Hepatic and renal toxicity and associated factors among HIV-infected children on antiretroviral therapy: a prospective cohort study.

OBJECTIVES: The aim of the study was to investigate the prevalence of renal function and liver enzyme abnormalities among HIV-infected children, changes in prevalence with time on combination antiretroviral therapy (cART), and the factors associated with these abnormalities. METHODS: A prospective cohort study was conducted among HIV-infected children < 18 years old (n = 705) who were on first-line cART. Liver enzymes, renal function, haematology, immunology and virological response were assessed at enrolment and followed bi-annually for 18 months. Liver fibrosis and cirrhosis were assessed using noninvasive markers including the aspartate aminotransferase (AST) to platelet ratio index (APRI) and fibrosis score (FIB-4). RESULTS: The median age was 12 [interquartile range (IQR) 8-14] years; 53.3% of patients were male. At enrolment, the median cART duration was 3.3 (IQR 1.1-6.1) years; 177 (25.1%) and 83 (11.8%) patients had elevated AST and alanine aminotransferase (ALT), respectively. A tenth of the children had an APRI score > 0.5, suggesting liver fibrosis. Being on a zidovudine (ZDV)- or nevirapine (NVP)-based regimen and having a viral load > 1000 HIV-1 RNA copies/mL were significantly associated with elevated ALT. Twenty-four (3.4%) and 84 (12.1%) patients had elevated creatinine and blood urea nitrogen (BUN), respectively. As cART duration increased by 6 months, median BUN increased by 1.6 [95% confidence interval (CI) 0.4-2.7] mg/dL (P = 0.01); the glomerular filtration rate (GFR) decreased by 35.6 (95% CI 17.7-53.4) mL/min/1.73 m2 (P < 0.0001); and AST and ALT decreased by 1.4 (95% CI 0.4-2.5) IU/L (P = 0.01) and 1.4 (95% CI 0.2-2.6) IU/L (P = 0.01), respectively. CONCLUSIONS: A high prevalence of liver enzyme and renal function abnormalities was observed at enrolment. Decreasing liver enzyme levels during follow-up are possibly reassuring, while the progressive reduction in GFR and the increase in BUN are worrisome and require further study.

Pharmacogenetic and pharmacokinetic aspects of CYP3A induction by efavirenz in HIV patients.

We investigated the effects of pharmacogenetic variations and efavirenz pharmacokinetics on inter-individual differences in the extent of CYP3A induction by efavirenz using 4ß-hydroxycholesterol/cholesterol (4ß-OHC/Chol) as a marker for CYP3A induction. Plasma 4ß-hydroxycholesterol and cholesterol concentrations were determined at baseline, and at the 4th, 16th and 48th week of efavirenz-based highly active antiretroviral therapy in antiretroviral therapy-naive HIV patients (n=77). Efavirenz plasma concentrations were quantified at weeks 4 and 16. CYP2B6, CYP3A5, ABCB1, UGT2B7 genotyping were done. Compared with baseline, the median plasma 4ß-OHC/Chol ratio increased at the 4th (257%), 16th (291%) and 48th (165%) week (P<0.0001). CYP2B6*6 genotype significantly influenced 4ß-OHC/Chol ratio at weeks 16 (P=0.02) and 48 (P=0.04) being highest in CYP2B6*6/*6>*1/*6>*1/*1. There were positive correlations between plasma efavirenz and 4ß-OHC/Chol ratios (week 4: P=0.02, week 16: P=0.001). CYP3A enzyme induction by efavirenz is pronounced in CYP2B6 slow metabolizers who have high efavirenz plasma exposure.

High plasma efavirenz level and CYP2B6*6 are associated with efavirenz-based HAART-induced liver injury in the treatment of naïve HIV patients from Ethiopia: a prospective cohort study.

The objective of this study was to assess the incidence, timing and identify pharmacogenetic, efavirenz (EFV) pharmacokinetic and biochemical predictors of EFV-based antiretroviral therapy (ART) drug-induced liver injury (DILI). ART-naïve HIV patients (n = 285) were prospectively enrolled. Pretreatment laboratory evaluations included hepatitis B surface antigen and C antibody, CD4 count and viral load. Liver tests were done at baseline, 1st, 2nd, 4th, 8th, 12th, 24th and 48th weeks during ART. Plasma EFV and 8-hydroxyefvairenz concentration was determined at week 4 using liquid chromatography-mass spectrometry. CYP2B6, CYP3A5, ABCB1 3435C/T and UGT2B7*2 genotyping was done using Taqman genotyping assay. Data were analyzed using survival analysis and Cox proportional hazards model. The incidence of DILI was 15.7% or 27.9 per 100 person-years and that of severe injury was 3.4% or 6.13 per 100 person-years. The median time for the development of DILI and severe injury was 2 and 4 weeks after initiation of ART, respectively. There was significant association of DILI with lower baseline platelet, albumin, log plasma viral load and CD4 count (P = 0.031, 0.037, 0.06 and 0.019, respectively). Elevated baseline alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, plasma EFV level and CYP2B6*6 were good predictors for the development of DILI (P = 0.03, 0.01, 0.016, 0.017 and 0.04, respectively). We report for the first time CYP2B6*6 as a putative genetic marker and high plasma EFV concentration as intermediate biomarker for vulnerability to EFV-induced liver injury in HIV patients. CYP2B6 genotyping and/or regular monitoring of EFV and lever enzymes level during early therapy is advised for early diagnosis and management of DILI.

Haemonchus contortus: in vitro and in vivo anthelmintic activity of aqueous and hydro-alcoholic extracts of Hedera helix.

In vitro anthelmintic activity of crude extracts of the ripe fruits of Hedera helix was investigated on eggs and adult nematode parasites Haemonchus contortus. Aqueous extract of H. helix was also evaluated for in vivo anthelmintic activity at dose of 1.13 and 2.25 g/kg in sheep artificially infected with H. contortus. ED(50) for egg hatch inhibition was 0.12 and 0.17 mg/ml for aqueous and hydro-alcoholic extracts, respectively. There was no statistically significant difference in the activity of the two extract types (p>0.05). Hydro-alcoholic extract showed better in vitro activity against adult parasites compared to the aqueous extract. Significant faecal egg count reduction (FECR) was detected in groups treated with both doses of H. helix (p<0.05) on day 2 post-treatment. On day 7 post-treatment significant reduction was detected only for higher dose of H. helix (p<0.05) while on day 14 post-treatment there was no significant FECR in both groups treated with H. helix. The percentage of larvae recovered from culturing faeces obtained from groups of sheep treated with lower and higher doses of H. helix was 47.52% and 36.07%, respectively, which was significantly lower than (p<0.05) that recovered from the control group (60%). Significant (p<0.05), dose dependent total worm count reduction (WCR) was observed for groups of sheep treated with H. helix. Increasing the dose of H. helix improved the efficacy against the male than the female parasites. Treatment with both doses of H. helix helped the animals maintain their packed cell volume (PCV) unlike the untreated control group. The overall findings of the current study indicated that H. helix has a potential anthelmintic benefit and further in vitro and in vivo evaluation of the different parts and fractions is needed to make use of this plant for therapeutic purposes.

In vitro and in vivo anthelmintic activity of crude extracts of Coriandrum sativum against Haemonchus contortus.

In vitro anthelmintic activities of crude aqueous and hydro-alcoholic extracts of the seeds of Coriandrum sativum (Apiaceae) were investigated on the egg and adult nematode parasite Haemonchus contortus. The aqueous extract of Coriandrum sativum was also investigated for in vivo anthelmintic activity in sheep infected with Haemonchus contortus. Both extract types of Coriandrum sativum inhibited hatching of eggs completely at a concentration less than 0.5 mg/ml. ED(50) of aqueous extract of Coriandrum sativum was 0.12 mg/ml while that of hydro-alcoholic extract was 0.18 mg/ml. There was no statistically significant difference between aqueous and hydro-alcoholic extracts (p>0.05). The hydro-alcoholic extract showed better in vitro activity against adult parasites than the aqueous one. For the in vivo study, 24 sheep artificially infected with Haemonchus contortus were randomly divided into four groups of six animals each. The first two groups were treated with crude aqueous extract of Coriandrum sativum at 0.45 and 0.9 g/kg dose levels, the third group with albendazole at 3.8 mg/kg and the last group was left untreated. Efficacy was tested by faecal egg count reduction (FECR) and total worm count reduction (TWCR). On day 2 post treatment, significant FECR was detected in groups treated with higher dose of Coriandrum sativum (p<0.05) and albendazole (p<0.001). On days 7 and 14 post treatment, significant FECR was not detected for both doses of Coriandrum sativum (p>0.05). Significant (p<0.05) TWCR was detected only for higher dose of Coriandrum sativum compared to the untreated group. Reduction in male worms was higher than female worms. Treatment with both doses of Coriandrum sativum did not help the animals improve or maintain their PCV while those treated with albendazole showed significant increase in PCV (p<0.05).

Pain management in mice using the aqueous and ethanol extracts of four medicinal plants.

BACKGROUND: There are many traditionally used analgesic plants in Ethiopia. They, however, have not been subject to scientific investigation for their efficacy and safety. OBJECTIVE: To evaluate both prophylactic and relieving effects of aqueous and ethanol extracts of four traditionally used medicinal plants in Ethiopia. DESIGN: An experimental design in which five group of albino mice weighing 30-35 grams representing positive and negative control, and extract treated groups respectively. The extracts, standard drugs and normal saline were administered into GIT by gavage to evaluate the analgesic effect. SETTING: Department of Drug Research at Ethiopian Health and Nutrition Research Institute and Department of Pharmacology at Faculty of Medicine, Addis Ababa university. METHODS: Analgesic effects of water and ethanol extracts of four plants were evaluated against distilled water and standard analgesics (morphine and acetylsalicylic acid) with acetic acid induced writhing tests in mice. The four plants used for this screening were Ocimum sauve, Ocimum lamiifolium, Lippia adoensis and Ajuga remota. RESULTS: All extracts of the four plant materials were observed to possess both inhibiting and treatment activities against acetic acid induced pain. Dose related analgesic effect was also observed with all extracts of all plants with different potencies. Ethanol extracts of all the four plant materials were more potent than their water extracts at all dose levels except O. sauve, and L. adoensis whose water extracts seem to be a bit more potent at low dose. The analgesic potencies of both extracts of all the four plants were shown to be less than those of the standard analgesics. Of all the extracts, the ethanol extract of O. lamiifolium was found to be the most potent, while its water extract was the least. Acetic acid induced writhing was relieved with medium dose of both extracts in most cases and with low dose in few. Hundred percent relief was achieved with both standard analgesics at a very low dose. CONCLUSION: The present study show that all the extracts of all the plant materials have got both inhibiting and relieving effects of pain.

Constipating and spasmolytic effects of Khat (Catha edulis Forsk) in experimental animals.

The constipating and spasmolytic effects of Catha edulis Forsk (Khat) were investigated in whole mice and on isolated guinea pig ileum. D-amphetamine was employed in both experiments for comparison. The total distance travelled (expressed in percentage) by charcoal suspension in the gastrointestinal tract of mice was determined before and after khat administration. The procedure was repeated with amphetamine and normal saline. The results were compared. Amplitudes of contraction were recorded with standard spasmogens, histamine and carbachol, in the presence and absence of khat extract of different concentrations. The same was done with amphetamine. Khat extract was observed to reduce the total distance travelled by charcoal suspension, comparable to D-amphetamine. The spasmogenic effects of both histamine and carbachol were observed to be antagonized by the khat extract in a concentration-dependent manner. The antispasmodic effect of khat extract was observed to be similar to that of D-amphetamine.

Comparison of analgesic effects of khat (Catha edulis Forsk) extract, D-amphetamine and ibuprofen in mice.

We have compared the analgesic properties of khat (Catha edulis Forsk) extract, amphetamine and ibuprofen in mice. After intragastric administration of the drugs analgesia was measured relative to water-injected controls using the hot-plate, the tail-flick, and abdominal-constriction tests. At the highest doses examined (amphetamine 1.8 mg kg(-1), ibuprofen 90 mg kg(-1), khat extract 1800 mg kg(-1)), all three substances produced analgesia, but the order of efficacy varied with the test. Khat and ibuprofen were significantly different from the control in the hot-plate assay at three or more time points post-injection. In the tail-flick test, khat and amphetamine were efficacious; ibuprofen means were somewhat lower but still significantly different from control. Higher doses of the drugs decreased the number of responses in the acetic acid-induced abdominal-constriction assay. We conclude that khat, like amphetamine and ibuprofen, can relieve pain. Differences in assay results may reflect differences in modes and sites of action, as well as in the type of pain generated by the chemical and thermal stimuli for nociception.

Comparison of rectal artemisinin with intravenous quinine in the treatment of severe malaria in Ethiopia.

OBJECTIVE: To compare the clinical efficacy and safety of artemisinin suppository with quinine injection. DESIGN: Comparative open randomised study. SETTING: A government regional referral hospital in Ethiopia. SUBJECTS: Sixty five adult patients of both sexes: 32 for artemisinin and 33 for quinine with complicated severe falciparum malaria. MAIN OUTCOME MEASURES: Therapeutic responses and adverse reactions. RESULTS: The clinical and laboratory data in both groups of patients on admission were comparable. The parasite clearance time (PCT), fever subsidence time (FST) and coma resolution time (CRT) were shorter in the artemisinin treated group. There was no significant different in the parasitological cure rates in both arms of treatment. No correlation was observed between the initial parasite density and PCT or FST in both groups of treatment. Mortality rates were similar both in the artemisinin and quinine groups. The common adverse effects observed in most patients receiving quinine, in an increasing order of occurrence were; vomiting, dizziness, hypoglycaemia and tinnitus, which were all relatively rare with artemisinin. Some patients treated with artemisinin showed tenesmus which was not observed in any patient treated with quinine. CONCLUSION: The rectal artemisinin is more efficacious and safer than the intravenous quinine. Thus, artemisinin may be considered a potential drug which can replace quinine in the treatment of severe malaria in Ethiopia provided it is made available at affordable prices.

Comparative efficacy and safety of chloroquine and alternative antimalarial drugs: a meta-analysis from six African countries.

OBJECTIVE: To evaluate the safety and efficacy of the currently used antimalarial drugs in six African countries. DESIGN: A meta-analysis. MAIN OUTCOME MEASURES: The role of efficacy, safety and cost on the selection of antimalarial drugs. RESULTS: The comparative efficacy study showed that amodiaquine (with > 90% cure rate) was superior to chloroquine and sulphadoxine-pyrimethamine at seven days schedule. The efficacy of amodiaquine was also observed to be comparable to that of mefloquine and halofantrine. The parasite clearance time (PCT) of these drugs ranged between two days and a week and the fever clearance time (FCT) was within 48 hours. The recrudescence rate at D14-D21 was found to be 12-17% in chloroquine and amodiaquine, while sulphadoxine-pyrimethamine showed a trend similar to halofantrine and mefloquine (0-12% recrudescence rate). Similarly, a big difference was also noted in the cost of the different antimalarial drugs. The pharmacokinetic data, however, showed that they are of similar profile, except in adverse features and contraindications, and values like their half-life (t1/2) where the long (t1/2) in drugs like sulphadoxine-pyrimethamine endows them with suppressive-cure feature, especially against recrudescent strains. Nevertheless, as these data are obtained from resident population in Africa, who however naive are exposed to few malaria challenges in their life, the results should not be directly extrapolated to total non immunes such as visitors from Europe. CONCLUSION: The choice of alternative antimalarial drugs should be mainly based on their relative efficacy, safety and cost.

PIP: A meta-analysis study evaluating the efficacy and safety of chloroquine and alternative antimalarial drugs used in six African countries including Ethiopia, Kenya, Uganda, Cote D'Ivoire, Gambia and Nigeria is presented. Findings from the six countries showed a higher efficacy of amodiaquine and quinine (over 90%) in malaria treatment compared to chloroquine, which was found to be 70% or more effective. The efficacy of amodiaquine can also be compared to other antimalarial drugs such as mefloquine and halofantrine. Data showed that fever clearance time of these drugs was less than 2 days, but parasite clearance time ranged from 2.5 days to 1 week. Recrudescence rate also varied among the different drugs. This is a very important indicator in determining which drug can be used for prophylactic or suppressive treatment of malaria. Pharmacokinetic profile demonstrates that all these drugs have similar therapeutic effects, but differ in their adverse reactions, contraindications, and half-life. A significant difference was also noted in the cost of these antimalarial drugs; chloroquine was the cheapest, while halofantrine was the most expensive among the drugs. Based on these results, the study recommends that different aspects of antimalarial drugs have to be considered before deciding which drug is the best alternative treatment.

Antifertility activity of Ricinus communis seed in female guinea pigs.

OBJECTIVE: To investigate the anti-fertility effect of Ricinus communis seed extract. DESIGN: Laboratory-based experiment. SETTING: Laboratory of the Department of Pharmacology, Faculty of Medicine, Addis Ababa University, Addis Ababa, Ethiopia in 1996. RESULTS: The seed extract was found to possess anti-implantation and abortifacient effects. It was also observed that the seed extract prolonged the oestrus cycle of guinea pigs. The dioestrus phase was significantly prolonged as well. After stopping administering the extract, however, the normal dioestrus phase and oestrus cycle started to resume. The seed extract also reduced the weight of the uterus without affecting that of the ovaries significantly. CONCLUSION: Ricinus communis possesses an anti-fertility effect in female guinea pigs, which might be extrapolated in human beings. These findings might support the accredited claim of its traditional use to avoid unwanted pregnancies. Further studies, however, should be pursued.