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Omali D, Buzibye A, Kwizera R, Byakika-Kibwika P, Namakula R, Matovu J, Mbabazi O, Mande E, Sekaggya-Wiltshire C, Nakanjako D, Gutteck U, McAdam K, Easterbrook P, Kambugu A, Fehr J, Castelnuovo B, Manabe YC, Lamorde M, Mueller D, Merry C. Building clinical pharmacology laboratory capacity in low- and middle-income countries: Experience from Uganda. Afr J Lab Med 2023; 12:1956. [PMID: 36873289 PMCID: PMC9982508 DOI: 10.4102/ajlm.v12i1.1956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 11/30/2022] [Indexed: 02/05/2023] Open
Abstract
Background Research and clinical use of clinical pharmacology laboratories are limited in low- and middle-income countries. We describe our experience in building and sustaining laboratory capacity for clinical pharmacology at the Infectious Diseases Institute, Kampala, Uganda. Intervention Existing laboratory infrastructure was repurposed, and new equipment was acquired. Laboratory personnel were hired and trained to optimise, validate, and develop in-house methods for testing antiretroviral, anti-tuberculosis and other drugs, including 10 high-performance liquid chromatography methods and four mass spectrometry methods. We reviewed all research collaborations and projects for which samples were assayed in the laboratory from January 2006 to November 2020. We assessed laboratory staff mentorship from collaborative relationships and the contribution of research projects towards human resource development, assay development, and equipment and maintenance costs. We further assessed the quality of testing and use of the laboratory for research and clinical care. Lessons learnt Fourteen years post inception, the clinical pharmacology laboratory had contributed significantly to the overall research output at the institute by supporting 26 pharmacokinetic studies. The laboratory has actively participated in an international external quality assurance programme for the last four years. For clinical care, a therapeutic drug monitoring service is accessible to patients living with HIV at the Adult Infectious Diseases clinic in Kampala, Uganda. Recommendations Driven primarily by research projects, clinical pharmacology laboratory capacity was successfully established in Uganda, resulting in sustained research output and clinical support. Strategies implemented in building capacity for this laboratory may guide similar processes in other low- and middle-income countries.
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Affiliation(s)
- Denis Omali
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Allan Buzibye
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Richard Kwizera
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Pauline Byakika-Kibwika
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rhoda Namakula
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joshua Matovu
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Olive Mbabazi
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Emmanuel Mande
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Damalie Nakanjako
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ursula Gutteck
- Department of Clinical Chemistry, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Keith McAdam
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Philippa Easterbrook
- Department of Human Immunodeficiency Virus, World Health Organization, Geneva, Switzerland
| | - Andrew Kambugu
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jan Fehr
- Department of Clinical Chemistry, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Barbara Castelnuovo
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Yukari C Manabe
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Daniel Mueller
- Department of Clinical Chemistry, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Concepta Merry
- Department of Pharmacology and Therapeutics, Trinity College Dublin, Dublin, Ireland
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Kim HY, Ruiter E, Jongedijk EM, Ak HK, Marais BJ, Pk B, Sawleshwarkar S, Touw DJ, Alffenaar JW. Saliva-based linezolid monitoring on a mobile UV spectrophotometer. J Antimicrob Chemother 2021; 76:1786-1792. [PMID: 33734351 DOI: 10.1093/jac/dkab075] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/15/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND In TB, therapeutic drug monitoring (TDM) is recommended for linezolid; however, implementation is challenging in endemic settings. Non-invasive saliva sampling using a mobile assay would increase the feasibility of TDM. OBJECTIVES To validate a linezolid saliva assay using a mobile UV spectrophotometer. METHODS The saliva assay was developed using NanoPhotometer NP80® and linezolid concentrations were quantified using second-order derivative spectroscopy. Sample preparation involved liquid-liquid extraction of saliva, using saturated sodium chloride and ethyl acetate at 1:1:3 (v/v/v). The assay was validated for accuracy, precision, selectivity, specificity, carry-over, matrix effect, stability and filters. Acceptance criteria were bias and coefficient of variation (CV) <15% for quality control (QC) samples and <20% for the lower limit of quantification (LLOQ). RESULTS Linezolid concentrations correlated with the amplitude between 250 and 270 nm on the second-order derivative spectra. The linezolid calibration curve was linear over the range of 3.0 to 25 mg/L (R2 = 0.99) and the LLOQ was 3.0 mg/L. Accuracy and precision were demonstrated with bias of -7.5% to 2.7% and CV ≤5.6%. The assay met the criteria for selectivity, matrix effect, carry-over, stability (tested up to 3 days) and use of filters (0.22 μM Millex®-GV and Millex®-GP). Specificity was tested with potential co-medications. Interferences from pyrazinamide, levofloxacin, moxifloxacin, rifampicin, abacavir, acetaminophen and trimethoprim were noted; however, with minimal clinical implications on linezolid dosing. CONCLUSIONS We validated a UV spectrophotometric assay using non-invasive saliva sampling for linezolid. The next step is to demonstrate clinical feasibility and value to facilitate programmatic implementation of TDM.
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Affiliation(s)
- Hannah Yejin Kim
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia.,Westmead Hospital, Westmead, NSW, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW, Australia
| | - Evelien Ruiter
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia.,School of Pharmacy, Utrecht University, Utrecht, The Netherlands
| | - Erwin M Jongedijk
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | | | - Ben J Marais
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW, Australia.,Department of Infectious Diseases and Microbiology, The Children's Hospital at Westmead, Westmead, Australia
| | - Bhavani Pk
- National Institute for Research in Tuberculosis, Chennai, India
| | - Shailendra Sawleshwarkar
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW, Australia.,Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Westmead, NSW, Australia
| | - Daan J Touw
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Jan-Willem Alffenaar
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia.,Westmead Hospital, Westmead, NSW, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW, Australia
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Mugusi SF, Mopei N, Minzi O. Adherence to combination antiretroviral therapy among orphaned children in Dar es Salaam, Tanzania. South Afr J HIV Med 2019; 20:954. [PMID: 31534787 PMCID: PMC6739535 DOI: 10.4102/sajhivmed.v20i1.954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 05/05/2019] [Indexed: 11/03/2022] Open
Abstract
Background Adherence to combination antiretroviral therapy (cART) among HIV-infected children is often complicated by various factors including medication formulation, dosing frequency, drug toxicities, age and developmental stage, psychosocial and behavioural characteristics of both children and caregivers and can additionally be complicated by being an orphan. Objectives This study was aimed at determining the factors and the extent of their influence on cART adherence among HIV-infected orphaned children attending Care and Treatment Centres (CTCs) in Dar es Salaam, Tanzania. Methods A cross-sectional study was performed, which assessed adherence in HIV-positive orphaned children aged 2–14 years receiving nevirapine (NVP) based cART for at least 6 months. Data was collected using questionnaires administered to primary caregivers of HIV-infected orphaned children, the review of medical files, and the laboratory measurement of NVP plasma concentrations and CD4 counts. Adherence to cART was determined based on caregivers’ self-report, consistency of clinic attendance and NVP plasma concentrations. Results Among the 216 enrolled orphaned children, adherence to cART was found to be 79.6%, 82.9% and 72.2% respectively based on caregivers’ self-report, clinic attendance and NVP plasma levels. Significant reductions in NVP concentrations (< 3 µg/mL) were seen among children with poor immunological outcomes, poor clinic attendance (p < 0.05) and were suggested by caregivers’ self-reported adherence (p = 0.06). Adherence challenges identified by caregivers included financial constraints (87.5%), lengthy waiting times at clinics (75.5% spent > 2 h at the clinic) and low HIV knowledge among caregivers. Conclusion Significant numbers of HIV-infected orphans have poor adherence to cART ranging between 17% and 28% based on different assessment methods. Inadequate caregiver knowledge of HIV/AIDS, long clinic waiting times and forgetfulness were identified as barriers to cART adherence in these orphans.
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Affiliation(s)
- Sabina F Mugusi
- Department of Clinical Pharmacology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Nassoro Mopei
- Local Government Authority, Dar es Salaam, United Republic of Tanzania
| | - Omary Minzi
- Department of Clinical Pharmacology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
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Kimulwo MJ, Okendo J, Aman RA, Ogutu BR, Kokwaro GO, Ochieng DJ, Muigai AWT, Oloo FA, Ochieng W. Plasma nevirapine concentrations predict virological and adherence failure in Kenyan HIV-1 infected patients with extensive antiretroviral treatment exposure. PLoS One 2017; 12:e0172960. [PMID: 28235021 PMCID: PMC5325546 DOI: 10.1371/journal.pone.0172960] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 02/13/2017] [Indexed: 11/19/2022] Open
Abstract
Treatment failure is a key challenge in the management of HIV-1 infection. We conducted a mixed-model survey of plasma nevirapine (NVP) concentrations (cNVP) and viral load in order to examine associations with treatment and adherence outcomes among Kenyan patients on prolonged antiretroviral therapy (ART). Blood plasma was collected at 1, 4 and 24 hours post-ART dosing from 58 subjects receiving NVP-containing ART and used to determine cNVP and viral load (VL). Median duration of treatment was 42 (range, 12–156) months, and 25 (43.1%) of the patients had virologic failure (VF). cNVP was significantly lower for VF than non- VF at 1hr (mean, 2,111ng/ml vs. 3,432ng/ml, p = 0.003) and at 4hr (mean 1,625ng/ml vs. 3,999ng/ml, p = 0.001) but not at 24hr post-ART dosing. Up to 53.4%, 24.1% and 22.4% of the subjects had good, fair and poor adherence respectively. cNVP levels peaked and were > = 3μg.ml at 4 hours in a majority of patients with good adherence and those without VF. Using a threshold of 3μg/ml for optimal therapeutic nevirapine level, 74% (43/58), 65.5% (38/58) and 86% (50/58) of all patients had sub-therapeutic cNVP at 1, 4 and 24 hours respectively. cNVP at 4 hours was associated with adherence (p = 0.05) and virologic VF (p = 0.002) in a chi-square test. These mean cNVP levels differed significantly in non-parametric tests between adherence categories at 1hr (p = 0.005) and 4hrs (p = 0.01) and between ART regimen categories at 1hr (p = 0.004) and 4hrs (p<0.0001). Moreover, cNVP levels correlated inversely with VL (p< = 0.006) and positively with adherence behavior. In multivariate tests, increased early peak NVP (cNVP4) was independently predictive of lower VL (p = 0.002), while delayed high NVP peak (cNVP24) was consistent with increased VL (p = 0.033). These data strongly assert the need to integrate plasma concentrations of NVP and that of other ART drugs into routine ART management of HIV-1 patients.
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Affiliation(s)
- Maureen J. Kimulwo
- Center for Research in Therapeutic Sciences, Strathmore University, Nairobi, Kenya
- ITROMID, Jomo Kenyatta University of Science and Technology, Nairobi, Kenya
| | - Javan Okendo
- Center for Research in Therapeutic Sciences, Strathmore University, Nairobi, Kenya
| | - Rashid A. Aman
- Center for Research in Therapeutic Sciences, Strathmore University, Nairobi, Kenya
- Institute of Healthcare Management, Strathmore University, Nairobi, Kenya
- African Centre for Clinical Trials, Nairobi, Kenya
| | - Bernhards R. Ogutu
- Center for Research in Therapeutic Sciences, Strathmore University, Nairobi, Kenya
- Institute of Healthcare Management, Strathmore University, Nairobi, Kenya
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Gilbert O. Kokwaro
- Institute of Healthcare Management, Strathmore University, Nairobi, Kenya
| | - Dorothy J. Ochieng
- School of Pharmacy, MCPHS University, Worcester, Massachusetts, United States of America
| | - Anne W. T. Muigai
- ITROMID, Jomo Kenyatta University of Science and Technology, Nairobi, Kenya
| | - Florence A. Oloo
- Center for Research in Therapeutic Sciences, Strathmore University, Nairobi, Kenya
- Department of Chemical Science and Technology, Technical University of Kenya, Nairobi, Kenya
| | - Washingtone Ochieng
- Center for Research in Therapeutic Sciences, Strathmore University, Nairobi, Kenya
- Institute of Healthcare Management, Strathmore University, Nairobi, Kenya
- Kenya Medical Research Institute, Nairobi, Kenya
- Immunology and Infectious Diseases Department, Harvard School of Public Health, Boston, Massachusetts, United States of America
- * E-mail:
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Vanstraelen K, Maertens J, Augustijns P, Lagrou K, de Loor H, Mols R, Annaert P, Malfroot A, Spriet I. Investigation of Saliva as an Alternative to Plasma Monitoring of Voriconazole. Clin Pharmacokinet 2016; 54:1151-60. [PMID: 25910879 DOI: 10.1007/s40262-015-0269-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Therapeutic drug monitoring (TDM) of voriconazole is increasingly being implemented in clinical practice. However, as blood sampling can be difficult in paediatric and ambulatory patients, a non-invasive technique for TDM is desirable. The aim of this study was to compare the pharmacokinetics of voriconazole in saliva with the pharmacokinetics of unbound and total voriconazole in plasma in order to clinically validate saliva as an alternative to plasma in voriconazole TDM. METHODS In this pharmacokinetic study, paired plasma and saliva samples were taken at steady state in adult haematology and pneumology patients treated with voriconazole. Unbound and bound plasma voriconazole concentrations were separated using high-throughput equilibrium dialysis. Voriconazole concentrations were determined with liquid chromatography-tandem mass spectrometry. Pharmacokinetic parameters were calculated using log-linear regression. RESULTS Sixty-three paired samples were obtained from ten patients (seven haematology and three pneumology patients). Pearson's correlation coefficients (R values) for saliva versus unbound and total plasma voriconazole concentrations showed a very strong correlation, with values of 0.970 (p < 0.001) and 0.891 (p < 0.001), respectively. Linear mixed modelling revealed strong agreement between voriconazole concentrations in saliva and unbound plasma voriconazole concentrations, with a mean bias of -0.03 (95 % confidence interval -0.14 to 0.09; p = 0.60). For total concentrations below 10 mg/L, the mean ratio of saliva to total plasma voriconazole concentrations was 0.51 ± 0.08 (n = 63), which did not differ significantly (p = 0.76) from the unbound fraction of voriconazole in plasma of 0.49 ± 0.03 (n = 36). CONCLUSIONS Saliva can serve as a reliable alternative to plasma in voriconazole TDM, and it can easily be implemented in clinical practice.
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Affiliation(s)
- Kim Vanstraelen
- Clinical Pharmacology and Pharmacotherapy, KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Herestraat 49, 3000, Leuven, Belgium.
| | - Johan Maertens
- Acute Leukaemia and Stem Cell Transplantation Unit, Clinical Department of Haematology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Patrick Augustijns
- Drug Delivery and Disposition, KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Herestraat 49, 3000, Leuven, Belgium
| | - Katrien Lagrou
- Clinical Department of Laboratory Medicine, Department of Microbiology and Immunology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Henriette de Loor
- Laboratory of Nephrology and Renal Transplantation, KU Leuven Department of Microbiology and Immunology, Herestraat 49, 3000, Leuven, Belgium
| | - Raf Mols
- Drug Delivery and Disposition, KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Herestraat 49, 3000, Leuven, Belgium
| | - Pieter Annaert
- Drug Delivery and Disposition, KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Herestraat 49, 3000, Leuven, Belgium
| | - Anne Malfroot
- Cystic Fibrosis Clinic, Research Group GRON, Universitair Ziekenhuis Brussel (UZ Brussel); Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Isabel Spriet
- Clinical Pharmacology and Pharmacotherapy, KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Herestraat 49, 3000, Leuven, Belgium
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Biomarkers and biometric measures of adherence to use of ARV-based vaginal rings. J Int AIDS Soc 2016; 19:20746. [PMID: 27142091 PMCID: PMC4854848 DOI: 10.7448/ias.19.1.20746] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 03/21/2016] [Accepted: 03/31/2016] [Indexed: 11/13/2022] Open
Abstract
Introduction Poor adherence to product use has been observed in recent trials of antiretroviral (ARV)-based oral and vaginal gel HIV prevention products, resulting in an inability to determine product efficacy. The delivery of microbicides through vaginal rings is widely perceived as a way to achieve better adherence but vaginal rings do not eliminate the adherence challenges exhibited in clinical trials. Improved objective measures of adherence are needed as new ARV-based vaginal ring products enter the clinical trial stage. Methods To identify technologies that have potential future application for vaginal ring adherence measurement, a comprehensive literature search was conducted that covered a number of biomedical and public health databases, including PubMed, Embase, POPLINE and the Web of Science. Published patents and patent applications were also searched. Technical experts were also consulted to gather more information and help evaluate identified technologies. Approaches were evaluated as to feasibility of development and clinical trial implementation, cost and technical strength. Results Numerous approaches were identified through our landscape analysis and classified as either point measures or cumulative measures of vaginal ring adherence. Point measurements are those that give a measure of adherence at a particular point in time. Cumulative measures attempt to measure ring adherence over a period of time. Discussion Approaches that require modifications to an existing ring product are at a significant disadvantage, as this will likely introduce additional regulatory barriers to the development process and increase manufacturing costs. From the point of view of clinical trial implementation, desirable attributes would be high acceptance by trial participants, and little or no additional time or training requirements on the part of participants or clinic staff. We have identified four promising approaches as being high priority for further development based on the following measurements: intracellular drug levels, drug levels in hair, the accumulation of a vaginal analyte that diffuses into the ring, and the depletion of an intrinsic ring constituent. Conclusions While some approaches show significant promise over others, it is recommended that a strategy of using complementary biometric and behavioural approaches be adopted to best understand participants’ adherence to ARV-based ring products in clinical trials.
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