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Bengu N, Cromhout G, Adland E, Govender K, Herbert N, Lim N, Fillis R, Sprenger K, Vieira V, Kannie S, van Lobenstein J, Chinniah K, Kapongo C, Bhoola R, Krishna M, Mchunu N, Pascucci GR, Cotugno N, Palma P, Tagarro A, Rojo P, Roider J, Garcia-Guerrero MC, Ochsenbauer C, Groll A, Reddy K, Giaquinto C, Rossi P, Hong S, Dong K, Ansari MA, Puertas MC, Ndung'u T, Capparelli E, Lichterfeld M, Martinez-Picado J, Kappes JC, Archary M, Goulder P. Sustained aviremia despite anti-retroviral therapy non-adherence in male children after in utero HIV transmission. Nat Med 2024:10.1038/s41591-024-03105-4. [PMID: 38843818 DOI: 10.1038/s41591-024-03105-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 06/03/2024] [Indexed: 07/04/2024]
Abstract
After sporadic reports of post-treatment control of HIV in children who initiated combination anti-retroviral therapy (cART) early, we prospectively studied 284 very-early-cART-treated children from KwaZulu-Natal, South Africa, after vertical HIV transmission to assess control of viremia. Eighty-four percent of the children achieved aviremia on cART, but aviremia persisting to 36 or more months was observed in only 32%. We observed that male infants have lower baseline plasma viral loads (P = 0.01). Unexpectedly, a subset (n = 5) of males maintained aviremia despite unscheduled complete discontinuation of cART lasting 3-10 months (n = 4) or intermittent cART adherence during 17-month loss to follow-up (n = 1). We further observed, in vertically transmitted viruses, a negative correlation between type I interferon (IFN-I) resistance and viral replication capacity (VRC) (P < 0.0001) that was markedly stronger for males than for females (r = -0.51 versus r = -0.07 for IFN-α). Although viruses transmitted to male fetuses were more IFN-I sensitive and of higher VRC than those transmitted to females in the full cohort (P < 0.0001 and P = 0.0003, respectively), the viruses transmitted to the five males maintaining cART-free aviremia had significantly lower replication capacity (P < 0.0001). These data suggest that viremic control can occur in some infants with in utero-acquired HIV infection after early cART initiation and may be associated with innate immune sex differences.
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Affiliation(s)
- Nomonde Bengu
- Queen Nandi Regional Hospital, Empangeni, South Africa
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Gabriela Cromhout
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Paediatrics, University of KwaZulu-Natal, Durban, South Africa
| | - Emily Adland
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | | | - Nicholas Lim
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Rowena Fillis
- Harry Gwala Regional Hospital, Pietermaritzburg, South Africa
| | - Kenneth Sprenger
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | - Samantha Kannie
- General Justice Gizenga Mpanza Regional Hospital, Stanger, South Africa
| | | | | | | | - Roopesh Bhoola
- Harry Gwala Regional Hospital, Pietermaritzburg, South Africa
| | - Malini Krishna
- Harry Gwala Regional Hospital, Pietermaritzburg, South Africa
| | - Noxolo Mchunu
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Giuseppe Rubens Pascucci
- Clinical Immunology and Vaccinology Unit, IRCCS, Ospedale Pediatrico Bambino Gesù, Rome, Italy
- Probiomics S.r.l., Rome, Italy
| | - Nicola Cotugno
- Clinical Immunology and Vaccinology Unit, IRCCS, Ospedale Pediatrico Bambino Gesù, Rome, Italy
- University of Rome Tor Vergata, Rome, Italy
| | - Paolo Palma
- Clinical Immunology and Vaccinology Unit, IRCCS, Ospedale Pediatrico Bambino Gesù, Rome, Italy
- University of Rome Tor Vergata, Rome, Italy
| | - Alfredo Tagarro
- Fundación de Investigación Biomédica Hospital 12 de Octubre, Instituto de Investigación 12 de Octubre (imas12), Madrid, Spain
- Department of Pediatrics, Infanta Sofia University Hospital and Henares University Hospital Foundation for Biomedical Research and Innovation, Madrid, Spain
- Universidad Europea de Madrid, Madrid, Spain
| | - Pablo Rojo
- Fundación de Investigación Biomédica Hospital 12 de Octubre, Instituto de Investigación 12 de Octubre (imas12), Madrid, Spain
| | | | | | | | | | - Kavidha Reddy
- Africa Health Research Institute, Durban, South Africa
| | | | - Paolo Rossi
- Clinical Immunology and Vaccinology Unit, IRCCS, Ospedale Pediatrico Bambino Gesù, Rome, Italy
- University of Rome Tor Vergata, Rome, Italy
| | - Seohyun Hong
- Ragon Institute of MGH, MIT and Harvard, Boston, MA, USA
| | - Krista Dong
- Ragon Institute of MGH, MIT and Harvard, Boston, MA, USA
| | - M Azim Ansari
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Maria C Puertas
- IrsiCaixa AIDS Research Institute, Barcelona, Spain
- Consorcio Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Thumbi Ndung'u
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Africa Health Research Institute, Durban, South Africa
- Ragon Institute of MGH, MIT and Harvard, Boston, MA, USA
- Division of Infection and Immunity, University College London, London, UK
| | | | | | - Javier Martinez-Picado
- IrsiCaixa AIDS Research Institute, Barcelona, Spain
- Consorcio Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - John C Kappes
- University of Alabama at Birmingham, Birmingham, AL, USA
- Birmingham Veterans Affairs Medical Center, Research Service, Birmingham, AL, USA
| | - Moherndran Archary
- Department of Paediatrics, University of KwaZulu-Natal, Durban, South Africa
| | - Philip Goulder
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
- Department of Paediatrics, University of Oxford, Oxford, UK.
- Africa Health Research Institute, Durban, South Africa.
- Ragon Institute of MGH, MIT and Harvard, Boston, MA, USA.
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2
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Alshogran OY, Dodeja P, Albukhaytan H, Laffey T, Chaphekar N, Caritis S, Shaik IH, Venkataramanan R. Drugs in Human Milk Part 1: Practical and Analytical Considerations in Measuring Drugs and Metabolites in Human Milk. Clin Pharmacokinet 2024; 63:561-588. [PMID: 38748090 DOI: 10.1007/s40262-024-01374-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2024] [Indexed: 05/22/2024]
Abstract
Human milk is a remarkable biofluid that provides essential nutrients and immune protection to newborns. Breastfeeding women consuming medications could pass the drug through their milk to neonates. Drugs can be transferred to human milk by passive diffusion or active transport. The physicochemical properties of the drug largely impact the extent of drug transfer into human milk. A comprehensive understanding of the physiology of human milk formation, composition of milk, mechanisms of drug transfer, and factors influencing drug transfer into human milk is critical for appropriate selection and use of medications in lactating women. Quantification of drugs in the milk is essential for assessing the safety of pharmacotherapy during lactation. This can be achieved by developing specific, sensitive, and reproducible analytical methods using techniques such as liquid chromatography coupled with mass spectrometry. The present review briefly discusses the physiology of human milk formation, composition of human milk, mechanisms of drug transfer into human milk, and factors influencing transfer of drugs from blood to milk. We further expand upon and critically evaluate the existing analytical approaches/assays used for the quantification of drugs in human milk.
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Affiliation(s)
- Osama Y Alshogran
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Prerna Dodeja
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hamdan Albukhaytan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Taylor Laffey
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nupur Chaphekar
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steve Caritis
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, UPMC Magee-Women's Hospital, Pittsburgh, PA, USA
| | - Imam H Shaik
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, 3501 Terrace Street, Room 7406, Salk Hall, Pittsburgh, PA, 15261, USA.
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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Nauwelaerts N, Macente J, Deferm N, Bonan RH, Huang MC, Van Neste M, Bibi D, Badee J, Martins FS, Smits A, Allegaert K, Bouillon T, Annaert P. Generic Workflow to Predict Medicine Concentrations in Human Milk Using Physiologically-Based Pharmacokinetic (PBPK) Modelling-A Contribution from the ConcePTION Project. Pharmaceutics 2023; 15:pharmaceutics15051469. [PMID: 37242712 DOI: 10.3390/pharmaceutics15051469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/28/2023] [Accepted: 05/03/2023] [Indexed: 05/28/2023] Open
Abstract
Women commonly take medication during lactation. Currently, there is little information about the exposure-related safety of maternal medicines for breastfed infants. The aim was to explore the performance of a generic physiologically-based pharmacokinetic (PBPK) model to predict concentrations in human milk for ten physiochemically diverse medicines. First, PBPK models were developed for "non-lactating" adult individuals in PK-Sim/MoBi v9.1 (Open Systems Pharmacology). The PBPK models predicted the area-under-the-curve (AUC) and maximum concentrations (Cmax) in plasma within a two-fold error. Next, the PBPK models were extended to include lactation physiology. Plasma and human milk concentrations were simulated for a three-months postpartum population, and the corresponding AUC-based milk-to-plasma (M/P) ratios and relative infant doses were calculated. The lactation PBPK models resulted in reasonable predictions for eight medicines, while an overprediction of human milk concentrations and M/P ratios (>2-fold) was observed for two medicines. From a safety perspective, none of the models resulted in underpredictions of observed human milk concentrations. The present effort resulted in a generic workflow to predict medicine concentrations in human milk. This generic PBPK model represents an important step towards an evidence-based safety assessment of maternal medication during lactation, applicable in an early drug development stage.
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Affiliation(s)
- Nina Nauwelaerts
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
| | - Julia Macente
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
| | - Neel Deferm
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
- Simcyp Division, Certara UK Ltd., Sheffield S1 2BJ, UK
| | | | - Miao-Chan Huang
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
| | - Martje Van Neste
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
| | - David Bibi
- Global Research and Development, Teva Pharmaceutical Industries Ltd., Netanya 42504, Israel
| | - Justine Badee
- Novartis Institutes for BioMedical Research, Novartis, CH-4056 Basel, Switzerland
| | - Frederico S Martins
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
- L-C&Y, KU Leuven Child & Youth Institute, 3000 Leuven, Belgium
- Neonatal Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Karel Allegaert
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
- L-C&Y, KU Leuven Child & Youth Institute, 3000 Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | | | - Pieter Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
- BioNotus GCV, 2845 Niel, Belgium
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Fraissinet F, Oumar AA, Seraissol P, Cere MC, Lavit M, Chatelut E, Gandia P. Method validation and clinical application for the quantification of lopinavir, efavirenz, and ritonavir in breast milk using liquid chromatography tandem mass spectrometry. JOURNAL OF MASS SPECTROMETRY : JMS 2022; 57:e4897. [PMID: 36463890 DOI: 10.1002/jms.4897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 10/21/2022] [Accepted: 11/09/2022] [Indexed: 06/17/2023]
Abstract
A liquid chromatography tandem mass spectrometry (LC-MS/MS) method has been validated for quantification of three antiretroviral drugs (efavirenz [EFV], lopinavir [LPV], and ritonavir [RTV]) from human breast milk. The samples were extracted employing protein precipitation method using methanol as precipitating agent. The supernatant was evaporated and reconstituted before injecting into the chromatograph and separated on a biphenyl column. Calibration curves for the three tested antiretroviral drugs were linear (r ≥ 0.999) over the range examined. The inter- and intra-day coefficients of variation (CV) were ≤15% for efavirenz, lopinavir, and ritonavir. Mean recovery ranged from 96% to 105% and no major matrix effects were observed. This validated LC-MS/MS method was efficiently applied to determine EFV, LPV, and RTV concentrations in breast milk from Human Immunodeficiency Virus (HIV)-positive breastfeeding mothers. This assay requires a simple sample processing method with a short run time, making it well suited for high-throughput routine clinical or research purposes.
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Affiliation(s)
- Francois Fraissinet
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan Hospital University, Toulouse, France
| | - Aboubacar A Oumar
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan Hospital University, Toulouse, France
- HIV/TB Research and Training Center, Bamako, Mali
- UMR INSERM 1037 Pharmacology and Pharmacogenetic Laboratory, University Institute of Cancer Oncopôle, Toulouse, France
| | - Patrick Seraissol
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan Hospital University, Toulouse, France
| | - Marie Christine Cere
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan Hospital University, Toulouse, France
| | - Michel Lavit
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan Hospital University, Toulouse, France
| | - Etienne Chatelut
- UMR INSERM 1037 Pharmacology and Pharmacogenetic Laboratory, University Institute of Cancer Oncopôle, Toulouse, France
| | - Peggy Gandia
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan Hospital University, Toulouse, France
- UMR INSERM 1037 Pharmacology and Pharmacogenetic Laboratory, University Institute of Cancer Oncopôle, Toulouse, France
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5
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Mother-to-Child HIV Transmission With In Utero Dolutegravir vs. Efavirenz in Botswana. J Acquir Immune Defic Syndr 2021; 84:235-241. [PMID: 32195745 DOI: 10.1097/qai.0000000000002338] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A large-scale evaluation of mother-to-child transmission (MTCT) with dolutegravir (DTG)-based antiretroviral treatment (ART) has not been conducted previously. SETTING Botswana was the first African country to change from efavirenz (EFV)/tenofovir (TDF)/emtricitabine (FTC) to DTG/TDF/FTC first-line ART. METHODS From April 2015 to July 2018, the Early Infant Treatment Study offered HIV DNA testing at <96 hours of life. Maternal ART regimen was available for screened infants who could be linked to the separate Tsepamo surveillance study database. We evaluated characteristics of HIV-positive infants, and compared MTCT rates by ART regimen for linked infants. RESULTS Of 10,622 HIV-exposed infants screened, 42 (0.40%) were HIV-positive. In total, 5064 screened infants could be linked to the surveillance database, including 1235 (24.4%) exposed to DTG/TDF/FTC and 2411 (47.6%) exposed to EFV/TDF/FTC. MTCT was rare when either regimen was started before conception: 0/213 [0.00%, 95% confidence interval (CI): 0.00% to 1.72%] on DTG, 1/1497 (0.07%, 95% CI: 0.00% to 0.37%) on EFV. MTCT was similar for women starting each ART regimen in pregnancy: 8/999 (0.80%, 95% CI: 0.35% to 1.57%) for DTG and 8/883 (0.91%, 95% CI: 0.39% to 1.78%) for EFV (risk difference 0.11%, 95% CI: -0.79% to 1.06%). Most MTCT events (4/8 with DTG, 6/9 with EFV) occurred when ART was started <90 days before delivery. Infants exposed to DTG in utero had lower baseline HIV RNA compared with other HIV-infected infants. CONCLUSION In utero MTCT in Botswana remains rare in the DTG era. No significant MTCT differences were observed between DTG/TDF/FTC and EFV/TDF/FTC. Risk was highest for both groups when ART was started in the third trimester.
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Hodel EM, Marzolini C, Waitt C, Rakhmanina N. Pharmacokinetics, Placental and Breast Milk Transfer of Antiretroviral Drugs in Pregnant and Lactating Women Living with HIV. Curr Pharm Des 2020; 25:556-576. [PMID: 30894103 DOI: 10.2174/1381612825666190320162507] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/18/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Remarkable progress has been achieved in the identification of HIV infection in pregnant women and in the prevention of vertical HIV transmission through maternal antiretroviral treatment (ART) and neonatal antiretroviral drug (ARV) prophylaxis in the last two decades. Millions of women globally are receiving combination ART throughout pregnancy and breastfeeding, periods associated with significant biological and physiological changes affecting the pharmacokinetics (PK) and pharmacodynamics (PD) of ARVs. The objective of this review was to summarize currently available knowledge on the PK of ARVs during pregnancy and transport of maternal ARVs through the placenta and into the breast milk. We also summarized main safety considerations for in utero and breast milk ARVs exposures in infants. METHODS We conducted a review of the pharmacological profiles of ARVs in pregnancy and during breastfeeding obtained from published clinical studies. Selected maternal PK studies used a relatively rich sampling approach at each ante- and postnatal sampling time point. For placental and breast milk transport of ARVs, we selected the studies that provided ratios of maternal to the cord (M:C) plasma and breast milk to maternal plasma (M:P) concentrations, respectively. RESULTS We provide an overview of the physiological changes during pregnancy and their effect on the PK parameters of ARVs by drug class in pregnancy, which were gathered from 45 published studies. The PK changes during pregnancy affect the dosing of several protease inhibitors during pregnancy and limit the use of several ARVs, including three single tablet regimens with integrase inhibitors or protease inhibitors co-formulated with cobicistat due to suboptimal exposures. We further analysed the currently available data on the mechanism of the transport of ARVs from maternal plasma across the placenta and into the breast milk and summarized the effect of pregnancy on placental and of breastfeeding on mammal gland drug transporters, as well as physicochemical properties, C:M and M:P ratios of individual ARVs by drug class. Finally, we discussed the major safety issues of fetal and infant exposure to maternal ARVs. CONCLUSIONS Available pharmacological data provide evidence that physiological changes during pregnancy affect maternal, and consequently, fetal ARV exposure. Limited available data suggest that the expression of drug transporters may vary throughout pregnancy and breastfeeding thereby possibly impacting the amount of ARV crossing the placenta and secreted into the breast milk. The drug transporter's role in the fetal/child exposure to maternal ARVs needs to be better understood. Our analysis underscores the need for more pharmacological studies with innovative study design, sparse PK sampling, improved study data reporting and PK modelling in pregnant and breastfeeding women living with HIV to optimize their treatment choices and maternal and child health outcomes.
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Affiliation(s)
- E M Hodel
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Molecular & Clinical Pharmacology, Liverpool, United Kingdom.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom.,Division of Paediatric Pharmacology & Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - C Marzolini
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Molecular & Clinical Pharmacology, Liverpool, United Kingdom.,Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - C Waitt
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Molecular & Clinical Pharmacology, Liverpool, United Kingdom.,Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - N Rakhmanina
- Department of Pediatrics, The George Washington University, School of Medicine & Health Sciences, Washington, DC, United States.,Division of Infectious Diseases, Children's National Medical Center, Washington, DC, United States.,Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States
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7
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Oumar AA, Bagayoko-Maiga K, Bahachimi A, Maiga M, Cere MC, Diarra Z, Chatelut E, Sylla M, Murphy RL, Dao S, Gandia P. Efavirenz and Lopinavir Levels in HIV-Infected Women and Their Nursing Infants, in Mali. J Pharmacol Exp Ther 2018; 366:479-484. [PMID: 29986950 PMCID: PMC11056435 DOI: 10.1124/jpet.118.249938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 06/29/2018] [Indexed: 11/22/2022] Open
Abstract
Limited data are currently available on antiretroviral pharmacokinetics in breast milk (BM) and in breastfed infants' blood. To explore these parameters in patients in Mali, we measured plasma antiretroviral levels in human immunodeficiency virus (HIV)-infected mothers and their breastfed infants over 6 months. We specifically analyzed the concentrations of efavirenz (EFV) and lopinavir (LPV) in the plasma of mothers living with HIV and their breastfed infants. Blood samples were collected at delivery and at month 1, 3, and 6 postpartum. EFV and LPV concentrations were measured by liquid chromatography-tandem mass spectrometry. HIV-1 RNA load was measured by Abbott M2000RT RealTime System at delivery and 6 months postpartum for mothers, and at 3 and 6 months postbirth for infants. The median duration of antiretroviral therapy at study inclusion was 57 months [interquartile range (IQR), 0-168 months]. The median EFV ratios of infant plasma/maternal plasma (MP) were 0.057 at month 1, 0.072 at month 3, and 0.048 at month 6. During the study period, the median BM/MP ratio of EFV was 1.16 (IQR, 0.96-20.62), which corresponds to a relative infant dose of 2.46% of the recommended weight-adjusted pediatric EFV dose at month 6. The apparent infant clearance of EFV was 0.146 l/h per kilogram at month 6. The LPV concentrations in the plasma of all infants were undetectable. No drug-related adverse reaction or toxicity was observed in any of the infants. The two women who presented a viral load of >50 copies/ml at month 6 had undetectable plasma drug concentrations at the same period. This study showed that breastfed infants received a low level of EFV but not LPV from their treated mothers.
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Affiliation(s)
- Aboubacar Alassane Oumar
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan Hospital University, Toulouse, France (A.A.O., M.-C.C., P.G.); Institut National de la Sante et de la Recherche Medicale, Unité Mixte de Recherche 1037, Pharmacology and Pharmacogenetics Laboratory, University Institute of Cancer Oncopôle, Toulouse, France (A.A.O., E.C.); HIV/Tuberculosis Research and Training Center, University of Science, Techniques and Technologies, Bamako, Mali (A.A.O., A.B., M.M., S.D.); Center for Global Health, Northwestern University, Chicago, Illinois (M.M., R.L.M.); Department of Pediatric, University Hospital of Gabriel Touré, Bamako, Mali (K.B.-M., M.S.); Referral Health Center V, Bamako, Mali (Z.D.); and Institut National de la Recherche Agronomique Unité Mixte de Recherche 1331-TOXALIM, Veterinary School of Toulouse, Toulouse, France (P.G.)
| | - Kadiatou Bagayoko-Maiga
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan Hospital University, Toulouse, France (A.A.O., M.-C.C., P.G.); Institut National de la Sante et de la Recherche Medicale, Unité Mixte de Recherche 1037, Pharmacology and Pharmacogenetics Laboratory, University Institute of Cancer Oncopôle, Toulouse, France (A.A.O., E.C.); HIV/Tuberculosis Research and Training Center, University of Science, Techniques and Technologies, Bamako, Mali (A.A.O., A.B., M.M., S.D.); Center for Global Health, Northwestern University, Chicago, Illinois (M.M., R.L.M.); Department of Pediatric, University Hospital of Gabriel Touré, Bamako, Mali (K.B.-M., M.S.); Referral Health Center V, Bamako, Mali (Z.D.); and Institut National de la Recherche Agronomique Unité Mixte de Recherche 1331-TOXALIM, Veterinary School of Toulouse, Toulouse, France (P.G.)
| | - Aliou Bahachimi
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan Hospital University, Toulouse, France (A.A.O., M.-C.C., P.G.); Institut National de la Sante et de la Recherche Medicale, Unité Mixte de Recherche 1037, Pharmacology and Pharmacogenetics Laboratory, University Institute of Cancer Oncopôle, Toulouse, France (A.A.O., E.C.); HIV/Tuberculosis Research and Training Center, University of Science, Techniques and Technologies, Bamako, Mali (A.A.O., A.B., M.M., S.D.); Center for Global Health, Northwestern University, Chicago, Illinois (M.M., R.L.M.); Department of Pediatric, University Hospital of Gabriel Touré, Bamako, Mali (K.B.-M., M.S.); Referral Health Center V, Bamako, Mali (Z.D.); and Institut National de la Recherche Agronomique Unité Mixte de Recherche 1331-TOXALIM, Veterinary School of Toulouse, Toulouse, France (P.G.)
| | - Mamoudou Maiga
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan Hospital University, Toulouse, France (A.A.O., M.-C.C., P.G.); Institut National de la Sante et de la Recherche Medicale, Unité Mixte de Recherche 1037, Pharmacology and Pharmacogenetics Laboratory, University Institute of Cancer Oncopôle, Toulouse, France (A.A.O., E.C.); HIV/Tuberculosis Research and Training Center, University of Science, Techniques and Technologies, Bamako, Mali (A.A.O., A.B., M.M., S.D.); Center for Global Health, Northwestern University, Chicago, Illinois (M.M., R.L.M.); Department of Pediatric, University Hospital of Gabriel Touré, Bamako, Mali (K.B.-M., M.S.); Referral Health Center V, Bamako, Mali (Z.D.); and Institut National de la Recherche Agronomique Unité Mixte de Recherche 1331-TOXALIM, Veterinary School of Toulouse, Toulouse, France (P.G.)
| | - Marie-Christine Cere
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan Hospital University, Toulouse, France (A.A.O., M.-C.C., P.G.); Institut National de la Sante et de la Recherche Medicale, Unité Mixte de Recherche 1037, Pharmacology and Pharmacogenetics Laboratory, University Institute of Cancer Oncopôle, Toulouse, France (A.A.O., E.C.); HIV/Tuberculosis Research and Training Center, University of Science, Techniques and Technologies, Bamako, Mali (A.A.O., A.B., M.M., S.D.); Center for Global Health, Northwestern University, Chicago, Illinois (M.M., R.L.M.); Department of Pediatric, University Hospital of Gabriel Touré, Bamako, Mali (K.B.-M., M.S.); Referral Health Center V, Bamako, Mali (Z.D.); and Institut National de la Recherche Agronomique Unité Mixte de Recherche 1331-TOXALIM, Veterinary School of Toulouse, Toulouse, France (P.G.)
| | - Zoumana Diarra
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan Hospital University, Toulouse, France (A.A.O., M.-C.C., P.G.); Institut National de la Sante et de la Recherche Medicale, Unité Mixte de Recherche 1037, Pharmacology and Pharmacogenetics Laboratory, University Institute of Cancer Oncopôle, Toulouse, France (A.A.O., E.C.); HIV/Tuberculosis Research and Training Center, University of Science, Techniques and Technologies, Bamako, Mali (A.A.O., A.B., M.M., S.D.); Center for Global Health, Northwestern University, Chicago, Illinois (M.M., R.L.M.); Department of Pediatric, University Hospital of Gabriel Touré, Bamako, Mali (K.B.-M., M.S.); Referral Health Center V, Bamako, Mali (Z.D.); and Institut National de la Recherche Agronomique Unité Mixte de Recherche 1331-TOXALIM, Veterinary School of Toulouse, Toulouse, France (P.G.)
| | - Etienne Chatelut
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan Hospital University, Toulouse, France (A.A.O., M.-C.C., P.G.); Institut National de la Sante et de la Recherche Medicale, Unité Mixte de Recherche 1037, Pharmacology and Pharmacogenetics Laboratory, University Institute of Cancer Oncopôle, Toulouse, France (A.A.O., E.C.); HIV/Tuberculosis Research and Training Center, University of Science, Techniques and Technologies, Bamako, Mali (A.A.O., A.B., M.M., S.D.); Center for Global Health, Northwestern University, Chicago, Illinois (M.M., R.L.M.); Department of Pediatric, University Hospital of Gabriel Touré, Bamako, Mali (K.B.-M., M.S.); Referral Health Center V, Bamako, Mali (Z.D.); and Institut National de la Recherche Agronomique Unité Mixte de Recherche 1331-TOXALIM, Veterinary School of Toulouse, Toulouse, France (P.G.)
| | - Mariam Sylla
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan Hospital University, Toulouse, France (A.A.O., M.-C.C., P.G.); Institut National de la Sante et de la Recherche Medicale, Unité Mixte de Recherche 1037, Pharmacology and Pharmacogenetics Laboratory, University Institute of Cancer Oncopôle, Toulouse, France (A.A.O., E.C.); HIV/Tuberculosis Research and Training Center, University of Science, Techniques and Technologies, Bamako, Mali (A.A.O., A.B., M.M., S.D.); Center for Global Health, Northwestern University, Chicago, Illinois (M.M., R.L.M.); Department of Pediatric, University Hospital of Gabriel Touré, Bamako, Mali (K.B.-M., M.S.); Referral Health Center V, Bamako, Mali (Z.D.); and Institut National de la Recherche Agronomique Unité Mixte de Recherche 1331-TOXALIM, Veterinary School of Toulouse, Toulouse, France (P.G.)
| | - Robert Leo Murphy
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan Hospital University, Toulouse, France (A.A.O., M.-C.C., P.G.); Institut National de la Sante et de la Recherche Medicale, Unité Mixte de Recherche 1037, Pharmacology and Pharmacogenetics Laboratory, University Institute of Cancer Oncopôle, Toulouse, France (A.A.O., E.C.); HIV/Tuberculosis Research and Training Center, University of Science, Techniques and Technologies, Bamako, Mali (A.A.O., A.B., M.M., S.D.); Center for Global Health, Northwestern University, Chicago, Illinois (M.M., R.L.M.); Department of Pediatric, University Hospital of Gabriel Touré, Bamako, Mali (K.B.-M., M.S.); Referral Health Center V, Bamako, Mali (Z.D.); and Institut National de la Recherche Agronomique Unité Mixte de Recherche 1331-TOXALIM, Veterinary School of Toulouse, Toulouse, France (P.G.)
| | - Sounkalo Dao
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan Hospital University, Toulouse, France (A.A.O., M.-C.C., P.G.); Institut National de la Sante et de la Recherche Medicale, Unité Mixte de Recherche 1037, Pharmacology and Pharmacogenetics Laboratory, University Institute of Cancer Oncopôle, Toulouse, France (A.A.O., E.C.); HIV/Tuberculosis Research and Training Center, University of Science, Techniques and Technologies, Bamako, Mali (A.A.O., A.B., M.M., S.D.); Center for Global Health, Northwestern University, Chicago, Illinois (M.M., R.L.M.); Department of Pediatric, University Hospital of Gabriel Touré, Bamako, Mali (K.B.-M., M.S.); Referral Health Center V, Bamako, Mali (Z.D.); and Institut National de la Recherche Agronomique Unité Mixte de Recherche 1331-TOXALIM, Veterinary School of Toulouse, Toulouse, France (P.G.)
| | - Peggy Gandia
- Pharmacokinetics and Toxicology Laboratory, Federative Institute of Biology, Purpan Hospital University, Toulouse, France (A.A.O., M.-C.C., P.G.); Institut National de la Sante et de la Recherche Medicale, Unité Mixte de Recherche 1037, Pharmacology and Pharmacogenetics Laboratory, University Institute of Cancer Oncopôle, Toulouse, France (A.A.O., E.C.); HIV/Tuberculosis Research and Training Center, University of Science, Techniques and Technologies, Bamako, Mali (A.A.O., A.B., M.M., S.D.); Center for Global Health, Northwestern University, Chicago, Illinois (M.M., R.L.M.); Department of Pediatric, University Hospital of Gabriel Touré, Bamako, Mali (K.B.-M., M.S.); Referral Health Center V, Bamako, Mali (Z.D.); and Institut National de la Recherche Agronomique Unité Mixte de Recherche 1331-TOXALIM, Veterinary School of Toulouse, Toulouse, France (P.G.)
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8
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Toward a universal antiretroviral regimen: special considerations of pregnancy and breast feeding. Curr Opin HIV AIDS 2018; 12:359-368. [PMID: 28426519 DOI: 10.1097/coh.0000000000000386] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW As optimized antiretroviral therapy (ART) regimens are prepared for introduction in low-income and middle-income countries (LMIC), we consider the current evidence related to dosing, efficacy and safety during pregnancy and breastfeeding of next-generation first-line and second-line ART regimens proposed for imminent introduction in the global marketplace. RECENT FINDINGS Pregnancy pharmacokinetic considerations include potentially insufficient efavirenz exposure if dosed at 400 mg/day, the need for twice daily darunavir dosing and the paucity of data related to tenofovir alafenamide and dolutegravir dosing, safety and efficacy. Increasingly evidence suggests an association with adverse birth outcomes, particularly in women conceiving on ART, and with varying risk by drug and drug combination. Clinical trials and studies are in progress or planned that aim to determine dosing, safety and efficacy of several new antiretrovirals (ARVs). SUMMARY Having a universal, highly potent and safe ART regimen for all individuals living with HIV in LMIC including pregnant women is clearly the most beneficial strategy to keep mothers alive and healthy and to prevent transmission of HIV to their children. It will have to be determined whether the use of this next generation of optimized ARVs will also optimize health outcomes of pregnant women and their children.
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9
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Mofenson LM. Tenofovir Pre-exposure Prophylaxis for Pregnant and Breastfeeding Women at Risk of HIV Infection: The Time is Now. PLoS Med 2016; 13:e1002133. [PMID: 27676386 PMCID: PMC5038968 DOI: 10.1371/journal.pmed.1002133] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
In this Perspective, Lynne Mofenson discusses the implications of Mugwanya and colleagues' findings for protection of women against HIV infection during breastfeeding.
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Affiliation(s)
- Lynne M. Mofenson
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, D.C., United States of America
- * E-mail:
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10
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Nagot N, Kankasa C, Tumwine JK, Meda N, Hofmeyr GJ, Vallo R, Mwiya M, Kwagala M, Traore H, Sunday A, Singata M, Siuluta C, Some E, Rutagwera D, Neboua D, Ndeezi G, Jackson D, Maréchal V, Neveu D, Engebretsen IMS, Lombard C, Blanche S, Sommerfelt H, Rekacewicz C, Tylleskär T, Van de Perre P. Extended pre-exposure prophylaxis with lopinavir-ritonavir versus lamivudine to prevent HIV-1 transmission through breastfeeding up to 50 weeks in infants in Africa (ANRS 12174): a randomised controlled trial. Lancet 2016; 387:566-573. [PMID: 26603917 DOI: 10.1016/s0140-6736(15)00984-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Strategies to prevent postnatal mother-to-child transmission of HIV-1 in Africa, including infant prophylaxis, have never been assessed past 6 months of breastfeeding, despite breastfeeding being recommended up to 12 months after birth. We aimed to compare the efficacy and safety of infant prophylaxis with the two drug regimens (lamivudine or lopinavir-ritonavir) to prevent postnatal HIV-1 transmission up to 50 weeks of breastfeeding. METHODS We did a randomised controlled trial in four sites in Burkina Faso, South Africa, Uganda, and Zambia in children born to HIV-1-infected mothers not eligible for antiretroviral therapy (CD4 count >350 cells per μL). An independent researcher electronically generated a randomisation schedule; we then used sequentially numbered envelopes to randomly assign (1:1) HIV-1-uninfected breastfed infants aged 7 days to either lopinavir-ritonavir or lamivudine (paediatric liquid formulations, twice a day) up to 1 week after complete cessation of breastfeeding or at the final visit at week 50. We stratified the randomisation by country and used permuted blocks of four and six. We used a study label on drug bottles to mask participants, study physicians, and assessors to the treatment allocation. The primary outcome was infant HIV-1 infection between age 7 days and 50 weeks, diagnosed every 3 months with HIV-1 DNA PCR, in the modified intention-to-treat population (all who attended at least one follow-up visit). This trial is registered with ClinicalTrials.gov, number NCT00640263. FINDINGS Between Nov 16, 2009, and May 7, 2012, we enrolled and randomised 1273 infants and analysed 1236; 615 assigned to lopinavir-ritonavir or 621 assigned to lamivudine. 17 HIV-1 infections were diagnosed in the study period (eight in the lopinavir-ritonavir group and nine in the lamivudine group), resulting in cumulative HIV-1 infection of 1.4% (95% CI 0.4-2.5) and 1.5% (0.7-2.5), respectively. Infection rates did not differ between the two drug regimens (hazard ratio [HR] of lopinavir-ritonavir versus lamivudine of 0.90, 95% CI 0.35-2.34; p=0.83). Clinical and biological severe adverse events did not differ between groups; 251 (51%) infants had a grade 3-4 event in the lopinavir-ritonavir group compared with 246 (50%) in the lamivudine group. INTERPRETATION Infant HIV-1 prophylaxis with lopinavir-ritonavir was not superior to lamivudine and both drugs led to very low rates of HIV-1 postnatal transmission for up to 50 weeks of breastfeeding. Infant pre-exposure prophylaxis should be extended until the end of HIV-1 exposure and mothers should be informed about the persistent risk of transmission throughout breastfeeding. FUNDING INSERM/National Agency for Research on AIDS and Viral Hepatitis (including funds from the Total Foundation), European Developing Countries Clinical Trials Partnership, Research Council of Norway.
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Affiliation(s)
- Nicolas Nagot
- INSERM U 1058, Montpellier, France; Université Montpellier, Montpellier, France; CHU Montpellier, Montpellier, France
| | - Chipepo Kankasa
- University of Zambia, School of Medicine, Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - James K Tumwine
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Nicolas Meda
- Centre of International Research for Health, Faculty of Health Sciences, University of Ouagadougou, Ouagadougou, Burkina Faso
| | - G Justus Hofmeyr
- Effective Care Research Unit, Cecilia Makiwane Hospital, East London Hospital Complex, East London, South Africa; School of Public Health, University of the Western Cape, South Africa
| | - Roselyne Vallo
- INSERM U 1058, Montpellier, France; Université Montpellier, Montpellier, France
| | - Mwiya Mwiya
- University of Zambia, School of Medicine, Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Mary Kwagala
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Hugues Traore
- Centre of International Research for Health, Faculty of Health Sciences, University of Ouagadougou, Ouagadougou, Burkina Faso
| | - Amwe Sunday
- Effective Care Research Unit, Cecilia Makiwane Hospital, East London Hospital Complex, East London, South Africa; School of Public Health, University of the Western Cape, South Africa
| | - Mandisa Singata
- Effective Care Research Unit, Cecilia Makiwane Hospital, East London Hospital Complex, East London, South Africa; School of Public Health, University of the Western Cape, South Africa
| | - Chafye Siuluta
- University of Zambia, School of Medicine, Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Eric Some
- Centre of International Research for Health, Faculty of Health Sciences, University of Ouagadougou, Ouagadougou, Burkina Faso
| | - David Rutagwera
- University of Zambia, School of Medicine, Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Desire Neboua
- Centre of International Research for Health, Faculty of Health Sciences, University of Ouagadougou, Ouagadougou, Burkina Faso
| | - Grace Ndeezi
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Debra Jackson
- School of Public Health, University of the Western Cape, South Africa
| | - Valérie Maréchal
- INSERM U 1058, Montpellier, France; Université Montpellier, Montpellier, France
| | - Dorine Neveu
- INSERM U 1058, Montpellier, France; Université Montpellier, Montpellier, France
| | | | - Carl Lombard
- Biostatistics Unit, Medical Research Council of South Africa, Cape Town, South Africa
| | - Stéphane Blanche
- University of Paris V, Department of Paediatrics, URC/CIC Necker-Cochin, Hôpital Necker, Paris, France
| | - Halvor Sommerfelt
- Centre for International Health, University of Bergen, Bergen, Norway; Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Bergen, Norway; Department of International Public Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Claire Rekacewicz
- French National Institute of Health and Medical Research-National Agency for Research on AIDS and Viral Hepatitis (INSERM-ANRS), Paris, France
| | | | - Philippe Van de Perre
- INSERM U 1058, Montpellier, France; Université Montpellier, Montpellier, France; CHU Montpellier, Montpellier, France.
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11
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No Need for Lopinavir Dose Adjustment during Pregnancy: a Population Pharmacokinetic and Exposure-Response Analysis in Pregnant and Nonpregnant HIV-Infected Subjects. Antimicrob Agents Chemother 2015; 60:400-8. [PMID: 26525798 DOI: 10.1128/aac.01197-15] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 10/24/2015] [Indexed: 11/20/2022] Open
Abstract
Lopinavir-ritonavir is frequently prescribed to HIV-1-infected women during pregnancy. Decreased lopinavir exposure has been reported during pregnancy, but the clinical significance of this reduction is uncertain. This analysis aimed to evaluate the need for lopinavir dose adjustment during pregnancy. We conducted a population pharmacokinetic analysis of lopinavir and ritonavir concentrations collected from 84 pregnant and 595 nonpregnant treatment-naive and -experienced HIV-1-infected subjects enrolled in six clinical studies. Lopinavir-ritonavir doses in the studies ranged between 400/100 and 600/150 mg twice daily. In addition, linear mixed-effect analysis was used to compare the area under the concentration-time curve from 0 to 12 h (AUC0-12) and concentration prior to dosing (Cpredose) in pregnant women and nonpregnant subjects. The relationship between lopinavir exposure and virologic suppression in pregnant women and nonpregnant subjects was evaluated. Population pharmacokinetic analysis estimated 17% higher lopinavir clearance in pregnant women than in nonpregnant subjects. Lopinavir clearance values postpartum were 26.4% and 37.1% lower than in nonpregnant subjects and pregnant women, respectively. As the tablet formulation was estimated to be 20% more bioavailable than the capsule formulation, no statistically significant differences between lopinavir exposure in pregnant women receiving the tablet formulation and nonpregnant subjects receiving the capsule formulation were identified. In the range of lopinavir AUC0-12 or Cpredose values observed in the third trimester, there was no correlation between lopinavir exposure and viral load or proportion of subjects with virologic suppression. Similar efficacy was observed between pregnant women and nonpregnant subjects receiving lopinavir-ritonavir at 400/100 mg twice daily. The pharmacokinetic and pharmacodynamic results support the use of a lopinavir-ritonavir 400/100-mg twice-daily dose during pregnancy.
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Olagunju A, Bolaji OO, Amara A, Waitt C, Else L, Soyinka J, Adeagbo B, Adejuyigbe E, Siccardi M, Back D, Owen A, Khoo S. Development, validation and clinical application of a novel method for the quantification of efavirenz in dried breast milk spots using LC-MS/MS. J Antimicrob Chemother 2014; 70:555-61. [PMID: 25326089 DOI: 10.1093/jac/dku420] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES This manuscript describes the development, validation and clinical application of a novel method for the quantification of the antiretroviral drug efavirenz in dried breast milk spots using LC-MS. METHODS Dried breast milk spots were prepared by spotting 30 μL of human breast milk on each circle of Whatman 903 Protein Saver cards. Chromatographic separation was achieved on a reverse-phase C18 column with 1 mM ammonium acetate in water/acetonitrile using a solvent gradient at a flow rate of 400 μL/min and detection was by TSQ Quantum Access triple quadrupole mass spectrometer equipped with a heated electrospray ionization source. The method was applied to characterize the breast milk pharmacokinetic profile of efavirenz in HIV-positive nursing mothers receiving regimens containing 600 mg of efavirenz once daily. RESULTS The assay was validated over the concentration range 50-7500 ng/mL. Accuracy ranged between 95.2% and 102.5% and precision ranged between 1.05% and 9.53%. The average recovery of efavirenz from dried breast milk spots was 106.4% and the matrix effect was 8.14%. Stability of efavirenz in dried breast milk spots and processed samples at room temperature, -40°C and -80°C was demonstrated. In the pharmacokinetic study, the mean (SD) AUC0-24, Cmax and Cmin of efavirenz in breast milk were 59,620 ng·h/mL (17,440), 4527 ng/mL (1767) and 1261 ng/mL (755.9), respectively. The mean (range) milk-to-plasma concentration ratio over the dosing interval was 0.78 (0.57-1.26). CONCLUSIONS The dried breast milk spot method is simple, robust, accurate and precise, and can be used in settings with limited resources.
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Affiliation(s)
- Adeniyi Olagunju
- Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool L69 3GF, UK Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Oluseye O Bolaji
- Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Alieu Amara
- Liverpool Bioanalytical Facility, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool L69 3GA, UK
| | - Catriona Waitt
- Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool L69 3GF, UK
| | - Laura Else
- Liverpool Bioanalytical Facility, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool L69 3GA, UK
| | - Julius Soyinka
- Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria
| | | | - Ebunoluwa Adejuyigbe
- Department of Paediatric and Child Health, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Marco Siccardi
- Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool L69 3GF, UK
| | - David Back
- Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool L69 3GF, UK
| | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool L69 3GF, UK
| | - Saye Khoo
- Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool L69 3GF, UK
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