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Magnitude of Drug–Drug Interactions in Special Populations. Pharmaceutics 2022; 14:pharmaceutics14040789. [PMID: 35456623 PMCID: PMC9027396 DOI: 10.3390/pharmaceutics14040789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/28/2022] [Accepted: 04/01/2022] [Indexed: 02/05/2023] Open
Abstract
Drug–drug interactions (DDIs) are one of the most frequent causes of adverse drug reactions or loss of treatment efficacy. The risk of DDIs increases with polypharmacy and is therefore of particular concern in individuals likely to present comorbidities (i.e., elderly or obese individuals). These special populations, and the population of pregnant women, are characterized by physiological changes that can impact drug pharmacokinetics and consequently the magnitude of DDIs. This review compiles existing DDI studies in elderly, obese, and pregnant populations that include a control group without the condition of interest. The impact of physiological changes on the magnitude of DDIs was then analyzed by comparing the exposure of a medication in presence and absence of an interacting drug for the special population relative to the control population. Aging does not alter the magnitude of DDIs as the related physiological changes impact the victim and perpetrator drugs to a similar extent, regardless of their elimination pathway. Conversely, the magnitude of DDIs can be changed in obese individuals or pregnant women, as these conditions impact drugs to different extents depending on their metabolic pathway.
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Pharmacokinetic Changes during Pregnancy According to Genetic Variants: a Prospective Study in HIV-Infected Patients Receiving Atazanavir-Ritonavir. Antimicrob Agents Chemother 2018; 62:AAC.00309-18. [PMID: 29760129 DOI: 10.1128/aac.00309-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/21/2018] [Indexed: 01/11/2023] Open
Abstract
Atazanavir-ritonavir concentrations change over time during pregnancy in HIV-positive patients; the impact of genetic variants is unknown. Twenty patients were enrolled in this study; plasma and intracellular concentrations of antiretrovirals were measured, in addition to single-nucleotide polymorphisms in transport-related genes. Linear logistic regression showed that genetic variants in organic-anion-transporter-1B1- and pregnane-X-receptor-encoding genes affected third-trimester atazanavir exposure. In this prospective study, genetic variants partially explained the observed interpatient variability in third-trimester exposure to antiretrovirals.
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Focà E, Calcagno A, Bonito A, Simiele M, Domenighini E, D'Avolio A, Quiros Roldan E, Trentini L, Casari S, Di Perri G, Castelli F, Bonora S. Atazanavir intracellular concentrations remain stable during pregnancy in HIV-infected patients. J Antimicrob Chemother 2018; 72:3163-3166. [PMID: 28961777 DOI: 10.1093/jac/dkx274] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 07/07/2017] [Indexed: 11/13/2022] Open
Abstract
Background Atazanavir (300 mg) boosted by ritonavir (100 mg) is the preferred third drug in pregnancy. However, there is still discordance on atazanavir dose increase during the third trimester. Objectives To evaluate plasma and intracellular atazanavir and ritonavir concentrations in HIV-infected women during pregnancy and after delivery. Methods This was an observational study. HIV-infected pregnant patients treated with atazanavir/ritonavir plus either tenofovir/emtricitabine or abacavir/lamivudine had been prospectively enrolled after having signed a written informed consent form. Plasma and intracellular atazanavir and ritonavir Ctrough (24 ± 3 h after drug intake) were measured at each visit during the first, second and third trimesters and post-partum using validated HPLC-MS and HPLC-photodiode array methods (with direct evaluation of cellular volume). Data are described as median (IQR) and compared through non-parametric tests. Results Twenty-five patients were enrolled; at baseline, the median age was 32 years (27-35). All patients had plasma HIV RNA <50 copies/mL; the median CD4+ count was 736 cells/mm3 (542-779). Atazanavir plasma concentrations were 441 ng/mL (261-1557), 710 ng/mL (338-1085), 556 ng/mL (334-1022) and 837 ng/mL (608-1757) during the first, second and third trimesters and post-partum, respectively; intracellular concentrations were 743 ng/mL (610-1928), 808 ng/mL (569-1620), 756 ng/mL (384-1074) and 706 ng/mL (467-2688), respectively. Atazanavir intracellular/plasma ratios were 1.32 (0.98-2.77), 1.34 (1.13-1.88), 1.38 (0.61-2.63) and 1.07 (0.56-2.69), respectively. Atazanavir intracellular concentrations and intracellular/plasma ratios showed non-significant changes over time (P > 0.05). Conclusions This is the first demonstration that intracellular atazanavir exposure remains unchanged during pregnancy supporting the standard 300/100 mg atazanavir/ritonavir dosing throughout pregnancy.
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Affiliation(s)
- Emanuele Focà
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, University of Brescia and Spedali Civili General Hospital, Brescia, Italy
| | - Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Andrea Bonito
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, University of Brescia and Spedali Civili General Hospital, Brescia, Italy
| | - Marco Simiele
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Elisabetta Domenighini
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, University of Brescia and Spedali Civili General Hospital, Brescia, Italy
| | - Antonio D'Avolio
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | | | - Laura Trentini
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Salvatore Casari
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, University of Brescia and Spedali Civili General Hospital, Brescia, Italy
| | - Giovanni Di Perri
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Francesco Castelli
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, University of Brescia and Spedali Civili General Hospital, Brescia, Italy
| | - Stefano Bonora
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
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Postorino MC, Prosperi M, Focà E, Quiros-Roldan E, Di Filippo E, Maggiolo F, Borghetti A, Ladisa N, Di Pietro M, Gori A, Sighinolfi L, Pan A, Mazzini N, Torti C. Role of systemic inflammation scores for prediction of clinical outcomes in patients treated with atazanavir not boosted by ritonavir in the Italian MASTER cohort. BMC Infect Dis 2017; 17:212. [PMID: 28298195 PMCID: PMC5353877 DOI: 10.1186/s12879-017-2322-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/11/2017] [Indexed: 11/10/2022] Open
Abstract
Background Atazanavir (ATV) not boosted by ritonavir (uATV) has been frequently used in the past for switching combination antiretroviral therapy (cART). However, the clinical outcomes and predictors of such strategy are unknown. Methods An observational study was carried out on the Italian MASTER, selecting HIV infected patients on cART switching to an uATV-containing regimen. Baseline was set as the last visit before uATV initiation. In the primary analysis, a composite clinical end-point was defined as the first occurring of any condition among: liver, cardiovascular, kidney, diabetes, non AIDS related cancer or death events. Incidence of AIDS events and incidence of composite clinical end-point were estimated. Kaplan-Meier and multivariable Cox regression analysis were used to assess predictors of the composite clinical end-point. Results 436 patients were observed. The majority of patients were males (61.5%) and Italians (85.3%), mean age was 42.7 years (IQR: 37.7–42), the most frequent route of transmission was heterosexual intercourse (47%), followed by injection drug use (25%) and homosexual contact (24%); the rate of HCV-Ab positivity was 16.3%. Patients were observed for a median time of 882 days (IQR: 252-1,769) under uATV. We recorded 93 clinical events (3 cardiovascular events, 20 kidney diseases, 33 liver diseases, 9 non AIDS related cancers, 21 diabetes, 7 AIDS events), and 19 deaths, accounting for an incidence of 3.7 (composite) events per 100 PYFU. At multivariable analysis, factors associated with the composite clinical end-point were intravenous drug use as risk factor for HIV acquisition vs. heterosexual intercourses [HR: 2.608, 95% CI 1.31–5.19, p = 0.0063], HIV RNA per Log10 copies/ml higher [HR: 1.612, 95% CI 1.278–2.034, p < 0.0001], number of switches in the nucleoside/nucleotide (NRTI) backbone of cART (performed to compose the uATV regimen under study or occurred in the past) per each more [HR: 1.085, 95% CI 1.025–1.15, p = 0.0051], Fib-4 score per unit higher [HR: 1.03, 95% CI 1.018–1.043, p < 0.0001] and Neutrophil/lymphocytes ratio (NLR inflammation score) per Log10 higher [HR: 1.319, 95% CI 1.047–1.662, p = 0.0188]. Conclusions Intravenous drug users with high HIV RNA, high Fib-4 levels and more heavily exposed to antiretroviral drugs appeared to be more at risk of clinical events. Interestingly, high levels of inflammation measured through NLR, were also associated with clinical events. So, these patients should be monitored more strictly.
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Affiliation(s)
- Maria Concetta Postorino
- Infectious and Tropical Diseases Unit, Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Mattia Prosperi
- Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, USA
| | - Emanuele Focà
- University Department of Infectious and Tropical Diseases, University of Brescia and Spedali Civili General Hospital, Brescia, Italy
| | - Eugenia Quiros-Roldan
- University Department of Infectious and Tropical Diseases, University of Brescia and Spedali Civili General Hospital, Brescia, Italy
| | - Elisa Di Filippo
- Clinic of Infectious Diseases of "Papa Giovanni XXIII" Hospital of Bergamo, Bergamo, Italy
| | - Franco Maggiolo
- Clinic of Infectious Diseases of "Papa Giovanni XXIII" Hospital of Bergamo, Bergamo, Italy
| | - Alberto Borghetti
- Institute of Clinical Infectious Diseases of Catholic University of Sacred Heart, Rome, Italy
| | | | - Massimo Di Pietro
- Clinic of Infectious Diseases of "Azienda Ospedaliera S.M. Annunziata", Florence, Italy
| | - Andrea Gori
- Clinic of Infectious Diseases, San Gerardo de' Tintori Hospital, Monza, Italy
| | - Laura Sighinolfi
- Clinic of Infectious Diseases of "Azienda Ospedaliera S. Anna" of Ferrara, Ferrara, Italy
| | - Angelo Pan
- Clinic of Infectious Diseases of "Istituti Ospitalieri" of Cremona, Cremona, Italy
| | | | - Carlo Torti
- Infectious and Tropical Diseases Unit, Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy.
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Abstract
HIV-1-infected patients with suppressed plasma viral loads often require changes to their antiretroviral (ARV) therapy to manage drug toxicity and intolerance, to improve adherence, and to avoid drug interactions. In patients who have never experienced virologic failure while receiving ARV therapy and who have no evidence of drug resistance, switching to any of the acceptable US Department of Health and Human Services first-line therapies is expected to maintain virologic suppression. However, in virologically suppressed patients with a history of virologic failure or drug resistance, it can be more challenging to change therapy while still maintaining virologic suppression. In these patients, it may be difficult to know whether the discontinuation of one of the ARVs in a suppressive regimen constitutes the removal of a key regimen component that will not be adequately supplanted by one or more substituted ARVs. In this article, we review many of the clinical scenarios requiring ARV therapy modification in patients with stable virologic suppression and outline the strategies for modifying therapy while maintaining long-term virologic suppression.
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Llibre JM, Cozzi-Lepri A, Pedersen C, Ristola M, Losso M, Mocroft A, Mitsura V, Falconer K, Maltez F, Beniowski M, Vullo V, Hassoun G, Kuzovatova E, Szlavik J, Kuznetsova A, Stellbrink HJ, Duvivier C, Edwards S, Laut K, Paredes R. Long-term effectiveness of unboosted atazanavir plus abacavir/lamivudine in subjects with virological suppression: A prospective cohort study. Medicine (Baltimore) 2016; 95:e5020. [PMID: 27749561 PMCID: PMC5059063 DOI: 10.1097/md.0000000000005020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Effectiveness data of an unboosted atazanavir (ATV) with abacavir/lamivudine (ABC/3TC) switch strategy in clinical routine are scant.We evaluated treatment outcomes of ATV + ABC/3TC in pretreated subjects in the EuroSIDA cohort when started with undetectable plasma HIV-1 viral load (pVL), performing a time to loss of virological response (TLOVR <50 copies/mL) and a snapshot analysis at 48, 96, and 144 weeks. Virological failure (VF) was defined as confirmed pVL >50 copies/mL.We included 285 subjects, 67% male, with median baseline CD4 530 cells, and 44 months with pVL ≤50 copies/mL. The third drug in the previous regimen was ritonavir-boosted atazanavir (ATV/r) in 79 (28%), and another ritonavir-boosted protease inhibitor (PI/r) in 29 (10%). Ninety (32%) had previously failed with a PI. Proportions of people with virological success at 48/96/144 weeks were 90%/87%/88% (TLOVR) and 74%/67%/59% (snapshot analysis), respectively. The rates of VF were 8%/8%/6%. Rates of adverse events leading to study discontinuation were 0.4%/1%/2%. The multivariable adjusted analysis showed an association between VF and nadir CD4+ (hazard ratio [HR] 0.63 [95% confidence interval [CI]: 0.42-0.93] per 100 cells higher), time with pVL ≤50 copies/mL (HR 0.87 [95% CI: 0.79-0.96] per 6 months longer), and previous failure with a PI (HR 2.78 [95% CI: 1.28-6.04]). Resistance selection at failure was uncommon.A switch to ATV + ABC/3TC in selected subjects with suppressed viremia was associated with low rates of VF and discontinuation due to adverse events, even in subjects not receiving ATV/r. The strategy might be considered in those with long-term suppression and no prior PI failure.
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Affiliation(s)
- Josep M. Llibre
- Infectious Diseases and “Lluita contra la SIDA” Foundation, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
- Correspondence: Josep M. Llibre, HIV Unit, Hospital Universitari Germans Trias i Pujol, Ctra de Canyet, s/n, 08916 Badalona, Barcelona, Spain (e-mail: )
| | - Alessandro Cozzi-Lepri
- Research Department of Infection and Population Health, University College London, London, UK
| | - Court Pedersen
- Odense University Hospital, Department of Infectious Diseases, Odense, Denmark
| | - Matti Ristola
- Helsinki University Hospital, Department of Infectious Diseases, Helsinki, Finland
| | - Marcelo Losso
- Hospital General de Agudos JM Ramos Mejía, Department of Infectious Diseases, Buenos Aires, Argentina
| | - Amanda Mocroft
- Department of Epidemiology and Medical Statistics, University College London, London, UK
| | - Viktar Mitsura
- Department of Infectious Diseases, Gomel State Medical University, Gomel, Belarus
| | | | - Fernando Maltez
- Curry Cabral Hospital, Department of Infectious Diseases, Lisbon, Portugal
| | - Marek Beniowski
- Specialistic Hospital, Outpatient Clinic for AIDS Diagnostics and Therapy, Chorzów, Poland
| | | | | | - Elena Kuzovatova
- Nizhny Novgorod Scientific and Research Institute of Epidemiology and Microbiology named after Academician I.N. Blokhina, Russia
| | | | | | | | - Claudine Duvivier
- Infectious Diseases Center Necker-Pasteur, APHP-Hôpital Necker-Enfants Malades, Paris, France
| | | | - Kamilla Laut
- Centre for Health & Infectious Diseases Research (CHIP), Department of Infectious Diseases, Section 2100, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Roger Paredes
- Infectious Diseases and “Lluita contra la SIDA” Foundation, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
- Irsi-Caixa AIDS Research Institute, Badalona, Spain
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Focà E, Nunnari G, Calcagno A. The good, the bad and the ugly: determinants of antiretroviral-associated toxicities. Future Virol 2016. [DOI: 10.2217/fvl-2016-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Emanuele Focà
- Department of Infectious & Tropical Diseases, University of Brescia, Brescia, Italy
| | - Giuseppe Nunnari
- Division of Infectious Diseases, Department of Clinical & Experimental Medicine, AOU G Martino, University of Messina, Messina, Italy
- Department of Microbiology, Thomas Jefferson University, Philadelphia, USA
| | - Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, c/o Ospedale Amedeo di Savoia, C so Svizzera 164, 10159, Torino, Italy
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Lin KY, Liao SH, Liu WC, Cheng A, Lin SW, Chang SY, Tsai MS, Kuo CH, Wu MR, Wang HP, Hung CC, Chang SC. Cholelithiasis and Nephrolithiasis in HIV-Positive Patients in the Era of Combination Antiretroviral Therapy. PLoS One 2015; 10:e0137660. [PMID: 26360703 PMCID: PMC4567270 DOI: 10.1371/journal.pone.0137660] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 08/19/2015] [Indexed: 12/25/2022] Open
Abstract
Objectives This study aimed to describe the epidemiology and risk factors of cholelithiasis and nephrolithiasis among HIV-positive patients in the era of combination antiretroviral therapy. Methods We retrospectively reviewed the medical records of HIV-positive patients who underwent routine abdominal sonography for chronic viral hepatitis, fatty liver, or elevated aminotransferases between January 2004 and January 2015. Therapeutic drug monitoring of plasma concentrations of atazanavir was performed and genetic polymorphisms, including UDP-glucuronosyltransferase (UGT) 1A1*28 and multidrug resistance gene 1 (MDR1) G2677T/A, were determined in a subgroup of patients who received ritonavir-boosted or unboosted atazanavir-containing combination antiretroviral therapy. Information on demographics, clinical characteristics, and laboratory testing were collected and analyzed. Results During the 11-year study period, 910 patients who underwent routine abdominal sonography were included for analysis. The patients were mostly male (96.9%) with a mean age of 42.2 years and mean body-mass index of 22.9 kg/m2 and 85.8% being on antiretroviral therapy. The anchor antiretroviral agents included non-nucleoside reverse-transcriptase inhibitors (49.3%), unboosted atazanavir (34.4%), ritonavir-boosted lopinavir (20.4%), and ritonavir-boosted atazanavir (5.5%). The overall prevalence of cholelithiasis and nephrolithiasis was 12.5% and 8.2%, respectively. Among 680 antiretroviral-experienced patients with both baseline and follow-up sonography, the crude incidence of cholelithiasis and nephrolithiasis was 4.3% and 3.7%, respectively. In multivariate analysis, the independent factors associated with incident cholelithiasis were exposure to ritonavir-boosted atazanavir for >2 years (adjusted odds ratio [AOR], 6.29; 95% confidence interval [CI], 1.12–35.16) and older age (AOR, 1.04; 95% CI, 1.00–1.09). The positive association between duration of exposure to ritonavir-boosted atazanavir and incident cholelithiasis was also found (AOR, per 1-year exposure, 1.49; 95% CI, 1.05–2.10). The associated factors with incident nephrolithiasis were hyperlipidemia (AOR, 3.97; 95% CI, 1.32–11.93), hepatitis B or C coinfection (AOR, 3.41; 95% CI, 1.09–10.62), and exposure to abacavir (AOR, 12.01; 95% CI, 1.54–93.54). Of 180 patients who underwent therapeutic drug monitoring of plasma atazanavir concentrations and pharmacogenetic investigations, we found that the atazanavir concentrations and UGT 1A1*28 and MDR1 G2677T/A polymorphisms were not statistically significantly associated with incident cholelithiasis and nephrolithiasis. Conclusions In HIV-positive patients in the era of combination antiretroviral therapy, a high prevalence of cholelithiasis and nephrolithiasis was observed, and exposure to ritonavir-boosted atazanavir for >2 years was associated with incident cholelithiasis.
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Affiliation(s)
- Kuan-Yin Lin
- Division of Infectious Diseases, Department of Internal Medicine, Taipei City Hospital, Kun-Ming Branch, Taipei, Taiwan
| | - Sih-Han Liao
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Wen-Chun Liu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Aristine Cheng
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Shu-Wen Lin
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Pharmacy, National Taiwan University, Taipei, Taiwan
| | - Sui-Yuan Chang
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Clinical Laboratory Sciences and Medical Biotechnology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Mao-Song Tsai
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Ching-Hua Kuo
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
- School of Pharmacy, National Taiwan University, Taipei, Taiwan
| | - Mon-Ro Wu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- * E-mail: (CCH); (HPW)
| | - Chien-Ching Hung
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
- China Medical University, Taichung, Taiwan
- * E-mail: (CCH); (HPW)
| | - Shan-Chwen Chang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Metabolic and kidney disorders correlate with high atazanavir concentrations in HIV-infected patients: is it time to revise atazanavir dosages? PLoS One 2015; 10:e0123670. [PMID: 25875091 PMCID: PMC4398451 DOI: 10.1371/journal.pone.0123670] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 03/06/2015] [Indexed: 01/11/2023] Open
Abstract
Introduction Ritonavir-boosted atazanavir (ATV/r) is a relatively well tolerated antiretroviral drug. However, side effects including hyperbilirubinemia, dyslipidemia, nephrolithiasis and cholelithiasis have been reported in the medium and long term. Unboosted ATV may be selected for some patients because it has fewer gastrointestinal adverse effects, less hyperbilirubinemia and less impact on lipid profiles. Methods We investigated the distribution of ATV plasma trough concentrations according to drug dosage and the potential relationship between ATV plasma trough concentrations and drug-related adverse events in a consecutive series of 240 HIV-infected patients treated with ATV/r 300/100 mg (68%) or ATV 400 mg (32%). Results 43.9% of patients treated with ATV/r 300/100 mg had ATV concentrations exceeding the upper therapeutic threshold. A significant and direct association has been observed between the severity of hyperbilirubinemia and ATV plasma trough concentrations (ATV concentrations: 271 [77–555], 548 [206–902], 793 [440–1164], 768 [494–1527] and 1491 [1122–1798] ng/mL in patients with grade 0, 1, 2, 3 and 4 hyperbilirubinemia, respectively). In an exploratory analysis we found that patients with dyslipidemia or nephrolitiasis had ATV concentrations significantly higher (582 [266–1148], and 1098 [631–1238] ng/mL, respectively) (p<0.001), as compared with patients with no ATV-related complications (218 [77–541] ng/mL). Conclusions A significant proportion of patients treated with the conventional dosage of ATV (300/100) had plasma concentrations exceeding the upper therapeutic threshold. These patients that are at high risk to experience ATV-related complications may benefit from TDM-driven adjustments in ATV dosage with potential advantages in terms of costs and toxicity.
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French 2013 guidelines for antiretroviral therapy of HIV-1 infection in adults. J Int AIDS Soc 2014; 17:19034. [PMID: 24942364 PMCID: PMC4062879 DOI: 10.7448/ias.17.1.19034] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 04/28/2014] [Accepted: 05/01/2014] [Indexed: 12/18/2022] Open
Abstract
Introduction These guidelines are part of the French Experts’ recommendations for the management of people living with HIV/AIDS, which were made public and submitted to the French health authorities in September 2013. The objective was to provide updated recommendations for antiretroviral treatment (ART) of HIV-positive adults. Guidelines included the following topics: when to start, what to start, specific situations for the choice of the first session of antiretroviral therapy, optimization of antiretroviral therapy after virologic suppression, and management of virologic failure. Methods Ten members of the French HIV 2013 expert group were responsible for guidelines on ART. They systematically reviewed the most recent literature. The chairman of the subgroup was responsible for drafting the guidelines, which were subsequently discussed within, and finalized by the whole expert group to obtain a consensus. Recommendations were graded for strength and level of evidence using predefined criteria. Economic considerations were part of the decision-making process for selecting preferred first-line options. Potential conflicts of interest were actively managed throughout the whole process. Results ART should be initiated in any HIV-positive person, whatever his/her CD4 T-cell count, even when >500/mm3. The level of evidence of the individual benefit of ART in terms of mortality or progression to AIDS increases with decreasing CD4 cell count. Preferred initial regimens include two nucleoside reverse transcriptase inhibitors (tenofovir/emtricitabine or abacavir/lamivudine) plus a non-nucleoside reverse transcriptase inhibitor (efavirenz or rilpivirine), or a ritonavir-boosted protease inhibitor (atazanavir or darunavir). Raltegravir, lopinavir/r, and nevirapine are recommended as alternative third agents, with specific indications and restrictions. Specific situations such as HIV infection in women, primary HIV infection, severe immune suppression with or without identified opportunistic infection, and person who injects drugs are addressed. Options for optimization of ART once virologic suppression is achieved are discussed. Evaluation and management of virologic failure are described, the aim of any intervention in such situation being to reduce plasma viral load to <50 copies/ml. Conclusion These guidelines recommend that any HIV-positive individual should be treated with ART. This recommendation was issued both for the patient’s own sake and for promoting treatment as prevention.
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Baril J, Conway B, Giguère P, Ferko N, Hollmann S, Angel JB. A meta-analysis of the efficacy and safety of unboosted atazanavir compared with ritonavir-boosted protease inhibitor maintenance therapy in HIV-infected adults with established virological suppression after induction. HIV Med 2013; 15:301-10. [PMID: 24314017 DOI: 10.1111/hiv.12118] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Treatment simplification involving induction with a ritonavir (RTV)-boosted protease inhibitor (PI) replaced by a nonboosted PI (i.e. atazanavir) has been shown to be a viable option for long-term antiretroviral therapy. To evaluate the clinical evidence for this approach, we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating efficacy and safety in patients with established virological suppression. METHODS Several databases were searched without limits on time or language. Searches of conferences were also conducted. RCTs were included if they compared a PI/RTV regimen to unboosted atazanavir, after induction with PI/RTV. The meta-analysis was conducted using a random effects model for the proportion achieving virological suppression (i.e. HIV RNA < 50 and <400 HIV-1 RNA copies/mL), CD4 cell counts, lipid levels and liver function tests. Dichotomous outcomes were reported as risk ratios (RRs) and continuous outcomes as mean differences (MDs). RESULTS Five studies (n = 1249) met the inclusion criteria. The meta-analysis demonstrated no statistically significant difference in efficacy (i.e. HIV RNA < 50 copies/mL) between PI/RTV and unboosted atazanavir [RR = 1.04; 95% confidence interval (CI) 0.99 to 1.10], with no heterogeneity. Findings were similar in a subanalysis of studies where atazanavir/RTV was the only PI/RTV used during induction. Additional efficacy results support these findings. A significant reduction in total cholesterol (P < 0.00001), triglycerides (P = 0.0002), low-density lipoprotein (LDL) cholesterol (P = 0.009) and hyperbilirubinaemia (P = 0.02) was observed with unboosted atazanavir vs. PI/RTV. CONCLUSIONS The meta-analysis demonstrated that switching patients with virological suppression from an RTV-boosted PI to unboosted atazanavir leads to improvements in safety (i.e. blood parameter abnormalities) without sacrificing virological efficacy.
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Affiliation(s)
- J Baril
- Hospital of the University of Montreal, Montréal, QC, Canada
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Goutelle S, Baudry T, Gagnieu MC, Boibieux A, Livrozet JM, Peyramond D, Chidiac C, Tod M, Ferry T. Pharmacokinetic-pharmacodynamic modeling of unboosted Atazanavir in a cohort of stable HIV-infected patients. Antimicrob Agents Chemother 2013; 57:517-23. [PMID: 23147727 PMCID: PMC3535925 DOI: 10.1128/aac.01822-12] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 11/03/2012] [Indexed: 11/20/2022] Open
Abstract
Limited data on the pharmacokinetics and pharmacodynamics (PK/PD) of unboosted atazanavir (uATV) in treatment-experienced patients are available. The aim of this work was to study the PK/PD of unboosted atazanavir in a cohort of HIV-infected patients. Data were available for 58 HIV-infected patients (69 uATV-based regimens). Atazanavir concentrations were analyzed by using a population approach, and the relationship between atazanavir PK and clinical outcome was examined using logistic regression. The final PK model was a linear one-compartment model with a mixture absorption model to account for two subgroups of absorbers. The mean (interindividual variability) of population PK parameters were as follows: clearance, 13.4 liters/h (40.7%), volume of distribution, 71.1 liters (29.7%), and fraction of regular absorbers, 0.49. Seven subjects experienced virological failure after switch to uATV. All of them were identified as low absorbers in the PK modeling. The absorption rate constant (0.38 ± 0.20 versus 0.75 ± 0.28 h(-1); P = 0.002) and ATV exposure (area under the concentration-time curve from 0 to 24 h [AUC(0-24)], 10.3 ± 2.1 versus 22.4 ± 11.2 mg · h · liter(-1); P = 0.001) were significantly lower in patients with virological failure than in patients without failure. In the logistic regression analysis, both the absorption rate constant and ATV trough concentration significantly influenced the probability of virological failure. A significant relationship between ATV pharmacokinetics and virological response was observed in a cohort of HIV patients who were administered unboosted atazanavir. This study also suggests that twice-daily administration of uATV may optimize drug therapy.
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Affiliation(s)
- Sylvain Goutelle
- Service Pharmaceutique—Groupement Hospitalier de Gériatrie
- Université Claude Bernard Lyon 1, Lyon, France
- Laboratoire de Biométrie et Biologie Evolutive, UMR CNRS 5558, Villeurbanne, France
| | - Thomas Baudry
- Service de Maladies Infectieuses et Tropicales
- Université Claude Bernard Lyon 1, Lyon, France
| | - Marie-Claude Gagnieu
- Laboratoire de Biochimie et Biologie Moléculaire—UF de Pharmacologie Spécialisée, Groupement Hospitalier E. Herriot
| | | | | | - Dominique Peyramond
- Service de Maladies Infectieuses et Tropicales
- Université Claude Bernard Lyon 1, Lyon, France
| | - Christian Chidiac
- Service de Maladies Infectieuses et Tropicales
- Université Claude Bernard Lyon 1, Lyon, France
- INSERM U851, Immunité, Infection, Vaccination, Lyon, France
| | - Michel Tod
- Service Pharmaceutique, Groupement Hospitalier Nord
- Université Claude Bernard Lyon 1, Lyon, France
| | - Tristan Ferry
- Service de Maladies Infectieuses et Tropicales
- Université Claude Bernard Lyon 1, Lyon, France
- INSERM U851, Immunité, Infection, Vaccination, Lyon, France
| | - on behalf of the Lyon HIV Cohort Study Group
- Service Pharmaceutique—Groupement Hospitalier de Gériatrie
- Service de Maladies Infectieuses et Tropicales
- Laboratoire de Biochimie et Biologie Moléculaire—UF de Pharmacologie Spécialisée, Groupement Hospitalier E. Herriot
- Service Pharmaceutique, Groupement Hospitalier Nord
- Service d'Immunologie Clinique, Hospices Civils de Lyon, Lyon, France
- Université Claude Bernard Lyon 1, Lyon, France
- Laboratoire de Biométrie et Biologie Evolutive, UMR CNRS 5558, Villeurbanne, France
- INSERM U851, Immunité, Infection, Vaccination, Lyon, France
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15
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De Clercq E. The nucleoside reverse transcriptase inhibitors, nonnucleoside reverse transcriptase inhibitors, and protease inhibitors in the treatment of HIV infections (AIDS). ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2013; 67:317-58. [PMID: 23886005 DOI: 10.1016/b978-0-12-405880-4.00009-3] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The majority of the drugs currently used for the treatment of HIV infections (AIDS) belong to either of the following three classes: nucleoside reverse transcriptase inhibitors (NRTIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), and protease inhibitors (PIs). At present, there are 7 NRTIs, 5 NNRTIs, and 10 PIs approved for clinical use. They are discussed from the following viewpoints: (i) chemical formulae; (ii) mechanism of action; (iii) drug combinations; (iv) clinical aspects; (v) preexposure prophylaxis; (vi) prevention of mother-to-child transmission; (vii) their use in children; (viii) toxicity; (ix) adherence (compliance); (x) resistance; (xi) new NRTIs, NNRTIs, or PIs in (pre)clinical development; and (xii) the prospects for a "cure" of the disease.
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Affiliation(s)
- Erik De Clercq
- Rega Institute for Medical Research, KU Leuven, Leuven, Belgium.
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