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Cirrincione LR, Huang KJ, Sequeira GM. Clinical pharmacology in adolescent transgender medicine. Br J Clin Pharmacol 2024. [PMID: 39187392 DOI: 10.1111/bcp.16213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 07/18/2024] [Accepted: 07/19/2024] [Indexed: 08/28/2024] Open
Abstract
Adolescent transgender medicine is a growing clinical field. Gender-affirming medications for transgender youth may include gonadotropin-releasing hormone (GnRH) agonists, gender-affirming hormones or both. To evaluate the potential effects of GnRH agonists (puberty suppression) on pharmacokinetic processes for transgender youth, we searched PubMed from inception to May 2024 for publications on the effects of GnRH agonists on drug absorption, distribution, metabolism or excretion for transgender adolescents or effects on hormones (including gonadotropins, adrenal androgens, sex steroids) that are associated with changes in drug metabolism during puberty in the general adolescent population. No publications discussed the effects of GnRH agonist treatment on pharmacokinetic processes for adolescent transgender people. Sixteen publications observed marked decreases in gonadotropins and sex steroids for both adolescent transgender men and adolescent transgender women and slight effects on adrenal androgens. During GnRH agonist treatment, changes in body composition and body shape were greater for adolescent transgender people than for cisgender adolescent people. Further research is needed to better understand the effects of GnRH agonists on drug metabolism and other pharmacokinetic processes for transgender adolescents receiving GnRH agonists and other gender-affirming medications.
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Affiliation(s)
| | - Kai J Huang
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Gina M Sequeira
- Seattle Children's Hospital, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
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Naz-McLean S, Clark J, Huerta L, Mayer KH, Lama JR, Reisner S, Perez-Brumer A. Social, economic, and physical side effects impact PrEP uptake and persistence among transgender women in Peru. BMC Public Health 2024; 24:1985. [PMID: 39054504 PMCID: PMC11270771 DOI: 10.1186/s12889-024-19474-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 07/12/2024] [Indexed: 07/27/2024] Open
Abstract
INTRODUCTION Oral pre-exposure prophylaxis (PrEP) for HIV-1 infection is over 99% effective in protecting against HIV acquisition when used consistently and appropriately. However, PrEP uptake and persistent use remains suboptimal, with a substantial gap in utilization among key populations who could most benefit from PrEP. In Latin America specifically, there is poor understanding of barriers to PrEP uptake and persistence among transgender (trans) women. METHODS In April-May 2018, we conducted qualitative interviews lasting 25-45 min as part of an end-of-project evaluation of TransPrEP, a pilot RCT that examined the impact of a social network-based peer support intervention on PrEP adherence among trans women in Lima, Peru. Participants in the qualitative evaluation, all adult trans women, included individuals who either (1) screened eligible to participate in the TransPrEP pilot, but opted not to enroll (n = 8), (2) enrolled, but later withdrew (n = 6), (3) were still actively enrolled at the time of interview and/or successfully completed the study (n = 16), or (4) were study staff (n = 4). Interviews were audio recorded and transcribed verbatim. Codebook development followed an immersion/crystallization approach, and coding was completed using Dedoose. RESULTS Evaluation participants had a mean age of 28.2 years (range 19-47). When describing experiences taking PrEP, participant narratives highlighted side effects that spanned three domains: physical side effects, such as prolonged symptoms of gastrointestinal distress or somnolence; economic challenges, including lost income due to inability to work; and social concerns, including interpersonal conflicts due to HIV-related stigma. Participants described PrEP use within a broader context of social and economic marginalization, with a focus on daily survival, and how PrEP side effects negatively contributed to these stressors. Persistence was, in some cases, supported through the intervention's educational workshops. CONCLUSION This research highlights the ways that physical, economic, and social side effects of PrEP can impact acceptability and persistence among trans women in Peru, amplifying and layering onto existing stressors including economic precarity. Understanding the unique experiences of trans women taking PrEP is crucial to informing tailored interventions to improve uptake and persistence.
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Affiliation(s)
- Sarah Naz-McLean
- Department of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Health Sciences Building 155 College Street, Toronto, ON, M5T 3M7, Canada.
- Department of Medicine, Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA.
| | - Jesse Clark
- Department of Medicine, Division of Infectious Diseases, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | | | - Kenneth H Mayer
- The Fenway Institute, Fenway Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Javier R Lama
- Asociacion Civil Impacta Salud y Educacion, Lima, Peru
| | - Sari Reisner
- The Fenway Institute, Fenway Health, Boston, MA, USA
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, USA
| | - Amaya Perez-Brumer
- Division of Social and Behavioural Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Senneker T. Drug-drug interactions between gender-affirming hormone therapy and antiretrovirals for treatment/prevention of HIV. Br J Clin Pharmacol 2024. [PMID: 38866600 DOI: 10.1111/bcp.16097] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/17/2024] [Accepted: 04/21/2024] [Indexed: 06/14/2024] Open
Abstract
Transgender persons face a greater burden of HIV compared to cisgender counterparts. Concerns around drug-drug interactions (DDIs) have been cited as reasons for lower engagement in HIV care and lower pre-exposure prophylaxis (PrEP) uptake among transgender populations. It is therefore imperative for hormone therapy, PrEP and antiretroviral therapy providers to understand the DDI potential between these therapies. Studies of tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) PrEP with feminizing hormone therapies (FHTs) show reduced plasma tenofovir concentrations, but intracellular concentrations of tenofovir-diphosphate are not reduced. Efficacy of PrEP is expected to be maintained despite this interaction. Masculinizing hormone therapies have no effect on tenofovir concentrations but may increase FTC to a nonclinically relevant extent. No interactions between FHT and cabotegravir or tenofovir alafenamide have been demonstrated. Administration of TDF/FTC PrEP has no effect on hormone levels in transmen or transwomen. PrEP is expected to be effective and safe in transpersons and should be provided to high-risk individuals regardless of gender affirming hormone use. Enzyme inducing/inhibiting antiretroviral therapy may decrease or increase, respectively, the concentrations of FHT and masculinizing hormone therapy. Unboosted integrase inhibitors or enzyme neutral non-nucleoside reverse transcriptase inhibitors are not expected to affect and are not affected by gender affirming hormones and can be considered in transmen and transwomen. Overlapping toxicities including weight gain, dyslipidaemia, cardiovascular disease and bone density effects should be considered, and antiretroviral modifications can be made to minimize toxicities. Interactions between supportive care medications should be assessed to avoid chelation interactions and hyperkalaemia.
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Affiliation(s)
- Tessa Senneker
- Kingston Health Sciences Centre, Kingston, Ontario, Canada
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Patel N, Morris S, Burke L, Chow K, Pacheco D, Anderson P, Stancyzk F, Blumenthal J. No observed bidirectional effect between tenofovir diphosphate concentrations and gender-affirming hormone concentrations among transgender persons switching from tenofovir disoproxil fumarate/emtricitabine to tenofovir alafenamide/emtricitabine for HIV pre-exposure prophylaxis. Br J Clin Pharmacol 2024. [PMID: 38646796 DOI: 10.1111/bcp.16071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/17/2024] [Accepted: 03/21/2024] [Indexed: 04/23/2024] Open
Abstract
AIMS Many transgender and gender diverse (TGD) individuals have expressed concerns about the potential for oral pre-exposure prophylaxis to affect hormonal concentrations achieved from taking gender-affirming hormone therapy (GAHT). The purpose of this study was to understand the bidirectional effects between hormone and intraerythrocytic tenofovir diphosphate concentrations when switching from tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) to tenofovir alafenamide/emtricitabine (TAF/FTC) in TGD users/nonusers of GAHT. METHODS The study evaluated stored blood samples and dried blood spot cards from TGD adults without HIV who took ≥12 weeks of TDF/FTC and then switched to ≥12 weeks of TAF/FTC for pre-exposure prophylaxis. RESULTS Thirty-nine individuals met the study inclusion criteria. Regardless of sex assigned at birth and the use of GAHT, there were no significant differences in hormone concentrations when individuals taking GAHT were taking TDF/FTC and then switched to TAF/FTC. Further, there was no significant difference in intraerythrocytic tenofovir diphosphate concentrations between users and nonusers of GAHT. CONCLUSION There are no bidirectional effects between hormone and intraerythocytic tenofovir diphosphate concentrations when switching from TDF/FTC to TAF/FTC in TGD users/nonusers of GAHT.
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Affiliation(s)
- Nimish Patel
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
| | - Sheldon Morris
- School of Medicine, University of California San Diego, La Jolla, California, USA
- AntiViral Research Center, University of California San Diego, La Jolla, California, USA
| | - Leah Burke
- AntiViral Research Center, University of California San Diego, La Jolla, California, USA
| | - Karen Chow
- AntiViral Research Center, University of California San Diego, La Jolla, California, USA
| | - Deedee Pacheco
- AntiViral Research Center, University of California San Diego, La Jolla, California, USA
| | - Peter Anderson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Frank Stancyzk
- University of Southern California, Los Angeles, California, USA
| | - Jill Blumenthal
- School of Medicine, University of California San Diego, La Jolla, California, USA
- AntiViral Research Center, University of California San Diego, La Jolla, California, USA
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Lam K, Kraft WK, Zhan T, Lam E. Bidirectional pharmacokinetics of doravirine, tenofovir, and feminizing hormones in transgender women (IDentify): A randomized crossover trial. Clin Transl Sci 2024; 17:e13721. [PMID: 38421210 PMCID: PMC10903328 DOI: 10.1111/cts.13721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/18/2023] [Accepted: 12/22/2023] [Indexed: 03/02/2024] Open
Abstract
Transgender women may have concerns of drug interactions between feminizing hormone therapy (FHT) and antiretrovirals, leading to nonadherence. This randomized, three-period crossover, open-label, phase I trial assessed the effects of doravirine (DOR) and tenofovir disoproxil fumarate (TDF) on the pharmacokinetics (PKs) of estradiol, spironolactone, and total testosterone and vice versa in healthy transgender women. Volunteers were randomized 1:1 into two sequences containing three treatment groups (DOR, lamivudine [3TC], and TDF alone; estradiol, spironolactone, and placebo; and DOR/3TC/TDF, estradiol, and spironolactone). Eight subjects enrolled in the study and six had completed all study periods. The geometric mean ratios for DOR area under the concentration-time curve from zero to last measured concentration (AUC0-last ), maximum concentration (Cmax ), and concentration at 24 h (C24 ) were similar. However, tenofovir (TFV) AUC0-last , Cmax , and C24 moderately increased by 14%-38%. Last, estradiol AUC0-last , Cmax , and C24 were increased by 10%-13%. Whereas most 90% confidence intervals did not meet the bioequivalence bounds of 80%-125%, the point estimates fell within the intervals. Log-transformed DOR, TFV, and estradiol PK parameters computed with and without co-administration were not statistically different (p > 0.05). There were no serious adverse events. There is not a clinically significant impact of FHT on DOR/TFV PKs. Similarly, there is no observed impact on estradiol PKs and total testosterone following use of DOR/3TC/TDF.
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Affiliation(s)
- Kevin Lam
- Department of Pharmacology, Physiology, and Cancer BiologyThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Walter K. Kraft
- Department of Pharmacology, Physiology, and Cancer BiologyThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Tingting Zhan
- Department of Pharmacology, Physiology, and Cancer BiologyThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Edwin Lam
- Clinical Pharmacokinetics Research LabNational Institutes of HealthBethesdaMarylandUSA
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Cespedes MS, Das M, Yager J, Prins M, Krznaric I, de Jong J, Xiao D, Shao Y, Wong P, Kintu A, Carter C, Hoornenborg E, Ruane P, Phoenix J, Younis I, Halperin J. Gender Affirming Hormones Do Not Affect the Exposure and Efficacy of F/TDF or F/TAF for HIV Preexposure Prophylaxis: A Subgroup Analysis from the DISCOVER Trial. Transgend Health 2024; 9:46-52. [PMID: 38312459 PMCID: PMC10835152 DOI: 10.1089/trgh.2022.0048] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose Transgender women are disproportionately affected by HIV and are underutilizing preexposure prophylaxis (PrEP). The lower uptake of PrEP by transgender women may be, in part, owing to the perception that taking PrEP may lower the efficacy of gender-affirming hormone therapy (GAHT) or to provider concerns that GAHT may lower the efficacy of PrEP. Methods DISCOVER was a randomized, double-blind, noninferiority trial comparing emtricitabine (FTC, F) and tenofovir alafenamide (F/TAF) versus emtricitabine and tenofovir disoproxil fumarate (F/TDF) as PrEP among transgender women and cisgender men who have sex with men (MSM). This nested substudy of the DISCOVER trial compared the exposure of the active intracellular metabolites of FTC and tenofovir (TFV), FTC triphosphate (FTC-TP) and TFV diphosphate (TFV-DP), in peripheral blood mononuclear cells (PBMC) among transgender women receiving GAHT versus MSM within the F/TAF and F/TDF groups. Results Our results demonstrate that TFV-DP and FTC-TP levels in PBMC were comparable between transgender women on GAHT and MSM receiving F/TAF, and between transgender women on GAHT and MSM receiving F/TDF. TFV-DP concentrations remained above the EC90 of 40 fmol/106 cells across all groups. No clinically significant drug-drug interactions of GAHT were observed with either F/TAF or F/TDF in this subanalysis. Conclusions These findings are consistent with the clinical pharmacology of GAHT, FTC, TDF, and TAF reported in previous studies, and support the continued use of F/TAF and F/TDF for PrEP in transgender women. Clinicaltrials.gov registration number: NCT02842086.
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Affiliation(s)
- Michelle S Cespedes
- Division of Infectious Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Moupali Das
- Gilead Sciences, Foster City, California, USA
| | - Jenna Yager
- Gilead Sciences, Foster City, California, USA
| | - Maria Prins
- Department of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Centers (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Ivanka Krznaric
- Zentrum für Infektiologie Berlin Prenzlauer Berg, Berlin, Germany
| | - Jan de Jong
- Gilead Sciences, Foster City, California, USA
| | - Deqing Xiao
- Gilead Sciences, Foster City, California, USA
| | - Yongwu Shao
- Gilead Sciences, Foster City, California, USA
| | - Pamela Wong
- Gilead Sciences, Foster City, California, USA
| | | | | | - Elske Hoornenborg
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, The Netherlands
| | - Peter Ruane
- Ruane Clinical Research Group, Inc., Los Angeles, California, USA
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Cattani VB, Jalil EM, Eksterman L, Torres T, Wagner Cardoso S, Castro CRV, Monteiro L, Wilson E, Bushman L, Anderson P, Veloso VG, Grinsztejn B, Estrela R. Estradiol and Spironolactone Plasma Pharmacokinetics Among Brazilian Transgender Women Using HIV Pre-Exposure Prophylaxis: Analysis of Potential Interactions. Clin Pharmacokinet 2023; 62:1031-1041. [PMID: 37261664 PMCID: PMC10338392 DOI: 10.1007/s40262-023-01248-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND AND OBJECTIVE An important barrier to HIV prevention among transgender women (TGW) is the concern that oral pre-exposure prophylaxis (PrEP) negatively affects the efficacy of feminizing hormone therapy (FHT). We aimed to assess the impact of PrEP on FHT pharmacokinetics (PK) among TGW from Brazil. METHODS We performed a drug-drug interaction sub-study among TGW enrolled in a daily oral PrEP demonstration study (PrEParadas, NCT03220152). Participants had a first PK assessment (PK1) 15 days after FHT (estradiol valerate 2-6 mg plus spironolactone 100-200 mg) initiation and then started PrEP (tenofovir disoproxil fumarate 300 mg/emtricitabine 200 mg). A second PK evaluation was performed 12 weeks later (PK2). Blood samples were collected prior and after the directly observed dosing (0, 0.5, 1, 2, 4, 6, 8, and 24 hours). Pharmacokinetic parameters of estradiol, spironolactone, and metabolites were estimated by non-compartmental analysis (Monolix 2021R2, Lixoft®) and compared as geometric mean ratios (GMRs, 90% confidence interval [CI]). RESULTS Among 19 TGW who completed the substudy, median age was 26 years (interquartile range: 23-27.5). Estradiol area under the plasma concentration-time curve (AUCτ) and trough concentrations did not differ between PK1 and PK2 evaluations (GMR [90% CI]: 0.89 [0.76-1.04] and 1.06 [0.94-1.20], respectively). Spironolactone and canrenone AUCτ were statistically lower at PK2 than PK1 (0.76 [0.65-0.89] and 0.85 [0.78-0.94], respectively). Canrenone maximum concentration was also lower at PK2 than PK1 (0.82 [0.74-0.91]). CONCLUSION Estradiol PK was not influenced by PrEP concomitant use. The small differences observed in some spironolactone and canrenone PK parameters should not prevent the concomitant use of estradiol-based FHT and PrEP. TRIAL REGISTRATION This trial (NCT03220152) was registered on July 18, 2017.
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Affiliation(s)
- Vitória Berg Cattani
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil.
| | - Emilia Moreira Jalil
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Leonardo Eksterman
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Thiago Torres
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Sandra Wagner Cardoso
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Cristiane R V Castro
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Laylla Monteiro
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Erin Wilson
- University of California, San Francisco, USA
| | | | | | | | - Beatriz Grinsztejn
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Rita Estrela
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil.
- Faculty of Pharmacy, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
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