Pharmacokinetics of dolutegravir, tenofovir and lamivudine during venous–venous extracorporeal membrane oxygenation (VV‐ECMO): A case report

While providing potentially life-saving cardiorespiratory support for critically ill patients, extracorporeal membrane oxygenation (ECMO) may detrimentally affect pharmacokinetic (PK) performance and concurrent drug efficacy and safety. We describe a patient with Pneumocystis jirovecii pneumonia (PJP) in the context of acquired immunodeficiency syndrome (AIDS) who received dolutegravir, tenofovir and lamivudine while undergoing venous-venous (VV-) ECMO. Initial therapeutic drug monitoring (TDM) during VV-ECMO revealed 9.6-fold lower dolutegravir, 1.5-fold lower tenofovir and 1.7-fold higher lamivudine exposure as compared to reference populations. Our findings support considerations for pre-emptive dose intensification for dolutegravir and tenofovir in patients with human immunodeficiency virus (HIV)/AIDS undergoing ECMO to ensure adequate antiretroviral treatment. The case is illustrative for the clinical pharmacological challenges faced in critically ill patients with HIV/AIDS undergoing ECMO and provides guidance for future cases.