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Getahun KA, Angaw DA, Asres MS, Kahaliw W, Petros Z, Abay SM, Yimer G, Berhane N. The Role of Pharmacogenomics Studies for Precision Medicine Among Ethiopian Patients and Their Clinical Implications: A Scoping Review. Pharmgenomics Pers Med 2024; 17:347-361. [PMID: 38974617 PMCID: PMC11226858 DOI: 10.2147/pgpm.s454328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 06/12/2024] [Indexed: 07/09/2024] Open
Abstract
Background Pharmacogenomics research is currently revolutionizing treatment optimization by discovering molecular markers. Medicines are the cornerstone of treatment for both acute and chronic diseases. Pharmacogenomics associated treatment response varies from 20% to 95%, resulting in from lack of efficacy to serious toxicity. Pharmacogenomics has emerged as a useful tool for therapy optimization and plays a bigger role in clinical care going forward. However, in Africa, in particular in Ethiopia, such studies are scanty and not generalizing. Therefore, the objective of this review was to outline such studies, generating comprehensive evidence and identify studied variants' association with treatment responses in Ethiopian patients. Methods The Joanna Briggs Institute's updated 2020 methodological guidelines for conducting and guidance for scoping reviews were used. We meticulously adhered to the systemic review reporting items checklist and scoping review meta-analyses extension. Results Two hundred twenty-nine possibly relevant studies were searched. These include: 64, 54, 21, 48 and 42 from PubMed, Scopus, Google Scholar, EMBASE, and manual search, respectively. Seventy-seven duplicate studies were removed. Thirty-nine papers were rejected with justification, whereas 58 studies were qualified for full-text screening. Finally 19 studies were examined. The primary pharmacogene that was found to have a significant influence on the pharmacokinetics of efavirenz was CYP2B6. Drug-induced liver injury has frequently identified toxicity among studied medications. Conclusion and Future Perspectives Pharmacogenomics studies in Ethiopian populations are less abundant. The studies conducted focused on infectious diseases, specifically on HAART commonly efavirenz and backbone first-line anti-tuberculosis drugs. There is a high need for further pharmacogenomics research to verify the discrepancies among the studies and for guiding precision medicine. Systematic review and meta-analysis are also recommended for pooled effects of different parameters in pharmacogenomics studies.
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Affiliation(s)
- Kefyalew Ayalew Getahun
- Department of Pharmacology, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Dessie Abebaw Angaw
- Department of Biostatistics and Epidemiology, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mezgebu Silamsaw Asres
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Wubayehu Kahaliw
- Department of Pharmacology, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Zelalem Petros
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Solomon Mequanente Abay
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Getnet Yimer
- Department of Genetics and Center for Global Genomics and Health Equity, School of Medicine, University of Pennsylvania, Pennsylvania, US, USA
| | - Nega Berhane
- Department of Medical Biotechnology, Institute of Biotechnology, University of Gondar, Gondar, Ethiopia
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Lusiki Z, Blom D, Soko ND, Malema S, Jones E, Rayner B, Blackburn J, Sinxadi P, Dandara MT, Dandara C. Major Genetic Drivers of Statin Treatment Response in African Populations and Pharmacogenetics of Dyslipidemia Through a One Health Lens. OMICS : A JOURNAL OF INTEGRATIVE BIOLOGY 2024; 28:261-279. [PMID: 37956269 DOI: 10.1089/omi.2023.0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
A One Health lens is increasingly significant to address the intertwined challenges in planetary health concerned with the health of humans, nonhuman animals, plants, and ecosystems. A One Health approach can benefit the public health systems in Africa that are overburdened by noncommunicable, infectious, and environmental diseases. Notably, the COVID-19 pandemic revealed the previously overlooked two-fold importance of pharmacogenetics (PGx), for individually tailored treatment of noncommunicable diseases and environmental pathogens. For example, dyslipidemia, a common cardiometabolic risk factor, has been identified as an independent COVID-19 severity risk factor. Observational data suggest that patients with COVID-19 infection receiving lipid-lowering therapy may have better outcomes. However, among African patients, the response to these drugs varies from patient to patient, pointing to the possible contribution of genetic variation in important pharmacogenes. The PGx of lipid-lowering therapies may underlie differences in treatment responses observed among dyslipidemia patients as well as patients comorbid with COVID-19 and dyslipidemia. Genetic variations in APOE, ABCB1, CETP, CYP2C9, CYP3A4, CYP3A5, HMGCR, LDLR, NPC1L1, and SLCO1B1 genes affect the pharmacogenomics of statins, and they have individually been linked to differential responses to dyslipidemia and COVID-19 treatment. African populations are underrepresented in PGx research. This leads to poor accounting of additional diverse genetic variants that could be important in understanding interindividual and between-population variations in therapeutic responses to dyslipidemia and COVID-19. This expert review examines and synthesizes the salient and priority PGx variations, as seen through a One Health lens in Africa, to improve and inform personalized medicine in both dyslipidemia and COVID-19.
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Affiliation(s)
- Zizo Lusiki
- Division of Human Genetics, Department of Pathology, Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
- Platform for Pharmacogenomics Research and Translation (PREMED) Unit, South African Medical Research Council (SAMRC), Cape Town, South Africa
| | - Dirk Blom
- Platform for Pharmacogenomics Research and Translation (PREMED) Unit, South African Medical Research Council (SAMRC), Cape Town, South Africa
- Division of Lipidology and Cape Heart Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Nyarai D Soko
- Division of Human Genetics, Department of Pathology, Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
- Platform for Pharmacogenomics Research and Translation (PREMED) Unit, South African Medical Research Council (SAMRC), Cape Town, South Africa
| | - Smangele Malema
- Platform for Pharmacogenomics Research and Translation (PREMED) Unit, South African Medical Research Council (SAMRC), Cape Town, South Africa
| | - Erika Jones
- Platform for Pharmacogenomics Research and Translation (PREMED) Unit, South African Medical Research Council (SAMRC), Cape Town, South Africa
- Division of Nephrology and Hypertension, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Brian Rayner
- Platform for Pharmacogenomics Research and Translation (PREMED) Unit, South African Medical Research Council (SAMRC), Cape Town, South Africa
- Division of Nephrology and Hypertension, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jonathan Blackburn
- Division of Chemical and Systems Biology, Department of Integrative Biomedical Sciences, University of Cape Town, Cape Town, South Africa
| | - Phumla Sinxadi
- Platform for Pharmacogenomics Research and Translation (PREMED) Unit, South African Medical Research Council (SAMRC), Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Michelle T Dandara
- Platform for Pharmacogenomics Research and Translation (PREMED) Unit, South African Medical Research Council (SAMRC), Cape Town, South Africa
| | - Collet Dandara
- Division of Human Genetics, Department of Pathology, Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
- Platform for Pharmacogenomics Research and Translation (PREMED) Unit, South African Medical Research Council (SAMRC), Cape Town, South Africa
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Sileshi T, Makonnen E, Telele NF, Barclay V, Zumla A, Aklillu E. Variability in plasma rifampicin concentrations and role of SLCO1B1, ABCB1, AADAC2 and CES2 genotypes in Ethiopian patients with tuberculosis. Infect Dis (Lond) 2024; 56:308-319. [PMID: 38315168 PMCID: PMC11134291 DOI: 10.1080/23744235.2024.2309348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 01/15/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Rifampicin, a key drug against tuberculosis (TB), displays wide between-patient pharmacokinetics variability and concentration-dependent antimicrobial effect. We investigated variability in plasma rifampicin concentrations and the role of SLCO1B1, ABCB1, arylacetamide deacetylase (AADAC) and carboxylesterase 2 (CES-2) genotypes in Ethiopian patients with TB. METHODS We enrolled adult patients with newly diagnosed TB (n = 119) who had received 2 weeks of rifampicin-based anti-TB therapy. Venous blood samples were obtained at three time points post-dose. Genotypes for SLCO1B1 (c.388A > G, c.521T > C), ABCB1 (c.3435C > T, c.4036A > G), AADACc.841G > A and CES-2 (c.269-965A > G) were determined. Rifampicin plasma concentration was quantified using LC-MS/MS. Predictors of rifampicin Cmax and AUC0-7 h were analysed. RESULTS The median rifampicin Cmax and AUC0-7 were 6.76 µg/mL (IQR 5.37-8.48) and 17.05 µg·h/mL (IQR 13.87-22.26), respectively. Only 30.3% of patients achieved the therapeutic efficacy threshold (Cmax>8 µg/mL). The allele frequency for SLCO1B1*1B (c.388A > G), SLCO1B1*5 (c.521T > C), ABCB1 c.3435C > T, ABCB1c.4036A > G, AADAC c.841G > A and CES-2 c.269-965A > G were 2.2%, 20.2%, 24.4%, 14.6%, 86.1% and 30.6%, respectively. Sex, rifampicin dose and ABCB1c.4036A > G, genotypes were significant predictors of rifampicin Cmax and AUC0-7. AADACc.841G > A genotypes were significant predictors of rifampicin Cmax. There was no significant influence of SLCO1B1 (c.388A > G, c.521T > C), ABCB1c.3435C > T and CES-2 c.269-965A > G on rifampicin plasma exposure variability. CONCLUSIONS Subtherapeutic rifampicin plasma concentrations occurred in two-thirds of Ethiopian TB patients. Rifampicin exposure varied with sex, dose and genotypes. AADACc.841G/G and ABCB1c.4036A/A genotypes and male patients are at higher risk of lower rifampicin plasma exposure. The impact on TB treatment outcomes and whether high-dose rifampicin is required to improve therapeutic efficacy requires further investigation.
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Affiliation(s)
- Tesemma Sileshi
- Department of Pharmacy, Ambo University, Ambo, Ethiopia
- Department of Pharmacology and Clinical Pharmacy, Addis Ababa University, Addis Ababa, Ethiopia
| | - Eyasu Makonnen
- Department of Pharmacology and Clinical Pharmacy, Addis Ababa University, Addis Ababa, Ethiopia
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Nigus Fikrie Telele
- Department of Laboratory Medicines, Karolinska Institutet, Stockholm, Sweden
| | - Victoria Barclay
- Department of Laboratory Medicines, Karolinska Institutet, Stockholm, Sweden
| | - Alimuddin Zumla
- Department of Infection, Division of Infection and Immunity, University College London; NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, UK
| | - Eleni Aklillu
- Department of Global Public Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Chala A, Kitabi EN, Ahmed JH, Tadesse BT, Chaka TE, Makonnen E, Aklillu E. Genetic and non-genetic factors influencing efavirenz population pharmacokinetics among human immunodeficiency virus-1-infected children in Ethiopia. CPT Pharmacometrics Syst Pharmacol 2023; 12:783-794. [PMID: 36840416 PMCID: PMC10272302 DOI: 10.1002/psp4.12951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 02/11/2023] [Accepted: 02/20/2023] [Indexed: 02/26/2023] Open
Abstract
Despite the potential for efavirenz (EFV) to be an effective alternative antiretroviral agent, its sources of wide inter- and intra-individual pharmacokinetic (PK) variability are not well-characterized in children. We investigated the effects of genetic and non-genetic factors, including demographic, treatment duration, baseline clinical, and biochemical characteristics, on the PKs of EFV through population-PK modeling. Antiretroviral therapy (ART) naïve HIV infected children, 3-16 years (n = 100), were enrolled in Ethiopia and received EFV-based combination ART. EFV concentrations after the first dose and at steady-state collected over a span of 1 year were modeled using population-based methods. A one-compartment model with first-order absorption kinetics described the observed EFV data adequately. The CYP2B6*6 and ABCB1c.4036A>G genotypes were identified as major factors influencing EFV clearance. The typical estimates of oral clearance, volume of distribution, and absorption rate constant for typical 22 kg children with CYP2B6 *1/*1 and ABCB1c.4036G/G genotypes were 4.3 L/h, 124 L, and 0.776/h, respectively. Clearance was reduced by 28% and 72% in CYP2B6*1/*6 and CYP2B6*6/*6 genotypes, respectively. Compared to week 1, clearance was higher from weeks 8 and 12 in CYP2B6*1/*6 and CYP2B6*1/*1 genotypes, respectively. Simulations indicated that EFV 12-h concentrations were comparable across weight bands, but more than 80% of subjects with CYP2B6*6/*6 had EFV concentrations greater than 4 μg/mL. EFV PK variability among children is partly explained by body weight, treatment duration, CYP2B6*6, and ABCB1 rs3842 genotypes. Therefore, in addition to body weight, pediatric dosing of EFV should consider pharmacogenetic variability, duration of therapy, and individual treatment outcomes.
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Affiliation(s)
- Adugna Chala
- Department of Pharmacology and Clinical Pharmacy, College of Health SciencesAddis Ababa UniversityAddis AbabaEthiopia
- Department of Global Public HealthKarolinska Institutet, Widerströmska HusetStockholmSweden
| | - Eliford Ngaimisi Kitabi
- Division of PharmacometricsOffice of Clinical Pharmacology, Food and Drugs AdministrationSilver SpringMarylandUSA
| | | | - Birkneh Tilahun Tadesse
- Department of Global Public HealthKarolinska Institutet, Widerströmska HusetStockholmSweden
- Department of Pediatrics, College of Medicine and Health SciencesHawassa UniversityHawassaEthiopia
| | - Tolossa Eticha Chaka
- Department of Pediatrics and Child HealthAdama Hospital Medical CollegeAdamaEthiopia
| | - Eyasu Makonnen
- Department of Pharmacology and Clinical Pharmacy, College of Health SciencesAddis Ababa UniversityAddis AbabaEthiopia
- Center for Innovative Drug Development and Therapeutic Trials for Africa, College of Health SciencesAddis Ababa UniversityAddis AbabaEthiopia
| | - Eleni Aklillu
- Department of Global Public HealthKarolinska Institutet, Widerströmska HusetStockholmSweden
- Department of Medicine SolnaKarolinska InstituteStockholmSweden
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Zhang L, Meng X, Dong P, Qi T, Liu L, Wang B. Effects of rifampicin, CYP2B6 and ABCB1 polymorphisms on efavirenz plasma concentration in Chinese patients living with HIV and tuberculosis. Int J STD AIDS 2023; 34:37-47. [PMID: 36356965 DOI: 10.1177/09564624221134137] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Tuberculosis (TB) is the leading opportunistic infection of people living with human immunodeficiency virus (HIV; PLWH). Cytochrome P450 (CYP) 2B6 and ATP-binding cassette sub-family B member 1 (ABCB1) are involved in the metabolism and transportation of efavirenz. The study was aimed to investigate the effects of rifampicin, CYP2B6 and ABCB1 polymorphisms on efavirenz exposure in Chinese PLWH co-infected with TB. METHOD PLWH were screened according to inclusion and exclusion criteria and divided into HIV group and HIV/TB group. Efavirenz plasma concentration (C0) was determined, dose-adjusted concentration (C0/D) was calculated, and genotypes of CYP2B6 516G>T, 785A>G, and ABCB1 2677G>T, 3435C>T were analyzed. RESULTS 252 PLWH were enrolled, including 75 co-infected with TB and concomitant with rifampicin. Efavirenz C0 and C0/D were both higher in HIV group (1.94 μg/mL, 0.2007 (μg/ml)/(mg/kg/d)) compared with HIV/TB group (1.52 μg/mL, 0.1557 (μg/ml)/(mg/kg/d)) (p = .001). Efavirenz C0/D was significantly higher in patients with variant genotypes of CYP2B6 516G>T and 785A>G (p<.001), and was significantly lower in HIV/TB group compared with HIV group among patients with CYP2B6 516 GG, TT, and 785 AA, AG genotypes (p < .05). CONCLUSION Efavirenz exposure is reduced by co-administration with rifampicin, and related to genetic polymorphisms of CYP2B6.
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Affiliation(s)
- Li Zhang
- Department of Pharmacy, 159397Huashan Hospital Fudan University, Shanghai, People's Republic of China.,Department of Pharmacy, 34748Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Xianmin Meng
- Department of Pharmacy, 34748Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Ping Dong
- Department of Pharmacy, 34748Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Tangkai Qi
- Department of Infectious Disease, 34748Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Li Liu
- Department of Infectious Disease, 34748Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Bin Wang
- Department of Pharmacy, 159397Huashan Hospital Fudan University, Shanghai, People's Republic of China
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CYP3A and CYP2B6 Genotype Predicts Glucose Metabolism Disorder among HIV Patients on Long-Term Efavirenz-Based ART: A Case-Control Study. J Pers Med 2022; 12:jpm12071087. [PMID: 35887584 PMCID: PMC9315529 DOI: 10.3390/jpm12071087] [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: 05/22/2022] [Revised: 06/25/2022] [Accepted: 06/28/2022] [Indexed: 11/17/2022] Open
Abstract
Long-term antiretroviral treatment (cART) increases the risk of glucose metabolism disorders (GMDs). Genetic variation in drug-metabolizing enzymes and transporters may influence susceptibility to cART-associated GMDs. We conducted a case-control study to investigate the association of pharmacogenetic variations with cART-induced GMDs. A total of 240 HIV patients on long-term efavirenz-based cART (75 GMD cases and 165 controls without GMDs) were genotyped for CYP3A4*1B, CYP3A5 (*3,*6), CYP2B6*6, UGT2B7*2, ABCB1 (c.3435C>T, c.4036A>G), and SLCO1B1 (*1b, *5). GMD cases were defined as the presence of impaired fasting glucose, insulin resistance, or diabetes mellitus (DM). Case-control genotype/haplotype association and logistic regression analysis were performed by adjusting for age, sex, and BMI. The major CYP3A haplotype were CYP3A5*3 (53.8%), CYP3A4*1B (17.3%), combinations of CYP3A4*1B, and CYP3A5*6 (10.9%), and CYP3A wild type (7%). CYP3A5*6 allele (p = 0.005) and CYP3A5*6 genotype (p = 0.01) were significantly associated with GMD cases. Multivariate analysis indicated CYP3A haplotype as a significant predictor of GMD (p = 0.02) and IFG (p = 0.004). CYP2B6*6 significantly predicted DM (p = 0.03). CYP3A haplotype and CYP2B6*6 genotype are independent significant predictors of GMD and DM, respectively, among HIV patients on long-term EFV-based cART.
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Ximenez JP, Elias ABR, Nardotto GHB, Barroso PF, Bollela VR, Lanchote VL, Suarez-Kurtz G. Pharmacogenetic predictors of variability in efavirenz pharmacokinetics in an admixed Brazilian HIV cohort. Br J Clin Pharmacol 2022; 88:4585-4594. [PMID: 35514050 DOI: 10.1111/bcp.15387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/25/2022] [Accepted: 04/27/2022] [Indexed: 11/24/2022] Open
Abstract
AIMS To investigate the influence of pharmacogenetic polymorphisms on efavirenz (EFV) exposure and metabolism in HIV-infected Brazilians under treatment with EFV-containing antiretroviral (ART) regimens. METHODS HIV-positive adults (n=82) on stable ART regimens containing 600 mg EFV once daily for at least 6 months were recruited at two university hospitals. Blood samples collected at mid-dose interval were used to quantify the plasma concentrations of EFV (denoted [EFV]), its major metabolite 8-OH-EFV ([8-OH-EFV]) and [8-OH-EFV]/[EFV] metabolic ratio, and to genotype single nucleotide polymorphisms (SNPs) in CYP2B6 (rs3745274, c.516G>T; rs28399499, c.983T>C) and ABCB1 (rs3842, c.4036G>A). CYP2B6 metabolic phenotypes were inferred from the CYP2B6 diplotypes. Linear regression modeling was applied to identify sociodemographic, clinical and pharmacogenetic predictors of [EFV] and [8-OH-EFV]/[EFV] metabolic ratio. RESULTS Wide (50-fold) interindividual variation in [EFV], [8-OH-EFV] and [8-OH-EFV]/[EFV] was observed; 69.5% of participants had [EFV] within the nominal therapeutic range (1000-4000 ng/ml), while 19.5%, and 11.0% had [EFV] below and above this range, respectively. Multiple regression modeling retained only CYP2B6 metabolic phenotypes or the combined rs3745274 and rs28399499 genotypes, as significant predictors of [EFV] and [8-OH-EFV]/[EFV]. CONCLUSION EFV exposure and disposition varied widely among HIV-infected Brazilians under stable treatment with EFV-containing ART regimens. About one-tenth of the participants had [EFV] exceeding nominal supratherapeutic concentration (4000 ng/mL), but reported tolerance to the ARV regimens, while one fifth of participants had nominal subtherapeutic [EFV] (<1000 ng/ml) but adequate virological response. Genotype for the two CYP2B6 SNPs studied explained 48% of variation in [EFV] and 35% of variation in [8-OH-EFV]/[EFV].
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Affiliation(s)
- João Paulo Ximenez
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | | | | | - Paulo Feijó Barroso
- Hospital Universitário Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Valdes Roberto Bollela
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Vera Lucia Lanchote
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
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