Host exposure to a common pollutant can influence diversity-disease relationships

Hosts and parasites are embedded in communities where species richness and composition can influence disease outcomes (diversity-disease relationships). The direction and magnitude of diversity-disease relationships are influenced by variation in competence (ability to support and transmit infections) of hosts in a community. However, host susceptibility to parasites, which mediates host competence, is not static and is influenced by environmental factors, including pollutants. Despite the role that pollutants can play in augmenting host susceptibility, how pollutants influence diversity-disease dynamics is not well understood. Using an amphibian-trematode model, we tested how NaCl influences diversity-disease dynamics. We predicted that NaCl exposure can alter relative susceptibility of host species to trematodes, leading to cascading effects on the diversity-disease relationship. To test these predictions, we exposed hosts to benign or NaCl environments and generated communities that differed in number and composition of host species. We exposed these communities to trematodes and measured disease outcomes at the community (total infections across all hosts within a community) and species levels (average number of infections per host species within a community). Host species differed in their relative susceptibility to trematodes when exposed to NaCl. Consequently, at the community level (total infections across all hosts within a community), we only detected diversity-disease relationships (dilution effects) in communities where hosts were exposed to NaCl. At the species level, disease outcomes (average number of infections/species) and whether multi-species communities supported lower number of infections relative to single-species communities depended on community composition. Notably, however, as with overall community infection, diversity-disease relationships only emerged when hosts were exposed to NaCl. Synthesis. Pollutants are ubiquitous in nature and can influence disease dynamics across a number of host-parasite systems. Here, we show that NaCl exposure can alter the relative susceptibility of host species to parasites, influencing the relationship between biodiversity and disease at both community and species levels. Collectively, our study contributes to the limited knowledge surrounding environmental mediators of host susceptibility and their influence on diversity-disease dynamics.

Gene therapy ameliorates spontaneous seizures associated with cortical neuron loss in a Cln2R207X mouse model

Although a disease-modifying therapy for classic late infantile neuronal ceroid lipofuscinosis (CLN2 disease) exists, poor understanding of cellular pathophysiology has hampered the development of more effective and persistent therapies. Here, we investigated the nature and progression of neurological and underlying neuropathological changes in Cln2R207X mice, which carry one of the most common pathogenic mutations in human patients but are yet to be fully characterized. Long-term electroencephalography recordings revealed progressive epileptiform abnormalities, including spontaneous seizures, providing a robust, quantifiable, and clinically relevant phenotype. These seizures were accompanied by the loss of multiple cortical neuron populations, including those stained for interneuron markers. Further histological analysis revealed early localized microglial activation months before neuron loss started in the thalamocortical system and spinal cord, which was accompanied by astrogliosis. This pathology was more pronounced and occurred in the cortex before the thalamus or spinal cord and differed markedly from the staging seen in mouse models of other forms of neuronal ceroid lipofuscinosis. Neonatal administration of adeno-associated virus serotype 9-mediated gene therapy ameliorated the seizure and gait phenotypes and prolonged the life span of Cln2R207X mice, attenuating most pathological changes. Our findings highlight the importance of clinically relevant outcome measures for judging preclinical efficacy of therapeutic interventions for CLN2 disease.

Effects of Polyester Microplastic Fiber Contamination on Amphibian-Trematode Interactions

Microplastic contamination poses a global threat to aquatic organisms, yet we know little as to how microplastics may indirectly affect organismal health via their influence on species-species interactions (e.g., host-parasite interactions). This is problematic because microplastic-mediated alterations to host-parasite dynamics could negatively impact individual- population-level health of hosts. Using a larval amphibian (host) and free-living trematode (parasite) model, we asked whether 1) polyester microplastic fibers influence parasite survival; 2) whether polyester microplastic fiber ingestion by amphibians alters amphibian susceptibility to infection; and 3) whether simultaneous exposure of amphibians and trematodes to polyester microplastic fibers influences infection outcomes. Polyester microplastic fibers did not alter trematode survival, nor did their ingestion by amphibians increase amphibian susceptibility to infection. However, when amphibians and trematodes were exposed simultaneously to the fibers, the infection success of the parasite was reduced. Lastly, we conducted a field survey for microfiber contamination across multiple ponds and found microfibers across each of the sampled ponds. Overall, our results contribute to the limited knowledge surrounding the ecological consequences of microplastic contamination. Environ Toxicol Chem 2022;41:869-879. © 2021 SETAC.

Characterization of AAV-mediated dorsal root ganglionopathy

Recent studies in non-human primates administered recombinant adeno-associated viruses (rAAVs) have shown lesions in the dorsal root ganglia (DRG) of unknown pathogenesis. In this study, rAAV9s manufactured using different purification methods alongside a non-expressing Null AAV9 vector was administered to groups of cynomolgus monkeys followed by neuropathological evaluation after 4 weeks. Lesions, including neuronal degeneration, increased cellularity, and nerve fiber degeneration, were observed in the DRG, regardless of purification methods. Animals did not develop any neurological signs throughout the study, and there was no loss of function observed in neuro-electrophysiological endpoints or clear effects on intraepidermal nerve fiber density. However, magnetic resonance imaging (MRI) of animals with axonopathy showed an increase in short tau inversion recovery (STIR) intensity and decrease in fractional anisotropy. In animals administered the Null AAV9 vector, DRG lesions were not observed despite vector DNA being detected in the DRG at levels equivalent to or greater than rAAV9-treated animals. This study further supports that DRG toxicity is associated with transgene overexpression in DRGs, with particular sensitivity at the lumbar and lumbosacral level. The data from this study also showed that the nerve fiber degeneration did not correlate with any functional effect on nerve conduction but was detectable by MRI.

Amphibian breeding phenology influences offspring size and response to a common wetland contaminant

Background

Increases in temperature variability associated with climate change have critical implications for the phenology of wildlife across the globe. For example, warmer winter temperatures can induce forward shifts in breeding phenology across taxa (“false springs”), which can put organisms at risk of freezing conditions during reproduction or vulnerable early life stages. As human activities continue to encroach on natural ecosystems, it is also important to consider how breeding phenology interacts with other anthropogenic stressors (e.g., pollutants). Using 14 populations of a widespread amphibian (wood frog; Rana sylvatica), we compared 1) growth; 2) tolerance to a common wetland contaminant (NaCl); and 3) the ability of tadpoles to acclimate to lethal NaCl exposure following sublethal exposure earlier in life. We evaluated these metrics across two breeding seasons (2018 and 2019) and across populations of tadpoles whose parents differed in breeding phenology (earlier- versus later-breeding cohorts). In both years, the earlier-breeding cohorts completed breeding activity prior to a winter storm and later-breeding cohorts completed breeding activities after a winter storm. The freezing conditions that later-breeding cohorts were exposed to in 2018 were more severe in both magnitude and duration than those in 2019.

Results

In 2018, offspring of the later-breeding cohort were larger but less tolerant of NaCl compared to offspring of the earlier-breeding cohort. The offspring of the earlier-breeding cohort additionally were able to acclimate to a lethal concentration of NaCl following sublethal exposure earlier in life, while the later-breeding cohort became less tolerant of NaCl following acclimation. Interestingly, in 2019, the warmer of the two breeding seasons, we did not detect the negative effects of later breeding phenology on responses to NaCl.

Conclusions

These results suggest that phenological shifts that expose breeding amphibians to freezing conditions can have cascading consequences on offspring mass and ability to tolerate future stressors but likely depends on the severity of the freeze event.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12983-021-00413-0.

Effects of different roadway deicing salts on host-parasite interactions: The importance of salt type

The application of roadway deicing salts is increasing the salinity of freshwater systems. Increased salinization from salts, such as NaCl, CaCl₂ and MgCl_2, can have direct, negative impacts on freshwater organisms at concentrations found in nature. Yet, our understanding of how these salts can indirectly impact freshwater organisms by altering important ecological interactions, such as those between hosts and their parasites, is limited. Using a larval amphibian and infectious free-living helminth (i.e. trematode) model, we examined whether exposure to environmentally relevant concentrations of NaCl, CaCl₂ and MgCl₂ 1) influence trematode mortality; 2) alter amphibian-trematode interactions; and 3) alter larval amphibian activity (a behavior associated with parasite avoidance). We found that exposure to CaCl₂ greatly reduced trematode survival across all Cl^- concentrations (230, 500, 860 and 1000 mg Cl^- L^-1) while NaCl and MgCl₂ had no effect. When both host and parasites were exposed to the salts, exposure to NaCl, but not MgCl₂ or CaCl₂, increased infection. The lack of effect of CaCl₂ on infection was likely driven by CaCl₂ reducing trematode survival. Exposure to NaCl increased infection at 500 mg Cl^- L^-1, but not 230 or 860 mg Cl^- L^-1. Increased infection was not due to salt exposure altering tadpole behavior. Our results suggest that NaCl can negatively impact amphibian populations indirectly by increasing trematode infections in tadpole hosts.

Drug-induced myocardial dysfunction - recommendations for assessment in clinical and pre-clinical studies

Introduction: Drug-induced myocardial dysfunction is an important safety concern during drug development. Oncology compounds can cause myocardial dysfunction, leading to decreased left ventricular ejection fraction and heart failure via several mechanisms. Cardiovascular imaging has a major role in the early detection and monitoring of cardiotoxicity. Echocardiography is the method of choice because of its widespread availability, low cost, and absence of radiation exposure. Cardiac magnetic resonance imaging can provide better reliability, reproducibility, and accuracy in the detection of drug-induced myocardial dysfunction. In addition, it enables assessment of myocardial edema, fibrosis, and necrosis. Cardiac serologic biomarkers such as troponins and B-type natriuretic peptides are used in combination with imaging during drug development. This article provides a general overview of each imaging modality and practical guidance for early detection and monitoring of cardiotoxicity.Areas covered: Cardiovascular imaging modalities and cardiac biomarkers for monitoring of cardiac function and early detection of drug-induced myocardial dysfunction in drug development.Expert opinion: Some new drugs especially in the oncology field, can cause myocardial dysfunction. Depending on the strength of pre-clinical or clinical data, CV imaging modalities and cardiac biomarkers play an important role in the early detection and mitigation plans for such drugs during their development.

AAV8-vectored suprachoroidal gene transfer produces widespread ocular transgene expression

There has been great progress in ocular gene therapy, but delivery of viral vectors to the retinal pigmented epithelium (RPE) and retina can be challenging. Subretinal injection, the preferred route of delivery for most applications, requires a surgical procedure that has risks. Herein we report a novel gene therapy delivery approach, suprachoroidal injection of AAV8 vectors, which is less invasive and could be done in an outpatient setting. Two weeks after suprachoroidal injection of AAV8.GFP in rats, GFP fluorescence covered 18.9% of RPE flat mounts and extended entirely around sagittal and transverse sections in RPE and photoreceptors. After 2 suprachoroidal injections of AAV8.GFP, GFP fluorescence covered 30.5% of RPE flat mounts. Similarly, widespread expression of GFP occurred in nonhuman primate and pig eyes after suprachoroidal injection of AAV8.GFP. Compared with subretinal injection in rats of RGX-314, an AAV8 vector expressing an anti-VEGF Fab, suprachoroidal injection of the same dose of RGX-314 resulted in similar expression of anti-VEGF Fab and similar suppression of VEGF-induced vascular leakage. Suprachoroidal AAV8 vector injection provides a noninvasive outpatient procedure to obtain widespread transgene expression in retina and RPE.

Direct and indirect effects of a common cyanobacterial toxin on amphibian-trematode dynamics

Wildlife diseases are emerging at unprecedented rates. While there are likely several factors at play, human-mediated environmental alterations may play a significant role. Of growing interest is the effect that microcystin-LR (MC-LR), a cyanotoxin, may have on disease outcomes. In this study, using an amphibian-trematode model we examined (1) the lethal effects of MC-LR on cercariae of trematodes; (2) the sublethal effects of MC-LR exposure on the ability for trematodes to infect green frog tadpoles; and (3) the sublethal effects of MC-LR on green frog tadpole susceptibility to trematodes. We found that environmentally-relevant concentrations of MC-LR at 50, 100, and 500 μg L^-1 increased cercariae rate of mortality (LC_50-14h = 134.24 μg L^-1). However, sublethal exposure of trematodes to 2 and 10 μg L^-1 MC-LR did not alter their infectivity. Conversely, sublethal exposure of tadpoles to 2 μg L^-1 increased their susceptibility to trematodes by 147%. However, 10 μg L^-1 of MC-LR did not affect tadpole susceptibility to trematodes, indicating a non-linear response to sublethal MC-LR exposure. Overall, our findings suggest that high concentrations of MC-LR (≥50 μg L^-1) have the potential to limit trematode transmission to amphibian hosts through MC-LR-induced mortality. However, at lower concentrations (<10 μg L^-1) MC-LR's effect on tadpole-cercariae disease outcome is likely driven by its effect on the tadpole host. Collectively, this work highlights the need to consider how toxicants influence both host and parasite at multiple concentrations to better understand the impacts of cyanotoxins on disease dynamics.

Parasite susceptibility in an amphibian host is modified by salinization and predators

Secondary salinization represents a global threat to freshwater ecosystems. Salts, such as NaCl, can be toxic to freshwater organisms and may also modify the outcome of species interactions (e.g. host-parasite interactions). In nature, hosts and their parasites are embedded in complex communities where they face anthropogenic and biotic (i.e. predators) stressors that influence host-parasite interactions. As human populations grow, considering how anthropogenic and natural stressors interact to shape host-parasite interactions will become increasingly important. We conducted two experiments investigating: (1) the effects of NaCl on tadpole susceptibility to trematodes and (2) whether density- and trait-mediated effects of a parasite-predator (i.e. damselfly) and a host-predator (i.e. dragonfly), respectively, modify the effects of NaCl on susceptibility to trematode infection. In the first experiment, we exposed tadpoles to three concentrations of NaCl and measured parasite infection in tadpoles. In the second experiment, we conducted a 2 (tadpoles exposed to 0 g L^-1 NaCl vs. 1 g L^-1 NaCl) x 4 (no predator, free-ranging parasite-predator (damselfly), non-lethal host-predator (dragonfly kairomone), and free-ranging parasite-predator + dragonfly kairomone) factorial experiment. In the absence of predators, exposure to NaCl increased parasite infection. Of the predator treatments, NaCl only caused an increase in parasite infection in the presence of the parasite-predator. However, direct consumption of trematodes caused a reduction in overall infection in the parasite-predator treatment. In the dragonfly kairomone treatment, a reduction in tadpole movement (i.e. trematode avoidance behavior) led to an increase in overall infection. In the parasite-predator + dragonfly kairomone treatment, antagonistic effects of the parasite-predator (reduction in trematode abundance) and dragonfly kairomone (reduction in parasite avoidance behavior) resulted in intermediate parasite infection. Collectively, these findings demonstrate that NaCl can increase amphibian susceptibility to parasites, and underscores the importance of considering predator-mediated interactions in understanding how contaminants influence host-parasite interactions.

Potent Immune Modulation by MEDI6383, an Engineered Human OX40 Ligand IgG4P Fc Fusion Protein

Ligation of OX40 (CD134, TNFRSF4) on activated T cells by its natural ligand (OX40L, CD252, TNFSF4) enhances cellular survival, proliferation, and effector functions such as cytokine release and cellular cytotoxicity. We engineered a recombinant human OX40L IgG4P Fc fusion protein termed MEDI6383 that assembles into a hexameric structure and exerts potent agonist activity following engagement of OX40. MEDI6383 displayed solution-phase agonist activity that was enhanced when the fusion protein was clustered by Fc gamma receptors (FcγRs) on the surface of adjacent cells. The resulting costimulation of OX40 on T cells induced NFκB promoter activity in OX40-expressing T cells and induced Th1-type cytokine production, proliferation, and resistance to regulatory T cell (Treg)-mediated suppression. MEDI6383 enhanced the cytolytic activity of tumor-reactive T cells and reduced tumor growth in the context of an alloreactive human T cell:tumor cell admix model in immunocompromised mice. Consistent with the role of OX40 costimulation in the expansion of memory T cells, MEDI6383 administered to healthy nonhuman primates elicited peripheral blood CD4 and CD8 central and effector memory T-cell proliferation as well as B-cell proliferation. Together, these results suggest that OX40 agonism has the potential to enhance antitumor immunity in human malignancies. Mol Cancer Ther; 17(5); 1024-38. ©2018 AACR.

Proteome of H-411E (liver) cells exposed to insulin and tumor necrosis factor-alpha: analysis of proteins involved in insulin resistance

Insulin resistance may be modeled in H-411E liver cells in tissue culture with the use of the cytokine tumor necrosis factor-alpha (TNF-alpha) and insulin. This tissue-culture model nicely mimics IR in human type 2 diabetes mellitus. After incubation of liver cells in tissue culture with INS alone, TNF-alpha alone, and TNF-alpha plus insulin, as well as a control sample, liver-cell extracts were separated on 2D polyacrylamide-gel electrophoresis on the basis of isoelectric point and molecular weight. We analyzed the gel images with the use of PD Quest software (Bio-Rad Laboratories, Hercules, Calif) to identify differentially expressed protein spots (ie, up or down with insulin vs down or up with TNF-alpha plus insulin). In separate experiments, phosphorus-32 incorporation/autoradiography and phosphoprotein staining were used to characterize treatment-induced phosphorylations. Affected protein spots were identified with the use of peptide fingerprinting and matrix-assisted laser desorption ionization time of flight mass spectrometry. The first series of experiments identified 6 differentially expressed proteins: eukaryotic translation initiation factor-3, subunit 2, regulator of G-protein signaling-5, superoxide dismutase, protein disulfide isomerase A6, proteasome subunit-alpha type 3, and regucalcin. In addition, we observed changes in the phosphorylation of protein disulfide isomerase A6. A second series of experiments identified 7 additional proteins with significantly altered differential expression: cell-division protein kinase-4, kinogen heavy chain, carbonic anhydrase-7, E 3 ubiquitin protein ligase, URE-B1; Rab GDP dissociation inhibitor-beta, Rab GDP dissociation inhibitor-beta2, and MAWDBP. It can be seen that differentially expressed proteins, affected by treatment with insulin or with TNF-alpha plus insulin, include regulators of translation, protein degradation, cellular Ca ++ , G-proteins, and free-radical production. Although one cannot detail the mechanism or mechanisms of TNF-alpha induced IR from this data alone, it is easy to relate all of these proteins to a role in insulin signal transduction and, hence, insulin resistance.

The effect of ritonavir on saquinavir plasma concentration is independent of ritonavir dosage: combined analysis of pharmacokinetic data from 97 subjects

OBJECTIVE

To determine the correlation between ritonavir (RTV) dose and the degree of enhancement of saquinavir (SQV) exposure.

METHODS

Combined analysis of pharmacokinetic data at steady state obtained from two open-label, randomized, parallel-group, multiple-dose, single-centre studies involving healthy volunteers. Plasma samples for SQV assay were obtained from 97 healthy subjects following multiple dosing of a range of SQV (400-1800 mg) plus RTV (100-400 mg) dosages for 13-14 days. The pharmacokinetics of SQV were derived by model-independent, noncompartmental methods. Data were analysed by multivariate regression of log transformed Cmin and Cmax (geometric means) of SQV dosage as the dependent variable and independent variables of SQV and RTV dosage. Ritonavir was fitted as both a continuous and a categorical variable.

RESULTS

There is a strong effect of any dose of RTV on Cmax and Cmin of SQV (P < 0.0001 for both parameters), but no greater effect of higher vs. lower RTV dosages on either parameter (Cmax: P=0.4373; Cmin: P=0.3393). Higher SQV dosage correlates linearly with higher Cmax (P=0.0093) and Cmin (P=0.0010), but the effects of increasing SQV dosages are less than with the addition of any RTV dose.

CONCLUSIONS

RTV enhances SQV concentrations to increase Cmax and Cmin. This effect is similar for RTV dosages of 100-400 mg twice daily. Based on this concept of 'mini-dose' RTV, once-daily dosing of 1600 mg SQV/100 mg RTV and twice-daily 1000 mg SQV/100 mg RTV are currently being evaluated in clinical trials.

Saquinavir and ritonavir pharmacokinetics following combined ritonavir and saquinavir (soft gelatin capsules) administration

AIMS

To investigate the influence of combined ritonavir (RTV) and saquinavir (soft-gelatin capsule formulation; SQV) on systemic exposure to SQV with a view to optimizing the dosing regimen of combined RTV and SQV antiretroviral therapy.

METHODS

In this open labelled, randomized, parallel group study, SQV and RTV were administered twice daily for 14 days to groups of eight healthy subjects. The two antiretrovirals were either administered alone (800 mg SQV, regimen A, and 400 mg RTV, B) or in combination at various dose levels (RTV : SQV: 400 : 400 mg, C; 300 : 600 mg, D; 200 : 800 mg, E; 300 : 800 mg, F; 400 : 800 mg, G; and 400 : 600 mg, H). Pharmacokinetic parameters of saquinavir and ritonavir were determined and adverse events, vital signs, and clinical laboratory variables recorded.

RESULTS

RTV substantially increased the plasma concentration of saquinavir for all dose combinations, compared with SQV alone. Based on the primary statistical analysis there was an overall 17-, 22-, and 23-fold increase in saquinavir AUC(0,24 h) on day 14 with regimens E, F, and G, respectively (with confidence intervals of 10-30, 13-37, and 13-39). The lowest combination dose of RTV (200 : 800 mg; E) significantly increased the saquinavir AUC(0,24 h) from below 5 to 57 microg ml(-1) h, which was higher than the exposure obtained with the 400 : 400 mg twice daily regimen (i.e. 36 microg ml(-1) h). RTV also reduced intersubject variability in AUC(0,24 h) for saquinavir from 105% to 32-68%, and C(max)(0,24 h) from 124% to 30-49%. In contrast, SQV showed no clinically significant effect on the pharmacokinetics of ritonavir. The combination regimens were well tolerated, with the least number of adverse events recorded for the 200 : 800 mg (RTV : SQV) combination regimen.

CONCLUSIONS

RTV significantly increases saquinavir exposure as a consequence of inhibiting SQV metabolism and possibly P-glycoprotein efflux. Pharmacokinetic and safety profiles obtained in the current study indicate that the use of a combination with a lower dose of RTV and a higher dose of SQV than the 400 : 400 mg combination frequently used in clinical practice should be further explored.

Measuring the effectiveness of antiretroviral agents

Considerable progress has been made recently in developing effective antiretroviral combination therapy that can suppress viral replication and delay disease progression in individuals infected with HIV. A range of up to 15 approved antiretroviral agents is now available, which target two different viral enzymes, while several agents are in clinical development. The rapid development and approval of antiretroviral agents, driven by the urgency of clinical need as well as the complexity of possible combinations, has precluded the extensive comparative clinical testing of regimens, which is necessary to establish the relative efficacy of various different agents. The lack of an appropriate animal model for HIV disease also increases reliance on in vitro measures. Several different in vitro and in vivo parameters have been defined in an attempt to quantify the effectiveness of antiretroviral agents, most importantly the 50% inhibitory and effective concentrations (IC50 and EC50). However, the clinical relevance of these measures is uncertain. Additionally, considerable variation exists in the usage of the terms 'IC50' and 'EC50' in recent publications in the literature. These issues pose interpretation problems to clinicians seeking information on the relative clinical efficacy of the agents. In this brief review, we attempt to clarify the different measures available and their potential utility for clinical decision-making, focusing particularly on the example of HIV protease inhibitors. There are many different quantifiable parameters that give information regarding the effectiveness of an antiviral drug. These include: inhibition of the viral target enzyme (inhibition constant, Ki); selectivity for viral versus host enzymes; inhibition of viral replication in cell culture (IC50); ratio of efficacy to cytotoxicity in vitro (therapeutic index); inhibition of viral replication or symptoms in an appropriate animal model of the disease (EC50); and the effect on surrogate markers, such as viral load or CD4 cell count, after administration to humans (in vivo EC50). Each of these different parameters gives valid information about the properties of an antiretroviral agent, which can help to build up a picture of its potential clinical utility relative to other drugs. However, to gain meaningful results, it is important to apply this information intelligently, understanding the limitations of each parameter.

Safety and pharmacokinetics of once-daily regimens of soft-gel capsule saquinavir plus minidose ritonavir in human immunodeficiency virus-negative adults

Human immunodeficiency virus type 1 (HIV-1) protease inhibitors have dramatically improved treatment options for HIV infection, but frequent dosing may impact adherence to highly active antiretroviral treatment regimens (HAART). Previous studies demonstrated that combined therapy with ritonavir and saquinavir allows a decrease in frequency of saquinavir dosing to twice daily. In this study, we evaluated the safety and pharmacokinetics of combining once-daily doses of the soft-gel capsule (SGC) formulation of saquinavir (saquinavir-SGC) and minidose ritonavir. Forty-four healthy HIV-negative volunteers were randomized into groups receiving once-daily doses of saquinavir-SGC (1,200 to 1,800 mg) plus ritonavir (100 to 200 mg) or a control group receiving only saquinavir-SGC (1,200 mg) three times daily. Saquinavir-SGC alone and saquinavir-SGC-ritonavir combinations were generally well tolerated, and there were no safety concerns. Addition of ritonavir (100 mg) to saquinavir-SGC (1,200 to 1,800 mg/day) increased the area under the concentration-time curve (AUC) for saquinavir severalfold, and the intersubject peak concentration in plasma and AUC variability were reduced compared to those achieved with saquinavir-SGC alone (3,600 mg/day), while trough saquinavir levels (24 h post-dose) were substantially higher than the 90% inhibitory concentration calculated from HIV-1 clinical isolates. Neither increasing the saquinavir-SGC dose to higher than 1,600 mg nor increasing ritonavir from 100 to 200 mg appeared to further enhance the AUC. These results suggest that an all once-daily HAART regimen, utilizing saquinavir-SGC plus a more tolerable low dose of ritonavir, may be feasible. Studies of once-daily saquinavir-SGC (1,600 mg) in combination with ritonavir (100 mg) in HIV-infected patients are underway.

Pharmacokinetic interactions between sildenafil and saquinavir/ritonavir

AIMS

To investigate the effect of the antiretroviral protease inhibitors saquinavir (soft gelatin capsule) and ritonavir on the pharmacokinetic properties and tolerability of sildenafil and to investigate the effect of sildenafil on the steady-state pharmacokinetics of saquinavir and ritonavir.

METHODS

Two independent, 8 day, open, randomized, placebo-controlled, parallel-group studies (containing a double-blind crossover phase) were conducted at Pfizer Clinical research units (Canterbury, UK. and Brussels, Belgium). Twenty-eight healthy male volunteers entered each study. In each study, volunteers were randomized (n = 14 per group) to receive sildenafil on day 1 followed by a 7-day treatment period (days 2-8) with saquinavir or placebo (Study I) or ritonavir or placebo (Study II). Sildenafil or placebo (Study I and Study II) was administered alternately on day 7 or day 8, depending on initial randomization. The effect of saquinavir and ritonavir on the pharmacokinetics of sildenafil and its primary circulating metabolite (UK-103, 320) and the effect of single-dose sildenafil on the steady-state pharmacokinetics of saquinavir (1200 mg three times daily) and ritonavir (500 mg twice daily) were determined. The safety and tolerability of sildenafil coadministered with saquinavir or ritonavir were also assessed.

RESULTS

Both protease inhibitors significantly increased Cmax, AUC, tmax and t(1/2) values for both sildenafil and UK-103, 320. Ritonavir showed a significantly greater effect than saquinavir with increases in sildenafil AUC and Cmax of 11-fold (95% CI: 9.0, 12.0) and 3.9-fold (95% CI: 3.2, 4.9), respectively. This compared with increases of 3.1-fold (95% CI: 2.5, 4.0) and 2.4-fold (95% CI: 1.8, 3.3) for coadministration with saquinavir. In contrast, the steady-state pharmacokinetics of saquinavir and ritonavir were unaffected by sildenafil. The increases in systemic exposure to sildenafil and UK-103, 320 were not associated with an increased incidence of adverse events or clinically significant changes in blood pressure, heart rate or ECG parameters.

CONCLUSIONS

These results indicate that both saquinavir and ritonavir modify the pharmacokinetics of sildenafil presumably through inhibition of CYP3A4. The more pronounced effect of ritonavir may be attributed to its additional potent inhibition of CYP2C9. No change in safety or tolerability was observed when sildenafil was coadministered with either protease inhibitor. However, given the extent of the interactions, a lower sildenafil starting dose (25 mg) should be considered for patients receiving saquinavir and it is recommended not to exceed a maximum single dose of 25 mg in a 48 h period for patients receiving ritonavir.

Relationships between exposure to saquinavir monotherapy and antiviral response in HIV-positive patients

OBJECTIVE

The aim of this study was to confirm the most appropriate dosage of a new soft gelatin capsule (SGC) formulation of the HIV protease inhibitor saquinavir by investigating the relationships between systemic (plasma) exposure to saquinavir and plasma HIV RNA and CD4+ cell counts using empirical mathematical modelling.

DESIGN AND SETTING

A randomised, non-blind, multicentre, dose-ranging 8-week study of monotherapy with 400, 800 or 1200 mg of saquinavir-SGC or 600 mg of the hard gelatin capsule (HGC) formulation, both administered 3 times daily, was carried out in protease inhibitor-naive, HIV-positive adults. Two surrogate markers of response, plasma HIV RNA level and CD4+ cell count, were fitted to 2 measures of systemic drug exposure, the area under the plasma concentration-time curve (AUC) and trough plasma concentration (Cmin), using 6 exposure-response models of progressively increasing complexity. Akaike and Schwarz model selection criteria were applied to determine the most effective pharmacokinetic-pharmacodynamic relationship.

RESULTS

A total of 88 patients were randomised; pharmacokinetic and pharmacodynamic data were available for 84 patients. In terms of plasma HIV RNA, pharmacokinetic-pharmacodynamic relationships were best described by a 2-parameter maximum effect (Emax) model, which predicted a typical maximum reduction in viral load of 1.94 log10 copies/ml [coefficient of variation (CV) 12%], with a half-maximal antiviral response occurring at a Cmin of 50 micrograms/L (CV 40%). Saquinavir-SGC 1200 mg administered 3 times daily produced a median AUC to 24 hours (AUC24) of approximately 20,000 micrograms/L.h, corresponding to 85% of the maximum achievable antiviral effect as defined by the model. None of the models yielded a satisfactory fit for CD4+ cell count.

CONCLUSION

Empirical mathematical modelling confirmed that, when administered 3 times daily, the optimum dose of saquinavir-SGC is 1200 mg, corresponding to 3600 mg/day.