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Current HIV Research
ISSN (Print): 1570-162X
ISSN (Online): 1873-4251
Epub Full Text Article
DOI: 10.2174/1570162X12666140526120831      Price:  $95









Modeling and Simulation Approach to Support Dosing and Study Design Requirements for Treating HIV-Related Neuropsychiatric Disease with the NK1-R Antagonist Aprepitant

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Author(s): Jeffrey S Barrett, Gaurav Bajaj, Jennifer McGuire, Di Wu, Sergei Spitsin, Ganesh Moorthy, Xianguo Zhao, Pablo Tebas, Dwight L Evans and Steven D Douglas
Abstract:
Psychiatric illness is common in HIV-infected patients and underlines the importance for screening not only for cognitive impairment but also for co-morbid mental disease. The rationale for combining immunomodulatory neurokinin-1 receptor (NK1-R) antagonists with combined antiretroviral therapy (cART) is based on multimodal pharmacologic mechanisms. The NK1-R antagonist aprepitant’s potential utility as a drug for depression is complicated by >99.9% protein binding and both enzyme inhibition and induction of CYP3A4. A population-based PK model developed from a pilot Phase 1B trial in 19 HIV-infected patients (125 or 250 mg/d aprepitant for 2 weeks) was modified to account for enzyme induction and impact of an exposure enhancer on CYP3A4 metabolism. Likelihood of clinical success in depression was assessedbased on achievement of target trough plasma concentration and evaluated using Monte Carlo simulation. Scenarios were generated for varying daily dose (375, 625, 750 and 875 mg), pharmacokinetic variability, exposure enhancement (EE), duration (2 and 6 months) and sample size (n=12 and 24 / arm). Daily dosing of ≥625 mg with EE yielded desirable troughs (based on in vitro infectivity experiments) of > 2.65 ug/mL for the majority of virtual patients simulated. Results are dependent on the degree of exposure enhancement and extent of enzyme induction. Actual threshold exposure requirements for aprepitant in HIV-associated depression are unknown though preclinical evidence supports trough levels > 2.65 ug/mL.If 100% NK1r blockage is necessary for efficacy, doses of 875 mg (625 mg with EE) or higher may be required. The benefit of aprepitant on innate immunity(natural killer cells) and absence of negative effects onex vivo neutrophil chemotaxis alleviates concerns regarding drug dependent inhibition (DDI)-mediated infection risk
Graphical Abstract:
Keywords:
Aprepitant, clinical trial simulation, depression, NK1r antagonism
Affiliation:
Divisions of Clinical Pharmacology and Therapeutics Divisions of Clinical Pharmacology andTherapeutics Divisions of Clinical Pharmacology and Therapeutics Neurology and Allergy & Immunology The Childrens Hospital of Philadelphia Research Institute Philadelphia, PA 19104