Suboptimal lopinavir exposure in infants on rifampicin treatment receiving double-dosed or semi-superboosted lopinavir/ritonavir: time for a change.
J Acquir Immune Defic Syndr 2023;
93:42-46. [PMID:
36724434 PMCID:
PMC10069754 DOI:
10.1097/qai.0000000000003168]
[Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/17/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND
While super-boosted lopinavir/ritonavir (LPV/r; ratio 4:4 instead of 4:1) is recommended for infants living with HIV and receiving concomitant rifampicin, in clinical practice many different LPV/r dosing strategies are applied due to poor availability of paediatric separate ritonavir formulations needed to super-boost. We evaluated LPV pharmacokinetics in infants with HIV receiving LPV/r dosed according to local guidelines in various sub-Saharan African countries with or without rifampicin-based tuberculosis (TB)-treatment.
METHODS
This was a 2-arm pharmacokinetic sub-study nested within the EMPIRICAL trial (#NCT03915366). Infants aged 1-12 months recruited into the main study were administered LPV/r according to local guidelines and drug availability either with or without rifampicin-based TB-treatment; during rifampicin co-treatment they received double-dosed (ratio 8:2) or semi-superboosted LPV/r (adding a ritonavir 100mg crushed tablet to the evening LPV/r dose). Six blood samples were taken over 12 hours after intake of LPV/r.
RESULTS
In total, 14/16 included infants had evaluable pharmacokinetic curves; 9/14 had rifampicin co-treatment (5 received double-dosed and 4 semi-superboosted LPV/r). The median (IQR) age was 6.4 months (5.4-9.8), weight 6.0kg (5.2-6.8) and 10/14 were male. Of those receiving rifampicin, 6/9 (67%) infants had LPV C trough <1.0mg/L compared to 1/5 (20%) in the control arm. LPV apparent oral clearance was 3.3-fold higher for infants receiving rifampicin.
CONCLUSION
Double-dosed or semi-superboosted LPV/r for infants aged 1-12 months receiving rifampicin resulted in substantial proportions of subtherapeutic LPV levels. There is an urgent need for data on alternative antiretroviral regimens in infants with HIV/TB co-infection, including twice-daily dolutegravir.
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