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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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Wei Y, Wu D, Chen Y, Dong C, Qi J, Wu Y, Cai R, Zhou S, Li C, Niu L, Wu T, Xiao Y, Liu T. Population pharmacokinetics of mycophenolate mofetil in pediatric patients early after liver transplantation. Front Pharmacol 2022; 13:1002628. [PMID: 36313303 PMCID: PMC9608800 DOI: 10.3389/fphar.2022.1002628] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: To investigate the factors influencing the pharmacokinetics of mycophenolate mofetil (MMF) in pediatric patients after liver transplantation, and to establish a population pharmacokinetics model, which can provide a reference for clinical dosage adjustment. Methods: A prospective study in a single center was performed on pediatric patients who were administrated with mycophenolate mofetil dispersible tablets (MMFdt) for at least 4 days after liver transplantation continuously. Blood samples were collected in ethylene diamine tetraacetic acid anticoagulant tubes before dosing and 0.5, 1, 2, 4, 8, and 12 h after the morning intake of MMFdt. The concentrations of mycophenolic acid (MPA) in plasma were assayed with a validated reverse-phase high-performance liquid chromatography method. UGT1A8 518C > G, UGT1A9 -275T > A, UGT1A9 -2152C > T, UGT2B7 211G > T, SLC O 1B1 521T > C polymorphism were determined by Sanger sequencing. Nonlinear mixed effects modeling was used to establish the population pharmacokinetics (PPK) model. The predictability and stability of the model were internally evaluated by the goodness of fit plots, visual prediction check, normalized prediction errors, and bootstraps. Results: A two-compartment model with first-order absorption and first-order elimination was established with 115 MPA concentrations from 20 pediatric patients. The final model were: CL/F (L/h) = 14.8×(WT/7.5)0.75×(DOSE/11.16)0.452×е0.06, Ka (h−1) = 2.02×(WT/7.5)−0.25, Vc/F (L) = 6.01×(WT/7.5), Vp/F (L) = 269 (fixed), Q/F (L/h) = 15.4×(WT/7.5)0.75×е1.39. Where CL/F was the apparent clearance rate, Ka was the absorption rate constant, Vc/F was the apparent distribution volume of the central compartment, Vp/F was the apparent distribution volume of the peripheral compartment, Q/F was the atrioventricular clearance rate, WT was the body weight of the subject, and DOSE was the MMFdt administered dose. The model indicated there was large inter-individual variability in CL/F and Q/F after multiple dosing of MMFdt. Internal evaluation results showed that the final model had good stability and prediction performance. Conclusion: A stable and predictive population pharmacokinetic model of MMFdt in pediatric patients after the early stage of liver transplantation was established. The pediatric patient’s weight and the dose of MMFdt can be a reference to adjust the MMFdt dose.
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Affiliation(s)
- Yinyi Wei
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Dongni Wu
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yiyu Chen
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- *Correspondence: Taotao Liu, ; Yiyu Chen,
| | - Chunqiang Dong
- Department of Organ Transplant, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jianying Qi
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yun Wu
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Rongda Cai
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Siru Zhou
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Chengxin Li
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lulu Niu
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Tingqing Wu
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yang Xiao
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Taotao Liu
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- *Correspondence: Taotao Liu, ; Yiyu Chen,
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Population Pharmacokinetics of Enteric-Coated Mycophenolate Sodium in Children after Renal Transplantation and Initial Dosage Recommendation Based on Body Surface Area. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:1881176. [PMID: 36124167 PMCID: PMC9482478 DOI: 10.1155/2022/1881176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/21/2022] [Accepted: 08/12/2022] [Indexed: 11/29/2022]
Abstract
Objective Enteric-coated mycophenolate sodium (EC-MPS) is widely used in renal transplant recipients. There is a lack of study on the pharmacokinetics of this drug in children. This study is aimed at developing a population pharmacokinetic model of mycophenolic acid in children who were treated with EC-MPS after renal transplantation and to recommend initial dosage. Methods Pediatric patients who had undergone renal transplantation and received EC-MPS were included. Data on demographic characteristics, biochemical tests, blood routine examinations, mycophenolic acid plasma concentrations, dosing amount and frequency of EC-MPS, and coadministered medications were retrospective collected from June 2018 to August 2019. Nonlinear mixed effect modeling methods were adopted to develop a population pharmacokinetic model with the data above. Additional data from September 2019 to July 2020 were used to validate the model. Simulations under different dosage regimen were conducted to evaluate the percentage of target attainment (PTA, AUC0-12h 30–60 mg·h/L). Results A total of 96 pediatric patients aged at 13.3 (range 4.3–18.0) years were included in the modeling group. Data from 32 patients aged at 13.0 (range 3.6–18.3) years were used to validate the model. A one-compartment model with a double extravascular absorption was developed. Body surface area (BSA) was added as a covariate. Simulations showed that for different dosing regimens, the highest percentage of target attainment is around 50%. The best dosing regimen is 180 mg every 48 hours for patients with BSA of 0.22–0.46 m2, 180 mg every 24 hours with BSA of 0.47–0.67 m2, 180 mg every 24 hours with BSA of 0.68–0.96 m2, 360 mg every 24 hours with BSA of 0.97–1.18 m2, 540 mg every 24 hours with BSA of 1.19–1.58 m2, and 360 mg every 12 hours with BSA of 1.59–2.03 m2. Conclusion BSA could affect the area under curve of mycophenolic acid with the administration of EC-MPS. Considering the inflexibility of the dosage form, future development of smaller amount per tablet suitable for younger children with BSA < 1.19 m2 is warranted.
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Zhang L, Poland B, Green M, Wong S, Slatter JG. A Population Pharmacokinetic-Pharmacodynamic Model of Navtemadlin, its Major Active Metabolite (M1) and Serum Macrophage Inhibitory Cykokine-1 (MIC-1). Xenobiotica 2022; 52:555-566. [PMID: 36052821 DOI: 10.1080/00498254.2022.2114116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Navtemadlin is a potent, selective, orally available inhibitor of murine double minute 2 that restores p53 activity to induce apoptosis in TP53 wild-type malignancies. Using richly sampled pharmacokinetic (PK) and pharmacodynamic (PD) data from healthy volunteers, a population PK/PD model was developed. A population PK (PPK) model described the PK characteristics of navtemadlin and its major metabolite acyl glucuronide (M1) and quantified enterohepatic recirculation (EHR). Post hoc individual PK parameters from this model were coupled with PD data for serum macrophage inhibitory cytokine-1 (MIC-1, GDF15), a cytokine biomarker of p53 activation, to construct a population PK/PD model that described plasma concentration-driven MIC-1 excursions and enabled simulation of the extent and duration of navtemadlin PD effects. The median apparent clearance (CL/F) and apparent central volume (V2/F) of navtemadlin were 36.4 L/hr and 159 L. The typical maximum stimulatory effect (Smax) was close to the median maximum MIC-1 ratio to baseline of 7.29 in observed data. Simulation revealed a dose-dependent increase of MIC-1 with steady state attained in approximately 7 days, in a 7-day-on/21-day-off dose regimen. Elevated MIC-1 concentrations persist through 17-19 days, leaving about 9-11 PD-free days in a 28-day cycle.
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Affiliation(s)
- Lu Zhang
- Certara Integrated Drug Development, Princeton, NJ, USA
| | - Bill Poland
- Certara Integrated Drug Development, Princeton, NJ, USA
| | | | - Shekman Wong
- Kartos Therapeutics, Inc, Redwood City, CA and Bellevue, WA USA
| | - J Greg Slatter
- Kartos Therapeutics, Inc, Redwood City, CA and Bellevue, WA USA
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Sobiak J, Resztak M, Zachwieja J, Ostalska-Nowicka D. Inosine monophosphate dehydrogenase activity and mycophenolate pharmacokinetics in children with nephrotic syndrome treated with mycophenolate mofetil. Clin Exp Pharmacol Physiol 2022; 49:1197-1208. [PMID: 35877984 DOI: 10.1111/1440-1681.13706] [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: 04/04/2022] [Revised: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 11/28/2022]
Abstract
Some studies have shown that the area under the concentration-time curve (AUC) of mycophenolic acid (MPA) should be higher for children with nephrotic syndrome (NS) than after renal transplantation. The pharmacodynamic aspect of MPA, the activity of inosine monophosphate dehydrogenase (IMPDH), has not been studied in children with NS. The study included 21 children (4-16 years) with NS treated with mycophenolate mofetil. MPA and its glucuronide plasma concentrations were determined using validated high-performance liquid chromatography (HPLC-UV). The separate HPLC-UV method was applied for IMPDH activity determination. The variability was expressed by the coefficient of variation (CV). IMPDH activity and MPA concentration (Ctrough ) before the morning dose amounted to 29.95 μmol·s-1 ·mol-1 AMP (range, 6.71-98.60 μmol·s-1 ·mol-1 AMP) and 1.72 μg/mL (range, 0.39-4.34 μg/mL), respectively, whereas the area under the effect-time curve from 0 to 4 h and MPA AUC0-4 were 130.36 μmol·s-1 ·mol-1 AMP∙h (range, 23.58-306.57 μmol·s-1 ·mol-1 AMP∙h) and 24.63 μg·h/mL (range, 12.21-67.48 μg·h/mL), respectively. IMPDH activity decreased concomitantly with MPA concentration increase, however, the variability of the pharmacodynamic parameters was greater than of the pharmacokinetics. The median degree of maximum IMPDH inhibition was 61%. MPA Ctrough and predicted AUC were lower than in our previous study. Only a few MPA pharmacokinetic parameters correlated with the pharmacodynamics. IMPDH activity did not correlate with children's age and did not differ between boys and girls. MPA clearance was the highest in younger children (median 10.54 L/m2 /h) and cholesterol correlated negatively with children's age (r=-0.659, p=0.003). IMPDH minimum activity and the degree of maximum IMPDH inhibition were similar to those obtained in renal transplant recipients. IMPDH activity does not undergo developmental or gender-specific regulation in children with NS. MPA underexposure might be more frequent in younger children, especially with high cholesterol and triglycerides levels due to high MPA clearance.
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Affiliation(s)
- Joanna Sobiak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences
| | - Matylda Resztak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences
| | - Jacek Zachwieja
- Department of Pediatric Nephrology and Hypertension, Poznan University of Medical Sciences
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Miller KC, Hall AC, Cohen-Bucay A, Chen YBA. Delayed Kidney Transplantation after HLA-Haploidentical Hematopoietic Cell Transplantation in a Young Woman with Myelodysplastic Syndrome. Leuk Res Rep 2022; 17:100302. [PMID: 35360511 PMCID: PMC8961207 DOI: 10.1016/j.lrr.2022.100302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/16/2022] [Indexed: 11/02/2022] Open
Abstract
Patients with end-stage renal disease (ESRD) are often excluded from potentially curative allogeneic hematopoietic cell transplantation (alloHCT). Our institution pioneered simultaneous living donor kidney transplantation in patients undergoing alloHCT from the same donor for hematologic malignancies. Herein, we present the case of a 31-year-old woman diagnosed with myelodysplastic syndrome who developed ESRD during cytoreductive induction therapy. She achieved disease control, then successfully underwent a human leukocyte antigen (HLA)-haploidentical alloHCT while on hemodialysis. After rapidly tapering off graft-versus-host disease prophylaxis, fourteen months from her alloHCT she received a kidney transplant from her same haploidentical sibling donor, which obviated the need for further systemic immunosuppression.
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Rong Y, Patel V, Kiang TKL. Recent lessons learned from population pharmacokinetic studies of mycophenolic acid: physiological, genomic, and drug interactions leading to the prediction of drug effects. Expert Opin Drug Metab Toxicol 2022; 17:1369-1406. [PMID: 35000505 DOI: 10.1080/17425255.2021.2027906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Mycophenolic acid (MPA) is a widely used immunosuppressant in transplantation and autoimmune disease. Highly variable pharmacokinetics have been observed with MPA, but the exact mechanisms remain largely unknown. AREAS COVERED The current review provided a critical, comprehensive update of recently published population pharmacokinetic/dynamic models of MPA (n=16 papers identified from PubMed and Embase, inclusive from January 2017 to August 2021), with specific emphases on the intrinsic and extrinsic factors influencing the pharmacology of MPA. The significance of the identified covariates, potential mechanisms, and comparisons to historical literature have been provided. EXPERT OPINION While select covariates affecting the population pharmacokinetics of MPA are consistently observed and mechanistically supported, some variables have not been regularly reported and/or lacked mechanistic explanation. Very few pharmacodynamic models were available, pointing to the need to extrapolate pharmacokinetic findings. Ideal models of MPA should consist of: i) utilizing optimal sampling points to allow the characterizations of absorption, re-absorption, and elimination phases; ii) characterizing unbound/total MPA, MPA metabolites, plasma/urinary concentrations, and genetic polymorphisms to facilitate mechanistic interpretations; and iii) incorporating actual outcomes and pharmacodynamic data to establish clinical relevance. We anticipate the field will continue to expand in the next 5 to 10 years.
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Affiliation(s)
- Yan Rong
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Vrunda Patel
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Tony K L Kiang
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
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Gao X, Wu L, Tsai RYL, Ma J, Liu X, Chow DSL, Liang D, Xie H. Pharmacokinetic Model Analysis of Supralingual, Oral and Intravenous Deliveries of Mycophenolic Acid. Pharmaceutics 2021; 13:pharmaceutics13040574. [PMID: 33920640 PMCID: PMC8072905 DOI: 10.3390/pharmaceutics13040574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 01/20/2023] Open
Abstract
Mycophenolic acid (MPA) is commonly used for organ rejection prophylaxis via oral administration in the clinic. Recent studies have shown that MPA also has anticancer activities. To explore new therapeutic options for oral precancerous/cancerous lesions, MPA was designed to release topically on the dorsal tongue surface via a mucoadhesive patch. The objective of this study was to establish the pharmacokinetic (PK) and tongue tissue distribution of mucoadhesive MPA patch formulation after supralingual administration in rats and also compare the PK differences between oral, intravenous, and supralingual administration of MPA. Blood samples were collected from Sprague Dawley rats before and after a single intravenous bolus injection, a single oral dose, or a mucoadhesive patch administration on the dorsal tongue surface for 4 h, all with a dose of 0.5 mg/kg of MPA. Plots of MPA plasma concentration versus time were obtained. As multiple peaks were found in all three curves, the enterohepatic recycling (EHR) model in the Phoenix software was adapted to describe their PK parameters with an individual PK analysis method. The mean half-lives of intravenous and oral administrations were 10.5 h and 7.4 h, respectively. The estimated bioavailability after oral and supralingual administration was 72.4% and 7.6%, respectively. There was a 0.5 h lag-time presented after supralingual administration. The results suggest that the systemic plasma MPA concentrations were much lower in rats receiving supralingual administration compared to those receiving doses from the other two routes, and the amount of MPA accumulated in the tongue after patch application showed a sustained drug release pattern. Studies on the dynamic of drug retention in the tongue after supralingual administration showed that ~3.8% of the dose was accumulated inside of tongue right after the patch removal, ~0.11% of the dose remained after 20 h, and ~20.6% of MPA was not released from the patches 4 h after application. The data demonstrate that supralingual application of an MPA patch can deliver a high amount of drug at the site of administration with little systemic circulation exposure, hence lowering the potential gastrointestinal side effects associated with oral administration. Thus, supralingual administration is a potential alternative route for treating oral lesions.
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Affiliation(s)
- Xiuqing Gao
- Department of Pharmaceutical Science, College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX 77004, USA; (X.G.); (J.M.); (D.L.)
| | - Lei Wu
- Department of Pharmcological & Pharmaceutical Sciences, College of Pharmacy, University of Houston, Houston, TX 77204, USA; (L.W.); (D.S.-L.C.)
| | - Robert Y. L. Tsai
- Department of Translational Medical Sciences, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, TX 77030, USA;
| | - Jing Ma
- Department of Pharmaceutical Science, College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX 77004, USA; (X.G.); (J.M.); (D.L.)
| | - Xiaohua Liu
- Department of Biomedical Sciences, Baylor College of Dentistry, Dallas, TX 75246, USA;
| | - Diana S.-L. Chow
- Department of Pharmcological & Pharmaceutical Sciences, College of Pharmacy, University of Houston, Houston, TX 77204, USA; (L.W.); (D.S.-L.C.)
| | - Dong Liang
- Department of Pharmaceutical Science, College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX 77004, USA; (X.G.); (J.M.); (D.L.)
| | - Huan Xie
- Department of Pharmaceutical Science, College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX 77004, USA; (X.G.); (J.M.); (D.L.)
- Correspondence: ; Tel.: +1-713-775-6235
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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: 85] [Impact Index Per Article: 28.3] [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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10
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Rong Y, Jun H, Kiang TKL. Population pharmacokinetics of mycophenolic acid in paediatric patients. Br J Clin Pharmacol 2021; 87:1730-1757. [PMID: 33118201 DOI: 10.1111/bcp.14590] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/07/2020] [Accepted: 09/22/2020] [Indexed: 12/14/2022] Open
Abstract
Mycophenolic acid (MPA) is widely used in paediatric kidney transplant patients and sometimes prescribed for additional indications. Population pharmacokinetic or pharmacodynamic modelling has been frequently used to characterize the fixed, random and covariate effects of MPA in adult patients. However, MPA population pharmacokinetic data in the paediatric population have not been systematically summarized. The objective of this narrative review was to provide an up-to-date critique of currently available paediatric MPA population pharmacokinetic models, with emphases on modelling techniques, pharmacological findings and clinical relevance. PubMed and EMBASE were searched from inception of database to May 2020, where a total of 11 studies have been identified representing kidney transplant (n = 4), liver transplant (n = 1), haematopoietic stem cell transplant (n = 1), idiopathic nephrotic syndrome (n = 2), systemic lupus erythematosus (n = 2), and a combined population consisted of kidney, liver and haematopoietic stem cell transplant patients (n = 1). Critical analyses were provided in the context of MPA absorption, distribution, metabolism, excretion and bioavailability in this paediatric database. Comparisons to adult patients were also provided. With respect to clinical utility, Bayesian estimation models (n = 6) with acceptable accuracy and precision for MPA exposure determination have also been identified and systematically evaluated. Overall, our analyses have identified unique features of MPA clinical pharmacology in the paediatric population, while recognizing several gaps that still warrant further investigations. This review can be used by pharmacologists and clinicians for improving MPA pharmacokinetic-pharmacodynamic modelling and patient care.
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Affiliation(s)
- Yan Rong
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Heajin Jun
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada.,College of Pharmacy, Seoul National University, Seoul, Republic of Korea
| | - Tony K L Kiang
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
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11
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Catić-Đorđević A, Pavlović I, Spasić A, Stefanović N, Pavlović D, Damnjanović I, Mitić B, Veličković-Radovanović R. Assessment of pharmacokinetic mycophenolic acid clearance models using Monte Carlo numerical analysis. Xenobiotica 2021; 51:387-393. [PMID: 33416418 DOI: 10.1080/00498254.2020.1871532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Previously, we performed population pharmacokinetic analysis and indicated age, mycophenolate mofetil (MMF)/mycophenolic acid (MPA) daily dose, and presence of nifedipine in patient therapy as significant predictors of MPA apparent clearance (CL/F) variability. This study aimed to determine the reliability of previously published population pharmacokinetic models derived from similar studies. Furthermore, this study investigated correspondence between chosen population models from the literature.By means of the Monte Carlo simulation method, pharmacokinetic models from different studies are simulated and analysed in the range of standard deviations of measured system parameters as well as the range of observed model parameters taken from the comparison studies.The 1000 numerical simulations were performed for every analysed model in order to calculate the most possible MPA CL/F values according to the expected values from the performed experiment. Fitting our results with other models showed how the presence of nifedipine makes difference in MPA CL/F values.By testing the data from selected studies into our model, a similar range of expected CL/F values was obtained, which may confirm the validity of our model. The results of our population pharmacokinetic study are partially applicable in models by other researchers.
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Affiliation(s)
| | - Ivan Pavlović
- Faculty of Mechanical Engineering, University of Nis, Nis, Serbia
| | - Ana Spasić
- Faculty of Medicine, University of Nis, Nis, Serbia
| | | | | | | | - Branka Mitić
- Faculty of Medicine, University of Nis, Nis, Serbia.,Clinic of Nephrology, Clinical Center Nis, Nis, Serbia
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12
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Uchiyama K, Saito Y, Takekuma Y, Sugita J, Teshima T, Sugawara M. Pharmacokinetics of mycophenolic acid after haplo-hematopoietic stem cell transplantation in Japanese recipients. J Oncol Pharm Pract 2020; 28:31-38. [PMID: 33349149 DOI: 10.1177/1078155220980815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Mycophenolate mofetil (MMF), a mycophenolic acid (MPA) prodrug, is used to prevent graft-versus-host disease (GVHD) in hematopoietic stem cell transplantation (HSCT). Although previous studies have reported that enterohepatic circulation (EHC) of MPA, which is usually observed in MMF-treated patients, does not occur in HSCT patients, it is unclear what happens in haploidentical-HSCT (haplo-HSCT) patients, who are using post-transplant cyclophosphamide. This study was conducted to investigate MPA pharmacokinetics in haplo-HSCT patients. METHODS Seventeen haplo-HSCT patients, who received MMF for GVHD prophylaxis, were enrolled in this study. We collected blood samples on days 14 and 28, and plasma MPA concentrations were measured by high-performance liquid chromatography; pharmacokinetic parameters such as area under the curve (AUC), mean residence time (MRT), and apparent oral clearance (CL/F) were measured with moment analysis. We also evaluated EHC as AUC6-12h/AUC0-12h. RESULTS There was no significant difference in MPA pharmacokinetic parameters between days 14 and 28. There was also no difference between the pharmacokinetic parameter changes and diarrhea. Additionally, varying plasma MPA concentrations suggested that MPA EHC did not occur. CONCLUSION In this study, we revealed the pharmacokinetics of MMF in Japanese haplo-HSCT recipients. Additionally, our study demonstrated that MPA EHC might not occur in Japanese haplo-HSCT recipients.
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Affiliation(s)
- Kazuki Uchiyama
- Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan
| | - Yoshitaka Saito
- Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan
| | - Yoh Takekuma
- Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan
| | - Junichi Sugita
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Mitsuru Sugawara
- Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan.,Laboratory of Pharmacokinetics, Faculty of Pharmaceutical Sciences, Hokkaido University, Sapporo, Japan
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13
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Chen Y, Sun L, Xu H, Dong M, Mizuno T, Vinks AA, Brunner HI, Li Y, Li Z. PK/PD Study of Mycophenolate Mofetil in Children With Systemic Lupus Erythematosus to Inform Model-Based Precision Dosing. Front Pharmacol 2020; 11:605060. [PMID: 33488386 PMCID: PMC7819284 DOI: 10.3389/fphar.2020.605060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/27/2020] [Indexed: 11/20/2022] Open
Abstract
Objectives: To evaluate the mycophenolic acid [MPA, the active form of mycophenolate mofetil (MMF)] pharmacokinetic parameters in relation to clinical response to identify target exposure ranges in pediatric patients with systemic lupus erythematosus (SLE). Methods: This was a retrospective study using pharmacokinetic data collected in 67 pediatric patients aged 4–18 years with SLE. Target MPA exposures for effective inhibition of SLE activity (as measured by SLE disease Activity Index (SLEDAI), active SLE was defined as a SLEDAI score of ≥6, and a controlled disease was defined as a SLEDAI score of ≤4) were assessed by receiver operating characteristic (ROC) curve and logistic regression. Exposure-response models were developed to quantitatively describe the relationship between SLEDAI score and AUC0–12 or Ctrough, respectively. Results: The MPA AUC0-12 in patients with active SLE was significantly lower than that in patients with inactive SLE. ROC analysis revealed that an AUC0–12 threshold of 39 μg h/ml or a Ctrough of 1.01 μg/ml was associated with the lowest risk of active SLE. Logistic regression analysis revealed that an AUC0–12 of less than 34 μg h/ml or a Ctrough of less than 1.2 μg/ml probably is associated with active SLE. The results of the exposure-response modeling also indicated that an AUC0-12 less than 32 μg h/ml or a Ctrough less than 1.1 μg/ml was associated with suboptimal clinical outcome. An AUC0-12 above 50 μg h/ml or a Ctrough above 1.7 ug/ml was associated with disease control. Conclusion: Both AUC0–12 and Ctrough of MPA are predictive of the likelihood of active SLE in pediatric patients receiving MMF. An individualized dosing regimen of MMF, with a target AUC0–12 or Ctrough, should be considered for SLE patients.
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Affiliation(s)
- Yewei Chen
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
| | - Li Sun
- Division of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Hong Xu
- Division of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Min Dong
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
| | - Hermine I Brunner
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States.,Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Yifan Li
- Division of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Zhiping Li
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
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14
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Herrera-Espejo S, Cebrero-Cangueiro T, Labrador-Herrera G, Pachón J, Pachón-Ibáñez ME, Álvarez-Marín R. In Vitro Activity of Pentamidine Alone and in Combination with Antibiotics against Multidrug-Resistant Clinical Pseudomonas aeruginosa Strains. Antibiotics (Basel) 2020; 9:E885. [PMID: 33317111 PMCID: PMC7764095 DOI: 10.3390/antibiotics9120885] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 11/25/2020] [Accepted: 12/07/2020] [Indexed: 11/22/2022] Open
Abstract
Multidrug-resistant (MDR) Pseudomonas aeruginosa is a public health problem causing both community and hospital-acquired infections, and thus the development of new therapies for these infections is critical. The objective of this study was to analyze in vitro the activity of pentamidine as adjuvant in combinations to antibiotics against seven clinical P. aeruginosa strains. The Minimum Inhibitory Concentration (MIC) was determined following standard protocols, and the results were interpreted according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoints; however, the gentamicin activity was interpreted according to the Clinical and Laboratory Standards Institute (CLSI) recommendations. The bactericidal in vitro activity was studied at 1×MIC concentrations by time-kill curves, and also performed in three selected strains at 1/2×MIC of pentamidine. All studies were performed in triplicate. The pentamidine MIC range was 400-1600 μg/mL. Four of the strains were MDR, and the other three were resistant to two antibiotic families. The combinations of pentamidine at 1×MIC showed synergistic activity against all the tested strains, except for pentamidine plus colistin. Pentamidine plus imipenem and meropenem were the combinations that showed synergistic activity against the most strains. At 1/2×MIC, pentamidine plus antibiotics were synergistic with all three analyzed strains. In summary, pentamidine in combination with antibiotics showed in vitro synergy against multidrug-resistant P. aeruginosa clinical strains, which suggests its possible use as adjuvant to antibiotics for the therapy of infections from MDR P. aeruginosa.
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Grants
- PI18-01842 Instituto de Salud Carlos III
- REIPI RD16/0016/0009 Subdirección General de Redes y Centros de Investigación Cooperativa, Ministerio de Economía, Industria y Competitividad, Spanish Network for Research in Infectious Diseases
- 2014-2020 co-financed by European Development Regional Fund A way to achieve Europe, Operative program Intelligent Growth
- C1-0038-2019 M.E.P.I. is a researcher belonging to the program "Nicolás Monardes" (C1-0038-2019), Servicio Andaluz de Salud, Junta de Andalucía, Spain
- RD16/0016/0009 GLH has a grant from the Ministerio de Ciencia, Innovación y Universidades, Instituto de Salud Carlos III, cofinanced by the European Development Regional Fund (A Way to Achieve Europe) and by the Spanish Network for Research in Infectious Disease
- JR17/00025 RAM has a grant Juan Rodes grant from the Ministerio de Ciencia, Innovación y Universidades, Instituto de Salud Carlos III, cofinanced by the European Development Regional Fund (A Way to Achieve Europe) and by the Spanish Network for Research in Infectiou
- - T.C.C. is supported by the V Plan Propio of the University of Seville with a postdoctoral contract as research personnel in training
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Affiliation(s)
- Soraya Herrera-Espejo
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville, 41013 Seville, Spain; (S.H.-E.); (T.C.-C.); (G.L.-H.); (J.P.); (R.Á.-M.)
- Clinical Unit of Infectious Diseases, Microbiology, and Preventive Medicine, Virgen del Rocio University Hospital, 41013 Seville, Spain
| | - Tania Cebrero-Cangueiro
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville, 41013 Seville, Spain; (S.H.-E.); (T.C.-C.); (G.L.-H.); (J.P.); (R.Á.-M.)
- Department of Medicine, University of Seville, 41009 Seville, Spain
| | - Gema Labrador-Herrera
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville, 41013 Seville, Spain; (S.H.-E.); (T.C.-C.); (G.L.-H.); (J.P.); (R.Á.-M.)
- Clinical Unit of Infectious Diseases, Microbiology, and Preventive Medicine, Virgen del Rocio University Hospital, 41013 Seville, Spain
| | - Jerónimo Pachón
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville, 41013 Seville, Spain; (S.H.-E.); (T.C.-C.); (G.L.-H.); (J.P.); (R.Á.-M.)
- Department of Medicine, University of Seville, 41009 Seville, Spain
| | - María Eugenia Pachón-Ibáñez
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville, 41013 Seville, Spain; (S.H.-E.); (T.C.-C.); (G.L.-H.); (J.P.); (R.Á.-M.)
- Clinical Unit of Infectious Diseases, Microbiology, and Preventive Medicine, Virgen del Rocio University Hospital, 41013 Seville, Spain
| | - Rocío Álvarez-Marín
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville, 41013 Seville, Spain; (S.H.-E.); (T.C.-C.); (G.L.-H.); (J.P.); (R.Á.-M.)
- Clinical Unit of Infectious Diseases, Microbiology, and Preventive Medicine, Virgen del Rocio University Hospital, 41013 Seville, Spain
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15
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Wang G, Ye Q, Huang Y, Lu J, Xu H, Li Z. Population pharmacokinetics of mycophenolic acid in pediatric patients with juvenile dermatomyositis and optimization of limited sampling strategy. Xenobiotica 2020; 51:167-176. [PMID: 32903096 DOI: 10.1080/00498254.2020.1819579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Juvenile dermatomyositis (JDM) is a rare systemic autoimmune disease specifically affecting children. Mycophenolate mofetil (MMF) is an immunosuppressant used to treat JDM. Mycophenolic acid (MPA) is an active metabolite of MMF. This study aimed to develop a population pharmacokinetic (PPK) model of MPA in children with JDM and optimize the limited sampling strategy (LSS). Fifteen JDM patients treated with MMF, at a median age of 7.35 (range, 3.09-16.1) years, were included. Blood samples were collected at 30 minutes pre-dose, 20 minutes, 60 minutes and 180 minutes post-dose to measure the MPA concentrations. Data were retrospectively collected from the electronic medical records. A two-compartment model with first-order absorption, lag time in absorption, and first-order elimination was developed. Height and co-administered cotrimoxazole were added as the covariates to the model. Concentrations at different time points were simulated and area under the concentration-time curve (AUC0-12 h) was calculated. By removing one sampling point at a time, AUC0-12 h from three-point sampling strategy was re-calculated via Bayesian approach. AUC0-12 h from the three-point sampling strategy (by removing the point at 20 minutes post-dose) had the strongest correlation with AUC0-12 h from the four-point sampling strategy (Pearson's r = 0.971).
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Affiliation(s)
- Guangfei Wang
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Qiaofeng Ye
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Yidie Huang
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Jinmiao Lu
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Hong Xu
- Department of Nephrology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Zhiping Li
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
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16
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Klaasen RA, Bergan S, Bremer S, Hole K, Nordahl CB, Andersen AM, Midtvedt K, Skauby MH, Vethe NT. Pharmacodynamic assessment of mycophenolic acid in resting and activated target cell population during the first year after renal transplantation. Br J Clin Pharmacol 2020; 86:1100-1112. [PMID: 31925806 PMCID: PMC7256122 DOI: 10.1111/bcp.14218] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 12/10/2019] [Accepted: 12/19/2019] [Indexed: 12/31/2022] Open
Abstract
Aims To explore the pharmacodynamics of mycophenolic acid (MPA) through inosine monophosphate dehydrogenase (IMPDH) capacity measurement and purine levels in peripheral blood mononuclear cells (PBMC) longitudinally during the first year after renal transplantation (TX). Methods PBMC were isolated from renal recipients 0–4 days prior to and 6–9 days, 5–7 weeks and 1 year after TX (before and 1.5 hours after dose). IMPDH capacity and purine (guanine and adenine) levels were measured in stimulated and nonstimulated PBMC. Results Twenty‐nine patients completed the follow‐up period, of whom 24 received MPA. In stimulated PBMC, the IMPDH capacity (pmol 10−6 cells min−1) was median (interquartile range) 127 (95.8–147) before TX and thereafter 44.9 (19.2–93.2) predose and 12.1 (4.64–23.6) 1.5 hours postdose across study days after TX. The corresponding IMPDH capacity in nonstimulated PBMC was 5.71 (3.79–6.93), 3.35 (2.31–5.62) and 2.71 (1.38–4.08), respectively. Predose IMPDH capacity in nonstimulated PBMC increased with time, reaching pre‐TX values at 1 year. In stimulated PBMC, both purines were reduced before (median 39% reduction across days after TX) and after (69% reduction) dose compared to before TX. No alteration in the purine levels was observed in nonstimulated PBMC. Patients needing dose reductions during the first year had lower pre‐dose IMPDH capacity in nonstimulated PBMC (1.87 vs 3.00 pmol 10−6 cells min−1, P = .049) at 6–9 days. Conclusion The inhibitory effect of MPA was stronger in stimulated PBMC. Nonstimulated PBMC became less sensitive to MPA during the first year after TX. Early IMPDH capacity appeared to be predictive of dose reductions.
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Affiliation(s)
| | - Stein Bergan
- Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Sara Bremer
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Kristine Hole
- Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | | | | | - Karsten Midtvedt
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Morten Heier Skauby
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Nils Tore Vethe
- Department of Pharmacology, Oslo University Hospital, Oslo, Norway
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17
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Yano I. [Clinical Pharmacometrics for Rational Drug Treatment]. YAKUGAKU ZASSHI 2019; 139:1227-1234. [PMID: 31582605 DOI: 10.1248/yakushi.19-00124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pharmacometrics is the mathematical study of pharmacokinetics, disease progression, and clinical outcomes. One objective of pharmacometrics is to facilitate rational drug treatment in patients, also termed clinical pharmacometrics. In this review, our clinical pharmacometric studies conducted over the last 10 years are discussed. Population pharmacokinetic analysis using therapeutic monitoring data for levetiracetam revealed that oral clearance allometrically scaled to both body weight and estimated glomerular filtration rate can accurately predict clinical data from patients of various ages (pediatric to elderly) with varying renal function. Dosage adjustments based on renal function in the package information are effective in controlling the trough and peak concentrations in similar ranges. In addition, a retrospective pharmacokinetic and pharmacodynamic study revealed that the efficacy of low-dose clobazam therapy was significantly influenced by CYP2C19 polymorphisms. Pharmacokinetic and pharmacodynamic models were successfully built using electronic medical information to explain retrospective international normalized ratio values of prothrombin time before and after catheter ablation in warfarin-treated patients. Simulation studies suggest that more than 20 mg of vitamin K2 is unnecessary in the preoperative period of catheter ablation. A physiologically based pharmacokinetic model adapted to tacrolimus pharmacokinetic data in patients who underwent living-donor liver transplantation was constructed, and clarified that oral clearance of this drug was affected by CYP3A5 genotypes in both the liver and intestine to the same extent. In conclusion, pharmacometrics is a useful methodology for individualized and optimized drug therapy.
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Affiliation(s)
- Ikuko Yano
- Department of Pharmacy, Kobe University Hospital
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18
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Slovak JE, Hwang JK, Rivera SM, Villarino NF. Pharmacokinetics of mycophenolic acid and its effect on CD4 + and CD8 + T cells after oral administration of mycophenolate mofetil to healthy cats. J Vet Intern Med 2019; 33:2020-2028. [PMID: 31423655 PMCID: PMC6766527 DOI: 10.1111/jvim.15585] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 07/23/2019] [Indexed: 12/01/2022] Open
Abstract
Background Mycophenolate mofetil (MMF) is an immunosuppressant used in human and veterinary medicine. Little pharmacokinetic and pharmacodynamic information on MMF is available in cats. Objective To evaluate the plasma disposition of mycophenolic acid (MPA) and assess its effect on total peripheral blood mononuclear cells and CD4+/CD8+ ratios after PO administration of MMF. Animals Healthy cats (n = 10). Methods Mycophenolate mofetil was administered at a dosage of 10 mg/kg q12h (n = 3), 15 mg/kg q12h (n = 3), and 15 mg/kg q8h (n = 4) for 7 days. Concentrations of MPA and derivatives were determined using ultra‐high‐performance liquid chromatography. Flow cytometry was used to assess CD4+/CD8+ T‐cell ratios. Results All cats biotransformed MMF into MPA. Half of the cats (5/10) had adverse effects within 1 week of MMF administration. Area under the curve limit of quantification (AUC0‐LOQh) of MPA ranged from 1.27 to 2.03 hours·μg/mL and from 1.77 to 8.54 hours·μg/mL after the first and last PO dose of 10 mg/kg. The AUC0‐loqh of MPA ranged from 2.18 to 31 hours·μg/mL after the first dose of 15 mg/kg of MMF. Before the first dose of MMF, the average total number of PBMC ranged from 1.2 to 9.3 million/mL. At the last dose of MMF, the average total number of PBMC ranged from 3 to 5 million/mL. Conclusion Mycophenolic acid was detected in all cats. The dose 10 mg/kg given q12h for 1 week was tolerated (n = 3). The efficacy of MMF as an immunosuppressant and long‐term safety in cats of this dosage regimen is unknown.
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Affiliation(s)
- Jennifer E Slovak
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington
| | - Julianne K Hwang
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington
| | - Sol M Rivera
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington
| | - Nicolas F Villarino
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington
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19
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Slovak JE, Rivera-Velez SM, Hwang JK, Villarino NF. Pharmacokinetics and pharmacodynamics of mycophenolic acid in healthy cats after twice-daily intravenous infusion of mycophenolate mofetil for three days. Am J Vet Res 2019; 79:1093-1099. [PMID: 30256137 DOI: 10.2460/ajvr.79.10.1093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the plasma disposition of mycophenolic acid (MPA) and its derivatives MPA glucuronide and MPA glucoside after twice-daily infusions of mycophenolate mofetil (MMF) in healthy cats for 3 days and to assess the effect of MMF administration on peripheral blood mononuclear cell (PBMC) counts and CD4+-to-CD8+ ratios. ANIMALS 5 healthy adult cats. PROCEDURES MMF was administered to each cat (10 mg/kg, IV, q 12 h for 3 days). Each dose of MMF was diluted with 5% dextrose in water and then administered over a 2-hour period with a syringe pump. Blood samples were collected for analysis. A chromatographic method was used to quantitate concentrations of MPA and its metabolites. Effects of MMF on PBMC counts and CD4+-to-CD8+ ratios were assessed by use of flow cytometry. RESULTS All cats biotransformed MMF into MPA. The MPA area under the plasma concentration-time curve from 0 to 14 hours ranged from 14.6 to 37.6 mg·h/L and from 14.4 to 22.3 mg·h/L after the first and last infusion, respectively. Total number of PBMCs was reduced in 4 of 5 cats (mean ± SD reduction, 25.9 ± 15.8% and 26.7 ± 19.3%) at 24 and 48 hours after the end of the first infusion of MMF, respectively. CONCLUSIONS AND CLINICAL RELEVANCE Plasma disposition of MPA after twice-daily IV infusions for 3 days was variable in all cats. There were no remarkable changes in PBMC counts and CD4+-to-CD8+ ratios.
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Hecht M, Veigure R, Couchman L, S Barker CI, Standing JF, Takkis K, Evard H, Johnston A, Herodes K, Leito I, Kipper K. Utilization of data below the analytical limit of quantitation in pharmacokinetic analysis and modeling: promoting interdisciplinary debate. Bioanalysis 2018; 10:1229-1248. [PMID: 30033744 DOI: 10.4155/bio-2018-0078] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Traditionally, bioanalytical laboratories do not report actual concentrations for samples with results below the LOQ (BLQ) in pharmacokinetic studies. BLQ values are outside the method calibration range established during validation and no data are available to support the reliability of these values. However, ignoring BLQ data can contribute to bias and imprecision in model-based pharmacokinetic analyses. From this perspective, routine use of BLQ data would be advantageous. We would like to initiate an interdisciplinary debate on this important topic by summarizing the current concepts and use of BLQ data by regulators, pharmacometricians and bioanalysts. Through introducing the limit of detection and evaluating its variability, BLQ data could be released and utilized appropriately for pharmacokinetic research.
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Affiliation(s)
- Max Hecht
- Chair of Analytical Chemistry, Institute of Chemistry, University of Tartu, 14a Ravila Street, 50411 Tartu, Estonia
- Analytical Services International, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Rūta Veigure
- Chair of Analytical Chemistry, Institute of Chemistry, University of Tartu, 14a Ravila Street, 50411 Tartu, Estonia
| | - Lewis Couchman
- Analytical Services International, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Charlotte I S Barker
- Paediatric Infectious Diseases Research Group, Institute for Infection & Immunity, St George's University of London, London, SW17 0RE, UK
- Inflammation, Infection & Rheumatology Section, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Paediatric Infectious Diseases Unit, St George's University Hospitals NHS Foundation Trust, London, SW17 0RE, UK
| | - Joseph F Standing
- Paediatric Infectious Diseases Research Group, Institute for Infection & Immunity, St George's University of London, London, SW17 0RE, UK
- Inflammation, Infection & Rheumatology Section, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
| | - Kalev Takkis
- Analytical Services International, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Hanno Evard
- Chair of Analytical Chemistry, Institute of Chemistry, University of Tartu, 14a Ravila Street, 50411 Tartu, Estonia
| | - Atholl Johnston
- Analytical Services International, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
- Clinical Pharmacology, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
| | - Koit Herodes
- Chair of Analytical Chemistry, Institute of Chemistry, University of Tartu, 14a Ravila Street, 50411 Tartu, Estonia
| | - Ivo Leito
- Chair of Analytical Chemistry, Institute of Chemistry, University of Tartu, 14a Ravila Street, 50411 Tartu, Estonia
| | - Karin Kipper
- Chair of Analytical Chemistry, Institute of Chemistry, University of Tartu, 14a Ravila Street, 50411 Tartu, Estonia
- Analytical Services International, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
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Yoshimura K, Yano I, Yamamoto T, Kondo T, Kawanishi M, Isomoto Y, Yonezawa A, Takaori-Kondo A, Matsubara K. Pharmacokinetic and Pharmacodynamic Markers of Mycophenolic Acid Associated with Effective Prophylaxis for Acute Graft-Versus-Host Disease and Neutrophil Engraftment in Cord Blood Transplant Patients. Biol Blood Marrow Transplant 2018; 24:1441-1448. [DOI: 10.1016/j.bbmt.2018.01.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 01/30/2018] [Indexed: 10/18/2022]
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