51
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Keutzer L, Wicha SG, Simonsson US. Mobile Health Apps for Improvement of Tuberculosis Treatment: Descriptive Review. JMIR Mhealth Uhealth 2020; 8:e17246. [PMID: 32314977 PMCID: PMC7201317 DOI: 10.2196/17246] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/10/2020] [Accepted: 02/22/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Mobile health (mHealth) is a rapidly emerging market, which has been implemented in a variety of different disease areas. Tuberculosis remains one of the most common causes of death from an infectious disease worldwide, and mHealth apps offer an important contribution to the improvement of tuberculosis treatment. In particular, apps facilitating dose individualization, adherence monitoring, or provision of information and education about the disease can be powerful tools to prevent the development of drug-resistant tuberculosis or disease relapse. OBJECTIVE The aim of this review was to identify, describe, and categorize mobile and Web-based apps related to tuberculosis that are currently available. METHODS PubMed, Google Play Store, Apple Store, Amazon, and Google were searched between February and July 2019 using a combination of 20 keywords. Apps were included in the analysis if they focused on tuberculosis, and were excluded if they were related to other disease areas or if they were games unrelated to tuberculosis. All apps matching the inclusion criteria were classified into the following five categories: adherence monitoring, individualized dosing, eLearning/information, diagnosis, and others. The included apps were then summarized and described based on publicly available information using 12 characteristics. RESULTS Fifty-five mHealth apps met the inclusion criteria and were included in this analysis. Of the 55 apps, 8 (15%) were intended to monitor patients' adherence, 6 (11%) were designed for dosage adjustment, 29 (53%) were designed for eLearning/information, 3 (6%) were focused on tuberculosis diagnosis, and 9 (16%) were related to other purposes. CONCLUSIONS The number of mHealth apps related to tuberculosis has increased during the past 3 years. Although some of the discovered apps seem promising, many were found to contain errors or provided harmful or wrong information. Moreover, the majority of mHealth apps currently on the market are focused on making information about tuberculosis available (29/55, 53%). Thus, this review highlights a need for new, high-quality mHealth apps supporting tuberculosis treatment, especially those supporting individualized optimized treatment through model-informed precision dosing and video observed treatment.
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Affiliation(s)
- Lina Keutzer
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Ulrika Sh Simonsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
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Abdel-Rahman SM, Gill H, Carpenter SL, Gueye P, Wicklund B, Breitkreutz M, Ghosh A, Kollu A. Design and Usability of an Electronic Health Record-Integrated, Point-of-Care, Clinical Decision Support Tool for Modeling and Simulation of Antihemophilic Factors. Appl Clin Inform 2020; 11:253-264. [PMID: 32268389 DOI: 10.1055/s-0040-1708050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND With the consequences of inadequate dosing ranging from increased bleeding risk to excessive drug costs and undesirable administration regimens, the antihemophilic factors are uniquely suited to dose individualization. However, existing options for individualization are limited and exist outside the flow of care. We developed clinical decision support (CDS) software that is integrated with our electronic health record (EHR) and designed to streamline the process for our hematology providers. OBJECTIVES The aim of this study is to develop and examine the usability of a CDS tool for antihemophilic factor dose individualization. METHODS Our development strategy was based on the features associated with successful CDS tools and driven by a formal requirements analysis. The back-end code was based on algorithms developed for manual individualization and unit tested with 23,000 simulated patient profiles created from the range of patient-derived pharmacokinetic parameter estimates defined in children and adults. A 296-item heuristic checklist was used to guide design of the front-end user interface. Content experts and end-users were recruited to participate in traditional usability testing under an institutional review board approved protocol. RESULTS CDS software was developed to systematically walk the point-of-care clinician through dose individualization after seamlessly importing the requisite patient data from the EHR. Classical and population pharmacokinetic approaches were incorporated with clearly displayed estimates of reliability and uncertainty. Users can perform simulations for prophylaxis and acute bleeds by providing two of four therapeutic targets. Testers were highly satisfied with our CDS and quickly became proficient with the tool. CONCLUSION With early and broad stakeholder engagement, we developed a CDS tool for hematology provider that affords seamless transition from patient assessment, to pharmacokinetic modeling and simulation, and subsequent dose selection.
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Affiliation(s)
- Susan M Abdel-Rahman
- Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy, Kansas City, Missouri, United States.,Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, United States
| | - Harpreet Gill
- Department of Research Informatics, Children's Research Institute, Children's Mercy, Kansas City, Missouri, United States
| | - Shannon L Carpenter
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, United States.,Division of Hematology/Oncology, Children's Mercy, Kansas City, Missouri, United States
| | - Pathe Gueye
- Department of Research Informatics, Children's Research Institute, Children's Mercy, Kansas City, Missouri, United States
| | - Brian Wicklund
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, United States.,Division of Hematology/Oncology, Children's Mercy, Kansas City, Missouri, United States
| | - Matt Breitkreutz
- Department of Research Informatics, Children's Research Institute, Children's Mercy, Kansas City, Missouri, United States
| | - Arindam Ghosh
- Department of Research Informatics, Children's Research Institute, Children's Mercy, Kansas City, Missouri, United States
| | - Avinash Kollu
- Department of Research Informatics, Children's Research Institute, Children's Mercy, Kansas City, Missouri, United States
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53
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Märtson AG, Sturkenboom MGG, Stojanova J, Cattaneo D, Hope W, Marriott D, Patanwala AE, Peloquin CA, Wicha SG, van der Werf TS, Tängdén T, Roberts JA, Neely MN, Alffenaar JWC. How to design a study to evaluate therapeutic drug monitoring in infectious diseases? Clin Microbiol Infect 2020; 26:1008-1016. [PMID: 32205294 DOI: 10.1016/j.cmi.2020.03.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/03/2020] [Accepted: 03/10/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) is a tool to personalize and optimize dosing by measuring the drug concentration and subsequently adjusting the dose to reach a target concentration or exposure. The evidence to support TDM is however often ranked as expert opinion. Limitations in study design and sample size have hampered definitive conclusions of the potential added value of TDM. OBJECTIVES We aim to give expert opinion and discuss the main points and limitations of available data from antibiotic TDM trials and emphasize key elements for consideration in design of future clinical studies to quantify the benefits of TDM. SOURCES The sources were peer-reviewed publications, guidelines and expert opinions from the field of TDM. CONTENT This review focuses on key aspects of antimicrobial TDM study design: describing the rationale for a TDM study, assessing the exposure of a drug, assessing susceptibility of pathogens and selecting appropriate clinical endpoints. Moreover we provide guidance on appropriate study design. IMPLICATIONS This is an overview of different aspects relevant for the conduct of a TDM study. We believe that this paper will help researchers and clinicians to design and conduct high-quality TDM studies.
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Affiliation(s)
- A-G Märtson
- University of Groningen, University Medical Centre Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - M G G Sturkenboom
- University of Groningen, University Medical Centre Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - J Stojanova
- Interdisciplinary Centre for Health Studies (CIESAL), Universidad de Valparaíso, Valparaíso, Chile
| | - D Cattaneo
- ASST Fatebenefratelli Sacco University Hospital, Unit of Clinical Pharmacology, Department of Laboratory Medicine, Milan, Italy
| | - W Hope
- University of Liverpool, Antimicrobial Pharmacodynamics and Therapeutics, Liverpool, UK; Royal Liverpool Broadgreen University Hospital Trust, Liverpool, United Kingdom
| | - D Marriott
- St Vincent's Hospital, Sydney, Australia
| | - A E Patanwala
- The University of Sydney, Sydney Pharmacy School, Sydney, New South Wales, Australia; Royal Prince Alfred Hospital, Sydney, Australia
| | - C A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - S G Wicha
- University of Hamburg, Department of Clinical Pharmacy, Institute of Pharmacy, Hamburg, Germany
| | - T S van der Werf
- University of Groningen, University Medical Centre Groningen, Department of Pulmonary Diseases and Tuberculosis, Groningen, the Netherlands; University of Groningen, University Medical Centre Groningen, Department of Internal Medicine, Groningen, the Netherlands
| | - T Tängdén
- Uppsala University, Department of Medical Sciences, Uppsala, Sweden
| | - J A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine & Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia; Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - M N Neely
- Children's Hospital of Los Angeles, Laboratory of Applied Pharmacokinetics and Bioinformatics, Los Angeles, CA, USA
| | - J-W C Alffenaar
- University of Groningen, University Medical Centre Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands; The University of Sydney, Sydney Pharmacy School, Sydney, New South Wales, Australia; Westmead Hospital, Sydney, Australia; Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia.
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Krukas A, Franklin E, Bonk C, Howe J, Dixit R, Adams K, Krevat S, Jones R, Ratwani R. Identifying Safety Hazards Associated With Intravenous Vancomycin Through the Analysis
of Patient Safety Event Reports. PATIENT SAFETY 2020. [DOI: 10.33940/data/2020.3.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Intravenous (IV) vancomycin is one of the most commonly used antibiotics in U.S. hospitals. There are several complexities associated with IV vancomycin use, including the need to have an accurate patient weight for dosing, to provide close monitoring to ensure appropriate drug levels, to monitor renal function, and to continue delivery of the medication at prescribed intervals. There are numerous healthcare system factors, including workflow processes, policies, health information technology, and clinical knowledge that impact the safe use of IV vancomycin. Past literature has identified several safety hazards associated with IV vancomycin use and there are some proposed
solutions. Despite this literature, IV vancomycin–related safety issues persist. We analyzed patient safety event reports describing IV vancomycin–related issues in order to identify where in the medication process these issues were appearing, the type of medication error associated with each report, and general contributing factor themes. Our results demonstrate that recent safety reports are aligned with the issues already identified in the literature, suggesting that improvements discussed in the literature have not translated to clinical practice. Based on our analysis and current literature,
we have developed a shareable infographic to improve clinician awareness of the complications and safety hazards associated with IV vancomycin and a self-assessment tool to support identification of opportunities to improve patient safety during IV vancomycin therapy. We also recommend development of clear guidelines to optimize health information technology systems to better support safe IV vancomycin use.
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Affiliation(s)
- Adam Krukas
- MedStar Health National Center for Human Factors in Healthcare
| | - Ella Franklin
- MedStar Health National Center for Human Factors in Healthcare
| | - Chris Bonk
- MedStar Health National Center for Human Factors in Healthcare
| | - Jessica Howe
- MedStar Health National Center for Human Factors in Healthcare
| | - Ram Dixit
- MedStar Health National Center for Human Factors in Healthcare
| | - Katie Adams
- MedStar Health National Center for Human Factors in Healthcare
| | - Seth Krevat
- MedStar Health National Center for Human Factors in Healthcare
| | | | - Raj Ratwani
- MedStar Health National Center for Human Factors in Healthcare and Georgetown University School of Medicine
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55
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Buclin T, Thoma Y, Widmer N, André P, Guidi M, Csajka C, Decosterd LA. The Steps to Therapeutic Drug Monitoring: A Structured Approach Illustrated With Imatinib. Front Pharmacol 2020; 11:177. [PMID: 32194413 PMCID: PMC7062864 DOI: 10.3389/fphar.2020.00177] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 02/07/2020] [Indexed: 01/07/2023] Open
Abstract
Pharmacometric methods have hugely benefited from progress in analytical and computer sciences during the past decades, and play nowadays a central role in the clinical development of new medicinal drugs. It is time that these methods translate into patient care through therapeutic drug monitoring (TDM), due to become a mainstay of precision medicine no less than genomic approaches to control variability in drug response and improve the efficacy and safety of treatments. In this review, we make the case for structuring TDM development along five generic questions: 1) Is the concerned drug a candidate to TDM? 2) What is the normal range for the drug's concentration? 3) What is the therapeutic target for the drug's concentration? 4) How to adjust the dosage of the drug to drive concentrations close to target? 5) Does evidence support the usefulness of TDM for this drug? We exemplify this approach through an overview of our development of the TDM of imatinib, the very first targeted anticancer agent. We express our position that a similar story shall apply to other drugs in this class, as well as to a wide range of treatments critical for the control of various life-threatening conditions. Despite hurdles that still jeopardize progress in TDM, there is no doubt that upcoming technological advances will shape and foster many innovative therapeutic monitoring methods.
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Affiliation(s)
- Thierry Buclin
- Service of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Yann Thoma
- School of Management and Engineering Vaud (HEIG-VD), University of Applied Science Western Switzerland (HES-SO), Yverdon-les-Bains, Switzerland
| | - Nicolas Widmer
- Service of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland.,Pharmacy of Eastern Vaud Hospitals, Rennaz, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Pascal André
- Service of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Monia Guidi
- Service of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Chantal Csajka
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland.,Center for Research and Innovation in Clinical Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Laurent A Decosterd
- Service of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
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56
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Daylami AA, Sridharan K, Qader AM. Vancomycin nomograms in children admitted to an intensive care unit. DRUGS & THERAPY PERSPECTIVES 2020. [DOI: 10.1007/s40267-020-00708-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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57
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Stifft F, Vandermeer F, Neef C, van Kuijk S, Christiaans MHL. A limited sampling strategy to estimate exposure of once-daily modified release tacrolimus in renal transplant recipients using linear regression analysis and comparison with Bayesian population pharmacokinetics in different cohorts. Eur J Clin Pharmacol 2020; 76:685-693. [DOI: 10.1007/s00228-019-02814-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 12/05/2019] [Indexed: 11/30/2022]
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58
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Hartman SJF, Orriëns LB, Zwaag SM, Poel T, de Hoop M, de Wildt SN. External Validation of Model-Based Dosing Guidelines for Vancomycin, Gentamicin, and Tobramycin in Critically Ill Neonates and Children: A Pragmatic Two-Center Study. Paediatr Drugs 2020; 22:433-444. [PMID: 32507958 PMCID: PMC7383037 DOI: 10.1007/s40272-020-00400-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Dutch Pediatric Formulary (DPF) increasingly bases its guidelines on model-based dosing simulations from pharmacokinetic studies. This resulted in nationwide dose changes for vancomycin, gentamicin, and tobramycin in 2015. OBJECTIVE We aimed to evaluate target attainment of these altered, model-based doses in critically ill neonates and children. METHODS This was a retrospective cohort study in neonatal intensive care unit (NICU) and pediatric ICU (PICU) patients receiving vancomycin, gentamicin, or tobramycin between January 2015 and March 2017 in two university hospitals. The first therapeutic drug monitoring concentration for each patient was collected, as was clinical and dosing information. Vancomycin and tobramycin target trough concentrations were 10-15 and ≤ 1 mg/L, respectively. Target gentamicin trough and peak concentrations were < 1 and 8-12 mg/L, respectively. RESULTS In total, 482 patients were included (vancomycin [PICU] n = 62, [NICU] n = 102; gentamicin [NICU] n = 97; tobramycin [NICU] n = 221). Overall, median trough concentrations were within the target range for all cohorts but showed large interindividual variability, causing nontarget attainment. Trough concentrations were outside the target range in 66.1%, 60.8%, 14.7%, and 23.1% of patients in these four cohorts, respectively. Gentamicin peak concentrations were outside the range in 69% of NICU patients (term neonates 87.1%, preterm infants 57.1%). Higher creatinine concentrations were associated with higher vancomycin and tobramycin trough concentrations. CONCLUSION This study illustrates the need to validate model-based dosing advice in the real-world setting as both sub- and supratherapeutic concentrations of vancomycin, gentamicin, and tobramycin were very prevalent. Our data underline the necessity for further individualization by addressing the high interindividual variability to improve target attainment.
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Affiliation(s)
- Stan J. F. Hartman
- grid.10417.330000 0004 0444 9382Department of Pharmacology and Toxicology and Department of Intensive Care, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Lynn B. Orriëns
- grid.10417.330000 0004 0444 9382Department of Pharmacology and Toxicology and Department of Intensive Care, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Samanta M. Zwaag
- grid.10417.330000 0004 0444 9382Department of Pharmacology and Toxicology and Department of Intensive Care, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Tim Poel
- grid.10417.330000 0004 0444 9382Department of Pharmacology and Toxicology and Department of Intensive Care, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Marika de Hoop
- grid.489189.50000 0001 0708 7338Royal Dutch Pharmacists Association (KNMP), Den Haag, The Netherlands ,Dutch Knowledge Center Pharmacotherapy for Children, The Hague, The Netherlands
| | - Saskia N. de Wildt
- grid.10417.330000 0004 0444 9382Department of Pharmacology and Toxicology and Department of Intensive Care, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands ,grid.5645.2000000040459992XIntensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands ,Dutch Knowledge Center Pharmacotherapy for Children, The Hague, The Netherlands
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59
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Vinks AA, Peck RW, Neely M, Mould DR. Development and Implementation of Electronic Health Record–Integrated Model‐Informed Clinical Decision Support Tools for the Precision Dosing of Drugs. Clin Pharmacol Ther 2019; 107:129-135. [DOI: 10.1002/cpt.1679] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/14/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Alexander A. Vinks
- Division of Clinical Pharmacology Cincinnati Children's Hospital Medical Center Cincinnati Ohio USA
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - Richard W. Peck
- Pharma Research and Exploratory Development Roche Innovation Center Basel Basel Switzerland
| | - Michael Neely
- Children's Hospital Los Angeles University of Southern California Los Angeles California USA
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60
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He N, Su S, Yan Y, Liu W, Zhai S. The Benefit of Individualized Vancomycin Dosing Via Pharmacokinetic Tools: A Systematic Review and Meta-analysis. Ann Pharmacother 2019; 54:331-343. [PMID: 31694384 DOI: 10.1177/1060028019887363] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Various pharmacokinetic (PK) equations and software have been developed to individualize vancomycin dosing. However, the benefit of using any PK information to guide vancomycin dosing has not been fully elucidated. Objective: To appraise available evidence on the effectiveness and safety of individualized vancomycin dosing via PK tools. Methods: PubMed, EMBASE, the Cochrane Library, and 2 Chinese literature databases were searched through August 1, 2019. Randomized controlled trials (RCTs) and cohort studies that reported the PK and clinical outcomes of individualized vancomycin dosing versus empirical dosing were included. Pooled risk ratios (RRs) and mean differences were calculated for dichotomous and continuous outcomes, respectively. Results: A total of 21 studies involving 4346 patients were finally included, of which 3 were RCTs and 18 were cohort studies. Meta-analysis revealed that PK-guided vancomycin dosing significantly increased the attainment of target trough concentration (RR = 1.59; 95% CI = 1.49-1.70) and decreased the incidence of nephrotoxicity (RR = 0.57; 95% CI = 0.46-0.71). Additionally, the available evidence showed that target area under the curve/minimum inhibitory concentration attainment rate and time to target concentration could improve. However, the evidence on clinical outcomes was scarce, and no significant differences were detected in clinical response rate, microbiological eradication rate, mortality, and length of hospital stay between PK-guided vancomycin dosing and empirical dosing strategies. Conclusion and Relevance: Individualized vancomycin dosing via PK tools significantly increases the attainment of target trough concentration and decreases the incidence of nephrotoxicity. Evidence on clinical effectiveness was limited and showed no significant benefit. Further well-designed studies are warranted to assess its clinical effectiveness and inform routine care.
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Affiliation(s)
- Na He
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Shan Su
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Yingying Yan
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Wenxi Liu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
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Lim WXS, Chua WBB, Chua JM, Lee Q, Chan JW, Sultana R, Poh BH. A Retrospective Review of the Efficiency of First‐Dose Therapeutic Drug Monitoring of Gentamicin, Amikacin, and Vancomycin in the Pediatric Population. J Clin Pharmacol 2019; 60:7-15. [DOI: 10.1002/jcph.1509] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/28/2019] [Indexed: 01/05/2023]
Affiliation(s)
- Wan Xuan Selina Lim
- Department of PharmacyKK Women's and Children's Hospital Singhealth Singapore
| | | | - Jie Min Chua
- Department of PharmacyKK Women's and Children's Hospital Singhealth Singapore
| | - Qianyu Lee
- Department of PharmacyKK Women's and Children's Hospital Singhealth Singapore
| | - Jer Wei Chan
- Department of PharmacyKK Women's and Children's Hospital Singhealth Singapore
| | - Rehena Sultana
- Centre for Quantitative MedicineDuke‐National University of Singapore Singapore
| | - Bao Hui Poh
- Department of PharmacyKK Women's and Children's Hospital Singhealth Singapore
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62
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Avent ML, Rogers BA. Optimising antimicrobial therapy through the use of Bayesian dosing programs. Int J Clin Pharm 2019; 41:1121-1130. [PMID: 31392582 DOI: 10.1007/s11096-019-00886-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 07/27/2019] [Indexed: 01/06/2023]
Abstract
The optimisation of antibiotic dosing therapy with therapeutic drug monitoring is widely recommended. The aim of therapeutic drug monitoring is to help the clinician to achieve target pharmacokinetic/pharmacodynamic parameters, maximising efficacy and minimising toxicity. Computerised programs, utilising the Bayesian estimation procedures, are able to achieve target concentrations in a greater percentage of patients earlier in the course of therapy compared to linear regression analysis and population methods. This article summarises various methods for dose optimisation of antibiotics with a focus on Bayesian programs.
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Affiliation(s)
- M L Avent
- Infection and Immunity Theme, UQ Centre for Clinical Research (UQCCR), The University of Queensland, Level 5, Building 71/918 Royal Brisbane Hospital, Herston, QLD, 4006, Australia.
- Queensland Statewide Antimicrobial Stewardship Program, Royal Brisbane and Women's Hospital, Herston, QLD, Australia.
| | - B A Rogers
- Centre for Inflammatory Diseases, Monash University, Clayton, VIC, Australia
- Monash Infectious Diseases, Monash Health, Clayton, VIC, Australia
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Kumar AA, Burgard M, Stacey S, Sandaradura I, Lai T, Coorey C, Cincunegui M, Staatz CE, Hennig S. An evaluation of the user-friendliness of Bayesian forecasting programs in a clinical setting. Br J Clin Pharmacol 2019; 85:2436-2441. [PMID: 31313335 DOI: 10.1111/bcp.14066] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/25/2019] [Accepted: 07/02/2019] [Indexed: 12/29/2022] Open
Abstract
AIMS To evaluate 3 Bayesian forecasting (BF) programs-TDMx, InsightRx and DoseMe-on their user-friendliness and common liked and disliked features through a survey of hospital pharmacists. METHODS Clinical pharmacists across 3 Australian hospitals that did not use a BF program were invited to a BF workshop and complete a survey on programs they trialled. Participants were given 4 case scenarios to work through and asked to complete a 5-point Likert scale survey evaluating the program's user-friendliness. Liked and disliked features of each program were ascertained through written responses to open-ended questions. Survey results were compared using a χ2 test of equal or given proportions to identify significant differences in response. RESULTS Twenty-seven pharmacists, from hospitals, participated. BF programs were rated overall as user-friendly with 70%, 41% and 37% (P = .02) of participants recording a Likert score of 4 or 5 for DoseMe, TDMx and InsightRx, respectively. Participants found it easy to access all required information to use the programs, understood dosing recommendations and visualisations given by each program, and thought programs supported decision-making with >50% of participants scoring a 4 or 5 across the programs in these categories. Common liked features across all programs were the graphical displays and ease of data entry, while common disliked features were related to the units, layout and information display. CONCLUSION Although differences exist between programs, all 3 programs were most commonly rated as user-friendly across all themes evaluated, which provides useful information for healthcare facilities wanting to implement a BF program.
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Affiliation(s)
- Alzana A Kumar
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Marc Burgard
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Sonya Stacey
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia.,Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Indy Sandaradura
- Westmead Hospital, Westmead, NSW, Australia.,School of Medicine, The University of Sydney, Sydney, NSW, Australia
| | - Tony Lai
- The Children's Hospital at Westmead, Westmead, NSW, Australia
| | | | | | - Christine E Staatz
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Stefanie Hennig
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
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Choi R, Woo HI, Park HD, Lee SY. A nationwide utilization survey of therapeutic drug monitoring for five antibiotics in South Korea. Infect Drug Resist 2019; 12:2163-2173. [PMID: 31410036 PMCID: PMC6646174 DOI: 10.2147/idr.s208783] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 05/31/2019] [Indexed: 12/15/2022] Open
Abstract
Purpose The current status of therapeutic drug monitoring (TDM) assay utilization by clinical laboratories in South Korea remains little known. We investigated the TDM status of five antibiotics known for nephrotoxicity (vancomycin, amikacin, gentamicin, tobramycin, and teicoplanin) for the improvement of TDM in South Korea among patients with infectious diseases using a cross-sectional nationwide survey. Patients and methods We developed an online questionnaire and collected responses using a user-friendly web-based platform. The survey included questions about laboratory characteristics, implementation and operation of drug assays, implementation and operation of TDM consulting services, patient needs, and barriers to providing better TDM service including expectations and concerns about other platform-based drug assays. Results Among a total of 235 clinical laboratories, 112 (47.7%) responded, and 62 of the responding laboratories (55.4%) possessed drug assay facilities. Only 41.2% to 58.1% of respondents were providing TDM consulting services for each antibiotic. Respondents indicated that there are unmet needs regarding drug assays and TDM consultation as well as barriers to TDM utilization including high operating costs, lack of knowledge about TDM, lack of user-friendly software, lack of medical and laboratory information systems that can access patient information critical for TDM dose calculation, and reimbursement issues. Conclusion This study, the first nationwide survey addressing these questions, showed that there are barriers against the utilization of TDM in South Korea. These barriers may be addressed by improving drug assays and TDM consulting services with the goals of new analytical method development, better interpretation of results, consultation services, and quality control.
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Affiliation(s)
- Rihwa Choi
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Department of Laboratory Medicine, Green Cross Laboratories, Yongin, Gyeonggi, Republic of Korea
| | - Hye In Woo
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyung-Doo Park
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Soo-Youn Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Department of Clinical Pharmacology and Therapeutics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Groenland SL, Mathijssen RHJ, Beijnen JH, Huitema ADR, Steeghs N. Individualized dosing of oral targeted therapies in oncology is crucial in the era of precision medicine. Eur J Clin Pharmacol 2019; 75:1309-1318. [PMID: 31175385 DOI: 10.1007/s00228-019-02704-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 05/30/2019] [Indexed: 01/05/2023]
Abstract
PURPOSE While in the era of precision medicine, the right drug for each patient is selected based on molecular tumor characteristics, most novel oral targeted anticancer agents are still being administered using a one-size-fits-all fixed dosing approach. In this review, we discuss the scientific evidence for dose individualization of oral targeted therapies in oncology, based on therapeutic drug monitoring (TDM). METHODS Based on literature search and our own experiences, seven criteria for drugs to be suitable candidates for TDM will be addressed: (1) absence of an easily measurable biomarker for drug effect; (2) long-term therapy; (3) availability of a validated sensitive bioanalytical method; (4) significant variability in pharmacokinetic exposure; (5) narrow therapeutic range; (6) defined and consistent exposure-response relationships; (7) feasible dose-adaptation strategies. RESULTS All of these requirements are met for most oral targeted therapies in oncology. Also, prospective studies have already shown TDM to be feasible for imatinib, pazopanib, sunitinib, everolimus, and endoxifen. CONCLUSIONS In order to realize the full potential of personalized medicine in oncology, patients should not only be treated with the right drug, but also at the right dose. TDM could be a suitable tool to achieve this.
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Affiliation(s)
- Stefanie L Groenland
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Department of Clinical Pharmacy, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Neeltje Steeghs
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
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Abrantes JA, Jönsson S, Karlsson MO, Nielsen EI. Handling interoccasion variability in model-based dose individualization using therapeutic drug monitoring data. Br J Clin Pharmacol 2019; 85:1326-1336. [PMID: 30767254 DOI: 10.1111/bcp.13901] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 01/15/2019] [Accepted: 02/04/2019] [Indexed: 01/19/2023] Open
Abstract
AIMS This study aims to assess approaches to handle interoccasion variability (IOV) in a model-based therapeutic drug monitoring (TDM) context, using a population pharmacokinetic model of coagulation factor VIII as example. METHODS We assessed 5 model-based TDM approaches: empirical Bayes estimates (EBEs) from a model including IOV, with individualized doses calculated based on individual parameters either (i) including or (ii) excluding variability related to IOV; and EBEs from a model excluding IOV by (iii) setting IOV to zero, (iv) summing variances of interindividual variability (IIV) and IOV into a single IIV term, or (v) re-estimating the model without IOV. The impact of varying IOV magnitudes (0-50%) and number of occasions/observations was explored. The approaches were compared with conventional weight-based dosing. Predictive performance was assessed with the prediction error percentiles. RESULTS When IOV was lower than IIV, the accuracy was good for all approaches (50th percentile of the prediction error [P50] <7.4%), but the precision varied substantially between IOV magnitudes (P97.5 61-528%). Approach (ii) was the most precise forecasting method across a wide range of scenarios, particularly in case of sparse sampling or high magnitudes of IOV. Weight-based dosing led to less precise predictions than the model-based TDM approaches in most scenarios. CONCLUSIONS Based on the studied scenarios and theoretical expectations, the best approach to handle IOV in model-based dose individualization is to include IOV in the generation of the EBEs but exclude the portion of unexplained variability related to IOV in the individual parameters used to calculate the future dose.
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Affiliation(s)
- João A Abrantes
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Siv Jönsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Mats O Karlsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Elisabet I Nielsen
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
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Muller AE, Huttner B, Huttner A. Therapeutic Drug Monitoring of Beta-Lactams and Other Antibiotics in the Intensive Care Unit: Which Agents, Which Patients and Which Infections? Drugs 2019; 78:439-451. [PMID: 29476349 DOI: 10.1007/s40265-018-0880-z] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Antibiotics are among the medications most frequently administered to the critically ill, a population with high levels of intra- and inter-individual pharmacokinetic variability. Our knowledge of the relationships among antibiotic dosing, exposure and clinical effect in this population has increased in recent decades. Therapeutic drug monitoring (TDM) of serum antibiotic concentrations is the most practical means of assessing adequate antibiotic exposure, though until recently, it has been underutilised for this end. Now TDM is becoming more widespread, particularly for the beta-lactam antibiotics, a class historically thought to have a wide therapeutic range. We review the basic requirements, indications, and targets for effective TDM of the glycopeptides, aminoglycosides, quinolones and beta-lactam antibiotics in the adult intensive-care setting, with a special focus on TDM of the beta-lactam antibiotics, the most widely used antibiotic class.
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Affiliation(s)
- Anouk E Muller
- Department of Medical Microbiology, Haaglanden Medisch Centrum, The Hague, The Netherlands.,Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Benedikt Huttner
- Division of Infectious Diseases, University Hospitals of Geneva, Rue Gabrielle-Gentil-Perret 4, 1205, Geneva, Switzerland
| | - Angela Huttner
- Division of Infectious Diseases, University Hospitals of Geneva, Rue Gabrielle-Gentil-Perret 4, 1205, Geneva, Switzerland.
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Johannsen JO, Reuter H, Hoffmann F, Blaich C, Wiesen MH, Streichert T, Müller C. Reliable and easy-to-use LC–MS/MS-method for simultaneous determination of the antihypertensives metoprolol, amlodipine, canrenone and hydrochlorothiazide in patients with therapy-refractory arterial hypertension. J Pharm Biomed Anal 2019; 164:373-381. [DOI: 10.1016/j.jpba.2018.11.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 10/31/2018] [Accepted: 11/01/2018] [Indexed: 12/24/2022]
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69
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The dosing and monitoring of vancomycin: what is the best way forward? Int J Antimicrob Agents 2018; 53:401-407. [PMID: 30599240 DOI: 10.1016/j.ijantimicag.2018.12.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 12/19/2018] [Accepted: 12/22/2018] [Indexed: 11/22/2022]
Abstract
We have evaluated the literature to review optimal dosing and monitoring of intravenous vancomycin in adults, in response to evolving understanding of targets associated with efficacy and toxicity. The area under the total concentration-time curve (0-24 h) divided by the minimum inhibitory concentration (AUC24/MIC) is the most commonly accepted index to guide vancomycin dosing for the treatment of Staphylococcus aureus infections, with a value of 400 h a widely recommended target for efficacy. Upper limits of AUC24 exposure of around 700 (mg/L).h have been proposed, based on the hypothesis that higher exposures of vancomycin are associated with an unacceptable risk of nephrotoxicity. If AUC24/MIC targets are used, sources of variability in the assessment of both AUC24 and MIC need to be considered. Current consensus guidelines recommend measuring trough vancomycin concentrations during intermittent dosing as a surrogate for the AUC24. Trough concentrations are a misleading surrogate for AUC24 and a poor end-point in themselves. AUC24 estimation using log-linear pharmacokinetic methods based on two plasma concentrations, or Bayesian methods are superior. Alternatively, a single concentration measured during continuous infusion allows simple AUC24 estimation and dose-adjustment. All of these methods have logistical challenges which must be overcome if they are to be adopted successfully.
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Heil EL, Claeys KC, Mynatt RP, Hopkins TL, Brade K, Watt I, Rybak MJ, Pogue JM. Making the change to area under the curve–based vancomycin dosing. Am J Health Syst Pharm 2018; 75:1986-1995. [DOI: 10.2146/ajhp180034] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Emily L. Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, and Department of Pharmacy, University of Maryland Medical Center, Baltimore MD
| | - Kimberly C. Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, and Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
| | - Ryan P. Mynatt
- Department of Pharmacy, Detroit Receiving Hospital, Detroit Medical Center, Detroit, MI
| | - Teri L. Hopkins
- Department of Pharmacy, South Texas Veterans Health Care System, San Antonio, TX
| | - Karrine Brade
- Department of Pharmacy, Boston Medical Center, Boston, MA
| | - Ian Watt
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
| | - Michael J. Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Wayne State University, Detroit, MI, and Department of Pharmacy, Detroit Receiving Hospital, Detroit Medical Center, Detroit, MI
| | - Jason M. Pogue
- Department of Pharmacy, Sinai Grace Hospital, Detroit Medical Center, Detroit, MI
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72
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Pearce NF, Giblin EM, Buckthal C, Ferrari A, Powell JR, Cao Y, Patterson JH. Precision drug dosing: A major opportunity for patients and pharmacists. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2018. [DOI: 10.1002/jac5.1017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Natalie F. Pearce
- Division of Pharmacotherapy and Experimental Therapeutics UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - Erika M. Giblin
- Division of Pharmacotherapy and Experimental Therapeutics UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - Catherine Buckthal
- Division of Pharmacotherapy and Experimental Therapeutics UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - Alana Ferrari
- Division of Pharmacotherapy and Experimental Therapeutics UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - J. Robert Powell
- Division of Pharmacotherapy and Experimental Therapeutics UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - Yanguang Cao
- Division of Pharmacotherapy and Experimental Therapeutics UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - J. Herbert Patterson
- Division of Pharmacotherapy and Experimental Therapeutics UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill Chapel Hill North Carolina
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Bartoletti M, Lewis RE, Giannella M, Tedeschi S, Viale P. The role of extended infusion β-lactams in the treatment of bloodstream infections in patients with liver cirrhosis. Expert Rev Anti Infect Ther 2018; 16:771-779. [DOI: 10.1080/14787210.2018.1523716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Michele Bartoletti
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant’Orsola Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Russell Edward Lewis
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant’Orsola Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Maddalena Giannella
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant’Orsola Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Sara Tedeschi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant’Orsola Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant’Orsola Hospital, Alma Mater University of Bologna, Bologna, Italy
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74
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Euteneuer JC, Kamatkar S, Fukuda T, Vinks AA, Akinbi HT. Suggestions for Model-Informed Precision Dosing to Optimize Neonatal Drug Therapy. J Clin Pharmacol 2018; 59:168-176. [PMID: 30204236 DOI: 10.1002/jcph.1315] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/17/2018] [Indexed: 12/19/2022]
Abstract
Evidence for dosing, efficacy, and safety of most medications used to treat neonates is sparse. Thus, dosing is usually derived by extrapolation from adult and pediatric pharmacologic data with scaling by body weight or body surface area. This may lead to drug dosing that is unsafe or ineffective. However, new strategies are being developed and studied to dose medications in critically ill neonates. Mass spectroscopy technology capable of quickly analyzing drug levels is readily available. Software that integrates population pharmacokinetics and pharmacodynamics with data from sparse samples from neonates allows for timely adjustments of dosing to achieve the desired effect while minimizing adverse outcomes. Some genetic polymorphisms that affect drug response in neonates have also been reported. This review highlights aspects of drug response and how it is impacted by prematurity, assesses pharmacogenomic studies in neonates, and offers suggestions for innovative pharmacokinetic/pharmacodynamic model-based approaches that combine population- or physiology-based pharmacology data, Bayesian analysis, and electronic decision support tools for precision dosing in neonates while illustrating examples where this approach can be used to optimize medical therapy in neonates. Barriers to implementing precision dosing in neonates and how to overcome them are also discussed.
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Affiliation(s)
- Joshua C Euteneuer
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA.,Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Suyog Kamatkar
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Henry T Akinbi
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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75
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Roberts DM, Sevastos J, Carland JE, Stocker SL, Lea-Henry TN. Clinical Pharmacokinetics in Kidney Disease: Application to Rational Design of Dosing Regimens. Clin J Am Soc Nephrol 2018; 13:1254-1263. [PMID: 30042221 PMCID: PMC6086693 DOI: 10.2215/cjn.05150418] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A change in pharmacokinetics can alter drug exposure and predispose the patient to either over- or underdosing, potentially resulting in adverse drug reactions or therapeutic failure. Kidney disease is characterized by multiple physiologic effects, which induce clinically significant changes in pharmacokinetics. These vary between individuals and may be quantitated in certain instances. An understanding of pharmacokinetic concepts is, therefore, important for a rational approach to the design of drug dosing regimens for the delivery of personalized medical care. Whether kidney disease is acute or chronic, drug clearance decreases and the volume of distribution may remain unchanged or increase. AKI is defined by dynamic changes in kidney function, which complicates attempts to accurately quantify drug clearance. In contrast, changes in drug clearance progress more slowly with CKD. In general, kidney replacement therapies increase drug clearance, but the extent to which this occurs depends on the modality used and its duration, the drug's properties, and the timing of drug administration. However, the changes in drug handling associated with kidney disease are not isolated to reduced kidney clearance and an appreciation of the scale of potential derangements is important. In most instances, the first dose administered in patients with kidney disease is the same as in patients with normal kidney function. However, in some cases, a higher (loading) initial dose is given to rapidly achieve therapeutic concentrations, followed by a lower maintenance dose, as is well described when prescribing anti-infectives to patients with sepsis and AKI. This review provides an overview of how pharmacokinetic principles can be applied to patients with kidney disease to personalize dosage regimens. Patients with kidney disease are a vulnerable population and the increasing prevalence of kidney disease means that these considerations are important for all prescribers.
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Affiliation(s)
- Darren M. Roberts
- Departments of Clinical Pharmacology and Toxicology, and
- Department of Renal Medicine, The Canberra Hospital, Woden, Australian Capital Territory, Australia
- Medical School, Australian National University, Acton, Australian Capital Territory, Australia
| | - Jacob Sevastos
- Nephrology and Renal Transplantation, St. Vincent’s Hospital, Darlinghurst, New South Wales, Australia
- Department of Medicine, St. Vincent’s Clinical School, University of New South Wales, Sydney, Australia; and
| | - Jane E. Carland
- Departments of Clinical Pharmacology and Toxicology, and
- Department of Medicine, St. Vincent’s Clinical School, University of New South Wales, Sydney, Australia; and
| | - Sophie L. Stocker
- Departments of Clinical Pharmacology and Toxicology, and
- Department of Medicine, St. Vincent’s Clinical School, University of New South Wales, Sydney, Australia; and
| | - Tom N. Lea-Henry
- Department of Renal Medicine, The Canberra Hospital, Woden, Australian Capital Territory, Australia
- Nephrology and Transplantation Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
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de Velde F, Mouton JW, de Winter BCM, van Gelder T, Koch BCP. Clinical applications of population pharmacokinetic models of antibiotics: Challenges and perspectives. Pharmacol Res 2018; 134:280-288. [PMID: 30033398 DOI: 10.1016/j.phrs.2018.07.005] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/05/2018] [Accepted: 07/05/2018] [Indexed: 11/26/2022]
Abstract
Because of increasing antimicrobial resistance and the shortage of new antibiotics, there is a growing need to optimize the use of old and new antibiotics. Modelling of the pharmacokinetic/pharmacodynamic (PK/PD) characteristics of antibiotics can support the optimization of dosing regimens. Antimicrobial efficacy is determined by susceptibility of the drug to the microorganism and exposure to the drug, which relies on the PK and the dose. Population PK models describe relationships between patients characteristics and drug exposure. This article highlights three clinical applications of these models applied to antibiotics: 1) dosing evaluation of old antibiotics, 2) setting clinical breakpoints and 3) dosing individualization using therapeutic drug monitoring (TDM). For each clinical application, challenges regarding interpretation are discussed. An important challenge is to improve the understanding of the interpretation of modelling results for good implementation of the dosing recommendations, clinical breakpoints and TDM advices. Therefore, also background information on PK/PD principles and approaches to analyse PK/PD data are provided.
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Affiliation(s)
- Femke de Velde
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands.
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Brenda C M de Winter
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands; Department of Hospital Pharmacy, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
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77
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Li ZL, Liu YX, Jiao Z, Qiu G, Huang JQ, Xiao YB, Wu SJ, Wang CY, Hu WJ, Sun HJ. Population Pharmacokinetics of Vancomycin in Chinese ICU Neonates: Initial Dosage Recommendations. Front Pharmacol 2018; 9:603. [PMID: 29997498 PMCID: PMC6029141 DOI: 10.3389/fphar.2018.00603] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 05/21/2018] [Indexed: 01/21/2023] Open
Abstract
The main goal of our study was to characterize the population pharmacokinetics of vancomycin in critically ill Chinese neonates to develop a pharmacokinetic model and investigate factors that have significant influences on the pharmacokinetics of vancomycin in this population. The study population consisted of 80 neonates in the neonatal intensive care unit (ICU) from which 165 trough and peak concentrations of vancomycin were obtained. Nonlinear mixed effect modeling was used to develop a population pharmacokinetic model for vancomycin. The stability and predictive ability of the final model were evaluated based on diagnostic plots, normalized prediction distribution errors and the bootstrap method. Serum creatinine (Scr) and body weight were significant covariates on the clearance of vancomycin. The average clearance was 0.309 L/h for a neonate with Scr of 23.3 μmol/L and body weight of 2.9 kg. No obvious ethnic differences in the clearance of vancomycin were found relative to the earlier studies of Caucasian neonates. Moreover, the established model indicated that in patients with a greater renal clearance status, especially Scr < 15 μmol/L, current guideline recommendations would likely not achieve therapeutic area under the concentration-time curve over 24 h/minimum inhibitory concentration (AUC24h/MIC) ≥ 400. The exceptions to this are British National Formulary (2016-2017), Blue Book (2016) and Neofax (2017). Recommended dose regimens for neonates with different Scr levels and postmenstrual ages were estimated based on Monte Carlo simulations and the established model. These findings will be valuable for developing individualized dosage regimens in the neonatal ICU setting.
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Affiliation(s)
- Zhi-ling Li
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yi-xi Liu
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Zheng Jiao
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Gang Qiu
- Department of Neonatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jian-quan Huang
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yu-bo Xiao
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
- Department of Pharmacy, Renmin Hospital of Wuhan University, Wuhan, China
| | - Shu-jin Wu
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
- Department of Pharmacy, Gansu Provincial Hospital, Lanzhou, China
| | - Chen-yu Wang
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Wen-juan Hu
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Hua-jun Sun
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Abulfathi AA, Chirehwa M, Rosenkranz B, Decloedt EH. Evaluation of the Effectiveness of Dose Individualization to Achieve Therapeutic Vancomycin Concentrations. J Clin Pharmacol 2018; 58:1134-1139. [DOI: 10.1002/jcph.1254] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 04/08/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Ahmed A. Abulfathi
- Division of Clinical Pharmacology; Department of Medicine; Faculty of Medicine and Health Sciences; University of Stellenbosch; South Africa
| | - Maxwell Chirehwa
- Biostatistics Unit; Centre for Evidence Based Health Care (CEHBC); Faculty of Medicine and Health Sciences; University of Stellenbosch; South Africa
| | - Bernd Rosenkranz
- Division of Clinical Pharmacology; Department of Medicine; Faculty of Medicine and Health Sciences; University of Stellenbosch; South Africa
| | - Eric H. Decloedt
- Division of Clinical Pharmacology; Department of Medicine; Faculty of Medicine and Health Sciences; University of Stellenbosch; South Africa
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Woillard JB, Saint-Marcoux F, Debord J, Åsberg A. Pharmacokinetic models to assist the prescriber in choosing the best tacrolimus dose. Pharmacol Res 2018; 130:316-321. [DOI: 10.1016/j.phrs.2018.02.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 01/10/2018] [Accepted: 02/12/2018] [Indexed: 12/20/2022]
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80
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Donagher J, Martin JH, Barras MA. Individualised medicine: why we need Bayesian dosing. Intern Med J 2018; 47:593-600. [PMID: 28503880 DOI: 10.1111/imj.13412] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 12/25/2016] [Accepted: 12/26/2016] [Indexed: 11/29/2022]
Abstract
Individualised drug dosing has been shown to improve patient outcomes and reduce adverse drug events. One method of individualised medicine is the Bayesian approach, which uses prior information about how the population responds to therapy, to inform clinicians about how a specific individual is responding to their current therapy. This information is then used to make changes to the dose. Studies using a Bayesian approach to adjust drug dosing have shown that clinicians are able to achieve a therapeutic range quicker than standard practice. If concentration is related to a pharmacodynamic end-point, this means that the drug will be more effective, and the side-effects will be minimised. Unfortunately, the software options to assist with Bayesian dosing in Australia are limited. The aims of this article are to demystify the concepts of Bayesian dosing, set the context of the Bayesian approach using reference to other dosing strategies and discuss its benefits over current dosing methods for a number of drugs. The article is targeted to medical and pharmacy clinicians, and there is a practical clinical case to demonstrate how this method could be used in everyday clinical practice.
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Affiliation(s)
- Joni Donagher
- Department of Pharmacy, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jennifer H Martin
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Michael A Barras
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia.,Pharmacy Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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81
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DosOpt: A Tool for Personalized Bayesian Dose Adjustment of Vancomycin in Neonates. Ther Drug Monit 2017; 39:604-613. [DOI: 10.1097/ftd.0000000000000456] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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82
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Šíma M, Bakhouche H, Hartinger J, Cikánková T, Slanař O. Therapeutic drug monitoring of antibiotic agents: evaluation of predictive performance. Eur J Hosp Pharm 2017; 26:85-88. [PMID: 31157105 DOI: 10.1136/ejhpharm-2017-001396] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 10/09/2017] [Accepted: 10/10/2017] [Indexed: 01/24/2023] Open
Abstract
Background The precision of the population pharmacokinetic model used in therapeutic drug monitoring (TDM) is essential for successful dosage optimisation. Objective To evaluate the predictive performance of pharmacokinetic models used in our hospital and to evaluate the possible impact of demographic characteristics or renal function on TDM accuracy. Methods We compared a posteriori an adjusted concentration-time curve profile based on the first measured drug concentration with the second measured drug concentration. Linear regression models were used to compare predicted and observed drug serum concentrations, and to evaluate potential relationships between predictive performance and patients´ demographic/clinical features. Predictive performance of TDM was expressed using accuracy, precision, sensitivity and specificity. Results One hundred and fifty-two patients were enrolled in the study. All pharmacokinetic models showed good predictive performance expressed by the coefficient of determination (r2) of 0.5642, 0.7263, 0.9001 and 0.9454 for continuous vancomycin, intermittent vancomycin, amikacin and gentamicin, respectively. Accuracy was 93.3%, 91.2%, 113.9% and 130.9% for continuous vancomycin, intermittent vancomycin, amikacin and gentamicin, respectively. Demographic characteristics or renal functions had no substantial impact on the accuracy of TDM. Conclusion We found the predictive performance of both aminoglycosides and vancomycin pharmacokinetic models to be satisfactory.
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Affiliation(s)
- Martin Šíma
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Praha, Czech Republic
| | - Hana Bakhouche
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Praha, Czech Republic
| | - Jan Hartinger
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Praha, Czech Republic
| | - Tereza Cikánková
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Praha, Czech Republic
| | - Ondřej Slanař
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Praha, Czech Republic
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83
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Mizuno K, Dong M, Fukuda T, Chandra S, Mehta PA, McConnell S, Anaissie EJ, Vinks AA. Population Pharmacokinetics and Optimal Sampling Strategy for Model-Based Precision Dosing of Melphalan in Patients Undergoing Hematopoietic Stem Cell Transplantation. Clin Pharmacokinet 2017; 57:625-636. [DOI: 10.1007/s40262-017-0581-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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84
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Dong M, Mizuno T, Vinks AA. Opportunities for model-based precision dosing in the treatment of sickle cell anemia. Blood Cells Mol Dis 2017; 67:143-147. [PMID: 28807656 DOI: 10.1016/j.bcmd.2017.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 08/07/2017] [Indexed: 12/16/2022]
Abstract
Hydroxyurea is the primary pharmacotherapy to prevent complications of sickle cell anemia (SCA). Accumulated clinical experience across multiple age ranges has suggested that the use of an individualized maximum tolerated dose (MTD) will achieve optimal benefit of hydroxyurea treatment. However, the current empirical and trial-and-error approach for dose escalation often results in a lengthy titration process and is not strictly implemented in many clinics. Opportunities exist for pharmacokinetics model-based precision dosing of hydroxyurea to quickly achieve individual MTD. This review intends to introduce the use of a quantitative modeling approach including a Bayesian adaptive control strategy for the precision dosing of hydroxyurea. The rationale and practical considerations for the implementation of this approach are discussed. Future research directions with a focus on integrating specific safety and other clinical outcome endpoints into dose selection decision making are also discussed.
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Affiliation(s)
- Min Dong
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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85
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Continuous and Prolonged Intravenous β-Lactam Dosing: Implications for the Clinical Laboratory. Clin Microbiol Rev 2017; 29:759-72. [PMID: 27413094 DOI: 10.1128/cmr.00022-16] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Beta-lactam antibiotics serve as a cornerstone in the management of bacterial infections because of their wide spectrum of activity and low toxicity. Since resistance rates among bacteria are continuously on the rise and the pipeline for new antibiotics does not meet this trend, an optimization of current beta-lactam treatment is needed. This review provides an overview of optimization through use of prolonged- and continuous-infusion dosing strategies compared with more traditional intermittent infusions. Included is an overview of the scientific basis for using these nontraditional prolonged- and continuous-infusion-based regimens, with a focus on major areas in which the clinical laboratory can support the clinical use of these regimens.
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86
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Darwich AS, Ogungbenro K, Vinks AA, Powell JR, Reny JL, Marsousi N, Daali Y, Fairman D, Cook J, Lesko LJ, McCune JS, Knibbe CAJ, de Wildt SN, Leeder JS, Neely M, Zuppa AF, Vicini P, Aarons L, Johnson TN, Boiani J, Rostami-Hodjegan A. Why Has Model-Informed Precision Dosing Not Yet Become Common Clinical Reality? Lessons From the Past and a Roadmap for the Future. Clin Pharmacol Ther 2017; 101:646-656. [DOI: 10.1002/cpt.659] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 02/07/2017] [Accepted: 02/07/2017] [Indexed: 12/17/2022]
Affiliation(s)
- A S Darwich
- Centre for Applied Pharmacokinetic Research, Division of Pharmacy and Optometry; University of Manchester; Manchester UK
| | - K Ogungbenro
- Centre for Applied Pharmacokinetic Research, Division of Pharmacy and Optometry; University of Manchester; Manchester UK
| | - A A Vinks
- Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
- Department of Pediatrics; University of Cincinnati School of medicine; Cincinnati Ohio USA
| | - J R Powell
- Eshelman School of Pharmacy; University of North Carolina; Chapel Hill North Carolina USA
| | - J-L Reny
- Geneva Platelet Group, School of Medicine; University of Geneva; Geneva Switzerland
- Department of Internal Medicine, Rehabilitation and Geriatrics; Geneva University Hospitals; Geneva Switzerland
| | - N Marsousi
- Clinical Pharmacology and Toxicology; Geneva University Hospitals; Geneva Switzerland
| | - Y Daali
- Geneva Platelet Group, School of Medicine; University of Geneva; Geneva Switzerland
- Clinical Pharmacology and Toxicology; Geneva University Hospitals; Geneva Switzerland
| | - D Fairman
- Clinical Pharmacology Modeling and Simulation, GSK Stevenage; UK
| | - J Cook
- Clinical Pharmacology, Pfizer Inc; Groton Connecticut USA
| | - L J Lesko
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology; University of Florida at Lake Nona (Orlando); Orlando Florida USA
| | - J S McCune
- University of Washington Department of Pharmaceutics and Fred Hitchinson Cancer Research Center Clinical Research Division; Seattle Washington USA
| | - C A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, the Netherlands and Division of Pharmacology, Leiden Academic Centre for Drug Research; Leiden University; the Netherlands
| | - S N de Wildt
- Department of Pharmacology and Toxicology; Radboud University; Nijmegen the Netherlands
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital; Rotterdam the Netherlands
| | - J S Leeder
- Division of Pediatric Pharmacology and Medical Toxicology, Department of Pediatrics, Children's Mercy Hospitals and Clinics; Kansas City Missouri USA
- Department of Pharmacology; University of Missouri-Kansas City; Kansas City Missouri USA
| | - M Neely
- University of Southern California and the Children's Hospital of Los Angeles; Los Angeles California USA
| | - A F Zuppa
- Children's Hospital of Philadelphia; Philadelphia Pennsylvania USA
| | - P Vicini
- Clinical Pharmacology, Pharmacometrics and DMPK, MedImmune; Cambridge UK
| | - L Aarons
- Centre for Applied Pharmacokinetic Research, Division of Pharmacy and Optometry; University of Manchester; Manchester UK
| | - T N Johnson
- Certara, Blades Enterprise Centre; Sheffield UK
| | - J Boiani
- Epstein Becker & Green; Washington DC USA
| | - A Rostami-Hodjegan
- Centre for Applied Pharmacokinetic Research, Division of Pharmacy and Optometry; University of Manchester; Manchester UK
- Epstein Becker & Green; Washington DC USA
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87
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Al-Metwali B, Mulla H. Personalised dosing of medicines for children. J Pharm Pharmacol 2017; 69:514-524. [DOI: 10.1111/jphp.12709] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 01/12/2017] [Indexed: 12/16/2022]
Abstract
Abstract
Objectives
Doses for most drugs are determined from population-level information, resulting in a standard ?one-size-fits-all’ dose range for all individuals. This review explores how doses can be personalised through the use of the individuals’ pharmacokinetic (PK)-pharmacodynamic (PD) profile, its particular application in children, and therapy areas where such approaches have made inroads.
Key findings
The Bayesian forecasting approach, based on population PK/PD models that account for variability in exposure and response, is a potent method for personalising drug therapy. Its potential utility is even greater in young children where additional sources of variability are observed such as maturation of eliminating enzymes and organs. The benefits of personalised dosing are most easily demonstrated for drugs with narrow therapeutic ranges such as antibiotics and cytotoxics and limited studies have shown improved outcomes. However, for a variety of reasons the approach has struggled to make more widespread impact at the bedside: complex dosing algorithms, high level of technical skills required, lack of randomised controlled clinical trials and the need for regulatory approval.
Summary
Personalised dosing will be a necessary corollary of the new precision medicine initiative. However, it faces a number of challenges that need to be overcome before such an approach to dosing in children becomes the norm.
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Affiliation(s)
- Basma Al-Metwali
- School of Pharmacy, De Montfort University, Leicester, UK
- Department of Pharmacy, Glenfield Hospital, University Hospitals of Leicester, Leicester, UK
| | - Hussain Mulla
- Department of Pharmacy, Glenfield Hospital, University Hospitals of Leicester, Leicester, UK
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88
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Neely M. Scalpels not hammers: The way forward for precision drug prescription. Clin Pharmacol Ther 2017; 101:368-372. [PMID: 27984653 DOI: 10.1002/cpt.593] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 12/06/2016] [Accepted: 12/08/2016] [Indexed: 12/24/2022]
Affiliation(s)
- M Neely
- Children's Hospital Los Angeles and the University of Southern California, Los Angeles, California, USA
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89
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Nekka F, Csajka C, Wilbaux M, Sanduja S, Li J, Pfister M. Pharmacometrics-based decision tools facilitate mHealth implementation. Expert Rev Clin Pharmacol 2016; 10:39-46. [PMID: 27813436 DOI: 10.1080/17512433.2017.1251837] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION The healthcare system is experiencing a paradigm shift in delivering its services, evolving from a reactive 'one size-fits-all' structure to a patient-centric model focusing on individualized medicine. This change is driven by scientific progress, including quantitative evaluation and optimization of treatment strategies through pharmacometric approaches, harnessing the power of the digital revolution. Areas covered: This review describes four main steps to apply pharmacometrics-based decision support tools, consisting of validated scientific components, available technical options, consideration of regulatory aspects, and achievement of efficient commercialization. Examples of pharmacometrics-based decision tools that support monitoring of patients and individualization of treatment strategies in neonates, children and adults are presented. Expert commentary: We envision that user-friendly decision support tools will facilitate implementation of mobile health approaches (mHealth) realizing benefits to paediatric and adult patients and their caregivers.
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Affiliation(s)
- Fahima Nekka
- a NSERC-Industrial Chair in Pharmacometrics, Full Professor, Faculty of Pharmacy , Université de Montréal , Montreal , Qc , Canada
| | - Chantal Csajka
- b Division of Pharmacology and Toxicology , Lausanne University Hospital, Head Research Unit , Lausanne , Switzerland
| | - Mélanie Wilbaux
- c Pharmacometrician , University Children's Hospital Basel (UKBB), Paediatric Pharmacology and Pharmacometrics , Basel , Switzerland
| | | | - Jun Li
- e Faculty of Pharmacy , Université de Montréal , Montreal , Qc , Canada
| | - Marc Pfister
- f Vice-Chair Paediatric Pharmacology and Pharmacometrics , University Children's Hospital Basel (UKBB) , Basel , Switzerland
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90
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Decosterd L, Widmer N, André P, Aouri M, Buclin T. The emerging role of multiplex tandem mass spectrometry analysis for therapeutic drug monitoring and personalized medicine. Trends Analyt Chem 2016. [DOI: 10.1016/j.trac.2016.03.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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91
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Standing JF. Understanding and applying pharmacometric modelling and simulation in clinical practice and research. Br J Clin Pharmacol 2016; 83:247-254. [PMID: 27567102 PMCID: PMC5237699 DOI: 10.1111/bcp.13119] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 08/12/2016] [Accepted: 08/16/2016] [Indexed: 12/13/2022] Open
Abstract
Understanding the dose–concentration–effect relationship is a fundamental component of clinical pharmacology. Interpreting data arising from observations of this relationship requires the use of mathematical models; i.e. pharmacokinetic (PK) models to describe the relationship between dose and concentration and pharmacodynamic (PD) models describing the relationship between concentration and effect. Drug development requires several iterations of pharmacometric model‐informed learning and confirming. This includes modelling to understand the dose–response in preclinical studies, deriving a safe dose for first‐in‐man, and the overall analysis of Phase I/II data to optimise the dose for safety and efficacy in Phase III pivotal trials. However, drug development is not the boundary at which PKPD understanding and application stops. PKPD concepts will be useful to anyone involved in the prescribing and administration of medicines for purposes such as determining off‐label dosing in special populations, individualising dosing based on a measured biomarker (personalised medicine) and in determining whether lack of efficacy or unexpected toxicity maybe solved by adjusting the dose rather than the drug. In clinical investigator‐led study design, PKPD can be used to ensure the optimal dose is used, and crucially to define the expected effect size, thereby ensuring power calculations are based on sound prior information. In the clinical setting the most likely people to hold sufficient expertise to advise on PKPD matters will be the pharmacists and clinical pharmacologists. This paper reviews fundamental PKPD principles and provides some real‐world examples of PKPD use in clinical practice and applied clinical research.
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Affiliation(s)
- Joseph F Standing
- Infection, Immunity, Inflammation Section, UCL Institute of Child Health, 30 Guilford Street, London, WC1N 1EH.,Department of Pharmacy, Great Ormond Street Hospital for Children, London, WC1N 3JH.,Paediatric Infectious Diseases Research Group, St George's, University of London, Cranmer Terrace, London, SW17 0RE
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92
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Sibertin-Blanc C, Ciccolini J, Norguet E, Lacarelle B, Dahan L, Seitz JF. Monoclonal antibodies for treating gastric cancer: promises and pitfalls. Expert Opin Biol Ther 2016; 16:759-69. [PMID: 26971395 DOI: 10.1517/14712598.2016.1164137] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Gastric cancer (GC) presents dismal prognosis when diagnosed at advanced stages, standard chemotherapy having shown little efficacy. Introduction of biotherapies interfering with novel targets and signaling pathways is currently an emerging strategy. AREAS COVERED Only two monoclonal antibodies (trastuzumab and ramucirumab) have been approved, mostly in association with cytotoxics. Conversely, testing other promising biotherapies (panitumumab, cetuximab, bevacizumab, rilotumumab) have yielded conflicting results, since encouraging early clinical trials have failed to be confirmed in larger phase-III studies. Empirical and underpowered strategies when designing combinational studies, lack of comprehensive knowledge of pharmacokinetics/pharmacodynamics (PK/PD) relationships, and underestimation of the large inter-patient variability in drug exposure levels with monoclonal antibodies, could explain the failures in developing biotherapies in gastric cancer. This review covers the achievements and limits of monoclonal antibodies in gastric cancer and proposes clues to overcome current failures. EXPERT OPINION Trastuzumab efficacy could be improved thanks to its combination with triplet chemotherapy or with another anti-HER2 agents or in continuation during second-line chemotherapy. Concerning ramucirumab, further studies are necessary to prove its interest in first line treatment of advanced GC, to use the optimal dose in each patient-given the large inter-patients variability, and to find predictive biomarkers of efficacy.
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Affiliation(s)
- Camille Sibertin-Blanc
- a Department of Digestive Oncology , Aix-Marseille University - Assistance Publique Hôpitaux de Marseille , Marseille , France
| | - Joseph Ciccolini
- b Laboratoire de Pharmacocinétique , SMARTc Inserm S_911 CRO2 Aix Marseille University , Marseille , France
| | - Emmanuelle Norguet
- a Department of Digestive Oncology , Aix-Marseille University - Assistance Publique Hôpitaux de Marseille , Marseille , France
| | - Bruno Lacarelle
- b Laboratoire de Pharmacocinétique , SMARTc Inserm S_911 CRO2 Aix Marseille University , Marseille , France
| | - Laetitia Dahan
- a Department of Digestive Oncology , Aix-Marseille University - Assistance Publique Hôpitaux de Marseille , Marseille , France
| | - Jean-François Seitz
- a Department of Digestive Oncology , Aix-Marseille University - Assistance Publique Hôpitaux de Marseille , Marseille , France
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93
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Ciccolini J, Serdjebi C, Le Thi Thu H, Lacarelle B, Milano G, Fanciullino R. Nucleoside analogs: ready to enter the era of precision medicine? Expert Opin Drug Metab Toxicol 2016; 12:865-77. [DOI: 10.1080/17425255.2016.1192128] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Joseph Ciccolini
- SMARTc Unit, Inserm S_911 CRO2 Aix-Marseille University, Marseille, France
| | - Cindy Serdjebi
- Assistance Publique Hôpitaux de Marseille. Multidisciplinary Oncology & Therapeutic Innovations dpt, Aix Marseille University, Marseille, France
| | - Hau Le Thi Thu
- SMARTc Unit, Inserm S_911 CRO2 Aix-Marseille University, Marseille, France
| | - Bruno Lacarelle
- SMARTc Unit, Inserm S_911 CRO2 Aix-Marseille University, Marseille, France
| | - Gerard Milano
- Oncopharmacology Unit, Centre Antoine Lacassagne, Nice, France
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94
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Brooks E, Tett SE, Isbel NM, Staatz CE. Population Pharmacokinetic Modelling and Bayesian Estimation of Tacrolimus Exposure: Is this Clinically Useful for Dosage Prediction Yet? Clin Pharmacokinet 2016; 55:1295-1335. [DOI: 10.1007/s40262-016-0396-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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95
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Wilbaux M, Fuchs A, Samardzic J, Rodieux F, Csajka C, Allegaert K, van den Anker JN, Pfister M. Pharmacometric Approaches to Personalize Use of Primarily Renally Eliminated Antibiotics in Preterm and Term Neonates. J Clin Pharmacol 2016; 56:909-35. [PMID: 26766774 DOI: 10.1002/jcph.705] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 01/05/2016] [Accepted: 01/06/2016] [Indexed: 12/13/2022]
Abstract
Sepsis remains a major cause of mortality and morbidity in neonates, and, as a consequence, antibiotics are the most frequently prescribed drugs in this vulnerable patient population. Growth and dynamic maturation processes during the first weeks of life result in large inter- and intrasubject variability in the pharmacokinetics (PK) and pharmacodynamics (PD) of antibiotics. In this review we (1) summarize the available population PK data and models for primarily renally eliminated antibiotics, (2) discuss quantitative approaches to account for effects of growth and maturation processes on drug exposure and response, (3) evaluate current dose recommendations, and (4) identify opportunities to further optimize and personalize dosing strategies of these antibiotics in preterm and term neonates. Although population PK models have been developed for several of these drugs, exposure-response relationships of primarily renally eliminated antibiotics in these fragile infants are not well understood, monitoring strategies remain inconsistent, and consensus on optimal, personalized dosing of these drugs in these patients is absent. Tailored PK/PD studies and models are useful to better understand relationships between drug exposures and microbiological or clinical outcomes. Pharmacometric modeling and simulation approaches facilitate quantitative evaluation and optimization of treatment strategies. National and international collaborations and platforms are essential to standardize and harmonize not only studies and models but also monitoring and dosing strategies. Simple bedside decision tools assist clinical pharmacologists and neonatologists in their efforts to fine-tune and personalize the use of primarily renally eliminated antibiotics in term and preterm neonates.
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Affiliation(s)
- Mélanie Wilbaux
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Aline Fuchs
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Janko Samardzic
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland.,Institute of Pharmacology, Clinical Pharmacology and Toxicology, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Frédérique Rodieux
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Chantal Csajka
- Division of Clinical Pharmacology, Service of Biomedicine, Department of Laboratory, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Department of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Belgium.,Intensive Care and Department of Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Johannes N van den Anker
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland.,Intensive Care and Department of Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Marc Pfister
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland.,Quantitative Solutions LP, Menlo Park, CA, USA
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96
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Abdel-Rahman SM, Breitkreutz ML, Bi C, Matzuka BJ, Dalal J, Casey KL, Garg U, Winkle S, Leeder JS, Breedlove J, Rivera B. Design and Testing of an EHR-Integrated, Busulfan Pharmacokinetic Decision Support Tool for the Point-of-Care Clinician. Front Pharmacol 2016; 7:65. [PMID: 27065859 PMCID: PMC4811899 DOI: 10.3389/fphar.2016.00065] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/07/2016] [Indexed: 12/12/2022] Open
Abstract
Background: Busulfan demonstrates a narrow therapeutic index for which clinicians routinely employ therapeutic drug monitoring (TDM). However, operationalizing TDM can be fraught with inefficiency. We developed and tested software encoding a clinical decision support tool (DST) that is embedded into our electronic health record (EHR) and designed to streamline the TDM process for our oncology partners. Methods: Our development strategy was modeled based on the features associated with successful DSTs. An initial Requirements Analysis was performed to characterize tasks, information flow, user needs, and system requirements to enable push/pull from the EHR. Back-end development was coded based on the algorithm used when manually performing busulfan TDM. The code was independently validated in MATLAB using 10,000 simulated patient profiles. A 296-item heuristic checklist was used to guide design of the front-end user interface. Content experts and end-users (n = 28) were recruited to participate in traditional usability testing under an IRB approved protocol. Results: Decision support software was developed to systematically walk the point-of-care clinician through the TDM process. The system is accessed through the EHR which transparently imports all of the requisite patient data. Data are visually inspected and then curve fit using a model-dependent approach. Quantitative goodness-of-fit are converted to single tachometer where “green” alerts the user that the model is strong, “yellow” signals caution and “red” indicates that there may be a problem with the fitting. Override features are embedded to permit application of a model-independent approach where appropriate. Simulations are performed to target a desired exposure or dose as entered by the clinician and the DST pushes the user approved recommendation back into the EHR. Usability testers were highly satisfied with our DST and quickly became proficient with the software. Conclusions: With early and broad stake-holder engagement we developed a clinical DST for the non-pharmacologist. This tools affords our clinicians the ability to seamlessly transition from patient assessment, to pharmacokinetic modeling and simulation, and subsequent prescription order entry.
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Affiliation(s)
- Susan M Abdel-Rahman
- Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy HospitalKansas City, MO, USA; Department of Pediatrics, University of Missouri-Kansas City School of MedicineKansas City, MO, USA
| | | | - Charlie Bi
- Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy Hospital Kansas City, MO, USA
| | - Brett J Matzuka
- Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy Hospital Kansas City, MO, USA
| | - Jignesh Dalal
- Division of Hematology/Oncology, Rainbow Babies and Children's Hospital, Case Western Reserve University Cleveland, OH, USA
| | - K Leigh Casey
- Department of Pharmacy, Children's Mercy Hospital Kansas City, MO, USA
| | - Uttam Garg
- Department of Pediatrics, University of Missouri-Kansas City School of MedicineKansas City, MO, USA; Department of Laboratory Medicine, Children's Mercy HospitalKansas City, MO, USA
| | - Sara Winkle
- Department of Information Systems, Children's Mercy Hospital Kansas City, MO, USA
| | - J Steven Leeder
- Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy HospitalKansas City, MO, USA; Department of Pediatrics, University of Missouri-Kansas City School of MedicineKansas City, MO, USA
| | - JeanAnn Breedlove
- Department of Information Systems, Children's Mercy Hospital Kansas City, MO, USA
| | - Brian Rivera
- Department of Information Systems, Children's Mercy Hospital Kansas City, MO, USA
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97
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Moes DJAR, Swen JJ, van der Bent SAS, van der Straaten T, Inderson A, Olofsen E, Verspaget HW, Guchelaar HJ, den Hartigh J, van Hoek B. Response: Limited sampling strategies for once daily tacrolimus exposure monitoring. Eur J Clin Pharmacol 2016; 72:775-6. [PMID: 26931555 DOI: 10.1007/s00228-016-2036-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 02/25/2016] [Indexed: 12/01/2022]
Affiliation(s)
- D J A R Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands.
| | - J J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - S A S van der Bent
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - T van der Straaten
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - A Inderson
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - E Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - H W Verspaget
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - H J Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - J den Hartigh
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - B van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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98
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Mould DR, D'Haens G, Upton RN. Clinical Decision Support Tools: The Evolution of a Revolution. Clin Pharmacol Ther 2016; 99:405-18. [PMID: 26785109 DOI: 10.1002/cpt.334] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 01/06/2016] [Accepted: 01/07/2016] [Indexed: 12/23/2022]
Abstract
Dashboard systems for clinical decision support integrate data from multiple sources. These systems, the newest in a long line of dose calculators and other decision support tools, utilize Bayesian approaches to fully individualize dosing using information gathered through therapeutic drug monitoring. In the treatment of inflammatory bowel disease patients with infliximab, dashboards may reduce therapeutic failures and treatment costs. The history and future development of modern Bayesian dashboard systems is described.
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Affiliation(s)
- D R Mould
- Projections Research Inc., Phoenixville, Pennsylvania, USA
| | - G D'Haens
- Inflammatory Bowel Disease Centre Academic Medical Centre 1105 AZ, Amsterdam, The Netherlands
| | - R N Upton
- Projections Research Inc., Phoenixville, Pennsylvania, USA.,Australian Centre for Pharmacometrics and Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, South Australia, Australia
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99
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Martin-Suarez A, García González D, Macías Núñez JF, Ardanuy Albajar R, Calvo Hernández MV. A New Method for Individualized Digoxin Dosing in Elderly Patients. Drugs Aging 2016; 33:277-84. [PMID: 26833352 DOI: 10.1007/s40266-016-0346-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Digoxin is a frequently prescribed drug in the elderly population. Estimated glomerular filtration rate is widely used to adjust dosages. The HUGE value is a tool for differentiating the presence or absence of chronic kidney disease in elderly patients. We aimed to investigate the usefulness of the HUGE value to predict the initial dose of digoxin in patients aged older than 70 years. METHODS We reviewed retrospectively the medical records of patients aged older than 70 years with serum digoxin concentrations (SDCs) monitored over a 6-month period (63 patients). A linear regression relating the patient's SDC, maintenance dose of digoxin and the HUGE value was estimated to generate a dosage equation. This equation was validated retrospectively (33 patients) and prospectively (35 patients) in comparison with two existing methods based on creatinine clearance. RESULTS An equation (HUGE_DIG) was generated to calculate the initial digoxin dose to reach a specific target SDC. Thus, to achieve a SDC of 0.8 ng/mL: Digoxin (mg/day) = 0.091 - 0.006 x HUGE. After retrospective validation, the calculated digoxin doses with this equation were administered in the prospective phase and we did not observe statistical differences between measured and desired SDCs. Moreover, the predictive performance of our equation was better than that obtained with the compared methods. CONCLUSIONS We offer a new validated digoxin dosing equation for elderly patients. Our results support the need to perform digoxin dosing in elderly people, bearing in mind the changes in renal physiology secondary to ageing and not merely the estimated glomerular filtration rate.
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Affiliation(s)
- Ana Martin-Suarez
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca, University Hospital of Salamanca, Salamanca, Spain
| | | | - Juan F Macías Núñez
- Nefrology Services, University Hospital of Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca, University Hospital of Salamanca, Salamanca, Spain
| | - Ramón Ardanuy Albajar
- Department of Statistics, Faculty of Sciences, University of Salamanca, Salamanca, Spain
| | - M Victoria Calvo Hernández
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Salamanca, Salamanca, Spain. .,Pharmacy Services, University Hospital of Salamanca, Salamanca, Spain. .,Instituto de Investigación Biomédica de Salamanca, University Hospital of Salamanca, Salamanca, Spain.
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100
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Improved Tacrolimus Target Concentration Achievement Using Computerized Dosing in Renal Transplant Recipients--A Prospective, Randomized Study. Transplantation 2016; 99:2158-66. [PMID: 25886918 DOI: 10.1097/tp.0000000000000708] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early after renal transplantation, it is often challenging to achieve and maintain tacrolimus concentrations within the target range. Computerized dose individualization using population pharmacokinetic models may be helpful. The objective of this study was to prospectively evaluate the target concentration achievement of tacrolimus using computerized dosing compared with conventional dosing performed by experienced transplant physicians. METHODS A single-center, prospective study was conducted. Renal transplant recipients were randomized to receive either computerized or conventional tacrolimus dosing during the first 8 weeks after transplantation. The median proportion of tacrolimus trough concentrations within the target range was compared between the groups. Standard risk (target, 3-7 μg/L) and high-risk (8-12 μg/L) recipients were analyzed separately. RESULTS Eighty renal transplant recipients were randomized, and 78 were included in the analysis (computerized dosing (n = 39): 32 standard risk/7 high-risk, conventional dosing (n = 39): 35 standard risk/4 high-risk). A total of 1711 tacrolimus whole blood concentrations were evaluated. The proportion of concentrations per patient within the target range was significantly higher with computerized dosing than with conventional dosing, both in standard risk patients (medians, 90% [95% confidence interval {95% CI}, 84-95%] vs 78% [95% CI, 76-82%], respectively, P < 0.001) and in high-risk patients (medians, 77% [95% CI, 71-80%] vs 59% [95% CI, 40-74%], respectively, P = 0.04). CONCLUSIONS Computerized dose individualization improves target concentration achievement of tacrolimus after renal transplantation. The computer software is applicable as a clinical dosing tool to optimize tacrolimus exposure and may potentially improve long-term outcome.
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