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Singh RSP, LaBadie RR, Toussi SS, Shi H, Berg JK, Neutel JM, Aggarwal S. Effect of Hepatic Impairment on the Pharmacokinetics of Nirmatrelvir/Ritonavir, the First Oral Protease Inhibitor for the Treatment of COVID-19. J Clin Pharmacol 2024; 64:145-154. [PMID: 37751891 DOI: 10.1002/jcph.2353] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 04/26/2023] [Accepted: 09/22/2023] [Indexed: 09/28/2023]
Abstract
Nirmatrelvir, a novel, potent, orally bioavailable severe acute respiratory syndrome coronavirus 2 main protease inhibitor, coadministered with ritonavir for pharmacokinetic (PK) enhancement is licensed for the treatment of mild to moderate COVID-19 in individuals at increased risk of progression to severe disease. Cytochrome P450 3A4 is the primary metabolic enzyme responsible for nirmatrelvir metabolism; however, when cytochrome P450 3A4 is inhibited by ritonavir, nirmatrelvir is primarily excreted, unchanged, in urine. Because of intended use of nirmatrelvir among individuals with hepatic impairment, this Phase 1 study (NCT05005312) evaluated the effects of hepatic impairment on nirmatrelvir PK parameters to assess the potential need for any dose adjustments in this population. Participants with normal hepatic function or moderate hepatic impairment (n = 8 each) were administered a single 100-mg nirmatrelvir dose, with 100 mg of ritonavir administered 12 hours before, together with, and 12 and 24 hours after nirmatrelvir. Nirmatrelvir median plasma concentrations and systemic exposure measured by area under the plasma concentration-time curve from time zero extrapolated to infinite time and maximum observed plasma concentration values were comparable in both groups. Nirmatrelvir/ritonavir had an acceptable safety profile in both groups, and no clinically significant changes in laboratory measurements, vital signs, or electrocardiogram assessments were observed. Based on these results, no dose adjustment is deemed necessary in patients with moderate hepatic impairment and, by extension, in patients with mild hepatic impairment.
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Affiliation(s)
| | | | - Sima S Toussi
- Worldwide Research, Development and Medical, Pfizer Inc, Pearl River, NY, USA
| | - Haihong Shi
- Global Product Development, Pfizer Inc, Groton, CT, USA
| | | | | | - Sudeepta Aggarwal
- Worldwide Research, Development and Medical, Pfizer Inc, Cambridge, MA, USA
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Cheruvu N, van Duijn E, Spigt PA, Barbu IM, Toussi SS, Schildknegt K, Jones RM, Obach RS. The Metabolism of Lufotrelvir, a Prodrug Investigated for the Treatment of SARS-COV2 in Humans Following Intravenous Administration. Drug Metab Dispos 2023; 51:1419-1427. [PMID: 37429728 DOI: 10.1124/dmd.123.001416] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 06/30/2023] [Accepted: 07/05/2023] [Indexed: 07/12/2023] Open
Abstract
The metabolism of lufotrelvir, a novel phosphate prodrug of PF-00835231 for the treatment of COVID-19, was evaluated in healthy human volunteers and clinical trial participants with COVID-19 following intravenous infusion. The prodrug was completely converted to PF-00835231 that was subsequently cleared by hydrolysis, hydroxylation, ketoreduction, epimerization, renal clearance, and secretion into the feces. The main circulating metabolite was a hydrolysis product (M7) that was present at concentrations greater than PF-00835231, and this was consistent between healthy volunteers and participants with COVID-19. On administration of [14C]lufotrelvir, only 63% of the dose was obtained in excreta over 10 days and total drug-related material demonstrated a prolonged terminal phase half-life in plasma. A considerable portion of the labeled material was unextractable from fecal homogenate and plasma. The position of the carbon-14 atom in the labeled material was at a leucine carbonyl, and pronase digestion of the pellet derived from extraction of the fecal homogenate showed that [14C]leucine was released. SIGNIFICANCE STATEMENT: Lufotrelvir is an experimental phosphate prodrug intravenous therapy investigated for the potential treatment of COVID-19 in a hospital setting. The overall metabolism of lufotrelvir was determined in human healthy volunteers and clinical trial participants with COVID-19. Conversion of the phosphate prodrug to the active drug PF-00835231 was complete and the subsequent metabolic clearance of the active drug was largely via amide bond hydrolysis. Substantial drug-related material was not recovered due to loss of the carbon-14 label to endogenous metabolism.
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Affiliation(s)
- Narayan Cheruvu
- Pfizer Worldwide Research, Development and Medical, Groton, Connecticut (R.S.O., K.S.); Pfizer Worldwide Research, Development and Medical, La Jolla, California (R.M.J.); Pfizer Worldwide Research, Development and Medical, Collegeville, Pennsylvania (N.C.); Pfizer Worldwide Research, Development and Medical, Pearl River, New York (S.S.T.); and The Netherlands Organization for Applied Scientific Research (T.N.O.), Zeist, Netherlands (E.v.D., P.A.S., I.M.B.)
| | - Esther van Duijn
- Pfizer Worldwide Research, Development and Medical, Groton, Connecticut (R.S.O., K.S.); Pfizer Worldwide Research, Development and Medical, La Jolla, California (R.M.J.); Pfizer Worldwide Research, Development and Medical, Collegeville, Pennsylvania (N.C.); Pfizer Worldwide Research, Development and Medical, Pearl River, New York (S.S.T.); and The Netherlands Organization for Applied Scientific Research (T.N.O.), Zeist, Netherlands (E.v.D., P.A.S., I.M.B.)
| | - Pieter A Spigt
- Pfizer Worldwide Research, Development and Medical, Groton, Connecticut (R.S.O., K.S.); Pfizer Worldwide Research, Development and Medical, La Jolla, California (R.M.J.); Pfizer Worldwide Research, Development and Medical, Collegeville, Pennsylvania (N.C.); Pfizer Worldwide Research, Development and Medical, Pearl River, New York (S.S.T.); and The Netherlands Organization for Applied Scientific Research (T.N.O.), Zeist, Netherlands (E.v.D., P.A.S., I.M.B.)
| | - Ioana M Barbu
- Pfizer Worldwide Research, Development and Medical, Groton, Connecticut (R.S.O., K.S.); Pfizer Worldwide Research, Development and Medical, La Jolla, California (R.M.J.); Pfizer Worldwide Research, Development and Medical, Collegeville, Pennsylvania (N.C.); Pfizer Worldwide Research, Development and Medical, Pearl River, New York (S.S.T.); and The Netherlands Organization for Applied Scientific Research (T.N.O.), Zeist, Netherlands (E.v.D., P.A.S., I.M.B.)
| | - Sima S Toussi
- Pfizer Worldwide Research, Development and Medical, Groton, Connecticut (R.S.O., K.S.); Pfizer Worldwide Research, Development and Medical, La Jolla, California (R.M.J.); Pfizer Worldwide Research, Development and Medical, Collegeville, Pennsylvania (N.C.); Pfizer Worldwide Research, Development and Medical, Pearl River, New York (S.S.T.); and The Netherlands Organization for Applied Scientific Research (T.N.O.), Zeist, Netherlands (E.v.D., P.A.S., I.M.B.)
| | - Klaas Schildknegt
- Pfizer Worldwide Research, Development and Medical, Groton, Connecticut (R.S.O., K.S.); Pfizer Worldwide Research, Development and Medical, La Jolla, California (R.M.J.); Pfizer Worldwide Research, Development and Medical, Collegeville, Pennsylvania (N.C.); Pfizer Worldwide Research, Development and Medical, Pearl River, New York (S.S.T.); and The Netherlands Organization for Applied Scientific Research (T.N.O.), Zeist, Netherlands (E.v.D., P.A.S., I.M.B.)
| | - Rhys M Jones
- Pfizer Worldwide Research, Development and Medical, Groton, Connecticut (R.S.O., K.S.); Pfizer Worldwide Research, Development and Medical, La Jolla, California (R.M.J.); Pfizer Worldwide Research, Development and Medical, Collegeville, Pennsylvania (N.C.); Pfizer Worldwide Research, Development and Medical, Pearl River, New York (S.S.T.); and The Netherlands Organization for Applied Scientific Research (T.N.O.), Zeist, Netherlands (E.v.D., P.A.S., I.M.B.)
| | - R Scott Obach
- Pfizer Worldwide Research, Development and Medical, Groton, Connecticut (R.S.O., K.S.); Pfizer Worldwide Research, Development and Medical, La Jolla, California (R.M.J.); Pfizer Worldwide Research, Development and Medical, Collegeville, Pennsylvania (N.C.); Pfizer Worldwide Research, Development and Medical, Pearl River, New York (S.S.T.); and The Netherlands Organization for Applied Scientific Research (T.N.O.), Zeist, Netherlands (E.v.D., P.A.S., I.M.B.)
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3
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Robinson P, Toussi SS, Aggarwal S, Bergman A, Zhu T, Hackman F, Sathish JG, Updyke L, Loudon P, Krishna G, Clevenbergh P, Hernandez-Mora MG, Cisneros Herreros JM, Albertson TE, Dougan M, Thacker A, Baniecki ML, Soares H, Whitlock M, Nucci G, Menon S, Anderson AS, Binks M. Safety, Tolerability, and Pharmacokinetics of Single and Multiple Ascending Intravenous Infusions of PF-07304814 (Lufotrelvir) in Participants Hospitalized With COVID-19. Open Forum Infect Dis 2023; 10:ofad355. [PMID: 37559753 PMCID: PMC10407246 DOI: 10.1093/ofid/ofad355] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 07/06/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND An urgent need remains for antiviral therapies to treat patients hospitalized with COVID-19. PF-07304814-the prodrug (lufotrelvir) and its active moiety (PF-00835231)-is a potent inhibitor of the SARS-CoV-2 3CL protease. METHOD Eligible participants were 18 to 79 years old and hospitalized with confirmed COVID-19. This first-in-human phase 1b study was designed with 2 groups: single ascending dose (SAD) and multiple ascending dose (MAD). Participants could receive local standard-of-care therapy. In SAD, participants were randomized to receive a 24-hour infusion of lufotrelvir/placebo. In MAD, participants were randomized to receive a 120-hour infusion of lufotrelvir/placebo. The primary endpoint was to assess the safety and tolerability of lufotrelvir. The secondary endpoint was to evaluate the pharmacokinetics of lufotrelvir and PF-00835231. RESULTS In SAD, participants were randomized to receive 250 mg lufotrelvir (n = 2), 500 mg lufotrelvir (n = 2), or placebo (n = 4) by continuous 24-hour infusion. In MAD, participants were randomized to receive 250 mg lufotrelvir (n = 7), 500 mg lufotrelvir (n = 6), or placebo (n = 4) by continuous 120-hour infusion. No adverse events or serious adverse events were considered related to lufotrelvir. At doses of 250 and 500 mg, concentrations for the prodrug lufotrelvir and active moiety PF-00835231 increased in a dose-related manner. Unbound concentrations of the lufotrelvir active metabolite reached steady state approximately 2- and 4-fold that of in vitro EC90 following 250- and 500-mg doses, respectively. CONCLUSIONS These safety and pharmacokinetic findings support the continued evaluation of lufotrelvir in clinical studies. Clinical Trials Registration. ClinicalTrials.gov NCT04535167.
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Affiliation(s)
- Philip Robinson
- Infectious Disease, Hoag Memorial Hospital Presbyterian, Newport Beach, California, USA
| | - Sima S Toussi
- Pfizer Worldwide Research, Development and Medical, Pfizer Inc, Pearl River, New York, USA
| | - Sudeepta Aggarwal
- Early Clinical Development, Pfizer Inc, Cambridge, Massachusetts, USA
| | - Arthur Bergman
- Pfizer Worldwide Research, Development and Medical, Pfizer Inc, Cambridge, Massachusetts, USA
| | - Tong Zhu
- Pfizer Worldwide Research, Development and Medical, Pfizer Inc, Cambridge, Massachusetts, USA
| | - Frances Hackman
- Pfizer Worldwide Research, Development and Medical, Pfizer Ltd, Cambridge, UK
| | - Jean G Sathish
- Drug Safety Unit, Pfizer Inc, Pearl River, New York, USA
| | | | | | | | | | | | | | | | - Michael Dougan
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | | | - Holly Soares
- Early Clinical Development, Pfizer Inc, Cambridge, Massachusetts, USA
| | - Mark Whitlock
- Early Clinical Development, Pfizer Inc, Cambridge, UK
| | - Gianluca Nucci
- Pfizer Worldwide Research, Development and Medical, Pfizer Ltd, Cambridge, UK
| | - Sandeep Menon
- Pfizer Worldwide Research, Development and Medical, Pfizer Ltd, Cambridge, UK
| | | | - Michael Binks
- Pfizer Worldwide Research, Development and Medical, Pfizer Ltd, Cambridge, UK
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Toussi SS, Hammond JL, Gerstenberger BS, Anderson AS. Therapeutics for COVID-19. Nat Microbiol 2023; 8:771-786. [PMID: 37142688 DOI: 10.1038/s41564-023-01356-4] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 03/09/2023] [Indexed: 05/06/2023]
Abstract
Vaccines and monoclonal antibody treatments to prevent severe coronavirus disease 2019 (COVID-19) illness were available within a year of the pandemic being declared but there remained an urgent need for therapeutics to treat patients who were not vaccinated, were immunocompromised or whose vaccine immunity had waned. Initial results for investigational therapies were mixed. AT-527, a repurposed nucleoside inhibitor for hepatitis C virus, enabled viral load reduction in a hospitalized cohort but did not reduce viral load in outpatients. The nucleoside inhibitor molnupiravir prevented death but failed to prevent hospitalization. Nirmatrelvir, an inhibitor of the main protease (Mpro), co-dosed with the pharmacokinetic booster ritonavir, reduced hospitalization and death. Nirmatrelvir-ritonavir and molnupiravir received an Emergency Use Authorization in the United States at the end of 2021. Immunomodulatory drugs such as baricitinib, tocilizumab and corticosteroid, which target host-driven COVID-19 symptoms, are also in use. We highlight the development of COVID-19 therapies and the challenges that remain for anticoronavirals.
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Zhu T, Pawlak S, Toussi SS, Hackman F, Thompson K, Song W, Salageanu J, Winter E, Shi H, Winton J, Binks M. Safety, Tolerability, and Pharmacokinetics of Intravenous Doses of PF-07304814, a Phosphate Prodrug Protease Inhibitor for the Treatment of SARS-CoV-2, in Healthy Adult Participants. Clin Pharmacol Drug Dev 2022; 11:1382-1393. [PMID: 36285536 PMCID: PMC9874748 DOI: 10.1002/cpdd.1174] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 08/16/2022] [Indexed: 01/28/2023]
Abstract
Studies on targeted antivirals for treatment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of the ongoing pandemic, are limited. PF-07304814 (lufotrelvir) is the phosphate prodrug of PF-00835231, a protease inhibitor targeting the 3C-like protease of SARS-CoV-2. This phase 1 study evaluated the safety, tolerability, and pharmacokinetics (PK) of single ascending intravenous doses of lufotrelvir (continuous 24-hour infusion of 50, 150, 500, or 700 mg) versus placebo in healthy volunteers (2 interleaving cohorts: 1, n = 8; 2, n = 7). Each dosing period was separated by a washout interval (≥5 days). Treatment-emergent adverse events, PK, and biomarker concentrations were estimated from plasma/urine samples. Lufotrelvir was administered to 15 volunteers (mean [SD] age 39.7 [11.8] years). No serious adverse events, discontinuations, or deaths were reported. Mean maximum observed concentration of PF-00835231 (active moiety; 97.0 ng/mL to 1288 ng/mL) were observed between median time to maximum concentration of 14 to 16 hours after the start of the lufotrelvir infusion. Near-maximum plasma concentrations of PF-00835231 were observed ≈6 hours after infusion start and sustained until infusion end. PF-00835231 plasma concentrations declined rapidly after infusion end (mean terminal half-life: 500 mg, 2.0 hours; 700 mg, 1.7 hours). Approximately 9%-11% of the dose was recovered in urine as PF-00835231 across doses. A continuous, single-dose, 24-hour infusion of lufotrelvir (50-700 mg) was rapidly converted to PF-00835231 (active moiety), with dose-proportional PK exposures and no significant safety concerns. A daily, 24-hour continuous infusion of 270 to 350 mg is expected to maintain PF-00835231 concentration at steady state/above effective antiviral concentrations. Further studies exploring lufotrelvir efficacy in patients with coronavirus disease 2019 are ongoing.
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Affiliation(s)
- Tong Zhu
- Pfizer Worldwide ResearchDevelopment and MedicalCambridgeMassachusettsUSA
| | | | - Sima S. Toussi
- Pfizer Worldwide ResearchDevelopment and Medical, Pearl RiverNew YorkUSA
| | | | | | - Wei Song
- Pfizer Worldwide ResearchDevelopment and MedicalGrotonConnecticutUSA
| | | | - Erica Winter
- Pfizer Global Product DevelopmentGrotonConnecticutUSA
| | - Haihong Shi
- Pfizer Global Product DevelopmentGrotonConnecticutUSA
| | | | - Michael Binks
- Pfizer Worldwide ResearchDevelopment and MedicalCambridgeMassachusettsUSA
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Singh RSP, Walker GS, Kadar EP, Cox LM, Eng H, Sharma R, Bergman AJ, Van Eyck L, Hackman F, Toussi SS, Kalgutkar AS, Obach RS. Metabolism and Excretion of Nirmatrelvir in Humans Using Quantitative Fluorine Nuclear Magnetic Resonance Spectroscopy: A Novel Approach for Accelerating Drug Development. Clin Pharmacol Ther 2022; 112:1201-1206. [PMID: 35678736 DOI: 10.1002/cpt.2683] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 06/06/2022] [Indexed: 01/31/2023]
Abstract
Typically human absorption, distribution, metabolism, and excretion (ADME) studies are executed using radiolabeled (e.g., carbon-14) material, the synthesis of which is a time-consuming activity. In this study, we were able to assess the metabolism and excretion of unlabeled nirmatrelvir (PF-07321332) within the first-in-human study via a novel application of quantitative fluorine (19 F) nuclear magnetic resonance (NMR) spectroscopy in place of a standard radiolabel ADME study. Six healthy participants received a single 300-mg oral dose of nirmatrelvir (in combination with ritonavir), and excreta were collected up to 10 days. Virtually all drug-related material was recovered within 5 days, and mass balance was achieved with 84.9 ± 8.9% (range = 70.7-95.5%) of the administered dose recovered in urine and feces. The excretion of fluorine-containing material in urine and feces was 47.0% and 33.7%, respectively. Unchanged nirmatrelvir represented 82.5% of the normalized drug-related material with a carboxylic acid metabolite M5, derived from hydrolysis of the P2 amide bond, present at 12.1% of dose. Nirmatrelvir was the only drug-related entity observed in plasma. Approximately 4.2% of the dose was excreted as metabolite M8 (measured by liquid chromatography-mass spectrometry), which was 19 F NMR silent due to hydrolysis of the trifluoroacetamide moiety. Hydrolysis of nirmatrelvir to M5 and M8 was shown to occur in cultures of human gut microflora. This successful demonstration of quantitative 19 F NMR spectroscopy to establish the mass-balance, excretion, and metabolic profile of nirmatrelvir offers an advantageous means to execute human ADME studies for fluorine-containing compounds early in drug development.
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Affiliation(s)
| | - Gregory S Walker
- Pfizer Worldwide Research, Development & Medical, Groton, Connecticut, USA
| | - Eugene P Kadar
- Pfizer Worldwide Research, Development & Medical, Groton, Connecticut, USA
| | - Loretta M Cox
- Pfizer Worldwide Research, Development & Medical, Groton, Connecticut, USA
| | - Heather Eng
- Pfizer Worldwide Research, Development & Medical, Groton, Connecticut, USA
| | - Raman Sharma
- Pfizer Worldwide Research, Development & Medical, Groton, Connecticut, USA
| | - Arthur J Bergman
- Pfizer Worldwide Research, Development & Medical, Cambridge, Massachusetts, USA
| | | | - Frances Hackman
- Pfizer Worldwide Research, Development and Medical, Cambridge, UK
| | - Sima S Toussi
- Pfizer Clinical Development, Pearl River, New York, USA
| | - Amit S Kalgutkar
- Pfizer Worldwide Research, Development & Medical, Cambridge, Massachusetts, USA
| | - R Scott Obach
- Pfizer Worldwide Research, Development & Medical, Groton, Connecticut, USA
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Singh RSP, Toussi SS, Hackman F, Chan PL, Rao R, Allen R, Van Eyck L, Pawlak S, Kadar EP, Clark F, Shi H, Anderson AS, Binks M, Menon S, Nucci G, Bergman A. Innovative Randomized Phase I Study and Dosing Regimen Selection to Accelerate and Inform Pivotal COVID-19 Trial of Nirmatrelvir. Clin Pharmacol Ther 2022; 112:101-111. [PMID: 35388471 PMCID: PMC9087011 DOI: 10.1002/cpt.2603] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/24/2022] [Indexed: 12/12/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is a continued leading cause of hospitalization and death. Safe, efficacious COVID-19 antivirals are needed urgently. Nirmatrelvir (PF-07321332), the first orally bioavailable, severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) Mpro inhibitor against the coronaviridae family, has demonstrated potent preclinical antiviral activity and benign safety profile. We report safety, tolerability, and pharmacokinetic data of nirmatrelvir with and without ritonavir as a pharmacokinetic enhancer, from an accelerated randomized, double-blind, placebo-controlled, phase I study. Two interleaving single-ascending dose (SAD) cohorts were evaluated in a three-period crossover. Multiple-ascending dose (MAD) with nirmatrelvir/ritonavir twice daily (b.i.d.) dosing was evaluated over 10 days in five parallel cohorts. Safety was assessed, including in a supratherapeutic exposure cohort. Dose and dosing regimen for clinical efficacy evaluation in phase II/III clinical trials were supported by integrating modeling and simulations of SAD/MAD data with nonclinical data and a quantitative systems pharmacology model (QSP). In SAD, MAD, and supratherapeutic exposure cohorts, nirmatrelvir/ritonavir was safe and well-tolerated. Nirmatrelvir exposure and half-life were considerably increased by ritonavir, enabling selection of nirmatrelvir/ritonavir dose and regimen for phase II/III trials (300/100 mg b.i.d.), to achieve concentrations continuously above those required for 90% inhibition of viral replication in vitro. The QSP model suggested that a 5-day regimen would significantly decrease viral load in SARS-CoV-2-infected patients which may prevent development of severe disease, hospitalization, and death. In conclusion, an innovative and seamless trial design expedited establishment of phase I safety and pharmacokinetics of nirmatrelvir/ritonavir, enabling high confidence in phase II/III dose selection and accelerated pivotal trials' initiation (NCT04756531).
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Affiliation(s)
| | - Sima S. Toussi
- Pfizer Worldwide Research, Development and MedicalPearl RiverNew YorkUSA
| | - Frances Hackman
- Pfizer Worldwide Research, Development and MedicalCambridgeUK
| | | | - Rohit Rao
- Pfizer Worldwide Research, Development and MedicalCambridgeMassachusettsUSA
| | - Richard Allen
- Pfizer Worldwide Research, Development and MedicalCambridgeMassachusettsUSA
| | | | | | - Eugene P. Kadar
- Pfizer Worldwide Research, Development and MedicalGrotonConnecticutUSA
| | - Frances Clark
- Pfizer Worldwide Research, Development and MedicalGrotonConnecticutUSA
| | - Haihong Shi
- Pfizer Global Product DevelopmentGrotonConnecticutUSA
| | | | - Michael Binks
- Pfizer Worldwide Research, Development and MedicalCambridgeMassachusettsUSA
| | - Sandeep Menon
- Pfizer Worldwide Research, Development and MedicalCambridgeMassachusettsUSA
| | - Gianluca Nucci
- Pfizer Worldwide Research, Development and MedicalCambridgeMassachusettsUSA
| | - Arthur Bergman
- Pfizer Worldwide Research, Development and MedicalCambridgeMassachusettsUSA
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8
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Toussi SS, Neutel JM, Navarro J, Preston RA, Shi H, Kavetska O, LaBadie RR, Binks M, Chan PL, Demers N, Corrigan B, Damle B. Pharmacokinetics of Oral Nirmatrelvir/Ritonavir, a Protease Inhibitor for Treatment of COVID-19, in Subjects With Renal Impairment. Clin Pharmacol Ther 2022; 112:892-900. [PMID: 35712797 PMCID: PMC9349773 DOI: 10.1002/cpt.2688] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [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: 03/15/2022] [Accepted: 05/23/2022] [Indexed: 12/02/2022]
Abstract
Nirmatrelvir coadministered with ritonavir is highly efficacious in reducing the risk of coronavirus disease 2019 (COVID‐19) adverse outcomes among patients at increased risk of progression to severe disease, including patients with chronic kidney disease. Because nirmatrelvir is eliminated by the kidneys when given with ritonavir, this phase I study evaluated the effects of renal impairment on pharmacokinetics, safety, and tolerability of nirmatrelvir/ritonavir. Participants with normal renal function (n = 10) or mild, moderate, or severe renal impairment (n = 8 each) were administered a single 100‐mg nirmatrelvir dose with 100 mg ritonavir given 12 hours before, together with and 12 and 24 hours after the nirmatrelvir dose. Systemic nirmatrelvir exposure increased with increasing renal impairment, with mild, moderate, and severe renal impairment groups having respective adjusted geometric mean ratio areas under the plasma concentration‐time profile from time 0 extrapolated to infinite time of 124%, 187%, and 304% vs. the normal renal function group. Corresponding ratios for maximum plasma concentration were 130%, 138%, and 148%. Apparent clearance was positively correlated with estimated glomerular filtration rate, and geometric mean renal clearance values were particularly lower for the moderate (47% decrease) and severe (80% decrease) renal impairment groups vs. the normal renal function group. Nirmatrelvir/ritonavir exhibited an acceptable safety profile; treatment‐related adverse events were mild in severity, and there were no significant findings regarding laboratory measurements, vital signs, or electrocardiogram assessments. These findings led to a dose reduction recommendation for nirmatrelvir/ritonavir in patients with moderate renal impairment (150/100 mg nirmatrelvir/ritonavir instead of 300/100 mg twice daily for 5 days). NCT04909853.
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Affiliation(s)
- Sima S. Toussi
- Worldwide Research, Development and MedicalPfizer IncPearl RiverNew YorkUSA
| | | | | | - Richard Alfred Preston
- Division of Clinical Pharmacology, Department of Medicine, Katz Drug Discovery Center, Clinical and Translational Sciences InstituteMiller School of Medicine University of MiamiMiamiFloridaUSA
| | - Haihong Shi
- Global Product DevelopmentPfizer IncGrotonConnecticutUSA
| | - Olga Kavetska
- Global Product DevelopmentPfizer IncGrotonConnecticutUSA
| | | | - Michael Binks
- Worldwide Research, Development and MedicalPfizer IncCambridgeMassachusettsUSA
| | - Phylinda L.S. Chan
- Global Product DevelopmentPfizer Research & Development UK LtdSandwich, KentUK
| | - Neil Demers
- Global Product DevelopmentPfizer IncGrotonConnecticutUSA
| | - Brian Corrigan
- Global Product DevelopmentPfizer IncGrotonConnecticutUSA
| | - Bharat Damle
- Global Product DevelopmentPfizer IncNew YorkNew YorkUSA
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Trachtman R, Murray E, Wang CM, Szymonifka J, Toussi SS, Walters H, Nellis ME, Onel KB, Mandl LA. Procalcitonin Differs in Children With Infection and Children With Disease Flares in Juvenile Idiopathic Arthritis. J Clin Rheumatol 2021; 27:87-91. [PMID: 31693652 PMCID: PMC10364140 DOI: 10.1097/rhu.0000000000001170] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND/OBJECTIVE Patients with juvenile idiopathic arthritis (JIA) often present with signs and symptoms suggestive of serious bacterial infection (SBI). Procalcitonin (PCT) is a biomarker that is elevated in SBI. We conducted a comparative cohort study to test the hypothesis that PCT levels will differ between active JIA, quiescent JIA, and bacteremic patients and healthy controls. METHODS From October 2016 to May2018, consecutive children 6 months to 18 years of age with (a) active untreated JIA, (b) quiescent JIA, and (c) healthy elective presurgical candidates were recruited from clinics at a musculoskeletal specialty hospital. Juvenile idiopathic arthritis was defined according to the International League of Associations for Rheumatology criteria. Clinical data and serum samples meeting the same criteria were included from a prior study. Consecutive bacteremic patients were identified over the same period. Procalcitonin and other common measures of inflammation were measured. Descriptive statistics and univariate logistic analyses were performed. RESULTS Ninety-two study subjects were recruited. Erythrocyte sedimentation rate, C-reactive protein (CRP), and PCT levels were all elevated in bacteremic patients in comparison to the other groups. Erythrocyte sedimentation rate and CRP both had wide ranges that overlapped between groups; however, the PCT concentration was 0.15 μg/mL or greater in 1 of 59 patients with JIA, whereas it was 0.15 μg/mL or less in only 1 bacteremic patient. CONCLUSIONS Our study indicates that serum erythrocyte sedimentation rate, CRP, and PCT levels are all biomarkers that can be used to distinguish SBI versus active JIA at presentation. However, PCT is the most accurate, with the least overlap between patients with infection and noninfectious inflammatory arthritis. This finding can help clinicians direct therapy.
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Affiliation(s)
| | | | | | | | | | | | | | - Karen B. Onel
- Hospital for Special Surgery
- Weill Cornell Medicine, New York
| | - Lisa A. Mandl
- Hospital for Special Surgery
- Northwell Health, Lake Success, NY
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10
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Baker T, Patel A, Halteh P, Toussi SS, DeLaMora P, Lipner S, Schuetz AN, Hartman B. Blastomycosis during pregnancy: a case report and review of the literature. Diagn Microbiol Infect Dis 2017; 88:145-151. [PMID: 28291633 DOI: 10.1016/j.diagmicrobio.2017.02.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 02/07/2017] [Accepted: 02/21/2017] [Indexed: 01/21/2023]
Abstract
The diagnosis of blastomycosis during pregnancy is rare, but can carry significant clinical questions for both the infected mother and developing fetus. Furthermore, given its rarity, providers have little available data to help manage and counsel patients in this uncommon, yet serious, scenario. We present a case of blastomycosis in a woman at 38weeks' gestation and review all published cases of blastomycosis during pregnancy. It is our hope to provide a multidisciplinary understanding of the current knowledge surrounding the presentation, diagnosis, management, and outcome of this unusual infection.
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Affiliation(s)
- Thomas Baker
- NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, 525 E 68th St, New York, NY 10065.
| | - Ami Patel
- NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, 525 E 68th St, New York, NY 10065
| | - Pierre Halteh
- NewYork-Presbyterian Hospital, Weill Cornell Medicine, Department of Dermatology, 1305 York Avenue, 9th Floor, New York, NY 10021
| | - Sima S Toussi
- NewYork-Presbyterian Hospital, Weill Cornell Medicine, Department of Pediatrics, 525 E 68th St, New York, NY 10065
| | - Patricia DeLaMora
- NewYork-Presbyterian Hospital, Weill Cornell Medicine, Department of Pediatrics, 525 E 68th St, New York, NY 10065
| | - Shari Lipner
- NewYork-Presbyterian Hospital, Weill Cornell Medicine, Department of Dermatology, 1305 York Avenue, 9th Floor, New York, NY 10021
| | - Audrey N Schuetz
- Mayo Clinic, Rochester, MN, Department of Laboratory Medicine and Pathology, 200 1st St SW, Rochester, MN 55905
| | - Barry Hartman
- NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, 525 E 68th St, New York, NY 10065
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11
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Salvatore CM, Chen TK, Toussi SS, DeLaMora P, Petraitiene R, Finkelman MA, Walsh TJ. (1→3)-β-d-Glucan in Cerebrospinal Fluid as a Biomarker for Candida and Aspergillus Infections of the Central Nervous System in Pediatric Patients. J Pediatric Infect Dis Soc 2016; 5:277-86. [PMID: 26407252 PMCID: PMC6281134 DOI: 10.1093/jpids/piv014] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [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] [Received: 10/08/2014] [Accepted: 02/24/2015] [Indexed: 11/14/2022]
Abstract
BACKGROUND Fungal infections of the central nervous system (FICNS) are important causes of morbidity and mortality among immunocompromised pediatric patients. Standard diagnostic modalities lack the sensitivity for detecting and therapeutically monitoring these life-threatening diseases. Current molecular methods remain investigational. (1→3)-β-d-glucan (BDG) is a cell wall component found in several fungal pathogens, including Candida and Aspergillus spp. Detecting BDG in cerebrospinal fluid (CSF) may be an important approach for detecting and therapeutically monitoring FICNS. To date, there has been no study that has investigated the effectiveness of CSF BDG as a diagnostic and therapeutic marker of FICNS in children. METHODS Serial BDG levels were measured in serum and CSF samples obtained from pediatric patients (aged 0-18 years) with a diagnosis of probable or proven Candida or Aspergillus CNS infection. RESULTS Nine cases of FICNS were identified in patients aged 1 month to 18 years. Two patients were infected with an Aspergillus species, and 7 patients were infected with a Candida species. All the patients at baseline had detectable BDG in their CSF. Among 7 patients who completed therapy for an FICNS, all elevated CSF BDG levels decreased to <31 pg/mL. At the time of this writing, 1 patient was still receiving therapy and continued to have elevated BDG levels. One patient died from overwhelming disseminated candidiasis. The lengths of therapy for these 9 children ranged from 2 weeks to 28 months. CONCLUSION The BDG assay is useful in diagnosing and therapeutically monitoring Candida and Aspergillus CNS infections in pediatric patients.
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Affiliation(s)
- Christine M. Salvatore
- Division of Pediatrics Infectious Diseases, Department of Pediatrics, New York-Presbyterian Hospital, Weill Cornell Medical College, New York,Corresponding Author:
Christine M. Salvatore, MD, Division of Pediatric Infectious Diseases, Weill Cornell Medical College, 505 E 70th St, 3rd Floor, Box 279, New York, NY 10065. E-mail:
| | - Tempe K. Chen
- Department of Pediatrics, University of California Irvine School of Medicine, Miller Children's and Women's Hospital Long Beach
| | - Sima S. Toussi
- Division of Pediatrics Infectious Diseases, Department of Pediatrics, New York-Presbyterian Hospital, Weill Cornell Medical College, New York
| | - Patricia DeLaMora
- Division of Pediatrics Infectious Diseases, Department of Pediatrics, New York-Presbyterian Hospital, Weill Cornell Medical College, New York
| | - Ruta Petraitiene
- Transplantation-Oncology Infectious Diseases Program, Division of Infectious Diseases, Department of Medicine, Weill Cornell Medical Center of Cornell University, New York
| | | | - Thomas J. Walsh
- Transplantation-Oncology Infectious Diseases Program, Division of Infectious Diseases, Department of Medicine, Weill Cornell Medical Center of Cornell University, New York,Department of Microbiology and Immunology, Weill Cornell Medical Center of Cornell University, New York
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12
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Walters HM, Pan N, Lehman TJA, Adams A, Kalliolias GD, Zhu YS, Santiago F, Nguyen J, Sitaras L, Cunningham-Rundles S, Walsh TJ, Toussi SS. The impact of disease activity and tumour necrosis factor-α inhibitor therapy on cytokine levels in juvenile idiopathic arthritis. Clin Exp Immunol 2016; 184:308-17. [PMID: 26934060 DOI: 10.1111/cei.12782] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2016] [Indexed: 12/31/2022] Open
Abstract
The aim of this study was to evaluate prospectively cytokine levels and disease activity in juvenile idiopathic arthritis (JIA) patients treated with and without tumour necrosis factor (TNF)-α inhibitors. TNF-α inhibitor-naive JIA subjects were followed prospectively for 6 months. Cytokine levels of TNF-α, interleukin (IL)-1β, IL-6, IL-8, IL-10 and IL-17 were measured at baseline for JIA subjects and healthy controls (HCs). Cytokine levels were then measured at four time-points after initiation of TNF-α inhibition for anti-TNF-α-treated (anti-TNF) JIA subjects, and at two subsequent time-points for other JIA (non-TNF) subjects. JIA disease activity by Childhood Health Assessment Questionnaire (CHAQ) disability index/pain score and physician joint count/global assessment was recorded. Sixteen anti-TNF, 31 non-TNF and 16 HCs were analysed. Among JIA subjects, those with higher baseline disease activity (subsequent anti-TNFs) had higher baseline TNF-α, IL-6 and IL-8 than those with lower disease activity (non-TNFs) (P < 0·05). TNF-α and IL-10 increased, and IL-6 and IL-8 no longer remained significantly higher after TNF-α inhibitor initiation in anti-TNF subjects. Subgroup analysis of etanercept versus adalimumab-treated subjects showed that TNF-α and IL-17 increased significantly in etanercept but not adalimumab-treated subjects, despite clinical improvement in both groups of subjects. JIA subjects with increased disease activity at baseline had higher serum proinflammatory cytokines. TNF-α inhibition resulted in suppression of IL-6 and IL-8 in parallel with clinical improvement in all anti-TNF-treated subjects, but was also associated with elevated TNF-α and IL-17 in etanercept-treated subjects.
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Affiliation(s)
- H M Walters
- Department of Pediatric Rheumatology, Cohen Children's Medical Center, North-Shore-Long Island Jewish Health System, Lake Success, NY
| | - N Pan
- Department of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - T J A Lehman
- Department of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - A Adams
- Department of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - G D Kalliolias
- Department of Rheumatology, Hospital for Special Surgery, New York, NY, USA.,Arthritis and Tissue Degeneration Program, Hospital for Special Surgery, New York, NY, USA.,Department of Medicine, New York, NY, USA
| | - Y S Zhu
- Clinical and Translational Science Center, Weill Cornell Medical College, New York, NY, USA
| | - F Santiago
- Clinical and Translational Science Center, Weill Cornell Medical College, New York, NY, USA
| | - J Nguyen
- Department of Epidemiology and Biostatistics, Hospital for Special Surgery, New York, NY, USA
| | - L Sitaras
- Department of Pediatrics, New York, NY, USA
| | | | - T J Walsh
- Department of Pediatrics, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, USA
| | - S S Toussi
- Department of Pediatrics, New York, NY, USA
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13
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Walters HM, Pan N, Lehman TJA, Adams A, Huang WT, Sitaras L, Cunningham-Rundles S, Walsh TJ, Toussi SS. A prospective study comparing infection risk and disease activity in children with juvenile idiopathic arthritis treated with and without tumor necrosis factor-alpha inhibitors. Clin Rheumatol 2014; 34:457-64. [PMID: 25227771 DOI: 10.1007/s10067-014-2779-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 08/25/2014] [Accepted: 09/07/2014] [Indexed: 12/19/2022]
Abstract
Tumor necrosis factor-alpha (TNF-α) inhibitors are effective treatment for juvenile idiopathic arthritis (JIA) but may increase infection rates. However, active JIA may also render patients vulnerable to infection. In this study, we prospectively assessed infection rates in JIA patients treated with and without TNF-α inhibitors and correlated disease activity with infection risk. TNF-α inhibitor-naïve JIA subjects were followed up for 12 months. Subjects initiated on TNF-α inhibitors after enrollment were analyzed in the TNF group. Subjects treated without TNF-α inhibitors were analyzed in the non-TNF group. Questionnaires captured mild or severe infections. JIA disease activity by Childhood Health Assessment Questionnaire (CHAQ) disability index/pain score and physician joint count/global assessment was recorded. Twenty TNF and 36 non-TNF subjects were analyzed. The total infection rate ratio for TNF versus non-TNF group subjects was 1.14 (95% CI, 0.78-1.66; p = 0.51). The average rate of infections per month was 0.29 for TNF and 0.24 for non-TNF subjects. No severe infections or hospitalizations occurred in either group. Secondary infectious outcomes were also similar between groups. Controlling for study group, an increase in CHAQ pain score correlated with an increase in several infectious outcome measures. Our results suggest no difference in infection rates between JIA subjects treated with and without TNF-α inhibitors. Additionally, JIA disease activity may have contributed to infection risk in our cohort, irrespective of immunosuppressive therapy. Future analysis of the relationship between treatment regimens, disease activity, and infection rates may help to further delineate predictors of infection risk in JIA patients.
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Affiliation(s)
- Heather M Walters
- Department of Pediatric Rheumatology, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA,
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14
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Dunn-Navarra AM, Toussi SS, Cohn E, Neu N, Larson EL. Measuring media use in college students with and without human immunodeficiency virus infection. J Pediatr Health Care 2014; 28:342-9. [PMID: 24139566 DOI: 10.1016/j.pedhc.2013.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 07/09/2013] [Accepted: 07/17/2013] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Media applications have shown promise for health education. The aims of this study were to develop and evaluate a media survey measure and compare media use among college students with and without human immunodeficiency virus (HIV) infection. METHODS Using a cross-sectional, descriptive design, a convenience sample of college students (N = 53) were recruited. Psychometric testing of the media instrument was performed, and the tool was then used to compare media use among HIV-infected undergraduates (n = 15), other undergraduates (n = 23), and nursing students (n = 15). RESULTS Psychometric testing of the media instrument demonstrated a high degree of reliability (intraclass correlation = .998; 95% confidence intervals = .997, .999). All respondents had computers with Internet access and cellular phones. Among HIV-infected undergraduate students, 86.7% reported spending 5 minutes or more viewing television during the previous 24 hours outside of school and or work, in comparison with 34.8% of the other undergraduate students with no known chronic illness and 46.7% of the nursing students (p = .002 and .05, respectively). Preferred modes to access health information and communicate with health care providers for all respondents were the Internet (86.8%) and telephone (62.3%), respectively. DISCUSSION Assessment of media use among adolescents and young adults will aid in planning for their health education needs.
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Toussi SS, Pan N, Walters HM, Walsh TJ. Infections in children and adolescents with juvenile idiopathic arthritis and inflammatory bowel disease treated with tumor necrosis factor-α inhibitors: systematic review of the literature. Clin Infect Dis 2013; 57:1318-30. [PMID: 23899685 DOI: 10.1093/cid/cit489] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [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: 01/08/2023] Open
Abstract
Tumor necrosis factor alpha (TNF-α) inhibitors are increasingly administered to children and adolescents with juvenile idiopathic arthritis (JIA) and pediatric inflammatory bowel disease (pIBD). Adult studies indicate that TNF-α inhibitors lead to an increased risk of serious infections compared to other disease-modifying antirheumatic drugs. We report herein a systematic literature review detailing the epidemiology and types of infections reported in children with JIA and pIBD treated with TNF-α inhibitors. The most frequently reported infections were mild and characterized as viral in etiology. Severe bacterial and fungal infections also occurred, but were less common and possibly associated with intrinsic risk factors and concurrent immunosuppressive therapy. Few pediatric patients developed Mycobacterium tuberculosis, likely due to effective screening. There were 8 infectious fatalities in children treated with TNF-α inhibitors. Overall, although rare, serious infections occur in immunocompromised children and adolescents with JIA and pIBD receiving TNF-α inhibitors.
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Affiliation(s)
- Sima S Toussi
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Weill Cornell Medical Center
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