1
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Ogura T, Shiraishi C, Urawa A. Analysis of death avoidance by concomitant use of prednisone in patients with renal transplant using the Food and Drug Administration Adverse Event Reporting System. Transpl Immunol 2023; 80:101900. [PMID: 37433397 DOI: 10.1016/j.trim.2023.101900] [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: 04/03/2023] [Revised: 07/04/2023] [Accepted: 07/07/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Patients with renal transplant are frequently administered immunosuppressants to prevent transplant-related adverse events. There are mainly nine immunosuppressants on the market, and multiple immunosuppressants are frequently administered for patients with renal transplant. Identifying which immunosuppressant was responsible when efficacy or safety was observed in patients taking multiple immunosuppressants is difficult. This study aimed to identify the immunosuppressant that was effective in reducing death in patients with renal transplant. A very large sample size was required to conduct prospective clinical trials of immunosuppressant combinations, which is impractical. We investigated cases wherein death occurred despite immunosuppressant administration in patients with renal transplant using Food and Drug Administration Adverse Event Reporting System (FAERS) data. MATERIAL AND METHOD We used FAERS data reported between January 2004 and December 2022 in patients with renal transplant who received one or more immunosuppressants. Groups were defined for each combination of immunosuppressants. Comparison between two identical groups except for the presence or absence of prednisone was performed using the reporting odds ratio (ROR) and the adjusted ROR (aROR) controlling for differences in patient background. RESULTS When the group without prednisone was set as the reference, the aROR for death was significantly <1.000 in several cases in the group to which prednisone was added. CONCLUSIONS The inclusion of prednisone in the immunosuppressant combinations was suggested to be effective in reducing death. We provided the sample code of software R that can reproduce the results.
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Affiliation(s)
- Toru Ogura
- Clinical Research Support Center, Mie University Hospital, 2-174 Edobashi, Tsu, Mie 514-8507, Japan.
| | - Chihiro Shiraishi
- Department of Pharmacy, Mie University Hospital, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Aiko Urawa
- Organ Transplantation Centre, Mie University Hospital, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
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2
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Božina T, Karačić E, Ganoci L, Čuković-Čavka S, Palić J, Božina N, Šimičević L. UGT2B7 c.-161C>T polymorphism frequency in Croatian population. Arh Hig Rada Toksikol 2022; 73:303-307. [PMID: 36607721 PMCID: PMC9985345 DOI: 10.2478/aiht-2022-73-3663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 05/01/2022] [Accepted: 11/01/2022] [Indexed: 01/07/2023] Open
Abstract
Uridine diphosphate glucuronosyltransferase-2B7 (UGT2B7), enzyme responsible for the elimination of a number of xenobiotics through glucuronidation, is expressed in the gut, kidneys, intestines, and brain. However, data on the frequency of UGT2B7 polymorphisms in the Croatian population are limited. The aim of this study was to assess the frequency of the UGT2B7 c.-161C>T (rs7668258) polymorphism in the Croatian population and to compare it with reported frequencies in other populations. This polymorphism is in complete linkage disequilibrium with the UGT2B7 c.802C>T (UGT2B7*2, rs7439366) variant, which is important in clinical medicine. The study reports data of 501 participants from University Hospital Centre Zagreb. All data were collected and analysed retrospectively. Genotyping was performed by real-time polymerase chain reaction (PCR) using the TaqMan® Drug Metabolism Genotyping Assay for UGT2B7 c.-161C>T (rs7668258). We found that 120 (23.95 %) participants were carriers of the UGT2B7 c.-161CC genotype and 255 (50.9 %) were heterozygous carriers (UGT2B7 c.-161CT), while 126 (25.15 %) were homozygous carriers of the variant allele (UGT2B7 c.-161TT). The frequency of the variant UGT2B7 c.-161C>T allele in this study was T=0.506. The frequency of the UGT2B7 c.-161C>T allelic variants and genotypes in the Croatian population is similar to other European populations.
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Affiliation(s)
- Tamara Božina
- University of Zagreb School of Medicine, Department of Medical Chemistry, Biochemistry, and Clinical Chemistry, Zagreb, Croatia
| | - Ena Karačić
- University of Zagreb Faculty of Pharmacy and Biochemistry, Zagreb, Croatia
| | - Lana Ganoci
- University Hospital Centre Zagreb, Division of Pharmacogenomics and Therapy Individualisation, Department of Laboratory Diagnostics, Zagreb, Croatia
| | - Silvija Čuković-Čavka
- University of Zagreb School of Medicine, University Hospital Centre Zagreb, Department of Gastroenterology, Zagreb, Croatia
| | - Jozefina Palić
- University of Zagreb School of Medicine, Department of Medical Chemistry, Biochemistry, and Clinical Chemistry, Zagreb, Croatia
| | - Nada Božina
- University of Zagreb School of Medicine, Department of Pharmacology, Zagreb, Croatia
| | - Livija Šimičević
- University Hospital Centre Zagreb, Division of Pharmacogenomics and Therapy Individualisation, Department of Laboratory Diagnostics, Zagreb, Croatia
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3
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van Gelder T. How cyclosporin reduces mycophenolic acid exposure by 40% while other calcineurin inhibitors do not. Kidney Int 2021; 100:1185-1189. [PMID: 34284043 DOI: 10.1016/j.kint.2021.06.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/08/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022]
Abstract
The most frequently used immunosuppressive treatment in kidney transplant recipients is the combination therapy of a calcineurin inhibitor and mycophenolate mofetil (MMF), with or without corticosteroids. Cyclosporin and tacrolimus are the two calcineurin inhibitors registered for this indication. Also in the treatment of glomerular diseases calcineurin inhibitors and mycophenolic acid are being used on a worldwide scale, either alone or as combined treatment. In January 2021 the U.S. Food and Drug Administration (FDA) has approved voclosporin, a novel calcineurin inhibitor for the treatment of adult patients with active lupus nephritis. There is a clinically relevant drug-drug interaction between cyclosporin and mycophenolate. As a result of cyclosporin-induced inhibition of the enterohepatic recirculation of mycophenolate, the mycophenolic acid-AUC is significantly lower (40%) in case of cyclosporin co-administration as compared to cotreatment with either tacrolimus or voclosporin (or no CNI co-treatment). The aim of this mini review is to summarize this potential drug-drug interaction and explain how cyclosporin affects the pharmacokinetics of mycophenolate. The optimal dose of MMF is likely to depend on the calcineurin inhibitor with which it is co-administered. Furthermore clinical implications are discussed, including the potential emergence of mycophenolic acid (MPA)-related side effects after discontinuation of cyclosporin co-treatment.
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Affiliation(s)
- Teun van Gelder
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands Albinusdreef 2 2333 ZA Leiden The Netherlands
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4
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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: 92] [Impact Index Per Article: 30.7] [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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5
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Initial mycophenolate dose in tacrolimus treated renal transplant recipients, a cohort study comparing leukopaenia, rejection and long-term graft function. Sci Rep 2020; 10:19379. [PMID: 33168923 PMCID: PMC7653942 DOI: 10.1038/s41598-020-76379-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/27/2020] [Indexed: 12/03/2022] Open
Abstract
The evidence supporting an initial mycophenolate mofetil (MMF) dose of 2 g daily in tacrolimus-treated renal transplant recipients is limited. In a non-contemporaneous single-centre cohort study we compared the incidence of leukopaenia, rejection and graft dysfunction in patients initiated on MMF 1.5 g and 2 g daily. Baseline characteristics and tacrolimus trough levels were similar by MMF group. MMF doses became equivalent between groups by 12-months post-transplant, driven by dose reductions in the 2 g group. Leukopaenia occurred in 42.4% of patients by 12-months post-transplant. MMF 2 g was associated with a 1.80-fold increased risk of leukopaenia compared to 1.5 g. Rejection occurred in 44.8% of patients by 12-months post-transplantation. MMF 2 g was associated with half the risk of rejection relative to MMF 1.5 g. Over the first 7-years post-transplantation there was no difference in renal function between groups. Additionally, the development of leukopaenia or rejection did not result in reduced renal function at 7-years post-transplant. Leukopaenia was not associated with an increased incidence of serious infections or rejection. This study demonstrates the initial MMF dose has implications for the incidence of leukopaenia and rejection. Since neither dose produced superior long-term graft function, clinical equipoise remains regarding the optimal initial mycophenolate dose in tacrolimus-treated renal transplant recipients.
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Gaied H, Bacha MM, Mesbahi T, Ounissi M, Aoudia R, Jerbi M, Jones M, Ksantini M, Rammeh S, Hedri H, Goucha R, Abdallah TB. Mycophenolate Mofetil-induced Oral Ulcerations in a Kidney Transplant Recipient. Curr Drug Saf 2019; 15:73-76. [PMID: 31660841 DOI: 10.2174/1574886314666191011153609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/16/2019] [Accepted: 09/17/2019] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Mycophenolate Mofetil (MMF) is an immunosuppressive drug usually used in kidney transplants to prevent rejection. It has various adverse effects such as leucopenia, anemia, diarrhea but Mouth ulcers are rarely reported. METHOD We present a case report of MMF-induced mouth ulcers in an African patient. CASE REPORT A 41-year-old African-male patient has painful oral ulcers which developed 5 months after kidney transplantation. The immunosuppressive maintenance regimen comprised Steroids, Tacrolimus and MMF. RESULT These ulcers were firstly related to a fungic or viral infection so the patient was prescribed Fluconazole and Aciclovir without any improvement. Then, Tacrolimus blood level was checked and it was in a therapeutic range. Finally, we decide to stop MMF and the ulcers healed quickly. DISCUSSION Oral ulcers are frequently seen complications in immunosuppressant patient but are rarely described with MMF. These ulcers can become large and very painful and degrade patient's life quality. So when infections causes are excluded, we have to keep in mind that these ulcers can be a drug adverse effect.
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Affiliation(s)
- Hanène Gaied
- Department of Nephrology, Mongi Slim Hospital, La Marsa, Tunisia.,Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia
| | - Mohamed Mongi Bacha
- Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia.,Department of Internal Medicine A, Charles Nicolle Hospital, Tunis, Tunisia
| | - Tasnim Mesbahi
- Department of Internal Medicine A, Charles Nicolle Hospital, Tunis, Tunisia
| | - Mondher Ounissi
- Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia.,Department of Internal Medicine A, Charles Nicolle Hospital, Tunis, Tunisia
| | - Raja Aoudia
- Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia.,Department of Internal Medicine A, Charles Nicolle Hospital, Tunis, Tunisia
| | - Mouna Jerbi
- Department of Nephrology, Mongi Slim Hospital, La Marsa, Tunisia.,Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia
| | - Mariem Jones
- Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia.,Department of Dermatology, Charles Nicolle Hospital, Tunis, Tunisia
| | - Mariem Ksantini
- Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia.,Laboratory of Histopathology, Charles Nicolle Hospital, Tunis, Tunisia
| | - Soumaya Rammeh
- Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia.,Laboratory of Histopathology, Charles Nicolle Hospital, Tunis, Tunisia
| | - Hafedh Hedri
- Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia.,Department of Internal Medicine A, Charles Nicolle Hospital, Tunis, Tunisia
| | - Rim Goucha
- Department of Nephrology, Mongi Slim Hospital, La Marsa, Tunisia.,Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia
| | - Taieb Ben Abdallah
- Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia.,Department of Internal Medicine A, Charles Nicolle Hospital, Tunis, Tunisia
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Colom H, Andreu F, van Gelder T, Hesselink DA, de Winter BCM, Bestard O, Torras J, Cruzado JM, Grinyó JM, Lloberas N. Prediction of Free from Total Mycophenolic Acid Concentrations in Stable Renal Transplant Patients: A Population-Based Approach. Clin Pharmacokinet 2019; 57:877-893. [PMID: 29159710 DOI: 10.1007/s40262-017-0603-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND A population pharmacokinetic (PK) protein-binding model was developed to (1) predict free mycophenolic acid (fMPA) based on total MPA (tMPA) concentrations in renal transplant patients, to establish the therapeutic range of fMPA through pharmacokinetic-pharmacodynamic studies; and (2) provide a guideline for dosing mycophenolate mofetil (MMF). METHODS Full PK profiles of 56 patients (from five different occasions) during the first year after transplantation who were treated with oral MMF and cyclosporine, or macrolides (either tacrolimus or sirolimus), were analysed. fMPA protein-binding was modelled using nonlinear mixed effects modelling (NONMEM). The influence of physiological factors and coadministered immunosupressant was studied. RESULTS A two-compartment model with first-order absorption and elimination, linear protein binding and enterohepatic circulation (EHC) best described the PK of MPA. Different recycling rate constants were considered depending on the coadministered immunosuppressant. The protein-binding rate constant (KB [relative standard error, RSE%]) increased nonlinearly with renal function according to K B = 43.1 (3.13)·(CLCR/59.51)0.394(10.66) h-1. Furthermore, fMPA plasma clearance, given by clearance of the free mycophenolic acid (CLfMPA), CLfMPA = 410 (RSE%3.00)·(1+CsA·0.594 (22.39)) L/h, was 59.4% greater in cyclosporine-treated patients than in macrolide-treated patients, leading to lower MPA exposures. External evaluation proved acceptable area under the plasma concentration-time curve and trough concentration predictions. CONCLUSIONS A reliable protein-binding population PK model was developed for prediction of fMPA or tMPA from each other and for dose guiding in stable renal transplant recipients.
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Affiliation(s)
- Helena Colom
- Department of Pharmacy and Pharmaceutical Technology and Physical-Chemistry, Biopharmaceutics and Pharmacokinetics Unit, School of Pharmacy, University of Barcelona, Barcelona, Spain
| | - Franc Andreu
- Department of Pharmacy and Pharmaceutical Technology and Physical-Chemistry, Biopharmaceutics and Pharmacokinetics Unit, School of Pharmacy, University of Barcelona, Barcelona, Spain.,Nephrology Department, Bellvitge University Hospital (IDIBELL), Barcelona, Spain
| | - Teun van Gelder
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Brenda C M de Winter
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Oriol Bestard
- Nephrology Department, Bellvitge University Hospital (IDIBELL), Barcelona, Spain
| | - Joan Torras
- Nephrology Department, Bellvitge University Hospital (IDIBELL), Barcelona, Spain
| | - Josep M Cruzado
- Nephrology Department, Bellvitge University Hospital (IDIBELL), Barcelona, Spain
| | - Josep M Grinyó
- Nephrology Department, Bellvitge University Hospital (IDIBELL), Barcelona, Spain
| | - Núria Lloberas
- Nephrology Department, Bellvitge University Hospital (IDIBELL), Barcelona, Spain.
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8
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She WH, Chok KSH, Li IWS, Ma KW, Sin SL, Dai WC, Fung JYY, Lo CM. Pneumocystis jirovecii-related spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema in a liver transplant recipient: a case report. BMC Infect Dis 2019; 19:66. [PMID: 30658592 PMCID: PMC6339407 DOI: 10.1186/s12879-019-3723-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 01/11/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Pneumocystis pneumonia (PCP) is a common opportunistic infection caused by Pneumocystis jirovecii. Its incidence at 2 years or more after liver transplant (LT) is < 0.1%. PCP-related spontaneous pneumothorax and/or pneumomediastinum is rare in patients without the human immunodeficiency virus, with an incidence of 0.4-4%. CASE PRESENTATION A 65-year-old woman who had split-graft deceased-donor LT for primary biliary cirrhosis developed fever, dyspnea and dry coughing at 25 months after transplant. Her immunosuppressants included tacrolimus, mycophenolate mofetil, and prednisolone. PCP infection was confirmed by molecular detection of Pneumocystis jirovecii,in bronchoalveolar lavage. On day-10 trimethoprim-sulphamethoxazole, her chest X-ray showed subcutaneous emphysema bilaterally, right pneumothorax and pneumomediastinum. Computed tomography of the thorax confirmed the presence of right pneumothorax, pneumomediastinum and subcutaneous emphysema. She was managed with 7-day right-sided chest drain and a 21-day course of trimethoprim-sulphamethoxazole before discharge. CONCLUSION Longer period of PCP prophylaxis should be considered in patients who have a higher risk compared to general LT patients. High index of clinical suspicion, prompt diagnosis and treatment with ongoing patient reassessment to detect and exclude rare, potentially fatal but treatable complications are essential, especially when clinical deterioration has developed.
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Affiliation(s)
- Wong Hoi She
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Kenneth S H Chok
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China. .,State Key Laboratory for Liver Research, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China.
| | - Iris W S Li
- School of Public Health, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Ka Wing Ma
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Sui Ling Sin
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Wing Chiu Dai
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - James Y Y Fung
- State Key Laboratory for Liver Research, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China.,Department of Medicine, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Chung Mau Lo
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China.,State Key Laboratory for Liver Research, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
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9
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Kizilbash SJ, Rheault MN, Bangdiwala A, Matas A, Chinnakotla S, Chavers BM. Infection rates in tacrolimus versus cyclosporine-treated pediatric kidney transplant recipients on a rapid discontinuation of prednisone protocol: 1-year analysis. Pediatr Transplant 2017; 21:10.1111/petr.12919. [PMID: 28371243 PMCID: PMC5423828 DOI: 10.1111/petr.12919] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2017] [Indexed: 12/16/2022]
Abstract
AR is lower in pKTx recipients on Tac vs CsA. Data comparing infection outcomes for children treated with these agents are limited. We retrospectively studied infection outcomes in 96 pKTx recipients on a RDP. PS, DCGS, AR, and infection-free survival were assessed using Kaplan-Meier/log-rank tests and proportional hazards models. There were no differences in 1-year PS, DCGS, or AR between Tac and CsA recipients. After adjusting for AR, the hazard of CMV viremia was 4.0 times higher (95%CI: 1.04, 15.5; P = .044) and that of BK viremia was 3.8 times higher (95%CI: 1.5, 10.2; P = .007) in Tac recipients. The incidence of EBV viremia was similar between the groups (P = .56). PostTx lymphoproliferative disease was only observed in Tac recipients (3%). There was no difference in the incidence of pneumonia, urinary tract, or Clostridium difficile infections between Tac and CsA recipients. Among KTx recipients on RDP, the hazards of CMV and BK viremia within 1 year post-KTx were significantly higher in Tac recipients compared to CsA. Regular assessment for infections and lower Tac trough levels may be warranted in Tac recipients.
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Affiliation(s)
- Sarah J Kizilbash
- Department of Pediatric Nephrology, University of Minnesota, Minneapolis, MN, United States
| | - Michelle N Rheault
- Department of Pediatric Nephrology, University of Minnesota, Minneapolis, MN, United States
| | - Ananta Bangdiwala
- Biostatistics and Bioinformatics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN, United States
| | - Arthur Matas
- Department of Transplant Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Srinath Chinnakotla
- Department of Transplant Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Blanche M Chavers
- Department of Pediatric Nephrology, University of Minnesota, Minneapolis, MN, United States
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10
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Takahashi K, Go P, Stone CH, Safwan M, Putchakayala KG, Kane WJ, Malinzak LE, Kim DY, Denny JE. Mycophenolate Mofetil and Pulmonary Fibrosis After Kidney Transplantation: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:399-404. [PMID: 28408734 PMCID: PMC5398249 DOI: 10.12659/ajcr.902380] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Male, 50 Final Diagnosis: Pulmonary fibrosis Symptoms: Short of breath Medication: — Clinical Procedure: — Specialty: Transplantology
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Affiliation(s)
- Kazuhiro Takahashi
- Department of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Pauline Go
- Department of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Chad H Stone
- Department of Pathology, Henry Ford Hospital, Detroit, MI, USA
| | - Mohamed Safwan
- Department of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Krishna G Putchakayala
- Department of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - William J Kane
- Department of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Lauren E Malinzak
- Department of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Dean Y Kim
- Department of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Jason E Denny
- Department of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
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11
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Filler G, Alvarez-Elías AC, McIntyre C, Medeiros M. The compelling case for therapeutic drug monitoring of mycophenolate mofetil therapy. Pediatr Nephrol 2017; 32:21-29. [PMID: 26921212 DOI: 10.1007/s00467-016-3352-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/25/2016] [Accepted: 01/29/2016] [Indexed: 11/26/2022]
Abstract
We have reviewed current evidence on the therapeutic drug monitoring (TDM) of mycophenolic acid (MPA) in relationship to drug efficacy and safety. The relationship between actual MPA exposure and mycophenolate mofetil (MMF) dose has been shown to be weak in children and adolescents. The TDM of MPA exposure should ideally be performed using full pharmacokinetic profiles or limited sampling strategies. Recent evidence has provided some rationale for using the post-dose trough level as a single measure. In terms of short-term efficacy, there is strong evidence that a MPA area under the time-concentration curve of >30 mg × h/L reduces acute rejection episodes early after renal transplantation, and there is evolving evidence that aiming for the same exposure over the long term may be a viable strategy to reduce the formation of donor-specific antibodies. Strong evidence also supports the existence of important drug interactions and age/developmental dependent differences in drug metabolism that may necessitate the need for TDM of MMF therapy. Based on these findings and given the substantial inter- and intra-patient variability of MPA exposure, it would appear that MMF therapy should be subject to TDM to avoid over- and under-dosing. This may be a viable strategy to reduce treatment-emergent adverse events and to increase the effective pediatric transplant survival rates.
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Affiliation(s)
- Guido Filler
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5 W9, Canada.
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, N5A 5A5, Canada.
- Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5 W9, Canada.
- Department of Pediatrics, Children's Hospital, London Health Science Centre, Western University, 800 Commissioners Road East, London, ON, N6A 5 W9, Canada.
| | - Ana Catalina Alvarez-Elías
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5 W9, Canada
- Universidad Nacional Autónoma de México, Mexico City, 04510, Mexico
- Laboratorio de Investigacion en Nefrologia, Hospital Infantil de Mexico Federico Gomez, Mexico City, Mexico
| | - Christopher McIntyre
- Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5 W9, Canada
| | - Mara Medeiros
- Laboratorio de Investigacion en Nefrologia, Hospital Infantil de Mexico Federico Gomez, Mexico City, Mexico
- Departamento de Farmacología, Facultad de Medicina, Universidad Nacional Autónoma de México, México City, Mexico
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12
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Ku YM, McCartan M, Collier D. Clinical Pharmacokinetic and Pharmacodynamic Monitoring for Mycophenolate Mofetil. J Pharm Pract 2016. [DOI: 10.1177/0897190005282360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The use of mycophenolate mofetil (MMF), in combination with cyclosporine (CsA) or tacrolimus (FK) and corticosteroids, has been shown to improve clinical outcomes through significant reduction in the incidence of acute rejection in solid organ transplant patients. A fixed oral dosing regimen of 1 or 1.5 g MMF twice daily received Food and Drug Administration approval in 1995 with no recommendations for concentration monitoring at that time. Subsequent evidence has generated substantial debate on the need of clinical monitoring for MMF. This article summarizes the rationale, evidence, and approaches of clinical monitoring for MMF. Mycophenolic acid (MPA), the active moiety of MMF, noncompetitively inhibits the enzyme inosine monophosphate dehydrogenase (IMPDH), which is the target enzyme for MPA. Pharmacokinetic monitoring, by use of MPA predose or MPA area under the concentration-time curve (AUC) values, and pharmacodynamic monitoring by analysis of inhibition of IMPDH have been evaluated in organ transplant patients. The possibility of drug interactions between other immunosuppressive agents has also received attention recently. The clinical implications of drug interactions are discussed in this article.
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Affiliation(s)
- Yi-Min Ku
- Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, Bristol-Myers Squibb company, P.O. Box 865122 Plano, TX 75086-5122
| | - Megan McCartan
- Department of Pharmacy, Pharmaceutical and Nutrition Care, Nebraska Medical Center, Omaha, Nebraska
| | - Dean Collier
- Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska
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13
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Abstract
Since the early 1980s, the combination of cyclosporine, azathioprine, and prednisone has been the mainstay tripledrug immunosuppressive regimen used in transplantation. However, advances in drug research, design, and development have allowed for the introduction of new agents that have greatly increased the number of immunosuppressive agents available for use in transplant recipients. Particularly, the newer antiproliferative immunosuppressive drugs (agents that directly inhibit the proliferation of T and B lymphocytes) have had an important impact on patient outcomes posttransplant. These agents are mycophenolate mofetil and sirolimus.
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Affiliation(s)
- Theodore M. Sievers
- Transplant Pharmacokinetic Laboratory, Dumont-UCLA Transplant Center, 10833 LeConte Avenue, Room 77-120, Los Angeles, CA 90025
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14
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Ferjani H, El Arem A, Bouraoui A, Achour A, Abid S, Bacha H, Boussema-Ayed I. Protective effect of mycophenolate mofetil against nephrotoxicity and hepatotoxicity induced by tacrolimus in Wistar rats. J Physiol Biochem 2016; 72:133-44. [PMID: 26746208 DOI: 10.1007/s13105-015-0451-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 11/20/2015] [Indexed: 11/26/2022]
Abstract
Tacrolimus (TAC), a calcineurin inhibitor (CNI), is clinically used as an immunosuppressive agent in the transplant recipient; however, the use of TAC is greatly limited by its nephrotoxicity and hepatotoxicity. Mycophenolate mofetil (MMF), an inhibitor of the purine synthesis, has been used in combination with many immunosuppressive drugs such as TAC. The association TAC/MMF was used in organ transplantation to increase the efficiency and reduce acute rejection rates, but the effects of MMF on TAC-induced kidney and liver injuries are still not well investigated. The aims of this study are to explore whether MMF co-administration with TAC has a renoprotective and hepatoprotective effect against TAC-induced renal and hepatic injuries and to check the implication of oxidative stress in the MMF's possible protective effect. Our results showed that MMF (at 50 mg kg(-1) body weight (b.w.)) restored creatinine, in addition to increased AST and ALT levels by TAC (at 60 mg kg(-1) b.w.). Furthermore, MMF decreased DNA damage induced by TAC in the kidney and liver of rats as assessed by comet assay. This renoprotective and hepatoprotective effect of MMF was associated with an antioxidant effect. In fact, MMF co-treatment with TAC decreased oxidative damage induced by TAC. It reduced malondialdehyde (MDA) and protein carbonyl (PC) levels as well as catalase and superoxide dismutase (SOD) activities. We conclude that the co-administration MMF with TAC protect liver and kidney against TAC toxicity via an antioxidant process.
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Affiliation(s)
- Hanen Ferjani
- Laboratory of Research on Biologically Compatible Compounds, Dental Medicine Faculty, 5019, Monastir, Tunisia
| | - Amira El Arem
- Laboratory of Bioresources, Biology Integrative and Valorization, Higher Institute of Biotechnology of Monastir, Avenue Tahar Hadded, BP 74, 5000, Monastir, Tunisia
| | - Aicha Bouraoui
- Laboratory of Research on Biologically Compatible Compounds, Dental Medicine Faculty, 5019, Monastir, Tunisia
| | - Abedellatif Achour
- Department of Nephrology, Dialysis and Transplant, University Hospital of Sahloul, 4021, Sousse, Tunisia
| | - Salwa Abid
- Laboratory of Research on Biologically Compatible Compounds, Dental Medicine Faculty, 5019, Monastir, Tunisia
| | - Hassen Bacha
- Laboratory of Research on Biologically Compatible Compounds, Dental Medicine Faculty, 5019, Monastir, Tunisia.
| | - Imen Boussema-Ayed
- Laboratory of Research on Biologically Compatible Compounds, Dental Medicine Faculty, 5019, Monastir, Tunisia
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15
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Salik J, Tang R, Nord K, Schneiderman PI, Grossman ME. Mycophenolate mofetil-induced oral ulcerations in solid organ transplant recipients: A report of 3 cases. JAAD Case Rep 2015; 1:261-3. [PMID: 27051747 PMCID: PMC4809219 DOI: 10.1016/j.jdcr.2015.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Jonathan Salik
- Columbia University, College of Physicians and Surgeons, New York, New York
| | - Randy Tang
- Department of Dermatology, Columbia University, College of Physicians and Surgeons, New York, New York
| | - Kristin Nord
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
| | - Paul I Schneiderman
- Department of Dermatology, Columbia University, College of Physicians and Surgeons, New York, New York
| | - Marc E Grossman
- Department of Dermatology, Columbia University, College of Physicians and Surgeons, New York, New York
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16
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Modeling approach for multiple transporters-mediated drug–drug interactions in sandwich-cultured human hepatocytes: Effect of cyclosporin A on hepatic disposition of mycophenolic acid phenyl-glucuronide. Drug Metab Pharmacokinet 2015; 30:142-8. [DOI: 10.1016/j.dmpk.2014.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 09/25/2014] [Accepted: 10/11/2014] [Indexed: 12/31/2022]
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17
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Optimizing drug therapy in pediatric SCT: focus on pharmacokinetics. Bone Marrow Transplant 2014; 50:165-72. [PMID: 25347008 DOI: 10.1038/bmt.2014.235] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 08/08/2014] [Accepted: 08/27/2014] [Indexed: 12/19/2022]
Abstract
Given age-related differences in drug metabolism and indications for hematopoietic SCT (HSCT), personalized drug dosing of the conditioning regimen and post-transplant immunosuppression may reduce graft rejection, relapse rates and toxicity in pediatric HSCT recipients. This manuscript summarizes the pharmacokinetic/dynamic data of HSCT conditioning and post-grafting immunosuppression, presented at the First Annual Pediatric Bone Marrow Transplant Consortium (PBMTC) meeting in April 2013. Personalized dosing of BU to a target plasma exposure reduces graft rejection in children and improves relapse/toxicity rates in adults. Current weight-based dosing achieves the target BU exposure in only a minority (24.3%) of children. The initial BU dose should be based on the European Medicines Agency nomogram or population pharmacokinetic models to improve the numbers of children achieving the target exposure. There are limited pharmacokinetic data for treosulfan, CY, fludarabine and alemtuzumab as HSCT conditioning in children. For post-grafting immunosuppression, mycophenolic acid (MPA) clearance may be increased in younger children (<12 years). The preferred MPA pharmacokinetic monitoring parameters and target range are still evolving in HSCT recipients. Multi-institutional trials incorporating properly powered pharmacokinetic/dynamic studies are needed to assess the effect of variability in the plasma exposure of drugs/metabolites on clinical outcomes in pediatric HSCT recipients.
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18
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Li P, Shuker N, Hesselink DA, van Schaik RHN, Zhang X, van Gelder T. Do Asian renal transplant patients need another mycophenolate mofetil dose compared with Caucasian or African American patients? Transpl Int 2014; 27:994-1004. [PMID: 24963914 DOI: 10.1111/tri.12382] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 04/22/2014] [Accepted: 06/17/2014] [Indexed: 01/01/2023]
Affiliation(s)
- Pengmei Li
- Department of Hospital Pharmacy; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
- Department of Pharmacy; China-Japan Friendship Hospital; Beijing China
| | - Nauras Shuker
- Department of Hospital Pharmacy; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
- Department of Internal Medicine; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
| | - Dennis A. Hesselink
- Department of Internal Medicine; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
| | - Ron H. N. van Schaik
- Department of Clinical Chemistry; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
| | - Xianglin Zhang
- Department of Pharmacy; China-Japan Friendship Hospital; Beijing China
| | - Teun van Gelder
- Department of Hospital Pharmacy; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
- Department of Internal Medicine; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
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19
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Klawitter J, Klawitter J, Schmitz V, Shokati T, Epshtein E, Thurman JM, Christians U. Mycophenolate mofetil enhances the negative effects of sirolimus and tacrolimus on rat kidney cell metabolism. PLoS One 2014; 9:e86202. [PMID: 24497939 PMCID: PMC3907404 DOI: 10.1371/journal.pone.0086202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 12/08/2013] [Indexed: 12/12/2022] Open
Abstract
Background and Purpose Mycophenolate mofetil (MMF) per se is not known to have negative effects on the kidney. MMF alone or in combination with sirolimus, can be the basis of calcineurin inhibitor (CNI)-free, kidney sparing drug protocols. However, long-term outcomes in patients on MMF/SRL seem to be inferior to those treated with regimens that include the CNI tacrolimus (TAC) due to an increased risk of allo-immune reactions. Interestingly, potential enhancement of the negative effects of SRL and TAC on the kidney by MMF has never been considered. Experimental Approach It was our aim to study the effects of TAC, SRL and MMF alone and evaluate their interactions when combined on the rat kidney. For this purpose we used a comprehensive molecular marker approach including measurements of urinary 8-isoprostane concentrations (oxidative stress marker) and changes of urinary metabolite patterns (1H-NMR spectroscopy) and comparing these markers to renal function (glomerular filtration rate (GFR)) and morphologic alterations (histology). Key Results While MMF alone did not impact GFR, its interaction with SRL and TAC led to a significant decrease of rats’ renal function. The decline went in parallel with a significant increase in urinary isoprostane concentrations and an enhancement of negative effects on urinary metabolite patterns. Conclusions In broad summary, the present study showed that MMF may enhance the negative effects of TAC on kidney function and may even display nephrotoxic properties when combined with SRL.
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Affiliation(s)
- Jelena Klawitter
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, United States of America
- Division of Renal Diseases and Hypertension, University of Colorado, Aurora, Colorado, United States of America
- * E-mail:
| | - Jost Klawitter
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, United States of America
| | - Volker Schmitz
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, United States of America
- Department of General-, Visceral- and Transplantation Surgery, Charité, Campus Virchow, Berlin, Germany
| | - Touraj Shokati
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, United States of America
| | - Ekaterina Epshtein
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, United States of America
| | - Joshua M. Thurman
- Division of Renal Diseases and Hypertension, University of Colorado, Aurora, Colorado, United States of America
| | - Uwe Christians
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, United States of America
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20
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Srinivas TR, Schold JD, Meier-Kriesche HU. Mycophenolate mofetil: long-term outcomes in solid organ transplantation. Expert Rev Clin Immunol 2014; 2:495-518. [DOI: 10.1586/1744666x.2.4.495] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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21
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Roberts JA, Barrios R, Cagle PT, Ge Y, Takei H, Haque AK, Burns KM, Land GA, Dilioglou S, Bernard DW. The Presence of Anti-HLA Donor-Specific Antibodies in Lung Allograft Recipients Does Not Correlate With C4d Immunofluorescence in Transbronchial Biopsy Specimens. Arch Pathol Lab Med 2013; 138:1053-8. [DOI: 10.5858/arpa.2013-0539-oa] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—C4d immunofluorescence (IF) is a surrogate for development of donor-specific antibodies (DSAs) against human leukocyte antigen (HLA) class I and II antigens in kidney and heart biopsy specimens for monitoring of antibody-mediated (humoral) allograft rejection (AMR). Use of C4d IF in monitoring of lung allografts has shown conflicting results.
Objective.—To determine if C4d IF can be used as a reliable marker for AMR and if it correlates with the presence of DSAs and histologic findings on biopsy.
Design.—All transbronchial biopsies in lung allograft recipients, performed at our institution in a 3-year period, were reviewed. A cohort of 92 patients with 110 corresponding biopsies met the inclusion criteria of (1) having a resulted DSA within 2 weeks of biopsy and (2) having C4d immunofluorescence studies performed and confirmed.
Results.—Twenty-nine patients (31.5%) were positive for DSAs and 63 patients (68.5%) did not develop DSAs. Positive C4d capillary IF was seen in 18 of 110 total biopsy specimens (16.4%). Eight of these biopsy samples were from patients positive for DSAs and 10 were from patients negative for DSAs. The correlation coefficient between the presence of DSAs and C4d IF was 0.1628 (P = .09).
Conclusions.—A significant proportion of DSA-positive patients had negative C4d IF results and frequently have no histologic changes on biopsy specimens. DSA-negative patients can be positive for C4d and may show the same histologic changes as reported for DSA-positive patients. Diagnosis of AMR in lung may require a collaborative approach combining clinical data, DSA status, and histology.
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Affiliation(s)
- Jordan A. Roberts
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas (Drs Roberts, Barrios, Cagle, Ge, Takei, Haque, Burns, Land, Dilioglou, and Bernard); and the Department of Pathology, Weill Cornell Medical College of Cornell University, Houston, Texas (Drs Barrios, Cagle, Ge, and Takei)
| | - Roberto Barrios
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas (Drs Roberts, Barrios, Cagle, Ge, Takei, Haque, Burns, Land, Dilioglou, and Bernard); and the Department of Pathology, Weill Cornell Medical College of Cornell University, Houston, Texas (Drs Barrios, Cagle, Ge, and Takei)
| | - Philip T. Cagle
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas (Drs Roberts, Barrios, Cagle, Ge, Takei, Haque, Burns, Land, Dilioglou, and Bernard); and the Department of Pathology, Weill Cornell Medical College of Cornell University, Houston, Texas (Drs Barrios, Cagle, Ge, and Takei)
| | - Yimin Ge
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas (Drs Roberts, Barrios, Cagle, Ge, Takei, Haque, Burns, Land, Dilioglou, and Bernard); and the Department of Pathology, Weill Cornell Medical College of Cornell University, Houston, Texas (Drs Barrios, Cagle, Ge, and Takei)
| | - Hidehiro Takei
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas (Drs Roberts, Barrios, Cagle, Ge, Takei, Haque, Burns, Land, Dilioglou, and Bernard); and the Department of Pathology, Weill Cornell Medical College of Cornell University, Houston, Texas (Drs Barrios, Cagle, Ge, and Takei)
| | - Abida K. Haque
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas (Drs Roberts, Barrios, Cagle, Ge, Takei, Haque, Burns, Land, Dilioglou, and Bernard); and the Department of Pathology, Weill Cornell Medical College of Cornell University, Houston, Texas (Drs Barrios, Cagle, Ge, and Takei)
| | - Kevin M. Burns
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas (Drs Roberts, Barrios, Cagle, Ge, Takei, Haque, Burns, Land, Dilioglou, and Bernard); and the Department of Pathology, Weill Cornell Medical College of Cornell University, Houston, Texas (Drs Barrios, Cagle, Ge, and Takei)
| | - Geoffrey A. Land
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas (Drs Roberts, Barrios, Cagle, Ge, Takei, Haque, Burns, Land, Dilioglou, and Bernard); and the Department of Pathology, Weill Cornell Medical College of Cornell University, Houston, Texas (Drs Barrios, Cagle, Ge, and Takei)
| | - Smaroula Dilioglou
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas (Drs Roberts, Barrios, Cagle, Ge, Takei, Haque, Burns, Land, Dilioglou, and Bernard); and the Department of Pathology, Weill Cornell Medical College of Cornell University, Houston, Texas (Drs Barrios, Cagle, Ge, and Takei)
| | - David W. Bernard
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas (Drs Roberts, Barrios, Cagle, Ge, Takei, Haque, Burns, Land, Dilioglou, and Bernard); and the Department of Pathology, Weill Cornell Medical College of Cornell University, Houston, Texas (Drs Barrios, Cagle, Ge, and Takei)
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22
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Passey C, Birnbaum AK, Brundage RC, Schladt DP, Oetting WS, Leduc RE, Israni AK, Guan W, Matas AJ, Jacobson PA. Validation of tacrolimus equation to predict troughs using genetic and clinical factors. Pharmacogenomics 2013; 13:1141-7. [PMID: 22909204 DOI: 10.2217/pgs.12.98] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Tacrolimus is an immunosuppressant used in transplantation. This article reports the validation of the authors' recently developed genetics-based tacrolimus equation that predicts troughs. METHODS Validation was performed in an independent cohort of 795 kidney transplant recipients receiving tacrolimus. The performance of the equation to predict initial troughs was assessed by calculating the bias and precision of the equation. For all troughs in the first 6 months post-transplant, a comparison was made between the troughs predicted using the equation versus those predicted using a basic apparent clearance model with no covariates. RESULTS For initial troughs, the equation had a low bias (0.2 ng/ml) and high precision (1.8 ng/ml). For all troughs, the equation predicted troughs significantly better than the basic apparent clearance model. CONCLUSION The tacrolimus equation had good bias and precision in predicting initial troughs and performed better than a basic apparent clearance model for all the troughs.
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Affiliation(s)
- Chaitali Passey
- Department of Experimental & Clinical Pharmacology, 717 Delaware Street, University of Minnesota, Minneapolis, MN 55455, USA
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23
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Picard N. The pharmacokinetic interaction between mycophenolic acid and cyclosporine revisited: a commentary on “Mycophenolic acid glucuronide is transported by multidrug resistance-associated protein 2 and this transport is not inhibited by cyclosporine, tacrolimus or sirolimus”. Xenobiotica 2013; 43:836-8. [DOI: 10.3109/00498254.2012.761742] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Renal Function and NODM in De Novo Renal Transplant Recipients Treated with Standard and Reduced Levels of Tacrolimus in Combination with EC-MPS. J Transplant 2012; 2012:941640. [PMID: 23227307 PMCID: PMC3512323 DOI: 10.1155/2012/941640] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 08/21/2012] [Indexed: 11/17/2022] Open
Abstract
Information is lacking concerning concomitant administration of enteric-coated mycophenolate sodium with tacrolimus (EC-MPS+Tac) in renal transplant recipients (RTxR). In this 6-month, prospective, open-label, multicenter study, de novo RTxR were randomized (1 : 1) to low-dose (LD) or standard-dose (SD) Tac with basiliximab, EC-MPS 720 mg bid, and steroids. Primary objective was to compare renal function at 6-month posttransplantation. Secondary objectives were to compare the incidences of biopsy-proven acute rejection (BPAR), graft loss and death, and new-onset diabetes mellitus (NODM). 292 patients (LD n = 151, SD n = 141) were included. Mean Tac levels were at the low end of the target range in standard-exposure patients (SD, n = 141) and exceeded target range in low-exposure patients (LD = 151) throughout the study. There was no significant difference in mean glomerular filtration rate (GFR) between treatments (ITT-population: 63.6 versus 61.0 mL/min). Incidence of BPAR was similar (10.6% versus 9.9%). NODM was significantly less frequent in LD Tac (17% versus 31%; P = 0.02); other adverse effects (AEs) were comparable. EC-MPS+Tac (LD/SD) was efficacious and well tolerated with well-preserved renal function. No renal function benefits were demonstrated, possibly related to poor adherence to reduced Tac exposure.
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Renal Function and NODM in De Novo Renal Transplant Recipients Treated with Standard and Reduced Levels of Tacrolimus in Combination with EC-MPS. J Transplant 2012. [PMID: 23227307 DOI: 10.1155/2012/94164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Information is lacking concerning concomitant administration of enteric-coated mycophenolate sodium with tacrolimus (EC-MPS+Tac) in renal transplant recipients (RTxR). In this 6-month, prospective, open-label, multicenter study, de novo RTxR were randomized (1 : 1) to low-dose (LD) or standard-dose (SD) Tac with basiliximab, EC-MPS 720 mg bid, and steroids. Primary objective was to compare renal function at 6-month posttransplantation. Secondary objectives were to compare the incidences of biopsy-proven acute rejection (BPAR), graft loss and death, and new-onset diabetes mellitus (NODM). 292 patients (LD n = 151, SD n = 141) were included. Mean Tac levels were at the low end of the target range in standard-exposure patients (SD, n = 141) and exceeded target range in low-exposure patients (LD = 151) throughout the study. There was no significant difference in mean glomerular filtration rate (GFR) between treatments (ITT-population: 63.6 versus 61.0 mL/min). Incidence of BPAR was similar (10.6% versus 9.9%). NODM was significantly less frequent in LD Tac (17% versus 31%; P = 0.02); other adverse effects (AEs) were comparable. EC-MPS+Tac (LD/SD) was efficacious and well tolerated with well-preserved renal function. No renal function benefits were demonstrated, possibly related to poor adherence to reduced Tac exposure.
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Lee PC, Chang SS, Shieh SC, Wu ZC, Wang WM, Wang JD, Hung CJ, Lin YJ, Chou TC, Chan RH. Cyclosporine or tacrolimus: which is the better partner for myfortic or cellcept? Transplant Proc 2012; 44:137-9. [PMID: 22310598 DOI: 10.1016/j.transproceed.2011.12.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND Mycophenolic acid (MPA) pharmacokinetics using the mycophenolate mofetil (CellCept) formulation are known to differ between patients receiving tacrolimus (FK) or cyclosporine (CyA), but only limited data exist concerning concomitant use of FK or CyA with enteric-coated mycophenolate sodium (EC-MPS; Myfortic). This retrospective study compared the drug interactions with the mycophenolic acid blood levels using different immunosuppressants and their relation to graft survival. PATIENTS AND METHODS We studied MPA levels in posttransplant sera from 298 renal transplant recipients. RESULTS Patients receiving immunosuppression with CyA + Myfortic showed 94% at 5- and 10-year graft survivals, which were better than CyA + CellCept (75%, 63%). This combination suppressed posttransplant human leukocyte antigen (HLA) antibody development significantly (P = .03) with higher MPA levels. CONCLUSION Patients immunosuppressed with CyA + Myfortic showed higher MPA levels and lower posttransplant HLA antibody development as well as the best graft survival. CyA + Myfortic or FK + Cellcept may be better combinations.
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Affiliation(s)
- P-C Lee
- Department of Surgery, National Cheng-Kung University Medical College and Hospital, Tainan, Taiwan.
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Greanya ED, Poulin E, Partovi N, Shapiro RJ, Al-Khatib M, Ensom MHH. Pharmacokinetics of tacrolimus and mycophenolate mofetil in renal transplant recipients on a corticosteroid-free regimen. Am J Health Syst Pharm 2012; 69:134-42. [DOI: 10.2146/ajhp110287] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Erica D. Greanya
- Vancouver Coastal Health Authority, Vancouver, Canada, and Clinical Assistant Professor, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver
| | | | - Nilufar Partovi
- Vancouver Coastal Health Authority, and Clinical Professor, Faculty of Pharmaceutical Sciences, University of British Columbia
| | - R. Jean Shapiro
- Solid Organ Transplantation, Vancouver General Hospital, Vancouver, and Clinical Associate Professor, Faculty of Medicine, University of British Columbia
| | - Mai Al-Khatib
- Faculty of Pharmaceutical Sciences, University of British Columbia
| | - Mary H. H. Ensom
- Doctor of Pharmacy Program, Faculty of Pharmaceutical Sciences, and Distinguished University Scholar, University of British Columbia, and Clinical Pharmacy Specialist, Department of Pharmacy, Children’s and Women’s Health Centre of British Columbia, Vancouver
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Geng F, Jiao Z, Dao YJ, Qiu XY, Ding JJ, Shi XJ, Li ZD, Zhong MK. The association of the UGT1A8, SLCO1B3 and ABCC2/ABCG2 genetic polymorphisms with the pharmacokinetics of mycophenolic acid and its phenolic glucuronide metabolite in Chinese individuals. Clin Chim Acta 2011; 413:683-90. [PMID: 22227166 DOI: 10.1016/j.cca.2011.12.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Revised: 12/06/2011] [Accepted: 12/06/2011] [Indexed: 01/25/2023]
Abstract
BACKGROUND This study aimed to evaluate the effect of UGT1A8*2, SLCO1B3 T334G, ABCC2 C-24T and ABCG2 C421A polymorphisms on the pharmacokinetics (PKs) of mycophenolic acid (MPA) and its phenolic glucuronide (MPAG) in healthy Chinese volunteers and in stable renal transplant patients. METHODS The data were extracted from comparative bioavailability studies conducted in 42 healthy individuals and 37 renal transplant patients. A complete PK profile was obtained over 48 h for healthy volunteers and over 12h for the transplant patients. The MPA/MPAG plasma concentrations were measured by HPLC. The genotypes were determined using either the Taqman probe technique or direct sequencing. A multivariate analysis was used to assess the effect of the genotypes (UGT1A8*2, SLCO1B3 T334G, ABCC2 C-24T and ABCG2 C421A) and other covariates (age, weight, height, calculated creatinine clearance, serum albumin, haemoglobin and drug comedication) on the AUC(4-12) and AUC(0-12) for MPA and MPAG in the healthy volunteers and patients. RESULTS In the healthy volunteers, the dose-adjusted geometric means (GM) of the MPA AUC(4-12) in individuals with the SLCO1B3 334T allele were 30.4% lower than those values in the 334G homozygote carriers (P<0.05); in the transplant patients, the steroid dose was associated with a negative effect on the AUC of MPAG (P<0.03) and weight was associated with a negative effect on the AUC for MPA in the healthy volunteers and patients (P<0.03). No other significant effect of genotype or of the other studied variables on AUC(4-12) or AUC(0-12) of MPA/MPAG was found in the healthy volunteers or patients. CONCLUSIONS The PKs of MPA is affected by the SLCO1B3 polymorphism in healthy Chinese individuals. The absence of an effect of SLCO1B3 polymorphisms in transplant patients may be due to the co-administration of cyclosporine (CsA). Concomitant steroid dose and weight are two important covariates of the AUC of MPA and MPAG, which should be taken into account in clinical use. Further confirmatory in vivo studies are needed.
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Affiliation(s)
- Fang Geng
- Clinical Pharmacy Laboratory, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
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Large scale analysis of routine dose adjustments of mycophenolate mofetil based on global exposure in renal transplant patients. Ther Drug Monit 2011; 33:285-94. [PMID: 21516060 DOI: 10.1097/ftd.0b013e31821633a6] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We report a feasibility study based on our large-scale experience with mycophenolate mofetil dose adjustment based on mycophenolic acid interdose area under the curve (AUC) in renal transplant patients. METHODS Between 2005 and 2010, 13,930 requests for 7090 different patients (outside any clinical trial) were posted by more than 30 different transplantation centers on a free, secure web site for mycophenolate mofetil dose recommendations using three plasma concentrations and Bayesian estimation. RESULTS This retrospective study showed that 1) according to a consensually recommended 30- to 60-mg·h/L target, dose adjustment was needed for approximately 35% of the patients, 25% being underexposed with the highest proportion observed in the first weeks after transplantation; 2) when dose adjustment had been previously proposed, the subsequent AUC was significantly more often in the recommended range if the dose was applied than not at all posttransplantation periods (72-80% vs. 43-54%); and 3) the interindividual AUC variability in the "respected-dose" group was systematically lower than that in the "not respected-dose" group (depending on the posttransplantation periods; coefficient of variation %, 31-41% vs 49-70%, respectively). Further analysis suggested that mycophenolic acid AUC should best be monitored at least every 2 weeks during the first month, every 1 to 3 months between months 1 and 12, whereas in the stable phase, the odds to be still in the 30- to 60-mg·h/L range on the following visit was still 75% up to 1 year after the previous dose adjustment. CONCLUSION This study showed that the monitoring of mycophenolate mofetil on the basis of AUC measurements is a clinically feasible approach, apparently acceptable by the patients, the nurses, and the physicians owing to its large use in routine clinics.
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Ciancio G, Monte AL, Buscemi G, Miller J, Burke G. Use of tacrolimus and mycophenolate mofetil as induction and maintenance in simultaneous pancreas-kidney transplantation. Transpl Int 2011. [DOI: 10.1111/j.1432-2277.2000.tb02017.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Vethe N, Midtvedt K, Åsberg A, Amundsen R, Bergan S. Legemiddelinteraksjoner og immunsuppresjon hos organtransplanterte. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2011; 131:2000-3. [DOI: 10.4045/tidsskr.11.0138] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Hwang HS, Hyoung BJ, Kim S, Oh HY, Kim YS, Kim JK, Kim YH, Kim YL, Kim CD, Shin GT, Yang CW. Improved gastrointestinal symptoms and quality of life after conversion from mycophenolate mofetil to enteric-coated mycophenolate sodium in renal transplant patients receiving tacrolimus. J Korean Med Sci 2010; 25:1759-65. [PMID: 21165291 PMCID: PMC2995230 DOI: 10.3346/jkms.2010.25.12.1759] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 08/19/2010] [Indexed: 11/20/2022] Open
Abstract
It is reported that a conversion from mycophenolate mofetil (MMF) to enteric-coated mycophenolate sodium (EC-MPS) relieves gastrointestinal (GI) symptom burden and improves health-related quality of life (HRQoL). However, it is unclear whether renal transplant recipients using tacrolimus receive the same benefit from the conversion. In this prospective, multi-center, open-label trial, patients were categorized into two groups by their GI symptom screening. Equimolar EC-MPS (n=175) was prescribed for patients with GI burdens; those with no complaints remained on MMF (n=83). Gastrointestinal Symptom Rating Scale (GSRS) and Gastrointestinal Quality of Life Index (GIQLI) were evaluated at baseline and after one month. Patients and physicians completed Overall Treatment Effect (OTE) at one month. EC-MPS-converted patients had worse GSRS and GIQLI scores at baseline than MMF-continued patients (all P<0.001). Significant improvements in GSRS and GIQLI scores were observed for EC-MPS-converted patients at one month, but MMF-continued patients showed worsened GSRS scores (all P<0.05). OTE scale indicated that EC-MPS patients improved in overall GI symptoms and HRQoL more than MMF patients did (P<0.001). In tacrolimus-treated renal transplant recipients with GI burdens, a conversion from MMF to EC-MPS improves GI-related symptoms and HRQoL.
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Affiliation(s)
- Hyeon Seok Hwang
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bok Jin Hyoung
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sol Kim
- Department of Bioengineering, University of Pensylvania, Philadelphia, PA, USA
| | - Ha Young Oh
- Division of Nephrology, Department of Internal Medicine, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
| | - Yon Su Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Kyung Kim
- Division of Nephrology, Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Yeong Hoon Kim
- Division of Nephrology, Department of Internal Medicine, Busan Paik Hospital College of Medicine, Inje University, Busan, Korea
| | - Yong Lim Kim
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Chan Duck Kim
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Gyu Tae Shin
- Department of Nephrology, Ajou University School of Medicine, Suwon, Korea
| | - Chul Woo Yang
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Park JM, Lake KD, Cibrik DM. Impact of changing from cyclosporine to tacrolimus on pharmacokinetics of mycophenolic acid in renal transplant recipients with diabetes. Ther Drug Monit 2010; 30:591-6. [PMID: 18708992 DOI: 10.1097/ftd.0b013e3181858169] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The rate of mycophenolic acid (MPA) absorption after oral administration of mycophenolate mofetil (MMF) is delayed in patients with diabetes. Cyclosporine (CsA) decreases MPA exposure by inhibiting enterohepatic recirculation of MPA/MPA glucuronide, and tacrolimus (TRL) may alter the rate and extent of MPA absorption due to its prokinetic properties especially in patients with diabetic gastroparesis. This study evaluated the effect of changing from CsA to TRL on pharmacokinetics of MPA in stable renal transplant recipients with long-standing diabetes. Eight patients were switched from a stable dose of CsA to TRL while taking MMF 1 g twice daily. The 12-hour steady-state total plasma concentration-time profiles of MPA and MPA glucuronide were obtained after oral administration of MMF on 2 occasions: first while taking CsA and second after changing to TRL. Pharmacokinetic parameters of MPA were calculated by the noncompartmental method. Changing from CsA to TRL resulted in significantly increased MPA exposure (area under the concentration-time curve from 0 to 12 hours, AUC0-12) by 46 +/- 32% (P = 0.012) and MPA predose concentration (C0) by 121 +/- 67% (P = 0.008). The magnitude of change in MPA exposure did not correlate well with MPA-C0 or CsA trough concentration. Switching to TRL had minimal impact on peak concentration of MPA (15.0 +/- 6.9 mg/L with CsA versus 16.1 +/- 9.7 mg/L with TRL, P = 0.773) and time to reach the peak concentration (1.0 +/- 0.4 hours with CsA versus 1.2 +/- 0.8 hours with TRL, P = 0.461). Highly variable and unpredictable changes in MPA exposure among renal transplant patients with diabetes do not support a strategy of preemptively adjusting MMF dose when switching calcineurin inhibitors in this population.
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Affiliation(s)
- Jeong M Park
- College of Pharmacy, Department of Pharmacy Services, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5008, USA.
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Monchaud C, Marquet P. Pharmacokinetic optimization of immunosuppressive therapy in thoracic transplantation: part II. Clin Pharmacokinet 2010; 48:489-516. [PMID: 19705921 DOI: 10.2165/11317240-000000000-00000] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Part I of this article, which appeared in the previous issue of the Journal, reviewed calcineurin inhibitors--ciclosporin and tacrolimus. In part II, we review the pharmacokinetics and therapeutic drug monitoring of mycophenolate and mammalian target of rapamycin inhibitors--sirolimus and everolimus--in thoracic transplantation, and we provide an overall discussion and suggest various areas for future study.
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Affiliation(s)
- Caroline Monchaud
- INSERM Unit 850, CHU Limoges, University of Limoges, Limoges, France
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Etienne I, Toupance O, Bénichou J, Thierry A, Al Najjar A, Hurault de Ligny B, Le Meur Y, Westeel PF, Marquet P, François A, Hellot MF, Godin M. A 50% reduction in cyclosporine exposure in stable renal transplant recipients: renal function benefits. Nephrol Dial Transplant 2010; 25:3096-106. [PMID: 20299336 DOI: 10.1093/ndt/gfq135] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although cyclosporine maintenance therapy reduces the risk of acute rejection and increases short-term graft survival in renal transplant recipients, its associated nephrotoxicity increases the risk of chronic graft dysfunction. The dose that allows an optimal risk-to-benefit ratio has not been established. METHODS This multicentre study enrolled stable renal allograft recipients receiving cyclosporine and mycophenolate mofetil without corticosteroids in their second year post-transplant. Patients were randomized to a cyclosporine dose targeted to a standard area under the concentration-time curve (AUC)(0-12 h) (usual exposure, n = 104) or 50% of the study standard AUC(0-12 h) (low exposure, n = 108) using a three-point pharmacokinetic sampling. The primary endpoint was the percentage of patients with treatment failure at 24 months (graft loss/acute rejection/nephrotoxicity/>15% serum creatinine level increase). RESULTS Treatment failure was reported in 37 out of 101 (37%) patients in the usual-exposure and 19 out of 106 (18%) patients in the low-exposure groups (P = 0.003). Mean estimated glomerular filtration rate decreased from baseline to 2 years with usual exposure and increased with low exposure (P < 0.001). Mean systolic and diastolic blood pressures were lower with low exposure (P = 0.03 and P = 0.008, respectively). CONCLUSION In renal transplant recipients receiving maintenance therapy without corticosteroids, a minimization strategy using three-point pharmacokinetic sampling to reduce and maintain cyclosporine exposure to 50% of the usual levels is safe and reduces the risk of graft dysfunction.
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Affiliation(s)
- Isabelle Etienne
- Department of Nephrology, Rouen University Hospital, and Inserm CIC 0204, Institute of Biomedical Research, University of Rouen, Rouen, France.
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Bruchet NK, Ensom MHH. Limited sampling strategies for mycophenolic acid in solid organ transplantation: a systematic review. Expert Opin Drug Metab Toxicol 2009; 5:1079-97. [PMID: 19689217 DOI: 10.1517/17425250903114182] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Mycophenolic acid (MPA) is the active metabolite of mycophenolate mofetil, a widely used immunosuppressant. Numerous studies have developed limited sampling strategies (LSSs) to predict MPA AUC in solid organ transplant recipients. OBJECTIVES To systematically review and assess quality of literature pertaining to MPA LSSs, evaluate clinical implications and provide suggestions for future research. METHODS Literature searches of MEDLINE (1966 - May 2009) and EMBASE (1980 - May 2009) for English articles in solid organ transplantation, along with manual review of article references were conducted. Included articles were categorized according to criteria adapted from levels of evidence of the US Preventative Services Task Force. RESULTS Of a total of 29 studies identified, 20 were in kidney, 4 in heart, 4 in liver and 1 in lung transplantation and 7 were in pediatrics. A total of 14 studies were deemed to be Level I evidence studies, 3 were Level II-1, 1 was Level II-2 and 11 were Level III. CONCLUSIONS Although various LSSs that are well correlated to MPA AUC while being relatively unbiased and precise to predict MPA AUC have been developed, further research is needed to determine validity of these LSSs in a variety of patient populations and to determine if these LSSs improve patient outcomes.
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Kurnatowska I, Banasiak M, Daniel P, Wagrowska-Danilewicz M, Nowicki M. Two cases of severe de novo colitis in kidney transplant recipients after conversion to prolonged-release tacrolimus. Transpl Int 2009; 23:553-8. [PMID: 19951264 DOI: 10.1111/j.1432-2277.2009.01009.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Diarrhea is a frequent complication in patients after solid organ transplantation. We describe two cases of severe new onset colitis in kidney transplant recipients that developed shortly after the introduction of the therapy with prolonged-release formulation of tacrolimus replacing standard twice daily formulation of tacrolimus in one case and cyclosporine A in the second case. Both patients developed severe, intermittent bloody diarrhea with abdominal pain, weight loss, dehydration and worsening graft function that required immediate hospitalization. The symptoms did not diminish after dose reduction or withdrawal of mycophenolic acid derivatives. After excluding bacterial, viral, fungal, and parasite infections, colonoscopy with colonic biopsy was performed in both patients, which revealed features typical of colitis. Both patients received mesalazine until the symptoms stopped. In one of the patients, standard formulation of tacrolimus was immediately reintroduced. The second patient was given everolimus in an acute phase of diarrhea. Although the two cases presented in this report cannot fully support a causal relationship between the prolonged-release tacrolimus and colitis, they should increase awareness among transplant physicians and prompt more close monitoring of such potential side effects as a part of the pharmacovigilance plan for a new formulation of the well-established immunosuppressive drug.
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Affiliation(s)
- Ilona Kurnatowska
- Department of Nephrology, Hypertension and Kidney Transplantation, Medical University of Łódź, Łódź, Poland
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Abstract
PURPOSE OF REVIEW Adverse events due to drug-drug interactions remain a challenge in the postsurgical care of transplant recipients. A combination of potent and selective immunosuppressive drugs, which have a narrow therapeutic index, with medications for the treatment of comorbidities such as dyslipidemia, infection, psychiatric conditions, and hypertension, can lead to life-threatening drug-drug interactions. RECENT FINDINGS There are a number of important drug-drug interactions which are important for physicians to consider. It is critical to understand the pharmacodynamics and pharmacokinetics of drug-drug interactions, their potential impact on patient care, and the management strategies. SUMMARY Close therapeutic drug monitoring and evaluation of drug-specific side effects continue to be an important key to minimize adverse events due to drug-drug interactions.
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Kuypers DRJ. Immunotherapy in elderly transplant recipients: a guide to clinically significant drug interactions. Drugs Aging 2009; 26:715-37. [PMID: 19728747 DOI: 10.2165/11316480-000000000-00000] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Currently, >50% of candidates for solid organ transplantation in Europe and the US are aged >50 years while approximately 15% of potential recipients are aged >or=65 years. Elderly transplant candidates are characterized by specific co-morbidity profiles that compromise graft and patient outcome after transplantation. The presence of coronary artery or peripheral vascular disease, cerebrovascular disease, history of malignancy, chronic obstructive lung disease or diabetes mellitus further increases the early post-transplant mortality risk in elderly recipients, with infections and cardiovascular complications as the leading causes of death. Not only are elderly patients more prone to developing drug-related adverse effects, but they are also more susceptible to pharmacokinetic and pharmacodynamic drug interactions because of polypharmacy. The majority of currently used immunosuppressant drugs in organ transplantation are metabolized by cytochrome P450 (CYP) or uridine diphosphate-glucuronosyltransferases and are substrates of the multidrug resistance (MDR)-1 transporter P-glycoprotein, the MDR-associated protein 2 or the canalicular multispecific organic anion transporter, which predisposes these immunosuppressant compounds to specific interactions with commonly prescribed drugs. In addition, important drug interactions between immunosuppressant drugs have been identified and require attention when choosing an appropriate immunosuppressant drug regimen for the frail elderly organ recipient. An age-related 34% decrease in total body clearance of the calcineurin inhibitor ciclosporin was observed in elderly renal recipients (aged >65 years) compared with younger patients, while older recipients also had 44% higher intracellular lymphocyte ciclosporin concentrations. Similarly, using a Bayesian approach, an inverse relationship was noted between sirolimus clearance and age in stable kidney recipients. Ciclosporin and tacrolimus have distinct pharmacokinetics, but both are metabolized by intestinal and hepatic CYP3A4/3A5 and transported across the cell membrane by P-glycoprotein. The most common drug interactions with ciclosporin are therefore also observed with tacrolimus, but the two drugs do not interact identically when administered with CYP3A inhibitors or inducers. The strongest effects on calcineurin-inhibitor disposition are observed with azole antifungals, macrolide antibacterials, rifampicin, calcium channel antagonists, grapefruit juice, St John's wort and protease inhibitors. Drug interactions with mycophenolic acids occur mainly through inhibition of their enterohepatic recirculation, either by interference with the intestinal flora (antibacterials) or by limiting drug absorption (resins and binders). Rifampicin causes a reduction in mycophenolic acid exposure probably through induction of uridine diphosphate-glucuronosyltransferases. Proliferation signal inhibitors (PSIs) such as sirolimus and everolimus are substrates of CYP3A4 and P-glycoprotein and have a macrolide structure very similar to tacrolimus, which explains why common drug interactions with PSIs are comparable to those with calcineurin inhibitors. Ciclosporin, in contrast to tacrolimus, inhibits the enterohepatic recirculation of mycophenolic acids, resulting in significantly lower concentrations and hence risk of underexposure. Therefore, when switching from tacrolimus to ciclosporin and vice versa or when reducing or withdrawing ciclosporin, this interaction needs to be taken into account. The combination of ciclosporin with PSIs requires dose reductions of both drugs because of a synergistic interaction that causes nephrotoxicity when left uncorrected. Conversely, when switching between calcineurin inhibitors, intensified monitoring of PSI concentrations is mandatory. Increasing age is associated with structural and functional changes in body compartments and tissues that alter absorptive capacity, volume of distribution, hepatic metabolic function and renal function and ultimately drug disposition. While these age-related changes are well-known, few specific effects of the latter on immunosuppressant drug metabolism have been reported. Therefore, more clinical data from elderly organ recipients are urgently required.
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Affiliation(s)
- Dirk R J Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals of Leuven, Leuven, Belgium.
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Monchaud C, Marquet P. Pharmacokinetic optimization of immunosuppressive therapy in thoracic transplantation: part I. Clin Pharmacokinet 2009; 48:419-62. [PMID: 19691367 DOI: 10.2165/11317230-000000000-00000] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Although immunosuppressive treatments and therapeutic drug monitoring (TDM) have significantly contributed to the increased success of thoracic transplantation, there is currently no consensus on the best immunosuppressive strategies. Maintenance therapy typically consists of a triple-drug regimen including corticosteroids, a calcineurin inhibitor (ciclosporin or tacrolimus) and either a purine synthesis antagonist (mycophenolate mofetil or azathioprine) or a mammalian target of rapamycin inhibitor (sirolimus or everolimus). The incidence of acute and chronic rejection and of mortality after thoracic transplantation is still high compared with other types of solid organ transplantation. The high allogenicity and immunogenicity of the lungs justify the use of higher doses of immunosuppressants, putting lung transplant recipients at a higher risk of drug-induced toxicities. All immunosuppressants are characterized by large intra- and interindividual variability of their pharmacokinetics and by a narrow therapeutic index. It is essential to know their pharmacokinetic properties and to use them for treatment individualization through TDM in order to improve the treatment outcome. Unlike the kidneys and the liver, the heart and the lungs are not directly involved in drug metabolism and elimination, which may be the cause of pharmacokinetic differences between patients from all of these transplant groups. TDM is mandatory for most immunosuppressants and has become an integral part of immunosuppressive drug therapy. It is usually based on trough concentration (C(0)) monitoring, but other TDM tools include the area under the concentration-time curve (AUC) over the (12-hour) dosage interval or the AUC over the first 4 hours post-dose, as well as other single concentration-time points such as the concentration at 2 hours. Given the peculiarities of thoracic transplantation, a review of the pharmacokinetics and TDM of the main immunosuppressants used in thoracic transplantation is presented in this article. Even more so than in other solid organ transplant populations, their pharmacokinetics are characterized by wide intra- and interindividual variability in thoracic transplant recipients. The pharmacokinetics of ciclosporin in heart and lung transplant recipients have been explored in a number of studies, but less is known about the pharmacokinetics of mycophenolate mofetil and tacrolimus in these populations, and there are hardly any studies on the pharmacokinetics of sirolimus and everolimus. Given the increased use of these molecules in thoracic transplant recipients, their pharmacokinetics deserve to be explored in depth. There are very few data, some of which are conflicting, on the practices and outcomes of TDM of immunosuppressants after thoracic transplantation. The development of sophisticated TDM tools dedicated to thoracic transplantation are awaited in order to accurately evaluate the patients' exposure to drugs in general and, in particular, to immunosuppressants. Finally, large cohort TDM studies need to be conducted in thoracic transplant patients in order to identify the most predictive exposure indices and their target values, and to validate the clinical usefulness of improved TDM in these conditions. In part I of the article, we review the pharmacokinetics and TDM of calcineurin inhibitors. In part II, we will review the pharmacokinetics and TDM of mycophenolate and mammalian target of rapamycin inhibitors, and provide an overall discussion along with perspectives.
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Affiliation(s)
- Caroline Monchaud
- INSERM Unit 850, CHU Limoges, University of Limoges, Limoges, France
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Sabry W, Le Blanc R, Labbé AC, Sauvageau G, Couban S, Kiss T, Busque L, Cohen S, Lachance S, Roy DC, Roy J. Graft-versus-Host Disease Prophylaxis with Tacrolimus and Mycophenolate Mofetil in HLA-Matched Nonmyeloablative Transplant Recipients Is Associated with Very Low Incidence of GVHD and Nonrelapse Mortality. Biol Blood Marrow Transplant 2009; 15:919-29. [DOI: 10.1016/j.bbmt.2009.04.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Accepted: 04/07/2009] [Indexed: 10/20/2022]
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Rath T, Küpper M. Comparison of Inosine-Monophosphate-Dehydrogenase Activity in Patients With Enteric-Coated Mycophenolate Sodium or Mycophenolate Mofetil After Renal Transplantation. Transplant Proc 2009; 41:2524-8. [DOI: 10.1016/j.transproceed.2009.06.124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Pharmacokinetics of mycophenolic acid and its glucuronide metabolites in stable adult liver transplant recipients with renal dysfunction on a low-dose calcineurin inhibitor regimen and mycophenolate mofetil. Ther Drug Monit 2009; 31:205-10. [PMID: 19307937 DOI: 10.1097/ftd.0b013e31819743d9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Low-dose calcineurin inhibitors (CNIs) in combination with a fixed dose (2 g/d) of mycophenolate mofetil (MMF) are a strategy to minimize exposure to cyclosporine (CSA) or tacrolimus (TAC) and thus reduce CNI-related side effects. This study compared the pharmacokinetics (PK) of mycophenolic acid (MPA) and its glucuronide metabolites in stable adult liver transplant recipients with moderately impaired renal function converted from a standard to a low-dose CNI regimen in combination with a fixed dose of MMF. Full 12-hour PK profiles of MPA, free MPA, the aryl glucuronide (MPAG), and the acyl glucuronide (AcMPAG) were obtained from 30 stable liver transplant patients on low-dose CNI (CSA, n = 12; TAC, n = 18) therapy at least 3 months after initiation of low-dose therapy. Predose CSA and TAC concentrations (quantified by liquid chromatography-tandem mass spectrometry) ranged from 17 to 35 and 1.1 to 3.7 microg/L, respectively. The PK variables for MPA, MPAG, AcMPAG, and free MPA displayed wide interindividual variability. Of note was the observation that there were no significant differences in the exposure to MPA, MPAG, and free MPA between the CSA and TAC groups. MPA area under the concentration-time curves (AUCs) ranged from 31.8 to 102.1 (median: 52.9) mg.h(-1).L(-1) in the CSA group and from 22.9 to 144.8 (median: 55.9) mg.h(-1).L(-1) in the TAC group. The AcMPAG AUC on patients under low-dose CSA therapy was higher than that observed under patients on low-dose TAC therapy, although this did not quite reach statistical significance (P = 0.057). Patients receiving CSA had a significantly higher AcMPAG Cmax but not AcMPAG AUC, suggesting that only peak CSA concentrations on a low-dose CSA regimen are sufficient to impair the biliary excretion of AcMPAG. In summary, the influence of CSA on the exposure to MPA was attenuated in stable adult liver transplant recipients on a low-dose CNI therapy in combination with a fixed dose of MMF as compared with patients on a standard CNI therapy. Dose adjustment according to drug concentration measurements is recommended to optimize dosing of MMF and to maintain adequate immunosuppression in patients converted to low-dose CNI therapy.
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Grinyó JM, Ekberg H, Mamelok RD, Oppenheimer F, Sánchez-Plumed J, Gentil MA, Hernandez D, Kuypers DR, Brunet M. The pharmacokinetics of mycophenolate mofetil in renal transplant recipients receiving standard-dose or low-dose cyclosporine, low-dose tacrolimus or low-dose sirolimus: the Symphony pharmacokinetic substudy. Nephrol Dial Transplant 2009; 24:2269-76. [PMID: 19357111 DOI: 10.1093/ndt/gfp162] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Exposure to mycophenolic acid (MPA), the primary active metabolite of mycophenolate mofetil (MMF), is correlated with therapeutic efficacy of MMF but varies depending on the concomitantly administered immunosuppressive drugs. METHODS A 3-month pharmacokinetic substudy of the prospective, randomized, multicentre, open-label Symphony study was performed. Eighty-three adult renal transplant patients received standard-dose cyclosporine, MMF 2 g/day and corticosteroids, or daclizumab induction, MMF 2 g/day and corticosteroids plus low-dose cyclosporine, low-dose tacrolimus or low-dose sirolimus. The area under the concentration-time curve (AUC(0-12)) of MPA and its metabolites between treatment groups was compared. Pharmacokinetic sampling was performed before MMF administration and at 20, 40, 75 min; 2, 3, 6, 8, 10 and 12 h post-dose on Day 7 and Months 1 and 3. RESULTS Compared with standard-dose cyclosporine, patients receiving low-dose tacrolimus or low-dose sirolimus had significantly higher AUC(0-12) values for MPA at Day 7 and Month 1 and for free MPA at Day 7, and significantly lower AUC(0-12) values for 7-O-MPA-glucuronide (MPAG) at Month 1 and for acyl-glucuronide at Months 1 and 3 (P < 0.05). AUC(0-12) of MPA and free MPA was significantly greater with low-dose tacrolimus and low-dose sirolimus than with low-dose cyclosporine in the first month (P < 0.05). The ratio of MPA to MPAG exposure was significantly higher in the three low-dose groups than in the standard-dose cyclosporine group (P < 0.05). CONCLUSIONS Standard- and low-dose cyclosporine reduces the exposure of MPA and free MPA compared to low-dose tacrolimus or low-dose sirolimus in patients given the same dose of MMF.
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Evaluation of mycophenolate mofetil for initial treatment of chronic graft-versus-host disease. Blood 2009; 113:5074-82. [PMID: 19270260 DOI: 10.1182/blood-2009-02-202937] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We conducted a double-blind, randomized multicenter trial to determine whether the addition of mycophenolate mofetil (MMF) improves the efficacy of initial systemic treatment of chronic graft-versus-host disease (GVHD). The primary endpoint was resolution of chronic GVHD and withdrawal of all systemic treatment within 2 years, without secondary treatment. Enrollment of 230 patients was planned, providing 90% power to observe a 20% difference in success rates between the 2 arms. The study was closed after 4 years because the interim estimated cumulative incidence of success for the primary endpoint was 23% among 74 patients in the MMF arm and 18% among 77 patients in the control arm, indicating a low probability of positive results for the primary endpoint after completing the study as originally planned. Analysis of secondary endpoints showed no evidence of benefit from adding MMF to the systemic regimen first used for treatment of chronic GVHD. The estimated hazard ratio of death was 1.99 (95% confidence interval, 0.9-4.3) among patients in the MMF arm compared with the control arm. MMF should not be added to the initial systemic treatment regimen for chronic GVHD. This trial was registered at www.clinicaltrials.gov as #NCT00089141 on August 4, 2004.
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Nashan B, Saliba F, Durand F, Barcéna R, Herrero JI, Mentha G, Neuhaus P, Bowles M, Patch D, Bernardos A, Klempnauer J, Bouw R, Ives J, Mamelok R, McKay D, Truman M, Marotta P. Pharmacokinetics, efficacy, and safety of mycophenolate mofetil in combination with standard-dose or reduced-dose tacrolimus in liver transplant recipients. Liver Transpl 2009; 15:136-47. [PMID: 19177449 DOI: 10.1002/lt.21657] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The pharmacokinetics of mycophenolate mofetil (MMF) in liver transplant recipients may change because of pharmacokinetic interactions with coadministered immunosuppressants or because changes in the enterohepatic anatomy may affect biotransformation of MMF to mycophenolic acid (MPA) and enterohepatic recirculation of MPA through the hydrolysis of mycophenolate acid glucuronide to MPA in the gut. In the latter case, the choice of formulation (oral versus intravenous) could have important clinical implications. We randomized liver transplant patients (n = 60) to standard (10-15 ng/mL) or reduced (5-8 ng/mL) trough levels of tacrolimus plus intravenous MMF followed by oral MMF (1 g twice daily) with corticosteroids. Pharmacokinetic sampling was performed after the last intravenous MMF dose, after the first oral MMF dose, and at selected times over 52 weeks. The efficacy and safety of the 2 regimens were also assessed. Twenty-eight and 27 patients in the tacrolimus standard-dose and reduced-dose groups, respectively, were evaluated. No significant differences between the tacrolimus standard-dose and reduced-dose groups were seen in dose-normalized MPA values of the time to the maximum plasma concentration (1.25 versus 1.28 hours), the maximum plasma concentration (15.5 +/- 7.93 versus 13.6 +/- 7.03 microg/mL), or the area under the concentration-time curve from 0 to 12 hours (AUC(0-12); 53.0 +/- 20.6 versus 43.8 +/- 15.5 microg h/mL) at week 26 or at any other time point. No relationship was observed between the tacrolimus trough or AUC(0-12) and MPA AUC(0-12). Exposure to MPA after oral and intravenous administration was similar. Safety and efficacy were similar in the two treatment groups. In conclusion, exposure to MPA is not a function of exposure to tacrolimus. The similar safety and efficacy seen with MMF plus standard or reduced doses of tacrolimus suggest that MMF could be combined with reduced doses of tacrolimus.
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Affiliation(s)
- Björn Nashan
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Jacobson P, El-Massah SF, Rogosheske J, Kerr A, Long-Boyle J, DeFor T, Jennissen C, Brunstein C, Wagner J, Tomblyn M, Weisdorf D. Comparison of two mycophenolate mofetil dosing regimens after hematopoietic cell transplantation. Bone Marrow Transplant 2009; 44:113-20. [PMID: 19151792 DOI: 10.1038/bmt.2008.428] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Mycophenolic acid (MPA) is the active component of mycophenolate mofetil (MMF). Low MPA exposure is associated with a higher incidence of acute GVHD and possibly worse engraftment. Therapeutic plasma targets have been proposed in hematopoietic cell transplantation (HCT), however, are difficult to achieve in adult patients with MMF doses of 2 g/day. Mycophenolate pharmacokinetics was prospectively studied in adults undergoing nonmyeloablative HCT who received MMF 3 g/day with CYA. The first 15 individuals received 1.5 g every 12 h and the second 15 received 1 g every 8 h. Sampling was performed in each patient with i.v. and oral administration. There were no differences in total or unbound MPA 24-h cumulative area under the curves (AUCs), concentrations at steady state (Css) or troughs between the two dosing regimens (all P>0.01). The previously proposed total MPA Css target of 3 microg/ml and trough >or=1 micro/ml were achieved in only 13-27% and 20-53% of patients, respectively, on 3 g/day. However, the 3 g/day regimens readily achieved satisfactory unbound 24-h cumulative AUC targets of 0.600 microg(*)h/ml in 87-100% of subjects. There appears to be no significant difference in daily MPA exposure when MMF of 3 g/day is divided into two or three equal doses.
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Affiliation(s)
- P Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA.
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Zahr N, Amoura Z, Debord J, Hulot JS, Saint-Marcoux F, Marquet P, Piette JC, Lechat P. Pharmacokinetic study of mycophenolate mofetil in patients with systemic lupus erythematosus and design of Bayesian estimator using limited sampling strategies. Clin Pharmacokinet 2008; 47:277-84. [PMID: 18336056 DOI: 10.2165/00003088-200847040-00005] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Monitoring of the area under the plasma concentration-time curve (AUC) of mycophenolic acid (MPA) has been developed for individual dose adjustment of mycophenolate mofetil (MMF) in renal allograft recipients. MMF is currently used as an off-label drug in the treatment of systemic lupus erythematosus (SLE), but factors of its exposition may be different in these patients and need to be determined for therapeutic drug monitoring (TDM) purposes. OBJECTIVE The aim of the study was to develop a maximum a posteriori probability (MAP) Bayesian estimator of MPA exposition in patients with SLE, with the objective of TDM based on a limited sample strategy. METHODS Twenty adult patients with SLE given a stable 1 g/day, 2 g/day or 3 g/day dose of MMF orally for at least 10 weeks were included in the study. MPA was measured by high-performance liquid chromatography (HPLC) coupled to a photodiode array detector (11 plasma measurements over 12 hours post-dose per patient). Free MPA concentrations were measured by HPLC with fluorescence detection. Two different one-compartment models with first-order elimination were tested to fit the data: one convoluted with a double gamma distribution to describe secondary concentrations peaks, and one convoluted with a triple gamma distribution to model a third, later peak. RESULTS A large interindividual variability in MPA concentration-time profiles was observed. The mean maximum plasma concentration, trough plasma concentration, time to reach the maximum plasma concentration and AUC from 0 to 12 hours (AUC(12)) were 13.6 +/- 8.4 microg/mL, 1.4 +/- 1.2 microg/mL, 1.1 +/- 1.2 hours and 32.2 +/- 17.1microg . h/mL, respectively. The mean free fraction of MPA was 1.7%. The one-compartment model with first-order elimination convoluted with a triple gamma distribution best fitted the data. Accurate Bayesian estimates of the AUC(12) were obtained using three blood samples collected at 40 minutes, 2 hours and 3 hours, with a coefficient of correlation (R) = 0.95 between the observed and predicted AUC(12) and with a difference of <20% in 16 of the 20 patients. CONCLUSION A specific pharmacokinetic model was built to accurately fit MPA blood concentration-time profiles after MMF oral dosing in SLE patients, which allowed development of an accurate Bayesian estimator of MPA exposure that should allow MMF monitoring based on the AUC(12) in these patients. The predictive value of targeting one specific or different AUC values on patients' outcome using this estimator in SLE will need to be evaluated.
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Affiliation(s)
- Noël Zahr
- Department of Pharmacology, Pitié-Salpêtrière Hospital, Faculté Pierre et Marie Curie, Paris VI, Assistance Publique Hôpitaux de Paris, Paris, France.
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Hao C, Anwei M, Bing C, Baiyong S, Weixia Z, Chuan S, Erzhen C, Xiaxing D, Weihua Q, Weiping Y, Chenghong P, Hongwei L. Monitoring mycophenolic acid pharmacokinetic parameters in liver transplant recipients: prediction of occurrence of leukopenia. Liver Transpl 2008; 14:1165-73. [PMID: 18668650 DOI: 10.1002/lt.21600] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Mycophenolate mofetil (MMF) is a very powerful immunosuppressive drug used in preventing acute rejection in liver transplantation. However, MMF has some serious side effects, including hematologic and gastrointestinal disorders. This study was designed to investigate the relationship between the clinical events and the pharmacokinetics of mycophenolic acid (MPA) in Chinese liver transplant recipients. Sixty-three adult liver transplant recipients receiving 1.0 g of MMF twice daily in combination with tacrolimus were prospectively included. The MPA pharmacokinetic profiles (blood sampling time points: before the dose and 0.5, 1, 1.5, 2, 4, 6, 8, 10, and 12 hours after the dose) were monitored after transplantation. Every clinical event, including acute and MMF-related side effects, was monitored in all patients within 3 months. Two patients (3.2%) had an episode of acute rejection. Forty-two patients (66.7%) had 52 episodes of MMF-related side effects, including leukopenia, diarrhea, and infection. The 0-hour concentration (C(0h)), maximum (peak) concentration (C(max)), and area under the curve from 0 to 12 hours (AUC(0-12h)) in patients with side effects were significantly higher than those in patients without side effects (P < 0.05). The thresholds of side effects from receiver operating characteristic analysis were 2 mg/L (sensitivity, 52.4%; specificity, 90.5%) for C(0h), 10 mg/L (sensitivity, 45.2%; specificity, 85.7%) for C(max), and 40 mg h/L (sensitivity, 71.4%; specificity, 61.9%) for AUC(0-12h) (P < 0.05). Leukopenia was discriminated effectively in C(0h) and in C(max) (P < 0.05). These results demonstrate the close relationship between leukopenia and MPA pharmacokinetic parameters in the early period after liver transplantation. C(0h) and AUC(0-12h) of MPA could predict the subsequent occurrence of leukopenia. These values may be used in routine monitoring for MMF therapy.
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Affiliation(s)
- Chen Hao
- Center of Organ Transplantation, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China.
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