1
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Reduced Enterohepatic Recirculation of Mycophenolate and Lower Blood Concentrations are Associated with the Stool Bacterial Microbiome After Hematopoietic Cell Transplantation. Transplant Cell Ther 2022; 28:372.e1-372.e9. [PMID: 35489611 DOI: 10.1016/j.jtct.2022.04.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/11/2022] [Accepted: 04/19/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Mycophenolate mofetil (MMF) is an important immunosuppressant used after allogeneic hematopoietic cell transplant (HCT). MMF has a narrow therapeutic index and blood concentrations of mycophenolic acid (MPA), the active component of MMF, are highly variable. Low MPA concentrations are associated with risk of graft vs host disease (GvHD) while high concentrations are associated with toxicity. Reasons for variability are not well known and may be due, at least in part, to the presence of β-glucuronidase producing bacteria in the gastrointestinal tract which enhance MPA enterohepatic recirculation (EHR) by transforming MPA metabolites formed in the liver back to MPA. OBJECTIVE To determine if individuals with high MPA EHR have a greater abundance of β-glucuronidase producing bacteria in their stool and higher MPA concentrations relative to those with low EHR. STUDY DESIGN We conducted a pharmacomicrobiomics study in 20 adult HCT recipients receiving a myeloablative or reduced intensity preparative regimen. Participants received MMF 1g IV every 8 hours with tacrolimus. Intensive pharmacokinetic sampling of mycophenolate was conducted before hospital discharge. Total MPA, MPA glucuronide (MPAG) and acylMPAG were measured. EHR was defined as a ratio of MPA area under the concentration-versus-time curve (AUC)4-8 to MPA AUC0-8. Differences in stool microbiome diversity and composition, determined by shotgun metagenomic sequencing, were compared above and below the median EHR (22%, range 5-44%). RESULTS Median EHR was 12% and 29% in the low and high EHR groups, respectively. MPA troughs, MPA AUC4-8 and acylMPAG AUC4-8/AUC0-8, were greater in the high EHR group vs low EHR group [1.53 vs 0.28 mcg/mL, p = 0.0001], [7.33 vs 1.79 hr*mcg/mL, p = 0.0003] and [0.33 vs 0.24 hr*mcg/mL, p = 0.0007], respectively. MPA AUC0-8 was greater in the high EHR than the low EHR group and trended towards significance [22.8 vs. 15.3 hr*mcg/mL, p=0.06]. Bacteroides vulgatus, stercoris and thetaiotaomicron were 1.2-2.4 times more abundant (p=0.039, 0.024, 0.046, respectively) in the high EHR group. MPA EHR was positively correlated with B. vulgatus (⍴=0.58, p≤0.01) and B. thetaiotaomicron (⍴=0.46, p<0.05) and negatively correlated with Blautia hydrogenotrophica (⍴=-0.53, p<0.05). Therapeutic MPA troughs were achieved in 80% of patients in the high EHR group and 0% in the low EHR. There was a trend towards differences in MPA AUC0-8 and MPA Css mcg/mL in high vs. low EHR groups (p=0.06). CONCLUSION MPA EHR was variable. Patients with high MPA EHR had greater abundance of Bacteroides species in stool and higher MPA exposure than patients with low MPA EHR. Bacteroides may therefore be protective from poor outcomes such as graft vs host disease but in others it may increase the risk of MPA adverse effects. These data need to be confirmed and studied after oral MMF.
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2
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Chalklin CG, Koimtzis G, Khalid U, Carrington-Windo E, Elker D, Asderakis A. SARS-CoV-2 Infection Can Lead to an Increase in Tacrolimus Levels in Renal Transplant Patients: A Cohort Study. Transpl Int 2022; 35:10127. [PMID: 35387396 PMCID: PMC8977848 DOI: 10.3389/ti.2022.10127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/16/2022] [Indexed: 11/13/2022]
Abstract
The aim of this study is to evaluate the effect of SARS-CoV-2 infection on serum tacrolimus levels. Tacrolimus levels of 34 transplant patients diagnosed with SARS-CoV-2 in 2020 were compared with their pre-infection values and those of a control group with alternative infections. 20 out of 34 (59%) had high levels. At diagnosis, median tacrolimus level in the SARS-CoV-2 cohort was 9.6 μg/L (2.7-23) compared to 7.9 μg/L in the control group (p = 0.07, 95% CI for difference -0.3-5.8). The ratio of post-infection to pre-infection tacrolimus values was higher in the SARS-CoV-2 group (1.7) compared to the control group (1.25, p = 0.018, 95% CI for difference 0.08-0.89). The acute kidney injury rate was 65% (13 of 20) in SARS-CoV-2 patients with a level >8 μg/dl, compared to 29% (4 of 14) in those with lower levels (p = 0.037). Median length of stay was 10 days among SARS-CoV-2 infected patients with high tacrolimus levels compared to 0 days in the rest (p = 0.04). Four patients with high levels died compared to 2 in the control group. Clinicians should be aware of this potential effect on tacrolimus levels and take appropriate measures.
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Affiliation(s)
- Christopher G Chalklin
- Cardiff Transplant Unit, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Georgios Koimtzis
- Cardiff Transplant Unit, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Usman Khalid
- Cardiff Transplant Unit, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, United Kingdom.,College of Medicine, Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Eliot Carrington-Windo
- Cardiff Transplant Unit, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Doruk Elker
- Cardiff Transplant Unit, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Argiris Asderakis
- Cardiff Transplant Unit, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, United Kingdom.,College of Medicine, Infection and Immunity, Cardiff University, Cardiff, United Kingdom
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Gota V, Purohit V, Gurjar M, Nayak L, Punatar S, Gokarn A, Bonda A, Bagal B, Vora CS, Patil A, Nookala M, Khattry N. A Limited Sampling Strategy for Therapeutic Drug Monitoring of Mycophenolate Mofetil for Prophylaxis of Acute Graft-Versus-Host Disease in Allogeneic Stem Cell Transplantation. Cell Transplant 2021; 29:963689720912925. [PMID: 32495641 PMCID: PMC7444217 DOI: 10.1177/0963689720912925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A universally accepted strategy for therapeutic drug monitoring (TDM) of
mycophenolate mofetil (MMF) in the prevention of acute graft-versus-host disease
(aGVHD) in allogenic hematopoietic stem cell transplantation (alloHSCT) does not
exist. We explored the feasibility of developing a limited sampling strategy
(LSS) for TDM of MMF in this setting. Patients undergoing alloHSCT received
standard MMF-cyclosporine prophylaxis, with MMF administered twice daily (BD)
for matched transplant recipients or thrice daily (TID) in haploidentical
transplantation. Intensive blood sampling was carried out on day 7 and area
under the concentration–time curve (AUC) of mycophenolic acid (MPA), the active
metabolite, was estimated using noncompartmental analysis. The ability of MPA
exposure defined by AUC0-12 to discriminate between responders
(patients who did not develop GVHD) and nonresponders (patients who developed
GVHD) was determined by receiver operating characteristic curve analysis.
Patients were divided into training and validation sets within BD and TID
groups. Mathematical equations were developed from the training set to predict
AUC0-12 from an abbreviated AUC involving a limited number of
sampling points. The equations were validated in the validation set by comparing
the MPA AUC0-12 predicted from LSS with the observed
AUC0-12. It was observed that patients with AUC0-12
≤18.99 mg*h/L had a higher risk of developing aGVHD [odds ratio (OR) = 2.63
(1.17 to 5.87), P = 0.06]. The benefit was more in matched
transplant recipients [OR = 3.5 (1.30 to 9.49), P = 0.05] as
compared to haploindentical transplant [OR = 2.8 (0.49 to 15.91),
P = NS]. Using the mathematical equations, the observed
AUC0-12 was predicted with 92.31% accuracy in the BD subset and
100% accuracy in the TID subset for a combined accuracy of 94.76%. A set of just
three samples that constituted the abbreviated AUC1-4 was used to
develop the predictive models. The LSS could be employed for the therapeutic
monitoring of MMF particularly in patients undergoing matched hematopoietic stem
cell transplantation.
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Affiliation(s)
- Vikram Gota
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharastra, India
| | - Vaitashi Purohit
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Murari Gurjar
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Lingaraj Nayak
- Homi Bhabha National Institute, Mumbai, Maharastra, India.,Bone Marrow Transplant Unit, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Sachin Punatar
- Homi Bhabha National Institute, Mumbai, Maharastra, India.,Bone Marrow Transplant Unit, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Anant Gokarn
- Homi Bhabha National Institute, Mumbai, Maharastra, India.,Bone Marrow Transplant Unit, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Avinash Bonda
- Homi Bhabha National Institute, Mumbai, Maharastra, India.,Bone Marrow Transplant Unit, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Bhausaheb Bagal
- Homi Bhabha National Institute, Mumbai, Maharastra, India.,Bone Marrow Transplant Unit, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Chakor Sunil Vora
- Homi Bhabha National Institute, Mumbai, Maharastra, India.,Bone Marrow Transplant Unit, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Anand Patil
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Manjunath Nookala
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Navin Khattry
- Homi Bhabha National Institute, Mumbai, Maharastra, India.,Bone Marrow Transplant Unit, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
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4
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Uchiyama K, Saito Y, Takekuma Y, Sugita J, Teshima T, Sugawara M. Pharmacokinetics of mycophenolic acid after haplo-hematopoietic stem cell transplantation in Japanese recipients. J Oncol Pharm Pract 2020; 28:31-38. [PMID: 33349149 DOI: 10.1177/1078155220980815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Mycophenolate mofetil (MMF), a mycophenolic acid (MPA) prodrug, is used to prevent graft-versus-host disease (GVHD) in hematopoietic stem cell transplantation (HSCT). Although previous studies have reported that enterohepatic circulation (EHC) of MPA, which is usually observed in MMF-treated patients, does not occur in HSCT patients, it is unclear what happens in haploidentical-HSCT (haplo-HSCT) patients, who are using post-transplant cyclophosphamide. This study was conducted to investigate MPA pharmacokinetics in haplo-HSCT patients. METHODS Seventeen haplo-HSCT patients, who received MMF for GVHD prophylaxis, were enrolled in this study. We collected blood samples on days 14 and 28, and plasma MPA concentrations were measured by high-performance liquid chromatography; pharmacokinetic parameters such as area under the curve (AUC), mean residence time (MRT), and apparent oral clearance (CL/F) were measured with moment analysis. We also evaluated EHC as AUC6-12h/AUC0-12h. RESULTS There was no significant difference in MPA pharmacokinetic parameters between days 14 and 28. There was also no difference between the pharmacokinetic parameter changes and diarrhea. Additionally, varying plasma MPA concentrations suggested that MPA EHC did not occur. CONCLUSION In this study, we revealed the pharmacokinetics of MMF in Japanese haplo-HSCT recipients. Additionally, our study demonstrated that MPA EHC might not occur in Japanese haplo-HSCT recipients.
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Affiliation(s)
- Kazuki Uchiyama
- Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan
| | - Yoshitaka Saito
- Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan
| | - Yoh Takekuma
- Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan
| | - Junichi Sugita
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Mitsuru Sugawara
- Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan.,Laboratory of Pharmacokinetics, Faculty of Pharmaceutical Sciences, Hokkaido University, Sapporo, Japan
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5
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Zhang D, Chow DSL. Clinical Pharmacokinetics of Mycophenolic Acid in Hematopoietic Stem Cell Transplantation Recipients. Eur J Drug Metab Pharmacokinet 2017; 42:183-189. [PMID: 27677732 DOI: 10.1007/s13318-016-0378-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mycophenolate mofetil (MMF), an ester prodrug of mycophenolic acid (MPA), is widely used as a maintenance immunosuppressive regimen in solid organ transplant patients. It is increasingly used for the prophylaxis and treatment of graft-versus-host disease (GVHD) in hematopoietic stem cell transplantation (HSCT) patients. MPA displays extensive binding to serum albumin and glucuronidation to the inactive MPA-7-O-glucuronide (MPAG). Here, we review and discuss the pertinent information regarding the clinical pharmacokinetics of MPA in HSCT patients. The pharmacokinetics of MPA are altered in HSCT patients with lower oral bioavailability, shorter half-life and higher clearance than those in healthy volunteers and renal transplant recipients. Moreover, clearance may be increased in young pediatric patients. The optimal MMF dosing and preferred targets are still under investigation in HSCT patients due to the substantial intra- and inter-individual pharmacokinetic variability of MPA and broad range of transplants (malignant vs. nonmalignant, related vs. unrelated donor, and human leukocyte antigen mismatch). The complex pharmacokinetics of MPA have partly hampered the efficient use of MMF, and pharmacokinetic studies in HSCT patients have been limited in size and mostly inconclusive. Future research should be multi-institutional and focus on developing clinical decisions with adequate statistical power to improve clinical care of HSCT recipients.
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Affiliation(s)
- Daping Zhang
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, 1441 Moursund Street, Houston, TX, 77030, USA.
| | - Diana S-L Chow
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, 1441 Moursund Street, Houston, TX, 77030, USA
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6
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Pharmacokinetics, Pharmacodynamics, and Pharmacogenomics of Immunosuppressants in Allogeneic Hematopoietic Cell Transplantation: Part II. Clin Pharmacokinet 2016; 55:551-93. [PMID: 26620047 DOI: 10.1007/s40262-015-0340-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Part I of this article included a pertinent review of allogeneic hematopoietic cell transplantation (alloHCT), the role of postgraft immunosuppression in alloHCT, and the pharmacokinetics, pharmacodynamics, and pharmacogenomics of the calcineurin inhibitors and methotrexate. In this article (Part II), we review the pharmacokinetics, pharmacodynamics, and pharmacogenomics of mycophenolic acid (MPA), sirolimus, and the antithymocyte globulins (ATG). We then discuss target concentration intervention (TCI) of these postgraft immunosuppressants in alloHCT patients, with a focus on current evidence for TCI and on how TCI may improve clinical management in these patients. Currently, TCI using trough concentrations is conducted for sirolimus in alloHCT patients. Several studies demonstrate that MPA plasma exposure is associated with clinical outcomes, with an increasing number of alloHCT patients needing TCI of MPA. Compared with MPA, there are fewer pharmacokinetic/dynamic studies of rabbit ATG and horse ATG in alloHCT patients. Future pharmacokinetic/dynamic research of postgraft immunosuppressants should include '-omics'-based tools: pharmacogenomics may be used to gain an improved understanding of the covariates influencing pharmacokinetics as well as proteomics and metabolomics as novel methods to elucidate pharmacodynamic responses.
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7
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Harnicar S, Ponce DM, Hilden P, Zheng J, Devlin SM, Lubin M, Pozotrigo M, Mathew S, Adel N, Kernan NA, O'Reilly R, Prockop S, Scaradavou A, Hanash A, Jenq R, van den Brink M, Giralt S, Perales MA, Young JW, Barker JN. Intensified Mycophenolate Mofetil Dosing and Higher Mycophenolic Acid Trough Levels Reduce Severe Acute Graft-versus-Host Disease after Double-Unit Cord Blood Transplantation. Biol Blood Marrow Transplant 2015; 21:920-5. [PMID: 25687796 DOI: 10.1016/j.bbmt.2015.01.024] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 01/28/2015] [Indexed: 12/18/2022]
Abstract
Although mycophenolate mofetil (MMF) has replaced corticosteroids as immunosuppression in cord blood transplantation (CBT), optimal MMF dosing has yet to be established. We intensified MMF dosing from every 12 to every 8 hours to augment graft-versus-host disease (GVHD) prophylaxis in double-unit cord blood transplantation (dCBT) and evaluated outcomes according to the total daily MMF dose/kg in 174 dCBT recipients (median age, 39 years; range, 1 to 71) who underwent transplantation for hematologic malignancies. Recipients of an MMF dose ≤ the median (36 mg/kg/day) had an increased day 100 grade III and IV acute GVHD (aGVHD) incidence compared with patients who received >36 mg/kg/day (24% versus 8%, P = .008). Recipients of ≤ the median dose who had highly HLA allele (1 to 3 of 6) mismatched dominant units had the highest day 100 grade III and IV aGVHD incidence of 37% (P = .009). This finding was confirmed in multivariate analysis (P = .053). In 83 patients evaluated for mycophenolic acid (MPA) troughs, those with a mean week 1 and 2 trough < .5 μg/mL had an increased day 100 grade III and IV aGVHD of 26% versus 9% (P = .063), and those who received a low total daily MMF dose and had a low mean week 1 and 2 MPA trough had a 40% incidence (P = .008). Higher MMF dosing or MPA troughs had no impact on engraftment after myeloablation. This analysis supports intensified MMF dosing in milligram per kilogram per day and MPA trough level monitoring early after transplantation in dCBT recipients.
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Affiliation(s)
- Stephen Harnicar
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Doris M Ponce
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Patrick Hilden
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Junting Zheng
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean M Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marissa Lubin
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa Pozotrigo
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York; Bone Marrow Transplantation Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sherry Mathew
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nelly Adel
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nancy A Kernan
- Bone Marrow Transplantation Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard O'Reilly
- Bone Marrow Transplantation Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Susan Prockop
- Bone Marrow Transplantation Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andromachi Scaradavou
- Bone Marrow Transplantation Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alan Hanash
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Robert Jenq
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Marcel van den Brink
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Sergio Giralt
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Miguel A Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - James W Young
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Juliet N Barker
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
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McDermott CL, Sandmaier BM, Storer B, Li H, Mager DE, Boeckh MJ, Bemer MJ, Knutson J, McCune JS. Nonrelapse mortality and mycophenolic acid exposure in nonmyeloablative hematopoietic cell transplantation. Biol Blood Marrow Transplant 2013; 19:1159-66. [PMID: 23660171 PMCID: PMC3720781 DOI: 10.1016/j.bbmt.2013.04.026] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 04/30/2013] [Indexed: 01/25/2023]
Abstract
We evaluated the pharmacodynamic relationships between mycophenolic acid (MPA), the active metabolite of mycophenolate mofetil (MMF), and outcomes in 308 patients after nonmyeloablative hematopoietic cell transplantation. Patients were conditioned with total body irradiation ± fludarabine, received grafts from HLA-matched related (n = 132) or unrelated (n = 176) donors, and received postgrafting immunosuppression with MMF and a calcineurin inhibitor. Total and unbound MPA pharmacokinetics were determined to day 25; maximum a posteriori Bayesian estimators were used to estimate total MPA concentration at steady state (Css). Rejection occurred in 9 patients, 8 of whom had a total MPA Css less than 3 μg/mL. In patients receiving a related donor graft, MPA Css was not associated with clinical outcomes. In patients receiving an unrelated donor graft, low total MPA Css was associated with increased grades III to IV acute graft-versus-host disease and increased nonrelapse mortality but not with day 28 T cell chimerism, disease relapse, cytomegalovirus reactivation, or overall survival. We conclude that higher initial oral MMF doses and subsequent targeting of total MPA Css to greater than 2.96 μg/mL could lower grades III to IV acute graft-versus-host disease and nonrelapse mortality in patients receiving an unrelated donor graft.
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Affiliation(s)
| | - Brenda M. Sandmaier
- School of Medicine, University of Washington, Seattle, WA, USA
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Barry Storer
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Hong Li
- University of Buffalo, Buffalo, NY, USA
| | | | - Michael J. Boeckh
- School of Medicine, University of Washington, Seattle, WA, USA
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | - Jeannine S. McCune
- School of Pharmacy, University of Washington, Seattle, WA, USA
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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9
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Mycophenolate mofetil: fully utilizing its benefits for GvHD prophylaxis. Int J Hematol 2012; 96:10-25. [DOI: 10.1007/s12185-012-1086-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 04/18/2012] [Accepted: 04/19/2012] [Indexed: 10/28/2022]
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10
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11
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Schieveen PGV, Royer B. Niveau de preuve du suivi thérapeutique pharmacologique de l’acide mycophénolique administré pour la prévention des réactions du greffon contre l’hôte au cours des greffes de cellules souches avec un conditionnement réduit. Therapie 2011; 66:51-5. [DOI: 10.2515/therapie/2010024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Accepted: 11/30/2010] [Indexed: 12/19/2022]
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12
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Jacobson PA, Huang J, Wu J, Kim M, Logan B, Alousi A, Grimley M, Bolaños-Meade J, Ho V, Levine JE, Weisdorf D. Mycophenolate pharmacokinetics and association with response to acute graft-versus-host disease treatment from the Blood and Marrow Transplant Clinical Trials Network. Biol Blood Marrow Transplant 2010; 16:421-9. [PMID: 19925875 DOI: 10.1016/j.bbmt.2009.11.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2009] [Accepted: 11/10/2009] [Indexed: 11/29/2022]
Abstract
There are limited data as to the effectiveness of mycophenolate mofetil (MMF) plus high-dose corticosteroids for the treatment of acute graft-versus-host disease (aGVHD), and even less data regarding the pharmacokinetic disposition and exposure-response relationship of MMF in individuals with GVHD. MMF pharmacokinetics were studied in a multicenter Blood and Marrow Transplant Clinical Trials Network randomized phase II trial evaluating the effectiveness of MMF as one of 4 agents added to corticosteroids as treatment of aGVHD. Thirty-two of the patients randomized to receive MMF underwent pharmacokinetic sampling in weeks 1 and 2 were studied. Mean age was 41 +/- 13.6 years. Twenty one (65.6%), 5 (15.6%), 6 (18.8%) patients had a complete response (CR), partial response (PR) or lesser response by day 28, respectively. Twenty-five (78.1%), 2 (6.3%), 5 (15.6%) patients had a CR, PR, or other response by day 56 to treatment, respectively. Mycophenolic acid (MPA) pharmacokinetic measurements from weeks 1 and 2 did not correlate with CR at either day 28 or day 56 (P > .07); however, if the mean of weeks 1 and 2 total MPA troughs was >0.5 microg/mL or that of an unbound trough was >0.015 microg/mL, then a significantly greater proportion achieved CR + PR at days 28 and 56. CR + PR at day 28 was observed in 19 of 19 patients (100%) with a mean total trough >0.5 mg/mL, but in only 7 of 13 (54%) with a mean total trough < or =0.5 microg/mL (P = .002). Similarly, CR + PR at day 28 was seen in 15 of 15 patients (100%) with an unbound trough concentration >0.015 microg/mL, but in only 11 of 17 (65%) with an unbound trough concentration < or =0.015 microg/mL (P = .02). There was no association between the pharmacokinetic measures and risk of infection by day 90 or overall survival (OS) at day 180 postrandomization. About one-half of subjects did not achieve the favorable MPA total and unbound trough concentrations. The current practice of MMF 1 gm twice daily dosing provides low plasma concentrations in many patients. Higher doses may improve the efficacy of MMF as aGVHD therapy.
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Affiliation(s)
- Pamala A Jacobson
- Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, 308 Harvard Street SE, Minneapolis, MN 55455, USA.
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Okamura A, Shimoyama M, Ishii S, Wakahashi K, Asada N, Kawano H, Kawamori Y, Nishikawa S, Minagawa K, Katayama Y, Matsui T. Delayed neutrophil engraftment in cord blood transplantation with intensive administration of mycophenolate mofetil for GVHD prophylaxis. Bone Marrow Transplant 2010; 46:148-9. [PMID: 20228852 DOI: 10.1038/bmt.2010.59] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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