Hyperbilirubinemia in atazanavir treated HIV-infected patients: the impact of the UGT1A1*28 allele

Dose of ritonavir-boosted atazanavir for HIV patient: a reappraisal based on genetic polymorphism epidemiology in Southeast Asia

Several anti-HIV medications are currently available and used in medical care for HIV-positive people all over the world. Drug resistance is a global problem that necessitates the development of a new treatment regimen to address it. In several countries, ritonavir (RTV)-boosted atazanavir (ATV) is now used. There is evidence that patients taking RTV-boosted ATV on a regular basis have a higher ATV exposure, increasing the risk of toxicity. A recent theory suggests that a smaller dose of ATV/r may be sufficient. In this article, the authors reevaluate the dose of ATV/r for HIV patients based on existing data on the genetic epidemiology of CYP3A5 6986 A > G. According to the research, the likelihood of an individual achieving the therapeutic range of ATV through concentrations in various ATV/r regimens differs depending on baseline sex and CYP3A5 6986 A > G type. With the exception of a normal dosing regimen for male subjects, all have a chance of reaching the therapeutic range of ATV through concentrations (overall probability greater than 1). As a result, the lowering of the ATV/r dose should be considered primarily for male HIV infected patients.

Effectiveness and Safety of Atazanavir Use for the Treatment of Children and Adolescents Living With HIV: A Systematic Review

BACKGROUND

Atazanavir/ritonavir is recommended as a preferred second-line antiretroviral regimen in children older than 3 months, alternatively to lopinavir/ritonavir. We performed a systematic review to assess safety and effectiveness of atazanavir use in children and adolescents.

METHODS

We searched observational studies and clinical trials on Web of Science, Embase and Cochrane CENTRAL database between 2009/01/01 and 2020/10/01; as well as grey literature. We extracted safety (adverse events, grade 3 or 4 adverse events, treatment discontinuation) and effectiveness (CD4 cell counts and HIV viral load) outcomes. We estimated weighted summary pooled incidence with corresponding 95% confidence intervals.

RESULTS

Out of the 1,085 records screened, we included five studies (one comparative cohort, three single phase 2-3 trial arms, one retrospective cohort) reporting 975 children and adolescents, of whom 56% (544) received atazanavir. Three studies reported all-cause treatment discontinuation rates, yielding a pooled incidence of 19% [15-22] at 12 months. The comparative cohort compared atazanavir to darunavir, with few grade 3-4 adverse events, except transient hyperbilirubinemia, occurring in half (92/188) of the atazanavir patients. No death occurred (two studies reporting). Four studies described increased CD4 cell counts and decreased HIV viral load at 6 or 12 months.

CONCLUSION

Few safety and effectiveness data were available for children and adolescents exposed to atazanavir. Transient grade 3-4 hyperbilirubinemia was the main adverse outcome reported. Immune and viral responses were descriptive. The use of atazanavir/ritonavir in children and adolescents needs further investigation, but remains a suitable option for a preferred second-line antiretroviral regimen.

PROSPERO NUMBER

CRD42022309230.