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Li X, Kalwak K, Beier R, Kehne J, Möller AK, Baumgart J, Beelen DW, Hilger RA, Vora A, Sykora KW. Population pharmacokinetic modeling of treosulfan and rationale for dose recommendation in children treated for conditioning prior to allogeneic hematopoietic stem cell transplantation. Drug Metab Pharmacokinet 2023; 52:100515. [PMID: 37481830 DOI: 10.1016/j.dmpk.2023.100515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 05/10/2023] [Accepted: 05/21/2023] [Indexed: 07/25/2023]
Abstract
Intravenously infused treosulfan was evaluated in adult and pediatric patients for conditioning regimen prior to allogeneic hematopoietic stem cell transplantation. A population pharmacokinetic (PK) model was initially developed on 116 adult and pediatric PK profiles from historical trials, to support treosulfan dose recommendations for children in 2 prospective trials. The aim was to assess and update the initial population PK model by inclusion of additional 83 pediatric PK profiles from these 2 trials. The final population PK model was 2-compartmental with dosing in the central compartment, linear elimination, and inter-compartmental clearance. Inter-individual variability was included on clearance (CL), central volume (V1), peripheral volume (V2), and inter-compartmental clearance (Q). The final model described an effect of the body surface area (BSA) on CL, V1, V2, and Q. The final model resulted in a modified dose recommendation for children and advises treosulfan doses of 10 g/m2, 12 g/m2, and 14 g/m2 for BSAs of <0.4 m2, ≥0.4 to <0.9 m2, and ≥0.9 m2, respectively. This simplified BSA-dependent dose recommendation was developed for children, ensuring a well comparable treosulfan exposure as a dose of 14 g/m2 in adults - irrespective of their age and without applying individual therapeutic drug monitoring.
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Affiliation(s)
- Xieran Li
- medac GmbH, Theaterstraße 6, 22880, Wedel, Germany.
| | - Krzysztof Kalwak
- Wroclaw Medical University, Department of Pediatric Hematology, Oncology and Bone Marrow Transplantation, Wybrzeze Ludwika Pasteura 1, 50-367, Wroclaw, Poland
| | - Rita Beier
- Hannover Medical School, Department of Paediatric Haematology and Oncology, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Jochen Kehne
- medac GmbH, Theaterstraße 6, 22880, Wedel, Germany
| | | | | | - Dietrich W Beelen
- University Hospital Essen, Department of Haematology and Stem Cell Transplantation, West-German Cancer Centre, Hufelandstraße 55, 45147, Essen, Germany
| | - Ralf A Hilger
- University Hospital Essen, West-German Cancer Center, Department of Medical Oncology, Hufelandstraße 55, 45147, Essen, Germany
| | - Ajay Vora
- Great Ormond Street Hospital for Children NHS Foundation, Great Ormond Street, WC1N 3JH, London, United Kingdom
| | - Karl-Walter Sykora
- Hannover Medical School, Department of Paediatric Haematology and Oncology, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
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van der Stoep MYEC, Oostenbrink LVE, Bredius RGM, Moes DJAR, Guchelaar HJ, Zwaveling J, Lankester AC. Therapeutic Drug Monitoring of Conditioning Agents in Pediatric Allogeneic Stem Cell Transplantation; Where do We Stand? Front Pharmacol 2022; 13:826004. [PMID: 35330826 PMCID: PMC8940165 DOI: 10.3389/fphar.2022.826004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/18/2022] [Indexed: 11/13/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is an established curative treatment that has significantly improved clinical outcome of pediatric patients with malignant and non-malignant disorders. This is partly because of the use of safer and more effective combinations of chemo- and serotherapy prior to HSCT. Still, complications due to the toxicity of these conditioning regimens remains a major cause of transplant-related mortality (TRM). One of the most difficult challenges to further improve HSCT outcome is reducing toxicity while maintaining efficacy. The use of personalized dosing of the various components of the conditioning regimen by means of therapeutic drug monitoring (TDM) has been the topic of interest in the last decade. TDM could play an important role, especially in children who tend to show greater pharmacokinetic variability. However, TDM should only be performed when it has clear added value to improve clinical outcome or reduce toxicity. In this review, we provide an overview of the available evidence for the relationship between pharmacokinetic parameters and clinical outcome or toxicities of the most commonly used conditioning agents in pediatric HSCT.
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Affiliation(s)
- M. Y. Eileen C. van der Stoep
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
- *Correspondence: M. Y. Eileen C. van der Stoep,
| | - Lisa V. E. Oostenbrink
- Willem-Alexander Children’s Hospital, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Robbert G. M. Bredius
- Willem-Alexander Children’s Hospital, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Dirk Jan A. R. Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - Juliette Zwaveling
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - Arjan C. Lankester
- Willem-Alexander Children’s Hospital, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
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Langenhorst JB, Dorlo TPC, van Maarseveen EM, Nierkens S, Kuball J, Boelens JJ, van Kesteren C, Huitema ADR. Population Pharmacokinetics of Fludarabine in Children and Adults during Conditioning Prior to Allogeneic Hematopoietic Cell Transplantation. Clin Pharmacokinet 2020; 58:627-637. [PMID: 30327943 PMCID: PMC6451721 DOI: 10.1007/s40262-018-0715-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Fludarabine is often used as an important drug in reduced toxicity conditioning regimens prior to hematopoietic cell transplantation (HCT). As no definitive pharmacokinetic (PK) basis for HCT dosing for the wide age and weight range in HCT is available, linear body surface area (BSA)-based dosing is still used. Objective We sought to describe the population PK of fludarabine in HCT recipients of all ages. Methods From 258 HCT recipients aged 0.3–74 years, 2605 samples were acquired on days 1 (42%), 2 (17%), 3 (4%) and 4 (37%) of conditioning. Herein, the circulating metabolite of fludarabine was quantified, and derived concentration-time data were used to build a population PK model using non-linear mixed-effects modelling. Results Variability was extensive where area under the curve ranged from 10 to 66 mg h/L. A three-compartment model with first-order kinetics best described the data. Actual body weight (BW) with standard allometric scaling was found to be the best body-size descriptor for all PK parameters. Estimated glomerular filtration rate (eGFR) was included as a descriptor of renal function. Thus, clearance was differentiated into a non-renal (3.24 ± 20% L/h/70 kg) and renal (eGFR × 0.782 ± 11% L/h/70 kg) component. The typical volumes of distribution of the central (V1), peripheral (V2), and second peripheral (V3) compartments were 39 ± 8%, 20 ± 11%, and 50 ± 9% L/70 kg respectively. Intercompartmental clearances between V1 and V2, and V1 and V3, were 8.6 ± 8% and 3.8 ± 13% L/h/70 kg, respectively. Conclusion BW and eGFR are important predictors of fludarabine PK. Therefore, current linear BSA-based dosing leads to highly variable exposure, which may lead to variable treatment outcome.
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Affiliation(s)
- Jurgen B Langenhorst
- Pediatric Blood and Marrow Transplant Program, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Laboratory of Translational Immunology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Thomas P C Dorlo
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital/Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Erik M van Maarseveen
- Department of Clinical Pharmacy, University Medical Centre, Utrecht, Utrecht University, Heidelberglaan 100: D.00.X, 3584 CX, Utrecht, The Netherlands
| | - Stefan Nierkens
- Laboratory of Translational Immunology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jürgen Kuball
- Laboratory of Translational Immunology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Hematology, University Medical Centre, Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jaap Jan Boelens
- Pediatric Blood and Marrow Transplant Program, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Stem Cell Transplant and Cellular Therapies; Pediatrics, Memorial Sloan Kettering Cancer Centre, New York, NY, USA
| | - Charlotte van Kesteren
- Pediatric Blood and Marrow Transplant Program, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Laboratory of Translational Immunology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital/Netherlands Cancer Institute, Amsterdam, The Netherlands. .,Department of Clinical Pharmacy, University Medical Centre, Utrecht, Utrecht University, Heidelberglaan 100: D.00.X, 3584 CX, Utrecht, The Netherlands.
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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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