51
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Xu LP, Xu ZL, Zhang YY, Cheng YF, Mo XD, Han TT, Wang FR, Yan CH, Sun YQ, Chen YH, Tang FF, Han W, Wang Y, Zhang XH, Liu KY, Huang XJ. Bulsufan decreases the incidence of mixed chimaerism in HLA-matched donor transplantation for severe aplastic anaemia. Bone Marrow Transplant 2022; 57:1204-1206. [PMID: 35508709 DOI: 10.1038/s41409-022-01682-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 04/04/2022] [Accepted: 04/05/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Lan-Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Zheng-Li Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yuan-Yuan Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yi-Fei Cheng
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Dong Mo
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Ting-Ting Han
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Feng-Rong Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Chen-Hua Yan
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yu-Qian Sun
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yu-Hong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Fei-Fei Tang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Wei Han
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Kai-Yan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China. .,National Clinical Research Center for Hematologic Disease, Beijing, China. .,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China. .,Peking-Tsinghua Center for Life Sciences, Beijing, China.
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52
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Alatrash G, Saberian C, Bassett R, Thall PF, Ledesma C, Lu Y, Daher M, Valdez BC, Kawedia J, Popat U, Mehta R, Oran B, Nieto Y, Olson A, Anderlini P, Marin D, Hosing C, Alousi AM, Shpall EJ, Rondon G, Chen J, Qazilbash M, Champlin RE, Andersson BS, Kebriaei P. Vorinostat combined with Busulfan, Fludarabine, and Clofarabine Conditioning Regimen for Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Acute Leukemia: Long-term Study Outcomes. Transplant Cell Ther 2022; 28:501.e1-501.e7. [DOI: 10.1016/j.jtct.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 04/15/2022] [Accepted: 05/14/2022] [Indexed: 11/30/2022]
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Veldkamp SR, Jansen MHA, Swart JF, Lindemans CA. Case Report: Lessons Learned From Subsequent Autologous and Allogeneic Hematopoietic Stem Cell Transplantations in a Pediatric Patient With Relapsing Polychondritis. Front Immunol 2022; 13:812927. [PMID: 35359992 PMCID: PMC8960202 DOI: 10.3389/fimmu.2022.812927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/17/2022] [Indexed: 12/29/2022] Open
Abstract
Background Autologous hematopoietic stem cell transplantation (autoHSCT) is increasingly being recognized as a treatment option for severe refractory autoimmune diseases (AD). However, efficacy is hampered by high relapse rates. In contrast, allogeneic HSCT (alloHSCT) has high potential to cure AD, but is associated with significant morbidity and mortality, and data in AD are limited. Experience with autoHSCT in relapsing polychondritis, a rare episodic inflammatory disorder characterized by destruction of cartilage, is scarce and alloHSCT has not been described before. Case Presentation Here, we present a case of a 9-year-old girl who was diagnosed with relapsing polychondritis, with severe airway involvement requiring a tracheostomy. The disease proved to be steroid-dependent and refractory to a wide array of disease-modifying anti-rheumatic drugs and biologicals. After an autoHSCT procedure, the disease became inactive for a short period of time, until the patient experienced a relapse after 31 days, accompanied by repopulation of effector/memory CD8+ T cells. Because of persistent inflammation and serious steroid toxicity, including severe osteoporosis, growth restriction, and excessive weight gain, the patient was offered an alloHSCT. She experienced transient antibody-mediated immune events post-alloHSCT, which subsided after rituximab. She ultimately developed a balanced immune reconstitution and is currently still in long-term disease remission, 8 years after alloHSCT. Conclusion This case adds to the few existing reports on autoHSCT in relapsing polychondritis and gives new insights in its pathogenesis, with a possible role for CD8+ T cells. Moreover, it is the first report of successful alloHSCT as a treatment for children with this severe autoimmune disease.
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Affiliation(s)
- Saskia R Veldkamp
- Center for Translational Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marc H A Jansen
- Pediatric Rheumatology and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Joost F Swart
- Pediatric Rheumatology and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Caroline A Lindemans
- Pediatric Rheumatology and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands.,Blood and Bone Marrow Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
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54
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Improvement of ovarian insufficiency from alginate oligosaccharide in mice. J Funct Foods 2022. [DOI: 10.1016/j.jff.2022.104995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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55
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Shah GL, Boelens JJ, Carlow D, Lin A, Schofield R, Cruz Sitner N, Alperovich A, Ruiz J, Proli A, Dahi P, Tamari R, Giralt SA, Scordo M, Admiraal R. Population Pharmacokinetics of Melphalan in a Large Cohort of Autologous and Allogeneic Hematopoietic Cell Transplantation Recipients: Towards Individualized Dosing Regimens. Clin Pharmacokinet 2022; 61:553-563. [PMID: 34859337 PMCID: PMC9415324 DOI: 10.1007/s40262-021-01093-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND OBJECTIVES High-dose melphalan is an integral part of conditioning chemotherapy prior to both autologous and allogeneic hematopoietic cell transplantation. While underexposure may lead to relapse, overexposure may lead to toxicities include mucositis, diarrhea, bone marrow suppression, and rarely sinusoidal obstruction syndrome. In this study, we describe the population pharmacokinetics of high-dose melphalan as a first step towards individualized dosing. METHODS Melphalan samples were collected in patients receiving an allogeneic or autologous hematopoietic cell transplantation between August 2016 and August 2020 at the Memorial Sloan Kettering Cancer Center. A population-pharmacokinetic model was developed using NONMEM. RESULTS Based on a total of 3418 samples from 452 patients receiving a median cumulative dose of 140 mg/m2, a two-compartment population-pharmacokinetic model was developed. Fat-free mass was a covariate for clearance, central volume of distribution, and inter-compartmental clearance, while glomerular filtration rate predicted clearance. Simulation studies showed that based on fixed body surface area-based dosing, renal impairment has a higher impact in increasing melphalan exposure compared with obesity. CONCLUSIONS The proposed model adequately describes the population pharmacokinetics of melphalan in adult patients receiving a hematopoietic cell transplantation. This model can be used to define the therapeutic window of melphalan, and subsequently to develop individualized dosing regimens aiming for that therapeutic window in all patients.
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Affiliation(s)
- Gunjan L Shah
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Jaap Jan Boelens
- Stem Cell Transplantation and Cellular Therapies Program, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Dean Carlow
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew Lin
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ryan Schofield
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nancy Cruz Sitner
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anna Alperovich
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Josel Ruiz
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anthony Proli
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Parastoo Dahi
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Roni Tamari
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Sergio A Giralt
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Michael Scordo
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Rick Admiraal
- Pediatric Hematopoeitic Cell Transplantation Program, Princess Maxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands.
- Department of Pediatrics, University Medical Center Utrecht, Utrecht, the Netherlands.
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56
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Verougstraete N, Stove V, Verstraete AG, Oyaert M. Automation in Busulfan Therapeutic Drug Monitoring: Evaluation of an Immunoassay on two Routine Chemistry Analyzers. Ther Drug Monit 2022; 44:335-339. [PMID: 34985848 DOI: 10.1097/ftd.0000000000000933] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/03/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) of busulfan is recommended for hematopoietic stem cell transplant recipients. Timely reporting of these TDM results is essential given the short administration period and the planned dose adjustments on day 2. The authors evaluated the performance of a new nanoparticle-based competitive immunoassay on two routine clinical chemistry analyzers and compared its performance to that of an in-house high-resolution mass spectrometry (HRMS) method. METHODS The MyCare Oncology Busulfan Assay Kit (Saladax Biomedical) was applied on two routine clinical chemistry analyzers (Abbott Architect c8000 and Roche Cobas c502) with a linearity range of 187-2000 ng/mL. The study evaluation measured imprecision and accuracy, sample probe carry-over, and dilution integrity. Method comparison with liquid chromatography (LC)-HRMS was performed using samples from patients undergoing busulfan treatment. RESULTS Within- and between-run coefficient of variations for both analyzers were ≤5.23% and ≤8.45%, respectively, across the busulfan concentration range. The obtained biases were ≤10.3%. Both analyzers met the acceptance criteria for sample probe carry-over and dilution integrity. Agreement between the immunoassay and LC-HRMS was high: 92% and 89% of the samples measured on Architect and Cobas, respectively, were within the ±15% limit compared to the corresponding LC-HRMS results. CONCLUSIONS Overall, good analytical performance and high agreement with LC-HRMS results were obtained for the immunoassay installed on both routine clinical chemistry analyzers. Therefore, this assay could be implemented as a valid alternative for LC methods in clinical laboratories on different open-channel clinical chemistry analyzers, resulting in shorter turn-around times for reporting busulfan TDM results with subsequent faster dosage adjustments.
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Affiliation(s)
- Nick Verougstraete
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium; and
| | - Veronique Stove
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium; and
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Alain G Verstraete
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium; and
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Matthijs Oyaert
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium; and
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57
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Seydoux C, Battegay R, Halter J, Heim D, Rentsch KM, Passweg JR, Medinger M. Impact of busulfan pharmacokinetics on outcome in adult patients receiving an allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2022; 57:903-910. [PMID: 35361896 PMCID: PMC9200635 DOI: 10.1038/s41409-022-01641-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 03/02/2022] [Accepted: 03/11/2022] [Indexed: 11/09/2022]
Abstract
Busulfan (Bu) is widely used in conditioning regimens before allogeneic hematopoietic cell transplantation, with variable metabolism due to interindividual differences of pharmacokinetics (PK). The purpose of this study was to correlate pharmacokinetics and clinical outcomes. Lower-AUC, in range-AUC and higher-AUC were defined as ±25% of the targeted Bu-AUC. In 2019, we changed Bu dosing from 4×/day (Bu-4) to 1×/day (Bu-1) for ease of application. AUC-target range was reached in 46% of patients; 40% were in low-AUC and 14% in high-AUC. Among all toxicities, viral and fungal infections were significantly more frequent in high-AUC compared with low-AUC (20% vs. 8%; p = 0.01 and 37% vs. 17%; p = 0.03). Bu-1 showed lower PK values (66% vs. 36% of Bu-4 in low-AUC; p < 0.01) and higher incidence of mucositis (p = 0.02). Long-term outcomes at 2 years showed a higher non-relapse mortality (NRM) (p < 0.01) and higher relative risk of death in the high-AUC group compared to the other groups. Cumulative incidence of relapse and acute/chronic GvHD were not significantly different. The optimal cut-off in Bu-AUC associated with low NRM was 969 µmol/l*min (ROC AUC 0.67, sensitivity 0.86 and specificity 0.47) for Bu-4. In conclusion, low-AUC BU-PK seems of benefit regarding NRM and survival.
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Affiliation(s)
- Claire Seydoux
- Division of Hematology, University Hospital of Basel, Basel, Switzerland.
| | - Raphael Battegay
- Division of Hematology, University Hospital of Basel, Basel, Switzerland
| | - Joerg Halter
- Division of Hematology, University Hospital of Basel, Basel, Switzerland
| | - Dominik Heim
- Division of Hematology, University Hospital of Basel, Basel, Switzerland
| | - Katharina M Rentsch
- Department of Laboratory Medicine, University Hospital of Basel, Basel, Switzerland
| | - Jakob R Passweg
- Division of Hematology, University Hospital of Basel, Basel, Switzerland
| | - Michael Medinger
- Division of Hematology, University Hospital of Basel, Basel, Switzerland.
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Bertaina A, Abraham A, Bonfim C, Cohen S, Purtill D, Ruggeri A, Weiss D, Wynn R, Boelens JJ, Prockop S. An ISCT Stem Cell Engineering Committee Position Statement on Immune Reconstitution: the importance of predictable and modifiable milestones of immune reconstitution to transplant outcomes. Cytotherapy 2022; 24:385-392. [PMID: 35331394 DOI: 10.1016/j.jcyt.2021.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/14/2021] [Accepted: 09/18/2021] [Indexed: 11/19/2022]
Abstract
Allogeneic stem cell transplantation is a potentially curative therapy for some malignant and non-malignant disease. There have been substantial advances since the approaches first introduced in the 1970s, and the development of approaches to transplant with HLA incompatible or alternative donors has improved access to transplant for those without a fully matched donor. However, success is still limited by morbidity and mortality from toxicity and imperfect disease control. Here we review our emerging understanding of how reconstitution of effective immunity after allogeneic transplant can protect from these events and improve outcomes. We provide perspective on milestones of immune reconstitution that are easily measured and modifiable.
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Affiliation(s)
- Alice Bertaina
- Center for Cancer and Immunology Research, CETI, Children's National Hospital, Washington, District of Columbia, USA
| | - Allistair Abraham
- Division of Hematology, Oncology, Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Carmem Bonfim
- Pediatric Bone Marrow Transplantation Division, Hospital Pequeno Principe, Curitiba, Brazil
| | - Sandra Cohen
- Université de Montréal and Maisonneuve Rosemont Hospital, Montréal, Québec, Canada
| | - Duncan Purtill
- Department of Haematology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | | | | | - Robert Wynn
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Jaap Jan Boelens
- Stem Cell Transplantation and Cellular Therapies, Memorial Sloan Kettering Cancer Center, and Department of Pediatrics, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Susan Prockop
- Stem Cell Transplant Program, Division of Hematology/Oncology Boston Children's Hospital and Department of Pediatric Oncology, Dana Farber Cancer Institute.
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Development of a Population Pharmacokinetic Model of Busulfan in Children and Evaluation of Different Sampling Schedules for Precision Dosing. Pharmaceutics 2022; 14:pharmaceutics14030647. [PMID: 35336021 PMCID: PMC8948694 DOI: 10.3390/pharmaceutics14030647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/10/2022] [Accepted: 03/12/2022] [Indexed: 12/10/2022] Open
Abstract
We develop a population pharmacokinetic model to describe Busulfan pharmacokinetics in paediatric patients and investigate by simulations the impact of various sampling schedules on the calculation of AUC. Seventy-six children had 2 h infusions every 6 h. A two-compartment linear model was found to adequately describe the data. A lag-time was introduced to account for the delay of the administration of the drug through the infusion pump. The mean values of clearance, central volume of distribution, intercompartmental clearance, and peripheral volume of distribution were 10.7 L/h, 39.5 L, 4.68 L/h and 17.5 L, respectively, normalized for a Body Weight (BW) of 70 kg. BW was found to explain a portion of variability with an allometric relationship and fixed exponents of 0.75 on clearance parameters and 1 on volumes. Interindividual variability for clearance and volume of distribution was found to be 28% and 41%, respectively, and interoccasion variability for clearance was found to be 11%. Three sampling schedules were assessed by simulations for bias and imprecision to calculate AUC by a non-compartmental and a model-based method. The latter was found to be superior in all cases, while the non-compartmental was unbiased only in sampling up to 12 h corresponding to a once-daily dosing regimen.
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60
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van der Stoep MYEC, Oostenbrink LVE, Bredius RGM, Moes DJAR, Guchelaar HJ, Zwaveling J, Lankester AC. Therapeutic Drug Monitoring of Conditioning Agents in Pediatric Allogeneic Stem Cell Transplantation; Where do We Stand? Front Pharmacol 2022; 13:826004. [PMID: 35330826 PMCID: PMC8940165 DOI: 10.3389/fphar.2022.826004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/18/2022] [Indexed: 11/13/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is an established curative treatment that has significantly improved clinical outcome of pediatric patients with malignant and non-malignant disorders. This is partly because of the use of safer and more effective combinations of chemo- and serotherapy prior to HSCT. Still, complications due to the toxicity of these conditioning regimens remains a major cause of transplant-related mortality (TRM). One of the most difficult challenges to further improve HSCT outcome is reducing toxicity while maintaining efficacy. The use of personalized dosing of the various components of the conditioning regimen by means of therapeutic drug monitoring (TDM) has been the topic of interest in the last decade. TDM could play an important role, especially in children who tend to show greater pharmacokinetic variability. However, TDM should only be performed when it has clear added value to improve clinical outcome or reduce toxicity. In this review, we provide an overview of the available evidence for the relationship between pharmacokinetic parameters and clinical outcome or toxicities of the most commonly used conditioning agents in pediatric HSCT.
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Affiliation(s)
- M. Y. Eileen C. van der Stoep
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
- *Correspondence: M. Y. Eileen C. van der Stoep,
| | - Lisa V. E. Oostenbrink
- Willem-Alexander Children’s Hospital, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Robbert G. M. Bredius
- Willem-Alexander Children’s Hospital, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Dirk Jan A. R. Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - Juliette Zwaveling
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - Arjan C. Lankester
- Willem-Alexander Children’s Hospital, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
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Nijstad AL, Barnett S, Lalmohamed A, Bérénos IM, Parke E, Carruthers V, Tweddle DA, Kong J, Zwaan CM, Huitema ADR, Veal GJ. Clinical pharmacology of cytotoxic drugs in neonates and infants: Providing evidence-based dosing guidance. Eur J Cancer 2022; 164:137-154. [PMID: 34865945 PMCID: PMC8914347 DOI: 10.1016/j.ejca.2021.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/11/2021] [Accepted: 11/01/2021] [Indexed: 01/29/2023]
Abstract
Cancer in neonates and infants is a rare but challenging entity. Treatment is complicated by marked physiological changes during the first year of life, excess rates of toxicity, mortality, and late effects. Dose optimisation of chemotherapeutics may be an important step to improving outcomes. Body size-based dosing is used for most anticancer drugs used in infants. However, dose regimens are generally not evidence based, and dosing strategies are frequently inconsistent between tumour types and treatment protocols. In this review, we collate available pharmacological evidence supporting dosing regimens in infants for a wide range of cytotoxic drugs. A systematic review was conducted, and available data ranked by a level of evidence (1-5) and a grade of recommendation (A-D) provided on a consensus basis, with recommended dosing approaches indicated as appropriate. For 9 of 29 drugs (busulfan, carboplatin, cyclophosphamide, daunorubicin, etoposide, fludarabine, isotretinoin, melphalan and vincristine), grade A was scored, indicating sufficient pharmacological evidence to recommend a dosing algorithm for infants. For busulfan and carboplatin, sufficient data were available to recommend therapeutic drug monitoring in infants. For eight drugs (actinomycin D, blinatumomab, dinutuximab, doxorubicin, mercaptopurine, pegaspargase, thioguanine and topotecan), some pharmacological evidence was available to guide dosing (graded as B). For the remaining drugs, including commonly used agents such as cisplatin, cytarabine, ifosfamide, and methotrexate, pharmacological evidence for dosing in infants was limited or non-existent: grades C and D were scored for 10 and 2 drugs, respectively. The review provides clinically relevant evidence-based dosing guidance for cytotoxic drugs in neonates and infants.
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Affiliation(s)
- A Laura Nijstad
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands.
| | - Shelby Barnett
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK
| | - Arief Lalmohamed
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, the Netherlands
| | - Inez M Bérénos
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, the Netherlands
| | - Elizabeth Parke
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK
| | - Vickyanne Carruthers
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK
| | - Deborah A Tweddle
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK; Great North Children's Hospital, NE1 4LP Newcastle Upon Tyne, UK
| | - Jordon Kong
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - C Michel Zwaan
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Department of Pediatric Oncology, Erasmus MC-Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
| | - Gareth J Veal
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK.
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Gurevich E, Hayoz M, Aebi Y, Largiadèr CR, Mansouri Taleghani B, Bacher U, Pabst T. Comparison of Melphalan Combined with Treosulfan or Busulfan as High-Dose Chemotherapy before Autologous Stem Cell Transplantation in AML. Cancers (Basel) 2022; 14:cancers14041024. [PMID: 35205772 PMCID: PMC8869805 DOI: 10.3390/cancers14041024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/07/2022] [Accepted: 02/12/2022] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Different consolidation strategies are available for acute myeloid leukemia (AML) patients fit for intensive treatment. For favorable- or intermediate-risk AML, high-dose chemotherapy (HDCT) followed by autologous stem cell transplantation (ASCT) is one of these options. Busulfan plus melphalan is a frequently used and efficient HDCT regimen, but it bears neurotoxic potential and may cause irreversible alopecia, amongst other toxicities. Thus, improving HDCT regimens with lesser toxicity, albeit at comparable anti-leukemic efficacy, is wishful. We combined treosulfan with its more favorable toxicity profile with melphalan for HDCT and compared these patients with a group receiving busulfan/treosulfan. Whereas disease-free and overall survival did not differ significantly, the treosulfan regimen compared favorably, with the absence of neurotoxicity and irreversibly alopecia. Treosulfan serum levels by mass cytometry demonstrated considerable interindividual biovariability. Further studies should explore treosulfan/melphalan for HDCT/ASCT in AML, aiming to improve the quality of life of AML survivors and offer safer consolidation strategies. Abstract (1) Background: High-dose chemotherapy (HDCT) before autologous stem cell transplantation (ASCT) in acute myeloid leukemia (AML) patients predominantly combines busulfan with cyclophosphamide or melphalan. Treosulfan compares favorably regarding lower inter-individual bioavailability and neurotoxicity, but so far, had not been studied before ASCT in AML. (2) Methods: This single-center study investigated AML patients undergoing ASCT in CR1 between November 2017 and September 2020. The first 16 patients received busulfan 16 mg/kg b.w. (days −5 to −2) and melphalan 140 mg/m2 (day −1) (BuMel). In a subsequent (TreoMel) cohort, 20 patients received treosulfan 14 g/m2 (days −4 to −2) and melphalan. Plasma concentrations of busulfan and treosulfan were determined by mass spectrometry. (3) Results: Neutrophil engraftment and platelet recovery were similar, and PFS and OS were comparable. In only the BuMel cohort, patients reported central nervous toxicities, including seizures (6%) and encephalopathy (12%). The mean AUC for busulfan was 1471.32 μM*min, and for treosulfan it was 836.79 mg/L*h, with ranges of 804.1–2082 μM*min and 454.2–1402 mg/L*h. The peak values for busulfan ranged between 880.19–1734 μg/L and for treosulfan between 194.3–489.25 mg/L. (4) Conclusions: TreoMel appears to be safe and effective for pre-ASCT treatment in AML patients. Due to considerable interindividual biovariability, pharmacologic monitoring may also be warranted for the use of treosulfan.
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Affiliation(s)
- Ekaterina Gurevich
- Department of Medical Oncology, Inselspital, University of Bern, CH-3010 Bern, Switzerland;
| | - Michael Hayoz
- Department of Clinical Chemistry, Inselspital, University of Bern, CH-3010 Bern, Switzerland; (M.H.); (Y.A.); (C.R.L.)
- Center of Laboratory Medicine (ZLM), Inselspital, University of Bern, CH-3010 Bern, Switzerland
| | - Yolanda Aebi
- Department of Clinical Chemistry, Inselspital, University of Bern, CH-3010 Bern, Switzerland; (M.H.); (Y.A.); (C.R.L.)
- Center of Laboratory Medicine (ZLM), Inselspital, University of Bern, CH-3010 Bern, Switzerland
| | - Carlo R. Largiadèr
- Department of Clinical Chemistry, Inselspital, University of Bern, CH-3010 Bern, Switzerland; (M.H.); (Y.A.); (C.R.L.)
- Center of Laboratory Medicine (ZLM), Inselspital, University of Bern, CH-3010 Bern, Switzerland
| | | | - Ulrike Bacher
- Department of Hematology, Inselspital, University of Bern, CH-3010 Bern, Switzerland; (B.M.T.); (U.B.)
| | - Thomas Pabst
- Department of Medical Oncology, Inselspital, University of Bern, CH-3010 Bern, Switzerland;
- Correspondence:
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Hematopoietic stem cell transplantation for Wiskott-Aldrich syndrome: an EBMT inborn errors working party analysis. Blood 2022; 139:2066-2079. [PMID: 35100336 DOI: 10.1182/blood.2021014687] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/17/2022] [Indexed: 11/20/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is a potentially curative treatment for patients affected by Wiskott-Aldrich syndrome (WAS). Reported HSCT outcomes have improved over time with respect to overall survival, but some studies have identified older age and HSCT from alternative donors as risk factors predicting poorer outcome. We analyzed 197 patients transplanted at EBMT centers between 2006 and 2017, who received conditioning as recommended by the inborn errors working party (IEWP): either busulfan (n=103) or treosulfan (n=94) combined with fludarabine ± thiotepa. After a median follow-up after HSCT of 44.9 months, 176 patients were alive, resulting in a 3-year overall survival of 88.7%, and chronic GVHD-free survival (CRFS; events: death, graft failure, severe chronic GVHD) of 81.7%. Overall survival and CRFS were not significantly impacted by conditioning regimen (busulfan- versus treosulfan-based), donor type (MSD/MFD vs MUD/MMUD vs. MMFD), and period of HSCT (2006-2013 vs. 2014-2017). Patients younger than 5 years at HSCT had a significantly better overall survival. The overall cumulative incidences of grade III-IV acute GVHD and extensive/moderate/severe chronic GVHD were 6.6% and 2.1%, respectively. Patients receiving treosulfan-based conditioning had a higher incidence of graft failure, mixed donor chimerism and more frequently received secondary procedures (2nd HSCT, unconditioned stem cell boost, donor lymphocyte infusion, or splenectomy). In summary, HSCT for WAS with conditioning regimens currently recommended by IEWP results in excellent survival and low rates of GVHD, regardless of donor or stem cell source, but age ≥5 years remains a risk factor for overall survival.
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Chen T, Chen C, He X, Guo J, Liu M, Zheng B. Fixed-dose administration and pharmacokinetically guided adjustment of busulfan dose for patients undergoing hematopoietic stem cell transplantation: a meta-analysis and cost-effectiveness analysis. Ann Hematol 2022; 101:667-679. [DOI: 10.1007/s00277-021-04733-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 11/29/2021] [Indexed: 11/01/2022]
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Wang Q, Xu N, Wang Y, Zhang X, Liu L, Zhou H, Wang H, Zhang X, Tang X, Fu C, Miao M, Wu D. Allogeneic Stem Cell Transplantation Combined With Transfusion of Mesenchymal Stem Cells in Primary Myelofibrosis: A Multicenter Retrospective Study. Front Oncol 2022; 11:792142. [PMID: 35141151 PMCID: PMC8818875 DOI: 10.3389/fonc.2021.792142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 12/21/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Allogeneic stem cell transplantation (allo-SCT) remains the only effective curative therapy for primary myelofibrosis. Utilization and efficacy of allo-SCT are limited by lethal complications, including engraftment failure, and acute (aGVHD) and chronic graft-versus-host disease (cGVHD). Several clinical trials have explored the use of mesenchymal stem cells (MSCs) in allo-SCT to prevent hematopoietic stem cell (HSC) engraftment failure and control GVHD. METHODS Clinical data of 17 patients with primary myelofibrosis who underwent allo-SCT combined with ex vivo expanded MSC transfusion in four centers from February 2011 to December 2018 were retrospectively analyzed. RESULTS All patients received myeloablative conditioning regimen. The median number of transplanted nucleated cells (NCs) per kilogram body weight was 11.18 × 108 (range: 2.63-16.75 × 108), and the median number of CD34+ cells was 4.72 × 106 (range: 1.32-8.4 × 106). MSCs were transfused on the day of transplant or on day 7 after transplant. The median MSC infusion number was 6.5 × 106 (range: 0.011-65 × 106). None of the patients experienced primary or secondary graft failure in the study. The median time to neutrophil engraftment was 13 days (range: 11-22 days), and the median time to platelet engraftment was 21 days (range: 12-184 days). The median follow-up time was 40.3 months (range: 1.8-127.8 months). The estimated relapse-free survival (RFS) at 5 years was 79.1%, and overall survival (OS) at 5 years was 64.7%. Analysis showed that the cumulative incidence of aGVHD grade II to IV was 36% (95% CI: 8%-55%) and that of grade III to IV was 26% (95% CI: 0%-45%) at day 100. The cumulative incidence of overall cGVHD at 2 years for the entire study population was 63% (95% CI: 26%-81%). The cumulative incidence of moderate to severe cGVHD at 2 years was 17% (95% CI: 0%-42%). Seven patients died during the study, with 5 patients succumbing from non-relapse causes and 2 from disease relapse. CONCLUSION The findings of the study indicate that allo-SCT combined with MSC transfusion may represent an effective treatment option for primary myelofibrosis.
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Affiliation(s)
- Qingyuan Wang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Na Xu
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yu Wang
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xi Zhang
- Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Limin Liu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Huifen Zhou
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Hong Wang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Xiang Zhang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Xiaowen Tang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Chengcheng Fu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Miao Miao
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
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Individualized Dosage Optimization for Myeloablative Conditioning before Unrelated Cord Blood Transplantation in a Diamond–Blackfan Anemia Patient with Germline RPL11 Mutation: A Case Study. Processes (Basel) 2022. [DOI: 10.3390/pr10020201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022] Open
Abstract
Unrelated cord blood transplantation (CBT) for Diamond–Blackfan anemia (DBA), a systemic ribosomopathy affecting the disposition of conditioning agents, has resulted in outcomes inferior to those by transplantations from matched donors. We report the experience of the pharmacokinetics-guided myeloablative unrelated CBT in a DBA patient with a germline RPL11 mutation. The conditioning consisted of individualized dosing of fludarabine (based on weight and renal function with a target area under the curve (AUC) of 17.5 mg·h/L) and busulfan (based on therapeutic drug monitoring with a target AUC of 90 mg·h/L), as well as dosing and timing of thymoglobulin (based on body weight and pre-dose lymphocyte count to target pre-CBT AUC of 30.7 AU·day/mL and post-CBT AUC of 4.3 AU·day/mL, respectively). The pharmacokinetic measures resulted in a 27.5% reduction in busulfan and a 35% increase in fludarabine, as well as an over three-fold increase in thymoglobulin dosage with the start time changed to day-9 instead of day-2 compared to regular regimens. The transplantation resulted in rapid, complete, and sustained hematopoietic engraftment. The patient is now healthy over 3 years after CBT. A pharmacokinetics-guided individualized dosing strategy for conditioning might be a feasible option to improve the outcomes of DBA patients receiving unrelated myeloablative CBT.
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Li S, Dvorak CC, Lu Y, Chan D, Gobburu JV, Long‐Boyle J, Winger BA. Population Pharmacokinetics of Melphalan for Pediatric Patients Undergoing Hematopoietic Cell Transplantation. J Clin Pharmacol 2022; 62:873-882. [DOI: 10.1002/jcph.2030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 01/16/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Shuhui Li
- Center for Translational Medicine School of Pharmacy University of Maryland Baltimore Maryland USA
| | - Christopher C. Dvorak
- Department of Pediatrics Division of Allergy Immunology, and Bone Marrow Transplantation University of California San Francisco San Francisco California USA
| | - Ying Lu
- Department of Pediatrics Division of Allergy Immunology, and Bone Marrow Transplantation University of California San Francisco San Francisco California USA
| | - Danna Chan
- Department of Pediatrics Division of Allergy Immunology, and Bone Marrow Transplantation University of California San Francisco San Francisco California USA
- ASTEX Pharmaceuticals Pleasanton California USA
| | - Jogarao V.S. Gobburu
- Center for Translational Medicine School of Pharmacy University of Maryland Baltimore Maryland USA
| | - Janel Long‐Boyle
- Department of Pediatrics Division of Allergy Immunology, and Bone Marrow Transplantation University of California San Francisco San Francisco California USA
- Department of Clinical Pharmacy University of California San Francisco San Francisco California USA
| | - Beth Apsel Winger
- Department of Pediatrics Division of Allergy Immunology, and Bone Marrow Transplantation University of California San Francisco San Francisco California USA
- Department of Pediatrics Division of Hematology University of California San Francisco San Francisco California USA
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68
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Jeppesen H, Kielsen K, Siersma V, Lindegaard J, Julian HO, Heegaard S, Sengeløv H, Müller K. Ocular graft-versus-host disease and dry eye disease after paediatric haematopoietic stem cell transplantation - incidence and risk factors. Bone Marrow Transplant 2022; 57:487-498. [PMID: 35042981 DOI: 10.1038/s41409-022-01564-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 12/07/2021] [Accepted: 01/04/2022] [Indexed: 01/28/2023]
Abstract
Ocular graft-versus-host disease (oGVHD) contributes substantially to morbidity after allogeneic haematopoietic stem cell transplantation (HSCT) but is sparsely investigated in children. We assessed incidence and risk factors for oGVHD and dry eye disease (DED) in a nationwide, single-centre study of 484 consecutive children receiving HSCT during the period 1980-2016. Ophthalmological examinations were performed before and annually at least until five years after HSCT. Twenty-five patients had DED before transplantation (5.6%). The cumulative incidence was 1.9% for acute oGVHD, 6.0% for chronic oGVHD, 8.7% for new onset DED, and 12.7% for new onset Corneal Fluorescein Staining (CFS). In adjusted Fine-Gray regression models, the use of Busulfan was a risk factor for developing acute oGVHD (HR 5.01, p = 0.03), and malignant disease was a risk factor for developing CFS (HR 2.00, p = 0.047). Younger recipient age was associated with reduced risk of DED when comparing children aged 0-4 years with 10-16 years (HR 0.33, p = 0.03). These data underscore the need of attention to DED and oGVHD in relation to HSCT leading to our recommendation of performing ophthalmic examinations in all children before HSCT, and after HSCT when needed, in order to secure diagnosis and treatment of these complications.
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69
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Shao DF, Li JH, Hu T, Zhang ZX, Zhang L, Li JJ, Cao J, Feng SQ, Tang RH, Zhong DX, Song ZL, Yue M, Hu MZ, Xuan LT, Zhai MN, Zhang HF, Wang XY, Shi XD, Liu R. Clinical outcomes of individualized busulfan-dosing in hematopoietic stem cell transplantation in Chinese children undergoing with therapeutic drug monitoring. Bone Marrow Transplant 2022; 57:473-478. [PMID: 35039622 DOI: 10.1038/s41409-021-01545-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 09/21/2021] [Accepted: 11/30/2021] [Indexed: 12/19/2022]
Abstract
To identify relationships between busulfan (Bu) exposure and outcomes of a cohort pediatric patients receiving hematopoietic stem cell transplantation (HSCT), along with a targeted busulfan-based conditioning regimen. We retrospectively evaluated targeted busulfan concentrations in 53 pediatric patients (age 0.4-16 years) who received busulfan 4 times daily according to recommended weight-based doses in a single-center analysis between 2018 and 2020. In this trial, individual busulfan pharmacokinetics were performed following dose 5 of the conditioning regimen. Twenty four of 53 patients (45.3%) studies did not require dose adjustments. Equal number of patients (24/53) required one dose adjustments while two-dose adjustment applied for 5 of 53 (9.4%). Twenty-one percent of the patients exhibited ll-lV aGVHD. The incidence of veno-occlusive disease (VOD) was in 3.8% of the 53 patients, while incidence of hemorrhagic cystitis (II-III) reached to 9.7%. Engraftment was successful in 98% of the 53 patients with relapse in 2% of cases. The probability of overall survival and disease-free survival at day 100 was 96% and 94%, respectively. In conclusion, therapeutic drug monitoring (TDM) and individualization of Bu dosage are essential to improve the efficacy and safety of busulfan-based regimen in Chinese pediatric HSCT recipients.
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Affiliation(s)
- Duan-Fang Shao
- Department of Hematology and Oncology, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Jun-Hui Li
- Department of Hematology and Oncology, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Tao Hu
- Department of Hematology and Oncology, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Zhao-Xia Zhang
- Department of Hematology and Oncology, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Lei Zhang
- Department of Hematology and Oncology, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Juan-Juan Li
- Department of Hematology and Oncology, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Jing Cao
- Department of Hematology and Oncology, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Shun-Qiao Feng
- Department of Hematology and Oncology, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Rui-Hong Tang
- Department of Hematology and Oncology, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Di-Xiao Zhong
- Department of Hematology and Oncology, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Ze-Liang Song
- Department of Hematology and Oncology, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Mei Yue
- Department of Hematology and Oncology, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Meng-Ze Hu
- Department of Hematology and Oncology, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Li-Tian Xuan
- Department of Hematology and Oncology, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Meng-Na Zhai
- Department of Hematology and Oncology, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Hai-Feng Zhang
- Department of experimental center, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Xiang-Yan Wang
- Department of Clinical Pharmacology, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Xiao-Dong Shi
- Department of Hematology and Oncology, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China.
| | - Rong Liu
- Department of Hematology and Oncology, Children's Hospital of Capital Institute of Pediatrics, No. 2, Yabao Road, Chaoyang District, Beijing, 100020, China.
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The Role of γδ T Cells as a Line of Defense in Viral Infections after Allogeneic Stem Cell Transplantation: Opportunities and Challenges. Viruses 2022; 14:v14010117. [PMID: 35062321 PMCID: PMC8779492 DOI: 10.3390/v14010117] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/30/2021] [Accepted: 01/05/2022] [Indexed: 02/04/2023] Open
Abstract
In the complex interplay between inflammation and graft-versus-host disease (GVHD) after allogeneic stem cell transplantation (allo-HSCT), viral reactivations are often observed and cause substantial morbidity and mortality. As toxicity after allo-HSCT within the context of viral reactivations is mainly driven by αβ T cells, we describe that by delaying αβ T cell reconstitution through defined transplantation techniques, we can harvest the full potential of early reconstituting γδ T cells to control viral reactivations. We summarize evidence of how the γδ T cell repertoire is shaped by CMV and EBV reactivations after allo-HSCT, and their potential role in controlling the most important, but not all, viral reactivations. As most γδ T cells recognize their targets in an MHC-independent manner, γδ T cells not only have the potential to control viral reactivations but also to impact the underlying hematological malignancies. We also highlight the recently re-discovered ability to recognize classical HLA-molecules through a γδ T cell receptor, which also surprisingly do not associate with GVHD. Finally, we discuss the therapeutic potential of γδ T cells and their receptors within and outside the context of allo-HSCT, as well as the opportunities and challenges for developers and for payers.
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71
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Challenges and opportunities targeting mechanisms of epithelial injury and recovery in acute intestinal graft-versus-host disease. Mucosal Immunol 2022; 15:605-619. [PMID: 35654837 PMCID: PMC9259481 DOI: 10.1038/s41385-022-00527-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/21/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023]
Abstract
Despite advances in immunosuppressive prophylaxis and overall supportive care, gastrointestinal (GI) graft-versus-host disease (GVHD) remains a major, lethal side effect after allogeneic hematopoietic stem cell transplantation (allo-HSCT). It has become increasingly clear that the intestinal epithelium, in addition to being a target of transplant-related toxicity and GVHD, plays an important role in the onset of GVHD. Over the last two decades, increased understanding of the epithelial constituents and their microenvironment has led to the development of novel prophylactic and therapeutic interventions, with the potential to protect the intestinal epithelium from GVHD-associated damage and promote its recovery following insult. In this review, we will discuss intestinal epithelial injury and the role of the intestinal epithelium in GVHD pathogenesis. In addition, we will highlight possible approaches to protect the GI tract from damage posttransplant and to stimulate epithelial regeneration, in order to promote intestinal recovery. Combined treatment modalities integrating immunomodulation, epithelial protection, and induction of regeneration may hold the key to unlocking mucosal recovery and optimizing therapy for acute intestinal GVHD.
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Boulad F, Maggio A, Wang X, Moi P, Acuto S, Kogel F, Takpradit C, Prockop S, Mansilla-Soto J, Cabriolu A, Odak A, Qu J, Thummar K, Du F, Shen L, Raso S, Barone R, Di Maggio R, Pitrolo L, Giambona A, Mingoia M, Everett JK, Hokama P, Roche AM, Cantu VA, Adhikari H, Reddy S, Bouhassira E, Mohandas N, Bushman FD, Rivière I, Sadelain M. Lentiviral globin gene therapy with reduced-intensity conditioning in adults with β-thalassemia: a phase 1 trial. Nat Med 2022; 28:63-70. [PMID: 34980909 PMCID: PMC9380046 DOI: 10.1038/s41591-021-01554-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 09/23/2021] [Indexed: 01/05/2023]
Abstract
β-Thalassemias are inherited anemias that are caused by the absent or insufficient production of the β chain of hemoglobin. Here we report 6-8-year follow-up of four adult patients with transfusion-dependent β-thalassemia who were infused with autologous CD34+ cells transduced with the TNS9.3.55 lentiviral globin vector after reduced-intensity conditioning (RIC) in a phase 1 clinical trial ( NCT01639690) . Patients were monitored for insertional mutagenesis and the generation of a replication-competent lentivirus (safety and tolerability of the infusion product after RIC-primary endpoint) and engraftment of genetically modified autologous CD34+ cells, expression of the transduced β-globin gene and post-transplant transfusion requirements (efficacy-secondary endpoint). No unexpected safety issues occurred during conditioning and cell product infusion. Hematopoietic gene marking was very stable but low, reducing transfusion requirements in two patients, albeit not achieving transfusion independence. Our findings suggest that non-myeloablative conditioning can achieve durable stem cell engraftment but underscore a minimum CD34+ cell transduction requirement for effective therapy. Moderate clonal expansions were associated with integrations near cancer-related genes, suggestive of non-erythroid activity of globin vectors in stem/progenitor cells. These correlative findings highlight the necessity of cautiously monitoring patients harboring globin vectors.
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Affiliation(s)
- Farid Boulad
- Stem Cell Transplant and Cellular Therapy Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Aurelio Maggio
- Department of Hematology and Rare Diseases, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Xiuyan Wang
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Cell Therapy and Cell Engineering Laboratory, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paolo Moi
- Ospedale Pediatrico Microcitemie 'A.Cao', A.O. 'G.Brotzu', Cagliari, Italy
| | - Santina Acuto
- Department of Hematology and Rare Diseases, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Friederike Kogel
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Chayamon Takpradit
- Stem Cell Transplant and Cellular Therapy Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Susan Prockop
- Stem Cell Transplant and Cellular Therapy Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jorge Mansilla-Soto
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Annalisa Cabriolu
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ashlesha Odak
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jinrong Qu
- Cell Therapy and Cell Engineering Laboratory, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Keyur Thummar
- Cell Therapy and Cell Engineering Laboratory, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Fang Du
- Cell Therapy and Cell Engineering Laboratory, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lingbo Shen
- Cell Therapy and Cell Engineering Laboratory, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Simona Raso
- Department of Hematology and Rare Diseases, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Rita Barone
- Department of Hematology and Rare Diseases, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Rosario Di Maggio
- Department of Hematology and Rare Diseases, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Lorella Pitrolo
- Department of Hematology and Rare Diseases, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Antonino Giambona
- Department of Hematology and Rare Diseases, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Maura Mingoia
- Ospedale Pediatrico Microcitemie 'A.Cao', A.O. 'G.Brotzu', Cagliari, Italy
| | - John K Everett
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Pascha Hokama
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Aoife M Roche
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Vito Adrian Cantu
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Hriju Adhikari
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Shantan Reddy
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Eric Bouhassira
- Department of Cell Biology, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Narla Mohandas
- Laboratory of Red Cell Physiology, New York Blood Center, New York, NY, USA
| | - Frederic D Bushman
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Isabelle Rivière
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Cell Therapy and Cell Engineering Laboratory, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michel Sadelain
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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73
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Alsultan A, Albassam AA, Alturki A, Alsultan A, Essa M, Almuzzaini B, Alfadhel S. Can First-Dose Therapeutic Drug Monitoring Predict the Steady State Area Under the Blood Concentration-Time Curve of Busulfan in Pediatric Patients Undergoing Hematopoietic Stem Cell Transplantation? Front Pediatr 2022; 10:834773. [PMID: 35463912 PMCID: PMC9021690 DOI: 10.3389/fped.2022.834773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/14/2022] [Indexed: 11/26/2022] Open
Abstract
Busulfan has high intra-individual variability and possible time-dependent changes in clearance, which complicates therapeutic drug monitoring (TDM), as first dose sampling may not predict the steady state concentrations. In this study, we aimed to use Bayesian pharmacokinetic parameters estimated from the first dose to predict the steady state AUC for busulfan. This observational study was conducted among pediatric patients at King Abdullah Specialist Children's Hospital. From each patient, we collected six blood samples (2, 2.25, 2.5, 3, 4, and 6 h after the start of IV infusion of the first dose). A subset of patients were also sampled at the steady state. First, we modeled the data using only the first dose. The model was used to estimate the empirical Bayesian estimates of clearance for each individual patient, then we used the empirical Bayesian estimates of clearance to predict the AUC0-tau at steady state (i.e., predicted AUC0-tau). Steady state AUC0-tau was also calculated for patients sampled at steady state using the trapezoidal method using raw time concentration data; this was considered the reference AUC0-tau.. Then, we compared the AUC0-tau predicted using the Bayesian approach with the reference AUC0-tau values. We calculated bias and precision to assess predictability. In total we had 33 patients sampled after first dose and at steady state. Using the Bayesian approach to predict the AUC0-tau, bias was -2.8% and precision was 33%. This indicates that first dose concentrations cannot accurately predict steady state busulfan concentrations; therefore, follow-up TDM may be required for optimal dosing.
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Affiliation(s)
- Abdullah Alsultan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.,Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ahmed A Albassam
- Department of Clinical Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Abdullah Alturki
- Pharmaceutical Analysis Lab-King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdulrahman Alsultan
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Oncology Center, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Mohammed Essa
- Department of Pediatric Hematology/Oncology, King Abdullah Specialist Children Hospital, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Bader Almuzzaini
- Medical Genomics Research Department, King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Salman Alfadhel
- Pharmaceutical Analysis Lab-King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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74
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Nichols-Vinueza DX, Parta M, Shah NN, Cuellar-Rodriguez JM, Bauer TR, West RR, Hsu AP, Calvo KR, Steinberg SM, Notarangelo LD, Holland SM, Hickstein DD. Donor source and post-transplantation cyclophosphamide influence outcome in allogeneic stem cell transplantation for GATA2 deficiency. Br J Haematol 2022; 196:169-178. [PMID: 34580862 PMCID: PMC8702451 DOI: 10.1111/bjh.17840] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/02/2021] [Accepted: 09/03/2021] [Indexed: 01/03/2023]
Abstract
GATA2 deficiency was described in 2011, and shortly thereafter allogeneic hematopoietic stem cell transplantation (HSCT) was shown to reverse the hematologic disease phenotype. However, there remain major unanswered questions regarding the type of conditioning regimen, type of donors, and graft-versus-host disease (GVHD) prophylaxis. We report 59 patients with GATA2 mutations undergoing HSCT at National Institutes of Health between 2013 and 2020. Primary endpoints were engraftment, reverse of the clinical phenotype, secondary endpoints were overall survival (OS), event-free survival (EFS), and the incidence of acute and chronic GVHD. The OS and EFS at 4 years were 85·1% and 82·1% respectively. Ninety-six percent of surviving patients had reversal of the hematologic disease phenotype by one-year post-transplant. Incidence of grade III-IV aGVHD in matched related donor (MRD) and matched unrelated donor recipients (URD) patients receiving Tacrolimus/Methotrexate for GVHD prophylaxis was 32%. In contrast, in the MRD and URD who received post-transplant cyclophosphamide (PT/Cy), no patient developed grade III-IV aGVHD. Six percent of haploidentical related donor (HRD) recipients developed grade III-IV aGVHD. In summary, a busulfan-based HSCT regimen in GATA2 deficiency reverses the hematologic disease phenotype, and the use of PT/Cy reduced the risk of both aGVHD and cGVHD.
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Affiliation(s)
- Diana X. Nichols-Vinueza
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institute of Health, Bethesda, MD
| | - Mark Parta
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Nirali N. Shah
- Pediatric Oncology Branch, National Cancer Institute, Bethesda, MD
| | - Jennifer M. Cuellar-Rodriguez
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institute of Health, Bethesda, MD
| | - Thomas R. Bauer
- Immune Deficiency – Cellular Therapy Program, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Robert R. West
- Immune Deficiency – Cellular Therapy Program, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Amy P. Hsu
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institute of Health, Bethesda, MD
| | | | - Seth M. Steinberg
- Biostatistics and Data Management Section, Office of the Clinical Director, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Luigi D. Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institute of Health, Bethesda, MD
| | - Steven M. Holland
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institute of Health, Bethesda, MD
| | - Dennis D. Hickstein
- Immune Deficiency – Cellular Therapy Program, National Cancer Institute, National Institutes of Health, Bethesda, MD
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75
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Bognàr T(T, Bartelink I(IH, Egberts T(A, Rademaker C(C, Versluys B(AB, Slatter M(MA, Kletzel M(M, Nath C(CE, Cuvelier G(G, Savic R(RM, Dvorak C(C, Long-Boyle J(JR, Cowan M(MJ, Bittencourt H(H, Bredius R(RGM, Güngör T(T, Shaw P(PJ, Ansari M(M, Hassan M(M, Krajinovic M(M, Hempel G(G, Marktel S(S, Chiesa R(R, Théoret Y(Y, Lund T(T, Orchard P(P, Wynn R(RF, Boelens JJ(J, Lalmohamed A(A. Association between the magnitude of intravenous busulfan exposure and development of hepatic veno-occlusive disease in children and young adults undergoing myeloablative allogeneic hematopoietic cell transplantation. Transplant Cell Ther 2022; 28:196-202. [DOI: 10.1016/j.jtct.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/13/2022] [Accepted: 01/13/2022] [Indexed: 11/30/2022]
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76
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Saraceni F, Scortechini I, Fiorentini A, Dubbini MV, Mancini G, Federici I, Colaneri FR, Lotito AF, Guerzoni S, Puglisi B, Olivieri A. Conditioning Regimens for Frail Patients with Acute Leukemia Undergoing Allogeneic Stem Cell Transplant: How to Strike Gently. Clin Hematol Int 2021; 3:153-160. [PMID: 34938987 PMCID: PMC8690700 DOI: 10.2991/chi.k.210731.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 07/25/2021] [Indexed: 01/06/2023] Open
Abstract
Despite the recent dramatic progress in acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) therapy, allogeneic transplant remains a mainstay of treatment for patients with acute leukemia. The availability of novel compounds and low intensity chemotherapy regimens made it possible for a significant proportion of elderly and comorbid patients with AML or ALL to undergo curative treatment protocols. In addition, the expansion of donor availability and the recent dramatic progress in haploidentical stem cell transplant, allow the identification of an available donor for nearly every patient. Therefore, an increasing number of transplants are currently performed in elderly and frail patients with AML or ALL. However, allo-Hematopoietic stem cell transplant (HSCT) in this delicate setting represents an important challenge, especially regarding the selection of the conditioning protocol. Ideally, conditioning intensity should be reduced as much as possible; however, in patients with acute leukemia relapse remains the major cause of transplant failure. In this article we present modern tools to assess the patient health status before transplant, review the available data on the outcome of frail AML an ALL patients undergoing allo-HSCT, and discuss how preparatory regimens can be optimized in this setting.
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Affiliation(s)
- Francesco Saraceni
- Hematology and Stem Cell Transplant, Ospedali Riuniti Ancona, Via Conca 71, Ancona, Italy
| | - Ilaria Scortechini
- Hematology and Stem Cell Transplant, Ospedali Riuniti Ancona, Via Conca 71, Ancona, Italy
| | - Alessandro Fiorentini
- Hematology and Stem Cell Transplant, Ospedali Riuniti Ancona, Via Conca 71, Ancona, Italy
| | - Maria Vittoria Dubbini
- Hematology and Stem Cell Transplant, Ospedali Riuniti Ancona, Via Conca 71, Ancona, Italy
| | - Giorgia Mancini
- Hematology and Stem Cell Transplant, Ospedali Riuniti Ancona, Via Conca 71, Ancona, Italy
| | - Irene Federici
- Hematology and Stem Cell Transplant, Ospedali Riuniti Ancona, Via Conca 71, Ancona, Italy
| | | | | | - Selene Guerzoni
- Hematology and Stem Cell Transplant, Ospedali Riuniti Ancona, Via Conca 71, Ancona, Italy
| | - Bruna Puglisi
- Hematology and Stem Cell Transplant, Ospedali Riuniti Ancona, Via Conca 71, Ancona, Italy
| | - Attilio Olivieri
- Hematology and Stem Cell Transplant, Ospedali Riuniti Ancona, Via Conca 71, Ancona, Italy
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77
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Takahashi T, Illamola SM, Jennissen CA, Long SE, Lund TC, Orchard PJ, Gupta AO, Long-Boyle JR. Busulfan dose recommendation in inherited metabolic disorders: Population pharmacokinetic analysis. Transplant Cell Ther 2021; 28:104.e1-104.e7. [PMID: 34883294 DOI: 10.1016/j.jtct.2021.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/28/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022]
Abstract
Busulfan is a commonly used alkylating agent in the conditioning regimens of hematopoietic cell transplantation (HCT). Population pharmacokinetic (popPK) models enable the description of busulfan PK and optimization of exposure, which leads to improvement of event-free survival after HCT. Prior busulfan popPK analysis has been limited by small numbers in patients with inherited metabolic disorders (IMD). The primary objective was to characterize population PK of busulfan in a large cohort of children and young adults undergoing HCT for IMD. PopPK analysis of busulfan drug concentrations was performed using data from 78 patients with IMD who received intravenous busulfan (every 24 hours, 4 doses) as part of pretransplantation combination chemotherapy. The final model for busulfan drug clearance was then used to estimate individual doses aimed to achieve a target cumulative area under the curve (cAUC) of 80 to 100 mg · h/L. We then compared the probability of cAUC within the range of 80 to 100 mg · h/L by the developed dosing regimen versus conventional regimen. A 1-compartment, linear elimination model best described the PK of busulfan. Significant covariates demonstrated to affect busulfan clearance included total body weight and the time (in days) from busulfan infusion start. The probability of target cumulative AUC attainment by the developed dosing versus the conventional dosing were 47% versus 43% for body weight <12 kg, and 48% versus 36% for body weight ≥12 kg. We described population PK of intravenous busulfan in a large IMD cohort. The proposed dosing regimen based on the developed model can improve the target cAUC attainment of busulfan for IMD.
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Affiliation(s)
- Takuto Takahashi
- Division of Pediatric Blood and Marrow Transplant, University of Minnesota, Minneapolis, Minnesota; Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota.
| | - Sílvia M Illamola
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota
| | | | - Susan E Long
- Department of Pharmacy, Fairview MHealth, Minneapolis, Minnesota
| | - Troy C Lund
- Division of Pediatric Blood and Marrow Transplant, University of Minnesota, Minneapolis, Minnesota
| | - Paul J Orchard
- Division of Pediatric Blood and Marrow Transplant, University of Minnesota, Minneapolis, Minnesota
| | - Ashish O Gupta
- Division of Pediatric Blood and Marrow Transplant, University of Minnesota, Minneapolis, Minnesota
| | - Janel R Long-Boyle
- Departments of Clinical Pharmacy, University of California San Francisco, Mission Bay, California; Division of Pediatric Allergy/Immunology/Bone Marrow Transplantation, University of California San Francisco, Mission Bay, California
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78
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Pita-Oliveira M, Rodrigues-Soares F. Influence of GSTM1, GSTT1, and GSTP1 genetic polymorphisms on disorders in transplant patients: a systematic review. Drug Metab Pers Ther 2021; 37:123-131. [PMID: 34856092 DOI: 10.1515/dmpt-2021-0165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 11/03/2021] [Indexed: 11/15/2022]
Abstract
The glutathione-S-transferase (GST) enzymes are phase II isoenzymes responsible for protection against free radicals and xenobiotics. Since these proteins are described as polymorphic, polymorphisms in genes that encode them may alter enzymatic function and contribute to oxidative stress. In this context, such polymorphisms were already associated with several diseases and multiple therapeutic outcomes. A systematic review was performed to evaluate studies regarding the association between polymorphisms in three genes encoding enzymes of the GST family - GSTM1, GSTT1, and GSTP1 - and disorders in transplant patients. A total of 125 articles on which inclusion and exclusion criteria were applied were identified at PubMed database. Thirty-two studies met the target criteria and were included in the review. The mechanisms by which GST genotypes influence the development of disorders in transplant patients differ by disorder: they may participate in it by decreasing metabolism of drugs administered to patients undergoing transplantation, then exposing them to greater toxicity; by decreasing the repair ability against oxidative stress; or by encoding proteins that may be recognized as foreign, setting of an alloimmune reaction. Although some results are better established - such as GSTM1 null genotype's role in the development of toxicity events in transplant patients - others require further evidences, as GST influence on the development of pulmonary decline and posttransplant diabetes mellitus (PTDM). The importance of investigating these associations lies in a personalized medicine, in which the high-risk genotype patient has its treatment individualized and its care for prophylaxis and surveillance increased, potentially reducing this population's morbimortality.
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Affiliation(s)
- Murilo Pita-Oliveira
- Departamento de Patologia, Genética e Evolução, Instituto de Ciências Biológicas e Naturais, Universidade Federal do Triângulo Mineiro, Uberaba, Minas Gerais, Brazil
| | - Fernanda Rodrigues-Soares
- Departamento de Patologia, Genética e Evolução, Instituto de Ciências Biológicas e Naturais, Universidade Federal do Triângulo Mineiro, Uberaba, Minas Gerais, Brazil
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79
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Essmann S, Dadkhah A, Janson D, Wolschke C, Ayuk F, Kröger NM, Langebrake C. Iron Chelation With Deferasirox Increases Busulfan AUC During Conditioning Chemotherapy Prior to Allogeneic Stem Cell Transplantation. Transplant Cell Ther 2021; 28:115.e1-115.e5. [PMID: 34775147 DOI: 10.1016/j.jtct.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/01/2021] [Accepted: 11/03/2021] [Indexed: 01/19/2023]
Abstract
The negative effects of iron overload caused by repetitive blood transfusions and iron release during cytotoxic chemotherapy might be ameliorated by early treatment with an iron chelator. However, in the setting of allogeneic hematopoietic stem cell transplantation (HSCT), chelation therapy is often postponed until the late post-transplantation period because of potential drug interactions. We wanted to systematically investigate the influence of iron chelation with deferasirox on the pharmacokinetics of intravenous busulfan in adult patients in the context of routine therapeutic drug monitoring (TDM) before HSCT. We conducted a single-center, prospective, observational study in 25 adult patients with planned allogeneic HSCT after myeloablative, busulfan-based, TDM-guided conditioning chemotherapy. Busulfan was administered intravenously over 3 hours with an initial dose of 3.2 mg/kg once daily (based on adjusted ideal body weight [AIBW] in overweight patients). Four consecutive dosages were planned to achieve a cumulative area under the curve (AUC) of 80 mg · h/L. Patients received deferasirox for transfusional iron overload as per approval from the start of conditioning until day 3 after transplantation. Model-based calculation of the busulfan AUC was carried out by means of Bayesian prediction based on a population pharmacokinetic model after the first or second dose of busulfan, and dose adjustments were performed accordingly. Calculated median cumulative AUC before dose adjustment was 93.7 mg · h/L (65.1-151.4 mg · h/L), which was considerably above the target AUC of 80 mg · h/L ± 10%. Median dose adjustment was -17.1% (-50.0% to 18.2%), and patients ultimately received busulfan with a median cumulative dose of 10.60 mg/kg (6.38-15.62 mg/kg). A busulfan dose reduction was necessary in 19 patients (76%) whereas a dose increase was only necessary in 1 patient. After dose adjustment the median AUC was 79.7 mg/L · h (62.5 - 84.2 mg/L · h). Median busulfan clearance was 0.134 L/h/kg (0.084-0.203 L/h/kg), which is significantly lower than the average clearance of 0.2 L/h/kg reported in the literature, whereas volume of distribution was not altered. We were able to demonstrate, that TDM is the key point to facilitate a safe co-administration of both medications, because the intake of deferasirox leads to a considerable increase in the busulfan AUC of about 35% to 40%. The reason for the increase in busulfan AUC is a reduction in busulfan clearance by about one third; therefore a lower initial dose of busulfan followed by TDM could be considered in this case.
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Affiliation(s)
- Sonja Essmann
- University Medical Centre Hamburg-Eppendorf, Department of Stem Cell Transplantation, Hamburg, Germany
| | - Adrin Dadkhah
- University Medical Centre Hamburg-Eppendorf, Hospital Pharmacy, Hamburg, Germany
| | - Dietlinde Janson
- University Medical Centre Hamburg-Eppendorf, Department of Stem Cell Transplantation, Hamburg, Germany
| | - Christine Wolschke
- University Medical Centre Hamburg-Eppendorf, Department of Stem Cell Transplantation, Hamburg, Germany
| | - Francis Ayuk
- University Medical Centre Hamburg-Eppendorf, Department of Stem Cell Transplantation, Hamburg, Germany
| | - Nicolaus M Kröger
- University Medical Centre Hamburg-Eppendorf, Department of Stem Cell Transplantation, Hamburg, Germany
| | - Claudia Langebrake
- University Medical Centre Hamburg-Eppendorf, Department of Stem Cell Transplantation, Hamburg, Germany; University Medical Centre Hamburg-Eppendorf, Hospital Pharmacy, Hamburg, Germany.
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80
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Huang H, Liu M, Ren J, Hu J, Lin S, Li D, Huang W, Chen S, Yang T, Wu X. Can Published Population Pharmacokinetic Models of Busulfan Be Used for Individualized Dosing in Chinese Pediatric Patients Undergoing Hematopoietic Stem Cell Transplantation? An External Evaluation. J Clin Pharmacol 2021; 62:609-619. [PMID: 34695225 DOI: 10.1002/jcph.1992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 10/20/2021] [Indexed: 02/02/2023]
Abstract
Busulfan is a bifunctional alkylating agent that is widely used before hematopoietic stem cell transplantation (HSCT), in combination with other chemotherapeutic drugs. As of 2020, there is no population pharmacokinetic (popPK) model for busulfan in Chinese pediatric patients. A systemic external evaluation of 11 published popPK models was conducted in Chinese pediatric patients undergoing HSCT. Forty pediatric patients were enrolled in this study, with a total of 183 blood concentrations. The relative prediction error (PE%), median PE%, median absolute PE%, and percentage of PE% within ±20% and ±30% were calculated in prediction-based diagnostics. Simulation-based diagnostics were conducted through a prediction- and variability-corrected visual predictive check and the normalized prediction distribution error. The relative individual prediction error was calculated using Bayesian forecasting with 1 to 3 concentration points. The 1-compartment open linear popPK model, which was built by Su-jin Rhee et al (model H), incorporating the patient's body surface area, age, dosing day, and aspartate aminotransferase as significant covariates had preferable predictability than other popPK models. In prediction-based diagnostics, the median PE%, percentage of PE% within ±20%, and percentage of PE% within ±30% of model H were 8.48%, 45.35%, and 59.56%, respectively. The normalized prediction distribution error of model H showed that it followed the normal distribution. Based on Bayesian forecasting, model H showed good predictive performance. Thus, model H was the most appropriate model that can be used clinically for individualized dosage adjustments in Chinese pediatric HSCT patients.
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Affiliation(s)
- Huiping Huang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China.,School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Jinhua Ren
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Jianda Hu
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Shenglu Lin
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Dandan Li
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China.,School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Weikun Huang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China.,School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Shaozhen Chen
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Ting Yang
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Xuemei Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
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81
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Dadkhah A, Alihodzic D, Broeker A, Kröger N, Langebrake C, Wicha SG. Evaluation of the Robustness of Therapeutic Drug Monitoring Coupled with Bayesian Forecasting of Busulfan with Regard to Inaccurate Documentation. Pharm Res 2021; 38:1721-1729. [PMID: 34664209 PMCID: PMC8602150 DOI: 10.1007/s11095-021-03115-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/20/2021] [Indexed: 12/13/2022]
Abstract
Background Inaccurate documentation of sampling and infusion times is a potential source of error in personalizing busulfan doses using therapeutic drug monitoring (TDM). Planned times rather than the actual times for sampling and infusion time are often documented. Therefore, this study aimed to evaluate the robustness of a limited sampling TDM of busulfan with regard to inaccurate documentation. Methods A pharmacometric analysis was conducted in NONMEM® 7.4.3 and “R” by performing stochastic simulation and estimation with four, two and one sample(s) per patient on the basis of a one-compartment- (1CMT) and two-compartment (2CMT) population pharmacokinetic model. The dosing regimens consisted of i.v. busulfan (0.8 mg/kg) every 6 h (Q6H) or 3.2 mg/kg every 24 h (Q24H) with a 2 h- and 3 h infusion time, respectively. The relative prediction error (rPE) and relative root-mean-square error (rRmse) were calculated in order to determine the accuracy and precision of the individual AUC estimation. Results A noticeable impact on the estimated AUC based on a 1CMT-model was only observed if uncertain documentation reached ± 30 min (1.60% for Q24H and 2.19% for Q6H). Calculated rPEs and rRmse for Q6H indicate a slightly lower level of accuracy and precision when compared to Q24H. Spread of rPE’s and rRmse for the 2CMT-model were wider and higher compared to estimations based on a 1CMT-model. Conclusions The estimated AUC was not affected substantially by inaccurate documentation of sampling and infusion time. The calculated rPEs and rRmses of estimated AUC indicate robustness and reliability for TDM of busulfan, even in presence of erroneous records. Supplementary Information The online version contains supplementary material available at 10.1007/s11095-021-03115-8.
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Affiliation(s)
- Adrin Dadkhah
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany. .,Dept. of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany.
| | - Dzenefa Alihodzic
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Astrid Broeker
- Dept. of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Claudia Langebrake
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian G Wicha
- Dept. of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
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82
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McCune JS, Punt AM, Yeh RF, Dupuis LL, Kweekel DM, Franssen EJF, Ritchie JC, van Maarseveen E, Huitema ADR. Quality Control of Busulfan Plasma Quantitation, Modeling, and Dosing: An Interlaboratory Proficiency Testing Program. Ther Drug Monit 2021; 43:657-663. [PMID: 33675302 DOI: 10.1097/ftd.0000000000000862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Personalizing busulfan doses to target a narrow plasma exposure has improved the efficacy and lowered the toxicity of busulfan-based conditioning regimens used in hematopoietic cell transplant. Regional regulations guide interlaboratory proficiency testing for busulfan concentration quantification and monitoring. To date, there have been no comparisons of the busulfan pharmacokinetic modeling and dose recommendation protocols used in these laboratories. Here, in collaboration with the Dutch Association for Quality Assessment in Therapeutic Drug Monitoring and Clinical Toxicology, a novel interlaboratory proficiency program for the quantitation in plasma, pharmacokinetic modeling, and dosing of busulfan was designed. The methods and results of the first 2 rounds of this proficiency testing are described herein. METHODS A novel method was developed to stabilize busulfan in N,N-dimethylacetamide, which allowed shipping of the proficiency samples without dry ice. In each round, participating laboratories reported their results for 2 proficiency samples (one low and one high busulfan concentrations) and a theoretical case assessing their pharmacokinetic modeling and dose recommendations. All participants were blinded to the answers; descriptive statistics were used to evaluate their overall performance. The guidelines suggested that answers within ±15% for busulfan concentrations and ±10% for busulfan plasma exposure and dose recommendation were to be considered accurate. RESULTS Of the 4 proficiency samples evaluated, between 67% and 85% of the busulfan quantitation results were accurate (ie, within 85%-115% of the reference value). The majority (88% round #1; 71% round #2) of the dose recommendation answers were correct. CONCLUSIONS A proficiency testing program by which laboratories are alerted to inaccuracies in their quantitation, pharmacokinetic modeling, and dose recommendations for busulfan in hematopoietic cell transplant recipients was developed. These rounds of proficiency testing suggests that additional educational efforts and proficiency rounds are needed to ensure appropriate busulfan dosing.
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Affiliation(s)
- Jeannine S McCune
- Department of Hematologic Malignancies Translational Sciences, Beckman Research Institute at City of Hope, Duarte, California
| | - Arjen M Punt
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Rosa F Yeh
- Pharmacokinetics Laboratory, Seattle Cancer Care Alliance, Seattle, Washington
| | - L Lee Dupuis
- Department of Pharmacy and Research Institute, The Hospital for Sick Children and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Dina M Kweekel
- Drug Analysis and Toxicology Division (KKGT) of the Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Amsterdam, the Netherlands
| | - Eric J F Franssen
- Drug Analysis and Toxicology Division (KKGT) of the Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Amsterdam, the Netherlands
| | - James C Ritchie
- Pathology and Laboratory Medicine Department, Emory University, Atlanta, Georgia
| | - Erik van Maarseveen
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, and Drug Analysis, and Toxicology Division (KKGT) of the Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Utrecht, the Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Pharmacy and Pharmacology, Netherlands Cancer Institute, Amsterdam, the Netherlands ; and
- Department of Pharmacology, Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands
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83
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van der Stoep MYEC, Bertaina A, Moes DJAR, Algeri M, Bredius RGM, Smiers FJW, Berghuis D, Buddingh EP, Mohseny AB, Guchelaar HJ, Locatelli F, Zwaveling J, Lankester AC. Impact of Treosulfan Exposure on Early and Long-Term Clinical Outcomes in Pediatric Allogeneic Hematopoietic Stem Cell Transplantation Recipients: A Prospective Multicenter Study. Transplant Cell Ther 2021; 28:99.e1-99.e7. [PMID: 34607071 DOI: 10.1016/j.jtct.2021.09.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 11/11/2022]
Abstract
Treosulfan-based conditioning has gained popularity in pediatric allogeneic hematopoietic stem cell transplantation (HSCT) because of its presumed favorable efficacy and toxicity profile. Treosulfan is used in standardized dosing regimens based on body surface area. The relationships between systemic treosulfan exposure and early and long-term clinical outcomes in pediatric patients undergoing allogeneic HSCT for nonmalignant diseases remain unclear. In this a multicenter, prospective observational study, we assessed the association between treosulfan exposure and early and, in particular, long-term clinical outcomes. Our study cohort comprised 110 pediatric patients with nonmalignant diseases who underwent HSCT between 2011 and 2019 in Leiden, The Netherlands and Rome, Italy. Blood samples were collected, and treosulfan area under the receiver operating characteristic curve (AUC0-∞) was estimated as a measure of exposure. Cox proportional hazard survival analyses were performed to assess the relationships between treosulfan exposure and overall survival (OS) and event-free survival (EFS). The predictive value of systemic treosulfan exposure for the occurrence of toxicity within 28 days was evaluated using a multivariable logistic regression analysis. In the overall cohort, OS and EFS at 2 years were 89.0% and 75.3%, respectively, with an excellent OS of 97% in children age <2 years. The occurrence of grade II-IV acute graft-versus-host disease, the level of 1-year whole blood chimerism, and 2-year OS and EFS were not correlated with treosulfan exposure. The occurrence of skin toxicity (odds ratio [OR], 3.97; 95% confidence interval [CI], 1.26-13.68; P = .02) and all-grade mucositis (OR, 4.43; 95% CI, 1.43-15.50; P = .02), but not grade ≥2 mucositis (OR, 1.51; 95% CI, 0.52 to 4.58; P = .46) was related to high treosulfan exposure (>1750 mg*h/L). Our study demonstrates that standardized treosulfan-based conditioning results in a favorable OS and EFS in infants and children with nonmalignant diseases, independent of interindividual variation in treosulfan exposure. These outcomes can be achieved without the need for therapeutic drug monitoring, thereby emphasizing the advantage of treosulfan use in this category of patients. Although higher treosulfan exposure increases the risk of skin toxicity, there is no absolute necessity for therapeutic drug monitoring if proper preventive skin measures are taken. More research is needed to assess whether deescalation of treosulfan doses is possible to minimize early and long-term toxicity without compromising efficacy.
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Affiliation(s)
- M Y Eileen C van der Stoep
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alice Bertaina
- Department of Paediatric Hematology/Oncology and Cell and Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico Bambino Gesù Children's Hospital, Rome, Sapienza, University of Rome, Italy
| | - Dirk Jan A R Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mattia Algeri
- Department of Paediatric Hematology/Oncology and Cell and Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico Bambino Gesù Children's Hospital, Rome, Sapienza, University of Rome, Italy
| | - Robbert G M Bredius
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Frans J W Smiers
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dagmar Berghuis
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Emilie P Buddingh
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexander B Mohseny
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Franco Locatelli
- Department of Paediatric Hematology/Oncology and Cell and Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico Bambino Gesù Children's Hospital, Rome, Sapienza, University of Rome, Italy
| | - Juliette Zwaveling
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan C Lankester
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
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84
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TCRαβ/CD19 depleted HSCT from an HLA-haploidentical relative to treat children with different non-malignant disorders. Blood Adv 2021; 6:281-292. [PMID: 34592755 PMCID: PMC8753220 DOI: 10.1182/bloodadvances.2021005628] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/02/2021] [Indexed: 11/20/2022] Open
Abstract
Several non-malignant disorders (NMDs), either inherited or acquired, can be cured by allogeneic hematopoietic stem cell transplantation (HSCT). Between January 2012 and April 2020, 70 consecutive children affected by primary immunodeficiencies, inherited/acquired bone marrow failure syndromes, red blood cell disorders or metabolic diseases, lacking a fully-matched donor or requiring urgent transplantation, underwent TCRαβ/CD19-depleted haploidentical HSCT from an HLA-partially matched relative as part of a prospective study (#NCT01810120). Median age at transplant was 3.5 years (range 0.3-16.1); median time from diagnosis to transplant was 10.5 months (2.7 for SCID patients). Primary engraftment was obtained in 51 patients, while 19 and 2 patients experienced either primary or secondary graft failure (GF), the overall incidence of this complication being 30.4%. Most GFs were observed in children with disease at risk for this complication (e.g., aplastic anemia, thalassemia). All but 5 patients experiencing GF were successfully retransplanted. Six patients died of infectious complications (4 had active/recent infections at time of HSCT), the cumulative incidence of transplant-related mortality (TRM) being 8.5%. Cumulative incidence of grade I-II acute GvHD was 14.4% (no patient developed grade III-IV acute GVHD). Only one patient at risk developed mild chronic GvHD. With a median follow-up of 3.5 years, the 5-year probability of overall and disease-free survival was 91.4% and 86.8%, respectively. In conclusion, TCRαβ/CD19-depleted haploidentical HSCT from an HLA-partially matched relative is confirmed to be an effective treatment for children with NMDs. Prompt donor availability, low incidence of GvHD and TRM make this strategy an attractive option in NMDs patients.
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85
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GSTM1 and GSTT1 double null genotypes determining cell fate and proliferation as potential risk factors of relapse in children with hematological malignancies after hematopoietic stem cell transplantation. J Cancer Res Clin Oncol 2021; 148:71-86. [PMID: 34499222 PMCID: PMC8752561 DOI: 10.1007/s00432-021-03769-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/14/2021] [Indexed: 10/29/2022]
Abstract
PURPOSE This study aimed to retrospectively evaluate the genetic association of null variants of glutathione S-transferases GSTM1 and GSTT1 with relapse incidence in children with hematological malignancies (HMs) undergoing busulfan (BU)- containing allogeneic hematopoietic stem cell transplantation (HSCT) and to assess the impact of these variants on BU-induced cytotoxicity on the immortalized lymphoblastoid cell lines (LCLs) and tumor THP1 GST gene-edited cell models. METHODS GSTM1- and GSTT1-null alleles were genotyped using germline DNA from whole blood prior to a conditioning BU-based regimen. Association of GSTM1- and GSTT1-null variants with relapse incidence was analyzed using multivariable competing risk analysis. BU-induced cell death studies were conducted in GSTs- null and non-null LCLs and CRISPR-Cas9 gene-edited THP1 leukemia cell lines. RESULTS Carrying GSTM1/GSTT1 double null genotype was found to be an independent risk factor for post-HSCT relapse in 86 children (adjusted HR: 6.52 [95% Cl, 2.76-15.42; p = 1.9 × 10-5]). BU-induced cell death preferentially in THP1GSTM1(non-null) and LCLsGSTM1(non-null) as shown by decreased viability, increased necrosis and levels of the oxidized form of glutathione compared to null cells, while GSTT1 non-null cells showed increased baseline proliferation. CONCLUSION The clinical association suggests that GSTM1/GSTT1 double null genotype could serve as genetic stratification biomarker for the high risk of post-HSCT relapse. Functional studies have indicated that GSTM1 status modulates BU-induced cell death. On the other hand, GSTT1 is proposed to be involved in baseline cell proliferation.
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86
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Friend BD, Schiller GJ. Beyond steroids: A systematic review and proposed solutions to managing acute graft-versus-host disease in adolescents and young adults. Blood Rev 2021; 52:100886. [PMID: 34509319 DOI: 10.1016/j.blre.2021.100886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 08/18/2021] [Accepted: 08/26/2021] [Indexed: 12/11/2022]
Abstract
The outcomes of allogeneic hematopoietic cell transplantation (HCT) in adolescents and young adults (AYAs) with hematologic malignancies have been shown to be poorer when compared to results in children, due to a combination of higher relapse rates and greater treatment-related mortality (TRM). Although differences in relapse risk have been studied extensively, toxicity has been examined and reported less often. In this systematic review, we summarize recently published studies that have examined the differences in rates of TRM and acute graft-versus-host disease (GVHD) in AYAs and children with hematologic malignancies, and attempt to explain why these disparities exist and how they impact outcomes. In addition, we present best practices for management of steroid-refractory GVHD that are likely to improve survival in this patient population. Further, we propose the development of personalized, risk-based approaches for the prevention and treatment of GVHD that incorporate novel platforms and interventions. We believe this individualized approach is likely to reduce toxicity and greatly improve outcomes for this vulnerable population.
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Affiliation(s)
- Brian D Friend
- Department of Pediatrics, Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital, 1102 Bates Ave, Suite 1630, Houston, TX 77030, USA.
| | - Gary J Schiller
- Department of Medicine, Division of Hematology-Oncology, University of California Los Angeles, 10833 Le Conte Ave, 42-121 CHS, Los Angeles, CA 90095, USA.
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87
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Ben Hassine K, Nava T, Théoret Y, Nath CE, Daali Y, Kassir N, Lewis V, Bredius RGM, Shaw PJ, Bittencourt H, Krajinovic M, Uppugunduri CRS, Ansari M. Precision dosing of intravenous busulfan in pediatric hematopoietic stem cell transplantation: Results from a multicenter population pharmacokinetic study. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2021; 10:1043-1056. [PMID: 34453497 PMCID: PMC8452291 DOI: 10.1002/psp4.12683] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/14/2021] [Accepted: 06/11/2021] [Indexed: 12/13/2022]
Abstract
Busulfan (Bu) is a common component of conditioning regimens before hematopoietic stem cell transplantation (HSCT) and is known for high interpatient pharmacokinetic (PK) variability. This study aimed to develop and externally validate a multicentric, population PK (PopPK) model for intravenous Bu in pediatric patients before HSCT to first study the influence of glutathione‐s‐transferase A1 (GSTA1) polymorphisms on Bu's PK in a large multicentric pediatric population while accounting for fludarabine (Flu) coadministration and, second, to establish an individualized, model‐based, first‐dose recommendation for intravenous Bu that can be widely used in pediatric patients. The model was built using data from 302 patients from five transplantation centers who received a Bu‐based conditioning regimen. External model validation used data from 100 patients. The relationship between body weight and Bu clearance (CL) was best described by an age‐dependent allometric scaling of a body weight model. A stepwise covariate analysis identified Day 1 of Bu conditioning, GSTA1 metabolic groups based on GSTA1 polymorphisms, and Flu coadministration as significant covariates influencing Bu CL. The final model adequately predicted Bu first‐dose CL in the external cohort, with 81% of predicted area under the curves within the therapeutic window. The final model showed minimal bias (mean prediction error, −0.5%; 95% confidence interval [CI], −3.1% to 2.0%) and acceptable precision (mean absolute prediction error percentage, 18.7%; 95% CI, 17.0%–20.5%) in Bu CL prediction for dosing. This multicentric PopPK study confirmed the influence of GSTA1 polymorphisms and Flu coadministration on Bu CL. The developed model accurately predicted Bu CL and first doses in an external cohort of pediatric patients.
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Affiliation(s)
- Khalil Ben Hassine
- CANSEARCH Research Platform in Pediatric Oncology and Hematology, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Geneva, Switzerland.,Division of Pediatric Oncology and Hematology, Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Tiago Nava
- CANSEARCH Research Platform in Pediatric Oncology and Hematology, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Geneva, Switzerland.,Division of Pediatric Oncology and Hematology, Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Yves Théoret
- Charles-Bruneau Cancer Center, Sainte-Justine University Health Center (SJUHC), Montreal, Quebec, Canada.,Department of Pharmacology and Physiology, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada.,Clinical Pharmacology Unit, Sainte-Justine University Health Center (SJUHC), Montreal, Quebec, Canada.,Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Christa E Nath
- Department of Biochemistry, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,The Cancer Centre for Children, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Youssef Daali
- Clinical Pharmacology and Toxicology Division, Geneva University Hospitals and University of Geneva, Geneva, Switzerland.,Faculty of Medicine & Sciences, University of Geneva, Geneva, Switzerland
| | - Nastya Kassir
- Genentech/Roche, Clinical Pharmacology, South San Francisco, California, USA
| | - Victor Lewis
- Department of Pediatrics, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Robbert G M Bredius
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter J Shaw
- The Cancer Centre for Children, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Henrique Bittencourt
- Charles-Bruneau Cancer Center, Sainte-Justine University Health Center (SJUHC), Montreal, Quebec, Canada.,Department of Pharmacology and Physiology, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada.,Clinical Pharmacology Unit, Sainte-Justine University Health Center (SJUHC), Montreal, Quebec, Canada.,Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Maja Krajinovic
- Charles-Bruneau Cancer Center, Sainte-Justine University Health Center (SJUHC), Montreal, Quebec, Canada.,Department of Pharmacology and Physiology, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada.,Clinical Pharmacology Unit, Sainte-Justine University Health Center (SJUHC), Montreal, Quebec, Canada.,Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Chakradhara Rao Satyanarayana Uppugunduri
- CANSEARCH Research Platform in Pediatric Oncology and Hematology, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Geneva, Switzerland.,Division of Pediatric Oncology and Hematology, Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Marc Ansari
- CANSEARCH Research Platform in Pediatric Oncology and Hematology, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Geneva, Switzerland.,Division of Pediatric Oncology and Hematology, Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
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88
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Is Salivary Busulfan the Cause of Oral Mucositis and the Changes in Salivary Antioxidant Enzymes After Hematopoietic Cell Transplantation? Ther Drug Monit 2021; 42:565-571. [PMID: 32205679 DOI: 10.1097/ftd.0000000000000757] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND To determine whether the busulfan (Bu) present in saliva during hematopoietic cell transplantation (HCT) conditioning correlates with oral mucositis and the changes in salivary antioxidant enzymes. METHODS Bu levels in the plasma and saliva of 19 patients who received HCTs were quantified. Salivary flow and salivary superoxide dismutase and catalase activities were measured during HCT. For the toxicity analysis of salivary Bu, an in vitro assay was conducted by exposing human keratinocytes to artificial saliva containing Bu. RESULTS Plasma and salivary Bu concentrations were very similar (rho = 0.92, P < 0.001). Salivary Bu concentration correlated with the degree of oral mucositis severity (rho = 0.391, P = 0.029) and was inversely proportional to salivary superoxide dismutase and catalase activities (rho = -0.458, P = 0.036; rho = -0.424, P = 0.043, respectively). Cells exposed to Bu-containing saliva had fewer viable cells (P < 0.01) and more apoptotic cells (P = 0.001) than those exposed to non-Bu-containing saliva. CONCLUSIONS Bu found in saliva during HCT conditioning was correlated with severe oral mucositis and the reduction in salivary antioxidative activity. Furthermore, Bu can be toxic to keratinocytes.
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89
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Bramanti S, De Philippis C, Bartoli A, Giordano L, Mariotti J, Sarina B, Mannina D, Valli V, De Gregori S, Roperti M, Pieri G, Castagna L. Feasibility and Efficacy of a Pharmacokinetics-Guided Busulfan Conditioning Regimen for Allogeneic Stem Cell Transplantation with Post-Transplantation Cyclophosphamide as Graft-versus-Host Disease Prophylaxis in Adult Patients with Hematologic Malignancies. Transplant Cell Ther 2021; 27:912.e1-912.e6. [PMID: 34403790 DOI: 10.1016/j.jtct.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
Busulfan (Bu) is an alkylating agent routinely used for conditioning regimens before allogeneic stem cell transplantation (allo-SCT). Bu shows wide pharmacokinetic (PK) variability among patients. Patients can have a higher systemic exposure (expressed as area under the curve [AUC]) with an increased risk of toxicity or a lower AUC with a higher probability of graft rejection and/or disease relapse. After i.v. administration, an optimal Bu therapeutic window (AUC target of 16,000 to 24,000 μM·minute) has been identified. The use of PK-guided Bu dosing leads to improved overall survival (OS) and progression-free survival (PFS) compared with fixed-dose administration in a variety of hematologic diseases. The aim of this study was to evaluate the outcomes and feasibility of a reduced-toxicity conditioning (RTC) regimen comprising thiotepa, Bu, and fludarabine (TBF) with therapeutic drug monitoring of Bu in patients with hematologic disorders. We report on 41 adult patients with myeloid or lymphoid malignancies who underwent an allo-SCT with a PK-guided Bu-based RTC regimen between January 2019 and October 2020. Patients received a total Bu dose to achieve a target AUC of 16,000 μM·minute in combination with Flu and thiotepa. The median time to absolute neutrophil count recovery and transfusion-independent platelet count recovery was 23 days (range, 15 to 42 days) and 29 days (range, 14 to 97 days), respectively. The cumulative incidence (CI) of nonrelapse mortality was 7% at 100 days and 13% at 1 year. Grade 3 liver toxicity was observed in 6 patients. One patient developed sinusoidal obstruction syndrome at day +27. Grade 3 mucositis occurred in 18 patients. Looking at grade ≥3 infections, the CI was 29% at 30 days, 34% at 60 days, 44% at 100 days, and 56% at 1 year. The 180-day CI of grade II-IV acute graft-versus-host disease (GVHD) was 15%, and the 1-year CI of overall chronic GVHD was 20%. With a median follow-up of alive patients of 14.4 months (range, 3.2 to 24 months), the CI of relapse at 1 year was 6%. The 1-year PFS was 81%, and 1-year OS was 84%. In conclusion, these data support the efficacy of PK-guided Bu dose in the context of a TBF conditioning regimen and the feasibility of therapeutic dosage monitoring of i.v. Bu for patients with hematologic diseases. © 2021 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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Affiliation(s)
- Stefania Bramanti
- IRCCS Humanitas Research Hospital-Humanitas Cancer Center, Milan, Italy
| | | | - Antonella Bartoli
- Fondazione IRCCS Policlinico San Matteo, Clinical and Experimental Pharmacokinetics Unit(,) Pavia, Italy
| | - Laura Giordano
- Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Jacopo Mariotti
- IRCCS Humanitas Research Hospital-Humanitas Cancer Center, Milan, Italy
| | - Barbara Sarina
- IRCCS Humanitas Research Hospital-Humanitas Cancer Center, Milan, Italy
| | - Daniele Mannina
- IRCCS Humanitas Research Hospital-Humanitas Cancer Center, Milan, Italy
| | - Viviana Valli
- IRCCS Humanitas Research Hospital-Humanitas Cancer Center, Milan, Italy
| | - Simona De Gregori
- Fondazione IRCCS Policlinico San Matteo, Clinical and Experimental Pharmacokinetics Unit(,) Pavia, Italy
| | - Martina Roperti
- IRCCS Humanitas Research Hospital-Humanitas Cancer Center, Milan, Italy
| | - Gabriella Pieri
- IRCCS Humanitas Research Hospital-Humanitas Cancer Center, Milan, Italy
| | - Luca Castagna
- IRCCS Humanitas Research Hospital-Humanitas Cancer Center, Milan, Italy.
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90
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Rossoff J, Jacobsohn D, Kwon S, Kletzel M, Duerst RE, Tse WT, Schneiderman J, Chaudhury S. Reduced-toxicity conditioning regimen with busulfan, fludarabine, rATG, and 400 cGy TBI in pediatric patients undergoing hematopoietic stem cell transplant for high-risk hematologic malignancies. Pediatr Blood Cancer 2021; 68:e29087. [PMID: 34022093 DOI: 10.1002/pbc.29087] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/30/2021] [Accepted: 04/09/2021] [Indexed: 11/07/2022]
Abstract
Myeloablative conditioning regimens decrease the risk of relapse in pediatric patients undergoing allogeneic hematopoietic stem cell transplant (HCT) for hematologic malignancies, but cause significant toxicities PROCEDURE: This prospective study evaluated the use of a reduced-toxicity, myeloablative regimen with dose-adjusted busulfan, fludarabine, antithymocyte globulin and 400 cGy of total body irradiation in 40 patients < 21 years of age undergoing HCT for high-risk leukemias. Busulfan pharmacokinetics were measured to target 4000 μmol*min/day in the first 30 patients; this was increased to 5000 μmol*min/day in the subsequent 10 in efforts to further decrease relapse risk RESULTS: Overall survival at two- and five-years post-HCT was 67% and 51%, respectively. Relapse occurred in 11 patients (28%) at a median of seven months and was the leading cause of death. Transplant-related mortality was 8% and 13% at 100 days and one-year post-HCT, respectively. Trends toward improved survival were seen in patients transplanted for myeloid disease using bone marrow as stem cell source who achieved a busulfan AUC > 4000 μmol*min/day with two-year relapse-free survival approaching 80% CONCLUSIONS: This conditioning regimen is safe and effective in patients with high-risk leukemias, particularly myeloid disease. Larger studies are needed to compare its safety and efficacy to other myeloablative regimens in this population.
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Affiliation(s)
- Jenna Rossoff
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David Jacobsohn
- Children's National Medical Center, Washington, District of Columbia
| | - Soyang Kwon
- Stanley Manne Children's Research Institute, Chicago, Illinois
| | - Morris Kletzel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Reggie E Duerst
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Jennifer Schneiderman
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sonali Chaudhury
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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91
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Utano T, Kato M, Sakamoto K, Osumi T, Matsumoto K, Tomizawa D, Matsumoto K, Yamatani A. Two-point blood sampling is sufficient and necessary to estimate the area under the concentration-time curve for intravenous busulfan in infants and young children. Pediatr Blood Cancer 2021; 68:e29069. [PMID: 33881202 DOI: 10.1002/pbc.29069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/30/2021] [Accepted: 04/02/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Therapeutic drug monitoring for busulfan is important to prevent adverse events and improve outcomes in stem cell transplantation. We investigated intravenous busulfan pharmacokinetics and evaluated the utility of limited sampling strategy (LSS) as a simple method to estimate the area under the concentration-time curve (AUC). PROCEDURE The study comprised 87 busulfan measurements in 54 children who received intravenous busulfan between August 2015 and May 2020. AUCs were calculated from three to five blood sampling points in each patient, and the correlation between AUC and plasma concentrations (ng/mL) at 1, 2, 3, 4, and 6 h after initiating busulfan infusion (C1 , C2 , C3 , C4 , and C6 , respectively). RESULTS By one-point sampling strategy, the most relevant predicted AUC was based on C6 (r2 = 0.789; precision, 11.0%) in all patients. The predicted AUC based on C6 was acceptable (r2 = 0.937; precision, 5.9%) for adolescent patients weighing >23 kg, but the correlation was poor in infants and young children weighing ≤ 23 kg (r2 = 0.782; precision, 11.4%). By two-point sampling strategy, the predicted AUC based on C3 and C6 showed the most relevant concentrations (r2 = 0.943; precision, 6.4%), even in infants and young children, whereas the predicted AUC based on C3 and C6 was acceptable (r2 = 0.963; precision, 5.7%). CONCLUSIONS The AUC of busulfan can be predicted based on C6 in adolescent patients. However, there was substantial interindividual variation in busulfan pharmacokinetics in infants and young children, in whom two-point LSS was necessary for accurate AUC prediction.
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Affiliation(s)
- Tomoyuki Utano
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan
| | - Motohiro Kato
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kenichi Sakamoto
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Tomoo Osumi
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kana Matsumoto
- Department of Clinical Pharmaceutics, Faculty of Pharmaceutical Sciences, Doshisha Women's College of Liberal Arts, Kyoto, Japan
| | - Daisuke Tomizawa
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kimikazu Matsumoto
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akimasa Yamatani
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan
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92
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Nijstad AL, Nierkens S, Lindemans CA, Boelens JJ, Bierings M, Versluys AB, van der Elst KC, Huitema AD. Population pharmacokinetics of clofarabine for allogeneic hematopoietic cell transplantation in paediatric patients. Br J Clin Pharmacol 2021; 87:3218-3226. [PMID: 33444472 PMCID: PMC8359279 DOI: 10.1111/bcp.14738] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/23/2020] [Accepted: 01/06/2021] [Indexed: 12/17/2022] Open
Abstract
AIMS Clofarabine has recently been evaluated as part of the conditioning regimen for allogeneic hematopoietic stem cell transplantation (HCT) in children. Pharmacokinetic (PK) exposure of different agents commonly used in conditioning regimens is strongly related to HCT outcome. Consequently, the PK of clofarabine may be important for outcome. This report describes the population PK of clofarabine in paediatric patients and one adult. METHODS From 80 paediatric (0.5-18 years) and 1 adult patient (37 years), 805 plasma concentrations were included in pharmacokinetic analyses using nonlinear mixed effects modelling. RESULTS A two-compartment model adequately described the PK of clofarabine. Body weight and estimated glomerular filtration rate (eGFR) were included as covariates. Clearance was differentiated into nonrenal and renal clearance (approximately 55% of total clearance), resulting in population estimates of 24.0 L/h (95% confidence interval [CI] 13.7-34.4) and 29.8 L/h (95% CI 23.9-36.1) for a patient of 70 kg with normal renal function, respectively. Unexplained interindividual variability in clearance was 17.8% (95% CI 14.6-22.4). A high variability in exposure was observed (range area under the curveT0-inf 1.8-6.0 mg/L*h) after body surface area (BSA) based dosing. Interestingly, children with low body weight had a lower exposure than children with a higher body weight, which indicates that the currently practised BSA-based dosing is not adequate for clofarabine. CONCLUSION A clofarabine dosing algorithm based on this PK model, using body weight and eGFR, results in a more predictable exposure than BSA-based dosing. However, the exact target exposure needs to be further investigated.
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Affiliation(s)
- A. Laura Nijstad
- Department of Clinical Pharmacy, Division of Laboratory Medicine and Pharmacy, University Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Stefan Nierkens
- Center for Translational Immunology, University Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
- Pediatric Blood and Bone Marrow TransplantationPrincess Máxima Center for Pediatric OncologyUtrechtthe Netherlands
| | - Caroline A. Lindemans
- Pediatric Blood and Bone Marrow TransplantationPrincess Máxima Center for Pediatric OncologyUtrechtthe Netherlands
- Department of Pediatrics, University Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Jaap Jan Boelens
- Pediatric Blood and Bone Marrow TransplantationPrincess Máxima Center for Pediatric OncologyUtrechtthe Netherlands
- Stem Cell Transplantation and Cellular Therapies, MSK KidsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Marc Bierings
- Pediatric Blood and Bone Marrow TransplantationPrincess Máxima Center for Pediatric OncologyUtrechtthe Netherlands
- Department of Pediatrics, University Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - A. Birgitta Versluys
- Pediatric Blood and Bone Marrow TransplantationPrincess Máxima Center for Pediatric OncologyUtrechtthe Netherlands
- Department of Pediatrics, University Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Kim C.M. van der Elst
- Department of Clinical Pharmacy, Division of Laboratory Medicine and Pharmacy, University Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Alwin D.R. Huitema
- Department of Clinical Pharmacy, Division of Laboratory Medicine and Pharmacy, University Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
- Department of Pharmacy & PharmacologyNetherlands Cancer InstituteAmsterdamthe Netherlands
- Department of PharmacologyPrincess Máxima Center for Pediatric OncologyUtrechtthe Netherlands
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93
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Cokyaman T, Elli M, Aydin ÖF, Albayrak C, Albayrak D, Özyürek E. Neuroprotective Efficacy of Prophylactic Antiepileptic Therapies in Busulfan Conditioning Regimen. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0040-1708833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AbstractBusulfan (BU) is commonly used in the anticancer treatment and bone marrow/hematopoietic stem cell transplantation (BM/HSCT) conditioning regimen. This study aimed to evaluate the neuroprotective efficacy of antiepileptic therapies in the BU conditioning regimen. Patients who underwent BM/HSCT between January 1, 2009, and January 1, 2014, were evaluated retrospectively. Diagnosis, demographic characteristics, neurological side effects, electroencephalography (EEG) abnormalities, and antiepileptic drugs were determined. Levetiracetam was given to 49% and phenytoin to 23% of patients as antiepileptic prophylaxis. After BU treatment, seizures developed in three patients, posterior reversible leukoencephalopathy in two patients, and peripheral neuropathy in two patients. Forty-five patients who underwent EEG before and after BU treatment were identified. The effects of antiepileptic prophylaxis over the electroencephalographic abnormalities after the BU conditioning regimen were found to be not different (p = 0.491). Neurological side effects and electroencephalographic abnormalities following BU conditioning regimen under antiepileptic prophylaxis are comparable.
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Affiliation(s)
- Turgay Cokyaman
- Division of Pediatric Neurology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Murat Elli
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Ömer F. Aydin
- Division of Pediatric Neurology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Canan Albayrak
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Davut Albayrak
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Emel Özyürek
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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94
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Neroutsos E, Athanasiadou I, Paisiou A, Zisaki K, Goussetis E, Archontaki H, Tsirigotis P, Kitra M, Grafakos S, Spyridonidis A, Dokoumetzidis A, Valsami G. Dose individualization of intravenous busulfan in pediatric patients undergoing bone marrow transplantation: impact and in vitro evaluation of infusion lag-time. J Pharm Pharmacol 2021; 73:1340-1350. [PMID: 34244783 DOI: 10.1093/jpp/rgab087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/20/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES To apply therapeutic drug monitoring and dose-individualization of intravenous Busulfan to paediatric patients and evaluate the impact of syringe-pump induced Busulfan infusion lag-time after in vitro estimation. METHODS 76 children and adolescents were administered 2 h intravenous Busulfan infusion every 6 h (16 doses). Busulfan plasma levels, withdrawn by an optimized sampling scheme and measured by a validated HPLC-PDA method, were used to estimate basic PK parameters, AUC, Cmax, kel, t1/2, applying Non-Compartmental Analysis. In vivo infusion lag-time was simulated in vitro and used to evaluate its impact on AUC estimation. KEY FINDINGS Mean (%CV) Busulfan AUC, Cmax, clearance and t1/2 for pediatric population were found 962.3 μm × min (33.1), 0.95 mg/L (41.4), 0.27 L/h/kg (33.3), 2.2 h (27.8), respectively. TDM applied to 76 children revealed 6 (7.9%) being above and 25 (32.9%) below therapeutic-range (AUC: 900-1350 μm × min). After dose correction, all patients were measured below toxic levels (AUC < 1500 μm × min), no patient below 900 μm × min. Incorporation of infusion lag-time revealed lower AUCs with 17.1% more patients and 23.1% more younger patients, with body weight <16 kg, being below the therapeutic-range. CONCLUSIONS TDM, applied successfully to 76 children, confirmed the need for Busulfan dose-individualization in paediatric patients. Infusion lag-time was proved clinically significant for younger, low body-weight patients and those close to the lower therapeutic-range limit.
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Affiliation(s)
- E Neroutsos
- Laboratory of Biopharmaceutics & Pharmacokinetics, Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, Athens, Greece
| | - I Athanasiadou
- Laboratory of Biopharmaceutics & Pharmacokinetics, Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, Athens, Greece
| | - A Paisiou
- Bone Marrow Transplantation Unit, "Agia Sophia" General Children's Hospital of Athens, Athens, Greece
| | - K Zisaki
- Bone Marrow Transplantation Unit, "Agia Sophia" General Children's Hospital of Athens, Athens, Greece
| | - E Goussetis
- Bone Marrow Transplantation Unit, "Agia Sophia" General Children's Hospital of Athens, Athens, Greece
| | - H Archontaki
- Laboratory of Analytical Chemistry, Department of Chemistry, School of Sciences, National & Kapodistrian University of Athens, Athens, Greece
| | - P Tsirigotis
- Clinic of Internal Medicine, University Hospital "Attikon", Department of Medicine, School of Health Sciences, National & Kapodistrian University of Athens, Athens, Greece
| | - M Kitra
- Bone Marrow Transplantation Unit, "Agia Sophia" General Children's Hospital of Athens, Athens, Greece
| | - S Grafakos
- Bone Marrow Transplantation Unit, "Agia Sophia" General Children's Hospital of Athens, Athens, Greece
| | - A Spyridonidis
- Bone Marrow Transplant Unit, University Hospital of Patras, Department of Medicine, School of Health Sciences, University of Patras, Rio, Patras, Greece
| | - A Dokoumetzidis
- Laboratory of Biopharmaceutics & Pharmacokinetics, Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, Athens, Greece
| | - G Valsami
- Laboratory of Biopharmaceutics & Pharmacokinetics, Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, Athens, Greece
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95
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Barrett JS, Barrett RF, Vinks AA. Status Toward the Implementation of Precision Dosing in Children. J Clin Pharmacol 2021; 61 Suppl 1:S36-S51. [PMID: 34185896 DOI: 10.1002/jcph.1830] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/04/2021] [Indexed: 01/19/2023]
Abstract
Precision dosing is progressing beyond the conceptual and proof-of-concept stages toward implementation. As the availability of dosing algorithms, tools, and platforms increases, so do the investment in technology services and actual implementation of clinical services offering these solutions to patients. Nowhere is this needed more than in pediatric populations, which are still reliant on adult drug development and bridging strategies to support dosing, often in the absence of actual dose-finding studies in the target pediatric population. Still, there is more work to be done to ensure that proper governance of these services is maintained, and that sustainability of these early implementations is guided by new science as it evolves and meaningful outcome data to confirm that such services deliver on both clinical and economic return on investment. In addition, the field should ensure that all approaches beyond a therapeutic drug monitoring-driven, pharmacokinetic-centric approach should be considered as the tools and services evolve, especially when pediatric-specific pharmacokinetic/pharmacodyamic and pharmacogenetic data are available and shown to be useful to guide dosing. This review evaluates current pediatric precision dosing efforts, highlighting their utility, longevity, and sustainability and assesses the current process for implementing such approaches examining current barriers that stand in the way of broader implementation and the stakeholders that must engage to ensure its ultimate success.
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Affiliation(s)
- Jeffrey S Barrett
- Quantitative Medicine, Critical Path Institute, Tucson, Arizona, USA
| | - Ryan F Barrett
- College of Chemical and Biological Engineering, Drexel University, Philadelphia, Pennsylvania, USA
| | - 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
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96
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Chen RL, Fang LH, Yang XY, El Amrani M, Uijtendaal EV, Chen YF, Ku WC. Therapeutic Drug Monitoring of Busulfan in Patients Undergoing Hematopoietic Cell Transplantation: A Pilot Single-Center Study in Taiwan. Pharmaceuticals (Basel) 2021; 14:613. [PMID: 34206798 PMCID: PMC8308703 DOI: 10.3390/ph14070613] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/24/2021] [Indexed: 01/02/2023] Open
Abstract
(1) Background: Busulfan has been used as a conditioning regimen in allogeneic hematopoietic cell stem transplantation (HSCT). Owing to a large inter-individual variation in pharmacokinetics, therapeutic drug monitoring (TDM)-guided busulfan dosing is necessary to reduce graft failure and relapse rate. As there exists no TDM of busulfan administration for HCT in Taiwan, we conducted a pilot study to assess the TDM-dosing of busulfan in the Taiwanese population; (2) Methods: Seven patients with HCT from The Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan, received conditioning regimens consisting of intravenous busulfan and other chemotherapies. After the initial busulfan dose, blood samples were collected for busulfan TDM at 5 min, 1 h, 2 h, and 3 h. Busulfan was extracted and detected by performing stable-isotope dilution LC-MS/MS. Plasma busulfan concentration was quantified and used for dose adjustment. Potential adverse effects of busulfan, such as mucositis and hepatic veno-occlusive disease (VOD), were also evaluated; (3) Results: The LC-MS/MS method was validated with an analyte recovery of 88-99%, within-run and between-run precision of <15%, and linearity ranging from 10 to 10,000 ng/mL. Using TDM-guided busulfan dosing, dose adjustment was necessary and performed in six out of seven patients (86%) with successful engraftments in all patients (100%). Mild mucositis was observed, and VOD was diagnosed in only one patient; (4) Conclusions: This single-center study in Taiwan demonstrated the importance of busulfan TDM in increasing the success rate of HCT transplantation. It is also necessary to further investigate the optimal busulfan target value in the Taiwanese population in the future.
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Affiliation(s)
- Rong-Long Chen
- Department of Pediatric Hematology and Oncology, Koo Foundation Sun Yat-Sen Cancer Center, Taipei City 112019, Taiwan;
| | - Li-Hua Fang
- Department of Pharmacy, Koo Foundation Sun Yat-Sen Cancer Center, Taipei City 112019, Taiwan; (L.-H.F.); (X.-Y.Y.)
| | - Xin-Yi Yang
- Department of Pharmacy, Koo Foundation Sun Yat-Sen Cancer Center, Taipei City 112019, Taiwan; (L.-H.F.); (X.-Y.Y.)
| | - Mohsin El Amrani
- Department of Clinical Pharmacy, Division Laboratory, Medicine and Pharmacy, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands; (M.E.A.); (E.V.U.)
| | - Esther Veronique Uijtendaal
- Department of Clinical Pharmacy, Division Laboratory, Medicine and Pharmacy, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands; (M.E.A.); (E.V.U.)
| | - Yen-Fu Chen
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City 242062, Taiwan;
| | - Wei-Chi Ku
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City 242062, Taiwan;
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97
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Fast and reliable quantification of busulfan in blood plasma using two-channel liquid chromatography tandem mass spectrometry: Validation of assay performance in the presence of drug formulation excipients. J Pharm Biomed Anal 2021; 203:114216. [PMID: 34182411 DOI: 10.1016/j.jpba.2021.114216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/11/2021] [Accepted: 06/15/2021] [Indexed: 11/23/2022]
Abstract
A fast and reliable method based on two-channel liquid chromatography coupled to tandem mass spectrometry was developed and successfully validated for quantification of busulfan. The drug vehicle polyethylene glycol 400 was quantified simultaneously in patient samples. The sample preparation consisted of simple protein precipitation using a mixture of methanol and zinc sulphate containing busulfan-d8 as internal standard. Chromatographic separation was performed on a short biphenyl column (30 mm × 3.0 mm, 5 μm particles) using a step gradient from 30 % to 85 % methanol, ensuring co-elution of the analyte and internal standard. Quantification was performed using the mass transition of 264.1 > 151.1 for busulfan and 272.1 > 159.1 for the internal standard. Using only 20 μL of plasma sample, the lower limit of quantification was 25 ng/mL. Signal to noise ratio at the lower limit of quantification exceeded 300. The assay performance was not adversely affected by matrix effects originating from drug formulation excipients or other sample components. The coefficient of variation was ≤4 % and the mean accuracy 101-108 % across the calibration range 25-5 000 ng/mL. Chromatographic run time was 2 min and 8 s, allowing an effective run-time of 1 min and 10 s when using two alternating LC-channels. The assay has been implemented in routine practice with accreditation according to the ISO 15189 standard, and performs well in external quality control assessments. We present for the first time that shortly after an IV infusion of busulfan, the plasma levels of polyethylene glycol 400 may be in the range of 400-800 mg/L. The presence of these levels of detergent in patient samples may have detrimental effects on assay performance in LC-MS/MS, not limited to busulfan assays. This may be a concern for any LC-MS/MS analysis performed on samples collected within the first 24 h after an IV infusion of busulfan.
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98
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de Witte M, Daenen LGM, van der Wagen L, van Rhenen A, Raymakers R, Westinga K, Kuball J. Allogeneic Stem Cell Transplantation Platforms With Ex Vivo and In Vivo Immune Manipulations: Count and Adjust. Hemasphere 2021; 5:e580. [PMID: 34095763 PMCID: PMC8171366 DOI: 10.1097/hs9.0000000000000580] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 04/14/2021] [Indexed: 01/16/2023] Open
Abstract
Various allogeneic (allo) stem cell transplantation platforms have been developed over the last 2 decades. In this review we focus on the impact of in vivo and ex vivo graft manipulation on immune reconstitution and clinical outcome. Strategies include anti-thymocyte globulin- and post-transplantation cyclophosphamide-based regimens, as well as graft engineering, such as CD34 selection and CD19/αβT cell depletion. Differences in duration of immune suppression, reconstituting immune repertoires, and associated graft-versus-leukemia effects and toxicities mediated through viral reactivations are highlighted. In addition, we discuss the impact of different reconstituting repertoires on donor lymphocyte infusions and post allo pharmacological interventions to enhance tumor control. We advocate for precisely counting all graft ingredients and therapeutic drug monitoring during conditioning in the peripheral blood, and for adjusting dosing accordingly on an individual basis. In addition, we propose novel trial designs to better assess the impact of variations in transplantation platforms in order to better learn from our diversity of "counts" and potential "adjustments." This will, in the future, allow daily clinical practice, strategic choices, and future trial designs to be based on data guided decisions, rather than relying on dogma and habits.
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Affiliation(s)
- Moniek de Witte
- Department of Hematology, University Medical Center Utrecht, The Netherlands
| | - Laura G. M. Daenen
- Department of Hematology, University Medical Center Utrecht, The Netherlands
| | - Lotte van der Wagen
- Department of Hematology, University Medical Center Utrecht, The Netherlands
| | - Anna van Rhenen
- Department of Hematology, University Medical Center Utrecht, The Netherlands
| | - Reiner Raymakers
- Department of Hematology, University Medical Center Utrecht, The Netherlands
| | - Kasper Westinga
- Cell Therapy Facility, University Medical Center Utrecht, The Netherlands
| | - Jürgen Kuball
- Department of Hematology, University Medical Center Utrecht, The Netherlands
- Center for Translational Immunology, University Medical Center Utrecht, The Netherlands
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99
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Granzotto FCN, da Silva ACC, Lizot LF, Antunes MV, Linden R. Dried Plasma Spots and Oral Fluid as Alternative Matrices for Therapeutic Drug Monitoring of Busulfan: Analytical Method Development and Clinical Evaluation. Ther Drug Monit 2021; 43:376-385. [PMID: 32960547 DOI: 10.1097/ftd.0000000000000807] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/13/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Busulfan (BU) is an alkylating agent with a narrow therapeutic index and high intraindividual pharmacokinetic variability used in conditioning therapy for hematopoietic stem cell transplantation. Monitoring BU exposure during high-dose conditioning regimens is recommended and positively impacts outcomes. We aimed to develop, validate, and apply a ultra-high-performance liquid chromatography-mass spectrometry (MS)/MS assay to measure BU concentrations in oral fluid and dried plasma spots (DPS) as alternative matrices to plasma. METHODS We prepared plasma and oral fluid samples by protein precipitation and DPS after liquid extraction. We analyzed extracts using an LC-MS/MS system with an Acquity HSS T3 column in the positive electrospray ionization mode. The method was validated and applied to 79 paired plasma and oral fluid samples from 7 patients on BU conditioning treatment. DPS were prepared by pipetting plasma onto Whatman 903 paper. The correlation between BU in plasma, oral fluid, and DPS samples was evaluated. RESULTS Run time was 4.0 minutes. The assay was linear at 50-5000 ng mL-1 (r > 0.99), precise (1.9%-5.3% oral fluid and 1.8%-5.9% DPS), and accurate (98.1%-108.9% oral fluid and 93%-103.1% DPS). BU was stable in DPS at 23°C for 24 hours. BU levels in oral fluid (r = 0.927) and DPS (r = 0.982) were significantly correlated with plasma. Despite the good correlation, we found a wide variation between oral fluid and plasma levels. The area under curves (AUCs) calculated with oral fluid concentrations were 79.1%-167.1% of plasma AUCs. Bland-Altman plots found a better agreement for DPS, with AUCs estimated from corrected DPS levels at 83.1%-114.1% of plasma values. CONCLUSIONS We developed and validated a simple and fast ultra-high-performance liquid chromatography-MS/MS assay to measure BU in oral fluid and DPS. The results do not support the use of oral fluid as a matrix for routine therapeutic drug monitoring of BU. The AUC estimated from BU measurements in DPS was comparable to that in plasma, supporting the use of DPS in BU therapeutic drug monitoring as an alternative matrix, with adequate short-term stability and logistic advantages.
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Affiliation(s)
- Fabiana C N Granzotto
- Laboratory of Analytical Toxicology, Universidade Feevale ; and
- Graduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Rio Grande do Sul, Brazil
| | - Anne C C da Silva
- Laboratory of Analytical Toxicology, Universidade Feevale ; and
- Graduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Rio Grande do Sul, Brazil
| | - Lilian F Lizot
- Laboratory of Analytical Toxicology, Universidade Feevale ; and
| | - Marina V Antunes
- Laboratory of Analytical Toxicology, Universidade Feevale ; and
- Graduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Rio Grande do Sul, Brazil
| | - Rafael Linden
- Laboratory of Analytical Toxicology, Universidade Feevale ; and
- Graduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Rio Grande do Sul, Brazil
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100
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Solans BP, Garrido MJ, Trocóniz IF. Drug Exposure to Establish Pharmacokinetic-Response Relationships in Oncology. Clin Pharmacokinet 2021; 59:123-135. [PMID: 31654368 DOI: 10.1007/s40262-019-00828-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In the oncology field, understanding the relationship between the dose administered and the exerted effect is particularly important because of the narrow therapeutic index associated with anti-cancer drugs and the high interpatient variability. Therefore, in this review, we provide a critical perspective of the different methods of characterising treatment exposure in the oncology setting. The increasing number of modelling applications in oncology reflects the applicability and the impact of pharmacometrics on all phases of the drug development process and patient management as well. Pharmacometric modelling is a worthy component within the current paradigm of model-based drug development, but pharmacometric modelling techniques are also accessible for the clinician in the optimisation of current oncology therapies. Consequently, the application of population models in a hospital setting by generating close collaborations between physicians and pharmacometricians is highly recommended, providing a systematic means of developing and assessing model-based metrics as 'drivers' for various responses to treatments, which can then be evaluated as predictors for treatment success. Characterising the key determinants of variability in exposure is of particular importance for anticancer agents, as efficacy and toxicity are associated with exposure. We present the different strategies to describe and predict drug exposure that can be applied depending on the data available, with the objective of obtaining the most useful information in the patients' favour throughout the full drug cycle. Therefore, the objective of the present article is to review the different approaches used to characterise a patient's exposure to oncology drugs, which will result in a better understanding of the time course of the response and the magnitude of interpatient variability.
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Affiliation(s)
- Belén P Solans
- Pharmacometrics & Systems Pharmacology, Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Navarra, C/Irunlarrea s/n, 31008, Pamplona, Navarra, Spain. .,Navarra Institute for Health Research (IdisNA), University of Navarra, Pamplona, Spain.
| | - María Jesús Garrido
- Pharmacometrics & Systems Pharmacology, Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Navarra, C/Irunlarrea s/n, 31008, Pamplona, Navarra, Spain.,Navarra Institute for Health Research (IdisNA), University of Navarra, Pamplona, Spain
| | - Iñaki F Trocóniz
- Pharmacometrics & Systems Pharmacology, Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Navarra, C/Irunlarrea s/n, 31008, Pamplona, Navarra, Spain. .,Navarra Institute for Health Research (IdisNA), University of Navarra, Pamplona, Spain.
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