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Wang X, Xiong W, Zhong M, Liu Y, Xiong Y, Yi X, Wang X, Zhang H. Pharmacokinetics of polymyxin B in different populations: a systematic review. Eur J Clin Pharmacol 2024; 80:813-826. [PMID: 38483544 DOI: 10.1007/s00228-024-03666-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/04/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND AND OBJECTIVES Despite being clinically utilized for the treatment of infections, the limited therapeutic range of polymyxin B (PMB), along with considerable interpatient variability in its pharmacokinetics and frequent occurrence of acute kidney injury, has significantly hindered its widespread utilization. Recent research on the population pharmacokinetics of PMB has provided valuable insights. This study aims to review relevant literature to establish a theoretical foundation for individualized clinical management. METHODS Follow PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, Pop-PK studies of PMB were searched in PubMed and EMBASE database systems from the inception of the database until March 2023. RESULT To date, a total of 22 population-based studies have been conducted, encompassing 756 subjects across six different countries. The recruited population in these studies consisted of critically infected individuals with multidrug-resistant bacteria, patients with varying renal functions, those with cystic fibrosis, kidney or lung transplant recipients, patients undergoing extracorporeal membrane oxygenation (ECMO) or continuous renal replacement therapy (CRRT), as well as individuals with obesity or pediatric populations. Among these studies, seven employed a one-compartmental model, with the range of typical clearance (CL) and volume (Vc) being 1.18-2.5L /h and 12.09-47.2 L, respectively. Fifteen studies employed a two-compartmental model, with the ranges of the clearance (CL) and volume of the central compartment (Vc), the volume of the peripheral compartment (Vp), and the intercompartment clearance (Q) were 1.27-8.65 L/h, 5.47-38.6 L, 4.52-174.69 L, and 1.34-24.3 L/h, respectively. Primary covariates identified in these studies included creatinine clearance and body weight, while other covariates considered were CRRT, albumin, age, and SOFA scores. Internal evaluation was conducted in 19 studies, with only one study being externally validated using an independent external dataset. CONCLUSION We conclude that small sample sizes, lack of multicentre collaboration, and patient homogeneity are the primary reasons for the discrepancies in the results of the current studies. In addition, most of the studies limited in the internal evaluation, which confined the implementation of model-informed precision dosing strategies.
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Affiliation(s)
- Xing Wang
- School of Pharmacy, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Wenqiang Xiong
- School of Pharmacy, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Maolian Zhong
- School of Pharmacy, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Yan Liu
- School of Pharmacy, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Yuqing Xiong
- School of Pharmacy, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Xiaoyi Yi
- Clinical Medicine Research Center, Jiangxi Cancer Hospital, Jiangxi Cancer Hospital of Nanchang University, Nanchang, 330029, China
| | - Xiaosong Wang
- Clinical Medicine Research Center, Jiangxi Cancer Hospital, Jiangxi Cancer Hospital of Nanchang University, Nanchang, 330029, China
| | - Hong Zhang
- Clinical Medicine Research Center, Jiangxi Cancer Hospital, Jiangxi Cancer Hospital of Nanchang University, Nanchang, 330029, China.
- Jiangxi Clinical Research Center for Cancer, Nanchang, 330029, China.
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Oda K, Jono H, Kamohara H, Saito H. Population Pharmacokinetic Modeling of Unbound Meropenem in Patients Undergoing Continuous Renal Replacement Therapy: An Observational Cohort Study. Ther Drug Monit 2024:00007691-990000000-00227. [PMID: 38758632 DOI: 10.1097/ftd.0000000000001222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/15/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND The most effective dosing strategy of meropenem for patients undergoing continuous renal replacement therapy (CRRT) remains uncertain. This study aimed to analyze the population pharmacokinetics (popPKs) of unbound meropenem and establish an appropriate dosing approach. METHODS This prospective study involved 19 patients for the development of a popPK model and an additional 10 for its validation. Ethical approval was obtained. RESULTS The clearance of unbound meropenem was influenced by the sequential organ failure assessment (SOFA) score [=2.22 × (SOFA score/12)^1.88] and the effluent flow rate from the CRRT device, with an interindividual variability of 44.5%. The volume of distribution was affected by the simplified acute physiology score II [=23.1 × (simplified acute physiology score II/52)^1.54]. Monte Carlo simulations suggested meropenem doses ranging from 1.0 to 3.0 g/d using continuous infusion to achieve a target time above the 4 times of minimum inhibitory concentration of the unbound form (%fT>4×MIC) of 100% for definitive therapy. For empirical therapy, a dose of 1.0 g/d using continuous infusion was recommended to target %fT>MIC of 100%. CONCLUSIONS This study developed a popPK model for unbound meropenem in patients undergoing CRRT and formulated dosing guidelines. CLINICAL TRIAL REGISTRATION UMIN000024321.
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Affiliation(s)
- Kazutaka Oda
- Department of Pharmacy, Kumamoto University Hospital, Kumamoto, Japan
| | - Hirofumi Jono
- Department of Pharmacy, Kumamoto University Hospital, Kumamoto, Japan
- Department of Clinical Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Hidenobu Kamohara
- Department of Intensive Care Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Hideyuki Saito
- Department of Pharmacy, Kumamoto University Hospital, Kumamoto, Japan
- Department of Clinical Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan; and
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Wang P, Liu S, Sun T, Yang J. Daily fluid intake as a novel covariate affecting the population pharmacokinetics of polymyxin B in patients with sepsis. Int J Antimicrob Agents 2024; 63:107099. [PMID: 38280575 DOI: 10.1016/j.ijantimicag.2024.107099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/08/2023] [Accepted: 01/18/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Polymyxin B dosing in patients with sepsis is difficult because pathophysiological changes and supportive therapies alter drug pharmacokinetics (PK). This study aimed to investigate the impact of fluid management and renal function on the PK of polymyxin B and to propose alternative dosing regimens. METHODS Patients (aged ≥ 18 y) with sepsis and receiving intravenous polymyxin B for ≥ 96 h were enrolled. Blood samples were collected at steady state. Plasma concentrations were measured by liquid chromatography-tandem mass spectrometry and subjected to population PK modelling. Monte Carlo simulations were used to optimise dosage regimens. RESULTS Eighty-three patients with a median (range) daily fluid intake of 4.2 (1.3-8.4) L and a creatinine clearance (CrCL) of 87.5 (17.3-309.7) mL/min were included. Polymyxin B PK was adequately characterised by a two-compartment model. The PK covariate analysis revealed daily fluid intake statistically significantly affected central volume of distribution and central compartment clearance (CL), and CrCL influenced CL. Simulation indicated that a decreased dosing would be suitable for patients with renal dysfunction (CrCL < 40 mL/min), and therapeutic drug monitoring is recommended to avoid exposure fluctuation when patients have fluid overload. CONCLUSIONS Fluid management as well as renal function are essential factors affecting polymyxin B PK for patients with sepsis, which can help optimise dosage regimens.
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Affiliation(s)
- Peile Wang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China; Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China; Henan Engineering Research Center for Application & Translation of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Shaohua Liu
- Department of General Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tongwen Sun
- Department of General Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Jing Yang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China; Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China; Henan Engineering Research Center for Application & Translation of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China.
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Hanafin PO, Kwa A, Zavascki AP, Sandri AM, Scheetz MH, Kubin CJ, Shah J, Cherng BPZ, Yin MT, Wang J, Wang L, Calfee DP, Bolon M, Pogue JM, Purcell AW, Nation RL, Li J, Kaye KS, Rao GG. A population pharmacokinetic model of polymyxin B based on prospective clinical data to inform dosing in hospitalized patients. Clin Microbiol Infect 2023; 29:1174-1181. [PMID: 37217076 DOI: 10.1016/j.cmi.2023.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/03/2023] [Accepted: 05/14/2023] [Indexed: 05/24/2023]
Abstract
OBJECTIVES To develop a population pharmacokinetic (PK) model with data from the largest polymyxin B-treated patient population studied to date to optimize its dosing in hospitalized patients. METHODS Hospitalized patients receiving intravenous polymyxin B for ≥48 hours were enrolled. Blood samples were collected at steady state and drug concentrations were analysed by liquid chromotography tandem mass spectrometry (LC-MS/MS). Population PK analysis and Monte Carlo simulations were performed to determine the probability of target attainment (PTA). RESULTS One hundred and forty-two patients received intravenous polymyxin B (1.33-6 mg/kg/day), providing 681 plasma samples. Twenty-four patients were on renal replacement therapy, including 13 on continuous veno-venous hemodiafiltration (CVVHDF). A 2-compartment model adequately described the PK with body weight as a covariate on the volume of distribution that affected Cmax, but it did not impact clearance or exposure. Creatinine clearance was a statistically significant covariate on clearance, although clinically relevant variations of dose-normalized drug exposure were not observed across a wide creatinine clearance range. The model described higher clearance in CVVHDF patients than in non-CVVHDF patients. Maintenance doses of ≥2.5 mg/kg/day or ≥150 mg/day had a PTA ≥90% (for non-pulmonary infections target) at a steady state for minimum inhibitory concentrations ≤2 mg/L. The PTA at a steady state for CVVHDF patients was lower. DISCUSSION Fixed loading and maintenance doses of polymyxin B seemed to be more appropriate than weight-based dosing regimens in patients weighing 45-90 kg. Higher doses may be needed in patients on CVVHDF. Substantial variability in polymyxin B clearance and volume of distribution was found, suggesting that therapeutic drug monitoring may be indicated.
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Affiliation(s)
- Patrick O Hanafin
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andrea Kwa
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore; Emerging Infectious Diseases, Duke-NUS Medical School, Singapore, Singapore
| | - Alexandre P Zavascki
- Infectious Diseases Service, Hospital Moinhos de Vento, Porto Alegre, Brazil; Department of Internal Medicine, Medical School, Universidade Federal, Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Ana Maria Sandri
- Infection Control Department, Hospital São Lucas da Pontifícia Universidade Católica Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Marc H Scheetz
- Department of Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Downers Grove, IL, USA
| | - Christine J Kubin
- New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Jayesh Shah
- Division of Infectious Diseases, Department of Internal Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Benjamin P Z Cherng
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore
| | - Michael T Yin
- Division of Infectious Diseases, Department of Internal Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Jiping Wang
- Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Lu Wang
- Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - David P Calfee
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Maureen Bolon
- Department of Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, IL, USA; Department of Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jason M Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Anthony W Purcell
- Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia; Department of Biochemistry and Molecular Biology, Monash University, Clayton, Victoria, Australia
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Jian Li
- Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Keith S Kaye
- Division of Allergy, Immunology and Infectious Diseases, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Gauri G Rao
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Liang D, Liang Z, Deng G, Cen A, Luo D, Zhang C, Ni S. Population pharmacokinetic analysis and dosing optimization of polymyxin B in critically ill patients. Front Pharmacol 2023; 14:1122310. [PMID: 37063299 PMCID: PMC10090446 DOI: 10.3389/fphar.2023.1122310] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/16/2023] [Indexed: 03/31/2023] Open
Abstract
Objectives: Since the global broadcast of multidrug-resistant gram-negative bacteria is accelerating, the use of Polymyxin B is sharply increasing, especially in critically ill patients. Unsatisfactory therapeutic effects were obtained because of the abnormal physiological function in critically ill patients. Therefore, the determination of optimal polymyxin B dosage becomes highly urgent. This study aimed to illustrate the polymyxin B pharmacokinetic characteristics by defining the influencing factors and optimizing the dosing regimens to achieve clinical effectiveness.Methods: Steady-state concentrations of polymyxin B from twenty-two critically ill patients were detected by a verified liquid chromatography-tandem mass spectrometry approach. The information on age, weight, serum creatinine, albumin levels, and Acute Physiology and Chronic Health Evaluation-II (APACHE-II) score was also collected. The population PK parameters were calculated by the non-parametric adaptive grid method in Pmetrics software, and the pharmacokinetic/pharmacodynamics target attainment rate was determined by the Monte Carlo simulation method.Results: The central clearance and apparent volume of distribution for polymyxin B were lower in critically ill patients (1.24 ± 0.38 L h-1 and 16.64 ± 12.74 L, respectively). Moreover, albumin (ALB) levels can be used to explain the variability in clearance, and age can be used to describe the variability in the apparent volume of distribution. For maintaining clinical effectiveness and lowering toxicity, 75 mg q12 h is the recommended dosing regimen for most patients suffering from severe infections.Conclusion: This study has clearly defined that in critically ill patients, age and ALB levels are potentially important factors for the PK parameters of polymyxin B. Since older critically ill patients tend to have lower ALB levels, so higher dosages of polymyxin B are necessary for efficacy.
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Affiliation(s)
- Danhong Liang
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou, Guangdong, China
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Zhi Liang
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Guoliang Deng
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou, Guangdong, China
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Anfen Cen
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou, Guangdong, China
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Dandan Luo
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Chen Zhang
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou, Guangdong, China
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
- *Correspondence: Chen Zhang, ; Suiqin Ni,
| | - Suiqin Ni
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou, Guangdong, China
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
- *Correspondence: Chen Zhang, ; Suiqin Ni,
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Surovoy YA, Burkin MA, Galvidis IA, Sobolev MA, Rende OC, Tsarenko SV. Comparative polymyxin B pharmacokinetics in critically ill patients with renal insufficiency and in continuous veno-venous hemodialysis. Eur J Clin Pharmacol 2023; 79:79-87. [PMID: 36378296 DOI: 10.1007/s00228-022-03415-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/02/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE The aim of this study was to assess polymyxin B pharmacokinetics (PK) in patients with varying degrees of renal dysfunction and in patients who require continuous veno-venous hemodialysis (CVVHD). METHODS The study enrolled 37 patients with sepsis, including 13 patients with glomerular filtration rate (GFR) below 80 mL/min and 11 patients on CVVHD. Each patient received a loading dose of polymyxin B (200-300 mg) and at least 3 subsequent doses of 100-150 mg every 12 h. For every patient, 6-8 blood samples were collected between doses. Polymyxin B (PMB) serum concentration was determined using enzyme-linked immunosorbent assay. RESULTS In sepsis, patients with preserved renal function mean area under the curve over 24 h (AUC0-24 h) value reached 67.8 ± 9.8 mg*h/L, while in patients with GFR below 80 mL/min, mean AUC0-24 h was 87 ± 5.8 mg*h/L. PMB PK in patients with renal insufficiency was characterized by significantly lower clearance (CL) compared to the normal renal function group (2.1 ± 0.1 L/h vs 3.9 ± 0.4 L/h respectively). In patients on CVVHD, mean AUC0-24 h was 110.4 ± 10.3 mg*h/L, while CL reached 2 ± 0.23 L/h. The median recovery rate from dialysate constituted 22%. Simulation of different dosage regimens that indicate a fixed maintenance dose of 100 mg q12h with a loading dose of 200 mg is optimal for patients on CVVHD, and no dosage increase is required. CONCLUSION This study demonstrates decreased clearance of PMB in patients with renal insufficiency, which puts them at risk of toxicity. Therefore, patients with extremes of renal function might benefit from therapeutic drug monitoring. For patients with anuria, who require CVVHD, we suggest a fixed dose of 100 mg q12h.
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Affiliation(s)
- Yury A Surovoy
- I.I. Mechnikov Research Institute for Vaccines and Sera, Moscow, 105064, Russia. .,Faculty of Medicine, M.V. Lomonosov Moscow State University, Moscow, 119991, Russia.
| | - Maksim A Burkin
- I.I. Mechnikov Research Institute for Vaccines and Sera, Moscow, 105064, Russia
| | - Inna A Galvidis
- I.I. Mechnikov Research Institute for Vaccines and Sera, Moscow, 105064, Russia
| | | | - Onur Can Rende
- Faculty of Medicine, M.V. Lomonosov Moscow State University, Moscow, 119991, Russia
| | - Sergei V Tsarenko
- Faculty of Medicine, M.V. Lomonosov Moscow State University, Moscow, 119991, Russia.,Moscow City Clinical Hospital #52, Moscow, 123182, Russia
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