Dried blood spots for monitoring and individualization of antiepileptic drug treatment

An LC-MS/MS Method for Quantification of Lamotrigine and Its Main Metabolite in Dried Blood Spots

BACKGROUND

The antiepileptic drug lamotrigine (LTG) shows high pharmacokinetic variability due to genotype influence and concomitant use of glucuronidation inducers and inhibitors, both of which may be frequently taken by elderly patients. Our goal was to develop a reliable quantification method for lamotrigine and its main glucuronide metabolite lamotrigine-N2-glucuronide (LTG-N2-GLU) in dried blood spots (DBS) to enable routine therapeutic drug monitoring and to identify altered metabolic activity for early detection of drug interactions possibly leading to suboptimal drug response.

RESULTS

The analytical method was validated in terms of selectivity, accuracy, precision, matrix effects, haematocrit, blood spot volume influence, and stability. It was applied to a clinical study, and the DBS results were compared to the concentrations determined in plasma samples. A good correlation was established for both analytes in DBS and plasma samples, taking into account the haematocrit and blood cell-to-plasma partition coefficients. It was demonstrated that the method is suitable for the determination of the metabolite-to-parent ratio to reveal the metabolic status of individual patients.

CONCLUSIONS

The clinical validation performed confirmed that the DBS technique is a reliable alternative for plasma lamotrigine and its glucuronide determination.

Development and validation of a UPLC-PDA method for quantifying ceftazidime in dried blood spots

Bacterial infection is a leading cause of neonatal death. Ceftazidime, commonly used for neonatal infections, is often used off-label. Blood sampling limits pharmacokinetic (PK) studies in neonatal patients. The dried blood spots (DBS) are a potential matrix for microsampling. Herein, we describe an ultra-performance liquid chromatography with a photodiode array (UPLC-PDA) to determine ceftazidime in DBS from neonatal patients in support of pharmacokinetic studies. The Capitainer® device-based DBS samples containing 10 µL blood were extracted in 70% methanol/water (v/v) with acetaminophen as the internal standard (IS). The extraction process was carried out at 20 °C using a block bath shaker at 1000 rpm for 30 min. The extracted ceftazidime was subsequently eluted through an Acquity UPLC HSS T3 column (2.1 × 50 mm, 1.8 µm). Elution was achieved using a water (containing 0.1% trifluoroacetic acid)/acetonitrile linear gradient at a flow rate of 0.5 mL/min, and the analytical time was 3.2 min. The PDA detection wavelength was set at 259 nm. The method underwent thorough validation following the recommendation of the European Bioanalysis Forum (EBF) and the bioanalytical guideline established by the European Medicines Agency (EMA). No interfering peaks were detected at the retention times of ceftazidime and IS. The ceftazidime exhibited a quantification range spanning from 0.5 to 200 µg/mL, and the assay demonstrated good accuracy (intra/inter-assay ranging from 90.1% to 104.8%) and precision (intra/inter-assay coefficient of variations ranging from 4.8% to 11.7%). The method's applicability was demonstrated by analyzing clinical DBS samples collected from neonatal patients.

Development of an LC-MS/MS-based method for quantification and pharmacokinetics study on SCID mice of a dehydroabietylamine-adamantylamine conjugate, a promising inhibitor of the DNA repair enzyme

Earlier, it was found that the agent KS-389, a conjugate of dehydroabietylamine and 1-aminoadamantane, possess inhibiting activity with regard to Tdp1. It this study, LC-MS/MS-based methods of quantification of KS-389 in mice blood and several organs (brain, liver and kidney) were developed and validated. Validation of the methods was performed according to the guidelines of U.S. Food and Drug Administration and European Medicines Agency in terms of selectivity, linearity, accuracy, precision, recovery, matrix effect, stability and carry-over. Dried blood spots (DBS) method was used for blood sample preparation. HPLC separation was performed on a reversed-phase column; the total analysis time was 12 min. Mass spectral detection was performed on a 6500 QTRAP mass spectrometer in multiple reaction monitoring mode. Transitions 463.5→135.1/107.2 and 336.2→332.2/176.2 were scanned for KS-389 and 2,5-bis(4-diethylaminophenyl)-1,3,4-oxadiazole used as the internal standard, respectively. Pharmacokinetics of the compound as well as its distribution in the organs were studied on SCID mice after intraperitoneal administration of the substance at a dose of 5 mg/kg, and it was found that its maximum concentration in blood is reached in 1-1.5 h and was 80 ng/mL. The maximum concentration in all organs is reached after the same time and is approximately 1500 ng/g and 1100 ng/g in liver and kidney, respectively. This is the first report on the pharmacokinetics of Tdp1 inhibitor based on dehydroabietylamine and 1-aminoadamantane after a single administration to mice. Also, the substance was found to be able to penetrate the blood-brain barrier which is important for, and its maximum concentration was c.a. 25-30 ng/g. These results are important for glioma treatment and make it promising for this purpose.

Dried Blood Spots-A Platform for Therapeutic Drug Monitoring (TDM) and Drug/Disease Response Monitoring (DRM)

This review provides an overview on the current applications of dried blood spots (DBS) as matrices for therapeutic drug (TDM) and drug or disease response monitoring (DRM). Compared with conventional methods using plasma/serum, DBS offers several advantages, including minimally invasiveness, a small blood volume requirement, reduced biohazardous risk, and improved sample stability. Numerous assays utilising DBS for TDM have been reported in the literature over the past decade, covering a wide range of therapeutic drugs. Several factors can affect the accuracy and reliability of the DBS sampling method, including haematocrit (HCT), blood volume, sampling paper and chromatographic effects. It is crucial to evaluate the correlation between DBS concentrations and conventional plasma/serum concentrations, as the latter has traditionally been used for clinical decision. The feasibility of using DBS sampling method as an option for home-based TDM is also discussed. Furthermore, DBS has also been used as a matrix for monitoring the drug or disease responses (DRM) through various approaches such as genotyping, viral load measurement, assessment of inflammatory factors, and more recently, metabolic profiling. Although this research is still in the development stage, advancements in technology are expected to lead to the identification of surrogate biomarkers for drug treatment in DBS and a better understanding of the correlation between DBS drug levels and drug responses. This will make DBS a valuable matrix for TDM and DRM, facilitating the achievement of pharmacokinetic and pharmacodynamic correlations and enabling personalised therapy.

Biological Fluid Microsampling for Therapeutic Drug Monitoring: A Narrative Review

Therapeutic drug monitoring (TDM) is a specialized area of laboratory medicine which involves the measurement of drug concentrations in biological fluids with the aim of optimizing efficacy and reducing side effects, possibly modifying the drug dose to keep the plasma concentration within the therapeutic range. Plasma and/or whole blood, usually obtained by venipuncture, are the "gold standard" matrices for TDM. Microsampling, commonly used for newborn screening, could also be a convenient alternative to traditional sampling techniques for pharmacokinetics (PK) studies and TDM, helping to overcome practical problems and offering less invasive options to patients. Although technical limitations have hampered the use of microsampling in these fields, innovative techniques such as 3-D dried blood spheroids, volumetric absorptive microsampling (VAMS), dried plasma spots (DPS), and various microfluidic devices (MDS) can now offer reliable alternatives to traditional samples. The application of microsampling in routine clinical pharmacology is also hampered by the need for instrumentation capable of quantifying analytes in small volumes with sufficient sensitivity. The combination of microsampling with high-sensitivity analytical techniques, such as liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS), is particularly effective in ensuring high accuracy and sensitivity from very small sample volumes. This manuscript provides a critical review of the currently available microsampling devices for both whole blood and other biological fluids, such as plasma, urine, breast milk, and saliva. The purpose is to provide useful information in the scientific community to laboratory personnel, clinicians, and researchers interested in implementing the use of microsampling in their routine clinical practice.

A retrospective comparative fractal and radiomorphometric analysis of the effect of 3 generations of anti-epileptic drugs on the mandible

OBJECTIVE

The present study investigated the possible impacts of anti-epileptic drugs (AEDs) on trabecular and cortical bone in the mandible.

STUDY DESIGN

Fractal dimension (FD) and the radiomorphometric parameters of mandibular cortical width (MCW), panoramic mandibular index (PMI), and mandibular cortical index (MCI) were assessed on 497 dental panoramic radiographs (DPRs) of patients in the case group and controls. AEDs were compared according to 3 generations, duration of use, and patient age and sex.

RESULTS

FD of the angle and body of the mandible and MCW were significantly lower in the case group than in the control group (P < .001). FD values in the ramus and angle were lower in first-generation and third-generation AEDs than in second-generation drugs (P ≤ .011). FD in the mandibular body was lower in first-generation and second-generation AED users than in third-generation drugs (P = .017). Drug use for at least 1 year resulted in significantly lower values for all FDs and MCW values and more class 3 MCI assessments than short-duration use, but PMI was higher with more than 1 year of AED use (P ≤ .020). Age and sex had no significant effects.

CONCLUSIONS

AEDs caused significant changes in bone compared with controls in some FD values, MCW, and MCI. The effect of drug generation is pronounced in trabecular bone. Anti-epileptic drug use for more than 1 year had a greater effect than short-term use.

Phenytoin concentration in people with epilepsy: a comparative study in serum and saliva

In clinical practice, therapeutic drug monitoring (TDM) makes it possible to measure the concentration of drugs in serum or saliva, the purpose of which is to reduce adverse effects and optimize pharmacological therapy. The objective was to determine the concentrations of Phenytoin in saliva and serum of people with epilepsy. Cross-sectional, descriptive study with dynamic recruitment of 30 people with epilepsy (n = 30; 17 men, 56.7% and 13 women, 43.3%; mean age 33.9 ± 11.83 years). Serum and saliva samples were collected at trough levels from patients, who were under phenytoin treatment for at least three months. Drug levels were assessed by the Cloned Donor Enzyme Immunoassay method. Phenytoin levels were found in saliva between 0.01 to 3.56 mg/L and in serum between 0.09 to 36.60 mg/L. Pearson’s analysis showed an association between the estimated serum and saliva phenytoin concentrations (R2 0.7026; 95% CI 0.685-0.921), with a significant statistical correlation (p &lt; 0.05). The Bland-Altman test broke concordance, the difference between the two saliva/serum methods is within 95% confidence. It is concluded that there is an association and concordance between the concentrations of phenytoin in serum and saliva, therefore, this technique can be useful in the clinical monitoring of phenytoin.

Automated Sequential Injection-Capillary Electrophoresis for Dried Blood Spot Analysis: A Proof-of-Concept Study

A hyphenated analytical platform that enables fully automated analyses of dried blood spots (DBSs) is proposed by the at-line coupling of sequential injection (SI) to capillary electrophoresis (CE). The SI system, exploited herein for the first time for unattended DBS handling, serves as the "front end" mesofluidic platform for facilitating exhaustive elution of the entire DBS by flow programming. The DBS eluates are thus free from hematocrit and nonhomogeneity biases. The SI pump transfers the resulting DBS eluates into CE sample vials through an internal port of the CE instrument and homogenizes the eluates, whereupon the eluted blood compounds are automatically injected, separated, and quantified by the CE instrument. The SI and CE are commercially available off-the-shelf instruments and are interconnected through standard nuts, ferrules, and tubing without additional instrumental adjustments. They are controlled by dedicated software and are synchronized for a fully autonomous operation. The direct determination of endogenous (potassium and sodium) and exogenous (lithium as a model drug) inorganic cations in DBS samples has been used for the proof-of-concept demonstration. The hyphenated SI-CE platform provides excellent precision of the analytical method with relative standard deviation (RSD) values of peak areas below 1.5 and 3.5% for intraday and interday analyses, respectively, of the endogenous concentrations of the two inorganic cations. For the determination of lithium, calibration is linear in a typical clinical range of the drug (R² better than 0.9993 for 2-20 mg/L), RSD values of peak areas are below 4.5% (in the entire calibration range), the limit of detection (0.4 mg/L) and the limit of quantification (1.3 mg/L) are well below the drug's minimum therapeutic concentration (4 mg/L), and total analysis time is shorter than 5 min. The SI-CE platform reflects the actual trends in the automation of analytical methods, offers rapid and highly flexible DBS elution/analysis processes, and might thus provide a general solution to modern clinical analysis as it can be applied to a broad range of analytes and dried biological materials.

Optimizing detection of erythropoietin receptor agonists from dried blood spots for anti-doping application

The World Anti‐Doping Agency (WADA) has recently implemented dried blood spots (DBSs) as a matrix for doping control. However, specifications regarding the analysis of the class of prohibited substances called erythropoietin (EPO) receptor agonists (ERAs) from DBSs are not yet described. The aim of this study was to find optimal conditions (sample volume and storage) to sensitively detect endogenous erythropoietin (hEPO) and prohibited ERAs from DBSs and compare detection limits to WADA‐stipulated minimum required performance levels (MRPLs) for ERAs in serum/plasma samples. Venous whole blood was spotted onto Whatman 903 DBS cards with primarily 60 μl of blood, but various volumes from 20 to75 μl were tested. All samples were immunopurified with MAIIA EPO Purification Gel kit (EPGK) and analysed with sodium N‐lauroylsarcosinate polyacrylamide gel electrophoresis (SAR‐PAGE) and Western blot. Sixty‐microliter DBSs allowed the detection of the four main ERAs (BRP, NESP, CERA and EPO‐Fc) at concentrations close to WADA's MRPLs described for 500 μl of serum/plasma. Different storage temperatures, from −20°C to 37°C, were evaluated and did not affect ERA detection. A comparison of the detection of endogenous EPO from the different anti‐doping matrices (urine, serum and DBSs produced from upper arm capillary blood) from five participants for 6 weeks was performed. Endogenous EPO extracted from DBSs showed intra‐individual variations in male and female subjects, but less than in urine. Doping controls would benefit from the stability of ERAs on DBSs: It can be a complementary matrix for ERA analysis, particularly in the absence of EPO signals in urine.

Pharmacokinetic Drug-Drug Interactions among Antiepileptic Drugs, Including CBD, Drugs Used to Treat COVID-19 and Nutrients

Anti-epileptic drugs (AEDs) are an important group of drugs of several generations, ranging from the oldest phenobarbital (1912) to the most recent cenobamate (2019). Cannabidiol (CBD) is increasingly used to treat epilepsy. The outbreak of the SARS-CoV-2 pandemic in 2019 created new challenges in the effective treatment of epilepsy in COVID-19 patients. The purpose of this review is to present data from the last few years on drug–drug interactions among of AEDs, as well as AEDs with other drugs, nutrients and food. Literature data was collected mainly in PubMed, as well as google base. The most important pharmacokinetic parameters of the chosen 29 AEDs, mechanism of action and clinical application, as well as their biotransformation, are presented. We pay a special attention to the new potential interactions of the applied first-generation AEDs (carbamazepine, oxcarbazepine, phenytoin, phenobarbital and primidone), on decreased concentration of some medications (atazanavir and remdesivir), or their compositions (darunavir/cobicistat and lopinavir/ritonavir) used in the treatment of COVID-19 patients. CBD interactions with AEDs are clearly defined. In addition, nutrients, as well as diet, cause changes in pharmacokinetics of some AEDs. The understanding of the pharmacokinetic interactions of the AEDs seems to be important in effective management of epilepsy.

Stability study of the antiviral agent camphecene in dried blood spots at different temperatures

In this study, an optimized procedure of sample preparation for quantitative determination of the antiviral agent camphecene in dried rat blood spots was developed. It has been shown that when using methanol containing 0.1% HCOOH as an extractant, the recovery of the substance increases in comparison with the previously developed method. In addition to this, there is no need to dilute the obtained solutions with water for the analysis of the sample by high-performance liquid chromatography (HPLC) on a column with a reversed-phase sorbent. By using the developed method, the stability of samples of dried rat blood spots containing camphecene in different concentrations at different temperatures was studied. It was found that while the samples were stored at room temperature, apparently, desorption of the substance occurs leading to a loss of more than 15% of its initial amount after 5-10 days. Lowering the temperature increases the stability of samples and their storage at -70°C is possible for 4 weeks.

Liquid chromatographic methods for determination of the new antiepileptic drugs stiripentol, retigabine, rufinamide and perampanel: A comprehensive and critical review

The new antiepileptic drugs perampanel, retigabine, rufinamide and stiripentol have been recently approved for different epilepsy types. Being them an innovation in the antiepileptics armamentarium, a lot of investigations regarding their pharmacological properties are yet to be performed. Besides, considering their broad anticonvulsant activities, an extension of their therapeutic indications may be worthy of investigation, especially regarding other seizure types as well as other central nervous system disorders. Although different liquid chromatographic (LC) methods coupled with ultraviolet, fluorescence, mass or tandem-mass spectrometry detection have already been developed for the determination of perampanel, retigabine, rufinamide and stiripentol, new and more cost-effective methods are yet required. Therefore, this review summarizes the main analytical aspects regarding the liquid chromatographic methods developed for the analysis of perampanel, retigabine (and its main active metabolite), rufinamide and stiripentol in biological samples and pharmaceutical dosage forms. Furthermore, the physicochemical and stability properties of the target compounds will also be addressed. Thus, this review gathers, for the first time, important background information on LC methods that have been developed and applied for the determination of perampanel, retigabine, rufinamide and stiripentol, which should be considered as a starting point if new (bio)analytical techniques are aimed to be implemented for these drugs.

A novel method for the storage and transport of biological samples of therapeutic proteins prior to the detection of analytes using ELISA

Therapeutic proteins have exhibited promising clinical applications in the diagnosis and treatment of some diseases. Prior to the detection of analytes using enzyme-linked immunosorbent assay, biological samples of therapeutic proteins are conventionally frozen at temperatures ranging from - 20 to - 80 °C to increase the stability of analytes. However, therapeutic proteins destabilization and aggregation may occur during the frozen storage or the freeze-thawing step. In this work, an effective method was proposed to freeze-dry therapeutic protein samples to allow subsequent storage or transport of samples without freezing them. This new method was validated with quality control samples of adalimumab and etanercept, and it was also used in the bioanalysis of adalimumab and etanercept in pharmacokinetic (PK) studies. Adalimumab and etanercept were stable for 14 days at 4 °C after being prepared and stored using the new method, with detection that was accurate and repeatable. Studies of adalimumab and etanercept in animals and humans showed that the PK parameters of the analytes stored with the new method were consistent with those of analytes stored using the conventional method. This effective method will be attractive for facilitating the storage and transport of plasma samples containing therapeutic proteins.

Therapeutic drug monitoring of valproic acid using a dried plasma spot sampling device

Valproic acid (VPA) dosing needs to be individualized for epilepsy patients through therapeutic drug monitoring (TDM). The patients must show up in the clinic at the therapeutic window time to venipuncture sample. Dried plasma spot (DPS) sampling is an alternative way to replace conventional venipuncture sampling. The aim of this study was to develop and validate a DPS-based liquid chromatography-tandem mass spectrometry (LC-MS/MS) method to monitor VPA in a routine clinical laboratory setting. We compare the DPS with the wet plasma method of clinical samples by LC-MS/MS. The method was linear over the dynamic range of 10-200 μg/ml (covering entire therapeutic range) with a correlation coefficient r² ≥ 0.995. Both the DPS and wet plasma methods were fully validated for the accuracy, precision, recovery, and matrix effect. The analyte stability was examined under conditions mimicking the sample storage, transport, and analysis procedures. A clinical study with epilepsy patients receiving VPA (n = 35) showed that, after correction for hematocrit (HCT), plasma concentrations can be successfully calculated from the DPS quantification results. Passing-Bablok regression coefficients showed no proportional bias between estimated and measured plasma concentrations. Similar agreement was found by Bland-Altman plots. The dried sample could be mailed to the clinical lab to test by regular mail service. So DPS can be used for drug monitoring with self-sampling strategy at the patient's convenient time and place specially for ambulatory patients not attending a clinic.

Dried Blood Spot Self-Sampling with Automated Capillary Electrophoresis Processing for Clinical Analysis

A simple and convenient concept of blood sampling followed by a fully automated analysis is presented. A disposable sampling kit is used for accurate self-sampling of capillary blood from a finger prick. A high-throughput blood sampling is thus enabled, which is essential in many clinical assays and considerably improves life quality and comfort of involved subjects. The collected blood samples are mailed to a laboratory for a fully automated dried blood spot (DBS) processing and analysis, which are performed with a commercial capillary electrophoresis instrument. Quantitative results are obtained within 20 min from the DBS delivery to the laboratory. The presented concept is exemplified by the determination of warfarin blood concentrations and demonstrates excellent analytical performance. Moreover, this concept is generally applicable to a wide range of endogenous and exogenous blood compounds and represents a novel and attractive analytical tool for personalized health monitoring.

Review of Chromatographic Methods Coupled with Modern Detection Techniques Applied in the Therapeutic Drugs Monitoring (TDM)

Therapeutic drug monitoring (TDM) is a tool used to integrate pharmacokinetic and pharmacodynamics knowledge to optimize and personalize various drug therapies. The optimization of drug dosing may improve treatment outcomes, reduce toxicity, and reduce the risk of developing drug resistance. To adequately implement TDM, accurate and precise analytical procedures are required. In clinical practice, blood is the most commonly used matrix for TDM; however, less invasive samples, such as dried blood spots or non-invasive saliva samples, are increasingly being used. The choice of sample preparation method, type of column packing, mobile phase composition, and detection method is important to ensure accurate drug measurement and to avoid interference from matrix effects and drug metabolites. Most of the reported procedures used liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS) techniques due to its high selectivity and sensitivity. High-performance chromatography with ultraviolet detection (HPLC-UV) methods are also used when a simpler and more cost-effective methodology is desired for clinical monitoring. The application of high-performance chromatography with fluorescence detection (HPLC-FLD) with and without derivatization processes and high-performance chromatography with electrochemical detection (HPLC-ED) techniques for the analysis of various drugs in biological samples for TDM have been described less often. Before chromatographic analysis, samples were pretreated by various procedures-most often by protein precipitation, liquid-liquid extraction, and solid-phase extraction, rarely by microextraction by packed sorbent, dispersive liquid-liquid microextraction. The aim of this article is to review the recent literature (2010-2020) regarding the use of liquid chromatography with various detection techniques for TDM.

Recent advances in electroanalytical methods for the therapeutic monitoring of antiepileptic drugs: A comprehensive review

Frequency of seizures is often managed by a wide group of antiepileptic drugs. Regarding the pharmacokinetic variability, narrow targeted range, and difficulty of detecting signs of toxicity based on laboratory responses, therapeutic monitoring of antiepileptic drugs can play a pivotal role in optimizing the drug dosage. Electrochemical sensors and biosensors can facilitate analysis of these drugs due to their unique advantages such as fast analysis, sensitivity, selectivity, and low cost. This review article, for the first time, describes the recent advances in electrochemical sensors and biosensors developed for the analysis of antiepileptic drugs. General electrochemical measuring techniques and types of applied electrode substrates were described first. To simplify the work, various chemical and biological modifiers applied to improve the sensitivity and selectivity of the sensors were classified and explained briefly. Finally, the future prospective on the development of electrochemical platforms in the quantification of antiepileptic drugs will be presented.

Capillary Electrophoresis with Capacitively Coupled Contactless Conductivity Detection for Quantitative Analysis of Dried Blood Spots with Unknown Blood Volume

Blood volume in dried blood spot (DBS) analysis is assumed to be constant for DBS punches with a fixed area. However, blood volume in the punch is dependent on several factors associated with the blood composition and is preferentially normalized by off-line analysis for quantitative purposes. Instead of using external instrumentation, we present an all-in-one approach for the simultaneous determination of exact blood volume in the DBS punch and the quantitation of target analytes. A DBS is eluted with 500 μL of elution solvent in a sample vial, and the eluate is directly subjected to an automated analysis by capillary electrophoresis with capacitively coupled contactless conductivity detection (CE-C⁴D). The capillary blood volume in the eluate is calculated from the concentrations of the inorganic blood constituents (K⁺, Na⁺, or Cl^-) determined by CE-C⁴D, which are linearly proportional to the blood volume originally sampled onto the DBS card. Alternatively, conductivity of the DBS eluate can be used for the blood volume determination by using C⁴D in a nonseparation flow-through mode. The methods are suitable for the determination of blood volume in unknown DBS samples by punching out the entire DBS or by subpunching a small section of a large DBS with variations of the true vs the determined volume ≤5.5%. Practical suitability was demonstrated by the simultaneous CE-C⁴D determination of K⁺ and Na⁺ (for DBS volume calculation) and amino acids (target analytes) in unknown DBS samples. Quantitative analysis of selected amino acids (related to inborn metabolic disorders) in the unknown DBS was compared with a standard analytical procedure using wet-blood chemistry, and an excellent fit was obtained. The use of CE-C⁴D represents an important milestone in quantitative DBS analysis since the detection technique is universal, and the separation technique enables the determination of cations and/or anions and the use of multiple detectors, which further enhance selectivity/sensitivity of the analysis and the range of detectable analytes.

Biomarkers in epilepsy-A modelling perspective

Biomarkers can be categorised from type 0 (genotype or phenotype), through 6 (clinical scales), each level representing a part of the processes involved in the biological system and drug treatment. This classification facilitates the identification and connection of information required to fully (mathematically) model a disease and its treatment using integrated information from biomarkers. Two recent reviews thoroughly discussed the current status and development of biomarkers for epilepsy, but a path towards the integration of such biomarkers for the personalisation of anti-epileptic drug treatment is lacking. Here we aim to 1) briefly categorise the available epilepsy biomarkers and identify gaps, and 2) provide a modelling perspective on approaches to fill such gaps. There is mainly a lack of biomarker types 2 (target occupancy) and 3 (target activation). Current literature typically focuses on qualitative biomarkers for diagnosis and prediction of treatment response or failure, leaving a need for biomarkers that help to quantitatively understand the overall system to explain and predict differences in disease and treatment outcome. Due to the complexity of epilepsy, filling the biomarker gaps will require collaboration and expertise from the fields of systems biology and systems pharmacology.

Dried Blood Spot sampling in psychiatry: Perspectives for improving therapeutic drug monitoring

Assessment of drug concentrations is indicated to guide dosing of a selected number of drugs used in psychiatry. Conventionally this is done by vena puncture. Novel sampling strategies such as dried blood spot (DBS) sampling have been developed for various drugs, including antipsychotics, antidepressants and mood-stabilizers. DBS sampling is typically performed by means of a finger prick. This method allows for remote sampling, which means that patients are not required to travel to a health care facility. The number of DBS assays for drugs used in psychiatry has increased over the last decade and includes antidepressants (tricyclic and serotonin and/or norepinephrine reuptake inhibitors), mood stabilizers and first- and second-generation antipsychotics. Available assays often comply with analytical validation criteria but are seldom used in routine clinical care. Little attention has been paid to the clinical validation and implementation processes of home sampling. Ideally, not only medicines but also clinical chemistry parameters should be measured within the same sample. This article reflects on the position of DBS remote sampling in psychiatry and provides insight in the requisites of making such a sampling tool successful.

DBS-LC-MS/MS assay for caffeine: validation and neonatal application

AIM

DBS might be an appropriate microsampling technique for therapeutic drug monitoring of caffeine in infants. Nevertheless, its application presents several issues that still limit its use. This paper describes a validated DBS-LC-MS/MS method for caffeine.

RESULTS

The results of the method validation showed an hematocrit dependence. In the analysis of 96 paired plasma and DBS clinical samples, caffeine levels measured in DBS were statistically significantly lower than in plasma but the observed differences were independent from hematocrit.

CONCLUSION

These results clearly showed the need for extensive validation with real-life samples for DBS-based methods. DBS-LC-MS/MS can be considered to be a good alternative to traditional methods for therapeutic drug monitoring or PK studies in preterm infants.

An effective and economical method for the storage of plasma samples using a novel freeze-drying device

Biological samples, especially plasma samples, are conventionally stored under freezing conditions to maintain sample integrity prior to the detections of analytes. However, the storage of samples in a low-temperature environment is electric energy consuming, and the preparation of samples prior to analytes detection may be complicated. In this work, an effective and economical method was proposed to freeze-dry the samples using a novel device to allow subsequent storage of samples at ambient temperature. The sample preparations integrated in the new method are simple and easy to follow. Analytes were directly extracted with the extraction agent before sample injections. This new method was validated with quality control (QC) samples of levetiracetam and mycophenolic acid (MPA), and it was also applied to the pharmacokinetic (PK) studies of both drugs in healthy volunteers. When QC samples were stored and prepared with the new method, the detections of analytes were accurate and repeatable, and the analytes maintained stability for a long time. The PK studies of levetiracetam and MPA in healthy volunteers showed that the PK parameters of analytes stored with the new method were consistent with those stored with the conventional method. In conclusion, this effective and economical method is a practical option in reality and can play a big role in clinical and scientific drug researches.

Pharmacotherapy in pediatric epilepsy: from trial and error to rational drug and dose selection - a long way to go

INTRODUCTION

Whereas ongoing efforts in epilepsy research focus on the underlying disease processes, the lack of a physiologically based rationale for drug and dose selection contributes to inadequate treatment response in children. In fact, limited information on the interindividual variation in pharmacokinetics and pharmacodynamics of anti-epileptic drugs (AEDs) in children drive prescription practice, which relies primarily on dose regimens according to a mg/kg basis. Such practice has evolved despite advancements in pediatric pharmacology showing that growth and maturation processes do not correlate linearly with changes in body size.

AREAS COVERED

In this review we aim to provide 1) a comprehensive overview of the sources of variability in the response to AEDs, 2) insight into novel methodologies to characterise such variation and 3) recommendations for treatment personalisation.

EXPERT OPINION

The use of pharmacokinetic-pharmacodynamic principles in clinical practice is hindered by the lack of biomarkers and by practical constraints in the evaluation of polytherapy. The identification of biomarkers and their validation as tools for drug development and therapeutics will require some time. Meanwhile, one should not miss the opportunity to integrate the available pharmacokinetic data with modeling and simulation concepts to prevent further delays in the development of personalised treatments for pediatric patients.

Is there a role for microsampling in antibiotic pharmacokinetic studies?

INTRODUCTION

Clinical pharmacokinetic studies of antibiotics can establish evidence-based dosing regimens that improve the likelihood of eradicating the pathogen at the site of infection, reduce the potential for selection of resistant pathogens, and minimize harm to the patient. Innovations in small volume sampling (< 50 μL) or 'microsampling' may result in less-invasive sample collection, self-sampling and dried storage. Microsampling may open up opportunities in patient groups where sampling is challenging.

AREAS COVERED

The challenges for implementation of microsampling to assure suitability of the results, include: acceptable study design, regulatory agency acceptance, and meeting bioanalytical validation requirements. This manuscript covers various microsampling methods, including dried blood/plasma spots, volumetric absorptive microsampling, capillary microsampling, plasma preparation technologies and solid-phase microextraction.

EXPERT OPINION

The available analytical technology is being underutilized due to a lack of bridging studies and validated bioanalytical methods. These deficiencies represent major impediments to the application of microsampling to antibiotic pharmacokinetic studies. A conceptual framework for the assessment of the suitability of microsampling in clinical pharmacokinetic studies of antibiotics is provided. This model establishes a 'contingency approach' with consideration of the antibiotic and the type and location of the patient, as well as the more prescriptive bioanalytical validation protocols.