1
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Ragonnet G, Laroche H, Néant N, Benkouiten S, Dos Santos MC, Faucher-Zaegel O, Solas C, Bregigeon-Ronot S. Enteral administration of crushed rilpivirine in a patient with HIV: A case report. Br J Clin Pharmacol 2024; 90:895-899. [PMID: 38163749 DOI: 10.1111/bcp.15994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 12/09/2023] [Accepted: 12/13/2023] [Indexed: 01/03/2024] Open
Abstract
Antiretroviral therapy administration is challenging in patients with HIV requiring enteral nutrition. There are limited pharmacokinetic data available regarding the absorption of crushed rilpivirine (RPV) and its impact on drug bioavailability, plasma concentrations and, consequently, the efficacy of treatment. We present the case of a 60-year-old woman with HIV diagnosed with squamous cell carcinoma who needed enteral administration of antiretroviral therapy following the insertion of a gastrotomy tube in September 2018. Initially, the patient was treated with a daily dose of RPV 25 mg, dolutegravir 50 mg and emtricitabine 200 mg. The treatment was later intensified with darunavir boosted with ritonavir. RPV and dolutegravir were crushed, dissolved in water and administered via a percutaneous endoscopic gastrostomy tube. Therapeutic drug and viral load monitoring determined the adequacy of enteral antiretroviral dosing. RPV plasma concentrations remained within the expected therapeutic range of 43-117 ng/mL, with only 1 below the currently used 50 ng/mL efficacy threshold. After the treatment intensification with darunavir boosted with ritonavir, the patient achieved an undetectable viral load. While we observed satisfactory RPV plasma concentrations, it is essential to maintain strict monitoring of administration method, plasma concentrations and virological responses when initiating treatment with crushed RPV. Hence, additional pharmacokinetic data are necessary to ensure the effective enteral administration of RPV and to establish the best antiretroviral dosing regimens.
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Affiliation(s)
- Gwendoline Ragonnet
- Laboratoire de Pharmacocinétique et Toxicologie, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Hélène Laroche
- Service d'Immuno-hématologie clinique, Hôpital de Sainte-Marguerite, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Nadège Néant
- Laboratoire de Pharmacocinétique et Toxicologie, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Samir Benkouiten
- Service d'Immuno-hématologie clinique, Hôpital de Sainte-Marguerite, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Maeva Cacilda Dos Santos
- Service d'Immuno-hématologie clinique, Hôpital de Sainte-Marguerite, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Olivia Faucher-Zaegel
- Service d'Immuno-hématologie clinique, Hôpital de Sainte-Marguerite, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Caroline Solas
- Aix-Marseille Univ, APHM, Unité des virus émergents IRD190, INSERM 1207, Laboratoire de Pharmacocinétique et Toxicologie, Marseille, France
| | - Sylvie Bregigeon-Ronot
- Service d'Immuno-hématologie clinique, Hôpital de Sainte-Marguerite, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
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2
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LoFaso M, Marchionda O, Bass S, Torbic H, Blackewicz C, Pallotta A. Evaluation of Dolutegravir- and Bictegravir-Based Antiretroviral Regimen Utilization in Patients who Cannot Take Medications by Mouth. Open Forum Infect Dis 2023; 10:ofad554. [PMID: 38088984 PMCID: PMC10712287 DOI: 10.1093/ofid/ofad554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/08/2023] [Indexed: 12/30/2023] Open
Abstract
A retrospective review of patients unable to take medications by mouth showed short interruptions of therapy for most patients. In a secondary analysis, our data showed maintenance and/or achievement of viral suppression for most patients. A retrospective review of intensive care patients unable to take antiretrovirals by mouth showed 56.6% of patients experiencing a transient interruption in therapy. Additionally, our case series further supports previous literature on crushing dolutegravir and bictegravir regimens to maintain and achieve viral suppression.
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Affiliation(s)
- Megan LoFaso
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Stephanie Bass
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Heather Torbic
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Caitlin Blackewicz
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andrea Pallotta
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
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3
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Porter AM, Baker CR, Fulco PP. Administration of Crushed Doravirine via Nasojejunal Feeding Tube in a Patient With Treatment-Experienced Human Immunodeficiency Virus. J Pharm Pract 2022:8971900221104258. [PMID: 35610547 DOI: 10.1177/08971900221104258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Allison M Porter
- Clinical Pharmacy Manager, 23726Fairview Park Hospital, Dublin, GA, USA
| | - Cassandra R Baker
- Department of Pharmacy, 6887Virginia Commonwealth University Health, Richmond, VA, USA
| | - Patricia P Fulco
- Department of Pharmacy, 6887Virginia Commonwealth University Health, Richmond, VA, USA.,Division of Infectious Diseases, 6887Virginia Commonwealth University Health, Richmond, VA, USA
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4
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Roa PAE, Bazzi R. Crushed bictegravir/emtricitabine/tenofovir alafenamide in a human immunodeficiency virus-positive patient with pancreatic cancer. Int J STD AIDS 2021; 33:97-98. [PMID: 34787026 DOI: 10.1177/09564624211048702] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We present the case of a 78-year-old African American man with a history of human immunodeficiency virus diagnosed in 2007 who was newly diagnosed with pancreatic cancer. A percutaneous endoscopic gastrostomy tube was placed during the initial inpatient visit of pancreatic cancer diagnosis due to persistent dysphagia. Due to PEG placement and the patient's wish to continue his previous antiretroviral therapy, the patient crushed his fixed-dose bictegravir/emtricitabine/tenofovir alafenamide under the direction of a physician and has maintained virologic suppression.
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Affiliation(s)
- Pia-Allison E Roa
- Department of Pharmacy Resident, 7005Beaumont Hospital, Dearborn, MI, USA
| | - Rima Bazzi
- Department of Pharmacy Resident, 7005Beaumont Hospital, Dearborn, MI, USA
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5
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Walker CK, Shaw CM, Moss Perry MV, Claborn MK. Antiretroviral Therapy Management in Adults With HIV During ICU Admission. J Pharm Pract 2021; 35:952-962. [PMID: 33858244 DOI: 10.1177/08971900211000692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The extended lifespan of people living with human immunodeficiency (HIV) and acquired immune deficiency syndrome (AIDS) (PLWHA) has increased the potential for ICU admissions unrelated to HIV infection. The objective of this review is to guide continued management of antiretroviral therapy (ART) recommended by the United States Department of Health and Human Services Antiretroviral Guidelines in critically ill adult PLWHA admitted to the intensive care unit (ICU). Pharmacists are uniquely positioned to mitigate these concerns, including whether to continue ART in the ICU, drug interactions with common ICU drugs, renal and hepatic dosing considerations, and alternative methods of administration. Despite these concerns, the original ART regimen should be continued or modified in conjunction with an HIV specialist. Discontinuation greater than 2 weeks should be avoided due to potential resistance and future HIV treatment failure. Use of ART in critically ill patients presents challenges that pharmacists are best equipped to address to prevent adverse events, administration errors, and treatment failure.
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Affiliation(s)
- Cheri K Walker
- 8452Southwestern Oklahoma State University College of Pharmacy, Weatherford, OK, USA
| | - Cassie M Shaw
- 8452Southwestern Oklahoma State University College of Pharmacy, Weatherford, OK, USA
| | | | - Melanie K Claborn
- 8452Southwestern Oklahoma State University College of Pharmacy, Weatherford, OK, USA
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6
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Boullata JI. Enteral Medication for the Tube-Fed Patient: Making This Route Safe and Effective. Nutr Clin Pract 2020; 36:111-132. [PMID: 33373487 DOI: 10.1002/ncp.10615] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/15/2020] [Indexed: 12/26/2022] Open
Abstract
The administration of medication through an enteral access device requires important forethought. Meeting a patient's therapeutic needs requires achieving expected drug bioavailability without increasing the risk for toxicity, therapeutic failure, or feeding tube occlusion. Superimposing gut dysfunction, critical illness, or enteral nutrition-drug interaction further increases the need for a systematic approach to prescribing, evaluating, and preparing a drug for administration through an enteral access device. This review will explain the fundamental factors involved in drug bioavailability through the gut, address the influencing considerations for the enterally fed patient, and describe best practices for enteral drug preparation and administration.
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Affiliation(s)
- Joseph I Boullata
- Department of Clinical Nutrition Support Services, Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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7
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Moore SE, Huesgen E, Howe Z. Sustained virologic suppression with abacavir, emtricitabine, and crushed dolutegravir and tenofovir alafenamide in a patient with HIV and eosinophilic esophagitis. Int J STD AIDS 2020; 31:285-287. [PMID: 32036755 DOI: 10.1177/0956462419895690] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
We report the use of crushed dolutegravir (DTG) and tenofovir alafenamide (TAF) tablets in a 27-year-old man with progressive dysphagia due to eosinophilic esophagitis, which severely limited compliance, leading to viral resistance. Based on his drug resistance history, allergies, and inability to swallow tablets intact, he was transitioned to DTG 50 mg (crushed), TAF 25 mg (crushed), liquid abacavir (20 mg/ml) 30 ml, and liquid emtricitabine (10 mg/ml) 24 ml orally daily. After receiving this regimen for five months, the patient’s HIV viral load decreased from 9910 to 59 copies/ml and after ten total months became suppressed at <20 copies/ml. Our case report suggests administration of crushed DTG and TAF tablets may be a viable option for patients with dysphagia and limited treatment options.
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Affiliation(s)
- Sarah E Moore
- Department of Pharmacy Practice, Franciscan Health Indianapolis, Indianapolis, IN, USA
| | - Emily Huesgen
- Department of Pharmacy Practice, Indiana University Health, Indianapolis, IN, USA
| | - Zachary Howe
- Department of Pharmacy Practice, Indiana University Health, Indianapolis, IN, USA
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8
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Blackman AL, Heil EL, Devanathan AS, Pandit NS. The effect of veno-arterial extracorporeal oxygenation and nasogastric tube administration on the pharmacokinetic profile of abacavir, lamivudine and dolutegravir: a case report. Antivir Ther 2020; 25:115-119. [PMID: 32341207 DOI: 10.3851/imp3355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Pharmacokinetic (PK) changes can affect antiretroviral (ARV) systemic exposure for critically ill patients living with HIV (CI-PLWH). Studies to guide ARV adjustments in this population are limited. METHODS A PK analysis was conducted in a 44-year-old CI-PLWH who presented for a heart and lung transplant on veno-arterial extracorporeal membrane oxygenation (VA ECMO). Home ARV therapy (ART) of co-formulated abacavir/lamivudine/dolutegravir (ABC/3TC/DTG) was continued. ARV serum concentrations were obtained during and after VA ECMO. Two blood levels were drawn at 1 h, for maximum serum concentration (Cmax) and a serum trough (Ct). ARVs were given as a single tablet crushed via nasogastric tube. RESULTS Area under the concentration-time curve (AUC0-t) was calculated using non-compartmental analysis. Cmax and AUC0-t were higher during VA ECMO compared with post-decannulation. The Cmax of ABC was >2.5-fold higher than the mean in the reference. Cmax and Ct post VA ECMO were within range of referenced literature for all ARVs. Cmax and AUC0-t of DTG post VA ECMO was approximately four- to fivefold lower than referenced literature. HIV virological suppression was maintained throughout the hospitalization. CONCLUSIONS ART adjustments would not be required for this patient. Additional studies are needed to assess effects of VA ECMO and crushed tube administration of ARVs in CI-PLWH.
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Affiliation(s)
- Alison L Blackman
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA.,Department of Pharmacy Practice and Sciences, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Sciences, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Aaron S Devanathan
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Neha Sheth Pandit
- Department of Pharmacy Practice and Sciences, University of Maryland School of Pharmacy, Baltimore, MD, USA
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9
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San C, Lê MP, Matheron S, Mourvillier B, Caseris M, Timsit JF, Wolff M, Yazdanpanah Y, Descamps D, Peytavin G. Management of oral antiretroviral administration in patients with swallowing disorders or with an enteral feeding tube. Med Mal Infect 2019; 50:537-544. [PMID: 31722864 DOI: 10.1016/j.medmal.2019.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 12/14/2018] [Accepted: 10/18/2019] [Indexed: 02/07/2023]
Abstract
HIV infection has evolved into a chronic disease with comorbidities since the combination antiretroviral therapy era. Complications still occur and patients may need to be admitted to an intensive care unit. Acute respiratory failure is the first cause of these admissions, questioning the administration of solid oral dosage formulations. This issue is also observed in geriatric units where the prevalence of dysphagia is high and underestimated. The problem of antiretroviral administration is critical: altered solid oral dosage formulations and/or administration via enteral feeding tubes are sometimes the only option. The aim is to help manage antiretroviral treatment in unconscious or intubated patients and those with swallowing disorders who are hospitalized in intensive care units or geriatric units. This review provides information on the main antiretroviral regimens and on practical and legal aspects of manipulating solid oral dosage formulations and administration via enteral feeding tubes. Alternatives to the solid formulation are available for most of the 27 oral antiretrovirals available, or manufacturers provide recommendations for patients who are unable to swallow. Manipulation of solid oral dosage formulations such as crushing tablets or opening capsules and administration via feeding tubes are frequently reported but should be the last option for safety and liability issues. Before any off-label administration of a drug, physicians should consider alternatives to the solid oral dosage formulation and check whether the drug can be altered. Therapeutic monitoring is important in this particular setting as the pharmacokinetic profile of drugs is difficult to predict.
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Affiliation(s)
- Carine San
- Laboratoire de pharmacologie-toxicologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - M P Lê
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Laboratoire de pharmacologie-toxicologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France.
| | - S Matheron
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Service de maladies infectieuses et tropicales, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - B Mourvillier
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Réanimation médicale et infectieuse, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - M Caseris
- Service de pédiatrie, AP-HP, Hôpital Robert Debré, 75019 Paris, France
| | - J-F Timsit
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Réanimation médicale et infectieuse, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - M Wolff
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Réanimation médicale et infectieuse, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - Y Yazdanpanah
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Service de maladies infectieuses et tropicales, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - D Descamps
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Laboratoire de virologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - G Peytavin
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Laboratoire de pharmacologie-toxicologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
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10
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Roskam-Kwint M, Bollen P, Colbers A, Duisenberg-van Essenberg M, Harbers V, Burger D. Crushing of dolutegravir fixed-dose combination tablets increases dolutegravir exposure. J Antimicrob Chemother 2019; 73:2430-2434. [PMID: 29796595 DOI: 10.1093/jac/dky191] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 04/22/2018] [Indexed: 11/13/2022] Open
Abstract
Background If HIV patients are unconscious or cannot swallow tablets for other reasons, antiretroviral medication is crushed and dissolved prior to administration. Crushing can alter drug exposure, possibly leading to treatment failure, development of resistance or toxicity. Currently, there is no information about crushing of the branded fixed-dose combination of dolutegravir/abacavir/lamivudine (Triumeq®, referred to as TRI); therefore, crushing of TRI is not recommended. Objectives To investigate whether the TRI fixed-dose combination tablet can be crushed and combined with enteral nutrition without influencing pharmacokinetics (PK). Methods We carried out an open-label, three-period, randomized, single-dose, crossover trial in 22 healthy adult volunteers. Subjects randomly received whole-tablet TRI with fasting (reference), crushed and suspended TRI with fasting or crushed and suspended TRI with oral intake of enteral nutrition. Bioequivalence criteria (80%-125% acceptance range) of AUC0-∞ and Cmax were used. ClinicalTrials.gov: NCT02569346. Results Crushing TRI leads to higher dolutegravir exposure (AUC0-∞: +26% and Cmax: +30%) and, if crushed TRI is combined with enteral nutrition, to a decrease in abacavir Cmax (-17%). Lamivudine concentrations were not affected as geometric mean ratios with 90% CIs fell within the 80%-125% range. Conclusions Bioequivalence could not be demonstrated for a crushed and suspended tablet or a crushed and suspended tablet with oral intake of enteral nutrition compared with whole-tablet TRI with fasting. Both scenarios led to higher dolutegravir exposure, but this did not exceed exposure after intake with food or in twice-daily dosing. In our opinion, TRI can be crushed for patients with swallowing difficulties and can be simultaneously administered with enteral nutrition.
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Affiliation(s)
- Marieke Roskam-Kwint
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands.,Department of Pharmacy, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Pauline Bollen
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Angela Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | | | - Veroniek Harbers
- Clinical Research Centre Nijmegen, Radboud university medical center, Nijmegen, The Netherlands
| | - David Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
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11
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Pecora Fulco P, Gatesman TL. Administration of crushed maraviroc via percutaneous gastrostomy tube in a patient with human immunodeficiency virus and progressive multifocal leukoencephalopathy. Am J Health Syst Pharm 2019; 76:265-267. [DOI: 10.1093/ajhp/zxy046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Travis L Gatesman
- Department of Pharmacy Virginia Commonwealth University Health Richmond, VA
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12
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Finocchio T, Coolidge W, Johnson T. The ART of Antiretroviral Therapy in Critically Ill Patients With HIV. J Intensive Care Med 2018; 34:897-909. [PMID: 30309292 DOI: 10.1177/0885066618803871] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The management of patients with human immunodeficiency virus (HIV) can be a complicated specialty within itself, made even more complex when there are so many unanswered questions regarding the care of critically ill patients with HIV. The lack of consensus on the use of antiretroviral medications in the critically ill patient population has contributed to an ongoing clinical debate among intensivists. This review focuses on the pharmacological complications of antiretroviral therapy (ART) in the intensive care setting, specifically the initiation of ART in patients newly diagnosed with HIV, immune reconstitution inflammatory syndrome (IRIS), continuation of ART in those who were on a complete regimen prior to intensive care unit admission, barriers of drug delivery alternatives, and drug-drug interactions.
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Affiliation(s)
- Tyler Finocchio
- Avera McKennan Hospital & University Health Center, Sioux Falls, SD, USA
| | - William Coolidge
- Avera McKennan Hospital & University Health Center, Sioux Falls, SD, USA
| | - Thomas Johnson
- Avera McKennan Hospital & University Health Center, Sioux Falls, SD, USA
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13
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Chrdle A, Jerhotová Z, Vacík M, Linka M, Chmelík V. Crushed dolutegravir/abacavir/lamivudine given via nasogastric tube in gastric outlet obstruction caused by cancer resulted in rapid viral load suppression. Int J STD AIDS 2018; 30:94-98. [PMID: 30231834 DOI: 10.1177/0956462418797847] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Alternative modes of antiretroviral administration are sought for people with impaired intestinal passage and/or absorption. We present a case of late HIV diagnosis (CD4+ count 160 cells/µL) with gastric outlet obstruction due to stomach adenocarcinoma. Co-morbidities included oesophageal candidiasis, Helicobacter pylori-positive duodenal ulcers and cytomegalovirus duodenitis. The gastric outlet obstruction required total parenteral nutrition and parenteral medication during four weeks of diagnostic work-up leading to pyloric resection. Crushed dolutegravir, abacavir and lamivudine were administered during this time in the evening via nasogastric tube, which was kept clamped overnight. The tube was unclamped in the morning and stomach content was drained during the daytime. This mode of administration resulted in rapid and sustained viral load suppression (from 300,000 to 115 copies per mL in 28 days, 81 copies/mL after 42 days of treatment and less than 40 copies/mL thereafter). Therapeutic drug monitoring confirmed sufficient antiretroviral plasma levels during this mode of administration. The absorption of crushed dolutegravir, abacavir and lamivudine in the stomach may be considered in people with questionable gastrointestinal passage or impaired gastric emptying to achieve viral load suppression.
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Affiliation(s)
- Aleš Chrdle
- 1 Infectious Diseases Department, České Budějovice Hospital, České Budějovice, Czech Republic.,2 Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Zdeňka Jerhotová
- 1 Infectious Diseases Department, České Budějovice Hospital, České Budějovice, Czech Republic
| | - Michal Vacík
- 3 Gastroenterology Department, České Budějovice Hospital, České Budějovice, Czech Republic
| | - Marek Linka
- 4 National Reference Laboratory for HIV/AIDS, National Institute of Public Health, Prague, Czech Republic
| | - Václav Chmelík
- 1 Infectious Diseases Department, České Budějovice Hospital, České Budějovice, Czech Republic
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14
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Brooks KM, Garrett KL, Kuriakose SS, George JM, Balba G, Bailey B, Anderson M, Lane HC, Maldarelli F, Pau AK. Decreased Absorption of Dolutegravir and Tenofovir Disoproxil Fumarate, But Not Emtricitabine, in an HIV-Infected Patient Following Oral and Jejunostomy-Tube Administration. Pharmacotherapy 2017; 37:e82-e89. [PMID: 28556353 PMCID: PMC5559318 DOI: 10.1002/phar.1960] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The use of enteral feeding tubes to administer antiretroviral medications is necessary in certain patients with human immunodeficiency virus (HIV) infection. However, adequacy of drug exposures after these administration routes are largely unknown, making dosing recommendations and the attainment of viral suppression challenging in this patient population. This report describes a patient with advanced HIV infection and a complicated medical history including long-term intractable nausea/vomiting necessitating antiretroviral medication administration via a Roux-en-Y jejunostomy (J)-tube. Pharmacokinetic assessments were performed to compare differences in antiretroviral drug absorption and plasma exposure following oral and J-tube administration of dolutegravir, tenofovir disoproxil fumarate, and emtricitabine. Results were also compared with published pharmacokinetic data in HIV-infected individuals. Exposure to dolutegravir and tenofovir were similar between J-tube and oral administration routes, whereas emtricitabine exposure was 38% lower when administered via J-tube. However, in comparison with reference data in HIV-infected individuals taking these medications orally, exposure to dolutegravir and tenofovir was 75-76% and 55-61% lower, respectively, following both routes of administration. Emtricitabine exposure was similar to and 71% higher than reference data following J-tube and oral administration, respectively. This report highlights the importance of performing pharmacokinetic assessments in patients with the potential for impaired drug absorption to ensure antiretroviral treatment success.
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Affiliation(s)
- Kristina M Brooks
- Clinical Pharmacokinetics Research Unit, Clinical Center Pharmacy Department, National Institutes of Health (NIH), Bethesda, Maryland
| | - Katy L Garrett
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina at Chapel Hill-Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Safia S Kuriakose
- Clinical Research Directorate/Clinical Monitoring Research Program, Leidos Biomedical Research, Inc., Frederick, Maryland
| | - Jomy M George
- Clinical Pharmacokinetics Research Unit, Clinical Center Pharmacy Department, National Institutes of Health (NIH), Bethesda, Maryland
| | - Gayle Balba
- Division of Infectious Diseases, Georgetown University Hospital, Washington, DC
| | - Bria Bailey
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland
| | - Megan Anderson
- Division of Intramural Research, NIAID, NIH, Bethesda, Maryland
| | - H Clifford Lane
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland
- Division of Intramural Research, NIAID, NIH, Bethesda, Maryland
| | - Frank Maldarelli
- Host Virus Interaction Branch, National Cancer Institute, NIH, Bethesda, Maryland
| | - Alice K Pau
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland
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