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Ragonnet G, Laroche H, Néant N, Benkouiten S, Dos Santos MC, Faucher-Zaegel O, Solas C, Bregigeon-Ronot S. Enteral administration of crushed rilpivirine in a patient with HIV: A case report. Br J Clin Pharmacol 2024; 90:895-899. [PMID: 38163749 DOI: 10.1111/bcp.15994] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 12/09/2023] [Accepted: 12/13/2023] [Indexed: 01/03/2024] Open
Abstract
Antiretroviral therapy administration is challenging in patients with HIV requiring enteral nutrition. There are limited pharmacokinetic data available regarding the absorption of crushed rilpivirine (RPV) and its impact on drug bioavailability, plasma concentrations and, consequently, the efficacy of treatment. We present the case of a 60-year-old woman with HIV diagnosed with squamous cell carcinoma who needed enteral administration of antiretroviral therapy following the insertion of a gastrotomy tube in September 2018. Initially, the patient was treated with a daily dose of RPV 25 mg, dolutegravir 50 mg and emtricitabine 200 mg. The treatment was later intensified with darunavir boosted with ritonavir. RPV and dolutegravir were crushed, dissolved in water and administered via a percutaneous endoscopic gastrostomy tube. Therapeutic drug and viral load monitoring determined the adequacy of enteral antiretroviral dosing. RPV plasma concentrations remained within the expected therapeutic range of 43-117 ng/mL, with only 1 below the currently used 50 ng/mL efficacy threshold. After the treatment intensification with darunavir boosted with ritonavir, the patient achieved an undetectable viral load. While we observed satisfactory RPV plasma concentrations, it is essential to maintain strict monitoring of administration method, plasma concentrations and virological responses when initiating treatment with crushed RPV. Hence, additional pharmacokinetic data are necessary to ensure the effective enteral administration of RPV and to establish the best antiretroviral dosing regimens.
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Affiliation(s)
- Gwendoline Ragonnet
- Laboratoire de Pharmacocinétique et Toxicologie, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Hélène Laroche
- Service d'Immuno-hématologie clinique, Hôpital de Sainte-Marguerite, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Nadège Néant
- Laboratoire de Pharmacocinétique et Toxicologie, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Samir Benkouiten
- Service d'Immuno-hématologie clinique, Hôpital de Sainte-Marguerite, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Maeva Cacilda Dos Santos
- Service d'Immuno-hématologie clinique, Hôpital de Sainte-Marguerite, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Olivia Faucher-Zaegel
- Service d'Immuno-hématologie clinique, Hôpital de Sainte-Marguerite, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Caroline Solas
- Aix-Marseille Univ, APHM, Unité des virus émergents IRD190, INSERM 1207, Laboratoire de Pharmacocinétique et Toxicologie, Marseille, France
| | - Sylvie Bregigeon-Ronot
- Service d'Immuno-hématologie clinique, Hôpital de Sainte-Marguerite, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
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LoFaso M, Marchionda O, Bass S, Torbic H, Blackewicz C, Pallotta A. Evaluation of Dolutegravir- and Bictegravir-Based Antiretroviral Regimen Utilization in Patients who Cannot Take Medications by Mouth. Open Forum Infect Dis 2023; 10:ofad554. [PMID: 38088984 PMCID: PMC10712287 DOI: 10.1093/ofid/ofad554] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/08/2023] [Indexed: 12/30/2023] Open
Abstract
A retrospective review of patients unable to take medications by mouth showed short interruptions of therapy for most patients. In a secondary analysis, our data showed maintenance and/or achievement of viral suppression for most patients. A retrospective review of intensive care patients unable to take antiretrovirals by mouth showed 56.6% of patients experiencing a transient interruption in therapy. Additionally, our case series further supports previous literature on crushing dolutegravir and bictegravir regimens to maintain and achieve viral suppression.
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Affiliation(s)
- Megan LoFaso
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Stephanie Bass
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Heather Torbic
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Caitlin Blackewicz
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andrea Pallotta
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
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Çelik Aİ, Özkılıç YO, Zeybek Ö, Karalar M, Qaidi S, Ahmad J, Burduhos-Nergis DD, Bejinariu C. Mechanical Behavior of Crushed Waste Glass as Replacement of Aggregates. Materials (Basel) 2022; 15:ma15228093. [PMID: 36431578 PMCID: PMC9692602 DOI: 10.3390/ma15228093] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/06/2022] [Accepted: 11/09/2022] [Indexed: 06/01/2023]
Abstract
In this study, ground glass powder and crushed waste glass were used to replace coarse and fine aggregates. Within the scope of the study, fine aggregate (FA) and coarse aggregate (CA) were changed separately with proportions of 10%, 20%, 40%, and 50%. According to the mechanical test, including compression, splitting tensile, and flexural tests, the waste glass powder creates a better pozzolanic effect and increases the strength, while the glass particles tend to decrease the strength when they are swapped with aggregates. As observed in the splitting tensile test, noteworthy progress in the tensile strength of the concrete was achieved by 14%, while the waste glass used as a fractional replacement for the fine aggregate. In samples where glass particles were swapped with CA, the tensile strength tended to decrease. It was noticed that with the adding of waste glass at 10%, 20%, 40%, and 50% of FA swapped, the increase in flexural strength was 3.2%, 6.3%, 11.1%, and 4.8%, respectively, in amount to the reference one (6.3 MPa). Scanning electron microscope (SEM) analysis consequences also confirm the strength consequences obtained from the experimental study. While it is seen that glass powder provides better bonding with cement with its pozzolanic effect and this has a positive effect on strength consequences, it is seen that voids are formed in the samples where large glass pieces are swapped with aggregate and this affects the strength negatively. Furthermore, simple equations using existing data in the literature and the consequences obtained from the current study were also developed to predict mechanical properties of the concrete with recycled glass for practical applications. Based on findings obtained from our study, 20% replacement for FA and CA with waste glass is recommended.
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Affiliation(s)
- Ali İhsan Çelik
- Tomarza Mustafa Akincioglu Vocational School, Department of Construction, Kayseri University, Kayseri 38940, Turkey
| | - Yasin Onuralp Özkılıç
- Department of Civil Engineering, Faculty of Engineering, Necmettin Erbakan University, Konya 42000, Turkey
| | - Özer Zeybek
- Department of Civil Engineering, Faculty of Engineering, Mugla Sitki Kocman University, Mugla 48000, Turkey
| | - Memduh Karalar
- Faculty of Engineering, Department of Civil Engineering, Zonguldak Bulent Ecevit University, Zonguldak 67100, Turkey
| | - Shaker Qaidi
- Department of Civil Engineering, College of Engineering, University of Duhok, Duhok 42001, Iraq
- Department of Civil Engineering, College of Engineering, Nawroz University, Duhok 42001, Iraq
| | - Jawad Ahmad
- Department of Civil Engineering, Military College of Engineering (Nust), Risalpur 24080, Pakistan
| | - Dumitru Doru Burduhos-Nergis
- Faculty of Materials Science and Engineering, Gheorghe Asachi Technical University of Iasi, 700050 Iasi, Romania
| | - Costica Bejinariu
- Faculty of Materials Science and Engineering, Gheorghe Asachi Technical University of Iasi, 700050 Iasi, Romania
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Guo C, Zhao JR, Chen MJ, Zhang Y, Wu RY, Li QQ, Zhao H, Wei J. Crushed/chewed administration of potent P2Y 12 inhibitors in ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: Systematic review and meta-analysis. Platelets 2021; 33:679-686. [PMID: 34472997 DOI: 10.1080/09537104.2021.1974370] [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: 10/20/2022]
Abstract
Crushed or chewed potent P2Y12 inhibitors are commonly used in the hope of bridging the gap of platelet inhibition in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). The study aimed to investigate the efficacy and safety of this alternative oral administration strategy by performing a meta-analysis of available randomized clinical trials (RCTs). PubMed, Embase, the Cochrane Library and Web of Science medical literature databases were searched for RCTs comparing crushed/chewed vs. integral administration of loading dose potent P2Y12 inhibitors in patients with STEMI undergoing pPCI with no language restrictions from inception to January 20th, 2021. The primary efficacy endpoints of high on treatment platelet reactivity (HPR) and P2Y12 reaction units (PRU) at 1 hour together with safety and additional clinical endpoints were evaluated by pooled odds ratio (OR) or mean differences (MD) with 95% confidence intervals (95% CI). A total of 973 patents in six RCTs were eligible for analysis, while 876 patients present baseline and procedural characteristics. HPR and PRU at 1 hour were significantly reduced in the group receiving crushed/chewed P2Y12 inhibitors compared with integral tablets (OR 0.28, 95% CI 0.16 to 0.49, P < .0001; MD -60.62, 95% CI -97.06 to -24.19, P = .001, respectively). Safety endpoints of major bleeding (OR 0.54, 95% CI 0.11 to 2.73, P = .46) and any bleeding (OR 0.84, 95% CI 0.43 to 1.64, P = .61), as well as additional clinical endpoints of cardiovascular death, myocardial infarction, and stroke were not affected by the oral administration strategy. In STEMI patients undergoing pPCI, crushed or chewed administration of potent P2Y12 inhibitors are associated with enhanced early platelet inhibition and appear to be safe. The clinical profile transformed from this pharmacodynamic benefit need to be determined by further researches.
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Affiliation(s)
- Chen Guo
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Jin-Rui Zhao
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Meng-Jie Chen
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Yue Zhang
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Rui-Yun Wu
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Qiang-Qiang Li
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Hong Zhao
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Jin Wei
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
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Capranzano P, Angiolillo DJ. Tackling the gap in platelet inhibition with oral antiplatelet agents in high-risk patients undergoing percutaneous coronary intervention. Expert Rev Cardiovasc Ther 2021; 19:519-535. [PMID: 33881367 DOI: 10.1080/14779072.2021.1920925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Oral P2Y12 inhibitors represent the mainstay therapy for the prevention of thrombotic complications in patients presenting with an acute coronary syndrome and/or undergoing percutaneous coronary intervention (PCI). However, the onset of antiplatelet action of the oral P2Y12 inhibitors is affected by their need to be absorbed in the gastrointestinal (GI) tract before becoming systemically available.Areas covered: Following oral intake of P2Y12 inhibitors, the timeframe required for GI absorption leads to a window of inadequate antiplatelet protection during which patients are at increased thrombotic risk. The onset of action of the oral P2Y12 inhibitors is even further delayed in high-risk patients, underscoring the need to define strategies to bridge the gap in platelet inhibitory effects following their intake.Expert opinion: Multiple mechanisms may impair GI absorption leading to a delay in the onset of action of oral P2Y12 inhibitors. Several strategies have been tested to overcome the gap in platelet inhibition in high-risk patients undergoing PCI. These include administration of crushed or chewed tablets to improve the dissolution rate and use of opioid receptor antagonists or metoclopramide to counteract impairment of gastric motility induced by opioids. However, intravenous antiplatelet therapies represent the most effective strategy to bridge such gap in platelet inhibition.
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Affiliation(s)
- Piera Capranzano
- Division of Cardiology, Policlinico Hospital, University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
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Court R, Chirehwa MT, Wiesner L, de Vries N, Harding J, Gumbo T, Maartens G, McIlleron H. Effect of tablet crushing on drug exposure in the treatment of multidrug-resistant tuberculosis. Int J Tuberc Lung Dis 2019; 23:1068-1074. [PMID: 31627771 PMCID: PMC7402384 DOI: 10.5588/ijtld.18.0775] [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] [Indexed: 11/10/2022] Open
Abstract
SETTING: Treatment outcomes in multidrug-resistant tuberculosis (MDR-TB) are poor. Due to drug toxicity and a long treatment duration, approximately half of patients are treated successfully. Medication is often crushed for patients who have difficulty swallowing whole tablets. Whether crushing tablets affects drug exposure in MDR-TB treatment is not known.OBJECTIVE AND DESIGN: We performed a sequential pharmacokinetic study in patients aged >18 years on MDR-TB treatment at two hospitals in Cape Town, South Africa. We compared the bioavailability of pyrazinamide, moxifloxacin, isoniazid (INH), ethambutol and terizidone when the tablets were crushed and mixed with water before administration vs. swallowed whole. We sampled blood at six time points over 10 h under each condition separated by 2 weeks. Non-compartmental analysis was used to derive the key pharmacokinetic measurements.RESULTS: Twenty participants completed the study: 15 were men, and the median age was 31.5 years. There was a 42% reduction in the area under the curve AUC0-10 of INH when the tablets were crushed compared with whole tablets (geometric mean ratio 58%; 90%CI 47-73). Crushing tablets of pyrazinamide, moxifloxacin, ethambutol and terizidone did not affect the bioavailability significantly.CONCLUSION: We recommend that crushing of INH tablets in the MDR-TB treatment regimen be avoided. Paediatric INH formulations may be a viable alternative if the crushing of INH tablets is indicated.
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Affiliation(s)
- R Court
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town
| | - M T Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town
| | - L Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town
| | | | - J Harding
- DP Marais Hospital, Cape Town, South Africa
| | - T Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - G Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town
| | - H McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town
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Serenelli M, Pavasini R, Vitali F, Tonet E, Bilotta F, Parodi G, Campo G. Efficacy and safety of alternative oral administrations of P2Y12-receptor inhibitors: Systematic review and meta-analysis. J Thromb Haemost 2019; 17:944-950. [PMID: 30884109 DOI: 10.1111/jth.14434] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 03/13/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Early administration of P2Y12-receptor inhibitors is recommended in all patients with acute coronary syndrome undergoing invasive management, with the aim to achieve the fastest and most effective platelet inhibition. Several trials investigated alternative methods of P2Y12-receptor inhibitor administration (mainly chewed or crushed) aimed at ensuring faster and higher platelet inhibition. Thus, we decided to perform a systematic review and meta-analysis analyzing efficacy and safety of alternative P2Y12-receptor inhibitor administration strategies. METHODS Systematic research was performed on Pubmed, Cochrane Library, Biomed Central, and Web of Science databases. We included randomized or observational trials testing at least one P2Y12-receptor inhibitor alternative administration. The primary outcome of the study was the value of the platelet reactivity unit (PRU) at 1 h after drug administration, assessed by VerifyNow P2Y12 test (Accumetrics, Inc., San Diego, CA). Secondary outcomes were adverse bleeding events (safety outcome). RESULTS AND DISCUSSION Fourteen studies were selected for qualitative analysis. Five studies, all focused on ticagrelor, were selected for quantitative efficacy analyses. These five studies compared the administration of crushed/chewed ticagrelor 180 mg loading dose (LD) with the standard whole tablets LD. The pooled mean difference between the two administrations was -59.24 PRU (95% CI from -30.61 to -87.87 PRU) in favor of the crushed/chewed administration, corresponding to a 25% mean relative PRU reduction between alternative and standard P2Y12-receptor inhibitor administrations at 1 h after drug intake. A similar relationship was found in other studies on alternative administration of clopidogrel and prasugrel, not included in the quantitative analysis.
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Affiliation(s)
- Matteo Serenelli
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona (FE), Italy
| | - Rita Pavasini
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona (FE), Italy
| | - Francesco Vitali
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona (FE), Italy
| | - Elisabetta Tonet
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona (FE), Italy
| | - Ferruccio Bilotta
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari (SA), Italy
| | - Guido Parodi
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari (SA), Italy
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona (FE), Italy
- Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
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Turley SL, Fulco PP. Enteral Administration of Twice-Daily Dolutegravir and Rilpivirine as a Part of a Triple-Therapy Regimen in a Critically Ill Patient with HIV. J Int Assoc Provid AIDS Care 2017; 16:117-119. [PMID: 28198203 DOI: 10.1177/2325957417692678] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The administration of antiretroviral therapy (ART) in intubated critically ill patients may be challenging. Limited pharmacokinetic data exist characterizing the effects of crushed ART with subsequent enteral administration on antiretroviral drug concentrations or the clinical impact on HIV virologic suppression. We report a case of a 27-year-old HIV-positive male with presumed multidrug-resistant HIV and a diagnosis of lymphoma who required enteral ART administration after intensive care unit admission. Crushed twice-daily dolutegravir (separated from enteral nutrition by 2 hours) and rilpivirine (concurrently with a bolus feed) were administered via an orogastric tube. Therapeutic drug monitoring for both dolutegravir and rilpivirine demonstrated antiretroviral absorption via the enteral route (both values slightly below the therapeutic laboratory reference range) with continued virologic suppression.
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Affiliation(s)
- Sarah Lynn Turley
- 1 Department of Pharmacy, Virginia Commonwealth University Health, Richmond, VA, USA
| | - Patricia Pecora Fulco
- 1 Department of Pharmacy, Virginia Commonwealth University Health, Richmond, VA, USA
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