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Salcedo-Mingoarranz AL, Medellín-Garibay SE, Barcia-Hernández E, García-Díaz B. Population Pharmacokinetics of Digoxin in Nonagenarian Patients: Optimization of the Dosing Regimen. Clin Pharmacokinet 2023; 62:1725-1738. [PMID: 37816957 DOI: 10.1007/s40262-023-01313-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 10/12/2023]
Abstract
OBJECTIVE The aim of this study was to develop a population pharmacokinetic model of digoxin in patients over 90 years old and to propose an equation for adjusting digoxin dose in this population. METHODS We included 326 nonagenarian patients admitted to Severo Ochoa University Hospital (Spain) who received digoxin and were under therapeutic drug monitoring. All data were retrospectively collected, and population modeling was performed with non-linear mixed-effect modeling software (NONMEM®). One- and two-compartment models were tested to calculate digoxin clearance (Cl), volume of distribution (Vd), absorption rate constant (Ka), and bioavailability (bioavailable fraction, F). The covariates were evaluated by stepwise covariate model building, and the final model was internally validated by bootstrap analysis with 1000 resamples. External validation was performed with another population of 95 patients with the same characteristics as the modeling group. RESULTS The population was 26% males, with a mean age of 93.2 years (90-103 years), mean creatinine 1.11 mg/dL (0.42-3.81 mg/dL), and mean total body weight 61.2 kg (40-100 kg). The pharmacokinetics of digoxin were best described by a one-compartment model (ADVAN2 TRANS2), with first-order conditional estimation with interaction. The covariates with influence on our model were creatinine clearance based on the Cockcroft-Gault equation (CG), serum potassium (K), co-administration of loop diuretics, and sex: Cl/F = 4.55 · (CG/36.4)0.468 · 0.83LD · 1.21SEX; Vd/F = 355 · (K/4.3)-0.849; Ka = 1.22 h-1 [where LD indicates loop diuretics (1 for administered, 0 for otherwise) and SEX indicates patient sex (1 for male, 0 for female)]. Based on our results, we proposed an equation to adjust the digoxin dosing regimen in nonagenarian patients: dose (mg) = 0.144 · (CG/36.4)0.468 · 0.83LD · 1.21SEX. CONCLUSIONS The greatest influence on digoxin clearance came from renal function calculated by the Cockcroft-Gault equation. Vd was decreased by K. The model developed showed a precise predictive performance to be applied for therapeutic drug monitoring.
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Affiliation(s)
| | - Susanna Edith Medellín-Garibay
- Department of Pharmacy and Drug Technology, Faculty of Chemical Sciences, Universidad Autónoma de San Luis Potosí, San Luis Potosí, Mexico
| | - Emilia Barcia-Hernández
- Department of Pharmaceutics and Food Technology, Faculty of Pharmacy, Universidad Complutense de Madrid, Ciudad Universitaria s/n, 28040, Madrid, Spain
| | - Benito García-Díaz
- Pharmacy Department, Severo Ochoa University Hospital, Avenida Orellana s/n, 28911, Leganés, Spain
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Lin ZQ, Guo L, Zhang LM, Lu JJ, Jiang X. Dosage Optimization of Digoxin in Older Patients with Heart Failure and Chronic Kidney Disease: A Population Pharmacokinetic Analysis. Drugs Aging 2023; 40:539-549. [PMID: 37157010 DOI: 10.1007/s40266-023-01026-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Renal function is an important index for digoxin dose adjustment, especially in patients with chronic kidney disease (CKD). Decreased glomerular filtration rate is common in older patients with cardiovascular disease. OBJECTIVE The aim of this study was to establish a digoxin population pharmacokinetic model in older patients with heart failure and CKD and to optimize the digoxin dose strategy. METHODS Older patients with heart failure and CKD aged > 60 years from January 2020 to January 2021 and who had an estimated glomerular filtration rate (eGFR) < 90 mL/min/1.73 m2 or urine protein production were enrolled in this retrospective study. Population pharmacokinetic analysis and Monte Carlo simulations (n = 1000) were performed using NONMEN software. The precision and stability of the final model were analyzed by graphical and statistical methods. RESULTS Overall, 269 older patients with heart failure were enrolled. A total of 306 digoxin concentrations were collected, with a median value of 0.98 ng/mL (interquartile range [IQR] 0.62-1.61, range 0.04-4.24). The median age was 68 years (IQR 64-71, range 60-94) and eGFR was 53.6 mL/min/1.73 m2 (IQR 38.1-65.2, range 11.4-89.8). A one-compartment model with first-order elimination was developed to describe the digoxin pharmacokinetics. Typical values for clearance and volume of distribution were 2.67 L/h and 36.9 L, respectively. Dosage simulations were stratified by eGFR and metoprolol. Doses of 62.5 and 125 μg were recommended for older patients with eGFR < 60 mL/min/1.73 m2. CONCLUSIONS A population pharmacokinetic model of digoxin in older patients with heart failure and CKD was established in this study. A novel digoxin dosage strategy was recommended in this vulnerable population.
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Affiliation(s)
- Zhong-Qiu Lin
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Ling Guo
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Li-Min Zhang
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Jie-Jiu Lu
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China.
| | - Xia Jiang
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China.
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Kurata Y, Muraki S, Hirota T, Araki H, Ieiri I. Effect of Liver Cirrhosis on Theophylline Trough Concentrations: A Comparative Analysis of Organ Impairment Using Child-Pugh and MELD Scores. Br J Clin Pharmacol 2022; 88:3819-3828. [PMID: 35338501 DOI: 10.1111/bcp.15333] [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: 07/27/2021] [Revised: 03/09/2022] [Accepted: 03/16/2022] [Indexed: 11/29/2022] Open
Abstract
AIMS Theophylline clearance is known to be reduced in patients with chronic liver diseases (CLDs) such as chronic hepatitis (CH) and liver cirrhosis (LC). The Child-Pugh (CP) score is generally used for pharmacokinetic evaluation, whilst a model for end-stage liver disease (MELD) has not yet been fully evaluated. This study aimed to predict theophylline clearance in patients with LC classified based on CP and MELD scores by population pharmacokinetic (PPK) analysis. METHODS PPK analysis included 433 steady-state trough concentrations from 192 Japanese bronchial asthma patients with and without CLDs and was performed using NONMEM. The severity of LC was assessed by CP and MELD scores. RESULTS The final CP and MELD models which described apparent theophylline clearance (CL/F) were obtained. The CP model showed that the mean CL/F in patients without CLDs, CH patients, and LC patients with CP class A, B, and C was 0.0473, 0.0413, 0.0330, 0.0280, and 0.0209 L/h kg-1, respectively. The MELD model predicted that CL/F in patients without CLDs, CH patients, and LC patients with MELD scores of < 10, 10-14, 15-19, 20-24, and ≥ 25 was 0.0472, 0.0413, 0.0324, 0.0268, 0.0230, 0.0197, and 0.0155 L/h kg-1, respectively. CONCLUSIONS CL/F in various stages of LC was evaluated, and a change in CL/F was highly dependent on the severity of CLDs in both models. The MELD model provided a more accurate and precise description of theophylline clearance in LC than the CP model, which may be due to the wider dynamic range of the MELD score.
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Affiliation(s)
- Yasuo Kurata
- Department of Pharmacy, Fukuoka City Hospital, Fukuoka City Hospital Organization, Local Incorporated Administrative Agency, Fukuoka, Japan
| | - Shota Muraki
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Takeshi Hirota
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan.,Department of Pharmacy, Kyushu University Hospital, Fukuoka, Japan
| | - Hiroshi Araki
- Department of Pharmacy, Fukuoka City Hospital, Fukuoka City Hospital Organization, Local Incorporated Administrative Agency, Fukuoka, Japan
| | - Ichiro Ieiri
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan.,Department of Pharmacy, Kyushu University Hospital, Fukuoka, Japan
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Abdel Jalil M, Abdullah N, Alsous M, Abu-Hammour K. Population Pharmacokinetic Studies of Digoxin in Adult Patients: A Systematic Review. Eur J Drug Metab Pharmacokinet 2021; 46:325-342. [PMID: 33616855 DOI: 10.1007/s13318-021-00672-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Digoxin is a cardiac glycoside that was introduced to cardiovascular medicine more than 200 years ago. Its use is associated with large variability, which complicates achieving the desired therapeutic outcomes. OBJECTIVES To present a synthesis of the available literature on the population pharmacokinetics of digoxin in adults and to identify the sources of variability in its pharmacokinetics. METHODS This is a PROSPERO registered systematic review (CRD42018105300). A literature search was conducted using the ISI Web of Science, Science Direct, PubMed, and SCOPUS databases to identify digoxin population pharmacokinetic studies of adults that utilized the nonlinear mixed-effect modeling approach. RESULTS Sixteen articles were included in the present analysis. Only two studies were conducted in elderly subjects as a separate population. Both the pharmacokinetics and pharmacodynamics of digoxin were investigated in one study. Furthermore, the reviewed studies were mostly conducted in East Asian populations (68.8%). Digoxin's pharmacokinetics were usually described by a one-compartment model because of the nature of the collected data. Weight, age, kidney function, presence of heart failure, and co-administered medications such as calcium channel blockers were the most commonly identified predictors of digoxin clearance. The value of apparent clearance in a typical study individual ranged from 0.005 to 0.2 l/h/kg, while the value of the apparent volume of distribution ranged from 3.14 to 15.2 l/kg. The quality of model evaluation was deemed excellent only in 31.3% of the studies. CONCLUSION This review provides information about variables that need to be considered when prescribing digoxin. The results highlight the need for prospective studies that allow two-compartment pharmacokinetic/pharmacodynamic models to be established, with a special focus on the elderly subpopulation.
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Affiliation(s)
- Mariam Abdel Jalil
- Department of Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, University of Jordan, Amman, 11942, Jordan.
| | - Noura Abdullah
- Department of Pharmacology, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Mervat Alsous
- Department of Pharmacy Practice, Faculty of Pharmacy, Yarmouk University, Irbid, Jordan
| | - Khawla Abu-Hammour
- Department of Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, University of Jordan, Amman, 11942, Jordan
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Abdel Jalil MH, Abdullah N, Alsous MM, Saleh M, Abu-Hammour K. A systematic review of population pharmacokinetic analyses of digoxin in the paediatric population. Br J Clin Pharmacol 2020; 86:1267-1280. [PMID: 32153059 DOI: 10.1111/bcp.14272] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/29/2019] [Accepted: 02/25/2020] [Indexed: 12/21/2022] Open
Abstract
This is a PROSPERO registered systematic review (CRD42018105207), conducted to summarize the available knowledge regarding the population pharmacokinetics of digoxin in paediatrics and to identify the sources of variability in its disposition. PubMed, ISI Web of Science, SCOPUS and Science Direct databases were searched from inception to January 2019. All paediatric population pharmacokinetic studies of digoxin that utilized the nonlinear mixed-effect modelling approach were incorporated in this review, and data were synthesized descriptively. After application of the inclusion-exclusion criteria 8 studies were included. Most studies described digoxin pharmacokinetics as a 1-compartment model with only 1 study describing its pharmacokinetics as 2-compartments. Age was an important predictor of clearance in studies involving neonates or infants, other predictors of clearance were weight, height, serum creatinine, coadministration of spironolactone and presence of congestive heart failure. Congestive heart failure was also associated with an increased volume of distribution in 1 study. The estimated value of apparent clearance in a typical individual standardized by mean weight ranged between 0.24 and 0.56 L/h/kg, the interindividual variability in clearance ranged between 7.0 and 35.1%. Half of the studies evaluated the performance of their developed models via external evaluation. In conclusion, substantial predictors of digoxin pharmacokinetics in the paediatric population in addition to model characteristics and evaluation techniques are presented. For clinicians, clearance could be predicted using age especially in neonates or infants, weight, height, serum creatinine, coadministration of medications and disease status. For future researchers, designing pharmacokinetic studies that allow 2-compartment modelling and linking pharmacokinetics with pharmacodynamics is recommended.
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Affiliation(s)
- Mariam H Abdel Jalil
- Department of Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, University of Jordan, Amman, Jordan
| | - Noura Abdullah
- Department of Pharmacology, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Mervat M Alsous
- Department of Pharmacy Practice, Faculty of Pharmacy, Yarmouk University, Irbid, Jordan
| | - Mohammad Saleh
- Department of Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, University of Jordan, Amman, Jordan
| | - Khawla Abu-Hammour
- Department of Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, University of Jordan, Amman, Jordan
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Clinical Pharmacokinetics of Drugs in Patients with Heart Failure: An Update (Part 2, Drugs Administered Orally). Clin Pharmacokinet 2014; 53:1083-114. [DOI: 10.1007/s40262-014-0189-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Abstract
Today, the lifetime risk of patients aged 55-65 years to receive antihypertensive drugs approaches 60%. Yet, recent trials suggest that hypertension is not adequately controlled in the majority of patients. The prevalence of hypertension increases with advancing age, as does the prevalence of comorbid conditions and the total number of medications taken. Multi-drug therapy, advancing age and comorbid conditions are also key risk factors for adverse drug reactions and drug interactions. In this review, the authors evaluate the most frequently used antihypertensive drugs (diuretics, beta-adrenergic blockers, angiotensin-converting enzyme inhibitors, calcium channel blockers, angiotensin II receptor Type 1 blockers and alpha-adrenergic blockers) with special reference to pharmacodynamic and pharmacokinetic drug interactions. As the spectrum of drugs prescribed is constantly changing, safety yesterday does not imply safety today and safety today does not imply safety tomorrow. Furthermore, therapeutic efficacy should not be neglected over concerns regarding drug interactions. Many patients are at risk of clinically relevant drug interactions involving antihypertensive drugs but, presently, even more patients may be at risk of suffering from the consequences of their inadequately treated hypertension. In this respect, the authors discuss controversial viewpoints on the overall clinical relevance of drug interactions occurring at the level of cytochrome P450 metabolism.
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Affiliation(s)
- Renke Maas
- Institut für Experimentelle und Klinische Pharmakologie, Universitätsklinikum HamburgEppendorf, Martinistrasse 52, 20246 Hamburg, Germany.
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2003; 12:73-88. [PMID: 12616852 DOI: 10.1002/pds.787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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