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The Application of Inosine 5'-Monophosphate Dehydrogenase Activity Determination in Peripheral Blood Mononuclear Cells for Monitoring Mycophenolate Mofetil Therapy in Children with Nephrotic Syndrome. Pharmaceuticals (Basel) 2020; 13:ph13080200. [PMID: 32824803 PMCID: PMC7463457 DOI: 10.3390/ph13080200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/14/2020] [Accepted: 08/16/2020] [Indexed: 11/16/2022] Open
Abstract
In pediatric nephrotic syndrome, recommended mycophenolic acid (MPA) pharmacokinetics are higher than those for transplant recipients. In MPA therapeutic monitoring, inosine-5'-monophosphate dehydrogenase (IMPDH) activity may be useful. We modified the method established for renal transplant recipients and determined IMPDH activity in peripheral blood mononuclear cells (PBMCs) from healthy volunteers and children (4-16 years) with nephrotic syndrome treated with mycophenolate mofetil (MMF). From children, four blood samples were collected, and MPA concentrations were also determined. IMPDH activity was calculated using xanthosine monophosphate (XMP) normalized with adenosine monophosphate (AMP), both determined with the HPLC-UV method. The modified method was accurate, precise, and linear for AMP and XMP within 0.50-50.0 μmoL/L. Mean IMPDH activity in volunteers was 45.97 ± 6.24 µmoL·s-1·moL-1 AMP, whereas for children, the values were variable and amounted to 39.23 ± 27.40 µmoL·s-1·moL-1 AMP and 17.97 ± 15.24 µmoL·s-1·moL-1 AMP before the next MMF dose and 1 h afterward, respectively. The modified method may be applied to IMPDH activity determination in children with nephrotic syndrome treated with MMF. IMPDH activity should be determined after one thawing of PBMCs due to the change in AMP and XMP concentrations after subsequent thawing. For children, the lowest IMPDH activity was observed concomitantly with the highest MPA concentration.
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Klotsman M, Sathyan G, Anderson WH, Garden OA, Shivanand P. Mycophenolic acid in patients with immune-mediated inflammatory diseases: From humans to dogs. J Vet Pharmacol Ther 2018; 42:127-138. [PMID: 30375004 DOI: 10.1111/jvp.12731] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/02/2018] [Accepted: 10/03/2018] [Indexed: 12/26/2022]
Abstract
Mycophenolic acid (MPA), a noncompetitive, selective and reversible inhibitor of inosine 5'-monophosphate dehydrogenase (IMPDH), is an immunosuppressive agent that has a long history in medicine. Mechanistically, the inhibition of IMPDH leads to the selective and eventual arrest of T- and B-lymphocyte proliferation. Mycophenolate mofetil (MMF), the first MPA-based product to receive marketing approval over two decades ago, was originally indicated for the prophylaxis of organ rejection in human transplant patients. Given its broad immunosuppressive properties and ability to selectively inhibit lymphocyte division and effector functions, the clinical utility of MPA was subsequently explored in a host of autoimmune diseases. Human clinical studies have shown MPA to be safe and effective and support its off-label administration for immune-mediated diseases such as lupus, myasthenia gravis and atopic dermatitis. MMF became generically available in the United States in 2008, and its clinical utility is increasingly being explored as a treatment option for dogs with immune-mediated diseases. This review summarizes the available literature for MPA pharmacokinetics and pharmacodynamics, and the current status of MPA as a treatment for client-owned dogs diagnosed with immune-mediated diseases.
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Affiliation(s)
| | | | - Wayne H Anderson
- Okava Pharmaceuticals, San Francisco, California.,Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Oliver A Garden
- Clinical Sciences & Advanced Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania
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Optimization and application of an HPLC method for quantification of inosine-5'-monophosphate dehydrogenase activity as a pharmacodynamic biomarker of mycophenolic acid in Chinese renal transplant patients. Clin Chim Acta 2018; 485:333-339. [PMID: 29964005 DOI: 10.1016/j.cca.2018.06.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/27/2018] [Accepted: 06/27/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND The immunosuppressive agent mycophenolic acid (MPA) is a non-competitive, reversible inhibitor of inosine-5'-monophosphate dehydrogenase (IMPDH). Thus, IMPDH activity can serve as a potential pharmacodynamic biomarker to optimize dosing of MPA. METHODS Peripheral blood mononuclear cells were isolated from 2 mL blood samples and an in vitro enzymatic reaction was subsequently performed for 120 min. To determine IMPDH activity in Chinese healthy volunteers and renal transplant patients, a high performance liquid chromatography assay was established and validated by subtracting adenosine monophosphate (AMP) from blank samples for eliminating exogenous AMP interference. RESULTS The accuracy of our method ranged between -0.8% and 12.5%, and the precision ranged between 0.7% and 6.3%. The mean value of IMPDH activity across 11 healthy volunteers was 46.60 ± 14.28 μmol/s/mol AMP. A negative relationship between MPA concentration and IMPDH activity was observed in four renal transplant patients treated with MPA 13 days post-transplantation, while the inhibitory rate of IMPDH activity ranged from 24% to 42%. CONCLUSION A bioanalytical assay for IMPDH quantification was optimized and evaluated. The differences in the pharmacodynamics of MPA between Asians and Caucasians may provide some evidence for dosing differences among ethnicities.
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Kauke T, Oberhauser C, Lin V, Coenen M, Fischereder M, Dick A, Schoenermarck U, Guba M, Andrassy J, Werner J, Meiser B, Angele M, Stangl M, Habicht A. De novo donor-specific anti-HLA antibodies after kidney transplantation are associated with impaired graft outcome independently of their C1q-binding ability. Transpl Int 2017; 30:360-370. [PMID: 27862352 DOI: 10.1111/tri.12887] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 07/28/2016] [Accepted: 11/09/2016] [Indexed: 12/16/2022]
Abstract
Many aspects of post-transplant monitoring of donor-specific (DSA) and non-donor-specific (nDSA) anti-HLA antibodies on renal allograft survival are still unclear. Differentiating them by their ability to bind C1q may offer a better risk assessment. We retrospectively investigated the clinical relevance of de novo C1q-binding anti-HLA antibodies on graft outcome in 611 renal transplant recipients. Acute rejection (AR), renal function, and graft survival were assessed within a mean follow-up of 6.66 years. Post-transplant 6.5% patients developed de novo DSA and 11.5% de novo nDSA. DSA (60.0%; P < 0.0001) but not nDSA (34.1%, P = 0.4788) increased rate of AR as compared with controls (27.4%). C1q-binding anti-HLA antibodies did not alter rate of AR in both groups. Renal function was only significantly diminished in patients with DSAC1q+ . However, DSA significantly impaired 5-year graft survival (65.2%; P < 0.0001) in comparison with nDSA (86.7%; P = 0.0054) and controls (90.7%). While graft survival did not differ between DSAC1q- and DSAC1q+ recipients, 5-year allograft survival was reduced in nDSAC1q+ (80.9%) versus nDSAC1q- (90.7%, P = 0.0251). De novo DSA independently of their ability to bind C1q are associated with diminished graft survival.
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Affiliation(s)
- Teresa Kauke
- Laboratory of Immunogenetics, University Hospital Munich, Munich, Germany.,Clinic of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Munich, Munich, Germany.,Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Cornelia Oberhauser
- Department of Medical Informatics, Biometry and Epidemiology - IBE, Chair for Public Health and Health Services Research, Munich, Germany.,Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Viviane Lin
- Laboratory of Immunogenetics, University Hospital Munich, Munich, Germany.,Transplant Center, University Hospital Munich, Munich, Germany.,Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Michaela Coenen
- Department of Medical Informatics, Biometry and Epidemiology - IBE, Chair for Public Health and Health Services Research, Munich, Germany.,Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Michael Fischereder
- Renal Division, Department of Internal Medicine IV, University Hospital Munich, Munich, Germany.,Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Andrea Dick
- Laboratory of Immunogenetics, University Hospital Munich, Munich, Germany.,Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Ulf Schoenermarck
- Renal Division, Department of Internal Medicine IV, University Hospital Munich, Munich, Germany.,Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Markus Guba
- Clinic of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Munich, Munich, Germany.,Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Joachim Andrassy
- Clinic of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Munich, Munich, Germany.,Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Jens Werner
- Clinic of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Munich, Munich, Germany.,Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Bruno Meiser
- Transplant Center, University Hospital Munich, Munich, Germany.,Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Martin Angele
- Clinic of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Munich, Munich, Germany.,Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Manfred Stangl
- Clinic of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Munich, Munich, Germany.,Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Antje Habicht
- Transplant Center, University Hospital Munich, Munich, Germany.,Ludwig-Maximilians-University (LMU), Munich, Germany
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Filler G, Alvarez-Elías AC, McIntyre C, Medeiros M. The compelling case for therapeutic drug monitoring of mycophenolate mofetil therapy. Pediatr Nephrol 2017; 32:21-29. [PMID: 26921212 DOI: 10.1007/s00467-016-3352-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/25/2016] [Accepted: 01/29/2016] [Indexed: 11/26/2022]
Abstract
We have reviewed current evidence on the therapeutic drug monitoring (TDM) of mycophenolic acid (MPA) in relationship to drug efficacy and safety. The relationship between actual MPA exposure and mycophenolate mofetil (MMF) dose has been shown to be weak in children and adolescents. The TDM of MPA exposure should ideally be performed using full pharmacokinetic profiles or limited sampling strategies. Recent evidence has provided some rationale for using the post-dose trough level as a single measure. In terms of short-term efficacy, there is strong evidence that a MPA area under the time-concentration curve of >30 mg × h/L reduces acute rejection episodes early after renal transplantation, and there is evolving evidence that aiming for the same exposure over the long term may be a viable strategy to reduce the formation of donor-specific antibodies. Strong evidence also supports the existence of important drug interactions and age/developmental dependent differences in drug metabolism that may necessitate the need for TDM of MMF therapy. Based on these findings and given the substantial inter- and intra-patient variability of MPA exposure, it would appear that MMF therapy should be subject to TDM to avoid over- and under-dosing. This may be a viable strategy to reduce treatment-emergent adverse events and to increase the effective pediatric transplant survival rates.
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Affiliation(s)
- Guido Filler
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5 W9, Canada.
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, N5A 5A5, Canada.
- Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5 W9, Canada.
- Department of Pediatrics, Children's Hospital, London Health Science Centre, Western University, 800 Commissioners Road East, London, ON, N6A 5 W9, Canada.
| | - Ana Catalina Alvarez-Elías
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5 W9, Canada
- Universidad Nacional Autónoma de México, Mexico City, 04510, Mexico
- Laboratorio de Investigacion en Nefrologia, Hospital Infantil de Mexico Federico Gomez, Mexico City, Mexico
| | - Christopher McIntyre
- Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5 W9, Canada
| | - Mara Medeiros
- Laboratorio de Investigacion en Nefrologia, Hospital Infantil de Mexico Federico Gomez, Mexico City, Mexico
- Departamento de Farmacología, Facultad de Medicina, Universidad Nacional Autónoma de México, México City, Mexico
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6
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Barcelona Consensus on Biomarker-Based Immunosuppressive Drugs Management in Solid Organ Transplantation. Ther Drug Monit 2016; 38 Suppl 1:S1-20. [PMID: 26977997 DOI: 10.1097/ftd.0000000000000287] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
With current treatment regimens, a relatively high proportion of transplant recipients experience underimmunosuppression or overimmunosuppression. Recently, several promising biomarkers have been identified for determining patient alloreactivity, which help in assessing the risk of rejection and personal response to the drug; others correlate with graft dysfunction and clinical outcome, offering a realistic opportunity for personalized immunosuppression. This consensus document aims to help tailor immunosuppression to the needs of the individual patient. It examines current knowledge on biomarkers associated with patient risk stratification and immunosuppression requirements that have been generally accepted as promising. It is based on a comprehensive review of the literature and the expert opinion of the Biomarker Working Group of the International Association of Therapeutic Drug Monitoring and Clinical Toxicology. The quality of evidence was systematically weighted, and the strength of recommendations was rated according to the GRADE system. Three types of biomarkers are discussed: (1) those associated with the risk of rejection (alloreactivity/tolerance), (2) those reflecting individual response to immunosuppressants, and (3) those associated with graft dysfunction. Analytical aspects of biomarker measurement and novel pharmacokinetic-pharmacodynamic models accessible to the transplant community are also addressed. Conventional pharmacokinetic biomarkers may be used in combination with those discussed in this article to achieve better outcomes and improve long-term graft survival. Our group of experts has made recommendations for the most appropriate analysis of a proposed panel of preliminary biomarkers, most of which are currently under clinical evaluation in ongoing multicentre clinical trials. A section of Next Steps was also included, in which the Expert Committee is committed to sharing this knowledge with the Transplant Community in the form of triennial updates.
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Lim TY, Heneghan M. Biomarkers of immunosuppression. Clin Liver Dis (Hoboken) 2016; 8:34-38. [PMID: 31041060 PMCID: PMC6490196 DOI: 10.1002/cld.570] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 06/09/2016] [Accepted: 06/20/2016] [Indexed: 02/04/2023] Open
Affiliation(s)
- Tiong Yeng Lim
- King's College HospitalInstitute of Liver StudiesLondonUnited Kingdom
| | - Michael Heneghan
- King's College HospitalInstitute of Liver StudiesLondonUnited Kingdom
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8
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Target Enzyme Activity and Phosphorylation of Pathway Molecules As Specific Biomarkers in Transplantation. Ther Drug Monit 2016; 38 Suppl 1:S43-9. [DOI: 10.1097/ftd.0000000000000288] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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9
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Bergan S, Bremer S, Vethe NT. Drug target molecules to guide immunosuppression. Clin Biochem 2015; 49:411-8. [PMID: 26453533 DOI: 10.1016/j.clinbiochem.2015.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 09/25/2015] [Accepted: 10/03/2015] [Indexed: 10/22/2022]
Abstract
The individual and interindividual variability of response to immunosuppressants combined with the prevailing concept of lifelong immunosuppression following any organ transplantation motivates the search for methods to further individualize such therapy. Traditional therapeutic drug monitoring, adapting dose according to concentrations in blood, targets the pharmacokinetic variability. It has been increasingly recognized, however, that there is also a considerable variability in the response to a given concentration. Attempts to overcome this variability in response include the efforts to identify relevant targets and methods for pharmacodynamic monitoring. For several of the currently used immunosuppressants there is experimental data suggesting markers that are relevant as indicators for individual monitoring of the effects of these drugs. There are also some clinical data to support these approaches; however what is generally missing, are studies that in a prospective manner demonstrates the benefits and effects on outcome. The monitoring of antithymocyte globulin by lymphocyte subset counts is actually the only well established example of pharmacodynamic monitoring. For drugs such as MPA and mTOR inhibitors, there are candidates such as IMPDH activity expression and p70SK6 phosphorylation status, respectively. The monitoring of CNIs using assays for NFAT RGE, either alone or combined with concentration measurements, is already well documented. Even here, some further investigations relating to the categories of organ transplant, combination of immunosuppressants etc. will be requested. Although some further standardization of the assay is warranted and there is a need for specific recommendations of target levels and how to adjust dose, the NFAT RGE approach to pharmacodynamic monitoring of CNIs may be close to implementation in clinical routine.
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Affiliation(s)
- Stein Bergan
- Oslo University Hospital, Department of Pharmacology, Oslo, Norway; University of Oslo, School of Pharmacy, Oslo, Norway.
| | - Sara Bremer
- Oslo University Hospital, Department of Medical Biochemistry, Oslo, Norway
| | - Nils Tore Vethe
- Oslo University Hospital, Department of Pharmacology, Oslo, Norway
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10
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Rissling O, Glander P, Hambach P, Mai M, Brakemeier S, Klonower D, Halleck F, Singer E, Schrezenmeier EV, Dürr M, Neumayer HH, Budde K. No relevant pharmacokinetic interaction between pantoprazole and mycophenolate in renal transplant patients: a randomized crossover study. Br J Clin Pharmacol 2015; 80:1086-96. [PMID: 25913040 DOI: 10.1111/bcp.12664] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 04/04/2015] [Accepted: 04/20/2015] [Indexed: 02/03/2023] Open
Abstract
AIMS Mycophenolic acid (MPA) suppresses lymphocyte proliferation through inosine monophosphate dehydrogenase (IMPDH) inhibition. Two formulations have been approved: mycophenolate mofetil (MMF) and enteric-coated mycophenolate sodium (EC-MPS). Pantoprazole (PAN) inhibits gastric acid secretion, which may alter MPA exposure. Data from healthy volunteers suggest a significant drug-drug interaction (DDA) between pantoprazole and MPA. In transplant patients, a decreased MPA area under the concentration-time curve (AUC) may lead to higher IMPDH activity, which may lead to higher acute rejection risk. Therefore this DDA was evaluated in renal transplant patients under maintenance immunosuppressive therapy. METHODS In this single-centre, open, randomized, four-sequence, four-treatment crossover study, the influence of PAN 40 mg on MPA pharmacokinetics such as (dose-adjusted) AUC0-12 h (dAUC) was analysed in 20 renal transplant patients (>6 months post-transplantation) receiving MMF (1-2 g day(-1) ) and EC-MPS in combination with ciclosporin. The major metabolite MPA glucuronide (MPAG) and the IMPDH activity were also examined. RESULTS MMF + PAN intake led to a lowest mean dAUC for MPA of 41.46 ng h ml(-1) mg(-1) [95% confidence interval (CI) 32.38, 50.54], while MPA exposure was highest for EC-MPS + PAN [dAUC: 46.30 ng h ml(-1) mg(-1) (95% CI 37.11, 55.49)]. Differences in dAUC and dose-adjusted maximum concentration (dCmax) were not significant. Only for MMF [dAUC: 41.46 ng h ml(-1) mg(-1) (95% CI 32.38, 50.54)] and EC-MPS [dAUC: 43.39 ng h ml(-1) mg(-1) (95% CI 33.44, 53.34)] bioequivalence was established for dAUC [geometric mean ratio: 101.25% (90% CI 84.60, 121.17)]. Simultaneous EC-MPS + PAN intake led to an earlier time to Cmax (tmax) [median: 2.0 h (min-max: 0.5-10.0)] than EC-MPS intake alone [3 h (1.5-12.0); P = 0.037]. Tmax was not affected for MMF [1.0 h (0.5-5.0)] ± pantoprazole [1.0 h (0.5-6.0), P = 0.928). No impact on MPAG pharmacokinetics or IMPDH activity was found. CONCLUSION Pantoprazole influences EC-MPS and MMF pharmacokinetics but as it had no impact on MPA pharmacodynamics, the immunosuppressive effect of the drug was not impaired.
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Affiliation(s)
- Olesja Rissling
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany.,Institute of Pharmacy, Department of Biology, Chemistry, Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Petra Glander
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | - Pia Hambach
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | - Marco Mai
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | - Susanne Brakemeier
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | - Daniela Klonower
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | - Eugenia Singer
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | | | - Michael Dürr
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
| | | | - Klemens Budde
- Department of Nephrology, Charité University Hospital Berlin, Berlin, Germany
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Kawanishi M, Yano I, Yoshimura K, Yamamoto T, Hashi S, Masuda S, Kondo T, Takaori-Kondo A, Matsubara K. Sensitive and validated LC-MS/MS methods to evaluate mycophenolic acid pharmacokinetics and pharmacodynamics in hematopoietic stem cell transplant patients. Biomed Chromatogr 2015; 29:1309-16. [DOI: 10.1002/bmc.3423] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 11/07/2014] [Accepted: 12/02/2014] [Indexed: 01/16/2023]
Affiliation(s)
- Misaki Kawanishi
- Department of Clinical Pharmacy and Education, Graduate School of Pharmaceutical Sciences; Kyoto University; Kyoto Japan
- Department of Clinical Pharmacology and Therapeutics; Kyoto University Hospital; Kyoto Japan
| | - Ikuko Yano
- Department of Clinical Pharmacy and Education, Graduate School of Pharmaceutical Sciences; Kyoto University; Kyoto Japan
- Department of Clinical Pharmacology and Therapeutics; Kyoto University Hospital; Kyoto Japan
| | - Kazuaki Yoshimura
- Department of Clinical Pharmacy and Education, Graduate School of Pharmaceutical Sciences; Kyoto University; Kyoto Japan
- Department of Clinical Pharmacology and Therapeutics; Kyoto University Hospital; Kyoto Japan
| | - Takashi Yamamoto
- Department of Clinical Pharmacology and Therapeutics; Kyoto University Hospital; Kyoto Japan
| | - Sachiyo Hashi
- Department of Clinical Pharmacology and Therapeutics; Kyoto University Hospital; Kyoto Japan
| | - Satohiro Masuda
- Department of Clinical Pharmacology and Therapeutics; Kyoto University Hospital; Kyoto Japan
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Kazuo Matsubara
- Department of Clinical Pharmacology and Therapeutics; Kyoto University Hospital; Kyoto Japan
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Abstract
The transplantation literature includes numerous papers that report associations between polymorphisms in genes encoding metabolizing enzymes and drug transporters, and pharmacokinetic data on immunosuppressive drugs. Most of these studies are retrospective in design, and although a substantial number report significant associations, pharmacogenetic tests are hardly used in clinical practice. One of the reasons for this poor implementation is the current lack of evidence of improved clinical outcome with pharmacogenetic testing. Furthermore, with efficient therapeutic drug monitoring it is possible to rapidly correct for the effect of genotypic deviations on pharmacokinetics, thereby decreasing the utility of genotype-based dosing. The future of pharmacogenetics will be in treatment models in which patient characteristics are combined with data on polymorphisms in multiple genes. These models should focus on pharmacodynamic parameters, variations in the expression of drug transporter proteins, and predictors of toxicity. Such models will provide more information than the relatively small candidate gene studies performed so far. For implementation of these models into clinical practice, linkage of genotype data to medication prescription systems within electronic health records will be crucial.
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13
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Rana A, Alex JM, Chauhan M, Joshi G, Kumar R. A review on pharmacophoric designs of antiproliferative agents. Med Chem Res 2014. [DOI: 10.1007/s00044-014-1196-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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14
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15
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Muller-Haegele S, Muller L, Whiteside TL. Immunoregulatory activity of adenosine and its role in human cancer progression. Expert Rev Clin Immunol 2014; 10:897-914. [DOI: 10.1586/1744666x.2014.915739] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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16
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Dostalek M, Gohh RY, Akhlaghi F. Inosine monophosphate dehydrogenase expression and activity are significantly lower in kidney transplant recipients with diabetes mellitus. Ther Drug Monit 2013; 35:374-83. [PMID: 23666569 PMCID: PMC4109137 DOI: 10.1097/ftd.0b013e3182852697] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Inosine 5'-monophosphate dehydrogenase (IMPDH) is a target of the immunosuppressive drug, mycophenolic acid (MPA). A 12-hour clinical pharmacokinetic and pharmacodynamic study was conducted to compare IMPDH1 and IMPDH2 gene expression, IMPDHI and IMPDHII protein levels, and enzyme activity between kidney transplant recipients with respect to diabetes status. METHODS Nondiabetic (ND, n = 11) and diabetic (D, n = 9) kidney transplant recipients and on nontransplant nondiabetic (n = 10) and diabetic (n = 10) volunteers were included in the study. RESULTS Area under the effect curve values for gene expression: IMPDH1 [ND: 22.1 (13.8-31.3) versus D: 4.5 (2.3-6.5), P < 0.001] and IMPDH2 [ND: 15.3 (11.0-21.7) versus D: 6.1 (4.6-8.6), P < 0.001], protein level: IMPDHI [ND: 1.0 (0.5-1.3) versus 0.5 (0.4-0.7), P = 0.002] and IMPDHII [ND: 1.0 (0.6-1.6) versus D: 0.7 (0.6-0.8) P < 0.001] and enzyme activity [ND: 180 (105-245) versus D: 29.9 (15.3-35.6) µmole·s(-1)·mole(-1) adenosine monophosphate, P < 0.001] was significantly lower in transplant recipients with diabetes. Similar results were observed in nontransplanted volunteers. Kinetic studies of MPA-mediated suppression of IMPDH activity in nontransplanted individuals revealed an approximately 2.5-fold lower half-maximum effective concentration (EC50) for diabetic as compared with nondiabetic [ND: 50.2 (49.8-50.7) versus D: 15.8 (15.6-16.3) nmole/L, P = 0.004] volunteers. This difference was not related to several IMPDH gene variants. CONCLUSIONS This study indicates a significantly lower IMPDH gene expression, protein level, and enzyme activity in diabetic patients. Further clinical studies in a larger number of patients are warranted to verify whether MPA dosing must be optimized for kidney transplant recipients with diabetes mellitus.
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Affiliation(s)
- Miroslav Dostalek
- Department of Biomedical and Pharmaceutical Sciences, University of Rhode Island, Kingston, RI, USA
| | - Reginald Y. Gohh
- Division of Organ Transplantation, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Fatemeh Akhlaghi
- Department of Biomedical and Pharmaceutical Sciences, University of Rhode Island, Kingston, RI, USA
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Abd Rahman AN, Tett SE, Staatz CE. Clinical Pharmacokinetics and Pharmacodynamics of Mycophenolate in Patients with Autoimmune Disease. Clin Pharmacokinet 2013; 52:303-31. [DOI: 10.1007/s40262-013-0039-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Daleboudt GMN, Reinders MEJ, Hartigh JD, Huizinga TWJ, Rabelink AJ, de Fijter JW, Berger SP. Concentration-controlled treatment of lupus nephritis with mycophenolate mofetil. Lupus 2012; 22:171-9. [DOI: 10.1177/0961203312469261] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background: Mycophenolate mofetil (MMF) has recently been established as a potent drug in maintenance treatment for lupus nephritis. However, there is no consensus on the optimal dosing regimen because of a high inter-individual variability of mycophenolic acid (MPA), the active metabolite of MMF. This retrospective study aimed to investigate the effect of an individualized dosing regimen through concentration-controlled treatment on MPA exposure and renal outcome in patients with lupus nephritis. Methods: Sixteen patients with lupus nephritis and treatment with low-dose intravenous cyclophosphamide followed by MMF were included. MPA area under the plasma concentration-time curve from 0 to 12 hours (MPA-AUC0–12) was assessed within a month after MMF initiation. After determination of MPA-AUC0–12, MMF doses were titrated to achieve a target MPA-AUC0–12 of 60–90 mg*h/l. After on average six months, MPA-AUC0–12 measures were repeated to assess the effect of dose adjustment. Results: One month after introducing MMF, MPA-AUC0–12 was low and showed a high inter-individual variability. Dose adjustment with a target MPA-AUC0–12 of 60–90 mg*h/l resulted in individualized MMF dosing, significantly higher MPA-AUC0–12 levels, and a non-significant reduction in variability of MPA-AUC0–12. Adverse effects were reported by 37.5% of patients, which resulted in a switch to azathioprine in two patients. There was no significant relationship between the occurrence of adverse effects and MPA-AUC0–12. At 12 months of follow-up 87.5% of patients had achieved either partial (18.7%) or complete (68.8%) remission. Conclusion: Concentration-controlled dose adjustments with a target MPA-AUC0–12 of 60–90 mg*h/l was associated with optimized MPA exposure and an excellent renal outcome at 12 months of follow-up in a small sample of SLE patients with lupus nephritis.
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Affiliation(s)
- GMN Daleboudt
- Department of Nephrology, Leiden University Medical Center, The Netherlands
| | - MEJ Reinders
- Department of Nephrology, Leiden University Medical Center, The Netherlands
| | - J den Hartigh
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, The Netherlands
| | - TWJ Huizinga
- Department of Rheumatology, Leiden University Medical Center, The Netherlands
| | - AJ Rabelink
- Department of Nephrology, Leiden University Medical Center, The Netherlands
| | - JW de Fijter
- Department of Nephrology, Leiden University Medical Center, The Netherlands
| | - SP Berger
- Department of Nephrology, Leiden University Medical Center, The Netherlands
- Department of Internal Medicine, Erasmus Medical Center, The Netherlands
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Molinaro M, Chiarelli LR, Biancone L, Castagneto M, Boschiero L, Pisani F, Sabbatini M, Sandrini S, Arbustini E, Tinelli C, Regazzi M, Schena FP, Segoloni GP. Monitoring of inosine monophosphate dehydrogenase activity and expression during the early period of mycophenolate mofetil therapy in de novo renal transplant patients. Drug Metab Pharmacokinet 2012; 28:109-17. [PMID: 22892445 DOI: 10.2133/dmpk.dmpk-12-rg-048] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Measurement of inosine-monophosphate dehydrogenase (IMPDH) activity or gene expression was used as a further approach in pharmacokinetics (PK)/pharmacodynamic (PD)-guided mycophenolate mofetil (MMF) therapy. Forty-four de novo kidney transplant patients were enrolled; 35 of these completed the study, and were followed for 24 weeks for clinical status, PK parameters, IMPDH activity and IMPDH1/2 gene expression. IMPDH activity and expression were measured in peripheral blood mononuclear cells before transplant and at week 2,4,12 and 24, drawn before (t0) and 2 h (t2 h) after MMF administration. No significant correlation was found between IMPDH activity/expression and PK parameters. For both genes, significant enhancement in t2 h expression was observed, then decreases towards week 24 with a trend following steroid dosages. Seven patients experienced acute rejection (AR) and exhibited significantly higher pre-transplant expression of both IMPDH1 (median 3.42 vs. 0.84; p=0.0025), and IMPDH2 genes (135 vs. 104; p=0.0218) with respect to non-rejecting patients. A significant association was also found between pre-transplant IMPDH1 mRNA and haematological complications (p=0.032). This study suggests that high steroid dosages may influence IMPDH1/2 expression, hampering their use as a PD biomarker, particularly during the early post-transplant period. The measurement of pre-transplant levels of IMPDH1/2 may contribute to prediction of individual drug responsiveness to improve the clinical management of patients in MMF therapy.
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Affiliation(s)
- Mariadelfina Molinaro
- Clinical Pharmacokinetics in Transplantation and Autoimmune Diseases, Foundation IRCCS Policlinico S. Matteo, Pavia, Italy.
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Optimizing immunosuppressive drug dosing in pediatric renal transplantation. Pharmacol Res 2012; 65:163-7. [DOI: 10.1016/j.phrs.2011.09.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Revised: 09/28/2011] [Accepted: 09/29/2011] [Indexed: 12/17/2022]
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