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The increasing global prevalence of human immunodeficiency virus (HIV) is estimated at 36.7 million people currently infected. Lifelong antiretroviral (ARV) drug combination dosing allows management as a chronic condition by suppressing circulating viral load to allow for a near-normal life; however, the daily burden of oral administration may lead to non-adherence and drug resistance development. Long-acting (LA) depot injections of nanomilled poorly water-soluble ARVs have shown highly promising clinical results with drug exposure largely maintained over months after a single injection. ARV oral combinations rely on water-soluble backbone drugs which are not compatible with nanomilling. Here, we evaluate a unique prodrug/nanoparticle formation strategy to facilitate semi-solid prodrug nanoparticles (SSPNs) of the highly water-soluble nucleoside reverse transcriptase inhibitor (NRTI) emtricitabine (FTC), and injectable aqueous nanodispersions; in vitro to in vivo extrapolation (IVIVE) modelling predicts sustained prodrug release, with activation in relevant biological environments, representing a first step towards complete injectable LA regimens containing NRTIs. Non-adherence to daily drug regimens is responsible for many negative clinical effects including drug resistance in life-long treatments for HIV. Here, the authors report on a HIV prodrug nanoparticle platform for long-acting sustained release of water-soluble drug compounds following injection.

The successful development of a chemoprophylaxis against SARS-CoV-2 could provide a tool for infection prevention that is implementable alongside vaccination programmes. Nafamostat is a serine protease inhibitor that inhibits SARS-CoV-2 entry in vitro, but it has not been characterised for chemoprophylaxis in animal models. Clinically, nafamostat is limited to intravenous delivery and has an extremely short plasma half-life. This study sought to determine whether intranasal dosing of nafamostat at 5 mg/kg twice daily was able to prevent the airborne transmission of SARS-CoV-2 from infected to uninfected Syrian Golden hamsters. SARS-CoV-2 RNA was detectable in the throat swabs of the water-treated control group 4 days after cohabitation with a SARS-CoV-2 inoculated hamster. However, throat swabs from the intranasal nafamostat-treated hamsters remained SARS-CoV-2 RNA negative for the full 4 days of cohabitation. Significantly lower SARS-CoV-2 RNA concentrations were seen in the nasal turbinates of the nafamostat-treated group compared to the control (p = 0.001). A plaque assay quantified a significantly lower concentration of infectious SARS-CoV-2 in the lungs of the nafamostat-treated group compared to the control (p = 0.035). When taken collectively with the pathological changes observed in the lungs and nasal mucosa, these data are strongly supportive of the utility of intranasally delivered nafamostat for the prevention of SARS-CoV-2 infection.

Favipiravir (FVP) and remdesivir (RDV) have demonstrable antiviral activity against SARS-CoV-2. Here, the efficacy of FVP, RDV, and FVP with RDV (FVP + RDV) in combination was assessed in Syrian golden hamsters challenged with SARS-CoV- 2 (B.1.1.7) following intraperitoneal administration. At day 4 post infection, viral RNA and viral antigen expression were significantly lower in lungs for all three treatment groups compared to the sham treatment. Similarly, viral titres in the lungs were lower in all treatment groups compared to the sham treatment. The FVP + RDV combination was the only treatment group where viral RNA in nasal turbinate and lung, virus titres in lung, and viral antigen expression (lung) were all lower than those for the sham treatment group. Moreover, lower viral titre values were observed in the FVP + RDV group compared to other treatment groups, albeit only significantly lower in comparison to those in the RDV-only-treated group. Further assessment of the potential utility of FVP in combination with RDV may be warranted. Future studies should also consider whether the combination of these two drugs may reduce the speed at which drug resistance mutations are selected.

Pibrentasvir (PIB) has been demonstrated to block exonuclease activity of the SARS-CoV-2 polymerase, protecting favipiravir (FVP) and remdesivir (RDV) from post-incorporation excision and eliciting antiviral synergy in vitro. The present study investigated the chemoprophylactic efficacy of PIB, FVP, RDV, FVP with PIB, or RDV with PIB dosed intranasally twice a day, using a Syrian golden hamster contact transmission model. Compared to the saline control, viral RNA levels were significantly lower in throat swabs in FVP (day 7), RDV (day 3, 5, 7), and RDV+PIB (day 3, 5) treatment groups. Similarly, findings were evident for nasal turbinate after PIB and RDV treatment, and lungs after PIB, FVP, and FVP+PIB treatment at day 7. Lung viral RNA levels after RDV and RDV+PIB treatment were only detectable in two animals per group, but the overall difference was not statistically significant. In situ examination of the lungs confirmed SARS-CoV-2 infection in all animals, except for one in each of the RDV and RDV+PIB treatment groups, which tested negative in all virus detection approaches. Overall, prevention of transmission was observed in most animals treated with RDV, while other agents reduced the viral load following contact transmission. No benefit of combining FVP or RDV with PIB was observed.

Long-acting injectable (LAI) formulations promise to deliver patient benefits by overcoming issues associated with non-adherence. A preclinical assessment of semi-solid prodrug nanoparticle (SSPN) LAI formulations of emtricitabine (FTC) is reported here. Pharmacokinetics over 28 days were assessed in Wistar rats, New Zealand white rabbits, and Balb/C mice following intramuscular injection. Two lead formulations were assessed for the prevention of an HIV infection in NSG-cmah−/− humanised mice to ensure antiviral activities were as anticipated according to the pharmacokinetics. Cmax was reached by 12, 48, and 24 h in rats, rabbits, and mice, respectively. Plasma concentrations were below the limit of detection (2 ng/mL) by 21 days in rats and rabbits, and 28 days in mice. Mice treated with SSPN formulations demonstrated undetectable viral loads (700 copies/mL detection limit), and HIV RNA remained undetectable 28 days post-infection in plasma, spleen, lung, and liver. The in vivo data presented here demonstrate that the combined prodrug/SSPN approach can provide a dramatically extended pharmacokinetic half-life across multiple preclinical species. Species differences in renal clearance of FTC mean that longer exposures are likely to be achievable in humans than in preclinical models.

Background Digitized (scanned) medical records have been seen as a means for hospitals to reduce costs and improve access to records. However, clinical usability of digitized records can potentially have negative effects on productivity. Methods Data were collected during follow-up outpatient consultations in two NHS hospitals by non-clinical observers using a work sampling approach in which pre-defined categories of clinician time usage were specified. Quantitative data was analysed using two-way ANOVA models and the Mann-Whitney U test. A focus group was held with clinicians to qualitatively explore their experiences using digitized medical records. The quantitative and qualitative results were synthesized. Results Four hundred six consultations were observed. Using paper records, there was a significant difference in consultation times between hospitals ( p  = 0.016) and a significant difference in consultation times between specialties within hospitals ( p  = 0.003). Using digitized records there was a significant difference in consultation times between specialties within a hospital ( p  = 0.001). Excluding outliers, there was no significant difference between consultation times using digitized records compared with consultations using paper records in the same hospital, either at site ( p  > =0.285) or specialty level ( p  > =0.122). With digitized records at site A, two out of three specialties showed a significant increase in time spent searching computer records ( p  < =0.010, Δ = 01:50–07:10) and one specialty had a corresponding reduction in time spent searching paper records ( p  = 0.015, Δ = −00:28). Site B showed a notable increase in direct patient care ( p  < 0.001, Δ = 04:20–06:00) and time spent searching computer records ( p  < =0.043, Δ = 00:10–01:40) and reductions in the other time categories. The focus group confirmed that the most recent clinical letter was a vital document in the patient record, often containing most of the required information. Concerns were expressed about consistency of scanning practice, causing uncertainty about what could be relied upon to exist in the digitized record. Benefits of digitized records included: access from multiple locations, better prepared ward rounds, improved inpatient handovers and an improved timeline of patient events. Limitations of digitized records included: increased complexity of creating a patient summary, display of specialised content such as hand-drawn diagrams, inability to quickly flick through the pages to find relevant content. Conclusions Digitized medical records can be implemented without detrimental operational impact. Inherent differences between specialties can outweigh the differences between paper and digitized records. Clear and consistent operational processes are vital for the reliability and usability of digitized medical records. Divergent views about usability (such as whether patient summary information is better or worse) may reflect familiarity with features of the digitized record.

Abstract Background Cabotegravir and rilpivirine are 2 long-acting (LA) antiretrovirals that can be administered intramuscularly; their interaction with rifampicin, a first-line antituberculosis agent, has not been investigated. The aim of this study was to simulate and predict drug–drug interactions (DDIs) between these LA antiretroviral agents and rifampicin using physiologically based pharmacokinetic (PBPK) modeling. Methods The designed PBPK models were qualified (according to European Medicines Agency guidelines) against observed data for oral formulations of cabotegravir, rilpivirine, and rifampicin. Induction potential of rifampicin was also qualified by comparing the DDI between oral cabotegravir and oral rilpivirine with rifampicin. Qualified PBPK models were utilized for pharmacokinetic prediction of DDIs. Results PBPK models predicted a reduction in both area under the curve (AUC0-28 days) and trough concentration (Ctrough, 28th day) of LA cabotegravir of 41%–46% for the first maintenance dose coadministered with 600 mg once-daily oral rifampicin. Rilpivirine concentrations were predicted to decrease by 82% for both AUC0-28 days and Ctrough, 28th day following the first maintenance dose when coadministered with rifampicin. Conclusions The developed PBPK models predicted the theoretical effect of rifampicin on cabotegravir and rilpivirine LA intramuscular formulations. According to these simulations, it is likely that coadministration of rifampicin with these LA formulations will result in subtherapeutic concentrations of both drugs. This article highlights the use of physiologically based pharmacokinetic models for the evaluation of drug–drug interaction magnitude between long-acting antiretroviral formulations of cabotegravir and rilpivirine coadministered with oral rifampicin in an adult population.

Efavirenz displays many desirable pharmacokinetic properties such as a long half-life allowing once daily dosing and potency against HIV. Despite these favourable properties efavirenz-containing therapy is associated with the development of central nervous system (CNS) toxicities. Current investigations indicate that high plasma concentrations of efavirenz play a putative role in the development of CNS side effects, but there is a current paucity of data relating to the underlying mechanisms of toxicity. Various nanotechnologies have been explored in attempts to mitigate some of the limitations with efavirenz. While there has been progress in increasing the bioavailability of efavirenz there has been no attempt to assess the impact of increased exposure to efavirenz on CNS toxicity. The body of work presented in this thesis aimed firstly to investigate the underlying mechanism of efavirenz CNS toxicity and secondly to assess uptake and CNS toxicity of efavirenz and a novel solid drug nanoformulation (SDN) of efavirenz. The work presented in this thesis utilised a variety of in vitro, in vivo and in silico methodologies. Chapter 2 utilised allelic discrimination polymerase chain reaction in order to investigate the association of single nucleotide polymorphism (SNPs) in the gamma aminobutyric acid receptor with early treatment discontinuation of efavirenz. In order to assess the effects of SDN efavirenz on the occurrence of CNS toxicities, an in vivo model of anxiety (elevated plus maze) was employed (chapter 3). Chapter 4 detailed the development of a robust and sensitive liquid chromatography tandem mass spectrometer assay for the detection of efavirenz in multiple matrices. The uptake of efavirenz and SDN efavirenz in the CNS was investigated utilising cellular uptake and inhibition studies (chapter 5). Physiologically based pharmacokinetic (PBPK) simulations were used to investigate the distribution of efavirenz in plasma, cerebrospinal fluid (CSF) and brain tissue (chapter 6). Despite an initial trend with Rs211014 and Rs6556547 (univariate analysis) of the training cohort, these SNPs were not found to be significant in the multivariate analysis or in either analysis of the test cohort. Following multiple doses rats treated with efavirenz, but not SDN efavirenz, exhibited anxiety-like behaviour in the EPM. The profile of changes indicated some clear behavioural effects that are likely to be linked to drug-related CNS effects. In particular, a tendency of efavirenz to increase time spent on the central platform may be indicative of anxiogenesis. Cellular accumulation of efavirenz was reduced significantly by montelukast and amantadine, with the reduction in accumulation by prazosin bordering on significance (indicating efavirenz may be a substrate for OCT1 and an SLCO transporter). Additionally, cellular accumulation of SDN efavirenz particles was reduced by dynasore, indicating dynamin-mediated uptake. PBPK simulations predicted efavirenz accumulation in brain tissue, with a tissue to plasma ratio 15.8. The natural occurrence of conditions such as depression involves a complex interplay of factors influencing neurotransmission. This makes identifying single predictors of efavirenz CNS toxicity more difficult. The data presented in this thesis may be built upon to understand the mechanisms governing efavirenz disposition in the CNS and factors influencing the occurrence of CNS toxicity.

Misoprostol, a prostaglandin analogue used for the treatment of postpartum hemorrhage and termination of pregnancy, can cause high fevers. Genetic susceptibility may play a role in misoprostol-induced fever. Body temperature of women treated with misoprostol for termination of pregnancy in the UK (n = 107) and for postpartum hemorrhage in Ecuador (n = 50) was measured. Genotyping for 33 single nucleotide polymorphisms in 15 candidate genes was performed. Additionally, we investigated the transport of radiolabeled misoprostol acid across biological membranes in vitro. The ABCC4 single nucleotide polymorphism rs11568658 was associated with misoprostol-induced fever. Misoprostol acid was transported across a blood-brain barrier model by MRP4 and SLCO1B1. Genetic variability in ABCC4 may contribute to misoprostol-induced fever in pregnant women. Original submitted 21 January 2015; Revision submitted 24 April 2015.

Misoprostol, a prostaglandin analogue used for the treatment of postpartum hemorrhage and termination of pregnancy, can cause high fevers. Genetic susceptibility may play a role in misoprostol-induced fever. Body temperature of women treated with misoprostol for termination of pregnancy in the UK (n = 107) and for postpartum hemorrhage in Ecuador (n = 50) was measured. Genotyping for 33 single nucleotide polymorphisms in 15 candidate genes was performed. Additionally, we investigated the transport of radiolabeled misoprostol acid across biological membranes . The single nucleotide polymorphism rs11568658 was associated with misoprostol-induced fever. Misoprostol acid was transported across a blood-brain barrier model by MRP4 and SLCO1B1. Genetic variability in ABCC4 may contribute to misoprostol-induced fever in pregnant women. Original submitted 21 January 2015; Revision submitted 24 April 2015