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Shen G, Moua KTY, Perkins K, Johnson D, Li A, Curtin P, Gao W, McCune JS. Precision sirolimus dosing in children: The potential for model-informed dosing and novel drug monitoring. Front Pharmacol 2023; 14:1126981. [PMID: 37021042 PMCID: PMC10069443 DOI: 10.3389/fphar.2023.1126981] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 02/14/2023] [Indexed: 04/07/2023] Open
Abstract
The mTOR inhibitor sirolimus is prescribed to treat children with varying diseases, ranging from vascular anomalies to sporadic lymphangioleiomyomatosis to transplantation (solid organ or hematopoietic cell). Precision dosing of sirolimus using therapeutic drug monitoring (TDM) of sirolimus concentrations in whole blood drawn at the trough (before the next dose) time-point is the current standard of care. For sirolimus, trough concentrations are only modestly correlated with the area under the curve, with R 2 values ranging from 0.52 to 0.84. Thus, it should not be surprising, even with the use of sirolimus TDM, that patients treated with sirolimus have variable pharmacokinetics, toxicity, and effectiveness. Model-informed precision dosing (MIPD) will be beneficial and should be implemented. The data do not suggest dried blood spots point-of-care sampling of sirolimus concentrations for precision dosing of sirolimus. Future research on precision dosing of sirolimus should focus on pharmacogenomic and pharmacometabolomic tools to predict sirolimus pharmacokinetics and wearables for point-of-care quantitation and MIPD.
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Affiliation(s)
- Guofang Shen
- Department of Hematologic Malignancies Translational Sciences, City of Hope, and Department of Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, CA, United States
| | - Kao Tang Ying Moua
- Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, CA, United States
| | - Kathryn Perkins
- Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, CA, United States
| | - Deron Johnson
- Clinical Informatics, City of Hope Medical Center, Duarte, CA, United States
| | - Arthur Li
- Division of Biostatistics, City of Hope, Duarte, CA, United States
| | - Peter Curtin
- Department of Hematologic Malignancies Translational Sciences, City of Hope, and Department of Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, CA, United States
| | - Wei Gao
- Division of Engineering and Applied Science, Andrew and Peggy Cherng Department of Medical Engineering, California Institute of Technology, Pasadena, CA, United States
| | - Jeannine S. McCune
- Department of Hematologic Malignancies Translational Sciences, City of Hope, and Department of Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, CA, United States
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Mizuno T, Dong M, Taylor ZL, Ramsey LB, Vinks AA. Clinical implementation of pharmacogenetics and model-informed precision dosing to improve patient care. Br J Clin Pharmacol 2020; 88:1418-1426. [PMID: 32529759 DOI: 10.1111/bcp.14426] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/15/2020] [Accepted: 05/26/2020] [Indexed: 12/15/2022] Open
Abstract
Providing maximal therapeutic efficacy without toxicity is a universal goal of rational drug therapy. However, substantial between-patient variability in drug response often impedes such successful treatments and brings the necessity of tailoring drug dose to individual needs for more precise therapy. In many cases plenty of patient characteristics, such as body size, genetic makeup and environmental factors, need to be taken into consideration to find the optimal dose in clinical practice. A pharmacokinetics and pharmacodynamics (PK/PD) model-informed approach offers integration of various patient information to provide an expectation of drug response and derive practical dose estimates to support clinicians' dosing decisions. Such an approach was pioneered in the late 1970s, but its broad clinical acceptance and implementation have been hampered by the lack of widespread computer technology, including user-friendly software tools. This has significantly changed in recent years. With the advent of electronic health records (EHRs) and the ubiquity of user-friendly software tools, we now experience a convergence of clinical information, pharmacogenetics, systems pharmacology and pharmacometrics, and technology. Advanced pharmacometrics research is now more appliable and implementable to improve health care. This article presents examples of successful development and implementation of pharmacogenetics-guided and PK/PD model-informed decision support to facilitate precision dosing, including the development of an EHR-embedded decision support tool. Through the integration of clinical decision support tools in EHRs, clinical pharmacometrics support can be brought directly to the clinical team and the bedside.
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Affiliation(s)
- Tomoyuki Mizuno
- 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
| | - Min Dong
- 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
| | - Zachary L Taylor
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Molecular, Cellular, and Biochemical Pharmacology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Laura B Ramsey
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Research in Patient Services, 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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Li Y, Yan L, Shi Y, Bai Y, Tang J, Wang L. CYP3A5 and ABCB1 genotype influence tacrolimus and sirolimus pharmacokinetics in renal transplant recipients. SPRINGERPLUS 2015; 4:637. [PMID: 26543771 PMCID: PMC4628029 DOI: 10.1186/s40064-015-1425-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 10/11/2015] [Indexed: 02/05/2023]
Abstract
CYP3A5 and ABCB1 polymorphisms have been shown to influence tacrolimus blood concentrations and dose requirements, but the conclusion in the current reports were inconformity. Sirolimus are also metabolized by CYP3A subfamily and are substrates of the P-gp. The aim was to determine whether these polymorphisms affect tacrolimus (TAC) and sirolimus (SRL) trough concentrations and dose requirements after renal transplantation. 153 renal transplant recipients were enrolled into this study, 112 were treated with TAC-based regimen, Another 43 recipients received SRL-based regimen. The recipients’ mean follow-up time was 20 mo (range 15–27 mo). All renal transplant recipients were all in a stable stage. The trough concentration and daily dose of TAC and SRL were gained from each recipient. All recipients were genotyped for CYP3A5 (6986A>G), CYP3A4 intron 6 (CYP3A4*22), CYP3A4*18, ABCB1 exon 26 (3435C>T), exon 12 (1236C>T) and 2677G>T/A SNPs by HRM analysis (high-resolution melting curve analysis). The TAC and SRL concentration/dose ratio (C/D) in recipients with CYP3A5 (*)3/(*)3 were significantly higher than that of those with (*)1 allele (P < 0.05). However, there was no significant correlation between adjusted TAC and SRL trough concentrations or dose requirements with CYP3A4 and ABCB1 SNPs genetic polymorphisms. In recipients with TAC-based or SRL-based therapy, the CYP3A5 genes (6986A>G) can influence the TAC and SRL pharmacokinetics in renal transplant recipients.
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Affiliation(s)
- Yi Li
- Department of Clinical Immunological Laboratory, West China Hospital, Sichuan University, Chengdu, 610041 The People's Republic of China
| | - Lin Yan
- Department of Clinical Immunological Laboratory, West China Hospital, Sichuan University, Chengdu, 610041 The People's Republic of China
| | - Yunying Shi
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, 610041 The People's Republic of China
| | - Yangjuan Bai
- Department of Clinical Immunological Laboratory, West China Hospital, Sichuan University, Chengdu, 610041 The People's Republic of China
| | - Jiangtao Tang
- Department of Clinical Immunological Laboratory, West China Hospital, Sichuan University, Chengdu, 610041 The People's Republic of China
| | - Lanlan Wang
- Department of Clinical Immunological Laboratory, West China Hospital, Sichuan University, Chengdu, 610041 The People's Republic of China
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