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Chabala C, Wobudeya E, van der Zalm MM, Kapasa M, Raichur P, Mboizi R, Palmer M, Kinikar A, Hissar S, Mulenga V, Mave V, Musoke P, Hesseling AC, McIlleron H, Gibb D, Crook A, Turkova A. Clinical Outcomes in Children With Human Immunodeficiency Virus Treated for Nonsevere Tuberculosis in the SHINE Trial. Clin Infect Dis 2024; 79:70-77. [PMID: 38592950 PMCID: PMC11259218 DOI: 10.1093/cid/ciae193] [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] [Received: 12/08/2023] [Revised: 03/23/2024] [Accepted: 04/05/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Children with human immunodeficiency virus (HIV, CWH) are at high risk of tuberculosis (TB) and face poor outcomes, despite antiretroviral therapy (ART). We evaluated outcomes in CWH and children not living with HIV treated for nonsevere TB in the SHINE trial. METHODS SHINE was a randomized trial that enrolled children aged <16 years with smear-negative, nonsevere TB who were randomized to receive 4 versus 6 months of TB treatment and followed for 72 weeks. We assessed TB relapse/recurrence, mortality, hospitalizations, grade ≥3 adverse events by HIV status, and HIV virological suppression in CWH. RESULTS Of 1204 children enrolled, 127 (11%) were CWH, of similar age (median, 3.6 years; interquartile range, 1.2, 10.3 versus 3.5 years; 1.5, 6.9; P = .07) but more underweight (weight-for-age z score, -2.3; (3.3, -0.8 versus -1.0; -1.8, -0.2; P < .01) and anemic (hemoglobin, 9.5 g/dL; 8.7, 10.9 versus 11.5 g/dL; 10.4, 12.3; P < .01) compared with children without HIV. A total of 68 (54%) CWH were ART-naive; baseline median CD4 count was 719 cells/mm3 (241-1134), and CD4% was 16% (10-26). CWH were more likely to be hospitalized (adjusted odds ratio, 2.4; 1.3-4.6) and to die (adjusted hazard ratio [aHR], 2.6; 95% confidence interval [CI], 1.2 to 5.8). HIV status, age <3 years (aHR, 6.3; 1.5, 27.3), malnutrition (aHR, 6.2; 2.4, 15.9), and hemoglobin <7 g/dL (aHR, 3.8; 1.3,11.5) independently predicted mortality. Among children with available viral load (VL), 45% and 61% CWH had VL <1000 copies/mL at weeks 24 and 48, respectively. There was no difference in the effect of randomized treatment duration (4 versus 6 months) on TB treatment outcomes by HIV status (P for interaction = 0.42). CONCLUSIONS We found no evidence of a difference in TB outcomes between 4 and 6 months of treatment for CWH treated for nonsevere TB. Irrespective of TB treatment duration, CWH had higher rates of mortality and hospitalization than their counterparts without HIV. Clinical Trials Registration. ISRCTN63579542.
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Affiliation(s)
- Chishala Chabala
- Department of Paediatrics, School of Medicine, University of Zambia, Lusaka, Zambia
- Children's Hospital, University Teaching Hospitals, Lusaka, Zambia
- Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Eric Wobudeya
- Mulago Hospital, Makerere University–John Hopkins Hospital Research Collaboration, Kampala, Uganda
| | - Marieke M van der Zalm
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Monica Kapasa
- Children's Hospital, University Teaching Hospitals, Lusaka, Zambia
| | - Priyanka Raichur
- Byramjee Jeejeebhoy Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Robert Mboizi
- Mulago Hospital, Makerere University–John Hopkins Hospital Research Collaboration, Kampala, Uganda
| | - Megan Palmer
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Syed Hissar
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Veronica Mulenga
- Department of Paediatrics, School of Medicine, University of Zambia, Lusaka, Zambia
- Children's Hospital, University Teaching Hospitals, Lusaka, Zambia
| | - Vidya Mave
- Byramjee Jeejeebhoy Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Philippa Musoke
- Mulago Hospital, Makerere University–John Hopkins Hospital Research Collaboration, Kampala, Uganda
| | - Anneke C Hesseling
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Helen McIlleron
- Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Diana Gibb
- Institute of Clinical Trials and Methodology, Medical Research Council–Clinical Trials Unit at University College London, London, United Kingdom
| | - Angela Crook
- Institute of Clinical Trials and Methodology, Medical Research Council–Clinical Trials Unit at University College London, London, United Kingdom
| | - Anna Turkova
- Institute of Clinical Trials and Methodology, Medical Research Council–Clinical Trials Unit at University College London, London, United Kingdom
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Chabala C, Turkova A, Kapasa M, LeBeau K, Tembo CH, Zimba K, Weisner L, Zyambo K, Choo L, Chungu C, Lungu J, Mulenga V, Crook A, Gibb D, McIlleron H. Inadequate Lopinavir Concentrations With Modified 8-Hourly Lopinavir/Ritonavir 4:1 Dosing During Rifampicin-based Tuberculosis Treatment in Children Living With HIV. Pediatr Infect Dis J 2023; 42:899-904. [PMID: 37506295 PMCID: PMC10501348 DOI: 10.1097/inf.0000000000004047] [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] [Accepted: 06/25/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Lopinavir/ritonavir plasma concentrations are profoundly reduced when co-administered with rifampicin. Super-boosting of lopinavir/ritonavir is limited by nonavailability of single-entity ritonavir, while double-dosing of co-formulated lopinavir/ritonavir given twice-daily produces suboptimal lopinavir concentrations in young children. We evaluated whether increased daily dosing with modified 8-hourly lopinavir/ritonavir 4:1 would maintain therapeutic plasma concentrations of lopinavir in children living with HIV receiving rifampicin-based antituberculosis treatment. METHODS Children with HIV/tuberculosis coinfection weighing 3.0 to 19.9 kg, on rifampicin-based antituberculosis treatment were commenced or switched to 8-hourly liquid lopinavir/ritonavir 4:1 with increased daily dosing using weight-band dosing approach. A standard twice-daily dosing of lopinavir/ritonavir was resumed 2 weeks after completing antituberculosis treatment. Plasma sampling was conducted during and 4 weeks after completing antituberculosis treatment. RESULTS Of 20 children enrolled; 15, 1-7 years old, had pharmacokinetics sampling available for analysis. Lopinavir concentrations (median [range]) on 8-hourly lopinavir/ritonavir co-administered with rifampicin (n = 15; area under the curve 0-24 55.32 mg/h/L [0.30-398.7 mg/h/L]; C max 3.04 mg/L [0.03-18.6 mg/L]; C 8hr 0.90 mg/L [0.01-13.7 mg/L]) were lower than on standard dosing without rifampicin (n = 12; area under the curve 24 121.63 mg/h/L [2.56-487.3 mg/h/L]; C max 9.45 mg/L [0.39-26.4 mg/L]; C 12hr 3.03 mg/L [0.01-17.7 mg/L]). During and after rifampicin cotreatment, only 7 of 15 (44.7%) and 8 of 12 (66.7%) children, respectively, achieved targeted pre-dose lopinavir concentrations ≥1mg/L. CONCLUSIONS Modified 8-hourly dosing of lopinavir/ritonavir failed to achieve adequate lopinavir concentrations with concurrent antituberculosis treatment. The subtherapeutic lopinavir exposures on standard dosing after antituberculosis treatment are of concern and requires further evaluation.
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Affiliation(s)
- Chishala Chabala
- From the Department of Paediatrics, University of Zambia, School of Medicine, Lusaka, Zambia
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Faculty of Health Sciences, Cape Town, South Africa
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Anna Turkova
- Medical Research Council–Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Monica Kapasa
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Kristen LeBeau
- Medical Research Council–Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Chimuka H. Tembo
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Kevin Zimba
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Lubbe Weisner
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Faculty of Health Sciences, Cape Town, South Africa
| | - Khozya Zyambo
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Louise Choo
- Medical Research Council–Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Chalilwe Chungu
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Joyce Lungu
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Veronica Mulenga
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Angela Crook
- Medical Research Council–Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Diana Gibb
- Medical Research Council–Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Helen McIlleron
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Faculty of Health Sciences, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Salerno SN, Capparelli EV, McIlleron H, Gerhart JG, Dumond JB, Kashuba AD, Denti P, Gonzalez D. Leveraging physiologically based pharmacokinetic modeling to optimize dosing for lopinavir/ritonavir with rifampin in pediatric patients. Pharmacotherapy 2023; 43:638-649. [PMID: 35607886 PMCID: PMC9684348 DOI: 10.1002/phar.2703] [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] [Received: 02/16/2022] [Accepted: 04/28/2022] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVE Treatment of HIV and tuberculosis co-infection leads to significant mortality in pediatric patients, and treatment can be challenging due to the clinically significant drug-drug interaction (DDI) between lopinavir/ritonavir (LPV/RTV) and rifampin. Doubling LPV/RTV results in insufficient lopinavir trough concentrations in pediatric patients. The objective of this study was to leverage physiologically based pharmacokinetic (PBPK) modeling to optimize the adjusted doses of LPV/RTV in children receiving the WHO-revised doses of rifampin (15 mg/kg daily). DESIGN Adult and pediatric PBPK models for LPV/RTV with rifampin were developed, including CYP3A and P-glycoprotein inhibition and induction. SETTING (OR DATA SOURCE) Data for LPV/RTV model development and evaluation were available from the pediatric AIDS Clinical Trials Group. PATIENTS Dosing simulations were next performed to optimize dosing in children (2 months to 8 years of age). INTERVENTION Exposure following super-boosted LPV/RTV with 10 and 15 mg/kg PO daily rifampin was simulated. MEASUREMENTS AND MAIN RESULTS Simulated parameters were within twofold observations for LPV, RTV, and rifampin in adults and children ≥2 weeks old. The model predicted that, in healthy adults receiving 400/100 mg oral LPV/RTV twice daily (BID), co-treatment with 600 mg oral rifampin daily decreased the steady-state area under the concentration vs. time curve of LPV by 79%, in line with the observed change of 75%. Simulated and observed concentration profiles were comparable for LPV/RTV (230/57.5 mg/m2 ) PO BID without rifampin and 230/230 mg/m2 LPV/RTV PO BID with 10 mg/kg PO daily rifampin in pediatric patients. Sixteen mg/kg of super-boosted LPV (LPV/RTV 1:1) PO BID with 15 mg/kg PO daily rifampin achieved simulated LPV troughs >1 mg/L in ≥93% of virtual children weighing 3.0-24.9 kg, which was comparable with 10 mg/kg PO daily rifampin. CONCLUSIONS Super-boosted LPV/RTV with 15 mg/kg rifampin achieves therapeutic LPV troughs in HIV/TB-infected simulated children.
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Affiliation(s)
- Sara N. Salerno
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Edmund V. Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, USA
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
| | - Jacqueline G. Gerhart
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Julie B. Dumond
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Angela D.M. Kashuba
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Vonasek BJ, Rabie H, Hesseling AC, Garcia-Prats AJ. Tuberculosis in Children Living With HIV: Ongoing Progress and Challenges. J Pediatric Infect Dis Soc 2022; 11:S72-S78. [PMID: 36314545 DOI: 10.1093/jpids/piac060] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
There has been much recent progress on control of the tuberculosis (TB) and human immunodeficiency virus (HIV) epidemics globally. However, advances in children have lagged behind, and TB-HIV coinfection continues to be a major driver of pediatric mortality in many settings. This review highlights recent research findings in the areas of prevention, diagnosis, and treatment of HIV-associated childhood TB. Key areas for future research are defined. Current prevention efforts such as vaccination, TB symptom screening, and TB preventive treatment are demonstrated as beneficial but need to be optimized for children living with HIV (CLHIV). Diagnosis of HIV-associated TB in children remains a major challenge, depending heavily on clinicians' ability to judge an array of signs, symptoms, and imaging findings, but there are a growing number of promising diagnostic tools with improved accuracy and feasibility. Treatment of TB-HIV coinfection has also seen recent progress with more evidence demonstrating the safety and effectiveness of shorter regimens for treatment of TB infection and disease and improved understanding of interactions between antiretrovirals and TB medications. However, several evidence gaps on drug-drug interactions persist, especially for young children and those with drug-resistant TB. Accelerated efforts are needed in these areas to build upon current progress and reduce the burden of TB on CLHIV.
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Affiliation(s)
- Bryan J Vonasek
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Helena Rabie
- FAMCRU, Department of Pediatrics and Child Health, Stellenbosch University, Cape Town, South Africa.,Tygerberg Hospital, Cape Town, South Africa
| | - Anneke C Hesseling
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anthony J Garcia-Prats
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Jacobs TG, Svensson EM, Musiime V, Rojo P, Dooley KE, McIlleron H, Aarnoutse RE, Burger DM, Turkova A, Colbers A. Pharmacokinetics of antiretroviral and tuberculosis drugs in children with HIV/TB co-infection: a systematic review. J Antimicrob Chemother 2020; 75:3433-3457. [PMID: 32785712 PMCID: PMC7662174 DOI: 10.1093/jac/dkaa328] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/29/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Management of concomitant use of ART and TB drugs is difficult because of the many drug-drug interactions (DDIs) between the medications. This systematic review provides an overview of the current state of knowledge about the pharmacokinetics (PK) of ART and TB treatment in children with HIV/TB co-infection, and identifies knowledge gaps. METHODS We searched Embase and PubMed, and systematically searched abstract books of relevant conferences, following PRISMA guidelines. Studies not reporting PK parameters, investigating medicines that are not available any longer or not including children with HIV/TB co-infection were excluded. All studies were assessed for quality. RESULTS In total, 47 studies met the inclusion criteria. No dose adjustments are necessary for efavirenz during concomitant first-line TB treatment use, but intersubject PK variability was high, especially in children <3 years of age. Super-boosted lopinavir/ritonavir (ratio 1:1) resulted in adequate lopinavir trough concentrations during rifampicin co-administration. Double-dosed raltegravir can be given with rifampicin in children >4 weeks old as well as twice-daily dolutegravir (instead of once daily) in children older than 6 years. Exposure to some TB drugs (ethambutol and rifampicin) was reduced in the setting of HIV infection, regardless of ART use. Only limited PK data of second-line TB drugs with ART in children who are HIV infected have been published. CONCLUSIONS Whereas integrase inhibitors seem favourable in older children, there are limited options for ART in young children (<3 years) receiving rifampicin-based TB therapy. The PK of TB drugs in HIV-infected children warrants further research.
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Affiliation(s)
- Tom G Jacobs
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - Elin M Svensson
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Victor Musiime
- Research Department, Joint Clinical Research Centre, Kampala, Uganda
- Department of Paediatrics and Child Health, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Pablo Rojo
- Pediatric Infectious Diseases Unit. Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Kelly E Dooley
- Divisions of Clinical Pharmacology and Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rob E Aarnoutse
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - David M Burger
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - Anna Turkova
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Angela Colbers
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
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Engelbrecht AE, Wiesner L, Norman J, Rabie H, Decloedt EH. Pediatric Antiretroviral Therapeutic Drug Monitoring: A Five and a Half Year Experience from a South African Tertiary Hospital. J Trop Pediatr 2020; 66:385-394. [PMID: 31754710 DOI: 10.1093/tropej/fmz077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Antiretroviral therapeutic drug monitoring (TDM) is not routinely used in the management of human immunodeficiency virus, but may be useful in pediatric patients who are prone to altered pharmacokinetics. Data on the routine use of antiretroviral TDM in pediatrics are sparse especially data from sub-Saharan Africa. METHODS We retrospectively reviewed the antiretroviral TDM indications at Tygerberg Children's Hospital, identified pediatric patients who had antiretroviral TDM requests from January 2012 until June 2017 and reviewed their clinical records. RESULTS Fifty-nine patients were identified who presented with 64 clinical problems for which TDM was requested. TDM was requested for lopinavir, efavirenz and nevirapine in 83% (53/64), 14% (9/64) and 3% (2/64) of clinical problems, respectively. Lopinavir was mostly requested in patients when adherence measures did not correlate with the clinical picture, suspected non-adherence, lopinavir-rifampicin interactions and for neonatal safety monitoring. Efavirenz was requested when toxicity was suspected and nevirapine in patients receiving rifampicin. Lopinavir TDM confirmed non-adherence in 25% (4/16) of cases when adherence measures did not correlate with the clinical picture and in 43% (3/7) of cases when non-adherence was suspected by the clinician. Efavirenz TDM confirmed toxicity in 100% (6/6) of patients. CONCLUSIONS Lopinavir TDM was mostly requested when adherence measures did not correlate with the clinical picture, when rifampicin was co-administered and for perinatal safety monitoring. Lopinavir TDM excluded pharmacokinetic reasons for failure in patients failing treatment when lopinavir dosing was supervised. Efavirenz TDM was requested for suspected toxicity with a 100% positive predictive value.
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Affiliation(s)
- Anton E Engelbrecht
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Jennifer Norman
- Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Helena Rabie
- Division of Infectious Diseases, Department of Pediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
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Establishing Dosing Recommendations for Efavirenz in HIV/TB-Coinfected Children Younger Than 3 Years. J Acquir Immune Defic Syndr 2020; 81:473-480. [PMID: 31241542 DOI: 10.1097/qai.0000000000002061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND CYP2B6 516 genotype-directed dosing improves efavirenz (EFV) exposures in HIV-infected children younger than 36 months, but such data are lacking in those with tuberculosis (TB) coinfection. METHODS Phase I, 24-week safety and pharmacokinetic (PK) study of EFV in HIV-infected children aged 3 to <36 months, with or without TB. CYP2B6 516 genotype classified children into extensive metabolizers (516 TT/GT) and poor metabolizers [(PMs), 516 TT]. EFV doses were 25%-33% higher in children with HIV/TB coinfection targeting EFV area under the curve (AUC) 35-180 μg × h/mL, with individual dose adjustment as necessary. Safety and virologic evaluations were performed every 4-8 weeks. RESULTS Fourteen children from 2 African countries and India with HIV/TB enrolled, with 11 aged 3 to <24 months and 3 aged 24-36 months, 12 extensive metabolizers and 2 PMs. Median (Q1, Q3) EFV AUC was 92.87 (40.95, 160.81) μg × h/mL in 8/9 evaluable children aged 3 to <24 months and 319.05 (172.56, 360.48) μg × h/mL in children aged 24-36 months. AUC targets were met in 6/8 and 2/5 of the younger and older age groups, respectively. EFV clearance was reduced in PM's and older children. Pharmacokinetic modeling predicted adequate EFV concentrations if children younger than 24 months received TB-uninfected dosing. All 9 completing 24 weeks achieved viral suppression. Five/14 discontinued treatment early: 1 neutropenia, 3 nonadherence, and 1 with excessive EFV AUC. CONCLUSIONS Genotype-directed dosing safely achieved therapeutic EFV concentrations and virologic suppression in HIV/TB-coinfected children younger than 24 months, but further study is needed to confirm appropriate dosing in those aged 24-36 months. This approach is most important for young children and currently a critical unmet need in TB-endemic countries.
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Rabie H, Rawizza H, Zuidewind P, Winckler J, Zar H, Van Rie A, Wiesner L, McIlleron H. Pharmacokinetics of adjusted-dose 8-hourly lopinavir/ritonavir in HIV-infected children co-treated with rifampicin. J Antimicrob Chemother 2019; 74:2347-2351. [PMID: 31081020 PMCID: PMC6640304 DOI: 10.1093/jac/dkz171] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/03/2019] [Accepted: 04/03/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To evaluate the proportion of children with lopinavir Cmin ≥1 mg/L when receiving a novel 8-hourly lopinavir/ritonavir dosing strategy during rifampicin co-treatment. METHODS HIV-infected children on lopinavir/ritonavir and rifampicin were enrolled in a prospective pharmacokinetic study. Children were switched from standard-of-care lopinavir/ritonavir-4:1 with additional ritonavir (1:1 ratio) twice daily to 8-hourly lopinavir/ritonavir-4:1 using weight-banded dosing. Rifampicin was dosed at 10-20 mg/kg/day. After 2 weeks, plasma samples were collected ∼2, 4, 6, 8 and 10 h after the morning lopinavir/ritonavir-4:1 dose, ALT was obtained to assess safety and treatment was switched back to standard of care. ClinicalTrials.gov registration number: NCT01637558. RESULTS We recruited 11 children in two weight bands: 5 (45%) were 10-13.9 kg and received 20-24 mg/kg/dose of lopinavir and 6 (55%) children weighed 6-9.9 kg and received 20-23 mg/kg/dose of lopinavir. The median age was 15 months (IQR = 12.6-28.8 months). The median (IQR) lopinavir Cmin was 3.0 (0.1-5.5) mg/L. Seven (63.6%) of the 11 children had Cmin values ≥1 mg/L. Children with a lopinavir mg/kg dose below the median 21.5 were more likely to have Cmin <1 mg/L (P = 0.02). There was a strong positive correlation between lopinavir and ritonavir concentrations. No associations were found between lopinavir AUC2-10 and age, sex, weight, nutritional status or mg/kg/dose of lopinavir. CONCLUSIONS These data do not support the use of 8-hourly lopinavir/ritonavir at studied doses. Evaluation of higher doses is needed to optimize treatment outcomes of TB and HIV in young children.
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Affiliation(s)
- Helena Rabie
- Department of Paediatrics and Child Health and Children’s Infectious Diseases Clinical Research Unit, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Holly Rawizza
- Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
| | - Peter Zuidewind
- Department of Paediatrics and Child Health and Children’s Infectious Diseases Clinical Research Unit, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Jana Winckler
- Department of Paediatrics and Child Health, and Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Heather Zar
- Department of Paediatrics and Child Health, and Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Annelies Van Rie
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- International Health Unit, Epidemiology and Social Medicine, Faculty of Medicine, University of Antwerp, Antwerp, Belgium
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Jadhav M, Khan T, Bhavsar C, Momin M, Omri A. Novel therapeutic approaches for targeting TB and HIV reservoirs prevailing in lungs. Expert Opin Drug Deliv 2019; 16:687-699. [PMID: 31111766 DOI: 10.1080/17425247.2019.1621287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Coinfection with Mycobacterium tuberculosis is the leading cause of death in HIV positive patients. In 2017, about 0.3 million HIV positive people died of tuberculosis. There is high load of mycobacteria and HIV in the lungs and eradication of the same is vital for patient survival. AREAS COVERED This review focuses on the pathogenesis of HIV-TB coinfection and the current management approaches of this coinfection. It presents a detailed discussion of current investigations in novel drug delivery systems for effective targeting of HIV-TB lung reservoirs, especially via pulmonary drug delivery. Additionally, emphasis is given to the need of HIV-TB cotargeting, an unmet need in management of HIV-TB coinfection. EXPERT OPINION To achieve the goal of complete eradication of HIV-TB reservoirs in lungs requires focused research strategies to be undertaken in the area of pulmonary delivery systems. These endeavors could eventually lead to better patient compliance and improved treatment outcomes. The treatment regimen of HIV-TB coinfection is associated with a major drawback of low therapeutic concentration of drugs in lungs. Nanotechnology provides an excellent platform for delivery of anti-TB and anti-HIV drugs via the pulmonary route thereby serving as a viable and effective means of managing the mycobacterial and HIV reservoirs in the lungs.
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Affiliation(s)
- Mrunal Jadhav
- a Department of pharmaceutical chemistry and QA , SVKM's Dr. Bhanuben nanavati college of pharmacy , Mumbai , India
| | - Tabassum Khan
- a Department of pharmaceutical chemistry and QA , SVKM's Dr. Bhanuben nanavati college of pharmacy , Mumbai , India
| | - Chintan Bhavsar
- a Department of pharmaceutical chemistry and QA , SVKM's Dr. Bhanuben nanavati college of pharmacy , Mumbai , India
| | - Munira Momin
- a Department of pharmaceutical chemistry and QA , SVKM's Dr. Bhanuben nanavati college of pharmacy , Mumbai , India
| | - Abdelwahab Omri
- b Department of chemistry & biochemistry , Laurentian university , Sudbury , ON , Canada
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Fry SHL, Barnabas SL, Cotton MF. Tuberculosis and HIV-An Update on the "Cursed Duet" in Children. Front Pediatr 2019; 7:159. [PMID: 32211351 PMCID: PMC7073470 DOI: 10.3389/fped.2019.00159] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 04/04/2019] [Indexed: 11/13/2022] Open
Abstract
HIV and tuberculosis (TB) often occur together with each exacerbating the other. Improvements in vertical transmission prevention has reduced the number of HIV-infected children being born and early antiretroviral therapy (ART) protects against tuberculosis. However, with delayed HIV diagnosis, HIV-infected infants often present with tuberculosis co-infection. The number of HIV exposed uninfected children has increased and these infants have high exposure to TB and may be more immunologically vulnerable due to HIV exposure in utero. Bacillus Calmette-Guérin (BCG) immunization shortly after birth is essential for preventing severe TB in infancy. With early infant HIV diagnosis and ART, disseminated BCG is no longer an issue. TB prevention therapy should be implemented for contacts of a source case and for all HIV-infected individuals over a year of age. Although infection can be identified through skin tests or interferon gamma release assays, the non-availability of these tests should not preclude prevention therapy, once active TB has been excluded. Therapeutic options have moved from isoniazid only for 6-9 months to shorter regimens. Prevention therapy after exposure to a source case with resistant TB should also be implemented, but should not prevent pivotal prevention trials already under way. A microbiological diagnosis for TB remains the gold standard because of increasing drug resistance. Antiretroviral therapy for rifampicin co-treatment requires adaptation for those on lopinavir-ritonavir, which requires super-boosting with additional ritonavir. For those with drug resistant TB, the main problems are identification and overlapping toxicity between antiretroviral and anti-TB therapy. In spite of renewed focus and improved interventions, infants are still vulnerable to TB.
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Affiliation(s)
| | | | - Mark F. Cotton
- Family Centre for Research with Ubuntu (FAM-CRU), Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
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11
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Sarfo FS, Castelnuovo B, Fanti I, Feldt T, Incardona F, Kaiser R, Lwanga I, Marrone G, Sonnerborg A, Tufa TB, Zazzi M, De Luca A. Longer-term effectiveness of protease-inhibitor-based second line antiretroviral therapy in four large sub-Saharan African clinics. J Infect 2019; 78:402-408. [PMID: 30849438 DOI: 10.1016/j.jinf.2019.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 02/26/2019] [Accepted: 03/03/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Data on the longer-term effectiveness of second line combination antiretroviral therapy (ART) in sub-Saharan Africa (SSA) are lacking. We sought to assess the probability and determinants of 2nd line ART failure in SSA. METHODS A retrospective, multi-center study of 2nd line ART initiated between 2005 and 2017 at four ART centers in Ethiopia, Ghana and Uganda. Main outcome measure was virologic failure (VF) defined as VL>1000 copies/ml after >6 months on 2nd line therapy. Predictors of VF and virologic re-suppression on 2nd line were evaluated using Cox Proportional Hazards and multivariable logistic regression models, respectively. RESULTS 2191 subjects started 2nd line therapy, 61.5% females. Switching from 1st line (56.4% NVP-based, 70.3% including thymidine-analogues) to 2nd line therapy occurred after mean of 4.1 years. 98.9% of patients started boosted PI with NRTI backbone (TDF+3TC/FTC 67.3%, AZT+3TC 18.5%, others 14.2%). There were 267 (12.0%) VF with a 5-year estimated probability of 15.0% (95% CI 13.2-16.9). Key determinants of VF were concomitant rifampicin use (aHR 2.50 [95% CI 1.54-4.05]) and clinical/immunological failure versus virologic failure as reason for switching therapy (aHR, 0.53 [0.33-0.86]). 138 of 267 (51.7%) subsequently achieved virologic re-suppression and predictors included HIV RNA levels at 2nd-line failure: +1 log higher aOR 0.59 [0.43-0.80], experiencing change within 2nd line ART before VF: aOR 0.17 [0.05-0.56], and more recent calendar year of 2nd line initiation: aOR 0.85 [0.75-0.94]. CONCLUSIONS The effectiveness of current 2nd line ART regimens in SSA is good but challenged by interactions with TB therapy.
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Affiliation(s)
- Fred S Sarfo
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Private Mail Bag, Kumasi, Ghana.
| | | | | | - Torsten Feldt
- Clinic of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Dusseldorf, Germany
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12
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Abstract
PURPOSE OF REVIEW To provide an update on the patterns of HIV drug resistance in children, including pretreatment drug resistance (PDR) and acquired drug resistance (ADR), focusing on children in low- and middle-income countries (LMICs) for whom empiric first-line (FL) and second-line (SL) antiretroviral regimens are usually recommended. RECENT FINDINGS High levels of PDR, particularly to non-nucleoside reverse transcriptase inhibitors (NNRTIs), and poor treatment outcomes on NNRTI-based FL antiretroviral therapy (ART) have been widely reported among infants and young children. There is a paucity of recent data on the use of protease inhibitor (PI)-based FL and SL regimens in children, but studies have reported poor tolerability, adherence problems and the development of PI resistance. Limited access to virological monitoring and HIV drug resistance testing contributes to delays in identifying treatment failure due to ADR and delays in switching to SL regimens in children. Implementation of FL ART regimens that have a higher barrier to developing resistance and are safe and well tolerated is required in order to attain global treatment targets. Although PI-based regimens may be effective as FL or SL treatment in children, lack of appropriate formulations leading to poor tolerability, drug-drug interactions, and cost considerations have negatively impacted their use among children in LMICs. There is hope that dolutegravir-based regimens recommended for children by the World Health Organization will be widely implemented once child-friendly formulations are available, and dosing and safety studies currently underway are completed, and that this will significantly improve treatment outcomes.
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Affiliation(s)
- J Nuttall
- Paediatric Infectious Diseases Unit, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Rondebosch, Cape Town, 7700, South Africa.
| | - V Pillay
- Paediatric Infectious Diseases Unit, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Rondebosch, Cape Town, 7700, South Africa
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Nuttall JJC. Current antimicrobial management of community-acquired pneumonia in HIV-infected children. Expert Opin Pharmacother 2019; 20:595-608. [PMID: 30664362 DOI: 10.1080/14656566.2018.1561864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Community-acquired pneumonia is a leading cause of morbidity and mortality amongst HIV-infected infants and children. Polymicrobial infection is common and, due to the difficulties in confirming the etiology of pneumonia, empiric broad-spectrum antimicrobial therapy is frequently used. AREAS COVERED The author based this article on literature identified from PubMed. The author's search terms included: pneumonia, community-acquired pneumonia, HIV, children. The articles reviewed included original studies, recent review articles and current guidelines on the management of pneumonia in HIV-infected children. The microbiological etiology and the empiric and pathogen-specific antimicrobial therapy of community-acquired pneumonia in HIV-infected and HIV-exposed infants and children are also discussed. EXPERT OPINION There are many changing epidemiological factors impacting antimicrobial management of community-acquired pneumonia in the context of HIV infection in infants and children. These include vaccination strategies, antimicrobial prophylaxis, emerging drug-resistant pathogens, and recognition of the importance of viruses and tuberculosis in the etiology of community-acquired pneumonia. Further research is needed on optimal amtimicrobial management strategies in HIV-exposed uninfected children, and HIV-infected children receiving antiretroviral therapy.
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Affiliation(s)
- James J C Nuttall
- a Department of Paediatrics and Child Health, Faculty of Health Sciences , University of Cape Town and Red Cross War Memorial Children's Hospital , Cape Town , South Africa
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14
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Rabie H, Denti P, Lee J, Masango M, Coovadia A, Pillay S, Liberty A, Simon F, McIlleron H, Cotton MF, Lallemant M. Lopinavir-ritonavir super-boosting in young HIV-infected children on rifampicin-based tuberculosis therapy compared with lopinavir-ritonavir without rifampicin: a pharmacokinetic modelling and clinical study. Lancet HIV 2018; 6:S2352-3018(18)30293-5. [PMID: 30529029 DOI: 10.1016/s2352-3018(18)30293-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/08/2018] [Accepted: 10/12/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Rifampicin reduces lopinavir concentrations in HIV and tuberculosis co-treated patients. We hypothesised that adding ritonavir to co-formulated lopinavir-ritonavir (4:1) to achieve a one-to-one ratio would overcome this drug-drug interaction in young children. METHODS We did a prospective, open-label, one-group, one-sequence study at five sites in three South African provinces. We included HIV-infected children with tuberculosis, a bodyweight of 3-15 kg, and a post-conceptional age of more than 42 weeks. Children received the standard four-to-one ratio of lopinavir-ritonavir in the absence of rifampicin-based anti-tuberculosis treatment, whereas super-boosting of lopinavir-ritonavir with additional ritonavir was given orally twice a day to achieve a one-to-one ratio during rifampicin treatment. The primary outcome was the comparison of the proportion of children with predicted lopinavir morning minimum concentrations (Cmin) of more than 1·0 mg/L during super-boosting with the proportion of more than 1·0 mg/L during standard lopinavir-ritonavir treatment without rifampicin. Lopinavir concentrations were determined before and at 1, 2, 4, 6, and 10 h after the morning dose during the second and the last month of tuberculosis co-treatment, and 4-6 weeks after stopping rifampicin. A non-linear mixed-effects model was implemented to interpret the data and Monte Carlo simulations were used to compare the percentage of lopinavir with morning Cmin values of less than 1·0 mg/L for the two dosing schemes. A non-inferiority margin of 10% was used. This study is registered with ClinicalTrials.gov, number NCT02348177. FINDINGS Between Jan 30, 2013, and Nov 9, 2015, 96 children with a median age of 18·2 months (IQR 9·6-26·8) were enrolled. Of these 96 children, 80 (83%) completed the first three pharmacokinetic evaluations. Tuberculosis therapy was started before antiretrovirals in 70 (73%) children. The model-predicted percentage of morning Cmin of less than 1·0 mg/L after tuberculosis treatment without super-boosting was 8·8% (95% CI 0·6-19·8) versus 7·6% (0·4-16·2) during super-boosting and tuberculosis treatment. The difference of -1·1% (95% CI -6·9 to 3·2), at a non-inferiority margin of 10%, confirmed the non-inferiority of lopinavir trough concentrations during rifampicin co-treatment. 19 serious adverse events were reported in 12 participants. Three deaths and a temporary treatment interruption due to jaundice were unrelated to study treatment. INTERPRETATION Lopinavir exposure with ritonavir super-boosting in a one-to-one ratio during rifampicin-based tuberculosis treatment was non-inferior to the exposure with lopinavir-ritonavir without rifampicin. Safe and effective, field application of super-boosting is limited by poor acceptability. Access to better adapted solid formulations will most likely facilitate public health implementation of this strategy. FUNDING DNDi, French Development Agency, UBS Optimus Foundation, and Unitaid.
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Affiliation(s)
- Helena Rabie
- Department of Pediatrics and Child Health and Family Clinical Research Unit, University of Stellenbosch, Cape Town, South Africa.
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Janice Lee
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Mhleli Masango
- Shandukani Research Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Ashraf Coovadia
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Sandy Pillay
- Enhancing Care Foundation-Durban International Clinical Research, Wentworth Hospital, Durban, South Africa
| | - Afaaf Liberty
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - François Simon
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mark F Cotton
- Department of Pediatrics and Child Health and Family Clinical Research Unit, University of Stellenbosch, Cape Town, South Africa
| | - Marc Lallemant
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
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Weld ED, Dooley KE. State-of-the-Art Review of HIV-TB Coinfection in Special Populations. Clin Pharmacol Ther 2018; 104:1098-1109. [PMID: 30137652 DOI: 10.1002/cpt.1221] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 08/14/2018] [Indexed: 12/17/2022]
Abstract
Children and pregnant and postpartum women experience an undue burden of HIV-associated tuberculosis (TB), but data are lacking on key aspects of their complex management. Often excluded from clinical trials, they are left with limited options for HIV-TB cotreatment. This review will focus on pharmacologic aspects of the treatment of HIV-TB coinfection in the special populations of children and pregnant and postpartum women. Pharmacogenomic considerations, rational dosing, drug-drug interactions, safety, immune reconstitution inflammatory syndrome, and ethical and policy aspects of the inclusion of special populations in research will be surveyed. Considerations related to the treatment of both HIV-associated TB disease and HIV-associated latent TB infection will be summarized. Relevant knowledge gaps and research priorities in special populations will be outlined.
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Affiliation(s)
- Ethel D Weld
- Division of Clinical Pharmacology, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly E Dooley
- Division of Clinical Pharmacology, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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16
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Abstract
BACKGROUND Tuberculosis (TB) is the major cause of mortality in HIV-infected children globally. Current guidelines about the management of antiretroviral therapy in children with TB are based on a limited number of nonrandomized studies involving small numbers of participants. The aim of the study was to systematically retrieve and critically appraise available evidence on the efficacy and safety of different antiretroviral regimens in children with HIV infection who are receiving treatment for active TB. METHODS We conducted a systematic review of the literature according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Records were retrieved through March 2016 from Medline, Embase and manual screening of key conference proceedings. Four specific research questions assessing available treatment options were defined. RESULTS Although 4 independent searches were conducted (1 for each Population, Intervention, Comparator, Outcomes question), results were elaborated and interpreted together because of significant overlap among the retrieved records. Six observational studies were selected for qualitative synthesis while meta-analysis could not be performed. CONCLUSION Evidence for optimal treatment options for HIV/TB coinfected children is limited. As the global community strives to reach the fast-track HIV treatment targets and eliminate childhood TB deaths, it must ensure that coinfected children are included in key treatment studies and expand this neglected but crucial area of research.
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Clarke DF, Penazzato M, Capparelli E, Cressey TR, Siberry G, Sugandhi N, Mirochnick M. Prevention and treatment of HIV infection in neonates: evidence base for existing WHO dosing recommendations and implementation considerations. Expert Rev Clin Pharmacol 2017; 11:83-93. [PMID: 29039686 DOI: 10.1080/17512433.2018.1393331] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Antiretroviral drugs are used in neonates for prevention and treatment of HIV infection. Use of antiretrovirals to prevent perinatal HIV transmission is well established. Early identification of neonates infected with HIV and rapid initiation of combination antiretroviral treatment during the neonatal period is now recommended by WHO and DHHS. However, few antiretrovirals are available in formulations suitable for neonates and there are limited safety and pharmacokinetic data for most antiretrovirals in neonates. Areas covered: We summarize existing neonatal antiretroviral safety and pharmacokinetic information and discuss implementation considerations for programs providing antiretrovirals to neonates and young infants. Expert commentary: Antiretrovirals currently recommended by WHO for use in neonates are zidovudine, lamivudine, lopinavir/ritonavir, nevirapine, and raltegravir. Significant implementation challenges exist to the widespread use of these antiretrovirals in neonates. Optimal, feasible treatment of HIV-exposed and HIV-infected newborns will require development of practical neonatal dosage forms and their study in neonates for a wide range of antiretrovirals.
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Affiliation(s)
- Diana F Clarke
- a Department of Pediatric Infectious Diseases , Boston Medical Center , Boston , MA , USA.,b Department of Pediatrics , Boston University School of Medicine , Boston , MA , USA
| | - Martina Penazzato
- c Department of HIV/AIDS , World Health Organization , Geneva , Switzerland
| | - Edmund Capparelli
- d Skaggs School of Pharmacy and Pharmaceutical Sciences , University of California San Diego , La Jolla , CA , USA
| | - Tim R Cressey
- e PHPT-IRD (UMI 174), Faculty of Associated Medical Sciences , Chiang Mai University , Chiang Mai , Thailand.,f Department of Immunology & Infectious Diseases , Harvard T.H. Chan School of Public Health , Boston , MA , USA.,g Department of Molecular & Clinical Pharmacology , University of Liverpool , Liverpool , UK
| | - George Siberry
- h Office of the Global AIDS , U.S. Department of State , Washington , DC , USA
| | | | - Mark Mirochnick
- b Department of Pediatrics , Boston University School of Medicine , Boston , MA , USA
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Rabie H, Decloedt EH, Garcia-Prats AJ, Cotton MF, Frigati L, Lallemant M, Hesseling A, Schaaf HS. Antiretroviral treatment in HIV-infected children who require a rifamycin-containing regimen for tuberculosis. Expert Opin Pharmacother 2017; 18:589-598. [PMID: 28346018 DOI: 10.1080/14656566.2017.1309023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION In high prevalence settings, tuberculosis and HIV dual infection and co-treatment is frequent. Rifamycins, especially rifampicin, in combination with isoniazid, ethambutol and pyrazinamide are key components of short-course antituberculosis therapy. Areas covered: We reviewed available data, for which articles were identified by a Pubmed search, on rifamycin-antiretroviral interactions in HIV-infected children. Rifamycins have potent inducing effects on phase I and II drug metabolising enzymes and transporters. Antiretroviral medications are often metabolised by the enzymes induced by rifamycins or may suppress specific enzyme activity leading to drug-drug interactions with rifamycins. These may cause significant alterations in their phamacokinetic and pharmacodynamic properties, and sometimes that of the rifamycin. Recommended strategies to adapt to these interactions include avoidance and dose adjustment. Expert opinion: Despite the importance and frequency of tuberculosis as an opportunistic disease in HIV-infected children, current data on the management of co-treated children is based on few studies. We need new strategies to rapidly assess the use of rifamycins, new anti-tuberculosis drugs and antiretroviral drugs together as information on safety and dosing of individual drugs becomes available.
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Affiliation(s)
- Helena Rabie
- a Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences , Stellenbosch University and Tygerberg Hospital , Cape Town , South Africa.,b Children's Infectious Diseases Clinical Research Unit , Stellenbosch University , Cape Town , South Africa
| | - Eric H Decloedt
- c Division of Clinical Pharmacology, Faculty of Medicine and Health Sciences , Stellenbosch University and Tygerberg Hospital , Cape Town , South Africa
| | - Anthony J Garcia-Prats
- d Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences , Stellenbosch University , Cape Town , South Africa
| | - Mark F Cotton
- a Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences , Stellenbosch University and Tygerberg Hospital , Cape Town , South Africa.,b Children's Infectious Diseases Clinical Research Unit , Stellenbosch University , Cape Town , South Africa
| | - Lisa Frigati
- a Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences , Stellenbosch University and Tygerberg Hospital , Cape Town , South Africa.,b Children's Infectious Diseases Clinical Research Unit , Stellenbosch University , Cape Town , South Africa
| | - Marc Lallemant
- e Pediatric HIV Program , Drugs for Neglected Diseases Initiative , Geneva , Switzerland
| | - Anneke Hesseling
- d Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences , Stellenbosch University , Cape Town , South Africa
| | - H Simon Schaaf
- a Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences , Stellenbosch University and Tygerberg Hospital , Cape Town , South Africa.,d Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences , Stellenbosch University , Cape Town , South Africa
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Egelund EF, Dupree L, Huesgen E, Peloquin CA. The pharmacological challenges of treating tuberculosis and HIV coinfections. Expert Rev Clin Pharmacol 2016; 10:213-223. [PMID: 27828731 DOI: 10.1080/17512433.2017.1259066] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Tuberculosis (TB) is the most prevalent opportunistic infection among HIV patients, and the leading cause of death among HIV patients worldwide. Simultaneous treatment of both diseases is recommended by current guidelines, but can be challenging due to the potential for drug-drug interactions, overlapping toxicities, difficulty adhering to medications, and an increased risk for immune reconstitution inflammatory syndrome (IRIS). Clinical manifestations of TB can also vary between HIV-infected patients and uninfected patients, which can increase the risk for delayed diagnosis. Areas covered: Topics covered in this review include the following: the inter-related pathophysiology of HIV and TB; clinical manifestations and diagnosis; drug-drug interactions, particularly the rifamycins with the antiretrovirals; IRIS presentation and treatment, as well as a discussion on overlapping toxicity between the two disease states. Expert commentary: The complexity of managing these two disease states simultaneously requires a multidisciplinary approach to care and dedicated resources. If properly funded, TB/HIV co-infection will continue to decline over the coming years.
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Affiliation(s)
- Eric F Egelund
- a Department of Pharmacotherapy and Translational Research , College of Pharmacy.,b Infectious Disease Pharmacokinetics Laboratory
| | - Lori Dupree
- a Department of Pharmacotherapy and Translational Research , College of Pharmacy
| | - Emily Huesgen
- a Department of Pharmacotherapy and Translational Research , College of Pharmacy
| | - Charles A Peloquin
- a Department of Pharmacotherapy and Translational Research , College of Pharmacy.,b Infectious Disease Pharmacokinetics Laboratory.,c Emerging Pathogens Institute , University of Florida , Gainesville , FL , USA
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Pharmacokinetic, Pharmacogenetic, and Other Factors Influencing CNS Penetration of Antiretrovirals. AIDS Res Treat 2016; 2016:2587094. [PMID: 27777797 PMCID: PMC5061948 DOI: 10.1155/2016/2587094] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 08/21/2016] [Indexed: 12/22/2022] Open
Abstract
Neurological complications associated with the human immunodeficiency virus (HIV) are a matter of great concern. While antiretroviral (ARV) drugs are the cornerstone of HIV treatment and typically produce neurological benefit, some ARV drugs have limited CNS penetration while others have been associated with neurotoxicity. CNS penetration is a function of several factors including sieving role of blood-brain and blood-CSF barriers and activity of innate drug transporters. Other factors are related to pharmacokinetics and pharmacogenetics of the specific ARV agent or mediated by drug interactions, local inflammation, and blood flow. In this review, we provide an overview of the various factors influencing CNS penetration of ARV drugs with an emphasis on those commonly used in sub-Saharan Africa. We also summarize some key associations between ARV drug penetration, CNS efficacy, and neurotoxicity.
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Seddon JA, McKenna L, Shah T, Kampmann B. Recent Developments and Future Opportunities in the Treatment of Tuberculosis in Children. Clin Infect Dis 2016; 61Suppl 3:S188-99. [PMID: 26409282 DOI: 10.1093/cid/civ582] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Tuberculosis in children accounts for a significant proportion of the overall burden of disease, and yet for many years research into pediatric treatment has been neglected. Recently, there have been major developments in our understanding of pediatric tuberculosis, and a large number of studies are under way or planned. New drugs and regimens are being evaluated, and older drugs are being repurposed. Shorter regimens with potentially fewer side effects are being assessed for the treatment and prevention of both drug-susceptible and drug-resistant tuberculosis. It may be possible to tailor treatment so that children with less severe disease are given shorter regimens, and weekly dosing is under investigation for preventive therapy and for the continuation phase of treatment. The interaction with human immunodeficiency virus and the management of tuberculosis meningitis are also likely to be better understood. Exciting times lie ahead for pediatric tuberculosis, but much work remains to be done.
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Affiliation(s)
- James A Seddon
- Academic Department of Paediatrics, Imperial College London Department of Paediatric Infectious Diseases, Imperial College London NHS Healthcare Trust, United Kingdom
| | | | - Tejshri Shah
- Department of Paediatric Infectious Diseases, Imperial College London NHS Healthcare Trust, United Kingdom
| | - Beate Kampmann
- Academic Department of Paediatrics, Imperial College London Department of Paediatric Infectious Diseases, Imperial College London NHS Healthcare Trust, United Kingdom Vaccines & Immunity Theme, MRC Unit, The Gambia, Fajara
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Hennig S, Svensson EM, Niebecker R, Fourie PB, Weiner MH, Bonora S, Peloquin CA, Gallicano K, Flexner C, Pym A, Vis P, Olliaro PL, McIlleron H, Karlsson MO. Population pharmacokinetic drug-drug interaction pooled analysis of existing data for rifabutin and HIV PIs. J Antimicrob Chemother 2016; 71:1330-40. [PMID: 26832753 DOI: 10.1093/jac/dkv470] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 12/04/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Extensive but fragmented data from existing studies were used to describe the drug-drug interaction between rifabutin and HIV PIs and predict doses achieving recommended therapeutic exposure for rifabutin in patients with HIV-associated TB, with concurrently administered PIs. METHODS Individual-level data from 13 published studies were pooled and a population analysis approach was used to develop a pharmacokinetic model for rifabutin, its main active metabolite 25-O-desacetyl rifabutin (des-rifabutin) and drug-drug interaction with PIs in healthy volunteers and patients who had HIV and TB (TB/HIV). RESULTS Key parameters of rifabutin affected by drug-drug interaction in TB/HIV were clearance to routes other than des-rifabutin (reduced by 76%-100%), formation of the metabolite (increased by 224% in patients), volume of distribution (increased by 606%) and distribution to the peripheral compartment (reduced by 47%). For des-rifabutin, clearance was reduced by 35%-76% and volume of distribution increased by 67%-240% in TB/HIV. These changes resulted in overall increased exposure to rifabutin in TB/HIV patients by 210% because of the effects of PIs and 280% with ritonavir-boosted PIs. CONCLUSIONS Given together with non-boosted or ritonavir-boosted PIs, rifabutin at 150 mg once daily results in similar or higher exposure compared with rifabutin at 300 mg once daily without concomitant PIs and may achieve peak concentrations within an acceptable therapeutic range. Although 300 mg of rifabutin every 3 days with boosted PI achieves an average equivalent exposure, intermittent doses of rifamycins are not supported by current guidelines.
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Affiliation(s)
- Stefanie Hennig
- School of Pharmacy, University of Queensland, Brisbane, Australia Department of Pharmaceutical Bioscience, Uppsala University, Uppsala, Sweden
| | - Elin M Svensson
- Department of Pharmaceutical Bioscience, Uppsala University, Uppsala, Sweden
| | - Ronald Niebecker
- Department of Pharmaceutical Bioscience, Uppsala University, Uppsala, Sweden
| | - P Bernard Fourie
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| | - Marc H Weiner
- Department of Medicine, University of Texas Health Science Center and Veterans Administration Medical Center, San Antonio, TX, USA
| | - Stefano Bonora
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Charles A Peloquin
- College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | | | - Charles Flexner
- Johns Hopkins Adult AIDS Clinical Trials Unit, Division of Clinical Pharmacology, Baltimore, MD, USA
| | - Alex Pym
- Tuberculosis Research Unit, Medical Research Council and KwaZulu-Natal Research Institute for Tuberculosis and HIV (K-RITH), Durban, South Africa
| | - Peter Vis
- Janssen Infectious Diseases BVBA, Beerse, Belgium
| | - Piero L Olliaro
- Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organization (WHO), Geneva, Switzerland
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mats O Karlsson
- Department of Pharmaceutical Bioscience, Uppsala University, Uppsala, Sweden
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Tuberculosis: opportunities and challenges for the 90-90-90 targets in HIV-infected children. J Int AIDS Soc 2015; 18:20236. [PMID: 26639110 PMCID: PMC4670842 DOI: 10.7448/ias.18.7.20236] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 09/09/2015] [Accepted: 09/25/2015] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION In 2014 the Joint United Nations Programme on HIV/AIDS defined the ambitious 90-90-90 targets for 2020, in which 90% of people living with HIV must be diagnosed, 90% of those diagnosed should be on sustained therapy and 90% of those on therapy should have an undetectable viral load. Children are considered to be a key focus population for these targets. This review will highlight key components of the epidemiology, prevention and treatment of tuberculosis (TB) in HIV-infected children in the era of increasing access to antiretroviral therapy (ART) and their relation to the 90-90-90 targets. DISCUSSION The majority of HIV-infected children live in countries with a high burden of TB. In settings with a high burden of both diseases such as in sub-Saharan Africa, up to 57% of children diagnosed with and treated for TB are HIV-infected. TB results in substantial morbidity and mortality in HIV-infected children, so preventing TB and optimizing its treatment in HIV-infected children will be important to ensuring good long-term outcomes. Prevention of TB can be achieved by increasing access to ART to both children and adults, and appropriate provision of isoniazid preventative therapy. Co-treatment of HIV and TB is complicated by drug-drug interactions particularly due to the use of rifampicin; these may compromise virologic outcomes if appropriate corrective actions are not taken. There remain substantial operational challenges, and improved integration of paediatric TB and HIV services, including with antenatal and routine under-five care, is an important priority. CONCLUSIONS TB may be an important barrier to achievement of the 90-90-90 targets, but specific attention to TB care in HIV-infected children may provide important opportunities to enhance the care of both TB and HIV in children.
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Rossouw TM, Feucht UD, Melikian G, van Dyk G, Thomas W, du Plessis NM, Avenant T. Factors Associated with the Development of Drug Resistance Mutations in HIV-1 Infected Children Failing Protease Inhibitor-Based Antiretroviral Therapy in South Africa. PLoS One 2015. [PMID: 26196688 PMCID: PMC4510388 DOI: 10.1371/journal.pone.0133452] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE Limited data are available from the developing world on antiretroviral drug resistance in HIV-1 infected children failing protease inhibitor-based antiretroviral therapy, especially in the context of a high tuberculosis burden. We describe the proportion of children with drug resistance mutations after failed protease inhibitor-based antiretroviral therapy as well as associated factors. METHODS Data from children initiated on protease inhibitor-based antiretroviral therapy with subsequent virological failure referred for genotypic drug resistance testing between 2008 and 2012 were retrospectively analysed. Frequencies of drug resistance mutations were determined and associations with these mutations identified through logistic regression analysis. RESULTS The study included 65 young children (median age 16.8 months [IQR 7.8; 23.3]) with mostly advanced clinical disease (88.5% WHO stage 3 or 4 disease), severe malnutrition (median weight-for-age Z-score -2.4 [IQR -3.7;-1.5]; median height-for-age Z-score -3.1 [IQR -4.3;-2.4]), high baseline HIV viral load (median 6.04 log10, IQR 5.34;6.47) and frequent tuberculosis co-infection (66%) at antiretroviral therapy initiation. Major protease inhibitor mutations were found in 49% of children and associated with low weight-for-age and height-for-age (p = 0.039; p = 0.05); longer duration of protease inhibitor regimens and virological failure (p = 0.001; p = 0.005); unsuppressed HIV viral load at 12 months of antiretroviral therapy (p = 0.001); tuberculosis treatment at antiretroviral therapy initiation (p = 0.048) and use of ritonavir as single protease inhibitor (p = 0.038). On multivariate analysis, cumulative months on protease inhibitor regimens and use of ritonavir as single protease inhibitor remained significant (p = 0.008; p = 0.033). CONCLUSION Major protease inhibitor resistance mutations were common in this study of HIV-1-infected children, with the timing of tuberculosis treatment and subsequent protease inhibitor dosing strategy proving to be important associated factors. There is an urgent need for safe, effective, and practicable HIV/tuberculosis co-treatment in young children and the optimal timing of treatment, optimal dosing of antiretroviral therapy, and alternative tuberculosis treatment strategies should be urgently addressed.
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Affiliation(s)
- Theresa M. Rossouw
- Institute for Cellular and Molecular Medicine, Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- * E-mail:
| | - Ute D. Feucht
- Department of Paediatrics, Kalafong Provincial Tertiary Hospital, University of Pretoria, Pretoria, South Africa
| | - George Melikian
- AIDS Healthcare Foundation, Los Angeles, CA, United States of America
| | - Gisela van Dyk
- Institute for Cellular and Molecular Medicine, Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Winifred Thomas
- Department of Paediatrics, Kalafong Provincial Tertiary Hospital, University of Pretoria, Pretoria, South Africa
| | - Nicolette M. du Plessis
- Department of Paediatrics, Kalafong Provincial Tertiary Hospital, University of Pretoria, Pretoria, South Africa
| | - Theunis Avenant
- Department of Paediatrics, Kalafong Provincial Tertiary Hospital, University of Pretoria, Pretoria, South Africa
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McIlleron H, Abdel-Rahman S, Dave JA, Blockman M, Owen A. Special populations and pharmacogenetic issues in tuberculosis drug development and clinical research. J Infect Dis 2015; 211 Suppl 3:S115-25. [PMID: 26009615 PMCID: PMC4551115 DOI: 10.1093/infdis/jiu600] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Special populations, including children and pregnant women, have been neglected in tuberculosis drug development. Patients in developing countries are inadequately represented in pharmacology research, and postmarketing pharmacovigilance activities tend to be rudimentary in these settings. There is an ethical imperative to generate evidence at an early stage to support optimal treatment in these populations and in populations with common comorbid conditions, such as diabetes and human immunodeficiency virus (HIV) infection. This article highlights the research needed to support equitable access to new antituberculosis regimens. Efficient and opportunistic pharmacokinetic study designs, typically using sparse sampling and population analysis methods, can facilitate optimal dose selection for children and pregnant women. Formulations suitable for children should be developed early and used in pharmacokinetic studies to guide dose selection. Drug-drug interactions between commonly coprescribed medications also need to be evaluated, and when these are significant, alternative approaches should be sought. A potent rifamycin-sparing regimen could revolutionize the treatment of adults and children requiring a protease inhibitor as part of antiretroviral treatment regimens for HIV infection. A sufficiently wide formulary of drugs should be developed for those with contraindications to the standard approaches. Because genetic variations may influence an individual's response to tuberculosis treatment, depending on the population being treated, it is important that samples be collected and stored for pharmacogenetic study in future clinical trials.
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Affiliation(s)
| | - Susan Abdel-Rahman
- Division of Clinical Pharmacology, Children's Mercy Hospital
- Department of Pediatrics, School of Medicine, University of Missouri–Kansas City,Missouri
| | - Joel Alex Dave
- Division of Diabetic Medicine and Endocrinology, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, South Africa
| | | | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, United Kingdom
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Meyers T, Sawry S, Wong JY, Moultrie H, Pinillos F, Fairlie L, van Zyl G. Virologic failure among children taking lopinavir/ritonavir-containing first-line antiretroviral therapy in South Africa. Pediatr Infect Dis J 2015; 34:175-9. [PMID: 25741970 PMCID: PMC4352713 DOI: 10.1097/inf.0000000000000544] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To report the outcomes, clinical management decisions and results of resistance testing among a group of children who developed virologic failure on first-line lopinavir/ritonavir (LPV/r)-based therapy from a large cohort of antiretroviral therapy-treated children in Soweto. DESIGN Historical cohort study. METHODS Children with virologic failure were identified from a group of 1692 children <3 years who had initiated first-line LPV/r-containing therapy since 2000 up to the end November 2011. Genotyping was conducted in some children, and outcomes, management decisions and resistance results were described. RESULTS A total of 152 children with virologic failure on first-line LPV/r-containing antiretroviral therapy were included. Resistance testing was performed in 75/152 (49%), and apart from a younger age (11.1 vs. 15.1 months, P = 0.04), the children with versus those without resistance testing were similar for baseline characteristics (weight, CD4, viral load and time to failure). Genotyping revealed that 8/75 (10.7%) had significant LPV/r-associated resistance mutations, including 2 with intermediate darunavir resistance. Among 63/75 (84%) children remaining on LPV/r-based therapy, 32/63 (51%) achieved virologic suppression, and 2 of these children with significant LPV mutations. In accordance with the local guidelines at the time, 12/152 (8%) children were switched to non-nucleoside reverse-transcriptase inhibitors-based therapy. Of these, 4/12 (33%) resuppressed, and the rest did not achieve virologic suppression including the 2 with lopinavir mutations. CONCLUSIONS Virologic failure of LPV/r-containing first-line regimens is associated with accumulation of LPV/r mutations in children. The implications are unclear, and surveillance at selected sites is warranted for long-term virologic outcomes and development of resistance.
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Affiliation(s)
- Tammy Meyers
- Department of Paediatrics, Chris Hani Baragwanath Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shobna Sawry
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jessica Y. Wong
- Division of Epidemiology and Biostatistics, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Harry Moultrie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Francoise Pinillos
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,Empilweni Services and Research Unit (ESRU), Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gert van Zyl
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service, Tygerberg
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The effect of tuberculosis treatment on virologic and immunologic response to combination antiretroviral therapy among South African children. J Acquir Immune Defic Syndr 2015; 67:136-44. [PMID: 25072611 DOI: 10.1097/qai.0000000000000284] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many HIV-infected children are diagnosed with tuberculosis (TB), but the effect of TB treatment on virologic and immunologic response to combination antiretroviral therapy (cART) is not well documented. METHODS Secondary analysis of a prospective cohort of cART-naive HIV-infected South African children aged 0-8 years initiating cART to assess the effect of TB treatment at the time of cART initiation on virologic suppression (HIV RNA < 50 copies/mL), virologic rebound (HIV RNA > 1000 copies/mL after suppression), and CD4 cell percent (CD4%) increase during the first 24 months of cART. RESULTS Of 199 children (median age 2.1 years), 92 (46%) were receiving TB treatment at cART initiation. Children receiving and not receiving TB treatment at cART initiation had similar median baseline HIV RNA (5.4 vs. 5.6 copies/mL), median time to virologic suppression (6.2 months in each group, adjusted hazard ratio, 1.36, 95% confidence interval: 0.94 to 1.96), and rates of virologic rebound by 24 months (23% vs. 24%, adjusted hazard ratio 1.53, 95% confidence interval: 0.71 to 3.30). Children on TB treatment had significantly lower median CD4% at baseline (15.3% vs. 18.8%, P < 0.01) and during the first 12 months of cART but experienced similar median increases in CD4% at 6 months (9.9% vs. 9.6%), 12 months (14.2% vs. 11.9%), and 24 months of cART (14.5% vs. 14.2%). Exploratory analyses suggest that children receiving lopinavir/ritonavir-based cART and TB treatment may have inferior virologic and immunologic response compared with children receiving efavirenz-based cART. CONCLUSIONS Receiving TB treatment at the time of cART initiation did not substantially affect virologic or immunologic response to cART in young children.
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Moultrie H, McIlleron H, Sawry S, Kellermann T, Wiesner L, Kindra G, Gous H, Van Rie A. Pharmacokinetics and safety of rifabutin in young HIV-infected children receiving rifabutin and lopinavir/ritonavir. J Antimicrob Chemother 2014; 70:543-9. [PMID: 25281400 PMCID: PMC4291235 DOI: 10.1093/jac/dku382] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives Co-treatment of HIV and TB in young children is complicated by limited treatment options and complex drug–drug interactions. Rifabutin is an alternative to rifampicin for adults receiving a ritonavir-boosted PI. We aimed to evaluate the short-term safety and pharmacokinetics of rifabutin when given with lopinavir/ritonavir in children. Patients and methods We conducted an open-label study of rifabutin dosed at 5 mg/kg three times a week in HIV-infected children ≤5 years of age receiving lopinavir/ritonavir. Intensive steady-state pharmacokinetic sampling was conducted after six doses. The Division of AIDS 2004, clarification 2009, table for grading severity of adverse events was used to classify drug toxicities. The study was registered with ClinicalTrials.gov, number NCT01259219. Results Six children completed the study prior to closure by institutional review boards. The median (range) AUC0–48 of rifabutin was 6.91 (3.52–8.67) μg · h/mL, the median (range) Cmax of rifabutin was 0.39 (0.19–0.46) μg/mL, the median (range) AUC0–48 of 25-O-desacetyl rifabutin was 5.73 (2.85–9.13) μg · h/mL and the median (range) Cmax of 25-O-desacetyl rifabutin was 0.17 (0.08–0.32) μg/mL. The neutrophil count declined in all children; two children experienced grade 4 neutropenia, which resolved rapidly without complications. There was strong correlation between AUC0–48 measures and neutrophil counts. Conclusions Rifabutin dosed at 5 mg/kg three times per week resulted in lower AUC0–48, AUC0–24 and Cmax values for rifabutin and 25-O-desacetyl rifabutin compared with adults receiving 150 mg of rifabutin daily, the current recommended dose. We observed high rates of severe transient neutropenia, possibly due to immaturity of CYP3A4 in young children. It remains unclear whether a safe and effective rifabutin dose exists for treatment of TB in children receiving lopinavir/ritonavir.
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Affiliation(s)
- Harry Moultrie
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Shobna Sawry
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Tracy Kellermann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gurpreet Kindra
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Hermien Gous
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Annelies Van Rie
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
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Zhang C, Denti P, Decloedt EH, Ren Y, Karlsson MO, McIlleron H. Model-based evaluation of the pharmacokinetic differences between adults and children for lopinavir and ritonavir in combination with rifampicin. Br J Clin Pharmacol 2014; 76:741-51. [PMID: 23432610 DOI: 10.1111/bcp.12101] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 02/10/2013] [Indexed: 11/28/2022] Open
Abstract
AIMS Rifampicin profoundly reduces lopinavir concentrations. Doubled doses of lopinavir/ritonavir compensate for the effect of rifampicin in adults, but fail to provide adequate lopinavir concentrations in young children on rifampicin-based antituberculosis therapy. The objective of this study was to develop a population pharmacokinetic model describing the pharmacokinetic differences of lopinavir and ritonavir, with and without rifampicin, between children and adults. METHODS An integrated population pharmacokinetic model developed in nonmem 7 was used to describe the pharmacokinetics of lopinavir and ritonavir in 21 HIV infected adults, 39 HIV infected children and 35 HIV infected children with tuberculosis, who were established on lopinavir/ritonavir-based antiretroviral therapy with and without rifampicin-containing antituberculosis therapy. RESULTS The bioavailability of lopinavir was reduced by 25% in adults whereas children on antituberculosis treatment experienced a 59% reduction, an effect that was moderated by the dose of ritonavir. Conversely, rifampicin increased oral clearance of both lopinavir and ritonavir to a lesser extent in children than in adults. Rifampicin therapy in administered doses increased CL of lopinavir by 58% in adults and 48% in children, and CL of ritonavir by 34% and 22% for adults and children, respectively. In children, the absorption half-life of lopinavir and the mean transit time of ritonavir were lengthened, compared with those in adults. CONCLUSIONS The model characterized important differences between adults and children in the effect of rifampicin on the pharmacokinetics of lopinavir and ritonavir. As adult studies cannot reliably predict their magnitude in children, drug-drug interactions should be evaluated in paediatric patient populations.
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Affiliation(s)
- Chao Zhang
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Slaughter RL. Pharmacokinetic behavior presents drug therapy challenges. Expert Rev Clin Pharmacol 2013; 6:627-39. [PMID: 24164611 DOI: 10.1586/17512433.2013.849196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
There are conditions that cause a substantial change in drug clearance to such a degree that how a specific drug is managed to optimize drug response and minimize drug toxicity presents a challenge. This review will focus on recent literature (within the past 5 years) that evaluates pathophysiologic and genetic conditions and drug interactions which can change drug clearance to the magnitude that response is affected. Situations discussed that cause an increase in drug clearance will include: augmented renal clearance in critically ill patients; ultrafast drug metabolism caused by gene duplication; and enzyme induction interactions caused by rifampin. Situations discussed that result in a reduction in clearance will include: multiple organ failure in critically ill, patients with non-functioning CYP2D6 and CYP2C8/9 alleles, and CYP3A4 drug interactions with erythromycin and clarithromycin. In each case evaluated clearance is changed to the magnitude such that managing drug therapy can be difficult.
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Affiliation(s)
- Richard L Slaughter
- Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, 259 Mack Ave, Detroit, MI 48201, USA +313 577 1574
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Agwu AL, Fairlie L. Antiretroviral treatment, management challenges and outcomes in perinatally HIV-infected adolescents. J Int AIDS Soc 2013; 16:18579. [PMID: 23782477 PMCID: PMC3687074 DOI: 10.7448/ias.16.1.18579] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 04/17/2013] [Indexed: 02/06/2023] Open
Abstract
Three decades into the HIV/AIDS epidemic there is a growing cohort of perinatally HIV-infected adolescents globally. Their survival into adolescence and beyond represent one of the major successes in the battle against the disease that has claimed the lives of millions of children. This population is diverse and there are unique issues related to antiretroviral treatment and management. Drawing from the literature and experience, this paper discusses several broad areas related to antiretroviral management, including: 1) diverse presentation of HIV, (2) use of combination antiretroviral therapy including in the setting of co-morbidities and rapid growth and development, (3) challenges of cART, including nonadherence, resistance, and management of the highly treatment-experienced adolescent patient, (4) additional unique concerns and management issues related to PHIV-infected adolescents, including the consequences of longterm inflammation, risk of transmission, and transitions to adult care. In each section, the experience in both resource-rich and limited settings are discussed with the aim of highlighting the differences and importantly the similarities, to share lessons learnt and provide insight into the multi-faceted approaches that may be needed to address the challenges faced by this unique and resilient population.
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Affiliation(s)
- Allison L Agwu
- Division of Paediatric Infectious Diseases, Department of Paediatrics, Johns Hopkins School of Medicine Baltimore, MD, USA.
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Teasdale CA, Abrams EJ, Coovadia A, Strehlau R, Martens L, Kuhn L. Adherence and viral suppression among infants and young children initiating protease inhibitor-based antiretroviral therapy. Pediatr Infect Dis J 2013; 32:489-94. [PMID: 23249913 PMCID: PMC3624073 DOI: 10.1097/inf.0b013e31827e84ba] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND High levels of adherence to antiretroviral therapy are considered necessary to achieve viral suppression. We analyzed data from a cohort of HIV-infected children who were <2 years of age receiving protease inhibitor-based antiretroviral therapy to investigate associations between viral suppression and adherence ascertained using different methods. METHODS Data were from the prerandomization phase of a clinical trial in South Africa of HIV-infected children initiating either ritonavir-boosted lopinavir (LPV/r) or ritonavir-based antiretroviral therapy. At scheduled visits during the first 24 weeks of enrollment, study pharmacists measured quantities of medications returned to the clinic. Caregivers answered questionnaires on missed doses and adherence barriers. Associations between adherence and viral suppression (HIV-1 RNA <400 copies/mL) were investigated by regimen. RESULTS By 24 weeks, 197 of the 269 (73%) children achieved viral suppression. There was no association between viral suppression and caregiver reported missed doses or adherence barriers. For children receiving the LPV/r-based regimen, medication return adherence to each of the 3 drugs in the regimen (LPV/r, lamivudine or stavudine) individually or together was associated with viral suppression at different adherence thresholds. For example, <85% adherence to any of the 3 medications significantly increased odds of lack of viral suppression (odds ratio: 2.30, 95% confidence interval: 1.30-4.07, P = 0.004). In contrast, for children receiving the ritonavir-based regimen, there was no consistent pattern of association between medication return and viral suppression. CONCLUSIONS Caregiver reports of missed doses did not predict virologic response to treatment. Pharmacist medication reconciliation correlated strongly with virologic response for children taking a LPV/r-based regimen and appears to be a valid method for measuring pediatric adherence.
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Affiliation(s)
- Chloe A Teasdale
- ICAP, Mailman School of Public Health, Columbia University, New York, USA,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Elaine J Abrams
- ICAP, Mailman School of Public Health, Columbia University, New York, USA,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Ashraf Coovadia
- Empilweni Services and Research Unit (ESRU), Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Renate Strehlau
- Empilweni Services and Research Unit (ESRU), Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Leigh Martens
- Empilweni Services and Research Unit (ESRU), Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Louise Kuhn
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA,Gertrude H. Sergievsky Center, College of Physicians and Surgeons, Columbia University, NY
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Antiretroviral regimens containing a single protease inhibitor increase risk of virologic failure in young HIV-infected children. Pediatr Infect Dis J 2013; 32:361-3. [PMID: 23114373 DOI: 10.1097/inf.0b013e318279c800] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Rifampin-based tuberculosis treatment can cause subtherapeutic concentrations of protease inhibitors and virologic failure in children receiving antiretroviral therapy. Among 217 children on antiretroviral therapy, tuberculosis cotreatment (in 78) was associated with virologic failure. Ritonavir-based single protease inhibitor antiretroviral therapy regimen predicted virologic failure (adjusted odds ratio 3.7, 95% confidence interval 1.5-8.9, P = 0.004) on multivariate analysis.
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Zhang C, McIlleron H, Ren Y, van der Walt JS, Karlsson MO, Simonsson USH, Denti P. Population pharmacokinetics of lopinavir and ritonavir in combination with rifampicin-based antitubercular treatment in HIV-infected children. Antivir Ther 2013; 17:25-33. [PMID: 22267466 DOI: 10.3851/imp1915] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The preferred antiretroviral regimen for young children previously exposed to non-nucleoside reverse transcriptase inhibitors is lopinavir/ritonavir plus two nucleoside reverse transcriptase inhibitors. Rifampicin-based antitubercular treatment reduces lopinavir concentrations. Adding extra ritonavir to lopinavir/ritonavir overcomes the effect of rifampicin, however this approach is not feasible in many settings. METHODS We developed an integrated population model describing lopinavir and ritonavir pharmacokinetics to predict lopinavir/ritonavir (4:1) doses achieving target lopinavir exposures in children treated for tuberculosis. The model included data from 15 children given 'super-boosted' lopinavir (lopinavir/ritonavir =1:1) and 20 children given twice the standard dose of lopinavir/ritonavir every 12 h during antitubercular treatment, and from children given standard lopinavir/ritonavir doses every 12 h (39 without tuberculosis and 11 sampled again after antitubercular treatment). RESULTS A one-compartment model with first-order absorption and elimination best described the pharmacokinetics of lopinavir and a one-compartment model with transit absorption compartments described ritonavir pharmacokinetics. The dynamic influence of ritonavir concentration on lopinavir oral clearance was modelled as direct inhibition with an E(max) model. Antitubercular treatment reduced the oral bioavailability of lopinavir by 77% in children receiving twice usual lopinavir/ritonavir doses and increased ritonavir clearance by 50%. Simulations predicted that respective 27, 21, 20 and 18 mg/kg 8-hourly doses of lopinavir (in lopinavir/ritonavir, 4:1) maintains lopinavir concentrations >1 mg/l in at least 95% of children weighing 3-5.9, 6-9.9, 10-13.9 and 14-19.9 kg. CONCLUSIONS The model describing the interactions between lopinavir, ritonavir and rifampicin in young children predicted feasible 8-hourly doses of lopinavir/ritonavir resulting in therapeutic lopinavir concentrations during antitubercular treatment.
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Affiliation(s)
- Chao Zhang
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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van Dijk JH, Sutcliffe CG, Hamangaba F, Bositis C, Watson DC, Moss WJ. Effectiveness of efavirenz-based regimens in young HIV-infected children treated for tuberculosis: a treatment option for resource-limited settings. PLoS One 2013; 8:e55111. [PMID: 23372824 PMCID: PMC3555823 DOI: 10.1371/journal.pone.0055111] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 12/19/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Antiretroviral treatment (ART) options for young children co-infected with HIV and tuberculosis are limited in resource-poor settings due to limited data on the use of efavirenz (EFV). Using available pharmacokinetic data, an EFV dosing schedule was developed for young co-infected children and implemented as the standard of care at Macha Hospital in Southern Province, Zambia. Treatment outcomes in children younger than 3 years of age or weighing less than 10 kg receiving either EFV-based ART plus anti-tuberculous treatment or nevirapine-based (NVP) ART were compared. METHODS Treatment outcomes were measured in a cohort of HIV-infected children seeking care at Macha Hospital in rural Zambia from 2007 to 2010. Information on the diagnosis and treatment of tuberculosis was abstracted from medical records. RESULTS Forty-five children treated for tuberculosis initiated an EFV-based regimen and 69 children initiated a NVP-based regimen, 7 of whom also were treated for tuberculosis. Children receiving both regimens were comparable in age, but children receiving EFV started ART with a lower CD4(+) T-cell percentage and weight-for-age z-score. Children receiving EFV experienced increases in both CD4(+) T-cell percentage and weight-for-age z-score during follow-up, such that levels were comparable to children receiving NVP after two years of ART. Cumulative survival after 12 months of ART did not differ between groups (NVP:87%;EFV:80%;p = 0.25). Eleven children experienced virologic failure during follow-up.The adjusted hazard ratio of virologic failure comparing EFV to NVP was 0.25 (95% CI:0.05,1.24) and 0.13 (95% CI:0.03,0.62) using thresholds of 5000 and 400 copies/mL, respectively.Five children receiving EFV were reported to have had convulsions after ART initiation compared to only one child receiving NVP (p = 0.04). CONCLUSIONS Despite poorer health at ART initiation, children treated for tuberculosis and receiving EFV-based regimens showed significant improvements comparable to children receiving NVP-based regimens. EFV-based regimens should be considered for young HIV-infected children co-infected with tuberculosis in resource-limited settings.
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Affiliation(s)
- Janneke H. van Dijk
- Macha Research Trust, Macha Hospital, Choma, Zambia
- Department of Immunology and Infectious Diseases, Erasmus University, Rotterdam, The Netherlands
| | - Catherine G. Sutcliffe
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | | | - Christopher Bositis
- Greater Lawrence Family Health Center, Lawrence, Massachusetts, United States of America
| | - Douglas C. Watson
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - William J. Moss
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
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Turkova A, Webb RH, Lyall H. When to start, what to start and other treatment controversies in pediatric HIV infection. Paediatr Drugs 2012; 14:361-76. [PMID: 23013459 DOI: 10.2165/11599640-000000000-00000] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Over the last decade there have been dramatic changes in the management of pediatric HIV infection. Whilst observational studies and several randomized control trials (RCTs) have addressed some questions about when to start antiretroviral therapy (ART) in children and what antiretrovirals to start, many others remain unanswered. In infants, early initiation of ART greatly reduces mortality and disease progression. Treatment guidelines now recommend ART in all infants younger than 1 or 2 years of age depending on geographical setting. In children >1 year of age, US, European (Paediatric European Network for Treatment of AIDS; PENTA) and WHO guidelines differ and debate is ongoing. Recent data from an RCT in Thailand in children with moderate immune suppression indicate that it is safe to monitor asymptomatic children closely without initiating ART, although earlier treatment was associated with improved growth. Untreated HIV progression in children aged over 5 years is similar to that in adults, and traditionally adult treatment thresholds are applied. Recent adult observational and modeling studies showed a survival advantage and reduction of age-associated complications with early treatment. The current US guidelines have lowered CD4+ cell count thresholds for ART initiation for children aged >5 years to 500 cells/mm3. Co-infections influence the choice of drugs and the timing of starting ART. Drug interactions, overlapping toxicities and adherence problems secondary to increased pill burden are important issues. Rapid changes in the pharmacokinetics of antiretrovirals in the first years of life, limited pharmacokinetic data in children and genetic variation in metabolism of many antiretrovirals make correct dosing difficult. Adherence should always be addressed prior to starting ART or switching regimens. The initial ART regimen depends on previous exposure, including perinatal administration for prevention of mother to child transmission (PMTCT), adherence, co-infections, drug availability and licensing. A European cohort study in infants indicated that treatment with four drugs produced superior virologic suppression and immune recovery. Protease inhibitor (PI)-based ART has the advantage of a high barrier to viral resistance. A recent RCT conducted in several African countries showed PI-based ART to be advantageous in children aged <3 years compared with nevirapine-based ART irrespective of previous nevirapine exposure. Another trial in older children from resource rich settings showed both regimens were equally effective. Treatment interruption remains a controversial issue in children, but one study in Europe demonstrated no short-term detrimental effects. ART in children is a rapidly evolving area with many new antiretrovirals being developed and undergoing trials. The aim of ART has shifted from avoiding mortality and morbidity to achieving a normal life expectancy and quality of life, minimizing toxicities and preventing early cancers and age-related illnesses.
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Affiliation(s)
- Anna Turkova
- Department of Paediatric Infectious Diseases, St Mary's Hospital, Imperial College NHS Trust, London, UK
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Zanoni BC, Sunpath H, Feeney ME. Pediatric response to second-line antiretroviral therapy in South Africa. PLoS One 2012; 7:e49591. [PMID: 23185373 PMCID: PMC3502491 DOI: 10.1371/journal.pone.0049591] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 10/12/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND With improved access to pediatric antiretroviral therapy (ART) in resource-limited settings, more children could experience first-line ART treatment failure. METHODS We performed a retrospective cohort analysis using electronic medical records from HIV-infected children who initiated ART at McCord Hospital's Sinikithemba Clinic in KwaZulu-Natal, South Africa, from August 2003 to December 2010. We analyzed all records from children who began second-line ART due to first-line treatment failure. We used logistic regression to compare viral outcomes in Protease Inhibitor (PI)-based versus Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI)-based second-line ART, controlling for time on first-line ART, sex, and whether HIV genotyping guided the regimen change. RESULTS Of the 880 children who initiated ART during this time period, 80 (9.1%) switched to second-line ART due to therapeutic failure of first-line ART after a median of 95 weeks (IQR 65-147 weeks). Eight (10%) of the failures received NNRTI-based second-line ART, all of whom failed a PI-based first-line regimen. Seventy (87.5%) received PI-based second-line ART, all of whom failed a NNRTI-based first-line regimen. Two children (2.5%) received non-standard dual therapy as second-line ART. Six months after switching ART regimens, the viral suppression rate was significantly higher in the PI group (82%) than in the NNRTI group (29%; p=0.003). Forty-one children (51%) were tested for genotypic resistance prior to switching to second-line ART. There was no significant difference in six month viral suppression (p=0.38) between children with and without genotype testing. CONCLUSION NNRTI-based second-line ART carries a high risk of virologic failure compared to PI-based second-line ART.
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Affiliation(s)
- Brian C. Zanoni
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology, and Harvard, Charlestown, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
| | - Henry Sunpath
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
- Infectious Diseases Unit, Nelson Mandela School of Medicine, Durban, South Africa
| | - Margaret E. Feeney
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology, and Harvard, Charlestown, Massachusetts, United States of America
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
- Division of Experimental Medicine, University of California San Francisco, San Francisco, California, United States of America
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Population Pharmacokinetic Model for Adherence Evaluation Using Lamivudine Concentration Monitoring. Ther Drug Monit 2012; 34:481-4. [DOI: 10.1097/ftd.0b013e31825c6067] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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TB and HIV Therapeutics: Pharmacology Research Priorities. AIDS Res Treat 2012; 2012:874083. [PMID: 22829999 PMCID: PMC3398575 DOI: 10.1155/2012/874083] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Accepted: 03/13/2012] [Indexed: 01/16/2023] Open
Abstract
An unprecedented number of investigational drugs are in the development pipeline for the treatment of tuberculosis. Among patients with tuberculosis, co-infection with HIV is common, and concurrent treatment of tuberculosis and HIV is now the standard of care. To ensure that combinations of anti-tuberculosis drugs and antiretrovirals are safe and are tested at doses most likely to be effective, selected pharmacokinetic studies based on knowledge of their metabolic pathways and their capacity to induce or inhibit metabolizing enzymes of companion drugs must be conducted. Drug interaction studies should be followed up by evaluations in larger populations to evaluate safety and pharmacodynamics more fully. Involving patients with HIV in trials of TB drugs early in development enhances the knowledge gained from the trials and will ensure that promising new tuberculosis treatments are available to patients with HIV as early as possible. In this review, we summarize current and planned pharmacokinetic and drug interaction studies involving investigational and licensed tuberculosis drugs and antiretrovirals and suggest priorities for tuberculosis-HIV pharmacokinetic, pharmacodynamic, and drug-drug interaction studies for the future. Priority studies for children and pregnant women with HIV and tuberculosis co-infection are briefly discussed.
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Zhang C, Denti P, Decloedt E, Maartens G, Karlsson MO, Simonsson USH, McIlleron H. Model-based approach to dose optimization of lopinavir/ritonavir when co-administered with rifampicin. Br J Clin Pharmacol 2012; 73:758-67. [PMID: 22126409 PMCID: PMC3403203 DOI: 10.1111/j.1365-2125.2011.04154.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AIMS Rifampicin, a key component of antitubercular treatment, profoundly reduces lopinavir concentrations. The aim of this study was to develop an integrated population pharmacokinetic model accounting for the drug-drug interactions between lopinavir, ritonavir and rifampicin, and to evaluate optimal doses of lopinavir/ritonavir when co-administered with rifampicin. METHODS Steady-state pharmacokinetics of lopinavir and ritonavir were sequentially evaluated after the introduction of rifampicin and gradually escalating the dose in a cohort of 21 HIV-infected adults. Intensive pharmacokinetic sampling was performed after each dose adjustment following a morning dose administered after fasting overnight. A population pharmacokinetic analysis was conducted using NONMEM 7. RESULTS A simultaneous integrated model was built. Rifampicin reduced the oral bioavailability of lopinavir and ritonavir by 20% and 45% respectively, and it increased their clearance by 71% and 36% respectively. With increasing concentrations of ritonavir, clearance of lopinavir decreased in an E(max) relationship. Bioavailability was 42% and 45% higher for evening doses compared with morning doses for lopinavir and ritonavir, respectively, while oral clearance of both drugs was 33% lower overnight. Simulations predicted that 99.5% of our patients receiving doubled doses of lopinavir/ritonavir achieve morning trough concentrations of lopinavir > 1 mg l(-1) during rifampicin co-administration, and 95% of those weighing less than 50 kg achieve this target already with 600/150 mg doses of lopinavir/ritonavir. CONCLUSIONS The model describes the drug-drug interactions between lopinavir, ritonavir and rifampicin in adults. The higher trough concentrations observed in the morning were explained by both higher bioavailability with the evening meal and lower clearance overnight.
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Affiliation(s)
- Chao Zhang
- Division of Clinical Pharmacology, Department of Medicine, University of Cape TownCape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape TownCape Town, South Africa
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, University of Cape TownCape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape TownCape Town, South Africa
| | - Mats O Karlsson
- Department of Pharmaceutical Biosciences, Uppsala UniversityUppsala, Sweden
| | | | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape TownCape Town, South Africa
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Curran A, Ribera E. HIV and TB coinfection: using adjusted doses of lopinavir/ritonavir with rifampin. Expert Rev Anti Infect Ther 2012; 9:1115-8. [PMID: 22114961 DOI: 10.1586/eri.11.143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Evaluation of: Decloedt E, McIlleron H, Smith P, Merry C, Orrell C, Maartens G. Pharmacokinetics of lopinavir in HIV-infected adults receiving rifampin with adjusted doses of lopinavir-ritonavir tablets. Antimicrob. Agents Chemother. 55(7), 3195-3200 (2011). HIV and TB coinfection is a widespread problem, especially in resource-limited settings. Interactions between drugs metabolized through cytochrome P450 enzymes and p-glycoprotein efflux pump, such as rifampin and HIV protease inhibitors, complicate the management of both pathologies when they coexist. The article by Decloedt et al. elegantly assesses the pharmacokinetics of three twice-daily escalating doses of lopinavir/ritonavir (400/100 mg, 600/150 mg and 800/200 mg), together with 600 mg daily of rifampin in 21 black African HIV-infected patients without TB. The article also reports safety, tolerability and virological outcomes after 3 weeks. Doubling lopinavir/ritonavir dose overcomes rifampin induction effect with good tolerability. However, concerns arise regarding the real interactions, tolerability and virological efficacy in HIV-TB-coinfected patients, which may differ from healthy volunteers or HIV-infected patients without TB.
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Affiliation(s)
- Adrian Curran
- Infectious Diseases Department, Hospital Universitari Vall de Hebron, Universitat Autònoma de Barcelona, Passeig Vall de Hebron 119-129, 08035 Barcelona, Spain
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Unresolved antiretroviral treatment management issues in HIV-infected children. J Acquir Immune Defic Syndr 2012; 59:161-9. [PMID: 22138766 DOI: 10.1097/qai.0b013e3182427029] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Antiretroviral therapy in children has expanded dramatically in low-income and middle-income countries. The World Health Organization revised its pediatric HIV guidelines to recommend initiation of antiretroviral therapy in all HIV-infected children younger than 2 years, regardless of CD4 count or clinical stage. The number of children starting life-long antiretroviral therapy should therefore expand dramatically over time. The early initiation of antiretroviral therapy has indisputable benefits for children, but there is a paucity of definitive information on the potential adverse effects. In this review, a comprehensive literature search was conducted to provide an overview of our knowledge about the complications of treating pediatric HIV. Antiretroviral therapy in children, as in adults, is associated with enhanced survival, reduction in opportunistic infections, improved growth and neurocognitive function, and better quality of life. Despite antiretroviral therapy, HIV-infected children may continue to lag behind their uninfected peers in growth and development. In addition, epidemic concurrent conditions, such as tuberculosis, malaria, and malnutrition, can combine with HIV to yield more rapid disease progression and poor treatment outcomes. Additional studies are required to evaluate the long-term effects of antiretroviral therapy in HIV-infected infants, children, and adolescents, particularly in resource-limited countries where concomitant infections and conditions may enhance the risk of adverse effects. There is an urgent need to evaluate drug-drug interactions in children to determine optimal treatment regimens for both HIV and coinfections.
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Eley BS, Meyers T. Antiretroviral therapy for children in resource-limited settings: current regimens and the role of newer agents. Paediatr Drugs 2011; 13:303-16. [PMID: 21888444 DOI: 10.2165/11593330-000000000-00000] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
WHO antiretroviral treatment guidelines for HIV-infected children have influenced the design of treatment programmes in resource-limited settings. This review analyses the latest WHO first- and second-line regimen recommendations. The recommendation to use lopinavir/ritonavir-containing first-line regimens in young children with prior non-nucleoside reverse transcriptase inhibitor (NNRTI) exposure is based on good quality evidence. Recent research suggests that lopinavir/ritonavir-containing first-line regimens should be extended to all young children, irrespective of prior NNRTI exposure. Strategies for overcoming the adverse metabolic effects of rifampicin-containing anti-tuberculosis therapy on antiretroviral therapy regimens have been under-researched in HIV-infected children, creating uncertainty about global recommendations. Preferred second-line recommendations are largely predictable. The exception is that NNRTI-containing second-line regimens are recommended for children previously exposed to NNRTIs and who subsequently did not respond to lopinavir/ritonavir-containing first-line therapy. In these patients, second-line regimens containing newer protease inhibitors (PIs) such as darunavir and tipranavir, or integrase inhibitors such as raltegravir, should be evaluated. Newer antiretroviral agents including second-generation NNRTIs and PIs, C-C chemokine receptor type 5 inhibitors, and integrase inhibitors may assist in further refinement of existing regimen options.
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Affiliation(s)
- Brian S Eley
- Paediatric Infectious Diseases Unit, Red Cross War Memorial Childrens Hospital, Cape Town, South Africa.
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Kigen G, Kimaiyo S, Nyandiko W, Faragher B, Sang E, Jakait B, Owen A, Back D, Gibbons S, Seden K, Khoo SH. Prevalence of potential drug-drug interactions involving antiretroviral drugs in a large Kenyan cohort. PLoS One 2011; 6:e16800. [PMID: 21373194 PMCID: PMC3044141 DOI: 10.1371/journal.pone.0016800] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 12/24/2010] [Indexed: 12/31/2022] Open
Abstract
Background Clinically significant drug-drug interactions (CSDIs) involving antiretrovirals are frequent and under-recognized in developed countries, but data are lacking for developing countries. Methodology and Principal Findings To investigate the prevalence of CSDIs between antiretrovirals and coadministered drugs, we surveyed prescriptions dispensed in a large HIV clinic in Kenya. Of 1040 consecutive patients screened, 996 were eligible for inclusion. CSDIs were defined as ‘major’ (capable of causing severe or permanent damage, contraindicated, avoid or not recommended by the manufacturer, or requiring dose modification) or ‘moderate’ (manufacturers advise caution, or close monitoring, or capable of causing clinical deterioration). A total of 334 patients (33.5%) were at risk for a CSDI, potentially lowering antiretroviral drug concentrations in 120 (12%) patients. Major interactions most frequently involved rifampicin (12.4%, mostly with efavirenz) and azoles (2.7%) whereas moderate interactions were frequently azoles (13%), steroids (11%), and antimalarials (3%). Multivariable analyses suggested that patients at risk for CSDIs had lower CD4 counts (P = 0.006) and baseline weight (P = 0.023) and WHO Stage 3 or 4 disease (P≤0.007). Risk for CSDIs was not associated with particular regimens, although only 116 (11.6%) patients were receiving WHO second line regimens. Conclusions One in three patients receiving antiretrovirals in our programme were at risk of CSDIs. Strategies need to be urgently developed to avoid important drug interactions, to identify early markers of toxicity and to manage unavoidable interactions safely in order to reduce risk of harm, and to maximize the effectiveness of mass antiretroviral deployment in Africa.
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Affiliation(s)
- Gabriel Kigen
- Department of Pharmacology and Toxicology, Moi University School of Medicine, Eldoret, Kenya
- Department of Pharmacology, Institute of Translational Medicine, The University of Liverpool, Liverpool, United Kingdom
| | - Sylvester Kimaiyo
- USAID-Academic Model Providing Access to Healthcare (AMPATH), Moi University School of Medicine, Eldoret, Kenya
| | - Winstone Nyandiko
- USAID-Academic Model Providing Access to Healthcare (AMPATH), Moi University School of Medicine, Eldoret, Kenya
| | - Brian Faragher
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Edwin Sang
- USAID-Academic Model Providing Access to Healthcare (AMPATH), Moi University School of Medicine, Eldoret, Kenya
| | - Beatrice Jakait
- Department of Pharmacology and Toxicology, Moi University School of Medicine, Eldoret, Kenya
| | - Andrew Owen
- Department of Pharmacology, Institute of Translational Medicine, The University of Liverpool, Liverpool, United Kingdom
| | - David Back
- Department of Pharmacology, Institute of Translational Medicine, The University of Liverpool, Liverpool, United Kingdom
| | - Sara Gibbons
- Department of Pharmacology, Institute of Translational Medicine, The University of Liverpool, Liverpool, United Kingdom
| | - Kay Seden
- NIHR Biomedical Research Centre for Microbial Diseases, Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Saye H. Khoo
- Department of Pharmacology, Institute of Translational Medicine, The University of Liverpool, Liverpool, United Kingdom
- NIHR Biomedical Research Centre for Microbial Diseases, Royal Liverpool University Hospital, Liverpool, United Kingdom
- * E-mail:
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