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Avedissian SN, Malik JR, Podany AT, Neely M, Rhodes NJ, Scarsi KK, Scheetz MH, Duryee MJ, Modebelu UO, Mykris TM, Winchester LC, Byrareddy SN, Fletcher CV. In-vitro and in-vivo assessment of nirmatrelvir penetration into CSF, central nervous system cells, tissues, and peripheral blood mononuclear cells. Sci Rep 2024; 14:10709. [PMID: 38729980 PMCID: PMC11087525 DOI: 10.1038/s41598-024-60935-5] [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: 11/01/2023] [Accepted: 04/29/2024] [Indexed: 05/12/2024] Open
Abstract
Three years after SARS-CoV-2 emerged as a global infectious threat, the virus has become endemic. The neurological complications such as depression, anxiety, and other CNS complications after COVID-19 disease are increasing. The brain, and CSF have been shown as viral reservoirs for SARS-CoV-2, yielding a potential hypothesis for CNS effects. Thus, we investigated the CNS pharmacology of orally dosed nirmatrelvir/ritonavir (NMR/RTV). Using both an in vitro and an in vivo rodent model, we investigated CNS penetration and potential pharmacodynamic activity of NMR. Through pharmacokinetic modeling, we estimated the median CSF penetration of NMR to be low at 18.11% of plasma with very low accumulation in rodent brain tissue. Based on the multiples of the 90% maximal effective concentration (EC90) for SARS-CoV-2, NMR concentrations in the CSF and brain do not achieve an exposure level similar to that of plasma. A median of only 16% of all the predicted CSF concentrations in rats were > 3xEC90 (unadjusted for protein binding). This may have implications for viral persistence and neurologic post-acute sequelae of COVID-19 if increased NMR penetration in the CNS leads to decreased CNS viral loads and decreased CNS inflammation.
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Affiliation(s)
- Sean N Avedissian
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA.
| | - Johid R Malik
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
| | - Anthony T Podany
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
| | - Michael Neely
- Department of Pediatrics, Division of Infectious Diseases, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Nathaniel J Rhodes
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL, USA
| | - Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL, USA
| | - Michael J Duryee
- Division of Rheumatology, Department of Pharmacology & Experimental Neurosciences Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ukamaka O Modebelu
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
| | - Timothy M Mykris
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
| | - Lee C Winchester
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
| | - Siddappa N Byrareddy
- Department of Pharmacology & Experimental Neurosciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Courtney V Fletcher
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA.
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, NE, USA.
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Gupta N, Swindells S, Scarsi KK, Furl R, Thomas DL, Weld ED, Ofimboudem JD, Desalegn H, Hamid S, Rosas ADLT, Miranda AE, Owen A, Rannard S, Hiebert L, Sun K, Ward JW. Preferences and feasibility of long-acting technologies for treatment of hepatitis C virus in low- and middle-income countries: A survey of providers and policymakers. J Viral Hepat 2024; 31:221-232. [PMID: 38545826 DOI: 10.1111/jvh.13921] [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] [Received: 10/16/2023] [Revised: 12/15/2023] [Accepted: 01/10/2024] [Indexed: 04/18/2024]
Abstract
Long-acting technologies (LATs) for hepatitis C virus (HCV) are under development as a strategy to improve linkage to care, treatment adherence and outcomes. We conducted a survey of HCV treatment prescribers and HCV policymakers in low- and middle-income countries (LMICs) regarding acceptability and feasibility of HCV LATs. We included one-time intramuscular injection, subdermal implant and transdermal patch as potential LAT options. We surveyed participants regarding optimal health system and patient characteristics, concerns, potential barriers, overall feasibility and preferences for HCV LAT as compared to daily oral medication. Overall, 122 providers and 50 policymakers from 42 LMICs completed the survey. Among providers, 93% (113/122) expressed willingness to prescribe LAT and 72% (88/120) of providers preferred LAT if provided at comparable efficacy, safety and cost as current oral treatments. Of providers preferring HCV LAT to daily oral medication, 67% (59/88) preferred injection, 24% (21/88) preferred patch and 9% (8/88) preferred implant. Only 20% (24/122) would prescribe LAT if it were more costly than oral treatment. In regression analysis, no provider characteristics were associated with preference for LAT over oral treatment. Policymakers reported high likelihood that LAT would be included in treatment guidelines (42/50; 84%) and national drug formularies (39/50; 78%) if efficacy, safety and cost were similar to oral treatment. HCV LATs could advance progress to HCV elimination in LMICs by diversifying treatment options to improve treatment coverage and outcomes. Provider preferences from LMICs are a critical consideration in the development of HCV LATs to ensure its early and equitable availability in LMICs.
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Affiliation(s)
- Neil Gupta
- Coalition for Global Hepatitis Elimination, The Task Force for Global Health, Decatur, Georgia, USA
| | - Susan Swindells
- Section of Infectious Diseases, Department of Internal Medicine, The University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Kimberly K Scarsi
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Renae Furl
- Section of Infectious Diseases, Department of Internal Medicine, The University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - David L Thomas
- Division of Infectious Diseases, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ethel D Weld
- Division of Infectious Diseases, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Clinical Pharmacology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Hailemichael Desalegn
- Medical Department, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Saeed Hamid
- Section of Gastroenterology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | | | - Angelica E Miranda
- Post-Graduation Program in Infectious Diseases, Federal University of Espirito Santo, Vitória, Brazil
| | - Andrew Owen
- Department of Pharmacology and Therapeutics, Centre of Excellence in Long acting Therapeutics (CELT), University of Liverpool, Liverpool, UK
| | - Steve Rannard
- Department of Chemistry, Centre of Excellence in Long acting Therapeutics (CELT), University of Liverpool, Liverpool, UK
| | - Lindsey Hiebert
- Coalition for Global Hepatitis Elimination, The Task Force for Global Health, Decatur, Georgia, USA
| | - Katherine Sun
- Coalition for Global Hepatitis Elimination, The Task Force for Global Health, Decatur, Georgia, USA
| | - John W Ward
- Coalition for Global Hepatitis Elimination, The Task Force for Global Health, Decatur, Georgia, USA
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Chappell CA, Lamorde M, Nakalema S, Kyohairwe I, Byakika-Kibwika P, Meyn LA, Pham MM, Scarsi KK. A randomized trial of double vs single-dose etonogestrel implant to overcome the interaction with efavirenz-based antiretroviral therapy. Am J Obstet Gynecol 2024:S0002-9378(24)00424-1. [PMID: 38458408 DOI: 10.1016/j.ajog.2024.03.001] [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: 11/27/2023] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Concomitant use of efavirenz-based antiretroviral therapy and a standard-dose etonogestrel contraceptive implant led to 82% lower etonogestrel exposure when compared with women who do not receive antiretroviral therapy. The clinical impact of this reduced exposure is supported by retrospective cohort evaluations that demonstrated higher rates of unintended pregnancies when contraceptive implants were combined with efavirenz. We hypothesized that placement of 2 etonogestrel implants in those taking efavirenz-based antiretroviral therapy could increase etonogestrel exposure and improve measures of contraceptive efficacy. OBJECTIVE This study compared the rate of ovulation and etonogestrel pharmacokinetics among women on efavirenz-based antiretroviral therapy who received 2 etonogestrel implants (136 mg; double implant group) in comparison with those who received 1 etonogestrel implant (68 mg; control group). STUDY DESIGN This randomized, open-label study enrolled Ugandan women with regular menstrual periods who were receiving efavirenz-based antiretroviral therapy for the treatment of HIV. Participants were randomized 1:1 to the double implant or control group, and the etonogestrel implant(s) were placed in the same arm at enrollment. All participants used a copper intrauterine device to prevent pregnancy. Ovulation was evaluated by weekly serum progesterone concentrations measured over 4 consecutive weeks at months 3 (weeks 9-12), 6 (weeks 21-24), and 12 (weeks 45-48). Progesterone concentrations >3 ng/mL were interpreted as ovulation. The ovulation rate in each group was compared using Fisher's exact tests for each month and generalized estimating equations over 48 weeks. Plasma was collected at day 3 and weeks 1, 4, 12, 24, 36, and 48 after implant placement and analyzed using a validated liquid chromatography-triple quadrupole mass spectrometry method for etonogestrel. Etonogestrel concentrations were summarized as median (interquartile range) and compared between groups by geometric mean ratio with 90% confidence intervals. RESULTS All participants (n=72) were cisgender Ugandan women with a median age of 31 years (interquartile range, 29-36), and 36 participants were enrolled in each study group. Two participants in the control group discontinued the trial; 1 at week 1 because of undetected pregnancy at entry and another at week 45 because of clinically significant depression. There were 47 ovulations over 104 person-months (45%) in 25 of 34 participants in the control group, and 2 ovulations over 108 person-months (2%) in 2 of 36 participants in the double implant group (month 3: 11 [31%] vs 0 [0%]; month 6: 17 [49%] vs 0 [0%]; month 12: 19 [56%] vs 2 [6%], respectively; all P<.001). The odds of ovulation were reduced by 97.7% (95% confidence interval, 90.1-99.5) in the double implant group over 48 weeks. At each time point, etonogestrel concentration was more than 2-fold higher in the double implant group than in the controls (geometric mean ratio, 2.30-2.83) with a geometric mean ratio of 2.83 (90% confidence interval, 1.89-3.35) at week 48. There were no differences in the adverse events between groups and no participant discontinued because of adverse events. CONCLUSION Over 48 weeks of combined use, placing 2 etonogestrel implants suppressed ovulation and increased plasma etonogestrel exposure when compared with 1 etonogestrel implant among women on efavirenz-based antiretroviral therapy. Doubling the dose of etonogestrel during efavirenz-based antiretroviral therapy could improve contraceptive effectiveness.
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Affiliation(s)
- Catherine A Chappell
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA; Magee-Womens Research Institute, Pittsburgh, PA.
| | - Mohammed Lamorde
- Infectious Diseases Institute, Kampala, Uganda; Department of Medicine, Makerere University, Kampala, Uganda
| | - Shadia Nakalema
- Infectious Diseases Institute, Kampala, Uganda; Department of Medicine, Makerere University, Kampala, Uganda
| | | | - Pauline Byakika-Kibwika
- Infectious Diseases Institute, Kampala, Uganda; Department of Medicine, Makerere University, Kampala, Uganda
| | - Leslie A Meyn
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Michelle M Pham
- Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, NE; Quantitative Pharmacology and Pharmacometrics, Merch & Co., Rahway, NJ
| | - Kimberly K Scarsi
- Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, NE; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
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Maaskant A, Scarsi KK, Meijer L, Roubos S, Louwerse AL, Remarque EJ, Langermans JAM, Stammes MA, Bakker J. Long-acting reversible contraception with etonogestrel implants in female macaques ( Macaca mulatta and Macaca fascicularis). Front Vet Sci 2024; 10:1319862. [PMID: 38260208 PMCID: PMC10800480 DOI: 10.3389/fvets.2023.1319862] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 12/04/2023] [Indexed: 01/24/2024] Open
Abstract
Introduction Contraception is often required for management and population control purposes in group-housed and free-roaming non-human primates. Long-acting reversible contraceptives, including subdermal progestin-releasing implants, are preferred as they eliminate challenges associated with frequent administration. Etonogestrel (ENG)-releasing subdermal implants are reversible and long-acting for a minimum of 3 years, and are commercially available for human use as Implanon® or Nexplanon®. Methods A retrospective analysis was performed detailing the contraceptive effectiveness and reversibility of subdermal placement of one-fourth or one-third of an ENG implant (68 mg/implant) in 129 female rhesus macaques (Macaca mulatta) and 67 cynomolgus macaques (Macaca fascicularis) at the Biomedical Primate Research Centre (Rijswijk, Netherlands). Furthermore, single cross-sectional ENG serum concentrations were measured for 16 rhesus and 10 cynomolgus macaques, and hemoglobin and blood chemistry pre-ENG and at timepoints >0.5, >1.5, and > 2.5 years post-ENG insertion were evaluated for 24 rhesus macaques. Finally, data were obtained using trans-abdominal ultrasound regarding the influence of ENG on uterine volume and endometrial thickness in 14 rhesus and 11 cynomolgus macaques. Results As a contraceptive ENG was in 99.80% (CI 93.50-99.99) and 99.95% (CI 99.95-100) effective in rhesus and cynomolgus macaques, respectively. Prolonged ENG durations of implant use in 14 rhesus macaques (range 3.1-5.0 years) and eight cynomolgus macaques (range 3.2-4.0 years) resulted in no unintended pregnancies. A total of 17 female macaques were allowed to breed after ENG removal, and among them, 14 female macaques (82%) had an uneventful delivery. Serum ENG concentrations with a median ENG duration of 1.2 years (range 0.1-6.0 years) and 1.9 years (range 0.6-4.7 years) resulted in median concentrations of 112 pg./mL (range 0-305 pg./mL) and 310 pg./mL (range 183-382 pg./mL) for rhesus and cynomolgus macaques, respectively. ENG had no clinical effect on hemoglobin and blood chemistry parameters nor on the thickness of the endometrial lining or uterus volume. Conclusion This study indicates that both one-fourth and one-third of the ENG implants are effective, long-acting, reversible, and safe contraceptive to use in macaques.
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Affiliation(s)
- Annemiek Maaskant
- Biomedical Primate Research Centre, Rijswijk, Netherlands
- Department Population Health Sciences, Animals in Science and Society, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
| | - Kimberly K. Scarsi
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, United States
| | - Lisette Meijer
- Biomedical Primate Research Centre, Rijswijk, Netherlands
| | - Sandra Roubos
- Biomedical Primate Research Centre, Rijswijk, Netherlands
| | | | | | - Jan A. M. Langermans
- Biomedical Primate Research Centre, Rijswijk, Netherlands
- Department Population Health Sciences, Animals in Science and Society, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
| | | | - Jaco Bakker
- Biomedical Primate Research Centre, Rijswijk, Netherlands
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Sunagawa SW, Havens JP, Podany A, Walker B, Scarsi KK, Bares SH. Long-Acting Cabotegravir/Rilpivirine Concentrations in Combination With Intravenous Rifampin: A Case Report. Open Forum Infect Dis 2023; 10:ofad604. [PMID: 38143853 PMCID: PMC10745268 DOI: 10.1093/ofid/ofad604] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/29/2023] [Indexed: 12/26/2023] Open
Abstract
As antiretroviral therapy advancements focus on long-acting medications, there is a need to assess the potential impact of drug-drug interactions. We present a real-world case of long-acting cabotegravir/rilpivirine co-administered with intravenous rifampin. The combination resulted in both cabotegravir and rilpivirine concentrations falling below 4 times the protein-adjusted IC90.
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Affiliation(s)
- Shawnalyn W Sunagawa
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Joshua P Havens
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Anthony Podany
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Bryan Walker
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Kimberly K Scarsi
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Sara H Bares
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Loutfy M, Lacombe-Duncan A, Tseng A, Persad Y, Underhill A, Kennedy VL, Armstrong I, Fung R, Bourns A, Nguyen Q, Hranilovic S, Weisdorf T, Chan LYL, Kia H, Halpenny R, Iyer H, Jeyarajah N, Kovchazov G, McCully J, Scarsi KK. Oestradiol concentrations in trans women with HIV suppressed on unboosted integrase inhibitor regimens versus trans women without HIV taking oral oestradiol: a pilot study. J Antimicrob Chemother 2023; 78:2653-2659. [PMID: 37681452 PMCID: PMC10631824 DOI: 10.1093/jac/dkad270] [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: 05/01/2023] [Accepted: 08/15/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Feminizing hormone therapy (FHT) is essential to many trans women. Concern about negative drug interactions between FHT and ART can be an ART adherence barrier among trans women with HIV. OBJECTIVES In this single-centre, parallel group, cross-sectional pilot study, we measured serum oestradiol concentrations in trans women with HIV taking FHT and unboosted integrase strand transfer inhibitor (INSTI)-based ART versus trans women without HIV taking FHT. METHODS We included trans women with and without HIV, aged ≥18 years, taking ≥2 mg/day of oral oestradiol for at least 3 months plus an anti-androgen. Trans women with HIV were on suppressive ART ≥3 months. Serum oestradiol concentrations were measured prior to medication dosing and 2, 4, 6 and 8 h post-dose. Median oestradiol concentrations were compared between groups using Wilcoxon rank-sum tests. RESULTS Participants (n = 8 with HIV, n = 7 without) had a median age of 32 (IQR: 28, 39) years. Among participants, the median oral oestradiol dose was 4 mg (range 2-6 mg). Participants had been taking FHT for a median of 4 years (IQR: 2, 8). Six trans women with HIV were taking bictegravir/emtricitabine/tenofovir alafenamide and two were taking dolutegravir/abacavir/lamivudine. All oestradiol concentrations were not significantly different between groups. Eleven (73%) participants had target oestradiol concentrations in the range 200-735 pmol/L at C4h (75% among women with HIV, 71% among those without HIV). CONCLUSIONS Oestradiol concentrations were not statistically different in trans women with HIV compared with those without HIV, suggesting a low probability of clinically relevant drug-drug interactions between FHT and unboosted INSTI-based ART.
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Affiliation(s)
- Mona Loutfy
- Women’s College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Maple Leaf Research, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ashley Lacombe-Duncan
- Women’s College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- School of Social Work, University of Michigan, Ann Arbor, MI, USA
| | - Alice Tseng
- Toronto General Hospital, Unity Health Network, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Yasmeen Persad
- Women’s College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Angela Underhill
- Women’s College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - V Logan Kennedy
- Women’s College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | | | - Raymond Fung
- Michael Garron Hospital, Toronto, Ontario, Canada
| | - Amy Bourns
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sherbourne Health, Toronto, Ontario, Canada
| | - Quang Nguyen
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sherbourne Health, Toronto, Ontario, Canada
| | - Sue Hranilovic
- Academic Family Health, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Thea Weisdorf
- Academic Family Health, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - L Y L Chan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Church-Wellesley Medical Clinic, Toronto, Ontario, Canada
| | - Hannah Kia
- School of Social Work, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Harshita Iyer
- Women’s College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | | | | | | | - Kimberly K Scarsi
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
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Scarsi KK, Sayles H, Kapungu K, Sifuna P, Ippolito MM, Furl R, Anderson MJ, Ofimboudem JD, Chongwe G, Hutter J, Rannard SP, Owen A, Swindells S. Preferences of Patients and Providers in High-Burden Malaria Settings for Long-Acting Malaria Chemoprevention. Am J Trop Med Hyg 2023; 109:752-760. [PMID: 37604474 PMCID: PMC10551098 DOI: 10.4269/ajtmh.23-0245] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/29/2023] [Indexed: 08/23/2023] Open
Abstract
Antimalarial medications are recommended for chemoprevention as part of malaria control programs to decrease the morbidity and mortality related to more than 200 million infections each year. We sought to evaluate patient and provider acceptability of malaria chemoprevention in a long-acting formulation. We administered questionnaires to patients and providers in malaria endemic districts in Kenya and Zambia. Questions explored preferences and concerns around long-acting antimalarial formulations compared with oral formulations. We recruited 202 patient respondents (Kenya, n = 102; Zambia, n = 100) and 215 provider respondents (Kenya, n = 105; Zambia, n = 110). Long-acting injection was preferred to oral pills, whereas oral pills were preferred to implant or transdermal administration by patient respondents. Of 202 patient respondents, 80% indicated that they 'definitely would try' malaria chemoprevention offered by injection instead of oral pills. Of parents or guardians, 84% of 113 responded that they 'definitely would' have their child age < 12 years and 90% of 88 'definitely would' have their child ≥12 years receive an injection for malaria prevention. Provider respondents indicated that they would be more likely to prescribe a long-acting injectable product compared with an oral product for malaria chemoprevention in adults (70%), adolescents ages 12 years and older (67%), and children <12 years (81%). Potential for prolonged adverse effects with long-acting products was the highest concern for patient respondents, while higher medication-related cost was cited as the most concerning barrier to implementation by providers. Overall, these findings indicate enthusiasm for the development of long-acting injectable antimalarials to provide individual delivery method options across age groups.
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Affiliation(s)
- Kimberly K. Scarsi
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Harlan Sayles
- College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - Kelvin Kapungu
- Department of Public Health and Epidemiology, Tropical Diseases Research Centre, Ndola, Zambia
| | - Peter Sifuna
- Kombewa Clinical Research Center, Kenya Medical Research Institute (KEMRI)/U.S. Army Medical Research Directorate–Africa (USAMRD-A), Kisumu, Kenya
| | - Matthew M. Ippolito
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- The Johns Hopkins Malaria Research Institute, John Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Renae Furl
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew J. Anderson
- College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | | | | | - Jack Hutter
- Kombewa Clinical Research Center, Kenya Medical Research Institute (KEMRI)/U.S. Army Medical Research Directorate–Africa (USAMRD-A), Kisumu, Kenya
| | - Steven P. Rannard
- Department of Chemistry, Centre of Excellence in Long-Acting Therapeutics (CELT), University of Liverpool, Liverpool, United Kingdom
| | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool, UK
| | - Susan Swindells
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
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Agyemang N, Scarsi KK, Baker P, Smeaton LM, Podany AT, Olefsky M, Woolley E, Barr E, Pham M, Mawlana S, Supparatpinyo K, Gatechompol S, Jalil EM, Gadama L, Badal-Faesen S, Van Schalkwyk M, Kayama C, Belaunzaran-Zamudio PF, Godfrey C, Cohn SE, Mngqibisa R, Haas DW. Pharmacogenetic interactions of efavirenz or rifampin and isoniazid with levonorgestrel emergency contraception during treatment of HIV or tuberculosis. Pharmacogenet Genomics 2023; 33:126-135. [PMID: 37306344 PMCID: PMC10309098 DOI: 10.1097/fpc.0000000000000501] [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: 03/01/2023] [Accepted: 05/16/2023] [Indexed: 06/13/2023]
Abstract
OBJECTIVE In AIDS Clinical Trials Group study A5375, a pharmacokinetic trial of levonorgestrel emergency contraception, double-dose levonorgestrel (3 mg, versus standard dose 1.5 mg) offset the induction effects of efavirenz or rifampin on plasma levonorgestrel exposure over 8 h post-dose (AUC 0-8h ). We characterized the pharmacogenetics of these interactions. METHODS Cisgender women receiving efavirenz- or dolutegravir-based HIV therapy, or on isoniazid-rifampin for tuberculosis, were followed after a single oral dose of levonorgestrel. Linear regression models, adjusted for BMI and age, characterized associations of CYP2B6 and NAT2 genotypes (which affect plasma efavirenz and isoniazid exposure, respectively) with levonorgestrel pharmacokinetic parameters. RESULTS Of 118 evaluable participants, 17 received efavirenz/levonorgestrel 1.5 mg, 35 efavirenz/levonorgestrel 3 mg, 34 isoniazid-rifampin/levonorgestrel 3 mg, and 32 (control group) dolutegravir/levonorgestrel 1.5 mg. There were 73 Black and 33 Asian participants. Regardless of genotype, women on efavirenz and isoniazid-rifampin had higher levonorgestrel clearance. In the efavirenz/levonorgestrel 3 mg group, CYP2B6 normal/intermediate metabolizers had levonorgestrel AUC 0-8h values similar to controls, while CYP2B6 poor metabolizers had AUC 0-8h values of 40% lower than controls. In the isoniazid-rifampin group, NAT2 rapid/intermediate acetylators had levonorgestrel AUC 0-8h values similar to controls, while NAT2 slow acetylators had AUC 0-8h values 36% higher than controls. CONCLUSION CYP2B6 poor metabolizer genotypes exacerbate the efavirenz-levonorgestrel interaction, likely by increased CYP3A induction with higher efavirenz exposure, making the interaction more difficult to overcome. NAT2 slow acetylator genotypes attenuate the rifampin-levonorgestrel interaction, likely by increased CYP3A inhibition with higher isoniazid exposure.
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Affiliation(s)
- Nana Agyemang
- Tufts University School of Medicine, Boston, Massachusetts
| | - Kimberly K. Scarsi
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska
| | - Paxton Baker
- Vanderbilt Technologies for Advanced Genomics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Laura M. Smeaton
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health; Boston, Massachusetts
| | - Anthony T. Podany
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska
| | - Maxine Olefsky
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health; Boston, Massachusetts
| | | | - Elizabeth Barr
- Office of Research on Women’s Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Michelle Pham
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska
| | - Sajeeda Mawlana
- Enhancing Care Foundation, Wentworth Hospital, Durban, South Africa
| | | | | | - Emilia M. Jalil
- Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | - Luis Gadama
- Johns Hopkins Research Project, Blantyre, Malawi
| | - Sharlaa Badal-Faesen
- Clinical HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg
| | - Marije Van Schalkwyk
- Family Center for Research with Ubuntu, Division of Infectious Diseases, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - Cecelia Kayama
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | | | - Catherine Godfrey
- Office of the Global AIDS Coordinator, Department of State, Washington, DC
| | - Susan E. Cohn
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rosie Mngqibisa
- Enhancing Care Foundation, Wentworth Hospital, Durban, South Africa
| | - David W. Haas
- Department of Medicine, Vanderbilt University School of Medicine
- Department of Internal Medicine, Meharry Medical College, Nashville, Tennessee, USA
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9
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Mykris TM, Weinhold J, Winchester LC, Scarsi KK, Fletcher CV, Podany AT, Avedissian SN. Quantification of nine antiretroviral drugs in cerebrospinal fluid: An approach to overcome sample collection tube adsorption. J Chromatogr B Analyt Technol Biomed Life Sci 2023; 1227:123810. [PMID: 37429153 PMCID: PMC10529871 DOI: 10.1016/j.jchromb.2023.123810] [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: 05/05/2023] [Revised: 06/20/2023] [Accepted: 06/23/2023] [Indexed: 07/12/2023]
Abstract
A highly sensitive LC-MS/MS methods were developed and validated to quantify nine antiretrovirals (atazanavir [ATV], tenofovir [TFV], emtricitabine [FTC], darunavir [DRV], dolutegravir [DTG], efavirenz [EFV], lamivudine [3TC], raltegravir [RAL], and ritonavir [RTV]) in human cerebral spinal fluid (CSF). The approach remedies adsorption issues caused by polypropylene based sample collection tubes. 1% ammonium hydroxide in methanol was added in an amount equal to the volume of each quality control (QC) or patient sample. Protein precipitation was utilized with a CSF sample volume of 100 μL and a 100 μL of methanol:ACN and vortexed. Chromatographic separation was achieved with a 3 × 100 ACE® C18 column for ATV, DRV, DTG, EFV, RTV and RAL, and a 2 × 100 Polar RP column for TFV/FTC/3TC. Mobile phase was methanol:water:formic acid (70:30:0.1, v/v/v) for ATV, DRV, DTG, EFV and RTV (10 uL injection, flow rate: 1.00 mL/min), ACN:water:formic acid (35:65:0.1, v/v/v) for RAL (50 uL injection, flow rate: 1.00 mL/min), ACN:water:formic acid (2:98:0.1, v/v/v) for TFV, FTC and 3TC (50 uL injection, flow rate: 0.35 mL/min). Column temperature was 40° C across all assays. The mass spectrometer was operated in positive, multiple-reaction-monitoring (MRM) mode with electrospray ionization (ESI) for all analytes with the exception of EFV, which was operated in negative, MRM mode with ESI. The assay was linear over the calibration range of 1 to 250 ng/mL for all analytes. The addition of 1% ammonium hydroxide in sample tubes overcame up to 44% negative bias in QC samples and allowed the methods to meet full validation criteria.
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Affiliation(s)
- Timothy M Mykris
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center. Omaha, NE, USA
| | - Jonathan Weinhold
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center. Omaha, NE, USA
| | - Lee C Winchester
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center. Omaha, NE, USA
| | - Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center. Omaha, NE, USA; Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center. Omaha, NE, USA
| | - Courtney V Fletcher
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center. Omaha, NE, USA; Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center. Omaha, NE, USA
| | - Anthony T Podany
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center. Omaha, NE, USA.
| | - Sean N Avedissian
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center. Omaha, NE, USA.
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10
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Malik JR, Fletcher CV, Podany AT, Dyavar SR, Scarsi KK, Pais GM, Scheetz MH, Avedissian SN. A novel 4-cell in-vitro blood-brain barrier model and its characterization by confocal microscopy and TEER measurement. J Neurosci Methods 2023; 392:109867. [PMID: 37116621 PMCID: PMC10275325 DOI: 10.1016/j.jneumeth.2023.109867] [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: 02/28/2023] [Revised: 04/18/2023] [Accepted: 04/25/2023] [Indexed: 04/30/2023]
Abstract
The blood-brain barrier (BBB) is a protective cellular anatomical layer with a dynamic micro-environment, tightly regulating the transport of materials across it. To achieve in-vivo characteristics, an in-vitro BBB model requires the constituent cell types to be layered in an appropriate order. A cost-effective in-vitro BBB model is desired to facilitate central nervous system (CNS) drug penetration studies. Enhanced integrity of tight junctions observed during the in-vitro BBB establishment and post-experiment is essential in these models. We successfully developed an in-vitro BBB model mimicking the in-vivo cell composition and a distinct order of seeding primary human brain cells. Unlike other in-vitro BBB models, our work avoids the need for pre-coated plates for cell adhesion and provides better cell visualization during the procedure. We found that using bovine collagen-I coating, followed by bovine fibronectin coating and poly-L-lysine coating, yields better adhesion and layering of cells on the transwell membrane compared to earlier reported use of collagen and poly-L-lysine only. Our results indicated better cell visibility and imaging with the polyester transwell membrane as well as point to a higher and more stable Trans Endothelial Electrical Resistance values in this plate. In addition, we found that the addition of zinc induced higher claudin 5 expressions in neuronal cells. Dolutegravir, a drug used in the treatment of HIV, is known to appear in moderate concentrations in the CNS. Thus, dolutegravir was used to assess the functionality of the final model and cells. Using primary cells and an in-house coating strategy substantially reduces costs and provides superior imaging of cells and their tight junction protein expression. Our 4-cell-based BBB model is a suitable experimental model for the drug screening process.
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Affiliation(s)
- Johid R Malik
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Courtney V Fletcher
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA; Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Anthony T Podany
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA; Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Gwendolyn M Pais
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA; Midwestern University, College of Pharmacy Center of Pharmacometric Excellence, Downers Grove, IL, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA; Midwestern University, College of Pharmacy Center of Pharmacometric Excellence, Downers Grove, IL, USA
| | - Sean N Avedissian
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA.
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11
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Scarsi KK, Smeaton LM, Podany AT, Olefsky M, Woolley E, Barr E, Pham M, Mawlana S, Supparatpinyo K, Gatechompol S, Jalil EM, Gadama L, Badal-Faesen S, Belaunzaran-Zamudio PF, Godfrey C, Cohn SE, Mngqibisa R. Pharmacokinetics of dose-adjusted levonorgestrel emergency contraception combined with efavirenz-based antiretroviral therapy or rifampicin-containing tuberculosis regimens. Contraception 2023; 121:109951. [PMID: 36641094 PMCID: PMC10187685 DOI: 10.1016/j.contraception.2023.109951] [Citation(s) in RCA: 1] [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: 06/25/2022] [Revised: 12/09/2022] [Accepted: 12/19/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To determine if double-dose levonorgestrel emergency contraception (EC) in combination with efavirenz or rifampicin, 2 drugs known to decrease levonorgestrel exposure, resulted in similar pharmacokinetics compared to standard-dose levonorgestrel EC without drug-drug interactions. STUDY DESIGN We conducted a phase 2, open-label, multicenter, partially randomized, 4 parallel group trial in pre-menopausal females ≥16 years old without an indication for EC and not on hormonal contraception. Participants on dolutegravir-based antiretroviral therapy (ART) received levonorgestrel 1.5 mg (control group); those on rifampicin-containing tuberculosis therapy received levonorgestrel 3 mg; those on efavirenz-based ART were randomized 1:2 to levonorgestrel 1.5 mg or 3 mg. Plasma was collected through 48 hours post-dose to assess levonorgestrel pharmacokinetics. Area under the concentration-time curve (AUC) over 8 hours was the primary outcome. Levonorgestrel pharmacokinetic parameters were compared between groups using geometric mean ratios (GMR) with 90% confidence intervals. RESULTS The median (Q1, Q3) age for all participants (n = 118) was 34 (27, 41) years and BMI was 23.2 (20, 26.3) kg/m2. Participants receiving levonorgestrel 1.5mg plus efavirenz (n = 17) had 50% lower AUC0-8h compared to the control group (n = 32) [0.50 (0.40, 0.62)]. Participants receiving levonorgestrel 3 mg had a similar AUC0-8h when receiving either efavirenz (n = 35) [0.99 (0.81, 1.20)] or rifampicin (n = 34) [1.16 (0.99, 1.36)] compared to control. Levonorgestrel 3 mg resulted in similar or higher maximum concentration with either efavirenz [1.17 (0.96, 1.41)] or rifampicin [1.27 (1.09, 1.49)] compared to the control group. CONCLUSIONS Doubling the dose of levonorgestrel EC successfully increased levonorgestrel exposure over the first 8 hours in participants receiving either efavirenz-based ART or rifampicin-containing tuberculosis therapy. IMPLICATIONS Adjusting levonorgestrel emergency contraception from 1.5 mg to 3 mg improves levonorgestrel pharmacokinetic exposure in participants receiving either efavirenz-based antiretroviral regimens or rifampicin-containing tuberculosis therapy. These data support guideline recommendations to double the dose of levonorgestrel emergency contraception in persons on medications that decrease levonorgestrel exposure by inducing levonorgestrel metabolism.
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Affiliation(s)
- Kimberly K Scarsi
- College of Pharmacy, University of Nebraska Medical Center; Omaha, NE, United States.
| | - Laura M Smeaton
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health; Boston, MA, United States
| | - Anthony T Podany
- College of Pharmacy, University of Nebraska Medical Center; Omaha, NE, United States
| | - Maxine Olefsky
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health; Boston, MA, United States
| | | | - Elizabeth Barr
- Office of Research on Women's Health, National Institutes of Health, Bethesda, MD, United States
| | - Michelle Pham
- College of Pharmacy, University of Nebraska Medical Center; Omaha, NE, United States
| | - Sajeeda Mawlana
- Enhancing Care Foundation, Wentworth Hospital, Durban, South Africa
| | | | | | - Emilia M Jalil
- Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | - Luis Gadama
- Johns Hopkins Research Project, Blantyre, Malawi
| | - Sharlaa Badal-Faesen
- Clinical HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, South Africa
| | - Pablo F Belaunzaran-Zamudio
- Contractor, Division of AIDS, National Institute of Allergy and Infectious Diseases; Bethesda, MD, United States
| | | | - Susan E Cohn
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Rosie Mngqibisa
- Enhancing Care Foundation, Wentworth Hospital, Durban, South Africa
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12
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Nachega JB, Scarsi KK, Gandhi M, Scott RK, Mofenson LM, Archary M, Nachman S, Decloedt E, Geng EH, Wilson L, Rawat A, Mellors JW. Long-acting antiretrovirals and HIV treatment adherence. Lancet HIV 2023; 10:e332-e342. [PMID: 37062293 PMCID: PMC10734401 DOI: 10.1016/s2352-3018(23)00051-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [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: 11/20/2022] [Revised: 01/26/2023] [Accepted: 02/10/2023] [Indexed: 04/18/2023]
Abstract
Intramuscular injection of long-acting cabotegravir and rilpivirine is a novel, long-acting antiretroviral therapy (ART) combination approved for use as a fully suppressive regimen for people living with HIV. Long-acting cabotegravir with rilpivirine ART has reduced required dosing frequency from once daily to once every month or every 2 months injections. This new era of long-acting ART, which includes other antiretrovirals and formulations in various stages of clinical development, holds tremendous promise to change the standard of HIV treatment. Although long-acting ART has high potential to be revolutionary in the landscape of HIV care, prevention, and treatment cascade, more data are needed to substantiate its efficacy and cost-effectiveness among patients at risk of non-adherence and across age groups, pregnancy, and post partum. Advocacy efforts and policy changes to optimise a sustained, high-quality, equitable reach of long-acting ART, especially in low-income and middle-income countries where most people living with HIV reside, are needed to realise the full benefits of long-acting ART.
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Affiliation(s)
- Jean B Nachega
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA; Department of Infectious Diseases and Microbiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA; Center for Global Health, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA; Department of Epidemiology and Department International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, and Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Rachel K Scott
- MedStar Health Research Institute and MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC, USA
| | | | - Moherndran Archary
- Department of Pediatrics, King Edward VIII Hospital, University of Kwa Zulu Natal, Durban, South Africa
| | - Sharon Nachman
- Department of Pediatrics, Stony Brook Children's, SUNY Stony Brook University, Stony Brook, NY, USA
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elvin H Geng
- Division of Infectious Diseases, Department of Medicine, and Institute for Public Health, Washington University, St Louis, MO, USA
| | | | - Angeli Rawat
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; School of Population and Public Heath, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John W Mellors
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
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13
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Havens JP, Bares SH, Lyden E, Podany AT, Scarsi KK, Fadul N, Swindells S. Effectiveness and Safety of Bictegravir/Emtricitabine/Tenofovir Alafenamide in Patients With HIV-1 Infection and Ongoing Substance Use Disorder: The BASE Study. Open Forum Infect Dis 2023; 10:ofad080. [PMID: 36910693 PMCID: PMC10003752 DOI: 10.1093/ofid/ofad080] [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: 11/29/2022] [Accepted: 02/09/2023] [Indexed: 02/14/2023] Open
Abstract
Background People with human immunodeficiency virus (HIV) and substance use disorder (PWH/SUD) are at higher risk of nonadherence to antiretroviral therapy. Bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) exhibits high rates of efficacy with a favorable adverse event profile. The BASE study (NCT03998176) is a phase 4, single-arm study evaluating the effectiveness and safety of B/F/TAF among PWH/SUD. Methods Viremic (HIV RNA >1000 copies/mL) PWH/SUD initiated B/F/TAF once daily for 48 weeks (W). The primary endpoint was proportion of participants with HIV RNA <50 copies/mL at W24. Secondary endpoints were proportion of participants with HIV-1 RNA <50 copies/mL at W48, safety, B/F/TAF adherence (dried blood spot [DBS] concentrations of emtricitabine triphosphate and tenofovir diphosphate [TFV-DP]), substance use (NIDA-ASSIST), and quality of life (SF-12). Results Forty-three participants were enrolled; 95% reported methamphetamine use. Median age was 38 (range, 21-62) years; 21% were female, 81% White, 14% Black, and 16% Hispanic. Thirty-two (74%) and 21 (49%) participants had HIV RNA <50 copies/mL (intention-to-treat) at W24 and W48, respectively. Seven participants (16%) experienced confirmed virologic failure through W48; 1 developed emergent drug resistance (M184V). Fifteen participants (35%) experienced grade ≥3 adverse events. Five participants (12%) reported suicidal ideation; none resulted in discontinuation. Median DBS concentrations were representative of 5-6 doses/week (TFV-DP, 1603 fmol/punches). NIDA-ASSIST scores declined from baseline to W48 with methamphetamine use decreasing most (-7.9 points; -29%), and SF-12 physical/mental scores increased 1.2 and 7.6 points, respectively. Conclusions B/F/TAF among a high-risk population of PWH/SUD resulted in an initial 72% viral suppression rate at W24 before dropping to 49% at W48 as retention declined. One participant developed emergent drug resistance (M184V).
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Affiliation(s)
- Joshua P Havens
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA.,College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Sara H Bares
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Elizabeth Lyden
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Anthony T Podany
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Kimberly K Scarsi
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA.,College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Nada Fadul
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Susan Swindells
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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14
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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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15
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Nakalema S, Chappell CA, Pham M, Byakika-Kibwika P, Kaboggoza J, Walimbwa SI, Musaazi J, Nakijoba R, Mbabazi L, Kyohairwe I, Nassiwa S, Jeppson J, Winchester L, Siccardi M, Fletcher CV, Scarsi KK, Lamorde M. Pharmacokinetics of levonorgestrel and etonogestrel contraceptive implants over 48 weeks with rilpivirine- or darunavir-based antiretroviral therapy. J Antimicrob Chemother 2022; 77:3144-3152. [PMID: 36059130 DOI: 10.1093/jac/dkac296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/04/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Pharmacokinetic data are lacking for progestin-releasing subdermal contraceptive implants when used with either rilpivirine- or darunavir/ritonavir-based ART. OBJECTIVES To characterize the pharmacokinetics of etonogestrel or levonorgestrel implants when administered with these ART regimens over 48 weeks. PATIENTS AND METHODS Two separate, parallel, three-group, non-randomized, pharmacokinetic studies evaluated either etonogestrel or levonorgestrel in women receiving rilpivirine- or darunavir-based ART compared with women without HIV (control group). Participants on ART were switched to rilpivirine-based ART with a run-in period of 6 weeks or darunavir-based ART with a run-in of 2 weeks prior to implant insertion. Plasma was collected on Day 0, and 1, 4, 12, 24, 36 and 48 weeks post-insertion. Plasma progestin concentrations were compared between ART and control groups by geometric mean ratio (GMR) and 90% CI. RESULTS At the primary endpoint of Week 24, progestin concentrations were similar between the rilpivirine and control groups [etonogestrel: 1.18 (0.99-1.37); levonorgestrel: 1.16 (0.97-1.33)]. At Week 24, progestin exposure was higher in the darunavir groups compared with the control group [etonogestrel: 2.56 (1.69-3.28); levonorgestrel: 1.89 (1.38-2.29)]. Results remained consistent through to Week 48. No differences in etonogestrel-related adverse events were observed, but both ART groups experienced more menstrual abnormalities versus the control group with levonorgestrel. CONCLUSIONS Etonogestrel and levonorgestrel concentrations were not altered by rilpivirine-based ART. Although progestin concentrations were higher in the ART groups containing ritonavir-boosted darunavir, no implant-related serious adverse events were observed. Both progestin-releasing implants are an appropriate contraceptive option with either rilpivirine- or darunavir/ritonavir-based ART.
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Affiliation(s)
- Shadia Nakalema
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Catherine A Chappell
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michelle Pham
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Julian Kaboggoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Joseph Musaazi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Ritah Nakijoba
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Leah Mbabazi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Sylvia Nassiwa
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jeffrey Jeppson
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Lee Winchester
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Marco Siccardi
- Department of Pharmacology, University of Liverpool, Liverpool, UK
| | | | - Kimberly K Scarsi
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
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16
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Abstract
PURPOSE OF REVIEW Cabotegravir (CAB) and rilpivirine (RPV) is the first long-acting injectable antiretroviral therapy (ART) option approved for virologically suppressed adults with HIV-1. In addition, long-acting CAB is a promising agent for HIV preexposure prophylaxis (PrEP). This review focuses on phase 3 clinical trial results and implementation considerations for these long-acting ART and PrEP strategies. RECENT FINDINGS Long-acting CAB and RPV administered every 4 weeks demonstrated noninferiority to oral ART through week 96 in both the ATLAS and FLAIR studies, whereas ATLAS-2M found similar efficacy through 96 weeks when the long-acting injectable ART was administered every 8 weeks instead of every 4 weeks. For prevention, two phase 3 trials were stopped early due to fewer incident HIV infections in participants receiving long-acting CAB every 8 weeks compared with daily oral tenofovir disoproxil fumarate-emtricitabine for PrEP. The long-acting therapies were well tolerated across all clinical trials. SUMMARY Clinical trial results support the use of long-acting CAB for HIV PrEP and long-acting CAB and RPV as a switch strategy for adults with HIV-1 who are first virologically suppressed with oral ART. Implementation challenges persist, and data are urgently needed in populations who may benefit most from long-acting therapy, including adolescents, pregnant individuals, and those with barriers to medication adherence.
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Affiliation(s)
- Sara H. Bares
- Department of Internal Medicine, College of Medicine
| | - Kimberly K. Scarsi
- Department of Internal Medicine, College of Medicine
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
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17
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Podany AT, Scarsi KK, Pham MM, Fletcher CV. Comparative Clinical Pharmacokinetics and Pharmacodynamics of HIV-1 Integrase Strand Transfer Inhibitors: An Updated Review. Clin Pharmacokinet 2021; 59:1085-1107. [PMID: 32462541 DOI: 10.1007/s40262-020-00898-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [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] [Indexed: 01/11/2023]
Abstract
Bictegravir, cabotegravir, dolutegravir, elvitegravir, and raltegravir are members of the latest class of antiretrovirals available to treat human immunodeficiency virus (HIV) infection, the integrase strand transfer inhibitors. Integrase strand transfer inhibitors are potent inhibitors of the HIV integrase enzyme with IC90/95 values in the low nanogram per milliliter range and they retain antiviral activity against strains of HIV with acquired resistance to other classes of antiretrovirals. Each of the integrase strand transfer inhibitors have unique pharmacokinetic/pharmacodynamic properties, influencing their role in clinical use in specific subsets of patients. Cabotegravir, approved for use in Canada but not yet by the US Food and Drug Administration, is formulated in both oral and intramuscular formulations; the latter of which has shown efficacy as a long-acting extended-release formulation. Cabotegravir, raltegravir, and dolutegravir have minimal drug-drug interaction profiles, as their metabolism has minimal cytochrome P450 involvement. Conversely, elvitegravir metabolism occurs primarily via cytochrome P450 3A4 and requires pharmacokinetic boosting to achieve systemic exposures amenable to once-daily dosing. Bictegravir metabolism has similar contributions from both cytochrome P450 3A4 and uridine 5'-diphospho-glucuronosyltransferase 1A1. Bictegravir, dolutegravir, and raltegravir are recommended components of initial regimens for most people with HIV in the US adult and adolescent HIV treatment guidelines. This review summarizes and compares the pharmacokinetics and pharmacodynamics of the integrase strand transfer inhibitor agents, and describes specific pharmacokinetic considerations for persons with hepatic impairment, renal dysfunction, pregnancy, and co-infections.
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Affiliation(s)
- Anthony T Podany
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, PDD Rm 3019, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA.
| | - Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, PDD Rm 3019, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
| | - Michelle M Pham
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, PDD Rm 3019, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
| | - Courtney V Fletcher
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, PDD Rm 3019, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
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18
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Roberts O, Kinvig H, Owen A, Lamorde M, Siccardi M, Scarsi KK. In vitro assessment of the potential for dolutegravir to affect hepatic clearance of levonorgestrel. HIV Med 2021; 22:898-906. [PMID: 34328253 PMCID: PMC9363158 DOI: 10.1111/hiv.13136] [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] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 06/07/2021] [Indexed: 12/01/2022]
Abstract
Objectives: The World Health Organization recommends that all countries adopt dolutegravir-based antiretroviral therapy as the preferred regimen for all individuals living with HIV. Levonorgestrel is a commonly used hormonal contraceptive, which undergoes drug–drug interactions with some antiretrovirals, but the potential interaction between dolutegravir and levonorgestrel has not been examined. We aimed to evaluate cytochrome P450 (CYP)-mediated levonorgestrel metabolism and quantify the effects of dolutegravir on levonorgestrel apparent intrinsic clearance (CLint.app.) and CYP gene expression. Methods: In vitro CYP-mediated CLint.app. of levonorgestrel was quantified using a recombinant human CYP (rhCYP) enzyme system. A primary human hepatocyte model of drug metabolism was used to assess the effects of dolutegravir on (1) levonorgestrel CLint.app., using liquid chromatography-tandem mass spectrometry, and (2) the expression of specific CYP enzymes, using quantitative real-time polymerase chain reaction. Results: Levonorgestrel clearance was mediated by multiple rhCYPs, including rhCYP3A4. Under control conditions, levonorgestrel CLint.app. was 22.4 ± 5.0 μL/min/106 hepatocytes. Incubation with 43.1 nM of unbound dolutegravir elevated levonorgestrel CLint.app. to 31.4 ± 7.8 μL/min/106 hepatocytes (P = 0.168), while 142.23 nM increased levonorgestrel CLint.app. to 37.0 ± 2.9 μL/min/106 hepatocytes (P = 0.012). Unbound dolutegravir ≥ 431 nM induced expression of CYP3A4 (≥ two-fold) in a dose-dependent manner, while 1.44 μM of unbound dolutegravir induced CYP2B6 expression 2.2 ± 0.3-fold (P = 0.0004). Conclusions: In summary, this in vitro study suggests that dolutegravir has the potential to increase hepatic clearance of levonorgestrel by inducing both CYP3A and non-CYP3A enzymes. The observed in vitro dolutegravir–levonorgestrel drug–drug interaction should be further examined in clinical studies.
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Affiliation(s)
- Owain Roberts
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Hannah Kinvig
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Andrew Owen
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, Materials Innovation Factory, University of Liverpool, Liverpool, UK
| | - Mohammed Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Marco Siccardi
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Kimberly K Scarsi
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
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19
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Cirrincione LR, Podany AT, Havens JP, Bares SH, Dyavar SR, Gwon Y, Johnson TM, Amoura NJ, Fletcher CV, Scarsi KK. Plasma and intracellular pharmacokinetics of tenofovir disoproxil fumarate and emtricitabine in transgender women receiving feminizing hormone therapy. J Antimicrob Chemother 2021; 75:1242-1249. [PMID: 32065631 DOI: 10.1093/jac/dkaa016] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 11/25/2019] [Accepted: 01/05/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Transwomen have an increased risk of HIV acquisition compared with other adults. Drug-drug interactions between pre-exposure prophylaxis (PrEP) and gender-affirming therapy are cited as a reason for poor PrEP uptake among transwomen. We evaluated plasma tenofovir and emtricitabine pharmacokinetics and their active intracellular anabolites, tenofovir-diphosphate and emtricitabine-triphosphate, in transwomen receiving feminizing hormones. METHODS We enrolled HIV-negative transwomen (≥19 years) not receiving PrEP. Participants took oral tenofovir disoproxil fumarate/emtricitabine 300/200 mg daily for 14 days. Plasma was collected at 0 h (pre-dose), 0.5, 1, 2, 3, 4, 6, 8 and 12 h on day 14 post-tenofovir disoproxil fumarate/emtricitabine dose. The plasma AUC0-24 was calculated using the trapezoidal rule and compared with historical HIV-negative cisgender adults as geometric mean ratios (GMRs, 90% CI). Secondarily, tenofovir-diphosphate and emtricitabine-triphosphate from PBMCs collected at 0 h and 12 h were reported descriptively as geometric means (90% CI). Clinical trials registration: NCT03270969. RESULTS Among 15 transwomen (mean age 32 years), geometric mean tenofovir and emtricitabine plasma AUC0-24 were lower compared with controls: tenofovir, 2.10 versus 2.76 mg·h/L, GMR 0.76 (0.65-0.90), P = 0.01; emtricitabine, 9.15 versus 10.64 mg·h/L, GMR 0.86 (0.75-0.98), P = 0.07. Tenofovir-diphosphate and emtricitabine-triphosphate concentrations were higher than previously reported in the literature: 167.1 (146.6-190.5) fmol/106 cells and 15.4 (13.8-17.3) pmol/106 cells, respectively. CONCLUSIONS We observed lower plasma tenofovir and emtricitabine concentrations in transwomen compared with historical cisgender adults, yet intracellular tenofovir-diphosphate and emtricitabine-triphosphate concentrations were higher than previously reported in PBMCs. Understanding the differences of PrEP pharmacokinetics in plasma and tissue compartments and the resultant impact on efficacy remains important for transwomen.
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Affiliation(s)
- Lauren R Cirrincione
- Antiviral Pharmacology Laboratory, Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Anthony T Podany
- Antiviral Pharmacology Laboratory, Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Joshua P Havens
- Antiviral Pharmacology Laboratory, Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sara H Bares
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Shetty Ravi Dyavar
- Antiviral Pharmacology Laboratory, Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Yeongjin Gwon
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Tanner M Johnson
- Antiviral Pharmacology Laboratory, Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - N Jean Amoura
- Department of Obstetrics and Gynecology, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Courtney V Fletcher
- Antiviral Pharmacology Laboratory, Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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20
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Rawizza HE, Oladokun R, Ejeliogu E, Oguche S, Ogunbosi BO, Agbaji O, Odaibo G, Imade G, Olaleye D, Wiesner L, Darin KM, Okonkwo P, Kanki PJ, Scarsi KK, McIlleron HM. Rifabutin pharmacokinetics and safety among TB/HIV-coinfected children receiving lopinavir/ritonavir-containing second-line ART. J Antimicrob Chemother 2021; 76:710-717. [PMID: 33294914 PMCID: PMC7879135 DOI: 10.1093/jac/dkaa512] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/09/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Treatment options are limited for TB/HIV-coinfected children who require PI-based ART. Rifabutin is the preferred rifamycin for adults on PIs, but the one study evaluating rifabutin with PIs among children was stopped early due to severe neutropenia. METHODS We evaluated rifabutin safety and plasma pharmacokinetics among coinfected children 3-15 years of age receiving rifabutin 2.5 mg/kg daily with standard doses of lopinavir/ritonavir. The AUC0-24 at 2, 4 and 8 weeks after rifabutin initiation was described using intensive sampling and non-compartmental analysis. Clinical and laboratory toxicities were intensively monitored at 12 visits throughout the study. RESULTS Among 15 children with median (IQR) age 13.1 (10.9-14.0) years and weight 25.5 (22.3-30.5) kg, the median (IQR) rifabutin AUC0-24 was 5.21 (4.38-6.60) μg·h/mL. Four participants had AUC0-24 below 3.8 μg·h/mL (a target for the population average exposure) at week 2 and all had AUC0-24 higher than 3.8 μg·h/mL at the 4 and 8 week visits. Of 506 laboratory evaluations during rifabutin, grade 3 and grade 4 abnormalities occurred in 16 (3%) and 2 (0.4%) instances, respectively, involving 9 (60%) children. Specifically, grade 3 (n = 4) and grade 4 (n = 1) neutropenia resolved without treatment interruption or clinical sequelae in all patients. One child died at week 4 of HIV-related complications. CONCLUSIONS In children, rifabutin 2.5 mg/kg daily achieved AUC0-24 comparable to adults and favourable HIV and TB treatment outcomes were observed. Severe neutropenia was relatively uncommon and improved with ongoing rifabutin therapy. These data support the use of rifabutin for TB/HIV-coinfected children who require lopinavir/ritonavir.
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Affiliation(s)
- Holly E Rawizza
- Brigham and Women’s Hospital, Boston, MA, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Regina Oladokun
- College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
| | - Emeka Ejeliogu
- College of Health Sciences, Jos University Teaching Hospital, University of Jos, Jos, Nigeria
| | - Stephen Oguche
- College of Health Sciences, Jos University Teaching Hospital, University of Jos, Jos, Nigeria
| | - Babatunde O Ogunbosi
- College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
| | - Oche Agbaji
- College of Health Sciences, Jos University Teaching Hospital, University of Jos, Jos, Nigeria
| | - Georgina Odaibo
- College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
| | - Godwin Imade
- College of Health Sciences, Jos University Teaching Hospital, University of Jos, Jos, Nigeria
| | - David Olaleye
- College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kristin M Darin
- Northwestern University School of Professional Studies, Chicago, IL, USA
| | | | | | - Kimberly K Scarsi
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Helen M McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, 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
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21
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Scarsi KK, Swindells S. The Promise of Improved Adherence With Long-Acting Antiretroviral Therapy: What Are the Data? J Int Assoc Provid AIDS Care 2021; 20:23259582211009011. [PMID: 33902356 PMCID: PMC8082990 DOI: 10.1177/23259582211009011] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [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: 02/09/2021] [Revised: 03/04/2021] [Accepted: 03/16/2021] [Indexed: 11/16/2022] Open
Abstract
As with other chronic conditions, adherence to daily medications remains a challenge for many individuals living with HIV due to structural, behavioral, and social barriers. Unfortunately, high levels of adherence to antiretroviral therapy are required to maintain virologic suppression. Alternative approaches are being explored to decrease the burden of daily pill administration, including long-acting injectable, oral, and implantable products. Phase 3 data support the efficacy of nanoformulated injectable cabotegravir and rilpivirine for HIV treatment in patients with undetectable viremia, but we have yet to learn how this strategy may benefit those with medication adherence challenges. Despite this, the affected community and HIV providers are very interested in exploring the role of long-acting therapies to address some types of barriers to medication adherence. This review summarizes available information about the potential for long-acting therapy to improve adherence for some patients and outlines associated opportunities and challenges with the implementation of long-acting therapy for the treatment and prevention of HIV.
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Affiliation(s)
- Kimberly K. Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Susan Swindells
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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22
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Abstract
The newest class of antiretrovirals for all persons living with HIV are the integrase strand transfer inhibitors (INSTIs). Since 2007, five INSTIs have been introduced: raltegravir, elvitegravir, dolutegravir, bictegravir, and cabotegravir. The INSTIs have favorable pharmacokinetic and pharmacodynamic properties, which contribute to both their effectiveness and their ease of use. With the exception of cabotegravir, each INSTI is US Food and Drug Administration approved for treatment-naïve individuals initiating antiretroviral therapy. All of the INSTIs, except raltegravir, are approved for antiretroviral treatment simplification for virologically suppressed patients without INSTI resistance. Data also support the use of dolutegravir and raltegravir in individuals with antiretroviral resistance as part of an optimized antiretroviral regimen. INSTIs are generally well tolerated by people living with HIV compared with older classes of antiretrovirals, but emerging data suggest that some INSTIs contribute to weight gain. Due to their efficacy, safety, and ease of use, HIV treatment guidelines recommend oral INSTIs as preferred components of antiretroviral therapy for individuals initiating therapy. The newest INSTI, cabotegravir, represents an alternative to oral administration of life-long antiretroviral therapy with the availability of a long-acting injectable formulation. This review summarizes the current use of INSTIs in adults living with HIV, highlighting the similarities and differences within the class related to pharmacodynamics, pharmacokinetics, safety, dosing, and administration that contribute to their role in modern antiretroviral therapy.
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Affiliation(s)
- Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA.
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Joshua P Havens
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Anthony T Podany
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
| | - Sean N Avedissian
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
| | - Courtney V Fletcher
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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23
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Johnson TM, Klepser DG, Bares SH, Scarsi KK. Predictors of vaccination rates in people living with HIV followed at a specialty care clinic. Hum Vaccin Immunother 2020; 17:791-796. [PMID: 32881642 DOI: 10.1080/21645515.2020.1802163] [Citation(s) in RCA: 5] [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] [Indexed: 12/31/2022] Open
Abstract
People Living with HIV (PLWH) remain disproportionately susceptible to vaccine-preventable illnesses due to increased morbidity and mortality from common pathogens, increased transmission related to epidemiologic factors, and decreased vaccination rates. We aimed to describe patient-specific predictive factors that may impact adherence to the CDC's recommended vaccination schedules in PLWH. We retrospectively evaluated adult PLWH in care at the University of Nebraska Medical Center's HIV clinic and collected information related to demographics, clinic visits, vaccination status, and measures of HIV disease control. Patients were categorized as "Adherent" if they had received all vaccinations for which they were eligible and were categorized as "Non-Adherent" if they were deficient or delayed in receiving one or more vaccinations. Participant characteristics were compared between groups by multivariable logistic regression to identify predictors associated with vaccine schedule non-adherence. We evaluated 502 PLWH who met our inclusion criteria; 206 of these (41%) had received all eligible vaccinations, while 296 (59%) were missing one or more vaccinations. The mean age of participants was 48 years old, 76% were male, and 53% were white. Our participants had a median of 2.83 clinic visits per year and missed 8.3% of scheduled clinic visits. Factors associated with non-adherence to vaccination schedules included a high frequency of missed clinic appointments (>10%), men who have sex with men, and a CD4 count <200 cells/mm3. Knowledge of variables associated with vaccination rates may be beneficial in identifying patients at-risk for under-vaccination and designing targeted education programs for providers and patients.
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Affiliation(s)
- Tanner M Johnson
- College of Pharmacy, Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, NE, USA.,Department of Pharmacy, UCHealth University of Colorado Hospital, Aurora, CO, USA.,Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Donald G Klepser
- College of Pharmacy, Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sara H Bares
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kimberly K Scarsi
- College of Pharmacy, Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, NE, USA.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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24
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Neary M, Chappell CA, Scarsi KK, Nakalema S, Matovu J, Achilles SL, Chen BA, Siccardi M, Owen A, Lamorde M. Effect of patient genetics on etonogestrel pharmacokinetics when combined with efavirenz or nevirapine ART. J Antimicrob Chemother 2020; 74:3003-3010. [PMID: 31299074 DOI: 10.1093/jac/dkz298] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 06/10/2019] [Accepted: 06/12/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND We previously demonstrated that etonogestrel concentrations were 82% lower in women using etonogestrel contraceptive implants plus efavirenz-based ART compared with women not receiving ART. OBJECTIVES To investigate the genetic contribution to this previously observed drug-drug interaction through studying SNPs in genes known to be involved in efavirenz, nevirapine or etonogestrel metabolism in the same group of women. PATIENTS AND METHODS Here, we present a secondary analysis evaluating SNPs involved in efavirenz, nevirapine and etonogestrel metabolism and associated etonogestrel pharmacokinetics among 57 women, 19 not receiving ART (control group), 19 receiving efavirenz- (600 mg daily) based ART and 19 receiving nevirapine- (200 mg twice daily) based ART. Associations between patient genotype and etonogestrel pharmacokinetic parameters were determined through univariate and multivariate linear regression. This study was registered at clinicaltrials.gov (NCT02082652). RESULTS Within the control group, CYP2B6 983 T>C was associated with 27% higher etonogestrel Cmax and 28% higher AUC0-24weeks. In the efavirenz group CYP2B6 516 G>T was associated with 43% lower etonogestrel Cmin and 34% lower AUC0-24weeks. For participants receiving nevirapine, NR1I2 63396 C>T was associated with 39% lower etonogestrel Cmin and 37% lower AUC0-24weeks. CONCLUSIONS This study demonstrates the influence of pharmacogenetics on the extent of drug-drug interactions between etonogestrel and efavirenz- or nevirapine-based ART. Efavirenz plus the etonogestrel contraceptive implant results in a detrimental drug-drug interaction irrespective of patient genetics, which is worsened in women possessing variant alleles for these CYP2B6 SNPs.
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Affiliation(s)
- Megan Neary
- Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Catherine A Chappell
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kimberly K Scarsi
- Department of Pharmacy Practice and Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Shadia Nakalema
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joshua Matovu
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Sharon L Achilles
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Beatrice A Chen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marco Siccardi
- Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Andrew Owen
- Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
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25
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Rawizza HE, Darin KM, Oladokun R, Brown B, Ogunbosi B, David N, Akanmu S, Olaitan O, Chang C, Scarsi KK, Okonkwo P, Kanki PJ. Safety and efficacy of rifabutin among HIV/TB-coinfected children on lopinavir/ritonavir-based ART. J Antimicrob Chemother 2020; 74:2707-2715. [PMID: 31139825 DOI: 10.1093/jac/dkz219] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 04/16/2019] [Accepted: 04/23/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND TB is the leading cause of death among HIV-infected children, yet treatment options for those who require PI-based ART are suboptimal. Rifabutin is the preferred rifamycin for adults on PI-based ART; only one study has evaluated its use among children on PIs and two of six children developed treatment-limiting neutropenia. METHODS Since 2009, rifabutin has been available for HIV/TB-coinfected children requiring PI-based ART in the Harvard/APIN programme in Nigeria. We retrospectively analysed laboratory and clinical toxicities at baseline and during rifabutin therapy, and examined HIV/TB outcomes. RESULTS Between 2009 and 2015, 48 children received rifabutin-containing TB therapy with PI (lopinavir/ritonavir)-based ART: 50% were female with a median (IQR) baseline age of 1.7 (0.9-5.0) years and a median (IQR) CD4+ cell percentage of 15% (9%-25%); 52% were ART experienced. Eighty-five percent completed the 6 month rifabutin course with resolution of TB symptoms and 79% were retained in care at 12 months. Adverse events (grade 1-4) were more common at baseline (27%) than during rifabutin treatment (15%) (P = 0.006). Absolute neutrophil count was lower during rifabutin compared with baseline (median = 1762 versus 2976 cells/mm3, respectively), but only one instance (2%) of grade 3 neutropenia occurred during rifabutin treatment. CONCLUSIONS With clinical and laboratory monitoring, our data suggest that rifabutin is a safe option for TB therapy among children on PI-based ART. By contrast with the only other study of this combination in children, severe neutropenia was rare. Furthermore, outcomes from this cohort suggest that rifabutin is effective, and a novel option for children who require PI-based ART. Additional study of rifabutin plus PIs in children is urgently needed.
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Affiliation(s)
- Holly E Rawizza
- Brigham and Women's Hospital, Boston, MA, USA.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Kristin M Darin
- Northwestern University School of Professional Studies, Chicago, IL, USA
| | - Regina Oladokun
- College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
| | - Biobele Brown
- College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
| | - Babatunde Ogunbosi
- College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
| | - Nkiruka David
- Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
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Chappell CA, Scarsi KK, Kirby BJ, Suri V, Gaggar A, Bogen DL, Macio IS, Meyn LA, Bunge KE, Krans EE, Hillier SL. Ledipasvir plus sofosbuvir in pregnant women with hepatitis C virus infection: a phase 1 pharmacokinetic study. Lancet Microbe 2020; 1:e200-e208. [PMID: 32939459 PMCID: PMC7491553 DOI: 10.1016/s2666-5247(20)30062-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Hepatitis C virus (HCV) infection is increasing among pregnant women because of the opioid epidemic, yet there are no interventions to reduce perinatal HCV transmission or to treat HCV during pregnancy. Physiological changes in pregnancy alter the pharmacokinetics of some medications; thus, our aim was to compare the pharmacokinetic parameters of ledipasvir 90 mg plus sofosbuvir 400 mg during pregnancy with non-pregnant women. Methods This was an open-label, phase 1 study of pregnant women with genotype 1 HCV infection and their infants. A reference group of women who had participated in pharmacokinetic studies of ledipasvir–sofosbuvir during phase 2 and 3 trials was used. Participants were enrolled at Magee-Womens Hospital (Pittsburgh, PA, USA) between 23 and 24 weeks’ gestation and had a 12-week course of oral ledipasvir–sofosbuvir (daily 90 mg ledipasvir plus 400 mg sofosbuvir). Three 12-h intensive pharmacokinetic visits were done at 25–26, 29–30, and 33–34 weeks’ gestation and individual pharmacokinetics were summarised by geometric mean across the three visits. The primary outcome, analysed in all participants without suspected dosing errors, was the ledipasvir–sofosbuvir area under the concentration–time curve of the dosing interval (AUCtau) during pregnancy compared with the reference group by geometric mean ratio. This study is registered with ClinicalTrials.gov, NCT02683005. Findings From Oct 1, 2016, to Sept 30, 2018, 29 pregnant women were screened and nine (31%) were enrolled. Eight (89%) women were included in the primary analysis. Ledipasvir and sofosbuvir exposures were similar in the pregnant women versus the non-pregnant reference group (geometric mean ratio of AUCtau ledipasvir 89·3% [90% CI 68·7–116·1]; sofosbuvir 91·1% [78·0–106·3]). Interpretation Ledipasvir–sofosbuvir was safe and effective without clinically meaningful differences in drug exposure among pregnant versus non-pregnant women. Funding National Institutes of Health/Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institutes of Health/Office of Research on Women’s Health, and Gilead Sciences.
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Affiliation(s)
- Catherine A Chappell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Kimberly K Scarsi
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | | | - Debra L Bogen
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Leslie A Meyn
- Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Katherine E Bunge
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Sharon L Hillier
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA
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27
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Affiliation(s)
- Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, and Division of Infectious Diseases, College of Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA.
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Koren DE, Scarsi KK, Farmer EK, Cha A, Adams JL, Pandit NS, Chang J, Scott J, Hardy WD. A Call to Action: The Role of Antiretroviral Stewardship in Inpatient Practice, a Joint Policy Paper of the Infectious Diseases Society of America, HIV Medicine Association, and American Academy of HIV Medicine. Clin Infect Dis 2020; 70:2241-2246. [PMID: 32445480 PMCID: PMC7245143 DOI: 10.1093/cid/ciz792] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/12/2019] [Indexed: 12/01/2022] Open
Abstract
Persons living with human immunodeficiency virus (HIV) and others receiving antiretrovirals are at risk for medication errors during hospitalization and at transitions of care. These errors may result in adverse effects or viral resistance, limiting future treatment options. A range of interventions is described in the literature to decrease the occurrence or duration of medication errors, including review of electronic health records, clinical checklists at care transitions, and daily review of medication lists. To reduce the risk of medication-related errors, antiretroviral stewardship programs (ARVSPs) are needed to enhance patient safety. This call to action, endorsed by the Infectious Diseases Society of America, the HIV Medicine Association, and the American Academy of HIV Medicine, is modeled upon the success of antimicrobial stewardship programs now mandated by the Joint Commission. Herein, we propose definitions of ARVSPs, suggest resources for ARVSP leadership, and provide a summary of published, successful strategies for ARVSP that healthcare facilities may use to develop locally appropriate programs.
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Affiliation(s)
- David E Koren
- Temple University Hospital, Philadelphia, Pennsylvania
| | - Kimberly K Scarsi
- Department of Pharmacy Practice and Science, University of Nebraska Medical Center College of Pharmacy, Omaha
| | - Eric K Farmer
- LifeCare Clinic at Indiana University Health, Indianapolis
| | - Agnes Cha
- Division of Pharmacy Practice, Arnold and Marie Schwartz College of Pharmacy and Health Sciences at Long Island University, Brooklyn, New York
| | - Jessica L Adams
- Department of Pharmacy Practice and Pharmacy Administration, Philadelphia College of Pharmacy at University of the Sciences, Pennsylvania
| | - Neha Sheth Pandit
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore
| | - Jennifer Chang
- Kaiser Permanente at Los Angeles Medical Center, Pomona, California
| | - James Scott
- Western University of Health Sciences College of Pharmacy, Pomona, California
| | - W David Hardy
- Johns Hopkins School of Medicine, Baltimore, Maryland
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29
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Gandhi M, Smeaton LM, Vernon C, Scully EP, Gianella S, Poongulali S, Sheth AN, Van Schalkwyk M, Klingman KL, Short WR, Opollo VS, Cohn SE, Scarsi KK, Firnhaber C, Bares S, Swaminathan S, Mngqibisa R, Connick E. Low Rate of Sex-specific Analyses in Presentations at the Conference on Retroviruses and Opportunistic Infections (CROI) Meeting, 2018: Room to Improve. J Acquir Immune Defic Syndr 2020; 81:e158-e160. [PMID: 31021991 PMCID: PMC6625875 DOI: 10.1097/qai.0000000000002073] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Monica Gandhi
- University of California San Francisco, San Francisco, CA
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Havens JP, Scarsi KK, Sayles H, Klepser DG, Swindells S, Bares SH. Response to Dong et al. Open Forum Infect Dis 2020; 7:ofaa032. [PMID: 32099845 PMCID: PMC7031060 DOI: 10.1093/ofid/ofaa032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 01/23/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Joshua P Havens
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA.,Department of Pharmacy Practice & Science, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Kimberly K Scarsi
- Department of Pharmacy Practice & Science, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Harlan Sayles
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Donald G Klepser
- Department of Pharmacy Practice & Science, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Susan Swindells
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Sara H Bares
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
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31
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Scarsi KK, Cramer YS, Rosenkranz SL, Aweeka F, Berzins B, Coombs RW, Coughlin K, Moran LE, Zorrilla CD, Akelo V, Aziz M, Friedman RK, Gingrich D, Swaminathan S, Godfrey C, Cohn SE. Antiretroviral therapy and vaginally administered contraceptive hormones: a three-arm, pharmacokinetic study. Lancet HIV 2019; 6:e601-e612. [PMID: 31498109 PMCID: PMC6765389 DOI: 10.1016/s2352-3018(19)30155-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 04/30/2019] [Accepted: 05/01/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Drug-drug interactions between orally administered antiretroviral therapy (ART) and hormones released from an intravaginal ring are not known. We hypothesised that ART containing either efavirenz or ritonavir-boosted atazanavir would alter plasma concentrations of vaginally administered etonogestrel and ethinylestradiol but that ART concentrations would be unchanged during use of an intravaginal ring. METHODS We did a parallel, three-group, pharmacokinetic evaluation at HIV clinics in Asia (two sites), South America (five), sub-Saharan Africa (three), and the USA (11) between Dec 30, 2014, and Sept 12, 2016. We enrolled women with HIV who were either ART-naive (control group; n=25), receiving efavirenz-based ART (n=25), or receiving atazanavir-ritonavir-based ART (n=24). Women receiving ART were required to be on the same regimen for at least 30 days, with 400 copies or less per mL of plasma HIV-1 RNA; women not receiving ART had CD4 counts of 350 cells per μL or less. We excluded participants who had a bilateral oophorectomy or conditions that were contraindicated in the intravaginal ring product labelling. An intravaginal ring releasing etonogestrel and ethinylestradiol was inserted at entry (day 0). Single plasma samples for hormone concentrations were collected on days 7, 14, and 21 after intravaginal ring insertion. The primary outcome was the plasma concentration of etonogestrel and ethinylestradiol on day 21. Etonogestrel and ethinylestradiol concentrations were compared between each ART group and the control group by geometric mean ratio (GMR) with 90% CIs and Wilcoxon rank-sum test. As secondary outcomes, efavirenz or ritonavir-boosted atazanavir concentrations were assessed by 8-h intensive pharmacokinetic sampling at entry before intravaginal ring insertion and before intravaginal ring removal on day 21. Antiretroviral areas under the concentration-time curve (AUC0-8 h) were compared before and after intravaginal ring insertion by GMR (90% CI) and Wilcoxon signed-rank test. This study is registered with ClinicalTrials.gov, number NCT01903031. FINDINGS Between Dec 30, 2014, and Sept 12, 2016, we enrolled 84 participants in the study; ten participants were excluded from the primary hormone analysis. 74 participants met the primary endpoint: 25 in the control group, 25 in the efavirenz group, and 24 in the atazanavir group. On day 21 of intravaginal ring use, participants receiving efavirenz had 79% lower etonogestrel (GMR 0·21, 90% CI 0·16-0·28; p<0·0001) and 59% lower ethinylestradiol (0·41, 0·32-0·52; p<0·0001) concentrations compared with the control group. By contrast, participants receiving ritonavir-boosted atazanavir had 71% higher etonogestrel (1·71, 1·37-2·14; p<0·0001), yet 38% lower ethinylestradiol (0·62, 0·49-0·79; p=0·0037) compared with the control group. The AUC0-8 h of efavirenz or atazanavir did not differ between the groups. INTERPRETATION Hormone exposure was significantly lower when an intravaginal ring contraceptive was combined with efavirenz-based ART. Further studies designed to examine pharmacodynamic endpoints, such as ovulation, when intravaginal ring hormones are combined with efavirenz are warranted. FUNDING National Institutes of Health, through the AIDS Clinical Trials Group and the International Maternal Pediatric Adolescent AIDS Clinical Trials Network, 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)
- Kimberly K Scarsi
- University of Nebraska Medical Center, Department of Pharmacy Practice and Science, Omaha, NE, USA.
| | - Yoninah S Cramer
- Harvard T H Chan School of Public Health, Boston, MA, USA; Frontier Science Foundation, Brookline, MA, USA
| | - Susan L Rosenkranz
- Harvard T H Chan School of Public Health, Boston, MA, USA; Frontier Science Foundation, Brookline, MA, USA
| | - Francesca Aweeka
- Department of Clinical Pharmacy, School of Pharmacy, University of California San Francisco, San Francisco, CA, USA
| | - Baiba Berzins
- Division of Infectious Diseases, Northwestern University, Chicago, IL, USA
| | - Robert W Coombs
- Department of Medicine and Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | | | | | - Carmen D Zorrilla
- University of Puerto Rico School of Medicine, Obstetrics and Gynecology Department, San Juan, Puerto Rico
| | | | - Mariam Aziz
- Division of Infectious Diseases, Rush University Medical Center, Chicago, IL, USA
| | - Ruth K Friedman
- Laboratório de Pesquisa Clínica em DST/Aids, Instituto Nacional de Infectologia Evandro Chagas, FIOCRUZ, Rio de Janeiro, Brazil
| | - David Gingrich
- Department of Clinical Pharmacy, School of Pharmacy, University of California San Francisco, San Francisco, CA, USA
| | - Shobha Swaminathan
- Division of Infectious Diseases, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, USA
| | - Catherine Godfrey
- Division of AIDS, National Institutions of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Susan E Cohn
- Division of Infectious Diseases, Northwestern University, Chicago, IL, USA
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Havens JP, Scarsi KK, Sayles H, Klepser DG, Swindells S, Bares SH. Acceptability and feasibility of a pharmacist-led HIV pre-exposure prophylaxis (PrEP) program in the Midwestern United States. Open Forum Infect Dis 2019; 6:5550068. [PMID: 31412131 PMCID: PMC6765348 DOI: 10.1093/ofid/ofz365] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [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: 06/24/2019] [Indexed: 12/02/2022] Open
Abstract
Background Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) substantially reduces the risk of HIV acquisition, yet significant barriers exist to its prescription and use. Incorporating pharmacists in the PrEP care process may help increase access to PrEP services. Methods Our pharmacist-led PrEP program (P-PrEP) included pharmacists from a university-based HIV clinic, a community pharmacy, and 2 community-based clinics. Through a collaborative practice agreement, pharmacists conducted PrEP visits with potential candidates for PrEP, according to the recommended Centers for Disease Control and Prevention guidelines, and authorized emtricitabine-tenofovir disoproxil fumarate prescriptions. Demographics and retention in care over 12 months were summarized, and participant satisfaction and pharmacist acceptability with the P-PrEP program were assessed by Likert-scale questionnaires. Results Sixty patients enrolled in the P-PrEP program between January and June 2017 completing 139 visits. The mean age was 34 years (range, 20–61 years), and 88% identified as men who have sex with men, 91.7% were men, 83.3% were white, 80% were commercially insured, and 89.8% had completed some college education or higher. Participant retention at 3, 6, 9, and 12 months was 73%, 58%, 43%, and 28%, respectively. To date, no participant has seroconverted. One hundred percent of the participants who completed the patient satisfaction questionnaire would recommend the P-PrEP program. Pharmacists reported feeling comfortable performing point-of-care testing and rarely reported feeling uncomfortable during PrEP visits (3 occasions, 2.2%) or experiencing workflow disruption (1 occasion, 0.7%). Conclusions Implementation of a pharmacist-led PrEP program is feasible and associated with high rates of patient satisfaction and pharmacist acceptability.
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Affiliation(s)
- Joshua P Havens
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska.,Department of Pharmacy Practice & Science, University of Nebraska Medical Center, Omaha, Nebraska
| | - Kimberly K Scarsi
- Department of Pharmacy Practice & Science, University of Nebraska Medical Center, Omaha, Nebraska
| | - Harlan Sayles
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska
| | - Donald G Klepser
- Department of Pharmacy Practice & Science, University of Nebraska Medical Center, Omaha, Nebraska
| | - Susan Swindells
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska
| | - Sara H Bares
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska
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Roberts O, Rajoli RKR, Back DJ, Owen A, Darin KM, Fletcher CV, Lamorde M, Scarsi KK, Siccardi M. Physiologically based pharmacokinetic modelling prediction of the effects of dose adjustment in drug-drug interactions between levonorgestrel contraceptive implants and efavirenz-based ART. J Antimicrob Chemother 2019; 73:1004-1012. [PMID: 29365101 DOI: 10.1093/jac/dkx515] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 12/07/2017] [Indexed: 01/11/2023] Open
Abstract
Background HIV-positive women receiving efavirenz-based ART and levonorgestrel contraceptive implants are at risk of low levonorgestrel exposure and unintended pregnancy. Objectives To investigate clinically applicable dose-adjustment strategies to overcome the known drug-drug interaction (DDI) between levonorgestrel and efavirenz, using a physiologically based pharmacokinetic (PBPK) modelling-based approach. Methods A PBPK model was qualified against clinical data to predict levonorgestrel plasma concentrations when standard-dose (150 mg) levonorgestrel implants were administered alone (control group), as well as when standard-dose or increased-dose (300 mg) levonorgestrel implants were coadministered with either 600 or 400 mg of efavirenz. Results No difference was seen between in vivo clinical and PBPK-model-simulated levonorgestrel plasma concentrations (P > 0.05). Simulated levonorgestrel plasma concentrations were ∼50% lower at 48 weeks post-implant-placement in virtual individuals receiving standard-dose levonorgestrel with either 600 or 400 mg of efavirenz compared with the control group (efavirenz:control geometric mean ratio = 0.42 and 0.49, respectively). Conversely, increased-dose levonorgestrel in combination with either 600 or 400 mg of efavirenz was sufficient to restore levonorgestrel concentrations to levels similar to those observed in the 150 mg levonorgestrel control group 48 weeks post-implant-placement (efavirenz:control geometric mean ratio = 0.86 and 1.03, respectively). Conclusions These results suggest that the clinically significant DDI between efavirenz and levonorgestrel is likely to persist despite efavirenz dose reduction, whereas dose escalation of implantable levonorgestrel may represent a successful clinical strategy to circumvent efavirenz-levonorgestrel DDIs and will be of use to inform clinical trial design to assess coadministration of efavirenz and levonorgestrel implants.
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Affiliation(s)
- Owain Roberts
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, 70 Pembroke Place, Liverpool L69 3GF, UK
| | - Rajith K R Rajoli
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, 70 Pembroke Place, Liverpool L69 3GF, UK
| | - David J Back
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, 70 Pembroke Place, Liverpool L69 3GF, UK
| | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, 70 Pembroke Place, Liverpool L69 3GF, UK
| | - Kristin M Darin
- School of Professional Studies, Northwestern University, Chicago, IL, USA
| | | | - Mohammed Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kimberly K Scarsi
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Marco Siccardi
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, 70 Pembroke Place, Liverpool L69 3GF, UK
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Broekhuis JM, Scarsi KK, Sayles HR, Klepser DG, Havens JP, Swindells S, Bares SH. Midwest pharmacists' familiarity, experience, and willingness to provide pre-exposure prophylaxis (PrEP) for HIV. PLoS One 2018; 13:e0207372. [PMID: 30427912 PMCID: PMC6235377 DOI: 10.1371/journal.pone.0207372] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 10/30/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction Pharmacist provision of pre-exposure prophylaxis (PrEP) through collaborative practice agreements with physicians could expand access to people at risk for HIV. We characterized pharmacists’ familiarity with and willingness to provide PrEP services in Nebraska and Iowa. Methods An invitation to complete an 18-question survey was emailed to 1,140 pharmacists in Nebraska and Iowa in June and July of 2016. Descriptive analyses and Pearson chi-square tests were used to determine to what extent demographics, familiarity and experience were associated with respondent willingness to provide PrEP. Wilcoxon rank-sum tests compared ages and years of experience between groups of respondents. Results One hundred forty pharmacists (12.3%) responded. Less than half were familiar with the use of PrEP (42%) or the CDC guidelines for its use (25%). Respondents who were older (p = .015) and in practice longer (p = .005) were less likely to be familiar with PrEP. Overall, 54% indicated they were fairly or very likely to provide PrEP services as part of a collaborative practice agreement and after additional training. While familiarity with PrEP use or guidelines did not affect respondents’ willingness to provide PrEP, respondents were more likely to provide PrEP with prior experience counseling HIV-infected patients on antiretroviral therapy (OR 2.43; p = 0.023) or PrEP (OR 4.67; p = 0.013), and with prior HIV-related continuing education (OR 2.77; p = 0.032). Conclusions Pharmacist respondents in Nebraska and Iowa had limited familiarity and experience with PrEP, but most indicated willingness to provide PrEP through collaborative practice agreements after additional training. Provision of PrEP-focused continuing education may lead to increased willingness to participate in PrEP programs.
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Affiliation(s)
- Jordan M. Broekhuis
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Kimberly K. Scarsi
- Department of Pharmacy Practice, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Harlan R. Sayles
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Donald G. Klepser
- Department of Pharmacy Practice, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Joshua P. Havens
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Susan Swindells
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Sara H. Bares
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
- * E-mail:
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Lee SS, Havens JP, Sayles HR, O'Neill JL, Podany AT, Swindells S, Scarsi KK, Bares SH. A pharmacist-led medication switch protocol in an academic HIV clinic: patient knowledge and satisfaction. BMC Infect Dis 2018; 18:310. [PMID: 29980192 PMCID: PMC6035459 DOI: 10.1186/s12879-018-3226-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 06/29/2018] [Indexed: 12/13/2022] Open
Abstract
Background Tenofovir alafenamide (TAF) is associated with less renal and bone toxicity compared with tenofovir disoproxil (TDF). TAF's recent FDA approval has spurred HIV providers to consider switching antiretroviral therapy (ART) regimens containing TDF to TAF to minimize long term risks. Patient views on the process of such medication switches have not been explored. Methods Patients taking elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate (E/C/F/TDF) following the Food and Drug Administration’s (FDA) approval of elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide (E/C/F/TAF) received medication education from an HIV pharmacist prior to switching to the tenofovir alafenamide (TAF) formulation. Patients were asked to complete a cross-sectional survey assessing satisfaction with the switch process and knowledge about the new medication 4 to 8 weeks post-switch. Results Sixty five patients completed the switch and 57 (88%) completed a follow-up survey. Most (86%) reported understanding why the switch was made, while 91% correctly identified that TAF is associated with reduced renal toxicity, and 73% correctly identified that TAF is associated with reduced bone toxicity. No statistically significant difference was found in satisfaction with or understanding of why the medication switch was made when assessed by sex, age, race, or education, but there was a trend toward significance in the distribution of answers based on education level with those with a high school diploma, General Educational Development (GED) or less being more likely to be satisfied with the medication switch (p = 0.074). Conclusions Education from an ambulatory clinic-based HIV pharmacist resulted in high rates of patient satisfaction and understanding of the switch from TDF to TAF-containing ART. Electronic supplementary material The online version of this article (10.1186/s12879-018-3226-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah S Lee
- College of Medicine, University of Nebraska Medical Center, NE, Omaha, NE, 68198-8106, USA
| | - Joshua P Havens
- Section of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Harlan R Sayles
- College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jennifer L O'Neill
- Section of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Anthony T Podany
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Susan Swindells
- Section of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kimberly K Scarsi
- College of Medicine, University of Nebraska Medical Center, NE, Omaha, NE, 68198-8106, USA.,College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sara H Bares
- Section of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA.
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Cirrincione LR, Penchala SD, Scarsi KK, Podany AT, Winchester LC, Back DJ, Khoo SH, Fletcher CV, Siccardi M, Else LJ. Development, validation and utilization of a highly sensitive LC-MS/MS method for quantification of levonorgestrel released from a subdermal implant in human plasma. J Chromatogr B Analyt Technol Biomed Life Sci 2018; 1084:106-112. [PMID: 29579732 PMCID: PMC5892837 DOI: 10.1016/j.jchromb.2018.03.023] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 03/07/2018] [Accepted: 03/11/2018] [Indexed: 01/11/2023]
Abstract
Levonorgestrel (LNG) is a synthetic progestin that is available in oral contraceptive tablets, a subdermal implant, and an intrauterine system for contraception. LNG pharmacokinetics are a pivotal determinant of contraceptive efficacy and essential in assessing drug-drug interactions influencing LNG exposure following different routes of LNG administration. A highly sensitive LC-MS/MS method was developed and validated to quantify levonorgestrel in human plasma. Liquid-liquid extraction was utilized with a sample volume of 500 μL to extract levonorgestrel from plasma. Chromatographic separation of LNG was achieved with a Fortis™ C18 (3 μm: 100 mm × 2.1 mm) reverse phase analytical column. The mobile phases consisted of de-ionized water plus 0.1% NH4OH (100:0.1%, v/v) (A), and methanol plus 0.1% NH4OH (100:0.1%, v/v) (B) delivered as a gradient at a flow rate of 400 μL/min. Detection of LNG and internal standard (D-(-)-norgestrel-d7) was achieved using positive polarity mode monitoring at 313.2-245.2 amu and 320.1-251.2 amu, respectively. The assay was linear over the calibration range of 49.6 to 1500 pg/mL. This method was used to quantify plasma LNG released by subdermal implant in support of a drug interaction study among women with HIV receiving efavirenz- or nevirapine-based antiretroviral therapy.
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Affiliation(s)
- Lauren R Cirrincione
- Antiviral Pharmacology Laboratory, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sujan Dilly Penchala
- Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Anthony T Podany
- Antiviral Pharmacology Laboratory, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Lee C Winchester
- Antiviral Pharmacology Laboratory, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - David J Back
- Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Saye H Khoo
- Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Courtney V Fletcher
- Antiviral Pharmacology Laboratory, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Marco Siccardi
- Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Laura J Else
- Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.
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Neary M, Lamorde M, Olagunju A, Darin KM, Merry C, Byakika-Kibwika P, Back DJ, Siccardi M, Owen A, Scarsi KK. The Effect of Gene Variants on Levonorgestrel Pharmacokinetics When Combined With Antiretroviral Therapy Containing Efavirenz or Nevirapine. Clin Pharmacol Ther 2017; 102:529-536. [PMID: 28187506 DOI: 10.1002/cpt.667] [Citation(s) in RCA: 23] [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] [Received: 11/03/2016] [Revised: 01/16/2017] [Accepted: 02/04/2017] [Indexed: 12/31/2022]
Abstract
Reduced levonorgestrel concentrations from the levonorgestrel contraceptive implant was previously seen when given concomitantly with efavirenz. We sought to assess whether single nucleotide polymorphisms (SNPs) in genes involved in efavirenz and nevirapine metabolism were linked to these changes in levonorgestrel concentration. SNPs in CYP2B6, CYP2A6, NR1I2, and NR1I3 were analyzed. Associations of participant demographics and genotype with levonorgestrel pharmacokinetics were evaluated in HIV-positive women using the levonorgestrel implant plus efavirenz- or nevirapine-based antiretroviral therapy (ART), in comparison to ART-naïve women using multivariate linear regression. Efavirenz group: CYP2B6 516G>T was associated with lower levonorgestrel log10 Cmax and log10 AUC. CYP2B6 15582C>T was associated with lower log10 AUC. Nevirapine group: CYP2B6 516G>T was associated with higher log10 Cmax and lower log10 Cmin . Pharmacogenetic variations influenced subdermal levonorgestrel pharmacokinetics in HIV-positive women, indicating that the magnitude of the interaction with non-nucleoside reverse transcriptase inhibitors (NNRTIs) is influenced by host genetics.
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Affiliation(s)
- M Neary
- Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - M Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - A Olagunju
- Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - K M Darin
- Center for Global Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - C Merry
- Department of Medicine, Trinity College Dublin, Dublin, Ireland
| | - P Byakika-Kibwika
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - D J Back
- Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - M Siccardi
- Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - A Owen
- Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - K K Scarsi
- Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Abstract
Dolutegravir (DTG), elvitegravir (EVG) and raltegravir (RAL) are members of the latest class of antiretrovirals (ARVs) that have become available to treat human immunodeficiency virus (HIV) infection: integrase strand transfer inhibitors (INSTIs). INSTIs are potent inhibitors of the HIV integrase enzyme, with protein binding-adjusted concentration inhibiting viral replication by 90/95 % [IC90/95] values in the low nanogram per millilitre range, and they retain antiviral activity against strains of HIV with acquired resistance to other classes of ARVs. Each of the INSTIs has unique pharmacokinetic/pharmacodynamic properties, influencing its role in clinical use in specific subsets of patients. RAL and DTG have minimal drug-drug interaction profiles, as their metabolism has minimal cytochrome P450 (CYP) involvement. Conversely, EVG metabolism occurs primarily via CYP3A4 and requires pharmacokinetic boosting to achieve systemic exposures amenable to once-daily dosing. EVG and DTG have the added benefit of availability of fixed-dose combination tablets, allowing for convenient and simplified ARV regimens. RAL is the only INSTI to be listed as a preferred agent in the current US perinatal treatment guidelines. All three INSTIs are recommended regimens for treatment-naïve individuals in the US adult and adolescent HIV treatment guidelines. This review summarizes and compares the pharmacokinetics and pharmacodynamics of the INSTIs, and describes specific pharmacokinetic considerations for special patient conditions: hepatic impairment, renal dysfunction, pregnancy and co-infections.
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Affiliation(s)
- Anthony T Podany
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986000 Nebraska Medical Center, Omaha, NE, 68198-6000, USA
| | - Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986000 Nebraska Medical Center, Omaha, NE, 68198-6000, USA
| | - Courtney V Fletcher
- Antiviral Pharmacology Laboratory, College of Pharmacy, University of Nebraska Medical Center, 986000 Nebraska Medical Center, Omaha, NE, 68198-6000, USA.
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Scarsi KK, Darin KM, Chappell CA, Nitz SM, Lamorde M. Drug-Drug Interactions, Effectiveness, and Safety of Hormonal Contraceptives in Women Living with HIV. Drug Saf 2016; 39:1053-1072. [PMID: 27562873 PMCID: PMC5048570 DOI: 10.1007/s40264-016-0452-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [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: 12/22/2022]
Abstract
Family planning options, including hormonal contraceptives, are essential for improving reproductive health among the more than 17 million women living with HIV worldwide. For these women, prevention of unintended pregnancy decreases maternal and child mortality, as well as reduces the risk of perinatal HIV transmission. Similarly, treatment of HIV with antiretroviral therapy (ART) is essential for reducing morbidity and mortality among HIV-positive individuals, as well as preventing HIV transmission between sexual partners or from mother to child. Importantly, despite the benefits of hormonal contraceptives, barriers to effective family planning methods exist for HIV-positive women. Specifically, drug-drug interactions can occur between some antiretroviral medications and some hormonal contraceptives, which may influence both contraceptive efficacy and tolerability. In addition, safety concerns have been raised about the impact of hormonal contraceptives on HIV disease progression, tolerability, and the risk of female-to-male HIV transmission. This review article summarizes the potential for drug-drug interactions, tolerability, and contraceptive effectiveness when hormonal contraceptives are combined with ART. In addition, the evidence surrounding the influence of hormonal contraceptives on HIV transmission and HIV disease progression in women living with HIV are summarized.
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Affiliation(s)
- Kimberly K Scarsi
- Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA.
| | - Kristin M Darin
- Center for Global Health, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Catherine A Chappell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Stephanie M Nitz
- Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, 986145 Nebraska Medical Center, Omaha, NE, 68198-6145, USA
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
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McLaughlin MM, Ammar AT, Gerzenshtein L, Scarsi KK. Dosing nucleoside reverse transcriptase inhibitors in adults receiving continuous veno-venous hemofiltration. Clin Drug Investig 2016; 35:275-80. [PMID: 25691260 DOI: 10.1007/s40261-015-0275-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Characteristics of nucleoside reverse transcriptase inhibitors (NRTIs) make the drug class susceptible to elimination via continuous veno-venous hemofiltration (CVVH), potentially leading to suboptimal drug concentrations if given at the recommended anephric doses during CVVH. The objective of this study was to formulate NRTI dosing recommendations for adults receiving CVVH. METHODS A mathematical formula that estimates the amount of drug likely to be removed during CVVH at various flow rates was used to calculate the supplemental NRTI dose required during CVVH. RESULTS A proposed table of dosing recommendations for NRTIs during CVVH is presented. CONCLUSION Clinicians should utilize these recommendations in the context of each individual patient, taking into consideration patient-specific factors and severity of illness. Future pharmacokinetic research correlating plasma and intracellular concentrations of NRTIs during CVVH is warranted to elucidate appropriate dosing.
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Affiliation(s)
- Milena M McLaughlin
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st Street, Downers Grove, IL, 60515, USA,
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Darin KM, Scarsi KK, Klepser DG, Klepser SA, Reeves A, Young M, Klepser ME. Consumer interest in community pharmacy HIV screening services. J Am Pharm Assoc (2003) 2016; 55:67-72. [PMID: 25414989 DOI: 10.1331/japha.2015.14069] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate consumers' interest in pharmacist-provided human immunodeficiency virus (HIV) screening and to evaluate potential barriers and facilitators to HIV screening in the community pharmacy setting. METHODS Cross-sectional survey of adult patients who presented to one of five community (chain and independent) pharmacies from November 2010 to August 2011. RESULTS Based on 380 usable surveys, 135 (35.8%) participants were interested in pharmacy-based HIV screening. Independent predictors of interest in HIV screening identified in multivariate analysis (reference groups: ages 30 to 49 years old and white, non-Hispanic race) included younger age (18 to 29 years old) (odds ratio [OR], 2.48; 95% confidence interval [CI], 1.31 to 4.71); black, non-Hispanic race (OR, 2.37; CI, 1.40 to 4.03); and other race (OR, 4.58; CI, 1.63 to 12.87). Lack of perceived risk for HIV was the most commonly cited barrier to HIV screening; and free, rapid, or confidential HIV testing were identified as potential facilitators. CONCLUSION Interest in pharmacy-based HIV screening was high among participants representing age and race groups disproportionately affected by HIV. Expansion of HIV screening efforts to community pharmacies warrants further consideration.
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Darin KM, Klepser ME, Klepser DE, Klepser SA, Reeves A, Young M, Scarsi KK. Pharmacist-provided rapid HIV testing in two community pharmacies. J Am Pharm Assoc (2003) 2016; 55:81-8. [PMID: 25415222 DOI: 10.1331/japha.2015.14070] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the acceptability and feasibility of pharmacist-provided rapid testing for human immunodeficiency virus (HIV) infection in community pharmacies. PRACTICE DESCRIPTION A pharmacist-provided HIV testing model-including rapid HIV testing, counseling, and linkage to confirmatory HIV testing services-was developed and implemented. SETTING Two independent pharmacies located in Michigan cities of different size and with different prevalence of HIV infection. MAIN OUTCOME MEASURES Number of HIV tests performed, time required for HIV testing services, description of participants who received an HIV test, and pharmacist and participant perception of the HIV testing experience. RESULTS From October 2011 to March 2013, pharmacists provided HIV tests to 69 participants. One (1.5%) participant had a reactive HIV test and was immediately referred to an appropriate health care provider for confirmatory testing. HIV testing services required a median time of 30 (range, 20-90) minutes. Participants had a median age of 23 (range, 18-61) years and were diverse by gender (59.4% women) and race (46.4% black; 39.1% white). This was the first HIV test for 42% of participants, many of whom reported high-risk behaviors in the prior 6 months. Participants and pharmacists reported favorable perceptions of the HIV testing experience. CONCLUSIONS This project demonstrates the acceptability and feasibility of pharmacist-provided rapid HIV testing in two community pharmacies with distinct characteristics. Further development of HIV testing services in this practice setting is warranted.
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Scarsi KK, Darin KM, Nakalema S, Back DJ, Byakika-Kibwika P, Else LJ, Dilly Penchala S, Buzibye A, Cohn SE, Merry C, Lamorde M. Unintended Pregnancies Observed With Combined Use of the Levonorgestrel Contraceptive Implant and Efavirenz-based Antiretroviral Therapy: A Three-Arm Pharmacokinetic Evaluation Over 48 Weeks. Clin Infect Dis 2015; 62:675-682. [PMID: 26646680 PMCID: PMC4772838 DOI: 10.1093/cid/civ1001] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [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: 10/02/2015] [Accepted: 11/25/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Levonorgestrel subdermal implants are preferred contraceptives with an expected failure rate of <1% over 5 years. We assessed the effect of efavirenz- or nevirapine-based antiretroviral therapy (ART) coadministration on levonorgestrel pharmacokinetics. METHODS This nonrandomized, parallel group, pharmacokinetic evaluation was conducted in three groups of human immunodeficiency virus-infected Ugandan women: ART-naive (n = 17), efavirenz-based ART (n = 20), and nevirapine-based ART (n = 20). Levonorgestrel implants were inserted at baseline in all women. Blood was collected at 1, 4, 12, 24, 36, and 48 weeks. The primary endpoint was week 24 levonorgestrel concentrations, compared between the ART-naive group and each ART group by geometric mean ratio (GMR) with 90% confidence interval (CI). Secondary endpoints included week 48 levonorgestrel concentrations and unintended pregnancies. RESULTS Week 24 geometric mean levonorgestrel concentrations were 528, 280, and 710 pg/mL in the ART-naive, efavirenz, and nevirapine groups, respectively (efavirenz: ART-naive GMR, 0.53; 90% CI, .50, .55 and nevirapine: ART-naive GMR, 1.35; 90% CI, 1.29, 1.43). Week 48 levonorgestrel concentrations were 580, 247, and 664 pg/mL in the ART-naive, efavirenz, and nevirapine groups, respectively (efavirenz: ART-naive GMR, 0.43; 90% CI, .42, .44 and nevirapine: ART-naive GMR, 1.14; 90% CI, 1.14, 1.16). Three pregnancies (3/20, 15%) occurred in the efavirenz group between weeks 36 and 48. No pregnancies occurred in the ART-naive or nevirapine groups. CONCLUSIONS Within 1 year of combined use, levonorgestrel exposure was markedly reduced in participants who received efavirenz-based ART, accompanied by contraceptive failures. In contrast, nevirapine-based ART did not adversely affect levonorgestrel exposure or efficacy. CLINICAL TRIALS REGISTRATION NCT01789879.
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Affiliation(s)
- Kimberly K Scarsi
- Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha
| | - Kristin M Darin
- Center for Global Health.,Division of Infectious Diseases, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Shadia Nakalema
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - David J Back
- Department of Molecular and Clinical Pharmacology, University of Liverpool, United Kingdom
| | - Pauline Byakika-Kibwika
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Laura J Else
- Department of Molecular and Clinical Pharmacology, University of Liverpool, United Kingdom
| | - Sujan Dilly Penchala
- Department of Molecular and Clinical Pharmacology, University of Liverpool, United Kingdom
| | - Allan Buzibye
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Susan E Cohn
- Division of Infectious Diseases, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Concepta Merry
- Center for Global Health.,Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Medicine, Trinity College Dublin, Ireland
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
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Scarsi KK, Eisen G, Darin KM, Meloni ST, Rawizza HE, Tchetgen Tchetgen EJ, Agbaji OO, Onwujekwe DI, Gashau W, Nkado R, Okonkwo P, Murphy RL, Kanki PJ. Superior Effectiveness of Zidovudine Compared With Tenofovir When Combined With Nevirapine-based Antiretroviral Therapy in a Large Nigerian Cohort. Clin Infect Dis 2015; 62:512-8. [PMID: 26561532 PMCID: PMC4725384 DOI: 10.1093/cid/civ928] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [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: 06/04/2015] [Accepted: 09/04/2015] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Despite sparse efficacy data, tenofovir-emtricitabine or tenofovir-lamivudine plus nevirapine is used in many resource-constrained settings. METHODS This retrospective cohort study included patients initiating nevirapine-based antiretroviral therapy (ART) with either tenofovir-emtricitabine or lamivudine (tenofovir group) or zidovudine-lamivudine (zidovudine group). Clinical, virologic, and immunologic evaluations were performed at baseline and every 6 months. Virologic failure was defined as 2 consecutive human immunodeficiency virus (HIV)-RNA values >1000 copies/mL. Patients were included from ART initiation until time of failure, regimen switch, discontinuation, or last HIV-RNA measurement. Cox proportional hazards regression was used to model factors influencing time to failure. Bias due to dependent censoring was investigated via inverse probability weighted pooled logistic regression. RESULTS A total of 5547 patients were evaluated; 1484 (26.8%) were in the tenofovir group and 4063 (73.2%) were in the zidovudine group. In the adjusted model, tenofovir regimen (hazard ratio [HR], 1.47; 95% confidence interval [CI], 1.21-1.79) and higher baseline log10 HIV-RNA (HR, 1.15; 95% CI, 1.03-1.28) were associated with virologic failure. Higher baseline log10 CD4+ cell count (HR, 0.50; 95% CI, .40-.63) and increasing age (HR, 0.98; 95% CI, .97-.99) decreased the risk of virologic failure. Inverse probability weighting results were consistent with the primary analysis. CONCLUSIONS Compared with zidovudine-lamivudine, the use of tenofovir-lamivudine or emtricitabine in combination with nevirapine was a strong predictor of virologic failure in our cohort, which was not explained by other risk factors or criteria for regimen selection.
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Affiliation(s)
- Kimberly K Scarsi
- Department of Pharmacy Practice, University of Nebraska Medical Center, Omaha
| | - Geoffrey Eisen
- Center for Global Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kristin M Darin
- Center for Global Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Seema T Meloni
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health
| | - Holly E Rawizza
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health Department of Medicine, Division of Infectious Diseases, Brigham and Women's Hospital
| | - Eric J Tchetgen Tchetgen
- Departments of Biostatistics and Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Oche O Agbaji
- Department of Medicine, University of Jos and Jos University Teaching Hospital
| | - Daniel I Onwujekwe
- Clinical Sciences Division, Nigerian Institute of Medical Research, Yaba
| | - Wadzani Gashau
- Department of Medicine, University of Maiduguri Teaching Hospital
| | - Reuben Nkado
- Department of Medicine, 68 Military Hospital, Yaba (formerly, at the time of this work)
| | - Prosper Okonkwo
- AIDS Prevention Initiative Nigeria, Ltd./Gte., Abuja, Nigeria
| | - Robert L Murphy
- Center for Global Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Phyllis J Kanki
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health
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Bares SH, Sandkovsky US, Talmon GA, Hutchins GF, Swindells S, Scarsi KK. Dolutegravir-induced colitis in an HIV-infected patient. J Antimicrob Chemother 2015; 71:281-2. [PMID: 26410169 DOI: 10.1093/jac/dkv296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Sara H Bares
- Department of Internal Medicine/Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Uriel S Sandkovsky
- Department of Internal Medicine/Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Geoffrey A Talmon
- Department of Pathology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Grant F Hutchins
- Department of Internal Medicine/Gastroenterology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Susan Swindells
- Department of Internal Medicine/Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kimberly K Scarsi
- Department of Pharmacy Practice, University of Nebraska Medical Center, Omaha, NE, USA
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Affiliation(s)
- Elise M. Gilbert
- Department of Pharmacy; Northwestern Memorial Hospital; Chicago Illinois
- Department of Pharmacy Practice; Chicago State University College of Pharmacy; Chicago Illinois
| | - Kristin M. Darin
- Feinberg School of Medicine; Division of Infectious Diseases and Center for Global Health; Northwestern University; Chicago Illinois
| | - Kimberly K. Scarsi
- Department of Pharmacy Practice; College of Pharmacy; University of Nebraska Medical Center; Omaha Nebraska
| | - Milena M. McLaughlin
- Department of Pharmacy; Northwestern Memorial Hospital; Chicago Illinois
- Department of Pharmacy Practice; Chicago College of Pharmacy; Midwestern University; Downers Grove Illinois
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Batra R, Wolbach-Lowes J, Swindells S, Scarsi KK, Podany AT, Sayles H, Sandkovsky U. Impact of an electronic medical record on the incidence of antiretroviral prescription errors and HIV pharmacist reconciliation on error correction among hospitalized HIV-infected patients. Antivir Ther 2015; 20:555-9. [PMID: 25560773 DOI: 10.3851/imp2930] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Previous review of admissions from 2009-2011 in our institution found a 35.1% error rate in antiretroviral (ART) prescribing, with 55% of errors never corrected. Subsequently, our institution implemented a unified electronic medical record (EMR) and we developed a medication reconciliation process with an HIV pharmacist. We report the impact of the EMR on incidence of errors and of the pharmacist intervention on time to error correction. METHODS Prospective medical record review of HIV-infected patients hospitalized for >24 h between 9 March 2013 and 10 March 2014. An HIV pharmacist reconciled outpatient ART prescriptions with inpatient orders within 24 h of admission. Prescribing errors were classified and time to error correction recorded. Error rates and time to correction were compared to historical data using relative risks (RR) and logistic regression models. RESULTS 43 medication errors were identified in 31/186 admissions (16.7%). The incidence of errors decreased significantly after EMR (RR 0.47, 95% CI 0.34, 0.67). Logistic regression adjusting for gender and race/ethnicity found that errors were 61% less likely to occur using the EMR (95% CI 40%, 75%; P<0.001). All identified errors were corrected, 65% within 24 h and 81.4% within 48 h. Compared to historical data where only 31% of errors were corrected in <24 h and 55% were never corrected, errors were 9.4× more likely to be corrected within 24 h with HIV pharmacist intervention (P<0.001). CONCLUSIONS Use of an EMR decreased the error rate by more than 50% but despite this, ART errors remained common. HIV pharmacist intervention was key to timely error correction.
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Affiliation(s)
- Rishi Batra
- Department of Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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Scarsi KK, Fehintola FA, Ma Q, Aweeka FT, Darin KM, Morse GD, Akinola IT, Adedeji WA, Lindegardh N, Tarning J, Ojengbede O, Adewole IF, Taiwo B, Murphy RL, Akinyinka OO, Parikh S. Disposition of amodiaquine and desethylamodiaquine in HIV-infected Nigerian subjects on nevirapine-containing antiretroviral therapy. J Antimicrob Chemother 2014; 69:1370-6. [PMID: 24446424 DOI: 10.1093/jac/dkt513] [Citation(s) in RCA: 13] [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] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Artesunate plus amodiaquine is used for malaria treatment in regions with overlapping HIV endemicity. Co-administration of artesunate/amodiaquine with antiretroviral therapy (ART) may result in drug-drug interactions, but minimal data exist. This study evaluated the impact of nevirapine-based ART, containing a backbone of zidovudine and lamivudine, on the disposition of amodiaquine and its active metabolite, desethylamodiaquine (DEAQ). METHODS This was an open-label, parallel-group pharmacokinetic comparison between HIV-infected, adult subjects receiving steady-state nevirapine-based ART (n = 10) and ART-naive subjects (control group, n = 11). All subjects received a loose formulation of artesunate/amodiaquine (200/600 mg) daily for 3 days, with serial pharmacokinetic sampling over 96 h following the final dose of artesunate/amodiaquine. Amodiaquine and DEAQ were quantified using a validated HPLC method with UV detection. Pharmacokinetic parameters were determined using standard non-compartmental methods. RESULTS Exposures to both amodiaquine and DEAQ were significantly lower in the nevirapine-based ART group compared with the control group (amodiaquine AUC₀₋₂₄ 145 versus 204 ng·h/mL, P = 0.02; DEAQ AUC₀₋₉₆ 14,571 versus 21,648 ng·h/mL, P < 0.01). The AUCDEAQ/AUC(amodiaquine) ratio was not different between groups (ART group 116 versus control group 102, P = 0.67). CONCLUSIONS Subjects on nevirapine-based ART had lower exposure to both amodiaquine and DEAQ (28.9% and 32.7%, respectively). Consequently, this may negatively impact the effectiveness of artesunate/amodiaquine in HIV-infected individuals on this ART combination.
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Affiliation(s)
- Kimberly K Scarsi
- Division of Infectious Diseases and Center for Global Health, Northwestern University, Chicago, IL, USA
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Rawizza HE, Chaplin B, Meloni ST, Darin KM, Olaitan O, Scarsi KK, Onwuamah CK, Audu RA, Chebu PR, Imade GE, Okonkwo P, Kanki PJ. Accumulation of protease mutations among patients failing second-line antiretroviral therapy and response to salvage therapy in Nigeria. PLoS One 2013; 8:e73582. [PMID: 24069209 PMCID: PMC3775797 DOI: 10.1371/journal.pone.0073582] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [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: 04/30/2013] [Accepted: 07/19/2013] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND To date, antiretroviral therapy (ART) guidelines and programs in resource-limited settings (RLS) have focused on 1(st)- and 2(nd)-line (2 L) therapy. As programs approach a decade of implementation, policy regarding access to 3(rd)-line (3 L) ART is needed. We aimed to examine the impact of maintaining patients on failing 2 L ART on the accumulation of protease (PR) mutations. METHODS AND FINDINGS From 2004-2011, the Harvard/APIN PEPFAR Program provided ART to >100,000 people in Nigeria. Genotypic resistance testing was performed on a subset of patients experiencing 2 L failure, defined as 2 consecutive viral loads (VL)>1000 copies/mL after ≥6 months on 2 L. Of 6714 patients who received protease inhibitor (PI)-based ART, 673 (10.0%) met virologic failure criteria. Genotypes were performed on 61 samples. Patients on non-suppressive 2 L therapy for <12 months prior to genotyping had a median of 2 (IQR: 0-5) International AIDS Society (IAS) PR mutations compared with 5 (IQR: 0-6) among patients failing for >24 months. Patients developed a median of 0.6 (IQR: 0-1.4) IAS PR mutations per 6 months on failing 2 L therapy. In 38% of failing patients no PR mutations were present. For patients failing >24 months, high- or intermediate-level resistance to lopinavir and atazanavir was present in 63%, with 5% to darunavir. CONCLUSIONS This is the first report assessing the impact of duration of non-suppressive 2 L therapy on the accumulation of PR resistance in a RLS. This information provides insight into the resistance cost of failing to switch non-suppressive 2 L regimens and highlights the issue of 3 L access.
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Affiliation(s)
- Holly E. Rawizza
- Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Beth Chaplin
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Seema T. Meloni
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Kristin M. Darin
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | | | - Kimberly K. Scarsi
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | | | | | | | | | | | - Phyllis J. Kanki
- Harvard School of Public Health, Boston, Massachusetts, United States of America
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Patterson KB, Dumond JB, Prince HA, Jenkins AJ, Scarsi KK, Wang R, Malone S, Hudgens MG, Kashuba ADM. Protein binding of lopinavir and ritonavir during 4 phases of pregnancy: implications for treatment guidelines. J Acquir Immune Defic Syndr 2013; 63:51-8. [PMID: 23221983 PMCID: PMC3625477 DOI: 10.1097/qai.0b013e31827fd47e] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [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: 01/30/2023]
Abstract
OBJECTIVE To investigate the intraindividual pharmacokinetics (PKs) of total (protein bound plus unbound) and unbound lopinavir/ritonavir (LPV/RTV) and to assess whether the pediatric formulation (100 mg/25 mg) can overcome any pregnancy-associated changes. DESIGN Prospective longitudinal PK study. METHODS HIV-infected pregnant antiretroviral therapy-naive and experienced women receiving LPV/RTV 400 mg/100 mg tablets twice daily. Intensive PK evaluations were performed at 20-24 weeks (PK1), 30 weeks (PK2) followed by empiric dose increase using the pediatric formulation (100 mg/25 mg twice daily), 32 weeks (PK3), and 8 weeks postpartum (PK4). RESULTS Twelve women completed prespecified PK evaluations. Median (range) age was 28 (18-35) years and baseline BMI was 32 (19-41) kg/m. During pregnancy, total area under the time concentration (AUC0-12h) for LPV was significantly lower than postpartum (PK1, PK2, or PK3 vs. PK4, P = 0.005). Protein-unbound LPV AUC0-12h remained unchanged during pregnancy [PK1: 1.6 (1.3-1.9) vs. PK2: 1.6 (1.3-1.9) μg·h/mL, P = 0.4] despite a 25% dose increase [PK2 vs. PK3: 1.8 (1.3-2.1) μg·h/mL, P = 0.5]. Protein-unbound LPV predose concentrations (C12h) did not significantly change despite dose increase [PK2: 0.10 (0.08-0.15) vs. PK3: 0.12 (0.10-0.15) μg/mL, P = 0.09]. Albumin and LPV AUC0-12h fraction unbound were correlated (rs = 0.3, P = 0.03). CONCLUSIONS Total LPV exposure was significantly decreased throughout pregnancy despite the increased dose. However, the exposure of unbound LPV did not change significantly regardless of trimester or dose. Predose concentrations of unbound LPV were not affected by the additional dose and were 70-fold greater than the minimum efficacy concentration. These findings suggest dose adjustments may not be necessary in all HIV-infected pregnant women.
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Affiliation(s)
- Kristine B Patterson
- Department of Medicine, University of North Carolina, Chapel Hill, NC 27599-7215, USA.
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