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Kim Y, Moon S, Rhee SJ. Optimal Once-Daily Busulfan Administration in Pediatric Patients: A Simulation-Based Investigation of Intravenous Infusion Times. Drug Des Devel Ther 2024; 18:871-879. [PMID: 38524879 PMCID: PMC10961087 DOI: 10.2147/dddt.s451970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/08/2024] [Indexed: 03/26/2024] Open
Abstract
Purpose Pediatric patients receiving hematopoietic stem cell transplantation undergo regular administration of intravenous busulfan as a conditioning regimen. Once-daily regimen of busulfan has been proposed as a more convenient alternative to the traditional regimen, but it may increase the risk of toxicity such as veno-occlusive disease (VOD). The study aims to evaluate the pharmacokinetics (PKs) of once-daily regimens and investigate appropriate intravenous infusion times to reduce the risk of toxicity. Patients and methods Once-daily busulfan dosing regimens for pediatric patient were reviewed and selected including EMA- and FDA-based once-daily dosing regimens. We generated busulfan PK data of virtual pediatric patients using a previously developed population PK model. PK profiles and proportion of patients achieving the referenced maximum concentration (Cmax) and exposure to busulfan were used to evaluate the appropriateness of both infusion time and dosing regimens. Results Predicted PK profiles and exposure of busulfan showed relatively similar distributions for all once-daily dosing regimens. Most patients exceeded the referenced Cmax possibly associated with a high risk of VOD with all once-daily regimens when applied with 3 hours of infusion. Conclusion While intravenous infusion of once-daily busulfan is typically administered over 3 hours, our findings emphasize the necessity of considering sufficient infusion times to ensure safe drug utilization and prevent toxicity, which will aid in optimal busulfan use in pediatric oncology.
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Affiliation(s)
- Yun Kim
- College of Pharmacy, Daegu Catholic University, Gyeongsan, 38430, Republic of Korea
| | - Sungha Moon
- College of Pharmacy, Wonkwang University, Iksan, 54538, Republic of Korea
| | - Su-Jin Rhee
- College of Pharmacy, Wonkwang University, Iksan, 54538, Republic of Korea
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Xu B, Zhou J, Zheng Y, Xu R, Liu Q, Li D, Liu M, Wu X. Limited Sampling Strategies for Estimating Busulfan Area Under the Concentration-Time Curve: Based on Peak and Trough Concentrations in Saliva. J Clin Pharmacol 2024; 64:58-66. [PMID: 37697452 DOI: 10.1002/jcph.2345] [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: 06/25/2023] [Accepted: 09/06/2023] [Indexed: 09/13/2023]
Abstract
Therapeutic drug monitoring for busulfan is currently performed by multiple plasma sampling. Saliva is considered a noninvasive therapeutic drug monitoring matrix. This study aimed to investigate intravenous busulfan pharmacokinetics (PK) in plasma and saliva, and establish a limited sampling strategy (LSS) for predicting the area under the concentration-time curve from time zero to infinity in plasma (AUC0-∞,p) by using saliva samples. Therefore, the PK of busulfan was studied in 37 Chinese patients. Pearson correlation analysis was used to evaluate the correlation between the AUC of busulfan in plasma and saliva. LSS models were established by the multiple linear regression analysis. The prediction error, the mean prediction error, and the root mean square error were used to evaluate the predictive accuracy. The agreement between the predicted and observed AUC0-∞ in saliva was investigated by the intraclass correlation coefficient and Bland-Altman analysis. The accuracy and robustness of the models were evaluated by using the bootstrap procedure. The result of PK analysis 62.2% of patients (23/37) was within the target range of AUC0-∞,p . A good correlation between saliva and plasma busulfan AUC0-∞ was observed (r = 0.63, p < .01). The bias and precision of the models 7 and 13 were less than 15%. The intraclass correlation coefficient exceeded 0.9, and the limits of agreement were within ±15%. The 2-point LSS model in saliva is a convenient and desirable approach to predict the AUC0-∞ of 4 times daily intravenous busulfan in plasma, which can be used to design personalized dosing for busulfan.
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Affiliation(s)
- Baohua Xu
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Jianxing Zhou
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - You Zheng
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Ruichao Xu
- Quantitative Clinical Pharmacology, Takeda Development Center Americas, Inc, Lexington, MA, USA
| | - Qingxia Liu
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Dandan Li
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Xuemei Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
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Salman BM, Al Riyami IM, AalHamad AH, Al-Khabori M. Limited Sampling Strategy Using End of Infusion and Six-Hour Concentrations Overestimates Intravenous Busulfan Clearance Compared With Standard Six-Point Sampling in Hematopoietic Stem Cell Transplant Patients. Ther Drug Monit 2023; 45:766-771. [PMID: 37488745 DOI: 10.1097/ftd.0000000000001126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/18/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Therapeutic drug monitoring for busulfan (Bu) is important to improve outcomes of hematopoietic stem cell transplantation. However, standard therapeutic drug monitoring requires multiple samples and is inconvenient, labor-intensive, and costly. Accordingly, a limited sampling strategy (LSS) was evaluated, using 2-point sampling at end of infusion and at 6 hours, and the area-under-the-curve and Bu clearances (CLs) were compared with the results obtained from the standard sampling strategy (SSS) using 5-6 samples. METHOD The analysis was based on retrospective clinical data from 202 patients receiving intravenous Bu before hematopoietic stem cell transplantation for malignant or nonmalignant conditions. Bu plasma concentrations were measured via liquid chromatography tandem-mass spectrometry, and pharmacokinetic parameters were calculated using the PKCNA package in R program. RESULT A total of 502 doses were analyzed by applying SSS and LSS. Using the modified Bland-Altman plot, the mean percentage difference in CL between the SSS and LSS estimates of Bu 6-hourly regimen was -41% (Limits: -53% and -30%). In the once daily regimen, the mean difference in CL between the 2 strategies on the modified Bland-Altman plot was -22% (Limits: -66% and +22%). CONCLUSIONS The Bu CL values estimated based on the BU concentration at end of infusion and at 6 hours postinfusion were significantly higher than the values obtained via the SSS.
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Affiliation(s)
- Bushra Mustafa Salman
- Pharmacy Department, Sultan Qaboos Comprehensive Cancer Care & Research Centre, Muscat, Oman
| | | | | | - Murtadha Al-Khabori
- Department of Hematology, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
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Du X, Huang C, Xue L, Jiao Z, Zhu M, Li J, Lu J, Xiao P, Zhou X, Mao C, Zhu Z, Dong J, Liu X, Chen Z, Zhang S, Ding Y, Hu S, Miao L. The Correlation Between Busulfan Exposure and Clinical Outcomes in Chinese Pediatric Patients: A Population Pharmacokinetic Study. Front Pharmacol 2022; 13:905879. [PMID: 35784763 PMCID: PMC9243314 DOI: 10.3389/fphar.2022.905879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/31/2022] [Indexed: 11/21/2022] Open
Abstract
Aims: The aims of the study were to 1) establish a population pharmacokinetic (Pop-PK) model for busulfan in Chinese pediatric patients undergoing hematopoietic stem cell transplantation (HSCT) and then estimate busulfan exposure and 2) explore the association between busulfan exposure and clinical outcomes. Methods: A total of 128 patients with 467 busulfan concentrations were obtained for Pop-PK modeling using nonlinear mixed effect model (NONMEM) software. Sixty-three patients who received the 16-dose busulfan conditioning regimen were enrolled to explore the correlations between clinical outcomes and the busulfan area under the concentration–time curve (AUC) using the Cox proportional hazards regression model, Kaplan–Meier method and logistic regression. Results: The typical values for clearance (CL) and distribution volume (V) of busulfan were 7.71 L h−1 and 42.4 L, respectively. The allometric normal fat mass (NFM) and maturation function (Fmat) can be used to describe the variability in CL, and the fat-free mass (FFM) can be used to describe the variability in V. Patients with AUCs of 950–1,600 µM × min had 83.7% (95% CI: 73.3–95.5) event-free survival (EFS) compared with 55.0% (95% CI: 37.0–81.8) for patients with low or high exposure (p = 0.024). The logistic regression analysis results showed no association between transplant-related toxicities and the busulfan AUC (p > 0.05). Conclusions: The variability in busulfan CL was related to the NFM and Fmat, while busulfan V was related to the FFM. Preliminary analysis results suggested that a busulfan AUC of 950–1,600 µM × min was associated with better EFS in children receiving the 16-dose busulfan regimen.
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Affiliation(s)
- Xiaohuan Du
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Pharmacy, The Children’s Hospital of Soochow University, Suzhou, China
| | - Chenrong Huang
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute for Interdisciplinary Drug Research and Translational Sciences, College of Pharmaceutical Science, Soochow University, Suzhou, China
| | - Ling Xue
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Pharmacology, University of the Basque Country (UPV/EHU), Leioa, Spain
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Min Zhu
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jie Li
- Department of Hematology and Oncology, The Children’s Hospital of Soochow University, Suzhou, China
| | - Jun Lu
- Department of Hematology and Oncology, The Children’s Hospital of Soochow University, Suzhou, China
| | - Peifang Xiao
- Department of Hematology and Oncology, The Children’s Hospital of Soochow University, Suzhou, China
| | - Xuemei Zhou
- Department of Hematology and Oncology, The Children’s Hospital of Soochow University, Suzhou, China
| | - Chenmei Mao
- Department of Pharmacy, The Children’s Hospital of Soochow University, Suzhou, China
| | - Zengyan Zhu
- Department of Pharmacy, The Children’s Hospital of Soochow University, Suzhou, China
| | - Ji Dong
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoxue Liu
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhiyao Chen
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shichao Zhang
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yiduo Ding
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shaoyan Hu
- Department of Hematology and Oncology, The Children’s Hospital of Soochow University, Suzhou, China
- *Correspondence: Liyan Miao, ; Shaoyan Hu,
| | - Liyan Miao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute for Interdisciplinary Drug Research and Translational Sciences, College of Pharmaceutical Science, Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
- *Correspondence: Liyan Miao, ; Shaoyan Hu,
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Myers AL. VOD/SOS and Alkylating Agents in the Hematopoietic Stem Cell Transplant Setting: New Insights and Further Questions. Transplant Cell Ther 2022; 28:179-180. [PMID: 35365336 DOI: 10.1016/j.jtct.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Alan L Myers
- The University of Texas Health Science Center at Houston, Houston, TX, USA.
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Bognàr T(T, Bartelink I(IH, Egberts T(A, Rademaker C(C, Versluys B(AB, Slatter M(MA, Kletzel M(M, Nath C(CE, Cuvelier G(G, Savic R(RM, Dvorak C(C, Long-Boyle J(JR, Cowan M(MJ, Bittencourt H(H, Bredius R(RGM, Güngör T(T, Shaw P(PJ, Ansari M(M, Hassan M(M, Krajinovic M(M, Hempel G(G, Marktel S(S, Chiesa R(R, Théoret Y(Y, Lund T(T, Orchard P(P, Wynn R(RF, Boelens JJ(J, Lalmohamed A(A. Association between the magnitude of intravenous busulfan exposure and development of hepatic veno-occlusive disease in children and young adults undergoing myeloablative allogeneic hematopoietic cell transplantation. Transplant Cell Ther 2022; 28:196-202. [DOI: 10.1016/j.jtct.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/13/2022] [Accepted: 01/13/2022] [Indexed: 11/30/2022]
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Clinical pharmacology of cytotoxic drugs in neonates and infants: Providing evidence-based dosing guidance. Eur J Cancer 2021; 164:137-154. [PMID: 34865945 PMCID: PMC8914347 DOI: 10.1016/j.ejca.2021.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/11/2021] [Accepted: 11/01/2021] [Indexed: 01/29/2023]
Abstract
Cancer in neonates and infants is a rare but challenging entity. Treatment is complicated by marked physiological changes during the first year of life, excess rates of toxicity, mortality, and late effects. Dose optimisation of chemotherapeutics may be an important step to improving outcomes. Body size–based dosing is used for most anticancer drugs used in infants. However, dose regimens are generally not evidence based, and dosing strategies are frequently inconsistent between tumour types and treatment protocols. In this review, we collate available pharmacological evidence supporting dosing regimens in infants for a wide range of cytotoxic drugs. A systematic review was conducted, and available data ranked by a level of evidence (1–5) and a grade of recommendation (A–D) provided on a consensus basis, with recommended dosing approaches indicated as appropriate. For 9 of 29 drugs (busulfan, carboplatin, cyclophosphamide, daunorubicin, etoposide, fludarabine, isotretinoin, melphalan and vincristine), grade A was scored, indicating sufficient pharmacological evidence to recommend a dosing algorithm for infants. For busulfan and carboplatin, sufficient data were available to recommend therapeutic drug monitoring in infants. For eight drugs (actinomycin D, blinatumomab, dinutuximab, doxorubicin, mercaptopurine, pegaspargase, thioguanine and topotecan), some pharmacological evidence was available to guide dosing (graded as B). For the remaining drugs, including commonly used agents such as cisplatin, cytarabine, ifosfamide, and methotrexate, pharmacological evidence for dosing in infants was limited or non-existent: grades C and D were scored for 10 and 2 drugs, respectively. The review provides clinically relevant evidence-based dosing guidance for cytotoxic drugs in neonates and infants. Treating cancer in neonates and infants is challenging. Dose optimisation of cytotoxic drugs is an important step to improving outcomes. Clinical pharmacological evidence supporting dosing regimens in infants was collated. All available pharmacological evidence was ranked by a level of evidence. A grade of recommendation was derived and a recommended dose per agent provided.
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Neroutsos E, Athanasiadou I, Paisiou A, Zisaki K, Goussetis E, Archontaki H, Tsirigotis P, Kitra M, Grafakos S, Spyridonidis A, Dokoumetzidis A, Valsami G. Dose individualization of intravenous busulfan in pediatric patients undergoing bone marrow transplantation: impact and in vitro evaluation of infusion lag-time. J Pharm Pharmacol 2021; 73:1340-1350. [PMID: 34244783 DOI: 10.1093/jpp/rgab087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/20/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES To apply therapeutic drug monitoring and dose-individualization of intravenous Busulfan to paediatric patients and evaluate the impact of syringe-pump induced Busulfan infusion lag-time after in vitro estimation. METHODS 76 children and adolescents were administered 2 h intravenous Busulfan infusion every 6 h (16 doses). Busulfan plasma levels, withdrawn by an optimized sampling scheme and measured by a validated HPLC-PDA method, were used to estimate basic PK parameters, AUC, Cmax, kel, t1/2, applying Non-Compartmental Analysis. In vivo infusion lag-time was simulated in vitro and used to evaluate its impact on AUC estimation. KEY FINDINGS Mean (%CV) Busulfan AUC, Cmax, clearance and t1/2 for pediatric population were found 962.3 μm × min (33.1), 0.95 mg/L (41.4), 0.27 L/h/kg (33.3), 2.2 h (27.8), respectively. TDM applied to 76 children revealed 6 (7.9%) being above and 25 (32.9%) below therapeutic-range (AUC: 900-1350 μm × min). After dose correction, all patients were measured below toxic levels (AUC < 1500 μm × min), no patient below 900 μm × min. Incorporation of infusion lag-time revealed lower AUCs with 17.1% more patients and 23.1% more younger patients, with body weight <16 kg, being below the therapeutic-range. CONCLUSIONS TDM, applied successfully to 76 children, confirmed the need for Busulfan dose-individualization in paediatric patients. Infusion lag-time was proved clinically significant for younger, low body-weight patients and those close to the lower therapeutic-range limit.
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Affiliation(s)
- E Neroutsos
- Laboratory of Biopharmaceutics & Pharmacokinetics, Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, Athens, Greece
| | - I Athanasiadou
- Laboratory of Biopharmaceutics & Pharmacokinetics, Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, Athens, Greece
| | - A Paisiou
- Bone Marrow Transplantation Unit, "Agia Sophia" General Children's Hospital of Athens, Athens, Greece
| | - K Zisaki
- Bone Marrow Transplantation Unit, "Agia Sophia" General Children's Hospital of Athens, Athens, Greece
| | - E Goussetis
- Bone Marrow Transplantation Unit, "Agia Sophia" General Children's Hospital of Athens, Athens, Greece
| | - H Archontaki
- Laboratory of Analytical Chemistry, Department of Chemistry, School of Sciences, National & Kapodistrian University of Athens, Athens, Greece
| | - P Tsirigotis
- Clinic of Internal Medicine, University Hospital "Attikon", Department of Medicine, School of Health Sciences, National & Kapodistrian University of Athens, Athens, Greece
| | - M Kitra
- Bone Marrow Transplantation Unit, "Agia Sophia" General Children's Hospital of Athens, Athens, Greece
| | - S Grafakos
- Bone Marrow Transplantation Unit, "Agia Sophia" General Children's Hospital of Athens, Athens, Greece
| | - A Spyridonidis
- Bone Marrow Transplant Unit, University Hospital of Patras, Department of Medicine, School of Health Sciences, University of Patras, Rio, Patras, Greece
| | - A Dokoumetzidis
- Laboratory of Biopharmaceutics & Pharmacokinetics, Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, Athens, Greece
| | - G Valsami
- Laboratory of Biopharmaceutics & Pharmacokinetics, Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, Athens, Greece
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Jansing T, Sanpakit K, Tharnpanich T, Jiranantakan T, Niphandwongkorn V, Chindavijak B, Suansanae T. Therapeutic drug monitoring of intravenous busulfan in Thai children undergoing hematopoietic stem cell transplantation: A pilot study. Pediatr Hematol Oncol 2021; 38:346-357. [PMID: 33656974 DOI: 10.1080/08880018.2020.1871136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Busulfan (Bu) is commonly used in myeloablative conditioning regimens for children undergoing hematopoietic stem cell transplantation. The standard target area under the concentration-time curve (AUC) of Bu is approximately 900-1500 µM min. In previous studies using five fixed doses (0.8-1.2 mg/kg) for Bu without dose adjustment, 75% patients achieved the target AUC. The aim of this pilot study was to determine the percentage of target AUC for intravenous (IV) Bu in Thai children. IV Bu was administered every 6 h over 16 doses. Blood samples were collected for pharmacokinetic (PK) analysis after the first, ninth, and thirteenth doses of Bu. Seven patients (2-14 years; median 6 years) were diagnosed with thalassemia (n = 4), acute myeloid leukemia (n = 2), and pure red cell aplasia. Three, two, and two patients received Bu at 1.1, 1.2, and 0.8 mg/kg, respectively. The AUC of Bu varied from 292-1714 µM min (median = 804). Nine (42.86%), eleven (52.38%), and one (4.76%) AUC values were within, below, and above the target, respectively. The median (range) Bu clearance was 5.93 (1.91-14.65) mL/min/kg. In this study, 42.86% AUC value achieved the target, which was lower than that in previous studies. Therapeutic drug monitoring (TDM) of Bu should be considered in Thai children receiving five fixed doses of IV Bu, and dose adjustment should be performed as necessary. Further PK studies for Bu with a larger sample size are warranted for confirming the necessity of TDM in every step dose of Bu.(Trial registration numbers; TCTR20190528003).
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Affiliation(s)
| | - Kleebsabai Sanpakit
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Trai Tharnpanich
- Department of Pharmacy, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thanjira Jiranantakan
- Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Vachira Niphandwongkorn
- Department of Nurse, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Busba Chindavijak
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Thanarat Suansanae
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
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10
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Poinsignon V, Faivre L, Nguyen L, Neven B, Broutin S, Moshous D, Bourget P, Dufour C, Dalle JH, Galambrun C, Devictor B, Kemmel V, De Berranger E, Gandemer V, Vannier JP, Jubert C, Bondu S, Mir O, Petain A, Vassal G, Paci A. New dosing nomogram and population pharmacokinetic model for young and very young children receiving busulfan for hematopoietic stem cell transplantation conditioning. Pediatr Blood Cancer 2020; 67:e28603. [PMID: 32706505 DOI: 10.1002/pbc.28603] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/09/2020] [Accepted: 07/05/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Busulfan (Bu) is the cornerstone of conditioning regimens prior to hematopoietic stem cell transplantation, widely used in both adults and children for the treatment of malignant and nonmalignant diseases. Despite an intravenous formulation, interindividual variability (IIV) remains high and optimal exposure difficult to achieve, especially in neonates and infants. PROCEDURE To ensure both efficacy and safety, we set up in 2005 an observational study designed for children not fully assessed during the drug registration procedure. From a large cohort of 540 patients, we developed a Bu population pharmacokinetic model based on body weight (BW) and maturation concepts to reduce IIV and optimize exposure. A new dosing nomogram was evaluated to better fit the population pharmacokinetic model. RESULTS Bu clearance IIV was significantly decreased from 61.3% (covariate-free model) to 28.6% when combining BW and maturation function. Median Bu area under the curve (AUC) was 1179 µmol/L × min compared to 1025 with the EMA dosing nomogram for children <9 kg. The target AUC was reached for each BW strata, significantly increasing the percentages of patients achieving reaching the targeted AUC as compared to FDA schedule. CONCLUSION This new model made it possible to propose a novel dosing nomogram that better considered children below 16 kg of BW and allowed better initial exposure as compared to existing dosing schedules. This nomogram, which would be easy to use to determine an optimal dosing schedule in daily practice, will need to be validated in clinical routine. Therapeutic drug monitoring remains strongly advisable for small children and those with specific diseases.
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Affiliation(s)
- Vianney Poinsignon
- Département de Biologie et Pathologie Médicale, Service de Pharmacologie, Gustave Roussy, Villejuif, France
| | - Laura Faivre
- Département de Biostatistiques, Gustave Roussy, Villejuif, France
| | - Laurent Nguyen
- Clinical Pharmacokinetics Department, Pierre Fabre Research Institute, Toulouse, France
| | - Benedicte Neven
- Pediatric Immunology and Hematology Department, Hôpital Necker Enfants-Malades, Paris, France
| | - Sophie Broutin
- Département de Biologie et Pathologie Médicale, Service de Pharmacologie, Gustave Roussy, Villejuif, France
| | - Despina Moshous
- Pediatric Immunology and Hematology Department, Hôpital Necker Enfants-Malades, Paris, France
| | - Philippe Bourget
- Pharmacy Department, Hôpital Necker Enfants-Malades, Paris, France
| | - Christelle Dufour
- Département de Cancérologie de l'enfant et l'adolescent, Gustave Roussy, Villejuif, France
| | | | - Claire Galambrun
- Department of Pediatric Hematology, La Timone Hospital, Marseille, France
| | | | - Veronique Kemmel
- Biology Department, Strasbourg Universitary Hospital, Strasbourg, France
| | - Eva De Berranger
- Department of Pediatrics, University Children's Hospital, Lille, France
| | - Virginie Gandemer
- Department of Paediatric Haematology/Oncology, University Hospital of Rennes, Rennes, France
| | - Jean Pierre Vannier
- Paediatric Oncology and Haematology Unit, Charles Nicolle Rouen University Hospital, Rouen, France
| | - Charlotte Jubert
- Department of Pediatric Oncology and Hematology, Hôpital Pellegrin, Bordeaux, France
| | - Sabrina Bondu
- Département de Biologie et Pathologie Médicale, Service de Pharmacologie, Gustave Roussy, Villejuif, France
| | - Olivier Mir
- Département de Biologie et Pathologie Médicale, Service de Pharmacologie, Gustave Roussy, Villejuif, France
| | - Aurelie Petain
- Clinical Pharmacokinetics Department, Pierre Fabre Research Institute, Toulouse, France
| | - Gilles Vassal
- Direction de la Recherche, Gustave Roussy, Villejuif, France
| | - Angelo Paci
- Département de Biologie et Pathologie Médicale, Service de Pharmacologie, Gustave Roussy, Villejuif, France.,Université Paris-Saclay, School of Pharmacy, F-92296, Chatenay-Malabry, France
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11
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Busulfan clearance does not predict the development of hepatic veno-occlusive disease in patients undergoing hematopoietic stem cell transplantation. Int J Hematol 2020; 112:210-216. [PMID: 32468179 DOI: 10.1007/s12185-020-02891-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/01/2020] [Accepted: 05/22/2020] [Indexed: 12/14/2022]
Abstract
Hepatic veno-occlusive disease (VOD) is a life-threatening complication following hematopoietic stem cell transplant (HSCT). Busulfan has a narrow therapeutic index and its concentration was found to correlate with VOD. Our primary objective was to assess the association between busulfan clearance and VOD in HSCT patients. In this retrospective analysis, we included patients who received their HSCT between 2003 and 2014 and followed at Sultan Qaboos University Hospital. All patients who received dose-targeted busulfan-containing conditioning were included. Target steady-state concentration (Css) was 800-900 ng/ml. VOD was assessed using modified Seattle criteria. The impact of busulfan clearance on VOD was analyzed using univariable logistic regression model. Seventy-three patients were included with a mean age of 15 years. Of those, 47% were transplanted for hematological malignancies and 53% for inherited hemoglobinopathies. Target Css was achieved in 85% of patients. The rate of VOD was 17%. There was no significant impact of busulfan clearance (p = 0.919) or area-under-the-concentration-time-curve (p = 0.275) on VOD. Targeting busulfan Css into narrow therapeutic range may have accounted for the findings. The risk of VOD might be related to other factors such as the genetic background, and more studies are required to investigate these factors.
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12
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Jinjie Y, Sun N, Zhang S, Feng X, Chen X, Zhao D, Zhao L. A rapid HPLC-MS/MS method for determining busulfan in hemolytic samples from children with hematopoietic stem cell transplantation. Biomed Chromatogr 2020; 34:e4898. [PMID: 32428257 DOI: 10.1002/bmc.4898] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 05/09/2020] [Accepted: 05/13/2020] [Indexed: 11/10/2022]
Abstract
A rapid and sensitive method for the quantitative detection of busulfan (BU) in children's hemolytic samples by HPLC-tandem mass spectrometry (MS/MS) was established. In this study, the sample preparation procedure involved a one-step protein precipitation with acetonitrile (ACN) solution, and the HPLC-MS/MS method used Hypersil GOLD C18 . The mobile phase consisted of 10 mM ammonium acetate solution (containing 0.1% formic acid) and ACN with a flow rate of 0.4 mL/min. Multiple reaction monitoring modes were used for quantitative analysis and the ion pairs of BU and BU-d8 were m/z 263.9 → 150.9 and 272.0 → 159.0, respectively. BU had a good linearity in the range of 0.01-10 μg mL-1 . The intra- and inter-day relative error was between -7.21% and 8.26%, and the coefficient of variation was less than 12.64%. The average extraction recovery rate in plasma samples was 99.76% ± 6.53%, and the matrix in normal plasma and hemolyzed plasma had no significant effect on the detection results. Normal and hemolytic samples could maintain good stability at 4, 25 and -40°C. As a result, this method is particularly suitable for determining BU in hemolytic samples from children with hematopoietic stem cell transplantation (HSCT), and this study provides the methodological basis for further research on the pharmacokinetics of BU in children with HSCT.
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Affiliation(s)
- Yuan Jinjie
- Clinical Research Center, Beijing Children's Hospital, Capital Medical University, Beijing, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Ning Sun
- Clinical Research Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Shuyu Zhang
- Clinical Research Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xinying Feng
- Phase I Clinical trials Centre, Luoyang Central Hospital Affiliated to Zhengzhou University, Luoyang, China
| | - Xijing Chen
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Di Zhao
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Libo Zhao
- Clinical Research Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
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13
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Feng X, Wu Y, Zhang J, Li J, Zhu G, Fan D, Yang C, Zhao L. Busulfan systemic exposure and its relationship with efficacy and safety in hematopoietic stem cell transplantation in children: a meta-analysis. BMC Pediatr 2020; 20:176. [PMID: 32312247 PMCID: PMC7168843 DOI: 10.1186/s12887-020-02028-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 03/12/2020] [Indexed: 12/04/2022] Open
Abstract
Background Busulfan (Bu) is a key component of several conditioning regimens used before hematopoietic stem cell transplantation (HSCT). However, the optimum systemic exposure (expressed as the area under the concentration-time curve [AUC]) of Bu for clinical outcome in children is controversial. Methods Research on pertinent literature was carried out at PubMed, EMBASE, Web of science, the Cochrane Library and ClinicalTrials.gov. Observational studies were included, which compared clinical outcomes above and below the area under the concentration-time curve (AUC) cut-off value, which we set as 800, 900, 1000, 1125, 1350, and 1500 μM × min. The primary efficacy outcome was notable in the rate of graft failure. In the safety outcomes, incidents of veno-occlusive disease (VOD) were recorded, as well as other adverse events. Results Thirteen studies involving 548 pediatric patients (aged 0.3–18 years) were included. Pooled results showed that, compared with the mean Bu AUC (i.e., the average value of AUC measured multiple times for each patient) of > 900 μM × min, the mean AUC value of < 900 μM × min significantly increased the incidence of graft failure (RR = 3.666, 95% CI: 1.419, 9.467). The incidence of VOD was significantly decreased with the mean AUC < 1350 μM × min (RR = 0.370, 95% CI: 0.205–0.666) and < 1500 μM × min (RR = 0.409, 95% CI: 0182–0.920). Conclusions In children, Bu mean AUC above the cut-off value of 900 μM × min (after every 6-h dosing) was associated with decreased rates of graft failure, while the cut-off value of 1350 μM × min were associated with increased risk of VOD, particularly for the patients without VOD prophylaxis therapy. Further well-designed prospective and multi centric randomized controlled trials with larger sample size are necessary before putting our result into clinical practices.
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Affiliation(s)
- Xinying Feng
- Clinical Research Center, Beijing Children's Hospital, Capital University of Medical Sciences, Beijing, 100045, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, 211198, China
| | - Yunjiao Wu
- Clinical Research Center, Beijing Children's Hospital, Capital University of Medical Sciences, Beijing, 100045, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, 211198, China
| | - Jingru Zhang
- Clinical Research Center, Beijing Children's Hospital, Capital University of Medical Sciences, Beijing, 100045, China
| | - Jiapeng Li
- Clinical Research Center, Beijing Children's Hospital, Capital University of Medical Sciences, Beijing, 100045, China.,Department of Clinical Pharmacy, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Guanghua Zhu
- Department of Hematology and Oncology, Beijing Children's Hospital, Capital University of Medical Sciences, Beijing, 100045, China
| | - Duanfang Fan
- Clinical Research Center, Beijing Children's Hospital, Capital University of Medical Sciences, Beijing, 100045, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, 211198, China
| | - Changqing Yang
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, 211198, China.
| | - Libo Zhao
- Clinical Research Center, Beijing Children's Hospital, Capital University of Medical Sciences, Beijing, 100045, China.
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14
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Population pharmacokinetics of busulfan in Saudi pediatric patients undergoing hematopoietic stem cell transplantation. Int J Clin Pharm 2020; 42:703-712. [PMID: 32140913 DOI: 10.1007/s11096-020-00989-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 02/03/2020] [Indexed: 10/24/2022]
Abstract
Background Busulfan is an antineoplastic drug that is used widely as part of a conditioning regimen in pediatric patients undergoing hematopoietic stem cell transplantation. It has a narrow therapeutic index and highly variable pharmacokinetics; therefore therapeutic drug monitoring is recommended to optimize busulfan dosing. Objective To study the population pharmacokinetics of busulfan in Saudi pediatric patients to optimize its dosing. Settings King Abdullah Specialist Children's Hospital in Riyadh, Saudi Arabia. Methods This pharmacokinetic observational study was conducted between January 2016 and December 2018. All pediatric patients receiving IV busulfan and undergoing routine therapeutic drug monitoring were included. Population pharmacokinetics modeling was conducted using Monolix2019R1. Pharmacokinetic data of busulfan in children. Results The study included 59 patients and 513 samples. The mean ± SD age was 6.10 ± 3.17 years, and the dose administered was 0.994 ± 0.15 mg/kg. The mean ± SD Cmax and area under the curve (AUC) were 900.60 ± 402.8 ng/mL and 1031.14 ± 300.75 µM min, respectively. Based on our simulations, the European Medicines Agency recommended dose were adequate for most patient's groups to achieve the conventional target of an AUC0-tau of 900-1350 µM min. For patients in the lower weight group < 9 kg, higher doses were need at 1.2 mg/kg. With regards to the newly proposed target of AUC 78-101 mg h/mL, all of the doses we tested had low probability of achieving it. Conclusions Most of our patients had less than a proportional increase in busulfan concentration suggesting autoinduction. The high interindividual variability and autoinduction make dose adjustments challenging and AUC at steady state difficult to predict from the first dose. One approach to improve dose predictions is to use Bayesian dosing software. Based on our simulations, the European Medicines Agency recommended doses were adequate for most patient groups, except those in the lower (< 9 kg) and higher weight groups (> 34 kg).
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15
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Chiesa R, Standing JF, Winter R, Nademi Z, Chu J, Pinner D, Kloprogge F, McLellen S, Amrolia PJ, Rao K, Lucchini G, Silva J, Ciocarlie O, Lazareva A, Gennery AR, Doncheva B, Cant AJ, Hambleton S, Flood T, Rogerson E, Devine K, Prunty H, Heales S, Veys P, Slatter M. Proposed Therapeutic Range of Treosulfan in Reduced Toxicity Pediatric Allogeneic Hematopoietic Stem Cell Transplant Conditioning: Results From a Prospective Trial. Clin Pharmacol Ther 2019; 108:264-273. [PMID: 31701524 PMCID: PMC7484914 DOI: 10.1002/cpt.1715] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/28/2019] [Indexed: 12/18/2022]
Abstract
Treosulfan is given off‐label in pediatric allogeneic hematopoietic stem cell transplant. This study investigated treosulfan's pharmacokinetics (PKs), efficacy, and safety in a prospective trial. Pediatric patients (n = 87) receiving treosulfan‐fludarabine conditioning were followed for at least 1 year posttransplant. PKs were described with a two‐compartment model. During follow‐up, 11 of 87 patients died and 12 of 87 patients had low engraftment (≤ 20% myeloid chimerism). For each increase in treosulfan area under the curve from zero to infinity (AUC(0‐∞)) of 1,000 mg hour/L the hazard ratio (95% confidence interval) for mortality increase was 1.46 (1.23–1.74), and the hazard ratio for low engraftment was 0.61 (0.36–1.04). A cumulative AUC(0‐∞) of 4,800 mg hour/L maximized the probability of success (> 20% engraftment and no mortality) at 82%. Probability of success with AUC(0‐∞) between 80% and 125% of this target were 78% and 79%. Measuring PK at the first dose and individualizing the third dose may be required in nonmalignant disease.
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Affiliation(s)
- Robert Chiesa
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Joseph F Standing
- Pharmacy Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK.,Infection, Immunity, and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Robert Winter
- Chemical Pathology Department, Great Ormond Street Hospital for Children,, NHS Foundation Trust, London, UK
| | - Zohreh Nademi
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK.,Bone Marrow Transplantation Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jan Chu
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Danielle Pinner
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Frank Kloprogge
- Institute for Global Health, University College London, London, UK
| | - Susan McLellen
- Clinical Biochemistry, Integrated Laboratory Medicine Directorate, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Persis J Amrolia
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK.,Infection, Immunity, and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Kanchan Rao
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Giovanna Lucchini
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Juliana Silva
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Oana Ciocarlie
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Arina Lazareva
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Andrew R Gennery
- Bone Marrow Transplantation Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Bilyana Doncheva
- Pharmacy Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Andrew J Cant
- Bone Marrow Transplantation Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sophie Hambleton
- Bone Marrow Transplantation Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Terence Flood
- Bone Marrow Transplantation Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Elizabeth Rogerson
- Bone Marrow Transplantation Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Kirsty Devine
- Bone Marrow Transplantation Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Helen Prunty
- Chemical Pathology Department, Great Ormond Street Hospital for Children,, NHS Foundation Trust, London, UK
| | - Simon Heales
- Chemical Pathology Department, Great Ormond Street Hospital for Children,, NHS Foundation Trust, London, UK
| | - Paul Veys
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK.,Infection, Immunity, and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Mary Slatter
- Bone Marrow Transplantation Department, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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16
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Monitoring of Busulphan Concentrations in Children Undergone Hematopoietic Stem Cell Transplantation: Unicentric Experience over 10 years. Eur J Drug Metab Pharmacokinet 2018; 43:173-181. [PMID: 28801891 DOI: 10.1007/s13318-017-0431-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES The aim of this report is to describe the experience in the management of busulphan-based conditioning regimen administered before hematopoietic stem cell transplantation (HSCT) in children. METHODS We report the values of the first dose AUC (area under the concentration-time curve, normal target between 3600 and 4800 ng·h/mL) in children treated with oral and intravenous busulphan, and we analyze the impact of some clinical variables in this cohort of patients. RESULTS 82 children treated with busulphan before HSCT were eligible for the study: 57 received oral busulphan with a mean AUC of 3586 ng·h/mL, while 25 received intravenous busulphan with a mean AUC of 4158 ng·h/mL. Dose adjustment was based on first dose AUC. The dose was increased in 36 children (43.9%) and decreased in 26 patients (31.7%). Age at HSCT (P = 0.015), cumulative dose of busulphan as mg/m2 (P < 0.001), busulphan dose prescribed as mg/Kg (P = 0.001), intravenous busulphan administration (P < 0.001), type of stem source cells (P = 0.016), and type of HSCT (P = 0.03) were associated with AUC levels. No statistically significant differences were found between transplant-related toxicity, acute and chronic graft versus host disease, engraftment, and AUC levels. CONCLUSIONS We concluded that older age at HSCT, intravenous administration of busulphan, cumulative, and prescribed dose of busulphan are associated with higher AUC levels. The absence of significant correlations between toxic events, graft failure, and AUC suggests the efficacy of busulphan concentrations monitoring in our patients.
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17
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Maximal concentration of intravenous busulfan as a determinant of veno-occlusive disease: a pharmacokinetic-pharmacodynamic analysis in 293 hematopoietic stem cell transplanted children. Bone Marrow Transplant 2018; 54:448-457. [PMID: 30108322 DOI: 10.1038/s41409-018-0281-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 06/27/2018] [Accepted: 06/29/2018] [Indexed: 12/28/2022]
Abstract
Veno-occlusive disease (VOD) is a severe adverse reaction to busulfan-containing regimens used in the preparation of children for hematopoietic stem cell transplantation (HSCT). We conducted a retrospective analysis of data to examine determinants of VOD in children who received IV busulfan for HSCT conditioning. Busulfan PK parameters as well as various indices (maximal concentration-Cmax, area under the concentration-time curve-AUC) were estimated using a validated Bayesian approach. The influence of available PK, demographic, and clinical variables on the incidence of VOD was evaluated by using logistic regression and classification and regression tree (CART) analyses. Among the 293 patients included, the mean age was 6.5 years and the mean actual body weight was 26.3 kg. The incidence of VOD was 25.6%. Busulfan Cmax as well as weight <9 kg or age <3 years were identified as independent predictors of VOD in logistic regression analysis. CART analysis identified busulfan Cmax over the entire regimen as the strongest predictor of VOD. This study suggests that busulfan-associated VOD is in part a concentration-dependent reaction. In addition, the youngest children showed the highest risk of VOD. These findings may have important implications for busulfan dosing and therapeutic drug monitoring practice in HSCT children.
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18
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Xiao Y, Li X, Fu X. A rapid and simple LC-MS/MS method for personalized busulfan dosing in pediatric patients undergoing hematopoietic stem cell transplantation (HSCT). Clin Chim Acta 2018; 479:190-195. [PMID: 29341904 DOI: 10.1016/j.cca.2018.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 12/11/2017] [Accepted: 01/12/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Busulfan is commonly used as a conditioning regimen before hematopoietic stem cell transplantation (HSCT). There is a big inter-individual variability in busulfan exposure and the narrow therapeutic index, especially in pediatric population. Therefore, to achieve therapeutic efficacy and safety concurrently, personalized busulfan dosing, guided by pharmacokinetic study with serial plasma samples, is needed a few hours afterwards. METHODS A fast, sensitive, and accurate method for busulfan measurement was developed, validated, and implemented with liquid-chromatography-mass spectrometry (HPLC-MS/MS). The sample preparation procedure involves only protein precipitation and dilution, and the HPLC-MS/MS method takes 3 min/sample. The assay was linear from 10 ng/ml to 7500 ng/ml (R2 = 0.99). Recoveries were above 90%. The precision was determined at 3 levels (30, 300 and 4000 ng/ml): the intra-day variability (%CV) ranged from 1.4% to 2.5% (n = 20); the inter-day variability ranged from 2.2% to 5.5% (n = 20). The accuracy of the HPLC-MS/MS test was evaluated with an old HPLC-fluorescence method (n = 84), and a Correlation Coefficient (R) of 0.99 was observed. CONCLUSIONS The analytical performance of the assay allows for timely dose adjustment and has been implemented in clinical service for better clinical outcome.
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Affiliation(s)
- Yi Xiao
- Department of Pathology and Laboratory Medicine, Children's Hospital of Los Angeles, Los Angeles, CA 90027, United States
| | - Xiaohan Li
- Department of Pathology, Shengjing Hospital of China Medical University, Shenyang 110004, PR China
| | - Xiaowei Fu
- Department of Pathology and Laboratory Medicine, Children's Hospital of Los Angeles, Los Angeles, CA 90027, United States; Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, United States.
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19
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Rhee SJ, Lee JW, Yu KS, Hong KT, Choi JY, Hong CR, Park KD, Shin HY, Song SH, Kang HJ, Lee H. Pediatric patients undergoing hematopoietic stem cell transplantation can greatly benefit from a novel once-daily intravenous busulfan dosing nomogram. Am J Hematol 2017; 92:607-613. [PMID: 28370238 DOI: 10.1002/ajh.24734] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 03/12/2017] [Accepted: 03/20/2017] [Indexed: 11/07/2022]
Abstract
Busulfan, a bifunctional alkylating agent, has been used as a conditioning regimen prior to allogeneic hematopoietic stem cell transplantation (HSCT). The aim of this study was to derive a novel once-daily intravenous (IV) busulfan dosing nomogram for pediatric patients undergoing HSCT using a population pharmacokinetic (PK) model. A population PK analysis was performed using 2183 busulfan concentrations in 137 pediatric patients (age: 0.6-22.2 years), who received IV busulfan once-daily for 4 days before undergoing HSCT. Based on the final population PK model, an optimal once-daily IV busulfan dosing nomogram was derived. The percentage of simulated patients achieving the daily target area under the concentration-time curve (AUC) by the new nomogram was compared with that by other busulfan dosing regimens including the FDA regimen, the EMA regimen, and the empirical once-daily regimen without therapeutic drug monitoring (TDM). A one-compartment open linear PK model incorporating patient's body surface area, age, dosing day, and aspartate aminotransferase as a significant covariate adequately described the concentration-time profiles of busulfan. An optimal dosing nomogram based on the PK model performed significantly better than the other dosing regimens, resulting in >60% of patients achieving the target AUC while the percentage of patients exceeding the toxic AUC level was kept <25% during the entire treatment period. A novel once-daily busulfan dosing nomogram for pediatric patients undergoing HSCT is useful for clinicians, particularly in a setting where TDM service is not readily available or to optimize the dose on day 1.
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Affiliation(s)
- Su-jin Rhee
- Department of Clinical Pharmacology and Therapeutics; Seoul National University College of Medicine and Hospital; Seoul Republic of Korea
| | - Ji Won Lee
- Department of Pediatrics; Cancer Research Institute, Seoul National University College of Medicine; Seoul Republic of Korea
| | - Kyung-Sang Yu
- Department of Clinical Pharmacology and Therapeutics; Seoul National University College of Medicine and Hospital; Seoul Republic of Korea
| | - Kyung Taek Hong
- Department of Pediatrics; Cancer Research Institute, Seoul National University College of Medicine; Seoul Republic of Korea
| | - Jung Yoon Choi
- Department of Pediatrics; Cancer Research Institute, Seoul National University College of Medicine; Seoul Republic of Korea
| | - Che Ry Hong
- Department of Pediatrics; Cancer Research Institute, Seoul National University College of Medicine; Seoul Republic of Korea
| | - Kyung Duk Park
- Department of Pediatrics; Cancer Research Institute, Seoul National University College of Medicine; Seoul Republic of Korea
| | - Hee Young Shin
- Department of Pediatrics; Cancer Research Institute, Seoul National University College of Medicine; Seoul Republic of Korea
| | - Sang Hoon Song
- Department of Laboratory Medicine; Seoul National University College of Medicine; Seoul Republic of Korea
| | - Hyoung Jin Kang
- Department of Pediatrics; Cancer Research Institute, Seoul National University College of Medicine; Seoul Republic of Korea
| | - Howard Lee
- Department of Clinical Pharmacology and Therapeutics; Seoul National University College of Medicine and Hospital; Seoul Republic of Korea
- Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology; Seoul National University; Seoul Republic of Korea
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20
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Salman B, Al-Za'abi M, Al-Huneini M, Dennison D, Al-Rawas A, Al-Kindi S, Al-Farsi K, Tauro M, Al-Khabori M. Therapeutic drug monitoring-guided dosing of busulfan differs from weight-based dosing in hematopoietic stem cell transplant patients. Hematol Oncol Stem Cell Ther 2017; 10:70-78. [PMID: 28408108 DOI: 10.1016/j.hemonc.2017.03.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 01/16/2017] [Accepted: 03/14/2017] [Indexed: 12/21/2022] Open
Abstract
Busulfan (Bu)-based preparative regimens in hematopoietic stem cell transplantation are commonly used. Previous studies have shown that Bu at a fixed dose of 3.2mg/kg/day (FBD) given intravenously decreases variability in drug pharmacokinetics and this decreases the dependency on therapeutic drug monitoring (TDM) of Bu. We compared the Bu dose given using TDM with the FBD of 3.2mg/kg/day. Seventy-three patients with acute leukemia, myelodysplasia, chronic myeloid leukemia, thalassemia major, and sickle cell disease were included. The mean age at transplant was 15years (range 2-55years) with 57% adults. Indication for transplantation was leukemia/myelodysplastic syndrome in 46% of the patients, while the remaining 54% were transplanted for inherited blood disorders. We found that the median FBD was lower than the median TDM dose by 39mg/day with a statistically significant difference (p<0.001) even after adjusting for the weight (median total FBD of 349mg, median TDM dose of 494mg, p<0.0001). Age and underlying condition (malignant vs. nonmalignant) were the main factors affecting Bu clearance (p<0.001 and p<0.07, respectively). TDM remains an important tool for the appropriate dosing of Bu in preparative regimens of hematopoietic stem cell transplantation, especially in populations with genetic admixture.
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Affiliation(s)
- Bushra Salman
- Pharmacy Department, Sultan Qaboos University Hospital, Muscat, Oman
| | | | | | - David Dennison
- Department of Hematology, Sultan Qaboos University Hospital, Muscat, Oman
| | | | - Salam Al-Kindi
- Department of Hematology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Khalil Al-Farsi
- Department of Hematology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Melanie Tauro
- Department of Hematology, Sultan Qaboos University Hospital, Muscat, Oman
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21
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Alloin AL, Leverger G, Dalle JH, Galambrun C, Bertrand Y, Baruchel A, Auvrignon A, Gandemer V, Ragu C, Loundou A, Bilhou-Nabera C, Lafage-Pochitaloff M, Dastugue N, Nelken B, Jubert C, Rialland F, Plat G, Pochon C, Vannier JP, Rohrlich PS, Kanold J, Lutz P, Sirvent A, Oudin C, Cuccuini W, Michel G. Cytogenetics and outcome of allogeneic transplantation in first remission of acute myeloid leukemia: the French pediatric experience. Bone Marrow Transplant 2016; 52:516-521. [PMID: 27941778 DOI: 10.1038/bmt.2016.293] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 09/14/2016] [Accepted: 09/20/2016] [Indexed: 01/04/2023]
Abstract
We analyzed the impact of cytogenetics on 193 children enrolled in two successive French trials (LAME89/91 and ELAM02), who received hematopoietic stem cell transplantation during CR1. Detailed karyotype was available for 66/74 (89%) in LAME89/91 and 118/119 (99%) in ELAM02. Several karyotype and transplant characteristics differed according to therapeutic protocol: unfavorable karyotypes were more frequent in ELAM02 (36% vs 18%), pretransplant chemotherapy included high-dose cytarabine in ELAM02 and not in LAME89/91, IV replaced oral busulfan in the conditioning regimen, methotrexate was removed from post-transplant immunosuppression, and matched unrelated donor and cord blood transplantation were introduced. Five-year overall survival (OS) was 78.2% in LAME89 and 81.4% in ELAM02. OS was significantly lower for the unfavorable cytogenetic risk group in LAME89/91 when compared with intermediate and favorable groups (50% vs 90.6 and 86.4%, P=0.001). This difference was no longer apparent in ELAM02 (80.9% vs 71.3% and 5/5, respectively). Survival improvement for children with unfavorable karyotype was statistically significant (P=0.026) and was due to decrease in relapse risk. Five-year transplantation-related mortality was 6.75% in LAME89/91. In ELAM02, it was 3.2% for patients with a sibling donor and 10.9% with an unrelated donor or cord blood. We conclude that the outcome of children with unfavorable karyotype transplanted in CR1 has improved.
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Affiliation(s)
- A-L Alloin
- Department of Pediatric Hematology and Oncology, Timone Enfants Hospital and Aix-Marseille University, Marseille, France
| | - G Leverger
- Department of Pediatric Hematology and Oncology, AP-HP, GH HUEP, Trousseau Hospital, Paris, France.,UPMC University Paris 6, Paris, France
| | - J-H Dalle
- Department of Pediatric Hematology and Oncology, Robert Debré Hospital, Paris, France
| | - C Galambrun
- Department of Pediatric Hematology and Oncology, Timone Enfants Hospital and Aix-Marseille University, Marseille, France
| | - Y Bertrand
- Department of Pediatric Hematology and Oncology, University Hospital of Lyon, Lyon, France
| | - A Baruchel
- Department of Pediatric Hematology and Oncology, Robert Debré Hospital, Paris, France
| | - A Auvrignon
- Department of Pediatric Hematology and Oncology, AP-HP, GH HUEP, Trousseau Hospital, Paris, France
| | - V Gandemer
- Department of Pediatric Hematology and Oncology, University Hospital of Rennes, Rennes, France
| | - C Ragu
- Department of Pediatric Hematology and Oncology, AP-HP, GH HUEP, Trousseau Hospital, Paris, France
| | - A Loundou
- Research Unit EA3279 and Department of Public Health, Aix-Marseille University and Timone Hospital Marseille, Marseille, France
| | | | - M Lafage-Pochitaloff
- Department of Genetics, Timone Enfants Hospital and Aix-Marseille University, Marseille, France
| | - N Dastugue
- Department of Genetics, University hospital of Toulouse, Toulouse, France
| | - B Nelken
- CHU Lille, Department of Pediatric Hematology and Oncology, Lille, France
| | - C Jubert
- Department of Pediatric Hematology and Oncology, University Hospital of Bordeaux, Bordeaux, France
| | - F Rialland
- Department of Pediatric Hematology and Oncology, University Hospital of Nantes, Nantes, France
| | - G Plat
- Department of Pediatric Hematology and Oncology, University Hospital of Toulouse, Toulouse, France
| | - C Pochon
- Department of Pediatric Hematology and Oncology, Hôpital d'Enfants de Brabois, Vandoeuvre Les Nancy, France
| | - J-P Vannier
- Department of Pediatric Hematology and Oncology, University Hospital of Rouen, Rouen, France
| | - P-S Rohrlich
- Department of Pediatric Hematology and Oncology, University Hospital L'Archet, Nice, France
| | - J Kanold
- Department of Pediatric Hematology and Oncology, CIC Inserm 501, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - P Lutz
- Department of Pediatric Hematology and Oncology, Hospital University, Strasbourg, France
| | - A Sirvent
- Department of Pediatric Hematology and Oncology, University Hospital, Montpellier, France
| | - C Oudin
- Department of Pediatric Hematology and Oncology, Timone Enfants Hospital and Aix-Marseille University, Marseille, France.,Research Unit EA3279 and Department of Public Health, Aix-Marseille University and Timone Hospital Marseille, Marseille, France
| | - W Cuccuini
- Department of Cytogenetics, Saint-Louis Hospital, Paris, France
| | - G Michel
- Department of Pediatric Hematology and Oncology, Timone Enfants Hospital and Aix-Marseille University, Marseille, France.,Research Unit EA3279 and Department of Public Health, Aix-Marseille University and Timone Hospital Marseille, Marseille, France
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22
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Palmer J, McCune JS, Perales MA, Marks D, Bubalo J, Mohty M, Wingard JR, Paci A, Hassan M, Bredeson C, Pidala J, Shah N, Shaughnessy P, Majhail N, Schriber J, Savani BN, Carpenter PA. Personalizing Busulfan-Based Conditioning: Considerations from the American Society for Blood and Marrow Transplantation Practice Guidelines Committee. Biol Blood Marrow Transplant 2016; 22:1915-1925. [PMID: 27481448 DOI: 10.1016/j.bbmt.2016.07.013] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 07/21/2016] [Indexed: 12/12/2022]
Abstract
The Practice Guidelines Committee of the American Society of Blood or Marrow Transplantation (ASBMT) sought to develop an evidence-based review about personalizing busulfan-based conditioning. The Committee sought to grade the relevant published studies (June 1, 2008 through March 31, 2016) according to criteria set forth by the Steering Committee for Evidence Based Reviews from ASBMT. Unfortunately, the published literature was too heterogeneous and lacked adequately powered and sufficiently controlled studies for this to be feasible. Despite this observation, the continued interest in this topic led the Practice Guidelines Committee to develop a list of most frequently asked questions (FAQs) regarding personalized busulfan dosing. This "Considerations" document is a list of these FAQs and their responses, addressing topics of practical relevance to hematopoietic cell transplantation clinicians.
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Affiliation(s)
- Jeanne Palmer
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona.
| | - Jeannine S McCune
- Department of Pharmacology University of Washington, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | - Miguel-Angel Perales
- Division of Hematology/Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David Marks
- Pediatric Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Joseph Bubalo
- Department of Pharmacy Practice, Oregon Health Sciences University, Portland, Oregon
| | - Mohamad Mohty
- Department of Hematology, Hospital Saint-Antoine, University UPMC, Paris, France
| | - John R Wingard
- Division of Hematology/Oncology, University of Florida, Gainesville, Florida
| | - Angelo Paci
- Pharmacology and Drug Analysis Department, Institut de Cancerologie Gustav Roussy, Villejuif, France
| | - Moustapha Hassan
- Department of Clinical Research Centre, Karolinska Institutet, Stockholm, Sweden
| | - Christopher Bredeson
- Hematology, Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Joseph Pidala
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Nina Shah
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Paul Shaughnessy
- Adult Blood and Marrow Transplant, Texas Transplant Physician's Group, San Antonio, Texas
| | - Navneet Majhail
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Jeff Schriber
- Cancer Transplant Institute, Honor Health, Scottsdale, Arizona
| | - Bipin N Savani
- Division of Hematology/Oncology, Vanderbuilt-Ingram Cancer Center, Nashville, Tennessee
| | - Paul A Carpenter
- Department of Pediatrics, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington
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23
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Philippe M, Goutelle S, Guitton J, Fonrose X, Bergeron C, Girard P, Bertrand Y, Bleyzac N. Should busulfan therapeutic range be narrowed in pediatrics? Experience from a large cohort of hematopoietic stem cell transplant children. Bone Marrow Transplant 2015; 51:72-8. [PMID: 26389835 DOI: 10.1038/bmt.2015.218] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 08/04/2015] [Accepted: 08/07/2015] [Indexed: 01/03/2023]
Abstract
Busulfan, the corner stone of hematopoietic stem cell transplantation regimens, has a narrow therapeutic window. Therapeutic drug monitoring (TDM)-guided dosing to reach the conventional area under the concentration-time curve (AUC) target range of 900-1500 μmol min/L is associated with better outcomes. We report our experience with busulfan TDM in a large cohort of children. The aims were to investigate the relevance of using a more restricted therapeutic range and investigate the association between busulfan therapeutic range and clinical outcome. This study includes 138 children receiving 16 doses of intravenous busulfan, with the first dose assigned based on weight and doses adjusted to a local AUC target range of 980-1250 μmol min/L. Busulfan TDM combined with model-based dose adjustment was associated with an increased probability of AUC target attainment, for both target range: 90.8% versus 74.8% for the conventional target range and 66.2% versus 43.9% for the local target range (P<0.001). The median follow-up was 56.2 months. Event-free survival was 88.5%, overall survival was 91.5% and veno-occlusive disease occurred in 18.3% of patients. No difference was observed for clinical outcomes depending on the selected target range. Pharmacokinetic monitoring and individualization of busulfan dosage regimen are useful in improving target attainment, but using a restricted target range has no impact on clinical outcomes.
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Affiliation(s)
- M Philippe
- Hematology Department, Institute of Pediatric Hematology and Oncology, and Hospices Civils de Lyon, Lyon, France.,Laboratoire de Biométrie et Biologie Evolutive, UMR CNRS 5558, Université Lyon 1, Villeurbanne, France
| | - S Goutelle
- Laboratoire de Biométrie et Biologie Evolutive, UMR CNRS 5558, Université Lyon 1, Villeurbanne, France.,ISPB - Faculté de Pharmacie de Lyon, Université Lyon 1, Lyon, France.,Service Pharmaceutique, Groupement Hospitalier de Gériatrie, Hospices Civils de Lyon, Lyon, France
| | - J Guitton
- ISPB - Faculté de Pharmacie de Lyon, Université Lyon 1, Lyon, France.,Laboratoire de Ciblage Thérapeutique en Cancérologie, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - X Fonrose
- Laboratoire de Pharmacologie, University Hospital Centre, Grenoble, France
| | - C Bergeron
- Hematology Department, Institute of Pediatric Hematology and Oncology, and Hospices Civils de Lyon, Lyon, France
| | - P Girard
- Clinique de Pédiatrie, Hôpital Couple Enfant, University Hospital Centre, Grenoble, France
| | - Y Bertrand
- Hematology Department, Institute of Pediatric Hematology and Oncology, and Hospices Civils de Lyon, Lyon, France
| | - N Bleyzac
- Hematology Department, Institute of Pediatric Hematology and Oncology, and Hospices Civils de Lyon, Lyon, France.,Laboratoire de Biométrie et Biologie Evolutive, UMR CNRS 5558, Université Lyon 1, Villeurbanne, France
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24
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Watanabe E, Nishikawa T, Ikawa K, Yamaguchi H, Abematsu T, Nakagawa S, Kurauchi K, Kodama Y, Tanabe T, Shinkoda Y, Matsumoto K, Okamoto Y, Takeda Y, Kawano Y. Trough level monitoring of intravenous busulfan to estimate the area under the plasma drug concentration-time curve in pediatric hematopoietic stem cell transplant recipients. Int J Hematol 2015; 102:611-6. [PMID: 26243625 DOI: 10.1007/s12185-015-1853-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 07/28/2015] [Accepted: 07/28/2015] [Indexed: 12/23/2022]
Abstract
Optimizing systemic busulfan exposure, the area under the concentration-time curve (AUC), improves the outcomes for hematopoietic stem cell transplantation (HSCT). The AUC is conventionally calculated using six plasma concentrations (AUC(0-∞)) drawn after the first of 16 intravenous busulfan doses given as a 2-h infusion every 6 h. The aim of the present study was to develop limited sampling strategies using three or fewer busulfan concentrations to reliably calculate AUC(0-∞) in patients undergoing HSCT. We investigated the pharmacokinetics of busulfan 46 times in 29 pediatric patients receiving intravenous busulfan. Limited sampling strategies using one, two, or three plasma busulfan concentrations were developed by multiple linear regression that showed excellent agreement with AUC(0-∞). In single-point sampling strategies, the AUC(0-∞) predicted based on C(6) (trough level: busulfan plasma concentration 6 h after the start of the infusion) was significantly correlated with, and not statistically different from, actual values as follows: AUC(0-∞) = 2556.5 C6 + 320.9 (r(2) = 0.929, P < 0.0001, mean bias 0.282 %, precision 7.91 %). In contrast, the predicted AUCs derived from the other sampling single points did not meet the criteria. The trough level well correlated with actual AUC(0-∞), suggesting that this time-point is acceptable for busulfan monitoring.
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Affiliation(s)
- Erika Watanabe
- Department of Clinical Pharmacy and Pharmacology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Takuro Nishikawa
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan.
| | - Kazuro Ikawa
- Department of Clinical Pharmacotherapy, Hiroshima University, Hiroshima, Japan
| | | | - Takanari Abematsu
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Shunsuke Nakagawa
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Koichiro Kurauchi
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Yuichi Kodama
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Takayuki Tanabe
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Yuichi Shinkoda
- Department of Pediatrics, Kagoshima City Hospital, Kagoshima, Japan
| | - Kazuaki Matsumoto
- Department of Clinical Pharmacy and Pharmacology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Yasuhiro Okamoto
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Yasuo Takeda
- Department of Clinical Pharmacy and Pharmacology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Yoshifumi Kawano
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
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25
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Ward J, Kletzel M, Duerst R, Fuleihan R, Chaudhury S, Schneiderman J, Tse WT. Single Daily Busulfan Dosing for Infants with Nonmalignant Diseases Undergoing Reduced-Intensity Conditioning for Allogeneic Hematopoietic Progenitor Cell Transplantation. Biol Blood Marrow Transplant 2015; 21:1612-21. [PMID: 26025482 DOI: 10.1016/j.bbmt.2015.05.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 05/19/2015] [Indexed: 11/15/2022]
Abstract
Busulfan (Bu) is widely used in conditioning regimens for infants undergoing allogeneic hematopoietic progenitor cell transplantation (HPCT), but the best approach to administer Bu in this population is still unknown. Here, we report a single-center experience of the use of a test dose to guide dose adjustment of intravenous (i.v.) Bu therapy in infants. Between 2004 and 2013, 33 infants younger than 1 year with nonmalignant conditions received allogeneic peripheral blood or cord blood HPCT after a reduced-intensity conditioning (RIC) regimen consisting of fludarabine, antithymocyte globulin, and 2 single daily doses of i.v. Bu. Pharmacokinetic results of a test dose of i.v. Bu (.8 mg/kg) were used to determine the dose of 2 single daily i.v. Bu regimen doses, adjusted to target an area under the curve (AUC) of 4000 μMol*minute per day in a first cohort (n = 12) and 5000 μMol*minute in a second cohort (n = 21). The mean Bu clearance in our infant patients was found to be 3.67 ± 1.03 mL/minute/kg, and the test dose clearance was highly predictive of the regimen dose clearance. The mean AUC achieved after the first single daily regimen dose was 3951 ± 1239 in the AUC 4000 cohort and 4884 ± 766 for the AUC 5000 cohort. No patient in either cohort developed hepatic sinusoidal obstructive syndrome or seizures attributable to Bu. Primary graft failure occurred in 4 patients and secondary graft failure occurred in 3, predominantly in the AUC 4000 cohort (6 of 7). Among the engrafted patients (n = 28), 16 achieved full donor chimerism and 9 patients attained stable mixed chimerism. Overall survival of patients at 6 years after transplantation was 59.5% for the AUC 4000 cohort and 85.4% for the AUC 5000 cohort, with primary graft failure in the first cohort being a major contributor to morbidity. Logistic regression analysis showed that the risk of graft failure increased significantly if cord blood hematopoietic progenitor cells were used or if total Bu exposure was below 4000 μMol*minute per day for 2 days. The difference in clinical outcomes between the 2 cohorts supports the conclusion that targeting a higher Bu AUC of 5000 μMol*minute per day for 2 days improves donor engraftment in infants with nonmalignant conditions undergoing RIC HPCT without increasing toxicity. Measuring i.v. Bu pharmokinetics using a test dose allows timely adjustment of single daily regimen doses and optimization of total Bu exposure, resulting in an effective and safe regimen for these infants.
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Affiliation(s)
- Jessica Ward
- Stem Cell Transplant Program, Division of Hematology-Oncology-Transplant, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Morris Kletzel
- Stem Cell Transplant Program, Division of Hematology-Oncology-Transplant, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Reggie Duerst
- Stem Cell Transplant Program, Division of Hematology-Oncology-Transplant, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ramsay Fuleihan
- Division of Allergy and Immunology, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sonali Chaudhury
- Stem Cell Transplant Program, Division of Hematology-Oncology-Transplant, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jennifer Schneiderman
- Stem Cell Transplant Program, Division of Hematology-Oncology-Transplant, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - William T Tse
- Stem Cell Transplant Program, Division of Hematology-Oncology-Transplant, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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26
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Gürlek Gökçebay D, Azik F, Ozbek N, Isik P, Avci Z, Tavil B, Kara A, Tunc B. Clinical comparison of weight- and age-based strategy of dose administration in children receiving intravenous busulfan for hematopoietic stem cell transplantation. Pediatr Transplant 2015; 19:307-15. [PMID: 25661259 DOI: 10.1111/petr.12430] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2014] [Indexed: 11/28/2022]
Abstract
Bu, combined with TDM-guided dosing, is associated with fewer graft failures/relapses and lower toxicity in pediatric HSCT. We aimed this retrospective study for comparison of weight- and age-based dosing in terms of clinical outcomes such as time to engraftment, early complications, EFS, OS, and toxicity profiles in children receiving iv Bu. Sixty-one children who underwent HSCT from April 2010 to February 2013 by means of a Bu-based conditioning regimen and completed 100 days after transplantation at Ankara Children?s Hematology and Oncology Hospital Bone Marrow Transplantation Unit were enrolled in this study. SOS and neutropenic fever occurred more frequently in the weight-based dosing group. We found a statistically significant correlation between Bu dose and the incidence of SOS (r = 0.26, p = 0.04). Multivariate analysis showed only weight-based dosing of Bu was a significant predictor of SOS (HR = 9.46; p = 0.009). However, no relationship was found between two groups in terms of hemorrhagic cystitis, engraftment syndrome, acute or chronic GvHD, time to engraftment, chimerism, TRM, OS, and EFS rates. Weight-based dosing of Bu may cause higher incidence of SOS and early infectious complications at the places where TDM of Bu cannot be performed.
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Affiliation(s)
- D Gürlek Gökçebay
- Department of Pediatric Hematology, Ankara Children's Hematology and Oncology Hospital, Ankara, Turkey
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27
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Gaziev J, Isgrò A, Mozzi AF, Petain A, Nguyen L, Ialongo C, Dinallo V, Sodani P, Marziali M, Andreani M, Testi M, Paciaroni K, Gallucci C, De Angelis G, Alfieri C, Ribersani M, Lucarelli G. New insights into the pharmacokinetics of intravenous busulfan in children with sickle cell anemia undergoing bone marrow transplantation. Pediatr Blood Cancer 2015; 62:680-6. [PMID: 25557687 DOI: 10.1002/pbc.25376] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 11/04/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Busulfan (Bu) is an integral part of conditioning regimens for patients with sickle cell anemia (SCA) undergoing transplantation. Patients with SCA might predispose to transplant-related neurological and pulmonary toxicities due to pre-existing disease-related cerebrovascular and lung injury. Bu therapy appears to be an important contributing factor in this context. PROCEDURE We studied the pharmacokinetics of intravenous Bu and clinical outcomes of 36 children with SCA undergoing bone marrow transplantation. Most patients had pre-existing organ system damage. Busulfan was administered every 6 hr for 4 days with pharmacokinetic-guided dose adjustment to target a conservative area under the concentration versus time curve (AUC) range of 900-1,350 µMol*min. RESULTS We found that the first-dose Bu clearance was significantly higher (P < 0.0005) than the subsequent daily clearance, which remained unchanged during the following days. After the first-dose, 69% of patients achieved the target range. We adapted a new dose-adjustment strategy targeting exposures to the lower end (900 µMol*min) of the AUC range after the first dose of Bu to avoid unnecessary dose increases on subsequent days due to differences in clearance. This strategy enabled most patients to maintain the AUC within therapeutic range following dose adjustments. CONCLUSIONS Differences in Bu clearance after the first-dose and subsequent daily doses in patients with SCA should be considered for pharmacokinetic-guided dose adjustment. Conservative AUC range and targeting exposures to the lower end of the range after the first dose was associated with negligible toxicity, and high engraftment and sickle cell-free survival rates.
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Affiliation(s)
- Javid Gaziev
- International Center for Transplantation in Thalassemia and Sickle Cell Anemia, Mediterranean Institute of Hematology, Policlinico Tor Vergata, Rome, Italy
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28
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Diestelhorst C, Boos J, McCune JS, Russell J, Kangarloo SB, Hempel G. Predictive performance of a physiologically based pharmacokinetic model of busulfan in children. Pediatr Hematol Oncol 2014; 31:731-42. [PMID: 25007236 DOI: 10.3109/08880018.2014.927945] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
A physiologically based pharmacokinetic (PBPK) model of the DNA-alkylating agent busulfan was slightly modified and scaled from adults to children in order to predict the systemic busulfan drug exposure in children. Capitalizing on the recent major software release of PK-Sim®, we refined our PBPK model by implementing glutathione S transferase (GST) in 11 organs using the software integrated enzyme expression database. In addition, two irreversible binding processes (i.e., DNA and plasma protein binding) were applied by using Koff and KD values. The model was scaled from adults to children. Simulations were computed and compared to concentration-time data after intravenous (i.v.) busulfan administration to 36 children. Based on the results, an age-dependent enzyme activity and maturation ratio was tailored and evaluated with an external dataset consisting of 23 children. Initial adult to children scaling indicated lower clearance values for children in comparison to adults. Subsequent age-dependent maturation ratio resulted in three different age groups: Activity of busulfan-glutathione conjugate formation was 80%, 61%, and 89% in comparison to adults for children with an age of up to 2 years, > 2-6 years, and > 6-18 years, respectively. Patients of the evaluation dataset were simulated with a mean percentage error (MPE) for all patients of 3.9% with 3/23 children demonstrating a MPE of > ±30%. The PBPK model parameterization sufficiently described the observed concentration-time data of the validation dataset while showing an adequate predictive performance. This PBPK model could be helpful to determine the first dose of busulfan in children.
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Affiliation(s)
- Christian Diestelhorst
- 1Department of Pharmaceutical and Medical Chemistry - Clinical Pharmacy, University of Münster, Münster, Germany
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29
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Association between busulfan exposure and outcome in children receiving intravenous busulfan before hematopoietic stem cell transplantation. Ther Drug Monit 2014; 36:93-9. [PMID: 24061446 DOI: 10.1097/ftd.0b013e3182a04fc7] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Intravenous (IV) busulfan (Bu) combined with therapeutic drug monitoring-guided dosing is associated with better event-free survival (EFS), lower transplant-related mortality. But optimal target steady-state concentration (Css) of Bu in children undergoing hematopoietic stem cell transplantation (HSCT) remains unclear. This study aimed to evaluate the relation between Css of Bu and clinical outcomes in children receiving Bu before HSCT. METHODS This study includes 75 children receiving IV Bu in 16 doses, with first dose assigned based on age. Bu first-dose pharmacokinetic parameters were estimated from Bu plasma concentrations measured at 6 time points by high-performance liquid chromatography. Doses were adjusted at the fifth dose to a target Css of 600-900 ng/mL. Cumulative incidence of overall survival (OS), EFS, transplant-related mortality, acute graft-versus host disease (aGVHD), and other toxicities in relation to Css of Bu were analyzed using Kaplan-Meier curves in univariate and Cox's proportional hazards model in multivariate analysis. RESULTS After the first dose, median Css was 578 (325-1227) ng/mL. Forty-one patients had Bu IV dose increased by > 10%. Neutrophil and platelet recoveries, grade 2-4 aGVHD, and nonrelapse mortality (NRM) incidences were 90%, 91%, 12%, and 13%, respectively. Relapse incidence was 33%. Incidence of veno-occlusive disease, hemorrhagic cystitis, and lung toxicities were 13%, 24%, and 7%, respectively. OS and EFS were 70% and 58%. First-dose Bu Css >600 ng/mL was associated with a higher NRM (P < 0.001) and grade 2-4 aGVHD (P = 0.04), a lower EFS (P < 0.001), and OS (P = 0.001). CONCLUSIONS This study demonstrated a significant association between the first-dose pharmacokinetics of Bu and NRM, OS, and EFS. Bu therapeutic drug monitoring provides information that potentially influences outcomes of HSCT in pediatric patients.
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Population pharmacokinetics of intravenous busulfan in children: revised body weight-dependent NONMEM® model to optimize dosing. Eur J Clin Pharmacol 2014; 70:839-47. [DOI: 10.1007/s00228-014-1692-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 04/24/2014] [Indexed: 10/25/2022]
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Okamoto Y, Nagatoshi Y, Kosaka Y, Kikuchi A, Kato S, Kigasawa H, Horikoshi Y, Oda M, Kaneda M, Mori T, Mugishima H, Tsuchida M, Taniguchi S, Kawano Y. Prospective pharmacokinetic study of intravenous busulfan in hematopoietic stem cell transplantation in 25 children. Pediatr Transplant 2014; 18:294-301. [PMID: 24506304 DOI: 10.1111/petr.12236] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2014] [Indexed: 11/29/2022]
Abstract
The aim of this study was to prospectively evaluate the PK and safety of ivBU in 25 Japanese children (median age six yr; range, five months-17 yr) as one of a combination of drugs in a pretransplant regimen. The patients had acute leukemia (n = 14), CML (2), JMML (5), solid tumors (2), chronic granulomatous disease (1), or metachromatic leukodystrophy (1). Five different dose schedules were used according to the patient's ABW: <9 kg (1.0 mg/kg), 9 to <16 (1.2 mg/kg), 16-23 (1.1 mg/kg), >23-34 (0.95 mg/kg), and >34 kg of BW (0.8 mg/kg). Each dose was given over two h, and sample blood was drawn at nine or 11 separate points for analysis by gas chromatography-mass spectrometry. The AUC varied from 796 to 1905 μmol min/L, and 19 of the 25 patients (76%) remained within the target range without dose adjustment. Two were diagnosed with engraftment failure. Hepatic VOD developed in four, and only one of these showed high AUC (>1500 μmol min/L). Toxicities did not correlate with the BU level. Our data showed very similar PK to those in previous studies, and these dose schedules are applicable to Japanese children.
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Affiliation(s)
- Yasuhiro Okamoto
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
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Bernard F, Auquier P, Herrmann I, Contet A, Poiree M, Demeocq F, Plantaz D, Galambrun C, Barlogis V, Berbis J, Garnier F, Sirvent N, Kanold J, Chastagner P, Chambost H, Michel G. Health status of childhood leukemia survivors who received hematopoietic cell transplantation after BU or TBI: an LEA study. Bone Marrow Transplant 2014; 49:709-16. [PMID: 24535128 DOI: 10.1038/bmt.2014.3] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Revised: 12/15/2013] [Accepted: 12/20/2013] [Indexed: 01/03/2023]
Abstract
The purpose of this multicenter study was to compare the long-term impact of a preparative regimen with either BUBU or TBI on health status and quality of life (QoL) in childhood acute leukemia survivors treated with hematopoietic SCT (HSCT). Two-hundred and forty patients were included. Sixty-six had received BU, while 174 had received TBI. Median follow-up from HSCT was 10.1 years. Multivariate analyses were performed to assess the occurrence of late effects according to treatment. QoL was assessed in 130 adults using SF-36 questionnaires. Patients developed fewer late complications after BU (2.35 vs 3.01, P=0.03) while the risk to present with at least one complication was equivalent in both groups (87.9% after BU and 93.1% after TBI, P=0.66). Detailed multivariate analyses revealed a lower risk of height growth failure (OR=0.2), cataract (OR=0.1) and iron overload (OR=0.2) after BU, and an increased risk of overweight (OR=3.9) and alopecia (OR=11.2). SF-36 mental and physical composite scores were similar in both treatment groups and proved significantly lower than French norms. Late effects induced by BU might differ from those experienced after TBI. Although less frequent, they are still of considerable importance and may affect patients' QoL.
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Affiliation(s)
- F Bernard
- Department of Pediatric Hematology-Oncology, La Timone Children's Hospital, Marseille, France
| | - P Auquier
- Department of Public Health -EA 3279 Research Unit, University Hospital of Marseille, Aix-Marseille University, Marseille, France
| | - I Herrmann
- Department of Pediatric Hematology-Oncology, La Timone Children's Hospital, Marseille, France
| | - A Contet
- Department of Pediatric Hematology-Oncology, Brabois Children's Hospital, Vandoeuvre-Les-Nancy, France
| | - M Poiree
- Department of Pediatric Hematology-Oncology, L'Archet II Hospital, Nice, France
| | - F Demeocq
- Department of Pediatric Hematology-Oncology, CIC Inserm 501, University Hospital of Clermont Ferrand, Clermont-Ferrand, France
| | - D Plantaz
- Department of Pediatric Hematology-Oncology, University Hospital of Grenoble, Grenoble, France
| | - C Galambrun
- Department of Pediatric Hematology-Oncology, La Timone Children's Hospital, Marseille, France
| | - V Barlogis
- Department of Pediatric Hematology-Oncology, La Timone Children's Hospital, Marseille, France
| | - J Berbis
- Department of Public Health -EA 3279 Research Unit, University Hospital of Marseille, Aix-Marseille University, Marseille, France
| | - F Garnier
- Department of Public Health -EA 3279 Research Unit, University Hospital of Marseille, Aix-Marseille University, Marseille, France
| | - N Sirvent
- Department of Pediatric Hematology-Oncology, Arnaud de Villeneuve Hospital, Montpellier, France
| | - J Kanold
- Department of Pediatric Hematology-Oncology, CIC Inserm 501, University Hospital of Clermont Ferrand, Clermont-Ferrand, France
| | - P Chastagner
- Department of Pediatric Hematology-Oncology, Brabois Children's Hospital, Vandoeuvre-Les-Nancy, France
| | - H Chambost
- Department of Pediatric Hematology-Oncology, La Timone Children's Hospital, Marseille, France
| | - G Michel
- 1] Department of Pediatric Hematology-Oncology, La Timone Children's Hospital, Marseille, France [2] Department of Public Health -EA 3279 Research Unit, University Hospital of Marseille, Aix-Marseille University, Marseille, France
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Kerl K, Diestelhorst C, Bartelink I, Boelens J, Trame MN, Boos J, Hempel G. Evaluation of effects of busulfan and DMA on SOS in pediatric stem cell recipients. Pediatr Blood Cancer 2014; 61:306-11. [PMID: 24174393 DOI: 10.1002/pbc.24827] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 09/24/2013] [Indexed: 11/06/2022]
Abstract
BACKGROUND Busulfan (Bu) is a DNA-alkylating agent used for myeloablative conditioning in stem cell transplantation in children and adults. While the use of intravenous rather than oral administration of Bu has reduced inter-individual variability in plasma levels, toxicity still occurs frequently after hematopoietic stem cell transplantation (HSCT). Toxicity (especially hepatotoxic effects) of intravenous (IV) Bu may be related to both Bu and/or N,N-dimethylacetamide (DMA), the solvent of Bu. In this study, we assessed the relation between the exposure of Bu and DMA with regards to the clinical outcome in children from two cohorts. METHODS In a two-centre study Bu and DMA AUC (area under the curve) were correlated in pediatric stem cell recipients to the risk of developing SOS and to the clinical outcome. RESULT In patients receiving Bu four times per day Bu levels >1,500 µmol/L minute correlate to an increased risk of developing a SOS. In the collective cohort, summarizing data of all 53 patients of this study, neither high area under the curve (AUC) of Bu nor high AUC of DMA appears to be an independent risk factor for the development of SOS in children. CONCLUSION In this study neither Bu nor DMA was observed as an independent risk factor for the development of SOS. To identify subgroups (e.g., infants), in which Bu or DMA might be risk factors for the induction of SOS, larger cohorts have to be evaluated.
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Affiliation(s)
- Kornelius Kerl
- Department of Pediatric Hematology and Oncology, University Childrens Hospital Münster, Muenster, Germany
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Targeted Busulfan therapy with a steady-state concentration of 600-700 ng/mL in patients with sickle cell disease receiving HLA-identical sibling bone marrow transplant. Bone Marrow Transplant 2013; 49:366-9. [PMID: 24317124 DOI: 10.1038/bmt.2013.188] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 09/30/2013] [Accepted: 10/10/2013] [Indexed: 11/09/2022]
Abstract
Busulfan (BU) has a narrow therapeutic window and the average concentration of BU at steady state (Css) is critical for successful engraftment in children receiving BU as part of the preparative regimen for allogeneic transplants. Sixteen patients with sickle cell disease (SCD) underwent allogeneic bone marrow transplant (BMT) from HLA-identical siblings. The preparative regimen consisted of intravenous BU 0.8-1 mg/kg/dose for 16 doses, cytoxan (CY) of 50 mg/kg daily for four doses and equine anti-thymocyte globulin (ATG) 30 mg/kg daily for three doses. BU levels were adjusted to provide a total exposure Css of 600-700 ng/mL. The median age at the time of transplant was 6.2 years (range 1.2-19.3). Fourteen (87%) patients required adjustment of the BU dose to achieve a median Css of 652 ng/mL (range 607-700). All patients achieved neutrophil and platelet engraftment without significant toxicity. Median donor engraftment at the last follow-up was 100% (range 80-100). None of the patients experienced sickle cell-related complications post transplant. With a median follow-up of 3 years (range 1.3-9), the event-free survival (EFS) and overall survival (OS) are both 100%. We conclude that targeting of BU Css between 600 and 700 ng/mL in this regimen can result in excellent and sustained engraftment in young patients with SCD.
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Kato M, Takahashi Y, Tomizawa D, Okamoto Y, Inagaki J, Koh K, Ogawa A, Okada K, Cho Y, Takita J, Goto H, Sakamaki H, Yabe H, Kawa K, Suzuki R, Kudo K, Kato K. Comparison of intravenous with oral busulfan in allogeneic hematopoietic stem cell transplantation with myeloablative conditioning regimens for pediatric acute leukemia. Biol Blood Marrow Transplant 2013; 19:1690-4. [PMID: 24071595 DOI: 10.1016/j.bbmt.2013.09.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 09/17/2013] [Indexed: 10/26/2022]
Abstract
Recent reports revealed that intravenous (iv) busulfan (BU) may not only reduce early nonrelapse mortality (NRM) but also improve overall survival (OS) probability in adults. Therefore, we retrospectively compared outcomes for 460 children with acute leukemia who underwent hematopoietic stem cell transplantation with either iv-BU (n = 198) or oral busulfan (oral-BU) (n = 262) myeloablative conditioning. OS at 3 years was 53.4% ± 3.7% with iv-BU and 55.1% ± 3.1% with oral-BU; the difference was not statistically significant (P = .77). OS at 3 years in 241 acute lymphoblastic leukemia and 219 acute myeloid leukemia patients was 56.4% ± 5.5% with iv-BU and 54.6% ± 4.1 with oral-BU (P = .51) and 51.0% ± 5.0% with iv-BU and 55.8% ± 4.8% with oral-BU (P = .83), respectively. Cumulative incidence of relapse at 3 years with iv-BU was similar to that with oral-BU (39.0% ± 3.6% and 36.4% ± 3.1%, respectively; P = .67). Cumulative incidence of NRM at 3 years was 16.6% ± 2.7% with iv-BU and 18.3% ± 2.5% with oral-BU (P = .51). Furthermore, multivariate analysis showed no significant survival advantage with iv-BU. In conclusion, iv-BU failed to show a significant survival advantage in children with acute leukemia.
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Affiliation(s)
- Motohiro Kato
- Department of Cell Therapy and Transplantation Medicine, The University of Tokyo, Tokyo, Japan; Department of Pediatrics, The University of Tokyo, Tokyo, Japan; Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan.
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Diestelhorst C, Boos J, McCune JS, Russell J, Kangarloo SB, Hempel G. Physiologically based pharmacokinetic modelling of Busulfan: a new approach to describe and predict the pharmacokinetics in adults. Cancer Chemother Pharmacol 2013; 72:991-1000. [PMID: 24061863 DOI: 10.1007/s00280-013-2275-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 08/20/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE A physiologically based pharmacokinetic (PBPK) model was established and evaluated describing the pharmacokinetics (PK) of the DNA-alkylating agent Busulfan in adults in order to predict the systemic Busulfan drug exposure in both plasma and toxicity-related organs. METHODS A generic PBPK model was tailored to describe Busulfan PK by implementing compound-specific physicochemical and metabolism data. With regard to possible influences of glutathione S transferase (GST) variations on Busulfan PK, two different PBPK model parameterizations were investigated: a first parameterization with individual GST activity (expressed as different estimated V(max) values) for each patient, and a resulting second model parameterization with a mean GST activity for all patients. Simulations were computed and compared to concentration-time data after intravenous Busulfan administration to 108 adults serving as development dataset. Subsequently, appropriateness of the PBPK model was evaluated with an external dataset not used for model development, consisting of 95 adults. RESULTS Both PBPK model parameterizations of Busulfan successfully described the observed plasma concentrations. For the validation dataset, calculated PK parameters were as follows: clearance 0.16 ± 0.03 L/h/kg and volume of distribution 0.65 ± 0.06 L/kg (mean ± standard deviation). Mean absolute percentage error was less than 30 % for each PK parameter. Mass balances for distribution and excretion were in good agreement with the literature data. CONCLUSIONS Both PBPK model parameterizations sufficiently described the observed concentration-time data while showing an adequate predictive performance. The model should be further evaluated for its ability to explain the between-subject variability in intravenous Busulfan PK parameters.
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Affiliation(s)
- Christian Diestelhorst
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Münster, Corrensstr. 48, 48149, Münster, Germany
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Reduced-intensity conditioning followed by allogeneic transplantation in pediatric malignancies: a report from the Société Française des Cancers de l'Enfant and the Société Française de Greffe de Moelle et de Thérapie Cellulaire. Bone Marrow Transplant 2013; 48:1401-8. [PMID: 23749103 DOI: 10.1038/bmt.2013.82] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 03/18/2013] [Accepted: 04/23/2013] [Indexed: 01/15/2023]
Abstract
We report French prospective experience with reduced-intensity conditioning-allo-SCT in 46 patients (median age: 15.5 years, 4.8-20.2) presenting high-risk AL (n=11), Hodgkin's lymphoma (n=15) or solid tumors (n=20). Graft sources were BM (n=21), PBSC (n=20) and cord blood (CB; n=5) from related (n=20) or unrelated (n=26) donors. For CB grafts, only one patient out of five achieved sustained engraftment. For PBSC/BM grafts, engraftment rate was 95%, hematopoietic recovery times were not significantly different between BM, PBSC, sibling or unrelated grafts, day+100. Full donor chimerism was achieved in 94% of patients, and incidences of primary acute GVHD and chronic GVHD were 49% and 14%, respectively. Underlying disease was fatal in 39% of patients. TRM was 6.9%. Three-year OS was 49.15%. OS and EFS were not significantly different between patients transplanted with different grafts and with or without primary GVHD. Patients with solid tumor or measurable disease at transplant had poorer outcomes. Three-year EFS: 33.3% for ALL, 75.0% for AML, 51.8% for Hodgkin's lymphoma, 28.6% for neuroblastoma and 22.2% for sarcoma patients. This multicentre study concluded that Bu/fludarabine/anti-thymocyte globulin conditioning with PB or BM, related or unrelated grafts in patients with various malignancies at high-risk for transplantation toxicity results in high engraftment rates, low TRM and acceptable survival.
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Scott LJ, Hoy SM, Lyseng-Williamson KA. Intravenous busulfan: a guide to its use as conditioning treatment before transplantation of haematopoietic progenitor cells. Clin Drug Investig 2012; 32:641-8. [PMID: 22877323 DOI: 10.1007/bf03261918] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
With intravenous administration of busulfan (Busilvex®), the therapeutic range of the drug is achieved in more paediatric patients than after oral busulfan administration. In clinical trials in paediatric and adult patients, intravenous busulfan-based preconditioning treatment regimen prior to haematopoietic progenitor cell transplantation (HPCT) provided high rates of engraftment, low transplant-related mortality rates and good overall survival and progression-free survival outcomes. Intravenous busulfan was considered to have an acceptable tolerability profile.
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Galaup A, Paci A. Pharmacology of dimethanesulfonate alkylating agents: busulfan and treosulfan. Expert Opin Drug Metab Toxicol 2012; 9:333-47. [PMID: 23157726 DOI: 10.1517/17425255.2013.737319] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Among the dimethanesulfonates, busulfan, in combination with other alkylating agents or nucleoside analogues, is the cornerstone of high-dose chemotherapy. It is used, and followed hematopoietic stem cell transplantation, for the treatment of various hematologic malignancies and immunodeficiencies. Treosulfan, which is a hydrophilic analogue of busulfan, was the first dimethanesufonate registered for the treatment of ovarian cancer. Recently, treosulfan has been investigated for the treatment of hematologic malignancies in combination with the same second agents before hematopoietic stem cell transplantation. AREAS COVERED This work reviews the pharmacological data of these two dimethanesulfonates alkylating agents. Specifically, the article looks at their chemistry, metabolism, anticancer activity, and their pharmacokinetics and pharmacodynamics. EXPERT OPINION Busulfan has been investigated widely for more than three decades leading to a large and precise handling of this agent with numerous studies on activity and pharmacokinetics and pharmacodynamics. In contrast, the behavior of treosulfan is still under investigation and not fully described. The complexity of treosulfan's metabolism and mechanism of action gives rise to the need of a deeper understanding of its pharmacological activity in a context of high-dose chemotherapy. Specifically, there is a great need to better understand its pharmacokinetics/pharmacodynamics relationship.
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Affiliation(s)
- Ariane Galaup
- Collège de France, Center for Interdisciplinary Research in Biology, CNRS UMR 7241, INSERM U 1050, MEMOLIFE Laboratory of Excellence & Paris Science et Lettres Research University, Paris, France
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Veal G, Nguyen L, Paci A, Riggi M, Amiel M, Valteau-Couanet D, Brock P, Ladenstein R, Vassal G. Busulfan pharmacokinetics following intravenous and oral dosing regimens in children receiving high-dose myeloablative chemotherapy for high-risk neuroblastoma as part of the HR-NBL-1/SIOPEN trial. Eur J Cancer 2012; 48:3063-72. [DOI: 10.1016/j.ejca.2012.05.020] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 04/30/2012] [Accepted: 05/22/2012] [Indexed: 01/08/2023]
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Scott LJ, Hoy SM, Lyseng-Williamson KA. Intravenous busulfan: a guide to its use as conditioning treatment before transplantation of haematopoietic progenitor cells. Clin Drug Investig 2012. [PMID: 22877323 DOI: 10.2165/11209670-000000000-00000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
With intravenous administration of busulfan (Busilvex®), the therapeutic range of the drug is achieved in more paediatric patients than after oral busulfan administration. In clinical trials in paediatric and adult patients, intravenous busulfan-based preconditioning treatment regimen prior to haematopoietic progenitor cell transplantation (HPCT) provided high rates of engraftment, low transplant-related mortality rates and good overall survival and progression-free survival outcomes. Intravenous busulfan was considered to have an acceptable tolerability profile.
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[A medical-pharmaceutical partnership model as a contributor to the success in conditioning regimen for allogenic hematopoietic stem cell transplantation in adults: a cross-reflection on our organizations]. Bull Cancer 2012; 99:643-53. [PMID: 22645281 DOI: 10.1684/bdc.2012.1589] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Allogeneic hematopoietic stem-cell transplant (allo-SCT) remains the only cure for many hematological malignancies and some benign and congenital diseases. Busulfan, proposed in its injectable form, has quickly become a mainstay of pharmacological and myeloablative (or non-myeloablative) conditioning. This is following the outbreak in 2010 of a multicenter international clinical phase II trial, we tested the robustness and reliability of our organization in a complex model of organization and multifactorial partnership. In this type "BuCy2" protocol based on a classical treatment duration of 4 consecutive days, the administration of IV busulfan is given in one single daily infusion instead of the conventional 16 infusions, while keeping the same total dose. Under these conditions, the treatment is totally secured using a therapeutic drug monitoring of busulfan, applied in real-time. The process is technically complex and requires the very close cooperation of the teams involved. A strength, weakness, opportunity and threat (SWOT) analysis has been constructed; it fully supports continuous quality improvement to the triple benefit of the nursing chain, the patients and their environment. Several critical points were identified and corrected. The experiment strongly contributes to the safety and security of the medication circuit at the hospital and, improves the performance of allo-SCT. It also contributes to the protection of all actors in the health field and their working environment via a well-functioning quality management system.
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Pharmacokinetic behavior and appraisal of intravenous busulfan dosing in infants and older children: the results of a population pharmacokinetic study from a large pediatric cohort undergoing hematopoietic stem-cell transplantation. Ther Drug Monit 2012; 34:198-208. [PMID: 22406655 DOI: 10.1097/ftd.0b013e31824c2f60] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intravenous (IV) busulfan (Bu) dosing approved in Europe based on 5 body weight (BW) strata has been validated for targeting Bu exposures in children undergoing hematopoietic stem-cell transplantation and with mostly malignant diseases. The authors conducted an observational study aiming to investigate the behavior and ontogeny of IV Bu pharmacokinetic (PK) disposition, and to reevaluate the consistency of the BW-based dosing in very young children with rare diseases. METHODS The observational study comprised 115 patients, mostly infants with immunodeficiencies and metabolic inherited disorders and with altered liver function and/or iron overload. Additional data (90 children, mostly malignant diseases) were pooled with the first data set. The overall data (205 children aged from 10 days to 15 years) were analyzed using population PK modeling. RESULTS The BW remained the main determinant of IV Bu PK, and no further covariate effect was identified. Bu clearance (CL) variability was best described by BW allometric functions. Increase of drug CL with the child's growth was faster in younger children. This pattern is likely related to the maturation of GSTA1 enzymes during infancy and was accounted for in the model by estimating a higher BW allometric exponent in children <9 kg compared with that in children ≥9 kg. IV Bu PK was not modified in children with altered liver function and/or iron overload, and no disease specific difference was observed. Bu dosing either adjusted according to the final model or with the approved EU labeling yields similar targeting performances. For both dosing strategies, the percent of patients achieving the therapeutic area under the curve window (900-1500 μmole·min/L were 60% and 70%-90% in children <9 and ≥9 kg, respectively. CONCLUSIONS A population PK model accounting for the highest Bu CL in the youngest patients was validated on training and evaluation data sets. The BW-based dosing strategy recommended in Europe proved to be consistent on a large paediatric cohort representative of the population heterogeneity observed in hematopoietic stem-cell transplantation.
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The pharmacokinetics and safety of twice daily i.v. BU during conditioning in pediatric allo-SCT recipients. Bone Marrow Transplant 2012; 48:19-25. [PMID: 22684047 DOI: 10.1038/bmt.2012.105] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Intravenous BU divided four times daily (q6 h) has been shown to be safe and effective in pediatric allo-SCT recipients. Though less frequent dosing is desirable, pharmacokinetic (PK) data on twice daily (q12 h) i.v. BU administration in pediatric allo-SCT recipients is limited. We prospectively examined the PK results in a cohort of pediatric allo-SCT recipients receiving i.v. BU q12 h as part of conditioning before allo-SCT. BU levels were obtained after the first dose of conditioning. PK parameter analysis (n=49) yielded the following 95% confidence intervals (CI₉₅): weight-normalized volume of distribution: 0.65-0.73 L/kg; t(1/2): 122-147 min; weight-normalized clearance (CL(n)): 3.4-4.3 mL/min/kg; and area under the curve: 1835-2180 mmol × min/L. From these results, a steady state concentration was calculated with CI₉₅ between 628-746 ng/mL. Comparison between recipients ≤4 vs >4 years old revealed significant differences in t(1/2) (mean: 115 vs 146 min, P=0.008) and CL(n) (mean: 4.4 vs 3.5 mL/min/kg, P=0.038). Intravenous BU q12 h had a comparable PK to i.v. BU q6 h PK seen in the literature, and in pediatric allo-SCT recipients, is a feasible, attractive alternative to i.v. q6h dosing.
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