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Westberg SM, Arellano R, Cieri-Hutcherson NE, Heinrich NT, Herman AM, Lodise NM, McBane S, Ofili TU, O'Grady N, Sankey KH. Pharmacotherapy of Chronic Neuropsychiatric Conditions During Pregnancy. Nurs Womens Health 2024; 28:227-241. [PMID: 38702041 DOI: 10.1016/j.nwh.2023.12.003] [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: 07/27/2023] [Revised: 12/08/2023] [Accepted: 03/28/2024] [Indexed: 05/06/2024]
Abstract
Many pregnant persons will experience neuropsychiatric conditions during pregnancy, including migraine, attention deficit disorder, depression, and anxiety. Treatment of each of these conditions requires shared decision-making among the individual, family, and health care team. Although medications may include risk, the benefits often outweigh the potential fetal risks. In this article, we review pharmacologic treatment options for each of these conditions and appropriate use in pregnancy to maintain the stability of conditions and to optimize maternal and fetal outcomes.
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Han LW, Wang L, Shi Y, Dempsey JL, Pershutkina OV, Dutta M, Bammler TK, Cui JY, Mao Q. Impact of Microbiome on Hepatic Metabolizing Enzymes and Transporters in Mice during Pregnancy. Drug Metab Dispos 2020; 48:708-722. [PMID: 32499338 PMCID: PMC7434050 DOI: 10.1124/dmd.120.000039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 05/12/2020] [Indexed: 12/30/2022] Open
Abstract
The microbiome and pregnancy are known to alter drug disposition, yet the interplay of the two physiologic factors on the expression and/or activity of drug metabolizing enzymes and transporters (DMETs) is unknown. This study investigated the effects of microbiome on host hepatic DMETs in mice during pregnancy by comparing four groups of conventional (CV) and germ-free (GF) female mice and pregnancy status, namely, CV nonpregnant, GF non-pregnant, CV pregnant, and GF pregnant mice. Transcriptomic and targeted proteomics of hepatic DMETs were profiled by using multiomics. Plasma bile acid and steroid hormone levels were quantified by liquid chromatography tandem mass spectrometry. CYP3A activities were measured by mouse liver microsome incubations. The trend of pregnancy-induced changes in the expression or activity of hepatic DMETs in CV and GF mice was similar; however, the magnitude of change was noticeably different. For certain DMETs, pregnancy status had paradoxical effects on mRNA and protein expression in both CV and GF mice. For instance, the mRNA levels of Cyp3a11, the murine homolog of human CYP3A4, were decreased by 1.7-fold and 3.3-fold by pregnancy in CV and GF mice, respectively; however, the protein levels of CYP3A11 were increased similarly ∼twofold by pregnancy in both CV and GF mice. Microsome incubations revealed a marked induction of CYP3A activity by pregnancy that was 10-fold greater in CV mice than that in GF mice. This is the first study to show that the microbiome can alter the expression and/or activity of hepatic DMETs in pregnancy. SIGNIFICANCE STATEMENT: We demonstrated for the first time that microbiome and pregnancy can interplay to alter the expression and/or activity of hepatic drug metabolizing enzymes and transporters. Though the trend of pregnancy-induced changes in the expression or activity of hepatic drug metabolizing enzymes and transporters in conventional and germ-free mice was similar, the magnitude of change was noticeably different.
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Affiliation(s)
- Lyrialle W Han
- Departments of Pharmaceutics (L.W.H., Q.M.) and Medicinal Chemistry (Y.S.), School of Pharmacy, Departments of Environmental and Occupational Health Sciences, School of Public Health (L.W., J.L.D., M.D., T.K.B., J.Y.C.), and Department of Comparative Medicine, School of Medicine (O.V.P.), University of Washington, Seattle, Washington
| | - Lu Wang
- Departments of Pharmaceutics (L.W.H., Q.M.) and Medicinal Chemistry (Y.S.), School of Pharmacy, Departments of Environmental and Occupational Health Sciences, School of Public Health (L.W., J.L.D., M.D., T.K.B., J.Y.C.), and Department of Comparative Medicine, School of Medicine (O.V.P.), University of Washington, Seattle, Washington
| | - Yuanyuan Shi
- Departments of Pharmaceutics (L.W.H., Q.M.) and Medicinal Chemistry (Y.S.), School of Pharmacy, Departments of Environmental and Occupational Health Sciences, School of Public Health (L.W., J.L.D., M.D., T.K.B., J.Y.C.), and Department of Comparative Medicine, School of Medicine (O.V.P.), University of Washington, Seattle, Washington
| | - Joseph L Dempsey
- Departments of Pharmaceutics (L.W.H., Q.M.) and Medicinal Chemistry (Y.S.), School of Pharmacy, Departments of Environmental and Occupational Health Sciences, School of Public Health (L.W., J.L.D., M.D., T.K.B., J.Y.C.), and Department of Comparative Medicine, School of Medicine (O.V.P.), University of Washington, Seattle, Washington
| | - Olesya V Pershutkina
- Departments of Pharmaceutics (L.W.H., Q.M.) and Medicinal Chemistry (Y.S.), School of Pharmacy, Departments of Environmental and Occupational Health Sciences, School of Public Health (L.W., J.L.D., M.D., T.K.B., J.Y.C.), and Department of Comparative Medicine, School of Medicine (O.V.P.), University of Washington, Seattle, Washington
| | - Moumita Dutta
- Departments of Pharmaceutics (L.W.H., Q.M.) and Medicinal Chemistry (Y.S.), School of Pharmacy, Departments of Environmental and Occupational Health Sciences, School of Public Health (L.W., J.L.D., M.D., T.K.B., J.Y.C.), and Department of Comparative Medicine, School of Medicine (O.V.P.), University of Washington, Seattle, Washington
| | - Theo K Bammler
- Departments of Pharmaceutics (L.W.H., Q.M.) and Medicinal Chemistry (Y.S.), School of Pharmacy, Departments of Environmental and Occupational Health Sciences, School of Public Health (L.W., J.L.D., M.D., T.K.B., J.Y.C.), and Department of Comparative Medicine, School of Medicine (O.V.P.), University of Washington, Seattle, Washington
| | - Julia Y Cui
- Departments of Pharmaceutics (L.W.H., Q.M.) and Medicinal Chemistry (Y.S.), School of Pharmacy, Departments of Environmental and Occupational Health Sciences, School of Public Health (L.W., J.L.D., M.D., T.K.B., J.Y.C.), and Department of Comparative Medicine, School of Medicine (O.V.P.), University of Washington, Seattle, Washington
| | - Qingcheng Mao
- Departments of Pharmaceutics (L.W.H., Q.M.) and Medicinal Chemistry (Y.S.), School of Pharmacy, Departments of Environmental and Occupational Health Sciences, School of Public Health (L.W., J.L.D., M.D., T.K.B., J.Y.C.), and Department of Comparative Medicine, School of Medicine (O.V.P.), University of Washington, Seattle, Washington
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Behura SK, Dhakal P, Kelleher AM, Balboula A, Patterson A, Spencer TE. The brain-placental axis: Therapeutic and pharmacological relevancy to pregnancy. Pharmacol Res 2019; 149:104468. [PMID: 31600597 PMCID: PMC6944055 DOI: 10.1016/j.phrs.2019.104468] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/23/2019] [Accepted: 09/27/2019] [Indexed: 12/22/2022]
Abstract
The placenta plays a critical role in mammalian reproduction. Although it is a transient organ, its function is indispensable to communication between the mother and fetus, and supply of nutrients and oxygen to the growing fetus. During pregnancy, the placenta is vulnerable to various intrinsic and extrinsic conditions which can result in increased risk of fetal neurodevelopmental disorders as well as fetal death. The placenta controls the neuroendocrine secretion in the brain as a means of adaptive processes to safeguard the fetus from adverse programs, to optimize fetal development and other physiological changes necessary for reproductive success. Although a wealth of information is available on neuroendocrine functions in pregnancy, they are largely limited to the regulation of hypothalamus-pituitary-adrenal/gonad (HPA/ HPG) axis, particularly the oxytocin and prolactin system. There is a major gap in knowledge on systems-level functional interaction between the brain and placenta. In this review, we aim to outline the current state of knowledge about the brain-placental axis with description of the functional interactions between the placenta and the maternal and fetal brain. While describing the brain-placental interactions, a special emphasis has been given on the therapeutics and pharmacology of the placental receptors to neuroligands expressed in the brain during gestation. As a key feature of this review, we outline the prospects of integrated pharmacogenomics, single-cell sequencing and organ-on-chip systems to foster priority areas in this field of research. Finally, we remark on the application of precision genomics approaches to study the brain-placental axis in order to accelerate personalized medicine and therapeutics to treat placental and fetal brain disorders.
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Affiliation(s)
- Susanta K Behura
- Division of Animal Sciences, University of Missouri, United States; Informatics Institute, University of Missouri, United States.
| | - Pramod Dhakal
- Division of Animal Sciences, University of Missouri, United States
| | | | - Ahmed Balboula
- Division of Animal Sciences, University of Missouri, United States
| | - Amanda Patterson
- Division of Animal Sciences, University of Missouri, United States; Department of Obstetrics, Gynecology and Women's Health, University of Missouri, United States
| | - Thomas E Spencer
- Division of Animal Sciences, University of Missouri, United States; Department of Obstetrics, Gynecology and Women's Health, University of Missouri, United States
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Heinonen E, Szymanska-von Schultz B, Kaldo V, Nasiell J, Andersson E, Bergmark M, Blomdahl-Wetterholm M, Forsberg L, Forsell E, Forsgren A, Frööjd S, Goldman A, Nordenadler EM, Sklivanioti M, Blennow M, Wide K, Gustafsson LL. MAGDALENA: study protocol of a randomised, placebo-controlled trial on cognitive development at 2 years of age in children exposed to SSRI in utero. BMJ Open 2018; 8:e023281. [PMID: 30082365 PMCID: PMC6078226 DOI: 10.1136/bmjopen-2018-023281] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Ten per cent of all pregnant women are depressed. Standard therapy of pregnant women with moderate depression is selective serotonin reuptakeinhibitors (SSRI). Observational studies on neurodevelopment after fetal SSRI exposure show conflicting results. Our primary objective is to compare the cognitive development in children exposed to sertraline and maternal depression with those exposed to maternal depression and placebo in utero. We hypothesise that there is a significant neurodevelopmental difference between the groups. As a secondary objective, we study the add-on effect of sertraline to internet-based cognitive behavioural therapy (ICBT) to treat moderate depression during pregnancy. METHODS AND ANALYSIS MAGDALENA is a randomised, placebo-controlled, double-blinded trial in Stockholm Healthcare Region with 2.3 million inhabitants. The women are recruited in weeks 9-21 of pregnancy either through Antenatal Health Clinics or through social media. They are to be diagnosed with moderate depression without ongoing antidepressive therapy or any serious comorbidity. The women in the intervention arm receive sertraline combined with a 12-week period of ICBT; the control arm is treated with placebo and ICBT. We assess the cognitive development in the offspring at the age of 2 years using Bayley Scales of Infant and Toddler Development, third edition (BSID-III). We aim at recruiting 200 women, 100 women in each treatment arm, to ensure statistical power to detect a clinically relevant difference between the groups. ETHICS AND DISSEMINATION This randomised trial will provide long-sought evidence about the effects of SSRI and maternal depression during pregnancy on the neurodevelopment in the offspring. The study is approved by the Regional Ethical Review Board at Karolinska Institutet in Stockholm and the Swedish Medical Products Agency. It is registered with the European Clinical Trials Database (EudraCT), Number: 2013-004444-31. Results will be disseminated at scientific conferences, published in peer-reviewed journals and made available to the public. TRIAL REGISTRATION NUMBER EudraCT2013-004444-31; Pre-results.
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Affiliation(s)
- Essi Heinonen
- Division of Paediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Huddinge, Stockholm
- Department of Paediatrics, Karolinska University Hospital, Stockholm, Sweden
| | - Barbara Szymanska-von Schultz
- Division of Obstetrics and Gynaecology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynaecology, Karolinska University Hospital, Stockholm, Sweden
| | - Viktor Kaldo
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Psychiatry South West, Stockholm Health Care Region, Stockholm, Sweden
- Department of Psychology, Faculty of Health and Life Sciences, Linnaeus University, Stockholm, Växjö, Sweden
| | - Josefine Nasiell
- Division of Obstetrics and Gynaecology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynaecology, Karolinska University Hospital, Stockholm, Sweden
| | - Ewa Andersson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Mikaela Bergmark
- Psychiatry South West, Stockholm Health Care Region, Stockholm, Sweden
| | | | - Lisa Forsberg
- Division of Paediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Huddinge, Stockholm
- Department of Paediatrics, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Forsell
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Psychiatry South West, Stockholm Health Care Region, Stockholm, Sweden
| | - Anna Forsgren
- Division of Paediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Huddinge, Stockholm
| | - Sandra Frööjd
- Psychiatry South West, Stockholm Health Care Region, Stockholm, Sweden
| | - Amy Goldman
- Psychiatry South West, Stockholm Health Care Region, Stockholm, Sweden
| | | | - Myrto Sklivanioti
- Psychiatry South West, Stockholm Health Care Region, Stockholm, Sweden
| | - Mats Blennow
- Division of Paediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Huddinge, Stockholm
- Department of Paediatrics, Karolinska University Hospital, Stockholm, Sweden
| | - Katarina Wide
- Division of Paediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Huddinge, Stockholm
- Department of Paediatrics, Karolinska University Hospital, Stockholm, Sweden
| | - Lars L Gustafsson
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
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Ilekis JV, Tsilou E, Fisher S, Abrahams VM, Soares MJ, Cross JC, Zamudio S, Illsley NP, Myatt L, Colvis C, Costantine MM, Haas DM, Sadovsky Y, Weiner C, Rytting E, Bidwell G. Placental origins of adverse pregnancy outcomes: potential molecular targets: an Executive Workshop Summary of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Am J Obstet Gynecol 2016; 215:S1-S46. [PMID: 26972897 DOI: 10.1016/j.ajog.2016.03.001] [Citation(s) in RCA: 175] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 02/11/2016] [Accepted: 03/01/2016] [Indexed: 12/26/2022]
Abstract
Although much progress is being made in understanding the molecular pathways in the placenta that are involved in the pathophysiology of pregnancy-related disorders, a significant gap exists in the utilization of this information for the development of new drug therapies to improve pregnancy outcome. On March 5-6, 2015, the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health sponsored a 2-day workshop titled Placental Origins of Adverse Pregnancy Outcomes: Potential Molecular Targets to begin to address this gap. Particular emphasis was given to the identification of important molecular pathways that could serve as drug targets and the advantages and disadvantages of targeting these particular pathways. This article is a summary of the proceedings of that workshop. A broad number of topics were covered that ranged from basic placental biology to clinical trials. This included research in the basic biology of placentation, such as trophoblast migration and spiral artery remodeling, and trophoblast sensing and response to infectious and noninfectious agents. Research findings in these areas will be critical for the formulation of the development of future treatments and the development of therapies for the prevention of a number of pregnancy disorders of placental origin that include preeclampsia, fetal growth restriction, and uterine inflammation. Research was also presented that summarized ongoing clinical efforts in the United States and in Europe that has tested novel interventions for preeclampsia and fetal growth restriction, including agents such as oral arginine supplementation, sildenafil, pravastatin, gene therapy with virally delivered vascular endothelial growth factor, and oxygen supplementation therapy. Strategies were also proposed to improve fetal growth by the enhancement of nutrient transport to the fetus by modulation of their placental transporters and the targeting of placental mitochondrial dysfunction and oxidative stress to improve placental health. The roles of microRNAs and placental-derived exosomes, as well as messenger RNAs, were also discussed in the context of their use for diagnostics and as drug targets. The workshop discussed the aspect of safety and pharmacokinetic profiles of potential existing and new therapeutics that will need to be determined, especially in the context of the unique pharmacokinetic properties of pregnancy and the hurdles and pitfalls of the translation of research findings into practice. The workshop also discussed novel methods of drug delivery and targeting during pregnancy with the use of macromolecular carriers, such as nanoparticles and biopolymers, to minimize placental drug transfer and hence fetal drug exposure. In closing, a major theme that developed from the workshop was that the scientific community must change their thinking of the pregnant woman and her fetus as a vulnerable patient population for which drug development should be avoided, but rather be thought of as a deprived population in need of more effective therapeutic interventions.
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Affiliation(s)
- John V Ilekis
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Department of Health and Human Services, Bethesda, MD.
| | - Ekaterini Tsilou
- Obstetric and Pediatric Pharmacology and Therapeutics Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Department of Health and Human Services, Bethesda, MD.
| | - Susan Fisher
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | - Vikki M Abrahams
- Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine; New Haven, CT
| | - Michael J Soares
- Institute of Reproductive Health and Regenerative Medicine and Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS
| | - James C Cross
- Comparative Biology and Experimental Medicine, University of Calgary Health Sciences Centre, Calgary, Alberta, Canada
| | - Stacy Zamudio
- Department of Obstetrics and Gynecology, Hackensack University Medical Center, Hackensack, NJ
| | - Nicholas P Illsley
- Department of Obstetrics and Gynecology, Hackensack University Medical Center, Hackensack, NJ
| | - Leslie Myatt
- Center for Pregnancy and Newborn Research, University of Texas Health Science Center, San Antonio, TX
| | - Christine Colvis
- Therapeutics Discovery Program, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD
| | - Maged M Costantine
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
| | - David M Haas
- Department of Obstetrics and Gynecology Indiana University, Indianapolis, IN
| | | | - Carl Weiner
- University of Kansas Medical Center, Kansas City, KS
| | - Erik Rytting
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
| | - Gene Bidwell
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS
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Tran AH, Best BM, Stek A, Wang J, Capparelli EV, Burchett SK, Kreitchmann R, Rungruengthanakit K, George K, Cressey TR, Chakhtoura N, Smith E, Shapiro DE, Mirochnick M. Pharmacokinetics of Rilpivirine in HIV-Infected Pregnant Women. J Acquir Immune Defic Syndr 2016; 72:289-96. [PMID: 26918544 PMCID: PMC4911231 DOI: 10.1097/qai.0000000000000968] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Rilpivirine pharmacokinetics is defined by its absorption, distribution, metabolism, and excretion. Pregnancy can affect these factors by changes in cardiac output, protein binding, volume of distribution, and cytochrome P450 (CYP) 3A4 activity. Rilpivirine is metabolized by CYP3A4. The impact of pregnancy on rilpivirine pharmacokinetics is largely unknown. METHODS International Maternal Pediatric Adolescent AIDS Clinical Trials P1026s is a multicenter, nonblinded, prospective study evaluating antiretroviral pharmacokinetics in HIV-infected pregnant women that included a cohort receiving rilpivirine 25 mg once daily as part of their combination antiretrovirals for clinical care. Thirty-two women were enrolled in this study. Intensive pharmacokinetic sampling was performed at steady state during the second trimester, the third trimester, and postpartum. Maternal and umbilical cord blood samples were obtained at delivery. Plasma rilpivirine concentration was measured using liquid chromatography-mass spectrometry; lower limit of quantitation was 10 ng/mL. RESULTS Median (range) AUC0-24 were 1969 (867-4987, n = 15), 1669 (556-4312, n = 28), and 2387 (188-6736, n = 28) ng·h/mL in the second trimester, the third trimester, and postpartum, respectively (P < 0.05 for either trimester vs postpartum). Median (range) C24 were 63 (37-225, n = 17), 56 (<10-181, n = 30), and 81 (<10-299, n = 28) ng/mL (P < 0.05 for either trimester vs postpartum). High variability in pharmacokinetic parameters was observed between subjects. Median (range) cord blood/maternal concentration ratio was 0.55 (0.3-0.8, n = 21). Delivery HIV-1 RNA was ≤50 copies per milliliter in 70% and ≤400 copies per milliliter in 90% of women. Cmin were significantly lower at 15 visits with detectable HIV-1 RNA compared with 61 visits with undetectable HIV-1 RNA, 29 (<10-93) vs 63 (15-200) ng/mL (P = 0.0001). Cmin was below the protein binding-adjusted EC90 concentration (12.2 ng/mL) at 4 visits in 3 of 31 women (10%). CONCLUSIONS Rilpivirine exposure is lower during pregnancy compared with postpartum and highly variable. Ninety percent of women had minimum concentrations above the protein binding-adjusted EC90 for rilpivirine.
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Affiliation(s)
- Anna H Tran
- *Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, CA; †Skaggs School of Pharmacy and Pharmaceutical Sciences, Pediatrics Department-Rady Children's Hospital, University of California, San Diego, CA; ‡Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA; §Department of Biostatistics, Harvard School of Public Health, Boston, MA; ‖Department of Medicine, Children's Hospital Boston, Boston, MA; ¶Irmandade da Santa Casa de Misericordia de Porto Alegre, HIV/AIDS Research Department, Porto Alegre, Brazil; #Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand; **FHI 360, IMPAACT Operations Office, Durham, NC; ††Program for HIV Prevention and Treatment, Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand; ‡‡Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institute of Health, DHHS, Bethesda, MD; §§National Institute of Allergy and Infectious Diseases, Bethesda, MD; and ‖‖Department of Pediatrics, Boston University School of Medicine, Boston, MA
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7
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Mutagonda RF, Kamuhabwa AAR, Minzi OMS, Massawe SN, Maganda BA, Aklillu E. Malaria prevalence, severity and treatment outcome in relation to day 7 lumefantrine plasma concentration in pregnant women. Malar J 2016; 15:278. [PMID: 27177586 PMCID: PMC4866074 DOI: 10.1186/s12936-016-1327-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 05/04/2016] [Indexed: 12/28/2022] Open
Abstract
Background Day 7 plasma concentrations of lumefantrine (LF) can serve as a marker to predict malaria treatment outcome in different study populations. Two main cut-off points (175 and 280 ng/ml) are used to indicate plasma concentrations of LF, below which treatment failure is anticipated. However, there is limited data on the cumulative risk of recurrent parasitaemia (RP) in relation to day 7 LF plasma concentrations in pregnant women. This study describes the prevalence, severity, factors influencing treatment outcome of malaria in pregnancy and day 7 LF plasma concentration therapeutic cut-off points that predicts treatment outcome in pregnant women. Methods This was a one-arm prospective cohort study whereby 89 pregnant women with uncomplicated Plasmodium falciparum malaria receiving artemether-lumefantrine (ALu) participated in pharmacokinetics and pharmacodynamics study. Blood samples were collected on days 0, 2, 7, 14, 21 and 28 for malaria parasite quantification. LF plasma concentrations were determined on day 7. The primary outcome measure was an adequate clinical and parasitological response (ACPR) after treatment with ALu. Results The prevalence of malaria in pregnant women was 8.1 % (95 % CI 6.85–9.35) of whom 3.4 % (95 % CI 1.49–8.51) had severe malaria. The overall PCR-uncorrected treatment failure rate was 11.7 % (95 % CI 0.54–13.46 %). Low baseline hemoglobin (<10 g/dl) and day 7 LF concentration <600 ng/ml were significant predictors of RP. The median day 7 LF concentration was significantly lower in pregnant women with RP (270 ng/ml) than those with ACPR (705 ng/ml) (p = 0.016). The relative risk of RP was 4.8 folds higher (p = 0.034) when cut-off of <280 ng/ml was compared to ≥280 ng/ml and 7.8-folds higher (p = 0.022) when cut-off of <600 ng/ml was compared to ≥600 ng/ml. The cut-off value of 175 ng/ml was not associated with the risk of RP (p = 0.399). Conclusions Pregnant women with day 7 LF concentration <600 ng/ml are at high risk of RP than those with ≥600 ng/ml. To achieve effective therapeutic outcome, higher day 7 venous plasma LF concentration ≥600 ng/ml is required for pregnant patients than the previously suggested cut-off value of 175 or 280 ng/ml for non-pregnant adult patients.
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Affiliation(s)
- Ritah F Mutagonda
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, P.O. BOX 65013, Dar es Salaam, Tanzania.
| | - Appolinary A R Kamuhabwa
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, P.O. BOX 65013, Dar es Salaam, Tanzania
| | - Omary M S Minzi
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, P.O. BOX 65013, Dar es Salaam, Tanzania
| | - Siriel N Massawe
- Department of Obstetrics and Gynaecology, School of Medicine, Muhimbili University of Allied Sciences, P.O. BOX 65013, Dar es Salaam, Tanzania
| | - Betty A Maganda
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, P.O. BOX 65013, Dar es Salaam, Tanzania
| | - Eleni Aklillu
- Department of Laboratory of Medicine, Division of Clinical Pharmacology, Karolinska Institutet, 141 86, Stockholm, Sweden
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8
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Shah RR, Gaedigk A, LLerena A, Eichelbaum M, Stingl J, Smith RL. CYP450 genotype and pharmacogenetic association studies: a critical appraisal. Pharmacogenomics 2016; 17:259-75. [DOI: 10.2217/pgs.15.172] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Despite strong pharmacological support, association studies using genotype-predicted phenotype as a variable have yielded conflicting or inconclusive evidence to promote personalized pharmacotherapy. Unless the patient is a genotypic poor metabolizer, imputation of patient's metabolic capacity (or metabolic phenotype), a major factor in drug exposure-related clinical response, is a complex and highly challenging task because of limited number of alleles interrogated, population-specific differences in allele frequencies, allele-specific substrate-selectivity and importantly, phenoconversion mediated by co-medications and inflammatory co-morbidities that modulate the functional activity of drug metabolizing enzymes. Furthermore, metabolic phenotype and clinical outcomes are not binary functions; there is large intragenotypic and intraindividual variability. Therefore, the ability of association studies to identify relationships between genotype and clinical outcomes can be greatly enhanced by determining phenotype measures of study participants and/or by therapeutic drug monitoring to correlate drug concentrations with genotype and actual metabolic phenotype. To facilitate improved analysis and reporting of association studies, we propose acronyms with the prefixes ‘g’ (genotype-predicted phenotype) and ‘m’ (measured metabolic phenotype) to better describe this important variable of the study subjects. Inclusion of actually measured metabolic phenotype, and when appropriate therapeutic drug monitoring, promises to reveal relationships that may not be detected by using genotype alone as the variable.
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Affiliation(s)
| | - Andrea Gaedigk
- Clinical Pharmacology, Toxicology &, Therapeutic Innovation, Children's Mercy-Kansas City, 2401 Gillham Rd, Kansas City, MO 64108, USA
- School of Medicine, University of Missouri-Kansas City, MO, USA
| | - Adrián LLerena
- CICAB Clinical Research Centre, Extremadura University Hospital & Medical School, Badajoz, Spain
| | - Michel Eichelbaum
- Dr. Margarete Fischer-Bosch – Institut für Klinische Pharmakologie, 70376 Stuttgart Auerbachstr., 112 Germany
| | - Julia Stingl
- Centre for Translational Medicine, University of Bonn Medical School, Bonn, Germany
| | - Robert L Smith
- Department of Surgery & Cancer, Faculty of Medicine, Imperial College, South Kensington Campus, London, UK
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Abstract
The use of prescribed and over-the-counter medications in pregnancy is on the rise. Many women become pregnant at an older age and with preexisting medical conditions that require pharmacotherapy. In addition, pregnancy is associated with profound changes in the physiology of virtually every organ in the body, which affect medications' pharmacokinetics and pharmacodynamics. Despite all of these, pregnant women are still considered therapeutic orphans, as the majority of current therapeutics were never studied in pregnancy. The goals of this review are to synthesize the available information regarding the epidemiology of medications use and the state of drug research in pregnancy, in an effort to highlight the need for pharmacologic research in pregnancy.
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Affiliation(s)
- Martina Ayad
- Fellow, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, The University of Texas Medical Branch, Galveston, TX
| | - Maged M. Costantine
- Associate Professor, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, The University of Texas Medical Branch, Galveston, TX
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