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McCann S, Helfer VE, Balevic SJ, Hornik CD, Goldstein SL, Autmizguine J, Meyer M, Al-Uzri A, Anderson SG, Payne EH, Turdalieva S, Gonzalez D. Using Real-World Data to Externally Evaluate Population Pharmacokinetic Models of Dexmedetomidine in Children and Infants. J Clin Pharmacol 2024; 64:963-974. [PMID: 38545761 DOI: 10.1002/jcph.2434] [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: 12/22/2023] [Accepted: 03/04/2024] [Indexed: 07/30/2024]
Abstract
Dexmedetomidine is a sedative used in both adults and off-label in children with considerable reported pharmacokinetic (PK) interindividual variability affecting drug exposure across populations. Several published models describe the population PKs of dexmedetomidine in neonates, infants, children, and adolescents, though very few have been externally evaluated. A prospective PK dataset of dexmedetomidine plasma concentrations in children and young adults aged 0.01-19.9 years was collected as part of a multicenter opportunistic PK study. A PubMed search of studies reporting dexmedetomidine PK identified five population PK models developed with data from demographically similar children that were selected for external validation. A total of 168 plasma concentrations from 102 children were compared with both population (PRED) and individualized (IPRED) predicted values from each of the five published models by quantitative and visual analyses using NONMEM (v7.3) and R (v4.1.3). Mean percent prediction errors from observed values ranged from -1% to 120% for PRED, and -24% to 60% for IPRED. The model by James et al, which was developed using similar "real-world" data, nearly met the generalizability criteria from IPRED predictions. Other models developed using clinical trial data may have been limited by inclusion/exclusion criteria and a less racially diverse population than this study's opportunistic dataset. The James model may represent a useful, but limited tool for model-informed dosing of hospitalized children.
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Affiliation(s)
- Sean McCann
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Victória E Helfer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephen J Balevic
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Chi D Hornik
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Julie Autmizguine
- Department of Pediatrics, Center Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Marisa Meyer
- Critical Care Medicine, Nemours Children's Hospital, Delaware, Wilmington, DE, USA
| | - Amira Al-Uzri
- Oregon Health and Science University, Portland, OR, USA
| | | | | | | | - Daniel Gonzalez
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Clinical Pharmacology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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Shannon ML, Muhammad A, James NT, Williams ML, Breeyear J, Edwards T, Mosley JD, Choi L, Kannankeril P, Van Driest S. Variant-based heritability assessment of dexmedetomidine and fentanyl clearance in pediatric patients. Clin Transl Sci 2023; 16:1628-1638. [PMID: 37353859 PMCID: PMC10499425 DOI: 10.1111/cts.13574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/12/2023] [Accepted: 06/01/2023] [Indexed: 06/25/2023] Open
Abstract
Despite complex pathways of drug disposition, clinical pharmacogenetic predictors currently rely on only a few high effect variants. Quantification of the polygenic contribution to variability in drug disposition is necessary to prioritize target drugs for pharmacogenomic approaches and guide analytic methods. Dexmedetomidine and fentanyl, often used in postoperative care of pediatric patients, have high rates of inter-individual variability in dosing requirements. Analyzing previously generated population pharmacokinetic parameters, we used Bayesian hierarchical mixed modeling to measure narrow-sense (additive) heritability (h SNP 2 ) of dexmedetomidine and fentanyl clearance in children and identify relative contributions of small, moderate, and large effect-size variants toh SNP 2 . We used genome-wide association studies (GWAS) to identify variants contributing to variation in dexmedetomidine and fentanyl clearance, followed by functional analyses to identify associated pathways. For dexmedetomidine, median clearance was 33.0 L/h (interquartile range [IQR] 23.8-47.9 L/h) andh SNP 2 was estimated to be 0.35 (90% credible interval 0.00-0.90), with 45% ofh SNP 2 attributed to large-, 32% to moderate-, and 23% to small-effect variants. The fentanyl cohort had median clearance of 8.2 L/h (IQR 4.7-16.7 L/h), with estimatedh SNP 2 of 0.30 (90% credible interval 0.00-0.84). Large-effect variants accounted for 30% ofh SNP 2 , whereas moderate- and small-effect variants accounted for 37% and 33%, respectively. As expected, given small sample sizes, no individual variants or pathways were significantly associated with dexmedetomidine or fentanyl clearance by GWAS. We conclude that clearance of both drugs is highly polygenic, motivating the future use of polygenic risk scores to guide appropriate dosing of dexmedetomidine and fentanyl.
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Affiliation(s)
| | - Ayesha Muhammad
- School of MedicineVanderbilt UniversityNashvilleTennesseeUSA
| | - Nathan T. James
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
- Present address:
Berry Consultants, LLCAustinTexasUSA
| | - Michael L. Williams
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
- Present address:
Department of Clinical Pharmacology and Quantitative PharmacologyAstraZenecaGothenburgSweden
| | - Joseph Breeyear
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Todd Edwards
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jonathan D. Mosley
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- Department of Biomedical InformaticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Leena Choi
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Prince Kannankeril
- Center for Pediatric Precision Medicine, Department of PediatricsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Sara Van Driest
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- Center for Pediatric Precision Medicine, Department of PediatricsVanderbilt University Medical CenterNashvilleTennesseeUSA
- Present address:
All of Us Research ProgramNational Institutes of HealthWashingtonDCUSA
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Fan ZW, Tang YX, Pan T, Zhang HT, Zhang H, Yan DL, Wang DJ, Li K. Dexmedetomidine as an anesthetic adjunct is associated with reduced complications and cardiac intensive care unit length of stay after heart valve surgery. BMC Anesthesiol 2023; 23:262. [PMID: 37543588 PMCID: PMC10403836 DOI: 10.1186/s12871-023-02227-5] [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: 04/06/2023] [Accepted: 07/30/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND We sought to explore the relationship between dexmedetomidine as an anesthetic adjuvant in cardiac surgery and postoperative complications and length of stay (LOS) in the cardiac intensive care unit (CICU). METHODS We conducted a retrospective study of patients aged 18 years and older who underwent heart valve surgery between October 2020 and June 2022. The primary endpoint of the study was major postoperative complications (cardiac arrest, atrial fibrillation, myocardial injury/infarction, heart failure) and the secondary endpoint was prolonged CICU LOS (defined as LOS > 90th percentile). Multivariate logistic regression analysis was performed for variables that were significant in the univariate analysis. RESULTS A total of 856 patients entered our study. The 283 patients who experienced the primary and secondary endpoints were included in the adverse outcomes group, and the remaining 573 were included in the prognostic control group. Multivariate logistic regression analysis revealed that age > 60 years (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.23-2.31; p < 0.01), cardiopulmonary bypass (CPB) > 180 min (OR, 1.62; 95% CI, 1.03-2.55; p = 0.04) and postoperative mechanical ventilation time > 10 h (OR, 1.84; 95% CI, 1.35-2.52; p < 0.01) were independent risk factors for major postoperative complications; Age > 60 years (OR, 3.20; 95% CI, 1.65-6.20; p < 0.01), preoperative NYHA class 4 (OR, 4.03; 95% CI, 1.74-9.33; p < 0.01), diabetes mellitus (OR, 2.57; 95% CI, 1.22-5.41; p = 0.01), Intraoperative red blood cell (RBC) transfusion > 650 ml (OR, 2.04; 95% CI, 1.13-3.66; p = 0.02), Intraoperative bleeding > 1200 ml (OR, 2.69; 95% CI, 1.42-5.12; p < 0.01) were independent risk factors for prolonged CICU length of stay. Intraoperative use of dexmedetomidine as an anesthetic adjunct was a protective factor for major complications (odds ratio, 0.51; 95% confidence interval, 0.35-0.74; p < 0.01) and prolonged CICU stay. (odds ratio, 0.37; 95% confidence interval, 0.19-0.73; p < 0.01). CONCLUSIONS In patients undergoing heart valve surgery, age, duration of cardiopulmonary bypass, and duration of mechanical ventilation are associated with major postoperative complication. Age, preoperative NYHA classification 4, diabetes mellitus, intraoperative bleeding, and RBC transfusion are associated with increased CICU length of stay. Intraoperative use of dexmedetomidine may improve such clinical outcomes.
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Affiliation(s)
- Zhi-Wei Fan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Yu-Xian Tang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Tuo Pan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Nanjing, 210008, Jiangsu, China
| | - Hai-Tao Zhang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Nanjing, 210008, Jiangsu, China
| | - He Zhang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Nanjing, 210008, Jiangsu, China
| | - Da-Liang Yan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, 210008, Jiangsu, China
| | - Dong-Jin Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China.
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Nanjing, 210008, Jiangsu, China.
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, 210008, Jiangsu, China.
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China.
| | - Kai Li
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China.
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Hejal R, Popa A, Rangel ML, Remy KE. What's New in Critical Illness and Injury Science? Weighing the evidence for dexmedetomidine dosing in critically ill patients with obesity. Int J Crit Illn Inj Sci 2023; 13:45-47. [PMID: 37547191 PMCID: PMC10401556 DOI: 10.4103/ijciis.ijciis_25_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 06/11/2023] [Accepted: 06/12/2023] [Indexed: 08/08/2023] Open
Affiliation(s)
- Rana Hejal
- Department of Medicine, Case Western Reserve University School of Medicine, University Hospitals of Cleveland, Ohio, USA
| | - Andrea Popa
- Department of Medicine, Case Western Reserve University School of Medicine, University Hospitals of Cleveland, Ohio, USA
- Department of Pharmacy, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Maribel Llamas Rangel
- Department of Pharmacy, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Kenneth E. Remy
- Department of Medicine, Case Western Reserve University School of Medicine, University Hospitals of Cleveland, Ohio, USA
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Alshemeili M, Lobo FA. Is dexmedetomidine a lazy drug or do we have lazy anesthesiologists? BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:128-131. [PMID: 36690207 PMCID: PMC10068531 DOI: 10.1016/j.bjane.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Affiliation(s)
- Maryam Alshemeili
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Francisco A Lobo
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.
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Crisamore KR, Empey PE, Pelletier JH, Clark RSB, Horvat CM. Patient-Specific Factors Associated with Dexmedetomidine Dose Requirements in Critically Ill Children. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1753537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
AbstractThe objective of this study was to evaluate patient-specific factors associated with dexmedetomidine dose requirements during continuous infusion. A retrospective cross-sectional analysis of electronic health record-derived data spanning 10 years for patients admitted with a primary respiratory diagnosis at a quaternary children's hospital and who received a dexmedetomidine continuous infusion (n = 346 patients) was conducted. Penalized regression was used to select demographic, clinical, and medication characteristics associated with a median daily dexmedetomidine dose. Identified characteristics were included in multivariable linear regression models and sensitivity analyses. Critically ill children had a median hourly dexmedetomidine dose of 0.5 mcg/kg/h (range: 0.1–1.8), median daily dose of 6.7 mcg/kg/d (range: 0.9–38.4), and median infusion duration of 1.6 days (range: 0.25–5.0). Of 26 variables tested, 15 were selected in the final model with days of dexmedetomidine infusion (β: 1.9; 95% confidence interval [CI]: 1.6, 2.3), median daily morphine milligram equivalents dosing (mg/kg/d) (β: 0.3; 95% CI: 0.1, 0.5), median daily ketamine dosing (mg/kg/d) (β: 0.2; 95% CI: 0.1, 0.3), male sex (β: −1.1; 95% CI: −2.0, −0.2), and non-Black reported race (β: −1.2; 95% CI: −2.3, −0.08) significantly associated with median daily dexmedetomidine dose. Approximately 56% of dose variability was explained by the model. Readily obtainable information such as demographics, concomitant medications, and duration of infusion accounts for over half the variability in dexmedetomidine dosing. Identified factors, as well as additional environmental and genetic factors, warrant investigation in future studies to inform precision dosing strategies.
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Affiliation(s)
- Karryn R. Crisamore
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, United States
| | - Philip E. Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Jonathan H. Pelletier
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, United States
| | - Robert S. B. Clark
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, United States
| | - Christopher M. Horvat
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, United States
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Ashraf MW, Uusalo P, Scheinin M, Saari TI. Population Modelling of Dexmedetomidine Pharmacokinetics and Haemodynamic Effects After Intravenous and Subcutaneous Administration. Clin Pharmacokinet 2021; 59:1467-1482. [PMID: 32462542 PMCID: PMC7658092 DOI: 10.1007/s40262-020-00900-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background and Objective Dexmedetomidine is a potent agonist of α2-adrenoceptors causing dose-dependent sedation in humans. Intravenous dexmedetomidine is commonly used perioperatively, but an extravascular route of administration would be favoured in palliative care. Subcutaneous infusions provide desired therapeutic plasma concentrations with fewer unwanted effects as compared with intravenous dosing. We aimed to develop semi-mechanistic population models for predicting pharmacokinetic and pharmacodynamic profiles of dexmedetomidine after intravenous and subcutaneous dosing. Methods Non-linear mixed-effects modelling was performed using previously collected concentration and haemodynamic effects data from ten (eight in the intravenous phase) healthy human subjects, aged 19–27 years, receiving 1 µg/kg of intravenous or subcutaneous dexmedetomidine during a 10-min infusion. Results The absorption of dexmedetomidine from the subcutaneous injection site, and distribution to local subcutaneous fat tissue was modelled using a semi-physiological approach consisting of a depot and fat compartment, while a two-compartment mammillary model explained further disposition. Dexmedetomidine-induced reductions in plasma norepinephrine concentrations were accurately described by an indirect response model. For blood pressure models, the net effect was specified as hyper- and hypotensive effects of dexmedetomidine due to vasoconstriction on peripheral arteries and sympatholysis mediated via the central nervous system, respectively. A heart rate model combined the dexmedetomidine-induced sympatholytic effect, and input from the central nervous system, predicted from arterial blood pressure levels. Internal evaluation confirmed the predictive performance of the final models, as well as the accuracy of the parameter estimates with narrow confidence intervals. Conclusions Our final model precisely describes dexmedetomidine pharmacokinetics and accurately predicts dexmedetomidine-induced sympatholysis and other pharmacodynamic effects. After subcutaneous dosing, dexmedetomidine is taken up into subcutaneous fat tissue, but our simulations indicate that accumulation of dexmedetomidine in this compartment is insignificant. ClinicalTrials.org NCT02724098 and EudraCT 2015-004698-34 Electronic supplementary material The online version of this article (10.1007/s40262-020-00900-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Muhammad W Ashraf
- Department of Anaesthesiology and Intensive Care, University of Turku, Kiinamyllynkatu 4-8 (11A5), P.O. Box 52, 20521, Turku, Finland
| | - Panu Uusalo
- Department of Anaesthesiology and Intensive Care, University of Turku, Kiinamyllynkatu 4-8 (11A5), P.O. Box 52, 20521, Turku, Finland.,Division of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - Mika Scheinin
- Institute of Biomedicine, University of Turku, Turku, Finland.,Unit of Clinical Pharmacology, Turku University Hospital, Turku, Finland
| | - Teijo I Saari
- Department of Anaesthesiology and Intensive Care, University of Turku, Kiinamyllynkatu 4-8 (11A5), P.O. Box 52, 20521, Turku, Finland. .,Division of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland.
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Morse JD, Cortinez LI, Anderson BJ. Pharmacokinetic concepts for dexmedetomidine target-controlled infusion pumps in children. Paediatr Anaesth 2021; 31:924-931. [PMID: 34085357 DOI: 10.1111/pan.14235] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 05/26/2021] [Accepted: 05/31/2021] [Indexed: 12/15/2022]
Abstract
Pharmacokinetic parameter estimates are used in mathematical equations (pharmacokinetic models) to describe concentration changes with time in a population and are specific to that population. Simulation using these models and their parameter estimates can enrich understanding of drug behavior and serve as a basis for study design. Pharmacokinetic concepts are presented pertaining to future designs of dexmedetomidine target-controlled infusion pumps in children. This manuscript provides the pediatric anesthesiologist with an understanding of the nuances that should be considered when using target-controlled infusion pumps; how the central volume may differ between populations, how clearance changes with age, and the impact of adverse effects on dose. In addition, the ideal loading dose and rate of delivery to achieve target concentration without adverse cardiovascular effects are reviewed, and finally, dose considerations for obese children, based on contact-sensitive half-time, are introduced. An understanding of context-sensitive half-time changes with age enables anesthetic practitioners to better estimate duration of effect after cessation of dexmedetomidine infusion. Use of these known pharmacokinetic parameters and covariate information for the pediatric patient could readily be incorporated into commercial target-controlled infusion pumps to allow effective and safe open-loop administration of dexmedetomidine in children.
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Affiliation(s)
- James D Morse
- Department of Pharmacology & Clinical Pharmacology, Auckland University, Auckland, New Zealand
| | - Luis Ignacio Cortinez
- División Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
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Yan X, Tse AHW, Lee A, Zhang L, Yang M, Zuo Z, Joynt GM. Protein Binding and Population Pharmacokinetics of Dexmedetomidine after Prolonged Infusions in Adult Critically Ill Patients. Clin Ther 2021; 43:1356-1369.e1. [PMID: 34304911 DOI: 10.1016/j.clinthera.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 05/14/2021] [Accepted: 06/07/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Dexmedetomidine (DEX) is a highly selective α2-adrenoceptor agonist with high protein binding of 94%. Critical illness may affect protein binding and the pharmacokinetic (PK) parameters of many drugs, including DEX. In critically ill patients receiving prolonged infusions of DEX, there is little information documenting the relationship between key pathophysiologic factors and DEX protein binding or PK parameters. The purpose of this study was to characterize the protein binding and PK profile of prolonged DEX infusion in critically ill patients. METHODS Critically ill, adult intensive care unit patients at a university hospital in Hong Kong were studied. The association between the pathophysiologic changes of critical illness and protein binding was evaluated using a generalized estimating equation. A population pharmacokinetic model to establish the PK profile of DEX was developed, and key pathophysiologic covariate effects of severity of illness, organ dysfunction measures, and altered protein binding on DEX PK parameters in this critically ill population were evaluated. FINDINGS A total of 22 critically ill patients and 1 healthy control were included. Mean protein binding of DEX in the critically ill patients was 90.4% (95% CI, 89.1-91.7), which was 4% lower than that in the healthy control. The PK data were adequately described by a 2-compartment model. The estimated population mean (relative standard error [RSE]) values of systemic clearance (CL), volume of distribution of the central compartment (V2), intercompartmental clearance (Q), and Vd in the peripheral compartment (V3) were 38.6 (11.7) L/h, 32.1 (46.1) L, 114.5 (58.3) L/h and 95.1 (30.6) L, respectively. The corresponding estimated interindividual variability expressed as CV% (RSE) was 52.4 (23.8) for CL, 172.9 (19.3) for V2, 123.7 (33.7) for Q, and 106 (39.9) for V3. No significant explanatory pathophysiologic covariates were identified. IMPLICATIONS Although a marginally significant reduction of protein binding in critically ill patients was demonstrated, the magnitude of the difference was unlikely to be of clinical significance. Higher alanine aminotransferase concentration was associated with decreased protein binding. No significant pathophysiologic covariates were associated with the observed PK parameters. The high interindividual variability of PK parameters supports the current practice of dose titration to ensure the desired clinical effects of DEX infusion in the intensive care unit setting.
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Affiliation(s)
- Xiaoyu Yan
- School of Pharmacy, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Andrew Ho Wai Tse
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, China
| | - Anna Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, China.
| | - Lin Zhang
- School of Pharmacy, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Mengbi Yang
- School of Pharmacy, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Zhong Zuo
- School of Pharmacy, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Gavin Matthew Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, China
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A Universal Pharmacokinetic Model for Dexmedetomidine in Children and Adults. J Clin Med 2020; 9:jcm9113480. [PMID: 33126702 PMCID: PMC7692360 DOI: 10.3390/jcm9113480] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 10/25/2020] [Accepted: 10/26/2020] [Indexed: 02/07/2023] Open
Abstract
A universal pharmacokinetic model was developed from pooled paediatric and adult data (40.6 postmenstrual weeks, 70.8 years, 3.1-152 kg). A three-compartment pharmacokinetic model with first-order elimination was superior to a two-compartment model to describe these pooled dexmedetomidine data. Population parameter estimates (population parameter variability%) were clearance (CL) 0.9 L/min/70 kg (36); intercompartmental clearances (Q2) 1.68 L/min/70 kg (63); Q3 0.62 L/min/70 kg (90); volume of distribution in the central compartment (V1) 25.2 L/70 kg (103.9); rapidly equilibrating peripheral compartment (V2) 34.4 L/70 kg (41.8); slow equilibrating peripheral compartment (V3) 65.4 L/70 kg (62). Obesity was best described by fat-free mass for clearances and normal fat mass for volumes with a factor for fat mass (FfatV) of 0.293. Models describing dexmedetomidine pharmacokinetics in adults can be applied to children by accounting for size (allometry) and age (maturation). This universal dexmedetomidine model is applicable to a broad range of ages and weights: neonates through to obese adults. Lean body weight is a better size descriptor for dexmedetomidine clearance than total body weight. This parameter set could be programmed into target-controlled infusion pumps for use in a broad population.
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Drug dosing in the critically ill obese patient-a focus on sedation, analgesia, and delirium. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:315. [PMID: 32513237 PMCID: PMC7282067 DOI: 10.1186/s13054-020-03040-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/27/2020] [Indexed: 12/12/2022]
Abstract
Practice guidelines provide clear evidence-based recommendations for the use of drug therapy to manage pain, agitation, and delirium associated with critical illness. Dosing recommendations however are often based on strategies used in patients with normal body habitus. Recommendations specific to critically ill patients with extreme obesity are lacking. Nonetheless, clinicians must craft dosing regimens for this population. This paper is intended to help clinicians design initial dosing regimens for medications commonly used in the management of pain, agitation, and delirium in critically ill patients with extreme obesity. A detailed literature search was conducted with an emphasis on obesity, pharmacokinetics, and dosing. Relevant manuscripts were reviewed and strategies for dosing are provided.
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Ber J, Wiczling P, Hołysz M, Klupczyńska A, Bartkowska-Śniatkowska A, Bieda K, Smuszkiewicz P, Nowicka M, Żurański Ł, Sobczyński P, Matysiak J, Grześkowiak E, Bienert A. Population Pharmacokinetic Model of Dexmedetomidine in a Heterogeneous Group of Patients. J Clin Pharmacol 2020; 60:1461-1473. [PMID: 32500578 DOI: 10.1002/jcph.1647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/28/2020] [Indexed: 11/11/2022]
Abstract
Dexmedetomidine is a hepatically eliminated drug with sedative, anxiolytic, sympatholytic, and analgesic properties that has been increasingly used for various indications in the form of a short or continuous intravenous infusion. This study aimed to propose a population pharmacokinetic (PK) model of dexmedetomidine in a heterogeneous group of intensive care unit patients, incorporating 29 covariates potentially linked with dexmedetomidine PK. Data were collected from 70 patients aged between 0.25 and 88 years and treated with dexmedetomidine infusion for various durations at 1 of 4 medical centers. Statistical analysis was performed using a nonlinear mixed-effect model. Categorical and continuous covariates including demographic data, hemodynamic parameters, biochemical markers, and 11 single-nucleotide polymorphisms were tested. A 2-compartment model was used to describe dexmedetomidine PK. An allometric/isometric scaling was used to account for body weight difference in PK parameters, and the Hill equation was used to describe the maturation of clearance. Typical values of the central and peripheral volume of distribution and the systemic and distribution clearance for a theoretical adult patient were central volume of distribution = 22.50 L, peripheral volume of distribution = 86.1 L, systemic clearance = 34.7 L/h, and distribution clearance = 40.8 L/h. The CYP1A2 genetic polymorphism and noradrenaline administration were identified as significant covariates for clearance. A population PK model of dexmedetomidine was successfully developed. The proposed model is well calibrated to the observed data. The identified covariates account for <5% of interindividual variability and consequently are of low clinical significance for the purpose of dose adjustment.
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Affiliation(s)
- Justyna Ber
- Department of Clinical Pharmacy and Biopharmacy, Poznan University of Medical Sciences, Poznan, Poland
| | - Paweł Wiczling
- Department of Biopharmacy and Pharmacodynamics, Medical University of Gdansk, Gdansk, Poland
| | - Marcin Hołysz
- Department of Biochemistry and Molecular Biology, Poznan University of Medical Sciences, Poznan, Poland
| | - Agnieszka Klupczyńska
- Department of Inorganic and Analytical Chemistry, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Krzysztof Bieda
- Anaesthesiology and Intensive Care Department, Greater Poland Cancer Centre, Poznan, Poland
| | - Piotr Smuszkiewicz
- Department of Anesthesiology, Intensive Therapy and Pain Treatment, Heliodor Swiecicki Clinical Hospital, Poznan University of Medical Sciences, Poznan, Poland
| | - Małgorzata Nowicka
- Anaesthetics and Critical Care Department, University Hospital of Lord's Transfiguration, Poznan University of Medical Sciences, Poznan, Poland
| | - Łukasz Żurański
- Anaesthetics and Critical Care Department, University Hospital of Lord's Transfiguration, Poznan University of Medical Sciences, Poznan, Poland
| | - Paweł Sobczyński
- Anaesthetics and Critical Care Department, University Hospital of Lord's Transfiguration, Poznan University of Medical Sciences, Poznan, Poland
| | - Jan Matysiak
- Department of Inorganic and Analytical Chemistry, Poznan University of Medical Sciences, Poznan, Poland
| | - Edmund Grześkowiak
- Department of Clinical Pharmacy and Biopharmacy, Poznan University of Medical Sciences, Poznan, Poland
| | - Agnieszka Bienert
- Department of Clinical Pharmacy and Biopharmacy, Poznan University of Medical Sciences, Poznan, Poland
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Damian MA, Hammer GB, Elkomy MH, Frymoyer A, Drover DR, Su F. Pharmacokinetics of Dexmedetomidine in Infants and Children After Orthotopic Liver Transplantation. Anesth Analg 2020; 130:209-216. [PMID: 30198929 DOI: 10.1213/ane.0000000000003761] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Dexmedetomidine (DEX) is a sedative and analgesic medication that is frequently used postoperatively in children after liver transplantation. Hepatic dysfunction, including alterations in drug clearance, is common immediately after liver transplantation. However, the pharmacokinetics (PK) of DEX in this population is unknown. The objective of this study was to determine the PK profile of DEX in children after liver transplantation. METHODS This was a single-center, open-label PK study of DEX administered as an intravenous loading dose of 0.5 μg/kg followed by a continuous infusion of 0.5 μg/kg/h. Twenty subjects, 1 month to 18 years of age, who were admitted to the pediatric intensive care unit after liver transplantation were enrolled. Whole blood was collected and analyzed for DEX concentration using a dried blood spot method. Nonlinear mixed-effects modeling was used to characterize the population PK of DEX. RESULTS DEX PK was best described by a 2-compartment model with first-order elimination. A typical child after liver transplantation with an international normalized ratio (INR) of 1.8 was found to have a whole blood DEX clearance of 52 L/h (95% confidence interval [CI], 31-73 L/h). In addition, intercompartmental clearance was 246 L/h (95% CI, 139-391 L/h), central volume of distribution was 186 L/70 kg (95% CI, 140-301 L/70 kg), and peripheral volume of distribution was 203 L (95% CI, 123-338 L). Interindividual variability ranged from 11% to 111% for all parameters. Clearance was not found to be associated with weight but was found to be inversely proportional to INR. An increase in INR to 3.2 resulted in a 50% decrease in DEX clearance. Weight was linearly correlated with central volume of distribution. All other covariates, including age, ischemic time, total bilirubin, and alanine aminotransferase, were not found to be significant predictors of DEX disposition. CONCLUSIONS Children who received DEX after liver transplantation have large variability in clearance, which was not found to be associated with weight but is influenced by underlying liver function, as reflected by INR. In this population, titration of DEX dosing to clinical effect may be important because weight-based dosing is poorly associated with blood concentrations. More attention to quality of DEX sedation may be warranted when INR values are changing.
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Affiliation(s)
- Mihaela A Damian
- From the Department of Pediatrics, Pediatric Critical Care Medicine
| | - Gregory B Hammer
- From the Department of Pediatrics, Pediatric Critical Care Medicine.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Mohammed H Elkomy
- Department of Pharmaceutics, Jouf University, Sakaka, Saudi Arabia.,Department of Pharmaceutics and Industrial Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Adam Frymoyer
- From the Department of Pediatrics, Pediatric Critical Care Medicine
| | - David R Drover
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Felice Su
- From the Department of Pediatrics, Pediatric Critical Care Medicine
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14
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Castillo RL, Ibacache M, Cortínez I, Carrasco-Pozo C, Farías JG, Carrasco RA, Vargas-Errázuriz P, Ramos D, Benavente R, Torres DH, Méndez A. Dexmedetomidine Improves Cardiovascular and Ventilatory Outcomes in Critically Ill Patients: Basic and Clinical Approaches. Front Pharmacol 2020; 10:1641. [PMID: 32184718 PMCID: PMC7058802 DOI: 10.3389/fphar.2019.01641] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 12/16/2019] [Indexed: 12/11/2022] Open
Abstract
Dexmedetomidine (DEX) is a highly selective α2-adrenergic agonist with sedative and analgesic properties, with minimal respiratory effects. It is used as a sedative in the intensive care unit and the operating room. The opioid-sparing effect and the absence of respiratory effects make dexmedetomidine an attractive adjuvant drug for anesthesia in obese patients who are at an increased risk for postoperative respiratory complications. The pharmacodynamic effects on the cardiovascular system are known; however the mechanisms that induce cardioprotection are still under study. Regarding the pharmacokinetics properties, this drug is extensively metabolized in the liver by the uridine diphosphate glucuronosyltransferases. It has a relatively high hepatic extraction ratio, and therefore, its metabolism is dependent on liver blood flow. This review shows, from a basic clinical approach, the evidence supporting the use of dexmedetomidine in different settings, from its use in animal models of ischemia-reperfusion, and cardioprotective signaling pathways. In addition, pharmacokinetics and pharmacodynamics studies in obese subjects and the management of patients subjected to mechanical ventilation are described. Moreover, the clinical efficacy of delirium incidence in patients with indication of non-invasive ventilation is shown. Finally, the available evidence from DEX is described by a group of Chilean pharmacologists and clinicians who have worked for more than 10 years on DEX.
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Affiliation(s)
- Rodrigo L Castillo
- Departamento de Medicina Interna Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Unidad de Paciente Crítico, Hospital del Salvador, Santiago, Chile
| | - Mauricio Ibacache
- Programa de Farmacología y Toxicología & División de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ignacio Cortínez
- Programa de Farmacología y Toxicología & División de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Catalina Carrasco-Pozo
- Discovery Biology, Griffith Institute for Drug Discovery, Griffith University, Nathan, QLD, Australia
| | - Jorge G Farías
- Departmento de Ingeniería Química, Facultad de Ingeniería y Ciencias, Universidad de La Frontera, Francisco Salazar, Chile
| | - Rodrigo A Carrasco
- Departamento de Cardiología, Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Patricio Vargas-Errázuriz
- Unidad de Paciente Crítico, Hospital del Salvador, Santiago, Chile.,Unidad de Paciente Crítico Adulto, Clínica Universidad de Los Andes, Santiago, Chile.,Unidad de Paciente Crítico, Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Daniel Ramos
- Departamento de Medicina Interna Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Rafael Benavente
- Departamento de Medicina Interna Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Daniela Henríquez Torres
- Departamento de Medicina Interna Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Aníbal Méndez
- Departamento de Medicina Interna Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile
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Yang M, Tse AH, Lee A, Joynt GM, Zuo Z. Large inter-individual variability in pharmacokinetics of dexmedetomidine and its two major N-glucuronides in adult intensive care unit patients. J Pharm Biomed Anal 2019; 175:112777. [DOI: 10.1016/j.jpba.2019.07.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 07/12/2019] [Accepted: 07/15/2019] [Indexed: 10/26/2022]
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16
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L-arginine and Arginase Products Potentiate Dexmedetomidine-induced Contractions in the Rat Aorta. Anesthesiology 2019; 128:564-573. [PMID: 29251642 DOI: 10.1097/aln.0000000000002032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The α2-adrenergic sedative/anesthetic agent dexmedetomidine exerts biphasic effects on isolated arteries, causing endothelium-dependent relaxations at concentrations at or below 30 nM, followed by contractions at higher concentrations. L-arginine is a common substrate of endothelial nitric oxide synthase and arginases. This study was designed to investigate the role of L-arginine in modulating the overall vascular response to dexmedetomidine. METHODS Isometric tension was measured in isolated aortic rings of Sprague Dawley rats. Cumulative concentrations of dexmedetomidine (10 nM to 10 μM) were added to quiescent rings (with and without endothelium) after previous incubation with vehicle, N-nitro-L-arginine methyl ester hydrochloride (L-NAME; nitric oxide synthase inhibitor), prazosin (α1-adrenergic antagonist), rauwolscine (α2-adrenergic antagonist), L-arginine, (S)-(2-boronethyl)-L-cysteine hydrochloride (arginase inhibitor), N-hydroxy-L-arginine (arginase inhibitor), urea and/or ornithine. In some preparations, immunofluorescent staining, immunoblotting, or measurement of urea content were performed. RESULTS Dexmedetomidine did not contract control rings with endothelium but evoked concentration-dependent increases in tension in such rings treated with L-NAME (Emax 50 ± 4%) or after endothelium-removal (Emax 74 ± 5%; N = 7 to 12). Exogenous L-arginine augmented the dexmedetomidine-induced contractions in the presence of L-NAME (Emax 75 ± 3%). This potentiation was abolished by (S)-(2-boronethyl)-L-cysteine hydrochloride (Emax 16 ± 4%) and N-hydroxy-L-arginine (Emax 18 ± 4%). Either urea or ornithine, the downstream arginase products, had a similar potentiating effect as L-arginine. Immunoassay measurements demonstrated an upregulation of arginase I by L-arginine treatment in the presence of L-NAME (N = 4). CONCLUSIONS These results suggest that when vascular nitric oxide homeostasis is impaired, the potentiation of the vasoconstrictor effect of dexmedetomidine by L-arginine depends on arginase activity and the production of urea and ornithine.
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Tse AH, Ling L, Lee A, Joynt GM. Altered Pharmacokinetics in Prolonged Infusions of Sedatives and Analgesics Among Adult Critically Ill Patients: A Systematic Review. Clin Ther 2018; 40:1598-1615.e2. [DOI: 10.1016/j.clinthera.2018.07.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 07/27/2018] [Accepted: 07/30/2018] [Indexed: 12/15/2022]
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18
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Wang L, Wang S, Qi J, Yu R, Zhuang J, Zhuang B, Lou Y, Ruan J, Ye H, Lin F. Impact of CYP2A6 gene polymorphism on the pharmacokinetics of dexmedetomidine for premedication. Expert Rev Clin Pharmacol 2018; 11:917-922. [PMID: 30092666 DOI: 10.1080/17512433.2018.1510312] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Dexmedetomidine is a widely used sedative in clinic, which is mainly metabolized by cytochrome P450 2A6 (CYP2A6). Dexmedetomidine was rarely reported for off-label usage of premedication, but lacking relevant pharmacokinetic investigations. Therefore, our study determined the dexmedetomidine pharmacokinetics of CYP2A6*4 allele in Chinese patients pretreated with dexmedetomidine whose mutation frequency of CYP2A6*4 are high, in order to provide clinical references. METHODS Thirty-one elective surgery patients received premedication with 0.5 μg/kg dexmedetomidine via intravenous pump. Their plasma concentrations at multiple time-points and polymorphism of CYP2A6*4 were determined and statistically analyzed. RESULTS 9 patients were *1/*4 or *4/*4, and 22 patients were *1/*1. The main pharmacokinetic parameters were area under curve (AUC) 1396.19 ± 332.47h· ng· l-1, peak blood concentration (Cmax) 495.50 ± 104.90ng· l-1, distribution volume (V) 0.68 ± 0.20 L/kg, clearance (CL) 0.38 ± 0.11 L/h/kg, distribution half-life (t1/2α) 0.05 ± 0.01h, elimination half-life (t1/2β) 2.53 ± 0.04h. No significant pharmacokinetic differences were found among CYP2A6*1/*1, *1/*4, and *4/*4 patients. CONCLUSIONS In Chinese patients pretreated with dexmedetomidine, T1/2β was consistent with that published, but T1/2α, V and Cl were lower. It was unnecessary to consider the mutation when developing the precision regimen of dexmedetomidine.
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Affiliation(s)
- Ling Wang
- a Department of Pharmacy , Fujian Provincial Hospital, Provincial Clinical College of Fujian Medical University , Fuzhou , China
| | - Shaoming Wang
- a Department of Pharmacy , Fujian Provincial Hospital, Provincial Clinical College of Fujian Medical University , Fuzhou , China
| | - Juan Qi
- b Second Department of Anesthesiology , Fujian Provincial Hospital, Provincial Clinical College of Fujian Medical University , Fuzhou , China
| | - Rongguo Yu
- c Surgery Intensive Care Unit , Fujian Provincial Hospital, Provincial Clinical College of Fujian Medical University , Fuzhou , China
| | - Jie Zhuang
- a Department of Pharmacy , Fujian Provincial Hospital, Provincial Clinical College of Fujian Medical University , Fuzhou , China
| | - Boyang Zhuang
- d Center for Certification and Evaluation , Fujian Food and Drug Administration , Fuzhou , China
| | - Yongming Lou
- e Chemical Laboratory , Fujian Institute for Food and Drug Quality Control , Fuzhou , China
| | - Junshan Ruan
- a Department of Pharmacy , Fujian Provincial Hospital, Provincial Clinical College of Fujian Medical University , Fuzhou , China
| | - Hong Ye
- a Department of Pharmacy , Fujian Provincial Hospital, Provincial Clinical College of Fujian Medical University , Fuzhou , China
| | - Fangfang Lin
- a Department of Pharmacy , Fujian Provincial Hospital, Provincial Clinical College of Fujian Medical University , Fuzhou , China
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Hecht M, Veigure R, Couchman L, S Barker CI, Standing JF, Takkis K, Evard H, Johnston A, Herodes K, Leito I, Kipper K. Utilization of data below the analytical limit of quantitation in pharmacokinetic analysis and modeling: promoting interdisciplinary debate. Bioanalysis 2018; 10:1229-1248. [PMID: 30033744 DOI: 10.4155/bio-2018-0078] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Traditionally, bioanalytical laboratories do not report actual concentrations for samples with results below the LOQ (BLQ) in pharmacokinetic studies. BLQ values are outside the method calibration range established during validation and no data are available to support the reliability of these values. However, ignoring BLQ data can contribute to bias and imprecision in model-based pharmacokinetic analyses. From this perspective, routine use of BLQ data would be advantageous. We would like to initiate an interdisciplinary debate on this important topic by summarizing the current concepts and use of BLQ data by regulators, pharmacometricians and bioanalysts. Through introducing the limit of detection and evaluating its variability, BLQ data could be released and utilized appropriately for pharmacokinetic research.
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Affiliation(s)
- Max Hecht
- Chair of Analytical Chemistry, Institute of Chemistry, University of Tartu, 14a Ravila Street, 50411 Tartu, Estonia
- Analytical Services International, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Rūta Veigure
- Chair of Analytical Chemistry, Institute of Chemistry, University of Tartu, 14a Ravila Street, 50411 Tartu, Estonia
| | - Lewis Couchman
- Analytical Services International, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Charlotte I S Barker
- Paediatric Infectious Diseases Research Group, Institute for Infection & Immunity, St George's University of London, London, SW17 0RE, UK
- Inflammation, Infection & Rheumatology Section, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Paediatric Infectious Diseases Unit, St George's University Hospitals NHS Foundation Trust, London, SW17 0RE, UK
| | - Joseph F Standing
- Paediatric Infectious Diseases Research Group, Institute for Infection & Immunity, St George's University of London, London, SW17 0RE, UK
- Inflammation, Infection & Rheumatology Section, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
| | - Kalev Takkis
- Analytical Services International, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Hanno Evard
- Chair of Analytical Chemistry, Institute of Chemistry, University of Tartu, 14a Ravila Street, 50411 Tartu, Estonia
| | - Atholl Johnston
- Analytical Services International, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
- Clinical Pharmacology, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
| | - Koit Herodes
- Chair of Analytical Chemistry, Institute of Chemistry, University of Tartu, 14a Ravila Street, 50411 Tartu, Estonia
| | - Ivo Leito
- Chair of Analytical Chemistry, Institute of Chemistry, University of Tartu, 14a Ravila Street, 50411 Tartu, Estonia
| | - Karin Kipper
- Chair of Analytical Chemistry, Institute of Chemistry, University of Tartu, 14a Ravila Street, 50411 Tartu, Estonia
- Analytical Services International, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
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20
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Hernando B, Martinez-Simon A, Cacho-Asenjo E, Troconiz IF, Honorato-Cia C, Panadero A, Naval LL, Nuñez-Cordoba JM. Recovery time after oral and maxillofacial ambulatory surgery with dexmedetomidine: an observational study. Clin Oral Investig 2018; 23:391-397. [PMID: 29679228 DOI: 10.1007/s00784-018-2447-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 04/12/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the relationship between pharmacokinetic descriptors of dexmedetomidine (predicted area under the curve during the procedure, predicted plasma level at the end of the procedure, and duration of procedure) and sedation depth (proportion of time with bispectral index < 85 during the procedure) with recovery time after ambulatory procedures. MATERIALS AND METHODS Clinical observational study of patients undergoing oral and maxillofacial ambulatory surgery with dexmedetomidine as sole sedative agent. Patients received a loading dose of dexmedetomidine (0.25-1 μg kg-1) followed by a maintenance infusion (0.2-1.4 μg kg-1 h-1) to keep a bispectral index < 85 until 5 min before the end of the procedure, and were transferred to a post-anesthesia care unit until criteria for discharge were met. RESULTS Data from 75 patients was analyzed. Sedation depth was directly associated with recovery time (Pearson correlation coefficient [r] = 0.26; p = 0.024). Around 7% of the variation in recovery time was explained by the proportion of time with bispectral index < 85. No association with procedure duration (r = 0.01; p = 0.9), predicted area under the curve (r = 0.1; p = 0.4), or predicted plasma level of dexmedetomidine at the end of the procedure (r = 0.12; p = 0.3) with recovery time was observed. CONCLUSIONS Sedation depth with dexmedetomidine could play a role in increasing recovery time after oral and maxillofacial ambulatory surgery. In our study, the pharmacokinetic descriptors of dexmedetomidine did not seem to influence recovery time. CLINICAL RELEVANCE Sedation depth with dexmedetomidine could play a role in increasing recovery time after ambulatory procedures.
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Affiliation(s)
- Belen Hernando
- Department of Anesthesia, Perioperative Medicine and Critical Care, University of Navarra Clinic, Pio XII n° 36, 31008, Pamplona, Spain.
| | - Antonio Martinez-Simon
- Department of Anesthesia, Perioperative Medicine and Critical Care, University of Navarra Clinic, Pio XII n° 36, 31008, Pamplona, Spain
| | - Elena Cacho-Asenjo
- Department of Anesthesia, Perioperative Medicine and Critical Care, University of Navarra Clinic, Pio XII n° 36, 31008, Pamplona, Spain
| | - Iñaki F Troconiz
- Pharmacometrics & Systems Pharmacology, Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain
| | - Cristina Honorato-Cia
- Department of Anesthesia, Perioperative Medicine and Critical Care, University of Navarra Clinic, Pio XII n° 36, 31008, Pamplona, Spain
| | - Alfredo Panadero
- Department of Anesthesia, Perioperative Medicine and Critical Care, University of Navarra Clinic, Pio XII n° 36, 31008, Pamplona, Spain
| | - Luis L Naval
- Department of Oral and Maxillofacial Surgery, University of Navarra Clinic, Pamplona, Spain
| | - Jorge M Nuñez-Cordoba
- Research Support Service, Central Clinical Trials Unit, University of Navarra Clinic, Pamplona, Spain
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Abstract
Dexmedetomidine is an α2-adrenoceptor agonist with sedative, anxiolytic, sympatholytic, and analgesic-sparing effects, and minimal depression of respiratory function. It is potent and highly selective for α2-receptors with an α2:α1 ratio of 1620:1. Hemodynamic effects, which include transient hypertension, bradycardia, and hypotension, result from the drug’s peripheral vasoconstrictive and sympatholytic properties. Dexmedetomidine exerts its hypnotic action through activation of central pre- and postsynaptic α2-receptors in the locus coeruleus, thereby inducting a state of unconsciousness similar to natural sleep, with the unique aspect that patients remain easily rousable and cooperative. Dexmedetomidine is rapidly distributed and is mainly hepatically metabolized into inactive metabolites by glucuronidation and hydroxylation. A high inter-individual variability in dexmedetomidine pharmacokinetics has been described, especially in the intensive care unit population. In recent years, multiple pharmacokinetic non-compartmental analyses as well as population pharmacokinetic studies have been performed. Body size, hepatic impairment, and presumably plasma albumin and cardiac output have a significant impact on dexmedetomidine pharmacokinetics. Results regarding other covariates remain inconclusive and warrant further research. Although initially approved for intravenous use for up to 24 h in the adult intensive care unit population only, applications of dexmedetomidine in clinical practice have been widened over the past few years. Procedural sedation with dexmedetomidine was additionally approved by the US Food and Drug Administration in 2003 and dexmedetomidine has appeared useful in multiple off-label applications such as pediatric sedation, intranasal or buccal administration, and use as an adjuvant to local analgesia techniques.
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Pharmacokinetics of dexmedetomidine during analgosedation in ICU patients. J Pharmacokinet Pharmacodyn 2017; 45:277-284. [PMID: 29290034 PMCID: PMC5845053 DOI: 10.1007/s10928-017-9564-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/21/2017] [Indexed: 12/28/2022]
Abstract
Dexmedetomidine (DEX) is a fairly new alfa2-agonist which has been increasingly used in recent years for analgosedation, mostly because it offers a unique ability of providing both moderate level of sedation and analgesia without respiratory depression. Despite of many papers published, there are still only a few concerning the PK of the drug given as long-term infusion in ICU patients. The aim of this work was to characterize the population pharmacokinetics of dexmedetomidine and to investigate the potential benefits of individualization of drug dosing based on patient characteristics in the heterogeneous group of medical and surgical patients staying in intensive care unit. This study was performed in the group of 17 males and 10 females patients with a median age of 59.5 years and median body weight of 75 kg. Blood samples for dexmedetomidine assay were collected from arterial catheter, during and after discontinuation of a standard infusion, that ranged from 24 to 102 h. The following covariates were examined to influence dexmedetomidine PK: age, sex, body weight, patients’ health status described by Sequential Organ Failure Assessment Score (SOFA), inotropes usage, and infusion duration. The dexmedetomidine PK was best described by a two-compartment model. The typical values of PK parameters were estimated as 27 L for the volume of the central compartment, 87.6 L for the volume of the peripheral compartment, 38.5 L/h (9.2 mL/min/kg for a 70 kg patient) for systemic clearance and 46.4 L/h for the distribution clearance. Those values are consistent with literature findings. We were unable to show any significant relationship between collected covariates and dexmedetomidine PK. This study does not provide sufficient evidence to support the individualization of dexmedetomidine dosing based on age, sex, body weight, SOFA, and infusion duration.
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Obara S, Imaizumi T, Hakozaki T, Hosono A, Iseki Y, Sanbe N, Murakawa M. Evaluation of pharmacokinetic models of intravenous dexmedetomidine in sedated patients under spinal anesthesia. J Anesth 2017; 32:33-40. [DOI: 10.1007/s00540-017-2424-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 10/28/2017] [Indexed: 12/19/2022]
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Gousheh SMR, Olapour AR, Nesioonpour S, Rashidi M, Pooyan S. The Effect of Intravenous Infusion of Dexmedetomidine to Prevent Bleeding During Functional Endoscopic Sinus Surgery: A Clinical Trial. Anesth Pain Med 2017; 7:e12682. [PMID: 29637043 PMCID: PMC5883081 DOI: 10.5812/aapm.12682] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 06/11/2017] [Accepted: 08/07/2017] [Indexed: 12/11/2022] Open
Abstract
Background Bleeding during surgery can lead to serious complications. Methods and drugs to control bleeding are always important both for the surgeon and anesthesiologist, especially in endoscopic procedures. A lot of efforts are made to optimize the surgical conditions for functional endoscopic sinus surgery. Induced hypotension is widely advocated to prevent bleeding and consequently to improve the quality of an operation . Amongst the pharmacological agents, dexmedetomidine is the most recently introduced drug to provide hypotensive anesthesia during functional endoscopic sinus surgery. Objectives The current study aimed at investigating the effects of intravenous infusion of dexmedetomidine on bleeding, nausea, awakening time, and other intravenous anesthetic doses during functional endoscopic sinus surgery. Methods Sixty patients aged 16 to 60 years with American society of anesthesiologists (ASA) class I or II in Imam Khomeini hospital of Ahvaz, Iran, who were the candidate for the elective functional endoscopic sinus surgery were enrolled in the current double-blind clinical trial. They were randomly divided into 2 groups: group D (receiving dexmedetomidine), and group N (receiving normal saline). Sampling was based on the block randomization method. In group D, a 1-μg/kg dexmedetomidine was injected during 10 minutes just before the induction. Then, 0.5 µg/ kg/ hour infusion was started. Both groups had the same induction and maintenance method as well as the drugs administered for general anesthesia induction. For maintenance, the patients received O2 50%: N2O 50% and 100 μg/kg/minute of propofol and 0.2 μg/kg/minute of remifentanil. In group N, instead of dexmedetomidine in bolus and maintenance, normal saline was used with the same volume. Mean arterial pressure was maintained between 65 to 75 mmHg. The incidence of bleeding, nausea and vomiting after surgery, the amount of maintenance drugs, and awakening time were recorded in a checklist. Results The intravenous use of dexmedetomidine significantly reduced the amount of bleeding (P < 0.0001); in addition, the need for opioids (P < 0.0001) and intravenous anesthetics significantly decreased (P = 0.001). Awakening time was significantly longer (P = 0.001), but its effect on postoperative nausea and vomiting was not significant (P = 0.052). Conclusions The current study showed that although propofol and remifentanil compounds can control hemodynamic state, but intravenous infusion of dexmedetomidine during the functional endoscopic sinus surgery reduced the amount of bleeding more significantly. It also reduced the dosage of maintenance drugs.
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Affiliation(s)
- Seyed Mohammad Reza Gousheh
- Pain Research Center, Department of Anesthesiology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ali Reza Olapour
- Pain Research Center, Department of Anesthesiology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Sholeh Nesioonpour
- Pain Research Center, Department of Anesthesiology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Corresponding author: Sholeh Nesioonpour, Pain Research Center, Department of Anesthesiology, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. Tel: +98-6132220168, Fax: +98-6132220168, E-mail:
| | - Mahboobeh Rashidi
- Pain Research Center, Department of Anesthesiology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Shahrzad Pooyan
- Pain Research Center, Department of Anesthesiology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Tse AHW, Ling L, Joynt GM, Lee A. Prolonged infusion of sedatives and analgesics in adult intensive care patients: A systematic review of pharmacokinetic data reporting and quality of evidence. Pharmacol Res 2016; 117:156-165. [PMID: 28012962 DOI: 10.1016/j.phrs.2016.12.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 12/20/2016] [Accepted: 12/20/2016] [Indexed: 11/16/2022]
Abstract
Although pharmacokinetic (PK) data for prolonged sedative and analgesic agents in intensive care unit (ICU) has been described, the number of publications in this important area appear relatively few, and PK data presented is not comprehensive. Known pathophysiological changes in critically ill patients result in altered drug PK when compared with non-critically ill patients. ClinPK Statement was recently developed to promote consistent reporting in PK studies, however, its applicability to ICU specific PK studies is unclear. In this systematic review, we assessed the overall ClinPK Statement compliance rate, determined the factors affecting compliance rate, graded the level of PK evidence and assessed the applicability of the ClinPK Statement to future ICU PK studies. Of the 33 included studies (n=2016), 22 (67%) were low evidence quality descriptive studies (Level 4). Included studies had a median compliance rate of 80% (IQR 66% to 86%) against the ClinPK Statement. Overall pooled compliance rate (78%, 95% CI 73% to 83%) was stable across time (P=0.38), with higher compliance rates found in studies fitting three compartments models (88%, P<0.01), two compartments models (83%, P<0.01) and one compartment models (77%, P=0.17) than studies fitting noncompartmental or unspecified models (69%) (P<0.01). Data unique to the interpretation of PK data in critically ill patients, such as illness severity (48%), organ dysfunction (36%) and renal replacement therapy use (32%), were infrequently reported. Discrepancy between the general compliance rate with ClinPK Statement and the under-reporting of ICU specific parameters suggests that the applicability of the ClinPK Statement to ICU PK studies may be limited in its current form.
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Affiliation(s)
- Andrew H W Tse
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Lowell Ling
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, China
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Anna Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China.
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Jarineshin H, Fekrat F, Kargar Kermanshah A. Treatment of Postoperative Pain in Pediatric Operations: Comparing the Efficiency of Bupivacaine, Bupivacaine-Dexmedetomidine and Bupivacaine-Fentanyl for Caudal Block. Anesth Pain Med 2016; 6:e39495. [PMID: 27847704 PMCID: PMC5101645 DOI: 10.5812/aapm.39495] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 06/25/2016] [Accepted: 06/27/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Caudal analgesia is a common method for postoperative pain management in pediatric patients. Additive agents such as opioids and α2 agonists have been used to enhance the analgesic effects of local anesthetics for caudal block. OBJECTIVES The aim of this study was to compare the additive effects of dexmedetomidine and fentanyl on bupivacaine-induced caudal analgesia in pediatric patients who had undergone elective inguinal hernia repair. METHODS This randomized, double-blind clinical trial included children aged 1 - 5 years who were divided into three groups: the bupivacaine group (Group B) received 0.25% bupivacaine (1 ml/kg), the bupivacaine-dexmedetomidine group (Group BD) received 0.25% bupivacaine (1 mL/kg) plus 2 µg/kg dexmedetomidine, and the bupivacaine-fentanyl group (Group BF) received 0.25% bupivacaine (1 mL/kg) plus 2 µg/kg fentanyl. The hemodynamic variables (heart rate, systolic blood pressure, respiratory rate, and peripheral arterial oxygen saturation) were measured perioperatively. Pain, sedation and motor block scores and adverse events (nausea and vomiting, pruritis, hypotension, bradycardia, urinary retention and respiratory depression) were documented at 30 and 60 minutes, and the 1st, 2nd, 4th, 6th, 12th and 24th hours after the operation. The other recordings include the duration of surgery and analgesic requirement. RESULTS A total of 61 patients were analyzed. The lowest pain scores were found in the BD group at all time points (P < 0.001). The sedation scores were higher in the BD group than in the other two groups at all time points (P < 0.001). No motor block was observed after the operation. Only three patients required analgesic administration 2 to 6 hours after the operation in group B. No side effects were observed in any of the groups, and there was no significant difference in the duration of surgery among the three groups. CONCLUSIONS The results show that the analgesic and sedative effects were better when dexmedetomidine was added to bupivacaine than when fentanyl was added or bupivacaine alone was administered in the pediatric population studied here that underwent elective inguinal hernia repair.
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Affiliation(s)
- Hashem Jarineshin
- Anesthesiology, Critical Care and Pain Management Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Fereydoon Fekrat
- Anesthesiology, Critical Care and Pain Management Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Aida Kargar Kermanshah
- Anesthesiology, Critical Care and Pain Management Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
- Corresponding author: Aida Kargar Kermanshah, Anesthesiology, Critical Care and Pain Management Research Center, Shahid Mohammadi Hospital, Hormozgan University of Medical Sciences, Bandar Abbas, Iran. Tel/Fax: +98-7633345009, E-mail:
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Wang XW, Cao JB, Lv BS, Mi WD, Wang ZQ, Zhang C, Wang HL, Xu Z. Effect of perioperative dexmedetomidine on the endocrine modulators of stress response: a meta-analysis. Clin Exp Pharmacol Physiol 2016; 42:828-36. [PMID: 26016707 DOI: 10.1111/1440-1681.12431] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 05/06/2015] [Accepted: 05/19/2015] [Indexed: 11/30/2022]
Abstract
This study examined the effects of perioperative dexmedetomidine treatment on physiological modulators of surgical stress response. The quality of the included studies was assessed prior to performing meta-analyses of the weighted mean differences in the changes from baseline of stress hormones and interpreted in the light of statistical heterogeneity between the studies. Nineteen studies (844 surgical subjects) data were used for this meta-analysis. Dexmedetomidine administration significantly decreased blood cortisol levels (μg/dL) postoperatively (mean difference with 95% confidence interval (CI) from controls: -18.78 (-28.45, -9.10); P < 0.05). In the subgroup analysis, the mean difference between dexmedetomidine-treated and saline-treated subjects in the changes from baseline of the cortisol levels was -20.10 (-30.96, -9.25; P < 0.05) but, between dexmedetomidine- and comparator-treated subjects, it was not statistically significantly different (-15.13 (-49.78, 19.52); P < 0.05). Compared with controls, dexmedetomidine treatment also decreased adrenaline and noradrenaline levels significantly (mean difference in the percent changes from baseline: -90.41 (-145.79, -35.03)%; P < 0.05 and -62.82 (-85.47, -0.40.17)%; P < 0.05, respectively). Dexmedetomidine also decreased prolactin levels with a mean difference of -19.42 (-39.37, 0.52) μg/L (P = 0.06). In conclusion, perioperative use of dexmedetomidine reduces serum catecholamine and cortisol levels but the decrease in cortisol levels was not statistically different from the comparator anaesthetics. More data will be required to assess the effects of dexmedetomidine on corticotropin, prolactin, and growth hormone.
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Affiliation(s)
- Xian-wang Wang
- Anaesthesia and Operation Centre, Chinese PLA General Hospital, Beijing, China.,Department of Anaesthesiology, The 309th Hospital of PLA, Beijing, China
| | - Jiang-bei Cao
- Anaesthesia and Operation Centre, Chinese PLA General Hospital, Beijing, China
| | - Bao-sheng Lv
- Department of Anaesthesiology, The 309th Hospital of PLA, Beijing, China
| | - Wei-dong Mi
- Anaesthesia and Operation Centre, Chinese PLA General Hospital, Beijing, China
| | - Zhuo-qiang Wang
- Department of Anaesthesiology, The 309th Hospital of PLA, Beijing, China
| | - Changsheng Zhang
- Anaesthesia and Operation Centre, Chinese PLA General Hospital, Beijing, China
| | - Heng-lin Wang
- Department of Anaesthesiology, The 309th Hospital of PLA, Beijing, China
| | - Zhen Xu
- Department of Anaesthesiology, The 309th Hospital of PLA, Beijing, China
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Abstract
OBJECTIVE To characterize fentanyl population pharmacokinetics in patients with critical illness and identify patient characteristics associated with altered fentanyl concentrations. DESIGN Prospective cohort study. SETTING Medical and surgical ICUs in a large tertiary care hospital in the United States. PATIENTS Patients with acute respiratory failure and/or shock who received fentanyl during the first 5 days of their ICU stay. MEASUREMENTS AND MAIN RESULTS We collected clinical and hourly drug administration data and measured fentanyl concentrations in plasma collected once daily for up to 5 days after enrollment. Among 337 patients, the mean duration of infusion was 58 hours at a median rate of 100 μg/hr. Using a nonlinear mixed-effects model implemented by NONMEM, we found that fentanyl pharmacokinetics were best described by a two-compartment model in which weight, severe liver disease, and congestive heart failure most affected fentanyl concentrations. For a patient population with a mean weight of 92 kg and no history of severe liver disease or congestive heart failure, the final model, which performed well in repeated 10-fold cross-validation, estimated total clearance, intercompartmental clearance (Q), and volumes of distribution for the central (V1) and peripheral compartments (V2) to be 35 L/hr (95% CI, 32-39 L/hr), 55 L/hr (95% CI, 42-68 L/hr), 203 L (95% CI, 140-266 L), and 523 L (95% CI, 428-618 L), respectively. Severity of illness was marginally associated with fentanyl pharmacokinetics but did not improve the model fit after liver and heart diseases were included. CONCLUSIONS In this study, fentanyl pharmacokinetics during critical illness were strongly influenced by severe liver disease, congestive heart failure, and weight, factors that should be considered when dosing fentanyl in the ICU. Future studies are needed to determine if data-driven fentanyl dosing algorithms can improve outcomes for ICU patients.
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Inhibition of the cardiac Na⁺ channel α-subunit Nav1.5 by propofol and dexmedetomidine. Naunyn Schmiedebergs Arch Pharmacol 2015; 389:315-25. [PMID: 26667357 DOI: 10.1007/s00210-015-1195-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 11/26/2015] [Indexed: 12/19/2022]
Abstract
Propofol and dexmedetomidine are very commonly used sedative agents. However, several case reports demonstrated cardiovascular adverse effects of these two sedatives. Both substances were previously demonstrated to quite potently inhibit neuronal voltage-gated Na(+) channels. Thus, a possible molecular mechanism for some of their cardiac side effects is an inhibition of cardiac voltage gated Na(+) channels. In this study, we therefore explored the effects of propofol and dexmedetomidine on the cardiac predominant Na(+) channel α-subunit Nav1.5. Effects of propofol and dexmedetomidine were investigated on constructs of the human α-subunit Nav1.5 stably expressed in HEK-293 cells by means of whole-cell patch clamp recordings. Both agents induced a concentration-dependent tonic inhibition of Nav1.5. The calculated IC50 value for propofol was 228 ± 10 μM, and for dexmedetomidine 170 ± 20 μM. Tonic block only marginally increased on inactivated channels, and a weak use-dependent block at 10 Hz was observed for dexmedetomidine (16 ± 2 % by 100 μM). The voltage dependencies of fast and slow inactivation as well as the time course of recovery from inactivation were shifted by both propofol and dexmedetomidine. Propofol (IC50 126 ± 47 μM) and dexmedetomidine (IC50 182 ± 27 μM) blocked the persistent sodium current induced by veratradine. Finally, the local-anesthetic (LA)-insensitive mutant Nav1.5-F1760A exhibited reduced tonic and use-dependent block by both substances. Dexmedetomidine was generally more potent as compared to propofol. Propofol and dexmedetomidine seem to interact with the LA-binding site to inhibit the cardiac Na(+) channel Nav1.5 in a state-dependent manner. These data suggest that Nav1.5 is a hitherto unrecognized molecular component of some cardiovascular side effects of these sedative agents.
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Ko KH, Jun IJ, Lee S, Lim Y, Yoo B, Kim KM. Effective dose of dexmedetomidine to induce adequate sedation in elderly patients under spinal anesthesia. Korean J Anesthesiol 2015; 68:575-80. [PMID: 26634081 PMCID: PMC4667143 DOI: 10.4097/kjae.2015.68.6.575] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 06/25/2015] [Accepted: 07/07/2015] [Indexed: 12/01/2022] Open
Abstract
Background During sedation with dexmedetomidine, a dose adjustment may be needed based on the invasiveness of the procedure, the patient's general condition, and their age. We aim here to determine the effective dose (ED) of dexmedetomidine to induce an adequate depth of sedation in elderly patients undergoing spinal anesthesia. Methods In this study, 47 patients aged 65 years or older, American Society of Anesthesiologists physical status I or II, undergoing spinal anesthesia were included. Patients were randomly allocated into group I, II, III, IV or V according to the dexmedetomidine loading dose of 0.1, 0.3, 0.5, 0.7 and 1.0 µg/kg, respectively. After spinal anesthesia, the assigned loading dose of dexmedetomidine was infused intravenously for 10 minutes, after which infusion was maintained at a rate of 0.3 µg/kg/h for the next 10 minutes in all groups. We assessed the depth of sedation with the Ramsay sedation scale every five minutes and measured vital signs and the oxygen saturation. The ED50 and ED95 of dexmedetomidine to obtain adequate sedation (Ramsay sedation score ≥ 3) upon the completion of the loading dose were calculated with logistic regression. Results The ED50 and ED95 of dexmedetomidine for adequate sedation were 0.29 µg/kg (95% confidence intervals [CI] 0.14-0.44) and 0.86 µg/kg (95% CI 0.52-1.20), respectively. Hypotension was frequent in groups IV, V compared to groups I, II, III (31.6 vs. 3.6%, P = 0.013). Conclusions ED95 of dexmedetomidine loading dose for adequate sedation is 0.86 µg/kg. However, dose higher than 0.5 µg/kg can lead to hemodynamic instability.
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Affiliation(s)
- Ki-Ho Ko
- Department of Medicine, Jodo Subcenter, Jindo Public Health Center, Jindo, Korea
| | - In-Jung Jun
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Sangseok Lee
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Yunhee Lim
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Byunghoon Yoo
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Kye-Min Kim
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Development of an Optimized Pharmacokinetic Model of Dexmedetomidine Using Target-controlled Infusion in Healthy Volunteers. Anesthesiology 2015; 123:357-67. [PMID: 26068206 DOI: 10.1097/aln.0000000000000740] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Several pharmacokinetic models are available for dexmedetomidine, but these have been shown to underestimate plasma concentrations. Most were developed with data from patients during the postoperative phase and/or in intensive care, making them susceptible to errors due to drug interactions. The aim of this study is to improve on existing models using data from healthy volunteers. METHODS After local ethics committee approval, the authors recruited 18 volunteers, who received a dexmedetomidine target-controlled infusion with increasing target concentrations: 1, 2, 3, 4, 6, and 8 ng/ml, repeated in two sessions, at least 1 week apart. Each level was maintained for 30 min. If one of the predefined safety criteria was breached, the infusion was terminated and the recovery period began. Arterial blood samples were collected at preset times, and NONMEM (Icon plc, Ireland) was used for model development. RESULTS The age, weight, and body mass index ranges of the 18 volunteers (9 male and 9 female) were 20 to 70 yr, 51 to 110 kg, and 20.6 to 29.3 kg/m, respectively. A three-compartment allometric model was developed, with the following estimated parameters for an individual of 70 kg: V1 = 1.78 l, V2 = 30.3 l, V3 = 52.0 l, CL = 0.686 l/min, Q2 = 2.98 l/min, and Q3 = 0.602 l/min. The predictive performance as calculated by the median absolute performance error and median performance error was better than that of existing models. CONCLUSIONS Using target-controlled infusion in healthy volunteers, the pharmacokinetics of dexmedetomidine were best described by a three-compartment allometric model. Apart from weight, no other covariates were identified.
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Callaway CW, Elmer J, Guyette FX, Molyneaux BJ, Anderson KB, Empey PE, Gerstel SJ, Holquist K, Repine MJ, Rittenberger JC. Dexmedetomidine Reduces Shivering during Mild Hypothermia in Waking Subjects. PLoS One 2015; 10:e0129709. [PMID: 26237219 PMCID: PMC4523180 DOI: 10.1371/journal.pone.0129709] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 05/12/2015] [Indexed: 12/20/2022] Open
Abstract
Background and Purpose Reducing body temperature can prolong tolerance to ischemic injury such as stroke or myocardial infarction, but is difficult and uncomfortable in awake patients because of shivering. We tested the efficacy and safety of the alpha-2-adrenergic agonist dexmedetomidine for suppressing shivering induced by a rapid infusion of cold intravenous fluids. Methods Ten subjects received a rapid intravenous infusion of two liters of cold (4°C) isotonic saline on two separate test days, and we measured their core body temperature, shivering, hemodynamics and sedation for two hours. On one test day, fluid infusion was preceded by placebo infusion. On the other test day, fluid infusion was preceded by 1.0 μg/kg bolus of dexmedetomidine over 10 minutes. Results All ten subjects experienced shivering on placebo days, with shivering beginning at a mean (SD) temperature of 36.6 (0.3)°C. The mean lowest temperature after placebo was 36.0 (0.3)°C (range 35.7-36.5°C). Only 3/10 subjects shivered on dexmedetomidine days, and the mean lowest temperature was 35.7 (0.4)°C (range 35.0-36.3°C). Temperature remained below 36°C for the full two hours in 6/10 subjects. After dexmedetomidine, subjects had moderate sedation and a mean 26 (13) mmHg reduction in blood pressure that resolved within 90 minutes. Heart rate declined a mean 23 (11) bpm after both placebo and dexmedetomidine. Dexmedetomidine produced no respiratory depression. Conclusion Dexmedetomidine decreases shivering in normal volunteers. This effect is associated with decreased systolic blood pressure and sedation, but no respiratory depression.
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Affiliation(s)
- Clifton W. Callaway
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Jonathan Elmer
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Francis X. Guyette
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Bradley J. Molyneaux
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Kacey B. Anderson
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Philip E. Empey
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Stacy J. Gerstel
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Kate Holquist
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Melissa J. Repine
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Jon C. Rittenberger
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
- * E-mail:
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Keating GM. Dexmedetomidine: A Review of Its Use for Sedation in the Intensive Care Setting. Drugs 2015; 75:1119-30. [DOI: 10.1007/s40265-015-0419-5] [Citation(s) in RCA: 136] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Obara S, Morimoto I, Iseki Y, Oishi R, Mogami M, Imaizumi T, Hosono A, Hakozaki T, Nakano Y, Isosu T, Murakawa M. THE EFFECT OF OBESITY ON DOSE OF DEXMEDETOMIDINE WHEN ADMINISTERED WITH FENTANYL DURING POSTOPERATIVE MECHANICAL VENTILATION--RETROSPECTIVE. Fukushima J Med Sci 2015; 61:38-46. [PMID: 25946907 DOI: 10.5387/fms.2014-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
We carried out a retrospective investigation on the effect of obesity on dexmedetomidine (DEX) requirements when administered with fentanyl (FEN) during mechanical ventilation after major surgeries. After Institutional Review Board approval, 14 obese patients with a body mass index (BMI) ≥ 30 kg/m(2) and the same number of non-obese patients with similar backgrounds to the obese patients were selected from medical records. Doses of DEX in the first 48 h or until the end of sedation or extubation were calculated for comparison. In addition to comparison of dosing between the groups, associations between total body weight (TBW), BMI, and lean body mass (LBM) values and doses of DEX (mcg/h), between BMI and various indices (i.e., amount per TBW per hour and amount per LBM per hour) of DEX doses, and between above indices of DEX and FEN doses were also examined. There were no significant differences in DEX dose indices between the groups. However, DEX requirements (mcg/h) were significantly increased with TBW (kg) (r = 0.51, P = 0.003), BMI (r = 0.49, P = 0.006) and LBM (kg) (r = 0.42, P = 0.02), which might have enhanced the DEX metabolism with physiological changes with obesity. These findings will be beneficial for future clinical pharmacological analysis of DEX.
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Affiliation(s)
- Shinju Obara
- Associate Professor, Surgical Operation Department, Fukushima Medical University Hospital
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Ranheim B, Risberg ÅI, Spadavecchia C, Landsem R, Haga HA. The pharmacokinetics of dexmedetomidine administered as a constant rate infusion in horses. J Vet Pharmacol Ther 2014; 38:93-6. [PMID: 25229603 DOI: 10.1111/jvp.12157] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 07/17/2014] [Indexed: 12/26/2022]
Abstract
Dexmedetomidine, the most selective α2-adrenoceptor agonist in clinical use, is increasingly being used in both conscious and anaesthetized horses; however, the pharmacokinetics and sedative effects of this drug administered alone as an infusion are not previously described in horses. Seven horses received an infusion of 8 μg dexmedetomidine/kg/h for 150 min, venous blood samples were collected, and dexmedetomidine concentrations were assayed using liquid chromatography-mass spectrometry (LC/MS) and analyzed using noncompartmental pharmacokinetic analysis. Sedation was scored as the distance from the lower lip of the horse to the ground measured in centimetre. The harmonic mean (SD) plasma elimination half-life (Lambda z half-life) for dexmedetomidine was 20.9 (5.1) min, clearance (Cl) was 0.3 (0.20) L/min/kg, and volume of distribution at steady-state (Vdss ) was 13.7 (7.9) L/kg. There was a considerable individual variation in the concentration of dexmedetomidine vs. time profile. The level of sedation covaried with the plasma concentration of dexmedetomidine. This implies that for clinical use of dexmedetomidine constant rate infusion in conscious horses, infusion rates can be easily adjusted to effect, and this is preferable to an infusion at a predetermined value.
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Affiliation(s)
- B Ranheim
- Faculty of Veterinary Medicine and Biosciences, The Norwegian University of Life Sciences, Oslo, Norway
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Holliday SF, Kane-Gill SL, Empey PE, Buckley MS, Smithburger PL. Interpatient variability in dexmedetomidine response: a survey of the literature. ScientificWorldJournal 2014; 2014:805013. [PMID: 24558330 PMCID: PMC3914598 DOI: 10.1155/2014/805013] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 10/22/2013] [Indexed: 12/28/2022] Open
Abstract
Fifty-five thousand patients are cared for in the intensive care unit (ICU) daily with sedation utilized to reduce anxiety and agitation while optimizing comfort. The Society of Critical Care Medicine (SCCM) released updated guidelines for management of pain, agitation, and delirium in the ICU and recommended nonbenzodiazepines, such as dexmedetomidine and propofol, as first line sedation agents. Dexmedetomidine, an alpha-2 agonist, offers many benefits yet its use is mired by the inability to consistently achieve sedation goals. Three hypotheses including patient traits/characteristics, pharmacokinetics in critically ill patients, and clinically relevant genetic polymorphisms that could affect dexmedetomidine response are presented. Studies in patient traits have yielded conflicting results regarding the role of race yet suggest that dexmedetomidine may produce more consistent results in less critically ill patients and with home antidepressant use. Pharmacokinetics of critically ill patients are reported as similar to healthy individuals yet wide, unexplained interpatient variability in dexmedetomidine serum levels exist. Genetic polymorphisms in both metabolism and receptor response have been evaluated in few studies, and the results remain inconclusive. To fully understand the role of dexmedetomidine, it is vital to further evaluate what prompts such marked interpatient variability in critically ill patients.
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Affiliation(s)
- Samantha F. Holliday
- University of Pittsburgh School of Pharmacy, 3501 Terrace Street, Pittsburgh, PA 15261, USA
| | - Sandra L. Kane-Gill
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace Street, Pittsburgh, PA 15261, USA
| | - Philip E. Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace Street, Pittsburgh, PA 15261, USA
| | - Mitchell S. Buckley
- Banner Good Samaritan Medical Center, Department of Pharmacy, 1111 E. McDowell Road, Phoenix, AZ 85006, USA
| | - Pamela L. Smithburger
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace Street, Pittsburgh, PA 15261, USA
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