In Vitro Study on the Effect of Maraviroc or Dolutegravir on Bilirubin to Albumin Binding

Single Doses of Pediatric Dolutegravir Dispersible Tablets in Neonates Support Multidosing: PETITE-Dolutegravir Study

BACKGROUND

Dolutegravir dispersible tablets (DTG-DTs) are approved for infants 4 weeks or older and ≥3 kg but their suitability for neonates remains unknown.

METHODS

PETITE-DTG is a phase I/II, open-label, single-center, 2-stage trial in South Africa to evaluate the pharmacokinetics (PK) and safety of DTG in term neonates of pregnant individuals receiving DTG-based therapy. In stage 1, neonates on standard antiretroviral prophylaxis received a single dose of 5 mg DTG-DT between ≥14 and <28 days of life (cohort 1A) or <14 days of life (cohort 1B), followed by PK and safety assessments. A population PK model was developed and multidose scenarios were simulated (DTG targets: geometric mean C tau > 0.67 µg/mL and C max < 17.0 µg/mL).

RESULTS

Sixteen neonates, 8 per cohort, completed stage 1. The median (range) birth weight was 3.1 (2.6-4.2) kg, and PK sampling was performed between 3 and 22 days of life. No grade 3 or higher adverse events were observed. DTG clearance was influenced by body weight and postnatal age. Simulations predicted that >10% of neonates would have a C max > 17.0 µg/mL with DTG once daily (q24) during the first 2 weeks of life. The administration of DTG every 48 hours (q48) from day 1-14 of life, followed by DTG every 24 hours through day 28, predicted a geometric mean C tau between 0.86 and 4.35 µg/mL; 98% with a C max < 17.0 µg/mL.

CONCLUSIONS

Owing to the slow postnatal DTG clearance after birth, a multidose strategy of 5 mg DTG-DT q48 for the first 2 weeks of life, followed by q24 through 28 days, was selected for assessment in stage 2.

Treatment of HIV Infection in Children Across the Age Spectrum: Achievements and New Prospects

Despite advances in human immunodeficiency virus (HIV) prevention, new pediatric HIV infections continue, necessitating optimized and simplified antiretroviral treatment (ART) regimens tailored for children. Advances in treatment options have been made possible by the availability of child-friendly fixed-dose formulations with decreased dosing frequency, especially in low- and middle-income countries. Ongoing work to improve ART options for neonates and supporting the shift toward long-acting ART for children and adolescents remains a priority. Achieving the UNAIDS goal of 95:95:95 for children will require a comprehensive and holistic approach that addresses both the biomedical and social challenges of managing children with HIV.

Raltegravir-based Postnatal HIV Prophylaxis Therapy in a Neonate After in Utero Dolutegravir Exposure

We present a case report of a neonate receiving raltegravir-based postnatal HIV prophylaxis after in utero dolutegravir exposure. High levels of raltegravir and dolutegravir can potentially cause bilirubin toxicity as they compete for albumin binding and follow the same metabolic pathway through UGT1A1. This case suggests delaying initiation of raltegravir-based postnatal prophylaxis by 24-48 hours after in utero dolutegravir exposure.

Optimizing Dolutegravir Initiation in Neonates Using Population Pharmacokinetic Modeling and Simulation

BACKGROUND

A knowledge gap exists for dolutegravir (DTG) pharmacokinetics and safety during the first 4 weeks of life, preventing safe and effective DTG use in neonates.

SETTING

Population pharmacokinetic modeling and simulation were used to assess newborn DTG dosing requirements during the first few days of life as a function of maternal DTG dosing history before delivery.

METHODS

DTG PK data were obtained from pregnant women and infants enrolled in the International Maternal Pediatric Adolescent AIDS Clinical Trials Network P1026S study. Maternal and neonate population pharmacokinetic models were separately developed. Monte Carlo simulations were performed to simulate neonatal concentrations after 2 doses of DTG after birth for infants born to mothers either receiving or not receiving DTG before delivery.

RESULTS

In DTG-naïve infants, a 5-mg DTG dose at birth with a second dose after 48 hours maintained median concentrations above the lower bound of the target range (0.77 μg/mL) and below the upper bound of the target range (7.34 μg/mL representing 2-fold above the adult Cmax value). In DTG-exposed infants, a 5-mg DTG dose at 24 hours after birth with a second dose after 48 hours maintained median concentrations within or nearly within the target range, even if the last maternal DTG dose was taken as soon as 6 hours or as long as 24 hours before delivery.

CONCLUSIONS

Newborn DTG dosing requirements during the first few days of life depend on maternal DTG dosing history before delivery. These results may help the design of future clinical studies of DTG in the neonatal population.