Efavirenz

Efavirenz
Systematic (IUPAC) name
(4S)-6-chloro-4-(2-cyclopropylethynyl)-4-(trifluoromethyl)-2,4-dihydro-1H-3,1-benzoxazin-2-one
Clinical data
Trade names Sustiva, Stocrin, others
AHFS/Drugs.com monograph
MedlinePlus a699004
Pregnancy
category
  • US: D (Evidence of risk)
Routes of
administration		 By mouth (capsules, tablets)
Legal status
Legal status
  • UK: POM (Prescription only)
  • US: ℞-only
  • ℞ (Prescription only)
Pharmacokinetic data
Bioavailability 40–45% (under fasting conditions)
Protein binding 99.5–99.75%
Metabolism Hepatic (CYP2A6 and CYP2B6-mediated)
Onset of action 3–5 hours
Biological half-life 40–55 hours
Excretion Urine (14–34%) and feces (16–61%)
Identifiers
CAS Number 154598-52-4 YesY
ATC code J05AG03 (WHO)
PubChem CID 64139
DrugBank DB00625 YesY
ChemSpider 57715 YesY
UNII JE6H2O27P8 YesY
KEGG D00896 YesY
ChEBI CHEBI:119486 YesY
ChEMBL CHEMBL223228 YesY
NIAID ChemDB 032934
PDB ligand ID EFZ (PDBe, RCSB PDB)
Chemical data
Formula C14H9ClF3NO2
Molar mass 315.675 g/mol
  (verify)

Efavirenz (EFV), sold under the brand names Sustiva among others, is a non-nucleoside reverse transcriptase inhibitor (NNRTI). It is used as part of highly active antiretroviral therapy (HAART) for the treatment of a human immunodeficiency virus (HIV) type 1. For HIV infection that has not previously been treated, the United States Department of Health and Human Services Panel on Antiretroviral Guidelines currently recommends the use of efavirenz in combination with tenofovir/emtricitabine (Truvada) as one of the preferred NNRTI-based regimens in adults and adolescents.[1] Efavirenz is also used in combination with other antiretroviral agents as part of an expanded postexposure prophylaxis regimen to reduce the risk of HIV infection in people exposed to a significant risk (e.g. needlestick injuries, certain types of unprotected sex etc.).

It is usually taken on an empty stomach at bedtime to reduce neurological and psychiatric adverse effects.

Efavirenz was combined with the HIV medications tenofovir and emtricitabine, all of which are reverse transcriptase inhibitors. This combination of three medications under the brand name Atripla, provides HAART in a single tablet taken once a day.

Efavirenz was discovered at Merck Research Laboratories. It is on the WHO Model List of Essential Medicines, the most important medication needed in a basic health system.[2] As of 2015 the cost for a typical month of medication in the United States is more than 200 USD.[3]

Medical uses

Efavirenz is used to treat HIV infection. It is never used alone and is always given in combination with other drugs. The decision on when to start treatment should take into account CD4 count, HIV viral load, treatment history, resistance profiles and patient preference.

Since the preliminary publication of the results of the ACTG 5142 trial in 2006 which compared efavirenz against lopinavir, efavirenz has been used as first line treatment in preference to the protease inhibitors. The ACTG 5095 trial showed that the potency of efavirenz is maintained at all CD4 counts and HIV viral loads.

Adverse effects

Drug interactions

Mechanism of action

Anti-HIV effects

Efavirenz falls in the NNRTI class of antiretrovirals. Both nucleoside and non-nucleoside RTIs inhibit the same target, the reverse transcriptase enzyme, an essential viral enzyme which transcribes viral RNA into DNA. Unlike nucleoside RTIs, which bind at the enzyme's active site, NNRTIs act allosterically by binding to a distinct site away from the active site known as the NNRTI pocket.

Efavirenz is not effective against HIV-2, as the pocket of the HIV-2 reverse transcriptase has a different structure, which confers intrinsic resistance to the NNRTI class.[10]

As most NNRTIs bind within the same pocket, viral strains which are resistant to efavirenz are usually also resistant to the other NNRTIs, nevirapine and delavirdine. The most common mutation observed after efavirenz treatment is K103N, which is also observed with other NNRTIs.[11]

Neuropsychiatric effects

Recently, efavirenz has been found to act as a(n) 5-HT2A receptor partial agonist (Ki = 2.2 μM),[12] 5-HT2C receptor ligand, serotonin and dopamine reuptake inhibitor (50% and 75% inhibition at 10 μM, respectively), vesicular monoamine transporter 2 (VMAT2) inhibitor (60% inhibition at 10 μM), and positive allosteric modulator of the GABAA receptor.[13] It is thought that these properties, especially its actions at the 5-HT2 receptors, are involved in its neuropsychiatric adverse effects (e.g., depression, anxiety, hallucinations, aggression, suicidal ideation, and sleep disturbance),[12][13] as they are alleviated by cyproheptadine, a drug with 5-HT2 receptor antagonist actions.[14][15]

Despite its actions at the GABAA receptor and the SERT, DAT, and VMAT2, efavirenz fails to produce self-administration or conditioned place preference in animals, suggesting that it lacks positive reinforcing effects.[13] However, efavirenz does show LSD-like effects in animals, including producing the head-twitch response and positive drug discrimination responding for LSD in rodents, and there is evidence that efavirenz produces LSD-like hallucinogenic effects in humans at sufficiently high doses.[13]

Chemical properties

Efavirenz is chemically described as (S)-6-chloro-(cyclopropylethynyl)-1,4-dihydro-4-(trifluoromethyl)-2H-3,1-benzoxazin-2-one. Its empirical formula is C14H9ClF3NO2. Efavirenz is a white to slightly pink crystalline powder with a molecular mass of 315.68 g/mol. It is practically insoluble in water (<10 µg/mL).

History

Efavirenz was approved by the FDA on September 21, 1998, making it the 14th approved antiretroviral drug.

Society and culture

Pricing information

A one-month supply of 600 mg tablets cost approximately $550 in April 2008.[16] Merck provides efavirenz in certain developing countries at cost, currently about $0.65 per day.[17] Some emerging countries have opted to purchase Indian generics[18] such as Efavir by Cipla Ltd.[19] In Thailand, one month supply of efavirenz + truvada, as of June 2012, costs THB 2900 ($90), there's also a social program for poorer patients who can't afford even this price. In South Africa, a license has been granted to generics giant Aspen Pharmacare to manufacture, and distribute to Sub-Saharan Africa, a cost-effective antiretroviral drug.[20]

Brand names

Generic brands India:[23]

Recreational use

Abuse of efavirenz by crushing and smoking the tablets for supposed hallucinogenic and dissociative effects has been reported in South Africa, where it is used in a mixture known as whoonga and nyaope.[27][28][29][30] This is believed to be because of activity at a side target, the 5-HT2A receptor, which is better known as the target of drugs such as LSD.[31]

References

  1. ↑ "Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents". Retrieved 10 May 2013.
  2. ↑ "WHO Model List of EssentialMedicines" (PDF). World Health Organization. October 2013. Retrieved 22 April 2014.
  3. ↑ Hamilton, Richart (2015). Tarascon Pocket Pharmacopoeia 2015 Deluxe Lab-Coat Edition. Jones & Bartlett Learning. p. 62. ISBN 9781284057560.
  4. ↑ Cespedes, MS; Aberg, JA (2006). "Neuropsychiatric complications of antiretroviral therapy.". Drug safety : an international journal of medical toxicology and drug experience 29 (10): 865–74. doi:10.2165/00002018-200629100-00004. PMID 16970510.
  5. ↑ "www.accessdata.fda.gov" (PDF).
  6. ↑ DHHS panel. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents (October 10, 2006). (Available for download from AIDSInfo)
  7. ↑ Ford, N.; Mofenson, L.; Kranzer, K.; Medu, L.; Frigati, L.; Mills, E. J.; Calmy, A. (2010). "Safety of efavirenz in first-trimester of pregnancy: A systematic review and meta-analysis of outcomes from observational cohorts". AIDS 24 (10): 1461–1470. doi:10.1097/QAD.0b013e32833a2a14. PMID 20479637.
  8. ↑ Rossi, S; Yaksh, T; Bentley, H; Van Den Brande, G; Grant, I; Ellis, R (2006). "Characterization of interference with 6 commercial delta9-tetrahydrocannabinol immunoassays by efavirenz (glucuronide) in urine". Clinical Chemistry 52 (5): 896–7. doi:10.1373/clinchem.2006.067058. PMID 16638958.
  9. ↑ Röder, CS; Heinrich, T; Gehrig, AK; Mikus, G (2007). "Misleading results of screening for illicit drugs during efavirenz treatment". AIDS (London, England) 21 (10): 1390–1. doi:10.1097/QAD.0b013e32814e6b3e. PMID 17545727.
  10. ↑ Ren J, Bird LE, Chamberlain PP; et al. (2002). "Structure of HIV-2 reverse transcriptase at 2.35-A resolution and the mechanism of resistance to non-nucleoside inhibitors". Proc Natl Acad Sci USA 99 (22): 14410–15. doi:10.1073/pnas.222366699. PMC 137897. PMID 12386343.
  11. ↑ Sustiva (efavirenz) capsules and tablets. Product information (April 2005)
  12. 1 2 Simen AA, Ma J, Svetnik V, Mayleben D, Maynard J, Roth A, Mixson L, Mogg R, Shera D, George L, Mast TC, Beals C, Stoch A, Struyk A, Shire N, Fraser I (2014). "Efavirenz modulation of sleep spindles and sleep spectral profile". J Sleep Res 24: 66–73. doi:10.1111/jsr.12196. PMID 25113527.
  13. 1 2 3 4 Gatch MB, Kozlenkov A, Huang RQ, Yang W, Nguyen JD, González-Maeso J, Rice KC, France CP, Dillon GH, Forster MJ, Schetz JA (2013). "The HIV antiretroviral drug efavirenz has LSD-like properties". Neuropsychopharmacology 38 (12): 2373–84. doi:10.1038/npp.2013.135. PMC 3799056. PMID 23702798.
  14. ↑ Dabaghzadeh F, Ghaeli P, Khalili H, Alimadadi A, Jafari S, Akhondzadeh S, Khazaeipour Z (2013). "Cyproheptadine for prevention of neuropsychiatric adverse effects of efavirenz: a randomized clinical trial". AIDS Patient Care STDS 27 (3): 146–54. doi:10.1089/apc.2012.0410. PMID 23442031.
  15. ↑ Dabaghzadeh F, Khalili H, Ghaeli P, Dashti-Khavidaki S (2012). "Potential benefits of cyproheptadine in HIV-positive patients under treatment with antiretroviral drugs including efavirenz". Expert Opin Pharmacother 13 (18): 2613–24. doi:10.1517/14656566.2012.742887. PMID 23140169.
  16. ↑ Price listed on http://drugstore.com website, 4/20/2008
  17. ↑ "Merck & Co., Inc., Again Reduces Price of Stocrin (efavirenz) for Patients in Least Developed Countries and Countries Hardest Hit by Epidemic - Drugs.com MedNews".
  18. ↑ IndiaDaily - A new trend in emerging nations - Brazil opts for Indian generic drug ignoring US pharmaceutical giant Merck’s patent on AIDS drug Efavirenz
  19. ↑ http://www.cipla.com
  20. ↑ Patrick Lumumba Osewe; Yvonne Korkoi Nkrumah; Emmanuel K. Sackey (15 June 2008). Improving Access to HIV/AIDS Medicines in Africa: Trade-Related Aspects of Intellectual Property Rights (TRIPS) Flexibilities Utilization. World Bank Publications. pp. 35–39. ISBN 978-0-8213-7544-0. Retrieved 30 June 2012.
  21. ↑ http://www.sustiva.com/
  22. ↑ http://www.medsafe.govt.nz/consumers/cmi/s/stocrin.pdf
  23. ↑ Drugsupdate.com generic brands list: http://www.drugsupdate.com/brand/generic/Efavirenz/87
  24. ↑ http://mcneilargusindia.com/
  25. ↑ http://www.alkemlabs.com/
  26. ↑ "Regast® (efavirenz) film-coated tablets.". http://www.pharmasyntez.com (in Russian). Pharmasyntez, 2011. Retrieved 28 June 2015. External link in |website= (help)
  27. ↑ IOL: Thugs get high on stolen Aids drugs IOL News May 12, 2007
  28. ↑ Getting high on HIV drugs in S Africa. BBC News, 8 December 2008.
  29. ↑ 'No Turning Back': Teens Abuse HIV Drugs. ABC News, April 6, 2009.
  30. ↑ Getting High On HIV Medication Vice 7.04.2014.
  31. ↑ Gatch, M. B.; Kozlenkov, A.; Huang, R. Q.; Yang, W.; Nguyen, J. D.; González-Maeso, J.; Rice, K. C.; France, C. P.; Dillon, G. H.; Forster, M. J.; Schetz, J. A. (2013). "The HIV Antiretroviral Drug Efavirenz has LSD-Like Properties". Neuropsychopharmacology 38 (12): 2373–84. doi:10.1038/npp.2013.135. PMC 3799056. PMID 23702798.

External links

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