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Dhanani JA, Shekar K, Parmar D, Lipman J, Bristow D, Wallis SC, Won H, Sumi CD, Abdul-Aziz MH, Roberts JA. COVID-19 Drug Treatments Are Prone to Sequestration in Extracorporeal Membrane Oxygenation Circuits: An Ex Vivo Extracorporeal Membrane Oxygenation Study. ASAIO J 2024; 70:546-552. [PMID: 38829573 DOI: 10.1097/mat.0000000000002120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
Drug treatments for coronavirus disease 2019 (COVID-19) dramatically improve patient outcomes, and although extracorporeal membrane oxygenation (ECMO) has significant use in these patients, it is unknown whether ECMO affects drug dosing. We used an ex vivo adult ECMO model to measure ECMO circuit effects on concentrations of specific COVID-19 drug treatments. Three identical ECMO circuits used in adult patients were set up. Circuits were primed with fresh human blood (temperature and pH maintained within normal limits). Three polystyrene jars with 75 ml fresh human blood were used as controls. Remdesivir, GS-441524, nafamostat, and tocilizumab were injected in the circuit and control jars at therapeutic concentrations. Samples were taken from circuit and control jars at predefined time points over 6 h and drug concentrations were measured using validated assays. Relative to baseline, mean (± standard deviation [SD]) study drug recoveries in both controls and circuits at 6 h were significantly lower for remdesivir (32.2% [±2.7] and 12.4% [±2.1], p < 0.001), nafamostat (21.4% [±5.0] and 0.0% [±0.0], p = 0.018). Reduced concentrations of COVID-19 drug treatments in ECMO circuits is a clinical concern. Remdesivir and nafamostat may need dose adjustments. Clinical pharmacokinetic studies are suggested to guide optimized COVID-19 drug treatment dosing during ECMO.
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Affiliation(s)
- Jayesh A Dhanani
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Dinesh Parmar
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Jeffrey Lipman
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Jamieson Trauma Institute, Royal Brisbane and Womens Hospital
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Debra Bristow
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Steven C Wallis
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
| | - Hayoung Won
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
| | - Chandra D Sumi
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
| | - Mohd H Abdul-Aziz
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
| | - Jason A Roberts
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Jamieson Trauma Institute, Royal Brisbane and Womens Hospital
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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Sunny S, Tran A, Lee J, Abdallah M, Chaudhry N, Quale J. Comparison of Tocilizumab vs Baricitinib in Clinical Outcomes Among Hospitalized Patients With COVID-19: Experience From a Public Hospital System in New York City. Open Forum Infect Dis 2023; 10:ofad426. [PMID: 37608917 PMCID: PMC10442059 DOI: 10.1093/ofid/ofad426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023] Open
Abstract
Background Tocilizumab and baricitinib are immunomodulators that have been repurposed for the treatment of coronavirus disease 2019 (COVID-19). Whether one medication should be preferred over the other has not been established. Methods This multicenter retrospective cohort study comprised hospitalized patients with COVID-19 who received either tocilizumab or baricitinib. The primary outcome was improvement in respiratory status (at least 1-point reduction on the respiratory ordinal scale) at day 7 and up to day 28. Secondary outcomes included mortality, disposition, deep vein thrombosis, pulmonary embolism, or positive blood culture. Outcomes were stratified by baseline respiratory status and variant-predominating periods. Results were reported for the overall and propensity-matched cohorts. Results A total of 921 patients received tocilizumab and 638 received baricitinib. The propensity-matched cohort included 597 patients in each group. At day 7 in the overall and propensity-matched cohorts, significantly more patients had improvement in respiratory status in the baricitinib group. These improvements were seen in patients requiring supplemental oxygen and noninvasive ventilation/high-flow oxygen but not in patients requiring mechanical ventilation. Favorable outcomes with baricitinib were observed during the Alpha and Omicron periods. By day 28, there were no differences in the changes of respiratory status for the treatment groups in either cohort. Also, no differences were seen in mortality, disposition, development of deep vein thrombosis/pulmonary embolism, or bloodstream infections. Conclusions Baricitinib treatment was associated with more favorable respiratory improvement at day 7 when compared with tocilizumab, but no differences were observed up to day 28.
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Affiliation(s)
- Subin Sunny
- Division of Infectious Diseases, Department of Medicine, NYC Health + Hospitals/Kings County, Brooklyn, New York, USA
| | - Ami Tran
- Division of Infectious Diseases, Department of Medicine, NYC Health + Hospitals/Kings County, Brooklyn, New York, USA
| | - Jennifer Lee
- Division of Infectious Diseases, Department of Medicine, NYC Health + Hospitals/Kings County, Brooklyn, New York, USA
| | - Marie Abdallah
- Division of Infectious Diseases, Department of Medicine, NYC Health + Hospitals/Kings County, Brooklyn, New York, USA
| | - Nimra Chaudhry
- Department of Pharmacy, NYC Health + Hospitals/Queens, Queens, New York, USA
| | - John Quale
- Division of Infectious Diseases, Department of Medicine, NYC Health + Hospitals/Kings County, Brooklyn, New York, USA
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Su YJ, Chen HM, Chan TM, Cheng TT, Yu SF, Chen JF, Lin CY, Hsu CY. Disease-modifying anti-rheumatic drugs associated with different diabetes risks in patients with rheumatoid arthritis. RMD Open 2023; 9:e003045. [PMID: 37460274 DOI: 10.1136/rmdopen-2023-003045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/25/2023] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVES Patients with rheumatoid arthritis are prone to developing diabetes, which may lead to various sequelae and even cardiovascular diseases, the most common cause of death in such patients. Previous research has shown that some rheumatoid arthritis treatments may help prevent the development of diabetes. This study aimed to investigate whether patients using disease-modifying anti-rheumatic drugs (DMARDs) may have different levels of risk for diabetes and to analyse other risk factors for diabetes. METHODS This cohort study used data from the Chang Gung Research Database. 5530 adults with rheumatoid arthritis but without diabetes were eligible for the analysis. The endpoint of this study was new-onset diabetes, defined as an HbA1c value ≥7% during follow-up. The entire follow-up period was divided into monthly subunits. These 1-month units were then divided into methotrexate (MTX) monotherapy, any biological DMARDs (bDMARDs), MTX combination, other conventional DMARDs (cDMARDs) and non-DMARDs. RESULTS A total of 546 participants (9.87%) developed diabetes between 2001 and 2018. The risk of diabetes was significantly lower in the bDMARD periods (HR 0.51; 95% CI 0.32 to 0.83), MTX combination periods (HR 0.50; 95% CI 0.32 to 0.78) and other cDMARD periods (HR 0.56; 95% CI 0.37 to 0.84) than in the MTX monotherapy periods. Individual drug analysis showed that hydroxychloroquine (HR 0.52; 95% CI 0.42 to 0.65) reduced the risk of diabetes. Tumour necrosis factor-α inhibitors (HR 0.69; 95% CI 0.46 to 1.03) tended to be protective. CONCLUSION Patients with rheumatoid arthritis may have different levels of risk of diabetes depending on the treatment options.
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Affiliation(s)
- Yu-Jih Su
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan, R O C
- Institute of Biopharmaceutical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan, R O C
| | - Hui-Ming Chen
- Department of Family Medicine and Occupational Medicine, Chang Gung Memorial Hospital Kaohsiung Branch, Kaohsiung, Taiwan
| | - Tien-Ming Chan
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung University and Chang Gung Memorial Hospital, Tao-Yuan, Taiwan
| | - Tien-Tsai Cheng
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan, R O C
| | - Shan-Fu Yu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan, R O C
| | - Jia-Feng Chen
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan, R O C
| | - Chun-Yu Lin
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Health Business Administration, Fooyin University, Kaohsiung, Taiwan
| | - Chung-Yuan Hsu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan, R O C
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Tomaszewska-Kiecana M, Dryja A, Ullmann M, Petit-Frere C, Illes A, Dagres C, Monnet J. Pharmacokinetics and tolerability of prefilled syringe and auto-injector presentations of MSB11456: results of a randomized, single-dose study in healthy adults. Expert Rev Clin Immunol 2023; 19:447-455. [PMID: 36789991 DOI: 10.1080/1744666x.2023.2174970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND Tocilizumab is a monoclonal immunoglobulin G interleukin-6 receptor antagonist. MSB11456 is a proposed tocilizumab biosimilar. OBJECTIVE To determine the pharmacokinetic equivalence of a single subcutaneous injection of MSB11456, when delivered via autoinjector (AI) and prefilled syringe (PFS), in healthy adult subjects. RESEARCH DESIGN AND METHODS In this randomized, open-label, single fixed-dose, crossover study, 91 subjects received subcutaneous administration of tocilizumab 162 mg via AI and PFS presentations. The primary endpoint pharmacokinetic parameters were analyzed using analysis of variance. Safety data were summarized descriptively. RESULTS There were no differences in pharmacokinetic parameters between presentations, and safety parameters were comparable. The 90% confidence intervals for the geometric least squares mean ratios of all primary pharmacokinetic parameters were contained within the predefined 80.00% to 125.00% bioequivalence limits, indicating pharmacokinetic equivalence between the AI and PFS. CONCLUSIONS MSB11456 administration via AI was bioequivalent to administration via PFS. MSB11456 can be administered by AI or PFS, increasing the available range of self-injection devices. TRIAL REGISTRATION The trial is registered at EudraCT, number 2020-003419-86.
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Affiliation(s)
| | - Anna Dryja
- MTZ Clinical Research Sp Z O O, Warsaw, Poland
| | | | | | - Andras Illes
- Biosimilars, Fresenius Kabi SwissBioSim, Switzerland
| | | | - Joëlle Monnet
- Biosimilars, Fresenius Kabi SwissBioSim, Switzerland
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Tomaszewska-Kiecana M, Ullmann M, Petit-Frere C, Monnet J, Dagres C, Illes A. Pharmacokinetics of a proposed tocilizumab biosimilar (MSB11456) versus US-licensed tocilizumab: results of a randomized, double-blind, single-intravenous dose study in healthy adults. Expert Rev Clin Immunol 2023; 19:439-446. [PMID: 36715299 DOI: 10.1080/1744666x.2023.2174104] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tocilizumab, a recombinant monoclonal immunoglobulin G, targets the interleukin-6 receptor. MSB11456 is a proposed tocilizumab biosimilar. OBJECTIVES To assess pharmacokinetic equivalence of intravenous MSB11456 to US-licensed tocilizumab. RESEARCH DESIGN AND METHODS In this double-blind, parallel-group, single-dose study, 128 healthy adults were randomized to a single one-hour 8 mg/kg IV infusion of either MSB11456 or US-licensed tocilizumab. Blood samples were collected pre-dose and at regular intervals up to day 48 post-dose. The primary endpoint pharmacokinetic parameter was analyzed using analysis of variance (ANOVA) model on the natural logarithm of the endpoint (AUC0-last), with treatment as a fixed effect. Immunogenicity and safety data were summarized descriptively. RESULTS Subjects received either MSB11456 (N = 62) or US-licensed tocilizumab (N = 66). Pharmacokinetic bioequivalence, defined as 90% confidence intervals for the geometric least squares mean ratio entirely contained within the 80.00% to 125.00% equivalence limits, was demonstrated between MSB11456 and US-licensed tocilizumab for the primary and secondary pharmacokinetic endpoints. Anti-drug antibody responses, frequency of neutralizing antibodies against tocilizumab, and safety profiles showed no notable between-treatment differences. Safety was comparable between treatments. CONCLUSIONS Pharmacokinetic similarity of MSB11456 and US-licensed tocilizumab was demonstrated, with comparable immunogenicity and safety profiles, supporting MSB11455 as a biosimilar to US-licensed tocilizumab. The trial is registered at EudraCT, number 2019-003484-22.
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Affiliation(s)
| | - Martin Ullmann
- Biosimilars, Fresenius Kabi SwissBioSim, Eysins, Switzerland
| | | | - Joëlle Monnet
- Biosimilars, Fresenius Kabi SwissBioSim, Eysins, Switzerland
| | - Christos Dagres
- Biosimilars, Fresenius Kabi SwissBioSim, Eysins, Switzerland
| | - Andras Illes
- Biosimilars, Fresenius Kabi SwissBioSim, Eysins, Switzerland
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Tavlueva EV, Zernova EV, Kutepova MP, Kostina NE, Lesina VS, Mould DR, Ito K, Zinchenko AV, Dolgorukova AN, Nikolskaya MV, Lemak MS, Filon OV, Samsonov MY. CHARACTERISTICS OF OLOKIZUMAB PHARMACOKINETICS IN PATIENTS WITH NOVEL CORONAVIRUS INFECTION COVID-19. PHARMACY & PHARMACOLOGY 2022. [DOI: 10.19163/2307-9266-2022-10-5-460-471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The aim of the article is to study pharmacokinetic characteristics of intravenous olokizumab in patients with moderate COVID-19 to relieve a hyperinflammation syndrome.Materials and methods. The pharmacokinetic study was conducted as a part of a phase III clinical study (RESET, NCT05187793) on the efficacy and safety of a new olokizumab regimen (intravenous, at the doses of 128 mg or 256 mg) in COVID-19 patients. Plasma concentrations of olokizumab were determined by the enzyme immunoassay. The population analysis was performed using a previously developed pharmacokinetic model based on a linear two compartment.Results. The pharmacokinetic analysis included the data from 8 moderate COVID-19 patients who had been administrated with olokizumab intravenously at the dose of 128 mg. According to the analysis results in this population, there was an increase in the drug clearance, compared with the data obtained in healthy volunteers and the patients with rheumatoid arthritis: 0.435, 0.178 and 0.147 l/day, respectively. The parameters analysis within the framework of a population pharmacokinetic model showed that the main factors for the increased olokizumab clearance are a high body mass index. In addition, the presence of COVID-19 itself is an independent factor in increasing the drug clearance.Conclusion. After the intravenous olokizumab administration, an increase in the drug clearance is observed in moderate COVID-19 patients against the background of the disease course. The main contribution to the increased clearance is made by the characteristics of the population of COVID-19 patients associated with the risk of a severe disease and inflammation. When administered intravenously at the dose of 128 mg, a therapeutically significant olokizumab level was maintained throughout the acute disease phase for 28 days.
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Affiliation(s)
| | | | | | | | | | | | - K. Ito
- Projections Research, Inc
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Righi E, Lambertenghi L, Gorska A, Sciammarella C, Ivaldi F, Mirandola M, Sartor A, Tacconelli E. Impact of COVID-19 and Antibiotic Treatments on Gut Microbiome: A Role for Enterococcus spp. Biomedicines 2022; 10:2786. [PMID: 36359311 PMCID: PMC9687172 DOI: 10.3390/biomedicines10112786] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 08/29/2023] Open
Abstract
OBJECTIVE Several studies showed the substantial use of antibiotics and increased risk of antimicrobial resistant infections in patients with COVID-19. The impact of COVID-19-related treatments and antibiotics on gut dysbiosis has not been clarified. DESIGN The prospective cohort study included hospitalized COVID-19 patients (April-December 2020). The gut microbiome composition was analysed by 16S sequencing. The gut diversity and changes in opportunistic bacteria (OBs) or symbionts were analysed according to clinical parameters, laboratory markers of disease progression, type of non-antibiotic COVID-19 treatments (NACT) and type, WHO AWaRe group, and duration of antibiotic therapy (AT). RESULTS A total of 82 patients (mean age 66 ± 13 years, 70% males) were enrolled. The relative abundance of Enterococcus was significantly correlated with duration of hospitalization, intensive care unit stay, O2 needs, and D-dimer, ferritin, and IL-6 blood levels. The presence of Enterococcus showed the highest number of correlations with NACT, AT, and AT + NACT (e.g., hydroxychloroquine ± lopinavir/ritonavir) and increased relative abundance with AWaRe Watch/Reserve antibiotics, AT duration, and combinations. Abundance of Dorea, Agathobacter, Roseburia, and Barnesiella was negatively correlated with AT and corticosteroids use. Patients with increased IL-6, D-dimer, and ferritin levels receiving AT were more likely to show dysbiosis with increased abundance of Enterococcus and Bilophila bacteria and decreased abundance of Roseburia compared with those not receiving AT. CONCLUSION Microbiome diversity is affected by COVID-19 severity. In this context, antibiotic treatment may shift the gut microbiome composition towards OBs, particularly Enterococcus. The impact of treatment-driven dysbiosis on OBs infections and long-term consequences needs further study to define the role of gut homeostasis in COVID-19 recovery and inform targeted interventions.
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Affiliation(s)
- Elda Righi
- Infectious Diseases Unit, Department of Diagnostics and Public Health, University of Verona, 37134 Verona, Italy
| | - Lorenza Lambertenghi
- Infectious Diseases Unit, Department of Diagnostics and Public Health, University of Verona, 37134 Verona, Italy
| | - Anna Gorska
- Infectious Diseases Unit, Department of Diagnostics and Public Health, University of Verona, 37134 Verona, Italy
| | - Concetta Sciammarella
- Infectious Diseases Unit, Department of Diagnostics and Public Health, University of Verona, 37134 Verona, Italy
| | - Federico Ivaldi
- Infectious Diseases Unit, Department of Diagnostics and Public Health, University of Verona, 37134 Verona, Italy
| | - Massimo Mirandola
- Infectious Diseases Unit, Department of Diagnostics and Public Health, University of Verona, 37134 Verona, Italy
| | - Assunta Sartor
- Microbiology Unit, Udine University Hospital, 33100 Udine, Italy
| | - Evelina Tacconelli
- Infectious Diseases Unit, Department of Diagnostics and Public Health, University of Verona, 37134 Verona, Italy
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Stukas S, Goshua G, Kinkade A, Grey R, Mah G, Biggs CM, Jamal S, Thiara S, Lau TT, Piszczek J, Partovi N, Sweet DD, Lee AY, Wellington CL, Sekhon MS, Chen LY. Reduced fixed dose tocilizumab 400 mg IV compared to weight-based dosing in critically ill patients with COVID-19: A before-after cohort study. THE LANCET REGIONAL HEALTH - AMERICAS 2022; 11:100228. [PMID: 35345649 PMCID: PMC8941850 DOI: 10.1016/j.lana.2022.100228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Interleukin-6 inhibitors reduce mortality in severe COVID-19. British Columbia began using tocilizumab 8 mg/kg (maximum 800 mg) in January 2021 in critically ill patients with COVID-19, but due to drug shortages, decreased dosing to 400 mg IV fixed dose in April 2021. The aims of this study were twofold: to compare physiological responses and clinical outcomes of these two strategies, and examine the cost-effectiveness of treating all patients with 400 mg versus half the patients with 8 mg/kg and the other half without tocilizumab. Methods This was a single-centre, before-after cohort study of critically ill COVID-19 patients treated with tocilizumab, and a control cohort treated with dexamethasone only. Physiological responses and clinical outcomes were compared between patients receiving both doses of tocilizumab and those receiving dexamethasone only. We built a decision tree model to examine cost-effectiveness. Findings 152 patients were included; 40 received tocilizumab 8 mg/kg, 59 received 400 mg and 53 received dexamethasone only. Median CRP fell from 103 mg/L to 5.2 mg/L, 96 mg/L to 6.8 mg/L and from 81.3 mg/L to 48 mg/L in the 8 mg/kg, 400 mg tocilizumab, and dexamethasone only groups, respectively. 28-day mortality was 5% (n=2) vs 8% (n=5) vs 13% (n=7), with no significant difference in all pair-wise comparison. At an assumed willingness-to-pay threshold of $50,000 Canadian per life-year, utilizing 400 mg for all patients rather than 8 mg/kg for half the patients is cost-effective in 51.6% of 10,000 Monte Carlo simulations. Interpretation Both doses of tocilizumab demonstrated comparable reduction of inflammation with similar 28-day mortality. Without consideration of equity, the net monetary benefits of providing 400 mg tocilizumab to all patients are comparable to 8 mg/kg to half the patients. In the context of ongoing drug shortages, fixed-dose 400 mg tocilizumab may be a practical, feasible and economical option. Funding This work was supported by a gift donation from Hsu & Taylor Family to the VGH Foundation, and the Yale Bernard G. Forget Scholarship.
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Barletta JF, Erstad BL. Drug dosing in hospitalized obese patients with COVID-19. Crit Care 2022; 26:60. [PMID: 35287690 PMCID: PMC8919144 DOI: 10.1186/s13054-022-03941-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/03/2022] [Indexed: 12/15/2022] Open
Abstract
Obesity is highly prevalent in hospitalized patients admitted with COVID-19. Evidence based guidelines are available for COVID-19-related therapies but dosing information specific to patients with obesity is lacking. Failure to account for the pharmacokinetic alterations that exist in this population can lead to underdosing, and treatment failure, or overdosing, resulting in an adverse effect. The objective of this manuscript is to provide clinicians with guidance for making dosing decisions for medications used in the treatment of patients with COVID-19. A detailed literature search was conducted for medications listed in evidence-based guidelines from the National Institutes of Health with an emphasis on pharmacokinetics, dosing and obesity. Retrieved manuscripts were evaluated and the following prioritization strategy was used to form the decision framework for recommendations: clinical outcome data > pharmacokinetic studies > adverse effects > physicochemical properties. Most randomized controlled studies included a substantial number of patients who were obese but few had large numbers of patients more extreme forms of obesity. Pharmacokinetic data have described alterations with volume of distribution and clearance but this variability does not appear to warrant dosing modifications. Future studies should provide more information on size descriptors and stratification of data according to obesity and body habitus.
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Affiliation(s)
- Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University, 19555 N 59th Avenue, Glendale, AZ, 85038, USA.
| | - Brian L Erstad
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, 1295 N Martin Ave, PO Box 210202, Tucson, AZ, 85721, USA
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