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Bekker A, Yang J, Wang J, Cotton MF, Cababasay M, Wiesner L, Moye J, Browning R, Nakwa FL, Rabie H, Violari A, Mirochnick M, Cressey TR, Capparelli EV. Safety and Pharmacokinetics of Lopinavir/Ritonavir Oral Solution in Preterm and Term Infants Starting Before 3 Months of Age. Pediatr Infect Dis J 2024; 43:355-360. [PMID: 38190642 PMCID: PMC10939833 DOI: 10.1097/inf.0000000000004243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND Study of liquid lopinavir/ritonavir (LPV/r) in young infants has been limited by concerns for its safety in neonates. METHODS International Maternal Pediatric Adolescent AIDS Clinical Trials Network P1106 was a phase IV, prospective, trial evaluating the safety and pharmacokinetics of antiretroviral medications administered according to local guidelines to South African preterm and term infants <3 months of age. Safety evaluation through 24-week follow-up included clinical, cardiac and laboratory assessments. Pharmacokinetic data from P1106 were combined with data from International Maternal Pediatric Adolescent AIDS Clinical Trials Network studies P1030 and P1083 in a population pharmacokinetics model used to simulate LPV exposures with a weight-band dosing regimen in infants through age 6 months. RESULTS Safety and pharmacokinetics results were similar in 13/28 (46%) infants initiating LPV/r <42 weeks postmenstrual age (PMA) and in those starting ≥42 weeks PMA. LPV/r was started at a median (range) age of 47 (13-121) days. No grade 3 or higher adverse events were considered treatment related. Modeling and simulation predicted that for infants with gestational age ≥27 weeks who receive the weight-band dosing regimen, 82.6% will achieve LPV trough concentration above the target trough concentration of 1.0 µg/mL and 56.6% would exceed the observed adult lower limit of LPV exposure of 55.9 µg·h/mL through age 6 months. CONCLUSIONS LPV/r oral solution was safely initiated in a relatively small sample size of infants ≥34 weeks PMA and >2 weeks of life. No serious drug-related safety signal was observed; however, adrenal function assessments were not performed. Weight-band dosing regimen in infants with gestational age ≥27 weeks is predicted to result in LPV exposures equivalent to those observed in other pediatric studies.
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Affiliation(s)
- Adrie Bekker
- Family Centre for Research with Ubuntu, Department of Pediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Jincheng Yang
- Department of Pediatrics and Skaggs School of Pharmacy and Pharmaceutical Science, University of California, San Diego, USA
- Clinical Pharmacology and Quantitative pharmacology, CPSS, AstraZeneca R&D, Waltham, MA, USA
| | - Jiajia Wang
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mark F. Cotton
- Family Centre for Research with Ubuntu, Department of Pediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Mae Cababasay
- Clinical Pharmacology and Quantitative pharmacology, CPSS, AstraZeneca R&D, Waltham, MA, USA
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Jack Moye
- Division of Extramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development
| | - Renee Browning
- Division of AIDS, National Institute of Allergy and Infectious Diseases
| | - Firdose L. Nakwa
- Department of Pediatrics and Child Health, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Helena Rabie
- Family Centre for Research with Ubuntu, Department of Pediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Avy Violari
- Perinatal HIV research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Mirochnick
- Division of Neonatology, Department of Pediatrics, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Tim. R Cressey
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Molecular & Clinical Pharmacology, University of Liverpool, UK
| | - Edmund V. Capparelli
- Department of Pediatrics and Skaggs School of Pharmacy and Pharmaceutical Science, University of California, San Diego, USA
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Persaud D, Bryson Y, Nelson BS, Tierney C, Cotton MF, Coletti A, Jao J, Spector SA, Mirochnick M, Capparelli EV, Costello D, Szewczyk J, Nicodimus N, Stranix-Chibanda L, Kekitiinwa AR, Korutaro V, Reding C, Carrington MN, Majji S, Yin DE, Jean-Philippe P, Chadwick EG. HIV-1 reservoir size after neonatal antiretroviral therapy and the potential to evaluate antiretroviral-therapy-free remission (IMPAACT P1115): a phase 1/2 proof-of-concept study. Lancet HIV 2024; 11:e20-e30. [PMID: 38061376 DOI: 10.1016/s2352-3018(23)00236-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/23/2023] [Accepted: 09/11/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Infants born with HIV-1 require lifelong antiretroviral therapy (ART). We aimed to assess whether very early ART in neonates might restrict HIV-1 reservoirs, an important step towards ART-free remission. METHODS IMPAACT P1115 is an ongoing, phase 1/2, proof-of-concept study in which infants were enrolled at 30 research clinics in 11 countries (Brazil, Haiti, Kenya, Malawi, South Africa, Tanzania, Thailand, Uganda, the USA, Zambia, and Zimbabwe) into two cohorts. Infants at least 34 weeks' gestational age at high risk for in-utero HIV-1 with either untreated maternal HIV-1 (cohort 1) or who were receiving pre-emptive triple antiretroviral prophylaxis outside of the study (maternal ART permissible; cohort 2) were included. All infants initiated treatment within 48 h of life. Cohort 1 initiated three-drug nevirapine-based ART, and cohort 2 initiated three-drug nevirapine-based prophylaxis then three-drug nevirapine-based ART following HIV diagnosis by age 10 days. We added twice-daily coformulated oral ritonavir 75 mg/m2 and lopinavir 300 mg/m2 from 14 days of life and 42 weeks postmenstrual age. We discontinued nevirapine 12 weeks after two consecutive plasma HIV-1 RNA levels below limit of detection. We tracked virological suppression, safety outcomes, and meeting a predetermined biomarker profile at age 2 years (undetectable RNA since week 48, HIV-1 antibody-negative, HIV-1 DNA not detected, and normal CD4 count and CD4 percentage) to assess qualification for analytical treatment interruption. This study is registered with ClinicalTrials.gov, NCT02140255. FINDINGS Between Jan 23, 2015, and Dec 14, 2017, 440 infants were included in cohort 1 and 20 were included in cohort 2. 54 of these infants (34 from cohort 1 and 20 from cohort 2) had confirmed in-utero HIV-1 and were enrolled to receive study ART. 33 (61%) of 54 infants were female and 21 (39%) were male. The estimated probability of maintaining undetectable plasma RNA through to 2 years was 33% (95% CI 17-49) in cohort 1 and 57% (28-78) in cohort 2. Among infants maintaining protocol-defined virological control criteria through to study week 108, seven of 11 (64%, 95% CI 31-89) in cohort 1 and five of seven (71%, 29-96) in cohort 2 had no detected HIV-1 DNA. Ten of 12 (83%, 52-100) in cohort 1 and all seven (100%, 59-100) in cohort 2 tested HIV-1 antibody-negative at week 108. Among 54 infants initiated on very early ART, ten (19%; six in cohort 1 and four in cohort 2) met all criteria for possible analytical treatment interruption. Reversible grade 3 or 4 adverse events occurred in 15 (44%) of 34 infants in cohort 1 and seven (35%) of 20 infants in cohort 2. INTERPRETATION Very early ART for in-utero HIV-1 can achieve sustained virological suppression in association with biomarkers indicating restricted HIV-1 reservoirs by age 2 years, which might enable potential ART-free remission. FUNDING National Institute of Allergy and Infectious Diseases, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Institute of Mental Health.
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Affiliation(s)
- Deborah Persaud
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Yvonne Bryson
- University of California Los Angeles, Los Angeles, CA, USA
| | - Bryan S Nelson
- Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Camlin Tierney
- Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | | | - Jennifer Jao
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stephen A Spector
- University of California San Diego School of Medicine, La Jolla, CA, USA
| | | | | | - Diane Costello
- University of California Los Angeles, Los Angeles, CA, USA
| | - Joseph Szewczyk
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nicol Nicodimus
- University of Zimbabwe, Clinical Trials Research Centre, Harare, Zimbabwe
| | | | | | - Violet Korutaro
- Baylor College of Medicine Children's Foundation, Kampala, Uganda
| | - Christina Reding
- Frontier Science and Technology Research Foundation, Amherst, NY, USA
| | - Mary N Carrington
- Frederick National Laboratory for Cancer Research and Laboratory of Integrative Cancer Immunology National Cancer Institute, MD, USA
| | - Sai Majji
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Dwight E Yin
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Patrick Jean-Philippe
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Ellen G Chadwick
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Momper JD, Nikanjam M, Best BM, Mirochnick M, Capparelli EV, Cressey TR. Brief Report: Dolutegravir Plasma Protein Binding and Unbound Concentrations During Pregnancy and Postpartum. J Acquir Immune Defic Syndr 2023; 94:332-336. [PMID: 37884053 PMCID: PMC10686188 DOI: 10.1097/qai.0000000000003281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/24/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Clinical interpretation of the reduced dolutegravir (DTG) plasma concentrations reported during pregnancy is complicated by its high plasma protein binding. Plasma proteins significantly decrease during pregnancy, and understanding changes in DTG protein binding and its therapeutically active unbound concentrations are necessary to evaluate the impact of pregnancy changes on DTG pharmacokinetics. METHODS Retrospective assessment of plasma samples from pregnant women living with HIV enrolled in the International Maternal Pediatric Adolescent AIDS Clinical Trials Network P1026s study receiving 50 mg DTG film-coated tablets once daily as part of clinical care. Unbound and total DTG concentrations were determined predose (C0) and at maximum (Cmax) concentrations during the second trimester (2T), third trimester (3T), and postpartum (PP). Percentage unbound was calculated as the ratio of ultrafiltrate unbound DTG concentration to total DTG concentration. RESULTS Twenty-nine mothers were included for protein binding evaluations; 15, 27, and 23 from the 2T, 3T, and PP, respectively. DTG % unbound for C0 and Cmax were significantly different by stage of pregnancy, with 3T significantly higher compared with PP; 1.02% vs. 0.69% (P = 0.0067) for C0 and 0.76% vs. 0.46% for Cmax (P = 0.0056). Median (IQR) unbound concentrations for C0 were 6.3 (4.7-18.4) for the 2T, 8.0 (5.6-16.9) for the 3T, and 13.3 (8.4-22.7) ng/mL PP, significantly different between 2T and PP (P = 0.0039), but not different between 3T and PP (P = 0.46). CONCLUSION Lower total DTG plasma concentrations during pregnancy coincide with temporal decreases in DTG protein binding, resulting in comparable unbound DTG concentrations during the 3T and PP.
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Affiliation(s)
- Jeremiah D. Momper
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Mina Nikanjam
- School of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Brookie M. Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, USA
- School of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Mark Mirochnick
- Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Edmund V. Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, USA
- School of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Tim R. Cressey
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Molecular & Clinical Pharmacology, University of Liverpool, UK
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Van Schalkwyk M, Bekker A, Decloedt E, Wang J, Theron GB, Cotton MF, Eke AC, Cressey TR, Shapiro DE, Bacon K, Knowles K, George K, Browning R, Chakhtoura N, Rungruengthanakit K, Wiesner L, Capparelli EV, Stek AM, Mirochnick M, Best BM. Pharmacokinetics and safety of first-line tuberculosis drugs rifampin, isoniazid, ethambutol, and pyrazinamide during pregnancy and postpartum: results from IMPAACT P1026s. Antimicrob Agents Chemother 2023; 67:e0073723. [PMID: 37882552 PMCID: PMC10648924 DOI: 10.1128/aac.00737-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/14/2023] [Indexed: 10/27/2023] Open
Abstract
Physiological changes during pregnancy may alter the pharmacokinetics (PK) of antituberculosis drugs. The International Maternal Pediatric Adolescent AIDS Clinical Trials Network P1026s was a multicenter, phase IV, observational, prospective PK and safety study of antiretroviral and antituberculosis drugs administered as part of clinical care in pregnant persons living with and without HIV. We assessed the effects of pregnancy on rifampin, isoniazid, ethambutol, and pyrazinamide PK in pregnant and postpartum (PP) persons without HIV treated for drug-susceptible tuberculosis disease. Daily antituberculosis treatment was prescribed following World Health Organization-recommended weight-band dosing guidelines. Steady-state 12-hour PK profiles of rifampin, isoniazid, ethambutol, and pyrazinamide were performed during second trimester (2T), third trimester (3T), and 2-8 of weeks PP. PK parameters were characterized using noncompartmental analysis, and comparisons were made using geometric mean ratios (GMRs) with 90% confidence intervals (CI). Twenty-seven participants were included: 11 African, 9 Asian, 3 Hispanic, and 4 mixed descent. PK data were available for 17, 21, and 14 participants in 2T, 3T, and PP, respectively. Rifampin and pyrazinamide AUC0-24 and C max in pregnancy were comparable to PP with the GMR between 0.80 and 1.25. Compared to PP, isoniazid AUC0-24 was 25% lower and C max was 23% lower in 3T. Ethambutol AUC0-24 was 39% lower in 3T but limited by a low PP sample size. In summary, isoniazid and ethambutol concentrations were lower during pregnancy compared to PP concentrations, while rifampin and pyrazinamide concentrations were similar. However, the median AUC0-24 for rifampin, isoniazid, and pyrazinamide met the therapeutic targets. The clinical impact of lower isoniazid and ethambutol exposure during pregnancy needs to be determined.
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Affiliation(s)
- Marije Van Schalkwyk
- Division of Adult Infectious Diseases, Department of Medicine, Family Centre for Research with Ubuntu, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Adrie Bekker
- Department of Pediatrics and Child Health, Family Centre for Research with Ubuntu, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Jiajia Wang
- Department of Biostatistics, Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Gerhard B. Theron
- Department of Obstetrics and Gynecology, Stellenbosch University, Cape Town, South Africa
| | - Mark F. Cotton
- Department of Pediatrics and Child Health, Family Centre for Research with Ubuntu, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Ahizechukwu C. Eke
- Division of Maternal Fetal Medicine and Clinical Pharmacology, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tim R. Cressey
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - David E. Shapiro
- Department of Biostatistics, Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kira Bacon
- Frontier Science Foundation, Amherst, New York, USA
| | | | | | - Renee Browning
- Division of AIDS, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland, USA
| | - Nahida Chakhtoura
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, Maryland, USA
| | | | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Edmund V. Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, California, USA
- Department of Pediatrics, School of Medicine, University of California, San Diego, California, USA
| | - Alice M. Stek
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Los Angeles, California, USA
| | - Mark Mirochnick
- Division of Neonatology, Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Brookie M. Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, California, USA
- Department of Pediatrics, School of Medicine, University of California, San Diego, California, USA
| | - on behalf of the IMPAACT P1026s Protocol Team
- Division of Adult Infectious Diseases, Department of Medicine, Family Centre for Research with Ubuntu, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
- Department of Pediatrics and Child Health, Family Centre for Research with Ubuntu, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
- Department of Biostatistics, Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Obstetrics and Gynecology, Stellenbosch University, Cape Town, South Africa
- Division of Maternal Fetal Medicine and Clinical Pharmacology, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Frontier Science Foundation, Amherst, New York, USA
- FHI 360, Durham, North Carolina, USA
- Division of AIDS, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland, USA
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, Maryland, USA
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, California, USA
- Department of Pediatrics, School of Medicine, University of California, San Diego, California, USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Los Angeles, California, USA
- Division of Neonatology, Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
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Brooks KM, Scarsi KK, Mirochnick M. Antiretrovirals for Human Immunodeficiency Virus Treatment and Prevention in Pregnancy. Obstet Gynecol Clin North Am 2023; 50:205-218. [PMID: 36822704 DOI: 10.1016/j.ogc.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Safe and effective antiretroviral medications are needed during pregnancy to reduce maternal morbidity and mortality associated with untreated human immunodeficiency virus (HIV) infection and to prevent viral transmission to the infant. Pharmacokinetic studies have helped inform the appropriate dosing of antiretroviral medications during pregnancy. However, data from these studies consistently become available years after initial regulatory approvals in nonpregnant adults. In this article, the authors provide an overview of considerations in use of antiretroviral medications in pregnant people with or at risk for HIV, pharmacokinetic studies that helped support recommended options, and therapies either under active investigation or in need of prospective study.
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Affiliation(s)
- Kristina M Brooks
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
| | - Kimberly K Scarsi
- Department of Pharmacy Practice and Science, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Room 3021, Omaha, NE 68198, USA.
| | - Mark Mirochnick
- Boston University School of Medicine, 801 Albany Street, Room 2021, Boston, MA 20118, USA
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Liu XI, Dallmann A, Brooks K, Best BM, Clarke DF, Mirochnick M, van den Anker JN, Capparelli EV, Momper JD. Physiologically-based pharmacokinetic modeling of remdesivir and its metabolites in pregnant women with COVID-19. CPT Pharmacometrics Syst Pharmacol 2023; 12:148-153. [PMID: 36479969 PMCID: PMC9877749 DOI: 10.1002/psp4.12900] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022] Open
Abstract
Pregnant individuals are at high risk for severe illness from COVID-19, and there is an urgent need to identify safe and effective therapeutics for this population. Remdesivir (RDV) is a SARS-CoV-2 nucleotide analog RNA polymerase inhibitor. Limited RDV pharmacokinetic (PK) and safety data are available for pregnant women receiving RDV. The aims of this study were to translate a previously published nonpregnant adult physiologically based PK (PBPK) model for RDV to pregnancy and evaluate model performance with emerging clinical PK data in pregnant women with COVID-19. The pregnancy model was built in the Open Systems Pharmacology software suite (Version 10) including PK-Sim® and MoBi® with pregnancy-related changes of relevant enzymes applied. PK were predicted in a virtual population of 1000 pregnant subjects, and prediction results were compared with in vivo PK data from the International Maternal, Pediatric, Adolescent AIDS Clinical Trials (IMPAACT) Network 2032 study. The developed PBPK model successfully captured RDV and its metabolites' plasma concentrations during pregnancy. The ratios of prediction versus observation for RDV area under the curve from time 0 to infinity (AUC0-∞ ) and maximum concentration (Cmax ) were 1.61 and 1.17, respectively. For GS-704277, the ratios of predicted versus observed were 0.94 for AUC0-∞ and 1.20 for Cmax . For GS-441524, the ratios of predicted versus observed were 1.03 for AUC0-24 , 1.05 for Cmax , and 1.07 for concentrations at 24 h. All predictions of AUC and Cmax for RDV and its metabolites were within a twofold error range, and about 60% of predictions were within a 10% error range. These findings demonstrate the feasibility of translating PBPK models to pregnant women to potentially guide trial design, clinical decision making, and drug development.
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Affiliation(s)
- Xiaomei I. Liu
- Division of Clinical PharmacologyChildren's National HospitalWashingtonDCUSA
| | - André Dallmann
- Pharmacometrics/Modeling and Simulation, Research and Development, Pharmaceuticals, Bayer AGLeverkusenGermany
| | - Kristina Brooks
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical SciencesUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Brookie M. Best
- Skaggs School of Pharmacy and Pharmaceutical SciencesUniversity of California, San DiegoLa JollaCaliforniaUSA
- Pediatrics Department, School of Medicine‐Rady Children's Hospital San DiegoUniversity of California, San DiegoLa JollaCaliforniaUSA
| | - Diana F. Clarke
- Section of Pediatrics Infectious Diseases, Boston Medical CenterBostonMassachusettsUSA
| | - Mark Mirochnick
- Department of PediatricsBoston University School of MedicineBostonMassachusettsUSA
| | | | - Edmund V. Capparelli
- Skaggs School of Pharmacy and Pharmaceutical SciencesUniversity of California, San DiegoLa JollaCaliforniaUSA
- Pediatrics Department, School of Medicine‐Rady Children's Hospital San DiegoUniversity of California, San DiegoLa JollaCaliforniaUSA
| | - Jeremiah D. Momper
- Skaggs School of Pharmacy and Pharmaceutical SciencesUniversity of California, San DiegoLa JollaCaliforniaUSA
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Eke AC, Mirochnick M, Lockman S. Antiretroviral Therapy and Adverse Pregnancy Outcomes in People Living with HIV. N Engl J Med 2023; 388:344-356. [PMID: 36720135 PMCID: PMC10400304 DOI: 10.1056/nejmra2212877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Ahizechukwu C Eke
- From the Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, and the Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore (A.C.E.); the Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine (M.M.), the Division of Infectious Diseases, Brigham and Women's Hospital (S.L.), and the Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health (S.L.) - all in Boston; and the Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana (S.L.)
| | - Mark Mirochnick
- From the Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, and the Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore (A.C.E.); the Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine (M.M.), the Division of Infectious Diseases, Brigham and Women's Hospital (S.L.), and the Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health (S.L.) - all in Boston; and the Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana (S.L.)
| | - Shahin Lockman
- From the Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, and the Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore (A.C.E.); the Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine (M.M.), the Division of Infectious Diseases, Brigham and Women's Hospital (S.L.), and the Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health (S.L.) - all in Boston; and the Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana (S.L.)
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Coutinho CM, Warshaw MG, Duarte G, Stek A, Violari A, Hofer CB, Deville JG, Ngocho JS, Pilotto JH, Correa MD, Shapiro DE, Fuller TL, Chakhtoura N, Mirochnick M, João EC. Effects of Initiating Raltegravir-Based Versus Efavirenz-Based Antiretroviral Regimens During Pregnancy on Weight Changes and Perinatal Outcomes: NICHD P1081. J Acquir Immune Defic Syndr 2022; 91:403-409. [PMID: 36049477 PMCID: PMC9613542 DOI: 10.1097/qai.0000000000003081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/16/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Integrase inhibitors have been associated with excess gestational weight gain that may lead to adverse pregnancy outcomes (APOs). This post hoc analysis of NICHD P1081 compared antepartum changes in weight and body mass index (BMI) in pregnant women initiating raltegravir- or efavirenz-based combined antiretroviral therapy (cART) and examined associations between rates of weight gain and APOs. SETTING NICHD P1081 enrolled antiretroviral-naive pregnant women living with HIV in the second and third trimester in Brazil, Tanzania, South Africa, Thailand, Argentina, and the United States. METHODS Two hundred eighty-one women enrolled between 20 and 31 gestational weeks were randomized to raltegravir- or efavirenz-based cART and followed for ≥4 weeks. A low rate of weight gain was defined as <0.18 kg/wk and high as >0.59 kg/wk. We compared weight gain and BMI increase between treatment arms using Kruskal-Wallis tests. Logistic regression was used to investigate the association between weight gain and APOs. RESULTS Raltegravir-based cART was associated with significantly higher antepartum weight gain (median 0.36 kg/wk versus 0.29 kg/wk, P = 0.01) and BMI increase (median 0.14 kg/m 2 /wk versus 0.11 kg/m 2 /wk, P = 0.01) compared with efavirenz-based treatment. Women on raltegravir had less low weight gain (18% versus 36%) and more high weight gain (21% versus 12%) ( P = 0.001). Women with low weight gain were more likely than those with normal weight gain to have small for gestational age infants or a composite of APOs. CONCLUSIONS A raltegravir-based antiretroviral regimen was associated with significantly higher antepartum rate of weight gain and BMI increase compared with efavirenz-based treatment in antiretroviral-naive pregnant women.
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Affiliation(s)
- Conrado Milani Coutinho
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Meredith G Warshaw
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Geraldo Duarte
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Alice Stek
- Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Los Angeles, CA
| | - Avy Violari
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Cristina B Hofer
- Infectious Diseases Department, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jaime G Deville
- Department of Pediatrics, University of California, Los Angeles, CA
| | - James Samwel Ngocho
- Department of Epidemiology and Applied Biostatistics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - José Henrique Pilotto
- Infectious Diseases Department, Hospital Geral de Nova Iguaçu & Laboratório de AIDS e Imunologia Molecular/IOC/Fiocruz, Rio de Janeiro, Brazil
| | - Mario Dias Correa
- Department of Gynecology and Obstetrics, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - David E Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Trevon L Fuller
- Infectious Diseases Department, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
- University of California, Los Angeles, CA
| | - Nahida Chakhtoura
- Maternal and Pediatric Infectious Disease Branch at the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD; and
| | - Mark Mirochnick
- Department of Pediatrics, Boston University School of Medicine, Boston, MA
| | - Esaú C João
- Infectious Diseases Department, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
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9
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Abrams EJ, Capparelli E, Ruel T, Mirochnick M. Potential of Long-Acting Products to Transform the Treatment and Prevention of Human Immunodeficiency Virus (HIV) in Infants, Children, and Adolescents. Clin Infect Dis 2022; 75:S562-S570. [PMID: 36410381 PMCID: PMC10200315 DOI: 10.1093/cid/ciac754] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Long-acting antiretroviral products have the potential to transform human immunodeficiency virus (HIV) prevention and treatment approaches in pediatric populations. Broadly neutralizing antibodies and/or long-acting antiretroviral formulations by injection could dramatically improve provision of HIV prophylaxis and/or early treatment to newborns and infants at risk of HIV infection. Challenges in daily oral antiretroviral administration to toddlers and school age children living with HIV may be relieved by use of long-acting formulations, but the pharmacokinetics and safety of these products in children must be studied before they can enter routine clinical use. Although some initial studies of broadly neutralizing antibodies and injectable long-acting agents in infants and young children are underway, more studies of these and other long-acting products are needed. For many adolescents, compliance with daily medication administration is especially challenging. Long-acting products hold particular promise for adolescents living with HIV as well as those at high risk of HIV acquisition, and adolescents can usually be included in the drug development pipeline simultaneously with adults. Long-acting products have the potential to provide alternatives to lifelong daily oral drug administration across the pediatric age spectrum, leading to more effective prevention and treatment of HIV infection in infants, children, and adolescents.
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Affiliation(s)
- Elaine J Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, USA
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Edmund Capparelli
- Department of Pediatrics and Clinical Pharmacy, University of California San Diego, La Jolla, California, USA
| | - Theodore Ruel
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Mark Mirochnick
- Department of Pediatrics, Boston University, Boston, Massachusetts, USA
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10
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Liyanage M, Nikanjam M, McFadyen L, Vourvahis M, Rogg L, Moye J, Chadwick EG, Jean-Philippe P, Mirochnick M, Whitson K, Bradford S, Capparelli EV, Best BM. Maraviroc Population Pharmacokinetics Within the First 6 Weeks of Life. Pediatr Infect Dis J 2022; 41:885-890. [PMID: 35980827 PMCID: PMC9560968 DOI: 10.1097/inf.0000000000003665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Treatment and prophylaxis options for neonatal HIV are limited. This study aimed to develop a population pharmacokinetic model to characterize the disposition of maraviroc in neonates to inform dosing regimens and expand available options. METHODS Using maraviroc concentrations from neonates who received either a single dose or multiple doses of 8 mg/kg of maraviroc in the first 6 weeks of life, a population pharmacokinetic model was developed to determine the effects of age, sex, maternal efavirenz exposure and concomitant ARV therapy on maraviroc disposition. The final model was used in Monte Carlo simulations to generate expected exposures with recommended dosing regimens. RESULTS A total of 396 maraviroc concentrations, collected in the first 4 days of life, at 1 week, at 4 weeks and at 6 weeks, from 44 neonates were included in the analysis. After allometrically scaling for weight, age less than 4 days was associated with a 44% decreased apparent clearance compared with participants 7 days to 6 weeks of life. There were no differences identified in apparent clearance or volume of distribution from ages 7 days to 6 weeks, sex, maternal efavirenz exposure or concomitant nevirapine therapy. Monte Carlo simulations with FDA-approved weight band dosing resulted in the majority of simulated patients (84.3%) achieving an average concentration of ≥75 ng/mL. CONCLUSIONS While maraviroc apparent clearance is decreased in the first few days of life, the current FDA-approved maraviroc weight band dosing provides maraviroc exposures for neonates in the first 6 weeks of life, which were consistent with adult maraviroc exposure range. Maraviroc provides another antiretroviral treatment option for very young infants.
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Affiliation(s)
- Marlon Liyanage
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Mina Nikanjam
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Lynn McFadyen
- Pharmacometrics, Pfizer Global Research and Development, Sandwich, UK
| | - Manoli Vourvahis
- Clinical Pharmacology, Pfizer Global Research and Development, New York, New York, USA
| | - Luise Rogg
- ViiV Healthcare, Research Triangle, North Carolina, USA
| | - John Moye
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda
| | - Ellen G. Chadwick
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | | | - Mark Mirochnick
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Kyle Whitson
- Frontier Science Foundation, Amherst, New York, USA
| | | | - Edmund V. Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
- Pediatrics Department, School of Medicine, University of California San Diego-Rady Children’s Hospital San Diego, San Diego, CA
| | - Brookie M. Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
- Pediatrics Department, School of Medicine, University of California San Diego-Rady Children’s Hospital San Diego, San Diego, CA
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11
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Béranger A, Bekker A, Solans BP, Cotton MF, Mirochnick M, Violari A, Wang J, Cababasay M, Wiesner L, Browning R, Moye J, Capparelli EV, Savic RM. Influence of NAT2 Genotype and Maturation on Isoniazid Exposure in Low-Birth-Weight and Preterm Infants With or Without Human Immunodeficiency Virus (HIV) Exposure. Clin Infect Dis 2022; 75:1037-1045. [PMID: 35134861 PMCID: PMC9522418 DOI: 10.1093/cid/ciac001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Isoniazid (INH) metabolism depends on the N-acetyl transferase 2 (NAT2) enzyme, whose maturation process remains unknown in low birth weight (LBW) and preterm infants. We aimed to assess INH exposure and safety in infants receiving oral tuberculosis prevention. METHODS This population pharmacokinetics (PK) analysis used INH and N-acetyl-isoniazid (ACL) concentrations in infants (BW ≤ 4 kg), including preterm, with follow-up for 6 months. PK parameters were described using nonlinear mixed effects modeling. Simulations were performed to assess INH exposure and optimal dosing regimens, using 2 targets: Cmax at 3-6 mg/L and area under the curve (AUC) ≥ 10.52 mg h/L. RESULTS We included 57 infants (79% preterm, 84% LBW) in the PK analysis, with a median (range) gestational age of 34 (28.7-39.4) weeks. At the time of sampling, postnatal age was 2.3 (0.2-7.3) months and weight (WT) was 3.7 (0.9-9.3) kg. NAT2 genotype was available in 43 (75.4%) patients (10 slow, 26 intermediate, and 7 fast metabolizers). Ninety percent of NAT2 maturation was attained by 4.4 post-natal months. WT, postmenstrual age, and NAT2 genotype significantly influenced INH exposure, with a 5-fold difference in AUC between slow and fast metabolizers for the same dose. INH appeared safe across the broad range of exposure for 61 infants included in the safety analysis. CONCLUSIONS In LBW/preterm infants, INH dosing needs frequent adjustment to account for growth and maturation. Pharmacogenetics-based dosing regimens is the most powerful approach to deliver safe and equalized exposures for all infants, because NAT2 genotype highly impacts INH pharmacokinetic variability.
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Affiliation(s)
- Agathe Béranger
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Adrie Bekker
- Family Center for Research with Ubuntu, Department of Paediatrics and Child Health, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Belén P Solans
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Mark F Cotton
- Family Center for Research with Ubuntu, Department of Paediatrics and Child Health, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Mark Mirochnick
- Division of Neonatology, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Avy Violari
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Jiajia Wang
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Heath, Boston, Massachusetts, USA
| | - Mae Cababasay
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Heath, Boston, Massachusetts, USA
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Renee Browning
- Division of AIDS, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland, USA
| | - Jack Moye
- Division of Extramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Edmund V Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
- Pediatrics Department, Rady Children’s Hospital San Diego, University of California San Diego, La Jolla, California, USA
| | - Radojka M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, California, USA
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12
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Brooks KM, Pinilla M, Stek AM, Shapiro DE, Barr E, Febo IL, Paul ME, Deville JG, George K, Knowles K, Rungruengthanakit K, Browning R, Chakhtoura N, Capparelli EV, Mirochnick M, Best BM. Pharmacokinetics of Tenofovir Alafenamide With Boosted Protease Inhibitors in Pregnant and Postpartum Women Living With HIV: Results From IMPAACT P1026s. J Acquir Immune Defic Syndr 2022; 90:343-350. [PMID: 35195573 PMCID: PMC9203910 DOI: 10.1097/qai.0000000000002944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tenofovir alafenamide (TAF) is a key component of HIV treatment, but pharmacokinetic data supporting the use of TAF during pregnancy are limited. In this study, we report pharmacokinetic, safety, and birth outcomes for TAF 25 mg with a boosted protease inhibitor in pregnant women living with HIV. METHODS IMPAACT P1026s was a multicenter, nonrandomized, open-label, phase IV prospective study. Pregnant women living with HIV receiving TAF 25 mg with a boosted protease inhibitor were eligible. Intensive pharmacokinetic assessments were performed during the second and third trimesters and 6-12 weeks postpartum. Maternal and cord blood samples were collected at delivery. Infant washout samples were collected through 5-9 days postbirth. Comparisons of paired pharmacokinetic data between pregnancy and postpartum were made using geometric mean ratios (GMR) [90% confidence intervals (CIs)] and Wilcoxon signed-rank tests with P < 0.10 considered significant. RESULTS Twenty-nine women were enrolled from the United States (median age 31 years and weight 84.5 kg during the third trimester; 48% Black, 45% Hispanic/Latina). TAF AUCtau did not significantly differ in the second [GMR 0.62 (90% CI: 0.29 to 1.34); P = 0.46] or third trimester [GMR 0.94 (90% CI: 0.63 to 1.39); P = 0.50] vs. postpartum and were comparable with historical data in nonpregnant adults. TAF was only quantifiable in 2/25 maternal delivery samples and below the limit of quantification in all cord blood and infant washout samples, likely because of the short half-life of TAF. CONCLUSION TAF AUCtau did not significantly differ between pregnancy and postpartum. These findings provide reassurance as TAF use during pregnancy continues to expand.
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Affiliation(s)
- Kristina M. Brooks
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Mauricio Pinilla
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alice M. Stek
- Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Los Angeles, CA, USA
| | - David E. Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Emily Barr
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Irma L. Febo
- Department of Pediatrics, School of Medicine, University of Puerto Rico, San Juan, PR, USA
| | - Mary E. Paul
- Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | - Jaime G. Deville
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | | | | | | | - Renee Browning
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Nahida Chakhtoura
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, MD, USA
| | - Edmund V. Capparelli
- Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, CA, USA
- Pediatrics Department, University of California San Diego – Rady Children’s Hospital San Diego, San Diego, CA, USA
| | | | - Brookie M. Best
- Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, CA, USA
- Pediatrics Department, University of California San Diego – Rady Children’s Hospital San Diego, San Diego, CA, USA
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13
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Momper JD, Wang J, Stek A, Shapiro DE, Powis KM, Paul ME, Badell ML, Browning R, Chakhtoura N, Denson K, Rungruengthanakit K, George K, Capparelli EV, Mirochnick M, Best BM. Pharmacokinetics of Atazanavir Boosted With Cobicistat in Pregnant and Postpartum Women With HIV. J Acquir Immune Defic Syndr 2022; 89:303-309. [PMID: 34732682 PMCID: PMC8837686 DOI: 10.1097/qai.0000000000002856] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/11/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study evaluated atazanavir and cobicistat pharmacokinetics during pregnancy compared with postpartum and in infant washout samples. SETTING A nonrandomized, open-label, parallel-group, multicenter prospective study of atazanavir and cobicistat pharmacokinetics in pregnant women with HIV and their children. METHODS Intensive steady-state 24-hour pharmacokinetic profiles were performed after administration of 300 mg of atazanavir and 150 mg of cobicistat orally in fixed-dose combination once daily during the second trimester, third trimester, and postpartum. Infant washout samples were collected after birth. Atazanavir and cobicistat were measured in plasma by validated high-performance liquid chromatography-ultraviolet and liquid chromatography-tandem mass spectrometry assays, respectively. A 2-tailed Wilcoxon signed-rank test (α = 0.10) was used for paired within-participant comparisons. RESULTS A total of 11 pregnant women enrolled in the study. Compared with paired postpartum data, atazanavir AUC0-24 was 26% lower in the second trimester [n = 5, P = 0.1875, geometric mean of ratio (GMR) = 0.739, 90% CI: 0.527 to 1.035] and 54% lower in the third trimester (n = 6, GMR = 0.459, P = 0.1563, 90% CI: 0.190 to 1.109), whereas cobicistat AUC0-24 was 35% lower in the second trimester (n = 5, P = 0.0625, GMR = 0.650, 90% CI: 0.493 to 0.858) and 52% lower in the third trimester (n = 7, P = 0.0156, GMR = 0.480, 90% CI: 0.299 to 0.772). The median (interquartile range) 24-hour atazanavir trough concentration was 0.21 μg/mL (0.16-0.28) in the second trimester, 0.21 μg/mL (0.11-0.56) in the third trimester, and 0.61 μg/mL (0.42-1.03) in postpartum. Placental transfer of atazanavir and cobicistat was limited. CONCLUSIONS Standard atazanavir/cobicistat dosing during pregnancy results in lower exposure which may increase the risk of virologic failure and perinatal transmission.
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Affiliation(s)
| | - Jiajia Wang
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alice Stek
- University of Southern California, Los Angeles, CA, USA
| | - David E. Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Kathleen M. Powis
- Departments of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Renee Browning
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Nahida Chakhtoura
- National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Kayla Denson
- Frontier Science & Technology Research Foundation, Inc, Amherst, NY, USA
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14
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Bekker A, Capparelli EV, Violari A, Cotton MF, Cababasay M, Wang J, Mathiba R, Wiesner L, Wiznia A, Samson P, Browning R, Moye J, Nakwa FL, Decloedt E, Rabie H, Mirochnick M, Cressey TR. Abacavir dosing in neonates from birth to 3 months of life: a population pharmacokinetic modelling and simulation study. Lancet HIV 2022; 9:e24-e31. [PMID: 34883066 PMCID: PMC8760861 DOI: 10.1016/s2352-3018(21)00266-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND No evidence-based optimal dosing guidance is available for abacavir liquid formulation use from birth. We used abacavir pharmacokinetic data from neonates and infants to determine an exact abacavir dosing strategy (mg/kg) for infants aged 0-3 months and to propose dosing by WHO weight band for neonates. METHODS Abacavir pharmacokinetic and safety data were pooled from three completed studies (1997-2020): PACTG 321 (USA), the Tygerberg Cohort (South Africa), and IMPAACT P1106 (South Africa). PACTG 321 and the Tygerberg Cohort were performed in neonates exposed to HIV receiving a single dose of abacavir. IMPAACT P1106 included predominantly low birthweight (<2500 g) infants on antiretroviral therapy enrolled when they were younger than 3 months. We developed a population pharmacokinetic model and performed simulations to achieve abacavir exposures (area under the curve for 0-12 h) within the target range of 3·2-25·2 μg·h/mL, previously reported in older children. FINDINGS 45 infants contributed 308 abacavir concentrations; 21 neonates were younger than 15 days. At first pharmacokinetic assessment, median postnatal age for PACTG 321 was 1 day and median bodyweight was 3·1 kg; for the Tygerberg Cohort it was 10 days and 3·3 kg; and for IMPAACT P1106 it was 73 days and 3·8 kg. Our model predicted a slow abacavir clearance of 2·51 mL/min per kg at birth, which doubled by 4 weeks of age. Therapeutic targets were achieved with exact abacavir doses of 2·0 mg/kg twice daily from 0 weeks to 4 weeks and 4·0 mg/kg twice daily from 4 weeks to 12 weeks. A fixed weight-band dosing strategy of 8 mg (for 2-3 kg), 10 mg (3-4 kg), and 12 mg (4-5 kg) abacavir twice daily achieved target exposures throughout the first 4 weeks of life without the need for dose adjustment due to age or bodyweight changes. No adverse events of grade 3 or higher were related to abacavir. INTERPRETATION Integration of these dosing strategies into national and international guidelines for the abacavir liquid formulation will expand antiretroviral options from birth and simplify the clinical management of neonates with HIV. FUNDING National Institute of Allergy and Infectious Diseases, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institute of Mental Health, and the Collaborative Initiative for Paediatric HIV Education and Research Programme.
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Affiliation(s)
- Adrie Bekker
- Family Centre for Research with Ubuntu, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa.
| | | | - Avy Violari
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark F Cotton
- Family Centre for Research with Ubuntu, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Mae Cababasay
- Center for Biostatistics in AIDS Research, Harvard T H Chan School of Public Heath, Boston, MA, USA
| | - Jiajia Wang
- Center for Biostatistics in AIDS Research, Harvard T H Chan School of Public Heath, Boston, MA, USA
| | - Ruth Mathiba
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | | | | | - Renee Browning
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jack Moye
- Division of Extramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Firdose L Nakwa
- Department of Paediatrics, University of the Witwatersrand, Johannesburg, South Africa
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - Helena Rabie
- Family Centre for Research with Ubuntu, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | | | - Tim R Cressey
- AMS/PHPT Research Collaboration, Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand; MIVEGEC, University of Montpellier, CNRS, IRD, Montpellier, France; Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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15
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Kreitchmann R, Stek A, Best BM, Capparelli E, Wang J, Shapiro D, Chakhtoura N, Mirochnick M, Eke AC. Interactions between etonogestrel-releasing contraceptive implant and 3 antiretroviral regimens. Contraception 2022; 105:67-74. [PMID: 34407424 PMCID: PMC8678338 DOI: 10.1016/j.contraception.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 08/05/2021] [Accepted: 08/09/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Long-acting reversible contraceptives are effective contraceptives for women with HIV, but there are limited data on etonogestrel implant and antiretroviral therapy pharmacokinetic drug-drug interactions. We evaluated etonogestrel/antiretroviral therapy drug-drug interactions, and the effects of etonogestrel on ritonavir-boosted-atazanavir, ritonavir-boosted-lopinavir, and efavirenz pharmacokinetics. STUDY DESIGN We enrolled postpartum women using etonogestrel implants and receiving ritonavir-boosted-atazanavir, ritonavir-boosted-lopinavir, or efavirenz-based regimens between 2012 and 2015. Etonogestrel implants were inserted 2 to 12 weeks postpartum. We performed pharmacokinetic sampling pre-etonogestrel insertion and 6 to 7 weeks postinsertion. We measured antiretroviral concentrations pre and postetonogestrel insertion, and compared etonogestrel concentrations between antiretroviral regimens. We considered a minimum serum etonogestrel concentration of 90 pg/mL adequate for ovulation suppression. RESULTS We collected pharmacokinetic data for 74 postpartum women, 22 on ritonavir-boosted-atazanavir, 26 on ritonavir-boosted-lopinavir, and 26 on efavirenz. The median serum concentrations of etonogestrel when co-administered were highest with etonogestrel/ritonavir-boosted-atazanavir (604 pg/mL) and etonogestrel/ritonavir-boosted-lopinavir (428 pg/mL), and lowest with etonogestrel/efavirenz (125 pg/mL); p < 0.001. Minimum concentration (Cmin) of ritonavir-boosted-atazanavir and ritonavir-boosted-lopinavir were lower after etonogestrel implant insertion, but overall exposure, predose concentrations, clearance, and half-lives were unchanged. We found no significant change in efavirenz exposure after etonogestrel insertion. CONCLUSIONS Unlike efavirenz, ritonavir-boosted-atazanavir and ritonavir-boosted-lopinavir were not associated with significant decreases in etonogestrel concentrations. Efavirenz was associated with a significant decrease in etonogestrel concentrations. IMPLICATIONS The findings demonstrate no interactions between etonogestrel and ritonavir-boosted-lopinavir or ritonavir-boosted-atazanavir, but confirm the decreased efficacy of etonogestrel with efavirenz-based antiretrovirals. This information should be used to counsel women with HIV who desire long-acting reversible contraceptives.
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Affiliation(s)
- Regis Kreitchmann
- Irmandade da Santa Casa de Misericordia de Porto Alegre, Porto Alegre, Brazil,Federal University of Health Sciences of Porto Alegre, Brazil
| | - Alice Stek
- University of Southern California School of Medicine, Los Angeles, CA, USA
| | | | | | - JiaJia Wang
- Harvard T.H Chan School of Public Health, Center for Biostatistics in AIDS Research, Boston, MA, USA
| | - David Shapiro
- Harvard T.H Chan School of Public Health, Center for Biostatistics in AIDS Research, Boston, MA, USA
| | - Nahida Chakhtoura
- Maternal and Pediatric Infectious Diseases Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, MD, USA
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16
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Piscitelli J, Nikanjam M, Best BM, Acosta E, Mirochnick M, Clarke DF, Capparelli EV, Momper JD. Optimizing Dolutegravir Initiation in Neonates Using Population Pharmacokinetic Modeling and Simulation. J Acquir Immune Defic Syndr 2022; 89:108-114. [PMID: 34629412 PMCID: PMC8665018 DOI: 10.1097/qai.0000000000002830] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 09/27/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND A knowledge gap exists for dolutegravir (DTG) pharmacokinetics and safety during the first 4 weeks of life, preventing safe and effective DTG use in neonates. SETTING Population pharmacokinetic modeling and simulation were used to assess newborn DTG dosing requirements during the first few days of life as a function of maternal DTG dosing history before delivery. METHODS DTG PK data were obtained from pregnant women and infants enrolled in the International Maternal Pediatric Adolescent AIDS Clinical Trials Network P1026S study. Maternal and neonate population pharmacokinetic models were separately developed. Monte Carlo simulations were performed to simulate neonatal concentrations after 2 doses of DTG after birth for infants born to mothers either receiving or not receiving DTG before delivery. RESULTS In DTG-naïve infants, a 5-mg DTG dose at birth with a second dose after 48 hours maintained median concentrations above the lower bound of the target range (0.77 μg/mL) and below the upper bound of the target range (7.34 μg/mL representing 2-fold above the adult Cmax value). In DTG-exposed infants, a 5-mg DTG dose at 24 hours after birth with a second dose after 48 hours maintained median concentrations within or nearly within the target range, even if the last maternal DTG dose was taken as soon as 6 hours or as long as 24 hours before delivery. CONCLUSIONS Newborn DTG dosing requirements during the first few days of life depend on maternal DTG dosing history before delivery. These results may help the design of future clinical studies of DTG in the neonatal population.
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Affiliation(s)
- Joseph Piscitelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Mina Nikanjam
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Brookie M. Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Edward Acosta
- Department of Pharmacology, University of Alabama Birmingham, Birmingham, AL
| | - Mark Mirochnick
- Department of Pediatrics, Boston University School of Medicine, Boston, MA
| | - Diana F. Clarke
- Section of Pediatrics Infectious Diseases, Boston Medical Center, Boston, MA
| | - Edmund V. Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Jeremiah D. Momper
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
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17
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Frenkel LM, Morrison RL, Fuller TL, Gouvêa MI, Benamor Teixeira MDL, Coombs RW, Shapiro DE, Mirochnick M, Hennessey R, Whitson K, Chakhtoura N, João EC. Brief Report: Vaginal Viral Shedding With Undetectable Plasma HIV Viral Load in Pregnant Women Receiving 2 Different Antiretroviral Regimens: A Randomized Clinical Trial. J Acquir Immune Defic Syndr 2021; 88:361-365. [PMID: 34369908 PMCID: PMC8547747 DOI: 10.1097/qai.0000000000002771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/13/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pregnant women using antiretrovirals (ARVs) may have persistent vaginal viral shedding, which could be associated with sexual and perinatal HIV transmission. However, there are scant data on vaginal viral load (VVL) in pregnant women with undetectable plasma viral load (PVL). METHODS This study was a post hoc analysis of an open-label randomized trial to evaluate the virologic response of 2 ART regimens. The participants were ART-naive women living with HIV initiating ART regimens between 20 and 36 weeks of pregnancy recruited at 19 clinical sites in 6 countries. Participants were randomized to receive 400 mg of raltegravir 2 times a day or 600 mg of efavirenz 4 times a day in addition to 150 mg of lamivudine and 300 mg of zidovudine 2 times a day. VVL and PVL tests were performed at every study visit. The primary outcome measures were HIV-1 PVL and VVL at maternal study week 4 and rates of perinatal HIV transmission. RESULTS A total of 408 were enrolled, of whom 323 had VVL samples 4 weeks after enrollment and were included in this analysis. Among women with undetectable/nonquantifiable PVL during ART, the overall rate of quantifiable VVL at week 4 was 2.54% (7/275). Of the 275 with nonquantifiable PVL, 99.1% (115/116) and 96.2% (153/159) had nonquantifiable VVL in the efavirenz and raltegravir arms, respectively. None of the 7 women with quantifiable VVL at the week 4 study visit transmitted HIV to their infants. CONCLUSIONS Detectable VVL in pregnant women with undetectable/nonquantifiable PVL while receiving ART was rare and not associated with perinatal HIV transmission.
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Affiliation(s)
- Lisa M. Frenkel
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA
- Department of Pediatrics
- Laboratory Medicine and Pathology; and
- Global Health and Medicine, University of Washington, Seattle, WA
| | - R. Leavitt Morrison
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Trevon L. Fuller
- Infectious Diseases Department, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
| | - Maria Isabel Gouvêa
- Infectious Diseases Department, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
- Evandro Chagas National Institute of Infectious Diseases, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Maria de Lourdes Benamor Teixeira
- Infectious Diseases Department, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
- Evandro Chagas National Institute of Infectious Diseases, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | - David E. Shapiro
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Mark Mirochnick
- Department of Pediatrics, Boston University School of Medicine, Boston, MA
| | | | | | - Nahida Chakhtoura
- Maternal and Pediatric Infectious Diseases Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Esaú C. João
- Infectious Diseases Department, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
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18
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Denti P, Wasmann RE, Francis J, McIlleron H, Sugandhi N, Cressey TR, Mirochnick M, Capparelli EV, Penazzato M. One dose does not fit all: revising the WHO paediatric dosing tool to include the non-linear effect of body size and maturation. Lancet Child Adolesc Health 2021; 6:9-10. [PMID: 34678142 DOI: 10.1016/s2352-4642(21)00302-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/08/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa.
| | - Roeland E Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa
| | - Jose Francis
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Tim R Cressey
- PHPT/Institut de recherche pour le développement (IRD), MIVEGEC (Maladies Infectieuses et Vecteurs: Ecologie, Génétique, Evolution et Contrôle) Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand; Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | | | - Edmund V Capparelli
- University of California, San Diego Schools of Medicine and Skaggs School of Pharmacy, La Jolla, CA, USA
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19
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Mulligan N, Salama E, Momper JD, Capparelli EV, Stek A, Chakhtoura N, Mirochnick M, Best BM. Lopinavir and tenofovir interaction observed in non-pregnant adults altered during pregnancy. J Clin Pharm Ther 2021; 46:1459-1464. [PMID: 34254323 DOI: 10.1111/jcpt.13477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 06/10/2021] [Accepted: 06/22/2021] [Indexed: 11/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Tenofovir exposure is increased in non-pregnant adults when tenofovir disoproxil fumarate is coadministered with lopinavir/ritonavir. In pregnant women, tenofovir exposure is decreased. Our objective is to describe the effect of lopinavir/ritonavir on tenofovir pharmacokinetics during pregnancy. METHODS Data were collected through the International Maternal Pediatric and Adolescent AIDS Clinical Trials (IMPAACT) Network P1026s protocol. This was a nonrandomized, open-label, parallel-group and multicentre phase-IV prospective study in pregnant women with HIV. Intensive steady-state 24-h pharmacokinetic profiles were collected during the third trimester of pregnancy and postpartum. Tenofovir was measured in plasma using validated liquid chromatography-mass spectrometry method (quantification limit: 10 ng/ml). Statistical tests compared paired and between group pharmacokinetic data. RESULTS AND DISCUSSION In women not receiving lopinavir/ritonavir (n = 28), tenofovir AUC0-24 was 27% lower (2.2 mcg·h/ml vs 2.8 mcg·h/ml, p = 0.002) and oral clearance was 27% higher (61 L/h vs 48 L/h, p = 0.001) during the third trimester compared to paired postpartum data. In women receiving lopinavir/ritonavir (n = 10), tenofovir AUC0-24 and oral clearance were not different antepartum compared to postpartum. Women with and women without concomitant lopinavir/ritonavir displayed no significant differences in postpartum tenofovir pharmacokinetics. WHAT IS NEW AND CONCLUSION Tenofovir exposure during the third trimester was reduced compared to postpartum in pregnant women not receiving lopinavir/ritonavir, but not in pregnant women also receiving lopinavir/ritonavir. Our findings suggest that pregnancy confounds the expected decrease in tenofovir exposure with concomitant lopinavir/ritonavir in non-pregnant adults. These findings illustrate the need for drug-drug interaction studies in pregnant women as drug disposition differs significantly in pregnant women compared to non-pregnant adults.
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Affiliation(s)
- Nikki Mulligan
- Riverside University Health System, Moreno Valley, CA, USA
| | - Engie Salama
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, CA, USA
| | - Jeremiah D Momper
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, CA, USA
| | - Edmund V Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, CA, USA.,Pediatrics Department, School of Medicine, University of California San Diego-Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Alice Stek
- University of Southern California School of Medicine, Los Angeles, CA, USA
| | - Nahida Chakhtoura
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, MD, USA
| | | | - Brookie M Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, CA, USA.,Pediatrics Department, School of Medicine, University of California San Diego-Rady Children's Hospital San Diego, San Diego, CA, USA
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20
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Eke AC, Olagunju A, Momper J, Penazzato M, Abrams EJ, Best BM, Capparelli EV, Bekker A, Belew Y, Kiser JJ, Struble K, Taylor G, Waitt C, Mirochnick M, Cressey TR, Colbers A. Optimizing Pharmacology Studies in Pregnant and Lactating Women Using Lessons From HIV: A Consensus Statement. Clin Pharmacol Ther 2021; 110:36-48. [PMID: 32930408 PMCID: PMC8167886 DOI: 10.1002/cpt.2048] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/16/2020] [Indexed: 12/02/2022]
Abstract
Information on the extent of drug exposure to mothers and infants during pregnancy and lactation normally becomes available years after regulatory approval of a drug. Clinicians face knowledge gaps on drug selection and dosing in pregnancy and infant exposure during breastfeeding. Physiological changes during pregnancy often result in lower drug exposures of antiretrovirals, and in some cases a risk of reduced virologic efficacy. The International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) network and the World Health Organization (WHO)-convened Pediatric Antiretrovirals Working Group collaboratively organized a workshop of key stakeholders in June 2019 to define key standards to generate pharmacology data for antiretrovirals to be used among pregnant and lactating women; review the antiretroviral product pipeline; describe key gaps for use in low-income and middle-income countries; and identify opportunities to undertake optimal studies allowing for rapid implementation in the clinical field. We discussed ethical and regulatory principles, systemic approaches to obtaining data for pregnancy pharmacokinetic/pharmacodynamic (PK/PD) studies, control groups, optimal sampling times during pregnancy, and pharmacokinetic parameters to be considered as primary end points in pregnancy PK/PD studies. For lactation studies, the type of milk to collect, ascertainment of maternal adherence, and optimal PK methods to estimate exposure were discussed. Participants strongly recommended completion of preclinical reproductive toxicology studies prior to phase III, to allow study protocols to include pregnant women or to allow women who become pregnant after enrolment to continue in the trial. The meeting concluded by developing an algorithm for design and interpretation of results and noted that recruitment of pregnant and lactating women into clinical trials is critical.
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Affiliation(s)
- Ahizechukwu C. Eke
- Division of Maternal Fetal MedicineDepartment of Gynecology & ObstetricsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Adeniyi Olagunju
- Faculty of PharmacyObafemi Awolowo UniversityIle‐IfeNigeria
- Department of Molecular & Clinical PharmacologyUniversity of LiverpoolLiverpoolUK
| | - Jeremiah Momper
- Skaggs School of Pharmacy and Pharmaceutical SciencesUniversity of California San DiegoLa JollaCaliforniaUSA
| | - Martina Penazzato
- HIV, Hepatitis and STI DepartmentWorld Health OrganizationGenevaSwitzerland
| | - Elaine J. Abrams
- Mailman School of Public HealthICAP at Columbia UniversityNew YorkNew YorkUSA
- Department of PediatricsVagelos College of Physicians & SurgeonsColumbia UniversityNew YorkNew YorkUSA
| | - Brookie M. Best
- Skaggs School of Pharmacy and Pharmaceutical SciencesUniversity of California San DiegoLa JollaCaliforniaUSA
- Pediatrics DepartmentUniversity of California San Diego School of Medicine‐Rady Children’s Hospital San DiegoSan DiegoCaliforniaUSA
- University of LiverpoolLiverpoolUK
| | - Edmund V. Capparelli
- Skaggs School of Pharmacy and Pharmaceutical SciencesUniversity of California San DiegoLa JollaCaliforniaUSA
- Pediatrics DepartmentUniversity of California San Diego School of Medicine‐Rady Children’s Hospital San DiegoSan DiegoCaliforniaUSA
- University of LiverpoolLiverpoolUK
| | - Adrie Bekker
- Department of Paediatrics and Child HealthStellenbosch UniversityCape TownSouth Africa
| | - Yodit Belew
- Division of Antiviral Products, US Food and Drug Administration (FDA)Silver SpringMarylandUSA
| | - Jennifer J. Kiser
- Department of Pharmaceutical SciencesUniversity of Colorado Skaggs School of Pharmacy and Pharmaceutical SciencesAuroraColoradoUSA
| | - Kimberly Struble
- Division of Antiviral Products, US Food and Drug Administration (FDA)Silver SpringMarylandUSA
| | - Graham Taylor
- Department of Infectious DiseaseFaculty of MedicineImperial CollegeLondonUK
| | - Catriona Waitt
- Department of HIV PharmacologyUniversity of LiverpoolLiverpoolUK
| | | | - Tim R. Cressey
- Department of Molecular & Clinical PharmacologyUniversity of LiverpoolLiverpoolUK
- PHPT/IRD UMI 174Faculty of Associated Medical SciencesChiang Mai UniversityChiang MaiThailand
- Department of Immunology & Infectious DiseasesHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Angela Colbers
- Department of PharmacyRadboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
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21
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Momper JD, Wang J, Stek A, Shapiro DE, Scott GB, Paul ME, Febo IL, Burchett S, Smith E, Chakhtoura N, Denson K, Rungruengthanakit K, George K, Yang DZ, Capparelli EV, Mirochnick M, Best BM. Pharmacokinetics of darunavir and cobicistat in pregnant and postpartum women with HIV. AIDS 2021; 35:1191-1199. [PMID: 34076612 PMCID: PMC8173003 DOI: 10.1097/qad.0000000000002857] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate darunavir and cobicistat pharmacokinetics during pregnancy compared with postpartum and in infant washout samples after delivery. DESIGN Nonrandomized, open-label, parallel-group, multicenter phase-IV prospective study of darunavir and cobicistat pharmacokinetics in pregnant women with HIV and their children in the United States. METHODS Intensive steady-state 24-h pharmacokinetic profiles were performed after administration of 800 mg of darunavir and 150 mg of cobicistat orally in fixed dose combination once-daily during the second trimester, third trimester, and postpartum. Infant washout samples were collected after birth. Darunavir and cobicistat were measured in plasma by validated HPLC-UV and liquid chromatography with tandem mass spectrometry detection (LC-MS)/MS assays, respectively. A two-tailed Wilcoxon signed-rank test (α = 0.10) was employed for paired within-participant comparisons. RESULTS A total of 29 pregnant women receiving darunavir and cobicistat once-daily enrolled in the study. Compared with paired postpartum data, darunavir AUC0--24 was 53% lower in the second trimester [n = 12, P = 0.0024, geometric mean of ratio (GMR)=0.47, 90% confidence interval (CI) 0.33 - 0.68] and 56% lower in the third trimester (n = 18, P < 0.0001, GMR = 0.44, 90% CI 0.36 - 0.54), whereas cobicistat AUC0--24 was 50% lower in the second trimester (n = 12, P = 0.0024, GMR = 0.50, 90% CI 0.36-0.69) and 56% lower in the third trimester (n = 18, P < 0.0001, GMR = 0.44, 90% CI 0.35-0.55). Placental transfer of darunavir and cobicistat was limited. CONCLUSION Standard darunavir/cobicistat dosing during pregnancy results in significantly lower exposure during pregnancy, which may increase the risk of virologic failure and perinatal transmission.
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Affiliation(s)
| | - Jiajia Wang
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Alice Stek
- University of Southern California, Los Angeles, CA
| | - David E Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | | | | | - Irma L Febo
- University of Puerto Rico, School of Medicine, San Juan, PR
| | - Sandra Burchett
- Harvard Medical School and Boston Children's Hospital, Boston, MA
| | | | - Nahida Chakhtoura
- National Institute of Child Health and Human Development, Bethesda, MD
| | - Kayla Denson
- Frontier Science & Technology Research Foundation, Inc, Amherst, NY, USA
| | | | | | - Derek Z Yang
- University of California, San Diego, La Jolla, CA
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22
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Bunglawala F, Rajoli RKR, Mirochnick M, Owen A, Siccardi M. Prediction of dolutegravir pharmacokinetics and dose optimization in neonates via physiologically based pharmacokinetic (PBPK) modelling. J Antimicrob Chemother 2021; 75:640-647. [PMID: 31860112 DOI: 10.1093/jac/dkz506] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/23/2019] [Accepted: 11/05/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Only a few antiretroviral drugs (ARVs) are recommended for use during the neonatal period and there is a need for more to be approved to increase treatment and prophylaxis strategies. Dolutegravir, a selective integrase inhibitor, has potential for treatment of HIV infection and prophylaxis of transmission in neonates. OBJECTIVES To model the pharmacokinetics of dolutegravir in neonates and to simulate a theoretical optimal dosing regimen. METHODS The physiologically based pharmacokinetic (PBPK) model was built incorporating the age-related changes observed in neonates. Virtual neonates between 0 and 28 days were simulated. The model was validated against observed clinical data for raltegravir and midazolam in neonates, prior to the prediction of dolutegravir pharmacokinetics. RESULTS Both raltegravir and midazolam passed the criteria for model qualification, with simulated data within 1.8-fold of clinical data. The qualified model predicted the pharmacokinetics for several multidose regimens of dolutegravir. Regimen 6 involved 5 mg doses with a 48 h interval from Day 1-20, increasing to 5 mg once daily on Week 3, yielding AUC and Ctrough values of 37.2 mg·h/L and 1.3 mg/L, respectively. These exposures are consistent with those observed in paediatric patients receiving dolutegravir. CONCLUSIONS Dolutegravir pharmacokinetics were successfully simulated in the neonatal PBPK model. The predictions suggest that during the first 3 weeks of life a 5 mg dose administered every 48 h may achieve plasma exposures needed for therapy and prophylaxis.
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Affiliation(s)
- Fazila Bunglawala
- Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool L69 3GF, UK
| | - Rajith K R Rajoli
- Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool L69 3GF, UK
| | | | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool L69 3GF, UK
| | - Marco Siccardi
- Department of Molecular and Clinical Pharmacology, University of Liverpool, 70 Pembroke Place, Liverpool L69 3GF, UK
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23
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Abrams EJ, Mofenson LM, Pozniak A, Lockman S, Colbers A, Belew Y, Clayden P, Mirochnick M, Siberry GK, Ford N, Khoo S, Renaud F, Vitoria M, Venter WDF, Doherty M, Penazzato M. Enhanced and Timely Investigation of ARVs for Use in Pregnant Women. J Acquir Immune Defic Syndr 2021; 86:607-615. [PMID: 33298793 DOI: 10.1097/qai.0000000000002597] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/23/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Concerns have been voiced that the exclusion of pregnant women from clinical trials results in a lack of safety and pharmacokinetic data for antiretroviral drugs (ARVs) in pregnancy, creating clear risks to pregnant women living with HIV (PWLHIV), and their infants. SETTING The World Health Organization convened a Paediatric Antiretroviral Drug Optimization group meeting, December 10-12, 2018, in Geneva, Switzerland. METHODS The group, comprised of clinicians, scientists, HIV program managers, regulators, and community representatives, were tasked to consider how ARVs are studied in PWLHIV, define alternative approaches to studying ARVs in PWLHIV, identify ways to shorten the timeline to determine safe use of new agents during pregnancy, and define strategies to collaborate with regulators and industry to change longstanding practices. RESULTS Most new ARVs are not studied in pregnant populations until after drug licensure, primarily opportunistically among women who become pregnant while taking the ARV of interest. Acceleration of the timeline will require earlier completion of preclinical studies and a new paradigm, namely-under certain conditions-allow women who become pregnant while participating in phase III ARV studies the option of remaining on study and enroll pregnant women into phase III trials of new agents to obtain preliminary safety and dosing and efficacy data. CONCLUSION A revision of the current approach to the study of antiretrovirals in pregnant women is urgently needed to improve timely access and safe use of new agents during pregnancy.
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Affiliation(s)
- Elaine J Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Lynne M Mofenson
- Research Program, Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC
| | - Anton Pozniak
- HIV and Sexual Health Clinic, Chelsea and Westminster Hospital NHS Foundation Trust and LSHTM London, London, United Kingdom
| | - Shahin Lockman
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Angela Colbers
- Radboud University Medical Center, and HIV Institute, Nijmegen, the Netherlands
| | - Yodit Belew
- Division of Antiviral Products, US Food and Drug Administration (FDA), Silver Spring, MD
| | | | - Mark Mirochnick
- Department of Pediatrics, Boston University School of Medicine, Boston, MA
| | - George K Siberry
- Division of Prevention Care and Treatment, Office of HIV/AIDS, United States Agency for International Development (USAID), Washington, DC
| | - Nathan Ford
- Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Saye Khoo
- Department of Pharmacy, Research Institute, University of Liverpool, United Kingdom; and
| | - Francoise Renaud
- Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Marco Vitoria
- Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Willem D F Venter
- Ezintsha, Wits Reproductive Health Sciences, University of Witwatersrand, South Africa
| | - Meg Doherty
- Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Martina Penazzato
- Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
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24
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Brooks KM, Momper JD, Pinilla M, Stek AM, Barr E, Weinberg A, Deville JG, Febo IL, Cielo M, George K, Denson K, Rungruengthanakit K, Shapiro DE, Smith E, Chakhtoura N, Rooney JF, Haubrich R, Espina R, Capparelli EV, Mirochnick M, Best BM. Pharmacokinetics of tenofovir alafenamide with and without cobicistat in pregnant and postpartum women living with HIV. AIDS 2021; 35:407-417. [PMID: 33252495 PMCID: PMC8238253 DOI: 10.1097/qad.0000000000002767] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To evaluate the pharmacokinetics of tenofovir alafenamide (TAF) 10 mg with cobicistat and 25 mg without boosting in pregnant and postpartum women with HIV and to characterize TAF placental transfer and infant washout pharmacokinetics. DESIGN Open-label, multicenter phase IV prospective study of TAF pharmacokinetics during pregnancy, postpartum, delivery, and infant washout. METHODS Pregnant women receiving TAF 10 mg with cobicistat or TAF 25 mg without boosting as part of clinical care had intensive pharmacokinetic assessments performed during the second and third trimesters, and 6-12 weeks postpartum. Maternal and cord blood samples were collected at delivery, and washout pharmacokinetic samples were collected in infants. TAF concentrations were quantified using liquid chromatography/mass spectrometry. Comparisons between pregnancy and postpartum were made using geometric mean ratios (90% confidence intervals) and Wilcoxon signed-rank tests. RESULTS Thirty-one pregnant women receiving TAF 10 mg with cobicistat-boosting and 27 women receiving TAF 25 mg without boosting were enrolled. TAF exposures did not significantly differ between pregnancy and postpartum when administered as 10 mg with cobicistat. Antepartum TAF exposures with the 25 mg dose were 33-43% lower in comparison with postpartum, but comparable with those measured in nonpregnant adults. TAF was below the lower limit of quantitation in 43 of 44 cord blood, 41 of 45 maternal blood at delivery, and all infant washout samples. CONCLUSION TAF exposures were comparable or higher than those measured in nonpregnant adults during pregnancy and postpartum. These findings provide reassurance on adequate TAF exposures during pregnancy, and support efforts to expand the use of TAF in pregnant women with HIV.
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Affiliation(s)
- Kristina M Brooks
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jeremiah D Momper
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, California
| | - Mauricio Pinilla
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Alice M Stek
- Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Los Angeles, California
| | | | - Adriana Weinberg
- Departments of Pediatrics, Medicine and Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jaime G Deville
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Irma L Febo
- Department of Pediatrics, School of Medicine, University of Puerto Rico, San Juan, Puerto Rico
| | - Mikhaela Cielo
- Department of Pediatrics, University of Southern California School of Medicine, Los Angeles, California
| | | | - Kayla Denson
- Frontier Science & Technology Research Foundation, Inc., Amherst, New York, USA
| | | | - David E Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Nahida Chakhtoura
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, Maryland
| | | | | | - Rowena Espina
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, California
| | - Edmund V Capparelli
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, California
- Pediatrics Department, University of California San Diego - Rady Children's Hospital San Diego, San Diego, California
| | - Mark Mirochnick
- Division of Neonatology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Brookie M Best
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, California
- Pediatrics Department, University of California San Diego - Rady Children's Hospital San Diego, San Diego, California
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25
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Ruel TD, Capparelli EV, Tierney C, Nelson BS, Coletti A, Bryson Y, Cotton MF, Spector SA, Mirochnick M, LeBlanc R, Reding C, Zimmer B, Persaud D, Bwakura-Dangarembizi M, Naidoo KL, Hazra R, Jean-Philippe P, Chadwick EG. Pharmacokinetics and safety of early nevirapine-based antiretroviral therapy for neonates at high risk for perinatal HIV infection: a phase 1/2 proof of concept study. Lancet HIV 2021; 8:e149-e157. [PMID: 33242457 PMCID: PMC7933083 DOI: 10.1016/s2352-3018(20)30274-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 09/11/2020] [Accepted: 10/02/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND With increasing intention to treat HIV as early as possible, evidence to confirm the safety and therapeutic drug concentrations of a nevirapine-based antiretroviral regimen in the early neonatal period is needed. This study aims to establish dosing of nevirapine for very early treatment of HIV-exposed neonates at high risk of HIV acquisition. METHODS IMPAACT P1115 is a multinational phase 1/2 proof-of-concept study in which presumptive treatment for in-utero HIV infection is initiated within 48 h of birth in HIV-exposed neonates at high risk of HIV acquisition. Participants were neonates who were at least 34 weeks gestational age at birth and enrolled within 48 h of birth, born to women with presumed or confirmed HIV infection who had not received antiretrovirals during this pregnancy. The regimen consisted of two nucleoside reverse transcriptase inhibitors plus nevirapine dosed at 6 mg/kg twice daily for term neonates (≥37 weeks gestational age) or 4 mg/kg twice daily for 1 week and 6 mg/kg twice daily thereafter for preterm neonates (34 to <37 weeks gestational age). Here, we report the secondary outcomes of the study: nevirapine exposures in study weeks 1 and 2 and treatment-associated grade 3 or 4 adverse events at least possibly related to study treatment up to study week 4. A population pharmacokinetic model to assess nevirapine exposure was developed from dried blood spot and plasma nevirapine concentrations at study weeks 1 and 2. Nevirapine exposure was assessed in all patients with available blood samples and safety was assessed in all participants. This trial is registered at ClinicalTrials.gov (NCT02140255). FINDINGS Between Jan 23, 2015, and Sept 4, 2017, 438 neonates were enrolled and included in analyses; 36 had in-utero HIV infection and 389 (89%) were born at term. Neonates without confirmed in-utero HIV infection received nevirapine for a median of 13 days (IQR 7-14). Measured dried blood spot nevirapine concentrations were higher than the minimum HIV treatment target (3 μg/mL) in 314 (90%, 95% CI 86-93) of 349 neonates at week 1 and 174 (87%, 81-91) of 201 at week 2. In Monte-Carlo simulations, week 1 nevirapine concentrations exceeded 3 μg/mL in 80% of term neonates and 82% of preterm neonates. DAIDS grade 3 or 4 adverse events at least possibly related to antiretrovirals occurred in 30 (7%, 95% CI 5-10) of 438 infants but did not lead to nevirapine cessation in any neonates; neutropenia (25 [6%] neonates) and anaemia (six [1%]) were most common. INTERPRETATION Nevirapine at the dose studied was confirmed to be safe and provides therapeutic exposure concentrations. These data support nevirapine as a component of presumptive HIV treatment in high-risk neonates. FUNDING National Institute of Allergy and Infectious Diseases, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Institute of Mental Health.
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Affiliation(s)
- Theodore D Ruel
- University of California San Francisco, San Francisco, CA, USA.
| | | | - Camlin Tierney
- Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Bryan S Nelson
- Harvard TH Chan School of Public Health, Boston, MA, USA
| | | | | | | | | | | | - Rebecca LeBlanc
- Frontier Science and Technology Research Foundation, Amherst, NY, USA
| | - Christina Reding
- Frontier Science and Technology Research Foundation, Amherst, NY, USA
| | - Bonnie Zimmer
- Frontier Science and Technology Research Foundation, Amherst, NY, USA
| | - Deborah Persaud
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Rohan Hazra
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Patrick Jean-Philippe
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Ellen G Chadwick
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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26
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Rosebush JC, Best BM, Chadwick EG, Butler K, Moye J, Smith E, Bradford S, Reding CA, Mathiba SR, Hanley S, Aziz M, Homans J, Acosta EP, Murtaugh W, Vourvahis M, Mcfadyen L, Hayward K, Mirochnick M, Samson P. Pharmacokinetics and safety of maraviroc in neonates. AIDS 2021; 35:419-427. [PMID: 33252481 PMCID: PMC7856036 DOI: 10.1097/qad.0000000000002762] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate safety and pharmacokinetics of maraviroc administered with standard antiretroviral prophylaxis to HIV-1 exposed infants and to determine the appropriate dose of maraviroc during the first 6 weeks of life. DESIGN A phase I, multicentre, open-label study enrolling two sequential cohorts. METHODS IMPAACT 2007 participants enrolled by day 3 of life and were stratified by exposure to maternal efavirenz. Cohort 1 participants received two single 8 mg/kg maraviroc doses 1 week apart with pharmacokinetic sampling after each dose. Cohort 2 participants received 8 mg/kg maraviroc twice daily through 6 weeks of life with pharmacokinetic sampling at weeks 1 and 4. Maraviroc exposure target was Cavg at least 75 ng/ml. Laboratory and clinical evaluations assessed safety. RESULTS Fifteen Cohort 1 and 32 Cohort 2 HIV-exposed neonates were enrolled (median gestational age 39 weeks, 51% male). All 13 evaluable Cohort 1 infants met the pharmacokinetic target. Median exposure for the 25 evaluable Cohort 2 infants met the pharmacokinetic target but variability was high, with 17-33% of infants below target at Weeks 1 and 4. Pharmacokinetic target achievement was similar between efavirenz exposure strata. No Grade 3+ toxicities, early study or treatment discontinuations due to maraviroc occurred. CONCLUSION Median maraviroc exposure met the Cavg target in neonates receiving 8 mg/kg twice daily, although exposures were variable. Maternal efavirenz use did not impact maraviroc exposure and no discontinuations were due to maraviroc toxicity/intolerance. No infants acquired HIV-1 infection during follow-up. Maraviroc 8 mg/kg twice daily appears well tolerated during the first 6 weeks of life.
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Affiliation(s)
| | - Brookie M Best
- University of California San Diego, La Jolla, California
| | - Ellen G Chadwick
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Kevin Butler
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - John Moye
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda
| | - Elizabeth Smith
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Rockville, Maryland
| | | | - Christina A Reding
- Frontier Science & Technology Research Foundation, Inc., Amherst, New York, USA
| | | | - Sherika Hanley
- Centre for the AIDS Programme in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Mariam Aziz
- Rush University Medical Center, Chicago, Illinois
| | - James Homans
- University of Southern California, Los Angeles, California
| | - Edward P Acosta
- Deparment of Pharmacology and Toxicology, University of Alabama at Birmingham, Birmingham, Alabama
| | - William Murtaugh
- IMPAACT Laboratory Center, Children's Hospital of Los Angeles, Los Angeles, California
| | - Manoli Vourvahis
- Clinical Pharmacology, Pfizer Global Research and Development, New York, New York, USA
| | - Lynn Mcfadyen
- Pharmacometrics, Pfizer Global Research and Development, Sandwich, UK
| | - Katy Hayward
- ViiV HealthCare, Research Triangle Park, North Carolina
| | | | - Pearl Samson
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Frontier Science & Technology Research Foundation, Inc., Amherst, New York, USA
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27
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Liu XI, Momper JD, Rakhmanina NY, Green DJ, Burckart GJ, Cressey TR, Mirochnick M, Best BM, van den Anker JN, Dallmann A. Physiologically Based Pharmacokinetic Modeling Framework to Predict Neonatal Pharmacokinetics of Transplacentally Acquired Emtricitabine, Dolutegravir, and Raltegravir. Clin Pharmacokinet 2021; 60:795-809. [PMID: 33527213 DOI: 10.1007/s40262-020-00977-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Little is understood about neonatal pharmacokinetics immediately after delivery and during the first days of life following intrauterine exposure to maternal medications. Our objective was to develop and evaluate a novel, physiologically based pharmacokinetic modeling workflow for predicting perinatal and postnatal disposition of commonly used antiretroviral drugs administered prenatally to pregnant women living with human immunodeficiency virus. METHODS Using previously published, maternal-fetal, physiologically based pharmacokinetic models for emtricitabine, dolutegravir, and raltegravir built with PK-Sim/MoBi®, placental drug transfer was predicted in late pregnancy. The total drug amount in fetal compartments at term delivery was estimated and subsequently integrated as initial conditions in different tissues of a whole-body, neonatal, physiologically based pharmacokinetic model to predict drug concentrations in the neonatal elimination phase after birth. Neonatal elimination processes were parameterized according to published data. Model performance was assessed by clinical data. RESULTS Neonatal physiologically based pharmacokinetic models generally captured the initial plasma concentrations after delivery but underestimated concentrations in the terminal phase. The mean percentage error for predicted plasma concentrations was - 71.5%, - 33.8%, and 76.7% for emtricitabine, dolutegravir, and raltegravir, respectively. A sensitivity analysis suggested that the activity of organic cation transporter 2 and uridine diphosphate glucuronosyltransferase 1A1 during the first postnatal days in term newborns is ~11% and ~30% of that in adults, respectively. CONCLUSIONS These findings demonstrate the general feasibility of applying physiologically based pharmacokinetic models to predict washout concentrations of transplacentally acquired drugs in newborns. These models can increase the understanding of pharmacokinetics during the first postnatal days and allow the prediction of drug exposure in this vulnerable population.
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Affiliation(s)
- Xiaomei I Liu
- Division of Clinical Pharmacology, Children's National Hospital, 10430 Owen Brown Road, Columbia, Maryland, 21044, USA. .,Division of Infectious Diseases, Children's National Hospital, Washington, DC, USA.
| | - Jeremiah D Momper
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, USA.,Pediatric Department, School of Medicine, Rady Children's Hospital San Diego, La Jolla, CA, USA
| | - Natella Y Rakhmanina
- Division of Infectious Diseases, Children's National Hospital, Washington, DC, USA.,Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | - Dionna J Green
- Office of Pediatric Therapeutics, US Food and Drug Administration, Silver Spring, MD, USA
| | - Gilbert J Burckart
- Office of Clinical Pharmacology, US Food and Drug Administration, Silver Spring, MD, USA
| | - Tim R Cressey
- PHPT/IRD 174, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand.,Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | | | - Brookie M Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, USA.,Pediatric Department, School of Medicine, Rady Children's Hospital San Diego, La Jolla, CA, USA
| | - John N van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, 10430 Owen Brown Road, Columbia, Maryland, 21044, USA.,Division of Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
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28
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Zhao S, Gockenbach M, Grimstein M, Sachs HC, Mirochnick M, Struble K, Belew Y, Wang J, Capparelli EV, Best BM, Johnson T, Momper JD, Maharaj AR. Characterization of Plasma Protein Alterations in Pregnant and Postpartum Individuals Living With HIV to Support Physiologically-Based Pharmacokinetic Model Development. Front Pediatr 2021; 9:721059. [PMID: 34722417 PMCID: PMC8550258 DOI: 10.3389/fped.2021.721059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 09/09/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Alterations in plasma protein concentrations in pregnant and postpartum individuals can influence antiretroviral (ARV) pharmacokinetics. Physiologically-based pharmacokinetic (PBPK) models can serve to inform drug dosing decisions in understudied populations. However, development of such models requires quantitative physiological information (e.g., changes in plasma protein concentration) from the population of interest. Objective: To quantitatively describe the time-course of albumin and α1-acid glycoprotein (AAG) concentrations in pregnant and postpartum women living with HIV. Methods: Serum and plasma protein concentrations procured from the International Maternal Pediatric Adolescent AIDS Clinical Trial Protocol 1026s (P1026s) were analyzed using a generalized additive modeling approach. Separate non-parametric smoothing splines were fit to albumin and AAG concentrations as functions of gestational age or postpartum duration. Results: The analysis included 871 and 757 serum albumin concentrations collected from 380 pregnant (~20 to 42 wks gestation) and 354 postpartum (0 to 46 wks postpartum) women, respectively. Thirty-six and 32 plasma AAG concentrations from 31 pregnant (~24 to 38 wks gestation) and 30 postpartum women (~2-13 wks postpartum), respectively, were available for analysis. Estimated mean albumin concentrations remained stable from 20 wks gestation to term (33.4 to 34.3 g/L); whereas, concentrations rapidly increased postpartum until stabilizing at ~42.3 g/L 15 wk after delivery. Estimated AAG concentrations slightly decreased from 24 wks gestation to term (53.6 and 44.9 mg/dL) while postpartum levels were elevated at two wks after delivery (126.1 mg/dL) and subsequently declined thereafter. Computational functions were developed to quantitatively communicate study results in a form that can be readily utilized for PBPK model development. Conclusion: By characterizing the trajectory of plasma protein concentrations in pregnant and postpartum women living with HIV, our analysis can increase confidence in PBPK model predictions for HIV antiretrovirals and better inform drug dosing decisions in this understudied population.
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Affiliation(s)
- Sherry Zhao
- Division of Pediatrics and Maternal Health, Office of Rare Diseases, Pediatrics, Urologic and Reproductive Medicine, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Mary Gockenbach
- Division of Pediatrics and Maternal Health, Office of Rare Diseases, Pediatrics, Urologic and Reproductive Medicine, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Manuela Grimstein
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Hari Cheryl Sachs
- Division of Pediatrics and Maternal Health, Office of Rare Diseases, Pediatrics, Urologic and Reproductive Medicine, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Mark Mirochnick
- Boston University School of Medicine, Boston, MA, United States
| | - Kimberly Struble
- Division of Antivirals, Office of Antimicrobials, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Yodit Belew
- Division of Antivirals, Office of Antimicrobials, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Jian Wang
- Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Edmund V Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, San Diego, CA, United States.,Pediatrics Department, School of Medicine, San Diego-Rady Children's Hospital San Diego, University of California, San Diego, San Diego, CA, United States
| | - Brookie M Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, San Diego, CA, United States.,Pediatrics Department, School of Medicine, San Diego-Rady Children's Hospital San Diego, University of California, San Diego, San Diego, CA, United States
| | - Tamara Johnson
- Division of Pediatrics and Maternal Health, Office of Rare Diseases, Pediatrics, Urologic and Reproductive Medicine, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Jeremiah D Momper
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, San Diego, CA, United States
| | - Anil R Maharaj
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
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29
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Eke AC, Olagunju A, Best BM, Mirochnick M, Momper JD, Abrams E, Penazzato M, Cressey TR, Colbers A. Innovative Approaches for Pharmacology Studies in Pregnant and Lactating Women: A Viewpoint and Lessons from HIV. Clin Pharmacokinet 2020; 59:1185-1194. [PMID: 32757103 PMCID: PMC7550310 DOI: 10.1007/s40262-020-00915-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Medication use during pregnancy in the absence of pharmacokinetic and safety data is common, particularly for antiretrovirals, as pregnant women are not usually included in clinical trials leading to drug licensure. To date, data are typically generated through opportunistic pregnancy studies performed in the postmarketing setting, leading to a substantial time-lag between initial regulatory approval of a drug and availability of essential pregnancy-specific pharmacokinetic and safety data. During this period, health care providers lack key information on human placental transfer, fetal exposure, optimal maternal dosing in pregnancy, and maternal and fetal drug toxicity, including teratogenicity risk. We discuss new approaches that could facilitate the acquisition of these critical data earlier in the drug development process, aiding clinicians and patients in making informed decisions on drug selection and dosing during pregnancy. An integrated approach utilizing multiple novel methodologies (in vitro, ex vivo, in silico and in vivo) is needed to accelerate the availability of pharmacology data in pregnancy and lactation.
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Affiliation(s)
- Ahizechukwu C Eke
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, 600N Wolfe Street, Phipps 215, Baltimore, MD, 21287, USA
| | - Adeniyi Olagunju
- Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Brookie M Best
- University of California San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, USA
- Pediatrics Department, University of California San Diego School of Medicine-Rady Children's Hospital San Diego, San Diego, CA, USA
| | | | - Jeremiah D Momper
- University of California San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, USA
| | - Elaine Abrams
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Martina Penazzato
- HIV, Hepatitis and STI Department, World Health Organization, Geneva, Switzerland
| | - Tim R Cressey
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
- PHPT/IRD 174, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Immunology and Infectious Diseases, Harvard T.H Chan School of Public Health, Boston, MA, USA
| | - Angela Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
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30
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Colbers A, Mirochnick M, Schalkwijk S, Penazzato M, Townsend C, Burger D. Importance of Prospective Studies in Pregnant and Breastfeeding Women Living With Human Immunodeficiency Virus. Clin Infect Dis 2020; 69:1254-1258. [PMID: 30783649 PMCID: PMC6743813 DOI: 10.1093/cid/ciz121] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 02/08/2019] [Indexed: 12/02/2022] Open
Abstract
Recently, the US Food and Drug Administration and European Medicines Agency issued warnings on the use of dolutegravir and darunavir/cobicistat for treatment of pregnant women living with human immunodeficiency virus (HIV). It took 3–5 years to identify the risks associated with the use of these antiretroviral drugs, during which time pregnant women were exposed to these drugs in clinical care, outside of controlled clinical trial settings. Across all antiretroviral drugs, the interval between registration of new drugs and first data on pharmacokinetics and safety in pregnancy becoming available is around 6 years. In this viewpoint, we provide considerations for clinical pharmacology research to provide safe and effective treatment of pregnant and breastfeeding women living with HIV and their children. These recommendations will lead to timelier availability of safety and pharmacokinetic information needed to develop safe treatment strategies for pregnant and breastfeeding women living with HIV, and are applicable to other chronic disease areas requiring medication during pregnancy.
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Affiliation(s)
- Angela Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Stein Schalkwijk
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Claire Townsend
- HIV Department, World Health Organization, Geneva, Switzerland.,Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, University College London, United Kingdom
| | - David Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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31
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Salama E, Eke AC, Best BM, Mirochnick M, Momper JD. Pharmacokinetic Enhancement of HIV Antiretroviral Therapy During Pregnancy. J Clin Pharmacol 2020; 60:1537-1550. [PMID: 32798276 DOI: 10.1002/jcph.1714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/21/2020] [Indexed: 12/21/2022]
Abstract
Pharmacokinetic boosting of antiretroviral (ARV) therapies with either ritonavir or cobicistat is used to achieve target drug exposure, lower pill burden, and provide simplified dosing schedules. Several ARVs require boosting, including the integrase inhibitor elvitegravir as well as protease inhibitors such as darunavir, atazanavir, and lopinavir. The use of boosted regimens in pregnant women living with HIV has been studied for a variety of ARVs; however, a recent recommendation by the US Food and Drug Administration advised against cobicistat-boosted regimens in pregnancy due to substantially lower drug exposures observed in clinical pharmacokinetic studies. The objectives of this article are to review pharmacokinetic enhancement of ARVs with ritonavir and cobicistat during pregnancy and postpartum, describe clinical implications, and provide recommendations for future research.
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Affiliation(s)
- Engie Salama
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California, USA
| | - Ahizechukwu C Eke
- Division of Maternal Fetal Medicine & Clinical Pharmacology, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Doctoral Training Program (PhD), Graduate Training Program in Clinical Investigation (GTPCI), Johns Hopkins University School of Public Health, Baltimore, Maryland, USA
| | - Brookie M Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California, USA.,Department of Pediatrics, University of California San Diego - Rady Children's Hospital San Diego, San Diego, California, USA
| | - Mark Mirochnick
- Division of Neonatology, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jeremiah D Momper
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California, USA
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Schalkwijk S, Ter Heine R, Colbers A, Capparelli E, Best BM, Cressey TR, Greupink R, Russel FGM, Moltó J, Mirochnick M, Karlsson MO, Burger DM. Evaluating darunavir/ritonavir dosing regimens for HIV-positive pregnant women using semi-mechanistic pharmacokinetic modelling. J Antimicrob Chemother 2020; 74:1348-1356. [PMID: 30715324 DOI: 10.1093/jac/dky567] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 12/04/2018] [Accepted: 12/10/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Darunavir 800 mg once (q24h) or 600 mg twice (q12h) daily combined with low-dose ritonavir is used to treat HIV-positive pregnant women. Decreased total darunavir exposure (17%-50%) has been reported during pregnancy, but limited data on unbound exposure are available. OBJECTIVES To evaluate total and unbound darunavir exposures following standard darunavir/ritonavir dosing and to explore the value of potential optimized darunavir/ritonavir dosing regimens for HIV-positive pregnant women. PATIENTS AND METHODS A population pharmacokinetic analysis was conducted based on data from 85 women. The final model was used to simulate total and unbound darunavir AUC0-τ and Ctrough during the third trimester of pregnancy, as well as to assess the probability of therapeutic exposure. RESULTS Simulations predicted that total darunavir exposure (AUC0-τ) was 24% and 23% lower in pregnancy for standard q24h and q12h dosing, respectively. Unbound darunavir AUC0-τ was 5% and 8% lower compared with post-partum for standard q24h and q12h dosing, respectively. The probability of therapeutic exposure (unbound) during pregnancy was higher for standard q12h dosing (99%) than for q24h dosing (94%). CONCLUSIONS The standard q12h regimen resulted in maximal and higher rates of therapeutic exposure compared with standard q24h dosing. Darunavir/ritonavir 600/100 mg q12h should therefore be the preferred regimen during pregnancy unless (adherence) issues dictate q24h dosing. The value of alternative dosing regimens seems limited.
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Affiliation(s)
- Stein Schalkwijk
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud university medical center, Nijmegen, The Netherlands.,Department of Pharmacology & Toxicology, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud university medical center, Nijmegen, The Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud university medical center, Nijmegen, The Netherlands
| | - Angela Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud university medical center, Nijmegen, The Netherlands
| | - Edmund Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences & School of Medicine, University of California San Diego, San Diego, CA, USA
| | - Brookie M Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences & School of Medicine, University of California San Diego, San Diego, CA, USA
| | - Tim R Cressey
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand.,Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Rick Greupink
- Department of Pharmacology & Toxicology, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud university medical center, Nijmegen, The Netherlands
| | - Frans G M Russel
- Department of Pharmacology & Toxicology, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud university medical center, Nijmegen, The Netherlands
| | - José Moltó
- Fundació Lluita contra la Sida, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Infectious Diseases Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Mark Mirochnick
- Department of Pediatrics, Boston University School of Medicine, Boston, MA, USA
| | - Mats O Karlsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud university medical center, Nijmegen, The Netherlands
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Liu XI, Momper JD, Rakhmanina NY, Green DJ, Burckart GJ, Cressey TR, Mirochnick M, Best BM, van den Anker JN, Dallmann A. Prediction of Maternal and Fetal Pharmacokinetics of Dolutegravir and Raltegravir Using Physiologically Based Pharmacokinetic Modeling. Clin Pharmacokinet 2020; 59:1433-1450. [PMID: 32451908 DOI: 10.1007/s40262-020-00897-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Predicting drug pharmacokinetics in pregnant women including placental drug transfer remains challenging. This study aimed to develop and evaluate maternal-fetal physiologically based pharmacokinetic models for two antiretroviral drugs, dolutegravir and raltegravir.
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Affiliation(s)
- Xiaomei I Liu
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA.
| | - Jeremiah D Momper
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, USA
| | - Natella Y Rakhmanina
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | - Dionna J Green
- Office of Pediatric Therapeutics, US Food and Drug Administration, Silver Spring, MD, USA
| | - Gilbert J Burckart
- Office of Clinical Pharmacology, US Food and Drug Administration, Silver Spring, MD, USA
| | - Tim R Cressey
- PHPT/IRD 174, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | | | - Brookie M Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, USA
| | - John N van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
- Division of Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - André Dallmann
- Division of Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
- Clinical Pharmacometrics, Bayer, Leverkusen, Germany
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Kreitchmann R, Schalkwijk S, Best B, Wang J, Colbers A, Stek A, Shapiro D, Cressey T, Mirochnick M, Burger D. Efavirenz pharmacokinetics during pregnancy and infant washout. Antivir Ther 2020; 24:95-103. [PMID: 30530925 DOI: 10.3851/imp3283] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Limited data exist on efavirenz pharmacokinetics in HIV-positive pregnant women and neonatal washout. METHODS HIV-infected pregnant women receiving 600 mg efavirenz once daily had intensive steady-state 24-h pharmacokinetics profiles during the second trimester (2T), third trimester (3T) and 6-12 weeks postpartum (PP). Maternal and umbilical cord blood samples were drawn at delivery and neonatal washout pharmacokinetics were determined. Therapeutic targets were the estimated 10th percentile efavirenz area under the concentration-time curve (AUC) in non-pregnant historical controls (40.0 μg•h/ml) and a trough concentration (C24 h) of 1 μg/ml. Data were prospectively collected within two trials: IMPAACT P1026s (United States) and PANNA (Europe). RESULTS Among 42 women studied, 15, 42 and 40 had efavirenz pharmacokinetic data available in 2T, 3T and PP, respectively. Median (range) 3T age 33 (20.7-43.5) years, weight 74 (50-132) kg and gestational age 33.4 (28.4-37.9 weeks). Efavirenz AUC during the 3T (60 μg•h/ml) was similar to that reported in non-pregnant adults (58 μg•h/ml). Exposure in the 2T was lower, but within the 0.80-1.25 range. C24 concentrations during pregnancy were lower compared to historical controls on 600 mg efavirenz, however, they were similar to the C24 concentrations after equally potent dose of 400 mg efavirenz. Cord blood/maternal plasma concentration ratio (range) was 0.67 (0.36-0.95). Among 23 infants with washout data available, median (interquartile range) elimination half-life was 65.6 h (40.6-129). HIV RNA viral loads at delivery were <400 and <50 copies/ml for 96.7% and 86.7% of women, respectively. In 3T and PP, respectively, 8/41 (19%) and 6/40 (15%) had AUC below target; 7/41 (17%) and 3/39 (8%) had C24 below target. CONCLUSIONS Efavirenz exposure was similar during pregnancy compared with PP, C24 was in line with C24 after 400 mg equipotent efavirenz dosing. Efavirenz readily crossed the placenta and infant elimination half-life was over twice that of maternal participants. Clincaltrials.gov identifiers: NCT00825929 and NCT00042289.
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Affiliation(s)
- Regis Kreitchmann
- HIV Research Department, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | - Stein Schalkwijk
- Departments of Pharmacy and Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Brookie Best
- University of California, San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences & Department of Pediatrics, University of California San Diego/Rady Children's Hospital-San Diego, San Diego, CA, USA
| | - Jiajia Wang
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Angela Colbers
- Departments of Pharmacy and Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Alice Stek
- Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Los Angeles, CA, USA
| | - David Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Tim Cressey
- Department of Medical Technology, Faculty of Associated Medical Sciences, PHPT/IRD 174, Chiang Mai University, Chiang Mai, Thailand.,Department of Immunology & Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | | | - David Burger
- Departments of Pharmacy and Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands
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Eke AC, Brooks KM, Gebreyohannes RD, Sheffield JS, Dooley KE, Mirochnick M. Tenofovir alafenamide use in pregnant and lactating women living with HIV. Expert Opin Drug Metab Toxicol 2020; 16:333-342. [PMID: 32125906 DOI: 10.1080/17425255.2020.1738384] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: Tenofovir alafenamide (TAF)-containing fixed-dose drug combinations (FDCs) are increasingly being used in managing pregnant women living with HIV. However, TAF is not currently recommended during pregnancy due to limited pharmacokinetic and safety data. TAF, a newer nucleotide phosphonamidate prodrug of tenofovir (TFV), achieves high levels of tenofovir-diphosphate in lymphoid cells and hepatocytes, and 90% lower systemic concentrations of TFV compared to tenofovir disoproxil fumarate (TDF), thereby maximizing TAF's antiviral efficacy, potency and clinical safety.Areas covered: This review discusses the currently available information on the pharmacology of TAF in pregnant women living with HIV. Pharmacokinetic studies with TAF during pregnancy have yielded varying results compared to postpartum, but TAF exposures during pregnancy have been within the range of those typically observed in non-pregnant adults. The efficacy and safety of TAF in treatment-naïve pregnant women living with HIV is currently being evaluated in the VESTED study, a phase-III NIH randomized clinical trial.Expert opinion: Initial pregnancy data suggest that TAF-based FDCs have high efficacy and low risk of adverse effects during pregnancy. TAF is likely to become part of first-line regimens for use in pregnant women living with HIV once additional pregnancy data from phase III trials are available.
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Affiliation(s)
- Ahizechukwu C Eke
- Division of Maternal Fetal Medicine & Clinical Pharmacology, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Doctoral Training Program (Phd), Graduate Training Program in Clinical Investigation (GTPCI), Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | - Kristina M Brooks
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Rahel D Gebreyohannes
- Department of Obstetrics & Gynecology, Addis Ababa University College of Health Science, Addis Ababa, Ethiopia
| | - Jeanne S Sheffield
- Division of Maternal Fetal Medicine & Clinical Pharmacology, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly E Dooley
- Division of Clinical Pharmacology & Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mark Mirochnick
- Division of Neonatology, Department of Pediatrics, Boston University School of Medicine, Boston, MA, USA
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Liu XI, Momper JD, Rakhmanina N, van den Anker JN, Green DJ, Burckart GJ, Best BM, Mirochnick M, Capparelli EV, Dallmann A. Physiologically Based Pharmacokinetic Models to Predict Maternal Pharmacokinetics and Fetal Exposure to Emtricitabine and Acyclovir. J Clin Pharmacol 2019; 60:240-255. [PMID: 31489678 DOI: 10.1002/jcph.1515] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/11/2019] [Indexed: 12/28/2022]
Abstract
Pregnancy is associated with physiological changes that may impact drug pharmacokinetics (PK). The goals of this study were to build maternal-fetal physiologically based pharmacokinetic (PBPK) models for acyclovir and emtricitabine, 2 anti(retro)viral drugs with active renal net secretion, and to (1) evaluate the predicted maternal PK at different stages of pregnancy; (2) predict the changes in PK target parameters following the current dosing regimen of these drugs throughout pregnancy; (3) evaluate the predicted concentrations of these drugs in the umbilical vein at delivery; (4) compare the model performance for predicting maternal PK of emtricitabine in the third trimester with that of previously published PBPK models; and (5) compare different previously published approaches for estimating the placental permeability of these 2 drugs. Results showed that the pregnancy PBPK model for acyclovir predicted all maternal concentrations within a 2-fold error range, whereas the model for emtricitabine predicted 79% of the maternal concentrations values within that range. Extrapolation of these models to earlier stages of pregnancy indicated that the change in the median PK target parameters remained well above the target threshold. Concentrations of acyclovir and emtricitabine in the umbilical vein were overall adequately predicted. The comparison of different emtricitabine PBPK models suggested an overall similar predictive performance in the third trimester, but the comparison of different approaches for estimating placental drug permeability revealed large differences. These models can enhance the understanding of the PK behavior of renally excreted drugs, which may ultimately inform pharmacotherapeutic decision making in pregnant women and their fetuses.
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Affiliation(s)
- Xiaomei I Liu
- Children's National Medical Center, Washington, DC, USA
| | - Jeremiah D Momper
- University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, California, USA
| | - Natella Rakhmanina
- Children's National Medical Center, Washington, DC, USA.,Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | - John N van den Anker
- Children's National Medical Center, Washington, DC, USA.,Pediatric Surgery and Intensive Care, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands.,Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital Basel (UKBB), Basel, Switzerland
| | - Dionna J Green
- Office of Pediatric Therapeutics, Office of Medical Products and Tobacco, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Gilbert J Burckart
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Brookie M Best
- University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, California, USA
| | - Mark Mirochnick
- Boston University, School of Medicine, Boston, Massachusetts, USA
| | - Edmund V Capparelli
- University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, California, USA
| | - André Dallmann
- Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital Basel (UKBB), Basel, Switzerland.,Bayer AG, Clinical Pharmacometrics, Leverkusen, Germany
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Nachman S, Townsend CL, Abrams EJ, Archary M, Capparelli E, Clayden P, Lockman S, Jean-Philippe P, Mayer K, Mirochnick M, McKenzie-White J, Struble K, Watts H, Flexner C. Long-acting or extended-release antiretroviral products for HIV treatment and prevention in infants, children, adolescents, and pregnant and breastfeeding women: knowledge gaps and research priorities. Lancet HIV 2019; 6:e552-e558. [PMID: 31307946 PMCID: PMC7152795 DOI: 10.1016/s2352-3018(19)30147-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 03/14/2019] [Accepted: 04/04/2019] [Indexed: 12/31/2022]
Abstract
Antiretroviral agents with long-acting properties have potential to improve treatment outcomes substantially for people living with HIV. In November 2017, the Long acting/Extended Release Antiretroviral Resource Program (LEAP) convened a workshop with the aim of shaping the research agenda and promoting early development of long-acting or extended release products for key populations: pregnant and lactating women, children aged up to 10 years, and adolescents aged 10-19 years. Goals included strategies and principles to ensure that the needs of children, adolescents, and pregnant and lactating women are considered when developing long-acting formulations. Research should focus not only on how best to transition long-acting products to these populations, but also on early engagement across sectors and among stakeholders. A parallel rather than sequential approach is needed when establishing adult, adolescent, and paediatric clinical trials and seeking regulatory approval. Pregnant and lactating women should be included in adult clinical trials. Adolescent-friendly trial design is needed to improve recruitment and retention of young people.
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Affiliation(s)
- Sharon Nachman
- Health Sciences Center, SUNY Stony Brook, Pediatrics, New York, NY, USA.
| | | | - Elaine J Abrams
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, NY, USA; Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | | | - Edmund Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, CA, USA
| | | | - Shahin Lockman
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Department of Immunology and Infectious Diseases, Harvard TH Chan School of Public Health, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Kenneth Mayer
- School of Medicine, Harvard University, Cambridge, MA, USA
| | | | | | | | - Heather Watts
- Office of the Global AIDS Coordinator and Health Diplomacy, Washington, DC, USA
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Lommerse J, Clarke D, Kerbusch T, Merdjan H, Witjes H, Teppler H, Mirochnick M, Acosta EP, Wenning L, Nachman S, Chain A. Maternal-Neonatal Raltegravir Population Pharmacokinetics Modeling: Implications for Initial Neonatal Dosing. CPT Pharmacometrics Syst Pharmacol 2019; 8:643-653. [PMID: 31215170 PMCID: PMC6765695 DOI: 10.1002/psp4.12443] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 05/10/2019] [Indexed: 01/08/2023]
Abstract
Raltegravir readily crosses the placenta to the fetus with maternal use during pregnancy. After birth, neonatal raltegravir elimination is highly variable and often extremely prolonged, with some neonates demonstrating rising profiles after birth despite removal from the source of extrinsic raltegravir. To establish an appropriate dosing regimen, an integrated maternal–neonatal pharmacokinetics model was built to predict raltegravir plasma concentrations in neonates with in utero raltegravir exposure. Postnatal age and body weight were used as structural covariates. The model predicted rising or decreasing neonatal elimination profiles based on the time of maternal drug administration relative to time of birth and degree of in utero drug disposition into the central and peripheral compartments. Based on this model, it is recommended to delay the first oral dose of raltegravir until 1–2 days of age in those neonates born to mothers who received raltegravir during pregnancy, labor, and delivery.
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Affiliation(s)
- Jos Lommerse
- Certara Strategic Consulting, Oss, The Netherlands
| | - Diana Clarke
- Boston Medical Center, Boston, Massachusetts, USA
| | | | | | - Han Witjes
- Certara Strategic Consulting, Oss, The Netherlands
| | - Hedy Teppler
- Merck & Co., Inc., Upper Gwynedd, Pennsylvania, USA
| | - Mark Mirochnick
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Edward P Acosta
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Sharon Nachman
- State University of New York, Stony Brook, New York, USA
| | - Anne Chain
- Merck & Co., Inc., Rahway, New Jersey, USA
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Affiliation(s)
- Ahizechukwu C Eke
- a Division of Maternal Fetal Medicine & Clinical Pharmacology, Department of Gynecology & Obstetrics , Johns Hopkins University School of Medicine , Baltimore , MD , USA.,b Doctoral Training Program (PhD), Graduate Training Program in Clinical Investigation (GTPCI) , Johns Hopkins University School of Public Health , Baltimore , MD , USA
| | - Mark Mirochnick
- c Division of Neonatology, Department of Pediatrics , Boston University School of Medicine , Boston , MA , USA
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Momper JD, Best BM, Wang J, Capparelli EV, Stek A, Barr E, Badell ML, Acosta EP, Purswani M, Smith E, Chakhtoura N, Park K, Burchett S, Shapiro DE, Mirochnick M. Elvitegravir/cobicistat pharmacokinetics in pregnant and postpartum women with HIV. AIDS 2018; 32:2507-2516. [PMID: 30134297 PMCID: PMC6209536 DOI: 10.1097/qad.0000000000001992] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To evaluate elvitegravir and cobicistat pharmacokinetics during pregnancy compared with postpartum and in infant washout samples after delivery. DESIGN Nonrandomized, open-label, parallel-group, multicenter phase-IV prospective study of antiretroviral pharmacokinetics in HIV-infected pregnant women and their children in the United States. METHODS Intensive steady-state 24-h pharmacokinetic profiles after 150 mg of elvitegravir and 150 mg of cobicistat given orally in fixed dose combination once-daily were performed during the second trimester, third trimester, and postpartum. Infant washout samples were collected after birth. Elvitegravir and cobicistat were measured in plasma by a validated liquid chromatography with tandem mass spectrometry assay with a lower quantitation limit of 10 ng/ml. A two-tailed Wilcoxon signed-rank test (α = 0.10) was employed for paired within-participant comparisons. RESULTS Thirty pregnant women taking elvitegravir and cobicistat once-daily enrolled in the study. Compared with paired postpartum data, elvitegravir AUC0-24 was 24% lower in the second trimester [n = 14, P = 0.058, geometric mean ratios (GMR) = 0.76, 90% confidence interval (CI) 0.57-1.0] and 44% lower in the third trimester (n = 24, P = 0.0001, GMR = 0.56, 90% CI 0.42-0.73), while cobicistat AUC0-24 was 44% lower in the second trimester (n = 14, P = 0.0085, GMR = 0.56, 90% CI 0.37-0.85) and 59% lower in the third trimester (n = 24, P < 0.0001, GMR = 0.41, 90% CI 0.30-0.57). Median cord blood elvitegravir concentration was 540.6 ng/ml and the median ratio of cord blood to maternal plasma elvitegravir concentrations was 0.91. CONCLUSION Standard elvitegravir and cobicistat dosing during pregnancy results in significantly lower exposure which may increase the risk of virologic failure and mother-to-child transmission. Additional studies are needed to optimize elvitegravir and cobicistat dosing regimens in pregnant women.
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Affiliation(s)
- Jeremiah D Momper
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California
| | - Brookie M Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California
| | - Jiajia Wang
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Edmund V Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California
| | - Alice Stek
- University of Southern California School of Medicine, Los Angeles, California
| | - Emily Barr
- University of Colorado, Children's Hospital Colorado, Aurora, Colorado
| | | | | | - Murli Purswani
- Bronx-Lebanon Hospital Center, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elizabeth Smith
- Maternal, Adolescent, and Pediatric Research Branch, National Institute of Allergy and Infectious Diseases (NIAID)
| | - Nahida Chakhtoura
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, Maryland
| | - Kyunghun Park
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California
| | | | - David E Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Mark Mirochnick
- Boston University School of Medicine, Boston, Massachusetts, USA
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Schalkwijk S, Ter Heine R, Colbers AC, Huitema ADR, Denti P, Dooley KE, Capparelli E, Best BM, Cressey TR, Greupink R, Russel FGM, Mirochnick M, Burger DM. A Mechanism-Based Population Pharmacokinetic Analysis Assessing the Feasibility of Efavirenz Dose Reduction to 400 mg in Pregnant Women. Clin Pharmacokinet 2018; 57:1421-1433. [PMID: 29520730 PMCID: PMC6182466 DOI: 10.1007/s40262-018-0642-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Reducing the dose of efavirenz can improve safety, reduce costs, and increase access for patients with HIV infection. According to the World Health Organization, a similar dosing strategy for all patient populations is desirable for universal roll-out; however, it remains unknown whether the 400 mg daily dose is adequate during pregnancy. METHODS We developed a mechanistic population pharmacokinetic model using pooled data from women included in seven studies (1968 samples, 774 collected during pregnancy). Total and free efavirenz exposure (AUC24 and C12) were predicted for 400 (reduced) and 600 mg (standard) doses in both pregnant and non-pregnant women. RESULTS Using a 400 mg dose, the median efavirenz total AUC24 and C12 during the third trimester of pregnancy were 91 and 87% of values among non-pregnant women, respectively. Furthermore, the median free efavirenz C12 and AUC24 were predicted to increase during pregnancy by 11 and 15%, respectively. CONCLUSIONS It was predicted that reduced-dose efavirenz provides adequate exposure during pregnancy. These findings warrant prospective confirmation.
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Affiliation(s)
- Stein Schalkwijk
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Rob Ter Heine
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Angela C Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Edmund Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences and School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Brookie M Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences and School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Tim R Cressey
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Rick Greupink
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frans G M Russel
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
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Eke AC, McCormack SA, Best BM, Stek AM, Wang J, Kreitchmann R, Shapiro D, Smith E, Mofenson LM, Capparelli EV, Mirochnick M. Pharmacokinetics of Increased Nelfinavir Plasma Concentrations in Women During Pregnancy and Postpartum. J Clin Pharmacol 2018; 59:386-393. [PMID: 30358179 DOI: 10.1002/jcph.1331] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 10/02/2018] [Indexed: 11/05/2022]
Abstract
This study aims to evaluate the safety, acceptability, and pharmacokinetics (PK) of an increased dose of nelfinavir (NFV) during the third trimester of pregnancy. The study was registered as part of the International Maternal Pediatric Adolescent AIDS Clinical Trials network (IMPAACT-P1026s), an ongoing multicenter prospective cohort study of antiretroviral PK during pregnancy (NCT00042289). NFV intensive PK evaluations were performed at steady state during the third trimester of pregnancy and 2-3 weeks postpartum. Plasma concentrations of NFV and its active metabolite, hydroxyl-tert-butylamide (M8) were measured using high-performance liquid chromatography with ultraviolet detection. A total of 18 women are included in the analysis. NFV area under the concentration-time curve (AUC) with the increased dose during the third trimester was nearly identical to the standard dose postpartum, with a geometric mean ratio for third trimester to postpartum AUC of 0.98 (90%CI 0.71-1.35). Despite the increased dose, M8 AUC was lower during the third trimester compared to postpartum (0.53, IQR [0.38-0.75]), as was the M8/NFV AUC ratio (0.51, IQR [0.42-0.63]). NFV AUC0-12 was above target in 15 of 18 (83%) of participants during the third trimester compared to 14 of 16 (88%) postpartum. No major safety concerns were noted. Increasing the NFV dose to 1875 mg twice daily during the third trimester achieved similar concentrations postpartum compared to standard dosing (1250 mg twice daily). Increased NFV dose regimens may still have some benefit to human immunodeficiency virus (HIV)-positive pregnant women living in countries where novel protease inhibitors are currently unavailable or in individuals who are intolerant to ritonavir-boosted HIV medications.
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Affiliation(s)
- Ahizechukwu C Eke
- Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Brookie M Best
- University of California San Diego School of Medicine, San Diego, CA, USA.,University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego, CA, USA
| | - Alice M Stek
- University of Southern California School of Medicine, Los Angeles, CA, USA
| | - Jiajia Wang
- Harvard School of Public Health, Center for Biostatistics in AIDS Research, Boston, MA, USA
| | - Regis Kreitchmann
- Irmandade da Santa Casa de Misericórdia de Porto Alegre, HIV/AIDS Research Department, Porto Alegre, Rio Grande do Sul, Brazil
| | - David Shapiro
- Harvard School of Public Health, Center for Biostatistics in AIDS Research, Boston, MA, USA
| | - Elizabeth Smith
- National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD, USA
| | - Lynne M Mofenson
- National Institute of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, MD, USA
| | - Edmund V Capparelli
- University of California San Diego School of Medicine, San Diego, CA, USA.,University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego, CA, USA
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- Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Adachi K, Xu J, Ank B, Watts DH, Camarca M, Mofenson LM, Pilotto JH, Joao E, Gray G, Theron G, Santos B, Fonseca R, Kreitchmann R, Pinto J, Mussi-Pinhata MM, Machado DM, Ceriotto M, Morgado MG, Bryson YJ, Veloso VG, Grinsztejn B, Mirochnick M, Moye J, Nielsen-Saines K. Congenital Cytomegalovirus and HIV Perinatal Transmission. Pediatr Infect Dis J 2018; 37:1016-1021. [PMID: 30216294 PMCID: PMC6129438 DOI: 10.1097/inf.0000000000001975] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Congenital cytomegalovirus (CMV) infection (cCMV) is an important cause of hearing loss and cognitive impairment. Prior studies suggest that HIV-exposed children are at higher risk of acquiring cCMV. We assessed the presence, magnitude and risk factors associated with cCMV among infants born to HIV-infected women, who were not receiving antiretrovirals during pregnancy. METHODS cCMV and urinary CMV load were determined in a cohort of infants born to HIV-infected women not receiving antiretrovirals during pregnancy. Neonatal urines obtained at birth were tested for CMV DNA by qualitative and reflex quantitative real-time polymerase chain reaction. RESULTS Urine specimens were available for 992 (58.9%) of 1684 infants; 64 (6.5%) were CMV-positive. Mean CMV load (VL) was 470,276 copies/ml (range: < 200-2,000,000 copies/ml). Among 89 HIV-infected infants, 16 (18%) had cCMV versus 42 (4.9%) of 858 HIV-exposed, uninfected infants (P < 0.0001). cCMV was present in 23.2% of infants with in utero and 9.1% infants with intrapartum HIV infection (P < 0.0001). Rates of cCMV among HIV-infected infants were 4-fold greater (adjusted OR, 4.4; 95% CI: 2.3-8.2) and 6-fold greater among HIV in utero-infected infants (adjusted OR, 6; 95% CI: 3-12.1) compared with HIV-exposed, uninfected infants. cCMV was not associated with mode of delivery, gestational age, Apgar scores, 6-month infant mortality, maternal age, race/ethnicity, HIV viral load or CD4 count. Primary cCMV risk factors included infant HIV-infection, particularly in utero infection. CONCLUSION High rates of cCMV with high urinary CMV VL were observed in HIV-exposed infants. In utero HIV infection appears to be a major risk factor for cCMV in infants whose mothers have not received combination antiretroviral therapy in pregnancy.
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Affiliation(s)
- Kristina Adachi
- David Geffen UCLA School of Medicine, Los Angeles, CA 90095-1406,
U.S
| | | | - Bonnie Ank
- David Geffen UCLA School of Medicine, Los Angeles, CA 90095-1406,
U.S
| | - D. Heather Watts
- Office of the Global AIDS Coordinator, U.S. Department of State,
Washington D.C., 20522-2920, U.S
| | | | - Lynne M. Mofenson
- Eunice Kennedy Shriver National Institute of Child
Health and Human Development, National Institutes of Health, Bethesda, MD,
20892-7510, U.S
| | | | - Esau Joao
- Hospital Federal dos Servidores do Estado, Rio de Janeiro, RJ,
20221-903, Brazil
| | - Glenda Gray
- SAMRC and Perinatal HIV Research Unit, University of Witwatersrand,
Cape Town, 7441, South Africa
| | - Gerhard Theron
- Stellenbosch University/Tygerberg Hospital, Cape Town, 7505, South
Africa
| | - Breno Santos
- Hospital Conceicao, Porto Alegre, RS, 91350-200, Brazil
| | | | - Regis Kreitchmann
- Irmandade da Santa Casa de Misericordia de Porto Alegre, RS,
90020-090, Brazil
| | - Jorge Pinto
- Federal University of Minas Gerais, Belo Horizonte, MG, 30130-100,
Brazil
| | | | - Daisy Maria Machado
- Escola Paulista de Medicina-Universidade Federal de São
Paulo, São Paulo, SP, 04939-002, Brazil
| | - Mariana Ceriotto
- Foundation for Maternal and Infant Health (FUNDASAMIN), Buenos
Aires, C1439CNU, Argentina
| | - Mariza G. Morgado
- Fundacao Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, RJ, 21045-900,
Brazil
| | - Yvonne J. Bryson
- David Geffen UCLA School of Medicine, Los Angeles, CA 90095-1406,
U.S
| | | | | | | | - Jack Moye
- Eunice Kennedy Shriver National Institute of Child
Health and Human Development, National Institutes of Health, Bethesda, MD,
20892-7510, U.S
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Mulligan N, Best BM, Wang J, Capparelli EV, Stek A, Barr E, Buschur SL, Acosta EP, Smith E, Chakhtoura N, Burchett S, Mirochnick M. Dolutegravir pharmacokinetics in pregnant and postpartum women living with HIV. AIDS 2018; 32:729-737. [PMID: 29369162 PMCID: PMC5854536 DOI: 10.1097/qad.0000000000001755] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate dolutegravir pharmacokinetics during pregnancy compared with postpartum and in infant washout samples after delivery. DESIGN Ongoing, nonrandomized, open-label, parallel-group, multicenter phase-IV prospective study of antiretroviral pharmacokinetics in HIV-infected pregnant women and infants. METHODS Intensive steady-state 24 h pharmacokinetic profiles after dolutegravir 50 mg once-daily were performed during the second trimester (2T), third trimester (3T) and postpartum. Maternal delivery and postnatal infant samples were collected after birth. Dolutegravir was measured by validated LC-MS/MS; quantitation limit was 0.005 μg/ml. A two-tailed Wilcoxon signed-rank test (α = 0.10) was employed for paired within-subject comparisons. RESULTS Twenty-nine enrolled participants had a median age of 32 years (range 21-42). Pharmacokinetic data were available for 15 (2T), 28 (3T) and 23 (postpartum) women. Median dolutegravir AUC0-24,Cmax and C24 were 25-51% lower in the 2T and 3T compared with postpartum. The median cord blood/maternal plasma concentration ratio was 1.25 (n = 18). In 21 infants, median elimination half-life was 32.8 h after in utero exposure. Viral load at delivery was less than 50 copies/ml for 27/29 women (93%). Twenty-nine infants were HIV-negative. Renal abnormalities noted on ultrasound in two infants were deemed possibly related to dolutegravir. CONCLUSION Dolutegravir exposure is lower in pregnancy compared with postpartum in the same women on once-daily dosing. Median AUC0-24 during pregnancy was similar to, whereas trough concentrations were lower than, those seen in nonpregnant adults. Trough concentrations in pregnancy were well above dolutegravir EC90 (0.064 μg/ml). Dolutegravir readily crosses the placenta. Infant elimination is prolonged, with half-life over twice that of historical adult controls.
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Affiliation(s)
- Nikki Mulligan
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, California
| | - Brookie M Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, California
| | - Jiajia Wang
- Harvard T.H. Chan School of Public Health, Center for Biostatistics in AIDS Research, Boston, Massachusetts
| | - Edmund V Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, California
| | - Alice Stek
- University of Southern California School of Medicine, Los Angeles, California
| | - Emily Barr
- University of Colorado, Children's Hospital Colorado, Aurora, Colorado
| | | | | | - Elizabeth Smith
- Maternal, Adolescent, and Pediatric Research Branch, National Institute of Allergy and Infectious Diseases
| | - Nahida Chakhtoura
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, Maryland
| | | | - Mark Mirochnick
- Boston University School of Medicine, Boston, Massachusetts, USA
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Pinto JA, Capparelli EV, Warshaw M, Zimmer B, Cressey TR, Spector SA, Qin M, Smith B, Siberry GK, Mirochnick M. A Phase II/III Trial of Lopinavir/Ritonavir Dosed According to the WHO Pediatric Weight Band Dosing Guidelines. Pediatr Infect Dis J 2018; 37:e29-e35. [PMID: 29088027 PMCID: PMC5762400 DOI: 10.1097/inf.0000000000001817] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The World Health Organization (WHO) recommends weight band dosing of antiretrovirals for children. Data are limited describing drug exposure/safety of lopinavir/ritonavir using WHO weight band dosing. METHODS International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) P1083 was a phase II/III trial assessing the pharmacokinetics (PK) and short-term safety, tolerance and efficacy of lopinavir/ritonavir in human immunodeficiency virus-infected children 3-25 kg dosed according to WHO weight bands, with liquid solution or meltrex extrusion tablets. The main PK target was an area under the curve (AUC0-24) of 80-320 μg·h/mL. RESULTS Of 97 enrolled participants, median age 2.5 years, 89 (91.8%) completed the protocol. Median LPV dose was 303 mg/m. The geometric mean (90% confidence limits) LPV PK AUC0-24 was 196 (177-217) μg·h/mL and Cmin was 2.47 (1.52-4.02) μg/mL. AUC0-24 was within the target range for 79% of participants. The median (Q1, Q3) difference between individual observed PK parameters and those expected if Food and Drug Administration dosing guidelines were followed was 30.7 (7.9, 54.3) for AUC0-24 and 0.56 (0, 1.27) for Cmin. Ten (10%) participants had grade 3 or 4 events deemed related to study treatment, mostly asymptomatic laboratory abnormalities. Three participants died of unrelated study treatment causes. At week 24, 57 of 79 (72%) participants reached viral suppression and the median increase in CD4% (n = 83) was 6.0 (P < 0.0001). CONCLUSIONS WHO weight band dosing guidelines in children achieved adequate LPV plasma exposure but was higher than that expected with Food and Drug Administration dosing guidelines. Despite the higher LPV exposure, the treatment was well tolerated and the 24-week efficacy data were favorable.
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Affiliation(s)
- Jorge A. Pinto
- Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Edmund V. Capparelli
- University of California, San Diego, CA, and Rady Children’s Hospital San Diego, USA
| | | | - Bonnie Zimmer
- Frontier Science & Technology Research Foundation, Buffalo, NY, USA
| | - Tim R. Cressey
- Harvard TH Chan School of Public Health, Boston, MA, USA,Program for HIV Prevention and Treatment (PHPT/IRD UMI174), Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand,Department of Molecular & Clinical Pharmacology, University of Liverpool, UK
| | - Stephen A. Spector
- University of California, San Diego, CA, and Rady Children’s Hospital San Diego, USA
| | - Min Qin
- Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Betsy Smith
- National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - George K. Siberry
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD, USA
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Adachi K, Xu J, Yeganeh N, Camarca M, Morgado MG, Watts DH, Mofenson LM, Veloso VG, Pilotto JH, Joao E, Gray G, Theron G, Santos B, Fonseca R, Kreitchmann R, Pinto J, Mussi-Pinhata MM, Ceriotto M, Machado DM, Bryson YJ, Grinsztejn B, Moye J, Klausner JD, Bristow CC, Dickover R, Mirochnick M, Nielsen-Saines K. Combined evaluation of sexually transmitted infections in HIV-infected pregnant women and infant HIV transmission. PLoS One 2018; 13:e0189851. [PMID: 29304083 PMCID: PMC5755782 DOI: 10.1371/journal.pone.0189851] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 11/30/2017] [Indexed: 11/21/2022] Open
Abstract
Background Sexually transmitted infections (STIs) including Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Treponema pallidum (TP), and cytomegalovirus (CMV) may lead to adverse pregnancy and infant outcomes. The role of combined maternal STIs in HIV mother-to-child transmission (MTCT) was evaluated in mother-infant pairs from NICHD HPTN 040. Methodology Urine samples from HIV-infected pregnant women during labor were tested by polymerase chain reaction (PCR) for CT, NG, and CMV. Infant HIV infection was determined by serial HIV DNA PCR testing. Maternal syphilis was tested by VDRL and confirmatory treponemal antibodies. Results A total of 899 mother-infant pairs were evaluated. Over 30% had at least one of the following infections (TP, CT, NG, and/or CMV) detected at the time of delivery. High rates of TP (8.7%), CT (17.8%), NG (4%), and CMV (6.3%) were observed. HIV MTCT was 9.1% (n = 82 infants). HIV MTCT was 12.5%, 10.3%, 11.1%, and 26.3% among infants born to women with CT, TP, NG or CMV respectively. Forty-two percent of HIV-infected infants were born to women with at least one of these 4 infections. Women with these infections were nearly twice as likely to have an HIV-infected infant (aOR 1.9, 95% CI 1.1–3.0), particularly those with 2 STIs (aOR 3.4, 95% CI 1.5–7.7). Individually, maternal CMV (aOR 4.4 1.5–13.0) and infant congenital CMV (OR 4.1, 95% CI 2.2–7.8) but not other STIs (TP, CT, or NG) were associated with an increased risk of HIV MTCT. Conclusion HIV-infected pregnant women identified during labor are at high risk for STIs. Co-infection with STIs including CMV nearly doubles HIV MTCT risk. CMV infection appears to confer the largest risk of HIV MTCT. Trial registration NCT00099359.
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Affiliation(s)
- Kristina Adachi
- David Geffen UCLA School of Medicine, Los Angeles, CA, United States of America
- * E-mail:
| | - Jiahong Xu
- Westat, Rockville, MD, United States of America
| | - Nava Yeganeh
- David Geffen UCLA School of Medicine, Los Angeles, CA, United States of America
| | | | | | - D. Heather Watts
- Office of the Global AIDS Coordinator, U.S. Department of State, Washington D.C., United States of America
| | - Lynne M. Mofenson
- Elizabeth Glaser Pediatric AIDS Foundation, Washington D.C., United States of America
| | | | | | - Esau Joao
- Hospital Federal dos Servidores do Estado, Rio de Janeiro, RJ, Brazil
| | - Glenda Gray
- SAMRC and Perinatal HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa
| | - Gerhard Theron
- Stellenbosch University/Tygerberg Hospital, Cape Town, South Africa
| | | | | | - Regis Kreitchmann
- Irmandade da Santa Casa de Misericordia de Porto Alegre, Porto Alegre, RS, Brazil
| | - Jorge Pinto
- Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | | | - Mariana Ceriotto
- Foundation for Maternal and Infant Health (FUNDASAMIN), Buenos Aires, Argentina
| | - Daisy Maria Machado
- Escola Paulista de Medicina-Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Yvonne J. Bryson
- David Geffen UCLA School of Medicine, Los Angeles, CA, United States of America
| | | | - Jack Moye
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States of America
| | - Jeffrey D. Klausner
- David Geffen UCLA School of Medicine, Los Angeles, CA, United States of America
- UCLA Fielding School of Public Health, Los Angeles, CA, United States of America
| | | | - Ruth Dickover
- UC Davis School of Medicine, Davis, CA, United States of America
| | - Mark Mirochnick
- Boston University School of Medicine, Boston, MA, United States of America
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Clarke DF, Penazzato M, Capparelli E, Cressey TR, Siberry G, Sugandhi N, Mirochnick M. Prevention and treatment of HIV infection in neonates: evidence base for existing WHO dosing recommendations and implementation considerations. Expert Rev Clin Pharmacol 2017; 11:83-93. [PMID: 29039686 DOI: 10.1080/17512433.2018.1393331] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Antiretroviral drugs are used in neonates for prevention and treatment of HIV infection. Use of antiretrovirals to prevent perinatal HIV transmission is well established. Early identification of neonates infected with HIV and rapid initiation of combination antiretroviral treatment during the neonatal period is now recommended by WHO and DHHS. However, few antiretrovirals are available in formulations suitable for neonates and there are limited safety and pharmacokinetic data for most antiretrovirals in neonates. Areas covered: We summarize existing neonatal antiretroviral safety and pharmacokinetic information and discuss implementation considerations for programs providing antiretrovirals to neonates and young infants. Expert commentary: Antiretrovirals currently recommended by WHO for use in neonates are zidovudine, lamivudine, lopinavir/ritonavir, nevirapine, and raltegravir. Significant implementation challenges exist to the widespread use of these antiretrovirals in neonates. Optimal, feasible treatment of HIV-exposed and HIV-infected newborns will require development of practical neonatal dosage forms and their study in neonates for a wide range of antiretrovirals.
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Affiliation(s)
- Diana F Clarke
- a Department of Pediatric Infectious Diseases , Boston Medical Center , Boston , MA , USA.,b Department of Pediatrics , Boston University School of Medicine , Boston , MA , USA
| | - Martina Penazzato
- c Department of HIV/AIDS , World Health Organization , Geneva , Switzerland
| | - Edmund Capparelli
- d Skaggs School of Pharmacy and Pharmaceutical Sciences , University of California San Diego , La Jolla , CA , USA
| | - Tim R Cressey
- e PHPT-IRD (UMI 174), Faculty of Associated Medical Sciences , Chiang Mai University , Chiang Mai , Thailand.,f Department of Immunology & Infectious Diseases , Harvard T.H. Chan School of Public Health , Boston , MA , USA.,g Department of Molecular & Clinical Pharmacology , University of Liverpool , Liverpool , UK
| | - George Siberry
- h Office of the Global AIDS , U.S. Department of State , Washington , DC , USA
| | | | - Mark Mirochnick
- b Department of Pediatrics , Boston University School of Medicine , Boston , MA , USA
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Osorio LE, Boechat MI, Mirochnick M, Kumwenda N, Kreitchmann R, Emel L, Pinto J, Joao E, Santos B, Swenson M, George K, Sato P, Mofenson L, Nielsen-Saines K. Bone Age and Mineral Density Assessments Using Plain Roentgenograms in Tenofovir-exposed Infants in Malawi and Brazil Enrolled in HIV Prevention Trials Network 057. Pediatr Infect Dis J 2017; 36:184-188. [PMID: 27798550 PMCID: PMC5233548 DOI: 10.1097/inf.0000000000001386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Tenofovir disoproxil fumarate (TDF) use during pregnancy has been increasing, and studies linking bone toxicity with exposure to TDF have raised concern for its use in infants. METHODS Hand/wrist and spine radiographs were obtained at 3 days and 12 weeks of age in infants born to HIV-infected pregnant women enrolled in the HIV Prevention Trials Network 057 pharmacokinetic study of TDF conducted in Malawi and Brazil assigned to 3 TDF dosing cohorts. In cohort 1, mothers received 600 mg of TDF during labor. In cohort 2, infants received 4 mg/kg dose on days 0, 3 and 5. In cohort 3, a 900 mg maternal dose was given during labor, followed by a 6 mg/kg infant dose on days 0, 3 and 5 of life. RESULTS Across all 3 cohorts, 89 infants had radiographs performed at either time point, and 85 had radiographs performed at both time points. Metaphyseal lucency was present in 1 case in Brazil and 2 in Malawi. Fifteen percent of infants from Brazil and 9% of infants from Malawi presented bone age discrepancies. No other abnormalities were identified in Brazil, whereas in Malawi, there were 7 more cases of wrist osteopenia, 2 of spine osteopenia and 3 other abnormalities. CONCLUSION Bone abnormalities were not uncommon in the overall cohort of HIV-exposed infants. Because of very limited study drug exposure at the time of birth, it is unlikely that TDF was associated with these findings. Untreated maternal HIV disease and/or maternal nutritional status could potentially be related to fetal bone development. This association should be explored in future cohort studies.
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Affiliation(s)
| | | | | | | | | | - Lynda Emel
- SCHARP Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jorge Pinto
- Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Esau Joao
- Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
| | | | - Molly Swenson
- SCHARP Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Paul Sato
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Lynne Mofenson
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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49
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Mulligan N, Schalkwijk S, Best BM, Colbers A, Wang J, Capparelli EV, Moltó J, Stek AM, Taylor G, Smith E, Hidalgo Tenorio C, Chakhtoura N, van Kasteren M, Fletcher CV, Mirochnick M, Burger D. Etravirine Pharmacokinetics in HIV-Infected Pregnant Women. Front Pharmacol 2016; 7:239. [PMID: 27540363 PMCID: PMC4972814 DOI: 10.3389/fphar.2016.00239] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 07/21/2016] [Indexed: 01/05/2023] Open
Abstract
Background: The study goal was to describe etravirine pharmacokinetics during pregnancy and postpartum in HIV-infected women. Methods: IMPAACT P1026s and PANNA are on-going, non-randomized, open-label, parallel-group, multi-center phase-IV prospective studies in HIV-infected pregnant women. Intensive steady-state 12-h pharmacokinetic profiles were performed from 2nd trimester through postpartum. Etravirine was measured at two labs using validated ultra performance liquid chromatography (detection limits: 0.020 and 0.026 mcg/mL). Results: Fifteen women took etravirine 200 mg twice-daily. Etravirine AUC0–12 was higher in the 3rd trimester compared to paired postpartum data by 34% (median 8.3 vs. 5.3 mcg*h/mL, p = 0.068). Etravirine apparent oral clearance was significantly lower in the 3rd trimester of pregnancy compared to paired postpartum data by 52% (median 24 vs. 38 L/h, p = 0.025). The median ratio of cord blood to maternal plasma concentration at delivery was 0.52 (range: 0.19–4.25) and no perinatal transmission occurred. Conclusion: Etravirine apparent oral clearance is reduced and exposure increased during the third trimester of pregnancy. Based on prior dose-ranging and safety data, no dose adjustment is necessary for maternal health but the effects of etravirine in utero are unknown. Maternal health and infant outcomes should be closely monitored until further infant safety data are available. Clinical Trial registration: The IMPAACT protocol P1026s and PANNA study are registered at ClinicalTrials.gov under NCT00042289 and NCT00825929.
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Affiliation(s)
- Nikki Mulligan
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, USA
| | - Stein Schalkwijk
- Department of Pharmacy, Radboud University Medical Center Nijmegen, Netherlands
| | - Brookie M Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, USA
| | - Angela Colbers
- Department of Pharmacy, Radboud University Medical Center Nijmegen, Netherlands
| | - Jiajia Wang
- Center for Biostatistics in AIDS Research, Harvard School of Public Health Boston, MA, USA
| | - Edmund V Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, USA
| | - José Moltó
- Fundació Lluita contra la Sida, Hospital Universitari Germans Trias I Pujol Badalona, Spain
| | - Alice M Stek
- Maternal Child and Adolescent/Adult Center, University of Southern California School of Medicine Los Angeles, CA, USA
| | - Graham Taylor
- Imperial College Healthcare National Health Service Trust London, UK
| | - Elizabeth Smith
- Maternal, Adolescent, and Pediatric Research Branch, National Institute of Allergy and Infectious Diseases Bethesda, MD, USA
| | | | - Nahida Chakhtoura
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development Bethesda, MD, USA
| | - Marjo van Kasteren
- Department of Internal Medicine, St. Elisabeth Hospital Tilburg, Netherlands
| | - Courtney V Fletcher
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center Omaha, NE, USA
| | - Mark Mirochnick
- Department of Pediatrics, Boston University School of Medicine Boston, MA, USA
| | - David Burger
- Department of Pharmacy, Radboud University Medical Center Nijmegen, Netherlands
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50
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Gupta A, Mathad JS, Abdel-Rahman SM, Albano JD, Botgros R, Brown V, Browning RS, Dawson L, Dooley KE, Gnanashanmugam D, Grinsztejn B, Hernandez-Diaz S, Jean-Philippe P, Kim P, Lyerly AD, Mirochnick M, Mofenson LM, Montepiedra G, Piper J, Sahin L, Savic R, Smith B, Spiegel H, Swaminathan S, Watts DH, White A. Toward Earlier Inclusion of Pregnant and Postpartum Women in Tuberculosis Drug Trials: Consensus Statements From an International Expert Panel. Clin Infect Dis 2016; 62:761-769. [PMID: 26658057 PMCID: PMC4772846 DOI: 10.1093/cid/civ991] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 11/20/2015] [Indexed: 12/29/2022] Open
Abstract
Tuberculosis is a major cause of morbidity and mortality in women of childbearing age (15-44 years). Despite increased tuberculosis risk during pregnancy, optimal clinical treatment remains unclear: safety, tolerability, and pharmacokinetic data for many tuberculosis drugs are lacking, and trials of promising new tuberculosis drugs exclude pregnant women. To advance inclusion of pregnant and postpartum women in tuberculosis drug trials, the US National Institutes of Health convened an international expert panel. Discussions generated consensus statements (>75% agreement among panelists) identifying high-priority research areas during pregnancy, including: (1) preventing progression of latent tuberculosis infection, especially in women coinfected with human immunodeficiency virus; (2) evaluating new agents/regimens for treatment of multidrug-resistant tuberculosis; and (3) evaluating safety, tolerability and pharmacokinetics of tuberculosis drugs already in use during pregnancy and postpartum. Incorporating pregnant women into clinical trials would extend evidence-based tuberculosis prevention and treatment standards to this special population.
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Affiliation(s)
- Amita Gupta
- Division of Infectious Diseases and Department of International Health, Johns Hopkins University
| | - Jyoti S Mathad
- Division of Infectious Diseases, Center for Global Health Weill Cornell Medical College, New York, New York
| | - Susan M Abdel-Rahman
- Division of Clinical Pharmacology, Children's Mercy Hospital, Kansas City, Missouri
| | | | - Radu Botgros
- European Medicines Agency, London, United Kingdom
| | - Vikki Brown
- Women's Health and Medical Affairs, INC Research, Raleigh
| | - Renee S Browning
- Division of AIDS, National Institute of Allergy and Infectious Diseases
| | - Liza Dawson
- Division of AIDS, National Institute of Allergy and Infectious Diseases
| | - Kelly E Dooley
- Divisions of Clinical Pharmacology and Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore
| | | | - Beatriz Grinsztejn
- Instituto de Pesquisa Clinica Evandro Chagas-Fiocruz, Rio de Janeiro, Brazil
| | | | - Patrick Jean-Philippe
- Department of Health and Human Services, HJF-DAIDS, a division of The Henry M. Jackson Foundation for the Advancement of Military Medicine, contractor to the National Institute of Allergy and Infectious Diseases
| | - Peter Kim
- Division of AIDS, National Institute of Allergy and Infectious Diseases
| | - Anne D Lyerly
- University of North Carolina at Chapel Hill Center for Bioethics and Department of Social Medicine
| | - Mark Mirochnick
- Department of Pediatrics, Boston University School of Medicine, Massachusetts
| | - Lynne M Mofenson
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health
| | - Grace Montepiedra
- Department of Biostatistics, Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health
| | - Jeanna Piper
- Division of AIDS, National Institute of Allergy and Infectious Diseases
| | - Leyla Sahin
- Division of Pediatric and Maternal Health, FDA Office of New Drugs, Silver Spring, Maryland
| | - Radojka Savic
- Department of Bioengineering and Therapeutic Sciences, Schools of Pharmacy and Medicine, University of California San Francisco
| | - Betsy Smith
- Division of AIDS, National Institute of Allergy and Infectious Diseases
| | - Hans Spiegel
- Department of Health and Human Services, HJF-DAIDS, a division of The Henry M. Jackson Foundation for the Advancement of Military Medicine, contractor to the National Institute of Allergy and Infectious Diseases
| | | | - D Heather Watts
- Office of the Global AIDS Coordinator, US Department of State, Washington D.C
| | - Amina White
- Department of Bioethics, NIH Clinical Center, Bethesda
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