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Open Access Highly Accessed Research article

Therapeutic drug monitoring of nevirapine in saliva in Uganda using high performance liquid chromatography and a low cost thin-layer chromatography technique

Mohammed Lamorde1*, Quirine Fillekes2, Kim Sigaloff3, Cissy Kityo4, Allan Buzibye1, Joshua Kayiwa4, Concepta Merry156, Lillian Nakatudde-Katumba4, David Burger2 and Tobias F Rinke de Wit3

Author Affiliations

1 Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda

2 Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands

3 Department of Global Health and Department of Internal Medicine; Academic Medical Center, University of Amsterdam; Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands

4 Joint Clinical Research Centre, Kampala, Uganda

5 Trinity College Dublin, Dublin, Ireland

6 Northwestern University, Chicago, USA

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BMC Infectious Diseases 2014, 14:473  doi:10.1186/1471-2334-14-473

Published: 1 September 2014

Abstract

Background

In resource limited settings access to laboratory monitoring of HIV treatment is limited and therapeutic drug monitoring is generally unavailable. This study aimed to evaluate nevirapine concentrations in saliva using low-cost thin-layer chromatography (TLC) and nevirapine concentrations in plasma and saliva using high performance liquid chromatography (HPLC) methods; and to correlate nevirapine plasma concentrations to HIV treatment outcomes in Ugandan patients.

Methods

Paired plasma and stimulated saliva samples were obtained from Ugandan, HIV-infected adults on nevirapine-based ART. Nevirapine concentrations were measured using a validated HPLC method and a novel TLC method. Plasma nevirapine concentrations <3.0 mg/L using HPLC were considered subtherapeutic. Negative/positive predictive values of different thresholds for subtherapeutic nevirapine concentrations in saliva were determined. Virologic testing and, if applicable, HIV drug resistance testing was performed.

Results

Median (interquartile range, IQR) age of 297 patients was 39.1 (32.8-45.2) years. Three hundred saliva and 287 plasma samples were available for analysis. Attempts failed to determine nevirapine saliva concentrations by TLC. Using HPLC, median (IQR) nevirapine concentrations in saliva and plasma were 3.40 (2.59-4.47) mg/L and 6.17 (4.79-7.96) mg/L, respectively. The mean (coefficient of variation,%) nevirapine saliva/plasma ratio was 0.58 (62%). A cut-off value of 1.60 mg/L nevirapine in saliva was associated with a negative/positive predictive value of 0.99/0.72 and a sensitivity/specificity of 87%/98% for predicting subtherapeutic nevirapine plasma concentrations, respectively. Only 5% (15/287) of patients had subtherapeutic nevirapine plasma concentrations, of which 3 patients had viral load results > 400 copies/mL. Patients with nevirapine concentrations in plasma <3.0 mg/L had an Odds Ratio of 3.29 (95% CI: 1.00 – 10.74) for virological failure (viral load >400 copies/mL).

Conclusions

The low-cost TLC technique for monitoring nevirapine in saliva was unsuccessful but monitoring nevirapine saliva and plasma concentrations using HPLC was shown to be feasible in the research/specialist context in Uganda. Further optimization and validation is required for the low-cost TLC technique.