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Cusato J, Manca A, Palermiti A, Mula J, Antonucci M, Chiara F, De Nicolò A, Lupia T, Stroffolini G, Boglione L, D'Avolio A. Pharmacogenetics of tenofovir drug transporters in the context of HBV: Is there an impact? Biomed Pharmacother 2024; 175:116678. [PMID: 38713940 DOI: 10.1016/j.biopha.2024.116678] [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: 02/07/2024] [Revised: 04/19/2024] [Accepted: 04/29/2024] [Indexed: 05/09/2024] Open
Abstract
BACKGROUND Current treatments for chronic hepatitis B management include orally administered nucleos(t)ide analogues, such as tenofovir (TDF), which is an acyclic adenine nucleotide analogue used both in HBV and human immune deficiency virus (HIV). The course of HBV infection is mainly dependent on viral factors, such as HBV genotypes, immunological features and host genetic variables, but a few data are available in the context of HBV, in particular for polymorphisms of genes encoding proteins involved in drug metabolism and elimination. Consequently, the aim of this study was to evaluate the potential impact of genetic variants on TDF plasma and urine concentrations in patients with HBV, considering the role of HBV genotypes. METHODS A retrospective cohort study at the Infectious Disease Unit of Amedeo di Savoia Hospital, Torino, Italy, was performed. Pharmacokinetic analyses were performed through liquidi chromatography, whereas pharmacogenetic analyses through real-time PCR. FINDINGS Sixty - eight patients were analyzed: ABCC4 4976 C>T genetic variant showed an impact on urine TDF drug concentrations (p = 0.014). In addition, SLC22A6 453 AA was retained in the final regression multivariate model considering factors predicting plasma concentrations, while ABCC4 4976 TC/CC was the only predictor of urine concentrations in the univariate model. INTERPRETATION In conclusion, this is the first study showing a potential impact of genetic variants on TDF plasma and urine concentrations in the HBV context, but further studies in different and larger cohorts of patients are required.
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Affiliation(s)
- J Cusato
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital, Corso Svizzera, 164, Turin 10149, Italy
| | - A Manca
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital, Corso Svizzera, 164, Turin 10149, Italy
| | - A Palermiti
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital, Corso Svizzera, 164, Turin 10149, Italy.
| | - J Mula
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital, Corso Svizzera, 164, Turin 10149, Italy.
| | - M Antonucci
- Amedeo di Savoia Hospital, ASL Città di Torino, Turin, Italy
| | - F Chiara
- University of Turin, Department of Clinical and Biological Sciences, Laboratory of Clinical Pharmacology San Luigi A.O.U., Orbassano, TO, Italy
| | - A De Nicolò
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital, Corso Svizzera, 164, Turin 10149, Italy
| | - Tommaso Lupia
- Department of Medical Sciences, Infectious Diseases, University of Turin, Italy
| | - Giacomo Stroffolini
- Department of Medical Sciences, Infectious Diseases, University of Turin, Italy
| | - L Boglione
- University of Eastern Piedmont, Department of Translational Medicine, Novara, Italy
| | - A D'Avolio
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital, Corso Svizzera, 164, Turin 10149, Italy
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2
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Zhang L, Iannuzzi S, Chaturvedula A, Irungu E, Haberer JE, Hendrix CW, von Kleist M. Model-based predictions of protective HIV pre-exposure prophylaxis adherence levels in cisgender women. Nat Med 2023; 29:2753-2762. [PMID: 37957377 PMCID: PMC10667095 DOI: 10.1038/s41591-023-02615-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/26/2023] [Indexed: 11/15/2023]
Abstract
Most human immunodeficiency virus (HIV) infections occur in cisgender women in resource-limited settings. In women, self-protection with emtricitabine/tenofovir disoproxil fumarate pre-exposure prophylaxis (FTC/TDF-PrEP) constitutes a major pillar of HIV prevention. However, clinical trials in women had inconsistent outcomes, sparking uncertainty about adherence requirements and reluctance in evaluating on-demand regimens. We analyzed data from published FTC/TDF-PrEP trials to establish efficacy ranges in cisgender women. In a 'bottom-up' approach, we modeled hypotheses in the context of risk-group-specific, adherence-efficacy profiles and challenged those hypotheses with clinical data. We found that different clinical outcomes were related to the proportion of women taking the product, allowing coherent interpretation of the data. Our analysis showed that 90% protection was achieved when women took some product. We found that hypotheses of putative male/female differences were either not impactful or statistically inconsistent with clinical data. We propose that differing clinical outcomes could arise from pill-taking behavior rather than biological factors driving specific adherence requirements in cisgender women.
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Affiliation(s)
- Lanxin Zhang
- Project group 5 'Systems Medicine of Infectious Diseases', Robert Koch Institute, Berlin, Germany
| | - Sara Iannuzzi
- Project group 5 'Systems Medicine of Infectious Diseases', Robert Koch Institute, Berlin, Germany
- International Max-Planck Research School 'Biology and Computation', Max-Planck Institute for Molecular Genetics, Berlin, Germany
| | - Ayyappa Chaturvedula
- Department of Pharmacotherapy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | | | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Craig W Hendrix
- Division of Clinical Pharmacology, Johns Hopkins University, Baltimore, MD, USA
| | - Max von Kleist
- Project group 5 'Systems Medicine of Infectious Diseases', Robert Koch Institute, Berlin, Germany.
- Department of Mathematics and Computer Science, Freie Universität Berlin, Berlin, Germany.
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3
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Scott RK, Yu Y, Marzinke MA, Coleman JS, Hendrix CW, Bies R. Clinical trial simulation to evaluate tenofovir disoproxil fumarate/emtricitabine HIV pre-exposure prophylaxis dosing during pregnancy. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1224580. [PMID: 37830105 PMCID: PMC10565828 DOI: 10.3389/frph.2023.1224580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 09/04/2023] [Indexed: 10/14/2023] Open
Abstract
Objective To evaluate upward-adjustment of tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) pre-exposure prophylaxis (PrEP) dosing during pregnancy in order to maintain target plasma concentrations associated with HIV protection. Design Population pharmacokinetic (PK) modeling and clinical trial simulation (CTS). Material and methods We developed population pharmacokinetic models for TFV and FTC using data from the Partners Demonstration Project and a PK study of TDF/FTC among cisgender women by Coleman et al., and performed an in-silico simulation. Pregnancy-trimester was identified as a significant covariate on apparent clearance in the optimized final model. We simulated 1,000 pregnant individuals starting standard daily oral TDF/FTC (300 mg/200 mg) prior to pregnancy. Upon becoming pregnant, simulated patients were split into two study arms: one continuing standard-dose and the other receiving double standard-dose throughout pregnancy. Results Standard-dose trough TFV concentrations were significantly lower in pregnancy compared to pre-pregnancy, with 34.0%, 43.8%, and 65.1% of trough plasma concentrations below the lower bound of expected trough concentrations presumed to be the protective threshold in the 1st, 2nd, and 3rd trimesters, respectively. By comparison, in the simulated double-dose group, 10.7%, 14.4%, and 27.8% of trough concentrations fell below the estimated protective thresholds in the 1st, 2nd, and 3rd trimesters, respectively. The FTC trough plasma concentration during pregnancy was also lower than pre-pregnancy, with 45.2% of the steady-state trough concentrations below the estimated protective trough concentrations of FTC. In the pregnancy-adjusted double-dose group, 24.1% of trough plasma concentrations were lower than protective levels. Conclusions Our simulation shows >50% of research participants on standard dosing would have 3rd trimester trough plasma TFV concentrations below levels associated with protection. This simulation provides the quantitative basis for the design of prospective TDF/FTC studies during pregnancy to evaluate the safety and appropriateness of pregnancy-adjusted dosing.
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Affiliation(s)
- Rachel K. Scott
- Women’s Health Research, MedStar Health Research Institute, Washington, DC, United States
| | - Yifan Yu
- Department of Pharmaceutical Sciences, University of Buffalo, Buffalo, NY, United States
| | - Mark A. Marzinke
- Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jenell S. Coleman
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Craig W. Hendrix
- Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Robert Bies
- Department of Pharmaceutical Sciences, University of Buffalo, Buffalo, NY, United States
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4
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Gunawardana M, Remedios-Chan M, Sanchez D, Fanter R, Webster S, Webster P, Moss JA, Trinh M, Beliveau M, Ramirez CM, Marzinke MA, Kuo J, Gallay PA, Baum MM. Preclinical Considerations for Long-acting Delivery of Tenofovir Alafenamide from Subdermal Implants for HIV Pre-exposure Prophylaxis. Pharm Res 2023; 40:1657-1672. [PMID: 36418671 PMCID: PMC10421770 DOI: 10.1007/s11095-022-03440-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 11/15/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Long-acting formulations of the potent antiretroviral prodrug tenofovir alafenamide (TAF) hold potential as biomedical HIV prevention modalities. Here, we present a rigorous comparison of three animal models, C57BL/6 J mice, beagle dogs, and merino sheep for evaluating TAF implant pharmacokinetics (PKs). METHODS Implants delivering TAF over a wide range of controlled release rates were tested in vitro and in mice and dogs. Our existing PK model, supported by an intravenous (IV) dosing dog study, was adapted to analyze mechanistic aspects underlying implant TAF delivery. RESULTS TAF in vitro release in the 0.13 to 9.8 mg d-1 range with zero order kinetics were attained. Implants with equivalent fabrication parameters released TAF in mice and sheep at rates that were not statistically different, but were 3 times higher in dogs. When two implants were placed in the same subcutaneous pocket, a two-week creep to Cmax was observed in dogs for systemic drug and metabolite concentrations, but not in mice. Co-modeling IV and TAF implant PK data in dogs led to an apparent TAF bioavailability of 9.6 in the single implant groups (compared to the IV group), but only 1.5 when two implants were placed in the same subcutaneous pocket. CONCLUSIONS Based on the current results, we recommend using mice and sheep, with macaques as a complementary species, for preclinical TAF implant evaluation with the caveat that our observations may be specific to the implant technology used here. Our report provides fundamental, translatable insights into multispecies TAF delivery via long-acting implants.
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Affiliation(s)
- Manjula Gunawardana
- Department of Chemistry, Oak Crest Institute of Science, 128-132 W. Chestnut Ave., Monrovia, CA, USA
| | - Mariana Remedios-Chan
- Department of Chemistry, Oak Crest Institute of Science, 128-132 W. Chestnut Ave., Monrovia, CA, USA
| | - Debbie Sanchez
- Department of Chemistry, Oak Crest Institute of Science, 128-132 W. Chestnut Ave., Monrovia, CA, USA
| | - Rob Fanter
- Department of Chemistry, Oak Crest Institute of Science, 128-132 W. Chestnut Ave., Monrovia, CA, USA
| | - Simon Webster
- Department of Chemistry, Oak Crest Institute of Science, 128-132 W. Chestnut Ave., Monrovia, CA, USA
| | - Paul Webster
- Department of Chemistry, Oak Crest Institute of Science, 128-132 W. Chestnut Ave., Monrovia, CA, USA
| | - John A Moss
- Department of Chemistry, Oak Crest Institute of Science, 128-132 W. Chestnut Ave., Monrovia, CA, USA
| | - MyMy Trinh
- Certara USA, Inc., Integrated Drug Development, 100 Overlook Center, Suite 101, Princeton, NJ, USA
| | - Martin Beliveau
- Certara USA, Inc., Integrated Drug Development, 100 Overlook Center, Suite 101, Princeton, NJ, USA
| | - Christina M Ramirez
- Department of Biostatistics, UCLA Fielding School of Public Health, University of California, Los Angeles (UCLA), 650 Charles E. Young Drive, Los Angeles, CA, USA
| | - Mark A Marzinke
- Department of Medicine, Johns Hopkins University, 600 N. Wolfe Street, Baltimore, MD, USA
- Department of Pathology, Johns Hopkins University, 600 N. Wolfe Street/Carnegie 417, Baltimore, MD, USA
| | - Joseph Kuo
- Department of Immunology & Microbiology, The Scripps Research Institute, 10550 North Torrey Pines Road, La Jolla, CA, USA
| | - Philippe A Gallay
- Department of Immunology & Microbiology, The Scripps Research Institute, 10550 North Torrey Pines Road, La Jolla, CA, USA
| | - Marc M Baum
- Department of Chemistry, Oak Crest Institute of Science, 128-132 W. Chestnut Ave., Monrovia, CA, USA.
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Bertrand J, Barrail-Tran A, Fayette L, Savic R, Goujard C, Teicher E, Barau C, Pruvost A, Taburet AM, Mentré F, Verstuyft C. Pharmacokinetic Model of Tenofovir and Emtricitabine and Their Intracellular Metabolites in Patients in the ANRS 134-COPHAR 3 Trial Using Dose Records. Antimicrob Agents Chemother 2023; 67:e0233918. [PMID: 37098914 PMCID: PMC10190280 DOI: 10.1128/aac.02339-18] [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: 11/05/2018] [Accepted: 03/22/2023] [Indexed: 04/27/2023] Open
Abstract
Tenofovir (TFV) and emtricitabine (FTC) are part of the recommended highly active antiretroviral therapy (ART). Both molecules show a large interindividual pharmacokinetic (PK) variability. Here, we modeled the concentrations of plasma TFV and FTC and their intracellular metabolites (TFV diphosphate [TFV-DP] and FTC triphosphate [FTC-TP]) collected after 4 and 24 weeks of treatment in 34 patients from the ANRS 134-COPHAR 3 trial. These patients received daily (QD) atazanavir (300 mg), ritonavir (100 mg), and a fixed-dose combination of coformulated TFV disoproxil fumarate (300 mg) and FTC (200 mg). Dosing history was collected using a medication event monitoring system. A three-compartment model with absorption delay (Tlag) was selected to describe the PK of, respectively, TFV/TFV-DP and FTC/FTC-TP. TFV and FTC apparent clearances, 114 L/h (relative standard error [RSE] = 8%) and 18.1 L/h (RSE = 5%), respectively, were found to decrease with age. However, no significant association was found with the polymorphisms ABCC2 rs717620, ABCC4 rs1751034, and ABCB1 rs1045642. The model allows prediction of TFV-DP and FTC-TP concentrations at steady state with alternative regimens.
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Affiliation(s)
- Julie Bertrand
- UMR 1137, IAME, INSERM, Université Paris Cité, Paris, France
| | - Aurélie Barrail-Tran
- AP-HP, Hôpital Bicêtre, Pharmacie Clinique, Le Kremlin-Bicêtre, France
- UMR 1184, Center for Immunology of Viral Infections and Autoimmune Diseases, INSERM, Université Paris Sud, Paris, France
| | - Lucie Fayette
- UMR 1137, IAME, INSERM, Université Paris Cité, Paris, France
| | - Rada Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Cécile Goujard
- AP-HP, Hôpital Bicêtre, Service de médecine interne et d’immunologie clinique, Le Kremlin-Bicêtre, France
- CESP, Team Epidémiologie Clinique, INSERM UMR 1018, Faculté de Médecine, Univ Paris-Saclay, Le Kremlin Bicêtre, France
| | - Elina Teicher
- AP-HP, Hôpital Bicêtre, Service de médecine interne et d’immunologie clinique, Le Kremlin-Bicêtre, France
| | - Caroline Barau
- AP-HP, Hôpital Henri Mondor, Plateforme de Ressources Biologiques, Créteil, France
| | - Alain Pruvost
- Département Médicaments et Technologies pour la Santé, SPI, CEA, INRAE, Université Paris Saclay, Paris, France
| | - Anne-Marie Taburet
- AP-HP, Hôpital Bicêtre, Pharmacie Clinique, Le Kremlin-Bicêtre, France
- UMR 1184, Center for Immunology of Viral Infections and Autoimmune Diseases, INSERM, Université Paris Sud, Paris, France
| | - France Mentré
- UMR 1137, IAME, INSERM, Université Paris Cité, Paris, France
| | - Céline Verstuyft
- CESP, Team Epidémiologie Clinique, INSERM UMR 1018, Faculté de Médecine, Univ Paris-Saclay, Le Kremlin Bicêtre, France
- AP-HP, Hôpital Bicêtre, Service de génétique moléculaire et pharmacogénétique, Le Kremlin-Bicêtre, France
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6
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Zhang L, Iannuzzi S, Chaturvedula A, Haberer JE, Hendrix CW, von Kleist M. Synthesis of protective oral PrEP adherence levels in cisgender women using convergent clinical- and bottom-up modeling. RESEARCH SQUARE 2023:rs.3.rs-2772765. [PMID: 37131701 PMCID: PMC10153398 DOI: 10.21203/rs.3.rs-2772765/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Globally, most HIV infections occur in heterosexual women in resource-limited settings. In these settings, female self-protection with generic emtricitabine/tenofovir disoproxil fumarate pre-exposure prophylaxis (FTC/TDF-PrEP) may constitute a major pillar of the HIV prevention portfolio. However, clinical trials in women had inconsistent outcomes, sparking uncertainty regarding risk-group specific adherence requirements and causing reluctance in testing and recommending on-demand regimen in women. We analyzed all FTC/TDF-PrEP trials to establish PrEP efficacy ranges in women. In a 'bottom-up' approach, we modeled hypotheses corroborating risk-group specific adherence-efficacy profiles. Finally, we used the clinical efficacy ranges to (in-)validate hypotheses. We found that different clinical outcomes could solely be explained by the proportion of enrolled participants not taking the product, allowing, for the first time, to unify clinical observations. This analysis showed that 90% protection was achieved, when women took some of the product. Using 'bottom-up' modelling, we found that hypotheses of putative male/female differences were either irrelevant, or statistically inconsistent with clinical data. Furthermore, our multiscale modelling indicated that 90% protection was achieved if oral FTC/TDF was taken at least twice weekly.
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Affiliation(s)
- Lanxin Zhang
- Project group 5 “Systems Medicine of Infectious Disease”, Robert Koch Institute, Berlin, Germany
| | - Sara Iannuzzi
- Project group 5 “Systems Medicine of Infectious Disease”, Robert Koch Institute, Berlin, Germany
- International Max-Planck Research School “Biology and Computation” (IMPRS-BAC), Max-Planck Institute for Molecular Genetics, Berlin, Germany
| | - Ayyappa Chaturvedula
- The University of North Texas; Health Science Center, Fort Worth, United States
- Pumas-AI Inc
| | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, United States
- Department of Medicine, Harvard Medical School, Boston, United States
| | - Craig W. Hendrix
- Division of Clinical Pharmacology, Johns-Hopkins University, Baltimore, United States
| | - Max von Kleist
- Project group 5 “Systems Medicine of Infectious Disease”, Robert Koch Institute, Berlin, Germany
- Department of Mathematics and Computer Science, Freie Universität Berlin, Berlin, Germany
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Duga AL, Magongo S, Nhlabatsi S, Ladwar DO, Härmark L, Rolfes L. An evaluation of postmarketing reports of hyperglycaemia associated with dolutegravir for treatment of HIV in Eswatini. AIDS Res Ther 2022; 19:54. [PMID: 36424607 PMCID: PMC9694599 DOI: 10.1186/s12981-022-00481-0] [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: 04/13/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Dolutegravir (DTG) is an Integrase Strand Transfer Inhibitor (INSTI) indicated in combination with other antiretroviral agents for the treatment of HIV infection. It is available in a number of pharmaceutical preparations including the fixed-dose combination (TLD) containing tenofovir (300 mg) + lamivudine (300 mg) + dolutegravir (50 mg). In 2018, Eswatini adopted TLD as the preferred first-line HIV treatment regimen for adults and adolescents as per WHO recommendations. From March 2019 to March 2020, the National Pharmacovigilance Center (NPC) in Eswatini received 8 reports of hyperglycaemia associated with the use of DTG. This study was conducted to investigate if Eswatini NPC database included cases suggestive of causality between dolutegravir and hyperglycaemia. METHOD A qualitative synthesis of information from the Eswatini national pharmacovigilance database from March 2019 to March 2020 was conducted to investigate a casual association between hyperglycaemia and dolutegravir. RESULTS All reports with dolutegravir containing regimen and suspected Adverse Event of hyperglycaemia in the period of March 2019 to March 2020 were included in the study. Seven of the reports were serious (resulted in hospitalization and one case concerned optic neuritis, leading to blindness). Two patients had a medical history of diabetes while the rest of the patients had never experienced hyperglycaemia before starting dolutegravir. For all the reports, the time to onset of hyperglycaemia ranges from 2-5 months after the initiation of DTG. None of the patients discontinued the use of DTG. All the patients were treated with oral hypoglycaemic medication. In severe cases, patients were treated with intravenous normal saline and ringer lactate as well as rapid-acting insulins. All patients are currently stable on oral hypoglycaemic drugs. CONCLUSION Cases that support causality between dolutegravir containing regimen and hyperglycaemia were found. These cases were mainly serious. Based on these findings it is recommended that healthcare professionals (HCPs) actively screen all patients for risk factors of hyperglycaemia before DTG initiation. In addition, it is important that HCPs are aware of the possible association between DTG and hyperglycaemia.
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Affiliation(s)
- Alemayehu L. Duga
- grid.463475.7National Pharmacovigilance Center, Eswatini Ministry of Health, Matsapha, Eswatini ,Baylor College of Medicine Children’s Foundation, Mbabane, Eswatini
| | - Sibongile Magongo
- grid.463475.7Medicine Regulatory Unit, Eswatini Ministry of Health, Matsapha, Eswatini
| | - Siphesihle Nhlabatsi
- grid.463475.7National Pharmacovigilance Center, Eswatini Ministry of Health, Matsapha, Eswatini
| | | | - Linda Härmark
- The Netherlands Pharmacovigilance Center Lareb, s-Hertogenbosch, The Netherlands
| | - Leàn Rolfes
- The Netherlands Pharmacovigilance Center Lareb, s-Hertogenbosch, The Netherlands
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8
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Gunawardana M, Remedios-Chan M, Sanchez D, Webster S, Castonguay AE, Webster P, Buser C, Moss JA, Trinh M, Beliveau M, Hendrix CW, Marzinke MA, Tuck M, Caprioli RM, Reyzer ML, Kuo J, Gallay PA, Baum MM. Fundamental aspects of long-acting tenofovir alafenamide delivery from subdermal implants for HIV prophylaxis. Sci Rep 2022; 12:8224. [PMID: 35581262 PMCID: PMC9114338 DOI: 10.1038/s41598-022-11020-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 04/15/2022] [Indexed: 01/04/2023] Open
Abstract
Global efforts aimed at preventing human immunodeficiency virus type one (HIV-1) infection in vulnerable populations appear to be stalling, limiting our ability to control the epidemic. Long-acting, controlled drug administration from subdermal implants holds significant potential by reducing the compliance burden associated with frequent dosing. We, and others, are exploring the development of complementary subdermal implant technologies delivering the potent prodrug, tenofovir alafenamide (TAF). The current report addresses knowledge gaps in the preclinical pharmacology of long-acting, subdermal TAF delivery using several mouse models. Systemic drug disposition during TAF implant dosing was explained by a multi-compartment pharmacokinetic (PK) model. Imaging mass spectrometry was employed to characterize the spatial distribution of TAF and its principal five metabolites in local tissues surrounding the implant. Humanized mouse studies determined the effective TAF dose for preventing vaginal and rectal HIV-1 acquisition. Our results represent an important step in the development of a safe and effective TAF implant for HIV-1 prevention.
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Affiliation(s)
- Manjula Gunawardana
- Department of Chemistry, Oak Crest Institute of Science, 128-132 W. Chestnut Ave., Monrovia, CA, USA
| | - Mariana Remedios-Chan
- Department of Chemistry, Oak Crest Institute of Science, 128-132 W. Chestnut Ave., Monrovia, CA, USA
| | - Debbie Sanchez
- Department of Chemistry, Oak Crest Institute of Science, 128-132 W. Chestnut Ave., Monrovia, CA, USA
| | - Simon Webster
- Department of Chemistry, Oak Crest Institute of Science, 128-132 W. Chestnut Ave., Monrovia, CA, USA
| | - Amalia E Castonguay
- Department of Chemistry, Oak Crest Institute of Science, 128-132 W. Chestnut Ave., Monrovia, CA, USA
| | - Paul Webster
- Department of Chemistry, Oak Crest Institute of Science, 128-132 W. Chestnut Ave., Monrovia, CA, USA
| | - Christopher Buser
- Department of Chemistry, Oak Crest Institute of Science, 128-132 W. Chestnut Ave., Monrovia, CA, USA
| | - John A Moss
- Department of Chemistry, Oak Crest Institute of Science, 128-132 W. Chestnut Ave., Monrovia, CA, USA
| | - MyMy Trinh
- Certara Integrated Drug Development, 2000 Peel Street, Suite 570, Montreal, QC, Canada
| | - Martin Beliveau
- Certara Integrated Drug Development, 2000 Peel Street, Suite 570, Montreal, QC, Canada
| | - Craig W Hendrix
- Department of Medicine, Johns Hopkins University, 600 N. Wolfe Street, Baltimore, MD, USA
| | - Mark A Marzinke
- Department of Medicine, Johns Hopkins University, 600 N. Wolfe Street, Baltimore, MD, USA.,Department of Pathology, Johns Hopkins University, 600 N. Wolfe Street/Carnegie 417, Baltimore, MD, USA
| | - Michael Tuck
- Department of Biochemistry, Vanderbilt University, 9160 MRB III, 465 21st Ave. South, Nashville, TN, USA
| | - Richard M Caprioli
- Department of Biochemistry, Vanderbilt University, 9160 MRB III, 465 21st Ave. South, Nashville, TN, USA
| | - Michelle L Reyzer
- Department of Biochemistry, Vanderbilt University, 9160 MRB III, 465 21st Ave. South, Nashville, TN, USA
| | - Joseph Kuo
- Department of Immunology & Microbiology, The Scripps Research Institute, 10550 North Torrey Pines Road, La Jolla, CA, USA
| | - Philippe A Gallay
- Department of Immunology & Microbiology, The Scripps Research Institute, 10550 North Torrey Pines Road, La Jolla, CA, USA
| | - Marc M Baum
- Department of Chemistry, Oak Crest Institute of Science, 128-132 W. Chestnut Ave., Monrovia, CA, USA.
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9
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Tanaudommongkon A, Chaturvedula A, Hendrix CW, Fuchs EJ, Shieh E, Bakshi RP, Marzinke MA. Population pharmacokinetics of tenofovir, emtricitabine and intracellular metabolites in transgender women. Br J Clin Pharmacol 2022; 88:3674-3682. [PMID: 35285974 PMCID: PMC9296590 DOI: 10.1111/bcp.15310] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/07/2022] [Accepted: 03/02/2022] [Indexed: 11/03/2022] Open
Abstract
Aims Transgender women (TGW) have been underrepresented in trials and use gender‐affirming hormonal therapies (GAHT) that may alter renal function by significantly increasing creatinine clearance. Population pharmacokinetic (popPK) models and simulations would aid in understanding potential differences in emtricitabine/tenofovir disproxil fumarate (F/TDF) parent–metabolite concentrations in TGW on GAHT when compared to cisgender men (CGM) not exposed to GAHT. Methods Pharmacokinetic (PK) data from a Phase 1, open‐label clinical trial with directly observed therapy of daily F/TDF consisting of 8 TGW and 8 CGM was utilized for model building. PopPK analysis was performed using nonlinear mixed effects modelling (NONMEM 7.5.0). Covariates of body weight, creatinine clearance, and gender were evaluated. Final models were subjected to Monte Carlo simulations to compare drug exposure following once daily and on‐demand (IPERGAY 2 + 1 + 1) dosing of F/TDF. Results Tenofovir (TFV) and emtricitabine PK were best described by a 2‐compartment model, first‐order absorption/elimination with absorption lag time. Parent models were linked to their metabolites by first order formation and elimination. Creatinine clearance was a significant covariate influencing clearance in both models. Simulations demonstrated that at least 2, weekly 2 + 1 + 1 cycles of on‐demand dosing in TGW on GAHT is necessary for TFV‐diphosphate to reach similar exposure after the initial week of on‐demand dosing in CGM not on GAHT. Conclusion PopPK models of TFV, emtricitabine and intracellular metabolites in TGW were established. Dose simulations revealed that TGW should be treated for at least 2 weeks to have comparable exposures to CGM.
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Affiliation(s)
- Asama Tanaudommongkon
- College of Pharmacy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Ayyappa Chaturvedula
- College of Pharmacy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Craig W Hendrix
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Edward J Fuchs
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eugenie Shieh
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rahul P Bakshi
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mark A Marzinke
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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10
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Zhang L, Wang J, von Kleist M. Numerical approaches for the rapid analysis of prophylactic efficacy against HIV with arbitrary drug-dosing schemes. PLoS Comput Biol 2021; 17:e1009295. [PMID: 34941864 PMCID: PMC8741042 DOI: 10.1371/journal.pcbi.1009295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 01/07/2022] [Accepted: 12/03/2021] [Indexed: 11/18/2022] Open
Abstract
Pre-exposure prophylaxis (PrEP) is an important pillar to prevent HIV transmission. Because of experimental and clinical shortcomings, mathematical models that integrate pharmacological, viral- and host factors are frequently used to quantify clinical efficacy of PrEP. Stochastic simulations of these models provides sample statistics from which the clinical efficacy is approximated. However, many stochastic simulations are needed to reduce the associated sampling error. To remedy the shortcomings of stochastic simulation, we developed a numerical method that allows predicting the efficacy of arbitrary prophylactic regimen directly from a viral dynamics model, without sampling. We apply the method to various hypothetical dolutegravir (DTG) prophylaxis scenarios. The approach is verified against state-of-the-art stochastic simulation. While the method is more accurate than stochastic simulation, it is superior in terms of computational performance. For example, a continuous 6-month prophylactic profile is computed within a few seconds on a laptop computer. The method’s computational performance, therefore, substantially expands the horizon of feasible analysis in the context of PrEP, and possibly other applications. Pre-exposure prophylaxis (PrEP) is an important tool to prevent HIV transmission. However, experimental identification of parameters that determine prophylactic efficacy is extremely difficult. Clues about these parameters could prove essential for the design of next-generation PrEP compounds. Integrative mathematical models can fill this void: Based on stochastic simulation, a sample statistic can be generated, from which the prophylactic efficacy is estimated. However, for this sample statistic to be accurate, many simulations need to be performed. Here, we introduce a numerical method to directly compute the prophylactic efficacy from a viral dynamics model, without the need for sampling. Based on several examples with dolutegravir (DTG) -based short- and long-term PrEP, as well as post-exposure prophylaxis we demonstrate the correctness of the new method and its outstanding computational performance. Due to the method’s computational performance, a number of analyses, including formal sensitivity analysis, are becoming feasible with the proposed method.
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Affiliation(s)
- Lanxin Zhang
- Project group 5 “Systems Medicine of Infectious Disease”, Robert Koch Institute, Berlin, Germany
| | - Junyu Wang
- Project group 5 “Systems Medicine of Infectious Disease”, Robert Koch Institute, Berlin, Germany
| | - Max von Kleist
- Project group 5 “Systems Medicine of Infectious Disease”, Robert Koch Institute, Berlin, Germany
- * E-mail:
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11
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Lin YH, Satani N, Hammoudi N, Yan VC, Barekatain Y, Khadka S, Ackroyd JJ, Georgiou DK, Pham CD, Arthur K, Maxwell D, Peng Z, Leonard PG, Czako B, Pisaneschi F, Mandal P, Sun Y, Zielinski R, Pando SC, Wang X, Tran T, Xu Q, Wu Q, Jiang Y, Kang Z, Asara JM, Priebe W, Bornmann W, Marszalek JR, DePinho RA, Muller FL. An enolase inhibitor for the targeted treatment of ENO1-deleted cancers. Nat Metab 2020; 2:1413-1426. [PMID: 33230295 PMCID: PMC7744354 DOI: 10.1038/s42255-020-00313-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 10/15/2020] [Indexed: 12/15/2022]
Abstract
Inhibiting glycolysis remains an aspirational approach for the treatment of cancer. We have previously identified a subset of cancers harbouring homozygous deletion of the glycolytic enzyme enolase (ENO1) that have exceptional sensitivity to inhibition of its redundant paralogue, ENO2, through a therapeutic strategy known as collateral lethality. Here, we show that a small-molecule enolase inhibitor, POMHEX, can selectively kill ENO1-deleted glioma cells at low-nanomolar concentrations and eradicate intracranial orthotopic ENO1-deleted tumours in mice at doses well-tolerated in non-human primates. Our data provide an in vivo proof of principle of the power of collateral lethality in precision oncology and demonstrate the utility of POMHEX for glycolysis inhibition with potential use across a range of therapeutic settings.
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Affiliation(s)
- Yu-Hsi Lin
- Department of Cancer Systems Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nikunj Satani
- Department of Cancer Systems Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Institute of Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Naima Hammoudi
- Department of Cancer Systems Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Victoria C Yan
- Department of Cancer Systems Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yasaman Barekatain
- Department of Cancer Systems Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sunada Khadka
- Department of Cancer Systems Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey J Ackroyd
- Department of Cancer Systems Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dimitra K Georgiou
- Department of Cancer Systems Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cong-Dat Pham
- Department of Cancer Systems Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kenisha Arthur
- Department of Cancer Systems Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Maxwell
- Institutional Analytics & Informatics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Paul G Leonard
- Core for Biomolecular Structure and Function, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Institute for Applied Cancer Sciences, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Barbara Czako
- Institute for Applied Cancer Sciences, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Federica Pisaneschi
- Department of Cancer Systems Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pijus Mandal
- Institute for Applied Cancer Sciences, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yuting Sun
- Institute for Applied Cancer Sciences, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rafal Zielinski
- Department of Experimental Therapeutics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susana Castro Pando
- Department of Cancer Systems Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiaobo Wang
- Department of Cancer Systems Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Theresa Tran
- Department of Cancer Systems Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Quanyu Xu
- Pharmaceutical Science Facility, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Qi Wu
- Pharmaceutical Science Facility, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yongying Jiang
- Pharmaceutical Science Facility, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhijun Kang
- Institute for Applied Cancer Sciences, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John M Asara
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Waldemar Priebe
- Department of Experimental Therapeutics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William Bornmann
- Director of Drug Discovery and Development, Advanced Organic Synthesis LLC, Houston, Texas, USA
| | - Joseph R Marszalek
- Center for Co-Clinical Trials, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ronald A DePinho
- Department of Cancer Biology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Florian L Muller
- Department of Cancer Systems Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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12
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Chen J, Chen R, Shen Y, Wei H, Wang X, Zhang R, Hu Z, Xie R, Huang Q, Wang J, Liu L, Qi T, Wang Z, Song W, Tang Y, Sun J, Lu H. Efficacy and safety of lower dose tenofovir disoproxil fumarate and efavirenz versus standard dose in HIV-infected, antiretroviral-naive adults: a multicentre, randomized, noninferiority trial. Emerg Microbes Infect 2020; 9:843-850. [PMID: 32267205 PMCID: PMC7241516 DOI: 10.1080/22221751.2020.1752609] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Reduced doses of antiretroviral (ARV) drugs may lower toxicity while preserving efficacy. We aimed to evaluate the efficacy of reduced doses of both tenofovir disoproxil fumarate (TDF) and efavirenz for the treatment of HIV-1 infection. In this open-label, non-inferiority trial, HIV-1-infected antiretroviral-naive adults were randomly assigned to receive either a lower dose anti-retroviral regimen comprised of TDF (200 mg), efavirenz (400 mg), and standard dose lamivudine (300 mg) or the standard dose regimen. The primary endpoint was the proportion of participants with HIV-1 RNA≤ 50 copies/mL at week 48 using a non-inferiority margin of –10%. At week 48, 79 of 92 (85.9%) participants in the lower dose regimen group and 78 of 92 (84.8%) in the standard dose regimen group achieved HIV-1 RNA≤ 50 copies/mL (treatment difference 1.1%, 95% CI −9.1 to 11.3) in the intention-to-treat analysis. Drug-related adverse events occurred more frequently in the participants receiving the standard dose regimen compared with the lower dose one (63.0% vs 80.4%). Changes in estimated glomerular filtration rate and bone mineral density were comparable between the two groups. The non-inferior efficacy and better safety profile of the lower dose ARV regimen support its use as alternative initial therapy for HIV-1 infected patients.
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Affiliation(s)
- Jun Chen
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Rong Chen
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Yinzhong Shen
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Hongxia Wei
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, People's Republic of China
| | - Xicheng Wang
- Yunnan AIDS Care Center (YNACC), Yunnan Provincial Infectious Disease Hospital, Kunming, People's Republic of China
| | - Renfang Zhang
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Zhiliang Hu
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, People's Republic of China
| | - Ronghui Xie
- Yunnan AIDS Care Center (YNACC), Yunnan Provincial Infectious Disease Hospital, Kunming, People's Republic of China
| | - Qiong Huang
- Yunnan AIDS Care Center (YNACC), Yunnan Provincial Infectious Disease Hospital, Kunming, People's Republic of China
| | - Jiangrong Wang
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Li Liu
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Tangkai Qi
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Zhenyan Wang
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Wei Song
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Yang Tang
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Jianjun Sun
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Hongzhou Lu
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
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13
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Bierhoff M, Smolders EJ, Tarning J, Burger DM, Spijker R, Rijken MJ, Angkurawaranon C, McGready R, White NJ, Nosten F, van Vugt M. Pharmacokinetics of oral tenofovir disoproxil fumarate in pregnancy and lactation: a systematic review. Antivir Ther 2020; 24:529-540. [PMID: 31868655 DOI: 10.3851/imp3341] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Tenofovir disoproxil fumarate (TDF), the oral prodrug of tenofovir (TFV), is advocated in pregnancy for prevention of mother-to-child transmission (PMCT) with failure of hepatitis B immunoglobulin and vaccination. The pharmacokinetics of TDF monotherapy for PMCT-HBV is important if deployment is to emulate the success of multiple antiretrovirals (ARVs) for PMCT-HIV in resource-constrained settings. METHODS This systematic review followed a protocol and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA) guidelines. We included studies that enrolled pregnant women who received oral TDF therapy as monotherapy or in combination with other ARVs: irrespective of the reason for receiving the drug (for example, HIV, HBV or pre-exposure prophylaxis); and reported pharmacokinetics. RESULTS The area under the concentration-time curve (AUC), maximum plasma concentrations (Cmax) and last measurable plasma concentration (Clast) of TFV were decreased in the second and third trimester compared with first trimester or post-partum. In none of the manuscripts was the non-pregnant HBV threshold of Cmax of 300 ng/ml reached, but the 50% effective concentration (EC50) of TFV is lower for treatment of HBV compared with HIV. The TFV concentration in breastfed infants was 0.03% of the recommended infant dose. CONCLUSIONS Most knowledge of pharmacokinetics of TFV in pregnancy results from studies on HIV involving multiple ARVs. Increased TFV clearance occurred in the second and third trimester when optimal TFV concentrations are required to maximize suppression of HBV in the window before birth. Dose or duration adjustments will be better conceptualized with concurrent analysis of the pharmacokinetics of TFV monotherapy and hepatitis B pharmacodynamics in pregnancy.
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Affiliation(s)
- Marieke Bierhoff
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,Department of Internal Medicine and Tropical Diseases, Amsterdam University Medical Center, location Academic Medical Center Amsterdam, Amsterdam, the Netherlands
| | - Elise J Smolders
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Pharmacy, Isala Hospital, Zwolle, the Netherlands
| | - Joel Tarning
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - David M Burger
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rene Spijker
- Department of Internal Medicine and Tropical Diseases, Amsterdam University Medical Center, location Academic Medical Center Amsterdam, Amsterdam, the Netherlands
| | - Marcus J Rijken
- Utrecht University Medical Centre, Utrecht, the Netherlands.,Julius Centre Global Health, Utrecht, the Netherlands
| | - Chaisiri Angkurawaranon
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Rose McGready
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicholas J White
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Francois Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Michèle van Vugt
- Department of Internal Medicine and Tropical Diseases, Amsterdam University Medical Center, location Academic Medical Center Amsterdam, Amsterdam, the Netherlands
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14
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De Sousa Mendes M, Chetty M. Are Standard Doses of Renally-Excreted Antiretrovirals in Older Patients Appropriate: A PBPK Study Comparing Exposures in the Elderly Population With Those in Renal Impairment. Drugs R D 2020; 19:339-350. [PMID: 31602556 PMCID: PMC6890626 DOI: 10.1007/s40268-019-00285-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The elderly population receives the majority of prescription drugs but are usually excluded from Phase 1 clinical trials. Alternative approaches to estimate increases in toxicity risk or decreases in efficacy are therefore needed. This study predicted the pharmacokinetics (PK) of three renally excreted antiretroviral drugs in the elderly population and compared them with known exposures in renal impairment, to evaluate the need for dosing adjustments. METHODS The performance of the physiologically based pharmacokinetic (PBPK) models for tenofovir, lamivudine and emtricitabine were verified using clinical data in young and older subjects. Models were then used to predict PK profiles in a virtual population aged 20 to 49 years (young) and a geriatric population aged 65 to 74 years (elderly). Predicted exposure in the elderly was then compared with exposure reported for different degrees of renal impairment, where doses have been defined. RESULTS An increase in exposure (AUC) with advancing age was predicted for all drugs. The mean ratio of the increase in exposure were 1.40 for emtricitabine, 1.42 for lamivudine and 1.48 for tenofovir. The majority of virtual patients had exposures that did not require dosage adjustments. About 22% of patients on tenofovir showed exposures similar to that in moderate renal impairment, where dosage reduction may be required. CONCLUSION Comparison of the exposure in the elderly with exposure observed in patients with different levels of renal impairment, indicated that a dosage adjustment may not be required in elderly patients on lamivudine, emtricitabine and the majority of the patients on tenofovir. Clinical trials to verify these predictions are essential.
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15
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Straubinger T, Kay K, Bies R. Modeling HIV Pre-Exposure Prophylaxis. Front Pharmacol 2020; 10:1514. [PMID: 32082142 PMCID: PMC7005100 DOI: 10.3389/fphar.2019.01514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 11/21/2019] [Indexed: 11/26/2022] Open
Abstract
Pre-exposure prophylaxis (PrEP) has emerged as a promising strategy for preventing the transmission of HIV. Although only one formulation is currently approved for PrEP, research into both new compounds and new delivery systems for PrEP regimens offer intriguing challenges from the perspective of pharmacokinetic and pharmacodynamic modeling. This review aims to provide an overview the current modeling landscape for HIV PrEP, focused on PK/PD and QSP models relating to antiretroviral agents. Both current PrEP treatments and new compounds that show promise as PrEP agents are highlighted, as well as models of uncommon administration routes, predictions based on models of mechanism of action and viral dynamics, and issues related to adherence to therapy. The spread of human immunodeficiency virus (HIV) remains one of the foremost global health concerns. In the absence of a vaccine, other prophylactic strategies have been developed to prevent HIV transmission. One approach, known as pre-exposure prophylaxis (PrEP), allows HIV-negative individuals who are at high risk of exposure to the virus, be it through an HIV-positive sexual partner or through the shared use of drug injection equipment, to substantially reduce the risk of developing an HIV infection. PrEP is a relatively recent approach to combating the HIV epidemic, with the only currently approved treatment being Truvada, a daily oral antiretroviral (ARV) therapy initially indicated in the treatment of active HIV-1 infections, but approved for HIV PrEP in 2012. Although PrEP therapy has consistently demonstrated high efficacy in preventing HIV infection, this efficacy is dependent on patient adherence to the prescribed treatment regimen. This can present a significant problem in low- and middle-income countries, which may lack the infrastructure to provide sufficient access to PrEP medication to maintain daily dosing regimens. Furthermore, while the conventional approach has generally been to advocate for continuous administration akin to regimens used for viral suppression in infected patients, there has been some discussion of whether a better treatment paradigm might be to push for PrEP therapy primarily during those known periods of heightened exposure risk, while relying on post-exposure prophylaxis regimens to prevent infection after unanticipated exposures during low-risk periods. These considerations have led to a push for the development of long-duration and on-demand PrEP formulations, including subdermal and subcutaneous implants, slow-release intramuscular depot injections, vaginal and rectal antimicrobial gels, and intravaginal rings and dissolving films. PrEP therapy is a quickly evolving field, with a variety of antiretroviral compounds and formulations under investigation. This review aims to report on notable drugs and formulations from a pharmacokinetic/pharmacodynamic (PK/PD) modeling perspective. Given the nature of PrEP as a preventive therapy designed for long-term use, clinical trials for PrEP therapies can last for months or even years, particularly in the case of long-duration formulations. Furthermore, in contrast to antiretroviral trials in infected patients, pharmacodynamic endpoints in PrEP therapies are difficult to quantify, as the primary endpoint for efficacy is generally the rate of seroconversion. Computational modeling approaches offer flexible and powerful tools to provide insight into drug behavior in clinical settings, and can ultimately reduce the time, expense, and patient burden incurred in the development of PrEP therapies.
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Affiliation(s)
- Thomas Straubinger
- Department of Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, NY, United States
| | - Katherine Kay
- Metrum Research Group, Tariffville, CT, United States
| | - Robert Bies
- Department of Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, NY, United States
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16
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Integration of Computational and Experimental Approaches to Elucidate Mechanisms of First-Pass Lymphatic Drug Sequestration and Long-Acting Pharmacokinetics of the Injectable Triple-HIV Drug Combination TLC-ART 101. J Pharm Sci 2020; 109:1789-1801. [PMID: 32006525 DOI: 10.1016/j.xphs.2020.01.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/16/2020] [Accepted: 01/16/2020] [Indexed: 01/09/2023]
Abstract
TLC-ART101 is a long-acting triple-HIV drug combination of lopinavir-ritonavir-tenofovir in one nanosuspension intended for subcutaneous injection. After a single TLC-ART 101 administration in nonhuman primates, drug concentrations in both plasma and HIV-target lymph node mononuclear cells were sustained for 2 weeks. Nevertheless, the mechanisms leading to the targeted long-acting pharmacokinetics remain elusive. Therefore, an intravenous study of TLC-ART 101 in nonhuman primates was conducted to elucidate the degree of association of drugs in vivo, estimate subcutaneous bioavailability, and refine a mechanism-based pharmacokinetic (MBPK2) model. The MBPK2 model considers TLC-ART 101 systemic drug clearances, nanoparticle-associated/dissociated species, more detailed mechanisms of lymphatic first-pass retention of associated-drugs after subcutaneous administrations, and the prediction of drug concentration time-courses in lymph node mononuclear cells. For all 3 drugs, we found a high association with the nanoparticles in plasma (>87% lopinavir-ritonavir, 97% tenofovir), and an incomplete subcutaneous bioavailability (<29% lopinavir-ritonavir, 85% tenofovir). As hypothesized by the MBPK2 model, the incomplete SC bioavailability observed is due to sequestration into a lymphatic node depot after subcutaneous absorption (unlike most intramuscular nanodrug products having near-to-injection depots), which contributes to long-acting profiles detected in plasma and target cells. This combined experimental and modeling approach may be applicable for the clinical development of other long-acting drug-combination injectables.
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17
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Liu SN, Desta Z, Gufford BT. Probenecid-Boosted Tenofovir: A Physiologically-Based Pharmacokinetic Model-Informed Strategy for On-Demand HIV Preexposure Prophylaxis. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2019; 9:40-47. [PMID: 31749296 PMCID: PMC6966182 DOI: 10.1002/psp4.12481] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/03/2019] [Indexed: 11/28/2022]
Abstract
Multiple doses of tenofovir disoproxil fumarate (TDF) together with emtricitabine is effective for HIV preexposure prophylaxis (PrEP). TDF is converted to tenofovir (TFV) in circulation, which is subsequently cleared via tubular secretion by organic ion transporters (OATs; OAT1 and OAT3). Using in vitro kinetic parameters for TFV and the OAT1 and OAT3 inhibitor probenecid, a bottom‐up physiologically‐based pharmacokinetic model was successfully developed for the first time that accurately describes the probenecid–TFV interaction. This model predicted an increase in TFV plasma exposure by 60%, which was within 15% of the observed clinical pharmacokinetic data, and a threefold decrease in renal cells exposure following coadministration of a 600 mg TDF dose with 2 g probenecid. When compared with multiple‐dose regimens, a single‐dose probenecid‐boosted TDF regimen may be effective for HIV PrEP and improve adherence and safety by minimizing TFV‐induced nephrotoxicity by reducing TFV accumulation in renal cells.
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Affiliation(s)
- Stephanie N Liu
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Brandon T Gufford
- Division of Clinical Pharmacology, Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana, USA
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18
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Mallayasamy S, Chaturvedula A, Fossler MJ, Sale ME, Hendrix CW, Haberer JE. Assessment of Demographic and Socio-Behavioral Factors on Adherence to HIV Pre-Exposure Prophylaxis Using a Markov Modeling Approach. Front Pharmacol 2019; 10:785. [PMID: 31354496 PMCID: PMC6639421 DOI: 10.3389/fphar.2019.00785] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 06/17/2019] [Indexed: 12/26/2022] Open
Abstract
Purpose: Adherence is important for the effectiveness of human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP). The objective of the current work is to assess the impact of multiple demographic and socio-behavioral factors on the adherence to tenofovir-based PrEP among HIV serodiscordant couples in East Africa using Markov mixed-effects modeling approach. Methods: The Partners Demonstration Project was a prospective, open-label, implementation science-driven study of HIV PrEP among heterosexual HIV serodiscordant couples in Kenya and Uganda. The uninfected partner received oral PrEP according to the “bridge to antiretroviral therapy [ART]” strategy (i.e., until the infected partner had been on ART for ≥6 months). Adherence was monitored electronically; demographic and socio-behavioral data were collected during study visits. Analyzed data reflect 12 months of follow-up per participant. A two-state, first-order, discrete time Markov model was developed with longitudinal adherence data characterized by “dose taking (1)” and “dose missing (0).” Covariate effects were linearly added in the logit domain of transition probability parameters (P01 and P10) in the model. The full covariate model was initially developed, followed by backward elimination process to reduce the model. All significant covariates reported by a prior primary statistical analysis of the same data were included in the full covariate model. Results: The model included data from 920 participants, who were predominantly male (65%). Significant covariates associated with higher adherence were 25 years or older [odds ratio (OR) for P10, 0.61], female sex (OR for P10, 0.67), participant wanting the relationship with the partner to succeed (OR for P10, 0.79; OR for P01, 1.45), and sex with partner either with 100% or <100% condom use compared to those reported no sex (OR for P10, 0.84; OR for P01, 1.21). Significant covariates associated with lower adherence were partner on ART >6 months (OR for P01, 0.86; OR for P10, 1.34), subject in the study for >6 months (OR for P01, 0.8; OR for P10, 1.25), and problematic alcohol use (OR for P01, 0.63; OR for P10, 1.16). Conclusion: The developed Markov model provides a mechanistic understanding of relationship between demographic, socio-behavioral covariates, and PrEP adherence, by indicating the pattern of adherence influenced by each factor over time. Such data can be used for further intervention development to promote PrEP adherence.
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Affiliation(s)
| | | | - Michael J Fossler
- UNT System College of Pharmacy, UNTHSC, Fort Worth, TX, United States.,Trevena Inc, King of Prussia, PA, United States
| | - Mark E Sale
- UNT System College of Pharmacy, UNTHSC, Fort Worth, TX, United States.,Nuventra, Raleigh, NC, United States
| | - Craig W Hendrix
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jessica E Haberer
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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Holec AD, Mandal S, Prathipati PK, Destache CJ. Nucleotide Reverse Transcriptase Inhibitors: A Thorough Review, Present Status and Future Perspective as HIV Therapeutics. Curr HIV Res 2019; 15:411-421. [PMID: 29165087 DOI: 10.2174/1570162x15666171120110145] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 11/02/2017] [Accepted: 11/15/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Human immunodeficiency virus type-1 (HIV-1) infection leads to acquired immunodeficiency syndrome (AIDS), a severe viral infection that has claimed approximately 658,507 lives in the US between the years 2010-2014. Antiretroviral (ARV) therapy has proven to inhibit HIV-1, but unlike other viral illness, not cure the infection. OBJECTIVE Among various Food and Drug Administration (FDA)-approved ARVs, nucleoside/ nucleotide reverse transcriptase inhibitors (NRTIs) are most effective in limiting HIV-1 infection. This review focuses on NRTIs mechanism of action and metabolism. METHODS A search of PubMed (1982-2016) was performed to capture relevant articles regarding NRTI pharmacology. RESULTS The current classical NRTIs pharmacology for HIV-1 prevention and treatment are presented. Finally, various novel strategies are proposed to improve the efficacy of NRTIs, which will increase therapeutic efficiency of present-day HIV-1 prevention/treatment regimen. CONCLUSION Use of NRTIs will continue to be critical for successful treatment and prevention of HIV-1.
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Affiliation(s)
- Ashley D Holec
- Creighton University Medical Microbiology and Immunology, Omaha, NE, United States
| | - Subhra Mandal
- Creighton University School of Pharmacy & Health Professions, Omaha, NE, United States
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20
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Semi-solid prodrug nanoparticles for long-acting delivery of water-soluble antiretroviral drugs within combination HIV therapies. Nat Commun 2019; 10:1413. [PMID: 30926773 PMCID: PMC6441007 DOI: 10.1038/s41467-019-09354-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 03/01/2019] [Indexed: 12/29/2022] Open
Abstract
The increasing global prevalence of human immunodeficiency virus (HIV) is estimated at 36.7 million people currently infected. Lifelong antiretroviral (ARV) drug combination dosing allows management as a chronic condition by suppressing circulating viral load to allow for a near-normal life; however, the daily burden of oral administration may lead to non-adherence and drug resistance development. Long-acting (LA) depot injections of nanomilled poorly water-soluble ARVs have shown highly promising clinical results with drug exposure largely maintained over months after a single injection. ARV oral combinations rely on water-soluble backbone drugs which are not compatible with nanomilling. Here, we evaluate a unique prodrug/nanoparticle formation strategy to facilitate semi-solid prodrug nanoparticles (SSPNs) of the highly water-soluble nucleoside reverse transcriptase inhibitor (NRTI) emtricitabine (FTC), and injectable aqueous nanodispersions; in vitro to in vivo extrapolation (IVIVE) modelling predicts sustained prodrug release, with activation in relevant biological environments, representing a first step towards complete injectable LA regimens containing NRTIs. Non-adherence to daily drug regimens is responsible for many negative clinical effects including drug resistance in life-long treatments for HIV. Here, the authors report on a HIV prodrug nanoparticle platform for long-acting sustained release of water-soluble drug compounds following injection.
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21
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Duwal S, Seeler D, Dickinson L, Khoo S, von Kleist M. The Utility of Efavirenz-based Prophylaxis Against HIV Infection. A Systems Pharmacological Analysis. Front Pharmacol 2019; 10:199. [PMID: 30918485 PMCID: PMC6424904 DOI: 10.3389/fphar.2019.00199] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 02/18/2019] [Indexed: 11/13/2022] Open
Abstract
Pre-exposure prophylaxis (PrEP) is considered one of the five “pillars” by UNAIDS to reduce HIV transmission. Moreover, it is a tool for female self-protection against HIV, making it highly relevant to sub-Saharan regions, where women have the highest infection burden. To date, Truvada is the only medication for PrEP. However, the cost of Truvada limits its uptake in resource-constrained countries. Similarly, several currently investigated, patent-protected compounds may be unaffordable in these regions. We set out to explore the potential of the patent-expired antiviral efavirenz (EFV) as a cost-efficient PrEP alternative. A population pharmacokinetic model utilizing data from the ENCORE1 study was developed. The model was refined for metabolic autoinduction. We then explored EFV cellular uptake mechanisms, finding that it is largely determined by plasma protein binding. Next, we predicted the prophylactic efficacy of various EFV dosing schemes after exposure to HIV using a stochastic simulation framework. We predicted that plasma concentrations of 11, 36, 1287 and 1486ng/mL prevent 90% sexual transmissions with wild type and Y181C, K103N and G190S mutants, respectively. Trough concentrations achieved after 600 mg once daily dosing (median: 2017 ng/mL, 95% CI:445–9830) and after reduced dose (400 mg) efavirenz (median: 1349ng/mL, 95% CI: 297–6553) provided complete protection against wild-type virus and the Y181C mutant, and median trough concentrations provided about 90% protection against the K103N and G190S mutants. As reduced dose EFV has a lower toxicity profile, we predicted the reduction in HIV infection when 400 mg EFV-PrEP was poorly adhered to, when it was taken “on demand” and as post-exposure prophylaxis (PEP). Once daily EFV-PrEP provided 99% protection against wild-type virus, if ≥50% of doses were taken. PrEP “on demand” provided complete protection against wild-type virus and prevented ≥81% infections in the mutants. PEP could prevent >98% infection with susceptible virus when initiated within 24 h after virus exposure and continued for at least 9 days. We predict that 400 mg oral EFV may provide superior protection against wild-type HIV. However, further studies are warranted to evaluate EFV as a cost-efficient alternative to Truvada. Predicted prophylactic concentrations may guide release kinetics of EFV long-acting formulations for clinical trial design.
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Affiliation(s)
- Sulav Duwal
- Department of Mathematics and Computer Science, Systems Pharmacology and Disease Control, Institute of Bioinformatics, Freie Universität Berlin, Berlin, Germany
| | - Daniel Seeler
- Department of Mathematics and Computer Science, Systems Pharmacology and Disease Control, Institute of Bioinformatics, Freie Universität Berlin, Berlin, Germany
| | - Laura Dickinson
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Saye Khoo
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Max von Kleist
- Department of Mathematics and Computer Science, Systems Pharmacology and Disease Control, Institute of Bioinformatics, Freie Universität Berlin, Berlin, Germany
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22
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Duwal S, Dickinson L, Khoo S, von Kleist M. Mechanistic framework predicts drug-class specific utility of antiretrovirals for HIV prophylaxis. PLoS Comput Biol 2019; 15:e1006740. [PMID: 30699105 PMCID: PMC6370240 DOI: 10.1371/journal.pcbi.1006740] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 02/11/2019] [Accepted: 12/20/2018] [Indexed: 11/21/2022] Open
Abstract
Currently, there is no effective vaccine to halt HIV transmission. However, pre-exposure prophylaxis (PrEP) with the drug combination Truvada can substantially decrease HIV transmission in individuals at risk. Despite its benefits, Truvada-based PrEP is expensive and needs to be taken once-daily, which often leads to inadequate adherence and incomplete protection. These deficits may be overcome by next-generation PrEP regimen, including currently investigated long-acting formulations, or patent-expired drugs. However, poor translatability of animal- and ex vivo/in vitro experiments, and the necessity to conduct long-term (several years) human trials involving considerable sample sizes (N>1000 individuals) are major obstacles to rationalize drug-candidate selection. We developed a prophylaxis modelling tool that mechanistically considers the mode-of-action of all available drugs. We used the tool to screen antivirals for their prophylactic utility and identify lower bound effective concentrations that can guide dose selection in PrEP trials. While in vitro measurable drug potency usually guides PrEP trial design, we found that it may over-predict PrEP potency for all drug classes except reverse transcriptase inhibitors. While most drugs displayed graded concentration-prophylaxis profiles, protease inhibitors tended to switch between none- and complete protection. While several treatment-approved drugs could be ruled out as PrEP candidates based on lack-of-prophylactic efficacy, darunavir, efavirenz, nevirapine, etravirine and rilpivirine could more potently prevent infection than existing PrEP regimen (Truvada). Notably, some drugs from this candidate set are patent-expired and currently neglected for PrEP repurposing. A next step is to further trim this candidate set by ruling out compounds with ominous safety profiles, to assess different administration schemes in silico and to test the remaining candidates in human trials. Pre-exposure prophylaxis (PrEP) is a novel, promising strategy to halt HIV transmission. PrEP with Truvada can substantially decrease the risk of infection. However, individuals often inadequately adhere to the once-daily regimen and the drug is expensive. These shortcomings may be overcome by next-generation PrEP compounds, including long-acting formulations. However, poor translatability of animal- and ex vivo/in vitro experiments, and difficulties in conducting long-term trials involving considerable sample sizes (N > 1000 individuals) make drug-candidate selection and optimization of administration schemes costly and often infeasible. We developed a simulation tool that mechanistically considers the mode-of-action of all antivirals. We used the tool to screen all available antivirals for their prophylactic utility and identified lower bound effective concentrations for designing PrEP dosing regimen in clinical trials. We found that in vitro measured drug potency may over-predict PrEP potency, for all antiviral classes except reverse transcriptase inhibitors. We could rule out a number of antivirals for PrEP repurposing and predicted that darunavir, efavirenz, nevirapine, etravirine and rilpivirine provide complete protection at clinically relevant concentrations. Further trimming of this candidate set by compound-safety and by assessing different implementation schemes is envisaged.
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Affiliation(s)
- Sulav Duwal
- Department of Mathematics & Computer Science, Freie Universität Berlin, Germany
- * E-mail: (SD); (MvK)
| | - Laura Dickinson
- Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Saye Khoo
- Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Max von Kleist
- Department of Mathematics & Computer Science, Freie Universität Berlin, Germany
- * E-mail: (SD); (MvK)
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23
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Hendrix CW. HIV Antiretroviral Pre-Exposure Prophylaxis: Development Challenges and Pipeline Promise. Clin Pharmacol Ther 2018; 104:1082-1097. [PMID: 30199098 PMCID: PMC6925668 DOI: 10.1002/cpt.1227] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/20/2018] [Indexed: 12/17/2022]
Abstract
The US Food and Drug Administration (FDA) approved oral daily tenofovir/emtricitabine (Truvada) for pre-exposure prophylaxis of human immunodeficiency virus (HIV) infection in 2012 on the basis of two randomized controlled trials (RCTs), one in men who have sex with men (MSM) and another in HIV serodiscordant heterosexual couples. Subsequently, even greater efficacy has been demonstrated in MSM with rapid population-level incidence reductions in some locations. In contrast, studies of antiretroviral pre-exposure prophylaxis (PrEP) in heterosexual women showed only modest or no efficacy, largely attributed to low adherence. The mixed results of antiretroviral-based PrEP bear witness to unique drug development challenges at this complicated intersection of sexual behavior, public health, and drug development. Multiple innovative methods and formulation strategies followed to address unmet medical needs of persons struggling with daily oral PrEP adherence or preference for nonsystemic PrEP options. Clinical pharmacology plays essential roles throughout this PrEP development process, especially in early product development and through pharmacologically informed enhancement and interpretation of clinical trials.
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Affiliation(s)
- Craig W Hendrix
- 1Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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24
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Duwal S, Dickinson L, Khoo S, von Kleist M. Hybrid stochastic framework predicts efficacy of prophylaxis against HIV: An example with different dolutegravir prophylaxis schemes. PLoS Comput Biol 2018; 14:e1006155. [PMID: 29902179 PMCID: PMC6001963 DOI: 10.1371/journal.pcbi.1006155] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 04/21/2018] [Indexed: 01/02/2023] Open
Abstract
To achieve the 90-90-90 goals set by UNAIDS, the number of new HIV infections needs to decrease to approximately 500,000 by 2020. One of the 'five pillars' to achieve this goal is pre-exposure prophylaxis (PrEP). Truvada (emtricitabine-tenofovir) is currently the only medication approved for PrEP. Despite its advantages, Truvada is costly and requires individuals to adhere to the once-daily regimen. To improve PrEP, many next-generation regimen, including long-acting formulations, are currently investigated. However, pre-clinical testing may not guide candidate selection, since it often fails to translate into clinical efficacy. On the other hand, quantifying prophylactic efficacy in the clinic is ethically problematic and requires to conduct long (years) and large (N>1000 individuals) trials, precluding systematic evaluation of candidates and deployment strategies. To prioritize- and help design PrEP regimen, tools are urgently needed that integrate pharmacological-, viral- and host factors determining prophylactic efficacy. Integrating the aforementioned factors, we developed an efficient and exact stochastic simulation approach to predict prophylactic efficacy, as an example for dolutegravir (DTG). Combining the population pharmacokinetics of DTG with the stochastic framework, we predicted that plasma concentrations of 145.18 and 722.23nM prevent 50- and 90% sexual transmissions respectively. We then predicted the reduction in HIV infection when DTG was used in PrEP, PrEP 'on demand' and post-exposure prophylaxis (PEP) before/after virus exposure. Once daily PrEP with 50mg oral DTG prevented 99-100% infections, and 85% of infections when 50% of dosing events were missed. PrEP 'on demand' prevented 79-84% infections and PEP >80% when initiated within 6 hours after virus exposure and continued for as long as possible. While the simulation framework can easily be adapted to other PrEP candidates, our simulations indicated that oral 50mg DTG is non-inferior to Truvada. Moreover, the predicted 90% preventive concentrations can guide release kinetics of currently developed DTG nano-formulations.
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Affiliation(s)
- Sulav Duwal
- Department of Mathematics & Computer Science, Freie Universität Berlin, Berlin, Germany
| | - Laura Dickinson
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Saye Khoo
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Max von Kleist
- Department of Mathematics & Computer Science, Freie Universität Berlin, Berlin, Germany
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25
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Acute Kidney Injury After Efavirenz/Tenofovir Disoproxil Fumarate/Emtricitabine (Atripla) Overdose. Ther Drug Monit 2017; 39:91-92. [PMID: 28230617 DOI: 10.1097/ftd.0000000000000386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We describe a patient with acute renal failure and irreversible kidney damage after an overdose with the fixed dose combination of efavirenz/tenofovir disoproxil fumarate/emtricitabine (Atripla). The acute kidney injury was most probably caused by tenofovir. Efavirenz and emtricitabine seemed relatively safe in overdose. The pharmacokinetics in overdose of all 3 drugs and the effect of hemodialysis on the tenofovir clearance were studied by measuring the plasma concentrations and by the use of clinical pharmacokinetic software.
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26
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Abstract
Studies of tenofovir disoproxil fumarate (TDF)-emtricitabine (FTC)-based preexposure prophylaxis (PrEP) have not focused on transgendered women who are at disproportionate risk of HIV acquisition. Concerns exist for drug interactions between cross-sex therapy (estradiol, progestins, and spironolactone) with tenofovir disoproxil fumarate-emtricitabine. This review assessed the experimental and theoretical risk for such drug interactions. It was found that none of these medications are implicated as major perpetrators of drug interactions, and the classes use different metabolic pathways for clearance, suggesting a low likelihood for interactions in either direction. Subanalyses of transgender women in Preexposure Prophylaxis Initiative suggested PrEP efficacy if adherence was high. Nevertheless, several research gaps were identified, particularly the need for controlled interaction studies in transgendered women, including effects on renal clearance, intracellular tenofovir diphosphate and emtricitabine triphosphate in target cells, as well as hormone effects on HIV susceptibility and immunity. PrEP should continue to be offered to transgender women while additional research is planned or pending.
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27
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Schiffer JT, Swan DA, Magaret A, Corey L, Wald A, Ossig J, Ruebsamen-Schaeff H, Stoelben S, Timmler B, Zimmermann H, Melhem MR, Van Wart SA, Rubino CM, Birkmann A. Mathematical modeling of herpes simplex virus-2 suppression with pritelivir predicts trial outcomes. Sci Transl Med 2016; 8:324ra15. [PMID: 26843190 DOI: 10.1126/scitranslmed.aad6654] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pharmacokinetic and pharmacodynamic models estimate the potency of antiviral agents but do not capture viral and immunologic factors that drive the natural dynamics of infection. We designed a mathematical model that synthesizes pharmacokinetics, pharmacodynamics, and viral pathogenesis concepts to simulate the activity of pritelivir, a DNA helicase-primase inhibitor that targets herpes simplex virus. Our simulations recapitulate detailed viral kinetic shedding features in five dosage arms of a phase 2 clinical trial. We identify that in vitro estimates of median effective concentration (EC50) are lower than in vivo values for the drug. Nevertheless, pritelivir potently decreases shedding at appropriate doses based on its mode of action and long half-life. Although pritelivir directly inhibits replication in epithelial cells, our model indicates that pritelivir also indirectly limits downstream viral spread from neurons to genital keratinocytes, within genital ulcers, and from ulcer to new mucosal sites of infection. We validate our model based on its ability to predict outcomes in a subsequent trial with a higher dose. The model can therefore be used to optimize dose selection in clinical practice.
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Affiliation(s)
- Joshua T Schiffer
- Department of Medicine, University of Washington, Seattle, WA 98105, USA. Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA. Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA.
| | - David A Swan
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Amalia Magaret
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA. Department of Laboratory Medicine, University of Washington, Seattle, WA 98105, USA
| | - Lawrence Corey
- Department of Medicine, University of Washington, Seattle, WA 98105, USA. Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA. Department of Laboratory Medicine, University of Washington, Seattle, WA 98105, USA
| | - Anna Wald
- Department of Medicine, University of Washington, Seattle, WA 98105, USA. Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA. Department of Laboratory Medicine, University of Washington, Seattle, WA 98105, USA. Department of Epidemiology, University of Washington, Seattle, WA 98105, USA
| | | | | | | | | | | | - Murad R Melhem
- Institute for Clinical Pharmacodynamics, Latham, NY 12307, USA
| | - Scott A Van Wart
- Institute for Clinical Pharmacodynamics, Latham, NY 12307, USA. School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14260, USA
| | - Christopher M Rubino
- Institute for Clinical Pharmacodynamics, Latham, NY 12307, USA. School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14260, USA
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28
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Madrasi K, Chaturvedula A, Haberer JE, Sale M, Fossler MJ, Bangsberg D, Baeten JM, Celum C, Hendrix CW. Markov Mixed Effects Modeling Using Electronic Adherence Monitoring Records Identifies Influential Covariates to HIV Preexposure Prophylaxis. J Clin Pharmacol 2016; 57:606-615. [PMID: 27922719 DOI: 10.1002/jcph.843] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/14/2016] [Indexed: 02/02/2023]
Abstract
Adherence is a major factor in the effectiveness of preexposure prophylaxis (PrEP) for HIV prevention. Modeling patterns of adherence helps to identify influential covariates of different types of adherence as well as to enable clinical trial simulation so that appropriate interventions can be developed. We developed a Markov mixed-effects model to understand the covariates influencing adherence patterns to daily oral PrEP. Electronic adherence records (date and time of medication bottle cap opening) from the Partners PrEP ancillary adherence study with a total of 1147 subjects were used. This study included once-daily dosing regimens of placebo, oral tenofovir disoproxil fumarate (TDF), and TDF in combination with emtricitabine (FTC), administered to HIV-uninfected members of serodiscordant couples. One-coin and first- to third-order Markov models were fit to the data using NONMEM® 7.2. Model selection criteria included objective function value (OFV), Akaike information criterion (AIC), visual predictive checks, and posterior predictive checks. Covariates were included based on forward addition (α = 0.05) and backward elimination (α = 0.001). Markov models better described the data than 1-coin models. A third-order Markov model gave the lowest OFV and AIC, but the simpler first-order model was used for covariate model building because no additional benefit on prediction of target measures was observed for higher-order models. Female sex and older age had a positive impact on adherence, whereas Sundays, sexual abstinence, and sex with a partner other than the study partner had a negative impact on adherence. Our findings suggest adherence interventions should consider the role of these factors.
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Affiliation(s)
- Kumpal Madrasi
- Department of Pharmacy Practice and Pharmaceutical Sciences, Mercer University, Atlanta, GA, USA.,Orise Fellow, Office of Clinical Pharmacology, CDER, FDA, Silver Spring, MD, USA
| | - Ayyappa Chaturvedula
- Department of Pharmacy Practice and Pharmaceutical Sciences, Mercer University, Atlanta, GA, USA.,Pharmacotherapy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | - David Bangsberg
- Center for Global Health, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jared M Baeten
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
| | - Connie Celum
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
| | - Craig W Hendrix
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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29
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Chen X, Seifert SM, Castillo-Mancilla JR, Bushman LR, Zheng JH, Kiser JJ, MaWhinney S, Anderson PL. Model Linking Plasma and Intracellular Tenofovir/Emtricitabine with Deoxynucleoside Triphosphates. PLoS One 2016; 11:e0165505. [PMID: 27832147 PMCID: PMC5104339 DOI: 10.1371/journal.pone.0165505] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 10/12/2016] [Indexed: 02/07/2023] Open
Abstract
The coformulation of the nucleos(t)ide analogs (NA) tenofovir (TFV) disoproxil fumarate (TDF) and emtricitabine (FTC) is approved for HIV-infection treatment and prevention. Plasma TFV and FTC undergo complicated hybrid processes to form, accumulate, and retain as their active intracellular anabolites: TFV-diphosphate (TFV-DP) and FTC-triphosphate (FTC-TP). Such complexities manifest in nonlinear intracellular pharmacokinetics (PK). In target cells, TFV-DP/FTC-TP compete with endogenous deoxynucleoside triphosphates (dNTP) at the active site of HIV reverse transcriptase, underscoring the importance of analog:dNTP ratios for antiviral efficacy. However, NA such as TFV and FTC have the potential to disturb the dNTP pool, which could augment or reduce their efficacies. We conducted a pharmacokinetics-pharmacodynamics (PKPD) study among forty subjects receiving daily TDF/FTC (300 mg/200 mg) from the first-dose to pharmacological intracellular steady-state (30 days). TFV/FTC in plasma, TFV-DP/FTC-TP and dNTPs in peripheral blood mononuclear cells (PBMC) were quantified using validated LC/MS/MS methodologies. Concentration-time data were analyzed using nonlinear mixed effects modeling (NONMEM). Formations and the accumulation of intracellular TFV-DP/FTC-TP was driven by plasma TFV/FTC, which was described by a hybrid of first-order formation and saturation. An indirect response link model described the interplay between TFV-DP/FTC-TP and the dNTP pool change. The EC50 (interindividual variability, (%CV)) of TFV-DP and FTC-TP on the inhibition of deoxyadenosine triphosphate (dATP) and deoxycytidine triphosphate (dCTP) production were 1020 fmol/106 cells (130%) and 44.4 pmol/106 cells (82.5%), resulting in (90% prediction interval) 11% (0.45%, 53%) and 14% (2.6%, 35%) reductions. Model simulations of analog:dNTP molar ratios using IPERGAY dosing suggested that FTC significantly contributes to the protective effect of preexposure prophylaxis (PrEP). Simulation-based intracellular operational multiple dosing half-lives of TFV-DP and FTC-TP were 6.7 days and 33 hours. This model described the formation of intracellular TFV-DP/FTC-TP and the interaction with dNTPs, and can be used to simulate analog:dNTP time course for various dosing strategies.
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Affiliation(s)
- Xinhui Chen
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, United States of America
| | - Sharon M. Seifert
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, United States of America
| | - Jose R. Castillo-Mancilla
- University of Colorado, School of Medicine, Division of Infectious Diseases, Aurora, CO, United States of America
| | - Lane R. Bushman
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, United States of America
| | - Jia-Hua Zheng
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, United States of America
| | - Jennifer J. Kiser
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, United States of America
| | - Samantha MaWhinney
- University of Colorado, Colorado School of Public Health, Department of Biostatistics and Informatics, Aurora, CO, United States of America
| | - Peter L. Anderson
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, United States of America
- * E-mail:
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Seifert SM, Chen X, Meditz AL, Castillo-Mancilla JR, Gardner EM, Predhomme JA, Clayton C, Austin G, Palmer BE, Zheng JH, Klein B, Kerr BJ, Guida LA, Rower C, Rower JE, Kiser JJ, Bushman LR, MaWhinney S, Anderson PL. Intracellular Tenofovir and Emtricitabine Anabolites in Genital, Rectal, and Blood Compartments from First Dose to Steady State. AIDS Res Hum Retroviruses 2016; 32:981-991. [PMID: 27526873 DOI: 10.1089/aid.2016.0008] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The pharmacokinetics (PK) of tenofovir-diphosphate (TFV-DP) and emtricitabine-triphosphate (FTC-TP), the active anabolites of tenofovir disoproxil fumarate (TDF), and emtricitabine (FTC) in blood, genital, and rectal compartments was determined in HIV-positive and seronegative adults who undertook a 60-day intensive PK study of daily TDF/FTC (plus efavirenz in HIV positives). Lymphocyte cell sorting, genital, and rectal sampling occurred once per subject, at staggered visits. Among 19 HIV-positive (3 female) and 21 seronegative (10 female) adults, TFV-DP in peripheral blood mononuclear cells (PBMC) accumulated 8.6-fold [95% confidence interval (CI): 7.2-10] from first-dose to steady-state concentration (Css) versus 1.7-fold (95% CI: 1.5-1.9) for FTC-TP. Css was reached in ∼11 and 3 days, respectively. Css values were similar between HIV-negative and HIV-positive individuals. Css TFV-DP in rectal mononuclear cells (1,450 fmol/106 cells, 898-2,340) was achieved in 5 days and was >10 times higher than PBMC (95 fmol/106 cells, 85-106), seminal cells (22 fmol/106 cells, 6-79), and cervical cells (111 fmol/106 cells, 64-194). FTC-TP Css was highest in PBMC (5.7 pmol/106 cells, 5.2-6.1) and cervical cells (7 pmol/106 cells, 2-19) versus rectal (0.8 pmol/106 cells, 0.6-1.1) and seminal cells (0.3 pmol/106 cells, 0.2-0.5). Genital drug concentrations on days 1-7 overlapped with estimated Css, but accumulation characteristics were based on limited data. TFV-DP and FTC-TP in cell sorted samples were highest and achieved most rapidly in CD14+ compared with CD4+, CD8+, and CD19+ cells. Together, these findings demonstrate cell-type and tissue-dependent cellular pharmacology, preferential accumulation of TFV-DP in rectal mononuclear cells, and rapid distribution into rectal and genital compartments.
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Affiliation(s)
- Sharon M. Seifert
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Xinhui Chen
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Amie L. Meditz
- Boulder Community Hospital, Beacon Center for Infectious Diseases, Boulder, Colorado
| | - Jose R. Castillo-Mancilla
- Division of Infectious Diseases, School of Medicine, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | | | - Julie A. Predhomme
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Carolyn Clayton
- Department of Biostatistics and Informatics, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Gregory Austin
- School of Medicine, Internal Medicine, Gastroenterology, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Brent E. Palmer
- Division of Allergy and Clinical Immunology, School of Medicine, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Jia-Hua Zheng
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Brandon Klein
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Becky J. Kerr
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - L. Anthony Guida
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Caitlin Rower
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Joseph E. Rower
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Jennifer J. Kiser
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Lane R. Bushman
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Samantha MaWhinney
- Department of Biostatistics and Informatics, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Peter L. Anderson
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
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Population Pharmacokinetics of Tenofovir in HIV-1-Uninfected Members of Serodiscordant Couples and Effect of Dose Reporting Methods. Antimicrob Agents Chemother 2016; 60:5379-86. [PMID: 27353269 DOI: 10.1128/aac.00559-16] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 06/23/2016] [Indexed: 12/22/2022] Open
Abstract
Antiretroviral preexposure prophylaxis (PrEP) with once-daily dosing of tenofovir and tenofovir-emtricitabine was shown to be effective for preventing HIV-1 infection in individuals who had HIV-1-seropositive partners (the Partners PrEP Study). We developed a population pharmacokinetic model for tenofovir and investigated the impacts of different dose reporting methods. Dosing information was collected as patient-reported dosing information (PRDI) from 404 subjects (corresponding to 1,280 drug concentration records) from the main trial and electronic monitoring-based adherence data collected from 211 subjects (corresponding to 327 drug concentration records) in an ancillary adherence study. Model development was conducted with NONMEM (7.2), using PRDI with a steady-state assumption or using PRDI replaced with electronic monitoring records where available. A two-compartment model with first-order absorption was the best model in both modeling approaches, with the need for an absorption lag time when electronic monitoring-based dosing records were included in the analysis. Age, body weight, and creatinine clearance were significant covariates on clearance, but only creatinine clearance was retained in the final models per stepwise selection. Sex was not a significant covariate on clearance. Tenofovir population pharmacokinetic parameter estimates and the precisions of the parameters from the two final models were comparable with the point estimates of the parameters, differing from 0% to 35%, and bootstrap confidence intervals widely overlapped. These findings indicate that PRDI was sufficient for population pharmacokinetic model development in this study, with a high level of adherence per multiple measures.
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Duwal S, Sunkara V, von Kleist M. Multiscale Systems-Pharmacology Pipeline to Assess the Prophylactic Efficacy of NRTIs Against HIV-1. CPT Pharmacometrics Syst Pharmacol 2016; 5:377-87. [PMID: 27439573 PMCID: PMC4961081 DOI: 10.1002/psp4.12095] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 06/20/2016] [Accepted: 06/20/2016] [Indexed: 12/14/2022] Open
Abstract
While HIV-1 continues to spread, the use of antivirals in preexposure prophylaxis (PrEP) has recently been suggested. Here we present a modular systems pharmacology modeling pipeline, predicting PrEP efficacy of nucleotide reverse transcriptase inhibitors (NRTIs) at the scale of reverse transcription, target-cell, and systemic infection and after repeated viral exposures, akin to clinical trials. We use this pipeline to benchmark the prophylactic efficacy of all currently approved NRTIs in wildtype and mutant viruses. By integrating pharmacokinetic models, we find that intracellular tenofovir-diphosphate builds up too slowly to halt infection when taken "on demand" and that lamivudine may substitute emtricitabine in PrEP combinations. Lastly, we delineate factors confounding clinical PrEP efficacy estimates and provide a method to overcome these. The presented framework is useful to screen and optimize PrEP candidates and strategies and to understand their clinical efficacy by integrating the diverse scales which determine PrEP efficacy.
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Affiliation(s)
- S Duwal
- Department of Mathematics & Computer ScienceFreie Universität BerlinBerlinGermany
| | - V Sunkara
- Department of Mathematics & Computer ScienceFreie Universität BerlinBerlinGermany
- Konrad‐Zuse‐Institut für InformationstechnikBerlinGermany
| | - M von Kleist
- Department of Mathematics & Computer ScienceFreie Universität BerlinBerlinGermany
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Topical Tenofovir Disoproxil Fumarate Nanoparticles Prevent HIV-1 Vaginal Transmission in a Humanized Mouse Model. Antimicrob Agents Chemother 2016; 60:3633-9. [PMID: 27044548 DOI: 10.1128/aac.00450-16] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 03/26/2016] [Indexed: 01/12/2023] Open
Abstract
Preexposure prophylaxis (PrEP) with 1% tenofovir (TFV) vaginal gel has failed in clinical trials. To improve TFV efficacy in vaginal gel, we formulated tenofovir disoproxil fumarate nanoparticles in a thermosensitive (TMS) gel (TDF-NP-TMS gel). TDF-NPs were fabricated using poly(lactic-co-glycolic acid) (PLGA) polymer and an ion-pairing agent by oil-in-water emulsification. The efficacy of TDF-NP-TMS gel was tested in humanized bone marrow-liver-thymus (hu-BLT) mice. Hu-BLT mice in the treatment group (Rx; n = 15) were administered TDF-NP-TMS gel intravaginally, having TDF at 0.1%, 0.5%, and 1% (wt/vol) concentrations, whereas the control (Ctr; n = 8) group received a blank TMS gel. All Rx mice (0.1% [n = 4], 0.5% [n = 6], and 1% [n = 5]) were vaginally challenged with two transmitted/founder (T/F) HIV-1 strains (2.5 × 10(5) 50% tissue culture infectious doses). Rx mice were challenged at 4 h (0.1%), 24 h (0.5%), and 7 days (1%) posttreatment (p.t.) and Ctr mice were challenged at 4 h p.t. Blood was drawn weekly for 4 weeks postinoculation (p.i.) for plasma viral load (pVL) using reverse transcription-quantitative PCR. Ctr mice had positive pVL within 2 weeks p.i. Rx mice challenged at 4 h and 24 h showed 100% protection and no detectable pVL throughout the 4 weeks of follow-up (P = 0.009; Mantel-Cox test). Mice challenged at 7 days were HIV-1 positive at 14 days p.i. Further, HIV-1 viral RNA (vRNA) in vaginal and spleen tissues of Rx group mice with negative pVL were examined using an in situ hybridization (ISH) technique. The detection of vRNA was negative in all Rx mice studied. The present studies elucidate TDF-NP-TMS gel as a long-acting, coitus-independent HIV-1 vaginal protection modality.
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Rajoli RKR, Back DJ, Rannard S, Freel Meyers CL, Flexner C, Owen A, Siccardi M. Physiologically Based Pharmacokinetic Modelling to Inform Development of Intramuscular Long-Acting Nanoformulations for HIV. Clin Pharmacokinet 2016; 54:639-50. [PMID: 25523214 DOI: 10.1007/s40262-014-0227-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Antiretrovirals are currently used for the treatment and prevention of HIV infection. However, poor adherence and low tolerability of some existing oral formulations can hinder their efficacy. Long-acting (LA) injectable nanoformulations could help address these complications by simplifying antiretroviral administration. The aim of this study is to inform the optimisation of intramuscular LA formulations for eight antiretrovirals through physiologically based pharmacokinetic (PBPK) modelling. METHODS A whole-body PBPK model was constructed using mathematical descriptions of molecular, physiological and anatomical processes defining pharmacokinetics. These models were validated against available clinical data and subsequently used to predict the pharmacokinetics of injectable LA formulations RESULTS The predictions suggest that monthly intramuscular injections are possible for dolutegravir, efavirenz, emtricitabine, raltegravir, rilpivirine and tenofovir provided that technological challenges to control their release rate can be addressed. CONCLUSIONS These data may help inform the target product profiles for LA antiretroviral reformulation strategies.
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Affiliation(s)
- Rajith K R Rajoli
- Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool, L69 3GF, UK
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du Toit EF, Craig IK. Selective pinning control of the average disease transmissibility in an HIV contact network. PHYSICAL REVIEW. E, STATISTICAL, NONLINEAR, AND SOFT MATTER PHYSICS 2015; 92:012810. [PMID: 26274228 DOI: 10.1103/physreve.92.012810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Indexed: 05/27/2023]
Abstract
Medication is applied to the HIV-infected nodes of high-risk contact networks with the aim of controlling the spread of disease to a predetermined maximum level. This intervention, known as pinning control, is performed both selectively and randomly in the network. These strategies are applied to 300 independent realizations per reference level of incidence on connected undirectional networks without isolated components and varying in size from 100 to 10,000 nodes per network. It is shown that a selective on-off pinning control strategy can control the networks studied with limited steady-state error and, comparing the medians of the doses from both strategies, uses 51.3% less medication than random pinning of all infected nodes. Selective pinning could possibly be used by public health specialists to identify the maximum level of HIV incidence in a population that can be achieved in a constrained funding environment.
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Affiliation(s)
- E F du Toit
- Department of Electrical, Electronic and Computer Engineering, University of Pretoria, 0002 Pretoria, South Africa
| | - I K Craig
- Department of Electrical, Electronic and Computer Engineering, University of Pretoria, 0002 Pretoria, South Africa
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Duwal S, Winkelmann S, Schütte C, von Kleist M. Optimal Treatment Strategies in the Context of 'Treatment for Prevention' against HIV-1 in Resource-Poor Settings. PLoS Comput Biol 2015; 11:e1004200. [PMID: 25927964 PMCID: PMC4423987 DOI: 10.1371/journal.pcbi.1004200] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 02/18/2015] [Indexed: 12/15/2022] Open
Abstract
An estimated 2.7 million new HIV-1 infections occurred in 2010. `Treatment-for-prevention’ may strongly prevent HIV-1 transmission. The basic idea is that immediate treatment initiation rapidly decreases virus burden, which reduces the number of transmittable viruses and thereby the probability of infection. However, HIV inevitably develops drug resistance, which leads to virus rebound and nullifies the effect of `treatment-for-prevention’ for the time it remains unrecognized. While timely conducted treatment changes may avert periods of viral rebound, necessary treatment options and diagnostics may be lacking in resource-constrained settings. Within this work, we provide a mathematical platform for comparing different treatment paradigms that can be applied to many medical phenomena. We use this platform to optimize two distinct approaches for the treatment of HIV-1: (i) a diagnostic-guided treatment strategy, based on infrequent and patient-specific diagnostic schedules and (ii) a pro-active strategy that allows treatment adaptation prior to diagnostic ascertainment. Both strategies are compared to current clinical protocols (standard of care and the HPTN052 protocol) in terms of patient health, economic means and reduction in HIV-1 onward transmission exemplarily for South Africa. All therapeutic strategies are assessed using a coarse-grained stochastic model of within-host HIV dynamics and pseudo-codes for solving the respective optimal control problems are provided. Our mathematical model suggests that both optimal strategies (i)-(ii) perform better than the current clinical protocols and no treatment in terms of economic means, life prolongation and reduction of HIV-transmission. The optimal diagnostic-guided strategy suggests rare diagnostics and performs similar to the optimal pro-active strategy. Our results suggest that ‘treatment-for-prevention’ may be further improved using either of the two analyzed treatment paradigms. HIV-1 continues to spread globally. Antiviral treatment cannot cure patients, but it slows disease progression and may prevent HIV transmission by decreasing the amount of transmittable viruses in treated individuals. ‘Treatment-for-prevention’ argues for immediate treatment initiation and may reduce transmission by 96% (CI: 73–99%), according to the results of a large clinical study (HPTN052). In order to ensure long-lasting treatment success, early therapy initiation demands more sophisticated treatment strategies & exceeding funds. However, countries facing the highest HIV burden are among the poorest. Within this work, we provide a mathematical framework that allows assessing different treatment paradigms using optimal control theory together with stochastic modelling of within-host viral dynamics and drug resistance development. We use this framework to compute and evaluate two distinct optimal long-term treatment strategies for resource-constrained settings: (i) a diagnostic-guided and (ii) a pro-active treatment strategy. The cost of a strategy is evaluated from a national economic perspective, valuating a severe patient health status in terms of an economic loss. The optimal strategies are compared with current clinical treatment protocols and no treatment in terms of costs, life expectation and reduction of secondary cases. Our simulations indicate that the pro-active treatment strategy performs comparably to the diagnostic-guided treatment strategy. Both strategies perform better than current clinical protocols, suggesting directions for improvement.
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Affiliation(s)
- Sulav Duwal
- Department of Mathematics and Computer Science, Freie Universität Berlin, Germany
- Junior Research Group “Systems Pharmacology & Disease Control”
| | - Stefanie Winkelmann
- Department of Mathematics and Computer Science, Freie Universität Berlin, Germany
| | - Christof Schütte
- Department of Mathematics and Computer Science, Freie Universität Berlin, Germany
- Zuse Institute Berlin, Germany
| | - Max von Kleist
- Department of Mathematics and Computer Science, Freie Universität Berlin, Germany
- Junior Research Group “Systems Pharmacology & Disease Control”
- * E-mail:
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Seifert SM, Glidden DV, Meditz AL, Castillo-Mancilla JR, Gardner EM, Predhomme JA, Rower C, Klein B, Kerr BJ, Guida LA, Zheng JH, Bushman LR, Anderson PL. Dose response for starting and stopping HIV preexposure prophylaxis for men who have sex with men. Clin Infect Dis 2015; 60:804-10. [PMID: 25409469 PMCID: PMC4402345 DOI: 10.1093/cid/ciu916] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 11/07/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND This study estimated the number of daily tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) doses required to achieve and maintain (after discontinuation) intracellular drug concentrations that protect against human immunodeficiency virus (HIV) infection for men who have sex with men (MSM). METHODS Tenofovir diphosphate (TFV-DP) concentrations in peripheral blood mononuclear cells (PBMCs) and rectal mononuclear cells from an intensive pharmacokinetic study ("Cell-PrEP" [preexposure prophylaxis]) of 30 days of daily TDF/FTC followed by 30 days off drug were evaluated. A regression formula for HIV risk reduction derived from PBMCs collected in the preexposure prophylaxis initiative study was used to calculate inferred risk reduction. The time required to reach steady state for TFV-DP in rectal mononuclear cells was also determined. RESULTS Twenty-one HIV-uninfected adults participated in Cell-PrEP. The inferred HIV risk reduction, based on PBMC TFV-DP concentration, reached 99% (95% confidence interval [CI], 69%-100%) after 5 daily doses, and remained >90% for 7 days after stopping drug from steady-state conditions. The proportion of participants reaching the 90% effective concentration (EC90) was 77% after 5 doses and 89% after 7 doses. The percentage of steady state for natural log [TFV-DP] in rectal mononuclear cells was 88% (95% CI, 66%-94%) after 5 doses and 94% (95% CI, 78%-98%) after 7 doses. CONCLUSIONS High PrEP activity for MSM was achieved by approximately 1 week of daily dosing. Although effective intracellular drug concentrations persist for several days after stopping PrEP, a reasonable recommendation is to continue PrEP dosing for 4 weeks after the last potential HIV exposure, similar to recommendations for postexposure prophylaxis.
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Affiliation(s)
- Sharon M. Seifert
- Skaggs School of Pharmacy and Pharmaceutical Sciences Department of Pharmaceutical Sciences, University of Colorado Denver, Aurora
| | - David V. Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Amie L. Meditz
- Beacon Center for Infectious Disease, Boulder Community Hospital
| | | | - Edward M. Gardner
- School of Medicine, Division of Infectious Diseases, University of Colorado Denver, Aurora
- Denver Public Health, Colorado
| | - Julie A. Predhomme
- Skaggs School of Pharmacy and Pharmaceutical Sciences Department of Pharmaceutical Sciences, University of Colorado Denver, Aurora
| | - Caitlin Rower
- Skaggs School of Pharmacy and Pharmaceutical Sciences Department of Pharmaceutical Sciences, University of Colorado Denver, Aurora
| | - Brandon Klein
- Skaggs School of Pharmacy and Pharmaceutical Sciences Department of Pharmaceutical Sciences, University of Colorado Denver, Aurora
| | - Becky J. Kerr
- Skaggs School of Pharmacy and Pharmaceutical Sciences Department of Pharmaceutical Sciences, University of Colorado Denver, Aurora
| | - L. Anthony Guida
- Skaggs School of Pharmacy and Pharmaceutical Sciences Department of Pharmaceutical Sciences, University of Colorado Denver, Aurora
| | - Jia-Hua Zheng
- Skaggs School of Pharmacy and Pharmaceutical Sciences Department of Pharmaceutical Sciences, University of Colorado Denver, Aurora
| | - Lane R. Bushman
- Skaggs School of Pharmacy and Pharmaceutical Sciences Department of Pharmaceutical Sciences, University of Colorado Denver, Aurora
| | - Peter L. Anderson
- Skaggs School of Pharmacy and Pharmaceutical Sciences Department of Pharmaceutical Sciences, University of Colorado Denver, Aurora
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Burns RN, Hendrix CW, Chaturvedula A. Population pharmacokinetics of tenofovir and tenofovir-diphosphate in healthy women. J Clin Pharmacol 2015; 55:629-38. [PMID: 25581815 PMCID: PMC5008110 DOI: 10.1002/jcph.461] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 01/01/2015] [Indexed: 01/01/2023]
Abstract
The objective of this analysis was to develop and qualify a population pharmacokinetic model describing plasma tenofovir (TFV) concentrations and tenofovir‐diphosphate (TFV‐DP) concentrations in peripheral blood mononuclear cell (PBMC) in healthy women volunteers from the MTN‐001 clinical trial, an open label 3‐way crossover study of oral tenofovir disoproxil fumarate 300 mg tablet, TFV 1% vaginal gel, or both. TFV pharmacokinetics were best described by a 2‐compartment, first‐order absorption/elimination model with absorption lag time. TFV was linked to PBMC TFV‐DP by first‐order uptake with first‐order elimination. An adherence adjustment was included to account for nonadherence by explicitly modeling a bioavailability parameter on the previous day's dose. The final model included weight as a covariate on central compartment volume (Vc) with estimates as follows: absorption rate constant (Ka) 9.79 h−1, absorption lag time 0.5 hours, Vc 385.71–2.16*(73‐WT(kg)), and apparent TFV clearance of 56.7 L/h ((K20 + K24)*Vc). TFV‐DP's half‐life was 53.3 hours. All diagnostic plots and bootstrap confidence intervals were acceptable. Model validation was conducted using simulations compared to data from the MTN‐001 oral + vaginal period and other clinical trial data. The resulting model closely predicted the disposition of TFV and TFV‐DP when compared to healthy participant data from another clinical trial.
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Affiliation(s)
- Rebecca N Burns
- Department of Pharmaceutical Sciences, Mercer University College of Pharmacy, Atlanta, GA, USA
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Madrasi K, Burns RN, Hendrix CW, Fossler MJ, Chaturvedula A. Linking the population pharmacokinetics of tenofovir and its metabolites with its cellular uptake and metabolism. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2014; 3:e147. [PMID: 25390686 PMCID: PMC4260001 DOI: 10.1038/psp.2014.46] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 09/03/2014] [Indexed: 01/06/2023]
Abstract
Empirical pharmacokinetic models are used to explain the pharmacokinetics of the antiviral drug tenofovir (TFV) and its metabolite TFV diphosphate (TFV-DP) in peripheral blood mononuclear cells. These empirical models lack the ability to explain differences between the disposition of TFV-DP in HIV-infected patients vs. healthy individuals. Such differences may lie in the mechanisms of TFV transport and phosphorylation. Therefore, we developed an exploratory model based on mechanistic mass transport principles and enzyme kinetics to examine the uptake and phosphorylation kinetics of TFV. TFV-DP median Cmax from the model was 38.5 fmol/106 cells, which is bracketed by two reported healthy volunteer studies (38 and 51 fmol/106 cells). The model presented provides a foundation for exploration of TFV uptake and phosphorylation kinetics for various routes of TFV administration and can be updated as more is known on actual mechanisms of cellular transport of TFV.
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Affiliation(s)
- K Madrasi
- Department of Pharmacy Practice, Mercer University, Atlanta, Georgia, USA
| | - R N Burns
- Department of Pharmaceutical Sciences, Mercer University, Atlanta, Georgia, USA
| | - C W Hendrix
- Division of Clinical Pharmacology, John Hopkins University, Baltimore, Maryland, USA
| | - M J Fossler
- Clinical Pharmacology Modeling and Simulation, GlaxoSmithKline, King of Prussia, Pennsylvania, USA
| | - A Chaturvedula
- Department of Pharmacy Practice, Mercer University, Atlanta, Georgia, USA
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40
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Daskalakis DC. HIV preexposure prophylaxis in the real world. TOPICS IN ANTIVIRAL MEDICINE 2014; 22:670-675. [PMID: 25398067 PMCID: PMC6148852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
According to evolving guidelines, candidates for HIV preexposure prophylaxis (PrEP) include HIV-uninfected men who have sex with men who engage in condomless anal intercourse, individuals in HIV-serodifferent sexual relationships, those with frequent anogenital sexually transmitted infections, and those who have received repeated nonoccupational postexposure prophylaxis treatment courses. In the real-world setting, indications for PrEP and management of PrEP candidates and patients may be less than clear-cut. Factors to be considered when assessing candidacy for PrEP and maximizing efficacy of treatment are discussed. This article summarizes a presentation by Demetre C. Daskalakis, MD, MPH, at the IAS-USA continuing education program held in Los Angeles, California, in April 2014.
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41
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A Rapid and Sensitive LC Method for Determination of Diastereomeric Purity of Tenofovir Alafenamide. Chromatographia 2014. [DOI: 10.1007/s10337-014-2745-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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42
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Moss DM, Siccardi M. Optimizing nanomedicine pharmacokinetics using physiologically based pharmacokinetics modelling. Br J Pharmacol 2014; 171:3963-79. [PMID: 24467481 DOI: 10.1111/bph.12604] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 12/13/2013] [Accepted: 01/06/2014] [Indexed: 12/16/2022] Open
Abstract
The delivery of therapeutic agents is characterized by numerous challenges including poor absorption, low penetration in target tissues and non-specific dissemination in organs, leading to toxicity or poor drug exposure. Several nanomedicine strategies have emerged as an advanced approach to enhance drug delivery and improve the treatment of several diseases. Numerous processes mediate the pharmacokinetics of nanoformulations, with the absorption, distribution, metabolism and elimination (ADME) being poorly understood and often differing substantially from traditional formulations. Understanding how nanoformulation composition and physicochemical properties influence drug distribution in the human body is of central importance when developing future treatment strategies. A helpful pharmacological tool to simulate the distribution of nanoformulations is represented by physiologically based pharmacokinetics (PBPK) modelling, which integrates system data describing a population of interest with drug/nanoparticle in vitro data through a mathematical description of ADME. The application of PBPK models for nanomedicine is in its infancy and characterized by several challenges. The integration of property-distribution relationships in PBPK models may benefit nanomedicine research, giving opportunities for innovative development of nanotechnologies. PBPK modelling has the potential to improve our understanding of the mechanisms underpinning nanoformulation disposition and allow for more rapid and accurate determination of their kinetics. This review provides an overview of the current knowledge of nanomedicine distribution and the use of PBPK modelling in the characterization of nanoformulations with optimal pharmacokinetics.
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Affiliation(s)
- Darren Michael Moss
- Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Solomon MM, Mayer KH, Glidden DV, Liu AY, McMahan VM, Guanira JV, Chariyalertsak S, Fernandez T, Grant RM. Syphilis predicts HIV incidence among men and transgender women who have sex with men in a preexposure prophylaxis trial. Clin Infect Dis 2014; 59:1020-6. [PMID: 24928295 PMCID: PMC4166980 DOI: 10.1093/cid/ciu450] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Syphilis infection was associated with HIV incidence in an HIV-prevention trial that randomized participants to once-daily emtricitabine/tenofovir (FTC/TDF) vs placebo. FTC/TDF had no effect on the association between incident syphilis and HIV acquisition; syphilis infection did not decrease FTC/TDF efficacy. Background. Syphilis infection may potentiate transmission of human immunodeficiency virus (HIV). We sought to determine the extent to which HIV acquisition was associated with syphilis infection within an HIV preexposure prophylaxis (PrEP) trial and whether emtricitabine/tenofovir (FTC/TDF) modified that association. Methods. The Preexposure Prophylaxis Initiative (iPrEx) study randomly assigned 2499 HIV-seronegative men and transgender women who have sex with men (MSM) to receive oral daily FTC/TDF or placebo. Syphilis prevalence at screening and incidence during follow-up were measured. Hazard ratios for the effect of incident syphilis on HIV acquisition were calculated. The effect of FTC/TDF on incident syphilis and HIV acquisition was assessed. Results. Of 2499 individuals, 360 (14.4%) had a positive rapid plasma reagin test at screening; 333 (92.5%) had a positive confirmatory test, which did not differ between the arms (FTC/TDF vs placebo, P = .81). The overall syphilis incidence during the trial was 7.3 cases per 100 person-years. There was no difference in syphilis incidence between the study arms (7.8 cases per 100 person-years for FTC/TDF vs 6.8 cases per 100 person-years for placebo, P = .304). HIV incidence varied by incident syphilis (2.8 cases per 100 person-years for no syphilis vs 8.0 cases per 100 person-years for incident syphilis), reflecting a hazard ratio of 2.6 (95% confidence interval, 1.6–4.4; P < .001). There was no evidence for interaction between randomization to the FTC/TDF arm and incident syphilis on HIV incidence. Conclusions. In HIV-seronegative MSM, syphilis infection was associated with HIV acquisition in this PrEP trial; a syphilis diagnosis should prompt providers to offer PrEP unless otherwise contraindicated.
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Affiliation(s)
- Marc M Solomon
- The Gladstone Institutes University of California, San Francisco
| | - Kenneth H Mayer
- Fenway Health, Beth Israel Deaconess Medical Center, Fenway Institute Harvard Medical School, Boston, Massachusetts
| | | | - Albert Y Liu
- Bridge HIV, San Francisco Department of Public Health, California
| | | | | | - Suwat Chariyalertsak
- Research Institute for Health Sciences and Department of Community Medicine, Faculty of Medicine, Chiang Mai University, Thailand
| | | | - Robert M Grant
- The Gladstone Institutes University of California, San Francisco
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Anderson PL, Glidden DV, Bushman LR, Heneine W, García-Lerma JG. Tenofovir diphosphate concentrations and prophylactic effect in a macaque model of rectal simian HIV transmission. J Antimicrob Chemother 2014; 69:2470-6. [PMID: 24862094 DOI: 10.1093/jac/dku162] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES This study evaluated the relationship between intracellular tenofovir diphosphate concentrations in peripheral blood mononuclear cells and prophylactic efficacy in a macaque model for HIV pre-exposure prophylaxis (PrEP). METHODS Macaques were challenged with simian HIV (SHIV) via rectal inoculation once weekly for up to 14 weeks. A control group (n=34) received no drug, a second group (n=6) received oral tenofovir disoproxil fumarate/emtricitabine 3 days before each virus challenge and a third group (n=6) received the same dosing plus another dose 2 h after virus challenge. PBMCs were collected just before each weekly virus challenge. The relationship between tenofovir diphosphate in PBMCs and prophylactic efficacy was assessed with a Cox proportional hazards model. RESULTS The percentages of animals infected in the control, one-dose and two-dose groups were 97, 83 and 17, respectively. The mean (SD) steady-state tenofovir diphosphate concentration (fmol/10(6) cells) was 15.8 (7.6) in the one-dose group and 30.7 (10.1) in the two-dose group. Each 5 fmol tenofovir diphosphate/10(6) cells was associated with a 40% (95% CI 17%-56%) reduction in risk of SHIV acquisition, P=0.002. The tenofovir diphosphate concentration associated with a 90% reduction in risk (EC90) was 22.6 fmol/10(6) cells (95% CI 13.8-60.8). CONCLUSIONS The prophylactic EC90 for tenofovir diphosphate identified in macaques exposed rectally compares well with the EC90 previously identified in men who have sex with men (MSM; 16 fmol/10(6) cells, 95% CI 3-28). These results highlight the relevance of this model to inform human PrEP studies of oral tenofovir disoproxil fumarate/emtricitabine for MSM.
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Affiliation(s)
- Peter L Anderson
- The Department of Pharmaceutical Sciences, University of Colorado Denver, 12850 E. Montview Blvd, Aurora, CO 80045, USA
| | - David V Glidden
- The Department of Epidemiology and Biostatistics, University of California San Francisco, 185 Berry St W., San Francisco, CA 94143, USA
| | - Lane R Bushman
- The Department of Pharmaceutical Sciences, University of Colorado Denver, 12850 E. Montview Blvd, Aurora, CO 80045, USA
| | - Walid Heneine
- The Laboratory Branch, Division of HIV/AIDS Prevention, Centers for Disease Control, 1600 Clifton Rd, Atlanta, GA 30329, USA
| | - J Gerardo García-Lerma
- The Laboratory Branch, Division of HIV/AIDS Prevention, Centers for Disease Control, 1600 Clifton Rd, Atlanta, GA 30329, USA
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Biodistribution and pharmacokinetics of dapivirine-loaded nanoparticles after vaginal delivery in mice. Pharm Res 2014; 31:1834-45. [PMID: 24449442 DOI: 10.1007/s11095-013-1287-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 12/31/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE To assess the potential of polymeric nanoparticles (NPs) to affect the genital distribution and local and systemic pharmacokinetics (PK) of the anti-HIV microbicide drug candidate dapivirine after vaginal delivery. METHODS Dapivirine-loaded, poly(ethylene oxide)-coated poly(epsilon-caprolactone) (PEO-PCL) NPs were prepared by a nanoprecipitation method. Genital distribution of NPs and their ability to modify the PK of dapivirine up to 24 h was assessed after vaginal instillation in a female mouse model. Also, the safety of NPs upon daily administration for 14 days was assessed by histological analysis and chemokine/cytokine content in vaginal lavages. RESULTS PEO-PCL NPs (180-200 nm) were rapidly eliminated after administration but able to distribute throughout the vagina and lower uterus, and capable of tackling mucus and penetrate the epithelial lining. Nanocarriers modified the PK of dapivirine, with higher drug levels being recovered from vaginal lavages and vaginal/lower uterine tissues as compared to a drug suspension. Systemic drug exposure was reduced when NPs were used. Also, NPs were shown safe upon administration for 14 days. CONCLUSIONS Dapivirine-loaded PEO-PCL NPs were able to provide likely favorable genital drug levels, thus attesting the potential value of using this vaginal drug delivery nanosystem in the context of HIV prophylaxis.
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Abstract
HIV pre-exposure prophylaxis (PrEP) with daily oral tenofovir disoproxil fumarate (TDF) or TDF–emtricitabine (FTC) has been shown to be effective against sexual and injection-drug related HIV acquisition in four out of six large clinical trials. This article reviews the pharmacology of TDF and FTC as it relates both to PrEP efficacy and the emergence of viral resistance, summarizes the six trials and the inherent challenges to PrEP they highlighted, and proposes some future areas for further exploration.
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Affiliation(s)
- Lynn A Paxton
- Division of HIV/AIDS Prevention, Centers for Disease Control & Prevention, Atlanta, GA, USA and USAID, 686 Old Bagamoyo Road, Msasani, PO Box 9130, Dar es Salaam, Tanzania
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Chaturvedula A, Fossler MJ, Hendrix CW. Estimation of tenofovir's population pharmacokinetic parameters without reliable dosing histories and application to tracing dosing history using simulation strategies. J Clin Pharmacol 2013; 54:150-60. [PMID: 24203458 DOI: 10.1002/jcph.221] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 10/28/2013] [Indexed: 01/17/2023]
Abstract
The objectives of this analysis were to develop a population pharmacokinetic model (PPK) for tenofovir without using potentially unreliable patient reported dosing records and to retrace patient dosing history using pharmacokinetic simulations conditioned on protocol design constraints to assess patient adherence. MTN-001 is a multi-center, open label, 3-way cross over study comparing oral, vaginal and combination (oral and vaginal) administration of tenofovir in healthy women. It was reported that self-reported adherence in this study was high (94%), but serum concentrations indicated only 64% of participants used tablets consistently. A method based on superposition was applied to develop the population PPK considering only observable clinic visit dosing information. A two compartment model described the data well and the parameters agree with the literature reported values. Race was not a significant covariate on clearance. Retracing of the dosing history with 3-past dose resolution was not successful. Trial simulations with full adherence assumption predict a median Cmin of 68 ng/mL, which is in agreement with literature reports. Non-adherence at 25% resulted in 37-51% reduction in Cmin using one coin and two coin models, respectively. Population analyses should consider some method of correction for non-adherence to avoid biased estimates.
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Affiliation(s)
- Ayyappa Chaturvedula
- Departments of Pharmacy Practice & Pharmaceutical Sciences, Mercer University College of Pharmacy, Atlanta, GA, USA
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Hendrix CW. Exploring concentration response in HIV pre-exposure prophylaxis to optimize clinical care and trial design. Cell 2013; 155:515-8. [PMID: 24243011 DOI: 10.1016/j.cell.2013.09.030] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Indexed: 10/26/2022]
Abstract
HIV pre-exposure prophylaxis trials with antiretroviral drugs have been variably successful. Even trials demonstrating the best efficacy leave room for improvement. Pharmacological data illuminate several sources of outcome variability, especially the impact of poor adherence, which is critical to manage PrEP in the clinic and to develop the next generation of PrEP candidates.
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Affiliation(s)
- Craig W Hendrix
- Department of Medicine (Clinical Pharmacology), Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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