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Clark ED, Lawley SD. How drug onset rate and duration of action affect drug forgiveness. J Pharmacokinet Pharmacodyn 2024; 51:213-226. [PMID: 38198076 DOI: 10.1007/s10928-023-09897-1] [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: 08/09/2023] [Accepted: 12/07/2023] [Indexed: 01/11/2024]
Abstract
Medication nonadherence is one of the largest problems in healthcare today, particularly for patients undergoing long-term pharmacotherapy. To combat nonadherence, it is often recommended to prescribe so-called "forgiving" drugs, which maintain their effect despite lapses in patient adherence. Nevertheless, drug forgiveness is difficult to quantify and compare between different drugs. In this paper, we construct and analyze a stochastic pharmacokinetic/pharmacodynamic (PK/PD) model to quantify and understand drug forgiveness. The model parameterizes a medication merely by an effective rate of onset of effect when the medication is taken (on-rate) and an effective rate of loss of effect when a dose is missed (off-rate). Patient dosing is modeled by a stochastic process that allows for correlations in missed doses. We analyze this "on/off" model and derive explicit formulas that show how treatment efficacy depends on drug parameters and patient adherence. As a case study, we compare the effects of nonadherence on the efficacy of various antihypertensive medications. Our analysis shows how different drugs can have identical efficacies under perfect adherence, but vastly different efficacies for adherence patterns typical of actual patients. We further demonstrate that complex PK/PD models can indeed be parameterized in terms of effective on-rates and off-rates. Finally, we have created an online app to allow pharmacometricians to explore the implications of our model and analysis.
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Affiliation(s)
- Elias D Clark
- Metrum Research Group, 2 Tunxis Road, Suite 112, Tariffville, CT, 06081, USA
- Department of Mathematics, University of Utah, Salt Lake City, UT, 84112, USA
| | - Sean D Lawley
- Department of Mathematics, University of Utah, Salt Lake City, UT, 84112, USA.
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2
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Reeves S, Bertrand J, Obee SJ, Hunter S, Howard R, Flanagan RJ. A population pharmacokinetic model to guide clozapine dose selection, based on age, sex, ethnicity, body weight and smoking status. Br J Clin Pharmacol 2024; 90:135-145. [PMID: 36793249 DOI: 10.1111/bcp.15691] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 02/02/2023] [Accepted: 02/05/2023] [Indexed: 02/17/2023] Open
Abstract
AIMS Guidance on clozapine dosing in treatment-resistant schizophrenia is based largely on data from White young adult males. This study aimed to investigate the pharmacokinetic profiles of clozapine and N-desmethylclozapine (norclozapine) across the age range, accounting for sex, ethnicity, smoking status and body weight. METHODS A population pharmacokinetic model, implemented in Monolix, that linked plasma clozapine and norclozapine via a metabolic rate constant, was used to analyse data from a clozapine therapeutic drug monitoring service, 1993-2017. RESULTS There were 17 787 measurements from 5960 patients (4315 male) aged 18-86 years. The estimated clozapine plasma clearance was reduced from 20.2 to 12.0 L h-1 between 20 and 80 years. Model-based dose predictions to attain a predose plasma clozapine concentration of 0.35 mg L-1 was 275 (90% prediction interval 125, 625) mg day-1 in nonsmoking, White males weighing 70 kg and aged 40 years. The corresponding predicted dose was increased by 30% in smokers, decreased by 18% in females, and was 10% higher and 14% lower in otherwise analogous Afro-Caribbean and Asian patients, respectively. Overall, the predicted dose decreased by 56% between 20 and 80 years. CONCLUSION The large sample size and wide age range of the patients studied allowed precise estimation of dose requirements to attain predose clozapine concentration of 0.35 mg L-1 . The analysis was, however, limited by the absence of data on clinical outcome and future studies are required to determine optimal predose concentrations specifically in those aged over 65 years.
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Affiliation(s)
- Suzanne Reeves
- Division of Psychiatry, University College London, London, UK
| | - Julie Bertrand
- Institute of Genetics, University College London, London, UK
- UMR 1137 Infection, Antimicrobials, Modelling, Evolution (IAME) French Institute for Medical Research (INSERM), University of Paris, Paris, France
| | - Stephen John Obee
- Precision Medicine, Networked Services, Bessemer Wing, King's College Hospital NHS Foundation Trust, London, UK
| | - Samora Hunter
- Precision Medicine, Networked Services, Bessemer Wing, King's College Hospital NHS Foundation Trust, London, UK
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK
| | - Robert James Flanagan
- Precision Medicine, Networked Services, Bessemer Wing, King's College Hospital NHS Foundation Trust, London, UK
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3
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Carral N, Lukas JC, Estradé O, Jauregizar N, Morillas H, Suárez E. Non-Adherence in Adult Male Patients with Community-Acquired Pneumonia: Relative Forgiveness of Amoxicillin versus Respiratory Fluoroquinolones. Antibiotics (Basel) 2023; 12:antibiotics12050838. [PMID: 37237741 DOI: 10.3390/antibiotics12050838] [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: 03/01/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023] Open
Abstract
The consequences of non-adherence to treatment (NAT) on antimicrobial efficacy may depend on drug forgiveness-a property that should account for pharmacokinetics (PK) and pharmacodynamics (PD) as well as interindividual variability. In this simulation study, relative forgiveness (RF) in NAT, defined as the probability of a successful PK/PD target (PTA) attained under perfect adherence compared to imperfect adherence, was evaluated for amoxicillin (AMOX) (oral 1000 mg/8 h) and two respiratory fluoroquinolones-levofloxacin (LFX) (oral 750 mg/24 h) and moxifloxacin (MOX) (oral 400 mg/24 h)-in virtual outpatients with community-acquired pneumonia for S. pneumoniae. Several NAT scenarios (delay in dose intake and a missed dose) were considered. PK characteristics of virtual patients, including variability in creatinine clearance (70-131 mL/min) and S. pneumoniae susceptibility variability associated with geographical location, were simulated in NAT. In this regard, in regions of low MIC delays from 1 h to 7 h or omission of dose ingestion would not have negative consequences on the efficacy of AMOX because of its good RF associated with the AMOX PK and PD properties; RF of LFX 750 mg or MOX 400 mg/24 h regimen vs. AMOX 1000 mg/8 h is one. However, in regions of elevated MIC for S. pneumoniae AMOX loses its RF, LFX and MOX vs. AMOX, showing higher RF (>1) depending on the CLCR of patients. These results illustrate the importance of considering the RF of antimicrobial drugs in NAT and provide a framework for further studying its implications for clinical success rates.
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Affiliation(s)
- Nerea Carral
- Department of Pharmacology, School of Medicine and Nursing, University of the Basque Country UPV/EHU, 48940 Leioa, Spain
| | - John C Lukas
- Drug Modeling & Consulting, Dynakin SL, 48160 Derio, Spain
| | - Oskar Estradé
- Department of Pharmacology, School of Medicine and Nursing, University of the Basque Country UPV/EHU, 48940 Leioa, Spain
| | - Nerea Jauregizar
- Department of Pharmacology, School of Medicine and Nursing, University of the Basque Country UPV/EHU, 48940 Leioa, Spain
| | - Héctor Morillas
- Department of Analytical Chemistry, Faculty of Science and Technology, University of the Basque Country UPV/EHU, 48080 Bilbao, Spain
| | - Elena Suárez
- Department of Pharmacology, School of Medicine and Nursing, University of the Basque Country UPV/EHU, 48940 Leioa, Spain
- Pharmacokinetic, Nanotechnology and Gene Therapy Group (PharmaNanoGene), University of the Basque Country UPV/EHU, 48940 Leioa, Spain
- Biocruces Health Research Institute, 48903 Barakaldo, Spain
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4
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Clark ED, Lawley SD. Should patients skip late doses of medication? A pharmacokinetic perspective. J Pharmacokinet Pharmacodyn 2022; 49:429-444. [PMID: 35726046 DOI: 10.1007/s10928-022-09812-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 06/01/2022] [Indexed: 11/25/2022]
Abstract
Missed doses, late doses, and other dosing irregularities are major barriers to effective pharmacotherapy, especially for the treatment of chronic conditions. What should a patient do if they did not take their last dose at the prescribed time? Should they take it late or skip it? In this paper, we investigate the pharmacokinetic effects of taking a late dose. We consider a single compartment model with linear absorption and elimination for a patient instructed to take doses at regular time intervals. We suppose that the patient forgets to take a dose and then realizes some time later and must decide what remedial steps to take. Using mathematical analysis, we derive several metrics which quantify the effects of taking the dose late. The metrics involve the difference between the drug concentration time courses for the case that the dose is taken late and the case that the dose is taken on time. In particular, the metrics are the integral of the absolute difference over all time, the maximum of the difference, and the maximum of the integral of the difference over any single dosing interval. We apply these general mathematical formulas to levothyroxine, atorvastatin, and immediate release and extended release formulations of lamotrigine. We further show how population variability can be immediately incorporated into these results. Finally, we use this analysis to propose general principles and strategies for dealing with dosing irregularities.
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Affiliation(s)
- Elias D Clark
- Department of Mathematics, University of Utah, Salt Lake City, UT, 84112, USA
| | - Sean D Lawley
- Department of Mathematics, University of Utah, Salt Lake City, UT, 84112, USA.
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5
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McAllister NP, Lawley SD. A pharmacokinetic and pharmacodynamic analysis of drug forgiveness. J Pharmacokinet Pharmacodyn 2022; 49:363-379. [DOI: 10.1007/s10928-022-09808-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 01/29/2022] [Indexed: 12/24/2022]
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6
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Albassam A, Hughes DA. What should patients do if they miss a dose? A systematic review of patient information leaflets and summaries of product characteristics. Eur J Clin Pharmacol 2020; 77:251-260. [PMID: 32989529 PMCID: PMC7803707 DOI: 10.1007/s00228-020-03003-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/16/2020] [Indexed: 12/05/2022]
Abstract
Purpose Medicines regulatory authorities advise that patient information leaflets (PILs) should provide specific advice on what actions to take if one or more doses are missed. We aimed to assess the content in this regard, of PILs and Summaries of Product Characteristics (SmPCs) of prescription only medicines (POMs) marketed in the UK. Methods PILs and SmPCs were accessed via the electronic Medicines Compendium. The following terms were used in the advanced search facility: miss(ed), omit(ted), adhere(d), delay(ed), forgot, forget, lapse. Identified documents were screened for instructions on missed doses which were categorised according to level of specificity, and cross-referenced to the National Patient Safety Agency (NPSA) grading of risk of harm from omitted and delayed medicines. Any supporting clinical or pharmacological evidence was identified from SmPCs. Results Two thousand two hundred eighty-four documents were identified from 7248 PILs and SmPCs relating to 1501 POMs. Seven hundred eighty-three (52%) POMs had SmPCs or PILs with no instructions on missed doses; 487 POMs (32%) included non-specific advice (e.g. “take as soon as possible”); 138 (9%) provided specific instructions; and 93 (6%) referred patients to seek medical advice. SmPCs for only 13/138 (9%) of those which included specific instructions provided any supporting clinical or pharmacological evidence. Instructions were absent for several medicines where the NPSA assessed that dose omissions may result in significant risk of harm. Conclusions Advice on missed doses is generally inadequate. Pharmaceutical companies and regulatory authorities should produce clear and concise instructions on what patients should do if they miss doses, with supporting evidence where necessary.
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Affiliation(s)
- Abdullah Albassam
- Department of Pharmacy Practice, Faculty of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, LL57 2PZ, UK.
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7
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Hill‐McManus D, Marshall S, Soto E, Hughes DA. Integration of Pharmacometrics and Pharmacoeconomics to Quantify the Value of Improved Forgiveness to Nonadherence: A Case Study of Novel Xanthine Oxidase Inhibitors for Gout. Clin Pharmacol Ther 2019; 106:652-660. [DOI: 10.1002/cpt.1454] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/04/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Daniel Hill‐McManus
- Centre for Health Economics and Medicines Evaluation Bangor University Bangor UK
| | | | | | - Dyfrig A. Hughes
- Centre for Health Economics and Medicines Evaluation Bangor University Bangor UK
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8
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Peck RW. Precision Medicine Is Not Just Genomics: The Right Dose for Every Patient. Annu Rev Pharmacol Toxicol 2018; 58:105-122. [DOI: 10.1146/annurev-pharmtox-010617-052446] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Richard W. Peck
- Pharma Research and Exploratory Development, Roche Innovation Center Basel, 4070 Basel, Switzerland
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9
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Browne SH, Peloquin C, Santillo F, Haubrich R, Muttera L, Moser K, Savage GM, Benson CA, Blaschke TF. Digitizing Medicines for Remote Capture of Oral Medication Adherence Using Co-encapsulation. Clin Pharmacol Ther 2017; 103:502-510. [PMID: 28597911 PMCID: PMC5836848 DOI: 10.1002/cpt.760] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 05/08/2017] [Accepted: 05/29/2017] [Indexed: 11/14/2022]
Abstract
High‐resolution measurement of medication adherence is essential to personalized drug therapy. A US Food and Drug Administration (FDA)‐cleared device, using an edible ingestion sensor (IS), external wearable patch, and paired mobile device can detect and record ingestion events. Oral medications must be combined with an IS to generate precise “digitized‐medication” ingestion records. We developed a Good Manufacturing Practice protocol to repackage oral medications with the IS within certified Capsugel capsules, termed co‐encapsulation (CoE). A randomized bioequivalence study of CoE‐IS‐Rifamate (Isoniazid/Rifampin 150/300 mg) vs. native‐Rifamate was conducted in 12 patients with active Mycobacterium tuberculosis and demonstrated bioequivalence using the population method ratio test (95% confidence interval). Subsequently, CoE‐IS‐medications across all biopharmaceutical classes underwent in vitro dissolution testing utilizing USP and FDA guidelines. CoE‐IS medications tested met USP dissolution specifications and were equivalent to their native formulations. CoE combines oral medications with the IS without altering the quality of the native formulation, generating “digitized” medications for remote capture of dosing histories.
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Affiliation(s)
- S H Browne
- University of California, San Diego School of Medicine, Division of Infectious Diseases, San Diego, California, USA
| | - C Peloquin
- University of Florida, College of Pharmacy and Emerging Pathogens Institute, Gainesville, Florida, USA
| | - F Santillo
- Research and Analytic Services, Sharp Clinical Services, Pennsylvania, USA
| | - R Haubrich
- University of California, San Diego School of Medicine, Division of Infectious Diseases, San Diego, California, USA.,Gilead Sciences, Gilead Sciences, Inc., Foster City, California, USA
| | - L Muttera
- University of California, San Diego Department of Medicine, Research Pharmacy, San Diego, California, USA
| | - K Moser
- San Diego County Health and Human Services Agency, San Diego, California, USA.,Centers for Disease Control, National Center for Emerging and Zoonotic Infectious Diseases, Atlanta, Georgia, USA
| | - G M Savage
- Proteus Digital Health, Inc., Redwood City, California, USA
| | - C A Benson
- University of California, San Diego School of Medicine, Division of Infectious Diseases, San Diego, California, USA
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10
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Lucas CJ, Martin JH. Pharmacokinetic-Guided Dosing of New Oral Cancer Agents. J Clin Pharmacol 2017; 57 Suppl 10:S78-S98. [DOI: 10.1002/jcph.937] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 04/10/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Catherine J. Lucas
- Discipline of Clinical Pharmacology, School of Medicine and Public Health; University of Newcastle; New South Wales Australia
| | - Jennifer H. Martin
- Discipline of Clinical Pharmacology, School of Medicine and Public Health; University of Newcastle; New South Wales Australia
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11
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Reeves S, McLachlan E, Bertrand J, D'Antonio F, Brownings S, Nair A, Greaves S, Smith A, Taylor D, Dunn J, Marsden P, Kessler R, Howard R. Therapeutic window of dopamine D2/3 receptor occupancy to treat psychosis in Alzheimer's disease. Brain 2017; 140:1117-1127. [PMID: 28334978 DOI: 10.1093/brain/aww359] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 11/30/2016] [Indexed: 12/31/2022] Open
Abstract
See Caravaggio and Graff-Guerrero (doi:10.1093/awx023) for a scientific commentary on this article.Antipsychotic drugs, originally developed to treat schizophrenia, are used to treat psychosis, agitation and aggression in Alzheimer's disease. In the absence of dopamine D2/3 receptor occupancy data to inform antipsychotic prescribing for psychosis in Alzheimer's disease, the mechanisms underpinning antipsychotic efficacy and side effects are poorly understood. This study used a population approach to investigate the relationship between amisulpride blood concentration and central D2/3 occupancy in older people with Alzheimer's disease by combining: (i) pharmacokinetic data (280 venous samples) from a phase I single (50 mg) dose study in healthy older people (n = 20, 65-79 years); (ii) pharmacokinetic, 18F-fallypride D2/3 receptor imaging and clinical outcome data on patients with Alzheimer's disease who were prescribed amisulpride (25-75 mg daily) to treat psychosis as part of an open study (n = 28; 69-92 years; 41 blood samples, five pretreatment scans, 19 post-treatment scans); and (iii) 18F-fallypride imaging of an antipsychotic free Alzheimer's disease control group (n = 10, 78-92 years), to provide additional pretreatment data. Non-linear mixed effects modelling was used to describe pharmacokinetic-occupancy curves in caudate, putamen and thalamus. Model outputs were used to estimate threshold steady state blood concentration and occupancy required to elicit a clinically relevant response (>25% reduction in scores on delusions, hallucinations and agitation domains of the Neuropsychiatric Inventory) and extrapyramidal side effects (Simpson Angus Scale scores > 3). Average steady state blood levels were low (71 ± 30 ng/ml), and associated with high D2/3 occupancies (65 ± 8%, caudate; 67 ± 11%, thalamus; 52 ± 11%, putamen). Antipsychotic clinical response occurred at a threshold concentration of 20 ng/ml and D2/3 occupancies of 43% (caudate), 25% (putamen), 43% (thalamus). Extrapyramidal side effects (n = 7) emerged at a threshold concentration of 60 ng/ml, and D2/3 occupancies of 61% (caudate), 49% (putamen) and 69% (thalamus). This study has established that, as in schizophrenia, there is a therapeutic window of D2/3 receptor occupancy for optimal treatment of psychosis in Alzheimer's disease. We have also shown that occupancies within and beyond this window are achieved at very low amisulpride doses in Alzheimer's disease due to higher than anticipated occupancies for a given blood drug concentration. Our findings support a central pharmacokinetic contribution to antipsychotic sensitivity in Alzheimer's disease and implicate the blood-brain barrier, which controls central drug access. Whether high D2/3 receptor occupancies are primarily accounted for by age- or disease-specific blood-brain barrier disruption is unclear, and this is an important future area of future investigation, as it has implications beyond antipsychotic prescribing.
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Affiliation(s)
- Suzanne Reeves
- Division of Psychiatry, 149 Tottenham Court Road, London W1T 7NF, University College London, UK.,Department of Old Age Psychiatry, London, SE58AF, Kings College London, UK
| | - Emma McLachlan
- Department of Old Age Psychiatry, London, SE58AF, Kings College London, UK
| | - Julie Bertrand
- UMR 1137 IAME INSERM University Paris 7, France; and Genetics Institute, WC1E6BT, University College London, UK
| | - Fabrizia D'Antonio
- Division of Psychiatry, 149 Tottenham Court Road, London W1T 7NF, University College London, UK.,Department of Old Age Psychiatry, London, SE58AF, Kings College London, UK
| | - Stuart Brownings
- Division of Psychiatry, 149 Tottenham Court Road, London W1T 7NF, University College London, UK
| | - Akshay Nair
- Division of Psychiatry, 149 Tottenham Court Road, London W1T 7NF, University College London, UK
| | - Suki Greaves
- South London and Maudsley NHS Foundation Trust, London, SE58AZ, UK
| | - Alan Smith
- South London and Maudsley NHS Foundation Trust, London, SE58AZ, UK
| | - David Taylor
- South London and Maudsley NHS Foundation Trust, London, SE58AZ, UK
| | - Joel Dunn
- Division of Imaging Sciences, St Thomas Hospital, London, SE17EH, UK
| | - Paul Marsden
- Division of Imaging Sciences, St Thomas Hospital, London, SE17EH, UK
| | | | - Robert Howard
- Division of Psychiatry, 149 Tottenham Court Road, London W1T 7NF, University College London, UK.,Department of Old Age Psychiatry, London, SE58AF, Kings College London, UK
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Urquhart J, Vrijens B. Commentary on "A Framework for Quantifying the Influence of Adherence and Dose Individualization". Clin Pharmacol Ther 2015; 99:354-6. [PMID: 26575322 DOI: 10.1002/cpt.304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 11/10/2015] [Accepted: 11/12/2015] [Indexed: 11/10/2022]
Abstract
Drugs that provide long durations of action after a last-taken dose are said to be "forgiving," as they allow the patient a degree of latitude in the timing of sequential doses. New research, by Assawasuwannakit et al.,(1) based on exemplary methods, enriches the pharmacometric analysis of forgiveness, which for several decades had been a simply descriptive reminder that the beneficial actions of some drugs can continue for hours or days after the disappearance of detectable drug.
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Affiliation(s)
- J Urquhart
- WestRock Healthcare, Visé, Belgium.,Department of Bioengineering & Therapeutic Sciences, UCSF, San Francisco, California, USA
| | - B Vrijens
- WestRock Healthcare, Visé, Belgium.,University of Liège, Belgium
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