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ART Selection in Women of Childbearing Age and During Pregnancy

Susan Cu-Uvin, MD
Program Director
Jean Rene Anderson, MD
Released: August 6, 2020

Pharmacokinetic Considerations for ART During Pregnancy

Pharmacokinetic Issues With ARV Agents in Pregnancy

This table lists some of the PK concerns with ARVs during pregnancy and the key agents for which these concerns apply.[5] It should be noted that, for NRTIs and INSTIs, there are no recognized PK concerns during pregnancy.

For EVG/COBI, EVG concentrations are reduced when using standard doses during pregnancy, and higher-than-standard doses have not been studied in pregnancy. Therefore, there are insufficient data available to recommend a specific dose for use in pregnancy.

For ATV/RTV, ATV concentrations are reduced in pregnancy. This is a greater consideration if ATV/RTV is given in combination with TDF or with an H2-receptor antagonist, and therefore, ATV/RTV is not recommended for ARV-experienced pregnant women who are receiving either TDF or an H2-receptor antagonist. Use of an increased dose may be considered during the second and third trimesters, as it has been shown to result in ATV concentrations equivalent to nonpregnant adults receiving standard dosing.

As previously mentioned, DRV boosted with RTV is a preferred agent during pregnancy but should be given twice daily in pregnancy. DRV or ATV boosted with COBI is not recommended in pregnancy because of the risk for lower drug levels and viral rebound in the second and third trimesters.

Lopinavir/RTV is listed as an alternative PI during pregnancy, but once-daily dosing is not recommended. Furthermore, some experts recommend increasing the dose in the second and third trimesters, especially in PI-experienced pregnant women or women who start treatment during pregnancy without viral suppression. If the standard dosing is used, providers should monitor the viral response and consider lopinavir drug levels.

Finally, the rilpivirine (RPV) PKs are highly variable during pregnancy. Indeed, the RPV area under the curve at trough concentrations are 20% to 50% lower in pregnancy compared with the postpartum period. Although the target exposure was exceeded in most pregnant women, those who had detectable HIV-1 RNA had lower RPV trough concentrations. So far, higher-than-standard doses of RPV have not been studied, and there are insufficient data to recommend a dosing change during pregnancy.

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