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Roy H, Bertoldi C, Farrell C, Rousseau E. Prescribing drugs to overweight and obese children: Balancing efficacy and safety. Paediatr Child Health 2021; 26:e236-e239. [PMID: 34552680 DOI: 10.1093/pch/pxaa108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 09/05/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Helene Roy
- CHU Sainte Justine/University of Montreal, Montreal, Quebec
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2
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Kyler KE, Bettenhausen JL, Hall M, Glynn EF, Hoffman MA, Shakhnovich V, Smolderen K, Davis AM. Obesity and Corticosteroid Dosing Guideline Adherence in Children Hospitalized With Asthma. Hosp Pediatr 2021; 11:380-388. [PMID: 33664119 DOI: 10.1542/hpeds.2020-001420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Drug dosing recommendations for children with obesity remain limited. This may lead to variability in medication dosing among children with obesity. Therefore, our objective was to determine differences in the prevalence of guideline-nonadherent systemic corticosteroid orders by weight category in children hospitalized for asthma. METHODS We performed a retrospective cross-sectional study of children aged 2 to 17 years hospitalized with asthma and prescribed systemic corticosteroids between January 1, 2010, and December 31, 2017, using the Cerner Health Facts deidentified database. Weight categories ranging from underweight to class III obesity were defined on the basis of BMI percentiles by using CDC guidelines. Corticosteroid orders were categorized as guideline adherent or nonadherent on the basis of total body weight-based dosing guidelines from the National Heart, Lung, and Blood Institute. χ2 test and multivariable logistic regression models were used to determine differences in guideline adherence between weight categories. RESULTS We identified 21 488 children prescribed systemic corticosteroids during asthma hospitalizations. Most (54.2%) had a healthy weight, and 23.8% had obesity. Almost one-quarter received guideline-nonadherent orders (22.2%), with increasing prevalence among higher weight categories (19.4% of healthy weight children versus 36.0% of those with class III obesity; P < .001). After controlling for demographic and clinical covariates, weight category remained significantly associated with receiving a guideline-nonadherent order (P < .001). CONCLUSIONS The prevalence of guideline-nonadherent corticosteroid orders for children hospitalized with asthma increases linearly with weight category, disproportionately affecting children with severe obesity. Standardization of drug dosing guidelines for children with obesity may help reduce variability in drug doses prescribed that may increase risk of harm.
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Affiliation(s)
- Kathryn E Kyler
- Children's Mercy Hospital, Kansas City, Missouri; .,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Jessica L Bettenhausen
- Children's Mercy Hospital, Kansas City, Missouri.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Matt Hall
- Children's Mercy Hospital, Kansas City, Missouri.,Children's Hospital Association, Lenexa, Kansas
| | - Earl F Glynn
- Children's Mercy Hospital, Kansas City, Missouri
| | - Mark A Hoffman
- Children's Mercy Hospital, Kansas City, Missouri.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Valentina Shakhnovich
- Children's Mercy Hospital, Kansas City, Missouri.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri.,Center for Children's Healthy Lifestyles and Nutrition, Kansas City, Missouri; and
| | - Kim Smolderen
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Ann M Davis
- Center for Children's Healthy Lifestyles and Nutrition, Kansas City, Missouri; and.,University of Kansas Medical Center, Kansas City, Kansas
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3
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Green TP, Binns HJ, Wu H, Ariza AJ, Perrin EM, Quadri M, Hornik CP, Cohen‐Wolkowiez M. Estimation of Body Fat Percentage for Clinical Pharmacokinetic Studies in Children. Clin Transl Sci 2021; 14:509-517. [PMID: 33142010 PMCID: PMC7993323 DOI: 10.1111/cts.12896] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/31/2020] [Indexed: 12/19/2022] Open
Abstract
Obesity is a prevalent childhood condition and the degree of adiposity appears likely to be an important covariate in the pharmacokinetics (PKs) of many drugs. We undertook these studies to facilitate the evaluation and, where appropriate, quantification of the covariate effect of body fat percentage (BF%) on PK parameters in children. We examined two large databases to determine the values and variabilities of BF% in children with healthy body weights and in those with obesity, comparing the accuracy and precision of BF% estimation by both clinical methods and demographically derived techniques. Additionally, we conducted simulation studies to evaluate the utility of the several methods for application in clinical trials. BF% was correlated with body mass index (BMI), but was highly variable among both children with healthy body weights and those with obesity. Bio-impedance and several demographically derived techniques produced mean estimates of BF% that differed from dual x-ray absorptiometry by < 1% (accuracy) and a SD of 5% or less (precision). Simulation studies confirmed that when the differences in precision among the several methods were small compared with unexplained between-subject variability of a PK parameter, the techniques were of similar value in assessing the contribution of BF%, if any, as a covariate for that PK parameter. The combination of sex and obesity stage explained 68% of the variance of BF% with BMI. The estimation of BF% from sex and obesity stage can routinely be applied to PK clinical trials to evaluate the contribution of BF% as a potential covariate.
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Affiliation(s)
- Thomas P. Green
- Department of PediatricsAnn & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
| | - Helen J. Binns
- Department of PediatricsAnn & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
- Center on Obesity Management and PreventionStanley Manne Children's Research InstituteChicagoIllinoisUSA
- Department of Preventive MedicineFeinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
| | - Huali Wu
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Adolfo J. Ariza
- Department of PediatricsAnn & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
- Center on Obesity Management and PreventionStanley Manne Children's Research InstituteChicagoIllinoisUSA
| | - Eliana M. Perrin
- Duke Center for Childhood Obesity Research and Division of Primary CareDepartment of PediatricsDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Maheen Quadri
- Department of PediatricsAnn & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
- Center on Obesity Management and PreventionStanley Manne Children's Research InstituteChicagoIllinoisUSA
| | - Christoph P. Hornik
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNorth CarolinaUSA
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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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5
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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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6
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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] [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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7
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Kang K, Absher R, Farrington E, Ackley R, So TY. Evaluation of Different Methods Used to Calculate Ideal Body Weight in the Pediatric Population. J Pediatr Pharmacol Ther 2019; 24:421-430. [PMID: 31598106 DOI: 10.5863/1551-6776-24.5.421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Accurate determination of ideal body weight (IBW) in pediatric patients is important for the proper dosing of many medications and the classification of nutritional status. There is no consensus on the best method to calculate IBW. The purpose of this study is to evaluate and compare 7 different methods used to calculate IBW in the pediatric population. METHODS This was a retrospective observational study. All subjects were pediatric inpatients at a 536-bed community teaching hospital between January 1, 2016, and June 30, 2017. Subjects were divided into 2 cohorts: cohort 1 was aged 12 months and 0 day to 35 months and 30 days, and cohort 2 was aged 36 months and 0 day to 17 years and 364 days. The McLaren method was used as the reference to compare with 6 other methods: Moore method, Devine method, American Dietetic Association (ADA) method, body mass index (BMI) method, Traub equation, and simplified Traub equation. RESULTS For cohort 1 (n = 347), the Moore method was not statistically different from the McLaren method with a mean difference of -0.07 kg (95% CI: -0.14 to 0.01, p = 0.07). For cohort 2 (n = 1095), the BMI method was not statistically different from the McLaren method with a mean difference of 0.17 kg (95% CI: -0.07 to 0.40, p = 0.17). CONCLUSIONS In both cohorts, the majority of methods used to calculate IBW in pediatric patients leads to statistically different results when compared with the McLaren method. For certain methods, these differences become pronounced at high and low height percentiles and in older age groups.
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Zimmerman KO, Benjamin DK, Becker ML, Anand R, Hornik CP. Product Labeling of Drugs Commonly Administered to Children and Adults with Obesity. PHARMACEUTICAL REGULATORY AFFAIRS : OPEN ACCESS 2019; 8:219. [PMID: 37220561 PMCID: PMC10201954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Obesity is a major public health problem that can affect drug disposition and dosing, particularly in vulnerable pediatric populations. Despite potentially detrimental consequences from inappropriately dosed drugs in children with obesity, drug product labels largely fail to include dosing or guidance specific to this population. Failure to include this information results in an increased incidence of adverse events, and concerns from treating physicians regarding their ability to provide appropriate care for children with obesity. Using data from the National Institute of Child Health and Human Development-funded Pediatric Trials Network (PTN), we explore possible ways to improve drug labeling in children with obesity. In order to improve health outcomes of children with obesity, carefully designed and executed PK trials and comprehensive PK analysis strategies are needed. Early collaboration with the Food and Drug Administration may be helpful in developing studies and analyses that are most beneficial for child health. This collaboration is particularly important for drugs that treat potentially life-threatening diseases, where inclusion of PK and dosing on the drug label is vital. We hope that increasing the body of knowledge on drug dosing in children with obesity will open the door to regulatory guidance based on extrapolation or population-specific PK studies, similar to other currently-recognized special populations. Given the magnitude of the pediatric obesity pandemic, recognition as a special population will offer substantial public health value.
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Affiliation(s)
- Kanecia O. Zimmerman
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Mara L. Becker
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO
| | | | - Christoph P. Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
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McLaughlin MJ, Wagner J, Shakhnovich V, Carleton B, Leeder JS. Considerations for Implementing Precision Therapeutics for Children. Clin Transl Sci 2019; 12:140-150. [PMID: 30516322 PMCID: PMC6440566 DOI: 10.1111/cts.12607] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 11/13/2018] [Indexed: 12/12/2022] Open
Abstract
Improving the utilization of pharmacologic agents in the pediatric population yields significant, perhaps life‐long, benefits. Genetic factors related to the disposition of a medication or an alteration at the target receptor site contributes to the observed variability of exposure and response between individuals. An additional source of this variability specific to the pediatric population is ontogeny, where age‐specific changes during development may require dose adjustments to obtain the same levels of drug exposure and response. With significant improvements in characterizing both the ontogeny and genetic contributions of drug metabolizing enzymes, the time is right to begin placing more emphasis on response rather than only the dose‐exposure relationship. The amount of drug target receptors and the relative affinity for binding at that target site may require different levels of systemic exposure to achieve a desired response. Concentration‐controlled studies can identify the needed exposure for a response at the drug target, the level of expression of the target site in an individual patient, and the tools required to individualize response. Although pediatrics represents a large spectrum of growth and development, developing tools to improve drug delivery for each individual patient across the spectrum of the ages treated by clinicians remains valuable.
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Affiliation(s)
| | | | | | - Bruce Carleton
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
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10
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Wells M. A validation of the PAWPER XL-MAC tape for total body weight estimation in preschool children from low- and middle-income countries. PLoS One 2019; 14:e0210332. [PMID: 30615693 PMCID: PMC6322773 DOI: 10.1371/journal.pone.0210332] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 12/20/2018] [Indexed: 12/31/2022] Open
Abstract
Importance The PAWPER tape system is one of the three most accurate paediatric weight estimation systems in the world. The latest version of the tape, which does not rely on a subjective assessment of habitus, is the PAWPER XL-MAC method which uses length and mid-arm circumference (MAC) to estimate weight. It was derived and validated in a population in the USA and has not yet been fully validated in a population from a resource-limited setting. Objective The objective of this study was to evaluate the performance of the PAWPER XL-MAC tape weight estimation system in a large dataset sample of children from resource-limited settings. Methods This was a “virtual” study in which weight estimates were generated using the PAWPER XL-MAC tape and Broselow tape 2007B and 2011A editions in a very large open access dataset. The dataset contained anthropometric information of children aged 6 to 59 months from standardised nutritional surveys in 51 low- and middle-income countries. The performance of PAWPER XL-MAC method was compared with the Broselow tape and a new length- and habitus-based tape, the Ralston method. Main outcomes and measures The bias of the weight estimation methods was assessed using the mean percentage error (MPE) and precision using the 95% limits of agreement (LOA) of the MPE. The overall accuracy was denoted by the percentage of weight estimates falling within 10% and 20% of actual weight (abbreviated as p10 and p20 respectively). Results The MPE (LOA) for the PAWPER XL-MAC tape, the Broselow 2007B and 2011A and Ralston method were 1.9 (-15.3, 19.2), 5.4 (-15.9, 26.7), 7.7 (-13.3, 30.5) and -0.7 (-20.2, 19.3) respectively. The p10 and p20 for each method were 79.3% and 96.9% for the PAWPER XL-MAC tape, 64.3% and 91.0% for the Broselow tape 2007B, 55.5% and 85.9% for the Broselow tape 2011A and 67.4 and 94.0% for the Ralston method respectively. The PAWPER XL-MAC system was statistically significantly more accurate than the Broselow tape 2011A, the Broselow tape 2007B and the Ralston method. The relative difference in accuracy (p10) was 43% (odds ratio 4.4 (4.4, 4.5), p<0.001), 23% (odds ratio 2.9 (2.8, 2.9), p<0.001) and 18% (odds ratio 1.8 (1.8, 1.8), p<0.001) compared to each method, respectively. Conclusions and relevance The PAWPER XL-MAC tape performed well in this study and was statistically significantly more accurate than both the Broselow tape editions and the Ralston method. This difference was substantial and clinically important. The tape did not perform as well at extremes of habitus-type, however, and might benefit from recalibration.
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Affiliation(s)
- Mike Wells
- Division of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
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11
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Wells M, Goldstein LN. An algorithm to improve the accuracy of emergency weight estimation in obese children. Pan Afr Med J 2018; 31:90. [PMID: 31011391 PMCID: PMC6461967 DOI: 10.11604/pamj.2018.31.90.13821] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 09/25/2018] [Indexed: 11/23/2022] Open
Abstract
Introduction During medical emergencies in children, accurate and appropriate weight estimations may ultimately influence the outcome by facilitating the delivery of safe and effective doses of medications. Children at the extremes of habitus, especially obese children, are more at risk of an inaccurate weight estimation and therefore may be more at risk of medication errors. The objective was therefore to develop an algorithm to guide accurate emergency weight estimation in obese children. Methods Relevant medical evidence was reviewed regarding weight estimation and its role and timing in the resuscitation of obese children. This was used as the basis for a weight-estimation algorithm. Results There was limited evidence regarding the way the weight-estimation systems should be used in obese children other than that the dual length- and habitus-based systems were the most accurate. The methods included in the algorithm were the Broselow tape, the Mercy method, parental estimates, the paediatric advanced weight prediction in the emergency room/ eXtra Length-eXtra Large (PAWPER XL) tape and the Traub-Johnson formula. The algorithm recognised several ways in which weight estimation could be tailored to the clinical scenario to estimate both ideal and total body weight. Conclusion Weight-estimation in obese children must be conducted appropriately to avoid medication errors. This algorithm provides a framework to achieve this.
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Affiliation(s)
- Mike Wells
- Division of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lara Nicole Goldstein
- Division of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Shakhnovich V, Brian Smith P, Guptill JT, James LP, Collier DN, Wu H, Livingston CE, Zhao J, Kearns GL, Cohen-Wolkowiez M. A Population-Based Pharmacokinetic Model Approach to Pantoprazole Dosing for Obese Children and Adolescents. Paediatr Drugs 2018; 20:483-495. [PMID: 30097906 PMCID: PMC6178956 DOI: 10.1007/s40272-018-0305-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND AIMS Pharmacokinetic data for proton pump inhibitors (PPIs), acid-suppression drugs commonly prescribed to children, are lacking for obese children who are at greatest risk for acid-related disease. In a recent multi-center investigation, we demonstrated decreased, total body weight adjusted, apparent clearance (CL/F) of the PPI pantoprazole for obese children compared with their non-obese peers. Subsequently, we developed a population-based pharmacokinetic (PopPK) model to characterize pantoprazole disposition and evaluated appropriate pantoprazole dosing strategies for obese pediatric patients, using simulation. METHODS Pharmacokinetic data from the only prospective study of PPIs in obese children (aged 6-17 years; n = 40) included 273 pantoprazole and 256 pantoprazole-sulfone plasma concentrations, after single oral-dose administration, and were used for pantoprazole model development and covariate analysis (NONMEM®). Model evaluation was performed via bootstrapping and predictive checks, and the final model was applied to simulate systemic pantoprazole exposures for common dosing scenarios. RESULTS A two-compartment PopPK model, which included CYP2C19 genotype and total body weight, provided the best fit. Resultant, typical, weight-normalized pantoprazole parameter estimates were different than previously reported for children or adults, with significantly reduced pantoprazole CL/F for obese children. Of the dosing scenarios evaluated, the weight-tiered approach, approved by the US Food and Drug Administration, achieved pantoprazole exposures [area under the curve (AUC0-∞)] within ranges previously reported as therapeutic, without over- or under-prediction for obese children. CONCLUSIONS Our data argue against empiric dose escalation of PPIs for obese children and support current FDA-approved pediatric weight-tiered dosing for pantoprazole; however, 3- to 5-fold inter-individual variability in pantoprazole AUC0-∞ remained using this dosing approach.
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Affiliation(s)
- Valentina Shakhnovich
- The Children's Mercy Hospital, Kansas City, MO, USA.
- University of Missouri-Kansas City School of Medicine, Kansas City, USA.
| | | | | | | | | | - Huali Wu
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Jian Zhao
- The Emmes Corporation, Rockville, MD, USA
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13
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Ameer B, Weintraub MA. Pediatric Obesity: Influence on Drug Dosing and Therapeutics. J Clin Pharmacol 2018; 58 Suppl 10:S94-S107. [DOI: 10.1002/jcph.1092] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 01/11/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Barbara Ameer
- Department of Medicine; Rutgers - Robert Wood Johnson Medical School; Piscataway NJ USA
| | - Michael A. Weintraub
- Department of Medicine; Thomas Jefferson University Hospitals; Philadelphia PA USA
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14
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Optimising emergency weight estimation in underweight and obese children: the accuracy of estimations of total body weight and ideal body weight. Eur J Emerg Med 2018; 26:301-307. [PMID: 30044240 DOI: 10.1097/mej.0000000000000561] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE During medical emergencies, underweight and obese children are at a higher risk of weight-estimation errors than 'average' children, which may lead to poorer outcomes. In obese children, optimum drug dosing requires a measure of both total body weight (TBW) and ideal body weight (IBW) for appropriate scaling. We evaluated the ability of the Broselow tape, the Mercy method and the PAWPER XL tape to estimate TBW and IBW in obese and underweight children. PARTICIPANTS AND METHODS Data for children aged 0-18 years were extracted and pooled from three previous weight-estimation studies. The accuracy of estimation of TBW and IBW by each method was evaluated using percentage of estimations within 10% of target weight (PW10) as the primary outcome measure. RESULTS The Broselow tape estimated TBW poorly in obese and underweight children (PW10: 3.9 and 41.4%), but estimated IBW extremely accurately (PW10: 90.6%). The Mercy method estimated TBW accurately in both obese and underweight children (PW10: 74.3 and 76.3%) but did not predict IBW accurately (PW10: 14.3%). The PAWPER XL tape predicted TBW well (PW10: 73.0% in obese children and 74.9% in underweight children) and predicted IBW extremely accurately (PW10: 100%). CONCLUSION The Broselow tape predicted IBW, but not TBW, accurately. The Mercy method estimated TBW very accurately, but not IBW. The PAWPER XL tape estimated both TBW and IBW accurately. The PAWPER XL tape should be considered when choosing a weight-estimation strategy for obese and underweight children.
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15
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van Rongen A, Brill MJE, Vaughns JD, Välitalo PAJ, van Dongen EPA, van Ramshorst B, Barrett JS, van den Anker JN, Knibbe CAJ. Higher Midazolam Clearance in Obese Adolescents Compared with Morbidly Obese Adults. Clin Pharmacokinet 2018; 57:601-611. [PMID: 28785981 PMCID: PMC5904241 DOI: 10.1007/s40262-017-0579-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The clearance of cytochrome P450 (CYP) 3A substrates is reported to be reduced with lower age, inflammation and obesity. As it is unknown what the overall influence is of these factors in the case of obese adolescents vs. morbidly obese adults, we studied covariates influencing the clearance of the CYP3A substrate midazolam in a combined analysis of data from obese adolescents and morbidly obese adults. METHODS Data from 19 obese adolescents [102.7 kg (62-149.5 kg)] and 20 morbidly obese adults [144 kg (112-186 kg)] receiving intravenous midazolam were analysed, using population pharmacokinetic modelling (NONMEM 7.2). In the covariate analysis, the influence of study group, age, total body weight (TBW), developmental weight (WTfor age and length) and excess body weight (WTexcess = TBW - WTfor age and length) was evaluated. RESULTS The population mean midazolam clearance was significantly higher in obese adolescents than in morbidly obese adults [0.71 (7%) vs. 0.44 (11%) L/min; p < 0.01]. Moreover, clearance in obese adolescents increased with TBW (p < 0.01), which seemed mainly explained by WTexcess, and for which a so-called 'excess weight' model scaling WTfor age and length to the power of 0.75 and a separate function for WTexcess was proposed. DISCUSSION We hypothesise that higher midazolam clearance in obese adolescents is explained by less obesity-induced suppression of CYP3A activity, while the increase with WTexcess is explained by increased liver blood flow. The approach characterising the influence of obesity in the paediatric population we propose here may be of value for use in future studies in obese adolescents.
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Affiliation(s)
- Anne van Rongen
- Department of Clinical Pharmacy, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Department of Clinical Pharmacy, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Margreke J E Brill
- Department of Clinical Pharmacy, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Janelle D Vaughns
- Division of Anesthesiology and Pain Medicine, Children's National Health System, Washington, DC, USA
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Pyry A J Välitalo
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Eric P A van Dongen
- Department of Anesthesiology and Intensive Care, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Bert van Ramshorst
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jeffrey S Barrett
- Laboratory for Applied PK/PD, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Johannes N van den Anker
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
- Division of Pediatric Pharmacology and Pharmacometrics, University Children's Hospital, Basel, Switzerland
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.
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16
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Shakhnovich V, Smith PB, Guptill JT, James LP, Collier DN, Wu H, Livingston CE, Zhao J, Kearns GL. Obese Children Require Lower Doses of Pantoprazole Than Nonobese Peers to Achieve Equal Systemic Drug Exposures. J Pediatr 2018; 193:102-108.e1. [PMID: 29389444 PMCID: PMC5806153 DOI: 10.1016/j.jpeds.2017.10.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 10/04/2017] [Accepted: 10/11/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess appropriate pantoprazole dosing for obese children, we conducted a prospective pharmacokinetics (PK) investigation of pantoprazole in obese children, a patient population that is traditionally excluded from clinical trials. STUDY DESIGN A total of 41 obese children (6-17 years of age), genotyped for CYP2C19 variants *2, *3, *4, and *17, received a single oral dose of pantoprazole, ~1.2 mg/kg lean body weight (LBW), with LBW calculated via a validated formula. Ten post-dose pantoprazole plasma concentrations were measured, and PK variables generated via noncompartmental methods (WinNonlin). Linear and nonlinear regression analyses and analyses of variance were used to explore obesity, age, and CYP2C19 genotype contribution to pantoprazole PK. PK variables of interest were compared with historic nonobese peers treated with pantoprazole. RESULTS Independent of genotype, when normalized to dose per kg total body weight, pantoprazole apparent clearance and apparent volume of distribution were significantly lower (P < .05) and systemic exposure significantly higher (P < .01) in obese vs nonobese children. When normalized per kg LBW, these differences were not evident in children ≥12 years of age and markedly reduced in children <12 years of age. CONCLUSIONS LBW dosing of pantoprazole led to pantoprazole PK similar to nonobese peers. Additional factors, other than body size (eg, age-related changes in CYP2C19 activity), appear to affect pantoprazole PK in children <12 years of age. TRIAL REGISTRATION ClinicalTrials.gov: NCT02186652.
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Affiliation(s)
- Valentina Shakhnovich
- Divisions of Gastroenterology & Clinical Pharmacology, Toxicology and Therapeutic Innovation, The Children's Mercy Hospital, Kansas City, MO.
| | - P Brian Smith
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Duke Clinical Research Institute, Durham, NC
| | - Jeffrey T Guptill
- Department of Neurology, Division of Neuromuscular Medicine, Duke Clinical Research Institute, Durham, NC
| | - Laura P James
- Department of Pediatrics, University of Arkansas for Medical Sciences Section of Clinical Pharmacology and Toxicology, Arkansas Children's Hospital, Little Rock, AR
| | - David N Collier
- Department of Pediatrics and Center for Health Disparities, Division of General Pediatrics, East Carolina University, Greenville, NC
| | - Huali Wu
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Duke Clinical Research Institute, Durham, NC
| | | | - Jian Zhao
- The Emmes Statistical Group, Rockville, MD
| | - Gregory L Kearns
- Department of Pediatrics, University of Arkansas for Medical Sciences Section of Clinical Pharmacology and Toxicology, Arkansas Children's Hospital, Little Rock, AR
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17
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A systematic review and meta-analysis of the accuracy of weight estimation systems used in paediatric emergency care in developing countries. Afr J Emerg Med 2017; 7:S36-S54. [PMID: 30505673 PMCID: PMC6246873 DOI: 10.1016/j.afjem.2017.06.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 06/13/2017] [Accepted: 06/29/2017] [Indexed: 11/23/2022] Open
Abstract
Introduction When weight cannot be measured during the management of medical emergencies in children, a convenient, quick and accurate method of weight estimation is required, as many drug doses and other interventions are based on body weight. Many weight estimation methodologies in current use have been shown to be inaccurate, especially in low- and middle-income countries with a high prevalence of underweight children. This meta-analysis evaluated the accuracy of weight estimation systems in children from studies from low- and middle-income countries. Methods Articles from low- and middle-income countries were screened for inclusion to evaluate and compare the accuracy of existing systems and the newer dual length- and habitus-based methods, using standard meta-analysis techniques. Results The 2D systems and parental estimates performed best overall. The PAWPER tape, parental estimates, the Wozniak method and the Mercy method were the most accurate systems with percentage of weight estimates within 10% of actual weight (PW10) accuracies of 86.9%, 80.4%, 72.1% and 71.4% respectively. The Broselow tape (PW10 47.1%) achieved a moderate accuracy and age-based estimates a very low accuracy (PW10 11.8–47.5%). Conclusions The PAWPER tape, the Wozniak method and the Mercy method achieved an acceptable level of accuracy in studies from low- and middle-income countries and should preferentially be used and further advanced for clinical emergency medicine practice. Parental estimates may be considered if the regular caregiver of the child is present and a recent measured weight is known. The Broselow tape and age-based formulas should be abandoned in low- and middle-income country populations as they are potentially dangerously inaccurate.
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18
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Abstract
Before prescribing, the pediatrician typically considers recommended dosing guidelines and issues related to safety. Rarely does (s)he consider the impact of normal growth and development on drug disposition and by extension drug action. This paper reviews how the processes of absorption, distribution, metabolism and elimination differ between healthy children and adults and briefly discusses considerations for medication prescribing in children where these processes are altered secondary to comorbidities.
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19
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Young KD, Korotzer NC. Weight Estimation Methods in Children: A Systematic Review. Ann Emerg Med 2016; 68:441-451.e10. [DOI: 10.1016/j.annemergmed.2016.02.043] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 02/09/2016] [Accepted: 02/19/2016] [Indexed: 01/08/2023]
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20
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Walson PD. Pediatric Obesity. Clin Ther 2015; 37:1895-6. [DOI: 10.1016/j.clinthera.2015.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 08/14/2015] [Indexed: 10/23/2022]
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21
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Shader RI. More Reflections on Obesity. Clin Ther 2015; 37:1873-5. [DOI: 10.1016/j.clinthera.2015.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 08/17/2015] [Indexed: 11/16/2022]
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