1
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Park HJ, Hong KT, Han N, Kim IW, Oh JM, Kang HJ. Body Surface Area-Based Dosing of Mycophenolate Mofetil in Pediatric Hematopoietic Stem Cell Transplant Recipients: A Prospective Population Pharmacokinetic Study. Pharmaceutics 2023; 15:2741. [PMID: 38140082 PMCID: PMC10748085 DOI: 10.3390/pharmaceutics15122741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/03/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
Mycophenolate mofetil (MMF) is commonly used for acute graft-versus-host disease (aGVHD) after allogeneic hematopoietic stem cell transplantation (HSCT). However, limited population pharmacokinetic (PPK) data are available for pediatric HSCT patients. This study aimed to develop a PPK model and recommend optimal oral MMF dosage in pediatric HSCT patients. This prospective study involved pediatric HSCT patients at a tertiary academic institution. Patients received oral MMF 15-20 mg/kg twice daily for aGVHD prophylaxis and treatment. The PPK analysis was conducted using a nonlinear mixed-effects modeling method. Simulation was performed considering different body surface areas (BSAs) (0.5 m2, 1.0 m2, 1.5 m2) and dosing (400 mg/m2, 600 mg/m2, 900 mg/m2 twice daily). Based on the simulation, an optimal dosage of oral MMF was suggested. A total of 20 patients and 80 samples were included in the PPK model development. A one-compartment model with first-order absorption adequately described the pharmacokinetics of mycophenolic acid (MPA). BSA was a statistically significant covariate on Vd/F. Simulation suggested the optimal dosage of oral MMF as 900 mg/m2 twice daily, respectively. A reliable PPK model was developed with good predictive performance. This model-informed optimal MMF dosage in pediatric HSCT patients can provide valuable dosing guidance in real-world clinical practice.
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Affiliation(s)
- Hyun Jin Park
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 08826, Republic of Korea; (H.J.P.); (N.H.); (I.-W.K.)
| | - Kyung Taek Hong
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Cancer Research Institute, Seoul National University Children’s Hospital, Seoul 03080, Republic of Korea;
| | - Nayoung Han
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 08826, Republic of Korea; (H.J.P.); (N.H.); (I.-W.K.)
- College of Pharmacy, Jeju National University, Jeju 63243, Republic of Korea
| | - In-Wha Kim
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 08826, Republic of Korea; (H.J.P.); (N.H.); (I.-W.K.)
| | - Jung Mi Oh
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 08826, Republic of Korea; (H.J.P.); (N.H.); (I.-W.K.)
| | - Hyoung Jin Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Cancer Research Institute, Seoul National University Children’s Hospital, Seoul 03080, Republic of Korea;
- Wide River Institute of Immunology, Hongcheon 25159, Republic of Korea
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2
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Hassan S, Hassanain O, Kamal S, Shalaby L, Nagy M. Knowledge, attitudes and practices of Egyptian healthcare professionals toward therapeutic drug monitoring service as a principal component of personalized medicine. Per Med 2022; 19:509-521. [DOI: 10.2217/pme-2022-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim: To assess pharmacists' and physicians' knowledge, attitudes and practices toward therapeutic drug monitoring (TDM) service at the Children's Cancer Hospital Egypt 57357. Materials & methods: This was a single-site cross-sectional study where all practicing pharmacists and physicians were eligible to participate. Results: A statistically significant difference in the knowledge scores between pharmacists and physicians (p = 0.022) was found. In general, attitudes toward TDM among pharmacists and physicians were positive. Regarding practices, pharmacists were more likely than physicians to agree or strongly agree that they have studied some scientific references on TDM (p = 0.034), but more physicians recommend the TDM service (p = 0.046). Conclusion: A multidisciplinary educational program in Egypt for TDM for both medicine and pharmacy staff will improve interprofessional collaboration in the clinical setting, leading to better personalized medication management.
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Affiliation(s)
- Sahar Hassan
- Department of Pharmaceutical Services, Children's Cancer Hospital Egypt, Cairo, 57357, Egypt
- Department of Clinical Pharmacy, Saarland University, Campus C5 3, Saarbrücken, 66123, Germany
| | - Omneya Hassanain
- Epidemiology and Biostatistics Unit, Department of Clinical Research, Children's Cancer Hospital Egypt, Cairo, 57357, Egypt
| | - Sherif Kamal
- Department of Pharmaceutical Services, Children's Cancer Hospital Egypt, Cairo, 57357, Egypt
| | - Lobna Shalaby
- Infectious Disease Unit, Children's Cancer Hospital Egypt, Cairo, 57357, Egypt
- Department of Pediatric Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mohamed Nagy
- Department of Pharmaceutical Services, Children's Cancer Hospital Egypt, Cairo, 57357, Egypt
- Personalized Medication Management Unit, Children's Cancer Hospital Egypt, Cairo, 57357, Egypt
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3
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Gota V, Purohit V, Gurjar M, Nayak L, Punatar S, Gokarn A, Bonda A, Bagal B, Vora CS, Patil A, Nookala M, Khattry N. A Limited Sampling Strategy for Therapeutic Drug Monitoring of Mycophenolate Mofetil for Prophylaxis of Acute Graft-Versus-Host Disease in Allogeneic Stem Cell Transplantation. Cell Transplant 2021; 29:963689720912925. [PMID: 32495641 PMCID: PMC7444217 DOI: 10.1177/0963689720912925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A universally accepted strategy for therapeutic drug monitoring (TDM) of
mycophenolate mofetil (MMF) in the prevention of acute graft-versus-host disease
(aGVHD) in allogenic hematopoietic stem cell transplantation (alloHSCT) does not
exist. We explored the feasibility of developing a limited sampling strategy
(LSS) for TDM of MMF in this setting. Patients undergoing alloHSCT received
standard MMF-cyclosporine prophylaxis, with MMF administered twice daily (BD)
for matched transplant recipients or thrice daily (TID) in haploidentical
transplantation. Intensive blood sampling was carried out on day 7 and area
under the concentration–time curve (AUC) of mycophenolic acid (MPA), the active
metabolite, was estimated using noncompartmental analysis. The ability of MPA
exposure defined by AUC0-12 to discriminate between responders
(patients who did not develop GVHD) and nonresponders (patients who developed
GVHD) was determined by receiver operating characteristic curve analysis.
Patients were divided into training and validation sets within BD and TID
groups. Mathematical equations were developed from the training set to predict
AUC0-12 from an abbreviated AUC involving a limited number of
sampling points. The equations were validated in the validation set by comparing
the MPA AUC0-12 predicted from LSS with the observed
AUC0-12. It was observed that patients with AUC0-12
≤18.99 mg*h/L had a higher risk of developing aGVHD [odds ratio (OR) = 2.63
(1.17 to 5.87), P = 0.06]. The benefit was more in matched
transplant recipients [OR = 3.5 (1.30 to 9.49), P = 0.05] as
compared to haploindentical transplant [OR = 2.8 (0.49 to 15.91),
P = NS]. Using the mathematical equations, the observed
AUC0-12 was predicted with 92.31% accuracy in the BD subset and
100% accuracy in the TID subset for a combined accuracy of 94.76%. A set of just
three samples that constituted the abbreviated AUC1-4 was used to
develop the predictive models. The LSS could be employed for the therapeutic
monitoring of MMF particularly in patients undergoing matched hematopoietic stem
cell transplantation.
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Affiliation(s)
- Vikram Gota
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharastra, India
| | - Vaitashi Purohit
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Murari Gurjar
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Lingaraj Nayak
- Homi Bhabha National Institute, Mumbai, Maharastra, India.,Bone Marrow Transplant Unit, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Sachin Punatar
- Homi Bhabha National Institute, Mumbai, Maharastra, India.,Bone Marrow Transplant Unit, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Anant Gokarn
- Homi Bhabha National Institute, Mumbai, Maharastra, India.,Bone Marrow Transplant Unit, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Avinash Bonda
- Homi Bhabha National Institute, Mumbai, Maharastra, India.,Bone Marrow Transplant Unit, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Bhausaheb Bagal
- Homi Bhabha National Institute, Mumbai, Maharastra, India.,Bone Marrow Transplant Unit, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Chakor Sunil Vora
- Homi Bhabha National Institute, Mumbai, Maharastra, India.,Bone Marrow Transplant Unit, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Anand Patil
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Manjunath Nookala
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
| | - Navin Khattry
- Homi Bhabha National Institute, Mumbai, Maharastra, India.,Bone Marrow Transplant Unit, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India
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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: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/29/2021] [Indexed: 12/13/2022]
Abstract
ABSTRACT When mycophenolic acid (MPA) was originally marketed for immunosuppressive therapy, fixed doses were recommended by the manufacturer. Awareness of the potential for a more personalized dosing has led to development of methods to estimate MPA area under the curve based on the measurement of drug concentrations in only a few samples. This approach is feasible in the clinical routine and has proven successful in terms of correlation with outcome. However, the search for superior correlates has continued, and numerous studies in search of biomarkers that could better predict the perfect dosage for the individual patient have been published. As it was considered timely for an updated and comprehensive presentation of consensus on the status for personalized treatment with MPA, this report was prepared following an initiative from members of the International Association of Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT). Topics included are the criteria for analytics, methods to estimate exposure including pharmacometrics, the potential influence of pharmacogenetics, development of biomarkers, and the practical aspects of implementation of target concentration intervention. For selected topics with sufficient evidence, such as the application of limited sampling strategies for MPA area under the curve, graded recommendations on target ranges are presented. To provide a comprehensive review, this report also includes updates on the status of potential biomarkers including those which may be promising but with a low level of evidence. In view of the fact that there are very few new immunosuppressive drugs under development for the transplant field, it is likely that MPA will continue to be prescribed on a large scale in the upcoming years. Discontinuation of therapy due to adverse effects is relatively common, increasing the risk for late rejections, which may contribute to graft loss. Therefore, the continued search for innovative methods to better personalize MPA dosage is warranted.
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Affiliation(s)
- Stein Bergan
- Department of Pharmacology, Oslo University Hospital and Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Mercè Brunet
- Pharmacology and Toxicology Laboratory, Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBERehd, Spain
| | - Dennis A Hesselink
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Kamisha L Johnson-Davis
- Department of Pathology, University of Utah Health Sciences Center and ARUP Laboratories, Salt Lake City, Utah
| | - Paweł K Kunicki
- Department of Drug Chemistry, Faculty of Pharmacy, Medical University of Warsaw, Warszawa, Poland
| | - Florian Lemaitre
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, Rennes, France
| | - Pierre Marquet
- INSERM, Université de Limoges, Department of Pharmacology and Toxicology, CHU de Limoges, U1248 IPPRITT, Limoges, France
| | - Mariadelfina Molinaro
- Clinical and Experimental Pharmacokinetics Lab, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Ofelia Noceti
- National Center for Liver Tansplantation and Liver Diseases, Army Forces Hospital, Montevideo, Uruguay
| | | | - Tomasz Pawinski
- Department of Drug Chemistry, Faculty of Pharmacy, Medical University of Warsaw, Warszawa, Poland
| | | | - Maria Shipkova
- Synlab TDM Competence Center, Synlab MVZ Leinfelden-Echterdingen GmbH, Leinfelden-Echterdingen, Germany
| | - Jesse J Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Teun van Gelder
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy and Department of Pathology, Starzl Transplantation Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eberhard Wieland
- Synlab TDM Competence Center, Synlab MVZ Leinfelden-Echterdingen GmbH, Leinfelden-Echterdingen, Germany
| | - Jean-Baptiste Woillard
- INSERM, Université de Limoges, Department of Pharmacology and Toxicology, CHU de Limoges, U1248 IPPRITT, Limoges, France
| | - Tom C Zwart
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Markus J Barten
- Department of Cardiac- and Vascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Maja-Theresa Dieterlen
- Department of Cardiac Surgery, Heart Center, HELIOS Clinic, University Hospital Leipzig, Leipzig, Germany
| | - Laure Elens
- Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics (PMGK) Research Group, Louvain Drug Research Institute (LDRI), Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Vincent Haufroid
- Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut de Recherche Expérimentale et Clinique, UCLouvain and Department of Clinical Chemistry, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Satohiro Masuda
- Department of Pharmacy, International University of Health and Welfare Narita Hospital, Chiba, Japan
| | - Olga Millan
- Pharmacology and Toxicology Laboratory, Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBERehd, Spain
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Dirk J A R Moes
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Michael Oellerich
- Department of Clinical Pharmacology, University Medical Center Göttingen, Georg-August-University Göttingen, Göttingen, Germany
| | - Nicolas Picard
- INSERM, Université de Limoges, Department of Pharmacology and Toxicology, CHU de Limoges, U1248 IPPRITT, Limoges, France
| | | | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Nils Tore Vethe
- Department of Pharmacology, Oslo University Hospital and Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Alexander A Vinks
- Department of Pharmacy, International University of Health and Welfare Narita Hospital, Chiba, Japan
| | - Pierre Wallemacq
- Clinical Chemistry Department, Cliniques Universitaires St Luc, Université Catholique de Louvain, LTAP, Brussels, Belgium
| | - Anders Åsberg
- Department of Transplantation Medicine, Oslo University Hospital-Rikshospitalet and Department of Pharmacy, University of Oslo, Oslo, Norway; and
| | - Loralie J Langman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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5
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Wölfl M, Qayed M, Benitez Carabante MI, Sykora T, Bonig H, Lawitschka A, Diaz-de-Heredia C. Current Prophylaxis and Treatment Approaches for Acute Graft-Versus-Host Disease in Haematopoietic Stem Cell Transplantation for Children With Acute Lymphoblastic Leukaemia. Front Pediatr 2021; 9:784377. [PMID: 35071133 PMCID: PMC8771910 DOI: 10.3389/fped.2021.784377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/09/2021] [Indexed: 11/13/2022] Open
Abstract
Acute graft-versus-host disease (aGvHD) continues to be a leading cause of morbidity and mortality following allogeneic haematopoietic stem cell transplantation (HSCT). However, higher event-free survival (EFS) was observed in patients with acute lymphoblastic leukaemia (ALL) and grade II aGvHD vs. patients with no or grade I GvHD in the randomised, controlled, open-label, international, multicentre Phase III For Omitting Radiation Under Majority age (FORUM) trial. This finding suggests that moderate-severity aGvHD is associated with a graft-versus-leukaemia effect which protects against leukaemia recurrence. In order to optimise the benefits of HSCT for leukaemia patients, reduction of non-relapse mortality-which is predominantly caused by severe GvHD-is of utmost importance. Herein, we review contemporary prophylaxis and treatment options for aGvHD in children with ALL and the key challenges of aGvHD management, focusing on maintaining the graft-versus-leukaemia effect without increasing the severity of GvHD.
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Affiliation(s)
- Matthias Wölfl
- Pediatric Hematology, Oncology and Stem Cell Transplantation, Children's Hospital, Würzburg University Hospital, Würzburg, Germany
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Maria Isabel Benitez Carabante
- Department of Pediatric Hematology and Oncology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Tomas Sykora
- Haematopoietic Stem Cell Transplantation Unit, Department of Pediatric Haematology and Oncology, Comenius University Children's Hospital, Bratislava, Slovakia
| | - Halvard Bonig
- Institute for Transfusion Medicine and Immunohematology, Goethe-University Frankfurt/Main, Frankfurt, Germany.,German Red Cross Blood Service BaWüHe, Frankfurt, Germany
| | - Anita Lawitschka
- Department of Pediatrics, St. Anna Kinderspital and Children's Cancer Research Institute, Medical University of Vienna, Vienna, Austria
| | - Cristina Diaz-de-Heredia
- Department of Pediatric Hematology and Oncology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
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6
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Chung H, Hong KT, Lee JW, Rhee SJ, Kim S, Yoon SH, Yu KS, Kang HJ. Pharmacokinetics of fludarabine and its association with clinical outcomes in paediatric haematopoietic stem cell transplantation patients. Bone Marrow Transplant 2018; 54:284-292. [DOI: 10.1038/s41409-018-0260-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 05/15/2018] [Accepted: 05/31/2018] [Indexed: 12/21/2022]
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7
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Zhang D, Chow DSL. Clinical Pharmacokinetics of Mycophenolic Acid in Hematopoietic Stem Cell Transplantation Recipients. Eur J Drug Metab Pharmacokinet 2017; 42:183-189. [PMID: 27677732 DOI: 10.1007/s13318-016-0378-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mycophenolate mofetil (MMF), an ester prodrug of mycophenolic acid (MPA), is widely used as a maintenance immunosuppressive regimen in solid organ transplant patients. It is increasingly used for the prophylaxis and treatment of graft-versus-host disease (GVHD) in hematopoietic stem cell transplantation (HSCT) patients. MPA displays extensive binding to serum albumin and glucuronidation to the inactive MPA-7-O-glucuronide (MPAG). Here, we review and discuss the pertinent information regarding the clinical pharmacokinetics of MPA in HSCT patients. The pharmacokinetics of MPA are altered in HSCT patients with lower oral bioavailability, shorter half-life and higher clearance than those in healthy volunteers and renal transplant recipients. Moreover, clearance may be increased in young pediatric patients. The optimal MMF dosing and preferred targets are still under investigation in HSCT patients due to the substantial intra- and inter-individual pharmacokinetic variability of MPA and broad range of transplants (malignant vs. nonmalignant, related vs. unrelated donor, and human leukocyte antigen mismatch). The complex pharmacokinetics of MPA have partly hampered the efficient use of MMF, and pharmacokinetic studies in HSCT patients have been limited in size and mostly inconclusive. Future research should be multi-institutional and focus on developing clinical decisions with adequate statistical power to improve clinical care of HSCT recipients.
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Affiliation(s)
- Daping Zhang
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, 1441 Moursund Street, Houston, TX, 77030, USA.
| | - Diana S-L Chow
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, 1441 Moursund Street, Houston, TX, 77030, USA
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8
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Pharmacokinetics, Pharmacodynamics, and Pharmacogenomics of Immunosuppressants in Allogeneic Hematopoietic Cell Transplantation: Part II. Clin Pharmacokinet 2016; 55:551-93. [PMID: 26620047 DOI: 10.1007/s40262-015-0340-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Part I of this article included a pertinent review of allogeneic hematopoietic cell transplantation (alloHCT), the role of postgraft immunosuppression in alloHCT, and the pharmacokinetics, pharmacodynamics, and pharmacogenomics of the calcineurin inhibitors and methotrexate. In this article (Part II), we review the pharmacokinetics, pharmacodynamics, and pharmacogenomics of mycophenolic acid (MPA), sirolimus, and the antithymocyte globulins (ATG). We then discuss target concentration intervention (TCI) of these postgraft immunosuppressants in alloHCT patients, with a focus on current evidence for TCI and on how TCI may improve clinical management in these patients. Currently, TCI using trough concentrations is conducted for sirolimus in alloHCT patients. Several studies demonstrate that MPA plasma exposure is associated with clinical outcomes, with an increasing number of alloHCT patients needing TCI of MPA. Compared with MPA, there are fewer pharmacokinetic/dynamic studies of rabbit ATG and horse ATG in alloHCT patients. Future pharmacokinetic/dynamic research of postgraft immunosuppressants should include '-omics'-based tools: pharmacogenomics may be used to gain an improved understanding of the covariates influencing pharmacokinetics as well as proteomics and metabolomics as novel methods to elucidate pharmacodynamic responses.
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9
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Jaiswal SR, Chakrabarti A, Chatterjee S, Ray K, Chakrabarti S. Haploidentical transplantation in children with unmanipulated peripheral blood stem cell graft: The need to look beyond post-transplantation cyclophosphamide in younger children. Pediatr Transplant 2016; 20:675-82. [PMID: 27217372 DOI: 10.1111/petr.12724] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2016] [Indexed: 12/21/2022]
Abstract
Haploidentical transplantation with PTCY following marrow or PBSC graft has been associated with low incidence of GVHD in adults with similar data lacking in children. We report on the outcome of 25 patients <20 yr of age (median age 12 yr), undergoing a haploidentical PBSC transplantation for both malignant and non-malignant disorders. Engraftment was prompt and sustained. Cumulative incidences of acute GVHD and chronic GVHD were 40.3% and 16.7%, respectively. On subgroup analysis, it was evident that acute GVHD developed in 80% of patients <10 yr compared to only 13.3% in those between 10 and 20 yr [log-rank p = 0.001], despite similar graft composition with significantly higher NRM (60% vs. 0%; p = 0.001). The FFS was 63.5%; (79% in >10 yr and 40% in <10 yr, p = 0.01). Our data suggest that PTCY-based haploidentical PBSC transplantation is feasible in older children, but results in early and severe alloreactivity in younger children. These findings, despite being counterintuitive, could be explained by the variable metabolism of CY and oral mycophenolate in younger children indicating that PTCY-based approach as used in adults might not be adequate for younger children.
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Affiliation(s)
- Sarita Rani Jaiswal
- Department of Blood and Marrow Transplantation, Dharamshila Hospital and Research Centre, New Delhi, India.,Manashi Chakrabarti Foundation, Kolkata, India
| | | | - Sumita Chatterjee
- Manashi Chakrabarti Foundation, Kolkata, India.,Apollo Gleneagles Hospital, Kolkata, India
| | - Kunal Ray
- CSIR-Indian Institute of Chemical Biology, Kolkata, India.,Academy of Scientific and Innovative Research, CSIR-CRRI, New Delhi, India
| | - Suparno Chakrabarti
- Department of Blood and Marrow Transplantation, Dharamshila Hospital and Research Centre, New Delhi, India.,Manashi Chakrabarti Foundation, Kolkata, India
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10
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Bocci G, Kerbel RS. Pharmacokinetics of metronomic chemotherapy: a neglected but crucial aspect. Nat Rev Clin Oncol 2016; 13:659-673. [DOI: 10.1038/nrclinonc.2016.64] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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11
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A Pilot Study of Continuous Infusion of Mycophenolate Mofetil for Prophylaxis of Graft-versus-Host-Disease in Pediatric Patients. Biol Blood Marrow Transplant 2016; 22:682-689. [DOI: 10.1016/j.bbmt.2015.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 12/15/2015] [Indexed: 12/30/2022]
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