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Streekstra EJ, Keuper-Navis M, van den Heuvel JJWM, van den Broek P, Greupink R, Stommel MWJ, de Boode WP, Botden SMBI, Russel FGM, van de Steeg E, de Wildt SN. The potential of enteroids derived from children and adults to study age-dependent differences in intestinal CYP3A4/5 metabolism. Eur J Pharm Sci 2024; 201:106868. [PMID: 39084538 DOI: 10.1016/j.ejps.2024.106868] [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: 03/29/2024] [Revised: 07/12/2024] [Accepted: 07/27/2024] [Indexed: 08/02/2024]
Abstract
Drug metabolism in the intestinal wall affects bioavailability of orally administered drugs and is influenced by age. Hence, it is important to fully understand the drug metabolizing capacity of the gut to predict systemic exposure. The aim of this study was to investigate the potential of enteroids as a tool to study CYP3A4/5 -mediated metabolism in both children and adults. Bioconversion of midazolam, a CYP3A4/5 model substrate, was studied using enteroid monolayers as well as tissue explants in the Ussing chamber, both derived from pediatric [median (range age): 54 weeks (2 days - 13 years), n = 21] and adult (n = 5) tissue. Caco-2 cellular monolayers were employed as controls. In addition, mRNA expression of CYP3A4 was determined in enteroid monolayers (n = 11), tissue (n = 23) and Caco-2 using RT-qPCR. Midazolam metabolism was successfully detected in all enteroid monolayers, as well as in all tissue explants studied in the Ussing chamber, whereas Caco-2 showed no significant metabolite formation. The extracted fraction of midazolam was similar between enteroid monolayers and tissue. The fraction of midazolam extracted increased with age in enteroid monolayers derived from 0 to 70 week old donors. No statistically significant correlation was observed in tissue likely due to high variability observed and the smaller donor numbers included in the study. At the level of gene expression, CYP3A4 increased with age in tissues (n = 32), while this was not reflected in enteroid monolayers (n = 16). Notably, asymmetric metabolite formation was observed in enteroids and tissue, with higher metabolite formation on the luminal side of the barrier. In summary, we demonstrated that enteroids can be used to measure CYP3A4/5 midazolam metabolism, which we show is similar as observed in fresh isolated tissue. This was the case both in children and adults, indicating the potential of enteroids to predict intestinal metabolism. This study provides promising data to further develop enteroids to study drug metabolism in vitro and potentially predict oral absorption for special populations as an alternative to using fresh tissue.
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Affiliation(s)
- Eva J Streekstra
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Metabolic Health Research, Netherlands Organization for Applied Scientific Research (TNO), Leiden, the Netherlands
| | - Marit Keuper-Navis
- Department of Metabolic Health Research, Netherlands Organization for Applied Scientific Research (TNO), Leiden, the Netherlands; Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Jeroen J W M van den Heuvel
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Petra van den Broek
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rick Greupink
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Willem P de Boode
- Department of Pediatrics, Division of Neonatology, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Sanne M B I Botden
- Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frans G M Russel
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Evita van de Steeg
- Department of Metabolic Health Research, Netherlands Organization for Applied Scientific Research (TNO), Leiden, the Netherlands
| | - Saskia N de Wildt
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Intensive Care, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Neonatal and Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands.
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2
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Johnson TN, Batchelor HK, Goelen J, Horniblow RD, Dinh J. Combining data on the bioavailability of midazolam and physiologically-based pharmacokinetic modeling to investigate intestinal CYP3A4 ontogeny. CPT Pharmacometrics Syst Pharmacol 2024. [PMID: 38923249 DOI: 10.1002/psp4.13192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 06/06/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
Pediatric physiologically-based modeling in drug development has grown in the past decade and optimizing the underlying systems parameters is important in relation to overall performance. In this study, variation of clinical oral bioavailability of midazolam as a function of age is used to assess the underlying ontogeny models for intestinal CYP3A4. Data on midazolam bioavailability in adults and children and different ontogeny patterns for intestinal CYP3A4 were first collected from the literature. A pediatric PBPK model was then used to assess six different ontogeny models in predicting bioavailability from preterm neonates to adults. The average fold error ranged from 0.7 to 1.38, with the rank order of least to most biased model being No Ontogeny < Upreti = Johnson < Goelen < Chen < Kiss. The absolute average fold error ranged from 1.17 to 1.64 with the rank order of most to least precise being Johnson > Upreti > No Ontogeny > Goelen > Kiss > Chen. The optimal ontogeny model is difficult to discern when considering the possible influence of CYP3A5 and other population variability; however, this study suggests that from term neonates and older a faster onset Johnson model with a lower fraction at birth may be close to this. For inclusion in other PBPK models, independent verification will be needed to confirm these results. Further research is needed in this area both in terms of age-related changes in midazolam and similar drug bioavailability and intestinal CYP3A4 ontogeny.
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Affiliation(s)
| | - Hannah K Batchelor
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Jan Goelen
- Centre for Neonatal and Paediatric Infection, Antimicrobial Resistance Research Group, St George's, University of London, London, UK
| | - Richard D Horniblow
- School of Biomedical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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3
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Šoša I. Ingestion of Fluids of the Ocular Surface Containing Eye Drops of Imidazole Derivatives-Alpha Adrenergic Receptor Agonists as Paragons. Pharmaceuticals (Basel) 2024; 17:758. [PMID: 38931425 PMCID: PMC11206365 DOI: 10.3390/ph17060758] [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: 04/25/2024] [Revised: 06/03/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
Accidental poisonings by ingesting conjunctival fluid mixed with eye drops commonly involve alpha-2 adrenergic receptor agonists and tetrahydrozoline. These substances are recognized in commonly reported ingestions. Victims of all ages, otherwise in good health, often present as pale and lethargic to the emergency department (ED) after unintentionally ingesting topical eye medication. While eye drop poisoning cases in childhood include accidents during the play and poisonings in adults mean either suicide attempts or side effects caused by the systemic absorption of the substance, fluid of the ocular surface is a risk to all age groups. With this in mind, this study aimed to summarize data in the literature on tetrahydrozoline and alpha-2 adrenergic receptor agonists as dangerous medications, even when administered in low-bioavailability forms, such as eye drops. With this aim, a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic review of relevant studies was conducted. A search of PubMed, Scopus, Web of Science, and EBSCOhost yielded nine studies that met the rigorous inclusion criteria. The primary studies were subject to a meta-analysis once a quality appraisal of the studies and a narrative synthesis of the extracted data had been conducted. The author hopes that this information will provide observations that will lead to better designs for over-the-counter eye drops, off-label drug usage policies, and parental attention.
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Affiliation(s)
- Ivan Šoša
- Department of Anatomy, Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia
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4
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Xie H, Zhao J, Tu H, Wang W, Hu Y. Combined sedation in pediatric magnetic resonance imaging: determination of median effective dose of intranasal dexmedetomidine combined with oral midazolam. BMC Anesthesiol 2024; 24:112. [PMID: 38521913 PMCID: PMC10960491 DOI: 10.1186/s12871-024-02493-x] [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: 11/17/2023] [Accepted: 03/12/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND The exact median effective dose (ED50) of intranasal dexmedetomidine combined with oral midazolam sedation for magnetic resonance imaging (MRI) examination in children remains unknow and the aim of this study was to determine the ED50 of their combination. METHODS This is a prospective dose-finding study. A total of 53 children aged from 2 months to 6 years scheduled for MRI examination from February 2023 to April 2023 were randomly divided into group D (to determine the ED50 of intranasal dexmedetomidine) and group M (to determine the ED50 of oral midazolam). The dosage of dexmedetomidine and midazolam was adjusted according to the modified Dixon's up-and-down method, and the ED50 was calculated with a probit regression approach. RESULTS The ED50 of intranasal dexmedetomidine when combined with 0.5 mg∙kg- 1 oral midazolam was 0.39 µg∙kg- 1 [95% confidence interval (CI) 0.30 to 0.46 µg∙kg- 1] while the ED50 of oral midazolam was 0.17 mg∙kg- 1 (95% CI 0.01 to 0.29 mg∙kg- 1) when combined with 1 µg∙kg- 1 intranasal dexmedetomidine. The sedation onset time of children with successful sedation in group D was longer than in group M (30.0[25.0, 38.0]vs 19.5[15.0, 35.0] min, P < 0.05). No other adverse effects were observed in the day and 24 h after medication except one dysphoria. CONCLUSION This drug combination sedation regimen appears suitable for children scheduled for MRI examinations, offering a more precise approach to guide the clinical use of sedative drugs in children. TRIAL REGISTRATION Chinese Clinical Trial Registry, identifier: ChiCTR2300068611(24/02/2023).
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Affiliation(s)
- Hao Xie
- Department of Anesthesiology, Children's Hospital, School of Medicine, Zhejiang University, 3333 Binsheng Rd, Hangzhou, Zhejiang, 310052, P.R. China
| | - Jialian Zhao
- Department of Anesthesiology, Children's Hospital, School of Medicine, Zhejiang University, 3333 Binsheng Rd, Hangzhou, Zhejiang, 310052, P.R. China
| | - Haiya Tu
- Department of Anesthesiology, Children's Hospital, School of Medicine, Zhejiang University, 3333 Binsheng Rd, Hangzhou, Zhejiang, 310052, P.R. China
| | - Wenyang Wang
- Department of Anesthesiology, Children's Hospital, School of Medicine, Zhejiang University, 3333 Binsheng Rd, Hangzhou, Zhejiang, 310052, P.R. China
| | - Yaoqin Hu
- Department of Anesthesiology, Children's Hospital, School of Medicine, Zhejiang University, 3333 Binsheng Rd, Hangzhou, Zhejiang, 310052, P.R. China.
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Ni MJ, Jin YT, Wu QL, Zhang N, Tian JH, Li J, Yuan KM. Effective dose of intranasal remimazolam for preoperative sedation in preschool children: a dose-finding study using Dixon's up-and-down method. Front Pharmacol 2024; 15:1372139. [PMID: 38572430 PMCID: PMC10987844 DOI: 10.3389/fphar.2024.1372139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/05/2024] [Indexed: 04/05/2024] Open
Abstract
Background Most preschool children are distressed during anesthesia induction. While current pharmacological methods are useful, there is a need for further optimization to an "ideal" standard. Remimazolam is an ultra-short-acting benzodiazepine, and intranasal remimazolam for pre-induction sedation may be promising. Methods This study included 32 preschool children who underwent short and minor surgery between October 2022 and January 2023. After pretreatment with lidocaine, remimazolam was administered to both nostrils using a mucosal atomizer device. The University of Michigan Sedation Score (UMSS) was assessed for sedation 6, 9, 12, 15, and 20 min after intranasal atomization. We used Dixon's up-and-down method, and probit and isotonic regressions to determine the 50% effective dose (ED50) and 95% effective dose (ED95) of intranasal remimazolam for pre-induction sedation. Results: Twenty-nine pediatric patients were included in the final analysis. The ED50 and ED95 of intranasal remimazolam for successful pre-induction sedation, when processed via probit analysis, were 0.65 (95% confidence interval [CI], 0.59-0.71) and 0.78 mg/kg (95% CI, 0.72-1.07), respectively. In contrast, when processed by isotonic regression, they were 0.65 (95% CI: 0.58-0.72 mg/kg) and 0.78 mg/kg (95% CI: 0.69-1.08 mg/kg), respectively. At 6 min after intranasal remimazolam treatment, 81.2% (13/16) of "positive" participants were successfully sedated with a UMSS ≧ 1. All the "positive" participants were successfully sedated within 9 min. Conclusion Intranasal remimazolam is feasible for preschool children with a short onset time. For successful pre-induction sedation, the ED50 and ED95 of intranasal remimazolam were 0.65 and 0.78 mg/kg, respectively.
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Affiliation(s)
- Ming-Jie Ni
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Pediatric Anesthesiology, Ministry of Education, Wenzhou Medical University, Key Laboratory of Anesthesiology of Zhejiang Province, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yu-Ting Jin
- Department of Anesthesiology, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Qian-Lin Wu
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Pediatric Anesthesiology, Ministry of Education, Wenzhou Medical University, Key Laboratory of Anesthesiology of Zhejiang Province, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ning Zhang
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Pediatric Anesthesiology, Ministry of Education, Wenzhou Medical University, Key Laboratory of Anesthesiology of Zhejiang Province, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jia-He Tian
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Pediatric Anesthesiology, Ministry of Education, Wenzhou Medical University, Key Laboratory of Anesthesiology of Zhejiang Province, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jun Li
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Pediatric Anesthesiology, Ministry of Education, Wenzhou Medical University, Key Laboratory of Anesthesiology of Zhejiang Province, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Kai-Ming Yuan
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Pediatric Anesthesiology, Ministry of Education, Wenzhou Medical University, Key Laboratory of Anesthesiology of Zhejiang Province, Wenzhou Medical University, Wenzhou, Zhejiang, China
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6
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Keuper-Navis M, Walles M, Poller B, Myszczyszyn A, van der Made TK, Donkers J, Eslami Amirabadi H, Wilmer MJ, Aan S, Spee B, Masereeuw R, van de Steeg E. The application of organ-on-chip models for the prediction of human pharmacokinetic profiles during drug development. Pharmacol Res 2023; 195:106853. [PMID: 37473876 DOI: 10.1016/j.phrs.2023.106853] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/11/2023] [Accepted: 07/14/2023] [Indexed: 07/22/2023]
Abstract
Organ-on-chip (OoC) technology has led to in vitro models with many new possibilities compared to conventional in vitro and in vivo models. In this review, the potential of OoC models to improve the prediction of human oral bioavailability and intrinsic clearance is discussed, with a focus on the functionality of the models and the application in current drug development practice. Multi-OoC models demonstrating the application for pharmacokinetic (PK) studies are summarized and existing challenges are identified. Physiological parameters for a minimal viable platform of a multi-OoC model to study PK are provided, together with PK specific read-outs and recommendations for relevant reference compounds to validate the model. Finally, the translation to in vivo PK profiles is discussed, which will be required to routinely apply OoC models during drug development.
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Affiliation(s)
- Marit Keuper-Navis
- Department of Metabolic Health Research, Netherlands Organisation for Applied Scientific Research (TNO), Leiden, the Netherlands; Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Markus Walles
- Pharmacokinetic Sciences, Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Birk Poller
- Pharmacokinetic Sciences, Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Adam Myszczyszyn
- Faculty of Veterinary Medicine & Regenerative Medicine Center Utrecht (RMCU), Utrecht University, Utrecht, the Netherlands
| | - Thomas K van der Made
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Joanne Donkers
- Department of Metabolic Health Research, Netherlands Organisation for Applied Scientific Research (TNO), Leiden, the Netherlands
| | | | | | - Saskia Aan
- Stichting Proefdiervrij, Den Haag, the Netherlands
| | - Bart Spee
- Faculty of Veterinary Medicine & Regenerative Medicine Center Utrecht (RMCU), Utrecht University, Utrecht, the Netherlands
| | - Rosalinde Masereeuw
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Evita van de Steeg
- Department of Metabolic Health Research, Netherlands Organisation for Applied Scientific Research (TNO), Leiden, the Netherlands.
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7
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Baboolal HA, Gulati A. Residual unabsorbed midazolam: a case report. J Med Case Rep 2023; 17:118. [PMID: 36964603 PMCID: PMC10039542 DOI: 10.1186/s13256-023-03817-0] [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: 11/02/2022] [Accepted: 02/10/2023] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND Oral midazolam is commonly administered to reduce anxiety in children presenting for medical procedures or surgery. It is unclear what volume of medication remains unabsorbed in the stomach when the child presents for anesthetic induction prior to these procedures. The presence of any significant residual medication in the stomach has significant clinical implications in the postoperative period. CASE PRESENTATION A 5-year-old white Caucasian boy presented for upper gastrointestinal endoscopy after receiving oral midazolam liquid. Insertion of the endoscope into the stomach revealed a significant amount of unabsorbed medication remaining within the gastric cavity. CONCLUSION Clinicians should be aware that the sedative effects of midazolam may be present before the medication is fully absorbed. A significant amount of unabsorbed medication may be present in the stomach during medical procedures/surgery. This may continue to be absorbed in the intraoperative and postoperative period, with unwanted clinical effect.
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Affiliation(s)
- Hemanth A Baboolal
- Department of Anesthesiology, University of North Carolina Hospital, 101 Manning Drive, Chapel Hill, NC, 27514, USA.
| | - A Gulati
- Department of Pediatrics, University of North Carolina, Chapel Hill, USA
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8
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Smits A, Annaert P, Cavallaro G, De Cock PAJG, de Wildt SN, Kindblom JM, Lagler FB, Moreno C, Pokorna P, Schreuder MF, Standing JF, Turner MA, Vitiello B, Zhao W, Weingberg AM, Willmann R, van den Anker J, Allegaert K. Current knowledge, challenges and innovations in developmental pharmacology: A combined conect4children Expert Group and European Society for Developmental, Perinatal and Paediatric Pharmacology White Paper. Br J Clin Pharmacol 2022; 88:4965-4984. [PMID: 34180088 PMCID: PMC9787161 DOI: 10.1111/bcp.14958] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/22/2021] [Accepted: 05/30/2021] [Indexed: 12/30/2022] Open
Abstract
Developmental pharmacology describes the impact of maturation on drug disposition (pharmacokinetics, PK) and drug effects (pharmacodynamics, PD) throughout the paediatric age range. This paper, written by a multidisciplinary group of experts, summarizes current knowledge, and provides suggestions to pharmaceutical companies, regulatory agencies and academicians on how to incorporate the latest knowledge regarding developmental pharmacology and innovative techniques into neonatal and paediatric drug development. Biological aspects of drug absorption, distribution, metabolism and excretion throughout development are summarized. Although this area made enormous progress during the last two decades, remaining knowledge gaps were identified. Minimal risk and burden designs allow for optimally informative but minimally invasive PK sampling, while concomitant profiling of drug metabolites may provide additional insight in the unique PK behaviour in children. Furthermore, developmental PD needs to be considered during drug development, which is illustrated by disease- and/or target organ-specific examples. Identifying and testing PD targets and effects in special populations, and application of age- and/or population-specific assessment tools are discussed. Drug development plans also need to incorporate innovative techniques such as preclinical models to study therapeutic strategies, and shift from sequential enrolment of subgroups, to more rational designs. To stimulate appropriate research plans, illustrations of specific PK/PD-related as well as drug safety-related challenges during drug development are provided. The suggestions made in this joint paper of the Innovative Medicines Initiative conect4children Expert group on Developmental Pharmacology and the European Society for Developmental, Perinatal and Paediatric Pharmacology, should facilitate all those involved in drug development.
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Affiliation(s)
- Anne Smits
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Neonatal intensive Care unit, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Giacomo Cavallaro
- Neonatal intensive care unit, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milan, Italy
| | - Pieter A J G De Cock
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium.,Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.,Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | - Saskia N de Wildt
- Intensive Care and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Pharmacology and Toxicology, Radboud Institute Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jenny M Kindblom
- Pediatric Clinical Research Center, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Florian B Lagler
- Institute for Inherited Metabolic Diseases and Department of Pediatrics, Paracelsus Medical University, Clinical Research Center Salzburg, Salzburg, Austria
| | - Carmen Moreno
- Institute of Psychiatry and Mental Health, Child and Adolescent Psychiatry Department, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, Madrid, Spain
| | - Paula Pokorna
- Intensive Care and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.,Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.,Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Joseph F Standing
- UCL Great Ormond Street Institute of Child Health, London, UK.,Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Mark A Turner
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | - Benedetto Vitiello
- Division of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Wei Zhao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, China.,Department of Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China.,Clinical Research Centre, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | | | | | - John van den Anker
- Intensive Care and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland.,Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Hospital Pharmacy, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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9
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Svedmyr A, Hack H, Anderson BJ. Interactions of the protease inhibitor, ritonavir, with common anesthesia drugs. Paediatr Anaesth 2022; 32:1091-1099. [PMID: 35842922 PMCID: PMC9543968 DOI: 10.1111/pan.14529] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 11/27/2022]
Abstract
The protease inhibitor, ritonavir, is a strong inhibitor of CYP 3A. The drug is used for management of the human immunovirus and is currently part of an oral antiviral drug combination (nirmatrelvir-ritonavir) for the early treatment of SARS-2 COVID-19-positive patients aged 12 years and over who have recognized comorbidities. The CYP 3A enzyme system is responsible for clearance of numerous drugs used in anesthesia (e.g., alfentanil, fentanyl, methadone, rocuronium, bupivacaine, midazolam, ketamine). Ritonavir will have an impact on drug clearances that are dependent on ritonavir concentration, anesthesia drug intrinsic hepatic clearance, metabolic pathways, concentration-response relationship, and route of administration. Drugs with a steep concentration-response relationship (ketamine, midazolam, rocuronium) are mostly affected because small changes in concentration have major changes in effect response. An increase in midazolam concentration is observed after oral administration because CYP 3A in the gastrointestinal wall is inhibited, causing a large increase in relative bioavailability. Fentanyl infusion may be associated with a modest increase in plasma concentration and effect, but the large between subject variability of pharmacokinetic and pharmacodynamic concentration changes suggests it will have little impact on an individual patient, especially when used with adverse effect monitoring. It has been proposed that drugs that have no or only a small metabolic pathway involving the CYP 3A enzyme be used during anesthesia, for example, propofol, atracurium, remifentanil, and the volatile agents. That anesthesia approach denies children of drugs with considerable value. It is better that the inhibitory changes in clearance of these drugs are understood so that rational drug choices can be made to tailor drug use to the individual patient. Altered drug dose, anticipation of duration of effect, timing of administration, use of reversal agents and perioperative monitoring would better behoove children undergoing anesthesia.
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Affiliation(s)
- Anders Svedmyr
- Dept AnaesthesiaStarship Children's HospitalAucklandNew Zealand
| | - Henrik Hack
- Dept AnaesthesiaStarship Children's HospitalAucklandNew Zealand
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10
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Guo X, Cao X, Fang X, Guo A, Li E. Involvement of phase II enzymes and efflux transporters in the metabolism and absorption of naringin, hesperidin and their aglycones in rats. Int J Food Sci Nutr 2022; 73:480-490. [PMID: 34974785 DOI: 10.1080/09637486.2021.2012562] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/18/2021] [Accepted: 11/26/2021] [Indexed: 10/19/2022]
Abstract
This study examined the effects of phase II metabolism and efflux transportation on the bioavailability of naringin, hesperidin, and their aglycones (naringenin and hesperetin) in rats. Results indicated naringin and hesperidin have a lower oral bioavailability than their aglycones. Of all the phase II enzymes tested, UDP-glucuronosyltransferase (UGT) 1A1, UGT1A2, UGT1A3, UGT1A7 and SULT sulfotransferase (SULT) 1B1 were of minor importance regarding the phase II metabolism of naringenin and hesperetin in the small intestine. Naringin, hesperidin, and their aglycones were all extensively metabolised in the liver. Naringin and hesperidin were more extensively transported by efflux transporters compared to their aglycones. Significant correlations between phase II enzymes and efflux transporters were detected. In conclusion, more extensive metabolism of naringin and hesperidin than their aglycones in the small intestine, and the interplay of phase II enzymes and efflux transporters in the small intestine explain the lower relative oral bioavailability of naringin and hesperidin than their aglycones.
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Affiliation(s)
- Xiao Guo
- College of Food Science and Technology, Huazhong Agricultural University, Wuhan, China
| | - Xuedan Cao
- Zhejiang Citrus Research Institute, Zhejiang Academy of Agricultural Sciences, Taizhou, China
| | - Xiugui Fang
- Zhejiang Citrus Research Institute, Zhejiang Academy of Agricultural Sciences, Taizhou, China
| | - Ailing Guo
- College of Food Science and Technology, Huazhong Agricultural University, Wuhan, China
| | - Erhu Li
- College of Food Science and Technology, Huazhong Agricultural University, Wuhan, China
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11
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Zhang J, Liu JB, Zeng FN, Ren Q, Lin HL, Jian LL, Liu GL. Safety and efficacy of dexmedetomidine hydrochloride combined with midazolam in fiberoptic bronchoscopy in children: a prospective randomized controlled study. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:981-986. [PMID: 34719411 DOI: 10.7499/j.issn.1008-8830.2107075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To study the safety and efficacy of dexmedetomidine hydrochloride combined with midazolam in fiberoptic bronchoscopy in children. METHODS A total of 118 children who planned to undergo fiberoptic bronchoscopy from September 2018 to February 2021 were enrolled. They were divided into a control group (n=60) and an observation group (n=58) using a random number table. The observation group received intravenous pumping of dexmedetomidine hydrochloride (2 μg/mL) at 1 μg/kg and then intravenous injection of midazolam at 0.05 mg/kg, followed by dexmedetomidine hydrochloride pumped intravenously at 0.5-0.7 μg/(kg·h) 10 minutes later to maintain anesthesia. The control group was given intravenous pumping of propofol at 2 mg/kg and then intravenous injection of midazolam at 0.05 mg/kg, followed by propofol pumped intravenously at 4-6 mg/(kg·h) 10 minutes later to maintain anesthesia. Fiberoptic bronchoscopy was performed after the children were unconscious. Heart rate (HR), respiratory rate, blood oxygen saturation, and mean arterial pressure (MAP) were recorded before inserting the bronchoscope (T0), at the time of inserting the bronchoscope (T1), when the bronchoscope reached the glottis (T2), when the bronchoscope reached the carina (T3), and when the bronchoscope entered the bronchus (T4). The intraoperative peak airway pressure (Ppeak), examination time, degree of sedation, extent of amnesia, incidence of adverse reactions, postoperative awakening time, and postoperative agitation score were also recorded. RESULTS Compared with the control group, the observation group had significantly decreased MAP at T1 to T4 and HR at T1 to T3 (P<0.05). Compared with that at T0, MAP was significantly increased at T1 to T4 in the control group and at T3 in the observation group (P<0.05). HR was significantly higher at T1 to T3 than at T0 (P<0.05). Compared with the control group, the observation group showed significantly lower intraoperative Ppeak value, incidence of intraoperative adverse reactions, and postoperative agitation score, significantly shorter examination time, and better effects of amnesia and anesthesia (P<0.05). There was no significant difference in the degree of intraoperative sedation and postoperative awakening time between the two groups (P>0.05). CONCLUSIONS Dexmedetomidine hydrochloride combined with midazolam is a safe and effective way to administer general anesthesia for fiberoptic bronchoscopy in children, which can ensure stable vital signs during examination, reduce intraoperative adverse reactions and postoperative agitation, shorten examination time, and increase amnesic effect.
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Affiliation(s)
- Jin Zhang
- Department of Pediatrics, Shenzhen Luohu People's Hospital, Shenzhen, Guangdong 518000, China (Liu J-B, )
| | - Jie-Bo Liu
- Department of Pediatrics, Shenzhen Luohu People's Hospital, Shenzhen, Guangdong 518000, China (Liu J-B, )
| | - Fen-Na Zeng
- Department of Pediatrics, Shenzhen Luohu People's Hospital, Shenzhen, Guangdong 518000, China (Liu J-B, )
| | - Qiao Ren
- Department of Pediatrics, Shenzhen Luohu People's Hospital, Shenzhen, Guangdong 518000, China (Liu J-B, )
| | - Hui-Ling Lin
- Department of Pediatrics, Shenzhen Luohu People's Hospital, Shenzhen, Guangdong 518000, China (Liu J-B, )
| | - Li-Li Jian
- Department of Pediatrics, Shenzhen Luohu People's Hospital, Shenzhen, Guangdong 518000, China (Liu J-B, )
| | - Guo-Le Liu
- Department of Pediatrics, Shenzhen Luohu People's Hospital, Shenzhen, Guangdong 518000, China (Liu J-B, )
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12
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De Corte T, Elbers P, De Waele J. The future of antimicrobial dosing in the ICU: an opportunity for data science. Intensive Care Med 2021; 47:1481-1483. [PMID: 34633485 DOI: 10.1007/s00134-021-06549-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/29/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Thomas De Corte
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium. .,Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium.
| | - Paul Elbers
- Department of Intensive Care Medicine, Amsterdam Infection and Immunity Institute (AI&II), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Sciences (ACS), VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Jan De Waele
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
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13
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Vinarov Z, Abrahamsson B, Artursson P, Batchelor H, Berben P, Bernkop-Schnürch A, Butler J, Ceulemans J, Davies N, Dupont D, Flaten GE, Fotaki N, Griffin BT, Jannin V, Keemink J, Kesisoglou F, Koziolek M, Kuentz M, Mackie A, Meléndez-Martínez AJ, McAllister M, Müllertz A, O'Driscoll CM, Parrott N, Paszkowska J, Pavek P, Porter CJH, Reppas C, Stillhart C, Sugano K, Toader E, Valentová K, Vertzoni M, De Wildt SN, Wilson CG, Augustijns P. Current challenges and future perspectives in oral absorption research: An opinion of the UNGAP network. Adv Drug Deliv Rev 2021; 171:289-331. [PMID: 33610694 DOI: 10.1016/j.addr.2021.02.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/12/2021] [Accepted: 02/01/2021] [Indexed: 02/06/2023]
Abstract
Although oral drug delivery is the preferred administration route and has been used for centuries, modern drug discovery and development pipelines challenge conventional formulation approaches and highlight the insufficient mechanistic understanding of processes critical to oral drug absorption. This review presents the opinion of UNGAP scientists on four key themes across the oral absorption landscape: (1) specific patient populations, (2) regional differences in the gastrointestinal tract, (3) advanced formulations and (4) food-drug interactions. The differences of oral absorption in pediatric and geriatric populations, the specific issues in colonic absorption, the formulation approaches for poorly water-soluble (small molecules) and poorly permeable (peptides, RNA etc.) drugs, as well as the vast realm of food effects, are some of the topics discussed in detail. The identified controversies and gaps in the current understanding of gastrointestinal absorption-related processes are used to create a roadmap for the future of oral drug absorption research.
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Affiliation(s)
- Zahari Vinarov
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium; Department of Chemical and Pharmaceutical Engineering, Sofia University, Sofia, Bulgaria
| | - Bertil Abrahamsson
- Oral Product Development, Pharmaceutical Technology & Development, Operations, AstraZeneca, Gothenburg, Sweden
| | - Per Artursson
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Hannah Batchelor
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, United Kingdom
| | - Philippe Berben
- Pharmaceutical Development, UCB Pharma SA, Braine- l'Alleud, Belgium
| | - Andreas Bernkop-Schnürch
- Department of Pharmaceutical Technology, Institute of Pharmacy, University of Innsbruck, Innsbruck, Austria
| | - James Butler
- GlaxoSmithKline Research and Development, Ware, United Kingdom
| | | | - Nigel Davies
- Advanced Drug Delivery, Pharmaceutical Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | | | - Gøril Eide Flaten
- Department of Pharmacy, UiT The Arctic University of Norway, Tromsø, Norway
| | - Nikoletta Fotaki
- Department of Pharmacy and Pharmacology, University of Bath, Bath, United Kingdom
| | | | | | | | | | | | - Martin Kuentz
- Institute for Pharma Technology, University of Applied Sciences and Arts Northwestern Switzerland, Basel, Switzerland
| | - Alan Mackie
- School of Food Science & Nutrition, University of Leeds, Leeds, United Kingdom
| | | | | | - Anette Müllertz
- Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | | | | | | | - Petr Pavek
- Faculty of Pharmacy, Charles University, Hradec Králové, Czech Republic
| | | | - Christos Reppas
- Department of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Kiyohiko Sugano
- College of Pharmaceutical Sciences, Ritsumeikan University, Shiga, Japan
| | - Elena Toader
- Faculty of Medicine, University of Medicine and Pharmacy of Iasi, Romania
| | - Kateřina Valentová
- Institute of Microbiology of the Czech Academy of Sciences, Prague, Czech Republic
| | - Maria Vertzoni
- Department of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - Saskia N De Wildt
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Clive G Wilson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, United Kingdom
| | - Patrick Augustijns
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
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14
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Impact of gastrointestinal tract variability on oral drug absorption and pharmacokinetics: An UNGAP review. Eur J Pharm Sci 2021; 162:105812. [PMID: 33753215 DOI: 10.1016/j.ejps.2021.105812] [Citation(s) in RCA: 136] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 02/19/2021] [Accepted: 03/16/2021] [Indexed: 12/17/2022]
Abstract
The absorption of oral drugs is frequently plagued by significant variability with potentially serious therapeutic consequences. The source of variability can be traced back to interindividual variability in physiology, differences in special populations (age- and disease-dependent), drug and formulation properties, or food-drug interactions. Clinical evidence for the impact of some of these factors on drug pharmacokinetic variability is mounting: e.g. gastric pH and emptying time, small intestinal fluid properties, differences in pediatrics and the elderly, and surgical changes in gastrointestinal anatomy. However, the link of colonic factors variability (transit time, fluid composition, microbiome), sex differences (male vs. female) and gut-related diseases (chronic constipation, anorexia and cachexia) to drug absorption variability has not been firmly established yet. At the same time, a way to decrease oral drug pharmacokinetic variability is provided by the pharmaceutical industry: clinical evidence suggests that formulation approaches employed during drug development can decrease the variability in oral exposure. This review outlines the main drivers of oral drug exposure variability and potential approaches to overcome them, while highlighting existing knowledge gaps and guiding future studies in this area.
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15
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Ayuso M, Buyssens L, Stroe M, Valenzuela A, Allegaert K, Smits A, Annaert P, Mulder A, Carpentier S, Van Ginneken C, Van Cruchten S. The Neonatal and Juvenile Pig in Pediatric Drug Discovery and Development. Pharmaceutics 2020; 13:44. [PMID: 33396805 PMCID: PMC7823749 DOI: 10.3390/pharmaceutics13010044] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/22/2020] [Accepted: 12/22/2020] [Indexed: 02/06/2023] Open
Abstract
Pharmacotherapy in pediatric patients is challenging in view of the maturation of organ systems and processes that affect pharmacokinetics and pharmacodynamics. Especially for the youngest age groups and for pediatric-only indications, neonatal and juvenile animal models can be useful to assess drug safety and to better understand the mechanisms of diseases or conditions. In this respect, the use of neonatal and juvenile pigs in the field of pediatric drug discovery and development is promising, although still limited at this point. This review summarizes the comparative postnatal development of pigs and humans and discusses the advantages of the juvenile pig in view of developmental pharmacology, pediatric diseases, drug discovery and drug safety testing. Furthermore, limitations and unexplored aspects of this large animal model are covered. At this point in time, the potential of the neonatal and juvenile pig as nonclinical safety models for pediatric drug development is underexplored.
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Affiliation(s)
- Miriam Ayuso
- Comparative Perinatal Development, Department of Veterinary Sciences, University of Antwerp, 2610 Wilrijk, Belgium; (L.B.); (M.S.); (A.V.); (C.V.G.)
| | - Laura Buyssens
- Comparative Perinatal Development, Department of Veterinary Sciences, University of Antwerp, 2610 Wilrijk, Belgium; (L.B.); (M.S.); (A.V.); (C.V.G.)
| | - Marina Stroe
- Comparative Perinatal Development, Department of Veterinary Sciences, University of Antwerp, 2610 Wilrijk, Belgium; (L.B.); (M.S.); (A.V.); (C.V.G.)
| | - Allan Valenzuela
- Comparative Perinatal Development, Department of Veterinary Sciences, University of Antwerp, 2610 Wilrijk, Belgium; (L.B.); (M.S.); (A.V.); (C.V.G.)
| | - Karel Allegaert
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (K.A.); (P.A.)
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium;
- Department of Hospital Pharmacy, Erasmus MC Rotterdam, 3000 CA Rotterdam, The Netherlands
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium;
- Neonatal Intensive Care Unit, University Hospitals UZ Leuven, 3000 Leuven, Belgium
| | - Pieter Annaert
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (K.A.); (P.A.)
| | - Antonius Mulder
- Department of Neonatology, University Hospital Antwerp, 2650 Edegem, Belgium;
- Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, 2610 Wilrijk, Belgium
| | | | - Chris Van Ginneken
- Comparative Perinatal Development, Department of Veterinary Sciences, University of Antwerp, 2610 Wilrijk, Belgium; (L.B.); (M.S.); (A.V.); (C.V.G.)
| | - Steven Van Cruchten
- Comparative Perinatal Development, Department of Veterinary Sciences, University of Antwerp, 2610 Wilrijk, Belgium; (L.B.); (M.S.); (A.V.); (C.V.G.)
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