Dolutegravir pharmacokinetics in pregnant and postpartum women living with HIV

Nikki Mulligan, Brookie M Best, Jiajia Wang, Edmund V Capparelli, Alice Stek, Emily Barr, Shelley L Buschur, Edward P Acosta, Elizabeth Smith, Nahida Chakhtoura, Sandra Burchett, Mark Mirochnick, IMPAACT P1026s Protocol Team, Nikki Mulligan, Brookie M Best, Jiajia Wang, Edmund V Capparelli, Alice Stek, Emily Barr, Shelley L Buschur, Edward P Acosta, Elizabeth Smith, Nahida Chakhtoura, Sandra Burchett, Mark Mirochnick, IMPAACT P1026s Protocol Team

Abstract

Objective: To evaluate dolutegravir pharmacokinetics during pregnancy compared with postpartum and in infant washout samples after delivery.

Design: Ongoing, nonrandomized, open-label, parallel-group, multicenter phase-IV prospective study of antiretroviral pharmacokinetics in HIV-infected pregnant women and infants.

Methods: Intensive steady-state 24 h pharmacokinetic profiles after dolutegravir 50 mg once-daily were performed during the second trimester (2T), third trimester (3T) and postpartum. Maternal delivery and postnatal infant samples were collected after birth. Dolutegravir was measured by validated LC-MS/MS; quantitation limit was 0.005 μg/ml. A two-tailed Wilcoxon signed-rank test (α = 0.10) was employed for paired within-subject comparisons.

Results: Twenty-nine enrolled participants had a median age of 32 years (range 21-42). Pharmacokinetic data were available for 15 (2T), 28 (3T) and 23 (postpartum) women. Median dolutegravir AUC0-24,Cmax and C24 were 25-51% lower in the 2T and 3T compared with postpartum. The median cord blood/maternal plasma concentration ratio was 1.25 (n = 18). In 21 infants, median elimination half-life was 32.8 h after in utero exposure. Viral load at delivery was less than 50 copies/ml for 27/29 women (93%). Twenty-nine infants were HIV-negative. Renal abnormalities noted on ultrasound in two infants were deemed possibly related to dolutegravir.

Conclusion: Dolutegravir exposure is lower in pregnancy compared with postpartum in the same women on once-daily dosing. Median AUC0-24 during pregnancy was similar to, whereas trough concentrations were lower than, those seen in nonpregnant adults. Trough concentrations in pregnancy were well above dolutegravir EC90 (0.064 μg/ml). Dolutegravir readily crosses the placenta. Infant elimination is prolonged, with half-life over twice that of historical adult controls.

Conflict of interest statement

Conflicts of Interest and Sources of Funding:

Overall support for the International Maternal Pediatric Adolescent AIDS Clinical Trials Network (IMPAACT) was provided by the National Institute of Allergy and Infectious Diseases (NIAID) of the National Institutes of Health (NIH) under Award Numbers UM1AI068632 (IMPAACT LOC), UM1AI068616 (IMPAACT SDMC) and UM1AI106716 (IMPAACT LC), with co-funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and the National Institute of Mental Health (NIMH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. No author conflicts were declared.

Figures

Figure 1
Figure 1
Maternal median (± standard error of the median) dolutegravir concentrations versus time post-dose.
Figure 2
Figure 2
Individual infant dolutegravir concentrations versus time post-delivery.

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