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Md S, Kotta S. Advanced drug delivery technologies for postmenopausal effects. J Control Release 2024; 373:426-446. [PMID: 39038543 DOI: 10.1016/j.jconrel.2024.07.038] [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: 05/14/2024] [Revised: 07/08/2024] [Accepted: 07/15/2024] [Indexed: 07/24/2024]
Abstract
Postmenopause is the 12-month absence of menstrual periods, characterized by decreased estrogen and progesterone levels, leading to physical and psychological alterations such as hot flashes, mood swings, sleep disruptions, and skin changes. Present postmenopausal treatments include hormone replacement therapy, non-hormonal drugs, lifestyle modifications, vaginal estrogen therapy, bone health treatments, and alternative therapies. Advanced drug delivery systems (ADDSs) are essential in managing postmenopausal effects (PMEs), offering targeted and controlled delivery to alleviate symptoms and improve overall health. This review emphasizes such ADDSs for addressing PMEs. Emerging trends such as artificial ovaries are also reviewed. Additionally, the prospects of technologies such as additive manufacturing (3D and 4D printing) and artificial intelligence in further tailoring therapeutic strategies against PMEs are provided.
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Affiliation(s)
- Shadab Md
- Department of Pharmaceutics, Faculty of Pharmacy, King Abdulaziz University, Jeddah 21589, Saudi Arabia; Center of Excellence for Drug Research and Pharmaceutical Industries, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Sabna Kotta
- Department of Pharmaceutics, Faculty of Pharmacy, King Abdulaziz University, Jeddah 21589, Saudi Arabia; Center of Excellence for Drug Research and Pharmaceutical Industries, King Abdulaziz University, Jeddah 21589, Saudi Arabia.
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Hicks AJ, Roberts C, Robinson A, Wilson K, Kotamreddy V, LaRue T, Veyssi A, Beltran F, Hakim J, Rausch MK, Grunlan M, Cosgriff-Hernandez E. Polycaprolactone-based shape memory foams as self-fitting vaginal stents. Acta Biomater 2024:S1742-7061(24)00487-2. [PMID: 39214160 DOI: 10.1016/j.actbio.2024.08.041] [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: 05/06/2024] [Revised: 08/16/2024] [Accepted: 08/23/2024] [Indexed: 09/04/2024]
Abstract
There is an urgent critical need for a patient-forward vaginal stent that can prevent debilitating vaginal stenosis that occurs after pelvic radiation treatments and vaginal reconstruction. To this end, we developed a self-fitting vaginal stent based on a shape-memory polymer (SMP) foam that can assume a secondary, compressed shape for ease of deployment. Upon insertion, the change in temperature and hydration initiates foam expansion to shape fit to the individual patient and restore the lumen of the stent to allow egress of vaginal secretions. To achieve rapid actuation at physiological temperature, we investigated the effect of architecture of two photocurable, polycaprolactone (PCL) macromers. Star-PCL-tetraacrylate displayed a reduced melting temperature as compared to a linear-PCL-diacrylate. Upon fabrication into high porosity foams with emulsion-templating, both compositions displayed shape fixity (>90 %) in a crimped, temporary shape. However, only the PCL star-foams displayed shape recovery (∼84 %) at 37 °C with expansion back to its permanent shape. A custom mold and curing system were then used to fabricate the PCL star-foams into hollow, cylindrical stents. The stent was crimped to its temporary insertion shape (50 % reduction in diameter, OD ∼ 11 mm) with a custom radial crimper and displayed excellent shape fixity for deployment (> 95 %) and shape recovery (∼ 100 %). To screen vaginal stents, we developed a custom benchtop pelvic model that simulated vaginal anatomy, temperatures, and pressures with an associated computational model. The crimped SMP vaginal stent was deployed in the model and expanded to walls of the canal (∼70 % increase in cross-sectional area) in less than 5 min after irrigation with warm water. The vaginal stent demonstrated retention of vaginal caliber with less than 10 % decrease in cross-sectional area under physiological pressures. Collectively, this work demonstrates the potential for SMP foams as self-fitting vaginal stents to prevent stenosis and provides new open-source tools for the iterative design of other gynecological devices. STATEMENT OF SIGNIFICANCE: Vaginal stenosis, a painful narrowing of the vaginal canal, is a common complication after pelvic radiation therapy or reconstructive surgery. To address this clinical need, we have created a self-fitting vaginal stent from a shape-memory polymer foam. The stent compresses for easy insertion and then expands to adapt to each patient's anatomy to maintain an open vaginal canal and prevent stenosis. This innovative stent provides a patient-friendly solution that could make a significant difference for women undergoing pelvic treatments by reducing pain, aiding recovery, and improving quality of life.
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Affiliation(s)
- Ashley J Hicks
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78712, United States.
| | - Courteney Roberts
- Department of Biomedical Engineering, Texas A&M University, College Station, TX 77843, United States.
| | - Andrew Robinson
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78712, United States.
| | - Kailey Wilson
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78712, United States
| | - Varsha Kotamreddy
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78712, United States.
| | - Trace LaRue
- Department of Aerospace Engineering & Engineering Mechanics, The University of Texas at Austin, Austin, TX 78712, United States.
| | - Arian Veyssi
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78712, United States.
| | - Felipe Beltran
- Department of Biomedical Engineering, Texas A&M University, College Station, TX 77843, United States
| | - Julie Hakim
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX 77030, United States.
| | - Manuel K Rausch
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78712, United States; Department of Aerospace Engineering & Engineering Mechanics, The University of Texas at Austin, Austin, TX 78712, United States; Walker Department of Mechanical Engineering, The University of Texas at Austin, Austin, TX 78712, United States.
| | - Melissa Grunlan
- Department of Biomedical Engineering, Texas A&M University, College Station, TX 77843, United States.
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de Laat W, Pagan L, Malcolm RK, Wiegerinck M, Nickolson V, Huisman B, Stuurman R, van Esdonk M, Klarenbeek N. First-in-human study to assess the pharmacokinetics, tolerability, and safety of single-dose oxybutynin hydrochloride administered via a microprocessor-controlled intravaginal ring. Drug Deliv 2023; 30:2180113. [PMID: 36815245 PMCID: PMC9970198 DOI: 10.1080/10717544.2023.2180113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/08/2023] [Indexed: 02/24/2023] Open
Abstract
Polymeric drug-releasing vaginal rings are useful for both local and systemic administration of drugs via the intravaginal route. Typically, they provide continuous sustained or controlled release of drug(s) over extended time periods, thereby avoiding overdose and improving adherence. This first-in-human study (EudraCT number: 2020-0050044-30) evaluated the pharmacokinetics, safety, and tolerability of a single dose of oxybutynin administered by a novel microprocessor-controlled vaginal ring (MedRing). Eight healthy female subjects received an electronically controlled single intravaginal dose of 3 mg oxybutynin hydrochloride (100 mg/mL) dissolved in 1:1 water/propylene glycol administered via MedRing. Following dosing, MedRing was kept in situ for up to 6 h. Blood samples were collected 1 h prior to oxybutynin dosing and subsequently at regular intervals post-dose for the assessment of plasma concentrations of oxybutynin and its active metabolite N-desethyloxybutynin. The results showed that MedRing efficiently administered oxybutynin via the intravaginal route, resulting in plasma oxybutynin levels comparable to orally administered oxybutynin. The mean ± standard deviation pharmacokinetic parameters for oxybutynin were Cmax 5.4 ± 2.7 ng/mL, AUCinf 34.9 ± 17.4 h ng/mL, t1/2 8.5 ± 3.5 h and for N-desethyloxybutynin were Cmax 3.9 ± 2.5 ng/mL, AUCinf 51.1 ± 43.1 h ng/mL, t1/2 7.7 ± 5.9 h. No serious adverse events were reported. The study demonstrates that intravaginal administration of oxybutynin hydrochloride using the MedRing device was well tolerated.
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Affiliation(s)
| | - Lisa Pagan
- Centre for Human Drug Research, Leiden, The Netherlands
- Department of Gynaecology and Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - R. Karl Malcolm
- School of Pharmacy, Queen’s University Belfast, United Kingdom
| | | | | | - Bertine Huisman
- Centre for Human Drug Research, Leiden, The Netherlands
- Department of Gynaecology and Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Rik Stuurman
- Centre for Human Drug Research, Leiden, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, The Netherlands
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Johnston DS, Goldberg E. Preclinical contraceptive development for men and women. Biol Reprod 2021; 103:147-156. [PMID: 32561907 DOI: 10.1093/biolre/ioaa076] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/07/2020] [Accepted: 05/09/2020] [Indexed: 12/16/2022] Open
Abstract
This manuscript endeavors to present research considerations for the preclinical development of non-hormonal contraceptives. Topics include (1) how advances in genomics and bioinformatics impact the identification of novel targets for non-hormonal contraception, (2) the importance of target validation prior to investment in a contraceptive development campaign, (3) considerations on targeting gametogenesis vs gamete maturation/function, (4) how targets from the male reproductive system are expanding women's options for 'on demand' contraception, and (5) some emerging non-hormonal methods that are not based on a specific molecular target. Also presented are ideas for developing a pipeline of non-hypothalamic-pituitary-gonadal-acting contraceptives for men and women while balancing risk and innovation, and our perspective on the pros and cons of industry and academic environments on contraceptive development. Three product development programs are highlighted that are biologically interesting, innovative, and likely to influence the field of contraceptive development in years to come.
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Affiliation(s)
- Daniel S Johnston
- Contraception Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Erwin Goldberg
- Department of Molecular Biosciences, Northwestern University, Evanston, IL, USA
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Cam ME, Hazar-Yavuz AN, Cesur S, Ozkan O, Alenezi H, Turkoglu Sasmazel H, Sayip Eroglu M, Brako F, Ahmed J, Kabasakal L, Ren G, Gunduz O, Edirisinghe M. A novel treatment strategy for preterm birth: Intra-vaginal progesterone-loaded fibrous patches. Int J Pharm 2020; 588:119782. [PMID: 32822780 DOI: 10.1016/j.ijpharm.2020.119782] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 08/11/2020] [Accepted: 08/15/2020] [Indexed: 02/06/2023]
Abstract
Progesterone-loaded poly(lactic) acid fibrous polymeric patches were produced using electrospinning and pressurized gyration for intra-vaginal application to prevent preterm birth. The patches were intravaginally inserted into rats in the final week of their pregnancy, equivalent to the third trimester of human pregnancy. Maintenance tocolysis with progesterone-loaded patches was elucidated by recording the contractile response of uterine smooth muscle to noradrenaline in pregnant rats. Both progesterone-loaded patches indicated similar results from release and thermal studies, however, patches obtained by electrospinning had smaller average diameters and more uniform dispersion compared to pressurized gyration. Patches obtained by pressurized gyration had better results in production yield and tensile strength than electrospinning; thereby pressurized gyration is better suited for scaled-up production. The patches did not affect cell attachment, viability, and proliferation on Vero cells negatively. Consequently, progesterone-loaded patches are a novel and successful treatment strategy for preventing preterm birth.
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Affiliation(s)
- Muhammet Emin Cam
- Department of Mechanical Engineering, University College London, Torrington Place, London WC1E 7JE, UK; Center for Nanotechnology and Biomaterials Application and Research, Marmara University, Istanbul 34722, Turkey; Department of Pharmacology, Faculty of Pharmacy, Marmara University, Istanbul 34668, Turkey.
| | - Ayse Nur Hazar-Yavuz
- Department of Pharmacology, Faculty of Pharmacy, Marmara University, Istanbul 34668, Turkey
| | - Sumeyye Cesur
- Center for Nanotechnology and Biomaterials Application and Research, Marmara University, Istanbul 34722, Turkey; Department of Metallurgy and Material Engineering, Faculty of Technology, Marmara University, Istanbul 34722, Turkey
| | - Ozan Ozkan
- Department of Metallurgical and Materials Engineering, Faculty of Engineering, Atilim University, 06836 Ankara, Turkey
| | - Hussain Alenezi
- Department of Mechanical Engineering, University College London, Torrington Place, London WC1E 7JE, UK; Department of Manufacturing Engineering, College of Technological Studies, PAAET, 13092 Kuwait City, Kuwait
| | - Hilal Turkoglu Sasmazel
- Department of Metallurgical and Materials Engineering, Faculty of Engineering, Atilim University, 06836 Ankara, Turkey
| | - Mehmet Sayip Eroglu
- Department of Chemical Engineering, Marmara University, Faculty of Engineering, Goztepe Campus, 34722 Kadikoy/Istanbul, Turkey; TUBITAK-UME, Chemistry Group Laboratories, 41470 Gebze/Kocaeli, Turkey
| | - Francis Brako
- Department of Mechanical Engineering, University College London, Torrington Place, London WC1E 7JE, UK; School of Pharmacy, University College London, 29-39 Brunswick Square, London WC1N 1AX, UK
| | - Jubair Ahmed
- Department of Mechanical Engineering, University College London, Torrington Place, London WC1E 7JE, UK
| | - Levent Kabasakal
- Department of Pharmacology, Faculty of Pharmacy, Marmara University, Istanbul 34668, Turkey
| | - Guogang Ren
- Mechanical and Mechatronics Engineering Division, School of Engineering and Technology, University of Hertfordshire, UK
| | - Oguzhan Gunduz
- Center for Nanotechnology and Biomaterials Application and Research, Marmara University, Istanbul 34722, Turkey; Department of Metallurgy and Material Engineering, Faculty of Technology, Marmara University, Istanbul 34722, Turkey
| | - Mohan Edirisinghe
- Department of Mechanical Engineering, University College London, Torrington Place, London WC1E 7JE, UK.
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Boyd P, Merkatz R, Variano B, Malcolm RK. The ins and outs of drug-releasing vaginal rings: a literature review of expulsions and removals. Expert Opin Drug Deliv 2020; 17:1519-1540. [DOI: 10.1080/17425247.2020.1798927] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Peter Boyd
- School of Pharmacy, Queen’s University Belfast, Belfast, UK
| | - Ruth Merkatz
- Population Council, One Dag Hammarskjold Plaza, New York, NY, USA
| | - Bruce Variano
- Population Council, One Dag Hammarskjold Plaza, New York, NY, USA
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Murphy DJ, McCoy CF, Plagianos M, RamaRao S, Merkatz R, Clark H, Boyd P, Variano B, Malcolm RK. Post-use ring weight and residual drug content as potential objective measures of user adherence to a contraceptive progesterone vaginal ring. Contraception 2019; 100:241-246. [DOI: 10.1016/j.contraception.2019.06.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 06/17/2019] [Accepted: 06/18/2019] [Indexed: 10/26/2022]
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Rapid measures of user's adherence to vaginal drug products using attenuated total reflectance Fourier transform infrared spectroscopy (ATR-FTIR) and multivariate discriminant techniques. PLoS One 2018; 13:e0197906. [PMID: 29799875 PMCID: PMC5969765 DOI: 10.1371/journal.pone.0197906] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 05/10/2018] [Indexed: 11/30/2022] Open
Abstract
Background The topical HIV prevention (microbicides) field is in acute need of a method to rapidly and objectively measure adherence to product use in clinical trials. Infrared (IR) spectroscopy has been used in many pharmaceutical and forensic applications but has yet to be applied to adherence monitoring. In this study, we report on efforts to test the feasibility of using IR spectroscopy as a means to measure residual active or placebo vaginal product, semen exposure and vaginal insertion from a single swab. Methods A portable IR spectrometer equipped with diamond attenuated total reflectance (ATR) was used to capture spectra of unused vs. vaginally-used swabs, vaginal swabs containing semen, and vaginal swabs to which either tenofovir-containing or matching placebo products (vaginal gel or insert) were added. Spectral data obtained from swabs placed directly on the spectrometer were divided into calibration and testing sets for developing and validating discriminant models set up to provide yes/no predictions of: vaginal vs. non-vaginal use, presence vs. no presence of each test product, and presence vs. no presence of semen. Further validation of models was performed using vaginal swabs collected from a clinical study evaluating vaginally administered placebo insert formulations. Results For each discriminant model developed to predict vaginal vs. non-vaginal use, presence vs. no presence of each test product, and presence vs. no presence of semen, classified validation samples not included in the model development were correctly identified into their respective classes with minimal prediction error. Clinically obtained vaginal swabs collected 15–60 minutes after placebo insert use were also correctly identified, further validating the models. Conclusion Our findings demonstrate the proof of concept that IR spectroscopy can be a method for rapid detection and characterization of microbicide products and biological fluids present in vaginal swabs. This novel method has potential to support real-time, on-site adherence monitoring in clinical or field settings.
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Moss JA, Baum MM, Easley JT, Cox DM, Smith TJ. An intravaginal ring for real-time evaluation of adherence to therapy. PLoS One 2017; 12:e0174729. [PMID: 28384179 PMCID: PMC5383054 DOI: 10.1371/journal.pone.0174729] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 03/14/2017] [Indexed: 12/18/2022] Open
Abstract
Two recent Phase III clinical trials to investigate an intravaginal ring for preventing HIV infection demonstrated that adherence to prescribed device use was a primary driver of efficacy. Surrogate methods for determining adherence in the studies were limited in their inability to monitor temporal patterns of use and allow deconvolution of the effects of adherence and device efficacy on HIV infection rates. To address this issue, we have developed functionality in an intravaginal ring to continuously monitor when the device is being used and maintain a log of adherence that can be accessed by clinicians after it is removed. An electronic module fabricated with common, inexpensive electronic components was encapsulated in a silicone intravaginal ring. The device uses temperature as a surrogate measure of periods of device insertion and removal, and stores a record of the data for subsequent retrieval. The adherence-monitoring intravaginal ring accurately recorded the device status over 33 simulated IN-OUT cycles and more than 1000 measurement cycles in vitro. Following initial in vitro testing in a temperature-controlled chamber, the device was evaluated in vivo in sheep using a predetermined insertion/removal pattern to simulate intravaginal ring use. After insertion into the vaginal cavity of a sheep, the logged data correctly indicated the device status over 29 hours of continuous measurement including three cycles of insertion and removal. The device described here is a promising, low-cost method for real-time adherence assessment in clinical trials involving medicated intravaginal rings or other intravaginal devices.
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Affiliation(s)
- John A. Moss
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
- * E-mail:
| | - Marc M. Baum
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - Jeremiah T. Easley
- Preclinical Surgical Research Laboratory, Colorado State University, Fort Collins, Colorado, United States of America
| | - Darren M. Cox
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - Thomas J. Smith
- Auritec Pharmaceuticals, Inc., Pasadena, California, United States of America
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Cell Phone-Based and Adherence Device Technologies for HIV Care and Treatment in Resource-Limited Settings: Recent Advances. Curr HIV/AIDS Rep 2016; 12:523-31. [PMID: 26439917 DOI: 10.1007/s11904-015-0282-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Numerous cell phone-based and adherence monitoring technologies have been developed to address barriers to effective HIV prevention, testing, and treatment. Because most people living with HIV and AIDS reside in resource-limited settings (RLS), it is important to understand the development and use of these technologies in RLS. Recent research on cell phone-based technologies has focused on HIV education, linkage to and retention in care, disease tracking, and antiretroviral therapy adherence reminders. Advances in adherence devices have focused on real-time adherence monitors, which have been used for both antiretroviral therapy and pre-exposure prophylaxis. Real-time monitoring has recently been combined with cell phone-based technologies to create real-time adherence interventions using short message service (SMS). New developments in adherence technologies are exploring ingestion monitoring and metabolite detection to confirm adherence. This article provides an overview of recent advances in these two families of technologies and includes research on their acceptability and cost-effectiveness when available. It additionally outlines key challenges and needed research as use of these technologies continues to expand and evolve.
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Malcolm RK, Boyd PJ, McCoy CF, Murphy DJ. Microbicide vaginal rings: Technological challenges and clinical development. Adv Drug Deliv Rev 2016; 103:33-56. [PMID: 26829289 DOI: 10.1016/j.addr.2016.01.015] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 01/13/2016] [Accepted: 01/20/2016] [Indexed: 10/22/2022]
Abstract
Vaginal rings (VRs) are flexible, torus-shaped, polymeric devices designed to sustain delivery of pharmaceutical drugs to the vagina for clinical benefit. Following first report in a 1970 patent application, several steroid-releasing VR products have since been marketed for use in hormone replacement therapy and contraception. Since 2002, there has been growing interest in the use of VR technology for delivery of drugs that can reduce the risk of sexual acquisition of human immunodeficiency virus type 1 (HIV-1), the causative agent of acquired immunodeficiency syndrome (AIDS). Although no vaginally-administered product has yet been approved for HIV reduction/prevention, extensive research efforts are continuing and a number of VR devices offering sustained release of so-called 'HIV microbicide' compounds are currently being evaluated in late-stage clinical studies. This review article provides an overview of the published scientific literature within this important field of research, focusing primarily on articles published within peer-reviewed journal publications. Many important aspects of microbicide-releasing VR technology are discussed, with a particular emphasis on the technological, manufacturing and clinical challenges that have emerged in recent years.
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Biomarkers and biometric measures of adherence to use of ARV-based vaginal rings. J Int AIDS Soc 2016; 19:20746. [PMID: 27142091 PMCID: PMC4854848 DOI: 10.7448/ias.19.1.20746] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 03/21/2016] [Accepted: 03/31/2016] [Indexed: 11/13/2022] Open
Abstract
Introduction Poor adherence to product use has been observed in recent trials of antiretroviral (ARV)-based oral and vaginal gel HIV prevention products, resulting in an inability to determine product efficacy. The delivery of microbicides through vaginal rings is widely perceived as a way to achieve better adherence but vaginal rings do not eliminate the adherence challenges exhibited in clinical trials. Improved objective measures of adherence are needed as new ARV-based vaginal ring products enter the clinical trial stage. Methods To identify technologies that have potential future application for vaginal ring adherence measurement, a comprehensive literature search was conducted that covered a number of biomedical and public health databases, including PubMed, Embase, POPLINE and the Web of Science. Published patents and patent applications were also searched. Technical experts were also consulted to gather more information and help evaluate identified technologies. Approaches were evaluated as to feasibility of development and clinical trial implementation, cost and technical strength. Results Numerous approaches were identified through our landscape analysis and classified as either point measures or cumulative measures of vaginal ring adherence. Point measurements are those that give a measure of adherence at a particular point in time. Cumulative measures attempt to measure ring adherence over a period of time. Discussion Approaches that require modifications to an existing ring product are at a significant disadvantage, as this will likely introduce additional regulatory barriers to the development process and increase manufacturing costs. From the point of view of clinical trial implementation, desirable attributes would be high acceptance by trial participants, and little or no additional time or training requirements on the part of participants or clinic staff. We have identified four promising approaches as being high priority for further development based on the following measurements: intracellular drug levels, drug levels in hair, the accumulation of a vaginal analyte that diffuses into the ring, and the depletion of an intrinsic ring constituent. Conclusions While some approaches show significant promise over others, it is recommended that a strategy of using complementary biometric and behavioural approaches be adopted to best understand participants’ adherence to ARV-based ring products in clinical trials.
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Nel A, Bekker LG, Bukusi E, Hellstrӧm E, Kotze P, Louw C, Martinson F, Masenga G, Montgomery E, Ndaba N, van der Straten A, van Niekerk N, Woodsong C. Safety, Acceptability and Adherence of Dapivirine Vaginal Ring in a Microbicide Clinical Trial Conducted in Multiple Countries in Sub-Saharan Africa. PLoS One 2016; 11:e0147743. [PMID: 26963505 PMCID: PMC4786336 DOI: 10.1371/journal.pone.0147743] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 01/04/2016] [Indexed: 11/28/2022] Open
Abstract
Background This was the first microbicide trial conducted in Africa to evaluate an antiretroviral-containing vaginal ring as an HIV prevention technology for women. Objectives The trial assessed and compared the safety, acceptability and adherence to product use of a 4-weekly administered vaginal ring containing the antiretroviral microbicide, dapivirine, with a matching placebo ring among women from four countries in sub-Saharan Africa. Methods 280 Healthy, sexually active, HIV-negative women, aged 18 to 40 years were enrolled with 140 women randomised to a dapivirine vaginal ring (25 mg) and 140 women to a matching placebo ring, inserted 4-weekly and used over a 12-week period. Safety was evaluated by pelvic examination, colposcopy, clinical laboratory assessments, and adverse events. Blood samples for determination of plasma concentrations of dapivirine were collected at Weeks 0, 4 and 12. Residual dapivirine levels in returned rings from dapivirine ring users were determined post-trial. Participant acceptability and adherence to ring use were assessed by self-reports. Results No safety concerns or clinically relevant differences were observed between the dapivirine and placebo ring groups. Plasma dapivirine concentrations immediately prior to ring removal were similar after removal of the first and third ring, suggesting consistent ring use over the 12-week period. No clear relationship was observed between the residual amount of dapivirine in used rings and corresponding plasma concentrations. Self-reported adherence to daily use of the vaginal rings over the 12-week trial period was very high. At the end of the trial, 96% of participants reported that the ring was usually comfortable to wear, and 97% reported that they would be willing to use it in the future if proven effective. Conclusions The dapivirine vaginal ring has a favourable safety and acceptability profile. If proven safe and effective in large-scale trials, it will be an important component of combination HIV prevention approaches for women. Trial Registration ClinicalTrials.gov NCT01071174
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Affiliation(s)
- Annalene Nel
- International Partnership for Microbicides, Silver Spring, Maryland, United States of America
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | | | | | - Philip Kotze
- Qhakaza Mbokodo Research Clinic, Ladysmith, South Africa
| | - Cheryl Louw
- Madibeng Centre for Research, Brits, South Africa
| | | | | | | | - Nelisiwe Ndaba
- Maternal, Adolescent and Child Health, Edendale, South Africa
| | | | - Neliëtte van Niekerk
- International Partnership for Microbicides, Silver Spring, Maryland, United States of America
- * E-mail:
| | - Cynthia Woodsong
- International Partnership for Microbicides, Silver Spring, Maryland, United States of America
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Nelson AG, Zhang X, Ganapathi U, Szekely Z, Flexner CW, Owen A, Sinko PJ. Drug delivery strategies and systems for HIV/AIDS pre-exposure prophylaxis and treatment. J Control Release 2015; 219:669-680. [PMID: 26315816 PMCID: PMC4879940 DOI: 10.1016/j.jconrel.2015.08.042] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 08/20/2015] [Accepted: 08/20/2015] [Indexed: 01/08/2023]
Abstract
The year 2016 will mark an important milestone - the 35th anniversary of the first reported cases of HIV/AIDS. Antiretroviral Therapy (ART) including Highly Active Antiretroviral Therapy (HAART) drug regimens is widely considered to be one of the greatest achievements in therapeutic drug research having transformed HIV infection into a chronically managed disease. Unfortunately, the lack of widespread preventive measures and the inability to eradicate HIV from infected cells highlight the significant challenges remaining today. Moving forward there are at least three high priority goals for anti-HIV drug delivery (DD) research: (1) to prevent new HIV infections from occurring, (2) to facilitate a functional cure, i.e., when HIV is present but the body controls it without drugs and (3) to eradicate established infection. Pre-exposure Prophylaxis (PrEP) represents a significant step forward in preventing the establishment of chronic HIV infection. However, the ultimate success of PrEP will depend on achieving sustained antiretroviral (ARV) tissue concentrations and will require strict patient adherence to the regimen. While first generation long acting/extended release (LA/ER) DD Systems (DDS) currently in development show considerable promise, significant DD treatment and prevention challenges persist. First, there is a critical need to improve cell specificity through targeting in order to selectively achieve efficacious drug concentrations in HIV reservoir sites to control/eradicate HIV as well as mitigate systemic side effects. In addition, approaches for reducing cellular efflux and metabolism of ARV drugs to prolong effective concentrations in target cells need to be developed. Finally, given the current understanding of HIV pathogenesis, next generation anti-HIV DDS need to address selective DD to the gut mucosa and lymph nodes. The current review focuses on the DDS technologies, critical challenges, opportunities, strategies, and approaches by which novel delivery systems will help iterate towards prevention, functional cure and eventually the eradication of HIV infection.
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Affiliation(s)
- Antoinette G Nelson
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA.
| | - Xiaoping Zhang
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA.
| | - Usha Ganapathi
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA.
| | - Zoltan Szekely
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA.
| | - Charles W Flexner
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA.
| | - Andrew Owen
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA.
| | - Patrick J Sinko
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA.
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