Use of modelling to predicting paediatric dosing of long acting antiretrovirals

CROI 2016Polly Clayden, HIV i-Base

Physiologically based pharmacokinetic (PBPK) modeling can help predict dosing strategies for long-acting (LA) antiretrovirals, according to data presented at CROI 2016.

LA antiretrovirals could provide an important option for children and adolescents. LA regimens have the potential to simplify regimens, reduce drug costs and improve adherence to both treatment and PrEP.

Paediatric dose optimisation is complicated due to differences in anatomical and physiological processes compared with adults. PBPK modelling is a mathematical approach to predict pharmacokinetics (PK) using the description of molecular and physiological processes defining drug disposition. This modelling can be used to identify promising paediatric dosing strategies.

Rajith Jajoli and colleagues from the Department of Molecular and Clinical Pharmacology at University of Liverpool showed data from a study designed to simulate the PK of LA antiretrovirals in children and adolescents and predict optimal doses using PBPK modelling.

The investigators integrated in vitro PK data from cabotegravir (CBV) and rilpivirine (RPV) into their models. These models were validated against available clinical data for the doses of LA formulations in adults: 800 mg CBV and 900 mg RPV. The investigators extrapolated the rate of drug release from injection sites for the two drugs from clinical data in adults.

The anatomy and physiology of children aged 3-18 years was validated against data available in the literature. World Health Organization (WHO) weight band recommendations were used. The investigators simulated PK for 200 paediatric patients for each weight band after intramuscular (IM) injection of LA CBV and RPV.

They validated weights and blood flow rates of children and adolescents at different ages using available anatomical and anthropometric data. And they validated parameters of existing available adult IM formulations of CBV and RPV against available clinical data.

According to the models, mean values for 800 mg CBV quarterly IM injection were: AUC 4467 vs 5257 ug.h/mL, Cmax 3.3 vs 3.54 ug/mL and Ctrough 1.1 vs 1.2 ug/mL. Mean values for 900 mg IM RPV monthly administration were: AUC 74,420 vs 91,087 ng.h/mL, Cmax 168 vs 168.7 ng/mL and Ctrough 79.1 vs 78.3 ng/mL.

The models predicted optimal antiretroviral doses with which at least 95% of patients achieved Ctrough over the cut-off values for quarterly CBV or monthly RPV IM injections. Table 1 shows predicted CBV and RPV doses for all WHO weight bands.

Table 1: Optimised doses of CBV and RPV LA formulations for WHO weight bands
Age (years) Weight (kg) Rilpivirine Cabotegravir
Duration 1 month 3 months
Cut-off limit (ng/mL) 20.3 (PAIC90) 80 (MEC) 166 (PAIC90) 664 (MEC)
3-5.75 14-19.9 180 720 30 110
5.75-7.75 20-24.9 190 720 30 130
7.75-9.4 25-29.9 190 730 35 150
9.4-10.75 30-34.9 200 735 35 160
10.75-11.9 35-39.9 200 770 45 170
11.9-12.8 40-44.9 210 790 45 180
12.8-13.7 45-49.9 220 810 50 190
13.7-14.75 50-54.9 225 825 50 200
14.75-15.75 55-59.9 230 840 55 210
15.75-17.25 60-64.9 240 860 55 220
17.25-19.5 65-69.9 240 880 60 240

The investigators noted that the roles of transporters, the immune system, and drug diffusion through the lymphatic system during long-term treatment are potential limitations that they did not consider in these PBPK models.

But they conclude that PBPK models can help predict dosing strategies and could provide innovative ways to optimise dose requirements in special populations such as paediatrics.


Rajoli RKR et al. Predicting utility of long-acting injectables in paediatric patients with PBPK models. Conference on Retroviruses and Opportunistic Infections. 22-26 February 2016. Boston. Poster abstract 442. (Abstract) (PDF)

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