Urine colorimetry to detect Low rifampin exposure during tuberculosis therapy: a proof-of-concept study.

BACKGROUND: The cost and complexity of current approaches to therapeutic drug monitoring during tuberculosis (TB) therapy limits widespread use in areas of greatest need. We sought to determine whether urine colorimetry could have a novel application as a form of therapeutic drug monitoring during anti-TB therapy. METHODS: Among healthy volunteers, we evaluated 3 dose sizes of rifampin (150 mg, 300 mg, and 600 mg), performed intensive pharmacokinetic sampling, and collected a timed urine void at 4 h post-dosing. The absorbance peak at 475 nm was measured after rifamycin extraction. The optimal cutoff was evaluated in a study of 39 HIV/TB patients undergoing TB treatment in Botswana. RESULTS: In the derivation study, a urine colorimetric assay value of 4.0 × 10(-2) Abs, using a timed void 4 h after dosing, demonstrated a sensitivity of 92 % and specificity of 60 % to detect a peak rifampin concentration (Cmax) under 8 mg/L, with an area under the ROC curve of 0.92. In the validation study, this cutoff was specific (100 %) but insensitive (28 %). We observed similar test characteristics for a target Cmax target of 6.6 mg/L, and a target area under the drug concentration-versus-time curve (AUC0-8) target of 24.1 mg•hour/L. CONCLUSIONS: The urine colorimetric assay was specific but insensitive to detect low rifampin serum concentrations among HIV/TB patients. In future work we will attempt to optimize sampling times and assay performance, with the goal of delivering a method that can translate into a point-of-care assessment of rifampin exposure during anti-TB therapy.

Detection of residual rifampicin in urine via fluorescence quenching of gold nanoclusters on paper.

BACKGROUND: Rifampicin or rifampin (R) is a common drug used to treat inactive meningitis, cholestatic pruritus and tuberculosis (TB), and it is generally prescribed for long-term administration under regulated dosages. Constant monitoring of rifampicin is important for controlling the side effects and preventing overdose caused by chronic medication. In this study, we present an easy to use, effective and less costly method for detecting residual rifampicin in urine samples using protein (bovine serum albumin, BSA)-stabilized gold nanoclusters (BSA-Au NCs) adsorbed on a paper substrate in which the concentration of rifampicin in urine can be detected via fluorescence quenching. The intensity of the colorimetric assay performed on the paper-based platforms can be easily captured using a digital camera and subsequently analyzed. RESULTS: The decreased fluorescence intensity of BSA-Au NCs in the presence of rifampicin allows for the sensitive detection of rifampicin in a range from 0.5 to 823 µg/mL. The detection limit for rifampicin was measured as 70 ng/mL. The BSA-Au NCs were immobilized on a wax-printed paper-based platform and used to conduct real-time monitoring of rifampicin in urine. CONCLUSION: We have developed a robust, cost-effective, and portable point-of-care medical diagnostic platform for the detection of rifampicin in urine based on the ability of rifampicin to quench the fluorescence of immobilized BSA-Au NCs on wax-printed papers. The paper-based assay can be further used for the detection of other specific analytes via surface modification of the BSA in BSA-Au NCs and offers a useful tool for monitoring other diseases.

Adsorptive stripping voltammetry of antibiotics rifamycin SV and rifampicin at renewable pencil electrodes.

Adsorptive stripping voltammetry of antibiotics of rifamycin SV (RSV) and rifampicin (RIF) was investigated by cyclic voltammetry and differential pulse voltammetry using a renewable pencil graphite electrode (PGE). The nature of the oxidation process of RSV and RIF taking place at the PGE was characterized. The results show that the determination of highly sensitive oxidation peak current is the basis of a simple, accurate and rapid method for quantification of RSV and RIF in bulk forms, pharmaceutical formulations and biological fluids by differential pulse adsorptive stripping voltammetry (DPASV). Factors influencing the trace measurement of RSV and RIF at PGE are assessed. The limits of detection for the determination of RSV and RIF in bulk forms are 6.0 × 10(-8) mol/L and 1.3 × 10(-8) mol/L, respectively. Moreover, the proposed procedure was successfully applied to assay both RSV and RIF in pharmaceutical formulations and in biological fluids. The capability of the proposed procedure for simultaneous assay of antibiotics RSV-isoniazid and RIF-isoniazid was achieved. The statistical analysis and calibration curve data for trace determination of RSV and RIF are reported.

Urine levels of rifampicin & isoniazid in asymptomatic HIV-positive individuals.

BACKGROUND & OBJECTIVE: AIDS and its associated gastrointestinal complications may impair the absorption of anti-tuberculosis (TB) drugs. Impaired absorption of anti-TB drugs could lead to low drug exposure, which might contribute to acquired drug resistance and reduced effectiveness of anti-TB treatment. The aim of this study was to obtain information on the status of absorption of rifampicin (RMP) and isoniazid (INH) in asymptomatic HIV- positive individuals, who are less immunocompromised. The D-xylose absorption test was also carried out to assess the absorptive capacity of intestive. METHODS: The absorption of RMP, INH and D-xylose was studied in 15 asymptomatic HIV-positive individuals with CD4 cell counts>350 cells/mm3 and 16 healthy volunteers, after oral administration of single doses of RMP (450 mg), INH (300 mg) and D-xylose (5 g). Urine was collected up to 8 h after drug administration. Percentage dose of the drugs and their metabolites and D-xylose excreted in urine were calculated. RESULTS: A significant reduction in the urinary excretion of INH and D-xylose in HIV-positive persons compared to healthy volunteers was observed. The per cent dose of RMP and its metabolite, desacetyl RMP was also lower in HIV-positive persons compared to healthy volunteers, but this difference was not statistically significant. INTERPRETATION & CONCLUSION: Decreased urinary excretion of D-xylose and INH are suggestive of intestinal malabsorption in HIV-positive individuals. HIV infection could cause malabsorption of anti-TB drugs even at an early stage of the disease. The clinical implications of these findings need to be confirmed in larger studies.

Electrochemiluminescence from successive electro- and chemo-oxidation of rifampicin and its application to the determination of rifampicin in pharmaceutical preparations and human urine.

A novel electrochemiluminescence (ECL) type was proposed based on successive electro- and chemo-oxidation of oxidable analyte, which was different from both annihilation and coreactant ECL types in mechanism. Rifampicin was used as a model compound. No any chemiluminescence (CL) was produced by either electrochemical oxidation or chemical oxidation of rifampicin in KH(2)PO(4)--Na(2)B(4)O(7) (pH 6.6) buffer-dodecyl trimethyl ammonium chloride (DTAC) solution. However, an ECL was observed by electrochemical oxidization of rifampicin in the same solution in the presence of oxidant such as dissolved oxygen, activated oxygen and potassium peroxydisulfate (K(2)S(2)O(8)). The ECL was attributed to electrochemical oxidation of rifampicin to form semiquinone free radical, and then subsequently chemical oxidation of the formed radical by oxidant to form excited state rifampicin quinone. The proposed ECL type introduced additional advantages such as high selectivity, simple and convenient operation, and effective avoidance of side reaction that often took place in homogenous CL reaction, and will open a novel application field. In addition, with the ECL in the presence of K(2)S(2)O(8) as oxidant, a flow injection ECL method for the determination of rifampicin was proposed. The ECL intensity was linear with rifampicin concentration in the range of 1.0 x 10(-7) to 4.0 x 10(-5) mol l(-1) and the limit of detection (s/n=3) was 3.9 x 10(-8) mol l(-1). The proposed method was applied to the determination of rifampicin in pharmaceutical preparations and human urine.

Spectrophotometric determination of rifampicin through chelate formation and charge transfer complexation in pharmaceutical preparation and biological fluids.

Two simple and accurate spectrophotometric methods for determination of Rifampicin (RIF) are described. The first method is based on charge transfer (CT) complex formation of the drug with three pi-electron acceptors either 2,3-dichloro-5,6-dicyano-1,4-benzoquinone (DDQ), 7,7,7,8-Tetracyanoquinodimethane (TCNQ) or 2,3,5,6-Tetrachloro-1,4-benzoquinone (p-chloranil) in acetonitrile. The method is followed spectrophotometrically by measuring the maximum absorbance at 584 nm, 761 nm (680 nm) or 560 nm for DDQ, TCNQ and p-chloranil, respectively. Under the optimized experimental conditions, the calibration curves showed a linear relationship over the concentration ranges of 5-140 microg/ml, 2-45 microg/ml (5-120 microg/ml) and 15-200 microg/ml, respectively. The second method is based on the reaction of RIF with iron(III) forming a water insoluble violet complex which is extracted into chloroform. The method determines RIF in concentration range of 10-240 microg/ml at 540 nm. The proposed methods applied to determination of RIF in capsule, human serum and urine samples with good accuracy and precision. The results were compared statistically with the official method and showed no significant different between the methods compared in terms of accuracy and precision.

Effect of milk thistle (Silybum marianum) and black cohosh (Cimicifuga racemosa) supplementation on digoxin pharmacokinetics in humans.

Phytochemical-mediated modulation of P-glycoprotein (P-gp) and other drug transporters may underlie many herb-drug interactions. Serial serum concentration-time profiles of the P-gp substrate, digoxin, were used to determine whether supplementation with milk thistle or black cohosh modified P-gp activity in vivo. Sixteen healthy volunteers were randomly assigned to receive a standardized milk thistle (900 mg daily) or black cohosh (40 mg daily) supplement for 14 days, followed by a 30-day washout period. Subjects were also randomized to receive rifampin (600 mg daily, 7 days) and clarithromycin (1000 mg daily, 7 days) as positive controls for P-gp induction and inhibition, respectively. Digoxin (Lanoxicaps, 0.4 mg) was administered orally before and at the end of each supplementation and control period. Serial digoxin serum concentrations were obtained over 24 h and analyzed by chemiluminescent immunoassay. Comparisons of area under the serum concentration time curves from 0 to 3 h (AUC(0-3)), AUC(0-24), Cmax, apparent oral clearance of digoxin (CL/F), and elimination half-life were used to assess the effects of milk thistle, black cohosh, rifampin, and clarithromycin on digoxin pharmacokinetics. Rifampin produced significant reductions (p < 0.01) in AUC(0-3), AUC(0-24), and Cmax, whereas clarithromycin increased these parameters significantly (p < 0.01). Significant changes in digoxin half-life and CL/F were also observed with clarithromycin. No statistically significant effects on digoxin pharmacokinetics were observed following supplementation with either milk thistle or black cohosh, although digoxin AUC(0-3) and AUC(0-24) approached significance (p = 0.06) following milk thistle administration. When compared with rifampin and clarithromycin, supplementation with these specific formulations of milk thistle or black cohosh did not appear to affect digoxin pharmacokinetics, suggesting that these supplements are not potent modulators of P-gp in vivo.

Monitoring the ingestion of anti-tuberculosis drugs by simple non-invasive methods.

This investigation retrospectively assessed inexpensive non-invasive qualitative methods to monitor the ingestion of anti-tuberculosis drugs isoniazid, rifampicin and rifapentine. Results showed that commercial test strips detected the isoniazid metabolites isonicotinic acid and isonicotinylglycine as efficiently as the isonicotinic acid method in 150 urine samples. The presence of rifamycins in urine samples (n=1085) was detected by microbiological assay techniques and the sensitivity compared to the n-butanol extraction colour test in 91 of these specimens. The proportions detected by the two methods were significantly different and the sensitivity of the n-butanol procedure was only 63.8% (95% CL 51.2-76.4%) as compared to that of the superior microbiological method. Final validation (n=691) showed that qualitative assays measure isoniazid and rifamycin ingestion with an efficiency similar to high-performance liquid chromatography. The qualitative procedures may therefore be valuable in clinical trials and in tuberculosis clinics to confirm drug ingestion.

Quantitative determinations of levofloxacin and rifampicin in pharmaceutical and urine samples using nuclear magnetic resonance spectroscopy.

Rapid, specific and simple methods for determining levofloxacin and rifampicin antibiotic drugs in pharmaceutical and human urine samples were developed. The methods are based on (1)H NMR spectroscopy using maleic acid as an internal standard and DMSO-d6 as NMR solvent. Integration of NMR signals at 8.9 and 8.2 ppm were, respectively, used for calculating the concentration of levofloxacin and rifampicin drugs per unit dose. Maleic acid signal at 6.2 ppm was used as the reference signal. Recoveries of (97.0-99.4)+/-0.5 and (98.3-99.7)+/-1.08% were obtained for pure levofloxacin and rifampicin, respectively. Corresponding recoveries of 98.5-100.3 and 96.8-100.0 were, respectively, obtained in pharmaceutical capsules and urine samples. Relative standard deviations (R.S.D.) values < or =2.7 were obtained for analyzed drugs in pure, pharmaceutical and urine samples. Statistical Student's t-test gave t-values < or =2.87 indicating insignificant difference between the real and the experimental values at the 95% confidence level. F-test revealed insignificant difference in precisions between the developed NMR methods and each of fluorimetric and HPLC methods for analyzing levofloxacin and rifampicin.

Urinary excretion of rifampicin in the presence of ciprofloxacin.

To investigate the effect of the ciprofloxacin on the urinary excretion of the rifampicin in humans, ciprofloxacin and rifampicin were coadministered. Five healthy volunteers between the ages of 20 and 35 years received, on 2 separate occasions (phases 1 and 2) and at weekly intervals, 600 mg rifampicin and 600 mg plus 500 mg ciprofloxacin, respectively, with 350 mL of water. Urinary levels of rifampicin were measured from 1-72 hours later. In phase 1, 15.6% urinary rifampicin was recovered compared with 15.5% urinary rifampicin recovered in the second phase. An increased excretion rate and higher plateau were obtained in ciprofloxacin plus rifampicin treatment. The study indicates that rifampicin may be coadministered with ciprofloxacin to check the development of drug resistance to single-drug therapy by susceptible organisms.

Effect of pefloxacin on the urinary excretion of rifampicin.

The effect of pefloxacin on the urinary excretion of rifampicin was investigated in 5 healthy volunteers between the ages of 20 and 35 years. The investigation was carried out in 2 different phases, with a 1-week drug washout separating the phases. Each subject received 600 mg rifampicin with 350 mL of water. After 1 week, the subjects were given 600 mg rifampicin plus 500 mg pefloxacin with 350 mL of water. Urinary levels of rifampicin were measured spectrophotometrically for the 2 phases from 0 to 72 hours. Coadministration of rifampicin with pefloxacin led to 20.1% urinary recovery of rifampicin. The increased rifampicin excretion rate following pefloxacin coadministration is supported by the competitive liver clearance between rifampicin and pefloxacin, which favors pefloxacin and causes rifampicin secretion, thus increasing its elimination through the kidney. Pefloxacin increases the absorption and urinary excretion of rifampicin by decreasing the gastrointestinal motility through chelation mechanisms.

Low level of compliance with tuberculosis treatment in children: monitoring by urine tests.

Patient compliance should be ensured in an effective tuberculosis control programme. We measured patient compliance by detecting antituberculous drugs in the urine of 237 outpatients receiving one to three antituberculous drugs. Positive controls were 20 hospitalised patients, supervised to receive isoniazid (INH), rifampicin (RIF) and pyrazinamide (PZA), and negative controls were not on any drugs. Among the 237 study patients, only 67% were found to be taking the appropriate treatment and 8% had taken none. We conclude that a remarkable number of patients (33%) were non-compliant with treatment. The detection of antituberculous drugs in the urine is a quick, simple and inexpensive means of measuring adherence to treatment. Unless directly observed therapy (DOT) is adopted, we recommend routine urine testing for antituberculous drugs to identify defaulting patients.

The value of urine testing for verifying adherence to anti-tuberculosis chemotherapy in children and adults in Uganda.

SETTING: Mulago Hospital, Kampala, Uganda. OBJECTIVE: To evaluate the usefulness of urine dipsticks for monitoring adherence to anti-tuberculosis chemotherapy. DESIGN: In-house urine dipsticks for detection of isoniazid (INH) metabolites were compared to commercial test strips. The value of n-butanol to detect rifampicin was compared to coloration of the urine. Non-adherence was assessed through a questionnaire and reviews of the Mulago Hospital TB register. RESULTS: Urine was obtained from 236 patients (127 adults and 109 children) on daily chemotherapy. Using commercial test strips as standard, the sensitivity of in-house urine dipsticks was 99.5% and specificity was 96.4%. The sensitivity and the specificity of n-butanol and of coloration of urine to detect rifampicin were low (64.0% and 54.9%, and 85.5% and 64.8%, respectively). Fifty patients (21.2%) admitted non-adherence to treatment during the previous month. An additional 15 (6.8%) were detected through urine testing. Of 911 patients in the TB register of Mulago Hospital who had started treatment in the first 3 months of 2000, 39.7% did not complete their treatment. Two-thirds of these had discontinued treatment in the first 2 months. CONCLUSION: In-house INH test strips are as effective as commercially available strips for detecting isoniazid in the urine. They are a simple tool for monitoring adherence. Adherence to anti-tuberculosis chemotherapy as determined by the use of isoniazid test strips and review of the TB register showed poor compliance. Tests for rifampicin are less sensitive and specific.

Impaired bioavailability of rifampicin in presence of isoniazid from fixed dose combination (FDC) formulation.

The present study describes comparative bioavailability of rifampicin (RIF) after administration of a single component RIF (450 mg) capsule and rifampicin-isoniazid (RIF-INH) (450+300 mg) fixed dose combination (FDC) capsule formulations. Six healthy male volunteers participated in a single dose, two treatment, two period, cross-over study. A sensitive, specific and accurate HPTLC method was developed, validated and employed for estimation of RIF and its major active metabolite, 25-Desacetylrifampicin (25-DAR) levels, in urine. Using the urinary excretion data various pharmacokinetic parameters: AUC(0-24), AUC(0-infinity), cumulative amount excreted in 24 h, peak excretion rate, etc. for both RIF and 25-DAR were calculated and compared statistically (ANOVA, 90% confidence interval for ratio). Significant decrease in the bioavailability ( approximately 32% as RIF and approximately 28% as 25-DAR) of RIF from FDC capsules was observed. The present bioavailability study confirms our serious doubts about the stability of RIF in presence of INH in acidic environment of stomach, which probably is the main factor responsible for the reduced bioavailability of RIF from RIF-INH combination formulations. This study underlines the fact that there is an urgent need to reconsider the formulation of the FDC product in order to minimize or avoid the decomposition of RIF in gastrointestinal tract.

The potential use of urinary excretion data for assessing the relative bioavailability of rifampicin in fixed dose combination anti-tuberculosis formulations.

SETTING: The perceived need for simple, non-invasive methods of assessing the relative bioavailability of rifampicin in fixed-dose combination (FDC) anti-tuberculosis formulations. OBJECTIVE: To compare the performance of methods based on urinary excretion data with those utilising plasma concentration-time profiles to assess the relative bioavailability of rifampicin in combined and single-drug formulations. DESIGN: A two-period randomised crossover bioequivalence study in healthy male volunteers with a 1 week washout period between treatments. Plasma rifampicin concentrations were measured at 0, 1, 2, 4, 6 and 8 hours after each drug administration using a high performance liquid chromatography (HPLC) method. The rifampicin and desacetylrifampicin content of complete urinary collections made from 0-4 and 4-8 hours after dosage were determined using both the HPLC and a much simpler colorimetric procedure. RESULTS: There was good agreement between the relative bioavailability of the formulations using plasma and urinary excretion data, although the precision of the urinary-based estimates was slightly less than those derived from the plasma findings. There was also good agreement between the HPLC and colorimetric estimates of the combined urinary excretion of rifampicin plus desacetylrifampicin. CONCLUSIONS: Urinary excretion data may be used for ongoing quality control to confirm that commercial combined rifampicin-containing formulations that were initially shown to be satisfactory continue to be so.

The evaluation of rifampicin bioavailabilities of fixed-dose combinations of anti-tuberculosis drugs: procedures for ensuring laboratory proficiency.

SETTING: The perceived need to demonstrate whether or not the rifampicin bioavailability of commercially manufactured fixed-dose combinations is satisfactory. OBJECTIVE: To establish an international laboratory network to assess rifampicin bioavailability. DESIGN: Convenient assay kits were devised to evaluate the ability of laboratories in China, India, Italy, South Africa, Thailand and the USA to determine plasma and urinary concentrations of rifampicin and desacetyl-rifampicin. RESULTS: Five laboratories, all of whom used high pressure liquid chromatographic methods, were shown to be able to accurately and precisely determine the two compounds. CONCLUSION: Such a procedure is simple, convenient and objective and could be further employed to enlarge the intended international laboratory network.

The WHO simplified study protocol in practice: investigation of combined formulations supplied by the WHO.

SETTING: The benefits of fixed-dose combination (FDC) formulations of rifampicin, isoniazid and pyrazinamide over individual formulations are well recognised. OBJECTIVES: To evaluate the comparative bioavailability of antituberculosis drugs in FDC formulations and the same doses in separate formulations of antituberculosis drugs, using a simplified protocol developed by the World Health Organization (WHO). METHODS: Twenty healthy volunteers were included in the study and evaluated for bioequivalence of rifampicin in a cross-over experimental design. After administration of drugs the plasma concentration of rifampicin and desacetyl-rifampicin was measured repeatedly up to 8 hours in both plasma and urine. Various pharmacokinetic parameters of rifampicin, such as Cmax, Tmax, elimination rate constant, area under the curve (AUC) up to 8 hours and absorption efficiency were calculated. RESULTS: No significant differences were observed between the FDCs and separate formulations when Cmax, Tmax, AUC and absorption efficiencies were compared by parametric test and Hauschke's analysis. CONCLUSION: The WHO simplified protocol is suitable for evaluating bioequivalence of antituberculosis drugs.