JAC Advance Access originally published online on October 30, 2008
Journal of Antimicrobial Chemotherapy 2009 63(1):170-177; doi:10.1093/jac/dkn441
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Original research |
Persistence of nevirapine in breast milk and plasma of mothers and their children after single-dose administration
1 Institute of Tropical Medicine and International Health, Charité—University Medicine Berlin, Berlin, Germany 2 Institute of Pharmacy, Martin-Luther-Universitaet Halle-Wittenberg, Halle, Germany 3 MoH/GTZ PMTCT Project western Uganda, Fort Portal, Uganda 4 Therapia HIV-Lab, Auguste-Viktoria Hospital, Berlin, Germany
Received 12 June 2008; returned 30 July 2008; revised 9 September 2008; accepted 26 September 2008
* Corresponding author. Tel: +49-30-30116-700; Fax: +49-30-30116-710; E-mail: andrea-ursula.kunz{at}charite.de
Objectives: Nevirapine is widely used in the developing world for the prevention of mother-to-child transmission (PMTCT) of HIV. A single mutation in the HIV genome is sufficient to lead to significant nevirapine resistance. Persistence of low-level drug concentrations in body compartments can foster resistance formation. In this study, concentration–time courses of nevirapine after single-dose administration were analysed over an extended post-partum period.
Patients and methods: Breast milk and plasma samples of 62 HIV-positive Ugandan mother–child pairs who had received single-dose nevirapine were collected at delivery and 1, 2 and 6 weeks post-partum. Nevirapine concentrations were quantified by LC/tandem-mass-spectrometry using a quantification limit of 15 ng/mL, and a population pharmacokinetic (PK) analysis was performed.
Results: Concentration–time profiles in breast milk, maternal plasma and child plasma showed similar shapes. At week 1, median nevirapine concentrations were 164 ng/mL in maternal plasma, 114 ng/mL in breast milk and 183 ng/mL in child plasma. The population PK model predicted nevirapine concentrations >10 ng/mL (IC50 for nevirapine) for 13 days in breast milk, 14 days in maternal plasma and 18 days in child plasma in 80% of the samples.
Conclusions: Nevirapine concentrations were present for 2–3 weeks in the three compartments. The concentrations are probably sufficiently high to protect most breastfed children from HIV transmission during the first 2 weeks. The long presence of slowly decreasing levels of nevirapine is likely to induce resistance formation. Post-natal addition of antiretrovirals for 1 week only, as recommended in the current PMTCT guidelines, will not suffice to avoid nevirapine resistance formation.
Keywords: HIV , breastfeeding , population pharmacokinetics , Uganda