Neuropsychiatric side effects of efavirenz therapy

Depression associated with antiretroviral drug therapy in HIV: case report and overview

Depression is the main psychiatric symptom in patients living with HIV. Genetic predisposition, stress from disease as well as the antiretroviral therapy itself are discussed as pathogenic factors. We report a 35-year-old HIV-positive man suffering from bipolar disorder who developed major depression shortly after commercing combination antiretroviral therapy (cART) on three occasions. The first two times the patient ceased therapy autonomously, and the depression disappeared completely. The close connection between cART and major depression in the present case supports the depression-inducing potential of cART. Additionally, we present an overview of literature.

Safety considerations in drug treatment of depression in HIV-positive patients: an updated review

Major depressive disorder (MDD) is one of the most prevalent illnesses associated with HIV infection, and negatively affects medication adherence, disease progression and mortality in HIV disease. Co-morbid treatment of major depression in HIV disease is the optimal therapeutic approach, but discriminating MDD from normal fluctuations in mood state, personality or physiology is difficult. Definitive diagnosis of MDD is critical for drug safety and for avoiding unnecessary exposure to psychotropic medications. HIV patients respond to antidepressant treatment like the general population, and medication adverse effects and patient adherence are the best predictors of treatment outcome. This review attempts to assist the medical provider with the diagnosis and treatment of MDD in HIV patients. We outline the initial steps in screening and psychiatric referral, the antidepressants that are particularly useful in HIV-infected patients, and the adverse effects and pharmacological strategies for overcoming potential barriers to medication adherence. Potential interactions between the various classes of antidepressants and HIV/antiretroviral therapy, as well as management of HIV medication-related psychiatric adverse effects, are also discussed.

HIV-1 NNRTIs: structural diversity, pharmacophore similarity, and implications for drug design

Nonnucleoside reverse transcriptase inhibitors (NNRTIs) nowadays represent very potent and most promising anti-AIDS agents that specifically target the HIV-1 reverse transcriptase (RT). However, the effectiveness of NNRTI drugs can be hampered by rapid emergence of drug-resistant viruses and severe side effects upon long-term use. Therefore, there is an urgent need to develop novel, highly potent NNRTIs with broad spectrum antiviral activity and improved pharmacokinetic properties, and more efficient strategies that facilitate and shorten the drug discovery process would be extremely beneficial. Fortunately, the structural diversity of NNRTIs provided a wide space for novel lead discovery, and the pharmacophore similarity of NNRTIs gave valuable hints for lead discovery and optimization. More importantly, with the continued efforts in the development of computational tools and increased crystallographic information on RT/NNRTI complexes, structure-based approaches using a combination of traditional medicinal chemistry, structural biology, and computational chemistry are being used increasingly in the design of NNRTIs. First, this review covers two decades of research and development for various NNRTI families based on their chemical scaffolds, and then describes the structural similarity of NNRTIs. We have attempted to assemble a comprehensive overview of the general approaches in NNRTI lead discovery and optimization reported in the literature during the last decade. The successful applications of medicinal chemistry strategies, crystallography, and computational tools for designing novel NNRTIs are highlighted. Future directions for research are also outlined.

Treatment considerations for psychiatric syndromes associated with HIV infection

Psychiatric syndromes associated with HIV disease were recognized early in the AIDS epidemic. Public education, new technologies and antiretroviral therapies have resulted in earlier recognition and therapautic interventions of HIV infection, improving the physical health for individuals living with HIV. While HIV-associated psychiatric symptoms have been recognized for more than 20 years, our understanding of the mechanisms underlying psychiatric symptoms among HIV-infected individuals and treatments for these symptoms have not kept pace with advances in HIV therapies. In this article, we discuss current knowledge of the psychiatric symptoms occurring with HIV disease, specifically mood, anxiety and psychotic disorders, evidence-based treatments and treatment considerations, new strategies for the treatments of psychiatric symptoms in HIV disease are also discussed.

N1-Alkyl pyrimidinediones as non-nucleoside inhibitors of HIV-1 reverse transcriptase

A series of N1-alkyl pyrimidinediones were designed, synthesized and evaluated as HIV-1 non-nucleoside reverse transcriptase inhibitors (NNRTIs). Our efforts identified compound 10b, which represents the lead compound in this series with pharmacokinetics and antiviral potency that may support once-daily dosing.

Anti-HIV drugs nevirapine and efavirenz affect anxiety-related behavior and cognitive performance in mice

Nevirapine (NVP) and efavirenz (EFV) belong to the class of anti-HIV drugs called non-nucleoside reverse transcriptase inhibitors (NNRTIs), commonly used as part of highly active antiretroviral therapy (HAART). Although the HAART is able to bring down viral load to undetectable levels and restore immune function, their prolonged use causes several adverse effects. It has been demonstrated that both NVP and EFV are able to cross the blood-brain barrier, causing important central nervous system-related side effects. Thus, this study investigated the effects of chronic administration of EFV (10 mg/kg) and NVP (3.3 mg/kg) in mice submitted to two distinct series of experiments, which aimed to evaluate: (1) the emotional behavior (elevated plus-maze, forced swimming, and open-field test) and (2) the cognitive performance (object recognition and inhibitory avoidance test) of mice. Our results demonstrated that EFV, but not NVP, reduced the exploration to open arms in the elevated plus-maze test. Neither NVP nor EFV altered mouse behavior in the forced swimming and open-field tests. Both drugs reduced the recognition index in the object recognition test, but only EFV significantly impaired the aversive memory assessed in the inhibitory avoidance test 24 h after training. In conclusion, our findings point to a genuine anxiogenic-like effect to EFV, since it reduced exploration to open arms of elevated plus-maze test without affecting spontaneous locomotion. Additionally, both drugs impaired recognition memory, while only the treatment with EFV impaired significantly aversive memory.

Efavirenz: a decade of clinical experience in the treatment of HIV

Efavirenz, a non-nucleoside reverse transcriptase inhibitor, has been an important component of the treatment of HIV infection for 10 years and has contributed significantly to the evolution of highly active antiretroviral therapy (HAART). The efficacy of efavirenz has been established in numerous randomized trials and observational studies in HAART-naive patients, including those with advanced infection. In the ACTG A5142 study, efavirenz showed greater virological efficacy than the boosted protease inhibitor (PI), lopinavir. Efavirenz is more effective as a third agent than unboosted PIs or the nucleoside analogue abacavir. Some, but not all, studies have suggested that efavirenz (added to two nucleoside reverse transcriptase inhibitors) is more effective than nevirapine. Virological and immunological responses achieved with efavirenz-based HAART have been maintained for 7 years. Dosing convenience predicts adherence, and studies have demonstrated that patients can be switched from PI-based therapy to simplified, once-daily efavirenz-based regimens without losing virological control. The one-pill, once-daily formulation of efavirenz plus tenofovir and emtricitabine offers a particular advantage in this regard. Efavirenz also retains a role after failure of a first PI-based regimen. Efavirenz is generally well tolerated: rash and neuropsychiatric disturbances are the most notable adverse events. Neuropsychiatric disturbances generally develop early in treatment and they tend to resolve with continued administration, but they are persistent and troubling in a minority of patients. Efavirenz has less effect on plasma lipid profiles than some boosted PIs. Lipodystrophy can occur under treatment with efavirenz but it may be reduced if the concurrent use of thymidine analogues is avoided. Efavirenz resistance mutations (especially K103N) can be selected during long-term treatment, underscoring the importance of good adherence. Recent data have confirmed that efavirenz is a cost-effective option for first-line HAART. In light of these features, efavirenz retains a key role in HIV treatment strategies and is the first-line agent recommended in some guidelines.

Management of common psychiatric conditions in the HIV-positive population

Presentation and management of psychiatric illness in HIV-infected patients can pose a challenge for clinicians. Psychiatric illness can exist premorbidly or result from the progression and treatment of HIV infection, influencing the course of the illness both through behavior and putative biological factors. Mood disorders, anxiety, psychosis, delirium, dementia, and substance abuse disorders all factor heavily into the care of HIV-infected patients. Management, however, continues to draw on small and skewed datasets, and remains largely an extrapolation from seronegative patient experience. The following is a discussion of treatment considerations derived from recent literature, as well as a consideration of judgments that clinicians may make in the absence of available data. The use of antidepressants, stimulants, mood stabilizers, and antipsychotics is discussed, as are precautions that must be taken with the HIV population when using these medications, not only because of side effect vulnerability, but because of significant drug-drug interactions.

Effects of the HIV treatment drugs nevirapine and efavirenz on brain creatine kinase activity

Nevirapine (NVP) and efavirenz (EFV) are antiretroviral drugs belonging to potent class of non-nucleoside reverse transcriptase inhibitors (NNRTIs) widely used for the treatment human immunodeficiency virus (HIV) infection. It has been demonstrated that NVP and EFV are able to cross the blood-brain barrier and arrive at the central nervous system (CNS), causing important adverse effects related to their presence within this tissue. Considering that the exact mechanisms responsible for CNS toxicity associated with NVP and EFV remain unknown and that creatine kinase (CK) plays an important role in cell energy homeostasis, in the present work we evaluated CK activity in brain of mice after chronic administration of these drugs. Our results demonstrated that NVP and EFV significantly inhibited CK activity in cerebellum, hippocampus, striatum and cortex of mice. Although it is difficult to extrapolate our findings to the human condition, the inhibition of brain CK activity by NVP and EFV may be associated with neurological adverse symptoms of these drugs.

Impact of depression on HIV outcomes in the HAART era

Highly active antiretroviral therapy (HAART) has significantly decreased the morbidity and mortality of persons infected with HIV. The extent of the benefits, however, is not uniform, and certain factors including ethnicity, gender, baseline HIV viral load and CD4+ T lymphocyte count, adherence and intravenous drug abuse are associated with different immunological, virological and clinical outcomes. Mental health illness (MHI) and specifically depression may be associated with worse outcomes, although studies exploring the impact of MHI on HIV outcomes in both the pre-HAART and post-HAART eras have shown mixed results. The objective of the current paper is to review the available literature on the impact of MHI on HIV outcomes in the HAART era.

Targeting protein–protein interactions for HIV therapeutics

The majority of current anti-HIV drugs target the viral reverse transcriptase or protease enzymes. However, enfuvirtide and maraviroc are drugs that have been US FDA approved recently and which function by inhibiting virus cell binding and entry which normally occurs through the interaction of the viral envelope protein with its cellular coreceptor. As HIV-1 utilizes many cellular cofactors during its replication cycle, there are a number of other protein–protein interactions that can serve as targets for anti-HIV drug development. In this review article we discuss the general method used to identify anti-HIV drugs that function through targeting protein–protein interactions. We also discuss the currently known cellular cofactors that may serve as targets in future drugs screens.