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Jager NGL, Van Ewijk-Beneken Kolmer E, Aarnoutse R, Te Brake LHM. Influence of ultrafiltration conditions on the measurement of unbound drug concentrations: flucloxacillin as an example. J Antimicrob Chemother 2024; 79:1187-1190. [PMID: 38569058 PMCID: PMC11062936 DOI: 10.1093/jac/dkae092] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 03/09/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND When performing therapeutic drug monitoring (TDM) for flucloxacillin, it is advised to measure the unbound, not the total, flucloxacillin concentration. To be able to accurately quantify unbound flucloxacillin concentrations, a reliable analytical method is indispensable. OBJECTIVE To determine the influence of temperature and pH of the sample during ultrafiltration on the measured unbound fraction of flucloxacillin. MATERIALS AND METHODS We performed three different experiments. In a single laboratory experiment, we investigated the influence of ultrafiltration temperature (10°C, room temperature and 37°C) on the measured unbound fraction of flucloxacillin for three concentration levels. In a multiple laboratory experiment, the results of eight laboratories participating in an international quality control programme measuring unbound flucloxacillin concentrations were analysed. In the third experiment, patient samples were ultrafiltrated using four different conditions: (i) physiological pH and room temperature; (ii) unadjusted pH (pH 9 after freezing) and room temperature; (iii) physiological pH and 37°C and (iv) unadjusted pH and 37°C. RESULTS For all experiments, measurement of samples that were ultrafiltrated at room temperature resulted in a substantially lower unbound fraction compared to samples that were ultrafiltrated at 37°C. Adjusting the pH to physiological pH only had a minimal impact on the measured unbound fraction. CONCLUSIONS On the basis of these findings and considering the need for fast, simple and reproducible sample pretreatment for TDM purposes, we conclude that ultrafiltration of flucloxacillin should be performed at physiological temperature (37°C), but adjustment of pH does not seem to be necessary.
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Affiliation(s)
- Nynke G L Jager
- Department of Pharmacy, Radboud Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Rob Aarnoutse
- Department of Pharmacy, Radboud Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lindsey H M Te Brake
- Department of Pharmacy, Radboud Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
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2
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Stemkens R, Mouhdad C, Franssen EJF, Touw D, Alffenaar JW, Te Brake LHM, Sturkenboom MGG, Aarnoutse RE. Ten-year results of an international external quality control programme for measurement of anti-tuberculosis drug concentrations. J Antimicrob Chemother 2024:dkae105. [PMID: 38581098 DOI: 10.1093/jac/dkae105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/19/2024] [Indexed: 04/08/2024] Open
Abstract
OBJECTIVES Participation in an external (interlaboratory) quality control (QC) programme is an essential part of quality assurance as it provides laboratories with valuable insights into their analytical performance. We describe the 10 year results of an international QC programme for the measurement of anti-tuberculosis (TB) drugs. METHODS Each year, two rounds were organized in which serum (or plasma) samples, spiked with known concentrations of anti-TB drugs, were provided to participating laboratories for analysis. Reported measurements within 80%-120% of weighed-in concentrations were considered accurate. Mixed model linear regression was performed to assess the effect of the measured drug, concentration level, analytical technique and performing laboratory on the absolute inaccuracy. RESULTS By 2022, 31 laboratories had participated in the QC programme and 13 anti-TB drugs and metabolites were included. In total 1407 measurements were reported. First-line TB drugs (isoniazid, rifampicin, pyrazinamide and ethambutol) represented 58% of all measurements. Overall, 83.2% of 1407 measurements were accurate, and the median absolute inaccuracy was 7.3% (IQR, 3.3%-15.1%). The absolute inaccuracy was related to the measured anti-TB drug and to the performing laboratory, but not to the concentration level or to the analytical technique used. The median absolute inaccuracies of rifampicin and isoniazid were relatively high (10.2% and 10.9%, respectively). CONCLUSIONS The 10 year results of this external QC programme illustrate the need for continuous external QC for the measurement of anti-TB drugs for research and patient care purposes, because one in six measurements was inaccurate. Participation in the programme alerts laboratories to previously undetected analytical problems.
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Affiliation(s)
- Ralf Stemkens
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chaima Mouhdad
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eric J F Franssen
- Department of Clinical Pharmacy, OLVG Hospital, 1066 CX Amsterdam, The Netherlands
- Drug Analysis and Toxicology section (KKGT), Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Nijmegen, The Netherlands
| | - Daniel Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan-Willem Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia
- The University of Sydney Institute for Infectious Diseases, Sydney, NSW, Australia
- Department of Pharmacy, Westmead Hospital, Sydney, NSW, Australia
| | - Lindsey H M Te Brake
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marieke G G Sturkenboom
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
- Drug Analysis and Toxicology section (KKGT), Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Nijmegen, The Netherlands
| | - Rob E Aarnoutse
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
- Drug Analysis and Toxicology section (KKGT), Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Nijmegen, The Netherlands
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Schildkraut JA, Coolen JPM, Ruesen C, van den Heuvel JJMW, Aceña LE, Wertheim HFL, Jansen RS, Koenderink JB, Te Brake LHM, van Ingen J. The potential role of drug transporters and amikacin modifying enzymes in M. avium. J Glob Antimicrob Resist 2023; 34:161-165. [PMID: 37453496 DOI: 10.1016/j.jgar.2023.07.007] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/27/2023] [Accepted: 07/11/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVES Mycobacterium avium (M. avium) complex bacteria cause opportunistic infections in humans. Treatment yields cure rates of 60% and consists of a macrolide, a rifamycin, and ethambutol, and in severe cases, amikacin. Mechanisms of antibiotic tolerance remain mostly unknown. Therefore, we studied the contribution of efflux and amikacin modification to antibiotic susceptibility. METHODS We characterised M. avium ABC transporters and studied their expression together with other transporters following exposure to clarithromycin, amikacin, ethambutol, and rifampicin. We determined the effect of combining the efflux pump inhibitors berberine, verapamil and CCCP (carbonyl cyanide m-chlorophenyl hydrazone), to study the role of efflux on susceptibility. Finally, we studied the modification of amikacin by M. avium using metabolomic analysis. RESULTS Clustering shows conservation between M. avium and M. tuberculosis and transporters from most bacterial subfamilies (2-6, 7a/b, 10-12) were found. The largest number of transporter encoding genes was up-regulated after clarithromycin exposure, and the least following amikacin exposure. Only berberine increased the susceptibility to clarithromycin. Finally, because of the limited effect of amikacin on transporter expression, we studied amikacin modification and showed that M. avium, in contrast to M. abscessus, is not able to modify amikacin. CONCLUSION We show that M. avium carries ABC transporters from all major families important for antibiotic efflux, including homologues shown to have affinity for drugs included in treatment. Efflux inhibition in M. avium can increase susceptibility, but this effect is efflux pump inhibitor- and antibiotic-specific. Finally, the lack of amikacin modifying activity in M. avium is important for its activity.
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Affiliation(s)
- Jodie A Schildkraut
- Radboudumc Centre for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - Jordy P M Coolen
- Radboudumc Centre for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Carolien Ruesen
- Centre for Epidemiology and Surveillance of Infectious Diseases, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | | | - Laura Edo Aceña
- Radboudumc Centre for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Heiman F L Wertheim
- Radboudumc Centre for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Robert S Jansen
- Department of Microbiology, RIBES, Radboud University, Nijmegen, the Netherlands
| | - Jan B Koenderink
- Department of Pharmacology and toxicology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Lindsey H M Te Brake
- Radboudumc Centre for Infectious Diseases, Department of Pharmacy, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Jakko van Ingen
- Radboudumc Centre for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, the Netherlands
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Bukkems VE, Necsoi C, Tenorio CH, Garcia C, Alejandre IA, Weiss F, Lambert JS, van Hulzen A, Richel O, Te Brake LHM, van der Meulen E, Burger D, Konopnicki D, Colbers A. Tenofovir alafenamide plasma concentrations are reduced in pregnant women living with HIV: data from the PANNA Network. Clin Infect Dis 2021; 75:623-629. [PMID: 34864950 PMCID: PMC9464066 DOI: 10.1093/cid/ciab1010] [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: 10/19/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Tenofovir alafenamide (TAF), a prodrug of tenofovir (TFV), is included in the majority of the recommended first-line antiretroviral regimens for patients living with HIV, but there are limited data on TAF use in pregnant women. We aimed to examine the plasma pharmacokinetics of TAF and TFV in pregnant women from Europe. METHODS Pregnant women living with HIV were included from treatment centers across Europe, and intensive pharmacokinetic sampling in the third trimester and postpartum was performed. Pharmacokinetic parameters of TAF and TFV were determined with noncompartmental analysis. The proportion of women with a TAF AUCtau below the target of 53.1 ng*h/mL was determined. Clinical efficacy and safety outcome parameters were reported. RESULTS In total, 20 pregnant women living with HIV were included. At the third trimester, geometric mean TAF AUClast and Cmax were decreased by 46% and 52%, respectively, compared with postpartum. TFV AUC0-24h, Cmax, and Ctrough decreased by 33%, 30% and 34%, respectively. The proportion of women with a TAF AUClast <53.1 ng*h/mL was 6% at third trimester and 0% postpartum. One out of 20 women had a viral load >50 copies/mL at third trimester and no mother-to-child transmission occurred. CONCLUSIONS TAF plasma concentrations were reduced by about half in women living with HIV during third trimester of pregnancy, but remained above the predefined efficacy target in the majority of the pregnant women. TFV concentrations were reduced by approximately 30% during third trimester. Despite the observed exposure decrease, high virologic efficacy was observed in this study.
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Affiliation(s)
- Vera E Bukkems
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud university medical center, Nijmegen, the Netherlands
| | - Coca Necsoi
- Saint-Pierre University Hospital, Brussels, Belgium
| | | | - Coral Garcia
- Hospital Universtario Virgen de las Nieves, Granada, Spain
| | - Irene Alba Alejandre
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Germany
| | - Fabian Weiss
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Germany
| | - John S Lambert
- Mater Misericordiae University Hospital, Dublin, Ireland.,Rotunda hospitals, Dublin, Ireland.,UCD school of medicine and medical science, Dublin, Ireland
| | - Astrid van Hulzen
- Department of internal medicine, Isala Hospital, Zwolle, the Netherlands
| | - Olivier Richel
- Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
| | - Lindsey H M Te Brake
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud university medical center, Nijmegen, the Netherlands
| | - Eric van der Meulen
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud university medical center, Nijmegen, the Netherlands
| | - David Burger
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud university medical center, Nijmegen, the Netherlands
| | | | - Angela Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud university medical center, Nijmegen, the Netherlands
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5
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Litjens CHC, Verscheijden LFM, Bolwerk C, Greupink R, Koenderink JB, van den Broek PHH, van den Heuvel JJMW, Svensson EM, Boeree MJ, Magis-Escurra C, Hoefsloot W, van Crevel R, van Laarhoven A, van Ingen J, Kuipers S, Ruslami R, Burger DM, Russel FGM, Aarnoutse RE, Te Brake LHM. Prediction of Moxifloxacin Concentrations in Tuberculosis Patient Populations by Physiologically Based Pharmacokinetic Modeling. J Clin Pharmacol 2021; 62:385-396. [PMID: 34554580 PMCID: PMC9297990 DOI: 10.1002/jcph.1972] [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: 02/27/2021] [Accepted: 09/18/2021] [Indexed: 02/03/2023]
Abstract
Moxifloxacin has an important role in the treatment of tuberculosis (TB). Unfortunately, coadministration with the cornerstone TB drug rifampicin results in suboptimal plasma exposure. We aimed to gain insight into the moxifloxacin pharmacokinetics and the interaction with rifampicin. Moreover, we provided a mechanistic framework to understand moxifloxacin pharmacokinetics. We developed a physiologically based pharmacokinetic model in Simcyp version 19, with available and newly generated in vitro and in vivo data, to estimate pharmacokinetic parameters of moxifloxacin alone and when administered with rifampicin. By combining these strategies, we illustrate that the role of P-glycoprotein in moxifloxacin transport is limited and implicate MRP2 as transporter of moxifloxacin-glucuronide followed by rapid hydrolysis in the gut. Simulations of multiple dose area under the plasma concentration-time curve (AUC) of moxifloxacin (400 mg once daily) with and without rifampicin (600 mg once daily) were in accordance with clinically observed data (predicted/observed [P/O] ratio of 0.87 and 0.80, respectively). Importantly, increasing the moxifloxacin dose to 600 mg restored the plasma exposure both in actual patients with TB as well as in our simulations. Furthermore, we extrapolated the single dose model to pediatric populations (P/O AUC ratios, 1.04-1.52) and the multiple dose model to children with TB (P/O AUC ratio, 1.51). In conclusion, our combined approach resulted in new insights into moxifloxacin pharmacokinetics and accurate simulations of moxifloxacin exposure with and without rifampicin. Finally, various knowledge gaps were identified, which may be considered as avenues for further physiologically based pharmacokinetic refinement.
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Affiliation(s)
- Carlijn H C Litjens
- Department of Pharmacy, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Laurens F M Verscheijden
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Celine Bolwerk
- Department of Pharmacy, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rick Greupink
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan B Koenderink
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Petra H H van den Broek
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen J M W van den Heuvel
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Elin M Svensson
- Department of Pharmacy, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Martin J Boeree
- Department of Pulmonary Diseases, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cecile Magis-Escurra
- Department of Pulmonary Diseases, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wouter Hoefsloot
- Department of Pulmonary Diseases, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Reinout van Crevel
- Department of Internal Medicine, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arjan van Laarhoven
- Department of Internal Medicine, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jakko van Ingen
- Department of Medical Microbiology, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Saskia Kuipers
- Department of Medical Microbiology, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rovina Ruslami
- TB/HIV Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia.,Department of Biomedical Sciences, Division of Pharmacology and Therapy, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frans G M Russel
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lindsey H M Te Brake
- Department of Pharmacy, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
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6
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Te Brake LHM, de Jager V, Narunsky K, Vanker N, Svensson EM, Phillips PPJ, Gillespie SH, Heinrich N, Hoelscher M, Dawson R, Diacon AH, Aarnoutse RE, Boeree MJ. Increased bactericidal activity but dose-limiting intolerability at 50 mg·kg -1 rifampicin. Eur Respir J 2021; 58:13993003.00955-2020. [PMID: 33542056 PMCID: PMC8411896 DOI: 10.1183/13993003.00955-2020] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [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: 04/10/2020] [Accepted: 12/07/2020] [Indexed: 01/16/2023]
Abstract
Background Accumulating data indicate that higher rifampicin doses are more effective and shorten tuberculosis (TB) treatment duration. This study evaluated the safety, tolerability, pharmacokinetics, and 7- and 14-day early bactericidal activity (EBA) of increasing doses of rifampicin. Here we report the results of the final cohorts of PanACEA HIGHRIF1, a dose escalation study in treatment-naive adult smear-positive patients with TB. Methods Patients received, in consecutive cohorts, 40 or 50 mg·kg−1 rifampicin once daily in monotherapy (day 1–7), supplemented with standard dose isoniazid, pyrazinamide and ethambutol between days 8 and 14. Results In the 40 mg·kg−1 cohort (n=15), 13 patients experienced a total of 36 adverse events during monotherapy, resulting in one treatment discontinuation. In the 50 mg·kg−1 cohort (n=17), all patients experienced adverse events during monotherapy, 93 in total; 11 patients withdrew or stopped study medication. Adverse events were mostly mild/moderate and tolerability rather than safety related, i.e. gastrointestinal disorders, pruritis, hyperbilirubinaemia and jaundice. There was a more than proportional increase in the rifampicin geometric mean area under the plasma concentration–time curve from time 0 to 12 h (AUC0–24 h) for 50 mg·kg−1 compared with 40 mg·kg−1; 571 (range 320–995) versus 387 (range 201–847) mg·L−1·h, while peak exposures saw proportional increases. Protein-unbound exposure after 50 mg·kg−1 (11% (range 8–17%)) was comparable with lower rifampicin doses. Rifampicin exposures and bilirubin concentrations were correlated (Spearman's ρ=0.670 on day 3, p<0.001). EBA increased considerably with dose, with the highest seen after 50 mg·kg−1: 14-day EBA −0.427 (95% CI −0.500– −0.355) log10CFU·mL−1·day−1. Conclusion Although associated with an increased bactericidal effect, the 50 mg·kg−1 dose was not well tolerated. Rifampicin at 40 mg·kg−1 was well tolerated and therefore selected for evaluation in a phase IIc treatment-shortening trial. While bactericidal activity continues to increase with dose, for the first time we identified dose-limiting intolerability for rifampicin dosed at 50 mg·kg−1; 40 mg·kg−1 seems the optimal tolerable dose for evaluation in TB treatment-shortening trialshttps://bit.ly/37dUIuB
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Affiliation(s)
- Lindsey H M Te Brake
- Dept of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Kim Narunsky
- UCT Lung Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Elin M Svensson
- Dept of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Dept of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Patrick P J Phillips
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Stephen H Gillespie
- School of Medicine, Medical and Biological Sciences, University of St Andrews, St Andrews, UK
| | - Norbert Heinrich
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany.,German Center for Infection Research (DZIF), Munich, Germany
| | - Michael Hoelscher
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany.,German Center for Infection Research (DZIF), Munich, Germany
| | - Rodney Dawson
- UCT Lung Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Rob E Aarnoutse
- Dept of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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7
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Marais S, Cresswell FV, Hamers RL, Te Brake LHM, Ganiem AR, Imran D, Bangdiwala A, Martyn E, Kasibante J, Kagimu E, Musubire A, Maharani K, Estiasari R, Kusumaningrum A, Kusumadjayanti N, Yunivita V, Naidoo K, Lessells R, Moosa Y, Svensson EM, Huppler Hullsiek K, Aarnoutse RE, Boulware DR, van Crevel R, Ruslami R, Meya DB. High dose oral rifampicin to improve survival from adult tuberculous meningitis: A randomised placebo-controlled double-blinded phase III trial (the HARVEST study). Wellcome Open Res 2020; 4:190. [PMID: 33083560 PMCID: PMC7542255 DOI: 10.12688/wellcomeopenres.15565.2] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2020] [Indexed: 12/18/2022] Open
Abstract
Background: Tuberculous meningitis (TBM), the most severe form of tuberculosis (TB), results in death or neurological disability in >50%, despite World Health Organisation recommended therapy. Current TBM regimen dosages are based on data from pulmonary TB alone. Evidence from recent phase II pharmacokinetic studies suggests that high dose rifampicin (R) administered intravenously or orally enhances central nervous system penetration and may reduce TBM associated mortality. We hypothesize that, among persons with TBM, high dose oral rifampicin (35 mg/kg) for 8 weeks will improve survival compared to standard of care (10 mg/kg), without excess adverse events. Protocol: We will perform a parallel group, randomised, placebo-controlled, double blind, phase III multicentre clinical trial comparing high dose oral rifampicin to standard of care. The trial will be conducted across five clinical sites in Uganda, South Africa and Indonesia. Participants are HIV-positive or negative adults with clinically suspected TBM, who will be randomised (1:1) to one of two arms: 35 mg/kg oral rifampicin daily for 8 weeks (in combination with standard dose isoniazid [H], pyrazinamide [Z] and ethambutol [E]) or standard of care (oral HRZE, containing 10 mg/kg/day rifampicin). The primary end-point is 6-month survival. Secondary end points are: i) 12-month survival ii) functional and neurocognitive outcomes and iii) safety and tolerability. Tertiary outcomes are: i) pharmacokinetic outcomes and ii) cost-effectiveness of the intervention. We will enrol 500 participants over 2.5 years, with follow-up continuing until 12 months post-enrolment. Discussion: Our best TBM treatment still results in unacceptably high mortality and morbidity. Strong evidence supports the increased cerebrospinal fluid penetration of high dose rifampicin, however conclusive evidence regarding survival benefit is lacking. This study will answer the important question of whether high dose oral rifampicin conveys a survival benefit in TBM in HIV-positive and -negative individuals from Africa and Asia. Trial registration: ISRCTN15668391 (17/06/2019)
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Affiliation(s)
- Suzaan Marais
- Department of Neurology, Inkosi Albert Luthuli Central Hospital, Durban, 4091, South Africa
| | - Fiona V Cresswell
- Infectious Diseases Institute, Mulago College of Health Sciences, Kampala, PO Box 22418, Uganda.,Clinical Research Department, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.,MRC-UVRI, London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Raph L Hamers
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Lindsey H M Te Brake
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ahmad R Ganiem
- Department of Neurology, Faculty of Medicine, Universitas Padjadjaran/ Hasan Sadikin Hospital, Bandung, 40161, Indonesia.,Infectious Disease Research Centre, Faculty of Medicine, Universitas Padjadaran, Bandung, 40161, Indonesia
| | - Darma Imran
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Dr Cipto Mangukusumo Hospital, Jakarta, 10430, Indonesia
| | - Ananta Bangdiwala
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Emily Martyn
- Infectious Diseases Institute, Mulago College of Health Sciences, Kampala, PO Box 22418, Uganda
| | - John Kasibante
- Infectious Diseases Institute, Mulago College of Health Sciences, Kampala, PO Box 22418, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, Mulago College of Health Sciences, Kampala, PO Box 22418, Uganda
| | - Abdu Musubire
- Infectious Diseases Institute, Mulago College of Health Sciences, Kampala, PO Box 22418, Uganda
| | - Kartika Maharani
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Dr Cipto Mangukusumo Hospital, Jakarta, 10430, Indonesia
| | - Riwanti Estiasari
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Dr Cipto Mangukusumo Hospital, Jakarta, 10430, Indonesia
| | - Ardiana Kusumaningrum
- Department of Microbiology, Faculty of Medicine, Universitas Indonesia, Dr Cipto Mangukusumo Hospital, Jakarta, 10430, Indonesia
| | - Nadytia Kusumadjayanti
- Infectious Disease Research Centre, Faculty of Medicine, Universitas Padjadaran, Bandung, 40161, Indonesia
| | - Vycke Yunivita
- Department of Neurology, Faculty of Medicine, Universitas Padjadjaran/ Hasan Sadikin Hospital, Bandung, 40161, Indonesia.,Infectious Disease Research Centre, Faculty of Medicine, Universitas Padjadaran, Bandung, 40161, Indonesia
| | - Kogieleum Naidoo
- Centre for the AIDS programme of research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Durban, 4041, South Africa.,CAPRISA-MRC HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu Natal, Durban, South Africa
| | - Richard Lessells
- Centre for the AIDS programme of research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Durban, 4041, South Africa.,KwaZulu-Natal Research Innovation and Sequencing Platform, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, 4001, South Africa
| | - Yunus Moosa
- Department of Infectious Diseases, Division of Internal Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, 4013, South Africa
| | - Elin M Svensson
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands.,Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Katherine Huppler Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - David R Boulware
- Division of Medicine, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Reinout van Crevel
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Department of Internal Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Rovina Ruslami
- Infectious Disease Research Centre, Faculty of Medicine, Universitas Padjadaran, Bandung, 40161, Indonesia.,Department of Biomedical Sciences, Division of Pharmacology and Therapy, Faculty of Medicine, Universitas Padjadjaran, Bandung, 40161, Indonesia
| | - David B Meya
- Infectious Diseases Institute, Mulago College of Health Sciences, Kampala, PO Box 22418, Uganda
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8
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Litjens CHC, Aarnoutse RE, van Ewijk-Beneken Kolmer EWJ, Svensson EM, Colbers A, Burger DM, Boeree MJ, Te Brake LHM. Protein binding of rifampicin is not saturated when using high-dose rifampicin. J Antimicrob Chemother 2020; 74:986-990. [PMID: 30597025 DOI: 10.1093/jac/dky527] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/30/2018] [Accepted: 11/21/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Higher doses of rifampicin are being investigated as a means to optimize response to this pivotal TB drug. It is unknown whether high-dose rifampicin results in saturation of plasma protein binding and a relative increase in protein-unbound (active) drug concentrations. OBJECTIVES To assess the free fraction of rifampicin based on an in vitro experiment and data from a clinical trial on high-dose rifampicin. METHODS Protein-unbound rifampicin concentrations were measured in human serum spiked with increasing total concentrations (up to 64 mg/L) of rifampicin and in samples obtained by intensive pharmacokinetic sampling of patients who used standard (10 mg/kg daily) or high-dose (35 mg/kg) rifampicin up to steady-state. The performance of total AUC0-24 to predict unbound AUC0-24 was evaluated. RESULTS The in vitro free fraction of rifampicin remained unaltered (∼9%) up to 21 mg/L and increased up to 13% at 41 mg/L and 17% at 64 mg/L rifampicin. The highest (peak) concentration in vivo was 39.1 mg/L (high-dose group). The arithmetic mean percentage unbound to total AUC0-24in vivo was 13.3% (range = 8.1%-24.9%) and 11.1% (range = 8.6%-13.6%) for the standard group and the high-dose group, respectively (P = 0.214). Prediction of unbound AUC0-24 based on total AUC0-24 resulted in a bias of -0.05% and an imprecision of 13.2%. CONCLUSIONS Plasma protein binding of rifampicin can become saturated, but exposures after high-dose rifampicin are not high enough to increase the free fraction in TB patients with normal albumin values. Unbound rifampicin exposures can be predicted from total exposures, even in the higher dose range.
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Affiliation(s)
- Carlijn H C Litjens
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands.,Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | | | - 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
| | - Angela Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Martin J Boeree
- Department of Pulmonary Diseases, Radboud university medical center, Nijmegen, The Netherlands
| | - Lindsey H M Te Brake
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
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9
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Te Brake LHM, Boeree MJ, Aarnoutse RE. Conflicting Findings on an Intermediate Dose of Rifampicin for Pulmonary Tuberculosis. Am J Respir Crit Care Med 2020; 199:1166-1167. [PMID: 30645149 PMCID: PMC6515878 DOI: 10.1164/rccm.201811-2101le] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
| | - Martin J Boeree
- 1 Radboud university medical center Nijmegen, the Netherlands
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10
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Svensson EM, Svensson RJ, Te Brake LHM, Boeree MJ, Heinrich N, Konsten S, Churchyard G, Dawson R, Diacon AH, Kibiki GS, Minja LT, Ntingiya NE, Sanne I, Gillespie SH, Hoelscher M, Phillips PPJ, Simonsson USH, Aarnoutse R. The Potential for Treatment Shortening With Higher Rifampicin Doses: Relating Drug Exposure to Treatment Response in Patients With Pulmonary Tuberculosis. Clin Infect Dis 2019; 67:34-41. [PMID: 29917079 PMCID: PMC6005123 DOI: 10.1093/cid/ciy026] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [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: 10/06/2017] [Accepted: 01/10/2018] [Indexed: 12/27/2022] Open
Abstract
Background Tuberculosis remains a huge public health problem and the prolonged treatment duration obstructs effective tuberculosis control. Higher rifampicin doses have been associated with better bactericidal activity, but optimal dosing is uncertain. This analysis aimed to characterize the relationship between rifampicin plasma exposure and treatment response over 6 months in a recent study investigating the potential for treatment shortening with high-dose rifampicin. Methods Data were analyzed from 336 patients with pulmonary tuberculosis (97 with pharmacokinetic data) treated with rifampicin doses of 10, 20, or 35 mg/kg. The response measure was time to stable sputum culture conversion (TSCC). We derived individual exposure metrics with a previously developed population pharmacokinetic model of rifampicin. TSCC was modeled using a parametric time-to-event approach, and a sequential exposure-response analysis was performed. Results Higher rifampicin exposures increased the probability of early culture conversion. No maximal limit of the effect was detected within the observed range. The expected proportion of patients with stable culture conversion on liquid medium at week 8 was predicted to increase from 39% (95% confidence interval, 37%-41%) to 55% (49%-61%), with the rifampicin area under the curve increasing from 20 to 175 mg/L·h (representative for 10 and 35 mg/kg, respectively). Other predictors of TSCC were baseline bacterial load, proportion of culture results unavailable, and substitution of ethambutol for either moxifloxacin or SQ109. Conclusions Increasing rifampicin exposure shortened TSCC, and the effect did not plateau, indicating that doses >35 mg/kg could be yet more effective. Optimizing rifampicin dosage while preventing toxicity is a clinical priority.
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Affiliation(s)
- Elin M Svensson
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pharmaceutical Biosciences, Uppsala University, Sweden
| | - Robin J Svensson
- Department of Pharmaceutical Biosciences, Uppsala University, Sweden
| | - Lindsey H M Te Brake
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Martin J Boeree
- Department of Lung Diseases, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Norbert Heinrich
- Medical Centre of the University of Munich (LMU), Munich Partner Site, Germany.,German Center for Infection Research (DZIF), Munich Partner Site, Germany
| | - Sarah Konsten
- Medical Centre of the University of Munich (LMU), Munich Partner Site, Germany.,German Center for Infection Research (DZIF), Munich Partner Site, Germany
| | - Gavin Churchyard
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of Witwatersr, Johannesburg, South Africa.,Advancing Treatment and Care for TB and HIV, South African Medical Research Council, Johannesburg, South Africa
| | - Rodney Dawson
- University of Cape Town Lung Institute, Cape Town, South Africa
| | | | | | | | | | - Ian Sanne
- University of the Witswatersrand, Johannesburg, South Africa
| | | | - Michael Hoelscher
- Medical Centre of the University of Munich (LMU), Munich Partner Site, Germany.,German Center for Infection Research (DZIF), Munich Partner Site, Germany
| | - Patrick P J Phillips
- MRC Clinical Trials Unit, University College of London, United Kingdom.,Division of Pulmonary and Critical Care Medicine, University of California San Francisco, US
| | | | - Rob Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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11
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Te Brake LHM, Yunivita V, Livia R, Soetedjo N, van Ewijk-Beneken Kolmer E, Koenderink JB, Burger DM, Santoso P, van Crevel R, Alisjahbana B, Aarnoutse RE, Ruslami R. Rifampicin Alters Metformin Plasma Exposure but Not Blood Glucose Levels in Diabetic Tuberculosis Patients. Clin Pharmacol Ther 2018; 105:730-737. [PMID: 30222857 PMCID: PMC6587702 DOI: 10.1002/cpt.1232] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 02/19/2018] [Accepted: 08/26/2018] [Indexed: 12/14/2022]
Abstract
The pharmacokinetic (PK) and clinical implications of combining metformin with rifampicin are relevant to increasing numbers of patients with diabetic tuberculosis (TB) across the world and are yet unclear. We assessed the impact of rifampicin on metformin PKs and its glucose‐lowering effect in patients with diabetic TB by measuring plasma metformin and blood glucose during and after TB treatment. Rifampicin increased metformin exposure: plasma area under the plasma concentration‐time curve from time point 0 to the end of the dosing interval (AUC0–τ) and peak plasma concentration (Cmax) geometric mean ratio (GMR; during vs. after TB treatment) were 1.28 (90% confidence interval (CI) 1.13–1.44) and 1.19 (90% CI 1.02–1.38; n = 22). The metformin glucose‐lowering efficacy did not change (Δglucose − Cmax; P = 0.890; n = 18). Thus, we conclude that additional glucose monitoring in this population is not warranted. Finally, 57% of patients on metformin and rifampicin, and 38% of patients on metformin alone experienced gastrointestinal adverse effects. Considering this observation, we advise patients to take metformin and rifampicin with food and preferably separated in time. Clinicians could consider metoclopramide if gastrointestinal adverse effects occur.
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Affiliation(s)
- Lindsey H M Te Brake
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Vycke Yunivita
- Department of Pharmacology and Therapy, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Resvi Livia
- TB-HIV Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Nanny Soetedjo
- Internal Medicine, Division of Endocrinology, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | | | - Jan B Koenderink
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Prayudi Santoso
- Internal Medicine, Division of Pulmonary Medicine, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Reinout van Crevel
- Department of Internal Medicine, Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bachti Alisjahbana
- TB-HIV Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rovina Ruslami
- Department of Pharmacology and Therapy, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
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12
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Te Brake LHM, de Knegt GJ, de Steenwinkel JE, van Dam TJP, Burger DM, Russel FGM, van Crevel R, Koenderink JB, Aarnoutse RE. The Role of Efflux Pumps in Tuberculosis Treatment and Their Promise as a Target in Drug Development: Unraveling the Black Box. Annu Rev Pharmacol Toxicol 2017; 58:271-291. [PMID: 28715978 DOI: 10.1146/annurev-pharmtox-010617-052438] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [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: 11/09/2022]
Abstract
Insight into drug transport mechanisms is highly relevant to the efficacious treatment of tuberculosis (TB). Major problems in TB treatment are related to the transport of antituberculosis (anti-TB) drugs across human and mycobacterial membranes, affecting the concentrations of these drugs systemically and locally. Firstly, transporters located in the intestines, liver, and kidneys all determine the pharmacokinetics and pharmacodynamics of anti-TB drugs, with a high risk of drug-drug interactions in the setting of concurrent use of antimycobacterial, antiretroviral, and antidiabetic agents. Secondly, human efflux transporters limit the penetration of anti-TB drugs into the brain and cerebrospinal fluid, which is especially important in the treatment of TB meningitis. Finally, efflux transporters located in the macrophage and Mycobacterium tuberculosis cell membranes play a pivotal role in the emergence of phenotypic tolerance and drug resistance, respectively. We review the role of efflux transporters in TB drug disposition and evaluate the promise of efflux pump inhibition from a novel holistic perspective.
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Affiliation(s)
- Lindsey H M Te Brake
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; .,Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Gerjo J de Knegt
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, 3015 CN Rotterdam, The Netherlands
| | - Jurriaan E de Steenwinkel
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, 3015 CN Rotterdam, The Netherlands
| | - Teunis J P van Dam
- Centre for Molecular and Biomolecular Informatics, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands;
| | - Frans G M Russel
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Reinout van Crevel
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Jan B Koenderink
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands;
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13
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Te Brake LHM, Russel FGM, van den Heuvel JJMW, de Knegt GJ, de Steenwinkel JE, Burger DM, Aarnoutse RE, Koenderink JB. Inhibitory potential of tuberculosis drugs on ATP-binding cassette drug transporters. Tuberculosis (Edinb) 2015; 96:150-7. [PMID: 26682943 DOI: 10.1016/j.tube.2015.08.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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: 03/17/2015] [Revised: 08/05/2015] [Accepted: 08/10/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Multiple-drug therapy for tuberculosis (TB) and TB-associated co-morbidity increase the likelihood of drug-drug interactions (DDIs). Inhibition of membrane transporters is an important mechanism underlying DDIs. In this study, we assessed the in vitro inhibitory potential of currently used first and second-line TB drugs and of proposed mycobacterial efflux pump inhibitors (EPIs) on the major ABC transporters relevant to drug transport, namely P-gp, BCRP, BSEP and MRP1-5. METHODS Membrane vesicles isolated from transporter-overexpressing HEK293 cells were used to study the inhibitory action of TB drugs and EPIs on the transport of model substrates [(3)H]-NMQ (P-gp); [(3)H]-E1S (BCRP); [(3)H]-TCA (BSEP); [(3)H]-E217βG (MRP1, 3 and 4) and [(3)H]-MTX (MRP2 and 5). RESULTS A strong inhibition (IC50 value <15 μM) was observed for clofazimine (P-gp, BCRP and MRP1), thioridazine (BCRP), timcodar (P-gp, BSEP and MRP1) and SQ109 (P-gp and BCRP). Rifampicin inhibited all transporters, but less potently. CONCLUSIONS Co-administration of clofazimine, thioridazine, timcodar, SQ109 and possibly rifampicin with drugs that are substrates for the inhibited transporters may lead to DDIs. The mycobacterial EPIs potently inhibited a wider range of human ABC transporters than previously reported. These vesicular transport data are especially valuable considering the current emphasis on development of TB drug regimens.
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Affiliation(s)
- Lindsey H M Te Brake
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Geert Grooteplein 26, 6525 GA, Internal Postal Code 149, Nijmegen, The Netherlands; Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA, Internal Postal Code 864, Nijmegen, The Netherlands.
| | - Frans G M Russel
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Geert Grooteplein 26, 6525 GA, Internal Postal Code 149, Nijmegen, The Netherlands.
| | - Jeroen J M W van den Heuvel
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Geert Grooteplein 26, 6525 GA, Internal Postal Code 149, Nijmegen, The Netherlands.
| | - Gerjo J de Knegt
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
| | - Jurriaan E de Steenwinkel
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
| | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA, Internal Postal Code 864, Nijmegen, The Netherlands.
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA, Internal Postal Code 864, Nijmegen, The Netherlands.
| | - Jan B Koenderink
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Geert Grooteplein 26, 6525 GA, Internal Postal Code 149, Nijmegen, The Netherlands.
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