1
|
Boelig RC, Lam K, Rochani A, Soni V, Kaushal G, Kraft WK. Azithromycin Dosing and Preterm premature rupture of membranes Treatment (ADAPT): A randomized controlled Phase I trial. Am J Obstet Gynecol MFM 2024:101423. [PMID: 38977063 DOI: 10.1016/j.ajogmf.2024.101423] [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: 06/19/2024] [Accepted: 07/01/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Seven days of antibiotics are recommended in the setting of preterm premature rupture of membranes (PPROM) to promote latency. Azithromycin has generally replaced a seven-day course of erythromycin in current clinical practice. Azithromycin clears from plasma quickly and concentrates in local tissue which is why daily dosing is not always needed and local tissue, rather than plasma, concentrations are used to determine dosing. Based on limited pharmacokinetic studies in pregnancy, 1g one time dose of azithromycin may not maintain local (amniotic fluid) drug concentrations above minimum inhibitory concentrations (MIC50) for common genitourinary pathogens (50-500ng/ml). OBJECTIVE We aim to compare the pharmacokinetics of one-time vs daily dosing of azithromycin in the setting of preterm pre-labor rupture of membranes (PPROM) STUDY DESIGN: This is a randomized clinical trial of singletons with PPROM randomized to 1gram oral azithromycin once or 500mg oral azithromycin daily x7 days. Primary outcome was amniotic fluid azithromycin concentrations over 8 days. Secondary outcomes included plasma azithromycin trough concentrations. Plasma was collected at time points 1-4hrs and 12-24hrs after first dose, and then every 24hrs through 8 days. Amniotic fluid was collected opportunistically throughout the day noninvasively with Always Flex-foam pads. We aimed to enroll 20 participants to achieve N=5 still pregnant through 8 days in each group. Continuous variables compared with Mann Whitney U test and relationship between azithromycin concentration and time assessed with linear regression. RESULTS The study was halted after N=6 enrolled due to lagging enrollment, with 3 in each group. The mean gestational age of enrollment was 27.1±1.7weeks in the 1g group and 31.0±1.4 weeks in the 500mg daily group. One participant in each group had latency to delivery >7days. Regarding amniotic fluid azithromycin concentration, there was a difference in change in amniotic fluid azithromycin concentration over time between groups (p<0.001). Amniotic fluid concentration of azithromycin was relatively stable in the 1g once group (B=-0.07 (-0.44 - 0.31), p=0.71), in contrast, amniotic fluid concentration (ng/ml) increased over time (hours) in the 500mg daily group (B=1.3 (0.7 - 1.9), p<0.001). By ≥96hours median amniotic fluid levels of azithromycin were lower in the 1g once dosing group (median 11[7-56]) compared to 500mg daily (median 46 [23-196]), with a median difference -27 (-154 to -1), p=0.03. In plasma, there was higher azithromycin concentration during the first 24hrs with 1g once vs 500mg daily (median difference 637ng/ml (101-1547), p=0.01), however by ≥96hrs plasma azithromycin declined and was virtually undetectable in the 1g once group, while trough plasma levels in the 500mg remained elevated (median difference -207ng/ml (-271 to -155), p=0.03). CONCLUSION 500mg daily dosing of azithromycin maintains higher amniotic fluid concentrations, and more consistently greater than common MICs, over eight days compared to 1g once in the setting of PPROM.
Collapse
Affiliation(s)
- Rupsa C Boelig
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University; Department of Pharmacology, Physiology, and Cancer Biology, Sidney Kimmel Medical College, Thomas Jefferson University.
| | - Kevin Lam
- Department of Pharmacology, Physiology, and Cancer Biology, Sidney Kimmel Medical College, Thomas Jefferson University
| | | | - Viren Soni
- College of Pharmacy, Thomas Jefferson University
| | | | | |
Collapse
|
2
|
Koldeweij C, Kleuskens M, Litjens C, Franklin BD, Scheepers HCJ, de Wildt SN. Perceived barriers and facilitators for model-informed dosing in pregnancy: a qualitative study across healthcare practitioners and pregnant women. BMC Med 2024; 22:248. [PMID: 38886762 PMCID: PMC11184760 DOI: 10.1186/s12916-024-03450-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 05/28/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Most women use medication during pregnancy. Pregnancy-induced changes in physiology may require antenatal dose alterations. Yet, evidence-based doses in pregnancy are missing. Given historically limited data, pharmacokinetic models may inform pregnancy-adjusted doses. However, implementing model-informed doses in clinical practice requires support from relevant stakeholders. PURPOSE To explore the perceived barriers and facilitators for model-informed antenatal doses among healthcare practitioners (HCPs) and pregnant women. METHODS Online focus groups and interviews were held among healthcare practitioners (HCPs) and pregnant women from eight countries across Europe, Africa and Asia. Purposive sampling was used to identify pregnant women plus HCPs across various specialties prescribing or providing advice on medication to pregnant women. Perceived barriers and facilitators for implementing model-informed doses in pregnancy were identified and categorised using a hybrid thematic analysis. RESULTS Fifty HCPs and 11 pregnant women participated in 12 focus groups and 16 interviews between January 2022 and March 2023. HCPs worked in the Netherlands (n = 32), the UK (n = 7), South Africa (n = 5), Uganda (n = 4), Kenya, Cameroon, India and Vietnam (n = 1 each). All pregnant women resided in the Netherlands. Barriers and facilitators identified by HCPs spanned 14 categories across four domains whereas pregnant women described barriers and facilitators spanning nine categories within the same domains. Most participants found current antenatal dosing information inadequate and regarded model-informed doses in pregnancy as a valuable and for some, much-needed addition to antenatal care. Although willingness-to-follow model-informed antenatal doses was high across both groups, several barriers for implementation were identified. HCPs underlined the need for transparent model validation and endorsement of the methodology by recognised institutions. Foetal safety was deemed a critical knowledge gap by both groups. HCPs' information needs and preferred features for model-informed doses in pregnancy varied. Several pregnant women expressed a desire to access information and partake in decisions on antenatal dosing. CONCLUSIONS Given the perceived limitations of current pharmacotherapy for pregnant women and foetuses, model-informed dosing in pregnancy was seen as a promising means to enhance antenatal care by pregnant women and healthcare practitioners.
Collapse
Affiliation(s)
- Charlotte Koldeweij
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Mirèse Kleuskens
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carlijn Litjens
- Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, The Netherlands
| | - Bryony Dean Franklin
- Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, UK
- Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Hubertina C J Scheepers
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Grow, School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Saskia N de Wildt
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pediatric and Neonatal Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| |
Collapse
|
3
|
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.
Collapse
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.
| |
Collapse
|
4
|
Guinn D, Sahin L, Fletcher EP, Choi SY, Johnson T, Dinatale M, Baisden K, Sun W, Pillai VC, Morales JP, Yao L. Pharmacokinetic Evaluation in Pregnancy-Current Status and Future Considerations: Workshop Summary. J Clin Pharmacol 2023; 63 Suppl 1:S7-S17. [PMID: 37317499 DOI: 10.1002/jcph.2230] [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: 12/06/2022] [Accepted: 01/03/2023] [Indexed: 06/16/2023]
Abstract
As pregnant individuals have traditionally been excluded from clinical trials, there is a gap in knowledge at the time of drug approval regarding safety, efficacy, and appropriate dosing for most prescription medications used during pregnancy. Physiologic changes in pregnancy can result in changes in pharmacokinetics that can impact safety or efficacy. This highlights the need to foster further research and collection of pharmacokinetic data in pregnancy to ensure appropriate drug dosing in pregnant individuals. Therefore, the US Food and Drug Administration and the University of Maryland Center of Excellence in Regulatory Science and Innovation hosted a workshop on May 16 and 17, 2022, titled "Pharmacokinetic Evaluation in Pregnancy." This is a summary of the workshop proceedings.
Collapse
Affiliation(s)
- Daphne Guinn
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Leyla Sahin
- Division of Pediatric and Maternal Health, Office of Drug Evaluation IV, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Elimika Pfuma Fletcher
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Su-Young Choi
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Tamara Johnson
- Division of Pediatric and Maternal Health, Office of Drug Evaluation IV, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Miriam Dinatale
- Division of Pediatric and Maternal Health, Office of Drug Evaluation IV, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Kristie Baisden
- Division of Pediatric and Maternal Health, Office of Drug Evaluation IV, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Wenjie Sun
- Division of Pediatric and Maternal Health, Office of Drug Evaluation IV, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Venkateswaran C Pillai
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jose Pablo Morales
- Office of Clinical Policy, Office of the Commissioner, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lynne Yao
- Division of Pediatric and Maternal Health, Office of Drug Evaluation IV, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| |
Collapse
|
5
|
Luterbach CL, Rao GG. Use of pharmacokinetic/pharmacodynamic approaches for dose optimization: a case study of plazomicin. Curr Opin Microbiol 2022; 70:102204. [PMID: 36122516 DOI: 10.1016/j.mib.2022.102204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/11/2022] [Accepted: 08/16/2022] [Indexed: 01/25/2023]
Abstract
With limited treatment options available for multidrug-resistant bacteria, dose optimization is critical for achieving effective drug concentrations at the site of infection. Yet, selecting an appropriate dose and appropriate time to administer the dose with dosing frequency requires extensive understanding of the interplay between drug pharmacokinetics/pharmacodynamics (PK/PD), the host immune system, and bacterial-resistant mechanisms. Model-informed dose optimization (MIDO) uses PK/PD models (e.g. population PK, mechanism-based models, etc.) that incorporate preclinical and clinical data to simulate/predict performance of treatment regimens in appropriate patient populations and/or infection types that may not be well-represented in clinical trials. Here, we highlight the stages of a MIDO approach for designing optimized regimens by reviewing current clinical, preclinical, and PK/PD modeling data available for plazomicin. Plazomicin is an aminoglycoside approved in 2018 for the treatment of complicated urinary tract infections in adults. Applying knowledge gained by PK/PD modeling can guide therapeutic drug monitoring to ensure that drug exposure is appropriate for clinical efficacy while limiting drug-related toxicity.
Collapse
Affiliation(s)
- Courtney L Luterbach
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina, Chapel Hill, NC, United States; Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC, United States
| | - Gauri G Rao
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina, Chapel Hill, NC, United States.
| |
Collapse
|
6
|
Allegaert K. Pharmacotherapy during Pregnancy, Childbirth, and Lactation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11336. [PMID: 36141608 PMCID: PMC9517125 DOI: 10.3390/ijerph191811336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/06/2022] [Indexed: 06/16/2023]
Abstract
Pharmacotherapy is a very powerful approach to truly improve outcomes for pregnant women and their newborns [...].
Collapse
Affiliation(s)
- Karel Allegaert
- Child and Youth Institute, KU Leuven, Herestraat 49, 3000 Leuven, Belgium; ; Tel.: +32-(0)-1634-2020
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus Medical Center, 3000 GA Rotterdam, The Netherlands
| |
Collapse
|
7
|
Zhou J, You X, Guo G, Ke M, Xu J, Ye L, Wu W, Huang P, Lin C. Ceftaroline Dosage Optimized for Pediatric Patients With Renal Impairment Using Physiologically Based Pharmacokinetic Modeling. J Clin Pharmacol 2021; 61:1646-1656. [PMID: 34329494 DOI: 10.1002/jcph.1944] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 07/26/2021] [Indexed: 11/07/2022]
Abstract
Ceftaroline fosamil is a fifth-generation cephalosporin approved as a treatment for adults and children with community-acquired bacterial pneumonia and acute bacterial skin and skin structure infections. However, its pharmacokinetics have not been fully evaluated in children with renal impairment. This study aimed to propose proper ceftaroline dosages optimized for the renally impaired pediatric population using physiologically based pharmacokinetic (PBPK) modeling. A PBPK model of ceftaroline was established and verified to simulate its disposition in the healthy population and renally impaired adults and to predict the exposure in renally impaired pediatric patients. Consistency was confirmed between simulated and observed data after intravenous administration of various ceftaroline regimens; fold errors were within the 2-fold error range. Among 6-year-old children, healthy subjects had 1.5-fold, 2-fold, and 2.6-fold lower areas under the plasma concentration-time curve (AUCs) than the moderate, severe, and end-stage renally impaired patient groups, respectively; among 1-year-old children, healthy subjects had 1.5-fold, 2.1-fold, and 2.5-fold lower AUCs than the respective renally impaired patient groups; among 1-month-old children, healthy subjects had 1.5-fold, 1.8-fold, and 2.2-fold lower AUCs than the respective renally impaired patient groups. The proposed dosage should be adjusted to 8, 6, and 5 mg/kg every 8 hours for patients aged ≥2 years to <18 years (≤33 kg) with moderate, severe, and end-stage renal impairment, respectively; 5, 4, and 3 mg/kg every 8 hours for patients aged 2 months to <2 years with moderate, severe, and end-stage renal impairment, respectively; 4, 3.5, and 2.5 mg/kg every 8 hours for patients 0 to <2 months of age with moderate, severe, and end-stage renal impairment, respectively. Furthermore, pharmacodynamic investigations demonstrated that adequate antimicrobial effects were attained at the proposed doses in 3 age groups. Hence, our PBPK model can be an effective tool to support ceftaroline dosage proposals for renally impaired pediatric patients.
Collapse
Affiliation(s)
- Jie Zhou
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China
| | - Xiang You
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China
| | - Guimu Guo
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China
| | - Meng Ke
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China
| | - Jianwen Xu
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China
| | - Lingling Ye
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China
| | - Wanhong Wu
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China
| | - Pinfang Huang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China
| | - Cuihong Lin
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China
| |
Collapse
|
8
|
Liu XI, Green DJ, van den Anker JN, Rakhmanina NY, Ahmadzia HK, Momper JD, Park K, Burckart GJ, Dallmann A. Mechanistic Modeling of Placental Drug Transfer in Humans: How Do Differences in Maternal/Fetal Fraction of Unbound Drug and Placental Influx/Efflux Transfer Rates Affect Fetal Pharmacokinetics? Front Pediatr 2021; 9:723006. [PMID: 34733804 PMCID: PMC8559552 DOI: 10.3389/fped.2021.723006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/13/2021] [Indexed: 01/16/2023] Open
Abstract
Background: While physiologically based pharmacokinetic (PBPK) models generally predict pharmacokinetics in pregnant women successfully, the confidence in predicting fetal pharmacokinetics is limited because many parameters affecting placental drug transfer have not been mechanistically accounted for. Objectives: The objectives of this study were to implement different maternal and fetal unbound drug fractions in a PBPK framework; to predict fetal pharmacokinetics of eight drugs in the third trimester; and to quantitatively investigate how alterations in various model parameters affect predicted fetal pharmacokinetics. Methods: The ordinary differential equations of previously developed pregnancy PBPK models for eight drugs (acyclovir, cefuroxime, diazepam, dolutegravir, emtricitabine, metronidazole, ondansetron, and raltegravir) were amended to account for different unbound drug fractions in mother and fetus. Local sensitivity analyses were conducted for various parameters relevant to placental drug transfer, including influx/efflux transfer clearances across the apical and basolateral membrane of the trophoblasts. Results: For the highly-protein bound drugs diazepam, dolutegravir and ondansetron, the lower fraction unbound in the fetus vs. mother affected predicted pharmacokinetics in the umbilical vein by ≥10%. Metronidazole displayed blood flow-limited distribution across the placenta. For all drugs, umbilical vein concentrations were highly sensitive to changes in the apical influx/efflux transfer clearance ratio. Additionally, transfer clearance across the basolateral membrane was a critical parameter for cefuroxime and ondansetron. Conclusion: In healthy pregnancies, differential protein binding characteristics in mother and fetus give rise to minor differences in maternal-fetal drug exposure. Further studies are needed to differentiate passive and active transfer processes across the apical and basolateral trophoblast membrane.
Collapse
Affiliation(s)
- Xiaomei I. Liu
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, United States
| | - Dionna J. Green
- Office of Pediatric Therapeutics, Office of the Commissioner, US Food and Drug Administration, Silver Spring, MD, United States
| | - John N. van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, United States
| | - Natella Y. Rakhmanina
- Division of Infectious Diseases, Children's National Hospital, Washington, DC, United States
- Technical Strategies and Innovation, Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States
| | - Homa K. Ahmadzia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, School of Medicine and Health Sciences, The George Washington University, Washington, DC, United States
| | - Jeremiah D. Momper
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, United States
| | - Kyunghun Park
- Office of Clinical Pharmacology, US Food and Drug Administration, Silver Spring, MD, United States
| | - Gilbert J. Burckart
- Office of Clinical Pharmacology, US Food and Drug Administration, Silver Spring, MD, United States
| | - André Dallmann
- Pharmacometrics/Modeling and Simulation, Research and Development, Pharmaceuticals, Bayer AG, Leverkusen, Germany
| |
Collapse
|
9
|
Mian P, Nolan B, van den Anker JN, van Calsteren K, Allegaert K, Lakhi N, Dallmann A. Mechanistic Coupling of a Novel in silico Cotyledon Perfusion Model and a Physiologically Based Pharmacokinetic Model to Predict Fetal Acetaminophen Pharmacokinetics at Delivery. Front Pediatr 2021; 9:733520. [PMID: 34631628 PMCID: PMC8496351 DOI: 10.3389/fped.2021.733520] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/20/2021] [Indexed: 01/24/2023] Open
Abstract
Little is known about placental drug transfer and fetal pharmacokinetics despite increasing drug use in pregnant women. While physiologically based pharmacokinetic (PBPK) models can help in some cases to shed light on this knowledge gap, adequate parameterization of placental drug transfer remains challenging. A novel in silico model with seven compartments representing the ex vivo cotyledon perfusion assay was developed and used to describe placental transfer and fetal pharmacokinetics of acetaminophen. Unknown parameters were optimized using observed data. Thereafter, values of relevant model parameters were copied to a maternal-fetal PBPK model and acetaminophen pharmacokinetics were predicted at delivery after oral administration of 1,000 mg. Predictions in the umbilical vein were evaluated with data from two clinical studies. Simulations from the in silico cotyledon perfusion model indicated that acetaminophen accumulates in the trophoblasts; simulated steady state concentrations in the trophoblasts were 4.31-fold higher than those in the perfusate. The whole-body PBPK model predicted umbilical vein concentrations with a mean prediction error of 24.7%. Of the 62 concentration values reported in the clinical studies, 50 values (81%) were predicted within a 2-fold error range. In conclusion, this study presents a novel in silico cotyledon perfusion model that is structurally congruent with the placenta implemented in our maternal-fetal PBPK model. This allows transferring parameters from the former model into our PBPK model for mechanistically exploring whole-body pharmacokinetics and concentration-effect relationships in the placental tissue. Further studies should investigate acetaminophen accumulation and metabolism in the placenta as the former might potentially affect placental prostaglandin synthesis and subsequent fetal exposure.
Collapse
Affiliation(s)
- Paola Mian
- Department of Clinical Pharmacy, Medisch Spectrum Twente, Enschede, Netherlands
| | - Bridget Nolan
- Department of Obstetrics and Gynecology, Richmond University Medical Center, Staten Island, NY, United States
- Department of Obstetrics and Gynecology, New York Medical College, Valhalla, NY, United States
| | - John N. van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, United States
- Department of Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, Basel, Switzerland
| | - Kristel van Calsteren
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Gynecology and Obstetrics, UZ Gasthuisberg, Leuven, Belgium
| | - 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 Medical Center Rotterdam, Rotterdam, Netherlands
| | - Nisha Lakhi
- Department of Obstetrics and Gynecology, Richmond University Medical Center, Staten Island, NY, United States
- Department of Obstetrics and Gynecology, New York Medical College, Valhalla, NY, United States
| | - André Dallmann
- Pharmacometrics/Modeling and Simulation, Research and Development, Pharmaceuticals, Bayer AG, Leverkusen, Germany
| |
Collapse
|
10
|
Szeto KX, Le Merdy M, Dupont B, Bolger MB, Lukacova V. PBPK Modeling Approach to Predict the Behavior of Drugs Cleared by Kidney in Pregnant Subjects and Fetus. AAPS JOURNAL 2021; 23:89. [PMID: 34169370 PMCID: PMC8225528 DOI: 10.1208/s12248-021-00603-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/27/2021] [Indexed: 12/21/2022]
Abstract
The purpose of this study was to develop a physiologically based pharmacokinetic (PBPK) model predicting the pharmacokinetics (PK) of different compounds in pregnant subjects. This model considers the differences in tissue sizes, blood flow rates, enzyme expression levels, glomerular filtration rates, plasma protein binding, and other factors affected during pregnancy in both the maternal and fetal models. The PBPKPlus™ module in GastroPlus® was used to model the PK of cefuroxime and cefazolin. For both compounds, the model was first validated against PK data in healthy non-pregnant volunteers and then applied to predict pregnant groups PK. The model accurately described the PK in both non-pregnant and pregnant groups and explained well differences in the plasma concentration due to pregnancy. The fetal plasma and amniotic fluid concentrations were also predicted reasonably well at different stages of pregnancy. This work describes the use of a PBPK approach for drug development and demonstrates the ability to predict differences in PK in pregnant subjects and fetal exposure for compounds excreted renally. The prediction for pregnant groups is also improved when the model is calibrated with postpartum or non-pregnant female group if such data are available.
Collapse
Affiliation(s)
- Ke Xu Szeto
- Simulations Plus, Inc., 42505 10th Street West, Lancaster, California, 93534, USA
| | - Maxime Le Merdy
- Simulations Plus, Inc., 42505 10th Street West, Lancaster, California, 93534, USA
| | - Benjamin Dupont
- PhinC Development, 36 Rue Victor Basch, 91300, Massy, France
| | - Michael B Bolger
- Simulations Plus, Inc., 42505 10th Street West, Lancaster, California, 93534, USA
| | - Viera Lukacova
- Simulations Plus, Inc., 42505 10th Street West, Lancaster, California, 93534, USA.
| |
Collapse
|