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One third of French HIV group uses illicit drugs, often risking antiretroviral interactions
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20th International Workshop on Clinical Pharmacology of HIV, Hepatitis & Other Antiviral Drugs. May 14-16, 2019. Noordwijk, the Netherlands
Mark Mascolini
One in 3 people in a 286-person French HIV group took illicit drugs that sometimes posed a risk of severe interactions with antiretrovirals [1]. Many potential interactions involved the boosting agents ritonavir or cobicistat.
New psychoactive substances like cathinones amplify the illicit drug options available to people with HIV. Chemically similar to ephedrine and other amphetamines, cathinones are called khat or bath salts on the street. Substantial proportions of HIV-positive people use such drugs to enhance sex, a practice called chemsex. In PrEP studies chemsex prevalence has reached 30% to 44%, but its prevalence in people with HIV remains poorly understood. These illicit agents can interact with antiretrovirals and may cause life-threatening toxicities.
As part of their Therapeutic Patient Education Program (TPEP), French investigators asked people with HIV to complete self-administered questionnaires to collect data on illicit drug use. They gathered demographic and clinical findings from medical records and used the University of Liverpool antiretroviral interaction database [2] and expert knowledge to define potential interactions between antiretrovirals and illicit drugs.
Since March 2018 at a single center in Marseille, the researchers recorded drug use rates and behaviors in 286 people with HIV, 75% of them men, with a median age of 52 years (range 19 to 83). Almost two thirds of illicit drug users (62%) took triple antiretroviral therapy, 34% took rilpivirine, and 33% used a pharmacokinetic (PK) booster (ritonavir or cobicistat).
Ninety-three survey respondents (33%) reported using illicit drugs, 52% of them men who have sex with men, 28% people who inject drugs, and 13% who acquired HIV heterosexually. Among all illicit drug users, 59% used 1 drug and 41% used more than 1. While 42% used cannabis, lower proportions used poppers (17%), cocaine (16%), ecstasy/MDMA (7%), GHB/GBL (5%), cathinones (4%), methamphetamine derivatives (2%), ketamine (2%), synthetic cannabinoids (1%), and LSD (1%).
Among people who took illicit drugs, 18% used them for chemsex, usually involving poppers (37%), cathinones (13%), ecstasy/MDMA (12%), GHB/GBL (10%), and cannabis (10%).
The researchers identified potential interactions with antiretrovirals in 38 people, representing 13.3% of the 286-person study population. Twenty-four people, 8.4% of the study group, had potentially moderate to severe interactions with antiretrovirals.
Detected interactions between illicit drugs and antiretrovirals included (1) PK booster-induced inhibition of CYP2D6 and/or CYP3A4 involving MDMA, methamphetamine, cathinones, GHB/GBL, or ketamine (10 cases), (2) CYP2C9 inhibition resulting from using cannabis with efavirenz or etravirine (5 cases), or (3) concomitant use of cocaine and rilpivirine, both of which induce QT prolongation (9 cases). The investigators spotted 13 other potential lower-risk drug-drug interactions in people taking boosted regimens with poppers (7 cases) or cocaine (6 cases).
The researchers recommended systematic screening for illicit drug use in people with HIV "to avoid high risk of potential life-threatening toxicities by adjusting the antiretroviral regimen." People taking illicit drugs with antiretrovirals should be warned of potential drug-drug interactions and made aware of toxicity signals.
References
1. Martin T, Lions C, Laroche H, et al. Drug abuse and chemsex: a new challenge for antiretroviral drug-drug interaction. 20th International Workshop on Clinical Pharmacology of HIV, Hepatitis & Other Antiviral Drugs. May 14-16, 2019. Noordwijk, the Netherlands. Abstract 6.
2. University of Liverpool. HIV Drug Interactions. https://www.hiv-druginteractions.org/
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