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Schultheiß M, Kling S, Lenker U, von Bibra M, Rosenkranz B, Klinker H. Lopinavir serum concentrations of critically ill infants: a pharmacokinetic investigation in South Africa. Med Microbiol Immunol 2018; 207:339-343. [PMID: 29974233 DOI: 10.1007/s00430-018-0550-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/29/2018] [Indexed: 10/28/2022]
Abstract
The role of therapeutic drug monitoring in pediatric antiretroviral therapy is unclear. A little pharmacokinetic datum from clinical practice exists beyond controlled approval studies including clinically stable children. The aim of this study is to quantify LPV exposure of critically ill infants in an ICU and-by identifying risk factors for inadequate exposure-to define sensible indications for TDM in pediatric HIV care; in addition, assume total drug adherence in ICU to compare LPV exposure with a setting of unknown adherence. In this prospective investigation, 15 blood samples from critically ill infants in the pediatric ICU at Tygerberg Hospital were analyzed for LPV-serum concentrations. They were then compared to those of 22 blood samples from out-patient children. Serum-level measurements were performed with an established high-performance liquid chromatography method. All LPV-serum levels of ICU patients were higher than a recommended Ctrough (= 1.000 ng/ml), 60% of levels were higher than Cmax (8.200 ng/ml). Partly, serum levels reached were extremely high (Maximum: 28.778 ng/ml). Low bodyweight and age correlated significantly with high LPV concentrations and were risk factors for serum levels higher than Cmax. Significantly fewer serum levels from infants in ICU care (mean: 11.552 ng/ml ± SD 7760 ng/ml) than from out-patient children (mean: 6.756 ng/ml ± SD 6.003 ng/ml) were subtherapeutic (0 vs. 28%, p = 0.008). Under total adherence in the ICU group, there were no subtherapeutic serum levels, while, in out-patient, children with unknown adherence 28% of serum levels were found subtherapeutic. Low bodyweight and age are risk factors for reaching potentially toxic LPV levels in this extremely fragile population. TDM can be a reasonable tool to secure sufficient and safe drug exposure in pediatric cART.
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Affiliation(s)
- Michael Schultheiß
- Medizinische Klinik und Poliklinik II, Schwerpunkt Infektiologie, Universitätsklinikum Würzburg, ZIM Haus A3/A4, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.
| | - Sharon Kling
- Department of Pediatrics and Child Health, Ward A9, Tygerberg Hospital, University of Stellenbosch, Francie van Zijl Drive, Tygerberg, 7505, South Africa
| | - Ulrike Lenker
- Medizinische Klinik und Poliklinik II, Schwerpunkt Infektiologie, Universitätsklinikum Würzburg, ZIM Haus A3/A4, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Miriam von Bibra
- Medizinische Klinik und Poliklinik II, Schwerpunkt Infektiologie, Universitätsklinikum Würzburg, ZIM Haus A3/A4, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Bernd Rosenkranz
- Division of Clinical Pharmacology, Department of Medicine, Tygerberg Hospital, University of Stellenbosch, Francie van Zijl Drive, Tygerberg, 7505, South Africa
| | - Hartwig Klinker
- Medizinische Klinik und Poliklinik II, Schwerpunkt Infektiologie, Universitätsklinikum Würzburg, ZIM Haus A3/A4, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
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Harrison L, Melvin A, Fiscus S, Saidi Y, Nastouli E, Harper L, Compagnucci A, Babiker A, McKinney R, Gibb D, Tudor-Williams G. HIV-1 Drug Resistance and Second-Line Treatment in Children Randomized to Switch at Low Versus Higher RNA Thresholds. J Acquir Immune Defic Syndr 2015; 70:42-53. [PMID: 26322666 PMCID: PMC4556171 DOI: 10.1097/qai.0000000000000671] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The PENPACT-1 trial compared virologic thresholds to determine when to switch to second-line antiretroviral therapy (ART). Using PENPACT-1 data, we aimed to describe HIV-1 drug resistance accumulation on first-line ART by virologic threshold. METHODS PENPACT-1 had a 2 × 2 factorial design, randomizing HIV-infected children to start protease inhibitor (PI) versus nonnucleoside reverse transcriptase inhibitor (NNRTI)-based ART, and switch at a 1000 copies/mL versus 30,000 copies/mL threshold. Switch criteria were not achieving the threshold by week 24, confirmed rebound above the threshold thereafter, or Center for Disease Control and Prevention stage C event. Resistance tests were performed on samples ≥1000 copies/mL before switch, resuppression, and at 4-years/trial end. RESULTS Sixty-seven children started PI-based ART and were randomized to switch at 1000 copies/mL (PI-1000), 64 PIs and 30,000 copies/mL (PI-30,000), 67 NNRTIs and 1000 copies/mL (NNRTI-1000), and 65 NNRTI and 30,000 copies/mL (NNRTI-30,000). Ninety-four (36%) children reached the 1000 copies/mL switch criteria during 5-year follow-up. In 30,000 copies/mL threshold arms, median time from 1000 to 30,000 copies/mL switch criteria was 58 (PI) versus 80 (NNRTI) weeks (P = 0.81). In NNRTI-30,000, more nucleoside reverse transcriptase inhibitor (NRTI) resistance mutations accumulated than other groups. NNRTI mutations were selected before switching at 1000 copies/mL (23% NNRTI-1000, 27% NNRTI-30,000). Sixty-two children started abacavir + lamivudine, 166 lamivudine + zidovudine or stavudine, and 35 other NRTIs. The abacavir + lamivudine group acquired fewest NRTI mutations. Of 60 switched to second-line, 79% PI-1000, 63% PI-30,000, 64% NNRTI-1000, and 100% NNRTI-30,000 were <400 copies/mL 24 weeks later. CONCLUSIONS Children on first-line NNRTI-based ART who were randomized to switch at a higher virologic threshold developed the most resistance, yet resuppressed on second-line. An abacavir + lamivudine NRTI combination seemed protective against development of NRTI resistance.
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Affiliation(s)
- Linda Harrison
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Ann Melvin
- Seattle Children's Hospital, Seattle, WA
| | - Susan Fiscus
- University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC
| | | | - Eleni Nastouli
- University College London Hospitals, University College London, UK
| | - Lynda Harper
- Medical Research Council Clinical Trials Unit at University College London, UK
| | | | - Abdel Babiker
- Medical Research Council Clinical Trials Unit at University College London, UK
| | | | - Diana Gibb
- Medical Research Council Clinical Trials Unit at University College London, UK
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Novel nelfinavir mesylate loaded d-α-tocopheryl polyethylene glycol 1000 succinate micelles for enhanced pediatric anti HIV therapy: In vitro characterization and in vivo evaluation. Colloids Surf B Biointerfaces 2014; 123:302-10. [PMID: 25270729 DOI: 10.1016/j.colsurfb.2014.09.031] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2014] [Revised: 09/10/2014] [Accepted: 09/15/2014] [Indexed: 11/22/2022]
Abstract
Worldwide more than 35 million people are living with Human Immunodeficiency Virus (HIV) where 3.3 million are children. This translates in approximately 700 new daily infections in children only in 2012. Prolonged High Activity Antiretroviral Therapy (HAART) regimes could present low-patient compliance, especially in children, affecting therapeutic success. Nelfinavir mesylate (NFV) is a non-peptidic HIV-1 protease inhibitor (IP) which was the first IP recommended for pediatric use (>2 years-old). It exhibits pH-dependant aqueous solubility which results highly restricted at physiological pH values. The former represents a main clinical limitation due to the reduction on drug absorption along the small intestine after an oral administration, leading to unpredictable drug bioavailability. Moreover a liquid formulation of NFV is not available worldwide, preventing appropriate dose adjustment and more convenient administration. In this framework, the present investigation reports the development of a NFV highly concentrated aqueous formulation for a more appropriate management of pediatric anti-HIV therapy. The aim was to encapsulate NFV within D-α-tocopheryl polyethylene glycol 1000 succinate micelles to improve its aqueous solubility and its oral pharmacokinetic parameters. Results show that NFV aqueous solubility was increased up to 80.3 mg/mL. NFV-loaded micelles exhibited a hydrodynamic diameter of 5.6 nm and a spherical morphology as determined by dynamic light scattering and transmission electronic microscopy, respectively. In vitro NFV release profile demonstrated a cumulative drug release of 56% at 6 h. Finally, in vivo data showed a significant (p<0.01) increase of Area-Under-the-Curve between 0 and 24 h for NFV encapsulated in micelles in comparison with a NFV suspension prepared with glycerin 20% v/v and carboxymethylcellulose sodium 0.5% w/v, representing an increment on drug oral relative bioavailability of 1.71-fold. Thereby, this formulation represents an innovative nanotechnological platform to improve pediatric HIV pharmacotherapy.
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Verweel G, Burger DM, Sheehan NL, Bergshoeff AS, Warris A, Van Der Knaap LC, Driessen G, de Groot R, Hartwig NG. Plasma Concentrations of the HIV-Protease Inhibitor Lopinavir are Suboptimal in Children Aged 2 Years and Below. Antivir Ther 2007. [DOI: 10.1177/135965350701200405] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Lopinavir/ritonavir (LPV/r) has been licensed for the treatment of HIV-infected children >6 months in the US and >2 years in the EU. Limited LPV paediatric pharmacokinetic data are available. We studied LPV pharmacokinetics to determine whether the recommended dose (230/57.5 mg/m2 twice daily) results in optimal LPV exposure in all age groups. Virological efficacy was a secondary objective. Methods HIV-1-infected children who started treatment with LPV/r and two nucleoside reverse transcriptase inhibitors underwent a 12-h pharmacokinetic curve. LPV plasma concentrations were determined with a validated HPLC method with UV detection. If Cmin was <1.0 mg/l LPV/r dose was increased by 33%. Plasma trough levels were drawn subsequently. HIV-1 RNA was followed-up until week 48. Results A total of 23 children were included (seven girls; 16 boys), with a median (range) age of 5.6 (0.4–13.2) years. Mean (±SD) AUC0–12h, Cmax and Cmin of LPV were 75.3 (±33.7) mg/l.h, 9.33 (±3.27) mg/l and 3.68 (±2.48) mg/l, respectively, which is similar to previously published data. Interindividual variability was large. Cmin was inadequate in 7/23 children. Significantly more children <2 years had inadequate Cmin compared with children >2 years. Dose increase to ±300/75 mg/m2 LPV/r led to Cmin >1.0 mg/l. The studied regimen provided excellent viral suppression for naive and pretreated patients. Conclusions Mean LPV pharmacokinetic parameters in these HIV-infected children are similar to published data, but exposure is significantly reduced in children <2 years. Prospective pharmacokinetic studies using 300/75 mg/m2 LPV/r in this age population are urgently warranted.
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Affiliation(s)
- Gwenda Verweel
- Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - David M Burger
- Radboud University Medical Centre Nijmegen, the Netherlands
- Nijmegen University Centre for Infectious Diseases (NUCI), the Netherlands
| | - Nancy L Sheehan
- McGill University Health Centre & University of Montréal, Canada
| | - Alina S Bergshoeff
- Radboud University Medical Centre Nijmegen, the Netherlands
- Nijmegen University Centre for Infectious Diseases (NUCI), the Netherlands
| | - Adilia Warris
- Radboud University Medical Centre Nijmegen, the Netherlands
- Nijmegen University Centre for Infectious Diseases (NUCI), the Netherlands
| | | | - Gertjan Driessen
- Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Ronald de Groot
- Radboud University Medical Centre Nijmegen, the Netherlands
- Nijmegen University Centre for Infectious Diseases (NUCI), the Netherlands
| | - Nico G Hartwig
- Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
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van der Lee M, Verweel G, de Groot R, Burger D. Pharmacokinetics of a Once-Daily Regimen of Lopinavir/Ritonavir in HIV-1-Infected Children. Antivir Ther 2006. [DOI: 10.1177/135965350601100412] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Lopinavir is an HIV protease inhibitor that is co-formulated with ritonavir. The approved paediatric dose is 230/57.5 mg/m2 twice daily. Once-daily dosing may offer an advantage to adherence. We studied the pharmacokinetics of lopinavir/ritonavir in a once-daily regimen in HIV-1-infected children. Methods HIV-1-infected children on stable antiretroviral therapy with a viral load <50 copies/ml for at least 6 months received lopinavir/ritonavir 460/115 mg/m2 once daily with zidovudine and lamivudine. Blood samples were collected at 0, 2, 4, 6, 8, 12, 18 and 24 h after observed intake during steady state. Target level for lopinavir Cmin was 1.0 mg/l, based on in vitro IC50 data. Results Nineteen HIV-1-infected children with a median (range) age of 4.5 (1.4–12.9) years were enrolled. The median (interquartile range) dose of lopinavir was 456 (444–477) mg/m2. The mean (standard deviation) AUC0–24, Cmax and Cmin of lopinavir were 149.8 ±58.8 h*mg/l, 10.77 ±2.90 mg/l and 2.88 ±3.74 mg/l respectively. These values are comparable to data observed in adults using lopinavir/ritonavir 800/200 mg once daily. In 10/19 (53%) children Cmin was considered to be too low (<1.0 mg/l). Younger children more often experienced subtherapeutic trough levels. Conclusion Our findings indicate that 460/115 mg/m2 lopinavir/ritonavir once daily leads to mean pharmacokinetic parameters comparable to data of 800/200 mg lopinavir/ritonavir once daily in adults, although the variability observed in the trough levels is much higher in children. Further research, especially in young children, is necessary to determine whether a higher dosage of lopinavir/ritonavir once daily must be given to reach the target level for Cmin.
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Affiliation(s)
- Manon van der Lee
- Department of Clinical Pharmacy, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
- Nijmegen University Centre for Infectious Diseases, Nijmegen, the Netherlands
| | - Gwenda Verweel
- Department of Pediatrics, Erasmus Medical Centre/Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Ronald de Groot
- Nijmegen University Centre for Infectious Diseases, Nijmegen, the Netherlands
- Department of Pediatrics, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - David Burger
- Department of Clinical Pharmacy, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
- Nijmegen University Centre for Infectious Diseases, Nijmegen, the Netherlands
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Boffito M, Acosta E, Burger D, Fletcher CV, Flexner C, Garaffo R, Gatti G, Kurowski M, Perno CF, Peytavin G, Regazzi M, Back D. Current Status and Future Prospects of Therapeutic Drug Monitoring and Applied Clinical Pharmacology in Antiretroviral Therapy. Antivir Ther 2005. [DOI: 10.1177/135965350501000307] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The consensus of current international guidelines for the treatment of HIV infection is that data on therapeutic drug monitoring (TDM) of non-nucleoside reverse transcriptase inhibitors and protease inhibitors provide a framework for the implementation of TDM in certain defined scenarios in clinical practice. However, the utility of TDM is considered to be on an individual basis until more data are obtained from large clinical trials showing the benefit of TDM. In April 2004, a panel of experts met in Rome, Italy. This followed an inaugural meeting in Perugia, Italy, in October 2000, which resulted in the article published in AIDS 2002, 16(Suppl 1):S5–S37. The objectives of this second meeting were to review the questions surrounding TDM of antiretroviral drugs and discuss the clinical utility, current concerns and future prospects of drug concentration monitoring in the care of HIV-1-infected individuals. This report, which has been updated to include material published or presented at international conferences up to the end of September 2004, reviews pharmacokinetic and pharmacodynamic data and reports the issues discussed by the panel, offering advice to clinical care providers who may be currently, or are considering incorporating TDM into the routine care of their patients. In addition, the panel formulated a series of position statements that are relevant to the interpretation of current data and can aid the design of future clinical trials. Part 2 of this Special article, Therapeutic drug monitoring and drug–drug interactions involving antiretroviral drugs, will be published in Antiviral Therapy 10(4).
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Affiliation(s)
- Marta Boffito
- Chelsea and Westminster Hospital, London, UK
- University of Turin, Department of Infectious Diseases, Turin, Italy
| | - Edward Acosta
- Division of Clinical Pharmacology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David Burger
- Department of Clinical Pharmacy & Nijmegen University Centre for Infectious Diseases, University Medical Centre, Nijmegen, The Netherlands
| | - Courtney V Fletcher
- Department of Clinical Pharmacy, University of Colorado Health Sciences Center, Denver, CO, USA
| | - Charles Flexner
- Johns Hopkins University, School of Medicine, Division of Clinical Pharmacology, Baltimore, MD, USA
| | - Rodolphe Garaffo
- Unité de Pharmacocinetique Clinique, Pasteur University Hospital, Nice, France
| | - Giorgio Gatti
- Vertex Pharmaceuticals (Europe) Ltd, Genoa, Italy and University of Genoa, c/o San Martino Hospital, Genoa, Italy
| | | | | | - Gilles Peytavin
- Département de Pharmacocinétique Clinique, Hôpital Bichat-Claude Bernard, Paris, France
| | - Mario Regazzi
- Service of Clinical Pharmacology, IRCCS Policlinico S Matteo, Pavia, Italy
| | - David Back
- Department of Pharmacology, University of Liverpool, Liverpool, UK
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