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Ahmad G, Moinard N, Jouanolou V, Daudin M, Gandia P, Bujan L. In vitro assessment of the adverse effects of antiretroviral drugs on the human male gamete. Toxicol In Vitro 2011; 25:485-91. [DOI: 10.1016/j.tiv.2010.11.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2010] [Revised: 11/14/2010] [Accepted: 11/26/2010] [Indexed: 10/18/2022]
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Abstract
The natural history of chronic viral hepatitis is altered by HIV coinfection. Liver fibrosis rates and clinical features of liver disease develop more rapidly. Although HIV-hepatitis C virus coinfected subjects may progress more rapidly to AIDS, this is probably explained by comorbid illness, substance abuse and socioeconomic circumstances. Safe and virologically active treatment of HIV-hepatitis B virus coinfection can be concurrently achieved by the use of highly active antiretroviral therapy regimens containing lamivudine and/or tenofovir. In most cases, highly active antiretroviral therapy represents the most beneficial initial pharmaceutical intervention for HIV-hepatitisC virus coinfection. HepatitisC virus antiviral therapy should, in most cases, be reserved for those achieving HIV RNA suppression and immune restoration from highly active antiretroviral therapy or with nadir CD4 T-lymphocytes above 350 cells/microl.
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Affiliation(s)
- Curtis L Cooper
- The Ottawa Hospital--General Campus, Room G12, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada.
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3
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Lori F, Kelly LM, Foli A, Lisziewicz J. Safety of hydroxyurea in the treatment of HIV infection. Expert Opin Drug Saf 2005; 3:279-88. [PMID: 15268646 DOI: 10.1517/14740338.3.4.279] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Lifelong adherence to very complex anti-HIV therapy presents drawbacks such as drug resistance and chronic drug-related toxicity, underscoring the need for innovative therapeutic options. As it is becoming increasingly evident that immune activation may be responsible for immune pathology, novel approaches to limit immune activation are under investigation. Hydroxyurea is the prototype of a new family of anti-HIV drugs called virostatics, acting both as an antiviral (directly suppressing HIV) and cytostatic (preventing immune system overactivation). Data from in vitro and clinical studies have proven that hydroxyurea-based regimens are effective options for patients with HIV. However, concerns over hydroxyurea toxicity have limited its use. This review critically examines the role of hydroxyurea for HIV-infected patients, focusing on past and recent clinical trials including the RIGHT 702 study, which identified the safest and most efficacious hydroxyurea dose.
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Affiliation(s)
- Franco Lori
- Research Institute for Genetic and Human Therapy (RIGHT) at IRCCS Policlinico S. Matteo, Pavia, Italy
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Moreno A, Quereda C, Moreno L, Perez-Elías MJ, Muriel A, Casado JL, Antela A, Dronda F, Navas E, Bárcena R, Moreno S. High Rate of Didanosine-Related Mitochondrial Toxicity in HIV/HCV-Coinfected Patients Receiving Ribavirin. Antivir Ther 2004. [DOI: 10.1177/135965350400900108] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Nucleoside analogues may induce mitochondrial toxicity, particularly didanosine. Ribavirin increases didanosine exposure, which might be clinically relevant when coadministered in HIV/HCV-coinfected patients. Objective To evaluate, among 89 patients receiving highly active antiretroviral therapy (HAART) and therapy for chronic hepatitis C, clinically relevant mitochondrial toxicity in those treated with concomitant ribavirin and didanosine ( n=35, 39%). Methods From January 2000 to July 2002 longitudinal analysis of the incidence and clinical course of didanosine-related hyperamylasaemia, pancreatitis, hyperlactataemia/lactic acidosis or neuropathy. Risk factors were evaluated using univariate and multivariate Cox's proportional hazards model. Results Among 35 patients who received concomitant didanosine (400 mg/day in 86%) and ribavirin (≥10 mg/kg/day in 91%), 20 (57%) developed one or more adverse events after a mean of 87 days. Most frequent laboratory abnormalities were hyperamylasaemia (18 patients, 51%) and hyperlactataemia (eight patients, 23%). Acute pancreatitis and symptomatic hyperlactataemia developed in 10 (28%) and six (17%) patients, respectively. Two patients (6%) with pancreatitis and severe lactic acidosis died; the other patients recovered uneventfully despite continuation of anti-HCV therapy in 83% after didanosine withdrawal in 40%. In the Cox's model higher baseline amylase levels (HR: 1.04, 95% CI: 1.02–1.06, P=0.001) and three nucleoside reverse transcriptase inhibitor-based HAART (HR: 5.3, 95% CI: 1.73–16.24, P=0.003) were significantly associated to toxicity. Conclusions The coadministration of didanosine and ribavirin should be avoided in HIV/HCV-coinfected patients, due to a high rate of clinically significant toxicity, particularly in triple nucleoside-based HAART. Amylase levels should be strictly monitored, especially if elevated at baseline.
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Affiliation(s)
- Ana Moreno
- Infectious Diseases, Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, Spain
| | - Carmen Quereda
- Infectious Diseases, Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, Spain
| | - Leonor Moreno
- Infectious Diseases, Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, Spain
| | - María J Perez-Elías
- Infectious Diseases, Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, Spain
| | - Alfonso Muriel
- Infectious Diseases, Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, Spain
| | - Jose L Casado
- Infectious Diseases, Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, Spain
| | - Antonio Antela
- Infectious Diseases, Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, Spain
| | - Fernando Dronda
- Infectious Diseases, Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, Spain
| | - Enrique Navas
- Infectious Diseases, Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, Spain
| | - Rafael Bárcena
- Liver-Gastroenterology Services, Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, Spain
| | - Santiago Moreno
- Infectious Diseases, Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, Spain
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Lisziewicz J, Foli A, Wainberg M, Lori F. Hydroxyurea in the treatment of HIV infection: clinical efficacy and safety concerns. Drug Saf 2003; 26:605-24. [PMID: 12814330 DOI: 10.2165/00002018-200326090-00002] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Data from basic science and clinical studies suggest that hydroxyurea (hydroxycarbamide)-based regimens are effective treatment options for patients with HIV at various stages of disease. In vitro studies of HIV-infected lymphocytes have shown that hydroxyurea: (i) inhibits viral DNA synthesis; (ii) synergistically interacts with nucleoside reverse transcriptase inhibitors (NRTI); and (iii) increases the antiviral activity of didanosine. Clinical studies have confirmed that hydroxyurea in combination with didanosine produces potent and sustained viral suppression in patients with HIV infection. However, some concerns have been recently raised on the use of hydroxyurea in association with NRTI. Hydroxyurea can cause myelosuppression, skin toxicities, mild gastrointestinal toxicity, and abnormalities of renal and liver functions. In addition, hydroxyurea may accentuate the toxic effects of nucleoside analogues. In fact, some clinical data seem to indicate an increased risk of pancreatitis and neuropathy when hydroxyurea is combined with didanosine and stavudine. Since hydroxyurea-related toxicity is dose dependent, a systematic study of hydroxyurea optimal dosage and schedule was initiated to monitor patients for possible nucleoside toxicity. In the Research Institute for Genetic and Human Therapy (RIGHT) 702 study it was shown that a low, well-tolerated hydroxyurea dose (600 mg daily) achieved better antiretroviral activity than higher doses, together with better CD4+ cell count increase and fewer adverse effects. In this paper the effects of hydroxyurea as salvage therapy for heavily pretreated patients with advanced HIV disease are presented. These studies have shown that some patients with extensive pretreatment experience and advanced disease can respond substantially to the addition of hydroxyurea. The addition of hydroxyurea to didanosine does not prevent the emergence of resistance to didanosine; nonetheless, the efficacy of this therapeutic regimen may not be attenuated by the presence of didanosine-resistant HIV mutants. Since CD4 T lymphocyte activation is essential for virus replication and CD8 T lymphocyte activation may contribute to pathogenesis, the combination of hydroxyurea with other drugs may lead to the inhibition of HIV, by blocking the 'cell activation-virus production-pathogenesis' cycle. Clinical data indicate that hydroxyurea may play a role in attenuation of viral rebound and immune reconstitution by decreasing CD4 T cell proliferation, as well as preventing the exhaustion of CD8 T cell populations that may result from excessive activation during HIV infection. While the combination of hydroxyurea with didanosine has provided hope, future studies including those that evaluate optimal dosing and long-term toxicity are needed to define the role for this agent in the treatment of HIV infection.
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Cooper DA. Update on didanosine. JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PHYSICIANS IN AIDS CARE (CHICAGO, ILL. : 2002) 2003; 1:15-25. [PMID: 12942665 DOI: 10.1177/154510970200100105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Didanosine (ddl) has been a cornerstone of HIV management since it was made available in October 1991. Didanosine was originally introduced as an alternative to zidovudine (ZDV) for patients who were intolerant of ZDV or experienced disease progression during ZDV monotherapy. Didanosine is now used extensively as an integral component of multidrug combination regimens in both adults and children with HIV infection, and is now available for once-daily administration in the United States, Canada, and Europe. The recently approved Videx EC is an enteric-coated didanosine capsule dosed as one capsule, once daily. This paper provides an update of recently published studies on the use of ddl in combination anti-HIV therapy. In particular, these studies examine the rationale for the use of ddl as first-line anti-HIV therapy, and describe newer findings concerning its long-term efficacy, side effects, compliance, resistance, and once-daily use. The increased survival of HIV-infected patients is largely attributed to the introduction of the triple combination drug therapy but is probably also due to the long-term clinical efficacy of ddl.
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Affiliation(s)
- David A Cooper
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, Australia.
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Foli A, Benvenuto F, Piccinini G, Bareggi A, Cossarizza A, Lisziewicz J, Lori F. Direct analysis of mitochondrial toxicity of antiretroviral drugs. AIDS 2001; 15:1687-94. [PMID: 11546944 DOI: 10.1097/00002030-200109070-00012] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Mitochondrial toxicity is a serious side-effect of antiretroviral drugs, especially nucleoside reverse transcriptase inhibitors (NRTI). An in vitro assay to predict mitochondrial toxicity of in-use and developmental NRTI would be invaluable. To test the ability of a cytofluorimetric technique to predict the mitochondrial-dependent pancreatic and hepatic toxicity we used didanosine (ddI) alone or in combination with hydroxyurea (HU). METHODS The technique is based on the ability of the lipophilic cation JC-1 to enter selectively into mitochondria and change its colour as the membrane potential changes due to toxicity. Mitochondrial toxicity by HU and ddI was evaluated in pancreatic and hepatic human cell lines. The results were expressed as mitochondrial toxicity index (MTI), ranging from 0 to 100: the negative control was 0, and 100 indicating maximal toxicity. RESULTS Dose-dependent pancreatic toxicity of ddI was evident after 14 days of culture (MTI 34 +/- 4 at 100 microM, 10 +/- 4 at 10 microM, 2 +/- 3 at 1 microM ddI). HU alone was not toxic (MTI 7 +/- 10 at 100 microM, 2 +/- 2 at 50 microM and 2 +/- 4 at 10 microM HU); however, HU increased the toxicity of high, but not low, concentrations of ddI. For example, the MTI of 10 microM ddI plus 50 microM HU was 54 +/- 9. Negligible mitochondrial toxicity was observed in the hepatic cell line exposed to ddI alone or in combination with HU. CONCLUSIONS This in vitro assay might have in vivo relevance. First, ddI-related pancreatitis is dose dependent, and is reported more frequently than hepatic failure, consistent with our in vitro results. Second, patients who developed pancreatitis during randomized, controlled trials were treated with HU in combination with 400 mg ddI once daily (high peak concentration of ddI in the blood). In contrast, no pancreatitis was observed when HU was combined with 200 mg ddI twice daily (low peak concentration of ddI). These in vivo results are consistent with our in vitro observation that HU increases pancreatic cell toxicity in the presence of high concentrations of ddI. The in vitro assay described here might be used to predict the mitochondrial toxicity of other NRTI, alone or in combination.
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Affiliation(s)
- A Foli
- Research Institute for Genetic and Human Therapy, IRCCS Policlinico S. Matteo, Pavia, Italy
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Abstract
The management of HIV disease has evolved into a complicated and sophisticated subspecialty in recent years. Fourteen drugs, in various combinations, are being used in increasingly complex treatment regimens. The side effects of some of these drugs, as well as certain drug-drug interactions may mimic signs and symptoms of HIV disease itself. Therefore it is imperative for the emergency physician to be knowledgeable about the new medications as well as about selected adverse effect and drug interaction profiles in order to be able to take care of the increasing numbers of HIV-positive patients presenting to emergency departments. This article aims to provide a focused review of these topics. In addition, health care workers with significant exposures to HIV-infected body fluids may present to the emergency department for initial evaluation. This presents a situation whereby emergency physicians may have to prescribe appropriate combinations of antiretroviral agents themselves. Thus familiarity with the basic principles of post-exposure prophylaxis is desirable and current Centers for Disease Control and Prevention guidelines are briefly reviewed.
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Affiliation(s)
- H C Hovanessian
- Department of Emergency Medicine, University of California-San Francisco University Medical Center, Fresno, CA, USA.
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Brinkman K, ter Hofstede HJ, Burger DM, Smeitink JA, Koopmans PP. Adverse effects of reverse transcriptase inhibitors: mitochondrial toxicity as common pathway. AIDS 1998; 12:1735-44. [PMID: 9792373 DOI: 10.1097/00002030-199814000-00004] [Citation(s) in RCA: 669] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- K Brinkman
- Department of General Internal Medicine, University Hospital Nijmegen, The Netherlands
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Notermans DW, van Leeuwen R, Lange JM. Treatment of HIV infection. Tolerability of commonly used antiretroviral agents. Drug Saf 1996; 15:176-87. [PMID: 8879972 DOI: 10.2165/00002018-199615030-00003] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
There are a number of agents available that are active against HIV. Eight drugs are already licensed in the US: the nucleoside analogue reverse transcriptase inhibitors--zidovudine, didanosine, zalcitabine, stavudine and lamivudine--and the HIV protease inhibitors--saquinavir, indinavir and ritonavir. Antiretroviral drugs have been given as monotherapy, often as sequential monotherapy, and in alternating or simultaneous combinations. Since combination therapy has recently been shown to be superior to monotherapy, antiretrovirals will increasingly be given in combination. All available antiretroviral drugs show considerable toxicity complicating their use. In this article we describe the adverse effects of the above mentioned nucleoside analogues used in monotherapy and of several combinations of antiretroviral drugs. No unexpected toxicities were found in several different combinations tested to date and, for most combinations, no synergistic toxic effects have been reported.
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Affiliation(s)
- D W Notermans
- National AIDS Therapy Evaluation Center, University of Amsterdam, The Netherlands
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Campbell DA, Shah VR, Srinivas NR, Shyu WC. High-performance liquid chromatographic analysis of 2'-fluoro-2',3'-dideoxyadenosine and 2'-fluoro-2',3'-dideoxyinosine in dog plasma and urine. J Pharm Sci 1996; 85:890-2. [PMID: 8863284 DOI: 10.1021/js960025p] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A high-performance liquid chromatographic assay was developed and validated for a simulataneous determination of 2'-fluoro-2' 3'-dideoxyadenosine (FddA) and its metabolite, 2'-fluoro-2',3'-dideoxyinosine (Fddl) in dog plasma and urine. In vitro, FddA and Fddl exhibit activity against human immunodeficiency virus (HIV). A solid phase extraction was applied to extract FddA, Fddl, and the internal standard (IS; 3',5'-anhydrothymidine) from the biomatrices. The processed samples were chromatographed using a C8 column coupled with a mobile phase consisting of monobasic phosphate, dibasic phosphate, ethylene glycol monomethyl ether, and water. Detection was performed at 257 nm. The nominal retention times were 9, 14, and 26 min for Fddl, IS, and FddA, respectively. The lower limits of quantitation were 0.1 and 2.0 micrograms/mL in plasma and urine, respectively, for both analytes. The accuracy of the assay deviated < or = 10% from the nominal concentrations, and the precision was < or = 14% coefficient of variation. In either matrix, both analytes were stable for at least three freeze-thaw cycles and in the injection media for at least 54 h. The extraction recoveries of the analytes were greater than 80%. The application of this assay was demonstrated in a preliminary pharmacokinetic study of FddA and Fddl in dogs. Two male dogs per dose level received a 100, 250, or 500 mg/kg oral dose of FddA once daily for 14 days. The early appearance of Fddl in plasma (0.25 h; the first sampling time) and greater plasma levels of Fddl than FddA (> 50-fold of Cmax), suggested that the conversion of FddA to Fddl was rapid and extensive. Renal excretion appeared to be the major route of elimination of Fddl.
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Affiliation(s)
- D A Campbell
- Department of Metabolism and Pharmacokinetics, Bristol-Myers Squibb Pharmaceutical Research Institute, Bristol-Myers Squibb Company, Princeton, NJ 08543, USA
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Affiliation(s)
- B A Styrt
- Division of Epidemiology and Surveillance, Food and Drug Administration, Rockville, MD 20857, USA
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Mofenson LM. The role of antiretroviral therapy in the management of HIV infection in women. Clin Obstet Gynecol 1996; 39:361-85. [PMID: 8734002 DOI: 10.1097/00003081-199606000-00010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- L M Mofenson
- National Institutes of Health, Rockville, Maryland, USA
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