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Hu L, Wu X, Peng J, Yan B, Li J, Guo Y, Han J. Subchronic oral toxic effects of 2,4-dinitroaniline in wistar rats: A comprehensive toxicity evaluation. Food Chem Toxicol 2024; 191:114846. [PMID: 38960084 DOI: 10.1016/j.fct.2024.114846] [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: 04/03/2024] [Revised: 06/21/2024] [Accepted: 06/29/2024] [Indexed: 07/05/2024]
Abstract
2,4-dinitroaniline (2,4-D), a widely used dye intermediate, is one of the typical pollutants, and its potential health risks and toxicity are still largely unknown. To explore its subchronic oral toxicity, Wistar rats (equal numbers of males and females) were used as test animals, and a 90-day oral dosing experiment was conducted, divided into control group, low-dose group (0.055 mg/kg), medium-dose group (0.22 mg/kg), medium-high dose group (0.89 mg/kg), and high-dose group (3.56 mg/kg). The body weight data, clinical appearance, and drug reactions of each test rat within 90 days of dosing were recorded; morning urine samples were collected four times to test for eight urinary indicators; blood samples were collected to test for nineteen hematological indicators and sixteen biochemical indicators; tissue samples were collected for pathological analysis; moreover, the no-observed-adverse-effect level (NOAEL) was determined, and the benchmark dose method was used to support this determination and provide a statistical estimate of the dose corresponding. The results indicated that the chronic toxicity of 2,4-dinitroaniline showed certain gender differences, with the eyes, liver, and kidneys being the main potential target organs of toxicity. Moreover, the subchronic oral NOAEL for 2,4-dinitroaniline was determined to be 0.22 mg/kg body weight (0.22 mg/kg for males and 0.89 mg/kg for females), and a preliminary calculation of the safe exposure limit for human was 0.136 mg/kg. The research results greatly enriched the safety evaluation data of 2,4-dinitroaniline, contributing to a robust scientific foundation for the development of informed safety regulations and public health precautions.
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Affiliation(s)
- Ling Hu
- Wuhan Science and Technology Center of Ecology and Environment, Wuhan 430015, China
| | - Xiaoxu Wu
- Wuhan Science and Technology Center of Ecology and Environment, Wuhan 430015, China
| | - Jinjin Peng
- Wuhan Science and Technology Center of Ecology and Environment, Wuhan 430015, China
| | - Biao Yan
- Xianning Medical College, Hubei University of Science and Technology, Xianning 437100, China; State Key Laboratory of Freshwater Ecology and Biotechnology, Institute of Hydrobiology, Chinese Academic of Sciences, Wuhan 430072, China.
| | - Jinquan Li
- Brain Science and Advanced Technology Institute, School of Medicine, Wuhan University of Science and Technology, Wuhan 430065, China
| | - Yongyong Guo
- State Key Laboratory of Freshwater Ecology and Biotechnology, Institute of Hydrobiology, Chinese Academic of Sciences, Wuhan 430072, China
| | - Jian Han
- State Key Laboratory of Freshwater Ecology and Biotechnology, Institute of Hydrobiology, Chinese Academic of Sciences, Wuhan 430072, China.
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Malin Igra A, Trask M, Rahman SM, Dreij K, Lindh C, Krais AM, Persson LÅ, Rahman A, Kippler M. Maternal exposure to polycyclic aromatic hydrocarbons during pregnancy and timing of pubertal onset in a longitudinal mother-child cohort in rural Bangladesh. ENVIRONMENT INTERNATIONAL 2024; 189:108798. [PMID: 38875814 DOI: 10.1016/j.envint.2024.108798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 05/06/2024] [Accepted: 05/31/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND In experimental studies, several polycyclic aromatic hydrocarbons (PAHs) have shown endocrine disrupting properties, but very few epidemiological studies have examined their impact on pubertal development and results have been heterogenous. OBJECTIVE To explore if maternal PAH exposure during pregnancy was associated with the offspring's timing of pubertal onset. METHODS We studied 582 mother-daughter dyads originating from a population-based cohort in a rural setting in Bangladesh. Maternal urinary samples, collected in early pregnancy (on average, gestational week 8), were analyzed for monohydroxylated metabolites of phenanthrene (1-OH-Phe, Σ2-,3-OH-Phe, and 4-OH-Phe), fluorene (Σ2-,3-OH-Flu), and pyrene (1-OH-Pyr) using liquid chromatography with tandem mass spectrometry (LC-MS/MS). The girls were interviewed on two separate occasions concerning date of menarche, as well as breast and pubic hair development according to Tanner. Associations were assessed using Kaplan-Meier analysis and multivariable-adjusted Cox proportional hazards regression or ordered logistic regression. RESULTS In early pregnancy, the mothers' median urinary concentrations of Σ1-,2-,3-,4-OH-Phe, Σ2-,3-OH-Flu, and 1-OH-Pyr were 3.25 ng/mL, 2.0 ng/mL, and 2.3 ng/mL respectively. At the second follow-up, 78 % of the girls had reached menarche, and the median age of menarche was 12.7 ± 0.81 years. Girls whose mothers belonged to the second and third quintiles of ΣOH-Phe metabolites had a higher rate of menarche, indicating a younger menarcheal age (HR 1.39; 95 % CI 1.04, 1.86, and HR 1.41; 95 % CI 1.05, 1.88, respectively), than girls of mothers in the lowest quintile. This trend was not observed in relation to either breast or pubic hair development. None of the other maternal urinary PAH metabolites or the sum of all thereof in early pregnancy were associated with age at menarche or pubertal stage. CONCLUSIONS Indications of non-monotonic associations of prenatal phenanthrene exposure with the daughters' age of menarche were found, warranting further investigation.
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Affiliation(s)
| | - Mercedes Trask
- Global Health and Migration Unit, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Syed Moshfiqur Rahman
- Global Health and Migration Unit, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Kristian Dreij
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Christian Lindh
- Department of Laboratory Medicine, Division of Occupational and Environmental Medicine, Lund University, Lund, Sweden
| | - Annette M Krais
- Department of Laboratory Medicine, Division of Occupational and Environmental Medicine, Lund University, Lund, Sweden
| | - Lars-Åke Persson
- Global Health and Migration Unit, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; London School of Hygiene and Tropical Medicine, London, UK
| | - Anisur Rahman
- Global Health and Migration Unit, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Maria Kippler
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
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Authement AK, Isoherranen N. The impact of pregnancy and associated hormones on the pharmacokinetics of Δ 9-tetrahydrocannabinol. Expert Opin Drug Metab Toxicol 2024; 20:73-93. [PMID: 38258511 DOI: 10.1080/17425255.2024.2309213] [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: 10/24/2023] [Accepted: 01/19/2024] [Indexed: 01/24/2024]
Abstract
INTRODUCTION (-)-Δ9-tetrahydrocannabinol (THC) is the main psychoactive component of cannabis. Cannabis is the most widely used drug of abuse by pregnant individuals, but its maternal-fetal safety is still unclear. The changes in THC disposition during pregnancy may affect THC safety and pharmacology. AREAS COVERED This review summarizes the current literature on THC metabolism and pharmacokinetics in humans. It provides an analysis of how hormonal changes during pregnancy may alter the expression of cannabinoid metabolizing enzymes and THC and its metabolite pharmacokinetics. THC is predominately (>70%) cleared by hepatic metabolism to its psychoactive active metabolite, 11-OH-THC by cytochrome P450 (CYP) 2C9 and to other metabolites (<30%) by CYP3A4. Other physiological processes that change during pregnancy and may alter cannabinoid disposition are also reviewed. EXPERT OPINION THC and its metabolites disposition likely change during pregnancy. Hepatic CYP2C9 and CYP3A4 are induced in pregnant individuals and in vitro by pregnancy hormones. This induction of CYP2C9 and CYP3A4 is predicted to lead to altered THC and 11-OH-THC disposition and pharmacodynamic effects. More in vitro studies of THC metabolism and induction of the enzymes metabolizing cannabinoids are necessary to improve the prediction of THC pharmacokinetics in pregnant individuals.
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Affiliation(s)
- Aurora K Authement
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, WA, USA
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Altan F, Cizmeci SU, Kose AM, Corum O, Uney K. Determination of temporal changes in hepatic drug-oxidizing capacity using plasma metabolite/caffeine ratios in non-pregnant and pregnant goats. J Vet Pharmacol Ther 2024; 47:28-35. [PMID: 37435998 DOI: 10.1111/jvp.13401] [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: 01/25/2023] [Revised: 06/20/2023] [Accepted: 06/29/2023] [Indexed: 07/13/2023]
Abstract
Caffeine (CF) is a metabolic probe drug used in the determination of the hepatic drug-oxidizing capacity. The aim of this study was to investigate temporal changes in the hepatic drug-oxidizing capacity using plasma metabolite/CF ratios in non-pregnant goats (n = 11) and pregnant goats (n = 23). CF (5 mg/kg, intravenous) was administered in six periods (Period 1-6) with 45 days between two periods. The plasma levels of CF and its metabolites, theophylline (TP), theobromine (TB) and paraxanthine (PX), were determined by HPLC-UV. To evaluate hepatic drug-oxidizing capacity in terms of enzymes that play a role in CF metabolism, the plasma metabolic ratios including TB/CF, PX/CF, TP/CF and TB + PX + TP/CF were determined at 10 h following CF administration. Plasma metabolite/CF ratios were similar between non-pregnant and pregnant goats. However, plasma metabolite/CF ratios in Period 3 (45 days in pregnant goats) were significantly higher than those other periods in both pregnant and non-pregnant goats. The effect of pregnancy may not be observed on drugs that are substrates of enzymes involved in CF metabolism in goats.
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Affiliation(s)
- Feray Altan
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Sakine Ulkum Cizmeci
- Department of Obstetrics and Gynecology, Faculty of Veterinary Medicine, Selcuk University, Konya, Turkey
| | - Ayse Merve Kose
- Department of Obstetrics and Gynecology, Faculty of Veterinary Medicine, Hatay Mustafa Kemal University, Hatay, Turkey
| | - Orhan Corum
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Hatay Mustafa Kemal University, Hatay, Turkey
| | - Kamil Uney
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Selcuk University, Konya, Turkey
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Merrill AK, Sobolewski M, Susiarjo M. Exposure to endocrine disrupting chemicals impacts immunological and metabolic status of women during pregnancy. Mol Cell Endocrinol 2023; 577:112031. [PMID: 37506868 PMCID: PMC10592265 DOI: 10.1016/j.mce.2023.112031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/12/2023] [Accepted: 07/24/2023] [Indexed: 07/30/2023]
Affiliation(s)
- Alyssa K Merrill
- Department of Environmental Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | - Marissa Sobolewski
- Department of Environmental Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | - Martha Susiarjo
- Department of Environmental Medicine, University of Rochester School of Medicine, Rochester, NY, USA.
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Coppola P, Butler A, Cole S, Kerwash E. Total and Free Blood and Plasma Concentration Changes in Pregnancy for Medicines Highly Bound to Plasma Proteins: Application of Physiologically Based Pharmacokinetic Modelling to Understand the Impact on Efficacy. Pharmaceutics 2023; 15:2455. [PMID: 37896215 PMCID: PMC10609738 DOI: 10.3390/pharmaceutics15102455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/27/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Free drug concentrations are generally considered the pharmacologically active moiety and are important for cellular diffusion and distribution. Pregnancy-related changes in plasma protein binding and blood partitioning are due to decreases in plasma albumin, alpha-1-acid glycoprotein, and haematocrit; this may lead to increased free concentrations, tissue distribution, and clearance during pregnancy. In this paper we highlight the importance and challenges of considering changes in total and free concentrations during pregnancy. For medicines highly bound to plasma proteins, such as tacrolimus, efavirenz, clindamycin, phenytoin, and carbamazepine, differential changes in concentrations of free drug during pregnancy may be clinically significant and have important implications for dose adjustment. Therapeutic drug monitoring usually relies on the measurement of total concentrations; this can result in dose adjustments that are not necessary when changes in free concentrations are considered. We explore the potential of physiologically based pharmacokinetic (PBPK) models to support the understanding of the changes in plasma proteins binding, using tacrolimus and efavirenz as example drug models. The exposure to either drug was predicted to be reduced during pregnancy; however, the decrease in the exposure to the total tacrolimus and efavirenz were significantly larger than the reduction in the exposure to the free drug. These data show that PBPK modelling can support the impact of the changes in plasma protein binding and may be used for the simulation of free concentrations in pregnancy to support dosing decisions.
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Rosen Vollmar AK, Rattray NJW, Cai Y, Jain A, Yan H, Deziel NC, Calafat AM, Wilcox AJ, Jukic AMZ, Johnson CH. Urinary Paraben Concentrations and Associations with the Periconceptional Urinary Metabolome: Untargeted and Targeted Metabolomics Analyses of Participants from the Early Pregnancy Study. ENVIRONMENTAL HEALTH PERSPECTIVES 2023; 131:97006. [PMID: 37702489 PMCID: PMC10498870 DOI: 10.1289/ehp12125] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 08/05/2023] [Accepted: 08/10/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Parabens, found in everyday items from personal care products to foods, are chemicals with endocrine-disrupting activity, which has been shown to influence reproductive function. OBJECTIVES This study investigated whether urinary concentrations of methylparaben, propylparaben, or butylparaben were associated with the urinary metabolome during the periconceptional period, a critical window for female reproductive function. Changes to the periconceptional urinary metabolome could provide insights into the mechanisms by which parabens could impact fertility. METHODS Urinary paraben concentrations were measured in paired pre- and postconception urine samples from 42 participants in the Early Pregnancy Study, a prospective cohort of 221 women attempting to conceive. We performed untargeted and targeted metabolomics analyses using ultrahigh-performance liquid chromatography quadrupole time-of-flight mass spectrometry. We used principal component analysis, orthogonal partial least-squares discriminant analysis, and permutation testing, coupled with univariate statistical analyses, to find metabolites associated with paraben concentration at the two time points. Potential confounders were identified with a directed acyclic graph and used to adjust results with multivariable linear regression. Metabolites were identified using fragmentation data. RESULTS Seven metabolites were associated with paraben concentration (variable importance to projection score > 1 , false discovery rate-corrected q -value < 0.1 ). We identified four diet-related metabolites to the Metabolomics Standards Initiative (MSI) certainty of identification level 2, including metabolites from smoke flavoring, grapes, and olive oil. One metabolite was identified to the class level only (MSI level 3). Two metabolites were unidentified (MSI level 4). After adjustment, three metabolites remained associated with methylparaben and propylparaben, two of which were diet-related. No metabolomic markers of endocrine disruption were associated with paraben concentrations. DISCUSSION This study identified novel relationships between urinary paraben concentrations and diet-related metabolites but not with metabolites on endocrine-disrupting pathways, as hypothesized. It demonstrates the feasibility of integrating untargeted metabolomics data with environmental exposure information and epidemiological adjustment for confounders. The findings underscore a potentially important connection between diet and paraben exposure, with applications to nutritional epidemiology and dietary exposure assessment. https://doi.org/10.1289/EHP12125.
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Affiliation(s)
- Ana K Rosen Vollmar
- Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Nicholas J W Rattray
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Yuping Cai
- Shanghai Institute of Organic Chemistry, Chinese Academy of Sciences, Shanghai, China
| | - Abhishek Jain
- Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Hong Yan
- Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Nicole C Deziel
- Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Antonia M Calafat
- Organic Analytical Toxicology Branch, National Center for Environmental Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Allen J Wilcox
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
| | - Anne Marie Z Jukic
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
| | - Caroline H Johnson
- Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut, USA
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Fashe MM, Miner TA, Fallon JK, Schauer AP, Sykes C, Smith PC, Lee CR. Pregnancy related hormones increase CYP3A mediated buprenorphine metabolism in human hepatocytes: a comparison to CYP3A substrates nifedipine and midazolam. Front Pharmacol 2023; 14:1218703. [PMID: 37475714 PMCID: PMC10354249 DOI: 10.3389/fphar.2023.1218703] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/22/2023] [Indexed: 07/22/2023] Open
Abstract
Introduction: Pregnancy increases the clearance of CYP3A4 substrate drugs and pregnancy-related hormones (PRHs) induce hepatic CYP3A4 expression and metabolism. However, it remains unclear to what extent the magnitude of PRH-evoked changes in hepatic CYP3A metabolism varies across multiple substrates. This study quantified the impact of PRHs on CYP3A protein concentrations and buprenorphine metabolism in human hepatocytes, and compared the magnitude of these effects to nifedipine and midazolam metabolism. Methods: Sandwich-cultured human hepatocytes (SCHH) from female donors were exposed to PRHs, administered in combination across a range of physiologically relevant concentrations, for 72 h. Absolute protein concentrations of CYP3A4, CYP3A5, and CYP3A7 in SCHH membrane fractions were quantified by nanoLC-MS/MS, and norbuprenorphine (nor-BUP), dehydro-nifedipine (dehydro-NIF), and 1-hydroxy-midazolam (1-OH-MDZ) formation was evaluated. Results: Compared to control, PRH exposure increased CYP3A4, CYP3A7, and total CYP3A protein concentrations, but not CYP3A5 concentrations, and increased nor-BUP, dehydro-NIF, and 1-OH-MDZ formation in a concentration-dependent manner. The formation of nor-BUP, dehydro-NIF, and 1-OH-MDZ each positively correlated with PRH-mediated changes in total CYP3A protein concentrations. The PRH-evoked increase in nor-BUP formation was evident in all donors; however, the PRH induction of dehydro-NIF and 1-OH-MDZ formation was diminished in a hepatocyte donor with high basal CYP3A5 expression. Discussion: These findings demonstrate that PRHs increase buprenorphine, nifedipine, and midazolam metabolism in SCHH via induction of CYP3A4 and total CYP3A protein concentrations, and the magnitude of these effects vary across hepatocyte donors in a substrate-specific manner. These data provide insight into the contribution of PRH induction of CYP3A4 metabolism to increased buprenorphine clearance during pregnancy.
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Affiliation(s)
- Muluneh M Fashe
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Taryn A Miner
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - John K Fallon
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Amanda P Schauer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Craig Sykes
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Philip C Smith
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Palmen R, Sandritter T, Malloy-Walton L, Follansbee C, Wagner JB. Case report: Use of therapeutic drug monitoring and pharmacogenetic testing as opportunities to individualize care in a case of flecainide toxicity after fetal supraventricular tachycardia. Front Pediatr 2023; 11:1168619. [PMID: 37449265 PMCID: PMC10337585 DOI: 10.3389/fped.2023.1168619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Flecainide is a class IC antiarrhythmic utilized in prophylaxis of refractory paroxysmal supraventricular tachycardias in pediatric populations. Despite being a highly effective agent, its narrow therapeutic index increases the risk of toxicity and proarrhythmic events, including wide-complex tachycardia. In the absence of direct plasma sampling in the fetus to quantitate flecainide systemic concentrations, clinicians typically make drug dosing decisions from maternal plasma concentrations and QRS duration on maternal ECGs. There remains a paucity of standard guidelines and data to inform the timing and frequency of the aforementioned test in pregnancy and timing of flecainide discontinuation prior to childbirth. Flecainide primarily undergoes metabolism via cytochrome P450 (CYP). Given the variance of CYP-mediated metabolism at the level of the individual patient, pharmacogenomics can be considered in patients who present with flecainide toxicity to determine the maternal vs. fetal factors as an etiology for the event. Finally, pharmacogenetic testing can be utilized as an adjunct to guide flecainide dosing decisions, but must be done with caution in neonates <2 weeks of age. This case report highlights utilization of pharmacogenomic testing and therapeutic drug monitoring as adjuncts to guide therapy for a newborn with refractory supraventricular tachycardia, who experienced flecainide toxicity immediately post-partum and was trialed unsuccessfully on multiple alternative antiarrhythmics without rhythm control.
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Affiliation(s)
- Ronald Palmen
- Children’s Mercy, Kansas City, MO, United States
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - Tracy Sandritter
- Children’s Mercy, Kansas City, MO, United States
- University of Missouri-Kansas City School of Pharmacy, Kansas City, MO, United States
| | - Lindsey Malloy-Walton
- Children’s Mercy, Kansas City, MO, United States
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
- Ward Family Heart Center, Kansas City, MO, United States
| | - Christopher Follansbee
- Children’s Mercy, Kansas City, MO, United States
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
- Ward Family Heart Center, Kansas City, MO, United States
| | - Jonathan B. Wagner
- Children’s Mercy, Kansas City, MO, United States
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
- Ward Family Heart Center, Kansas City, MO, United States
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Kansas City, MO, United States
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10
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Leong R, Grimstein M, DeMaria P, Norsworthy KJ, Fletcher EP, Shord S. Landscape and Regulatory Perspective on Oncology Drugs in Pregnancy. J Clin Pharmacol 2023; 63 Suppl 1:S170-S175. [PMID: 37317488 DOI: 10.1002/jcph.2224] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/21/2023] [Indexed: 06/16/2023]
Abstract
Cancers affecting pregnant women include breast cancer, melanoma, thyroid cancer, cervical cancer, lymphomas, and leukemias. The medical management of cancer during pregnancy with molecularly targeted oncology drugs remains quite challenging, with knowledge gaps about the drugs' safety and efficacy due to exclusion of pregnant women from cancer clinical trials, discontinuation of individuals who become pregnant during clinical trials, and limited information on appropriate dosing of molecularly targeted oncology drugs during pregnancy. Physiological changes occur during pregnancy and may result in alterations in the absorption, distribution, metabolism, and excretion of drugs used in pregnant women. Physiologically based pharmacokinetic modeling that incorporates physiological changes induced by both the cancer disease state and pregnancy has the potential to inform dosing of molecularly targeted oncology drugs for pregnant women, improve our understanding of the pharmacokinetic changes associated with pregnancy in patients with cancer, facilitate the design of potential studies of molecularly targeted oncology drugs in pregnant women to support dosing recommendations, and provide model-informed pharmacokinetic data to support regulatory decision making.
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Affiliation(s)
- Ruby Leong
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Manuela Grimstein
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Peter DeMaria
- Office of Oncologic Diseases, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Kelly J Norsworthy
- Office of Oncologic Diseases, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Elimika Pfuma Fletcher
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Stacy Shord
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
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11
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Marques L, Vale N. Prediction of CYP-Mediated Drug Interaction Using Physiologically Based Pharmacokinetic Modeling: A Case Study of Salbutamol and Fluvoxamine. Pharmaceutics 2023; 15:1586. [PMID: 37376035 DOI: 10.3390/pharmaceutics15061586] [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: 04/25/2023] [Revised: 05/15/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
Drug-drug interactions (DDIs) represent a significant concern in healthcare, particularly for patients undergoing polytherapy. DDIs can lead to a range of outcomes, from decreased therapeutic effectiveness to adverse effects. Salbutamol, a bronchodilator recommended for the treatment of respiratory diseases, is metabolized by cytochrome P450 (CYP) enzymes, which can be inhibited or induced by co-administered drugs. Studying DDIs involving salbutamol is crucial for optimizing drug therapy and preventing adverse outcomes. Here, we aimed to investigate CYP-mediated DDIs between salbutamol and fluvoxamine through in silico approaches. The physiologically based pharmacokinetic (PBPK) model of salbutamol was developed and validated using available clinical PK data, whereas the PBPK model of fluvoxamine was previously verified by GastroPlus. Salbutamol-fluvoxamine interaction was simulated according to different regimens and patient's characteristics (age and physiological status). The results demonstrated that co-administering salbutamol with fluvoxamine enhanced salbutamol exposure in certain situations, especially when fluvoxamine dosage increased. To sum up, this study demonstrated the utility of PBPK modeling in predicting CYP-mediated DDIs, making it a pioneer in PK DDI research. Furthermore, this study provided insights into the relevance of regular monitoring of patients taking multiple medications, regardless of their characteristics, to prevent adverse outcomes and for the optimization of the therapeutic regimen, in cases where the therapeutic benefit is no longer experienced.
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Affiliation(s)
- Lara Marques
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
- Faculty of Medicine, University of Coimbra, Azinhaga de Santa Comba, Celas, 3000-548 Coimbra, Portugal
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Nuno Vale
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Community Medicine, Health Information and Decision (MEDCIDS), Faculty of Medicine, University of Porto, Rua Dr. Plácido da Costa, 4200-450 Porto, Portugal
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12
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Kumari U, Sharma RK, Keshari JR, Sinha A. Environmental Exposure: Effect on Maternal Morbidity and Mortality and Neonatal Health. Cureus 2023; 15:e38548. [PMID: 37273345 PMCID: PMC10239284 DOI: 10.7759/cureus.38548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 06/06/2023] Open
Abstract
Environmental factors are important causes that impair global pregnancy outcomes and are, importantly, responsible for maternal morbidity and mortality. However, apart from the direct reasons for maternal deaths, mainly obstetric and neonatal complications, such factors are ignored or given less importance. The recent surge in research on the impact of various environmental factors on pregnancy outcomes suggests the need for immediate attention to such factors and device-specific policies to counter the situation. Moreover, the recent coronavirus disease of 2019 (COVID-19) pandemic, global warming, and climate change showed a lack of preparedness to counter the impact of such events on maternal survival and safe and successful pregnancy outcomes. In the present review, we have emphasized the specific factors responsible for increased maternal and neonatal deaths and their association with specific environmental factors. Increased attention on maternal healthcare, preparedness to counter sudden environmental challenges and improvement of the conventional requirement for better maternal healthcare access and nutrition at a global level may improve the scenario.
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Affiliation(s)
- Usha Kumari
- Biochemistry, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | | | - J R Keshari
- Biochemistery, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Archana Sinha
- Obstetrics and Gynaecology, Indira Gandhi Institute of Medical Sciences, Patna, IND
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13
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Nachega JB, Scarsi KK, Gandhi M, Scott RK, Mofenson LM, Archary M, Nachman S, Decloedt E, Geng EH, Wilson L, Rawat A, Mellors JW. Long-acting antiretrovirals and HIV treatment adherence. Lancet HIV 2023; 10:e332-e342. [PMID: 37062293 PMCID: PMC10734401 DOI: 10.1016/s2352-3018(23)00051-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/26/2023] [Accepted: 02/10/2023] [Indexed: 04/18/2023]
Abstract
Intramuscular injection of long-acting cabotegravir and rilpivirine is a novel, long-acting antiretroviral therapy (ART) combination approved for use as a fully suppressive regimen for people living with HIV. Long-acting cabotegravir with rilpivirine ART has reduced required dosing frequency from once daily to once every month or every 2 months injections. This new era of long-acting ART, which includes other antiretrovirals and formulations in various stages of clinical development, holds tremendous promise to change the standard of HIV treatment. Although long-acting ART has high potential to be revolutionary in the landscape of HIV care, prevention, and treatment cascade, more data are needed to substantiate its efficacy and cost-effectiveness among patients at risk of non-adherence and across age groups, pregnancy, and post partum. Advocacy efforts and policy changes to optimise a sustained, high-quality, equitable reach of long-acting ART, especially in low-income and middle-income countries where most people living with HIV reside, are needed to realise the full benefits of long-acting ART.
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Affiliation(s)
- Jean B Nachega
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA; Department of Infectious Diseases and Microbiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA; Center for Global Health, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA; Department of Epidemiology and Department International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, and Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Rachel K Scott
- MedStar Health Research Institute and MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC, USA
| | | | - Moherndran Archary
- Department of Pediatrics, King Edward VIII Hospital, University of Kwa Zulu Natal, Durban, South Africa
| | - Sharon Nachman
- Department of Pediatrics, Stony Brook Children's, SUNY Stony Brook University, Stony Brook, NY, USA
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elvin H Geng
- Division of Infectious Diseases, Department of Medicine, and Institute for Public Health, Washington University, St Louis, MO, USA
| | | | - Angeli Rawat
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; School of Population and Public Heath, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John W Mellors
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
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14
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Pizzi G, Mazzola SM, Pecile A, Bronzo V, Groppetti D. Tobacco Smoke Exposure in Pregnant Dogs: Maternal and Newborn Cotinine Levels: A Pilot Study. Vet Sci 2023; 10:vetsci10050321. [PMID: 37235404 DOI: 10.3390/vetsci10050321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/22/2023] [Accepted: 04/25/2023] [Indexed: 05/28/2023] Open
Abstract
Active and passive smoking in pregnant women is associated with perinatal morbidity and mortality risk, including abortion, preterm birth, low birthweight, and malformations. No data are available on intrauterine exposure to smoking during pregnancy in dogs. This study aimed to fill this gap by exploring the detectability and quantity of cotinine, the major metabolite of nicotine, in maternal (serum and hair) and newborn (amniotic fluid and hair) biospecimens collected at birth in dogs. For this purpose, twelve pregnant bitches, six exposed to the owner's smoke and six unexposed, were enrolled. A further six non-pregnant bitches exposed to passive smoke were included to investigate the role of pregnancy status on cotinine uptake. Exposed dogs, dams, and puppies had greater cotinine concentrations than unexposed ones. Although without statistical significance, serum and hair cotinine concentrations were higher in pregnant compared to non-pregnant bitches, suggesting a different sensitivity to tobacco smoke exposure during gestation. The present results provide evidence for cotinine transplacental passage in the dog. It is conceivable that fragile patients such as pregnant, lactating, and neonate dogs may be more susceptible to the harmful effects of second-hand smoke exposure. Owners should be sensitized to the risk of smoke exposure for their pets.
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Affiliation(s)
- Giulia Pizzi
- Department of Veterinary Medicine and Animal Sciences, Università degli Studi di Milano, 26900 Lodi, Italy
| | - Silvia Michela Mazzola
- Department of Veterinary Medicine and Animal Sciences, Università degli Studi di Milano, 26900 Lodi, Italy
| | - Alessandro Pecile
- Department of Veterinary Medicine and Animal Sciences, Università degli Studi di Milano, 26900 Lodi, Italy
| | - Valerio Bronzo
- Department of Veterinary Medicine and Animal Sciences, Università degli Studi di Milano, 26900 Lodi, Italy
| | - Debora Groppetti
- Department of Veterinary Medicine and Animal Sciences, Università degli Studi di Milano, 26900 Lodi, Italy
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15
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Methaneethorn J, Tengcharoen K, Leelakanok N, AlEjielat R. Population pharmacokinetics of doxorubicin: A systematic review. Asia Pac J Clin Oncol 2023; 19:9-26. [PMID: 35415961 DOI: 10.1111/ajco.13776] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 10/21/2021] [Accepted: 03/03/2022] [Indexed: 01/20/2023]
Abstract
Because of the high interindividual pharmacokinetic variability, several population pharmacokinetic (PopPK) models of doxorubicin (DOX) were developed to characterize factors influencing such variability. However, significant predictors for DOX pharmacokinetics identified using PopPK models varied across studies. Thus, this review aims to summarize PopPK models of DOX and its metabolites (if any) as well as significant covariates influencing DOX (and its metabolites) pharmacokinetic variability. A systematic search from PubMed, CINAHL Complete, Science Direct, and SCOPUS databases identified 503 studies. Of these, 16 studies met the inclusion criteria and were included in this review. DOX pharmacokinetics was described with two- or three-compartment models. Most studies found a significant increase in DOX clearance with an increase in body surface area from the median value of 1.8 m2 . Moreover, this review identified that while a 10-year increase in patient age resulted in a decrease in DOX clearance in adults and the elderly, younger children had lower DOX clearance compared to older children. Further, low DOX exposure was observed in pregnant women, and thus dosage adjustment is required. Concerning model applicability, predictive performance assessment of these published models should be performed before implementing such models in clinical practice.
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Affiliation(s)
- Janthima Methaneethorn
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand.,Center of Excellence for Environmental Health and Toxicology, Naresuan University, Phitsanulok, Thailand
| | - Kanokkan Tengcharoen
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Nattawut Leelakanok
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Burapha University, Sean Suk, Thailand
| | - Rowan AlEjielat
- Faculty of Pharmacy and Medical Sciences, University of Petra, Amman, Jordan
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16
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Shaaban S, Ji Y. Pharmacogenomics and health disparities, are we helping? Front Genet 2023; 14:1099541. [PMID: 36755573 PMCID: PMC9900000 DOI: 10.3389/fgene.2023.1099541] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/10/2023] [Indexed: 01/24/2023] Open
Abstract
Pharmacogenomics has been at the forefront of precision medicine during the last few decades. Precision medicine carries the potential of improving health outcomes at both the individual as well as population levels. To harness the benefits of its initiatives, careful dissection of existing health disparities as they relate to precision medicine is of paramount importance. Attempting to address the existing disparities at the early stages of design and implementation of these efforts is the only guarantee of a successful just outcome. In this review, we glance at a few determinants of existing health disparities as they intersect with pharmacogenomics research and implementation. In our opinion, highlighting these disparities is imperative for the purpose of researching meaningful solutions. Failing to identify, and hence address, these disparities in the context of the current and future precision medicine initiatives would leave an already strained health system, even more inundated with inequality.
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Affiliation(s)
- Sherin Shaaban
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah, United States,ARUP Laboratories, Salt Lake City, Utah, United States,*Correspondence: Sherin Shaaban,
| | - Yuan Ji
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah, United States,ARUP Laboratories, Salt Lake City, Utah, United States
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17
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Fashe MM, Fallon JK, Miner TA, Tiley JB, Smith PC, Lee CR. Impact of pregnancy related hormones on drug metabolizing enzyme and transport protein concentrations in human hepatocytes. Front Pharmacol 2022; 13:1004010. [PMID: 36210832 PMCID: PMC9532936 DOI: 10.3389/fphar.2022.1004010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
Pregnancy alters the disposition and exposure to multiple drugs indicated for pregnancy-related complications. Previous in vitro studies have shown that pregnancy-related hormones (PRHs) alter the expression and function of certain cytochrome P450s (CYPs) in human hepatocytes. However, the impact of PRHs on hepatic concentrations of non-CYP drug-metabolizing enzymes (DMEs) and transport proteins remain largely unknown. In this study, sandwich-cultured human hepatocytes (SCHH) from five female donors were exposed to vehicle or PRHs (estrone, estradiol, estriol, progesterone, cortisol, and placental growth hormone), administered individually or in combination, across a range of physiologically relevant PRH concentrations for 72 h. Absolute concentrations of 33 hepatic non-CYP DMEs and transport proteins were quantified in SCHH membrane fractions using a quantitative targeted absolute proteomics (QTAP) isotope dilution nanoLC-MS/MS method. The data revealed that PRHs altered the absolute protein concentration of various DMEs and transporters in a concentration-, isoform-, and hepatocyte donor-dependent manner. Overall, eight of 33 (24%) proteins exhibited a significant PRH-evoked net change in absolute protein concentration relative to vehicle control (ANOVA p < 0.05) across hepatocyte donors: 1/11 UGTs (9%; UGT1A4), 4/6 other DMEs (67%; CES1, CES2, FMO5, POR), and 3/16 transport proteins (19%; OAT2, OCT3, P-GP). An additional 8 (24%) proteins (UGT1A1, UGT2B4, UGT2B10, FMO3, OCT1, MRP2, MRP3, ENT1) exhibited significant PRH alterations in absolute protein concentration within at least two individual hepatocyte donors. In contrast, 17 (52%) proteins exhibited no discernable impact by PRHs either within or across hepatocyte donors. Collectively, these results provide the first comprehensive quantitative proteomic evaluation of PRH effects on non-CYP DMEs and transport proteins in SCHH and offer mechanistic insight into the altered disposition of drug substrates cleared by these pathways during pregnancy.
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Affiliation(s)
- Muluneh M. Fashe
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - John K. Fallon
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Taryn A. Miner
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Jacqueline B. Tiley
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Philip C. Smith
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Craig R. Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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18
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Gaylord A, Kannan K, Lakuleswaran M, Zhu H, Ghassabian A, Jacobson MH, Long S, Liu H, Afanasyeva Y, Kahn LG, Gu B, Liu M, Mehta-Lee SS, Brubaker SG, Trasande L. Variability and correlations of synthetic chemicals in urine from a New York City-based cohort of pregnant women. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2022; 309:119774. [PMID: 35841991 PMCID: PMC9600950 DOI: 10.1016/j.envpol.2022.119774] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 07/05/2022] [Accepted: 07/10/2022] [Indexed: 05/19/2023]
Abstract
Fetal exposure to environmental chemicals has been associated with adverse health outcomes in children and later into adulthood. While several studies have examined correlations and variability of non-persistent chemical exposures throughout pregnancy, many do not capture more recent exposures, particularly in New York City. Our goal was to characterize exposure to phthalates, bisphenols, polycyclic aromatic hydrocarbons, and organophosphate pesticides among pregnant women residing in New York City who enrolled in the New York University Children's Health and Environment Study (NYU CHES) between 2016 and 2018. We measured urinary chemical metabolite concentrations in 671 women at early, mid, and late pregnancy (median 10.8, 20.8, and 29.3 weeks, respectively). We calculated Spearman correlation coefficients among chemical concentrations at each measurement time point. We compared changes in population-level urinary metabolites at each stage using paired Wilcoxon signed-rank tests and calculated intraclass correlation coefficients (ICCs) to quantify intra-individual variability of metabolites across pregnancy. Geometric means and ICCs were compared to nine other pregnancy cohorts that recruited women in 2011 or later as well as nationally reported levels from women of child-bearing age. Compared with existing cohorts, women in NYU CHES had higher geometric means of organophosphate pesticides (Σdiethylphosphates = 28.7 nmol/g cr, Σdimethylphosphates = 57.3 nmol/g cr, Σdialkyl phosphates = 95.9 nmol/g cr), bisphenol S (0.56 μg/g cr), and 2-naphthalene (8.98 μg/g cr). Five PAH metabolites and two phthalate metabolites increased between early to mid and early to late pregnancy at the population level. Spearman correlation coefficients for chemical metabolites were generally below 0.50. Intra-individual exposures varied over time, as indicated by low ICCs (0.22-0.88, median = 0.38). However, these ICCs were often higher than those observed in other pregnancy cohorts. These results provide a general overview of the chemical metabolites measured in NYU CHES in comparison to other contemporary pregnancy cohorts and highlight directions for future studies.
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Affiliation(s)
- Abigail Gaylord
- Department of Population Health, New York University School of Medicine, New York, NY, USA.
| | - Kurunthachalam Kannan
- Department of Pediatrics, New York University School of Medicine, New York, NY, USA; Department of Environmental Medicine, New York University School of Medicine, New York, NY, USA
| | - Mathusa Lakuleswaran
- Department of Pediatrics, New York University School of Medicine, New York, NY, USA
| | - Hongkai Zhu
- Department of Pediatrics, New York University School of Medicine, New York, NY, USA
| | - Akhgar Ghassabian
- Department of Population Health, New York University School of Medicine, New York, NY, USA; Department of Pediatrics, New York University School of Medicine, New York, NY, USA; Department of Environmental Medicine, New York University School of Medicine, New York, NY, USA
| | - Melanie H Jacobson
- Department of Pediatrics, New York University School of Medicine, New York, NY, USA
| | - Sara Long
- Department of Pediatrics, New York University School of Medicine, New York, NY, USA
| | - Hongxiu Liu
- Department of Pediatrics, New York University School of Medicine, New York, NY, USA; Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430000, Hubei, PR China
| | - Yelena Afanasyeva
- Department of Population Health, New York University School of Medicine, New York, NY, USA; Department of Pediatrics, New York University School of Medicine, New York, NY, USA
| | - Linda G Kahn
- Department of Population Health, New York University School of Medicine, New York, NY, USA; Department of Pediatrics, New York University School of Medicine, New York, NY, USA
| | - Bo Gu
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Mengling Liu
- Department of Population Health, New York University School of Medicine, New York, NY, USA; Department of Environmental Medicine, New York University School of Medicine, New York, NY, USA
| | - Shilpi S Mehta-Lee
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
| | - Sara G Brubaker
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
| | - Leonardo Trasande
- Department of Population Health, New York University School of Medicine, New York, NY, USA; Department of Pediatrics, New York University School of Medicine, New York, NY, USA; Department of Environmental Medicine, New York University School of Medicine, New York, NY, USA; New York University Wagner School of Public Service, New York, NY, USA; New York University College of Global Public Health, New York, NY, USA
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19
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Sayaf K, Gabbia D, Russo FP, De Martin S. The Role of Sex in Acute and Chronic Liver Damage. Int J Mol Sci 2022; 23:ijms231810654. [PMID: 36142565 PMCID: PMC9505609 DOI: 10.3390/ijms231810654] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
Acute and chronic hepatic damages are caused by xenobiotics or different diseases affecting the liver, characterized by different etiologies and pathological features. It has been demonstrated extensively that liver damage progresses differently in men and women, and some chronic liver diseases show a more favorable prognosis in women than in men. This review aims to update the most recent advances in the comprehension of the molecular basis of the sex difference observed in both acute and chronic liver damage. With this purpose, we report experimental studies on animal models and clinical observations investigating both acute liver failure, e.g., drug-induced liver injury (DILI), and chronic liver diseases, e.g., viral hepatitis, alcoholic liver disease (ALD), non-alcoholic fatty liver disease (NAFLD), autoimmune liver diseases, and hepatocellular carcinoma (HCC).
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Affiliation(s)
- Katia Sayaf
- Department of Surgery, Oncology and Gastroenterology, University of Padova, 35131 Padova, Italy
| | - Daniela Gabbia
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, 35131 Padova, Italy
| | - Francesco Paolo Russo
- Department of Surgery, Oncology and Gastroenterology, University of Padova, 35131 Padova, Italy
- Gastroenterology and Multivisceral Transplant Units, Azienda Ospedale—Università di Padova, 35131 Padova, Italy
- Correspondence:
| | - Sara De Martin
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, 35131 Padova, Italy
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20
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Gebreyesus MS, Decloedt EH, Cluver CA, Hunfeld NGM, Helgadóttir H, Björnsson ES, Wasmann RE, Denti P. Population pharmacokinetics of esomeprazole in patients with preterm preeclampsia. Br J Clin Pharmacol 2022; 88:4639-4645. [PMID: 35599445 DOI: 10.1111/bcp.15416] [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: 02/21/2022] [Revised: 04/19/2022] [Accepted: 05/05/2022] [Indexed: 11/30/2022] Open
Abstract
Esomeprazole is a proton pump inhibitor being investigated for treatment of preeclampsia. Esomeprazole pharmacokinetics during pregnancy are unknown. We used data from 10 pregnant participants with preterm preeclampsia, and 49 non-pregnant participants to develop a population pharmacokinetic model of esomeprazole. A two-compartment model described the data well. In pregnant participants after single dose, clearance was 42.2% (14.9% - 61.6%) lower compared to non-pregnant, most likely due to inhibition of CYP2C19. In non-pregnant after repeated dosing, clearance was 54.9% (48.2% - 63.5%) lower in extensive metabolizers and bioavailability was 33% (10.0% - 52.0%) higher compared to single dosing, which could be due to autoinhibition of CYP2C19. During pregnancy, the CYP2C19 autoinhibition effect with repeated dosing is expected to lead to much lower increase in exposure compared to non-pregnant, since CYP2C19 is already inhibited due to pregnancy.
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Affiliation(s)
- Manna Semere Gebreyesus
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Stellenbosch, South Africa
| | - Catherine A Cluver
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Hospital, Stellenbosch, South Africa
| | - Nicole G M Hunfeld
- Department of Pharmacy and Intensive Care, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Hólmfríður Helgadóttir
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Einar S Björnsson
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Roeland E Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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21
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Le A, Huang KJ, Cirrincione LR. Regulation of drug-metabolizing enzymes by sex-related hormones: clinical implications for transgender medicine. Trends Pharmacol Sci 2022; 43:582-592. [PMID: 35487786 DOI: 10.1016/j.tips.2022.03.006] [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: 11/07/2021] [Revised: 03/11/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
Abstract
Transgender medicine is a diverse and growing clinical field with unmet gaps in pharmacological knowledge. Hormone therapy (testosterone or estrogen treatment), one part of the standard of medical care for transgender adults, aligns secondary sex characteristics with an individual's gender identity and expression. Despite established effects of sex steroids on drug-metabolizing enzyme expression and activity in vitro and in animal models, the effect of long-term, supraphysiological sex hormone treatment on drug metabolism in transgender adults is not yet established. Here, we synthesize available in vitro and animal model data with pharmacological concepts in transgender medicine to predict potential effects of sex steroids on drug-metabolizing enzymes, and their relationship with potential hormone-drug interactions, in transgender medicine.
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Affiliation(s)
- An Le
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kai J Huang
- Center for Transyouth Health and Development, Children's Hospital Los Angeles, Los Angeles, CA, USA
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22
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Momper JD, Wang J, Stek A, Shapiro DE, Powis KM, Paul ME, Badell ML, Browning R, Chakhtoura N, Denson K, Rungruengthanakit K, George K, Capparelli EV, Mirochnick M, Best BM. Pharmacokinetics of Atazanavir Boosted With Cobicistat in Pregnant and Postpartum Women With HIV. J Acquir Immune Defic Syndr 2022; 89:303-309. [PMID: 34732682 PMCID: PMC8837686 DOI: 10.1097/qai.0000000000002856] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/11/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study evaluated atazanavir and cobicistat pharmacokinetics during pregnancy compared with postpartum and in infant washout samples. SETTING A nonrandomized, open-label, parallel-group, multicenter prospective study of atazanavir and cobicistat pharmacokinetics in pregnant women with HIV and their children. METHODS Intensive steady-state 24-hour pharmacokinetic profiles were performed after administration of 300 mg of atazanavir and 150 mg of cobicistat orally in fixed-dose combination once daily during the second trimester, third trimester, and postpartum. Infant washout samples were collected after birth. Atazanavir and cobicistat were measured in plasma by validated high-performance liquid chromatography-ultraviolet and liquid chromatography-tandem mass spectrometry assays, respectively. A 2-tailed Wilcoxon signed-rank test (α = 0.10) was used for paired within-participant comparisons. RESULTS A total of 11 pregnant women enrolled in the study. Compared with paired postpartum data, atazanavir AUC0-24 was 26% lower in the second trimester [n = 5, P = 0.1875, geometric mean of ratio (GMR) = 0.739, 90% CI: 0.527 to 1.035] and 54% lower in the third trimester (n = 6, GMR = 0.459, P = 0.1563, 90% CI: 0.190 to 1.109), whereas cobicistat AUC0-24 was 35% lower in the second trimester (n = 5, P = 0.0625, GMR = 0.650, 90% CI: 0.493 to 0.858) and 52% lower in the third trimester (n = 7, P = 0.0156, GMR = 0.480, 90% CI: 0.299 to 0.772). The median (interquartile range) 24-hour atazanavir trough concentration was 0.21 μg/mL (0.16-0.28) in the second trimester, 0.21 μg/mL (0.11-0.56) in the third trimester, and 0.61 μg/mL (0.42-1.03) in postpartum. Placental transfer of atazanavir and cobicistat was limited. CONCLUSIONS Standard atazanavir/cobicistat dosing during pregnancy results in lower exposure which may increase the risk of virologic failure and perinatal transmission.
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Affiliation(s)
| | - Jiajia Wang
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alice Stek
- University of Southern California, Los Angeles, CA, USA
| | - David E. Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Kathleen M. Powis
- Departments of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Renee Browning
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Nahida Chakhtoura
- National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Kayla Denson
- Frontier Science & Technology Research Foundation, Inc, Amherst, NY, USA
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Eke AC. An update on the physiologic changes during pregnancy and their impact on drug pharmacokinetics and pharmacogenomics. J Basic Clin Physiol Pharmacol 2021; 33:581-598. [PMID: 34881531 DOI: 10.1515/jbcpp-2021-0312] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 11/21/2021] [Indexed: 01/23/2023]
Abstract
For many years, the medical community has relied in clinical practice on historic data about the physiological changes that occur during pregnancy. However, some newer studies have disputed a number of assumptions in these data for not being evidence-based or derived from large prospective cohort-studies. Accurate knowledge of these physiological changes is important for three reasons: Firstly, it facilitates correct diagnosis of diseases during pregnancy; secondly, it enables us to answer questions about the effects of medication during pregnancy and the ways in which pregnancy alters pharmacokinetic and drug-effects; and thirdly, it allows for proper modeling of physiologically-based pharmacokinetic models, which are increasingly used to predict gestation-specific changes and drug-drug interactions, as well as develop new knowledge on the mode-of-action of drugs, the mechanisms underlying their interactions, and any adverse effects following drug exposure. This paper reviews new evidence regarding the physiologic changes during pregnancy in relation to existing knowledge.
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Affiliation(s)
- Ahizechukwu C Eke
- Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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24
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Welch BM, Keil AP, Bommarito PA, van T' Erve TJ, Deterding LJ, Williams JG, Lih FB, Cantonwine DE, McElrath TF, Ferguson KK. Longitudinal exposure to consumer product chemicals and changes in plasma oxylipins in pregnant women. ENVIRONMENT INTERNATIONAL 2021; 157:106787. [PMID: 34314981 PMCID: PMC8490329 DOI: 10.1016/j.envint.2021.106787] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Exposure to consumer product chemicals during pregnancy may increase susceptibility to pregnancy disorders by influencing maternal inflammation. However, effects on specific inflammatory pathways have not been well characterized. Oxylipins are a diverse class of lipids that act as important mediators and biomarkers of several biological pathways that regulate inflammation. Adverse pregnancy outcomes have been associated with circulating oxylipin levels in pregnancy. In this study, we aimed to determine the longitudinal associations between plasma oxylipins and urinary biomarkers of three classes of consumer product chemicals among pregnant women. METHODS Data come from a study of 90 pregnant women nested within the LIFECODES cohort. Maternal plasma and urine were collected at three prenatal visits. Plasma was analyzed for 61 oxylipins, which were grouped according to biosynthetic pathways that we defined by upstream: 1) fatty acid precursor, including linoleic, arachidonic, docosahexaenoic, or eicosapentaenoic acid; and 2) enzyme pathway, including cyclooxygenase (COX), lipoxygenase (LOX), or cytochrome P450 (CYP). Urine was analyzed for 12 phenol, 12 phthalate, and 9 organophosphate ester (OPE) biomarkers. Linear mixed effect models were used for single-pollutant analyses. We implemented a novel extension of quantile g-computation for longitudinal data to examine the joint effect of class-specific chemical mixtures on individual plasma oxylipin concentrations. RESULTS We found that urinary biomarkers of consumer product chemicals were positively associated with pro-inflammatory oxylipins from several biosynthetic pathways. Importantly, these associations depended upon the chemical class of exposure biomarker. We estimated positive associations between urinary phenol biomarkers and oxylipins produced from arachidonic acid by LOX enzymes, including several important pro-inflammatory hydroxyeicosatetraenoic acids (HETEs). On average, mean concentrations of oxylipin produced from the arachidonic acid/LOX pathway were 48%-71% higher per quartile increase in the phenol biomarker mixture. For example, a simultaneous quartile increase in all urinary phenols was associated with 53% higher (95% confidence interval [CI]: 11%, 111%) concentrations of 12-HETE. The positive associations among phenols were primarily driven by methyl paraben, 2,5-dichlorophenol, and triclosan. Additionally, we observed that phthalate and OPE metabolites were associated with higher concentrations of oxylipins produced from linoleic acid by CYP enzymes, including the pro-inflammatory dihydroxy-octadecenoic acids (DiHOMEs). Associations among DiHOME oxylipins were driven by metabolites of benzylbutyl and di-isodecyl phthalate, and by the metabolite of tris(1,3-dichloro-2-propyl) phosphate among OPEs. We also observed inverse associations between phthalate and OPE metabolites and oxylipins produced from other pathways; however, adjusting for a plasma indicator of dietary fatty acid intake attenuated those results. CONCLUSIONS Our findings support the hypothesis that consumer product chemicals may have diverse impacts on inflammation processes in pregnancy. Certain pro-inflammatory oxylipins were generally higher among participants with higher urinary chemical biomarker concentrations. Associations varied by class of chemical and by the biosynthetic pathway of oxylipin production, indicating potential specificity in the inflammatory effects of these environmental chemicals during pregnancy that warrant investigation in larger studies.
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Affiliation(s)
- Barrett M Welch
- Epidemiology Branch, National Institute of Environmental Health Sciences (NIEHS), United States
| | - Alexander P Keil
- Epidemiology Branch, National Institute of Environmental Health Sciences (NIEHS), United States; Department of Epidemiology, University of North Carolina, United States
| | - Paige A Bommarito
- Epidemiology Branch, National Institute of Environmental Health Sciences (NIEHS), United States
| | | | | | - Jason G Williams
- Mass Spectrometry Research and Support Group, NIEHS, United States
| | - Fred B Lih
- Mass Spectrometry Research and Support Group, NIEHS, United States
| | - David E Cantonwine
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, United States
| | - Thomas F McElrath
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, United States
| | - Kelly K Ferguson
- Epidemiology Branch, National Institute of Environmental Health Sciences (NIEHS), United States.
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McBride GM, Meakin AS, Soo JY, Darby JRT, Varcoe TJ, Bradshaw EL, Lock MC, Holman SL, Saini BS, Macgowan CK, Seed M, Berry MJ, Wiese MD, Morrison JL. Intrauterine growth restriction alters the activity of drug metabolising enzymes in the maternal-placental-fetal unit. Life Sci 2021; 285:120016. [PMID: 34614415 DOI: 10.1016/j.lfs.2021.120016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/20/2021] [Accepted: 09/29/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE Ten percent of pregnancies are affected by intrauterine growth restriction (IUGR), and evidence suggests that affected neonates have reduced activity of hepatic cytochrome P450 (CYP) drug metabolising enzymes. Given that almost all pregnant individuals take medications and additional medications are often required during an IUGR pregnancy, we aimed to determine the impact of IUGR on hepatic CYP activity in sheep fetuses and pregnant ewes. METHODS Specific probes were used to determine the impact of IUGR on the activity of several CYP isoenzymes (CYP1A2, CYP2C19, CYP2D6 and CYP3A) in sheep fetuses and pregnant ewes. Probes were administered intravenously to the ewe at 132 days (d) gestation (term 150 d), followed by blood sampling from the maternal and fetal circulation over 24 h. Maternal and fetal liver tissue was collected at 139-140 d gestation, from which microsomes were isolated and incubated with probes. Metabolite and maternal plasma cortisol concentrations were measured using Liquid Chromatography - tandem mass spectrometry (LC-MS/MS). RESULTS Maternal plasma cortisol concentration and maternal hepatic CYP1A2 and CYP3A activity was significantly higher in IUGR pregnancies. Maternal hepatic CYP activity was higher than fetal hepatic CYP activity for all CYPs tested, and there was minimal CYP1A2 or CYP3A activity in the late gestation fetus when assessed using in vitro methods. CONCLUSIONS The physiological changes to the maternal-placental-fetal unit in an IUGR pregnancy have significant effects on maternal drug metabolism, suggesting changes in medications and/or doses may be required to optimise maternal and fetal health.
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Affiliation(s)
- Grace M McBride
- Early Origins of Adult Health Research Group, Australia; Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide 5000, Australia
| | - Ashley S Meakin
- Early Origins of Adult Health Research Group, Australia; Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide 5000, Australia
| | - Jia Yin Soo
- Early Origins of Adult Health Research Group, Australia; Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide 5000, Australia
| | - Jack R T Darby
- Early Origins of Adult Health Research Group, Australia; Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide 5000, Australia
| | - Tamara J Varcoe
- Early Origins of Adult Health Research Group, Australia; Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide 5000, Australia
| | - Emma L Bradshaw
- Early Origins of Adult Health Research Group, Australia; Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide 5000, Australia
| | - Mitchell C Lock
- Early Origins of Adult Health Research Group, Australia; Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide 5000, Australia
| | | | - Brahmdeep S Saini
- The Hospital for Sick Children and University of Toronto, Toronto M5G 1X8, Canada
| | | | - Mike Seed
- The Hospital for Sick Children and University of Toronto, Toronto M5G 1X8, Canada
| | - Mary J Berry
- University of Otago, Wellington, NZ 6242, New Zealand
| | - Michael D Wiese
- Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide 5000, Australia
| | - Janna L Morrison
- Early Origins of Adult Health Research Group, Australia; Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide 5000, Australia.
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Mulrenin IR, Garcia JE, Fashe MM, Loop MS, Daubert MA, Urrutia RP, Lee CR. The impact of pregnancy on antihypertensive drug metabolism and pharmacokinetics: current status and future directions. Expert Opin Drug Metab Toxicol 2021; 17:1261-1279. [PMID: 34739303 DOI: 10.1080/17425255.2021.2002845] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Hypertensive disorders of pregnancy (HDP) are rising in prevalence, and increase risk of adverse maternal and fetal outcomes. Physiologic changes occur during pregnancy that alter drug pharmacokinetics. However, antihypertensive drugs lack pregnancy-specific dosing recommendations due to critical knowledge gaps surrounding the extent of gestational changes in antihypertensive drug pharmacokinetics and underlying mechanisms. AREAS COVERED This review (1) summarizes currently recommended medications and dosing strategies for non-emergent HDP treatment, (2) reviews and synthesizes existing literature identified via a comprehensive Pubmed search evaluating gestational changes in the maternal pharmacokinetics of commonly prescribed HDP drugs (notably labetalol and nifedipine), and (3) offers insight into the metabolism and clearance mechanisms underlying altered HDP drug pharmacokinetics during pregnancy. Remaining knowledge gaps and future research directions are summarized. EXPERT OPINION A series of small pharmacokinetic studies illustrate higher oral clearance of labetalol and nifedipine during pregnancy. Pharmacokinetic modeling and preclinical studies suggest these effects are likely due to pregnancy-associated increases in hepatic UGT1A1- and CYP3A4-mediated first-pass metabolism and lower bioavailability. Accordingly, higher and/or more frequent doses may be needed to lower blood pressure during pregnancy. Future research is needed to address various evidence gaps and inform the development of more precise antihypertensive drug dosing strategies.
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Affiliation(s)
- Ian R Mulrenin
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Julian E Garcia
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Muluneh M Fashe
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Matthew Shane Loop
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Melissa A Daubert
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Rachel Peragallo Urrutia
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Patel SK, Valicherla GR, Micklo AC, Rohan LC. Drug delivery strategies for management of women's health issues in the upper genital tract. Adv Drug Deliv Rev 2021; 177:113955. [PMID: 34481034 DOI: 10.1016/j.addr.2021.113955] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/23/2021] [Accepted: 08/28/2021] [Indexed: 02/08/2023]
Abstract
The female upper genital tract (UGT) hosts important reproductive organs including the cervix, uterus, fallopian tubes, and ovaries. Several pathologies affect these organ systems such as infections, reproductive issues, structural abnormalities, cancer, and inflammatory diseases that could have significant impact on women's overall health. Effective disease management is constrained by the multifaceted nature of the UGT, complex anatomy and a dynamic physiological environment. Development of drug delivery strategies that can overcome mucosal and safety barriers are needed for effective disease management. This review introduces the anatomy, physiology, and mucosal properties of the UGT and describes drug delivery barriers, advances in drug delivery technologies, and opportunities available for new technologies that target the UGT.
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Kamath P, Kamath A, Ullal SD. Liver injury associated with drug intake during pregnancy. World J Hepatol 2021; 13:747-762. [PMID: 34367496 PMCID: PMC8326163 DOI: 10.4254/wjh.v13.i7.747] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/14/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
Drug use during pregnancy is not common. Drug-induced liver injury (DILI) is a potential complication that is rare but can adversely affect both the mother and the fetus. Although many drugs can directly cause hepatotoxicity, idiosyncratic liver injury is common in pregnancy. Underreporting of adverse drug reactions, lack of adequate literature regarding drug safety in pregnancy, and the inherent difficulty in diagnosing DILI during pregnancy make the management of this condition challenging. This review attempts to describe the existing literature regarding DILI in pregnancy, which is mainly in the form of case reports; several studies have looked at the safety of antithyroid drugs, antiretroviral drugs, and paracetamol, which have an indication for use in pregnancy; the relevant data from these studies with regard to DILI has been presented. In addition, the review describes the diagnosis of DILI, grading the disease severity, assessment of causality linking the drug to the adverse event, regulatory guidelines for evaluating the potential of drugs to cause liver injury, efforts to ensure better participation of women in clinical trials and studies in pregnant women population in particular, and the challenges involved in generating adequate research evidence. The establishment of DILI registries in various countries is an encouraging development; however, there is a need for promoting active, spontaneous reporting of adverse events during pregnancy to ensure rapid generation of evidence regarding the safety of a drug in pregnant women.
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Affiliation(s)
- Priyanka Kamath
- Department of Pharmacology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India - 575001
| | - Ashwin Kamath
- Department of Pharmacology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India - 575001
| | - Sheetal D Ullal
- Department of Pharmacology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India - 575001
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Abstract
BACKGROUND In the United States, drug addiction has become a nationwide health crisis. Recently, buprenorphine (BUP), a maintenance therapy approved by the Food and Drug Administration, has been increasingly used in pregnant women for the treatment of opioid use disorder. Pregnancy is associated with various anatomic and physiological changes, which may result in altered drug pharmacokinetics (PKs). Previously, we reported that dose-adjusted plasma concentrations of BUP are lower during pregnancy than after pregnancy. The mechanism(s) responsible for this difference has not yet been defined. Our study aimed to evaluate alterations in cytochromes P450 (CYP)- and uridine diphosphate glucunosyltransferases (UGT)-mediated metabolism of BUP during pregnancy to determine the mechanism(s) responsible for this observation. METHODS Data from 2 clinical studies were included in the current analysis. Study 1 was a prospective, open-labeled, nonrandomized longitudinal BUP PK study in pregnant women with a singleton gestation, stabilized on twice-daily sublingual BUP opioid substitution therapy. Each subject participated in up to 3 studies during and after pregnancy (the second, third trimester, and postpartum). The design of study 2 was similar to study 1, with patients evaluated at different time points during the pregnancy (first, second-half of pregnancy), as well as during the postpartum period. In addition, the dosing frequency of BUP study 2 participants was not restricted to twice-daily dosing. At each study visit, blood samples were collected before a BUP dose, followed by multiple collection times (10-12) after the dose, for up to 12 hours or till the end of the dosing interval. Plasma concentrations of BUP and 3 metabolites were quantified using validated ultraperformance liquid chromatography-tandem mass spectrometric assays. RESULTS In total, 19, 18, and 14 subjects completed the PK study during 1/2 trimester, third trimester, and postpartum, respectively. The AUC ratios of norbuprenorphine and norbuprenorphine glucuronide to buprenorphine, a measure of CYP3A mediated N-demethylation, were 1.89, 1.84, and 1.33 during the first and second, third trimesters, and postpartum, respectively. The AUC ratios of buprenorphine glucuronide to BUP, indicative of UGT activity, were 0.71, 2.07, and 0.3 at first/second trimesters, third trimester, and postpartum, respectively. Linear mixed-effect modeling analysis indicated that the AUC ratios of CYP- and UGT-mediated metabolism of BUP were significantly higher during pregnancy compared with postpartum. CONCLUSIONS The CYP and UGT activities were significantly increased as determined by the metabolic ratios of BUP during pregnancy compared with the postpartum period. The increased UGT activity appeared to account for a substantial part of the observed change in metabolic activity during pregnancy. This is in agreement with the need for BUP dose increment in pregnant women to reach similar BUP exposure and therapeutic effect as in nonpregnant subjects.
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Abstract
During pregnancy, there are several physiological changes during each trimester that can affect the absorption, distribution, metabolism, and elimination of drugs. Although there is a potential need to understand the pharmacokinetics and pharmacodynamics of drugs in pregnant patients, therapeutic drug monitoring is not well established for various drug classes due to ethical and safety concerns regarding the neonate. Potential risks from in utero drug exposure to the fetus may impact growth and development and may cause malformations or teratogenesis. The clinician must consider the benefits of drug treatment for the pregnant mother versus the risk to the fetus, before prescribing medications during pregnancy. The objective of this review is to aid clinicians, pharmacists, and laboratorians in understanding the pharmacokinetic and pharmacodynamic changes during pregnancy, to provide drug class recommendations for monitoring therapy throughout pregnancy via therapeutic drug monitoring, and to highlight the recent directives of governing agencies on maternal and fetal health.
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Mangold JF, Goswami R, Nelson AN, Martinez DR, Fouda GG, Permar SR. Maternal Intervention to Prevent Mother-to-Child Transmission of HIV: Moving Beyond Antiretroviral Therapy. Pediatr Infect Dis J 2021; 40:S5-S10. [PMID: 34042904 PMCID: PMC9215267 DOI: 10.1097/inf.0000000000002774] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Widespread availability of antiretroviral therapy among pregnant women living with HIV has greatly reduced the rate of mother-to-child transmission (MTCT) of HIV across the globe. However, while Joint United Nations Programme on HIV/AIDS has set targets to reduce the annual number of new pediatric HIV infections to fewer than 40,000 in 2018 and fewer than 20,000 in 2020, progress towards these targets has plateaued at an unacceptably high global estimate of greater than 160,000 children newly infected with HIV in 2018. Moreover, it has become clear that expansion of maternal antiretroviral therapy alone will not be sufficient to close the remaining gap and eliminate MTCT of HIV. Additional strategies such as maternal or infant passive and/or active immunization that synergize with maternal antiretroviral therapy will be required to end the pediatric HIV epidemic. In this review, we outline the landscape of existing maternal interventions and emerging maternal immune-based approaches to prevent MTCT of HIV.
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Affiliation(s)
- Jesse F. Mangold
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
| | - Ria Goswami
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
| | - Ashley N. Nelson
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
| | - David R. Martinez
- Department of Epidemiology, University of North Carolina at Chapel Hill School of Global Public Health, Chapel Hill, NC, USA
| | - Genevieve G. Fouda
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Sallie R. Permar
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
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Khatri R, Fallon JK, Sykes C, Kulick N, Rementer RJB, Miner TA, Schauer AP, Kashuba ADM, Boggess KA, Brouwer KLR, Smith PC, Lee CR. Pregnancy-Related Hormones Increase UGT1A1-Mediated Labetalol Metabolism in Human Hepatocytes. Front Pharmacol 2021; 12:655320. [PMID: 33995076 PMCID: PMC8115026 DOI: 10.3389/fphar.2021.655320] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/11/2021] [Indexed: 11/25/2022] Open
Abstract
Pregnancy-related hormones (PRH) are recognized as important regulators of hepatic cytochrome P450 enzyme expression and function. However, the impact of PRH on the hepatic expression and function of uridine diphosphate glucuronosyltransferases (UGTs) remains unclear. Using primary human hepatocytes, we evaluated the effect of PRH exposure on mRNA levels and protein concentrations of UGT1A1, UGT2B7, and other key UGT enzymes, and on the metabolism of labetalol (a UGT1A1 and UGT2B7 substrate commonly prescribed to treat hypertensive disorders of pregnancy). Sandwich-cultured human hepatocytes (SCHH) from female donors were exposed to the PRH estradiol, estriol, estetrol, progesterone, and cortisol individually or in combination. We quantified protein concentrations of UGT1A1, UGT2B7, and four additional UGT1A isoforms in SCHH membrane fractions and evaluated the metabolism of labetalol to its glucuronide metabolites in SCHH. PRH exposure increased mRNA levels and protein concentrations of UGT1A1 and UGT1A4 in SCHH. PRH exposure also significantly increased labetalol metabolism to its UGT1A1-derived glucuronide metabolite in a concentration-dependent manner, which positively correlated with PRH-induced changes in UGT1A1 protein concentrations. In contrast, PRH did not alter UGT2B7 mRNA levels or protein concentrations in SCHH, and formation of the UGT2B7-derived labetalol glucuronide metabolite was decreased following PRH exposure. Our findings demonstrate that PRH alter expression and function of UGT proteins in an isoform-specific manner and increase UGT1A1-mediated labetalol metabolism in human hepatocytes by inducing UGT1A1 protein concentrations. These results provide mechanistic insight into the increases in labetalol clearance observed in pregnant individuals.
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Affiliation(s)
- Raju Khatri
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - John K. Fallon
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Craig Sykes
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Natasha Kulick
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Rebecca J. B. Rementer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Taryn A. Miner
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Amanda P. Schauer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Angela D. M. Kashuba
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Kim A. Boggess
- Department of Obstetrics and Gynecology, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Kim L. R. Brouwer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Philip C. Smith
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Craig R. Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Gausi K, Wiesner L, Norman J, Wallis CL, Onyango‐Makumbi C, Chipato T, Haas DW, Browning R, Chakhtoura N, Montepiedra G, Aaron L, McCarthy K, Bradford S, Vhembo T, Stranix‐Chibanda L, Masheto GR, Violari A, Mmbaga BT, Aurpibul L, Bhosale R, Nevrekhar N, Rouzier V, Kabugho E, Mutambanengwe M, Chanaiwa V, Nyati M, Mhembere T, Tongprasert F, Hesseling A, Shin K, Zimmer B, Costello D, Jean‐Philippe P, Sterling TR, Theron G, Weinberg A, Gupta A, Denti P. Pharmacokinetics and Drug-Drug Interactions of Isoniazid and Efavirenz in Pregnant Women Living With HIV in High TB Incidence Settings: Importance of Genotyping. Clin Pharmacol Ther 2021; 109:1034-1044. [PMID: 32909316 PMCID: PMC8048881 DOI: 10.1002/cpt.2044] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 08/30/2020] [Indexed: 01/11/2023]
Abstract
The World Health Organization guidelines recommend that individuals living with HIV receive ≥ 6 months of isoniazid preventive therapy, including pregnant women. Yet, plasma isoniazid exposure during pregnancy, in the antiretroviral therapy era, has not been well-described. We investigated pregnancy-induced and pharmacogenetic-associated pharmacokinetic changes and drug-drug interactions between isoniazid and efavirenz in pregnant women. Eight hundred forty-seven women received isoniazid for 28 weeks, either during pregnancy or at 12 weeks postpartum, and 786 women received efavirenz. After adjusting for NAT2 and CYP2B6 genotype and weight, pregnancy increased isoniazid and efavirenz clearance by 26% and 15%, respectively. Isoniazid decreased efavirenz clearance by 7% in CYP2B6 normal metabolizers and 13% in slow and intermediate metabolizers. Overall, both isoniazid and efavirenz exposures were reduced during pregnancy, but the main determinants of drug concentration were NAT2 and CYP2B6 genotypes, which resulted in a five-fold difference for both drugs between rapid and slow metabolizers.
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Affiliation(s)
- Kamunkhwala Gausi
- Division of Clinical PharmacologyDepartment of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Lubbe Wiesner
- Division of Clinical PharmacologyDepartment of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Jennifer Norman
- Division of Clinical PharmacologyDepartment of MedicineUniversity of Cape TownCape TownSouth Africa
| | | | | | - Tsungai Chipato
- Department of Obstetrics and GynaecologyUniversity of Zimbabwe College of Health SciencesHarareZimbabwe
| | - David W. Haas
- Departments of Medicine, Pharmacology, Pathology, Microbiology, and ImmunologyVanderbilt University School of MedicineNashvilleTennesseeUSA,Department of Internal MedicineMeharry Medical CollegeNashvilleTennesseeUSA
| | - Renee Browning
- Division of AIDSNational Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMarylandUSA
| | - Nahida Chakhtoura
- National Institutes of Health (NIH), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)BethesdaMarylandUSA
| | - Grace Montepiedra
- Center for Biostatistics in AIDS ResearchHarvard T. H. Chan School of Public HealthBostonMassachusettsUSA
| | - Lisa Aaron
- Center for Biostatistics in AIDS ResearchHarvard T. H. Chan School of Public HealthBostonMassachusettsUSA
| | | | | | - Tichaona Vhembo
- Department of Obstetrics and GynaecologyUniversity of Zimbabwe College of Health SciencesHarareZimbabwe
| | - Lynda Stranix‐Chibanda
- Department of Obstetrics and GynaecologyUniversity of Zimbabwe College of Health SciencesHarareZimbabwe
| | | | - Avy Violari
- The Perinatal HIV Research UnitUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | - Linda Aurpibul
- Research Institute for Health SciencesChiang Mai UniversityChiang MaiThailand
| | | | - Neetal Nevrekhar
- Byramjee Jeejeebhoy Government College–Johns Hopkins Clinical Research SitePuneIndia
| | - Vanessa Rouzier
- Weill Cornell Center for Global Health New YorkNew YorkNew YorkUSA,Centres GHESKIOPort‐au‐PrinceHaiti
| | | | - Mercy Mutambanengwe
- University of Zimbabwe College of Health Sciences Clinical Trials Research CentreHarareZimbabwe
| | - Vongai Chanaiwa
- University of Zimbabwe College of Health Sciences Clinical Trials Research CentreHarareZimbabwe
| | - Mandisa Nyati
- Perinatal HIV Research UnitUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Tsungai Mhembere
- University of Zimbabwe College of Health Sciences Clinical Trials Research CentreHarareZimbabwe
| | - Fuanglada Tongprasert
- Department of Obstetrics and GynecologyFaculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Anneke Hesseling
- Department of Paediatrics and Child HealthThe Desmond Tutu TB CenterStellenbosch UniversityTygerbergSouth Africa
| | - Katherine Shin
- Division of AIDSNational Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMarylandUSA
| | | | | | - Patrick Jean‐Philippe
- Division of AIDSNational Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMarylandUSA
| | - Timothy R. Sterling
- Vanderbilt Tuberculosis CenterVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Gerhard Theron
- Department of Obstetrics and GynaecologyStellenbosch UniversityCape TownSouth Africa
| | - Adriana Weinberg
- University of Colorado Denver Anschutz Medical CampusAuroraColoradoUSA
| | - Amita Gupta
- Johns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Paolo Denti
- Division of Clinical PharmacologyDepartment of MedicineUniversity of Cape TownCape TownSouth Africa
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Sertraline concentrations in pregnant women are steady and the drug transfer to their infants is low. Eur J Clin Pharmacol 2021; 77:1323-1331. [PMID: 33751155 PMCID: PMC8346399 DOI: 10.1007/s00228-021-03122-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/09/2021] [Indexed: 01/30/2023]
Abstract
Purpose Sertraline, a selective serotonin reuptake inhibitor (SSRI), is one of the most commonly used antidepressant during pregnancy. Plasma sertraline concentrations vary markedly between individuals, partly explained by variability in hepatic drug metabolizing cytochrome P450-enzyme activity. Our purpose was to study the variability in the plasma concentrations in pregnant women and the passage to their infants. Method Pregnant women with moderate untreated depression were recruited in 2016–2019 in Stockholm Region and randomized to treatment with sertraline or placebo. All received Internet-based cognitive behavior therapy as non-medical treatment. Sertraline plasma concentrations were measured around pregnancy weeks 21 and 30, at delivery, 1-month postpartum, in cord blood and at 48 h of age in the infant. The clinical course of the infants was followed. Results Nine mothers and 7 infants were included in the analysis. Median dose-adjusted sertraline concentration in second trimester was 0.15(ng/mL) /(mg/day), in third trimester and at delivery 0.19 and 1-month postpartum 0.25, with a 67% relative difference between second trimester and postpartum. The interindividual variation was 10-fold. Median concentrations in the infants were 33% and 25% of their mothers’, measured in cord blood, and infant plasma, respectively. Only mild and transient adverse effects were seen on the infants. Conclusion Placental passage of sertraline to the infant is low. However, the interindividual variation in maternal concentrations during pregnancy is huge, why therapeutic drug monitoring might assist in finding the poor metabolizers at risk for adversity and increase the safety of the treatment. Trial registration The trial was registered at clinicaltrials.gov July 9, 2014 with TRN: NCT02185547. Supplementary Information The online version contains supplementary material available at 10.1007/s00228-021-03122-z.
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Influence of selected polymorphisms in disposition genes on lumefantrine pharmacokinetics when coadministered with efavirenz. Pharmacogenet Genomics 2021; 30:96-106. [PMID: 32209837 DOI: 10.1097/fpc.0000000000000401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Coadministration of artemether-lumefantrine and efavirenz has been shown to result in significant interactions. The influence of functional genetic polymorphisms in selected CYPs on the magnitude of this interaction was investigated in pregnant and nonpregnant adults. METHOD A standard 3-day regimen of artemether-lumefantrine was administered to each patient on steady-state efavirenz-based antiretroviral therapy (ART). Pharmacokinetic parameters were obtained from intensive plasma concentration-time data. Genotyping data were tested for compliance with Hardy-Weinberg equilibrium by Chi-square test. Linear regressions, Mann-Whitney U-test or Kruskal-Wallis tests were conducted to examine the association of lumefantrine plasma level with CYP2B6 c.516G>T, NR1I3 152c-1089T>C, CYP2B6 c.983T>C, CYP3A5*3 and CYP3A4*22. RESULTS Among a total of 69 malaria-HIV coinfected patients (34 nonpregnant and 35 pregnant), median (interquartile range) age was 33 (27-36.5) years and body weight was 59.5 (50-67.5) kg. In nonpregnant group, CYP2B6 c.516G>T was significantly associated with lower log Cday 7 of lumefantrine using multivariate linear regressions (β = -0.239; P = 0.013). In 59% of women with CYP2B6 c.516T, Cday 7 of lumefantrine was below the target of 280 ng/mL compared to 47% in the noncarriers. CYP2B6 c.983T>C significantly associated with higher log Cday 7 of desbutyl lumefantrine in both pregnant (β = 0.383; P = 0.033) and nonpregnant (β = 0.395; P = 0.023) groups. Composite genotypes for both CYP2B6 Single-nucleotide polymorphisms strongly associated with lumefantrine plasma concentration. An associative trend between lumefantrine pharmacokinetics and NR1I3 152c-1089T>C genotypes indicated that 70% of the Cday 7 of lumefantrine in those with NR1I3 152c-1089TT genotype was below 280 ng/mL compared to 53% in those with NR1I3 152c-1089CC or CT genotype. CONCLUSION The findings revealed that the efavirenz-lumefantrine interaction was accentuated in the group with CYP2B6 c.516T, c.983C and NR1I3 152c-1089T alleles. This warrants further investigations of other drug-drug interactions for optimising dosing in genetically defined subgroups, particularly during drug development.
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Coppola P, Kerwash E, Cole S. Physiologically Based Pharmacokinetics Model in Pregnancy: A Regulatory Perspective on Model Evaluation. Front Pediatr 2021; 9:687978. [PMID: 34249817 PMCID: PMC8262675 DOI: 10.3389/fped.2021.687978] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/10/2021] [Indexed: 11/13/2022] Open
Abstract
Physiologically based pharmacokinetics (PBPK) modelling is widely used in medicine development and regulatory submissions. The lack of clinical pharmacokinetic data in pregnancy is widely acknowledged; therefore, one area of current interest is in the use of PBPK modelling to describe the potential impact of anatomical and physiological changes during pregnancy on the medicine's pharmacokinetics. PBPK modelling could possibly represent a predictive tool to support the medicine benefit-risk decision and inform dose adjustment in this population and also to investigate medicine levels in the foetus to support the risk assessment to the foetus. In the context of regulatory application, there are, however, a number of considerations around model evaluation, and this should be tailored to the model purpose, in order to inform the confidence in the model for the intended application. A number of gestational age-related physiological changes are expected to alter the pharmacokinetics of medicines during pregnancy, and there are uncertainties on some parameters; therefore, well-qualified models are needed to improve assurance in the model prediction before this approach can be used to inform with confidence high-impact decisions as part of regulatory submissions.
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Affiliation(s)
- Paola Coppola
- Medicines and Healthcare Products Regulatory Agency, London, United Kingdom
| | - Essam Kerwash
- Medicines and Healthcare Products Regulatory Agency, London, United Kingdom
| | - Susan Cole
- Medicines and Healthcare Products Regulatory Agency, London, United Kingdom
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Chaphekar N, Dodeja P, Shaik IH, Caritis S, Venkataramanan R. Maternal-Fetal Pharmacology of Drugs: A Review of Current Status of the Application of Physiologically Based Pharmacokinetic Models. Front Pediatr 2021; 9:733823. [PMID: 34805038 PMCID: PMC8596611 DOI: 10.3389/fped.2021.733823] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/16/2021] [Indexed: 12/31/2022] Open
Abstract
Pregnancy and the postpartum period are associated with several physiological changes that can alter the pharmacokinetics (PK) and pharmacodynamics (PD) of drugs. For certain drugs, dosing changes may be required during pregnancy and postpartum to achieve drug exposures comparable to what is observed in non-pregnant subjects. There is very limited data on fetal exposure of drugs during pregnancy, and neonatal exposure through transfer of drugs via human milk during breastfeeding. Very few systematic clinical pharmacology studies have been conducted in pregnant and postpartum women due to ethical issues, concern for the fetus safety as well as potential legal ramifications. Over the past several years, there has been an increase in the application of modeling and simulation approaches such as population PK (PopPK) and physiologically based PK (PBPK) modeling to provide guidance on drug dosing in those special patient populations. Population PK models rely on measured PK data, whereas physiologically based PK models incorporate physiological, preclinical, and clinical data into the model to predict drug exposure during pregnancy. These modeling strategies offer a promising approach to identify the drugs with PK changes during pregnancy to guide dose optimization in pregnancy, when there is lack of clinical data. PBPK modeling is also utilized to predict the fetal exposure of drugs and drug transfer via human milk following maternal exposure. This review focuses on the current status of the application of PBPK modeling to predict maternal and fetal exposure of drugs and thereby guide drug therapy during pregnancy.
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Affiliation(s)
- Nupur Chaphekar
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States
| | - Prerna Dodeja
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States
| | - Imam H Shaik
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States
| | - Steve Caritis
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee Women's Hospital of UPMC, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Obstetrics, Gynecology and Reproductive Sciences, Magee Women's Hospital of UPMC, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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Seeman MV. The Pharmacodynamics of Antipsychotic Drugs in Women and Men. Front Psychiatry 2021; 12:650904. [PMID: 33897500 PMCID: PMC8062799 DOI: 10.3389/fpsyt.2021.650904] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/16/2021] [Indexed: 12/31/2022] Open
Abstract
Background: Animal and human experiments have confirmed sex differences in the expression of hepatic enzymes that metabolize antipsychotic drugs and that may, in this way, be partly responsible for the clinical sex/gender differences observed in the efficacy and tolerability of antipsychotic treatment. Aim: The aim of this mini review is to synthesize the literature on the pharmacodynamics of male/female differential response to antipsychotic drugs. Method: Relevant search terms were used to search for pre-clinical and human trials and analysis of antipsychotic differential drug response and occurrence/severity of adverse effects in women and men. Results: The search found that sex influences drug response via the amount of a given drug that enters the brain and the number of neurotransmitter receptors to which it can bind. Consequently, sex partly determines the efficacy of a specific drug and its liability to induce unwanted effects. There are other factors that can overshadow or enhance the dimorphic effect of sex, for instance, the host's age, hormonal status, diet and life style as well as the molecular structure of the drug and its dose, and the method of its administration. Most of all, the host's individual genetics affects each step of a drug's pharmacodynamics. Conclusion: On average, women's psychotic symptoms respond to antipsychotic drugs at doses lower than men's. This means that many women may be de facto overdosed and, thus, experience unnecessary adverse effects. That being said, factors such as genetics and age probably determine drug response and tolerability to a greater degree than do biological sex or gender social roles.
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Affiliation(s)
- Mary V Seeman
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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Lin YS, Thummel KE, Thompson BD, Totah RA, Cho CW. Sources of Interindividual Variability. Methods Mol Biol 2021; 2342:481-550. [PMID: 34272705 DOI: 10.1007/978-1-0716-1554-6_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The efficacy, safety, and tolerability of drugs are dependent on numerous factors that influence their disposition. A dose that is efficacious and safe for one individual may result in sub-therapeutic or toxic blood concentrations in others. A significant source of this variability in drug response is drug metabolism, where differences in presystemic and systemic biotransformation efficiency result in variable degrees of systemic exposure (e.g., AUC, Cmax, and/or Cmin) following administration of a fixed dose.Interindividual differences in drug biotransformation have been studied extensively. It is recognized that both intrinsic factors (e.g., genetics, age, sex, and disease states) and extrinsic factors (e.g., diet , chemical exposures from the environment, and the microbiome) play a significant role. For drug-metabolizing enzymes, genetic variation can result in the complete absence or enhanced expression of a functional enzyme. In addition, upregulation and downregulation of gene expression, in response to an altered cellular environment, can achieve the same range of metabolic function (phenotype), but often in a less predictable and time-dependent manner. Understanding the mechanistic basis for variability in drug disposition and response is essential if we are to move beyond the era of empirical, trial-and-error dose selection and into an age of personalized medicine that will improve outcomes in maintaining health and treating disease.
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Affiliation(s)
- Yvonne S Lin
- Department of Pharmaceutics, University of Washington, Seattle, WA, USA.
| | - Kenneth E Thummel
- Department of Pharmaceutics, University of Washington, Seattle, WA, USA
| | - Brice D Thompson
- Department of Pharmaceutics, University of Washington, Seattle, WA, USA
| | - Rheem A Totah
- Department of Medicinal Chemistry, University of Washington, Seattle, WA, USA
| | - Christi W Cho
- Department of Medicinal Chemistry, University of Washington, Seattle, WA, USA
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Campbell KSJ, Collier AC, Irvine MA, Brain U, Rurak DW, Oberlander TF, Lim KI. Maternal Serotonin Reuptake Inhibitor Antidepressants Have Acute Effects on Fetal Heart Rate Variability in Late Gestation. Front Psychiatry 2021; 12:680177. [PMID: 34483982 PMCID: PMC8415315 DOI: 10.3389/fpsyt.2021.680177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/14/2021] [Indexed: 01/30/2023] Open
Abstract
Background: Prenatal exposure to serotonin reuptake inhibitor (SRI) antidepressants increases risk for adverse neurodevelopmental outcomes, yet little is known about whether effects are present before birth. In relation to maternal SRI pharmacokinetics, this study investigated chronic and acute effects of prenatal SRI exposure on third-trimester fetal heart rate variability (HRV), while evaluating confounding effects of maternal depressed mood. Methods: At 36-weeks' gestation, cardiotocograph measures of fetal HR and HRV were obtained from 148 pregnant women [four groups: SRI-Depressed (n = 31), SRI-Non-Depressed (n = 18), Depressed (unmedicated; n = 42), and Control (n = 57)] before, and ~5-h after, typical SRI dose. Maternal plasma drug concentrations were quantified at baseline (pre-dose) and four time-points post-dose. Mixed effects modeling investigated group differences between baseline/pre-dose and post-dose fetal HR outcomes. Post hoc analyses investigated sex differences and dose-dependent SRI effects. Results: Maternal SRI plasma concentrations were lowest during the baseline/pre-dose fetal assessment (trough) and increased to a peak at the post-dose assessment; concentration-time curves varied widely between individuals. No group differences in fetal HR or HRV were observed at baseline/pre-dose; however, following maternal SRI dose, short-term HRV decreased in both SRI-exposed fetal groups. In the SRI-Depressed group, these post-dose decreases were displayed by male fetuses, but not females. Further, episodes of high HRV decreased post-dose relative to baseline, but only among SRI-Non-Depressed group fetuses. Higher maternal SRI doses also predicted a greater number of fetal HR decelerations. Fetuses exposed to unmedicated maternal depressed mood did not differ from Controls. Conclusions: Prenatal SRI exposure had acute post-dose effects on fetal HRV in late gestation, which differed depending on maternal mood response to SRI pharmacotherapy. Importantly, fetal SRI effects were sex-specific among mothers with persistent depressive symptoms, as only male fetuses displayed acute HRV decreases. At trough (pre-dose), chronic fetal SRI effects were not identified; however, concurrent changes in maternal SRI plasma levels suggest that fetal drug exposure is inconsistent. Acute SRI-related changes in fetal HRV may reflect a pharmacologic mechanism, a transient impairment in autonomic functioning, or an early adaption to altered serotonergic signaling, which may differ between males and females. Replication is needed to determine significance with postnatal development.
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Affiliation(s)
- Kayleigh S J Campbell
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Abby C Collier
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Michael A Irvine
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Ursula Brain
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Dan W Rurak
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Tim F Oberlander
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Kenneth I Lim
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
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Khatri R, Kulick N, Rementer RJB, Fallon JK, Sykes C, Schauer AP, Malinen MM, Mosedale M, Watkins PB, Kashuba ADM, Boggess KA, Smith PC, Brouwer KLR, Lee CR. Pregnancy-Related Hormones Increase Nifedipine Metabolism in Human Hepatocytes by Inducing CYP3A4 Expression. J Pharm Sci 2021; 110:412-421. [PMID: 32931777 PMCID: PMC7750305 DOI: 10.1016/j.xphs.2020.09.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/07/2020] [Accepted: 09/10/2020] [Indexed: 12/24/2022]
Abstract
Pregnancy-related hormones (PRH) have emerged as key regulators of hepatic cytochrome P450 (CYP) enzyme expression and function. The impact of PRH on protein levels of CYP3A4 and other key CYP enzymes, and the metabolism of nifedipine (a CYP3A4 substrate commonly prescribed during pregnancy), was evaluated in primary human hepatocytes. Sandwich-cultured human hepatocytes (SCHH) from female donors were exposed to PRH (estradiol, estriol, estetrol, progesterone, and cortisol), individually or in combination as a cocktail. Absolute protein concentrations of twelve CYP isoforms in SCHH membrane fractions were quantified by nanoLC-MS/MS, and metabolism of nifedipine to dehydronifedipine in SCHH was evaluated. PRH significantly increased CYP3A4 protein concentrations and nifedipine metabolism to dehydronifedipine in a concentration-dependent manner. CYP3A4 mRNA levels in hepatocyte-derived exosomes positively correlated with CYP3A4 protein levels and dehydronifedipine formation in SCHH. PRH also increased CYP2B6, CYP2C8 and CYP2A6 levels. Our findings demonstrate that PRH increase nifedipine metabolism in SCHH by inducing CYP3A4 expression and alter expression of other key CYP proteins in an isoform-specific manner, and suggest that hepatocyte-derived exosomes warrant further investigation as biomarkers of hepatic CYP3A4 metabolism. Together, these results offer mechanistic insight into the increases in nifedipine metabolism and clearance observed in pregnant women.
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Affiliation(s)
- Raju Khatri
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Natasha Kulick
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rebecca J B Rementer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - John K Fallon
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Craig Sykes
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Amanda P Schauer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Melina M Malinen
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Merrie Mosedale
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Paul B Watkins
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Angela D M Kashuba
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kim A Boggess
- Department of Obstetrics and Gynecology, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Philip C Smith
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kim L R Brouwer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Abstract
BACKGROUND This study aims to evaluate the pharmacokinetics of an increased dose of darunavir (800 mg twice daily) with 100 mg ritonavir during pregnancy and postpartum. METHODS Darunavir (DRV) and ritonavir (RTV; r) intensive pharmacokinetic evaluations were performed at steady state during the second and third trimesters of pregnancy (DRV/r 800/100 mg bid) and 2-3 weeks postpartum (DRV/r 600/100 mg twice daily). Plasma concentrations of darunavir and ritonavir were measured using high-performance liquid chromatography. Target darunavir area under the concentration time curve (AUC) was >70% (43.6 μg × h/mL) of median AUC (62.3 μg × h/mL) in nonpregnant adults on twice daily darunavir-ritonavir 600/100 mg. RESULTS Twenty-four women were included in the analysis. Darunavir AUC0-12 was lower with the increased dose during the second {[geometric mean ratio (GMR) of 0.62 (IQR 0.44-0.88); P = 0.055]} and third trimesters [GMR 0.64 (IQR 0.55-0.73); P = <0.001] compared with postpartum. Darunavir apparent clearance was higher during the second [GMR 1.77 (IQR 1.24-2.51); P = 0.039] and third trimesters [GMR 2.01 (IQR 1.17-2.35); P = <0.001] compared with postpartum. Similarly, ritonavir AUC0-12 was lower during the third trimester [GMR 0.65 (IQR 0.52-0.82); P = 0.007] compared with postpartum, whereas its apparent clearance was higher during the third trimester [GMR 1.53 (IQR 1.22-1.92); P = 0.008] compared with postpartum. No major drug-related safety concerns were noted. CONCLUSIONS Increasing darunavir dose to 800 mg BID failed to significantly increase darunavir exposure compared with 600 mg BID. Other strategies, such as increasing the ritonavir dose should be investigated.
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Population Pharmacokinetics of Praziquantel in Pregnant and Lactating Filipino Women Infected with Schistosoma japonicum. Antimicrob Agents Chemother 2020; 64:AAC.00566-20. [PMID: 32631820 PMCID: PMC7449211 DOI: 10.1128/aac.00566-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/08/2020] [Indexed: 01/16/2023] Open
Abstract
An estimated 40 million women of reproductive age are infected with one of three species of the waterborne parasite Schistosoma spp. Treatment with praziquantel (PZQ) via mass drug administration (MDA) campaigns is the mainstay of schistosomiasis control for populations living in areas of endemicity. The World Health Organization recommends that pregnant and lactating women be included in schistosomiasis MDA programs, and several recent studies have evaluated the safety and efficacy of PZQ use during pregnancy. To date, there are no data describing PZQ pharmacokinetics (PK) during pregnancy or among lactating postpartum women. As part of a randomized controlled trial investigating the safety and efficacy of PZQ during human pregnancy, we examined the PK of this therapeutic drug among three distinct cohorts of women infected with S. japonicum in Leyte, Philippines. Specifically, we studied the PK properties of PZQ among early- and late-gestation pregnant women (n = 15 each) and lactating postpartum women (n = 15) with schistosomiasis. We found that women in early pregnancy had increased apparent clearance and lower area-under-the-curve (AUC0-24) values that may be related to physiological changes in drug clearance and/or changes in oral bioavailability. There was no relationship between body weight and apparent clearance. The mean ± standard deviation partition ratio of plasma to breast milk was 0.36. ± 0.13. The estimated median infant PZQ daily dose would be 0.037 mg/kg of body weight ingested from breast milk, which is significantly lower than the dosage required for antischistosomal activity and not known to be harmful to the infant. Our PK data do not support the suggestion to delay breastfeeding 72 h after taking PZQ. Results can help inform future drug efficacy studies in pregnant and lactating women with schistosomiasis.
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Moore BR, Davis TM. Updated pharmacokinetic considerations for the use of antimalarial drugs in pregnant women. Expert Opin Drug Metab Toxicol 2020; 16:741-758. [PMID: 32729740 DOI: 10.1080/17425255.2020.1802425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The association between pregnancy and altered drug pharmacokinetic (PK) properties is acknowledged, as is its impact on drug plasma concentrations and thus therapeutic efficacy. However, there have been few robust PK studies of antimalarial use in pregnancy. Given that inadequate dosing for prevention or treatment of malaria in pregnancy can result in negative maternal/infant outcomes, along with the potential to select for parasite drug resistance, it is imperative that reliable pregnancy-specific dosing recommendations are established. AREAS COVERED PK studies of antimalarial drugs in pregnancy. The present review summarizes the efficacy and PK properties of WHO-recommended therapies used in pregnancy, with a focus on PK studies published since 2014. EXPERT OPINION Changes in antimalarial drug disposition in pregnancy are well described, yet pregnant women continue to receive treatment regimens optimized for non-pregnant adults. Contemporary in silico modeling has recently identified a series of alternative dosing regimens that are predicted to provide optimal therapeutic efficacy for pregnant women.
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Affiliation(s)
- Brioni R Moore
- School of Pharmacy and Biomedical Sciences, Curtin University , Bentley, Western Australia, Australia.,Medical School, University of Western Australia , Crawley, Western Australia, Australia
| | - Timothy M Davis
- Medical School, University of Western Australia , Crawley, Western Australia, Australia
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Kazma JM, van den Anker J, Allegaert K, Dallmann A, Ahmadzia HK. Anatomical and physiological alterations of pregnancy. J Pharmacokinet Pharmacodyn 2020; 47:271-285. [PMID: 32026239 PMCID: PMC7416543 DOI: 10.1007/s10928-020-09677-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/28/2020] [Indexed: 02/07/2023]
Abstract
The extensive metabolic demands of pregnancy require specific physiological and anatomical changes. These changes affect almost all organ systems, including the cardiovascular, respiratory, renal, gastrointestinal, and hematologic system. The placenta adds another layer of complexity. These changes make it challenging for clinicians to understand presenting signs and symptoms, or to interpret laboratory and radiological tests. Furthermore, these physiological alterations can affect the pharmacokinetics and pharmacodynamics of drugs. Drug safety in lactation is only supported by limited evidence. In addition, the teratogenic effects of medications are often extrapolated from animals, which further adds uncertainties. Unfortunately, pregnant women are only rarely included in clinical drug trials, while doses, regimens, and side effects are often extrapolated from studies conducted in non-pregnant populations. In this comprehensive review, we present the changes occurring in each system with its effects on the pharmacokinetic variables. Understanding these physiological changes throughout normal pregnancy helps clinicians to optimize the health of pregnant women and their fetuses. Furthermore, the information on pregnancy-related physiology is also critical to guide study design in this vulnerable 'orphan' population, and provides a framework to explore pregnancy-related pathophysiology such as pre-eclampsia.
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Affiliation(s)
- Jamil M Kazma
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
- Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Karel Allegaert
- Department of Development and Regeneration, and Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
- Department of Clinical Pharmacy, Erasmus MC, Rotterdam, The Netherlands
| | - André Dallmann
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals, Bayer AG, Leverkusen, Germany
| | - Homa K Ahmadzia
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
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The impact of intrauterine growth restriction on cytochrome P450 enzyme expression and activity. Placenta 2020; 99:50-62. [PMID: 32755725 DOI: 10.1016/j.placenta.2020.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/14/2020] [Indexed: 01/16/2023]
Abstract
With the increased prevalence of non-communicable disease and availability of medications to treat these and other conditions, a pregnancy free from prescribed medication exposure is rare. Up to 99% of women take at least one medication during pregnancy. These medications can be divided into those used to improve maternal health and wellbeing (e.g., analgesics, antidepressants, antidiabetics, antiasthmatics), and those used to promote the baby's wellbeing in either fetal (e.g., anti-arrhythmics) or postnatal life (e.g., antenatal glucocorticoids). These medications are needed for pre-existing or coincidental illnesses in the mother, maternal conditions induced by the pregnancy itself through to conditions that arise in the fetus or that will be encountered by the newborn. Thus, medications administered to the mother may be used to treat the mother, the fetus or both. Metabolism of medications is regulated by a range of physiological processes that change during pregnancy. Other pathological processes such as placental insufficiency can in turn have both immediate and lifelong adverse health consequences for babies. Individuals born growth restricted are more likely to require medications but may also have an altered ability to metabolise these medications in fetal and postnatal life. This review aims to determine the effect of suboptimal fetal growth on the fetal expression of the drug metabolising enzymes (DMEs) that convert medications into active or inactive metabolites, and the transporters that remove both these medications and their metabolites from the fetal compartment.
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Cui C, Zhang M, Yao X, Tu S, Hou Z, Jie En VS, Xiang X, Lin J, Cai T, Shen N, Song C, Qiao J, Zhang S, Li H, Liu D. Dose selection of chloroquine phosphate for treatment of COVID-19 based on a physiologically based pharmacokinetic model. Acta Pharm Sin B 2020; 10:1216-1227. [PMID: 32834950 PMCID: PMC7252145 DOI: 10.1016/j.apsb.2020.04.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 03/24/2020] [Accepted: 03/25/2020] [Indexed: 01/05/2023] Open
Abstract
Chloroquine (CQ) phosphate has been suggested to be clinically effective in the treatment of coronavirus disease 2019 (COVID-19). To develop a physiologically-based pharmacokinetic (PBPK) model for predicting tissue distribution of CQ and apply it to optimize dosage regimens, a PBPK model, with parameterization of drug distribution extrapolated from animal data, was developed to predict human tissue distribution of CQ. The physiological characteristics of time-dependent accumulation was mimicked through an active transport mechanism. Several dosing regimens were proposed based on PBPK simulation combined with known clinical exposure-response relationships. The model was also validated by clinical data from Chinese patients with COVID-19. The novel PBPK model allows in-depth description of the pharmacokinetics of CQ in several key organs (lung, heart, liver, and kidney), and was applied to design dosing strategies in patients with acute COVID-19 (Day 1: 750 mg BID, Days 2-5: 500 mg BID, CQ phosphate), patients with moderate COVID-19 (Day 1: 750 mg and 500 mg, Days 2-3: 500 mg BID, Days 4-5: 250 mg BID, CQ phosphate), and other vulnerable populations (e.g., renal and hepatic impairment and elderly patients, Days 1-5: 250 mg BID, CQ phosphate). A PBPK model of CQ was successfully developed to optimize dosage regimens for patients with COVID-19.
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Affiliation(s)
- Cheng Cui
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing 100191, China
| | - Miao Zhang
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing 100191, China
| | - Xueting Yao
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing 100191, China
| | - Siqi Tu
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing 100191, China
| | - Zhe Hou
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing 100191, China
| | - Valerie Sia Jie En
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing 100191, China
| | - Xiaoqiang Xiang
- Department of Clinical Pharmacy, School of Pharmacy, Fudan University, Shanghai 201203, China
| | - Jing Lin
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, HwaMei Hospital, University of Chinese Academy of Sciences (Ningbo No.2 Hospital), Ningbo 315010, China
| | - Ting Cai
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, HwaMei Hospital, University of Chinese Academy of Sciences (Ningbo No.2 Hospital), Ningbo 315010, China
| | - Ning Shen
- Department of Respirator, Peking University Third Hospital, Beijing 100191, China
| | - Chunli Song
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
| | - Jie Qiao
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
| | - Shun Zhang
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, HwaMei Hospital, University of Chinese Academy of Sciences (Ningbo No.2 Hospital), Ningbo 315010, China
| | - Haiyan Li
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing 100191, China
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Dongyang Liu
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing 100191, China
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Mutagonda RF, Minzi OMS, Massawe SN, Asghar M, Färnert A, Kamuhabwa AAR, Aklillu E. Pregnancy and CYP3A5 Genotype Affect Day 7 Plasma Lumefantrine Concentrations. Drug Metab Dispos 2020; 47:1415-1424. [PMID: 31744845 DOI: 10.1124/dmd.119.088062] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 09/27/2019] [Indexed: 12/21/2022] Open
Abstract
Pregnancy and pharmacogenetics variation alter drug disposition and treatment outcome. The objective of this study was to investigate the effect of pregnancy and pharmacogenetics variation on day 7 lumefantrine (LF) plasma concentration and therapeutic responses in malaria-infected women treated with artemether-lumefantrine (ALu) in Tanzania. A total of 277 (205 pregnant and 72 nonpregnant) women with uncomplicated Plasmodium falciparum malaria were enrolled. Patients were treated with ALu and followed up for 28 days. CYP3A4, CYP3A5, and ABCB1 genotyping were done. Day 7 plasma LF concentration and the polymerase chain reaction (PCR) - corrected adequate clinical and parasitological response (ACPR) at day 28 were determined. The mean day 7 plasma LF concentrations were significantly lower in pregnant women than nonpregnant women [geometric mean ratio = 1.40; 95% confidence interval (CI) of geometric mean ratio (1.119-1.1745), P < 0.003]. Pregnancy, low body weight, and CYP3A5*1/*1 genotype were significantly associated with low day 7 LF plasma concentration (P < 0.01). PCR-corrected ACPR was 93% (95% CI = 89.4-96.6) in pregnant women and 95.7% (95% CI = 90.7-100) in nonpregnant women. Patients with lower day 7 LF concentration had a high risk of treatment failure (mean 652 vs. 232 ng/ml, P < 0.001). In conclusion, pregnancy, low body weight, and CYP3A5*1 allele are significant predictors of low day 7 LF plasma exposure. In turn, lower day 7 LF concentration is associated with a higher risk of recrudescence. SIGNIFICANCE STATEMENT: This study reports a number of factors contributing to the lower day 7 lumefantrine (LF) concentration in women, which includes pregnancy, body weight, and CYP3A5*1/*1 genotype. It also shows that day 7 LF concentration is a main predictor of malaria treatment. These findings highlight the need to look into artemether-LF dosage adjustment in pregnant women so as to be able to maintain adequate drug concentration, which is required to reduce treatment failure rates in pregnant women.
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Affiliation(s)
- Ritah F Mutagonda
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy (R.F.M., O.O.M.S.M., A.A.R.K.), and Department of Obstetrics and Gynecology, School of Medicine (S.N.M.), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (M.A., A.F.); Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden (A.F.); and Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden (E.A.)
| | - Omary M S Minzi
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy (R.F.M., O.O.M.S.M., A.A.R.K.), and Department of Obstetrics and Gynecology, School of Medicine (S.N.M.), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (M.A., A.F.); Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden (A.F.); and Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden (E.A.)
| | - Siriel N Massawe
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy (R.F.M., O.O.M.S.M., A.A.R.K.), and Department of Obstetrics and Gynecology, School of Medicine (S.N.M.), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (M.A., A.F.); Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden (A.F.); and Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden (E.A.)
| | - Muhammad Asghar
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy (R.F.M., O.O.M.S.M., A.A.R.K.), and Department of Obstetrics and Gynecology, School of Medicine (S.N.M.), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (M.A., A.F.); Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden (A.F.); and Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden (E.A.)
| | - Anna Färnert
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy (R.F.M., O.O.M.S.M., A.A.R.K.), and Department of Obstetrics and Gynecology, School of Medicine (S.N.M.), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (M.A., A.F.); Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden (A.F.); and Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden (E.A.)
| | - Appolinary A R Kamuhabwa
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy (R.F.M., O.O.M.S.M., A.A.R.K.), and Department of Obstetrics and Gynecology, School of Medicine (S.N.M.), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (M.A., A.F.); Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden (A.F.); and Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden (E.A.)
| | - Eleni Aklillu
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy (R.F.M., O.O.M.S.M., A.A.R.K.), and Department of Obstetrics and Gynecology, School of Medicine (S.N.M.), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (M.A., A.F.); Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden (A.F.); and Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden (E.A.)
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Neary M, Owen A, Olagunju A. Pharmacokinetics of HIV therapies in pregnant patients: an update. Expert Opin Drug Metab Toxicol 2020; 16:449-461. [PMID: 32271621 DOI: 10.1080/17425255.2020.1754792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Mother-to-child transmission (MTCT) of HIV is thought to account for over 90% of new pediatric infections, and is associated with poor maternal and fetal outcomes. As such ensuring further reduction in MTCT is a priority in HIV treatment and prevention programs. AREAS COVERED This review aims to provide a comprehensive update on the pharmacokinetics of recently approved antiretroviral drugs and novel drug formulations and delivery systems. Alongside recent recommendations for dose adjustments, and an overview of the implications of co-infections on the pharmacokinetics of antiretrovirals relevant to pregnant HIV positive patients. Additionally, potential opportunities to progress pharmacokinetic research of new treatments in this population are highlighted. EXPERT OPINION In order to improve our understanding of how to provide safe and effective treatment to HIV positive pregnant women, further work is required to enable their inclusion in early stages of clinical trials. Incentives must be created for this research, in the form of additional investment by key stakeholders and regulatory agencies. Furthermore, as the incidence of MTCT is reduced globally there is a need to conduct long-term pharmacovigilance studies in uninfected children exposed to HIV and antiretrovirals in utero, in order to determine the safest and most effective antiretroviral therapies.
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Affiliation(s)
- Megan Neary
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool , Liverpool, UK
| | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool , Liverpool, UK
| | - Adeniyi Olagunju
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool , Liverpool, UK.,Faculty of Pharmacy, Obafemi Awolowo University , Ile-Ife, Nigeria
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Fosamprenavir with Ritonavir Pharmacokinetics during Pregnancy. Antimicrob Agents Chemother 2020; 64:AAC.02260-19. [PMID: 32015036 DOI: 10.1128/aac.02260-19] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 01/07/2020] [Indexed: 12/17/2022] Open
Abstract
The purpose of this study was to evaluate the pharmacokinetics of ritonavir-boosted fosamprenavir during pregnancy and postpartum. Amprenavir (the active moiety of fosamprenavir) and ritonavir intensive pharmacokinetic evaluations were performed at steady state during the second and third trimesters of pregnancy and postpartum. Plasma concentrations of amprenavir and ritonavir were measured using high-performance liquid chromatography. The target amprenavir area under the concentration-versus-time curve (AUC) was higher than the 10th percentile (27.7 μg · h/ml) of the median area under the curve for ritonavir-boosted fosamprenavir in adults receiving twice-daily fosamprenavir-ritonavir at 700 mg/100 mg. Twenty-nine women were included in the analysis. The amprenavir AUC from time zero to 12 h (AUC0-12) was lower (geometric mean ratio [GMR], 0.60 [confidence interval {CI}, 0.49 to 0.72] [P < 0.001]) while its apparent oral clearance was higher (GMR, 1.68 [CI, 1.38 to 2.03] [P < 0.001]) in the third trimester than postpartum. Similarly, the ritonavir AUC0-12 was lower in the second (GMR, 0.51 [CI, 0.28 to 0.91] [P = 0.09]) and third (GMR, 0.72 [CI, 0.55 to 0.95] [P = 0.005]) trimesters than postpartum, while its apparent oral clearance was higher in the second (GMR, 1.98 [CI, 1.10 to 3.56] [P = 0.06]) and third (GMR, 1.38 [CI, 1.05 to 1.82] [P = 0.009]) trimesters than postpartum. The amprenavir area under the curve exceeded the target for 6/8 (75%) women in the 2nd trimester, 18/28 (64%) in the 3rd trimester, and 19/22 (86.4%) postpartum, and the trough concentrations (C min) of amprenavir were 4- to 16-fold above the mean amprenavir-protein-adjusted 50% inhibitory concentration (IC50) of 0.146 μg/ml. Although amprenavir plasma concentrations in women receiving ritonavir-boosted fosamprenavir were lower during pregnancy than postpartum, the reduced amprenavir concentrations were still above the exposures needed for viral suppression.
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