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Cheng Y, Zhang Y, Zhang Y, Liu M, Zhao L. Population pharmacokinetic analyses of methotrexate in pediatric patients: a systematic review. Eur J Clin Pharmacol 2024; 80:965-982. [PMID: 38498098 DOI: 10.1007/s00228-024-03665-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/04/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND AND OBJECTIVES Methotrexate is widely utilized in the chemotherapy of malignant tumors and autoimmune diseases in the pediatric population, but dosing can be challenging. Several population pharmacokinetic models were developed to characterize factors influencing variability and improve individualization of dosing regimens. However, significant covariates included varied across studies. The primary objective of this review was to summarize and discuss population pharmacokinetic models of methotrexate and covariates that influence pharmacokinetic variability in pediatric patients. METHODS Systematic searches were conducted in the PubMed and EMBASE databases from inception to 7 July 2023. Reporting Quality was evaluated based on a checklist with 31 items. The characteristics of studies and information for model construction and validation were extracted, summarized, and discussed. RESULTS Eighteen studies (four prospective studies and fourteen retrospective studies with sample sizes of 14 to 772 patients and 2.7 to 93.1 samples per patient) were included in this study. Two-compartment models were the commonly used structural models for methotrexate, and the clearance range of methotrexate ranged from 2.32 to 19.03 L/h (median: 6.86 L/h). Body size and renal function were found to significantly affect the clearance of methotrexate for pediatric patients. There were limited reports on the role of other covariates, such as gene polymorphisms and co-medications, in the pharmacokinetic parameters of methotrexate pediatric patients. Internal and external evaluations were used to assess the performance of the population pharmacokinetic models. CONCLUSION A more rigorous external evaluation needs to be performed before routine clinical use to select the appropriate PopPK model. Further research is necessary to incorporate larger cohorts or pool analyses in specific susceptible pediatric populations to improve the understanding of predicted exposure profiles and covariate identification.
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Affiliation(s)
- Yu Cheng
- Department of Pharmacy, Shengjing Hospital Affiliated to China Medical University, 36 Sanhao Street, Shenyang, 110004, Liaoning Province, China
- Department of Pharmacy, Fujian Medical University Union Hospital, 29 Xin Quan Rd, Gulou, Fuzhou, 350001, Fujian Province, People's Republic of China
| | - Yujia Zhang
- Department of Pharmacy, Shengjing Hospital Affiliated to China Medical University, 36 Sanhao Street, Shenyang, 110004, Liaoning Province, China
| | - Ying Zhang
- Department of Pharmacy, Shengjing Hospital Affiliated to China Medical University, 36 Sanhao Street, Shenyang, 110004, Liaoning Province, China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, 29 Xin Quan Rd, Gulou, Fuzhou, 350001, Fujian Province, People's Republic of China.
| | - Limei Zhao
- Department of Pharmacy, Shengjing Hospital Affiliated to China Medical University, 36 Sanhao Street, Shenyang, 110004, Liaoning Province, China.
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Bielack S, Fox CP, Hoang‐Xuan K, Giró‐Perafita A, Rizzari C. A Delphi study to determine the epidemiology and clinical management of patients treated with HDMTX who develop methotrexate (MTX) delayed elimination in France, Germany, Italy, and the UK. Health Sci Rep 2024; 7:e1749. [PMID: 38186937 PMCID: PMC10768314 DOI: 10.1002/hsr2.1749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 11/07/2023] [Accepted: 11/21/2023] [Indexed: 01/09/2024] Open
Abstract
Introduction High-dose methotrexate (HDMTX) is administered for the treatment of some malignancies. Serious complications after the administration of HDMTX are rare, but occasionally MTX may precipitate in the renal tubes causing a delayed elimination leading to renal, multiorgan toxicities and to life-threatening complications. This study aims to estimate the incidence and clinical management of delayed MTX elimination in France, Germany, Italy, and the UK. Methods Twelve haemato-oncology and pediatric oncology clinical experts from leading European hospitals participated in the study. A two-round Delphi methodology was used to gather data on different variables relevant to evaluate the HDMTX induced-toxicity impact. For quantitative data, median and interquartile ranges were calculated. Data on prevalence was calculated considering the number of patients in each hospital and the population they cover, and then, extrapolated to the country population. Results The total number of patients treated annually with HDMTX in France, Germany, Italy, and the UK is estimated in 7155. Of these, 16% are estimated to develop delayed MTX elimination and around 9% may develop HDMTX-induced acute kidney injury (AKI). Leucovorin, hyperhydration and urine alkalinization are applied to prevent MTX toxicity and precipitation whilst glucarpidase, hemofiltration and hemodialysis are being used for persisting toxic MTX serum levels. Grade 3 systemic toxicities are common in these patients, hematologic and gastrointestinal being the most common ones. Conclusions This report provides expert clinical practice experience and opinion of the incidence and management of HDMTX-delayed elimination in France, Germany, Italy and the UK, thereby contributing to the evidence available on this relevant medical condition which can be life-threatening.
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Affiliation(s)
- Stefan Bielack
- Cooperative Osteosarcoma Study Group, Pediatric Oncology, Hematology, Immunology, Klinikum Stuttgart‐OlgahospitalStuttgart Cancer CenterStuttgartGermany
| | | | - Khê Hoang‐Xuan
- IHU, Department of Neuro‐oncology Mazarin, APHPSorbonne UniversityParisFrance
| | | | - Carmelo Rizzari
- Unit of PediatricsUniversity of Milano‐BicoccaMonzaItaly
- Fondazione IRCCS San Gerardo dei TintoriMonzaItaly
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de Oliveira Henz P, Pinhatti AV, Gregianin LJ, Martins M, Curra M, de Araújo BV, Dalla Costa T. Population Pharmacokinetic Model of Methotrexate in Brazilian Pediatric Patients with Acute Lymphoblastic Leukemia. Pharm Res 2023; 40:1777-1787. [PMID: 37291462 DOI: 10.1007/s11095-023-03544-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/24/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Methotrexate (MTX) is subject to therapeutic drug monitoring because of its high pharmacokinetic variability and safety risk outside the therapeutic window. This study aimed to develop a population pharmacokinetic model (popPK) of MTX for Brazilian pediatric acute lymphoblastic leukemia (ALL) patients who attended the Hospital de Clínicas de Porto Alegre, Brazil. METHODS The model was developed using NONMEM 7.4 (Icon®), ADVAN3 TRANS4, and FOCE-I. To explain inter-individual variability, we evaluated covariates from demographic, biochemical, and genetic data (single nucleotide polymorphisms [SNPs] related to the transport and metabolism of drugs). RESULTS A two-compartment model was built using 483 data points from 45 patients (0.33-17.83 years of age) treated with MTX (0.25-5 g/m2) in different cycles. Serum creatinine (SCR), height (HT), blood urea nitrogen (BUN) and a low BMI stratification (according to the z-score defined by the World Health Organization [LowBMI]) were added as clearance covariates. The final model described MTX clearance as [Formula: see text]. In the two-compartment structural model, the central and peripheral compartment volumes were 26.8 L and 8.47 L, respectively, and the inter-compartmental clearance was 0.218 L/h. External validation of the model was performed through a visual predictive test and metrics using data from 15 other pediatric ALL patients. CONCLUSION The first popPK model of MTX was developed for Brazilian pediatric ALL patients, which showed that inter-individual variability was explained by renal function and factors related to body size.
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Affiliation(s)
- Pricilla de Oliveira Henz
- Pharmacokinetics and PK/PD Modeling Laboratory, Pharmaceutical Sciences Graduate Program, Federal University of Rio Grande do Sul, 2752 Ipiranga Ave., Santana, RS, 90610-000, Porto Alegre, Brazil
| | - Amanda Valle Pinhatti
- Medical Sciences Graduate Program, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
- Pediatric Oncology Service, Hospital de Clínicas de Porto Alegre, Department of Pediatrics, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Lauro José Gregianin
- Pediatric Oncology Service, Hospital de Clínicas de Porto Alegre, Department of Pediatrics, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Manoela Martins
- Faculty of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Marina Curra
- Faculty of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Bibiana Verlindo de Araújo
- Pharmacokinetics and PK/PD Modeling Laboratory, Pharmaceutical Sciences Graduate Program, Federal University of Rio Grande do Sul, 2752 Ipiranga Ave., Santana, RS, 90610-000, Porto Alegre, Brazil
- Medical Sciences Graduate Program, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Teresa Dalla Costa
- Pharmacokinetics and PK/PD Modeling Laboratory, Pharmaceutical Sciences Graduate Program, Federal University of Rio Grande do Sul, 2752 Ipiranga Ave., Santana, RS, 90610-000, Porto Alegre, Brazil.
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Shenoy R, Panda G, Bonda VNA, Sengar M, Thorat J, Jain H. Feasibility of Delivering High-Dose Methotrexate in Adolescent and Adult All Patients: A Retrospective Study. Indian J Hematol Blood Transfus 2022; 38:638-642. [PMID: 36258731 PMCID: PMC9569244 DOI: 10.1007/s12288-021-01502-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/18/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction HD-MTX is a key drug in the treatment protocols for ALL. The regimen needs to be administered with appropriate supportive measures and serum methotrexate level monitoring. A limited testing strategy is relevant in resource constraint settings since it allows a shorter duration of hospitalization. We report our experience with this strategy and its impact on the patient safety outcomes. Methods This is a retrospective study of all patients ≥ 15 years of age with newly diagnosed ALL or Lymphoblastic lymphoma (LBL) who were administered HDMTX (part of BFM-90 ALL protocol) at our institute between March 2013 to November 2013.The medical records were reviewed for clinical characteristics, disease-related details, HDMTX dose and cycles administered, leucovorin rescue and toxicities. Results A total of 423 cycles of HD-MTX were administered to 106 patients during the study period. The median duration for completion of all 4 cycles of HDMTX was 53 (IQR 49-60) days. The grade 3 or higher toxicities were anemia in 9.6%, neutropenia 19.4%, febrile neutropenia 5.7%, thrombocytopenia 4.4% and mucositis in 0.7%. There was statistically significant correlation between the levels at 42 h (≤ 1 mmol/L vs > 1 mmol/L) and toxicity- anemia, FN and mucositis observed more in the late clearance group. With limited sampling strategy whereby if the 42- hour level MTX level are < 1 mmol/L, 57% of patients could be discharged early. Conclusion HD-MTX can be safely administered to adolescent and adult ALL patients. A limited methotrexate level monitoring is a safe strategy that can optimize the resources better.
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Affiliation(s)
- Ramnath Shenoy
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National University, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Goutam Panda
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National University, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - V. N. Avinash Bonda
- Adult Hematolymphoid Unit, Tata Memorial Centre, Homi Bhabha National University, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Manju Sengar
- Adult Hematolymphoid Unit, Tata Memorial Centre, Homi Bhabha National University, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Jayashree Thorat
- Adult Hematolymphoid Unit, Tata Memorial Centre, Homi Bhabha National University, E Borges Road, Mumbai, Maharashtra 400 012 India
| | - Hasmukh Jain
- Adult Hematolymphoid Unit, Tata Memorial Centre, Homi Bhabha National University, E Borges Road, Mumbai, Maharashtra 400 012 India
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Nijstad AL, Barnett S, Lalmohamed A, Bérénos IM, Parke E, Carruthers V, Tweddle DA, Kong J, Zwaan CM, Huitema ADR, Veal GJ. Clinical pharmacology of cytotoxic drugs in neonates and infants: Providing evidence-based dosing guidance. Eur J Cancer 2022; 164:137-154. [PMID: 34865945 PMCID: PMC8914347 DOI: 10.1016/j.ejca.2021.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [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.
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Affiliation(s)
- A Laura Nijstad
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands.
| | - Shelby Barnett
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK
| | - Arief Lalmohamed
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, the Netherlands
| | - Inez M Bérénos
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, the Netherlands
| | - Elizabeth Parke
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK
| | - Vickyanne Carruthers
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK
| | - Deborah A Tweddle
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK; Great North Children's Hospital, NE1 4LP Newcastle Upon Tyne, UK
| | - Jordon Kong
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - C Michel Zwaan
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Department of Pediatric Oncology, Erasmus MC-Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
| | - Gareth J Veal
- Newcastle University Centre for Cancer, Newcastle University, NE2 4HH Newcastle Upon Tyne, UK.
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Gros L, Roldán A, Cabero-Martínez A, Domínguez-Pinilla N, de la Fuente A, González-Barca E, Tasso M, Torrent M, Gallardo E, Del Cerro I, Giró-Perafita A, Badia X. Incidence and management of patients with methotrexate delayed elimination in the clinical practice: A Delphi study. J Oncol Pharm Pract 2022:10781552221079568. [PMID: 35147457 DOI: 10.1177/10781552221079568] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION High-dose methotrexate (HDMTX) is administered for the treatment of some cancers. HDMTX is usually safe but may crystallize in renal tubules causing acute kidney injury (AKI). Consequently, MTX elimination is delayed, resulting in a severe and life-threatening condition. No studies have been published about the impact of MTX toxicity in Spain. This study aims to estimate the incidence and management of MTX delayed elimination and toxicity. METHODS A two-round Delphi study was performed to reach consensus between 10 medical experts on haemato-oncology and paediatric oncology with experience in the management of HDMTX treated patients from leading Spanish hospitals. An online questionnaire was developed based on national and international guidelines and previous evidence regarding HDMTX-related toxicity. Consensus was established at 80% agreement. Median and interquartile ranges were calculated, and incidence data were extrapolated to the Spanish general population. RESULTS Out of 1.475 patients estimated to receive HDMTX treatment annually in Spain, 27.5% present MTX delayed elimination and 11.6% develop HDMTX-induced AKI (35.4% with severe systemic toxicities (>grade 3) and 18.8% develop chronic renal disease). Mortality is estimated in 4.2%. Immuno-enzymatic assay is used in most of the hospitals (90%) for MTX serum level monitoring. All experts use increased supportive care and high leucovorin as first-line treatment. Available treatments in experts' hospitals in case toxicity persists are haemodialysis (90% of hospitals), glucarpidase (60%) and hemofiltration (50%). Most prevalent non-renal systemic toxicities are haematologic and mucositis (21-40% of patients). Patients with HDMTX-induced AKI require from intensive care (5% of patients), more than 3 sessions and 4 days of dialysis, and about 8.5 days of hospitalization (non-ICU patients) and 12 days in case of patients requiring ICU. CONCLUSIONS These results are the first evidence regarding HDMTX-induced AKI in Spain. Incidence and mortality results are in line with previous studies. Clinical management is based on preventive measures and the treatment depend on the availability in the hospital. The need for effective, safe and rapid treatment for the reduction of MTX toxic levels and the improvement of monitoring methods were noted by experts as urgent needs. Further observational studies to validate these results would be needed.
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Affiliation(s)
- Luis Gros
- Servicio de Oncología y Hematología Pediátricas, 16810Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Alicia Roldán
- Sección de Hematología y Hemoterapia, 161633Hospital Universitario Infanta Sofía, Madrid, Spain
| | - Almudena Cabero-Martínez
- Departamento de Hematología y Hemoterapia, 37479Hospital Universitario de Salamanca (HUS), Instituto Biomédico de Salamanca (IBSAL), Salamanca, Spain
| | - Nerea Domínguez-Pinilla
- Unidad de Hemato-Oncología Pediátrica, 16350Complejo Hospitalario de Toledo, Toledo, Spain; Unidad de Hemato-Oncología Pediátrica, Hospital 12 de Octubre, Madrid. Instituto de Investigación i + 12, Hospital 12 de Octubre, Madrid
| | | | - Eva González-Barca
- Institut Català d'Oncologia, Hematology Department, 16529Hospital Duran i Reynals, IDIBELL, Universitat de Barcelona, Barcelona, Spain
| | - María Tasso
- Unidad de Oncología y Hematología Pediátrica, 16802Hospital General Universitario de Alicante, Alicante, Spain
| | - Montserrat Torrent
- Servicio de Onco-hematología pediátrica, 16689Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Eva Gallardo
- BTG Specialty Pharmaceuticals, Llandysul, UK of Great Britain and Northern Ireland
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Zhang Y, Sun L, Chen X, Zhao L, Wang X, Zhao Z, Mei S. A Systematic Review of Population Pharmacokinetic Models of Methotrexate. Eur J Drug Metab Pharmacokinet 2022; 47:143-164. [PMID: 34985725 DOI: 10.1007/s13318-021-00737-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND OBJECTIVES Methotrexate (MTX) is widely used for the treatment of a variety of neoplastic and autoimmune diseases. However, its toxicity and efficacy varied greatly among individuals, and they could be predicted by its pharmacokinetics. Many population pharmacokinetic models have been published to describe MTX pharmacokinetics. The objective of this systematic review was to summarize and discuss covariates with significant influence on MTX pharmacokinetics. METHODS We searched PubMed and EMBASE databases from their inception to April 2021 for population pharmacokinetic of MTX. The articles were screened by inclusion and exclusion criteria. The characteristics of studies and information for model construction and validation were extracted, summarized and discussed. RESULTS Thirty-five articles were included. The two-compartment model well described the pharmacokinetic behavior of MTX. For inter-individual variability, an exponential distribution error model was usually used for high-dose MTX population pharmacokinetic models, while a proportional distribution error model was used for low-dose MTX population pharmacokinetic models. Proportional and combined proportional and additive error models were used to describe residual error. Renal function was an independent indicator of MTX clearance. Body weight, age, gene polymorphisms (SLCO1B1, ABCC2, ABCB1, ABCG2 and MTHFR) and co-medications (proton pump inhibitors, non-steroidal anti-inflammatory drug, dexamethasone, vancomycin, penicillin and salicylic acid) could influence MTX clearance. Body weight, body surface area, age and dosage regimen have significant influence on MTX central compartment volume. Internal bootstrap test, external validation and visual predictive check were used to evaluate model predictive ability. CONCLUSIONS Various covariates could affect MTX pharmacokinetics, and their relationships have been summarized and discussed. This review will be helpful for researchers to develop their own population pharmacokinetic models and select appropriate models for individualized therapy of MTX.
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Affiliation(s)
- Yiming Zhang
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan West Road, Fengtai District, Beijing, 100070, People's Republic of China.,Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, 100069, People's Republic of China
| | - Liyu Sun
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan West Road, Fengtai District, Beijing, 100070, People's Republic of China.,Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, 100069, People's Republic of China
| | - Xinwei Chen
- Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, 100069, People's Republic of China.,Department of Pharmacy, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, 100045, People's Republic of China
| | - Libo Zhao
- Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, 100069, People's Republic of China.,Department of Pharmacy, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, 100045, People's Republic of China
| | - Xiaoling Wang
- Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, 100069, People's Republic of China.,Department of Pharmacy, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, 100045, People's Republic of China
| | - Zhigang Zhao
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan West Road, Fengtai District, Beijing, 100070, People's Republic of China. .,Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, 100069, People's Republic of China.
| | - Shenghui Mei
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan West Road, Fengtai District, Beijing, 100070, People's Republic of China. .,Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, 100069, People's Republic of China.
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Özlem T, Ali A, Ezgi U, Duygu Y, Fatma S, Cengiz B. Utility of repeated drug level measurements after high dose methotrexate infusion for treatment planning in pediatric leukemia. SANAMED 2022. [DOI: 10.5937/sanamed17-40079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Introduction: Although high-dose Methotrexate (MTX) is a successful chemotherapeutic agent used in the treatment of acute lymphoblastic leukemia in childhood, life-threatening toxic effects are rarely seen. Therefore, frequent follow-up of drug levels is recommended. The study researched the necessity of drug level measurement and a minimum safe number of measurements. Materials and Methods: The files of pediatric patients with Acute Lymphoblastic Leukemia receiving high-dose MTX treatment in a single center between 2018 and 2021 were retrospectively reviewed. The treatment protocol was: 3000 mL/m2 alkaline hydration fluid was continued until the 72nd hour together with 2 gr/m2 continuous MTX infusion in the low-risk group and 5 gr/m2 in moderate and high-risk groups, and 15 mg/m2 /dose folinic acid was given at the 42nd, 48thand 54th hours. Findings: 456 MTX treatments were evaluated in 114 patients. Similar results (p>0.05) were obtained in the MTX level measurements performed at the 24th, 42nd, 48th, and 54th hours after MTX administration. In the repeated measurements, the data at the 42nd hour were similar (p=0.021). The number of cases that were >150 µmol/L at the 24th hour of methotrexate infusion and above 1 µmol/L at the 42nd, 48th, and 52nd hours were found to be similar in the repeated measurements. Conclusion: Although recommended, frequent follow-up of MTX levels might not always indicate toxicity. In centers with limited laboratory facilities, the MTX level measured at the 42nd hour in the first treatment might be a practical approach to guide the management of other MTX treatments.
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Göksel Y, Zor K, Rindzevicius T, Thorhauge Als-Nielsen BE, Schmiegelow K, Boisen A. Quantification of Methotrexate in Human Serum Using Surface-Enhanced Raman Scattering-Toward Therapeutic Drug Monitoring. ACS Sens 2021; 6:2664-2673. [PMID: 34143600 DOI: 10.1021/acssensors.1c00643] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Therapeutic drug monitoring (TDM) can improve clinical care when using drugs with pharmacokinetic variability and a narrow therapeutic window. Rapid, reliable, and easy-to-use detection methods are required in order to decrease the time of analysis and can also enable TDM in resource-limited settings or even at bedside. Monitoring methotrexate (MTX), an anticancer drug, is critical since it is needed to follow the drug clearance rate and decide how to administer the rescue drug, leucovorin (LV), in order to avoid toxicity and even death. We show that with the optimized nanopillar-assisted separation (NPAS) method using surface-enhanced Raman scattering, we were able to measure MTX in PBS and serum in the linear range of 5-150 μM and confirmed that MTX detection can be carried out even in the presence of LV. Additionally, when NPAS was combined with centrifugal filtration, a quantification limit of 2.1 μM for MTX in human serum sample was achieved. The developed detection method enables fast detection (10 min) and quantification of MTX from human serum (>90% accuracy). Furthermore, we show the potential of the developed method for TDM, when quantifying MTX from clinical samples, collected from patients who are undergoing high-dose MTX therapy.
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Affiliation(s)
- Yaman Göksel
- Center for Intelligent Drug Delivery and Sensing Using Microcontainers and Nanomechanics (IDUN), Department of Health Technology, Technical University of Denmark, Kongens Lyngby 2800, Denmark
| | - Kinga Zor
- Center for Intelligent Drug Delivery and Sensing Using Microcontainers and Nanomechanics (IDUN), Department of Health Technology, Technical University of Denmark, Kongens Lyngby 2800, Denmark
- BioInnovation Institute Foundation, Copenhagen N 2200, Denmark
| | - Tomas Rindzevicius
- Center for Intelligent Drug Delivery and Sensing Using Microcontainers and Nanomechanics (IDUN), Department of Health Technology, Technical University of Denmark, Kongens Lyngby 2800, Denmark
- BioInnovation Institute Foundation, Copenhagen N 2200, Denmark
| | | | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet University Hospital, Copenhagen 2100, Denmark
| | - Anja Boisen
- Center for Intelligent Drug Delivery and Sensing Using Microcontainers and Nanomechanics (IDUN), Department of Health Technology, Technical University of Denmark, Kongens Lyngby 2800, Denmark
- BioInnovation Institute Foundation, Copenhagen N 2200, Denmark
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Gao X, Qian XW, Zhu XH, Yu Y, Miao H, Meng JH, Jiang JY, Wang HS, Zhai XW. Population Pharmacokinetics of High-Dose Methotrexate in Chinese Pediatric Patients With Acute Lymphoblastic Leukemia. Front Pharmacol 2021; 12:701452. [PMID: 34326772 PMCID: PMC8313761 DOI: 10.3389/fphar.2021.701452] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/30/2021] [Indexed: 12/31/2022] Open
Abstract
High-dose methotrexate (HD-MTX) is widely used in pediatric acute lymphoblastic leukemia (ALL) treatment regimens. In this study, we aimed to develop a population pharmacokinetic (PK) model of HD-MTX in Chinese pediatric patients with ALL for designing personalized dosage regimens. In total, 4,517 MTX serum concentration data for 311 pediatric patients with ALL, aged 0.75–15.2 years and under HD-MTX treatment, were retrospectively collected at a tertiary Children’s Hospital in China. The non-linear mixed-effect model was used to establish the population PK model, using NONMEM software. The potential covariate effects of age, body weight, and biochemical measurements (renal and liver function) on MTX PK disposition were investigated. The model was then evaluated using goodness-of-fit, visual predictive check. MTX PK disposition was described using a three-compartment model reasonable well. Body weight, implemented as a fixed allometric function on all clearance and volume of distribution parameters, showed a substantial improvement in model fit. The final population model demonstrated that the MTX clearance estimate in a typical child with body weight of 19 kg was 6.9 L/h and the central distribution of volume estimate was 20.7 L. The serum creatinine significantly affected the MTX clearance, with a 0.97% decrease in clearance per 1 μmol/L of serum creatinine. Other covariates (e.g., age, sex, bilirubin, albumin, aspartate transaminase, concomitant medication) did not significantly affect PK properties of MTX. The proposed population PK model could describe the MTX concentration data in Chinese pediatric patients with ALL. This population PK model combined with a maximum a posteriori Bayesian approach could be used to estimate individual PK parameters, and optimize personalized MTX therapy in target patients, thus aiming to reduce toxicity and improve treatment outcomes.
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Affiliation(s)
- Xuan Gao
- Outpatient and Emergency Management Office, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Xiao-Wen Qian
- Department of Hematology and Oncology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Xiao-Hua Zhu
- Department of Hematology and Oncology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Yi Yu
- Department of Hematology and Oncology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Hui Miao
- Department of Hematology and Oncology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Jian-Hua Meng
- Department of Hematology and Oncology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Jun-Ye Jiang
- Department of Hematology and Oncology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Hong-Sheng Wang
- Department of Hematology and Oncology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Xiao-Wen Zhai
- Department of Hematology and Oncology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
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11
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Arshad U, Taubert M, Seeger-Nukpezah T, Ullah S, Spindeldreier KC, Jaehde U, Hallek M, Fuhr U, Vehreschild JJ, Jakob C. Evaluation of body-surface-area adjusted dosing of high-dose methotrexate by population pharmacokinetics in a large cohort of cancer patients. BMC Cancer 2021; 21:719. [PMID: 34147089 PMCID: PMC8214796 DOI: 10.1186/s12885-021-08443-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/02/2021] [Indexed: 12/03/2022] Open
Abstract
Background The aim of this study was to identify sources of variability including patient gender and body surface area (BSA) in pharmacokinetic (PK) exposure for high-dose methotrexate (MTX) continuous infusion in a large cohort of patients with hematological and solid malignancies. Methods We conducted a retrospective PK analysis of MTX plasma concentration data from hematological/oncological patients treated at the University Hospital of Cologne between 2005 and 2018. Nonlinear mixed effects modeling was performed. Covariate data on patient demographics and clinical chemistry parameters was incorporated to assess relationships with PK parameters. Simulations were conducted to compare exposure and probability of target attainment (PTA) under BSA adjusted, flat and stratified dosing regimens. Results Plasma concentration over time data (2182 measurements) from therapeutic drug monitoring from 229 patients was available. PK of MTX were best described by a three-compartment model. Values for clearance (CL) of 4.33 [2.95–5.92] L h− 1 and central volume of distribution of 4.29 [1.81–7.33] L were estimated. An inter-occasion variability of 23.1% (coefficient of variation) and an inter-individual variability of 29.7% were associated to CL, which was 16 [7–25] % lower in women. Serum creatinine, patient age, sex and BSA were significantly related to CL of MTX. Simulations suggested that differences in PTA between flat and BSA-based dosing were marginal, with stratified dosing performing best overall. Conclusion A dosing scheme with doses stratified across BSA quartiles is suggested to optimize target exposure attainment. Influence of patient sex on CL of MTX is present but small in magnitude. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08443-x.
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Affiliation(s)
- Usman Arshad
- Department I of Pharmacology, Faculty of Medicine and University Hospital Cologne, Center for Pharmacology, University of Cologne, Gleueler Str 24, 50931, Cologne, Germany. .,Institute of Pharmacy, Clinical Pharmacy, University of Bonn, Bonn, Germany.
| | - Max Taubert
- Department I of Pharmacology, Faculty of Medicine and University Hospital Cologne, Center for Pharmacology, University of Cologne, Gleueler Str 24, 50931, Cologne, Germany
| | - Tamina Seeger-Nukpezah
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Sami Ullah
- Department I of Pharmacology, Faculty of Medicine and University Hospital Cologne, Center for Pharmacology, University of Cologne, Gleueler Str 24, 50931, Cologne, Germany.,Institute of Pharmacy, Clinical Pharmacy, University of Bonn, Bonn, Germany
| | | | - Ulrich Jaehde
- Institute of Pharmacy, Clinical Pharmacy, University of Bonn, Bonn, Germany
| | - Michael Hallek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Uwe Fuhr
- Department I of Pharmacology, Faculty of Medicine and University Hospital Cologne, Center for Pharmacology, University of Cologne, Gleueler Str 24, 50931, Cologne, Germany
| | - Jörg Janne Vehreschild
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,German Center for Infection Research (DZIF), Partner site Bonn-Cologne, Cologne, Germany.,Department of Internal Medicine, Hematology and Oncology, Faculty of Medicine and University Hospital of Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Carolin Jakob
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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12
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Yang L, Wu H, de Winter BCM, Sheng CC, Qiu HQ, Cheng Y, Chen J, Zhao QL, Huang J, Jiao Z, Xie RX. Pharmacokinetics and pharmacogenetics of high-dose methotrexate in Chinese adult patients with non-Hodgkin lymphoma: a population analysis. Cancer Chemother Pharmacol 2020; 85:881-897. [PMID: 32246190 DOI: 10.1007/s00280-020-04058-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 03/12/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE High-dose methotrexate (HD-MTX) is widely used in the treatment of non-Hodgkin lymphoma (NHL), but the pharmacokinetic properties of HD-MTX in Chinese adult patients with NHL have not yet been established through an approach that integrates genetic covariates. The purposes of this study were to identify both physiological and pharmacogenomic covariates that can explain the inter- and intraindividual pharmacokinetic variability of MTX in Chinese adult patients with NHL and to explore a new sampling strategy for predicting delayed MTX elimination. METHODS A total of 852 MTX concentrations from 91 adult patients with NHL were analyzed using the nonlinear mixed-effects modeling method. FPGS, GGH, SLCO1B1, ABCB1 and MTHFR were genotyped using the Sequenom MassARRAY technology platform and were screened as covariates. The ability of different sampling strategies to predict the MTX concentration at 72 h was assessed through maximum a posteriori Bayesian forecasting using a validation dataset (18 patients). RESULTS A two-compartment model adequately described the data, and the estimated mean MTX clearance (CL) was 6.03 L/h (9%). Creatinine clearance (CrCL) was identified as a covariate for CL, whereas the intercompartmental clearance (Q) was significantly affected by the body surface area (BSA). However, none of the genotypes exerted a significant effect on the pharmacokinetic properties of MTX. The percentage of patients with concentrations below 0.2 µmol/L at 72 h decreased from 65.6 to 42.6% when the CrCL decreased from 90 to 60 ml/min/1.73 m2 with a scheduled dosing of 3 g/m2, and the same trend was observed with dose regimens of 1 g/m2 and 2 g/m2. Bayesian forecasting using the MTX concentrations at 24 and 42 h provided the best predictive performance for estimating the MTX concentration at 72 h after dosing. CONCLUSIONS The MTX population pharmacokinetic model developed in this study might provide useful information for establishing personalized therapy involving MTX for the treatment of adult patients with NHL.
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Affiliation(s)
- Lin Yang
- Department of Pharmacy, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuma Road 420, Fuzhou, 350014, China
| | - Hui Wu
- Department of Medical Oncology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Brenda C M de Winter
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Chang-Cheng Sheng
- Department of Pharmacy, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, China.,Department of Pharmacy, Guizhou Provincial People's Hospital, Guiyang, China
| | - Hong-Qiang Qiu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yu Cheng
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Juan Chen
- Department of Pharmacy, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuma Road 420, Fuzhou, 350014, China
| | - Qiu-Ling Zhao
- Department of Pharmacy, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuma Road 420, Fuzhou, 350014, China
| | - Jing Huang
- Department of Pharmacy, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuma Road 420, Fuzhou, 350014, China
| | - Zheng Jiao
- Department of Pharmacy, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, 200040, China. .,Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 West Huaihai Road, Shanghai, 200030, China.
| | - Rui-Xiang Xie
- Department of Pharmacy, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuma Road 420, Fuzhou, 350014, China.
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13
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Population pharmacokinetics of methotrexate in Mexican pediatric patients with acute lymphoblastic leukemia. Cancer Chemother Pharmacol 2019; 85:21-31. [DOI: 10.1007/s00280-019-03977-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 10/15/2019] [Indexed: 12/20/2022]
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14
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Beechinor RJ, Thompson PA, Hwang MF, Vargo RC, Bomgaars LR, Gerhart JG, Dreyer ZE, Gonzalez D. The Population Pharmacokinetics of High-Dose Methotrexate in Infants with Acute Lymphoblastic Leukemia Highlight the Need for Bedside Individualized Dose Adjustment: A Report from the Children's Oncology Group. Clin Pharmacokinet 2019; 58:899-910. [PMID: 30810947 PMCID: PMC6658326 DOI: 10.1007/s40262-018-00734-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Infants with acute lymphoblastic leukemia (ALL) treated with high-dose methotrexate may have reduced methotrexate clearance (CL) due to renal immaturity, which may predispose them to toxicity. OBJECTIVE The aim of this study was to develop a population pharmacokinetic (PK) model of methotrexate in infants with ALL. METHODS A total of 672 methotrexate plasma concentrations were obtained from 71 infants enrolled in the Children's Oncology Group (COG) Clinical Trial P9407. Infants received methotrexate 4 g/m2 intravenously for four cycles during weeks 4-12 of intensification. A population PK analysis was performed using NONMEM® version 7.4. The final model was evaluated using a non-parametric bootstrap and a visual predictive check. Simulations were performed to evaluate methotrexate dose and the utility of a bedside algorithm for dose individualization. RESULTS Methotrexate was best characterized by a two-compartment model with allometric scaling. Weight was the only covariate included in the final model. The coefficient of variation for interoccasion variability (IOV) on CL was relatively high at 25.4%, compared with the interindividual variability for CL and central volume of distribution (10.7% and 13.2%, respectively). Simulations identified that 21.1% of simulated infants benefitted from bedside dose adjustment, and adjustment of methotrexate doses during infusions can avoid supratherapeutic concentrations. CONCLUSION Infants treated with high-dose methotrexate demonstrated a relatively high degree of IOV in methotrexate CL. The magnitude of IOV in the CL of methotrexate suggests that use of a bedside algorithm may avoid supratherapeutic methotrexate concentrations resulting from high IOV in methotrexate CL.
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Affiliation(s)
- Ryan J Beechinor
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, CB #7569, Chapel Hill, NC, 27599-7569, USA
| | - Patrick A Thompson
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Michael F Hwang
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, CB #7569, Chapel Hill, NC, 27599-7569, USA
| | - Ryan C Vargo
- Pharmacokinetics, Pharmacodynamics, and Drug Metabolism, Merck & Co., Inc., Kenilworth, NJ, USA
| | - Lisa R Bomgaars
- Texas Children's Cancer and Hematology Center, Baylor College of Medicine, Houston, TX, USA
| | - Jacqueline G Gerhart
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, CB #7569, Chapel Hill, NC, 27599-7569, USA
| | - ZoAnn E Dreyer
- Texas Children's Cancer and Hematology Center, Baylor College of Medicine, Houston, TX, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, CB #7569, Chapel Hill, NC, 27599-7569, USA.
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15
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Plasma 7-Hydroxymethotrexate Levels Versus Methotrexate to Predict Delayed Elimination in Children Receiving High-Dose Methotrexate. Ther Drug Monit 2018; 40:76-83. [DOI: 10.1097/ftd.0000000000000445] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Howard SC, McCormick J, Pui CH, Buddington RK, Harvey RD. Preventing and Managing Toxicities of High-Dose Methotrexate. Oncologist 2016; 21:1471-1482. [PMID: 27496039 PMCID: PMC5153332 DOI: 10.1634/theoncologist.2015-0164] [Citation(s) in RCA: 479] [Impact Index Per Article: 59.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 06/20/2016] [Indexed: 12/29/2022] Open
Abstract
: High-dose methotrexate (HDMTX), defined as a dose higher than 500 mg/m2, is used to treat a range of adult and childhood cancers. Although HDMTX is safely administered to most patients, it can cause significant toxicity, including acute kidney injury (AKI) in 2%-12% of patients. Nephrotoxicity results from crystallization of methotrexate in the renal tubular lumen, leading to tubular toxicity. AKI and other toxicities of high-dose methotrexate can lead to significant morbidity, treatment delays, and diminished renal function. Risk factors for methotrexate-associated toxicity include a history of renal dysfunction, volume depletion, acidic urine, and drug interactions. Renal toxicity leads to impaired methotrexate clearance and prolonged exposure to toxic concentrations, which further worsen renal function and exacerbate nonrenal adverse events, including myelosuppression, mucositis, dermatologic toxicity, and hepatotoxicity. Serum creatinine, urine output, and serum methotrexate concentration are monitored to assess renal clearance, with concurrent hydration, urinary alkalinization, and leucovorin rescue to prevent and mitigate AKI and subsequent toxicity. When delayed methotrexate excretion or AKI occurs despite preventive strategies, increased hydration, high-dose leucovorin, and glucarpidase are usually sufficient to allow renal recovery without the need for dialysis. Prompt recognition and effective treatment of AKI and associated toxicities mitigate further toxicity, facilitate renal recovery, and permit patients to receive other chemotherapy or resume HDMTX therapy when additional courses are indicated. IMPLICATIONS FOR PRACTICE High-dose methotrexate (HDMTX), defined as a dose higher than 500 mg/m2, is used for a range of cancers. Although HDMTX is safely administered to most patients, it can cause significant toxicity, including acute kidney injury (AKI), attributable to crystallization of methotrexate in the renal tubular lumen, leading to tubular toxicity. When AKI occurs despite preventive strategies, increased hydration, high-dose leucovorin, and glucarpidase allow renal recovery without the need for dialysis. This article, based on a review of the current associated literature, provides comprehensive recommendations for prevention of toxicity and, when necessary, detailed treatment guidance to mitigate AKI and subsequent toxicity.
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Affiliation(s)
- Scott C Howard
- School of Health Studies, University of Memphis, Memphis, Tennessee, USA
| | - John McCormick
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, New York, New York, USA
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, New York, New York, USA
| | | | - R Donald Harvey
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
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Methotrexate Associated Renal Impairment Is Related to Delayed Elimination of High-Dose Methotrexate. ScientificWorldJournal 2015; 2015:751703. [PMID: 26185782 PMCID: PMC4491404 DOI: 10.1155/2015/751703] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 06/08/2015] [Indexed: 11/21/2022] Open
Abstract
Although Methotrexate (MTX) is an effective drug for the treatment of acute lymphoblastic leukemia (ALL), the toxicity remains a significant problem. In this prospective study, fifty-four patients with ALL were enrolled. 3 g or 5 g MTX/m2 was administered over 24 hours. Serum MTX concentrations were determined in 24, 48, and 96 hours after MTX infusion. Serum creatinine concentrations and creatinine clearance rate (CCR) were determined before and 24 and 48 hours after MTX infusion. A total of 173 courses of MTX infusion were administered. The serum creatinine concentrations did not change much after MTX infusion while the CCR was gradually decreased. MTX clearance status was independently related to CCR decrease, with the risk of 8.07 to develop renal impairment in patients with delayed MTX elimination. Serum creatinine concentration, serum creatinine ratio, CCR, and CCR ratio at 24 hours were all related to MTX elimination delay. Patients with serum creatinine level >35.0 μmol/L, creatinine ratio >1.129, or CCR <100.0 mL/min were more likely to undergo MTX elimination delay. In conclusion, MTX could induce transient renal impairment and compromised renal function will delay MTX clearance. The serum creatinine concentration and the ratio and CCR are useful tools for evaluating MTX elimination status.
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18
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van Hasselt JGC, van Eijkelenburg NKA, Beijnen JH, Schellens JHM, Huitema ADR. Optimizing drug development of anti-cancer drugs in children using modelling and simulation. Br J Clin Pharmacol 2014; 76:30-47. [PMID: 23216601 DOI: 10.1111/bcp.12062] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 11/30/2012] [Indexed: 01/04/2023] Open
Abstract
Modelling and simulation (M&S)-based approaches have been proposed to support paediatric drug development in order to design and analyze clinical studies efficiently. Development of anti-cancer drugs in the paediatric population is particularly challenging due to ethical and practical constraints. We aimed to review the application of M&S in the development of anti-cancer drugs in the paediatric population, and to identify where M&S-based approaches could provide additional support in paediatric drug development of anti-cancer drugs. A structured literature search on PubMed was performed. The majority of identified M&S-based studies aimed to use population PK modelling approaches to identify determinants of inter-individual variability, in order to optimize dosing regimens and to develop therapeutic drug monitoring strategies. Prospective applications of M&S approaches for PK-bridging studies have scarcely been reported for paediatric oncology. Based on recent developments of M&S in drug development there are several opportunities where M&S could support more informative bridging between children and adults, and increase efficiency of the design and analysis of paediatric clinical trials, which should ultimately lead to further optimization of drug treatment strategies in this population.
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Affiliation(s)
- Johan G C van Hasselt
- Department of Clinical Pharmacology, Netherlands Cancer Institute; Department of Pharmacy & Pharmacology, Slotervaart Hospital/Netherlands Cancer Institute, Amsterdam, the Netherlands.
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Population PK/PD model of homocysteine concentrations after high-dose methotrexate treatment in patients with acute lymphoblastic leukemia. PLoS One 2012; 7:e46015. [PMID: 23049924 PMCID: PMC3457953 DOI: 10.1371/journal.pone.0046015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Accepted: 08/27/2012] [Indexed: 11/25/2022] Open
Abstract
Elevated homocysteine concentrations have been associated with methotrexate-induced neurotoxicity. Based on methotrexate and homocysteine plasma concentrations of 494 children with acute lymphoblastic leukemia treated with high-dose methotrexate in the TOTAL XV study, a pharmacokinetic/pharmacodynamic (PK/PD) model was built with NONMEM. Several compartment and indirect response models were investigated. The pharmacokinetic disposition of methotrexate was best described by a two-compartment model. Homocysteine concentrations were included by an indirect response model where methotrexate inhibition of the homocysteine elimination rate was described by an Emax model. The homocysteine baseline level was found to be age-dependent. Simulations revealed that folinate rescue therapy does not affect peak concentrations of homocysteine but leads to a modestly reduced homocysteine exposure. In conclusion, our PK/PD model describes the increase of methotrexate-induced HCY concentrations with satisfactory precision and can be applied to assess the effect of folinate regimens on the HCY concentration-time course.
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Csordás K, Eipel O, Hegyi M, Csóka M, Pap E, Kovács G. [Pharmacokinetic analysis of high-dose methotrexate treatments in children with hematologic malignancies]. Orv Hetil 2011; 152:1609-17. [PMID: 21945870 DOI: 10.1556/oh.2011.29143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
UNLABELLED Monitoring the pharmacokinetic parameters of different anticancer drugs is necessary because they might have several side effects. AIM Pharmacokinetic and toxicity evaluation of high-dose methotrexate treatments in children with acute lymphoblastic leukemia. PATIENTS AND METHODS 43 children (28 boys, 15 girls, mean age: 7.03 years) in 147 cases were treated with 5 g/m2/24h MTX according to ALL-BFM 1995 and 2002 protocols. Methotrexate and 7-hydroxi-methotrexate levels were measured with high pressure liquid chromatography at 24, 36, 48 hours. Authors registered the development of hepatotoxicity, nephrotoxicity, grade III/IV oral mucositis. RESULTS Therapeutic methotrexate serum concentrations (30-100µmol/l) were achieved in 72.5% of the cases. Repeated treatments resulted similar serum levels. Hepatotoxicity and hypoproteinemia occurred in 17% and in 48.9% of the cases. There was significant correlation between serum 7-hydroxi-methotrexate and creatinine levels (p<0.05). CONCLUSION 5 g/m2 methotrexate resulted reliable therapeutic serum levels with mild and reversible toxicity. 7-hydroxi-methotexate measurements might be more useful than methotrexate levels to detect toxicity.
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Affiliation(s)
- Katalin Csordás
- Semmelweis Egyetem, Általános Orvostudományi Kar II. Gyermekgyógyászati Klinika Budapest Tűzoltó u. 7-9. 1094
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Evaluating performance of a decision support system to improve methotrexate pharmacotherapy in children and young adults with cancer. Ther Drug Monit 2011; 33:99-107. [PMID: 21192315 DOI: 10.1097/ftd.0b013e318203b41e] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The management of high-dose methotrexate (MTX) therapy in patients with cancer depends on the routine monitoring of drug exposures in conjunction with leucovorin (LV), urine pH, patient hydration, and other clinical indices of patient well-being. A key factor in patient oversight is the facilitation of MTX clearance to minimize drug-related toxicity. The aim of this investigation was to evaluate the performance of a clinical decision support system and Bayesian forecasting algorithm in the prediction of MTX concentrations and assessment of LV dosing requirements in pediatric and young adult patients with cancer based on the current practice at the Children's Hospital of Philadelphia. Fifty patients ranging in age from 8 months to 21 years (weight range, 7.6-163.3 kg) contributing 80 total dosing events (183 MTX serum concentrations) were studied. The forecasting model was able to consistently predict future MTX concentrations with the knowledge of one prior concentration and continued to improve with additional concentration data made available through daily therapeutic drug monitoring. Precision was good at 12.9% with low bias at 2.2%. Comparison between the decision support system recommendations for LV rescue relative to the actual LV administration was also made. Sixteen patients would have initiated rescue therapy earlier, seven patients would have received a larger dose (42 smaller), and LV would have been given less often for 37 patients. The forecasting algorithm in the MTX dashboard was reasonably accurate in predicting MTX concentrations and should improve further as the underlying model and prediction algorithm evolves. This decision support system can be useful in helping physicians decide if a patient is clearing MTX as expected or if more aggressive rescue therapy is warranted.
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Association of genetic polymorphism in the folate metabolic pathway with methotrexate pharmacokinetics and toxicity in childhood acute lymphoblastic leukaemia and malignant lymphoma. Eur J Clin Pharmacol 2011; 67:993-1006. [DOI: 10.1007/s00228-011-1046-z] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Accepted: 03/25/2011] [Indexed: 01/11/2023]
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Martelli N, Mathieu O, Margueritte G, Bozonnat MC, Daurès JP, Bressolle F, Hillaire-Buys D, Peyrière H. Methotrexate pharmacokinetics in childhood acute lymphoblastic leukaemia: a prognostic value? J Clin Pharm Ther 2010; 36:237-45. [PMID: 21366654 DOI: 10.1111/j.1365-2710.2010.01179.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE In industrialized countries, acute lymphoblastic leukaemia (ALL) is the most frequent cancer in children aged less than 15 years. High-dose methotrexate is a common component of many chemotherapeutic protocols for childhood with ALL. Our objective was to retrospectively evaluate the pharmacokinetics and plasma levels of high-dose methotrexate as it relates to event-free survival (EFS) in children with ALL. METHODS Relapsed patients and subjects in EFS were compared for MTX serum concentrations 24, 36, 48 and 72 h after the start of 24 h infusion. Clearance (Cl), area under the curve (AUC) and volume of distribution (V(d) ) of the drug were estimated by the NONMEM computer program and also compared between both groups. RESULTS AND DISCUSSION Among 69 children included, 54 (78·3%) were still in EFS, whereas 15 (21·7%) relapsed. The difference between relapsed and EFS patients for the pharmacokinetic parameters studied was not significant. On the contrary, the cohort studied was representative and known prognostic factors for relapse in ALL were significantly associated with relapse. WHAT IS NEW AND CONCLUSION Serum concentrations and pharmacokinetic parameters of MTX are not associated with outcome in ALL. Prognoses based on single-drug pharmacokinetic estimates within a complex multiple-agent protocol appear to be unreliable. However, therapeutic drug monitoring of high-dose methotrexate remains a useful tool for early detection of impaired elimination and for avoiding systemic toxicity.
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Affiliation(s)
- N Martelli
- Medical Pharmacology and Toxicology Department, Lapeyronie Hospital, University Hospital of Montpellier, Montpellier, France
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Veal GJ, Hartford CM, Stewart CF. Clinical pharmacology in the adolescent oncology patient. J Clin Oncol 2010; 28:4790-9. [PMID: 20439647 DOI: 10.1200/jco.2010.28.3473] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Numerous studies have documented that adolescents and young adults (AYAs) experience a significant cancer burden as well as significant cancer mortality compared with other age groups. The reasons for the disparate outcomes of AYAs and other age groups are not completely understood and are likely to be multifactorial, including a range of sociodemographic issues unique to these individuals as well as differences between adolescents, younger pediatric patients, and adults in the pharmacology of anticancer agents. Because adolescence is a period of transition from childhood to early adulthood, numerous physical, physiologic, cognitive, and behavioral changes occur during this time. In this review, we provide an overview of the unique developmental physiology of the adolescent and explain how these factors and the behavioral characteristics of adolescents may affect the pharmacology of anticancer agents in this patient population. Finally, we describe examples of studies that have assessed the relation between drug disposition and age, focusing on the AYA age group.
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Affiliation(s)
- Gareth J Veal
- Newcastle University, Newcastle upon Tyne, United Kingdom
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25
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Buitenkamp TD, Mathôt RAA, de Haas V, Pieters R, Zwaan CM. Methotrexate-induced side effects are not due to differences in pharmacokinetics in children with Down syndrome and acute lymphoblastic leukemia. Haematologica 2010; 95:1106-13. [PMID: 20418240 DOI: 10.3324/haematol.2009.019778] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Children with Down syndrome have an increased risk of developing acute lymphoblastic leukemia and a poor tolerance of methotrexate. This latter problem is assumed to be caused by a higher cellular sensitivity of tissues in children with Down syndrome. However, whether differences in pharmacokinetics play a role is unknown. DESIGN AND METHODS We compared methotrexate-induced toxicity and pharmacokinetics in a retrospective case-control study between patients with acute lymphoblastic leukemia who did or did not have Down syndrome. Population pharmacokinetic models were fitted to data from all individuals simultaneously, using non-linear mixed effect modeling. RESULTS Overall, 468 courses of methotrexate (1-5 g/m(2)) were given to 44 acute lymphoblastic leukemia patients with Down syndrome and to 87 acute lymphoblastic leukemia patients without Down syndrome. Grade 3-4 gastrointestinal toxicity was significantly more frequent in the children with Down syndrome than in those without (25.5% versus 3.9%; P=0.001). The occurrence of grade 3-4 gastrointestinal toxicity was not related to plasma methotrexate area under the curve. Methotrexate clearance was 5% lower in the acute lymphoblastic leukemia patients with Down syndrome (P=0.001); however, this small difference is probably clinically not relevant, because no significant differences in methotrexate plasma levels were detected at 24 and 48 hours. CONCLUSIONS We did not find evidence of differences in the pharmacokinetics of methotrexate between patients with and without Down syndrome which could explain the higher frequency of gastrointestinal toxicity and the greater need for methotrexate dose reductions in patients with Down syndrome. Hence, these problems are most likely explained by differential pharmaco-dynamic effects in the tissues between children with and without Down syndrome. Although the number of patients was limited to draw conclusions, we feel that it may be safe in children with Down syndrome to start with intermediate dosages of methotrexate (1-3 g/m(2)) and monitor the patients carefully.
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Affiliation(s)
- Trudy D Buitenkamp
- Pediatric Oncology/Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
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Noble SL, Sherer E, Hannemann RE, Ramkrishna D, Vik T, Rundell AE. Using adaptive model predictive control to customize maintenance therapy chemotherapeutic dosing for childhood acute lymphoblastic leukemia. J Theor Biol 2010; 264:990-1002. [PMID: 20138060 DOI: 10.1016/j.jtbi.2010.01.031] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Revised: 01/29/2010] [Accepted: 01/29/2010] [Indexed: 01/18/2023]
Abstract
Acute lymphoblastic leukemia (ALL) is a common childhood cancer in which nearly one-quarter of patients experience a disease relapse. However, it has been shown that individualizing therapy for childhood ALL patients by adjusting doses based on the blood concentration of active drug metabolite could significantly improve treatment outcome. An adaptive model predictive control (MPC) strategy is presented in which maintenance therapy for childhood ALL is personalized using routine patient measurements of red blood cell mean corpuscular volume as a surrogate for the active drug metabolite concentration. A clinically relevant mathematical model is developed and used to describe the patient response to the chemotherapeutic drug 6-mercaptopurine, with some model parameters being patient-specific. During the course of treatment, the patient-specific parameters are adaptively identified using recurrent complete blood count measurements, which sufficiently constrain the patient parameter uncertainty to support customized adjustments of the drug dose. While this work represents only a first step toward a quantitative tool for clinical use, the simulated treatment results indicate that the proposed mathematical model and adaptive MPC approach could serve as valuable resources to the oncologist toward creating a personalized treatment strategy that is both safe and effective.
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Affiliation(s)
- Sarah L Noble
- Weldon School of Biomedical Engineering, Purdue University, 206 South Martin Jischke Drive, West Lafayette, IN 47907, USA.
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Min Y, Qiang F, Peng L, Zhu Z. High dose methotrexate population pharmacokinetics and Bayesian estimation in patients with lymphoid malignancy. Biopharm Drug Dispos 2010; 30:437-47. [PMID: 19746402 DOI: 10.1002/bdd.678] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The purpose of present study was to develop a population pharmacokinetic model of high dose methotrexate (HD-MTX) infusion in patients with lymphoid malignancy, to investigate the biological and clinical covariates related to the drug distribution and elimination. It is also the purpose to propose a limited sampling strategy (LSS) for the estimation of the time above the threshold (0.2 micromol.L(-1)). A total 82 patients with lymphoid malignancy were involved in the study. A pharmacokinetic model was developed using nonlinear mixed-effect model. The influence of demographic characteristics, biological factors, and concurrent administration were investigated. The final predictive performance was validated by bootstrap and cross-validation. Bayesian estimation was evaluated. The pharmacokinetics of HD-MTX was described by a two-compartment model. The pharmacokinetic parameters and the inter-individual variability were as follows: the clearance CL, 7.45 L.h(-1) (inter-individual variability 50.6%), the volume of the central and peripheral compartment V(1), 25.9 L (22.5%), V(2), 9.23 L (97.8%), respectively, and the intercompartmental clearance Q, 0.333 L.h(-1) (70.4%). The influence of serum creatinine on CL and weight on V(1) was retained in the final model. The protocol involved one sampling time at 44 h after the start of the infusion, allowing one to predict the time at which the MTX concentration reached the expected threshold (0.2 micromol.L(-1)). Serum creatinine and weight showed significant influence on methotrexate CL and V(1), respectively. Furthermore, a Bayesian estimation based on the covariates and 44 h sample was developed, allowing prediction of the individual methotrexate pharmacokinetic parameters and the time to 0.2 micromol.L(-1).
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Affiliation(s)
- Ye Min
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences-Peking Union Medical College, Beijing 100730, China.
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Barrett JS, Mondick JT, Narayan M, Vijayakumar K, Vijayakumar S. Integration of modeling and simulation into hospital-based decision support systems guiding pediatric pharmacotherapy. BMC Med Inform Decis Mak 2008; 8:6. [PMID: 18226244 PMCID: PMC2254609 DOI: 10.1186/1472-6947-8-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2007] [Accepted: 01/28/2008] [Indexed: 11/23/2022] Open
Abstract
Background Decision analysis in hospital-based settings is becoming more common place. The application of modeling and simulation approaches has likewise become more prevalent in order to support decision analytics. With respect to clinical decision making at the level of the patient, modeling and simulation approaches have been used to study and forecast treatment options, examine and rate caregiver performance and assign resources (staffing, beds, patient throughput). There us a great need to facilitate pharmacotherapeutic decision making in pediatrics given the often limited data available to guide dosing and manage patient response. We have employed nonlinear mixed effect models and Bayesian forecasting algorithms coupled with data summary and visualization tools to create drug-specific decision support systems that utilize individualized patient data from our electronic medical records systems. Methods Pharmacokinetic and pharmacodynamic nonlinear mixed-effect models of specific drugs are generated based on historical data in relevant pediatric populations or from adults when no pediatric data is available. These models are re-executed with individual patient data allowing for patient-specific guidance via a Bayesian forecasting approach. The models are called and executed in an interactive manner through our web-based dashboard environment which interfaces to the hospital's electronic medical records system. Results The methotrexate dashboard utilizes a two-compartment, population-based, PK mixed-effect model to project patient response to specific dosing events. Projected plasma concentrations are viewable against protocol-specific nomograms to provide dosing guidance for potential rescue therapy with leucovorin. These data are also viewable against common biomarkers used to assess patient safety (e.g., vital signs and plasma creatinine levels). As additional data become available via therapeutic drug monitoring, the model is re-executed and projections are revised. Conclusion The management of pediatric pharmacotherapy can be greatly enhanced via the immediate feedback provided by decision analytics which incorporate the current, best-available knowledge pertaining to dose-exposure and exposure-response relationships, especially for narrow therapeutic agents that are difficult to manage.
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Affiliation(s)
- Jeffrey S Barrett
- Department of Pediatrics, Division of Clinical Pharmacology and Therapeutics, The Children's Hospital of Philadelphia, USA.
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Zandvliet AS, Schellens JHM, Beijnen JH, Huitema ADR. Population Pharmacokinetics and Pharmacodynamics for Treatment Optimization??in Clinical Oncology. Clin Pharmacokinet 2008; 47:487-513. [DOI: 10.2165/00003088-200847080-00001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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