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Tropea T, Mavichak W, Evangelinos A, Brennan-Richardson C, Cottrell EC, Myers JE, Johnstone ED, Brownbill P. Fetoplacental vascular effects of maternal adrenergic antihypertensive and cardioprotective medications in pregnancy. J Hypertens 2023; 41:1675-1687. [PMID: 37694528 PMCID: PMC10552840 DOI: 10.1097/hjh.0000000000003532] [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: 03/16/2023] [Revised: 06/07/2023] [Accepted: 07/24/2023] [Indexed: 09/12/2023]
Abstract
Maternal cardiovascular diseases, including hypertension and cardiac conditions, are associated with poor fetal outcomes. A range of adrenergic antihypertensive and cardioprotective medications are often prescribed to pregnant women to reduce major maternal complications during pregnancy. Although these treatments are not considered teratogenic, they may have detrimental effects on fetal growth and development, as they cross the fetoplacental barrier, and may contribute to placental vascular dysregulation. Medication risk assessment sheets do not include specific advice to clinicians and women regarding the safety of these therapies for use in pregnancy and the potential off-target effects of adrenergic medications on fetal growth have not been rigorously conducted. Little is known of their effects on the fetoplacental vasculature. There is also a dearth of knowledge on adrenergic receptor activation and signalling within the endothelium and vascular smooth muscle cells of the human placenta, a vital organ in the maintenance of adequate blood flow to satisfy fetal growth and development. The fetoplacental circulation, absent of sympathetic innervation, and unique in its reliance on endocrine, paracrine and autocrine influence in the regulation of vascular tone, appears vulnerable to dysregulation by adrenergic antihypertensive and cardioprotective medications compared with the adult peripheral circulation. This semi-systematic review focuses on fetoplacental vascular expression of adrenergic receptors, associated cell signalling mechanisms and predictive consequences of receptor activation/deactivation by antihypertensive and cardioprotective medications.
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Affiliation(s)
- Teresa Tropea
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Weerawaroon Mavichak
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Angelos Evangelinos
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Charlotte Brennan-Richardson
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Elizabeth C. Cottrell
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Jenny E. Myers
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Edward D. Johnstone
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Paul Brownbill
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Song Y, Wang W, Liu X, Chen J, Chen D, Wang X, Li W, Ouyang D. Physiologically Based Pharmacokinetic Modeling for Multiple Oral Administration Labetalol in Pregnant Women. Pharm Res 2023; 40:1765-1775. [PMID: 37142805 DOI: 10.1007/s11095-023-03523-y] [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: 12/27/2022] [Accepted: 04/13/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Labetalol has an irreplaceable role in treating Hypertensive disorders of pregnancy (HDP), a common disease during pregnancy with a prevalence of 5.2-8.2%. However, there were big differences in dosage regimens between various guidelines. PURPOSE A physiologically-based pharmacokinetics (PBPK) model was established and validated to evaluate the existing oral dosage regimens, and to compare the difference in plasma concentration between pregnant and non-pregnant women. METHODS First, non-pregnant woman models with specific plasma clearance or enzymatic metabolism (UGT1A1, UGT2B7, CYP2C19) were established and validated. For CYP2C19, slow, intermediate, and rapid metabolic phenotypes were considered. Then, a pregnant model with proper structure and parameters adjustment was established and validated against the multiple oral administration data. RESULTS The predicted labetalol exposure captured the experimental data well. The following simulations with criteria lowering 15 mmHg blood pressure (corresponding to around 108 ng/ml plasma labetalol) found that the maximum daily dosage in the Chinese guideline may be insufficient for some severe HDP patients. Moreover, similar predicted steady-state trough plasma concentration was found between the maximum daily dosage in the American College of Obstetricians and Gynecologists (ACOG) guideline, 800 mg Q8h and a regimen of 200 mg Q6h. Simulations comparing non-pregnant and pregnant women found that the difference in labetalol exposure highly depended on the CYP2C19 metabolic phenotype. CONCLUSIONS In summary, this work initially established a PBPK model for multiple oral administration of labetalol for pregnant women. This PBPK model may lead to personalized labetalol medication in the future.
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Affiliation(s)
- Yudi Song
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences (ICMS), University of Macau, Macau, China
| | - Wei Wang
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences (ICMS), University of Macau, Macau, China
| | - Xinyang Liu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences (ICMS), University of Macau, Macau, China
| | - Jingsi Chen
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
- Key Laboratories for Major Obstetric Diseases of Guangdong Province, Guangzhou, 510150, China
| | - Dunjin Chen
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
- Key Laboratories for Major Obstetric Diseases of Guangdong Province, Guangzhou, 510150, China
| | - Xiaoyi Wang
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
- Key Laboratories for Major Obstetric Diseases of Guangdong Province, Guangzhou, 510150, China
| | - Wei Li
- Department of Pharmacy, The Third People's Hospital of Shenzhen, Shenzhen, Guangdong, People's Republic of China
| | - Defang Ouyang
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences (ICMS), University of Macau, Macau, China.
- Department of Public Health and Medicinal Administration, Faculty of Health Sciences (FHS), University of Macau, Macau, China.
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van de Vusse D, Mian P, Schoenmakers S, Flint RB, Visser W, Allegaert K, Versmissen J. Pharmacokinetics of the most commonly used antihypertensive drugs throughout pregnancy methyldopa, labetalol, and nifedipine: a systematic review. Eur J Clin Pharmacol 2022; 78:1763-1776. [PMID: 36104450 PMCID: PMC9474278 DOI: 10.1007/s00228-022-03382-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/03/2022] [Indexed: 01/09/2023]
Abstract
Abstract
Purpose
Antihypertensive drugs are among the most prescribed drugs during pregnancy. Methyldopa, labetalol, and nifedipine have been perceived safe to use during pregnancy and are therefore recommended in international guidelines for treatment of hypertension. In this review, we provide a complete overview of what is known on the pharmacokinetics (PK) of the antihypertensive drugs methyldopa, labetalol, and nifedipine throughout pregnancy.
Methods
A systematic search was performed to retrieve studies on the PK of methyldopa, labetalol, and nifedipine used throughout pregnancy. The search was restricted to English and original studies. The systematic search was conducted on July 27, 2021, in Embase, Medline Ovid, Web of Science, Cochrane Library, and Google Scholar. Keywords were methyldopa, labetalol, nifedipine, pharmacokinetics, pregnancy, and placenta.
Results
A total of 1459 unique references were identified of which title and abstract were screened. Based on this screening, 67 full-text papers were assessed, to retain 30 PK studies of which 2 described methyldopa, 12 labetalol, and 16 nifedipine. No fetal accumulation is found for any of the antihypertensive drugs studied.
Conclusion
We conclude that despite decades of prescribing methyldopa, labetalol, and nifedipine throughout pregnancy, descriptions of their PK during pregnancy are hampered by a large heterogeneity in the low number of available studies. Aiming for evidence-based and personalized dosing of antihypertensive medication in the future, further studies on the relationship of both PK and pharmacodynamics (including the optimal blood pressure targeting) during pregnancy and pregnancy-related pathology are urgently needed to prevent undertreatment, overtreatment, and side effects.
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Affiliation(s)
- Dylan van de Vusse
- Department of Internal Medicine, Division of Pharmacology and Vascular Medicine, Erasmus MC University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Clinical Pharmacy, Erasmus MC University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Paola Mian
- Department of Clinical Pharmacy, Erasmus MC University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
- Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Sam Schoenmakers
- Obstetrics and Gynecology, Division Obstetrics and Prenatal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Robert B Flint
- Department of Clinical Pharmacy, Erasmus MC University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
- Pediatrics, Division of Neonatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Willy Visser
- Department of Internal Medicine, Division of Pharmacology and Vascular Medicine, Erasmus MC University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
- Obstetrics and Gynecology, Division Obstetrics and Prenatal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Karel Allegaert
- Department of Clinical Pharmacy, Erasmus MC University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Jorie Versmissen
- Department of Internal Medicine, Division of Pharmacology and Vascular Medicine, Erasmus MC University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
- Department of Clinical Pharmacy, Erasmus MC University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Mulrenin IR, Garcia JE, Fashe MM, Loop MS, Daubert MA, Urrutia RP, Lee CR. The impact of pregnancy on antihypertensive drug metabolism and pharmacokinetics: current status and future directions. Expert Opin Drug Metab Toxicol 2021; 17:1261-1279. [PMID: 34739303 DOI: 10.1080/17425255.2021.2002845] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Hypertensive disorders of pregnancy (HDP) are rising in prevalence, and increase risk of adverse maternal and fetal outcomes. Physiologic changes occur during pregnancy that alter drug pharmacokinetics. However, antihypertensive drugs lack pregnancy-specific dosing recommendations due to critical knowledge gaps surrounding the extent of gestational changes in antihypertensive drug pharmacokinetics and underlying mechanisms. AREAS COVERED This review (1) summarizes currently recommended medications and dosing strategies for non-emergent HDP treatment, (2) reviews and synthesizes existing literature identified via a comprehensive Pubmed search evaluating gestational changes in the maternal pharmacokinetics of commonly prescribed HDP drugs (notably labetalol and nifedipine), and (3) offers insight into the metabolism and clearance mechanisms underlying altered HDP drug pharmacokinetics during pregnancy. Remaining knowledge gaps and future research directions are summarized. EXPERT OPINION A series of small pharmacokinetic studies illustrate higher oral clearance of labetalol and nifedipine during pregnancy. Pharmacokinetic modeling and preclinical studies suggest these effects are likely due to pregnancy-associated increases in hepatic UGT1A1- and CYP3A4-mediated first-pass metabolism and lower bioavailability. Accordingly, higher and/or more frequent doses may be needed to lower blood pressure during pregnancy. Future research is needed to address various evidence gaps and inform the development of more precise antihypertensive drug dosing strategies.
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Affiliation(s)
- Ian R Mulrenin
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Julian E Garcia
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Muluneh M Fashe
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Matthew Shane Loop
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Melissa A Daubert
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Rachel Peragallo Urrutia
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Khatri R, Fallon JK, Sykes C, Kulick N, Rementer RJB, Miner TA, Schauer AP, Kashuba ADM, Boggess KA, Brouwer KLR, Smith PC, Lee CR. Pregnancy-Related Hormones Increase UGT1A1-Mediated Labetalol Metabolism in Human Hepatocytes. Front Pharmacol 2021; 12:655320. [PMID: 33995076 PMCID: PMC8115026 DOI: 10.3389/fphar.2021.655320] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/11/2021] [Indexed: 11/25/2022] Open
Abstract
Pregnancy-related hormones (PRH) are recognized as important regulators of hepatic cytochrome P450 enzyme expression and function. However, the impact of PRH on the hepatic expression and function of uridine diphosphate glucuronosyltransferases (UGTs) remains unclear. Using primary human hepatocytes, we evaluated the effect of PRH exposure on mRNA levels and protein concentrations of UGT1A1, UGT2B7, and other key UGT enzymes, and on the metabolism of labetalol (a UGT1A1 and UGT2B7 substrate commonly prescribed to treat hypertensive disorders of pregnancy). Sandwich-cultured human hepatocytes (SCHH) from female donors were exposed to the PRH estradiol, estriol, estetrol, progesterone, and cortisol individually or in combination. We quantified protein concentrations of UGT1A1, UGT2B7, and four additional UGT1A isoforms in SCHH membrane fractions and evaluated the metabolism of labetalol to its glucuronide metabolites in SCHH. PRH exposure increased mRNA levels and protein concentrations of UGT1A1 and UGT1A4 in SCHH. PRH exposure also significantly increased labetalol metabolism to its UGT1A1-derived glucuronide metabolite in a concentration-dependent manner, which positively correlated with PRH-induced changes in UGT1A1 protein concentrations. In contrast, PRH did not alter UGT2B7 mRNA levels or protein concentrations in SCHH, and formation of the UGT2B7-derived labetalol glucuronide metabolite was decreased following PRH exposure. Our findings demonstrate that PRH alter expression and function of UGT proteins in an isoform-specific manner and increase UGT1A1-mediated labetalol metabolism in human hepatocytes by inducing UGT1A1 protein concentrations. These results provide mechanistic insight into the increases in labetalol clearance observed in pregnant individuals.
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Affiliation(s)
- Raju Khatri
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - John K Fallon
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Craig Sykes
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Natasha Kulick
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Rebecca J B Rementer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Taryn A Miner
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Amanda P Schauer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Angela D M Kashuba
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Kim A Boggess
- Department of Obstetrics and Gynecology, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Kim L R Brouwer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Philip C Smith
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Liu Y, Manners J, Bittar Y, Chou SHY, Gopalakrishnan V. Towards precision critical care management of blood pressure in hemorrhagic stroke patients using dynamic linear models. PLoS One 2019; 14:e0220283. [PMID: 31381589 PMCID: PMC6681940 DOI: 10.1371/journal.pone.0220283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 07/14/2019] [Indexed: 11/18/2022] Open
Abstract
Finding optimal blood pressure (BP) target and BP treatment after acute ischemic or hemorrhagic strokes is an area of controversy and a significant unmet need in the critical care of stroke victims. Numerous large prospective clinical trials have been done to address this question but have generated neutral or conflicting results. One major limitation that may have contributed to so many neutral or conflicting clinical trial results is the "one-size fit all" approach to BP targets, while the optimal BP target likely varies between individuals. We address this problem with the Acute Intervention Model of Blood Pressure (AIM-BP) framework: an individualized, human interpretable model of BP and its control in the acute care setting. The framework consists of two components: one, a model of BP homeostasis and the various effects that perturb it; and two, a parameter estimator that can learn clinically important model parameters on a patient by patient basis. By estimating the parameters of the AIM-BP model for a given patient, the effectiveness of antihypertensive medication can be quantified separately from the patient's spontaneous BP trends. We hypothesize that the AIM-BP is a sufficient framework for estimating parameters of a homeostasis perturbation model of a stroke patient's BP time course and the AIM-BP parameter estimator can do so as accurately and consistently as a state-of-the-art maximum likelihood estimation method. We demonstrate that this is the case in a proof of concept of the AIM-BP framework, using simulated clinical scenarios modeled on stroke patients from real world intensive care datasets.
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Affiliation(s)
- Yuzhe Liu
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Jody Manners
- Department of Neurology, Naval Medical Center Portsmouth, Portsmouth, VA, United States of America
| | - Yazan Bittar
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States of America
| | - Sherry H-Y. Chou
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Vanathi Gopalakrishnan
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States of America
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7
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The effect of labetalol and nifedipine MR on blood pressure in women with chronic hypertension in pregnancy. Pregnancy Hypertens 2018. [PMID: 29523282 DOI: 10.1016/j.preghy.2017.12.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
AIM To compare the blood pressure (BP) lowering effects of labetalol and nifedipine modified release (MR) in hypertensive pregnant women. We also investigated the effect on the heart rate (HR) and determined the proportion of time spent in target. METHODS This was an exploratory study. Women with chronic hypertension taking either labetalol or nifedipine were offered 24-h ambulatory blood pressure monitoring (ABPM). Sleep, wake and drug ingestion times were self-reported. An indirect response model was used to analyse the systolic BP (SBP), diastolic BP (DBP) and HR time-series; the effect of gestation and type of drug was evaluated. RESULTS Forty-eight women were recruited: 24 in each group. There was no difference in clinical characteristics. In women taking nifedipine there was a positive association between the dose of nifedipine and pre-dose BP p = .002, this was not present in the labetalol group. There was a difference between the drug effects on both the SBP and DBP time-series (p = .014). In comparison to labetalol, there was less variation in day time BP in those women prescribed nifedipine. Women on labetalol spent a larger proportion of time with their DBP below target (<80 mmHg). The HR dynamics were qualitatively different, a stimulatory effect was found with nifedipine compared to an inhibitory effect with labetalol. CONCLUSION There are significant and important differences between the BP lowering effects of nifedipine and labetalol. A large randomised control trial is required to investigate the relationship between BP variability and time in target on pregnancy outcomes.
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Amro FH, Moussa HN, Ashimi OA, Sibai BM. Treatment options for hypertension in pregnancy and puerperium. Expert Opin Drug Saf 2016; 15:1635-1642. [DOI: 10.1080/14740338.2016.1237500] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Thewissen L, Pistorius L, Baerts W, Naulaers G, Van Bel F, Lemmers P. Neonatal haemodynamic effects following foetal exposure to labetalol in hypertensive disorders of pregnancy. J Matern Fetal Neonatal Med 2016; 30:1533-1538. [PMID: 27294851 DOI: 10.1080/14767058.2016.1193145] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Hypertensive disorders of pregnancy (HDP) affect foetal outcome. Labetalol is frequently used to lower maternal blood pressure and prolong pregnancy. Conflicting evidence exists for specific neonatal side effects described after maternal labetalol treatment. Our aim was to investigate neonatal effects of foetal exposure to labetalol on cerebral oxygenation and extraction. METHODS In a prospective observational study, clinical characteristics, vital parameters and cerebral oxygen delivery and extraction were collected during the first 24 h of life in labetalol-exposed preterm neonates and compared with two control groups. RESULTS Twenty-two infants with a mean gestational age of 28.9 weeks, born from labetalol-treated mothers with HDP were included and matched with 22 infants with non-labetalol-treated mothers with HDP and 22 infants without maternal HDP. No significant differences between groups were found neither in heart rate, blood pressure and inotropic support, nor in mean regional cerebral oxygen saturation and fractional tissue oxygen extraction. CONCLUSION Foetal labetalol exposure associated effects on preterm heart rate, blood pressure, cerebral oxygenation and extraction are not demonstrated. Maternal disease severity seems to play a more important role in neonatal cerebral haemodynamics. Maternal labetalol treatment has no clinically important short term side effects in the preterm neonate.
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Affiliation(s)
| | - Lou Pistorius
- b Department of Perinatology , University Medical Center Utrecht , Utrecht , Netherlands , and
| | | | - Gunnar Naulaers
- c Department of Neonatology , University Hospitals Leuven , Leuven , Belgium
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10
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Clark SM, Dunn HE, Hankins GDV. A review of oral labetalol and nifedipine in mild to moderate hypertension in pregnancy. Semin Perinatol 2015; 39:548-55. [PMID: 26344738 DOI: 10.1053/j.semperi.2015.08.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hypertension is the most commonly encountered medical condition in pregnancy, contributing significantly to maternal and perinatal morbidity and mortality. Mild to moderate hypertension in pregnancy is defined as systolic blood pressure of 140-159 mmHg or diastolic blood pressure of 90-109 mmHg (7-9% of pregnancies). When treating hypertension in pregnancy, not only do physiologic changes of pregnancy have an effect on the pharmacokinetics and pharmacodynamics of the drugs used, but the pathophysiology of hypertensive disorders of pregnancy also have an effect. To date, evidence is lacking on the pharmacokinetics and pharmacodynamics of commonly used antihypertensive drugs, which often times leads to suboptimal treatment of hypertensive pregnant women. When considering which agents to use for treatment of mild to moderate hypertension, specifically in gestational and chronic hypertension, oral labetalol and nifedipine are valid options. An overview of the profile for use, safety, and current pharmacokinetic data for each agent is presented here.
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Affiliation(s)
- Shannon M Clark
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The University of Texas Medical Branch-Galveston, 301 University Blvd., Route 0587, Galveston, TX 77550.
| | - Holly E Dunn
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The University of Texas Medical Branch-Galveston, 301 University Blvd., Route 0587, Galveston, TX 77550
| | - Gary D V Hankins
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The University of Texas Medical Branch-Galveston, 301 University Blvd., Route 0587, Galveston, TX 77550
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11
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Fischer JH, Sarto GE, Hardman J, Endres L, Jenkins TM, Kilpatrick SJ, Jeong H, Geller S, Deyo K, Fischer PA, Rodvold KA. Influence of gestational age and body weight on the pharmacokinetics of labetalol in pregnancy. Clin Pharmacokinet 2014; 53:373-83. [PMID: 24297680 PMCID: PMC4310214 DOI: 10.1007/s40262-013-0123-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Labetalol is frequently prescribed for the treatment of hypertension during pregnancy; however, the influence of pregnancy on labetalol pharmacokinetics is uncertain, with inconsistent findings reported by previous studies. This study examined the population pharmacokinetics of oral labetalol during and after pregnancy in women receiving labetalol for hypertension. METHODS Data were collected from 57 women receiving the drug for hypertension from the 12th week of pregnancy through 12 weeks postpartum using a prospective, longitudinal design. A sparse sampling strategy guided collection of plasma samples. Samples were assayed for labetalol by high-performance liquid chromatography. Estimation of population pharmacokinetic parameters and covariate effects was performed by nonlinear mixed effects modeling using NONMEM. The final population model was validated by bootstrap analysis and visual predictive check. Simulations were performed with the final model to evaluate the appropriate body weight to guide labetalol dosing. RESULTS Lean body weight (LBW) and gestational age, i.e. weeks of pregnancy, were identified as significantly influencing oral clearance (CL/F) of labetalol, with CL/F ranging from 1.4-fold greater than postpartum values at 12 weeks' gestational age to 1.6-fold greater at 40 weeks. Doses adjusted for LBW provide more consistent drug exposure than doses adjusted for total body weight. The apparent volumes of distribution for the central compartment and at steady-state were 1.9-fold higher during pregnancy. CONCLUSIONS Gestational age and LBW impact the pharmacokinetics of labetalol during pregnancy and have clinical implications for adjusting labetalol doses in these women.
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Affiliation(s)
- James H Fischer
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, 833 S Wood Street, Room 164, Chicago, IL, 60612, USA,
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12
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Höcht C, Bertera FM, Del Mauro JS, Taira CA. Models for evaluating the pharmacokinetics and pharmacodynamics for β-blockers. Expert Opin Drug Metab Toxicol 2014; 10:525-41. [DOI: 10.1517/17425255.2014.885951] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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13
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Influence of gestational diabetes mellitus on the stereoselective kinetic disposition and metabolism of labetalol in hypertensive patients. Eur J Clin Pharmacol 2010; 67:55-61. [PMID: 20848091 DOI: 10.1007/s00228-010-0896-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 08/28/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE This study investigated the influence of gestational diabetes mellitus on the kinetic disposition and stereoselective metabolism of labetalol administered intravenously or orally. METHODS Thirty hypertensive women during the last trimester of pregnancy were divided into four groups: non-diabetic and diabetic women treated with intravenous or oral labetalol. RESULTS The pharmacokinetics of labetalol was not stereoselective in diabetic or non-diabetic pregnant women receiving the drug intravenously. However, oral administration of labetalol resulted in lower values of the area under the plasma concentration versus time curve (AUC) for the β-blocker (RR) than for the other enantiomers in both diabetic and non-diabetic women. Gestational diabetes mellitus caused changes in the kinetic disposition of the labetalol stereoisomers when administered orally. The AUC values for the less potent adrenoceptor antagonist (SS) and for the α-blocking (SR) isomers were higher in diabetic than in non-diabetic pregnant women. CONCLUSIONS The approximately 100% higher AUC values obtained for the (SR) isomer in diabetic pregnant women treated with oral labetalol may be of clinical relevance in terms of the α-blocking activity of this isomer.
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Carvalho TMDJP, Cavalli RDC, Marques MP, Da Cunha SP, Baraldi CDO, Lanchote VL. Stereoselective analysis of labetalol in human plasma by LC-MS/MS: application to pharmacokinetics. Chirality 2009; 21:738-44. [PMID: 19006203 DOI: 10.1002/chir.20673] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Labetalol is clinically available as a mixture of two racemates (four stereoisomers). The stereoisomer (R,R) has as main activity the beta1-antagonism and the stereoisomer (S,R) is highly selective for the alpha1 adrenoceptor and is responsible for most of the alpha-blocker activity. In the present investigation, a method for the analysis of labetalol stereoisomers in human plasma was developed and applied to pharmacokinetic studies. Plasma samples (0.5 ml) were extracted with methyl tert-butyl ether at pH 9.5. The four labetalol stereoisomers were analyzed by LC-MS/MS on a Chirobiotic V column using a mobile phase consisting of methanol, acetic acid, and diethylamine, with a recovery of more than 90% for all four. The quantitation limit was 0.5 ng/ml and linearity was observed at 250 ng/ml plasma for each stereoisomer. Studies of precision and accuracy presented coefficients of variation and percentage inaccuracy of less than 15%, indicating that the method is precise and accurate. The method was applied to the study of the kinetic disposition of labetalol over a period of 12 h after oral administration of a single 100 mg dose to a hypertensive pregnant woman. The clinical study revealed stereoselectivity in the pharmacokinetics of labetalol, with a lower plasma proportion for the active stereoisomers (R,R)-labetalol and (S,R)-labetalol. The stereoselectivity observed after oral administration is due to the hepatic metabolism and the first pass effect, with an AUC(R,R)/AUC(S,S) ratio of 0.5.
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Affiliation(s)
- Teresa Maria De Jesus Ponte Carvalho
- Department of Clinical, Toxicologic, and Bromatologic Analysis, Faculty of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
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Abstract
Hypertensive disorders in pregnancy are a leading cause of maternal and perinatal morbidity and mortality. Overall, hypertension complicates approximately 10% of pregnancies. The incidence is higher in patients with predisposing factors including nulliparity, multiple gestation, preexisting hypertension or diabetes, a previous pregnancy complicated by preeclampsia-eclampsia, familial history of preeclampsia, hydrops fetalis and rapidly growing hydatidiform moles.
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16
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État des connaissances : prise en charge thérapeutique de la prééclampsie. ACTA ACUST UNITED AC 2008; 37:5-15. [DOI: 10.1016/j.jgyn.2007.09.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Revised: 08/23/2007] [Accepted: 09/07/2007] [Indexed: 12/15/2022]
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17
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Dawes M, Chowienczyk PJ. Drugs in pregnancy. Pharmacokinetics in pregnancy. Best Pract Res Clin Obstet Gynaecol 2001; 15:819-26. [PMID: 11800526 DOI: 10.1053/beog.2001.0231] [Citation(s) in RCA: 127] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pharmacokinetics describes the handling of a drug by the body - how the drug is absorbed, distributed and eliminated and how these processes determine plasma concentrations of the drug. Changes in maternal physiology during pregnancy influence pharmacokinetics, and this may have important sequelae for drug dosing, especially for drugs for which adverse effects occur at concentrations within, or just above, the therapeutic range. For many drugs absorption is decreased and elimination increased, thus tending to reduce plasma concentrations. There are, however, relatively few specific data on pharmacokinetics in pregnancy, compared to the non-gravid state, because of the obvious ethical issues surrounding studies during pregnancy. Most therapeutic guidelines are thus based on observational studies and basic principles.
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Affiliation(s)
- M Dawes
- Department of Clinical Pharmacology, St Thomas' Hospital, Lambeth Palace Road, London, SE1 7EH, UK
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18
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Abstract
The modern approach in the field of pharmacokinetics/pharmacodynamics is the development of models based on the mechanisms of drug action and their alteration of physiologic processes. Such models often require consideration of the input and disposition kinetics of the drug, distribution to sites of action (biophase), processes controlling receptor binding or mediator turnover, mechanisms of drug activity, and signal transduction steps. Responses can often be categorized as: Direct (rapidly or slowly reversible), Indirect (inhibitory or stimulatory), or Irreversible. Further, there may be alterations in the system owing to tolerance, counter-regulation, pathophysiology, or physiological changes such as gender or pregnancy. Mathematical and computational tools are necessary for processing data. This article overviews many available pharmacodynamic models with an indication of the diverse approaches for quantitation of pharmacologic responses. Examples from the literature are illustrated with emphasis on changes occurring in kinetics and dynamics during pregnancy.
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Affiliation(s)
- E Wyska
- Department of Pharmaceutical Sciences, State University of New York at Buffalo, USA
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19
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20
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Steffenson MB, Kost TM. Treatment of Pregestational Diabetes Mellitus. J Pharm Pract 1999. [DOI: 10.1177/089719009901200204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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21
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Renwick AG, Lazarus NR. Human variability and noncancer risk assessment- An analysis of the default uncertainty factor. Regul Toxicol Pharmacol 1998; 27:3-20. [PMID: 9618319 DOI: 10.1006/rtph.1997.1195] [Citation(s) in RCA: 197] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A 10-fold uncertainty factor is used for noncancer risk assessments to allow for possible interindividual differences between humans in the fate of the chemical in the body (kinetics) and target organ sensitivity (dynamics). Analysis of a database on the variability in each of these aspects is consistent with an even subdivision of the 10-fold factor into 10(0.5) (3.16) for kinetics and 10(0.5) (3.16) for dynamics. Analysis of the number of subjects in a normally and log-normally distributed population which would not be covered by factors of 3.16 supports this subdivision and also the use of a 10-fold factor to allow for both aspects. Analysis of kinetic data for subgroups of the population indicates that the standard default value of 3.16 for kinetics will not be adequate for all routes of elimination and all groups of the population. A scheme is proposed which would allow the selection of appropriate default uncertainty factors based on knowledge of the biological fate and effects of the chemical under review. Copyright 1998 Academic Press.
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Affiliation(s)
- AG Renwick
- Clinical Pharmacology Group, University of Southampton, Biomedical Sciences Building, Bassett Crescent East, Southampton, SO16 7PX, United Kingdom
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Khedun SM, Moodley J, Naicker T, Maharaj B. Drug management of hypertensive disorders of pregnancy. Pharmacol Ther 1997; 74:221-58. [PMID: 9336024 DOI: 10.1016/s0163-7258(97)82005-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Drugs used in the acute and long-term management of hypertension in pregnancy and the preeclampsia-eclampsia syndrome have been reviewed and their therapeutic effects and maternal and fetal adverse effects have been considered. The review also focuses on recent developments in the areas of prevention and management of pre-eclampsia-eclampsia syndrome. Although a number of new drugs have emerged, as potentially useful in the management of hypertension in pregnancy and pre-eclampsia-eclampsia syndrome, some remain at the cornerstone of therapy; for example, methyldopa for long-term treatment of chronic hypertension, hydralazine or nifedipine for rapid reduction of severely elevated blood pressure, and magnesium sulphate for eclampsia. Some of these agents, especially the calcium antagonists, show promise in that their use is associated with fewer side effects. Safety for the fetus, however, has not been adequately evaluated yet. Neither aspirin nor calcium supplements appear to improve the outcome in pregnancy. Currently, the dilemma whether to treat hypertension in pregnancy and pre-eclampsia-eclampsia syndrome with old, established, cost-effective drugs or the promising newer drugs provides an interesting academic challenge.
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Affiliation(s)
- S M Khedun
- Department of Experimental and Clinical Pharmacology, University of Natal Medical School, Durban, South Africa
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