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Lanoiselée J, Mourer J, Jungling M, Molliex S, Thellier L, Tabareau J, Jeanpierre E, Robin E, Susen S, Tavernier B, Vincentelli A, Ollier E, Moussa MD. Heparin Dosing Regimen Optimization in Veno-Arterial Extracorporeal Membrane Oxygenation: A Pharmacokinetic Analysis. Pharmaceutics 2024; 16:770. [PMID: 38931891 PMCID: PMC11207075 DOI: 10.3390/pharmaceutics16060770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/24/2024] [Accepted: 05/31/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Unfractionated heparin is administered in patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Anticoagulation monitoring is recommended, with an anti-activated factor X (anti-Xa) targeting 0.3 to 0.7 IU/mL. Owing to heparin's heterogeneous pharmacokinetic properties, anti-Xa is unpredictable, generating a challenge in anticoagulation practices. The aim of this study was to build a pharmacokinetic model of heparin accounting for potential confounders, and derive an optimized dosing regimen for a given anti-Xa target. METHODS Adult patients undergoing VA-ECMO were included between January 2020 and June 2021. Anticoagulation was managed with an initial 100 IU/kg heparin loading dose followed by a continuous infusion targeting 0.2 to 0.7 IU/mL anti-Xa. The data were split into model development and model validation cohorts. Statistical analysis was performed using a nonlinear mixed effects modeling population approach. Model-based simulations were performed to develop an optimized dosing regimen targeting the desired anti-Xa. RESULTS A total of 74 patients were included, with 1703 anti-Xa observations. A single-compartment model best fitted the data. Interpatient variability for distribution volume was best explained by body weight, C-reactive protein and ECMO indication (post-cardiotomy shock or medical cardiogenic shock), and interpatient variability for elimination clearance was best explained by serum creatinine and C-reactive protein. Simulations using the optimized regimen according to these covariates showed accurate anti-Xa target attainment. CONCLUSION In adult patients on VA-ECMO, heparin's effect increased with serum creatinine and medical indication, whereas it decreased with body weight and systemic inflammation. We propose an optimized dosing regimen accounting for key covariates, capable of accurately predicting a given anti-Xa target.
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Affiliation(s)
- Julien Lanoiselée
- Department of Anesthesiology and Intensive Care Medicine, Saint-Etienne University Hospital, F-42055 Saint-Etienne, France
- INSERM U1059, Dysfonction Vasculaire et Hémostase, F-42055 Saint-Etienne, France
| | - Jérémy Mourer
- Department of Anesthesiology and Intensive Care Medicine, CHU Lille, F-59000 Lille, France
| | - Marie Jungling
- Department of Cardiac Surgery, CHU Lille, F-59000 Lille, France
| | - Serge Molliex
- Department of Anesthesiology and Intensive Care Medicine, Saint-Etienne University Hospital, F-42055 Saint-Etienne, France
- INSERM U1059, Dysfonction Vasculaire et Hémostase, F-42055 Saint-Etienne, France
| | - Lise Thellier
- Department of Anesthesiology and Intensive Care Medicine, CHU Lille, F-59000 Lille, France
| | - Julien Tabareau
- Department of Anesthesiology and Intensive Care Medicine, CHU Lille, F-59000 Lille, France
| | - Emmanuelle Jeanpierre
- Inserm, CHU Lille, Institut Pasteur de Lille, U1011-EGID, University of Lille, F-59000 Lille, France
| | - Emmanuel Robin
- Department of Anesthesiology and Intensive Care Medicine, CHU Lille, F-59000 Lille, France
| | - Sophie Susen
- Inserm, CHU Lille, Institut Pasteur de Lille, U1011-EGID, University of Lille, F-59000 Lille, France
| | - Benoit Tavernier
- Department of Anesthesiology and Intensive Care Medicine, CHU Lille, F-59000 Lille, France
- ULR 2694-METRICS, Évaluation des Technologies de Santé et des Pratiques Médicales, University of Lille, F-59000 Lille, France
| | - André Vincentelli
- Department of Cardiac Surgery, CHU Lille, F-59000 Lille, France
- Inserm, CHU Lille, Institut Pasteur de Lille, U1011-EGID, University of Lille, F-59000 Lille, France
| | - Edouard Ollier
- INSERM U1059, Dysfonction Vasculaire et Hémostase, F-42055 Saint-Etienne, France
- Unité de Recherche Clinique Innovation et Pharmacologie, Saint-Etienne University Hospital, F-42270 Saint-Etienne, France
| | - Mouhamed Djahoum Moussa
- Department of Anesthesiology and Intensive Care Medicine, CHU Lille, F-59000 Lille, France
- ULR 2694-METRICS, Évaluation des Technologies de Santé et des Pratiques Médicales, University of Lille, F-59000 Lille, France
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Gibert A, Lanoiselée J, Gouin-Thibault I, Pontis A, Azarnoush K, Petrosyan A, Grand N, Molliex S, Morel J, Gergelé L, Hodin S, Bin V, Chaux R, Delavenne X, Ollier E. Factors Influencing Unfractionated Heparin Pharmacokinetics and Pharmacodynamics During a Cardiopulmonary Bypass. Clin Pharmacokinet 2024; 63:211-225. [PMID: 38169065 DOI: 10.1007/s40262-023-01334-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Unfractionated heparin (UFH) is commonly used during cardiac surgery with a cardiopulmonary bypass to prevent blood clotting. However, empirical administration of UFH leads to variable responses. Pharmacokinetic and pharmacodynamic modeling can be used to optimize UFH dosing and perform real-time individualization. In previous studies, many factors that could influence UFH pharmacokinetics/pharmacodynamics had not been taken into account such as hemodilution or the type of UFH. Few covariates were identified probably owing to a lack of statistical power. This study aims to address these limitations through a meta-analysis of individual data from two studies. METHODS An individual patient data meta-analysis was conducted using data from two single-center prospective observational studies, where different UFH types were used for anticoagulation. A pharmacodynamic/pharmacodynamic model of UFH was developed using a non-linear mixed-effects approach. Time-varying covariates such as hemodilution and fluid infusions during a cardiopulmonary bypass were considered. RESULTS Activities of UFH's anti-activated factor/anti-thrombin were best described by a two-compartment model. Unfractionated heparin clearance was influenced by body weight and the specific UFH type. Volume of distribution was influenced by body weight and pre-operative fibrinogen levels. Pharmacodynamic data followed a log-linear model, accounting for the effect of hemodilution and the pre-operative fibrinogen level. Equations were derived from the model to personalize UFH dosing based on the targeted activated clotting time level and patient covariates. CONCLUSIONS The population model effectively characterized UFH's pharmacokinetics/pharmacodynamics in cardiopulmonary bypass patients. This meta-analysis incorporated new covariates related to UFH's pharmacokinetics/pharmacodynamics, enabling personalized dosing regimens. The proposed model holds potential for individualization using a Bayesian estimation.
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Affiliation(s)
- Audrick Gibert
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France.
| | - Julien Lanoiselée
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Isabelle Gouin-Thibault
- Laboratory of Hematology, Pontchaillou, University Hospital of Rennes, University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR_S 1085, Rennes, France
| | - Adeline Pontis
- Laboratory of Hematology, Pontchaillou, University Hospital of Rennes, University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR_S 1085, Rennes, France
| | - Kasra Azarnoush
- Service de Chirurgie Cardiaque, CHU de Saint-Etienne, Saint-Etienne, France
| | - Andranik Petrosyan
- Service de Chirurgie Cardiaque, CHU de Saint-Etienne, Saint-Etienne, France
| | - Nathalie Grand
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Serge Molliex
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Jérome Morel
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Laurent Gergelé
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Sophie Hodin
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
| | - Valérie Bin
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
| | - Robin Chaux
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
- Unité de Recherche Clinique Innovation et Pharmacologie, CHU de Saint-Etienne, Saint-Etienne, France
| | - Xavier Delavenne
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
- Laboratoire de Pharmacologie Toxicologie Gaz du sang, CHU de Saint-Etienne, Saint-Etienne, France
| | - Edouard Ollier
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
- Unité de Recherche Clinique Innovation et Pharmacologie, CHU de Saint-Etienne, Saint-Etienne, France
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Salem AM, Smith T, Wilkes J, Bailly DK, Heyrend C, Profsky M, Yellepeddi VK, Gopalakrishnan M. Pharmacokinetic Modeling Using Real-World Data to Optimize Unfractionated Heparin Dosing in Pediatric Patients on Extracorporeal Membrane Oxygenation and Evaluate Target Achievement-Clinical Outcomes Relationship. J Clin Pharmacol 2024; 64:30-44. [PMID: 37565528 DOI: 10.1002/jcph.2333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/07/2023] [Indexed: 08/12/2023]
Abstract
Unfractionated heparin (UFH) is a commonly used anticoagulant for pediatric patients undergoing extracorporeal membrane oxygenation (ECMO), but evidence is lacking on the ideal dosing. We aimed to (1) develop a population pharmacokinetic (PK) model for UFH, measured through anti-factor Xa assay; (2) optimize UFH starting infusions and dose titrations through simulations; and (3) explore UFH exposure-clinical outcomes relationship. Data from 218 patients admitted to Utah's Primary Children's Hospital were retrospectively collected. A 1-compartment PK model with time-varying clearance (CL) adequately described UFH PK. Weight on CL and volume of distribution and ECMO circuit change on CL were significant covariates. The typical estimates for initial CL and first-order rate constant to reach steady-state CL were 0.57 L/(h·10 kg) and 0.02/h. Comparable to non-ECMO patients, the typical steady-state CL was 0.81 L/(h·10 kg). Simulations showed that a 75 IU/kg UFH bolus dose followed by starting infusions of 25 and 20 IU/h/kg for patients aged younger than 6 years and 6 years or older, respectively, achieved the therapeutic target in 56.6% of all patients, whereas only 3.1% exceeded the target. The proposed UFH titration schemes achieved the target in more than 90% of patients while less than 0.63% were above the target after 24 and 48 hours of treatment. The median intensive care unit survival time in patients within and below the target at 24 hours was 136 and 66 hours, respectively. In conclusion, PK model of UFH was developed for pediatric patients on ECMO. The proposed UFH dosing scheme attained the anti-factor Xa target rapidly and safely.
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Affiliation(s)
- Ahmed M Salem
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Trey Smith
- Department of Pharmacy, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Jacob Wilkes
- Pediatric Analytics, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - David K Bailly
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Caroline Heyrend
- Department of Pharmacy, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Michael Profsky
- Mechanical Circulatory Support, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Venkata K Yellepeddi
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Molecular Pharmaceutics, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Salem AM, Dvergsten E, Karovic S, Maitland ML, Gopalakrishnan M. Model-based approach to identify predictors of paclitaxel-induced myelosuppression in "real-world" administration. CPT Pharmacometrics Syst Pharmacol 2023; 12:929-940. [PMID: 37101403 PMCID: PMC10349185 DOI: 10.1002/psp4.12963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 03/11/2023] [Accepted: 03/22/2023] [Indexed: 04/28/2023] Open
Abstract
Taxanes are currently the most frequently used chemotherapeutic agents in cancer care, where real-world use has focused on minimizing adverse events and standardizing the delivery. Myelosuppression is a well-characterized, adverse pharmacodynamic effect of taxanes. Electronic health records (EHRs) comprise data collected during routine clinical care that include patients with heterogeneous demographic, clinical, and treatment characteristics. Application of pharmacokinetic/pharmacodynamic (PK/PD) modeling to EHR data promises new insights on the real-world use of taxanes and strategies to improve therapeutic outcomes especially for populations who are typically excluded from clinical trials, including the elderly. This investigation: (i) leveraged previously published PK/PD models developed with clinical trial data and addressed challenges to fit EHR data, and (ii) evaluated predictors of paclitaxel-induced myelosuppression. Relevant EHR data were collected from patients treated with paclitaxel-containing chemotherapy at Inova Schar Cancer Institute between 2015 and 2019 (n = 405). Published PK models were used to simulate mean individual exposures of paclitaxel and carboplatin, which were linearly linked to absolute neutrophil count (ANC) using a published semiphysiologic myelosuppression model. Elderly patients (≥70 years) constituted 21.2% of the dataset and 2274 ANC measurements were included in the analysis. The PD parameters were estimated and matched previously reported values. The baseline ANC and chemotherapy regimen were significant predictors of paclitaxel-induced myelosuppression. The nadir ANC and use of supportive treatments, such as growth factors and antimicrobials, were consistent across age quantiles suggesting age had no effect on paclitaxel-induced myelosuppression. In conclusion, EHR data could complement clinical trial data in answering key therapeutic questions.
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Affiliation(s)
- Ahmed M. Salem
- Center for Translational MedicineUniversity of Maryland School of PharmacyBaltimoreMarylandUSA
| | | | | | - Michael L. Maitland
- Inova Schar Cancer InstituteFairfaxVirginiaUSA
- University of Virginia Comprehensive Cancer CenterCharlottesvilleVirginiaUSA
| | - Mathangi Gopalakrishnan
- Center for Translational MedicineUniversity of Maryland School of PharmacyBaltimoreMarylandUSA
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