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Omidi N, Forouzannia SK, Poorhosseini H, Tafti SHA, Salehbeigi S, Lotfi‐Tokaldany M. Prosthetic heart valves and the COVID-19 pandemic era: What should we be concerned about? J Card Surg 2020; 35:2500-2505. [PMID: 33043651 PMCID: PMC7597203 DOI: 10.1111/jocs.14707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The disturbance in the international normalized ratio (INR) in patients receiving warfarin therapy is of concern. We aimed to evaluate coagulation features in hospitalized patients under warfarin treatment for prosthetic heart valves during the novel coronavirus disease 2019 (COVID-19) pneumonia pandemic. METHODS Between 20 February and 28 March 2020, 10 patients (7 males) who were under warfarin therapy for prosthetic heart valves were hospitalized after a diagnosis of COVID-19 in Tehran Heart Center, Tehran, Iran. The clinical, paraclinical, and in-hospital outcomes were described. The patients were followed for 4 weeks. RESULTS The median age was 62 years. All the patients received antiviral treatment, either lopinavir/ritonavir or oseltamivir. The serum level of high-sensitivity C-reactive protein ranged between 0.24 and 15.24 mg/dL. Alanine aminotransaminase was normal in all the patients except for two, with levels 1.6 and 4.2 times above normal values. The INR increased in all the patients. One (10%) patient died in the hospital. No bleeding, ischemic, or thrombotic events occurred during the hospital stay and within the 4-week follow-up. CONCLUSIONS Antiviral therapy in patients with COVID-19 with prosthetic heart valves might be an issue responsible for an uncontrolled INR. Liver injury may happen in a minority of patients. Bridging in these patients during the antiviral treatment might be required and because of significant INR fluctuations, it might be safer to prescribe antiviral treatment in an inpatient setting.
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Affiliation(s)
- Negar Omidi
- Cardiology DepartmentTehran Heart CenterTehran University of Medical SciencesTehranIran
| | - Seyed Khalil Forouzannia
- Cardiac Surgery DepartmentTehran Heart Center and Research DevelopmentTehran University of Medical SciencesTehranIran
| | - Hamidreza Poorhosseini
- Interventional DepartmentTehran Heart Center and Research DevelopmentTehran University of Medical SciencesTehranIran
| | - Seyed Hossein Ahmadi Tafti
- Cardiac Surgery DepartmentTehran Heart Center and Research DevelopmentTehran University of Medical SciencesTehranIran
| | - Shahrzad Salehbeigi
- Research DepartmentTehran Heart Center and Research DevelopmentTehran University of Medical SciencesTehranIran
| | - Masoumeh Lotfi‐Tokaldany
- Research DepartmentTehran Heart Center and Research DevelopmentTehran University of Medical SciencesTehranIran
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Lopinavir-Ritonavir in SARS-CoV-2 Infection and Drug-Drug Interactions with Cardioactive Medications. Cardiovasc Drugs Ther 2020; 35:427-440. [PMID: 32918656 PMCID: PMC7486594 DOI: 10.1007/s10557-020-07070-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 12/23/2022]
Abstract
Lopinavir-ritonavir combination is being used for the treatment of SARS-CoV-2 infection. A low dose of ritonavir is added to other protease inhibitors to take advantage of potent inhibition of cytochrome (CYP) P450 3A4, thereby significantly increasing the plasma concentration of coadministered lopinavir. Ritonavir also inhibits CYP2D6 and induces CYP2B6, CYP2C19, CYP2C9, and CYP1A2. This potent, time-dependent interference of major hepatic drug-metabolizing enzymes by ritonavir leads to several clinically important drug-drug interactions. A number of patients presenting with acute coronary syndrome and acute heart failure may have SARS-CoV-2 infection simultaneously. Lopinavir-ritonavir is added to their prescription of multiple cardiac medications leading to potential drug-drug interactions. Many cardiology, pulmonology, and intensivist physicians have never been exposed to clinical scenarios requiring co-prescription of cardiac and antiviral therapies. Therefore, it is essential to enumerate these drug-drug interactions, to avoid any serious drug toxicity, to consider alternate and safer drugs, and to ensure better patient care.
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Vitrone M, Parrella A, Albisinni R, Durante-Mangoni E, Zampino R. Dynamics and management of oral anticoagulant treatment in chronic hepatitis C patients undergoing therapy with direct antiviral agents. J Chemother 2019; 31:86-89. [PMID: 30784359 DOI: 10.1080/1120009x.2019.1571661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Current regimens of direct-acting antiviral agents (DAA) are effective and safe for chronic hepatitis C (CHC). However, DAA often interfere with concomitant medications. We treated seven CHC patients with DAA who were on chronic anticoagulant treatment with warfarin, and describe the dynamics of prothrombin time, providing novel data, useful for the clinician.
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Affiliation(s)
- Martina Vitrone
- a Department of Internal Medicine , University of Campania 'L. Vanvitelli ', Caserta CE, Italy
| | - Antonio Parrella
- a Department of Internal Medicine , University of Campania 'L. Vanvitelli ', Caserta CE, Italy
| | - Rosina Albisinni
- b Unit of Infectious and Transplant Medicine , AORN dei Colli-Monaldi Hospital , Naples , Italy
| | - Emanuele Durante-Mangoni
- a Department of Internal Medicine , University of Campania 'L. Vanvitelli ', Caserta CE, Italy.,b Unit of Infectious and Transplant Medicine , AORN dei Colli-Monaldi Hospital , Naples , Italy
| | - Rosa Zampino
- a Department of Internal Medicine , University of Campania 'L. Vanvitelli ', Caserta CE, Italy.,b Unit of Infectious and Transplant Medicine , AORN dei Colli-Monaldi Hospital , Naples , Italy
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Puglisi GM, Smith SM, Jankovich RD, Ashby CR, Jodlowski TZ. Paritaprevir/ritonavir/ombitasvir+dasabuvir plus ribavirin therapy and inhibition of the anticoagulant effect of warfarin: a case report. J Clin Pharm Ther 2016; 42:115-118. [PMID: 27813106 DOI: 10.1111/jcpt.12475] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 10/02/2016] [Indexed: 12/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Paritaprevir/ritonavir/ombitasvir+dasabuvir (PrOD) is a direct-acting antiviral (DAA) approved for the treatment of chronic hepatitis C virus. We report on a probable interaction between PrOD with ribavirin and warfarin. CASE DESCRIPTION Two weeks after the start of PrOD with ribavirin, the patient's international normalized ratio (INR) became subtherapeutic. Eleven weeks into therapy and following a 125% total increase in the weekly warfarin dose, therapeutic INR was achieved. Thirteen days after DAA therapy was completed and discontinued, the patient's INR became critically supratherapeutic. WHAT IS NEW AND CONCLUSION Patients on PrOD plus ribavirin with warfarin should have INR followed closely upon initiation and discontinuation of therapy due to a probable drug interaction.
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Affiliation(s)
- G M Puglisi
- PGY2 Pharmacy Resident, Ambulatory Care, VA Maine Healthcare System, Augusta, ME, USA
| | - S M Smith
- Clinical Pharmacy Specialist, Pharmacy Service, VA Maine Healthcare System, Augusta, ME, USA
| | - R D Jankovich
- Gastroenterology Section, Medical Service, VA Maine Healthcare System, Augusta, ME, USA
| | - C R Ashby
- Department of Pharmaceutical Sciences, St. John's University, Queens, NY, USA
| | - T Z Jodlowski
- Clinical Pharmacy Specialist, Pharmacy Service, VA North Texas Health Care System, Dallas, TX, USA
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5
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Esterly JS, Darin KM, Gerzenshtein L, Othman F, Postelnick MJ, Scarsi KK. Clinical implications of antiretroviral drug interactions with warfarin: a case-control study. J Antimicrob Chemother 2013; 68:1360-3. [PMID: 23425779 DOI: 10.1093/jac/dkt043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Warfarin, a frequently prescribed anticoagulant with a narrow therapeutic index, is susceptible to drug-drug interactions with antiretroviral therapy (ART). This study compared the warfarin maintenance dose (WMD) between patients receiving and not receiving ART and evaluated predictors of warfarin dosage among those on ART. METHODS This was a case-control (1:2) study. Cases were HIV-infected patients receiving warfarin and protease inhibitor (PI)- and/or non-nucleoside reverse transcriptase inhibitor (NNRTI)-based ART. Controls were randomly selected HIV-uninfected patients receiving warfarin. The WMD was compared between cases and controls and between cases on varying ART regimens. Bivariate comparisons were performed and a linear regression model was developed to identify predictors of WMD. RESULTS We identified 18 case and 36 control patients eligible for inclusion. Cases were younger than controls (mean age: 45.8 versus 63.1 years, P < 0.01), more often male (72.2% versus 36.1%, P=0.02) and more likely to be African American (50.0% versus 22.2%, P=0.04). ART was classified as PI-based (n=9), NNRTI-based (n=7) and PI + NNRTI-based (n=2). The WMD (mean ± SD) differed between cases and controls (8.6 ± 3.4 mg versus 5.1 ± 1.5 mg, P < 0.01), but not ART regimens (PI: 8.8 ± 4.5 mg; NNRTI: 8.6 ± 1.8 mg; PI + NNRTI: 7.3 ± 3.3 mg; P = 0.86). Race and ritonavir dose were independent predictors of WMD, predicting an increase of 3.9 mg (95% CI: 0.88-6.98, P = 0.02) if a patient was African American or 3.7 mg (95% CI: 0.53-6.89, P = 0.03) if the total daily ritonavir dose was 200 mg. CONCLUSIONS The required WMD was significantly higher in patients receiving ART. Prompt dose titration to achieve a higher WMD with vigilant monitoring may be required due to these drug-drug interactions.
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Affiliation(s)
- John S Esterly
- Department of Pharmacy Practice, Chicago State University College of Pharmacy, 9501 S. King Drive, DH 206, Chicago, IL 60628, USA
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Abstract
It is estimated that by 2015 more than half of all HIV-infected individuals in the United States will be 50 years of age or older. As this population ages, the frequency of non-AIDS related comorbidities increases, which includes cardiovascular, metabolic, gastrointestinal, genitourinary and psychiatric disorders. As a result, medical management of the aging HIV population can be complicated by polypharmacy and higher pill burden, leading to poorer antiretroviral therapy (ART) adherence. Adherence to ART is generally better in older populations when compared to younger populations; however, cognitive impairment in elderly patients can impair adherence, leading to worse treatment outcomes. Practical monitoring tools can improve adherence and increase rates of viral load suppression. Several antiretroviral drugs exhibit inhibitory and/or inducing effects on cytochrome P450 isoenzymes, which are responsible for the metabolism of many medications used for the treatment of comorbidities in the aging HIV population. The combination of ART with polypharmacy significantly increases the chance of potentially serious drug-drug interactions (DDIs), which can lead to drug toxicity, poorer ART adherence, loss of efficacy of the coadministered medication, or virologic breakthrough. Increasing clinicians awareness of common DDIs and the use of DDI programs can prevent coadministration of potentially harmful combinations in elderly HIV-infected individuals. Well designed ART adherence interventions and DDI studies are needed in the elderly HIV population.
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7
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Nutescu E, Chuatrisorn I, Hellenbart E. Drug and dietary interactions of warfarin and novel oral anticoagulants: an update. J Thromb Thrombolysis 2011; 31:326-43. [PMID: 21359645 DOI: 10.1007/s11239-011-0561-1] [Citation(s) in RCA: 159] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Clinicians and patients around the world have been intrigued by the concept of developing an oral anticoagulant with a broad therapeutic window and few drug and dietary interactions that can be administered at fixed doses with no or minimal monitoring. The recently approved oral direct thrombin inhibitor dabigatran, along with the emerging oral anti-factor Xa inhibitors, rivaroxaban, apixaban, and edoxaban, have been developed to address many of the shortcomings of warfarin therapy. As warfarin is associated with extensive food and drug interactions, there is also a need to consider such interactions with the new oral anticoagulants. While to date few drug and dietary interactions have been reported with the new oral anticoagulants, it is still early in their development and clinical use cycle. Pharmacokinetic and pharmacodynamic profiles will have to be closely accounted for when determining the likelihood of a potential drug interaction prior to therapy initiation. As the list of drugs and supplements that interact with warfarin is continuously expanding, and the knowledge on drug interactions with the novel oral anticoagulants is still in its infancy, clinicians need to be vigilant when initiating any of these agents or when any changes in the patient's medication profile occur and perform a close screening for potential drug and dietary interactions. The objective of this paper is to give an update on drug and dietary interactions with warfarin and the novel oral anticoagulants, dabigatran, rivaroxaban, apixaban, and edoxaban.
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Affiliation(s)
- Edith Nutescu
- Department of Pharmacy Practice and Center for Pharmacoeconomic Research, University of Illinois at Chicago, College of Pharmacy, 833 S. Wood St. MC 886, Rm 164, Chicago, IL 60612, USA.
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Bungard TJ, Yakiwchuk E, Foisy M, Brocklebank C. Drug Interactions Involving Warfarin: Practice Tool and Practical Management Tips. Can Pharm J (Ott) 2011. [DOI: 10.3821/1913-701x-144.1.21] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Tammy J. Bungard
- From the Anticoagulation Management Service and Division of Cardiology, Department of Medicine, University of Alberta (Bungard), Edmonton, Alberta; College of Pharmacy and Nutrition, University of Saskatchewan (Yakiwchuk [student]), Saskatoon, Saskatchewan; Northern Alberta HIV Program, Alberta Health Services (Foisy), Edmonton, Alberta; Anticoagulation Program, Alberta Health Services (Brockle-bank), Calgary, Alberta. Contact
| | - Erin Yakiwchuk
- From the Anticoagulation Management Service and Division of Cardiology, Department of Medicine, University of Alberta (Bungard), Edmonton, Alberta; College of Pharmacy and Nutrition, University of Saskatchewan (Yakiwchuk [student]), Saskatoon, Saskatchewan; Northern Alberta HIV Program, Alberta Health Services (Foisy), Edmonton, Alberta; Anticoagulation Program, Alberta Health Services (Brockle-bank), Calgary, Alberta. Contact
| | - Michelle Foisy
- From the Anticoagulation Management Service and Division of Cardiology, Department of Medicine, University of Alberta (Bungard), Edmonton, Alberta; College of Pharmacy and Nutrition, University of Saskatchewan (Yakiwchuk [student]), Saskatoon, Saskatchewan; Northern Alberta HIV Program, Alberta Health Services (Foisy), Edmonton, Alberta; Anticoagulation Program, Alberta Health Services (Brockle-bank), Calgary, Alberta. Contact
| | - Cynthia Brocklebank
- From the Anticoagulation Management Service and Division of Cardiology, Department of Medicine, University of Alberta (Bungard), Edmonton, Alberta; College of Pharmacy and Nutrition, University of Saskatchewan (Yakiwchuk [student]), Saskatoon, Saskatchewan; Northern Alberta HIV Program, Alberta Health Services (Foisy), Edmonton, Alberta; Anticoagulation Program, Alberta Health Services (Brockle-bank), Calgary, Alberta. Contact
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9
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Abstract
With HIV-infected patients living longer and recommendations to initiate antiretrovirals (ARVs) being made earlier, the likelihood for potential drug-drug interactions between ARVs and concurrent medications used to manage co-morbid conditions will increase. In order to maximize the clinical benefit and minimize potential toxicity of ARVs and co-administered medications, it is important for clinicians to recognize significant drug-drug interactions. This article highlights clinically significant drug-drug interactions with antituberculosis agents, antimalarials, anticoagulants, chemotherapeutic agents and pulmonary antihypertensive agents when they are co-administered with newer ARVs (e.g. darunavir, raltegravir, maraviroc and etravirine).
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Affiliation(s)
- Paul A Pham
- Division of Infectious Diseases, Johns Hopkins University, School of Medicine, Baltimore, MD 21287, USA.
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10
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Abstract
IMPORTANCE OF THE FIELD Antiretroviral therapy exhibits significant potential to alter the metabolism of other medications. Warfarin is widely used for the management of clotting disorders and is prone to drug-drug interactions that can result in subtherapeutic anticoagulation or over-anticoagulation. AREAS COVERED IN THIS REVIEW The mechanism and clinical significance of drug-drug interactions between warfarin and individual antiretrovirals are discussed. Literature searches were conducted in August of 2009 using multiple databases including Medline (1950 - 2009), EMBASE (1980 - 2009), International Pharmaceutical Abstracts (1970 - 2009) and the Cochrane Database of Systematic Reviews. The following search terms were utilized: warfarin, HIV, antiretroviral, drug interaction, protease inhibitor (PI), non-nucleoside reverse-transcriptase inhibitor (NNRTI), cytochrome P450 (CYP450), CYP2C9 and individual antiretrovirals by name. The manufacturers of PIs and NNRTIs were also contacted regarding unpublished data. WHAT THE READER WILL GAIN Clinicians will gain an understanding of the antiretrovirals that are prone to alter warfarin metabolism and the implications for warfarin dose modification. TAKE HOME MESSAGE Metabolic interaction between warfarin and antiretrovirals is likely, particularly if NNRTIs or PIs are included in the antiretroviral regimen. Titration of warfarin dose should be conducted on the basis of close monitoring of the international normalized ratio. Empiric warfarin dose modifications should be considered for individual antiretrovirals.
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Affiliation(s)
- Michelle D Liedtke
- Department of Pharmacy, University of Oklahoma, Health Sciences Center, College of Pharmacy, 1110 N Stonewall, CPB 206, Oklahoma City, OK 73117, USA.
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Dumond JB, Vourvahis M, Rezk NL, Patterson KB, Tien HC, White N, Jennings SH, Choi SO, Li J, Wagner MJ, La-Beck NM, Drulak M, Sabo JP, Castles MA, Macgregor TR, Kashuba ADM. A phenotype-genotype approach to predicting CYP450 and P-glycoprotein drug interactions with the mixed inhibitor/inducer tipranavir/ritonavir. Clin Pharmacol Ther 2010; 87:735-42. [PMID: 20147896 DOI: 10.1038/clpt.2009.253] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The effects of tipranavir/ritonavir (TPV/r) on hepatic and intestinal P-glycoprotein (P-gp) and cytochrome P450 (CYP) enzyme activity were evaluated in 23 volunteers. The subjects received oral (p.o.) caffeine, warfarin + vitamin K, omeprazole, dextromethorphan, and midazolam and digoxin (p.o. and intravenous (i.v.)) at baseline, during the first three doses of TPV/r (500 mg/200 mg b.i.d.), and at steady state. Plasma area under the curve (AUC)(0-infinity) and urinary metabolite ratios were used for quantification of protein activities. A single dose of TPV/r had no effect on the activity of CYP1A2 and CYP2C9; it weakly inhibited CYP2C19 and P-gp; and it potently inhibited CYP2D6 and CYP3A. Multiple dosing produced weak induction of CYP1A2, moderate induction of CYP2C19, potent induction of intestinal P-gp, and potent inhibition of CYP2D6 and CYP3A, with no significant effects on CYP2C9 and hepatic P-gp. Several P450/transporter single-nucleotide polymorphisms correlated with the baseline phenotype but not with the extent of inhibition or induction. Although mixed induction and inhibition are present, this approach offers an understanding of drug interaction mechanisms and ultimately assists in optimizing the clinical use of TPV/r.
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Affiliation(s)
- J B Dumond
- Division of Pharmacotherapy and Experimental Therapeutics, School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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12
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Abstract
OBJECTIVE To review the literature for information regarding interactions between warfarin and antiretroviral agents and evaluate the clinical significance of these interactions. DATA SOURCES Primary literature was identified through a search of MEDLINE (1950-July 2008) and International Pharmaceutical Abstracts (1970-July 2008) using individual antiretroviral drug names and the following key search terms: warfarin, antiretroviral, protease inhibitor, nonnucleoside reverse transcriptase inhibitor, cytochrome P450, 2C9, HIV, and drug interactions. Relevant abstracts from infectious disease and HIV conferences (2005-2008), reference citations from relevant articles, and manufacturers' product information were also reviewed. STUDY SELECTION AND DATA EXTRACTION All English-language articles identified through the data search were examined. Studies and reports addressing warfarin interactions with antiretrovirals, CYP2C9 polymorphism, and antiretroviral CYP2C9 effects were evaluated. A total of 12 case reports were identified that described interactions between warfarin and either protease inhibitors (PIs) or nonnucleoside reverse transcriptase inhibitors (NNRTIs). DATA SYNTHESIS The drugs used in the case reports were limited to 6 antiretroviral agents (efavirenz, nevirapine, lopinavir/ritonavir, nelfinavir, saquinavir, ritonavir). The mechanism of interaction between antiretroviral agents and warfarin appears to be mediated through alteration in CYP2C9 metabolism. Concurrent use of warfarin with efavirenz or saquinavir was associated with overanticoagulation, identified by increases in international normalized ratio (INR). Use of warfarin with lopinavir/ritonavir, nelfinavir, ritonavir, and nevirapine resulted in subtherapeutic INRs. Interactions with delavirdine, etravirine, and atazanavir are anticipated; however, no published cases have reported these interactions. Interactions between warfarin and nucleoside reverse transcriptase inhibitors, integrase inhibitors, fusion inhibitors, and CCR5 antagonists are not anticipated. CONCLUSIONS Interactions between warfarin and antiretrovirals are likely, especially when PIs or NNRTIs are used. Induction or inhibition of warfarin metabolism may occur, depending on the specific antiretroviral agent. When warfarin is used concurrently with antiretrovirals, close monitoring of INR response is recommended in lieu of empiric warfarin dosing adjustments, given the limited information available and the quality of evidence.
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Affiliation(s)
- Michelle D Liedtke
- Department of Pharmacy, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73117, USA.
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13
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Fulco PP, Zingone MM, Higginson RT. Possible antiretroviral therapy-warfarin drug interaction. Pharmacotherapy 2008; 28:945-9. [PMID: 18576910 DOI: 10.1592/phco.28.7.945] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Highly active antiretroviral therapy (HAART) for human immunodeficiency virus (HIV) has resulted in significant morbidity and mortality reductions. Lifelong antiretroviral therapy must be incorporated into each patient's medical regimen. Patients with HIV may also have simultaneous chronic medical conditions, resulting in the possibility of complex drug-drug interactions. We report a possible drug-drug interaction between HAART and warfarin in two patients, as assessed by the Naranjo adverse drug reaction probability scale and the Drug Interaction probability scale. Both patients' pharmacotherapy regimens included a nonnucleoside reverse transcriptase inhibitor (NNRTI), nevirapine, or a protease inhibitor, nelfinavir or lopinavir-ritonavir, and two nucleoside analogs. In both patients, high warfarin doses were required to maintain therapeutic international normalized ratios (INRs). Warfarin has two enantiomers, R-and S-warfarin, which are substrates primarily of cytochrome P450 (CYP) 3A4 (R-warfarin), CYP1A2 (R-warfarin), and CYP2C9 (S-warfarin). Protease inhibitors and NNRTIs have variable effects on CYP: induction, inhibition, or mixed. The increased warfarin doses required in these two patients may have been caused by induction of CYP3A4 by nevirapine, CYP2C9 by nelfinavir, or CYP2C9 by lopinavir-ritonavir. Thus, practitioners should prudently monitor INRs in patients receiving warfarin with concomitant HAART that includes either a protease inhibitor or an NNRTI.
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Affiliation(s)
- Patricia Pecora Fulco
- Department of Pharmacy, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
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14
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Foisy MM, Yakiwchuk EM, Hughes CA. Induction effects of ritonavir: implications for drug interactions. Ann Pharmacother 2008; 42:1048-59. [PMID: 18577765 DOI: 10.1345/aph.1k615] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review the literature on the induction effects of ritonavir on the cytochrome P450 enzyme system and glucuronyl transferase and identify resultant established and potential drug interactions. DATA SOURCES Primary literature was identified from MEDLINE (1950-April 2008), EMBASE (1988-April 2008) and International Pharmaceutical Abstracts (1970-April 2008) using the search terms ritonavir, cytochrome P450 enzyme system, enzyme induction, glucuronyl transferase, and drug interactions. Additionally, relevant conference abstracts and references of relevant articles were reviewed. STUDY SELECTION AND DATA ABSTRACTION All English-language articles and abstracts identified were reviewed. DATA SYNTHESIS Ritonavir is a well-known inhibitor of the metabolism of numerous medications that are substrates of the CYP3A and CYP2D6 pathways. It also exhibits a biphasic, time-dependent effect on P-glycoprotein of inhibition followed by induction. Numerous pharmacokinetic studies suggested that ritonavir induces cytochrome P450 enzymes 3A, 1A2, 2B6, 2C9, and 2C19, as well as glucuronyl transferase. Additionally, several case reports described clinically significant subtherapeutic effects of drugs metabolized by these isoenzymes when coadministered with ritonavir. Both therapeutic and boosting doses of ritonavir appear to induce these enzymes; however, most of the studies of low-dose ritonavir involved a second protease inhibitor such as lopinavir, darunavir, or tipranavir. It is, therefore, difficult to distinguish the relative effects of additional medications unless well-designed, 3-way studies are conducted. CONCLUSIONS At both therapeutic and boosting doses, ritonavir exhibits a clinically relevant induction effect on numerous drug-metabolizing enzymes. A decrease or loss of therapeutic effect may be observed when ritonavir is coadministered with medications that are substrates for these enzymes. It is important for clinicians to be aware of drugs potentially impacted by ritonavir therapy to identify and manage these interactions.
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Affiliation(s)
- Michelle M Foisy
- Northern Alberta HIV Program & Regional Pharmacy Services, Capital Health Authority, Edmonton, Alberta, Canada.
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15
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Walubo A. The role of cytochrome P450 in antiretroviral drug interactions. Expert Opin Drug Metab Toxicol 2007. [DOI: 10.1517/17425255.3.4.583] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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16
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Abstract
Drug interactions involving protease inhibitors are common. Protease inhibitors are well known inhibitors of the 3A4 isozyme of cytochrome P450. Select protease inhibitors, including co-formulated lopinavir/ritonavir, may induce glucuronidation or the activity of other CYP450 isozymes. We describe the case of a patient taking warfarin who experienced a significantly decreased international normalized ratio after the initiation of antiretroviral therapy that included lopinavir/ritonavir. We review the possible mechanisms of this interaction and the reported interactions between warfarin and other protease inhibitors.
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Affiliation(s)
- Christine A Hughes
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alta.
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17
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Dixit V, Hariparsad N, Li F, Desai P, Thummel KE, Unadkat JD. Cytochrome P450 Enzymes and Transporters Induced by Anti-Human Immunodeficiency Virus Protease Inhibitors in Human Hepatocytes: Implications for Predicting Clinical Drug Interactions. Drug Metab Dispos 2007; 35:1853-9. [PMID: 17639026 DOI: 10.1124/dmd.107.016089] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Although many of the clinically significant drug interactions of the anti-human immunodeficiency virus (HIV) protease inhibitors (PIs) can be explained by their propensity to inactivate CYP3A enzymes, paradoxically these drugs cause (or lack) interactions with CYP3A substrates that cannot be explained by this mechanism (e.g., alprazolam). To better understand these paradoxical interactions (or lack thereof), we determined the cytochromes P450 and transporters induced by various concentrations (0-25 microM) of two PIs, ritonavir and nelfinavir, and rifampin (positive control) in primary human hepatocytes. At 10 microM, ritonavir and nelfinavir suppressed CYP3A4 activity but induced its transcripts and protein expression (19- and 12- and 12- and 6-fold, respectively; a >2-fold change over control was interpreted as induction). At 10 microM, rifampin induced CYP3A4 transcripts, CYP3A protein, and activity by 23-, 12-, and 13-fold, respectively. The induction by rifampin of CYP3A activity was significantly correlated with its induction of CYP3A4 transcripts (r = 0.96, p < 0.05) and CYP3A protein (r = 0.89, p < 0.05). All three drugs (10 microM) induced CYP2B6 activity by 2- to 4-fold, CYP2C8 and 2C9 activity by 2- to 4-fold and the transcripts of CYP2B6, 2C8, and 2C9 by >3-, 5-, and 3-fold, respectively. CYP2C19 and 1A2 activity and transcripts were modestly induced (2-fold), whereas, as expected, CYP2D6 was not induced by any of the drugs. Of the transporters studied, protease inhibitors moderately induced multidrug resistance 1 (ABCB1) and multidrug resistance-associated protein (ABCC1) transcripts but had no or minimal effect on the transcripts of breast cancer resistance protein (ABCG2), organic anion-transporting peptide (OATP) 1B1 (SLCO1B1), or OATP1B3 (SLCO1B3). On the basis of these data, we concluded that many of the paradoxical drug interactions (or lack thereof) with the PIs are metabolismrather than transporter-based and are due to induction of CYP2B6 and 2C enzymes.
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Affiliation(s)
- Vaishali Dixit
- Department of Pharmaceutics, University of Washington, Box 357610, Seattle, WA 98195, USA
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Yeh RF, Gaver VE, Patterson KB, Rezk NL, Baxter-Meheux F, Blake MJ, Eron JJ, Klein CE, Rublein JC, Kashuba ADM. Lopinavir/ritonavir induces the hepatic activity of cytochrome P450 enzymes CYP2C9, CYP2C19, and CYP1A2 but inhibits the hepatic and intestinal activity of CYP3A as measured by a phenotyping drug cocktail in healthy volunteers. J Acquir Immune Defic Syndr 2006; 42:52-60. [PMID: 16639344 DOI: 10.1097/01.qai.0000219774.20174.64] [Citation(s) in RCA: 153] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE The effect of lopinavir/ritonavir (LPV/r) administration on cytochrome P450 (CYP) enzyme activity was quantified using a phenotyping biomarker cocktail. Changes in CYP2C9, CYP2C19, CYP3A, CYP1A2, N-acetyltransferase-2 (NAT-2), and xanthine oxidase (XO) activities were evaluated using warfarin (WARF) + vitamin K, omeprazole (OMP), intravenous (IV) and oral (PO) midazolam (MDZ), and caffeine (CAF). DESIGN : Open-label, multiple-dose, pharmacokinetic study in healthy volunteers. METHODS Subjects (n = 14) simultaneously received PO WARF 10 mg, vitamin K 10 mg, OMP 40 mg, CAF 2 mg/kg, and IV MDZ 0.025 mg/kg on days (D) 1 and 14, and PO MDZ 5 mg on D2 and D15. LPV/r (400/100 mg twice daily) was administered on D4-17. CYP2C9 and CYP2C19 activities were quantified by S-WARF AUC0-inf and OMP/5-hydroxy OMP ratio, respectively. CYP1A2, NAT-2, and XO activities were quantified by urinary CAF metabolite ratios. Hepatic and intestinal + hepatic CYP3A activities were quantified by IV (CL) and PO (CL/F) MDZ clearance, respectively. RESULTS After LPV/r therapy, CYP2C9, CYP2C19, and CYP1A2 activity increased by 29%, 100%, and 43% (P = 0.001, 0.046, and 0.001), respectively. No changes were seen in NAT-2 or XO activity. Hepatic and intestinal + hepatic CYP3A activity decreased by 77% (P < 0.001) and 92% (P = 0.001), respectively. CONCLUSION LPV/r therapy results in modest induction of CYP1A2 and CYP2C9 and potent induction of CYP2C19 activity. Increasing doses of concomitant medications metabolized by these enzymes may be necessary. LPV/r inhibited intestinal CYP3A to a greater extent than hepatic CYP3A activity. Doses of concomitant CYP3A substrates should be reduced when combined with LPV/r, although intravenously administered compounds may require less of a relative dose reduction than orally administered compounds.
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Affiliation(s)
- Rosa F Yeh
- School of Pharmacy, University of North Carolina at Chapel Hill, NC 27599, USA
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Lim ML, Min SS, Eron JJ, Bertz RJ, Robinson M, Gaedigk A, Kashuba ADM. Coadministration of Lopinavir/Ritonavir and Phenytoin Results in Two-Way Drug Interaction Through Cytochrome P-450 Induction. J Acquir Immune Defic Syndr 2004; 36:1034-40. [PMID: 15247556 DOI: 10.1097/00126334-200408150-00006] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Lopinavir/ritonavir (LPV/RTV) is a CYP3A4 inhibitor and substrate; it also may induce cytochrome P-450 (CYP) isozymes. Phenytoin (PHT) is a CYP3A4 inducer and CYP2C9/CYP2C19 substrate. This study quantified the pharmacokinetic (PK) drug interaction between LPV/RTV and PHT. Open-label, randomized, multiple-dose, PK study in healthy volunteers. Subjects in arm A (n = 12) received LPV/RTV 400/100 mg twice daily (BID) (days 1-10), followed by LPV/RTV 400/100 mg BID + PHT 300 mg once daily (QD) (days 11-22). Arm B (n = 12) received PHT 300 mg QD (days 1-11), followed by PHT 300 mg QD + LPV/RTV 400/100 mg BID (days 12-23). Plasma samples were collected on day 11 and day 22; PK parameters were compared by geometric mean ratio (GMR, day 22:day 11). P values <0.05 were considered significant. Following PHT addition, LPV area under the concentration-time curve (AUC0-12h) decreased from 70.9 +/-37.0 to 49.6 +/- 25.1 microg.h/mL (GMR 0.67, P = 0.011) and C0h decreased from 6.0 +/- 3.2 to 3.6 +/- 2.3 microg/mL (GMR 0.54, P = 0.001). Following LPV/RTV addition, PHT AUC0-24h decreased from 191.0+/-89.2 to 147.8+/-104.5 microg.h/mL (GMR 0.69, P = 0.009) and C0h decreased from 7.0+/-4.0 to 5.3+/-4.1 microg/mL (GMR 0.66, P = 0.033). Concomitant LPV/RTV and PHT use results in a 2-way drug interaction. Phenytoin appears to increase LPV clearance via CYP3A4 induction, which is not offset by the presence of low-dose RTV. LPV/RTV may increase PHT clearance via CYP2C9 induction. Management should be individualized to each patient; dosage or medication adjustments may be necessary.
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Affiliation(s)
- Michael L Lim
- School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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de Maat MMR, Ekhart GC, Huitema ADR, Koks CHW, Mulder JW, Beijnen JH. Drug interactions between antiretroviral drugs and comedicated agents. Clin Pharmacokinet 2003; 42:223-82. [PMID: 12603174 DOI: 10.2165/00003088-200342030-00002] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
HIV-infected individuals usually receive a wide variety of drugs in addition to their antiretroviral drug regimen. Since both non-nucleoside reverse transcriptase inhibitors and protease inhibitors are extensively metabolised by the cytochrome P450 system, there is a considerable potential for pharmacokinetic drug interactions when they are administered concomitantly with other drugs metabolised via the same pathway. In addition, protease inhibitors are substrates as well as inhibitors of the drug transporter P-glycoprotein, which also can result in pharmacokinetic drug interactions. The nucleoside reverse transcriptase inhibitors are predominantly excreted by the renal system and may also give rise to interactions. This review will discuss the pharmacokinetics of the different classes of antiretroviral drugs and the mechanisms by which drug interactions can occur. Furthermore, a literature overview of drug interactions is given, including the following items when available: coadministered agent and dosage, type of study that is performed to study the drug interaction, the subjects involved and, if specified, the type of subjects (healthy volunteers, HIV-infected individuals, sex), antiretroviral drug(s) and dosage, interaction mechanism, the effect and if possible the magnitude of interaction, comments, advice on what to do when the interaction occurs or how to avoid it, and references. This discussion of the different mechanisms of drug interactions, and the accompanying overview of data, will assist in providing optimal care to HIV-infected patients.
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Affiliation(s)
- Monique M R de Maat
- Department of Pharmacy and Pharmacology, Slotervaart Hospital, Amsterdam, The Netherlands.
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Scully C, Wolff A. Oral surgery in patients on anticoagulant therapy. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 2002; 94:57-64. [PMID: 12193895 DOI: 10.1067/moe.2002.123828] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Surgery is the main oral healthcare hazard to the patient with a bleeding tendency, which is mostly caused by the use of anticoagulants. The traditional management entails the interruption of anticoagulant therapy for dental surgery to prevent hemorrhage. However, this practice may increase the risk of a potentially life-threatening thromboembolism. Because this issue is still controversial, it is the aim of this paper to review the evidence, to highlight the areas of major concern, and to suggest management regimens for patients on the 3 main types of anticoagulants: coumarins, heparins, and aspirin. MATERIALS REVIEWED: The pertinent literature and clinical protocols of hospital dentistry departments have been extensively reviewed and discussed. RESULTS Several evolving clinical practices in the last years have been detected: anticoagulant use is generally not discontinued; oral surgery is performed despite laboratory values showing significant bleeding tendency; new effective local methods are used to prevent bleeding; and patients at risk are referred to hospital-based clinics. CONCLUSION The management of oral surgery procedures on patients treated with anticoagulants should be influenced by several factors: extent and urgency of surgery, laboratory values, treating physician's recommendation, available facilities, dentist expertise, and patient's oral, medical, and general condition.
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Affiliation(s)
- Crispian Scully
- Eastman Dental Institute, University College London, University of London, 256 Gray's Inn Road, Lonsion WC1X 8LD, UK.
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