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Wong DD, Ho SA, Domazetovska A, Yong MK, Rawlinson WD. Evidence supporting the use of therapeutic drug monitoring of ganciclovir in transplantation. Curr Opin Infect Dis 2023; 36:505-513. [PMID: 37729654 DOI: 10.1097/qco.0000000000000965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
PURPOSE OF REVIEW This review describes current knowledge of ganciclovir (GCV) and valganciclovir (ValGCV) pharmacokinetic/pharmacodynamic characteristics, highlighting the likely contribution from host genetic factors to interpatient variability. The evidence and challenges surrounding optimization of drug dosing through therapeutic drug monitoring (TDM) are examined, with recommendations made. RECENT FINDINGS Pharmacokinetic studies of current dosing guidelines have shown high interindividual and intraindividual variability of GCV concentrations. This is sometimes associated with a slow decline in cytomegalovirus (CMV) viral load in some transplant recipients. A high incidence of GCV-associated myelosuppression has limited the use of this drug in the transplant setting. Patient groups identified to benefit from GCV TDM include pediatric patients, cystic fibrosis with lung transplantation, obese with kidney transplantation, and patients with fluctuating renal function or on hemodialysis. The emergence of refractory resistant CMV, particularly in immune compromised patients, highlights the importance of appropriate dosing of these antivirals. Host genetic factors need to be considered where recently, two host genes were shown to account for interpatient variation during ganciclovir therapy. Therapeutic Drug Monitoring has been shown to improve target antiviral-level attainment. The use of TDM may guide concentration-based dose adjustment, potentially improving virological and clinical outcomes. However, evidence supporting the use of TDM in clinical practice remains limited and further study is needed in the transplant cohort. SUMMARY Further studies examining novel biomarkers are needed to guide target concentrations in prophylaxis and treatment. The use of TDM in transplant recipients is likely to improve the clinical efficacy of current antivirals and optimize outcomes in transplant recipients.
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Affiliation(s)
- Diana D Wong
- National Measurement Institute, Lindfield, Sydney, New South Wales
| | - Su Ann Ho
- Peter MacCallum Cancer Centre
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria
| | - Ana Domazetovska
- Serology and Virology Division, NSW Health Pathology, Prince of Wales Hospital, Sydney, New South Wales
| | - Michelle K Yong
- Peter MacCallum Cancer Centre
- Department Infectious Diseases, Royal Melbourne Hospital
- National Centre for Infections in Cancer, Parkville
| | - William D Rawlinson
- Serology and Virology Division, NSW Health Pathology, Prince of Wales Hospital, Sydney, New South Wales
- Schools of Biomedical Sciences, Biotechnology and Biomolecular Sciences, Clinical Sciences, University of NSW, Sydney New South Wales, Australia
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Fang H, Yan HHN, Bilardi RA, Flensburg C, Yang H, Barbour JA, Siu HC, Turski M, Chew E, Xu Z, Lam ST, Sharma R, Xu M, Li J, Ip HW, Cheung CYM, Huen MSY, Sweet-Cordero EA, Majewski IJ, Leung SY, Wong JWH. Ganciclovir-induced mutations are present in a diverse spectrum of post-transplant malignancies. Genome Med 2022; 14:124. [PMID: 36316687 PMCID: PMC9620652 DOI: 10.1186/s13073-022-01131-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 10/20/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Ganciclovir (GCV) is widely used in solid organ and haematopoietic stem cell transplant patients for prophylaxis and treatment of cytomegalovirus. It has long been considered a mutagen and carcinogen. However, the contribution of GCV to cancer incidence and other factors that influence its mutagenicity remains unknown. METHODS This retrospective cohort study analysed genomics data for 121,771 patients who had undergone targeted sequencing compiled by the Genomics Evidence Neoplasia Information Exchange (GENIE) or Foundation Medicine (FM). A statistical approach was developed to identify patients with GCV-associated mutational signature (GCVsig) from targeted sequenced data of tumour samples. Cell line exposure models were further used to quantify mutation burden and DNA damage caused by GCV and other antiviral and immunosuppressive drugs. RESULTS Mutational profiles from 22 of 121,771 patient samples in the GENIE and FM cohorts showed evidence of GCVsig. A diverse range of cancers was represented. All patients with detailed clinical history available had previously undergone solid organ transplantation and received GCV and mycophenolate treatment. RAS hotspot mutations associated with GCVsig were present in 9 of the 22 samples, with all samples harbouring multiple GCV-associated protein-altering mutations in cancer driver genes. In vitro testing in cell lines showed that elevated DNA damage response and GCVsig are uniquely associated with GCV but not acyclovir, a structurally similar antiviral. Combination treatment of GCV with the immunosuppressant, mycophenolate mofetil (MMF), increased the misincorporation of GCV in genomic DNA and mutations attributed to GCVsig in cell lines and organoids. CONCLUSIONS In summary, GCV can cause a diverse range of cancers. Its mutagenicity may be potentiated by other therapies, such as mycophenolate, commonly co-prescribed with GCV for post-transplant patients. Further investigation of the optimal use of these drugs could help reduce GCV-associated mutagenesis in post-transplant patients.
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Affiliation(s)
- Hu Fang
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Department of Research & Development, South China Hospital, Health Science Center, Shenzhen University, Shenzhen, 518116, China
| | - Helen H N Yan
- Department of Pathology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Centre for Oncology and Immunology,, Hong Kong Science Park, Hong Kong SAR, China
| | - Rebecca A Bilardi
- The Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
- Department of Medical Biology, University of Melbourne, 1G Royal Parade, Parkville, VIC, 3052, Australia
| | - Christoffer Flensburg
- The Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
- Department of Medical Biology, University of Melbourne, 1G Royal Parade, Parkville, VIC, 3052, Australia
| | - Haocheng Yang
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Jayne A Barbour
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Hoi Cheong Siu
- Department of Pathology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Michelle Turski
- Division of Hematology/Oncology, Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Edward Chew
- The Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
| | - Zhen Xu
- The Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
- Department of Medical Biology, University of Melbourne, 1G Royal Parade, Parkville, VIC, 3052, Australia
| | - Siu T Lam
- Centre for PanorOmic Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Rakesh Sharma
- Centre for PanorOmic Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Mengya Xu
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Junshi Li
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ho W Ip
- Department of Pathology, Queen Mary Hospital, Hong Kong SAR, China
| | - Carol Y M Cheung
- Department of Medicine, Queen Mary Hospital, Hong Kong SAR, China
| | - Michael S Y Huen
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - E Alejandro Sweet-Cordero
- Division of Hematology/Oncology, Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Ian J Majewski
- The Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia.
- Department of Medical Biology, University of Melbourne, 1G Royal Parade, Parkville, VIC, 3052, Australia.
| | - Suet Y Leung
- Department of Pathology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
- Centre for Oncology and Immunology,, Hong Kong Science Park, Hong Kong SAR, China.
- Centre for PanorOmic Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
- The Jockey Club Centre for Clinical Innovation and Discovery, LKS Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China.
| | - Jason W H Wong
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
- Centre for Oncology and Immunology,, Hong Kong Science Park, Hong Kong SAR, China.
- Centre for PanorOmic Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
- The Jockey Club Centre for Clinical Innovation and Discovery, LKS Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China.
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Thomas SN, French D, Jannetto PJ, Rappold BA, Clarke WA. Liquid chromatography–tandem mass spectrometry for clinical diagnostics. NATURE REVIEWS. METHODS PRIMERS 2022; 2:96. [PMCID: PMC9735147 DOI: 10.1038/s43586-022-00175-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/07/2022] [Indexed: 12/13/2022]
Abstract
Mass spectrometry is a powerful analytical tool used for the analysis of a wide range of substances and matrices; it is increasingly utilized for clinical applications in laboratory medicine. This Primer includes an overview of basic mass spectrometry concepts, focusing primarily on tandem mass spectrometry. We discuss experimental considerations and quality management, and provide an overview of some key applications in the clinic. Lastly, the Primer discusses significant challenges for implementation of mass spectrometry in clinical laboratories and provides an outlook of where there are emerging clinical applications for this technology. Tandem mass spectrometry is increasingly utilized for clinical applications in laboratory medicine. In this Primer, Thomas et al. discuss experimental considerations and quality management for implementing clinical tandem mass spectrometry in the clinic with an overview of some key applications.
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Affiliation(s)
- Stefani N. Thomas
- grid.17635.360000000419368657Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN USA
| | - Deborah French
- grid.266102.10000 0001 2297 6811Laboratory Medicine, University of California San Francisco, San Francisco, CA USA
| | - Paul J. Jannetto
- grid.66875.3a0000 0004 0459 167XDepartment of Pathology & Laboratory Medicine, Mayo Clinic, Rochester, MN USA
| | - Brian A. Rappold
- grid.419316.80000 0004 0550 1859Research and Development, Labcorp, Burlington, NC USA
| | - William A. Clarke
- grid.21107.350000 0001 2171 9311Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD USA
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Jadav T, Jain S, Kalia K, Sengupta P. Current Standing and Technical Guidance on Intracellular Drug Quantification: A New Site Specific Bioavailability Prediction Approach. Crit Rev Anal Chem 2019; 50:50-61. [DOI: 10.1080/10408347.2019.1570462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Tarang Jadav
- Department of Pharmaceutical Analysis, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gujarat, India
| | - Sonali Jain
- Department of Pharmaceutical Analysis, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gujarat, India
| | - Kiran Kalia
- Department of Biotechnology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gujarat, India
| | - Pinaki Sengupta
- Department of Pharmaceutical Analysis, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gujarat, India
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Abstract
Ganciclovir is synthetic nucleoside analog of guanine closely related to acyclovir but has greater activity against cytomegalovirus. This comprehensive profile on ganciclovir starts with a description of the drug: nomenclature, formulae, chemical structure, elemental composition, and appearance. The uses and application of the drug are explained. The methods that were used for the preparation of ganciclovir are described and their respective schemes are outlined. The methods which were used for the physical characterization of the dug are: ionization constant, solubility, X-ray powder diffraction pattern, crystal structure, melting point, and differential scanning calorimetry. The chapter contains the spectra of the drug: ultraviolet spectrum, vibrational spectrum, nuclear magnetic resonance spectra, and the mass spectrum. The compendial methods of analysis of ganciclovir include the United States Pharmacopeia methods. Other methods of analysis that were reported in the literature include: high-performance liquid chromatography alone or with mass spectrometry, electrophoresis, spectrophotometry, voltammetry, chemiluminescence, and radioimmunoassay. Biological investigation on the drug includes: pharmacokinetics, metabolism, bioavailability, and biological analysis. Reviews on the methods used for preparation or for analysis of the drug are provided. The stability of the drug in various media and storage conditions is reported. More than 240 references are listed at the end of the chapter.
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Affiliation(s)
- Abdullah A Al-Badr
- College of Pharmacy, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Tariq D S Ajarim
- College of Pharmacy, King Saud University, Riyadh, Kingdom of Saudi Arabia
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