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Cha A, Elsamadisi P, Su CP, Phipps E, Birnbaum JM. Prevention of perinatal transmission of zidovudine- and nevirapine-resistant HIV. Am J Health Syst Pharm 2016; 73:451-5. [PMID: 27001986 DOI: 10.2146/ajhp150620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The use of a three-drug regimen for the prevention of perinatal transmission of zidovudine- and nevirapine-resistant HIV is described. SUMMARY A 17-year-old Hispanic woman infected with HIV arrived at our clinic for the management of her first pregnancy. The patient was in her second trimester of her pregnancy, had not previously been treated with antiretroviral therapy, and was only taking daily prenatal vitamins at the time of her first clinic visit. Her HIV RNA viral load was 240 copies/mL, and the virus was resistant to both zidovudine and nevirapine. Nelfinavir (compounded suspension), lamivudine, and zidovudine were prescribed for the mother, though she was generally nonadherent to therapy. Nelfinavir, lamivudine, and zidovudine were initiated for the newborn within eight hours of delivery. Six months later, the patient returned to the clinic in the first trimester of her second pregnancy. At this visit, her HIV RNA viral load was 120 copies/mL. After the birth of her second child, the infant received the same regimen received by her firstborn: zidovudine 4 mg/kg orally twice daily for six weeks, lamivudine 2 mg/kg orally twice daily for two weeks, and nelfinavir 55 mg/kg orally twice daily for two weeks. At four months of age, each infant was found to be HIV-negative. CONCLUSION A prophylactic regimen that included nelfinavir, lamivudine, and zidovudine was used to prevent perinatal transmission of HIV in two neonates. The regimen was well tolerated, and both infants were determined to be HIV-negative at four months of age.
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Affiliation(s)
- Agnes Cha
- Long Island University Pharmacy, Brooklyn, NY, and Brooklyn Hospital Center, Brooklyn, NY
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Huesgen E, DeSear KE, Egelund EF, Smith R, Max B, Janelle J. A HAART-Breaking Review of Alternative Antiretroviral Administration: Practical Considerations with Crushing and Enteral Tube Scenarios. Pharmacotherapy 2016; 36:1145-1165. [PMID: 27636237 DOI: 10.1002/phar.1835] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Selection of an appropriate antiretroviral regimen for the patient infected with human immunodeficiency virus can be challenging, as various considerations must be taken into account including viral resistance mutations, patient comorbidities, drug interactions, and the potential for drug-related adverse effects and toxicities. Treatment is further complicated when a clinical scenario arises requiring an alteration in the dosage form. Factors ranging from dysphagia to administration through an enteral feeding tube can affect decisions regarding antiretroviral dosage forms. Limited pharmacokinetic data exist regarding the alteration of antiretroviral medications from their original form. Bioavailability may vary substantially between dosage forms, which can lead to unpredictable drug concentrations. Supratherapeutic or subtherapeutic antiretroviral drug concentrations can result in increased toxicity, virologic failure, or the emergence of drug resistance. We performed a systematic literature search to review the available antiretroviral literature on the modification of solid dosage forms as well as alternative routes of administration of oral antiretroviral agents and their application to clinical practice.
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Affiliation(s)
- Emily Huesgen
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Kathryn E DeSear
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Eric F Egelund
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Renata Smith
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois
| | - Blake Max
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois.,Ruth M. Rothstein CORE Center, Cook County Health & Hospital System, Chicago, Illinois
| | - Jennifer Janelle
- Department of Medicine, University of Florida, Gainesville, Florida
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Duggan JM, Akpanudo B, Shukla V, Gutterson G, Eitniear L, Sahloff EG. Alternative antiretroviral therapy formulations for patients unable to swallow solid oral dosage forms. Am J Health Syst Pharm 2016; 72:1555-65. [PMID: 26346211 DOI: 10.2146/ajhp140575] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Evidence-based guidance is presented to assist clinicians in selecting alternative formulations of antiretroviral (ARV) agents for patients with human immunodeficiency virus (HIV) infection who are unable to swallow tablets or capsules. SUMMARY The inability to take medications in standard oral dosage forms can be associated with nonadherence or the use of alternative administration strategies such as capsule or tablet breaking, crushing, or chewing. Patients with HIV infection require long-term ARV therapy to maintain viral suppression; ARV agents are predominately available as tablets and capsules that may pose swallowing difficulties for some patients. Using a variety of sources (the primary literature, pharmaceutical package inserts, and requests for unpublished data from drug manufacturers), available evidence on the bioavailability of ARV medications after disruption of the capsule or tablet matrix was reviewed; information on alternative formulations of ARV agents was also assessed. With several ARV agents, disruption of the solid oral dosage form by crushing, chewing, or breaking tablets or opening capsules prior to ingestion has been shown to result in altered bioavailability or pharmacokinetics and thus the potential for incomplete virological suppression, increased adverse effects, and suboptimal health outcomes. CONCLUSION Of the 33 single-agent ARV medications and combination ARV products in five classes available at the time of review, approximately half exist as powders, liquids, injectables, or chewable or dissolvable tablets. If alternative ARV formulations or administration methods are used, close monitoring for achievement of virological and immunologic success and potential toxicities is recommended.
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Affiliation(s)
- Joan M Duggan
- Joan M. Duggan, M.D., FACP, FIDSA, AAHIVS, is Infectious Diseases Specialist; and Barbara Akpanudo, M.S.N., M.P.H., CNP, is Family Nurse Practitioner, Division of Infectious Diseases, Department of Medicine, University of Toledo Medical Center (UTMC), Toledo, OH. Vipul Shukla, B.S., is a medical student; and Glen Gutterson, B.S., is a medical student, College of Medicine, University of Toledo. Lindsey Eitniear, Pharm.D., is Clinical Pharmacist, UTMC. Eric G. Sahloff, Pharm.D., AAHIVP, is Associate Professor of Pharmacy Practice, College of Pharmacy and Pharmaceutical Sciences, University of Toledo
| | - Barbara Akpanudo
- Joan M. Duggan, M.D., FACP, FIDSA, AAHIVS, is Infectious Diseases Specialist; and Barbara Akpanudo, M.S.N., M.P.H., CNP, is Family Nurse Practitioner, Division of Infectious Diseases, Department of Medicine, University of Toledo Medical Center (UTMC), Toledo, OH. Vipul Shukla, B.S., is a medical student; and Glen Gutterson, B.S., is a medical student, College of Medicine, University of Toledo. Lindsey Eitniear, Pharm.D., is Clinical Pharmacist, UTMC. Eric G. Sahloff, Pharm.D., AAHIVP, is Associate Professor of Pharmacy Practice, College of Pharmacy and Pharmaceutical Sciences, University of Toledo
| | - Vipul Shukla
- Joan M. Duggan, M.D., FACP, FIDSA, AAHIVS, is Infectious Diseases Specialist; and Barbara Akpanudo, M.S.N., M.P.H., CNP, is Family Nurse Practitioner, Division of Infectious Diseases, Department of Medicine, University of Toledo Medical Center (UTMC), Toledo, OH. Vipul Shukla, B.S., is a medical student; and Glen Gutterson, B.S., is a medical student, College of Medicine, University of Toledo. Lindsey Eitniear, Pharm.D., is Clinical Pharmacist, UTMC. Eric G. Sahloff, Pharm.D., AAHIVP, is Associate Professor of Pharmacy Practice, College of Pharmacy and Pharmaceutical Sciences, University of Toledo
| | - Glen Gutterson
- Joan M. Duggan, M.D., FACP, FIDSA, AAHIVS, is Infectious Diseases Specialist; and Barbara Akpanudo, M.S.N., M.P.H., CNP, is Family Nurse Practitioner, Division of Infectious Diseases, Department of Medicine, University of Toledo Medical Center (UTMC), Toledo, OH. Vipul Shukla, B.S., is a medical student; and Glen Gutterson, B.S., is a medical student, College of Medicine, University of Toledo. Lindsey Eitniear, Pharm.D., is Clinical Pharmacist, UTMC. Eric G. Sahloff, Pharm.D., AAHIVP, is Associate Professor of Pharmacy Practice, College of Pharmacy and Pharmaceutical Sciences, University of Toledo
| | - Lindsey Eitniear
- Joan M. Duggan, M.D., FACP, FIDSA, AAHIVS, is Infectious Diseases Specialist; and Barbara Akpanudo, M.S.N., M.P.H., CNP, is Family Nurse Practitioner, Division of Infectious Diseases, Department of Medicine, University of Toledo Medical Center (UTMC), Toledo, OH. Vipul Shukla, B.S., is a medical student; and Glen Gutterson, B.S., is a medical student, College of Medicine, University of Toledo. Lindsey Eitniear, Pharm.D., is Clinical Pharmacist, UTMC. Eric G. Sahloff, Pharm.D., AAHIVP, is Associate Professor of Pharmacy Practice, College of Pharmacy and Pharmaceutical Sciences, University of Toledo
| | - Eric G Sahloff
- Joan M. Duggan, M.D., FACP, FIDSA, AAHIVS, is Infectious Diseases Specialist; and Barbara Akpanudo, M.S.N., M.P.H., CNP, is Family Nurse Practitioner, Division of Infectious Diseases, Department of Medicine, University of Toledo Medical Center (UTMC), Toledo, OH. Vipul Shukla, B.S., is a medical student; and Glen Gutterson, B.S., is a medical student, College of Medicine, University of Toledo. Lindsey Eitniear, Pharm.D., is Clinical Pharmacist, UTMC. Eric G. Sahloff, Pharm.D., AAHIVP, is Associate Professor of Pharmacy Practice, College of Pharmacy and Pharmaceutical Sciences, University of Toledo.
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Brüning A, Friese K, Burges A, Mylonas I. Tamoxifen enhances the cytotoxic effects of nelfinavir in breast cancer cells. Breast Cancer Res 2010; 12:R45. [PMID: 20594311 PMCID: PMC2949632 DOI: 10.1186/bcr2602] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 05/31/2010] [Accepted: 07/01/2010] [Indexed: 12/17/2022] Open
Abstract
Introduction The HIV protease inhibitor nelfinavir is currently under investigation as a new anti-cancer drug. Several studies have shown that nelfinavir induces cell cycle arrest, endoplasmic reticulum stress, autophagy, and apoptosis in cancer cells. In the present article, the effect of nelfinavir on human breast cancer cells is examined and potential combination treatments are investigated. Methods The effects of nelfinavir and tamoxifen on the human breast cancer cell lines MCF7, T47 D, MDA-MB-453, and MDA-MB-435 were tested by analysing their influence on cell viability (via 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay), apoptosis (annexin binding, poly(ADP-ribose) polymerase cleavage), autophagy (autophagy marker light chain 3B expression), endoplasmic reticulum stress (binding protein and activating transcription factor 3 expression), and the occurrence of oxidative stress (intracellular glutathione level). Results Nelfinavir induced apoptosis in all four breast cancer cell lines tested, although the extent of autophagy and endoplasmic reticulum stress varied among the cell lines. The concentration of nelfinavir needed for an efficient induction of apoptosis in breast cancer cells could be reduced from 15 μg/ml to 6 μg/ml when combined with tamoxifen. At a concentration of 6 μg/ml, tamoxifen substantially enhanced the endoplasmic reticulum stress reaction in those cell lines that responded to nelfinavir with binding protein (BiP) upregulation (MCF7, T47D), and enhanced autophagy in cell lines that responded to nelfinavir treatment with autophagy marker light chain 3B upregulation (MDA-MB-453). Although tamoxifen has been described to be able to induce oxidative stress at concentrations similar to those applied in this study (6 μg/ml), we observed that nelfinavir but not tamoxifen reduced the intracellular glutathione level of breast cancer cells within hours of application by up to 32%, suggesting the induction of oxidative stress was an early event and an additional cause of the apoptosis induced by nelfinavir. Conclusions The results demonstrate that nelfinavir may be an effective drug against breast cancer and could be combined with tamoxifen to enhance its efficacy against breast cancer cells. Moreover, the cytotoxic effect of a tamoxifen and nelfinavir combination was independent of the oestrogen receptor status of the analysed breast cancer cells, suggesting a potential benefit of a combination of these two drugs even in patients with no hormone-responsive tumours. We therefore recommend that clinical studies on nelfinavir with breast cancer patients should include this drug combination to analyse the therapeutic efficacy as well as the safety and tolerability of this potential treatment option.
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Affiliation(s)
- Ansgar Brüning
- Department of Obstetrics and Gynaecology, Campus Innenstadt, Ludwig-Maximilians-University Munich, 11 Maistrasse, Munich 80337, Germany.
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