Nirmatrelvir/ritonavir treatment of patients with COVID-19 taking tacrolimus: case series describing the results of drug-drug interactions.

Nirmatrelvir/ritonavir is a novel drug combination that is authorized by the Food and Drug Administration for the treatment of coronavirus disease 2019 (COVID-19). Ritonavir is a cytochrome P450 3A inhibitor and a P-glycoprotein inhibitor that increases the plasma concentration of tacrolimus and other medications. We describe the cases of two patients treated with nirmatrelvir/ritonavir: a patient who had undergone kidney transplantation and another with a history of hematopoietic stem cell transplantation. Toxic concentrations of tacrolimus were induced in both. This case series highlights the risk associated with the concomitant administration of tacrolimus and nirmatrelvir/ritonavir.

Biomimetic exosomal vesicles loaded with siRNA improves antitumor immune responses by inhibiting the secretion of tumor-derived exosome PD-L1.

Tumor-derived exosome PD-L1 exhaustsTcells and permits tumor cells to evade immune surveillance; thus, the inhibition of ExoPD-L1 secretion can significantly enhance the clinical efficacy of PD-L1 antibody. In this study, we combined exosome membrane, apoA1 and phospholipid into biomimetic exosome vesicles (apoA1-bExo) which were then incubated with cholesterol modified siRNA to generate apoA1-bExo containing siRNA (apoA1-bExo/siRNA). Thepreparedvesicleswere uniformandsphericalin size and could be loaded effectively with siRNA to protect from nuclease degradation. Compared with bExo/siRNA, apoA1-bExo/siRNA showed stronger tumor targeting, tissue permeability, intracellular accumulation efficiency and antitumor efficiency. A portion of apoA1-bExo/siRNA transport siRNA occurred through the endosome-Golgi-ER pathway similar to bExo/siRNA, but mostly occurred directly through selective uptake pathways mediated by the SR-B1 receptor. apoA1-bExo/siRNA successfully achieved silencing efficiency at the transcription and protein levels (96.78 % and 94.07 %, respectively) and reduced the secretion of ExoPD-L1 from HepG2 cells to 15.92 % of that in the PBS group, thus enhancing the killing activity of co-cultured T cells on HepG2 cells. In addition, relevant pharmacodynamic indices were positively correlated with delivery efficiency and the modification of apoA1 could significantly enhance the intracellular accumulation of siRNA, thus exhibiting stronger activity than bExo/siRNA. Moreover, in addition to curing mice of their implanted tumors, blocking ExoPD-L1 secretion in combination with αPD-1 promoted the infiltration of durable antitumor hCD8+ T cells and hCD45+ T cells into tumor in a immune system-tumor dual humanized mice.

Ileus induced by the combination of vinca alkaloids and posaconazole in a patient with acute lymphoblastic leukemia: a case report and literature review.

Vinca alkaloid (VA)-induced ileus, a rare but severe autonomic neuropathy, can be enhanced by concomitant use of antifungal triazole agents. We herein present a case of VA-induced ileus in a 17-year-old girl who was diagnosed with B-cell acute lymphoblastic leukemia. On day 1, the patient received cyclophosphamide, vincristine, and methylprednisolone. On day 2, she began treatment with posaconazole oral suspension at 200 mg three times daily for prophylaxis against invasive fungal infection. On day 5, she began induction therapy consisting of vindesine, methylprednisolone, daunorubicin, and cyclophosphamide. The patient developed severe abdominal pain with marked constipation on day 11 and was diagnosed with incomplete ileus. After switching the antifungal agent to micafungin, performing gastrointestinal decompression, administering parenteral nutrition, and omitting the fourth dose of vindesine, the ileus symptoms were relieved. This case emphasizes the potential interaction between VAs and posaconazole. We also herein present a review of the literature on ileus caused by the combination of VAs and antifungal triazole agents. In clinical practice, physicians and pharmacists should be aware of the possibility of ileus caused by the use of VAs in combination with posaconazole. It is important to reduce complications during chemotherapy to improve patients' prognosis.

A case of toxic epidermal necrolysis associated with lenvatinib and sintilimab therapy for intrahepatic cholangiocarcinoma.

Lenvatinib is used as the first-line treatment for intrahepatic cholangiocarcinoma. Sintilimab is a programmed cell death receptor-1 (PD-1) antibody used in the treatment of solid tumors. We present the case of a 78-year-old man with fatal toxic epidermal necrolysis (TEN) associated with the use of sintilimab followed by lenvatinib. This patient, who presented with intrahepatic cholangiocarcinoma, first received immunotherapy with sintilimab according to the standard schedule of 200 mg every 3 weeks. The patient began to receive 8 mg of lenvatinib daily 1 day after sintilimab therapy was initiated. Multiple erythematous papules and blisters appeared on the patient's face and trunk and gradually spread to his arms and legs, and the lesions extensively involved >30% of the body surface area 18 days after lenvatinib initiation. The patient stopped taking lenvatinib on the next day. The skin rash quickly progressed over 1 week to a tender, exfoliative dermatosis. Despite treatment with high-dose steroids and intravenous immunoglobulin, the patient died. To the best of our knowledge, this is the first case of TEN associated with the use of sintilimab followed by lenvatinib. Early diagnosis and treatment of possibly fatal TEN reaction secondary to anti-PD-1 antibody therapy followed by lenvatinib is necessary.

Implementation effect of a hierarchical pharmaceutical service pattern in patients with systemic lupus erythematosus.

OBJECTIVES: This study evaluated the effect of implementing a hierarchical pharmaceutical service pattern based on the knowledge-attitude-practice (KAP) intervention theory on patients with systemic lupus erythematosus. METHODS: Eligible patients were randomly divided into an intervention or control group. Pharmaceutical service classification criteria were formulated and used to provide patients with differing levels of pharmaceutical services. The classification scores and KAP levels of patients before and at various time points after the intervention were analyzed. The rates of acute attacks and adverse reactions, related clinical test indices, and disease activity were evaluated in both groups. RESULTS: After 9 months of intervention, the proportions of first- and second-level services in the intervention group declined by 14.43% and 3.94%, respectively, compared with the control group, and the rates of acute attacks and adverse reactions declined by 18.26% and 12.43%, respectively. The KAP level, clinical test indices, and disease activity were significantly different between the groups. CONCLUSION: Providing patients with systemic lupus erythematosus with pertinent hierarchical pharmaceutical services based on the KAP theory was instrumental in changing patients' behavior and contributed to facilitating disease self-management, thus improving the quality of pharmaceutical services.

The Efficacy and Cost-Effectiveness of Umeclidinium/Vilanterol versus Tiotropium in Symptomatic Patients with Chronic Obstructive Pulmonary Disease.

Background: Both long-acting muscarinic antagonists (LAMAs) and long-acting ß2-agonists (LABAs) are widely used in the treatment of chronic obstructive pulmonary disease (COPD). A novel LAMA/LABA combination of umeclidinium/vilanterol (UMEC/VI; 62.5 µg/25 µg) is approved for chronic obstructive pulmonary disease (COPD) treatment. Objective: This study aimed to assess the efficacy and cost-effectiveness of UMEC/VI versus tiotropium (TIO) 18 µg in symptomatic patients with COPD from the perspective of the Chinese National Healthcare System. Methods: A simple analysis included three studies in the meta-analysis that compared UMEC/VI with TIO. A Markov model was developed to estimate the cost-effectiveness of UMEC/VI compared with TIO treatment in symptomatic patients with COPD. First, utilities, clinical efficacy, and adverse events obtained from the literature were utilized as model inputs. Costs were from Chinese average data, including local data. Costs were expressed in dollars based on 2020 prices. Then, the model outputs including drug costs, other medical costs, and total costs, and quality-adjusted life years (QALYs) were estimated. Costs and outcomes were discounted at a 5% annual rate. Furthermore, incremental cost-effective ratios (ICERs) were analyzed. Finally, the influences of changing parameters on the uncertainty of the results were assessed by means of one-way and probabilistic sensitivity analyses. Results: This study revealed that UMEC/VI treatment had a higher rate of clinical efficacy in comparison with TIO, and the differences in the rate of adverse events between the two treatments were not significant. The results indicated that UMEC/VI was superior to TIO, which provided an increase in QALYs (0.002) and a total cost savings of $765.67 per patient over 3 years. In the base case, the ICER of UMEC/VI is -$397468.04/QALY compared with TIO, suggesting that UMEC/VI may be considered a dominant option over TIO. According to the Chinese medical system, the probability of UMEC/VI being cost-effective was 61.6% at a willingness-to-pay (WTP) of $31554/QALY. Sensitivity analyses confirmed that the results were robust. Conclusion: UMEC/VI could be considered a cost-effective treatment compared with TIO in symptomatic COPD patients from the Chinese National Healthcare System perspective. These results may help decision-makers in China when making judgements on which treatments to administer.

Maternal antiviral treatment safeguards infants from hepatitis B transmission in contingencies of delayed immunoprophylaxis.

BACKGROUND & AIMS: Effectiveness of maternal antiviral prophylaxis in mother-to-child transmission of hepatitis B virus (HBV) has been extensively explored in studies where standard immunoprophylaxis is well secured to the newborns. This real-world study aims to test if maternal antiviral prophylaxis can safeguard the newborn when immunoprophylaxis administration was delayed or missed. METHODS: Hepatitis B surface antigen-positive pregnant women were categorized into mothers with HBV DNA levels ≥2 × 105 IU/mL receiving nucleos(t)ide analogue during the third trimester; mothers with HBV DNA levels ≥2 × 105 IU/mL without antiviral treatment; and those with HBV DNA levels <2 × 105 IU/mL without antiviral treatment. The immunoprophylaxis procedure was collected and verified by the delivery medical document and logbook of biological product usage. The primary end point was the rate of chronic HBV infection (CHB) in infants. RESULTS: From 2011 to 2017, 251 mother-child pairs were enrolled. Among 187 infants of mothers with HBV DNA levels ≥2 × 105 IU/mL, none developed CHB when mothers received antiviral treatment, as compared to 13.0% (10/77) of infants born to untreated mothers (P < .001). None of the infants of mothers with HBV DNA levels <2 × 105 IU/mL were infected. Stratified by the time of immunoprophylaxis administration after birth, maternal antiviral prophylaxis predominately benefited infants who failed to receive immunoprophylaxis within 24 hours (100% [6/6] vs 0% [0/2], P = .036) and those who received delayed immunoprophylaxis between 2 and 24 hours (18.8% [3/16] vs 0% [0/32], P = .032). CONCLUSIONS: Antiviral prophylaxis in high viraemic mothers is effective in contingencies of missed or delayed neonatal immunoprophylaxis.

A statistical analysis of the correlations among various types of clinical indexes for patients with chronic hepatitis B: A hospital-based study.

Hepatitis B virus (HBV) is one of the commonest chronic infections, especially in Asia and Africa, which put a heavy burden worldwide. With the advanced knowledge of HBV, early detection, primary care, and hepatology have made huge progression than before. However, the relationship between gender, age, and different key parameters in HBV patients remains to be determined.In this study, we measured various physiological and biochemical indexes in a large cohort of HBV patients as well as healthy control. We investigated the strength of correlations among those indexes and reported instantaneous imaging results. Moreover, we examined the effects of various grouping modes such as by gender or age on liver stiffness measurement (LSM) and controlled attenuation parameters (CAPs). We compared their diagnostic values for hepatic fibrosis in HBV patients.The results showed that specimens from a healthy control were obviously clustering tightly together, while the specimens from the HBV patients were clustering into several subgroups. Direct bilirubin (DB), total bilirubin (TB), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) occurred together with the diagnosis of HBV. Furthermore, groups categorized by Gender had significant effects on fibrotouch measurement not only in HBV patients but also in healthy control.Our research was to evaluate the actual effects of various parameters on Fibrotouch and make improvement of the critical value of those medical indexes.

A novel multi-unit tablet for treating circadian rhythm diseases.

This study aimed to develop and evaluate a novel multi-unit tablet that combined a pellet with a sustained-release coating and a tablet with a pulsatile coating for the treatment of circadian rhythm diseases. The model drug, isosorbide-5-mononitrate, was sprayed on microcrystalline cellulose (MCC)-based pellets and coated with Eudragit(®) NE30D, which served as a sustained-release layer. The coated pellets were compressed with cushion agents (a mixture of MCC PH-200/ MCC KG-802/PC-10 at a ratio of 40:40:20) at a ratio of 4:6 using a single-punch tablet machine. An isolation layer of OpadryII, swellable layer of HPMC E5, and rupturable layer of Surelease(®) were applied using a conventional pan-coating process. Central-composite design-response surface methodology was used to investigate the influence of these coatings on the square of the difference between release times over a 4 h time period. Drug release studies were carried out on formulated pellets and tablets to investigate the release behaviors, and scanning electron microscopy (SEM) was used to monitor the pellets and tablets and their cross-sectional morphology. The experimental results indicated that this system had a pulsatile dissolution profile that included a lag period of 4 h and a sustained-release time of 4 h. Compared to currently marketed preparations, this tablet may provide better treatment options for circadian rhythm diseases.

An excellent delivery system for improving the oral bioavailability of natural vitamin E in rats.

This study set out to develop a novel and stable nanoemulsion formulation of natural vitamin E with increased oral bioavailability. The natural vitamin E nanoemulsion was prepared by a modified emulsification technique. The physicochemical characteristics of natural vitamin E nanoemulsion were characterized and its pharmacokinetics study was performed as well. The experimental results showed droplet diameters ranging from 20 to 400 nm (average, 87.7 nm) with a negative electrostatic potential (-23.5 ± 1.5 mv). The pharmacokinetics study of this nanoemulsion and corresponding soft capsule was carried out using noncompartment model method. Compared with the marketed soft capsule, the C (max) of the natural vitamin E nanoemulsion was higher, while the T (max) was shorter. Thus, plasma concentration-time profiles in rats dosed with nanoemulsion showed a 1.6-fold enhancement in the area under the curve of natural vitamin E compared with the marketed soft capsule. The antioxidative effects of the natural vitamin E nanoemulsion and the marketed soft capsule were also evaluated by the levels of superoxide dismutase (SOD) activity and malondialdehyde (MDA) concentration in serum and liver tissue. According to the SOD activity and the MDA concentration determined, the nanoemulsion was superior to the marketed soft as an antioxidative agent. The overall results demonstrated that the nanoemulsion drug delivery system could be a promising strategy for the delivery of natural vitamin E, which showed great potential for clinical application.