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Nakamura T, Okumura M, Takamune N, Hirotsu T, Sugiura M, Yasunaga J, Nakata H. Conversion of raltegravir carrying a 1,3,4-oxadiazole ring to a hydrolysis product upon pH changes decreases its antiviral activity. PNAS NEXUS 2024; 3:pgad446. [PMID: 38170115 PMCID: PMC10758923 DOI: 10.1093/pnasnexus/pgad446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/14/2023] [Indexed: 01/05/2024]
Abstract
Raltegravir (RAL), a human immunodeficiency virus (HIV)-1 integrase inhibitor, has been administered as part of antiretroviral therapy. Studies in patients with HIV-1 have shown high variability in the pharmacokinetics of RAL, and in healthy volunteers, coadministration of proton-pump inhibitors has been shown to increase the plasma RAL concentrations. Here, we found that RAL containing a 1,3,4-oxadiazole ring is converted to a hydrolysis product (H-RAL) with a cleaved 1,3,4-oxadiazole ring at pH 1.0 and 13.0 conditions in vitro, thereby reducing the anti-HIV activity of the drug. The inclusion of cyclodextrins (beta-cyclodextrin [βCD], random methyl-βCD [RAM-βCD], and hydroxypropyl-βCD [HP-βCD]) can protect RAL from pH-induced changes. The conversion of RAL to H-RAL was detected by using various mass spectrometry analyses. The chromatogram of H-RAL increased in a time-dependent manner similar to another 1,3,4-oxadiazole-containing drug, zibotentan, using high-performance liquid chromatography. Oral bioavailability and target protein interactions of H-RAL were predicted to be lower than those of RAL. Moreover, H-RAL exhibited significantly reduced anti-HIV-1 activity, whereas combinations with βCD, RAM-βCD, and HP-βCD attenuated this effect in cell-based assays. These findings suggest that βCDs can potentially protect against the conversion of RAL to H-RAL under acidic conditions in the stomach, thereby preserving the anti-HIV-1 effect of RAL. Although clinical trials are needed for evaluation, we anticipate that protective devices such as βCDs may improve the pharmacokinetics of RAL, leading to better treatment outcomes, including reduced dosing, long-term anti-HIV-1 activity, and deeper HIV-1 suppression.
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Affiliation(s)
- Tomofumi Nakamura
- Department of Hematology, Rheumatology, and Infectious Diseases, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, Honjyo 1-1-1, Chuo-ku, Kumamoto 860-8556, Japan
- Department of Laboratory Medicine, Kumamoto University Hospital, Honjyo 1-1-1, Chuo-ku, Kumamoto 860-8556, Japan
| | - Mayu Okumura
- Department of Hematology, Rheumatology, and Infectious Diseases, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, Honjyo 1-1-1, Chuo-ku, Kumamoto 860-8556, Japan
| | - Nobutoki Takamune
- Kumamoto Innovative Development Organization, Kumamoto University, Kurokami 2-39-1, Chuo-ku, Kumamoto 860-0862, Japan
| | - Tatsunori Hirotsu
- CyDing Company Limited, Oehonmachi 5-1, Chuo-ku, Kumamoto 862-0973, Japan
| | - Masaharu Sugiura
- Faculty of Pharmaceutical Sciences, Sojo University, Ikeda 4-22-1, Nishi-ku, Kumamoto 860-0082, Japan
| | - Junichiro Yasunaga
- Department of Hematology, Rheumatology, and Infectious Diseases, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, Honjyo 1-1-1, Chuo-ku, Kumamoto 860-8556, Japan
| | - Hirotomo Nakata
- Department of Hematology, Rheumatology, and Infectious Diseases, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, Honjyo 1-1-1, Chuo-ku, Kumamoto 860-8556, Japan
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Amariles P, Rivera-Cadavid M, Ceballos M. Clinical Relevance of Drug Interactions in People Living with Human Immunodeficiency Virus on Antiretroviral Therapy-Update 2022: Systematic Review. Pharmaceutics 2023; 15:2488. [PMID: 37896248 PMCID: PMC10610003 DOI: 10.3390/pharmaceutics15102488] [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: 06/07/2023] [Revised: 09/25/2023] [Accepted: 09/29/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND The clinical outcomes of antiretroviral drugs may be modified through drug interactions; thus, it is important to update the drug interactions in people living with HIV (PLHIV). AIM To update clinically relevant drug interactions in PLHIV on antiretroviral therapy with novel drug interactions published from 2017 to 2022. METHODS A systematic review in Medline/PubMed database from July 2017 to December 2022 using the Mesh terms antiretroviral agents and drug interactions or herb-drug interactions or food-drug interactions. Publications with drug interactions in humans, in English or Spanish, and with full-text access were retrieved. The clinical relevance of drug interactions was grouped into five levels according to the gravity and probability of occurrence. RESULTS A total of 366 articles were identified, with 219 (including 87 citation lists) were included, which allowed for the identification of 471 drug interaction pairs; among them, 291 were systematically reported for the first time. In total 42 (14.4%) and 137 (47.1%) were level one and two, respectively, and 233 (80.1%) pairs were explained with the pharmacokinetic mechanism. Among these 291 pairs, protease inhibitors (PIs) and ritonavir/cobicistat-boosted PIs, as well as integrase strand transfer inhibitors (InSTIs), with 70 (24.1%) and 65 (22.3%) drug interaction pairs of levels one and two, respectively, were more frequent. CONCLUSIONS In PLHIV on antiretroviral therapy, we identify 291 drug interaction pairs systematically reported for the first time, with 179 (61.5%) being assessed as clinically relevant (levels one and two). The pharmacokinetic mechanism was the most frequently identified. PIs, ritonavir/cobicistat-boosted PIs, and InSTIs were the antiretroviral groups with the highest number of clinically relevant drug interaction pairs (levels one and two).
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Affiliation(s)
- Pedro Amariles
- Research Group on Pharmaceutical Promotion and Prevention, University of Antioquia, UdeA, AA 1226, Medellin 050010, Colombia; (M.R.-C.); (M.C.)
- Research Group on Pharmaceutical Care, University of Granada, 18071 Granada, Spain
| | - Mónica Rivera-Cadavid
- Research Group on Pharmaceutical Promotion and Prevention, University of Antioquia, UdeA, AA 1226, Medellin 050010, Colombia; (M.R.-C.); (M.C.)
| | - Mauricio Ceballos
- Research Group on Pharmaceutical Promotion and Prevention, University of Antioquia, UdeA, AA 1226, Medellin 050010, Colombia; (M.R.-C.); (M.C.)
- Research Group on Pharmacy Regency Technology, University of Antioquia, Medellin 050010, Colombia
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Implications of Bariatric Surgery on the Pharmacokinetics of Antiretrovirals in People Living with HIV. Clin Pharmacokinet 2022; 61:619-635. [PMID: 35404470 PMCID: PMC9095546 DOI: 10.1007/s40262-022-01120-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2022] [Indexed: 11/06/2022]
Abstract
Bariatric surgery is increasingly applied among people living with HIV to reduce obesity and the associated morbidity and mortality. In people living with HIV, sufficient antiretroviral exposure and activity should always be maintained to prevent development of resistance and disease progression. However, bariatric surgery procedures bring various gastrointestinal modifications including changes in gastric volume, and acidity, gastrointestinal emptying time, enterohepatic circulation and delayed entry of bile acids. These alterations may affect many aspects of antiretroviral pharmacokinetics. Some drug characteristics may result in subtherapeutic exposure and the potential related risk of treatment failure and resistance. Antiretrovirals that require low pH, administration of fatty meals, longer intestinal exposure, and an enterohepatic recirculation for their absorption may be most impacted by bariatric surgery procedures. Additionally, some antiretrovirals can interact with the polyvalent cations in supplements or drugs inhibiting gastric acid, thereby preventing their use as these comedications are commonly prescribed post-bariatric surgery. Predicting pharmacokinetics on the basis of drug characteristics solely proved to be challenging, therefore pharmacokinetic studies remain crucial in this population. Here, we discuss general implications of bariatric surgery on antiretroviral outcomes in people living with HIV as well as drug properties that are relevant for the choice of antiretroviral treatment in this special patient population. Additionally, we summarise studies that evaluated the pharmacokinetics of antiretrovirals post-bariatric surgery. Finally, we performed a comprehensive analysis of theoretical considerations and published pharmacokinetic and pharmacodynamic data to provide recommendations on antiretrovirals for people living with HIV undergoing bariatric surgery.
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4
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Lu CH, Bednarczyk EM, Catanzaro LM, Shon A, Xu JC, Ma Q. Pharmacokinetic drug interactions of integrase strand transfer inhibitors. CURRENT RESEARCH IN PHARMACOLOGY AND DRUG DISCOVERY 2021; 2:100044. [PMID: 34909672 PMCID: PMC8663927 DOI: 10.1016/j.crphar.2021.100044] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 01/11/2023] Open
Abstract
The integrase strand transfer inhibitor (INSTI)-containing regimens are currently considered as the first-line treatment of human immunodeficiency virus (HIV) infection. Although possessing a common mechanism of action to inhibit HIV integrase irreversibly to stop HIV replication cycle, the INSTIs, including raltegravir, elvitegravir, dolutegravir, and bictegravir, differ in pharmacokinetic characteristics. While raltegravir undergoes biotransformation by the UDP-glucuronosyltransferases (UGTs), elvitegravir is primarily metabolized by cytochrome P450 (CYP) 3A4 and co-formulated with cobicistat to increase its plasma exposure. The metabolism pathways of dolutegravir and bictegravir are similar, both including CYP3A and UGT1A1, and both agents are substrates to different drug transporters. Because of their differences in metabolism, INSTIs interact with other medications differently through CYP enzymes and transporters as inducers or inhibitors. These drug interactions may become an important consideration in the long-term clinical use because the life expectancy of people with HIV (PWH) approaches to that of the general population. Also, common geriatric challenges such as multimorbidity and polypharmacy have been increasingly recognized in PWH. This review provides a summary of pharmacokinetic interactions with INSTIs and future perspectives in implications of INSTI drug interactions.
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Affiliation(s)
- Chi-Hua Lu
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Edward M Bednarczyk
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Linda M Catanzaro
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Alyssa Shon
- Department of Medicine, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Jia-Chen Xu
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Qing Ma
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
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5
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Peng AT, Huang SH, Sun HY, Huang YC, Chuang YC, Wu PY, Chen LY, Chang HY, Luo YZ, Liu WC, Kuo HY, Hung CC. Use of dietary supplements containing polyvalent cations and antacids among people with HIV and its impact on viral suppression. AIDS 2021; 35:2054-2057. [PMID: 34074818 DOI: 10.1097/qad.0000000000002967] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Dietary supplements and medications containing polyvalent cations can interact with integrase strand transfer inhibitors (INSTIs) and decrease exposure to INSTIs. In this cross-sectional study of 513 people with HIV (PWH) who were on stable antiretroviral therapy, 57.5% and 6.6% reported concurrent use of dietary supplements and antacids, respectively. In the multivariable analysis, the use of antacids, but not dietary supplements containing polyvalent cations, was associated with HIV viremia in PWH who received INSTI-based ART.
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Affiliation(s)
| | - Sung-Hsi Huang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine
| | - Hsin-Yun Sun
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
| | - Yi-Chia Huang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Biomedical Park Branch, Hsin-Chu
| | - Yu-Chung Chuang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
| | - Pei-Ying Wu
- Center of Infection Control, National Taiwan University Hospital, Taipei
| | - Ling-Ya Chen
- Center of Infection Control, National Taiwan University Hospital, Taipei
| | - Hsi-Yen Chang
- Center of Infection Control, National Taiwan University Hospital, Taipei
| | - Yu-Zhen Luo
- Center of Infection Control, National Taiwan University Hospital, Taipei
| | - Wen-Chun Liu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
| | - Han-Yueh Kuo
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu
| | - Chien-Ching Hung
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
- Department of Medical Research, China Medical University Hospital
- China Medical University, Taichung, Taiwan
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6
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Podany AT, Scarsi KK, Pham MM, Fletcher CV. Comparative Clinical Pharmacokinetics and Pharmacodynamics of HIV-1 Integrase Strand Transfer Inhibitors: An Updated Review. Clin Pharmacokinet 2021; 59:1085-1107. [PMID: 32462541 DOI: 10.1007/s40262-020-00898-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Bictegravir, cabotegravir, dolutegravir, elvitegravir, and raltegravir are members of the latest class of antiretrovirals available to treat human immunodeficiency virus (HIV) infection, the integrase strand transfer inhibitors. Integrase strand transfer inhibitors are potent inhibitors of the HIV integrase enzyme with IC90/95 values in the low nanogram per milliliter range and they retain antiviral activity against strains of HIV with acquired resistance to other classes of antiretrovirals. Each of the integrase strand transfer inhibitors have unique pharmacokinetic/pharmacodynamic properties, influencing their role in clinical use in specific subsets of patients. Cabotegravir, approved for use in Canada but not yet by the US Food and Drug Administration, is formulated in both oral and intramuscular formulations; the latter of which has shown efficacy as a long-acting extended-release formulation. Cabotegravir, raltegravir, and dolutegravir have minimal drug-drug interaction profiles, as their metabolism has minimal cytochrome P450 involvement. Conversely, elvitegravir metabolism occurs primarily via cytochrome P450 3A4 and requires pharmacokinetic boosting to achieve systemic exposures amenable to once-daily dosing. Bictegravir metabolism has similar contributions from both cytochrome P450 3A4 and uridine 5'-diphospho-glucuronosyltransferase 1A1. Bictegravir, dolutegravir, and raltegravir are recommended components of initial regimens for most people with HIV in the US adult and adolescent HIV treatment guidelines. This review summarizes and compares the pharmacokinetics and pharmacodynamics of the integrase strand transfer inhibitor agents, and describes specific pharmacokinetic considerations for persons with hepatic impairment, renal dysfunction, pregnancy, and co-infections.
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Affiliation(s)
- Anthony T Podany
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, PDD Rm 3019, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA.
| | - Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, PDD Rm 3019, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
| | - Michelle M Pham
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, PDD Rm 3019, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
| | - Courtney V Fletcher
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, PDD Rm 3019, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
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7
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Hodge D, Back DJ, Gibbons S, Khoo SH, Marzolini C. Pharmacokinetics and Drug-Drug Interactions of Long-Acting Intramuscular Cabotegravir and Rilpivirine. Clin Pharmacokinet 2021. [PMID: 33830459 DOI: 10.1007/s40262-021-01005-1/figures/4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2023]
Abstract
Combined antiretroviral treatments have significantly improved the morbidity and mortality related to HIV infection, thus transforming HIV infection into a chronic disease; however, the efficacy of antiretroviral treatments is highly dependent on the ability of infected individuals to adhere to life-long drug combination therapies. A major milestone in HIV treatment is the marketing of the long-acting intramuscular antiretroviral drugs cabotegravir and rilpivirine, allowing for infrequent drug administration, with the potential to improve adherence to therapy and treatment satisfaction. Intramuscular administration of cabotegravir and rilpivirine leads to differences in pharmacokinetics and drug-drug interaction (DDI) profiles compared with oral administration. A notable difference is the long elimination half-life with intramuscular administration, which reaches 5.6-11.5 weeks for cabotegravir and 13-28 weeks for rilpivirine, compared with 41 and 45 h, respectively, with their oral administration. Cabotegravir and rilpivirine have a low potential to cause DDIs, however these drugs can be victims of DDIs. Cabotegravir is mainly metabolized by UGT1A1, and rilpivirine is mainly metabolized by CYP3A4, therefore these agents are susceptible to DDIs with inhibitors, and particularly inducers of drug-metabolizing enzymes. Intramuscular administration of cabotegravir and rilpivirine has the advantage of eliminating DDIs occurring at the gastrointestinal level, however interactions can still occur at the hepatic level. This review provides insight on the intramuscular administration of drugs and summarizes the pharmacology of long-acting cabotegravir and rilpivirine. Particular emphasis is placed on DDI profiles after oral and intramuscular administration of these antiretroviral drugs.
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Affiliation(s)
- Daryl Hodge
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - David J Back
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Sara Gibbons
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Saye H Khoo
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Catia Marzolini
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland.
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8
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Hodge D, Back DJ, Gibbons S, Khoo SH, Marzolini C. Pharmacokinetics and Drug-Drug Interactions of Long-Acting Intramuscular Cabotegravir and Rilpivirine. Clin Pharmacokinet 2021; 60:835-853. [PMID: 33830459 PMCID: PMC8249281 DOI: 10.1007/s40262-021-01005-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 12/21/2022]
Abstract
Combined antiretroviral treatments have significantly improved the morbidity and mortality related to HIV infection, thus transforming HIV infection into a chronic disease; however, the efficacy of antiretroviral treatments is highly dependent on the ability of infected individuals to adhere to life-long drug combination therapies. A major milestone in HIV treatment is the marketing of the long-acting intramuscular antiretroviral drugs cabotegravir and rilpivirine, allowing for infrequent drug administration, with the potential to improve adherence to therapy and treatment satisfaction. Intramuscular administration of cabotegravir and rilpivirine leads to differences in pharmacokinetics and drug-drug interaction (DDI) profiles compared with oral administration. A notable difference is the long elimination half-life with intramuscular administration, which reaches 5.6-11.5 weeks for cabotegravir and 13-28 weeks for rilpivirine, compared with 41 and 45 h, respectively, with their oral administration. Cabotegravir and rilpivirine have a low potential to cause DDIs, however these drugs can be victims of DDIs. Cabotegravir is mainly metabolized by UGT1A1, and rilpivirine is mainly metabolized by CYP3A4, therefore these agents are susceptible to DDIs with inhibitors, and particularly inducers of drug-metabolizing enzymes. Intramuscular administration of cabotegravir and rilpivirine has the advantage of eliminating DDIs occurring at the gastrointestinal level, however interactions can still occur at the hepatic level. This review provides insight on the intramuscular administration of drugs and summarizes the pharmacology of long-acting cabotegravir and rilpivirine. Particular emphasis is placed on DDI profiles after oral and intramuscular administration of these antiretroviral drugs.
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Affiliation(s)
- Daryl Hodge
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - David J Back
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Sara Gibbons
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Saye H Khoo
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Catia Marzolini
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK. .,Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland.
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El Moussaoui M, Lambert I, Maes N, Sauvage AS, Frippiat F, Meuris C, Uurlings F, Lecomte M, Léonard P, Fombellida K, Vaira D, Vercheval C, Moutschen M, Darcis G. Evolution of Drug Interactions With Antiretroviral Medication in People With HIV. Open Forum Infect Dis 2020; 7:ofaa416. [PMID: 33204748 PMCID: PMC7651038 DOI: 10.1093/ofid/ofaa416] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 09/08/2020] [Indexed: 01/02/2023] Open
Abstract
Background Polypharmacy and drug interactions are important issues for HIV-infected individuals. The number and nature of those interactions are continuously evolving with the use of new antiretroviral drugs and the aging of HIV-infected individuals. We aimed to analyze this evolution over time. Methods This retrospective cohort study was conducted in the University Hospital of Liège (Belgium). Treatments of HIV-infected outpatients attending Liège University Hospital were collected and analyzed in 2012 and 2016. The University of Liverpool HIV drug interactions database was used to determine drug interactions. Results We included 1038 patients in 2016, of whom 78% had 1 comedication. Polypharmacy was seen in 20% of the cohort. Four percent of the patients presented red flag interactions, and 38% had orange flag interactions. Nonantiretroviral (non-ARV) therapeutic classes involved in drug interactions were mostly cardiovascular and central nervous system drugs. They were followed by hormone drugs and dietary supplements for orange flag interactions. Two factors significantly contributed to both red and orange flag interactions: the number of non-ARV comedications and protease inhibitor–based ARV regimens. The proportion of patients with red or orange flag interactions remained stable from 2012 to 2016. Conclusions This study highlights the persistence of an alarming number of contraindicated drug interactions and a high prevalence of potential drug interactions over time. Identification, prevention, and management of drug interactions remain a key priority in HIV care.
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Affiliation(s)
| | - Iseult Lambert
- Infectious Diseases Department, Liège University Hospital, Liège, Belgium
| | - Nathalie Maes
- Department of Biostatistics, Liège University Hospital, Liège, Belgium.,Department of Medico-Economic Information, Liège University Hospital, Liège, Belgium
| | | | - Frédéric Frippiat
- Infectious Diseases Department, Liège University Hospital, Liège, Belgium
| | - Christelle Meuris
- Infectious Diseases Department, Liège University Hospital, Liège, Belgium
| | - Françoise Uurlings
- Infectious Diseases Department, Liège University Hospital, Liège, Belgium
| | - Marianne Lecomte
- Infectious Diseases Department, Liège University Hospital, Liège, Belgium
| | - Philippe Léonard
- Infectious Diseases Department, Liège University Hospital, Liège, Belgium
| | - Karine Fombellida
- Infectious Diseases Department, Liège University Hospital, Liège, Belgium
| | - Dolores Vaira
- AIDS Reference Laboratory, Liège University, Liège, Belgium
| | | | - Michel Moutschen
- Infectious Diseases Department, Liège University Hospital, Liège, Belgium.,AIDS Reference Laboratory, Liège University, Liège, Belgium
| | - Gilles Darcis
- Infectious Diseases Department, Liège University Hospital, Liège, Belgium
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10
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Bukkems VE, Colbers A, Marzolini C, Molto J, Burger DM. Drug-Drug Interactions with Antiretroviral Drugs in Pregnant Women Living with HIV: Are They Different from Non-Pregnant Individuals? Clin Pharmacokinet 2020; 59:1217-1236. [PMID: 32696442 PMCID: PMC7550380 DOI: 10.1007/s40262-020-00914-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background and Objective Although the separate effects of drug–drug interactions and pregnancy on antiretroviral drug pharmacokinetics have been widely studied and described, their combined effect is largely unknown. Physiological changes during pregnancy may change the extent or clinical relevance of a drug–drug interaction in a pregnant woman. This review aims to provide a detailed overview of the mechanisms, magnitude, and clinical significance of antiretroviral drug–drug interactions in pregnant women. Methods We performed a literature search and selected studies that compared the magnitude of drug–drug interactions with antiretroviral drugs in pregnant vs non-pregnant women. Results Forty-eight papers examining drug–drug interactions during pregnancy were selected, of which the majority focused on pharmacokinetic boosting. Other selected studies examined the drug–drug interactions between efavirenz and lumefantrine, efavirenz and tuberculosis drugs, etravirine and tenofovir disoproxil fumarate, atazanavir and tenofovir disoproxil, and mefloquine and nevirapine in pregnant compared to non-pregnant women. The clinical significance of antiretroviral drug–drug interactions changed during pregnancy from a minimal effect to a contra-indication. In almost all cases, the clinical significance of a drug–drug interaction was more relevant in pregnant women, owing to the combined effects of pregnancy-induced physiological changes and drug–drug interactions leading to a lower absolute drug exposure. Conclusions Multiple studies show that the clinical relevance of a drug–drug interaction can change during pregnancy. Unfortunately, many potential interactions have not been studied in pregnancy, which may place pregnant women living with human immunodeficiency virus and their newborns at risk.
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Affiliation(s)
- Vera E Bukkems
- Department of Pharmacy, Radboud University Medical Center and Radboud Institute for Health Sciences (RIHS), Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Angela Colbers
- Department of Pharmacy, Radboud University Medical Center and Radboud Institute for Health Sciences (RIHS), Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands.
| | - Catia Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital of Basel and University of Basel, Basel, Switzerland.,Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Jose Molto
- Fundació Lluita Contra La Sida, Badalona, Spain.,Infectious Diseases Department, Hospital Universitari Germans Trias I Pujol, Badalona, Spain.,Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - David M Burger
- Department of Pharmacy, Radboud University Medical Center and Radboud Institute for Health Sciences (RIHS), Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
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Enoki Y, Suzuki N, Ito M, Uchiyama E, Kishi N, Ito C, Kitahiro Y, Sakamoto K, Taguchi K, Yokoyama Y, Kizu J, Matsumoto K. Concurrent administration with multivalent metal cation preparations or polycationic polymer preparations inhibits the absorption of raltegravir via its chelation. J Pharm Pharmacol 2020; 72:1361-1369. [PMID: 32657432 DOI: 10.1111/jphp.13330] [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: 04/06/2020] [Revised: 06/12/2020] [Accepted: 06/13/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Raltegravir (RAL) that can form chelates with multivalent metal cations shows lateral interactions with multivalent metal cation and polycationic polymer. We investigated the interactions of RAL with multivalent metal cation preparations, Al(OH)3 and LaCO3 , and polycationic polymer preparations, bixalomer (Bxl) and sevelamer (Svl). METHODS Immediately before the oral administration of 40 mg/kg RAL, the rats were administered orally with the vehicle, Al(OH)3 , LaCO3 , Bxl, or Svl, and the time course of RAL serum concentration was followed. The in vitro binding affinity of RAL with multivalent metal cation and polycationic polymer was also evaluated using isothermal titration calorimetry (ITC). RESULTS When Al(OH)3 , LaCO3 , Bxl, or Svl was concomitantly administered with RAL, the maximum concentration and area under the curve were significantly lower than those when RAL was administered alone. ITC showed the interaction of RAL with Al(OH)3 as an enthalpy-driven reaction and its interactions with LaCO3 and Bxl as entropy-enthalpy mixed reactions. CONCLUSIONS The interaction of RAL with Al(OH)3 , LaCO3, Bxl, or Svl can inhibit RAL absorption into the gastrointestinal tract, and thus, the multivalent metal cation and polycationic polymer are the modifying factors that can affect RAL pharmacokinetics.
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Affiliation(s)
- Yuki Enoki
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Norihiro Suzuki
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Motoyasu Ito
- Division of Practical Pharmacy, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Eri Uchiyama
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Nagomi Kishi
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Chihiro Ito
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Yuki Kitahiro
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Kazuki Sakamoto
- Division of Practical Pharmacy, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Kazuaki Taguchi
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Yuta Yokoyama
- Division of Practical Pharmacy, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Junko Kizu
- Division of Practical Pharmacy, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Tokyo, Japan.,Division of Practical Pharmacy, Faculty of Pharmacy, Keio University, Tokyo, Japan
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12
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Deutschmann E, Bucher HC, Jaeckel S, Gibbons S, McAllister K, Scherrer AU, Braun DL, Cavassini M, Hachfeld A, Calmy A, Battegay M, Cipriani M, Elzi L, Young J, Lopez-Centeno B, Berenguer J, Khoo S, Moffa G, Marzolini C. Prevalence of potential drug-drug interactions in patients of the Swiss HIV Cohort Study in the era of HIV integrase inhibitors. Clin Infect Dis 2020; 73:e2145-e2152. [PMID: 32634832 DOI: 10.1093/cid/ciaa918] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 06/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Prevalence of potential drug-drug interactions (PDDIs) between antiretroviral drugs (ARVs) and comedications was high in 2008 in a Swiss HIV Cohort Study (SHCS) survey. We reassessed the prevalence of PDDIs in the era of HIV integrase inhibitors (INIs), characterized by more favorable interaction profiles. METHODS The prevalence of PDDIs in treated HIV positive individuals was assessed for the period: 01-12/2018 by linkage of the Liverpool HIV drug interactions and SHCS databases. PDDIs were categorized as harmful (red flagged), of potential clinical relevance (amber flagged) or of weak clinical significance (yellow flagged). RESULTS In 9'298 included individuals, median age was 51 years (IQR 43; 58), and 72% were males. Individuals received unboosted INIs (40%), boosted ARVs (30%), and non-nucleoside reverse transcriptase inhibitors (NNRTIs) (32%) based regimens. In the entire cohort, 68% received > 1 comedication, 14% had polypharmacy (> 5 comedications) and 29% had > 1 PDDI. Among individuals with comedication, the prevalence of combined amber and yellow PDDIs was 43% (33% amber - mostly with cardiovascular drugs - and 20% yellow flagged PDDIs) compared to 59% in 2008. Two percent had red flagged PDDIs (mostly with corticosteroids), the same as in the 2008 survey. Compared to 2008, fewer individuals received boosted ARVs (-24%) and NNRTIs (-13%) but the use of comedications was higher. CONCLUSIONS Prevalence of PDDIs was lower with more widespread use of INIs in 2018 than in 2008. Continued use of boosted regimens and increasing needs for comedications in this aging population impeded lower rates of PDDIs.
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Affiliation(s)
- Elisabeth Deutschmann
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.,Division of Infectious Diseases & Hospital Hygiene, University Hospital Basel and University of Basel, Basel, Switzerland
| | | | - Sara Gibbons
- Department of Pharmacology, University of Liverpool, UK
| | | | - Alexandra U Scherrer
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich and University of Zurich, Switzerland.,Institute of Medical Virology, University of Zürich, Switzerland
| | - Dominique L Braun
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich and University of Zurich, Switzerland
| | - Matthias Cavassini
- Division of Infectious Diseases, University Hospital Lausanne, Lausanne, Switzerland
| | - Anna Hachfeld
- Department of Infectious Diseases, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Alexandra Calmy
- Division of Infectious Diseases, University Hospital Geneva, Geneva, Switzerland
| | - Manuel Battegay
- Division of Infectious Diseases & Hospital Hygiene, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Michela Cipriani
- Division of Infectious Diseases and Hospital Epidemiology, Canton Hospital St. Gallen, St. Gallen, Switzerland
| | - Luigia Elzi
- Ospedale Regionale di Bellinzone e Valli, Bellinzona, Switzerland
| | - James Young
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Beatriz Lopez-Centeno
- Subdirección General de Farmacia y Productos Sanitarios. Servicio Madrileño de Salud (SERMAS), Spain
| | - Juan Berenguer
- Hospital General Universitario Gregorio Marañón (IiSGM), Madrid, Spain
| | - Saye Khoo
- Department of Pharmacology, University of Liverpool, UK
| | - Giusi Moffa
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Catia Marzolini
- Division of Infectious Diseases & Hospital Hygiene, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Pharmacology, University of Liverpool, UK
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13
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Kang-Birken SL, El-Sayed D, Prichard J. HIV Viral Rebound Due to a Possible Drug-Drug Interaction between Elvitegravir/Cobicistat/Emtricitabine/Tenofovir Alafenamide and Calcium-Containing Products: Report of 2 Cases. J Int Assoc Provid AIDS Care 2020; 18:2325958218821653. [PMID: 30798679 PMCID: PMC6748456 DOI: 10.1177/2325958218821653] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide (E/C/F/TAF) is a potent fixed-dose, once-daily regimen for HIV-1 treatment and has rare emergence of drug resistance. We report a potential drug–drug interaction in 2 female patients both receiving treatment for HIV and cerebral toxoplasmosis: one case between E/C/F/TAF with calcium carbonate and a second case involving leucovorin as calcium salt. Both cases resulted in rise in HIV RNA levels and emergence of M184 V mutation and resistance to elvitegravir and raltegravir. To the best of our knowledge, these 2 cases are the first reports of rapid emergence of mutation from coadministration of E/C/F/TAF and calcium.
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Affiliation(s)
- S Lena Kang-Birken
- 1 Immunology Clinic, Ventura County Medical Center, Ventura, CA, USA.,2 Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA, USA
| | - Dena El-Sayed
- 1 Immunology Clinic, Ventura County Medical Center, Ventura, CA, USA
| | - John Prichard
- 1 Immunology Clinic, Ventura County Medical Center, Ventura, CA, USA
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14
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The effect of multivitamins and polyvalent cations on virologic suppression with integrase strand transfer inhibitors. AIDS 2020; 34:487-489. [PMID: 31996598 DOI: 10.1097/qad.0000000000002438] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Back D, Marzolini C. The challenge of HIV treatment in an era of polypharmacy. J Int AIDS Soc 2020; 23:e25449. [PMID: 32011104 PMCID: PMC6996317 DOI: 10.1002/jia2.25449] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/26/2019] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The availability of potent antiretroviral therapy has transformed HIV infection into a chronic disease such that people living with HIV (PLWH) have a near normal life expectancy. However, there are continuing challenges in managing HIV infection, particularly in older patients, who often experience age-related comorbidities resulting in complex polypharmacy and an increased risk for drug-drug interactions. Furthermore, age-related physiological changes may affect the pharmacokinetics and pharmacodynamics of both antiretrovirals and comedications thereby predisposing elderly to adverse drug reactions. This review provides an overview of the therapeutic challenges when treating elderly PLWH (i.e. >65 years). Particular emphasis is placed on drug-drug interactions and other common prescribing issues (i.e. inappropriate drug use, prescribing cascade, drug-disease interaction) encountered in elderly PLWH. DISCUSSION Prescribing issues are common in elderly PLWH due to the presence of age-related comorbidities, organ dysfunction and physiological changes leading to a higher risk for drug-drug interactions, drugs dosage errors and inappropriate drug use. CONCLUSIONS The high prevalence of prescribing issues in elderly PLWH highlights the need for ongoing education on prescribing principles and the optimal management of individual patients. The knowledge of adverse health outcomes associated with polypharmacy and inappropriate prescribing should ensure that there are interventions to prevent harm including medication reconciliation, medication review and medication prioritization according to the risks/benefits for each patient.
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Affiliation(s)
- David Back
- Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Catia Marzolini
- Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
- Division of Infectious Diseases and Hospital EpidemiologyDepartments of Medicine and Clinical ResearchUniversity Hospital of Basel and University of BaselBaselSwitzerland
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16
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Abstract
Introduction: Combined antiretroviral therapy has transformed HIV infection into a chronic disease thus people living with HIV (PLWH) live longer. As a result, the management of HIV infection is becoming more challenging as elderly experience age-related comorbidities leading to complex polypharmacy and a higher risk for drug-drug or drug-disease interactions. Furthermore, age-related physiological changes affect pharmacokinetics and pharmacodynamics thereby predisposing elderly PLWH to incorrect dosing or inappropriate prescribing and consequently to adverse drug reactions and the subsequent risk of starting a prescribing cascade. Areas covered: This review discusses the demographics of the aging HIV population, physiological changes and their impact on drug response as well as comorbidities. Particular emphasis is placed on common prescribing issues in elderly PLWH including drug-drug interactions with antiretroviral drugs. A PubMed search was used to compile relevant publications until February 2019. Expert opinion: Prescribing issues are highly prevalent in elderly PLWH thus highlighting the need for education on geriatric prescribing principles. Adverse health outcomes potentially associated with polypharmacy and inappropriate prescribing should promote interventions to prevent harm including medication reconciliation, medication review, and medication prioritization according to the risks/benefits for a given patient. A multidisciplinary team approach is recommended for the care of elderly PLWH.
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Affiliation(s)
- Catia Marzolini
- a Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research , University Hospital of Basel and University of Basel , Basel , Switzerland.,b Department of Molecular and Clinical Pharmacology , University of Liverpool , Liverpool , UK
| | - Françoise Livio
- c Service of Clinical Pharmacology, Department of Laboratories , University Hospital of Lausanne , Lausanne , Switzerland
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17
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Brooks KM, Sherman EM, Egelund EF, Brotherton A, Durham S, Badowski ME, Cluck DB. Integrase Inhibitors: After 10 Years of Experience, Is the Best Yet to Come? Pharmacotherapy 2019; 39:576-598. [PMID: 30860610 DOI: 10.1002/phar.2246] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The era of the integrase strand transfer inhibitors (INSTIs) for the treatment of human immunodeficiency virus (HIV) infection began with raltegravir in 2007. Since that time, several other INSTIs have been introduced including elvitegravir, dolutegravir, and, most recently, bictegravir, that have shown great utility as part of antiretroviral regimens in both treatment-naive and treatment-experienced patients. At present, antiretroviral guidelines fully endorse the INSTI class as part of all first-line treatment regimens. After 10 years of experience with INSTIs, newer agents are on the horizon such as cabotegravir and MK-2048 for potential use as either HIV pre-exposure prophylaxis or maintenance therapy. This review provides a brief overview of the INSTI class including agents currently available and those still in development, reviews available data from both completed and ongoing clinical trials, and outlines simplification strategies using INSTIs.
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Affiliation(s)
- Kristina M Brooks
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Elizabeth M Sherman
- Department of Pharmacy Practice, Nova Southeastern University, Fort Lauderdale, Florida
| | - Eric F Egelund
- Department of Pharmacotherapy & Translational Research, University of Florida College of Pharmacy, Jacksonville, Florida
| | - Amy Brotherton
- Department of Pharmacy, The Miriam Hospital, Providence, Rhode Island
| | - Spencer Durham
- Department Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, Alabama
| | - Melissa E Badowski
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - David B Cluck
- Department of Pharmacy Practice, East Tennessee State University Gatton College of Pharmacy, Johnson City, Tennessee
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18
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Hughes C, Yoong D, Giguère P, Hull M, Tan DHS. Canadian guideline on HIV preexposure prophylaxis and nonoccupational postexposure prophylaxis for pharmacists. Can Pharm J (Ott) 2019; 152:81-91. [PMID: 30886661 DOI: 10.1177/1715163519826171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Christine Hughes
- Faculty of Pharmacy & Pharmaceutical Sciences (Hughes), University of Alberta, Edmonton, Alberta.,Department of Pharmacy (Yoong) and the Division of Infectious Diseases (Tan), St. Michael's Hospital, Toronto.,Department of Pharmacy (Giguère), The Ottawa Hospital, Ottawa, Ontario.,BC Centre for Excellence in HIV/AIDS, Vancouver, BC (Hull)
| | - Deborah Yoong
- Faculty of Pharmacy & Pharmaceutical Sciences (Hughes), University of Alberta, Edmonton, Alberta.,Department of Pharmacy (Yoong) and the Division of Infectious Diseases (Tan), St. Michael's Hospital, Toronto.,Department of Pharmacy (Giguère), The Ottawa Hospital, Ottawa, Ontario.,BC Centre for Excellence in HIV/AIDS, Vancouver, BC (Hull)
| | - Pierre Giguère
- Faculty of Pharmacy & Pharmaceutical Sciences (Hughes), University of Alberta, Edmonton, Alberta.,Department of Pharmacy (Yoong) and the Division of Infectious Diseases (Tan), St. Michael's Hospital, Toronto.,Department of Pharmacy (Giguère), The Ottawa Hospital, Ottawa, Ontario.,BC Centre for Excellence in HIV/AIDS, Vancouver, BC (Hull)
| | - Mark Hull
- Faculty of Pharmacy & Pharmaceutical Sciences (Hughes), University of Alberta, Edmonton, Alberta.,Department of Pharmacy (Yoong) and the Division of Infectious Diseases (Tan), St. Michael's Hospital, Toronto.,Department of Pharmacy (Giguère), The Ottawa Hospital, Ottawa, Ontario.,BC Centre for Excellence in HIV/AIDS, Vancouver, BC (Hull)
| | - Darrell H S Tan
- Faculty of Pharmacy & Pharmaceutical Sciences (Hughes), University of Alberta, Edmonton, Alberta.,Department of Pharmacy (Yoong) and the Division of Infectious Diseases (Tan), St. Michael's Hospital, Toronto.,Department of Pharmacy (Giguère), The Ottawa Hospital, Ottawa, Ontario.,BC Centre for Excellence in HIV/AIDS, Vancouver, BC (Hull)
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19
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Di Perri G, Calcagno A, Trentalange A, Bonora S. The clinical pharmacology of integrase inhibitors. Expert Rev Clin Pharmacol 2018; 12:31-44. [PMID: 30513008 DOI: 10.1080/17512433.2019.1553615] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Treatment of HIV infection has consistently evolved in the last three decades. A steady improvement in efficacy tolerability, safety, and practical aspects of treatment intake has made HIV infection much easier to manage over the long term, and in optimal treatment conditions the life expectancy of persons living with HIV infection now approaches the values of the general population. The last category of antiretrovirals to be fully developed for clinical use is the one of strand-transfer integrase inhibitors (INSTIs). Areas covered: In this review, the evolution of the knowledge on INSTIs use in the clinical setting is reviewed, analyzed, and interpreted. Emphasis is placed on the properties possibly accounting for several superiority results achieved by INSTIs in non-inferiority designed comparative clinical trials, which led to their inclusion as first line options in all versions of HIV therapeutic guidelines. Expert commentary: Some unprecedented clinical-pharmacological properties of INSTIs, such as their rapid and sustained action against HIV replication, the optimal tolerability and safety profile and a clinically proven robust genetic barrier are the main factors justifying the successful clinical use of INSTIs. Based on these unique features, novel INSTIs-based treatment modalities are being developed, including the reduction of antiretroviral regimens to two drugs only.
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Affiliation(s)
- Giovanni Di Perri
- a The Infectious Diseases Unit, Department of Medical Sciences, School of Medicine , The University of Torino , Torino , Italy
| | - Andrea Calcagno
- a The Infectious Diseases Unit, Department of Medical Sciences, School of Medicine , The University of Torino , Torino , Italy
| | - Alice Trentalange
- a The Infectious Diseases Unit, Department of Medical Sciences, School of Medicine , The University of Torino , Torino , Italy
| | - Stefano Bonora
- a The Infectious Diseases Unit, Department of Medical Sciences, School of Medicine , The University of Torino , Torino , Italy
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20
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Durham SH, Badowski ME, Liedtke MD, Rathbun RC, Pecora Fulco P. Acute Care Management of the HIV-Infected Patient: A Report from the HIV Practice and Research Network of the American College of Clinical Pharmacy. Pharmacotherapy 2017; 37:611-629. [PMID: 28273373 DOI: 10.1002/phar.1921] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients infected with human immunodeficiency virus (HIV) admitted to the hospital have complex antiretroviral therapy (ART) regimens with an increased medication error rate upon admission. This report provides a resource for clinicians managing HIV-infected patients and ART in the inpatient setting. METHODS A survey of the authors was conducted to evaluate common issues that arise during an acute hospitalization for HIV-infected patients. After a group consensus, a review of the medical literature was performed to determine the supporting evidence for the following HIV-associated hospital queries: admission/discharge orders, antiretroviral hospital formularies, laboratory monitoring, altered hepatic/renal function, drug-drug interactions (DDIs), enteral administration, and therapeutic drug monitoring. RESULTS With any hospital admission for an HIV-infected patient, a specific set of procedures should be followed including a thorough admission medication history and communication with the ambulatory HIV provider to avoid omissions or substitutions in the ART regimen. DDIs are common and should be reviewed at all transitions of care during the hospital admission. ART may be continued if enteral nutrition with a feeding tube is deemed necessary, but the entire regimen should be discontinued if no oral access is available for a prolonged period. Therapeutic drug monitoring is not generally recommended but, if available, should be considered in unique clinical scenarios where antiretroviral pharmacokinetics are difficult to predict. ART may need adjustment if hepatic or renal insufficiency ensues. CONCLUSIONS Treatment of hospitalized patients with HIV is highly complex. HIV-infected patients are at high risk for medication errors during various transitions of care. Baseline knowledge of the principles of antiretroviral pharmacotherapy is necessary for clinicians managing acutely ill HIV-infected patients to avoid medication errors, identify DDIs, and correctly dose medications if organ dysfunction arises. Timely ambulatory follow-up is essential to prevent readmissions and facilitate improved transitions of care.
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Affiliation(s)
- Spencer H Durham
- Department Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, Alabama
| | - Melissa E Badowski
- Section of Infectious Diseases, Department of Pharmacy Practice, University of Illinois at Chicago, College of Pharmacy, Chicago, Illinois
| | - Michelle D Liedtke
- Department of Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - R Chris Rathbun
- Department of Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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21
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Buchanan AM, Holton M, Conn I, Davies M, Choukour M, Wynne BR. Relative Bioavailability of a Dolutegravir Dispersible Tablet and the Effects of Low- and High-Mineral-Content Water on the Tablet in Healthy Adults. Clin Pharmacol Drug Dev 2017; 6:577-583. [PMID: 28168828 PMCID: PMC5697680 DOI: 10.1002/cpdd.332] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 12/12/2016] [Indexed: 12/13/2022]
Abstract
Dolutegravir (DTG) is approved in the United States to treat HIV‐1‐infected patients weighing ≥30 kg. A dispersible DTG tablet formulation was recently developed for pediatric patients. This study compares the pharmacokinetics (PK) of the dispersible tablet with that of a previously evaluated granule formulation. In this randomized, open‐label, crossover study, 15 healthy adults received single oral doses of DTG 20 mg every 7 days across 5 treatment arms: granules consumed immediately after mixture with purified water, dispersible DTG consumed immediately after reconstitution in low‐mineral‐content (LMC) or high‐mineral‐content (HMC) water, and dispersible DTG consumed 30 minutes after dispersal in LMC or HMC water. Primary endpoints were bioavailability of immediately consumed dispersible tablet in LMC water relative to granule formulation reconstituted in purified water and PK of the dispersible tablet. Secondary endpoints included tolerability and palatability. The DTG dispersible tablet showed equivalent exposures to the granule formulation with geometric least‐squares mean treatment ratios of 1.06 and 1.12 for AUC0‐∞ and Cmax, respectively. DTG PK parameters were unaffected by mineral content or the 30‐minute delay. Adverse events were mild; only nausea (n = 1) was considered drug related. DTG exposure observed with the dispersible tablet supports evaluation of this formulation for further development.
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Affiliation(s)
| | | | - Ian Conn
- GlaxoSmithKline, Harlow, Essex, UK
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22
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Podany AT, Scarsi KK, Fletcher CV. Comparative Clinical Pharmacokinetics and Pharmacodynamics of HIV-1 Integrase Strand Transfer Inhibitors. Clin Pharmacokinet 2017; 56:25-40. [PMID: 27317415 PMCID: PMC5164870 DOI: 10.1007/s40262-016-0424-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Dolutegravir (DTG), elvitegravir (EVG) and raltegravir (RAL) are members of the latest class of antiretrovirals (ARVs) that have become available to treat human immunodeficiency virus (HIV) infection: integrase strand transfer inhibitors (INSTIs). INSTIs are potent inhibitors of the HIV integrase enzyme, with protein binding-adjusted concentration inhibiting viral replication by 90/95 % [IC90/95] values in the low nanogram per millilitre range, and they retain antiviral activity against strains of HIV with acquired resistance to other classes of ARVs. Each of the INSTIs has unique pharmacokinetic/pharmacodynamic properties, influencing its role in clinical use in specific subsets of patients. RAL and DTG have minimal drug-drug interaction profiles, as their metabolism has minimal cytochrome P450 (CYP) involvement. Conversely, EVG metabolism occurs primarily via CYP3A4 and requires pharmacokinetic boosting to achieve systemic exposures amenable to once-daily dosing. EVG and DTG have the added benefit of availability of fixed-dose combination tablets, allowing for convenient and simplified ARV regimens. RAL is the only INSTI to be listed as a preferred agent in the current US perinatal treatment guidelines. All three INSTIs are recommended regimens for treatment-naïve individuals in the US adult and adolescent HIV treatment guidelines. This review summarizes and compares the pharmacokinetics and pharmacodynamics of the INSTIs, and describes specific pharmacokinetic considerations for special patient conditions: hepatic impairment, renal dysfunction, pregnancy and co-infections.
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Affiliation(s)
- Anthony T Podany
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986000 Nebraska Medical Center, Omaha, NE, 68198-6000, USA
| | - Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986000 Nebraska Medical Center, Omaha, NE, 68198-6000, USA
| | - Courtney V Fletcher
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986000 Nebraska Medical Center, Omaha, NE, 68198-6000, USA.
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23
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Brooks KM, George JM, Kumar P. Drug interactions in HIV treatment: complementary & alternative medicines and over-the-counter products. Expert Rev Clin Pharmacol 2016; 10:59-79. [PMID: 27715369 DOI: 10.1080/17512433.2017.1246180] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Use of complementary and alternative medicines (CAMs) and over-the-counter (OTC) medications are very common among HIV-infected patients. These products can cause clinically significant drug-drug interactions (DDIs) with antiretroviral (ARV) medications, thereby increasing risk for negative outcomes such as toxicity or loss of virologic control. Areas covered: This article provides an updated review of the different mechanisms by which CAM and OTC products are implicated in DDIs with ARV medications. Expert commentary: Much of the literature published to date involves studies of CAMs interacting with older ARV agents via the cytochrome P450 (CYP450) system. However, the HIV treatment and prevention arsenal is continually evolving. Furthermore, our elucidation of the role of non-CYP450 mediated DDIs with ARV medications is greatly increasing. Therefore, clinicians are well served to understand the various mechanisms and extent by which new ARV therapies may be involved in drug interactions with CAMs and OTC medications.
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Affiliation(s)
- Kristina M Brooks
- a Clinical Pharmacokinetics Research Unit, Clinical Center Pharmacy Department , National Institutes of Health , Bethesda , MD , USA
| | - Jomy M George
- a Clinical Pharmacokinetics Research Unit, Clinical Center Pharmacy Department , National Institutes of Health , Bethesda , MD , USA
| | - Parag Kumar
- a Clinical Pharmacokinetics Research Unit, Clinical Center Pharmacy Department , National Institutes of Health , Bethesda , MD , USA
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24
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Krishna R, East L, Larson P, Valiathan C, Butterfield K, Teng Y, Hernandez-Illas M. Effect of metal-cation antacids on the pharmacokinetics of 1200 mg raltegravir. ACTA ACUST UNITED AC 2016; 68:1359-1365. [PMID: 27671833 DOI: 10.1111/jphp.12632] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 08/10/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Raltegravir is a human immunodeficiency virus (HIV)-1 integrase strand transfer inhibitor currently marketed at a dose of 400 mg twice daily (BID). Raltegravir for once-daily regimen (QD) at a dose of 1200 mg is under development. The effect of calcium carbonate and magnesium/aluminium hydroxide antacids on the pharmacokinetics of a 1200 mg dose of raltegravir was assessed in this study. METHODS An open-label, four-period, four-treatment, fixed-sequence study in 20 HIV-infected patients was performed. Patients needed to be on raltegravir as part of a stable treatment regimen for HIV, and upon entry into the trial received 5 days of 1200 mg raltegravir as pretreatment, before they entered the four-period study: 1200 mg of raltegravir alone (period 1), calcium carbonate antacid as TUMS® Ultra Strength (US) 1000 and 1200 mg raltegravir given concomitantly (Period 2), magnesium/aluminium hydroxide antacid as 20 ml MAALOX® Maximum Strength substitute MS given 12 h after administration of 1200 mg raltegravir (period 3), and calcium carbonate antacid as TUMS® US 1000 given 12 h after administration of 1200 mg raltegravir (period 4). Patients received their dose of 1200 mg QD raltegravir during the intervals between periods to re-establish steady state. AUC0-24 , C24 , Cmax and Tmax were calculated from the individual plasma concentrations of 1200 mg QD raltegravir after administration alone or with a calcium carbonate antacid or with a staggered dose of a calcium carbonate antacid or magnesium/aluminium hydroxide antacid. Adverse events, in addition to laboratory safety tests (haematology, serum chemistry and urinalysis), 12-lead electrocardiograms and vital signs were assessed. KEY FINDINGS All treatments were well tolerated in the study. Metal-cation antacids variably affected the pharmacokinetics of 1200 mg QD raltegravir. When calcium carbonate antacid was given with 1200 mg raltegravir concomitantly, the geometric mean ratio (GMR) and its associated 90% confidence interval (90% CI) for AUC0-24 , Cmax and C24 h were 0.28 (0.24, 0.32), 0.26 (0.21, 0.32) and 0.52 (0.45, 0.61), respectively. When calcium carbonate antacid and magnesium/aluminium hydroxide were given 12 h after raltegravir 1200 mg QD dosing, the GMR (90% CI) values for AUC0-24 and Cmax were 0.90 (0.80, 1.03), 0.98 (0.81, 1.17), and 0.86 (0.73, 1.03), 0.86 (0.65, 1.15), respectively. However, significant reduction in the trough concentrations of raltegravir was observed: C24 h 0.43 (0.36, 0.51) in the presence of calcium carbonate antacids and 0.42 (0.34, 0.52) in presence of magnesium/aluminium hydroxide, respectively. CONCLUSIONS Overall, the use of metal-cation antacids with 1200 mg QD raltegravir is not recommended.
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Affiliation(s)
- Rajesh Krishna
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ, USA.
| | - Lilly East
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ, USA
| | - Patrick Larson
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ, USA
| | | | | | - Yang Teng
- QPS MRA (Miami Clinical Research), Miami, FL, USA
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Meditz AL, Palmer C, Predhomme J, Searls K, Kerr B, Seifert S, Caraway P, Gardner EM, MaWhinney S, Anderson PL. Relationship Between Genital Drug Concentrations and Cervical Cellular Immune Activation and Reconstitution in HIV-1-Infected Women on a Raltegravir Versus a Boosted Atazanavir Regimen. AIDS Res Hum Retroviruses 2015; 31:1015-22. [PMID: 26059647 DOI: 10.1089/aid.2014.0301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Determinants of HIV-infected women's genital tract mucosal immune health are not well understood. Because raltegravir (RAL) achieves relatively higher genital tract concentrations than ritonavir-boosted atazanavir (ATV), we examined whether an RAL-based regimen is associated with improved cervical immune reconstitution and less activation in HIV(+) women compared to an ATV-based regimen. Peripheral blood, cervical brushings, cervical-vaginal lavage (CVL), and cervical biopsies were collected from HIV(+) women on tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) and either RAL (n=14) or ATV (n=19) with CD4(+) T cells>300 cells/mm(3) and HIV RNA<48 copies/ml. HLA-DR(+)CD38(+) T cells were measured in blood and cervical cells using flow cytometry, CD4(+) and CD8(+) T cells were quantified in cervical biopsies by immunofluorescent analysis, and HIV RNA (VL), ATV, and RAL concentrations were measured in CVL. In a linear regression model of log(CVL concentration) versus both log(plasma concentration) and treatment group, the RAL CVL level was 519% (95% CI: 133, 1,525%) higher than for ATV (p<0.001). Genital tract VL was undetectable in 90% of subjects and did not differ by regimen. There were no significant differences between groups in terms of cervical %HLA-DR(+)CD38(+)CD4(+) or CD8(+) T cells, CD4(+) or CD8(+) T cells/mm(2), or CD4:CD8 ratio. After adjusting for treatment time and group, the CVL:plasma drug ratio was not associated with the cervical CD4:CD8 ratio or immune activation (p>0.6). Despite significantly higher genital tract penetration of RAL compared to ATV, there were no significant differences in cervical immune activation or reconstitution between women on these regimens, suggesting both drug regimens achieve adequate genital tract levels to suppress virus replication.
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Affiliation(s)
| | | | | | | | - Becky Kerr
- University of Colorado, Aurora, Colorado
| | | | | | - Edward M. Gardner
- University of Colorado, Aurora, Colorado
- Denver Public Health, Denver, Colorado
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Moss DM, Marzolini C, Rajoli RKR, Siccardi M. Applications of physiologically based pharmacokinetic modeling for the optimization of anti-infective therapies. Expert Opin Drug Metab Toxicol 2015; 11:1203-17. [PMID: 25872900 DOI: 10.1517/17425255.2015.1037278] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The pharmacokinetic properties of anti-infective drugs are a determinant part of treatment success. Pathogen replication is inhibited if adequate drug levels are achieved in target sites, whereas excessive drug concentrations linked to toxicity are to be avoided. Anti-infective distribution can be predicted by integrating in vitro drug properties and mathematical descriptions of human anatomy in physiologically based pharmacokinetic models. This method reduces the need for animal and human studies and is used increasingly in drug development and simulation of clinical scenario such as, for instance, drug-drug interactions, dose optimization, novel formulations and pharmacokinetics in special populations. AREAS COVERED We have assessed the relevance of physiologically based pharmacokinetic modeling in the anti-infective research field, giving an overview of mechanisms involved in model design and have suggested strategies for future applications of physiologically based pharmacokinetic models. EXPERT OPINION Physiologically based pharmacokinetic modeling provides a powerful tool in anti-infective optimization, and there is now no doubt that both industry and regulatory bodies have recognized the importance of this technology. It should be acknowledged, however, that major challenges remain to be addressed and that information detailing disease group physiology and anti-infective pharmacodynamics is required if a personalized medicine approach is to be achieved.
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Affiliation(s)
- Darren Michael Moss
- University of Liverpool, Institute of Translational Medicine, Molecular and Clinical Pharmacology , Liverpool , UK +44 0 151 794 8211 ; +44 0 151 794 5656 ;
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Foy M, Sperati CJ, Lucas GM, Estrella MM. Drug interactions and antiretroviral drug monitoring. Curr HIV/AIDS Rep 2015; 11:212-22. [PMID: 24950731 DOI: 10.1007/s11904-014-0212-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Owing to the improved longevity afforded by combination antiretroviral therapy (cART), HIV-infected individuals are developing several non-AIDS-related comorbid conditions. Consequently, medical management of the HIV-infected population is increasingly complex, with a growing list of potential drug-drug interactions (DDIs). This article reviews some of the most relevant and emerging potential interactions between antiretroviral medications and other agents. The most common DDIs are those involving protease inhibitors or non-nucleoside reverse transcriptase inhibitors, which alter the cytochrome P450 enzyme system and/or drug transporters such as p-glycoprotein. Of note are the new agents for the treatment of chronic hepatitis C virus infection. These new classes of drugs and others drugs that are increasingly used in this patient population represent a significant challenge with regard to achieving the goals of effective HIV suppression and minimization of drug-related toxicities. Awareness of DDIs and a multidisciplinary approach are imperative in reaching these goals.
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Affiliation(s)
- Matthew Foy
- Division of Nephrology, Department of Medicine, Louisiana State University Health Science Center, Baton Rouge, LA, 70805, USA
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Hughes CA, Tseng A, Cooper R. Managing drug interactions in HIV-infected adults with comorbid illness. CMAJ 2015; 187:36-43. [PMID: 25225224 PMCID: PMC4284166 DOI: 10.1503/cmaj.131626] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Christine A Hughes
- Faculty of Pharmacy and Pharmaceutical Sciences (Hughes) and Division of Infectious Diseases, Department of Medicine (Cooper), University of Alberta, Edmonton, Alta.; Northern Alberta HIV Program (Hughes), Edmonton, Alta.; Toronto General Hospital (Tseng), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (Tseng), University of Toronto, Toronto, Ont.
| | - Alice Tseng
- Faculty of Pharmacy and Pharmaceutical Sciences (Hughes) and Division of Infectious Diseases, Department of Medicine (Cooper), University of Alberta, Edmonton, Alta.; Northern Alberta HIV Program (Hughes), Edmonton, Alta.; Toronto General Hospital (Tseng), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (Tseng), University of Toronto, Toronto, Ont
| | - Ryan Cooper
- Faculty of Pharmacy and Pharmaceutical Sciences (Hughes) and Division of Infectious Diseases, Department of Medicine (Cooper), University of Alberta, Edmonton, Alta.; Northern Alberta HIV Program (Hughes), Edmonton, Alta.; Toronto General Hospital (Tseng), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (Tseng), University of Toronto, Toronto, Ont
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Song I, Borland J, Arya N, Wynne B, Piscitelli S. Pharmacokinetics of dolutegravir when administered with mineral supplements in healthy adult subjects. J Clin Pharmacol 2014; 55:490-6. [PMID: 25449994 PMCID: PMC4407950 DOI: 10.1002/jcph.439] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 11/24/2014] [Indexed: 11/22/2022]
Abstract
All commercially available integrase inhibitors are 2-metal binders and may be affected by co-administration with metal cations. The purpose of this study was to evaluate the effect of calcium and iron supplements on dolutegravir pharmacokinetics and strategies (dose separation and food) to attenuate the effects if significant reductions in dolutegravir exposure were observed. This was an open-label, crossover study that randomized 24 healthy subjects into 1 of 2 cohorts to receive 4 treatments: (1) dolutegravir alone, fasting; (2) dolutegravir with calcium carbonate or ferrous fumarate, fasting; (3) dolutegravir with calcium carbonate or ferrous fumarate with a moderate-fat meal; (4) dolutegravir administered 2 hours before calcium carbonate or ferrous fumarate, fasting. Plasma dolutegravir AUC(0–∞), Cmax, and C24 were reduced by 39%, 37%, and 39%, respectively, when co-administered with calcium carbonate while fasting and were reduced by 54%, 57%, and 56%, respectively, when co-administered with ferrous fumarate while fasting. Dolutegravir administration 2 hours before calcium or iron supplement administration (fasted), as well as administration with a meal, counteracted the effect. Dolutegravir and calcium or iron supplements can be co-administered if taken with a meal. Under fasted conditions, dolutegravir should be administered 2 hours before or 6 hours after calcium or iron supplements.
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Affiliation(s)
- Ivy Song
- GlaxoSmithKline, Research Triangle Park, NC, USA
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Moorehead KJ, Burton JR, Everson GT, Zheng JH, Kerr BJ, Bushman LR, Wang M, Ju C, Nydam T, Kiser JJ. Intrahepatic antiviral quantification in a patient undergoing orthotopic cadaveric liver transplantation. J Antimicrob Chemother 2014; 70:315-7. [PMID: 25213274 DOI: 10.1093/jac/dku334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Kaitlyn J Moorehead
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - James R Burton
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gregory T Everson
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jia-Hua Zheng
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Becky Jo Kerr
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Lane R Bushman
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Meng Wang
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Cynthia Ju
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Trevor Nydam
- Division of Transplant Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jennifer J Kiser
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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Moss DM, Curley P, Shone A, Siccardi M, Owen A. A multisystem investigation of raltegravir association with intestinal tissue: implications for pre-exposure prophylaxis and eradication. J Antimicrob Chemother 2014; 69:3275-81. [PMID: 25114168 DOI: 10.1093/jac/dku312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES Recent clinical data have suggested high raltegravir concentrations in gut tissue after oral administration, with implications for treatment and prevention. We have used in silico, in vitro, ex vivo and in vivo models to further investigate the accumulation of raltegravir in gut tissue. METHODS Affinity of raltegravir for gut tissue was assessed in silico (Poulin-Theil method), in vitro (Caco-2 accumulation) and ex vivo (rat intestine) and compared with the lipophilic drug lopinavir. Finally, raltegravir concentrations in plasma, gut contents, small intestine and large intestine were determined after oral dosing to Wistar rats 1 and 4 h post-dose. Samples were analysed using LC-MS/MS and scintillation counting. RESULTS Gut tissue accumulation of raltegravir was less than for lopinavir in silico, in vitro and ex vivo (P < 0.05). After oral administration to rats, raltegravir concentrations 4 h post-dose were lower in plasma (0.05 μM) compared with small intestine (0.47 μM, P = 0.06) and large intestine (1.36 μM, P < 0.05). However, raltegravir concentrations in the contents of both small intestine (4.0 μM) and large intestine (40.6 μM) were also high. CONCLUSIONS In silico, in vitro and ex vivo data suggest low raltegravir accumulation in intestinal tissue. In contrast, in vivo animal data suggest raltegravir concentrates in intestinal tissue even when plasma concentrations are minimal. However, high raltegravir concentrations in gut contents are the likely driving factor behind this observation, rather than blood-to-tissue drug distribution. The methods described can be combined with clinical investigations to provide a complete strategy for selection of drugs with high gut accumulation.
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Affiliation(s)
- Darren M Moss
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Paul Curley
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Alison Shone
- Department of Parasitology, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Marco Siccardi
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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Liedtke MD, Tomlin CR, Lockhart SM, Miller MM, Rathbun RC. Long-term efficacy and safety of raltegravir in the management of HIV infection. Infect Drug Resist 2014; 7:73-84. [PMID: 24672249 PMCID: PMC3965364 DOI: 10.2147/idr.s40168] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Raltegravir is an integrase strand-transfer inhibitor approved for the treatment of HIV infection. It was the first medication in a novel class of antiretroviral agents to be approved for use in the United States in 2007. Raltegravir exhibits potent activity against wild-type HIV-1, but resistance development has been noted through three different pathways. It is metabolized primarily through uridine diphosphate glucuronosyltransferase 1A1 and has a single inactive glucuronide metabolite. Raltegravir is not a substrate, inhibitor, or inducer of cytochrome P450 enzymes and exhibits low potential for drug–drug interactions; however, strong uridine diphosphate glucuronosyltransferase 1A1 inhibitors or inducers can alter the pharmacokinetics of raltegravir. It is well tolerated, and the most commonly reported adverse effects include headache, nausea, and diarrhea. Serious adverse effects with raltegravir are rare but include rhabdomyolysis and severe skin and hypersensitivity reactions. It has been approved for use in both treatment-naïve and treatment-experienced patients and is a preferred first-line agent in both United States and European HIV treatment guidelines. Although initial approval was granted on 48-week data, 5-year clinical data have recently been published. This article reviews the data supporting long-term efficacy and safety of raltegravir in the treatment of HIV infection.
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Affiliation(s)
- Michelle D Liedtke
- Department of Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - C Ryan Tomlin
- Department of Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Staci M Lockhart
- Department of Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Misty M Miller
- Department of Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - R Chris Rathbun
- Department of Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Pharmacokinetics of Once-Daily Boosted Elvitegravir When Administered in Combination With Acid-Reducing Agents. J Acquir Immune Defic Syndr 2013; 64:45-50. [DOI: 10.1097/qai.0b013e31829ecd3b] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Siccardi M, Rajoli RKR, Curley P, Olagunju A, Moss D, Owen A. Physiologically based pharmacokinetic models for the optimization of antiretroviral therapy: recent progress and future perspective. Future Virol 2013. [DOI: 10.2217/fvl.13.67] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Anti-HIV therapy is characterized by the chronic administration of antiretrovirals (ARVs), and consequently, several problems can arise during the management of HIV-positive patients. ARV disposition can be simulated by combining system data describing a population of patients and in vitro drug data through physiologically based pharmacokinetic (PBPK) models, which mathematically describe absorption, distribution, metabolism and elimination. PBPK modeling can find application in the investigation of clinically relevant scenarios, while providing the opportunity for a better understanding of the mechanisms regulating drug distribution. In this review, we have analyzed the most recent applications of PBPK models for ARVs and highlighted some of the most interesting areas of use, such as drug–drug interaction, pharmacogenetics, factors regulating absorption and tissue penetration, as well as therapy optimization in special populations. The application of the PBPK modeling approach might not be limited to the investigation of hypothetical clinical issues, but could be used to inform future prospective clinical trials.
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Affiliation(s)
- Marco Siccardi
- Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Rajith Kumar Reddy Rajoli
- Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Paul Curley
- Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Adeniyi Olagunju
- Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Darren Moss
- Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Andrew Owen
- Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Moss DM, Siccardi M, Back DJ, Owen A. Predicting intestinal absorption of raltegravir using a population-based ADME simulation. J Antimicrob Chemother 2013; 68:1627-34. [PMID: 23515248 DOI: 10.1093/jac/dkt084] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Raltegravir pharmacokinetics (PK) show high intra- and inter-patient variability and are also influenced by co-administered substances that alter the gastrointestinal tract environment, such as pH-altering or metal-containing agents. The aim of this investigation was to develop a population-based absorption, distribution, metabolism and excretion (ADME) model to investigate the effects of gastrointestinal pH and ingested magnesium on raltegravir PK. METHODS In vitro data describing the disposition of raltegravir were obtained from literature sources or generated by standard methods. Raltegravir (400 mg single dose) PK were simulated in healthy volunteers (50 subjects per group, 20-50 years old, 0.5 proportion female subjects) over a 12 h period. RESULTS Simulated raltegravir PK correlated well with data from clinical trials, with a mean deviation in C(max), AUC(0-12) and C(trough) of <20%. Solubility of raltegravir in the gastrointestinal tract was increased at higher luminal pH. Increased intestinal pH and transit time both correlated with higher raltegravir absorption (P<0.001). Magnesium ingestion reduced raltegravir exposure in simulated subjects, with mean C(trough) reduced by 32% (P<0.001). CONCLUSIONS The in vitro-in vivo extrapolation model developed in this study predicted raltegravir PK in virtual individuals with different gastrointestinal pH profiles. The main PK variables were predicted with good accuracy compared with reference data, and both luminal pH and magnesium were able to influence drug absorption. This modelling system provides a tool for investigating the absorption of other drugs, including HIV integrase inhibitors currently in development, which have also shown interactions with food and metal-containing products.
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Affiliation(s)
- Darren M Moss
- Molecular and Biochemical Parasitology Group, Liverpool School of Tropical Medicine, Liverpool, UK.
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Patel P, Song I, Borland J, Chen S, Peppercorn A, Wajima T, Funaki T, Fujita N, Hughes J, Piscitelli S. Relative bioavailability of a paediatric granule formulation of the HIV integrase inhibitor, dolutegravir, in healthy adult subjects. Antivir Ther 2013; 19:229-33. [DOI: 10.3851/imp2708] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2013] [Indexed: 10/26/2022]
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Abstract
PURPOSE OF REVIEW The purpose of this study is to review recent and relevant pharmacology data for three HIV integrase inhibitors: raltegravir (marketed), dolutegravir, and elvitegravir (both in phase III drug development). RECENT FINDINGS Data from January 2011 to April 2012 were evaluated. These data better characterized integrase inhibitor pharmacokinetics, assessed dosing regimens, and investigated previously undescribed drug-drug interactions. Due to formulation challenges, raltegravir inter-patient and intra-patient pharmacokinetic variability is high. Twice-daily 400 mg dosing has been shown to be clinically superior to 800 mg once-daily dosing. A pediatric formulation of raltegravir with less variable pharmacokinetics and greater bioavailability was US Food and Drug Administration (US FDA)-approved in December 2011. Cobicistat-boosted elvitegravir, and the second-generation integrase inhibitor dolutegravir, have lower pharmacokinetic variability and are dosed once daily. Dolutegravir drug interactions are similar to raltegravir, whereas boosted elvitegravir participates in additional CYP3A-mediated interactions. SUMMARY Raltegravir's potent antiretroviral activity has resulted in widespread use in both treatment-naïve and experienced patients. Dolutegravir and cobicistat-boosted elvitegravir have some pharmacokinetic advantages. Pharmacokinetic data in special populations (pregnancy, pediatrics) to optimize dosing are still required.
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Affiliation(s)
- Jessica L Adams
- University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC 27599-7569
| | - Benjamin N Greener
- University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC 27599-7569
| | - Angela DM Kashuba
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy Director, UNC Center for AIDS Research Clinical Pharmacology and Analytical Chemistry Core University of North Carolina at Chapel Hill, TEL: 919-966-9998 FAX: 919-962-0644
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Update on raltegravir and the development of new integrase strand transfer inhibitors. South Med J 2012; 105:370-8. [PMID: 22766666 DOI: 10.1097/smj.0b013e318258c847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Raltegravir (RAL) is the first antiretroviral in the integrase strand transfer inhibitors (INSTI) class. The use of RAL has expanded since its approval in October 2007 for multidrug-resistant human immunodeficiency virus type 1 infection in adults. RAL is now a guideline-preferred treatment option for antiretroviral-naïve patients, indicated for treatment in adolescents, and is being studied as an integral part of nucleoside sparing regimens. The development of resistance and the need for a once-daily dosing option has led to the development of new INSTIs, including elvitegravir and dolutegravir. Elvitegravir is being studied in a promising once-daily single-tablet regimen with tenofovir, emtricitabine, and the investigational pharmacoenhancer cobicistat. The development of cobicistat and the new once-daily INSTIs may revolutionize the treatment of human immunodeficiency virus type 1 infection. This article reviews the current literature on raltegravir and new developments in the INSTI class.
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Rokas KEE, Bookstaver PB, Shamroe CL, Sutton SS, Millisor VE, Bryant JE, Weissman SB. Role of raltegravir in HIV-1 management. Ann Pharmacother 2012; 46:578-89. [PMID: 22496475 DOI: 10.1345/aph.1q616] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To review the literature concerning the role of raltegravir in the treatment of HIV-1 in antiretroviral (ARV)-experienced and ARV-naïve patients. DATA SOURCES A PubMed search was conducted for published data through March 2012 using the search terms raltegravir, MK-0518, and integrase strand transfer inhibitor. An additional search of International Pharmaceutical Abstracts for unpublished data, including data from the Infectious Diseases Society of America, the Conference on Retroviruses and Opportunistic Infections, the International AIDS Society, and the Interscience Conference on Antimicrobial Agents and Chemotherapy, was conducted using similar search terms. STUDY SELECTION AND DATA EXTRACTION In vitro and in vivo Phase 2, Phase 3, and postmarketing studies available in English, evaluating antiretroviral regimens that contain raltegravir for the treatment of HIV-1 infection in both ARV-naïve and ARV-experienced patients, were evaluated. Studies assessing raltegravir pharmacokinetics and pharmacodynamics were included for review. DATA SYNTHESIS The nucleoside-based regimen of raltegravir with tenofovir/emtricitabine provides an effective first-line treatment option. However, nucleoside-sparing regimens appear unfavorable in ARV-naïve subjects and should be reserved for patients with limited treatment options. Raltegravir used with optimized background therapy provides an alternative regimen for ARV-experienced patients. This review describes the available in vitro and in vivo data on raltegravir potency, defined as the ability to achieve undetectable viral load, and safety profile, as well as comparison to standard HIV-1 therapies. CONCLUSIONS Raltegravir has demonstrated potent antiretroviral activity against HIV-1 in both ARV-naïve and ARV-experienced subjects, with the benefits of a favorable adverse effect profile and minimal drug interactions. Raltegravir must be dosed twice daily, as once daily raltegravir displays decreased virologic efficacy compared to twice daily dosing. However, the ongoing development of new integrase strand transfer inhibitors may provide potent once daily regimens.
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Affiliation(s)
- Kristina E E Rokas
- South Carolina College of Pharmacy, University of South Carolina Campus, Columbia, USA
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Abstract
Raltegravir shows marked pharmacokinetic variability in patients, with gastrointestinal pH and divalent-metal binding being potential factors. We investigated raltegravir solubility, lipophilicity, pK(a), and permeativity in vitro to elucidate known interactions with omeprazole, antacids, and food, all of which increase gastric pH. Solubility of raltegravir was determined at pH 1 to 8. Lipophilicity of raltegravir was determined using octanol-water partition. Raltegravir pK(a) was determined using UV spectroscopy. The effects of pH, metal salts, and omeprazole on the cellular permeativity of raltegravir were determined using Caco-2 monolayers. Cellular accumulation studies were used to determine the effect of interplay between pH and ABCB1 transport on raltegravir accumulation. Samples were analyzed using liquid chromatography-tandem mass spectroscopy (LC-MS/MS) or scintillation counting. Raltegravir at 10 mM was partly insoluble at pH 6.6 and below. Raltegravir lipophilicity was pH dependent and was reduced as pH was increased from 5 to 9. The pK(a) of raltegravir was 6.7. Raltegravir cellular permeativity was heavily influenced by changes in extracellular pH, where apical-to-basolateral permeativity was reduced 9-fold (P < 0.05) when apical pH was increased from 5 to 8.5. Raltegravir cellular permeativity was also reduced in the presence of magnesium and calcium. Omeprazole did not alter raltegravir cellular permeativity. Cellular accumulation of raltegravir was increased independently by inhibiting ABCB1 and by lowering extracellular pH from pH 8 to 5. Gastrointestinal pH and polyvalent metals can potentially alter the pharmacokinetic properties of raltegravir, and these data provide an explanation for the variability in raltegravir exposure in patients. The evaluation of how divalent-metal-containing products, such as multivitamins, that do not affect gastric pH alter raltegravir pharmacokinetics in patients is now justified.
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Abstract
One may consider that drug-drug interactions (DDIs) associated with antacids is an obsolete topic because they are prescribed less frequently by medical professionals due to the advent of drugs that more effectively suppress gastric acidity (i.e. histamine H(2)-receptor antagonists [H2RAs] and proton pump inhibitors [PPIs]). Nevertheless, the use of antacids by ambulant patients may be ever increasing, because they are freely available as over-the-counter (OTC) drugs. Antacids consisting of weak basic substances coupled with polyvalent cations may alter the rate and/or the extent of absorption of concomitantly administered drugs via different mechanisms. Polyvalent cations in antacid formulations may form insoluble chelate complexes with drugs and substantially reduce their bioavailability. Clinical studies demonstrated that two classes of antibacterials (tetracyclines and fluoroquinolones) are susceptible to clinically relevant DDIs with antacids through this mechanism. Countermeasures against this type of DDI include spacing out the dosing interval - taking antacid either 4 hours before or 2 hours after administration of these antibacterials. Bisphosphonates may be susceptible to DDIs with antacids by the same mechanism, as described in the prescription information of most bisphosphonates, but no quantitative data about the DDIs are available. For drugs with solubility critically dependent on pH, neutralization of gastric fluid by antacids may alter the dissolution of these drugs and the rate and/or extent of their absorption. However, the magnitude of DDIs elicited by antacids through this mechanism is less than that produced by H2RAs or PPIs; therefore, the clinical relevance of such DDIs is often obscure. Magnesium ions contained in some antacid formulas may increase gastric emptying, thereby accelerating the rate of absorption of some drugs. However, the clinical relevance of this is unclear in most cases because the difference in plasma drug concentration observed after dosing shortly disappears. Recent reports have indicated that some of the molecular-targeting agents such as the tyrosine kinase inhibitors dasatinib and imatinib, and the thrombopoietin receptor agonist eltrombopag may be susceptible to DDIs with antacids. Finally, the recent trend of developing OTC drugs as combination formulations of an antacid and an H2RA is a concern because these drugs will increase the risk of DDIs by dual mechanisms, i.e. a gastric pH-dependent mechanism by H2RAs and a cation-mediated chelation mechanism by antacids.
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Affiliation(s)
- Ryuichi Ogawa
- Department of Pharmacotherapy, Meiji Pharmaceutical University, Kiyose, Tokyo, Japan.
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Do VT, Higginson RT, Fulco PP. Raltegravir dosage adjustment in HIV-infected patients receiving etravirine. Am J Health Syst Pharm 2011; 68:2049-54. [DOI: 10.2146/ajhp110083] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Vi T. Do
- Internal Medicine, The Johns Hopkins Hospital, Baltimore, MD
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Antiretroviral drug interactions: overview of interactions involving new and investigational agents and the role of therapeutic drug monitoring for management. Pharmaceutics 2011; 3:745-81. [PMID: 24309307 PMCID: PMC3857057 DOI: 10.3390/pharmaceutics3040745] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 09/15/2011] [Accepted: 10/08/2011] [Indexed: 01/11/2023] Open
Abstract
Antiretrovirals are prone to drug-drug and drug-food interactions that can result in subtherapeutic or supratherapeutic concentrations. Interactions between antiretrovirals and medications for other diseases are common due to shared metabolism through cytochrome P450 (CYP450) and uridine diphosphate glucuronosyltransferase (UGT) enzymes and transport by membrane proteins (e.g., p-glycoprotein, organic anion-transporting polypeptide). The clinical significance of antiretroviral drug interactions is reviewed, with a focus on new and investigational agents. An overview of the mechanistic basis for drug interactions and the effect of individual antiretrovirals on CYP450 and UGT isoforms are provided. Interactions between antiretrovirals and medications for other co-morbidities are summarized. The role of therapeutic drug monitoring in the detection and management of antiretroviral drug interactions is also briefly discussed.
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Patel P, Song I, Borland J, Patel A, Lou Y, Chen S, Wajima T, Peppercorn A, Min SS, Piscitelli SC. Pharmacokinetics of the HIV integrase inhibitor S/GSK1349572 co-administered with acid-reducing agents and multivitamins in healthy volunteers. J Antimicrob Chemother 2011; 66:1567-72. [PMID: 21493648 DOI: 10.1093/jac/dkr139] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To evaluate the effect of pH-altering agents on S/GSK1349572 exposure in healthy subjects. METHODS S/GSK1349572 is an unboosted, once-daily, next-generation HIV integrase inhibitor. In the first study, 16 subjects received four single-dose treatments: (i) S/GSK1349572 50 mg; (ii) S/GSK1349572 50 mg with a multivitamin (MVI; One A Day Maximum); (iii) S/GSK1349572 50 mg with a liquid antacid (Maalox Advanced Maximum Strength); and (iv) S/GSK1349572 50 mg 2 h before an antacid. In the second study, 12 subjects received a single dose of S/GSK1349572 alone and on day 5 of omeprazole. RESULTS All treatments were well tolerated. MVI co-administration modestly decreased S/GSK1349572 AUC by 33%. Concurrent antacid co-administration reduced S/GSK1349572 AUC by 74% and staggered antacid dosing significantly diminished this interaction, with a reduction in S/GSK1349572 AUC of 26%. Omeprazole did not significantly affect S/GSK1349572 exposure. CONCLUSIONS S/GSK1349572 can be taken with proton pump inhibitors and MVIs without dose adjustment but should be administered 2 h before or 6 h after antacids.
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Affiliation(s)
- Parul Patel
- GlaxoSmithKline, Research Triangle Park, NC, USA
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Jiménez-Nácher I, Alvarez E, Morello J, Rodriguez-Nóvoa S, de Andrés S, Soriano V. Approaches for understanding and predicting drug interactions in human immunodeficiency virus-infected patients. Expert Opin Drug Metab Toxicol 2011; 7:457-77. [DOI: 10.1517/17425255.2011.558839] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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