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Pharmacokinetic Enhancement of Protease Inhibitor Therapy

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Abstract

Combination antiretroviral therapy with two or more protease inhibitors has become the standard of care in the treatment of HIV infection. Dual protein inhibitor (PI) regimens, such as lopinavir/ritonavir, are commonly used as initial PI therapy. As viral resistance increases and the development of mechanistically novel protease inhibitors decreases, clinicians turn to ritonavir-enhanced dual PI therpay to treat salvage patients. Potency of these combination regimens is increased while pill burden, food restrictions and often, side effects are decreased. These clincial advantages result from the enhancement of their pharmacological properties, including alterations in the absorption and metabolism process. Alterations in the absorption and metabolism of protease inhibitors when co-administered with a cytochrome P450 (CYP) enzyme inhibitor, such as low dose ritonavir, are reflected by impressive changes in pharmacokinetic parameters. For example, the addition of ritonavir 100 or 200mg to saquinavir 1200–1800mg has been shown to increase saquinavir area under the concentration-time curve (AUC) by approximately 300–800% compared with saquinavir alone. The ability of ritonavir to increase plasma trough concentrations (Cmin) of concomitantly administered PIs is perhaps the greatest clinical benefit of dual or ritonavir-enhanced dual PI therapy since inadequate concentrations of antiretrovirals may support long term antiretroviral resistance. For example, lopinavir 400mg alone in healthy volunteers produced plasma concentrations that briefly exceeded the concentration required to inhibit 50% of viral replication (IC50). Yet, when low doses of ritonavir were added, Cmin values were 50- to 100-fold greater than the concentration required to produce 50% of the maximum effect for wild-type HIV (EC50). The following manuscript will discuss the rationale for combining protease inhibitors and will review pertinent pharmacokinetic and clinical data on these combination regimens.

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Acknowledgements

This review was supported in part by grants UO1 AI-32775 and UO1 AI-41089 from the National Institutes of Allergy and Infectious Diseases, and NIH AI 27661 and the University of Minnesota International Center for Antiviral Research and Epidemiology. The authors have provided no information on conflicts of interest directly relevant to the content of this review.

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Authors and Affiliations

  1. Division of Clinical Pharmacology, School of Medicine, University of Alabama at Birmingham, 1530 3rd Avenue South, Birmingham, VH 116, Alabama, 35294-0019, USA

    Jennifer R. King &  Edward P. Acosta

  2. Department of Laboratory Medicine and Pathology, School of Medicine, University of Minnesota, Minneapolis, Minnesota, USA

    Heather Wynn

  3. Department of Experimental and Clinical Pharmacology, School of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA

    Richard Brundage

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  1. Jennifer R. King
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  2. Heather Wynn
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  3. Richard Brundage
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  4. Edward P. Acosta
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Correspondence to Edward P. Acosta.

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King, J.R., Wynn, H., Brundage, R. et al. Pharmacokinetic Enhancement of Protease Inhibitor Therapy. Clin Pharmacokinet 43, 291–310 (2004). https://doi.org/10.2165/00003088-200443050-00003

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