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Fragoulakis V, Koufaki MI, Tzerefou K, Koufou K, Patrinos GP, Mitropoulou C. Assessing the utility of measurement methods applied in economic evaluations of pharmacogenomics applications. Pharmacogenomics 2024; 25:79-95. [PMID: 38288576 DOI: 10.2217/pgs-2023-0221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
An increasing number of economic evaluations are published annually investigating the economic effectiveness of pharmacogenomic (PGx) testing. This work was designed to provide a comprehensive summary of the available utility methods used in cost-effectiveness/cost-utility analysis studies of PGx interventions. A comprehensive review was conducted to identify economic analysis studies using a utility valuation method for PGx testing. A total of 82 studies met the inclusion criteria. A majority of studies were from the USA and used the EuroQol-5D questionnaire, as the utility valuation method. Cardiovascular disorders was the most studied therapeutic area while discrete-choice studies mainly focused on patients' willingness to undergo PGx testing. Future research in applying other methodologies in PGx economic evaluation studies would improve the current research environment and provide better results.
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Affiliation(s)
| | - Margarita-Ioanna Koufaki
- University of Patras, School of Health Sciences, Department of Pharmacy, Laboratory of Pharmacogenomics & Individualized Therapy, 26504, Rio, Patras, Greece
| | - Korina Tzerefou
- University of Piraeus, Economics Department, 18534, Piraeus, Greece
| | | | - George P Patrinos
- University of Patras, School of Health Sciences, Department of Pharmacy, Laboratory of Pharmacogenomics & Individualized Therapy, 26504, Rio, Patras, Greece
- United Arab Emirates University, College of Medicine & Health Sciences, Department of Genetics & Genomics, P.O. Box. 15551, Al-Ain, Abu Dhabi, United Arab Emirates
- United Arab Emirates University, Zayed Center for Health Sciences, P.O. Box. 15551, Al-Ain, Abu Dhabi, United Arab Emirates
| | - Christina Mitropoulou
- The Golden Helix Foundation, London, SE1 8RT, UK
- United Arab Emirates University, Zayed Center for Health Sciences, P.O. Box. 15551, Al-Ain, Abu Dhabi, United Arab Emirates
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2
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Morris SA, Alsaidi AT, Verbyla A, Cruz A, Macfarlane C, Bauer J, Patel JN. Cost Effectiveness of Pharmacogenetic Testing for Drugs with Clinical Pharmacogenetics Implementation Consortium (CPIC) Guidelines: A Systematic Review. Clin Pharmacol Ther 2022; 112:1318-1328. [PMID: 36149409 PMCID: PMC9828439 DOI: 10.1002/cpt.2754] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/17/2022] [Indexed: 01/31/2023]
Abstract
The objective of this study was to evaluate the evidence on cost-effectiveness of pharmacogenetic (PGx)-guided treatment for drugs with Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines. A systematic review was conducted using multiple biomedical literature databases from inception to June 2021. Full articles comparing PGx-guided with nonguided treatment were included for data extraction. Quality of Health Economic Studies (QHES) was used to assess robustness of each study (0-100). Data are reported using descriptive statistics. Of 108 studies evaluating 39 drugs, 77 (71%) showed PGx testing was cost-effective (CE) (N = 48) or cost-saving (CS) (N = 29); 21 (20%) were not CE; 10 (9%) were uncertain. Clopidogrel had the most articles (N = 23), of which 22 demonstrated CE or CS, followed by warfarin (N = 16), of which 7 demonstrated CE or CS. Of 26 studies evaluating human leukocyte antigen (HLA) testing for abacavir (N = 8), allopurinol (N = 10), or carbamazepine/phenytoin (N = 8), 15 demonstrated CE or CS. Nine of 11 antidepressant articles demonstrated CE or CS. The median QHES score reflected high-quality studies (91; range 48-100). Most studies evaluating cost-effectiveness favored PGx testing. Limited data exist on cost-effectiveness of preemptive and multigene testing across disease states.
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Affiliation(s)
- Sarah A. Morris
- Department of Cancer Pharmacology and PharmacogenomicsLevine Cancer Institute, Atrium HealthCharlotteNorth CarolinaUSA
| | | | - Allison Verbyla
- Health Economics and Outcomes Research, Department of BiostatisticsLevine Cancer Institute, Atrium HealthCharlotteNorth CarolinaUSA
| | - Adilen Cruz
- Health Economics and Outcomes Research, Department of BiostatisticsLevine Cancer Institute, Atrium HealthCharlotteNorth CarolinaUSA
| | | | - Joseph Bauer
- Health Economics and Outcomes Research, Department of BiostatisticsLevine Cancer Institute, Atrium HealthCharlotteNorth CarolinaUSA
| | - Jai N. Patel
- Department of Cancer Pharmacology and PharmacogenomicsLevine Cancer Institute, Atrium HealthCharlotteNorth CarolinaUSA
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Turongkaravee S, Jittikoon J, Rochanathimoke O, Boyd K, Wu O, Chaikledkaew U. Pharmacogenetic testing for adverse drug reaction prevention: systematic review of economic evaluations and the appraisal of quality matters for clinical practice and implementation. BMC Health Serv Res 2021; 21:1042. [PMID: 34600523 PMCID: PMC8487501 DOI: 10.1186/s12913-021-07025-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 09/14/2021] [Indexed: 12/21/2022] Open
Abstract
Background Genetic testing has potential roles in identifying whether an individual would have risk of adverse drug reactions (ADRs) from a particular medicine. Robust cost-effectiveness results on genetic testing would be useful for clinical practice and policy decision-making on allocating resources effectively. This study aimed to update a systematic review on economic evaluations of pharmacogenetic testing to prevent ADRs and critically appraise the quality of reporting and sources of evidence for model input parameters. Methods We searched studies through Medline via PubMed, Scopus and CRD’s NHS Economic Evaluation up to October 2019. Studies investigating polymorphism-based pharmacogenetic testing, which guided drug therapies to prevent ADRs, using economic evaluation methods were included. Two reviewers independently performed data extraction and assessed the quality of reporting using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines and the quality of data sources using the hierarchy of evidence developed by Cooper et al. Results Fifty-nine economic evaluations of pharmacogenetic testing to avoid drug-induced ADRs were found between 2002 and 2018. Cost-utility and cost-effectiveness analyses were the most common methods of economic evaluation of pharmacogenetic testing. Most studies complied with the CHEERS checklist, except for single study-based economic evaluations which did not report uncertainty analysis (78%). There was a lack of high-quality evidence not only for estimating the clinical effectiveness of pharmacogenetic testing, but also baseline clinical data. About 14% of the studies obtained clinical effectiveness data of testing from a meta-analysis of case-control studies with direct comparison, which was not listed in the hierarchy of evidence used. Conclusions Our review suggested that future single study-based economic evaluations of pharmacogenetic testing should report uncertainty analysis, as this could significantly affect the robustness of economic evaluation results. A specific ranking system for the quality of evidence is needed for the economic evaluation of pharmacogenetic testing of ADRs. Differences in parameters, methods and outcomes across studies, as well as population-level and system-level differences, may lead to the difficulty of comparing cost-effectiveness results across countries. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07025-8.
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Affiliation(s)
- Saowalak Turongkaravee
- Social, Economic and Administrative Pharmacy (SEAP) Graduate Program, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Jiraphun Jittikoon
- Department of Biochemistry, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Onwipa Rochanathimoke
- Social, Economic and Administrative Pharmacy (SEAP) Graduate Program, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Kathleen Boyd
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Olivia Wu
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Usa Chaikledkaew
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447 Sri-Ayuthaya Rd, Payathai, Ratchathewi, Bangkok, 10400, Thailand. .,Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand.
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Chow NK, Harun SN, Wong EJ, Low LL, Sheikh Ghadzi SM, Khan AH. The association between cigarette smoking and efavirenz plasma concentration using the population pharmacokinetic approach. Br J Clin Pharmacol 2021; 87:3756-3765. [PMID: 33608883 DOI: 10.1111/bcp.14783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/01/2021] [Accepted: 02/13/2021] [Indexed: 11/29/2022] Open
Abstract
AIMS Efavirenz is still widely used as the preferred first-line antiretroviral agent in middle- and low-income countries, including Malaysia. The efavirenz population pharmacokinetic profile among HIV-positive smokers is still unknown. We aimed to assess the association of smoking with efavirenz and the differences in HIV clinical outcomes. METHODS A total of 154 stable HIV-positive patients on efavirenz in northern Malaysia were recruited with a sparse sampling for this multicentre prospective cohort study. The association between smoking and efavirenz pharmacokinetic parameters was determined using the nonlinear mixed-effect model. A mixture model of clearance was adopted to describe the metaboliser status because genetic data are unavailable. The effect of smoking on HIV clinical markers (CD4, CD4/CD8 ratio and viral blips) for at least 2 years after the antiretroviral initiation was also investigated. RESULTS Our data were best fitted with a 1-compartment mixture model with first-order absorption without lag time. Smoking significantly associated with higher clearance (β = 1.39; 95% confidence interval: 1.07 to 1.91), while weight affected both clearance and volume. From the mixture model, 20% of patients were in the slow clearance group, which mimic the genotype distribution of slow metaboliser. An efavirenz dose reduction is not recommended for smokers ≥60 kg with normal metabolism rate. Smoking significantly associated with slower normalisation of CD4 and CD4/CD8 ratio. CONCLUSIONS HIV-positive smokers presented with significantly higher efavirenz clearance and unfavourable clinical outcomes. Close monitoring of adherence and clinical response among smokers is warranted.
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Affiliation(s)
- Ngah Kuan Chow
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia.,Department of Pharmacy, Hospital Kulim, Kedah, Malaysia
| | - Sabariah Noor Harun
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - E-Jinq Wong
- Department of Pharmacy, Hospital Sultanah Bahiyah, Kedah, Malaysia
| | - Lee Lee Low
- Department of Medicine, Hospital Sultanah Bahiyah, Kedah, Malaysia
| | | | - Amer Hayat Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
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Ward T, Sugrue D, Hayward O, McEwan P, Anderson SJ, Lopes S, Punekar Y, Oglesby A. Estimating HIV Management and Comorbidity Costs Among Aging HIV Patients in the United States: A Systematic Review. J Manag Care Spec Pharm 2020; 26:104-116. [PMID: 32011956 PMCID: PMC10391104 DOI: 10.18553/jmcp.2020.26.2.104] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND As life expectancy of patients infected with human immunodeficiency virus (HIV) approaches that of the general population, the composition of HIV management costs is likely to change. OBJECTIVES To (a) review treatment and disease management costs in HIV, including costs of adverse events (AEs) related to antiretroviral therapy (ART) and long-term toxicities, and (b) explore the evolving cost drivers. METHODS A targeted literature review between January 2012 and November 2017 was conducted using PubMed and major conferences. Articles reporting U.S. costs of HIV management, acquired immunodeficiency syndrome (AIDS)-defining events, end of life care, and ART-associated comorbidities such as cardiovascular disease (CVD), chronic kidney disease (CKD), and osteoporosis were included. All costs were inflated to 2017 U.S. dollars. A Markov model-based analysis was conducted to estimate the effect of increased life expectancy on costs associated with HIV treatment and management. RESULTS 22 studies describing HIV costs in the United States were identified, comprising 16 cost-effectiveness analysis studies, 5 retrospective analyses of health care utilization, and 1 cost analysis in a resource-limited setting. Management costs per patient per month, including routine care costs (on/off ART), non-HIV medication, opportunistic infection prophylaxis, inpatient utilization, outpatient utilization, and emergency department utilization were reported as CD4+ cell-based health state costs ranging from $1,192 for patients with CD4 > 500 cells/mm3 to $2,873 for patients with CD4 < 50 cells/mm3. Event costs for AEs ranged from $0 for headache, pain, vomiting, and lipodystrophy to $31,545 for myocardial infarction. The mean monthly per-patient costs for CVD management, CKD management, and osteoporosis were $5,898, $6,108, and $4,365, respectively. Improvements in life expectancy, approaching that of the general population in 2018, are projected to increase ART-related and AE costs by 35.4% and comorbidity costs by 175.8% compared with estimated costs with HIV life expectancy observed in 1996. CONCLUSIONS This study identified and summarized holistic cost estimates appropriate for use within U.S. HIV cost-effectiveness analyses and demonstrates an increasing contribution of comorbidity outcomes, primarily associated with aging in addition to long-term treatment with ART, not typically evaluated in contemporary HIV cost-effectiveness analyses. DISCLOSURES This analysis was sponsored by ViiV Healthcare, which had no role in the analyses and interpretation of study results. Ward, Sugrue, Hayward, and McEwan are employees of HEOR Ltd, which received funding from ViiV Healthcare to conduct this study. Anderson is an employee of GlaxoSmithKline and holds shares in the company. Punekar and Oglesby are employees of ViiV Healthcare and hold shares in GlaxoSmithKline. Lopes was employed by ViiV Healthcare at the time of the study and holds shares in GlaxoSmithKline.
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Affiliation(s)
| | | | | | | | | | - Sara Lopes
- ViiV Healthcare, Brentford, United Kingdom
| | | | - Alan Oglesby
- ViiV Healthcare, Research Triangle, North Carolina
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Kasztura M, Richard A, Bempong NE, Loncar D, Flahault A. Cost-effectiveness of precision medicine: a scoping review. Int J Public Health 2019; 64:1261-1271. [PMID: 31650223 PMCID: PMC6867980 DOI: 10.1007/s00038-019-01298-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 08/19/2019] [Accepted: 09/04/2019] [Indexed: 12/16/2022] Open
Abstract
Objectives Precision medicine (PM) aims to improve patient outcomes by stratifying or individualizing diagnosis and treatment decisions. Previous reviews found inconclusive evidence as to the cost-effectiveness of PM. The purpose of this scoping review was to describe current research findings on the cost-effectiveness of PM and to identify characteristics of cost-effective interventions.
Methods We searched PubMed with a combination of terms related to PM and economic evaluations and included studies published between 2014 and 2017.
Results A total of 83 articles were included, of which two-thirds were published in Europe and the USA. The majority of studies concluded that the PM intervention was at least cost-effective compared to usual care. However, the willingness-to-pay thresholds varied widely. Key factors influencing cost-effectiveness included the prevalence of the genetic condition in the target population, costs of genetic testing and companion treatment and the probability of complications or mortality. Conclusions This review may help inform decisions about reimbursement, research and development of PM interventions. Electronic supplementary material The online version of this article (10.1007/s00038-019-01298-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Miriam Kasztura
- Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland.
| | - Aude Richard
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nefti-Eboni Bempong
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Dejan Loncar
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Antoine Flahault
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Mallayasamy S, Penzak SR. Pharmacogenomic Considerations in the Treatment of HIV Infection. Pharmacogenomics 2019. [DOI: 10.1016/b978-0-12-812626-4.00008-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Mu Y, Kodidela S, Wang Y, Kumar S, Cory TJ. The dawn of precision medicine in HIV: state of the art of pharmacotherapy. Expert Opin Pharmacother 2018; 19:1581-1595. [PMID: 30234392 DOI: 10.1080/14656566.2018.1515916] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Combination antiretroviral therapy (ART) reduces viral load to under the limit of detection, successfully decreasing HIV-related morbidity and mortality. Due to viral mutations, complex drug combinations and different patient response, there is an increasing demand for individualized treatment options for patients. AREAS COVERED This review first summarizes the pharmacokinetic and pharmacodynamic profile of clinical first-line drugs, which serves as guidance for antiretroviral precision medicine. Factors which have influential effects on drug efficacy and thus precision medicine are discussed: patients' pharmacogenetic information, virus mutations, comorbidities, and immune recovery. Furthermore, strategies to improve the application of precision medicine are discussed. EXPERT OPINION Precision medicine for ART requires comprehensive information on the drug, virus, and clinical data from the patients. The clinically available genetic tests are a good starting point. To better apply precision medicine, deeper knowledge of drug concentrations, HIV reservoirs, and efficacy associated genes, such as polymorphisms of drug transporters and metabolizing enzymes, are required. With advanced computer-based prediction systems which integrate more comprehensive information on pharmacokinetics, pharmacodynamics, pharmacogenomics, and the clinically relevant information of the patients, precision medicine will lead to better treatment choices and improved disease outcomes.
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Affiliation(s)
- Ying Mu
- a Department of Clinical Pharmacy and Translational Science , University of Tennessee Health Science Center College of Pharmacy , Memphis , USA
| | - Sunitha Kodidela
- b Department of Pharmaceutical Science , University of Tennessee Health Science Center College of Pharmacy , Memphis , USA
| | - Yujie Wang
- b Department of Pharmaceutical Science , University of Tennessee Health Science Center College of Pharmacy , Memphis , USA
| | - Santosh Kumar
- b Department of Pharmaceutical Science , University of Tennessee Health Science Center College of Pharmacy , Memphis , USA
| | - Theodore J Cory
- a Department of Clinical Pharmacy and Translational Science , University of Tennessee Health Science Center College of Pharmacy , Memphis , USA
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9
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Olagunju A, Schipani A, Bolaji O, Khoo S, Owen A. Evaluation of universal versus genotype-guided efavirenz dose reduction in pregnant women using population pharmacokinetic modelling. J Antimicrob Chemother 2018; 73:165-172. [PMID: 29029267 DOI: 10.1093/jac/dkx334] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 08/17/2017] [Indexed: 01/11/2023] Open
Abstract
Objectives Lack of data on the pharmacokinetics of efavirenz in pregnant women at the 400 mg reduced dose currently prevents universal roll-out. Population pharmacokinetic modelling was used to explore pharmacokinetic endpoints at 200, 400 and 600 mg daily doses in pregnant women stratified by CYP2B6 metabolic status. Methods The analysis was based on 252 plasma efavirenz concentrations from 77 pregnant women (77 sparse, 175 intensive) who received antiretroviral regimens containing 600 mg of efavirenz. The model was developed using NONMEM®. The effect of genetics was investigated and concentration-time courses at steady-state were simulated for individuals (n = 1000 each) classified as CYP2B6 slow, intermediate and fast metabolizers at 200, 400 and 600 mg daily doses. Results At a 400 mg reduced dose, predicted mean (90% CI) mid-dose efavirenz concentration (C12) was 2.24 μg/mL (0.89-4.18) in pregnant women classified as slow metabolizers, compared with 0.87 μg/mL (0.34-1.64) in intermediate metabolizers and 0.78 μg/mL (0.30-1.47) in fast metabolizers. C12 was below the 0.47 μg/mL threshold determined within the ENCORE 1 trial in 10% at 400 mg, 4.6% at 600 mg and 3.4% with genotype-guided dosing. The 4.0 μg/mL toxicity threshold was exceeded in 4.6% at 400 mg, 13.5% at 600 mg and 5.2% with genotype-guided dosing. Conclusions These data provide context for the ongoing debate about reduction in efavirenz dose to 400 mg during pregnancy and should be interpreted alongside the lower toxicity expected with the lower dose. Additional research is required to investigate genotype-guided dose reduction in pregnant women.
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Affiliation(s)
- Adeniyi Olagunju
- Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria.,Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool L693GF, UK
| | - Alessandro Schipani
- Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool L693GF, UK
| | - Oluseye Bolaji
- Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Saye Khoo
- Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool L693GF, UK
| | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool L693GF, UK
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Stillemans G, Belkhir L, Hesselink DA, Haufroid V, Elens L. Pharmacogenetic associations with cytochrome P450 in antiretroviral therapy: what does the future hold? Expert Opin Drug Metab Toxicol 2018; 14:601-611. [PMID: 29775551 DOI: 10.1080/17425255.2018.1478964] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Several antiretroviral drugs used to treat infection with the human immunodeficiency virus (HIV) are substrates of enzymes belonging to the cytochrome P450 (CYP) superfamily, which are polymorphically expressed. It may therefore be useful to take into account the genetic variation in these enzymes to predict the likelihood of anti-HIV treatment success, toxicity and the potential for drug-drug interactions. Areas covered: In this manuscript, the authors discuss the current state of knowledge regarding pharmacogenetic associations between CYP and all major antiretrovirals, as well as the importance of these associations. Expert opinion: While many pharmacogenetic associations for CYP have been described in the literature, replication studies are sometimes lacking. The implementation of this knowledge in clinical practice also remains difficult. Further efforts are required both to expand this field of knowledge and to enable its use in everyday clinical practice.
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Affiliation(s)
- Gabriel Stillemans
- a Integrated Pharmacometrics, Pharmacogenomics and Pharmacokinetics , Louvain Drug Research Institute, Université catholique de Louvain , Brussels , Belgium.,b Louvain centre for Toxicology and Applied Pharmacology, Institut de recherche expérimentale et clinique , Université catholique de Louvain , Brussels , Belgium
| | - Leila Belkhir
- b Louvain centre for Toxicology and Applied Pharmacology, Institut de recherche expérimentale et clinique , Université catholique de Louvain , Brussels , Belgium.,c AIDS Reference Center, Department of Internal Medicine , Cliniques universitaires Saint-Luc, Université catholique de Louvain , Brussels , Belgium
| | - Dennis A Hesselink
- d Department of Internal Medicine, Division of Nephrology and Transplantation and Rotterdam Transplant Group. Erasmus MC , University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Vincent Haufroid
- b Louvain centre for Toxicology and Applied Pharmacology, Institut de recherche expérimentale et clinique , Université catholique de Louvain , Brussels , Belgium.,e Department of Clinical Chemistry , Cliniques universitaires Saint-Luc , Brussels , Belgium
| | - Laure Elens
- a Integrated Pharmacometrics, Pharmacogenomics and Pharmacokinetics , Louvain Drug Research Institute, Université catholique de Louvain , Brussels , Belgium.,b Louvain centre for Toxicology and Applied Pharmacology, Institut de recherche expérimentale et clinique , Université catholique de Louvain , Brussels , Belgium
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Gonzalez D, Rao GG, Bailey SC, Brouwer KLR, Cao Y, Crona DJ, Kashuba ADM, Lee CR, Morbitzer K, Patterson JH, Wiltshire T, Easter J, Savage SW, Powell JR. Precision Dosing: Public Health Need, Proposed Framework, and Anticipated Impact. Clin Transl Sci 2017; 10:443-454. [PMID: 28875519 PMCID: PMC5698804 DOI: 10.1111/cts.12490] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 06/28/2017] [Indexed: 12/19/2022] Open
Affiliation(s)
- Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Gauri G Rao
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Stacy C Bailey
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kim L R Brouwer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Yanguang Cao
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Daniel J Crona
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA.,University of North Carolina Medical Center, Chapel Hill, NC
| | - Angela D M Kashuba
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kathryn Morbitzer
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - J Herbert Patterson
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Tim Wiltshire
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jon Easter
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Scott W Savage
- University of North Carolina Medical Center, Chapel Hill, NC.,Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - J Robert Powell
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
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12
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Pharmacogenetics of efavirenz discontinuation for reported central nervous system symptoms appears to differ by race. Pharmacogenet Genomics 2017; 26:473-80. [PMID: 27509478 DOI: 10.1097/fpc.0000000000000238] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Efavirenz frequently causes central nervous system (CNS) symptoms. We evaluated genetic associations with efavirenz discontinuation for CNS symptoms within 12 months of treatment initiation. METHODS Patients had initiated efavirenz-containing regimens at an HIV primary care clinic in the Southeastern United States and had at least 12 months of follow-up data. Polymorphisms in CYP2B6 and CYP2A6 defined efavirenz metabolizer categories. Genome-wide genotyping enabled adjustment for population stratification. RESULTS Among 563 evaluable patients, 99 (17.5%) discontinued efavirenz within 12 months, 29 (5.1%) for CNS symptoms. The hazard ratio (HR) for efavirenz discontinuation for CNS symptoms in slow versus extensive metabolizers was 4.9 [95% confidence interval (CI): 1.9-12.4; P=0.001]. This HR in Whites was 6.5 (95% CI: 2.3-18.8; P=0.001) and 2.6 in Blacks (95% CI: 0.5-14.1; P=0.27). Considering only slow metabolizers, the HR in Whites versus Blacks was 3.1 (95% CI: 0.9-11.0; P=0.081). The positive predictive value of slow metabolizer genotypes for efavirenz discontinuation was 27% in Whites and 11% in Blacks. CONCLUSION Slow metabolizer genotypes were associated significantly with efavirenz discontinuation for reported CNS symptoms. This association was considerably stronger in Whites than in Blacks.
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Abstract
After the introduction of highly active antiretroviral therapy in the 1990s, the perception of the diagnosis of HIV infection gradually shifted from a 'death sentence' to a chronic disease requiring long-term treatment. The host genetic variability has been shown to play a relevant role in both antiretroviral drugs bioavailability and adverse effects susceptibility. Knowledge about pharmacogenetics role in HIV infection treatment has largely increased over the last years, and is reviewed in the present report, as well as future perspectives for the inclusion of pharmacogenetics information in the directing of HIV infection treatment.
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Affiliation(s)
- Vanessa S Mattevi
- Graduate Program in Biosciences, Federal University of Health Sciences of Porto Alegre, Porto Alegre, RS, Brazil
| | - Carmela Fs Tagliari
- Graduate Program in Biosciences, Federal University of Health Sciences of Porto Alegre, Porto Alegre, RS, Brazil
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14
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Masimirembwa C, Dandara C, Leutscher PDC. Rolling out Efavirenz for HIV Precision Medicine in Africa: Are We Ready for Pharmacovigilance and Tackling Neuropsychiatric Adverse Effects? OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2016; 20:575-580. [PMID: 27627692 DOI: 10.1089/omi.2016.0120] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The introduction of antiretroviral therapy (ART) led to huge reductions in human immunodeficiency virus (HIV)-related deaths, turning HIV-infection into a chronic condition. Attention is now turning to quality of life for patients on lifelong ART treatment, reflecting on the safety of antiretroviral drugs. In sub-Saharan Africa, efavirenz (EFV) forms the preferred first-line ART but adverse drug events have also been reported. We express our concern on EFV-based regimens being part of mass rollout programs without full attention to toxicities. EFV is associated with various neuropsychiatric adverse events (AEs). If EFV use is not monitored, a huge burden of neuropsychiatric AEs and elevated risk of drug resistance due to nonadherence are likely to follow. A monumental EFV-based ART regimen rollout program, through the UNAIDS 90-90-90 and option B plus programs/approaches, is planned, which will more than double the number of patients on EFV-containing ART. According to this ambitious treatment target, by 2020, 90% of all people living with HIV will know their HIV status; 90% of all people with diagnosed HIV infection will receive sustained ART; and 90% of all people receiving ART will have viral suppression. On the other hand, HIV patients of African origin are predisposed to developing EFV-induced neuropsychiatric AEs due to specific CYP2B6 genetic variants causing impaired metabolism of EFV. It is our considered opinion that the potential quantitative and qualitative burden of EFV-induced neuropsychiatric AEs, which can vary from person-to-person and between populations, deserve special attention and action during the ART rollout program. We here make a case for Africa in particular where we project the burden of neuropsychiatric AEs to be greatest. We advocate for surveillance of neuropsychiatric AEs due to EFV therapy, incorporation of pharmacogenetics testing for CYP2B6 to assist in EFV dosing, and measurement of plasma EFV concentration, as a three-pronged rational therapeutic drug monitoring strategy to guide EFV treatment toward precision medicine.
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Affiliation(s)
- Collen Masimirembwa
- 1 Department of Drug Metabolism and Pharmacokinetics & Medical Analytics, African Institute of Biomedical Science and Technology , Harare, Zimbabwe .,2 Division of Clinical Pharmacology, Department of Medicine, University of Cape Town , Cape Town, South Africa
| | - Collet Dandara
- 3 Division of Human Genetics, Department of Pathology, Faculty of Healthy Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town , Cape Town, South Africa
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15
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Arwood MJ, Chumnumwat S, Cavallari LH, Nutescu EA, Duarte JD. Implementing Pharmacogenomics at Your Institution: Establishment and Overcoming Implementation Challenges. Clin Transl Sci 2016; 9:233-245. [PMID: 27214750 PMCID: PMC5121089 DOI: 10.1111/cts.12404] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 05/12/2016] [Indexed: 12/21/2022] Open
Affiliation(s)
- M J Arwood
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacogenomics, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - S Chumnumwat
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Rajathevi, Bangkok, Thailand
| | - L H Cavallari
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacogenomics, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - E A Nutescu
- Personalized Medicine Program, University of Illinois College of Pharmacy, Chicago, Illinois, USA.,Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois College of Pharmacy, Chicago, Illinois, USA.,Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois College of Pharmacy, Chicago, Illinois, USA
| | - J D Duarte
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacogenomics, University of Florida College of Pharmacy, Gainesville, Florida, USA
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16
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Mitchell M, Wells C, Zhang X, Hughes J, White J, Nash R, Haas DW. Patient willingness to undergo efavirenz dose reduction based on pharmacogenetic testing. Per Med 2016; 13:241-247. [PMID: 29767607 PMCID: PMC8926164 DOI: 10.2217/pme-2015-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 01/11/2016] [Indexed: 11/21/2022]
Abstract
AIM Among HIV-infected adults receiving efavirenz fixed-dose combination tablets, genotyping could guide efavirenz dose reduction but would require more pills. METHODS We assessed willingness to dose reduce among 129 patients at an HIV primary care clinic in the southeastern USA. RESULTS When told that switching from one pill to two or three pills "might make you feel a little better", 47% expressed definite or possible willingness. This decreased to 9% if there was "a small chance it might not control your HIV as well". Clinical variables were not associated with willingness. CONCLUSION Many patients receiving a fixed-dose combination tablet may be willing to take more pills in order to dose reduce, guided by genetic testing, but only if virologic control is not compromised.
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Affiliation(s)
| | - Caroline Wells
- Lipscomb University College of Pharmacy, Nashville, TN, USA
| | - Xuechao Zhang
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | | | - Robertson Nash
- Vanderbilt University School of Nursing, Nashville, TN, USA
- Vanderbilt Comprehensive Care Clinic, Nashville, TN, USA
| | - David W Haas
- Vanderbilt University School of Medicine, Nashville, TN, USA
- Meharry Medical College, Nashville, TN, USA
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17
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Bienczak A, Cook A, Wiesner L, Olagunju A, Mulenga V, Kityo C, Kekitiinwa A, Owen A, Walker AS, Gibb DM, McIlleron H, Burger D, Denti P. The impact of genetic polymorphisms on the pharmacokinetics of efavirenz in African children. Br J Clin Pharmacol 2016; 82:185-98. [PMID: 26991336 PMCID: PMC4917805 DOI: 10.1111/bcp.12934] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/07/2016] [Accepted: 03/10/2016] [Indexed: 01/11/2023] Open
Abstract
Aims Using a model‐based approach, the efavirenz steady‐state pharmacokinetics in African children is characterized, quantifying demographic and genotypic effects on the drug's disposition. Simulations are also conducted allowing prediction of optimized doses of efavirenz in this population. Methods We modelled the steady‐state population pharmacokinetics of efavirenz in Ugandan and Zambian children using nonlinear mixed‐effects modelling. Individual mid‐dose efavirenz concentrations were derived and simulations explored genotype‐based dose optimization strategies. Results A two‐compartment model with absorption through transit compartments well described 2086 concentration‐time points in 169 children. The combined effect of single nucleotide polymorphisms (SNPs) 516G>T and 983T>C explained 44.5% and 14.7% of the variability in efavirenz clearance and bioavailability, respectively. The detected frequencies of composite CYP2B6 genotype were 0.33 for 516GG|983TT, 0.35 for 516GT|983TT, 0.06 for 516GG|983TC, 0.18 for 516TT|983TT, 0.07 516GT|983TC and 0.01 for 516GG|983CC. The corresponding estimated clearance rates were 6.94, 4.90, 3.93, 1.92, 1.36, and 0.74 l h−1 for a 15.4 kg child and median (95% CI) observed mid‐dose concentrations 1.55 (0.51–2.94), 2.20 (0.97–4.40), 2.03 (1.19–4.53), 7.55 (2.40–14.74), 7.79 (3.66–24.59) and 18.22 (11.84–22.76) mg l−1, respectively. Simulations showed that wild‐type individuals had exposures at the bottom of therapeutic range, while slower metabolizers were overexposed. Conclusions Dosage guidelines for African children should take into consideration the combined effect of SNPs CYP2B6 516G>T and 983T>C.
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Affiliation(s)
- Andrzej Bienczak
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Adrian Cook
- MRC Clinical Trials Unit at University College London, London, UK
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Adeniyi Olagunju
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Veronica Mulenga
- University Teaching Hospital, Department of Paediatrics and Child Health, Lusaka, Zambia
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - Addy Kekitiinwa
- Baylor College of Medicine Bristol Myers Squibb Children's Clinical Centre of Excellence, Kampala, Uganda / Gulu Regional Centre of Excellence, Gulu, Uganda
| | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - A Sarah Walker
- MRC Clinical Trials Unit at University College London, London, UK
| | - Diana M Gibb
- MRC Clinical Trials Unit at University College London, London, UK
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - David Burger
- Department of Pharmacy, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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18
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Swart M, Evans J, Skelton M, Castel S, Wiesner L, Smith PJ, Dandara C. An Expanded Analysis of Pharmacogenetics Determinants of Efavirenz Response that Includes 3'-UTR Single Nucleotide Polymorphisms among Black South African HIV/AIDS Patients. Front Genet 2016; 6:356. [PMID: 26779253 PMCID: PMC4703773 DOI: 10.3389/fgene.2015.00356] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 12/10/2015] [Indexed: 01/11/2023] Open
Abstract
Introduction: Efavirenz (EFV) is a non-nucleoside reverse transcriptase inhibitor prescribed as part of first-line highly active antiretroviral therapy (HAART) in South Africa. Despite administration of fixed doses of EFV, inter-individual variability in plasma concentrations has been reported. Poor treatment outcomes such as development of adverse drug reactions or treatment failure have been linked to EFV plasma concentrations outside the therapeutic range (1–4 μg/mL) in some studies. The drug metabolizing enzyme (DME), CYP2B6, is primarily responsible for EFV metabolism with minor contributions by CYP1A2, CYP2A6, CYP3A4, CYP3A5, and UGT2B7. DME coding genes are also regulated by microRNAs through targeting the 3′-untranslated region. Expanded analysis of 30 single nucleotide polymorphisms (SNPs), including those in the 3′-UTR, was performed to identify pharmacogenetics determinants of EFV plasma concentrations in addition to CYP2B6 c.516G>T and c.983T>C SNPs. Methods: SNPs in CYP1A2, CYP2B6, UGT2B7, and NR1I2 (PXR) were selected for genotyping among 222 Bantu-speaking South African HIV-infected patients receiving EFV-containing HAART. This study is a continuation of earlier pharmacogenetics studies emphasizing the role of genetic variation in the 3′-UTR of genes which products are either pharmacokinetic or pharmacodynamic targets of EFV. Results: Despite evaluating thirty SNPs, CYP2B6 c.516G>T and c.983T>C SNPs remain the most prominent predictors of EFV plasma concentration. Conclusion: We have shown that CYP2B6 c.516G>T and c.983T>C SNPs are the most important predictors of EFV plasma concentration after taking into account all other SNPs, including genetic variation in the 3′-UTR, and variables affecting EFV metabolism.
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Affiliation(s)
- Marelize Swart
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Jonathan Evans
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Michelle Skelton
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Sandra Castel
- Division of Clinical Pharmacology, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Peter J Smith
- Division of Clinical Pharmacology, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Collet Dandara
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
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