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Henkel L, Jehn U, Thölking G, Reuter S. Tacrolimus-why pharmacokinetics matter in the clinic. FRONTIERS IN TRANSPLANTATION 2023; 2:1160752. [PMID: 38993881 PMCID: PMC11235362 DOI: 10.3389/frtra.2023.1160752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/07/2023] [Indexed: 07/13/2024]
Abstract
The calcineurin inhibitor (CNI) Tacrolimus (Tac) is the most prescribed immunosuppressant drug after solid organ transplantation. After renal transplantation (RTx) approximately 95% of recipients are discharged with a Tac-based immunosuppressive regime. Despite the high immunosuppressive efficacy, its adverse effects, narrow therapeutic window and high intra- and interpatient variability (IPV) in pharmacokinetics require therapeutic drug monitoring (TDM), which makes treatment with Tac a major challenge for physicians. The C/D ratio (full blood trough level normalized by daily dose) is able to classify patients receiving Tac into two major metabolism groups, which were significantly associated with the clinical outcomes of patients after renal or liver transplantation. Therefore, the C/D ratio is a simple but effective tool to identify patients at risk of an unfavorable outcome. This review highlights the challenges of Tac-based immunosuppressive therapy faced by transplant physicians in their daily routine, the underlying causes and pharmacokinetics (including genetics, interactions, and differences between available Tac formulations), and the latest data on potential solutions to optimize treatment of high-risk patients.
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Affiliation(s)
- Lino Henkel
- Department of Medicine D, University of Münster, Münster, Germany
| | - Ulrich Jehn
- Department of Medicine D, University of Münster, Münster, Germany
| | - Gerold Thölking
- Department of Medicine D, University of Münster, Münster, Germany
- Department of Internal Medicine and Nephrology, University Hospital of Münster Marienhospital Steinfurt, Steinfurt, Germany
| | - Stefan Reuter
- Department of Medicine D, University of Münster, Münster, Germany
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Kuan WYJ, Châteauvert N, Leclerc V, Drolet B. Tacrolimus Dose-Conversion Ratios Based on Switching of Formulations for Patients with Solid Organ Transplants. Can J Hosp Pharm 2021; 74:317-326. [PMID: 34602619 DOI: 10.4212/cjhp.v74i4.3193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Background Tacrolimus may be administered during hospitalization as an IV formulation or oral suspension. However, literature suggesting appropriate ratios for conversion from these formulations to capsules is limited. Objective To evaluate conversion ratios after a switch in formulation of tacrolimus for solid-organ transplant recipients. Methods This single-centre observational longitudinal study involved hospitalized patients who underwent a switch in formulation of tacrolimus according to 1 of 3 possible scenarios: IV to oral suspension, IV to capsule, or oral suspension to capsule. Data were collected from the earliest accessible electronic file (January 2009) to January 1, 2019. Conversion ratios were calculated for each of the 3 groups using data for blood concentrations and doses before and after the switch. The calculated ratios were then compared with recommended conversion ratios: 1:5 (i.e., 1 mg of IV tacrolimus is converted to 5 mg of oral tacrolimus, expressed as "5") for either of the switches involving an IV formulation and 1:1 (i.e., same amount, expressed as "1") for the switch from oral formulation to capsules. Results For the group who underwent switching from the IV formulation to oral suspension, the mean calculated conversion ratio was 3.04, which was significantly different from the recommended ratio of 5. For the group who underwent switching from the IV formulation to capsules, the calculated conversion ratio was 5.18, which was not significantly different from the recommended ratio of 5. For the group who underwent switching from oral suspension to capsules, the calculated conversion ratio was 1.17, which was not significantly different from the recommended ratio of 1. Conclusion In this small retrospective study of tacrolimus therapy, the calculated conversion ratio was significantly different from the recommended ratio for patients who were switched from IV administration to oral suspension, but not for those switched from IV administration or oral suspension to capsules. Therapeutic drug monitoring therefore appears indispensable, regardless of conversion ratios.
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Affiliation(s)
- Wen-Yuan Johnson Kuan
- , PharmD, MSc, is a Pharmacist with the Department of Pharmacy, Centre intégré de santé et de services sociaux des Laurentides, Hôpital de Saint-Eustache, Saint-Eustache, Quebec, and Chargé d'enseignement clinique (Clinical Preceptor) with the Faculty of Pharmacy, Université Laval, Québec, Quebec
| | - Nathalie Châteauvert
- , BPharm, MSc, is a Pharmacist with the Department of Pharmacy, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval (IUCPQ-UL), and Clinical Professor with the Faculty of Pharmacy, Université Laval, Québec, Quebec
| | - Vincent Leclerc
- , BPharm, MSc, is a Pharmacist with the Department of Pharmacy, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval (IUCPQ-UL), and Chargé d'enseignement clinique (Clinical Preceptor) with the Faculty of Pharmacy, Université Laval, Québec, Quebec
| | - Benoît Drolet
- , BPharm, PhD, is an Investigator with the Research Centre, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval (IUCPQ-UL), and Professor with the Faculty of Pharmacy, Université Laval, Québec, Quebec
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Sobiak J, Głyda M, Malec M, Chrzanowska M. Pharmacokinetics of Mycophenolate Mofetil Metabolites in Older Patients on the Seventh Day After Renal Transplantation. Transplant Proc 2021; 53:2212-2215. [PMID: 34412913 DOI: 10.1016/j.transproceed.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Currently, immunosuppression schemes are age-independent; however, physiological changes may alter drugs' pharmacokinetics in the older population. We compared mycophenolic acid (MPA) and its glucuronide metabolite (MPAG) pharmacokinetics among patients aged <60 and >60 years on the seventh day after renal transplantation. METHODS We included 7 and 10 renal transplant recipients, aged >60 and <60 years, respectively, treated with mycophenolate mofetil. MPA and MPAG concentrations were determined using the high-performance liquid chromatography method with ultraviolet detection (HPLC-UV). Noncompartmental pharmacokinetic analysis was performed. RESULTS In patients aged >60 years, mean MPA and MPAG concentrations before the next dose and ratio of MPAG area under the concentration-time curve (AUC0-12) to MPA AUC0-12 were higher by 1.6-fold, 1.4-fold, and 1.9-fold, respectively. Other MPAG concentrations appeared to be slightly higher (1.2- to 1.5-fold) in older patients. MPA apparent clearance was similar in both groups, whereas volume of distribution at steady state was slightly higher (1.6-fold) in patients aged >60 years. The variability of most MPA and some MPAG pharmacokinetics was greater in patients aged >60 years. The MPA AUC0-12 target was achieved in 40% and 14% of patients aged <60 and >60 years, respectively. The highest MPAG concentrations and AUC0-12 were observed for patients with the lowest glomerular filtration rate. CONCLUSIONS Higher variability of MPA and MPAG pharmacokinetic parameters, MPA AUC0-12 above the reference range, higher values of MPAG pharmacokinetics in patients with lower glomerular filtration rates, as well as lower proportion of patients achieving MPA targets all indicate the need for therapeutic drug monitoring in renal transplant recipients aged >60 years and to verify target MPA AUC0-12 for this population.
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Affiliation(s)
- J Sobiak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland.
| | - M Głyda
- Department of Transplantology and General Surgery, Poznań District Hospital, Poznań, Poland; Department of Hepatobiliary and General Surgery, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - M Malec
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
| | - M Chrzanowska
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
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Al-Kofahi M, Oetting WS, Schladt DP, Remmel RP, Guan W, Wu B, Dorr CR, Mannon RB, Matas AJ, Israni AK, Jacobson PA. Precision Dosing for Tacrolimus Using Genotypes and Clinical Factors in Kidney Transplant Recipients of European Ancestry. J Clin Pharmacol 2021; 61:1035-1044. [PMID: 33512723 PMCID: PMC11240873 DOI: 10.1002/jcph.1823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/26/2021] [Indexed: 12/14/2022]
Abstract
Genetic variation in the CYP3A4 and CYP3A5 (CYP3A4/5) genes, which encode the key enzymes in tacrolimus metabolism, is associated with tacrolimus clearance and dose requirements. Tacrolimus has a narrow therapeutic index with high intra- and intersubject variability, in part because of genetic variation. High tacrolimus clearance and low trough concentration are associated with a greater risk for rejection, whereas high troughs are associated with calcineurin-induced toxicity. The objective of this study was to develop a model of tacrolimus clearance with a dosing equation accounting for genotypes and clinical factors in adult kidney transplant recipients of European ancestry that could preemptively guide dosing. Recipients receiving immediate-release tacrolimus for maintenance immunosuppression from 2 multicenter studies were included. Participants in the GEN03 study were used for tacrolimus model development (n = 608 recipients) and was validated by prediction performance in the DeKAF Genomics study (n = 1361 recipients). Nonlinear mixed-effects modeling was used to develop the apparent oral tacrolimus clearance (CL/F) model. CYP3A4/5 genotypes and clinical covariates were tested for their influence on CL/F. The predictive performance of the model was determined by assessing the bias (median prediction error [ME] and median percentage error [MPE]) and the precision (root median squared error [RMSE]) of the model. CYP3A5*3, CYP3A4*22, corticosteroids, calcium channel blocker and antiviral drug use, age, and diabetes significantly contributed to the interindividual variability of oral tacrolimus apparent clearance. The bias (ME, MPE) and precision (RMSE) of the final model was good, 0.49 ng/mL, 6.5%, and 3.09 ng/mL, respectively. Prospective testing of this equation is warranted.
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Affiliation(s)
- Mahmoud Al-Kofahi
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - William S Oetting
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - David P Schladt
- Hennepin Health Research Institute, Minneapolis, Minnesota, USA
| | - Rory P Remmel
- Department of Medicinal Chemistry, University of Minnesota, Minneapolis, Minnesota, USA
| | - Weihua Guan
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Baolin Wu
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Casey R Dorr
- Hennepin Health Research Institute, Minneapolis, Minnesota, USA
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Roslyn B Mannon
- Division of Nephrology, University of Nebraska, Omaha, Nebraska, USA
| | - Arthur J Matas
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ajay K Israni
- Hennepin Health Research Institute, Minneapolis, Minnesota, USA
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Pamala A Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
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5
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Cossart AR, Isbel NM, Scuderi C, Campbell SB, Staatz CE. Pharmacokinetic and Pharmacodynamic Considerations in Relation to Calcineurin Usage in Elderly Kidney Transplant Recipients. Front Pharmacol 2021; 12:635165. [PMID: 33912051 PMCID: PMC8072471 DOI: 10.3389/fphar.2021.635165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 02/12/2021] [Indexed: 12/28/2022] Open
Abstract
This review summarizes how possible age-related changes in tacrolimus and cyclosporine pharmacokinetics and pharmacodynamics may influence drug dosing and monitoring in the elderly, and highlights how micro-sampling may be useful in this cohort in the future. Advancing biological age leads to physiological changes that can affect drug absorption, distribution, metabolism and excretion, as well as immune system responsiveness. Some studies have shown that elderly recipients may have higher dose-adjusted exposure and/or lower clearance of the calcineurin inhibitors, suggesting that doses may need to be lowered in elderly recipients. Only one study has examined how aging effects drug target enzyme activity and demonstrated that age does not correlate with the calcineurin inhibitor half-maximal inhibitory concentration. Several studies have shown elderly kidney transplant recipients have increased risk of both morbidity and mortality, compared to younger adults due to increased susceptibility to immunosuppressant side effects, particularly cardiovascular disease, infection and malignancy. Current immunosuppressant dosing and monitoring protocols often make no adjustments for age. Lower maintenance immunosuppressant targets in elderly recipients may decrease patient susceptibility to drug side effects, however, further studies are required and appropriate targets need to be established. Blood draw by micro-sampling may be useful for drug monitoring in this cohort in the future, as blood collection is minimally invasive and less painful than venepuncture. Micro-sampling could also make further pharmacokinetic, pharmacodynamics and outcome studies in the elderly more feasible.
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Affiliation(s)
- Amelia R Cossart
- School of Pharmacy, University of Queensland, Brisbane, QLD, Australia
| | - Nicole M Isbel
- Department of Nephrology, University of Queensland at the Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Carla Scuderi
- School of Pharmacy, University of Queensland, Brisbane, QLD, Australia.,Kidney Health Service, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Scott B Campbell
- Department of Nephrology, University of Queensland at the Princess Alexandra Hospital, Brisbane, QLD, Australia
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6
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Sobiak J, Głyda M, Chrzanowska M. Pharmacokinetics of Enteric-Coated Mycophenolate Sodium Metabolites in Patients Over 60 Years Old Within the First Year After Renal Transplantation. Transplant Proc 2020; 53:1001-1004. [PMID: 33246587 DOI: 10.1016/j.transproceed.2020.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/01/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVE It is still unclear whether mycophenolic acid (MPA) doses should be adjusted for older patients. Therefore, we compared the pharmacokinetics of MPA, mycophenolic acid glucuronide (MPAG), and free MPA (fMPA) between older and younger renal transplant recipients. METHODS We included 12 patients <60 years and 6 patients >60 years within the first year after renal transplantation, who were receiving enteric-coated mycophenolate sodium, tacrolimus, and steroids. Blood samples were collected up to 12 hours after drug administration. RESULTS MPA and fMPA pharmacokinetics were similar for patients <60 and >60 years; however, the MPA area under the concentration-time curve from 0 to 12 hours (AUC0-12) was 1.2-fold lower in the older patients. MPAG pharmacokinetics were more than 1.5-fold higher in patients >60 years, which might be related to deteriorated renal function in older people. Moreover, the mean (MPAG AUC0-12)/(MPA AUC0-12) ratio was more than 2-fold higher in patients >60 years. The second maximal MPA concentration was more frequently observed in patients <60 years, although all patients received tacrolimus. The percentage of patients with MPA concentration before the next drug dose (Ctrough) and AUC0-12 within and below target was the same in both groups. All patients >60 years had MPA AUC0-12 >30 μg·h/mL within 22 to 114 days after transplantation. CONCLUSIONS MPA therapeutic monitoring should be recommended in enteric-coated mycophenolate sodium--treated patients >60 years because MPA AUC0-12 exceeded the recommended value in half of the studied patients.
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Affiliation(s)
- J Sobiak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland.
| | - M Głyda
- Department of Transplantology and General Surgery, Poznań District Hospital, Poznań, Poland; Department of Hepatobiliary and General Surgery, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - M Chrzanowska
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
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7
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Nowicka M, Górska M, Nowicka Z, Edyko K, Edyko P, Wiślicki S, Zawiasa-Bryszewska A, Strzelczyk J, Matych J, Kurnatowska I. Tacrolimus: Influence of the Posttransplant Concentration/Dose Ratio on Kidney Graft Function in a Two-Year Follow-Up. Kidney Blood Press Res 2019; 44:1075-1088. [PMID: 31522184 DOI: 10.1159/000502290] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 07/22/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Tacrolimus (TAC) metabolism rate has the potential to impact graft function after kidney transplantation (KTx). We aimed to analyze the relationship between the early post-KTx TAC C/D ratio (blood trough concentration normalized by total daily dose) and kidney graft function in a 2-year follow-up. METHODS We retrospectively analyzed data from 101 post-KTx patients at 3, 6, 12, and 24 months after KTx to identify the C/D ratio cutoff value optimal for dividing patients into fast and slow TAC metabolizers. We investigated the relationship between their TAC metabolism rate and graft function. RESULTS Patients were divided based on the TAC C/D ratio at 6 months after KTx of 1.47 ng/mL * 1 mg. Fast metabolizers (C/D ratio <1.47 ng/mL * 1 mg) presented with significantly worse graft function throughout the whole study period (p < 0.05 at each timepoint) and were significantly less likely to develop good graft function (estimated glomerular filtration rate ≥45 mL/min/1.73 m2) than slow metabolizers. Our model based on donor and recipient age, recipient sex and slow/fast metabolism status allowed for identification of patients with compromised graft function in 2-year follow-up with 66.7% sensitivity and 94.6% specificity. CONCLUSION Estimating TAC C/D ratio at 6 months post-KTx might help identify patients at risk of developing deteriorated graft function in a 2-year follow-up.
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Affiliation(s)
- Maja Nowicka
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland
| | - Monika Górska
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland
| | - Zuzanna Nowicka
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland.,Department of Biostatistics and Translational Medicine, Medical University of Lodz, Lodz, Poland
| | - Krzysztof Edyko
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland
| | - Piotr Edyko
- Department of Urology and Kidney Transplantation, N Pirogov Provincial Specialist Hospital, Lodz, Poland
| | - Sebastian Wiślicki
- Clinical Department of Anesthesiology and Intensive Care and Pain Management, University Clinical Hospital No 1 N Barlicki in Lodz, Lodz, Poland
| | - Anna Zawiasa-Bryszewska
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland.,Department of Nephrology, University Clinical Hospital No 1 N Barlicki in Lodz, Lodz, Poland
| | - Janusz Strzelczyk
- Department of General and Transplant Surgery, Medical University of Lodz, Lodz, Poland
| | - Józef Matych
- Department of Urology and Kidney Transplantation, N Pirogov Provincial Specialist Hospital, Lodz, Poland
| | - Ilona Kurnatowska
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland, .,Department of Nephrology, University Clinical Hospital No 1 N Barlicki in Lodz, Lodz, Poland,
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8
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Cossart AR, Cottrell WN, Campbell SB, Isbel NM, Staatz CE. Characterizing the pharmacokinetics and pharmacodynamics of immunosuppressant medicines and patient outcomes in elderly renal transplant patients. Transl Androl Urol 2019; 8:S198-S213. [PMID: 31236338 DOI: 10.21037/tau.2018.10.16] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
This review examines what is currently known about the pharmacokinetics and pharmacodynamics of commonly prescribed immunosuppressant medicines, tacrolimus, cyclosporine, mycophenolate and prednisolone, in elderly renal transplant recipients, and reported patient outcomes in this cohort. Renal transplantation is increasing rapidly in the elderly, however, currently, long-term patient outcomes are relatively poor compared to younger adults. Some studies have suggested that elderly recipients may have higher dose-adjusted exposure and/or lower clearance of the calcineurin inhibitors tacrolimus and cyclosporine; with one study reporting up to 50% reduction in tacrolimus exposure in the elderly. Elderly transplant recipients do not appear to have higher dosage-adjusted exposure to mycophenolic acid (MPA). The effects of ageing on the pharmacokinetics of prednisolone are unknown. Only one study has examined how aging effects drug target enzymes, reporting no difference in baseline inosine 5'-monophosphate dehydrogenase (IMPDH) activity and MPA-induced IMPDH activity in elderly compared to younger adult renal transplant recipients. In elderly transplant recipients, immunosenescence likely lowers the risk of acute rejection, but increases the risk of drug-related adverse effects. Currently, the three main causes of death in elderly renal transplant recipients are cardiovascular disease, infection and malignancy. One study has showed that renal transplant recipients aged over 65 years are seven times more likely to die with a functioning graft compared with young adults (aged 18-29 years). This suggests that an optimal balance between immunosuppressant medicine efficacy and toxicity is not achieved in elderly recipients, and further studies are needed to foster long-term graft and patient survival. Lower maintenance immunosuppressant targets in elderly recipients may decrease patient susceptibility to drug side effects, however, further studies are required and appropriate targets need to be established.
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Affiliation(s)
- Amelia R Cossart
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - W Neil Cottrell
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Scott B Campbell
- Department of Nephrology, University of Queensland at the Princess Alexandra Hospital, Brisbane, Australia
| | - Nicole M Isbel
- Department of Nephrology, University of Queensland at the Princess Alexandra Hospital, Brisbane, Australia
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9
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Romano P, Agena F, de Almeida Rezende Ebner P, Massakazu Sumita N, Kamada Triboni AH, Ramos F, dos Santos Garcia M, Coelho Duarte NJ, Brambate Carvalhinho Lemos F, Zocoler Galante N, David-Neto E. Longitudinal Pharmacokinetics of Mycophenolic Acid in Elderly Renal Transplant Recipients Compared to a Younger Control Group: Data from the nEverOld Trial. Eur J Drug Metab Pharmacokinet 2018; 44:189-199. [DOI: 10.1007/s13318-018-0506-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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10
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Longitudinal Pharmacokinetics of Tacrolimus in Elderly Compared With Younger Recipients in the First 6 Months After Renal Transplantation. Transplantation 2017; 101:1365-1372. [PMID: 27482958 DOI: 10.1097/tp.0000000000001369] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Elderly (Eld) (≥60 years) recipients are receiving renal transplants more frequently. The pharmacokinetics (PK) studies of immunosuppressive drugs in healthy volunteers, rarely, include old patients. METHODS We studied 208 12-hour tacrolimus (TAC) PK (0, 20, 40, 60, 90, 120, 180, 240, 360, 480, 600, 720 min) in 44 Eld (65 ± 3 years) and compared the results with 31 younger controls (Ctrl) (35 ± 6 years) recipients, taking oral TAC/mycophenolate sodium (MPS)/prednisone, at 4 different timepoints: PK1 (8 ± 2 days; n = 72), PK2 (31 ± 4 days; n = 61), PK3 (63 ± 6 days; n = 44), and PK4 (185 ± 10 days; n = 31). Tacrolimus PK was measured by ultraperformance liquid chromatography coupled to a mass spectrometer repetition and noncompartmental PKs were analyzed using Phoenix WinNonlin. RESULTS Mean TAC dose was lower in the Eld group than in Ctrl ones throughout timepoints either by total daily dose or adjusted (Adj) per body weight. Mean TAC trough level (Cmin), used to adjust daily dose, was not different between the 2 groups in all timepoints. AdjCmax and AdjTAC-area under the curve at dosing interval were both higher in the Eld compared to the Ctrl group in PKs1, 3, and 4. Estimated total body clearance normalized by dose and weight was lower in the Eld group compared with the Ctrl in all PKs and statistically lower at PKs 1 and 3. Similar to younger recipients TAC trough level has also a high correlation (R = 0.76) with area under the curve at dosing interval. CONCLUSIONS These data indicate that Eld recipients have a lower TAC clearance and therefore need a lower TAC dose than younger recipients.
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11
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Streeter AJ, Faria EC. Analysis of the variability of the pharmacokinetics of multiple drugs in young adult and elderly subjects and its implications for acceptable daily exposures and cleaning validation limits. Int J Hyg Environ Health 2017; 220:659-672. [PMID: 28396010 DOI: 10.1016/j.ijheh.2017.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 03/17/2017] [Accepted: 03/17/2017] [Indexed: 10/19/2022]
Abstract
The elderly constitute a significant, potentially sensitive, subpopulation within the general population, which must be taken into account when performing risk assessments including determining an acceptable daily exposure (ADE) for the purpose of a cleaning validation. Known differences in the pharmacokinetics of drugs between young adults (who are typically the subjects recruited into clinical trials) and the elderly are potential contributors affecting the interindividual uncertainty factor (UFH) component of the ADE calculation. The UFH values were calculated for 206 drugs for young adult and elderly groups separately and combined (with the elderly assumed to be a sensitive subpopulation) from published studies where the pharmacokinetics of the young adult and elderly groups were directly compared. Based on the analysis presented here, it is recommended to use a default UFH value of 10 for worker populations (which are assumed to be approximately equivalent to the young adult groups) where no supporting pharmacokinetic data exist, while it is recommended to use a default UFH value of 15 for the general population, to take the elderly into consideration when calculating ADE values. The underlying reasons for the large differences between the exposures in the young adult and elderly subjects for the 10 compounds which show the greatest separation are different in almost every case, involving the OCT2 transporter, glucuronidation, hydrolysis, CYP1A2, CYP2A6, CYP2C19, CYP2D6, CYP3A4 or CYP3A5. Therefore, there is no consistent underlying mechanism which appears responsible for the largest differences in pharmacokinetic parameters between young adult and elderly subjects.
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Affiliation(s)
- Anthony J Streeter
- Janssen Research & Development LLC, Spring House, PA and Raritan, NJ, USA.
| | - Ellen C Faria
- Janssen Research & Development LLC, Spring House, PA and Raritan, NJ, USA.
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12
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Tang JT, de Winter BC, Hesselink DA, Sombogaard F, Wang LL, van Gelder T. The pharmacokinetics and pharmacodynamics of mycophenolate mofetil in younger and elderly renal transplant recipients. Br J Clin Pharmacol 2016; 83:812-822. [PMID: 27753146 DOI: 10.1111/bcp.13154] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 09/27/2016] [Accepted: 10/02/2016] [Indexed: 02/05/2023] Open
Abstract
AIMS Elderly transplant recipients have a lower incidence of acute rejection, and a higher risk to die from infectious complications. A potential cause may be differences in the pharmacokinetics (PK) or pharmacodynamics (PD) of the immunosuppressive drugs they are taking. This study was designed to comprehensively evaluate the influence of age on the PK and PD of mycophenolic acid (MPA). METHODS In this study the PK and PD of MPA was studied in 26 elderly and 54 younger renal transplant recipients treated with mycophenolate mofetil and tacrolimus. Patients were sampled repetitively, both before and during the first 6 months after kidney transplantation. Age-related variability in MPA PK, baseline IMPDH activity, as well as MPA-induced IMPDH inhibition were studied. RESULTS The IMPDH activity pre-transplantation did not differ between elderly and younger patients. Neither IMPDH activity pre-transplantation nor maximum IMPDH inhibition was significantly correlated with the patients' age. The area under the MPA plasma concentration-time curve (AUC0-12h ) and the area under the effect (IMPDH activity)-time curve (AEC0-12h ) from 0 to 12 h were also not significantly different between the two groups. We found no significant differences in EC50 and Emax between elderly and younger patients. CONCLUSIONS Age did not significantly affect the PK or PD of MPA. It is unlikely that the lower incidence of acute rejection in elderly patients, or the higher risk to die from a severe infection in elderly patients is due to different handling of MPA in the elderly.
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Affiliation(s)
- Jiang-Tao Tang
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, China.,Department of Hospital Pharmacy, Clinical Pharmacology Unit, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Brenda C de Winter
- Department of Hospital Pharmacy, Clinical Pharmacology Unit, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Ferdi Sombogaard
- Department of Hospital Pharmacy, VU Medical Center, Amsterdam, The Netherlands
| | - Lan-Lan Wang
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Teun van Gelder
- Department of Hospital Pharmacy, Clinical Pharmacology Unit, Erasmus MC, University Medical Center Rotterdam, The Netherlands.,Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
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13
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EXP CLIN TRANSPLANTExp Clin Transplant 2016; 14. [DOI: 10.6002/ect.2015.0273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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14
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Bunnapradist S, Rostaing L, Alloway RR, West-Thielke P, Denny J, Mulgaonkar S, Budde K. LCPT once-daily extended-release tacrolimus tablets versus twice-daily capsules: a pooled analysis of two phase 3 trials in important de novo and stable kidney transplant recipient subgroups. Transpl Int 2016; 29:603-11. [PMID: 26953629 DOI: 10.1111/tri.12770] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 11/07/2015] [Accepted: 02/26/2016] [Indexed: 11/29/2022]
Abstract
African-American and elderly kidney transplant recipients (KTR) have increased risk for poor clinical outcomes post-transplant. Management of immunosuppression may be challenging in these patients and contribute to worse outcomes. A novel once-daily formulation of tacrolimus (LCPT) has demonstrated noninferiority, similar safety, improved bioavailability, a consistent concentration time profile, and less peak and peak-trough fluctuations vs. tacrolimus twice-daily (Tac BID). This pooled analysis of two phase 3 randomized, controlled trials, including 861 (LCPT N = 428; Tac BID N = 433; 38% of patients were stable KTR, and 62% were de novo KTR) patients, examined the efficacy of LCPT in KTR subgroups (blacks, females, and age ≥65). Overall, treatment failure [death, graft failure, centrally read biopsy-proven acute rejection (BPAR), or lost to follow-up] at 12 months was as follows: LCPT: 11.9%, BID Tac: 13.4% [-1.48% (-5.95%, 2.99%)]. BPAR rates were as follows: LCPT: 8.2%, Tac BID: 9.5% [-1.29% (-5.14%, 2.55%)]. Numerically, fewer treatment failure events with LCPT were found in the majority of subgroups, with significantly less treatment failure associated with LCPT among black KTR [-13.82% (-27.22%, -0.31%)] and KTR ≥65 [-13.46% (-25.27%, -0.78%)]. This pooled analysis suggests numerically lower efficacy failure rates associated with LCPT among high-risk subgroups, in particular black KTR and KTR ≥65 years old.
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Affiliation(s)
| | | | - Rita R Alloway
- University of Cincinnati Medical Center & The Christ Hospital, Cincinnati, OH, USA
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15
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Vanhove T, Annaert P, Kuypers DRJ. Clinical determinants of calcineurin inhibitor disposition: a mechanistic review. Drug Metab Rev 2016; 48:88-112. [DOI: 10.3109/03602532.2016.1151037] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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16
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Abstract
Demographic changes are associated with a steady increase of older patients with end-stage organ failure in need for transplantation. As a result, the majority of transplant recipients are currently older than 50 years, and organs from elderly donors are more frequently used. Nevertheless, the benefit of transplantation in older patients is well recognized, whereas the most frequent causes of death among older recipients are potentially linked to side effects of their immunosuppressants.Immunosenescence is a physiological part of aging linked to higher rates of diabetes, bacterial infections, and malignancies representing the major causes of death in older patients. These age-related changes impact older transplant candidates and may have significant implications for an age-adapted immunosuppression. For instance, immunosenescence is linked to lower rates of acute rejections in older recipients, whereas the engraftment of older organs has been associated with higher rejection rates. Moreover, new-onset diabetes mellitus after transplantation is more frequent in the elderly, potentially related to corticosteroids, calcineurin inhibitors, and mechanistic target of rapamycin inhibitors.This review presents current knowledge for an age-adapted immunosuppression based on both, experimental and clinical studies in and beyond transplantation. Recommendations of maintenance and induction therapy may help to improve graft function and to design future clinical trials in the elderly.
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17
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Sanghavi K, Brundage RC, Miller MB, Schladt DP, Israni AK, Guan W, Oetting WS, Mannon RB, Remmel RP, Matas AJ, Jacobson PA. Genotype-guided tacrolimus dosing in African-American kidney transplant recipients. THE PHARMACOGENOMICS JOURNAL 2015; 17:61-68. [PMID: 26667830 PMCID: PMC4909584 DOI: 10.1038/tpj.2015.87] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 10/07/2015] [Accepted: 11/02/2015] [Indexed: 12/11/2022]
Abstract
Tacrolimus is dependent on CYP3A5 enzyme for metabolism. Expression of the CYP3A5 enzyme is controlled by several alleles including CYP3A5*1, CYP3A5*3, CYP3A5*6 and CYP3A5*7. African Americans (AAs) have on average higher tacrolimus dose requirements than Caucasians; however, some have requirements similar to Caucasians. Studies in AAs have primarily evaluated the CYP3A5*3 variant; however, there are other common nonfunctional variants in AAs (CYP3A5*6 and CYP3A5*7) that do not occur in Caucasians. These variants are associated with lower dose requirements and may explain why some AAs are metabolically similar to Caucasians. We created a tacrolimus clearance model in 354 AAs using a development and validation cohort. Time after transplant, steroid and antiviral use, age and CYP3A5*1, *3, *6 and *7 alleles were significant toward clearance. This study is the first to develop an AA-specific genotype-guided tacrolimus dosing model to personalize therapy.
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Affiliation(s)
- K Sanghavi
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - R C Brundage
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - M B Miller
- Department of Psychology, University of Minnesota, Minneapolis, MN, USA
| | - D P Schladt
- Department of Nephrology and Chronic Disease Research Group, Minneapolis Medical Research Foundation, Hennepin County Medical Center, Minneapolis, MN, USA
| | - A K Israni
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - W Guan
- Department of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - W S Oetting
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - R B Mannon
- Department of Nephrology, University of Alabama, Birmingham, AL, USA
| | - R P Remmel
- Department of Medicinal Chemistry, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - A J Matas
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - P A Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
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Shi YY, Hesselink DA, van Gelder T. Pharmacokinetics and pharmacodynamics of immunosuppressive drugs in elderly kidney transplant recipients. Transplant Rev (Orlando) 2015; 29:224-30. [PMID: 26048322 DOI: 10.1016/j.trre.2015.04.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 04/29/2015] [Accepted: 04/30/2015] [Indexed: 02/05/2023]
Abstract
Elderly patients are a fast growing population among transplant recipients over the past decades. Both the innate and adaptive immune reactivity decrease with age, which is believed to contribute to the decreased incidence of acute rejection and increased infectious death rate in elderly transplant recipients. In contrast to recipient age, donor age is associated with a higher incidence of acute rejection. Pharmacokinetic studies in renal transplant recipients show that CNI troughs are >5% higher in elderly compared to younger patients given the same dose normalized by body weight. This may impact the starting dose of tacrolimus and cyclosporine. Possibly in elderly patients the intracellular (in lymphocyte) concentrations are relatively high in relation to the whole blood concentration, resulting in a stronger pharmacodynamic effect at the same whole blood trough concentration. For cyclosporine this has been shown, but it is not clear if the same is true for other immunosuppressive drugs. Pharmacodynamic studies have compared the inhibition of target enzymes, or more downstream effects of immunosuppressive drugs, in younger and older patients. Measurement of nuclear factor of activated T-cell (NFAT)-regulated gene expression (RGE), a pharmacodynamic read-out of CNI, is a promising biomarker of immunosuppression. Low levels of NFAT RGE are associated with increased risk of infection and non-melanoma skin cancer in elderly patients. Clinical trials to evaluate the safety and efficacy of immunosuppression regimens in this specific patient population, which is underrepresented in published trials, are lacking. More studies in elderly patients are needed to investigate the impact of age on the pharmacokinetics or pharmacodynamics of immunosuppressive drugs, and to decide on the optimal regimen and target levels for elderly transplant recipients.
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Affiliation(s)
- Yun-Ying Shi
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Dennis A Hesselink
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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19
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Rojas L, Neumann I, Herrero MJ, Bosó V, Reig J, Poveda JL, Megías J, Bea S, Aliño SF. Effect of CYP3A5*3 on kidney transplant recipients treated with tacrolimus: a systematic review and meta-analysis of observational studies. THE PHARMACOGENOMICS JOURNAL 2014; 15:38-48. [PMID: 25201288 DOI: 10.1038/tpj.2014.38] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 03/26/2014] [Accepted: 06/04/2014] [Indexed: 12/21/2022]
Abstract
The highly variable pharmacokinetics of tacrolimus can hamper the optimal management of kidney transplant patients. This variability has been attributed to the genetic polymorphism of CYP3A5 6986A>G, but the evidence is not clear. We conducted a meta-analysis of studies evaluating the effect of CYP3A5 polymorphism on kidney transplant recipients with tacrolimus plasma concentration divided by daily dose per body weight (C/D) and clinical outcomes. We searched in MEDLINE and EMBASE. We found evidence suggesting a significantly lower C/D among CYP3A5*1 allele carriers compared with carriers of the CYP3A5*3/*3 genotype at weeks 1 and 2, and months 1, 3, 6 and 12. We demonstrated that the expresser genotype might have higher risk of acute rejection and chronic nephrotoxicity. In conclusion, CYP3A5 6986A>G polymorphism can affect tacrolimus pharmacokinetics and the incidence of acute rejection and chronic nephrotoxicity on kidney transplant recipients. Patients at high risk of developing tacrolimus-related complications could be detected even before their kidney transplant.
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Affiliation(s)
- L Rojas
- 1] Department of Internal Medicine, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile [2] Pharmacogenetic Unit, Drug Clinical Area, Hospital Universitari i Politècnic, La Fe and Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - I Neumann
- 1] Department of Internal Medicine, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile [2] Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - M José Herrero
- Pharmacogenetic Unit, Drug Clinical Area, Hospital Universitari i Politècnic, La Fe and Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - V Bosó
- Pharmacogenetic Unit, Drug Clinical Area, Hospital Universitari i Politècnic, La Fe and Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - J Reig
- Pharmacogenetic Unit, Drug Clinical Area, Hospital Universitari i Politècnic, La Fe and Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - J Luis Poveda
- Pharmacogenetic Unit, Drug Clinical Area, Hospital Universitari i Politècnic, La Fe and Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - J Megías
- Pharmacogenetic Unit, Drug Clinical Area, Hospital Universitari i Politècnic, La Fe and Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - S Bea
- Nephrology Department, Kidney transplant Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - S F Aliño
- 1] Pharmacogenetic Unit, Drug Clinical Area, Hospital Universitari i Politècnic, La Fe and Instituto de Investigación Sanitaria La Fe, Valencia, Spain [2] Clinical Pharmacology Unit, Drug Clinical Area, Hospital Universitari i Politècnic La Fe, Valencia, Spain [3] Department of Pharmacology, Faculty of Medicine, University of Valencia, Valencia, Spain
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Li P, Shuker N, Hesselink DA, van Schaik RHN, Zhang X, van Gelder T. Do Asian renal transplant patients need another mycophenolate mofetil dose compared with Caucasian or African American patients? Transpl Int 2014; 27:994-1004. [PMID: 24963914 DOI: 10.1111/tri.12382] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 04/22/2014] [Accepted: 06/17/2014] [Indexed: 01/01/2023]
Affiliation(s)
- Pengmei Li
- Department of Hospital Pharmacy; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
- Department of Pharmacy; China-Japan Friendship Hospital; Beijing China
| | - Nauras Shuker
- Department of Hospital Pharmacy; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
- Department of Internal Medicine; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
| | - Dennis A. Hesselink
- Department of Internal Medicine; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
| | - Ron H. N. van Schaik
- Department of Clinical Chemistry; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
| | - Xianglin Zhang
- Department of Pharmacy; China-Japan Friendship Hospital; Beijing China
| | - Teun van Gelder
- Department of Hospital Pharmacy; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
- Department of Internal Medicine; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
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21
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Welzl K, Kern G, Mayer G, Weinberger B, Säemann MD, Sturm G, Grubeck-Loebenstein B, Koppelstaetter C. Effect of different immunosuppressive drugs on immune cells from young and old healthy persons. Gerontology 2014; 60:229-38. [PMID: 24434865 DOI: 10.1159/000356020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Accepted: 09/16/2013] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Life expectancy, as well as the average age of patients undergoing solid organ transplantation, increases constantly. Consequently, immunosuppressive therapy is no longer limited to young organ recipients. OBJECTIVE Here, we investigate how different types of immunosuppressive therapy, namely the calcineurin inhibitors cyclosporin A and tacrolimus, as well as the mTOR inhibitor rapamycin, affect the function of immune cells in young and elderly persons. METHODS Proliferation, cell viability, cytokine production (IL-2, IFN-γ), H2O2 production and telomere length of phytohemagglutinin (PHA)-stimulated human peripheral blood mononuclear cells (PBMCs) of young (n = 13; median age 27 years) and old (n = 19; median age 71 years) healthy donors were analyzed. RESULTS The inhibition of proliferation was dampened in PBMCs from elderly donors, especially after incubation with rapamycin. All three immunosuppressive drugs inhibited the production of IL-2 equally well, whereas the production of IFN-γ was less well inhibited by rapamycin. Both calcineurin inhibitors increased H2O2 concentrations after stimulation with PHA and led to a shortening of telomeres in PBMCs from young and old individuals. Rapamycin had only minor effects on H2O2 production and telomere length. CONCLUSION Our results demonstrate that the effects of immunosuppressive drugs on PBMCs differ between young and elderly persons. Calcineurin inhibitors compared to rapamycin have a more pronounced prosenescence effect. These data indicate that specific treatment regimens for the elderly might therefore be considered.
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Affiliation(s)
- Kathrin Welzl
- Immunology Division, Research Institute of Biomedical Aging Research, University of Innsbruck, Innsbruck, Austria
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22
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Aron-Wisnewsky J, Lemaitre F, Clément K, Bouillot JL, Fernandez C, Basdevant A, Oppert JM, Buyse M. Pharmacokinetics of Immunomodulator Treatments After Roux-En-Y Bypass in Obese Patient. J Clin Pharmacol 2013; 53:779-84. [DOI: 10.1002/jcph.99] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 04/15/2013] [Indexed: 01/08/2023]
Affiliation(s)
| | - Florian Lemaitre
- Clinical Pharmacy Laboratory; Faculty of Pharmacy, University Paris XI; 5, rue Jean Baptiste Clément; 92296; Chatenay-Malabry; France
| | | | - Jean-Luc Bouillot
- Surgery Department; Ambroise Paré Hospital Assistance Publique-Hôpitaux de Paris; 9, avenue Charles de Gaulle; 92104; Boulogne-Billancourt cedex; France
| | | | | | - Jean-Michel Oppert
- Nutrition Department, Part of the Institute of Cardio-metabolism and Nutrition (ICAN); Pitié-Salpétrière Hospital (AP-HP) and Center for Human Nutrition Research-Ile-de-France (CRNH-IdF), University Pierre et Marie Curie-Paris 6; 83 boulevard de l'Hôpital; 75013; Paris; France
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23
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Comparison of pharmacokinetics and pharmacogenetics of once- and twice-daily tacrolimus in the early stage after renal transplantation. Transplantation 2013; 94:1013-9. [PMID: 23073468 DOI: 10.1097/tp.0b013e31826bc400] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study investigated pharmacokinetic and pharmacogenetic differences between a modified-release once-daily formulation of tacrolimus (Tac-QD) and the original formulation requiring twice-daily intake (Tac-BID) in de novo renal transplant recipients. METHODS Forty-seven and 25 patients who received Tac-BID and Tac-QD, respectively, were enrolled. The pharmacokinetics and CYP3A5 6986A>G and ABCB1 3435C>T pharmacogenetics of each formulation were analyzed on day 28 posttransplantation. RESULTS The dose-adjusted trough level (C0) and area under the concentration-time curve (AUC0-24) of tacrolimus were approximately 25% lower for Tac-QD than Tac-BID. However, there was a good correlation between the AUC0-24 and C0 in the Tac-BID and Tac-QD groups (r=0.575, P<0.001; and r=0.638, P<0.001, respectively) and a similar coefficient in each regression equation. The dose-adjusted AUC0-24 was approximately 25% lower in carriers of the CYP3A*1 allele (CYP3A5 expressers), but not individuals with the CYP3A*3/*3 genotype (nonexpressers), for TAC-QD than Tac-BID. In the Tac-QD group, the interpatient variability for dose-adjusted parameters was small, and the interquatile ranges of dose-adjusted parameters differed between CYP3A5 expressers and nonexpressers and did not overlap. The ABCB1 polymorphism was not associated with any pharmacokinetic parameters of Tac-QD. CONCLUSIONS C0-guided monitoring may lead to similar AUC0-24 values for both formulations. However, to maintain the same AUC0-24 value, a higher dose of Tac-QD than Tac-BID may be needed, especially for CYP3A5 expressers, in the early stage posttransplantation. The narrow interindividual variability of Tac-QD pharmacokinetics and its difference between CYP3A5 expressers and nonexpressers might contribute to a dosing strategy based on CYP3A5 genotype.
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24
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Jacobson PA, Schladt D, Oetting WS, Leduc R, Guan W, Matas AJ, Israni A. Lower calcineurin inhibitor doses in older compared to younger kidney transplant recipients yield similar troughs. Am J Transplant 2012; 12:3326-36. [PMID: 22947444 PMCID: PMC3513646 DOI: 10.1111/j.1600-6143.2012.04232.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The number of older adults undergoing kidney transplantation has increased, yet little is known about calcineurin inhibitor (CNI) metabolism in this group. We studied CNI troughs and doses to determine if there were age-related differences in metabolism and dose requirements. We studied 348 young (18-34 years), 1831 middle (35-64 years) and 374 older (65-84 years) adult kidney transplant recipients enrolled in a seven-center prospective study. Troughs were obtained from each patient 2×/week in weeks 1-8 and 2×/month in months 3-6. A multivariable linear-mixed model examined the effect of age on log dose and weight normalized troughs. Older recipients had higher normalized tacrolimus troughs than middle or young age adults despite receiving doses a median of 1-2 mg/day lower. Age and CYP3A5*1 genotype had the largest effect on tacrolimus troughs. Older recipients also had higher normalized cyclosporine troughs than middle or young adults despite receiving median doses 100 mg/day lower. After normalization for dose and weight, CNI troughs were more than 50% higher in older adults than young adults. These data support age-related changes in CNI metabolism. Further studies are needed to determine optimal dosing of CNIs in the elderly.
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Affiliation(s)
- Pamala A. Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, 7-151 Weaver Densford Hall, 308 Harvard St SE, Minneapolis, MN 55455
| | - David Schladt
- Division of Biostatistics, University of Minnesota, 2221 University Ave SE, Suite 200, Minneapolis, MN 55414
| | - William S. Oetting
- Department of Experimental and Clinical Pharmacology and Institute of Human Genetics, University of Minnesota, 14-255 Moos Tower, 515 Delaware Street SE, Minneapolis, MN 55455
| | - Robert Leduc
- Division of Biostatistics, University of Minnesota, 2221 University Ave SE, Suite 200, Minneapolis, MN 55414
| | - Weihau Guan
- Division of Biostatistics, University of Minnesota, 14-255 Moos Tower, 515 Delaware Street, S.E. Minneapolis, MN 55455
| | - Arthur J. Matas
- Division of Transplantation, Department of Surgery, University of Minnesota, 11-200 PWB, 516 Delaware St SE, Minneapolis, MN 55455
| | - Ajay Israni
- Department of Medicine, Nephrology Division, Hennepin County Medical Center, 5th Floor HFA Shapiro Building, 701 Park Avenue, Minneapolis, MN 55415
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Abecassis M, Bridges N, Clancy C, Dew M, Eldadah B, Englesbe M, Flessner M, Frank J, Friedewald J, Gill J, Gries C, Halter J, Hartmann E, Hazzard W, Horne F, Hosenpud J, Jacobson P, Kasiske B, Lake J, Loomba R, Malani P, Moore T, Murray A, Nguyen MH, Powe N, Reese P, Reynolds H, Samaniego M, Schmader K, Segev D, Shah A, Singer L, Sosa J, Stewart Z, Tan J, Williams W, Zaas D, High K. Solid-organ transplantation in older adults: current status and future research. Am J Transplant 2012; 12:2608-22. [PMID: 22958872 PMCID: PMC3459231 DOI: 10.1111/j.1600-6143.2012.04245.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
An increasing number of patients older than 65 years are referred for and have access to organ transplantation, and an increasing number of older adults are donating organs. Although short-term outcomes are similar in older versus younger transplant recipients, older donor or recipient age is associated with inferior long-term outcomes. However, age is often a proxy for other factors that might predict poor outcomes more strongly and better identify patients at risk for adverse events. Approaches to transplantation in older adults vary across programs, but despite recent gains in access and the increased use of marginal organs, older patients remain less likely than other groups to receive a transplant, and those who do are highly selected. Moreover, few studies have addressed geriatric issues in transplant patient selection or management, or the implications on health span and disability when patients age to late life with a transplanted organ. This paper summarizes a recent trans-disciplinary workshop held by ASP, in collaboration with NHLBI, NIA, NIAID, NIDDK and AGS, to address issues related to kidney, liver, lung, or heart transplantation in older adults and to propose a research agenda in these areas.
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Affiliation(s)
- M. Abecassis
- Departments of Surgery and Microbiology-Immunology, Northwestern University Feinberg School of Medicine
| | - N.D. Bridges
- Transplantation Immunobiology Branch and Clinical Transplantation Section, National Institute of Allergy and Infectious Diseases
| | | | - M.A. Dew
- Department of Psychiatry, University of Pittsburgh
| | - B. Eldadah
- Division of Geriatrics and Clinical Gerontology, National Institute on Aging
| | - M.J. Englesbe
- Division of Transplantation, Department of Surgery, University of Michigan Medical School
| | - M.F. Flessner
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases
| | - J.C. Frank
- Geffen School of Medicine at the University of California, Los Angeles
| | - J. Friedewald
- Departments of Medicine and Surgery, Northwestern University
| | - J Gill
- Division of Nephrology, University of British Columbia
| | - C. Gries
- University of Pittsburgh School of Medicine
| | - J.B. Halter
- Division of Geriatric and Palliative Medicine, University of Michigan Medical School
| | | | - W.R. Hazzard
- Division of Gerontology and Geriatric Medicine, University of Washington, VA Puget Sound Health Care System
| | | | | | - P. Jacobson
- Department of Experimental and Clinical Pharmacology, University of Minnesota
| | | | - J. Lake
- Liver Transplant Program, University of Minnesota
| | - R. Loomba
- University of California, San Diego School of Medicine
| | - P.N. Malani
- Department of Internal Medicine, University of Michigan Medical School
| | - T.M. Moore
- National Heart, Lung, and Blood Institute
| | - A. Murray
- Division of Geriatrics, University of Minnesota
| | | | - N.R. Powe
- University of California, San Francisco
| | | | | | | | - K.E. Schmader
- GRECC, Durham VA Medical Center and Division of Geriatric Medicine, Duke University School of Medicine
| | - D.L. Segev
- Division of Transplant Surgery, Johns Hopkins University School of Medicine
| | - A.S. Shah
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine
| | - L.G. Singer
- Toronto Lung Transplant Program, University of Toronto
| | - J.A. Sosa
- Divisions of Endocrine Surgery and Surgical Oncology, Department of Surgery, Yale University School of Medicine
| | | | - J.C. Tan
- Adult Kidney and Pancreas Transplant Program, Stanford University
| | - W.W. Williams
- Harvard University and Massachusetts General Hospital
| | - D.W. Zaas
- Department of Medicine, Duke University School of Medicine
| | - K.P. High
- Wake Forest School of Medicine,To Whom Correspondence Should be Sent: Kevin P. High, M.D., M.S., Professor of Medicine and Translational Science, Chief, Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC 27157-1042, Phone: (336) 716-4584, Fax: (336) 716-3825,
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26
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Clinical Pharmacokinetics and Pharmacodynamics of Prednisolone and Prednisone in Solid Organ Transplantation. Clin Pharmacokinet 2012; 51:711-41. [DOI: 10.1007/s40262-012-0007-8] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Wang P, Mao Y, Razo J, Zhou X, Wong STC, Patel S, Elliott E, Shea E, Wu AHB, Gaber AO. Using genetic and clinical factors to predict tacrolimus dose in renal transplant recipients. Pharmacogenomics 2011; 11:1389-402. [PMID: 21047202 DOI: 10.2217/pgs.10.105] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
AIMS Tacrolimus has a narrow therapeutic window and shows significant interindividual difference in dose requirement. In this study we aim to first identify genetic factors that impact tacrolimus dose using a candidate gene association approach, and then generate a personalized algorithm combining identified genetic and clinical factors to predict individualized tacrolimus dose. MATERIALS & METHODS We screened 768 SNPs in 15 candidate genes in metabolism, transport and calcineurin inhibition pathways of tacrolimus, for association with tacrolimus dose in a discovery cohort of 96 patients. RESULTS Four polymorphisms in CYP3A5 and one polymorphism in CYP3A4 were identified to be significantly associated with tacrolimus stable dose (p < 8.46 × 10(-5)). The same SNPs were identified when dose-normalized trough tacrolimus concentration was analyzed. The CYP3A5*1 allele was associated with significantly higher stable dose, bigger dose increase, higher risk of being underdosed and lower incidence of post-transplant hyperlipidemia. ABCB1 polymorphisms were not associated with stable dose. No significant difference was found between CYP3A5 expressers and nonexpressers in incidence of acute rejection and time to first rejection. Age, ethnicity and CYP3A inhibitor use could predict 30% of tacrolimus dosing variability. Adding the identified genetic polymorphisms to the algorithm increased the predictability to 58%. In two validation cohorts of 77 and 64 patients, the algorithm containing both genetic and clinical factors produced correlation coefficients of 0.63 and 0.42, respectively. This algorithm gave a prediction of the stable doses closer to the actual doses when compared with another algorithm based only on the CYP3A5 genotype. CONCLUSION CYP3A5 genotype is the most significant genetic factor that impacts tacrolimus dose among the genes studied. This study generated the first pharmacogenomics model that predicts tacrolimus stable dose based on age, ethnicity, genotype and comedication use. Our results highlight the importance of incorporating both genetic and clinical, demographic factors into dose prediction.
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Affiliation(s)
- Ping Wang
- Department of Pathology, The Methodist Hospital, The Methodist Hospital Research Institute, Houston, TX, USA.
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Andrés A, Delgado-Arranz M, Morales E, Dipalma T, Polanco N, Gutierrez-Solis E, Morales JM, Praga M, Gutierrez E, Gonzalez E. Extended-release tacrolimus therapy in de novo kidney transplant recipients: single-center experience. Transplant Proc 2011; 42:3034-7. [PMID: 20970602 DOI: 10.1016/j.transproceed.2010.07.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Available data for extended-release tacrolimus (Tac) except in clinical trials are limited. OBJECTIVE To describe our initial experience with once-daily Tac in combination with corticosteroids and mycophenolate mofetil therapy in patients undergoing de novo renal transplantation. PATIENTS AND METHODS In this retrospective, observational, single-center study, data were obtained for 49 adult recipients treated with extended-release Tac and 30 patients treated with standard-release Tac (control group). Mean (SD) follow-up in the 2 groups was 3.5 (2.5) months and 4.0 (2.6) months, respectively. The primary characteristics were comparable between the groups. RESULTS The acute rejection rate in the extended-release group was 10%, and 13% in the standard-release group. Patient and graft survival rates were 98% and 96% vs 100% and 90%, respectively. Renal function in the 2 groups was comparable: serum creatinine concentration 1.3 (0.2) mg/dL vs 1.45 (0.4) mg/dL. At day 14 posttransplantation, Tac doses were 0.17 mg/kg/d vs 0.14 mg/kg/d, and blood concentrations were 9.0 ng/mL vs 14.0 ng/mL. In recipients older than 60 years, lower dosages of Tac resulted in blood concentrations similar to those in younger patients, with less variation in dosage. CONCLUSIONS Short-term experience with extended-release Tac therapy in de novo renal recipients confirms its efficacy and safety. Adjusting blood concentrations in the immediate posttransplantation period is less difficult with extended-release Tac compared with the twice-daily formulation.
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Affiliation(s)
- A Andrés
- Nephrology Department, Hospital 12 de Octubre, Madrid, Spain.
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A Systematic Review of the Effect of CYP3A5 Genotype on the Apparent Oral Clearance of Tacrolimus in Renal Transplant Recipients. Ther Drug Monit 2010; 32:708-14. [DOI: 10.1097/ftd.0b013e3181f3c063] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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