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Le X, Shen Y. Advances in Antiretroviral Therapy for Patients with Human Immunodeficiency Virus-Associated Tuberculosis. Viruses 2024; 16:494. [PMID: 38675837 PMCID: PMC11054420 DOI: 10.3390/v16040494] [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: 02/06/2024] [Revised: 03/09/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024] Open
Abstract
Tuberculosis is one of the most common opportunistic infections and a prominent cause of death in patients with human immunodeficiency virus (HIV) infection, in spite of near-universal access to antiretroviral therapy (ART) and tuberculosis preventive therapy. For patients with active tuberculosis but not yet receiving ART, starting ART after anti-tuberculosis treatment can complicate clinical management due to drug toxicities, drug-drug interactions and immune reconstitution inflammatory syndrome (IRIS) events. The timing of ART initiation has a crucial impact on treatment outcomes, especially for patients with tuberculous meningitis. The principles of ART in patients with HIV-associated tuberculosis are specific and relatively complex in comparison to patients with other opportunistic infections or cancers. In this review, we summarize the current progress in the timing of ART initiation, ART regimens, drug-drug interactions between anti-tuberculosis and antiretroviral agents, and IRIS.
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Affiliation(s)
| | - Yinzhong Shen
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China;
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Maranchick NF, Kwara A, Peloquin CA. Clinical considerations and pharmacokinetic interactions between HIV and tuberculosis therapeutics. Expert Rev Clin Pharmacol 2024. [PMID: 38339997 DOI: 10.1080/17512433.2024.2317954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 02/08/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Tuberculosis(TB) is a leading infectious diseases cause of mortality worldwide,especially for people living with human immunodeficiency virus(PLWH). Treating TB in PLWH can be challenging due to numerous druginteractions. AREASCOVERED Thisreview discusses drug interactions between antitubercular andantiretroviral drugs. Due to its clinical importance, initiation ofantiretroviral therapy in patients requiring TB treatment isdiscussed. Special focus is placed on the rifamycin class, as itaccounts for the majority of interactions. Clinically relevantguidance is provided on how to manage these interactions. Anadditional section on utilizing therapeutic drug monitoring (TDM) tooptimize drug exposure and minimize toxicities is included. EXPERTOPINION Antitubercularand antiretroviral coadministration can be successfully managed. TDMcan be used to optimize drug exposure and minimize toxicity risk. Asnew TB and HIV drugs are discovered, additional research will beneeded to assess for clinically relevant drug interactions.
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Affiliation(s)
- Nicole F Maranchick
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
| | - Awewura Kwara
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
- Division of Infectious Diseases and Global Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
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Brooks KM, Pau AK, Swaim D, Bunn HT, Adeojo L, Peloquin CA, Kumar P, Kovacs JA, George JM. Pharmacokinetics, Safety, and Tolerability of Once-Daily Darunavir With Cobicistat and Weekly Isoniazid/Rifapentine. J Acquir Immune Defic Syndr 2023; 94:468-473. [PMID: 37955446 PMCID: PMC10651166 DOI: 10.1097/qai.0000000000003301] [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: 04/18/2023] [Accepted: 08/21/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Once-weekly isoniazid with rifapentine (HP) for 3 months is a recommended treatment for latent tuberculosis infection in persons with HIV. HP reduces exposures of certain antiretroviral medications, resulting in limited options for the concomitant use of these therapies. Here, we examined the pharmacokinetics (PK), safety, and tolerability of darunavir/cobicistat with HP. METHODS This was an open-label, fixed sequence, two-period crossover study in persons without HIV. Participants received darunavir 800 mg/cobicistat 150 mg once-daily alone for 4 days, then continued darunavir/cobicistat once-daily for days 5-19 with HP coadministration on days 5, 12, and 19. Intensive PK assessments were performed on days 4, 14, and 19. PK parameters were determined using noncompartmental methods. Geometric mean ratios with 90% confidence intervals (CIs) were calculated and compared between phases using mixed-effects models. RESULTS Thirteen participants were enrolled. Two withdrew after day 4, and one withdrew after day 14. Of the 3 withdrawals, 2 were attributed to drug-related adverse events. Darunavir area under the concentration-time curve, maximum concentrations (Cmax), and concentrations at 24 hours postdose (C24h) were reduced by 71%, 41%, and 96% ∼48-72 hours after HP administration (day 14), respectively, and 36%, 17%, and 89% with simultaneous HP administration (day 19), respectively. On day 14, 45% of the predose and 73% of C24h concentrations were below the darunavir EC50 (0.055 µg/mL). CONCLUSIONS Darunavir exposures were significantly decreased with HP coadministration. Temporal relationships between HP coadministration and the extent of induction or mixed inhibition/induction of darunavir metabolism were apparent. Coadministration of darunavir/cobicistat with 3HP should be avoided.
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Affiliation(s)
- Kristina M Brooks
- Clinical Pharmacokinetic Research Laboratory, Clinical Center Pharmacy Department, NIH Clinical Center, Bethesda, MD, USA
- Currently, Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Alice K Pau
- National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | - Doris Swaim
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Haden T Bunn
- Clinical Pharmacokinetic Research Laboratory, Clinical Center Pharmacy Department, NIH Clinical Center, Bethesda, MD, USA
- Currently, Pumas-AI, Inc., Centreville, VA
| | - Lilian Adeojo
- Clinical Pharmacokinetic Research Laboratory, Clinical Center Pharmacy Department, NIH Clinical Center, Bethesda, MD, USA
- Currently, Arcus Biosciences, Hayward, CA
| | - Charles A Peloquin
- University of Florida College of Pharmacy and Emerging Pathogens Institute, Gainesville, FL
| | - Parag Kumar
- Clinical Pharmacokinetic Research Laboratory, Clinical Center Pharmacy Department, NIH Clinical Center, Bethesda, MD, USA
- Currently, Gilead Sciences, Inc., Foster City, CA
| | - Joseph A Kovacs
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD; and
| | - Jomy M George
- Clinical Pharmacokinetic Research Laboratory, Clinical Center Pharmacy Department, NIH Clinical Center, Bethesda, MD, USA
- Currently, Office of Regulatory Affairs, Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, NIH, Rockville, MD
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Ibrahim SM, Pithavala YK, Vourvahis M, Chen J. A Literature Review of Liver Function Test Elevations in Rifampin Drug-Drug Interaction Studies. Clin Transl Sci 2022; 15:1561-1580. [PMID: 35470578 PMCID: PMC9283752 DOI: 10.1111/cts.13281] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/15/2022] [Accepted: 03/30/2022] [Indexed: 12/15/2022] Open
Abstract
Although rifampin drug–drug interaction (DDI) studies are routinely conducted, there have been instances of liver function test (LFT) elevations, warranting further evaluation. A literature review was conducted to identify studies in which combination with rifampin resulted in hepatic events and evaluate any similarities. Over 600 abstracts and manuscripts describing rifampin DDI studies were first evaluated, of which 30 clinical studies reported LFT elevations. Out of these, 11 studies included ritonavir in combination with other drug(s) in the rifampin DDI study. The number of subjects that were discontinued from treatment on these studies ranged from 0 to 71 (0–100% of subjects in each study). The number of subjects hospitalized for adverse events in these studies ranged from 0 to 41 (0–83.67% of subjects in each study). LFT elevations in greater than 50% of subjects were noted during the concomitant administration of rifampin with ritonavir‐boosted protease inhibitors and with lorlatinib; with labeled contraindication due to observed hepatotoxicity related safety findings only for saquinavir/ritonavir and lorlatinib. In the lorlatinib and ritonavir DDI studies, considerable LFT elevations were observed rapidly, typically within 24–72 h following co‐administration. A possible sequence effect has been speculated, where rifampin induction prior to administration of the combination may be associated with increased severity of the LFT elevations. The potential role of rifampin in the metabolic activation of certain drugs into metabolites with hepatic effects needs to be taken into consideration when conducting rifampin DDI studies, particularly those for which the metabolic profiles are not fully elucidated.
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Affiliation(s)
- Sherry M Ibrahim
- University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego, CA, USA
| | - Yazdi K Pithavala
- Pfizer Inc., Global Product Development, Clinical Pharmacology, La Jolla, CA, USA
| | - Manoli Vourvahis
- Pfizer Inc., Global Product Development, Clinical Pharmacology, New York, NY, USA
| | - Joseph Chen
- Pfizer Inc., Global Product Development, Clinical Pharmacology, San Francisco, CA, USA
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Predicting Drug-Drug Interactions between Rifampicin and Ritonavir-Boosted Atazanavir Using PBPK Modelling. Clin Pharmacokinet 2021; 61:375-386. [PMID: 34635995 PMCID: PMC9481493 DOI: 10.1007/s40262-021-01067-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2021] [Indexed: 01/12/2023]
Abstract
Objectives The aim of this study was to simulate the drug–drug interaction (DDI) between ritonavir-boosted atazanavir (ATV/r) and rifampicin (RIF) using physiologically based pharmacokinetic (PBPK) modelling, and to predict suitable dose adjustments for ATV/r for the treatment of people living with HIV (PLWH) co-infected with tuberculosis. Methods A whole-body DDI PBPK model was designed using Simbiology 9.6.0 (MATLAB R2019a) and verified against reported clinical data for all drugs administered alone and concomitantly. The model contained the induction mechanisms of RIF and ritonavir (RTV), the inhibition effect of RTV for the enzymes involved in the DDI, and the induction and inhibition mechanisms of RIF and RTV on the uptake and efflux hepatic transporters. The model was considered verified if the observed versus predicted pharmacokinetic values were within twofold. Alternative ATV/r dosing regimens were simulated to achieve the trough concentration (Ctrough) clinical cut-off of 150 ng/mL. Results The PBPK model was successfully verified according to the criteria. Simulation of different dose adjustments predicted that a change in regimen to twice-daily ATV/r (300/100 or 300/200 mg) may alleviate the induction effect of RIF on ATV Ctrough, with > 95% of individuals predicted to achieve Ctrough above the clinical cut-off. Conclusions The developed PBPK model characterized the induction-mediated DDI between RIF and ATV/r, accurately predicting the reduction of ATV plasma concentrations in line with observed clinical data. A change in the ATV/r dosing regimen from once-daily to twice-daily was predicted to mitigate the effect of the DDI on the Ctrough of ATV, maintaining plasma concentration levels above the therapeutic threshold for most patients. Supplementary Information The online version contains supplementary material available at 10.1007/s40262-021-01067-1.
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