Paediatric ARV
dosing dashboard

Drug dosing tool for prescribing
antiretroviral medications to infants
and children

flap-cover-NEW-01.svg

Introduction

The WHO Paediatric ARV dosing dashboard aims to support health care workers, researchers and policy makers in decisions around ARV dosing for children. It includes a dosing tool to assist in selecting the correct dose for infants, children and adolescents less than 18 years of age, background information to support WHO paediatric weight-band dosing recommendations for ARV drugs, and a tool for researchers who may want to investigate various ARV dosages and calculate the expected drug exposure in children relative to adult targets after administration of various doses.

The dosing tool generates an advice for the preferred ARVs combinations, preferred formulation, and recommended dose based on the child’s weight, age, swallowing capability, concomitant use of TB treatment, gestational age (only for neonates), and previous medications used (only for 2nd line treatment). The dose recommendations are based on the WHO paediatric dosing annex and reflect the dosing recommendations of the Paediatric ARV Working Group (PAWG).

With the introduction of harmonized paediatric weight-band dosing for ARVs, some WHO dose recommendations deviate from the manufacturer’s package insert. The background information pages include the scientific rationale and considerations behind the WHO recommended doses in case these deviate from the manufacturer’s package insert. The pages also include information about knowledge gaps, considerations with regards to formulations, frequently occurring drug-drug interactions, and other important information with regards to dosing.

In some instances, it is useful to investigate the expected exposure in children with a single or fixed-dose combination in more detail and compare this with the expected exposures found in adults. The WHO Generic Tool App can assist you in making evidence-based decisions when exploring (new) formulations by predicting relative exposures compared to an (adult) reference.

This tool will be periodically updated to reflect new evidence and new dosing recommendations as those become available.

side.png

Paediatric ARV dosing tool

Settings
child-age-70x70-01
child-age-70x70-01

Child's
Age

child-age-70x70-01
child-age-70x70-01

Date
of Birth

Years / Months / Days
  Child's
  Weight

. kg

Rounded to 1 Decimal

Is the child able to swallow tablets?

This child is aged less than 4 weeks:
What was the gestational age at birth?
  • < 35 weeks

  • > 35 weeks / unknown

Does the child also use treatment for TB or latent TB?

Is any of the following substances being used for TB treatment?

  • coming soon

  • coming soon
Generate dosing advice for 1st or 2nd line treatment?
  • First line treatment:
    No treatment failure and no suspected treatment failure on previous antiretroviral therapy.

  • Second line treatment:
    Known treatment failure or suspected treatment failure on previous antiretroviral therapy.

Decision tree for vertical transmission risk assessment
  • Generate dose advice for
    HIV treatment or high risk prevention

  • Generate dose advice for
    low risk HIV prevention

side.png
side.png

Optimal regimen and dosing for first line treatment?

Treatment HIV less than 4weeks

Select one of the options in this table to generate a dosing advice

Preferred ARVs AZT + 3TC + NVP
Preferred Regimen AZT + 3TC + RAL
Alternative Regimen AZT + 3TC + NVP
Special Circumstances AZT + 3TC + LPVr
Provide one of these formulations as a single agent. In special circumstances with stock out of NVP and/or AZT, alternative ARVs could be used: RAL with treatment dosing, 3TC or LPVr based on evidence gathered though the PROMISE trial.
Drug Strength 0-6 week     6-12 weeks     12 weeks to 6 months 9 months to 24 months
AM PM AM PM AM PM AM PM
NVPa 50 mg score
dispersible tablets
0.5    0.5    0.5 1
NVP 10 mg/ml 1.5 mL 2 mL 3 mL 4 mL
AZT 10 mg/ml 1.5 mL 1.5 mL 6 mL 6 mL
To avoid dose changes over a short period of time and to minimize the likelihood of errors, all ARV drugs except for RAL (dose change after week 1), should be dosed based on weight when treatment starts and maintained until four weeks of age (weight gain is limited during the first four weeks of life).
This simplified dosing was developed with WHO generic tool based on known NVP prophylactic targets.
Alternative Regimen
ABC + 3TC + LPVr
TAF + 3TC + DTG
ABC + 3TC + EFV
ABC + 3TC + NVP
ABC + 3TC + RAL
AZT + 3TC + EFV
AZT + 3TC + NVP
AZT + 3TC + LPVr
AZT + 3TC + RAL
dosage.svg

Dosage:
AZT + 3TC + NVP


Please consult with specialist for the appropriate dose

Formulation:
ABC + 3TC + LPVr

ARV Preferred Formulation Amount Frequency
Abacavir (ABC) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Lamivudine (3TC) Oral liquid 10mg/mL 10 ml BID
Lopinavir (LPV)/ritonavir(RTV) Raltegravir Oral liquid 10 mg/ml 3 ml BID
ARV Alternative Formulation Amount Frequency
Abacavir (ABC) - - -
Lamivudine (3TC) - - -
Lopinavir (LPV)/ritonavir(RTV) - - -

Formulation:
TAF + 3TC + DTG

ARV Preferred Formulation Amount Frequency
Tenofovir alafenamide (TAF) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Lamivudine (3TC) Oral liquid 10mg/mL 10 ml BID
Dolutegravir (DTG) Filmcoated tablets - 50 mg 3 ml BID
ARV Alternative Formulation Amount Frequency
Tenofovir alafenamide (TAF) - - -
Lamivudine (3TC) - - -
Dolutegravir (DTG) - - -

Formulation:
TAF + FTC + DTG

ARV Preferred Formulation Amount Frequency
Tenofovir alafenamide (TAF) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Emtricitabine (FTC) Oral liquid 10mg/mL 10 ml BID
Dolutegravir (DTG) Filmcoated tablets - 50 mg 3 ml BID
ARV Alternative Formulation Amount Frequency
Tenofovir alafenamide (TAF)/td> - - -
Emtricitabine (FTC) - - -
Dolutegravir (DTG)) - - -

Formulation:
ABC + 3TC + RAL

ARV Preferred Formulation Amount Frequency
Abacavir (ABC) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Lamivudine (3TC) Oral liquid 10mg/mL 10 ml BID
Raltegravir (RAL) Raltegravir Oral liquid 10 mg/ml 3 ml BID
ARV Alternative Formulation Amount Frequency
Abacavir (ABC) - - -
Lamivudine (3TC) - - -
Raltegravir (RAL) - - -

Formulation:
ABC + 3TC + EFV

ARV Preferred Formulation Amount Frequency
Abacavir (ABC) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Lamivudine (3TC) Oral liquid 10mg/mL 10 ml BID
Efavirenz (EFV) Raltegravir Oral liquid 10 mg/ml 3 ml BID
ARV Alternative Formulation Amount Frequency
Abacavir (ABC) - - -
Lamivudine (3TC) - - -
Efavirenz (EFV) - - -

Formulation:
ABC + 3TC + NVP

ARV Preferred Formulation Amount Frequency
Abacavir (ABC) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Lamivudine (3TC) Oral liquid 10mg/mL 10 ml BID
Nevirapine (NVP) Raltegravir Oral liquid 10 mg/ml 3 ml BID
ARV Alternative Formulation Amount Frequency
Abacavir (ABC) - - -
Lamivudine (3TC) - - -
Nevirapine (NVP) - - -

Formulation:
AZT + 3TC + EFV

ARV Preferred Formulation Amount Frequency
Zidovudine (AZT) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Lamivudine (3TC) Oral liquid 10mg/mL 10 ml BID
Efavirenz (EFV) Tablet (scored) - 200 mg 3 ml BID
ARV Alternative Formulation Amount Frequency
Zidovudine (AZT) - - -
Lamivudine (3TC) - - -
Efavirenz (EFV) - - -

Formulation:
AZT + 3TC + NVP

ARV Preferred Formulation Amount Frequency
Zidovudine (AZT) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Lamivudine (3TC) Oral liquid 10mg/mL 10 ml BID
Nevirapine (NVP) Oral solution 50 mg/5 mL 50 ml BID
ARV Alternative Formulation Amount Frequency
Zidovudine (AZT) - - -
Lamivudine (3TC) - - -
Nevirapine (NVP) - - -

Formulation:
AZT + 3TC + LPVr

ARV Preferred Formulation Amount Frequency
Zidovudine (AZT) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Lamivudine (3TC) Oral liquid 10mg/mL 10 ml BID
Lopinavir (LPV)/ritonavir(RTV) - - -
ARV Alternative Formulation Amount Frequency
Zidovudine (AZT) - - -
Lamivudine (3TC) - - -
Lopinavir (LPV)/ritonavir(RTV) - - -

Formulation:
AZT + 3TC + RAL

ARV Preferred Formulation Amount Frequency
Zidovudine (AZT) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Lamivudine (3TC) Oral liquid 10mg/mL 10 ml BID
Raltegravir (RAL) Raltegravir Oral liquid 10 mg/ml 3 ml BID
ARV Alternative Formulation Amount Frequency
Zidovudine (AZT) - - -
Lamivudine (3TC) - - -
Raltegravir (RAL) - - -

side.png
side.png

Previously given ART

For children older than 4 weeks of age

side.png
ART-previous.svg

What anchor drugs were given previously?

  • LPVr
  • DTG
  • RAL
  • DRVr
  • EFV
  • NVP
  • ATVr

Multiple choices possible

ART-previous.svg

What backbone drugs were given previously?

  • ABC
  • TDF
  • FTC
  • 3TC
  • AZT
  • TAF

Multiple choices possible

side.png

Optimal regimen and dosing for second line treatment

Treatment HIV less than 4weeks

Select one of the options in this table to generate a dosing advice

ABC + 3TC + LPVr
AZT + 3TC + DTG
AZT + 3TC + ATVr
TAF + 3TC + LPVr

Formulation:
ABC + 3TC + DTG

ARV Preferred Formulation Amount Frequency
Abacavir (ABC) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Lamivudine (3TC) Oral liquid 10mg/mL 10 ml BID
Dolutegravir (DTG) Dispersible tablets (scored) - 10 mg 3 ml BID
ARV Alternative Formulation Amount Frequency
Abacavir (ABC) - - -
Lamivudine (3TC) - - -
Dolutegravir (DTG) - - -

Formulation:
ABC + 3TC + LPVr

ARV Preferred Formulation Amount Frequency
Abacavir (ABC) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Lamivudine (3TC) Oral liquid 10mg/mL 10 ml BID
Lopinavir (LPV)/ritonavir(RTV) Raltegravir Oral liquid 10 mg/ml 3 ml BID
ARV Alternative Formulation Amount Frequency
Abacavir (ABC) - - -
Lamivudine (3TC) - - -
Lopinavir (LPV)/ritonavir(RTV) - - -

Formulation:
TAF + 3TC + DTG

ARV Preferred Formulation Amount Frequency
Tenofovir alafenamide (TAF) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Lamivudine (3TC) Oral liquid 10mg/mL 10 ml BID
Dolutegravir (DTG) Filmcoated tablets - 50 mg 3 ml BID
ARV Alternative Formulation Amount Frequency
Tenofovir alafenamide (TAF) - - -
Lamivudine (3TC) - - -
Dolutegravir (DTG) - - -

Formulation:
TAF + FTC + DTG

ARV Preferred Formulation Amount Frequency
Tenofovir alafenamide (TAF) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Emtricitabine (FTC) Oral liquid 10mg/mL 10 ml BID
Dolutegravir (DTG) Filmcoated tablets - 50 mg 3 ml BID
ARV Alternative Formulation Amount Frequency
Tenofovir alafenamide (TAF)/td> - - -
Emtricitabine (FTC) - - -
Dolutegravir (DTG)) - - -

Formulation:
ABC + 3TC + RAL

ARV Preferred Formulation Amount Frequency
Abacavir (ABC) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Lamivudine (3TC) Oral liquid 10mg/mL 10 ml BID
Raltegravir (RAL) Raltegravir Oral liquid 10 mg/ml 3 ml BID
ARV Alternative Formulation Amount Frequency
Abacavir (ABC) - - -
Lamivudine (3TC) - - -
Raltegravir (RAL) - - -

Formulation:
ABC + 3TC + EFV

ARV Preferred Formulation Amount Frequency
Abacavir (ABC) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Lamivudine (3TC) Oral liquid 10mg/mL 10 ml BID
Efavirenz (EFV) Raltegravir Oral liquid 10 mg/ml 3 ml BID
ARV Alternative Formulation Amount Frequency
Abacavir (ABC) - - -
Lamivudine (3TC) - - -
Efavirenz (EFV) - - -

Formulation:
ABC + 3TC + NVP

ARV Preferred Formulation Amount Frequency
Abacavir (ABC) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Lamivudine (3TC) Oral liquid 10mg/mL 10 ml BID
Nevirapine (NVP) Raltegravir Oral liquid 10 mg/ml 3 ml BID
ARV Alternative Formulation Amount Frequency
Abacavir (ABC) - - -
Lamivudine (3TC) - - -
Nevirapine (NVP) - - -

Formulation:
AZT + 3TC + EFV

ARV Preferred Formulation Amount Frequency
Zidovudine (AZT) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Lamivudine (3TC) Oral liquid 10mg/mL 10 ml BID
Efavirenz (EFV) Tablet (scored) - 200 mg 3 ml BID
ARV Alternative Formulation Amount Frequency
Zidovudine (AZT) - - -
Lamivudine (3TC) - - -
Efavirenz (EFV) - - -

Formulation:
AZT + 3TC + NVP

ARV Preferred Formulation Amount Frequency
Zidovudine (AZT) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Nevirapine (NVP) Oral solution 50 mg/5 mL 10 ml BID
Raltegravir (RAL) Raltegravir Oral liquid 10 mg/ml 3 ml BID
ARV Alternative Formulation Amount Frequency
Zidovudine (AZT) - - -
Lamivudine (3TC) - - -
Nevirapine (NVP) - - -

Formulation:
AZT + 3TC + LPVr

ARV Preferred Formulation Amount Frequency
Zidovudine (AZT) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Lamivudine (3TC) Oral liquid 10mg/mL 10 ml BID
Lopinavir (LPV)/ritonavir(RTV) - - -
ARV Alternative Formulation Amount Frequency
Zidovudine (AZT) - - -
Lamivudine (3TC) - - -
Lopinavir (LPV)/ritonavir(RTV) - - -

Formulation:
AZT + 3TC + RAL

ARV Preferred Formulation Amount Frequency
Zidovudine (AZT) Oral granules for suspension 100mg/sachet – 10mg/ml 3 ml BID
Lamivudine (3TC) Oral liquid 10mg/mL 10 ml BID
Raltegravir (RAL) Raltegravir Oral liquid 10 mg/ml 3 ml BID
ARV Alternative Formulation Amount Frequency
Zidovudine (AZT) - - -
Lamivudine (3TC) - - -
Raltegravir (RAL) - - -

side.png
side.png

WHO Generic Dosing Tool

The WHO generic dosing tool can predict relative exposure compared to an (adult) reference. Because it utilizes the general principles of the relation between body size and age with exposure it can predict this for any drug. The background, features and technical specifications are published in The Lancet Child and Adolescent Health (Denti P, Wasmann RE, Francis J, et al. 2021).


Arrow blue
Link to Publication


Arrow blue
Download the WHO Generic Dosing Tool

 

The tool can be adapted to the specific drug under investigation. In the first tab, the user defines the reference adult exposure, which will be used as a target. The tool automatically calculates this reference value based on the body weight and daily dose administered to a reference adult patient. Additionally, the tool requires the strength of the available or planned paediatric formulation.

The tool can analyse up to 4 drugs at the same time within a single formulation, which is applicable for the majority of FDCs. In the second tab, the user defines the dosing regimen they wish to explore by choosing the number of tablets administered in each weight-band. Alternatively, in the third tab, kg-by-kg steps can be used to define customised weight-bands more granularly.

After all settings have been entered, the tool predicts exposure at steady-state relative to the values achieved for the reference adult over the same dosing interval. The tool assumes similar bioavailability between children and adults and first-order elimination, i.e., the clearance is constant within the relevant concentration range, with no significant saturable elimination processes. It uses allometric scaling to adjust for the non-linear effect of body size on clearance and its subsequent effect onto the exposure, which is used to compare children and adults. For each weight-band, the tool graphically displays the value of the expected relative exposure in the child with the smallest and largest weight.

side.png
side.png

Settings

A. Input the target dose per drug in adults

The target exposure in children is the same as an adult receiving

Drug 1 600 mg daily
Drug 2 600 mg daily
Drug 3 300 mg daily
Drug 4 300 mg daily
B. Input the reference adults weight

The reference weight for an adult is here taken to be

  • 40
  • kg
This implies that the reference adult receives:
Drug 1 15 mg/kg
Drug 2 15 mg/kg
Drug 3 7.5 mg/kg
Drug 4 7.5 mg/kg
C. Set the strength of each component in the fixed dose combination

Target Fixed Dose Combination to explore Each tablet contains:

Drug 1 80 mg
Drug 2 60 mg
Drug 3 35 mg
Drug 4 50 mg
D. Set the acceptable exposure range

The acceptable range for median exposure (WRT the refence adult) is

Drug 1 from 80% to 125%
Drug 2 from 80% to 125%
Drug 3 from 80% to 125%
Drug 4 from 80% to 125%
E. Optionally, specify a maturation function, which will be plotted on the right

(Optional/Experimental)

Include maturation of clearance? Yes

Settings Drug 1 Drug 2 Drug 3 Drug 4
AGE 50%** 1.5 4.37 1.32 -9 (months from term birth)
Gamma 4.37 3.02 2.6 1 (unitless)
Maturation
side.png

Exposure by WHO weight bands

Choose the number of tablets per weight band

WHO Weight bands
Weight-band Lower bound Upper bound
3 - 5.9 3 5.9
6 - 9.9 6 9.9
10 - 13.9 10 13.9
14 - 19.9 14 19.9
20 - 24.9 20 24.9
25 - 34.9 25 34.9
# of tablets
  
1
2
3
4
5
6

The predicted equivalent exposure of the largest and smallest child per weight band is displayed in a graph

auc graph 1

And also in table form

Total dose achieved Smallest Child Largest Child Smallest Child Exposure Largest Child Exposure Equivalent high Equivalent low
mg mg/kg mg/kg (AUC) (AUC) mg/kg mg/kg
80 26.7 13.6 0.93 0.56 13.96 8.40
160 26.7 16.2 1.11 0.76 16.60 11.40
240 24.0 17.3 1.13 0.88 16.97 13.26
320 22.9 16.1 1.17 0.90 17.58 13.51
400 20.0 16.1 1.12 0.95 16.82 14.27
480 19.2 13.8 1.14 0.89 17.07 13.29

Exposure by custom weight bands

Choose the number of tablets per weight band

WHO Weight bands (colour-coded)
Weight-band Lower bound Upper bound
3 - 3.9 3 3.9
4 - 4.9 4 4.9
5 - 5.9 5 5.9
6 - 6.9 6 6.9
7 - 7.9 7 7.9
8 - 8.9 8 8.9
9 - 9.9 9 9.9
10 - 10.9 10 10.9
11 - 11.9 11 11.9
12 - 12.9 12 12.9
13 - 13.9 13 13.9
14 - 14.9 14 14.9
15 - 15.9 15 15.9
16 - 16.9 16 16.9
17 - 17.9 17 17.9
18 - 18.9 18 18.9
# of tablets
 
1
1.5
2
2
2
2
2
3
3
3
3
4
4
4
4
4
WHO Weight bands (colour-coded)
Weight-band Lower bound Upper bound
19 - 19.9 19 19.9
20 - 20.9 20 20.9
21 - 21.9 21 21.9
22 - 22.9 22 22.9
23 - 23.9 23 23.9
24 - 24.9 24 24.9
25 - 25.9 25 25.9
26 - 26.9 26 26.9
27 - 27.9 27 27.9
28 - 28.9 28 28.9
29 - 29.9 29 29.9
30 - 30.9 30 30.9
31 - 31.9 31 31.9
32 - 32.9 32 32.9
33 - 33.9 33 33.9
34 - 34.9 34 34.9
# of tablets
  
4
5
5
5
5
5
6
6
6
6
6
6
6
6
6
6

The predicted equivalent exposure will be outputted as graphs and tables for the largest and smallest child per weight band

auc image graph
side.png

Acknowledgements

The work to develop and update the WHO Paediatric ARV dosing dashboard has been conducted in collaboration with the Paediatric Antiretroviral Working Group, Radboud university medical center, University of Cape Town, and PENTA.

Development team: Tom Jacobs, Hylke Waalewijn, Angela Colbers from the Radboud university medical centre, Nijmegen, the Netherlands with input from WHO staff Martina Penazzato and Asma Hafiz.

We also thank experts from the Paediatric Antiretroviral Working Group (PAWG) who were consulted in the drafting of the background information on each ARV and testing of the tool: Anna Turkova, Brookie Best, Diana Clarke, Elaine Abrams, Lynne Mofenson, Mark Mirochnick, Natella Rakhmanina, Pablo Rojo, Paolo Denti, Theodore Ruel, Tim Cressey, and team PATA.

The WHO Generic Dosing Tool was developed by Paolo Denti, Roeland Wasmann, Jose Francis from the University of Cape Town, Cape Town, South Africa with input from Helen McIlleron, Nandita Sugandhi, Tim Cressey, Mark Mirochnick, Edmund Capparelli, Martina Penazzato and the Paediatric Antiretroviral Working Group (PAWG)

side.png