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Payra S, Harsha D, Kumar K, Manjhi PK, Singh S, Kumar R, Singh SK, Kumar A, Maharshi V. Risk of Congenital Anomalies with Dolutegravir-Based Anti-retroviral Regimens: A Systematic Review and Meta-analysis. Clin Drug Investig 2024:10.1007/s40261-024-01390-y. [PMID: 39302585 DOI: 10.1007/s40261-024-01390-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND AND OBJECTIVES Dolutegravir has been used as a first-line anti-human immunodeficiency virus drug because of its better efficacy compared with other counterpart medicines. However, making a unanimous decision on its use during pregnancy has become difficult for stakeholders following congenital anomalies reported with its use. The objective of this systematic review and meta-analysis was to study the risk of congenital anomalies in newborns exposed to dolutegravir-based-regimens compared with those exposed to non-dolutegravir-based regimens during the antenatal period. METHODS An extensive literature search was performed in MEDLINE (through PubMed), EMBASE, Cochrane Database of Systematic Reviews, Google Scholar, and ClinicalTrials.gov until 30 November, 2023. Studies reporting data on congenital anomalies following antenatal use of dolutegravir were included. Risk of bias for randomized controlled trials, non-randomized controlled trials, and observational studies was assessed using RoB2, ROBINS-I, and ROBINS-E tools, respectively. A meta-analysis was performed in 'RevMan 5.4.1' using a random-effects model. Heterogeneity was assessed by the 'Q' statistic and I2 value. A sensitivity analysis was performed for higher heterogeneity/high-risk studies. The study protocol was registered in PROSPERO [CRD42023446374] a priori. RESULTS Of 26 eligible studies, 12 (six randomized controlled trials and six observational studies with a pooled sample of 32,617) were included in a meta-analysis and 14 in a qualitative synthesis only. The meta-analysis does not show a statistically significant difference in the risk of congenital anomalies between newborns exposed antenatally to dolutegravir-based regimen(s) and those exposed to non-dolutegravir-based regimens [risk ratio 1.10; 95% confidence interval 0.79-1.53; p = 0.59]. Heterogeneity was moderate (I2 = 47%). Pooled results for randomized controlled trials and observational studies separately and the sensitivity analysis for heterogeneity provided similar results. CONCLUSIONS The risk of congenital anomalies was not significantly different between dolutegravir-based regimens and non-dolutegravir-based-regimens in newborns exposed during their antenatal period.
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Affiliation(s)
- Shuvasree Payra
- Department of Pharmacology, All India Institute of Medical Sciences, AIIMS Patna Road, Patna, 801507, Bihar, India
| | - Divya Harsha
- Department of Pharmacology, All India Institute of Medical Sciences, AIIMS Patna Road, Patna, 801507, Bihar, India
| | - Keshav Kumar
- Department of Pharmacology, All India Institute of Medical Sciences, AIIMS Patna Road, Patna, 801507, Bihar, India
| | - Pramod Kumar Manjhi
- Department of Pharmacology, All India Institute of Medical Sciences, AIIMS Patna Road, Patna, 801507, Bihar, India
| | - Shruti Singh
- Department of Pharmacology, All India Institute of Medical Sciences, AIIMS Patna Road, Patna, 801507, Bihar, India
| | - Rajesh Kumar
- Department of Pharmacology, All India Institute of Medical Sciences, AIIMS Patna Road, Patna, 801507, Bihar, India
| | - Sunil Kumar Singh
- Department of Pharmacology, All India Institute of Medical Sciences, AIIMS Patna Road, Patna, 801507, Bihar, India
| | - Alok Kumar
- Department of Pharmacology, All India Institute of Medical Sciences, AIIMS Patna Road, Patna, 801507, Bihar, India
| | - Vikas Maharshi
- Department of Pharmacology, All India Institute of Medical Sciences, AIIMS Patna Road, Patna, 801507, Bihar, India.
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Zizioli D, Quiros-Roldan E, Ferretti S, Mignani L, Tiecco G, Monti E, Castelli F, Zanella I. Dolutegravir and Folic Acid Interaction during Neural System Development in Zebrafish Embryos. Int J Mol Sci 2024; 25:4640. [PMID: 38731859 PMCID: PMC11083492 DOI: 10.3390/ijms25094640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/04/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Dolutegravir (DTG) is one of the most prescribed antiretroviral drugs for treating people with HIV infection, including women of child-bearing potential or pregnant. Nonetheless, neuropsychiatric symptoms are frequently reported. Early reports suggested that, probably in relation to folic acid (FA) shortage, DTG may induce neural tube defects in infants born to women taking the drug during pregnancy. Subsequent reports did not definitively confirm these findings. Recent studies in animal models have highlighted the association between DTG exposure in utero and congenital anomalies, and an increased risk of neurologic abnormalities in children exposed during in utero life has been reported. Underlying mechanisms for DTG-related neurologic symptoms and congenital anomalies are not fully understood. We aimed to deepen our knowledge on the neurodevelopmental effects of DTG exposure and further explore the protective role of FA by the use of zebrafish embryos. We treated embryos at 4 and up to 144 h post fertilization (hpf) with a subtherapeutic DTG concentration (1 μM) and observed the disruption of the anterior-posterior axis and several morphological malformations in the developing brain that were both prevented by pre-exposure (2 hpf) and rescued by post-exposure (10 hpf) with FA. By whole-mount in situ hybridization with riboprobes for genes that are crucial during the early phases of neurodevelopment (ntl, pax2a, ngn1, neurod1) and by in vivo visualization of the transgenic Tg(ngn1:EGFP) zebrafish line, we found that DTG induced severe neurodevelopmental defects over time in most regions of the nervous system (notochord, midbrain-hindbrain boundary, eye, forebrain, midbrain, hindbrain, spinal cord) that were mostly but not completely rescued by FA supplementation. Of note, we observed the disruption of ngn1 expression in the dopaminergic regions of the developing forebrain, spinal cord neurons and spinal motor neuron projections, with the depletion of the tyrosine hydroxylase (TH)+ dopaminergic neurons of the dorsal diencephalon and the strong reduction in larvae locomotion. Our study further supports previous evidence that DTG can interfere with FA pathways in the developing brain but also provides new insights regarding the mechanisms involved in the increased risk of DTG-associated fetal neurodevelopmental defects and adverse neurologic outcomes in in utero exposed children, suggesting the impairment of dopaminergic pathways.
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Affiliation(s)
- Daniela Zizioli
- Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy; (D.Z.); (S.F.); (L.M.); (E.M.); (I.Z.)
| | - Eugenia Quiros-Roldan
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, University of Brescia and ASST Spedali Civili di Brescia, 25123 Brescia, Italy; (G.T.); (F.C.)
| | - Sara Ferretti
- Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy; (D.Z.); (S.F.); (L.M.); (E.M.); (I.Z.)
| | - Luca Mignani
- Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy; (D.Z.); (S.F.); (L.M.); (E.M.); (I.Z.)
| | - Giorgio Tiecco
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, University of Brescia and ASST Spedali Civili di Brescia, 25123 Brescia, Italy; (G.T.); (F.C.)
| | - Eugenio Monti
- Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy; (D.Z.); (S.F.); (L.M.); (E.M.); (I.Z.)
| | - Francesco Castelli
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, University of Brescia and ASST Spedali Civili di Brescia, 25123 Brescia, Italy; (G.T.); (F.C.)
| | - Isabella Zanella
- Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy; (D.Z.); (S.F.); (L.M.); (E.M.); (I.Z.)
- Cytogenetics and Molecular Genetics Laboratory, Diagnostic Department, ASST Spedali Civili di Brescia, 25123 Brescia, Italy
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Goulding AN, Meeks K, Shay L, Casey S, Applegarth C, McKinney J. Antiretroviral Therapy in Pregnancy: A 2023 Review of the Literature. Curr HIV/AIDS Rep 2024; 21:1-10. [PMID: 38277098 PMCID: PMC11095844 DOI: 10.1007/s11904-024-00688-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 01/27/2024]
Abstract
PURPOSE OF REVIEW Selection of antiretroviral therapy during pregnancy must consider maternal physiology and resulting pharmacokinetic changes in pregnancy, resistance and efficacy profiles, tolerability and frequency of adverse effects, teratogenicity, and maternal, neonatal, and pregnancy outcomes. The objective of this review is to summarize the underlying data that informs the current clinical perinatal guidelines in the USA. RECENT FINDINGS Data now supports the use of dolutegravir at all stages of pregnancy with no significant increase in neural tube defects. Safety and pharmacokinetic data on newer antiretroviral medications in pregnancy continue to lag behind the general population. While there are multiple safety and tolerability concerns with older regimens, there are now multiple options of regimens that are highly efficacious and have good safety data in pregnancy. Most pregnant patients who are virally suppressed on a well-tolerated regimen are able to safely continue those medications during pregnancy.
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Affiliation(s)
- Alison N Goulding
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Kasey Meeks
- School of Medicine, Saint Louis University, Saint Louis, MO, USA
| | - Lena Shay
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Sarah Casey
- School of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Colton Applegarth
- School of Medicine, University of California San Diego, San Diego, CA, USA
| | - Jennifer McKinney
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA.
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