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Langevin B, Gobburu JVS, Gopalakrishnan M. Is There a Need for a Dedicated Pharmacokinetic Trial for a Drug in Obese Populations? A Drug Prioritization Decision Tree Framework. J Clin Pharmacol 2023; 63 Suppl 2:S48-S64. [PMID: 37942905 DOI: 10.1002/jcph.2304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/22/2023] [Indexed: 11/10/2023]
Abstract
Obesity is a growing global health concern associated with high comorbidity rates, leading to an increasing number of patients who are obese requiring medication. However, clinical trials often exclude or under-represent individuals who are obese, creating the need for a methodology to adjust labeling to ensure safe and effective dosing for all patients. To address this, we developed a 2-part decision tree framework to prioritize drugs for dedicated pharmacokinetic studies in obese subjects. Leveraging current drug knowledge and modeling techniques, the decision tree system predicts expected exposure changes and recommends labeling strategies, allowing stakeholders to prioritize resources toward the drugs most in need. In a case study evaluating 30 drugs from literature across different therapeutic areas, our first decision tree predicted the expected direction of exposure change accurately in 73% of cases. We conclude that this decision tree system offers a valuable tool to advance research in obesity pharmacology and personalize drug development for patients who are obese, ensuring safe and effective medication.
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Affiliation(s)
- Brooke Langevin
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Jogarao V S Gobburu
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Elrggal ME, Haseeb A, AlGethamy M, Ahsan U, Saleem Z, Althaqafi AS, Alshuail SS, Alsiddiqi ZA, Iqbal MS, Alzahrani AF, AlQarni A, Radwan RM, Qul AKS, Mahrous AJ, Alsharif JM, Alqurashi MK, Faidah HS, Aldurdunji M. Dose optimization of vancomycin in obese patients: A systematic review. Front Pharmacol 2023; 14:965284. [PMID: 37033643 PMCID: PMC10081578 DOI: 10.3389/fphar.2023.965284] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 02/27/2023] [Indexed: 04/11/2023] Open
Abstract
Background: Dose optimization of vancomycin plays a substantial role in drug pharmacokinetics because of the increased incidence of obesity worldwide. This systematic review was aimed to highlight the current dosing strategy of vancomycin among obese patients. Methods: This systematic review was in concordance with Preferred Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The literature search was carried out on various databases such as Scopus, PubMed/MEDLINE, ScienceDirect and EMBASE using Keywords and MeSH terms related to vancomycin dosing among obese patients. Google Scholar was also searched for additional articles. The English language articles published after January, 2000 were included in this study. The quality of the study was assessed using different assessment tools for cohort, and case reports. Results: A total of 1,029 records were identified. After screening, 18 studies were included for the final review. Of total, twelve studies are retrospective and remaining six are case-control studies. A total of eight studies were conducted in pediatrics while remaining studies were conducted in adult population. Most of the studies reported the dosing interval every 6-8 h. Differences in target trough concentration exist with respect to target ranges. The administration of loading dose (20-25 mg/kg) followed by maintenance dose (15-25 mg/kg) of vancomycin is recommended in adult patients to target therapeutic outcomes. Moreover, a dose of 40-60 mg/kg/day appears appropriate for pediatric patients. Conclusion: The initial dosing of vancomycin based on TBW could be better predictor of vancomycin trough concentration. However, the clinical significance is uncertain. Therefore, more studies are needed to evaluate the dosing strategy of vancomycin in overweight or obese patients.
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Affiliation(s)
- Mahmoud E. Elrggal
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
- *Correspondence: Abdul Haseeb,
| | - Manal AlGethamy
- Department of Infection Prevention and Control Program, Alnoor Specialist Hospital Makkah, Makkah, Saudi Arabia
| | - Umar Ahsan
- Department of Infection Prevention and Control Program, Alnoor Specialist Hospital Makkah, Makkah, Saudi Arabia
| | - Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan
| | - Areej Sultan Althaqafi
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Sattam Saad Alshuail
- Department of Internal Medicine, Alnoor Specialist Hospital Makkah, Makkah, Saudi Arabia
| | - Zohair Ahmad Alsiddiqi
- Department of Internal Medicine, Alnoor Specialist Hospital Makkah, Makkah, Saudi Arabia
| | - Muhammad Shahid Iqbal
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
| | - Albaraa Faraj Alzahrani
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Abdullmoin AlQarni
- Alnoor Specialist Hospital Makkah, Department of Infectious Diseases, Makkah, Saudi Arabia
| | - Rozan Mohammad Radwan
- Pharmaceutical Care Department, Alnoor Specialist Hospital Makkah, Department of Infection Prevention and Control Program, Makkah, Saudi Arabia
| | - Ameer Khalid Saab Qul
- Pharmaceutical Care Department, Alnoor Specialist Hospital Makkah, Department of Infection Prevention and Control Program, Makkah, Saudi Arabia
| | - Ahmad Jamal Mahrous
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Jumana Majdi Alsharif
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | | | - Hani Saleh Faidah
- Department of Microbiology, Faculty of Medicine, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Mohammed Aldurdunji
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
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Wong S, Reuter SE, Jones GR, Stocker SL. Review and evaluation of vancomycin dosing guidelines for obese individuals. Expert Opin Drug Metab Toxicol 2022; 18:323-335. [PMID: 35815356 DOI: 10.1080/17425255.2022.2098106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Vancomycin dosing decisions are informed by factors such as body weight and renal function. It is important to understand the impact of obesity on vancomycin pharmacokinetics and how this may influence dosing decisions. Vancomycin dosing guidelines use varied descriptors of body weight and renal function. There is uncertainty whether current dosing guidelines result in attainment of therapeutic targets in obese individuals. AREAS COVERED Literature was explored using PubMed, Embase and Google Scholar for articles from January 1980 to July 2021 regarding obesity-driven physiological changes, their influence on vancomycin pharmacokinetics and body size descriptors and renal function calculations in vancomycin dosing. Pharmacokinetic simulations reflective of international vancomycin dosing guidelines were conducted to evaluate the ability of using total, ideal and adjusted body weight, as well as Cockcroft-Gault and CKD-EPI equations to attain an area-under-the-curve to minimum inhibitory concentration ratio (AUC24/MIC) target (400-650) in obese individuals. EXPERT OPINION Vancomycin pharmacokinetics in obese individuals remains debated. Guidelines that determine loading doses using total body weight, and maintenance doses adjusted based on renal function and adjusted body weight, may be most appropriate for obese individuals. Use of ideal body weight leads to subtherapeutic vancomycin exposure and underestimation of renal function.
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Affiliation(s)
- Sherilyn Wong
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Stephanie E Reuter
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Graham Rd Jones
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia.,Department of Chemical Pathology and Clinical Pharmacology, SydPath, St Vincent's Hospital, Darlinghurst, Australia
| | - Sophie L Stocker
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia.,Sydney School of Pharmacy, The University of Sydney, Sydney, Australia.,Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney, Darlinghurst, Australia
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Garreau R, Falquet B, Mioux L, Bourguignon L, Ferry T, Tod M, Wallet F, Friggeri A, Richard JC, Goutelle S. Population Pharmacokinetics and Dosing Simulation of Vancomycin Administered by Continuous Injection in Critically Ill Patient. Antibiotics (Basel) 2021; 10:1228. [PMID: 34680809 PMCID: PMC8532763 DOI: 10.3390/antibiotics10101228] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/30/2021] [Accepted: 09/30/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Vancomycin is widely used for empirical antimicrobial therapy in critically ill patients with sepsis. Continuous infusion (CI) may provide more stable exposure than intermittent infusion, but optimal dosing remains challenging. The aims of this study were to perform population pharmacokinetic (PK) analysis of vancomycin administered by CI in intensive care unit (ICU) patients to identify optimal dosages. Methods: Patients who received vancomycin by CI with at least one measured concentration in our center over 16 months were included, including those under continuous renal replacement therapy (CRRT). Population PK was conducted and external validation of the final model was performed in a dataset from another center. Simulations were conducted with the final model to identify the optimal loading and maintenance doses for various stages of estimated creatinine clearance (CRCL) and in patients on CRRT. Target exposure was defined as daily AUC of 400-600 mg·h/L on the second day of therapy (AUC24-48 h). Results: A two-compartment model best described the data. Central volume of distribution was allometrically scaled to ideal body weight (IBW), whereas vancomycin clearance was influenced by CRRT and CRCL. Simulations performed with the final model suggested a loading dose of 27.5 mg/kg of IBW. The maintenance dose ranged from 17.5 to 30 mg/kg of IBW, depending on renal function. Overall, simulation showed that 55.8% (95% CI; 47-64%) of patients would achieve the target AUC with suggested dosages. Discussion: A PK model has been validated for vancomycin administered by CI in ICU patients, including patients under CRRT. Our model-informed precision dosing approach may help for early optimization of vancomycin exposure in such patients.
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Affiliation(s)
- Romain Garreau
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, 69005 Lyon, France
- Laboratoire de Biométrie et Biologie Evolutive, Université Lyon 1, UMR CNRS 5558, 69100 Villeurbanne, France
| | - Benoît Falquet
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, 69005 Lyon, France
| | - Lisa Mioux
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, 69005 Lyon, France
| | - Laurent Bourguignon
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, 69005 Lyon, France
- Laboratoire de Biométrie et Biologie Evolutive, Université Lyon 1, UMR CNRS 5558, 69100 Villeurbanne, France
- Facultés de Médecine et de Pharmacie de Lyon, Université Lyon 1, 69008 Lyon, France
| | - Tristan Ferry
- Facultés de Médecine et de Pharmacie de Lyon, Université Lyon 1, 69008 Lyon, France
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital de la Croix-Rousse, Service des Maladies Infectieuses et Tropicales, 69004 Lyon, France
| | - Michel Tod
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, 69005 Lyon, France
- Laboratoire de Biométrie et Biologie Evolutive, Université Lyon 1, UMR CNRS 5558, 69100 Villeurbanne, France
- Facultés de Médecine et de Pharmacie de Lyon, Université Lyon 1, 69008 Lyon, France
| | - Florent Wallet
- Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Critical Care, 69495 Pierre-Bénite, France
| | - Arnaud Friggeri
- Facultés de Médecine et de Pharmacie de Lyon, Université Lyon 1, 69008 Lyon, France
- Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Critical Care, 69495 Pierre-Bénite, France
- Centre International de Recherche en Infectiologie (CIRI) Inserm, Public Health, Epidemiology and Evolutionary Ecology of Infectious Diseases (PHE3ID), U1111, UCBL Lyon 1, CNRS, UMR5308, ENS de Lyon, 69364 Lyon, France
| | - Jean-Christophe Richard
- Facultés de Médecine et de Pharmacie de Lyon, Université Lyon 1, 69008 Lyon, France
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital de la Croix-Rousse, Service de Médecine Intensive-Réanimation, 69004 Lyon, France
| | - Sylvain Goutelle
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, 69005 Lyon, France
- Laboratoire de Biométrie et Biologie Evolutive, Université Lyon 1, UMR CNRS 5558, 69100 Villeurbanne, France
- Facultés de Médecine et de Pharmacie de Lyon, Université Lyon 1, 69008 Lyon, France
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Covvey JR, Erickson O, Fiumara D, Mazzei K, Moszczenski Z, Slipak K, Nemecek BD, Zimmerman DE, Guarascio AJ. Comparison of Vancomycin Area-Under-the-Curve Dosing Versus Trough Target-Based Dosing in Obese and Nonobese Patients With Methicillin-Resistant Staphylococcus aureus Bacteremia. Ann Pharmacother 2020; 54:644-651. [PMID: 31888350 DOI: 10.1177/1060028019897100] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background: A vancomycin target of area under the curve to minimum inhibitory concentration (AUC:MIC) ratio ≥400 is recommended for treatment of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Objective: To evaluate vancomycin total daily dose (TDD) achieving trough targets versus a calculated strategy achieving AUC targets based on body mass index (BMI). Methods: A retrospective cohort study was performed within a large hospital network. Patients with MRSA bacteremia were eligible if they received vancomycin with a steady-state trough (15-20 mg/L). Cockcroft-Gault was used to estimate creatinine clearance, calculating vancomycin clearance and AUC. Patients were stratified by BMI (less than/greater than 30 kg/m2). The primary outcome was vancomycin TDD for the trough-based strategy compared with an AUC-dosing strategy. Results: A total of 119 patients were included, including 51 (42.9%) and 68 (57.1%) patients with high- and low-BMI, respectively. The TDD for trough-based dosing (2390.76 ± 1224.59 mg) differed significantly from AUC-based dosing (1985.07 ± 616.18 mg) across the cohort (P = 0.0014). For patients with high BMI, there was a significant difference (P < 0.0001) in TDD between trough (2637.25 ± 1327.89 mg) versus AUC (1918.71 ± 625.89 mg) strategies. No difference in TDD between dosing strategies was observed among low-BMI patients. Across all patients, 46 (38.7%) experienced acute kidney injury (AKI); high-BMI patients experienced higher rates of AKI compared with low-BMI patients (54.9 vs 26.5%; P = 0.002). Conclusions and Relevance: An AUC-based dosing strategy may reduce vancomycin TDD required for MRSA bacteremia compared with trough-based dosing, particularly for patients with higher BMI.
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Affiliation(s)
| | - Olivia Erickson
- Duquesne University School of Pharmacy, Pittsburgh, PA, USA.,Delta Care Rx, Pittsburgh, PA, USA
| | - David Fiumara
- Duquesne University School of Pharmacy, Pittsburgh, PA, USA.,St Anthony's Hospital, St Petersburg, FL, USA
| | - Kelly Mazzei
- Duquesne University School of Pharmacy, Pittsburgh, PA, USA.,Louis A. Johnson VA Medical Center, Clarksburg, WV, USA
| | - Zachary Moszczenski
- Duquesne University School of Pharmacy, Pittsburgh, PA, USA.,Christian Hospital, St Louis, MO, USA
| | - Kelly Slipak
- Duquesne University School of Pharmacy, Pittsburgh, PA, USA
| | - Branden D Nemecek
- Duquesne University School of Pharmacy, Pittsburgh, PA, USA.,University of Pittsburgh Medical Center-Mercy Hospital, PA, USA
| | - David E Zimmerman
- Duquesne University School of Pharmacy, Pittsburgh, PA, USA.,University of Pittsburgh Medical Center-Mercy Hospital, PA, USA
| | - Anthony J Guarascio
- Duquesne University School of Pharmacy, Pittsburgh, PA, USA.,Allegheny General Hospital, Pittsburgh, PA, USA
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Batchelder N, Lutheran CF, Frens J. Evaluation of a modified vancomycin nomogram for obese adults. Eur J Clin Pharmacol 2019; 76:403-408. [PMID: 31834422 DOI: 10.1007/s00228-019-02811-0] [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: 09/16/2019] [Accepted: 11/27/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study was to compare therapeutic vancomycin trough levels in obese adults when using an original nomogram (phase I) versus a modified nomogram (phase II). METHODS This study compared a vancomycin nomogram with a modified vancomycin nomogram for obese adults over 100 kg. The primary endpoint compared the percentage of sub-therapeutic, therapeutic, and supra-therapeutic vancomycin trough concentrations between the nomograms. Patients were included if they were at least 18 years of age, had a total body weight of 100-299 kg, and had an initial vancomycin trough level collected. Patients were excluded if they had end-stage renal disease or were on continuous renal replacement therapy. RESULTS Therapeutic trough levels occurred in 85 out of 171 patients (50%) in phase I and 98 out of 149 patients (66%) in phase II. The incidence of both sub-therapeutic and supra-therapeutic troughs was less in phase II (p = 0.013). In the subgroup of adults aged 18 to 49 with a normalized creatinine clearance of greater than 90 mL/min, there was a trend in more therapeutic levels with the modified nomogram and less chance of sub-therapeutic levels (p = 0.088). In the subgroup of adults with a normalized creatinine clearance of 60-90 mL/min, there was significant improvement in therapeutic levels and a decrease in supra-therapeutic levels without increasing the percent of sub-therapeutic levels (p = 0.001). CONCLUSION The modified vancomycin nomogram at Cone Health showed significant improvement in therapeutic trough concentrations while reducing the rates of under and over dosing obese adults. The Cone Health-modified vancomycin nomogram could be a useful tool for initial dosing of vancomycin in the obese population.
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Affiliation(s)
- Nathan Batchelder
- Department of Pharmacy, Moses H. Cone Memorial Hospital, 1121 N. Church Street, Greensboro, NC, 27401, USA.
| | - Carrie Faith Lutheran
- Fred Wilson School of Pharmacy, High Point University, One University Parkway, High Point, NC, 27268, USA
| | - Jeremy Frens
- Department of Pharmacy, Moses H. Cone Memorial Hospital, 1121 N. Church Street, Greensboro, NC, 27401, USA
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Narayanan N, Adams CD, Kubiak DW, Cheng S, Stoianovici R, Kagan L, Brunetti L. Evaluation of treatment options for methicillin-resistant Staphylococcus aureus infections in the obese patient. Infect Drug Resist 2019; 12:877-891. [PMID: 31114267 PMCID: PMC6490236 DOI: 10.2147/idr.s196264] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 02/12/2019] [Indexed: 12/30/2022] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a major cause of infection in both the hospital and community setting. Obesity is a risk factor for infection, and the prevalence of this disease has reached epidemic proportions worldwide. Treatment of infections in this special population is a challenge given the lack of data on the optimal antibiotic choice and dosing strategies, particularly for treatment of MRSA infections. Obesity is associated with various physiological changes that may lead to altered pharmacokinetic parameters. These changes include altered drug biodistribution, elimination, and absorption. This review provides clinicians with a summary of the literature pertaining to the pharmacokinetic and pharmacodynamic considerations when selecting antibiotic therapy for the treatment of MRSA infections in obese patients.
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Affiliation(s)
- Navaneeth Narayanan
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
- Division of Infectious Diseases, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Christopher D Adams
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
| | - David W Kubiak
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, MA, USA
| | - Serena Cheng
- Department of Pharmacy, VA San Diego Healthcare System, San Diego, CA, USA
| | - Robyn Stoianovici
- Department of Pharmacy, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Leonid Kagan
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
- Department of Pharmaceutics, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
| | - Luigi Brunetti
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
- Department of Pharmaceutics, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
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Bowers RD, Cooper AA, Wente CL, Wilson DT, Johnson SW, Drew RH. Evaluation of a vancomycin dosing nomogram in obese patients weighing at least 100 kilograms. Pharm Pract (Granada) 2018; 16:1204. [PMID: 30416622 PMCID: PMC6207350 DOI: 10.18549/pharmpract.2018.03.1204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 07/04/2018] [Indexed: 11/14/2022] Open
Abstract
Background There remains variability in both practice and evidence related to optimal initial empiric dosing strategies for vancomycin. Objective Our primary objective was to describe the percentage of obese patients receiving vancomycin doses consistent with nomogram recommendations achieving targeted initial steady-state serum vancomycin concentrations. Secondary objectives were to describe the primary endpoint in subgroups based on patient weight and estimated creatinine clearance, to describe the rate of supratherapeutic vancomycin accumulation following an initial therapeutic trough concentration, and to describe the rate of vancomycin-related adverse events. Methods This single-center, IRB-approved, retrospective cohort included adult patients ≥ 100 kilograms total body weight with a body mass index (BMI) >30 kilograms/m2 who received a stable nomogram-based vancomycin regimen and had at least one steady-state vancomycin trough concentration. Data collected included vancomycin regimens and concentrations, vancomycin indication, serum creatinine, and vancomycin-related adverse events. Patients were divided into two cohorts by goal trough concentration: 10-15 mcg/mL and 15-20 mcg/mL. Results Of 325 patients screened, 85 were included. Goal steady-state concentrations were reached in 42/85 (49.4%) of total patients. Conclusions Achievement of initial steady-state vancomycin serum concentrations in the present study (approximately 50%) was consistent with the use of published vancomycin dosing nomograms.
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Affiliation(s)
- Riley D Bowers
- Department of Pharmacy Practice, College of Pharmacy & Health Sciences, Campbell University. Buies Creek, NC; & Cape Fear Valley Medical Center. Fayetteville, NC (United States).
| | - April A Cooper
- Department of Pharmacy Practice, College of Pharmacy & Health Sciences, Campbell University. Buies Creek, NC; & Duke Regional Hospital. Durham, NC (United States).
| | - Catherine L Wente
- Department of Pharmacy Practice, College of Pharmacy & Health Sciences, Campbell University. Buies Creek, NC; & Duke Regional Hospital. Durham, NC (United States).
| | - Dustin T Wilson
- Department of Pharmacy Practice, College of Pharmacy & Health Sciences, Campbell University. Buies Creek, NC; & Duke University Hospital. Durham, NC (United States).
| | - Steven W Johnson
- Department of Pharmacy Practice, College of Pharmacy & Health Sciences, Campbell University. Buies Creek, NC; & Novant Health - Forsyth Medical Center. Winston-Salem, NC (United States).
| | - Richard H Drew
- Department of Pharmacy Practice, College of Pharmacy & Health Sciences, Campbell University. Buies Creek, NC; & Duke University School of Medicine. Durham, NC (United States).
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Barber KE, Bell AM, Stover KR, Wagner JL. Intravenous Vancomycin Dosing in the Elderly: A Focus on Clinical Issues and Practical Application. Drugs Aging 2016; 33:845-854. [PMID: 27878526 PMCID: PMC5122618 DOI: 10.1007/s40266-016-0420-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The elderly population can be divided into three distinct age groups: 65-74 years (young-old), 75-84 years (middle-old), and 85+ years (old-old). Despite evidence of a shift in leading causes for mortality in the elderly from infectious diseases to chronic conditions, infections are still a serious cause of death in this population. These patients are at increased risk due to weakened immune systems, an increased prevalence of underlying comorbidities, and decreased physiologic reserves to fight infection. Additionally, elderly patients, especially adults in institutional settings, are at an increased risk of colonization and subsequent infection with methicillin-resistant Staphylococcus aureus at a rate that is five times higher than in younger individuals, causing an increase in empiric and definitive vancomycin use. Elderly patients have unique characteristics that make dosing vancomycin a challenge for clinicians, such as increased volume of distribution and decreased renal function. Using the best available evidence, it is recommended to initiate lower empiric maintenance doses and monitor vancomycin serum concentrations earlier than steady state to accurately calculate drug elimination and make appropriate dose adjustments.
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Affiliation(s)
- Katie E Barber
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, 2500 N. State Street, Jackson, MS, 39216, USA
| | - Allison M Bell
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, 2500 N. State Street, Jackson, MS, 39216, USA
| | - Kayla R Stover
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, 2500 N. State Street, Jackson, MS, 39216, USA
- Department of Medicine-Infectious Diseases, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS, 39216, USA
| | - Jamie L Wagner
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, 2500 N. State Street, Jackson, MS, 39216, USA.
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