleron H, Pillai G, Smith PJ, Simonsson USH. Variability in the population pharmacokinetics of isoniazid in South African tuberculosis patients. Br J Clin Pharmacol 2011; 72:51-62. [PMID: 21320152 DOI: 10.1111/j.1365-2125.2011.03940.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIM This study was designed to characterize the population pharmacokinetics of isoniazid in South African pulmonary tuberculosis patients. METHODS Concentration-time measurements obtained from 235 patients receiving oral doses of isoniazid as part of routine tuberculosis chemotherapy in two clinical studies were pooled and subjected to nonlinear mixed-effects analysis. RESULTS A two-compartmental model, including first-order absorption and elimination with allometric scaling, was found to describe the observed dose-exposure relationship for oral isoniazid adequately. A mixture model was used to characterize dual rates of isoniazid elimination. Estimates of apparent clearance in slow and fast eliminators were 9.70 and 21.6 l h(-1) , respectively. The proportion of fast eliminators in the population was estimated to be 13.2%. Central volume of distribution was estimated to be 10% smaller in female patients and clearance was found to be 17% lower in patients with HIV. Variability in absorption rate (90%) was completely interoccasional in nature, whereas in relative bioavailability, interoccasional variability (8.4%) was lower than interindividual variability (26%). Oral doses, given once daily according to dosing policies at the time, were sufficient to reach therapeutic concentrations in the majority of the studied population, regardless of eliminator phenotype. Simulations suggested that current treatment guidelines (5 mg kg(-1) ) may be suboptimal in fast eliminators with low body weight. CONCLUSIONS A population pharmacokinetic model was developed to characterize the highly variable pharmacokinetics of isoniazid in a South African pulmonary tuberculosis patient population. Current treatment guidelines may lead to underexposure in rapid isoniazid eliminators.
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Affiliation(s)
- Justin J Wilkins
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Seddon JA, Hesseling AC, Marais BJ, McIlleron H, Peloquin CA, Donald PR, Schaaf HS. Paediatric use of second-line anti-tuberculosis agents: a review. Tuberculosis (Edinb) 2011; 92:9-17. [PMID: 22118883 DOI: 10.1016/j.tube.2011.11.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Revised: 09/25/2011] [Accepted: 11/01/2011] [Indexed: 11/18/2022]
Abstract
Childhood multidrug-resistant tuberculosis (MDR-TB) is an emerging global epidemic. With the imminent roll-out of rapid molecular diagnostic tests, more children are likely to be identified and require treatment. As MDR-TB is resistant to the most effective first-line drugs, clinicians will have to rely on second-line medications which are less effective and often associated with more pronounced adverse effects than first-line therapy. Despite the fact that most of these agents were discovered many years ago, robust information is lacking regarding their pharmacokinetic and pharmacodynamic properties, adverse effects and drug interactions, especially in children. Children differ from adults in the way that drugs are administered, the manner in which they are metabolised and in the adverse effects experienced. The interaction of these drugs with human immunodeficiency virus infection and antiretroviral therapy is also poorly documented. This article reviews the available second-line drugs currently used in the treatment of MDR-TB in children and discusses medication properties and adverse effects while potential interactions with antiretroviral therapy are explored.
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Affiliation(s)
- James A Seddon
- Desmond Tutu TB Centre, Faculty of Health Sciences, Stellenbosch University, South Africa.
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Bolhuis MS, Panday PN, Pranger AD, Kosterink JGW, Alffenaar JWC. Pharmacokinetic drug interactions of antimicrobial drugs: a systematic review on oxazolidinones, rifamycines, macrolides, fluoroquinolones, and Beta-lactams. Pharmaceutics 2011; 3:865-913. [PMID: 24309312 PMCID: PMC3857062 DOI: 10.3390/pharmaceutics3040865] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Revised: 10/26/2011] [Accepted: 11/09/2011] [Indexed: 12/17/2022] Open
Abstract
Like any other drug, antimicrobial drugs are prone to pharmacokinetic drug interactions. These drug interactions are a major concern in clinical practice as they may have an effect on efficacy and toxicity. This article provides an overview of all published pharmacokinetic studies on drug interactions of the commonly prescribed antimicrobial drugs oxazolidinones, rifamycines, macrolides, fluoroquinolones, and beta-lactams, focusing on systematic research. We describe drug-food and drug-drug interaction studies in humans, affecting antimicrobial drugs as well as concomitantly administered drugs. Since knowledge about mechanisms is of paramount importance for adequate management of drug interactions, the most plausible underlying mechanism of the drug interaction is provided when available. This overview can be used in daily practice to support the management of pharmacokinetic drug interactions of antimicrobial drugs.
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Affiliation(s)
- Mathieu S Bolhuis
- Department of Hospital and Clinical Pharmacy, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands.
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Abstract
Ethionamide (ETH), a second-line antituberculosis drug, is frequently used in treating childhood tuberculosis. Data supporting ETH dose recommendations in children are limited. The aim of this study was to determine the pharmacokinetic parameters for ETH in children on antituberculosis treatment including ETH. ETH serum levels were prospectively assessed in 31 children in 3 age groups (0 to 2 years, 2 to 6 years, and 6 to 12 years). Within each age group, half received rifampin (RMP). Following an oral dose of ETH (15 to 20 mg/kg of body weight), blood samples were collected at 0, 1, 2, 3, 4, and 6 h following 1 and 4 months of ETH therapy. The maximum serum concentration (C(max)), time to C(max) (T(max)), and area under the time-concentration curve from 0 to 6 h (AUC(0-6)) were calculated. Younger children were exposed to lower ETH concentrations than older children at the same mg/kg body weight dose. Age correlated significantly with the AUC after both 1 month (r = 0.50, P = 0.001) and 4 months (r = 0.63, P = 0.001) of therapy. There was no difference in the AUC or C(max) between children receiving concomitant treatment with RMP and those who did not. Time on treatment did not influence the pharmacokinetic parameters of ETH following 1 and 4 months of therapy. HIV infection was associated with lower ETH exposure. In conclusion, ETH at an oral dose of 15 to 20 mg/kg results in sufficient serum concentrations compared to current adult recommended levels in the majority of children across all age groups. ETH levels were influenced by young age and HIV status but were not affected by concomitant RMP treatment and duration of therapy.
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41
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Population pharmacokinetics of ethambutol in South African tuberculosis patients. Antimicrob Agents Chemother 2011; 55:4230-7. [PMID: 21690284 DOI: 10.1128/aac.00274-11] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Ethambutol, one of four drugs in the first-line antitubercular regimen, is used to protect against rifampin resistance in the event of preexisting resistance to isoniazid. The population pharmacokinetics of ethambutol in South African patients with pulmonary tuberculosis were characterized using nonlinear mixed-effects modeling. Patients from 2 centers were treated with ethambutol (800 to 1,500 mg daily) combined with standard antitubercular medication. Plasma concentrations of ethambutol were measured following multiple doses at steady state and were determined using a validated high-pressure liquid chromatography-tandem mass spectrometric method. The data comprised 189 patients (54% male, 12% HIV positive) weighing 47 kg, on average (range, 29 to 86 kg), and having a mean age of 36 years (range, 16 to 72 years). The estimated creatinine clearance was 79 ml/min (range, 23 to 150 ml/min). A two-compartment model with one transit compartment prior to first-order absorption and allometric scaling by body weight on clearance and volume terms was selected. HIV infection was associated with a 15% reduction in bioavailability. Renal function was not related to ethambutol clearance in this cohort. Interoccasion variability exceeded interindividual variability for oral clearance (coefficient of variation, 36 versus 20%). Typical oral clearance in this analysis (39.9 liters/h for a 50-kg individual) was lower than that previously reported, a finding partly explained by the differences in body weight between the studied populations. In summary, a population model describing the pharmacokinetics of ethambutol in South African tuberculosis patients was developed, but additional studies are needed to characterize the effects of renal function.
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Heysell SK, Moore JL, Keller SJ, Houpt ER. Therapeutic drug monitoring for slow response to tuberculosis treatment in a state control program, Virginia, USA. Emerg Infect Dis 2011; 16:1546-53. [PMID: 20875279 PMCID: PMC3294393 DOI: 10.3201/eid1610.100374] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
TOC summary: Diabetes was associated with increased risk for slow response and low rifampin levels. Therapeutic drug monitoring may be useful in tuberculosis management, but programmatic implementation is understudied. We performed a retrospective cohort study to determine prevalence of lower than expected levels of isoniazid, rifampin, ethambutol, and pyrazinamide measured at time of estimated peak serum concentration. Patients were tested for serum concentration at 2 hours after medication administration. When patients were tested, 22 had concentrations lower than expected range for rifampin, 23 of 39 patients had low levels of isoniazid, and 8 of 26 patients had low levels of ethambutol; all 20 patients tested for pyrazinamide were within expected range. Over 26 months, 42 patients met criteria for slow response. Diabetes was associated with slow response (p<0.001), and persons with diabetes were more likely than persons without diabetes to have low rifampin levels (p = 0.03). Dosage adjustment of rifampin was more likely to elevate serum concentration to the target range than adjustment of isoniazid given in daily doses (p = 0.01).
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Affiliation(s)
- Scott K Heysell
- Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia 22908, USA.
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Dartois V, Barry CE. Clinical pharmacology and lesion penetrating properties of second- and third-line antituberculous agents used in the management of multidrug-resistant (MDR) and extensively-drug resistant (XDR) tuberculosis. CURRENT CLINICAL PHARMACOLOGY 2010; 5:96-114. [PMID: 20156156 PMCID: PMC6344931 DOI: 10.2174/157488410791110797] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Accepted: 12/17/2009] [Indexed: 11/22/2022]
Abstract
Failure of first-line chemotherapy to cure tuberculosis (TB) patients occurs, in part, because of the development of resistance to isoniazid (INH) and rifampicin (RIF) the two most sterilizing agents in the four-drug regimen used to treat primary infections. Strains resistant to both INH and RIF are termed multidrug-resistant (MDR). Treatment options for MDR patients involve a complex array of twenty different drugs only two classes of which are considered to be highly effective (fluoroquinolones and aminoglycosides). Resistance to these two classes results in strains known as extensively drug-resistant (XDR) and these types of infections are becoming increasingly common. Many of the remaining agents have poorly defined pharmacology but nonetheless are widely used in the treatment of this disease. Several of these agents are known to have highly variable exposures in healthy volunteers and little is known in the patients in which they must be used. Therapeutic drug monitoring (TDM) is infrequently used in the management of MDR or XDR disease yet the clinical pharmacokinetic studies that have been done suggest this might have a large impact on disease outcome. We review what is known about the pharmacologic properties of each of the major classes of second- and third-line antituberculosis agents and suggest where judicious use of TDM would have the maximum possible impact. We summarize the state of knowledge of drug-drug interactions (DDI) in these classes of agents and those that are currently in clinical trials. Finally we consider what little is known about the ability of TB drugs to reach their ultimate site of action--the interior of a granuloma by penetrating the diseased lung area. Careful consideration of the pharmacology of these agents is essential if we are to avoid further fueling the growing epidemic of highly drug-resistant TB and critical in the development of new antituberculosis drugs.
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Affiliation(s)
- Véronique Dartois
- The Novartis Institute for Tropical Diseases, Biopolis, Singapore, Singapore.
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Malhotra S, Cook VJ, Wolfe JN, Tang P, Elwood K, Sharma MK. A mutation in Mycobacterium tuberculosis rpoB gene confers rifampin resistance in three HIV-TB cases. Tuberculosis (Edinb) 2010; 90:152-7. [PMID: 20097612 DOI: 10.1016/j.tube.2010.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Revised: 12/18/2009] [Accepted: 01/02/2010] [Indexed: 11/15/2022]
Abstract
Rifampin is a key component of standard short-course first-line therapy against Mycobacterium tuberculosis (MTB). Rifampin monoresistant MTB, previously a rare phenomenon, is now being reported at increasing rates worldwide. We report a mutation in the rpoB region leading to low level rifampin monoresistance in a cluster of HIV-positive patients. All rifampin monoresistant isolates identified from 2004 to 2006 underwent susceptibility confirmation, sequencing of rpoB and genotyping. Three patients were found to have a previously undocumented 3 base pair insertion at codon 525 in the rpoB region. The earliest initial case was infected with fully susceptible MTB. Disease relapse occurred 7 months later with a genotypically identical MTB isolate, showing acquired rifampin monoresistance. MTB isolates from 2 subsequent patients showed primary rifampin monoresistance with an identical genotype to the index case. Patients with rifampin monoresistant MTB tend to have poorer outcomes than those with fully susceptible strains. Risk factors for the development of rifampin monoresistance include co-morbid HIV infection and previously treated tuberculosis. HIV infection has been associated with malabsorption of anti-tuberculous medications leading to sub-therapeutic levels of administered drugs. These factors may have played a role in the development of this previously undocumented mutation.
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Affiliation(s)
- Sangita Malhotra
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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45
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Abstract
The presence and consequences of resistance to drugs used for the treatment of tuberculosis have long been neglected. The recent detection and recognition of widespread multiple-drug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis have raised interest and concern among clinicians and public health authorities globally. In this article, we describe the current global status of drug-resistant tuberculosis. We discuss the development of resistance, current management, and strategies for control.
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Affiliation(s)
- Sheela Shenoi
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut 06510-8002, USA.
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46
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Becker C, Dressman JB, Junginger HE, Kopp S, Midha KK, Shah VP, Stavchansky S, Barends DM. Biowaiver monographs for immediate release solid oral dosage forms: rifampicin. J Pharm Sci 2009; 98:2252-67. [PMID: 19160441 DOI: 10.1002/jps.21624] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Literature data relevant to the decision to allow a waiver of in vivo bioequivalence (BE) testing for the approval of new multisource and reformulated immediate release (IR) solid oral dosage forms containing rifampicin as the only Active Pharmaceutical Ingredient (API) are reviewed. Rifampicin's solubility and permeability, its therapeutic use and index, pharmacokinetics, excipient interactions and reported BE/bioavailability (BA) problems were taken into consideration. Solubility and absolute BA data indicate that rifampicin is a BCS Class II drug. Of special concern for biowaiving is that many reports of failure of IR solid oral dosage forms of rifampicin to meet BE have been published and the reasons for these failures are yet insufficiently understood. Moreover, no reports were identified in which in vitro dissolution was shown to be predictive of nonequivalence among products. Therefore, a biowaiver based approval of rifampicin containing IR solid oral dosage forms cannot be recommended for either new multisource drug products or for major scale-up and postapproval changes (variations) to existing drug products.
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Affiliation(s)
- C Becker
- Institute of Pharmaceutical Technology, J.W. Goethe University, Frankfurt am Main, Germany
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47
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Chideya S, Winston CA, Peloquin CA, Bradford WZ, Hopewell PC, Wells CD, Reingold AL, Kenyon TA, Moeti TL, Tappero JW. Isoniazid, rifampin, ethambutol, and pyrazinamide pharmacokinetics and treatment outcomes among a predominantly HIV-infected cohort of adults with tuberculosis from Botswana. Clin Infect Dis 2009; 48:1685-94. [PMID: 19432554 PMCID: PMC3762461 DOI: 10.1086/599040] [Citation(s) in RCA: 163] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND We explored the association between antituberculosis drug pharmacokinetics and treatment outcomes among patients with pulmonary tuberculosis in Botswana. METHODS Consenting outpatients with tuberculosis had blood samples collected 1, 2, and 6 h after simultaneous isoniazid, rifampin, ethambutol, and pyrazinamide ingestion. Maximum serum concentrations (C(max)) and areas under the serum concentration time curve were determined. Clinical status was monitored throughout treatment. RESULTS Of the 225 participants, 36 (16%) experienced poor treatment outcome (treatment failure or death); 155 (69%) were infected with human immunodeficiency virus (HIV). Compared with published standards, low isoniazid C(max) occurred in 84 patients (37%), low rifampin C(max) in 188 (84%), low ethambutol C(max) in 87 (39%), and low pyrazinamide C(max) in 11 (5%). Median rifampin and pyrazinamide levels differed significantly by HIV status and CD4 cell count category. Only pyrazinamide pharmacokinetics were significantly associated with treatment outcome; low pyrazinamide C(max) was associated with a higher risk of documented poor treatment outcome, compared with normal C(max) (50% vs. 16%; P < .01). HIV-infected patients with a CD4 cell count <200 cells/microL had a higher risk of poor treatment outcome (27%) than did HIV-uninfected patients (11%) or HIV-infected patients with a CD4 cell count 200 cells/microL (12%; P = .01). After adjustment for HIV infection and CD4 cell count, patients with low pyrazinamide C(max) were 3 times more likely than patients with normal pyrazinamide C(max) to have poor outcomes (adjusted risk ratio, 3.38; 95% confidence interval, 1.84-6.22). CONCLUSIONS Lower than expected antituberculosis drug C(max) occurred frequently, and low pyrazinamide C(max) was associated with poor treatment outcome. Exploring the global prevalence and significance of these findings may suggest modifications in treatment regimens that could improve tuberculosis cure rates.
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Affiliation(s)
- Sekai Chideya
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
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48
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Holland DP, Hamilton CD, Weintrob AC, Engemann JJ, Fortenberry ER, Peloquin CA, Stout JE. Therapeutic drug monitoring of antimycobacterial drugs in patients with both tuberculosis and advanced human immunodeficiency virus infection. Pharmacotherapy 2009; 29:503-10. [PMID: 19397460 DOI: 10.1592/phco.29.5.503] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To determine the feasibility of therapeutic drug monitoring for adjusting low serum antimycobacterial concentrations in patients with both tuberculosis and advanced human immunodeficiency virus (HIV). DESIGN Retrospective cohort study. DATA SOURCE De-identified dataset from a tuberculosis clinic. PATIENTS Twenty-one patients (median age 38 yrs, range 25-68 yrs) with advanced HIV infection (CD4(+) cell count < 100 cells/mm(3)) who received treatment for active tuberculosis between March 2002 and September 2007. MEASUREMENTS AND MAIN RESULTS We evaluated data based on the practices performed at the tuberculosis clinic. After the daily doses of isoniazid and rifamycins (rifampin or rifabutin) were ingested, serum concentrations were obtained at 2 hours for isoniazid and rifampin, at 3 hours for rifabutin, and, when possible, at 6 hours for all three drugs to detect delayed absorption. Antimycobacterial drug concentrations were compared with published reference levels, and dosages were adjusted to achieve desired concentrations. Costs of monitoring were recorded for all patients. Of the 21 patients, 18 (86%) had low serum concentrations of at least one drug 2 hours after ingestion: 2 (10%) had low isoniazid concentrations, 5 (24%) had low rifamycin concentrations, and 11 (52%) had low serum concentrations of both drugs. The median number of dosage adjustments to attain normal concentrations was 1 (range 0-4 adjustments). The median cost/patient for therapeutic drug monitoring was $619 (range $230-1948). The median final doses to achieve normal concentrations were isoniazid 600 mg/day (range 300-1500 mg/day), rifampin 1050 mg/day (range 600-1200 mg/day), and rifabutin 300 mg (range 150-450 mg) 3 times/week. No patient demonstrated any adverse effects attributed to these higher doses. CONCLUSION Low serum concentrations of antituberculous drugs, which suggest malabsorption, are common among patients with advanced HIV who also have tuberculosis but can be overcome with higher doses. Therapeutic drug monitoring may be an effective tool to optimize therapy, but needs further study.
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Affiliation(s)
- David P Holland
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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49
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Schaaf HS, Willemse M, Cilliers K, Labadarios D, Maritz JS, Hussey GD, McIlleron H, Smith P, Donald PR. Rifampin pharmacokinetics in children, with and without human immunodeficiency virus infection, hospitalized for the management of severe forms of tuberculosis. BMC Med 2009; 7:19. [PMID: 19386087 PMCID: PMC2679060 DOI: 10.1186/1741-7015-7-19] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Accepted: 04/22/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rifampin is a key drug in antituberculosis chemotherapy because it rapidly kills the majority of bacilli in tuberculosis lesions, prevents relapse and thus enables 6-month short-course chemotherapy. Little is known about the pharmacokinetics of rifampin in children. The objective of this study was to evaluate the pharmacokinetics of rifampin in children with tuberculosis, both human immunodeficiency virus type-1-infected and human immunodeficiency virus-uninfected. METHODS Fifty-four children, 21 human immunodeficiency virus-infected and 33 human immunodeficiency virus-uninfected, mean ages 3.73 and 4.05 years (P = 0.68), respectively, admitted to a tuberculosis hospital in Cape Town, South Africa with severe forms of tuberculosis were studied approximately 1 month and 4 months after commencing antituberculosis treatment. Blood specimens for analysis were drawn in the morning, 45 minutes, 1.5, 3.0, 4.0 and 6.0 hours after dosing. Rifampin concentrations were determined by liquid chromatography tandem mass spectrometry. For two sample comparisons of means, the Welch version of the t-test was used; associations between variables were examined by Pearson correlation and by multiple linear regression. RESULTS The children received a mean rifampin dosage of 9.61 mg/kg (6.47 to 15.58) body weight at 1 month and 9.63 mg/kg (4.63 to 17.8) at 4 months after commencing treatment administered as part of a fixed-dose formulation designed for paediatric use. The mean rifampin area under the curve 0 to 6 hours after dosing was 14.9 and 18.1 microg/hour/ml (P = 0.25) 1 month after starting treatment in human immunodeficiency virus-infected and human immunodeficiency virus-uninfected children, respectively, and 16.52 and 17.94 microg/hour/ml (P = 0.59) after 4 months of treatment. The mean calculated 2-hour rifampin concentrations in these human immunodeficiency virus-infected and human immunodeficiency virus-uninfected children were 3.9 and 4.8 microg/ml (P = 0.20) at 1 month after the start of treatment and 4.0 and 4.6 microg/ml (P = 0.33) after 4 months of treatment. These values are considerably less than the suggested lower limit for 2-hour rifampin concentrations in adults of 8.0 microg/ml and even 4 microg/ml CONCLUSION Both human immunodeficiency virus-infected and human immunodeficiency virus-uninfected children with tuberculosis have very low rifampin serum concentrations after receiving standard rifampin dosages similar to those used in adults. Pharmacokinetic studies of higher dosages of rifampin are urgently needed in children to assist in placing the dosage of rifampin used in childhood on a more scientific foundation.
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Affiliation(s)
- Hendrik Simon Schaaf
- Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University and Tygerberg Children's Hospital, PO Box 19063, Tygerberg 7505, South Africa
| | - Marianne Willemse
- Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University and Tygerberg Children's Hospital, PO Box 19063, Tygerberg 7505, South Africa
| | - Karien Cilliers
- Department of Human Nutrition, Faculty of Health Sciences, Stellenbosch University, Tygerberg 7505, South Africa
| | - Demetre Labadarios
- Department of Human Nutrition, Faculty of Health Sciences, Stellenbosch University, Tygerberg 7505, South Africa
- Knowledge Systems, Human Sciences Research Council, Private Bag X9182, Cape Town 8000, South Africa
| | - Johannes Stephanus Maritz
- Division of Molecular Biology and Human Genetics and the Medical Research Council Centre for Molecular and Cellular Biology, Department of Science and Technology/National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, Faculty of Health Sciences, Stellenbosch University, PO Box 19063, Tygerberg 7505, South Africa
| | - Gregory D Hussey
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Rondebosch 7701, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, University of Cape Town, Rondebosch 7701, South Africa
| | - Peter Smith
- Division of Clinical Pharmacology, University of Cape Town, Rondebosch 7701, South Africa
| | - Peter Roderick Donald
- Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University and Tygerberg Children's Hospital, PO Box 19063, Tygerberg 7505, South Africa
- Division of Molecular Biology and Human Genetics and the Medical Research Council Centre for Molecular and Cellular Biology, Department of Science and Technology/National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, Faculty of Health Sciences, Stellenbosch University, PO Box 19063, Tygerberg 7505, South Africa
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50
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Population modeling and Monte Carlo simulation study of the pharmacokinetics and antituberculosis pharmacodynamics of rifampin in lungs. Antimicrob Agents Chemother 2009; 53:2974-81. [PMID: 19380594 DOI: 10.1128/aac.01520-08] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Little information exists on the pulmonary pharmacology of antituberculosis drugs. We used population pharmacokinetic modeling and Monte Carlo simulation to describe and explore the pulmonary pharmacokinetics and pharmacodynamics of rifampin (RIF; rifampicin). A population pharmacokinetic model that adequately described the plasma, epithelial lining fluid (ELF), and alveolar cell (AC) concentrations of RIF in a population of 34 human volunteers was made by use of the nonparametric adaptive grid (NPAG) algorithm. The estimated concentrations correlated well with the measured concentrations, and there was little bias and good precision. The results obtained with the NPAG algorithm were then imported into Matlab software to perform a 10,000-subject Monte Carlo simulation. The ability of RIF to suppress the development of drug resistance and to induce a sufficient bactericidal effect against Mycobacterium tuberculosis was evaluated by calculating the proportion of subjects achieving specific target values for the maximum concentration of drug (C(max))/MIC ratio and the area under the concentration-time curve from time zero to 24 h (AUC(0-24))/MIC ratio, respectively. At the lowest MIC (0.01 mg/liter), after the administration of one 600-mg oral dose, the rates of target attainment for C(max)/MIC (> or =175) were 95% in ACs, 48.8% in plasma, and 35.9% in ELF. Under the same conditions, the target attainment results for the killing effect were 100% in plasma (AUC(0-24)/MIC > or = 271) but only 54.5% in ELF (AUC(0-24)/MIC > or = 665). The use of a 1,200-mg RIF dose was associated with better results for target attainment. The overall results suggest that the pulmonary concentrations obtained with the standard RIF dose are too low in most subjects. This work supports the need to evaluate higher doses of RIF for the treatment of patients with tuberculosis.
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