Fridman Lisa B, Knerler Stephen, Price Amira-Storm, Ortiz Rodnie Colón, Mercado Alicia, Wilkins Hannah, Flores Bianca R, Orsburn Benjamin C, Williams Dionna W
Department of Molecular and Comparative Pathobiology, Johns Hopkins School of Medicine, Baltimore, Maryland 21205.
Department of Neuroscience, Johns Hopkins School of Medicine, Baltimore, Maryland 21205.
bioRxiv. 2023 Jul 29:2023.07.28.551042. doi: 10.1101/2023.07.28.551042.
Appropriate interactions between antiretroviral therapies (ART) and drug transporters and metabolizing enzymes at the blood brain barrier (BBB) are critical to ensure adequate dosing of the brain to achieve HIV suppression. These proteins are modulated by demographic and lifestyle factors, including substance use. While understudied, illicit substances share drug transport and metabolism pathways with ART, increasing the potential for adverse drug:drug interactions. This is particularly important when considering the brain as it is relatively undertreated compared to peripheral organs and is vulnerable to substance use-mediated damage.
We used an model of the human BBB to determine the extravasation of three first-line ART drugs, emtricitabine (FTC), tenofovir (TFV), and dolutegravir (DTG), in the presence and absence of cocaine, which served as our illicit substance model. The impact of cocaine on BBB integrity and permeability, drug transporters, metabolizing enzymes, and their master transcriptional regulators were evaluated to determine the mechanisms by which substance use impacted ART central nervous system (CNS) availability.
We determined that cocaine had a selective impact on ART extravasation, where it increased FTC's ability to cross the BBB while decreasing TFV. DTG concentrations that passed the BBB were below quantifiable limits. Interestingly, the potent neuroinflammatory modulator, lipopolysaccharide, had no effect on ART transport, suggesting a specificity for cocaine. Unexpectedly, cocaine did not breach the BBB, as permeability to albumin and tight junction proteins and adhesion molecules remained unchanged. Rather, cocaine selectively decreased the pregnane-x receptor (PXR), but not constitutive androstane receptor (CAR). Consequently, drug transporter expression and activity decreased in endothelial cells of the BBB, including p-glycoprotein (P-gp), breast cancer resistance protein (BCRP), and multidrug resistance-associated protein 4 (MRP4). Further, cytochrome P450 3A4 (CYP3A4) enzymatic activity increased following cocaine treatment that coincided with decreased expression. Finally, cocaine modulated adenylate kinases are required to facilitate biotransformation of ART prodrugs to their phosphorylated, pharmacologically active counterparts.
Our findings indicate that additional considerations are needed in CNS HIV treatment strategies for people who use cocaine, as it may limit ART efficacy through regulation of drug transport and metabolizing pathways at the BBB.
抗逆转录病毒疗法（ART）与血脑屏障（BBB）处的药物转运体和代谢酶之间的适当相互作用对于确保大脑有足够的药物剂量以实现HIV抑制至关重要。这些蛋白质受人口统计学和生活方式因素调节，包括药物使用。虽然研究较少，但非法药物与ART共享药物转运和代谢途径，增加了药物不良相互作用的可能性。考虑到大脑与外周器官相比治疗相对不足且易受药物使用介导的损害，这一点尤为重要。
我们使用人血脑屏障模型来确定三种一线抗逆转录病毒药物恩曲他滨（FTC）、替诺福韦（TFV）和多替拉韦（DTG）在有无可卡因（作为我们的非法药物模型）存在时的外渗情况。评估了可卡因对血脑屏障完整性和通透性、药物转运体、代谢酶及其主要转录调节因子的影响，以确定药物使用影响抗逆转录病毒疗法中枢神经系统（CNS）可用性的机制。
我们确定可卡因对抗逆转录病毒疗法的外渗有选择性影响，它增加了FTC穿过血脑屏障的能力，同时降低了TFV的能力。通过血脑屏障的DTG浓度低于可量化限度。有趣的是，强效神经炎症调节剂脂多糖对抗逆转录病毒疗法的转运没有影响，表明对可卡因具有特异性。出乎意料的是，可卡因并未破坏血脑屏障，因为白蛋白、紧密连接蛋白和黏附分子的通透性保持不变。相反，可卡因选择性降低孕烷X受体（PXR），但不降低组成型雄甾烷受体（CAR）。因此，血脑屏障内皮细胞中的药物转运体表达和活性降低，包括P-糖蛋白（P-gp）、乳腺癌耐药蛋白（BCRP）和多药耐药相关蛋白4（MRP4）。此外，可卡因处理后细胞色素P450 3A4（CYP3A4）酶活性增加，同时表达降低。最后，可卡因调节腺苷酸激酶，以促进抗逆转录病毒疗法前药向其磷酸化的、具有药理活性的对应物的生物转化。
我们的研究结果表明，对于使用可卡因的人，中枢神经系统HIV治疗策略需要额外考虑，因为它可能通过调节血脑屏障处的药物转运和代谢途径来限制抗逆转录病毒疗法的疗效。
