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Zimmerman KO, Wu H, Maharaj A, Turner A, Chen JY, Hornik CD, Arnold S, Muller W, Al-Uzri A, Meyer M, Shiloh-Malawsky Y, Taravath S, Lakhotia A, Joshi C, Jackman J, Hornik CP. Pharmacokinetics and Proposed Dosing of Levetiracetam in Children With Obesity. J Pediatr Pharmacol Ther 2023; 28:693-703. [PMID: 38094673 PMCID: PMC10715382 DOI: 10.5863/1551-6776-28.8.693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/26/2023] [Indexed: 02/01/2024]
Abstract
OBJECTIVE Characterize levetiracetam pharmacokinetics (PK) in children with obesity to inform dosing. METHODS Children 2 to <21 years old receiving standard of care oral levetiracetam across two opportunistic studies provided blood samples. Levetiracetam plasma PK data were analyzed with a nonlinear mixed-effects modeling approach. Indirect measures for body size and covariates were tested for model inclusion. Individual empirical Bayesian estimates using the final model parameters were compared by obesity status. Monte Carlo simulation using total body weight was performed in children with normal estimated glomerular filtration rate to identify dosing for children with obesity that resulted in comparable exposures to normal weight adults and children after receiving label dosing. RESULTS The population PK model was developed from 341 plasma concentrations from 169 children. A 1-compartment model best fit the data with fat-free mass as a significant covariate. Compared with children with normal weight, children with obesity had significantly lower body weight-normalized clearance (median [range], 4.77 [1.49-10.44] and 3.71 [0.86-13.55] L/h/70 kg, respectively). After label dosing with the oral formulation in children with obesity 4 to <16 years old, maximum and minimum steady-state concentrations were higher (25% and 41%, respectively [oral solution] and 27% and 19%, respectively [tablet]) compared with children with normal weight. Comparable exposures between children with and without obesity were achieved with weight-tiered dosing regimens of <75 kg or ≥75 kg. CONCLUSIONS Weight-tiered dosing for levetiracetam oral solution and tablets for children with obesity 4 to <16 years old results in more comparable exposures to children of normal weight.
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Affiliation(s)
- Kanecia O. Zimmerman
- Department of Pediatrics (KOZ, CDH, CPH), Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute (KOZ, HW, CDH, JJ, CPH), Duke University, Durham, NC
| | - Huali Wu
- Duke Clinical Research Institute (KOZ, HW, CDH, JJ, CPH), Duke University, Durham, NC
| | - Anil Maharaj
- Pharmaceutical Sciences (AM), The University of British Columbia, Vancouver, British Columbia, Canada
| | - Alex Turner
- Undergraduate Student (AT), North Carolina State University, Raleigh, NC
| | - Jia-Yuh Chen
- Senior Biostatistician (JYC), The EMMES Corporation, Rockville, MD
| | - Chi D. Hornik
- Department of Pediatrics (KOZ, CDH, CPH), Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute (KOZ, HW, CDH, JJ, CPH), Duke University, Durham, NC
| | - Susan Arnold
- Department of Neurology and Neurotherapeutics (SA), University of Texas Southwestern Medical Center Dallas, Dallas, TX
| | - William Muller
- Infectious Disease (WM), Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Amira Al-Uzri
- Pediatric Nephrology (AA-U), Oregon Health and Science University, Portland, OR
| | - Marisa Meyer
- Pediatric Critical Care (MM), Nemours Children’s Health, Wilmington, DE
| | - Yael Shiloh-Malawsky
- Department of Neurology (YS-M), University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Arpita Lakhotia
- Pediatric Neurology (AL), Norton Children’s Hospital and University of Louisville, Louisville, KY
| | - Charuta Joshi
- Pediatric Neurology (CJ), The Children’s Hospital Colorado, Aurora, CO
| | - Jennifer Jackman
- Duke Clinical Research Institute (KOZ, HW, CDH, JJ, CPH), Duke University, Durham, NC
| | - Christoph P. Hornik
- Department of Pediatrics (KOZ, CDH, CPH), Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute (KOZ, HW, CDH, JJ, CPH), Duke University, Durham, NC
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2
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Gaeta F, Conti V, Pepe A, Vajro P, Filippelli A, Mandato C. Drug dosing in children with obesity: a narrative updated review. Ital J Pediatr 2022; 48:168. [PMID: 36076248 PMCID: PMC9454408 DOI: 10.1186/s13052-022-01361-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/30/2022] [Indexed: 11/16/2022] Open
Abstract
Childhood obesity and its associated comorbidities are highly prevalent diseases that may add to any other possible health problem commonly affecting the pediatric age. Uncertainties may arise concerning drug dosing when children with obesity need pharmacologic therapies. In general, in pediatric practice, there is a tendency to adapt drug doses to a child's total body weight. However, this method does not consider the pharmacological impact that a specific drug can have under a two-fold point of view, that is, across various age and size groups as well. Moreover, there is a need for a therapeutic approach, as much as possible tailored considering relevant interacting aspects, such as modification in metabolomic profile, drug pharmacokinetics and pharmacodynamics. Taking into account the peculiar differences between children with overweight/obesity and those who are normal weight, the drug dosage in the case of obesity, cannot be empirically determined solely by the per kg criterion. In this narrative review, we examine the pros and cons of several drug dosing methods used when dealing with children who are affected also by obesity, focusing on specific aspects of some of the drugs most frequently prescribed in real-world practice by general pediatricians and pediatric subspecialists.
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Affiliation(s)
- Francesca Gaeta
- Pediatrics Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Valeria Conti
- Pharmacology Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Angela Pepe
- Pediatrics Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Pietro Vajro
- Pediatrics Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Amelia Filippelli
- Pharmacology Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy
| | - Claudia Mandato
- Pediatrics Section, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081, Baronissi, Salerno, Italy.
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3
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Salem AM, Niu T, Li C, Moffett BS, Ivaturi V, Gopalakrishnan M. Reassessing the Pediatric Dosing Recommendations for Unfractionated Heparin Using Real-World Data: a Pharmacokinetic-Pharmacodynamic Modeling Approach. J Clin Pharmacol 2021; 62:733-746. [PMID: 34816442 DOI: 10.1002/jcph.2007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/19/2021] [Indexed: 11/07/2022]
Abstract
Optimal pediatric dosing of unfractionated heparin (UFH) is challenging due to paucity of clinical outcome and pharmacokinetic-pharmacodynamic (PK/PD) studies in pediatrics. This study aimed to: (i) develop a PK/PD model for UFH, quantified by anti-factor Xa assay and the UFH effect measured by activated partial thromboplastin time (aPTT) (ii) evaluate pediatric UFH infusions in achieving anti-factor Xa (0.3 - 0.7 IU/mL) therapeutic target by simulations. Electronic health record data were retrospectively collected from 633 patients < 19 years old admitted to Texas Children's Hospital. The PK/PD model was developed using a 70% (training)-30% (test) data split approach. A one-compartment PK model with linear elimination adequately described the UFH PK. An allometrically scaled body weight on clearance (CL) and volume of distribution (Vd) with an age-dependent maturation function of extracellular water on Vd were the covariates identified. Comparable with literature, the typical values for CL and Vd were 3.28 L/(hr·50 kg) and 8.83 L/50 kg, respectively. A linear model adequately described the UFH-aPTT relationship with an estimated slope of 150. Simulations of the currently recommended starting infusions (28 IU/hr/kg for pediatrics < 1 year old or 20 IU/hr/kg for pediatrics > 1 year old) showed that anti-factor Xa therapeutic target was achieved only in 15.3%, 14.6%, 36.9% and 45.11% of subjects in the age groups of < 1 year, 1-6 years, 6-12 years, and 12-19 years, respectively. In conclusion, the UFH anti-factor Xa target is not achieved initially especially in young pediatrics, suggesting the need to optimize UFH dosing to achieve higher therapeutic success. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ahmed M Salem
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Tao Niu
- Modeling & Simulations, Vertex Pharmaceuticals, Boston, MA, USA
| | - Chao Li
- Fosun Pharma, Princeton, NJ, USA
| | - Brady S Moffett
- Department of Pharmacy, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Vijay Ivaturi
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
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4
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Tran VL, Parsons S, Varela CR. The Trilogy of SARS-CoV-2 in Pediatrics (Part 3): Thrombosis, Anticoagulant, and Antiplatelet Considerations. J Pediatr Pharmacol Ther 2021; 26:565-576. [PMID: 34421405 DOI: 10.5863/1551-6776-26.6.565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/06/2021] [Indexed: 12/20/2022]
Abstract
The hypercoagulable state induced by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) affects all patients regardless of age. The incidence of venous thromboembolism in pediatric patients with SARS-CoV-2-related illnesses is not well established. Although deep vein thrombosis is rare in children in the absence of risk factors, coagulopathy and the development of thromboses have been described in pediatric patients with acute COVID-19 and multisystem inflammatory syndrome. This comprehensive review provides a detailed overview of SARS-CoV-2-associated coagulopathy as well as strategies for optimizing the evaluation, management, and prevention of thrombosis in pediatric patients.
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5
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Kuhn AK, Saini S, Stanek J, Dunn A, Kumar R. Unfractionated heparin using actual body weight without dose capping in obese pediatric patients-Subgroup analysis from an observational cohort study. Pediatr Blood Cancer 2021; 68:e28872. [PMID: 33403793 DOI: 10.1002/pbc.28872] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
To evaluate the correlation between an uncapped, actual body weight-based unfractionated heparin dosing strategy, we performed a body mass index-based subanalysis of a previously reported pediatric cohort. Nearly half (45%) of obese patients were supra-therapeutic on initial anti-FXa assessment. Obese patients achieved therapeutic anti-FXa significantly faster than nonobese patients (median 4 vs 12 hours, P = .0192) and were more likely to have any supra-therapeutic anti-FXa levels (77% vs 35%; P = .0021). There was no statistically significant difference in major or clinically relevant nonmajor bleeding rates between weight categories (P = .69). Prospective pediatric studies are warranted to confirm our findings.
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Affiliation(s)
- Alexis K Kuhn
- Pharmacy Services, Mayo Clinic, Rochester, Minnesota
| | - Surbhi Saini
- Division of Pediatric Hematology/Oncology, St Louis Children's Hospital, St Louis, Missouri.,Department of Pediatrics, Washington University, St Louis, Missouri
| | - Joseph Stanek
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, Ohio
| | - Amy Dunn
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Riten Kumar
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Department of Pediatrics, Harvard University, Boston, Massachusetts
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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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7
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Antithrombin Population Pharmacokinetics in Pediatric Ventricular Assist Device Patients. Pediatr Crit Care Med 2019; 20:1157-1163. [PMID: 31232851 DOI: 10.1097/pcc.0000000000002039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Describe the pharmacokinetics of antithrombin in pediatric patients undergoing ventricular assist device therapy and provide dosing recommendations for antithrombin in this population. DESIGN A retrospective population pharmacokinetic study was designed. SETTING Large tertiary care children's hospital Subject inclusion criteria consisted of less than 19 years old. PATIENTS Subjects less than 19 years old undergoing therapy with a HeartWare ventricular assist device (HeartWare, Framingham, MA) or Berlin EXCOR ventricular assist device (Berlin GmbH, Berlin, Germany), who received a dose of antithrombin with a postdose antithrombin activity level from January 1, 2011, to June 30, 2017. INTERVENTIONS Population pharmacokinetic analysis and simulation using NONMEM v.7.4 (Icon, PLC, Dublin, Ireland). MEASUREMENTS AND MAIN RESULTS A total of 41 patients met study criteria (median age, 5.8 years [interquartile range, 1.6-9.9 yr]), and 53.7% underwent therapy with the pulsatile Berlin EXCOR pediatric ventricular assist device (Berlin Heart GmbH, Berlin, Germany). All patients received unfractionated heparin continuous infusion at a mean ± SD dose of 29 ± 14 U/kg/hr. A total of 181 antithrombin doses (44.1 ± 24.6 U/kg/dose) were included, and baseline antithrombin activity levels were 77 ± 12 U/dL. Antithrombin activity levels were drawn a median 19.9 hours (interquartile range, 8.8-41.6 hr) after antithrombin dose. A one-compartment proportional error model best fit the data, with allometric scaling of fat-free mass providing a better model fit than actual body weight. Unfractionated heparin and baseline antithrombin were identified as significant covariates. A 50 U/kg dose of antithrombin had a simulated half-life 13.2 ± 6.6 hours. CONCLUSIONS Antithrombin should be dosed on fat-free mass in pediatric ventricular assist device patients. Unfractionated heparin dose and baseline antithrombin activity level should be considered when dosing antithrombin in pediatric ventricular assist device patients.
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8
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Lejus C, Orliaguet G, Servin F, Dadure C, Michel F, Brasher C, Dahmani S. Peri-operative management of overweight and obese children and adolescents. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 1:311-322. [PMID: 30169186 DOI: 10.1016/s2352-4642(17)30090-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 07/27/2017] [Accepted: 08/15/2017] [Indexed: 12/11/2022]
Abstract
Obesity has become endemic, even in children. Systemic complications associated with obesity include metabolic syndrome, cardiovascular disease, and respiratory compromise. These comorbidities require adequate investigation, targeted optimisation, and, if surgery is required, specific management during the peri-operative period. Specific peri-operative strategies should be used for paediatric patients who are overweight or obese to prevent postoperative complications, and optimising the respiratory function during surgery is particularly crucial. This Review aims to provide up-to-date information on peri-operative management for physicians who are caring for children and adolescents (usually younger than 18 years) who are overweight or obese undergoing surgery, including bariatric surgery. We have particularly focussed on the physiological consequences of obesity-namely, obstructive sleep apnoea, respiratory compromise, and pharmacological considerations.
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Affiliation(s)
- Corinne Lejus
- Department of Anaesthesia and Intensive care, Hôtel Dieu Hospital, Nantes, France
| | - Gilles Orliaguet
- Department of Anaesthesia and Intensive Care, Assistance Publique Hôpitaux de Paris, Necker-Enfants Malades Hospital, Paris, France; EA08 Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, Paris-Descartes and Paris Descartes University (Paris V), PRES Paris Sorbonne Cité, Paris, France
| | - Frederique Servin
- Department of Anaesthesia and Intensive Care, Assistance Publique Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - Christophe Dadure
- Department of Anaesthesia and Intensive care, Lapeyronie University Hospital, Montpellier, France; Institut de Neuroscience de Montpellier, Unité INSERM, Montpellier, France
| | - Fabrice Michel
- Department of Anaesthesia and Intensive Care, La Timone Hospital, Marseille, France; Espace Ethique Méditerranéen, Aix-Marseille Université, Hôpital Timone Adulte, Marseille, France
| | - Christopher Brasher
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Melbourne, VIC, Australia; Anesthesia and Pain Management Research Group, Murdoch Children's Research Institute, VIC, Australia
| | - Souhayl Dahmani
- DHU PROTECT, INSERM U1141, Paris, France; Department of Anaesthesia and Intensive Care, Robert Debré University Hospital, Assistance Publique Hôpitaux de Paris, Paris Diderot University, PRES Paris Sorbonne Cité, Paris, France.
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9
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Chidambaran V, Tewari A, Mahmoud M. Anesthetic and pharmacologic considerations in perioperative care of obese children. J Clin Anesth 2018; 45:39-50. [DOI: 10.1016/j.jclinane.2017.12.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 12/11/2017] [Accepted: 12/14/2017] [Indexed: 10/18/2022]
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10
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Xiong Y, Fukuda T, Knibbe CAJ, Vinks AA. Drug Dosing in Obese Children: Challenges and Evidence-Based Strategies. Pediatr Clin North Am 2017; 64:1417-1438. [PMID: 29173794 DOI: 10.1016/j.pcl.2017.08.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
With the alarming increase of obesity in children, pediatricians are increasingly being confronted with difficult dosing decisions. Many drug labels do not provide specific dosing instructions for children who are obese. In this article, we describe the physiologic parameters altered by obesity and their influences on drug disposition and effect. We review the principles of allometry, and the key pharmacokinetic parameters that can be used to derive age appropriate dosing regimens. Last, we illustrate how appropriate weight descriptors can be selected, and how important PK parameters can be extrapolated for dosing in obese children when pediatric pharmacokinetic information is available.
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Affiliation(s)
- Ye Xiong
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229-3039, USA
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229-3039, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St Antonius Hospital, PO Box 2500, Nieuwegein 3430 EM, The Netherlands; Division of Pharmacology, Leiden Academic Center for Drug Research, Faculty of Science, Leiden University, PO Box 9502, 2300 RA, Leiden, The Netherlands
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229-3039, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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11
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McEneny-King A, Chelle P, Henrard S, Hermans C, Iorio A, Edginton AN. Modeling of Body Weight Metrics for Effective and Cost-Efficient Conventional Factor VIII Dosing in Hemophilia A Prophylaxis. Pharmaceutics 2017; 9:pharmaceutics9040047. [PMID: 29039750 PMCID: PMC5750653 DOI: 10.3390/pharmaceutics9040047] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 01/21/2023] Open
Abstract
The total body weight-based dosing strategy currently used in the prophylactic treatment of hemophilia A may not be appropriate for all populations. The assumptions that guide weight-based dosing are not valid in overweight and obese populations, resulting in overdosing and ineffective resource utilization. We explored different weight metrics including lean body weight, ideal body weight, and adjusted body weight to determine an alternative dosing strategy that is both safe and resource-efficient in normal and overweight/obese adult patients. Using a validated population pharmacokinetic model, we simulated a variety of dosing regimens using different doses, weight metrics, and frequencies; we also investigated the implications of assuming various levels of endogenous factor production. Ideal body weight performed the best across all of the regimens explored, maintaining safety while moderating resource consumption for overweight and obese patients.
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Affiliation(s)
| | - Pierre Chelle
- School of Pharmacy, University of Waterloo, Waterloo, ON N2L 3G1, Canada.
| | - Severine Henrard
- Louvain Drug Research Institute, Clinical Pharmacy Research Group and Institute of Health and Society (IRSS), Université catholique de Louvain, 1348 Brussels, Belgium.
| | - Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, 1348 Brussels, Belgium.
| | - Alfonso Iorio
- Department of Health Evidence, Research Methods and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada.
- Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada.
| | - Andrea N Edginton
- School of Pharmacy, University of Waterloo, Waterloo, ON N2L 3G1, Canada.
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12
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Evaluation of safety and effectiveness of standardized antifactor Xa-based unfractionated heparin protocols in obese versus non-obese patients. J Thromb Thrombolysis 2017; 43:476-483. [DOI: 10.1007/s11239-016-1466-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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13
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Pediatric Obesity: Pharmacokinetics and Implications for Drug Dosing. Clin Ther 2015; 37:1897-923. [DOI: 10.1016/j.clinthera.2015.05.495] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 05/14/2015] [Accepted: 05/19/2015] [Indexed: 02/01/2023]
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14
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Hong X, Shan PR, Huang WJ, Zhu QL, Xiao FY, Li S, Zhou H. Influence of Body Mass Index on the Activated Clotting Time Under Weight-Based Heparin Dose. J Clin Lab Anal 2014; 30:108-13. [PMID: 25425223 DOI: 10.1002/jcla.21823] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 10/22/2014] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Activated clotting time (ACT) has been successfully applied during percutaneous coronary intervention (PCI) to monitor the extent of thrombin inhibition and anti-coagulation from unfractionated heparin (UFH) aiming to reduce the incidence of thrombotic adverse events and hemorrhagic complications. And this investigation was to explore the influence of body mass index (BMI) on ACT in patients received weight-based dose of UFH during PCI treatment. METHODS 78 male patients undergoing coronary angiography or PCI treatment with a mean age of 63.86 ± 6.89 years were enrolled in this study. The patients were statistically divided into four quartiles according to their BMI. The ACT values were recorded as ACT0 , ACT5 , ACT10 , ACT30 and ACT60 , respectively. Taking the preoperative ACT0 as reference, and the differences of the other ACT values with ACT0 was indicated as ΔACTs. ACT values peaked at 5 min in 33.33% of the patients, 10 min in 51.33% of the patients and 30 min in 15.34% of the patients, respectively. RESULTS In addition, significant differences were found in overall maximum post-UFH ACT values among all BMI quartiles. UFH doses per blood volume were significantly different among the BMI quartiles, showing a positive association with BMI quartiles; further evidence revealed that the areas under the ΔACT-time curves increased gradually from quartile I to quartile IV. The proportions of ACT60 > 250 s and ACT60 > 300 s were found to be positively correlated with the increased BMI at 60 min after heparin loading. CONCLUSIONS The results of our study have shown that a standardized dosing nomogram that uses the actual body weight to calculate the heparin doses may result in UFH overdose for patients with higher BMI compared to patients with lower BMI.
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Affiliation(s)
- Xia Hong
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| | - Pei-Ren Shan
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| | - Wei-Jian Huang
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| | - Qian-Li Zhu
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| | - Fang-Yi Xiao
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| | - Sheng Li
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| | - Hao Zhou
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
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Abstract
Given the rising incidence of thrombotic complications in paediatric patients, understanding of the pharmacologic behaviour of anticoagulant drugs in children has gained importance. Significant developmental differences between children and adults in the haemostatic system and pharmacologic parameters for individual drugs highlight potentially unique aspects of anticoagulant pharmacology in this special and vulnerable population. This review focuses on pharmacologic information relevant to the dosing of unfractionated heparin, low molecular weight heparin, warfarin, bivalirudin, argatroban and fondaparinux in paediatric patients. The bulk of clinical experience with paediatric anticoagulation rests with the first three of these agents, each of which requires higher bodyweight-based dosing for the youngest patients, compared with adults, in order to achieve comparable pharmacodynamic effects, likely related to an inverse correlation between age and bodyweight-normalized clearance of these drugs. Whether extrapolation of therapeutic ranges targeted for adult patients prescribed these agents is valid for children, however, is unknown and a high priority for future research. Novel oral anticoagulants, such as dabigatran, rivaroxaban and apixaban, hold promise for future use in paediatrics but require further pharmacologic study in infants, children and adolescents.
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