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Attaianese F, Dalpiaz I, Failla M, Pasquali E, Galli L, Chiappini E. Fixed-dose antiretroviral combinations in children living with human immunodeficiency virus type 1 (HIV-1): a systematic review. J Chemother 2024; 36:355-369. [PMID: 38153234 DOI: 10.1080/1120009x.2023.2297095] [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: 03/18/2022] [Revised: 12/05/2023] [Accepted: 12/12/2023] [Indexed: 12/29/2023]
Abstract
Fixed-Dose antiretroviral Combinations (FDCs) are the most used drug regimes in adult patients with human-immunodeficiency virus 1 infection, since they increase adherence to antiretroviral therapy and enable good quality of life. The European AIDS Clinical Society guidelines recommend the use of FDCs in paediatrics. However, the use of FDCs in paediatric population is restricted since studies in children and adolescents are mostly conducted in small sample sizes and are heterogeneous in settings and design. This systematic review aims to summarize the current knowledge about the use of FDCs in paediatric population, highlighting the relevant outcomes regarding efficacy and effectiveness, adherence, safety, and adverse events of these regimens.
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Affiliation(s)
- Federica Attaianese
- Department of Health Sciences, Section of Paediatrics, University of Florence, Florence, Italy
| | - Irene Dalpiaz
- Department of Health Sciences, Section of Paediatrics, University of Florence, Florence, Italy
| | - Martina Failla
- Department of Health Sciences, Section of Paediatrics, University of Florence, Florence, Italy
| | - Elisa Pasquali
- Department of Health Sciences, Section of Paediatrics, University of Florence, Florence, Italy
| | - Luisa Galli
- Department of Health Sciences, Section of Paediatrics, University of Florence, Florence, Italy
- Paediatric Infectious Disease Unit, IRCCS Anna Meyer Children's Hospital, Florence, Italy
| | - Elena Chiappini
- Department of Health Sciences, Section of Paediatrics, University of Florence, Florence, Italy
- Paediatric Infectious Disease Unit, IRCCS Anna Meyer Children's Hospital, Florence, Italy
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2
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Mohsenian Naghani S, Jansen MM, Jaspers T, Bastiaans D, Burger D. Crushing lopinavir/ritonavir tablets does not result in lower exposure to lopinavir/ritonavir in adult patients with COVID-19. Eur J Hosp Pharm 2023; 30:e106-e108. [PMID: 33990390 PMCID: PMC10086723 DOI: 10.1136/ejhpharm-2020-002596] [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: 11/11/2020] [Revised: 03/13/2021] [Accepted: 03/16/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Lopinavir/ritonavir (LPV/RTV) exposure is decreased in children after crushing the tablets. Whether exposure is also decreased in adult patients is not known. This study evaluated the exposure of LPV/RTV in adult patients after administration of crushed LPV/RTV tablets. METHODS Blood samples were drawn from patients with COVID-19 who were receiving crushed LPV/RTV 400/100 mg tablets twice daily. RESULTS Plasma concentrations for 11 patients with COVID-19 (eight men, mean age 62.6 years) were included. The measured plasma concentrations of LPV were substantially higher than reported for patients with HIV. CONCLUSIONS There is adequate exposure from crushed LPV/RTV tablets, but because of limited experience, therapeutic drug monitoring is still advised.
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Affiliation(s)
| | - Mark Mpm Jansen
- Pharmacy, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Tessa Jaspers
- Pharmacy, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Diane Bastiaans
- Clinical Pharmacy, Catharina Ziekenhuis, Eindhoven, The Netherlands
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Impact of Therapeutic Drug Monitoring of Antiretroviral Drugs in Routine Clinical Management of People Living With HIV: A Narrative Review. Ther Drug Monit 2021; 42:64-74. [PMID: 31393332 DOI: 10.1097/ftd.0000000000000684] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The treatment of HIV infection has evolved significantly since the advent of highly active antiretroviral therapy. As a result, a response rate of 90%-95% now represents a realistically achievable target. Given this background, it is difficult to imagine the additional benefits that therapeutic drug monitoring (TDM) could provide in the management of HIV infection. METHODS This article is not intended to provide a systematic literature review on TDM of antiretroviral agents; rather, the authors aim to discuss the potential added value of TDM in the optimal management of people living with HIV (PLWH) in selected real-life clinical scenarios based on data collected over 10 years by their TDM service. RESULTS Some clinical situations, in which the selection of the optimal antiretroviral therapy is challenging, have been identified. These include poorly compliant patients, suboptimal antiretroviral therapies (in terms of both efficacy and toxicity), polypharmacy with a high risk of drug-drug interactions, and different patient populations, such as pregnant women. CONCLUSIONS The transformation of HIV infection from a near-universally fatal illness to a lifelong chronic disease has resulted in an HIV population that is growing and aging, placing new and increasing demands on public programs and health services. Increasingly, the management of comorbidities, polypharmacy, and drug-drug interaction, and their impact on antiretroviral therapy will have to be undertaken. These clinical settings represent some of the new frontiers for the use of TDM with the goal of achieving optimal prescription and outcome for PLWH.
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Schijvens AM, de Wildt SN, Cornelissen EAM, van Hesteren FHS, Schreuder MF, Ter Heine R. Low Bioavailability of Oral Tacrolimus Suspension in Pediatric Kidney Transplant Patients. Clin Pharmacokinet 2020; 59:1483-1485. [PMID: 32789820 DOI: 10.1007/s40262-020-00908-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Anne M Schijvens
- Department of Pediatric Nephrology, 804, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Saskia N de Wildt
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands.,Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Elisabeth A M Cornelissen
- Department of Pediatric Nephrology, 804, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Fransje H S van Hesteren
- Department of Pediatric Nephrology, 804, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, 804, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Halling Folkmar Andersen A, Tolstrup M. The Potential of Long-Acting, Tissue-Targeted Synthetic Nanotherapy for Delivery of Antiviral Therapy Against HIV Infection. Viruses 2020; 12:E412. [PMID: 32272815 PMCID: PMC7232358 DOI: 10.3390/v12040412] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 12/18/2022] Open
Abstract
Oral administration of a combination of two or three antiretroviral drugs (cART) has transformed HIV from a life-threatening disease to a manageable infection. However, as the discontinuation of therapy leads to virus rebound in plasma within weeks, it is evident that, despite daily pill intake, the treatment is unable to clear the infection from the body. Furthermore, as cART drugs exhibit a much lower concentration in key HIV residual tissues, such as the brain and lymph nodes, there is a rationale for the development of drugs with enhanced tissue penetration. In addition, the treatment, with combinations of multiple different antiviral drugs that display different pharmacokinetic profiles, requires a strict dosing regimen to avoid the emergence of drug-resistant viral strains. An intriguing opportunity lies within the development of long-acting, synthetic scaffolds for delivering cART. These scaffolds can be designed with the goal to reduce the frequency of dosing and furthermore, hold the possibility of potential targeting to key HIV residual sites. Moreover, the synthesis of combinations of therapy as one molecule could unify the pharmacokinetic profiles of different antiviral drugs, thereby eliminating the consequences of sub-therapeutic concentrations. This review discusses the recent progress in the development of long-acting and tissue-targeted therapies against HIV for the delivery of direct antivirals, and examines how such developments fit in the context of exploring HIV cure strategies.
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Affiliation(s)
- Anna Halling Folkmar Andersen
- Department of Infectious Diseases, Aarhus University Hospital, 8200 Aarhus, Denmark;
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus, Denmark
| | - Martin Tolstrup
- Department of Infectious Diseases, Aarhus University Hospital, 8200 Aarhus, Denmark;
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus, Denmark
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6
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Innovations in Pediatric Drug Formulations and Administration Technologies for Low Resource Settings. Pharmaceutics 2019; 11:pharmaceutics11100518. [PMID: 31597277 PMCID: PMC6835316 DOI: 10.3390/pharmaceutics11100518] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/01/2019] [Accepted: 10/01/2019] [Indexed: 12/11/2022] Open
Abstract
Despite advances in regulations and initiatives to increase pediatric medicine development, there is still an unmet need for age-appropriate medicines for children. The availability of pediatric formulations is particularly lacking in resource poor areas, due to, for example, area-specific disease burden and financial constraints, as well as disconnected supply chains and fragmented healthcare systems. The paucity of authorized pediatric medicines often results in the manipulation and administration of products intended for adults, with an increased risk of mis-dosing and adverse reactions. This article provides an overview of the some of the key difficulties associated with the development of pediatric medicines in both high and low resource areas, and highlights shared and location specific challenges and opportunities. The utilization of dispersible oral dosage forms and suppositories for low and middle-income countries (LMICs) are described in addition to other platform technologies that may in the future offer opportunities for future pediatric medicine development for low resource settings.
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Adeoye O, Conceição J, Serra PA, Bento da Silva A, Duarte N, Guedes RC, Corvo MC, Aguiar-Ricardo A, Jicsinszky L, Casimiro T, Cabral-Marques H. Cyclodextrin solubilization and complexation of antiretroviral drug lopinavir: In silico prediction; Effects of derivatization, molar ratio and preparation method. Carbohydr Polym 2019; 227:115287. [PMID: 31590843 DOI: 10.1016/j.carbpol.2019.115287] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/12/2019] [Accepted: 09/02/2019] [Indexed: 01/03/2023]
Abstract
Lopinavir (LPV) is currently used in combination with ritonavir for the clinical management of HIV infections due to its limited oral bioavailability. Herein, we report the application of an in silico method to study cyclodextrin (CyD) host-guest molecular interaction with LPV for the rational selection of the best CyD for developing a CyD based LPV delivery system. The predicted CyD, a (2-hydroxy)propyl-gamma derivative with high degree of substitution (HP17-γ-CyD) was synthesized and comparatively evaluated with γ-CyD and the commercially available HP-γ-CyD. All complexes were prepared by supercritical assisted spray drying (SASD) and co-evaporation (CoEva) at molar ratios (1:1 and 1:2); and afterwards fully characterized. Results indicate a higher LPV amorphization and solubilization ability of HP17-γ-CyD. The SASD processing technology also enhanced LPV solubilization and release from complexes. The application of in silico methodologies is a feasible approach for the rational and/or deductive development of CyD drug delivery systems.
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Affiliation(s)
- Oluwatomide Adeoye
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Jaime Conceição
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal; UCIBIO/REQUIMTE, MedTech - Laboratory of Pharmaceutical Technology, Department of Drug Sciences, Faculty of Pharmacy, University of Porto, Oporto, Portugal
| | - Patrícia A Serra
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Andreia Bento da Silva
- Faculdade de Farmácia da Universidade de Lisboa (FFULisboa), Avenida Prof. Gama Pinto, 1649-003, Lisboa, Portugal
| | - Noélia Duarte
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Rita C Guedes
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Marta C Corvo
- i3N|CENIMAT, Department of Materials Science, Faculty of Science and Technology, UNL, 2829-516, Caparica, Portugal
| | - Ana Aguiar-Ricardo
- LAQV-REQUIMTE, Departamento de Química, Faculdade de Ciências e Tecnologia, Universidade NOVA de Lisboa, 2829-516, Caparica, Portugal
| | - László Jicsinszky
- Department of Drug Science and Technology, University of Turin, Via P. Giuria 9, 10125, Turin, Italy
| | - Teresa Casimiro
- LAQV-REQUIMTE, Departamento de Química, Faculdade de Ciências e Tecnologia, Universidade NOVA de Lisboa, 2829-516, Caparica, Portugal
| | - Helena Cabral-Marques
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal.
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Pharmacokinetics, Safety, and Dosing of Novel Pediatric Levofloxacin Dispersible Tablets in Children with Multidrug-Resistant Tuberculosis Exposure. Antimicrob Agents Chemother 2019; 63:AAC.01865-18. [PMID: 30670421 DOI: 10.1128/aac.01865-18] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/03/2019] [Indexed: 11/20/2022] Open
Abstract
This study characterized the pharmacokinetics of novel 100-mg levofloxacin dispersible tablets in 24 children aged <5 years who had household multidrug-resistant tuberculosus (MDR-TB) exposure. The current data were pooled with previously published data from children (n = 109) with MDR-TB receiving adult (250-mg) levofloxacin tablets, using nonlinear mixed-effects modelling. The adult tablets had 41% lower bioavailability than the novel dispersible tablets, resulting in much higher exposures with the dispersible tablets with the same dose.
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Krovi SA, Gallovic MD, Keller AM, Bhat M, Tiet P, Chen N, Collier MA, Gurysh EG, Pino EN, Johnson MM, Shamim Hasan Zahid M, Cottrell ML, Pirone JR, Kashuba AD, Kwiek JJ, Bachelder EM, Ainslie KM. Injectable long-acting human immunodeficiency virus antiretroviral prodrugs with improved pharmacokinetic profiles. Int J Pharm 2018; 552:371-377. [PMID: 30308272 DOI: 10.1016/j.ijpharm.2018.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/26/2018] [Accepted: 10/06/2018] [Indexed: 12/20/2022]
Abstract
While highly active antiretroviral therapy (HAART) has significantly reduced mortality rates in patients with human immunodeficiency virus type 1 (HIV-1), its efficacy may be impeded by emergence of drug resistance caused by lack of patient adherence. A therapeutic strategy that requires infrequent drug administration as a result of sustained release of antiretroviral drugs would put less burden on the patient. Long-acting antiretroviral prodrugs for HIV therapy were synthesized through modification of the active drugs, emtricitabine (FTC) and elvitegravir (EVG), with docosahexaenoic acid (DHA) in one-step, one-pot, high-yielding reactions. The in vitro drug release profiles of these synthetic conjugates demonstrated sustained and controlled release of the active drug over a period of 3-4 weeks attributable to the hydrolysis of the chemical linker in conjunction with the hydrophilicity of the parent drug. Both conjugates exhibited superior antiviral activities in tissue culture models of HIV replication as compared to those of the free drugs, strengthening their role as potent prodrugs for HIV therapy. Pharmacokinetic analysis in CD1 mice further confirmed the long-acting aspect of these conjugates with released drug concentrations in plasma detected at their respective IC90/IC95 values over a period of 2 weeks and discernable amounts of active drug even at 6 weeks. Our findings suggest that the injectable small molecule conjugates could be used as long-acting controlled release of FTC and EVG in attempts to mitigate adherence-related HIV resistance.
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Affiliation(s)
- Sai Archana Krovi
- Division of Pharmacoengineering and Molecular Pharmaceutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA
| | - Matthew D Gallovic
- Division of Pharmacoengineering and Molecular Pharmaceutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA
| | - Austin M Keller
- Department of Microbiology, Ohio State University, Columbus, OH 43210, USA
| | - Menakshi Bhat
- Department of Microbiology, Ohio State University, Columbus, OH 43210, USA
| | | | - Naihan Chen
- Division of Pharmacoengineering and Molecular Pharmaceutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA
| | | | - Elizabeth G Gurysh
- Division of Pharmacoengineering and Molecular Pharmaceutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA
| | - Erica N Pino
- Division of Pharmacoengineering and Molecular Pharmaceutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA
| | - Monica M Johnson
- Division of Pharmacoengineering and Molecular Pharmaceutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA
| | - M Shamim Hasan Zahid
- Division of Pharmacoengineering and Molecular Pharmaceutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA
| | - Mackenzie L Cottrell
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA
| | - Jason R Pirone
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA
| | - Angela D Kashuba
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA
| | - Jesse J Kwiek
- Department of Microbiology, Ohio State University, Columbus, OH 43210, USA
| | - Eric M Bachelder
- Division of Pharmacoengineering and Molecular Pharmaceutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA
| | - Kristy M Ainslie
- Division of Pharmacoengineering and Molecular Pharmaceutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA; Department of Microbiology and Immunology, University of North Carolina, Chapel Hill, NC, USA.
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10
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Pharmacokinetics, Short-term Safety and Efficacy of the Approved Once-daily Darunavir/Ritonavir Dosing Regimen in HIV-infected Children. Pediatr Infect Dis J 2018; 37:1008-1010. [PMID: 29474261 DOI: 10.1097/inf.0000000000001964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In this multicenter pharmacokinetic study in HIV-infected children (6-12 years of age), we validated the approved once-daily darunavir/ritonavir dosing recommendations. The geometric mean darunavir area under the plasma concentration-time curve was 63.1 h·mg/L, substantially lower than the mean value observed in adults. However, all trough levels were adequate, and short-term virologic outcome was good. These data support the use of the darunavir/ritonavir once-daily dosing recommendations.
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Adkison K, Wolstenholme A, Lou Y, Zhang Z, Eld A, Perger T, Vangerow H, Hayward K, Shaefer M, McCoig C. Effect of Sorbitol on the Pharmacokinetic Profile of Lamivudine Oral Solution in Adults: An Open-Label, Randomized Study. Clin Pharmacol Ther 2017; 103:402-408. [PMID: 29150845 PMCID: PMC5836851 DOI: 10.1002/cpt.943] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
In children aged ≤4 years, the relative bioavailability of lamivudine oral solution was 37% lower than that of a tablet formulation. An open-label, four-way crossover study was conducted in healthy adults to evaluate the effect of sorbitol, a common liquid excipient, on the pharmacokinetics of lamivudine oral solution (ClinicalTrials.gov identifier, NCT02634073). Sixteen subjects were randomized to one of four sequences consisting of four doses of lamivudine 300 mg (10 mg/mL) alone or with sorbitol 3.2, 10.2, or 13.4 g. Sorbitol 3.2, 10.2, and 13.4 g decreased lamivudine maximum concentration (Cmax ) by 28%, 52%, and 55% and area under the concentration-time curve from time 0 to 24 h (AUC0-24 ) by 20%, 39%, and 44%, respectively. Three subjects (19%) reported five nonserious adverse events (one drug-related). The dose-dependent effects of sorbitol on lamivudine Cmax and AUC0-24 reveal an absorption-based interaction that may decrease lamivudine exposure in patients coadministered sorbitol-containing medicines.
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Affiliation(s)
| | | | - Yu Lou
- PAREXEL International, Durham, North Carolina, USA
| | | | - Amy Eld
- GlaxoSmithKline, Collegeville, Pennsylvania, USA
| | | | | | | | - Mark Shaefer
- ViiV Healthcare, Research Triangle Park, North Carolina, USA
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Kakuda TN, Brochot A, Green B, Nijs S, Vis P, Opsomer M, Tomaka FL, Hoetelmans RMW. Pharmacokinetics and Pharmacokinetic/Pharmacodynamic Relationships of Etravirine in HIV-1-Infected, Treatment-Experienced Children and Adolescents in PIANO. J Clin Pharmacol 2017; 56:1395-1405. [PMID: 27060341 DOI: 10.1002/jcph.746] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 03/29/2016] [Indexed: 11/09/2022]
Abstract
PIANO (NCT00665847) investigated etravirine pharmacokinetics, efficacy, and safety in children and adolescents. Treatment-experienced, HIV-1-infected patients (≥6 to <18 years) received etravirine 5.2 mg/kg twice daily (maximum 200 mg twice daily) plus background antiretrovirals. A population pharmacokinetic model was developed, and etravirine C0h and AUC0-12h were estimated. Relationships among intrinsic/extrinsic factors and etravirine pharmacokinetics and pharmacokinetics with pharmacodynamics were assessed. The best model describing etravirine pharmacokinetics consisted of a single compartment with sequential zero- and first-order absorption following a lag time. Interindividual variability terms were included on clearance (CL/F) and the first-order input rate constant (KA). The final model estimates (coefficient of variation, %) for CL/F and KA were 46.3 (11) L/h and 1.07 (34) h-1 , respectively. Overall, median (range) estimated etravirine C0h and AUC0-12h were 287 (2-2276) ng/mL and 4560 (62-28,865) ng · h/mL, respectively. Exposure was slightly lower in adolescents vs children. Sex and adherence did not affect etravirine pharmacokinetics. Factors significantly affecting etravirine exposure were body weight (higher with lower weight), race (lower in Asians than in white or black patients), and the use of certain HIV protease inhibitors. Virologic response (<50 copies/mL at week 48) was lower in the lowest etravirine AUC0-12h quartile vs the upper 3 quartiles (41% vs 67% to 76%). Rash occurred more frequently in the highest quartile than in the lower 3 quartiles (52% versus 8% to 20%). Etravirine 5.2 mg/kg twice daily in treatment-experienced, HIV-1-infected children and adolescents provides comparable exposure to that in adults receiving etravirine 200 mg twice daily and is the recommended dose for children and adolescents.
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Affiliation(s)
| | | | | | - Steven Nijs
- Janssen Infectious Diseases BVBA, Beerse, Belgium
| | - Peter Vis
- LAP&P Consultants BV, Leiden, The Netherlands
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Simulating Intestinal Transporter and Enzyme Activity in a Physiologically Based Pharmacokinetic Model for Tenofovir Disoproxil Fumarate. Antimicrob Agents Chemother 2017; 61:AAC.00105-17. [PMID: 28416547 DOI: 10.1128/aac.00105-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 04/09/2017] [Indexed: 01/16/2023] Open
Abstract
Tenofovir disoproxil fumarate (TDF), a prodrug of tenofovir, has oral bioavailability (25%) limited by intestinal transport (P-glycoprotein), and intestinal degradation (carboxylesterase). However, the influence of luminal pancreatic enzymes is not fully understood. Physiologically based pharmacokinetic (PBPK) modeling has utility for estimating drug exposure from in vitro data. This study aimed to develop a PBPK model that included luminal enzyme activity to inform dose reduction strategies. TDF and tenofovir stability in porcine pancrelipase concentrations was assessed (0, 0.48, 4.8, 48, and 480 U/ml of lipase; 1 mM TDF; 37°C; 0 to 30 min). Samples were analyzed using mass spectrometry. TDF stability and permeation data allowed calculation of absorption rates within a human PBPK model to predict plasma exposure following 6 days of once-daily dosing with 300 mg of TDF. Regional absorption of drug was simulated across gut segments. TDF was degraded by pancrelipase (half-lives of 0.07 and 0.62 h using 480 and 48 U/ml, respectively). Previously reported maximum concentration (Cmax; 335 ng/ml), time to Cmax (Tmax; 2.4 h), area under the concentration-time curve from 0 to 24 h (AUC0-24; 3,045 ng · h/ml), and concentration at 24 h (C24; 48.3 ng/ml) were all within a 0.5-fold difference from the simulated Cmax (238 ng/ml), Tmax (3 h), AUC0-24 (3,036 ng · h/ml), and C24 (42.7 ng/ml). Simulated TDF absorption was higher in duodenum and jejunum than in ileum (p<0.05). These data support that TDF absorption is limited by the action of intestinal lipases. Our results suggest that bioavailability may be improved by protection of drug from intestinal transporters and enzymes, for example, by coadministration of enzyme-inhibiting agents or nanoformulation strategies.
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Janssen EJH, Bastiaans DET, Välitalo PAJ, van Rossum AMC, Jacqz-Aigrain E, Lyall H, Knibbe CAJ, Burger DM. Dose evaluation of lamivudine in human immunodeficiency virus-infected children aged 5 months to 18 years based on a population pharmacokinetic analysis. Br J Clin Pharmacol 2017; 83:1287-1297. [PMID: 28079918 DOI: 10.1111/bcp.13227] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 11/16/2016] [Accepted: 12/18/2016] [Indexed: 01/16/2023] Open
Abstract
AIM The objectives of this study were to characterize age-related changes in lamivudine pharmacokinetics in children and evaluate lamivudine exposure, followed by dose recommendations for subgroups in which target steady state area under the daily plasma concentration-time curve (AUC0-24h ) is not reached. METHODS Population pharmacokinetic modelling was performed in NONMEM using data from two model-building datasets and two external datasets [n = 180 (age 0.4-18 years, body weight 3.4-60.5 kg); 2061 samples (median 12 per child); daily oral dose 60-300 mg (3.9-17.6 mg kg-1 )]. Steady state AUC0-24h was calculated per individual (adult target 8.9 mg·h l-1 ). RESULTS A two-compartment model with sequential zero order and first order absorption best described the data. Apparent clearance and central volume of distribution (% RSE) were 13.2 l h-1 (4.2%) and 38.9 l (7.0%) for a median individual of 16.6 kg, respectively. Bodyweight was identified as covariate on apparent clearance and volume of distribution using power functions (exponents 0.506 (20.2%) and 0.489 (32.3%), respectively). The external evaluation supported the predictive ability of the final model. In 94.5% and 35.8% of the children with a body weight >14 kg and <14 kg, respectively, the target AUC0-24h was reached. CONCLUSION Bodyweight best predicted the developmental changes in apparent lamivudine clearance and volume of distribution. For children aged 5 months-18 years with a body weight <14 kg, the dose should be increased from 8 to 10 mg kg-1 day-1 if the adult target for AUC0-24h is aimed for. In order to identify whether bodyweight influences bioavailability, clearance and/or volume of distribution, future analysis including data on intravenously administered lamivudine is needed.
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Affiliation(s)
- Esther J H Janssen
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands
| | - Diane E T Bastiaans
- Department of Pharmacy & Radboud Institute for Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Pyry A J Välitalo
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands
| | - Annemarie M C van Rossum
- Division of Pediatric Infectious Diseases and Immunology, Erasmus MC/Sophia, Rotterdam, the Netherlands
| | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, Université Paris VII, Paris, France.,Clinical Investigation Center CIC9202, INSERM, Paris, France
| | - Hermione Lyall
- Department of Pediatrics, St Mary's Hospital, London, UK
| | - Catherijne A J Knibbe
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands.,Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - David M Burger
- Department of Pharmacy & Radboud Institute for Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, the Netherlands
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15
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Huesgen E, DeSear KE, Egelund EF, Smith R, Max B, Janelle J. A HAART-Breaking Review of Alternative Antiretroviral Administration: Practical Considerations with Crushing and Enteral Tube Scenarios. Pharmacotherapy 2016; 36:1145-1165. [PMID: 27636237 DOI: 10.1002/phar.1835] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Selection of an appropriate antiretroviral regimen for the patient infected with human immunodeficiency virus can be challenging, as various considerations must be taken into account including viral resistance mutations, patient comorbidities, drug interactions, and the potential for drug-related adverse effects and toxicities. Treatment is further complicated when a clinical scenario arises requiring an alteration in the dosage form. Factors ranging from dysphagia to administration through an enteral feeding tube can affect decisions regarding antiretroviral dosage forms. Limited pharmacokinetic data exist regarding the alteration of antiretroviral medications from their original form. Bioavailability may vary substantially between dosage forms, which can lead to unpredictable drug concentrations. Supratherapeutic or subtherapeutic antiretroviral drug concentrations can result in increased toxicity, virologic failure, or the emergence of drug resistance. We performed a systematic literature search to review the available antiretroviral literature on the modification of solid dosage forms as well as alternative routes of administration of oral antiretroviral agents and their application to clinical practice.
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Affiliation(s)
- Emily Huesgen
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Kathryn E DeSear
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Eric F Egelund
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Renata Smith
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois
| | - Blake Max
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois.,Ruth M. Rothstein CORE Center, Cook County Health & Hospital System, Chicago, Illinois
| | - Jennifer Janelle
- Department of Medicine, University of Florida, Gainesville, Florida
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16
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Challenges in oral drug delivery of antiretrovirals and the innovative strategies to overcome them. Adv Drug Deliv Rev 2016; 103:105-120. [PMID: 26772138 DOI: 10.1016/j.addr.2015.12.022] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 12/20/2015] [Accepted: 12/28/2015] [Indexed: 01/30/2023]
Abstract
Development of novel drug delivery systems (DDS) represents a promising opportunity to overcome the various bottlenecks associated with the chronic antiretroviral (ARV) therapy of the human immunodeficiency virus (HIV) infection. Oral drug delivery is the most convenient and simplest route of drug administration that involves the swallowing of a pharmaceutical compound with the intention of releasing it into the gastrointestinal tract. In oral delivery, drugs can be formulated in such a way that they are protected from digestive enzymes, acids, etc. and released in different regions of the small intestine and/or the colon. Not surprisingly, with the exception of the subcutaneous enfuvirtide, all the marketed ARVs are administered orally. However, conventional (marketed) and innovative (under investigation) oral delivery systems must overcome numerous challenges, including the acidic gastric environment, and the poor aqueous solubility and physicochemical instability of many of the approved ARVs. In addition, the mucus barrier can prevent penetration and subsequent absorption of the released drug, a phenomenon that leads to lower oral bioavailability and therapeutic concentration in plasma. Moreover, the frequent administration of the cocktail (ARVs are administered at least once a day) favors treatment interruption. To improve the oral performance of ARVs, the design and development of more efficient oral drug delivery systems are called for. The present review highlights various innovative research strategies adopted to overcome the limitations of the present treatment regimens and to enhance the efficacy of the oral ARV therapy in HIV.
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17
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Schlatter AF, Deathe AR, Vreeman RC. The Need for Pediatric Formulations to Treat Children with HIV. AIDS Res Treat 2016; 2016:1654938. [PMID: 27413548 PMCID: PMC4927993 DOI: 10.1155/2016/1654938] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 05/25/2016] [Indexed: 11/17/2022] Open
Abstract
Over 3.2 million children worldwide are infected with HIV, but only 24% of these children receive antiretroviral therapy (ART). ART adherence among children is a crucial part of managing human-immunodeficiency virus (HIV) infection and extending the life and health of infected children. Important causes of poor adherence are formulation- and regimen-specific properties, including poor palatability, large pill burden, short dosing intervals, and the complex storage and transportation of drugs. This review aims to summarize the various regimen- and formulation-based barriers to ART adherence among children to support the need for new and innovative pediatric formulations for antiretroviral therapy (ART). Detailing the arguments both for and against investing in the development of pediatric HIV medications, as well as highlighting recent advances in pediatric ART formulation research, provides a synopsis of the current data related to pediatric ART formulations and adherence.
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Affiliation(s)
- Adrienne F. Schlatter
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret 30100, Kenya
| | - Andrew R. Deathe
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret 30100, Kenya
| | - Rachel C. Vreeman
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret 30100, Kenya
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18
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Ribone SR, Schenfeld EM, Madrid M, Pierini AB, Quevedo MA. Evaluation and synthesis of AZT prodrugs with optimized chemical stabilities: experimental and theoretical analyses. NEW J CHEM 2016. [DOI: 10.1039/c5nj03002a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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