The Effect of Veno-Arterial Extracorporeal Oxygenation and Nasogastric Tube Administration on the Pharmacokinetic Profile of Abacavir, Lamivudine and Dolutegravir: A Case Report

Abstract

Background Pharmacokinetic (PK) changes can affect antiretroviral (ARV) systemic exposure for critically ill patients living with HIV (CI-PLWH). Studies to guide ARV adjustments in this population are limited. Methods A PK analysis was conducted in a 44-year-old CI-PLWH who presented for a heart and lung transplant on veno-arterial extracorporeal membrane oxygenation (VA ECMO). Home ARV therapy (ART) of co-formulated abacavir/lamivudine/dolutegravir (ABC/3TC/DTG) was continued. ARV serum concentrations were obtained during and after VA ECMO. Two blood levels were drawn at 1 h, for maximum serum concentration (Cmax) and a serum trough (Ct). ARVs were given as a single tablet crushed via nasogastric tube. Results Area under the concentration–time curve (AUC0–t) was calculated using non-compartmental analysis. Cmax and AUC0–t were higher during VA ECMO compared with post-decannulation. The Cmax of ABC was >2.5-fold higher than the mean in the reference. Cmax and Ct post VA ECMO were within range of referenced literature for all ARVs. Cmax and AUC0–t of DTG post VA ECMO was approximately four- to fivefold lower than referenced literature. HIV virological suppression was maintained throughout the hospitalization. Conclusions ART adjustments would not be required for this patient. Additional studies are needed to assess effects of VA ECMO and crushed tube administration of ARVs in CI-PLWH.

Acute heart transplantation from mechanical circulatory support in a human immunodeficiency virus‐positive patient with fulminant myocarditis

“…15 Another recent publication described heart-lung transplantation bridged by VA-ECMO in an HIV-positive patient. 16 In comparison, experiences of VV-ECMO implementation among HIV-infected patients with respiratory failure are already more relevant. Favourable outcomes on the widespread use of VV-ECMO were published by Brogan et al and Capatos et al according to the results of their multicentre-based analysis and an observational study, respectively.…”

“…In one of these cases, ECMO was upgraded to long‐term LVAD, and the patient underwent successful HTx later 15 . Another recent publication described heart‐lung transplantation bridged by VA‐ECMO in an HIV‐positive patient 16 . In comparison, experiences of VV‐ECMO implementation among HIV‐infected patients with respiratory failure are already more relevant.…”

Antiretroviral Therapy Management in Adults With HIV During ICU Admission

“…Table 2 contains information on alternative methods of administration. 13,18,[23][24][25][26][27][28][29][30][31] Data on altering ARVs were collected from manufacturers, reviews, case series, case reports, and a drug information database. Lack of data regarding altering combination products is a concern.…”

Managing Modern Antiretroviral Therapy in the Intensive Care Unit: Overcoming Challenges for Critically Ill People With Human Immunodeficiency Virus

“…Previous case reports describe adequate concentrations when DTG/ABC/3TC tablets were crushed and administered via nasogastric tube, resulting in virologic suppression [ 58 , 59 ].…”