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Flatman LK, Malhamé I, Colmegna I, Bérard A, Bernatsky S, Vinet É. Tumour necrosis factor inhibitors and serious infections in reproductive-age women and their offspring: a narrative review. Scand J Rheumatol 2024; 53:295-306. [PMID: 38314746 DOI: 10.1080/03009742.2024.2303832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/08/2024] [Indexed: 02/07/2024]
Abstract
Tumour necrosis factor inhibitors (TNFi) are commonly used to treat patients with chronic inflammatory diseases, and function by inhibiting the pro-inflammatory cytokine tumour necrosis factor-α (TNF-α). Although beneficial in reducing disease activity, they are associated with an increased risk of serious infections. Data on the risk of serious infections associated with TNFi use during the reproductive years, particularly in pregnancy, are limited. For pregnant women, there is an additional risk of immunosuppression in the offspring as TNFi can be actively transported across the placenta, which increases in the second and third trimesters. Several studies have explored the risk of serious infections with TNFi exposure in non-pregnant and pregnant patients and offspring exposed in utero, indicating an increased risk in non-pregnant patients and a potentially increased risk in pregnant patients. The studies on TNFi-exposed offspring showed conflicting results between in utero TNFi exposure and serious infections during the offspring's first year. Further research is needed to understand differential risks based on TNFi subtypes. Guidelines conditionally recommend the rotavirus vaccine before 6 months of age for offspring exposed to TNFi in utero, but more data are needed to support these recommendations because of limited evidence. This narrative review provides an overview of the risk in non-pregnant patients and summarizes evidence on how pregnancy can increase vulnerability to certain infections and how TNFi may influence this susceptibility. This review focuses on the evidence regarding the risk of serious infections in pregnant patients exposed to TNFi and the risk of infections in their offspring.
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Affiliation(s)
- L K Flatman
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - I Malhamé
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - I Colmegna
- Division of Rheumatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - A Bérard
- Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada
- Research Center, CHU Sainte-Justine, Montreal, Quebec, Canada
- Faculty of Medicine, Université Claude Bernard Lyon 1, Lyon, France
| | - S Bernatsky
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- Division of Rheumatology, Division of Clinical Epidemiology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - É Vinet
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- Division of Rheumatology, Division of Clinical Epidemiology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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2
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van Gendt J, Emaus R, Visschedijk MC, Touw DJ, Bouwknegt DG, de Leeuw K, Prins JR, Malik P, Mian P. Pharmacokinetics of Monoclonal Antibodies Throughout Pregnancy: A Systematic Literature Review. Clin Pharmacokinet 2024; 63:589-622. [PMID: 38583128 PMCID: PMC11106164 DOI: 10.1007/s40262-024-01370-7] [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: 03/12/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND AND OBJECTIVE Although little information is available on the pharmacokinetics (PK) of monoclonal antibodies (mAbs) during pregnancy, multiple mAbs are being used during pregnancy for various indications. The aim of this systematic literature review was to characterize the PK of mAbs throughout pregnancy. METHODS A systematic literature search was carried out in PubMed and Embase on 21 April 2023. Articles were included when information on PK or exposure parameters of mAbs in pregnant women was available. RESULTS A total of 42 relevant articles were included, of which eight discussed adalimumab, three certolizumab pegol, five eculizumab, one golimumab, 12 infliximab (IFX), two natalizumab, one canakinumab, one omalizumab, five tocilizumab, eight ustekinumab, and five vedolizumab. One of the 42 studies reported information on clearance (CL) and volume of distribution (VD) of IFX; all other studies only reported on serum concentrations in the pre-pregnancy state, different trimesters, and the postpartum period. For all of the assessed mAbs except IFX, serum concentrations were similar to concentrations in the pre-pregnancy state or modestly decreased. In contrast, IFX trough concentrations generally increased in the second and third trimesters in comparison to the non-pregnant state. CONCLUSION Available information suggests that the anatomical and physiological changes throughout pregnancy may have meaningful effects on the PK of mAbs. For most mAbs (not IFX), modestly higher dosing (per mg) maybe needed during pregnancy to sustain a similar serum exposure compared to pre-pregnancy.
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Affiliation(s)
- J van Gendt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen and University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - R Emaus
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen and University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - M C Visschedijk
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - D J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen and University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Pharmaceutical Analysis, Groningen Research Institute for Pharmacy, University of Groningen, Groningen, The Netherlands
| | - D G Bouwknegt
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - K de Leeuw
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - J R Prins
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - P Malik
- Calico Life Sciences, South San Francisco, USA
| | - Paola Mian
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen and University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
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3
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Scott HM, Mehta R, Branda ME, Hughes J, Kane SV, Girard S, Norgan AP, Theiler RN, Enninga EAL. Effect of Anti-TNF Biologic Exposure During Pregnancy on Villitis of Unknown Etiology Diagnoses in Patients with Autoimmune Disease. Reprod Sci 2024; 31:997-1005. [PMID: 37973775 PMCID: PMC10960686 DOI: 10.1007/s43032-023-01402-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 11/04/2023] [Indexed: 11/19/2023]
Abstract
Tumor necrosis factor-α (TNF-α) antagonists are highly effective in controlling autoimmune diseases. This has led to speculation that they might also be useful in treating inflammatory placental conditions, such as chronic villitis of unknown etiology (VUE). VUE affects 10-15% of term placentas and is associated with recurrent fetal growth restriction (FGR) and pregnancy loss. We aimed to evaluate outcomes in patients with autoimmune diseases with and without anti-TNF-α biologic exposure during gestation. This retrospective cohort study compared pregnant women with autoimmune disease taking anti-TNF-α biologics (n = 89) to pregnant women with autoimmune disease but not taking a biologic (n = 53). We extracted data on all patients meeting our inclusion criteria over a 20-year period. Our primary outcome was the diagnosis of VUE by histology. Our secondary outcomes were maternal and neonatal complications such as preeclampsia, FGR, and neonatal intensive care admission. Kruskal-Wallis and chi-squared tests were performed as appropriate for statistical analysis. Maternal characteristics were comparable between groups, and there was no increase in adverse pregnancy outcomes based on anti-TNF-α treatment. Exposure to anti-TNF-α therapy had no significant effect on the incidence of VUE or other obstetric complications. Within the cohort exposed to anti-TNF-α biologics during pregnancy, the rate of VUE was 9.3%, which is comparable to the reported general population risk. Our data support the safety profile of biologic use in pregnancy.
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Affiliation(s)
- Hannah M Scott
- Department of Obstetrics and Gynecology, Mayo Clinic, 200 First Ave. SW, Rochester, MN, 55905, USA
| | - Ramila Mehta
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Megan E Branda
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Sylvie Girard
- Department of Obstetrics and Gynecology, Mayo Clinic, 200 First Ave. SW, Rochester, MN, 55905, USA
- Department of Immunology, Mayo Clinic, Rochester, MN, USA
| | - Andrew P Norgan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Regan N Theiler
- Department of Obstetrics and Gynecology, Mayo Clinic, 200 First Ave. SW, Rochester, MN, 55905, USA
| | - Elizabeth Ann L Enninga
- Department of Obstetrics and Gynecology, Mayo Clinic, 200 First Ave. SW, Rochester, MN, 55905, USA.
- Department of Immunology, Mayo Clinic, Rochester, MN, USA.
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4
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Eliesen GA, Fransen M, van Hove H, van den Broek PH, Greupink R. Placental transfer of tofacitinib in the ex vivo dual-side human placenta perfusion model. Curr Res Toxicol 2024; 6:100149. [PMID: 38292667 PMCID: PMC10825226 DOI: 10.1016/j.crtox.2024.100149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 02/01/2024] Open
Abstract
Tofacitinib is a small molecule Janus kinase (JAK) inhibitor, introduced to the European market in 2017, for the treatment of rheumatoid arthritis, psoriatic arthritis and ulcerative colitis. In the treatment of women with autoimmune diseases, pregnancy is a relevant issue, as such diseases typically affect women in their reproductive years. Currently, there is limited data on the use of tofacitinib during pregnancy. To estimate the extent of placental transfer in the absence of clinical data, we conducted ex vivo dual-side perfused human placental cotyledon perfusions. Term placentas were perfused for 180 min with tofacitinib (100 nM, added to the maternal circuit) in a closed-closed configuration. At the end of the perfusions, drug concentrations in the maternal and fetal reservoirs were near equilibrium, at 35.6 ± 5.5 and 24.8 ± 4.7 nM, respectively. Transfer of tofacitinib was similar to that observed for the passive diffusion marker antipyrine (100 µg/mL, added to the maternal reservoir). Final antipyrine maternal and fetal concentrations amounted to 36.9 ± 3.0 and 36.7 ± 1.3 µg/mL, respectively. In conclusion, in the ex vivo perfused placenta tofacitinib traverses the placental barrier rapidly and extensively. This suggests that substantial fetal tofacitinib exposure will take place after maternal drug dosing.
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Affiliation(s)
- Gaby A.M. Eliesen
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands
- Centre for Safety of Substances and Products, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Milou Fransen
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hedwig van Hove
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Petra H.H. van den Broek
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rick Greupink
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands
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5
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Sakowicz A, Bralewska M, Rybak-Krzyszkowska M, Grzesiak M, Pietrucha T. New Ideas for the Prevention and Treatment of Preeclampsia and Their Molecular Inspirations. Int J Mol Sci 2023; 24:12100. [PMID: 37569476 PMCID: PMC10418829 DOI: 10.3390/ijms241512100] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
Preeclampsia (PE) is a pregnancy-specific disorder affecting 4-10% of all expectant women. It greatly increases the risk of maternal and foetal death. Although the main symptoms generally appear after week 20 of gestation, scientific studies indicate that the mechanism underpinning PE is initiated at the beginning of gestation. It is known that the pathomechanism of preeclampsia is strongly related to inflammation and oxidative stress, which influence placentation and provoke endothelial dysfunction in the mother. However, as of yet, no "key players" regulating all these processes have been discovered. This might be why current therapeutic strategies intended for prevention or treatment are not fully effective, and the only effective method to stop the disease is the premature induction of delivery, mostly by caesarean section. Therefore, there is a need for further research into new pharmacological strategies for the treatment and prevention of preeclampsia. This review presents new preventive methods and therapies for PE not yet recommended by obstetrical and gynaecological societies. As many of these therapies are in preclinical studies or under evaluation in clinical trials, this paper reports the molecular targets of the tested agents or methods.
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Affiliation(s)
- Agata Sakowicz
- Department of Medical Biotechnology, Medical University of Lodz, Zeligowskiego 7/9, 90-752 Lodz, Poland; (M.B.); (T.P.)
| | - Michalina Bralewska
- Department of Medical Biotechnology, Medical University of Lodz, Zeligowskiego 7/9, 90-752 Lodz, Poland; (M.B.); (T.P.)
| | - Magda Rybak-Krzyszkowska
- Department of Obstetrics and Perinatology, University Hospital in Krakow, 31-501 Krakow, Poland;
| | - Mariusz Grzesiak
- Department of Perinatology, Obstetrics and Gynecology, Polish Mother’s Memorial Hospital-Research Institute in Lodz, 93-338 Lodz, Poland;
- Department of Gynecology and Obstetrics, Medical University of Lodz, 93-338 Lodz, Poland
| | - Tadeusz Pietrucha
- Department of Medical Biotechnology, Medical University of Lodz, Zeligowskiego 7/9, 90-752 Lodz, Poland; (M.B.); (T.P.)
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Chen X, Unadkat JD, Mao Q. Maternal and Fetal Exposure to (-)-Δ 9-tetrahydrocannabinol and Its Major Metabolites in Pregnant Mice Is Differentially Impacted by P-glycoprotein and Breast Cancer Resistance Protein. Drug Metab Dispos 2023; 51:269-275. [PMID: 36446608 PMCID: PMC10029818 DOI: 10.1124/dmd.122.001110] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/13/2022] [Accepted: 11/16/2022] [Indexed: 12/02/2022] Open
Abstract
(-)-Δ9-tetrahydrocannabinol (THC) is the primary pharmacological active constituent of cannabis. 11-hydroxy-THC (11-OH-THC) and 11-nor-9-carboxy-THC (THC-COOH) are respectively the active and nonactive circulating metabolites of THC in humans. While previous animal studies reported that THC could be a substrate of mouse P-glycoprotein (P-gp) and breast cancer resistance protein (Bcrp), we have shown, in vitro, that only THC-COOH is a weak substrate of human BCRP, but not of P-gp. To confirm these findings and to investigate the role of P-gp and/or Bcrp in the maternal-fetal disposition of THC and its metabolites, we administrated 3 mg/kg of THC retro-orbitally to FVB wild-type (WT), P-gp -/-, Bcrp -/-, or P-gp-/- /Bcrp-/- pregnant mice on gestation day 18 and estimated the area under the concentration-time curve (AUC) of the cannabinoids in the maternal plasma, maternal brain, placenta, and fetus, as well as the tissue/maternal plasma AUC geometric mean ratios (GMRs) using a pooled data bootstrap approach. We found that the dose-normalized maternal plasma AUCs of THC in P-gp-/- and P-gp-/- /Bcrp-/- mice, and the placenta-to-maternal plasma AUC GMR of THC in Bcrp-/- mice were 279%, 271%, and 167% of those in WT mice, respectively. Surprisingly, the tissue-to-maternal plasma AUC GMRs of THC and its major metabolites in the maternal brain, placenta, or fetus in P-gp -/-, Bcrp -/- or P-gp-/- /Bcrp-/- mice were 28-78% of those in WT mice. This study revealed that P-gp and Bcrp do not play a role in limiting maternal brain and fetal exposure to THC and its major metabolites in pregnant mice. SIGNIFICANCE STATEMENT: This study systematically investigated whether P-gp and/or Bcrp in pregnant mice can alter the disposition of THC, 11-OH-THC, and THC-COOH. Surprisingly, except for Bcrp, which limits placental (but not fetal) exposure to THC, we found that P-gp-/- , Bcrp-/- , and/or P-gp-/- /Bcrp-/- significantly decreased exposure to THC and/or its metabolites in maternal brain, placenta, or fetus. The mechanistic basis for this decrease is unclear and needs further investigation. If replicated in humans, P-gp- or BCRP-based drug-cannabinoid interactions are not of concern.
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MESH Headings
- Pregnancy
- Mice
- Female
- Humans
- Animals
- ATP Binding Cassette Transporter, Subfamily B, Member 1/genetics
- ATP Binding Cassette Transporter, Subfamily B, Member 1/metabolism
- Dronabinol/metabolism
- Placenta/metabolism
- ATP Binding Cassette Transporter, Subfamily G, Member 2/genetics
- ATP Binding Cassette Transporter, Subfamily G, Member 2/metabolism
- ATP-Binding Cassette Transporters/metabolism
- Neoplasm Proteins/genetics
- Neoplasm Proteins/metabolism
- ATP Binding Cassette Transporter, Subfamily B/genetics
- ATP Binding Cassette Transporter, Subfamily B/metabolism
- Breast Neoplasms/metabolism
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Affiliation(s)
- Xin Chen
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, Washington 98195
| | - Jashvant D Unadkat
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, Washington 98195
| | - Qingcheng Mao
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, Washington 98195
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Mizutani S, Okunishi Y, Tamada T, Tanaka H, Ito Y, Yamamoto Y, Kitamura A, Tanaka H, Ikeda T, Nakajima A. A Woman with Rheumatoid Arthritis Who Successfully Delivered a Healthy Child with Continuous Administration of Sarilumab Throughout Pregnancy. Intern Med 2023; 62:633-636. [PMID: 35871593 PMCID: PMC10017234 DOI: 10.2169/internalmedicine.9607-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein report a patient with rheumatoid arthritis (RA) who successfully delivered a healthy child with continuous administration of sarilumab throughout pregnancy. She delivered her first child, a healthy boy, following in vitro fertilization-embryo transfer (IVF-ET) while using etanercept and low-dose prednisolone. Disease activity persisted after delivery, so etanercept was switched to sarilumab. She became pregnant by IVF-ET again. Because RA was still active, sarilumab was continued during pregnancy. She delivered a healthy girl at the 38th week of gestation by Caesarean section. No abnormalities were detected at or within 6 months after birth. Sarilumab was safe and effective in this pregnant woman with RA.
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Affiliation(s)
| | - Yuki Okunishi
- Center for Rheumatic Diseases, Mie University Hospital, Japan
| | - Tatsuya Tamada
- Center for Rheumatic Diseases, Mie University Hospital, Japan
| | - Hiroyuki Tanaka
- Center for Rheumatic Diseases, Mie University Hospital, Japan
| | - Yuhei Ito
- Center for Rheumatic Diseases, Mie University Hospital, Japan
| | | | - Asa Kitamura
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Japan
| | - Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Japan
| | - Ayako Nakajima
- Center for Rheumatic Diseases, Mie University Hospital, Japan
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8
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Schneider H, Albrecht C, Ahmed MS, Broekhuizen M, Aengenheister L, Buerki-Thurnherr T, Danser AHJ, Gil S, Hansson SR, Greupink R, Lewis RM, Markert UR, Mathiesen L, Powles-Glover N, Wadsack C, Brownbill P. Ex vivo dual perfusion of an isolated human placenta cotyledon: Towards protocol standardization and improved inter-centre comparability. Placenta 2022; 126:83-89. [PMID: 35785693 DOI: 10.1016/j.placenta.2022.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 04/06/2022] [Accepted: 05/04/2022] [Indexed: 12/29/2022]
Abstract
Since the full development of the ex vivo dual perfusion model of the human placenta cotyledon, the technique has provided essential insight into how nutrients, lipids, gases, immunoglobulins, endocrine agents, pharmaceuticals, chemicals, nanoparticles, micro-organisms and parasites might traverse the maternofetal barrier. Additionally, the model has been instrumental in gaining a better understanding of the regulation of vascular tone, endocrinology and metabolism within this organ. The human placenta is unique amongst species in its anatomy and transfer modalities. This orthologous diversity therefore requires an appropriate consideration of placental transfer rates of compounds, particles and micro-organisms specific to humans. Different research centres have adapted this model with a wide variation in perfusion parameters, including in the establishment of perfusion, perfusate composition, gassing regime, cannulation method, flow rates, perfused tissue mass, and also in the application of quality control measures. The requirement to harmonise and standardise perfusion practice between centres is largely driven by the need to obtain consistency in our understanding of placental function, but also in the qualification of the model for acceptance by regulatory agencies in drug and toxicology testing. A pilot study is proposed, aiming to describe how existing inter-centre variation in perfusion methodology affects placental metabolism, protein synthesis, oxygen consumption, the materno-fetal transfer of key molecular markers, and placental structure.
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Affiliation(s)
- Henning Schneider
- Dept. Obstetrics & Gynecology, Inselspital, Bern University Hospital, Switzerland.
| | - Christiane Albrecht
- Institute of Biochemistry & Molecular Medicine, University of Bern, Switzerland; Swiss National Centre of Competence in Research (NCCR) TransCure, University of Bern, Switzerland.
| | - Mahmoud S Ahmed
- Departments of Obstetrics and Gynecology and Pharmacology and Toxicology, University of Texas Medical Branch, Galveston, TX, USA.
| | - Michelle Broekhuizen
- Division of Neonatology, Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands; Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands.
| | - Leonie Aengenheister
- Particles-Biology Interactions, Empa, Swiss Federal Laboratories for Materials Science and Technology, St. Gallen, Switzerland.
| | - Tina Buerki-Thurnherr
- Particles-Biology Interactions, Empa, Swiss Federal Laboratories for Materials Science and Technology, St. Gallen, Switzerland.
| | - A H Jan Danser
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands.
| | - Sophie Gil
- University Paris Cité, Placentech®, Paris, F-75014, France.
| | - Stefan R Hansson
- Lund University, Department of Obstetrics and Gynecology, Institute of Clinical Sciences Lund, Lund University, Lund, Sweden.
| | - Rick Greupink
- Department of Pharmacology & Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands.
| | | | - Udo R Markert
- Department of Obstetrics, Placenta Lab, Jena University Hospital, Jena, Germany.
| | - Line Mathiesen
- Department of Public Health, University of Copenhagen, Faculty of Health Sciences, Copenhagen, Denmark.
| | | | - Christian Wadsack
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria.
| | - Paul Brownbill
- Maternal and Fetal Health Research Centre, University of Manchester, UK; Manchester Academic Health Sciences Centre, UK.
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9
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The Effect of Pregnancy and Inflammatory Bowel Disease on the Pharmacokinetics of Drugs Related to Inflammatory Bowel Disease-A Systematic Literature Review. Pharmaceutics 2022; 14:pharmaceutics14061241. [PMID: 35745812 PMCID: PMC9227141 DOI: 10.3390/pharmaceutics14061241] [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: 05/05/2022] [Revised: 05/27/2022] [Accepted: 06/06/2022] [Indexed: 11/19/2022] Open
Abstract
Due to ethical and practical reasons, a knowledge gap exists on the pharmacokinetics (PK) of inflammatory bowel disease (IBD)-related drugs in pregnant women with IBD. Before evidence-based dosing can be proposed, insight into the PK has to be gained to optimize drug therapy for both mother and fetus. This systematic review aimed to describe the effect of pregnancy and IBD on the PK of drugs used for IBD. One aminosalicylate study, two thiopurine studies and twelve studies with biologicals were included. Most drugs within these groups presented data over multiple moments before, during and after pregnancy, except for mesalazine, ustekinumab and golimumab. The studies for mesalazine, ustekinumab and golimumab did not provide enough data to demonstrate an effect of pregnancy on concentration and PK parameters. Therefore, no evidence-based dosing advice was given. The 6-thioguanine nucleotide levels decreased during pregnancy to 61% compared to pre-pregnancy levels. The potentially toxic metabolite 6-methylmercaptopurine (6-MMP) increased to maximal 209% of the pre-pregnancy levels. Although the PK of the thiopurines changed throughout pregnancy, no evidence-based dosing advice was provided. One study suggested that caution should be exercised when the thiopurine dose is adjusted, due to shunting 6-MMP levels. For the biologicals, infliximab levels increased, adalimumab stayed relatively stable and vedolizumab levels tended to decrease during pregnancy. Although the PK of the biologicals changed throughout pregnancy, no evidence-based dosing advice for biologicals was provided. Other drugs retrieved from the literature search were mesalazine, ustekinumab and golimumab. We conclude that limited studies have been performed on PK parameters during pregnancy for drugs used in IBD. Therefore, more extensive research to determine the values of PK parameters is warranted. After gathering the PK data, evidence-based dosing regimens can be developed.
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10
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Gill KL, Jones HM. Opportunities and Challenges for PBPK Model of mAbs in Paediatrics and Pregnancy. AAPS J 2022; 24:72. [PMID: 35650328 DOI: 10.1208/s12248-022-00722-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/20/2022] [Indexed: 12/20/2022] Open
Abstract
New drugs may in some cases need to be tested in paediatric and pregnant patients. However, it is difficult to recruit such patients and there are many ethical issues around their inclusion in clinical trials. Modelling and simulation can help to plan well-designed clinical trials with a reduced number of participants and to bridge gaps where recruitment is difficult. Physiologically based pharmacokinetic (PBPK) models for small molecule drugs have been used to aid study design and dose adjustments in paediatrics and pregnancy, with several publications in the literature. However, published PBPK models for monoclonal antibodies (mAb) in these populations are scarce. Here, the current status of mAb PBPK models in paediatrics and pregnancy is discussed. Seven mAb PBPK models published for paediatrics were found, which report good prediction accuracy across a wide age range. No mAb PBPK models for pregnant women have been published to date. Current challenges to the development of such PBPK models are discussed, including gaps in our knowledge of relevant physiological processes and availability of clinical data to verify models. As the availability of such data increases, it will help to improve our confidence in the PBPK model predictive ability. Advantages for using PBPK models to predict mAb PK in paediatrics and pregnancy are discussed. For example, the ability to incorporate ontogeny and gestational changes in physiology, prediction of maternal, placental and foetal exposure and the ability to make predictions from in vitro and preclinical data prior to clinical data being available.
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Affiliation(s)
- Katherine L Gill
- Certara UK Limited, Simcyp Division, Level 2-Acero, 1 Concourse Way, Sheffield, S1 2BJ, UK.
| | - Hannah M Jones
- Certara UK Limited, Simcyp Division, Level 2-Acero, 1 Concourse Way, Sheffield, S1 2BJ, UK
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11
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van Hove H, Mathiesen L, Freriksen J, Vähäkangas K, Colbers A, Brownbill P, Greupink R. Placental transfer and vascular effects of pharmaceutical drugs in the human placenta ex vivo: A review. Placenta 2022; 122:29-45. [DOI: 10.1016/j.placenta.2022.03.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/15/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
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12
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Ghalandari N, Kemper E, Crijns IH, Wolbink G, Rispens T, Smeele HT, Dolhain RJ. Analysing cord blood levels of TNF inhibitors to validate the EULAR points to consider for TNF inhibitor use during pregnancy. Ann Rheum Dis 2021; 81:402-405. [PMID: 34493490 PMCID: PMC8862049 DOI: 10.1136/annrheumdis-2021-221036] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/20/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND To minimise placental transfer of tumour necrosis factor inhibitors (TNFi), the European League Against Rheumatism (EULAR) created points to consider (PtC) for the use of TNFi during pregnancy. We are the first to validate the EULAR-PtC by analysing TNFi concentrations in cord blood. METHODS Patients were derived from the Preconceptional Counselling in Active Rheumatoid Arthritis Study. TNFi was stopped at the time points recommended by the EULAR. Maternal blood and cord blood were collected and analysed for the concentration of TNFi. RESULTS 111 patients were eligible for the analysis. Median stop time points were gestational age (GA) 37.0 weeks for certolizumab pegol, GA 25.0 weeks for etanercept, GA 19.0 weeks for adalimumab and GA 18.4 weeks for infliximab. Certolizumab pegol (n=68) was detectable in 5.9% of cord blood samples, with a median concentration of 0.3 µg/mL (IQR: 0.2-1.3) and a median cord/maternal concentration ratio of 0.010. Etanercept (n=30) was not detected in any cord blood samples. Adalimumab (n=25) was detectable in 48.0% of cord blood samples, with a median concentration of 0.5 µg/mL (IQR: 0.2-0.7) and a median concentration ratio of 0.062 (IQR: 0.018-0.15). Infliximab (n=14) was detectable in 57.1% of cord blood samples, with a median concentration of 0.4 µg/mL (IQR: 0.1-1.2) and a median concentration ratio of 0.012 (IQR: 0.006-0.081). CONCLUSION Compliance with the EULAR-PtC results in absence or low levels of TNFi in cord blood.
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Affiliation(s)
- Nafise Ghalandari
- Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands .,FT1/GMB, Medicines Evaluation Board, Utrecht, The Netherlands
| | - Erik Kemper
- Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands.,FT1/GMB, Medicines Evaluation Board, Utrecht, The Netherlands
| | | | - Gertjan Wolbink
- Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands.,Rheumatology, Jan van Breemen Research Institute
- Reade, Amsterdam, Netherlands
| | - Theo Rispens
- Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
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13
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Carnovale C, Parisi F, Battini V, Zavatta A, Cheli S, Cattaneo D, Gringeri M, Mosini G, Guarnieri G, Cammarata G, Cetin I. The use of biological agents in pregnant women affected by autoimmune disorders: Why we need more research of this neglected area. Pharmacol Res 2021; 171:105786. [PMID: 34314858 DOI: 10.1016/j.phrs.2021.105786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/12/2021] [Accepted: 07/22/2021] [Indexed: 11/20/2022]
Abstract
Women of childbearing age are largely affected by several autoimmune disorders (the estimates range between 1.5 and 10 per 10,000). The increasing number of effective biological agents has dramatically revolutionized the treatment of these clinical conditions, ameliorating the patient's quality of life. The use of these agents by women during pregnancy is growing to ensure the disease activity control and avoid adverse health outcomes. However, for many newer biological agents, the degree of information concerning their use in pregnancy is often incomplete to perform a conclusive risk assessment on fetal and maternal health given the exclusion of this specific population from pharmacological clinical trials. More recently, the COVID-19 pandemic has confirmed the unacceptable inequities of pharmacological research and medical treatment for pregnant and lactating women, exacerbating the need for filling the gaps of quantitative and qualitative pharmacology data in this sensitive population. ere we summarize (i) what is already known about safety and effectiveness of biological agents in this understudied population (with specific focus on pregnancy-related health outcomes), and what we are going to learn from the on-going studies among pregnant women treated with biological agents; (ii) the methodological and ethical considerations that characterize the pharmacological research in pregnancy, also discussing emerging evidence on the use of therapeutic drug monitoring (TDM) in this clinical setting.
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Affiliation(s)
- Carla Carnovale
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, Milan, Italy.
| | - Francesca Parisi
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, 20141 Milan, Italy
| | - Vera Battini
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, Milan, Italy
| | - Alice Zavatta
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, 20141 Milan, Italy
| | - Stefania Cheli
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital, Via GB Grassi 74, 20157 Milan, Italy
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital, Via GB Grassi 74, 20157 Milan, Italy
| | - Michele Gringeri
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, Milan, Italy
| | - Giulia Mosini
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, Milan, Italy
| | - Greta Guarnieri
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, Milan, Italy
| | - Gianluca Cammarata
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, Milan, Italy
| | - Irene Cetin
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, 20141 Milan, Italy; Department of Biomedical and Clinical Sciences, "Luigi Sacco", University of Milan, 20157 Milan, Italy
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14
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Christopoulos PF, Gjølberg TT, Krüger S, Haraldsen G, Andersen JT, Sundlisæter E. Targeting the Notch Signaling Pathway in Chronic Inflammatory Diseases. Front Immunol 2021; 12:668207. [PMID: 33912195 PMCID: PMC8071949 DOI: 10.3389/fimmu.2021.668207] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/24/2021] [Indexed: 12/14/2022] Open
Abstract
The Notch signaling pathway regulates developmental cell-fate decisions and has recently also been linked to inflammatory diseases. Although therapies targeting Notch signaling in inflammation in theory are attractive, their design and implementation have proven difficult, at least partly due to the broad involvement of Notch signaling in regenerative and homeostatic processes. In this review, we summarize the supporting role of Notch signaling in various inflammation-driven diseases, and highlight efforts to intervene with this pathway by targeting Notch ligands and/or receptors with distinct therapeutic strategies, including antibody designs. We discuss this in light of lessons learned from Notch targeting in cancer treatment. Finally, we elaborate on the impact of individual Notch members in inflammation, which may lay the foundation for development of therapeutic strategies in chronic inflammatory diseases.
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Affiliation(s)
| | - Torleif T. Gjølberg
- Institute of Clinical Medicine and Department of Pharmacology, University of Oslo and Oslo University Hospital, Oslo, Norway
- Centre for Eye Research and Department of Ophthalmology, University of Oslo and Oslo University Hospital, Oslo, Norway
- Department of Immunology, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Stig Krüger
- Department of Pathology, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Guttorm Haraldsen
- Department of Pathology, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Jan Terje Andersen
- Institute of Clinical Medicine and Department of Pharmacology, University of Oslo and Oslo University Hospital, Oslo, Norway
- Department of Immunology, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Eirik Sundlisæter
- Department of Pathology, University of Oslo and Oslo University Hospital, Oslo, Norway
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15
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Beltagy A, Aghamajidi A, Trespidi L, Ossola W, Meroni PL. Biologics During Pregnancy and Breastfeeding Among Women With Rheumatic Diseases: Safety Clinical Evidence on the Road. Front Pharmacol 2021; 12:621247. [PMID: 34122062 PMCID: PMC8189556 DOI: 10.3389/fphar.2021.621247] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 01/04/2021] [Indexed: 12/31/2022] Open
Abstract
Females are generally more affected by autoimmune diseases, a fact that underlines the relationship with pregnancy and the safety of anti-rheumatic drugs in pregnancy and lactation. Biologic therapies are increasingly prescribed to treat and maintain remission in a significant number of systemic autoimmune rheumatic diseases. The experience with the use of biologics during gestation is extremely lacking because of the observational nature of the available studies and the difficulty in designing proper clinical trials in pregnancy. Among the studied biologics, more information was published on TNFα inhibitors and, in particular, on their potential passage through the placenta and impact on the fetus. Currently, a fragment of anti-TNFα monoclonal IgG, certolizumab pegol, is considered safe with almost no placental transfer. Subsequent observations are suggesting a comparable safety for the soluble TNFα receptor etanercept. Another biologic, eculizumab, the anti-C5a antibody used to treat complement-mediated microangiopathies, is also considered safe due to the unique engineered IgG2/4κ formulation that limits its passage through the placental barrier. Still, long-term data about children born to women treated with biologics in pregnancy are not attainable. Data on breastfeeding are currently available for several biologics. This article reviews the literature available about which drugs are considered safe during pregnancy and lactation, which are not, and on future prospects.
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Affiliation(s)
- Asmaa Beltagy
- Istituto Auxologico Italiano, IRCCS, Immunorheumatology Research Laboratory, Milan, Italy.,Rheumatology and Clinical Immunology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Azin Aghamajidi
- Department of Immunology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Laura Trespidi
- Department of Obstetrics and Gynaecology, Fondazione Ca Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Wally Ossola
- Department of Obstetrics and Gynaecology, Fondazione Ca Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Pier Luigi Meroni
- Istituto Auxologico Italiano, IRCCS, Immunorheumatology Research Laboratory, Milan, Italy
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Schakenraad L, Van Es MJ, Meerman JJ, Van den Broek PHH, Van Hove H, Van Drongelen J, Eliesen GAM, Russel FGM, Greupink R. Transfer of uremic solutes across the human term placenta: An ex vivo study in the dual-side perfused cotyledon. Placenta 2021; 104:220-231. [PMID: 33429119 DOI: 10.1016/j.placenta.2020.12.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 10/25/2020] [Accepted: 12/17/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION An increasing number of women becomes pregnant while suffering from chronic kidney disease (CKD). As a result of decreased renal function, uremic solutes circulate at high levels in the maternal circulation. This study aimed to acquire more knowledge about the placental transfer of uremic solutes across the human placenta. METHODS Placental transfer was studied in healthy term placentas, via the ex vivo dual-side human cotyledon perfusion technique (closed-closed set-up for both maternal and fetal circulations). Uremic solute concentrations in maternal and fetal perfusates were measured via LC-MS/MS over 180 min of perfusion. RESULTS We found that the studied compounds demonstrated different degrees of placental transfer. Fetal-to-maternal perfusate ratios at t = 180 min were for anthranilic acid 1.00 ± 0.02, indole-3-acetic acid 0.47 ± 0.08, hippuric acid 0.36 ± 0.18, l-arabinitol 0.33 ± 0.04, indoxyl sulfate 0.33 ± 0.11, neopterin 0.28 ± 0.14 and kynurenic acid 0.13 ± 0.03. All uremic solutes studied also emerged in the perfusates when cotyledons were perfused in the absence of uremic solute concentrations added to the maternal reservoir. For kynurenin these concentrations were so high, it complicated the calculation of a transfer ratio for the exogenously administered compound. DISCUSSION After 180 min of exposure the extent of placental transfer differs substantially for the solutes studied, reflecting different transfer rates. Future studies should investigate to what extent specific uremic solutes reach the fetal circulation in vivo and how they may interfere with organ function and development of the unborn child.
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Affiliation(s)
- L Schakenraad
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - M J Van Es
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - J J Meerman
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - P H H Van den Broek
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - H Van Hove
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - J Van Drongelen
- Department of Obstetrics and Gynecology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - G A M Eliesen
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - F G M Russel
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - R Greupink
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
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