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Solanke T, Kamau F, Esterhuizen T, Maartens G, Khoo S, Joska JA, Kellermann T, Strijdom H, Decloedt EH. Concentrations of Efavirenz, Tenofovir, and Emtricitabine in Obesity: A Cross-Sectional Study. J Acquir Immune Defic Syndr 2022; 91:101-108. [PMID: 35972856 DOI: 10.1097/qai.0000000000003025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 05/16/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Obesity is increasing worldwide including in people living with HIV (PLWH). Antiretroviral pharmacokinetic data in obesity are limited. OBJECTIVES To measure antiretroviral drug concentrations in obese and nonobese PLWH treated with the fixed-dose combination of efavirenz-tenofovir-emtricitabine. To determine pharmacokinetic differences across indicators of obesity and their associated immunovirological outcomes. METHODS We conducted a cross-sectional sample analysis of 2 cohort studies. We measured mid-dose efavirenz, 8-hydroxy-efavirenz, tenofovir, and emtricitabine concentrations. Antiretroviral drug concentrations were analyzed by body mass index (BMI), waist circumference (WC), and waist-to-hip ratio (WHR). RESULTS We performed a study of 213 participants: General obesity was detected in 20.4% using BMI and abdominal obesity in 53.6% using WC and 62.4% using WHR, respectively. The median concentrations of all antiretroviral drugs were lower among obese participants determined by BMI and WC, with efavirenz showing greater differences than tenofovir or emtricitabine. For BMI, results were most striking for efavirenz (1752.3 vs 2342.9 ng/mL, P = 0.002) with lower concentrations in obese participants. Using WC, efavirenz (1845.8 vs 2571.2 ng/mL, P < 0.001), tenofovir (65.8 vs 73.2 ng/mL, P = 0.036), and emtricitabine (159.5 vs 221.0 ng/mL, P = 0.005) concentrations were lower in obese participants. Eight-hydroxyefavirenz concentrations were similar in nonobese and obese participants for WC. Using WHR, the concentrations of all antiretroviral drugs were lower in the obese population, most strikingly for emtricitabine (173.5 vs 229.0 ng/mL, P = 0.015). There were no immunovirological associations. CONCLUSION We found lower antiretroviral concentrations in all obese groups, most strikingly in participants with abdominal obesity determined by WC. Lower drug concentrations had no immunovirological associations.
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Affiliation(s)
- Toyosi Solanke
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Festus Kamau
- Division of Medical Physiology, Department of Biomedical Sciences, Centre for Cardio-metabolic Research in Africa (CARMA), Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Tonya Esterhuizen
- Division of Epidemiology and Biostatistics, Department of Global Health, Biostatistics Unit, Stellenbosch University, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Saye Khoo
- Department of Molecular and Clinical Pharmacology, University of Liverpool; and
| | - John A Joska
- HIV Mental Health Research Unit, Division of Neuropsychiatry, Department of Psychiatry and Mental Health, University of Cape Town, South Africa
| | - Tracy Kellermann
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Hans Strijdom
- Division of Medical Physiology, Department of Biomedical Sciences, Centre for Cardio-metabolic Research in Africa (CARMA), Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Corbett C, Brey N, Pitcher RD, O'Hagan S, Esterhuizen TM, Chow FC, Decloedt EH. Prevalence and Characteristics of HIV-Associated Stroke in a Tertiary Hospital Setting in South Africa. Neurology 2022; 99:e904-e915. [PMID: 36038281 PMCID: PMC9502736 DOI: 10.1212/wnl.0000000000200780] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 04/11/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Antiretroviral treatment (ART) era HIV-associated stroke data from sub-Saharan Africa are limited. We determined the prevalence of HIV in patients presenting with acute symptomatic stroke and compared risk factors, clinical characteristics, and brain imaging with age-matched stroke patients without HIV. METHODS We conducted a retrospective study of adults presenting with any type of stroke to Tygerberg Hospital in a 12-month period. Patients living with HIV (PLWH) and HIV-uninfected (HIV-) patients were matched based on age group (1:2 ratio). Patients were identified by keyword search, while HIV status was ascertained from laboratory data. Clinical and imaging data were extracted from medical records. RESULTS Among 884 patients presenting with acute strokes, the minimum prevalence of HIV infection was 9.3% (95% CI: 7.4%-11.2%), with 496 patients (56.1%) with negative HIV status and 306 patients with unknown HIV status (34.6%). The mean age at presentation in PLWH was 46 (±11) years compared with 55 (±14) years in HIV- patients (p < 0.001). Smoking was less prevalent in PLWH with an adjusted relative risk ratio of RR = 0.58 (95% CI: 0.39-0.86). Concurrent infection was more prevalent in PLWH (25.6% vs 4.9%, p ≤ 0.001) with an adjusted relative risk ratio of RR = 2.07 (95% CI: 1.49-2.84), largely in patients with a CD4 count <200 cells/μL. PLWH with higher CD4 counts (≥200 cells/μL, 51.3%) had more traditional risk factors and less concurrent infection. Among PLWH, 68.3% were on ART, and 39.3% of them had been started or restarted on ART within the past 6 months. Basal ganglia infarcts (35.6% vs 18.3%, p = 0.014) and multiple vascular territory involvement (25.4% vs 7.7%, p = 0.002) were more common in PLWH. Clinical presentation, ischemic stroke type, and in-hospital outcomes did not differ between the groups. DISCUSSION Stroke patients with HIV were younger, had less traditional cardiovascular risk factors, and more concurrent infections than patients without HIV, especially those with a lower CD4 count. Recent ART initiation or reinitiation rates were high. Significant differences in CT brain imaging findings were seen. Understanding the multifactorial mechanisms underlying increased stroke risk, including associated infections and potential ART-associated immune reconstitution, is crucial and needs further study.
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Affiliation(s)
- Craig Corbett
- From the Divisions of Clinical Pharmacology (C.C., E.H.D., F.C.C.) and Neurology (N.B.), Department of Medicine, Division of Radiodiagnosis (R.D.P., S.O.H.), Department of Medical Imaging and Clinical Oncology, and Biostatistics Unit (T.M.E.), Division of Epidemiology and Biostatistics, Stellenbosch University, Cape Town Western Cape, South Africa; and Departments of Neurology and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco
| | - Naeem Brey
- From the Divisions of Clinical Pharmacology (C.C., E.H.D., F.C.C.) and Neurology (N.B.), Department of Medicine, Division of Radiodiagnosis (R.D.P., S.O.H.), Department of Medical Imaging and Clinical Oncology, and Biostatistics Unit (T.M.E.), Division of Epidemiology and Biostatistics, Stellenbosch University, Cape Town Western Cape, South Africa; and Departments of Neurology and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco
| | - Richard D Pitcher
- From the Divisions of Clinical Pharmacology (C.C., E.H.D., F.C.C.) and Neurology (N.B.), Department of Medicine, Division of Radiodiagnosis (R.D.P., S.O.H.), Department of Medical Imaging and Clinical Oncology, and Biostatistics Unit (T.M.E.), Division of Epidemiology and Biostatistics, Stellenbosch University, Cape Town Western Cape, South Africa; and Departments of Neurology and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco
| | - Suzanne O'Hagan
- From the Divisions of Clinical Pharmacology (C.C., E.H.D., F.C.C.) and Neurology (N.B.), Department of Medicine, Division of Radiodiagnosis (R.D.P., S.O.H.), Department of Medical Imaging and Clinical Oncology, and Biostatistics Unit (T.M.E.), Division of Epidemiology and Biostatistics, Stellenbosch University, Cape Town Western Cape, South Africa; and Departments of Neurology and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco
| | - Tonya M Esterhuizen
- From the Divisions of Clinical Pharmacology (C.C., E.H.D., F.C.C.) and Neurology (N.B.), Department of Medicine, Division of Radiodiagnosis (R.D.P., S.O.H.), Department of Medical Imaging and Clinical Oncology, and Biostatistics Unit (T.M.E.), Division of Epidemiology and Biostatistics, Stellenbosch University, Cape Town Western Cape, South Africa; and Departments of Neurology and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco
| | - Felicia C Chow
- From the Divisions of Clinical Pharmacology (C.C., E.H.D., F.C.C.) and Neurology (N.B.), Department of Medicine, Division of Radiodiagnosis (R.D.P., S.O.H.), Department of Medical Imaging and Clinical Oncology, and Biostatistics Unit (T.M.E.), Division of Epidemiology and Biostatistics, Stellenbosch University, Cape Town Western Cape, South Africa; and Departments of Neurology and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco
| | - Eric H Decloedt
- From the Divisions of Clinical Pharmacology (C.C., E.H.D., F.C.C.) and Neurology (N.B.), Department of Medicine, Division of Radiodiagnosis (R.D.P., S.O.H.), Department of Medical Imaging and Clinical Oncology, and Biostatistics Unit (T.M.E.), Division of Epidemiology and Biostatistics, Stellenbosch University, Cape Town Western Cape, South Africa; and Departments of Neurology and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco.
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Pillay-Fuentes Lorente V, Van Rensburg R, Moolla MS, McCaul M, Parker A, Taljaard J, Reuter H, Decloedt EH. Bleeding and thrombosis outcomes in hospitalised COVID-19 patients on low-molecular-weight heparin and antiplatelet therapy. S Afr Med J 2022; 112:472-477. [PMID: 36217857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/01/2022] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND An increased incidence of thromboembolic events in hospitalised COVID‑19 patients has been demonstrated despite the use of low-molecular-weight heparin (LMWH). Antiplatelet therapy prior to admission and early in the disease course has been hypothesised to be protective against thrombosis. OBJECTIVES To describe the bleeding and thrombosis outcomes in hospitalised patients with confirmed COVID‑19 receiving LMWH, with and without concomitant antiplatelet therapy. Secondary objectives were to explore predictors of bleeding and thrombosis outcomes, and dosing practices of antiplatelet therapy and LMWH. METHODS We conducted a descriptive, cross-sectional study of bleeding and thrombosis outcomes at Tygerberg Academic Hospital, Cape Town, South Africa, during the first COVID‑19 wave, in 808 hospitalised patients with confirmed COVID‑19 receiving LMWH with and without concomitant antiplatelet therapy. Multivariate logistic regression analysis was performed if predictors were deemed statistically and clinically significant. RESULTS Patients receiving both LMWH and antiplatelet therapy had similar bleeding outcomes compared with patients only receiving LMWH (odds ratio (OR) 1.5; 95% confidence interval (CI) 0.6 - 4.0). Patients receiving both LMWH and antiplatelet therapy had increased odds of developing thrombosis compared with patients only receiving LMWH (OR 4.8; 95% CI 2.1 - 10.7). CONCLUSION The bleeding risk in COVID‑19 patients receiving both LMWH and antiplatelet therapy was not significantly increased. A potentially higher risk of thrombosis in patients receiving LMWH and antiplatelet therapy was observed. However, this could reflect confounding by indication. Randomised studies are required to further evaluate the use of antiplatelet therapy to treat hospitalised patients with COVID‑19.
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Affiliation(s)
- V Pillay-Fuentes Lorente
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
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Lopez-Varela E, Abulfathi AA, Strydom N, Goussard P, van Wyk AC, Demers AM, Deventer AV, Garcia-Prats AJ, van der Merwe J, Zimmerman M, Carter CL, Janson J, Morrison J, Reuter H, Decloedt EH, Seddon JA, Svensson EM, Warren R, Savic RM, Dartois V, Hesseling AC. Drug concentration at the site of disease in children with pulmonary tuberculosis. J Antimicrob Chemother 2022; 77:1710-1719. [PMID: 35468189 PMCID: PMC9155609 DOI: 10.1093/jac/dkac103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 03/07/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Current TB treatment for children is not optimized to provide adequate drug levels in TB lesions. Dose optimization of first-line antituberculosis drugs to increase exposure at the site of disease could facilitate more optimal treatment and future treatment-shortening strategies across the disease spectrum in children with pulmonary TB. OBJECTIVES To determine the concentrations of first-line antituberculosis drugs at the site of disease in children with intrathoracic TB. METHODS We quantified drug concentrations in tissue samples from 13 children, median age 8.6 months, with complicated forms of pulmonary TB requiring bronchoscopy or transthoracic surgical lymph node decompression in a tertiary hospital in Cape Town, South Africa. Pharmacokinetic models were used to describe drug penetration characteristics and to simulate concentration profiles for bronchoalveolar lavage, homogenized lymph nodes, and cellular and necrotic lymph node lesions. RESULTS Isoniazid, rifampicin and pyrazinamide showed lower penetration in most lymph node areas compared with plasma, while ethambutol accumulated in tissue. None of the drugs studied was able to reach target concentration in necrotic lesions. CONCLUSIONS Despite similar penetration characteristics compared with adults, low plasma exposures in children led to low site of disease exposures for all drugs except for isoniazid.
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Affiliation(s)
- Elisa Lopez-Varela
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic - Universidad de Barcelona, Barcelona, Spain
- Corresponding author: E-mail:
| | - Ahmed A. Abulfathi
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Clinical Pharmacology and Therapeutics, Faculty of Basic Clinical Sciences, College of Medical Sciences, University of Maiduguri, Maiduguri, Nigeria
- Center for Pharmacometrics & Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, USA
| | - Natasha Strydom
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, 94158, USA
| | - Pierre Goussard
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Abraham C. van Wyk
- Division of Anatomical Pathology, Tygerberg Hospital, National Health Laboratory Service, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anne Marie Demers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Service de microbiologie, Département clinique de médecine de laboratoire, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Anneen Van Deventer
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anthony J. Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Johannes van der Merwe
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Matthew Zimmerman
- Center for Discovery and Innovation, Hackensack Meridian Health, New Jersey, USA, and Department of Medical Sciences, Hackensack School of Medicine, Nutley, New Jersey, USA
| | - Claire L. Carter
- Center for Discovery and Innovation, Hackensack Meridian Health, New Jersey, USA, and Department of Medical Sciences, Hackensack School of Medicine, Nutley, New Jersey, USA
- Department of Pathology, Hackensack School of Medicine, Nutley, New Jersey 07110, USA
| | - Jacques Janson
- Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Julie Morrison
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Helmuth Reuter
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Eric H. Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - James A. Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Elin M. Svensson
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob Warren
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research/South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Radojka M. Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, 94158, USA
| | - Véronique Dartois
- Center for Discovery and Innovation, Hackensack Meridian Health, New Jersey, USA, and Department of Medical Sciences, Hackensack School of Medicine, Nutley, New Jersey, USA
| | - Anneke C. Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Gebreyesus MS, Decloedt EH, Cluver CA, Hunfeld NGM, Helgadóttir H, Björnsson ES, Wasmann RE, Denti P. Population pharmacokinetics of esomeprazole in patients with preterm preeclampsia. Br J Clin Pharmacol 2022; 88:4639-4645. [PMID: 35599445 DOI: 10.1111/bcp.15416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/19/2022] [Accepted: 05/05/2022] [Indexed: 11/30/2022] Open
Abstract
Esomeprazole is a proton pump inhibitor being investigated for treatment of preeclampsia. Esomeprazole pharmacokinetics during pregnancy are unknown. We used data from 10 pregnant participants with preterm preeclampsia, and 49 non-pregnant participants to develop a population pharmacokinetic model of esomeprazole. A two-compartment model described the data well. In pregnant participants after single dose, clearance was 42.2% (14.9% - 61.6%) lower compared to non-pregnant, most likely due to inhibition of CYP2C19. In non-pregnant after repeated dosing, clearance was 54.9% (48.2% - 63.5%) lower in extensive metabolizers and bioavailability was 33% (10.0% - 52.0%) higher compared to single dosing, which could be due to autoinhibition of CYP2C19. During pregnancy, the CYP2C19 autoinhibition effect with repeated dosing is expected to lead to much lower increase in exposure compared to non-pregnant, since CYP2C19 is already inhibited due to pregnancy.
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Affiliation(s)
- Manna Semere Gebreyesus
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Stellenbosch, South Africa
| | - Catherine A Cluver
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Hospital, Stellenbosch, South Africa
| | - Nicole G M Hunfeld
- Department of Pharmacy and Intensive Care, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Hólmfríður Helgadóttir
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Einar S Björnsson
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Roeland E Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Cluver CA, Hiscock R, Decloedt EH, Hall DR, Schell S, Mol BW, Brownfoot F, Kaitu'u-Lino TJ, Walker SP, Tong S. Use of Metformin to Prolong Gestation in Preterm Pre-eclampsia: Randomised, Double Blind, Placebo Controlled Trial. Obstet Gynecol Surv 2022. [DOI: 10.1097/01.ogx.0000822468.58359.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lalla U, Koegelenberg CFN, Allwood BW, Sigwadhi LN, Irusen EM, Zemlin AE, Masha TE, Erasmus RT, Chapanduka ZC, Prozesky H, Taljaard J, Parker A, Decloedt EH, Retief F, Jalavu TP, Ngah VD, Yalew A, Tamuzi JL, Baines N, McAllister M, Zumla A, Nyasulu PS. Comparison of patients with severe COVID-19 admitted to an intensive care unit in South Africa during the first and second wave of the COVID-19 pandemic. Afr J Thorac Crit Care Med 2021; 27:10.7196/AJTCCM.2021.v27i4.185. [PMID: 35359698 PMCID: PMC8948479 DOI: 10.7196/ajtccm.2021.v27i4.185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background The second wave of coronavirus disease 2019 (COVID-19), dominated by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Beta variant, has been reported to be associated with increased severity in South Africa (SA). Objectives To describe and compare clinical characteristics, management and outcomes of COVID-19 patients admitted to an intensive care unit (ICU) in SA during the first and second waves. Methods In a prospective, single-centre, descriptive study, we compared all patients with severe COVID-19 admitted to ICU during the first and second waves. The primary outcomes assessed were ICU mortality and ICU length of stay (LOS). Results In 490 patients with comparable ages and comorbidities, no difference in mortality was demonstrated during the second compared with the first wave (65.9% v. 62.5%, p=0.57). ICU LOS was longer in the second wave (10 v. 6 days, p<0.001). More female admissions (67.1% v. 44.6%, p<0.001) and a greater proportion of patients were managed with invasive mechanical ventilation than with non-invasive respiratory support (39.0% v. 14%, p<0.001) in the second wave. Conclusion While clinical characteristics were comparable between the two waves, a higher proportion of patients was invasively ventilated and ICU stay was longer in the second. ICU mortality was unchanged.
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Affiliation(s)
- U Lalla
- Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - C F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - B W Allwood
- Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - L N Sigwadhi
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - E M Irusen
- Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - A E Zemlin
- Division of Chemical Pathology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service (NHLS) Tygerberg Hospital, Cape Town, South Africa
| | - T E Masha
- Faculty of Health and Wellness Sciences, Peninsula University of Technology Bellville Campus, Cape Town
| | - R T Erasmus
- Division of Chemical Pathology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service (NHLS) Tygerberg Hospital, Cape Town, South Africa
| | - Z C Chapanduka
- Division of Haematological Pathology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University and NHLS Tygerberg Hospital, Cape Town, South Africa
| | - H Prozesky
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - J Taljaard
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - A Parker
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - E H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - F Retief
- Department of Anaesthesia and Critical Care, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - T P Jalavu
- Division of Chemical Pathology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service (NHLS) Tygerberg Hospital, Cape Town, South Africa
| | - V D Ngah
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - A Yalew
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Statistics, College of Natural and Computational Sciences, Addis Ababa University, Ethiopia
- National Data Management Centre for Health, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - J L Tamuzi
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - N Baines
- Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - M McAllister
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - A Zumla
- Division of Infection and Immunity, Centre for Clinical Microbiology, University College London, Royal Free Campus, London, UK; NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, UK
| | - P S Nyasulu
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Moolla MS, Whitelaw A, Decloedt EH, Koegelenberg CFN, Parker A. Opportunities to enhance antibiotic stewardship: colistin use and outcomes in a low-resource setting. JAC Antimicrob Resist 2021; 3:dlab169. [PMID: 34806008 PMCID: PMC8599735 DOI: 10.1093/jacamr/dlab169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/19/2021] [Accepted: 10/14/2021] [Indexed: 11/12/2022] Open
Abstract
Background Colistin use is increasing with the rise in MDR Gram-negative infections globally. Effective antibiotic stewardship is essential to preserve this antibiotic of last resort. Objectives This study investigated stewardship and safety errors related to colistin use to identify opportunities for improvement. Patients and methods A prospective descriptive study involving all patients 13 years and older treated with colistin at a tertiary hospital in Cape Town, South Africa, between August 2018 and June 2019. We collected clinical, laboratory and outcome data and assessed provided treatment for stewardship and safety errors. Results We included 44 patients. Treatment errors were identified for 34 (77%) patients (median = 1), most commonly inadequate monitoring of renal function (N = 16, 32%). We also identified no rational indication for colistin (N = 9, 20%), loading dose error (N = 12, 27%); maintenance dose error (N = 10, 23%); no prior culture (N = 11, 25%); and failure to de-escalate (2 of 9) or adjust dose to changes in renal function (6 of 15). All cause in-hospital mortality was 47%. Amongst survivors, median ICU stay was 6 days and hospital stay more than 30 days. Eight (18%) patients developed renal injury or failure during treatment. Three (7%) patients in this study were found to have colistin-resistant organisms including two prior to colistin exposure. Conclusions This study has identified opportunities to enhance colistin stewardship and improve efficacy and safety of prescription. The appearance of colistin-resistant organisms reinforces the urgent need to ensure effective and appropriate use of colistin.
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Affiliation(s)
- Muhammad S Moolla
- Division of General Medicine, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa.,Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Andrew Whitelaw
- Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Coenraad F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Arifa Parker
- Division of General Medicine, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa.,Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
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9
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van Rensburg R, Nightingale S, Brey N, Albertyn CH, Kellermann TA, Taljaard JJ, Esterhuizen TM, Sinxadi PZ, Decloedt EH. Pharmacogenetics of the Late-Onset Efavirenz Neurotoxicity Syndrome (LENS). Clin Infect Dis 2021; 75:399-405. [PMID: 34882770 DOI: 10.1093/cid/ciab961] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The late-onset efavirenz neurotoxicity syndrome (LENS) presents as ataxia and/or encephalopathy with supratherapeutic efavirenz plasma concentrations (>4 µg/mL). Efavirenz is primarily metabolized by cytochrome P450 2B6 (CYP2B6), with CYP2A6 as an accessory pathway. We hypothesized that participants with LENS would predominantly be CYP2B6 slow metabolizers. The aim of our study was to determine the frequency of CYP2B6 slow metabolizers in participants with LENS. METHODS Adult HIV-positive participants on efavirenz-based antiretroviral therapy presenting with LENS were prospectively enrolled. Genetic polymorphisms known to be associated with increased efavirenz plasma concentrations in CYP2B6 (rs3745274, rs28399499, rs4803419) and CYP2A6 (rs28399433) were selected and used to determine proportions of slow metabolizers. Pharmacokinetic analyses were performed using liquid chromatography-tandem mass spectrometry. Median (IQR) plasma efavirenz and 8-hydroxyefavirenz were described. RESULTS Fifteen participants were enrolled. Thirteen (13/15) were Black-African and 13 were female. Median weight was 49.9kg with a median duration on efavirenz of 2.2 years. All 15 participants were successfully genotyped as slow CYP2B6 metabolizers, with 6 participants additionally having CYP2A6 heterozygous genotype. Thirteen were receiving the CYP2A6 enzyme inhibitor isoniazid, and all 15 were genotypic NAT2 slow or intermediate acetylators. Efavirenz plasma concentration was markedly increased at 50.5 (47.0-65.4) µg/mL; 8-hydroxyefavirenz concentration was markedly decreased at 0.10 (0.07-0.15) µg/mL. CONCLUSIONS Our cohort provides definitive evidence that LENS is associated with the CYP2B6 slow metabolizer genotype, with a median efavirenz plasma concentration >12-fold higher than the defined upper limit of the therapeutic range. Isoniazid and low body weight are important contributors to LENS development.
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Affiliation(s)
- Roland van Rensburg
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - Sam Nightingale
- HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Naeem Brey
- Division of Neurology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - Christine H Albertyn
- Division of Neurology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - Tracy A Kellermann
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - Jantjie J Taljaard
- Division of Infectious Diseases, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - Tonya M Esterhuizen
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africaand
| | - Phumla Z Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
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10
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Cluver CA, Hiscock R, Decloedt EH, Hall DR, Schell S, Mol BW, Brownfoot F, Kaitu'u-Lino TJ, Walker SP, Tong S. Use of metformin to prolong gestation in preterm pre-eclampsia: randomised, double blind, placebo controlled trial. BMJ 2021; 374:n2103. [PMID: 34551918 PMCID: PMC8457042 DOI: 10.1136/bmj.n2103] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate whether extended release metformin could be used to prolong gestation in women being expectantly managed for preterm pre-eclampsia. DESIGN Randomised, double blind, placebo controlled trial. SETTING Referral hospital in Cape Town, South Africa. PARTICIPANTS 180 women with preterm pre-eclampsia between 26+0 to 31+6 weeks' gestation undergoing expectant management: 90 were randomised to extended release metformin and 90 to placebo. INTERVENTION 3 g of oral extended release metformin or placebo daily, in divided doses, until delivery. MAIN OUTCOME MEASURE The primary outcome was prolongation of gestation. RESULTS Of 180 participants, one woman delivered before taking any trial drug. The median time from randomisation to delivery was 17.7 days (interquartile range 5.4-29.4 days; n=89) in the metformin arm and 10.1 (3.7-24.1; n=90) days in the placebo arm, a median difference of 7.6 days (geometric mean ratio 1.39, 95% confidence interval 0.99 to 1.95; P=0.057). Among those who continued to take the trial drug at any dose, the median prolongation of gestation in the metformin arm was 17.5 (interquartile range 5.4-28.7; n=76) days compared with 7.9 (3.0-22.2; n=74) days in the placebo arm, a median difference of 9.6 days (geometric mean ratio 1.67, 95% confidence interval 1.16 to 2.42). Among those who took the full dosage, the median prolongation of gestation in the metformin arm was 16.3 (interquartile range 4.8-28.8; n=40) days compared with 4.8 (2.5-15.4; n=61) days in the placebo arm, a median difference of 11.5 days (geometric mean ratio 1.85, 95% confidence interval 1.14 to 2.88). Composite maternal, fetal, and neonatal outcomes and circulating concentrations of soluble fms-like tyrosine kinase-1, placental growth factor, and soluble endoglin did not differ. In the metformin arm, birth weight increased non-significantly and length of stay decreased in the neonatal nursery. No serious adverse events related to trial drugs were observed, although diarrhoea was more common in the metformin arm. CONCLUSIONS This trial suggests that extended release metformin can prolong gestation in women with preterm pre-eclampsia, although further trials are needed. It provides proof of concept that treatment of preterm pre-eclampsia is possible. TRIAL REGISTRATION Pan African Clinical Trial Registry PACTR201608001752102 https://pactr.samrc.ac.za/.
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Affiliation(s)
- Catherine A Cluver
- Department of Obstetrics and Gynaecology, Stellenbosch University, Tygerberg Hospital, 7505, Cape Town, South Africa
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Richard Hiscock
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
| | - Eric H Decloedt
- Department of Medicine, Division of Clinical Pharmacology, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - David R Hall
- Department of Obstetrics and Gynaecology, Stellenbosch University, Tygerberg Hospital, 7505, Cape Town, South Africa
| | - Sonja Schell
- Department of Obstetrics and Gynaecology, Stellenbosch University, Tygerberg Hospital, 7505, Cape Town, South Africa
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash School of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Fiona Brownfoot
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Tu'uhevaha J Kaitu'u-Lino
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Susan P Walker
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Stephen Tong
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
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11
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Pennefather C, Esterhuizen T, Doubell A, Decloedt EH. The 12-month period prevalence and cardiac manifestations of HIV in patients with acute coronary syndrome at a tertiary hospital in Cape Town, South Africa: a retrospective cross-sectional study. BMC Infect Dis 2021; 21:657. [PMID: 34233630 PMCID: PMC8261984 DOI: 10.1186/s12879-021-06367-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 06/28/2021] [Indexed: 11/21/2022] Open
Abstract
Background HIV-positive patients are increasingly being affected by non-communicable diseases such as coronary artery disease (CAD). Data from high-income countries (HICs) indicate that HIV-positive patients have different risk-factor profiles for acute coronary syndrome (ACS) as well as different cardiac manifestations of this syndrome compared to HIV-negative patients. There is limited data from Sub-Saharan Africa (SSA), and particularly from South Africa with the biggest HIV epidemic in the world. The objective of this study was to determine the 12-month period prevalence of HIV in patients with ACS and to compare the risk-factor profile, ACS presentation and management between HIV-positive and HIV-negative adults. Methods We included all patients hospitalised with ACS from 01 January to 31 December 2018 in a tertiary hospital, Tygerberg Hospital, in Cape Town, South Africa. The HIV-status of all patients was determined using routine clinical records. We performed multiple conditional logistic regression on HIV-positive and HIV-negative patients (1:3 ratio) to compare the risk factor profile, ACS presentation and management between the groups. Results Among 889 patients, 30 (3.4%) were HIV-positive (95% confidence interval (CI): 2.3–4.8). HIV-positive patients were younger, more frequently men, and had a lower prevalence of medical comorbidities and a family history of CAD. They were more likely to present with ST-elevation myocardial infarction (STEMI) [odd’s ratio (OR) (95% CI): 3.12 (1.2–8.4)], and have single-vessel disease [OR (95% CI): 3.03 (1.2–8.0)]. Angiographic and echocardiographic data, as well as management, did not differ between the groups. Among HIV-positive patients, 17 (65%) were virally suppressed (HIV viral load < 200 copies/mL) with a median CD4+ count of 271 cells/mm3. The majority (20, 67%) of HIV-positive patients were receiving antiretroviral therapy at the time of the ACS. Conclusions We found an HIV-prevalence of 3.4% (95% CI 2.3–4.8) in adults with ACS in a high endemic HIV region. HIV-positive patients were younger and more likely to present with STEMIs and single-vessel disease, but had fewer CAD risk factors, suggesting additional mechanisms for the development of ACS.
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Affiliation(s)
- Camilla Pennefather
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, PO Box 241, Cape Town, 8000, Republic of South Africa
| | - Tonya Esterhuizen
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, Republic of South Africa
| | - Anton Doubell
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, PO Box 241, Cape Town, 8000, Republic of South Africa
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, PO Box 241, Cape Town, 8000, Republic of South Africa.
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12
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Bekker A, Decloedt EH, Slade G, Cotton MF, Rabie H, Cressey TR. Single Dose Abacavir Pharmacokinetics and Safety in Neonates Exposed to Human Immunodeficiency Virus (HIV). Clin Infect Dis 2021; 72:2032-2034. [PMID: 32697327 DOI: 10.1093/cid/ciaa1026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/19/2020] [Indexed: 11/14/2022] Open
Abstract
Abacavir is a potential option for prophylaxis and early treatment of human immunodeficiency virus (HIV), but no data are available in neonates. Ten neonates administered a single abacavir dose of 8 mg/kg before 15 days of life had substantially higher exposures than those reported in infants and children, with no reported adverse events.
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Affiliation(s)
- Adrie Bekker
- Family Centre for Research with Ubuntu, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gretchen Slade
- Family Centre for Research with Ubuntu, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Mark F Cotton
- Family Centre for Research with Ubuntu, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Helena Rabie
- Family Centre for Research with Ubuntu, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Tim R Cressey
- PHPT/IRD UMI 174, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand.,Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom.,Department of Immunology & Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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13
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Pillay-Fuentes Lorente V, Bekker A, Kali GTJ, Lloyd LG, Van der Merwe AW, Abulfathi AA, Decloedt EH. The Pharmacokinetics of Crushed Levetiracetam Tablets Administered to Neonates. J Trop Pediatr 2021; 67:6296315. [PMID: 34114632 DOI: 10.1093/tropej/fmab041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Intravenous phenobarbital remains the first-line therapy in the management of neonatal seizures. Shortages of intravenous phenobarbital in South Africa necessitated the addition of oral levetiracetam as part of management of neonatal seizures. OBJECTIVE We evaluated the pharmacokinetics of crushed immediate-release levetiracetam tablets administered to neonates to terminate seizures. METHODS A prospective, observational study of neonates admitted with seizures to Tygerberg Hospital. Participants received crushed levetiracetam (diluted in saline) given orally or via naso-/orogastric tube. At steady-state, pharmacokinetic sampling was performed at pre-dose, 1.5, 2.5 and 4 h post-dose. Maximum concentration (Cmax), time to Cmax (Tmax), trough concentrations (Ctrough) and area under the concentration-time curve (AUC0-12) were calculated using non-compartmental analysis. Seizure termination and safety profiles were documented. RESULTS Nineteen participants were grouped into three dosing ranges: (i) 5-15 mg/kg/12-hourly, (ii) 15-25 mg/kg/12-hourly and (iii) 25-35 mg/kg/12-hourly. Range 1 demonstrated AUC0-12 167.0 ± 45.6 h*μg/mL, Cmax 19.19 ± 4.12 μg/mL and Ctrough 9.99 ± 3.86 µg/mL. Range 2, AUC0-12 316.5 ± 108.4 h*μg/mL, Cmax 35.12 ± 10.54 µg/mL and Ctrough 19.25 ± 8.48 µg/mL. Range 3, AUC0-12 290.9 (range 176.14-405.59) h*μg/mL, Cmax 36.11 (range 27.58-44.64) µg/mL and Ctrough 13.03 (2.98-23.07) µg/mL. Seizures terminated in 17/19 (90%) neonates by day 3 and 19/19 (100%) by day 4 post-levetiracetam initiation. CONCLUSION Crushed levetiracetam has comparable pharmacokinetics to historical data. No pharmacokinetic differences were observed between oral vs. naso-/orogastric administration. Crushed levetiracetam tablets can be considered for neonates in low-resource settings where intravenous and syrup access is limited. LAY SUMMARY Intravenous preparations of antiepileptic medications are used in the management of neonatal seizures. Various established standard of care intravenous antiepileptic medicines are unavailable nationally and internationally due to reasons outside our control. This stock shortage included intravenous phenobarbitone which is the first-line treatment for paediatric seizures. Due to phenobarbital shortage, levetiracetam has been identified by the neonatologists at Tygerberg Hospital, Cape Town, South Africa, as a suitable treatment option due to its efficacy and safety profile. However, intravenous levetiracetam and oral syrup is not registered in South Africa. Levetiracetam tablets are being crushed, dissolved and administered to neonates. There are no data available on the absorption of crushed levetiracetam tablets administered to neonates via a nasogastric tube. This study characterized the pharmacokinetic profile of crushed levetiracetam administered to neonates. We selected neonates receiving levetiracetam from the neonatal wards at Tygerberg hospital and drew blood to analyse the levetiracetam concentrations at 4 different time points. We found that the overall exposure of crushed levetiracetam tablets were comparable to the exposures achieved in historical data of the unaltered formulations. We concluded that crushed levetiracetam tablets can be considered for neonates in low resource settings where intravenous and syrup access is limited.
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Affiliation(s)
- Veshni Pillay-Fuentes Lorente
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Adrie Bekker
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Gugu T J Kali
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Lizel G Lloyd
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Alma W Van der Merwe
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Ahmed A Abulfathi
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa.,Department of Clinical Pharmacology and Therapeutics, Faculty of Basic Clinical Sciences, College of Medical Sciences, University of Maiduguri, Maiduguri 600004, Nigeria
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
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14
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Park JJH, Mogg R, Smith GE, Nakimuli-Mpungu E, Jehan F, Rayner CR, Condo J, Decloedt EH, Nachega JB, Reis G, Mills EJ. How COVID-19 has fundamentally changed clinical research in global health. Lancet Glob Health 2021; 9:e711-e720. [PMID: 33865476 PMCID: PMC8049590 DOI: 10.1016/s2214-109x(20)30542-8] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 12/07/2020] [Accepted: 12/10/2020] [Indexed: 01/07/2023]
Abstract
COVID-19 has had negative repercussions on the entire global population. Despite there being a common goal that should have unified resources and efforts, there have been an overwhelmingly large number of clinical trials that have been registered that are of questionable methodological quality. As the final paper of this Series, we discuss how the medical research community has responded to COVID-19. We recognise the incredible pressure that this pandemic has put on researchers, regulators, and policy makers, all of whom were doing their best to move quickly but safely in a time of tremendous uncertainty. However, the research community's response to the COVID-19 pandemic has prominently highlighted many fundamental issues that exist in clinical trial research under the current system and its incentive structures. The COVID-19 pandemic has not only re-emphasised the importance of well designed randomised clinical trials but also highlighted the need for large-scale clinical trials structured according to a master protocol in a coordinated and collaborative manner. There is also a need for structures and incentives to enable faster data sharing of anonymised datasets, and a need to provide similar opportunities to those in high-income countries for clinical trial research in low-resource regions where clinical trial research receives considerably less research funding.
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Affiliation(s)
- Jay J H Park
- Department of Experimental Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Robin Mogg
- Bill & Melinda Gates Medical Research Institute, Boston, MA, USA
| | - Gerald E Smith
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Fyezah Jehan
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Craig R Rayner
- Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia; Certara, Princeton, NJ, USA
| | - Jeanine Condo
- School of Public Health, University of Rwanda, Kigali, Rwanda
| | - Eric H Decloedt
- Department of Medicine, Division of Clinical Pharmacology, Stellenbosch University, Cape Town, South Africa
| | - Jean B Nachega
- Department of Medicine and Center for Infectious Diseases, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Department of Epidemiology and Department of Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA; Department of Epidemiology and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Gilmar Reis
- Departamento de Medicina, Pontifícia Universidade Católica de Minas Gerais, Belo Horizonte, Brazil
| | - Edward J Mills
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Cytel, Vancouver, BC, Canada; School of Public Health, University of Rwanda, Kigali, Rwanda.
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15
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Decloedt EH, Sinxadi PZ, Wiesner L, Joska JA, Haas DW, Maartens G. Pharmacogenetics of tenofovir and emtricitabine penetration into cerebrospinal fluid. South Afr J HIV Med 2021; 22:1206. [PMID: 34007475 PMCID: PMC8111650 DOI: 10.4102/sajhivmed.v22i1.1206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/09/2021] [Indexed: 01/31/2023] Open
Abstract
Background Blood-cerebrospinal fluid (CSF) barrier transporters affect the influx and efflux of drugs. The antiretrovirals tenofovir and emtricitabine may be substrates of blood-brain barrier (BBB) and blood-CSF barrier transporters, but data are limited regarding the pharmacogenetics and pharmacokinetics of their central nervous system (CNS) penetration. Objectives We investigated genetic polymorphisms associated with CSF disposition of tenofovir and emtricitabine. Method We collected paired plasma and CSF samples from 47 HIV-positive black South African adults who were virologically suppressed on efavirenz, tenofovir and emtricitabine. We considered 1846 single-nucleotide polymorphisms from seven relevant transporter genes (ABCC5, ABCG2, ABCB1, SLCO2B1, SCLO1A2, SLCO1B1 and ABCC4) and 782 met a linkage disequilibrium (LD)-pruning threshold. Results The geometric mean (95% confidence interval [CI]) values for tenofovir and emtricitabine CSF-to-plasma concentration ratios were 0.023 (0.021-0.026) and 0.528 (0.460-0.605), respectively. In linear regression models, the lowest p-value for association with the tenofovir CSF-to-plasma ratio was ABCB1 rs1989830 (p = 1.2 × 10-3) and for emtricitabine, it was ABCC5 rs11921035 (p = 1.4 × 10-3). None withstood correction for multiple testing. Conclusion No genetic polymorphisms were associated with plasma, CSF concentrations or CSF-to-plasma ratios for either tenofovir or emtricitabine.
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Affiliation(s)
- Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Phumla Z Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - John A Joska
- Department of Psychiatry and Mental Health, Health Sciences, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - David W Haas
- Department of Medicine, Vanderbilt University Medical Center, Vanderbilt University, Nashville, Tennessee, United States.,Department of Internal Medicine, Meharry Medical College, Nashville, Tennessee, United States
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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16
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Nachega JB, Kapata N, Sam-Agudu NA, Decloedt EH, Katoto PDMC, Nagu T, Mwaba P, Yeboah-Manu D, Chanda-Kapata P, Ntoumi F, Geng EH, Zumla A. Minimizing the impact of the triple burden of COVID-19, tuberculosis and HIV on health services in sub-Saharan Africa. Int J Infect Dis 2021; 113 Suppl 1:S16-S21. [PMID: 33757874 PMCID: PMC7980520 DOI: 10.1016/j.ijid.2021.03.038] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 02/28/2021] [Accepted: 03/10/2021] [Indexed: 02/08/2023] Open
Abstract
In this perspective, we discuss the impact of COVID-19 on tuberculosis (TB)/HIV health services and approaches to mitigating the growing burden of these three colliding epidemics in sub-Saharan Africa (SSA). SSA countries bear significantly high proportions of TB and HIV cases reported worldwide, compared to countries in the West. Whilst COVID-19 epidemiology appears to vary across Africa, most countries in this region have reported relatively lower-case counts compared to the West. Nevertheless, the COVID-19 pandemic has added an additional burden to already overstretched health systems in SSA, which, among other things, have been focused on the longstanding dual epidemics of TB and HIV. As with these dual epidemics, inadequate resources and poor case identification and reporting may be contributing to underestimations of the COVID-19 case burden in SSA. Modelling studies predict that the pandemic-related disruptions in TB and HIV services will result in significant increases in associated morbidity and mortality over the next five years. Furthermore, limited empirical evidence suggests that SARS-CoV-2 coinfections with TB and HIV are associated with increased mortality risk in SSA. However, predictive models require a better evidence-base to accurately define the impact of COVID-19, not only on communicable diseases such as TB and HIV, but on non-communicable disease comorbidities. Further research is needed to assess morbidity and mortality data among both adults and children across the African continent, paying attention to geographic disparities, as well as the clinical and socio-economic determinants of COVID-19 in the setting of TB and/or HIV.
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Affiliation(s)
- Jean B Nachega
- Department of Medicine and Center for Infectious Diseases, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa; Department of Epidemiology, Infectious Diseases and Microbiology, and Center for Global Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Nathan Kapata
- Zambia National Public Health Institute, University of Zambia-University College London Medical School Research and Training Project, University Teaching Hospital, Ministry of Health, Lusaka, Zambia.
| | - Nadia A Sam-Agudu
- International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria; Institute of Human Virology and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA; Department of Pediatrics and Child Health, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana.
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa.
| | - Patrick D M C Katoto
- Department of Medicine and Center for Infectious Diseases, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa.
| | - Tumaini Nagu
- School of Medicine, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania.
| | - Peter Mwaba
- Lusaka Apex Medical University, Lusaka, Zambia.
| | - Dorothy Yeboah-Manu
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana.
| | | | - Francine Ntoumi
- Fondation Congolaise pour la Recherche Médicale (FCRM), Brazzaville, Congo; Institute for Tropical Medicine, University of Tübingen, Tübingen, Germany.
| | - Elvin H Geng
- Division of Infectious Diseases, Department of Medicine, and Center for Dissemination and Implementation, Institute for Public Health, Washington University, St Louis, Missouri, USA.
| | - Alimuddin Zumla
- Division of Infection and Immunity, University College London, London, UK; NIHR Biomedical Research Centre, University College London Hospitals, London, UK.
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17
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du Toit T, Esterhuizen TM, Tiffin N, Abulfathi AA, Reuter H, Decloedt EH. Incident tuberculosis disease in patients receiving biologic therapies in the Western Cape, South Africa from 2007 to 2018. BMC Infect Dis 2020; 20:900. [PMID: 33256634 PMCID: PMC7706240 DOI: 10.1186/s12879-020-05624-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/17/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND South Africa has one of the highest tuberculosis incidence rates. Biologic disease-modifying anti-rheumatic drugs are associated with an increased risk of tuberculosis. The objective of this study was to describe the tuberculosis disease incidence rate among public sector patients receiving biologic therapies in the Western Cape Province. METHODS A retrospective, descriptive analysis was undertaken using routine health data collated by the Provincial Health Data Centre from January 2007 (first use of biologic therapy in the Western Cape) to September 2018. RESULTS We identified 609 patients treated with tumour necrosis factor-alpha (TNF-α) or non-TNF-α biologic therapies. Thirty-seven (37) patients developed tuberculosis after biologic therapy exposure, of whom the majority (78%) had an immune mediated inflammatory disease and the remainder (22%) a haematologic malignancy. The incidence rate of tuberculosis per 100,000 person-years was 2227 overall [95% confidence interval (CI): 1591, 3037]. Patients treated with TNF-α inhibitors and non-TNF-α inhibitors had estimated incidence rates of 2819 [95% CI: 1669, 4480] and 1825 [95% CI: 1131, 2797], respectively (p = 0.10). CONCLUSION Patients exposed to both TNF-α and non-TNF-α biologic therapies may have a higher incidence of tuberculosis disease compared to the background risk of 681 cases per 100,000 per year in the Western Cape.
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Affiliation(s)
- Tessa du Toit
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, Republic of South Africa
| | - Tonya M Esterhuizen
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Nicki Tiffin
- Computational Biology Division, Integrative Biomedical Sciences, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Ahmed A Abulfathi
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, Republic of South Africa
- Department of Clinical Pharmacology and Therapeutics, Faculty of Basic Clinical Sciences, College of Medical Sciences, University of Maiduguri, Maiduguri, Nigeria
| | - Helmuth Reuter
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, Republic of South Africa
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, Republic of South Africa.
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18
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Rayner CR, Dron L, Park JJH, Decloedt EH, Cotton MF, Niranjan V, Smith PF, Dodds MG, Brown F, Reis G, Wesche D, Mills EJ. Accelerating Clinical Evaluation of Repurposed Combination Therapies for COVID-19. Am J Trop Med Hyg 2020; 103:1364-1366. [PMID: 32828137 PMCID: PMC7543863 DOI: 10.4269/ajtmh.20-0995] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
As the global COVID-19 pandemic continues, unabated and clinical trials demonstrate limited effective pharmaceutical interventions, there is a pressing need to accelerate treatment evaluations. Among options for accelerated development is the evaluation of drug combinations in the absence of prior monotherapy data. This approach is appealing for a number of reasons. First, combining two or more drugs with related or complementary therapeutic effects permits a multipronged approach addressing the variable pathways of the disease. Second, if an individual component of a combination offers a therapeutic effect, then in the absence of antagonism, a trial of combination therapy should still detect individual efficacy. Third, this strategy is time saving. Rather than taking a stepwise approach to evaluating monotherapies, this strategy begins with testing all relevant therapeutic options. Finally, given the severity of the current pandemic and the absence of treatment options, the likelihood of detecting a treatment effect with combination therapy maintains scientific enthusiasm for evaluating repurposed treatments. Antiviral combination selection can be facilitated by insights regarding SARS-CoV-2 pathophysiology and cell cycle dynamics, supported by infectious disease and clinical pharmacology expert advice. We describe a clinical evaluation strategy using adaptive combination platform trials to rapidly test combination therapies to treat COVID-19.
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Affiliation(s)
- Craig R Rayner
- Certara, Princeton, New Jersey.,Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Louis Dron
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Cytel Inc., Vancouver, Canada
| | - Jay J H Park
- Department of Medicine, Experimental Medicine, University of British Columbia, Vancouver, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Mark F Cotton
- Family Clinical Research Unit, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | | | | | | | - Gilmar Reis
- PUC Minas Medical School of Medicine at Contagem, Belo Horizonte, Brazil
| | | | - Edward J Mills
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Cytel Inc., Vancouver, Canada
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19
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Abulfathi AA, Decloedt EH, Svensson EM, Diacon AH, Donald P, Reuter H. Clinical Pharmacokinetics and Pharmacodynamics of Rifampicin in Human Tuberculosis. Clin Pharmacokinet 2020; 58:1103-1129. [PMID: 31049868 DOI: 10.1007/s40262-019-00764-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The introduction of rifampicin (rifampin) into tuberculosis (TB) treatment five decades ago was critical for shortening the treatment duration for patients with pulmonary TB to 6 months when combined with pyrazinamide in the first 2 months. Resistance or hypersensitivity to rifampicin effectively condemns a patient to prolonged, less effective, more toxic, and expensive regimens. Because of cost and fears of toxicity, rifampicin was introduced at an oral daily dose of 600 mg (8-12 mg/kg body weight). At this dose, clinical trials in 1970s found cure rates of ≥ 95% and relapse rates of < 5%. However, recent papers report lower cure rates that might be the consequence of increased emergence of resistance. Several lines of evidence suggest that higher rifampicin doses, if tolerated and safe, could shorten treatment duration even further. We conducted a narrative review of rifampicin pharmacokinetics and pharmacodynamics in adults across a range of doses and highlight variables that influence its pharmacokinetics/pharmacodynamics. Rifampicin exposure has considerable inter- and intra-individual variability that could be reduced by administration during fasting. Several factors including malnutrition, HIV infection, diabetes mellitus, dose size, pharmacogenetic polymorphisms, hepatic cirrhosis, and substandard medicinal products alter rifampicin exposure and/or efficacy. Renal impairment has no influence on rifampicin pharmacokinetics when dosed at 600 mg. Rifampicin maximum (peak) concentration (Cmax) > 8.2 μg/mL is an independent predictor of sterilizing activity and therapeutic drug monitoring at 2, 4, and 6 h post-dose may aid in optimizing dosing to achieve the recommended rifampicin concentration of ≥ 8 µg/mL. A higher rifampicin Cmax is required for severe forms TB such as TB meningitis, with Cmax ≥ 22 μg/mL and area under the concentration-time curve (AUC) from time zero to 6 h (AUC6) ≥ 70 μg·h/mL associated with reduced mortality. More studies are needed to confirm whether doses achieving exposures higher than the current standard dosage could translate into faster sputum conversion, higher cure rates, lower relapse rates, and less mortality. It is encouraging that daily rifampicin doses up to 35 mg/kg were found to be safe and well-tolerated over a period of 12 weeks. High-dose rifampicin should thus be considered in future studies when constructing potentially shorter regimens. The studies should be adequately powered to determine treatment outcomes and should include surrogate markers of efficacy such as Cmax/MIC (minimum inhibitory concentration) and AUC/MIC.
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Affiliation(s)
- Ahmed Aliyu Abulfathi
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa.
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Elin M Svensson
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Andreas H Diacon
- Task Applied Science, Bellville, South Africa.,Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Peter Donald
- Paediatrics and Child Health and Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Helmuth Reuter
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
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20
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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21
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Decloedt EH, Sinxadi PZ, van Zyl GU, Wiesner L, Khoo S, Joska JA, Haas DW, Maartens G. Pharmacogenetics and pharmacokinetics of CNS penetration of efavirenz and its metabolites. J Antimicrob Chemother 2020; 74:699-709. [PMID: 30535366 DOI: 10.1093/jac/dky481] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 10/11/2018] [Accepted: 10/24/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND There are limited data on the pharmacogenetics and pharmacokinetics of the CNS penetration of efavirenz. OBJECTIVES We investigated genetic polymorphisms associated with CSF concentrations of efavirenz and its metabolites and explored the relationships with neurocognitive performance. METHODS We included 47 HIV-infected South African black adults with and without HIV-associated neurocognitive disorder on efavirenz/tenofovir/emtricitabine and collected paired plasma-CSF samples. We considered 2049 SNPs, including SNPs known to affect plasma efavirenz exposure, from potentially relevant genes (ABCC5, ABCG2, ABCB1, SLCO2B1, SCLO1A2, ABCC4, CYP2B6 and CYP2A6) and 880 met a linkage disequilibrium (LD)-pruning threshold. RESULTS We identified 9 slow, 21 intermediate and 17 extensive metabolizers. The CYP2B6 983 genotype in multivariate analyses predicted log10-transformed concentrations of plasma efavirenz (β = 0.38, P = 2.7 × 10-03), plasma 7-hydroxy-efavirenz (β = 0.59, P = 3.7 × 10-03), plasma 8-hydroxy-efavirenz:efavirenz ratio (β = -0.31, P = 1.8 × 10-04) and CSF efavirenz (β = 0.36, P = 0.01). Lower plasma 7-hydroxy-efavirenz concentrations were independently associated with CYP2A6 rs10853742 (β = -0.55, P = 3.5 × 10-05), ABCB1 rs115780656 (β = -0.65, P = 4.1 × 10-05) and CYP2A6 -48A→C (β = -0.59, P = 0.01). CYP2A6 -48A→C was independently associated with higher CSF 8-hydroxy-efavirenz:efavirenz ratio (β = 0.54, P = 0.048). CYP2B6 rs2279345 polymorphism was associated with lower plasma 7-hydroxy-efavirenz:efavirenz ratio in multivariate analyses (P < 0.05). No polymorphisms were associated with CSF:plasma ratios of efavirenz, plasma or CSF concentrations of 8-hydroxy-efavirenz or neurocognitive performance. CONCLUSIONS We identified novel genetic associations with plasma efavirenz, plasma 7-hydroxy-efavirenz, plasma 7-hydroxy-efavirenz:efavirenz ratio, plasma 8-hydroxy-efavirenz:efavirenz ratio, CSF efavirenz and CSF 8-hydroxy-efavirenz:efavirenz ratio.
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Affiliation(s)
- Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Phumla Z Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gert U van Zyl
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Saye Khoo
- Institute of Translational Medicine, University of Liverpool and Royal Liverpool University Hospital, Liverpool, UK
| | - John A Joska
- Division of Neuropsychiatry, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - David W Haas
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.,Department of Internal Medicine, Meharry Medical College, Nashville, TN, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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22
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Abena PM, Decloedt EH, Bottieau E, Suleman F, Adejumo P, Sam-Agudu NA, Muyembe TamFum JJ, Seydi M, Eholie SP, Mills EJ, Kallay O, Zumla A, Nachega JB. Chloroquine and Hydroxychloroquine for the Prevention or Treatment of COVID-19 in Africa: Caution for Inappropriate Off-label Use in Healthcare Settings. Am J Trop Med Hyg 2020; 102:1184-1188. [PMID: 32323646 PMCID: PMC7253100 DOI: 10.4269/ajtmh.20-0290] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 12/21/2022] Open
Abstract
The novel severe acute respiratory syndrome-coronavirus-2 pandemic has spread to Africa, where nearly all countries have reported laboratory-confirmed cases of novel coronavirus disease (COVID-19). Although there are ongoing clinical trials of repurposed and investigational antiviral and immune-based therapies, there are as yet no scientifically proven, clinically effective pharmacological treatments for COVID-19. Among the repurposed drugs, the commonly used antimalarials chloroquine (CQ) and hydroxychloroquine (HCQ) have become the focus of global scientific, media, and political attention despite a lack of randomized clinical trials supporting their efficacy. Chloroquine has been used worldwide for about 75 years and is listed by the WHO as an essential medicine to treat malaria. Hydroxychloroquine is mainly used as a therapy for autoimmune diseases. However, the efficacy and safety of CQ/HCQ for the treatment of COVID-19 remains to be defined. Indiscriminate promotion and widespread use of CQ/HCQ have led to extensive shortages, self-treatment, and fatal overdoses. Shortages and increased market prices leave all countries vulnerable to substandard and falsified medical products, and safety issues are especially concerning for Africa because of its healthcare system limitations. Much needed in Africa is a cross-continental collaborative network for coordinated production, distribution, and post-marketing surveillance aligned to low-cost distribution of any approved COVID-19 drug; this would ideally be piggybacked on existing global aid efforts. Meanwhile, African countries should strongly consider implementing prescription monitoring schemes to ensure that any off-label CQ/HCQ use is appropriate and beneficial during this pandemic.
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Affiliation(s)
- Pascale M. Abena
- Infectious Diseases Outpatient Clinic, Cameroon and Infectious Diseases Society of Cameroon, Yaoundé, Douala, Cameroon
| | - Eric H. Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - Emmanuel Bottieau
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Fatima Suleman
- Discipline of Pharmaceutical Sciences, University of Kwazulu-Natal, Durban, South Africa
| | - Prisca Adejumo
- Department of Nursing, University of Ibadan, Ibadan, Nigeria
| | - Nadia A. Sam-Agudu
- Institute of Human Virology and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
- International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria
- Department of Paediatrics, University of Cape Coast School of Medical Sciences, Cape Coast, Ghana
| | - Jean-Jacques Muyembe TamFum
- Department of Medical Microbiology and Virology, National Institute of Biomedical Research (INRB), Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Moussa Seydi
- Service de Maladies Infectieuses et Tropicales, Centre Hospitalo-Universitaire de Fann, Université Cheik Anta-Diop, Dakar, Sénégal
| | - Serge P. Eholie
- Unit of Infectious Diseases, Treichville University Teaching Hospital, Abidjan, Côte d’Ivoire
- Unité de Dermatologie et Infectiologie, Unité de Formation et de Recherche, Université Félix Houphouet Boigny, Abidjan, Côte d’Ivoire
| | - Edward J. Mills
- University of Kigali School of Public Health, Kigali, Rwanda
| | - Oscar Kallay
- Erasme Hospital, Free University of Brussels, Brussels, Belgium
| | - Alimuddin Zumla
- Department of Infection, Division of Infection and Immunity, Centre for Clinical Microbiology, University College London, London, United Kingdom
- National Institute for Health Research Biomedical Research Centre, University College London Hospitals, London, United Kingdom
| | - Jean B. Nachega
- Center for Infectious Diseases, at Stellenbosch University, Cape Town, South Africa
- Department of International Health and Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- University of Pittsburgh Graduate School of Public Health and Center for Global Health, Pittsburgh, Pennsylvania
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23
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van Rensburg R, Pillay-Fuentes Lorente V, Decloedt EH. Current evidence for directed and supportive investigational therapies against COVID-19. Afr J Thorac Crit Care Med 2020; 26:10.7196/AJTCCM.2020.v26i2.072. [PMID: 34235422 PMCID: PMC7221540 DOI: 10.7196/ajtccm.2020.v26i2.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2020] [Indexed: 12/04/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a global health crisis. There is currently a great need for effective and safe therapies directed at the disease, but no drugs are presently registered for use in COVID-19. Several directed therapies have been proposed, and most are still in clinical trials. Currently available published, peer-reviewed results mostly involve small sample sizes with study limitations restricting the interpretation of the findings. Many trials currently published also do not have a control group, limiting the interpretation of the effect of the intervention. Investigational directed therapies as well as investigational supportive therapies against COVID-19 are reviewed here. Chloroquine and hydroxychloroquine show promise as directed therapies, but current trial results are conflicting. Lopinavir/ritonavir also shows potential, but was started late in the disease course in most trials. No randomised controlled evidence is currently available for remdesivir and favipiravir. Corticosteroid use is not recommended for directed therapy against COVID-19, and the role of tocilizumab is currently unclear, based on limited evidence. Early initiation of investigational directed therapies may provide benefit in selected patients. The results from larger randomised controlled trials will clarify the place of these therapies in COVID-19 treatment.
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Affiliation(s)
- R van Rensburg
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - V Pillay-Fuentes Lorente
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - E H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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24
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Anderson SG, McCaul M, Khoo S, Wiesner L, Sacktor N, Joska JA, Decloedt EH. The neurologic phenotype of South African patients with HIV-associated neurocognitive impairment. Neurol Clin Pract 2019; 10:15-22. [PMID: 32190416 DOI: 10.1212/cpj.0000000000000687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 04/30/2019] [Indexed: 11/15/2022]
Abstract
Background The neurologic manifestations of HIV include a spectrum of HIV-associated neurocognitive disorders, as well as a cluster of neurologic symptoms and signs. The neurologic manifestations have been modified but not eradicated by antiretroviral therapy (ART). We describe the neurologic phenotype in South African patients with predominant HIV-1 subtype C infection on ART and its association with neurocognitive impairment and efavirenz and 8-hydroxy-efavirenz concentrations. Methods We conducted a cross-sectional analysis of the neurologic examination findings of HIV+ patients with neurocognitive impairment and used multiple linear regression to explore associations with neurocognitive impairment, efavirenz, and 8-hydroxy-efavirenz pharmacokinetics (plasma and CSF). Results We included 80 participants established on ART (median 40 months) of which 72 (90%) were female. The median age was 35 (interquartile range [IQR], 32-42) and the median Global Deficit Score was 0.94 (IQR 0.63-1.36). We found associations between neurocognitive impairment and neurologic signs: gait (slow walking speed [p = 0.03; R2 = 0.06], gait ataxia [p < 0.01; R2 = 0.21], and abnormal gait appearance [p < 0.01; R2 = 0.18]); coordination (upper limb bradykinesia [p < 0.01; R2 = 0.10] and lower limb bradykinesia [p = 0.01; R2 = 0.10]); reflexes (jaw jerk [p = 0.04; R2 = 0.05] and palmomental response [p = 0.03; R2 = 0.06]); ocular signs (impaired smooth pursuit [p = 0.01; R2 = 0.09] and impaired saccades [p < 0.01; R2 = 0.15]); and motor signs (spasticity [p ≤ 0.01; R2 = 0.15] and muscle weakness [p = 0.01; R2 = 0.08]). No significant associations were found between plasma and CSF efavirenz or 8-hydroxy efavirenz concentrations and any neurologic sign. Conclusion We found that individual neurologic signs were associated with neurocognitive impairment in South African HIV+ patients with predominant HIV-1 subtype C infection on ART and could be used in clinical practice to assess severity. Registration number PACTR201310000635418.
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Affiliation(s)
- Sean G Anderson
- Division of Clinical Pharmacology (SGA, EHD), Faculty of Medicine and Health Sciences, University of Stellenbosch; Biostatistics Unit (MM), Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; Institute of Translational Medicine (SK), University of Liverpool, and Royal Liverpool University Hospital, United Kingdom; Division of Clinical Pharmacology (LW), Department of Medicine, University of Cape Town, South Africa; Department of Neurology (NS), Johns Hopkins University School of Medicine, Baltimore, MD; and Division of Neuropsychiatry (JAJ), Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Michael McCaul
- Division of Clinical Pharmacology (SGA, EHD), Faculty of Medicine and Health Sciences, University of Stellenbosch; Biostatistics Unit (MM), Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; Institute of Translational Medicine (SK), University of Liverpool, and Royal Liverpool University Hospital, United Kingdom; Division of Clinical Pharmacology (LW), Department of Medicine, University of Cape Town, South Africa; Department of Neurology (NS), Johns Hopkins University School of Medicine, Baltimore, MD; and Division of Neuropsychiatry (JAJ), Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Saye Khoo
- Division of Clinical Pharmacology (SGA, EHD), Faculty of Medicine and Health Sciences, University of Stellenbosch; Biostatistics Unit (MM), Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; Institute of Translational Medicine (SK), University of Liverpool, and Royal Liverpool University Hospital, United Kingdom; Division of Clinical Pharmacology (LW), Department of Medicine, University of Cape Town, South Africa; Department of Neurology (NS), Johns Hopkins University School of Medicine, Baltimore, MD; and Division of Neuropsychiatry (JAJ), Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology (SGA, EHD), Faculty of Medicine and Health Sciences, University of Stellenbosch; Biostatistics Unit (MM), Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; Institute of Translational Medicine (SK), University of Liverpool, and Royal Liverpool University Hospital, United Kingdom; Division of Clinical Pharmacology (LW), Department of Medicine, University of Cape Town, South Africa; Department of Neurology (NS), Johns Hopkins University School of Medicine, Baltimore, MD; and Division of Neuropsychiatry (JAJ), Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Ned Sacktor
- Division of Clinical Pharmacology (SGA, EHD), Faculty of Medicine and Health Sciences, University of Stellenbosch; Biostatistics Unit (MM), Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; Institute of Translational Medicine (SK), University of Liverpool, and Royal Liverpool University Hospital, United Kingdom; Division of Clinical Pharmacology (LW), Department of Medicine, University of Cape Town, South Africa; Department of Neurology (NS), Johns Hopkins University School of Medicine, Baltimore, MD; and Division of Neuropsychiatry (JAJ), Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - John A Joska
- Division of Clinical Pharmacology (SGA, EHD), Faculty of Medicine and Health Sciences, University of Stellenbosch; Biostatistics Unit (MM), Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; Institute of Translational Medicine (SK), University of Liverpool, and Royal Liverpool University Hospital, United Kingdom; Division of Clinical Pharmacology (LW), Department of Medicine, University of Cape Town, South Africa; Department of Neurology (NS), Johns Hopkins University School of Medicine, Baltimore, MD; and Division of Neuropsychiatry (JAJ), Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Eric H Decloedt
- Division of Clinical Pharmacology (SGA, EHD), Faculty of Medicine and Health Sciences, University of Stellenbosch; Biostatistics Unit (MM), Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; Institute of Translational Medicine (SK), University of Liverpool, and Royal Liverpool University Hospital, United Kingdom; Division of Clinical Pharmacology (LW), Department of Medicine, University of Cape Town, South Africa; Department of Neurology (NS), Johns Hopkins University School of Medicine, Baltimore, MD; and Division of Neuropsychiatry (JAJ), Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa
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van Rensburg R, Decloedt EH. An Approach to the Pharmacotherapy of Neuroleptic Malignant Syndrome. Psychopharmacol Bull 2019; 49:84-91. [PMID: 30858642 PMCID: PMC6386430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Neuroleptic malignant syndrome is a rare, idiosyncratic emergency associated with exposure to dopamine antagonists, commonly antipsychotic drugs. The typical clinical picture consists of altered consciousness, muscular rigidity, fever, and autonomic instability. While the condition has generally been well described, the pathophysiology is still poorly understood. The importance of this case report is to highlight the lack of robust evidence-based treatment for this emergency. We submit an approach to the pharmacotherapy of neuroleptic malignant syndrome based on the available evidence.
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Affiliation(s)
- Roland van Rensburg
- Van Rensburg, MBChB Dip HIV Man(SA), Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa. Decloedt, MBChB BSc(Hons) FCCP(SA) MMed(Clin Pharm), Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Eric H Decloedt
- Van Rensburg, MBChB Dip HIV Man(SA), Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa. Decloedt, MBChB BSc(Hons) FCCP(SA) MMed(Clin Pharm), Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Affiliation(s)
- Eric H Decloedt
- Division of Clinical PharmacologyDepartment of MedicineFaculty of Medicine and Health SciencesStellenbosch University South Africa
| | - Susan Schalkwyk
- Centre for Health Professions EducationFaculty of Medicine and Health SciencesStellenbosch University South Africa
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Cluver CA, Hannan NJ, van Papendorp E, Hiscock R, Beard S, Mol BW, Theron GB, Hall DR, Decloedt EH, Stander M, Adams KT, Rensburg M, Schubert P, Walker SP, Tong S. Esomeprazole to treat women with preterm preeclampsia: a randomized placebo controlled trial. Am J Obstet Gynecol 2018; 219:388.e1-388.e17. [PMID: 30055127 DOI: 10.1016/j.ajog.2018.07.019] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/17/2018] [Accepted: 07/20/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND Preterm preeclampsia has a high rate of fetal death or disability. There is no treatment to slow the disease, except delivery. Preclinical studies have identified proton pump inhibitors as a possible treatment. OBJECTIVE The purpose of this study was to examine whether esomeprazole could prolong pregnancy in women who have received a diagnosis of preterm preeclampsia. STUDY DESIGN We performed a double-blind, randomized controlled trial at Tygerberg Hospital in South Africa. Women with preterm preeclampsia (gestational age 26 weeks+0 days to 31 weeks+6 days) were assigned randomly to 40-mg daily esomeprazole or placebo. The primary outcome was a prolongation of gestation of 5 days. Secondary outcomes were maternal and neonatal outcomes. We compared circulating markers of endothelial dysfunction that was associated with preeclampsia and performed pharmacokinetic studies. RESULTS Between January 2016 and April 2017, we recruited 120 participants. One participant was excluded because of incorrect randomization, which left 59 participants in the esomeprazole and 60 participants in the placebo group. Median gestational age at enrolment was 29+4 weeks gestation. There were no between-group differences in median time from randomization to delivery: 11.4 days (interquartile range, 3.6-19.7 days) in the esomeprazole group and 8.3 days (interquartile range, 3.8-19.6 days) in the placebo group (3 days longer in the esomeprazole arm; 95% confidence interval, -2.9-8.8; P=.31). There were no placental abruptions in the esomeprazole group and 6 (10%) in the placebo group (P=.01, P=.14 adjusted). There were no differences in other maternal or neonatal outcomes or markers of endothelial dysfunction. Esomeprazole and its metabolites were detected in maternal blood among those treated with esomeprazole, but only trace amounts in the umbilical cord blood. CONCLUSION Daily esomeprazole (40 mg) did not prolong gestation in pregnancies with preterm preeclampsia or decrease circulating soluble fms-like tyrosine kinase 1 concentrations. Higher levels in the maternal circulation may be needed for clinical effect.
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Koopmans LR, Finlayson H, Whitelaw A, Decloedt EH, Dramowski A. Paediatric antimicrobial use at a South African hospital. Int J Infect Dis 2018; 74:16-23. [PMID: 29935284 DOI: 10.1016/j.ijid.2018.05.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/24/2018] [Accepted: 05/29/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Data on antimicrobial use among hospitalized children in Africa are very limited due to the absence of electronic prescription tracking. METHODS This study evaluated antimicrobial consumption rates, the antimicrobial spectrum used, and the indications for therapy on a paediatric ward and in the paediatric intensive care unit (PICU) at Tygerberg Hospital, Cape Town, South Africa. Antimicrobial prescription and patient demographic data were collected prospectively from May 10, 2015 to November 11, 2015. For the same period, data on antimicrobials dispensed and costs were extracted from the pharmacy electronic medicine management system. The volume of antimicrobials dispensed (dispensing data) was compared with observed antimicrobial use (prescription data). RESULTS Of the 703 patients admitted, 415/451 (92%) paediatric ward admissions and 233/252 (92%) PICU admissions received ≥1 antimicrobials. On the ward, 89% of prescriptions were for community-acquired infections; 29% of PICU antimicrobials were prescribed for healthcare-associated infections. Ampicillin and third-generation cephalosporins were the most commonly prescribed agents. Antimicrobial costs were 67541 South African Rand (ZAR) (5680 United States Dollars (USD)) on the ward and 210484 ZAR (17702 USD) in the PICU. Ertapenem and meropenem were the single largest contributors to antimicrobial costs on the ward (43%) and PICU (30%), respectively. The volume of antimicrobials dispensed by the pharmacy (dispensing data) differed considerably from observed antimicrobial use (prescription data). CONCLUSIONS High rates of antimicrobial consumption were documented. Community-acquired infections were the main indication for prescription. Although pharmacy dispensing data did not closely approximate observed use, this represents a promising method for antimicrobial usage tracking in the future.
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Affiliation(s)
- L R Koopmans
- Undergraduate Research Elective Programme, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa; Radboud University, Radboud UMC, The Netherlands
| | - H Finlayson
- Department of Paediatrics and Child Health, Division of Paediatric Infectious Diseases, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - A Whitelaw
- Department of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; National Health Laboratory Services, Tygerberg Hospital, Cape Town, South Africa
| | - E H Decloedt
- Department of Medicine, Division of Clinical Pharmacology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - A Dramowski
- Department of Paediatrics and Child Health, Division of Paediatric Infectious Diseases, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
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Abulfathi AA, Chirehwa M, Rosenkranz B, Decloedt EH. Evaluation of the Effectiveness of Dose Individualization to Achieve Therapeutic Vancomycin Concentrations. J Clin Pharmacol 2018; 58:1134-1139. [DOI: 10.1002/jcph.1254] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 04/08/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Ahmed A. Abulfathi
- Division of Clinical Pharmacology; Department of Medicine; Faculty of Medicine and Health Sciences; University of Stellenbosch; South Africa
| | - Maxwell Chirehwa
- Biostatistics Unit; Centre for Evidence Based Health Care (CEHBC); Faculty of Medicine and Health Sciences; University of Stellenbosch; South Africa
| | - Bernd Rosenkranz
- Division of Clinical Pharmacology; Department of Medicine; Faculty of Medicine and Health Sciences; University of Stellenbosch; South Africa
| | - Eric H. Decloedt
- Division of Clinical Pharmacology; Department of Medicine; Faculty of Medicine and Health Sciences; University of Stellenbosch; South Africa
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Gouse H, Casson-Crook M, Decloedt EH, Joska JA, Thomas KGF. Adding a brief self-report cognitive tool to the IHDS improves effectiveness of identifying patients with HIV-associated dementia in South Africa. J Neurovirol 2017; 23:686-695. [PMID: 28748448 DOI: 10.1007/s13365-017-0551-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 06/02/2017] [Accepted: 06/25/2017] [Indexed: 01/17/2023]
Abstract
We compared the diagnostic accuracy of two brief screening tools (the International HIV Dementia Scale (IHDS), and the IHDS combined with a novel self-report instrument, the HIV Cognitive Symptom Questionnaire (HCSQ)) with that of three brief neuropsychological screening batteries (a 2-, a 3-, and a 4-test battery, each consisting of standardized cognitive tests) in discriminating individuals with HIV-associated dementia (HAD) from those with milder forms of cognitive impairment. We analyzed data from 94 isiXhosa-speaking South African HIV-infected participants who were screened as part of a clinical trial evaluating adjunctive treatment in patients with moderate to severe HIV-associated cognitive impairment. A comprehensive neuropsychological battery diagnosed 53% (50/94) of the participants with HAD. We evaluated the sensitivity and specificity for the screening tools and screening batteries. The brief screening tool performed better compared to the brief neuropsychology battery. The IHDS-HCSQ combination delivered 94% sensitivity and 63% specificity for HAD compared to the IHDS (74 and 70% at a cutoff of ≤8) which offers a viable and quick way to screen for HAD in people living with HIV. It is easy to administer, is time- and cost-efficient, and it appears to be a better option, for these purposes, than brief neuropsychology batteries. It is viable for use in clinical, research, and workplace settings when identification of HIV-infected people with severe cognitive impairment is required.
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Affiliation(s)
- Hetta Gouse
- Department of Psychiatry and Mental Health, HIV Mental Health Research Unit, University of Cape Town, Cape Town, South Africa.
| | - Martine Casson-Crook
- Department of Psychiatry and Mental Health, HIV Mental Health Research Unit, University of Cape Town, Cape Town, South Africa
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa.,Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - John A Joska
- Department of Psychiatry and Mental Health, HIV Mental Health Research Unit, University of Cape Town, Cape Town, South Africa
| | - Kevin G F Thomas
- Department of Psychology, University of Cape Town, Cape Town, South Africa
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Jacobs A, Bassa F, Decloedt EH. A preliminary review of warfarin toxicity in a tertiary hospital in Cape Town, South Africa. Cardiovasc J Afr 2017; 28:346-349. [PMID: 28656193 PMCID: PMC5885058 DOI: 10.5830/cvja-2017-029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 05/16/2017] [Indexed: 11/06/2022] Open
Abstract
AIM Warfarin is a widely used anticoagulant for the prevention and treatment of thromboembolism. We conducted a retrospective review to determine the causes and management of warfarin toxicity of patients admitted to Tygerberg hospital between June 2014 and June 2015. RESULTS We identified and evaluated 126 patients who met the inclusion criteria. The cause of warfarin toxicity was identified and addressed in only 14.3% (18/126) of patients. Where the cause was identified, 56% (10/18) was due to dosing errors and 17% (3/18) drug-drug interaction (DDI). However, 77% (97/126) of patients were retrospectively identified as receiving concomitant medicines known to interact with warfarin at the time of admission. Twenty-eight percent (35/126) of patients presented with major bleeding, which included seven cases of intracranial haemorrhage. Patients were admitted for a median of eight days at an average treatment cost of R10 578. CONCLUSION We found that warfarin toxicity carries significant mortality and cost, but little attention is paid to the causes of toxicity.
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Affiliation(s)
- Annemarie Jacobs
- Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa.
| | - Fatima Bassa
- Division of Haematology, Department of Medicine, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Decloedt EH, Lesosky M, Maartens G, Joska JA. Renal safety of lithium in HIV-infected patients established on tenofovir disoproxil fumarate containing antiretroviral therapy: analysis from a randomized placebo-controlled trial. AIDS Res Ther 2017; 14:6. [PMID: 28160772 PMCID: PMC5292145 DOI: 10.1186/s12981-017-0134-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 01/13/2017] [Indexed: 01/06/2023] Open
Abstract
Background The prevalence of bipolar disorder in HIV-infected patients is higher than the general population. Lithium is the most effective mood stabiliser, while tenofovir disoproxil fumarate (TDF) is frequently used as part of combination antiretroviral therapy (ART). Both TDF and lithium are associated with renal tubular toxicity, which could be additive, or a pharmacokinetic interaction may occur at renal transporters with a decrease in TDF elimination. Objective We report on the change in estimated glomerular filtration rate (eGFR) using the modification of diet in renal disease formula in participants who received ART including TDF and were enrolled in a 24 week randomised trial of lithium versus placebo in patients with HIV-associated neurocognitive impairment. Methods We included HIV-infected adults with cognitive impairment established on ART for at least 6 months with a suppressed viral load attending public sector ART clinics in Cape Town, South Africa. We excluded participants with an eGFR <60 mL/min and treated with medications predisposing to lithium toxicity. We reviewed participants weekly for the first month for adverse events followed by 4 weekly visits for renal function assessment, adverse event monitoring and adherence. Lithium dose was titrated to achieve the maintenance target plasma concentration of between 0.6 and 1.0 mmol/L. Sham lithium concentrations were generated for participants receiving placebo. Results We included 23 participants allocated to the lithium arm and 30 participants allocated to the placebo arm. Baseline characteristics were not statistically different with a mean age of 37.7 and 40.8 years, a median time on ART of 33 and 40 months and an eGFR of 139.3 and 131.0 mL/min in the lithium and placebo arms respectively. There was no statistical significant difference in the reduction in eGFR or increase in potassium between the two arms during the 24 weeks. Conclusions We found that 24-week treatment of HIV-infected patients with lithium and TDF did not result in increased nephrotoxicity. Trial registration The study was registered on the Pan African Clinical Trials Registry (PACTR) with the identifier number PACTR201310000635418. Registered 11 October 2013 before the first participant was enrolled
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Decloedt EH, Freeman C, Howells F, Casson-Crook M, Lesosky M, Koutsilieri E, Lovestone S, Maartens G, Joska JA. Moderate to severe HIV-associated neurocognitive impairment: A randomized placebo-controlled trial of lithium. Medicine (Baltimore) 2016; 95:e5401. [PMID: 27861379 PMCID: PMC5120936 DOI: 10.1097/md.0000000000005401] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND HIV-associated neurocognitive disorder (HAND) remains highly prevalent despite effective anti-retroviral therapy (ART). A number of adjunctive pharmacotherapies for HAND have been studied with disappointing results, but preliminary data suggest that lithium may provide clinical benefit. In addition, the low cost of lithium would facilitate access in low- and middle-income countries which carry the greatest burden of HIV. METHODS Our objective was to evaluate the 24-week efficacy and safety of lithium in patients with moderate to severe HAND. Our primary efficacy endpoint was the change in Global Deficit Score (GDS) from baseline to 24 weeks, whereas our secondary endpoint was the change in proton magnetic resonance spectroscopy (H-MRS) brain metabolite concentrations. We conducted a 24-week randomized placebo-controlled trial of lithium as adjunctive pharmacotherapy. We enrolled participants with moderate to severe HAND, on ART for at least 6 months, with suppressed viral loads and attending public sector primary care clinics in Cape Town, South Africa. We randomized 66 participants to lithium (n = 32) or placebo (n = 34). Lithium or placebo was dosed 12-hourly and titrated to achieve the maintenance target plasma concentration of 0.6 to 1.0 mmol/L. Sham lithium concentrations were generated for participants receiving placebo. RESULTS Totally 61 participants completed the study (lithium arm = 30; placebo arm = 31). Participants at enrolment had a mean age of 40 years and a median CD4+ T-cell count of 500 cells/μL. The median change in GDS between baseline and week 24 for the lithium and placebo arms were -0.57 (95% confidence interval [CI] -0.77, -0.32) and -0.56 (-0.69, -0.34) respectively, with a mean difference of -0.054 (95% CI -0.26, 0.15); P = 0.716. The improvement remained similar when analyzed according to age, severity of impairment, CD4+ count, time on ART, and ART regimen. Standard H-MRS metabolite concentrations were similar between the treatment arms. The study drug was well tolerated in both study arms. Six serious adverse events occurred, but none were considered related to the study drug. CONCLUSION Adjunctive lithium pharmacotherapy in patients on ART with HAND was well tolerated but had no additional benefit on neurocognitive impairment.
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Affiliation(s)
- Eric H. Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Carla Freeman
- Division of Neuropsychiatry, Department of Psychiatry and Mental Health, Faculty of Health Sciences
| | - Fleur Howells
- Division of Neuropsychiatry, Department of Psychiatry and Mental Health, Faculty of Health Sciences
| | - Martine Casson-Crook
- Division of Neuropsychiatry, Department of Psychiatry and Mental Health, Faculty of Health Sciences
| | - Maia Lesosky
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Eleni Koutsilieri
- Institute of Virology and Immunobiology, University of Würzburg, Germany
| | - Simon Lovestone
- Department of Psychiatry, University of Oxford, United Kingdom
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
| | - John A. Joska
- Division of Neuropsychiatry, Department of Psychiatry and Mental Health, Faculty of Health Sciences
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Decloedt EH, van der Walt JS, McIlleron H, Wiesner L, Maartens G. The pharmacokinetics of lopinavir/ritonavir when given with isoniazid in South African HIV-infected individuals. Int J Tuberc Lung Dis 2016; 19:1194-6. [PMID: 26459532 DOI: 10.5588/ijtld.15.0044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Isoniazid preventive therapy is recommended in patients on antiretroviral treatment (ART) with latent tuberculous infection to prevent progression to active tuberculosis disease. Isoniazid (INH) inhibits cytochrome (CY) P3A4, which metabolises lopinavir (LPV). The administration of INH may cause higher LPV concentrations, which may increase LPV toxicity. LPV bioavailability is increased by co-formulated ritonavir (r), which may enhance the interaction of INH on LPV. We studied the effect of INH on LPV concentrations by administering INH for 7 days and performing intensive pharmacokinetic sampling in 16 human immunodeficiency virus infected patients established on LPV/r-based ART. INH did not significantly increase steady-state LPV area under the plasma concentration-time curve calculated for the 12 h-dosing interval.
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Affiliation(s)
- E H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - J S van der Walt
- Division of Clinical Pharmacology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - H McIlleron
- Division of Clinical Pharmacology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - L Wiesner
- Division of Clinical Pharmacology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - G Maartens
- Division of Clinical Pharmacology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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van Zyl GU, Decloedt EH. Is HIV-1C a risk factor for protease inhibitor failure? Lancet HIV 2016; 3:e149-51. [PMID: 27036986 DOI: 10.1016/s2352-3018(16)00040-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 03/02/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Gert U van Zyl
- Division of Medical Virology, Department Pathology, Stellenbosch University, Faculty of Medicine and Health Sciences, Parow, Cape Town 8000, South Africa; National Health Laboratory Services, Tygerberg, Cape Town, South Africa.
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department Medicine, Stellenbosch University, Faculty of Medicine and Health Sciences, Parow, Cape Town, South Africa
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
INTRODUCTION Efavirenz commonly causes early neuropsychiatric side effects, but tolerance develops in most patients. There is emerging evidence that efavirenz use may damage neurons, which could result in impaired neurocognitive performance. AREAS COVERED The authors conducted a systematic review using the PubMed database, references cited by other articles and conference web sites to determine if there is evidence that efavirenz may contribute to cognitive impairment by damaging nerve cells. EXPERT OPINION There is weak clinical evidence suggesting that efavirenz use may worsen neurocognitive impairment or be associated with less improvement in neurocognitive impairment than other antiretrovirals. Efavirenz, especially its major metabolite 8-hydroxy-efavirenz, is toxic in neuron cultures at concentrations found in the cerebrospinal fluid. Extensive metabolizers of efavirenz may therefore be more likely to develop efavirenz toxicity by forming more 8-hydroxy-efavirenz. Several potential mechanisms exist to explain the observed efavirenz neurotoxicity, including altered calcium hemostasis, decreases in brain creatine kinase, mitochondrial damage, increases in brain proinflammatory cytokines and involvement of the cannabinoid system. There is a need for large randomized controlled trials to determine if the neuronal toxicity induced by efavirenz results in clinically significant neurological impairment.
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Affiliation(s)
- Eric H Decloedt
- Stellenbosch University, Faculty of Medicine and Health Sciences, Division of Clinical Pharmacology, Department of Medicine , PO Box 19063; Francie van Zijl Drive, Tygerberg 7505 , South Africa
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Decloedt EH, Mwansa-Kambafwile J, van der Walt JS, McIlleron H, Denti P, Smith P, Wiesner L, Rangaka M, Wilkinson RJ, Maartens G. The pharmacokinetics of nevirapine when given with isoniazid in South African HIV-infected individuals. Int J Tuberc Lung Dis 2013; 17:333-5. [PMID: 23407222 DOI: 10.5588/ijtld.12.0427] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Isoniazid preventive therapy (IPT) is recommended in patients on antiretroviral treatment. Isoniazid (INH) inhibits CYP3A4, which metabolises nevirapine (NVP). Administration of INH may cause higher NVP concentrations and toxicity. We studied the effect of INH on NVP concentrations in 21 patients randomised to either placebo (n = 13) or INH (n = 8) in an ongoing trial of IPT in patients on ART. INH was associated with a 24% increase in median NVP area under the plasma concentration-time curve for the 12 h dosing interval, which was not statistically significant (P = 0.66).
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Affiliation(s)
- E H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Groote Schuur Hospital University of Cape Town, Cape Town, South Africa
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Decloedt EH, Maartens G, Smith P, Merry C, Bango F, McIlleron H. The safety, effectiveness and concentrations of adjusted lopinavir/ritonavir in HIV-infected adults on rifampicin-based antitubercular therapy. PLoS One 2012; 7:e32173. [PMID: 22412856 PMCID: PMC3296695 DOI: 10.1371/journal.pone.0032173] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Accepted: 01/22/2012] [Indexed: 11/29/2022] Open
Abstract
Objective Rifampicin co-administration dramatically reduces plasma lopinavir concentrations. Studies in healthy volunteers and HIV-infected patients showed that doubling the dose of lopinavir/ritonavir (LPV/r) or adding additional ritonavir offsets this interaction. However, high rates of hepatotoxicity were observed in healthy volunteers. We evaluated the safety, effectiveness and pre-dose concentrations of adjusted doses of LPV/r in HIV infected adults treated with rifampicin-based tuberculosis treatment. Methods Adult patients on a LPV/r-based antiretroviral regimen and rifampicin-based tuberculosis therapy were enrolled. Doubled doses of LPV/r or an additional 300 mg of ritonavir were used to overcome the inducing effect of rifampicin. Steady-state lopinavir pre-dose concentrations were evaluated every second month. Results 18 patients were enrolled with a total of 79 patient months of observation. 11/18 patients were followed up until tuberculosis treatment completion. During tuberculosis treatment, the median (IQR) pre-dose lopinavir concentration was 6.8 (1.1–9.2) mg/L and 36/47 (77%) were above the recommended trough concentration of 1 mg/L. Treatment was generally well tolerated with no grade 3 or 4 toxicity: 8 patients developed grade 1 or 2 transaminase elevation, 1 patient defaulted additional ritonavir due to nausea and 1 patient developed diarrhea requiring dose reduction. Viral loads after tuberculosis treatment were available for 11 patients and 10 were undetectable. Conclusion Once established on treatment, adjusted doses of LPV/r co-administered with rifampicin-based tuberculosis treatment were tolerated and LPV pre-dose concentrations were adequate.
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Affiliation(s)
- Eric H. Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Peter Smith
- Division of Clinical Pharmacology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Concepta Merry
- Department of Pharmacology, St James's Hospital, Trinity College Dublin, Dublin, Ireland
| | - Funeka Bango
- Ubuntu Clinic, Site B Khayelitsha Day Hospital, Khayelitsha, Western Cape Department of Health, Cape Town, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
- * E-mail:
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Abstract
This article aims to highlight current trends in the pharmacologic management of obsessive-compulsive disorder (OCD). A systematic search of the electronic database MEDLINE was conducted. The first case report of clomipramine efficacy in the management OCD more than 40 years ago gave new hope for the treatment of this debilitating disorder. Selective serotonin reuptake inhibitors (SSRIs) proved to have a similar efficacy profile compared with clomipramine but had a superior tolerability profile. While many patients with OCD respond to SSRIs or clomipramine, the treatment of those with refractory OCD remains challenging. Different augmentation agents in treatment-resistant OCD have been explored, with antipsychotic agents having the largest supporting evidence base. Nevertheless, new pharmacologic treatment options are required and are under investigation.
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Affiliation(s)
- Eric H Decloedt
- Department of Internal Medicine, Division of Clinical Pharmacology.
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