Age-Related Change in Hepatic Clearance Inferred from Multiple Population Pharmacokinetic Studies: Comparison with Renal Clearance and Their Associations with Organ Weight and Blood Flow

PK/PD-Guided Strategies for Appropriate Antibiotic Use in the Era of Antimicrobial Resistance

Antimicrobial resistance (AMR) poses a critical global health threat, necessitating the optimal use of existing antibiotics. Pharmacokinetic/pharmacodynamic (PK/PD) principles provide a scientific framework for optimizing antimicrobial therapy, particularly to respond to evolving resistance patterns. This review examines PK/PD strategies for antimicrobial dosing optimization, focusing on three key aspects. First, we discuss the importance of drug concentration management for enhancing efficacy while preventing toxicity, considering various patient populations, including pediatric and elderly patients with their unique physiological characteristics. Second, we analyze different PK modeling approaches: the classic top-down approach exemplified by population PK analysis, the bottom-up approach represented by physiologically based PK modeling, and hybrid models combining both approaches for enhanced predictive performance. Third, we explore clinical applications, including nomogram-based dosing strategies, Bayesian estimation, and emerging artificial intelligence applications, for real-time dose optimization. Critical challenges in implementing PK/PD simulation are addressed, particularly the selection of appropriate PK models, the optimization of PK/PD indices, and considerations concerning antimicrobial concentrations at infection sites. Understanding these principles and challenges is crucial for optimizing antimicrobial therapy and combating AMR through improved dosing strategies.

[Promoting Research on Modeling and Simulation]

As I recently retired from Chiba University, I would like to describe how I began my research career, some of my accomplishments in the research field of modeling and simulation, and future prospects in this area. Here, I discuss the research topics of drug interactions, the oral absorption of drugs, analyses of between-group and individual differences in pharmacokinetics based on the theories of physiologically-based pharmacokinetics and population pharmacokinetics, and my roles in implementation of the drug interaction guideline. Furthermore, I also discuss modeling topics unrelated to pharmacokinetics, i.e., the analyses of the long-term progression of chronic diseases, such as Alzheimer's disease, Parkinson's disease, and chronic obstructive pulmonary disease using individual patient information; the spread of the coronavirus disease 2019 (COVID-19) pandemic; and prognostic factors of chronic heart failure with the view towards personalized medicine. After completing my Master's course at Hokkaido University, I joined a pharmaceutical company and worked as a pharmacokinetics researcher for 21 years, while obtaining my doctoral degree. I spent the next 9 years as a hospital pharmacist focusing on scientific research at the University of Tokyo Hospital, and the last 10 years as a Professor of Clinical Pharmacology and Pharmacometrics at Chiba University. My career is, therefore, characterized by involvement in pharmaceutical sciences from many different perspectives. This description focuses rather on the background of the studies than scientific details.

Presence of N, N'-Substituted p-Phenylenediamine-Derived Quinones in Human Urine

Human exposure to various N,N'-substituted p-phenylenediamine-derived quinones (PPDQs) has been of increasing concern. Recent studies have examined N-phenyl-N'-(1,3-dimethylbutyl)-p-phenylenediamine-derived quinone (6PPDQ) in human urine to evaluate human exposure. However, other PPDQs in human urine have not been thoroughly investigated. This study analyzed six PPDQs in urine collected from 149 healthy individuals in Taizhou, China. All target PPDQs were detected, with 6PPDQ (mean 2.4 ng/mL, Collapse

Key Words

• 6PPDQ
• CPPDQ
• human exposure
• human urine
• p-phenylenediamine-derived quinones

Collapse

MESH Headings Collapse

Grants

• LY21B070006 Natural Science Foundation of Zhejiang Province
• LY21H160008 Natural Science Foundation of Zhejiang Province
• LBY23H200003 Natural Science Foundation of Zhejiang Province

Collapse

Affiliation(s)

Juxiu Huang Taizhou Central Hospital (Taizhou University Hospital), School of Medicine, Taizhou University, Taizhou 318000, China; (J.H.); (L.Z.)
Hangbiao Jin Key Laboratory of Microbial Technology for Industrial Pollution Control of Zhejiang Province, College of Environment, Zhejiang University of Technology, Hangzhou 310032, China; (H.J.); (R.G.)
Yingying Zhu School of Life Sciences, Taizhou University, Taizhou 318000, China;
Ruyue Guo Key Laboratory of Microbial Technology for Industrial Pollution Control of Zhejiang Province, College of Environment, Zhejiang University of Technology, Hangzhou 310032, China; (H.J.); (R.G.)
Lisha Zhou Taizhou Central Hospital (Taizhou University Hospital), School of Medicine, Taizhou University, Taizhou 318000, China; (J.H.); (L.Z.)
Xiaoyu Wu Taizhou Central Hospital (Taizhou University Hospital), School of Medicine, Taizhou University, Taizhou 318000, China; (J.H.); (L.Z.)

Collapse

Effect of concomitant use of yokukansan on steady-state blood concentrations of donepezil and risperidone in real-world clinical practice

AIM

Yokukansan is one of the most frequently used herbal medicines that can improve the behavioral and psychological symptoms of dementia. In this exploratory study, we investigated whether yokukansan affects the steady-state blood concentrations of donepezil, risperidone, and the major metabolites of both drugs in a real-world clinical setting.

METHODS

A non-randomized, open-label, single-arm study examining drug-drug interactions was conducted. Fifteen dementia patients taking donepezil for at least 4 weeks and eight schizophrenia patients taking risperidone for at least 2 weeks were orally administered 2.5 g of yokukansan three times a day before or between meals, and blood samples were collected before and 8 weeks after starting co-treatment with yokukansan. Plasma concentrations of donepezil, risperidone, and each metabolite were measured using high-performance liquid chromatography-tandem mass spectrometry and compared before and after the 8-week administration of yokukansan.

RESULTS

The plasma concentrations of donepezil and its metabolites (6-O-desmethyl-donepezil, 5-O-desmethyl-donepezil, and donepezil-N-oxide), risperidone, and its metabolite paliperidone did not differ before and after the 8-week treatment with yokukansan.

CONCLUSIONS

The findings of this study show that the concomitant use of yokukansan may have little clinical impact on the steady-state blood levels of donepezil and risperidone in patients with dementia or schizophrenia.

From sutureless to standard: a comprehensive analysis of conversion rates in laparoscopic partial nephrectomy

OBJECTIVE

To assess the rate at which sutureless partial nephrectomy (SLPN) transitions to standard partial nephrectomy (SPN), focusing on preoperative factors that might prompt such conversions.

PATIENTS AND METHODS

In this retrospective study, we analyzed the efficacy of SLPN performed on adults at our institution from 2016 to 2023. The subjects were patients diagnosed with localized solid renal tumors. The primary technique employed was resection with scissors and argon beam coagulation for hemostasis, with suturing techniques used only when necessary. Predictive factors necessitating conversion to SPN were identified, and the associations among multiple variables were explored using various statistical analysis methods, including logistic regression, to identify key preoperative predictive factors.

RESULTS

Our institution performed 353 SLPN, with 21 cases (5.9%) necessitating conversion to SPN. The conversion rates for the Laparoscopic Partial Nephrectomy (LPN) subgroup and the Robotic-assist Partial Nephrectomy (RPN) subgroup were 7.9% (17/215) and 2.9% (4/138), respectively, nearing statistical significance (P = .066). Significant differences were observed between the conversion group and the no conversion group in terms of preoperative estimated Glomerular Filtration Rate (eGFR), age at surgery, tumor size, and exophytic/endophytic characteristics. Multivariate analysis identified age at surgery, preoperative eGFR, radiological tumor size, and tumor exophytic/endophytic nature as significant predictors for conversion to SPN.

CONCLUSION

This investigation highlights the efficacy and feasibility of SLPN while identifying critical factors influencing the necessity for conversion to SPN. The identified predictors, including younger surgical age, superior preoperative eGFR, and specific tumor characteristics, provide valuable insights for refining surgical strategies.

Association between use of vitamin and mineral supplement and non-alcoholic fatty liver disease in hypertensive adults

Non-alcoholic fatty liver disease (NAFLD) is the most common hepatic metabolic disorder in hypertensive adults. Impaired metabolism of micronutrients may increase NAFLD risk by exacerbating oxidative stress, insulin resistance, and inflammation among hypertensive adults. In this first cross-sectional analysis of 7,376 hypertensive adults with 2,015 NAFLD cases in the Korea National Health and Nutrition Examination Survey, vitamin and mineral supplements (VMS) use was identified via questionnaire. NAFLD was defined by a hepatic steatosis index > 36. Multivariable-adjusted odds ratios (MVOR) and 95% confidence intervals (CIs) were calculated using logistic regression models. In our study, 18.6% were current users of VMS; of these, 76.7% used multi-vitamin/mineral supplements. Current VMS users had significantly lower odds of NAFLD, compared with non-users (MVOR [95% CI]: 0.73 [0.58-0.92]). The inverse association became attenuated and non-significant among those consuming VMS at higher frequency (≥ 2 times/day), for longer duration (> 16 months), and taking ≥ 2 VMS products. The inverse association with current use of VMS was only evident in those aged < 56 years (MVOR [95% CI]: 0.54 [0.40-0.72]) and men (MVOR [95% CI]: 0.56 [0.40-0.80])(Pinteraction ≤ 0.04). Our results suggest that VMS use may lower NAFLD risk, particularly among younger or male hypertensive adults, if taken in moderation.

Exposure to volatile hydrocarbons and neurologic function among oil spill workers up to 6 years after the Deepwater Horizon disaster

BACKGROUND

During the 2010 Deepwater Horizon (DWH) disaster, oil spill response and cleanup (OSRC) workers were exposed to toxic volatile components of crude oil. Few studies have examined exposure to individual volatile hydrocarbon chemicals below occupational exposure limits in relation to neurologic function among OSRC workers.

OBJECTIVES

To investigate the association of several spill-related chemicals (benzene, toluene, ethylbenzene, xylene, n-hexane, i.e., BTEX-H) and total petroleum hydrocarbons (THC) with neurologic function among DWH spill workers enrolled in the Gulf Long-term Follow-up Study.

METHODS

Cumulative exposure to THC and BTEX-H across the oil spill cleanup period were estimated using a job-exposure matrix that linked air measurement data to detailed self-reported DWH OSRC work histories. We ascertained quantitative neurologic function data via a comprehensive test battery at a clinical examination that occurred 4-6 years after the DWH disaster. We used multivariable linear regression and modified Poisson regression to evaluate relationships of exposures (quartiles (Q)) with 4 neurologic function measures. We examined modification of the associations by age at enrollment (<50 vs. ≥50 years).

RESULTS

We did not find evidence of adverse neurologic effects from crude oil exposures among the overall study population. However, among workers ≥50 years of age, several individual chemical exposures were associated with poorer vibrotactile acuity of the great toe, with statistically significant effects observed in Q3 or Q4 of exposures (range of log mean difference in Q4 across exposures: 0.13-0.26 μm). We also observed suggestive adverse associations among those ≥ age 50 years for tests of postural stability and single-leg stance, although most effect estimates did not reach thresholds of statistical significance (p < 0.05).

CONCLUSIONS

Higher exposures to volatile components of crude oil were associated with modest deficits in neurologic function among OSRC workers who were age 50 years or older at study enrollment.

Hyperkalemia by eplerenone or esaxerenone in the presence or absence of clarithromycin in hypertensive patients: a retrospective observational cohort study

OBJECTIVE

Mineralocorticoid receptor antagonists (MRAs), eplerenone and esaxerenone, cause hyperkalemia dose-dependently. We investigated the cytochrome P450 3A4-mediated drug-drug interaction between the MRAs and clarithromycin.

METHODS

This retrospective observational study included adult hypertensive patients with MRA plus clarithromycin or MRA alone with a propensity score matching (1:1). The difference in serum potassium level (ΔK, maximum level - baseline level) between groups was compared using the Mann-Whitney U -test. Linear regression analysis was used to detect variables that correlated with ΔK in patients with MRA plus clarithromycin.

RESULTS

After propensity score matching (each nine patients), serum potassium level was elevated after treatment with MRA plus clarithromycin [4.3 (3.5 to 5.1) meq/l to 4.9 (4.0 to 5.5) meq/l, P  = 0.0234] and MRA alone [4.3 (4.0 to 4.7) meq/l to 4.6 (4.4 to 5.2) meq/l, P  = 0.0469]. Although there was no significant difference in ΔK between groups [MRA plus clarithromycin: 0.5 (0.1 to 1.1) meq/l vs. MRA alone: 0.3 (0.1 to 1.2) meq/l, P  = 0.7231], ΔK was significantly higher in esaxerenone plus clarithromycin than in esaxerenone alone [0.6 (0.5 to 1.1) meq/l vs. 0.1 (0.1 to 0.2) meq/l, P  = 0.0495]. Conversely, clarithromycin did not show a significant effect on ΔK in patients with eplerenone [0.4 (-0.2 to 1.2) meq/l vs. 0.8 (0.1 to 1.3) meq/l, P  = 0.5745]. A positive correlation was found between ΔK and age in patients with MRA plus clarithromycin ( y  = 0.03 ×  x - 1.38, r  = 0.71, P  = 0.0336).

CONCLUSION

The drug-drug interaction between MRAs and clarithromycin was evident, particularly in esaxerenone. Serum potassium levels should be closely monitored in older patients.

Positive Correlation Between Changes in Serum Albumin Levels and Breakfast Non-Protein Calorie/Nitrogen Ratio in Geriatric Patients

Background

Differences in nutrition intake by meal intake time of geriatric patients may affect albumin (Alb) synthesis ability.

Methods

We included 36 geriatric patients (81.7 ± 7.7 years; 20 males and 16 females) as subjects. We calculated their dietary patterns (DPs) by computing intake by breakfast, lunch, and dinner, as well as by nutrient, for a weight of 1 kg/day for 4 weeks after hospitalization. We confirmed the relationship between "DP with a positive correlation with breakfast protein" and the change rate of albumin (Alb-RC). Then, we performed linear regression analysis to explore factors influencing Alb-RC and compared non-protein calorie/nitrogen ratio (NPC/N) between the upper and lower Alb-RC groups.

Results

It was observed that Alb-RC was negatively correlated with "DP with a positive correlation with breakfast protein" (B = -0.055, P = 0.038) and positively correlated with breakfast NPC/N (B = 0.043, P = 0.029). Breakfast NPC/N tended to be higher in the upper group than in the lower group (P = 0.058).

Conclusion

The study revealed that there was a positive correlation between Alb-RC levels and breakfast NPC/N in geriatric patients at the care mix institution.

The status and natural impact of floriculture production in Ethiopia: a systematic review

Ethiopia's floriculture industry is exceedingly emerging, and, currently, it ranks as the sixth largest exporter of roses worldwide and second largest in Africa. Currently, many flowers, such as rose, gypsophila, carnations, and chrysanthemum, are growing. However, floriculture farms are contributing a high level of health risks and environmental problems in Ethiopia. Thus, the purpose of this paper is to scrutinize the status and impacts of floriculture industries in Ethiopia. The floriculture division is an emerging sector in Ethiopia, and the number of farms, income, job opportunities, and diversity of flowers are increasing. However, the health risks and environmental fates of the sector are also increasing. Ethiopian floriculture farms lack waste disposal technologies and workers' protective equipment and safety, and the chemicals, plastics, and corrugated irons used in the farms are carelessly disposed everywhere. Pesticides, plastics, and fertilizers are also freely discharged into water bodies and terrestrial land, which is causing the development of health risks; aquatic life hazards; and soil, water, and air pollution. However, Ethiopia has no strong and functional system or structure to control the impacts of floriculture farms. The government and the farm owners are not thoughtful about the environmental issues, health concerns, and socioeconomic impacts of the wastes. The government lacks regular control and assessment of farms, and the farms are engaging for their profit. Nevertheless, developed countries are currently using both natural and modern technologies to manage floricultural wastes. Ethiopia should therefore suggest manageable possible approaches and sound management strategies based on the findings of the analyses.

Population pharmacokinetics of nalbuphine in patients undergoing general anesthesia surgery

Purpose: The aim of this study was to build a population pharmacokinetics (PopPK) model of nalbuphine and to estimate the suitability of bodyweight or fixed dosage regimen. Method: Adult patients who were undergoing general anesthetic surgery using nalbuphine for induction of anesthesia were included. Plasma concentrations and covariates information were analyzed by non-linear mixed-effects modeling approach. Goodness-of-fit (GOF), non-parametric bootstrap, visual predictive check (VPC) and external evaluation were applied for the final PopPK model evaluation. Monte Carlo simulation was conducted to assess impact of covariates and dosage regimens on the plasma concentration to nalbuphine. Results: 47 patients aged 21-78 years with a body weight of 48-86 kg were included in the study. Among them, liver resection accounted for 14.8%, cholecystectomy for 12.8%, pancreatic resection for 36.2% and other surgeries for 36.2%. 353 samples from 27 patients were enrolled in model building group; 100 samples from 20 patients were enrolled in external validation group. The results of model evaluation showed that the pharmacokinetics of nalbuphine was adequately described by a two-compartment model. The hourly net fluid volume infused (HNF) was identified as a significant covariate about the intercompartmental clearance (Q) of nalbuphine with objective function value (OFV) decreasing by 9.643 (p < 0.005, df = 1). Simulation results demonstrated no need to adjust dosage based on HNF, and the biases of two dosage methods were less than 6%. The fixed dosage regimen had lower PK variability than the bodyweight regimen. Conclusion: A two-compartment PopPK model adequately described the concentration profile of nalbuphine intravenous injection for anesthesia induction. While HNF can affect the Q of nalbuphine, the magnitude of the effect was limited. Dosage adjustment based on HNF was not recommended. Furthermore, fixed dosage regimen might be better than body weight dosage regimen.

Pharmacokinetic Study of Nalbuphine in Surgical Patients Undergoing General Anesthesia with Varying Degrees of Liver Dysfunction

Purpose

This study aimed to characterize the pharmacokinetics of nalbuphine in patients undergoing general anesthesia with varying degrees of liver dysfunction.

Patients and Methods

Twenty-four patients were enrolled and divided into three cohorts based on liver function: normal liver function (n = 13), mild liver dysfunction (n = 5), and moderate/severe liver dysfunction (n = 6). During the induction of anesthesia, they received 15 mg of nalbuphine intravenously. Venous blood samples were collected from each patient. The plasma concentration of nalbuphine was determined using ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). The pharmacokinetic parameters of nalbuphine were calculated by non-compartmental analysis (NCA) using Phoenix WinNonlin software.

Results

Compared with the normal liver function group, the plasma elimination half-life (T_1/2) of nalbuphine was increased by approximately 33% in the moderate/severe liver dysfunction group (2.66 h vs 3.54 h, P<0.05), and the volume of distribution (V_d) increased by approximately 85% (100.08 L vs 184.95 L, P<0.05). Multivariate analysis revealed that weight and platelet were associated with clearance (CL); total bilirubin as an independent factor was associated with T_1/2, and weight associated with area under the curve (AUC_(0→∞)) independently.

Conclusion

The T_1/2, mean residence time, and V_d of nalbuphine in patients with moderate/severe liver dysfunction were prolonged or increased significantly compared with those in the normal liver function group. These data suggest that it may need to be used with caution when nalbuphine is administered to patients with moderate or severe liver dysfunction.

The characteristics of patients receiving psychotropic pro re nata medication at discharge for the treatment of schizophrenia and major depressive disorder: A nationwide survey from the EGUIDE project

BACKGROUND

Although several guidelines indicate that daily pharmacotherapy is an important part of the treatment of schizophrenia and major depressive disorder, there are few reports regarding pro re nata (PRN) prescriptions. The purpose of this study is to clarify the characteristics of patients receiving psychotropic PRN prescription for the treatment of schizophrenia and major depressive disorder.

METHOD

We used data from 'the effectiveness of guideline for dissemination and education in psychiatric treatment' (EGUIDE) project to evaluate the presence or absence of psychotropic PRN prescription at the time of discharge, the age and sex of patients receiving PRN prescription for each diagnosis, and the association between PRN prescription and regular daily psychotropics.

RESULTS

The psychotropic PRN prescription ratio was 29.9% among 2617 patients with schizophrenia and 31.1% among 1248 patients with major depressive disorder at discharge. In schizophrenia, the psychotropic PRN prescription ratio was 21.6% for patients aged 65 years or older, which was lower than that of all other age groups. In major depressive disorder, the psychotropic PRN prescription ratio was 34.2% for female patients, which was significantly higher than that for male patients (25.5%). In schizophrenia, there was an association between psychotropic PRN prescription and regular use of multiple psychotropic medications.

CONCLUSIONS

Psychotropic PRN prescription was less common in elderly patients with schizophrenia and more common in female patients with major depressive disorder. In schizophrenia, psychotropic PRN prescription led to polypharmacy of psychotropics. Further studies are needed to accumulate evidence and to provide education on appropriate PRN prescriptions.