Are Anticholinergic Symptoms a Risk Factor for Falls in Older General Practice Patients With Polypharmacy? Study Protocol for the Development and Validation of a Prognostic Model

Background: Cumulative anticholinergic exposure, also known as anticholinergic burden, is associated with a variety of adverse outcomes. However, studies show that anticholinergic effects tend to be underestimated by prescribers, and anticholinergics are the most frequently prescribed potentially inappropriate medication in older patients. The grading systems and drugs included in existing scales to quantify anticholinergic burden differ considerably and do not adequately account for patients’ susceptibility to medications. Furthermore, their ability to link anticholinergic burden with adverse outcomes such as falls is unclear. This study aims to develop a prognostic model that predicts falls in older general practice patients, to assess the performance of several anticholinergic burden scales, and to quantify the added predictive value of anticholinergic symptoms in this context.

Methods: Data from two cluster-randomized controlled trials investigating medication optimization in older general practice patients in Germany will be used. One trial (RIME, n = 1,197) will be used for the model development and the other trial (PRIMUM, n = 502) will be used to externally validate the model. A priori, candidate predictors will be selected based on a literature search, predictor availability, and clinical reasoning. Candidate predictors will include socio-demographics (e.g. age, sex), morbidity (e.g. single conditions), medication (e.g. polypharmacy, anticholinergic burden as defined by scales), and well-being (e.g. quality of life, physical function). A prognostic model including sociodemographic and lifestyle-related factors, as well as variables on morbidity, medication, health status, and well-being, will be developed, whereby the prognostic value of extending the model to include additional patient-reported symptoms will be also assessed. Logistic regression will be used for the binary outcome, which will be defined as “no falls” vs. “≥1 fall” within six months of baseline, as reported in patient interviews.

Discussion: As the ability of different anticholinergic burden scales to predict falls in older patients is unclear, this study may provide insights into their relative importance as well as into the overall contribution of anticholinergic symptoms and other patient characteristics. The results may support general practitioners in their clinical decision-making and in prescribing fewer medications with anticholinergic properties.

Recruitment and Baseline Characteristics of Participants in the AgeWell.de Study-A Pragmatic Cluster-Randomized Controlled Lifestyle Trial against Cognitive Decline

Targeting dementia prevention, first trials addressing multiple modifiable risk factors showed promising results in at-risk populations. In Germany, AgeWell.de is the first large-scale initiative investigating the effectiveness of a multi-component lifestyle intervention against cognitive decline. We aimed to investigate the recruitment process and baseline characteristics of the AgeWell.de participants to gain an understanding of the at-risk population and who engages in the intervention. General practitioners across five study sites recruited participants (aged 60–77 years, Cardiovascular Risk Factors, Aging, and Incidence of Dementia/CAIDE dementia risk score ≥ 9). Structured face-to-face interviews were conducted with eligible participants, including neuropsychological assessments. We analyzed group differences between (1) eligible vs. non-eligible participants, (2) participants vs. non-participants, and (3) between intervention groups. Of 1176 eligible participants, 146 (12.5%) dropped out before baseline; the study population was thus 1030 individuals. Non-participants did not differ from participants in key sociodemographic factors and dementia risk. Study participants were M = 69.0 (SD = 4.9) years old, and 52.1% were women. The average Montreal Cognitive Assessment/MoCA score was 24.5 (SD = 3.1), indicating a rather mildly cognitively impaired study population; however, 39.4% scored ≥ 26, thus being cognitively unimpaired. The bandwidth of cognitive states bears the interesting potential for differential trial outcome analyses. However, trial conduction is impacted by the COVID-19 pandemic, requiring adjustments to the study protocol with yet unclear methodological consequences.

Development and Pilot-Testing of Key Questions to Identify Patients' Difficulties in Medication Administration

PURPOSE

The development and testing of key questions suitable to identify patients' difficulties with medication administration.

MATERIALS AND METHODS

We used a consecutive five-step process to draft key questions regarding 43 aspects of medication administration that can be difficult for patients who manage a complex drug treatment: Step 1) Identification of potentially error-prone characteristics of drug treatment (such as certain dosage forms) and initial draft of key questions. Step 2) Assessment of how comprehensible the questions are for patients. Step 3) Pre-testing of exemplary key questions with patients and monitoring of patient's actual medication administration behavior. Step 4) Evaluation by general practitioners of how well the questions may be integrated into actual patient visits. Step 5) Final approval of the questions in an expert panel. Thereafter, we pilot-tested exemplary questions with 36 patients (43 tests). In the course of this pilot-testing, the patients' answers to the key questions were tested against both their actual behavior during medication administration and against their answers to more general questions regarding potential difficulties with medication administration.

RESULTS

More than half of the key questions (N = 24/43) were revised at least once during the development process. During the pilot-testing, 55.8% of the pilot-tests (N = 24/43) revealed medication administration difficulties. It was observed that the key questions identified significantly more difficulties (N = 17) than the general questions (N = 8; P = 0.021, positive predictive value = 94.4% vs 88.9%). In one case, both a key question and a general question identified difficulties, which, however, was not confirmed during the drug administration demonstration, indicating a false positive rate of 5.3% in both cases.

CONCLUSION

We developed key questions aimed at detecting administration errors with a high specificity and a significantly higher sensitivity than general questions, suggesting that the resource-intensive demonstration of medication administration can be reserved for the detection of rarer and uncommon administration errors.

Application of Microdosed Intravenous Omeprazole to Determine Hepatic CYP2C19 Activity

Omeprazole is an established probe drug to assess cytochrome P450 (CYP) 2C19 activity (phenotyping). Because it has nonlinear pharmacokinetics (PK) after oral administration (autoinhibition of metabolism), the true impact of coadministered perpetrators on CYP2C19 substrates might be underestimated after regular doses. We tested the dose linearity of an intravenous omeprazole microdose of 100 µg and compared it with a 20-mg dose in 4 healthy poor metabolizers (PMs) and 6 extensive metabolizers (EMs) of CYP2C19 in the presence and absence of a strong inhibitor (voriconazole). Without voriconazole, omeprazole exposure was dose-proportional irrespective of the genotype, but in PMs geometric mean ratios (GMRs) of AUC_0-∞ were 6.6-fold higher and molar metabolic ratios of 5-OH omeprazole/omeprazole approximately 10-fold lower. Voriconazole increased omeprazole exposure in EMs approximately 5-fold (AUC_0-4 GMR after 100 µg omeprazole, 4.61; 90% confidence interval [CI], 2.69-7.89; AUC_0-4 GMR after 20 mg omeprazole, 5.5; 90%CI, 1.07-1.46), whereas no clinically significant impact on PK in PMs was observed (GMR AUC_0-4 after 100 µg omeprazole, 1.29; 90%CI, 0.81-2.04; GMR AUC_0-4 after 20 mg omeprazole, 1.25; 90%CI, 1.07-1.46). Linear regression and Bland-Altman analyses revealed excellent agreement between AUC_0-∞ and AUC_0-4 of omeprazole (r² = 0.987; bias, 0.35%; 95%CI, -3.197% to 3.89%) and also the molar metabolic ratio, 5-OH omeprazole/omeprazole (r² = 0.987; bias, -3.939; 95%CI, -9.06% to -1.18%), suggesting that an abbreviated sampling protocol can be used for intravenous CYP2C19 phenotyping and drug interaction studies. In conclusion, the PK of intravenous omeprazole microdoses closely reflects the changes observed with regular omeprazole doses; however, to avoid autoinhibition of probe drugs, microdosing appears to be the favorable technique.

A nuclear factor kappa B reporter cell line used to evaluate ex vivo the net inflammatory effect of plasma samples from patients with rheumatoid arthritis, psoriasis, or COVID-19

BACKGROUND

The overall clinical outcome of inflammatory conditions is the result of the balance between pro-inflammatory and anti-inflammatory mediators. Because nuclear factor kappa B (NF-ĸB) is at the bottom of many inflammatory conditions, methods to evaluate the net effect of inflammation modulators on this master regulator have been conceptualized for years.

METHODS

Using an ex vivo NF-ĸB reporter cell line-based assay, plasma samples of patients with rheumatoid arthritis (n = 27), psoriasis (n = 15), or severe coronavirus disease-19 (COVID-19) (n = 21) were investigated for NF-ĸB activation compared to plasma samples from 9 healthy volunteers.

RESULTS

When separated by C-reactive protein (CRP) threshold levels, samples of patients exhibiting increased CRP levels (≥5 mg/l) activated NF-ĸB more efficiently than samples from patients with levels below 5 mg/l (P = 0.0001) or healthy controls (P = 0.04). Overall, there was a moderate association of CRP levels with NF-ĸB activation (Spearman r = 0.66; p < 0.0001). Plasma from COVID-19 patients activated NF-ĸB more efficiently (mean 2.4-fold compared to untreated reporter cells) than samples from any other condition (healthy controls, 1.8-fold, P = 0.0025; rheumatoid arthritis, 1.7-fold, P < 0.0001; psoriasis, 1.7-fold, P < 0.0001). In contrast, effects of rheumatoid arthritis, psoriasis, or healthy volunteer samples did not differ.

CONCLUSION

This study shows that a NF-ĸB reporter cell line can be used to evaluate the net inflammatory effect of clinical plasma samples. Patients with chronic but stable rheumatoid arthritis or psoriasis do not exhibit increased plasma levels of NF-ĸB-activating compounds as opposed to COVID-19 patients with high inflammatory burden.

Using the Causal Inference Framework to Support Individualized Drug Treatment Decisions Based on Observational Healthcare Data

When healthcare professionals have the choice between several drug treatments for their patients, they often experience considerable decision uncertainty because many decisions simply have no single “best” choice. The challenges are manifold and include that guideline recommendations focus on randomized controlled trials whose populations do not necessarily correspond to specific patients in everyday treatment. Further reasons may be insufficient evidence on outcomes, lack of direct comparison of distinct options, and the need to individually balance benefits and risks. All these situations will occur in routine care, its outcomes will be mirrored in routine data, and could thus be used to guide decisions. We propose a concept to facilitate decision-making by exploiting this wealth of information. Our working example for illustration assumes that the response to a particular (drug) treatment can substantially differ between individual patients depending on their characteristics (heterogeneous treatment effects, HTE), and that decisions will be more precise if they are based on real-world evidence of HTE considering this information. However, such methods must account for confounding by indication and effect measure modification, eg, by adequately using machine learning methods or parametric regressions to estimate individual responses to pharmacological treatments. The better a model assesses the underlying HTE, the more accurate are predicted probabilities of treatment response. After probabilities for treatment-related benefit and harm have been calculated, decision rules can be applied and patient preferences can be considered to provide individual recommendations. Emulated trials in observational data are a straightforward technique to predict the effects of such decision rules when applied in routine care. Prediction-based decision rules from routine data have the potential to efficiently supplement clinical guidelines and support healthcare professionals in creating personalized treatment plans using decision support tools.

[How complete is the Germany-wide standardised medication list ("Bundeseinheitlicher Medikationsplan")? An analysis at hospital admission.]

Einleitung  Bei stationärer Aufnahme scheint die Aktualität und Vollständigkeit des Bundeseinheitlichen Medikationsplans häufig nicht gegeben. Ebenso ist unklar, welche Charakteristiken der Pläne die Wahrscheinlichkeit für Diskrepanzen erhöhen.

Methoden  Retrospektiv wurden deshalb 100 Pläne, die zur Arzneimittelanamnese elektiver Patienten einer chirurgischen Klinik mitgebracht wurden, geprüft, ob und welche Abweichungen bestanden. Die Abweichungen wurden 7 Kategorien zugeordnet: Arzneimittel, das in der Anamnese erfasst wurde, fehlt auf dem Plan, Arzneimittel auf dem Plan wird nicht mehr eingenommen, Stärke oder Dosierung fehlt auf dem Plan bzw. ist falsch oder die Darreichungsform ist falsch dokumentiert. Hinweise zur Arzneimitteltherapiesicherheit, involvierte Arzneimittel und -formen wurden ebenfalls erfasst. Mithilfe multivariater Analysen wurde der Einfluss der Aktualität, der Anzahl der Arzneimittel und der ausstellenden Facharztdisziplin der Pläne auf die Art und Anzahl an Diskrepanzen untersucht.

Ergebnisse  Zur Arzneimittelanamnese wiesen 78 % (78/100) der Pläne Abweichungen auf. Insgesamt wurden 226 Abweichungen (2,3 ± 0,6 Abweichungen/Anamnese) dokumentiert. Am häufigsten fehlte ein Arzneimittel auf dem Plan (n = 103). Von allen Hinweisen und Empfehlungen betrafen 64 % (83/177) das perioperative Management von Antithrombotika (n = 55) und Antidiabetika (n = 28). In der multivariaten Analyse stieg nur das Risiko für fehlerhafte Angaben bei Stärke und Dosierung mit dem Alter der Pläne signifikant (p = 0,047) und war um mehr als das 2-fache erhöht, wenn der Plan älter als einen Monat war.

Diskussion  Die Aktualität, Vollständigkeit und Aspekte der Arzneimitteltherapiesicherheit des Bundeseinheitlichen Medikationsplans sollten umfassend und gezielt im Anamnesegespräch validiert werden. In der Praxis sollten Pläne, die älter als 1 Monat sind, besonders kritisch hinsichtlich Angaben zu Stärke und Dosierung geprüft und der Plan entsprechend regelmäßig aktualisiert werden.

Coping resources of heart failure patients - a comparison with cancer patients and individuals having no chronic condition results from the esther study

BACKGROUND

Heart failure (HF) and cancer patients share similarities in symptom burden and depression prevalence. Coping resources, such as optimism have been associated with improved health-related quality of life (HRQoL) and mental health.

OBJECTIVES

To investigate a wide range of resources in a large population-based sample of HF patients; to compare resources between three groups: HF patients, cancer patients, and individuals having no chronic condition.

METHODS

This cross-sectional analysis was performed among n = 2761 subjects who participated in home visits during the 11-year follow-up of the epidemiological ESTHER study. Resources were assessed by trained medical doctors through a questionnaire that lists 26 items. One-way analyses of covariance (ANCOVAs) controlled for sociodemographic variables and depression were performed to compare resources between groups.

RESULTS

Family and self-efficacy were the most frequently reported resources in all groups. HF patients reported optimism significantly less frequently as a resource in comparison to cancer patients (p=.031). HF patients showed significantly lower levels of resource factor 3 (positive attitude), compared to cancer patients (p=.006), and not chronically ill participants (p=.037).

CONCLUSIONS

Family and self-efficacy seem to be the most important resources, regardless of diagnosis. HF patients appear to have significantly lower levels of resources concerning positive attitude, compared to cancer patients, and not chronically ill individuals. We suggest the development of psychosocial interventions to enhance optimism in HF.

Development and Validation of an LC-MS-Based Quantification Assay for New Therapeutic Antibodies: Application to a Novel Therapy against Herpes Simplex Virus

Multiple therapeutic monoclonal antibodies (mAbs) are currently under development or in (pre)clinical study phases to reach regulatory approval. Among these, a new mAb against herpes simplex virus, HDIT101, was recently tested in healthy volunteers during a phase I clinical trial (first-in-human, dose escalation). In the frame of the pharmacokinetic evaluation of this new therapy, a mass spectrometric (MS)-based method was developed for the quantification of HDIT101 in human plasma using liquid chromatography coupled to tandem mass spectrometry. In this work, we describe the development of this bioanalytical assay using the quantification of a HDIT101 surrogate peptide, the assay validation procedure according to the FDA guidelines within the calibration range from 20 to 5000 μg/mL, and its application to plasma samples from the first-in-human clinical trial. This work presents a generic workflow for the development of MS-based quantification assays of new therapeutic antibodies that allows reaching high immunopurification recovery (>98% for HDIT101 over the full calibration range with a precision of 6.9% CV). Surrogate peptide and stable isotopically labeled internal standard were stable, and batch-to-batch accuracies and precisions at the four quality standard levels ranged between -2 and 5% bias and 8 and 11% CV, respectively.

Approaching sites of action of drugs in clinical pharmacology: New analytical options and their challenges

Clinical pharmacology is an important discipline for drug development aiming to define pharmacokinetics (PK), pharmacodynamics (PD) and optimum exposure to drugs, i.e. the concentration-response relationship and its modulators. For this purpose, information on drug concentrations at the anatomical, cellular and molecular sites of action is particularly valuable. In pharmacological assays, the limited accessibility of target cells in readily available samples (i.e. blood) often hampers mass spectrometry-based monitoring of the absolute quantity of a compound and the determination of its molecular action at the cellular level. Recently, new sample collection methods have been developed for the specific capture of rare circulating cells, especially for the diagnosis of circulating tumour cells. In parallel, new advances and developments in mass spectrometric instrumentation now allow analyses to be scaled down to the cellular level. Together, these developments may permit the monitoring of minute drug quantities and show their effect at the cellular level. In turn, such PK/PD associations on a cellular level would not only enrich our pharmacological knowledge of a given compound but also expand the basis for PK/PD simulations. In this review, we describe novel concepts supporting clinical pharmacology at the anatomical, cellular and molecular sites of action, and highlight the new challenges in mass spectrometry-based monitoring. Moreover, we present methods to tackle these challenges and define future needs.

Decreasing Use of Chemotherapy in Older Patients With Stage III Colon Cancer Irrespective of Comorbidities

BACKGROUND

Chemotherapy underuse in elderly patients (aged ≥75 years) with colon cancer has been reported in previous studies. However, these studies were mostly registry-based and limited in their potential to consider underlying reasons of such undertreatment. This study aimed to evaluate patient and hospital determinants of chemotherapeutic treatment in patients with stage III colon cancer, with a particular focus on age and underlying reasons for nontreatment of elderly patients.

METHODS

A total of 629 patients with stage III colon cancer who were diagnosed in 2003 through 2012 and recruited into a population-based study in the Rhine-Neckar region of Germany were included. Information on sociodemographic and lifestyle factors, comorbidities, and treatment was collected from patient interviews and physicians. Patient (with an emphasis on age) and hospital factors were evaluated for their associations with administration of adjuvant chemotherapy overall and of oxaliplatin specifically using multivariable logistic regression.

RESULTS

Administration of chemotherapy decreased from 94% in patients aged 30 to 64 years to 51% in those aged ≥75 years. A very strong decline in chemotherapy use with age persisted even after comprehensive adjustment for multiple patient factors-including comorbidities-and hospital factors and was also seen among patients without any major comorbidities. Between 2005 and 2008, and 2009 and 2012, chemotherapy administration in patients aged ≥75 years decreased from 60% to 41%. Among chemotherapy recipients, old age was also strongly associated with higher odds of nonadministration of oxaliplatin. The 2 most commonly reported reasons for chemotherapy nonreceipt among the study population were patient refusal (30%) and old age (24%).

CONCLUSIONS

Age was the strongest predictor of chemotherapy underuse, irrespective of comorbidities and even in patients without comorbidities. Such underuse due just to older age in otherwise healthy patients deserves increased attention in clinical practice to ensure that elderly patients also get the best possible care. Patients' refusal as the most frequent reason for chemotherapy nonreceipt also warrants further investigation to exclude misinformation as underlying cause.

Application of a microdosed cocktail of 3 oral factor Xa inhibitors to study drug-drug interactions with different perpetrator drugs

AIMS

Using 3 different perpetrators the impact of voriconazole, cobicistat and rifampicin (single dose), we evaluated the suitability of a microdose cocktail of factor Xa inhibitors (FXaI; rivaroxaban, apixaban and edoxaban; 100 μg in total) to study drug-drug interactions.

METHODS

Three cohorts of 6 healthy volunteers received 2 treatments with microdoses of rivaroxaban, apixaban and edoxaban alone and with coadministration of 1 of the perpetrators. Plasma and urine concentrations of microdosed apixaban, edoxaban and rivaroxaban were quantified using a validated ultra-performance liquid chromatography-tandem mass spectrometry with a lower limit of quantification of 2.5 pg/mL.

RESULTS

Voriconazole caused only a minor interaction with apixaban and rivaroxaban, none with edoxaban. Cobicistat significantly increased exposure of all 3 FXaI with area under the plasma concentration-time curve ratios of 1.67 (apixaban), 1.74 (edoxaban) and 2.0 (rivaroxaban). A single dose of rifampicin decreased the volume of distribution and elimination half-life of all 3 FXaI.

CONCLUSIONS

The microdosed FXaI cocktail approach is able to generate drug interaction data and can help elucidating the mechanism involved in the clearance of the different victim drugs. This is a safe approach to concurrently study drug-drug interactions with a drug class. (EudraCT 2016-003024-23).

Abstract A25: Evaluation of Drug Disposition in Supratentorial Ependymoma

Introduction: The majority of pediatric supratentorial (ST) ependymomas (EPN) is driven by distinct gene fusions between C11orf95 and RELA. The resultant molecular group of ST-EPN-RELA tumors is characterized by constitutive activation of NF-κB signaling and deregulation of the p53 pathway. In contrast to surgery and radiotherapy, chemotherapy has failed to demonstrate significant benefit in the management of affected children. Alternative strategies including enhanced drug delivery, combination treatments, or application of new selective compounds are needed to tackle this disease.

Material and Methods: RNAi and drug screening methods were applied to identify potential therapeutic approaches using ST-EPN-RELA cell lines. In order to identify optimal dosing strategies of selected drugs and to assess effects of combinatorial treatment approaches on blood-brain barrier (BBB) penetration, cerebral microdialysis combined with ultraperformance liquid chromatography and tandem mass spectrometry (UPLC-MS/MS) was applied. This approach allowed for exact, continuous, and time-dependent drug quantification in tumors or healthy tissue in freely moving experimental mice. Patient-derived xenograft models of ST-EPN-RELA were treated to investigate toxicity and outcome parameters.

Results: Regulation of p53 signaling and nuclear protein shuttling were identified as promising therapeutic approaches. While low-dose dactinomycin could successfully reestablish p53 function in ST-EPN-RELA cells in vitro, penetration of the drug across the BBB was found to be very poor and did not result in a survival benefit of tumor-bearing mice. Preliminary results of alternative strategies such as combination with efflux pump inhibitors, liposomal packaging, and inhibition of XPO1 being the sole nuclear exporter of p53 hold promise to overcome these constraints.

Conclusion: Oncogenic dependencies of ST-EPN-RELA are currently difficult to target. Preclinical evaluation of effective drug disposition combined with long-term treatment studies may help to better select promising compounds and thereby increase success rates of early clinical trials in patients with ST-EPN-RELA in the future.

Citation Format: Julia Benzel, Max Sauter, Norman Mack, Abigail Davis, Johanna Weiss, Philipp Uhl, Jürgen Burhenne, Kendra K. Maass, Jens-Martin Hübner, Hendrik Witt, Anang Shelat, Amar Gajjar, Santhosh A. Upadhyaya, Aylin Camgoz, Frank Buchholz, Sina Oppermann, Marcel Kool, Daisuke Kawauchi, Olaf Witt, Walter E. Haefeli, Stefan M. Pfister, Clinton Stewart, Kristian W. Pajtler. Evaluation of Drug Disposition in Supratentorial Ependymoma [abstract]. In: Proceedings of the AACR Special Conference on the Advances in Pediatric Cancer Research; 2019 Sep 17-20; Montreal, QC, Canada. Philadelphia (PA): AACR; Cancer Res 2020;80(14 Suppl):Abstract nr A25.

Development of an algorithm to detect and reduce complexity of drug treatment and its technical realisation

Background

The increasing complexity of current drug therapies jeopardizes patient adherence. While individual needs to simplify a medication regimen vary from patient to patient, a straightforward approach to integrate the patients’ perspective into decision making for complexity reduction is still lacking. We therefore aimed to develop an electronic, algorithm-based tool that analyses complexity of drug treatment and supports the assessment and consideration of patient preferences and needs regarding the reduction of complexity of drug treatment.

Methods

Complexity factors were selected based on literature and expert rating and specified for integration in the automated assessment. Subsequently, distinct key questions were phrased and allocated to each complexity factor to guide conversation with the patient and personalize the results of the automated assessment. Furthermore, each complexity factor was complemented with a potential optimisation measure to facilitate drug treatment (e.g. a patient leaflet). Complexity factors, key questions, and optimisation strategies were technically realized as tablet computer-based application, tested, and adapted iteratively until no further technical or content-related errors occurred.

Results

In total, 61 complexity factors referring to the dosage form, the dosage scheme, additional instructions, the patient, the product, and the process were considered relevant for inclusion in the tool; 38 of them allowed for automated detection. In total, 52 complexity factors were complemented with at least one key question for preference assessment and at least one optimisation measure. These measures included 29 recommendations for action for the health care provider (e.g. to suggest a dosage aid), 27 training videos, 44 patient leaflets, and 5 algorithms to select and suggest alternative drugs.

Conclusions

Both the set-up of an algorithm and its technical realisation as computer-based app was successful. The electronic tool covers a wide range of different factors that potentially increase the complexity of drug treatment. For the majority of factors, simple key questions could be phrased to include the patients’ perspective, and, even more important, for each complexity factor, specific measures to mitigate or reduce complexity could be defined.

Impact of pantoprazole on absorption and disposition of hydroxychloroquine, a drug used in Corona Virus Disease-19 (Covid-19): A structured summary of a study protocol for a randomised controlled trial

OBJECTIVES

Primary objective: Evaluation of the effect of the proton pump inhibitor (PPI) pantoprazole on the absorption of hydroxychloroquine (HCQ). Secondary objectives: • Evaluation of the relationship between HCQ concentrations in whole blood, plasma and intracellular concentrations in target cells - peripheral blood mononuclear cells (PBMCs). • Evaluation of HCQ as a potential perpetrator in drug-drug interactions at the level of cytochrome P450 (CYP) 3A4 and CYP2D6 (major drug metabolizing enzymes).

TRIAL DESIGN

Single centre, open-label, parallel group, two-arm, phase I drug-drug interaction trial.

PARTICIPANTS

Healthy volunteers (18-60 years old) are treated in the Clinical Pharmacological Trial Center of Heidelberg University Hospital, Germany.

INTERVENTION AND COMPARATOR

• Participants are randomized in a group to either receive a nine-day course of pantoprazole, or to a control group without pantoprazole. All participants receive a single dose of HCQ 400 mg. • Additionally, CYP3A4 and CYP2D6 phenotyping with microdosed probe drugs is performed using midazolam and yohimbine as enzyme activity markers, respectively.

MAIN OUTCOMES

Primary endpoint: Area under the curve (AUC)_{0-72 h} and maximum concentration (C_max) of a single oral dose of 400 mg HCQ with and without pantoprazole (changes in these two values describe relevant aspects of exposure to HCQ with and without administration of pantoprazole). Secondary endpoints: • AUC_{2-4 h}, AUC_{0-6 h} and C_max of midazolam and yohimbine. • Correlation of HCQ concentrations in whole blood with concentrations in plasma and peripheral blood mononuclear cells (PBMC).

RANDOMISATION

Participants are assigned to treatment groups by using a randomisation list (1:1, block size = 4) and consecutive enrolment.

BLINDING (MASKING)

The trial is an open-label trial, participants and investigators are not blinded.

NUMBERS TO BE RANDOMISED (SAMPLE SIZE)

A total number of 24 participants (12 per group) are planned to be randomised.

TRIAL STATUS

Protocol version 2.1 dated 24/04/2020, first patient first visit. April 30th, 2020, recruitment ongoing, anticipated end of study June 30th, 2020.

TRIAL REGISTRATION

EudraCT Number: 2020-001470-30 , registered on 31 March 2020 German Clinical trials register number / International Clinical Trials Registry Platform: DRKS00021573, registered on 27 April 2020 FULL PROTOCOL: The full trial protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full trial protocol. The trial protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2).

A proof of concept phase I/II pilot trial of LSD1 inhibition by tranylcypromine combined with ATRA in refractory/relapsed AML patients not eligible for intensive therapy

All-trans-retinoic acid (ATRA) is highly active in acute promyelocytic leukemia but not in other types of acute myeloid leukemia (AML). Previously, we showed that ATRA in combination with Lysine-specific demethylase 1 (LSD1) inhibition by tranylcypromine (TCP) can induce myeloid differentiation in AML blasts. This phase I/II clinical trial investigated the safety and efficacy of TCP/ATRA treatment as salvage therapy for relapsed/refractory (r/r) AML. The combination was evaluated in 18 patients, ineligible for intensive treatment. The overall response rate was 20%, including two complete remissions without hematological recovery and one partial response. We also observed myeloid differentiation upon TCP/ATRA treatment in patients who did not reach clinical remission. Median overall survival (OS) was 3.3 months, and one-year OS 22%. One patient developed an ATRA-induced differentiation syndrome. The most frequently reported adverse events were vertigo and hypotension. TCP plasma levels correlated with intracellular TCP concentration. Increased H3K4me1 and H3k4me2 levels were observed in AML blasts and white blood cells from some TCP/ATRA treated patients. Combined TCP/ATRA treatment can induce differentiation of AML blasts and lead to clinical response in heavily pretreated patients with r/r AML with acceptable toxicity. These findings emphasize the potential of LSD1 inhibition combined with ATRA for AML treatment.

A framework to build similarity-based cohorts for personalized treatment advice - a standardized, but flexible workflow with the R package SimBaCo

Along with increasing amounts of big data sources and increasing computer performance, real-world evidence from such sources likewise gains in importance. While this mostly applies to population averaged results from analyses based on the all available data, it is also possible to conduct so-called personalized analyses based on a data subset whose observations resemble a particular patient for whom a decision is to be made. Claims data from statutory health insurance companies could provide necessary information for such personalized analyses. To derive treatment recommendations from them for a particular patient in everyday care, an automated, reproducible and efficiently programmed workflow would be required. We introduce the R-package SimBaCo (Similarity-Based Cohort generation) offering a simple, but modular, and intuitive framework for this task. With the six built-in R-functions, this framework allows the user to create similarity cohorts tailored to the characteristics of particular patients. An exemplary workflow illustrates the distinct steps beginning with an initial cohort selection according to inclusion and exclusion criteria. A plotting function facilitates investigating a particular patient’s characteristics relative to their distribution in a reference cohort, for example the initial cohort or the precision cohort after the data has been trimmed in accordance with chosen variables for similarity finding. Such precision cohorts allow any form of personalized analysis, for example personalized analyses of comparative effectiveness or customized prediction models developed from precision cohorts. In our exemplary workflow, we provide such a treatment comparison whereupon a treatment decision for a particular patient could be made. This is only one field of application where personalized results can directly support the process of clinical reasoning by leveraging information from individual patient data. With this modular package at hand, personalized studies can efficiently weight benefits and risks of treatment options of particular patients.

Individual factors increasing complexity of drug treatment-a narrative review

Purpose

Complexity of drug treatment is known to be a risk factor for administration errors and nonadherence promoting higher healthcare costs, hospital admissions and increased mortality. Number of drugs and dose frequency are parameters often used to assess complexity related to the medication regimen. However, factors resulting from complex processes of care or arising from patient characteristics are only sporadically analyzed. Hence, the objective of this review is to give a comprehensive overview of relevant, patient-centered factors influencing complexity of drug treatment.

Methods

A purposeful literature search was performed in MEDLINE to identify potential complexity factors relating to the prescribed drug (i.e. dosage forms or other product characteristics), the specific medication regimen (i.e. dosage schemes or additional instructions), specific patient characteristics and process characteristics. Factors were included if they were associated to administration errors, nonadherence and related adverse drug events detected in community dwelling adult patients.

Results

Ninety-one influencing factors were identified: fourteen in “dosage forms”, five in “product characteristics”, twelve in “dosage schemes”, nine in “additional instructions”, thirty-one in “patient characteristics” and twenty in “process characteristics”.

Conclusions

Although the findings are limited by the non-systematic search process and the heterogeneous results, the search shows the influence of many factors on the complexity of drug treatment. However, to evaluate their relevance for individual patients, prospective studies are necessary.

Electronic supplementary material

The online version of this article (10.1007/s00228-019-02818-7) contains supplementary material, which is available to authorized users.

Rapid drug detection in whole blood droplets using a desorption electrospray ionization static profiling approach - a proof-of-concept

RATIONALE

The introduction of desorption electrospray ionization (DESI) - and ambient desorption/ionization (ADI) ion sources in general - in the 2000s has opened new possibilities for mass spectrometric (MS) analyses of biological sample surfaces. DESI allows for a rapid screening of solid samples because no sample preparation is needed and the analysis is performed at atmospheric pressure. In the present study, we used DESI as an ion source for the rapid detection of a small molecule in blood droplets deposited on glass slides.

METHODS

Blood was spiked with different concentrations of a model drug, mebendazole. One microliter blood droplets of each preparation were deposited on the surface of a glass slide and analyzed by DESI, either in imaging or profiling mode.

RESULTS

The results suggested that DESI imaging mode was not appropriate for the detection of mebendazole in blood droplets as an initial solvation time was necessary before the obtention of signal. A profiling approach consisting of analyzing a single position of the blood droplet was used for further analysis and allowed mebendazole to be detected in the fg range and to monitor the volume of sample analyzed.

CONCLUSIONS

The study suggests that profiling mode at a single position is adequate for DESI analyses in whole blood droplets. This proof-of-concept study illustrates the potential of DESI profiling as a possible alternative to liquid chromatography/MS analyses of whole blood, when analyses are needed within a restricted time. Rapid detection methods in blood at atmospheric pressure may find interesting applications in the fields of toxicology and pharmacology.

New Insights Into the Pharmacokinetics of Vancomycin After Oral and Intravenous Administration: An Investigation in Beagle Dogs

Intestinal absorption of orally administered peptides is often negligible because one or more key requirements for successful absorption (water solubility, peptic resistance, mucosal permeation) are not met. Due to its high water solubility and stability in the gastro-intestinal tract, vancomycin is an ideal model peptide for evaluating the factors influencing the critical step of mucosal permeation. Therefore, to support formulation development for the systemic oral delivery of peptide therapeutics, we investigated the pharmacokinetics of vancomycin in beagle dogs after intravenous and oral administration comparing enteric encapsulated drug to the drug in solution, which revealed mean absolute bioavailabilities of 0.27% and 1.66%, respectively. Additionally, in depth pharmacokinetic analyses of intravenously administered vancomycin revealed a deep compartment slowly releasing the compound over many hours into the blood.

Drug-Drug Interactions with Direct Oral Anticoagulants

A large body of evidence suggests that not only direct anticoagulant effects but also major bleeding events and stroke prevention depend on plasma concentrations of direct oral anticoagulants (DOACs). Concomitant drugs that cause drug–drug interactions (DDIs) alter DOAC exposure by increasing or decreasing DOAC bioavailability and/or clearance; hence, they might affect the efficacy and safety of DOAC therapy. Patients with renal impairment already receive smaller DOAC maintenance doses because avoidance of elevated DOAC exposure might prevent serious bleeding events. For other causes of increased exposure such as DDIs, management is often less well-defined. Considering that DOAC patients are often older and have multiple co-morbidities, polypharmacy is highly prevalent. However, the effect of multiple drugs on DOAC exposure, and especially the impact of DDIs when concurring with drug–disease interactions as observed in renal impairment, has not been thoroughly elucidated. In order to provide effective and safe anticoagulation with DOACs, understanding the mechanisms and magnitude of DDIs appears relevant. Instead of avoiding drug combinations with DOACs, more DDI trials should be conducted and new strategies such as dose adjustments based on therapeutic drug monitoring should be investigated. However, dose adjustments based on concentration measurements cannot currently be recommended because evidence-based data are missing.

Rapid and Sensitive Drug Quantification in Tissue Sections Using Matrix Assisted Laser Desorption Ionization-Ion Mobility-Mass Spectrometry Profiling

Ion mobility spectrometry (IMS) represents a considerable asset for analytics of complex samples as it allows for rapid mass spectrometric separation of compounds. IMS is even more useful for the separation of isobaric compounds when classical separation methods such as liquid chromatography or electrophoresis cannot be used, e.g., during matrix-assisted laser desorption/ionization (MALDI) analyses of biological surfaces. In the present study, we proved the usefulness of IMS for pharmacological applications of MALDI analyses on tissue sections. To illustrate our proof-of-concept, we used the anthelmintic drug mebendazole (MBZ) as a model. Using this exemplary drug, we demonstrated the possibility of using ion mobility to discriminate a drug in tissues from the biological background that masked its signal at low concentrations. In this proof-of-concept, the IMS mode together with the use of a profiling approach for sample preparation enabled quantification of the model drug MBZ from tissue sections in the concentration range 5 to 5,000 ng/g and with a limit of detection of 1 ng/g of tissue, within 2 h. This study highlights the importance of IMS as a separation method for on-surface quantification of drugs in tissue sections.