title: Nevirapine concentration in nonstimulated saliva: an alternative to plasma sampling in children with human immunodeficiency virus infection.
abstract: BACKGROUND
  The monitoring of nevirapine (NVP) concentrations in pediatric patients has gained interest since the introduction of NVP as part of the preferred first-line antiretroviral regimen for human immunodeficiency virus (HIV)-infected children in resource-limited settings. Adequate trough concentrations of NVP predict successful therapy, whereas subtherapeutic levels are correlated with virologic failure and development of resistance. The aim of this study was to determine the extent of agreement between total and free plasma NVP concentrations and nonstimulated saliva NVP concentrations and to evaluate the feasibility of saliva sampling as an alternative tool for therapeutic drug monitoring of NVP in children.
  
  
  METHODS
  The study was designed as an observational cohort analysis. NVP concentrations were obtained in paired plasma and saliva samples of pediatric patients receiving antiretroviral therapy, including NVP. NVP plasma and saliva concentrations were determined by a tandem-mass spectrometric method. The intraclass correlation coefficient and Bland-Altman analysis were used to evaluate agreement and to assess pattern in any discrepancies between measurements.
  
  
  RESULTS
  For the random paired plasma and saliva NVP sampling, 19 African-American children (8 boys, 11 girls) with a median age of 8.0 years were enrolled. Two male subjects were recruited for the 12 hour NVP plasma and saliva pharmacokinetics study. The intraclass correlations between saliva and serum measurements of NVP concentrations indicated >90% agreement between these two modes of measurement. The saliva concentrations reflected the free concentrations very closely but were on average 34% higher. The Bland-Altman plots indicated that the discrepancy between saliva and plasma measures is consistent across the range of average NVP concentrations.
  
  
  CONCLUSIONS
  Our study results strongly indicate agreement between saliva and plasma NVP concentrations in pediatric patients with HIV infection, on the basis of Bland-Altman analysis. Nonstimulated NVP saliva concentrations can be used as an alternative noninvasive, reliable, cost-effective method for direct measurement of adherence and application of therapeutic drug monitoring in NVP therapy.
authors.affiliation: Division of Infectious Disease, The George Washington University School of Medicine, Washington, DC 20010, USA. nrakhman@cnmc.org
authors.forename: Natella Y
authors.initials: NY
authors.lastname: Rakhmanina
authors.forename: Edmund V
authors.initials: EV
authors.lastname: Capparelli
authors.forename: John N
authors.initials: JN
authors.lastname: van den Anker
authors.forename: Keetra
authors.initials: K
authors.lastname: Williams
authors.forename: John L
authors.initials: JL
authors.lastname: Sever
authors.forename: Hans M L
authors.initials: HM
authors.lastname: Spiegel
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Soldin
mesh_terms: D019380:Anti-HIV Agents / Q000493:pharmacokinetics / Q000627:therapeutic use; D002648:Child; D003627:Data Interpretation, Statistical; D016903:Drug Monitoring / Q000379:methods; D005260:Female; D015658:HIV Infections / Q000097:blood / Q000188:drug therapy* / Q000378:metabolism; D006801:Humans; D008297:Male; D019829:Nevirapine / Q000097:blood / Q000493:pharmacokinetics* / Q000627:therapeutic use*; D010865:Pilot Projects; D012463:Saliva / Q000378:metabolism*
chemical_list: D019380:Anti-HIV Agents; D019829:Nevirapine