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Spiezia L, Campello E, Tormene D, Simioni P. Venous Thromboembolism in Children: The Rivaroxaban Experience. Semin Thromb Hemost 2024. [PMID: 38181816 DOI: 10.1055/s-0043-1778106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
The incidence of venous thromboembolism (VTE) in the pediatric population has increased more than 10-fold in the last 20 years, as a consequence of the advancement of resuscitation and surgical techniques and the global increase in life expectancy of children suffering from chronic pathologies. Monitoring anticoagulant therapy to achieve outcomes within the target range in childhood VTE, parenteral administration of medications, and frequent blood tests in children are often cumbersome. Availability of safe and effective oral agents with pediatric data to support use would be of clear benefit. A physiologically based pharmacokinetic model was developed to estimate the appropriate dosing schedule for rivaroxaban in children. This incorporated growth/maturation and variability in anthropometrics (e.g., body height, weight, and body mass index), anatomy (e.g., organ weight), physiology (e.g., blood flow rates), metabolism and excretion. Rivaroxaban use in pediatric population underwent a complete investigational program, consisting mainly of one phase I pharmacokinetics/pharmacodynamics trial, three phase II trials, one phase III trial. The phase III trial enrolled 500 patients from birth to <18 years and documented the efficacy and safety of rivaroxaban regimens at dose equivalent to the adult 20 mg dose for the prevention of fatal or symptomatic nonfatal recurrent VTE and major bleeding versus heparin or vitamin K antagonists. Results were similar to those in rivaroxaban studies in adults. The efficacy and safety of rivaroxaban in children reported in the EINSTEIN JUNIOR trial provide further support to previous trials in adults (EINSTEIN Program), which demonstrate a favorable profile for the use of rivaroxaban for the management of VTE in challenging patient populations. Other clinical evidence contributing to the use of rivaroxaban among different risk groups in pediatric VTE population confirms the consistency with principal trial. Our review aims to describe the rationale for using rivaroxaban oral suspension in clinical practice and to summarize its multiple indications in each vascular bed (e.g., cerebral venous thrombosis, symptomatic or asymptomatic central venous catheter-associated thrombosis), etiology, and patients setting.
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Affiliation(s)
- Luca Spiezia
- General Internal Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padova University School of Medicine, Padova, Italy
| | - Elena Campello
- General Internal Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padova University School of Medicine, Padova, Italy
| | - Daniela Tormene
- General Internal Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padova University School of Medicine, Padova, Italy
| | - Paolo Simioni
- General Internal Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padova University School of Medicine, Padova, Italy
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2
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Terrier J, Gaspar F, Gosselin P, Raboud O, Lenoir C, Rollason V, Csajka C, Samer C, Fontana P, Daali Y, Reny J. Apixaban and rivaroxaban's physiologically-based pharmacokinetic model validation in hospitalized patients: A first step for larger use of a priori modeling approach at bed side. CPT Pharmacometrics Syst Pharmacol 2023; 12:1872-1883. [PMID: 37794718 PMCID: PMC10725260 DOI: 10.1002/psp4.13036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/21/2023] [Accepted: 08/14/2023] [Indexed: 10/06/2023] Open
Abstract
When used in real-world conditions, substantial interindividual variations in direct oral anticoagulant (DOAC) plasma concentrations are observed for a given dose, leading to a risk of over- or under-exposure and clinically significant adverse events. Physiologically-based pharmacokinetic (PBPK) models could help physicians to tailor DOAC prescriptions in vulnerable patient populations, such as those in the hospital setting. The present study aims to validate prospectively PBPK models for rivaroxaban and apixaban in a large cohort of elderly, polymorbid, and hospitalized patients. In using a model of geriatric population integrating appropriate physiological parameters into models first optimized with healthy volunteer data, observed plasma concentration collected in hospitalized patients on apixaban (n = 100) and rivaroxaban (n = 100) were adequately predicted (ratio predicted/observed area under the concentration curve for a dosing interval [AUCtau ] = 0.97 [0.96-0.99] geometric mean, 90% confidence interval, ratio predicted/observed AUCtau = 1.03 [1.02-1.05]) for apixaban and rivaroxaban, respectively. Validation of the present PBPK models for rivaroxaban and apixaban in in-patients represent an additional step toward the feasibility of bedside use.
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Affiliation(s)
- Jean Terrier
- Division of General Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Geneva Platelet Group, Faculty of MedicineUniversity of GenevaGenevaSwitzerland
- Clinical Pharmacology and Toxicology Service, Anesthesiology, Pharmacology and Intensive Care DepartmentGeneva University HospitalsGenevaSwitzerland
| | - Frédéric Gaspar
- Center for Research and Innovation in Clinical Pharmaceutical SciencesLausanne University Hospital and University of LausanneLausanneSwitzerland
- School of Pharmaceutical SciencesUniversity of GenevaGenevaSwitzerland
- Institute of Pharmaceutical Sciences of Western SwitzerlandUniversity of Geneva, University of LausanneGeneva, LausanneSwitzerland
- Service of Clinical PharmacologyLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Pauline Gosselin
- Division of General Internal MedicineGeneva University HospitalsGenevaSwitzerland
| | - Olivier Raboud
- Center for Research and Innovation in Clinical Pharmaceutical SciencesLausanne University Hospital and University of LausanneLausanneSwitzerland
- School of Pharmaceutical SciencesUniversity of GenevaGenevaSwitzerland
- Institute of Pharmaceutical Sciences of Western SwitzerlandUniversity of Geneva, University of LausanneGeneva, LausanneSwitzerland
- Service of Clinical PharmacologyLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Camille Lenoir
- Clinical Pharmacology and Toxicology Service, Anesthesiology, Pharmacology and Intensive Care DepartmentGeneva University HospitalsGenevaSwitzerland
| | - Victoria Rollason
- Clinical Pharmacology and Toxicology Service, Anesthesiology, Pharmacology and Intensive Care DepartmentGeneva University HospitalsGenevaSwitzerland
| | - Chantal Csajka
- School of Pharmaceutical SciencesUniversity of GenevaGenevaSwitzerland
- Institute of Pharmaceutical Sciences of Western SwitzerlandUniversity of Geneva, University of LausanneGeneva, LausanneSwitzerland
- Service of Clinical PharmacologyLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Caroline Samer
- Clinical Pharmacology and Toxicology Service, Anesthesiology, Pharmacology and Intensive Care DepartmentGeneva University HospitalsGenevaSwitzerland
- School of Pharmaceutical SciencesUniversity of GenevaGenevaSwitzerland
| | - Pierre Fontana
- Geneva Platelet Group, Faculty of MedicineUniversity of GenevaGenevaSwitzerland
- Division of Angiology and HaemostasisGeneva University HospitalsGenevaSwitzerland
| | - Youssef Daali
- Geneva Platelet Group, Faculty of MedicineUniversity of GenevaGenevaSwitzerland
- Clinical Pharmacology and Toxicology Service, Anesthesiology, Pharmacology and Intensive Care DepartmentGeneva University HospitalsGenevaSwitzerland
| | - Jean‐Luc Reny
- Division of General Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Geneva Platelet Group, Faculty of MedicineUniversity of GenevaGenevaSwitzerland
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3
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Dinh J, Johnson TN, Grimstein M, Lewis T. Physiologically Based Pharmacokinetics Modeling in the Neonatal Population-Current Advances, Challenges, and Opportunities. Pharmaceutics 2023; 15:2579. [PMID: 38004559 PMCID: PMC10675397 DOI: 10.3390/pharmaceutics15112579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/24/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023] Open
Abstract
Physiologically based pharmacokinetic (PBPK) modeling is an approach to predicting drug pharmacokinetics, using knowledge of the human physiology involved and drug physiochemical properties. This approach is useful when predicting drug pharmacokinetics in under-studied populations, such as pediatrics. PBPK modeling is a particularly important tool for dose optimization for the neonatal population, given that clinical trials rarely include this patient population. However, important knowledge gaps exist for neonates, resulting in uncertainty with the model predictions. This review aims to outline the sources of variability that should be considered with developing a neonatal PBPK model, the data that are currently available for the neonatal ontogeny, and lastly to highlight the data gaps where further research would be needed.
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Affiliation(s)
- Jean Dinh
- Certara UK Limited, Sheffield S1 2BJ, UK; (J.D.); (T.N.J.)
| | | | - Manuela Grimstein
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20903, USA
| | - Tamorah Lewis
- Pediatric Clinical Pharmacology & Toxicology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
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4
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Hügl B, Horlitz M, Fischer K, Kreutz R. Clinical significance of the rivaroxaban-dronedarone interaction: insights from physiologically based pharmacokinetic modelling. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead004. [PMID: 36820238 PMCID: PMC9938521 DOI: 10.1093/ehjopen/oead004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 01/06/2023] [Accepted: 01/16/2023] [Indexed: 01/24/2023]
Abstract
Patients with atrial fibrillation may require rhythm control therapy in addition to anticoagulation therapy for the prevention of stroke. Since 2012, the European Society of Cardiology and European Heart Rhythm Association guidelines have recommended non-vitamin K antagonist oral anticoagulants, including rivaroxaban, for the prevention of stroke in patients with atrial fibrillation. During the same period, these guidelines have also recommended dronedarone or amiodarone as second-line rhythm control agents in certain patients with atrial fibrillation and no contraindications. Amiodarone and dronedarone both strongly inhibit P-glycoprotein, while dronedarone is a moderate and amiodarone a weak inhibitor of cytochrome P450 3A4 (CYP3A4). Based on these data and evidence from physiologically based pharmacokinetic modelling, amiodarone and dronedarone are expected to have similar effects on rivaroxaban exposure resulting from P-glycoprotein and CYP3A4 inhibition. However, the rivaroxaban label recommends against the concomitant use of dronedarone, but not amiodarone, citing a lack of evidence on the concomitant use of rivaroxaban and dronedarone as the reason for the different recommendations. In this report, we discuss evidence from clinical studies and physiologically based pharmacokinetic modelling on the potential for increased rivaroxaban exposure resulting from drug-drug interaction between rivaroxaban and dronedarone or amiodarone. The current evidence supports the same clinical status and concomitant use of either amiodarone or dronedarone with rivaroxaban, which could be considered in future recommendations.
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Affiliation(s)
| | - Marc Horlitz
- Klinik für Kardiologie, Elektrophysiologie und Rhythmologie, Krankenhaus Porz am Rhein, Universität Witten/Herdecke, Köln, Germany
| | - Kerstin Fischer
- Bayer AG, Research & Development, Pharmaceuticals Therapeutic Opportunity Expansion, Berlin, Germany
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Clinical Pharmacology and Toxicology, Charité University Medicine, Berlin, Germany
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5
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Thangaraju P, Velmurugan H, N K. Current Status of Pharmacokinetic Research in Children: A Systematic Review of Clinical Trial Records. Curr Rev Clin Exp Pharmacol 2022; 19:CRCEP-EPUB-128427. [PMID: 36573054 DOI: 10.2174/2772432818666221223155455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 09/05/2022] [Accepted: 10/18/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Many medications have different pharmacokinetics in children than in adults. Knowledge about the safety and efficacy of medications in children requires research into the pharmacokinetic profiles of children's medicines. By analysing registered clinical trial records, this study determined how frequently pharmacokinetic data is gathered in paediatric drug trials. METHODS We searched for the pharmacokinetic data from clinical trial records for preterm infants and children up to the age of 16 from January 2011 to April 2022. The records of trials involving one or more drugs in preterm infants and children up to the age of 16 were examined for evidence that pharmacokinetic data would be collected. RESULTS In a total of 1483 records of interventional clinical trials, 136 (9.17%) pharmacokinetic data involved adults. Of those 136 records, 60 (44.1%) records were pharmacokinetics trials involving one or more medicines in children up to the age of 16. 20 (33.3 %) in America, followed by 19 (31.6 %) in Europe. Most trials researched medicines in the field of infection or parasitic diseases 20 (33.3%). 27 (48.2%) and 26 (46.4%) trials investigated medicines that were indicated as essential medicine. CONCLUSION The pharmacokinetic characteristics of children's drugs need to be better understood. The current state of pharmacokinetic research appears to address the knowledge gap in this area adequately. Despite slow progress, paediatric clinical trials have experienced a renaissance as the significance of paediatric trials has gained international attention. The outcome of paediatric trials will have an impact on children's health in the future. In recent years, the need for greater availability and access to safe child-size pharmaceuticals has received a lot of attention.
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Affiliation(s)
- Pugazhenthan Thangaraju
- Department of Pharmacology, All India institute of medical sciences, Raipur, Chhattisgarh, India
| | - Hemasri Velmurugan
- Department of Pharmacology, All India institute of medical sciences, Raipur, Chhattisgarh, India
| | - Krishnapriya N
- Department of Pharmacology, All India institute of medical sciences, Raipur, Chhattisgarh, India
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6
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Ngo LT, Yang S, Shin S, Cao DT, Van Nguyen H, Jung S, Lee J, Lee J, Yun H, Chae J. Application of physiologically-based pharmacokinetic model approach to predict pharmacokinetics and drug-drug interaction of rivaroxaban: A case study of rivaroxaban and carbamazepine. CPT Pharmacometrics Syst Pharmacol 2022; 11:1430-1442. [PMID: 36193622 PMCID: PMC9662201 DOI: 10.1002/psp4.12844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 11/06/2022] Open
Abstract
Rivaroxaban (RIV; Xarelto; Janssen Pharmaceuticals, Beerse, Belgium) is one of the direct oral anticoagulants. The drug is a strong substrate of cytochrome P450 (CYP) enzymes and efflux transporters. This study aimed to develop a physiologically-based pharmacokinetic (PBPK) model for RIV. It contained three hepatic metabolizing enzyme reactions (CYP3A4, CYP2J2, and CYP-independent) and two active transporter-mediated transfers (P-gp and BCRP transporters). To illustrate the performance of the developed RIV PBPK model on the prediction of drug-drug interactions (DDIs), carbamazepine (CBZ) was selected as a case study due to the high DDI potential. Our study results showed that CBZ significantly reduces the exposure of RIV. The area under the concentration-time curve from zero to infinity (AUCinf ) of RIV was reduced by 35.2% (from 2221.3 to 1438.7 ng*h/ml) and by 25.5% (from 2467.3 to 1838.4 ng*h/ml) after the first dose and at the steady-state, respectively, whereas the maximum plasma concentration (Cmax ) of RIV was reduced by 37.7% (from 266.3 to 166.1 ng/ml) and 36.4% (from 282.3 to 179.5 ng/ml), respectively. The developed PBPK model of RIV could be paired with PBPK models of other interested perpetrators to predict DDI profiles. Further studies investigating the extent of DDI between CBZ and RIV should be conducted in humans to gain a full understanding of their safety and effects.
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Affiliation(s)
- Lien Thi Ngo
- College of PharmacyChungnam National UniversityDaejeonKorea
| | - Sung‐yoon Yang
- College of PharmacyChungnam National UniversityDaejeonKorea
| | | | - Duc Tuan Cao
- Department of Pharmaceutical Chemistry and Quality ControlFaculty of Pharmacy, Haiphong University Medicine and PharmacyHaiphongVietnam
| | - Hung Van Nguyen
- Department of Pharmacology, Faculty of PharmacyHaiphong University Medicine and PharmacyHaiphongVietnam
| | - Sangkeun Jung
- Department of Computer Science and EngineeringChungnam National UniversityDaejeonKorea
| | - Jae‐Young Lee
- Department of Computer Science and EngineeringChungnam National UniversityDaejeonKorea
| | - Jong‐Hwa Lee
- Korea Institute of ToxicologyDaejeonKorea,Department of Human and Environment ToxicologyUniversity of Science and TechnologyDaejeonKorea
| | - Hwi‐yeol Yun
- College of PharmacyChungnam National UniversityDaejeonKorea
| | - Jung‐woo Chae
- College of PharmacyChungnam National UniversityDaejeonKorea
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7
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Willmann S, Ince I, Ahsman M, Coboeken K, Zhang Y, Thelen K, Kubitza D, Zannikos P, Zhou W, Pina LM, Post T, Lippert J. Model‐informed bridging of rivaroxaban doses for thromboprophylaxis in pediatric patients aged 9 years and older with congenital heart disease. CPT Pharmacometrics Syst Pharmacol 2022; 11:1111-1121. [PMID: 35665486 PMCID: PMC9381895 DOI: 10.1002/psp4.12830] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/09/2022] [Accepted: 05/23/2022] [Indexed: 12/04/2022] Open
Abstract
Rivaroxaban is approved in various regions for the treatment of acute venous thromboembolism (VTE) in children aged between 0 and 18 years and was recently investigated for thromboprophylaxis in children aged between 2 and 8 years (with body weights <30 kg) with congenital heart disease who had undergone the Fontan procedure. In the absence of clinical data, rivaroxaban doses for thromboprophylaxis in post‐Fontan children aged 9 years and older or ≥30 kg were derived by a bridging approach that used physiologically‐based pharmacokinetic (PBPK) and population pharmacokinetic (popPK) models based on pharmacokinetic (PK) data from 588 pediatric patients and from adult patients who received 10 mg once daily for thromboprophylaxis after major orthopedic surgeries as a reference. Both models showed a tendency toward underestimating rivaroxaban exposure in post‐Fontan patients aged between 2 and 5 years but accurately described rivaroxaban PK in post‐Fontan patients aged between 5 and 8 years. Under the assumption that hepatic function is not impaired in post‐Fontan patients, PBPK and popPK simulations indicated that half of the rivaroxaban doses for the same body weight given to pediatric patients treated for acute VTE would yield in pediatric post‐Fontan patients exposures similar to the exposure observed in adult patients receiving 10 mg rivaroxaban once daily for thromboprophylaxis. Simulation‐derived doses (7.5 mg rivaroxaban once daily for body weights 30–<50 kg and 10 mg once daily for body weights ≥50 kg) were therefore included in the recent US label of rivaroxaban for thromboprophylaxis in children aged 2 years and older with congenital heart disease who have undergone the Fontan procedure.
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Affiliation(s)
- Stefan Willmann
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Ibrahim Ince
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Maurice Ahsman
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics Leiden The Netherlands
| | - Katrin Coboeken
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Yang Zhang
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Kirstin Thelen
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Dagmar Kubitza
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Peter Zannikos
- Janssen Research & Development, LLC Raritan New Jersey USA
| | - Wangda Zhou
- Janssen Research & Development, LLC Raritan New Jersey USA
| | | | - Teun Post
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics Leiden The Netherlands
| | - Jörg Lippert
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
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8
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Salem F, Small BG, Johnson TN. Development and application of a pediatric mechanistic kidney model. CPT Pharmacometrics Syst Pharmacol 2022; 11:854-866. [PMID: 35506351 PMCID: PMC9286721 DOI: 10.1002/psp4.12798] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 11/19/2022] Open
Abstract
Pediatric physiologically‐based pharmacokinetic (P‐PBPK) models have been used to predict age related changes in the pharmacokinetics (PKs) of renally cleared drugs mainly in relation to changes in glomerular filtration rate. With emerging data on ontogeny of renal transporters, mechanistic models of renal clearance accounting for the role of active and passive secretion should be developed and evaluated. Data on age‐related physiological changes and ontogeny of renal transporters were applied into a mechanistic kidney within a P‐PBPK model. Plasma concentration–time profile and PK parameters of cimetidine, ciprofloxacin, metformin, tenofovir, and zidovudine were predicted in subjects aged 1 day to 18 years. The predicted and observed plasma concentration–time profiles and PK parameters were compared. The predicted concentration–time profile means and 5th and 95th percent intervals generally captured the observed data and variability in various studies. Overall, based on drugs and age bands, predicted to observed clearance were all within two‐fold and in 11 of 16 cases within 1.5‐fold. Predicted to observed area under the curve (AUC) and maximum plasma concentration (Cmax) were within two‐fold in 12 of 14 and 12 of 15 cases, respectively. Predictions in neonates and early infants (up to 14 weeks postnatal age) were reasonable with 15–20 predicted PK parameters within two‐fold of the observed. ciprofloxacin but not zidovudine PK predictions were sensitive to basal kidney uptake transporter ontogeny. The results indicate that a mechanistic kidney model accounting for physiology and ontogeny of renal processes and transporters can predict the PK of renally excreted drugs in children. Further data especially in neonates are required to verify the model and ontogeny profiles.
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Affiliation(s)
- Farzaneh Salem
- Drug Metabolism and Pharmacokinetics GlaxoSmithKline R&D Ware UK
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9
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Male C. Anticoagulation in Pediatric Patients. Hamostaseologie 2022; 42:46-53. [PMID: 35042258 DOI: 10.1055/a-1703-0821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Special aspects of anticoagulation in children include the different epidemiology of thrombosis, developmental changes in the coagulation system, age-dependent pharmacokinetics of anticoagulants, risk of bleeding, and practical hurdles to anticoagulation. The classical anticoagulants so far used in children have several limitations, resulting in the need for regular monitoring. The pharmacological properties of direct oral anticoagulants (DOACs) and the special challenges of anticoagulation in children make the DOACs particularly attractive for children. All DOACs have pediatric development programs, targeting various indications for prevention and treatment of thrombosis. Child-appropriate formulations have been developed, age-specific dosing information generated, and safety and efficacy evaluated in ongoing phase 3 trials. Rivaroxaban and dabigatran have already been authorized for children for treatment of acute venous thrombosis and for extended secondary prevention. Their safety and efficacy have been demonstrated comparable to that of standard-of-care anticoagulants, without need for monitoring. Further studies are ongoing, which are expected to lead to pediatric authorizations of DOACs for primary venous thromboembolic event prevention in some high-risk settings. More real-life data will be necessary from postmarketing studies and registries to complement the evidence base for DOAC use in children, particularly in the youngest age groups and special disease populations.
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Affiliation(s)
- Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
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10
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Male C, Monagle P, Albisetti M, Brandão LR, Young G. Direct Oral Anticoagulants: Overcoming the Challenges of Managing Venous Thromboembolism in Children. J Pediatr 2022; 240:14-23. [PMID: 34687696 DOI: 10.1016/j.jpeds.2021.09.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Christoph Male
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria.
| | - Paul Monagle
- Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia; Australia and Kids Cancer Centre, Sydney Children's Hospital, Sydney, Australia
| | - Manuela Albisetti
- Division of Hematology, University Children's Hospital of Zurich, Zurich, Switzerland
| | - Leonardo R Brandão
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Guy Young
- Children's Hospital Los Angeles, University of Southern California, Keck School of Medicine, Los Angeles, CA
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11
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McCrindle BW, Michelson AD, Van Bergen AH, Suzana Horowitz E, Pablo Sandoval J, Justino H, Harris KC, Jefferies JL, Miriam Pina L, Peluso C, Nessel K, Lu W, Li JS. Thromboprophylaxis for Children Post-Fontan Procedure: Insights From the UNIVERSE Study. J Am Heart Assoc 2021; 10:e021765. [PMID: 34558312 PMCID: PMC8751951 DOI: 10.1161/jaha.120.021765] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Patients with single-ventricle physiology who undergo the Fontan procedure are at risk for thrombotic events associated with significant morbidity and mortality. The UNIVERSE Study evaluated the efficacy and safety of a novel liquid rivaroxaban formulation, using a body weight-adjusted dosing regimen, versus acetylsalicylic acid (ASA) in children post-Fontan. Methods and Results The UNIVERSE Study was a randomized, multicenter, 2-part, open-label study of rivaroxaban, in children who had undergone a Fontan procedure, to evaluate its dosing regimen, safety, and efficacy. Part A was the single-arm part of the study that determined the pharmacokinetics/pharmacodynamics and safety of rivaroxaban in 12 participants before proceeding to part B, whereby 100 participants were randomized 2:1 to open-label rivaroxaban versus ASA. The study period was 12 months. A total of 112 participants were enrolled across 35 sites in 10 countries. In part B, for safety outcomes, major bleeding occurred in one participant on rivaroxaban (epistaxis that required transfusion). Clinically relevant nonmajor bleeding occurred in 6% of participants on rivaroxaban versus 9% on ASA. Trivial bleeding occurred in 33% of participants on rivaroxaban versus 35% on ASA. For efficacy outcomes, 1 participant on rivaroxaban in part B had a pulmonary embolism (2% overall event rate); and for ASA, 1 participant had ischemic stroke and 2 had venous thrombosis (9% overall event rate). Conclusions In this study, participants who received rivaroxaban for thromboprophylaxis had a similar safety profile and fewer thrombotic events, albeit not statistically significant, compared with those in the ASA group. Registration URL: https://www.clinicaltrials.gov. Identifier: NCT02846532.
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Affiliation(s)
- Brian W McCrindle
- The Hospital for Sick Children University of Toronto Toronto ON Canada
| | | | | | - Estela Suzana Horowitz
- Institute of Cardiology of Rio Grande do Sul/University Foundation of Cardiology Porto Alegre Brazil
| | | | | | - Kevin C Harris
- Children's Heart CentreBC Children's Hospital Vancouver BC Canada
| | - John L Jefferies
- The Cardiac Institute University of Tennessee Health Science Center Memphis TN
| | | | | | | | - Wentao Lu
- Janssen Research and Development, LLC Raritan NJ
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12
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Zhu P, Willmann S, Zhou W, Yang H, Michelson AD, McCrindle BW, Li JS, Harris KC, Pina LM, Weber T, Nessel K, Lesko LJ, Kubitza D, Zannikos P. Dosing Regimen Prediction and Confirmation with Rivaroxaban for Thromboprophylaxis in Children after the Fontan Procedure: Insights from the Phase III UNIVERSE Study. J Clin Pharmacol 2021; 62:220-231. [PMID: 34524700 PMCID: PMC9303933 DOI: 10.1002/jcph.1966] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/10/2021] [Indexed: 11/09/2022]
Abstract
Thrombosis remains an important complication for children with single ventricle physiology post-Fontan procedure and effective thromboprophylaxis is an important unmet medical need. To obviate conventional dose-finding studies and expedite clinical development, a rivaroxaban dose regimen for this indication was determined utilizing a model-informed drug development approach. A physiologically based pharmacokinetic (PBPK) rivaroxaban model was used to predict a pediatric dosing regimen that would produce drug exposures similar to that of 10 mg once daily in adults. This regimen was used in an open-label, multicenter Phase 3 study, which investigated the use of rivaroxaban for thromboprophylaxis in post-Fontan patients 2 to 8 years of age. The pharmacokinetics (PK) of rivaroxaban was assessed in Part A (n = 12) and in Part B (n = 64) of UNIVERSE. The safety and efficacy in the rivaroxaban group were compared to those in the acetylsalicylic acid group for 12 months. Pharmacodynamic endpoints were assessed in both parts of the study. Rivaroxaban exposures achieved in Part A and B were similar to the adult reference exposures. Prothrombin time also showed similarity to the adult reference. Exposure-response analysis did not identify a quantitative relationship between rivaroxaban exposures and efficacy/safety outcomes within the observed exposure ranges. A body-weight based dose regimen selected by PBPK modeling was shown in the UNIVERSE study to be appropriate for thromboprophylaxis in the post-Fontan pediatric population. Model-based dose selection can support pediatric drug development and bridge adult dose data to pediatrics, thereby obviating the need for dose-finding studies in pediatric programs. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Peijuan Zhu
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Stefan Willmann
- Bayer AG, Pharmaceuticals, Research and Development, Wuppertal, Germany
| | - Wangda Zhou
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Haitao Yang
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Alan D Michelson
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian W McCrindle
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Kevin C Harris
- Children's Heart Centre, BC Children's Hospital, Vancouver, BC, Canada
| | | | - Traci Weber
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | | | | | - Dagmar Kubitza
- Bayer AG, Pharmaceuticals, Research and Development, Wuppertal, Germany
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13
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Willmann S, Coboeken K, Zhang Y, Mayer H, Ince I, Mesic E, Thelen K, Kubitza D, Lensing AWA, Yang H, Zhu P, Mück W, Drenth HJ, Lippert J. Population pharmacokinetic analysis of rivaroxaban in children and comparison to prospective physiologically-based pharmacokinetic predictions. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2021; 10:1195-1207. [PMID: 34292671 PMCID: PMC8520753 DOI: 10.1002/psp4.12688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Revised: 04/01/2021] [Accepted: 06/29/2021] [Indexed: 11/22/2022]
Abstract
Rivaroxaban has been investigated in the EINSTEIN‐Jr program for the treatment of acute venous thromboembolism (VTE) in children aged 0 to 18 years and in the UNIVERSE program for thromboprophylaxis in children aged 2 to 8 years with congenital heart disease after Fontan‐procedure. Physiologically‐based pharmacokinetic (PBPK) and population pharmacokinetic (PopPK) modeling were used throughout the pediatric development of rivaroxaban according to the learn‐and‐confirm paradigm. The development strategy was to match pediatric drug exposures to adult exposure proven to be safe and efficacious. In this analysis, a refined pediatric PopPK model for rivaroxaban based on integrated EINSTEIN‐Jr data and interim PK data from part A of the UNIVERSE phase III study was developed and the influence of potential covariates and intrinsic factors on rivaroxaban exposure was assessed. The model adequately described the observed pediatric PK data. PK parameters and exposure metrics estimated by the PopPK model were compared to the predictions from a previously published pediatric PBPK model for rivaroxaban. Ninety‐one percent of the individual post hoc clearance estimates were found within the 5th to 95th percentile of the PBPK model predictions. In patients below 2 years of age, however, clearance was underpredicted by the PBPK model. The iterative and integrative use of PBPK and PopPK modeling and simulation played a major role in the establishment of the bodyweight‐adjusted rivaroxaban dosing regimen that was ultimately confirmed to be a safe and efficacious dosing regimen for children aged 0 to 18 years with acute VTE in the EINSTEIN‐Jr phase III study.
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Affiliation(s)
- Stefan Willmann
- Research and Development, Pharmaceuticals, Bayer AG, Wuppertal/Leverkusen, Germany
| | - Katrin Coboeken
- Research and Development, Pharmaceuticals, Bayer AG, Wuppertal/Leverkusen, Germany
| | - Yang Zhang
- Research and Development, Pharmaceuticals, Bayer AG, Wuppertal/Leverkusen, Germany
| | - Hannah Mayer
- Research and Development, Pharmaceuticals, Bayer AG, Wuppertal/Leverkusen, Germany
| | - Ibrahim Ince
- Research and Development, Pharmaceuticals, Bayer AG, Wuppertal/Leverkusen, Germany
| | - Emir Mesic
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P, Leiden, The Netherlands
| | - Kirstin Thelen
- Research and Development, Pharmaceuticals, Bayer AG, Wuppertal/Leverkusen, Germany
| | - Dagmar Kubitza
- Research and Development, Pharmaceuticals, Bayer AG, Wuppertal/Leverkusen, Germany
| | - Anthonie W A Lensing
- Research and Development, Pharmaceuticals, Bayer AG, Wuppertal/Leverkusen, Germany
| | - Haitao Yang
- Janssen Research and Development, LLC, Raritan, New Jersey, USA
| | - Peijuan Zhu
- Janssen Research and Development, LLC, Raritan, New Jersey, USA
| | - Wolfgang Mück
- Research and Development, Pharmaceuticals, Bayer AG, Wuppertal/Leverkusen, Germany
| | - Henk-Jan Drenth
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics (LAP&P, Leiden, The Netherlands
| | - Jörg Lippert
- Research and Development, Pharmaceuticals, Bayer AG, Wuppertal/Leverkusen, Germany
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14
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Liu XI, van den Anker JN, Burckart GJ, Dallmann A. Evaluation of Physiologically Based Pharmacokinetic Models to Predict the Absorption of BCS Class I Drugs in Different Pediatric Age Groups. J Clin Pharmacol 2021; 61 Suppl 1:S94-S107. [PMID: 34185902 DOI: 10.1002/jcph.1845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 02/17/2021] [Indexed: 11/06/2022]
Abstract
Age-related changes in many parameters affecting drug absorption remain poorly characterized. The objective of this study was to apply physiologically based pharmacokinetic (PBPK) models in pediatric patients to investigate the absorption and pharmacokinetics of 4 drugs belonging to the Biopharmaceutics Classification System (BCS) class I administered as oral liquid formulations. Pediatric PBPK models built with PK-Sim/MoBi were used to predict the pharmacokinetics of acetaminophen, emtricitabine, theophylline, and zolpidem in different pediatric populations. The model performance for predicting drug absorption and pharmacokinetics was assessed by comparing the predicted absorption profile with the deconvoluted dose fraction absorbed over time and predicted with observed plasma concentration-time profiles. Sensitivity analyses were performed to analyze the effects of changes in relevant input parameters on the model output. Overall, most pharmacokinetic parameters were predicted within a 2-fold error range. The absorption profiles were generally reasonably predicted, but relatively large differences were observed for acetaminophen. Sensitivity analyses showed that the predicted absorption profile was most sensitive to changes in the gastric emptying time (GET) and the specific intestinal permeability. The drug's solubility played only a minor role. These findings confirm that gastric emptying time, more than intestinal permeability or solubility, is a key factor affecting BCS class I drug absorption in children. As gastric emptying time is prolonged in the fed state, a better understanding of the interplay between food intake and gastric emptying time in children is needed, especially in the very young in whom the (semi)fed condition is the prevailing prandial state, and hence prolonged gastric emptying time seems more plausible than the fasting state.
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Affiliation(s)
- Xiaomei I Liu
- Division of Clinical Pharmacology, Children's National Hospital, Washington, District of Columbia, USA
| | - John N van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, District of Columbia, USA.,Division of Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Gilbert J Burckart
- Office of Clinical Pharmacology, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - André Dallmann
- Pharmacometrics/Modeling & Simulation, Research & Development, Pharmaceuticals, Bayer AG, Leverkusen, Germany
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15
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Ince I, Dallmann A, Frechen S, Coboeken K, Niederalt C, Wendl T, Block M, Meyer M, Eissing T, Burghaus R, Lippert J, Willmann S, Schlender J. Predictive Performance of Physiology-Based Pharmacokinetic Dose Estimates for Pediatric Trials: Evaluation With 10 Bayer Small-Molecule Compounds in Children. J Clin Pharmacol 2021; 61 Suppl 1:S70-S82. [PMID: 34185905 PMCID: PMC8361729 DOI: 10.1002/jcph.1869] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/30/2021] [Indexed: 01/16/2023]
Abstract
Development and guidance of dosing schemes in children have been supported by physiology-based pharmacokinetic (PBPK) modeling for many years. PBPK models are built on a generic basis, where compound- and system-specific parameters are separated and can be exchanged, allowing the translation of these models from adults to children by accounting for physiological differences. Owing to these features, PBPK modeling is a valuable approach to support clinical decision making for dosing in children. In this analysis, we evaluate pediatric PBPK models for 10 small-molecule compounds that were applied to support clinical decision processes at Bayer for their predictive power in different age groups. Ratios of PBPK-predicted to observed PK parameters for the evaluated drugs in different pediatric age groups were estimated. Predictive performance was analyzed on the basis of a 2-fold error range and the bioequivalence range (ie, 0.8 ≤ predicted/observed ≤ 1.25). For all 10 compounds, all predicted-to-observed PK ratios were within a 2-fold error range (n = 27), with two-thirds of the ratios within the bioequivalence range (n = 18). The findings demonstrate that the pharmacokinetics of these compounds was successfully and adequately predicted in different pediatric age groups. This illustrates the applicability of PBPK for guiding dosing schemes in the pediatric population.
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Affiliation(s)
- Ibrahim Ince
- Pharmacometrics/Modeling and Simulation, Research and DevelopmentPharmaceuticalsBayerAGGermany
| | - André Dallmann
- Pharmacometrics/Modeling and Simulation, Research and DevelopmentPharmaceuticalsBayerAGGermany
| | - Sebastian Frechen
- Pharmacometrics/Modeling and Simulation, Research and DevelopmentPharmaceuticalsBayerAGGermany
| | - Katrin Coboeken
- Pharmacometrics/Modeling and Simulation, Research and DevelopmentPharmaceuticalsBayerAGGermany
| | - Christoph Niederalt
- Pharmacometrics/Modeling and Simulation, Research and DevelopmentPharmaceuticalsBayerAGGermany
| | - Thomas Wendl
- Pharmacometrics/Modeling and Simulation, Research and DevelopmentPharmaceuticalsBayerAGGermany
| | - Michael Block
- Pharmacometrics/Modeling and Simulation, Research and DevelopmentPharmaceuticalsBayerAGGermany
| | - Michaela Meyer
- Pharmacometrics/Modeling and Simulation, Research and DevelopmentPharmaceuticalsBayerAGGermany
| | - Thomas Eissing
- Pharmacometrics/Modeling and Simulation, Research and DevelopmentPharmaceuticalsBayerAGGermany
| | - Rolf Burghaus
- Pharmacometrics/Modeling and Simulation, Research and DevelopmentPharmaceuticalsBayerAGGermany
| | - Jörg Lippert
- Pharmacometrics/Modeling and Simulation, Research and DevelopmentPharmaceuticalsBayerAGGermany
| | - Stefan Willmann
- Pharmacometrics/Modeling and Simulation, Research and DevelopmentPharmaceuticalsBayerAGGermany
| | - Jan‐Frederik Schlender
- Pharmacometrics/Modeling and Simulation, Research and DevelopmentPharmaceuticalsBayerAGGermany
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16
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Branstetter JW, Kiskaddon AL, King MA, Coalter C, Grubbs KM, Fly H, Male C, Brandão L, Goldenberg NA. Efficacy and Safety of Non-Vitamin K Antagonist Oral Anticoagulants in Pediatric Venous Thromboembolism Treatment and Thromboprophylaxis: A Systematic Review of the Literature. Semin Thromb Hemost 2021; 47:643-653. [PMID: 33971679 DOI: 10.1055/s-0041-1725944] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Venous thromboembolism (VTE) in children can lead to significant morbidity and mortality. Traditionally, treatment for thrombotic events in pediatric patients has been limited mainly to unfractionated heparin, low-molecular-weight heparin (LMWH), or vitamin K antagonists. Since the first non-vitamin K antagonist oral anticoagulant (NOAC) was approved for adult use, these agents have gained popularity for a variety of indications. This is largely due to their ease of administration, favorable pharmacokinetic and pharmacodynamic profile, decreased food interactions, and decreased need for therapeutic drug monitoring. Treating and preventing VTE with traditional anticoagulants in pediatric patients presents many challenges. This systematic review evaluated the current literature regarding pediatric NOAC trials. Additionally, based on an up-to-date query of clinicaltrials.gov, we detail current ongoing and as-yet unpublished clinical trials, study outcomes, and projected completion dates. Published pediatric NOAC trials have included 1,007 total children to date and have ranged from phase 1 to 4, with "indications" including both thromboembolism prophylaxis and VTE treatment. Three recent phase 3 trials, specifically involving rivaroxaban and dabigatran, have shown the agents to be at least as effective as traditional anticoagulants for acute and/or extended VTE treatment, with low frequency of recurrent thrombosis and clinically significant bleeding rates. Additionally, specially developed and tested pediatric formulations have allowed for accurate and reliable dosing, oral administration, stable pharmacokinetics and pharmacodynamics, and fewer drug or food interactions. Ongoing trials, anticipated for completion in the next few years, will reveal important information with regard to thromboembolism prophylaxis in special pediatric subpopulations and settings.
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Affiliation(s)
| | - Amy L Kiskaddon
- Department of Pharmacy, The Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, Florida
| | - Madeleine A King
- Department of Pharmacy, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Carli Coalter
- College of Pharmacy, Union University, Jackson, Tennessee
| | - Kimberly M Grubbs
- Department of Pharmacy, Medical University of South Carolina, Charleston, South Carolina
| | - Hunter Fly
- Department of Pharmacy, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Austria
| | - Leonardo Brandão
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Neil A Goldenberg
- Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, Florida.,Thrombosis Program, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Department of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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17
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Xu R, Tang H, Chen L, Ge W, Yang J. Developing a physiologically based pharmacokinetic model of apixaban to predict scenarios of drug-drug interactions, renal impairment and paediatric populations. Br J Clin Pharmacol 2021; 87:3244-3254. [PMID: 33528059 DOI: 10.1111/bcp.14743] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 12/23/2020] [Accepted: 01/16/2021] [Indexed: 01/25/2023] Open
Abstract
AIMS To develop a physiologically based pharmacokinetic (PBPK) model for apixaban, an oral anticoagulant with a narrow therapeutic index, and to predict PK profiles and potential drug-drug interactions (DDIs) in patients with renal impairment and paediatrics. METHODS A whole-body apixaban PBPK model was developed and validated in SimCYP for healthy adults with or without interacting drugs. The model was extended to renal impairment and paediatrics. Observed PK data in adults were compared with predicted data. The effect of renal function, age and DDIs on apixaban PK was investigated. RESULTS The PBPK model successfully predicted the PK of apixaban alone and under the influence of interacting drugs. For patients with renal impairment, the PBPK model successfully predicted the fold change in each impairment group; inhibitory DDI and renal impairment had a synergistic effect on the increase of apixaban exposure (e.g., almost 3-fold increase of AUC in ketoconazole + severe renal impairment group). For infants younger than 1 year, the exposure of apixaban decreased with increased weight-normalized clearance. For newborn infants, AUC of apixaban was >2-fold higher than that in children older than 1 year. Meanwhile, the effect of DDI seems to be weakened while the effect of renal impairment might be enhanced in infants younger than 1 year. CONCLUSION Our study provides a reasonable approach to estimate the dose adjustment for the first use of apixaban in special populations with complex situations, which has the opportunity to make the clinical practice much safer.
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Affiliation(s)
- Ruijuan Xu
- Department of Pharmacy, Drum Tower Hospital Affiliated to Medical School of Nanjing University, Nanjing, China
| | - Hong Tang
- Department of Analysis, Nanjing GQ Laboratories Co., Ltd, Nanjing, China
| | - Lin Chen
- Center of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing, China
| | - Weihong Ge
- Department of Pharmacy, Drum Tower Hospital Affiliated to Medical School of Nanjing University, Nanjing, China
| | - Jin Yang
- Center of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing, China
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18
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Willmann S, Coboeken K, Kapsa S, Thelen K, Mundhenke M, Fischer K, Hügl B, Mück W. Applications of Physiologically Based Pharmacokinetic Modeling of Rivaroxaban-Renal and Hepatic Impairment and Drug-Drug Interaction Potential. J Clin Pharmacol 2021; 61:656-665. [PMID: 33205449 PMCID: PMC8048900 DOI: 10.1002/jcph.1784] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
The non–vitamin K antagonist oral anticoagulant rivaroxaban is used in several thromboembolic disorders. Rivaroxaban is eliminated via both metabolic degradation and renal elimination as unchanged drug. Therefore, renal and hepatic impairment may reduce rivaroxaban clearance, and medications inhibiting these clearance pathways could lead to drug‐drug interactions. This physiologically based pharmacokinetic (PBPK) study investigated the pharmacokinetic behavior of rivaroxaban in clinical situations where drug clearance is impaired. A PBPK model was developed using mass balance and bioavailability data from adults and qualified using clinically observed data. Renal and hepatic impairment were simulated by adjusting disease‐specific parameters, and concomitant drug use was simulated by varying enzyme activity in virtual populations (n = 1000) and compared with pharmacokinetic predictions in virtual healthy populations and clinical observations. Rivaroxaban doses of 10 mg or 20 mg were used. Mild to moderate renal impairment had a minor effect on area under the concentration‐time curve and maximum plasma concentration of rivaroxaban, whereas severe renal impairment caused a more pronounced increase in these parameters vs normal renal function. Area under the concentration‐time curve and maximum plasma concentration increased with severity of hepatic impairment. These effects were smaller in the simulations compared with clinical observations. AUC and Cmax increased with the strength of cytochrome P450 3A4 and P‐glycoprotein inhibitors in simulations and clinical observations. This PBPK model can be useful for estimating the effects of impaired drug clearance on rivaroxaban pharmacokinetics. Identifying other factors that affect the pharmacokinetics of rivaroxaban could facilitate the development of models that approximate real‐world pharmacokinetics more accurately.
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Affiliation(s)
| | | | - Stefanie Kapsa
- Clinical Pharmacokinetics Cardiovascular, Bayer AG, Wuppertal, Germany
| | - Kirstin Thelen
- Clinical Pharmacokinetics Cardiovascular, Bayer AG, Wuppertal, Germany
| | - Markus Mundhenke
- Medical Affairs Cardiovascular, Bayer Vital GmbH, Leverkusen, Germany
| | | | - Burkhard Hügl
- Clinic for Cardiology and Rhythmology, Marienhaus Klinikum St Elisabeth Neuwied, Neuwied, Germany
| | - Wolfgang Mück
- Clinical Pharmacokinetics Cardiovascular, Bayer AG, Wuppertal, Germany
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19
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Otsuka Y, Choules MP, Bonate PL, Komatsu K. Physiologically-Based Pharmacokinetic Modeling for the Prediction of a Drug-Drug Interaction of Combined Effects on P-glycoprotein and Cytochrome P450 3A. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2020; 9:659-669. [PMID: 33030266 PMCID: PMC7679072 DOI: 10.1002/psp4.12562] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/16/2020] [Indexed: 12/20/2022]
Abstract
Direct oral anticoagulants, such as apixaban and rivaroxaban, are important for the treatment and prophylaxis of venous thromboembolism and to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. Because apixaban and rivaroxaban are predominantly eliminated by cytochrome P450 (CYP) 3A and P‐glycoprotein (P‐gp), concomitant use of combined P‐gp and strong CYP3A4 inhibitors and inducers should be avoided. Physiologically‐based pharmacokinetic models for apixaban and rivaroxaban were developed to estimate the net effect of CYP3A induction, P‐gp inhibition, and P‐gp induction by rifampicin. The disposition of rivaroxaban is more complex compared with apixaban because both hepatic and renal P‐gp is considered to contribute to rivaroxaban elimination. Furthermore, organic anion transporter‐3, a renal uptake transporter, may also contribute the elimination of rivaroxaban from systemic circulation. The models were verified with observed clinical drug–drug interactions with CYP3A and P‐gp inhibitors. With the developed models, the predicted area under the concentration time curve and maximum concentration ratios were 0.43 and 0.48, respectively, for apixaban, and 0.50–0.52 and 0.72–0.73, respectively, for rivaroxaban when coadministered with 600 mg multiple doses of rifampicin and that were very close to observed data. The impact of each of the elimination pathways was assessed for rivaroxaban, and inhibition of CYP3A led to a larger impact over intestinal and hepatic P‐gp. Inhibition of renal organic anion transporter‐3 or P‐gp led to an overall modest interaction. The developed apixaban and rivaroxaban models can be further applied to the investigation of interactions with other P‐gp and/or CYP3A4 inhibitors and inducers.
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Affiliation(s)
- Yukio Otsuka
- Clinical Pharmacology and Exploratory Development, Astellas Pharma Inc., Tokyo, Japan
| | - Mary P Choules
- Clinical Pharmacology and Exploratory Development, Astellas Pharma Global Development Inc., Northbrook, Illinois, USA
| | - Peter L Bonate
- Clinical Pharmacology and Exploratory Development, Astellas Pharma Global Development Inc., Northbrook, Illinois, USA
| | - Kanji Komatsu
- Clinical Pharmacology and Exploratory Development, Astellas Pharma Inc., Tokyo, Japan
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20
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Ince I, Solodenko J, Frechen S, Dallmann A, Niederalt C, Schlender J, Burghaus R, Lippert J, Willmann S. Predictive Pediatric Modeling and Simulation Using Ontogeny Information. J Clin Pharmacol 2020; 59 Suppl 1:S95-S103. [PMID: 31502689 DOI: 10.1002/jcph.1497] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 07/01/2019] [Indexed: 12/19/2022]
Abstract
Food and Drug Administration submissions of physiologically based pharmacokinetic (PBPK) modeling and simulation of small-molecule drugs document the relevance of pediatric drug development and, in particular, information on dosing strategies in children. The most relevant prerequisite for reliable PBPK-based translation of adult pharmacokinetics of a small molecule to children is knowledge of the drug-specific absorption, distribution, metabolism, and elimination (ADME) processes in adults together with existing information about ontogeny of ADME processes relevant for the drug. All mechanisms driving a drug's clearance are of specific importance. For other drug modalities, our knowledge of ADME processes and ontogeny is still limited. More research is required, for example, to understand why some therapeutic proteins show complex differences in pharmacokinetics between adults and children, whereas other proteins seem to follow simple allometric scaling rules. Ontogeny information originates from various sources, such as (semi)quantitative mRNA expression, in vitro activity data, and deconvolution of in vivo pharmacokinetic data. The workflow for pediatric predictions is well described in several articles documenting successful translation from adults to children. The technical hurdles for PBPK modeling are low. State-of-the-art PBPK modeling software tools provide integrated pediatric translation workflows. For example, PK-Sim and MoBi are freely available as fully transparent open-source software via Open Systems Pharmacology (OSP). With the latest 2019 software release, version 8.0, OSP even provides a fully integrated technical framework for the qualification (and requalification) of any specific intended PBPK use in line with Food and Drug Administration and European Medicines Agency PBPK guidance. Qualification packages for pediatric translation are available on the OSP platform.
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Affiliation(s)
- Ibrahim Ince
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals, Bayer AG, Germany
| | - Juri Solodenko
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals, Bayer AG, Germany
| | - Sebastian Frechen
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals, Bayer AG, Germany
| | - André Dallmann
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals, Bayer AG, Germany
| | - Christoph Niederalt
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals, Bayer AG, Germany
| | - Jan Schlender
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals, Bayer AG, Germany
| | - Rolf Burghaus
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals, Bayer AG, Germany
| | - Jörg Lippert
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals, Bayer AG, Germany
| | - Stefan Willmann
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals, Bayer AG, Germany
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21
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van Groen BD, Allegaert K, Tibboel D, de Wildt SN. Innovative approaches and recent advances in the study of ontogeny of drug metabolism and transport. Br J Clin Pharmacol 2020; 88:4285-4296. [PMID: 32851677 PMCID: PMC9545189 DOI: 10.1111/bcp.14534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/10/2020] [Accepted: 08/16/2020] [Indexed: 11/30/2022] Open
Abstract
The disposition of a drug is driven by various processes, such as drug metabolism, drug transport, glomerular filtration and body composition. These processes are subject to developmental changes reflecting growth and maturation along the paediatric continuum. However, knowledge gaps exist on these changes and their clinical impact. Filling these gaps may aid better prediction of drug disposition and creation of age-appropriate dosing guidelines. We present innovative approaches to study these developmental changes in relation to drug metabolism and transport. First, analytical methods such as including liquid chromatography-mass spectrometry for proteomic analyses allow quantitation of the expressions of a wide variety of proteins, e.g. membrane transporters, in a small piece of organ tissue. The latter is specifically important for paediatric research, where tissues are scarcely available. Second, innovative study designs using radioactive labelled microtracers allowed study-without risk for the child-of the oral bioavailability of compounds used as markers for certain drug metabolism pathways. Third, the use of modelling and simulation to support dosing recommendations for children is supported by both the European Medicines Agency and the US Food and Drug Administration. This may even do away with the need for a paediatric trial. Physiologically based pharmacokinetics models, which include age-specific physiological information are, therefore, increasingly being used, not only to aid paediatric drug development but also to improve existing drug therapies.
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Affiliation(s)
- Bianca D van Groen
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Pharmacy and Pharmaceutical Sciences, KU Leuven, Leuven, Belgium.,Department of Clinical Pharmacy, Erasmus MC, Rotterdam, the Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Saskia N de Wildt
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Pharmacology and Toxicology, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
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Integration of physiological changes during the postpartum period into a PBPK framework and prediction of amoxicillin disposition before and shortly after delivery. J Pharmacokinet Pharmacodyn 2020; 47:341-359. [DOI: 10.1007/s10928-020-09706-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 07/21/2020] [Indexed: 12/16/2022]
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Challenges and Opportunities in the Pharmacological Treatment of Acute Venous Thromboembolism in Children. Paediatr Drugs 2020; 22:385-397. [PMID: 32519267 DOI: 10.1007/s40272-020-00403-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Venous thromboembolism (VTE) is an important but historically under-recognized problem in pediatrics, with an incidence concentrated in hospitalized children. A number of specific VTE diseases with discrete triggers have been described, but the most common pediatric trigger is the presence of central venous access devices. VTE diseases, though heterogenous in etiology, are linked by the common therapeutic strategies shared by their management. Historically, the most commonly used drug therapies have been unfractionated heparin, low-molecular-weight heparins, and vitamin K antagonists, based on extrapolation from adult data rather than any specific pediatric trials. Although these widely used drugs appear safe and effective in expert hands, the historical lack of pediatric data is problematic in view of the recognized significant differences between children and adults with regards to hemostatic physiology, VTE etiology, and drug pharmacokinetics. The increasing adult usage of novel VTE pharmacotherapies such as direct oral anticoagulants (DOACs) has led to considerable interest in exploring the pediatric applications of these newer drugs. This review summarizes the advantages and disadvantages of existing VTE pharmacotherapies and outlines emerging novel pediatric VTE therapies, particularly DOACs, within the context of the current pediatric trial landscape.
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Prediction of lisinopril pediatric dose from the reference adult dose by employing a physiologically based pharmacokinetic model. BMC Pharmacol Toxicol 2020; 21:56. [PMID: 32727574 PMCID: PMC7389632 DOI: 10.1186/s40360-020-00429-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 07/02/2020] [Indexed: 01/10/2023] Open
Abstract
Background This study aimed to assess the pediatric lisinopril doses using an adult physiological based pharmacokinetic (PBPK) model. As the empirical rules of dose calculation cannot calculate gender-specific pediatric doses and ignores the age-related physiological differences. Methods A PBPK model of lisinopril for the healthy adult population was developed for oral (fed and fasting) and IV administration using PK-Sim MoBI® and was scaled down to a virtual pediatric population for prediction of lisinopril doses in neonates to infants, infants to toddler, children at pre-school age, children at school age and the adolescents. The pharmacokinetic parameters were predicted for the above groups at decremental doses of 20 mg, 10 mg, 5 mg, 2.5 mg, and 1.5 mg in order to accomplish doses producing the pharmacokinetic parameters, similar (or comparable) to that of the adult population. The above simulated pediatric doses were compared to the doses computed using the conventional four methods, such as Young’s rule, Clark’s rule, and weight-based and body surface area-based equations and the dose reported in different studies. Results Though the doses predicted for all subpopulations of children were comparable to those calculated by Young’s rule, yet the conventional methods overestimated the pediatric doses when compared to the respective PBPK-predicted doses. The findings of previous real time pharmacokinetic studies in pediatric patients supported the present simulated dose. Conclusion Thus, PBPK seems to have predictability potential for pediatric dose since it takes into consideration the physiological changes related to age and gender.
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Young G, Lensing AWA, Monagle P, Male C, Thelen K, Willmann S, Palumbo JS, Kumar R, Nurmeev I, Hege K, Bajolle F, Connor P, Hooimeijer HL, Torres M, Chan AKC, Kenet G, Holzhauer S, Santamaría A, Amedro P, Beyer-Westendorf J, Martinelli I, Massicotte MP, Smith WT, Berkowitz SD, Schmidt S, Price V, Prins MH, Kubitza D. Rivaroxaban for treatment of pediatric venous thromboembolism. An Einstein-Jr phase 3 dose-exposure-response evaluation. J Thromb Haemost 2020; 18:1672-1685. [PMID: 32246743 DOI: 10.1111/jth.14813] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/04/2020] [Accepted: 03/23/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recently, the randomized EINSTEIN-Jr study showed similar efficacy and safety for rivaroxaban and standard anticoagulation for treatment of pediatric venous thromboembolism (VTE). The rivaroxaban dosing strategy was established based on phase 1 and 2 data in children and through pharmacokinetic (PK) modeling. METHODS Rivaroxaban treatment with tablets or the newly developed granules-for-oral suspension formulation was bodyweight-adjusted and administered once-daily, twice-daily, or thrice-daily for children with bodyweights of ≥30, ≥12 to <30, and <12 kg, respectively. Previously, these regimens were confirmed for children weighing ≥20 kg but only predicted in those <20 kg. Based on sparse blood sampling, the daily area under the plasma concentration-time curve [AUC(0-24)ss ] and trough [Ctrough,ss ] and maximum [Cmax,ss ] steady-state plasma concentrations were derived using population PK modeling. Exposure-response graphs were generated to evaluate the potential relationship of individual PK parameters with recurrent VTE, repeat imaging outcomes, and bleeding or adverse events. A taste-and-texture questionnaire was collected for suspension-recipients. RESULTS Of the 335 children (aged 0-17 years) allocated to rivaroxaban, 316 (94.3%) were evaluable for PK analyses. Rivaroxaban exposures were within the adult exposure range. No clustering was observed for any of the PK parameters with efficacy, bleeding, or adverse event outcomes. Results were similar for the tablet and suspension formulation. Acceptability and palatability of the suspension were favorable. DISCUSSION Based on this analysis and the recently documented similar efficacy and safety of rivaroxaban compared with standard anticoagulation, we conclude that bodyweight-adjusted pediatric rivaroxaban regimens with either tablets or suspension are validated and provide for appropriate treatment of children with VTE.
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Affiliation(s)
- Guy Young
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | | | - Paul Monagle
- Department of Clinical Haematology, Royal Children's Hospital, Haematology Research Murdoch Children's Research Institute, Parkville, Vic., Australia
- Department of Paediatrics, University of Melbourne, Parkville, Vic., Australia
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | | | | | - Joseph S Palumbo
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Riten Kumar
- Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | | | - Kerry Hege
- Riley Hospital For Children at IU Health, Indianapolis, IN, USA
| | - Fanny Bajolle
- M3C-Necker Enfants malades, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Philip Connor
- The Noah's Ark Children's Hospital for Wales, Cardiff, UK
| | - Hélène L Hooimeijer
- Department of Hematology and Oncology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Marcela Torres
- Department of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX, USA
| | | | - Gili Kenet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Israeli National Hemophilia Center and Thrombosis Unit, The Amalia Biron Thrombosis Research Institute, Sheba Medical Center, Tel Hashomer, Israel
| | - Susanne Holzhauer
- Department of Pediatric Hematology and Oncology, Charité University Medicine, Berlin, Germany
| | - Amparo Santamaría
- Hemostasis and Thrombosis Unit, Department of Hematology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Pascal Amedro
- Paediatric and Congenital Cardiology Department, M3C Regional Reference Centre, Montpellier University Hospital, PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Jan Beyer-Westendorf
- Division of Haematology and Haemostaseology, Department of Medicine I, Department of Haematology, University Hospital "Carl Gustav Carus" Dresden, King's Thrombosis Service, King's College London, London, UK
| | - Ida Martinelli
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milano, Italy
| | | | | | | | - Stephan Schmidt
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, University of Florida, OR, USA
| | - Victoria Price
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Dalhousie University, IWK Health Centre, Halifax, NS, Canada
| | - Martin H Prins
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
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Physiologically-based pharmacokinetic models for children: Starting to reach maturation? Pharmacol Ther 2020; 211:107541. [DOI: 10.1016/j.pharmthera.2020.107541] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 03/19/2020] [Indexed: 12/13/2022]
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Rivaroxaban compared with standard anticoagulants for the treatment of acute venous thromboembolism in children: a randomised, controlled, phase 3 trial. LANCET HAEMATOLOGY 2019; 7:e18-e27. [PMID: 31699660 DOI: 10.1016/s2352-3026(19)30219-4] [Citation(s) in RCA: 150] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/03/2019] [Accepted: 09/04/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Treatment of venous thromboembolism in children is based on data obtained in adults with little direct documentation of its efficacy and safety in children. The aim of our study was to compare the efficacy and safety of rivaroxaban versus standard anticoagulants in children with venous thromboembolism. METHODS In a multicentre, parallel-group, open-label, randomised study, children (aged 0-17 years) attending 107 paediatric hospitals in 28 countries with documented acute venous thromboembolism who had started heparinisation were assigned (2:1) to bodyweight-adjusted rivaroxaban (tablets or suspension) in a 20-mg equivalent dose or standard anticoagulants (heparin or switched to vitamin K antagonist). Randomisation was stratified by age and venous thromboembolism site. The main treatment period was 3 months (1 month in children <2 years of age with catheter-related venous thromboembolism). The primary efficacy outcome, symptomatic recurrent venous thromboembolism (assessed by intention-to-treat), and the principal safety outcome, major or clinically relevant non-major bleeding (assessed in participants who received ≥1 dose), were centrally assessed by investigators who were unaware of treatment assignment. Repeat imaging was obtained at the end of the main treatment period and compared with baseline imaging tests. This trial is registered with ClinicalTrials.gov, number NCT02234843 and has been completed. FINDINGS From Nov 14, 2014, to Sept 28, 2018, 500 (96%) of the 520 children screened for eligibility were enrolled. After a median follow-up of 91 days (IQR 87-95) in children who had a study treatment period of 3 months (n=463) and 31 days (IQR 29-35) in children who had a study treatment period of 1 month (n=37), symptomatic recurrent venous thromboembolism occurred in four (1%) of 335 children receiving rivaroxaban and five (3%) of 165 receiving standard anticoagulants (hazard ratio [HR] 0·40, 95% CI 0·11-1·41). Repeat imaging showed an improved effect of rivaroxaban on thrombotic burden as compared with standard anticoagulants (p=0·012). Major or clinically relevant non-major bleeding in participants who received ≥1 dose occurred in ten (3%) of 329 children (all non-major) receiving rivaroxaban and in three (2%) of 162 children (two major and one non-major) receiving standard anticoagulants (HR 1·58, 95% CI 0·51-6·27). Absolute and relative efficacy and safety estimates of rivaroxaban versus standard anticoagulation estimates were similar to those in rivaroxaban studies in adults. There were no treatment-related deaths. INTERPRETATION In children with acute venous thromboembolism, treatment with rivaroxaban resulted in a similarly low recurrence risk and reduced thrombotic burden without increased bleeding, as compared with standard anticoagulants. FUNDING Bayer AG and Janssen Research & Development.
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Schlender JF, Teutonico D, Coboeken K, Schnizler K, Eissing T, Willmann S, Jaehde U, Stass H. A Physiologically-Based Pharmacokinetic Model to Describe Ciprofloxacin Pharmacokinetics Over the Entire Span of Life. Clin Pharmacokinet 2019; 57:1613-1634. [PMID: 29737457 PMCID: PMC6267540 DOI: 10.1007/s40262-018-0661-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Physiologically-based pharmacokinetic (PBPK) modeling has received growing interest as a useful tool for the assessment of drug pharmacokinetics by continuous knowledge integration. Objective The objective of this study was to build a ciprofloxacin PBPK model for intravenous and oral dosing based on a comprehensive literature review, and evaluate the predictive performance towards pediatric and geriatric patients. Methods The aim of this report was to establish confidence in simulations of the ciprofloxacin PBPK model along the development process to facilitate reliable predictions outside of the tested adult age range towards the extremes of ages. Therefore, mean data of 69 published clinical trials were identified and integrated into the model building, simulation and verification process. The predictive performance on both ends of the age scale was assessed using individual data of 258 subjects observed in own clinical trials. Results Ciprofloxacin model verification demonstrated no concentration-related bias and accurate simulations for the adult age range, with only 4.8% of the mean observed data points for intravenous administration and 12.1% for oral administration being outside the simulated twofold range. Predictions towards the extremes of ages for the area under the plasma concentration–time curve (AUC) and the maximum plasma concentration (Cmax) over the entire span of life revealed a reliable estimation, with only two pediatric AUC observations outside the 90% prediction interval. Conclusion Overall, this ciprofloxacin PBPK modeling approach demonstrated the predictive power of a thoroughly informed middle-out approach towards age groups of interest to potentially support the decision-making process. Electronic supplementary material The online version of this article (10.1007/s40262-018-0661-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jan-Frederik Schlender
- Institute of Pharmacy, Clinical Pharmacy, University of Bonn, Bonn, Germany.
- Systems Pharmacology and Medicine, Bayer AG, 51373, Leverkusen, Germany.
| | - Donato Teutonico
- Systems Pharmacology and Medicine, Bayer AG, 51373, Leverkusen, Germany
- Division of Clinical Pharmacokinetics and Pharmacometrics, Institut de Recherches Internationales Servier, Suresnes, France
| | - Katrin Coboeken
- Systems Pharmacology and Medicine, Bayer AG, 51373, Leverkusen, Germany
| | - Katrin Schnizler
- Systems Pharmacology and Medicine, Bayer AG, 51373, Leverkusen, Germany
| | - Thomas Eissing
- Systems Pharmacology and Medicine, Bayer AG, 51373, Leverkusen, Germany
| | | | - Ulrich Jaehde
- Institute of Pharmacy, Clinical Pharmacy, University of Bonn, Bonn, Germany
| | - Heino Stass
- Clinical Pharmacology, Bayer AG, Wuppertal, Germany
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Baier V, Cordes H, Thiel C, Castell JV, Neumann UP, Blank LM, Kuepfer L. A Physiology-Based Model of Human Bile Acid Metabolism for Predicting Bile Acid Tissue Levels After Drug Administration in Healthy Subjects and BRIC Type 2 Patients. Front Physiol 2019; 10:1192. [PMID: 31611804 PMCID: PMC6777137 DOI: 10.3389/fphys.2019.01192] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 09/03/2019] [Indexed: 12/23/2022] Open
Abstract
Drug-induced liver injury (DILI) is a matter of concern in the course of drug development and patient safety, often leading to discontinuation of drug-development programs or early withdrawal of drugs from market. Hepatocellular toxicity or impairment of bile acid (BA) metabolism, known as cholestasis, are the two clinical forms of DILI. Whole-body physiology-based modelling allows a mechanistic investigation of the physiological processes leading to cholestasis in man. Objectives of the present study were: (1) the development of a physiology-based model of the human BA metabolism, (2) population-based model validation and characterisation, and (3) the prediction and quantification of altered BA levels in special genotype subgroups and after drug administration. The developed physiology-based bile acid (PBBA) model describes the systemic BA circulation in humans and includes mechanistically relevant active and passive processes such as the hepatic synthesis, gallbladder emptying, transition through the gastrointestinal tract, reabsorption into the liver, distribution within the whole body, and excretion via urine and faeces. The kinetics of active processes were determined for the exemplary BA glycochenodeoxycholic acid (GCDCA) based on blood plasma concentration-time profiles. The robustness of our PBBA model was verified with population simulations of healthy individuals. In addition to plasma levels, the possibility to estimate BA concentrations in relevant tissues like the intracellular space of the liver enhance the mechanistic understanding of cholestasis. We analysed BA levels in various tissues of Benign Recurrent Intrahepatic Cholestasis type 2 (BRIC2) patients and our simulations suggest a higher susceptibility of BRIC2 patients toward cholestatic DILI due to BA accumulation in the liver. The effect of drugs on systemic BA levels were simulated for cyclosporine A (CsA). Our results confirmed the higher risk of DILI after CsA administration in healthy and BRIC2 patients. The presented PBBA model enhances our mechanistic understanding underlying cholestasis and drug-induced alterations of BA levels in blood and organs. The developed PBBA model might be applied in the future to anticipate potential risk of cholestasis in patients.
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Affiliation(s)
- Vanessa Baier
- Institute of Applied Microbiology (iAMB), Aachen Biology and Biotechnology (ABBt), RWTH Aachen University, Aachen, Germany.,Department of Surgery, University Hospital Aachen, Aachen, Germany
| | - Henrik Cordes
- Institute of Applied Microbiology (iAMB), Aachen Biology and Biotechnology (ABBt), RWTH Aachen University, Aachen, Germany
| | - Christoph Thiel
- Institute of Applied Microbiology (iAMB), Aachen Biology and Biotechnology (ABBt), RWTH Aachen University, Aachen, Germany
| | - José V Castell
- Unit of Experimental Hepatology, IIS Hospital La Fe, Faculty of Medicine, University of Valencia and CIBEREHD, Valencia, Spain
| | - Ulf P Neumann
- Department of Surgery, University Hospital Aachen, Aachen, Germany
| | - Lars M Blank
- Institute of Applied Microbiology (iAMB), Aachen Biology and Biotechnology (ABBt), RWTH Aachen University, Aachen, Germany
| | - Lars Kuepfer
- Institute of Applied Microbiology (iAMB), Aachen Biology and Biotechnology (ABBt), RWTH Aachen University, Aachen, Germany
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Monagle P, Lensing AWA, Thelen K, Martinelli I, Male C, Santamaría A, Samochatova E, Kumar R, Holzhauer S, Saracco P, Simioni P, Robertson J, Grangl G, Halton J, Connor P, Young G, Molinari AC, Nowak-Göttl U, Kenet G, Kapsa S, Willmann S, Pap AF, Becka M, Twomey T, Beyer-Westendorf J, Prins MH, Kubitza D. Bodyweight-adjusted rivaroxaban for children with venous thromboembolism (EINSTEIN-Jr): results from three multicentre, single-arm, phase 2 studies. LANCET HAEMATOLOGY 2019; 6:e500-e509. [PMID: 31420317 DOI: 10.1016/s2352-3026(19)30161-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/10/2019] [Accepted: 06/13/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rivaroxaban has been shown to be efficacious for treatment of venous thromboembolism in adults, and has a reduced risk of bleeding compared with standard anticoagulants. We aimed to develop paediatric rivaroxaban regimens for the treatment of venous thromboembolism in children and adolescents. METHODS In this phase 2 programme, we did three studies to evaluate rivaroxaban treatment in children younger than 6 months, aged 6 months to 5 years, and aged 6-17 years. Our studies used a multicentre, single-arm design at 54 sites in Australia, Europe, Israel, Japan, and north America. We included children with objectively confirmed venous thromboembolism previously treated with low-molecular weight heparin, fondaparinux, or a vitamin K antagonist for at least 2 months or, in children who had catheter-related venous thromboembolism for at least 6 weeks. We administered rivaroxaban orally in a bodyweight-adjusted 20 mg-equivalent dose, based on physiologically-based pharmacokinetic modelling predictions and EINSTEIN-Jr phase 1 data in young adults, in either a once-daily (tablets; for those aged 6-17 years), twice-daily (in suspension; for those aged 6 months to 11 years), or three times-daily (in suspension; for those younger than 6 months) dosing regimen for 30 days (or 7 days for those younger than 6 months). The primary aim was to define rivaroxaban treatment regimens that match the target adult exposure range. The principal safety outcome was major bleeding and clinically relevant non-major bleeding. Analyses were per-protocol. The predefined efficacy outcomes were symptomatic recurrent venous thromboembolism, asymptomatic deterioration on repeat imaging at the end of the study treatment period. These trials are registered at ClinicalTrials.gov, numbers NCT02564718, NCT02309411, and NCT02234843. FINDINGS Between Feb 11, 2013, and Dec 20, 2017, we enrolled 93 children (ten children younger than 6 months; 15 children aged 6 months to 1 year; 25 children aged 2-5 years; 32 children aged 6-11 years; and 11 children aged 12-17 years) into our study. 89 (96%) children completed study treatment (30 days of treatment, or 7 days in those younger than 6 months), and 93 (100%) children received at least one dose of study treatment and were evaluable for the primary endpoints. None of the children had a major bleed, and four (4%, 95% CI 1·2-10·6) of these children had a clinically relevant non-major bleed (three children aged 12-17 years with menorrhagia and one child aged 6-11 years with gingival bleeding). We found no symptomatic recurrent venous thromboembolism in any patients (0%, 0·0-3·9). 24 (32%) of 75 patients with repeat imaging had their thrombotic burden resolved, 43 (57%) patients improved, and eight (11%) patients were unchanged. No patient deteriorated. We confirmed therapeutic rivaroxaban exposures with once-daily dosing in children with bodyweights of at least 30 kg and with twice-daily dosing in children with bodyweights of at least 20 kg and less than 30 kg. Children with low bodyweights (<20 kg, particularly <12 kg) showed low exposures so, for future studies, rivaroxaban dosages were revised for these weight categories, to match the target adult exposure range. 61 (66%) of 93 children had adverse events during the study. Pyrexia was the most common adverse event (ten [11%] events), and anaemia and neutropenia or febrile neutropenia were the most frequent grade 3 or worse events (four [4%] events each). No children died or were discontinued from rivaroxaban because of adverse events. INTERPRETATION Treatment with bodyweight-adjusted rivaroxaban appears to be safe in children. The treatment regimens that we confirmed in children with bodyweights of at least 20 kg and the revised treatment regimens that we predicted in those with bodyweights less than 20 kg will be evaluated in the EINSTEIN-Jr phase 3 trial in children with acute venous thromboembolism. FUNDING Bayer AG, Janssen Research and Development.
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Affiliation(s)
- Paul Monagle
- Department of Clinical Haematology, Royal Children's Hospital, Haematology Research Murdoch Children's Research Institute, and Department of Paediatrics, University of Melbourne, VIC, Australia
| | | | | | - Ida Martinelli
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Amparo Santamaría
- Department of Thrombosis and Haemostasis, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Elena Samochatova
- Federal Research and Clinical Centre of Paediatric Haematology, Oncology and Immunology, Moscow, Russia
| | - Riten Kumar
- Division of Pediatric Hematology and Oncology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Susanne Holzhauer
- Department of Paediatric Haematology and Oncology, Charité-Universitätsmedizin, Berlin, Germany
| | - Paola Saracco
- Department of Paediatrics, Haematology Unit, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza Torino, Turin, Italy
| | - Paolo Simioni
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Jeremy Robertson
- Haematology Service, Division of Medicine, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Gernot Grangl
- Department of Paediatrics and Adolescence Medicine, Division of Paediatric Cardiology, Medical University of Graz, Graz, Austria
| | - Jacqueline Halton
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Phillip Connor
- The Noah's Ark Children's Hospital for Wales, Cardiff, UK
| | - Guy Young
- Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Angelo C Molinari
- Thrombosis and Haemostasis Unit, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Ulrike Nowak-Göttl
- Thrombosis and Haemostasis Treatment Centre, Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Gili Kenet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Israeli National Haemophilia Centre and Thrombosis Unit and The Amalia Biron Thrombosis Research Institute, Sheba Medical Centre, Tel Hashomer, Israel
| | | | | | | | | | | | - Jan Beyer-Westendorf
- Department of Medicine I, Division of Haematology and Haemostaseology, University Hospital Carl Gustav Carus, Dresden, Germany; King's Thrombosis Service, Department of Haematology, King's College London, London, UK
| | - Martin H Prins
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
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Willmann S, Frei M, Sutter G, Coboeken K, Wendl T, Eissing T, Lippert J, Stass H. Application of Physiologically-Based and Population Pharmacokinetic Modeling for Dose Finding and Confirmation During the Pediatric Development of Moxifloxacin. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2019; 8:654-663. [PMID: 31310051 PMCID: PMC6765696 DOI: 10.1002/psp4.12446] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/15/2019] [Indexed: 12/14/2022]
Abstract
Moxifloxacin is a widely used fluoroquinolone for the treatment of complicated intra‐abdominal infections. We applied physiologically‐based pharmacokinetic (PBPK) and population pharmacokinetic (popPK) modeling to support dose selection in pediatric patients. We scaled an existing adult PBPK model to children based on prior physiological knowledge. The resulting model proposed an age‐dependent dosing regimen that was tested in a phase I study. Refined doses were then tested in a phase III study. A popPK analysis of all clinical pediatric data confirmed the PBPK predictions, including the proposed dosing schedule in children, and supported pharmacokinetics‐related safety/efficacy questions. The pediatric PBPK model adequately predicted the doses necessary to achieve antimicrobial efficacy while maintaining safety in the phase I and III pediatric studies. Altogether, this study retroactively demonstrated the robustness and utility of modeling to support dose finding and confirmation in pediatric drug development for moxifloxacin.
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Affiliation(s)
- Stefan Willmann
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals Bayer AG, Wuppertal, Germany
| | - Matthias Frei
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals Bayer AG, Berlin, Germany
| | - Gabriele Sutter
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals Bayer AG, Berlin, Germany
| | - Katrin Coboeken
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals Bayer AG, Leverkusen, Germany
| | - Thomas Wendl
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals Bayer AG, Leverkusen, Germany
| | - Thomas Eissing
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals Bayer AG, Leverkusen, Germany
| | - Jörg Lippert
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals Bayer AG, Wuppertal, Germany
| | - Heino Stass
- Clinical Pharmacology, Research & Development, Pharmaceuticals Bayer AG, Wuppertal, Germany
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Nicolas JM, de Lange ECM. Mind the Gaps: Ontogeny of Human Brain P-gp and Its Impact on Drug Toxicity. AAPS JOURNAL 2019; 21:67. [PMID: 31140038 DOI: 10.1208/s12248-019-0340-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 05/10/2019] [Indexed: 12/18/2022]
Abstract
Available data on human brain P-glycoprotein ontogeny during infancy and childhood are limited. This review discusses the current body of data relating to maturation of human brain P-glycoprotein including transporter expression levels in post-mortem human brain samples, in vivo transporter activity using probe substrates, surrogate marker endpoints, and extrapolations from animal models. Overall, the data tend to confirm that human brain P-glycoprotein activity keeps developing after birth, although with a developmental time frame that remains unclear. This knowledge gap is a concern given the critical role of brain P-glycoprotein in drug safety and efficacy, and the vulnerable nature of the pediatric population. Future research could include the measurement of brain P-glycoprotein activity across age groups using positron emission tomography or central pharmacodynamic responses. For now, caution is advised when extrapolating adult data to children aged younger than 2 years for drugs with P-glycoprotein-dependent central nervous system activity.
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Affiliation(s)
- Jean-Marie Nicolas
- Quantitative Pharmacology DMPK Department, UCB BioPharma, Chemin du Foriest, 1420, Braine L'Alleud, Belgium.
| | - Elizabeth C M de Lange
- Research Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
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Hanke N, Kunz C, Thiemann M, Fricke H, Lehr T. Translational PBPK Modeling of the Protein Therapeutic and CD95L Inhibitor Asunercept to Develop Dose Recommendations for Its First Use in Pediatric Glioblastoma Patients. Pharmaceutics 2019; 11:pharmaceutics11040152. [PMID: 30939793 PMCID: PMC6523206 DOI: 10.3390/pharmaceutics11040152] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 03/19/2019] [Accepted: 03/22/2019] [Indexed: 11/18/2022] Open
Abstract
The protein therapeutic and CD95L inhibitor asunercept is currently under clinical investigation for the treatment of glioblastoma and myelodysplastic syndrome. The purpose of this study was to predict the asunercept pharmacokinetics in children and to give dose recommendations for its first use in pediatric glioblastoma patients. A physiologically-based pharmacokinetic (PBPK) model of asunercept in healthy and diseased adults was successfully developed using the available clinical Phase I and Phase II study data. This model was then extrapolated to different pediatric populations, to predict the asunercept exposure in children and to find equivalent starting doses. Simulation of the asunercept serum concentration-time curves in children between 1–18 years of age shows that a dosing regimen based on body weight results in a similar asunercept steady-state exposure in all patients (pediatric or adult) above 12 years of age. For children between 1–12 years, higher doses per kg body weight are recommended, with the highest dose for the very young patients. Translational PBPK modeling is strongly encouraged by regulatory agencies to help with the initial dose selection for pediatric trials. To our knowledge, this is the first report of pediatric PBPK to support the dose selection of a therapeutic protein before its administration to children.
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Affiliation(s)
- Nina Hanke
- Clinical Pharmacy, Saarland University, 66123 Saarbrücken, Germany.
| | | | | | | | - Thorsten Lehr
- Clinical Pharmacy, Saarland University, 66123 Saarbrücken, Germany.
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Abouhussein DMN, Bahaa El Din Mahmoud D, Mohammad F E. Design of a liquid nano-sized drug delivery system with enhanced solubility of rivaroxaban for venous thromboembolism management in paediatric patients and emergency cases. J Liposome Res 2019; 29:399-412. [PMID: 30720378 DOI: 10.1080/08982104.2019.1576732] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The increasing incidence of venous thromboembolism (VTE) in paediatric population has stimulated the development of liquid anticoagulant formulations. Thus our goal is to formulate a liquid formulation of poorly-water soluble anticoagulant, rivaroxaban (RIVA), for paediatric use and to assess the possibility of its intravenous administration in emergencies. Self-nanoemulsifying drug delivery systems (SNEDDSs) were developed and characterized. SNEDDS constituents were estimated from the saturated solubility study followed by plotting the corresponding ternary phase diagrams to determine the best self-emulsified systems. Thermodynamic stability, emulsification, dispersibility, robustness to dilution tests, in vitro dissolution, particle size, and zeta potential were executed to optimize the formulations. The optimized formulation, that composed of Capryol 90:Tween 20:PEG 300 (5:45:50), increased RIVA solubility (285.7-fold than water), it formed nanoemulsion with a particle size of 16.15 nm, PDI of 0.25 and zeta potential of -21.8. It released 100.83 ± 2.78% of RIVA after 5 min. SNEDDS was robust to dilution with oral and parenteral fluids and showed safety to human RBCs. SNEDDS showed enhanced bioavailability after oral and intravenous administration than the oral drug suspension (by 1.25 and 1.26-fold, respectively). Moreover, it exhibited enhanced anticoagulant efficacy in the prevention and treatment of carrageenan-induced thrombosis rat model.
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Affiliation(s)
- Dalia M N Abouhussein
- Pharmaceutics Department, National Organization for Drug Control and Research (NODCAR) , Giza , Egypt
| | - Dina Bahaa El Din Mahmoud
- Pharmaceutics Department, National Organization for Drug Control and Research (NODCAR) , Giza , Egypt
| | - Ebtehal Mohammad F
- Department of Pharmacology, National Organization for Drug Control and Research (NODCAR) , Giza , Egypt
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Stass H, Lettieri J, Vanevski KM, Willmann S, James LP, Sullivan JE, Arrieta AC, Bradley JS. Pharmacokinetics, Safety, and Tolerability of Single‐Dose Intravenous Moxifloxacin in Pediatric Patients: Dose Optimization in a Phase 1 Study. J Clin Pharmacol 2019; 59:654-667. [DOI: 10.1002/jcph.1358] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 11/25/2018] [Indexed: 12/14/2022]
Affiliation(s)
| | | | | | | | - Laura P. James
- Department of PediatricsUniversity of Arkansas for Medical Science and Arkansas Children's Research Institute Little Rock AR USA
| | - Janice E. Sullivan
- University of Louisville/Kosair Charities Pediatric Clinical Research Unit/Norton Children's Hospital Louisville KY USA
| | | | - John S. Bradley
- University of CaliforniaSan Diego School of Medicine and Rady Children's Hospital San Diego San Diego CA USA
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Male C, Thom K, O'Brien SH. Direct oral anticoagulants: What will be their role in children? Thromb Res 2019; 173:178-185. [DOI: 10.1016/j.thromres.2018.06.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/16/2018] [Accepted: 06/26/2018] [Indexed: 01/01/2023]
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Lensing AWA, Male C, Young G, Kubitza D, Kenet G, Patricia Massicotte M, Chan A, Molinari AC, Nowak-Goettl U, Pap ÁF, Adalbo I, Smith WT, Mason A, Thelen K, Berkowitz SD, Crowther M, Schmidt S, Price V, Prins MH, Monagle P. Rivaroxaban versus standard anticoagulation for acute venous thromboembolism in childhood. Design of the EINSTEIN-Jr phase III study. Thromb J 2018; 16:34. [PMID: 30598642 PMCID: PMC6302520 DOI: 10.1186/s12959-018-0188-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 11/19/2018] [Indexed: 12/03/2022] Open
Abstract
Background Venous thromboembolism (VTE) is a relatively rare condition in childhood with treatment mainly based on extrapolation from studies in adults. Therefore, clinical trials of anticoagulation in children require novel approaches to deal with numerous challenges. The EINSTEIN-Jr program identified pediatric rivaroxaban regimens commencing with in vitro dose finding studies followed by evaluation of children of different ages through phase I and II studies using extensive modeling to determine bodyweight-related doses. Use of this approach resulted in drug exposure similar to that observed in young adults treated with rivaroxaban 20 mg once-daily. Methods EINSTEIN-Jr phase III is a randomized, open-label, study comparing the efficacy and safety of rivaroxaban 20 mg-equivalent dose regimens with those of standard anticoagulation for the treatment of any types of acute VTE in children aged 0–18 years. A total of approximately 500 children are expected to be included during the 4-year study window. Flexibility of treatment duration is allowed with study treatment to be given for 3 months with the option to continue treatment in 3-month increments, up to a total of 12 months. However, based on most common current practice, children younger than 2 years with catheter-related thrombosis will have a main treatment period of 1 month with the option to prolong treatment in 1-month increments, up to a total of 3 months. Conclusions EINSTEIN-Jr will compare previously established 20 mg-equivalent rivaroxaban dosing regimens with standard anticoagulation for the treatment of VTE in children. Demonstration of similarity of disease, as well as equivalent rivaroxaban exposure and exposure-response will enable extrapolation of efficacy from adult trials, which is critical given the challenges of enrollment in pediatric anticoagulation trials. Trial registration Clinicaltrials.gov NCT02234843, registered on 9 September 2014.
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Affiliation(s)
- Anthonie W A Lensing
- 1Bayer AG, Research and Development, Thrombosis and Hematology, Building 402, room 304, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Christoph Male
- 2Department of Paediatrics, Medical University of Vienna, Wien, Austria
| | - Guy Young
- 3Children's Hospital Los Angeles, Los Angeles, USA
| | - Dagmar Kubitza
- 1Bayer AG, Research and Development, Thrombosis and Hematology, Building 402, room 304, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Gili Kenet
- 4Sheba Medical Center, TelHashomer, Israel
| | | | - Anthony Chan
- 6Department of Pediatrics, McMaster University, Hamilton, Canada
| | | | | | - Ákos F Pap
- 1Bayer AG, Research and Development, Thrombosis and Hematology, Building 402, room 304, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Ivet Adalbo
- 1Bayer AG, Research and Development, Thrombosis and Hematology, Building 402, room 304, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - William T Smith
- 1Bayer AG, Research and Development, Thrombosis and Hematology, Building 402, room 304, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Amy Mason
- 1Bayer AG, Research and Development, Thrombosis and Hematology, Building 402, room 304, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Kirstin Thelen
- 1Bayer AG, Research and Development, Thrombosis and Hematology, Building 402, room 304, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Scott D Berkowitz
- 1Bayer AG, Research and Development, Thrombosis and Hematology, Building 402, room 304, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Mark Crowther
- 9Department of Medicine, Hematology and Thromboembolism McMaster University, Hamilton, ON Canada
| | - Stephan Schmidt
- 10Center for Pharmacometrics & Systems Pharmacology, Department of Pharmaceutics University of Florida, Orlando, FL USA
| | - Victoria Price
- 11Department of Pediatrics, Division of Pediatric Hematology-Oncology Dalhousie University, Halifax, Canada
| | - Martin H Prins
- 12Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Paul Monagle
- Royal Children's Hospital, University of Melbourne, Murdoch Childrens Research Institute, Melbourne, Australia
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Kubitza D, Willmann S, Becka M, Thelen K, Young G, Brandão LR, Monagle P, Male C, Chan A, Kennet G, Martinelli I, Saracco P, Lensing AWA. Exploratory evaluation of pharmacodynamics, pharmacokinetics and safety of rivaroxaban in children and adolescents: an EINSTEIN-Jr phase I study. Thromb J 2018; 16:31. [PMID: 30534007 PMCID: PMC6278122 DOI: 10.1186/s12959-018-0186-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 10/29/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The EINSTEIN-Jr program will evaluate rivaroxaban for the treatment of venous thromboembolism (VTE) in children, targeting exposures similar to the 20 mg once-daily dose for adults. METHODS This was a multinational, single-dose, open-label, phase I study to describe the pharmacodynamics (PD), pharmacokinetics (PK) and safety of a single bodyweight-adjusted rivaroxaban dose in children aged 0.5-18 years. Children who had completed treatment for a venous thromboembolic event were enrolled into four age groups (0.5-2 years, 2-6 years, 6-12 years and 12-18 years) receiving rivaroxaban doses equivalent to 10 mg or 20 mg (either as a tablet or oral suspension). Blood samples for PK and PD analyses were collected within specified time windows. RESULTS Fifty-nine children were evaluated. In all age groups, PD parameters (prothrombin time, activated partial thromboplastin time and anti-Factor Xa activity) showed a linear relationship versus rivaroxaban plasma concentrations and were in line with previously acquired adult data, as well as in vitro spiking experiments. The rivaroxaban pediatric physiologically based pharmacokinetic model, used to predict the doses for the individual body weight groups, was confirmed. No episodes of bleeding were reported, and treatment-emergent adverse events occurred in four children and all resolved during the study. CONCLUSIONS Bodyweight-adjusted, single-dose rivaroxaban had predictable PK/PD profiles in children across all age groups from 0.5 to 18 years. The PD assessments based on prothrombin time and activated partial thromboplastin time demonstrated that the anticoagulant effect of rivaroxaban was not affected by developmental hemostasis in children. TRIAL REGISTRATION ClinicalTrials.gov number, NCT01145859.
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Affiliation(s)
- Dagmar Kubitza
- Bayer AG, Global Drug Discovery – Clinical Sciences, Clinical Pharmacology Cardiovascular, Aprather Weg 18a, Gebäude 429, 42113 Wuppertal, Germany
| | - Stefan Willmann
- Bayer AG, Global Drug Discovery – Clinical Sciences, Clinical Pharmacology Cardiovascular, Aprather Weg 18a, Gebäude 429, 42113 Wuppertal, Germany
| | - Michael Becka
- Research and Clinical Sciences, Bayer AG, Wuppertal, Germany
| | - Kirstin Thelen
- Bayer AG, Global Drug Discovery – Clinical Sciences, Clinical Pharmacology Cardiovascular, Aprather Weg 18a, Gebäude 429, 42113 Wuppertal, Germany
| | - Guy Young
- Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA USA
| | - Leonardo R. Brandão
- Department of Paediatrics, Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Paul Monagle
- Department of Haematology Royal Children’s Hospital, Department of Paediatrics, University of Melbourne, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Christoph Male
- Thrombosis & Haemostasis Unit, Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Anthony Chan
- McMaster Children’s Hospital/Hamilton Health Sciences Foundation Pediatric Thrombosis and Hemostasis, Hamilton, Canada
| | - Gili Kennet
- National Hemophilia Center & Thrombosis Institute, Sheba Medical Center, Ramat Gan, Israel
| | - Ida Martinelli
- A.Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Saracco
- Pediatric Hematology, University Hospital Città della Salute e della Scienza, Torino, Italy
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Willmann S, Thelen K, Kubitza D, Lensing AWA, Frede M, Coboeken K, Stampfuss J, Burghaus R, Mück W, Lippert J. Pharmacokinetics of rivaroxaban in children using physiologically based and population pharmacokinetic modelling: an EINSTEIN-Jr phase I study. Thromb J 2018; 16:32. [PMID: 30534008 PMCID: PMC6278136 DOI: 10.1186/s12959-018-0185-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 10/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The EINSTEIN-Jr program will evaluate rivaroxaban for the treatment of venous thromboembolism (VTE) in children, targeting exposures similar to the 20 mg once-daily dose for adults. A physiologically based pharmacokinetic (PBPK) model for pediatric rivaroxaban dosing has been constructed. METHODS We quantitatively assessed the pharmacokinetics (PK) of a single rivaroxaban dose in children using population pharmacokinetic (PopPK) modelling and assessed the applicability of the PBPK model. Plasma concentration-time data from the EINSTEIN-Jr phase I study were analysed by non-compartmental and PopPK analyses and compared with the predictions of the PBPK model. Two rivaroxaban dose levels, equivalent to adult doses of rivaroxaban 10 mg and 20 mg, and two different formulations (tablet and oral suspension) were tested in children aged 0.5-18 years who had completed treatment for VTE. RESULTS PK data from 59 children were obtained. The observed plasma concentration-time profiles in all subjects were mostly within the 90% prediction interval, irrespective of dose or formulation. The PopPK estimates and non-compartmental analysis-derived PK parameters (in children aged ≥6 years) were in good agreement with the PBPK model predictions. CONCLUSIONS These results confirmed the applicability of the rivaroxaban pediatric PBPK model in the pediatric population aged 0.5-18 years, which in combination with the PopPK model, will be further used to guide dose selection for the treatment of VTE with rivaroxaban in EINSTEIN-Jr phase II and III studies. TRIAL REGISTRATION ClinicalTrials.gov number, NCT01145859; registration date: 17 June 2010.
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Affiliation(s)
- Stefan Willmann
- Clinical Sciences, Bayer AG, Bayer AG, Aprather Weg 18a, Wuppertal, Germany
| | - Kirstin Thelen
- Clinical Sciences, Bayer AG, Bayer AG, Aprather Weg 18a, Wuppertal, Germany
| | - Dagmar Kubitza
- Clinical Sciences, Bayer AG, Bayer AG, Aprather Weg 18a, Wuppertal, Germany
| | | | - Matthias Frede
- Clinical Sciences, Bayer AG, Bayer AG, Aprather Weg 18a, Wuppertal, Germany
| | | | | | - Rolf Burghaus
- Clinical Sciences, Bayer AG, Bayer AG, Aprather Weg 18a, Wuppertal, Germany
| | | | - Jörg Lippert
- Clinical Pharmacometrics, Bayer AG, Leverkusen, Germany
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Pollak U. Heparin-induced thrombocytopenia complicating extracorporeal membrane oxygenation support in pediatric patients: review of the literature and alternative anticoagulants. Perfusion 2018; 33:7-17. [PMID: 29788841 DOI: 10.1177/0267659118766723] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a prothrombotic, immune-mediated complication of unfractionated heparin (UFH) and low molecular weight heparin therapy. HIT is characterized by moderate thrombocytopenia 5-10 days after initial heparin exposure, detection of platelet-activating anti-platelet factor 4/heparin antibodies and an increased risk of venous and arterial thrombosis. Extracorporeal membrane oxygenation (ECMO) is a form of mechanical circulatory support used in critically ill patients with respiratory or cardiac failure. Systemic anticoagulation is used to alleviate the thrombotic complications that may occur when blood is exposed to artificial surfaces within the ECMO circuit. Therefore, when HIT complicates patients on ECMO support, it is associated with a high thrombotic morbidity and mortality. The following article reviews the current knowledge in pediatric HIT, especially in ECMO patients, and the alternative anticoagulation options in the presence of HIT.
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Affiliation(s)
- Uri Pollak
- 1 Pediatric Cardiac Intensive Care Unit, The Edmond J Safra International Congenital Heart Center; The Edmond and Lily Safra Children's Hospital; The Chaim Sheba Medical Center, Tel Hashomer, Israel.,2 Pediatric Cardiology, The Edmond J Safra International Congenital Heart Center; The Edmond and Lily Safra Children's Hospital; The Chaim Sheba Medical Center, Tel Hashomer, Israel.,3 ECMO service, The Edmond J Safra International Congenital Heart Center; The Edmond and Lily Safra Children's Hospital; The Chaim Sheba Medical Center, Tel Hashomer, Israel.,4 The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Seoane L, Cortés M, Aris Cancela ME, Furmento J, Baranchuk A, Conde D. Rivaroxaban in the cardiovascular world: a direct anticoagulant useful to prevent stroke and venous and arterial thromboembolism. Expert Rev Cardiovasc Ther 2018; 16:501-514. [PMID: 29862875 DOI: 10.1080/14779072.2018.1484281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 05/25/2018] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Until recently, vitamin K antagonists (VKA) were the only drugs available for long-term anticoagulation. The use of these drugs is laborious due to their variable pharmacokinetics and pharmacodynamics. The advent of direct oral anticoagulants has produced a paradigm shift due to their low incidence of drug interactions, their stable plasma levels, and their lack of monitoring. Rivaroxaban, a factor Xa inhibitor, has been tested in different clinical scenarios and has proved to be effective and safe, even increasing the scope of the old VKA. Areas covered: A non-systematic review of the literature was conducted using the PubMed and Cochrane databases, focusing on randomized clinical trials and real-world observational studies that evaluated rivaroxaban in patients with atrial fibrillation, venous thromboembolism, and atherosclerotic coronary and peripheral vascular disease. Expert commentary: The role of rivaroxaban keeps expanding into areas that were unimaginable few years ago, in the light of solid evidence that has eliminated old strict paradigms. Nonetheless, it will be necessary to adjust costs and better understand the perceived barriers to its widespread implementation, to get fully acceptation of rivaroxaban for the different clinical conditions that have been suggested.
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Affiliation(s)
- Leonardo Seoane
- a Department of Cardiology , Instituto cardiovascular de Buenos Aires , Buenos Aires , Argentina
| | - Marcia Cortés
- a Department of Cardiology , Instituto cardiovascular de Buenos Aires , Buenos Aires , Argentina
| | | | - Juan Furmento
- a Department of Cardiology , Instituto cardiovascular de Buenos Aires , Buenos Aires , Argentina
| | - Adrián Baranchuk
- b Department of Cardiology , Kingston General Hospital, Heart Rhythm Service , Kingston , Canada
| | - Diego Conde
- a Department of Cardiology , Instituto cardiovascular de Buenos Aires , Buenos Aires , Argentina
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Abstract
Pulmonary embolism (PE) in children is a rare condition with potential for high mortality. PE incidence is increasing owing to increased survival of children with predisposing conditions, increased use of central venous catheters, and improved awareness and recognition. Although pediatric PE is distinct from adult PE, management guidelines in children are extrapolated from the adult data. Treatment includes thrombolysis or thrombectomy, and pharmacologic anticoagulation. Ongoing clinical trials are evaluating the use of direct oral anticoagulants in children. Further research is required to develop pediatric-specific evidence-based guidelines for diagnosis and management of PE.
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Affiliation(s)
- Sarah Ramiz
- Division of Pediatric Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Street, Detroit, MI 48201, USA
| | - Madhvi Rajpurkar
- Division of Pediatric Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Street, Detroit, MI 48201, USA.
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Johnson T, Bonner J, Tucker G, Turner D, Jamei M. Development and applications of a physiologically-based model of paediatric oral drug absorption. Eur J Pharm Sci 2018; 115:57-67. [DOI: 10.1016/j.ejps.2018.01.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 12/18/2017] [Accepted: 01/03/2018] [Indexed: 11/30/2022]
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Newall F, Branchford B, Male C. Anticoagulant prophylaxis and therapy in children: current challenges and emerging issues. J Thromb Haemost 2018; 16:196-208. [PMID: 29316202 DOI: 10.1111/jth.13913] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This review is aimed at describing the unique challenges of anticoagulant prophylaxis and treatment in children, and highlighting areas for research for improving clinical outcomes of children with thromboembolic disease. The evidence presented demonstrates the challenges of advancing the evidence base informing optimal management of thromboembolic disease in children. Recent observational studies have identified risk factors for venous thromboembolism in children, but there are few interventional studies assessing the benefit-risk balance of using thromboprophylaxis in risk-stratified clinical subgroups. A risk level-based framework is proposed for administering mechanical and pharmacological thromboprophylaxis. More research is required to refine the assignment of risk levels. The anticoagulants currently used predominantly in children are unfractionated heparin, low molecular weight heparin, and vitamin K antagonists. There is a paucity of robust evidence on the age-specific pharmacology of these agents, and their efficacy and safety for prevention and treatment of thrombosis in children. The available literature is heterogeneous, reflecting age-specific differences, and the various clinical settings for anticoagulation in children. Monitoring assays and target ranges are not well established. Nevertheless, weight-based dosing appears to achieve acceptable outcomes in most indications. Given the limitations of the classical anticoagulants for children, there is great interest in the direct oral anticoagulants (DOACs), whose properties appear to be particularly suitable for children. All DOACs currently approved for adults have Pediatric Investigation Plans ongoing or planned. These are generating age-specific formulations and systematic dosing information. The ongoing pediatric studies still have to establish whether DOACs have a positive benefit-risk balance in the various pediatric indications and age groups.
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Affiliation(s)
- F Newall
- Clinical Haematology & Nursing Research, Royal Children's Hospital, Haematology Research Group, Murdoch Childrens Research Institute and Departments of Paediatrics and Nursing, The University of Melbourne, Melbourne, Australia
| | - B Branchford
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplant and the Hemophilia and Thrombosis Center, School of Medicine and Center for Cancer and Blood Disorders, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - C Male
- Haemostasis and Thrombosis Unit, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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The feasibility of physiologically based pharmacokinetic modeling in forensic medicine illustrated by the example of morphine. Int J Legal Med 2017; 132:415-424. [DOI: 10.1007/s00414-017-1754-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/28/2017] [Indexed: 12/18/2022]
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Moj D, Britz H, Burhenne J, Stewart CF, Egerer G, Haefeli WE, Lehr T. A physiologically based pharmacokinetic and pharmacodynamic (PBPK/PD) model of the histone deacetylase (HDAC) inhibitor vorinostat for pediatric and adult patients and its application for dose specification. Cancer Chemother Pharmacol 2017; 80:1013-1026. [PMID: 28988277 DOI: 10.1007/s00280-017-3447-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 09/23/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE This study aimed at recommending pediatric dosages of the histone deacetylase (HDAC) inhibitor vorinostat and potentially more effective adult dosing regimens than the approved standard dosing regimen of 400 mg/day, using a comprehensive physiologically based pharmacokinetic/pharmacodynamic (PBPK/PD) modeling approach. METHODS A PBPK/PD model for vorinostat was developed for predictions in adults and children. It includes the maturation of relevant metabolizing enzymes. The PBPK model was expanded by (1) effect compartments to describe vorinostat concentration-time profiles in peripheral blood mononuclear cells (PBMCs), (2) an indirect response model to predict the HDAC inhibition, and (3) a thrombocyte model to predict the dose-limiting thrombocytopenia. Parameterization of drug and system-specific processes was based on published and unpublished in silico, in vivo, and in vitro data. The PBPK modeling software used was PK-Sim and MoBi. RESULTS The PBPK/PD model suggests dosages of 80 and 230 mg/m2 for children of 0-1 and 1-17 years of age, respectively. In comparison with the approved standard treatment, in silico trials reveal 11 dosing regimens (9 oral, and 2 intravenous infusion rates) increasing the HDAC inhibition by an average of 31%, prolonging the HDAC inhibition by 181%, while only decreasing the circulating thrombocytes to a tolerable 53%. The most promising dosing regimen prolongs the HDAC inhibition by 509%. CONCLUSIONS Thoroughly developed PBPK models enable dosage recommendations in pediatric patients and integrated PBPK/PD models, considering PD biomarkers (e.g., HDAC activity and platelet count), are well suited to guide future efficacy trials by identifying dosing regimens potentially superior to standard dosing regimens.
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Affiliation(s)
- Daniel Moj
- Department of Pharmacy, Clinical Pharmacy, Saarland University, Campus C2 2, 66123, Saarbruecken, Germany
| | - Hannah Britz
- Department of Pharmacy, Clinical Pharmacy, Saarland University, Campus C2 2, 66123, Saarbruecken, Germany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Clinton F Stewart
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Gerlinde Egerer
- Department of Hematology, Oncology, and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Thorsten Lehr
- Department of Pharmacy, Clinical Pharmacy, Saarland University, Campus C2 2, 66123, Saarbruecken, Germany.
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Smania G, Baiardi P, Ceci A, Magni P, Cella M. Model-Based Assessment of Alternative Study Designs in Pediatric Trials. Part I: Frequentist Approaches. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2016; 5:305-12. [PMID: 27300083 PMCID: PMC5131885 DOI: 10.1002/psp4.12083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 03/25/2016] [Accepted: 04/18/2016] [Indexed: 11/10/2022]
Abstract
Alternative designs can increase the feasibility of pediatric trials when compared to classical parallel designs (PaD). In this work we present a model-based approach based on clinical trial simulations for the comparison of PaD with the alternative sequential, crossover, and randomized withdrawal (RWD) designs. Study designs were evaluated in terms of: type I and II errors, sample size per arm (SS), trial duration (TD), treatment exposures, and parameter estimate precision (EP). The crossover requires the lowest SS and TD, although it implies higher placebo and no treatment exposures. RWD maximizes exposure to active treatment while minimizing that to placebo, but requires the largest SS. SS of sequential designs can sometimes be smaller than the crossover one, although with poorer EP. This pharmacometric framework allows a multiscale comparison of alternative study designs that can be used for design selection in future pediatric trials.
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Affiliation(s)
- G Smania
- Consorzio per Valutazioni Biologiche e Farmacologiche, Pavia, Italy.,Dipartimento di Ingegneria Industriale e dell'Informazione, Università degli Studi di Pavia, Pavia, Italy
| | - P Baiardi
- Direzione Scientifica Centrale, Fondazione Salvatore Maugeri, IRCCS, Pavia, Italy
| | - A Ceci
- Consorzio per Valutazioni Biologiche e Farmacologiche, Pavia, Italy
| | - P Magni
- Dipartimento di Ingegneria Industriale e dell'Informazione, Università degli Studi di Pavia, Pavia, Italy
| | - M Cella
- Consorzio per Valutazioni Biologiche e Farmacologiche, Pavia, Italy.,Department of Clinical Pharmacology, Global Clinical Development, Chiesi Farmaceutici, Parma, Italy
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Mehrotra N, Bhattaram A, Earp JC, Florian J, Krudys K, Lee JE, Lee JY, Liu J, Mulugeta Y, Yu J, Zhao P, Sinha V. Role of Quantitative Clinical Pharmacology in Pediatric Approval and Labeling. ACTA ACUST UNITED AC 2016; 44:924-33. [PMID: 27079249 DOI: 10.1124/dmd.116.069559] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 04/13/2016] [Indexed: 12/18/2022]
Abstract
Dose selection is one of the key decisions made during drug development in pediatrics. There are regulatory initiatives that promote the use of model-based drug development in pediatrics. Pharmacometrics or quantitative clinical pharmacology enables development of models that can describe factors affecting pharmacokinetics and/or pharmacodynamics in pediatric patients. This manuscript describes some examples in which pharmacometric analysis was used to support approval and labeling in pediatrics. In particular, the role of pharmacokinetic (PK) comparison of pediatric PK to adults and utilization of dose/exposure-response analysis for dose selection are highlighted. Dose selection for esomeprazole in pediatrics was based on PK matching to adults, whereas for adalimumab, exposure-response, PK, efficacy, and safety data together were useful to recommend doses for pediatric Crohn's disease. For vigabatrin, demonstration of similar dose-response between pediatrics and adults allowed for selection of a pediatric dose. Based on model-based pharmacokinetic simulations and safety data from darunavir pediatric clinical studies with a twice-daily regimen, different once-daily dosing regimens for treatment-naïve human immunodeficiency virus 1-infected pediatric subjects 3 to <12 years of age were evaluated. The role of physiologically based pharmacokinetic modeling (PBPK) in predicting pediatric PK is rapidly evolving. However, regulatory review experiences and an understanding of the state of science indicate that there is a lack of established predictive performance of PBPK in pediatric PK prediction. Moving forward, pharmacometrics will continue to play a key role in pediatric drug development contributing toward decisions pertaining to dose selection, trial designs, and assessing disease similarity to adults to support extrapolation of efficacy.
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Affiliation(s)
- Nitin Mehrotra
- Division of Pharmacometrics, Office of Clinical Pharmacology (N.M., A.B., J.C.E., J.F., K.K., J.E.L., J.L., Y.M., J.Y., P.Z., V.S.), and Division of Biometrics VII, Office of Biostatistics (J.Y.L.), Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Atul Bhattaram
- Division of Pharmacometrics, Office of Clinical Pharmacology (N.M., A.B., J.C.E., J.F., K.K., J.E.L., J.L., Y.M., J.Y., P.Z., V.S.), and Division of Biometrics VII, Office of Biostatistics (J.Y.L.), Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Justin C Earp
- Division of Pharmacometrics, Office of Clinical Pharmacology (N.M., A.B., J.C.E., J.F., K.K., J.E.L., J.L., Y.M., J.Y., P.Z., V.S.), and Division of Biometrics VII, Office of Biostatistics (J.Y.L.), Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Jeffry Florian
- Division of Pharmacometrics, Office of Clinical Pharmacology (N.M., A.B., J.C.E., J.F., K.K., J.E.L., J.L., Y.M., J.Y., P.Z., V.S.), and Division of Biometrics VII, Office of Biostatistics (J.Y.L.), Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Kevin Krudys
- Division of Pharmacometrics, Office of Clinical Pharmacology (N.M., A.B., J.C.E., J.F., K.K., J.E.L., J.L., Y.M., J.Y., P.Z., V.S.), and Division of Biometrics VII, Office of Biostatistics (J.Y.L.), Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Jee Eun Lee
- Division of Pharmacometrics, Office of Clinical Pharmacology (N.M., A.B., J.C.E., J.F., K.K., J.E.L., J.L., Y.M., J.Y., P.Z., V.S.), and Division of Biometrics VII, Office of Biostatistics (J.Y.L.), Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Joo Yeon Lee
- Division of Pharmacometrics, Office of Clinical Pharmacology (N.M., A.B., J.C.E., J.F., K.K., J.E.L., J.L., Y.M., J.Y., P.Z., V.S.), and Division of Biometrics VII, Office of Biostatistics (J.Y.L.), Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Jiang Liu
- Division of Pharmacometrics, Office of Clinical Pharmacology (N.M., A.B., J.C.E., J.F., K.K., J.E.L., J.L., Y.M., J.Y., P.Z., V.S.), and Division of Biometrics VII, Office of Biostatistics (J.Y.L.), Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Yeruk Mulugeta
- Division of Pharmacometrics, Office of Clinical Pharmacology (N.M., A.B., J.C.E., J.F., K.K., J.E.L., J.L., Y.M., J.Y., P.Z., V.S.), and Division of Biometrics VII, Office of Biostatistics (J.Y.L.), Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Jingyu Yu
- Division of Pharmacometrics, Office of Clinical Pharmacology (N.M., A.B., J.C.E., J.F., K.K., J.E.L., J.L., Y.M., J.Y., P.Z., V.S.), and Division of Biometrics VII, Office of Biostatistics (J.Y.L.), Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Ping Zhao
- Division of Pharmacometrics, Office of Clinical Pharmacology (N.M., A.B., J.C.E., J.F., K.K., J.E.L., J.L., Y.M., J.Y., P.Z., V.S.), and Division of Biometrics VII, Office of Biostatistics (J.Y.L.), Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Vikram Sinha
- Division of Pharmacometrics, Office of Clinical Pharmacology (N.M., A.B., J.C.E., J.F., K.K., J.E.L., J.L., Y.M., J.Y., P.Z., V.S.), and Division of Biometrics VII, Office of Biostatistics (J.Y.L.), Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
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Block M. Physiologically based pharmacokinetic and pharmacodynamic modeling in cancer drug development: status, potential and gaps. Expert Opin Drug Metab Toxicol 2016; 11:743-56. [PMID: 25940026 DOI: 10.1517/17425255.2015.1037276] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Modeling and simulation have become important means of answering questions relevant to the development of a drug, making it possible to assess risks early and to reduce costs. Physiologically based pharmacokinetic and pharmacodynamic (PBPK/PD) models contribute to a comprehensive understanding of the drug, covering specific questions from early discovery through lifecycle management stages. As for other disease areas, in oncology, PBPK and PD models are important topics that remain to be addressed. AREAS COVERED This review describes current PBPK and PD approaches, their applicability in drug development in general and specifically in the area of oncology. It discusses the current status and then focuses on key challenges and the potential for future use. It provides cases in which modeling currently cannot answer the questions and assesses the requirements to close gaps for PBPK/PD in oncology. EXPERT OPINION PBPK/PD models have led to improvements in identifying risks and reducing costs during the drug development process. Nevertheless, there is a lot of potential, where more rigorous integration of biological knowledge and specific experimental design would result in a more comprehensive biological picture. Ideally, such approaches would reveal the extent to which preclinical work can be extrapolated to clinical settings, thus enabling reliable prediction and, ultimately, reducing failed trials in clinical oncology.
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Affiliation(s)
- Michael Block
- Bayer Technology Services GmbH - Systems Pharmacology ONC , Building B106 Leverkusen , Germany
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von Vajna E, Alam R, So TY. Current Clinical Trials on the Use of Direct Oral Anticoagulants in the Pediatric Population. Cardiol Ther 2016; 5:19-41. [PMID: 26739579 PMCID: PMC4906081 DOI: 10.1007/s40119-015-0054-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Indexed: 01/22/2023] Open
Abstract
Common treatment options for deep vein thrombosis and venous thromboembolism in the pediatric population include unfractionated heparin, low molecular weight heparin, and warfarin. Other alternatives are bivalirudin, argatroban, and fondaparinux. Warfarin is the only approved oral option, but an oral agent without frequent monitoring would be optimal for pediatric patients. Thus, there is an increasing need for new anticoagulation options in this population. None of the current direct oral anticoagulants have FDA-approved indications and dosing in children. The two classes of DOACs and the drugs they are comprised of are factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) and direct thrombin inhibitor (dabigatran). Off-label usage of these agents is largely based on adult doses. By far, rivaroxaban and dabigatran have the most published data and ongoing trials in pediatric patients compared to edoxaban and apixaban. After evaluating the current literature available on these agents, it is, however, still too early to make any definitive recommendations on their usage in this special population.
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Affiliation(s)
- Erika von Vajna
- Department of Pharmacy, Moses H. Cone Memorial Hospital, Greensboro, NC, USA
| | - Ruhaniyah Alam
- University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Tsz-Yin So
- Department of Pharmacy, Moses H. Cone Memorial Hospital, Greensboro, NC, USA.
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