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Omondi EO, Muigai A, Ngayo MO, Mungiria J, Lihana R. Nevirapine plasma concentration is associated with virologic failure and the emergence of drug-resistant mutations among HIV patients in Kenya: A cross sectional study. Medicine (Baltimore) 2022; 101:e32346. [PMID: 36550885 PMCID: PMC9771327 DOI: 10.1097/md.0000000000032346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
This study aimed to determine the association between the plasma concentration of nevirapine (NVP) and clinical outcomes. In this cross-sectional study, sociodemographic and clinical data were collected from 233 HIV patients receiving NVP-based first-line antiretroviral therapy (ART) regimens in Nairobi, Kenya. The mean age was 41.2 (SD ± 11.9) years. Fifty-four (23.2%) patients had virological failure (>1000 copies/mL), whereas 23 (9.9%) were infected with drug-resistant HIV strains. Eleven patients had nucleoside reverse transcriptase inhibitor resistance mutations, including M184V and T215Y, whereas 22 had non-nucleoside reverse transcriptase inhibitor resistance mutations, including G190A, K103N, V106A, Y181C, A98G, and Y188L. The median NVP plasma concentration was 6180 ng/mL (IQR 4444-8843 ng/mL), with 38 (16.3%) patients having suboptimal NVP plasma levels of <3400 ng/mL. The majority 23 of the 38 (60.5%) patients with NVP Cmin < 3400 ng/mL were significantly infected with drug-resistant HIV virus (P = .001). In the multivariate analysis, the time taken to arrive at the ART clinic (β -11.1, 95% CI -21.2 to -1.1; P = .031), higher HIV viral load (β -2008, 95% CI -3370.7 to -645.3; P = .004), and the presence of HIV drug resistance mutation (β 3559, 95% CI 2580.8-4537.2; P = .0001) were associated with NVP plasma concentration. A significant proportion of patients receiving the NVP-based regimen had supra- and sub-therapeutic plasma concentrations. Higher HIV viral load and the presence of HIV drug-resistant mutations are important factors associated with NVP plasma concentrations.
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Affiliation(s)
- Evans Okumu Omondi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- * Correspondence: Evans Okumu Omondi, Centre for Microbiology Research, Kenya Medical Research Institute, P.O. Box, Nairobi 54840-00200, Kenya (e-mail: )
| | - Anne Muigai
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Musa Otieno Ngayo
- Department of Botany, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Juster Mungiria
- Department of Botany, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Raphael Lihana
- Centre for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
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Fankhouser RW, Murrell DE, Anane YY, Hurley DL, Mamudu HM, Harirforoosh S. Type 2 diabetes: an exploratory genetic association analysis of selected metabolizing enzymes and transporters and effects on cardiovascular and renal biomarkers. Drug Metab Pers Ther 2022; 37:375-382. [PMID: 35749156 DOI: 10.1515/dmpt-2021-0135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 03/14/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES This study sought to identify potential pharmacogenetic associations of selected enzymes and transporters with type 2 diabetes (T2D). In addition, pharmacogenomic profiles, concentrations of asymmetric dimethylarginine (ADMA) or kidney injury molecule-1 (KIM-1), and several covariates were investigated. METHODS Whole blood was collected from 63 patients, with 32 individuals with T2D. A pharmacogenomic panel was used to assay genetic profiles, and biomarker ELISAs were run to determine subject concentrations of ADMA and KIM-1. Additive genetic modeling with multiple linear and logistic regressions were performed to discover potential SNPs-outcome associations using PLINK. RESULTS Ten SNPs were found to be significant (p<0.05) depending on the inclusion or exclusion of covariates. Of these, four were found in association with the presence of T2D, rs2231142, rs1801280, rs1799929, and rs1801265 depending on covariate inclusion or exclusion. Regarding ADMA, one SNP was found to be significant without covariates, rs1048943. Five SNPs were identified in association with KIM-1 and T2D in the presence of covariates, rs12208357, rs34059508, rs1058930, rs1902023, and rs3745274. Biomarker concentrations were not significantly different in the presence of T2D. CONCLUSIONS This exploratory study found several SNPs related to T2D; further research is required to validate and understand these relationships.
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Affiliation(s)
- Russell W Fankhouser
- Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA
| | - Derek E Murrell
- Department of Pharmaceutical Sciences, Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA
| | - Yaa Y Anane
- Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA
| | - David L Hurley
- Department of Pharmaceutical Sciences, Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA
| | - Hadii M Mamudu
- Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Johnson City, TN, USA
| | - Sam Harirforoosh
- Department of Pharmaceutical Sciences, Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA
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Ngayo MO, Oluka M, Kwena ZA, Bulimo WD, Okalebo FA. Effects of cytochrome P450 2B6 and constitutive androstane receptor genetic variation on Efavirenz plasma concentrations among HIV patients in Kenya. PLoS One 2022; 17:e0260872. [PMID: 35235559 PMCID: PMC8890732 DOI: 10.1371/journal.pone.0260872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 11/18/2021] [Indexed: 11/18/2022] Open
Abstract
The effects of genetic variation of cytochrome P450 2B6 (CYP2B6) and constitutive androstane receptor (CAR) on efavirenz (EFV) plasma concentration was evaluated among 312 HIV patients in Nairobi Kenya. The EFV plasma concentration at steady-state were determined using ultra-high-performance liquid chromatography with a tandem quadruple mass spectrometer (LC-MS/MS). Thirteen CYP2B6 (329G>T, 341T>C, 444 G>T/C, 15582C>T, 516G>T, 548T>G, 637T>C, 785A>G, 18492C>T, 835G>C, 1459C>T and 21563C>T) and one CAR (540C>T) single nucleotide polymorphisms (SNPs) were genotyped using real-time polymerase chain reaction. HIV drug resistance mutations were detected using an in-house genotypic assay. The EFV concentration of patients ranged from 4 ng/mL to 332697 ng/mL (median 2739.5 ng/mL, IQR 1878–4891.5 ng/mL). Overall, 22% patients had EFV concentrations beyond therapeutic range of 1000–4000 ng/mL (4.5%% < 1000 ng/mL and 31.7% > 4000 ng/mL). Five SNPs (15582C>T, 516G>T, 785A>G, 983T>C and 21563C>T) were associated with higher EFV plasma concentration while 18492C>T with lower EFV plasma concentration (p<0.05). Strong linkage disequilibrium (LD) was observed for 15582C>T, 516G>T, 785A>G, 18492C>T, 983T>C, 21563C>T, 1459C>T and CAR 540C>T. Sixteen haplotypes were observed and CTGCTTCC, CTGCTTCT, TTGCTTCT and CGACCCCT were associated with high EFV plasma concentration. In multivariate analysis, factors significantly associated with EFV plasma concentration included; the presence of skin rash (β = 1379, 95% confidence interval (CI) = 3216.9–3416.3; p < 0.039), T allele of CYP2B6 516G>T (β = 1868.9, 95% CI 3216.9–3416.3; p < 0.018), the C allele of CYP2B6 983T>C (β = 2638.3, 95% CI = 1348–3929; p < 0.0001), T allele of CYP2B6 21563C>T (β = 1737, 95% CI = 972.2–2681.9; p < 0.0001) and the presence of 5 to 7 numbers of SNPs per patient (β = 570, 95% CI = 362–778; p < 0.0001) and HIV viral load ≤1000 cells/mL (β = -4199.3, 95% CI = -7914.9 –-483.6; p = 0.027). About 36.2% of the patients had EFV plasma concentrations beyond therapeutic window, posing high risk of treatment failure or toxicity. The SNPs of CYP2B6 516G>T, CYP2B6 983T>C, 21563C>T, presence of higher numbers of SNPs per patient and haplotypes CTGCTTCC, CTGCTTCT, TTGCTTCT and CGACCCCT could efficiently serves as genetic markers for EFV plasma concentration and could guide personalization of EFV based ART treatment in Kenya.
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Affiliation(s)
- Musa Otieno Ngayo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Pharmacology and Pharmacognosy, School of Pharmacy, University of Nairobi, Nairobi, Kenya
- * E-mail:
| | - Margaret Oluka
- Department of Pharmacology and Pharmacognosy, School of Pharmacy, University of Nairobi, Nairobi, Kenya
| | - Zachari Arochi Kwena
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Wallace Dimbuson Bulimo
- Department of Biochemistry, School of Biological and Physical Sciences, University of Nairobi, Nairobi, Kenya
| | - Faith Apolot Okalebo
- Department of Pharmacology and Pharmacognosy, School of Pharmacy, University of Nairobi, Nairobi, Kenya
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Langmia IM, Just KS, Yamoune S, Brockmöller J, Masimirembwa C, Stingl JC. CYP2B6 Functional Variability in Drug Metabolism and Exposure Across Populations-Implication for Drug Safety, Dosing, and Individualized Therapy. Front Genet 2021; 12:692234. [PMID: 34322158 PMCID: PMC8313315 DOI: 10.3389/fgene.2021.692234] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/14/2021] [Indexed: 12/11/2022] Open
Abstract
Adverse drug reactions (ADRs) are one of the major causes of morbidity and mortality worldwide. It is well-known that individual genetic make-up is one of the causative factors of ADRs. Approximately 14 million single nucleotide polymorphisms (SNPs) are distributed throughout the entire human genome and every patient has a distinct genetic make-up which influences their response to drug therapy. Cytochrome P450 2B6 (CYP2B6) is involved in the metabolism of antiretroviral, antimalarial, anticancer, and antidepressant drugs. These drug classes are commonly in use worldwide and face specific population variability in side effects and dosing. Parts of this variability may be caused by single nucleotide polymorphisms (SNPs) in the CYP2B6 gene that are associated with altered protein expression and catalytic function. Population variability in the CYP2B6 gene leads to changes in drug metabolism which may result in adverse drug reactions or therapeutic failure. So far more than 30 non-synonymous variants in CYP2B6 gene have been reported. The occurrence of these variants show intra and interpopulation variability, thus affecting drug efficacy at individual and population level. Differences in disease conditions and affordability of drug therapy further explain why some individuals or populations are more exposed to CYP2B6 pharmacogenomics associated ADRs than others. Variabilities in drug efficacy associated with the pharmacogenomics of CYP2B6 have been reported in various populations. The aim of this review is to highlight reports from various ethnicities that emphasize on the relationship between CYP2B6 pharmacogenomics variability and the occurrence of adverse drug reactions. In vitro and in vivo studies evaluating the catalytic activity of CYP2B6 variants using various substrates will also be discussed. While implementation of pharmacogenomic testing for personalized drug therapy has made big progress, less data on pharmacogenetics of drug safety has been gained in terms of CYP2B6 substrates. Therefore, reviewing the existing evidence on population variability in CYP2B6 and ADR risk profiles suggests that, in addition to other factors, the knowledge on pharmacogenomics of CYP2B6 in patient treatment may be useful for the development of personalized medicine with regards to genotype-based prescription.
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Affiliation(s)
- Immaculate M. Langmia
- Institute of Clinical Pharmacology, University Hospital of Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Katja S. Just
- Institute of Clinical Pharmacology, University Hospital of Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Sabrina Yamoune
- Institute of Clinical Pharmacology, University Hospital of Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Jürgen Brockmöller
- Department of Clinical Pharmacology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany
| | - Collen Masimirembwa
- African Institute of Biomedical Science and Technology (AiBST), Harare, Zimbabwe
| | - Julia C. Stingl
- Institute of Clinical Pharmacology, University Hospital of Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
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Yoon HY, Cho YA, Yee J, Gwak HS. Effects of CYP2B6 polymorphisms on plasma nevirapine concentrations: a systematic review and meta-analysis. Sci Rep 2020; 10:17390. [PMID: 33060725 PMCID: PMC7562737 DOI: 10.1038/s41598-020-74506-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] [Received: 05/16/2020] [Accepted: 09/21/2020] [Indexed: 12/25/2022] Open
Abstract
Cytochrome P450 (CYP) is involved in the metabolism of nevirapine (NVP); especially, CYP2B6 has been known to be one of the main enzymes involved in NVP metabolism. The objective of this study was to investigate the effects of CYP2B6 variants on plasma concentrations of NVP by a systematic review and meta-analysis. A search for qualifying studies published until April 2020 was conducted using the EMBASE, PubMed, and Web of Science databases. The mean difference (MD) and 95% confidence intervals (CIs) were calculated. Data analysis was performed using R Studio (version 3.6) and Review Manager (version 5.3). In total, data from six studies involving 634 patients were analyzed in the systematic review and five studies in the meta-analysis. We found that carriers of the CYP2B6 516TT genotype had a 2.18 µg/mL higher NVP concentration than did the GG or GT (95% CI 1.28-3.08). In the respective comparisons of the three genotypes, it was found that the MD was 1.87 µg/mL between the TT and GT groups, 2.53 µg/mL between TT and GG, and 0.60 µg/mL between GT and GG. This meta-analysis confirmed that CYP2B6 polymorphisms was associated with plasma NVP concentrations. Therefore, CYP2B6 genotyping may be useful to predict the responses to NVP.
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Affiliation(s)
- Ha Young Yoon
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, Republic of Korea
| | - Young Ah Cho
- College of Pharmacy, Gyeongsang National University, Jinju, Gyeongnam, 52828, Republic of Korea.,Mokhwa Convalescent Hospital, Jinju, Gyeongnam, 52828, Republic of Korea
| | - Jeong Yee
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, Republic of Korea.
| | - Hye Sun Gwak
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, Republic of Korea.
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Teschke R, Danan G. Worldwide Use of RUCAM for Causality Assessment in 81,856 Idiosyncratic DILI and 14,029 HILI Cases Published 1993-Mid 2020: A Comprehensive Analysis. MEDICINES (BASEL, SWITZERLAND) 2020; 7:E62. [PMID: 33003400 PMCID: PMC7600114 DOI: 10.3390/medicines7100062] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/23/2020] [Accepted: 09/25/2020] [Indexed: 04/12/2023]
Abstract
Background: A large number of idiosyncratic drug induced liver injury (iDILI) and herb induced liver injury(HILI) cases of variable quality has been published but some are a matter of concern if the cases were not evaluated for causality using a robust causality assessment method (CAM) such as RUCAM (Roussel Uclaf Causality Assessment Method) as diagnostiinjuryc algorithm. The purpose of this analysis was to evaluate the worldwide use of RUCAM in iDILI and HILI cases. Methods: The PubMed database (1993-30 June 2020) was searched for articles by using the following key terms: Roussel Uclaf Causality Assessment Method; RUCAM; Idiosyncratic drug induced liver injury; iDILI; Herb induced liver injury; HILI. Results: Considering reports published worldwide since 1993, our analysis showed the use of RUCAM for causality assessment in 95,885 cases of liver injury including 81,856 cases of idiosyncratic DILI and 14,029 cases of HILI. Among the top countries providing RUCAM based DILI cases were, in decreasing order, China, the US, Germany, Korea, and Italy, with China, Korea, Germany, India, and the US as the top countries for HILI. Conclusion: Since 1993 RUCAM is certainly the most widely used method to assess causality in IDILI and HILI. This should encourage practitioner, experts, and regulatory agencies to use it in order to reinforce their diagnosis and to take sound decisions.
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Affiliation(s)
- Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, D-63450 Hanau, Teaching Hospital of the Medical Faculty of the Goethe University, D-60590 Frankfurt/Main, Germany
| | - Gaby Danan
- Pharmacovigilance Consultancy, F-75020 Paris, France;
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Gomez D, Power C, Fujiwara E. Neurocognitive Impairment and Associated Genetic Aspects in HIV Infection. Curr Top Behav Neurosci 2018; 50:41-76. [PMID: 30523615 DOI: 10.1007/7854_2018_69] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
HIV enters the central nervous system (CNS) early after infection. HIV-associated neurocognitive disorders (HAND) remain a serious complication of HIV infection despite available antiretroviral therapy (ART). Neurocognitive deficits observed in HAND are heterogeneous, suggesting a variability in individuals' susceptibility or resiliency to the detrimental CNS effects of HIV infection. This chapter reviews primary host genomic changes (immune-related genes, genes implicated in cognitive changes in primary neurodegenerative diseases), epigenetic mechanisms, and genetic interactions with ART implicated in HIV progression or HAND/neurocognitive complications of HIV. Limitations of the current findings include diversity of the HAND phenotype and limited replication of findings across cohorts. Strategies to improve the precision of future (epi)genetic studies of neurocognitive consequences of HIV infection are offered.
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Affiliation(s)
- Daniela Gomez
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - Christopher Power
- Departments of Psychiatry and Medicine, University of Alberta, Edmonton, AB, Canada
| | - Esther Fujiwara
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada.
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Giacomelli A, Riva A, Falvella FS, Oreni ML, Cattaneo D, Cheli S, Renisi G, Di Cristo V, Lupo A, Clementi E, Rusconi S, Galli M, Ridolfo AL. Clinical and genetic factors associated with increased risk of severe liver toxicity in a monocentric cohort of HIV positive patients receiving nevirapine-based antiretroviral therapy. BMC Infect Dis 2018; 18:556. [PMID: 30419834 PMCID: PMC6233541 DOI: 10.1186/s12879-018-3462-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 10/31/2018] [Indexed: 01/05/2023] Open
Abstract
Background Nevirapine has been used as antiretroviral agent since early ‘90. Although nevirapine is not currently recommended in initial anti-HIV regimens, its use remains consistent in a certain number of HIV-1-positive subjects. Thus, our aim was to determine clinical and genetic factors involved in the development of severe nevirapine induced liver toxicity. Methods We retrospectively analyzed all HIV positive patients who were followed at the Infectious Diseases Unit, DIBIC Luigi Sacco, University of Milan from May 2011 to December 2015. All patients treated with nevirapine who underwent a genotyping for the functional variants mapping into ABCB1, CYP2B6, CYP3A4 and CYP3A5 genes were included in the analysis. Severe hepatotoxicity was defined as ACTG grade 3–4 AST/ALT increase during the first three months of nevirapine treatment. The causality assessment between NVP exposure and drug-induced liver injury was performed by using the updated Roussel Uclaf Causality Assessment Methods. Hardy Weinberg equilibrium was tested by χ2 test. A multivariable logistic regression model was constructed using a backward elimination method. Results Three hundred and sixty-two patients were included in the analysis, of which 8 (2.2%) experienced a severe liver toxicity. We observed no differences between patients with and without liver toxicity as regards gender, ethnicity, age and immune-virological status. A higher prevalence of HCV coinfection (75.0% vs 30.2%; p = .0013) and higher baseline AST (58 IU/L vs 26 IU/L; p = 0.041) and ALT (82 IU/L vs 27 IU/L; p = 0.047) median levels were observed in patients with liver toxicity vs those without toxicity. The genotypes CT/TT at ABCB1 rs1045642 single nucleotide polymorphism (SNP), showed a protective effect for liver toxicity when compared with genotype CC (OR = 0.18, 95%CI 0.04–0.76; p = 0.020) in univariate analysis. In the multivariate model, HCV coinfection was independently associated with higher risk of developing liver toxicity (aOR = 8.00, 95%CI 1.27–50.29; p = 0.027), whereas ABCB1 rs1045642 CT/TT genotypes (aOR = 0.10, 95%CI 0.02–0.47; p = 0.004) was associated with a lower risk. Conclusions According to our findings HCV coinfection and ABCB1 rs1045642 SNP represent independent determinants of severe liver toxicity related to nevirapine. This genetic evaluation could be included as toxicity assessment in HIV-1-positive subjects treated with nevirapine.
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Affiliation(s)
- Andrea Giacomelli
- Infectious Diseases Unit, DIBIC Luigi Sacco - University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy.
| | - Agostino Riva
- Infectious Diseases Unit, DIBIC Luigi Sacco - University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | | | - Maria Letizia Oreni
- Infectious Diseases Unit, DIBIC Luigi Sacco - University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Dario Cattaneo
- ASST Fatebenefratelli-Sacco, Clinical Pharmacology Unit, Milan, Italy
| | - Stefania Cheli
- ASST Fatebenefratelli-Sacco, Clinical Pharmacology Unit, Milan, Italy
| | - Giulia Renisi
- Infectious Diseases Unit, DIBIC Luigi Sacco - University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Valentina Di Cristo
- Infectious Diseases Unit, DIBIC Luigi Sacco - University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Angelica Lupo
- Infectious Diseases Unit, DIBIC Luigi Sacco - University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Emilio Clementi
- ASST Fatebenefratelli-Sacco, Clinical Pharmacology Unit, Milan, Italy.,E. Medea Scientific Institute, Bosisio Parini, Italy
| | - Stefano Rusconi
- Infectious Diseases Unit, DIBIC Luigi Sacco - University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Massimo Galli
- Infectious Diseases Unit, DIBIC Luigi Sacco - University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
| | - Anna Lisa Ridolfo
- Infectious Diseases Unit, DIBIC Luigi Sacco - University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
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