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Apovian CM, Bruno CD, Kyle TK, Chow CR, Greenblatt DJ. Incomplete Data and Potential Risks of Drugs in People with Obesity. Curr Obes Rep 2023; 12:429-438. [PMID: 37980304 DOI: 10.1007/s13679-023-00532-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 11/20/2023]
Abstract
PURPOSE OF REVIEW To provide examples of knowledge gaps in current pharmaceutical treatments for people with obesity and call for changes to regulatory and pharmaceutical clinical research requirements during the drug discovery and development process. RECENT FINDINGS Treatment of obesity and its comorbidities often require the use of prescription drugs, many of which have not been fully evaluated in people with obesity. Despite a growing body of research on this topic, the impact of obesity on the pharmacokinetics and pharmacodynamics of drugs is often under-studied by drug sponsors and regulators, and subsequently underappreciated by clinicians and caretakers. There are currently multiple opportunities for pharmaceuticals to include dosing information specifically for patients with obesity in order to ensure safety and efficacy of drugs in this population. Additionally, there are serious gaps between what is known about the effects of obesity on drug disposition and the current use of drugs according to drug prescribing information and clinical practice. There is currently no requirement to test drugs in people with obesity during the drug approval process, even when preliminary data suggests there may be altered kinetics in this population. The lack of information on the safe and effective use of drugs in people with obesity may be contributing to poorer health outcomes in this population.
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Affiliation(s)
- Caroline M Apovian
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher D Bruno
- Program in Pharmacology and Drug Development, Tufts University School of Medicine, Boston, MA, USA
- Emerald Lake Safety, LLC, 23 Corporate Plaza Drive, Suite 150, Newport Beach, CA, USA
| | | | - Christina R Chow
- Emerald Lake Safety, LLC, 23 Corporate Plaza Drive, Suite 150, Newport Beach, CA, USA.
| | - David J Greenblatt
- Program in Pharmacology and Drug Development, Tufts University School of Medicine, Boston, MA, USA
- Clinical and Translational Science Institute, Tufts Medical Center, Boston, MA, USA
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Novy E, Martinière H, Roger C. The Current Status and Future Perspectives of Beta-Lactam Therapeutic Drug Monitoring in Critically Ill Patients. Antibiotics (Basel) 2023; 12:antibiotics12040681. [PMID: 37107043 PMCID: PMC10135361 DOI: 10.3390/antibiotics12040681] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023] Open
Abstract
Beta-lactams (BL) are the first line agents for the antibiotic management of critically ill patients with sepsis or septic shock. BL are hydrophilic antibiotics particularly subject to unpredictable concentrations in the context of critical illness because of pharmacokinetic (PK) and pharmacodynamics (PD) alterations. Thus, during the last decade, the literature focusing on the interest of BL therapeutic drug monitoring (TDM) in the intensive care unit (ICU) setting has been exponential. Moreover, recent guidelines strongly encourage to optimize BL therapy using a PK/PD approach with TDM. Unfortunately, several barriers exist regarding TDM access and interpretation. Consequently, adherence to routine TDM in ICU remains quite low. Lastly, recent clinical studies failed to demonstrate any improvement in mortality with the use of TDM in ICU patients. This review will first aim at explaining the value and complexity of the TDM process when translating it to critically ill patient bedside management, interpretating the results of clinical studies and discussion of the points which need to be addressed before conducting further TDM studies on clinical outcomes. In a second time, this review will focus on the future aspects of TDM integrating toxicodynamics, model informed precision dosing (MIPD) and “at risk” ICU populations that deserve further investigations to demonstrate positive clinical outcomes.
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Affiliation(s)
- Emmanuel Novy
- Department of Anesthesiology and Critical Care Medicine, Institut Lorrain du Coeur Et Des Vaisseaux, University Hospital of Nancy, Rue du Morvan, 54511 Vandoeuvre-les Nancy, France
- SIMPA, UR 7300, Faculté de Médecine, Maïeutique et Métiers de la Santé, Campus Brabois Santé, University of Lorraine, 54000 Nancy, France
| | - Hugo Martinière
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nimes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 09, 30029 Nimes, France
| | - Claire Roger
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nimes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 09, 30029 Nimes, France
- UR UM 103 IMAGINE, Faculty of Medicine, Montpellier University, 30029 Nimes, France
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Meng L, Mui E, Ha DR, Stave C, Deresinski SC, Holubar M. Comprehensive guidance for antibiotic dosing in obese adults: 2022 update. Pharmacotherapy 2023; 43:226-246. [PMID: 36703246 DOI: 10.1002/phar.2769] [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: 10/31/2022] [Revised: 01/19/2023] [Accepted: 01/23/2023] [Indexed: 01/28/2023]
Abstract
Drug dosing in obese patients continues to be challenging due to a lack of high-quality evidence to guide dosing recommendations. We first published guidance for antibiotic dosing in obese adults in 2017, in which we critically reviewed articles identified from a broad search strategy to develop dosing recommendations for 35 antimicrobials. In this updated narrative review, we searched Pubmed, Web of Science, and the Cochrane Library using Medical Subject Headings including anti-infectives, specific generic antimicrobial names, obese, pharmacokinetics, and others. We reviewed 393 articles, cross-referenced select cited references, and when applicable, referenced drug databases, package inserts, and clinical trial data to update dosing recommendations for 41 antimicrobials. Most included articles were pharmacokinetic studies, other less frequently included articles were clinical studies (mostly small, retrospective), case reports, and very rarely, guidelines. Pharmacokinetic changes are frequently reported, can be variable, and sometimes conflicting in this population, and do not always translate to a documented difference in clinical outcomes, yet are used to inform dosing strategies. Extended infusions, high doses, and therapeutic drug monitoring remain important strategies to optimize dosing in this population. Additional studies are needed to clinically validate proposed dosing strategies, clarify optimal body size descriptors, dosing weight scalars, and estimation method of renal function in obese patients.
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Affiliation(s)
- Lina Meng
- Department of Quality, Stanford Health Care, Stanford, California, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA.,Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
| | - Emily Mui
- Department of Quality, Stanford Health Care, Stanford, California, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA.,Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
| | - David R Ha
- Department of Quality, Stanford Health Care, Stanford, California, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA.,Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
| | - Christopher Stave
- Lane Medical Library, Stanford University School of Medicine, Stanford, California, USA
| | - Stan C Deresinski
- Department of Quality, Stanford Health Care, Stanford, California, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA.,Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
| | - Marisa Holubar
- Department of Quality, Stanford Health Care, Stanford, California, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA.,Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
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Baalbaki N, Blum S, Akerman M, Johnson D. Ceftriaxone 1 g Versus 2 g Daily for the Treatment of Enterobacterales Bacteremia: A Retrospective Cohort Study. J Pharm Technol 2022; 38:326-334. [PMID: 36311303 PMCID: PMC9608102 DOI: 10.1177/87551225221121252] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Background: Ceftriaxone is a commonly used antibiotic for the treatment of susceptible Enterobacterales infections. There is currently limited clinical data on the optimal dose of ceftriaxone for Enterobacterales bacteremia. Objectives: To evaluate the rate of clinical failure of ceftriaxone 1 g versus 2 g daily in patients with Enterobacterales bacteremia. Methods: This was a retrospective cohort study of patients admitted to any of the 3 New York University Hospitals: Long Island, Tisch, or Brooklyn, with ceftriaxone-susceptible Enterobacterales bacteremia, receiving ceftriaxone 1 or 2 g daily from October 2019 to September 2020. The primary outcome was 90-day rate of clinical failure. Clinical failure was defined as escalation of therapy, relapse of infection, or all-cause mortality. Results: A total of 124 patients, 58% in the 1-g group and 42% in the 2-g group, were included. There was no statistically significant difference found in the primary outcome. The 90-day rate of clinical failure was 16.7% versus 9.6%, P = 0.260. There were no statistically significant secondary outcomes, although infection relapse rates at 90 days were numerically greater in the 1-g group (11.1% vs 1.9%, P = 0.078). Hypoalbuminemia was the only variable associated with an increased risk of clinical failure (odds ratio = 4.03; 95% confidence interval [CI] = 1.12-14.50, P = 0.033). Conclusion: In our exploratory findings, there was no statistically significant difference with the 90-day rate of clinical failure between ceftriaxone 1 g versus 2 g daily, although there was a numeric trend toward an increased rate of infection relapse within the 1-g group. Hypoalbuminemia was associated with an increased risk of clinical failure. Prospective studies are warranted to confirm these findings.
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Affiliation(s)
- Nadeem Baalbaki
- Department of Pharmacy, NYU Langone Hospital–Long Island, Mineola, NY, USA
| | - Sharon Blum
- Department of Pharmacy, NYU Langone Hospital–Long Island, Mineola, NY, USA
| | - Meredith Akerman
- Biostatistics Core, Division of Health Services Research, NYU Long Island School of Medicine, Mineola, NY, USA
| | - Diane Johnson
- Department of Medicine, NYU Langone Hospital–Long Island, Mineola, NY, USA
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Fanton D'Andon C, Correia P, Rigaill J, Kably B, Perinel-Ragey S, Launay M. Ceftazidime dosing in obese patients: is it time for more? Expert Opin Drug Metab Toxicol 2022; 18:277-284. [PMID: 35583387 DOI: 10.1080/17425255.2022.2080052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Ceftazidime is used for the treatment of many bacterial infections, including severe P. aeruginosa infections. Like other beta-lactams, inter-individual variability in ceftazidime pharmacokinetics has been described. Due to its related pathophysiological modifications, obesity might influence ceftazidime pharmacokinetics. AREAS COVERED The objective of this review is to assess the current state of knowledge about the impact of obesity on ceftazidime treatment. A literature search was conducted on PubMed-MEDLINE (2016-2021) to retrieve pharmacokinetic studies published in English, matching the terms 'ceftazidime' AND 'pharmacokinetics.' EXPERT OPINION The impact of obesity on pharmacokinetics is generally poorly known, mainly because obese patients are often excluded from clinical studies. However, the published literature clearly shows that obese patients have significantly lower ceftazidime concentrations. This could be explained by increased volume of distribution and clearance. This low exposure represents a major factor of therapeutic failure, potentially fatal for critically ill patients. While further studies would be useful to better assess the magnitude and understanding of this variability, the use of higher doses of ceftazidime is needed in obese patients. Moreover, therapeutic drug monitoring for dose adaptation is of major interest for these patients, as the efficacy of ceftazidime seems to be directly related to its plasma concentration.
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Affiliation(s)
- Cornélie Fanton D'Andon
- - Gaz du Sang, Hôpital NordLaboratoire de Pharmacologie - Toxicologie , CHU de Saint-Etienne, France
| | - Patricia Correia
- Service de Médecine Intensive et Réanimation G, CHU de Saint-Etienne, Saint Etienne, France
| | - Josselin Rigaill
- Department of Infectious Agents and Hygiene, University-Hospital of Saint-Etienne, Saint-Etienne, France
| | - Benjamin Kably
- Laboratoire de Pharmacologie, Hôpital Européen Georges Pompidou, Paris, France
| | - Sophie Perinel-Ragey
- Service de Médecine Intensive et Réanimation G, CHU de Saint-Etienne, Saint Etienne, France
| | - Manon Launay
- - Gaz du Sang, Hôpital NordLaboratoire de Pharmacologie - Toxicologie , CHU de Saint-Etienne, France
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Ryu HY, Mohayya S, Hong T, Modi M, Yang J, Abdul Azim A, Bhatt PJ, Brunetti L, Narayanan N. Safety and effectiveness of high-dose cefazolin in patients with high body weight: A retrospective cohort study. Open Forum Infect Dis 2022; 9:ofac105. [PMID: 35350175 PMCID: PMC8946698 DOI: 10.1093/ofid/ofac105] [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: 12/21/2021] [Accepted: 02/25/2022] [Indexed: 11/15/2022] Open
Abstract
Background Cefazolin is a commonly used antibiotic for the treatment of mild to severe infections. Despite the use of higher dose of cefazolin (3 g/dose) for surgical prophylaxis in patients with obesity, there is currently a paucity of data identifying the optimal dose to treat infections in this specific patient population. Methods This was a multicenter, retrospective cohort study of patients who received cefazolin at weight-based (up to 9 g/day) or standard doses (up to 6 g/day) for the treatment of bacteremia or skin and soft tissue infection (SSTI). Study groups were stratified by body weight and cefazolin dose received. Primary outcome was the composite of treatment-emergent adverse events (TEAEs) and secondary outcome was treatment failure rate. Results A total of 208 patients were included for study analysis. Fifty-nine patients had body weight >120 kg. Of these, 33 received high-dose cefazolin while 26 received standard doses. The remaining 149 patients had body weight of ≤120 kg and received standard doses. The occurrence of TEAEs did not differ across the 3 groups. The study also did not find any difference between the rate of treatment failure between groups. Conclusions High-dose cefazolin (9 g/day) for the treatment of bacteremia or SSTIs in patients with high body weight was safe and well tolerated. Larger studies are needed to further explore the benefit of high-dose cefazolin in improving clinical outcomes.
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Affiliation(s)
- Ha Young Ryu
- Department of Pharmacy, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Sana Mohayya
- Department of Pharmacy, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Thomas Hong
- Rutgers University Robert Wood Johnson Medical School, Piscataway, NJ, USA
- Department of Pharmacy Practice and Administration, Rutgers University Ernest Mario School of Pharmacy, Piscataway, NJ, USA
| | - Mansi Modi
- Department of Pharmacy Practice and Administration, Rutgers University Ernest Mario School of Pharmacy, Piscataway, NJ, USA
| | - Jaehee Yang
- Department of Pharmacy Practice and Administration, Rutgers University Ernest Mario School of Pharmacy, Piscataway, NJ, USA
| | - Ahmed Abdul Azim
- Division of Allergy, Immunology and Infectious Diseases, Department of Medicine, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Pinki J Bhatt
- Department of Pharmacy Practice and Administration, Rutgers University Ernest Mario School of Pharmacy, Piscataway, NJ, USA
- Division of Allergy, Immunology and Infectious Diseases, Department of Medicine, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Luigi Brunetti
- Department of Pharmacy Practice and Administration, Rutgers University Ernest Mario School of Pharmacy, Piscataway, NJ, USA
- Center of Excellence in Pharmaceutical Translational Research and Education, Rutgers University Ernest Mario School of Pharmacy, Piscataway, NJ, USA
| | - Navaneeth Narayanan
- Department of Pharmacy Practice and Administration, Rutgers University Ernest Mario School of Pharmacy, Piscataway, NJ, USA
- Division of Allergy, Immunology and Infectious Diseases, Department of Medicine, Rutgers University Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Center of Excellence in Pharmaceutical Translational Research and Education, Rutgers University Ernest Mario School of Pharmacy, Piscataway, NJ, USA
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