Hemodialysis pathway types influence wound healing complications and survival in end-stage renal disease patients in a retrospective cohort study

This study evaluates the impact of different hemodialysis access types-central venous catheter (CVC), arteriovenous graft (AVG), and autologous arteriovenous fistula (AVF)-on wound healing, complication rates, and long-term survival in patients with end-stage renal disease (ESRD). A retrospective analysis of 323 ESRD patients receiving hemodialysis over a ten-year period revealed significant differences in outcomes across the three groups. AVF patients experienced the shortest wound healing times and the highest dialysis efficacy, while the CVC group had the highest infection and reoperation rates. Although there were no significant differences in cardiac function or cause-specific mortality, AVF patients had the longest median survival time, followed by those in the CVC and AVG groups. These findings suggest that while AVF provides superior dialysis efficiency and survival outcomes with fewer complications, patient suitability and individual health conditions must be carefully considered when selecting the appropriate vascular access for hemodialysis.

A novel scheme for non-invasive drug delivery with a magnetically controlled drug delivering capsule endoscope

There is a lack of effective means for precise drug delivery of gastrointestinal diseases. Herein we report a novel magnetically controlled drug delivering capsule endoscope (MDCE) to achieve precision drug delivery for gastrointestinal diseases. MDCE integrates a drug delivery system into conventional capsule endoscope. It can carry 0.5 ml of liquid medication, which can be sprayed onto the target area using an electric pump upon detecting lesions by convolutional neural network (CNN)-model. Additionally, with the aid of an external magnet, the operator can adjust the posture and drug delivery direction of the capsule endoscope to enhance the accuracy of drug release. This adjustment process is monitored in real-time through the camera at the front of the capsule endoscope. To validate the clinical efficacy of the MDCE, we established porcine intestinal epithelial injury and bleeding models, and we demonstrated that MDCE could accurately deliver drugs under magnetic control through direct visualization. MDCE could significantly reduce injury area by delivering organoids to porcine injury sites after 7 days compared to the control group (48 mm2vs. 21 mm2, p = 0.018). MDCE could significantly reduce bleeding time by spraying norepinephrine to porcine intestinal bleeding site compared to the control group (731 s vs. 418 s, p = 0.007). These demonstrate that MDCE could actively accurately release drugs under magnetic control through direct visualization in a non-invasive manner. This opens a new chapter for the precision treatment of gastrointestinal diseases and provides a novel approach for oral drug administration for systemic diseases.

Toxicological Response of the BEAS-2B Cell After Acute Exposure at the Air-Liquid Interface to Ethylbenzene and m-Xylene Alone and in Binary Mixtures

Benzene, toluene, ethylbenzene, and xylenes (o-, m-, and p-xylenes) constitute a family, named BTEX, of volatile organic compounds (VOCs) known for its toxicity. This study aimed to study the acute in vitro toxicity of ethylbenzene and m-xylene on human bronchial epithelial cells exposed at the air-liquid interface (ALI). The cells were exposed to VOCs alone and in a mixture for 1 h, followed by 5, 23, and 47 h of incubation. The kinetics of the cell response was characterized, including cytotoxicity, xenobiotic biotransformation, antioxidant defense system, inflammatory response, and apoptosis. The gene expression results showed major differences between these two compounds, even though their chemical structure is very similar. Ethylbenzene did not appear to be metabolized in BEAS-2B cells, as it inhibited gene expression of xenobiotic metabolizing enzymes (XME) and did not induce antioxidant defense systems or apoptosis. However, a slight inflammatory response was observed after exposure. m-Xylene was metabolized in BEAS-2B cells, inducing several XMEs and upregulating enzymes involved in the antioxidant defense system, as well as markers of inflammation and apoptosis. Co-exposure to the binary mixture resulted in an inhibition phenomenon, resulting in the inhibition of toxic action mechanisms studied. The results provide new information on the toxicity of ethylbenzene and m-xylene and highlight the importance of conducting ALI exposures to mixtures of toxicants.

Proximal tubular deletion of superoxide dismutase-2 reveals disparate effects on kidney function in diabetes

There is a large body of evidence implicating mitochondrial reactive oxygen species (ROS) overproduction and oxidative stress in the development of diabetic kidney disease and the deficiency of mitochondrial antioxidant systems in the kidney, such as manganese superoxide dismutase (MnSOD/SOD2) have been identified. The proximal tubules of the kidney are densely packed with mitochondria thereby providing energy via oxidative phosphorylation in order to drive active transport for proximal tubular reabsorption of solutes from the glomerular filtrate. We hypothesized that maintenance of MnSOD function in the proximal tubules would be critical to maintain kidney health in diabetes. Here, we induced targeted deletion of SOD2 in the proximal tubules of the kidney in Ins2Akita diabetic mice (SODptKO mice) and show that 20 weeks of SOD2 deletion leads to no major impairment of kidney function and structure, despite these mice displaying enhanced albuminuria and kidney lipid peroxidation (8-isoprostanes). Plasma cystatin C, which is a surrogate marker of glomerular filtration was not altered in SODptKO diabetic mice and histological assessment of the kidney cortex revealed no change in kidney fibrosis. Thus, our findings suggest that deletion of SOD2 in the proximal tubular compartment of the kidney induces a more subtle phenotype than expected, shedding light on the involvement of SOD2 and the proximal tubular compartment in the pathogenesis of diabetic kidney disease.

Exploring the comprehensive factors influencing tacrolimus pharmacokinetics in early renal transplant recipients: A population pharmacokinetic analysis

PURPOSE

To establish a population pharmacokinetic (PopPK) model of tacrolimus in the early stages after renal transplantation and evaluate the model's predictive performance with external data.

METHODS

Intravenous and oral tacrolimus were administered to 302 renal transplant recipients in the early posttransplantation stages. Related data were obtained from the electronic medical records. Single nucleotide polymorphisms in genes associated with tacrolimus pharmacokinetics were tested. The data were analyzed by NONMEM. The external data from 153 patients were subsequently used to evaluate model extrapolation.

RESULTS

A one-compartment model was used to determine tacrolimus pharmacokinetics. The estimated clearance (CL), volume of distribution (V) and bioavailability (F) of tacrolimus were 4.91 L/h, 77 L and 26.5%, respectively. CL and V decreased with increasing hematocrit. CL and F decreased with increasing operation time. Diltiazem and Wuzhi capsule resulted in 28.4% and 43.9% decreases in the CL, respectively. Omeprazole or esomeprazole resulted in a 9% increase in F. The value of F for patients expressing CYP3A5 was 36.6% lower than that for the patients who did not express CYP3A5. The evaluation of external data revealed that the proportion of individual prediction error within 20% of the observed tacrolimus concentration was greater than 77.3%.

CONCLUSIONS

A PopPK model for tacrolimus was established for early renal transplantation. CYP3A5 was a significant covariate for F. Fat-free mass was the best predictor of the influence of body size on CL and V. The model could be extrapolated to stable renal transplant recipients.

Orally Administered Functional Polyphenol-Nanozyme-Armored Probiotics for Enhanced Amelioration of Intestinal Inflammation and Microbiota Dysbiosis

Maintaining microbiota balance and enhancing the antioxidant performance of nanozyme-based probiotic systems are crucial for effective inflammatory bowel disease (IBD) therapy. Despite significant advancements, developing a green and safe coating technology that functionalizes probiotics with nanozymes while preserving the activity of both components remains a challenge. To address this, chitosan-modified epigallocatechin gallate (EGCG-CS, EC)is synthesized, leveraging the intrinsic adhesive and coordination properties of polyphenols to capture gold nanozymes (AuNPs), forming ECA complexes that enhance nanozyme activity. When coated onto Escherichia coli Nissle 1917 (EcN), the resulting ECA@EcN system effectively scavenged reactive oxygen species (ROS), improving probiotic viability and promoting colon accumulation. Mechanistically, ECA protected EcN by suppressing the activation of the Flagellar Assembly and Branched-Chain Amino Acid Synthesis pathways, ultimately alleviating inflammation and modulating intestinal microbial communities to relieve IBD symptoms. Given the biocompatibility of its components and the environmentally friendly assembly approach, this polyphenol-nanozyme-armored probiotic system represents a promising platform for IBD treatment.

Machine Learning for Prediction of Drug Concentrations: Application and Challenges

With the advancements in algorithms and increased accessibility of multi-source data, machine learning in pharmacokinetics is gaining interest. This review summarizes studies on machine learning-based pharmacokinetics analysis up to September 2024, identified from the PubMed and IEEE Xplore databases. The main focus of this review is on the use of machine learning in predicting drug concentration. This review provides a comprehensive summary of the advances in the machine learning algorithms for pharmacokinetics analysis. Specifically, we describe the common practices in data preprocessing, the application scenarios of various algorithms, and the critical challenges that require attention. Most machine learning models show comparable performance to those of population pharmacokinetics models. Tree-based algorithms and neural networks have the most applications. Furthermore, the use of ensemble modeling techniques can improve the accuracy of these models' predictions of drug concentrations, especially the ensembles of machine learning and pharmacometrics.

Study of factors affecting cellulose derivatives composite in anticancer drug delivery: A comprehensive review

The targeted distribution of therapeutic molecules in cancer cells poses several challenges for biomedical applications. Drug delivery systems (DDS) are primarily designed to target cancer cells effectively to achieve maximum therapeutic effects. Cellulose is a well-known organic molecule owing to its biodegradability, biocompatibility, low toxicity, prolonged stability, and superior loading characteristics. However, cellulose composites have faced numerous drawbacks, such as higher molecular size, non-covalent interactions, poor mechanical strength, and limited water solubility. In contrast, cellulose derivatization has enhanced drug loading and release efficiency, improved mechanical strength, and mitigated drug solubility issues. This review summarized the recent advancement in cellulose-based composites such as DDS for cancer cell treatment and discussed responsive factors. The pH, temperature, magnetic nanoparticles, solubility, porosity, mechanical strength, nanoparticle size, increased time of drug release, crosslinking efficiency, etc., are major responsive assays that influence the therapeutic potential of anticancer drugs. Furthermore, overviewed the cellulose nanoformulations in sustained anticancer drug release and successfully illustrated the synthesizing methodologies as well as challenges in efficient DDS applications. Moreover, a brief overview of the interdisciplinary industrial uses of cellulose composites, including paper, textiles, and nanotechnology, is presented. Finally, cellulose-based composites provide a novel way of producing excellent DDS with enhanced therapeutic properties.

Letter to the FDA Proposing Major Changes in the US Clozapine Package Insert Supported by Clozapine Experts Worldwide. Part I: A Review of the Pharmacokinetic Literature and Proposed Changes

PURPOSE/BACKGROUND

Clozapine was approved in the United States (US) using 1989 regulations and knowledge. After 30 years, many sections of the US package insert (PI) are outdated.

METHODS

We comprehensively reviewed the literature to propose PI updates. We present the information in 2 articles. In Part I, we focus on basic pharmacology based on 407 relevant articles. Part II focuses on clinical aspects and pharmacovigilance.

FINDINGS/RESULTS

Based on more recent expectations of Food and Drug Administration regulations, we reviewed clozapine basic pharmacology including the following: 1) clearance, 2) pharmacokinetics and pharmacodynamics, and 3) monitoring tools. We identified 9 major problems in the basic pharmacological sections of the PI including the following: 1) in vivo studies indicate that clozapine is dependent on CYP1A2 for its metabolism, 2) the minor role of CYP2D6 in clozapine metabolism requires removing the PI recommendation to lower clozapine doses in CYP2D6 poor metabolizers, 3) in nontoxic concentrations CYP3A4 has a minor role in clozapine metabolism and potent CYP3A4 inhibitors lack clinically relevant effects, 4) several drug-drug interactions need to be updated based on recent literature, 5) systemic inflammation may decrease clozapine metabolism and increase the risk of clozapine intoxication, 6) obesity may decrease clozapine metabolism, 7) patients of Asian and Indigenous American ancestry need lower clozapine doses, 8) personalized titration and c-reactive protein monitoring should be considered until prospective studies are available, and 9) the half-life section needs to be modified to acknowledge that single dosing at night is frequent in the US.

IMPLICATIONS/CONCLUSIONS

An improvement in the US clozapine PI may lead to improvement in PIs worldwide.

The Impact of a Prolonged Multivitamin Shortage on Home Parenteral Nutrition Patients: A Single-Center Retrospective Cohort Study with Case Reports of Wernicke's Encephalopathy

Background/Objectives: Shortages in parenteral nutrition (PN) micronutrient components can lead to deficiencies in patients heavily relying on home PN (HPN) to meet nutritional requirements. Despite monitoring, this can cause severe and even life-threatening conditions if intravenous (IV) micronutrients are not available for a prolonged period. Methods: We conducted a retrospective study to evaluate the effect of an IV multivitamin shortage that occurred between December 2022 and July 2023. The study included patients at high risk for multivitamin deficiencies who received HPN for at least 5 days. Patients were classified into two groups: those compliant with instructions to take additional oral multivitamin supplements to compensate for the shortage and those who were not compliant. Monitoring included tracking symptoms and routine bloodwork, which measured certain vitamins, excluding thiamine. Results: A total of 25 HPN patients were identified. Among them, 56% (n = 14) were compliant with daily oral multivitamin supplementation. No significant differences in pre- and post-shortage bloodwork were observed, but there was a significant difference in bicarbonate changes between the compliant and non-compliant groups (0 (-0.9, 1) vs. -2 (-8, -1), p = 0.04, respectively). Approximately 68% of all patients reported new symptoms during the shortage, but no significant difference was observed between groups. Three patients known to have increased gastrointestinal losses (two compliant and one non-compliant) required hospitalization: two had Wernicke's encephalopathy reversed with thiamine infusion. Conclusions: When IV multivitamins are unavailable for an extended period, at-risk patients need to be closely monitored by the HPN team, particularly for compliance to oral supplementation and for symptoms of thiamine deficiency when blood level monitoring is not feasible.

Potentially Inappropriate Prescribing to Older Patients Admitted to Units for Integrated Continuous Care: Application of STOPP/START Criteria

Background: Potentially inappropriate medications (PIMs) and potential prescription omissions (PPOs) have been widely explored, but few studies focused on patients aged 75 years and over. This study was planned to explore the demographic and clinical characteristics of the older patients admitted to Units for Integrated Continuous Care, and to assess the prevalence and potential predictors of PIMs and PPOs. Methods: An observational, retrospective, and multicenter study was performed on 135 patients aged 75 years or older (i.e., 75-84 years and ≥85 years). PIMs and PPOs were investigated by applying the Screening Tool of Older People's Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START) criteria. Results: The oldest-old patients (≥85 years) were less likely to come from a hospital, had fewer daily medications and a lower number of oral doses, but they presented a higher Charlson Comorbidity Index, were more dependent on activities of daily living, and were less obese than those aged 75-84 years. Results showed a high prevalence of PIMs and PPOs in both age groups. The more common PIMs and PPOs were the same in both age groups. The oldest-old patients who suffered falls were more likely to have a prescription omission of vitamin D supplements. The PIM index was not significantly different between age groups but was higher in the oldest-old group. Conclusions: Patients with a higher number of prescriptions had a higher risk of PIMs. Regarding PPOs, male gender and fall risk were predictors in the youngest group, while the number of comorbidities was significantly associated with PPOs in the oldest group. This study supports the usefulness of the STOPP/START criteria to identify PIMs and PPOs in these patients, but more research is required to determine the potential adverse outcomes of PIMs and PPOs and their clinical and economic consequences.

Exploring the Pharmacokinetics of Drugs in Disabled Saudi Patients: A Systematic Review

Background/Objectives: Disability is a term that involves mental, intellectual, or sensory impairment resulting in the loss of one's ability to walk or perform the activities necessary to live in a society. This study aims to collect all the data regarding the absorption, distribution, and disposition of drugs in disabled Saudi patients, i.e., patients suffering from epilepsy, cancer, cardiovascular diseases, etc., and then compare these results with data reported in other ethnicities. Methods: An exhaustive online search used the key terms in Google Scholar, PubMed, Cochrane Library, and Science Direct to extract all articles that met the eligibility criteria. All research studies containing pharmacokinetic (PK) parameters (area under the curve from 0 to infinity (AUC0-∞), maximal plasma concentration (Cmax), clearance (CL), volume of distribution, time to reach maximum plasma concentration, and half-life) were included in this review. Results: In pediatric epileptic patients, carbamazepine showed a notable decrease in Cmax with increasing age, which may be due to ontogenetic changes in its disposition. The AUC0-∞ of busulphan in adult hematopoietic stem cell transplantation patients was recorded as 4392.5 ± 1354.65 μg·h/mL, with high inter-individual variability. Moreover, the CL of vancomycin was reported to be 25% higher among cancer patients in comparison to non-cancer subjects. Conclusions: The complications in disabled patients due to alterations in cytochrome P450 enzymes, pathophysiology, genetics, and ethnicity emphasize the significance of patient-centered drug dosing. These findings may aid healthcare physicians in refining therapeutic care in this population.

Non-linear mixed-effects modelling and population-based model selection for 131I kinetics in benign thyroid disease

PURPOSE

This study aimed to determine a mathematical model for accurately calculating time-integrated activities (TIAs) of target tissue in 131I therapy for benign thyroid disease using the population-based model selection and non-linear mixed-effects (PBMS-NLME) method.

METHODS

Biokinetic data of 131I in target tissue were collected from seventy-three patients at 2, 6, 24, 48, and 96 (N = 53) or 120 (N = 20) h after oral capsule administration with 1 MBq 131I. Based on the Akaike weight, the best sum-of-exponential function (SOEF) describing the biokinetic data was selected using PBMS-NLME modelling. Nine SOEF with three to six parameters (including the function from the European Association of Nuclear Medicine Standard Operational Procedure (EANM SOP)) were used. The fittings were repeated 1000 times with different starting values of the SOE parameters to find the optimal fit. Akaike weight was used to identify the performance of the best model from PBMS-NLME and the EANM SOP SOE function with individual fitting.

RESULTS

Based on the PBMS-NLME analysis, the SOEFλ 1 λ 2 + λ 1 - λ 3 e - λ 3 + λ phys t - e - λ 1 + λ 2 + λ phys t + a 1 e - λ 1 + λ 2 + λ phys t was selected as the function most supported by the data. The Akaike weight of the best function was approximately 100%. The best SOEF from the PBMS-NLME approach shows a better performance in describing the biokinetic data of 131I in the thyroid gland than the function from the EANM SOP with individual fitting, based on the Akaike weight.

CONCLUSIONS

The best mathematical model from the PBMS-NLME approach has one more free parameter than the EANM SOP function, which could lead to more accurate TIAs.

External Evaluation of Population Pharmacokinetic Models of Ustekinumab in Patients with Inflammatory Bowel Disease

BACKGROUND

Population pharmacokinetic (popPK) models are essential tools for optimizing ustekinumab (UST) dosing for the treatment of inflammatory bowel disease (IBD) through therapeutic drug monitoring. The external validation of these models is necessary to ensure their predictive performance and clinical utility. The aim of the study was to externally validate 4 published popPK models of UST in a real-world cohort of patients with IBD using prediction-based and simulation-based diagnostics, as well as Bayesian forecasting.

METHODS

Four popPK models of UST, identified through a systematic literature review, were evaluated using data from 99 patients with IBD and 374 serum UST concentrations. Predictive performance and Bayesian forecasting were assessed using statistical metrics, including mean prediction error, median prediction error (MDPE), and median absolute prediction error (MADPE). The acceptability criteria (MDPE ±20%, MADPE ≤30%, F20 ≥35%, and F30 ≥50%) were applied.

RESULTS

None of the models satisfied the predefined acceptability criteria. The Xu et al model demonstrated the best performance, achieving an MDPE of 19.55% and the lowest RMSPE (2.88 mcg/mL), but F20 (20.1%) and F30 (32.4%) values fell below thresholds. The model proposed by Adedokun et al showed strong results in simulation-based diagnostics, with only 5.6% of the observed concentrations outside the prediction interval.

CONCLUSIONS

The models developed by Xu et al and Adedokun et al exhibited the most promising predictive performance and potential clinical applicability for model-informed precision dosing. Refinements to these models and further research are required to enhance their use in personalized UST therapies for IBD.

Population Pharmacokinetic Simulations for Dose Optimization of Tenofovir Disoproxil Fumarate in HIV-Infected Patients with Moderate-to-Severe Renal Impairment

Tenofovir disoproxil fumarate (TDF) requires dosage adjustments from the standard 300 mg once daily to every 48-96 h for moderate-to-severe renal impairment to avoid excessive exposure. However, this extended interval can lead to variable drug exposure and inconvenience. This study aimed to utilize the population pharmacokinetic (PPK) models to optimize TDF dosing regimens for HIV-infected patients with renal impairment. A systematic literature search was conducted across PubMed, Cochrane Library, and Scopus databases to identify relevant PPK studies of TDF in HIV-infected patients. From the included studies, the PPK models and associated parameters were extracted. Monte Carlo simulations (n = 2000) were performed to generate concentration-time profiles and derive PK parameters compared against reference ranges. For moderate renal impairment, the TDF 150 mg once-daily regimen achieved cumulative exposure comparable to the approved 300 mg every-other-day regimen. In severe renal impairment, TDF 75-100 mg administered once daily provided similar cumulative exposure as 300 mg every 72-96 h regimen while maintaining daily exposure comparable to the standard dose in patients with normal renal function. The approved extended dosing intervals of 72-96 h exhibited high drug exposure variability, initially resulting in supratherapeutic levels followed by suboptimal levels preceding the subsequent dose administration. In conclusion, administering smaller once-daily doses of TDF maintains consistent daily drug exposure comparable to the standard dose in patients with normal renal function while reducing variability in drug exposure, potentially mitigating the risk of nephrotoxicity. However, additional clinical studies are required to confirm these findings.

A framework for integrating artificial intelligence for clinical care with continuous therapeutic monitoring

The complex relationships between continuously monitored health signals and therapeutic regimens can be modelled via machine learning. However, the clinical implementation of the models will require changes to clinical workflows. Here we outline ClinAIOps ('clinical artificial-intelligence operations'), a framework that integrates continuous therapeutic monitoring and the development of artificial intelligence (AI) for clinical care. ClinAIOps leverages three feedback loops to enable the patient to make treatment adjustments using AI outputs, the clinician to oversee patient progress with AI assistance, and the AI developer to receive continuous feedback from both the patient and the clinician. We lay out the central challenges and opportunities in the deployment of ClinAIOps by means of examples of its application in the management of blood pressure, diabetes and Parkinson's disease. By enabling more frequent and accurate measurements of a patient's health and more timely adjustments to their treatment, ClinAIOps may substantially improve patient outcomes.

The interest of therapeutic and pharmacological drug monitoring of methotrexate: A systematic review

Methotrexate (MTX) is largely prescribed for cancers, particularly hematological malignancies. To reduce its toxicity, therapeutic drug monitoring (TDM) is highly recommended. This review aimed to assess knowledge on methotrexate monitoring and compare strategies for managing its toxicities. We searched several databases for articles that met the selection criteria. All articles were screened and data on analytical methods, results, and toxicities were extracted. Thirty articles were included in this review, consisting mainly of single-center studies. MTX monitoring studies have been conducted in various countries. Patient demographics covered children and adults, with one study focusing on elderly patients. MTX doses varied primarily between high-dose regimens. Sample collection times were varied. Various techniques were used to quantify MTX levels. This review highlights the diversity of study designs, patient populations, dosing regimens, and analytical techniques, emphasizing the need for standardized protocols and further research to optimize MTX treatment, ensuring both efficacy and safety.

An asthma self-management program based on WeChat to improve asthma control and quality of life: a randomized controlled trial

Background

Few studies have tested the feasibility and efficacy of WeChat-based asthma self-management, which supports patients in managing their asthma via mobile phone. We developed an intervention program based on the WeChat Mini program to support self-management. We evaluated the effectiveness and feasibility of improving asthma control and quality of life in patients with asthma.

Methods

Fifty and 53 patients were randomized into the control and WeChat groups, respectively, to receive traditional interventions and interventions based on the WeChat Mini program. We conducted the intervention for three months and then observed for three months.

Results

At the end of the third month, the Asthma Control Test (ACT) scores of the WeChat group were greater than those of the control group (P = 0.003), and the ACT scores of the two groups were significantly higher than those at baseline (P = 0.028; P < 0.001). At the end of the sixth month, the control group was not significantly different from the baseline group (P = 1.000), but the WeChat group was significantly different (P < 0.001). The ACT scores of the WeChat group were higher than those of the control group (P = 0.001). The ACT scores of the WeChat group were lower than those of the third month, but the difference was insignificant (P = 0.214). For asthma self-management and quality of life, the WeChat group improved more at the end of the third and sixth months (all P < 0.001).

Conclusion

Implementing an asthma self-management program based on the WeChat application is effective in helping patients with asthma improve their asthma control and quality of life.

Second-Generation Antipsychotic-Associated Serious Adverse Events in Women: An Analysis of a National Pharmacoepidemiologic Database

PURPOSE

Women have historically been underrepresented in second-generation antipsychotic (SGA) clinical trials, accounting for less than 35% of participants, which raises concerns about the generalizability of the safety profile for these medications.

METHODS

The US adverse event reporting system was queried for the dates January 1, 2019, to July 8, 2024, to examine the following 6 SGAs: aripiprazole, clozapine, olanzapine, quetiapine, risperidone, and ziprasidone. Reports were excluded if patients were under 18 years old, contained an unknown age or gender, or were duplicated. Five adverse events were examined: Torsades de pointes (TdP), neuroleptic malignant syndrome (NMS), tardive dyskinesia (TD), agranulocytosis (AG), and cerebrovascular adverse events (CVAE). Counts of these events were noted, and reporting odds ratios (ROR) were calculated.

RESULTS

The total study cohort was 87,356 reports, consisting of aripiprazole (n = 10,715, 12.2%), clozapine (n = 25,096, 28.7%), olanzapine (n = 11,587, 13.3%), quetiapine (n = 28,746, 32.9%), risperidone (n = 10,467, 12%), and ziprasidone (n = 745, 0.9%). The cohort's mean age was 48.6 ± 18.5 years and comprised 42,584 females (48.7%). Most cases were reported by healthcare professionals (74,836, 85.7%). A total of 3,754 reports contained at least 1 of the 5 adverse events. The RORs among females compared to males for TdP (5.55, 95% confidence interval [CI] = 3.78-8.47), NMS (0.59, 95% CI = 0.53-0.65), TD (0.88, 95% CI = 0.76-1.02), AG (0.59, 95% CI = 0.51-0.70), and CVAE (1.12, 95% CI = 0.89-1.41) were observed. Females had a significantly higher odds of hospitalization or death with TdP compared to males (ROR = 3.09, 95% CI = 1.36-7.01).

CONCLUSIONS

Our findings suggest higher odds of TdP and worse TdP-associated outcomes among females exposed to SGAs compared to males. Further studies are needed to confirm these preliminary findings.

Campesterol and dithymoquinone as a potent inhibitors of SARS cov-2 main proteases-promising drug candidates for targeting its novel variants

The sudden outbreak of the COVID-19 pandemic has currently taken approximately 2.4 million lives, with no specific medication and fast-tracked tested vaccines for prevention. These vaccines have their own adverse effects, which have severely affected the global healthcare system. The discovery of the main protease structure of coronavirus (Mpro/Clpro) has resulted in the identification of compounds having antiviral potential, especially from the herbal system. In this study, the computer-associated drug design tools were utilised to analyze the reported phytoconstituents of Nigella sativa for their antiviral activity against the main protease. Fifty-eight compounds were subjected to pharmacological parameter analysis to determine their lead likeness in comparison to the standard drugs (chloroquine and nirmatrelvir) used in the treatment of SARS-CoV-2. Nearly 31 compounds were docked against five different SARS-CoV-2 main proteases, and all compounds showed better binding affinity and inhibition constant against the proteases. However, dithymoquinone and campesterol displayed the best binding scores and hence were further subjected to dynamics and MMPBSA study for 100 ns. The stability analysis shows that dithymoquinone and campesterol show less variation in fluctuation in residues compared to standard complexes. Moreover, dithymoquinone exhibited higher binding affinity and favorable interaction followed by campesterol as compared to the standard drug. The in silico computational analysis provides a promising hit for regulating the main proteases activity.

Effect of age on the response to serotonergic and noradrenergic antidepressants: A systematic review, meta-regression and individual participant data pooled analysis

It is known that the serotonin and norepinephrine systems change with age. Consequently, response to antidepressants having different effects on these two systems may vary between patients of different ages. We systematically searched Embase/Medline/PsychINFO until December 2024 for randomised controlled trials (RCT) in patients with unipolar major depressive disorder comparing response rates to serotonergic versus noradrenergic antidepressants (PROSPERO pre-registration #CRD42020145386). Our primary outcome was to assess the effect of age on response rates to serotonergic versus noradrenergic antidepressants in unipolar depression. We then performed a pooled analysis of individual participant data (IPD). Seventy-four RCTs with a total of 8981 participants (4488 with serotonergic and 4493 with noradrenergic antidepressants) were included in the meta-analysis. We found no differences in the response rates to the two antidepressants, although the improvement in depressive symptoms was greater in the noradrenergic arm (subset of n = 31 studies, z = -2.61; p = 0.009); younger age was associated with a greater response to serotonergic than noradrenergic agents both in terms of response rates (estimate = -0.011; p-value = 0.041) and symptom improvement (estimate = -0.016; p-value<0.0001), even after controlling for year of publication, study design, baseline severity, type of noradrenergic medication, inpatients, and dropout rates. The effect of age on antidepressant response was also confirmed in the IPD pooled analysis (n = 339), in which responders to serotonergic antidepressants were significantly younger than non-responders (p-value = 0.028) and than responders to noradrenergic antidepressants (p-value = 0.034). Our study highlights the importance of age when considering the efficacy of serotonergic versus noradrenergic antidepressants as part of a precision psychiatry-oriented approach.

Promoting self-care and improving quality of life in cardiovascular disease patients: The role of pharmacist-led interventions in community pharmacies

BACKGROUND

Community pharmacists are underutilized in assisting patients with cardiovascular diseases within pharmacy settings. Monitoring and controlling cardiovascular risks could prevent deaths globally and save public health expenses. The aim of this study is to verify how self-care can impact the quality of life of patients with cardiovascular diseases.

METHODS

A quasi-experimental study lasting 12 months was designed, involving pharmacist intervention. The intervention provided to patients involved personalized guidance tailored to their activation level. This included recommendations for lifestyle changes aimed at improving their quality of life, as assessed using research tools. Key biochemical variables, such as cholesterol levels, cardiovascular risk scores, blood pressure, and patient activation, were measured alongside the patients' perceived quality of life.

RESULTS

Activation level increased significantly after 12 months (from 2.81 ± 1.02 to 3.25 ± 0.78; p = 0.09), and quality of life by 9.9 points out of 100 (p = 0.02). In terms of total cholesterol levels, a decrease was observed between the beginning and the end of the study of 18.7 mg/dL (p = 0.04) and in diastolic pressure by 21.1 mm Hg (p = 0.02). In addition, there is a protective factor against cholesterol increase in those patients with a high activation level (PAM level above 3; RR = 0.273; 95%CI = 0.104-0.716), and with an improvement in quality of life (β = 0.761; p = 0.011); and a lower diastolic pressure when activation was higher (β = -0.351; p = 0.025).

CONCLUSION

Community pharmacists have an impact on improving self-care behaviors among patients with cardiovascular diseases. Community pharmacists, through their proactive involvement and tailored care approaches, are identified as key agents in chronic disease management, empowering patients towards healthier outcomes in the face of ongoing health challenges.

Osteoporosis in Primary Care: An Analysis of Family Physicians' Knowledge, Attitudes, and Practices in Bahrain

BACKGROUND

Osteoporosis is a metabolic bone disease characterized by progressive loss of bone density. Osteoporotic fractures account for the significant morbidity and mortality of osteoporosis. Preventing and treating osteoporosis and its complications by proper screening and management will significantly improve prognosis and quality of life. Primary healthcare physicians play an important role in the primary prevention of chronic diseases. To that effect, we sought to assess the knowledge, attitude, and practices on the subject of osteoporosis among family physicians in Bahrain in order to identify the level of awareness in primary care centers.

METHODOLOGY

A cross-sectional study was conducted among family physicians working in primary healthcare centers across the Kingdom of Bahrain. Study participants were asked to complete an online revised osteoporosis knowledge test questionnaire. Data were collected and analyzed using IBM SPSS Statistics for Windows, Version 25 (Released 2017; IBM Corp., Armonk, New York).

RESULTS

A total of 210 family physicians participated in this study. More than half of the participants had not received any structured education on osteoporosis or professional development sessions in the past five years (65.7%). Electronic resources were the most utilized type of resource for osteoporosis (73.8%, n=155). The overall mean score for knowledge was 57.2%. Participants strongly agreed that patient education is crucial for disease prevention (72.7%). The three questions that received the highest percentage of neutral responses were related to the ability to screen for osteoporosis in at-risk populations, the ability to correctly diagnose osteoporosis, and effectively manage a patient with osteoporosis in the clinic (34.3%, 36.7%, and 37.1%, respectively). When analyzing the data of practice questions, it was evident that the most used method for diagnosing osteoporosis among primary care physicians was the dual-energy X-ray absorptiometry scan (79%), while the least utilized method was the calculation of an osteoporosis score (14.8%).

CONCLUSION

Our research demonstrated average levels of knowledge on osteoporosis among family physicians in Bahrain. There is also a deficiency in receiving formal updated training. The results highlight several specific deficiencies in both osteoporosis-related knowledge and clinical practice. Therefore, we suggest the need for a well-developed national screening and awareness program to increase screening practices and enhance knowledge about osteoporosis in primary healthcare.

The evolution and hotspots of radioactive iodine therapy in hyperthyroidism: a bibliometric analysis

OBJECTIVE

Hyperthyroidism, a prevalent endocrine disorder, disrupts metabolic balance and cardiovascular health, affecting millions globally. Radioactive iodine (RAI), a treatment for hyperthyroidism, employs high-energy beta particles to reduce thyroid tissue, lowering volume and hormone levels. This study utilizes bibliometric analysis to outline RAI's evolution and identify hotspots in hyperthyroidism treatment.

METHODS

A total of 2904 articles and reviews published between 1981 and 2023 were retrieved from the Web of Science Core Collection using the research strategy. Bibliometric analyses, employing VOSviewer and CiteSpace, were performed to visualize the cooperation network, evolution, and hot topics.

RESULTS

Annual publications rose in waves, 2904 papers from 2564 institutions, and 84 countries. The USA led, contributing the largest share, with the journal Thyroid dominating publication. The University of Pisa contributed the most articles. Co-occurrence analysis classified keywords into five clusters: treatment mechanism, safety, effectiveness assessment, individualized radioactive dosage, and management. The development of RAI therapy for hyperthyroidism can be divided into three stages: safety and efficacy assessment, personalized treatment plans, and treatment of drug-resistant and surgery-resistant hyperthyroidism.

CONCLUSION

Attention to RAI in hyperthyroidism should be significantly increased. It is necessary to establish collaborations between authors, countries, and institutions to promote the development of this field. Recent research has focused on personalized radioactive dosage formulation and follow-up. Future studies are likely to concentrate on drug-resistant and surgery-resistant hyperthyroidism, which is also worthy of investigation. These findings provide a new perspective on the study of RAI in hyperthyroidism, potentially contributing to the improvement of the quality of life for patients with hyperthyroidism.

Comparison of the nephroprotective effect of [6]-gingerol and the [6]-gingerol-β-cyclodextrin complex against cisplatin-induced AKI

Cisplatin is an antineoplastic agent effective for the treatment of several cancers. However, due to its nephrotoxicity, its use is limited. Acute kidney injury (AKI) induced by cisplatin is caused by inflammation, apoptosis, and oxidative stress in renal tubular cells. Natural compounds derived from ginger (Zingiber officinale) such as [6]-gingerol, possess anti-inflammatory and antioxidant properties. This study explores the protective effects of [6]-gingerol and its β-cyclodextrin complex ([6]-gingerol-β-CD) on cisplatin-induced AKI in mice. We hypothesize that complexing [6]-gingerol with β-cyclodextrin would enhance its solubility and reduce its pungency, making it more suitable for clinical use. Additionally, we aim to determine whether β-cyclodextrin complexation can improve the oral bioavailability of [6]-gingerol without compromising its therapeutic efficacy. The minimum dose of cisplatin required to induce AKI was determined to be 15 mg/kg. Female Swiss mice (n = 6-8) were divided into four groups: control, cisplatin (15 mg/kg), [6]-gingerol (12.5 mg/kg), and [6]-gingerol-β-CD (12.5 mg/kg). The treatments were administered orally for 5 days. On the third day, cisplatin was administered intraperitoneally (i.p.), and the animals were euthanized after 5 days. All biochemical parameters investigated, such as plasma urea and creatinine, urinary gamma GT, urinary protein, MPO, and GSH were altered by cisplatin. The parameters evaluated in this study were categorized into renal function, inflammation, and oxidative stress. Both [6]-gingerol and complexed gingerol effectively restored most of the evaluated parameters to control levels. Following these analyses, we investigated the JAK/STAT pathway and observed that gingerol deactivates this pathway, thereby preventing cisplatin-induced nephrotoxicity. In conclusion, β-CD complexation did not interfere with [6]-gingerol therapeutic, emphasizing its indication for future clinical tests. Further analysis showed that [6]-gingerol prevented cisplatin nephrotoxicity by deactivating JAK/STAT signaling pathway.

Protein abundance of drug transporters and drug-metabolizing enzymes in paired healthy and tumor tissue from colorectal cancer patients

The widespread prevalence of colorectal cancer and its high mortality rate emphasize the urgent need for more effective therapies. When developing new drug products, a key aspect is ensuring that sufficiently high concentrations of the active drug are reached at the site of action. Drug transporters and drug-metabolizing enzymes can significantly influence the absorption and local accumulation of drugs in intestinal tissue. To understand how their presence may affect local drug disposition, the protein abundance of multiple drug transporters and drug-metabolizing enzymes was quantified in paired healthy colonic mucosa and colorectal adenocarcinoma tissue from colorectal cancer patients, utilizing mass spectrometry-based targeted proteomics. Statistically significant changes in protein expression were observed for two transporters (MRP1 and BCRP) and three of the studied enzymes (CES1, CES2 and UGT2B17). MRP1 displayed higher levels in cancerous tissue compared to healthy mucosa samples, while BCRP, CES1, CES2 and UGT2B17 showed the opposite. Other proteins of interest which could be quantified in colonic samples were the drug transporters P-gp, MRP3, MRP4, OATP2B1, MCT1 and enzymes CYP4F2, CYP2J2 and UGT1A1. The insights from this study enhance our understanding of the extent to which drug disposition in tumor tissue of colorectal cancer patients could be impacted by drug transporters and drug-metabolizing enzymes and may facilitate a more accurate prediction of local drug concentrations.

Dose adjustment strategy for high-dose methotrexate-induced toxicities in pediatric acute lymphoblastic leukemia: based on population PK analysis and exposure-toxicity relationship

PURPOSE

High-dose methotrexate (HD-MTX) is the cornerstone of the therapy for acute lymphoblastic leukemia (ALL). However, severe adverse events are frequently reported despite standard supportive cares. Therefore, we aim to develop a new strategy to individualize HD-MTX and improve patient safety.

METHODS

A retrospective study was conducted in which toxicity were evaluated in 134 patients with 461 HD-MTX treatment courses. All of the patients experienced standard supportive cares. Exposure-toxicity analysis was conducted to obtain the target concentration and area under the curve (AUC) of MTX. Population PK model was established for dose simulations.

RESULTS

A high rate of severe toxicities (78.1%) was observed. Patients with C24h above 75 µmol/L were at high risk for developing serious myelosuppression (P < 0.001) or hepatic injury (P = 0.005) within each cycle. Moreover, although no effect of AUC0-24 h was found on toxicities within the relative cycle, a prolonged effect of MTX overexposure was observed on the toxicities in the next cycle. When the AUC0-24 h levels were above 1447 µmol/L·h, patients were more likely to develop serious myelosuppression (P = 0.004) in the subsequent cycle. Based on the C24h and AUC0-24 h levels and the known required effective doses, reducing the dose from 5 g/m2 to 2-3 g/m2 according to the risk stratification is recommended to prevent related toxicities.

CONCLUSION

MTX C24h and AUC0-24 h levels are the predictors of HD-MTX-related toxicity. For patients with overdose of HD-MTX, a new dose adjustment strategy is established to improve patient safety and optimize clinical benefit.

Using oral topiramate for primary generalized and focal-to-bilateral tonic-clonic seizures in patients 2 years of age and older: a review of the literature

INTRODUCTION

Topiramate is a drug belonging to the second generation of antiseizure arsenal, used to treat focal onset seizures without generalization, focal-to-bilateral tonic-clonic seizures, and primary generalized tonic-clonic seizures.

AREAS COVERED

The narrative evaluation of topiramate's clinical research that has been published in this article focuses on the medication's effectiveness and safety when used to treat primary generalized and focal-to-bilateral tonic-clonic seizures. From their founding to the present, the databases MEDLINE, SCOPUS, EBSCO, and GOOGLE SCHOLAR were searched.

EXPERT OPINION

Topiramate treatment has the obvious benefit of being effective in treating tonic-clonic seizures; nevertheless, it may have a drawback in that up to 56% of patients discontinue therapy due to its rather poor tolerability, particularly at doses exceeding 600 mg daily. Patients are most bothered by psychiatric and cognitive side effects, and then by appetite and weight decrease. While the onset of anorexia cannot be prevented by changing the dosage regimen, psychiatric and cognitive side effects can be mitigated by slowly titrating the topiramate dose.

How the Magenstrasse is formed after meals: Protein aggregation hypothesis

Magenstrasse (stomach road) is reported to potentially influence the absorption of orally administered drugs by facilitating a gastric emptying of ingested water under postprandial condition. We hypothesized the Magenstrasse is a consequence of the formation of protein aggregates due to the decrease in gastric pH associated with stimulated gastric acid secretion. The formation mechanism of the Magenstrasse was examined in vitro using a gastric chamber system which reproduces postprandial conditions in the stomach. Oral liquid meals containing different amounts of proteins were mixed with simulated gastric fluid containing pepsin in the gastric chamber. When a high-protein liquid meal was used, infusion of gastric acid caused protein denaturation, generating semisolid aggregates. Then, to evaluate the impact of the aggregates, fluorescein isothiocyanate-dextran 4000 (FD-4) solution was added. The presence of protein aggregates facilitated the elution of FD-4 from the gastric chamber, indicating that the semisolid aggregates suppressed mixing of FD-4 solution with meals. In addition, formation of the same type of protein aggregates was observed in vivo in rat stomach after ingesting a high-protein liquid meal. These in vitro and in vivo results support the idea that protein aggregation of liquid meals in the stomach contributes the formation of the Magenstrasse.

Customizing Tacrolimus Dosing in Kidney Transplantation: Focus on Pharmacogenetics

ABSTRACT

Different polymorphisms in genes encoding metabolizing enzymes and drug transporters have been associated with tacrolimus pharmacokinetics. In particular, studies on CYP3A4 and CYP3A5, and their combined cluster have demonstrated their significance in adjusting tacrolimus dosing to minimize under- and overexposure thereby increasing the proportion of patients who achieve tacrolimus therapeutic target. Many factors influence the pharmacokinetics of tacrolimus, contributing to inter-patient variability affecting individual dosing requirements. On the other hand, the growing use of population pharmacokinetic models in solid organ transplantation, including different tacrolimus formulations, has facilitated the integration of pharmacogenetic data and other variables into algorithms to easier implement the personalized dose adjustment in transplant centers. The future of personalized medicine in transplantation lies in implementing these models in clinical practice, with pharmacogenetics as a key factor to account for the high inter-patient variability in tacrolimus exposure. To date, three clinical trials have validated the clinical application of these approaches. The aim of this review is to provide an overview of the current studies regarding the different population pharmacokinetic including pharmacogenetics and those translated to the clinical practice for individualizing tacrolimus dose adjustment in kidney transplantation.

Nanomedicine for pediatric healthcare: A review of the current state and future prospectives

Nanomedicine has emerged as a valuable treatment and diagnosis option, due to its ability not only to address formulation challenges associated with new therapeutic moieties, but also to improve the existing drugs efficacy. Nanomedicine provides appealing advantages such as increased drug payload, enhanced stability, tailored drug release profile, improved bioavailability and targeted drug delivery, etc. Tremendous research and regulatory efforts have been made in the past decades to advance nanomedicine from the benchtop to clinic. Numerous nanotechnology-based formulation approaches have been seen succeeding in commercialization. Despite the progress in nanomedicine use in adults, the advancement in pediatric population has been much slower. Clearly the treatment of disease in children cannot be simplified by dose adjustment based on body weight or surface, due to the significant differences in physiology thus the drug absorption, distribution, metabolism, excretion and transport (ADMET), between children and adults. This inherent variable among others poses much more challenges when developing pediatric-specific nanomedicine or translating adult nanodrug to pediatric indication. This review therefore intends to highlight the physiological differences between children and adult, and the common pediatric diseases which are good candidates for nanomedicine. The formulation approaches utilized in the marketed nanomedicine with pediatric indications, including liposomes, nanocrystals, polymeric nanoparticles and lipid nanoemulsions are elaborated. Finally, the challenges and gaps in pediatric nanomedicine development and commercialization, and the future prospectives are discussed.

In silico identification of the anticataract target of βB2-crystallin from Phaseolus vulgaris: a new insight into cataract treatment

Introduction

Severe protein clumping in the lens can block light and lead to vision issues in cataract patients. Recent studies have linked β-crystallins, which are key proteins in the lens, to the development of cataracts. Specifically, the S175G/H181Q mutation in the βB2-crystallin gene plays a major role in cataract formation.

Methods

To understand how this mutation can be activated, we utilized computational methods to predict activators from Phaseolus vulgaris. The Schrödinger platform was employed to screen bioactive compounds and simulate molecular interactions in order to analyze binding and structural changes.

Results

Our results indicated that these phytochemicals are stable near S175G/H181Q.

Discussion

These findings suggest novel approaches that could potentially be developed into effective anticataract medications through further refinement and additional testing, ultimately resulting in the creation of more potent agents for cataract treatment.

Synergizing Digital and Physical Approaches: Experience Summary of the HIV PrEP Promotion Project

China's human immunodeficiency virus / acquired immune deficiency syndrome (HIV/AIDS) prevention and control efforts have entered a new stage, necessitating the exploration of more effective intervention strategies. HIV pre-exposure prophylaxis (PrEP) is a proven method to prevent HIV infection, but its promotion in China faces challenges such as low public acceptance and inadequate service capacity. To further promote PrEP, the "HIV PrEP Model Exploration Project" was launched, exploring three PrEP service models: PrEP clinics, Digital services and physical testing, and PrEP self-service vending machines. The project achieved certain results, establishing a PrEP service network, training professional staff, and promoting the use of PrEP. In the future, it is necessary to further expand publicity channels, enhance public awareness and acceptance, optimize follow-up management, and promote the popularization of PrEP and HIV/AIDS prevention and control efforts.

Drug-Drug Interactions Between HIV Antivirals and Concomitant Drugs in HIV Patients: What We Know and What We Need to Know

Highly active antiretroviral therapy has led to a significant increase in the life expectancy of people living with HIV. The trade-off is that HIV-infected patients often suffer from comorbidities that require additional treatment, increasing the risk of Drug-Drug Interactions (DDIs), the clinical relevance of which has often not been determined during registration trials of the drugs involved. Therefore, it is important to identify potential clinically relevant DDIs in order to establish the most appropriate therapeutic approaches. This review aims to summarize and analyze data from studies published over the last two decades on DDI-related adverse clinical outcomes involving anti-HIV drugs and those used to treat comorbidities. Several studies have examined the pharmacokinetics and tolerability of different drug combinations. Protease inhibitors, followed by nonnucleoside reverse transcriptase inhibitors and integrase inhibitors have been recognized as the main players in DDIs with antivirals used to control co-infection, such as Hepatitis C virus, or with drugs commonly used to treat HIV comorbidities, such as lipid-lowering agents, proton pump inhibitors and anticancer drugs. However, the studies do not seem to be consistent with regard to sample size and follow-up, the drugs involved, or the results obtained. It should be noted that most of the available studies were conducted in healthy volunteers without being replicated in patients. This hampered the assessment of the clinical burden of DDIs and, consequently, the optimal pharmacological management of people living with HIV.

Dosing Regimen Recommendations for Sirolimus in Adult Liver Transplant Recipients: Insights from a Population Pharmacokinetic Model

Background

Sirolimus is a commonly used immunosuppressant administered after solid organ transplantation. It is characterized by a narrow therapeutic window and highly variable exposure, necessitating the identification of the sources of variability and design of individualized drug therapies.

Aim

This study aimed to perform a population pharmacokinetic (PK) analysis of sirolimus in adult liver transplant recipients and develop dosing regimen recommendations according to patient characteristics.

Methodology

A total of 216 measurements of whole blood sirolimus concentrations in 103 adult patients were obtained for analysis. Covariates influencing the PKs of sirolimus were investigated using a stepwise procedure. Monte Carlo simulations were conducted to recommend dosing regimens for patients with different levels of covariates.

Results

A one-compartment model with first-order elimination provided the best fit of the data. Hematocrit (HCT) significantly influenced the apparent clearance of sirolimus. Monte Carlo simulations showed that for patients with a low HCT level of 28%, dosing regimens of 1.5 mg qd or 1 mg qd alternating with 1.5 mg qd should be recommended. For patients with a normal HCT level, the recommended dosing regimens were 1 mg qd, 2 mg qod, or 0.5 mg qd alternating with 1 mg qd.

Conclusion

Based on our population PK model of sirolimus in adult liver transplant recipients, which has the largest sample size to date, we recommend to tailor dosing regimens to various HCT levels in such patients.

Nutritional value, HPLC-DAD analysis and biological activities of Ceratonia siliqua L. pulp based on in vitro and in silico studies

The phytochemical, nutritional, and biological features of wild carob pulp from Tanzight (TN), Ait-Waada (AW), and Tizi-ghnayn (TG) in Azilal were studied. The results of the study reveal that the carob pulp examined has a low-fat level. AW had the most total sugar (78.34 ± 3.00%), total reducing sugar (27.20 ± 2.89%), crude fiber (14.21 ± 1.23%), sucrose (24.303 ± 0.038%), sodium (153.7 ± 18.52 mg/kg), pH (5.599 ± 0.05), and total polyphenol content (4134.50 ± 17.91 mg GAE/100 g DW). TG has higher amounts of potassium (11373 ± 153.7 mg/kg), calcium (4345 ± 7.211 mg/kg), phosphorus (3551 ± 175.1 mg/kg), magnesium (1347 ± 52.43 mg/kg), fructose (7.635 ± 0.012%), and total flavonoids (1678.08 ± 24.05 mg RE/100 g DW). TN has the highest levels of crude protein (5.607 ± 0.047%), moisture (9.33 ± 0.57%), ash (4.16 ± 0.02%), glucose (2.956 ± 0.047%), and total condensed tannins (529.61 ± 6.76 mg CE/100 g DW). The ethanol extract derived from AW exhibited noteworthy antioxidant activity, as evidenced by its total antioxidant capacity (TAC) of 1245.83 ± 26.33 µg ascorbic acid equivalent /mg extract and IC50 values of 18.45 ± 1.41 µg/mL, 124.98 ± 5.21 µg/mL, and 24.87 ± 1.30 µmol/mL for 2,2-Diphenyl-1-picrylhydrazil (DPPH), beta carotene (β-Carotene), and 2,2'-azino-bis (3-éthylbenzothiazoline-6-sulfonate) (ABTS), respectively. Furthermore, AW has demonstrated significant antibacterial activity against a variety of bacterial and fungal strains using disc diffusion and broth dilution techniques. The analysed samples also demonstrated encouraging anti-cancer effects on MDA-MB-231, MDA-MB-436, and MCF-7 cancer cell lines. The biological activities were confirmed through molecular docking analysis, identifying naringin and quercetin 3-O-β-glucoside as related compounds. Additionally, ADME analyses have revealed that all the synthetic compounds examined in this study demonstrate high intestinal absorption, meet Lipinski's criteria, indicating their potential suitability for oral drug development. Based on these findings, wild carob pulp from Azilal province may contain bioactive compounds and nutrients.

Variations in serum concentrations of sunitinib and its metabolites in patients receiving long-term sunitinib treatment

PURPOSE

The blood concentrations of some tyrosine kinase inhibitors are known to decrease with long-term administration. We evaluated the variability in the serum concentrations of sunitinib and its metabolites in patients receiving long-term sunitinib treatment.

METHODS

This study prospectively recruited patients who received sunitinib for metastatic renal cell carcinoma at the Showa University Hospital between March 2020 and January 2022. Bivariate correlations between the serum concentration/dose (C/D) ratios of sunitinib and its metabolites (i.e., N-desethyl sunitinib and sunitinib N-oxide) and treatment duration were evaluated using Pearson's correlation coefficient.

RESULTS

Seven patients were enrolled, and 79 blood samples were collected. Among six patients who received sunitinib for > 1 year, three showed a decreasing trend in the C/D ratio of sunitinib (Pt1: r = -0.608, p = 0.047; Pt2: r = -0.555, p = 0.077; Pt6: r = -0.590, p = 0.073). In these patients, the median annual decrease in the C/D ratio of sunitinib was 55.8% (26.5-63.2%). Additionally, two of the three patients also showed a decrease in the C/D ratio of N-desethyl sunitinib. The ratio of N-desethyl sunitinib/sunitinib concentration at baseline and the end of follow-up was similar between the C/D-decreased and C/D-non-decreased groups.

CONCLUSION

This study showed that the C/D ratio of sunitinib decreased by half over time in half of the patients who received long-term sunitinib treatment despite continuing the same dose. Therefore, serum concentrations of sunitinib and its metabolites should be monitored periodically in patients receiving long-term treatment to prevent decrease in serum sunitinib concentrations.

Vedolizumab Clearance as a Surrogate Marker for Remission in Inflammatory Bowel Disease Patients: Insights from Real-World Pharmacokinetics

Background/Objectives: Vedolizumab (VDZ) is approved in the treatment of patients with moderate to severe ulcerative colitis (UC) or Crohn's disease (CD). VDZ exhibits considerable variability in its pharmacokinetic (PK) profile, and its exposure-response relationship is not yet fully understood. The aim was to investigate the variability in VDZ trough levels and PK parameters, to assess the relationship between VDZ PK and biochemical response, as well as clinical and endoscopic outcomes. Methods: We included 61 UC and 45 CD patients. Patients' data and trough VDZ concentrations were retrospectively obtained. Population PK analysis was performed using non-linear mixed-effects modelling with NONMEM (version 7.5). Graphs and statistical analyses were performed using R (version 4.1.3). Results: In total, 116 trough VDZ concentrations from 106 patients were described by a two-compartment model. For a typical patient, clearance (CL) was estimated at 0.159 L/day, while in patients previously treated with anti-TNFα agents, VDZ CL increased by 26.4% on average. In univariate binary logistic regression, VDZ trough concentration was not statistically significant predictor of remission, whereas CL was. Moreover, combined CL and faecal calprotectin (FCP) were a statistically significant predictors of remission. The hazard ratio (HR) for CL above 0.1886 L/day was 0.35 (p = 0.05) and for FCP below 250 µg/g was 2.66 (p = 0.02) in a time-to-event analysis. Conclusions: Our population PK model incorporates the effect of prior anti-TNFα agents on CL, suggesting its association with more severe forms of IBD. VDZ CL emerged as a more robust and clinically relevant predictor of remission in IBD patients than trough concentration.

Factors Affecting Vancomycin Trough Concentration; a Population Pharmacokinetic Model in Non-Critical Care Saudi Patients

Background and Objective

Vancomycin is commonly prescribed in treatment of methicillin-resistant Staphylococcus aureus infections. While, vancomycins' pharmacokinetic vary among older patients, there is a paucity of data regarding specific characteristics influencing pharmacokinetics in Saudi adult patients. This study aims to establish a population-pharmacokinetic (Pop-PK) model for vancomycin in patients admitted to medical wards, with the focus on identification of patient characteristics influencing vancomycin trough concentrations.

Methods

A multicenter retrospective study was conducted involving patients aged ≥40 years admitted to medical wards in the Eastern Province, Saudi Arabia and initiated on vancomycin, between January to December 2022. Non-linear mixed-effects modelling (Monolix) was employed to develop the Pop-PK model. A base model was selected based on the Akaike information criterion. Covariates considered included age, sex, body weight, C-reactive protein (CRP), serum creatinine, creatinine clearance (CrCl), and albumin levels. A P-value of <0.05 was considered statistically significant for inclusion of covariates in the final model by stepwise addition. The simulation performance of the model was assessed by visual predictive check plot. The final model was simulated using Simulx software to assess the effect of the included covariates on vancomycin trough concentration.

Results

A total of 172 vancomycin trough concentrations from 124 patients were analyzed. The final Pop-PK model characterized vancomycin trough concentrations was one compartment distribution with linear elimination. CrCl and CRP were the only covariates included in the final model, as they reduced the between-subject variability (BSV) for clearance (from 173% to 81%). The simulated model demonstrated that high CRP value and low CrCl contributed to increased vancomycin trough concentrations.

Conclusion

This study highlights large BSV in trough concentrations among patients and emphasizes the influencing of CrCl and CRP on vancomycin pharmacokinetics in medical care settings.

Development of a recombinant human IgG1 monoclonal antibody against the TRBV5-1 segment of the T cell receptor for the treatment of mature T cell neoplasms

Background

Mature T-cell neoplasms arise from the neoplastic transformation of a single T lymphocyte, and all cells in a neoplastic clone share the same V segment in the beta chain of the T-cell receptor (TCR). These segments may represent an innovative target for the development of targeted therapies.

Methods

A specific V segment of the TCR beta chain (TRBV5-1) was analyzed using bioinformatic tools, identifying three potential antigenic peptides. One of these peptides, selected for synthesis, was used to screen a library of human single-chain variable fragments (scFv) through phage display. One fragment demonstrated high affinity and specificity for the antigen and was used to produce a human monoclonal antibody of the IgG1 class.

Results

Surface plasmon resonance (SPR) studies confirmed the high affinity of the monoclonal antibody for the antigen in the nanomolar range. Flow cytometry analysis on patients' samples demonstrated that the antibody, conjugated with a fluorochrome, selectively binds to tumor T lymphocytes expressing TRBV5-1, without binding to other lymphocytes or blood cell components.

Conclusions

The development of fully human IgG1 monoclonal antibodies targeting specific V segments of the TCR beta chain represents a potential therapeutic option for patients with mature T-cell neoplasms.

Age-related characteristics of sedation in pediatric patients and their correlated adverse events: a cohort study

Objective

The objective of this research was to examine the features and potential hazards of sedation in children of varying ages. Additionally, the study aimed to comprehend these variations to enhance the safety and efficacy of clinical applications.

Methods

A retrospective analysis was conducted on case data involving pediatric patients who underwent imaging procedures in outpatient settings and necessitated procedural sedation from 2022 to 2024. The research participants were categorized into three age groups: ≤1 year, 1-3 years, and 3-12 years. The primary sedative agents administered were oral midazolam in conjunction with intranasal dexmedetomidine. We examined the effects of sedation and the occurrence of adverse events across various age groups. Additionally, we applied multivariate logistic regression to identify factors linked to these adverse events.

Results

The study observed 2,194 children, with 879 (40.1%) being ≤1-year-old. The ≤1-year-old group achieved faster sleep onset at 18.7 ± 0.3 min, with no significant variance in awakening time and length of stay among the groups. The incidence of adverse events varied significantly by age, with the highest rate of 12.2% in the ≤1-year-old group and the lowest rate of 9.7% in the 3-12-year-old group. Multivariate analysis revealed age as an independent factor affecting adverse event occurrence, with a relative risk ratio (AOR) of 2.21 (95% CI: 1.31-3.75) for delayed awakening in children ≤1-year-old, 15.03 (95% CI: 1.92-117.61) for hypoglycemia, and a relative risk ratio (AOR) of 4.58 (95% CI: 2.22-9.42) for receiving a significant intervention.

Conclusions

Significant variations in sedation reactions and adverse events were observed across the different age groups. Specifically, children aged ≤1 year exhibited a higher susceptibility to adverse events such as delayed awakening and hypoglycemia.

Clinical Trial Registration

chictr.org.cn identifier (ChiCTR2400082774).

Association of acute exposure to PM2.5 constituents and sources with kidney injury: A longitudinal panel study of Nrf2 promoter polymorphism

Evidence on the effects of fine particulate matter (PM2.5) constituents and sources on kidney injury is limited. We designed a panel study with 4 repeated measurements to investigate the association of acute exposure to chemical constituents and source-specific PM2.5 with kidney function and renal tubular injury. We further evaluated the modifying effect of Nrf2 promoter polymorphism. In this study, a total of 64 participants were recruited and ambient PM2.5 constituents were monitored at a fixed-site station. We used a positive matrix factorization (PMF) model to identify emission sources and linear mixed-effect models to explore the associations. An interquartile range (IQR) increase in PM2.5 concentration was associated with a 1.40 % and 3.15 % decrease in eGFR-Cr (eGFR assessed by creatinine) and eGFR-Cys (eGFR assessed by cystatin-C), respectively, and 10.2 % higher kidney injury molecule 1 (KIM-1) levels. Carbonaceous components (EC and OC), metallic elements (Cr, K, Pb, Zn) and Cl- were robustly responsible for kidney injury. Per IQR increase in these constituents accounted for 0.57 % to 1.62 % declines in eGFR-Cr; 1.36 % to 3.66 % declines in eGFR-Cys; and 7.50 % to 19.83 % increments in KIM-1. Specific source analysis revealed that PM2.5 emitted by combustion was associated with the largest reduction in eGFR, while the secondary source played a more prominent role in renal tubular injury. The dominant models showed that the magnitudes of the effect estimates of PM2.5 and its constituents were generally larger in the participants with minor alleles of the Nrf2 promoter. These findings suggest that acute exposure to EC, OC, Cl- and several metallic constituents may be responsible for kidney injury induced by PM2.5, especially in individuals with unfavorable Nrf2 genotypes. PM2.5 from combustion and secondary sources impairs kidney health, highlighting the importance of source-oriented PM2.5 control strategies.

An Amorphous Solid Dispersion of Baicalin and its Oral Therapeutic Effect on Ulcerative Colitis

OBJECTIVE

Ulcerative colitis (UC) treatment currently faces multiple challenges including adverse effects, prolonged therapy durations, and high costs. Baicalin (BA) has demonstrated anti-inflammatory benefits for inflammatory bowel disease, and the objective of this scholarly work is to address the challenges associated with the poor aqueous solubility and diminished oral bioavailability of the compound in question, thereby offering an innovative therapeutic approach for the management of ulcerative colitis.

METHODS

We developed a baicalin-arginine complex (BA-Arg) by screening for suitable basic compounds and utilizing a freeze-drying method, resulting in an amorphous solid dispersion of BA.

RESULTS

Our findings revealed that BA·Arg significantly enhances the intestinal absorption and transmembrane transport of BA without inducing toxicity in Caco-2 cells. Pharmacokinetic studies in healthy Wistar rats demonstrated significantly higher plasma concentrations of BA compared to free BA. In a mouse model induced by 3.5% dextran sodium sulfate, BA·Arg treatment markedly alleviated colitis symptoms as evidenced by reduced inflammatory cell infiltration, decreased lymphocyte aggregation in the colon, and better preservation of intestinal mucosa. This improved the overall anti-colitis efficacy of BA.

CONCLUSIONS

Overall, our study presents a simple, eco-friendly formulation process that enhances BA solubility without the need for organic solvents, offering a practical and sustainable solution for developing BA-based therapies for UC.

Pharmacokinetics of Antiretroviral Drugs in Older People Living with HIV, Part II: Drugs Licensed Before 2005

BACKGROUND AND OBJECTIVE

Advances in antiretroviral therapy led to an increase in life expectancy among people living with human immunodeficiency virus (HIV). As aging is characterized by several physiological changes that can influence pharmacokinetics (PK), this systematic review aims to describe the impact of aging on the PK of antiretrovirals (ARV) approved by the Food and Drug Administration (FDA) before 2005.

METHODS

Searches were performed in BVS, EMBASE, and PubMed databases for publications until June 2024. Peer-reviewed published studies were included if they met the following criteria: adults (≥ 18 years) living with HIV; reporting at least one PK parameter or plasma concentration of any ARV approved by the US FDA before 2005 and still used in the clinic: lamivudine (3TC), emtricitabine (FTC), tenofovir disoproxil fumarate (TDF), abacavir (ABC), zidovudine (ZDV), efavirenz (EFV), nevirapine (NVP), atazanavir (ATV), lopinavir (LPV), ritonavir (RTV), tipranavir (TPV), and fosamprenavir (FPV); PK parameters stratified per age group as young (aged 18-49 years) or older (age ≥ 50 years) adults; and manuscripts published in English, Portuguese, or Spanish. All studies were evaluated for risk of bias. The review protocol was registered in the PROSPERO database (registration no. CRD42023463092).

RESULTS

Among 106 studies included, only 22 evaluated the PK of participants aged 50 years or older and only 5 studies compared the PK between young and older adults for ATV, RTV, EFV, and 3TC. Our analysis revealed an increase in minimal concentration (Cmin) values for LPV, RTV, and ATV in older adults. While increased values of the area under the curve (AUC) and maximum concentration (Cmax) were observed in older adults using ATV, 3TC, and FTC, no differences in PK were apparent between young and older adults for ABC and EFV, with no estimation possible for ZDV.

CONCLUSION

Exposure to 3TC, TDF, FTC, ATV, LPV, and RTV increases with age, while exposure to ABC and EFV appears to be unaffected. Despite the large quantity of data on PK in young adults, there is still a gap in knowledge about the effects of aging on the PK of these ARVs.

Population pharmacokinetic analysis of zastaprazan (JP-1366), a novel potassium-competitive acid blocker, in patients and healthy volunteers

Zastaprazan (JP-1366) is a novel potassium-competitive acid blocker for the treatment of acid-related disorders. We aimed to establish a population pharmacokinetic (PK) model of zastaprazan, thereby characterizing the PK of zastaprazan in patients with gastroesophageal reflux disease (GERD) as well as evaluating the impact of various covariates, including CYP2C19 phenotypes, on zastaprazan PK. This population PK analysis included zastaprazan plasma concentration-time data from 92 patients with erosive GERD and 68 healthy volunteers without any gastrointestinal disorders and was performed using nonlinear mixed-effect modeling. Simulations were conducted to predict zastaprazan PK under various dosing regimens in patients with GERD. The plasma PK of zastaprazan was adequately described by a two-compartment model with Erlang-type absorption (six sequential compartments) and first-order elimination. CYP2C19 phenotypes had no significant effect on zastaprazan PK. The disease status was identified as a significant covariate on apparent clearance of zastaprazan, showing lower values in patients with GERD compared to healthy volunteers. However, the model-based simulation indicated that the impact of disease status on zastaprazan exposure was not clinically meaningful. Overall, the current population PK model successfully characterized the observed zastaprazan PK in both patients with GERD and healthy volunteers.

Impact of aging on the digestive system related to protein digestion in vivo

For the current aging population, protein is an important macronutrient to counteract the development of sarcopenia. Protein digestion is influenced by the capacity of the digestive system. The current evidence is reviewed about the impact of aging on the human digestive system and related to protein digestion in vivo. Aging changes the digestive organs which impacts protein digestion. Dentition decreases and mastication changes, potentially affecting particle size reduction. Stomach gastric acidity is unchanged, gastric emptying is delayed, while total transit time remains unchanged. Production of enzymes by the pancreas is decreased, but any changes in the small intestine remain unresolved. Animal studies showed decreased fecal protein digestion in older compared to young animals. Human studies showed decreased postprandial peripheral plasma appearance of ingested amino acids and increased splanchnic extraction. The findings suggest that the deteriorating digestive system with aging results in decreased protein digestion. Interpretation of the results should be taken with caution because of interindividual differences in the aging process, and because studies on protein digestion in aging humans are scarce. More information is needed on healthy aging and its relation to the digestive tract and protein digestion, several methods including in vitro experiments are valuable in this perspective.

Type 1 Human Immunodeficiency Virus (HIV-1) Incidence, Adherence, and Drug Resistance in Individuals Taking Daily Emtricitabine/Tenofovir Disoproxil Fumarate for HIV-1 Pre-exposure Prophylaxis: Pooled Analysis From 72 Global Studies

BACKGROUND

Oral pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir disoproxil fumarate (F/TDF) has high efficacy against HIV-1 acquisition. Seventy-two prospective studies of daily oral F/TDF PrEP were conducted to evaluate HIV-1 incidence, drug resistance, adherence, and bone and renal safety in diverse settings.

METHODS

HIV-1 incidence was calculated from incident HIV-1 diagnoses after PrEP initiation and within 60 days of discontinuation. Tenofovir concentrations in dried blood spots (DBS), drug resistance, and bone/renal safety indicators were evaluated in a subset of studies.

RESULTS

Among 17 274 participants, there were 101 cases with new HIV-1 diagnosis (.77 per 100 person-years; 95% confidence interval [CI]: .63-.94). In 78 cases with resistance data, 18 (23%) had M184I or V, 1 (1.3%) had K65R, and 3 (3.8%) had both mutations. In 54 cases with tenofovir concentration data from DBS, 45 (83.3%), 2 (3.7%), 6 (11.1%), and 1 (1.9%) had average adherence of <2, 2-3, 4-6, and ≥7 doses/wk, respectively, and the corresponding incidence was 3.9 (95% CI: 2.9-5.3), .24 (.060-.95), .27 (.12-.60), and .054 (.008-.38) per 100 person-years. Adherence was low in younger participants, Hispanic/Latinx and Black participants, cisgender women, and transgender women. Bone and renal adverse event incidence rates were 0.69 and 11.8 per 100 person-years, respectively, consistent with previous reports.

CONCLUSIONS

Leveraging the largest pooled analysis of global PrEP studies to date, we demonstrate that F/TDF is safe and highly effective, even with less than daily dosing, in diverse clinical settings, geographies, populations, and routes of HIV-1 exposure.

Combined carbapenem resulted in a 4.48-fold increase in valproic acid clearance: a population pharmacokinetic model in Chinese children and adults with epilepsy or after neurosurgery

Our study aims to explore the pharmacokinetics of valproic acid (VPA) in Chinese patients with epilepsy or after neurosurgery and establish a robust population pharmacokinetics (PPK) model. The PPK model was developed using nonlinear mixed-effects modeling, incorporating a total of 615 VPA plasma concentration data points from 443 Chinese epilepsy or after neurosurgery patients. A one-compartment model with an additive residual model was established. Forward addition and backward elimination strategies were used to assess the impact of covariates on the model parameters. Goodness-of-fit plots, bootstrap, visual predict check and normalized prediction distribution errors were used for model validation. In the final model, the apparent clearance (CL) was estimated using the following formula: CL  L / h = 0.430 × BW / 60 0.787 × Cr / 50.3 - 0.253 × ALB / 39 - 0.873 × e gender × e CBP × e IND 2   × e η CL (gender = 0.121 when is female, otherwise = 0; CBP = 1.50 when combined with carbapenems, otherwise = 0; IND2 = 0.15 when combined with oxcarbazepine, carbamazepine, phenobarbital, or phenytoin, otherwise = 0). The volume of distribution (Vd) was estimated using the formula: Vd  L = 8.66 × BW / 60 0.751 . Comedication with carbapenems could increase VPA clearance by 4.48 times, and comedication with oxcarbazepine could enhance VPA clearance by 116%. Besides, creatinine and albumin could affect VPA clearance. Goodness-of-fit plots, bootstrap, visual predict check and normalized prediction distribution showed acceptable data fit, stability, and predictability of the model. In our study, a PPK model was utilized to attain a more comprehensive insight into these variables, improving the accuracy and individualization of VPA therapy in Chinese patients with epilepsy or after neurosurgery.

Effect of Valproate Coprescription on Clozapine Pharmacokinetics in Clinical Practice

BACKGROUND

Sodium valproate has been coprescribed with clozapine for seizure prophylaxis and for augmentation in treatment-refractory schizophrenia. However, the effect of valproate on clozapine metabolism and on the incidence of clozapine-related side effects is unclear.

METHODS

We compared clozapine dose and plasma clozapine and N-desmethylclozapine (norclozapine) concentrations in smokers and nonsmokers of both sexes in samples submitted for clozapine therapeutic drug monitoring, 1996-2017 in relation to valproate coprescription.

RESULTS

There were 1217 (665 patients) and 3823 (1600 patients) samples from nonsmokers and from smokers, respectively, who were coprescribed valproate and clozapine. Data from 9774 (5065 patients) and 15,465 (7298 patients) samples from nonsmokers and from smokers, respectively, for whom drugs other than valproate were coprescribed were used as controls. Valproate coprescription in nonsmokers was associated with an increase in average plasma clozapine of 22.5%, suggesting moderate inhibition of clozapine metabolism, but there was no marked effect of valproate coprescription on plasma clozapine in smokers. In all the valproate-treated groups (male and female smokers and nonsmokers), the median plasma norclozapine concentration and the median plasma clozapine-to-norclozapine ratio were significantly lower and higher, respectively, as compared with the controls. Mixed-effects models showed a significant dose-response effect of valproate on lowering the plasma norclozapine concentration and on increasing the plasma clozapine-to-norclozapine ratio.

IMPLICATIONS

Given the complexity of the effect of valproate coadministration on clozapine pharmacokinetics and the possibility that the toxicity of clozapine may be enhanced in the presence of valproate, the use of these drugs in combination must now be questioned in all patients and not only in women of childbearing age.

Population Pharmacokinetics and Loading Dose Optimization of Intravenous Valproic Acid in Hospitalized Thai Patients

Our goal is to create a population pharmacokinetic (PK) model and identify the best loading dose (LD) of intravenous valproic acid for hospitalized Thai patients. Data from patients who received intravenous valproic acid and underwent measurement of serum valproic acid concentrations during hospitalization were collected retrospectively. A nonlinear mixed-effects modeling approach was conducted to estimate the PK parameters of valproic acid. Covariates affecting the PK parameters of valproic acid were examined and ranked based on their impact on the model's performance. Monte Carlo simulations of 1000 patients were conducted to estimate the optimal LD of valproic acid. A total of 120 hospitalized patients (51.7% male) with 167 valproic acid concentrations were included in the study. A linear one-compartment model with constant residual error was the best base model. An age-covariate model was the best predictor of valproic acid clearance (CL). The typical values of CL and volume of distribution for valproic acid were 0.77 L/h and 14.56 L, respectively. The LD of 1000-1200 mg intravenous was identified as the pragmatic option as an empirical regimen for hospitalized Thai patients. The recommended time to initiate maintenance dose (MD) is 4-8 h following the LD. The population PK model and optimal LD of valproic acid in hospitalized Thai patients has been established, and it may be advisable to initiate the MD at a later time for the elderly.