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Duarte JD, Thomas CD, Lee CR, Huddart R, Agundez JAG, Baye JF, Gaedigk A, Klein TE, Lanfear DE, Monte AA, Nagy M, Schwab M, Stein CM, Uppugunduri CRS, van Schaik RHN, Donnelly RS, Caudle KE, Luzum JA. Clinical Pharmacogenetics Implementation Consortium Guideline (CPIC) for CYP2D6, ADRB1, ADRB2, ADRA2C, GRK4, and GRK5 Genotypes and Beta-Blocker Therapy. Clin Pharmacol Ther 2024. [PMID: 38951961 DOI: 10.1002/cpt.3351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/30/2024] [Indexed: 07/03/2024]
Abstract
Beta-blockers are widely used medications for a variety of indications, including heart failure, myocardial infarction, cardiac arrhythmias, and hypertension. Genetic variability in pharmacokinetic (e.g., CYP2D6) and pharmacodynamic (e.g., ADRB1, ADRB2, ADRA2C, GRK4, GRK5) genes have been studied in relation to beta-blocker exposure and response. We searched and summarized the strength of the evidence linking beta-blocker exposure and response with the six genes listed above. The level of evidence was high for associations between CYP2D6 genetic variation and both metoprolol exposure and heart rate response. Evidence indicates that CYP2D6 poor metabolizers experience clinically significant greater exposure and lower heart rate in response to metoprolol compared with those who are not poor metabolizers. Therefore, we provide therapeutic recommendations regarding genetically predicted CYP2D6 metabolizer status and metoprolol therapy. However, there was insufficient evidence to make therapeutic recommendations for CYP2D6 and other beta-blockers or for any beta-blocker and the other five genes evaluated (updates at www.cpicpgx.org).
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Affiliation(s)
- Julio D Duarte
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA
- Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Cameron D Thomas
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA
- Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Rachel Huddart
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Jose A G Agundez
- Institute of Molecular Pathology Biomarkers, University of Extremadura, Cáceres, Spain
| | - Jordan F Baye
- Department of Pharmacy Practice, South Dakota State University College of Pharmacy & Allied Health Professions, Brookings, South Dakota, USA
- Sanford Imagenetics, Sioux Falls, South Dakota, USA
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Research Institute and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - David E Lanfear
- Center for Individualized and Genomic Medicine Research (CIGMA), Henry Ford Hospital, Detroit, Michigan, USA
- Heart and Vascular Institute, Henry Ford Health, Detroit, Michigan, USA
| | - Andrew A Monte
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Mohamed Nagy
- Department of Pharmaceutical Services, Children's Cancer Hospital Egypt 57357, Cairo, Egypt
- Personalized Medication Management Unit, Children's Cancer Hospital Egypt 57357, Cairo, Egypt
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany
- Department of Clinical Pharmacology, University Hospital Tuebingen, Tuebingen, Germany
- Department of Biochemistry and Pharmacy, University Tuebingen, Tuebingen, Germany
| | - C Michael Stein
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Chakradhara Rao S Uppugunduri
- Division of Pediatric Oncology and Hematology, Department of Women, Child and Adolescent, University Geneva Hospitals, Geneva, Switzerland
- Department of Pediatrics, Gynecology and Obstetrics, Cansearch Research Platform for Pediatric Oncology and Hematology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Roseann S Donnelly
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts, USA
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Kelly E Caudle
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jasmine A Luzum
- Center for Individualized and Genomic Medicine Research (CIGMA), Henry Ford Hospital, Detroit, Michigan, USA
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
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Walton M, Wagner JB. Pediatric Beta Blocker Therapy: A Comprehensive Review of Development and Genetic Variation to Guide Precision-Based Therapy in Children, Adolescents, and Young Adults. Genes (Basel) 2024; 15:379. [PMID: 38540438 PMCID: PMC10969836 DOI: 10.3390/genes15030379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/08/2024] [Accepted: 03/15/2024] [Indexed: 06/14/2024] Open
Abstract
Beta adrenergic receptor antagonists, known as beta blockers, are one of the most prescribed medications in both pediatric and adult cardiology. Unfortunately, most of these agents utilized in the pediatric clinical setting are prescribed off-label. Despite regulatory efforts aimed at increasing pediatric drug labeling, a majority of pediatric cardiovascular drug agents continue to lack pediatric-specific data to inform precision dosing for children, adolescents, and young adults. Adding to this complexity is the contribution of development (ontogeny) and genetic variation towards the variability in drug disposition and response. In the absence of current prospective trials, the purpose of this comprehensive review is to illustrate the current knowledge gaps regarding the key drivers of variability in beta blocker drug disposition and response and the opportunities for investigations that will lead to changes in pediatric drug labeling.
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Affiliation(s)
- Mollie Walton
- Ward Family Heart Center, Kansas City, MO 64108, USA
| | - Jonathan B. Wagner
- Ward Family Heart Center, Kansas City, MO 64108, USA
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children’s Mercy, 2401 Gillham Road, Kansas City, MO 64108, USA
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO 64108, USA
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Tonti E, Lee YM, Gruenke N, Ferren J, Stutzman DL. Impact of Pharmacogenomics on Pediatric Psychotropic Medication Prescribing in an Ambulatory Care Setting. J Child Adolesc Psychopharmacol 2024; 34:52-60. [PMID: 38377527 DOI: 10.1089/cap.2023.0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Objective: Evidence for pharmacogenomic (PGx) guided treatment in child and adolescent psychiatry is growing. This study evaluated the impact of PGx testing on psychotropic medication prescribing in an ambulatory child and adolescent psychiatry and a developmental pediatrics clinic. Methods: This was a single-center, retrospective, descriptive analysis of patients who underwent PGx testing between January 2015 and October 2022 at a child and adolescent psychiatry clinic or developmental pediatrics clinic. The primary outcome was the proportion of patients with at least one psychotropic medication modification made 6-month posttesting that could be attributed to CYP2C19, CYP2D6, HLA-B*15:02, or HLA-A*31:01. Secondary outcomes included reason for testing, types of therapeutic modifications made, and whether the therapeutic modifications concorded with PGx guidelines. Results: A total of 193 patients were analyzed. The average age was 10 ± 4 years old, 60% were male, 78% were Caucasian. Sixty-eight percent had a primary diagnosis of a neurodevelopmental disorder, namely autism spectrum disorder (51%), and attention-deficit/hyperactivity disorder (14%). The reasons for PGx testing included medication inefficacy (34%), medication intolerance (20%), and family request (19%). At the time of PGx testing, 37% of patients were taking ≥1 psychotropic medication with PGx annotation. Overall, 35 PGx-related therapeutic modifications were made in 32 (17%) patients. These included continuing current PGx medication (6.2%) and starting PGx medication (5.2%). These modifications mainly involved antidepressants. Out of these 35 PGx-related therapeutic modifications, 94% were concordant with PGx guidelines. Among 29 patients who were prescribed at least one CYP2D6 inhibitor, 25 (86%) underwent CYP2D6 phenoconversion. Conclusions: It is critical to apply pediatric age-specific considerations when utilizing PGx testing in child and adolescent psychiatry. PGx testing stewardship could provide a framework to guide the clinical utility of PGx in a pediatric population with mental health conditions, including neurodevelopmental disorders.
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Affiliation(s)
- Erica Tonti
- Department of Pharmacy, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Yee Ming Lee
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, USA
| | - Nathan Gruenke
- Department of Pharmacy, Children's Hospital Colorado, Aurora, Colorado, USA
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, USA
| | - Janie Ferren
- Department of Pharmacy, Children's Hospital Colorado, Aurora, Colorado, USA
- Pediatric Mental Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Danielle L Stutzman
- Department of Pharmacy, Children's Hospital Colorado, Aurora, Colorado, USA
- Pediatric Mental Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Science, University of Colorado, Aurora, Colorado, USA
- Child and Adolescent Mental Health Division Department of Psychiatry, School of Medicine, University of Colorado, Aurora, Colorado, USA
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Principi N, Petropulacos K, Esposito S. Impact of Pharmacogenomics in Clinical Practice. Pharmaceuticals (Basel) 2023; 16:1596. [PMID: 38004461 PMCID: PMC10675377 DOI: 10.3390/ph16111596] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
Polymorphisms of genes encoding drug metabolizing enzymes and transporters can significantly modify pharmacokinetics, and this can be associated with significant differences in drug efficacy, safety, and tolerability. Moreover, genetic variants of some components of the immune system can explain clinically relevant drug-related adverse events. However, the implementation of drug dose individualization based on pharmacogenomics remains scarce. In this narrative review, the impact of genetic variations on the disposition, safety, and tolerability of the most commonly prescribed drugs is reported. Moreover, reasons for poor implementation of pharmacogenomics in everyday clinical settings are discussed. The literature analysis showed that knowledge of how genetic variations can modify the effectiveness, safety, and tolerability of a drug can lead to the adjustment of usually recommended drug dosages, improve effectiveness, and reduce drug-related adverse events. Despite some efforts to introduce pharmacogenomics in clinical practice, presently very few centers routinely use genetic tests as a guide for drug prescription. The education of health care professionals seems critical to keep pace with the rapidly evolving field of pharmacogenomics. Moreover, multimodal algorithms that incorporate both clinical and genetic factors in drug prescribing could significantly help in this regard. Obviously, further studies which definitively establish which genetic variations play a role in conditioning drug effectiveness and safety are needed. Many problems must be solved, but the advantages for human health fully justify all the efforts.
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Affiliation(s)
| | | | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy
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Dinh J, Johnson TN, Grimstein M, Lewis T. Physiologically Based Pharmacokinetics Modeling in the Neonatal Population-Current Advances, Challenges, and Opportunities. Pharmaceutics 2023; 15:2579. [PMID: 38004559 PMCID: PMC10675397 DOI: 10.3390/pharmaceutics15112579] [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: 09/26/2023] [Revised: 10/24/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023] Open
Abstract
Physiologically based pharmacokinetic (PBPK) modeling is an approach to predicting drug pharmacokinetics, using knowledge of the human physiology involved and drug physiochemical properties. This approach is useful when predicting drug pharmacokinetics in under-studied populations, such as pediatrics. PBPK modeling is a particularly important tool for dose optimization for the neonatal population, given that clinical trials rarely include this patient population. However, important knowledge gaps exist for neonates, resulting in uncertainty with the model predictions. This review aims to outline the sources of variability that should be considered with developing a neonatal PBPK model, the data that are currently available for the neonatal ontogeny, and lastly to highlight the data gaps where further research would be needed.
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Affiliation(s)
- Jean Dinh
- Certara UK Limited, Sheffield S1 2BJ, UK; (J.D.); (T.N.J.)
| | | | - Manuela Grimstein
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20903, USA
| | - Tamorah Lewis
- Pediatric Clinical Pharmacology & Toxicology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
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Bousman CA, Stevenson JM, Ramsey LB, Sangkuhl K, Kevin Hicks J, Strawn JR, Singh AB, Ruaño G, Mueller DJ, Tsermpini EE, Brown JT, Bell GC, Steven Leeder J, Gaedigk A, Scott SA, Klein TE, Caudle KE, Bishop JR. Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for CYP2D6, CYP2C19, CYP2B6, SLC6A4, and HTR2A Genotypes and Serotonin Reuptake Inhibitor Antidepressants. Clin Pharmacol Ther 2023; 114:51-68. [PMID: 37032427 PMCID: PMC10564324 DOI: 10.1002/cpt.2903] [Citation(s) in RCA: 71] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/29/2023] [Indexed: 04/11/2023]
Abstract
Serotonin reuptake inhibitor antidepressants, including selective serotonin reuptake inhibitors (SSRIs; i.e., citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline), serotonin and norepinephrine reuptake inhibitors (i.e., desvenlafaxine, duloxetine, levomilnacipran, milnacipran, and venlafaxine), and serotonin modulators with SSRI-like properties (i.e., vilazodone and vortioxetine) are primary pharmacologic treatments for major depressive and anxiety disorders. Genetic variation in CYP2D6, CYP2C19, and CYP2B6 influences the metabolism of many of these antidepressants, which may potentially affect dosing, efficacy, and tolerability. In addition, the pharmacodynamic genes SLC6A4 (serotonin transporter) and HTR2A (serotonin-2A receptor) have been examined in relation to efficacy and side effect profiles of these drugs. This guideline updates and expands the 2015 Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline for CYP2D6 and CYP2C19 genotypes and SSRI dosing and summarizes the impact of CYP2D6, CYP2C19, CYP2B6, SLC6A4, and HTR2A genotypes on antidepressant dosing, efficacy, and tolerability. We provide recommendations for using CYP2D6, CYP2C19, and CYP2B6 genotype results to help inform prescribing these antidepressants and describe the existing data for SLC6A4 and HTR2A, which do not support their clinical use in antidepressant prescribing.
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Affiliation(s)
- Chad A. Bousman
- Departments of Medical Genetics, Psychiatry, Physiology & Pharmacology, and Community Health Sciences, University of Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Alberta, Canada
- Mathison Centre for Mental Health Research and Education, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
| | - James M. Stevenson
- Departments of Medicine and Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Laura B. Ramsey
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Divisions of Clinical Pharmacology and Research in Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Katrin Sangkuhl
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - J. Kevin Hicks
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, FL, USA
| | - Jeffrey R. Strawn
- Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH, USA
- Divisions of Child & Adolescent Psychiatry and Clinical Pharmacology Cincinnati, Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Ajeet B. Singh
- School of Medicine, IMPACT Institute, Deakin University, Australia
| | - Gualberto Ruaño
- Institute of Living at Hartford Hospital, Hartford, CT, USA
- Department of Psychiatry, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Daniel J. Mueller
- Pharmacogenetics Research Clinic, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Ontario, Canada
| | - Evangelia Eirini Tsermpini
- Pharmacogenetics Laboratory, Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Jacob T. Brown
- Department of Pharmacy Practice & Pharmaceutical Sciences, University of Minnesota College of Pharmacy, Duluth, MN, USA
| | | | - J. Steven Leeder
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children’s Mercy Research Institute (CMRI), Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children’s Mercy Research Institute (CMRI), Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Stuart A. Scott
- Department of Pathology, Stanford University, Palo Alto, CA, USA
- Stanford Medicine Clinical Genomics Program, Stanford Medicine, Stanford, CA, USA
| | - Teri E. Klein
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Kelly E. Caudle
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Jeffrey R. Bishop
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, USA
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Minneapolis, MN, USA
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Palmen R, Sandritter T, Malloy-Walton L, Follansbee C, Wagner JB. Case report: Use of therapeutic drug monitoring and pharmacogenetic testing as opportunities to individualize care in a case of flecainide toxicity after fetal supraventricular tachycardia. Front Pediatr 2023; 11:1168619. [PMID: 37449265 PMCID: PMC10337585 DOI: 10.3389/fped.2023.1168619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Flecainide is a class IC antiarrhythmic utilized in prophylaxis of refractory paroxysmal supraventricular tachycardias in pediatric populations. Despite being a highly effective agent, its narrow therapeutic index increases the risk of toxicity and proarrhythmic events, including wide-complex tachycardia. In the absence of direct plasma sampling in the fetus to quantitate flecainide systemic concentrations, clinicians typically make drug dosing decisions from maternal plasma concentrations and QRS duration on maternal ECGs. There remains a paucity of standard guidelines and data to inform the timing and frequency of the aforementioned test in pregnancy and timing of flecainide discontinuation prior to childbirth. Flecainide primarily undergoes metabolism via cytochrome P450 (CYP). Given the variance of CYP-mediated metabolism at the level of the individual patient, pharmacogenomics can be considered in patients who present with flecainide toxicity to determine the maternal vs. fetal factors as an etiology for the event. Finally, pharmacogenetic testing can be utilized as an adjunct to guide flecainide dosing decisions, but must be done with caution in neonates <2 weeks of age. This case report highlights utilization of pharmacogenomic testing and therapeutic drug monitoring as adjuncts to guide therapy for a newborn with refractory supraventricular tachycardia, who experienced flecainide toxicity immediately post-partum and was trialed unsuccessfully on multiple alternative antiarrhythmics without rhythm control.
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Affiliation(s)
- Ronald Palmen
- Children’s Mercy, Kansas City, MO, United States
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - Tracy Sandritter
- Children’s Mercy, Kansas City, MO, United States
- University of Missouri-Kansas City School of Pharmacy, Kansas City, MO, United States
| | - Lindsey Malloy-Walton
- Children’s Mercy, Kansas City, MO, United States
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
- Ward Family Heart Center, Kansas City, MO, United States
| | - Christopher Follansbee
- Children’s Mercy, Kansas City, MO, United States
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
- Ward Family Heart Center, Kansas City, MO, United States
| | - Jonathan B. Wagner
- Children’s Mercy, Kansas City, MO, United States
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
- Ward Family Heart Center, Kansas City, MO, United States
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Kansas City, MO, United States
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Subasri M, Cressman C, Arje D, Schreyer L, Cooper E, Patel K, Ungar WJ, Barwick M, Denburg A, Hayeems RZ. Translating Precision Health for Pediatrics: A Scoping Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050897. [PMID: 37238445 DOI: 10.3390/children10050897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023]
Abstract
Precision health aims to personalize treatment and prevention strategies based on individual genetic differences. While it has significantly improved healthcare for specific patient groups, broader translation faces challenges with evidence development, evidence appraisal, and implementation. These challenges are compounded in child health as existing methods fail to incorporate the physiology and socio-biology unique to childhood. This scoping review synthesizes the existing literature on evidence development, appraisal, prioritization, and implementation of precision child health. PubMed, Scopus, Web of Science, and Embase were searched. The included articles were related to pediatrics, precision health, and the translational pathway. Articles were excluded if they were too narrow in scope. In total, 74 articles identified challenges and solutions for putting pediatric precision health interventions into practice. The literature reinforced the unique attributes of children and their implications for study design and identified major themes for the value assessment of precision health interventions for children, including clinical benefit, cost-effectiveness, stakeholder values and preferences, and ethics and equity. Tackling these identified challenges will require developing international data networks and guidelines, re-thinking methods for value assessment, and broadening stakeholder support for the effective implementation of precision health within healthcare organizations. This research was funded by the SickKids Precision Child Health Catalyst Grant.
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Affiliation(s)
- Mathushan Subasri
- Child Health Evaluative Sciences Program, The Hospital for Sick Children Research Institute, Toronto, ON M5G 1X8, Canada
| | - Celine Cressman
- Child Health Evaluative Sciences Program, The Hospital for Sick Children Research Institute, Toronto, ON M5G 1X8, Canada
| | - Danielle Arje
- Child Health Evaluative Sciences Program, The Hospital for Sick Children Research Institute, Toronto, ON M5G 1X8, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON M5G 1X8, Canada
| | - Leighton Schreyer
- Child Health Evaluative Sciences Program, The Hospital for Sick Children Research Institute, Toronto, ON M5G 1X8, Canada
| | - Erin Cooper
- Child Health Evaluative Sciences Program, The Hospital for Sick Children Research Institute, Toronto, ON M5G 1X8, Canada
| | - Komal Patel
- Child Health Evaluative Sciences Program, The Hospital for Sick Children Research Institute, Toronto, ON M5G 1X8, Canada
| | - Wendy J Ungar
- Child Health Evaluative Sciences Program, The Hospital for Sick Children Research Institute, Toronto, ON M5G 1X8, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada
| | - Melanie Barwick
- Child Health Evaluative Sciences Program, The Hospital for Sick Children Research Institute, Toronto, ON M5G 1X8, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada
| | - Avram Denburg
- Child Health Evaluative Sciences Program, The Hospital for Sick Children Research Institute, Toronto, ON M5G 1X8, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada
- Division of Haematology/Oncology, Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada
| | - Robin Z Hayeems
- Child Health Evaluative Sciences Program, The Hospital for Sick Children Research Institute, Toronto, ON M5G 1X8, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada
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9
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Personalizing atomoxetine dosing in children with ADHD: what can we learn from current supporting evidence. Eur J Clin Pharmacol 2023; 79:349-370. [PMID: 36645468 DOI: 10.1007/s00228-022-03449-1] [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: 08/24/2022] [Accepted: 12/20/2022] [Indexed: 01/17/2023]
Abstract
PURPOSE There is marked heterogeneity in treatment response of atomoxetine in patients with attention deficit/hyperactivity disorder (ADHD), especially for the pediatric population. This review aims to evaluate current evidence to characterize the dose-exposure relationship, establish clinically relevant metrics for systemic exposure to atomoxetine, define a therapeutic exposure range, and to provide a dose-adaptation strategy before implementing personalized dosing for atomoxetine in children with ADHD. METHODS A comprehensive search was performed across electronic databases (PubMed and Embase) covering the period of January 1, 1985 to July 10, 2022, to summarize recent advances in the pharmacokinetics, pharmacogenomics/pharmacogenetics (PGx), therapeutic drug monitoring (TDM), physiologically based pharmacokinetics (PBPK), and population pharmacokinetics (PPK) of atomoxetine in children with ADHD. RESULTS Some factors affecting the pharmacokinetics of atomoxetine were summarized, including food, CYP2D6 and CYP2C19 phenotypes, and drug‒drug interactions (DDIs). The association between treatment response and genetic polymorphisms of genes encoding pharmacological targets, such as norepinephrine transporter (NET/SLC6A2) and dopamine β hydroxylase (DBH), was also discussed. Based on well-developed and validated assays for monitoring plasma concentrations of atomoxetine, the therapeutic reference range in pediatric patients with ADHD proposed by several studies was summarized. However, supporting evidence on the relationship between systemic atomoxetine exposure levels and clinical response was far from sufficient. CONCLUSION Personalizing atomoxetine dosage may be even more complex than anticipated thus far, but elucidating the best way to tailor the non-stimulant to a patient's individual need will be achieved by combining two strategies: detailed research in linking the pharmacokinetics and pharmacodynamics in pediatric patients, and better understanding in nature and causes of ADHD, as well as environmental stressors.
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Leeder JS, Gaedigk A, Wright KJ, Staggs VS, Soden SE, Lin YS, Pearce RE. A longitudinal study of cytochrome P450 2D6 (CYP2D6) activity during adolescence. Clin Transl Sci 2022; 15:2514-2527. [PMID: 35997001 PMCID: PMC9579386 DOI: 10.1111/cts.13380] [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: 04/12/2022] [Revised: 07/07/2022] [Accepted: 07/09/2022] [Indexed: 01/25/2023] Open
Abstract
CYP2D6 substrates are among the most highly prescribed medications in teenagers and also commonly associated with serious adverse events. To investigate the relative contributions of genetic variation, growth, and development on CYP2D6 activity during puberty, healthy children and adolescents 7-15 years of age at enrollment participated in a longitudinal phenotyping study involving administration of 0.3 mg/kg dextromethorphan (DM) and 4-h urine collection every 6 months for 3 years (7 total visits). At each visit, height, weight, and sexual maturity were recorded, and CYP2D6 activity was determined as the urinary molar ratio of DM to its metabolite dextrorphan (DX). A total of 188 participants completed at least one visit, and 102 completed all seven study visits. Following univariate analysis, only CYP2D6 activity score (p < 0.001), urinary pH (p < 0.001), weight (p = 0.018), and attention-deficit/hyperactivity disorder (ADHD) diagnosis (p < 0.001) were significantly correlated with log(DM/DX). Results of linear mixed model analysis with random intercept, random slope covariance structure revealed that CYP2D6 activity score had the strongest effect on log(DM/DX), with model-estimated average log(DM/DX) being 3.8 SDs higher for poor metabolizers than for patients with activity score 3. A moderate effect on log(DM/DX) was observed for sex, and smaller effects were observed for ADHD diagnosis and urinary pH. The log(DM/DX) did not change meaningfully with age or pubertal development. CYP2D6 genotype remains the single, largest determinant of variability in CYP2D6 activity during puberty. Incorporation of genotype-based dosing guidelines should be considered for CYP2D6 substrates given the prevalent use of these agents in this pediatric age group.
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Affiliation(s)
- J. Steven Leeder
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Department of PediatricsChildren's Mercy Kansas CityKansas CityMissouriUSA,School of MedicineUniversity of Missouri‐Kansas CityKansas CityMissouriUSA
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Department of PediatricsChildren's Mercy Kansas CityKansas CityMissouriUSA,School of MedicineUniversity of Missouri‐Kansas CityKansas CityMissouriUSA
| | - Krista J. Wright
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Department of PediatricsChildren's Mercy Kansas CityKansas CityMissouriUSA
| | - Vincent S. Staggs
- School of MedicineUniversity of Missouri‐Kansas CityKansas CityMissouriUSA,Biostatistics & Epidemiology Core, Division of Health Services and Outcomes Research, Department of PediatricsChildren's Mercy Kansas CityKansas CityMissouriUSA,Division of Developmental and Behavioral Sciences, Department of PediatricsChildren's Mercy Kansas CityKansas CityMissouriUSA
| | - Sarah E. Soden
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Department of PediatricsChildren's Mercy Kansas CityKansas CityMissouriUSA,School of MedicineUniversity of Missouri‐Kansas CityKansas CityMissouriUSA
| | - Yvonne S. Lin
- Department of PharmaceuticsUniversity of WashingtonSeattleWashingtonUSA
| | - Robin E. Pearce
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Department of PediatricsChildren's Mercy Kansas CityKansas CityMissouriUSA,School of MedicineUniversity of Missouri‐Kansas CityKansas CityMissouriUSA
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11
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Behrle AC, Douglas J, Leeder JS, van Haandel L. Isolation and Identification of 3,4-Seco-Solanidine-3,4-dioic acid (SSDA) as a Urinary Biomarker of Cytochrome P450 2D6 (CYP2D6) Activity. Drug Metab Dispos 2022; 50:DMD-AR-2022-000957. [PMID: 35878926 PMCID: PMC9513856 DOI: 10.1124/dmd.122.000957] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/24/2022] [Accepted: 06/29/2022] [Indexed: 11/22/2022] Open
Abstract
Cytochrome P450 2D6 (CYP2D6), is responsible for the metabolism and elimination of approximately 25% of clinically used drugs, including antidepressants and antipsychotics, and its activity varies considerably on a population basis primary due to genetic variation. CYP2D6 phenotype can be assessed in vivo following administration of an exogenous probe compound, such as dextromethorphan or debrisoquine, but use of a biomarker that does not require administration of an exogenous compound (i.e., drug) has considerable appeal for assessing CYP2D6 activity in vulnerable populations, such as children. The goal of this study was to isolate, purify and identify an "endogenous" urinary biomarker (M1; m/z 444.3102) of CYP2D6 activity reported previously. Several chromatographic separation techniques (reverse phase HPLC, cation exchange and analytical reverse phase UPLC) were used to isolate and purify 96 μg of M1 from 40 L of urine. Subsequently, 1D and 2D NMR, and functional group modification reactions were used to elucidate its structure. Analysis of mass spectrometry and NMR data revealed M1 to have similar spectroscopic features to the nitrogen-containing steroidal alkaloid, solanidine. 2D NMR characterization by HMBC, COSY, TOCSY, and HSQC-TOCSY proved to be invaluable in the structural elucidation of M1; derivatization of M1 revealed the presence of two carboxylic acid moieties. M1 was determined to be a steroidal alkaloid with a solanidine backbone that had undergone C-C bond scission to yield 3,4-seco-solanidine-3,4-dioic acid (SSDA). SSDA may have value as a dietary biomarker of CYP2D6 activity in populations where potato consumption is common. Significance Statement Endogenous biomarkers of processes involved in drug disposition and response may allow improved individualization of drug treatment, especially in vulnerable populations, such as children. Given that several CYP2D6 substrates are commonly used in pediatrics and the ubiquitous nature of potato consumption in western diets, SSDA has considerable appeal as non-invasive biomarker of CYP2D6 activity to guide treatment with CYP2D6 substrates in children and adults.
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Affiliation(s)
- Andrew C Behrle
- Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Kansas City, United States
| | - Justin Douglas
- NMR Core Laboratory, University of Kansas, United States
| | - J Steven Leeder
- Children's Mercy Res Inst, Children's Mercy Kansas City, United States
| | - Leon van Haandel
- Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Kansas City, United States
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12
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Yalçin N, Flint RB, van Schaik RHN, Simons SHP, Allegaert K. The Impact of Pharmacogenetics on Pharmacokinetics and Pharmacodynamics in Neonates and Infants: A Systematic Review. Pharmgenomics Pers Med 2022; 15:675-696. [PMID: 35795337 PMCID: PMC9252316 DOI: 10.2147/pgpm.s350205] [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: 05/11/2022] [Accepted: 06/14/2022] [Indexed: 12/22/2022] Open
Abstract
In neonates, pharmacogenetics has an additional layer of complexity. This is because in addition to genetic variability in genes that code for proteins relevant to clinical pharmacology, there are rapidly maturational changes in these proteins. Consequently, pharmacotherapy in neonates has unique challenges. To provide a contemporary overview on pharmacogenetics in neonates, we conducted a systematic review to identify, describe and quantify the impact of pharmacogenetics on pharmacokinetics and -dynamics in neonates and infants (PROSPERO, CRD42022302029). The search was performed in Medline, Embase, Web of Science and Cochrane, and was extended by a PubMed search on the ‘top 100 Medicines’ (medicine + newborn/infant + pharmacogen*) prescribed to neonates. Following study selection (including data in infants, PGx related) and quality assessment (Newcastle–Ottawa scale, Joanna Briggs Institute tool), 55/789 records were retained. Retained records relate to metabolizing enzymes involved in phase I [cytochrome P450 (CYP1A2, CYP2A6, CYP2B6, CYP2C8/C9/C18, CYP2C19, CYP2D6, CYP3A5, CYP2E1)], phase II [glutathione-S-transferases, N-acetyl transferases, UDP-glucuronosyl-transferase], transporters [ATP-binding cassette transporters, organic cation transporters], or receptor/post-receptor mechanisms [opioid related receptor and post-receptor mechanisms, tumor necrosis factor, mitogen-activated protein kinase 8, vitamin binding protein diplotypes, corticotrophin-releasing hormone receptor-1, nuclear receptor subfamily-1, vitamin K epoxide reductase complex-1, and angiotensin converting enzyme variants]. Based on the available overview, we conclude that the majority of reported pharmacogenetic studies explore and extrapolate observations already described in older populations. Researchers commonly try to quantify the impact of these polymorphisms in small datasets of neonates or infants. In a next step, pharmacogenetic studies in neonatal life should go beyond confirmation of these associations and explore the impact of pharmacogenetics as a covariate limited to maturation of neonatal life (ie, fetal malformations, breastfeeding or clinical syndromes). The challenge is to identify the specific factors, genetic and non-genetic, that contribute to the best benefit/risk balance.
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Affiliation(s)
- Nadir Yalçin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Hacettepe University, Ankara, Turkey
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands
| | - Robert B Flint
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands
- Division of Neonatology, Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands
| | - Ron H N van Schaik
- Division of Neonatology, Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands
- Department of Clinical Chemistry, Erasmus MC, Rotterdam, the Netherlands
| | - Sinno H P Simons
- Division of Neonatology, Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Child and Youth Institute, KU Leuven, Leuven, Belgium
- Correspondence: Karel Allegaert, Neonatal Intensive Care Unit, UZ Leuven, Herestraat 49, Leuven, 3000, Belgium, Tel +32-016-342020, Fax +32-016-343209, Email
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13
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Leeder JS. Ontogeny of Pediatric Pharmacogenetics: Celebrating the Past and Vision for the Future. J Pediatr Pharmacol Ther 2021; 27:4-11. [PMID: 35002553 PMCID: PMC8717621 DOI: 10.5863/1551-6776-27.1.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Indexed: 11/11/2022]
Affiliation(s)
- J. Steven Leeder
- Children's Mercy Research Institute, Children's Mercy Kansas City, Kansas City, MO
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14
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Abstract
Almost 50% of prescription drugs lack age-appropriate dosing guidelines and therefore are used "off-label." Only ~10% drugs prescribed to neonates and infants have been studied for safety or efficacy. Immaturity of drug metabolism in children is often associated with drug toxicity. This chapter summarizes data on the ontogeny of major human metabolizing enzymes involved in oxidation, reduction, hydrolysis, and conjugation of drugs. The ontogeny data of individual drug-metabolizing enzymes are important for accurate prediction of drug pharmacokinetics and toxicity in children. This information is critical for designing clinical studies to appropriately test pharmacological hypotheses and develop safer pediatric drugs, and to replace the long-standing practice of body weight- or surface area-normalized drug dosing. The application of ontogeny data in physiologically based pharmacokinetic model and regulatory submission are discussed.
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15
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Li Q, Wu YE, Wang K, Shi HY, Zhou Y, Zheng Y, Hao GX, Yang YL, Su LQ, Wang WQ, Yang XM, Zhao W. Developmental Pharmacogenetics of CYP2D6 in Chinese Children: Loratadine as a Substrate Drug. Front Pharmacol 2021; 12:657287. [PMID: 34295246 PMCID: PMC8292113 DOI: 10.3389/fphar.2021.657287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/20/2021] [Indexed: 11/28/2022] Open
Abstract
Objective: The elucidation of CYP2D6 developmental pharmacogenetics in children has improved, however, these findings have been largely limited to studies of Caucasian children. Given the clear differences in CYP2D6 pharmacogenetic profiles in people of different ancestries, there remains an unmet need to better understand the developmental pharmacogenetics in populations of different ancestries. We sought to use loratadine as a substrate drug to evaluate the effects of ontogeny and pharmacogenetics on the developmental pattern of CYP2D6 in Chinese pediatric patients. Methods: Chinese children receiving loratadine treatment were enrolled in the present study. The metabolite-to-parent ratio (M/P ratio), defined as the molar ratio of desloratadine to loratadine of trough concentrations samples at steady-state condition, was used as a surrogate of CYP2D6 activity. Loratadine and desloratadine were determined by LC/MS/MS method. Variants of CYP2D6 were genotyped by polymerase chain reaction for CYP2D6 *4, *10, *41 and long polymerase chain reaction for CYP2D6 *5. Results: A total of 40 patients were available for final analysis. The mean age was 4.50 (range 0.50–9.00) years and the mean weight was 19.64 (range 7.00–42.00) kg. The M/P ratio was significantly lower in intermediate metabolizers (IMs) compared to normal metabolizers (NMs) (10.18 ± 7.97 vs. 18.80 ± 15.83, p = 0.03). Weight was also found to be significantly associated with M/P ratio (p = 0.03). Conclusion: The developmental pharmacogenetics of CYP2D6 in Chinese children was evaluated using loratadine as a substrate drug. This study emphasizes the importance of evaluating the developmental pharmacogenetics in populations of different ancestries.
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Affiliation(s)
- Qian Li
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Yue-E Wu
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Kai Wang
- Department of Pediatrics, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Jinan, China
| | - Hai-Yan Shi
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Yue Zhou
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yi Zheng
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yi-Lei Yang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Le-Qun Su
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Wen-Qi Wang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Xin-Mei Yang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Wei Zhao
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China.,Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
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16
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Hoshitsuki K, Fernandez CA, Yang JJ. Pharmacogenomics for Drug Dosing in Children: Current Use, Knowledge, and Gaps. J Clin Pharmacol 2021; 61 Suppl 1:S188-S192. [PMID: 34185912 DOI: 10.1002/jcph.1891] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/29/2021] [Indexed: 11/08/2022]
Abstract
Pharmacogenomics research ranges from the discovery of genetic factors to explain interpatient variability in drug exposure and response to clinical implementation of this knowledge to improve pharmacotherapy. Medications with actionable pharmacogenomic associations are frequently used in children, and therefore pharmacogenomics-guided precision medicine is readily applicable to the pediatric population. Although heritable genetics are considered immutable, the impact of genetic variation in pharmacogenes is modified by other factors such as age-dependent changes in gene expression. Early evidence has emerged indicating that the interaction between ontogeny and pharmacogenomics determines whether or how genetics-based dosing algorithms should be adjusted in children versus adults. However, there is still a paucity of data describing pharmacogenomic associations in patient populations across the life span. Future research is much needed to evaluate the impact of pharmacogenomics on drug dosing specific to the pediatric population, along with consideration of other developmental and physiological factors uniquely related to drug disposition in this population.
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Affiliation(s)
- Keito Hoshitsuki
- Center for Pharmacogenetics and Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA.,Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christian A Fernandez
- Center for Pharmacogenetics and Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Jun J Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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17
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Chapron BD, Chapron A, Leeder JS. Recent advances in the ontogeny of drug disposition. Br J Clin Pharmacol 2021; 88:4267-4284. [PMID: 33733546 DOI: 10.1111/bcp.14821] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 02/12/2021] [Accepted: 02/22/2021] [Indexed: 12/11/2022] Open
Abstract
Developmental changes that occur throughout childhood have long been known to impact drug disposition. However, pharmacokinetic studies in the paediatric population have historically been limited due to ethical concerns arising from incorporating children into clinical trials. As such, much of the early work in the field of developmental pharmacology was reliant on difficult-to-interpret in vitro and in vivo animal studies. Over the last 2 decades, our understanding of the mechanistic processes underlying age-related changes in drug disposition has advanced considerably. Progress has largely been driven by technological advances in mass spectrometry-based methods for quantifying proteins implicated in drug disposition, and in silico tools that leverage these data to predict age-related changes in pharmacokinetics. This review summarizes our current understanding of the impact of childhood development on drug disposition, particularly focusing on research of the past 20 years, but also highlighting select examples of earlier foundational research. Equally important to the studies reviewed herein are the areas that we cannot currently describe due to the lack of research evidence; these gaps provide a map of drug disposition pathways for which developmental trends still need to be characterized.
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Affiliation(s)
- Brian D Chapron
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA
| | - Alenka Chapron
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA
| | - J Steven Leeder
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA.,Schools of Medicine and Pharmacy, University of Missouri-Kansas City, MO, USA
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18
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Liko I, Lee YM, Stutzman DL, Blackmer AB, Deininger KM, Reynolds AM, Aquilante CL. Providers' perspectives on the clinical utility of pharmacogenomic testing in pediatric patients. Pharmacogenomics 2021; 22:263-274. [PMID: 33657875 DOI: 10.2217/pgs-2020-0112] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Aim: To assess providers' knowledge, attitudes, perceptions, and experiences related to pharmacogenomic (PGx) testing in pediatric patients. Materials & methods: An electronic survey was sent to multidisciplinary healthcare providers at a pediatric hospital. Results: Of 261 respondents, 71.3% were slightly or not at all familiar with PGx, despite 50.2% reporting prior PGx education or training. Most providers, apart from psychiatry, perceived PGx to be at least moderately useful to inform clinical decisions. However, only 26.4% of providers had recent PGx testing experience. Unfamiliarity with PGx and uncertainty about the clinical value of testing were common perceived challenges. Conclusion: Low PGx familiarity among pediatric providers suggests additional education and electronic resources are needed for PGx examples in which data support testing in children.
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Affiliation(s)
- Ina Liko
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO 80045, USA.,Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO 80045, USA
| | - Yee Ming Lee
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO 80045, USA
| | - Danielle L Stutzman
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO 80045, USA.,Department of Pharmacy, Children's Hospital Colorado, Aurora, CO 80045, USA.,Pediatric Mental Health Institute, Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Allison B Blackmer
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO 80045, USA.,Department of Pharmacy, Children's Hospital Colorado, Aurora, CO 80045, USA.,Special Care Clinic, Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Kimberly M Deininger
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO 80045, USA
| | - Ann M Reynolds
- Special Care Clinic, Children's Hospital Colorado, Aurora, CO 80045, USA.,Department of Pediatrics, University of Colorado School of Medicine & Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Christina L Aquilante
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO 80045, USA
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19
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Naji-Talakar S, Sharma S, Martin LA, Barnhart D, Prasad B. Potential implications of DMET ontogeny on the disposition of commonly prescribed drugs in neonatal and pediatric intensive care units. Expert Opin Drug Metab Toxicol 2021; 17:273-289. [PMID: 33256492 PMCID: PMC8346204 DOI: 10.1080/17425255.2021.1858051] [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: 09/23/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
Introduction: Pediatric patients, especially neonates and infants, are more susceptible to adverse drug events as compared to adults. In particular, immature small molecule drug metabolism and excretion can result in higher incidences of pediatric toxicity than adults if the pediatric dose is not adjusted.Area covered: We reviewed the top 29 small molecule drugs prescribed in neonatal and pediatric intensive care units and compiled the mechanisms of their metabolism and excretion. The ontogeny of Phase I and II drug metabolizing enzymes and transporters (DMETs), particularly relevant to these drugs, are summarized. The potential effects of DMET ontogeny on the metabolism and excretion of the top pediatric drugs were predicted. The current regulatory requirements and recommendations regarding safe and effective use of drugs in children are discussed. A few representative examples of the use of ontogeny-informed physiologically based pharmacokinetic (PBPK) models are highlighted.Expert opinion: Empirical prediction of pediatric drug dosing based on body weight or body-surface area from the adult parameters can be inaccurate because DMETs are not mature in children and the age-dependent maturation of these proteins is different. Ontogeny-informed-PBPK modeling provides a better alternative to predict the pharmacokinetics of drugs in children.
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Affiliation(s)
- Siavosh Naji-Talakar
- Department of Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
| | - Sheena Sharma
- Pediatrics and Neonatology, Providence Sacred Heart Medical Center and Children’s Hospital, Spokane, WA, USA
| | - Leslie A. Martin
- Pediatrics and Neonatology, Providence Sacred Heart Medical Center and Children’s Hospital, Spokane, WA, USA
| | - Derek Barnhart
- Pediatrics and Neonatology, Providence Sacred Heart Medical Center and Children’s Hospital, Spokane, WA, USA
| | - Bhagwat Prasad
- Department of Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
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20
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Allegaert K, van den Anker J. Ontogeny of Phase I Metabolism of Drugs. J Clin Pharmacol 2020; 59 Suppl 1:S33-S41. [PMID: 31502685 DOI: 10.1002/jcph.1483] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 06/17/2019] [Indexed: 12/17/2022]
Abstract
Capturing ontogeny of enzymes involved in phase I metabolism is crucial to improve prediction of dose-concentration and concentration-effect relationships throughout infancy and childhood. Once captured, these patterns can be integrated in semiphysiologically or physiology-based pharmacokinetic models to support predictions in specific pediatric settings or to support pediatric drug development. Although these translational efforts are crucial, isoenzyme-specific ontogeny-based models should also incorporate data on variability of maturational and nonmaturational covariates (eg, disease, treatment modalities, pharmacogenetics). Therefore, this review provides a summary of the ontogeny of phase I drug-metabolizing enzymes, indicating current knowledge gaps and recent progresses. Furthermore, we tried to illustrate that straightforward translation of isoenzyme-specific ontogeny to predictions does not allow full exploration of scenarios of potential variability related to maturational (non-age-related variability, other isoenzymes or transporters) or nonmaturational (disease, pharmacogenetics) covariates, and necessitates integration in a "systems" concept.
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Affiliation(s)
- Karel Allegaert
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
- Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
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21
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Gregornik D, Salyakina D, Brown M, Roiko S, Ramos K. Pediatric pharmacogenomics: challenges and opportunities: on behalf of the Sanford Children's Genomic Medicine Consortium. THE PHARMACOGENOMICS JOURNAL 2020; 21:8-19. [PMID: 32843689 DOI: 10.1038/s41397-020-00181-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 06/15/2020] [Accepted: 08/12/2020] [Indexed: 01/13/2023]
Abstract
The advent of digital, electronic, and molecular technologies has allowed the study of complete genomes. Integrating this information into drug development has opened the door for pharmacogenomic (PGx) interventions in direct patient care. PGx allows clinicians to better identify drug of choice and optimize dosing regimens based on an individual's genetic characteristics. Integrating PGx into pediatric care is a priority for the Sanford Children's Genomic Medicine Consortium, a partnership of ten children's hospitals across the US committed to the innovation and advancement of genomics in pediatric care. In this white paper, we review the current state of PGx research and its clinical utility in pediatrics, a largely understudied population, and make recommendations for advancing cutting-edge practice in pediatrics.
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Affiliation(s)
- David Gregornik
- Pharmacogenomics Program, Children's Minnesota, Minneapolis, MN, USA.
| | - Daria Salyakina
- Research Institute and Personalized Medicine Initiative, Nicklaus Children's Hospital, Miami, FL, USA
| | - Marilyn Brown
- Research Institute and Personalized Medicine Initiative, Nicklaus Children's Hospital, Miami, FL, USA
| | - Samuel Roiko
- Children's Research Institute, Minnesota, Minneapolis, MN, USA
| | - Kenneth Ramos
- Texas A&M University System, College Station, TX, USA.
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22
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Toward precision medicine in pediatric population using cytochrome P450 phenotyping approaches and physiologically based pharmacokinetic modeling. Pediatr Res 2020; 87:441-449. [PMID: 31600772 DOI: 10.1038/s41390-019-0609-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 09/04/2019] [Accepted: 09/22/2019] [Indexed: 01/18/2023]
Abstract
The activity of drug-metabolizing enzymes (DME) shows high inter- and intra-individual variability. Genetic polymorphisms, exposure to drugs, and environmental toxins are known to significantly alter DME expression. In addition, the activity of these enzymes is highly age-dependent due to maturation processes that occur during development. Currently, there is a vast choice of phenotyping methods in adults using exogenous probes to characterize the activity of these enzymes. However, this can hardly be applied to children since it requires the intake of non-therapeutic xenobiotics. In addition, sampling may be challenging in the pediatric population for a variety of reasons: limited volume (e.g., blood), inappropriate sampling methods for age (e.g., urine), and metric requiring invasive or multiple blood samples. This review covers the main existing methods that can be used in the pediatric population to determine DME activity, with a particular focus on cytochrome P450 enzymes. Less invasive tools are described, including phenotyping using endogenous probes. Finally, the potential of pediatric model-informed precision dosing using physiologically based pharmacokinetic modeling is discussed.
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23
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Nofziger C, Turner AJ, Sangkuhl K, Whirl-Carrillo M, Agúndez JAG, Black JL, Dunnenberger HM, Ruano G, Kennedy MA, Phillips MS, Hachad H, Klein TE, Gaedigk A. PharmVar GeneFocus: CYP2D6. Clin Pharmacol Ther 2020; 107:154-170. [PMID: 31544239 PMCID: PMC6925641 DOI: 10.1002/cpt.1643] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 08/29/2019] [Indexed: 01/13/2023]
Abstract
The Pharmacogene Variation Consortium (PharmVar) provides nomenclature for the highly polymorphic human CYP2D6 gene locus. CYP2D6 genetic variation impacts the metabolism of numerous drugs and, thus, can impact drug efficacy and safety. This GeneFocus provides a comprehensive overview and summary of CYP2D6 genetic variation and describes how the information provided by PharmVar is utilized by the Pharmacogenomics Knowledgebase (PharmGKB) and the Clinical Pharmacogenetics Implementation Consortium (CPIC).
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Affiliation(s)
| | - Amy J. Turner
- Department of Pediatrics, Section of Genomic Pediatrics and Children’s Research Institute, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- RPRD Diagnostics LLC, Wauwatosa, Wisconsin, USA
| | - Katrin Sangkuhl
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | | | - José A. G. Agúndez
- University Institute of Molecular Pathology Biomarkers, UEx, Cáceres; ARADyAL Instituto de Salud Carlos III. Spain
| | - John L. Black
- Personalized Genomics Laboratory, Division of Laboratory Genetics and Genomics, Mayo Clinic laboratories, Mayo Clinic, Rochester MN (200 1st Street SW, Rochester MN 55902)
| | - Henry M. Dunnenberger
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanton, IL, USA
| | - Gualberto Ruano
- Institute of Living at Hartford Hospital, Genomas Laboratory of Personalized Health, Hartford, Connecticut (67 Jefferson Street, Hartford, Connecticut 06106)
| | - Martin A. Kennedy
- Department of Pathology and Biomedical Science, University Otago, Christchurch, New Zealand
| | - Michael S. Phillips
- Sequence Bioinformatics Inc., 139 Water Street, 2 Floor, St. John’s NL, A1C 1B2, Canada
| | | | - Teri E. Klein
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children’s Mercy Kansas City, Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
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Matlock MK, Tambe A, Elliott-Higgins J, Hines RN, Miller GP, Swamidass SJ. A Time-Embedding Network Models the Ontogeny of 23 Hepatic Drug Metabolizing Enzymes. Chem Res Toxicol 2019; 32:1707-1721. [PMID: 31304741 PMCID: PMC6933754 DOI: 10.1021/acs.chemrestox.9b00223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pediatric patients are at elevated risk of adverse drug reactions, and there is insufficient information on drug safety in children. Complicating risk assessment in children, there are numerous age-dependent changes in the absorption, distribution, metabolism, and elimination of drugs. A key contributor to age-dependent drug toxicity risk is the ontogeny of drug metabolism enzymes, the changes in both abundance and type throughout development from the fetal period through adulthood. Critically, these changes affect not only the overall clearance of drugs but also exposure to individual metabolites. In this study, we introduce time-embedding neural networks in order to model population-level variation in metabolism enzyme expression as a function of age. We use a time-embedding network to model the ontogeny of 23 drug metabolism enzymes. The time-embedding network recapitulates known demographic factors impacting 3A5 expression. The time-embedding network also effectively models the nonlinear dynamics of 2D6 expression, enabling a better fit to clinical data than prior work. In contrast, a standard neural network fails to model these features of 3A5 and 2D6 expression. Finally, we combine the time-embedding model of ontogeny with additional information to estimate age-dependent changes in reactive metabolite exposure. This simple approach identifies age-dependent changes in exposure to valproic acid and dextromethorphan metabolites and suggests potential mechanisms of valproic acid toxicity. This approach may help researchers evaluate the risk of drug toxicity in pediatric populations.
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Affiliation(s)
- Matthew K Matlock
- Department of Pathology and Immunology , Washington University in St. Louis , Saint Louis , Missouri 63110 , United States
| | - Abhik Tambe
- Department of Pathology and Immunology , Washington University in St. Louis , Saint Louis , Missouri 63110 , United States
| | - Jack Elliott-Higgins
- Department of Pathology and Immunology , Washington University in St. Louis , Saint Louis , Missouri 63110 , United States
| | - Ronald N Hines
- National Health and Environmental Effects Research Laboratory , United States Environmental Protection Agency , Research Triangle Park , North Carolina 27709 , United States
| | - Grover P Miller
- Department of Biochemistry and Molecular Biology , University of Arkansas for Medical Sciences , Little Rock , Arkansas 72205 , United States
| | - S Joshua Swamidass
- Institute for Informatics , Washington University in St. Louis , Saint Louis , Missouri 63110 , United States
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25
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Salyakina D, Roy S, Wang W, Oliva M, Akhouri R, Sotto I, Mulas N, Solano R, Fernández JR, Sanchez S, Shamshad U, Perlyn C, McCafferty-Fernandez J. Results and challenges of Cytochrome P450 2D6 (CYP2D6) testing in an ethnically diverse South Florida population. Mol Genet Genomic Med 2019; 7:e922. [PMID: 31389673 PMCID: PMC6732280 DOI: 10.1002/mgg3.922] [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: 01/15/2019] [Revised: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 12/20/2022] Open
Abstract
Background This study focuses on the implementation of CYP2D6 genetic test profiling and the challenges associated with using standard pharmacogenetics panels in a diverse South Florida population. Methods A total of 413 participants were recruited to participate in this study through Nicklaus Children's Hospital. Buccal swabs were collected and tested using an extended CYP2D6 panel including 22 alleles. Phenotype, genotype, and allelic frequencies were compared among different racial and ethnic groups. Results The majority of participants (75.0%) self‐identified as Hispanics. Four alleles, CYP2D6*4, *17, *41, and *2A, showed a statistically significant difference between White Hispanics and Black Non‐Hispanics. Aggregate frequency of all alleles with decreased function varied between 2.8% and 50.0% in different racial and ethnic groups. Additionally, rare allele combinations were observed in this South Florida cohort. Conclusions The heterogeneity among Hispanic groups demonstrated in previous literature and by this study reflects the complexity of ethnicity and suggests that a more granular categorization is needed, one based on ancestry and migration history rather than primary language. Overall, we have determined that there are statistically significant differences in CYP2D6 allele frequencies in the distinct racial and ethnic populations of South Florida, demonstrating a unique genetic makeup within South Florida. However, overall, the frequencies of Poor Metabolizer, Normal Metabolizer, Intermediate Metabolizer, and Ultrarapid Metabolizer did not differ between racial and ethnic groups at a statistically significant level.
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Affiliation(s)
- Daria Salyakina
- Research Institute, Nicklaus Children's Hospital, Miami, Florida
| | - Sharmeen Roy
- Research Institute, Nicklaus Children's Hospital, Miami, Florida
| | - Weize Wang
- Research Institute, Nicklaus Children's Hospital, Miami, Florida
| | - Mailin Oliva
- Research Institute, Nicklaus Children's Hospital, Miami, Florida
| | - Rohan Akhouri
- Research Institute, Nicklaus Children's Hospital, Miami, Florida
| | - Ileana Sotto
- Research Institute, Nicklaus Children's Hospital, Miami, Florida
| | - Nicole Mulas
- Research Institute, Nicklaus Children's Hospital, Miami, Florida
| | - Rafaela Solano
- Research Institute, Nicklaus Children's Hospital, Miami, Florida
| | - José R Fernández
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Uzma Shamshad
- Research Institute, Nicklaus Children's Hospital, Miami, Florida
| | - Chad Perlyn
- Research Institute, Nicklaus Children's Hospital, Miami, Florida.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Jennifer McCafferty-Fernandez
- Research Institute, Nicklaus Children's Hospital, Miami, Florida.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
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Abstract
Pediatric clinical trials are often requested according to specific age ranges. In the past and still today, these ages may correspond to developmental stages, such as newborn, infancy, childhood, and adolescence. Selection of ages for pediatric participation in medication studies should correspond to ages of rapid changes in pharmacokinetics and pharmacodynamics. Age-related changes in several enzymes involved in drug metabolism and glomerular filtration are described as examples of optimal ages for study of specific drugs according to their pathways of disposition.
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Affiliation(s)
- Kathleen M Job
- 1 Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Margaret Gamalo
- 2 Global Statistical Sciences, Eli Lilly and Co, Indianapolis, IN, USA
| | - Robert M Ward
- 1 Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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27
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van den Anker J, Reed MD, Allegaert K, Kearns GL. Developmental Changes in Pharmacokinetics and Pharmacodynamics. J Clin Pharmacol 2018; 58 Suppl 10:S10-S25. [DOI: 10.1002/jcph.1284] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 06/21/2018] [Indexed: 12/22/2022]
Affiliation(s)
- John van den Anker
- Division of Clinical Pharmacology; Children's National Health System; Washington DC USA
- Division of Paediatric Pharmacology and Pharmacometrics; University of Basel Children's Hospital; Basel Switzerland
- Intensive Care and Department of Pediatric Surgery; Erasmus Medical Center-Sophia Children's Hospital; Rotterdam the Netherlands
| | - Michael D. Reed
- Emeritus Professor of Pediatrics; School of Medicine; Case Western Reserve University; Cleveland OH USA
| | - Karel Allegaert
- Intensive Care and Department of Pediatric Surgery; Erasmus Medical Center-Sophia Children's Hospital; Rotterdam the Netherlands
- Department of Pediatrics; Division of Neonatology; Erasmus Medical Center-Sophia Children's Hospital; Rotterdam the Netherlands
- Department of Development and Regeneration; KU Leuven; Leuven Belgium
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Adam de Beaumais T, Jacqz-Aigrain E. Pharmacogenetics: Applications to Pediatric Patients. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2018; 83:191-215. [PMID: 29801575 DOI: 10.1016/bs.apha.2018.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Individual genomic differences may affect drug disposition and effects of many drugs, and identification of biomarkers are crucial to personalize dosage and optimize response. In children, developmental changes associated with growth and maturation translate into different relationships between genotype and phenotype and different responses to treatment compared to adults. This review aims to summarize some developmental aspects of pharmacogenetics, based on practical examples.
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Affiliation(s)
- Tiphaine Adam de Beaumais
- Department of Paediatric Pharmacology and Pharmacogenetics, Robert Debré Hospital, APHP, Paris, France
| | - Evelyne Jacqz-Aigrain
- Department of Paediatric Pharmacology and Pharmacogenetics, Robert Debré Hospital, APHP, Paris, France; University Paris Diderot Sorbonne Paris Cité, Paris, France; Clinical Investigation Center CIC1426, INSERM, Paris, France.
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29
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Takechi T, Kumokawa T, Kato R, Higuchi T, Kaneko T, Ieiri I. Population Pharmacokinetics and Pharmacodynamics of Oral Propranolol in Pediatric Patients With Infantile Hemangioma. J Clin Pharmacol 2018; 58:1361-1370. [PMID: 29746707 PMCID: PMC6175224 DOI: 10.1002/jcph.1149] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 03/30/2018] [Indexed: 01/28/2023]
Abstract
This study aimed to characterize the population pharmacokinetics and exposure-response relationship of propranolol (Hemangiol® Syrup for Pediatric) in infants with infantile hemangioma. Using nonlinear mixed-effects modeling with 63 pooled sets of plasma concentration-time data from 32 Japanese patients aged 35-150 days, we described the disposition of propranolol adequately by a 1-compartment model with first-order absorption. The estimated population mean apparent clearance and apparent central volume of distribution were 9.34 L/h and 146 L, respectively. Body weight and postnatal age influenced the population pharmacokinetic model. The clinical end points-success (complete or nearly complete resolution of the target hemangioma) and failure-at weeks 12 and 24 were characterized by logistic regression using the area under the concentration-time curve (AUC), estimated from the final population pharmacokinetic model, as an exposure predictor. The logistic regression showed that a higher AUC was associated with a higher probability of successful treatment. At each exposure level, probability of successful treatment was correlated with gestational age and treatment duration. Model-predicted probabilities of successful treatment were consistent with actual results in the clinical trial. Simulations using several dosing regimens indicated that oral propranolol at 3 mg/kg per day was effective and would be appropriate for treating Japanese infants. These simulation results can support optimization of dosing regimens, such as selecting amounts, treatment durations, and dosing intervals, for clinical use.
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Affiliation(s)
- Tomoki Takechi
- Kyoto R&D Center, Maruho Co., Ltd, Kyoto, Japan.,Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Rumiko Kato
- Kyoto R&D Center, Maruho Co., Ltd, Kyoto, Japan
| | | | - Tsuyoshi Kaneko
- Department of Surgical Specialties, National Center for Child Health and Development, Tokyo, Japan
| | - Ichiro Ieiri
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
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30
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Dihydrocodeine Overdoses in a Neonate and in a 14-year-old Girl Who Were Both Genotyped as Cytochrome P450 2D6*1/*10-*36: Comparing Developmental Ages and Drug Monitoring Data With the Results of Pharmacokinetic Modeling. Ther Drug Monit 2018; 40:162-165. [DOI: 10.1097/ftd.0000000000000482] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Abstract
BACKGROUND This study determined whether the SLC22A1 [encoding the organic cation transporter 1 (OCT1)] genotype could explain, in addition to the postmenstrual age (referring to gestational plus postnatal age) and CYP2D6 genotype, the tramadol (M) pharmacokinetic variability in early infancy. METHODS Fifty infants, median postmenstrual age 39.5 (interquartile range: 36.8-41.3) weeks, received an i.v. M loading dose (2 mg/kg) followed by a continuous infusion (5-8 mg·kg·24 h). Blood was sampled from 4 to 24 hours after start of the M treatment, which generated 230 observations. M and O-desmethyltramadol (M1) concentrations were measured by high-performance liquid chromatography. RESULTS Linear mixed-model analysis illustrated that the SLC22A1/OCT1 genotype was independently associated with a log-transformed M1/M ratio (P = 0.013), with carriers of <2 SLC22A1/OCT1 functional gene copies having a higher M1/M ratio (2.25; 95% CI, 2.01-2.48) than infants with 2 functional gene copies (1.86; 95% CI, 1.66-2.06). The CYP2D6/SLC22A1 combined genotype was associated with 57.8% higher M1/M ratio in carriers of ≥2 CYP2D6 functional gene copies and <2 SLC22A1/OCT1 functional gene copies compared with infants with <2 active CYP2D6 functional gene copies and SLC22A1/OCT1 normal activity (P < 0.001). CONCLUSIONS These findings highlight the additional role of SLC22A1/OCT1 genetics in M1 exposure in neonates. They also suggest that OCT1 is already active early after birth, which may have impact on the disposition of other OCT1 substrates in this population.
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In vitro Phase I- and Phase II-Drug Metabolism in The Liver of Juvenile and Adult Göttingen Minipigs. Pharm Res 2017; 34:750-764. [DOI: 10.1007/s11095-017-2101-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 01/06/2017] [Indexed: 10/20/2022]
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33
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Paul IM, Reynolds KM, Kauffman RE, Banner W, Bond GR, Palmer RB, Burnham RI, Green JL. Adverse events associated with pediatric exposures to dextromethorphan. Clin Toxicol (Phila) 2016; 55:25-32. [DOI: 10.1080/15563650.2016.1240803] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Ian M. Paul
- Pediatrics & Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Kate M. Reynolds
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - Ralph E. Kauffman
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - William Banner
- Oklahoma Center for Poison and Drug Information, Oklahoma University College of Pharmacy, Oklahoma City, OK, USA
| | - G. Randall Bond
- School of Medicine, Hope Africa University, Bujumbura, Burundi
| | - Robert B. Palmer
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - Randy I. Burnham
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - Jody L. Green
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
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34
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Dinh JC, Pearce RE, Van Haandel L, Gaedigk A, Leeder JS. Characterization of Atomoxetine Biotransformation and Implications for Development of PBPK Models for Dose Individualization in Children. Drug Metab Dispos 2016; 44:1070-9. [PMID: 27052878 PMCID: PMC4931890 DOI: 10.1124/dmd.116.069518] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 04/04/2016] [Indexed: 11/22/2022] Open
Abstract
Atomoxetine (ATX) is a second-line nonstimulant medication used to control symptoms of attention deficit hyperactivity disorder (ADHD). Inconsistent therapeutic efficacy has been reported with ATX, which may be related to variable CYP2D6-mediated drug clearance. We characterized ATX metabolism in a panel of human liver samples as a basis for a bottom-up PBPK model to aid in ATX exposure prediction and control. Km, Vmax, and Clint values in pooled human liver microsomes (HLMs) were 2.4 µM, 479 pmol/min/mg protein, and 202 µl/min/mg protein, respectively. Mean population values of kinetic parameters are not adequate to describe variability in a population, given that Km, Vmax, and Clint values from single-donor HLMs ranged from 0.93 to 79.2 µM, 20.0 to 1600 pmol/min/mg protein, and 0.3 to 936 µl/min/mg protein. All kinetic parameters were calculated from 4-hydroxyatomoxetine (4-OH-ATX) formation. CYP2E1 and CYP3A contributed to 4-OH-ATX formation in livers with CYP2D6 intermediate and poor metabolizer status. In HLMs with lower CYP2D6 activity levels, 2-hydroxymethylatomoxetine (2-CH2OH-ATX) formation became a more predominant pathway of metabolism, which appeared to be catalyzed by CYP2B6. ATX biotransformation at clinically relevant plasma concentrations was characterized in a panel of pediatric HLM (n = 116) samples by evaluating primary metabolites. Competing pathways of ATX metabolism [N-desmethylatomoxetine (NDM-ATX) and 2-CH2OH-ATX formation] had increasing importance in livers with lesser CYP2D6 activity, but, overall ATX clearance was still compromised. Modeling ATX exposure to individualize therapy would require comprehensive knowledge of factors that affect CYP2D6 activity as well as an understanding of competing pathways, particularly for individuals with lower CYP2D6 activity.
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Affiliation(s)
- Jean C Dinh
- Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation (J.C.D., L.V.H., R.E.P., A.G., J.S.L.), Department of Pediatrics, Children's Mercy Hospital (L.V.H., R.E.P., A.G., J.S.L.), University of Kansas Medical Center (J.S.L.), and Department of Pharmacology (A.G., R.E.P., J.S.L.), University of Missouri-Kansas City, Kansas City, Missouri
| | - Robin E Pearce
- Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation (J.C.D., L.V.H., R.E.P., A.G., J.S.L.), Department of Pediatrics, Children's Mercy Hospital (L.V.H., R.E.P., A.G., J.S.L.), University of Kansas Medical Center (J.S.L.), and Department of Pharmacology (A.G., R.E.P., J.S.L.), University of Missouri-Kansas City, Kansas City, Missouri
| | - Leon Van Haandel
- Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation (J.C.D., L.V.H., R.E.P., A.G., J.S.L.), Department of Pediatrics, Children's Mercy Hospital (L.V.H., R.E.P., A.G., J.S.L.), University of Kansas Medical Center (J.S.L.), and Department of Pharmacology (A.G., R.E.P., J.S.L.), University of Missouri-Kansas City, Kansas City, Missouri
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation (J.C.D., L.V.H., R.E.P., A.G., J.S.L.), Department of Pediatrics, Children's Mercy Hospital (L.V.H., R.E.P., A.G., J.S.L.), University of Kansas Medical Center (J.S.L.), and Department of Pharmacology (A.G., R.E.P., J.S.L.), University of Missouri-Kansas City, Kansas City, Missouri
| | - J Steven Leeder
- Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation (J.C.D., L.V.H., R.E.P., A.G., J.S.L.), Department of Pediatrics, Children's Mercy Hospital (L.V.H., R.E.P., A.G., J.S.L.), University of Kansas Medical Center (J.S.L.), and Department of Pharmacology (A.G., R.E.P., J.S.L.), University of Missouri-Kansas City, Kansas City, Missouri
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35
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Rioux N, Waters NJ. Physiologically Based Pharmacokinetic Modeling in Pediatric Oncology Drug Development. Drug Metab Dispos 2016; 44:934-43. [DOI: 10.1124/dmd.115.068031] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 03/01/2016] [Indexed: 12/23/2022] Open
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36
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Nguyen L, Thomas KL, Lucke-Wold BP, Cavendish JZ, Crowe MS, Matsumoto RR. Dextromethorphan: An update on its utility for neurological and neuropsychiatric disorders. Pharmacol Ther 2016; 159:1-22. [PMID: 26826604 DOI: 10.1016/j.pharmthera.2016.01.016] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Dextromethorphan (DM) is a commonly used antitussive and is currently the only FDA-approved pharmaceutical treatment for pseudobulbar affect. Its safety profile and diverse pharmacologic actions in the central nervous system have stimulated new interest for repurposing it. Numerous preclinical investigations and many open-label or blinded clinical studies have demonstrated its beneficial effects across a variety of neurological and psychiatric disorders. However, the optimal dose and safety of chronic dosing are not fully known. This review summarizes the preclinical and clinical effects of DM and its putative mechanisms of action, focusing on depression, stroke, traumatic brain injury, seizure, pain, methotrexate neurotoxicity, Parkinson's disease and autism. Moreover, we offer suggestions for future research with DM to advance the treatment for these and other neurological and psychiatric disorders.
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Affiliation(s)
- Linda Nguyen
- Department of Behavioral Medicine and Psychiatry, School of Medicine, West Virginia University, Morgantown, WV 26506, USA; Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, WV 26506, USA
| | - Kelan L Thomas
- College of Pharmacy, Touro University California, Vallejo, CA 94592, USA
| | - Brandon P Lucke-Wold
- Graduate Program in Neuroscience, School of Medicine, West Virginia University, Morgantown, WV 26506, USA
| | - John Z Cavendish
- Graduate Program in Neuroscience, School of Medicine, West Virginia University, Morgantown, WV 26506, USA
| | - Molly S Crowe
- Department of Psychology, West Virginia University, Morgantown, WV 26506, USA
| | - Rae R Matsumoto
- Department of Behavioral Medicine and Psychiatry, School of Medicine, West Virginia University, Morgantown, WV 26506, USA; College of Pharmacy, Touro University California, Vallejo, CA 94592, USA.
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37
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Green DJ, Mummaneni P, Kim IW, Oh JM, Pacanowski M, Burckart GJ. Pharmacogenomic information in FDA-approved drug labels: Application to pediatric patients. Clin Pharmacol Ther 2016; 99:622-32. [DOI: 10.1002/cpt.330] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 11/18/2015] [Accepted: 12/17/2015] [Indexed: 01/05/2023]
Affiliation(s)
- DJ Green
- Pediatric Clinical Pharmacology Staff, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration; Silver Spring Maryland USA
| | - P Mummaneni
- Genomics and Targeted Therapy Group, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration; Silver Spring Maryland USA
| | - IW Kim
- School of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University; Seoul South Korea
| | - JM Oh
- School of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University; Seoul South Korea
| | - M Pacanowski
- Genomics and Targeted Therapy Group, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration; Silver Spring Maryland USA
| | - GJ Burckart
- Pediatric Clinical Pharmacology Staff, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration; Silver Spring Maryland USA
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Faqi AS, Holm KA. Metabolism and Drug–Drug Interaction in Pregnant Mother/Placenta/Fetus. METHODS IN PHARMACOLOGY AND TOXICOLOGY 2016. [DOI: 10.1007/7653_2016_64] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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He ZX, Chen XW, Zhou ZW, Zhou SF. Impact of physiological, pathological and environmental factors on the expression and activity of human cytochrome P450 2D6 and implications in precision medicine. Drug Metab Rev 2015; 47:470-519. [PMID: 26574146 DOI: 10.3109/03602532.2015.1101131] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
With only 1.3-4.3% in total hepatic CYP content, human CYP2D6 can metabolize more than 160 drugs. It is a highly polymorphic enzyme and subject to marked inhibition by a number of drugs, causing a large interindividual variability in drug clearance and drug response and drug-drug interactions. The expression and activity of CYP2D6 are regulated by a number of physiological, pathological and environmental factors at transcriptional, post-transcriptional, translational and epigenetic levels. DNA hypermethylation and histone modifications can repress the expression of CYP2D6. Hepatocyte nuclear factor-4α binds to a directly repeated element in the promoter of CYP2D6 and thus regulates the expression of CYP2D6. Small heterodimer partner represses hepatocyte nuclear factor-4α-mediated transactivation of CYP2D6. GW4064, a farnesoid X receptor agonist, decreases hepatic CYP2D6 expression and activity while increasing small heterodimer partner expression and its recruitment to the CYP2D6 promoter. The genotypes are key determinants of interindividual variability in CYP2D6 expression and activity. Recent genome-wide association studies have identified a large number of genes that can regulate CYP2D6. Pregnancy induces CYP2D6 via unknown mechanisms. Renal or liver diseases, smoking and alcohol use have minor to moderate effects only on CYP2D6 activity. Unlike CYP1 and 3 and other CYP2 members, CYP2D6 is resistant to typical inducers such as rifampin, phenobarbital and dexamethasone. Post-translational modifications such as phosphorylation of CYP2D6 Ser135 have been observed, but the functional impact is unknown. Further functional and validation studies are needed to clarify the role of nuclear receptors, epigenetic factors and other factors in the regulation of CYP2D6.
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Affiliation(s)
- Zhi-Xu He
- a Guizhou Provincial Key Laboratory for Regenerative Medicine, Stem Cell and Tissue Engineering Research Center & Sino-US Joint Laboratory for Medical Sciences, Guizhou Medical University , Guiyang , Guizhou , China
| | - Xiao-Wu Chen
- b Department of General Surgery , The First People's Hospital of Shunde, Southern Medical University , Shunde , Foshan , Guangdong , China , and
| | - Zhi-Wei Zhou
- c Department of Pharmaceutical Science , College of Pharmacy, University of South Florida , Tampa , FL , USA
| | - Shu-Feng Zhou
- a Guizhou Provincial Key Laboratory for Regenerative Medicine, Stem Cell and Tissue Engineering Research Center & Sino-US Joint Laboratory for Medical Sciences, Guizhou Medical University , Guiyang , Guizhou , China .,c Department of Pharmaceutical Science , College of Pharmacy, University of South Florida , Tampa , FL , USA
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Upreti VV, Wahlstrom JL. Meta-analysis of hepatic cytochrome P450 ontogeny to underwrite the prediction of pediatric pharmacokinetics using physiologically based pharmacokinetic modeling. J Clin Pharmacol 2015; 56:266-83. [DOI: 10.1002/jcph.585] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 06/29/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Vijay V. Upreti
- Clinical Pharmacology, Modeling and Simulation; Amgen, Inc.; South San Francisco CA USA
| | - Jan L. Wahlstrom
- Pharmacokinetics and Drug Metabolism; Amgen, Inc.; Thousand Oaks CA USA
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Allegaert K, Holford N, Anderson BJ, Holford S, Stuber F, Rochette A, Trocóniz IF, Beier H, de Hoon JN, Pedersen RS, Stamer U. Tramadol and o-desmethyl tramadol clearance maturation and disposition in humans: a pooled pharmacokinetic study. Clin Pharmacokinet 2015; 54:167-78. [PMID: 25258277 DOI: 10.1007/s40262-014-0191-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES We aimed to study the impact of size, maturation and cytochrome P450 2D6 (CYP2D6) genotype activity score as predictors of intravenous tramadol disposition. METHODS Tramadol and O-desmethyl tramadol (M1) observations in 295 human subjects (postmenstrual age 25 weeks to 84.8 years, weight 0.5-186 kg) were pooled. A population pharmacokinetic analysis was performed using a two-compartment model for tramadol and two additional M1 compartments. Covariate analysis included weight, age, sex, disease characteristics (healthy subject or patient) and CYP2D6 genotype activity. A sigmoid maturation model was used to describe age-related changes in tramadol clearance (CLPO), M1 formation clearance (CLPM) and M1 elimination clearance (CLMO). A phenotype-based mixture model was used to identify CLPM polymorphism. RESULTS Differences in clearances were largely accounted for by maturation and size. The time to reach 50 % of adult clearance (TM50) values was used to describe maturation. CLPM (TM50 39.8 weeks) and CLPO (TM50 39.1 weeks) displayed fast maturation, while CLMO matured slower, similar to glomerular filtration rate (TM50 47 weeks). The phenotype-based mixture model identified a slow and a faster metabolizer group. Slow metabolizers comprised 9.8 % of subjects with 19.4 % of faster metabolizer CLPM. Low CYP2D6 genotype activity was associated with lower (25 %) than faster metabolizer CLPM, but only 32 % of those with low genotype activity were in the slow metabolizer group. CONCLUSIONS Maturation and size are key predictors of variability. A two-group polymorphism was identified based on phenotypic M1 formation clearance. Maturation of tramadol elimination occurs early (50 % of adult value at term gestation).
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Affiliation(s)
- Karel Allegaert
- Neonatal Intensive Care Unit and Center for Clinical Pharmacology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium,
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Tanoshima R, Bournissen FG, Tanigawara Y, Kristensen JH, Taddio A, Ilett KF, Begg EJ, Wallach I, Ito S. Population PK modelling and simulation based on fluoxetine and norfluoxetine concentrations in milk: a milk concentration-based prediction model. Br J Clin Pharmacol 2015; 78:918-28. [PMID: 24773313 DOI: 10.1111/bcp.12409] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 04/19/2014] [Indexed: 11/29/2022] Open
Abstract
AIMS Population pharmacokinetic (pop PK) modelling can be used for PK assessment of drugs in breast milk. However, complex mechanistic modelling of a parent and an active metabolite using both blood and milk samples is challenging. We aimed to develop a simple predictive pop PK model for milk concentration-time profiles of a parent and a metabolite, using data on fluoxetine (FX) and its active metabolite, norfluoxetine (NFX), in milk. METHODS Using a previously published data set of drug concentrations in milk from 25 women treated with FX, a pop PK model predictive of milk concentration-time profiles of FX and NFX was developed. Simulation was performed with the model to generate FX and NFX concentration-time profiles in milk of 1000 mothers. This milk concentration-based pop PK model was compared with the previously validated plasma/milk concentration-based pop PK model of FX. RESULTS Milk FX and NFX concentration-time profiles were described reasonably well by a one compartment model with a FX-to-NFX conversion coefficient. Median values of the simulated relative infant dose on a weight basis (sRID: weight-adjusted daily doses of FX and NFX through breastmilk to the infant, expressed as a fraction of therapeutic FX daily dose per body weight) were 0.028 for FX and 0.029 for NFX. The FX sRID estimates were consistent with those of the plasma/milk-based pop PK model. CONCLUSIONS A predictive pop PK model based on only milk concentrations can be developed for simultaneous estimation of milk concentration-time profiles of a parent (FX) and an active metabolite (NFX).
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Affiliation(s)
- Reo Tanoshima
- Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Burgess KS, Philips S, Benson EA, Desta Z, Gaedigk A, Gaedigk R, Segar MW, Liu Y, Skaar TC. Age-Related Changes in MicroRNA Expression and Pharmacogenes in Human Liver. Clin Pharmacol Ther 2015; 98:205-15. [PMID: 25968989 PMCID: PMC4512918 DOI: 10.1002/cpt.145] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 05/07/2015] [Accepted: 05/07/2015] [Indexed: 11/10/2022]
Abstract
Developmental changes in the liver can significantly impact drug disposition. Due to the emergence of microRNAs (miRNAs) as important regulators of drug disposition gene expression, we studied age-dependent changes in miRNA expression. Expression of 533 miRNAs was measured in 90 human liver tissues (fetal, pediatric [1-17 years], and adult [28-80 years]; n = 30 each). In all, 114 miRNAs were upregulated and 72 were downregulated from fetal to pediatric, and 2 and 3, respectively, from pediatric to adult. Among the developmentally changing miRNAs, 99 miRNA-mRNA interactions were predicted or experimentally validated (e.g., hsa-miR-125b-5p-CYP1A1; hsa-miR-34a-5p-HNF4A). In human liver samples (n = 10 each), analyzed by RNA-sequencing, significant negative correlations were observed between the expression of >1,000 miRNAs and mRNAs of drug disposition and regulatory genes. Our data suggest a mechanism for the marked changes in hepatic gene expression between the fetal and pediatric developmental periods, and support a role for these age-dependent miRNAs in regulating drug disposition.
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Affiliation(s)
- K S Burgess
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - S Philips
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - E A Benson
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Z Desta
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - A Gaedigk
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Hospital, Kansas City, and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - R Gaedigk
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Hospital, Kansas City, and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - M W Segar
- Center for Computational Biology and Bioinformatics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Y Liu
- Center for Computational Biology and Bioinformatics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - T C Skaar
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Roth-Cline M, Nelson RM. Microdosing Studies in Children: A US Regulatory Perspective. Clin Pharmacol Ther 2015; 98:232-3. [DOI: 10.1002/cpt.165] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- M Roth-Cline
- Office of Pediatric Therapeutics; FDA; Silver Spring Maryland USA
| | - RM Nelson
- Office of Pediatric Therapeutics; FDA; Silver Spring Maryland USA
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Hicks JK, Bishop JR, Sangkuhl K, Müller DJ, Ji Y, Leckband SG, Leeder JS, Graham RL, Chiulli DL, LLerena A, Skaar TC, Scott SA, Stingl JC, Klein TE, Caudle KE, Gaedigk A. Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for CYP2D6 and CYP2C19 Genotypes and Dosing of Selective Serotonin Reuptake Inhibitors. Clin Pharmacol Ther 2015; 98:127-34. [PMID: 25974703 DOI: 10.1002/cpt.147] [Citation(s) in RCA: 650] [Impact Index Per Article: 72.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 05/05/2015] [Accepted: 05/08/2015] [Indexed: 11/11/2022]
Abstract
Selective serotonin reuptake inhibitors (SSRIs) are primary treatment options for major depressive and anxiety disorders. CYP2D6 and CYP2C19 polymorphisms can influence the metabolism of SSRIs, thereby affecting drug efficacy and safety. We summarize evidence from the published literature supporting these associations and provide dosing recommendations for fluvoxamine, paroxetine, citalopram, escitalopram, and sertraline based on CYP2D6 and/or CYP2C19 genotype (updates at www.pharmgkb.org).
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Affiliation(s)
- J K Hicks
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA; Genomic Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA; and Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - J R Bishop
- University of Minnesota College of Pharmacy, Department of Experimental and Clinical Pharmacology, Minneapolis, Minnesota, USA
| | - K Sangkuhl
- Department of Genetics, Stanford University, Stanford, California, USA
| | - D J Müller
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Y Ji
- Department of Laboratory Medicine and Pathology, Division of Laboratory Genetics, Mayo Clinic, Rochester, Minnesota, USA
| | - S G Leckband
- Veterans Affairs San Diego Healthcare System, Mental Health Care Line, University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences and Department of Psychiatry, San Diego, California, USA
| | - J S Leeder
- Division of Clinical Pharmacology, Toxicology & Innovative Therapeutics, Children's Mercy Hospital, Kansas City, Missouri and Department of Pediatrics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - R L Graham
- Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - D L Chiulli
- Veterans Affairs Palo Alto Health Care System, San Jose Division, San Jose, California, USA
| | - A LLerena
- CICAB Clinical Research Center, Extremadura University Hospital and Medical School, Badajoz, Spain
| | - T C Skaar
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - S A Scott
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J C Stingl
- Federal Institute of Drugs and Medical Devices, Bonn, Germany
| | - T E Klein
- Department of Genetics, Stanford University, Stanford, California, USA
| | - K E Caudle
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - A Gaedigk
- Division of Clinical Pharmacology, Toxicology & Innovative Therapeutics, Children's Mercy Hospital, Kansas City, Missouri and Department of Pediatrics, University of Missouri-Kansas City, Kansas City, Missouri, USA
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Tay-Sontheimer J, Shireman LM, Beyer RP, Senn T, Witten D, Pearce RE, Gaedigk A, Fomban CLG, Lutz JD, Isoherranen N, Thummel KE, Fiehn O, Leeder JS, Lin YS. Detection of an endogenous urinary biomarker associated with CYP2D6 activity using global metabolomics. Pharmacogenomics 2014; 15:1947-62. [PMID: 25521354 PMCID: PMC4486214 DOI: 10.2217/pgs.14.155] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 10/17/2014] [Indexed: 01/15/2023] Open
Abstract
AIM We sought to discover endogenous urinary biomarkers of human CYP2D6 activity. PATIENTS & METHODS Healthy pediatric subjects (n = 189) were phenotyped using dextromethorphan and randomized for candidate biomarker selection and validation. Global urinary metabolomics was performed using liquid chromatography quadrupole time-of-flight mass spectrometry. Candidate biomarkers were tested in adults receiving fluoxetine, a CYP2D6 inhibitor. RESULTS A biomarker, M1 (m/z 444.3102) was correlated with CYP2D6 activity in both the pediatric training and validation sets. Poor metabolizers had undetectable levels of M1, whereas it was present in subjects with other phenotypes. In adult subjects, a 9.56-fold decrease in M1 abundance was observed during CYP2D6 inhibition. CONCLUSION Identification and validation of M1 may provide a noninvasive means of CYP2D6 phenotyping.
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Affiliation(s)
| | - Laura M Shireman
- Department of Pharmaceutics, University of Washington, Seattle, WA, USA
| | - Richard P Beyer
- Center for Ecogenetics & Environmental Health, University of Washington, Seattle, WA, USA
| | - Taurence Senn
- Department of Pharmaceutics, University of Washington, Seattle, WA, USA
| | - Daniela Witten
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Robin E Pearce
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Hospitals & Clinics, Kansas City, MO, USA
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Hospitals & Clinics, Kansas City, MO, USA
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO, USA
| | | | - Justin D Lutz
- Department of Pharmaceutics, University of Washington, Seattle, WA, USA
| | - Nina Isoherranen
- Department of Pharmaceutics, University of Washington, Seattle, WA, USA
| | - Kenneth E Thummel
- Department of Pharmaceutics, University of Washington, Seattle, WA, USA
| | - Oliver Fiehn
- UC Davis Genome Center, University of California Davis, Davis, CA, USA
| | - J Steven Leeder
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Hospitals & Clinics, Kansas City, MO, USA
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Yvonne S Lin
- Department of Pharmaceutics, University of Washington, Seattle, WA, USA
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Knych HK, Steffey EP, White AM, McKemie DS. Effects of age on the pharmacokinetics of tramadol and its active metabolite,O-desmethyltramadol following intravenous administration to foals. Equine Vet J 2014; 48:65-71. [DOI: 10.1111/evj.12364] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- H. K. Knych
- K.L. Maddy Equine Analytical Chemistry Laboratory; School of Veterinary Medicine; University of California; Davis USA
- Department of Veterinary Molecular Biosciences; School of Veterinary Medicine; University of California; Davis USA
| | - E. P. Steffey
- K.L. Maddy Equine Analytical Chemistry Laboratory; School of Veterinary Medicine; University of California; Davis USA
- Department of Veterinary Surgery and Radiology; School of Veterinary Medicine; University of California; Davis USA
| | - A. M. White
- K.L. Maddy Equine Analytical Chemistry Laboratory; School of Veterinary Medicine; University of California; Davis USA
| | - D. S. McKemie
- K.L. Maddy Equine Analytical Chemistry Laboratory; School of Veterinary Medicine; University of California; Davis USA
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Abstract
Information on drug absorption and disposition in infants and children has increased considerably over the past 2 decades. However, the impact of specific age-related effects on pharmacokinetics, pharmacodynamics, and dose requirements remains poorly understood. Absorption can be affected by the differences in gastric pH and stomach emptying time that have been observed in the pediatric population. Low plasma protein concentrations and a higher body water composition can change drug distribution. Metabolic processes are often immature at birth, which can lead to a reduced clearance and a prolonged half-life for those drugs for which metabolism is a significant mechanism for elimination. Renal excretion is also reduced in neonates due to immature glomerular filtration, tubular secretion, and reabsorption. Limited data are available on the pharmacodynamic behavior of drugs in the pediatric population. Understanding these age effects provide a mechanistic way to identify initial doses for the pediatric population. The various factors that impact pharmacokinetics and pharmacodynamics mature towards adult values at different rates, thus requiring continual modification of drug dose regimens in neonates, infants, and children. In this paper, the age-related changes in drug absorption, distribution, metabolism, and elimination in infants and children are reviewed, and the age-related dosing regimens for this population are discussed.
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Affiliation(s)
- Hong Lu
- Department of Biomedical and Pharmaceutical Sciences, University of Rhode Island, Kingston, Rhode Island
| | - Sara Rosenbaum
- Department of Biomedical and Pharmaceutical Sciences, University of Rhode Island, Kingston, Rhode Island
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Haertter S. Recent examples on the clinical relevance of the CYP2D6 polymorphism and endogenous functionality of CYP2D6. ACTA ACUST UNITED AC 2014; 28:209-16. [PMID: 24088607 DOI: 10.1515/dmdi-2013-0032] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 08/22/2013] [Indexed: 11/15/2022]
Abstract
The cytochrome P450 2D6 (CYP2D6) belongs to a group of CYPs considered of utmost importance in the metabolism of xenobiotics. Despite being of only minor abundance in the liver, it is involved in the clearance of >25% of marketed drugs. Accordingly, CYP2D6 can be very efficiently inhibited by a couple of commonly used drugs such as some antidepressants, although induction by any drug has not been observed thus far. CYP2D6 was also one of the first enzymes for which a highly polymorphic expression could be shown leading to a widespread range of functionality, from a complete lack of a functional enzyme to overexpression due to multiplication of active alleles. A clear relationship between the CYP2D6 genotype and adverse events during treatment with CNS-active drugs such as codeine, antidepressants, or antipsychotics could be demonstrated. More recently, some new aspects emerged about the potential endogenous function of CYP2D6 in terms of behavior and brain disorders.
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Guenin E, Armogida M, Riff D. Pharmacokinetic Profile of Dextromethorphan Hydrobromide in a Syrup Formulation in Children and Adolescents. Clin Drug Investig 2014; 34:609-16. [DOI: 10.1007/s40261-014-0210-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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