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Penezić L, Nađ-Škegro S, Hadžavdić A, Ganoci L, Kaštelan Ž, Trkulja V, Božina N. Inosine monophosphate dehydrogenase type 2 polymorphism IMPDH2 3757T>C (rs11706052) and 12-month evolution of the graft function in renal transplant recipients on mycophenolate-based immunosuppression. THE PHARMACOGENOMICS JOURNAL 2024; 24:15. [PMID: 38769303 DOI: 10.1038/s41397-024-00335-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 04/26/2024] [Accepted: 05/08/2024] [Indexed: 05/22/2024]
Abstract
Variant allele at the inosine monophosphate dehydrogenase type 2 polymorphism IMPDH2 3757T>C has been associated with increased enzyme activity and reduced susceptibility to mycophenolic acid (MPA) in vitro. It has been suggested associated with an increased risk of acute rejection in renal transplant recipients on MPA-based immunosuppression, but not unambiguously. We assessed one-year evolution of the estimated glomerular filtration rate (eGFR) in transplanted variant allele carriers and wild-type subjects, while controlling for a number of demographic, pharmacogenetic, (co)morbidity, and treatment baseline and time-varying covariates. The eGFR slopes to day 28 (GMR = 1.01, 95% CI 0.93-1.09), and between days 28 and 365 (GMR = 1.01, 95% CI 0.99-1.02) were practically identical in 52 variant carriers and 202 wild-type controls. The estimates (95%CIs) remained within the limits of ±20% difference even after adjustment for a strong hypothetical effect of unmeasured confounders. Polymorphism IMPDH2 3757T>C does not affect the renal graft function over the 1st year after transplantation.
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Affiliation(s)
- Luka Penezić
- Department of Urology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Sandra Nađ-Škegro
- Department of Urology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Ayla Hadžavdić
- Teaching Institute for Emergency Medicine of Istria County, Zagreb, Croatia
| | - Lana Ganoci
- Division of Pharmacogenomics and Therapy Individualization, Department of Laboratory Diagnostics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Željko Kaštelan
- Department of Urology, University Hospital Center Zagreb, Zagreb, Croatia
- Department of Urology, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Vladimir Trkulja
- Department of Pharmacology, University of Zagreb School of Medicine, Zagreb, Croatia.
| | - Nada Božina
- Department of Pharmacology, University of Zagreb School of Medicine, Zagreb, Croatia
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Ntobe-Bunkete B, Lemaitre F. Therapeutic drug monitoring in kidney and liver transplantation: current advances and future directions. Expert Rev Clin Pharmacol 2024; 17:505-514. [PMID: 38725273 DOI: 10.1080/17512433.2024.2354276] [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: 08/12/2023] [Accepted: 05/08/2024] [Indexed: 05/24/2024]
Abstract
INTRODUCTION Immunosuppressive drugs (ISD) present a narrow therapeutic window and extremely high inter- and intra-individual pharmacokinetic variability, which complicates their use in solid organ transplant recipients. In order to find a narrow appropriate equilibrium for each patient with the aim of maintaining clinical efficacy and reducing the risk of adverse drug reactions, a complex both clinical and biological monitoring is required, in particular through the use of therapeutic drug monitoring (TDM). AREA COVERED This review provides an overview of the available information on the relationship between exposure to immunosuppressive drugs and their efficacy and/or toxicity in kidney and liver transplantation. The aim of the review is to describe the pharmacodynamic/pharmacokinetic relationship that exists for immunosuppressive drugs, to summarize the studies that assess the value of TDM for these drugs in clinical practice, and to present the target and monitoring strategies aimed at optimizing patient immunosuppression, which could help to take a step forward in the field of solid organ transplant patient care. EXPERT OPINION To improve the care of transplant patients, several TDM innovations can be pursued by investigators. Among these, the development of microsampling methods for TDM or the combination of pharmacodynamic biomarkers with ISD exposure measurements appear to be relevant strategies.
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Affiliation(s)
- Béni Ntobe-Bunkete
- Univ Rennes, CHU Rennes, EHESP, IRSET (Institut de Recherche en Santé, Environnement et Travail) - UMR S 1085, Rennes, France
- INSERM, Centre d'Investigation Clinique 1414, Rennes, France
| | - Florian Lemaitre
- Univ Rennes, CHU Rennes, EHESP, IRSET (Institut de Recherche en Santé, Environnement et Travail) - UMR S 1085, Rennes, France
- INSERM, Centre d'Investigation Clinique 1414, Rennes, France
- FHU SUPORT, Rennes, France
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Villeneuve C, Humeau A, Monchaud C, Labriffe M, Rerolle JP, Couzi L, Westeel PF, Etienne I, Kamar N, Büchler M, Thierry A, Marquet P. Better Rejection-Free Survival at Three Years in Kidney Transplant Recipients With Model-Informed Precision Dosing of Mycophenolate Mofetil. Clin Pharmacol Ther 2024. [PMID: 38372185 DOI: 10.1002/cpt.3206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/25/2024] [Indexed: 02/20/2024]
Abstract
The clinical impact of individual dose adjustment of mycophenolate mofetil is still debated, due to conflicting results from randomized clinical trials. This retrospective study aimed to compare 3-year rejection-free survival and adverse effects between adult kidney transplant recipients (KTRs) with or without mycophenolate mofetil model-informed precision dosing (MIPD). MIPD is defined here as mycophenolic acid area under the curve (AUC0-12h ) estimation using a limited sampling strategy, pharmacokinetic models and Bayesian estimators; dose recommendation to reach AUC0-12h = 45 mg.h/L; using a widely used online expert system. The study, nested in two multicenter prospective cohort studies, focused on patients who received a mycophenolate drug and were followed up for 1-3 years. Mycophenolate mofetil MIPD was prescribed as per local practice, on a regular basis, when deemed necessary, or not at all. The MIPD group included 341 KTRs and the control group 392. At 3 years, rejection-free survival was respectively 91.2% and 80.6% (P < 0.001) and the cumulative incidence of rejection 5.08% vs. 12.7% per patient × year (hazard ratio = 0.49 (0.34, 0.71), P < 0.001), corresponding to a 2.5-fold reduction. Significant association with rejection-free survival was confirmed in patients at low or high risk of rejection (P = 0.017 and 0.013) and in patients on tacrolimus, but not on cyclosporine (P < 0.001 and 0.205). The mycophenolate mofetil MIPD group had significantly more adverse effects, but most occurred before the first AUC0-12h , suggesting some may be the reason why MIPD was ordered.
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Affiliation(s)
- Claire Villeneuve
- Department of Pharmacology, Toxicology and Pharmacovigilance, Centre Hospitalier Universitaire de Limoges, Limoges, France
- Pharmacology & Transplantation, Institut National de la Santé et de la Recherche Médicale U1248, Université de Limoges, Limoges, France
- Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation (FHU SUPORT), Limoges, France
| | - Antoine Humeau
- Pharmacology & Transplantation, Institut National de la Santé et de la Recherche Médicale U1248, Université de Limoges, Limoges, France
- Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation (FHU SUPORT), Limoges, France
| | - Caroline Monchaud
- Department of Pharmacology, Toxicology and Pharmacovigilance, Centre Hospitalier Universitaire de Limoges, Limoges, France
- Pharmacology & Transplantation, Institut National de la Santé et de la Recherche Médicale U1248, Université de Limoges, Limoges, France
- Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation (FHU SUPORT), Limoges, France
| | - Marc Labriffe
- Department of Pharmacology, Toxicology and Pharmacovigilance, Centre Hospitalier Universitaire de Limoges, Limoges, France
- Pharmacology & Transplantation, Institut National de la Santé et de la Recherche Médicale U1248, Université de Limoges, Limoges, France
- Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation (FHU SUPORT), Limoges, France
| | - Jean-Phillipe Rerolle
- Pharmacology & Transplantation, Institut National de la Santé et de la Recherche Médicale U1248, Université de Limoges, Limoges, France
- Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation (FHU SUPORT), Limoges, France
- Department of Nephrology, Dialysis and Transplantation, Centre Hospitalier Universitaire de Limoges, Limoges, France
- Department of Nephrology, Transplantation, Dialysis, Centre Hospitalier Universitaire Pellegrin, Bordeaux, France
| | - Lionel Couzi
- Centre National de la Recherche Scientifique, UMR 5164 Immuno ConcEpT, Bordeaux University, Bordeaux, France
| | - Pierre-François Westeel
- Department of Nephrology and Kidney Transplantation, University Hospital of Amiens, Amiens, France
| | - Isabelle Etienne
- Service de Néphrologie, Rouen University Hospital, Rouen, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Université Paul Sabatier, Toulouse, France
- Institut National de la Santé et de la Recherche Médicale, U1043, IFR-BMT, Centre Hospitalier Universitaire Purpan, Toulouse, France
| | - Mathias Büchler
- Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation (FHU SUPORT), Limoges, France
- Department of Nephrology and Kidney Transplantation, University Hospital of Tours, Tours, France
- François Rabelais University, Tours, France
| | - Antoine Thierry
- Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation (FHU SUPORT), Limoges, France
- Department of Nephrology, Dialysis and Transplantation, Centre Hospitalier Universitaire de Poitiers, Tours, France
| | - Pierre Marquet
- Department of Pharmacology, Toxicology and Pharmacovigilance, Centre Hospitalier Universitaire de Limoges, Limoges, France
- Pharmacology & Transplantation, Institut National de la Santé et de la Recherche Médicale U1248, Université de Limoges, Limoges, France
- Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation (FHU SUPORT), Limoges, France
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Almeslet A. Mycophenolate Mofetil-Induced Aphthous Stomatitis After Kidney Transplant: A Clinical Case Report. Cureus 2023; 15:e50811. [PMID: 38249270 PMCID: PMC10797224 DOI: 10.7759/cureus.50811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 01/23/2024] Open
Abstract
Aphthous stomatitis, with frequent and painful aphthous ulcers (also called canker sores or simply oral ulcers) on the non-keratinized oral mucous membranes, is often a cutaneous complication in kidney transplant recipients. Mycophenolate mofetil is a drug that is part of an immunosuppressive regimen in kidney transplant recipients, along with corticosteroids and calcineurin inhibitors. Mycophenolate mofetil, the triggering agent for mouth ulcers in kidney transplant recipients, has been communicated in scientific literature. Herein, we report a case of multiple painful oral ulcerations secondary to mycophenolate mofetil in a 23-year-old female kidney transplant recipient. The oral ulcers resolved immediately after discontinuation of the mycophenolate mofetil. Withdrawal of mycophenolate mofetil or switching to other medicine must be considered when a patient with a kidney transplant history complains of oral ulcers and a negative workup for other etiologies.
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Affiliation(s)
- Asma Almeslet
- Department of Oral Maxillofacial Surgery and Diagnostic Sciences, Riyadh Elm University, Riyadh, SAU
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Xu G, Wang Z, Yan T, Li J, Zhou X. Bioequivalue of two mycophenolate sodium enteric-coated tablets and the drug monitoring based on limited sampling strategy: A single-center, randomized, open-label, three-period, reference-replicated, crossover study. Transpl Immunol 2023; 81:101923. [PMID: 37652363 DOI: 10.1016/j.trim.2023.101923] [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: 05/25/2023] [Revised: 08/18/2023] [Accepted: 08/27/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVE A mycophenolate sodium enteric-coated tablet has shown a satisfying anti-rejection effect in patients receiving solid organ transplantation. The current study evaluated the bioequivalence between the test (Ruiyirong®) vs. reference (Myfortic®) formulations by exploring equations for predicting their area under the concentration-time curve (AUC) using a limited sampling strategy in healthy subjects. METHODS Forty-eight healthy Chinese subjects were randomized into three administration sequences (test-reference-reference, reference-reference-test, and reference-test-reference) to receive the Ruiyirong or Myfortic treatment on days 1, 8, and 15. RESULTS The 90% confidential interval (CI) of the geometric mean ratios (test/reference) of maximum plasma concentration (Cmax), the AUC from time 0 to the last timepoint (AUC0-t), and the AUC from 0 to infinity (AUC0-∞) was 92.90%-110.57%, 96.91%- 101.80%, and 96.71%-101.84%, respectively. All these values fell into the bioequivalence criteria of 80.00%-125.00% (based on the criteria of the Food and Drug Administration). The adverse events were 10.4% in Ruiyirong test group and 14.6% in Myfortic reference group. Eight equations for estimating the AUC of the Ruiyirong test and Myfortic reference formulations were evaluated; most of them worked well with the R-value >0.8. Among the four chosen equations, the intragroup verification exhibited a high agreement with the R-value ranging from 0.857 to 0.971 and with the low predictive error (PE > 5% with absolute PE > 15%). Meanwhile, the intergroup verification indicated a high inter-agreement with the R-value ranging from 0.896 to 0.974 (all P < 0.001). CONCLUSION The Ruiyirong test vs. Myfortic reference formulations meet the bioequivalent criteria and are well tolerated. The further linear regression analysis explores eight equations predicting the AUC value and the chosen four equations for the Ruiyirong test and Mayfortic reference formulations are interchangeable.
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Affiliation(s)
- Guangxun Xu
- Hepato-Pancreato-Biliary Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing 102218, China
| | - Zhendi Wang
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Key Laboratory of Organ Transplantation, Ministry of Education, NHC, Chinese Academy of Medical Sciences, Wuhan 430030, China
| | - Tianzhong Yan
- Department of Urology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou 450003, China
| | - Jinyu Li
- Department of Urology Surgery, 909 Hospital, Joint logistic Support Force of PLA (Southeast Hospital, Xiamen University), Zhangzhou 363000, China
| | - Xiaofeng Zhou
- Department of Urology, China-Japan Friendship Hospital, Beijing 100029, China.
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Labriffe M, Micallef L, Woillard JB, Monchaud C, Saint-Marcoux F, Debord J, Marquet P. Mycophenolate Mofetil Dose Adjustment in Pediatric Kidney Transplant Recipients. Ther Drug Monit 2023; 45:591-598. [PMID: 36823705 DOI: 10.1097/ftd.0000000000001087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/14/2022] [Indexed: 02/25/2023]
Abstract
BACKGROUND The Immunosuppressant Bayesian Dose Adjustment web site aids clinicians and pharmacologists involved in the care of transplant recipients; it proposes dose adjustments based on the estimated area under the concentration-time curve (AUCs). Three concentrations (T 20 min , T 1 h , and T 3 h ) are sufficient to estimate mycophenolic acid (MPA) AUC 0-12 h in pediatric kidney transplant recipients. This study investigates mycophenolate mofetil (MMF) doses and MPA AUC values in pediatric kidney transplant recipients, and target exposure attainment when the proposed doses were followed, through a large-scale analysis of the data set collated since the inception of the Immunosuppressant Bayesian Dose Adjustment web site. METHODS In this study, 4051 MMF dose adjustment requests, corresponding to 1051 patients aged 0-18 years, were retrospectively analyzed. AUC calculations were performed in the back office of the Immunosuppressant Bayesian Dose Adjustment using published Bayesian and population pharmacokinetic models. RESULTS The first AUC request was posted >12 months posttransplantation for 41% of patients. Overall, only 50% had the first MPA AUC 0-12 h within the recommended 30-60 mg.h/L range. When the proposed dose was not followed, the proportion of patients with an AUC in the therapeutic range for MMF with cyclosporine or tacrolimus at the subsequent request was lower (40% and 45%, respectively) than when it was followed (58% and 60%, respectively): P = 0.08 and 0.006, respectively. Furthermore, 3 months posttransplantation, the dispersion of AUC values was often lower at the second visit when the proposed doses were followed, namely, P = 0.03, 0.003, and 0.07 in the 4 months-1 year, and beyond 1 year with <6-month or >6-month periods between both visits, respectively. CONCLUSIONS Owing to extreme interindividual variability in MPA exposure, MMF dose adjustment is necessary; it is efficient at reducing such variability when based on MPA AUC.
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Affiliation(s)
- Marc Labriffe
- Pharmacology and Transplantation, INSERM U1248, Université de Limoges ; and
- Department of Pharmacology, Toxicology and Pharmacovigilance, CHU de Limoges, Limoges, France
| | - Ludovic Micallef
- Pharmacology and Transplantation, INSERM U1248, Université de Limoges ; and
| | - Jean-Baptiste Woillard
- Pharmacology and Transplantation, INSERM U1248, Université de Limoges ; and
- Department of Pharmacology, Toxicology and Pharmacovigilance, CHU de Limoges, Limoges, France
| | - Caroline Monchaud
- Pharmacology and Transplantation, INSERM U1248, Université de Limoges ; and
- Department of Pharmacology, Toxicology and Pharmacovigilance, CHU de Limoges, Limoges, France
| | - Franck Saint-Marcoux
- Pharmacology and Transplantation, INSERM U1248, Université de Limoges ; and
- Department of Pharmacology, Toxicology and Pharmacovigilance, CHU de Limoges, Limoges, France
| | - Jean Debord
- Pharmacology and Transplantation, INSERM U1248, Université de Limoges ; and
- Department of Pharmacology, Toxicology and Pharmacovigilance, CHU de Limoges, Limoges, France
| | - Pierre Marquet
- Pharmacology and Transplantation, INSERM U1248, Université de Limoges ; and
- Department of Pharmacology, Toxicology and Pharmacovigilance, CHU de Limoges, Limoges, France
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Liu M, Bai Y, He Y, Zhou Y, Liu Z, Chen H, Liu X, Fu C. High-throughput detection of mycophenolic acid in human plasma based on sensitive and rapid fluorescence nitrogen-doped carbon dots sensing platform. J Pharm Biomed Anal 2023; 234:115545. [PMID: 37364453 DOI: 10.1016/j.jpba.2023.115545] [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: 04/17/2023] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 06/28/2023]
Abstract
In this experiment, a water-soluble, nitrogen-doped yellow-green fluorescent N-doped carbon dots (N-CDs) were synthesized by one-step hydrothermal method using β-cyclodextrin as carbon source and L-phenylalanine as nitrogen source. The fluorescence quantum yield of the obtained N-CDs was as high as 9.96%, and the N-CDs exhibited photostability at different pH, ionic strength and temperature. The morphology of the N-CDs was approximately spherical with an average particle size of about 9.4 nm. Based on the fluorescence enhancement effect of mycophenolic acid (MPA) on N-CDs, a quantitative detection method of MPA was established. This method had good selectivity and high sensitivity for MPA. The fluorescence sensing system was applied to the detection of MPA in human plasma. The linear range of MPA were 0.06-3 μg·mL-1 and 3-27 μg·mL-1 with a detection limit of 0.016 μg·mL-1, and the recoveries were 97.03∼100.64 % with the RSDs of 0.13∼2.90 %. The interference experiment results showed that the interference of other coexisting substances, including Fe3+, can be ignored in the actual detection. Comparing the results measured by the established method with the EMIT method, it was found that the results obtained by the two methods were similar, and the relative error was within ± 5 %. This study provided a simple, rapid, sensitive, selective and effective method for the quantitative analysis of MPA, and was expected to be applied to clinical MPA blood concentration monitoring.
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Affiliation(s)
- Mei Liu
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, PR China; SCMPA Key Laboratory for Quality Research and Control of Chemical Medicine, Chengdu, PR China
| | - Yangjuan Bai
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, PR China
| | - Yunan He
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, PR China
| | - Yanqu Zhou
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, PR China
| | - Zhonglin Liu
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, PR China
| | - Hong Chen
- SCMPA Key Laboratory for Quality Research and Control of Chemical Medicine, Chengdu, PR China
| | - Xiuxiu Liu
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, PR China
| | - Chunmei Fu
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, PR China.
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In 't Veld AE, Jansen MAA, de Kam ML, Yavuz Y, Moes DJAR, Oudhoff KA, van Poelgeest MIE, Burggraaf J, Moerland M. Immune Monitoring of Mycophenolate Mofetil Activity in Healthy Volunteers Using Ex Vivo T Cell Function Assays. Pharmaceutics 2023; 15:1635. [PMID: 37376083 DOI: 10.3390/pharmaceutics15061635] [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: 05/08/2023] [Revised: 05/23/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
Mycophenolate mofetil (MMF) is part of the standard immunosuppressive treatment after transplantation and usually given as "one-dose-fits-all" together with a calcineurin inhibitor (CNI). Although drug concentrations are frequently monitored, there is still a group of patients who experience side effects related to excessive or insufficient immune suppression. We therefore aimed to identify biomarkers that reflect the overall immune status of the patient and might support individualized dosing. We previously studied immune biomarkers for CNIs and aimed to investigate whether these are also suitable to monitor MMF activity. Healthy volunteers received a single dose of MMF or placebo, after which IMPDH enzymatic activity, T cell proliferation, and cytokine production were measured and compared to MPA (MMF's active metabolite) concentration in three different matrices (plasma, peripheral blood mononuclear cells, and T cells). MPA concentrations in T cells exceeded those in PBMCs, but all intracellular concentrations correlated strongly with plasma concentrations. At clinically relevant MPA concentrations, IL-2 and IFN-γ production was mildly suppressed, while MPA T cell proliferation was strongly inhibited. Based on these data, it is expected that monitoring of T cell proliferation in MMF-treated transplantation patients may be a valid strategy to avoid excessive immune suppression.
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Affiliation(s)
- Aliede E In 't Veld
- Centre for Human Drug Research, 2233 CL Leiden, The Netherlands
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | | | | | - Yalҫin Yavuz
- Centre for Human Drug Research, 2233 CL Leiden, The Netherlands
| | - Dirk Jan A R Moes
- Department of Pharmacy and Clinical Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Kathalijne A Oudhoff
- Department of Pharmacy and Clinical Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Mariette I E van Poelgeest
- Centre for Human Drug Research, 2233 CL Leiden, The Netherlands
- Department of Gynecology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Jacobus Burggraaf
- Centre for Human Drug Research, 2233 CL Leiden, The Netherlands
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Leiden Academic Centre of Drug Research, 2333 ZA Leiden, The Netherlands
| | - Matthijs Moerland
- Centre for Human Drug Research, 2233 CL Leiden, The Netherlands
- Department of Pharmacy and Clinical Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
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Tague LK, Oetjen KA, Mahadev A, Walter MJ, Anthony H, Kreisel D, Link DC, Gelman AE. Increased clonal hematopoiesis involving DNA damage response genes in patients undergoing lung transplantation. JCI Insight 2023; 8:e165609. [PMID: 36853803 PMCID: PMC10132147 DOI: 10.1172/jci.insight.165609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 02/21/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUNDCellular stressors influence the development of clonal hematopoiesis (CH). We hypothesized that environmental, inflammatory, and genotoxic stresses drive the emergence of CH in lung transplant recipients. METHODSWe performed a cross-sectional cohort study of 85 lung transplant recipients to characterize CH prevalence. We evaluated somatic variants using duplex error-corrected sequencing and germline variants using whole exome sequencing. We evaluated CH frequency and burden using χ2 and Poisson regression, and we evaluated associations with clinical and demographic variables and clinical outcomes using χ2, logistic regression, and Cox regression. RESULTSCH in DNA damage response (DDR) genes TP53, PPM1D, and ATM was increased in transplant recipients compared with a control group of older adults (28% versus 0%, adjusted OR [aOR], 12.9 [1.7-100.3], P = 0.0002). Age (OR, 1.13 [1.03-1.25], P = 0.014) and smoking history (OR 4.25 [1.02-17.82], P = 0.048) were associated with DDR CH. Germline variants predisposing to idiopathic pulmonary fibrosis were identified but not associated with CH. DDR CH was associated with increased cytomegalovirus viremia versus patients with no (OR, 7.23 [1.95-26.8], P = 0.018) or non-DDR CH (OR, 7.64 [1.77-32.89], P = 0.024) and mycophenolate discontinuation (aOR, 3.8 [1.3-12.9], P = 0.031). CONCLUSIONCH in DDR genes is prevalent in lung transplant recipients and is associated with posttransplant outcomes including cytomegalovirus activation and mycophenolate intolerance. FUNDINGNIH/NHLBI K01HL155231 (LKT), R25HL105400 (LKT), Foundation for Barnes-Jewish Hospital (LKT), Evans MDS Center at Washington University (KAO, MJW), ASH Scholar Award (KAO), NIH K12CA167540 (KAO), NIH P01AI116501 (AEG, DK), NIH R01HL094601 (AEG), and NIH P01CA101937 (DCL).
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Affiliation(s)
| | - Karolyn A. Oetjen
- Division of Oncology, Section of Stem Cell Biology, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | | | - Matthew J. Walter
- Division of Oncology, Section of Stem Cell Biology, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | | | - Daniel Kreisel
- Department of Surgery, Division of Cardiothoracic Surgery, and
| | - Daniel C. Link
- Division of Oncology, Section of Stem Cell Biology, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Pathology & Immunology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Andrew E. Gelman
- Department of Surgery, Division of Cardiothoracic Surgery, and
- Department of Pathology & Immunology, Washington University in St. Louis, St. Louis, Missouri, USA
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10
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Meziyerh S, Bouwmans P, van Gelder T, van der Helm D, Messchendorp L, van der Boog PJM, de Fijter JW, Moes DJAR, de Vries APJ. Mycophenolic Acid Exposure Determines Antibody Formation Following SARS-CoV-2 Vaccination in Kidney Transplant Recipients: A Nested Cohort Study. Clin Pharmacol Ther 2023. [PMID: 36789469 DOI: 10.1002/cpt.2872] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/07/2023] [Indexed: 02/16/2023]
Abstract
Despite (repeated) boosting, kidney transplant recipients (KTRs) may remain at increased risk of severe COVID-19 since a substantial number of individuals remain seronegative or with low antibody titers. In particular, mycophenolic acid use has been shown to affect antibody formation negatively and may be an important modifiable risk factor. We investigated the exposure-response relationship between mycophenolic acid 12-hour area under the curve (AUC0-12h ) exposure and seroconversion including antibody titers after vaccination using mRNA-1273 SARS-CoV-2 vaccine (Moderna) in 316 KTRs from our center that participated in the national Dutch renal patients COVID-19 vaccination - long term efficacy and safety of SARS-CoV-2 vaccination in kidney disease patients vaccination study. After two vaccination doses, 162 (51%) KTRs seroconverted. KTRs treated with mycophenolic acid showed less seroconversion and lower antibody titers compared with KTRs without mycophenolic acid (44% vs. 77%, and 36 binding antibody units (BAU)/mL vs. 340 BAU/mL; P < 0.001). The mean mycophenolic acid AUC0-12h exposure was significantly lower in KTRs who seroconverted compared with KTRs who did not (39 vs. 29 mg⋅h/L; P < 0.001). High mycophenolic acid exposure (±90 mg⋅h/L) and no exposure to mycophenolic acid resulted in a seroconversion rate ranging from 10% to 80%. Every 10 mg⋅h/L increase in mycophenolic acid AUC0-12h gave an adjusted odds ratio for seroconversion of 0.87 (95% confidence interval (CI), 0.79-0.97; P = 0.010) and 0.89 (95% CI, 0.85-0.93; P < 0.001) for KTRs on dual and triple maintenance immunosuppressive therapy, respectively. Higher mycophenolic acid AUC0-12h correlated with lower antibody titers (R = 0.44, P < 0.001). This study demonstrates the exposure-response relationship between gold standard mycophenolic acid exposure and antibody formation to support interventional studies investigating mycophenolic acid adjustment to improve antibody formation after further boosting.
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Affiliation(s)
- Soufian Meziyerh
- Department of Medicine, Division of Nephrology, Leiden University Medical Center, Leiden, The Netherlands.,Leiden University Medical Center Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Pim Bouwmans
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht School for Cardiovascular Disease, University of Maastricht, Maastricht, The Netherlands
| | - Teun van Gelder
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Danny van der Helm
- Leiden University Medical Center Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Lianne Messchendorp
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - Paul J M van der Boog
- Department of Medicine, Division of Nephrology, Leiden University Medical Center, Leiden, The Netherlands.,Leiden University Medical Center Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Johan W de Fijter
- Department of Medicine, Division of Nephrology, Leiden University Medical Center, Leiden, The Netherlands.,Leiden University Medical Center Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Dirk Jan A R Moes
- Cardiovascular Research Institute Maastricht School for Cardiovascular Disease, University of Maastricht, Maastricht, The Netherlands
| | - Aiko P J de Vries
- Department of Medicine, Division of Nephrology, Leiden University Medical Center, Leiden, The Netherlands.,Leiden University Medical Center Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
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11
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Borić-Bilušić AA, Božina N, Lalić Z, Lovrić M, Nađ-Škegro S, Penezić L, Barišić K, Trkulja V. Loss of Function ABCG2 c.421C>A (rs2231142) Polymorphism Increases Steady-State Exposure to Mycophenolic Acid in Stable Renal Transplant Recipients: An Exploratory Matched Cohort Study. Adv Ther 2023; 40:601-618. [PMID: 36434147 DOI: 10.1007/s12325-022-02378-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/08/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Polymorphism ABCG2 c.421C>A (rs2231142) results in reduced activity of the important drug efflux transporter breast cancer-resistance protein (BCRP/ABCG2). One study has suggested that it may affect enterohepatic recirculation of mycophenolic acid (MPA). We evaluated the effect of rs2231142 on steady-state exposure to MPA in renal transplant recipients. METHODS Consecutive, stable adult (age ≥ 16 years) renal transplant recipients on standard MPA-based immunosuppressant protocols (N = 68; 43 co-treated with cyclosporine, 25 with tacrolimus) underwent routine therapeutic drug monitoring after a week of initial treatment, and were genotyped for ABCG2 c.421C>A and 11 polymorphisms in genes encoding enzymes and transporters implicated in MPA pharmacokinetics. ABCG2 c.421C>A variant versus wild-type (wt) patients were matched with respect to demographic, biopharmaceutic, and genetic variables (full optimal combined with exact matching) and compared for dose-adjusted steady-state MPA pharmacokinetics [frequentist and Bayes (skeptical neutral prior) estimates of geometric means ratios, GMR]. RESULTS Raw data (12 variant versus 56 wt patients) indicated around 40% higher total exposure (frequentist GMR = 1.45, 95% CI 1.10-1.91; Bayes = 1.38, 95% CrI 1.07-1.81) and around 30% lower total body clearance (frequentist GMR = 0.66, 0.58-0.90; Bayes = 0.71, 0.53-0.95) in variant carriers than in wt controls. The estimates were similar in matched data (11 variant versus 43 wt patients): exposure GMR = 1.41 (1.11-1.79) frequentist, 1.39 (1.15-1.81) Bayes, with 90.7% and 85.5% probability of GMR > 1.20, respectively; clearance GMR = 0.73 (0.58-0.93) frequentist, 0.71 (0.54-0.95) Bayes. Sensitivity analysis indicated low susceptibility of the estimates to unmeasured confounding. CONCLUSIONS Loss-off-function polymorphism ABCG2 c.421C>A increases steady-state exposure to MPA in stable renal transplant patients.
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Affiliation(s)
- A Ana Borić-Bilušić
- Agency for Medicinal Products and Medical Devices of Croatia, Zagreb, Croatia
| | - Nada Božina
- Department of Pharmacology, Zagreb University School of Medicine, Šalata 11, 10000, Zagreb, Croatia
| | - Zdenka Lalić
- Department of Laboratory Diagnostics, Analytical Toxicology and Pharmacology Division, University Hospital Center Zagreb, Zagreb, Croatia
| | - Mila Lovrić
- Department of Laboratory Diagnostics, Analytical Toxicology and Pharmacology Division, University Hospital Center Zagreb, Zagreb, Croatia
| | - Sandra Nađ-Škegro
- Department of Urology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Luka Penezić
- Department of Urology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Karmela Barišić
- Department of Medical Biochemistry and Hematology, Faculty of Pharmacy and Biochemistry, Zagreb University, Zagreb, Croatia
| | - Vladimir Trkulja
- Department of Pharmacology, Zagreb University School of Medicine, Šalata 11, 10000, Zagreb, Croatia.
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12
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Mizaki T, Nobata H, Banno S, Yamaguchi M, Kinashi H, Iwagaitsu S, Ishimoto T, Kuru Y, Ohnishi M, Sako KI, Ito Y. Population pharmacokinetics and limited sampling strategy for therapeutic drug monitoring of mycophenolate mofetil in Japanese patients with lupus nephritis. J Pharm Health Care Sci 2023; 9:1. [PMID: 36624529 PMCID: PMC9830922 DOI: 10.1186/s40780-022-00271-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/25/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Mycophenolate mofetil (MMF), a prodrug of the immunosuppressive agent mycophenolic acid (MPA), is difficult to administer because of the pharmacokinetic complexity of MPA. Although dosage adjustment according to the 12-h area under the concentration-time curve (AUC0-12) is thought to be desirable, multiple blood samplings for AUC calculation may pose a clinical challenge. A limited sampling strategy (LSS) would provide a solution; however, little is known about MPA pharmacokinetics in lupus nephritis patients, especially in those with Asian backgrounds, or few, if any, LSSs are reported for them. METHODS Thirty-four adult Japanese patients receiving MMF for lupus nephritis were examined retrospectively. MPA pharmacokinetics were investigated, and a PPK model was developed using Phoenix® NLME™ software. Single and double blood sampling strategies from Bayesian estimation using the PPK model and from multiple linear regression were compared. Tolerability was also evaluated. RESULTS In the pharmacokinetic analysis, renal function and serum albumin had significant effects on dose-normalized AUC0-12; and serum albumin, concomitant proton pump inhibitor (PPI) and iron/magnesium oxide did on dose-normalized maximum concentration. As a PPK model, a two-compartment model was developed with a transit absorption model and first-order elimination, in which creatinine clearance and serum albumin were covariates for MPA clearance. The double sampling strategy at 1 and 4 h by multiple linear regression showed the best agreement with the observed AUC0-12 (r2 = 0.885). Of the single sampling strategies, the one at 6 h by Bayesian estimation performed best (r2 = 0.769). The tolerability evaluation showed that correlations were suggested for gastrointestinal involvement. CONCLUSIONS The present study developed the first PPK model of MPA for Japanese lupus nephritis patients. As for LSSs, a double sampling strategy at 1 and 4 h by multiple linear regression would work best; when only a single blood sampling is allowed, a strategy at 6 h by Bayesian estimation using the PPK model developed in this study would be best. The LSSs good enough for clinical use may facilitate safer, more effective, and individualized therapy.
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Affiliation(s)
- Tomoko Mizaki
- grid.411234.10000 0001 0727 1557Department of Pharmacy, Aichi Medical University Medical Center, 17-33 Nikkicho, Okazaki, Aichi 444-2148 Japan ,grid.411234.10000 0001 0727 1557Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Hironobu Nobata
- grid.411234.10000 0001 0727 1557Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Shogo Banno
- grid.411234.10000 0001 0727 1557Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Makoto Yamaguchi
- grid.411234.10000 0001 0727 1557Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Hiroshi Kinashi
- grid.411234.10000 0001 0727 1557Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Shiho Iwagaitsu
- grid.411234.10000 0001 0727 1557Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Takuji Ishimoto
- grid.411234.10000 0001 0727 1557Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Yukiko Kuru
- grid.411234.10000 0001 0727 1557Medical Education Center, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Masafumi Ohnishi
- grid.411234.10000 0001 0727 1557Department of Pharmacy, Aichi Medical University Medical Center, 17-33 Nikkicho, Okazaki, Aichi 444-2148 Japan ,grid.411234.10000 0001 0727 1557Department of Pharmacy, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Ken-ichi Sako
- grid.444657.00000 0004 0606 9754Department of Clinical Pharmacy, Nihon Pharmaceutical University, 10281 Komuro, Kitaadachigun Inamachi, Saitama, 362-0806 Japan
| | - Yasuhiko Ito
- grid.411234.10000 0001 0727 1557Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
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13
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 89] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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14
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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15
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Catić‐Đorđević A, Stefanović N, Pavlović I, Pavlović D, Živanović S, Kundalić A, Veličković‐Radovanović R, Mitić B. Utility of salivary mycophenolic acid concentration monitoring: Modeling and Monte Carlo validation approach. Pharmacol Res Perspect 2022; 10:e01034. [PMID: 36440680 PMCID: PMC9703583 DOI: 10.1002/prp2.1034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/20/2022] [Accepted: 11/06/2022] [Indexed: 11/29/2022] Open
Abstract
The results of the previous studies demonstrated an association between mycophenolic acid (MPA) exposure, serum albumin level (ALB), and adverse effects in kidney transplant patients. The aim was the identification of mathematical correlation and association between both, total and unbound MPA concentration in relation to ALB, body mass (BM), age and estimated glomerular filtration rate (eGFR) in stable kidney transplant recipients. Furthermore, investigation was conducted with the aim to clarify the role of salivary concentration (CSAL ) of MPA in adverse effect profile. In order to analyze the association between total and salivary concentration of MPA in relation to ALB, BM, age and eGFR, a least squares method for determining the correlation between these parameters was performed. In addition, derived mathematical model based on experimental data can also be performed and simulated through the Monte Carlo (MC) approach. Adverse effects were grouped according to the nature of symptoms and scored by a previously published validated system. Numerically calculated values of CSAL from the models [CSAL = f(ALB, BM, age, eGFR, CP ) = a00 + a10 *(ALB, BM, age, eGFR) + a01 *CP ] were then compared with those from validation set of patients, where the best fitting model was for ALB [CSAL = 54.96-1.64*ALB +13.4*CP ]. Adverse effects estimation showed the difference in esthetic score, positively correlated with CSAL in the lower ALB group (145.41 ± 219.02 vs. 354.08 ± 262.19; with statistical significance p = .014) and almost significant for gastrointestinal score (167.69 ± 174.79 vs. 347.55 ± 320.95; p = .247). The study showed that CSAL MPA may contribute to management of adverse effects, but these findings require confirmation of clinical utility.
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Affiliation(s)
| | - Nikola Stefanović
- Faculty of Medicine, Department of PharmacyUniversity of NisNisSerbia
| | - Ivan Pavlović
- Faculty of Mechanical EngineeringUniversity of NisNisSerbia
| | - Dragana Pavlović
- Faculty of Medicine, Department of PharmacyUniversity of NisNisSerbia
| | - Slavoljub Živanović
- Faculty of Medicine, Research Center for BiomedicineUniversity of NisNisSerbia
| | - Ana Kundalić
- Faculty of Medicine, Department of PharmacyUniversity of NisNisSerbia
| | | | - Branka Mitić
- Faculty of MedicineUniversity of NisNisSerbia
- Clinic of NephrologyUniversity Clinical Center NisNisSerbia
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16
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Individualization of Mycophenolic Acid Therapy through Pharmacogenetic, Pharmacokinetic and Pharmacodynamic Testing. Biomedicines 2022; 10:biomedicines10112882. [DOI: 10.3390/biomedicines10112882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 11/12/2022] Open
Abstract
Mycophenolic acid (MPA) is a widely used immunosuppressive agent and exerts its effect by inhibiting inosine 5′-monophosphate dehydrogenase (IMPDH), the main regulating enzyme of purine metabolism. However, significant unexplained differences in the efficacy and tolerability of MPA therapy pose a clinical challenge. Therefore, broad pharmacogenetic, pharmacokinetic, and pharmacodynamic approaches are needed to individualize MPA therapy. In this prospective cohort study including 277 renal transplant recipients, IMPDH2 rs11706052 SNP status was assessed by genetic sequencing, and plasma MPA trough levels were determined by HPLC and IMPDH enzyme activity in peripheral blood mononuclear cells (PBMCs) by liquid chromatography–mass spectrometry. Among the 277 patients, 84 were identified with episodes of biopsy-proven rejection (BPR). No association was found between rs11706052 SNP status and graft rejection (OR 1.808, and 95% CI, 0.939 to 3.479; p = 0.076). Furthermore, there was no association between MPA plasma levels and BPR (p = 0.69). However, the patients with graft rejection had a significantly higher predose IMPDH activity in PBMCs compared to the controls without rejection at the time of biopsy (110.1 ± 50.2 vs. 95.2 ± 45.4 pmol/h; p = 0.001), and relative to the baseline IMPDH activity before transplantation (p = 0.042). Our results suggest that individualization of MPA therapy, particularly through pharmacodynamic monitoring of IMPDH activity in PBMCs, has the potential to improve the clinical outcomes of transplant patients.
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17
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Population Pharmacokinetics of Enteric-Coated Mycophenolate Sodium in Children after Renal Transplantation and Initial Dosage Recommendation Based on Body Surface Area. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:1881176. [PMID: 36124167 PMCID: PMC9482478 DOI: 10.1155/2022/1881176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/21/2022] [Accepted: 08/12/2022] [Indexed: 11/29/2022]
Abstract
Objective Enteric-coated mycophenolate sodium (EC-MPS) is widely used in renal transplant recipients. There is a lack of study on the pharmacokinetics of this drug in children. This study is aimed at developing a population pharmacokinetic model of mycophenolic acid in children who were treated with EC-MPS after renal transplantation and to recommend initial dosage. Methods Pediatric patients who had undergone renal transplantation and received EC-MPS were included. Data on demographic characteristics, biochemical tests, blood routine examinations, mycophenolic acid plasma concentrations, dosing amount and frequency of EC-MPS, and coadministered medications were retrospective collected from June 2018 to August 2019. Nonlinear mixed effect modeling methods were adopted to develop a population pharmacokinetic model with the data above. Additional data from September 2019 to July 2020 were used to validate the model. Simulations under different dosage regimen were conducted to evaluate the percentage of target attainment (PTA, AUC0-12h 30–60 mg·h/L). Results A total of 96 pediatric patients aged at 13.3 (range 4.3–18.0) years were included in the modeling group. Data from 32 patients aged at 13.0 (range 3.6–18.3) years were used to validate the model. A one-compartment model with a double extravascular absorption was developed. Body surface area (BSA) was added as a covariate. Simulations showed that for different dosing regimens, the highest percentage of target attainment is around 50%. The best dosing regimen is 180 mg every 48 hours for patients with BSA of 0.22–0.46 m2, 180 mg every 24 hours with BSA of 0.47–0.67 m2, 180 mg every 24 hours with BSA of 0.68–0.96 m2, 360 mg every 24 hours with BSA of 0.97–1.18 m2, 540 mg every 24 hours with BSA of 1.19–1.58 m2, and 360 mg every 12 hours with BSA of 1.59–2.03 m2. Conclusion BSA could affect the area under curve of mycophenolic acid with the administration of EC-MPS. Considering the inflexibility of the dosage form, future development of smaller amount per tablet suitable for younger children with BSA < 1.19 m2 is warranted.
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18
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Huang YJ, Lin CH, Yang HY, Luo SF, Kuo CF. Urine Soluble CD163 Is a Promising Biomarker for the Diagnosis and Evaluation of Lupus Nephritis. Front Immunol 2022; 13:935700. [PMID: 35911758 PMCID: PMC9329951 DOI: 10.3389/fimmu.2022.935700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/16/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Urine-soluble CD163 (usCD163) is released from alternatively activated macrophages involved in the resolution of inflammation in glomeruli and plays an important role in glomerulonephritis. This study explored the role of usCD163 in patients with systemic lupus erythematosus (SLE). Materials and Methods usCD163 concentrations were measured cross-sectionally in 261 SLE patients in Taiwan. Clinical and laboratory data were collected, and SLE disease activity scores were calculated to assess the correlation with usCD163. Results SLE patients with high usCD163 levels tended to be younger, with a higher hospital admission rate, higher prednisolone dose, lower estimated glomerular filtration rate, higher urine protein creatinine ratio (UPCR), more pyuria and hematuria, higher levels of inflammatory markers, higher rates of anemia, neutropenia, and lymphopenia, lower complement 3 (C3) levels, higher anti-double-stranded DNA antibody (anti-dsDNA Ab) levels, and higher disease activity scores (p < 0.05). usCD163 levels were significantly higher in patients with active lupus nephritis (LN) than in those with extrarenal or inactive SLE and correlated with UPCR, disease activity, and anti-dsDNA Ab levels. SLE patients with high usCD163 levels tended to have a higher chronic kidney disease stage. Discussion and conclusion The usCD163 level correlates with the severity of LN and disease activity in renal SLE.
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Affiliation(s)
- Yun-Ju Huang
- School of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Chiung-Hung Lin
- School of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Division of Thoracic medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Huang-Yu Yang
- Division of Nephrology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Shue-Fen Luo
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Chang-Fu Kuo
- School of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- *Correspondence: Chang-Fu Kuo,
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19
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Wang P, Xie H, Zhang Q, Tian X, Feng Y, Qin Z, Yang J, Shang W, Feng G, Zhang X. Population Pharmacokinetics of Mycophenolic Acid in Renal Transplant Patients: A Comparison of the Early and Stable Posttransplant Stages. Front Pharmacol 2022; 13:859351. [PMID: 35614937 PMCID: PMC9126255 DOI: 10.3389/fphar.2022.859351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/22/2022] [Indexed: 11/13/2022] Open
Abstract
Mycophenolic acid (MPA) is an antimetabolic immunosuppressive drug widely used in solid organ transplantation and autoimmune diseases. Pharmacokinetics (PK) of MPA demonstrates high inter- and intra-variability. The aim of this study was to compare the population PK properties of MPA in adult renal transplant patients in the early and stable post-transplant stages and to simulate an optimal dosing regimen for patients at different stages. A total of 51 patients in the early post-transplant period (1 week after surgery) and 48 patients in the stable state (5.5–10 years after surgery) were included in the study. In the two-compartment population PK model, CL/F (23.36 L/h vs. 10.25 L/h) and V/F (78.07 vs. 16.24 L) were significantly different between the two stages. The dose-adjusted area under the concentration time curve (AUCss,12h/dose) for patients in the early stage were significantly lower than those for patients in the stable state (40.83 ± 22.26 mg h/L vs. 77.86 ± 21.34 mg h/L; p < 0.001). According to Monte Carlo simulations, patients with 1.0–1.5 g of mycophenolate mofetil twice daily in the early phase and 0.50–0.75 g twice daily in the stable phase had a high probability of achieving an AUCss,12h of 30–60 mg h/L. In addition, limited sampling strategies showed that two 4-point models (C0-C1-C2-C4 and C1-C2-C3-C6) performed well in predicting MPA exposure by both Bayesian estimate and regression equation and could be applied in clinical practice to assist therapeutic drug monitoring of MPA.
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Affiliation(s)
- Peile Wang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Hongchang Xie
- Department of Kidney Transplantation, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qiwen Zhang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Xueke Tian
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Yi Feng
- Department of Kidney Transplantation, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zifei Qin
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Jing Yang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Wenjun Shang
- Department of Kidney Transplantation, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guiwen Feng
- Department of Kidney Transplantation, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Guiwen Feng, ; Xiaojian Zhang,
| | - Xiaojian Zhang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
- *Correspondence: Guiwen Feng, ; Xiaojian Zhang,
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20
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Nanga TM, Woillard JB, Rousseau A, Marquet P, Prémaud A. Population Pharmacokinetics And Bayesian Estimation of Mycophenolate Mofetil In Patients With Autoimmune Hepatitis. Br J Clin Pharmacol 2022; 88:4732-4741. [PMID: 35514220 DOI: 10.1111/bcp.15389] [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: 10/25/2021] [Revised: 03/15/2022] [Accepted: 04/25/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Mycophenolate mofetil (MMF) is the most widely used second-line agent in auto-immune hepatitis (AIH). Individual dose adjustment of MMF may avoid adverse outcomes while maximizing efficacy. The aim of the present study was to develop population pharmacokinetic (popPK) models and Maximum A-Posteriori Bayesian estimators (MAP-BEs) to estimate MPA inter-dose area under the curve (AUC0-12h ) in AIH patients administered MMF using nonlinear mixed effect modelling. METHODS We analyzed 50 MPA PK profiles from 34 different patients, together with some demographic, clinical, and laboratory test data. The median number of plasma samples per profile, immediately preceding and following the morning MMF dose, was 7 [4 - 10]. PopPK modeling was performed using parametric, top-down, nonlinear mixed effect modelling with NONMEM 7.3. MAP-BEs were developed based on the best popPK model and the best limited sampling strategy (LSS) selected among several. RESULTS The pharmacokinetic data were best described by a 2-compartment model, Erlang distribution to describe the absorption phase, and a proportional error. The mean (RSE) of popPK parameter estimates of clearance, intercompartmental clearance, central volume and absorption rate with the final model were: 21.6 L.h-1 (11%), 22.7 L.h-1 (19%), 35.9 L (21%) and 8.7 h-1 (9%), respectively. The peripheral volume was fixed to 300 L. The best MAP-BE relied on the LSS at 0.33, 1 and 3 hours after mycophenolate mofetil dose administration and was very accurate (bias=5.6%) and precise (RMSE<20%). CONCLUSION The precise and accurate Bayesian estimator developed in this study for AIH patients on MMF can be used to improve the therapeutic management of these patients.
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Affiliation(s)
- Tom M Nanga
- Pharmacology & Transplantation, UMR1248, INSERM, University of Limoges, Limoges, France
| | - Jean-Baptiste Woillard
- Pharmacology & Transplantation, UMR1248, INSERM, University of Limoges, Limoges, France.,Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, Limoges, France
| | - Annick Rousseau
- Pharmacology & Transplantation, UMR1248, INSERM, University of Limoges, Limoges, France
| | - Pierre Marquet
- Pharmacology & Transplantation, UMR1248, INSERM, University of Limoges, Limoges, France.,Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, Limoges, France
| | - Aurélie Prémaud
- Pharmacology & Transplantation, UMR1248, INSERM, University of Limoges, Limoges, France
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21
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Wang X, Wu Y, Huang J, Shan S, Mai M, Zhu J, Yang M, Shang D, Wu Z, Lan J, Zhong S, Wu M. Estimation of Mycophenolic Acid Exposure in Heart Transplant Recipients by Population Pharmacokinetic and Limited Sampling Strategies. Front Pharmacol 2021; 12:748609. [PMID: 34867352 PMCID: PMC8640522 DOI: 10.3389/fphar.2021.748609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/14/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: The aim of this study is i) to establish a strategy to estimate the area under the curve of the dosing interval (AUC0-12h) of mycophenolic acid (MPA) in the heart transplant recipients and ii) to find the covariates that significantly affect the pharmacokinetics of MPA exposure. Methods: This single-center, prospective, open-label, observational study was conducted in 91 adult heart transplant recipients orally taking mycophenolate mofetil dispersible tablets. Samples collected intensively and sparsely were analyzed by the enzyme-multiplied immunoassay technique, and all the data were used in PPK modeling. Potential covariates were tested stepwise. The goodness-of-fit plots, the normalized prediction distribution error, and prediction-corrected visual predictive check were used for model evaluation. Optimal sampling times by ED-optimal strategy and multilinear regression (MLR) were analyzed based on the simulated data by the final PPK model. Moreover, using intensive data from 14 patients, the accuracy of AUC0-12h estimation was evaluated by Passing-Bablok regression analysis and Bland-Alman plots for both the PPK model and MLR equation. Results: A two-compartment model with first-order absorption and elimination with a lag time was chosen as the structure model. Co-medication of proton pump inhibitors (PPIs), estimated glomerular filtration rate (eGFR), and albumin (ALB) were found to significantly affect bioavailability (F), clearance of central compartment (CL/F), and the distribution volume of the central compartment (V2/F), respectively. Co-medication of PPIs decreased F by 27.6%. When eGFR decreased by 30 ml/min/1.73 m2, CL/F decreased by 23.7%. However, the impact of ALB on V2/F was limited to MPA exposure. The final model showed an adequate fitness of the data. The optimal sampling design was pre-dose and 1 and 4 h post-dose for pharmacokinetic estimation. The best-fit linear equation was finally established as follows: AUC0-12h = 3.539 × C0 + 0.288 × C0.5 + 1.349 × C1 + 6.773 × C4.5. Conclusion: A PPK model was established with three covariates in heart transplant patients. Co-medication of PPIs and eGFR had a remarkable impact on AUC0-12h of MPA. A linear equation was also concluded with four time points as an alternative way to estimate AUC0-12h for MPA.
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Affiliation(s)
- Xipei Wang
- Research Center of Medical Sciences, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yijin Wu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jinsong Huang
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Songgui Shan
- Department of Pharmacy, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Mingjie Mai
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jiade Zhu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Min Yang
- Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Dewei Shang
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zheng Wu
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou, China
| | - Jinhua Lan
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou, China
| | - Shilong Zhong
- Department of Pharmacy, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangzhou, China
| | - Min Wu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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22
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Cossart AR, Staatz CE, Gorham G, Barraclough KA. Comparison of free plasma versus saliva mycophenolic acid exposure following mycophenolate mofetil administration in adult kidney transplant recipients. Clin Biochem 2021; 100:78-81. [PMID: 34800491 DOI: 10.1016/j.clinbiochem.2021.11.008] [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: 08/15/2021] [Revised: 11/09/2021] [Accepted: 11/13/2021] [Indexed: 11/24/2022]
Abstract
Therapeutic monitoring (TDM) of mycophenolic acid (MPA) has the potential to improve drug inefficacy and toxicities in kidney transplantation. However, measurement of plasma MPA concentrations is laborious and invasive. This study examined the utility of saliva compared with plasma based TDM of MPA. Paired blood and saliva samples were collected from 47 adult kidney transplant recipients pre- and at 1-, 2-, and 4-hours post mycophenolate mofetil administration. No relationship was observed between saliva MPA concentrations and either total or free plasma MPA concentrations (p > 0.05). This suggests that saliva is a poor direct marker of plasma MPA concentrations and therefore should not be used for MPA TDM.
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Affiliation(s)
- Amelia R Cossart
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia.
| | - Christine E Staatz
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
| | - Gillian Gorham
- Menzies School of Health, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Katherine A Barraclough
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia
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23
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Sobiak J, Głyda M, Malec M, Chrzanowska M. Pharmacokinetics of Mycophenolate Mofetil Metabolites in Older Patients on the Seventh Day After Renal Transplantation. Transplant Proc 2021; 53:2212-2215. [PMID: 34412913 DOI: 10.1016/j.transproceed.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Currently, immunosuppression schemes are age-independent; however, physiological changes may alter drugs' pharmacokinetics in the older population. We compared mycophenolic acid (MPA) and its glucuronide metabolite (MPAG) pharmacokinetics among patients aged <60 and >60 years on the seventh day after renal transplantation. METHODS We included 7 and 10 renal transplant recipients, aged >60 and <60 years, respectively, treated with mycophenolate mofetil. MPA and MPAG concentrations were determined using the high-performance liquid chromatography method with ultraviolet detection (HPLC-UV). Noncompartmental pharmacokinetic analysis was performed. RESULTS In patients aged >60 years, mean MPA and MPAG concentrations before the next dose and ratio of MPAG area under the concentration-time curve (AUC0-12) to MPA AUC0-12 were higher by 1.6-fold, 1.4-fold, and 1.9-fold, respectively. Other MPAG concentrations appeared to be slightly higher (1.2- to 1.5-fold) in older patients. MPA apparent clearance was similar in both groups, whereas volume of distribution at steady state was slightly higher (1.6-fold) in patients aged >60 years. The variability of most MPA and some MPAG pharmacokinetics was greater in patients aged >60 years. The MPA AUC0-12 target was achieved in 40% and 14% of patients aged <60 and >60 years, respectively. The highest MPAG concentrations and AUC0-12 were observed for patients with the lowest glomerular filtration rate. CONCLUSIONS Higher variability of MPA and MPAG pharmacokinetic parameters, MPA AUC0-12 above the reference range, higher values of MPAG pharmacokinetics in patients with lower glomerular filtration rates, as well as lower proportion of patients achieving MPA targets all indicate the need for therapeutic drug monitoring in renal transplant recipients aged >60 years and to verify target MPA AUC0-12 for this population.
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Affiliation(s)
- J Sobiak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland.
| | - M Głyda
- Department of Transplantology and General Surgery, Poznań District Hospital, Poznań, Poland; Department of Hepatobiliary and General Surgery, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - M Malec
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
| | - M Chrzanowska
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
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24
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Barrett JS, Barrett RF, Vinks AA. Status Toward the Implementation of Precision Dosing in Children. J Clin Pharmacol 2021; 61 Suppl 1:S36-S51. [PMID: 34185896 DOI: 10.1002/jcph.1830] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/04/2021] [Indexed: 01/19/2023]
Abstract
Precision dosing is progressing beyond the conceptual and proof-of-concept stages toward implementation. As the availability of dosing algorithms, tools, and platforms increases, so do the investment in technology services and actual implementation of clinical services offering these solutions to patients. Nowhere is this needed more than in pediatric populations, which are still reliant on adult drug development and bridging strategies to support dosing, often in the absence of actual dose-finding studies in the target pediatric population. Still, there is more work to be done to ensure that proper governance of these services is maintained, and that sustainability of these early implementations is guided by new science as it evolves and meaningful outcome data to confirm that such services deliver on both clinical and economic return on investment. In addition, the field should ensure that all approaches beyond a therapeutic drug monitoring-driven, pharmacokinetic-centric approach should be considered as the tools and services evolve, especially when pediatric-specific pharmacokinetic/pharmacodyamic and pharmacogenetic data are available and shown to be useful to guide dosing. This review evaluates current pediatric precision dosing efforts, highlighting their utility, longevity, and sustainability and assesses the current process for implementing such approaches examining current barriers that stand in the way of broader implementation and the stakeholders that must engage to ensure its ultimate success.
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Affiliation(s)
- Jeffrey S Barrett
- Quantitative Medicine, Critical Path Institute, Tucson, Arizona, USA
| | - Ryan F Barrett
- College of Chemical and Biological Engineering, Drexel University, Philadelphia, Pennsylvania, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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25
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Therapeutic drug monitoring of immunosuppressive drugs in hepatology and gastroenterology. Best Pract Res Clin Gastroenterol 2021; 54-55:101756. [PMID: 34874840 DOI: 10.1016/j.bpg.2021.101756] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/11/2021] [Indexed: 01/31/2023]
Abstract
Immunosuppressive drugs have been key to the success of liver transplantation and are essential components of the treatment of inflammatory bowel disease (IBD) and autoimmune hepatitis (AIH). For many but not all immunosuppressants, therapeutic drug monitoring (TDM) is recommended to guide therapy. In this article, the rationale and evidence for TDM of tacrolimus, mycophenolic acid, the mammalian target of rapamycin inhibitors, and azathioprine in liver transplantation, IBD, and AIH is reviewed. New developments, including algorithm-based/computer-assisted immunosuppressant dosing, measurement of immunosuppressants in alternative matrices for whole blood, and pharmacodynamic monitoring of these agents is discussed. It is expected that these novel techniques will be incorporate into the standard TDM in the next few years.
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26
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Na Takuathung M, Sakuludomkan W, Koonrungsesomboon N. The Impact of Genetic Polymorphisms on the Pharmacokinetics and Pharmacodynamics of Mycophenolic Acid: Systematic Review and Meta-analysis. Clin Pharmacokinet 2021; 60:1291-1302. [PMID: 34105062 DOI: 10.1007/s40262-021-01037-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Mycophenolic acid (MPA) is among the most commonly prescribed medications for immunosuppression following organ transplantation. Highly variable MPA exposure and drug response are observed among individuals receiving the same dosage of the drug. Identification of candidate genes whose polymorphisms could be used to predict MPA exposure and clinical outcome is of clinical value. OBJECTIVES This study aimed to determine the impact of genetic polymorphisms on the pharmacokinetics and pharmacodynamics of MPA in humans by means of a systematic review and meta-analysis. METHODS A systematic search was conducted on PubMed, EMBASE, Web of Sciences, Scopus, and the Cochrane Library databases. A meta-analysis was conducted to determine any associations between genetic polymorphisms and pharmacokinetic or pharmacodynamic parameters of MPA. Pooled-effect estimates were calculated by means of the random-effects model. RESULTS A total of 37 studies involving 3844 individuals were included in the meta-analysis. Heterozygous carriers of the UGT1A9 -275T>A polymorphism were observed to have a significantly lower MPA exposure than wild-type individuals. Four single nucleotide polymorphisms (SNPs), namely UGT1A9 -2152C>T, UGT1A8 518C>G, UGT2B7 211G>T, and SLCO1B1 521T>C, were also significantly associated with altered MPA pharmacokinetics. However, none of the investigated SNPs, including SNPs in the IMPDH gene, were found to be associated with the clinical efficacy of MPA. The only SNP that was associated with adverse outcomes was SLCO1B3 344T>G. CONCLUSIONS The present systematic review and meta-analysis identified six SNPs that were significantly associated with pharmacokinetic variability or adverse effects of MPA. Our findings represent the basis for future research and clinical implications with regard to the role of pharmacogenetics in MPA pharmacokinetics and drug response.
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Affiliation(s)
- Mingkwan Na Takuathung
- Department of Pharmacology, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Road, Sriphoom, Muang, Chiang Mai, 50200, Thailand
| | - Wannachai Sakuludomkan
- Department of Pharmacology, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Road, Sriphoom, Muang, Chiang Mai, 50200, Thailand
| | - Nut Koonrungsesomboon
- Department of Pharmacology, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Road, Sriphoom, Muang, Chiang Mai, 50200, Thailand.
- Musculoskeletal Science and Translational Research (MSTR) Center, , Chiang Mai University, Muang, Chiang Mai, Thailand.
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27
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Woillard JB, Assikar S, Monchaud C, Couraud A, Marquet P, Bédane C. Towards therapeutic drug monitoring of mycophenolic acid in mucous membrane pemphigoid: A retrospective single-centre study. Fundam Clin Pharmacol 2021; 35:1179-1187. [PMID: 33914391 DOI: 10.1111/fcp.12688] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/31/2021] [Accepted: 04/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mycophenolate mofetil (MMF) is theoretically a treatment of choice for mucous membrane pemphigoid (MMP), due to its good long-term tolerance and efficacy especially in elderly patients. However, no therapeutic monitoring is currently performed despite its large inter-individual variability. OBJECTIVES The aim of this study was to investigate the exposure/effect relationship based on the area under the curve (AUC) or trough level of mycophenolic acid in MMP patients. METHODS Thirteen patients (n = 29 AUC measurements performed between February 2013 and November 2016) treated for MMP at Limoges University Hospital were evaluated using the Mucous Membrane Pemphigoid Disease Area Index score, and patients were classified as improvement (>50% decrease vs. baseline) vs. stabilisation (<50%) or non-response (no improvement). AUC was estimated using a population pharmacokinetic model and Bayesian estimation. The association between exposure parameters, demographic variables and response group was investigated using time-dependent Cox models, and an AUC threshold for 'improvement' was also investigated. RESULTS An improvement was observed in approximately 70% of the patients. Only the MPA AUC0-24 h was retained in the multivariate analysis with a decreased risk of stabilisation/non-response per 10 mg*h/L increase, (HR = 0.64, 95% CI = [0.43-0.94], P = 0.0038). That led to an AUC0-24 h threshold of 89 mg*h/L associated with excellent performances (AUC ROC = 0.828, Sen = 75%, Spe = 100%, P = 0.0001). DISCUSSION/CONCLUSION An association between MPA exposure and disease was observed. Therapeutic drug monitoring can be proposed with an AUC0-24 h threshold of 89 mg*h/L. It might improve the long-term response of patients to this drug with better tolerance than rituximab or cyclophosphamide.
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Affiliation(s)
- Jean-Baptiste Woillard
- INSERM U1248 IPPRITT, Univ. Limoges, Limoges, France.,Department of Pharmacology and Toxicology, CHU Limoges, Limoges, France
| | - Safae Assikar
- INSERM U1248 IPPRITT, Univ. Limoges, Limoges, France.,Department of Dermatology, CHU Limoges, National Reference Center for Bullous Diseases, Limoges, France
| | - Caroline Monchaud
- INSERM U1248 IPPRITT, Univ. Limoges, Limoges, France.,Department of Pharmacology and Toxicology, CHU Limoges, Limoges, France
| | - Amélie Couraud
- Department of Dermatology, CHU Limoges, National Reference Center for Bullous Diseases, Limoges, France
| | - Pierre Marquet
- INSERM U1248 IPPRITT, Univ. Limoges, Limoges, France.,Department of Pharmacology and Toxicology, CHU Limoges, Limoges, France
| | - Christophe Bédane
- INSERM U1248 IPPRITT, Univ. Limoges, Limoges, France.,Department of Dermatology, CHU Limoges, National Reference Center for Bullous Diseases, Limoges, France
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28
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Le suivi des patients greffés. ACTUALITES PHARMACEUTIQUES 2021. [DOI: 10.1016/j.actpha.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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29
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Bergan S, Brunet M, Hesselink DA, Johnson-Davis KL, Kunicki PK, Lemaitre F, Marquet P, Molinaro M, Noceti O, Pattanaik S, Pawinski T, Seger C, Shipkova M, Swen JJ, van Gelder T, Venkataramanan R, Wieland E, Woillard JB, Zwart TC, Barten MJ, Budde K, Dieterlen MT, Elens L, Haufroid V, Masuda S, Millan O, Mizuno T, Moes DJAR, Oellerich M, Picard N, Salzmann L, Tönshoff B, van Schaik RHN, Vethe NT, Vinks AA, Wallemacq P, Åsberg A, Langman LJ. Personalized Therapy for Mycophenolate: Consensus Report by the International Association of Therapeutic Drug Monitoring and Clinical Toxicology. Ther Drug Monit 2021; 43:150-200. [PMID: 33711005 DOI: 10.1097/ftd.0000000000000871] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/29/2021] [Indexed: 12/13/2022]
Abstract
ABSTRACT When mycophenolic acid (MPA) was originally marketed for immunosuppressive therapy, fixed doses were recommended by the manufacturer. Awareness of the potential for a more personalized dosing has led to development of methods to estimate MPA area under the curve based on the measurement of drug concentrations in only a few samples. This approach is feasible in the clinical routine and has proven successful in terms of correlation with outcome. However, the search for superior correlates has continued, and numerous studies in search of biomarkers that could better predict the perfect dosage for the individual patient have been published. As it was considered timely for an updated and comprehensive presentation of consensus on the status for personalized treatment with MPA, this report was prepared following an initiative from members of the International Association of Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT). Topics included are the criteria for analytics, methods to estimate exposure including pharmacometrics, the potential influence of pharmacogenetics, development of biomarkers, and the practical aspects of implementation of target concentration intervention. For selected topics with sufficient evidence, such as the application of limited sampling strategies for MPA area under the curve, graded recommendations on target ranges are presented. To provide a comprehensive review, this report also includes updates on the status of potential biomarkers including those which may be promising but with a low level of evidence. In view of the fact that there are very few new immunosuppressive drugs under development for the transplant field, it is likely that MPA will continue to be prescribed on a large scale in the upcoming years. Discontinuation of therapy due to adverse effects is relatively common, increasing the risk for late rejections, which may contribute to graft loss. Therefore, the continued search for innovative methods to better personalize MPA dosage is warranted.
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Affiliation(s)
- Stein Bergan
- Department of Pharmacology, Oslo University Hospital and Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Mercè Brunet
- Pharmacology and Toxicology Laboratory, Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBERehd, Spain
| | - Dennis A Hesselink
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Kamisha L Johnson-Davis
- Department of Pathology, University of Utah Health Sciences Center and ARUP Laboratories, Salt Lake City, Utah
| | - Paweł K Kunicki
- Department of Drug Chemistry, Faculty of Pharmacy, Medical University of Warsaw, Warszawa, Poland
| | - Florian Lemaitre
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, Rennes, France
| | - Pierre Marquet
- INSERM, Université de Limoges, Department of Pharmacology and Toxicology, CHU de Limoges, U1248 IPPRITT, Limoges, France
| | - Mariadelfina Molinaro
- Clinical and Experimental Pharmacokinetics Lab, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Ofelia Noceti
- National Center for Liver Tansplantation and Liver Diseases, Army Forces Hospital, Montevideo, Uruguay
| | | | - Tomasz Pawinski
- Department of Drug Chemistry, Faculty of Pharmacy, Medical University of Warsaw, Warszawa, Poland
| | | | - Maria Shipkova
- Synlab TDM Competence Center, Synlab MVZ Leinfelden-Echterdingen GmbH, Leinfelden-Echterdingen, Germany
| | - Jesse J Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Teun van Gelder
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy and Department of Pathology, Starzl Transplantation Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eberhard Wieland
- Synlab TDM Competence Center, Synlab MVZ Leinfelden-Echterdingen GmbH, Leinfelden-Echterdingen, Germany
| | - Jean-Baptiste Woillard
- INSERM, Université de Limoges, Department of Pharmacology and Toxicology, CHU de Limoges, U1248 IPPRITT, Limoges, France
| | - Tom C Zwart
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Markus J Barten
- Department of Cardiac- and Vascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Maja-Theresa Dieterlen
- Department of Cardiac Surgery, Heart Center, HELIOS Clinic, University Hospital Leipzig, Leipzig, Germany
| | - Laure Elens
- Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics (PMGK) Research Group, Louvain Drug Research Institute (LDRI), Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Vincent Haufroid
- Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut de Recherche Expérimentale et Clinique, UCLouvain and Department of Clinical Chemistry, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Satohiro Masuda
- Department of Pharmacy, International University of Health and Welfare Narita Hospital, Chiba, Japan
| | - Olga Millan
- Pharmacology and Toxicology Laboratory, Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBERehd, Spain
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Dirk J A R Moes
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Michael Oellerich
- Department of Clinical Pharmacology, University Medical Center Göttingen, Georg-August-University Göttingen, Göttingen, Germany
| | - Nicolas Picard
- INSERM, Université de Limoges, Department of Pharmacology and Toxicology, CHU de Limoges, U1248 IPPRITT, Limoges, France
| | | | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Nils Tore Vethe
- Department of Pharmacology, Oslo University Hospital and Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Alexander A Vinks
- Department of Pharmacy, International University of Health and Welfare Narita Hospital, Chiba, Japan
| | - Pierre Wallemacq
- Clinical Chemistry Department, Cliniques Universitaires St Luc, Université Catholique de Louvain, LTAP, Brussels, Belgium
| | - Anders Åsberg
- Department of Transplantation Medicine, Oslo University Hospital-Rikshospitalet and Department of Pharmacy, University of Oslo, Oslo, Norway; and
| | - Loralie J Langman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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Population Pharmacokinetic Model of Plasma and Cellular Mycophenolic Acid in Kidney Transplant Patients from the CIMTRE Study. Drugs R D 2021; 20:331-342. [PMID: 33025511 PMCID: PMC7691413 DOI: 10.1007/s40268-020-00319-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background and Objective Mycophenolate mofetil is widely used in kidney transplant recipients. Mycophenolate mofetil is hydrolysed by blood esterases to mycophenolic acid (MPA), the active drug. Although MPA therapeutic drug monitoring has been recommended to optimise the treatment efficacy by the area under the plasma concentration vs time curve, little is known regarding MPA concentrations in peripheral blood mononuclear cells, where MPA inhibits inosine monophosphate dehydrogenase. This study aimed to build a pharmacokinetic model using a population approach to describe MPA total and unbound concentrations in plasma and into peripheral blood mononuclear cells in 78 adult kidney transplant recipients receiving mycophenolate mofetil therapy combined with tacrolimus and prednisone. Methods Total and unbound plasma concentrations and peripheral blood mononuclear cell concentrations were assayed. A three-compartment model, two for plasma MPA and one for peripheral blood mononuclear cell MPA, with a zero-order absorption and a first-order elimination was used to describe the data. Results Mycophenolic acid average concentrations in peripheral blood mononuclear cells were well above half-maximal effective concentration for inosine monophosphate dehydrogenase and no relationship was found with the occurrence of graft rejection. Three covariates affected unbound and intracellular MPA pharmacokinetics: creatinine clearance, which has an effect on unbound MPA clearance, human serum albumin, which influences fraction unbound MPA and the ABCB1 3435 C>T (rs1045642) genetic polymorphism, which has an effect on MPA efflux transport from peripheral blood mononuclear cells. Conclusion This population pharmacokinetic model demonstrated the intracellular accumulation of MPA, the efflux of MPA out of the cells being dependent on P-glycoprotein transporters. Nevertheless, further studies are warranted to investigate the relevance of MPA concentrations in peripheral blood mononuclear cells to dosing regimen optimisation. Electronic supplementary material The online version of this article (10.1007/s40268-020-00319-y) contains supplementary material, which is available to authorized users.
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Klotsman M, Sathyan G, Anderson WH. Single-dose pharmacokinetics of mycophenolic acid following administration of immediate-release mycophenolate mofetil in healthy Beagle dogs. J Vet Pharmacol Ther 2021; 44:650-656. [PMID: 33580714 DOI: 10.1111/jvp.12950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/10/2021] [Accepted: 01/19/2021] [Indexed: 02/06/2023]
Abstract
Mycophenolic acid (MPA) is an immunomodulating agent commonly used in human medicine for the treatment of immune-mediated diseases. There is growing evidence that the immunomodulating properties of mycophenolate mofetil (MMF), a prodrug of MPA, are therapeutically beneficial for the treatment of immune-mediated diseases in dogs. A narrow therapeutic index and high inter-and intra-patient pharmacokinetic (PK) variability complicate the use of MMF. A better characterization of MPA pharmacokinetics is needed to help establish dosing regimens and standardized treatment protocols for canine patients. The purpose of this study was to evaluate the pharmacokinetics of MPA in dogs. MMF oral suspension (10 mg/kg) was administered to five healthy beagle dogs. Serial blood samples were collected from 0 to 18 hours after administration. The simultaneous quantification of MPA, and its metabolites MPA-7-O-glucuronide (MPAG), and acyl glucuronide (AcMPAG) was determined by liquid chromatography (LC)-mass spectrometry (MS)/MS. MPA peak concentrations were achieved rapidly (median Tmax of 0.5 h). Concentrations fell through 3 hours post-dose and then plateaued around 20% of Cmax. The mean elimination half-life was rapid (5.8 hours) and notable variability was observed in all PK parameters. The PK profiles for the MPAG and AcMPAG metabolites followed a similar pattern as MPA concentration. Future repeat-dose studies will be needed to evaluate steady-state PK parameters and to define therapeutic MPA dose levels.
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Affiliation(s)
| | | | - Wayne H Anderson
- Okava Pharmaceuticals, San Francisco, CA, USA.,Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Mycophenolic acid area under the concentration-time curve is associated with therapeutic response in childhood-onset lupus nephritis. Pediatr Nephrol 2021; 36:341-347. [PMID: 32856157 DOI: 10.1007/s00467-020-04733-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 07/15/2020] [Accepted: 07/28/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Mycophenolic acid (MPA), the active compound of mycophenolate mofetil (MMF), is widely used in lupus nephritis treatment. Therapeutic drug monitoring of adults suggests that area under the concentration-time curve (AUC) of MPA (MPA-AUC) is associated with clinical outcomes, but childhood data are scarce. METHODS Retrospective study of 27 children with biopsy-proven lupus nephritis treated with MMF between 2008 and 2016. In 25 children, MPA-AUC was performed within 6 months after kidney biopsy and MMF initiation. Treatment response at 6 months was defined as normal or improved GFR by 25% compared with baseline, 50% reduction of proteinuria to < 0.5 g/day or 50 mg/mmol, and no hematuria. RESULTS A total of 62 MPA-AUC were analyzed in 27 patients. Overall median was 44 mg h/L (interquartile range [IQR] 33-54). Individual dose adaptation was required in 32 cases (52%) to achieve target AUC of 30-60 mg h/L. At 6 months, 14/25 patients were defined as responders (56%, median MPA-AUC 49 mg h/L (40-59)) and 11/25 as non-responders (44%, 29 mg h/L (24-38)). Patients with MPA-AUC levels > 45, 30-45, and < 30 mg h/L had 6-month response rates of 89% (8/9), 60% (6/10), and 0% (0/6), respectively. In a logistic regression model adjusted for age, sex, lupus nephritis classification, and time since MMF initiation, an MPA-AUC > 45 mg h/L was significantly associated with therapeutic response (OR 3.6, 95% CI 2.4-9.5, p = 0.03). CONCLUSIONS Therapeutic drug monitoring leading to individualized dosing may improve efficacy of MMF. MPA-AUC > 45 mg h/L is associated with better response rate and may be considered as a target value in pediatric lupus nephritis.
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Legendre P, Blanchet B, Porcher R, Bérezné A, Allard M, London J, Terrier B, Cohen P, Le Jeunne C, Mouthon L. Mycophenolic acid drug monitoring in patients with systemic sclerosis associated with diffuse skin and/or pulmonary involvement: A monocentric and retrospective French study. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2021; 6:87-95. [PMID: 35382246 PMCID: PMC8922638 DOI: 10.1177/2397198320944342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 06/24/2020] [Indexed: 11/10/2023]
Abstract
OBJECTIVE To explore pharmacokinetic/pharmacodynamic relationship between mycophenolic acid area under the curve and clinical response at 1 year on skin involvement or interstitial lung disease in patients with systemic sclerosis. METHOD Retrospective, monocentric study based on French Scleroderma Database in patients receiving mycophenolate mofetil who experienced a limited sampling strategy to estimate individual mycophenolic acid area under the curve plus two pulmonary function tests and skin evaluation after 1 month and 1 year. Efficacy criterions were variations of modified Rodnan skin score, forced vital capacity, and diffusing lung capacity for carbon monoxide at 1 year. RESULTS We included 52 patients; mean age was 49 years (range 17-79), and 36 (69%) were females. Fifty patients (96%) had skin sclerosis, 39 (75%) had diffuse skin involvement with a median modified Rodnan skin score of 14 (0-38). Thirty-eight (76%) had interstitial lung disease, with median forced vital capacity and diffusing lung capacity for carbon monoxide of 81% (37-127) and 56% (28-103) from predicted values, respectively. Twenty-five (51%) patients had pulmonary fibrosis. Mycophenolate mofetil was given for 10 months (0-173) at a median dose of 2000 mg/day (500-3000). In the entire population, no relationship was found between area under the curve and modified Rodnan skin score (p = 0.085), forced vital capacity (p = 0.80), or diffusing lung capacity for carbon monoxide (p = 0.72) variations at 1 year. CONCLUSION In this retrospective study, we failed to document any relationship between mycophenolic acid area under the curve and skin involvement or interstitial lung disease evolution. Routine monitoring of mycophenolic acid in systemic sclerosis patients treated with mycophenolate mofetil cannot be recommended based on our results.
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Affiliation(s)
- Paul Legendre
- Service de Médecine Interne, Hôpital Cochin, Centre de Référence pour les Maladies Systémiques Autoimmunes Rares d'Ile de France, DHU Authors, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Benoit Blanchet
- UF de Pharmacocinétique et Pharmacochimie, Hôpital Cochin, AP-HP, Paris, France
- UMR8638 CNRS, Pharmacy UFR, University of Paris Descartes, PRES Sorbonne Paris Cité, Paris, France
- RAPIDEM (Research on Autoimmune Disease for Personalized Medicine), Paris, France
| | - Raphael Porcher
- Centre d'Epidémiologie Clinique, Hôpital Hôtel-Dieu, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Descartes, Paris, France
| | - Alice Bérezné
- Service de Médecine Interne, Hôpital Cochin, Centre de Référence pour les Maladies Systémiques Autoimmunes Rares d'Ile de France, DHU Authors, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Marie Allard
- UF de Pharmacocinétique et Pharmacochimie, Hôpital Cochin, AP-HP, Paris, France
| | - Jonathan London
- Service de Médecine Interne, Hôpital Cochin, Centre de Référence pour les Maladies Systémiques Autoimmunes Rares d'Ile de France, DHU Authors, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Benjamin Terrier
- Service de Médecine Interne, Hôpital Cochin, Centre de Référence pour les Maladies Systémiques Autoimmunes Rares d'Ile de France, DHU Authors, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- RAPIDEM (Research on Autoimmune Disease for Personalized Medicine), Paris, France
| | - Pascal Cohen
- Service de Médecine Interne, Hôpital Cochin, Centre de Référence pour les Maladies Systémiques Autoimmunes Rares d'Ile de France, DHU Authors, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Claire Le Jeunne
- Service de Médecine Interne, Hôpital Cochin, Centre de Référence pour les Maladies Systémiques Autoimmunes Rares d'Ile de France, DHU Authors, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Luc Mouthon
- Service de Médecine Interne, Hôpital Cochin, Centre de Référence pour les Maladies Systémiques Autoimmunes Rares d'Ile de France, DHU Authors, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris Descartes, Paris, France
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Klotsman M, Coquery S, Sathyan G, Naageshwaran V, Shivanand P, Fairchild AJ, Garden OA, Anderson WH. Pharmacokinetics and Pharmacodynamics of Immediate- and Modified-Release Mycophenolic Acid Preparations in Healthy Beagle Dogs. Front Vet Sci 2021; 7:611404. [PMID: 33585601 PMCID: PMC7876310 DOI: 10.3389/fvets.2020.611404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/22/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Mycophenolic acid (MPA) is a broad-acting immunomodulating agent that may be therapeutically beneficial for the treatment of immune-mediated diseases in canine patients. Objectives: To determine the suppressive effects of MPA on T-cell proliferation, and to assess the feasibility of a canine-specific q24 h modified-release MPA formulation (OKV-1001b). Animals: Fifteen healthy purpose-bred male beagle dogs. Methods: Two nearly identical open-label fifteen-day studies were conducted in which dogs were randomized to receive mycophenolate mofetil (MMF; 10 mg/kg q12h), or two doses of OKV-1001b (270 mg and 180 mg; q24h). Serial pharmacokinetic (PK) and pharmacodynamic (PD) samples were collected on Days 1, 8, and 15. MPA plasma concentrations were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS), while an ex vivo T-cell proliferation assay assessed PD effects. Dogs were continuously monitored for evidence of side effects and gastrointestinal tolerability. Results: MPA induced inhibition of T-cell proliferation was observed following administration of all MPA preparations in a clear concentration-dependent manner. The PK/PD relationship was maintained across all days and time-points. Data generated herein suggest that MPA plasma concentrations above 600 ng/mL achieve at least 50% inhibition of T-cell proliferation. Conclusions and Clinical Importance: MPA holds therapeutic potential for treating dogs with immune-mediated disease, but clinical trials will be necessary to determine its safety and efficacy in naturally occurring disease. Likewise, q24h oral modified release MPA preparations that maintain MPA plasma concentrations between 600 and 1,000 ng/mL are warranted for further studies in client-owned dogs.
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Affiliation(s)
| | | | | | | | | | - Amanda J Fairchild
- Department of Psychology, University of South Carolina, Columbia, SC, United States
| | - Oliver A Garden
- Clinical Sciences and Advanced Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, PA, United States
| | - Wayne H Anderson
- Okava Pharmaceuticals, San Francisco, CA, United States.,Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Lassailly G, Dumortier J, Saint-Marcoux F, El Amrani M, Boulanger J, Boleslawski E, Millet G, Ningarhari M, Truant S, Canva V, Goria O, Boillot O, Louvet A, Mathurin P, Lebuffe G, Pruvot FR, Marquet P, Dharancy S. Real life experience of mycophenolate mofetil monotherapy in liver transplant patients. Clin Res Hepatol Gastroenterol 2021; 45:101451. [PMID: 32536555 DOI: 10.1016/j.clinre.2020.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/23/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Mycophenolate mofetil (MMF) monotherapy following liver transplantation (LT) remains controversial due to a risk of acute rejection. The aim of this study was to report the largest multicenter experience of the use a MMF monotherapy guided by therapeutic drug monitoring using pharmacoslope modeling and Bayesian estimations of the MPA inter-dose AUC (BEAUCMPA) before withdrawing calcineurin inhibitors (CNI) and to evaluate the benefit of MMF monotherapy. METHODS MMF daily doses were adjusted to reach the BEAUCMPA target of 45μg.h/mL. Then CNI were withdrawn and patients were followed on liver test and clinical outcomes. MAIN FINDINGS From 2000-2014, in 2 transplantation centers, 94 liver transplant recipients received MMF monotherapy 6.5±4 years after LT. The mean BEAUCMPA was 45.5±16μg.h/mL. During follow-up, 4 patients experienced acute rejection (4%). During the first year, estimated glomerular filtration rate (eGFR) improved from 46.2±10.5 to 49.1±11.5mL/kg/min (P=0.025). Benefit persisted at year 5. In patients with metabolic syndrome, eGFR did not improve. CONCLUSION MMF monotherapy regimen appears usually safe and beneficial, with low risk of acute rejection and eGFR improvement. Therapeutic drug monitoring strategy seemed useful by identifying 14% of patients with low MMF exposure.
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Affiliation(s)
- Guillaume Lassailly
- Maladies Appareil Digestif, pole médico-chirurgical, Hôpital Huriez CHU Lille, Inserm U995, Université de Lille, France
| | - Jerome Dumortier
- Fédération des Spécialités Digestives, Hôpital Edouard Herriot, Hospices civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Franck Saint-Marcoux
- Département de Pharmacologie Toxicologie, CHU Limoges, Limoges, Inserm UMR 850, Université Limoges, Limoges, France
| | - Medhi El Amrani
- Département de Chirurgie Digestive et de Transplantation, pole médico-chirurgical, Hôpital Huriez CHU Lille, Université de Lille, Lille, France
| | - Juliette Boulanger
- Maladies Appareil Digestif, pole médico-chirurgical, Hôpital Huriez CHU Lille, Inserm U995, Université de Lille, France
| | - Emmanuel Boleslawski
- Département de Chirurgie Digestive et de Transplantation, pole médico-chirurgical, Hôpital Huriez CHU Lille, Université de Lille, Lille, France
| | - Guillaume Millet
- Département de Chirurgie Digestive et de Transplantation, pole médico-chirurgical, Hôpital Huriez CHU Lille, Université de Lille, Lille, France
| | - Massih Ningarhari
- Maladies Appareil Digestif, pole médico-chirurgical, Hôpital Huriez CHU Lille, Inserm U995, Université de Lille, France
| | - Stephanie Truant
- Département de Chirurgie Digestive et de Transplantation, pole médico-chirurgical, Hôpital Huriez CHU Lille, Université de Lille, Lille, France
| | - Valérie Canva
- Maladies Appareil Digestif, pole médico-chirurgical, Hôpital Huriez CHU Lille, Inserm U995, Université de Lille, France
| | - Odile Goria
- Département d'Hépato-gastroentérologie, Hôpital Charles Nicolle, CHU Rouen, Rouen, France
| | - Olivier Boillot
- Fédération des Spécialités Digestives, Hôpital Edouard Herriot, Hospices civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Alexandre Louvet
- Maladies Appareil Digestif, pole médico-chirurgical, Hôpital Huriez CHU Lille, Inserm U995, Université de Lille, France
| | - Philippe Mathurin
- Maladies Appareil Digestif, pole médico-chirurgical, Hôpital Huriez CHU Lille, Inserm U995, Université de Lille, France
| | - Gilles Lebuffe
- Département d'Hépato-gastroentérologie, Hôpital Charles Nicolle, CHU Rouen, Rouen, France
| | - François-René Pruvot
- Département de Chirurgie Digestive et de Transplantation, pole médico-chirurgical, Hôpital Huriez CHU Lille, Université de Lille, Lille, France
| | - Pierre Marquet
- Département de Pharmacologie Toxicologie, CHU Limoges, Limoges, Inserm UMR 850, Université Limoges, Limoges, France
| | - Sébastien Dharancy
- Maladies Appareil Digestif, pole médico-chirurgical, Hôpital Huriez CHU Lille, Inserm U995, Université de Lille, France.
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Chen Y, Sun L, Xu H, Dong M, Mizuno T, Vinks AA, Brunner HI, Li Y, Li Z. PK/PD Study of Mycophenolate Mofetil in Children With Systemic Lupus Erythematosus to Inform Model-Based Precision Dosing. Front Pharmacol 2020; 11:605060. [PMID: 33488386 PMCID: PMC7819284 DOI: 10.3389/fphar.2020.605060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/27/2020] [Indexed: 11/20/2022] Open
Abstract
Objectives: To evaluate the mycophenolic acid [MPA, the active form of mycophenolate mofetil (MMF)] pharmacokinetic parameters in relation to clinical response to identify target exposure ranges in pediatric patients with systemic lupus erythematosus (SLE). Methods: This was a retrospective study using pharmacokinetic data collected in 67 pediatric patients aged 4–18 years with SLE. Target MPA exposures for effective inhibition of SLE activity (as measured by SLE disease Activity Index (SLEDAI), active SLE was defined as a SLEDAI score of ≥6, and a controlled disease was defined as a SLEDAI score of ≤4) were assessed by receiver operating characteristic (ROC) curve and logistic regression. Exposure-response models were developed to quantitatively describe the relationship between SLEDAI score and AUC0–12 or Ctrough, respectively. Results: The MPA AUC0-12 in patients with active SLE was significantly lower than that in patients with inactive SLE. ROC analysis revealed that an AUC0–12 threshold of 39 μg h/ml or a Ctrough of 1.01 μg/ml was associated with the lowest risk of active SLE. Logistic regression analysis revealed that an AUC0–12 of less than 34 μg h/ml or a Ctrough of less than 1.2 μg/ml probably is associated with active SLE. The results of the exposure-response modeling also indicated that an AUC0-12 less than 32 μg h/ml or a Ctrough less than 1.1 μg/ml was associated with suboptimal clinical outcome. An AUC0-12 above 50 μg h/ml or a Ctrough above 1.7 ug/ml was associated with disease control. Conclusion: Both AUC0–12 and Ctrough of MPA are predictive of the likelihood of active SLE in pediatric patients receiving MMF. An individualized dosing regimen of MMF, with a target AUC0–12 or Ctrough, should be considered for SLE patients.
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Affiliation(s)
- Yewei Chen
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
| | - Li Sun
- Division of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Hong Xu
- Division of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Min Dong
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
| | - Hermine I Brunner
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States.,Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Yifan Li
- Division of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Zhiping Li
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
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Weber S, Tombelli S, Giannetti A, Trono C, O'Connell M, Wen M, Descalzo AB, Bittersohl H, Bietenbeck A, Marquet P, Renders L, Orellana G, Baldini F, Luppa PB. Immunosuppressant quantification in intravenous microdialysate - towards novel quasi-continuous therapeutic drug monitoring in transplanted patients. Clin Chem Lab Med 2020; 59:935-945. [PMID: 33554521 DOI: 10.1515/cclm-2020-1542] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/06/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Therapeutic drug monitoring (TDM) plays a crucial role in personalized medicine. It helps clinicians to tailor drug dosage for optimized therapy through understanding the underlying complex pharmacokinetics and pharmacodynamics. Conventional, non-continuous TDM fails to provide real-time information, which is particularly important for the initial phase of immunosuppressant therapy, e.g., with cyclosporine (CsA) and mycophenolic acid (MPA). METHODS We analyzed the time course over 8 h of total and free of immunosuppressive drug (CsA and MPA) concentrations measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS) in 16 kidney transplant patients. Besides repeated blood sampling, intravenous microdialysis was used for continuous sampling. Free drug concentrations were determined from ultracentrifuged EDTA-plasma (UC) and compared with the drug concentrations in the respective microdialysate (µD). µDs were additionally analyzed for free CsA using a novel immunosensor chip integrated into a fluorescence detection platform. The potential of microdialysis coupled with an optical immunosensor for the TDM of immunosuppressants was assessed. RESULTS Using LC-MS/MS, the free concentrations of CsA (fCsA) and MPA (fMPA) were detectable and the time courses of total and free CsA comparable. fCsA and fMPA and area-under-the-curves (AUCs) in µDs correlated well with those determined in UCs (r≥0.79 and r≥0.88, respectively). Moreover, fCsA in µDs measured with the immunosensor correlated clearly with those determined by LC-MS/MS (r=0.82). CONCLUSIONS The new microdialysis-supported immunosensor allows real-time analysis of immunosuppressants and tailor-made dosing according to the AUC concept. It readily lends itself to future applications as minimally invasive and continuous near-patient TDM.
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Affiliation(s)
- Susanne Weber
- Institute of Clinical Chemistry and Pathobiochemistry, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Sara Tombelli
- Institute of Applied Physics "Nello Carrara", National Research Council, Sesto Fiorentino (FI), Italy
| | - Ambra Giannetti
- Institute of Applied Physics "Nello Carrara", National Research Council, Sesto Fiorentino (FI), Italy
| | - Cosimo Trono
- Institute of Applied Physics "Nello Carrara", National Research Council, Sesto Fiorentino (FI), Italy
| | | | - Ming Wen
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Ana B Descalzo
- Department of Organic Chemistry, Universidad Complutense de Madrid, Madrid, Spain
| | - Heike Bittersohl
- Institute of Clinical Chemistry and Pathobiochemistry, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Andreas Bietenbeck
- Institute of Clinical Chemistry and Pathobiochemistry, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Pierre Marquet
- U1248 IPPRITT, INSERM, University of Limoges, Limoges, CHU Limoges, France
| | - Lutz Renders
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.,German Centre for Infection Research (DZIF), Munich, Germany
| | - Guillermo Orellana
- Department of Organic Chemistry, Universidad Complutense de Madrid, Madrid, Spain
| | - Francesco Baldini
- Institute of Applied Physics "Nello Carrara", National Research Council, Sesto Fiorentino (FI), Italy
| | - Peter B Luppa
- Institute of Clinical Chemistry and Pathobiochemistry, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Sobiak J, Głyda M, Chrzanowska M. Pharmacokinetics of Enteric-Coated Mycophenolate Sodium Metabolites in Patients Over 60 Years Old Within the First Year After Renal Transplantation. Transplant Proc 2020; 53:1001-1004. [PMID: 33246587 DOI: 10.1016/j.transproceed.2020.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/01/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVE It is still unclear whether mycophenolic acid (MPA) doses should be adjusted for older patients. Therefore, we compared the pharmacokinetics of MPA, mycophenolic acid glucuronide (MPAG), and free MPA (fMPA) between older and younger renal transplant recipients. METHODS We included 12 patients <60 years and 6 patients >60 years within the first year after renal transplantation, who were receiving enteric-coated mycophenolate sodium, tacrolimus, and steroids. Blood samples were collected up to 12 hours after drug administration. RESULTS MPA and fMPA pharmacokinetics were similar for patients <60 and >60 years; however, the MPA area under the concentration-time curve from 0 to 12 hours (AUC0-12) was 1.2-fold lower in the older patients. MPAG pharmacokinetics were more than 1.5-fold higher in patients >60 years, which might be related to deteriorated renal function in older people. Moreover, the mean (MPAG AUC0-12)/(MPA AUC0-12) ratio was more than 2-fold higher in patients >60 years. The second maximal MPA concentration was more frequently observed in patients <60 years, although all patients received tacrolimus. The percentage of patients with MPA concentration before the next drug dose (Ctrough) and AUC0-12 within and below target was the same in both groups. All patients >60 years had MPA AUC0-12 >30 μg·h/mL within 22 to 114 days after transplantation. CONCLUSIONS MPA therapeutic monitoring should be recommended in enteric-coated mycophenolate sodium--treated patients >60 years because MPA AUC0-12 exceeded the recommended value in half of the studied patients.
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Affiliation(s)
- J Sobiak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland.
| | - M Głyda
- Department of Transplantology and General Surgery, Poznań District Hospital, Poznań, Poland; Department of Hepatobiliary and General Surgery, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - M Chrzanowska
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
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Ehren R, Schijvens AM, Hackl A, Schreuder MF, Weber LT. Therapeutic drug monitoring of mycophenolate mofetil in pediatric patients: novel techniques and current opinion. Expert Opin Drug Metab Toxicol 2020; 17:201-213. [PMID: 33107768 DOI: 10.1080/17425255.2021.1843633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Introduction: Mycophenolate mofetil (MMF) is an ester prodrug of the immunosuppressant mycophenolic acid (MPA) and is recommended and widely used for maintenance immunosuppressive therapy in solid organ and stem-cell transplantation as well as in immunological kidney diseases. MPA is a potent, reversible, noncompetitive inhibitor of the inosine monophosphate dehydrogenase (IMPDH), a crucial enzyme in the de novo purine synthesis in T- and B-lymphocytes, thereby inhibiting cell-mediated immunity and antibody formation. The use of therapeutic drug monitoring (TDM) of MMF is still controversial as outcome data of clinical trials are equivocal. Areas covered: This review covers in great depth the existing literature on TDM of MMF in the field of pediatric (kidney) transplantation. In addition, the relevance of TDM in immunological kidney diseases, in particular childhood nephrotic syndrome is highlighted. Expert opinion: TDM of MMF has the potential to optimize therapy in pediatric transplantation as well as in nephrotic syndrome. Limited sampling strategies to estimate MPA exposure increase its feasibility. Future perspectives rather encompass approaches reflecting total immunosuppressive load than single drug TDM.
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Affiliation(s)
- Rasmus Ehren
- Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, University of Cologne , Cologne, Germany
| | - Anne M Schijvens
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center , Nijmegen, The Netherlands
| | - Agnes Hackl
- Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, University of Cologne , Cologne, Germany
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center , Nijmegen, The Netherlands
| | - Lutz T Weber
- Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, University of Cologne , Cologne, Germany
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40
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Liu Y, Liu L, Li J, Fu Q, Zhang H, Wu C, Li J, Zhong G, Zheng Y, Chen X, Wang C, Chen P. Validated LC-MS/MS method for quantitation of total and free mycophenolic acid concentration and its application to a pharmacokinetic study in pediatric renal transplant recipients. Biomed Chromatogr 2020; 35:e4989. [PMID: 32959916 DOI: 10.1002/bmc.4989] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/01/2020] [Accepted: 09/12/2020] [Indexed: 12/30/2022]
Abstract
A simple and sensitive LC-MS/MS method was established to quantify total and free mycophenolic acid (MPA) plasma concentrations during immunosuppressive medication for pediatric renal transplantation. The chromatographic separation was performed with the Hypersil GOLD C18 column, using a mobile phase consisting of 0.1% formic acid in water and acetonitrile (60:40, v/v) at an isocratic flow rate of 0.4 ml/min. An Agilent 6420 triple quadrupole mass spectrometer was operated via a positive electrospray ionization interface using the transitions m/z 321.14 → 206.9 for MPA and m/z 324.15 → 209.9 for MPA-d3 (internal standard). The linearity was 0.1-50 μg/ml for total MPA and 0.0025-0.5 μg/ml for free MPA. The within-run and between-run precisions were all <5% and accuracy was within 96.23-107.63%. The validated method was successfully aspplied to a pharmacokinetic study in 28 pediatric renal recipients. The mean free fraction of MPA in our patients was 0.89% (ranging from 0.62 to 1.25%) and albumin level played a major role in the variability of free fraction of MPA, thus, in pediatric patients with hypoproteinemia, close free drug monitoring and dose adjustments should be considered to prevent toxicity.
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Affiliation(s)
- Yan Liu
- Department of Pharmacy, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Department of Pharmacy, the Third Affiliated Hospital of Nanchang University, Nanchang, China
| | - Longshan Liu
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jingjie Li
- Reproductive medicine center, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qian Fu
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huanxi Zhang
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chenglin Wu
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jun Li
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Guoping Zhong
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, China
| | - Yifan Zheng
- Department of Pharmacy, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiao Chen
- Department of Pharmacy, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Changxi Wang
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory on Organ Donation and Transplant Immunology, Guangzhou, China
| | - Pan Chen
- Department of Pharmacy, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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41
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Tenório JR, Tuma M, Martins F, Ortega KL, Cristelli M, Gallottini M. Diagnosis and management of oral ulcerations associated with mycophenolate mofetil in kidney transplantation. SPECIAL CARE IN DENTISTRY 2020; 40:605-610. [PMID: 32950040 DOI: 10.1111/scd.12522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/22/2020] [Accepted: 08/26/2020] [Indexed: 11/28/2022]
Abstract
AIMS The final diagnosis of oral mucosal ulcerations in solid organ transplant recipients represents a challenge. We describe a unique case of oral ulceration related to mycophenolate mofetil (MMF) toxicity, 11 years after kidney transplantation, whose dose reduction was sufficient to resolve it. METHODS AND RESULTS A 54-year-old female patient, who underwent kidney transplantation 11 years ago, presents multiple ulcers on the buccal mucosa bilaterally, soft palate and tongue dorsum, for 8 months, with moderate pain. The diagnosis of oral ulcerations associated with MMF therapy was assumed by excluding infection and malignancy diagnosis. After MMF dose reduction, the oral ulcers healed utterly. CONCLUSIONS MMF toxicity manifested as oral ulcers. Reduction or discontinuation of MMF therapy should be considered in a patient with refractory oral ulcers and a negative workup for other causes.
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Affiliation(s)
- Jefferson R Tenório
- Special Care Dentistry Center, School of Dentistry of the University of São Paulo, São Paulo, Brazil
| | - Marina Tuma
- Special Care Dentistry Center, School of Dentistry of the University of São Paulo, São Paulo, Brazil
| | - Fabiana Martins
- Special Care Dentistry Center, School of Dentistry of the University of São Paulo, São Paulo, Brazil.,Dental School, University of Santo Amaro, São Paulo, Brazil
| | - Karem L Ortega
- Special Care Dentistry Center, School of Dentistry of the University of São Paulo, São Paulo, Brazil
| | - Marina Cristelli
- Department of Nephrologist, Oswaldo Ramos Foundation Kidney Hospital, São Paulo, Brazil
| | - Marina Gallottini
- Special Care Dentistry Center, School of Dentistry of the University of São Paulo, São Paulo, Brazil
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Wang G, Ye Q, Huang Y, Lu J, Xu H, Li Z. Population pharmacokinetics of mycophenolic acid in pediatric patients with juvenile dermatomyositis and optimization of limited sampling strategy. Xenobiotica 2020; 51:167-176. [PMID: 32903096 DOI: 10.1080/00498254.2020.1819579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Juvenile dermatomyositis (JDM) is a rare systemic autoimmune disease specifically affecting children. Mycophenolate mofetil (MMF) is an immunosuppressant used to treat JDM. Mycophenolic acid (MPA) is an active metabolite of MMF. This study aimed to develop a population pharmacokinetic (PPK) model of MPA in children with JDM and optimize the limited sampling strategy (LSS). Fifteen JDM patients treated with MMF, at a median age of 7.35 (range, 3.09-16.1) years, were included. Blood samples were collected at 30 minutes pre-dose, 20 minutes, 60 minutes and 180 minutes post-dose to measure the MPA concentrations. Data were retrospectively collected from the electronic medical records. A two-compartment model with first-order absorption, lag time in absorption, and first-order elimination was developed. Height and co-administered cotrimoxazole were added as the covariates to the model. Concentrations at different time points were simulated and area under the concentration-time curve (AUC0-12 h) was calculated. By removing one sampling point at a time, AUC0-12 h from three-point sampling strategy was re-calculated via Bayesian approach. AUC0-12 h from the three-point sampling strategy (by removing the point at 20 minutes post-dose) had the strongest correlation with AUC0-12 h from the four-point sampling strategy (Pearson's r = 0.971).
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Affiliation(s)
- Guangfei Wang
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Qiaofeng Ye
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Yidie Huang
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Jinmiao Lu
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Hong Xu
- Department of Nephrology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Zhiping Li
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
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43
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Pharmacologic Treatment of Transplant Recipients Infected With SARS-CoV-2: Considerations Regarding Therapeutic Drug Monitoring and Drug-Drug Interactions. Ther Drug Monit 2020; 42:360-368. [PMID: 32304488 PMCID: PMC7188032 DOI: 10.1097/ftd.0000000000000761] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
COVID-19 is a novel infectious disease caused by the severe acute respiratory distress (SARS)-coronavirus-2 (SARS-CoV-2). Several therapeutic options are currently emerging but none with universal consensus or proven efficacy. Solid organ transplant recipients are perceived to be at increased risk of severe COVID-19 because of their immunosuppressed conditions due to chronic use of immunosuppressive drugs (ISDs). It is therefore likely that solid organ transplant recipients will be treated with these experimental antivirals.
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44
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Labriffe M, Vaidie J, Monchaud C, Debord J, Turlure P, Girault S, Marquet P, Woillard JB. Population pharmacokinetics and Bayesian estimators for intravenous mycophenolate mofetil in haematopoietic stem cell transplant patients. Br J Clin Pharmacol 2020; 86:1550-1559. [PMID: 32073158 DOI: 10.1111/bcp.14261] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 11/12/2019] [Accepted: 12/11/2019] [Indexed: 01/13/2023] Open
Abstract
AIMS Intravenous mycophenolate mofetil (IV MMF), a prodrug of mycophenolic acid (MPA), is used during nonmyeloablative and reduced-intensity conditioning haematopoetic stem cell transplantation (HCT) to improve engraftment and reduce graft-versus-host disease. The aims of this study were to develop population pharmacokinetic models and Bayesian estimators based on limited sampling strategies to allow for individual dose adjustment of intravenous mycophenolate mofetil administered by infusion in haematopoietic stem cell transplant patients. METHODS Sixty-three MPA concentration-time profiles (median [min-max] = 6 [4-7] samples) were collected from 34 HCT recipients transplanted for 14 (1-45) days and administered IV MMF every 8 hours, concomitantly with cyclosporine. The database was split into development (75%) and validation (25%) datasets. Pharmacokinetic models characterized by a single compartment with first-order elimination, combined with two gamma distributions to describe the transformation of MMF into mycophenolic acid, were developed using in parallel nonparametric (Pmetrics) and parametric (ITSIM) approaches. The performances of the models and the derived Bayesian estimators were evaluated in the validation set. RESULTS The best limited sampling strategy led to a bias (min, max), root mean square error between observed and modeled interdose areas under the curve in the validation dataset of -11.72% (-31.08%, 5.00%), 14.9% for ITSIM and -2.21% (-23.40%, 30.01%), 12.4% for Pmetrics with three samples collected at 0.33, 2 and 3 hours post dosing. CONCLUSION Population pharmacokinetic models and Bayesian estimators for IV MMF in HCT have been developed and are now available online (https://pharmaco.chu-limoges.fr) for individual dose adjustment based on the interdose area under the curve.
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Affiliation(s)
- Marc Labriffe
- Department of Pharmacology and Toxicology, CHU Dupuytren, Limoges, France
| | - Julien Vaidie
- Department of Clinical Haematology and Cell Therapy, CHU Dupuytren, Limoges, France
| | - Caroline Monchaud
- Department of Pharmacology and Toxicology, CHU Dupuytren, Limoges, France.,INSERM UMR-S1248, University of Limoges, Limoges, France.,IPPRITT, University of Limoges, Limoges, France
| | - Jean Debord
- Department of Pharmacology and Toxicology, CHU Dupuytren, Limoges, France.,INSERM UMR-S1248, University of Limoges, Limoges, France.,IPPRITT, University of Limoges, Limoges, France
| | - Pascal Turlure
- Department of Clinical Haematology and Cell Therapy, CHU Dupuytren, Limoges, France
| | - Stephane Girault
- Department of Clinical Haematology and Cell Therapy, CHU Dupuytren, Limoges, France
| | - Pierre Marquet
- Department of Pharmacology and Toxicology, CHU Dupuytren, Limoges, France.,INSERM UMR-S1248, University of Limoges, Limoges, France.,IPPRITT, University of Limoges, Limoges, France
| | - Jean-Baptiste Woillard
- Department of Pharmacology and Toxicology, CHU Dupuytren, Limoges, France.,INSERM UMR-S1248, University of Limoges, Limoges, France.,IPPRITT, University of Limoges, Limoges, France
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45
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Tague LK, Scozzi D, Wallendorf M, Gage BF, Krupnick AS, Kreisel D, Byers D, Hachem R, Gelman AE. Lung transplant outcomes are influenced by severity of neutropenia and granulocyte colony-stimulating factor treatment. Am J Transplant 2020; 20:250-261. [PMID: 31452317 PMCID: PMC6940547 DOI: 10.1111/ajt.15581] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 08/01/2019] [Accepted: 08/10/2019] [Indexed: 01/25/2023]
Abstract
Although neutropenia is a common complication after lung transplant, its relationship with recipient outcomes remains understudied. We evaluated a retrospective cohort of 228 adult lung transplant recipients between 2008 and 2013 to assess the association of neutropenia and granulocyte colony-stimulating factor (GCSF) treatment with outcomes. Neutropenia was categorized as mild (absolute neutrophil count 1000-1499), moderate (500-999), or severe (<500) and as a time-varying continuous variable. Associations with survival, acute rejection, and chronic lung allograft dysfunction (CLAD) were assessed with the use of Cox proportional hazards regression. GCSF therapy impact on survival, CLAD, and acute rejection development was analyzed by propensity score matching. Of 228 patients, 101 (42.1%) developed neutropenia. Recipients with severe neutropenia had higher mortality rates than those of recipients with no (adjusted hazard ratio [aHR] 2.97, 95% confidence interval [CI] 1.05-8.41, P = .040), mild (aHR 14.508, 95% CI 1.58-13.34, P = .018), or moderate (aHR 3.27, 95% CI 0.89-12.01, P = .074) neutropenia. Surprisingly, GCSF treatment was associated with a higher risk for CLAD in mildly neutropenic patients (aHR 3.49, 95% CI 0.93-13.04, P = .063), although it did decrease death risk in severely neutropenic patients (aHR 0.24, 95% CI 0.07-0.88, P = .031). Taken together, our data point to an important relationship between neutropenia severity and GCSF treatment in lung transplant outcomes.
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Affiliation(s)
- Laneshia K. Tague
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri
| | - Davide Scozzi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St. Louis, Missouri
| | | | - Brian F. Gage
- Division of General Medical Sciences, Washington University, St. Louis, Missouri
| | - Alexander S. Krupnick
- Department of Surgery and Carter Center for Immunology, University of Virginia, Charlottesville, Virginia
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St. Louis, Missouri
| | - Derek Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri
| | - Ramsey Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri
| | - Andrew E. Gelman
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St. Louis, Missouri
- Department of Pathology & Immunology Washington University, St. Louis, Missouri
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46
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Silva R, Portela R, da Costa I, de Oliveira A, Woods D, de Oliveira C, Fonteles M, Beserra M. Immunosuppressives and enteral feeding tubes: An integrative review. J Clin Pharm Ther 2019; 45:408-418. [PMID: 31854065 DOI: 10.1111/jcpt.13093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/28/2019] [Accepted: 11/18/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Renan Silva
- Multidisciplinary Integrated Residence in Hospital Health Care—Transplant Care University Hospital Walter Cantídio Fortaleza Brazil
| | - Rosana Portela
- Multidisciplinary Integrated Residence in Hospital Health Care—Intensive Care University Hospital Walter Cantídio Fortaleza Brazil
| | - Iwyson da Costa
- Multidisciplinary Integrated Residence in Hospital Health Care—Transplant Care University Hospital Walter Cantídio Fortaleza Brazil
| | - Alene de Oliveira
- Clinical Pharmacy Service University Hospital Walter Cantídio Fortaleza Brazil
| | - David Woods
- School of Pharmacy Otago University Dunedin New Zealand
| | - Cristiani de Oliveira
- Postgraduate Program in Pharmaceutical Sciences Faculty of Pharmacy, Dentistry and Nursing Federal University of Ceará Fortaleza Brazil
| | - Marta Fonteles
- Postgraduate Program in Pharmaceutical Sciences Faculty of Pharmacy, Dentistry and Nursing Federal University of Ceará Fortaleza Brazil
| | - Milena Beserra
- Clinical Pharmacy Service University Hospital Walter Cantídio Fortaleza Brazil
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47
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Metz DK, Holford N, Kausman JY, Walker A, Cranswick N, Staatz CE, Barraclough KA, Ierino F. Optimizing Mycophenolic Acid Exposure in Kidney Transplant Recipients: Time for Target Concentration Intervention. Transplantation 2019; 103:2012-2030. [PMID: 31584924 PMCID: PMC6756255 DOI: 10.1097/tp.0000000000002762] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/29/2019] [Accepted: 04/03/2019] [Indexed: 12/24/2022]
Abstract
The immunosuppressive agent mycophenolate is used extensively in kidney transplantation, yet dosing strategy applied varies markedly from fixed dosing ("one-dose-fits-all"), to mycophenolic acid (MPA) trough concentration monitoring, to dose optimization to an MPA exposure target (as area under the concentration-time curve [MPA AUC0-12]). This relates in part to inconsistent results in prospective trials of concentration-controlled dosing (CCD). In this review, the totality of evidence supporting mycophenolate CCD is examined: pharmacological characteristics, observational data linking exposure to efficacy and toxicities, and randomized controlled trials of CCD, with attention to dose optimization method and exposure achieved. Fixed dosing of mycophenolate consistently leads to underexposure associated with rejection, as well as overexposure associated with toxicities. When CCD is driven by pharmacokinetic calculation to a target concentration (target concentration intervention), MPA exposure is successfully controlled and clinical benefits are seen. There remains a need for consensus on practical aspects of mycophenolate target concentration intervention in contemporary tacrolimus-containing regimens and future research to define maintenance phase exposure targets. However, given ongoing consequences of both overimmunosuppression and underimmunosuppression in kidney transplantation, impacting short- and long-term outcomes, these should be a priority. The imprecise "one-dose-fits-all" approach should be replaced by the clinically proven MPA target concentration strategy.
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Affiliation(s)
- David K. Metz
- Department of Nephrology, Royal Children’s Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
- Clinical Pharmacology Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Nick Holford
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Joshua Y. Kausman
- Department of Nephrology, Royal Children’s Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
| | - Amanda Walker
- Department of Nephrology, Royal Children’s Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
| | - Noel Cranswick
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
- Clinical Pharmacology Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
| | | | - Katherine A. Barraclough
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Francesco Ierino
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Department of Nephrology, St Vincent’s Health, Melbourne, VIC, Australia
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48
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Brooks E, Tett SE, Isbel NM, McWhinney B, Staatz CE. Investigation of the Association Between Total and Free Plasma and Saliva Mycophenolic Acid Concentrations Following Administration of Enteric-Coated Mycophenolate Sodium in Adult Kidney Transplant Recipients. Clin Drug Investig 2019; 39:1175-1184. [DOI: 10.1007/s40261-019-00844-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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49
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Abstract
The most recent comprehensive reviews on the population pharmacokinetics of mycophenolic acid (MPA) were published in 2014. Since then, several population pharmacokinetic studies on MPA have been published. The majority of literature is still focused on the kidney transplant population, although studies have also been conducted in liver and lung transplantation, autoimmune diseases, and hematopoietic stem cell transplant. While the majority of the model building is still based on parametric non-linear mixed-effects modeling, recent studies suggest the suitability of other methodologies. Additionally, instead of just focusing on pharmacokinetic modeling, a trend toward describing the relationships between pharmacokinetic and pharmacodynamic parameters is observed. Given the importance of enterohepatic recirculation (EHR) in the pharmacokinetics of MPA, more authors have attempted to characterize this process in their models. Overall, the recent models have become more sophisticated and incorporate EHR, pharmacodynamic relationships, and metabolites while maintaining many of the population values and covariates identified previously. However, the number of MPA population pharmacokinetic models describing the enteric-coated formulation of MPA (EC-MPA) is still limited. Given the increasing use of EC-MPA, more studies are needed to fill this literature gap. In addition, few studies are yet available characterizing free MPA concentration or MPA metabolites. Given the extensive protein binding, low to intermediate extraction, and intrinsic clearance characteristics of MPA in humans, including these variables would improve the population structural models.
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50
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Ezquer-Garin C, Ferriols-Lisart R, Alós-Almiñana M. Stability of mycophenolate mofetil in polypropylene 5% dextrose infusion bags and chemical compatibility associated with the use of the Equashield ® closed-system transfer device. Biomed Chromatogr 2019; 33:e4529. [PMID: 30845352 DOI: 10.1002/bmc.4529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 02/22/2019] [Accepted: 03/01/2019] [Indexed: 11/09/2022]
Abstract
Stability studies are necessary in healthcare settings as they facilitate fast, cost-effective and efficient work related to batch manufacturing and availability of supplies. We studied the stability of 1-10 mg/mL mycophenolate mofetil (MMF) in polypropylene 5% dextrose infusion bags prepared from Cellcept® and with a generic brand name (Micofenolato de Mofetilo Accord) at different storage temperatures. To ensure chemical compatibility during preparation, we also tested MMF sorption to the Equashield® closed-system drug transfer device used in this step. For this, a validated stability-indicating high-performance liquid chromatography method was developed for the quantification and identification of MMF in the infusion bags. The analytical selectivity of the assay was determined by subjecting an MMF sample to extreme values of pH, oxidative stress and heat conditions to force degradation. Protected from light, 1-10 mg/mL MMF in infusion polypropylene bags prepared from reconstituted Cellcept® 500 mg or Accord 500 mg in 5% dextrose was stable for at least 35 days when stored at 2-8°C or between -15 and -25°C, and for 14 days when stored at 25°C. MMF loss owing to chemical sorption to the Equashield® closed-system drug transfer device set was negligible.
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Affiliation(s)
- Carlos Ezquer-Garin
- Institute for Health Research (INCLIVA), Clinical University Hospital of Valencia, Spain
| | - Rafael Ferriols-Lisart
- Institute for Health Research (INCLIVA), Clinical University Hospital of Valencia, Spain.,Department of Pharmacy, University of Valencia, Valencia, Spain
| | - Manuel Alós-Almiñana
- Institute for Health Research (INCLIVA), Clinical University Hospital of Valencia, Spain.,Department of Pharmacy, University of Valencia, Valencia, Spain
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