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Pressiat C, Dainguy E, Tréluyer JM, Yonaba C, Urien S, Eboua F, Foissac F, Dahourou DL, Bouazza N, Malateste K, Desmonde S, Pruvost A, Leroy V, Hirt D, Study Group TMONODANRS. Comparison of three galenic forms of lamivudine in young West African children living with Human Immunodeficiency Virus. Antivir Ther 2021; 26:134-140. [DOI: 10.1177/13596535211058267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Few pharmacokinetic data were reported on dispersible tablets despite their increasing use. One hundred fifty HIV-infected children receiving lamivudine were enrolled in the MONOD ANRS 12,206 trial. Three galenic forms were administered: liquid formulation, tablet form and dispersible scored tablet. Method HIV-infected children <4 years old were enrolled in the MONOD ANRS 12,206 trial designed to assess the simplification of a successful 12-months lopinavir-based antiretroviral treatment with efavirenz. Lamivudine plasma concentrations were analysed using nonlinear mixed effects modelling approach. Results One hundred and fifty children (age: 2.5 years (1.9–3.2), weight 11.1 (9.5–12.5) kg (median (IQR)) were included in this study. Over the study period, 79 received only the syrup form, 29 children switched from syrup form to tablet 3TC/AZT form, 36 from syrup to the orodispersible ABC/3TC form and two from the 3TC/AZT form to the orodispersible ABC/3TC form. The 630 lamivudine concentrations were best described by a two-compartment model allometrically scaled. Galenic form had no significant effect on 3TC pharmacokinetic. Conclusion This trial provided an opportunity to compare three galenic forms (liquid formulation, tablet form and dispersible scored tablet) of lamivudine in the target population of young HIV–1-infected children. Galenic form had no significant effect on lamivudine pharmacokinetics.
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Affiliation(s)
- Claire Pressiat
- Pharmacology Department, AP-HP, Hôpitaux Universitaires Henri Mondor, Paris Est-Créteil University, Créteil, France
| | - Evelyne Dainguy
- Pediatric Department, Centre Hospitalier Universitaire of Cocody, Abidjan, Côte d’Ivoire
| | - Jean-Marc Tréluyer
- Paris Descartes University, Paris, France
- Clinical Pharmacology Department, AP-HP, Paris Centre Hospital Group, Paris, France
| | - Caroline Yonaba
- Pediatric Department, Centre Hospitalier Universitaire Yalgado Ouédraogo, Ouagadougou, Burkina Faso
| | - Saik Urien
- Paris Descartes University, Paris, France
| | - François Eboua
- Pediatric Department, Centre Hospitalier Universitaire de Yopougon, Abidjan, Côte d’Ivoire
| | | | - Désiré Lucien Dahourou
- MONOD Project, Centre de Recherche Internationale pour la Santé, Ouagadougou, Burkina Faso
- Centre Muraz, Bobo-Dioulasso, Burkina Faso
- Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso
| | | | - Karen Malateste
- Inserm, Institut de Recherche pour le Développement (IRD), University of Bordeaux, Bordeaux, France
| | - Sophie Desmonde
- Inserm, Unité U1027, CERPOP, Université Paul Sabatier of Toulouse3, Toulouse, France
| | - Alain Pruvost
- CEA, INRAE, SPI, Université Paris Saclay, Gif-sur-Yvette, France
| | - Valériane Leroy
- Inserm, Unité U1027, CERPOP, Université Paul Sabatier of Toulouse3, Toulouse, France
| | - Déborah Hirt
- Paris Descartes University, Paris, France
- Clinical Pharmacology Department, AP-HP, Paris Centre Hospital Group, Paris, France
- Inserm CESP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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Transparent reporting of recruitment and informed consent approaches in clinical trials recruiting children with minor parents in sub-Saharan Africa: a secondary analysis based on a systematic review. BMC Public Health 2021; 21:1473. [PMID: 34320934 PMCID: PMC8318049 DOI: 10.1186/s12889-021-11079-y] [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: 10/08/2020] [Accepted: 05/18/2021] [Indexed: 11/24/2022] Open
Abstract
Background Standardised checklists of items to be addressed in clinical study protocols and publications are promoting transparency in research. However, particular specifications for exceptional cases, such as children with minor parents are missing. This study aimed to examine the level of transparency regarding recruitment and informed consent approaches in publications of clinical trials recruiting children with minor parents in sub-Saharan Africa. We thereby focused particularly on the transparency about consenting persons (i.e. proxy decision-makers) and assessed the need to expand reporting guidelines for such exceptional cases. Methods We conducted a secondary analysis of clinical trial publications previously identified through a systematic review. Multiple scientific databases were searched up to March 2019. Clinical trial publications addressing consent and potentially recruiting children with minor parents in sub-Saharan Africa were included. 44 of the in total 4382 screened articles met our inclusion criteria. A descriptive analysis was performed. Results None of the included articles provided full evidence on whether any recruited children had minor parents and how consent was obtained for them. Four proxy decision-maker types were identified (parents; parents or guardians; guardians; or caregivers), with further descriptions provided rarely and mostly in referenced clinical trial registrations or protocols. Also, terminology describing proxy decision-makers was often used inconsistently. Conclusions Reporting the minimum maternal age alongside maternal data provided in baseline demographics can increase transparency on the recruitment of children with minor mothers. The CONSORT checklist should require clinical trial publications to state or reference exceptional informed consent procedures applied for special population groups. A standardized definition of proxy decision-maker types in international clinical trial guidelines would facilitate correct and transparent informed consent for children and children with minor parents. Study registration CRD42018074220. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11079-y.
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Gopalan BP, Mehta K, D'souza RR, Rajnala N, A. K. HK, Ramachandran G, Shet A. Sub-therapeutic nevirapine concentration during antiretroviral treatment initiation among children living with HIV: Implications for therapeutic drug monitoring. PLoS One 2017; 12:e0183080. [PMID: 28827836 PMCID: PMC5565187 DOI: 10.1371/journal.pone.0183080] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/29/2017] [Indexed: 12/04/2022] Open
Abstract
Nevirapine, a component of antiretroviral therapy (ART) in resource-limited settings, known for auto-induction of metabolism, is initiated at half therapeutic dose until day 14 (‘lead-in period’), and subsequently escalated to full dose. However, studies have shown that this dosing strategy based on adult studies may not be appropriate in children, given that younger children have higher drug clearance rates. In this prospective cohort study, we studied trough plasma nevirapine levels by high performance liquid chromatography (HPLC) at days 7, 14 (lead-in period) and 28 (full dose period) after ART initiation amongst HIV-1 infected children initiating nevirapine-based ART in southern India. Among the 20 children (50% male, median age 9 years) included in the study, sub-therapeutic trough plasma nevirapine concentration (<4μg/ml) was seen in 65% (13/20) of children during the lead-in period within two weeks of ART initiation and among 10% of children at 4 weeks during full-dose nevirapine. Adherence was documented as ≥95% in all children by both caregiver self-report and pill count. Median nevirapine concentrations achieved at week 1 was 4.8 μg/ml, significantly lower than 8 μg/ml, the concentration achieved at week 4 (p = 0.034). Virological failure at one year of ART was observed in six children, and was not associated with median nevirapine concentration achieved during week 1, 2 or 4. We conclude that the dose escalation strategy currently practiced among young children living with HIV-1 resulted in significant subtherapeutic nevirapine concentration (≤4μg/ml) during the lead-in period. We call for a closer look at pediatric-focused dosing strategies for nevirapine initiation in young children. Further studies to establish age-appropriate threshold nevirapine concentration are warranted in young children to corroborate the role of therapeutic drug monitoring in predicting virological outcome.
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Affiliation(s)
- Bindu Parachalil Gopalan
- Division of Infectious Diseases, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bangalore, Karnataka, India
- The Institute Of Trans-Disciplinary Health Sciences and Technology (TDU), Bangalore, Karnataka, India
| | - Kayur Mehta
- Department of Pediatrics, St. John's Medical College Hospital, Bangalore, Karnataka, India
| | - Reena R. D'souza
- Division of Infectious Diseases, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Niharika Rajnala
- Division of Infectious Diseases, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Hemanth Kumar A. K.
- National Institute for Research in Tuberculosis (Indian Council of Medical Research), Chennai, Tamil Nadu, India
| | - Geetha Ramachandran
- National Institute for Research in Tuberculosis (Indian Council of Medical Research), Chennai, Tamil Nadu, India
| | - Anita Shet
- Division of Infectious Diseases, St. John’s Research Institute, St. John’s National Academy of Health Sciences, Bangalore, Karnataka, India
- * E-mail:
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Richey RH, Hughes C, Craig JV, Shah UU, Ford JL, Barker CE, Peak M, Nunn AJ, Turner MA. A systematic review of the use of dosage form manipulation to obtain required doses to inform use of manipulation in paediatric practice. Int J Pharm 2017; 518:155-166. [DOI: 10.1016/j.ijpharm.2016.12.032] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 12/12/2016] [Accepted: 12/13/2016] [Indexed: 01/09/2023]
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Impact of adherence and anthropometric characteristics on nevirapine pharmacokinetics and exposure among HIV-infected Kenyan children. J Acquir Immune Defic Syndr 2014; 67:277-86. [PMID: 25140906 DOI: 10.1097/qai.0000000000000300] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND There are insufficient data on pediatric antiretroviral therapy (ART) pharmacokinetics (PK), particularly for children in low- and middle-income countries. METHODS We conducted a prospective nevirapine (NVP) PK study among HIV-infected Kenyan children aged 3-13 years initiating an NVP-based ART regimen. NVP dose timing was measured through medication event monitors. Participants underwent 2 inpatient assessments: 1 at 4-8 weeks after ART initiation and 1 at 3-4 months after ART initiation. Allometric scaling of oral clearance (CL)/bioavailability (F) and volume of distribution (Vd)/F values were computed. Nonlinear mixed-effects modeling using the first-order conditional estimation with interaction method was performed with covariates. The impact of adherence on time below minimum effective concentration was assessed in the final PK model using medication event monitors data and model-estimated individual parameters. RESULTS Among 21 children enrolled, mean age was 5.4 years and 57% were female. CL/F was 1.67 L/h and Vd/F was 3.8 L for a median child weighing 15 kg. Participants' age had a significant impact on CL/F (P < 0.05), with an estimated decrease in CL of 6.2% for each 1-year increase in age. Total body water percentage was significantly associated with Vd/F (P < 0.001). No children had >10% of time below minimum effective concentration when the PK model assumed perfect adherence compared with 10 children when adherence data were used. CONCLUSIONS Age and body composition were significantly associated with children's NVP PK parameters. ART adherence significantly impacted drug exposure over time, revealing subtherapeutic windows that may lead to viral resistance.
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Bastiaans DET, Cressey TR, Vromans H, Burger DM. The role of formulation on the pharmacokinetics of antiretroviral drugs. Expert Opin Drug Metab Toxicol 2014; 10:1019-37. [DOI: 10.1517/17425255.2014.925879] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Foissac F, Bouazza N, Frange P, Blanche S, Faye A, Lachassinne E, Dollfus C, Hirt D, Benaboud S, Treluyer JM, Urien S. Evaluation of nevirapine dosing recommendations in HIV-infected children. Br J Clin Pharmacol 2014; 76:137-44. [PMID: 23278548 DOI: 10.1111/bcp.12069] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 12/16/2012] [Indexed: 11/28/2022] Open
Abstract
AIMS Nevirapine (NVP) is a non-nucleoside reverse transcriptase inhibitor used for chronic human immunodeficiency virus infections in adults and children. The aims of this study were to investigate the population pharmacokinetics of NVP in children, establish factors that influence NVP pharmacokinetics and evaluate the current dosing recommendations. METHODS Concentrations were measured on a routine basis in 94 children aged from 2 months to 17 years. A total of 390 NVP plasma concentrations were retrospectively collected, and a population pharmacokinetic model was developed with Monolix 4.0. RESULTS Nevirapine pharmacokinetics was best described by a one-compartment model with first-order absorption and elimination. After standardization to a 70 kg adult using allometry, postmenstrual age had a significant effect on the bioavailability. Estimates of apparent clearance and volume of distribution were 3.9 l h(-1) (70 kg)(-1) and 140 l (70 kg)(-1) , respectively. Based on simulations of European Medicines Agency (EMA) and World Health Organization (WHO) dosing recommendations, the probability of observing minimal concentrations below the efficacy target of 3 mg l(-1) is higher following the EMA recommendations than the WHO recommendations. However, NVP underdosing persists for the 3-6 and 6-10 kg weight ranges following the WHO recommendations. CONCLUSIONS It is suggested to increase doses to 75 and 100 mg twice daily for the 3-6 and 6-10 kg weight ranges, respectively, in order to obtain more than 95% of children with concentrations above 3 mg l(-1) .
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Affiliation(s)
- Frantz Foissac
- EA 3620-Université Paris Descartes Sorbonne Paris Cité, Unité de RechercheClinique, Hôpital Tarnier, 89 rue d’Assas, Paris, France.
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Fabiano V, Mameli C, Cattaneo D, Delle Fave A, Preziosa A, Mele G, Clementi E, Zuccotti GV. Perceptions and patterns of use of generic drugs among Italian family pediatricians: first round results of a web survey. Health Policy 2012; 104:247-52. [PMID: 22217861 DOI: 10.1016/j.healthpol.2011.12.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 11/26/2011] [Accepted: 12/11/2011] [Indexed: 10/14/2022]
Abstract
Prescription of generic medicines represents an efficacious healthcare cost containment strategy. In some European countries and in the US, generic medicines are largely prescribed. In Italy, generic drugs prescription rate is lower. General Practitioners and Family Pediatricians may be less confident in prescribing generic equivalents instead of "branded" medicines. There are currently no data about Italian Family Pediatricians' perceptions and patterns of use of generic drugs. This is a first nationwide web survey conducted with the aim to evaluate generic medicines knowledge and prescribing habits of Italian Family Pediatricians. 303 Family Pediatricians completed the online questionnaire. 37.2% and 32.6% of them declared to have a sufficient or fairly good knowledge of generic medicines, respectively, and the majority of them believed that efficacy of generic medicines was sufficient (33.6%) or good (45.2%). Nevertheless, Italian Family Pediatricians are still prone to prescribe trade medicines more frequently, since only 13.5% of them declared that more than a half of their patients were treated with generic medicines. Major issues related with generic medicines prescriptions by Italian Family Pediatricians seem to be represented by diffuse scepticism about reliability of bioequivalence tests and safety of switchability from branded to generic equivalents. More information about generic drugs and more research in the field of pediatric pharmacology are needed for increasing generic medicines prescription rate among Italian Family Pediatricians.
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Affiliation(s)
- Valentina Fabiano
- Department of Pediatrics, Università degli Studi di Milano, Luigi Sacco Hospital, via GB Grassi 74, Milan, Italy.
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Best BM, Capparelli EV, Diep H, Rossi SS, Farrell MJ, Williams E, Lee G, van den Anker JN, Rakhmanina N. Pharmacokinetics of lopinavir/ritonavir crushed versus whole tablets in children. J Acquir Immune Defic Syndr 2011; 58:385-91. [PMID: 21876444 PMCID: PMC3205189 DOI: 10.1097/qai.0b013e318232b057] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Lopinavir/ritonavir (Kaletra) is first-line therapy for pediatric HIV infection. In clinical practice, Kaletra tablets are occasionally crushed for pediatric administration. This study compared lopinavir/ritonavir exposure between whole and crushed tablets in HIV-infected children. DESIGN This was a randomized, open-label, cross-over study of pediatric patients taking lopinavir/ritonavir as part of their antiretroviral regimen. Each subject had 2 separate (within 30 days) steady-state 12-hour pharmacokinetic (PK) studies with crushed and whole 200/50 mg lopinavir/ritonavir tablets. METHODS PK blood samples were drawn at 0 (predose), 1, 2, 4, 6, 8, and 12 hours postdose. Lopinavir and ritonavir plasma concentrations measured by high-performance liquid chromatography were used to calculate non-compartmental area under the concentration versus time curve (AUC) and clearance. Wilcoxon signed-rank tests compared PK values between crushed and whole tablets. RESULTS Twelve children, median age of 13 years (10-16 years), took 550/138 mg·m(-2) per day lopinavir/ritonavir divided every 12 hours. The median lopinavir AUC after crushed and whole tablets were 92 mg·hr·L(-1) and 144 mg·hr·L(-1), respectively, with an AUC ratio of 0.55 (P = 0.003). Median ritonavir AUC of crushed and whole tablets were 7 mg·hr·L(-1) and 13.3 mg·hr·L(-1), respectively, with an AUC ratio of 0.53 (P = 0.006). CONCLUSIONS Administration of crushed 200/50 mg lopinavir/ritonavir tablets to children significantly reduced lopinavir and ritonavir exposure with a decrease in AUC by 45% and 47%, respectively. The administration of crushed tablets would require higher doses and therapeutic drug monitoring to ensure adequate lopinavir exposure in patients requiring this practice. The use of crushed lopinavir/ritonavir tablets should be avoided, if possible.
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Affiliation(s)
- Brookie M Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA 92093-0719, USA.
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Brown KC, Hosseinipour MC, Hoskins JM, Thirumaran RK, Tien HC, Weigel R, Tauzie J, Shumba I, Lamba JK, Schuetz EG, McLeod HL, Kashuba ADM, Corbett AH. Exploration of CYP450 and drug transporter genotypes and correlations with nevirapine exposure in Malawians. Pharmacogenomics 2011; 13:113-21. [PMID: 22111602 DOI: 10.2217/pgs.11.132] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
AIM Genetic polymorphisms have the potential to influence drug metabolism and vary among ethnic groups. This study evaluated the correlation of genetic polymorphisms with nevirapine pharmacokinetics exposure in Malawians. MATERIALS & METHODS CYP450 2B6, 2D6, 3A4 and 3A5, ABCB1 and constitutive androstane receptor and pregnane X receptor, were analyzed for polymorphisms in 26 subjects. RESULTS Allele frequencies (variant) were: CYP2B6 514G>T (0.31) CYP2D6*4 (0.02); CYP2D6*17 (0.35); CYP3A4*1B (0.77); CYP3A5*3 (0.25); ABCB1 2677G>T (0.0), ABCB1 3435C>T (0.21), NR1I3 13711152T>C (0.02), NR1I2 44477T>C (0.10), NR1I2 63396C>T (0.33), NR1I2 6-bp indel (del: 0.17). CYP2B6 516G>T (non-wild-type/wild-type) correlated with nevirapine pharmacokinetic parameters; geometric mean ratios (95% CI): 1.75 (1.27-2.40) for area under the concentration time curve (AUC)(0-12 h), 1.58 (1.03-2.42) for C(0), and 0.53 (0.31-0.91) for clearance. In a multivariable model, nevirapine AUC increased by 1.5% per year of age (p < 0.0001), CYP2B6 516 T allele increased AUC by 92% (p < 0.0001), and CYP3A5*3 decreased AUC by 31% (p = 0.0027). CONCLUSION Allele frequencies were similar to other sub-Saharan African populations. The T allele for CYP2B6 516 was significantly associated with nevirapine exposure.
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Affiliation(s)
- Kevin C Brown
- University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, 3202 Kerr Hall, Chapel Hill, NC 27599-7569, USA
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Phelps BR, Rakhmanina N. Antiretroviral drugs in pediatric HIV-infected patients: pharmacokinetic and practical challenges. Paediatr Drugs 2011; 13:175-92. [PMID: 21500872 DOI: 10.2165/11587300-000000000-00000] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Antiretroviral (ARV) therapy has been shown to achieve high therapeutic efficacy in treating pediatric HIV disease. The delivery of affordable, child friendly, and easy to store and administer ARV drugs is key to the successful management of HIV in children. In recent years, significant progress has been made in scaling up the access to pediatric ARV therapy among children worldwide. Despite the improved ARV drug access, multiple challenges remain concerning palatability and efficient delivery of ARV drugs to children from infancy into adolescence. Data are limited regarding developmental changes in pharmacokinetics of individual ARV drugs, and pediatric and adult fixed-dose combinations. This review provides a practical discussion regarding the pharmacokinetics of ARV agents in pediatric HIV-infected patients, as well as the practical challenges of currently available formulations, such as palatability of liquid formulations, challenges of crushing tablets, and using adult and pediatric fixed-dose combinations.
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Affiliation(s)
- B Ryan Phelps
- Division of Infectious Disease, Childrens National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Drug resistance in human immunodeficiency virus type-1 infected Zambian children using adult fixed dose combination stavudine, lamivudine, and nevirapine. Pediatr Infect Dis J 2010; 29:e57-62. [PMID: 20508547 DOI: 10.1097/inf.0b013e3181e47609] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are few medium-term virologic data in children from resource-limited settings taking adult fixed-dose-combination antiretroviral therapy (cART) without viral load monitoring. METHODS CHAP2 (Children with HIV Antibiotic Prophylaxis 2) is a prospective cohort of Zambian children using d4T/3TC/NVP adult Triomune30 dosed according to WHO guidelines. RESULTS A total of 103 children (19 with previous antiretroviral therapy) had follow-up >6 months. Median age at cART initiation was 8 years (IQR, 6-12) and CD4 8% (4-12). At 24 months, CD4% had increased by a median of 15% (7-25). For 74 children viral load was known/inferred: 51 of 74 (69%) had viral load <50 copies/mL (45 of 63 [71%] with no previous cART, 6 of 11 [55%] with previous cART; difference P = 0.30); 22 of 74 (30%) had viral load >1000 copies/mL. Of 26 children with resistance data, 25 (96%) had NNRTI resistance; 22 (84%) had M184V; 2 (8%) had Q151M; and 1 (4%) each had K65R, L74V, or K70E. Eight (31%) had > or =1 TAM. Those failing virologically with a genotypic sensitivity score of 0 for first-line therapy had a somewhat smaller increase in CD4% from baseline compared with those failing therapy with a genotypic sensitivity score >0 (+3 vs. +8, P = 0.13), and had somewhat lower CD4% at initiation of cART (2 vs. 11, P = 0.09). In 6 children with >1 resistance test, the estimated rate of accumulation of TAMs was 0.59/yr (95% confidence interval: 0.22-1.29). CONCLUSIONS Twenty-four month virologic responses to cART were good. However, the rate of TAM accumulation in those with rebound was higher than reported in Western adult cohorts, and there was some indication of a detrimental effect of high level resistance on CD4% change from baseline.
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