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Burhanuddin K, Mohammed A, Badhan RKS. The Impact of Paediatric Obesity on Drug Pharmacokinetics: A Virtual Clinical Trials Case Study with Amlodipine. Pharmaceutics 2024; 16:489. [PMID: 38675150 PMCID: PMC11053426 DOI: 10.3390/pharmaceutics16040489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 04/28/2024] Open
Abstract
The incidence of paediatric obesity continues to rise worldwide and contributes to a range of diseases including cardiovascular disease. Obesity in children has been shown to impact upon the plasma concentrations of various compounds, including amlodipine. Nonetheless, information on the influence of obesity on amlodipine pharmacokinetics and the need for dose adjustment has not been studied previously. This study applied the physiologically based pharmacokinetic modelling and established a paediatric obesity population to assess the impact of obesity on amlodipine pharmacokinetics in children and explore the possible dose adjustments required to reach the same plasma concentration as non-obese paediatrics. The difference in predicted maximum concentration (Cmax) and area under the curve (AUC) were significant between children with and without obesity across the age group 2 to 18 years old when a fixed-dose regimen was used. On the contrary, a weight-based dose regimen showed no difference in Cmax between obese and non-obese from 2 to 9 years old. Thus, when a fixed-dose regimen is to be administered, a 1.25- to 1.5-fold increase in dose is required in obese children to achieve the same Cmax concentration as non-obese children, specifically for children aged 5 years and above.
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Affiliation(s)
| | | | - Raj K. S. Badhan
- School of Pharmacy, College of Health and Life Science, Aston University, Birmingham B4 7ET, UK; (K.B.); (A.M.)
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Lu H, Ayers E, Patel P, Mattoo TK. Body water percentage from childhood to old age. Kidney Res Clin Pract 2023; 42:340-348. [PMID: 37313612 DOI: 10.23876/j.krcp.22.062] [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: 03/28/2022] [Accepted: 08/20/2022] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Total body water (TBW) increases with growth, but the body water percentage (TBW%) decreases with aging. The objective of our study was to delineate TBW% in males and females by bioelectrical impedance analysis (BIA) from early childhood to old age. METHODS We enrolled 545 participants aged 3 to 98 years (258 male, 287 female). Among the participants, 256 had a normal weight and 289 were overweight. The TBW was measured by BIA, and TBW% was derived by dividing the TBW (L) value by body weight (kg). For analysis, we divided participants into the four age groups of 3-10, 11-20, 21-60, and ≥61 years. RESULTS In normal-weight subjects, the TBW% was similar at 62% between males and females in the 3-10-year group. It remained unchanged in males until and through adult life, then decreased to 57% in the ≥61-year group. In normal-weight female subjects, the TBW% decreased to 55% in the 11-20-year group, remained relatively unaltered in the 21-60-year group, then decreased to 50% in the ≥61-year group. In overweight subjects, the TBW% values in males, as well as females, were significantly lower as compared to those with normal weight. CONCLUSION Our study showed that the TBW% in normal-weight males changes very little from early childhood to adult life compared to that of females, who showed a decrease in TBW% during the pubertal years. In normal-weight subjects of both sexes, the TBW% decreased after the age of 60 years. Overweight subjects had significantly lower TBW% as compared to those with normal weight.
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Affiliation(s)
- Hong Lu
- Division of Nephrology, Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA
| | - Eric Ayers
- Wayne Health, Wayne State University School of Medicine, Detroit, MI, USA
| | - Pragnesh Patel
- Department of Geriatrics, Wayne State University School of Medicine, Detroit, MI, USA
| | - Tej K Mattoo
- Division of Nephrology, Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA
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Zhang T, Smit C, Sherwin CMT, Knibbe CAJ, Krekels EHJ. Vancomycin Clearance in Obese Adults is not Predictive of Clearance in Obese Adolescents. Clin Pharmacokinet 2023; 62:749-759. [PMID: 37017883 PMCID: PMC10182161 DOI: 10.1007/s40262-023-01227-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Contradictory pharmacokinetic (PK) results have been observed between obese adults and obese adolescents, with absolute clearance (CL) reported to be either unaltered, lower, or higher in obese adolescents compared to obese adults. This study investigates the PK of vancomycin in adolescents and adults who are overweight or obese. METHODS Data from 125 overweight and obese adolescents (aged 10-18 years, weight 28.3-188 kg) and 81 overweight and obese adults (aged 29-88 years, weight 66.7-143 kg) were analysed using population PK modelling. In addition to age, sex, renal function estimates, and regular weight descriptors, we evaluated standard weight (WTstandard, defined as weight for length, age, and sex in adolescents and weight for length in adults) and excess weight (WTexcess, defined as total body weight (TBW) minus WTstandard) as covariates in order to distinguish between weight resulting from length versus weight resulting from obesity. RESULTS Analyzing adolescents and adults together, vancomycin CL was found to increase with TBW and decrease with increasing age (p < 0.001). A covariate analysis investigating adolescents and adults separately found that vancomycin CL increased with WTstandard in adolescents and adults, albeit with different functions, with adolescents having a higher CL per WTstandard than adults. Moreover, in this separate model, adolescent males had 21% higher CL than adolescent females of the same WTstandard, while in adults, CL decreased with increasing age (p < 0.001). CONCLUSION There are apparent differences in vancomycin CL in overweight and obese adults versus overweight and obese adolescents, implying that dosing of vancomycin cannot be directly extrapolated between these populations.
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Affiliation(s)
- Tan Zhang
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Cornelis Smit
- Department of Clinical Pharmacy, Antonius Hospital, Sneek, The Netherlands
| | - Catherine M T Sherwin
- Department of Pediatrics, Wright State University Boonshoft School of Medicine/Dayton Children's Hospital, Dayton, USA
| | - Catherijne A J Knibbe
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | - Elke H J Krekels
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
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Research Progress of Population Pharmacokinetic of Metformin. BIOMED RESEARCH INTERNATIONAL 2022; 2022:4071111. [PMID: 36578804 PMCID: PMC9792241 DOI: 10.1155/2022/4071111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/21/2022] [Accepted: 12/03/2022] [Indexed: 12/23/2022]
Abstract
Metformin is commonly used as first-line treatment for T2DM (type2 diabetes mellitus). Owing to the high pharmacokinetic (PK) variability, several population pharmacokinetic (PPK) models have been developed for metformin to explore potential covariates that affect its pharmacokinetic variation. This comprehensive review summarized the published PPK studies of metformin, aimed to summarize PPK models of metformin. Most studies described metformin pharmacokinetics as a 2-compartment (2-CMT) model with 4 study describing its pharmacokinetics as 1-compartment (1-CMT). Studies on metformin PPK have shown that obesity, creatinine clearance (CLCr), gene polymorphism, degree of renal function damage, and pathological conditions all have a certain impact on the PK parameters of metformin. It is particularly important to formulate individualized dosing regimens. For future PPK studies of metformin, we believe that more attention should be paid to special populations.
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de Alwis N, Binder NK, Mangwiro YTM, Pritchard N, Beard S, Kaitu'u-Lino TJ, Brownfoot F, Hannan NJ. The effect of metformin on cardiovascular markers in female mice consuming a high fat diet. Obes Res Clin Pract 2022; 16:524-532. [PMID: 36333189 DOI: 10.1016/j.orcp.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 08/06/2022] [Accepted: 10/12/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Metformin, widely used to treat diabetes, is now considered a candidate therapeutic for treatment of cardiovascular disease. This study aimed to assess whether metformin's non-glycaemic effects could mitigate cardiovascular disease indices in female mice consuming a high fat diet (HFD). METHODS Four-week old female Arc:Arc(S) mice were placed on a standard (std) chow diet or Western-style HFD (22% fat, 0.15% cholesterol). At ∼8 months, the mice were administered 150 mg/kg metformin or vehicle (control) via intraperitoneal injection for 11 days. Blood pressure was measured (tail cuff plethysmography) at Day 9 and 11 of treatment. On Day 11, mice were weighed and culled. The mesenteric arcade and kidneys were collected for assessment of vascular reactivity (wire myography), and assessment of expression of cardiometabolic markers (qPCR), respectively. RESULTS The HFD fed female mice were significantly heavier than those receiving the std diet at 1-12 weeks on diet, and at cull. Mice on a std diet with metformin treatment were significantly heavier at cull than the mice on a std diet administered the control treatment. Metformin treatment did not alter the weight of the mice receiving the HFD. Neither the HFD (compared to the std diet), nor metformin treatment (compared to control treatment) altered blood pressure, vascular reactivity, or expression of cardiometabolic markers in the kidney. CONCLUSION Consumption of a Western-style HFD (without high salt/sugar levels) did not alter the cardiovascular markers measured. Further studies are required to establish the non-glycaemic, cardio-protective effects of metformin in high-risk cohorts.
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Affiliation(s)
- Natasha de Alwis
- Therapeutics Discovery and Vascular Function in Pregnancy Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia; Mercy Perinatal, Mercy Hospital for Women, Heidelberg 3084, Victoria, Australia
| | - Natalie K Binder
- Therapeutics Discovery and Vascular Function in Pregnancy Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia; Mercy Perinatal, Mercy Hospital for Women, Heidelberg 3084, Victoria, Australia
| | - Yeukai T M Mangwiro
- Therapeutics Discovery and Vascular Function in Pregnancy Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia; Mercy Perinatal, Mercy Hospital for Women, Heidelberg 3084, Victoria, Australia
| | - Natasha Pritchard
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg 3084, Victoria, Australia; Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
| | - Sally Beard
- Therapeutics Discovery and Vascular Function in Pregnancy Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia; Mercy Perinatal, Mercy Hospital for Women, Heidelberg 3084, Victoria, Australia
| | - Tu'uhevaha J Kaitu'u-Lino
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg 3084, Victoria, Australia; Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
| | - Fiona Brownfoot
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg 3084, Victoria, Australia; Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
| | - Natalie J Hannan
- Therapeutics Discovery and Vascular Function in Pregnancy Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia; Mercy Perinatal, Mercy Hospital for Women, Heidelberg 3084, Victoria, Australia.
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Zhang T, Krekels EHJ, Smit C, Knibbe CAJ. Drug pharmacokinetics in the obese population: challenging common assumptions on predictors of obesity-related parameter changes. Expert Opin Drug Metab Toxicol 2022; 18:657-674. [PMID: 36217846 DOI: 10.1080/17425255.2022.2132931] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Obesity is associated with many physiological changes. We review available evidence regarding five commonly accepted assumptions to a priori predict the impact of obesity on drug pharmacokinetics (PK). AREAS COVERED The investigated assumptions are: 1) lean body weight is the preferred descriptor of clearance and dose adjustments; 2) volume of distribution increases for lipophilic, but not for hydrophilic drugs; 3) CYP-3A4 activity is suppressed and UGT activity is increased, implying decreased and increased dose requirements for substrates of these enzyme systems, respectively; 4) glomerular filtration rate is enhanced, necessitating higher doses for drugs cleared through glomerular filtration; 5) drug dosing information from obese adults can be extrapolated to obese adolescents. EXPERT OPINION Available literature contradicts, or at least limits the generalizability, of all five assumptions. Clinical studies should focus on quantifying the impact of duration and severity of obesity on drug PK in adults and adolescents, and also include oral bioavailability and pharmacodynamics in these studies. Physiologically-based PK approaches can be used to predict PK changes for individual drugs, but can also be used to define in general terms based on patient characteristics and drug properties, when certain assumptions can or cannot be expected to be systematically accurate.
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Affiliation(s)
- Tan Zhang
- Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Elke H J Krekels
- Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Cornelis Smit
- Department of Clinical Pharmacy, Antonius Hospital Sneek, The Netherlands
| | - Catherijne A J Knibbe
- Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.,Department of Clinical Pharmacy, St. Antonius Hospital Nieuwegein, The Netherlands
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Gaeta F, Conti V, Pepe A, Vajro P, Filippelli A, Mandato C. Drug dosing in children with obesity: a narrative updated review. Ital J Pediatr 2022; 48:168. [PMID: 36076248 PMCID: PMC9454408 DOI: 10.1186/s13052-022-01361-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/30/2022] [Indexed: 11/16/2022] Open
Abstract
Childhood obesity and its associated comorbidities are highly prevalent diseases that may add to any other possible health problem commonly affecting the pediatric age. Uncertainties may arise concerning drug dosing when children with obesity need pharmacologic therapies. In general, in pediatric practice, there is a tendency to adapt drug doses to a child’s total body weight. However, this method does not consider the pharmacological impact that a specific drug can have under a two-fold point of view, that is, across various age and size groups as well. Moreover, there is a need for a therapeutic approach, as much as possible tailored considering relevant interacting aspects, such as modification in metabolomic profile, drug pharmacokinetics and pharmacodynamics. Taking into account the peculiar differences between children with overweight/obesity and those who are normal weight, the drug dosage in the case of obesity, cannot be empirically determined solely by the per kg criterion. In this narrative review, we examine the pros and cons of several drug dosing methods used when dealing with children who are affected also by obesity, focusing on specific aspects of some of the drugs most frequently prescribed in real-world practice by general pediatricians and pediatric subspecialists.
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Affiliation(s)
- Francesca Gaeta
- Pediatrics Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Valeria Conti
- Pharmacology Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Angela Pepe
- Pediatrics Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Pietro Vajro
- Pediatrics Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Amelia Filippelli
- Pharmacology Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Claudia Mandato
- Pediatrics Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy.
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Salem F, Small BG, Johnson TN. Development and application of a pediatric mechanistic kidney model. CPT Pharmacometrics Syst Pharmacol 2022; 11:854-866. [PMID: 35506351 PMCID: PMC9286721 DOI: 10.1002/psp4.12798] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 11/19/2022] Open
Abstract
Pediatric physiologically‐based pharmacokinetic (P‐PBPK) models have been used to predict age related changes in the pharmacokinetics (PKs) of renally cleared drugs mainly in relation to changes in glomerular filtration rate. With emerging data on ontogeny of renal transporters, mechanistic models of renal clearance accounting for the role of active and passive secretion should be developed and evaluated. Data on age‐related physiological changes and ontogeny of renal transporters were applied into a mechanistic kidney within a P‐PBPK model. Plasma concentration–time profile and PK parameters of cimetidine, ciprofloxacin, metformin, tenofovir, and zidovudine were predicted in subjects aged 1 day to 18 years. The predicted and observed plasma concentration–time profiles and PK parameters were compared. The predicted concentration–time profile means and 5th and 95th percent intervals generally captured the observed data and variability in various studies. Overall, based on drugs and age bands, predicted to observed clearance were all within two‐fold and in 11 of 16 cases within 1.5‐fold. Predicted to observed area under the curve (AUC) and maximum plasma concentration (Cmax) were within two‐fold in 12 of 14 and 12 of 15 cases, respectively. Predictions in neonates and early infants (up to 14 weeks postnatal age) were reasonable with 15–20 predicted PK parameters within two‐fold of the observed. ciprofloxacin but not zidovudine PK predictions were sensitive to basal kidney uptake transporter ontogeny. The results indicate that a mechanistic kidney model accounting for physiology and ontogeny of renal processes and transporters can predict the PK of renally excreted drugs in children. Further data especially in neonates are required to verify the model and ontogeny profiles.
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Affiliation(s)
- Farzaneh Salem
- Drug Metabolism and Pharmacokinetics GlaxoSmithKline R&D Ware UK
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Ford JL, Gerhart JG, Edginton AN, Yanovski JA, Hon YY, Gonzalez D. Physiologically Based Pharmacokinetic Modeling of Metformin in Children and Adolescents with Obesity. J Clin Pharmacol 2022; 62:960-969. [PMID: 35119103 PMCID: PMC9288496 DOI: 10.1002/jcph.2034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 01/30/2022] [Indexed: 11/06/2022]
Abstract
Childhood obesity continues to rise in the United States, and with it the off-label use of metformin for weight loss. The influence of age and obesity on the drug's disposition and exposure has not previously been studied using a mechanistic framework. Here, an adult physiologically based pharmacokinetic (PBPK) model of metformin was scaled to pediatric populations without obesity, with overweight / obesity, and with severe obesity; a published virtual population of children and adolescents with obesity was leveraged during model evaluation. When the pediatric model was simulated in groups 10 - 18 y of age, oral clearance (CL/F) following 1,000 mg of metformin was higher (∼1200 mL/min) in those with obesity and severe obesity compared to the groups without and with overweight (∼1000 mL/min). In addition, simulated AUC in older children and adolescents with obesity and severe obesity was comparable to that in adults with a similar dose-exposure relationship. Overall, simulations using the pediatric PBPK model support the use of adult doses of metformin in older children and adolescents with obesity. Moreover, the virtual population of children and adolescents with obesity offers a valuable tool to facilitate development of pediatric PBPK models for studying populations with obesity and, in turn, contribute information to inform drug labeling in this special population. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jennifer Lynn Ford
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jacqueline G Gerhart
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andrea N Edginton
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Jack A Yanovski
- Section on Growth and Obesity, Program in Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Yuen Yi Hon
- Division of Rare Diseases and Medical Genetics, Office of Rare Diseases, Pediatrics, Urologic and Reproductive Medicine, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Smit C, Goulooze SC, Brüggemann RJM, Sherwin CM, Knibbe CAJ. Dosing Recommendations for Vancomycin in Children and Adolescents with Varying Levels of Obesity and Renal Dysfunction: a Population Pharmacokinetic Study in 1892 Children Aged 1-18 Years. AAPS JOURNAL 2021; 23:53. [PMID: 33839974 PMCID: PMC8038958 DOI: 10.1208/s12248-021-00577-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 03/03/2021] [Indexed: 12/24/2022]
Abstract
Vancomycin is an effective but potentially nephrotoxic antibiotic commonly used for severe infections. Dosing guidelines for vancomycin in obese children and adolescents with or without renal impairment are currently lacking. This study describes the pharmacokinetics of vancomycin in a large pediatric cohort with varying degrees of obesity and renal function to design practical dosing guidelines for this population. A multi-center retrospective population pharmacokinetic study was conducted using data from patients aged 1−18 years who received >1 dose of vancomycin and had ≥1 vancomycin concentration measured between January 2006 and December 2012. Besides pharmacokinetic data, age, gender, body weight, creatinine clearance (CLcr, bedside Schwartz equation), ward, race, and neutropenic status were collected. Population pharmacokinetic analysis and simulations were performed using NONMEM7.4. A total of 1892 patients (5524 samples) were included, with total body weight (TBW) ranging 6−188 kg (1344 normal weight, 247 overweight, and 301 obese patients) and CLcr down to 8.6 mL/min/1.73 m2. The two-compartment model, with clearance (CL) significantly increasing with TBW and CLcr, central and peripheral volume of distribution and inter-compartmental clearance increasing with TBW, performed well for all age, weight, and renal function ranges. A dosing guideline is proposed that integrates body weight and CLcr resulting in effective and safe exposures across all ages, body weight, and renal functions in the pediatric population. We have characterized the full pharmacokinetic profile of vancomycin in obese children and adolescents aged 1−18 years and propose a practical dosing guideline that integrates both body weight and renal function.
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Affiliation(s)
- Cornelis Smit
- Department of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.,Pediatric Pharmacology and Pharmacometrics, University Children's Hospital (UKBB), Basel, Switzerland
| | - Sebastiaan C Goulooze
- Department of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Roger J M Brüggemann
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Catherine M Sherwin
- Department of Pediatrics, Wright State University Boonshoft School of Medicine/Dayton Children's Hospital, Dayton, Ohio, USA
| | - Catherijne A J Knibbe
- Department of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands. .,Department of Clinical Pharmacy, St. Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, The Netherlands.
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11
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Nguyen NM, Chanh HQ, Tam DTH, Vuong NL, Chau NTX, Chau NVV, Phong NT, Trieu HT, Luong Thi Hue T, Cao Thi T, Dinh The T, Duyen HTL, Van NTT, Nguyen Than Ha Q, Rivino L, Gallagher P, Jones NK, Geskus RB, Kestelyn E, Yacoub S. Metformin as adjunctive therapy for dengue in overweight and obese patients: a protocol for an open-label clinical trial (MeDO). Wellcome Open Res 2021; 5:160. [PMID: 33083561 PMCID: PMC7539082 DOI: 10.12688/wellcomeopenres.16053.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 12/03/2023] Open
Abstract
Background: Dengue is a disease of major global importance. While most symptomatic infections are mild, a small proportion of patients progress to severe disease with risk of hypovolaemic shock, organ dysfunction and death. In the absence of effective antiviral or disease modifying drugs, clinical management is solely reliant on supportive measures. Obesity is a growing problem among young people in Vietnam and is increasingly recognised as an important risk factor for severe dengue, likely due to alterations in host immune and inflammatory pathways. Metformin, a widely used anti-hyperglycaemic agent with excellent safety profile, has demonstrated potential as a dengue therapeutic in vitro and in a retrospective observational study of adult dengue patients with type 2 diabetes. This study aims to assess the safety and tolerability of metformin treatment in overweight and obese dengue patients, and investigate its effects on several clinical, immunological and virological markers of disease severity. Methods: This open label trial of 120 obese/overweight dengue patients will be performed in two phases, with a metformin dose escalation if no safety concerns arise in phase one. The primary endpoint is identification of clinical and laboratory adverse events. Sixty overweight and obese dengue patients aged 10-30 years will be enrolled at the Hospital for Tropical Diseases in Ho Chi Minh City, Vietnam. Participants will complete a 5-day course of metformin therapy and be compared to a non-treated group of 60 age-matched overweight and obese dengue patients. Discussion: Previously observed antiviral and immunomodulatory effects of metformin make it a promising dengue therapeutic candidate in appropriately selected patients. This study will assess the safety and tolerability of adjunctive metformin in the management of overweight and obese young dengue patients, as well as its effects on markers of viral replication, endothelial dysfunction and host immune responses. Trial registration: ClinicalTrials.gov: NCT04377451 (May 6 th 2020).
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Affiliation(s)
- Nguyet Minh Nguyen
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | - Ho Quang Chanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | - Dong Thi Hoai Tam
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | - Nguyen Lam Vuong
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | | | | | | | | | | | - Tam Cao Thi
- Hospital for Tropical Diseases, Ho Chi Minh City, 700000, Vietnam
| | - Trung Dinh The
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | - Huynh Thi Le Duyen
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | - Ninh Thi Thanh Van
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | | | - Laura Rivino
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | | | | | - Ronald B. Geskus
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
- Centre for Tropical Medicine and Global Health, Oxford University, Oxford, UK
| | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
- Centre for Tropical Medicine and Global Health, Oxford University, Oxford, UK
| | - Sophie Yacoub
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
- Centre for Tropical Medicine and Global Health, Oxford University, Oxford, UK
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12
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Nguyen NM, Chanh HQ, Tam DTH, Vuong NL, Chau NTX, Chau NVV, Phong NT, Trieu HT, Luong Thi Hue T, Cao Thi T, Dinh The T, Duyen HTL, Van NTT, Nguyen Than Ha Q, Rivino L, Gallagher P, Jones NK, Geskus RB, Kestelyn E, Yacoub S. Metformin as adjunctive therapy for dengue in overweight and obese patients: a protocol for an open-label clinical trial (MeDO). Wellcome Open Res 2021; 5:160. [PMID: 33083561 PMCID: PMC7539082 DOI: 10.12688/wellcomeopenres.16053.2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 12/30/2022] Open
Abstract
Background: Dengue is a disease of major global importance. While most symptomatic infections are mild, a small proportion of patients progress to severe disease with risk of hypovolaemic shock, organ dysfunction and death. In the absence of effective antiviral or disease modifying drugs, clinical management is solely reliant on supportive measures. Obesity is a growing problem among young people in Vietnam and is increasingly recognised as an important risk factor for severe dengue, likely due to alterations in host immune and inflammatory pathways. Metformin, a widely used anti-hyperglycaemic agent with excellent safety profile, has demonstrated potential as a dengue therapeutic
in vitro and in a retrospective observational study of adult dengue patients with type 2 diabetes. This study aims to assess the safety and tolerability of metformin treatment in overweight and obese dengue patients, and investigate its effects on several clinical, immunological and virological markers of disease severity. Methods: This open label trial of 120 obese/overweight dengue patients will be performed in two phases, with a metformin dose escalation if no safety concerns arise in phase one. The primary endpoint is identification of clinical and laboratory adverse events. Sixty overweight and obese dengue patients aged 10-30 years will be enrolled at the Hospital for Tropical Diseases in Ho Chi Minh City, Vietnam. Participants will complete a 5-day course of metformin therapy and be compared to a non-treated group of 60 age-matched overweight and obese dengue patients. Discussion: Previously observed antiviral and immunomodulatory effects of metformin make it a promising dengue therapeutic candidate in appropriately selected patients. This study will assess the safety and tolerability of adjunctive metformin in the management of overweight and obese young dengue patients, as well as its effects on markers of viral replication, endothelial dysfunction and host immune responses. Trial registration: ClinicalTrials.gov:
NCT04377451 (May 6
th 2020).
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Affiliation(s)
- Nguyet Minh Nguyen
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | - Ho Quang Chanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | - Dong Thi Hoai Tam
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | - Nguyen Lam Vuong
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | | | | | | | | | | | - Tam Cao Thi
- Hospital for Tropical Diseases, Ho Chi Minh City, 700000, Vietnam
| | - Trung Dinh The
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | - Huynh Thi Le Duyen
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | - Ninh Thi Thanh Van
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam
| | | | - Laura Rivino
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | | | | | - Ronald B Geskus
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam.,Centre for Tropical Medicine and Global Health, Oxford University, Oxford, UK
| | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam.,Centre for Tropical Medicine and Global Health, Oxford University, Oxford, UK
| | - Sophie Yacoub
- Oxford University Clinical Research Unit, Ho Chi Minh City, 700000, Vietnam.,Centre for Tropical Medicine and Global Health, Oxford University, Oxford, UK
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13
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Smit C, Wasmann RE, Goulooze SC, Hazebroek EJ, Van Dongen EPA, Burgers DMT, Mouton JW, Brüggemann RJM, Knibbe CAJ. A Prospective Clinical Study Characterizing the Influence of Morbid Obesity on the Pharmacokinetics of Gentamicin: Towards Individualized Dosing in Obese Patients. Clin Pharmacokinet 2020; 58:1333-1343. [PMID: 31016671 PMCID: PMC6768900 DOI: 10.1007/s40262-019-00762-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background and Objective Gentamicin is an aminoglycoside antibiotic predominantly used in bloodstream infections. Although the prevalence of obesity is increasing dramatically, there is no consensus on how to adjust the dose in obese individuals. In this prospective clinical study, we study the pharmacokinetics of gentamicin in morbidly obese and non-obese individuals to develop a dosing algorithm that results in adequate drug exposure across body weights. Methods Morbidly obese subjects undergoing bariatric surgery and non-obese healthy volunteers received one intravenous dose of gentamicin (obese: 5 mg/kg based on lean body weight, non-obese: 5 mg/kg based on total body weight [TBW]) with subsequent 24-h sampling. All individuals had a normal renal function. Statistical analysis, modelling and Monte Carlo simulations were performed using R version 3.4.4 and NONMEM® version 7.3. Results A two-compartment model best described the data. TBW was the best predictor for both clearance [CL = 0.089 × (TBW/70)0.73] and central volume of distribution [Vc = 11.9 × (TBW/70)1.25] (both p < 0.001). Simulations showed how gentamicin exposure changes across the weight range with currently used dosing algorithms and illustrated that using a nomogram based on a ‘dose weight’ [70 × (TBW/70)0.73] will lead to similar exposure across the entire population. Conclusions In this study in morbidly obese and non-obese individuals ranging from 53 to 221 kg we identified body weight as an important determinant for both gentamicin CL and Vc. Using a body weight-based dosing algorithm, optimized exposure across the entire population can be achieved, thereby potentially improving efficacy and safety of gentamicin in the obese and morbidly obese population. Trial Registration Registered in the Dutch Trial Registry (NTR6058). Electronic supplementary material The online version of this article (10.1007/s40262-019-00762-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Cornelis Smit
- Department of Clinical Pharmacy, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.,Department of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333 CC, Leiden, The Netherlands
| | - Roeland E Wasmann
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboudumc, Geert Grooteplein Zuid 8, 6525 GA, Nijmegen, The Netherlands
| | - Sebastiaan C Goulooze
- Department of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333 CC, Leiden, The Netherlands
| | - Eric J Hazebroek
- Department of Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Eric P A Van Dongen
- Department of Anesthesiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Desiree M T Burgers
- Department of Clinical Pharmacy, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Roger J M Brüggemann
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboudumc, Geert Grooteplein Zuid 8, 6525 GA, Nijmegen, The Netherlands
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands. .,Department of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333 CC, Leiden, The Netherlands.
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14
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Dosage adjustment in obese children, even for common drugs, is largely unclear and a treat-to-effect approach may work best. DRUGS & THERAPY PERSPECTIVES 2020. [DOI: 10.1007/s40267-020-00734-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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15
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Ameer B, Weintraub MA. Dosing Common Medications in Hospitalized Pediatric Patients with Obesity: A Review. Obesity (Silver Spring) 2020; 28:1013-1022. [PMID: 32441477 DOI: 10.1002/oby.22739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 12/17/2019] [Indexed: 12/31/2022]
Abstract
Medication management in children and adolescents with obesity is challenging because both developmental and pathophysiological changes may impact drug disposition and response. Evidence to date indicates an effect of obesity on drug disposition for certain drugs used in this population. This work identified published studies evaluating drug dosing, pharmacokinetics (PK), and effect in pediatric patients with obesity, focusing on 70 common medications used in a pediatric network of 42 US medical centers. A PubMed search revealed 33 studies providing PK and/or effectiveness data for 23% (16 of 70) of medications, 44% of which have just one study and can be considered exploratory. This work appraising 4 decades of literature shows several promising approaches: greater use of PK models applied to prospective clinical studies, dosing recommendations derived from both PK and safety, and multiyear effectiveness data on drugs for chronic conditions (e.g., asthma). Most studies make dose recommendations but are weakened by retrospective study design, small study populations, and no controls or historic controls. Dosing decisions continue to rely on extrapolating knowledge, including targeting systemic drug exposure typically achieved in adults. Optimal weight-based dosing strategies vary by drug and warrant prospective, controlled studies incorporating PK and modeling and simulation to complement clinical assessment.
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Affiliation(s)
- Barbara Ameer
- Department of Medicine, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - Michael A Weintraub
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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16
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Abstract
Medical research in children typically lags behind that of adult research in both quantity and quality. The conduct of rigorous clinical trials in children can raise ethical concerns because of children's status as a 'vulnerable' population. Moreover, carrying out studies in pediatrics also requires logistical considerations that rarely occur with adult clinical trials. Due to the relatively smaller number of pediatric studies to support evidence-based medicine, the practice of medicine in children is far more reliant upon expert opinion than in adult medicine. Children are at risk of not receiving the same level of benefits from precision medicine research, which has flourished with new technologies capable of generating large amounts of data quickly at an individual level. Although progress has been made in pediatric pharmacokinetics, which has led to safer and more effective dosing, gaps in knowledge still exists when it comes to characterization of pediatric disease and differences in pharmacodynamic response between children and adults. This review highlights three specific therapeutic areas where biomarker development can enhance precision medicine in children: asthma, type 2 diabetes mellitus, and pain. These 'case studies' are meant to update the reader on biomarkers used currently in the diagnosis and treatment of these conditions, and their shortcomings within a pediatric context. Current research on surrogate endpoints and pharmacodynamic biomarkers in the above therapeutic areas will also be described. These cases highlight the current lack in pediatric specific surrogate endpoints and pharmacodynamic biomarkers, as well as the research presently being conducted to address these deficiencies. We finally briefly highlight other therapeutic areas where further research in pediatric surrogate endpoints and pharmacodynamic biomarkers can be impactful to the care of children.
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17
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Krekels EHJ, Knibbe CAJ. Pharmacokinetics and Pharmacodynamics of Drugs in Obese Pediatric Patients: How to Map Uncharted Clinical Territories. Handb Exp Pharmacol 2020; 261:231-255. [PMID: 31598838 DOI: 10.1007/164_2019_250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Clinicians are increasingly faced with challenges regarding the pharmacological treatment of obese pediatric patients. To provide guidance for these treatments, a better understanding of the impact of obesity on pharmacological processes in children is needed. Results on pharmacological studies in adults show however ambiguous patterns regarding the impact of obesity on ADME processes or on drug pharmacodynamics. Additionally, based on the limited research performed in obese pediatric patients, it becomes clear that findings from obese adults cannot be expected to always translate directly to similar findings in obese children. To improve knowledge on drug pharmacology in obese pediatric patients, studies should focus on quantifying the impact of maturation, obesity, and other relevant variables on primary pharmacological parameters and on disentangling systemic (renal and/or hepatic) and presystemic (gut and/or first-pass hepatic) clearance. For this, data is required from well-designed clinical trials that include patients with not only a wide range in age but also a range in excess body weight, upon oral and intravenous dosing. Population modelling approaches are ideally suitable for this purpose and can also be used to link the pharmacokinetics to pharmacodynamics and to derive drug dosing regimens. Generalizability of research findings can be achieved by including mechanistic aspects in the data analysis, for instance, using either extrapolation approaches in population modelling or by applying physiologically based modelling principles. It is imperative that more and smarter studies are performed in obese pediatric patients to provide safe and effective treatment for this special patient population.
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Affiliation(s)
- Elke H J Krekels
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Catherijne A J Knibbe
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.
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18
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VOS MIRIAMB, Dimick-Santos L, Mehta R, Omokaro SO, Taminiau J, Schabel E, Kleiner DE, Szitanyi P, Socha P, Schwimmer JB, Noviello S, Silberg DG, Torstenson R, Miller V, Lavine JE, Baldyga W, Banerjee R, Behling C, Boulos S, Burgess G, Calboli D, Charles E, Christian R, Cohen-Bacrie C, Cosma-Roman D, Danzer CP, Delaet I, Delegge M, Dimick-Santos L, DiProspero N, Donohue K, Fischer L, Fitzpatrick E, Fried M, Hagerty D, Hale P, Hildick K, Hum D, Jamil K, Jiang L, Karpen S, Kelly M, Kleiner DE, Kohli R, Kordy K, Krieger N, Lavine J, Lee L, Lefebvre E, Lopez P, Lyons E, Malahias L, Megnien S, Mehta R, Mesenbrink P, Miller V, Minnick P, Murray C, Nghiem T, Nicholson N, Noviello S, Omokaro SO, Pang W, Percival L, Peres D, Powell M, Roman D, Root M, Sampson C, Sanyal A, Schabel E, Schwarz K, Schwimmer JB, Seyedkazemi S, Shapiro D, Shringarpure R, Silberg D, Smith E, Socha P, Squires R, Szitanyi P, Taminiau J, Torstenson R, Treem W, Vig P, Vos M, Yamashita M, Zemel M. Factors to Consider in Development of Drugs for Pediatric Nonalcoholic Fatty Liver Disease. Gastroenterology 2019; 157:1448-1456.e1. [PMID: 31520612 PMCID: PMC8996263 DOI: 10.1053/j.gastro.2019.08.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/13/2019] [Accepted: 08/17/2019] [Indexed: 02/07/2023]
Affiliation(s)
- MIRIAM B. VOS
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Ruby Mehta
- US Food and Drug Administration, Bethesda, Maryland
| | | | | | - Elmer Schabel
- Bundesinstitut für Arzneimittel und Medizinprodukte, Bonn, Germany
| | - David E Kleiner
- National Cancer Institute, Center for Cancer Research, Bethesda, Maryland
| | - Peter Szitanyi
- General University Hospital, Charles University, Prague, Czech Republic
| | - Piotr Socha
- Children's Memorial Health Institute, Warsaw, Poland
| | - Jeffrey B Schwimmer
- University of California, San Diego School of Medicine, La Jolla, California
| | | | | | | | | | - Joel E Lavine
- Columbia University Medical Center, New York, New York.
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19
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Kyler KE, Wagner J, Hosey-Cojocari C, Watt K, Shakhnovich V. Drug Dose Selection in Pediatric Obesity: Available Information for the Most Commonly Prescribed Drugs to Children. Paediatr Drugs 2019; 21:357-369. [PMID: 31432433 PMCID: PMC7681556 DOI: 10.1007/s40272-019-00352-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Obesity rates continue to rise in children, and little guidance exists regarding the need for adjustment away from total body weight-based doses for those prescribing drugs to this population of children. A majority of drugs prescribed to children with obesity result in either sub-therapeutic or supra-therapeutic concentrations, placing these children at risk for treatment failure and drug toxicities. In this review, we highlight available obesity-specific pharmacokinetic and dosing information for the most frequently prescribed drugs to children in the inpatient and outpatient clinical settings. We also comment on available dosing recommendations for drugs prescribed to treat common pediatric obesity-related comorbidities. This review highlights that there is no safe or proven 'rule of thumb,' for dosing drugs for children with obesity, and a striking lack of pharmacokinetic data to support the creation of dosing guidelines for children with obesity for the most commonly prescribed drugs. It is important that those prescribing for children with obesity are aware of these gaps in knowledge and of potential drug treatment failure or adverse events related to drug toxicity as a result of these knowledge gaps. Until more data are available, we recommend close monitoring of drug response and adverse events in children with obesity receiving commonly prescribed drugs.
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Affiliation(s)
- Kathryn E Kyler
- Children's Mercy Kansas City, 2401 Gillham Rd., Kansas City, MO, 64108, USA.
- University of Missouri Kansas City School of Medicine, Kansas City, MO, USA.
| | - Jonathan Wagner
- Children's Mercy Kansas City, 2401 Gillham Rd., Kansas City, MO, 64108, USA
- University of Missouri Kansas City School of Medicine, Kansas City, MO, USA
| | | | - Kevin Watt
- Duke University Medical Center, Durham, NC, USA
| | - Valentina Shakhnovich
- Children's Mercy Kansas City, 2401 Gillham Rd., Kansas City, MO, 64108, USA
- University of Missouri Kansas City School of Medicine, Kansas City, MO, USA
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20
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Common Variants in 22 Genes Regulate Response to Metformin Intervention in Children with Obesity: A Pharmacogenetic Study of a Randomized Controlled Trial. J Clin Med 2019; 8:jcm8091471. [PMID: 31527397 PMCID: PMC6780549 DOI: 10.3390/jcm8091471] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/10/2019] [Accepted: 09/11/2019] [Indexed: 12/19/2022] Open
Abstract
Metformin is a first-line oral antidiabetic agent that has shown additional effects in treating obesity and metabolic syndrome. Inter-individual variability in metformin response could be partially explained by the genetic component. Here, we aimed to test whether common genetic variants can predict the response to metformin intervention in obese children. The study was a multicenter and double-blind randomized controlled trial that was stratified according to sex and pubertal status in 160 children with obesity. Children were randomly assigned to receive either metformin (1g/d) or placebo for six months after meeting the defined inclusion criteria. We conducted a post hoc genotyping study in 124 individuals (59 placebo, 65 treated) comprising finally 231 genetic variants in candidate genes. We provide evidence for 28 common variants as promising pharmacogenetics regulators of metformin response in terms of a wide range of anthropometric and biochemical outcomes, including body mass index (BMI) Z-score, and glucose, lipid, and inflammatory traits. Although no association remained statistically significant after multiple-test correction, our findings support previously reported variants in metformin transporters or targets as well as identify novel and promising loci, such as the ADYC3 and the BDNF genes, with plausible biological relation to the metformin's action mechanism. Trial Registration: Registered on the European Clinical Trials Database (EudraCT, ID: 2010-023061-21) on 14 November 2011 (URL: https://www.clinicaltrialsregister.eu/ctr-search/trial/2010-023061-21/ES).
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21
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Lentferink YE, Knibbe CAJ, van der Vorst MMJ. Efficacy of Metformin Treatment with Respect to Weight Reduction in Children and Adults with Obesity: A Systematic Review. Drugs 2019; 78:1887-1901. [PMID: 30511324 DOI: 10.1007/s40265-018-1025-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Obesity and its related complications are increasing health issues. Since generally only minor weight loss is obtained with lifestyle intervention, additional pharmacological therapies such as metformin are often used. OBJECTIVE We conducted a systematic review to provide an overview of the efficacy of ≥ 6 months of metformin treatment in children and adults with respect to weight, insulin resistance, and progression toward type 2 diabetes mellitus (T2DM). METHODS In September 2018, we searched PubMed, Embase, and the Cochrane Library for studies published in English using the keywords metformin, obesity/overweight, and weight loss. Prospective studies reporting weight/body mass index (BMI) as a primary or secondary outcome in patients with overweight/obesity with ≥ 6 months' metformin treatment were included. Included subjects were children and adults with overweight/obesity who received ≥ 6 months of metformin and/or lifestyle intervention, and/or placebo and/or lifestyle intervention, and/or standard care. Studies were independently screened by two reviewers. Data were extracted by one and verified by the other reviewer, and both reviewers assessed the risk of bias using the Cochrane risk-of-bias tool. RESULTS Our review includes 15 pediatric and 14 adult studies. In children, after 6 months, more than half the studies reported a greater reduction in BMI with metformin versus controls. Only six studies had an intervention of > 6 months, and these studies found no further improvement in BMI in the metformin users, though their BMI was lower than that of controls. Three studies showed a significant improvement in insulin sensitivity in the metformin versus the control group. Adults using metformin experienced and maintained small decreases in weight irrespective of duration of intervention. In 11 of 14 studies, a greater reduction in weight/BMI was observed with metformin than with placebo. Progression toward T2DM was significantly reduced in adults using metformin, ranging from 7 to 31%. The safety and tolerability of metformin, withdrawal of participants, and comparison with other drugs were not taken into account. CONCLUSIONS The effects of metformin on weight/BMI vary, with smaller reductions in children than in adults. This could be because of differences in adherence, daily dosage, and insulin status. Metformin significantly reduced the progression toward T2DM in adults. Therefore, metformin should be considered as a treatment for obesity and its related complications.
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Affiliation(s)
- Y E Lentferink
- Department of Pediatrics, St. Antonius Hospital, Koekoekslaan 1, Nieuwegein, 3435 CM, Utrecht, The Netherlands
| | - C A J Knibbe
- Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, Utrecht, The Netherlands.,Division of Systems Biomedicine and Pharmacology, LACDR, Leiden University, Leiden, The Netherlands
| | - M M J van der Vorst
- Department of Pediatrics, St. Antonius Hospital, Koekoekslaan 1, Nieuwegein, 3435 CM, Utrecht, The Netherlands.
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22
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Ogungbenro K, Wagner JB, Abdel-Rahman S, Leeder JS, Galetin A. A population pharmacokinetic model for simvastatin and its metabolites in children and adolescents. Eur J Clin Pharmacol 2019; 75:1227-1235. [PMID: 31172248 PMCID: PMC6697721 DOI: 10.1007/s00228-019-02697-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 05/23/2019] [Indexed: 11/26/2022]
Abstract
Purpose Poor adherence to dietary/behaviour modifications as interventions for hypercholesterolemia in paediatric patients often necessitates the initiation of statin therapy. The aim of this study was to develop a joint population pharmacokinetic model for simvastatin and four metabolites in children and adolescents to investigate sources of variability in simvastatin acid exposure in this patient population, in addition to SLCO1B1 genotype status. Methods Plasma concentrations of simvastatin and its four metabolites, demographic and polymorphism data for OATP1B1 and CYP3A5 were analysed utilising a population pharmacokinetic modelling approach from an existing single oral dose (10 mg < 17 years and 20 mg ≥ 18 years) pharmacokinetic dataset of 32 children and adolescents. Results The population PK model included a one compartment disposition model for simvastatin with irregular oral absorption described by two parallel absorption processes each consisting of sequential zero and first-order processes. The data for each metabolite were described by a one-compartment disposition model with the formation and elimination apparent parameters estimated. The model confirmed the statistically significant effect of c.521T>C (rs4149056) on the pharmacokinetics of the active metabolite simvastatin acid in children/adolescents, consistent with adult data. In addition, age was identified as a covariate affecting elimination clearances of 6-hydroxymethyl simvastatin acid and 3, 5 dihydrodiol simvastatin metabolites. Conclusion The model developed describes the pharmacokinetics of simvastatin and its metabolites in children/adolescents capturing the effects of both c.521T>C and age on variability in exposure in this patient population. This joint simvastatin metabolite model is envisaged to facilitate optimisation of simvastatin dosing in children/adolescents. Electronic supplementary material The online version of this article (10.1007/s00228-019-02697-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kayode Ogungbenro
- Centre for Applied Pharmacokinetic Research, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PT, UK.
| | - Jonathan B Wagner
- Ward Family Heart Center, Children's Mercy Kansas City, Kansas City, MO, USA
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, MO, USA
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Susan Abdel-Rahman
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, MO, USA
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - J Steven Leeder
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, MO, USA
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Aleksandra Galetin
- Centre for Applied Pharmacokinetic Research, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PT, UK
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23
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Smit C, Wasmann RE, Wiezer MJ, van Dongen HPA, Mouton JW, Brüggemann RJM, Knibbe CAJ. Tobramycin Clearance Is Best Described by Renal Function Estimates in Obese and Non-obese Individuals: Results of a Prospective Rich Sampling Pharmacokinetic Study. Pharm Res 2019; 36:112. [PMID: 31147853 PMCID: PMC6542779 DOI: 10.1007/s11095-019-2651-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 05/22/2019] [Indexed: 01/05/2023]
Abstract
Purpose Tobramycin is an aminoglycoside antibiotic of which the 24 h exposure correlates with efficacy. Recently, we found that clearance of the aminoglycoside gentamicin correlates with total body weight (TBW). In this study, we investigate the full pharmacokinetic profile of tobramycin in obese and non-obese individuals with normal renal function. Methods Morbidly obese individuals (n = 20) undergoing bariatric surgery and non-obese healthy volunteers (n = 8), with TBW ranging 57–194 kg, received an IV dose of tobramycin with plasma concentrations measured over 24 h (n = 10 per individual). Statistical analysis, modelling and simulations were performed using NONMEM. Results In a two-compartment model, TBW was the best predictor for central volume of distribution (p < 0.001). For clearance, MDRD (de-indexed for body surface area) was identified as best covariate (p < 0.001), and was superior over TBW ((p < 0.05). Other renal function estimates (24 h urine GFR and de-indexed CKD-EPI) led to similar results as MDRD (all p < 0.001)). Conclusions In obese and non-obese individuals with normal renal function, renal function estimates such as MDRD were identified as best predictors for tobramycin clearance, which may imply that other processes are involved in clearance of tobramycin versus gentamicin. To ensure similar exposure across body weights, we propose a MDRD-based dosing nomogram for obese patients. Electronic supplementary material The online version of this article (10.1007/s11095-019-2651-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Cornelis Smit
- Department of Clinical Pharmacy, St. Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, The Netherlands.,Department of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Roeland E Wasmann
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Marinus J Wiezer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Roger J M Brüggemann
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, The Netherlands. .,Department of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.
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