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Scherkl C, Meid AD, Cuntz SE, Classen L, Weiss J, Czock D, Haefeli WE. Coadministration of fluconazole to boost subtherapeutic sirolimus concentrations: A case report. Pharmacol Res Perspect 2024; 12:e1198. [PMID: 38635290 PMCID: PMC11025614 DOI: 10.1002/prp2.1198] [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: 12/22/2023] [Revised: 02/21/2024] [Accepted: 03/20/2024] [Indexed: 04/19/2024] Open
Abstract
Individual sirolimus whole blood concentrations are highly variable, critically influenced by the concomitant use of cytochrome P450 (CYP) 3A inducers or inhibitors, and also modulated by food. Therapeutic drug monitoring is therefore recommended, especially at treatment start or in circumstances that can influence sirolimus exposure. In this case report, we highlight the challenge of achieving therapeutic sirolimus concentrations and present pragmatic solutions with regimen adaptions, pharmacokinetic enhancement (use of a drug–drug interaction), concentration monitoring, and subsequent modeling of population pharmacokinetics to support treatment decisions. In a 69-year-old female patient with allogeneic hematopoietic stem cell transplantation, sirolimus concentrations were stable until she developed cerebral toxoplasmosis with tonic–clonic seizures. During treatment of this acute infection, sirolimus concentrations dropped to subtherapeutic levels and remained largely unaffected by dose increases. [Correction added on 4 May 2024, after first online publication: The word “tacrolimus concentrations” has been changed to “sirolimus concentrations” in the preceding sentence.] Only the simultaneous administration of the CYP3A4 inhibitor fluconazole and a shortening of the sirolimus dosing intervals to a (non-approved) twice-daily administration led to successful control of the concentrations, which ultimately even made a dose reduction possible. This intervention resulted in an increase of sirolimus mean trough concentration to 5.85 ng/mL, i.e., into the desired target range. Additionally, a higher ratio of sirolimus trough levels/daily dose from 26.9 to 109 ng/mL/mg/kg/day was achieved with the initiation of fluconazole. Thus, this case report describes the use of clinical pharmacological concepts and pharmacokinetic modeling to optimize treatment strategies in an individual patient. This strategy could be generalized to other CYP inhibitors and other treatment regimens.
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Affiliation(s)
- Camilo Scherkl
- Internal Medicine IX: Department of Clinical Pharmacology and PharmacoepidemiologyHeidelberg University, Medical Faculty Heidelberg/Heidelberg University HospitalHeidelbergGermany
| | - Andreas D. Meid
- Internal Medicine IX: Department of Clinical Pharmacology and PharmacoepidemiologyHeidelberg University, Medical Faculty Heidelberg/Heidelberg University HospitalHeidelbergGermany
| | - Sven E. Cuntz
- Internal Medicine V: Department of Hematology, Oncology and RheumatologyHeidelberg University, Medical Faculty Heidelberg/Heidelberg University HospitalHeidelbergGermany
| | - Laura Classen
- Internal Medicine V: Department of Hematology, Oncology and RheumatologyHeidelberg University, Medical Faculty Heidelberg/Heidelberg University HospitalHeidelbergGermany
| | - Johanna Weiss
- Internal Medicine IX: Department of Clinical Pharmacology and PharmacoepidemiologyHeidelberg University, Medical Faculty Heidelberg/Heidelberg University HospitalHeidelbergGermany
| | - David Czock
- Internal Medicine IX: Department of Clinical Pharmacology and PharmacoepidemiologyHeidelberg University, Medical Faculty Heidelberg/Heidelberg University HospitalHeidelbergGermany
| | - Walter E. Haefeli
- Internal Medicine IX: Department of Clinical Pharmacology and PharmacoepidemiologyHeidelberg University, Medical Faculty Heidelberg/Heidelberg University HospitalHeidelbergGermany
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2
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Appelbaum J, Price AE, Oda K, Zhang J, Leung WH, Tampella G, Xia D, So PP, Hilton SK, Evandy C, Sarkar S, Martin U, Krostag AR, Leonardi M, Zak DE, Logan R, Lewis P, Franke-Welch S, Ngwenyama N, Fitzgerald M, Tulberg N, Rawlings-Rhea S, Gardner RA, Jones K, Sanabria A, Crago W, Timmer J, Hollands A, Eckelman B, Bilic S, Woodworth J, Lamble A, Gregory PD, Jarjour J, Pogson M, Gustafson JA, Astrakhan A, Jensen MC. Drug-regulated CD33-targeted CAR T cells control AML using clinically optimized rapamycin dosing. J Clin Invest 2024; 134:e162593. [PMID: 38502193 PMCID: PMC11060733 DOI: 10.1172/jci162593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 03/08/2024] [Indexed: 03/21/2024] Open
Abstract
Chimeric antigen receptor (CAR) designs that incorporate pharmacologic control are desirable; however, designs suitable for clinical translation are needed. We designed a fully human, rapamycin-regulated drug product for targeting CD33+ tumors called dimerizaing agent-regulated immunoreceptor complex (DARIC33). T cell products demonstrated target-specific and rapamycin-dependent cytokine release, transcriptional responses, cytotoxicity, and in vivo antileukemic activity in the presence of as little as 1 nM rapamycin. Rapamycin withdrawal paused DARIC33-stimulated T cell effector functions, which were restored following reexposure to rapamycin, demonstrating reversible effector function control. While rapamycin-regulated DARIC33 T cells were highly sensitive to target antigen, CD34+ stem cell colony-forming capacity was not impacted. We benchmarked DARIC33 potency relative to CD19 CAR T cells to estimate a T cell dose for clinical testing. In addition, we integrated in vitro and preclinical in vivo drug concentration thresholds for off-on state transitions, as well as murine and human rapamycin pharmacokinetics, to estimate a clinically applicable rapamycin dosing schedule. A phase I DARIC33 trial has been initiated (PLAT-08, NCT05105152), with initial evidence of rapamycin-regulated T cell activation and antitumor impact. Our findings provide evidence that the DARIC platform exhibits sensitive regulation and potency needed for clinical application to other important immunotherapy targets.
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MESH Headings
- Animals
- Female
- Humans
- Male
- Mice
- Immunotherapy, Adoptive
- Leukemia, Myeloid, Acute/immunology
- Leukemia, Myeloid, Acute/therapy
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/pathology
- Receptors, Chimeric Antigen/immunology
- Sialic Acid Binding Ig-like Lectin 3/immunology
- Sialic Acid Binding Ig-like Lectin 3/metabolism
- Sirolimus/pharmacology
- Sirolimus/administration & dosage
- T-Lymphocytes/immunology
- T-Lymphocytes/drug effects
- Xenograft Model Antitumor Assays
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Affiliation(s)
- Jacob Appelbaum
- Seattle Children’s Therapeutics, Seattle Children’s Research Institute, Seattle, Washington, USA
- Division of Hematology/Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
- Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Seattle Children’s Hospital, Seattle, Washington, USA
| | | | - Kaori Oda
- Seattle Children’s Therapeutics, Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Joy Zhang
- 2seventy bio, Cambridge, Massachusetts, USA
| | | | - Giacomo Tampella
- Seattle Children’s Therapeutics, Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Dong Xia
- 2seventy bio, Cambridge, Massachusetts, USA
| | | | | | - Claudya Evandy
- Seattle Children’s Therapeutics, Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Semanti Sarkar
- Seattle Children’s Therapeutics, Seattle Children’s Research Institute, Seattle, Washington, USA
| | | | | | - Marissa Leonardi
- Seattle Children’s Therapeutics, Seattle Children’s Research Institute, Seattle, Washington, USA
| | | | - Rachael Logan
- Seattle Children’s Therapeutics, Seattle Children’s Research Institute, Seattle, Washington, USA
| | | | | | | | - Michael Fitzgerald
- Seattle Children’s Therapeutics, Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Niklas Tulberg
- Seattle Children’s Therapeutics, Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Stephanie Rawlings-Rhea
- Seattle Children’s Therapeutics, Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Rebecca A. Gardner
- Seattle Children’s Therapeutics, Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Kyle Jones
- Inhibrx, Torrey Pines Science Park, La Jolla, California, USA
| | | | - William Crago
- Inhibrx, Torrey Pines Science Park, La Jolla, California, USA
| | - John Timmer
- Inhibrx, Torrey Pines Science Park, La Jolla, California, USA
| | - Andrew Hollands
- Inhibrx, Torrey Pines Science Park, La Jolla, California, USA
| | | | | | | | - Adam Lamble
- Seattle Children’s Therapeutics, Seattle Children’s Research Institute, Seattle, Washington, USA
- Seattle Children’s Hospital, Seattle, Washington, USA
| | | | | | | | - Joshua A. Gustafson
- Seattle Children’s Therapeutics, Seattle Children’s Research Institute, Seattle, Washington, USA
| | | | - Michael C. Jensen
- Seattle Children’s Therapeutics, Seattle Children’s Research Institute, Seattle, Washington, USA
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3
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Uenishi GI, Repic M, Yam JY, Landuyt A, Saikumar-Lakshmi P, Guo T, Zarin P, Sassone-Corsi M, Chicoine A, Kellogg H, Hunt M, Drow T, Tewari R, Cook PJ, Yang SJ, Cerosaletti K, Schweinoch D, Guiastrennec B, James E, Patel C, Chen TF, Buckner JH, Rawlings DJ, Wickham TJ, Mueller KT. GNTI-122: an autologous antigen-specific engineered Treg cell therapy for type 1 diabetes. JCI Insight 2024; 9:e171844. [PMID: 38516892 PMCID: PMC11063937 DOI: 10.1172/jci.insight.171844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 02/02/2024] [Indexed: 03/23/2024] Open
Abstract
Tregs have the potential to establish long-term immune tolerance in patients recently diagnosed with type 1 diabetes (T1D) by preserving β cell function. Adoptive transfer of autologous thymic Tregs, although safe, exhibited limited efficacy in previous T1D clinical trials, likely reflecting a lack of tissue specificity, limited IL-2 signaling support, and in vivo plasticity of Tregs. Here, we report a cell engineering strategy using bulk CD4+ T cells to generate a Treg cell therapy (GNTI-122) that stably expresses FOXP3, targets the pancreas and draining lymph nodes, and incorporates a chemically inducible signaling complex (CISC). GNTI-122 cells maintained an expression profile consistent with Treg phenotype and function. Activation of CISC using rapamycin mediated concentration-dependent STAT5 phosphorylation and, in concert with T cell receptor engagement, promoted cell proliferation. In response to the cognate antigen, GNTI-122 exhibited direct and bystander suppression of polyclonal, islet-specific effector T cells from patients with T1D. In an adoptive transfer mouse model of T1D, a mouse engineered-Treg analog of GNTI-122 trafficked to the pancreas, decreased the severity of insulitis, and prevented progression to diabetes. Taken together, these findings demonstrate in vitro and in vivo activity and support further development of GNTI-122 as a potential treatment for T1D.
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Affiliation(s)
| | | | | | | | | | - Tingxi Guo
- GentiBio Inc, Cambridge, Massachusetts, USA
| | | | | | | | | | - Martina Hunt
- Center for Immunity and Immunotherapies and the Program for Cell and Gene Therapy, Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Travis Drow
- Center for Immunity and Immunotherapies and the Program for Cell and Gene Therapy, Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Ritika Tewari
- Center for Translational Immunology, Benaroya Research Institute at Virginia Mason, Seattle, Washington, USA
| | - Peter J. Cook
- Center for Immunity and Immunotherapies and the Program for Cell and Gene Therapy, Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Soo Jung Yang
- Center for Translational Immunology, Benaroya Research Institute at Virginia Mason, Seattle, Washington, USA
| | - Karen Cerosaletti
- Center for Translational Immunology, Benaroya Research Institute at Virginia Mason, Seattle, Washington, USA
| | | | | | - Eddie James
- Center for Translational Immunology, Benaroya Research Institute at Virginia Mason, Seattle, Washington, USA
| | | | | | - Jane H. Buckner
- Center for Translational Immunology, Benaroya Research Institute at Virginia Mason, Seattle, Washington, USA
- Department of Medicine
- Department of Immunology, and
| | - David J. Rawlings
- Center for Immunity and Immunotherapies and the Program for Cell and Gene Therapy, Seattle Children’s Research Institute, Seattle, Washington, USA
- Department of Immunology, and
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
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4
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Yang Y, Jiang L, Zhu HR, Sun WX, Mao JY, Miao JW, Wang YC, He SM, Wang DD, Chen X. Remedial Dosing Recommendations for Sirolimus Delayed or Missed Dosages Caused by Poor Medication Compliance in Pediatric Tuberous Sclerosis Complex Patients. Curr Pharm Des 2024; 30:877-886. [PMID: 38454763 DOI: 10.2174/0113816128299479240213151714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/30/2024] [Accepted: 02/06/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Delayed or missed dosages caused by poor medication compliance significantly affected the treatment of diseases in children. AIMS The present study aimed to investigate the influence of delayed or missed dosages on sirolimus pharmacokinetics (PK) in pediatric tuberous sclerosis complex (TSC) patients and to recommend remedial dosages for nonadherent patients. METHODS A published sirolimus population PK model in pediatric TSC patients was used to assess the influence of different nonadherence scenarios and recommend optimally remedial dosages based on Monte Carlo simulation. Thirteen nonadherent scenarios were simulated in this study, including delayed 2h, 4 h, 6 h, 8 h, 10 h, 12 h, 14 h, 16 h, 18 h, 20 h, 22 h, 23.5 h, and missed one dosage. Remedial dosing strategies contained 10-200% of scheduled dosages. The optimal remedial dosage was that with the maximum probability of returning the individual therapeutic range. RESULTS For delayed or missed sirolimus dosages in pediatric TSC patients, when the delayed time was 0-8 h, 8-10 h, 10-18 h, 18-22.7 h, 22.7-24 h, 70%, 60%, 40%, 30%, 20% scheduled dosages were recommended to take immediately. When one dosage was missed, 120% of scheduled dosages were recommended at the next dose. CONCLUSION It was the first time to recommend remedial dosages for delayed or missed sirolimus therapy caused by poor medication compliance in pediatric TSC patients based on Monte Carlo simulation. Meanwhile, the present study provided a potential solution for delayed or missed dosages in clinical practice.
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Affiliation(s)
- Yang Yang
- Department of Pharmacy, The Affiliated Changzhou Children's Hospital of Nantong University, Changzhou, Jiangsu 213003, China
| | - Lei Jiang
- Department of Pharmacy, Taixing People's Hospital, Taixing, Jiangsu 225400, China
| | - Hai-Rong Zhu
- School of Nursing, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
| | - Wen-Xin Sun
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, School of Pharmacy, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
| | - Jing-Yu Mao
- School of Nursing, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
| | - Jing-Wen Miao
- School of Nursing, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
| | - Yi-Chen Wang
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, School of Pharmacy, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
| | - Su-Mei He
- Department of Pharmacy, Suzhou Hospital, Affiliated Hospital of Medical School, Nanjing University, Suzhou, Jiangsu 215153, China
| | - Dong-Dong Wang
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, School of Pharmacy, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
| | - Xiao Chen
- School of Nursing, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
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5
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Wang K, Amidon GL, Smith DE. Physiological Dynamics in the Upper Gastrointestinal Tract and the Development of Gastrointestinal Absorption Models for the Immediate-Release Oral Dosage Forms in Healthy Adult Human. Pharm Res 2023; 40:2607-2626. [PMID: 37783928 DOI: 10.1007/s11095-023-03597-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/26/2023] [Indexed: 10/04/2023]
Abstract
This review is a revisit of various oral drug absorption models developed in the past decades, focusing on how to incorporate the physiological dynamics in the upper gastrointestinal (GI) tract. For immediate-release oral drugs, GI absorption is a critical input of drug exposure and subsequent human body response, yet difficult to model largely due to the complex GI environment. One of the biggest hurdles lies at capturing the high within-subject variability (WSV) of bioavailability measures, which can be mechanistically explained by the GI physiological dynamics. A thorough summary of how GI dynamics is handled in the absorption models would promote the development of mechanism-based oral drug absorption models, aid in the design of clinical studies regarding dosing regimens and bioequivalence studies based on WSV, and advance the decision-making on formulation selection.
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Affiliation(s)
- Kai Wang
- Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, MI, 48109, USA.
| | - Gordon L Amidon
- Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, MI, 48109, USA
| | - David E Smith
- Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, MI, 48109, USA
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6
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Zhou Q, Doherty J, Akk A, Springer LE, Fan P, Spasojevic I, Halade GV, Yang H, Pham CTN, Wickline SA, Pan H. Safety Profile of Rapamycin Perfluorocarbon Nanoparticles for Preventing Cisplatin-Induced Kidney Injury. NANOMATERIALS (BASEL, SWITZERLAND) 2022; 12:336. [PMID: 35159680 PMCID: PMC8839776 DOI: 10.3390/nano12030336] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/09/2022] [Accepted: 01/14/2022] [Indexed: 12/30/2022]
Abstract
Cancer treatment-induced toxicities may restrict maximal effective dosing for treatment and cancer survivors' quality of life. It is critical to develop novel strategies that mitigate treatment-induced toxicity without affecting the efficacy of anti-cancer therapies. Rapamycin is a macrolide with anti-cancer properties, but its clinical application has been hindered, partly by unfavorable bioavailability, pharmacokinetics, and side effects. As a result, significant efforts have been undertaken to develop a variety of nano-delivery systems for the effective and safe administration of rapamycin. While the efficacy of nanostructures carrying rapamycin has been studied intensively, the pharmacokinetics, biodistribution, and safety remain to be investigated. In this study, we demonstrate the potential for rapamycin perfluorocarbon (PFC) nanoparticles to mitigate cisplatin-induced acute kidney injury with a single preventative dose. Evaluations of pharmacokinetics and biodistribution suggest that the PFC nanoparticle delivery system improves rapamycin pharmacokinetics. The safety of rapamycin PFC nanoparticles was shown both in vitro and in vivo. After a single dose, no disturbance was observed in blood tests or cardiac functional evaluations. Repeated dosing of rapamycin PFC nanoparticles did not affect overall spleen T cell proliferation and responses to stimulation, although it significantly decreased the number of Foxp3+CD4+ T cells and NK1.1+ cells were observed.
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Affiliation(s)
- Qingyu Zhou
- Department of Pharmaceutical Sciences, Taneja College of Pharmacy, University of South Florida, Tampa, FL 33612, USA
| | - Justin Doherty
- USF Health Heart Institute, University of South Florida, Tampa, FL 33602, USA; (J.D.); (G.V.H.); (S.A.W.)
| | - Antonina Akk
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; (A.A.); (L.E.S.); (C.T.N.P.)
| | - Luke E. Springer
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; (A.A.); (L.E.S.); (C.T.N.P.)
| | - Ping Fan
- School of Medicine, Duke University, Durham, NC 27708, USA; (P.F.); (I.S.); (H.Y.)
| | - Ivan Spasojevic
- School of Medicine, Duke University, Durham, NC 27708, USA; (P.F.); (I.S.); (H.Y.)
| | - Ganesh V. Halade
- USF Health Heart Institute, University of South Florida, Tampa, FL 33602, USA; (J.D.); (G.V.H.); (S.A.W.)
| | - Huanghe Yang
- School of Medicine, Duke University, Durham, NC 27708, USA; (P.F.); (I.S.); (H.Y.)
| | - Christine T. N. Pham
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; (A.A.); (L.E.S.); (C.T.N.P.)
- John Cochran Veterans Affairs Medical Center, St. Louis, MO 63106, USA
| | - Samuel A. Wickline
- USF Health Heart Institute, University of South Florida, Tampa, FL 33602, USA; (J.D.); (G.V.H.); (S.A.W.)
- Altamira Therapeutics Inc., Dover, DE 19901, USA
| | - Hua Pan
- USF Health Heart Institute, University of South Florida, Tampa, FL 33602, USA; (J.D.); (G.V.H.); (S.A.W.)
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7
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Zhang Y, Zhang X, Zou Y, Sun Y, Li X. Population pharmacokinetics of sirolimus in Chinese adult liver transplant recipients: a retrospective study. Xenobiotica 2022; 51:1408-1415. [PMID: 34983304 DOI: 10.1080/00498254.2022.2025628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Considering the significant interindividual variability and a narrow therapeutic index, we aimed to determine the population pharmacokinetics (PPK) of sirolimus and identify the factors in Chinese adult liver transplant recipients.Data were retrospectively extracted from adult liver transplant recipients receiving sirolimus in our hospital. The trough blood concentration data, obtained from traditional therapeutic drug monitoring-based dose adjustments, were used to develop a population pharmacokinetic model by non-linear mixed-effects modelling (NONMEM). The effect of demographic features, biological characteristics and concomitant medications was measured. The final model was verified by visual prediction check (VPC), bootstrap, and simulation.One hundred and sixteen blood concentrations from 63 patients were analysed. The PPK of sirolimus could be described by a one-compartment model with first-order absorption. Covariate analysis indicated that voriconazole co-therapy significantly decreased the oral clearance (CL) of sirolimus. The results of VPC and Bootstrap demonstrated that the final pharmacokinetic model adequately predicted observed concentrations. The simulation results showed that the dosage regimen of sirolimus should be reduced to 0.25 ∼ 0.45 mg/day for adult liver transplant recipients co-administered with voriconazole. The present study developed and validated a sirolimus PPK model for Chinese adult liver transplant recipients, and voriconazole co-therapy was found to be a significant covariate in the model. These results provide important information for clinicians to optimise the treatment regimens of sirolimus in Chinese adult liver transplant recipients.
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Affiliation(s)
- Yang Zhang
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Molecular Pharmaceutics and New Drug Delivery Systems, State Key Laboratory of Natural and Biomimetic Drugs, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Xuanling Zhang
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yue Zou
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yiqi Sun
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xingang Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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8
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Chen X, Wang DD, Xu H, Li ZP. Initial dose recommendation for sirolimus in paediatric kaposiform haemangioendothelioma patients based on population pharmacokinetics and pharmacogenomics. J Int Med Res 2021; 48:300060520947627. [PMID: 32815764 PMCID: PMC7444137 DOI: 10.1177/0300060520947627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objective Sirolimus has been used to treat paediatric kaposiform haemangioendothelioma patients. However, there is considerable pharmacokinetic variability among individuals, and it is difficult to develop an initial dosing regimen. The goal of the present study is to recommend an initial sirolimus dose in paediatric kaposiform haemangioendothelioma patients based on population pharmacokinetics and pharmacogenomics. Methods This was a retrospective clinical study. A population pharmacokinetics model was established and population characteristics, laboratory test results, drug combinations, and pharmacogenomics were considered as potential covariates. The Monte Carlo method was used to simulate the optimal initial dosage. Results The final covariates that affect sirolimus clearance include weight and the CYP3A5 genotype. The initial dosage of sirolimus for individuals with CYP3A5*3/*3 was 0.20 mg/kg split into two doses for 5 to 60 kg body weight. For individuals with CYP3A5*1, the initial dose was 0.23 mg/kg split into two doses for 5 to 30 kg body weight and 0.20 mg/kg split into two doses for 30 to 60 kg body weight. Conclusion The recommendation for the initial sirolimus dose in paediatric kaposiform haemangioendothelioma patients was based on population pharmacokinetics and pharmacogenomics. This study may provide practical value for sirolimus clinical use in paediatric kaposiform haemangioendothelioma patients.
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Affiliation(s)
- Xiao Chen
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
| | - Dong-Dong Wang
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
| | - Hong Xu
- Department of Nephrology, Children's Hospital of Fudan University, Shanghai, China
| | - Zhi-Ping Li
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai, China
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9
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Guan XD, Tang XG, Zhang YJ, Xie HM, Luo L, Wu D, Chen R, Hu P. Population Pharmacokinetic Analysis of Yimitasvir in Chinese Healthy Volunteers and Patients With Chronic Hepatitis C Virus Infection. Front Pharmacol 2021; 11:617122. [PMID: 33584296 PMCID: PMC7876056 DOI: 10.3389/fphar.2020.617122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/23/2020] [Indexed: 11/16/2022] Open
Abstract
Yimitasvir is a novel, oral hepatitis C virus (HCV) non-structural protein 5A inhibitor for the treatment of chronic HCV genotype 1 infection. The objective of this analysis was to develop a population pharmacokinetic model of yimitasvir in Chinese healthy volunteers and HCV infection patients. The model was performed using data from 219 subjects across six studies. Nonlinear mixed effects models were developed using Phoenix NLME software. The covariates were evaluated using a stepwise forward inclusion (p < 0.01) and then a backward exclusion procedure (p < 0.001). A two-compartment model with sequential zero-first order absorption and first-order elimination reasonably described yimitasvir pharmacokinetics (PK). The apparent oral clearance and central volume of distribution were 13.8 l·h−1 and 188 l, respectively. The bioavailability (F) of yimitasvir decreased 12.9% for each 100 mg dose increase. Food was found to affect absorption rate (Ka) and F. High-fat meal decreased Ka and F by 90.9% and 38.5%, respectively. Gender and alanine aminotransferase were identified as significant covariates on apparent oral clearance. Female subjects had lower clearance than male subjects. Zero-order absorption duration was longer in healthy volunteers (2.17 h) than that in patients (1.43 h). The population pharmacokinetic model described yimitasvir PK profile well. Food decreased Ka and F significantly, so it was recommended to take yimitasvir at least 2 h before or after a meal. Other significant covariates were not clinically important.
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Affiliation(s)
- Xiao-Duo Guan
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, Beijing, China
| | - Xian-Ge Tang
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, Beijing, China
| | - Ying-Jun Zhang
- State Key Laboratory of Anti-Infective Drug Development, Dongguan, China.,Sunshine Lake Pharma Co., Ltd., Dongguan, China
| | - Hong-Ming Xie
- State Key Laboratory of Anti-Infective Drug Development, Dongguan, China.,Sunshine Lake Pharma Co., Ltd., Dongguan, China
| | - Lin Luo
- State Key Laboratory of Anti-Infective Drug Development, Dongguan, China.,Sunshine Lake Pharma Co., Ltd., Dongguan, China
| | - Dan Wu
- State Key Laboratory of Anti-Infective Drug Development, Dongguan, China.,Sunshine Lake Pharma Co., Ltd., Dongguan, China
| | - Rui Chen
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, Beijing, China
| | - Pei Hu
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, Beijing, China
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10
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Nizzi F, Rees M, Salzberg D, Ngwube A. Successful management of sirolimus toxicity in a hematopoietic stem cell transplant patient using automated red blood cell exchange. Transfusion 2020; 60:3060-3063. [PMID: 32888326 DOI: 10.1111/trf.16064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/25/2020] [Accepted: 08/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Sirolimus is an immunosuppressive agent used in organ rejection prophylaxis in solid-organ transplantation, graft-vs-host disease prophylaxis in hematopoietic stem cell transplantation, and as an immune modulator for patients with lymphangioleiomyomatosis and vascular malformations. Sirolimus has a narrow therapeutic index with potential severe side effects, including hypertension, hepatotoxicity, nephrotoxicity, and neurotoxicity. CASE REPORT We report a case of a 19-year-old woman with severe sickle cell disease who underwent a matched unrelated hematopoietic stem cell transplantation, whose course was complicated by sirolimus toxicity. This case was challenging because sirolimus has no specific antidote, is largely bound to red blood cells (RBCs), has a high distribution volume, and cannot be removed by dialysis or plasmapheresis. RESULT Due to the concern for toxicity, we looked into possibilities for rapid sirolimus clearance using automated RBC exchange. The treatment was effective in decreasing blood sirolimus levels within the therapeutic ranges. CONCLUSION The use of RBC exchange is potentially safe and effective in the management of a case of sirolimus toxicity.
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Affiliation(s)
- Frank Nizzi
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Melissa Rees
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Dana Salzberg
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Alexander Ngwube
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, Arizona, USA.,University of Arizona School of Medicine, Department of Child Health, Phoenix, Arizona, USA.,Mayo Clinic, Scottsdale, Arizona, USA
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11
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Mizuno T, Dong M, Taylor ZL, Ramsey LB, Vinks AA. Clinical implementation of pharmacogenetics and model-informed precision dosing to improve patient care. Br J Clin Pharmacol 2020; 88:1418-1426. [PMID: 32529759 DOI: 10.1111/bcp.14426] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/15/2020] [Accepted: 05/26/2020] [Indexed: 12/15/2022] Open
Abstract
Providing maximal therapeutic efficacy without toxicity is a universal goal of rational drug therapy. However, substantial between-patient variability in drug response often impedes such successful treatments and brings the necessity of tailoring drug dose to individual needs for more precise therapy. In many cases plenty of patient characteristics, such as body size, genetic makeup and environmental factors, need to be taken into consideration to find the optimal dose in clinical practice. A pharmacokinetics and pharmacodynamics (PK/PD) model-informed approach offers integration of various patient information to provide an expectation of drug response and derive practical dose estimates to support clinicians' dosing decisions. Such an approach was pioneered in the late 1970s, but its broad clinical acceptance and implementation have been hampered by the lack of widespread computer technology, including user-friendly software tools. This has significantly changed in recent years. With the advent of electronic health records (EHRs) and the ubiquity of user-friendly software tools, we now experience a convergence of clinical information, pharmacogenetics, systems pharmacology and pharmacometrics, and technology. Advanced pharmacometrics research is now more appliable and implementable to improve health care. This article presents examples of successful development and implementation of pharmacogenetics-guided and PK/PD model-informed decision support to facilitate precision dosing, including the development of an EHR-embedded decision support tool. Through the integration of clinical decision support tools in EHRs, clinical pharmacometrics support can be brought directly to the clinical team and the bedside.
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Affiliation(s)
- Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Min Dong
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Zachary L Taylor
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Molecular, Cellular, and Biochemical Pharmacology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Laura B Ramsey
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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12
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Mizuno T, O'Brien MM, Vinks AA. Significant effect of infection and food intake on sirolimus pharmacokinetics and exposure in pediatric patients with acute lymphoblastic leukemia. Eur J Pharm Sci 2019; 128:209-214. [DOI: 10.1016/j.ejps.2018.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 12/03/2018] [Accepted: 12/07/2018] [Indexed: 12/21/2022]
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13
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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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14
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Population Pharmacokinetics and Safety of Solithromycin following Intravenous and Oral Administration in Infants, Children, and Adolescents. Antimicrob Agents Chemother 2018; 62:AAC.00692-18. [PMID: 29891609 DOI: 10.1128/aac.00692-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/04/2018] [Indexed: 01/10/2023] Open
Abstract
Solithromycin is a novel fluoroketolide antibiotic which was under investigation for the treatment of community-acquired bacterial pneumonia (CABP). A phase 1 study was performed to characterize the pharmacokinetics (PK) and safety of solithromycin in children. Eighty-four subjects (median age, 6 years [age range, 4 days to 17 years]) were administered intravenous (i.v.) or oral (capsules or suspension) solithromycin (i.v., 6 to 8 mg/kg of body weight; capsules/suspension, 14 to 16 mg/kg on days 1 and 7 to 15 mg/kg on days 2 to 5). PK samples were collected after the first and multidose administration. Data from 83 subjects (662 samples) were combined with previously collected adolescent PK data (n = 13; median age, 16 years [age range, 12 to 17 years]) following capsule administration to perform a population PK analysis. A 2-compartment PK model characterized the data well, and postmenstrual age was the only significant covariate after accounting for body size differences. Dosing simulations suggested that 8 mg/kg i.v. daily and oral dosing of 20 mg/kg on day 1 (800-mg adult maximum) followed by 10 mg/kg on days 2 to 5 (400-mg adult maximum) would achieve a pediatric solithromycin exposure consistent with the exposures observed in adults. Seventy-six treatment-emergent adverse events (TEAEs) were reported in 40 subjects. Diarrhea (6 subjects) and infusion site pain or phlebitis (3 subjects) were the most frequently reported adverse events related to treatment. Two subjects experienced TEAEs of increased hepatic enzymes that were deemed not to be related to the study treatment. (The phase 1 pediatric studies discussed in this paper have been registered at ClinicalTrials.gov under identifiers NCT01966055 and NCT02268279.).
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15
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Mizuno T, Emoto C, Fukuda T, Hammill AM, Adams DM, Vinks AA. Model-based precision dosing of sirolimus in pediatric patients with vascular anomalies. Eur J Pharm Sci 2017; 109S:S124-S131. [PMID: 28526601 DOI: 10.1016/j.ejps.2017.05.037] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/16/2017] [Indexed: 02/07/2023]
Abstract
Sirolimus is the first drug to show efficacy in the treatment of patients with complicated vascular anomalies. The current study expands on the evolution of a PK model-based strategy for the precision dosing of sirolimus as part of prospective concentration controlled clinical trials in pediatric patients with vascular anomalies. Twelve month follow up data collected from 52 pediatric patients participating in the Phase 2 clinical trial were analyzed. Target attainment across the age range of 3weeks to 18years after 2-3months of therapy was 94% (49 out of 52 patients). The mean sirolimus dose to achieve the target of ~10ng/mL for patients older than 2years was 1.8mg/m2 twice daily (range 0.8-2.9), while it was 0.7 to 1.6mg/m2 twice daily for patients 3weeks of age to 2years. A total of 676 blood concentration data were used for the population PK analysis by nonlinear mixed effect modeling using NONMEM. The final model included a maturation function for sirolimus clearance and allometrically scaled body weight to account for size differences. The mean allometrically scaled sirolimus clearance estimates increased from 3.9 to 17.0L/h per 70kg with age from shortly after the birth to 2years of age while the mean estimate for patients older than 2years was 18.5L/h per 70kg. The developed model based dosing strategy provides a foundation for ongoing efforts to define the sirolimus exposure-response and clinical outcome relationships across the pediatric age spectrum from birth to adolescence.
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Affiliation(s)
- Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Chie Emoto
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Adrienne M Hammill
- Division of Hematology, Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Denise M Adams
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.
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16
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Zimmerman KO, Wu H, Greenberg R, Hill K, Patel UD, Ku L, Gonzalez D, Hornik C, Jiang W, Zheng N, Melloni C, Cohen-Wolkowiez M. Therapeutic Drug Monitoring, Electronic Health Records, and Pharmacokinetic Modeling to Evaluate Sirolimus Drug Exposure-Response Relationships in Renal Transplant Patients. Ther Drug Monit 2016; 38:600-6. [PMID: 27259059 PMCID: PMC5025355 DOI: 10.1097/ftd.0000000000000313] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Sirolimus, an immunosuppressive agent used in renal transplantation, can prevent allograft rejection. Identification of the therapeutic index (the ratio of minimum toxic concentration to minimum therapeutic concentration) for immunosuppresants is necessary to optimize the care of patients and set standards for bioequivalence evaluation of sirolimus products. However, the therapeutic index for sirolimus has been inconsistently defined, potentially because of inconsistencies in sirolimus exposure-response relationships. METHODS The authors used retrospective therapeutic drug monitoring data from the electronic health records of patients treated in a tertiary health care system from 2008 to 2014 to (1) develop a population pharmacokinetic (PK) model, (2) use the model to simulate sirolimus concentrations, and (3) characterize the exposure-response relationship. Using Wilcoxon rank-sum and Fisher exact tests, the authors determined relationships between sirolimus exposure and adverse events (AEs) (anemia, leukopenia, thrombocytopenia, hyperlipidemia, and decline in renal function) and the composite efficacy end point of graft loss or rejection. RESULTS The developed 2-compartment population PK model showed appropriate goodness of fit. In a late-phase (>12 months), postrenal transplant population of 27 inpatients, the authors identified statistically significant relationships between 83 simulated peak and trough sirolimus concentrations and outcomes: graft loss or rejection (P = 0.018) and decline in renal function (P = 0.006), respectively. CONCLUSIONS Use of therapeutic drug monitoring results and PK modeling permitted correlation of sirolimus concentrations with graft loss or rejection and decline in renal function. However, the method was limited in its assessment of other AEs. To better evaluate sirolimus exposure-response relationships, the method should be applied to a larger sample of newly transplanted patients with a higher propensity toward AEs or efficacy failure.
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Affiliation(s)
- Kanecia O. Zimmerman
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Huali Wu
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rachel Greenberg
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kevin Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Uptal D. Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lawrence Ku
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Christoph Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Wenlei Jiang
- Office of Generic Drugs, US Food and Drug Administration, Silver Spring, MD, USA
| | - Nan Zheng
- Office of Generic Drugs, US Food and Drug Administration, Silver Spring, MD, USA
| | - Chiara Melloni
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
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17
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Emoto C, Fukuda T, Mizuno T, Schniedewind B, Christians U, Adams DM, Vinks AA. Characterizing the Developmental Trajectory of Sirolimus Clearance in Neonates and Infants. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2016; 5:411-7. [PMID: 27501453 PMCID: PMC4999604 DOI: 10.1002/psp4.12096] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/07/2016] [Accepted: 06/21/2016] [Indexed: 01/25/2023]
Abstract
Sirolimus is increasingly being used in neonates and infants, but the mechanistic basis of age‐dependent changes in sirolimus disposition has not been fully addressed yet. In order to characterize the age‐dependent changes, serial sirolimus clearance (CL) estimates in individual young pediatric patients were collected and analyzed by population modeling analysis. In addition, sirolimus metabolite formation was also investigated to further substantiate the corresponding age‐dependent change in CYP3A activity. The increasing pattern over time of allometrically size‐normalized sirolimus CL estimates vs. age was well described by a sigmoidal Emax model. This age‐dependent increase was also observed within each individual patient over a 4‐year study period. CYP3A‐dependent sirolimus metabolite formation changed in a similar fashion. This study clearly demonstrates the rapid increase of sirolimus CL over time in neonates and infants, indicating the developmental change. This developmental pattern can be explained by a parallel increase in CYP3A metabolic activity.
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Affiliation(s)
- C Emoto
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - T Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - T Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - B Schniedewind
- iC42 Integrated Solutions in Clinical Research and Development, University of Colorado, Anschutz Medical Center, Aurora, Colorado, USA
| | - Uwe Christians
- iC42 Integrated Solutions in Clinical Research and Development, University of Colorado, Anschutz Medical Center, Aurora, Colorado, USA
| | - D M Adams
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - A A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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18
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Ceschi A, Heistermann E, Gros S, Reichert C, Kupferschmidt H, Banner NR, Krähenbühl S, Taegtmeyer AB. Acute sirolimus overdose: a multicenter case series. PLoS One 2015; 10:e0128033. [PMID: 26020944 PMCID: PMC4447358 DOI: 10.1371/journal.pone.0128033] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 04/21/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There are few data relating to sirolimus overdose in the medical literature. Our objectives were to describe all cases of overdose with sirolimus reported to Swiss, German and Austrian Poisons Centres between 2002-2013. METHODS An observational case-series analysis was performed to determine circumstances, magnitude, management and outcome of sirolimus overdose. RESULTS Five cases of acute sirolimus overdose were reported--three in young children and two in adults. Four were accidental and one was with suicidal intent. Two patients developed symptoms probably related to sirolimus overdose: mild elevation of alkaline phosphatase, fever and gastroenteritis in a 2.5-year-old male who ingested 3 mg, and mild changes in total cholesterol in an 18-year-old female after ingestion of 103 mg. None of these events were life-threatening. Serial blood concentration measurements were performed starting 24 h after ingestion of 103 mg in a single case, and these followed a similar pharmacokinetic time-course to measurements taken after dosing in the therapeutic range. CONCLUSIONS Acute sirolimus overdose occurred accidentally in the majority of cases. Even large overdoses appeared to be well-tolerated, however children might be at greater risk of developing complications. Further study of sirolimus overdose is needed.
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Affiliation(s)
- Alessandro Ceschi
- Swiss Toxicological Information Centre, Associated Institute of the University of Zurich, Zurich, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
| | | | - Sonja Gros
- Mainz Poison Control Centre, Mainz, Germany
| | - Cornelia Reichert
- Swiss Toxicological Information Centre, Associated Institute of the University of Zurich, Zurich, Switzerland
| | - Hugo Kupferschmidt
- Swiss Toxicological Information Centre, Associated Institute of the University of Zurich, Zurich, Switzerland
| | - Nicholas R. Banner
- The Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, United Kingdom
- National Heart and Lung Institute and Institute of Cardiovascular Medicine and Research, Imperial College, London, United Kingdom
| | - Stephan Krähenbühl
- Department of Clinical Pharmacology and Toxicology, University and University Hospital Basel, Basel, Switzerland
| | - Anne B. Taegtmeyer
- Department of Clinical Pharmacology and Toxicology, University and University Hospital Basel, Basel, Switzerland
- * E-mail:
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