Journal of Neuroimmune Pharmacology
https://doi.org/10.1007/s11481-020-09904-z
LETTER TO THE EDITOR
Effect of Dolutegravir and Sertraline on the Blood Brain Barrier (BBB)
Qing Ma 1 & Giovanni Schifitto 2 & Charles Venuto 2 & Andrew Ocque 1 & Stephen Dewhurst 3 & Gene D. Morse 1 &
Ravikumar Aalinkeel 4 & Stanley A. Schwartz 4 & Supriya D. Mahajan 4
Received: 22 November 2019 / Accepted: 9 January 2020
# Springer Science+Business Media, LLC, part of Springer Nature 2020
To the Editor;
Depression is the most common co-morbidity in people living
with HIV requiring antidepressant therapy such as selective
serotonin reuptake inhibitors (SSRIs) (Do et al. 2014).
Prevalence of depression among HIV-infected persons in the
United States is 20–40%, up to 2-fold higher than it is among
HIV-uninfected persons. Depression among HIV-infected per-
sons is associated with increased high-risk behavior, non-
adherence to antiretroviral therapy, and progression to HIV
associated neurological disorders (National Institute of
Mental Health 2019).
Dolutegravir (DTG), is commonly prescribed in combina-
tions with abacavir (Triumeq®) or rilpivirine (Juluca®), and
has become an important first-line drug for HIV-infected pa-
tients in the US and Europe and recently is introduced to
developing countries as an Essential Medicine by the WHO
owing to its excellent efficacy (Kheloufi et al. 2017). At pres-
ent DTG-containing regimens account for ~50% of the first-
line combination antiretroviral therapy in the US and Europe,
it is estimated that their use will be remarkably increased to
40% by 2019 in low- and middle-income countries (de Boer
et al. 2016). Thus, the increasingly reported neuropsychiatric
adverse events (NP-AEs) from DTG-containing regimens, in-
cluding sleep disorders, depression, anxiety, and suicidal
* Supriya D. Mahajan
smahajan@buffalo.edu
1
Department of Pharmacy Practice, School of Pharmacy and
Pharmaceutical Sciences, University at Buffalo Center of Excellence
of the Global Virus Network, Buffalo, NY 14260, USA
2
Department of Neurology, University of Rochester Medical Center,
Rochester, NY 14642, USA
3
Department of Microbiology and Immunology, University of
Rochester Medical Center, School of Medicine and Dentistry,
Rochester, NY 14642, USA
4
Department of Medicine, Division of Allergy, Immunology &
Rheumatology, University at Buffalo, Clinical & Translational
Research Center, 875 Ellicott Street, Buffalo, NY 14203, USA
behaviors, have become an emerging concern worldwide (de
Boer et al. 2016). Analyses of CHARTER patients, attributed
DTG intolerance to NP-AEs (Hoffmann et al. 2017). More
recently, the Barcelona Cohort study has reported a significant
higher rate of DTG discontinuation due to CNS adverse ef-
fects than those with raltegravir or elvitegravir (Kheloufi et al.
2017). The underlying mechanisms for DTG-related NP-AEs
are not fully understood but recent data from 13 HIV-infected
patients receiving 16-week DTG-containing therapy, found
high DTG concentrations in the cerebrospinal fluid, suggest-
ing a possible mechanism by which concentration dependent
DTG toxicity promotes NP-AEs (Hoffmann et al. 2017).
An in-vitro study using human cell lines demonstrated sig-
nificant inhibitory effects of the SSRI sertraline, on P-
glycoprotein (P-gp) suggesting a potential drug interaction at
the BBB where P-gp-dependent DTG transport occurs
(Cottrell et al. 2013). Although the clinical use of DTG is
increasingly used worldwide, limited data are available on
its penetration through the BBB, its concentrations in the brain
or their relationship with NP-AEs. The distribution of DTG
across the blood-brain barrier (BBB) and blood-CSF barrier is
limited. Due to its high efficacy, even modest transport of
DTG across the BBB into the CNS may result in concentra-
tions that provide significant antiviral activity.
Two microvascular components maintain the dynamic and
selective permeability of the BBB, the tight junctions (TJ) that
anchor neighboring endothelial cells to one another and the
ATP-binding cassette (ABC) transporters that line both sides
of the capillary endothelium actively pump substrates between
brain parenchyma and blood circulation (Abbott et al. 2010).
The penetration of DTG and its effects on the vasculature of
the BBB and the effects of sertraline on DTG penetration and
the modulation of TJ proteins such as ZO-1/Claudin-5/JAM-2
and key drug transporters (P-gp/ABCB1), MRP-1/ABCC1)
were examined using a 2D in-vitro BBB model. Data shown
in Fig. 1 indicates that DTG nor sertraline treatment alone did
not significantly alter the BBB integrity, however, the two-
drugs in combination significantly reduced in the integrity of
Fig. 1 a Effect of DTG ± Sertraline on BBB permeability. BBB
permeability was evaluated by measuring transendothelial electrical
resistance (TEER) across an in vitro BBB treated with DTG (25 μM)
and/or Sertraline (55 ng/ml). Figure 1a shows that treatment of the intact
BBB with a combination of DTG and Sertraline resulted in a 27%
(p<0.05) decrease in TEER. Data obtained were from a total of n=3
separate experiments done in triplicate b Calculated Permeability
coefficients (Papp) for DTG ± Sertraline. Figure 1b shows the treatment
of the BBB with DTG (25 μM) ± Sertraline (55 ng/ml) resulted in a 54%
(p=0.0035) decrease in the permeability coefficient as compared to DTG
alone. The permeability coefficient (Papp, cm/s) was calculated using the
Papp = (dQ / dt) / (C0×A) equation. On statistical comparisons between
treatments and the untreated control, a p < 0.05 value was considered to
be a statistical significant difference. c Effect of DTG ± Sertraline on ZO-
the BBB, suggesting a significant drug-drug interaction be-
tween DTG and sertraline at the BBB might increase BBB
permeability and facilitate DTG NP-AEs. Disruption of TJ
alters BBB permeability, increases paracellular permeability
and contributes to neuroinflammation. DTG and sertraline
treatment significantly decreased the gene expression of TJ
proteins ZO-1, Claudin-5, JAM-2; ABCB1/ABCC1 gene ex-
pression levels (Fig. 1) and significantly increased levels of
pro-inflammatory cytokines TNFα, IL-1β and NO by the
BBB (Table 1).
It is speculated that increased penetration of DTG into the
CNS potentially contributes to neurotoxicity through
microglial activation and neuronal apoptosis leading to the
cognitive dysfunction typically observed in HIV+ patients
who receive DTG, however little is known about the mecha-
nisms involved in BBB modulation due to DTG and sertraline
1 gene expression. d Effect of DTG ± Sertraline on Claudin-5 gene
expression. e Effect of DTG ± Sertraline on JAM-2 gene expression. f
Effect of DTG ± Sertraline on gene expression of ABC transporter ABC-
B1. g Effect of DTG ± Sertraline on gene expression of ABC transporter
ABCC1. BMVEC cells that constitute the BBB, were treated with DTG
(25 μM) and/or Sertraline (55 ng/ml) and 24 hr later, RNA was extracted
and gene expression levels were analyzed by QPCR. Data showed that
both DTG and Sertraline alone decreased ZO-1, Claudin-5 & JAM-2
gene expression respectively, and a combination treatment of DTG and
Sertraline further decreased the TJ gene expression levels. Whereas, a
combination treatment of DTG and Sertraline decreased ABC-B1 gene
expression. A total of n=3 experiments in triplicate were done. On
statistical comparisons between treatments and the untreated control, a
p < 0.05 value was considered to be a statistical significant difference
interaction at the BBB. CNS drugs contribute to loss of barrier
integrity with altered expression of drug transporter molecules
and a pro-inflammatory response (Zlokovic 2008). Pro-
inflammatory cytokines can alter TJ expression and thereby
modulate BBB integrity. Iqbal et al. (2012) previously report-
ed cytokine-induced decrease in mRNA expression of ABC
transporters and consequent reductions in P-gp function. Our
findings suggest that neuro-inflammatory response is mediat-
ed by pro-inflammatory cytokines, which may bind to endo-
thelial cell surface receptors and trigger a wide range of chang-
es in endothelial cell function and alter the expression and
activity of ABC efflux transporters (von Wedel-Parlow et al.
2009). Evidence suggests that TNF-α is one of the most im-
portant inflammatory mediators that participates in the regu-
lation of ABC efflux transporters (von Wedel-Parlow et al.
2009). TNF-α induces the activation of endothelin receptor-
Table 1 Levels of pro-
inflammatory cytokines in BBB Treatments TNF-α (pg/ml) IL-1β (pg/ml) NO (μM)
culture supernatants
Untreated control 275.3 ± 12.1 34.7 ± 3.52 36.2 ± 11.8
Douletagvir (25 μM) 458.7 ± 25.2 (p < 0.05)* 152.62 ± 11.4 (p < 0.001)† 75.1 ± 15.6 (p < 0.05)*
Sertraline (55 ng/mL) 355.9 ± 18.2 p = NS 189.1 ± 10.8 (p < 0.001)† 60.9 ± 9.5 (p < 0.05)*
Sertraline (55 ng/ml) + 924.4 ± 33.1 (p < 0.001)† 377.2 ± 19.4 (p < 0.0001)** 121.4 ± 14.3 (p < 0.01)‡
Douletagvir (25 μM)

*, ‡, †, ** -Statistical comparisons between treatments and the untreated control, a p < 0.05 value was considered
to be a statistical significant difference

B (ETRB), which triggers the activation of inducible nitric
oxide synthase (iNOS) that activates a signaling cascade
resulting in reduction in P-gp expression (von Wedel-Parlow
et al. 2009). From the clinical perspective in HIV patients with
depression, P-gp plays an important role in multidrug resis-
tance and drug-drug interactions, derived primarily from its
broad substrate specificity and variable intrinsic and drug-
induced expression. Thus, regulation of the expression levels
of TJ and drug transporters proteins by DTG and the SSRI
sertraline affect BBB pathophysiology, and can modulate drug
penetration, diffusion and bioavailability of CNS therapeutics.
Increased penetration of DTG and Sertraline into the CNS
would potentially contribute to neurotoxicity in the CNS and
cause increased microglial activation and neuronal apoptosis
leading to cognitive dysfunction typically observed in HIV
patients who use DTG.
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