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Scherkl C, Meid AD, Cuntz SE, Classen L, Weiss J, Czock D, Haefeli WE. Coadministration of fluconazole to boost subtherapeutic sirolimus concentrations: A case report. Pharmacol Res Perspect 2024; 12:e1198. [PMID: 38635290 PMCID: PMC11025614 DOI: 10.1002/prp2.1198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/21/2024] [Accepted: 03/20/2024] [Indexed: 04/19/2024] Open
Abstract
Individual sirolimus whole blood concentrations are highly variable, critically influenced by the concomitant use of cytochrome P450 (CYP) 3A inducers or inhibitors, and also modulated by food. Therapeutic drug monitoring is therefore recommended, especially at treatment start or in circumstances that can influence sirolimus exposure. In this case report, we highlight the challenge of achieving therapeutic sirolimus concentrations and present pragmatic solutions with regimen adaptions, pharmacokinetic enhancement (use of a drug–drug interaction), concentration monitoring, and subsequent modeling of population pharmacokinetics to support treatment decisions. In a 69-year-old female patient with allogeneic hematopoietic stem cell transplantation, sirolimus concentrations were stable until she developed cerebral toxoplasmosis with tonic–clonic seizures. During treatment of this acute infection, sirolimus concentrations dropped to subtherapeutic levels and remained largely unaffected by dose increases. [Correction added on 4 May 2024, after first online publication: The word “tacrolimus concentrations” has been changed to “sirolimus concentrations” in the preceding sentence.] Only the simultaneous administration of the CYP3A4 inhibitor fluconazole and a shortening of the sirolimus dosing intervals to a (non-approved) twice-daily administration led to successful control of the concentrations, which ultimately even made a dose reduction possible. This intervention resulted in an increase of sirolimus mean trough concentration to 5.85 ng/mL, i.e., into the desired target range. Additionally, a higher ratio of sirolimus trough levels/daily dose from 26.9 to 109 ng/mL/mg/kg/day was achieved with the initiation of fluconazole. Thus, this case report describes the use of clinical pharmacological concepts and pharmacokinetic modeling to optimize treatment strategies in an individual patient. This strategy could be generalized to other CYP inhibitors and other treatment regimens.
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Affiliation(s)
- Camilo Scherkl
- Internal Medicine IX: Department of Clinical Pharmacology and PharmacoepidemiologyHeidelberg University, Medical Faculty Heidelberg/Heidelberg University HospitalHeidelbergGermany
| | - Andreas D. Meid
- Internal Medicine IX: Department of Clinical Pharmacology and PharmacoepidemiologyHeidelberg University, Medical Faculty Heidelberg/Heidelberg University HospitalHeidelbergGermany
| | - Sven E. Cuntz
- Internal Medicine V: Department of Hematology, Oncology and RheumatologyHeidelberg University, Medical Faculty Heidelberg/Heidelberg University HospitalHeidelbergGermany
| | - Laura Classen
- Internal Medicine V: Department of Hematology, Oncology and RheumatologyHeidelberg University, Medical Faculty Heidelberg/Heidelberg University HospitalHeidelbergGermany
| | - Johanna Weiss
- Internal Medicine IX: Department of Clinical Pharmacology and PharmacoepidemiologyHeidelberg University, Medical Faculty Heidelberg/Heidelberg University HospitalHeidelbergGermany
| | - David Czock
- Internal Medicine IX: Department of Clinical Pharmacology and PharmacoepidemiologyHeidelberg University, Medical Faculty Heidelberg/Heidelberg University HospitalHeidelbergGermany
| | - Walter E. Haefeli
- Internal Medicine IX: Department of Clinical Pharmacology and PharmacoepidemiologyHeidelberg University, Medical Faculty Heidelberg/Heidelberg University HospitalHeidelbergGermany
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McCune JS, Armenian SH, Nakamura R, Shan H, Kanakry CG, Mielcarek M, Gao W, Mager DE. Immunosuppressant adherence in adult outpatient hematopoietic cell transplant recipients. J Oncol Pharm Pract 2024; 30:322-331. [PMID: 37134196 PMCID: PMC10622331 DOI: 10.1177/10781552231171607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
INTRODUCTION Medication nonadherence continues to be challenging for allogeneic hematopoietic cell transplant (HCT) recipients. The risk and severity of chronic graft-versus-host disease (GVHD) are associated with low immunosuppressant concentrations (which can be improved with model-informed precision dosing (MIPD)) and with immunosuppressant nonadherence (which can be improved with acceptable interventions). METHODS With the goals of improving adherence and achieving therapeutic concentrations of immunosuppressants to eliminate GVHD, we characterized the feasibility of using the Medication Event Monitoring (MEMS®) Cap in adult HCT recipients. RESULTS Of the 27 participants offered the MEMS® Cap at the time of hospital discharge, 7 (25.9%) used it, which is below our a priori threshold of 70%. These data suggest the MEMS® Cap is not feasible for HCT recipients. The MEMS® Cap data were available for a median of 35 days per participant per medication (range: 7-109 days). The average daily adherence per participant ranged from 0 to 100%; four participants had an average daily adherence of over 80%. CONCLUSIONS MIPD may be supported by MEMS® technology to provide the precise time of immunosuppressant self-administration. The MEMS® Cap was used by only a small percentage (25.9%) of HCT recipients in this pilot study. In accordance with larger studies using less accurate tools to evaluate adherence, immunosuppressant adherence varied from 0% to 100%. Future studies should establish the feasibility and clinical benefit of combining MIPD with newer technology, specifically the MEMS® Button, which can inform the oncology pharmacist of the time of immunosuppressant self-administration.
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Affiliation(s)
- Jeannine S. McCune
- Department of Hematologic Malignancies Translational Sciences, City of Hope, and Department of Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, CA, USA
| | - Saro H. Armenian
- Department of Population Sciences, City of Hope, and Department of Pediatrics, City of Hope Medical Center, Duarte, CA, USA
| | - Ryotaro Nakamura
- Department of Hematologic Malignancies Translational Sciences, City of Hope, and Department of Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, CA, USA
| | - Hayoue Shan
- Department of Biostatistics, City of Hope, Duarte, CA, USA
| | - Christopher G. Kanakry
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Marco Mielcarek
- Clinical Research Division, Fred Hutchinson Cancer Center and Department of Medical Oncology, University of Washington, Seattle, WA, USA
| | - Wei Gao
- Andrew and Peggy Cherng Department of Medical Engineering, Division of Engineering and Applied Science, California Institute of Technology, Pasadena, CA, USA
| | - Donald E. Mager
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
- Enhanced Pharmacodynamics, LLC, Buffalo, NY, USA
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McCune JS, Navarro SL, Risler LJ, Phillips BR, Ren S, Schoch HG, Baker KS. The presence of busulfan metabolites and pharmacometabolomics in plasma drawn immediately before allograft infusion in hematopoietic cell transplant recipients. Clin Transl Sci 2023; 16:2577-2590. [PMID: 37749994 PMCID: PMC10719475 DOI: 10.1111/cts.13651] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/07/2023] [Accepted: 09/10/2023] [Indexed: 09/27/2023] Open
Abstract
Busulfan is hepatically metabolized through glutathione (GSH) conjugation; in vitro, this process depletes hepatocyte GSH stores and generates the cytotoxic metabolite γ-glutamyldehydroalanylglycine, which is too unstable to be quantitated in vivo. We sought to evaluate if pre-graft (i.e., immediately before allograft infusion) concentrations of busulfan metabolites' and of endogenous metabolomic compounds (EMCs) representing the glutathione pathway were associated with clinical outcomes in hematopoietic cell transplant (HCT) recipients receiving busulfan. The clinical outcomes evaluated were relapse, acute graft versus host disease (GVHD), chronic GVHD, non-relapse mortality, and neutrophil nadir. In pre-graft samples obtained from patients immediately before allograft infusion, our objectives were to evaluate for: (1) the presence of busulfan and its metabolites tetrahydrothiophenium ion (THT+), tetrahydrothiophene 1-oxide, sulfolane, and 3-hydroxysulfolane (N = 124); (2) EMCs using a global metabolomics assay (N = 77); and (3) the association of the busulfan metabolites and the EMCs with clinical outcomes. In the pre-graft samples, busulfan and THT+ could not be detected. THT 1-oxide, sulfolane, and 3-hydroxysulfolane were quantitated in 9.6%, 26%, and 58% of pre-graft samples; their concentrations were not associated with clinical outcomes. Four pre-graft EMCs were statistically significantly associated with the neutrophil nadir. The pre-graft EMCs were not associated with the other clinical outcomes. In conclusion, busulfan's metabolites are present in patients' plasma immediately before allograft infusion; the neutrophil nadir is associated with pre-graft EMCs. Future research should investigate the association of clinical outcomes with the concentrations of busulfan's metabolites and EMCs in the pre-graft plasma from allogeneic HCT recipients.
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Affiliation(s)
- Jeannine S. McCune
- Department of Hematologic Malignancies Translational SciencesCity of HopeDuarteCaliforniaUSA
| | - Sandi L. Navarro
- Division of Public Health SciencesFred Hutchinson Cancer CenterSeattleWashingtonUSA
| | - Linda J. Risler
- Department of PharmaceuticsUniversity of WashingtonSeattleWashingtonUSA
| | - Brian R. Phillips
- Department of PharmaceuticsUniversity of WashingtonSeattleWashingtonUSA
| | - Suping Ren
- Department of Hematologic Malignancies Translational SciencesCity of HopeDuarteCaliforniaUSA
| | - H. Gary Schoch
- Clinical Research DivisionFred Hutchinson Cancer CenterSeattleWashingtonUSA
| | - K. Scott Baker
- Clinical Research DivisionFred Hutchinson Cancer CenterSeattleWashingtonUSA
- Department of PediatricsUniversity of WashingtonSeattleWashingtonUSA
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Manes A, Di Renzo T, Dodani L, Reale A, Gautiero C, Di Lauro M, Nasti G, Manco F, Muscariello E, Guida B, Tarantino G, Cataldi M. Pharmacomicrobiomics of Classical Immunosuppressant Drugs: A Systematic Review. Biomedicines 2023; 11:2562. [PMID: 37761003 PMCID: PMC10526314 DOI: 10.3390/biomedicines11092562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
The clinical response to classical immunosuppressant drugs (cIMDs) is highly variable among individuals. We performed a systematic review of published evidence supporting the hypothesis that gut microorganisms may contribute to this variability by affecting cIMD pharmacokinetics, efficacy or tolerability. The evidence that these drugs affect the composition of intestinal microbiota was also reviewed. The PubMed and Scopus databases were searched using specific keywords without limits of species (human or animal) or time from publication. One thousand and fifty five published papers were retrieved in the initial database search. After screening, 50 papers were selected to be reviewed. Potential effects on cIMD pharmacokinetics, efficacy or tolerability were observed in 17/20 papers evaluating this issue, in particular with tacrolimus, cyclosporine, mycophenolic acid and corticosteroids, whereas evidence was missing for everolimus and sirolimus. Only one of the papers investigating the effect of cIMDs on the gut microbiota reported negative results while all the others showed significant changes in the relative abundance of specific intestinal bacteria. However, no unique pattern of microbiota modification was observed across the different studies. In conclusion, the available evidence supports the hypothesis that intestinal microbiota could contribute to the variability in the response to some cIMDs, whereas data are still missing for others.
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Affiliation(s)
- Annalaura Manes
- Section of Pharmacology, Department of Neuroscience, Reproductive Sciences and Dentistry, Federico II University of Naples, 80131 Naples, Italy; (A.M.); (L.D.); (F.M.)
| | - Tiziana Di Renzo
- Institute of Food Sciences, National Research Council, 83100 Avellino, Italy; (T.D.R.); (A.R.)
| | - Loreta Dodani
- Section of Pharmacology, Department of Neuroscience, Reproductive Sciences and Dentistry, Federico II University of Naples, 80131 Naples, Italy; (A.M.); (L.D.); (F.M.)
| | - Anna Reale
- Institute of Food Sciences, National Research Council, 83100 Avellino, Italy; (T.D.R.); (A.R.)
| | - Claudia Gautiero
- Physiology Nutrition Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy; (C.G.); (M.D.L.); (G.N.); (B.G.)
| | - Mariastella Di Lauro
- Physiology Nutrition Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy; (C.G.); (M.D.L.); (G.N.); (B.G.)
| | - Gilda Nasti
- Physiology Nutrition Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy; (C.G.); (M.D.L.); (G.N.); (B.G.)
| | - Federica Manco
- Section of Pharmacology, Department of Neuroscience, Reproductive Sciences and Dentistry, Federico II University of Naples, 80131 Naples, Italy; (A.M.); (L.D.); (F.M.)
| | - Espedita Muscariello
- Nutrition Unit, Department of Prevention, Local Health Authority Napoli 3 Sud, 80059 Naples, Italy;
| | - Bruna Guida
- Physiology Nutrition Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy; (C.G.); (M.D.L.); (G.N.); (B.G.)
| | - Giovanni Tarantino
- Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy;
| | - Mauro Cataldi
- Section of Pharmacology, Department of Neuroscience, Reproductive Sciences and Dentistry, Federico II University of Naples, 80131 Naples, Italy; (A.M.); (L.D.); (F.M.)
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Shen G, Moua KTY, Perkins K, Johnson D, Li A, Curtin P, Gao W, McCune JS. Precision sirolimus dosing in children: The potential for model-informed dosing and novel drug monitoring. Front Pharmacol 2023; 14:1126981. [PMID: 37021042 PMCID: PMC10069443 DOI: 10.3389/fphar.2023.1126981] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 02/14/2023] [Indexed: 04/07/2023] Open
Abstract
The mTOR inhibitor sirolimus is prescribed to treat children with varying diseases, ranging from vascular anomalies to sporadic lymphangioleiomyomatosis to transplantation (solid organ or hematopoietic cell). Precision dosing of sirolimus using therapeutic drug monitoring (TDM) of sirolimus concentrations in whole blood drawn at the trough (before the next dose) time-point is the current standard of care. For sirolimus, trough concentrations are only modestly correlated with the area under the curve, with R 2 values ranging from 0.52 to 0.84. Thus, it should not be surprising, even with the use of sirolimus TDM, that patients treated with sirolimus have variable pharmacokinetics, toxicity, and effectiveness. Model-informed precision dosing (MIPD) will be beneficial and should be implemented. The data do not suggest dried blood spots point-of-care sampling of sirolimus concentrations for precision dosing of sirolimus. Future research on precision dosing of sirolimus should focus on pharmacogenomic and pharmacometabolomic tools to predict sirolimus pharmacokinetics and wearables for point-of-care quantitation and MIPD.
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Affiliation(s)
- Guofang Shen
- Department of Hematologic Malignancies Translational Sciences, City of Hope, and Department of Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, CA, United States
| | - Kao Tang Ying Moua
- Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, CA, United States
| | - Kathryn Perkins
- Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, CA, United States
| | - Deron Johnson
- Clinical Informatics, City of Hope Medical Center, Duarte, CA, United States
| | - Arthur Li
- Division of Biostatistics, City of Hope, Duarte, CA, United States
| | - Peter Curtin
- Department of Hematologic Malignancies Translational Sciences, City of Hope, and Department of Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, CA, United States
| | - Wei Gao
- Division of Engineering and Applied Science, Andrew and Peggy Cherng Department of Medical Engineering, California Institute of Technology, Pasadena, CA, United States
| | - Jeannine S. McCune
- Department of Hematologic Malignancies Translational Sciences, City of Hope, and Department of Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, CA, United States
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Tian JX, Miao WJ, Yan HH, Wang XD, Liao YX, Li S, Jiang EL, Zhang P. Impact of carbapenem antibiotics on mycophenolate mofetil in hematopoietic stem cell transplant patients with interruption of the enterohepatic recycling: a retrospective study. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:82. [PMID: 36819591 PMCID: PMC9929831 DOI: 10.21037/atm-22-6341] [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: 12/01/2022] [Accepted: 01/10/2023] [Indexed: 01/18/2023]
Abstract
Background Mycophenolate mofetil (MMF), a prodrug of mycophenolic acid (MPA), is widely used in the prophylaxis for graft-versus-host disease (GVHD) following hematopoietic stem cell transplantation (HSCT). MPA undergoes enterohepatic recycling (EHR). Oral antibiotics can affect MPA concentration by reducing intestinal flora-mediated EHR. However, the effect of intravenous antibiotics on MPA concentration is not clear, especially in patients whose EHR is already interrupted. This study was conducted to determine whether intravenous carbapenem antibiotics (CBP) influence the pre-dose plasma concentration (C0) of MPA in HSCT patients when the EHR of MPA is interrupted by cyclosporine and gut decontamination. Methods The HSCT patients who received immunosuppressive therapy with MMF and cyclosporine, as well as treatment with CBP were screened as potential candidates. Patients who lacked MPA C0 measurements before or during CBP use, had combination therapy of rifampin with MMF, or switched from IV to oral MMF were excluded. The liver/renal function, demographic information, albumin/cyclosporine concentration, MPA C0 and medication information were collected. The changes in the MPA C0 before and during CBP use were evaluated, and the influence of related clinical factors was also estimated. Results CBP resulted in a significant reduction in the MPA C0 from 0.65±0.33 to 0.43±0.30 µg/mL. Linear regression analysis indicated a weak correlation between the dose-normalized C0 of MPA and the dosage of CBP during CBP use (r2=0.129, P=0.009). Univariate and multivariate analysis confirmed that the MPA C0 had no relevance to rifaximin administration (P=0.249-0.700), demographics (P=0.118-0.599), fluctuation of plasma albumin (ALB, P=0.943 and 0.609) and cyclosporine concentrations (P=0.647 and 0.112), or liver and renal functions (P=0.078-0.887) no matter whether the CBP were used. However, compared with the non-gut decontamination group, larger interindividual variabilities and smaller decreases in MPA C0 (6.60% vs. 41.73%) during CBP therapy were seen in the gut decontamination group, although it was a nonsignificant trend. Conclusions CBP decreased the MPA C0 in Chinese HSCT patients even when MMF is used in combination with cyclosporine and rifaximin. If antibiotics must be used, and CBP in particular, therapeutic drug monitoring should be performed to ensure adequate exposure.
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Affiliation(s)
- Ji-Xin Tian
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Institutes of Health Science, Tianjin, China
| | - Wen-Juan Miao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Institutes of Health Science, Tianjin, China
| | - Hai-Hong Yan
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Institutes of Health Science, Tianjin, China
| | - Xiao-Dan Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Institutes of Health Science, Tianjin, China
| | - Ying-Xi Liao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Institutes of Health Science, Tianjin, China
| | - Shan Li
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Institutes of Health Science, Tianjin, China
| | - Er-Lie Jiang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Institutes of Health Science, Tianjin, China
| | - Ping Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Institutes of Health Science, Tianjin, China
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Morawe MP, Liao F, Amberg W, van Bergeijk J, Chang R, Gulino M, Hamilton C, Hoft C, Lumpkin C, Mastis B, McGlame E, Nuber J, Plaas C, Ravikumar B, Roy K, Schanzenbächer M, Tierno J, Lakics V, Dellovade T, Townsend M. Pharmacological mTOR-inhibition facilitates clearance of AD-related tau aggregates in the mouse brain. Eur J Pharmacol 2022; 934:175301. [DOI: 10.1016/j.ejphar.2022.175301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 11/03/2022]
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Li S, Zhan M, Wu S, Liao J, Xu H, Sun D, Zhao X, Wang Y. Population Pharmacokinetic Analysis and Dosing Optimization of Sirolimus in Children With Tuberous Sclerosis Complex. J Clin Pharmacol 2022; 62:948-959. [PMID: 35094415 DOI: 10.1002/jcph.2033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 01/25/2022] [Indexed: 02/05/2023]
Abstract
Sirolimus is confirmed to be effective in the treatment of tuberous sclerosis complex (TSC) and related disorders. The study aims to establish a population pharmacokinetic model of oral sirolimus for children with TSC and provide an evidence-based approach for individualization of sirolimus dosing in the pediatric population. A total of 64 children were recruited in this multicenter, retrospective pharmacokinetic study. Whole-blood concentrations of sirolimus, demographic, and clinical information were collected and analyzed using a nonlinear mixed-effects population modeling method. The final model was internally and externally validated. Then Monte Carlo simulations were performed to evaluate and optimize the dosing regimens. In addition, the efficacy and safety of sirolimus therapy was assessed retrospectively in patients with epilepsy or cardiac rhabdomyomas associated with TSC. Finally, the sirolimus pharmacokinetic profile was described by a 1-compartment model with first-order absorption and elimination along with body weight and total daily dose as significant covariates. The typical population parameter estimates of apparent volume of distribution and apparent clearance were 69.48 L and 2.79 L/h, respectively. Simulations demonstrated that dosage regimens stratified by body surface area may be more appropriate for children with TSC. These findings could be used to inform individualized dosing strategies of sirolimus for pediatric patients with TSC.
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Affiliation(s)
- SiChan Li
- Department of Clinical Pharmacy, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
- Clinical Medical Research Center for Neurodevelopmental Disabilities in Children, Hubei Province, People's Republic of China
| | - Min Zhan
- Department of Pharmacy, Shenzhen Children's Hospital, Shenzhen, People's Republic of China
| | - SanLan Wu
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - JianXiang Liao
- Department of Neurology, Shenzhen Children's Hospital, Shenzhen, People's Republic of China
| | - Hua Xu
- Department of Clinical Pharmacy, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Dan Sun
- Clinical Medical Research Center for Neurodevelopmental Disabilities in Children, Hubei Province, People's Republic of China
- Department of Neurology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Xia Zhao
- Department of Neurology, Shenzhen Children's Hospital, Shenzhen, People's Republic of China
| | - Yang Wang
- Department of Clinical Pharmacy, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
- Clinical Medical Research Center for Neurodevelopmental Disabilities in Children, Hubei Province, People's Republic of China
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Reduced Enterohepatic Recirculation of Mycophenolate and Lower Blood Concentrations are Associated with the Stool Bacterial Microbiome After Hematopoietic Cell Transplantation. Transplant Cell Ther 2022; 28:372.e1-372.e9. [PMID: 35489611 DOI: 10.1016/j.jtct.2022.04.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/11/2022] [Accepted: 04/19/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Mycophenolate mofetil (MMF) is an important immunosuppressant used after allogeneic hematopoietic cell transplant (HCT). MMF has a narrow therapeutic index and blood concentrations of mycophenolic acid (MPA), the active component of MMF, are highly variable. Low MPA concentrations are associated with risk of graft vs host disease (GvHD) while high concentrations are associated with toxicity. Reasons for variability are not well known and may be due, at least in part, to the presence of β-glucuronidase producing bacteria in the gastrointestinal tract which enhance MPA enterohepatic recirculation (EHR) by transforming MPA metabolites formed in the liver back to MPA. OBJECTIVE To determine if individuals with high MPA EHR have a greater abundance of β-glucuronidase producing bacteria in their stool and higher MPA concentrations relative to those with low EHR. STUDY DESIGN We conducted a pharmacomicrobiomics study in 20 adult HCT recipients receiving a myeloablative or reduced intensity preparative regimen. Participants received MMF 1g IV every 8 hours with tacrolimus. Intensive pharmacokinetic sampling of mycophenolate was conducted before hospital discharge. Total MPA, MPA glucuronide (MPAG) and acylMPAG were measured. EHR was defined as a ratio of MPA area under the concentration-versus-time curve (AUC)4-8 to MPA AUC0-8. Differences in stool microbiome diversity and composition, determined by shotgun metagenomic sequencing, were compared above and below the median EHR (22%, range 5-44%). RESULTS Median EHR was 12% and 29% in the low and high EHR groups, respectively. MPA troughs, MPA AUC4-8 and acylMPAG AUC4-8/AUC0-8, were greater in the high EHR group vs low EHR group [1.53 vs 0.28 mcg/mL, p = 0.0001], [7.33 vs 1.79 hr*mcg/mL, p = 0.0003] and [0.33 vs 0.24 hr*mcg/mL, p = 0.0007], respectively. MPA AUC0-8 was greater in the high EHR than the low EHR group and trended towards significance [22.8 vs. 15.3 hr*mcg/mL, p=0.06]. Bacteroides vulgatus, stercoris and thetaiotaomicron were 1.2-2.4 times more abundant (p=0.039, 0.024, 0.046, respectively) in the high EHR group. MPA EHR was positively correlated with B. vulgatus (⍴=0.58, p≤0.01) and B. thetaiotaomicron (⍴=0.46, p<0.05) and negatively correlated with Blautia hydrogenotrophica (⍴=-0.53, p<0.05). Therapeutic MPA troughs were achieved in 80% of patients in the high EHR group and 0% in the low EHR. There was a trend towards differences in MPA AUC0-8 and MPA Css mcg/mL in high vs. low EHR groups (p=0.06). CONCLUSION MPA EHR was variable. Patients with high MPA EHR had greater abundance of Bacteroides species in stool and higher MPA exposure than patients with low MPA EHR. Bacteroides may therefore be protective from poor outcomes such as graft vs host disease but in others it may increase the risk of MPA adverse effects. These data need to be confirmed and studied after oral MMF.
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Improved Therapeutic Approaches are Needed to Manage Graft-versus-Host Disease. Clin Drug Investig 2021; 41:929-939. [PMID: 34657244 PMCID: PMC8556206 DOI: 10.1007/s40261-021-01087-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 11/25/2022]
Abstract
Allogeneic haematopoietic stem cell transplantation (alloHSCT) offers a potentially curative therapy for patients suffering from diseases of the haematopoietic system but requires a high level of expertise and is both resource intensive and expensive. A frequent and life-threatening complication is graft-versus-host disease (GvHD). Acute GvHD (aGvHD) generally causes skin, gastrointestinal and liver symptoms, but chronic GvHD (cGvHD) has a different pathophysiology and may affect nearly every organ or tissue of the body. In Europe, GvHD prophylaxis is generally a calcineurin inhibitor in combination with methotrexate, with high-dose systemic steroids used for advanced GvHD treatment. Between 39% and 59% of alloHSCT patients will develop aGvHD and around 36–37% will develop cGvHD. Steroid response decreases with increasing disease severity, which in turn leads to an increase in non-relapse mortality. GvHD imposes a financial burden on healthcare systems, significantly increasing post-alloHSCT costs. Increased GvHD disease severity magnifies this. Balancing immunosuppression to control the GvHD whilst maintaining a degree of immunocompetence against infection is critical. European GvHD guidelines acknowledge the lack of evidence to support a standard second-line therapy, and improved long-term outcomes and quality-of-life (QoL) remain an unmet need. Evidence generation for potential treatments is challenging. Issues to overcome include choice of comparator (extensive off-label usage); blinding; selection of relevant patient-reported outcome measures (PROMs); and rarity of the condition, which may infeasibly increase timescales to achieve clinical and statistical relevance.
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11
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Bergan S, Brunet M, Hesselink DA, Johnson-Davis KL, Kunicki PK, Lemaitre F, Marquet P, Molinaro M, Noceti O, Pattanaik S, Pawinski T, Seger C, Shipkova M, Swen JJ, van Gelder T, Venkataramanan R, Wieland E, Woillard JB, Zwart TC, Barten MJ, Budde K, Dieterlen MT, Elens L, Haufroid V, Masuda S, Millan O, Mizuno T, Moes DJAR, Oellerich M, Picard N, Salzmann L, Tönshoff B, van Schaik RHN, Vethe NT, Vinks AA, Wallemacq P, Åsberg A, Langman LJ. Personalized Therapy for Mycophenolate: Consensus Report by the International Association of Therapeutic Drug Monitoring and Clinical Toxicology. Ther Drug Monit 2021; 43:150-200. [PMID: 33711005 DOI: 10.1097/ftd.0000000000000871] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/29/2021] [Indexed: 12/13/2022]
Abstract
ABSTRACT When mycophenolic acid (MPA) was originally marketed for immunosuppressive therapy, fixed doses were recommended by the manufacturer. Awareness of the potential for a more personalized dosing has led to development of methods to estimate MPA area under the curve based on the measurement of drug concentrations in only a few samples. This approach is feasible in the clinical routine and has proven successful in terms of correlation with outcome. However, the search for superior correlates has continued, and numerous studies in search of biomarkers that could better predict the perfect dosage for the individual patient have been published. As it was considered timely for an updated and comprehensive presentation of consensus on the status for personalized treatment with MPA, this report was prepared following an initiative from members of the International Association of Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT). Topics included are the criteria for analytics, methods to estimate exposure including pharmacometrics, the potential influence of pharmacogenetics, development of biomarkers, and the practical aspects of implementation of target concentration intervention. For selected topics with sufficient evidence, such as the application of limited sampling strategies for MPA area under the curve, graded recommendations on target ranges are presented. To provide a comprehensive review, this report also includes updates on the status of potential biomarkers including those which may be promising but with a low level of evidence. In view of the fact that there are very few new immunosuppressive drugs under development for the transplant field, it is likely that MPA will continue to be prescribed on a large scale in the upcoming years. Discontinuation of therapy due to adverse effects is relatively common, increasing the risk for late rejections, which may contribute to graft loss. Therefore, the continued search for innovative methods to better personalize MPA dosage is warranted.
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Affiliation(s)
- Stein Bergan
- Department of Pharmacology, Oslo University Hospital and Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Mercè Brunet
- Pharmacology and Toxicology Laboratory, Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBERehd, Spain
| | - Dennis A Hesselink
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Kamisha L Johnson-Davis
- Department of Pathology, University of Utah Health Sciences Center and ARUP Laboratories, Salt Lake City, Utah
| | - Paweł K Kunicki
- Department of Drug Chemistry, Faculty of Pharmacy, Medical University of Warsaw, Warszawa, Poland
| | - Florian Lemaitre
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, Rennes, France
| | - Pierre Marquet
- INSERM, Université de Limoges, Department of Pharmacology and Toxicology, CHU de Limoges, U1248 IPPRITT, Limoges, France
| | - Mariadelfina Molinaro
- Clinical and Experimental Pharmacokinetics Lab, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Ofelia Noceti
- National Center for Liver Tansplantation and Liver Diseases, Army Forces Hospital, Montevideo, Uruguay
| | | | - Tomasz Pawinski
- Department of Drug Chemistry, Faculty of Pharmacy, Medical University of Warsaw, Warszawa, Poland
| | | | - Maria Shipkova
- Synlab TDM Competence Center, Synlab MVZ Leinfelden-Echterdingen GmbH, Leinfelden-Echterdingen, Germany
| | - Jesse J Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Teun van Gelder
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy and Department of Pathology, Starzl Transplantation Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eberhard Wieland
- Synlab TDM Competence Center, Synlab MVZ Leinfelden-Echterdingen GmbH, Leinfelden-Echterdingen, Germany
| | - Jean-Baptiste Woillard
- INSERM, Université de Limoges, Department of Pharmacology and Toxicology, CHU de Limoges, U1248 IPPRITT, Limoges, France
| | - Tom C Zwart
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Markus J Barten
- Department of Cardiac- and Vascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Maja-Theresa Dieterlen
- Department of Cardiac Surgery, Heart Center, HELIOS Clinic, University Hospital Leipzig, Leipzig, Germany
| | - Laure Elens
- Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics (PMGK) Research Group, Louvain Drug Research Institute (LDRI), Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Vincent Haufroid
- Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut de Recherche Expérimentale et Clinique, UCLouvain and Department of Clinical Chemistry, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Satohiro Masuda
- Department of Pharmacy, International University of Health and Welfare Narita Hospital, Chiba, Japan
| | - Olga Millan
- Pharmacology and Toxicology Laboratory, Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBERehd, Spain
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Dirk J A R Moes
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Michael Oellerich
- Department of Clinical Pharmacology, University Medical Center Göttingen, Georg-August-University Göttingen, Göttingen, Germany
| | - Nicolas Picard
- INSERM, Université de Limoges, Department of Pharmacology and Toxicology, CHU de Limoges, U1248 IPPRITT, Limoges, France
| | | | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Nils Tore Vethe
- Department of Pharmacology, Oslo University Hospital and Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Alexander A Vinks
- Department of Pharmacy, International University of Health and Welfare Narita Hospital, Chiba, Japan
| | - Pierre Wallemacq
- Clinical Chemistry Department, Cliniques Universitaires St Luc, Université Catholique de Louvain, LTAP, Brussels, Belgium
| | - Anders Åsberg
- Department of Transplantation Medicine, Oslo University Hospital-Rikshospitalet and Department of Pharmacy, University of Oslo, Oslo, Norway; and
| | - Loralie J Langman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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12
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Charra F, Philippe M, Herledan C, Caffin AG, Larbre V, Baudouin A, Schwiertz V, Vantard N, Labussiere-Wallet H, Ducastelle-Leprêtre S, Barraco F, Balsat M, Larcher MV, Salles G, Rioufol C, Ranchon F. Immunosuppression medication adherence after allogeneic hematopoietic stem cell transplant: Impact of a specialized clinical pharmacy program. J Oncol Pharm Pract 2021:10781552211000115. [PMID: 33683151 DOI: 10.1177/10781552211000115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study aims to evaluate the impact of implementing a specialized clinical pharmacy program in patients with allogeneic hematopoietic stem cell transplant (HSCT) on their adherence to the immunosuppression treatment after discharge. A prospective open interventional design using a retrospective control group was used. The intervention was based on pharmaceutical consultations: the first was performed the day before discharge of HSCT unit and the next consultations during day-care follow-up (weeks 2 and 4 after discharge). Proactive medication reconciliation was implemented with a complete list of medications before the discharge prescription. The discharge prescription summarized on a personalized drug schedule was explained to the patient. The importance of optimal adherence and the potential problems related to self-medication were explained to the patient. Immunosuppression drug adherence was assessed by a direct method using serum levels of calcineurin inhibitors. The potential impact on acute GvHD, and infection was investigated. Twenty-six patients were included in the specialized clinical pharmacy program and 35 patients were in the control group. Seventy-nine pharmaceutical consultations were conducted in the intervention group, lasting a mean 25 min and 16 min for the first and following consultations, respectively. Serum levels in the therapeutic target range were higher in the intervention group (61.5% versus 53.0%, p = 0.07), with greater intra-individual variation (p = 0.005). There was no significant intergroup difference in acute GvHD (53.8% versus 50.3%, p = 0.85) or infection (26.9 versus 22.8%, p = 0.72). The implementation of a specialized clinical pharmacy program for patients who have received allogeneic HSCT seems to be beneficial for immunosuppression drug adherence; this now needs to be confirmed in a multicenter study involving a larger number of patients.
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Affiliation(s)
- Florent Charra
- Hospices Civils de Lyon, Clinical Oncology Pharmacy Department, Groupement Hospitalier Sud, Pierre Bénite, France
| | - Michael Philippe
- Hospices Civils de Lyon, Clinical Oncology Pharmacy Department, Groupement Hospitalier Sud, Pierre Bénite, France
| | - Chloé Herledan
- Hospices Civils de Lyon, Clinical Oncology Pharmacy Department, Groupement Hospitalier Sud, Pierre Bénite, France
- University Lyon 1, EA CICLY Centre pour l'innovation en cancérologie, Lyon, France
| | - Anne-Gaëlle Caffin
- Hospices Civils de Lyon, Clinical Oncology Pharmacy Department, Groupement Hospitalier Sud, Pierre Bénite, France
| | - Virginie Larbre
- Hospices Civils de Lyon, Clinical Oncology Pharmacy Department, Groupement Hospitalier Sud, Pierre Bénite, France
- University Lyon 1, EA CICLY Centre pour l'innovation en cancérologie, Lyon, France
| | - Amandine Baudouin
- Hospices Civils de Lyon, Clinical Oncology Pharmacy Department, Groupement Hospitalier Sud, Pierre Bénite, France
| | - Vérane Schwiertz
- Hospices Civils de Lyon, Clinical Oncology Pharmacy Department, Groupement Hospitalier Sud, Pierre Bénite, France
| | - Nicolas Vantard
- Hospices Civils de Lyon, Clinical Oncology Pharmacy Department, Groupement Hospitalier Sud, Pierre Bénite, France
| | - Hélène Labussiere-Wallet
- Hospices Civils de Lyon, Hematology Department, Blood and Marrow Transplantation Unit, Pierre Bénite, France
| | - Sophie Ducastelle-Leprêtre
- Hospices Civils de Lyon, Hematology Department, Blood and Marrow Transplantation Unit, Pierre Bénite, France
| | - Fiorenza Barraco
- Hospices Civils de Lyon, Hematology Department, Blood and Marrow Transplantation Unit, Pierre Bénite, France
| | - Marie Balsat
- Hospices Civils de Lyon, Hematology Department, Blood and Marrow Transplantation Unit, Pierre Bénite, France
| | - Marie Virginie Larcher
- Hospices Civils de Lyon, Hematology Department, Blood and Marrow Transplantation Unit, Pierre Bénite, France
| | - Gilles Salles
- Hospices Civils de Lyon, Hematology Department, Blood and Marrow Transplantation Unit, Pierre Bénite, France
| | - Catherine Rioufol
- Hospices Civils de Lyon, Clinical Oncology Pharmacy Department, Groupement Hospitalier Sud, Pierre Bénite, France
- University Lyon 1, EA CICLY Centre pour l'innovation en cancérologie, Lyon, France
| | - Florence Ranchon
- Hospices Civils de Lyon, Clinical Oncology Pharmacy Department, Groupement Hospitalier Sud, Pierre Bénite, France
- University Lyon 1, EA CICLY Centre pour l'innovation en cancérologie, Lyon, France
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13
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Kawano N, Matsumoto K, Takami A, Tochigi T, Yoshida S, Kuriyama T, Nakaike T, Shimokawa T, Yamashita K, Mashiba K, Kikuchi I, Nakao S. Pharmacokinetics of anti-thymocyte globulin in a patient with severe aplastic anemia treated with allogeneic bone marrow transplantation from a matched unrelated donor. BLOOD CELL THERAPY 2020; 4:15-19. [PMID: 36712841 PMCID: PMC9847267 DOI: 10.31547/bct-2020-012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/26/2020] [Indexed: 02/01/2023]
Abstract
Anti-thymocyte globulin (ATG) is an important component of preparative regimens for allogeneic bone marrow transplantation (BMT) for aplastic anemia (AA). However, the pharmacokinetics (PK) of ATG are unclear. A 38-year-old woman with severe AA underwent BMT using a fludarabine (Flu)-based and reduced-dose cyclophosphamide (CPA)-conditioning regimen comprising rabbit ATG (2.5 mg/kg, days -7 and -6), Flu (30 mg/sqm, days -5 to -2), CPA (25 mg/kg, days -5 to -2), and total body irradiation (2 Gy, day -1), following a human leukocyte antigen-match with an unrelated donor. Notably, ATG was administered earlier than that recommended by conventional schedules. The engraftment was achieved on day 15 without reactivation of the Epstein-Barr virus and residual recipient cells. Absolute lymphocyte recovery (>0.5×109/L) was achieved on day 22. The ATG concentration on day 0 and the area under the concentration-time curve (AUC) for ATG after allogeneic BMT were 21.8 μg/mL and 464 μg・day/mL, respectively. The patient remained disease-free for 6 years after BMT without acute or chronic graft-versus-host disease. Moreover, based on serum PK monitoring of ATG, including ATG concentration on day 0 and the AUC for ATG after BMT, the patient safely underwent the less-toxic, Flu-based, reduced-dose CPA regimen containing a low dose of ATG. In conclusion, we present the first report that analyzed the PK of ATG in a patient with AA treated with BMT from a matched unrelated donor. These findings might be helpful to determine ATG dosages for such patients receiving similar transplantations.
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Affiliation(s)
- Noriaki Kawano
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Kana Matsumoto
- Department of Clinical Pharmaceutics, Faculty of Pharmaceutical Sciences, Doshisha Women's College of Liberal Arts, Kyotanabe, Japan
| | - Akiyoshi Takami
- Division of Hematology, Department of Internal Medicine, Aichi Medical University School of Medicine, Yazakokarimata, Nagakute, Japan
| | - Taro Tochigi
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Shuro Yoshida
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Takuro Kuriyama
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Takashi Nakaike
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Tomonori Shimokawa
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Kiyoshi Yamashita
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Koichi Mashiba
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Ikuo Kikuchi
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Shinji Nakao
- Department of Hematology, Faculty of Medicine, Institute of Medical Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
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14
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Partanen J, Hyvärinen K, Bickeböller H, Bogunia-Kubik K, Crossland RE, Ivanova M, Perutelli F, Dressel R. Review of Genetic Variation as a Predictive Biomarker for Chronic Graft-Versus-Host-Disease After Allogeneic Stem Cell Transplantation. Front Immunol 2020; 11:575492. [PMID: 33193367 PMCID: PMC7604383 DOI: 10.3389/fimmu.2020.575492] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/28/2020] [Indexed: 12/11/2022] Open
Abstract
Chronic graft-versus-host disease (cGvHD) is one of the major complications of allogeneic stem cell transplantation (HSCT). cGvHD is an autoimmune-like disorder affecting multiple organs and involves a dermatological rash, tissue inflammation and fibrosis. The incidence of cGvHD has been reported to be as high as 30% to 60% and there are currently no reliable tools for predicting the occurrence of cGvHD. There is therefore an important unmet clinical need for predictive biomarkers. The present review summarizes the state of the art for genetic variation as a predictive biomarker for cGvHD. We discuss three different modes of action for genetic variation in transplantation: genetic associations, genetic matching, and pharmacogenetics. The results indicate that currently, there are no genetic polymorphisms or genetic tools that can be reliably used as validated biomarkers for predicting cGvHD. A number of recommendations for future studies can be drawn. The majority of studies to date have been under-powered and included too few patients and genetic markers. Like in all complex multifactorial diseases, large collaborative genome-level studies are now needed to achieve reliable and unbiased results. Some of the candidate genes, in particular, CTLA4, HSPE, IL1R1, CCR6, FGFR1OP, and IL10, and some non-HLA variants in the HLA gene region have been replicated to be associated with cGvHD risk in independent studies. These associations should now be confirmed in large well-characterized cohorts with fine mapping. Some patients develop cGvHD despite very extensive immunosuppression and other treatments, indicating that the current therapeutic regimens may not always be effective enough. Hence, more studies on pharmacogenetics are also required. Moreover, all of these studies should be adjusted for diagnostic and clinical features of cGvHD. We conclude that future studies should focus on modern genome-level tools, such as machine learning, polygenic risk scores and genome-wide association study-transcription meta-analyses, instead of focusing on just single variants. The risk of cGvHD may be related to the summary level of immunogenetic differences, or whole genome histocompatibility between each donor-recipient pair. As the number of genome-wide analyses in HSCT is increasing, we are approaching an era where there will be sufficient data to incorporate these approaches in the near future.
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Affiliation(s)
- Jukka Partanen
- Finnish Red Cross Blood Service, Research and Development, Helsinki, Finland
| | - Kati Hyvärinen
- Finnish Red Cross Blood Service, Research and Development, Helsinki, Finland
| | - Heike Bickeböller
- Department of Genetic Epidemiology, University Medical Center Göttingen, Göttingen, Germany
| | - Katarzyna Bogunia-Kubik
- Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland
| | - Rachel E Crossland
- Haematological Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Milena Ivanova
- Medical University, University Hospital Alexandrovska, Sofia, Bulgaria
| | - Francesca Perutelli
- Haematological Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.,Section of Hematology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Ralf Dressel
- Institute of Cellular and Molecular Immunology, University Medical Center Göttingen, Göttingen, Germany
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15
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Littlejohn K, Tomlinson K, Armenian SH, Nakamura R, Sorror ML, McCune JS. Feasibility of geriatric assessment before transplant conditioning regimen in older HCT recipients. Bone Marrow Transplant 2020; 56:726-729. [PMID: 32989242 DOI: 10.1038/s41409-020-01064-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Kai Littlejohn
- Department of Population Sciences, Beckman Research Institute at City of Hope, Duarte, CA, USA
| | - Kelly Tomlinson
- Department of Hematology & HCT, City of Hope, Duarte, CA, USA
| | - Saro H Armenian
- Department of Population Sciences, Beckman Research Institute at City of Hope, Duarte, CA, USA.,Department of Pediatrics, City of Hope, Duarte, CA, USA
| | - Ryotaro Nakamura
- Department of Population Sciences, Beckman Research Institute at City of Hope, Duarte, CA, USA.,Department of Hematology & HCT, City of Hope, Duarte, CA, USA
| | - Mohamed L Sorror
- Clinical Research Division, Fred Hutchinson Cancer Research Center, and Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jeannine S McCune
- Department of Population Sciences, Beckman Research Institute at City of Hope, Duarte, CA, USA. .,Department of Hematology & HCT, City of Hope, Duarte, CA, USA.
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16
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Labriffe M, Vaidie J, Monchaud C, Debord J, Turlure P, Girault S, Marquet P, Woillard JB. Population pharmacokinetics and Bayesian estimators for intravenous mycophenolate mofetil in haematopoietic stem cell transplant patients. Br J Clin Pharmacol 2020; 86:1550-1559. [PMID: 32073158 DOI: 10.1111/bcp.14261] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 11/12/2019] [Accepted: 12/11/2019] [Indexed: 01/13/2023] Open
Abstract
AIMS Intravenous mycophenolate mofetil (IV MMF), a prodrug of mycophenolic acid (MPA), is used during nonmyeloablative and reduced-intensity conditioning haematopoetic stem cell transplantation (HCT) to improve engraftment and reduce graft-versus-host disease. The aims of this study were to develop population pharmacokinetic models and Bayesian estimators based on limited sampling strategies to allow for individual dose adjustment of intravenous mycophenolate mofetil administered by infusion in haematopoietic stem cell transplant patients. METHODS Sixty-three MPA concentration-time profiles (median [min-max] = 6 [4-7] samples) were collected from 34 HCT recipients transplanted for 14 (1-45) days and administered IV MMF every 8 hours, concomitantly with cyclosporine. The database was split into development (75%) and validation (25%) datasets. Pharmacokinetic models characterized by a single compartment with first-order elimination, combined with two gamma distributions to describe the transformation of MMF into mycophenolic acid, were developed using in parallel nonparametric (Pmetrics) and parametric (ITSIM) approaches. The performances of the models and the derived Bayesian estimators were evaluated in the validation set. RESULTS The best limited sampling strategy led to a bias (min, max), root mean square error between observed and modeled interdose areas under the curve in the validation dataset of -11.72% (-31.08%, 5.00%), 14.9% for ITSIM and -2.21% (-23.40%, 30.01%), 12.4% for Pmetrics with three samples collected at 0.33, 2 and 3 hours post dosing. CONCLUSION Population pharmacokinetic models and Bayesian estimators for IV MMF in HCT have been developed and are now available online (https://pharmaco.chu-limoges.fr) for individual dose adjustment based on the interdose area under the curve.
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Affiliation(s)
- Marc Labriffe
- Department of Pharmacology and Toxicology, CHU Dupuytren, Limoges, France
| | - Julien Vaidie
- Department of Clinical Haematology and Cell Therapy, CHU Dupuytren, Limoges, France
| | - Caroline Monchaud
- Department of Pharmacology and Toxicology, CHU Dupuytren, Limoges, France.,INSERM UMR-S1248, University of Limoges, Limoges, France.,IPPRITT, University of Limoges, Limoges, France
| | - Jean Debord
- Department of Pharmacology and Toxicology, CHU Dupuytren, Limoges, France.,INSERM UMR-S1248, University of Limoges, Limoges, France.,IPPRITT, University of Limoges, Limoges, France
| | - Pascal Turlure
- Department of Clinical Haematology and Cell Therapy, CHU Dupuytren, Limoges, France
| | - Stephane Girault
- Department of Clinical Haematology and Cell Therapy, CHU Dupuytren, Limoges, France
| | - Pierre Marquet
- Department of Pharmacology and Toxicology, CHU Dupuytren, Limoges, France.,INSERM UMR-S1248, University of Limoges, Limoges, France.,IPPRITT, University of Limoges, Limoges, France
| | - Jean-Baptiste Woillard
- Department of Pharmacology and Toxicology, CHU Dupuytren, Limoges, France.,INSERM UMR-S1248, University of Limoges, Limoges, France.,IPPRITT, University of Limoges, Limoges, France
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17
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Shekhovtsova Z, Shelikhova L, Balashov D, Zakharova V, Ilushina M, Voronin K, Kurnikova E, Muzalevskii Y, Kazachenok A, Pershin D, Novichkova G, Maschan A, Maschan M. Control of graft-versus-host disease with rabbit anti-thymocyte globulin, rituximab, and bortezomib in TCRαβ/CD19-depleted graft transplantation for leukemia in children: a single-center retrospective analysis of two GVHD-prophylaxis regimens. Pediatr Transplant 2020; 24:e13594. [PMID: 31680369 DOI: 10.1111/petr.13594] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 04/23/2019] [Accepted: 09/16/2019] [Indexed: 12/22/2022]
Abstract
Both acute GVHD and chronic GVHD remain the leading cause of morbidity and death after allogeneic HSCT. We conducted a retrospective analysis comparing two GVHD-prophylaxis regimens: 35 patients received "Regimen 1" (horse ATG, tacrolimus, and methotrexate) and 46 "Regimen 2" (rabbit ATG, rituximab, and peritransplant bortezomib). All 81 patients with a median age of 9 (0.6-23) years with ALL (n = 31) or AML (n = 50) in complete remission received TCRαβ/CD19-depleted transplants between May 2012 and October 2016, from 40 HLA-matched unrelated and 41 haploidentical donors. After a median follow-up of 3.9 years, the CI of acute GVHD II-IV was 15% (95% CI: 7-30) in the "Regimen 2" group and 34% (95% CI: -54) in the "Regimen 1" group, P = .05. "Regimen 2" was also more effective in the prevention of chronic GVHD; the CI at 1 year after HSCT was 7% (95% CI: 2-19) vs 31% (95% CI: 19-51), P = .005. The CI of relapse at 3 years adjusted for the GVHD-prophylaxis regimen groups 31% (95% CI: 19-51) for the "Regimen 1" vs 21% (95% CI: 11-37) for the "Regimen 2", P = .3. The retrospective observation suggests that the use of the rATG, rituximab, and bortezomib was associated with significantly lower rate of GVHD without the loss of anti-leukemic activity.
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Affiliation(s)
- Zhanna Shekhovtsova
- Department of Hematopoietic Stem Cell Transplantation, Dmitriy Rogachev National Center for Pediatric Hematology, Oncology and Immunology, Moscow, Russia.,Clinical Trials Unit, Dmitriy Rogachev National Center for Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Larisa Shelikhova
- Department of Hematopoietic Stem Cell Transplantation, Dmitriy Rogachev National Center for Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Dmitry Balashov
- Department of Hematopoietic Stem Cell Transplantation, Dmitriy Rogachev National Center for Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Viktoria Zakharova
- Molecular Biology Laboratory, Dmitriy Rogachev National Center for Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Maria Ilushina
- Department of Hematopoietic Stem Cell Transplantation, Dmitriy Rogachev National Center for Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Kirill Voronin
- Clinical Trials Unit, Dmitriy Rogachev National Center for Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Elena Kurnikova
- Transfusion Medicine Service, Dmitriy Rogachev National Center for Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Yakov Muzalevskii
- Transfusion Medicine Service, Dmitriy Rogachev National Center for Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Alexey Kazachenok
- Transfusion Medicine Service, Dmitriy Rogachev National Center for Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Dmitry Pershin
- Transplantation Immunology and Immunotherapy Laboratory, Dmitriy Rogachev National Center for Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Galina Novichkova
- Administration, Dmitriy Rogachev National Center for Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Alexey Maschan
- Department of Hematopoietic Stem Cell Transplantation, Dmitriy Rogachev National Center for Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Michael Maschan
- Department of Hematopoietic Stem Cell Transplantation, Dmitriy Rogachev National Center for Pediatric Hematology, Oncology and Immunology, Moscow, Russia
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Triana P, Miguel M, Díaz M, Cabrera M, López Gutiérrez JC. Oral Sirolimus: An Option in the Management of Neonates with Life-Threatening Upper Airway Lymphatic Malformations. Lymphat Res Biol 2019; 17:504-511. [DOI: 10.1089/lrb.2018.0068] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Paloma Triana
- Department of Pediatric Surgery, La Paz Children's Hospital, Madrid, Spain
| | - Miriam Miguel
- Department of Pediatric Plastic Surgery, La Paz Children's Hospital, Madrid, Spain
| | - Mercedes Díaz
- Department of Pediatric Plastic Surgery, La Paz Children's Hospital, Madrid, Spain
| | - Marta Cabrera
- Department of Neonatology, La Paz Children's Hospital, Madrid, Spain
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Triana Junco PE, Sánchez-Carpintero I, López-Gutiérrez JC. Preventive treatment with oral sirolimus and aspirin in a newborn with severe Sturge-Weber syndrome. Pediatr Dermatol 2019; 36:524-527. [PMID: 31134637 DOI: 10.1111/pde.13841] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Sturge-Weber syndrome (SWS) is characterized by facial capillary malformation, leptomeningeal capillary malformations, and choroidal and episcleral vascular malformations. These malformations produce neurologic and ophthalmological symptoms including seizures and glaucoma. A premature male newborn without prenatal diagnosis presented with severe bilateral SWS and was started on systemic sirolimus and aspirin. The patient has remained seizure-free for 23 months and demonstrated an excellent response to pulsed dye laser treatment.
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20
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Consensus recommendations for the role and competencies of the EBMT clinical pharmacist and clinical pharmacologist involved in hematopoietic stem cell transplantation. Bone Marrow Transplant 2019; 55:62-69. [PMID: 31101890 DOI: 10.1038/s41409-019-0538-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 04/24/2019] [Accepted: 04/27/2019] [Indexed: 11/09/2022]
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